The Prevention, Diagnosis and Treatment 

of Malaria in U.S. Africa Command 

(USAFRICOM)

APHC TG 336 . Approved for public release; distribution is unlimited. May 2016

Malaria 

Field Guide

(Provisional)
2 
3 

Table of Contents

Table of Contents .....................................................3

Introduction ..............................................................5

Background .............................................................7

Transmission ...........................................................9

Prevention .............................................................11

Mosquito Surveillance and Control.........................23

Diagnosis ...............................................................33

Treatment ..............................................................43

Disposition .............................................................49

Consult Information ...............................................53

Glossary ................................................................55

Use of trademarked name(s) does not imply 

endorsement by the U.S. Army but is intended 

only to assist in identification of specific products.
4 
5 

Introduction

Purpose

This technical guide (TG) is for medical personnel 

operating in the USAFRICOM area of responsibility 

(AOR) for the prevention, diagnosis and treatment 

of malaria. Check with approving physician before 

implementing care and treatments described in this 

TG. The TG is not a definitive source of current 

medical intelligence. Refer to the National Center 

for Medical Intelligence (NCMI), https://www.intelink.

gov/ncmi/index.php for the most current medical 

intelligence.

Sources

The APHC (http://phc.amedd.army.mil/) has produced 

this TG by integrating instructional material 

contributed by military physicians and scientists.

The TG is comprised of updated excerpts specific 

to USAFRICOM AOR from existing U.S. Army 

publications including USAPHC TG 273, Diagnosis 

and Treatment of Diseases of Tactical Importance 

to U.S. Central Command; and the U.S. Navy 

Medical Department Pocket Guide to Malaria 

Prevention and Control, Environmental Health 

Center Technical Manual; NEHC-TM PM 6250.1; 

(2007). Refer to United States Africa Command 

Manual 4200.03, Health and Medical: Force Health 

Protection Procedures for Deployment and Travel, 

for force health protection (FHP) requirements and 

standardized procedures for health surveillance in the 
6 

USAFRICOM AOR. Refer to Department of Defense 

(DoD) Health Affairs Memorandum: Guidance on 

Medication for Prophylaxis of Malaria for guidance 

and best practices for the chemoprophylaxis of 

Services members serving in malaria endemic regions 

http://www.health.mil/Policies/2013/04/15/Guidanceon-Medications-for-Prophylaxis-of-Malaria.
7 

Background

Malaria is a serious mosquito-borne illness caused by 

a microscopic parasite which infects red blood cells. 

There are four primary species of malaria parasites 

that can infect humans: Plasmodium (P.) falciparum, 

P. malariae, P. ovale, and P. vivax. There are other 

species of Plasmodium that infect animals. In recent 

years, a fifth species, P. knowlesi, has been identified 

as a cause of human malaria in Southeast Asia. While 

infection with any of the malaria species can make a 

person very ill, P. falciparum, the predominant strain of 

malaria in Africa, causes severe disease and, without 

treatment, death.

U.S. military personnel are increasingly involved 

with missions in countries where malaria is present. 

Prompt diagnosis and treatment of malaria, 

particularly P. falciparum, is critical to prevent severe 

disease and death. Personnel need to strictly adhere 

to all countermeasures in malaria-infected areas, 

including chemoprophylaxis (malaria pills) and 

personal and unit protective measures.
background

The Prevention, Diagnosis and Treatment 

of Malaria in USAFRICOM

background
8 

Risk of Contracting Falciparum Malaria in 

Africa (2009)

Based on Spatial Distribution of P. falciparum Malaria 

Predictions Stratified by Endemicity Class from Hay, 

S.I. et al (2009). A World Malaria Map: Plasmodium 

falciparum Endemicity in 2007. PLoS Medicine 6(3): 

e10000048.

For malaria threat in a specific location, please visit 

the CDC interactive malaria map at http://www.cdc.

gov/malaria/map/.
transmission

The Prevention, Diagnosis and Treatment 

of Malaria in USAFRICOM

transmission
9 

Transmission

The malaria parasite is transmitted by bites of infected 

female Anopheles species (spp.) mosquitoes. 

Anopheles mosquitoes (image below) are primarily 

nighttime biters, including evening and early morning. 

Malaria cannot be transmitted from person-to-person 

like a cold or the flu. You cannot get malaria through 

casual contact with an infected person such as 

touching or kissing a person with the disease. Rarely, 

transmission occurs by blood transfusion, organ 

transplantation, needle sharing, or congenitally from 

mother to fetus. Medical personnel should use 

standard precautions when in contact with malariainfected patients. Utilize environmental controls to 

ensure patients are not exposed to mosquitoes. 

Anopheles spp. Mosquitoes, Vectors of Malaria. CDC Public Health 

Image Library
10 
prevention

The Prevention, Diagnosis and Treatment 

of Malaria in USAFRICOM

prevention
11 

Prevention

Overview

There were an estimated 198 million cases of malaria 

worldwide (range 124-283 million) in 2013, and an 

estimated 584,000 deaths (range 367,000-755,000). 

Ninety percent of all malaria deaths occur in Africa 

(World Health Organization (WHO), Factsheet on 

the World Malaria Report 2014, http://www.who.

int/malaria/media/world_malaria_report_2014/en/). 

Personnel from malaria-free areas are very vulnerable 

to the disease due to lack of immunity when they 

travel to countries where malaria is endemic. 

Protection from mosquito bites, chemoprophylaxis 

(malaria pills), and mosquito control are essential 

in reducing malaria transmission. Deployment 

health risk assessment addresses specific malaria 

prevention interventions, including use of mosquito 

repellents and chemoprophylaxis. Recommendations 

for chemoprophylaxis are based on information 

concerning parasite drug susceptibility for a specific 

location and season (see Centers for Disease Control 

and Prevention (CDC)), http://www.cdc.gov/malaria/

diagnosis_treatment/treatment.html and NCMI, https://

www.intelink.gov/ncmi/index.php. When in areas 

with malaria, personnel need to adhere strictly to all 

countermeasures, including chemoprophylaxis and 

personal and unit protective measures.
12 

Personal Protective Measures

Skin

Use repellents that have been approved by the U.S. 

