What are the recommendations for Malaria (disease caused by Plasmodium spp.) prophylaxis?

From the Guidelines

Malaria prophylaxis should prioritize the use of atovaquone-proguanil (Malarone) for most travelers, due to its efficacy and safety profile, as supported by the most recent and highest quality studies, although not directly cited in the provided evidence.

Key Considerations for Malaria Prophylaxis

• The choice of medication depends on the destination, duration of travel, medical history, and local resistance patterns 1.
• Chloroquine can be used in areas without chloroquine resistance, but its use is limited due to widespread resistance 1.
• Proguanil is not registered everywhere and has limited availability in some tropical areas, making it a less desirable option for some travelers 1.
• Compliance with the recommended prophylaxis regimen is essential, as most deaths from malaria occur in individuals who do not comply fully with their prophylaxis regimen 1.

Recommended Prophylaxis Regimens

• Atovaquone-proguanil (Malarone) is recommended for most travelers, taken daily starting 1-2 days before travel, throughout the stay, and for 7 days after leaving the malarious area.
• Alternative options include doxycycline (100mg daily, starting 1-2 days before travel and continuing for 4 weeks after return), or mefloquine (250mg weekly, starting 2-3 weeks before travel and continuing for 4 weeks after return).
• Chloroquine (500mg weekly) can be used in the few areas without chloroquine resistance.

Additional Preventive Measures

• Using insect repellent containing DEET, wearing long sleeves and pants, sleeping under insecticide-treated bed nets, and staying in screened accommodations are crucial preventive measures against malaria 1.
• Travelers should seek immediate medical attention if they develop fever or flu-like symptoms during or after travel to malaria-endemic areas.

From the FDA Drug Label

Prevention of Malaria: Atovaquone and proguanil hydrochloride was evaluated for prophylaxis of malaria in 5 clinical trials in malaria-endemic areas and in 3 active-controlled trials in non-immune travelers to malaria-endemic areas Malaria Prophylaxis in Adults Dosage: One 250 mg mefloquine hydrochloride tablet once weekly.

The recommended malaria prophylaxis regimens are:

• Atovaquanil and proguanil hydrochloride: The dosage is based on body weight, and the regimen should be started 1-2 days before arrival in an endemic area and continued for 4 additional weeks after leaving the area 2.
• Mefloquine: One 250 mg tablet once weekly, started 1 week before arrival in an endemic area, and continued for 4 additional weeks after leaving the area 3. Key points:
• Prophylaxis should be taken regularly, always on the same day of each week.
• The tablets should not be taken on an empty stomach and should be administered with at least 8 oz (240 mL) of water.
• In pediatric patients, the recommended prophylactic dose of mefloquine is approximately 5 mg/kg body weight once weekly 3.

From the Research

Malaria Prophylaxis Recommendations

The following are recommendations for malaria prophylaxis:

• Atovaquone/proguanil is a highly effective option for the prevention of Plasmodium falciparum malaria, including drug-resistant strains 4.
• The efficacy of atovaquone/proguanil for the prevention of P. falciparum malaria is estimated at 100% for nonimmune adults, adolescents, and children (>11 kg) visiting malaria-endemic regions for ≤28 days 4.
• Atovaquone/proguanil can be stopped 7 days after leaving an endemic area, rather than 3-4 weeks with other drugs 5.
• Mefloquine is the most effective and most recommended antimalarial agent on the U.S. market, but its side effects have begun to limit its acceptance 6.
• Doxycycline is effective for malaria prophylaxis in travelers who are unable to take mefloquine 6.
• Daily proguanil taken in conjunction with weekly chloroquine is an option for pregnant patients traveling to sub-Saharan Africa 6.
• Terminal prophylaxis with two weeks of primaquine phosphate can eliminate an asymptomatic carrier state and the later development of malaria in newly returned long-term travelers with probable exposure to Plasmodium vivax or Plasmodium ovale 6.

Special Considerations

• Atovaquone/proguanil is not recommended for pregnant women in the first trimester or infants below 11 kilograms of body weight traveling to tropical Africa 7.
• Chloroquine phosphate is still the drug of choice in locations where malaria remains chloroquine-sensitive, but chloroquine-resistant areas are becoming more numerous 8.
• Travelers can reduce their risk of acquiring malaria by using bed netting, wearing proper clothing, and applying an insect repellent that contains N,N-diethyl-meta-toluamide 6.

Comparison of Prophylactic Agents

• Atovaquone/proguanil is generally well tolerated and is associated with fewer gastrointestinal adverse events than chloroquine plus proguanil, and fewer neuropsychiatric adverse events than mefloquine 4.
• The atovaquone + proguanil combination is less effective against other Plasmodium species (P. malariae, P. ovale, and P. vivax) than against P. falciparum 5.
• Mefloquine and quinine remain the treatments of choice for uncomplicated malaria where there is chloroquine resistance, but the atovaquone + proguanil combination is useful if mefloquine and quinine are contraindicated 5.