Editing Malaria (section)

==Treatment==
[[File:"British India", six stages of malaria. Wellcome L0022443.jpg|alt=Advertisement entitled "The Mosquito Danger". Includes 6 panel cartoon:#1 breadwinner has malaria, family starving; #2 wife selling ornaments; #3 doctor administers quinine; #4 patient recovers; #5 doctor indicating that quinine can be obtained from post office if needed again; #6 man who refused quinine, dead on stretcher.|thumb|An advertisement for [[quinine]] as a malaria treatment from 1927.]]

Malaria is treated with [[antimalarial medication]]s; the ones used depend on the type and severity of the disease.<ref>{{cite journal | vauthors = Hanboonkunupakarn B, White NJ | title = Advances and roadblocks in the treatment of malaria | journal = British Journal of Clinical Pharmacology | volume = 88 | issue = 2 | pages = 374–382 | date = February 2022 | pmid = 32656850 | pmc = 9437935 | doi = 10.1111/bcp.14474 | s2cid = 220502723 }}</ref> While [[antipyretics|medications against fever]] are commonly used, their effects on outcomes are not clear.<ref>{{cite journal | vauthors = Greenwood B | title = The use of anti-malarial drugs to prevent malaria in the population of malaria-endemic areas | journal = The American Journal of Tropical Medicine and Hygiene | volume = 70 | issue = 1 | pages = 1–7 | date = January 2004 | pmid = 14971690 | doi = 10.4269/ajtmh.2004.70.1 | url = https://researchonline.lshtm.ac.uk/id/eprint/14970/1/The%20use%20of%20anti-malarial%20drugs%20to%20prevent%20malaria%20in%20the%20population%20of%20malaria-endemic%20areas.pdf }}</ref><ref name="Meremikwu-2012b" /> Providing free antimalarial drugs to households may reduce childhood deaths when used appropriately. Programmes which presumptively treat all causes of fever with antimalarial drugs may lead to overuse of antimalarials and undertreat other causes of fever. Nevertheless, the use of malaria rapid-diagnostic kits can help to reduce over-usage of antimalarials.<ref>{{cite journal | vauthors = Okwundu CI, Nagpal S, Musekiwa A, Sinclair D | title = Home- or community-based programmes for treating malaria | journal = The Cochrane Database of Systematic Reviews | volume = 2013 | issue = 5 | pages = CD009527 | date = May 2013 | pmid = 23728693 | pmc = 6532579 | doi = 10.1002/14651858.CD009527.pub2 }}</ref><ref>{{cite web |title=Malaria-Malaria – Diagnosis & treatment |url=https://www.mayoclinic.org/diseases-conditions/malaria/diagnosis-treatment/drc-20351190 |website=Mayo Clinic |date=9 February 2023 }}</ref>