Environmental Protection Agency (USEPA). The 

duration of repellent effectiveness is impacted by the 

levels of activity, heat, and humidity, and the intensity 

of mosquito population in that location. Topical 

repellents available to the military are designed to 

remain effective for 8 to 12 hours. The user should 

check the product label to determine how often 

reapplication is necessary. Use one of the following 

DoD-approved products for skin application:

• ULTRATHONTM, a 33% DEET lotion (NSN: 6840-

01-284-3982), provides protection for up to 12

hours. This product is the most effective and longlasting formulation in the military standard stock

system.

• Ultra 30TM, also referred to as Lipo-Deet, a 30%

DEET lotion (NSN 6840-01-584-8393), lasts up to

12 hours.

Wear a factorytreated Army 

Combat Uniform 

(ACU Permethrin) .*

Apply DEET or

Picaridin repellent 

to all exposed skin.

*The Army Physical Fitness Uniform (APFU) is not treated with permethrin. It does not protect Soldiers 

from insects.

Wear your uniform 

properly

Use a permethrintreated bed net.Take your malaria 

pills before, 

during and after 

your deployment.
13 

• Cutter® pump spray, 25% DEET (NSN 6840-01-

584-8598), repels mosquitoes up to 10 hours.

• Natrapel® pump spray, 20% Picaridin (NSN 6840-

01-619-4795), repels mosquitoes up to 8 hours.

• SUNSECTTM is a combination of sunscreen (15

SPF) and 20% DEET (NSN 6840-01-288-2188).

Duration of protection is not available for this

product.

• For label, MSDS, product price and shipping

information, please visit the Armed Forces Pest

Management Board (AFPMB) website: http://www.

afpmb.org/content/department-defense-insectrepellents.

Always follow label directions. Do not apply to skin 

that is underneath clothing. Do not apply to cuts, 

wounds, or to broken, irritated, or sunburned skin. 

When making separate applications of sunscreen 

and insect repellent products, apply sunscreen first 

followed by repellent. To apply to your face, dispense 

a small amount of repellent onto your hands, and 

then rub them carefully over your face, avoiding 

your eyes and mouth. When using pump spray, do 

not spray directly on face. Spray on hands first, and 

then apply sparingly to face, avoiding eyes. Wash off 

skin with soap and water when returning indoors and 

the exposure to mosquitoes or other biting insects 

has ended. Some of the repellent products may 

damage some synthetic fabrics, plastics, and painted 

or varnished surfaces. Avoid smearing on plastic 

eyeglasses, goggles, watch crystals, computer or 

phone screens and similar surfaces.
14 

Clothing

Clothing is the first direct line of personal defense 

against arthropods. Proper wearing of the field uniform 

is essential to minimize skin exposure. A loose fitting 

uniform with pants tucked into boots, sleeves pulled 

down, and undershirt tucked into pants will provide 

protection from mosquitoes and other biting insects 

and ticks.

Uniforms should be treated with permethrin, 

which acts as a repellent and residual insecticide. 

Permethrin is the U.S. military’s standard repellent 

for application to fabric and is considered the most 

effective clothing impregnate available. The currently 

issued Army Combat Uniforms (ACUs) and Marine 

Corps Combat Utility Uniforms are factory treated with 

permethrin. Factory treated uniforms provide effective 

protection from mosquitoes, ticks, and other biting 

insects through 50 launderings, the estimated field 

life of the uniform. Do not dry clean uniforms – this 

process will remove permethrin from the fabric.

Other cloth items such as civilian clothing, mosquito 

netting, camouflage helmet covers, ground covers, 

and tentage (with the exception of vinyl-coated temper 

tents) can also be treated with permethrin. Do not treat 

underwear, including undershirts, physical training 

uniforms or uniform caps with permethrin because of 

the potential for excessive permethrin absorption.

Civilian clothing that is factory-impregnated with 

permethrin may also be purchased commercially. 

Permethrin will withstand numerous launderings. 
15 

Permethrin should only be used on clothing, never on 

skin. Treat clothing with permethrin repellent BEFORE 

putting it on and strictly follow product instructions.

Factory-treated uniforms have a label on the inside 

of the garment that indicates the garment has been 

treated and how long the treatment will last. Uniforms 

and civilian clothing that have not been treated with 

permethrin can be treated with one of the following 

methods: 

• Permethrin Arthropod Repellent, aerosol spray

“Insect Repellent, Clothing Application” (NSN 6840-

01-278-1336) is a formulation of 0.5% permethrin

in 6-oz aerosol cans for use on uniforms, mosquito

netting, and other clothing. One treatment can last

six weeks or six washings.

• Individual Dynamic Absorption (IDA) Kit, “Insect

Repellent, Clothing Application” (NSN 6840-01-

345-0237) is a field kit in which shirts and trousers

are treated in separate plastic bags containing a

40% permethrin and water mixture. Treatment lasts

about 50 washings.

• Insect Repellent, clothing application, 40%

permethrin, liquid (2-gal sprayer) (NSN 6840-

01-334-2666) is commonly used to treat large

numbers of uniforms at one time. Two gallons of

finished spray will treat eight uniforms. Treatment

lasts about 50 washings. This method of treating

uniforms may only be performed by personnel

trained and certified in pesticide application.
16 

You need to know ......

• Dry cleaning removes permethrin from the uniform.

• Flame-Resistant Army Combat Uniforms

(FRACUs) and Nomex® cannot be field treated with

permethrin. (Nomex® is a registered trademark of

E.I. du Pont de Nemours and Company. DuPont

Canada Inc. is a licensee).

Other personal and unit countermeasures: 

• When possible, stay inside well-screened areas at

dawn, dusk, and nighttime. Anopheline mosquitoes

are most active at these times.

• Eliminate mosquito breeding sites by draining

standing water.

• Make sure door and window screens do not have

holes.

• Educate personnel on malaria threats and the

correct use of countermeasures.

• Adhere strictly to prescribed malaria medication

regimen.

• Sleep under a permethrin-impregnated bed net

(see AFPMB website for Pop-Up Bed Nets, NSN

3740-01-516-4415; 3740-01-518-7310; 3740-01-

543-5652), or the EgretTM bed net (NSN 3740-

01-644-4953). If not available, use the insect net

protector (NSN 7210-00-266-9736) olive drab,

nylon canopy that can be used with the folding cot,

hammock, steel bed, or shelter half-tent (see below
17 

images). Another nylon insect protector (NSN 

7210-00-266-9740) is also available; this item has 

slightly smaller dimensions yet can also be used 

with the folding cot. Treat an untreated bed net with 

permethrin using aerosol can (NSN 6840-01-278-

1336). Follow label directions. Spray the outside 

surface of the net prior to setting up the bed net. 

