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Malaria Risk awareness When travelling to malarious areas you must be aware of the risk of malaria, take action to reduce the risk, and seek medical advice urgently if you get a fever or flu-like symptoms. Preventing or avoiding bites by mosquitoes Sleep in rooms that are properly screened. Spray the room with a knockdown insecticide in the late afternoon. When sleeping outdoors use impregnated mosquito nets around the bed. Alternatively mosquito coils may be burned. Long-sleeved clothing, loose long trousers and socks should be worn outdoors in the evening. Light colours are less attractive to mosquitoes. Insect repellents containing over 30% DEET will repel mosquitoes. Refined lemon eucalyptus oil on skin also repels mosquitoes. These can be applied to exposed skin. Compliance with appropriate antimalarials Taking the full course of the appropriate antimalarials is essential; most deaths occur in those who take the drugs irregularly or not at all. Start the medication before going abroad, continue medication while in the malarious area and for the appropriate time for that antimalarial after leaving the area. A drug that is not taken offers no protection and to take antimalarials irregularly is a dangerous risk to take. To minimise side effects you should take antimalarials after meals, with a drink. Z Drive, Leaflets 2009, Travel 06/01/09 Prompt diagnosis of Malaria Malaria can present up to 1 year after return from travelling therefore if you have any flu-like symptoms report this promptly to a doctor and let them know that you have been to a malarious area. You can get further information from: Fit for Travel A public website, provided by Health Protection Scotland (HPS), which gives travel health information for people travelling abroad from the UK. Website: www.fitfortravel.scot.nhs.uk International Travel Health This website provides information on malaria from the World Health Organisation, including travel requirements for every country in the world. Website: http:/www.who.int/ith/ For multiple country journeys, we recommend that an antimalarial drug is selected to suit the most drug resistant area on the itinerary. This drug would be used for the full trip rather than swapping and changing from one drug to another. Commonly used antimalarial regimes: The information given is for guidance only. Chloroquine Chloroquine is the antimalarial drug of choice for travellers to malarious areas where there is no resistance to chloroquine. You should start taking chloroquine one week before entering the malarious area, continue during your stay and continue for 4 weeks after leaving. UK trade names Avloclor, Nivaquine Dose (adults) 300mg of chloroquine base weekly. In the UK chloroquine is supplied as tablets containing 150mg of base so two tablets are taken weekly. Common side effects Chloroquine commonly causes minor symptoms of gastrointestinal upset usually on the day the drug is taken. These can be minimised by taking the drug after the last meal at night. Chloroquine sometimes causes headaches and may cause itching (particularly in dark skinned people). Occasionally the drug causes hair loss which is usually reversible and may cause temporary blurring of vision (often on the day after taking the drug). Who should not take chloroquine? Chloroquine should not be used by people who have epilepsy if they have had a seizure within the last 2 years or are taking antiepileptic drugs. Chloroquine may worsen psoriasis. A reduced dose may be needed in people with renal failure. Proguanil Proguanil may be used as an alternative to chloroquine in malarious areas where there is no resistance to chloroquine. You should start taking proguanil one week before entering the malarious area, continue during your stay and continue for 4 weeks after leaving. UK trade names Paludrine Dose (adults) 200mg of proguanil should be taken daily. In the UK proguanil is supplied as 100mg tablets so two tablets are taken daily. Common side effects Mild gastrointestinal upset may occur. The drug may cause mouth ulcers but this is more common when it is taken in combination with chloroquine (see below). Who should not take proguanil? The dose of the drug may need to be reduced in severe renal failure. Proguanil may affect the dose of anticoagulants needed for those on long term treatment. Proguanil is safe in pregnancy but a folate supplement should be used (such as folic acid 5mg daily). Chloroquine plus proguanil This combination is used to provide protection in areas where there is limited to moderate chloroquine resistant malaria. You should start taking chloroquine and proguanil one week before entering the malarious area, continue during your stay and continue for 4 weeks after leaving. UK trade names Chloroquine - Avloclor, Nivaquine Dose (adults) 300mg of chloroquine base should be taken weekly plus 200mg of proguanil should be taken daily. In the UK this means Proguanil – Paludrine taking two tablets of chloroquine weekly and two tablets of proguanil daily. Common side effects See above for individual side effects. Mouth ulcers are more common with this combination than when proguanil is taken alone. Who should not take this combination? See above for individual contraindications. Doxycycline Doxycycline is a useful alternative to mefloquine or Malarone