the ground. itns are beneficial towards pregnancy outcomes in malaria-endemic regions in africa but more data is needed in asia and latin america. in areas of high malaria resistance, piperonyl butoxide (pbo) combined with pyrethroids in mosquito netting is effective in reducing malaria infection rates. questions remain concerning the durability of pbo on nets as the impact on mosquito mortality was not sustained after twenty washes in experimental trials. indoor residual spraying indoor residual spraying is the spraying of insecticides on the walls inside a home. after feeding, many mosquitoes rest on a nearby surface while digesting the bloodmeal, so if the walls of houses have been coated with insecticides, the resting mosquitoes can be killed before they can bite another person and transfer the malaria parasite. as of 2006, the world health organization recommends 12 insecticides in irs operations, including ddt and the pyrethroids cyfluthrin and deltamethrin. this public health use of small amounts of ddt is permitted under the stockholm convention, which prohibits its agricultural use. one problem with all forms of irs is insecticide resistance. mosquitoes affected by irs tend to rest and live indoors, and due to the irritation caused by spraying, their descendants tend to rest and live outdoors, meaning that they are less affected by the irs. communities using insecticide treated nets, in addition to indoor residual spraying with 'non-pyrethroid-like' insecticides found associated reductions in malaria. additionally, the use of 'pyrethroid-like' insecticides in addition to indoor residual spraying did not result in a detectable additional benefit in communities using insecticide treated nets. housing modifications housing is a risk factor for malaria and modifying the house as a prevention measure may be a sustainable strategy that does not rely on the effectiveness of insecticides such as pyrethroids. the physical environment inside and outside the home that may improve the density of mosquitoes are considerations. examples of potential modifications include how close the home is to mosquito breeding sites, drainage and water supply near the home, availability of mosquito resting sites (vegetation around the home), the proximity to live stock and domestic animals, and physical improvements or modifications to the design of the home to prevent mosquitoes from entering. other mosquito control methods people have tried a number of other methods to reduce mosquito bites and slow the spread of malaria. efforts to decrease mosquito larvae by decreasing the availability of open water where they develop, or by adding substances to decrease their development, are effective in some locations. electronic mosquito repellent devices, which make very high-frequency sounds that are supposed to keep female mosquitoes away, have no supporting evidence of effectiveness. there is a low certainty evidence that fogging may have an effect on malaria transmission. larviciding by hand delivery of chemical or microbial insecticides into water bodies containing low larval distribution may reduce malarial transmission. there is insufficient evidence to determine whether larvivorous fish can decrease mosquito density and transmission in the area. medications main article: malaria prophylaxis there are a number of medications that can help prevent or interrupt malaria in travellers to places where infection is common. many of these medications are also used in treatment. in places where plasmodium is resistant to one or more medications, three medications—mefloquine, doxycycline, or the combination of atovaquone/proguanil (malarone)—are frequently used for prevention. doxycycline and the atovaquone/proguanil are better tolerated while mefloquine is taken once a week. areas of the world with chloroquine-sensitive malaria are uncommon. antimalarial mass drug administration to an entire population at the same time may reduce the risk of contracting malaria in the population, however the effectiveness of mass drug administration may vary depending on the prevalence of malaria in the area. other factors such as drug administration plus other protective measures such as mosiquito control, the proportion of people treated in the area, and the risk of reinfection with malaria may play a role in the effectiveness of mass drug treatment approaches. the protective effect does not begin immediately, and people visiting areas where malaria exists usually start taking the drugs one to two weeks before they arrive, and continue taking them for four weeks after leaving (except for atovaquone/proguanil, which only needs to be started two days before and continued for seven days afterward). the use of preventive drugs is often not practical for those who live in areas where malaria exists, and their use is usually given only to pregnant women and short-term visitors. this is due to the cost of the drugs, side effects from long-term use, and the difficulty in obtaining antimalarial drugs outside of wealthy nations. during pregnancy, medication to prevent malaria has been found to improve the weight of the baby at birth and decrease the risk of anaemia in the mother. the use of preventive drugs where malaria-bearing mosquitoes are present may encourage the development of partial resistance. giving antimalarial drugs to infants through intermittent preventive therapy can reduce the risk of having malaria infection, hospital admission, and anaemia. mefloquine is more effective than sulfadoxine-pyrimethamine in preventing malaria for hiv-negative pregnant women. cotrimoxazole is effective in preventing malaria infection and reduce the risk of getting anaemia in hiv-positive women. giving sulfadoxine-pyrimethamine for three or more doses as intermittent preventive therapy is superior than two doses for hiv-positive women living in malaria-endemic areas. prompt treatment of confirmed cases with artemisinin-based combination therapies (acts) may also reduce transmission. others community participation and health education strategies promoting awareness of malaria and the importance of control measures have been