Prevention of Malaria
	See also: Medicines to prevent and treat malaria
	Malaria - a serious tropical disease Malaria is a serious disease, which in the worst case may be fatal. It is widespread in tropical and subtropical areas. From a global viewpoint, malaria constitutes an enormous health problem, with 500 million new cases a year. In the UK about 2500 people come home from abroad every year with the disease, and an average of 12 people each year die. Prevention requires A, B, C, and D. Awareness of risk.  Bite avoidance (avoiding mosquito bites).  Chemoprophylaxis (taking preventive medicines if you are travelling to or living in a malaria region).  Diagnosis made promptly with early treatment of an infected case.  Avoid mosquito bites Mosquitoes bite particularly at twilight and at night. Therefore, you should take most precautions during this time. Sleep in rooms that are properly screened with gauze over the windows and doors, with no holes in the gauze and no unscreened entry points.  Air-conditioned rooms are good, too. Spray the room with an insecticide before entering to kill any mosquitoes that have entered during the day. Otherwise, you should use a mosquito net around your bed, impregnated with an insecticide such as pyrethrum (a harmless substance manufactured on the basis of extract of chrysanthemum) or permethrin (see below). Long trousers, long-sleeved clothing and socks thick enough to stop the mosquitoes biting you will also protect you, and should be worn outside after sunset, but it may be hard to follow such advice in a hot climate. Light colours are less attractive to mosquitoes. Use mosquito repellant cream Mosquito repellant containing diethyl toluamide (DEET) is recommended as the most effective form of bite-preventive treatment. It has an excellent safety profile in adults, children and pregnant women - it is important that the manufacturer's recommendations are not exceeded, particularly when using it on small children. Insect repellants containing over 30 per cent DEET will effectively repel mosquitoes when applied to exposed skin. Other products are less effective but may have some use. Lemon scent was found to protect citrus groves from mosquitoes and refined lemon eucalyptus oil on skin also repels mosquitoes.  Mosquito nets When sleeping outdoors or in an unscreened room, have an insecticide-treated mosquito net round your bed. This significantly reduces the risk of bites. The net should be small-meshed, with no holes, and tucked in under the bottom sheet. During the day, it should be rolled up, so that mosquitoes and other insects cannot get inside while it is not in use. Take your own net with you. You cannot always expect to find an impregnated net at your destination. Impregnation lasts from six months to one year, depending on how much the net is used and whether you pack it away in a plastic bag when you return from the tropics. Always remember not to wash the net in between re-impregnation with the insecticide! Preventive medicines Taking medicines to prevent malaria is essential if you are visiting an area where malaria is prevalent. The problem can be choosing the most appropriate antimalarial for the country you are visiting. You also need to take into account your individual circumstances. Because resistance to chloroquine (and other drugs) is spreading, preventive medicines that were effective five years ago may no longer be so. The geographic spread of chloroquine resistance in the malarial parasite Plasmodium falciparum is increasing, and exists throughout sub-Saharan Africa, Southeast Asia, the Indian subcontinent, and large portions of South America. There are currently six drugs on the market that are licensed for preventing malaria, and the most appropriate one(s) will depend on the country you are visiting and your individual circumstances. See below for more details. Chloroquine is taken weekly, and is the preferred drug for the few areas without chloroquine resistance. It is used in combination with proguanil in areas with a slightly higher risk of chloroquine-resistant malaria. However, this combination is becoming less effective due to increasing resistance to chloroquine, particularly in Africa.  Proguanil is taken daily, and is an alternative to chloroquine in areas without chloroquine resistance. Resistance to proguanil has also developed over the years.  The combination of chloroquine and proguanil was about 70 per cent effective in Africa 10 years ago, but is probably much less than this now in much of Africa (mainly south of the Sahara). However, it is still the recommended combination for the Indian subcontinent and various other low risk parts of the world. Both should be started one week before travel and continued for a further four weeks after leaving the malarious area. Mefloquine (Lariam) is much more effective for areas of chloroquine-resistant malaria - over 90 per cent in Africa. Its main side effects, such as mood changes and paranoia, have been well aired in the media. Other milder side effects include sleep disturbances and abnormal dreams. It is taken weekly and should be started two to three weeks before travelling, so that three doses have been taken before departure. This enables blood levels of the drug to reach a protective level. In addition, over 75 per cent of side effects will have appeared in this time if they are going to happen, allowing time to change to another antimalarial if necessary. Mefloquine should be continued for four weeks after leaving the malarious area. It should not be taken by people with a history of psychiatric disturbances (including depression) or convulsions (eg epilepsy).  Doxycycline is considered to be comparable in efficacy to mefloquine. It is taken daily, starting one to two days before travel and continuing for four weeks after leaving the malarious area. People who take doxycycline should be aware that it may make their skin very sensitive to the sun and women may be more prone to thrush.  Malarone (containing proguanil and atovaquone) is also considered to be similar in efficacy to mefloquine. It is only licensed to prevent Plasmodium falciparum malaria (the malignant type, which is often resistant to other antimalarials). It is not licensed for longer than 28 days of use and so may be particulalrly useful for brief visits to high-risk areas. It is taken daily and should be taken with a meal rich in fats (eg yoghurt) or a milky drink to avoid the risk of it not being adequately absorbed from the stomach. It should be started two to three days before travel and only needs to be continued for a week after leaving the malarious area.  Doxycyline or Malarone are considered to be the drugs of first choice in areas where the malaria is mefloquine resistant. They are also an alternative to mefloquine in areas of high chloroquine resistance. Maloprim (containing pyrimethamine and dapsone) has been largely superseded by the newer drugs, but can be of use in people with epilepsy, particularly children, going to areas with chloroquine resistance. It is taken weekly, starting one week before travelling and continuing for four weeks after the leaving the area.  