===Uncomplicated malaria===
Simple or uncomplicated malaria may be treated with oral medications. Artemisinin drugs are effective and safe in treating uncomplicated malaria.<ref>{{cite journal | vauthors = McIntosh HM, Olliaro P | title = Artemisinin derivatives for treating uncomplicated malaria | journal = The Cochrane Database of Systematic Reviews | volume = 1999 | issue = 2 | pages = CD000256 | date = 1999-04-26 | pmid = 10796519 | pmc = 6532741 | doi = 10.1002/14651858.CD000256 | collaboration = Cochrane Infectious Diseases Group }}</ref> Artemisinin in combination with other antimalarials (known as [[artemisinin-combination therapy]], or ACT) is about 90% effective when used to treat uncomplicated malaria.<ref name="Howitt-2012" /> The most effective treatment for ''P.&nbsp;falciparum'' infection is the use of ACT, which decreases resistance to any single drug component.<ref>{{cite journal | vauthors = Pousibet-Puerto J, Salas-Coronas J, Sánchez-Crespo A, Molina-Arrebola MA, Soriano-Pérez MJ, Giménez-López MJ, Vázquez-Villegas J, Cabezas-Fernández MT | title = Impact of using artemisinin-based combination therapy (ACT) in the treatment of uncomplicated malaria from Plasmodium falciparum in a non-endemic zone | journal = Malaria Journal | volume = 15 | issue = 1 | pages = 339 | date = July 2016 | pmid = 27368160 | pmc = 4930579 | doi = 10.1186/s12936-016-1408-1 | s2cid = 18043747 | doi-access = free }}</ref><ref name="Kokwaro-2009" /> Artemether-lumefantrine (six-dose regimen) is more effective than the artemether-lumefantrine (four-dose regimen) or other regimens not containing artemisinin derivatives in treating falciparum malaria.<ref>{{cite journal | vauthors = Omari AA, Gamble C, Garner P | title = Artemether-lumefantrine (four-dose regimen) for treating uncomplicated falciparum malaria | journal = The Cochrane Database of Systematic Reviews | volume = 2006 | issue = 2 | pages = CD005965 | date = April 2006 | pmid = 16625646 | pmc = 6532603 | doi = 10.1002/14651858.CD005965 | collaboration = Cochrane Infectious Diseases Group }}</ref><ref>{{cite journal | vauthors = Omari AA, Gamble C, Garner P | title = Artemether-lumefantrine (six-dose regimen) for treating uncomplicated falciparum malaria | journal = The Cochrane Database of Systematic Reviews | volume = 2005 | issue = 4 | pages = CD005564 | date = October 2005 | pmid = 16235412 | pmc = 6532733 | doi = 10.1002/14651858.CD005564 | collaboration = Cochrane Infectious Diseases Group }}</ref> Another recommended combination is [[dihydroartemisinin]] and [[piperaquine]].{{sfn|WHO|2015|p=9}}<ref name="Keating-2012" /><ref>{{cite journal | vauthors = Sinclair D, Zani B, Donegan S, Olliaro P, Garner P | title = Artemisinin-based combination therapy for treating uncomplicated malaria | journal = The Cochrane Database of Systematic Reviews | volume = 2009 | issue = 3 | pages = CD007483 | date = July 2009 | pmid = 19588433 | pmc = 6532584 | doi = 10.1002/14651858.CD007483.pub2 | collaboration = Cochrane Infectious Diseases Group }}</ref> Artemisinin-naphthoquine combination therapy showed promising results in treating falciparum malaria but more research is needed to establish its efficacy as a reliable treatment.<ref>{{cite journal | vauthors = Isba R, Zani B, Gathu M, Sinclair D | title = Artemisinin-naphthoquine for treating uncomplicated Plasmodium falciparum malaria | journal = The Cochrane Database of Systematic Reviews | volume = 2015 | issue = 2 | pages = CD011547 | date = February 2015 | pmid = 25702785 | pmc = 4453860 | doi = 10.1002/14651858.CD011547 | collaboration = Cochrane Infectious Diseases Group }}</ref> Artesunate plus mefloquine performs better than mefloquine alone in treating uncomplicated falciparum malaria in low transmission settings.<ref>{{cite journal | vauthors = Bukirwa H, Orton L | title = Artesunate plus mefloquine versus mefloquine for treating uncomplicated malaria | journal = The Cochrane Database of Systematic Reviews | volume = 2005 | issue = 4 | pages = CD004531 | date = October 2005 | pmid = 16235367 | pmc = 6532646 | doi = 10.1002/14651858.CD004531.pub2 | collaboration = Cochrane Infectious Diseases Group }}</ref> Atovaquone-proguanil is effective against uncomplicated falciparum with a possible failure rate of 5% to 10%; the addition of artesunate may reduce failure rate.<ref>{{cite journal | vauthors = Blanshard A, Hine P | title = Atovaquone-proguanil for treating uncomplicated Plasmodium falciparum malaria | journal = The Cochrane Database of Systematic Reviews | volume = 1 | issue = 1 | pages = CD004529 | date = January 2021 | pmid = 33459345 | pmc = 8094970 | doi = 10.1002/14651858.CD004529.pub3 }}</ref> Azithromycin monotherapy or combination therapy has not shown effectiveness in treating ''Plasmodium falciparum'' or ''Plasmodium vivax'' malaria.<ref>{{cite journal | vauthors = van Eijk AM, Terlouw DJ | title = Azithromycin for treating uncomplicated malaria | journal = The Cochrane Database of Systematic Reviews | volume = 2011 | issue = 2 | pages = CD006688 | date = February 2011 | pmid = 21328286 | pmc = 6532599 | doi = 10.1002/14651858.CD006688.pub2 | collaboration = Cochrane Infectious Diseases Group }}</ref> Amodiaquine plus sulfadoxine-pyrimethamine may achieve less treatment failures when compared to sulfadoxine-pyrimethamine alone in uncomplicated falciparum malaria.<ref>{{cite journal | vauthors = McIntosh HM, Jones KL | title = Chloroquine or amodiaquine combined with sulfadoxine-pyrimethamine for treating uncomplicated malaria | journal = The Cochrane Database of Systematic Reviews | volume = 2005 | issue = 4 | pages = CD000386 | date = October 2005 | pmid = 16235276 | pmc = 6532604 | doi = 10.1002/14651858.CD000386.pub2 | collaboration = Cochrane Infectious Diseases Group }}</ref> There is insufficient data on chlorproguanil-dapsone in treating uncomplicated falciparum malaria.<ref>{{cite journal | vauthors = Amukoye E, Winstanley PA, Watkins WM, Snow RW, Hatcher J, Mosobo M, Ngumbao E, Lowe B, Ton M, Minyiri G, Marsh K | title = Chlorproguanil-dapsone: effective treatment for uncomplicated falciparum malaria | journal = Antimicrobial Agents and Chemotherapy | volume = 41 | issue = 10 | pages = 2261–2264 | date = October 1997 | pmid = 9333058 | pmc = 164103 | doi = 10.1128/AAC.41.10.2261 }}</ref><ref>{{cite journal | vauthors = Bukirwa H, Garner P, Critchley J | title = Chlorproguanil-dapsone for treating uncomplicated malaria | journal = The Cochrane Database of Systematic Reviews | volume = 2004 | issue = 4 | pages = CD004387 | date = October 2004 | pmid = 15495106 | pmc = 6532720 | doi = 10.1002/14651858.CD004387.pub2 | collaboration = Cochrane Infectious Diseases Group }}</ref> The addition of primaquine with artemisinin-based combination therapy for falciparum malaria reduces its transmission at day 3–4 and day 8 of infection.<ref>{{cite journal | vauthors = Graves PM, Choi L, Gelband H, Garner P | title = Primaquine or other 8-aminoquinolines for reducing Plasmodium falciparum transmission | journal = The Cochrane Database of Systematic Reviews | volume = 2018 | issue = 2 | pages = CD008152 | date = February 2018 | pmid = 29393511 | pmc = 5815493 | doi = 10.1002/14651858.CD008152.pub5 | collaboration = Cochrane Infectious Diseases Group }}</ref> Sulfadoxine-pyrimethamine plus artesunate is better than sulfadoxine-pyrimethamine plus amodiaquine in controlling treatment failure at day 28. However, the latter is better than the former in reducing gametocytes in blood at day 7.<ref>{{cite journal | vauthors = Bukirwa H, Critchley J | title = Sulfadoxine-pyrimethamine plus artesunate versus sulfadoxine-pyrimethamine plus amodiaquine for treating uncomplicated malaria | journal = The Cochrane Database of Systematic Reviews | volume = 2006 | issue = 1 | pages = CD004966 | date = January 2006 | pmid = 16437507 | pmc = 6532706 | doi = 10.1002/14651858.CD004966.pub2 | collaboration = Cochrane Infectious Diseases Group }}</ref>

