Malaria prevention consists of a combination of mosquito avoidance measures and chemoprophylaxis. Although very efficacious, none of the recommended interventions are 100% effective.
Mosquito Avoidance Measures
- Because of the nocturnal feeding habits of Anopheles mosquitoes, malaria transmission occurs primarily between dusk and dawn.
- Contact with mosquitoes can be reduced by remaining in well-screened areas, using mosquito bed nets (preferably insecticide-treated nets), using a pyrethroid-containing flying-insect spray in living and sleeping areas during evening and nighttime hours, and wearing clothes that cover most of the body.
- All travelers should use an effective mosquito repellent.
- The most effective repellent against a wide range of vectors is DEET (N,N-diethylmetatoluamide), an ingredient in many commercially available insect repellents. The actual concentration of DEET varies widely among repellents. DEET formulations as high as 50% are recommended for both adults and children older than 2 months of age (see the Protection Against Mosquitoes, Ticks, and Other Insects and Arthropods section later in this chapter). DEET should be applied to the exposed parts of the skin when mosquitoes are likely to be present.
- In addition to using a topical insect repellent, a permethrin-containing product may be applied to bed nets and clothing for additional protection against mosquitoes.
- All currently recommended primary chemoprophylaxis regimens involve taking a medicine before travel, during travel, and for a period of time after leaving the malaria endemic area. Beginning the drug before travel allows the antimalarial agent to be in the blood before the traveler is exposed to malaria parasites.
- Presumptive antirelapse therapy (also known as terminal prophylaxis) uses a medication towards the end of the exposure period (or immediately thereafter) to prevent relapses or delayed-onset clinical presentations of malaria caused by hypnozoites (dormant liver stages) of P. vivax or P. ovale. Because most malarious areas of the world (except the Caribbean) have at least one species of relapsing malaria, travelers to these areas have some risk for acquiring either P. vivax or P. ovale, although the actual risk for an individual traveler is difficult to define. Presumptive anti-relapse therapy is generally indicated only for persons who have had prolonged exposure in malaria-endemic areas (e.g., missionaries, volunteers).
- In choosing an appropriate chemoprophylactic regimen before travel, the traveler and the health-care provider should consider several factors. The travel itinerary should be reviewed in detail and compared with the information on where malaria transmission occurs within a given country (see the Malaria Risk Information and Prophylaxis, by Country, section later in this chapter) to determine whether the traveler will actually be traveling in a part of the country where malaria occurs and if significant antimalarial drug resistance has been reported in that location.
- The resistance of P. falciparum to chloroquine has been confirmed in all areas with P. falciparum malaria except the Caribbean, Central America west of the Panama Canal, and some countries in the Middle East. In addition, resistance to sulfadoxine–pyrimethamine (e.g., Fansidar) is widespread in the Amazon River Basin area of South America, much of Southeast Asia, other parts of Asia, and in large parts of Africa. Resistance to mefloquine has been confirmed on the borders of Thailand with Burma (Myanmar) and Cambodia, in the western provinces of Cambodia, in the eastern states of Burma (Myanmar), on the border between Burma and China, along the borders of Laos and Burma, and the adjacent parts of the Thailand–Cambodia border, as well as in southern Vietnam (Map 2-9).
- Additional factors to consider are the patient’s other medical conditions, medications being taken (to assess potential drug–drug interactions), the cost of the medicines, and the potential side effects.
- The medications recommended for chemoprophylaxis of malaria may also be available at overseas destinations. However, combinations of these medications and additional drugs that are not recommended may be commonly prescribed and used in other countries. Travelers should be strongly discouraged from obtaining chemoprophylactic medications while abroad. The quality of these products is not known, and they may not be protective and may be dangerous. These medications may have been produced by substandard manufacturing practices, may be counterfeit, or may contain contaminants. Additional information on this topic can be found in an FDA document Purchasing Medications Outside the United States.
Medications Used for Chemoprophylaxis
- Atovaquone/proguanil is a fixed combination of the two drugs, atovaquone and proguanil.
- Prophylaxis should begin 1–2 days before travel to malarious areas and should be taken daily, at the same time each day, while in the malarious areas, and daily for 7 days after leaving the area (see Table 2-23 for recommended dosages).
