Prophylaxis Regimens

Treatment

1. Doxycycline 100 mg daily

Begin 1–2 days before travel to malaria-endemic areas, continue while in malaria-endemic areas, and daily for 4 weeks after leaving the endemic areas. Give 2.2 mg/kg body weight (maximum 100 mg per day). Prophylaxis in all malaria-endemic areas. It can cause photosensitivity skin reactions. Strongly contraindicated during pregnancy, breastfeeding and in children aged < 8 years.

2. Mefloquine (Lariam) 250 mg weekly

Begin taking ≥ 2 weeks before travel to malaria-endemic areas. Take 1 tablet weekly, on the same day each week while in endemic areas. Continue taking 1 tablet once a week for another 4 weeks after leaving endemic areas. Give 5 mg/kg body weight. Good choice for long trips because it is taken once a week. Can be used in all trimesters of pregnancy and during breastfeeding. Contraindicated in pilots. Not a good choice for last-minute travellers because drug needs to be started at least 2 weeks before travel.

Some people react badly — headache, insomnia, and feeling of unreality. In very few people there may be serious effects: psychosis, ataxia, convulsions. Avoid mefloquine in people with a history of cardiac disease, neurological disease or depression, and in those taking beta blocking drugs. Quite expensive, and not widely available in Malawi.

3. Atovaquone 250 mg-Proguanil 100 mg (Malarone) daily

Begin 1–2 days before travel to malaria-endemic areas, continue while there, and daily for 7 days after leaving. Suitable only for short-term use because of cost. It has the advantage that it needs to be taken only once a day and for only one week after exposure ends. Prophylaxis in all malaria-endemic areas. Contraindicated in people with severe renal impairment (creatinine clearance < 30 mL/min), children weighing < 5 kg, women who are pregnant or breastfeeding, and infants weighing < 5 kg.

4. Chloroquine 300 mg (base) — 2 tablets weekly

Chloroquine may now be efficacious in Malawi (P. falciparum resistance was extensive in the 1990s but has now diminished) but should be combined with daily proguanil. Chloroquine causes itching in 40% of black people. Avoid in persons with psoriasis or epilepsy. Give 5 mg/kg base. Begin taking 1–2 weeks before travel to malaria-endemic areas, continue on the same day each week while in endemic areas, and weekly for another 4 weeks after leaving the endemic areas.

There is risk of retinal damage if chloroquine is taken every week for more than 5 years. For clients expected to use chloroquine for longer than 5 years, a baseline retinal exam should be conducted at the onset of prophylaxis, and annual exams should be conducted beginning after 5 years of use.

5. Proguanil (Paludrine) 200 mg daily

Very few problems. Mouth ulcers sometimes troublesome. Moderately effective. Should combine with an additional drug such as weekly chloroquine. Chloroquine and proguanil are safe in pregnancy.