The main method of attacking adult mosquitoes in houses is spraying the inside surfaces of the walls, roof, and ceiling with a residual insecticide. The insecticide most widely used for house spraying has been DDT, which has continued to be recommended for this purpose long after it was banned for agricultural use in the USA and many other countries. It has been recommended because of its cheapness per unit weight and its durability, which allows programs to be based on spraying twice a year, or only once in areas with a short annual malaria mosquito season. However, there have been studies demonstrating ill-sided effects such as DDT residues in human breast milk, which may be the cause of neurological abnormalities in babies. DDT has already been replaced by organophosphate or carbamate insecticides such as malathion where DDT resistance has been detected. However, these compounds are considerably more expensive. Pyrethroids such as deltamethrin are effective at far lower doses than DDT. Although more expensive per unit weight, these pyrethroids are not much more expensive per house protected per year (Curtis).

The World Health Organization (WHO) and the United States Department of Health have created many instructional tools to teach people about the causes and prevention of malaria. One type of tool is a set of images that provides educational illustrations of transmission and disease. The visual nature of these images are particularly helpful for use in different cultural contexts. Shown here is an example one image from a set. The full set can be found at http://cube.ice.net/~malaria/docs/MalariaFamily.html (WHO)

1.Quinine sulphate 10 mg salt/kg 8 hourly for seven days plus doxycycline 100 mg daily for 7 days. Patients will usually develop 'cinchonism' (tinnitus, high-tone hearing loss, nausea, dysphoria) after 2-3 days but should be encouraged to complete the full course to avoid recrudescence.

2. Malarone^TM (atovaquone 250 mg plus proguanil 100 mg) 4 tablets daily for 3 consecutive days. This combination therapy has only recently come on the market and is relatively expensive. Data on efficacy are promising but limited.

3. Mefloquine (Larium^TM) given as 15 mg/kg in a divided dose followed by 10 mg/kg the following day. Antipyretic and antiemetic agents may need to be given prior to mefloquine administration to reduce the risk of vomiting.

Choice of regimen is based on:

• Local cost and availability of antimalarial drugs.
• Area of malaria acquisition (i.e. drug resistance pattern of P. falciparum).
• Prior chemoprophylaxis.
• Known allergies.
• Concomitant illnesses other than malaria.
• Age and pregnancy.
• Likely patient compliance with therapy.
• Risk of re-exposure to malaria after treatment.

In uncomplicated cases in which nausea and vomiting preclude oral therapy, quinine dyhidrochloride 10 mg salt/kg base can be given I.V. in 5% w/v dextrose or normal saline as a 4-hour infusion 8-hourly until the patient can take medication by mouth.

In patients who have not received quinine in the previous 48 hours, one of two regimens can be used:

1.Quinine dihydrochloride 20 mg salt/kg base given I.V. in 5% w/v dextrose or normal saline as a once-only 4 hour infusion followed, 4 hours later, by quinine dihydrochloride 10 mg salt/kg base 4-hour infusions 8 hourly.

2.Where a syringe pump or other accurate infusion device is available, quinine dihydrochloride 7 mg salt/kg base over 30 minutes followed immediately by quinine dihydrochloride 10 mg salt/kg base over 4 hours then, starting 4 hours later, quinine dihydrochloride 10 mg salt/kg base as 4 hour infusions, 8 hourly.

Electrocardiographic monitoring can be done if available but is not essential unless additional cardiac risks are present. Where patients have received quinine within the previous 24 hours, give quinine dihydrochloride 10 mg salt/kg base I.V. in 5% w/v dextrose or normal saline as 4-hour infusions, 8-hourly.