What antimalarial medication is recommended for travel to Africa?

Antimalarial Recommendations for Travel to Africa

For travelers to sub-Saharan Africa, atovaquone-proguanil is the recommended first-line antimalarial prophylaxis due to its high efficacy against chloroquine-resistant Plasmodium falciparum, excellent safety profile, and convenient dosing regimen. 1

Antimalarial Options Based on Region

Sub-Saharan Africa

The risk of malaria is high throughout sub-Saharan Africa, with chloroquine-resistant falciparum malaria being common. Deaths from malaria in travelers are most frequently associated with malaria contracted in Africa, especially Kenya 2.

• First-line: Atovaquone-proguanil

  • Daily dosing, starting 1-2 days before travel
  • Continue daily during travel and for 7 days after leaving the area 1
  • Better compliance due to shorter post-travel dosing (7 days vs 4 weeks) 1, 3

• Alternatives:

  • Mefloquine: 250mg weekly, starting 1-2 weeks before travel, continuing during travel and for 4 weeks after 1, 4
  • Doxycycline: Daily dosing, starting 1-2 days before travel, continuing during travel and for 4 weeks after 2, 1

North Africa

Malaria risk is very low in most tourist areas of North Africa. For most areas, avoiding mosquito bites and being aware of malaria symptoms is sufficient 2.

Selection Criteria Based on Patient Factors

Contraindications and Special Populations

1. Psychiatric history:

   • Avoid mefloquine in patients with psychiatric disorders or epilepsy 1
   • Mefloquine can cause anxiety, depression, sleep disturbances, and rarely hallucinations 1

2. Pregnancy:

   • Chloroquine and proguanil have a long history of safe use during pregnancy 2
   • Mefloquine can be used in second and third trimesters 2
   • Doxycycline is contraindicated in pregnancy 1

3. Children:

   • For children ≥15 kg: Same options as adults with adjusted dosing
   • For children <15 kg: Chloroquine is recommended as mefloquine is contraindicated 1
   • Doxycycline should be avoided in children <8 years 1

4. Renal impairment:

   • Mefloquine or doxycycline may be used since they are largely metabolized and excreted through the liver 2

Efficacy and Side Effect Considerations

Atovaquone-proguanil

• Highly effective against drug-resistant strains of P. falciparum 3
• Well-tolerated with fewer gastrointestinal adverse events than chloroquine plus proguanil 3
• Fewer neuropsychiatric adverse events than mefloquine 3
• Main side effects: digestive issues, more common in backpackers than in those visiting friends and relatives 5

Mefloquine

• Effective against chloroquine-resistant P. falciparum 2
• Side effects include neuropsychiatric reactions (anxiety, depression, sleep disturbances) 1
• Contraindicated for tasks requiring fine coordination 1

Doxycycline

• Effective alternative when other medications are contraindicated 2
• Side effects include photosensitivity and gastrointestinal issues 1
• Daily dosing required (compliance challenge) 1

Important Considerations

1. Start prophylaxis before travel:

   • Atovaquone-proguanil: 1-2 days before travel
   • Mefloquine: 1-2 weeks before travel
   • Doxycycline: 1-2 days before travel 1

2. Continue prophylaxis after leaving malarious area:

   • Atovaquone-proguanil: 7 days after
   • Mefloquine and doxycycline: 4 weeks after 1

3. Personal protective measures are essential:

   • DEET-containing repellent
   • Long-sleeved clothing treated with permethrin
   • Mosquito nets at night 1

4. Post-travel vigilance:

   • Seek medical attention immediately if fever develops within 3 months of return
   • Breakthroughs can occur on all regimens 2

Common Pitfalls to Avoid

1. Inadequate duration of prophylaxis
2. Poor compliance with daily medications
3. Inappropriate medication selection based on resistance patterns
4. Ignoring drug interactions
5. Failing to recognize symptoms of malaria after return 1

Remember that no antimalarial guarantees 100% protection, making personal protective measures against mosquito bites essential for all travelers to malaria-endemic regions.