- A wareness of the risk of malaria.
- B ites - reducing likelihood of bites from anopheline mosquitoes.
- C hemoprophylaxis.
- D iagnosis and prompt treatment to prevent complications.
No single measure is 100% effective but the combination of measures will significantly lessen the risk.
Risk assessment should include:
- Geographical destination - information online at the Foreign and Commonwealth Office's website is very helpful.
- Travellers to remote locations should seek expert advice (see resources for patients, below).
- The current highest risk areas are Africa, South and Central America, Asia and the Middle East. About 90% of the one million deaths occurring worldwide are in Africa.
- Health Protection Agency (HPA) figures for 2010 showed that of cases of malaria imported into the UK, 1,263 were due to Plasmodium falciparum, 350 were due to P. vivax, 99 to P. ovale and 37 to P. malariae. There were seven deaths.
- Type of travel: there is higher risk for tourists travelling outside urban areas to countryside or game parks, business travellers to downtown offices, overland backpackers, those undertaking prolonged travel, and expatriates intending to reside in the area.
- High-risk categories - pregnant women, asplenic patients, young children, people with HIV/AIDS.
- Avoidance of bites is important, particularly because chemoprophylaxis is never 100% effective, problems of drug resistance are increasing and there is evidence that the risk of contracting malaria is proportional to number of bites. Bites occur mainly between dusk and dawn, although some species of mosquito which can transmit dengue fever bite during the day also.
- Keep the arms and legs covered after sunset.
- There is good evidence that covering exposed limbs with repellant containing diethyltoluamide (DEET) is effective. When sunscreen is applied, it should be used before DEET. It is suitable for all adults, including children over the age of two months. 50% is the recommended strength. There is no evidence of serious toxicity, even in small children and pregnant women. Some patients develop an allergic or irritant response, in which case lower strengths are available. Preparations weaker than 50% will require more frequent application. There is no evidence of effectiveness of strengths of less than 20%.
- Picaridin (KBR3023) (1-piperidinecarboxylic acid, 2-(2-hydroxyethyl)-,1-methylpropylester) is reported to have repellent properties comparable with those of DEET. Picaridin is sold in Europe as a 20% formulation whilst a 7% picaridin formulation is on sale in the USA. If a traveller elects to use picaridin for mosquito bite prevention, a 20% preparation should be used.
- Permethrine is a useful insecticide to spray on clothing. Pre-treated clothing is available for purchase.
- Patients should be advised to sleep in air-conditioned rooms if possible, or screened accommodation.
- Use of sprays with knockdown insecticide or electrical pyrethroid vapourisers every evening after dusk is recommended.
- Insecticide-treated nets should be used by those sleeping outdoors or in unscreened rooms. The effectiveness is about 50%. Pyrethroid-impregnated nets improve protection and should be re-impregnated every 6-12 months, although resistance is becoming a problem. The search for newer, more effective insecticides is ongoing.
- Reinforce that prophylaxis is not absolute, breakthrough infection can occur, and that risk avoidance is still necessary.
- Consider risks versus benefits based on risk assessment. A suitable risk assessment template may be found in the document Guidelines for Malaria Prevention in Travellers from the United Kingdom from the Health Protection Agency (HPA).
- Start weekly drug regimes one or two weeks before departure (exceptions: 1-2 days for atovaquone with proguanil (Malarone®), two to three weeks for mefloquine) to get used to side-effects before travelling. Take after meals.
- Continue until four weeks after return, to deal with infection contracted towards the end of the stay. Discuss possible side-effects, and recommend seeking advice if there is any concern or medication has to be stopped.
- Warn that antimalarial medication bought abroad or purchased over the internet made be fake, and should be avoided.
- Seek specialist advice if the patient has severe hepatic or renal impairment.
- Where a journey requires two regimes, use the regime for the higher-risk area for the whole journey. Warn settled immigrants or long-term visitors to the UK that they may have lost some of their immunity and that previously uninfected areas may now be malarious.
- Malaria chemoprophylaxis is not prescribable on FP10. Chloroquine and proguanil can be bought over the counter. Mefloquine, doxycycline, and Malarone® require a private prescription.
- Chloroquine is rarely appropriate as single therapy due to the emerging resistance of P. falciparum.
- It is taken at a dose of 300 mg (two tablets) weekly for adults. It is also available as a syrup (equivalent to chloroquine base 50 mg/5 ml).
- It remains effective against most P. vivax, all P. ovale and virtually all P. malariae. It will, however, not prevent dormant liver stages of vivax and ovale malaria which can present up to a year after travel.
- Chloroquine plus proguanil:
- Proguanil is rarely given as a single agent due to resistance but combined with chloroquine it may be used in areas with moderate chloroquine resistance. The combination provides less protection than mefloquine. It is no longer recommended for travel to sub-Saharan Africa.