- Malarone is very well tolerated, and side effects are rare. The most common adverse effects reported in persons using atovaquone/proguanil for prophylaxis or treatment are abdominal pain, nausea, vomiting, and headache. Malarone should not be used for prophylaxis in children weighing <5 kg, pregnant women, or patients with severe renal impairment (creatinine clearance <30 mL/min). It should be used with caution by patients taking coumadin (warfarin) for anticoagulation.
Chloroquine (Aralen) and Hydroxychloroquine (Plaquenil)
- Chloroquine phosphate or hydroxychloroquine sulfate can be used for prevention of malaria only in destinations where chloroquine resistance is not present (see Maps 2-7 and 2-8 or the next section in this chapter, Malaria Risk Information and Prophylaxis, by Country).
- Prophylaxis should begin 1–2 weeks before travel to malarious areas. It should be continued by taking the drug once a week, on the same day of the week, during travel in malarious areas and for 4 weeks after a traveler leaves these areas (see Table 2-23 for recommended dosages).
- Reported side effects include gastrointestinal disturbance, headache, dizziness, blurred vision, insomnia, and pruritus, but generally these effects do not require that the drug be discontinued. High doses of chloroquine, such as those used to treat rheumatoid arthritis, have been associated with retinopathy; this serious side effect appears to be extremely unlikely when chloroquine is used for routine weekly malaria prophylaxis. Chloroquine and related compounds have been reported to exacerbate psoriasis. Persons who experience uncomfortable side effects after taking chloroquine may tolerate the drug better by taking it with meals. As an alternative, the related compound hydroxychloroquine sulfate may be better tolerated.
Doxycycline (Many Brand Names and Generic)
- Doxycycline prophylaxis should begin 1–2 days before travel to malarious areas. It should be continued once a day, at the same time each day, during travel in malarious areas and daily for 4 weeks after the traveler leaves such areas.
- Insufficient data exist on the antimalarial prophylactic efficacy of related compounds such as minocycline (commonly prescribed for the treatment of acne). Persons on a long-term regimen of minocycline who are in need of malaria prophylaxis should stop taking minocycline 1–2 days before travel and start doxycycline instead. The minocycline can be restarted after the full course of doxycycline is completed. (See Table 2-23 for recommended dosages.)
- Doxycycline can cause photosensitivity, usually manifested as an exaggerated sunburn reaction. The risk for such a reaction can be minimized by avoiding prolonged, direct exposure to the sun and by using sunscreens. In addition, doxycycline use is associated with an increased frequency of vaginal yeast infections. Gastrointestinal side effects (nausea or vomiting) may be minimized by taking the drug with a meal. To reduce the risk for esophagitis, travelers should be advised not to take doxycycline before going to bed. Doxycycline is contraindicated in persons with an allergy to tetracyclines, during pregnancy, and in infants and children <8 years of age.
- Vaccination with the oral typhoid vaccine Ty21a should be delayed for at least 24 hours after taking a dose of doxycycline.
- Mefloquine prophylaxis should begin at least 2 weeks before travel to malarious areas. It should be continued once a week, on the same day of the week, during travel in malarious areas and for 4 weeks after a traveler leaves such areas (See Table 2-23 for recommended dosages). (Updated April 20, 2010)
- Mefloquine has been associated with rare serious adverse reactions (e.g., psychoses, seizures) at prophylactic doses; these reactions are more frequent with the higher doses used for treatment. Other side effects that have occurred in chemoprophylaxis studies include gastrointestinal disturbance, headache, insomnia, abnormal dreams, visual disturbances, depression, anxiety disorder, and dizziness. Other more severe neuropsychiatric disorders occasionally reported during postmarketing surveillance include sensory and motor neuropathies (including paresthesia, tremor, and ataxia), agitation or restlessness, mood changes, panic attacks, forgetfulness, confusion, hallucinations, aggression, paranoia, and encephalopathy. On occasion, psychiatric symptoms have been reported to continue long after mefloquine has been stopped. Mefloquine is contraindicated for use by travelers with a known hypersensitivity to mefloquine or related compounds (e.g., quinine, quinidine) and in persons with active depression, a recent history of depression, generalized anxiety disorder, psychosis, schizophrenia, other major psychiatric disorders, or seizures. It should be used with caution in persons with psychiatric disturbances or a previous history of depression. A review of available data suggests that mefloquine may be used in persons concurrently on beta blockers, if they have no underlying arrhythmia. However, mefloquine is not recommended for persons with cardiac conduction abnormalities.
