Travel the world.


A STAMARIL Center
John D. Wilson, M.D.
1200 Hilyard St., Ste. 560
Eugene, Oregon 97401 USA
541.343.6028
fax 541.485.7702
www.TravelClinicOregon.com


MALARIA PREVENTION
 map 

the short version

Where there is malaria, you may become seriously ill if you don't take your pills as prescribed (either every day or every week). Please see the related handout on Mosquito Precautions. You may find the rest of this information interesting.

the long version

Malaria is caused by one-celled animals (called Plasmodia) transmitted by the bite of an infected female anopheles mosquito. Malaria causes fever, chills, headache, muscle aches and a general ill feeling; symptoms usually occur at intervals. Malaria may cause kidney failure, coma or death. Deaths due to malaria are preventable by using preventive medicines. Information on malaria risk in specific countries is available from various sources. The World Health Organization and the Centers for Disease Control are the best sources, but factors such as local weather conditions, mosquito density and prevalence of infection may have a different effect on local malaria transmission patterns from year to year. Locals will often provide useful information, but travelers need to be aware that locals sometimes minimize risk of a variety of diseases.

YOUR RISK OF CATCHING MALARIA Malaria transmission occurs in large areas of Central and South America, Hispanola, sub-Saharan Africa, the Indian subcontinent, Southeast Asia, the Middle East and Oceania, and is restricted to rural areas in some countries. The estimated risk of acquiring malaria may vary widely depending on intensity of transmission, itinerary, time of year, time of day and type of travel. American travelers import about 1000 cases into the US annually. About 60% of imported malaria (and most fatal cases; overall, about 4% of malaria is fatal) is acquired in sub-Saharan Africa, even though fewer Americans travel there. In contrast, an estimated 21 million Americans travel to malarious areas of Asia and Latin America each year, and bring home far fewer (about 30%) of the cases. This disparity in the risk of acquiring malaria is probably because travelers to Africa tend to spend considerable time (especially evening and nighttime hours) in rural areas where malaria risk is highest.

Estimating the risk of infection for different travelers is difficult, even among those who travel or reside temporarily in the same general areas within a country. For example, tourists staying in air-conditioned hotels are at lower risk than backpackers or adventure travelers. Similarly, long-term residents living in screened and air-conditioned housing are less likely to be exposed than missionaries or Peace Corps volunteers.

GENERAL ADVICE FOR TRAVELERS TO MALARIA ENDEMIC AREAS Travelers to malarious areas of the world are advised to use medications and personal protection measures to prevent malaria; however, travelers should be aware that regardless of methods employed, malaria still may be contracted. Malaria symptoms may develop as early as 8 days after initial exposure and as late as several months after departure from malarious area, and can occur after preventive medicines have been stopped, months after return. Travelers should understand that malaria can be treated effectively and easily early in the course of the disease, but that delay of appropriate therapy can have serious or even fatal consequences. Individuals who have symptoms of malaria should seek prompt medical evaluation including thick and thin blood smears as soon as possible.

CHEMOPROPHYLAXIS (prevention with medicines) When used as directed, these medications provide 99% protection from malaria. Malaria preventive treatment should usually begin before travel to malarious areas, should continue during travel in the malarious areas, and after leaving the malarious areas.

Malaria Prevention Regimens
**regimen A: For travel to areas of risk where chloroquine resistance has NOT been reported, once weekly use of chloroquine alone is recommended. The weekly dose is 500 mg, either one (1) 500 mg pill or two (2) 250 mg pills weekly. Chloroquine is usually very well tolerated. Chloroquine should begin 1 week before travel to malarious areas. It should be continued weekly during travel and for 4 weeks after leaving the area.

The estimated cost for chloroquine at a pharmacy is $50. - 70. for a 3 week exposure.

**regimen B: For travel to areas where chloroquine resistance DOES exist, use of doxycycline, mefloquine (Lariam) or Malarone is important. Doxycycline and Malarone are taken daily. Mefloquine (Lariam) should begin 2 weeks before travel to malarious areas. It should be continued weekly during travel and for 4 weeks after leaving the malarious area. Test doses of Lariam may be recommended (please see the chart below). NOTE: In some countries a fixed combination of mefloquine and Fansidar is marketed under the name Fansimef. Fansimef should not be confused with mefloquine and is not recommended for prevention of malaria.
 

prevention of malaria
  generic name brand name dose and
how often
start take medicine for how long after leaving area
regimen A: chloroquine Aralen 500 mg weekly one week before risk weekly for four weeks
     after risk
regimen B: mefloquine Lariam 250 mg weekly two weeks before risk
or doxycycline use
generic
100 mg daily one day
before risk
daily for four weeks
after risk
or atovaquone 250 mg
and 100 mg proguanil
Malarone one pill daily one day
before risk
daily for seven days
after risk

ADVERSE EFFECTS OF ANTIMALARIALS
Chloroquine
and hydroxychloroquine may rarely cause nausea, headache, dizziness, blurred vision or itching when taken in preventive doses for malaria, but generally these do not require stopping the drug. High doses of chloroquine used to treat rheumatoid arthritis have been associated with eye disease, but not with the very low doses used for malaria prevention or treatment. Chloroquine has been reported to worsen psoriasis. Chloroquine is so safe that it may be used to treat pregnant women.