Infection with ''P.&nbsp;vivax'', ''P.&nbsp;ovale'' or ''P.&nbsp;malariae'' usually does not require hospitalisation. Treatment of ''P.&nbsp;vivax'' malaria requires both elimination of the parasite in the blood with chloroquine or with artemisinin-based combination therapy and clearance of parasites from the liver with an [[8-aminoquinoline]] agent such as [[primaquine]] or [[tafenoquine]].<ref name="Waters-2011" /><ref>{{cite journal | vauthors = Rodrigo C, Rajapakse S, Fernando D | title = Tafenoquine for preventing relapse in people with Plasmodium vivax malaria | journal = The Cochrane Database of Systematic Reviews | volume = 9 | issue = 9 | pages = CD010458 | date = September 2020 | pmid = 32892362 | pmc = 8094590 | doi = 10.1002/14651858.CD010458.pub3 }}</ref> These two drugs act against blood stages as well, the extent to which they do so still being under investigation.<ref>{{cite journal | vauthors = Markus MB | title = Putative Contribution of 8-Aminoquinolines to Preventing Recrudescence of Malaria | journal = Tropical Medicine and Infectious Disease | volume = 8 | issue = 5 | page = 278 | date = May 2023 | pmid = 37235326 | pmc = 10223033 | doi = 10.3390/tropicalmed8050278 | doi-access = free }}</ref>

