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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.