Malaria prevention guidelines for travellers from the UK

The UKHSA Advisory Committee on Malaria Prevention updates and reissues these guidelines every year for UK travellers.

Published in: United Kingdom

Executive summary 7 2
Abbreviations 10 2
General issues 11 2
Awareness of risk 13 2
Bite prevention 19 2
Chemoprophylaxis 26 2
Diagnosis 51 2
Special groups (medical conditions) 54 2
Information resources 85 2
Appendices 87 2
Appendix 1a. Terms of reference 2023 87 2
Appendix 1b. ACMP member list 90 2
Appendix 1c. ACMP conflict of interest statements 91 2
Appendix 1d. ACMP methodology 93 2
Appendix 2. Template for risk assessment and summary of advice given 95 2
Appendix 3. Emergency standby medication: traveller information leaflet 100 2
Appendix 4. Destinations: maps showing the areas with appropriate malaria prevention measures recommended 102 2
References 157 2
About the UK Health Security Agency 166 2
List of tables 2
Table 1. Plasmodium species that infect humans 13 3
Table 2. Prophylactic regimens against malaria in adults in areas of chloroquine-resistant P. falciparum 36 3
Table 3. Doses of prophylactic antimalarials for children 36 3
Table 4. Table of doses by spoon or syringe measures for chloroquine syrup 37 3
Table 5. Table of paediatric doses of atovaquone/proguanil 38 3
Table 6. Country recommendations 40 3
Table 7. Emergency standby treatment for adults 50 3
Table 8. Long-term chemoprophylaxis for adults 75 3
Table 9. Half-lives of selected antimalarial drugs 75 3
List of figures 3
Figure 1. The malaria life cycle 14 3
Figure 2. Countries with indigenous cases in 2000 and their status by 2021 16 3
Figure 3. Cumulative risk of adverse events and malaria 72 3
Figure 4. Map of Afghanistan showing the areas with appropriate malaria prevention measures recommended 102 3
Figure 5. Map of Angola showing the areas with appropriate malaria prevention measures recommended 103 3
Figure 6. Map of Bangladesh showing the areas with appropriate malaria prevention measures recommended 104 3
Figure 7. Map of Benin showing the areas with appropriate malaria prevention measures recommended 105 3
Figure 8. Map of Bolivia showing the areas with appropriate malaria prevention measures recommended 106 3
Figure 9. Map of Botswana showing the areas with appropriate malaria prevention measures recommended 107 3
Figure 10. Map of Brazil showing the areas with appropriate malaria prevention measures recommended 108 3
Figure 11. Map of Cambodia showing the areas with appropriate malaria prevention measures recommended 109 3
Figure 12. Map of Cameroon showing the areas with appropriate malaria prevention measures recommended 110 4
Figure 13. Map of Colombia showing the areas with appropriate malaria prevention measures recommended 111 4
Figure 14. Map of Congo showing the areas with appropriate malaria prevention measures recommended 112 4
Figure 15. Map of Costa Rica showing the areas with appropriate malaria prevention measures recommended 113 4
Figure 16. Map of Cote D’Ivoire showing the areas with appropriate malaria prevention measures recommended 114 4
Figure 17. Map of Democratic Republic of Congo showing the areas with appropriate malaria prevention measures recommended 115 4
Figure 18. Map of Ecuador showing the areas with appropriate malaria prevention measures recommended 116 4
Figure 19. Map of Eritrea showing the areas with appropriate malaria prevention measures recommended 117 4
Figure 20. Map of Eswatini showing the areas with appropriate malaria prevention measures recommended 118 4
Figure 21. Map of Ethiopia showing the areas with appropriate malaria prevention measures recommended 119 4
Figure 22. Map of Gambia showing the areas with appropriate malaria prevention measures recommended 120 4
Figure 23. Map of Ghana showing the areas with appropriate malaria prevention measures recommended 121 4
Figure 24. Map of Guatemala showing the areas with appropriate malaria prevention measures recommended 122 4
Figure 25. Map of Guinea showing the areas with appropriate malaria prevention measures recommended 123 4
Figure 26. Map of Honduras showing the areas with appropriate malaria prevention measures recommended 124 4
Figure 27. Map of India showing the areas with appropriate malaria prevention measures recommended 125 4
Figure 28. Map of Indonesia and Indonesia (Borneo) showing the areas with appropriate malaria prevention measures recommended 126 4