- Any traveler receiving a prescription for mefloquine must also receive a copy of the FDA Medication Guide, which can be found at the following website: www.fda.gov/cder/foi/label/2003/19591s19lbl_Lariam.pdf (PDF).
- Primaquine phosphate has two distinct uses for malaria prevention: primary prophylaxis and presumptive antirelapse therapy (also called terminal prophylaxis).
- When taken for primary prophylaxis, primaquine should be taken 1–2 days before travel to malarious areas, daily, at the same time each day, while in the malarious areas, and daily for 7 days after leaving the areas (see Table 2-23 for recommended dosages). Primary prophylaxis with primaquine obviates the need for presumptive antirelapse therapy.
- When used for presumptive antirelapse therapy, primaquine is administered for 14 days after the traveler has left a malarious area. When chloroquine, doxycycline, or mefloquine is used for primary prophylaxis, primaquine is usually taken during the last 2 weeks of postexposure prophylaxis. When atovaquone/proguanil is used for prophylaxis, primaquine may be taken during the final 7 days of atovaquone/proguanil, and then for an additional 7 days. It is preferable that primaquine be given concurrently with the primary prophylaxis medication. However, if that is not feasible, the primaquine course should still be administered after the primary prophylaxis medication has been completed.
- The most common adverse event in glucose-6-phosphate dehydrogenase (G6PD) in normal persons is gastrointestinal upset if primaquine is taken on an empty stomach. This problem is minimized or eliminated if primaquine is taken with food.
- In G6PD-deficient persons, primaquine can cause hemolysis that can be fatal. Before primaquine is used, G6PD deficiency MUST be ruled out by appropriate laboratory testing.
Travel to Areas with Limited Malaria Transmission
For destinations (see the next section in this chapter, Malaria Risk Information and Prophylaxis, by Country) where malaria cases occur sporadically and risk for infection to travelers is assessed as being very low, it is recommended that travelers use mosquito avoidance measures only, and no chemoprophylaxis should be prescribed.
Travel to Areas with Mainly P. vivax Malaria
- For destinations where the main species of malaria present is P. vivax, in addition to mosquito avoidance measures, primaquine is a good choice for primary prophylaxis for travelers who are not G6PD-deficient. Its use for this indication is considered off-label use in the United States.
- The predominant species of malaria and the recommended chemoprohylaxis medicines are listed in the following section in this chapter, Malaria Risk Information and Prophylaxis, by Country.
- For persons unable to take primaquine, other drugs can be used as described below, depending on the presence of antimalarial drug resistance.
Travel to Areas with Chloroquine-Sensitive Malaria
- For destinations where chloroquine-sensitive malaria is present, in addition to mosquito avoidance measures, the many effective chemoprophylaxis alternatives include chloroquine, atovaquone/proguanil, doxycycline, mefloquine, and in some instances primaquine for travelers who are not G6PD-deficient.
- Longer-term travelers may prefer the convenience of weekly chloroquine, while shorter-term travelers may prefer the shorter course of atovaquone/proguanil or primaquine.
Travel to Areas with Chloroquine-Resistant Malaria
For destinations where chloroquine-resistant malaria is present, in addition to mosquito avoidance measures, chemoprophylaxis options are limited to atovaquone/proguanil, doxycycline, and mefloquine.
Travel to Areas with Mefloquine-Resistant Malaria
For destinations where mefloquine-resistant malaria is present, in addition to mosquito avoidance measures, chemoprophylaxis options are reduced to either atovaquone/proguanil or doxycycline.
Chemoprophylaxis for Infants, Children, and Adolescents
- Infants of any age or weight or children and adolescents of any age can contract malaria. Therefore, all children traveling to malaria-risk areas should take an antimalarial drug.
- In the United States, antimalarial drugs are available only in tablet form and may taste quite bitter. Pediatric dosages should be carefully calculated according to body weight but should never exceed adult dosage. Pharmacists can pulverize tablets and prepare gelatin capsules for each measured dose. If the child is unable to swallow the capsules or tablets, parents should prepare the child’s dose of medication by breaking open the gelatin capsule and mixing the drug with a small amount of something sweet, such as applesauce, chocolate syrup, or jelly, to ensure the entire dose is delivered to the child. Giving the dose on a full stomach may minimize stomach upset and vomiting.
