Malaria Chemoprophylaxis

1. See Also
   1. Malaria
   2. Prevention of Vector-borne Infection
2. 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
3. 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
4. Prevention: First-Line Chemoprophylaxis
   1. Indications (Areas of no Chloroquine Resistance)
      1. Mexico
      2. Caribbean
      3. Central America
      4. Argentina
      5. Some areas in Middle East
      6. Some areas of China
   2. Chloroquine (Aralen)
      1. Safe in pregnancy (all trimesters)
      2. Adult: 500 mg (300 mg base) orally once weekly
      3. Child: 8.3 mg/kg (5 mg/kg of base) once weekly
5. Prevention: Second-line chemoprophylaxis (if No Mefloquine resistance)
   1. Indications
      1. Chloroquine resistance
   2. Contraindications (relative)
      1. Seizure disorder
      2. Cardiac conduction abnormality
      3. Psychosis
   3. Mefloquine (Lariam)
      1. Safe in second and third trimesters of pregnancy (avoid in first trimester)
      2. Adult: 250 mg (228 mg base) orally weekly
      3. Child: Safe over 3 months of age
         1. See Mefloquine for pediatric dosing
6. Prevention: Third-Line Chemoprophylaxis
   1. Indications
      1. Short term travel to Chloroquine resistance areas
      2. Mefloquine resistance areas
         1. Thailand - Cambodia border
         2. Thailand - Myanmar (Burma) border
   2. Contraindications
      1. Lactating women
      2. Children under age 8 years
   3. Doxycycline (Vibramycin)
      1. Protocol differs from protocol with Chloroquine and Mefloquine
         1. Start 1-2 days before travel
         2. Continue for 4 weeks after return from travel
      2. Adult Dosing: 100 mg orally daily
      3. Pediatric Dosing (may use if older than age 8)
         1. Dose: 2 mg/kg/day up to 100 mg orally daily
7. 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 26.3 mg orally daily for 14 days
8. Prevention: Chemoprophylaxis with other agents (adult dosing)
   1. Primaquine 26.3 mg daily
      1. Start 1-2 days before travel
      2. Continue for 7 days after return
   2. Atovaquone/Proguanil (Malarone) 250/100 mg orally daily
      1. Start 1-2 days before travel
      2. Continue for 7 days after return
   3. Azithromycin (Zithromax) 250 mg PO qd
   4. Tafenoquine (Etaquine) 250 mg PO weekly
   5. Pyrimethamine with sulfadoxine (Fansidar)
9. 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)
10. Resources
    1. CDC Malaria hotline (physicians)
       1. Phone: 855-856-4713
    2. CDC Malaria Facts
       1. http://www.cdc.gov/malaria/about/facts.html
11. References
    1. Gilbert (2001) Sanford Guide, p. 88
    2. Kain (2001) Clin Infect Dis 33:226-34
    3. Lo Re (2003) Am Fam Physician 68(3):509-16
    4. Freedman (2008) N Engl J Med 359(6): 603-12
    5. Johnson (2012) Am Fam Physician 85(10): 973-7