Malaria facts and situation
Malaria is endemic throughout Guinea. Malaria is the leading cause of clinical consultations, hospitalizations, and hospital deaths in the country. It is also the biggest killer of children under five years of age (about 17 percent in the 2021 Multiple Indicator Cluster Survey (MIS)). High regional variation in malaria parasitemia prevalence continues, with high prevalence in some regions. The overarching goal of the National Malaria Strategic Plan (NMSP) 2018–2023 is to bring Guinea toward pre-elimination by reducing malaria morbidity and mortality by 75 percent from 2016 to 2023.
Malaria is endemic throughout Guinea, and the country is among the 17 highest burden malaria countries in the world (1.8% of all global malaria cases, and 1.6% of global malaria deaths in 2020 ). It accounts for 4% of malaria cases in West Africa.
The country has made important progress in malaria control and prevention, substantially reducing malaria prevalence in children under five years of age, annual malaria incidence, and in-patient deaths. Between 2020 and 2021, the case burden for malaria fell by 1% (from 334 to 331 per 1000 of the population at risk), while deaths decreased by 7.4% (from 0.75 to 0.70 per 1000 of the population at risk. 
These gains were driven by the rapid scale-up of malaria prevention and control interventions, led by the country’s National Malaria Control Programme (NMCP) and supported by the US President’s Malaria Initiative (PMI) and the Global Fund to Fight AIDS, Tuberculosis and Malaria.
There are two areas in Guinea where malaria is endemic (MICS 2016): a moderate transmission area, which covers five regions of the country and 63 % of the general population, and a low transmission area, which covers three regions, including the capital Conakry and 37 % of the population. 
The major vector of malaria is Anopheles gambiaes sensu lato, which is found throughout the country, with its density peaking in the rainy season, from June to October. The dominant plasmodium species is Plasmodium falciparum, at 96.5 %; P. malariae and P. ovale represent 3.3 % and 0.13 %, respectively. 
The percentage of malaria infections in children under 5 years and pregnant women between 2017 and 2019 were 37.3 % and 3.9 %, respectively.  According to routine NMCP data, the, compared with overall malaria morbidity. According to the 2018 DHS, 30 % of children under 5 years are stunted and 9 % are acutely malnourished, while 46 % of women of childbearing age are anaemic. 
Malaria case management is planned at the central level and implemented in all hospitals, health centers, health posts, and at the community level. The country’s malaria case management policy is to test first and, if the case is positive, treat. However, there are rare cases in which a case is treated without previous testing.
Furthermore, people who face difficulties in accessing health services are groups at increased risk of malaria. These include mobile populations and people who live in isolated areas or a long way from health care facilities. These groups include populations living in the mining areas of Kankan and Faranah, and the communities who live around the coastal areas. 
In collaboration with partners, NMCP revised the national guidelines for the fight against malaria in the context of COVID-19. This revised tool will serve as a reference document to guide the interventions of the implementing actors as well as the beneficiaries. The differential diagnosis between malaria and coronavirus disease is a major concern for providers because of the similarity of signs (e.g., fever, headache, muscle aches, etc.). Consequently, any patient received in health facilities or at the community level must be considered as both a suspected COVID-19 and a suspected malaria case.
Artemisinin-based combination therapies (ACTs) were introduced into national policy in 2005. The guidelines are to treat any case of severe malaria with artemisinin derivatives or parenteral quinine salts. As soon as the oral route is possible, the treatment should be done with ACTs. The management of severe malaria must be carried out in health facilities with capacities for adequate treatment. Any case of severe malaria in pregnant women should be treated with parenteral quinine during the first trimester of pregnancy, and artemisinin derivatives or parenteral quinine salts in the second and third trimesters. 
All cases of severe malaria seen in a health facility without adequate management capacity should benefit from specific pre-transfer management with artemisinin derivatives intramuscularly or as a rectal capsule before being referred. Children between six months and six years of age seen at the community level (RECOs trained on malaria) should benefit from specific pre-transfer management with rectal artesunate before being referred to the nearest health facility.
Prevention of malaria
Between 2012 and 2016, there were significant improvements in the use of insecticide-treated nets (ITNs) by vulnerable populations. The use by children under five years increased from 26% to 68% and use by pregnant women from 28% to 70%.  However, a dramatic decline in use was observed between 2016 and 2018 – household ownership fell from 84% to 44%, and the use by vulnerable populations returned to 2012 levels.
A nationwide ITN distribution mass campaign was implemented in 2019. The Against Malaria Foundation (AMF) supported this campaign by donating 5 million ITNs, which were distributed in 20 of the 38 districts in Guinea. A post-distribution evaluation, carried out 18 months after the 2019 campaign, showed that on average 85 percent of ITNs distributed were present in households.
