At a glance
- Drugs to prevent malaria differ by country of travel.
- Counsel patients to use personal protective measures along with malaria chemoprophylaxis.
- Consider contraindications and drug-drug interactions when prescribing a malaria prophylaxis.
- Consider the timing of when to start and stop chemoprophylaxis. Some medications require patients take them weeks in advance of travel and continued after leaving the malaria-endemic area.
Medication shortage
Mefloquine shortage
FDA has announced a temporary shortage of Mefloquine Hydrochloride, one of the medications used to prevent malaria. Clinicians who would like to discuss alternative options for specific populations can contact the CDC malaria hotline/clinical consult service at malaria@cdc.gov, or call Monday–Friday, 9 am–5 pm EST 770-488-7788 or 855-856-4713. (After hours call 770-488-7100.)
Considerations
Considerations when choosing a drug for malaria prophylaxis:
- Recommendations for drugs to prevent malaria differ by country of travel and can be found in CDC's Yellow Book chapter on Malaria Prevention Information, by Country. Recommended drugs for each country are listed in alphabetical order and have comparable efficacy in that country.
- When used correctly malaria chemoprophylaxis is very effective. Using multiple prevention strategies together offer additional protection. Counsel patients on the use of personal protective measures, (i.e., insect repellent, long sleeves, long pants, sleeping in a mosquito-free setting or using an insecticide-treated bed net) along with malaria chemoprophylaxis.
- For all medicines, also consider the possibility of drug-drug interactions with other medicines that the person might be taking as well as other medical contraindications, such as drug allergies.
- When several different drugs are recommended for an area, the following table might help in the decision process.
- CDC has replaced the Malaria Prevention Country Tables with the Yellow Book 2024 chapter on Malaria Prevention Information, by Country. You can find the same information regarding chemoprophylaxis by country or region.
Drug/Dosage
Reasons that might make you consider using this drug
Reasons that might make you avoid using this drug
Atovaquone/Proguanil (Malarone)
Begin 1 – 2 days before travel, daily during travel, and for 7 days after leaving.
Adults: 1 adult tablet daily.
Children: 5-8 kg: ½ pediatric tablet daily.
>8-10 kg: ¾ pediatric tablet daily.
>10-20 kg: 1 pediatric tablet daily.
>20-30 kg: 2 pediatric tablets daily.
>30-40 kg 3 pediatric tablets daily.
>40 kg and over: 1 adult tablet daily.
- Good for last-minute travelers because the drug is started 1-2 days before traveling to an area where malaria transmission occurs
- Some people prefer to take a daily medicine
- Good choice for shorter trips because you only have to take the medicine for 7 days after traveling rather than 4 weeks
- Very well tolerated medicine – side effects uncommon
- Pediatric tablets are available and may be more convenient
- Cannot be used by women who are pregnant or breastfeeding a child less than 5 kg
- Cannot be taken by people with severe renal impairment
- Tends to be more expensive than some of the other options (especially for trips of long duration)
- Some people (including children) would rather not take a medicine every day
Chloroquine
Begin 1 – 2 weeks before travel, once/week during travel, and for 4 weeks after leaving.
Adults: 300 mg base (500 mg salt), once/week.
Children: 5 mg/kg base (8.3 mg/kg salt) (maximum is adult dose), once/week.
- Some people would rather take medicine weekly
- Good choice for long trips because it is taken only weekly
- Some people are already taking hydroxychloroquine chronically for rheumatologic conditions. In those instances, they may not have to take an additional medicine
- Can be used in all trimesters of pregnancy
- Cannot be used in areas with chloroquine or mefloquine resistance
- May exacerbate psoriasis
- Some people would rather not take a weekly medication
- For trips of short duration, some people would rather not take medication for 4 weeks after travel
- Not a good choice for last-minute travelers because drug needs to be started 1-2 weeks prior to travel
Doxycycline
Begin 1 – 2 days before travel, daily during travel, and for 4 weeks after leaving.
Adults: 100 mg daily.
Children: ≥8 years old: 2.2 mg/kg (maximum is adult dose) daily.
