Last week, we discussed how your choice of destination determines, first of all, whether you take any anti-malarial tablets at all, and if so, which drug.
This week we shall focus on you as the individual.
You the traveller:
Your individual circumstances are important and are likely to influence the choice of anti-malarials. For example…
- Are you pregnant?
- Are you breastfeeding?
- Do you have significant illnesses such as epilepsy, depression or heart problems?
Pregnant women
- Malaria is more severe in pregnant women and there is an increased incidence of complications, such as stillbirth. For these reasons, you should therefore not travel to malaria endemic countries if you are pregnant
- If travel is essential and you are pregnant then chloroquine can be used but as already discussed there is widespread resistance to this drug.
- Mefloquine has also been used safely after 12 weeks of pregnancy. After 12 weeks it may be used but specialist advice is required.
- Malarone (atovaquone/proguanil) and doxycycline are not recommended in pregnancy
Breast-feeding mothers
- Small amounts of anti-malarial drugs are excreted in breast milk. Although this is not thought to be harmful, it will not protect your baby from malaria.
- Malarone (atovaquone/proguanil) and doxycycline should not be used during breastfeeding
Children
- Generally the recommendations are similar to those of adults with one or two important caveats
- Children’s’ doses should be adjusted for weight rather than age. Your general practitioner or specialist travel clinic will guide you on this
- If you or your child is less than 12 years of age then Doxycycline should not be prescribed because of its effect on growing teeth and bones.
Patients with existing medical conditions
- Adverse reactions – it seems like common sense but if you have had previous adverse reactions to anti-malarial drugs, you should consider suitable alternatives.
- Epilepsy – you should not take Mefloquine and chloroquine because both have been associated with seizures
- Neuropsychiatric illnesses (e.g. epilepsy, psychoses, depression) – you should inform your doctor if you are such illnesses as Mefloquine can make them worse
- Heart problems – again mefloquine may need to be avoided
- Severe liver disease – Most anti-malarial drugs are metabolised by the liver and cannot be prescribed and therefore specialist help is required
- Severe kidney disease – because most anti-malarial drugs are excreted by the kidneys, they should not be prescribed in patients with severe kidney disease. You may take doxycycline or mefloquine instead, as they are not excreted by the kidneys
Table 1 Geographical distribution of malaria and resistance to anti-malarial drugs
| Resistance | Regions | Recommended chemoprophylaxis |
| Chloroquine-sensitive falciparum areas (or where resistance is not widespread) | North Africa, parts of Middle East, Central America, Argentina, Paraguay | Chloroquine or chloroquine plus proguanil (licensed in UK) |
| Chloroquine-resistant falciparum areas | Sub-Saharan Africa, parts of Middle East, South East Asia, Pacific islands | Atovaquone/proguanil (Malarone®) or mefloquine or doxycycline |
| Mefloquine-resistant areas | Borders of Burma, Laos, Thailand, Cambodia and Southern Vietnam | Atovaquone/proguanil (Malarone®) or doxycycline |
The Centers for Disease Control and prevention provide more detailed maps of resistance and malaria distribution.
Once your specialist decided on the most suitable drug for you, they will advise on when to start prophylaxis, how often to take it, and for how long. They should also ensure that you have an adequate supply of the drug for your entire trip. You should avoid purchasing anti-malarials abroad as counterfeit anti-malarial drugs are an increasing problem around the world.
Table 2 provides guidance on common drugs. Malarone (Atovaquone and proguanil is effective, convenient and also well tolerated but it is more expensive. Doxycycline is cheap and effective but may have more side effects.
Table 2 – Commonly used anti-malarial drugs for prophylaxis
| Drug | When and how to take | Special considerations | Contraindications | Common side effects |
| Mefloquine (trade name Lariam®) | Dosing: Once a week
Start: 1 week prior to travel Continue: for 4 weeks after last exposure |
Advise taking trial dose for 3 weeks before departure | Avoid during 12 weeks of pregnancy.Avoid if history of seizures or psychiatric illness. |
|
| Chloroquine | Dosing: Once a week
Start: 1 week prior to travel Continue: for 4 weeks after last exposure |
Commonly used in conjunction with proguanil for the Indian subcontinent | Avoid in epilepsy and psoriasis |
|
| Proguanil | Dosing: Once a day
Start: 1 week prior to travel Continue: for 4 weeks after last exposure |
Commonly used in conjunction with chloroquine for the Indian subcontinent | Caution with kidney disease and those on anticoagulation (delays metabolism of warfarin) |
|
| Doxycycline | Dosing: Once a day
Start: 1-2 days prior to travel Continue: for 4 weeks after last exposure |
Can cause skin photosensitivity and heartburn | Should not be taken in pregnancy and in children |
|
| Atovaquone/ proguanil (Malarone®) |
Dosing: Once a day
Start: 1 to 2 days prior to travel Continue: for 7 days after last exposure |
Expensive but useful for short trips as only need to take for 7 days after exposure. | Avoid in pregnancy |
|
If you are travelling to the tropics but are unsure about how to protect yourself from malaria, please call Travel Klinix 02476 016519 or email appointments@travelklinix.com to make an appointment.
So you’ve taken all the correct precautions but despite this you fall ill with a fever on your return. Do you have malaria? If so how do we confirm it? Next week we’ll take you to through the necessary steps to make an accurate diagnosis and thus potentially save your life.