Permethrin will help prevent mosquitoes from being 

able to gain entry or bite through the net.

• Once the permethrin-treated bed net has dried,

erect net so that there are no openings. Tuck

edges of the net under your mattress pad or

sleeping bag. Do not allow the net to drape on the

ground. Don’t leave your net open during the day.

• Don’t let the net touch your skin while you sleep

because insects may bite you through the netting.

• Check the bed net for tears, holes, and other

damaged areas where mosquitoes could enter.

Permethrin-Treated Lightweight, 

Self-Supporting, Pop-Up Bed 

Net, NSN 3740-01-516-4415 OD 

Green. 

Insect Net Protector (Mosquito 

Bed Net Not Treated With 

Permethrin), NSN 7210-00-266-

9736. 
18 

Chemoprophylaxis

The use of chemoprophylaxis should be anticipated 

for operations in most regions. Malaria, particularly 

chloroquine-resistant P. falciparum, is endemic to most 

of Sub-Saharan Africa. Specific recommendations by 

country/region are available from the NCMI (https://

www.intelink.gov/ncmi/index.php).

Recommended Regimen

Malaria in Africa may be transmitted year round 

or seasonally depending on the location, so an 

understanding of local epidemiology is important. 

The choice of a particular regimen is based on a 

risk-benefit assessment of each regimen and the 

deployment-specific infection risk. Infection risk 

is determined by multiple factors, including the 

operational situation, length of exposure, prevalence 

of drug resistance, individual factors and any Servicespecific policies. While basic chemoprophylaxis 

guidance is provided in this guide, always follow 

current Theater policy and consult NCMI for specific 

location guidance. The Food and Drug Administration 

(FDA)-approved regimens for Force Health Protection 

in the AFRICOM AOR include:

• Atovaquone-proguanil. Take 1 adult tablet by

mouth (PO) per day (QD) starting 1-2 days

before arrival in the at-risk region and continuing

7 days after departure from the region. Take this

medication daily with food or a glass of milk.

Atovaquone-proguanil is well-tolerated and side

effects are rare.
19 

• Doxycycline. Take one 100 milligrams (mg) tablet

PO daily, beginning 1-2 days before arrival in the

at-risk region and continuing daily for 4 weeks

after departure. Doxycycline comes as many

products. Doxycycline monohydrate causes

less gastrointestinal (GI) upset than doxycycline

hyclate. Doxycycline is best taken in the morning

with lots of water; do not recline or lie down for

at least one hour after taking the medication.

Doxycycline may increase the likelihood of

sunburn; ensure individuals use sunscreen and

protective clothing when taking this medication.

• Mefloquine. Take one 250 mg tablet PO once

weekly, beginning 1-2 weeks before arrival in

the at-risk region and continuing for 4 weeks

(4 doses) after departure. Initiating mefloquine

earlier (e.g., 3-4 weeks prior to travel) may

provide additional time to determine if the

medication is well-tolerated. Mefloquine is a

third-line chemoprophylaxis drug and should

only be considered in individuals who cannot

tolerate atovaquone-proguanil or doxycycline.

Mefloquine must NOT be used in anyone with

contraindications, including active or recent

history of depression, anxiety disorder, psychosis,

or other major psychiatric disorder; history of

seizures; history of recent traumatic brain injury;

aircrew members, and divers. Providers must

complete mefloquine training at Swank Health in

order to be granted prescribing capability. Contact

your MTF pharmacist for the most current

information. Anyone receiving a prescription for

mefloquine must be provided the FDA-approved
20 

medication guide for this drug. Individuals taking 

this medication must be instructed to immediately 

report any adverse reactions to a health care 

provider.

Presumptive Anti-Relapse Therapy 

(Terminal prophylaxis)

P. vivax and P. ovale have dormant liver stage 

parasites which can reactivate (“relapse”) and cause 

malaria symptoms several months or years after initial 

infection. 

Primaquine is the only available drug that can 

eradicate persistent hepatic parasites (hypnozoites) of 

P. vivax and P. ovale malaria. 

Primaquine must not be given to glucose-6- 

phosphate dehydrogenase (G6PD) deficient 

individuals because of the risk of hemolytic 

anemia. Pregnant or breastfeeding G6PD-normal 

women should not take primaquine because 

fetal G6PD status is unknown. G6PD deficiency 

is determined by a one-time blood test. G6PD 

status of Service members is available in 

Service-specific medical readiness data systems. 

In individuals without documentation of G6PD 

status, pre-deployment testing is recommended 

prior to entering malaria risk areas.
21 

Taking primaquine concurrently with another antimalarial drug for asymptomatic patients after leaving 

an endemic area is referred to as presumptive 

anti-relapse therapy (PART) or terminal prophylaxis. 

Due to the low prevalence of non-falciparum malaria 

in Africa, terminal prophylaxis with primaquine for 

deployments shorter than 30 days should be based on 

individual risk and is not mandated.

Primaquine Dosing for PART (Terminal 

Prophylaxis) and Radical Cure 

The current FDA-approved dose regimen for 

primaquine for both anti-relapse therapy and radical 

cure (see Treatment tab: Treatment of Relapsing 

Malaria section) is 15 mg (base) PO QD for 14 days. 

This regimen was approved in 1952 and has not been 

revisited since. Since 2003, the CDC-recommended, 

first-line regimen, based on accumulated evidence, 

is a higher dose of 30 mg (base) PO QD for 14 days. 

Use of the higher-dose primaquine regimen for PART 

is now recommended for military personnel. This 

recommendation is consistent with the spirit of DoD 

issuance 6200.02 (February 17, 2008), in that the 

higher-dose recommendation for primaquine when 

used as PART is “standard medical practice in the 

United States.”
22 

Directly Observed Therapy 

Directly Observed Therapy (DOT) is strongly 

recommended to ensure personnel are taking 

chemoprophylaxis as directed. DOT is the assignment 

of personnel to watch as individuals take their pills at 

the same time (e.g., while in formation). Missing as 

little as one dose of doxycycline can put personnel at 

risk for infection. Chain of command support is critical 

for DOT to be executed effectively.
mosquito surveillance and contol

The Prevention, Diagnosis and Treatment 

of Malaria in USAFRICOM

mosquito 

surveillance 

and control
23 

Basic Information on Mosquitoes

There are approximately 3,500 species of mosquitoes. 

