MalariaBMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d1149 (Published 15 March 2011) Cite this as: BMJ 2011;342:d1149
- Deen M Mirza, assistant professor1,
- Muhammad Jawad Hashim, assistant professor1,
- Aziz Sheikh, professor of primary care research and development2
- 1Faculty of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, PO Box 17666, United Arab Emirates
- 2Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
- Correspondence to: D M Mirza
- Accepted 9 November 2010
A 30 year old pregnant woman going home on holiday to Nigeria attends the clinic to get a prescription for malaria prevention tablets for herself and her two children.
What you should cover
Malaria is a potentially life threatening but preventable infectious tropical disease, caused by the Plasmodium parasite and transmitted by the Anopheles mosquito.
Ask what type and duration of holiday they plan—Sub-Saharan Africa is endemic for the most severe form of malaria, caused by Plasmodium falciparum. Risk increases in rural regions, with high humidity (such as during monsoon season), and with length of stay in the endemic region.
Explore health beliefs about immunity to malaria—People who have survived childhood in malaria endemic regions usually have developed immunity. However, patients who migrate to non-endemic areas often believe that they are still immune although this type of immunity declines in the absence of regular exposure.
Advise on the complications of malaria in pregnant women and in children—P falciparum malaria in pregnant women can cause severe complications such as miscarriage and prematurity, and can increase maternal morbidity and mortality. Children are at risk of serious complications such as hypoglycaemia and cerebral malaria. No prophylactic regimen provides complete protection, and the patient should consider if travel is essential.
What you should do
Advise on the avoidance and prevention of mosquito bites—Emphasise the importance of wearing trousers, socks, and long sleeved shirts when outside between dusk and dawn (when the Anopheles mosquito bites). Insect repellents should be applied to exposed skin using formulations of between 30-50% diethyltoluamide (DEET), and may be used during pregnancy and on children aged over two months. A mosquito bed net impregnated with insecticide should be used, tucked in under the mattress, and re-impregnated with pyrethroids (such as permethrin) every six months.1
Identify which chemoprophylactic agents are effective in the region travelled to—Drugs used for malaria chemoprophylaxis are chloroquine and proguanil in combination, atovaquone and proguanil in combination (Malarone), mefloquine, or doxycycline. However, the falciparum malaria endemic to all of sub-Saharan Africa and to some parts of South East Asia and South America is now resistant to chloroquine and use is no longer recommended in these areas. Either Malarone, mefloquine, or doxycycline must be used instead.1 Country specific information can be found at the Centers for Disease Control and Prevention website.
Choose malaria prophylactic drugs appropriate for pregnant women (if travel cannot be postponed) or children—Chloroquine can be used in children and in all trimesters of pregnancy, but is often ineffective owing to resistance.1 Doxycycline is contraindicated in pregnant women, breastfeeding women, and in children under 12 years because it can cause staining in growing bones and teeth. Malarone can be used for children, but is contraindicated in pregnancy. Mefloquine can be used for children and in the last two trimesters of pregnancy. If travel cannot be postponed, mefloquine may be prescribed in the first trimester after taking expert advice (for example, by consulting a local travel health specialist, or by calling the National Travel Health Network and Centre advice line for health professionals, in the UK—see Useful reading).
Prescribe appropriately for the travel date and duration—Mefloquine should be started at least a week before travel, but starting two to three weeks before travel has the advantage of allowing tolerability to be assessed (particularly in those who have not tried it before). Doxycycline and Malarone can be started the day before travel. Chloroquine/proguanil should be started a week before travel. Malarone is not licensed for use for more than one month in a malarious area, whereas the other drugs can be used for longer periods.
Address issues of compliance, side effects, and follow-up—The main side effects of malaria prophylactic drugs are summarised in the box. Patients may prefer chloroquine (which is often ineffective) to Malarone because chloroquine is much cheaper and is often more familiar to patients (as it is much more widely used in sub-Saharan Africa). All the drugs apart from Malarone should be continued for four weeks after returning (Malarone should be continued for seven days). Counsel the patient about specific side effects particular to the drug chosen. Mefloquine can cause neuropsychiatric side effects1 and should be avoided in patients with psychiatric illnesses or epilepsy. Instruct the patient to seek immediate medical attention if they develop a fever from one week after arrival at their destination to 12 months after return. If a patient receives antimalarial treatment while on holiday, this should be communicated to their GP on their return.
Malaria chemoprophylactic agents and their main side effects
Chloroquine/proguanil: gastrointestinal disturbances (both drugs), and mouth ulcers (proguanil)
Mefloquine: neuropsychiatric disturbances
Doxycycline: photosensitivity (rare) and oesophagitis
Malarone (atovaquone/proguanil): gastrointestinal disturbances and headache
Information for clinicians
National Travel Health Network and Centre travel health information sheet—www.nathnac.org/pro/factsheets/malariaproph.htm; and advice line for health professionals: +44 0845 602 6712
Health Protection Agency Advisory Committee on Malaria Prevention in UK Travellers guidelines—www.hpa.org.uk/infections/topics_az/malaria/guidelines.htm
Health Protection Agency Malaria Reference Laboratory—www.malaria-reference.co.uk
Centers for Disease Control and Prevention—http://cdc.gov/malaria/travelers/index.html
Information for patients
Patient UK malaria prevention—www.patient.co.uk/health/Malaria-Prevention.htm
Cite this as: BMJ 2011;342:d1149
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.
Contributors: DMM conceived this paper. DMM, MJH, and AS contributed to writing the paper and are joint guarantors.
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; externally peer reviewed.