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
    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 (300 mg base) orally once weekly
    3. Child: 8.3 mg/kg (5 mg/kg of base, up to adult dose) once weekly
  5. Hydroxychloroquine (Plaquenil)
    1. Adult: 400 mg (310 mg base) orally once weekly
    2. Child: 6.5 mg/kg (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 (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. 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
  4. Atovaquone/Proguanil (Malarone)
    1. Contraindicated if GFR <30 ml/min
    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:

  1. Indications
    1. Short-term travel to areas with >90% Plasmodium VivaxMalaria (some regions of central and south america)
  2. Protocol
    1. Start 1-2 days before travel and continue for 1 week after travel
  3. Adults
    1. Primaquine 52.6 mg (30 mg base) orally daily
  4. Children
    1. Primaquine 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. Prevention: Chemoprophylaxis with other agents (adult dosing)

  1. Primaquine
    1. Dosing: 52.6 mg daily
    2. Start 1-2 days before travel
    3. Continue for 7 days after return
  2. Azithromycin (Zithromax) 250 mg PO qd
  3. Tafenoquine (Etaquine) 250 mg PO weekly
  4. Pyrimethamine with sulfadoxine (Fansidar)

XI. 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)

XII. Resources

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

XIII. 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]

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Ontology: Antimalarial prophylaxis (C0199244)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 420848008, 81364009, 268592001
Italian Profilassi della malaria, Profilassi malarica
English Anti-malarial prophylaxis, Antimalarial drug prophylaxis, Malarial prophylaxis, Antimalarial prophylaxis (procedure), Antimalarial prophylaxis, Malaria prophylaxis, malaria prophylaxis, Prescription of prophylactic anti-malarial, Prescription of prophylactic anti-malarial (procedure)
Spanish profilaxis antipalúdica, profilaxis contra la malaria, profilaxis antipalúdica (procedimiento), profilaxis farmacológica antipalúdica, prescripción de un agente profiláctico antipalúdico (procedimiento), prescripción de un agente profiláctico antipalúdico, Profilaxis de paludismo
Dutch malaria profylaxe, malariaprofylaxe
French Prophylaxie du paludisme, Prophylaxie antipaludéenne
Japanese マラリア予防, ﾏﾗﾘｱﾖﾎﾞｳ
Czech Profylaxe malárie, Antimalarická profylaxe
Hungarian Malária profilaxis
Portuguese Profilaxia da malária
German Malariaprophylaxe
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Parasitic Infections

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