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Severe falciparum malaria
World Health Organization, Communicable Diseases Cluster, 1211 Geneva 27, Switzerland
Introduction
The current knowledge of severe malaria was re-
viewed at informal technical meetings convened by the
World Health Organization (WHO)-in Kuala Lumpur,
Malavsia in 1985 and in Geneva. Switzerland in 1988.
These meetings resulted in thepublication of two edi-
tions of Severe and Complicated Malaria (Transactions of
the Royal Society of Tropical Medicine and Hygiene, vol.
80, supplement, 1986, and vol. 84, supplement 2, 1990
[also translated into French]), a publication entitled
Management of Severe and Complicated Malaria, A Erac-
tical Handbook (Geneva: WHO, 1991), the develop-
ment of guidelines for health care workers in tropical
Africa in 1992, and a training module for medical and
nursing professionals.
A further meeting, sponsored by WHO, was held on
4-8 December 1995 in Geneva. The purpose was to re-
view in great detail the latest scientific evidence for, and
practical experience in, the clinical management of se-
vere malaria in children, adults and pregnant women.
This present publication is based on that meeting and
subsequent discussion and correspondence with leaders
in this field.
Contributors
Professor I? F. Beales. Facultv of Tronical Medicine. Mahidol
University, Thailand, and’ Liverpbol School of Tropical
Medicine, Liverpool, UK.
Dr B. Brabin, Liverpool School of Tropical Medicine, Liver-
0001. UK.
D; E. Dorman, Wellcome Trust Laboratories, Kenya Medical
Research Institute (KEMRI) Coastal Unit, Kilifi, Kenya.
Professor H. M. Gilles, Department of Pharmacology and
Therapeutics, University of Liverpool, Liverpool, UK.
Dr L. Loutain, Community Medicine Unit, Cantonal Hospi-
tal, University of Geneva, Geneva, Switzerland.
Professor K. Marsh, KEMRI Clinical Research Centre,
(CRC), Kilifi Research Unit, Kilifi, Kenya.
Professor M. E. Molyneux, Malaria Project and Wellcome
Trust Centre, College of Medicine, Blantyre, Malawi and
University of Liverpool, Liverpool, UK
Dr I? Olliaro, UNDPNlrorld Bank/World Health Organization
Special Programme for Research and Training in Tropical
Diseases, WHO, Geneva, Switzerland.
Dr A. Schapira, WHO Malaria Control Programme, Hanoi,
Socialist Republic ofViet Nam.
Professor J.-E. Touze, Tropical Medical Institute for the
French Army, Laveran’s Hospital, Marseille, France.
Dr Tran Tinh Hien, Centre for Tropical Diseases, Cho Quan
Hosnital. Ho Chi Minh Citv.Viet Nam.
Profes$or 6. A. Warrell, Centrefor Tropical Medicine, Univer-
sity of Oxford, John Radcliffe Hospital, Headington, Ox-
ford, UK.
Professor N. White, Faculty of Tropical Medicine, Mahidol
University, Bangkok,Thailand.
Acknowledgements
The following persons and organizations supported the meet-
ing in 1995 and the preparation of this publication on behalf
ofWHO.
Dr Kazem Behbehani, Director, Division of Control ofTropi-
cal Diseases, WHO, Geneva, Switzerland.
Dr A. Bosman, Medical Officer, Malaria, Division of Control
ofTropical Diseases, WHO, Geneva, Switzerland.
Mrs E. M. Jordan,Training Unit, Division of Control ofTrop-
ical Diseases, WHO, Geneva, Switzerland.
Dr A. V. Kondrachine, Chief, Malaria, Division of Control of
Tropical Diseases, WHO, Geneva, Switzerland.
Dr E. A. Renganathan, Chief, Training Unit, Division of Con-
trol ofTropical Diseases, WHO, Geneva, Switzerland.
Dr F. A. Rio, Medical Officer,Training, Division of Control of
Tropical Diseases,WHO, Geneva, Switzerland.
Dr l? I. Trigg, Scientist, Malaria, Division of Control ofTrop-
ical Diseases, WHO, Geneva, Switzerland.
This publication was compiled and edited for the
World Health Organization by Professor P. F. Beales
and Professor D. A. Warrell, and edited for the Royal
Society of Tropical Medicine and Hygiene by Dr J. R.
Baker. It is recommended that it be cited in the follow-
ing style: World Health Organization [or WHO] (2000).
Severe falciparum malaria. Transactions of the Royal So-
ciety of Tropical Medicine and Hygiene, 94, supplement 1.
Definition of severe fakiparum malaria
Almost all of the estimated >l million deaths from
malaria each year world-wide are attributable to Plasmo-
dium falciparum.
Any patient with malaria who is unable to swallow
tablets, has any evidence of vital organ dysfunction, or a
high parasite count is at increased risk of dying. The ex-
act risk depends on the degree of abnormality, age,
background immunity, and access to appropriate treat-
ment. A strict definition of severe malaria has been in-
cluded in this and previous editions to assist clinical and
epidemiological descriptions. In clinical practice the pa-
tient must be assessed and treated immediately. The
parasite count, haematocrit, haemoglobin and blood
glucose levels may all be available immediately, but oth-
er laboratory indices will take time to obtain, and treat-
ment should not depend on fulfilling these criteria, or
waiting for all laboratory results to be available. As se-
vere malaria is a potentially fatal but treatable disease,
any patient considered at increased risk should be given
the benefit of the highest level of care available.
The purpose of attempting to define and describe se-
vere falcinarum malaria is twofold. First. to alert clini-
I
cians and other health care workers to the symptoms
and signs which are associated with progression to life-
threatening disease. Second, to indicate the clinical fea-
tures which should be looked for and systematically re-
corded in any research study of severe falciparum
malaria.
The appropriateness of any definition will vary with
the use to which it is to be nut. the facilities available
and the clinical spectrum of-disease in any given envi-
ronment. Thus a definition that seeks to measure the
clinical load on a health service needs to be broad and
inclusive whereas a definition used to identify groups for
studies of pathogenesis needs to be precise and exclu-
sive in order to achieve homogeneity.
Despite these difficulties, and accepting that defini-
tions are always likely to be controversial, we consider it
appropriate, useful and thought provoking to attempt to
define and to describe what is generally meant by severe
falciparum malaria.
Those at risk
In parts of the world where endemicity of falciparum
malaria is stable, severe malaria is mainly a disease of
children from the first few months of life to the age of 5
years. It is less common in older children and adults, be-
cause of the acquisition of partial immunity. In areas of
lower endemicity, severe malaria occurs in both adults
and children. Non-immune travellers and migrant
workers are also vulnerable to severe malaria. There are
important differences in the clinical spectrum of severe
malaria with age. In the following sections the same ba-
sic definition of severe disease is used and the accompa-
nying notes specify differences between children and
adults.
Severe manifestationsof I? falciparum malaria
In a patient with l? falciparum asexual parasitaemia