Figure 29. Map of Iran showing the areas with appropriate malaria prevention measures recommended 127 4
Figure 30. Map of Iraq showing the areas with appropriate malaria prevention measures recommended 128 5
Figure 31. Map of Kenya showing the areas with appropriate malaria prevention measures recommended 129 5
Figure 32. Map of Laos showing the areas with appropriate malaria prevention measures recommended 130 5
Figure 33. Map of Madagascar showing the areas with appropriate malaria prevention measures recommended 131 5
Figure 34. Map of Malawi showing the areas with appropriate malaria prevention measures recommended 132 5
Figure 35. Map of Malaysia and Malaysia (Borneo) showing the areas with appropriate malaria prevention measures recommended 133 5
Figure 36. Map of Mauritania showing the areas with appropriate malaria prevention measures recommended 134 5
Figure 37. Map of Mozambique showing the areas with appropriate malaria prevention measures recommended 135 5
Figure 38. Map of Namibia showing the areas with appropriate malaria prevention measures recommended 136 5
Figure 39. Map of Nepal showing the areas with appropriate malaria prevention measures recommended 137 5
Figure 40. Map of Nigeria showing the areas with appropriate malaria prevention measures recommended 138 5
Figure 41. Map of Pakistan showing the areas with appropriate malaria prevention measures recommended 139 5
Figure 42. Map of Panama showing the areas with appropriate malaria prevention measures recommended 140 5
Figure 43. Map of Papua New Guinea showing the areas with appropriate malaria prevention measures recommended 141 5
Figure 44. Map of Peru showing the areas with appropriate malaria prevention measures recommended 142 5
Figure 45. Map of Philippines showing the areas with appropriate malaria prevention measures recommended 143 5
Figure 46. Map of Rwanda showing the areas with appropriate malaria prevention measures recommended 144 5
Figure 47. Map of Saudi Arabia showing the areas with appropriate malaria prevention measures recommended 145 5
Figure 48. Map of Sierra Leone showing the areas with appropriate malaria prevention measures recommended 146 6
Figure 49. Map of Somalia showing the areas with appropriate malaria prevention measures recommended 147 6
Figure 50. Map of South Africa showing the areas with appropriate malaria prevention measures recommended 148 6
Figure 51. Map of Sudan showing the areas with appropriate malaria prevention measures recommended 149 6
Figure 52. Map of Tanzania showing the areas with appropriate malaria prevention measures recommended 150 6
Figure 53. Map of Thailand showing the areas with appropriate malaria prevention measures recommended 151 6
Figure 54. Map of Uganda showing the areas with appropriate malaria prevention measures recommended 152 6
Figure 55. Map of Vietnam showing the areas with appropriate malaria prevention measures recommended 153 6
Figure 56. Map of Yemen showing the areas with appropriate malaria prevention measures recommended 154 6
Figure 57. Map of Zambia showing the areas with appropriate malaria prevention measures recommended 155 6
Figure 58. Map of Zimbabwe showing the areas with appropriate malaria prevention measures recommended 156 6
Executive summary 7
Main changes in this update of the guidelines 7
The impact of COVID-19 7
Proguanil has been discontinued in the UK 8
Authorship 8
Acknowledgements 9
Citation 9
Abbreviations 10
General issues 11
How to give the advice 11
Medical history of the traveller 12
Awareness of risk 13
Malaria facts 13
Table 1. Plasmodium species that infect humans 13
Life cycle 13
Figure 1. The malaria life cycle 14
The malarial illness 15
Clinical symptoms and signs of malaria 15
(From the ACMP malaria treatment guidelines.) 15
Figure 2. Countries with indigenous cases in 2000 and their status by 2021 16
Where malaria is found 16
Factors affecting risk of exposure to malaria 17
Temperature, altitude and season 17
Rural versus urban location 17
Type of accommodation 17
Patterns of activity 18
Length of stay 18
Distribution of drug-resistant malaria 18
Bite prevention 19
When female Anopheles mosquitoes bite 19
Measures to prevent mosquito bites 19
Repellents 19
DEET 20
DEET and sunscreen 21
DEET and infants 21
DEET and pregnancy 21
Eucalyptus citriodora oil, hydrated, cyclized (PMD) 22
Icaridin (Picaridin) 22
3-ethlyaminopropionate 22
Oil of citronella 23
Insecticides 23
Nets 23
Clothing 23
