Malaria Chemoprophylaxis

Aka: Malaria Chemoprophylaxis, Malaria Prophylaxis

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II. Precautions

  1. Malaria Prophylaxis taken exactly as prescribed does not ensure complete protection
  2. Malaria may still occur at 1 week to 1 year after Parasite infection
  3. Malaria may also recur after completing treatment

III. Protocol

  1. Always check CDC for resistance before prescribing
    1. CDC Travelers Health for regional recommendations
      1. http://www.cdc.gov/travel
  2. Chemoprophylaxis is for prevention only
    1. Dosing below does not apply to Malaria treatment
  3. Chemoprophylaxis Schedule
    1. Agents are started 1-2 weeks before travel
    2. Agents are continued for 4 weeks after travel

IV. Prevention: First-Line Chemoprophylaxis

  1. See dosing protocol as above (i.e. starting before and ending after travel)
  2. Always recheck the CDC Travel Website (Yellow book) for current resistance guidelines
  3. Indications (Areas of no Chloroquine Resistance)
    1. Mexico
    2. Caribbean
    3. Haiti and Dominican Republic (Island of Hispanioia)
    4. Central America (west of Panama canal)
    5. Argentina
    6. Some areas in Middle East
    7. Some areas of China
  4. Chloroquine (Aralen)
    1. Safe in pregnancy (all trimesters)
    2. Adult: 500 mg salt (300 mg base) orally once weekly
    3. Child: 8.3 mg/kg salt (5 mg/kg of base, up to adult dose) once weekly
  5. Hydroxychloroquine (Plaquenil)
    1. Adult: 400 mg salt (310 mg base) orally once weekly
    2. Child: 6.5 mg/kg salt (5 mg/kg of base, up to adult dose) once weekly

V. Prevention: Second-line chemoprophylaxis with Mefloquine (if No Mefloquine resistance)

  1. Indications
    1. Chloroquine resistance
  2. Contraindications (relative)
    1. Seizure Disorder
    2. Cardiac conduction abnormality
    3. Psychosis history or other significant psychiatric history
  3. Mefloquine (Lariam)
    1. See Mefloquine for neuropsychiatric and vestibular adverse effects (FDA black box warnings)
    2. Safe in second and third trimesters of pregnancy (avoid in first trimester)
    3. Adult: 250 mg salt (228 mg base) orally weekly
    4. Child: Safe over 3 months of age
      1. See Mefloquine for pediatric dosing

VI. Prevention: Second-line chemoprophylaxis with Tafenoquine

  1. Indications
    1. Chloroquine Resistance
  2. Contraindications
    1. G6PD Deficiency
      1. All patients must be tested for G6PD before starting Tafenoquine
      2. Order quantitative G6PD Test ($40 and returned within days)
    2. Pregnancy (including for conception up to 3 months after last dose)
      1. Reliable Contraception should be continued for 3 months after last dose
      2. Use Mefloquine instead
    3. Children
      1. Use Mefloquine or Atovoquine/Proguanil (or Doxycycline if >8 years old) instead
    4. Psychosis history
  3. Tafenoquine (Arakoda)
    1. Adults: 100 mg daily for 3 days before travel, weekly while traveling, then once on return from travel
  4. References
    1. (2019) Presc Lett 26(8):47

VII. Prevention: Third-Line Chemoprophylaxis

  1. Indications
    1. Short term travel to Chloroquine resistance areas
    2. Children (if not using Mefloquine)
    3. Mefloquine resistance areas
      1. Thailand - Cambodia border
      2. Thailand - Myanmar (Burma) border
  2. Protocol for Doxycycline and Malarone
    1. Differs from protocol with Chloroquine and Mefloquine (which are instead taken weekly)
    2. Start 1-2 days before travel
    3. Continue for 4 weeks after return from travel
  3. Doxycycline (Vibramycin)
    1. Contraindicated in lactating women and children under age 8 years
    2. Adverse effects include photosensitivity (Sunburn risk) and pill eophagitis
    3. Adult Dosing: 100 mg orally daily
    4. Pediatric Dosing (may use if older than age 8)
      1. Dose: 2.2 mg/kg/day up to 100 mg orally daily
  4. Atovaquone/Proguanil (Malarone)
    1. Contraindicated if GFR <30 ml/min, pregnancy, Lactation in <5 kg infant
    2. Adults: 1 tablet (250 mg/100 mg) orally daily
      1. Start 1-2 days before travel
      2. Stop 7 days after return
    3. Children
      1. See Malarone

VIII. Prevention: Chemoprophylaxis with other agents (adult dosing)

  1. Azithromycin (Zithromax) 250 mg PO qd
  2. Pyrimethamine with sulfadoxine (Fansidar)
  3. Tafenoquine (Etaquine)
    1. Contraindicated in G6PD Deficiency, and Psychotic Disorder
    2. Not recommended for children
    3. Adult dosing
      1. Loading Dose: 200 mg once daily for 3 days before travel
      2. Maintenance Dose: 200 mg once per week, starting 7 days after loading dose
      3. Terminal Dose: 200 mg once, 7 days after last maintenance dose
  4. Primaquine
    1. Indicated in short-term travel to areas with >90% Plasmodium VivaxMalaria (some regions of central and south america)
    2. Contraindicated in G6PD Deficiency
    3. Start 1-2 days before travel and continue for 7 days after return
    4. Adult Dose: 52.6 mg salt (30 mg base) orally daily
    5. Child Dose: 0.8 mg/kg salt (0.5 mg/kg base) up to adult dose orally daily

IX. Prevention: Terminal Chemoprophylaxis

  1. Indications (on leaving endemic area)
    1. Prolonged exposure to P. vivax or P. ovale
    2. Taken for 14 days on leaving endemic area
  2. Contraindications
    1. Pregnancy (Pregnancy Category C)
    2. G6PD Deficiency
  3. Adult dose
    1. Primaquine 52.6 mg (30 mg base) orally daily for 14 days

X. Management: Emergency treatment prescription

  1. Indications
    1. Patients refusing Malaria Prophylaxis
    2. Travel to remote areas without medical facilities
  2. Protocol
    1. Start one of the followin agents at the first onset of fever, chills, or Muscle aches
    2. Prescribe 3 day course of one of the following agents
  3. Preparations
    1. Atovaquone/Proguanil (Malarone) high dose or
    2. Artemether/Lumefantrine (Coartam)

XI. Resources

  1. CDC Malaria hotline (physicians)
    1. Phone: 855-856-4713
  2. CDC Malaria Facts
    1. http://www.cdc.gov/malaria/about/facts.html

XII. References

  1. Gilbert (2001) Sanford Guide, p. 88
  2. Kain (2001) Clin Infect Dis 33:226-34 [PubMed]
  3. Lo Re (2003) Am Fam Physician 68(3):509-16 [PubMed]
  4. Freedman (2008) N Engl J Med 359(6): 603-12 [PubMed]
  5. Johnson (2012) Am Fam Physician 85(10): 973-7 [PubMed]
  6. Sanford (2016) Am Fam Physician 94(8): 620-7 [PubMed]
  7. Shahbodaghi (2022) Am Fam Physician 106(3): 270-8 [PubMed]

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