- Chloroquine and mefloquine are options for use in infants and children of all ages and weights, depending on the presence of drug resistance at their destination.
- Primaquine can be used for children who are not G6PD-deficient traveling to areas with principally P. vivax.
- Doxycycline may be used for children who are at least 8 years of age.
- Atovaquone/proguanil may be used for prophylaxis for infants and children weighing at least 5 kg (11 lbs). Providers should note that this prophylactic dosing for children weighing <11 kg constitutes off-label use in the United States.
- Pediatric dosing regimens are contained in Table 2-23.
Chemoprophylaxis during Pregnancy and Breastfeeding
- Malaria infection in pregnant women can be more severe than in nonpregnant women. Malaria can increase the risk for adverse pregnancy outcomes, including prematurity, abortion, and stillbirth. For these reasons, and because no chemoprophylactic regimen is completely effective, women who are pregnant or likely to become pregnant should be advised to avoid travel to areas with malaria transmission if possible (see the Traveling while Pregnant section in Chapter 8). If travel to a malarious area cannot be deferred, use of an effective chemoprophylaxis regimen is essential.
- Pregnant women traveling to areas where chloroquine-resistant P. falciparum has not been reported may take chloroquine prophylaxis. Chloroquine has not been found to have any harmful effects on the fetus when used in the recommended doses for malaria prophylaxis; therefore, pregnancy is not a contraindication for malaria prophylaxis with chloroquine phosphate or hydroxychloroquine sulfate.
- For travel to areas where chloroquine resistance is present, mefloquine is currently the only medication recommended for malaria chemoprophylaxis during pregnancy. A review of mefloquine use in pregnancy from clinical trials and reports of inadvertent use of mefloquine during pregnancy suggests that its use at prophylactic doses during the second and third trimesters of pregnancy is not associated with adverse fetal or pregnancy outcomes. More limited data suggest it is also safe to use during the first trimester.
- Because of insufficient data regarding the use during pregnancy, atovaquone/proguanil is not currently recommended for the prevention of malaria in pregnant women.
- Doxycycline is contraindicated for malaria prophylaxis during pregnancy because of the risk for adverse effects seen with tetracycline, a related drug, on the fetus, which include discoloration and dysplasia of the teeth and inhibition of bone growth.
- Primaquine should not be used during pregnancy because the drug may be passed transplacentally to a G6PD-deficient fetus and cause hemolytic anemia in utero.
- Health-care professionals who require additional assistance with the management of pregnant travelers who are unable to take mefloquine chemoprophylaxis should call the CDC Malaria Hotline (770-488-7788).
- Very small amounts of antimalarial drugs are excreted in the breast milk of lactating women. Because the quantity of antimalarial drugs transferred in breast milk is insufficient to provide adequate protection against malaria, infants who require chemoprophylaxis must receive the recommended dosages of antimalarial drugs listed in Table 2-23.
- Because chloroquine and mefloquine may be safely prescribed to infants, it is also safe for infants to be exposed to the small amounts excreted in breast milk.
- Although data are very limited about the use of doxycycline in lactating women, most experts consider the theoretical possibility of adverse events to the infant to be remote.
- Although no information is available on the amount of primaquine that enters human breast milk, the mother and infant should be tested for G6PD deficiency before primaquine is given to a woman who is breastfeeding.
- Because data are not yet available on the safety of atovaquone/proguanil prophylaxis in infants weighing <5 kg (<11 lbs), CDC does not currently recommend it for the prevention of malaria in women breastfeeding infants weighing <5 kg. However, it can be used for treatment of women who are breastfeeding infants of any weight when the potential benefit outweighs the potential risk to the infant (e.g., treating a breastfeeding woman who has acquired P. falciparum malaria in an area of multidrug-resistant strains and who cannot tolerate other treatment options).
Changing Medications during Chemoprophylaxis as a Result of Side Effects
- Medications recommended for prophylaxis against malaria have different modes of action that affect the parasites at different stages of the life cycle. Thus, if the medication needs to be changed because of side effects before a full course has been completed, there are some special considerations.
