Malaria Prophylaxis – Travel
Medicine
Bryan S. Delage MD MC FS SAS
North Dakota Air National Guard
RSV Training for FS 2013
Malaria Prophylaxis
• Objectives:
• 1. Be able to access and search the CDC for recommendations
for International Travel, and malaria prophylaxis.
• 2. Learner should be able to choose appropriate malaria
prophylaxis for travel to foreign countries
• 3. Learner should be able to determine appropriate alternatives
for Flyers and Non-Flyers for malaria prophylaxis
• 4. Learner should be able to educate patients on appropriate
ways to avoid contracting malaria while traveling, and the
reasoning for prophylaxis.
Malaria Prophylaxis
• Outline
• A. Review of Malaria
• B. Accessing the CDC web site for Travel
Information
• C. Appropriate antibiotics for prophylaxis
• D. Alternatives for prophylaxis
• D. Flyers vs. Non-flyers (Medication Guide)
• E. Prevention of malaria ( An ounce of prevention
is worth a pound of cure!)
Malaria Review
• Malaria Review:
• Infectious Agent :
protozoan genus
plasmodium; 4
species, falciparum,
ovale, vivax, and
malariae infect
humans. (knowlesi –
monkey, few human
infections and deaths)
Malaria Review
• All 4 species are
transmitted by a bite
from an infected
anopheles female
mosquito. Occasional
transmission from blood
transfusion, sharing
needles or congenitally.
• It accounts for 350-500
million infections yearly,
and 1 million deaths
Malaria Review
• Malaria transmission
occurs in large areas
of Africa, Central and
South America, in the
Caribbean, South and
Southeast Asia, the
South Pacific; as well
as the Middle East
and Eastern Europe
Malaria Review
Symptoms for malaria
are fever, and influenza
like symptoms: chills,
headache, myalgias
and malaise; and can
occur at intervals, and
uncomplicated disease
can show anemia and
jaundice; if severe,
seizures, confusion,
ARDS, coma and death
can occur.
Malaria Review
• Diagnosis by thick
blood smears is the
Gold Standard.
• The CDC
recommends only 2
treatments with
reliable supply, for
disease; atovaquoneproguanil, and
artemetherlumefantrine
Malaria Prophylaxis
• Preventing the
transmission of malaria
is best done by
avoidance measures,
and chemoprophylaxis
• The need for
chemoprophylaxis and
what to recommend
depends on the risk in
the destination for
travel.
Malaria Prophylaxis
• There are a number
of medications for
malaria prophylaxis:
• Atovaquone-Proguanil
(Malarone)
• Doxycycline
• Mefloquine
• Chloroquine and
hydroxychloroquine
• Primaquine
Malaria Prophylaxis
• Historically the biggest
problem with
chemoprophylaxis is the
resistance of some
plasmodium falciparum
strains to chloroquine. This
has been found in all strains
of falciparum in the world
except for some in the
Caribbean and Central
America west of the Panama
Canal and some countries in
the Middle East.
Malaria Prophylaxis
• Mefloquine resistance
has been confirmed
on the Borders of
Thailand with Burma
(Myanmar), and
Cambodia, in the
western provinces of
Cambodia, and
eastern States of
Burma between
Burma and China
Malaria Prophylaxis
• So making a travel
recommendation is
based on good
information of the risk
in that country, the
most reliable source
for recommendations
is the CDC, and
accessing that
information is easy.
• http://www.cdc.gov/tra
vel
• Travelers' Health CDC
Malaria Prophylaxis
• Atovaquone-Proguanil
• Doxycycline
• Mefloquine
• 1-2 days before, daily
while in country and 7
days after
• 1-2 days before, daily
in country and 4
weeks afterwards
• > = 2 weeks before,
weekly in country and
weekly for 4 weeks
afterwards
Malaria Prophylaxis
• Chloroquine and
hydroxychloroquine
• Primaquine
• 1-2 weeks before
travel, weekly while in
country, and for 4
weeks afterwards
• Only used for
prophylaxis in areas
with p. vivax, and for
terminal prophylaxis
Prophylaxis Side Effects and
Contraindications
• Atovaquone-Proguanil
•
• Doxycycline
•
• Mefloquine
•
Abdominal pain, nausea,
vomiting, headache,
contraindicated in children less
than 5kg, pregnant women, or
patients with renal impairment
Photosensitivity, vaginal yeast
infections, nausea/vomiting,
contraindicated if allergic, during
pregnancy, infants and children
less than 8
Rare psychoses or seizures, GI side
effects, HA, insomnia, abnormal
dreams, depression, anxiety, motor
neuropathies; contraindicated in
psychiatric patients and cardiac
conduction problems
Prophylaxis Side Effects and
Contraindications
• Chloroquine and
hydroxychloroquine
• Primaquine
• GI Disturbance, HA,
dizziness, blurred vision,
insomnia, pruritis, may
exacerbate psoriasis,
contraindicated where
plasmodium falciparum is
resistant
• Contraindicated for those
who have G6PD deficiency;
GI upset. Primarily for
P.vivax, not effective as
prophylaxis for other strains
Flyers and Prophylaxis
• Options
• 1. Prophylaxis with
Doxycycline
• 2. DNIF and mefloquine
• 3. Prophylaxis with
Malarone
(Atovaquone/proguanil)
• Historically cheap, but
supply may be issue,
and contraindicated if
allergic, no DNIF or GT
• Not the best option, but
if in a non-flying status
is an option
• According to Aircrew
Med List – may be used
after appropriate
Ground Trial
Prophylaxis and Flyers
• Aircrew Medication
• Aircrew medication
Guide does
guide does indicate in
recommend that the
those taking malarone
last 2 weeks of
prophylaxis
prophylaxis for
primaquine terminal
Doxycycline should be
prophylaxis for 2
taken with Primaquine
weeks, for the last
if not contraindicated
week with malarone,
and for another week
after malarone if not
contraindicated
Prophylaxis and Flyers
• Chloroquine can also
be used for areas
without mefloquine or
chloroquine
resistance – but also
requires terminal
prophylaxis with
primaquine and
ground testing prior to
use.
• So ground testing is
required for use of
malarone, primaquine,
and chloroquine prior
to use in Flyers,
Avoidance and Deterrence
• Insect Repellent
• Permethrin treatment
of clothing
• Lodging
• DEET (30% or more)
• Picaridin
• Oil of Lemon
Eucalyptus
• IR 3535
• Buy treated clothing
or treat long sleeve
clothing
• Stay inside in air
conditioned rooms at
night, use bed nets
Summary
• Malaria Prophylaxis is easy, recommendations
for meds are easily found at www.cdc.gov/travel
• The short supply of doxycycline may affect
choices, but for most including flyers after a
ground trial, malarone is a good substitute
• Avoidance measures and using insect repellent
and treating clothing with permethrin are helpful
adjuncts to malaria prophylaxis
• Stress the risk for disease and the benefits of
completing a full course, and if unable to
complete due to side effects, switch to other
meds for terminal prophylaxis