successfully used to reduce the incidence of malaria in some areas of the developing world. recognising the disease in the early stages can prevent it from becoming fatal. education can also inform people to cover over areas of stagnant, still water, such as water tanks that are ideal breeding grounds for the parasite and mosquito, thus cutting down the risk of the transmission between people. this is generally used in urban areas where there are large centers of population in a confined space and transmission would be most likely in these areas. intermittent preventive therapy is another intervention that has been used successfully to control malaria in pregnant women and infants, and in preschool children where transmission is seasonal. treatment an advertisement for quinine as a malaria treatment from 1927. malaria is treated with antimalarial medications; the ones used depends on the type and severity of the disease. while medications against fever are commonly used, their effects on outcomes are not clear. 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. further information: cotrifazid uncomplicated malaria simple or uncomplicated malaria may be treated with oral medications. artemisinin drugs are effective and safe in treating uncomplicated malaria. artemisinin in combination with other antimalarials (known as artemisinin-combination therapy, or act) is about 90% effective when used to treat uncomplicated malaria. the most effective treatment for p. falciparum infection is the use of act, which decreases resistance to any single drug component. 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. another recommended combination is dihydroartemisinin and piperaquine. artemisinin-naphthoquine combination therapy showed promising results in treating falciparum malaria. however, more research is needed to establish its efficacy as a reliable treatment. artesunate plus mefloquine performs better than mefloquine alone in treating uncomplicated falciparum malaria in low transmission settings. atovaquone-proguanil is effective against uncomplicated falciparum with a possible failure rate of 5% to 10%; the addition of artesunate may reduce failure rate. azithromycin monotherapy or combination therapy has not shown effectiveness in treating plasmodium or vivax malaria. amodiaquine plus sulfadoxine-pyrimethamine may achieve less treatment failures when compared to sulfadoxine-pyrimethamine alone in uncomplicated falciparum malaria. there is insufficient data on chlorproguanil-dapsone in treating uncomplicated falciparum malaria. the addition of primaquine with artemisinin-based combination therapy for falciparum malaria reduces its transmission at day 3-4 and day 8 of infection. 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. infection with p. vivax, p. ovale or p. malariae usually does not require hospitalisation. treatment of p. vivax malaria requires both elimination of blood stages (using chloroquine or artemisinin-based combination therapy) and clearance of liver forms with an 8-aminoquinoline agent such as primaquine or tafenoquine. the view that 8-aminoquinoline drugs kill parasites in the liver is the conventional one. however, there are reasons to believe that primaquine might, to a currently unknown extent, also inactivate non-circulating, extra-hepatic merozoites (clarity in this regard is expected to be forthcoming soon). to treat malaria during pregnancy, the who recommends the use of quinine plus clindamycin early in the pregnancy (1st trimester), and act in later stages (2nd and 3rd trimesters). there is limited safety data on the antimalarial drugs in pregnancy. 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. severe and complicated malaria cases are medical emergencies since mortality rates are high (10% to 50%). recommended treatment for severe malaria is the intravenous use of antimalarial drugs. for severe malaria, parenteral artesunate was superior to quinine in both children and adults. in another systematic review, artemisinin derivatives (artemether and arteether) were as efficacious as quinine in the treatment of cerebral malaria in children. treatment of severe malaria involves supportive measures that are best done in a critical care unit. this includes the management of high fevers and the seizures that may result from it. it also includes monitoring for poor breathing effort, low blood sugar, and low blood potassium. artemisinin derivatives have the same or better efficacy than quinolones in preventing deaths in severe or complicated malaria. quinine loading dose helps to shorten the duration of fever and increases parasite clearance from the body. there is no difference in effectiveness when using intrarectal quinine compared to intravenous or intramuscular quinine in treating uncomplicated/complicated falciparum malaria. there is insufficient evidence for intramuscular arteether to treat severe malaria. the provision of rectal artesunate before transfer to hospital may reduce the rate of death for children with severe malaria. 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. cerebral malaria is the form of severe and complicated malaria with the worst neurological symptoms. there is insufficient data on whether osmotic agents such as mannitol or urea are effective in treating cerebral malaria. routine phenobarbitone in cerebral malaria is associated with fewer convulsions but possibly more deaths. there is no evidence that steroids would bring treatment benefits for cerebral malaria. managing cerebral malaria cerebral malaria usually makes a patient comatose, if the cause of the coma is in doubt, test 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. to manage the cerebral malaria when confirmed the following can be done: patients 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. 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. there is insufficient evidence that iron chelating agents such as deferoxamine and deferiprone improve outcomes of those with malaria falciparum infection. 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. resistance drug resistance poses a growing problem in 21st-century malaria