Malaria prevention guidelines for travellers from the UK

Table of Contents

• 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