- Folate supplements are recommended during pregnancy.
- The dose for adults is: chloroquine 300 mg (two tablets) weekly and proguanil 200 mg (two tablets) daily.
- Common adverse reactions are nausea, diarrhoea, dyspepsia and itching.
- Chloroquine is available as syrup for young children. Proguanil tablets need to be crushed and can be administered in jam or butter.
- This is used for areas where there is a high incidence of chloroquine-resistant falciparum malaria (e.g sub-Saharan Africa).
- The usual adult dose is 250 mg weekly.
- It can be recommended for journeys of up to one year.
- It exhibits 90% efficacy in Africa but resistance is high in other areas (eg there is significant resistance of P. falciparum to mefloquine in some areas of Southeast Asia, and it is reported sporadically in the Amazon basin).
- Major adverse events (convulsions, coma and psychotic disturbances) are rare - 1 in every 10,000 users; however, they have been given high media profile. There is no evidence that mefloquine use increases the risk of first-time diagnosis of depression and no association between mefloquine prescriptions and hospitalisation.
- Lesser side-effects are similar to chloroquine and proguanil.
- Avoid in patients with a history of epilepsy or psychiatric disorder.
- It should not be used routinely in pregnancy but, if there is an unavoidable visit to an area where there is a high risk of choloroquine-resistant falciparum malaria, use cautiously during the second and third trimester. Data suggest it is safe in the first trimester.
- It is not for routine use in lactation, as it is secreted in breast milk.
- The Civil Aviation Authority has banned the use of mefloquine for its pilots, although there is no evidence that it affects function.
- This is a combination of proguanil and atovaquone.
- Its effectiveness against falciparum malaria is in excess of 90%.
- It is licensed in the UK for adults for up to 28 days.
- It can be used as an alternative to mefloquine or doxycycline for adults travelling to choloroquine-resistant areas, especially Africa and Southeast Asia.
- It is taken as a single daily dose and only needs to be continued for seven days after travel.
- Adverse effects are few - mainly gastrointestinal and headaches.
- This has comparable efficacy to mefloquine.
- It may be recommended as first-line for travel to Africa where high levels of protection are desirable but mefloquine is unsuitable.
- The main side-effects are diarrhoea, photosensitive dermatitis and vaginal thrush.
- It is not recommended for children aged under 12, pregnancy or lactation.
- It should be used with caution in patients with hepatic impairment, myasthenia gravis and systemic lupus erythematosus.
- Its use is limited to six months.
- Prophylactic doses are based on guidelines from UK malaria experts and may differ from advice in the product literature.
- Weight is a better guide than age.
- There are no large-scale studies supporting the effectiveness of antimalarial drugs in children, although encouraging results have been reported in a study using intermittent sulfadoxine-pyrimethamine in Gabon.
- If in doubt, telephone prophylaxis advice centres (see 'Helplines for further information and advice', listed under 'Prophylaxis advice centres', below).
- If chemoprophylaxis is contra-indicated or of limited effectiveness and it is necessary to travel to high-risk areas where access to medical expertise within 24 hours of the onset of fever is unlikely, medication may be prescribed to self-treat an episode of malaria.
- The patient must be carefully counselled regarding presenting symptoms, indications and safe use of drugs.
- Treatment should be started if the patient is unable to seek medical help within eight hours of onset of symptoms. Other preventative measures should be continued.
- The standard treatment course should be completed and antimalarial chemoprophylaxis commenced one week after taking the first treatment dose, except in the case of mefloquine prophylaxis, which should be resumed one week after the last treatment dose if quinine was used for standby treatment.
- Antipyretics should be used to treat fever.
- A second full treatment dose of the antimalarial medication should be taken if vomiting occurs within 30 minutes of taking it (half dose if vomiting occurs after 30-60 minutes).
- The drug used for emergency standby treatment should differ from that used for chemoprophylaxis, both to minimise drug toxicity and due to concerns over drug resistance.
- Warn the patient concerning the adverse reactions of quinine - for example, tinnitus, headache, flushed skin, nausea.
- Patients should be advised not to buy antimalarial drugs over the internet, as the sale of counterfeit products has been reported.
© HPA Guidelines for Malaria Prevention in Travellers. Reproduced with permission.
Chemoprophylaxis for long-term travellers
Seek specialist advice. Long-term travellers are defined as those travelling through or visiting malaria-endemic countries for over six months. As for short-term prophylaxis, a risk assessment should be done which includes risk of malaria, adverse events profile, compliance and efficacy.
- Chloroquine and proguanil are the only drugs licensed for long-term use but there effectiveness is reduced in some areas, due to resistance. They can be used indefinitely (but check for retinopathy if chloroquine is used for more than six years).