Room protection 24
Myths 24
Herbal remedies 24
Homoeopathy 24
Buzzers 25
Vitamin B1 25
Vitamin B12 25
Garlic 25
Savoury yeast extract spread 25
Tea tree oil 25
Bath oils and emollients 25
Alcohol 25
Chemoprophylaxis 26
Principles 26
Causal prophylaxis 26
Suppressive prophylaxis 26
Prophylaxis against hypnozoites 26
The drugs 27
Chloroquine 28
Mode of action 28
Efficacy 28
Formulations and method of administration 28
Prophylactic regimen 28
Contraindications 28
Cautions 28
Interactions 29
Side effects 29
Hydroxychloroquine 29
Proguanil has been discontinued in the UK 29
Mefloquine 29
Mode of action 30
Efficacy 30
Formulation and method of administration 30
Prophylactic regimen 30
Contraindications 30
Cautions 30
Diving and mefloquine 31
Pilots 31
The Military 31
Interactions 31
Side effects 31
Doxycycline 32
Mode of action 32
Efficacy 32
Formulations and method of administration 32
Prophylactic regimen 32
Contraindications 33
Cautions 33
Interactions 33
Side effects 34
Atovaquone plus proguanil combination preparation 34
Mode of action 34
Efficacy 34
Formulations and method of administration 34
Prophylactic regimen 34
Contraindications 34
Cautions 35
Vaccines 35
Side effects 35
Dosage tables 35
Table 2. Prophylactic regimens against malaria in adults in areas of chloroquine-resistant P. falciparum 36
Table 3. Doses of prophylactic antimalarials for children 36
Further important notes 37
Table 4. Table of doses by spoon or syringe3F measures for chloroquine syrup 37
Table 5. Table of paediatric doses of atovaquone/proguanil 38
Country recommendations 39
Key to Table 6 39
Notes 39
Table 6. Country recommendations 40
Emergency standby treatment 48
Table 7. Emergency standby treatment for adults 50
Mefloquine 36
Doxycycline 36
Atovaquone plus proguanil combination preparation 36
For adults weighing 40kg or more. (For adults weighing less than 40kg please consult Table 5) 36
Diagnosis 51
Blood tests and how to request them in the UK 51
Rapid diagnostic tests (RDTs) 51
Blood film and/or RDT negative malaria 52
Resources for treatment advice 52
Notification 53
Special groups (medical conditions) 54
Smoking cessation 54
Pregnancy 54
Chloroquine 54
Mefloquine 55
Doxycycline 55
Atovaquone/proguanil 55
Chemoprophylaxis prior to conception 56
Breastfeeding 56
Mefloquine 56
Doxycycline 56
Atovaquone/proguanil 57
Anticoagulants 57
The coumarins, including warfarin 57
Chloroquine 57
Mefloquine 57
Doxycycline 57
Atovaquone/proguanil 57
Direct oral anticoagulants (DOAC) 58
Epilepsy 59
Doxycycline 59
Glucose 6-phosphate dehydrogenase deficiency 59
Chloroquine 59
Atovaquone-proguanil, doxycycline, or mefloquine 59
Primaquine 59
Sickle cell disease and thalassaemia (102) 60
Immunocompromised travellers 60
Risks for transplant patients 60
Risks for those living with HIV 60
Liver disease 62
Severe liver disease 62
Moderate impairment 62
Mild impairment 62
Renal impairment 63
Chloroquine 63
Atovaquone/proguanil 63
Doxycycline or mefloquine 63
Splenectomy 63
Acute porphyrias 63
Special categories 64
Children 64
Chloroquine 64
Mefloquine 64
Doxycycline 64
Atovaquone-proguanil combination preparation 64
Elderly travellers 65
Multi-trip travel 66
Cruises 66
Oil rigs 66
Visits to national parks 67
Stopovers 67
Last-minute travellers 67
Visiting friends and relatives 68
Students and children at boarding school 69
The long-term traveller 70
Risk assessment 70
Visiting friends and relatives (VFR) 71
Expatriates 71
Backpackers 71
Chemoprophylaxis for long-term travellers 71
Adverse events 71
Adherence to chemoprophylaxis 71
Figure 3. Cumulative risk of adverse events and malaria 72
Efficacy of regimens 72
Licensing restrictions 72
General advice for all regimens 72
Specific considerations for infants and older children 73
Chloroquine 73
Mefloquine 73
Doxycycline 73
Atovaquone-proguanil combination preparation 73
Long-term visitors to the UK returning to live in malarious parts of the world 74
Preventive measures appropriate to an endemic setting (128) 74
Bed nets 74
Intermittent Preventive Therapy (IPT) 74
Case management of illness 74
Guidance 74
Prophylaxis 74
Intended use 74
Exception for pregnant women and young children 74
Standby treatment 75
Table 8. Long-term chemoprophylaxis for adults 75
Table 9. Half-lives of selected antimalarial drugs 75
Frequently asked questions 76
Malaria prevention advice for travellers going on cruises 76
‘Once you get malaria, it keeps coming back’ 76