To treat malaria during pregnancy, the [[World Health Organization|WHO]] recommends the use of quinine plus [[clindamycin]] early in the pregnancy (1st trimester), and ACT in later stages (2nd and 3rd trimesters).<ref>{{cite journal | vauthors = Tarning J | title = Treatment of Malaria in Pregnancy | journal = The New England Journal of Medicine | volume = 374 | issue = 10 | pages = 981–982 | date = March 2016 | pmid = 26962733 | doi = 10.1056/NEJMe1601193 | url = https://ora.ox.ac.uk/objects/uuid:e67b1397-c8ed-493f-a61e-f265d8a41c11 | access-date = 2023-01-15 | url-status = live | doi-access = free | archive-url = https://web.archive.org/web/20230426202218/https://ora.ox.ac.uk/objects/uuid:e67b1397-c8ed-493f-a61e-f265d8a41c11 | archive-date = 2023-04-26 }}</ref><ref name="Manyando-2012" /> There is limited safety data on the antimalarial drugs in pregnancy.<ref>{{cite journal | vauthors = Orton LC, Omari AA | title = Drugs for treating uncomplicated malaria in pregnant women | journal = The Cochrane Database of Systematic Reviews | volume = 2008 | issue = 4 | pages = CD004912 | date = October 2008 | pmid = 18843672 | pmc = 6532683 | doi = 10.1002/14651858.CD004912.pub3 | collaboration = Cochrane Infectious Diseases Group }}</ref>

===Severe and complicated malaria===
Cases of severe and complicated malaria are almost always caused by infection with ''P. falciparum''. The other species usually cause only febrile disease.<ref>{{cite journal | vauthors = Kochar DK, Saxena V, Singh N, Kochar SK, Kumar SV, Das A | title = Plasmodium vivax malaria | journal = Emerging Infectious Diseases | volume = 11 | issue = 1 | pages = 132–134 | date = January 2005 | pmid = 15705338 | pmc = 3294370 | doi = 10.3201/eid1101.040519 }}</ref> Severe and complicated malaria cases are medical emergencies since mortality rates are high (10% to 50%).<ref>{{cite journal | vauthors = Pasvol G | title = The treatment of complicated and severe malaria | journal = British Medical Bulletin | volume = 75–76 | pages = 29–47 | date = 2005 | pmid = 16495509 | doi = 10.1093/bmb/ldh059 | doi-access = free }}</ref>

