Clinical Review

Preventing malaria in travellers

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.a153 (Published 12 June 2008) Cite this as: BMJ 2008;336:1362
  1. David G Lalloo, reader in tropical medicine1,
  2. David R Hill, director 23
  1. 1Liverpool School of Tropical Medicine, Liverpool L3 5QA
  2. 2National Travel Health Network and Centre, London WC1E 6AU
  3. 3London School of Hygiene and Tropical Medicine, London WC1E 7HT
  1. Correspondence to: D G Lalloo dlalloo{at}liverpool.ac.uk

    Summary points

    • Malaria can be prevented by avoiding bites and using appropriate chemoprophylaxis

    • An individual harm-benefit assessment should be made for each traveller

    • The possibility of malaria should be kept in mind for any traveller returning from an endemic area

    Protecting travellers against malaria is increasingly important as the number travelling overseas continues to rise, with a disproportionate increase in visits to tropical areas where malaria transmission may occur. Each year about 1700 cases of malaria occur in the United Kingdom, 1300 in the United States, and 3000 in France.1 2 3 In the UK, about 75% of these cases are caused by Plasmodium falciparum, which produces the most severe form of malaria; five to 16 deaths occur annually and are nearly always in cases of falciparum malaria.1

    Most infections occur in travellers resident in the UK, rather than in visitors to the UK. Malaria is a major risk for travellers if they do not take chemoprophylaxis or if they take incorrect prophylaxis.4 5 This review explores how to protect travellers from malaria. Most of the evidence base for malaria prophylaxis comes from small randomised controlled trials or observational studies.

    Approach to preventing malaria

    A useful approach is the “ABCD” of malaria prevention: Awareness of risk, Bite avoidance, Compliance with chemoprophylaxis, and the prompt Diagnosis of malaria (box 1)

    Box 1 Harm-benefit assessment based on the “ABCD” approach to malaria prevention*

    Assessment and awareness of malaria risk
    • Detailed geographical location of trip (name of country alone not adequate); time of year may also be relevant. See www.nathnac.org or www.cdc.gov/malaria/travel/index.htm

    • Duration of time in the area

    • Activities to be undertaken (relates to likelihood of exposure to infected mosquitoes—urban environment is generally less risky than rural environment)

    Bite avoidance
    • Protective clothing

    • Repellents

    • Longlife insecticide-treated netting

    Chemoprophylaxis
    • Is chemoprophylaxis indicated or would bite avoidance be sufficient?

    • Does the area have chloroquine resistant P falciparum?

    • Consider medical history and other medications

    • Consider previous experience with antimalarials …

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