Malaria

Prevention

Malaria prevention is always a combination of several measures, abbreviated by the World Health Organization (WHO) as ABCDE:

• Awareness: Be aware of the risk according to the area, the incubation period, the possibility of delayed onset and the main symptoms.
• Bite prevention: Protect yourself from dusk till dawn.
• Chemoprophylaxis: Use preventive medication if indicated.
• Diagnosis: Immediately seek diagnosis and treatment if a fever develops one week or more after entering an area where there is a malaria risk and up to three months after return.
• Environment: Avoid outdoor activities in environments that are mosquito breeding places.

Travellers at higher risk

Travellers with a higher risk of contracting malaria are those who spend a lot of time outdoors in the evening and at night, for example during a hike, or travellers who stay in rural non-touristic regions.

People with a higher risk for developing severe malaria complications are:

• children younger than 12 years
• people older than 70 years
• pregnant women
• people with an immune disorder, such as a condition affecting the spleen
• people in poor general health

Travelers visiting friend and family (VFR) often underestimate the malaria risk. Previously built up immunity weans six months to several years after leaving the endemic area. Improving awareness in this specific population regarding this risk is important. 

Preventive measures

Travellers at risk for malaria should be advised on:

• Mosquito bite prevention: which consists of a combination of mosquito-repellent measures especially from dusk through to sunrise. These measures are also necessary when taking chemoprophylaxis, as the tablets never guarantee 100% protection.
• Chemoprophylaxis: whether this should be added to the other preventive measures depends on how high the risk is:
  • Low risk area (pink areas): Chemoprophylaxis is not needed.
  • Moderate risk area (orange areas): Usually mosquito bite prevention and awareness are recommended. In case of higher risk of contracting malaria or severe complications, or when mosquito bite prevention is not possible, chemoprophylaxis is recommended.
  • Seasonal risk (purple areas): Chemoprophylaxis is indicated during the rainy season, but not during dry season.
  • High risk (red areas): Chemoprophylaxis is recommended for all.

Chemoprophylaxis

The three most commonly prescribed medications for chemoprophylaxis are atovaquone-proguanil, doxycycline and mefloquine. Chloroquine could be prescribed in areas with P. vivax only or fully chloroquine sensitive P. falciparum, but since this is only the case in a few places in the world, the use is limited.

Atovaquone-proguanil is directed at the liver phase of the malaria parasite life cycle (causal prophylactic effect). Other chemoprophylactic agents are only directed at the erythrocytic phase (suppressive prophylactic effect). They don’t prevent infection as such, but they have a suppressive prophylactic effect by eradicating the malaria parasites when they infect the red blood cells. This is the reason why medication needs to be taken 28 days after leaving a malaria risk area. Atovaquone-proguanil has a causal prophylactic effect if started at least 24 hours before entering a malaria endemic area and therefore only needs to be taken until 7 days after leaving a risk area in case of good adherence. However, in case it was not started 24 hours prior to entering an endemic area or daily doses have been skipped while the traveller is potentially exposed to malaria, atovaquone–proguanil prophylaxis should also be taken for 28 days after return.

Atovaquone-proguanil (Malarone®)

Formulation: One adult tablet contains 250mg atovaquone and 100mg proguanil.
Half- Life: Atovaquone 2-3 days, proguanil 12-25 hours
Duration: Start 1-2 days before entering risk zone and take until 7 days after leaving.
Dose:
- Adults and children >40kg: 1 adult tablet per day
- Children >5kg: Can be used in adjusted dose based on the weight. Adult tablets can be cut into quarters using a tablet cutter or the pharmacist can prepare a special formulation. 
Administration: Take tablets with a fatty meal or with water containing milk to enhance absorption. In case of vomiting within the hour of administration, a repeat dose is advised.
Protection: Offers more than 95% protection against P. falciparum. Available data indicate protection against primary attacks of P. vivax, however it will not protect against hypnozoite-induced episodes of P. vivax or P. ovale.
Contra- indications:
- Do not administer in case of severe kidney insufficiency (creatinine clearance <30ml/min).
- Depression and epilepsy are not contra-indications.
- It can be used in those known to be G6PD-deficient.
Precautions:
- It may enhance the anticoagulant effect of warfarin or other coumarin- anticoagulation (increased risk of bleeding risk). Monitoring the anticoagulant response (INR and signs of bleeding), closely following the addition or cessation of atovaquone-proguanil, is advised.
- It should not be taken together with Vivotif (oral live attenuated typhoid fever vaccine) since it can diminish the efficacy of the vaccine. Preferably, an interval of 7 days with a minimum of 3 days is respected.
Pregnancy and breastfeeding: Malaria infection poses a significant risk in pregnancy, yet data on safety of prophylaxis in pregnancy are sparse. The current advise is that atovaquone- proguanil should only be used if there is no suitable alternative available.
According to the medication leaflet it can be used during pregnancy if there is a clear risk-benefit, but it mentions that it is contra-indicated in case of breastfeeding a child below 5kg. This is in line with the advice of the CDC. The WHO claims that there are insufficient data, and therefore it is not recommended.
The guidelines in the United Kingdom and France recommend that it can only be used during pregnancy and breastfeeding if there is no suitable alternative available.   
The studies performed during pregnancy are limited and retrospective. Animal studies showed no evidence for teratogenicity. A retrospective analyses looked at pregnancies and live births among active duty military woman in the United states. Among 198 164 pregnancies 50 were exposed to atovaquone-proguanil. They found a non-statistically significant increase in the risk of fetal loss. Overall 28% of exposed pregnancies ended in fetal loss, compared to 17.6% in unexposed pregnancies. However this is a small number of exposed pregnancies, the mothers in the exposed group were older and more of them (94%) were in the first trimester compared to the control groups ( 85% and 74%).
A systemic review of the safety of atovaquone-proguanil for malaria prevention and treatment in pregnancy suggested that, although only limited data available, outcomes following exposure during pregnancy are similar to expected rates in similar populations. A registry-based cohort study of the inadvertent use of atovaquone-proguanil in weeks 3 to 8 after conception identified 149 pregnancies and found no significant association between exposure to atovaquone-proguanil in early pregnancy and the risk of a major birth defect.
Side effects: Headaches and gastro-intestinal upsets may occur. 
Advantages/disadvantages: Very well tolerated. Tends to be more expensive, especially for trips of long duration. Good for last- minute travellers because the drug is started 1-2 days before entering an endemic area. Paediatric tablets are available. 