Recommended treatment for severe malaria is the [[Parenteral administration|intravenous]] use of antimalarial drugs. For severe malaria, [[parenteral]] artesunate was superior to quinine in both children and adults.<ref>{{cite web |publisher=Centers for Disease Control and Prevention |date=2022-04-11 |title=Malaria – Diagnosis & Treatment (United States) – Treatment (U.S.) – Artesunate dose 400 mg oral |url=https://www.cdc.gov/malaria/diagnosis_treatment/artesunate.html |access-date=2022-04-25 |language=en-US |archive-date=2016-10-29 |archive-url=https://web.archive.org/web/20161029044719/https://www.cdc.gov/malaria/diagnosis_treatment/artesunate.html |url-status=live }}</ref><ref name="Sinclair-2012" /> In another systematic review, artemisinin derivatives (artemether and arteether) were as efficacious as quinine in the treatment of cerebral malaria in children.<ref>{{cite journal | vauthors = Kyu HH, Fernández E | title = Artemisinin derivatives versus quinine for cerebral malaria in African children: a systematic review | journal = Bulletin of the World Health Organization | volume = 87 | issue = 12 | pages = 896–904 | date = December 2009 | pmid = 20454480 | pmc = 2789363 | doi = 10.2471/BLT.08.060327 | url = https://www.who.int/bulletin/volumes/87/12/08-060327/en/ | url-status = dead | archive-url = https://web.archive.org/web/20160304051023/http://www.who.int/bulletin/volumes/87/12/08-060327/en/ | archive-date = 2016-03-04 }}</ref> Treatment of severe malaria involves supportive measures that are best done in a [[critical care unit]]. This includes the management of [[hyperpyrexia|high fevers]] and the seizures that may result from it. It also includes monitoring for [[respiratory depression|poor breathing effort]], low blood sugar, and [[hypokalemia|low blood potassium]].<ref name="Sarkar-2009" /> Artemisinin derivatives have the same or better efficacy than quinolones in preventing deaths in severe or complicated malaria.<ref>{{cite journal | vauthors = McIntosh HM, Olliaro P | title = Artemisinin derivatives for treating severe malaria | journal = The Cochrane Database of Systematic Reviews | volume = 1998 | issue = 2 | pages = CD000527 | date = 1998-07-27 | pmid = 10796551 | pmc = 6532607 | doi = 10.1002/14651858.CD000527 | collaboration = Cochrane Infectious Diseases Group }}</ref> Quinine [[loading dose]] helps to shorten the duration of fever and increases parasite clearance from the body.<ref>{{cite journal | vauthors = Lesi A, Meremikwu M | title = High first dose quinine regimen for treating severe malaria | journal = The Cochrane Database of Systematic Reviews | volume = 2004 | issue = 3 | pages = CD003341 | date = 2004-07-19 | pmid = 15266481 | pmc = 6532696 | doi = 10.1002/14651858.CD003341.pub2 | collaboration = Cochrane Infectious Diseases Group }}</ref> There is no difference in effectiveness when using intrarectal quinine compared to intravenous or intramuscular quinine in treating uncomplicated/complicated falciparum malaria.<ref>{{cite journal | vauthors = Eisenhut M, Omari AA | title = Intrarectal quinine versus intravenous or intramuscular quinine for treating Plasmodium falciparum malaria | journal = The Cochrane Database of Systematic Reviews | volume = 2009 | issue = 1 | pages = CD004009 | date = January 2009 | pmid = 19160229 | pmc = 6532585 | doi = 10.1002/14651858.CD004009.pub3 | collaboration = Cochrane Infectious Diseases Group }}</ref> There is insufficient evidence for intramuscular arteether to treat severe malaria.<ref>{{cite journal | vauthors = Afolabi BB, Okoromah CN | title = Intramuscular arteether for treating severe malaria | journal = The Cochrane Database of Systematic Reviews | volume = 2004 | issue = 4 | pages = CD004391 | date = October 2004 | pmid = 15495107 | pmc = 6532577 | doi = 10.1002/14651858.CD004391.pub2 | collaboration = Cochrane Infectious Diseases Group }}</ref> The provision of rectal artesunate before transfer to hospital may reduce the rate of death for children with severe malaria.<ref>{{cite journal | vauthors = Okebe J, Eisenhut M | title = Pre-referral rectal artesunate for severe malaria | journal = The Cochrane Database of Systematic Reviews | volume = 2014 | issue = 5 | pages = CD009964 | date = May 2014 | pmid = 24869943 | pmc = 4463986 | doi = 10.1002/14651858.CD009964.pub2 | collaboration = Cochrane Infectious Diseases Group }}</ref> In children with malaria and concomitant hypoglycaemia, sublingual administration of glucose appears to result in better increases in blood sugar after 20 minutes when compared to oral administration, based on very limited data.<ref>{{cite journal | vauthors = De Buck E, Borra V, Carlson JN, Zideman DA, Singletary EM, Djärv T | title = First aid glucose administration routes for symptomatic hypoglycaemia | journal = The Cochrane Database of Systematic Reviews | volume = 2019 | issue = 4 | pages = CD013283 | date = April 2019 | pmid = 30973639 | pmc = 6459163 | doi = 10.1002/14651858.CD013283.pub2 | collaboration = Cochrane Metabolic and Endocrine Disorders Group }}</ref>