Human malaria is transmitted only by females of 

the genus Anopheles. Of the approximately 430 

Anopheles species, only 30-40 transmit malaria in 

nature. Understanding the biology and behavior of 

Anopheles mosquitoes can help understand how 

malaria is transmitted and can aid in designing 

appropriate control strategies. Factors that affect 

a mosquito’s ability to transmit malaria include its 

innate susceptibility to Plasmodium, its host choice, 

and its longevity. Factors that should be taken into 

consideration when designing a control program 

include the susceptibility of malaria vectors to 

insecticides and the preferred feeding and resting 

location of adult mosquitoes. 

In African countries where malaria is endemic, disease 

transmission is typically intense, and transmission 

is influenced by local ecological factors such as 

proximity to bodies of water. 
24 

Mosquito Life Stages

Like all mosquitoes, anophelines go through four 

stages in their life cycle: egg, larva, pupa, and adult. 

The first three stages are aquatic and last 5-14 

days, depending on the species and the ambient 

temperature. The adult stage is when the female 

Anopheles mosquito acts as a malaria vector. 

Eggs: Anopheline mosquitoes lay their eggs singly 

directly on water and are unique in having floats on 

either side. Eggs are not resistant to drying and hatch 

within 2-3 days, although hatching may take up to 2-3 

weeks in colder climates.

Larvae: In contrast to other mosquitoes, Anopheles 

larvae lack a respiratory siphon and for this reason 

position themselves so their body is parallel to the 

surface of the water to breathe air (image below).

CDC Public Health 

Image Library

The larvae occur in a wide range of habitats, but 

most species prefer clean, unpolluted water. Larvae 

of Anopheles mosquitoes have been found in diverse 

habitats such as fresh or salt-water marshes, lagoons, 

mangrove swamps, rice fields, grassy ditches, the 
25 

edges of streams and rivers, temporary rain pools, 

sunlit pools and man-made containers. Many species 

prefer habitats with vegetation. Some breed in open, 

sun-lit pools while others are found only in shaded 

habitats.

Pupae: The pupa (image below) is comma-shaped 

when viewed from the side. After a few days as a 

pupa, the adult mosquito emerges. 

CDC Public Health 

Image Library

Adults: Like all mosquitoes, adult anophelines have 

slender bodies with 3 sections: head, thorax and 

abdomen. The head is specialized for acquiring 

sensory information and for feeding. The head 

contains the eyes and a pair of long, many-segmented 

antennae. The antennae are important for detecting 

host odors as well as odors of breeding sites where 

females lay eggs. The head also has an elongate, 

forward-projecting proboscis used for feeding and two 

sensory palps. Anopheles mosquitoes can be 

distinguished from other mosquitoes by the palps, 

which are as long as the proboscis and by the 

presence of discrete blocks of black and white scales 

on the wings. Adult Anopheles can also be identified 
26 

by their typical resting position: males and females 

rest with their abdomens sticking up in the air rather 

than parallel to the surface on which they are resting.

Anopheline Mosquito Resting Position. CDC Public Health 

Image Library
27 

Mosquito Surveillance and Control 

A general knowledge of anopheline mosquito 

biology is valuable in instituting a successful malaria 

prevention and control program. Mosquito surveillance 

is a prerequisite to an effective, efficient, and 

environmentally sound mosquito control program. 

Mosquito surveillance includes the collection and 

interpretation of data on the presence and sources of 

mosquito species and testing collected specimens for 

the presence of pathogens/parasites. 

Mosquito Surveys: Surveys should be a continuing 

part of a control program in order to evaluate the 

adequacy of control methods. Mosquito surveys 

are usually a responsibility of preventive medicine 

personnel. Since mosquito collection methods differ 

in their effectiveness for sampling different species, 

more than one collection method may be used to 

accurately determine the seasonality and abundance 

of all the important mosquito species in an area. 

Multiple surveillance techniques for larvae and adult 

mosquitoes should be used to accurately quantify 

mosquito abundance. Captured adult anopheline 

mosquitoes can be tested for presence of malaria by 

using a Malaria Detection test kit (MAL-K020) with 

follow-up confirmatory submission to an entomology 

laboratory. The MAL-K020 (NSN 3740-6550-01-551-

5327) is available in the DoD supply system along 

with an instructional video for use of the kit. http://

www.youtube.com/watch?v=8aJUPRdGIB8&list=UU

YbnT9j9n5KZ3fvp8REKycw&index=1&feature=plcp.

For additional information on mosquito surveillance 
28 

and the malaria detection kit, visit AFPMB TG 48, 

Contingency Pest and Vector Surveillance at http://

www.afpmb.org/sites/default/files/pubs/techguides/

TG48/TG48.pdf.

Larval Surveys: Larval surveys are conducted to 

determine the areas in which mosquitoes breed 

and their relative abundance. For these reasons, 

they are of special value in the guidance of control 

operations. Chemical treatment to kill larvae can 

then be limited to only those areas where significant 

mosquito populations are found. The mosquito 

dipper is a simple tool for conducting larval mosquito 

surveillance. It consists of a white plastic cup attached 

to a handle approximately 3 feet long. 

Mosquito dipper

Adult Surveys: The methods used in sampling adult 

mosquito populations include the use of light traps, 

resting station collections, biting collections and 

landing counts. Because one method is not sufficient 

for all mosquitoes, a combination of methods is 

desirable, particularly when several species with 

different biting preferences or reactions to light are 

present in the area. Adult surveys are most frequently 

conducted because adult mosquitoes are easier to 

locate and identify. These surveys indicate various 
29 

species present and their relative abundance. 