Which antimalarial to give to a traveller with a history of psoriasis 76
Which antimalarial to give a traveller who is taking anticoagulants 76
The coumarins, including warfarin 76
Chloroquine 77
Mefloquine 77
Atovaquone/proguanil 77
Advice for travellers needing malaria chemoprophylaxis who are taking warfarin 77
Direct oral anticoagulants (DOAC) 78
How long a traveller can take different antimalarial drugs 78
Chloroquine 78
Mefloquine 79
Doxycycline 79
Atovaquone/proguanil 79
Antimalarial drugs which are suitable for women during pregnancy 79
Antimalarial drugs which can be taken by women breastfeeding 80
Antimalarial drugs which can be given to babies and young children 81
The easiest way to calculate the correct dose of chloroquine for babies and young children 81
Antimalarial drugs for a traveller who has epilepsy 82
Advice for a traveller with glucose 6- phosphate dehydrogenase deficiency 82
Chloroquine 83
Atovaquone-proguanil, doxycycline, or mefloquine prophylaxis 83
Primaquine 83
Advice for people working on oil rigs 83
Advice for the traveller on a stopover 83
Doxycycline’s affect on oral contraception 83
Advice for travellers who discontinue chemoprophylaxis on or after return to the UK due to drug side effects; or who lost their supply; or whose trip has been extended beyond their supply of antimalarials 84
Atovaquone-proguanil combination preparation 84
Suppressive prophylaxis (chloroquine, doxycycline, mefloquine) 84
Information resources 85
Expert centres 85
Prophylaxis advice 85
Diagnostic advice 85
Treatment advice 85
Useful websites 86
Information leaflets 86
Appendices 87
Appendix 1a. Terms of reference 2023 87
Background 87
Purpose 87
Membership 87
Accountability 88
Review process 88
Working methods 88
Meeting arrangements 88
Confidentiality or conflicts of interest 88
Funding 89
Equality and diversity 89
Appendix 1b. ACMP member list 90
Appendix 1c. ACMP conflict of interest statements 91
Appendix 1d. ACMP methodology 93
Purpose 93
Assessing in-country risk 93
Returned traveller data 93
Available preventive measures 94
Other jurisdictions 94
Reaching a decision 94
The future 94
Appendix 2. Template for risk assessment and summary of advice given 95
Underlying condition 95
Allergies 96
Medication 96
Area to be visited 97
Purpose of visit and type of accommodation: tick all those that apply 97
Record of advice given to traveller 98
Standby emergency medication 99
Appendix 3. Emergency standby medication: traveller information leaflet 100
Incubation period of malaria 100
Symptoms and signs of malaria 100
When to take your emergency standby medication 100
How to take your emergency standby medication 100
Appendix 4. Destinations: maps showing the areas with appropriate malaria prevention measures recommended 102
Figure 4. Map of Afghanistan showing the areas with appropriate malaria prevention measures recommended 102
Figure 5. Map of Angola showing the areas with appropriate malaria prevention measures recommended 103
Information about malaria in Angola on the Travel Health Pro website. 103
Figure 6. Map of Bangladesh showing the areas with appropriate malaria prevention measures recommended 104
Figure 7. Map of Benin showing the areas with appropriate malaria prevention measures recommended 105
Figure 8. Map of Bolivia showing the areas with appropriate malaria prevention measures recommended 106
Figure 9. Map of Botswana showing the areas with appropriate malaria prevention measures recommended 107
Figure 10. Map of Brazil showing the areas with appropriate malaria prevention measures recommended 108
Figure 11. Map of Cambodia showing the areas with appropriate malaria prevention measures recommended 109
Figure 12. Map of Cameroon showing the areas with appropriate malaria prevention measures recommended 110
Figure 13. Map of Colombia showing the areas with appropriate malaria prevention measures recommended 111
Figure 14. Map of Congo showing the areas with appropriate malaria prevention measures recommended 112
Figure 15. Map of Costa Rica showing the areas with appropriate malaria prevention measures recommended 113
Figure 16. Map of Cote D’Ivoire showing the areas with appropriate malaria prevention measures recommended 114
Figure 17. Map of Democratic Republic of Congo showing the areas with appropriate malaria prevention measures recommended 115
Figure 18. Map of Ecuador showing the areas with appropriate malaria prevention measures recommended 116