- If a traveler starts prophylaxis with a medication such as mefloquine or doxycycline and then changes to atovaquone/proguanil during or after travel, the standard duration of prophylaxis for atovaquone/proguanil would be insufficient.
- If the switch occurs 3 weeks or more before departure from the risk area, atovaquone/proguanil should be taken for the remainder of the stay in the risk area and for 1 week thereafter.
- If the switch occurs <3 weeks before departure from the risk area, atovaquone/proguanil should be taken for 4 weeks after the switch.
- If the switch occurs following departure from the risk area, atovaquone/proguanil should be continued until 4 weeks after the date of departure from the risk area.
- Due to their pharmacokinetics, switching from a daily medicine such as doxycycline to a weekly medicine such as mefloquine should be avoided.
- Health-care professionals who require additional assistance with the management of travelers who need to change medications during prophylaxis should call the CDC Malaria Hotline (770-488-7788).
Box 2-2. Clinical pearls
- Overdose of antimalarial drugs, particularly chloroquine, can be fatal. Medication should be stored in childproof containers out of the reach of infants and children.
- Chemoprophylaxis can be started earlier if there are particular concerns about tolerating one of the medications. For example, mefloquine can be started 3–4 weeks in advance to allow potential adverse events to occur before travel. If unacceptable side effects develop, there would be time to change the medication before the traveler’s departure.
- The drugs used for antimalarial chemoprophylaxis are generally well tolerated. However, side effects can occur. Minor side effects usually do not require stopping the drug. Travelers who have serious side effects should see a health-care provider who can determine if their symptoms are related to the medicine and make an appropriate medication change.
- In comparison with drugs with short half-lives, which are taken daily, drugs with longer half-lives, which are taken weekly, offer the advantage of a wider margin of error if the traveler is late with a dose. For example, if a traveler is 1–2 days late with a weekly drug, prophylactic blood levels can remain adequate; if the traveler is 1–2 days late with a daily drug, protective blood levels are less likely to be maintained.
- In those who are G6PD deficient, primaquine can cause hemolysis, which can be fatal. Be sure to document a normal G6PD level before prescribing primaquine.
- Travelers should be informed that malaria can be fatal if treatment is delayed. Medical help should be sought promptly if malaria is suspected, and a blood sample should be taken and examined for malaria parasites on one or more occasions.
- Malaria smear results or an RDT test must be available immediately. Sending specimens to offsite laboratories where results are not available for extended periods of time (days) is not acceptable. If a patient has an illness suggestive of severe malaria and a compatible travel history in an area where malaria transmission occurs, it is advisable to start treatment as soon as possible, even before the diagnosis is established. CDC recommendations for malaria treatment can be found at www.cdc.gov/malaria/diagnosis_treatment/index.html.
Table 2-23. Drugs used in the prophylaxis of malaria
|Drug||Usage||Adult Dose||Pediatric Dose||Comments|
|Atovaquone/proguanil (Malarone)||Prophylaxis in all areas||Adult tablets contain 250 mg atovaquone and 100 mg proguanil hydrochloride. 1 adult tablet orally, daily||Pediatric tablets contain 62.5 mg atovaquone and 25 mg proguanil hydrochloride.
