What are the recommendations for malaria prophylaxis (preventive measures)?

From the Guidelines

Travellers to malarious areas must take chemoprophylaxis, in addition to avoiding mosquito bites and urgently seeking early diagnosis and treatment for febrile illness, as no prophylaxis is infallible. When considering malaria prophylaxis, it is crucial to prioritize measures that prevent infection, given the increasing drug resistance in many areas 1. The key to preventing malaria is avoiding infective mosquito bites by using repellents, covering up at night, and sleeping with bednets if mosquitos cannot be excluded from the room.

Key Considerations for Malaria Prophylaxis

• Avoiding mosquito bites is paramount, and this can be achieved through the use of repellents, covering up, especially at night, and utilizing bednets.
• Chemoprophylaxis is essential but must be chosen based on the most current recommendations due to increasing drug resistance.
• Standby treatment may be necessary for individuals who will be in areas where medical services are not readily accessible.
• All febrile or flu-like illnesses occurring within a year of returning from malarious regions should be urgently investigated for malaria.

Given the information from 1, while specific drug regimens are not detailed, the emphasis on avoiding mosquito bites, taking appropriate chemoprophylaxis, and being vigilant for symptoms post-travel underscores the multifaceted approach to malaria prevention. It's also important to consider that guidelines may have evolved since the study was published, but the core principles of prevention remain critical.

Practical Application

In real-life clinical practice, determining the most appropriate malaria prophylaxis involves considering the traveler's destination, the presence of drug resistance in the area, and the individual's health status, including any concomitant illnesses or conditions such as pregnancy. Consulting with a travel medicine specialist is advisable to tailor the prophylaxis regimen to the individual's specific needs and travel plans.

From the FDA Drug Label

Doxycycline offers substantial but not complete suppression of the asexual blood stages of Plasmodium strains. Patients taking doxycycline for malaria prophylaxis should be advised:

• that no present-day antimalarial agent, including doxycycline, guarantees protection against malaria.
• to avoid being bitten by mosquitoes by using personal protective measures that help avoid contact with mosquitoes, especially from dusk to dawn (e.g., staying in well-screened areas, using mosquito nets, covering the body with clothing, and using an effective insect repellent).
• that doxycycline prophylaxis:
  • should begin 1 to 2 days before travel to the malarious area,
  • should be continued daily while in the malarious area and after leaving the malarious area,
  • should be continued for 4 further weeks to avoid development of malaria after returning from an endemic area,
  • should not exceed 4 months

Malaria Prophylaxis with Doxycycline:

• Start prophylaxis 1 to 2 days before travel to a malarious area.
• Continue daily while in the malarious area and after leaving.
• Continue for 4 weeks after returning from an endemic area.
• Do not exceed 4 months of prophylaxis.
• No guarantee of protection against malaria, so personal protective measures are also necessary. 2

From the Research

Malaria Prophylaxis Options

• Malaria is largely preventable, and travelers should be taught general protective measures and given appropriate chemoprophylaxis before they leave on their trip 3
• Chloroquine phosphate is still the drug of choice in locations where malaria remains chloroquine-sensitive, but chloroquine-resistant areas are becoming more numerous 3
• In chloroquine-resistant areas, mefloquine hydrochloride, doxycycline, or proguanil may be used 3
• Atovaquone-proguanil is a recommended option for malaria prophylaxis, with a lower frequency of treatment-related gastrointestinal adverse events compared to chloroquine-proguanil 4

Comparison of Malaria Prophylaxis Regimens

• Atovaquone-proguanil and doxycycline are the best tolerated regimens, while mefloquine is associated with adverse neuropsychiatric outcomes 5
• Mefloquine users are more likely to report abnormal dreams, insomnia, anxiety, and depressed mood compared to atovaquone-proguanil users 6
• Mefloquine users are also more likely to report nausea and dizziness compared to atovaquone-proguanil users 6
• Primaquine should be considered as the chemoprophylactic agent of choice for areas with high co-circulation of P. falciparum and P. vivax 7

Efficacy and Safety of Mefloquine

• Mefloquine is one of four antimalarial agents commonly recommended for preventing malaria in travelers to malaria-endemic areas 6
• Mefloquine has high efficacy, but there is controversy about its psychological side effects 6
• The choice of antimalarial agent depends on how individual travelers assess the importance of specific adverse effects, pill burden, and cost 6

Vivax Malaria Chemoprophylaxis

• Atovaquone-proguanil is considered causal prophylaxis for Plasmodium falciparum, but its causal prophylactic efficacy for Plasmodium vivax is not known 7
• Short-course atovaquone-proguanil appears to provide causal prophylaxis for P. vivax, but is ineffective against late, hypnozoite reactivation-related attacks 7