Malaria chemoprophylaxis

Background

• Chemoprophylaxis is recommended for travelers to endemic areas
• Agent chosen based on the local drug-resistance, patient age, and pregnancy status
• Also need to focus on personal protective measures such as bed nets, long-sleeved clothing, and insect repellant

Chemoprophylaxis Selection

Chloroquine-Sensitive Regions

• Regions include Haiti, the Dominican Republic, Central America north of the Panama Canal, parts of Mexico, parts of South America, north Africa, parts of the Middle East, and west/central China
  • See the CATMAT list for specific countries
• Drugs of choice
  • Chloroquine (Aralen) preferred, though hydroxychloroquine (Plaquenil) is also acceptable
  • Alternatives: atovaquone-proguanil, doxycycline, or mefloquine

Chloroquine-Resistant Regions

• Regions include most of sub-Saharan Africa, South America, Oceania and Asia
  • See the CATMAT list for specific countries
  • Some areas of Thailand, Myanmar (Burma), Laos and Cambodia, and southern Vietnam are both chloroquine-resistant and mefloquine-resistant
• Drugs of choice
  • Atovaquone-proguanil
  • Doxycycline
  • Mefloquine
  • Alternatives: Primaquine (contraindicated in G6PD deficiency and pregnancy)

Chloroquine- and Mefloquine-Resistant Regions

• Regions include Asia, Africa and the Amazon basin, specifically in rural, wooded regions on the Thai borders with Myanmar, Cambodia, and Laos, as well as in southern Vietnam
• Drugs of choice
  • Atovaquone-proguanil
  • Doxycycline
  • No approved drugs for pregnancy or children less than 5 kg, though atovaquone-proguanil may be considered after the first trimester

Pregnancy

• Mefloquine can be used, if they cannot avoid travelling to malaria-endemic areas
  • Can cause neuropsychiatric symptoms
• Atovaquone-proguanil may be considered after the first trimester

Chemoprophylaxis Doses

• Note that the medications that require 4 weeks after end of exposure are extended in this way because they do not treat the liver stage

Medication	Dose	Start	Stop
Atovaquone-proguanil	250 mg-100 mg po daily	1 day before	1 week after
Doxycycline	100 mg po daily	1 day before	4 weeks after
Mefloquine	250 mg po weekly	1-3 weeks before	4 weeks after
Primaquine	30 mg base po daily	1 day before	1 week after
Chloroquine	300 mg po weekly	1 week before	4 weeks after
Hydroxychloroquine	310 mg base po weekly	1 week before	4 weeks after