for travellers going to areas where there are high levels of chloroquine resistance (e.g. much of Sub-Saharan Africa). You should start taking doxycycline a couple of days before entering the malarious area, continue during your stay and continue for 4 weeks after leaving. UK trade names Vibramycin Dose (adults) 100mg taken once daily. Common side effects If the contents of the capsule/tablet come into contact with the oesophagus (the tube from the mouth to the stomach) they may irritate it leading to unpleasant "heartburn" symptoms. To prevent this it is important to wash down the capsule/tablet with plenty of water. It is also wise not to lie down immediately after taking the drug (to avoid reflux). As doxycycline is an antibiotic it may cause diarrhoea (paradoxically it will treat some causes of travellers diarrhoea) and may increase the incidence of vaginal thrush especially in those prone to this problem. Rarely, doxycycline may sensitise the skin to the sun (approximately 3% of people taking this dose of doxycycline will be affected) leading to an unpleasant rash or increased risk of sunburn. It is wise to use high factor sun screens covering both UVA and UVB. Travellers taking the combined oral contraceptive pill should take extra contraceptive precautions for the first 3 weeks of taking doxycycline. The Health Protection Agency have published some additional information for these travellers. Who should not take doxycycline? Pregnant women and children under 12 years of age should not take this drug. Malarone Malarone is a combination drug containing 250mg of atovaquone and 100mg of proguanil. A paediatric tablet is also now available containing 1/4 of the adult dose. Malarone has recently been licensed for the prevention of malaria by the UK authorities after large trials demonstrated that it was very effective and well tolerated. The drug is a suitable alternative to mefloquine and doxycycline for areas where there is significant chloroquine resistance (e.g. much of Sub-Saharan Africa). At present Malarone is not licensed for trips lasting longer than 28 days. However, we have seen safety studies on longer term use and current UK guidelines suggest it can be used for up to one year with caution. You should start Malarone 24 - 48 hrs before entering the malarious area, continue during your stay and for 7 days after leaving. UK trade names Malarone Dose (adults) 1 tablet taken once daily. Malarone should be taken with food or a milky drink at the same time each day. Dose (children) Each paediatric Malarone tablet is a quarter of the adult tablet. Dosage is weight related and licensed for children weighing 1139kg. Common side effects Side effects appear to be uncommon and are generally mild. In trials the most common side effects reported were headache, abdominal pain and diarrhoea. These side effects were also reported in people who were taking a placebo drug so it is difficult to decide if they were directly attributable to Malarone. Who should not take Malarone? There is insufficient data to recommend the use of Malarone in pregnancy or when breast-feeding. Malarone is not licensed for children under 11kgs. Mefloquine Mefloquine is an effective antimalarial for those at high risk of highly chloroquine resistant malaria. You should start taking mefloquine at least one week (ideally two or three weeks) before entering the malarious area, continue during your stay and continue for 4 weeks after leaving. UK trade names Lariam Dose (adults) 250mg of mefloquine taken weekly. In the UK this equates to one tablet of mefloquine weekly. Common side effects Mefloquine is a prescription only drug and is not suitable for everybody. Its use should be discussed with your travel health adviser. A study by MASTA and The London School of Hygiene and Tropical Medicine, published in the British Medical Journal (BMJ) shows that about 1 in 140 people taking mefloquine will experience temporarily disabling neuropsychiatric side effects. A previous study showed that very serious side effects can be expected in 1 in 10,000 people taking this drug. Most people who get side effects will develop them after the first few doses. We recommend that you start taking mefloquine 2 or 3 weeks before you are due to leave, so that if you develop early side effects an alternative can be found. For most countries where mefloquine is advised a suitable alternative is either doxycycline or Malarone. The most common side effects with mefloquine include dizziness, headache, gastrointestinal disturbances and sleep disorders. Who should not take mefloquine? It is particularly important to discuss the use of mefloquine with your travel health advisor if: • You have had fits or seizures in the past or any member of your immediate family suffers from fits or seizures. • You have a history of psychiatric illness. Depression should be included as a psychiatric illness but only if it was bad enough to require treatment. Travellers with a tendancy to be anxious may also want to avoid this drug. • You are in the first 3 months of pregnancy or you are planning to become pregnant within 3 months of stopping mefloquine unless after expert consulation this is considered to be the best option. • You will be undertaking activities which require precision (for example piloting a plane, scuba diving etc.) as mefloquine can cause dizziness.