Mefloquine (Lariam) can cause nausea and dizziness in preventive doses, but these symptoms tend to be mild, brief and self-limited. Vivid dreams and restless sleep may occur, and do not necessitate stopping treatment. Serious adverse reactions (confusion, psychosis, hallucinations or convulsions) are rare (one in 10,000) at low, preventive doses; these reactions are more frequent with higher dosages used in treatment of diagnosed malaria. Travelers considering taking Lariam for the first time should take four or five (4 - 5) weekly test doses while still at home to see if any side effects occur. An alternative may be substituted should side effects occur. Mefloquine is not recommended for use by travelers with a known hypersensitivity to mefloquine, travelers with heart conduction abnormalities, travelers involved in tasks requiring fine coordination and spatial discrimination (such as airline pilots or scuba divers), and travelers with a history of epilepsy, bipolar diease or psychosis. Studies to date confirm that mefloquine is well tolerated in 95% of travelers when taken weekly; however, those who may have a severe adverse reaction should consult their physician and the reactions should be reported to Malaria Branch, CDC, telephone (404) 488-4046. Beware of counterfeit drugs purchased outside the U.S.


Doxycycline may cause photosensitivity (sun sensitivity or an exaggerated sunburn reaction). The risk of such a reaction can be minimized by avoiding prolonged direct exposure to the sun and using sunscreens that absorb long-wave ultraviolet (UVA) radiation. Doxycycline use is theoretically associated with an increased frequency of yeast infection in women. Esophagitis, causing nausea, heartburn or abdominal pain, may occur and may be minimized by taking the drug with a meal followed by two large glasses of water, and not lying down within several hours after taking a dose. Test doses are often recommended before departure. Doxycycline should not be used in possible pregnancy or in children under age 8 years.

Malarone may be used in travelers weighing over 24 pounds. The main adverse effect the possibility of interaction with some prescription medications. Your list of medications taken each day should be evaluated for this problem if you are going to use Malarone. Malarone should not be used in pregnancy.

TREATMENT OF MALARIA  The malignant form of malaria may be rapidly fatal. If fever (consider taking a thermometer) indicating possible malaria occurs while overseas, medical care should be sought immediately. If it is known that significant time will be spent distant from medical care (over 12-24 hour transport time), and Malarone is not being used as the preventive medication, you may wish to carry treatment doses of Malarone (4 pills daily for 3 days). In this situation, medical advice should be sought after taking Malarone since about half of those who develop an illness with fever while in an area with malaria have an illness besides malaria.

PREVENTION OF RELAPSES
 Malaria parasites can persist in the liver and cause relapses for many years after chloroquine, mefloquine, doxycycline or Malarone are discontinued. Travelers to malarious areas should know that if fever occurs after leaving a malarious area, they should report their travel history and the possibility of malaria to a physician as soon as possible.

Primaquine decreases the risk of relapses by acting against the liver stages of malaria. Even if a traveler feels well, this drug should be given after the traveler has left a malarious area in which there have been numerous mosquito bites. Primaquine is usually taken during the last 2 weeks of the period of the primary preventive medication (either chloroquine, mefloquine, doxycycline or Malarone) after exposure in malaria-endemic areas.

For considerations for children, pregnancy and breast feeding, see more complete information in Health Information for International Travel published by the CDC. Detailed recommendations for the prevention of malaria are available 24 hours a day by calling the CDC Malaria Hotline at (404) 332-4555.
 

Options For Prevention Of Chloroquine-Resistant Malaria

 

doxycycline
(generic)

Lariam
(mefloquine)

Malarone (atovaquone/proguanil)

taken

daily

weekly (preferred)

daily

start

one day before *

two weeks before *

one day before *

finish

four weeks after *

four weeks after *

seven days after *

efficacy

98% if no missed doses

99+%

98% if no missed doses

treatment rescue?

Malarone

Malarone

?

 side effects

1-2% sun sensitivity,
1-2% vaginitis;
10-20% heartburn

common minor brain side effects; rare (0.01%) serious brain side effects

about the same
as placebo

nausea

10%

8%

2%

abdominal pain/heartburn

10%

- - - - -

- - - - -

dreams

- - - - -

14%

2%

insomnia

- - - - -

13%

3%

dizzyness

- - - - -

9%

2%

depression

- - - - -

4%

<1%

anxiety

- - - - -

4%

<1%

any neuropsych

- - - - -

29%

<1%

any side effect

- - - - -

42%

10%

test doses?

usually first time

first time only

no

cost

this office

pharmacy

this office

pharmacy

this office

pharmacy
 

1 week exposure

36 pills = $20.

?

8 pills =  $56.

$78.

15 pills =  $105.

$150.

2 week exposure

43 pills = $20.

?

9 pills =  $63.

$84.

22 pills =  $154.

$208.

3 week exposure

50 pills = $20.

?

10 pills =  $70.

$92.

29 pills =  $203.

$266.

4 week exposure

57 pills = $40.

?

11 pills =  $77.

$100.

36 pills =  $252.

$324.

 * being in an area at risk for malaria

** Note that insurance companies will not reimburse for medications dispensed in physician offices.  

Pharmacies can advise whether an insurance company will cover a certain medication.

 

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  John D. Wilson, M.D. 1999-2016; Last Update 4/23/2016