Prevention of Malaria in Travelers: Bite Avoidance and Chemoprophylactic Measures

Abstract

Prevention and management of malaria in travelers is dependent on awareness of risk, bite avoidance, chemoprophylaxis and early diagnosis. Prophylactic recommendations should be made based on details of travel itinerary and medical history. Travelers should be advised to use appropriate measures for avoiding mosquito bites, including insect repellent, insecticide-treated bed nets, and appropriate behavior modification. In areas of chloroquine sensitivity, chloroquine is usually the preferred chemoprophylactic agent. In areas of chloroquine resistance, atovaquone-proguanil, mefloquine or doxycycline may be used. Atovaquone-proguanil is highly effective in preventing Plasmodium falciparum malaria, is well-tolerated, and is active against both liver and blood stages, which decreases the length of time required for post-travel prophylaxis. Alternative agents include doxycycline and mefloquine. Doxycycline is also well-tolerated and is a less expensive alternative to atovaquone-proguanil, but must be taken for 4 weeks after leaving the malaria-endemic region. Mefloquine can also be considered, particularly in those who have previously demonstrated tolerance. Mefloquine is associated with increased risk of neuropsychiatric adverse events and is often started ∼ 3 weeks prior to departure to help determine tolerability. In areas of high P. vivax or P. ovale presence, the use of terminal primaquine prophylaxis can be considered to prevent relapses post-travel. As with all drug regimens, the risks and benefits of use must be weighed in each individual traveler. None of these agents are 100 % effective, and travelers should be informed to seek urgent medical attention if fever develops during or after travel, regardless of the agent used.