• Caused by parasitic protozoa species of the genus Plasmodium (P ovale, P vivax, P malariae, P knowlesi, and P falciparum) carried by the Anopheles mosquito
    • P falciparum most severe
  • Failure to consider for febrile illness following travel, even if seemingly temporally remote, can result in significant morbidity or mortality, especially in children and pregnant or immunocompromised patients
  • Chemoprophylaxsis does not guarantee protection
  • CDC Malaria Hotline: 770-488-7788
  • Malaria is a US nationally notifiable disease and all cases should be reported
  • Malaria vaccine with ~30% efficacy will be piloted in African countries in 2018, study to assess pediatric mortality[1]

Traveler Precautions

The CDC recommends travelers to malaria-endemic regions take the following precautions:[2]

  • Chemoprophylaxis
  • Use of insecticide-treated bed nets
  • Use of DEET-containing insect repellents
  • Wear long-sleeve shirts and pants

Clinical Features

  • Fever + exposure to endemic country
    • Cyclic fever only after chronic infection
  • Headache, cough, GI symptoms




  • None of the above

Differential Diagnosis

Fever in traveler


  • First smear positive in >90% of cases (thick and thin Giemsa stain)
    • If initial negative, must be repeated BID x 2-3 days for proper exclusion of malaria
    • Determines degree of parasitemia and type (e.g. P. falciparum)
  • Additional lab findings


  • Mixed infections involving more than one species of Plasmodium may occur in areas of high endemicity (have a low threshold for including treatment for P falciparum)[3]
  • Hyponatremia in the setting of hypovolemia does not require treatment beyond rehydration
  • Treat hypoglycemia
  • Check HIV status (coinfection can lead to worse clinical outcomes)
  • Exchange transfusion for patients with:
    • P falciparum malaria with a parasitemia greater than 10%
    • Life-threatening complications (ie, coma, respiratory failure, coagulopathy, fulminant kidney failure)
For specific dosing see the CDC Recommendations or call the Malaria CDC Hotline(855) 856-4713

Uncomplicated Malaria

  • Uncomplicated:
    • No evidence of organ dysfunction
    • Parasitemia <5%
    • Able to tolerate PO
  • Hospitalize:
    • Severe clinical manifestations in non-immune host for P. falciparum or P. knowlesi
  • Report to state health department
  • For non-pregnant patients (3 day course)
    • Artemether + lumefantrine
    • Artesunate + amodiaquine
    • Artesunate + mefloquine
    • Dihydroartemisinin + piperaquine
    • Artesunate + sulfadoxine–pyrimethamine (SP)
  • For pregnant (1st trimester)
  • Additional considerations
    • Avoid artesunate + SP in HIV/AIDS patients taking co-trimoxazole
    • Avoid artesunate + amodiaquine in HIV/AIDS patients taking efavirenz or zidovudine
    • P. vivax and P. ovale have dormant hypnozoites in the liver which require treatment with primaquine phosphate for complete eradication

Severe Malaria

  • Do not delay treatment in the unstable patient if strong suspicion for malaria as initial smear may be falsely negative
  • Treatment (IV for ≥24 hours then 3 days PO course)
    • Artesunate (IV)
      • Clears malaria faster than quinine
      • Distributed only through CDC
    • Quinidine (IV) also appropriate choice; more available in US

Cerebral Malaria

  • Insufficient evidence for or against giving antiepileptics
  • For severe cerebral edema, mannitol and steroids have not shown a demonstrable benefit


Admit for

  • Patients with suspected or confirmed P falciparum or P knowlesi infection
  • Young children
  • Pregnant women
  • Immunocompromised patients

Admit to ICU for

  • Severe complications (e.g.coagulopathy or end-organ failure)
  • Cerebral malaria (e.g. altered mental status, repeated seizures, coma)
  • Parasitemia
    • >2% in non-immune (i.e. travelers)
    • >5% in semi-immune (i.e. locals)

See Also

External Links


  1. WHO. Ghana, Kenya and Malawi to take part in WHO malaria vaccine pilot programme. 24 April 2017.
  2. WHO Malaria Policy Advisory Committee and Secretariat. Malaria Policy Advisory Committee to the WHO: conlusionsions and recommendations of September 2013 meeting. Malar J. 2013;12(1):456
  3. World Health Organization. Guidelines for the treatment of malaria, 3rd ed, WHO, Geneva 2015.