In the UK, the cost of drugs used for malaria prevention is not covered by the NHS. They have to be paid for by the traveller.
We advise a full risk assessment with one of our nurses to work out if you are at risk of malaria at anytime on your trip. If we find that you will be at risk, it is then important we find the right drug for you as an individual. Some malaria tablets are only effective in some malaria areas, so it is important to check that you are taking the correct tablets. Malaria Maps can be found on www.fitfortravel.nhs.uk.
Here is some information on the main malaria prophylaxis available at BMC Travel Clinic.
Malarone (Atovaquone/Proguanil)
DO NOT confuse with Maloprim® which is not now advised for prophylaxis since more effective alternatives are available.
Should be taken to 1 or 2 days before entering the malarious area, throughout exposure, and for 7 days after leaving the infected area.
Licensed for stays in malarious areas for periods of up to 28 days but can be used safely for up to 3 months (and possibly 6 months or longer). Specialist advice should be sought for long-term prophylaxis.
Protection against benign malaria: Malarone acts on blood forms of P. vivax and ovale malaria. However, it does not eliminate latent 'hypnozoites' from the liver and therefore will not prevent delayed primary attacks occurring after the drug is discontinued, sometimes months or rarely years after exposure. Malignant malaria due to P. falciparum does not have a hypnozoite stage, so delayed primary attacks are much rarer and Malarone is normally effective unless resistance is present.
Rashes, abdominal pain, headache, anorexia, nausea, diarrhoea, coughing and aphthous (simple) mouth ulcers can occur
Absorption may be reduced in diarrhoea and vomiting and blood levels are significantly reduced with concomitant use of tetracyclines, metoclopramide and especially rifampicin or rifabutin
Proguanil can delay the metabolism of the anticoagulant, warfarin, and result in bleeding. If it has to be used, re-stabilising the prothrombin time in advance of departure is advised.
Caution in renal impairment.
Lack of experience in pregnancy and during breast feeding means that it should be avoided in these circumstances unless there is no suitable alternative. Ideally pregnancy should also be avoided for 2 weeks after stopping the the medication.
No guidance is given by the manufacturers on prolonged usage for malaria prevention but has been used for periods of up to 2 years for acne without an increased risk of side effects.
Consider a trial course before departure, if you are using this regime for the first time, to detect if you are likely to get side effects (e.g. for one week). Otherwise doxycycline need only be started just before exposure (e.g. 2 days), continued through exposure and for 4 weeks afterwards.
When tetracyclines are being already used for acne this will provide protection against malaria so long as an adequate dose is taken (equivalent to 250mg oxytetracycline four times a day or 100 doxycycline per day)
Erythema (sun burn) due to sunlight photosensitivity can occur. Sunscreens are important and if severe alternative prophylaxis should be used.
Heartburn is common if capsules release their contents into the oesophagus so they should be taken with a full glass of water and preferably while standing upright.
Contraindicated in pregnancy (including one week after completing the course), breast feeding, in those with systemic lupus erythematosis, porphyria and children under 12 years because permanent tooth discoloration can occur.
It must be remembered that anti-epileptic drugs (phenytoin, barbiturates and carbamazapine) may reduce the efficacy of the doxycycline (some authorities increase the dose but whether this is necessary is unclear).
It may theoretically reduce the effectiveness of the oral contraceptive pill for about 3 weeks after starting doxycycline 1.
Occasionally anorexia, nausea, diarrhoea, candida infection and sore tongue (glossitis) have been reported and rarely hepatitis, colitis and blood dyscrasias.
Chloroquine
Preparations available: Avloclor® (Zeneca)and Nivaquine® (Rhône-Poulenc Rorer). Nivaquine is available in syrup form: adult dose is 2 tablets (each containing 150mg chloroquine as base) taken once a week.
Consider a trial course before departure, if using this regime for the first time, to detect if you are likely to get side effects (e.g. for two weeks). Otherwise, when possible, chloroquine should be started one week before exposure to ensure adequate blood levels, throughout exposure and for 4 weeks afterwards.
Nausea and sometimes diarrhoea can occur which may be reduced by taking tablets after food.
Headache, rashes, skin itch, disturbance of visual accommodation (often expressed as blurred distance vision which may take up to 4 weeks to reverse) or hair loss may warrant changing to alternative drugs.
Retinopathy which can be permanent is unlikely to occur until more than 100g have been consumed (i.e. over 5 years treatment at prophylactic doses).
Caution in hepatic and renal impairment.
Can aggravate psoriasis and very occasionally causes a convulsion so it should not normally be used in those with epilepsy or when first degree relatives have idiopathic epilepsy.
Chloroquine is very toxic in overdose - parents must take special care to store the tablets safely.
It is generally accepted, as a result of long usage, to be safe in pregnancy.
Proguanil
Preparations available: Paludrine® (Zeneca. Adult dose is 200mg daily.
Can normally be used continuously for a period of at least 5 years.
One or two doses should be taken before departure. It should be continued throughout exposure and for 4 weeks afterwards.
Anorexia, nausea, diarrhoea and aphthous (simple) mouth ulcers can occur.
Can delay the metabolism of the anticoagulant, warfarin, and result in bleeding. If it has to be used, restabilising the prothrombin time in advance of departure is advised.
Caution in renal impairment.
Safe in pregnancy, but folate supplement is advised.
Mefloquine®
Preparations available: Lariam® (Roche) Adult dose is 250mg weekly.
One dose should be taken a week before departure and it should be continued throughout exposure and for 4 weeks afterwardshowever three (3) doses at weekly intervals prior to departure are advised if the drug has not been used before - this can detect, in advance, those likely to get side effects so that an alternative can be prescribed.
Although not a licensed regime, some authorities recommend 1/2 tablet twice a week (instead of one tablet once a week) to try an minimise any 'hang-over' feeling the day after taking a dose. If this is done it may take longer for the traveller to reach stable protective blood levels so the regime should be started well in advance of exposure.
Licensed for 1 year's continuous use in Britain but there is no evidence that use for periods of up to 3 years carries any greater risk of side-effects.
Nausea, diarrhoea, dizziness, abdominal pain, rashes and pruritis can occur.
Headache, dizziness, convulsions, sleep disturbances (insomnia, vivid dreams) and psychotic reactions such as depression have been reported. These reactions most commonly begin within 2-3 weeks of starting the drug and may be worse if alcohol is taken around the same time as the mefloquine. Avoid in those with epilepsy (or when first degree relatives have idiopathic epilepsy) or when there is a history of psychiatric illness.
Caution, and avoid if alternatives are available, in severe renal or liver failure and those with cardiac conduction defects. Also caution in those taking digoxin, beta or calcium channel blockers when arrhythmias and bradycardia can occur.
Although there is no evidence to suggest that mefloquine has caused harm to the foetus it should normally be avoided during the first trimester of pregnancy or if pregnancy is considered possible within 3 months of stopping prophylaxis.