Doxycycline

Formulation: 100mg or 200mg tablets are available.
Half- Life: 15-24 hours
Duration: Start 1-2 days before entering risk zone and take until 28 days after leaving.
Dose:
- Adults and children >50kg: 100 mg per day
- Children from 8 years: 2mg/kg/day to a maximum of 100 mg/day.
Administration: Take with enough liquid or during a meal to reduce the risk of oesophageal ulcers. Avoid administration with antacids (containing aluminium, calcium, magnesium, zinc, iron salts or bismuth) as much as possible since it can impair the absorption of doxycycline. 
Protection: Between 92% and 96% for P. falciparum and 98% for primary P. vivax infection.
Contra- indications:
- Hypersensitivity to tetracyclines
- Depression and epilepsy are not contra-indications.
- It can be used in those known to be G6PD-deficient.
Precautions: The metabolism of doxycycline is accelerated by carbamazepine and phenytoin. Tetracyclines possibly enhance the anticoagulant effect of coumarins (e.g., warfarin).
Pregnancy and breastfeeding: It can be used in the first trimester of pregnancy but the full course (including 28 days after travel) must be completed before 15 weeks’ gestation. It can cross the placenta and can cause discoloration of teeth when given during the second or third trimester of pregnancy. 
According to the medication leaflet it is contraindicated during breastfeeding. However the American Academy of paediatrics and the CDC say it is compatible with breastfeeding since it is excreted at a low concentration of 30-40% of that found in maternal blood and it is thought that the drug absorption by infants is inhibited by the calcium in breast milk. Furthermore, tetracycline was undetectable in breastfed infants whose mothers were taking tetracycline.
Children: Prolonged use of doxycycline in children below the age of 8 year is contra-indicated due to the risk of yellow tooth discolouration and dental enamel hypoplasia with tetracyclines. In the early 1960s, dental side-effects were associated with the use of tetracycline, the incidence was greater with high doses of tetracycline and long term use. Doxycycline was developed later and is a newer medication in the tetracycline class but was labelled with the same side-effects as the earlier tetracyclines. However, recent studies report little or no effects of doxycycline on tooth staining or dental enamel hypoplasia in short term (3-10 days) use of doxycycline in children <8 years. Since currently no data on long term use is available the recommendations to avoid  doxycycline as malaria chemoprophylaxis for young children travellers below the age of 8 year remains unchanged.
Side effects: Vulvovaginitis (candida). Photosensitivity, so avoidance of excessive sun exposure and the correct use of high SPF sunscreen is advised. Gastric and intestinal discomfort.
Advantages/disadvantages: Tends to be less expensive than some of the other options, so good for long term travellers or a limited budget. Daily use and needs to be taken until 28 days after return which can influence adherence. 

Mefloquine (Lariam®)