Figure 19. Map of Eritrea showing the areas with appropriate malaria prevention measures recommended 117
Figure 20. Map of Eswatini showing the areas with appropriate malaria prevention measures recommended 118
Figure 21. Map of Ethiopia showing the areas with appropriate malaria prevention measures recommended 119
Figure 22. Map of Gambia showing the areas with appropriate malaria prevention measures recommended 120
Figure 23. Map of Ghana showing the areas with appropriate malaria prevention measures recommended 121
Figure 24. Map of Guatemala showing the areas with appropriate malaria prevention measures recommended 122
Figure 25. Map of Guinea showing the areas with appropriate malaria prevention measures recommended 123
Figure 26. Map of Honduras showing the areas with appropriate malaria prevention measures recommended 124
Figure 27. Map of India showing the areas with appropriate malaria prevention measures recommended 125
Figure 28. Map of Indonesia and Indonesia (Borneo) showing the areas with appropriate malaria prevention measures recommended 126
Figure 29. Map of Iran showing the areas with appropriate malaria prevention measures recommended 127
Figure 30. Map of Iraq showing the areas with appropriate malaria prevention measures recommended 128
Figure 31. Map of Kenya showing the areas with appropriate malaria prevention measures recommended 129
Figure 32. Map of Laos showing the areas with appropriate malaria prevention measures recommended 130
Figure 33. Map of Madagascar showing the areas with appropriate malaria prevention measures recommended 131
Figure 34. Map of Malawi showing the areas with appropriate malaria prevention measures recommended 132
Figure 35. Map of Malaysia and Malaysia (Borneo) showing the areas with appropriate malaria prevention measures recommended 133
Figure 36. Map of Mauritania showing the areas with appropriate malaria prevention measures recommended 134
Figure 37. Map of Mozambique showing the areas with appropriate malaria prevention measures recommended 135
Figure 38. Map of Namibia showing the areas with appropriate malaria prevention measures recommended 136
Figure 39. Map of Nepal showing the areas with appropriate malaria prevention measures recommended 137
Figure 40. Map of Nigeria showing the areas with appropriate malaria prevention measures recommended 138
Figure 41. Map of Pakistan showing the areas with appropriate malaria prevention measures recommended 139
Figure 42. Map of Panama showing the areas with appropriate malaria prevention measures recommended 140
Figure 43. Map of Papua New Guinea showing the areas with appropriate malaria prevention measures recommended 141
Figure 44. Map of Peru showing the areas with appropriate malaria prevention measures recommended 142
Figure 45. Map of Philippines showing the areas with appropriate malaria prevention measures recommended 143
Figure 46. Map of Rwanda showing the areas with appropriate malaria prevention measures recommended 144
Figure 47. Map of Saudi Arabia showing the areas with appropriate malaria prevention measures recommended 145
Figure 48. Map of Sierra Leone showing the areas with appropriate malaria prevention measures recommended 146
Figure 49. Map of Somalia showing the areas with appropriate malaria prevention measures recommended 147
Figure 50. Map of South Africa showing the areas with appropriate malaria prevention measures recommended 148
Figure 51. Map of Sudan showing the areas with appropriate malaria prevention measures recommended 149
Figure 52. Map of Tanzania showing the areas with appropriate malaria prevention measures recommended 150
Figure 53. Map of Thailand showing the areas with appropriate malaria prevention measures recommended 151
Figure 54. Map of Uganda showing the areas with appropriate malaria prevention measures recommended 152
Figure 55. Map of Vietnam showing the areas with appropriate malaria prevention measures recommended 153
Figure 56. Map of Yemen showing the areas with appropriate malaria prevention measures recommended 154
Figure 57. Map of Zambia showing the areas with appropriate malaria prevention measures recommended 155
Figure 58. Map of Zimbabwe showing the areas with appropriate malaria prevention measures recommended 156
References 157
About the UK Health Security Agency 166

Malaria prevention guidelines for travellers from the UK

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