5–8 kg: 1/2 pediatric tablet daily;
>8–10 kg: 3/4 pediatric tablet daily;
>10–20 kg: 1 pediatric tablet daily;
>20–30 kg: 2 pediatric tablets daily;
>30–40 kg: 3 pediatric tablets daily;
>40 kg: 1 adult tablet daily
|Begin 1–2 days before travel to malarious areas. Take daily at the same time each day while in the malarious area and for 7 days after leaving such areas. Contraindicated in persons with severe renal impairment (creatinine clearance <30 mL/min). Atovaquone/proguanil should be taken with food or a milky drink. Not recommended for prophylaxis for children <5 kg, pregnant women, and women breastfeeding infants weighing <5 kg. Partial tablet dosages may need to be prepared by a pharmacist and dispensed in individual capsules, as described in the text.|
|Chloroquine phosphate (Aralen and generic)||Prophylaxis only in areas with chloroquine-sensitive malaria||300 mg base (500 mg salt) orally, once/week||5 mg/kg base (8.3 mg/ kg salt) orally, once/week, up to maximum adult dose of 300 mg base||Begin 1–2 weeks before travel to malarious areas. Take weekly on the same day of the week while in the malarious area and for 4 weeks after leaving such areas. May exacerbate psoriasis.|
|Doxycycline (many brand names and generic)||Prophylaxis in all areas||100 mg orally, daily||≥8 years of age: 2 mg/ kg up to adult dose of 100 mg/day||Begin 1–2 days before travel to malarious areas. Take daily at the same time each day while in the malarious area and for 4 weeks after leaving such areas. Contraindicated in children <8 years of age and pregnant women.|
|Hydroxychloroquine sulfate (Plaquenil)||An alternative to chloroquine for prophylaxis only in areas with chloroquine-sensitive malaria||310 mg base (400 mg salt) orally, once/week||5 mg/kg base (6.5 mg/ kg salt) orally, once/week, up to maximum adult dose of 310 mg base||Begin 1–2 weeks before travel to malarious areas. Take weekly on the same day of the week while in the malarious area and for 4 weeks after leaving such areas.|
|Mefloquine||Prophylaxis in areas with mefloquine-sensitive malaria||228 mg base (250 mg salt) orally, once/week||≤9 kg: 4.6 mg/kg base (5 mg/kg salt) orally, once/week;
>9–19 kg: 1/4 tablet once/week;
>19–30 kg: 1/2 tablet once/week;
>31–45 kg: 3/4 tablet once/week;
≥45 kg: 1 tablet once/ week
|Begin at least 2 weeks before travel to malarious areas. Take weekly on the same day of the week while in the malarious area and for 4 weeks after leaving such areas. Contraindicated in persons allergic to mefloquine or related compounds (e.g., quinine, quinidine) and in persons with active depression, a recent history of depression, generalized anxiety disorder, psychosis, schizophrenia, other major psychiatric disorders, or seizures. Use with caution in persons with psychiatric disturbances or a previous history of depression. Not recommended for persons with cardiac conduction abnormalities. (Updated April 20, 2010)|
|Primaquine||Prophylaxis for short-duration travel to areas with principally P.vivax||30 mg base (52.6 mg salt) orally, daily||0.5 mg/kg base (0.8 mg/kg salt) up to adult dose orally, daily||Begin 1–2 days before travel to malarious areas. Take daily at the same time each day while in the malarious area and for 7 days after leaving such areas.
Contraindicated in persons with G6PD1 deficiency. Also contraindicated during pregnancy and lactation unless the infant being breastfed has a documented normal G6PD level.
|Primaquine||Used for presumptive antirelapse therapy (terminal prophylaxis) to decrease the risk for relapses of P. vivax and P. ovale||30 mg base (52.6 mg salt) orally, once/day for 14 days after departure from the malarious area.||0.5 mg/kg base (0.8 mg/kg salt) up to adult dose orally, once/day for 14 days after departure from the malarious area||Indicated for persons who have had prolonged exposure to P. vivax and P. ovale or both. Contraindicated in persons with G6PD1 deficiency. Also contraindicated during pregnancy and lactation unless the infant being breastfed has a documented normal G6PD level.|
1Glucose-6-phosphate dehydrogenase. All persons who take primaquine should have a documented normal G6PD level before starting the medication.
Source: CDC – Last updated, July 2, 2010
Mary Lou Harris says
I am a healthy senior citizen (73 years) and I am considering a trip with Semester at Sea. One of the ports they plan to visit is Ghana. I see the CDC says Ghana is a “high risk” area for malaria.
I think I remember being told (at the U of W Travel Medicine Clinic) a few years ago that the malaria drugs are problematic for Seniors.
With the Semester at Sea ship stopping at Takoradi, Ghana, how high a risk is malaria and what preventative measures could/should I take?
I have had no malaria treatment (preventive or due to illness) in the past.
I love this siteeee <3
Tricia Presson says
Whilst working in Mozambique in 2001, I contracted severe malaria. Blood tests showed the presence of plasmodium malaria and, as I had several re-occurrences once back home, vivax malaria was also Presumed.
Getting rid of the malaria proved problematic; I had fansidar, then a course of quinine, then a course of primaquine and finally two long courses of doxycycline with the malaria still making its presence felt from time to time even after this.
Despite all this, I would very much like to go to another malarious area (Uganda). What are my chances of a) getting malaria again and b) the dormant malaria re-occurring?
I should mention I was on malaria prophylaxis whilst in Mozambique.