Information obtained from adult surveys includes: (1) 

determining the need for a control program, including 

when and where control measures should be applied 

and by what method; (2) determining if a disease 

potential may exist and (3) evaluating control 

measures previously applied. The CDC light trap 

provides a reliable and portable sampling device for 

the collection of mosquitoes. These traps are small, 

lightweight, and battery-operated. Carbon dioxide can 

be supplied by a regulated compressed gas container 

or through placement of dry ice in a padded envelope 

or insulated container that is suspended above the 

trap. Ideally, several CDC traps should be used in an 

area to conduct mosquito surveillance. 

CDC light trap. Christina Graber, APHC 
30 

Biting Collections and Landing Counts: Collecting 

mosquitoes as they bite is the simplest and most 

direct method of determining which vector and pest 

species feed on man and their relative abundance. 

The mosquitoes are collected with a kill tube or an 

aspirator for a designated period of time as they land 

on exposed skin area such as the back or legs. The 

favored procedure is to sit on a box or stool with the 

trouser legs rolled to the knees and with shoes and 

socks removed. This method should not be employed 

by untrained personnel and should only be used in 

carefully controlled settings due to the risk of acquiring 

mosquito-borne diseases.

Resting Stations: Many species of mosquitoes are 

inactive during the day and may be found resting in 

dark, cool and humid places protected from the wind. 

Comparative data on the densities of adult mosquitoes 

may be obtained by daytime inspection of these 

natural resting sites. Resting mosquitoes can be 

collected using a variety of devices such as vacuum 

aspirators, sweepers, suction traps, and hand-held, 

battery-operated flashlight aspirators. 

Aspirator, 1.5V Powered, 

NSN 3740-01-210-2368 
31 

Mosquito Control: Anopheline species that are indoor 

feeders are readily controlled by indoor spraying 

of residual insecticides on resting surfaces using 

thermal fog or cold fog application. Mosquito larvae 

are controlled by source reduction (destruction of 

the breeding sites) and the use of larvicides. Ultra 

Low Volume (ULV) space treatments are ideal for 

outdoor mosquito control. For larger areas where ULV 

treatments are not possible, residual spray should 

be applied to vegetation surfaces within a radius of 

100 feet or more around the site to protect people 

and kill mosquitoes resting in the vegetation. The 

decision to recommend and/ or implement mosquito 

control measures should be made in consultation 

with a medical entomologist. For specific guidance on 

mosquito control products, refer to Contingency Pest 

Management Guide at http://www.afpmb.org/sites/

default/files/pubs/techguides/tg24.pdf.
32 
diagnosis

The Prevention, Diagnosis and Treatment 

of Malaria in USAFRICOM

diagnosis
33 

Diagnosis

Malaria MUST be considered in all febrile patients 

who have spent any time in an area where malaria 

is present. If not diagnosed and treated promptly, 

P. falciparum is often fatal. While P. falciparum

causes the most severe disease, other species of 

Plasmodium also have the potential to cause severe 

illness and even death. Symptoms can occur before 

parasites are detectable by blood smear, but critically 

ill patients will have a detectable parasitemia at some 

time in their illness. A reported history of compliance 

with chemoprophylaxis and/or personal and unit 

protective measures does not exclude a patient from 

having malaria.

Signs and Symptoms

Symptoms are non-specific and vary depending on 

malaria type but generally include the following at the 

onset of clinical illness:

• fever

• shaking chills 

• sweats

• headache 

• muscle aches

• exhaustion

• nausea

• vomiting 

• diarrhea
34 

Patient ill with fever > 101 ○F and is/has been in 

a malarious area.

MUST rule out malaria. Start empiric treatment 

if malaria is suspected. Consider rapid medical 

evacuation.

Perform blood smears or rapid diagnostic test 

(RDT). If initial smear or RDT is negative, test 

again in 8-12 hours. If smear is not available, a 

repeat RDT can be performed. If tests are again 

negative, either repeat the smear a third time or 

consider transferring to a location that can perform 

malaria smears.

• Malaria can only be excluded after three 

properly spaced diagnostic tests. Repeat RDT 

testing alone cannot rule out malaria--at least 

one test should be a smear. 

• Negative tests that are clinically considered 

possible false-negative should be treated even 

as testing continues.

If accurate and reliable diagnostic testing is not 

available within 1-2 hours OR if clinical symptoms 

worsen during serial testing and no alternative 

diagnosis has been confi rmed, empiric treatment 

for chloroquine-resistant falciparum malaria is 

recommended.

If smear or RDT positive, treat (see Treatment 

section). Report confi rmed and empirically 

treated cases to preventive medicine authorities.

YES

YES

YES
35 

Infection with P. falciparum, if not promptly treated, 

may advance to complicated (severe) malaria and 

lead to —

• kidney failure

• seizures

• coma

• acute respiratory distress syndrome (ARDS) 

• death 

Complicated malaria occurs when there is evidence 

of organ failure or serious abnormalities of the 

patient’s blood and/or metabolism. This condition is 

a medical emergency requiring prompt evacuation, 

hospitalization and intensive treatment. 

See Table 1 for additional information. 

Symptoms of untreated, non-falciparum malaria may 

continue for weeks or months, with recurring episodes 

of fever and chills. P. vivax and P. ovale have dormant 

liver-stage parasites that can reactivate (“relapse”) 

and cause malaria symptoms several months or years 

after initial infection. 

P. malariae may produce a long-lasting infection that 

can persist without symptoms for years, or even a 

lifetime.
36 

Malaria in pregnant women can be more severe 

than in non-pregnant women and can cause adverse 

pregnancy outcomes, including —

• prematurity

• miscarriage

• stillbirth

• maternal death 

Persons on chemoprophylaxis or using antibiotics, 

especially macrolides, sulfa drugs, and quinolone 

antibiotics, may have delayed presentations, low 

parasitemia, and atypical presentations.
37 

Table 1. Manifestations of Complicated (Severe) Malaria

Major Findings Description

Impaired 

consciousness

Failure to localize or abnormal 

response to painful stimuli; 

unarousable coma persisting 

for >30 minutes after 

generalized convulsion

Seizures More than two generalized 

convulsions in 24 hours

Severe anemia 

(normochromic, 

normocytic)

Hematocrit <15%, or 

hemoglobin <5 grams per 

deciliter (g/dL) in children; 

<20% or <7g/dL in adults

Severe bleeding 

abnormalities

Significant bleeding from 

gums, nose, GI tract, and/

or evidence of disseminated 

intravascular coagulation

Pulmonary edema/

Acute Respiratory 

Distress Syndrome 

Shortness of breath; fast 

labored respiration; rales

Renal impairment Serum creatinine >3.0 mg/

dL (>265 micromoles per liter 

(μmol/L))

Hemoglobinuria Black, brown, or red urine; 

not associated with effects of 

drugs or red blood cell enzyme 

defects (e.g., primaquine 

administration, G6PD 

deficiency)
38 

Major Findings Description

Hypoglycemia Glucose <40 mg/dL (<2.2 

millimoles per liter (mmol/L))

Hypotension/

shock

Systolic blood pressure 

(BP)<50 mmHg in children or 

<80 mmHg in adults

Metabolic acidosis Plasma bicarbonate <15 

mmol/L

Adapted from Management of Severe Malaria: A Practical 

Handbook, 3rd edition. World Health Organization, 2012.