Formulation: one adult tablet contains 250mg mefloquine
Half- Life: 2–4 weeks
Duration: Start 2-3 weeks before entering risk zone and take until 28 days after leaving. In case of previous proven tolerability and a lack of time, it could be started shorter before entering a risk zone, but at least 3 tablets should have been taken before entering an endemic area, e.g., a schedule with a loading dose of 250mg on day 1, 2 and 3 (or spread over the remaining days) with a fourth dose on day 10 and thereafter weekly, until 28 days after return.
Dose:
- Adults: 250mg once a week on the same day 
- Children >5kg: Can be used in adjusted dose based on the weight. 4-5 mg/kg/week to a maximum of 250 mg. Adult tablets can be cut into quarters using a tablet cutter or the pharmacist can prepare a special formulation.
Administration: If mefloquine has never been taken, it’s advised to start at least 2-3 weeks before travel to monitor side-effects. Since 2014, it’s mandatory to inform patients for potential side effects and a patient warning leaflet warning leaflet Nederlands/ Français needs to be signed and kept by the traveller during use. Taking mefloquine in the evening can sometimes reduce some of the side-effects. 
Protection: 90% or more. Significant resistance of P. falciparum to mefloquine is a problem only in some areas of South East Asia but is reported sporadically from the Amazon basin.
Contra-indications:
- Convulsions
- Psychoneurological: depression, generalised anxiety disorders, psychosis, suicide risk
- Vestibular disorders 
- Cardiac conduction abnormalities
- History of blackwater fever
- Severe impairment of liver function
- It can be used in those known to be G6PD-deficient.
Precautions: Tiredness, stress, exhaustion, and excessive alcohol use can increase the potential psychoneurological side-effects.
Pregnancy and breastfeeding: Can be used in pregnancy and breastfeeding (even if the infant is <5kg).
Side effects:
- In case of side effects, the use needs to be discontinued immediately.  
- Insomnia, abnormal dreams, anxiety, depressed and suicidal mood, psychosis.
Advantages/disadvantages: Not a good choice for last-minute travellers. Not always well tolerated, so the use is often limited to people with previous exposure. To be taken only once a week and can be taken during pregnancy. 

Chloroquine or hydroxychloroquine sulfate (Plaquenil®)

Chloroquine phosphate or hydroxychloroquine sulphate (Plaquenil) can be used in the prevention of malaria only in destinations where chloroquine resistance is not present.  Widespread resistance in most malaria-endemic countries has led to a decline in its use.

Formulation: One adult tablet contains 200mg hydroxychloroquine sulphate (=155 mg base).
Half- Life: 1–2 months
Duration: Start 1-2 weeks before entering risk zone and take until 28 days after leaving.
Dose:
- Adults: 300 mg base (500 mg salt) once a week
- Children >5kg: 5 mg/kg base (8.3mg/kg salt) orally once a week, up to maximum 300 mg base.
Protection: Chloroquine-resistant falciparum malaria is widespread (effectively universal), but it remains effective against most P. vivax, all P. ovale, P. knowlesi and virtually all P. malariae. Chloroquine-resistant P. vivax is found in the Indonesian archipelago, the Malay Peninsula, including Myanmar, and eastward to Southern Vietnam, and may have spread further.
Contra- indications:
- Convulsions
- Concomitant use with amiodarone (ventricular arrhythmias), ciclosporin (ciclosporin toxicity), digoxin (increases plasmaconcentration), mefloquine (convulsions), moxifloxacin (ventricular arrhythmias).
Precautions: It is highly toxic in overdose and children are particularly susceptible. Antacids can reduce the absorption of chloroquine so it should be taken with an interval of at least four hours.
Pregnancy and breastfeeding: Can be used in pregnancy and breastfeeding.
Side effects:  
- Potential exacerbation of psoriasis and myasthenia gravis
- Severe hypoglycaemia in diabetics and non-diabetics
- Gastrointestinal disturbances
- Headaches
- Itching (especially in African descents)
Advantages/disadvantages: Limited use due to increasing resistance.

Tafenoquine (ArakodaTM®)

Tafenoquine is not licensed in the European Union and therefor is not available in Belgium. It has been approved by the United States Food and Drug administration (FDA) since 2018 for the use of chemoprophylaxis for all malaria species in adults (>18 years) and the treatment of the dormant P. vivax and P. ovale liver-stage parasites (hypnozoites) from 16 years onwards.

Formulation: Not licensed in the European Union.
Half- Life: 14-28 days
Duration: Start 3 days before entering risk zone and take until 1 week after leaving.
Dose:
-Adults (18y): 200mg daily for the 3 days preceding the trip, 200mg weekly during the trip and a single 200mg dose during the week after returning. 
- Children: not licensed.
Contra- indications:
- G6PD deficiency or unknown G6PD status
- History of psychotic disorder or current psychotic symptoms
Pregnancy and breastfeeding: Not advised during pregnancy. Not advised in case of breastfeeding an infant with G6PD deficiency or unknown G6PD status.
Side effects:  
- Most common: headache, back pain, dizziness, nausea, diarrhoea
- Elevated liver enzyme levels, insomnia, depression, abnormal dreams, and anxiety
Advantages/disadvantages: Not available in European Union.

Non-pharmaceutical forms of Artemisia 

Artemisinin in any form does not work well as prevention against malaria. It has a short elimination half- life, meaning that it only remains in the blood at therapeutic levels for a short time.
The non-pharmaceutical forms of Artemisia, for example in juice extractions, teas, infusion preparations or other herbal remedies for the prevention or treatment of malaria, is not supported by the WHO. The content varies substantially and there is a high risk of delivering subtherapeutic doses, which are insufficient to kill all the parasites and to prevent recrudescence. Medication derived from artemisinin used for malaria treatment is always given in combination with another antimalarial drug to avoid the occurrence of resistance and to prevent recrudescence.