Chloroquine and proguanil are the only antimalarials that can be bought from your pharmacist without a prescription - the others are only available on prescription from your doctor. Your pharmacist will be able to tell you what the recommended regimen is for the country you are visiting, and whether you will need to visit your doctor. It is important that whatever preventive medicines are used, they are taken regularly and as directed by your doctor or pharmacist - both while you are away and when you return. The risk of malaria increases with the length of stay, so it is important to keep taking your preventative medicines throughout a long visit. Most deaths from malaria occur in those who take their preventive medicines irregularly, or not at all. Points to consider in choosing a preventive medicine The type of malaria present in the area you are travelling to. The risk of being bitten by a mosquito.  Individual considerations - are you pregnant, breastfeeding or epileptic; is the medicine for a child; are you already regularly taking other medicines?  What is the risk of malaria? The risk of being bitten by a mosquito and the type of malaria that is transmitted varies depending on the country you are visiting and the time of year. Measures to avoid bites should always be taken, and if malaria is prevalent in an area you are travelling to, you should always take preventive medicine. Areas of greatest risk are those where there is a high prevalence of multi-resistant Plasmodium falciparum malaria. There are guidelines on risk and preferable preventive regimens for each of the regions described below. For specific guidelines about the risks and recommendations for each individual country, talk to your pharmacist, doctor or travel health clinic. North Africa and the Middle East  Sub-Saharan Africa  South Asia  South East Asia  Oceania  Latin America and the Caribbean  Remember - for optimal prevention of malaria, protection from mosquito bites is essential, even if you are taking preventive medicines. Pregnant women and children According to the World Health Organisation (WHO), it is inadvisable to take infants and young children to areas where there is malaria, especially if there is chloroquine-resistant falciparum malaria. If you decide to go anyway, or if you are obliged to go, extra care should be taken to protect small children, as they get very ill very quickly if falciparum malaria is involved.  Therefore, it is even more important to get qualified medical help if a child develops a fever during or after a trip to a malarious region, even if you have done everything possible to avoid catching the disease. Remember to use: mosquito repellant.  impregnated mosquito net. Nets are available for cots and small beds and babies should be kept under one as much as possible between dusk and dawn.  regular, preventive medicines.  Which medicines may be used for children? Prophylactic medicines should be given to breastfed as well as to bottlefed babies because they are not protected by the mother's medicine passing into the breast milk. Chloroquine and proguanil may be given safely to babies and young children, but the doses used are much smaller than those recommended for adults. It is very important to check with your pharmacist or doctor regarding the correct doses for children aged 12 years or under.  Mefloquine may be given from three months onwards. There is little experience with this medicine in children under three months or weighing less than 5kg and it is not recommended in these cases.  Doxycycline should not be given to children under 12 years of age.  Malarone should not be given to children weighing less than 40kg.  Maloprim may be given to children from three months onwards.  For administration, antimalarial medicines may be crushed and mixed with jam, banana, or similar foods. Syrup formulations are available for certain medicines, but have shorter shelf-lives in tropical areas. Remember to keep all antimalarial medicines in childproof containers out of children's reach. Chloroquine in particular can be fatal to children if the recommended dose is exceeded. Which medicines may be used for pregnant women? Pregnant women are discouraged by the World Health Organisation from traveling to malarious regions where there is chloroquine-resistant falciparum malaria, because in pregnant women malaria increases the risk of abortion, premature birth, still-birth and maternal death. Just as for children, an extra effort should be made to protect oneself from mosquitoes and malaria if you are obliged to travel anyway.  If you are planning to travel to a malarious region or have any other travel vaccines, it is very important to tell your doctor if you are pregnant or planning to become pregnant.  As for children, both chloroquine and proguanil have no special risk for pregnant women, and should be administered together. Pregnant women who use proguanil should also take a daily folic acid supplement.  In countries where resistance to chloroquine and proguanil is high, it may be necessary for your doctor to prescribe mefloquine. There is evidence that mefloquine may be associated with an increased risk of stillbirths, so it should only be used during pregnancy if the need for it is great. The decision to prescribe mefloquine is made after weighing up the benefits of giving it and preventing malarial disease, versus the risks of harmful effects on the foetus, and the risk of contracting malaria. In scenarios where other medicines are not effective, the benefits of using mefloquine may outweigh the risks, but your doctor would need to decide this in conjunction with you. If pregnant women accidentally take mefloquine during pregnancy, there is no reason to terminate the pregnancy.  Maloprim may be used cautiously after the first trimester if a visit to a malarious area is unavoidable. Pregnant women who use Maloprim should also take a daily folic acid supplement.  Malarone should be avoided unless there is no suitable alternative. Pregnant women who use Malarone should also take a daily folic acid supplement.  Doxycycline should not be taken by pregnant women.  Which medicines may be taken by breastfeeding women? Breastfeeding mothers can safely take chloroquine and proguanil. However not enough of these medicines passes into the breast milk to provide protection for the child.  Mefloquine, doxycycline and Malarone should not be taken by breastfeeding mothers.  Anyone who develops a fever or flu-like illness within one year and especially within three months of visiting an area where they may possibly have been exposed to malaria should seek medical advice urgently, even if they have been taking preventive medicines.