Claire Standley, Editor says
You should certainly think about another course of primaquine to try to combat the vivax – I just found a paper which suggests that dosing is really important in ensuring primaquine treatment doesn’t fail, which might have been an issue for you last time. A link to the paper is here: http://www.ajtmh.org/content/62/3/393.full.pdf
As for your up-coming trip to Uganda, if you take appropriate prophylactic measures, including preventive medication, you should be fine. As falciparum malaria is predominantly resistant to chloroquine in this area, you should take atovaquone-proguanil (Malarone), mefloquine (Lariam) or doxycycline. The links to malaria prevention on our home page give more of the pros and cons to each of these – in addition, diet can affect the body’s ability to take up these medications, so you need to read up on that before you go (in my experience, many general doctors aren’t aware of these dietary considerations, unless you go to a specialized travel or tropical medicine clinic). For example, Malarone should be taken with fatty foods, to increase absorption, whereas doxycycline uptake can be inhibited by calcium, so shouldn’t be taken with dairy products. You should also sleep under a long-lasting insecticide treated bednet, wear long sleeved clothing at night and in the evenings, and cover exposed skin with insect repellant (preferably containing at least 15% DEET).
I should mention that there are some reports of P. vivax recurrence being triggered by mosquito bites, or indeed with P. falciparum infection. Therefore you should be vigilant in looking out for signs of symptoms of malaria while you are traveling, as well as once you are back. These days, the World Health Organization recommends artemisinin-based combination therapies (ACTs, such as Coartem) as the first-line treatment against uncomplicated malaria, so if you do have symptoms, which are confirmed by blood test as malaria, you should ask your doctor about taking this. Fansidar is not recommended for treating malaria anymore (especially not P. falciparum).
I hope this has been helpful!
Tricia Presson says
Thank you Claire for your very helpful advice.
The link you mentioned wasn’t shown on your posting – could you repost it please as I need all the ammunition I can get to show to my GP!
Claire Standley, Editor says
Whoops! Sorry about that. I have fixed the link – hopefully it will work for you now!
I’m traveling to Burma in 2 weeks, and I’m looking into prophylaxis with Duo-Cotexin.
Can’t find anything so far.
My friend gets severe headaches with Malarone, and I feel sick with antibiotics. Both better than malaria, but I think Duo-cotexin will be better tolerated.
What are your thoughts?
Judith Standley says
Duo-cotexin is an artemisinin compound used for treatment of malaria. For malaria prevention in Burma, you should take either Malarone (although your friend gets a headache from taking it, you may not) or Doxycycline. See http://malaria.com/overview/malaria-prevention for an overview of preventive medications.
Richard Smith says
I’m in a malarial area and am currently taking primaquine as a prophylaxis. I want to change to mephaquine/larium while I’m still here. Can I overlap the two drugs – start taking larium and then stop taking primaquine after three weeks (based on larium needing to be started two weeks before entering a malarial region and primaquine needing to be taken a week after leaving a malarial region)?
Claire Standley, Editor says
Thanks for your question, Richard – I’ll pass the query over to one of our medical advisors, who will be able to give you the information you need. Please check back here soon for an update. Thank you!
Claire Standley, Editor says
Hi Richard – our medical advisor says it’s fine to take both primaquine and mefloquine at the same time while you are transitioning over to the latter, and yes, you should overlap for two weeks. Good instincts!
Julie Wright says
My faMILy and i are traveling to Vietnam in 5 weeks. We will be going to Danag, Hoi an staying on the river then Hanoi onto Halong bay and Cat ba island. Do you feel we need anti malaria treatment. Im a little concerned as i and my daughter have sulfite allergies and IBS, I also suffer anxiety quite badly. My youngest daughter has food allergies and carries an epipen. What medication do you suggest if any.
Claire Standley, Editor says
According to the CDC, malaria in Vietnam is mainly restricted to rural areas, and moreover, there is none in the Red River Delta and the coast north of Nha Trang (and thus none on Cat Ba Island or Halong Bay), nor is there any in Danang or Hanoi. So you should be fine with just taking preventative precautions against getting bitten by mosquitoes, such as sleeping under a bednet (preferably a long-lasting insecticide treated one), wearing long-sleeved clothing (especially at night and in the evening) and wearing insect repellent.