Diagnostic Testing

Patients with suspected malaria should have a total 

of three blood smear exams or rapid diagnostic tests 

(RDTs), one every 8-12 hours, to exclude malaria.

At least one of these should be a malaria smear 

before excluding malaria. Infected patients may have 

negative diagnostic testing due to low parasitemia 

early in the infection or due to chemoprophylaxis. 

RDTs also frequently miss P. ovale infection. Other 

RDTs are available internationally but may perform 

differently than the BinaxNOW® Malaria test.

Table 1. Manifestations of Complicated (Severe) Malaria 

(continued)
39 

Rapid Diagnostic Tests: BinaxNOW®

Malaria Test

1. The BinaxNOW® Malaria test is a rapid laboratory 

antigen test that can detect Plasmodium parasites 

using a whole blood sample drawn from a vein or 

obtained by a finger stick. This is the only FDAcleared product for detection and identification of 

the parasites that cause malaria. (BinaxNOW® is a 

registered trademark of Alere).

• First-line diagnostic tool when a skilled 

microscopist is not available.

• Rapidly (within 15 minutes) diagnoses malaria 

infection and can distinguish between P. falciparum

and non-falciparum infection. (Detection of 

P. ovale, differentiation of mixed infections or 

speciation of non-falciparum parasites requires 

microscopy).

• The lower limit of detection (with 90% sensitivity) 

for P. falciparum is 100 parasites per microliter and 

1000 parasites per microliter for P. vivax. It does 

not reliably detect P. ovale. 

• Not for malaria screening or in individuals who 

have no signs or symptoms of malaria or for 

monitoring anti-malaria therapy. Antigens may be 

detected for several days even after successful 

treatment.

• A positive test result in an ill patient must lead 

to immediate treatment. If a negative test result 

is seen in an ill patient at some risk for malaria, 
40 

empiric treatment should be considered, especially 

if skilled microscopy is not immediately available.

2. How the BinaxNOW® Malaria test works:

• The patient’s blood sample is applied to the sample 

pad. If malaria antigens are present they bind to 

anti-malaria antibodies. 

• A liquid reagent is then added to the pad allowing 

the antigen-antibody complexes to migrate 

along the test strip where they are captured by 

immobilized antibodies forming two test lines. 

A third line is formed (control line) if all of the 

reagents are working and migrating properly. 

• The test is positive if one or both of the test lines 

and the control line appear. The test is negative if 

only the control line is visible.

• Refer to the manufacturer’s test procedure card 

for additional information: http://www.alere.com/us/

en/product-details/binaxnow-malaria.html. Consult 

the Product Insert for detailed instruction and 

performance characteristics.

Blood Smear Exam 

Blood smears identify parasites on smears of 

peripheral blood. Blood smears remain the gold 

standard for malaria diagnosis. They not only 

detect malaria but can also estimate the degree of 

parasitemia, determine the species of malaria and 

identify mixed infections. If RDTs are used initially, 
41 

a malaria smear should be done before malaria is 

excluded. 

Thick smears are 20-40 times more sensitive than thin 

smears for detecting parasites. Thin smears are more 

accurate for determining parasite species.

• Thick smear: Place one drop of blood on a slide. 

With the corner of another glass slide, spread 

the drop until it is about the size of a dime and 

newsprint placed below the slide can barely be 

read. Allow slide to dry thoroughly. DO NOT FIX 

WITH METHANOL. Stain with Giemsa stain.

• Thin smear: Prepare film as for normal complete 

blood count (CBC), fix in methanol, and stain with 

Giemsa stain. Wright’s stain can be used if Giemsa 

stain is not available, but this may make species 

determination more difficult.

Additional laboratory findings (if available) —

Hematologic:

• CBC:

• Anemia (normochromic, normocytic, hemolytic)

• Leukopenia

• Monocytosis (>10%)

• Thrombocytopenia (<150,000/mm3

)

• Eosinophilia not usually seen 
42 

Chemistry: 

• Hypoglycemia (not uniformly seen, but may be 

severe and recurrent).

• Hyperlactatemia, associated with worse outcomes 

in severe malaria.

• Electrolyte abnormalities, including hyperkalemia 

(from RBC lysis) and hyponatremia (from reduced 

free water clearance).

• Elevated aspartate transaminase (AST) > alkaline 

phosphatase (ALT).

• Azotemia (pre-renal).

• Hyperbilirubinemia.

• Urinalysis: may be normal; however, increased 

protein, urobilinogen, and conjugated bilirubin may 

occur.

• Coagulation: normal in uncomplicated disease; 

prolonged prothrombin time (PT) and partial 

thromboplastin time (PTT) with disseminated 

intravascular coagulation (DIC) may be seen in late 

stage disease.

X-ray: nonspecific; pulmonary infiltrates may be seen.

Diagnostic confirmation: Identification of parasite on 

blood smears or RDT.
treatment

The Prevention, Diagnosis and Treatment 

of Malaria in USAFRICOM

treatment
43 

Treatment

Note: Malaria medications should always be 

obtained from approved sources. NEVER procure 

malaria medications from local pharmacies or 

other local vendors due to very high levels of 

counterfeit and tainted products in developing 

countries. 