- Licensing restrictions can be mitigated by switching from one regime to another. Occasionally, strategies such as reliance on standby treatment or ignoring licensing restrictions have been employed.
- Mefloquine is licensed for up to one year (although it has been used for up to three years without problems).
- Doxycycline can be used for up to two years.
- Malarone® is licensed for up to 28 days but can be safely used for up to three months (and possibly six months or longer).
Diagnosis and prompt treatment
Advise patients regarding symptoms of malaria, to report any illness within three months of return, to make their doctor aware of history of malaria exposure and to monitor for symptoms of malaria for up to one year after travel.
- Chloroquine and mefloquine are unsuitable.
- In areas without chloroquine resistance, prescribe proguanil 200 mg daily.
- In areas with chloroquine resistance, consider doxycycline or Malarone®.
- In theory, doxycycline can reduce the plasma concentration of anticonvulsants but there is no evidence that this happens in practice and an increase in dosage of anticonvulsants is not recommended.
- Asplenia and severe splenic dysfunction - these patients are at high risk of severe malaria. If travel is unavoidable, take rigorous precautions and use drugs that give good protection.
- Renal impairment:
- Avoid or reduce the dosage of proguanil, as it is excreted by the kidneys.
- Avoid Malarone® in patients with low creatinine clearance (less than 30 ml/minute).
- Chloroquine only needs dosage reduction in severe renal impairment.
- Mefloquine and doxycycline can be used in normal dosage.
- Liver impairment:
- Mefloquine and doxycycline are contra-indicated, as they are excreted via the liver.
- Proguanil and chloroquine can be used in mild impairment and proguanil in moderate impairment.
- In severe liver failure, seek specialist advice.
- Evidence suggests pregnant women are twice as likely to be bitten by anopheline mosquitoes than non-pregnant women, the malaria is more severe and the disease can cause miscarriage.
- Avoid travel to malarious areas if possible.
- If unavoidable, give chloroquine and proguanil in usual doses in areas where P. falciparum strains are sensitive. A large trial using chloroquine as prophylaxis against P. vivax demonstrated a reassuring safety profile.
- If proguanil is used, prescribe folic acid 5 mg daily.
- Mefloquine is suitable in the second and third trimesters; in the first trimester lack of safety data concerning miscarriages suggests that caution should be exerted before prescribing.
- Avoid doxycycline; Malarone® should not be used due to lack of safety data.
- Consult prophylaxis advice centres for travel to resistant areas.
- Chloroquine, proguanil and mefloquine are suitable for lactating mothers. Doxycycline is contra-indicated.
- There is lack of safety data concerning Malarone® but this may be considered if there is no suitable alternative.
- Prophylaxis is required in breast-fed infants, as the amounts of antimalarial present in milk are too variable to give reliable protection.
Prophylaxis advice centres
|Helplines for further information and advice|
|Health Protection Agency (HPA) |
Prophylaxis Advice Fax Service
(complete the template available from the HPA website)
|020 7637 0248|
|National Travel Health Network and Centre|
|0845 602 6712|
|Scottish Centre for Infection and Environmental Health -|
maintained by Health Protection Scotland (www.travax.scot.nhs.uk)
|0141 300 1100|
Further reading & references
- Guidelines for Malaria Prevention in Travellers from the United Kingdom, Health Protection Agency, 2007
- Hughes C, Tucker R, Bannister B et al; Malaria prophylaxis for long-term travellers. Communicable Disease and Public Health 2003;6(3): 200-208
- Travel advice by country; Foreign & Commonwealth Office, 2011
- Imported malaria cases and deaths, United Kingdom: 1991-2010, Malaria Reference Laboratory, Health Protection Agency (HPA), 2011
- Malaria Fact Sheet No 94, World Health Organization, 2010
- Malaria; Foreign & Commonwealth Office, 2011
- Chen T, Burczynski FJ, Miller DW, et al; Percutaneous permeation comparison of repellents picaridin and DEET in concurrent Pharmazie. 2010 Nov;65(11):835-9.
- British National Formulary
- Grobusch MP, Lell B, Schwarz NG, et al; Intermittent preventive treatment against malaria in infants in Gabon--a randomized, double-blind, placebo-controlled trial. J Infect Dis. 2007 Dec 1;196(11):1595-602. Epub 2007 Oct 25.
- Villegas L, McGready R et al; Chloroquine prophylaxis against vivax malaria in pregnancy: a randomized, double-blind, placebo-controlled trial. Trop Med Int Health. 2007 Feb;12(2):209-18.
|Original Author: Dr Laurence Knott||Current Version: Dr Laurence Knott||Peer Reviewer: Dr Huw Thomas|
|Last Checked: 19/08/2011||Document ID: 231 Version: 6||© EMIS|
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.