Guidelines for malaria prevention in sub-Saharan Africa

Written by Helen Marshall, pharmacist The risk of falciparum malaria is very high in sub-Saharan Africa, except in the extreme South, and much of the malaria is resistant to chloroquine. Everyone visiting malarious parts of sub-Saharan Africa should take appropriate preventive medicines and use adequate protection to prevent mosquito bites. It is essential to regard all fevers and flu-like illnesses that occur up to a year after leaving Africa, and particularly in the first three months, as possible malaria, and to seek urgent medical advice, as almost all fatal cases of malaria in UK travellers have been contracted in Africa. The forest zone of West Africa has a high risk of falciparum malaria throughout the year. Chloroquineresistant parasites are widespread but their distribution is still patchy. Mefloquine or doxycycline or Malarone are the recommended preventive medicines for this area. Moving north towards the Sahara, malaria transmission becomes seasonal but remains intense, with most infections being contracted during or shortly after the rainy season. Inland, chloroquine resistance is patchy but widespread. Closer to the Sahara the high-risk season becomes shorter.

In particular, most cases in the Gambia are contracted between June and December. Mefloquine or doxycycline or Malarone are the medicines of choice for the Gambia, and for most of sub-Saharan Africa, because of the increasing chloroquine resistance. Risk Country Preferable regimen Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Comoros, Congo, Democratic Republic of the Congo (formely Zare), Djibouti, Equatorial Guinea, Eritrea, Gabon, Gambia, Ghana, Guinea, GuineaBissau, Ivory Coast, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Niger, Nigeria, Principe, Rwanda, So Tom, Senegal, Sierra Leone, Somalia, Sudan, Swaziland, Tanzania, Togo, Uganda, Zambia Botswana (only in the northern half of the country, November-June) Risk very high, or locally very high. Chloroquine resistance very widespread Ethiopia (areas below 2000m; no risk in Addis Ababa) Mauritania (year round in the south; July-October in the north) Namibia (all year along Kavongo and Kunene rivers; November-June in northern third) South Africa (low-altitude areas of Mpumalanga and Limpopo Provinces, Kruger National Park, and north-east KwaZulu-Natal as far south as Jozini) Zimbabwe (all year in Zambezi valley; November-June in other areas below 1200m; risk negligible in Harare and Bulawayo) Cape Verde (some risk on So Tiago) Avoid insect bites, but Low risk remember low risk exists if Mauritius fever develops Always see your pharmacist for more detailed information about the risks of malaria in each country you are visiting. Your pharmacist will be able to tell you which medicines are recommended. Remember to tell your pharmacist:

Mefloquine OR doxycycline OR Malarone

if you are pregnant, planning a pregnancy or breastfeeding if you suffer from any diseases or conditions if you are taking any regular medications if a child is travelling with you.

This information will help the pharmacist recommend the most appropriate regimen for you.

Remember to leave yourself enough time before you leave to obtain your medicines. All the malaria prevention medicines must be started before you travel. Mefloquine needs to be started two-and-a-half weeks before travel, chloroquine and proguanil should be started a week before, and Malarone and doxycycline one to two days before travelling. Chloroquine (Avloclor or Nivaquine) and proguanil (Paludrine) can be bought from pharmacies, but may have to be ordered in if you are going for a long trip. Mefloquine (Lariam), doxycycline (eg Vibramycin) and Malarone all require a prescription from your doctor. For these reasons always see your pharmacist at least three weeks before you plan to travel, to find out which (if any) medicines are recommended, when you need to start taking them, and whether you need a prescription to obtain them. Remember to take your medicines regularly while you are away, and continue taking them for four further weeks after leaving the malarious area, with the exception of Malarone, which only needs to be continued for one week after leaving. Always suspect malaria and seek urgent medical advice if you develop a fever or flu-like illness whilst you are away (even if you are taking preventive medicines) or up to a year after you return, in particular in the first three months.