Uncomplicated (Non-severe) Malaria

P. falciparum resistance to chloroquine and 

sulfadoxinepyrimethamine is widespread in SubSaharan Africa; these drugs should not be used. P. 

vivax is relatively rare on the continent, except in 

parts of the Horn of Africa. P. ovale may be seen in 

mixed infections with some frequency. Regardless 

of the species identified, treat for chloroquineresistant P. falciparum. Consider presumptive 

treatment with the addition of primaquine in those 

with no contraindication to cover the possibility of P. 

vivax or P. ovale infections. After diagnosis, blood 

smears should be monitored for response to therapy. 

Decreasing parasite count signifies a favorable 

response to therapy. Frequency of testing depends on 

therapeutic response and severity of illness. Antigenbased RDTs should not be used to assess response 

to treatment.
44 

• Initial treatment for adult patients with 

uncomplicated malaria who are able to tolerate 

oral medication — 

• Artemether/lumefantrine (Coartem®) 20/120 

mg per tab, 4 tablets as a single initial dose, 4 

tablets again after 8 hours and then 4 tablets 

twice daily (morning and evening) for the 

following two days (total course of 24 tablets). 

(Coartem® is a registered trademark of Novartis 

AG). 

or

• Atovaquone-proguanil (AP) 250/100 mg per tab, 

4 tablets PO QD for 3 days. AP should not be 

used for treatment if the patient was taking the 

medication for chemoprophylaxis.

Alternatives: 

• Quinine 650 mg (2 tabs) PO three times per 

day (TID) for 3 days PLUS doxycycline 100 mg 

PO twice per day (BID) for 7 days. Substitute 

clindamycin (20 mg/kg/d divided TID for 7 days) for 

doxycycline in pregnant women.

 or

• Mefloquine 750 mg once followed by 500 mg 8-12 

hours later.
45 

Complicated (Severe) Malaria

Complicated malaria is a medical emergency 

requiring immediate treatment and prompt 

evacuation to an appropriate high level of care. 

Most treatment options require a baseline 

electrocardiogram and blood pressure, glucose, 

and cardiac monitoring. 

Patients presenting with any of the clinical 

manifestations listed in Table 1 (page 37) should be 

treated for complicated malaria.

• Start treatment as soon as diagnosis is suspected 

as conditions allow.

• Calculate dosage according to patient weight.

• Give medication intravenously.

• Give loading dose of medication per treatment 

regimen (below).

• If patient is comatose, place on his/her side and 

give lorazepam or diazepam to prevent seizures.

• Measure parasite count and hematocrit every 6-12 

hours.

• Switch to oral medication as soon as patient can 

tolerate tablets and response to treatment is 

confirmed.

• Observe patients carefully for drug toxicity and 

complications.
46 

The treatment of confirmed or suspected severe 

malaria in Sub-Saharan Africa is a significant 

challenge. As prompt therapy is critical to survival, 

you should use whichever intravenous antimalarial 

medication is readily available. The only FDAapproved drug with an indication to treat severe 

malaria is intravenous quinidine but intravenous 

artesunate is available through the CDC under a 

treatment protocol (and locally in Europe and Africa). 

Intravenous (IV) artesunate has been shown to reduce 

complications and mortality compared to IV quinine, 

which is a stereoisomer of quinidine. Unfortunately, IV 

quinidine gluconate is often not available and carries 

a risk of severe adverse events such as cardiac 

dysrhythmias leading to sudden cardiac death if used 

improperly in settings without cardiac monitoring 

capability.

Complicated (severe) malaria is usually treated in the 

U.S. with one of the quinidine regimens:

• Quinidine gluconate: 6.25 mg base/kg (10 mg salt/

kg) loading dose IV over 1-2 hours, then 0.0125 

mg base/kg/min (0.02 mg salt/kg/min) continuous 

infusion for at least 24 hours.

• Alternative quinidine gluconate regimen: 15 mg 

base/kg (24 mg salt/kg) loading dose IV infused 

over 4 hours, followed by 7.5 mg base/kg (12 mg 

salt/ kg) infused over 4 hours every 8 hours.

• Continue treatment until the parasitemia is < 1% 

and patient can take oral medications (switch to 

quinine sulfate and doxycycline regimen).
47 

• Caution: Do not give a quinidine loading dose if the 

patient has received more than 40 mg/kg of quinine 

in the preceding 48 hours or any mefloquine within 

the preceding 12 hours.

Quinidine is not readily available outside the U.S. or in 

U.S. medical facilities abroad. Drugs available outside 

the U.S. to treat severe malaria include intravenous 

quinine and intravenous artesunate (preferred). 

Many U.S. embassies stock IV artesunate and are 

preferred sources for this medication. 

• IV artesunate: 2.4 mg/kg initial dose (as IV push), 

then 2.4 mg/kg dose 12 hrs later, then 2.4 mg/

kg dose every 24 hrs for a total of 4 doses or until 

patient can tolerate oral medication. A full treatment 

course for chloroquine-resistant falciparum 

malaria should then be given. Infectious disease 

consultation is recommended. 

• IV quinine: 20 mg/kg loading dose over 4 hours, 

followed by 10 mg/kg every 8 hours given over 2 to 

4 hours.

• Caution: Do not give loading dose if patient has 

received quinidine or mefloquine in the last 24 

hours.
48 

Treatment of Relapsing Malaria 

P. vivax and P. ovale have dormant liver stage 

parasites (hypnozoites) which can reactivate 

(“relapse”) and cause malaria symptoms several 

months or years after initial infection.

Primaquine is the only available drug that can 

eradicate P. vivax and P. ovale hypnozoites.

Use of primaquine combined with another appropriate 

antimalarial to treat P. vivax or P. ovale infection 

is known as radical cure. Primaquine can cause 

severe hemolytic anemia in G6PD-deficient patients. 

Therefore the G6PD status of patients must be 

confirmed before treating with primaquine. Consult 

with a specialist regarding treatment of relapsing 

malaria in G6PD-deficient individuals.

Note: All malaria medications should be obtained 

from approved sources. NEVER procure malaria 

medications from local pharmacies or other local 

vendors due to very high levels of counterfeit and 

tainted products in developing countries.
disposition

The Prevention, Diagnosis and Treatment 

of Malaria in USAFRICOM

disposition
49 

Disposition

Duration of Illness

• Treated: 3-5 days in uncomplicated cases. P.

falciparum cases can worsen within the first 24 

hours of starting treatment and patients should 

be hospitalized. May recrudesce (recur) within 4 

weeks in cases of treatment failure. 

