Updated October 2012

Malaria chemoprophylaxis                                                                

There are currently four drug regimens available in the United Kingdom (UK) for the prevention of malaria. Detailed information on each one, together with country recommendations, and interim updates, can be found in the Guidelines for malaria prevention in travellers from the United Kingdom 2007.

Updates to the malaria guidelines can be found on the HPA website at: http://www.hpa.org.uk/infections/topics_az/malaria/

guidelines.htm

The choice of drug should be determined following a malaria risk assessment.  It should be determined in consultation with the traveller and take into account potential medical contraindications to individual agents.

In addition to appropriate malaria chemoprophylaxis, travellers should be advised on methods of insect bite avoidance and the importance of prompt medical assistance should symptoms suggestive of malaria develop.

Table 1 provides a summary of the advantages and disadvantages of each regimen.

The adult and paediatric dosages can be found in Table 2 and Table 3.

Advice on malaria chemoprophylaxis for women who are pregnant or breastfeeding can be found in the FAQ section.

Table 1. Advantages and disadvantages of malaria chemoprophylactics

Chemoprophylaxis drug	Presentation	Advantages	Disadvantages
Proguanil	Paludrine® tablets	Low cost Well tolerated Suitable for pregnant* or breastfeeding women	Increasing resistance of P. falciparum to chloroquine Large number of tablets required if taken in combination
Chloroquine	Nivaquine® syrup Avloclor® tablets
Mefloquine	Lariam® tablets	Weekly dose Effective for most areas of the world Can be used in the last 2 trimesters of pregnancy. (Seek advice regarding use in 1st trimester)	Needs to be ideally commenced 2 to 3 weeks prior to departure. (Seek advice if travel is imminent) May cause neuro-psychiatric adverse events
Doxycycline	Capsule	Low cost Generally well tolerated Can be commenced close to departure date	May cause photosensitivity May cause vaginal yeast infections in women Unsuitable for children under 12 years
Atovaquone/proguanil	Malarone® tablets	Well tolerated Can be commenced close to departure date Short course	Expensive

*Pregnant women taking proguanil should receive supplementation with 5mg folic acid daily.

Table 2. Adult dosage of malaria chemoprophylaxis

Regimen	Tablet size	Adult dose
Proguanil	100 mg	2 tablets daily, begin 1 wk before travel and continue for 4 wk after travel
Chloroquine phosphate	250 mg salt (155 mg base)	2 tablets weekly, begin 1 wk before travel and continue for 4 wk after travel
Mefloquine	250 mg salt (228 mg base)	One tablet weekly, begin 2-3 wk before travel and continue for 4 wk after travel*
Doxycycline	100 mg	One tablet daily, begin 1 to 2 d before travel and continue for 4 wk after travel
Atovaquone/ proguanil	250 mg atovaquone/ 100 mg proguanil	One tablet daily, begin 1 to 2 d before travel and continue for 7 d after travel

* Mefloquine is ideally begun 2 - 3 weeks before departure to reach effective blood levels, and evaluate for adverse effects.  This is particularly important for first time users

 

Table 3. Paediatric dosage of malaria chemoprophylaxis

The dosage of malaria chemoprophylaxis for children should always be adjusted according to the weight of the child.

Dosages for children can be found in the table below.

Weight (kg)	Chloroquine 155mg base	Proguanil 100mg	Mefloquine 250mg	Doxycycline 100mg
Under 6kg	¼ tablet	¼ tablet	Not recommended	Not recommended
6.0 - 9.9	½ tablet	½ tablet	¼ tablet	Not recommended
10.0 - 15.9	¾ tablet	¾ tablet	¼ tablet	Not recommended
16.0 - 24.9	1 tablet	1 tablet	½ tablet	Not recommended
25.0 - 44.9	1½ tablets	1½ tablets	¾ tablet	Adult dose from 12 years of age 1 tablet
45 and over	2 tablets (adult dose)	2 tablets (adults dose)	1 tablet (adult dose)	1 tablet (adult dose)

Paediatric dosage of atovaquone/proguanil (Malarone®)

Weight (Kg)	Number of paediatric tablets
Under 11	Not recommended
11.0 - 20.9	1 paediatric tablet
21.0 - 30.9	2 paediatric tablets
31.0 - 40.0	3 paediatric tablets
Over 40.0	4 paediatric tablets, or 1 adult tablet

 

Counterfeit medication

Counterfeit or substandard medications are drugs that have been produced by unauthorised manufacturers, but presented to the consumer as an authorised product. Very often both the packaging and the medication appear virtually identical to the authentic medication.

 

In parts of Africa, Asia and Latin America, the proportion of counterfeit medication may be as high as 30% [1]. Counterfeit medications may contain inactive substances or toxic ingredients resulting in the individual not responding to treatment, or being harmed by it. Antimalarial medication is particularly prone to counterfeiting and is a contributing factor in malaria treatment failures and drug resistance [2, 3].

 

Wherever possible travellers should avoid the risk of purchasing counterfeit medication by purchasing all the medication they will need prior to travel. In case travellers require additional supplies they should take copies of their prescriptions of any regular medications with them and consult a legitimate pharmacy. Medications should not be purchased from open markets or street vendors.

 

The International Association for Medical Assistance to Travellers (IAMAT) and the International Society of Travel Medicine (ISTM) global clinic directory can provide contact details of medical practitioners overseas.

 

References

1. Green MD. Counterfeit Drugs. In: Centers for Disease Control and Prevention. Health information for international travel 2012. Atlanta, CDC

2. Newton PN, Green MD, Fernández FM et al. Counterfeit and anti-infective drugs. Lancet Inf Dis. 6, 602-13, 2006

3. Worldwide Antimalarial Resistance Network. Antimalarial quality. [Accessed 23 October 2012]. Available at: http://www.wwarn.org/about-us/scientific-groups/antimalarial-quality

 

Further reading

• Medicines and Healthcare products Regulatory Agency (MHRA)
• U.S Centers for Disease Control and Prevention (CDC)
• World Health Organization
• Worldwide Antimalarial Resistance Network