Long-Term Malaria Prophylaxis for Travelers

Jürgen Knobloch

In This Article

The Tools

Methods for prevention of exposure, believed to be initiated by armies of the classical era and later by Teutonic tribes, consist of avoiding swamps and staying in higher-altitude camps.[8] Today's recommendations include the use of window screens, pyrethroid-impregnated bed nets, repellents (on skin, soap, and clothes), and mosquito coils. Conventional formulas of repellents, such as diethyltoluamide, are more effective than plant products such as soybean oil or citronella.[9] Wearing long-sleeved shirts, pants, and socks to cover the skin is usually not acceptable to long-term travelers. Travelers should be encouraged to spray their residences with long-lasting insecticides and to destroy possible mosquito breeding grounds. When explained carefully, these methods are generally well accepted, and when appropriately applied, they are extremely helpful in preventing a reliance on prophylactic drugs.

It is more difficult to give standardized recommendations for chemoprophylaxis. Moreover, the compliance with malaria chemoprophylaxis is extremely poor, particularly in long-term, occupational travelers and backpackers. The main reasons for this reluctance seem to be fear of long-term side effects and conflicting advice on prophylaxis.[10,11] One option is to convince the traveler to take prophylactic drugs at least temporarily when the local transmission rate increases seasonally. For the rest of the year, standby treatment may be sufficient. Unfortunately, medical facilities capable of producing a qualified diagnosis are not common in hyper- and holoendemic malaria areas, where the patients sometimes seem more experienced than their physicians.[12] Thus, the appropriate application of standby treatment is currently more or less unverifiable in long-term travelers. In any case, travelers should be encouraged to use good manufacturing practice (GMP) drugs from home since the rate of counterfeit drugs is high in some developing countries.

Long-term malaria chemoprophylaxis is generally believed to have been implemented for the first time in 1854, when Dr. William Balfour Baikie effectively put his staff on quinine while exploring the Niger River in West Africa.[8] Reports of the US Sanitary Commission, however, provide evidence that quinine was added as early as 1840 to the whiskey of the military post staff at Tampa Bay, Florida, successfully preventing "miasmatic disease" or "African fever."[13]

Today the indications for various short-term prophylaxis measurements are well established, whereas the use of long-term chemoprophylaxis is still open for extensive modification. During recent decades the majority of malaria drugs have been tested for long-term use. Some of these drugs are no longer considered useful for travelers, such as sulfadoxine-pyrimethamine,[14,15,16] mefloquine-sulfadoxine-pyrimethamine,[17] and dapsone-pyrimethamine.[18]