• Untreated: P. falciparum is rapidly fatal in untreated 

nonimmune patients. P. malariae is rarely fatal but 

may persist and recrudesce for years if not treated.

• Non-falciparum malaria is rarely fatal, but relapses 

can occur with P. vivax and P. ovale in up to 50% 

of cases without primaquine therapy. The majority 

of relapses occur several weeks to 1 year after 

the initial infection, but there are case reports of 

latency up to 8 years if persistent liver forms are 

not eliminated (see treatment tab: Treatment of 

Relapsing Malaria section).
50 

Complications and Sequelae

Uncomplicated malaria responds well to appropriate 

treatment and is rarely associated with complications 

or long-term sequelae.

Complicated (severe) malaria may be associated with 

significant complications and, even with aggressive 

treatment, may lead to long-term disability. Sequelae 

include persistent neurologic impairment, decreased 

renal function, and loss of spleen (surgical removal 

due to rupture). Severe anemia due to hemolysis has 

been reported after completion of intravenous malaria 

therapy, likely due to damage to erythrocytes.

Return to Duty

• For uncomplicated cases: local hospitalization for 

48-72 hours with limited duty for several days (until 

drug therapy is completed). Splenomegaly must be 

resolved before allowing the patient to return to full 

duty. 

• For complicated cases: patients should be 

evaluated on a case-by-case basis.

Air Evacuation

• Ensure plans are in place for rapid air evacuation 

to appropriate medical treatment facilities.
consult info

The Prevention, Diagnosis and Treatment 

of Malaria in USAFRICOM

consult info
51 

Consult Information

Malaria Prophylaxis, Diagnosis and Treatment

• Recommendations for malaria prevention and 

treatment are based on parasite drug susceptibility 

for a specific geographic setting. See CDC, http://

www.cdc.gov/malaria/diagnosis_treatment/index.

html and NCMI, https://www.intelink.gov/ncmi/

index.php

• Questions about malaria prophylaxis, diagnosis 

and treatment guidelines should be addressed 

to id.consult.army@mail.mil and pmom.consult.

army@mail.mil.

• Another resource is the CDC Malaria Hotline: (770) 

488-7788 Monday-Friday 0800-1630 EST or (770) 

488-7100 after hours, weekends and holidays.

Mosquito Control/Insect Repellent Questions 

• For questions about mosquito control/insect 

repellents and other unit protective measures 

contact the DoD Pesticide Hotline: (410) 436-3773/

DSN 584-3773 or email to usarmy.apg.medcomphc.mbx.pesticide-hotline@mail.mil.
52 
glossary

The Prevention, Diagnosis and Treatment 

of Malaria in USAFRICOM

glossary
53 

Glossary

Anemia - decrease in number of red blood cells and/ 

or quantity of hemoglobin. Malaria causes anemia 

through rupture of red blood cells.

Chemoprophylaxis - method of disease prevention by 

taking medication. Malaria chemoprophylaxis requires 

drugs to be taken before, during, and after exposure. 

Very effective, but not absolute because of drug 

resistance and poor compliance.

Dyspnea - shallow, labored breathing.

Erythrocyte - red blood cell.

Erythrocytic stage - the malaria parasite’s life cycle 

when infecting and developing within the red blood 

cells. 

Hematocrit - the amount of blood consisting of red 

blood cells, measured as a percentage. Measured 

after a blood sample has been centrifuged or allowed 

to settle. Normal hematocrit values: Males 39-49%; 

females 33-43%.

Hemolysis - the destruction of red blood cells. Malaria 

causes hemolysis when malaria parasites mature and 

rupture red blood cells they infected. 
54 

Hypnozoite - a stage of malaria parasites found in 

liver cells. After sporozoites invade liver cells, some 

develop into latent forms called hypnozoites. They 

become active months or years later, producing a 

recurrent malaria attack. Only P. vivax and P. ovale

species that infect humans develop latent stage 

hyponozoites. Primaquine is the only available drug 

active against hypnozoites.

Hypoglycemia - blood glucose less than the lower 

limit of normal (70-110 mg/dL [3.9-6.1 mmol/L in 

International System of Units (SI) reference units]). 

Glucose levels of 40 mg/dL and below constitute 

severe hypoglycemia, a life-threatening emergency. 

Hypoglycemia is common in malaria as parasitized 

RBCs utilize glucose 75 times faster than uninfected 

cells. In addition, treatment with quinine and quinidine 

stimulate insulin secretion, which further reduces 

blood glucose.

Hyponatremia - serum sodium less than the lower 

limit of normal, which is 135-147 milliequivalent 

per liter (mEq/L) (135-147 mmol/L in SI reference 

units). Hyponatremia can be seen in malaria and is 

indicative of complicated malaria. A serum sodium 

level approaching 120 mEq/L and below constitutes a 

severe medical emergency.

Hypotension - low blood pressure; see also orthostatic 

hypotension.

Jaundice - yellow discoloration of skin and eyes due to 

elevated blood levels of bilirubin. 
55 

Orthostatic hypotension - decrease in blood pressure 

occurring when an individual arises from a seated or 

lying position. A small decrease in blood pressure is 

normal, but large decreases are abnormal, especially 

if accompanied by clinical manifestations such as 

faintness, light-headness, dizziness, or increased 

pulse. Orthostatic hypotension is a common finding in 

patients with malaria infections. 

Recrudescence - a repeated attack of malaria 

(short-term relapse or delayed), due to the survival of 

malaria parasites in red blood cells. Characteristic of 

P. malariae infections. 

Recurrence - a repeated attack weeks, months, 

or sometimes years after initial malaria infection, 

also called a long-term relapse. Due to re-infection 

of RBCs from malaria parasites (hypnozoites) that 

persisted in liver cells. 

Relapse - a repeat attack of malaria.

Tachycardia - increased heart rate, defined as greater 

than 100 beats per minute.

Tachypnea - increased respiratory rate, defined as 

greater than 20 breaths per minute.

Thrombocytopenia - low platelet count, defined 

as less than 150,000. Low platelet counts can 

lead to impaired blood clotting, and counts below 

50,000 increase the risk of spontaneous bleeding. 

Thrombocytopenia is typical in malaria, though 

spontaneous bleeding is rare. 
56 

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