Cerebral malaria is the form of severe and complicated malaria with the worst neurological symptoms.<ref>{{cite journal | vauthors = Idro R, Marsh K, John CC, Newton CR | title = Cerebral malaria: mechanisms of brain injury and strategies for improved neurocognitive outcome | journal = Pediatric Research | volume = 68 | issue = 4 | pages = 267–274 | date = October 2010 | pmid = 20606600 | pmc = 3056312 | doi = 10.1203/pdr.0b013e3181eee738 }}</ref> There is insufficient data on whether osmotic agents such as mannitol or urea are effective in treating cerebral malaria.<ref>{{cite journal | vauthors = Okoromah CA, Afolabi BB, Wall EC | title = Mannitol and other osmotic diuretics as adjuncts for treating cerebral malaria | journal = The Cochrane Database of Systematic Reviews | volume = 2011 | issue = 4 | pages = CD004615 | date = April 2011 | pmid = 21491391 | pmc = 4018680 | doi = 10.1002/14651858.CD004615.pub3 | collaboration = Cochrane Infectious Diseases Group }}</ref> Routine phenobarbitone in cerebral malaria is associated with fewer [[convulsion]]s but possibly more deaths.<ref>{{cite journal | vauthors = Meremikwu M, Marson AG | title = Routine anticonvulsants for treating cerebral malaria | journal = The Cochrane Database of Systematic Reviews | volume = 2002 | issue = 2 | pages = CD002152 | date = 2002-04-22 | pmid = 12076440 | pmc = 6532751 | doi = 10.1002/14651858.CD002152 | collaboration = Cochrane Infectious Diseases Group }}</ref> There is no evidence that steroids would bring treatment benefits for cerebral malaria.<ref>{{cite journal | vauthors = Prasad K, Garner P | title = Steroids for treating cerebral malaria | journal = The Cochrane Database of Systematic Reviews | volume = 1999 | issue = 2 | pages = CD000972 | date = 1999-07-26 | pmid = 10796562 | pmc = 6532619 | doi = 10.1002/14651858.CD000972 | collaboration = Cochrane Infectious Diseases Group }}</ref>

===Managing cerebral malaria===
Cerebral malaria usually makes a patient comatose. If the cause of the coma is in doubt, testing for other locally prevalent causes of encephalopathy (bacterial, viral or fungal infection) should be carried out. In areas where there is a high prevalence of malaria infection (e.g. tropical region) treatment can start without testing first.<ref name="US CDC-2022"/> To manage the cerebral malaria when confirmed the following can be done:

* People who are in coma should be given meticulous nursing care ( monitor vital signs, turn patient every 2 hours, avoid lying the patient in a wet bed etc.)
* A sterile urethral catheter should be inserted to help with urinating
* To aspirate stomach content, a sterile nasogastric tube should be inserted.
* In the occasion of convulsions, a slow intravenous injection of benzodiazepine is administered.<ref>{{cite book |title=A Practical Handbook (third edition) Management Of Severe Malaria |publisher=[[World Health Organization]] |year=2012 |isbn=9789241548526 |pages=43–44}}</ref>

There is insufficient evidence to show that blood transfusion is useful in either reducing deaths for children with severe anaemia or in improving their [[haematocrit]] in one month.<ref>{{cite journal | vauthors = Meremikwu M, Smith HJ | title = Blood transfusion for treating malarial anaemia | journal = The Cochrane Database of Systematic Reviews | volume = 1999 | issue = 2 | pages = CD001475 | date = 1999-10-25 | pmid = 10796646 | pmc = 6532690 | doi = 10.1002/14651858.CD001475 | collaboration = Cochrane Infectious Diseases Group }}</ref> There is insufficient evidence that iron chelating agents such as deferoxamine and deferiprone improve outcomes of those with malaria falciparum infection.<ref>{{cite journal | vauthors = Smith HJ, Meremikwu M | title = Iron chelating agents for treating malaria | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD001474 | date = 2003-04-22 | pmid = 12804409 | pmc = 6532667 | doi = 10.1002/14651858.CD001474 | collaboration = Cochrane Infectious Diseases Group }}</ref>