Guinea began implementing seasonal malaria chemoprevention (SMC) in 2015 in six health prefectures in the northern part of the country, representing a total population of 2.2 million.  The number of prefectures has gradually been expanded and SMC is currently implemented in 13 districts found to be meeting the criteria for the implementation of SMC (chosen by the NMCP). The SMC activities in eight of the prefectures are supported by PMI, while the other 5 are supported by the Global Fund. 
SMC implementation in Guinea comprises four cycles of the distribution of sulfadoxine-pyrimethamine and amodiaquine (SPAQ) to all children 3–59 months old. Each cycle of distribution lasts between four and five days and is done on a monthly basis between July and October, representing the highest transmission period in the area. . Recently, a pilot program, testing one additional cycle of SMC started in one of the districts. This implies starting the season earlier in June based on the rain falls and incidence peak data and the additional impact on malaria indicators is been explored.
Malaria in pregnancy
Guinea has among the highest maternal mortality rates in sub-Saharan Africa, at 679 per 100,000 women. Malaria in pregnancy (MIP) services are available in communal medical centers, improved health centers, and some integrated health posts. The national malaria strategic plan recommends pregnant women receive at least three doses of intermittent preventive treatment for pregnant women (IPTp) on a monthly basis, starting at the 13th week of the pregnancy until childbirth. The health workers providing MIP and antenatal (ANC) services have been trained by the Maternal Reproductive Health program at the request of NMCP. Those health workers are regularly supervised by NMCP and its partners.
Pregnant women receiving at least one dose of intermittent preventive treatment (IPTp) increased dramatically from 4 percent in 2005 to 79 percent in 2018. There is however a large gap between women who receive one dose and those who receive the recommended three doses. Just about 50 percent of pregnant women receive IPTp3 according to the 2021 malaria indicator survey. 
Women receiving at least three doses of malaria preventive treatment or IPTp during pregnancy have risen to 50 percent in 2021 from 11 percent in 2012 and 36 percent in 2018. Insecticide-treated mosquito nets (ITNs) were used by 39 percent of pregnant women, up from 28 percent in the two previous surveys.
The national strategy states that all cases of severe malaria in pregnant women should be treated with parenteral quinine during the first trimester of pregnancy, and intramuscular injection of artemisinin derivatives or parenteral quinine from the second trimester onward. The strategy follows WHO guidance regarding pregnant women who are HIV-positive.  Of note, the treatment guidelines for WHO also recommends using Inj AS also during the 1st trimester of pregnancy.
Women’s decisions pertaining to the use of mosquito nets, or where and when to access treatment for health services, is sometimes decided by male family members, especially if resources are required. Mothers-in-law can control the decisions of new daughters-in-law, particularly in relation to household care and health-related behaviors.
Digital management of health data
USAID/Guinea and other partners assisted the MOH to begin the adoption of the District Health Information System 2 (DHIS2) software to collect, analyze, and report in separate instances of DHIS2: 1) routine; and 2) case-based and weekly aggregate Integrated Disease Surveillance and Response (IDSR) health data. The NMCP and several partners support with the review of monthly data at the district level. However, monthly data quality at the health center level is sometimes inconsistent. This leads to challenges or delays in identifying, investigating, and responding.
To have visibility on the diverse malaria research projects in Guinea and to guide and prioritize activities based on NMCP’s strategy, the NMCP has created a research committee to coordinate malaria research activities.
Therapeutic efficacy studies (TES) are conducted every year in two out of the four fixed TES sentinel sites. Studies conducted to date in Guinea show very good efficacy of first line antimalarials, with polymerase chain reaction (PCR)-corrected or PCR-uncorrected efficacies above 90 percent in all arms to date. In 2022, pyronaridine–artesunate replaced artesunate-amodiaquine (AS/AQ) as the second treatment drug included in TES to reflect the national phase-out of AS/AQ.
The NMCP’s revised 2018–2023 Malaria Strategic Plan promotes SMC as a malaria prevention intervention in areas with highly seasonal malaria transmission. The NMCP case management objective, according to the extended 2018–2023 National Malaria Strategic Plan, is to ensure correct and early management of at least 90 percent of malaria cases.
There may be preliminary evidence on the selection of markers associated with amodiaquine resistance in SMC zones that requires further validation. There was no indication of high-level SP resistance in any of these four sites.
Challenges limiting access to healthcare
There is a prevailing perception that health-related information will not be kept confidential. Single mothers and teenage mothers are also susceptible to stigma and stereotyped treatment. What is more, widespread norms around masculinity prevent men from accessing healthcare and practicing appropriate health-seeking behaviors.
Informal and some formal payment schemes for healthcare limit access to services, with a disproportionate impact on women and adolescent girls. The limited number of female medical personnel affect female use of health services.
Policy and practice for treating severe malaria
|Injectable artesunate (IV or IM)