- Some people prefer to take a daily medicine
- Good for last-minute travelers because the drug is started 1-2 days before traveling to an area where malaria transmission occurs
- Tends to be the least expensive antimalarial
- Some people are already taking doxycycline chronically for prevention of acne. In those instances, they do not have to take an additional medicine
- Doxycycline also can prevent some additional infections (e.g., Rickettsiae and leptospirosis) and so it may be preferred by people planning to do lots of hiking, camping, and wading and swimming in fresh water
- Cannot be used by pregnant women and children <8 years old
- Some people would rather not take a medicine every day
- For trips of short duration, some people would rather not take medication for 4 weeks after travel
- Women prone to getting vaginal yeast infections when taking antibiotics may prefer taking a different medicine
- Persons planning on considerable sun exposure may want to avoid the increased risk of sun sensitivity
- Some people are concerned about the potential of getting an upset stomach from doxycycline
Mefloquine
Begin 1 – 2 weeks before travel, weekly during travel, and for 4 weeks after leaving.
Adults: 228 mg base (250 mg salt), weekly.
Children: ≤9 kg: 4.6 mg/kg base (5 mg/kg salt), weekly.
>9-19 kg: ¼ tablet weekly. >19-30 kg: ½ tablet weekly.
>30-45 kg: ¾ tablet weekly.
>45 kg: 1 tablet weekly.
- Some people would rather take medicine weekly
- Good choice for long trips because it is taken only weekly
- Can be used during pregnancy
- Cannot be used in areas with mefloquine resistance
- Cannot be used in patients with certain psychiatric conditions
- Cannot be used in patients with a seizure disorder
- Not recommended for persons with cardiac conduction abnormalities
- Not a good choice for last-minute travelers because drug needs to be started at least 2 weeks prior to travel
- Some people would rather not take a weekly medication
- For trips of short duration, some people would rather not take medication for 4 weeks after travel
Primaquine
Begin 1 – 2 days prior to travel, daily during travel, and for 7 days after leaving
Adults: 30 mg base (52.6 mg salt), daily
Children: 0.5 mg/kg base (0.8 mg/kg salt) up to adult dose daily
- It is one of the most effective medicines for preventing P. vivax and so it is a good choice for travel to places with > 90% P. vivax
- Good choice for shorter trips because you only have to take the medicine for 7 days after traveling rather than 4 weeks
- Good for last-minute travelers because the drug is started 1-2 days before traveling to an area where malaria transmission occurs
- Some people prefer to take a daily medicine
- Cannot be used in patients with glucose-6-phosphatase dehydrogenase (G6PD) deficiency
- Cannot be used in patients who have not been tested for G6PD deficiency
- There are costs and delays associated with getting a G6PD test done; however, it only has to be done once. Once a normal G6PD level is verified and documented, the test does not have to be repeated the next time primaquine is considered
- Cannot be used by pregnant women
- Cannot be used by women who are breastfeeding unless the infant has also been tested for G6PD deficiency
- Some people (including children) would rather not take a medicine every day
- Some people are concerned about the potential of getting an upset stomach from primaquine
Tafenoquine (ArakodaTM)
Begin daily for 3 days prior to travel, weekly during travel, and for 1 week after leaving.
Adults only: 200 mg per dose.
- One of the most effective drugs for prevention of P. vivax malaria, but also prevents P. falciparum
- Good choice for shorter trips because you only have to take the medicine once, 1 week after traveling rather than 4 weeks
- Good for last-minute travelers because the drug is started 3 days before traveling to an area where malaria transmission occurs
- Cannot be used in patients with glucose-6-phosphatase dehydrogenase (G6PD) deficiency
- Cannot be used in patients who have not been tested for G6PD deficiency
- There are costs and delays associated with getting a G6PD test done; however, it only has to be done once. Once a normal G6PD level is verified and documented, the test does not have to be repeated the next time tafenoquine is considered
- Cannot be used by children
- Cannot be used by pregnant women
- Cannot be used by women who are breastfeeding unless the infant has also been tested for G6PD deficiency
- Not recommended in those with psychotic disorders