===Monoclonal antibodies===
A 2022 clinical trial shows that a monoclonal antibody [[mAb L9LS]] offers protection against malaria. It binds the ''Plasmodium falciparum'' circumsporozoite protein (CSP-1), essential to disease, and makes it ineffective.<ref name="Nature Biotech-2022">{{cite journal | vauthors =  | title = Lab-made antibody stops malaria | journal = Nature Biotechnology | volume = 40 | issue = 9 | pages = 1304 | date = September 2022 | pmid = 36085505 | doi = 10.1038/s41587-022-01480-2 | s2cid = 252181345 }}</ref>

===Resistance===
[[Drug resistance]] poses a growing problem in 21st-century malaria treatment.<ref name="Sinha-2014" /> In the 2000s (decade), malaria with partial resistance to artemisins emerged in Southeast Asia.<ref name="O'Brien-2011" /><ref name="Fairhurst-2012" /> Resistance is now common against all classes of antimalarial drugs apart from [[artemisinin]]s. Treatment of resistant strains became increasingly dependent on this class of drugs. The cost of artemisinins limits their use in the developing world.<ref name="White-2008" /> Malaria strains found on the Cambodia–Thailand border are resistant to combination therapies that include artemisinins, and may, therefore, be untreatable.<ref name="Wongsrichanalai-2008" /> Exposure of the parasite population to artemisinin monotherapies in subtherapeutic doses for over 30 years and the availability of substandard artemisinins likely drove the selection of the resistant phenotype.<ref name="Dondorp-2010" /> Resistance to artemisinin has been detected in Cambodia, Myanmar, Thailand, and Vietnam,<ref>{{cite journal|author=World Health Organization |title=Q&A on artemisinin resistance |journal=WHO Malaria Publications |year=2013 |url=https://www.who.int/malaria/media/artemisinin_resistance_qa/en/index.html |url-status=dead |archive-url=https://web.archive.org/web/20160720075407/http://www.who.int/malaria/media/artemisinin_resistance_qa/en/index.html |archive-date=2016-07-20 }}</ref> and there has been emerging resistance in Laos.<ref name="Briggs-2014">{{cite news|vauthors=Briggs H|date=2014-07-30|title=Call for 'radical action' on drug-resistant malaria|language=en-GB|work=BBC News|url=https://www.bbc.com/news/health-28569966|access-date=2023-02-23|archive-date=2023-02-23|archive-url=https://web.archive.org/web/20230223035718/https://www.bbc.com/news/health-28569966|url-status=live}}</ref><ref name="Ashley-2014" /> Resistance to the combination of artemisinin and piperaquine was first detected in 2013 in Cambodia, and by 2019 had spread across Cambodia and into [[Laos]], [[Thailand]] and [[Vietnam]] (with up to 80 percent of malaria parasites resistant in some regions).<ref>{{cite news|url=https://www.bbc.com/news/health-49017699|title=Resistant malaria spreading in South East Asia|vauthors=Gallagher J|date=2019-07-23|access-date=2019-07-25|language=en-GB|archive-date=2019-07-24|archive-url=https://web.archive.org/web/20190724221856/https://www.bbc.com/news/health-49017699|url-status=live}}</ref>

There is insufficient evidence in unit packaged antimalarial drugs in preventing treatment failures of malaria infection. However, if supported by training of healthcare providers and patient information, there is improvement in compliance of those receiving treatment.<ref>{{cite journal | vauthors = Orton L, Barnish G | title = Unit-dose packaged drugs for treating malaria | journal = The Cochrane Database of Systematic Reviews | volume = 2005 | issue = 2 | pages = CD004614 | date = April 2005 | pmid = 15846723 | pmc = 6532754 | doi = 10.1002/14651858.CD004614.pub2 | collaboration = Cochrane Infectious Diseases Group }}</ref>