Know Your Family’s Risk of Malaria
Malaria is a serious illness transmitted by the bite of an infected mosquito. Travelers to Central and South America, the island of Hispaniola (includes Haiti and the Dominican Republic), Africa, Asia (including the Indian Subcontinent, South East Asia, and the Middle East), Eastern Europe, and the South Pacific may be at risk for this potentially deadly disease.
Children of any age can get malaria. All travelers to areas with malaria transmission, including infants, children, and former residents of these areas, should protect themselves from malaria by taking an antimalarial drug and by preventing mosquito bites.
To find out if your foreign travel will take you and your family into an area with malaria:
- Visit CDC’s Traveler’s Health website at http://wwwn.cdc.gov/travel
- Call CDC’s Voice Information Line at 1-877-FYI-TRIP (1-877-394-8747) and listen to pre-recorded messages
See Your Child’s Health Care Provider
Take your child to their health care provider at least 4-6 weeks before the time of your trip. Any vaccinations your child may need will have time to become fully protective. In addition, all the antimalarial drugs are prescription drugs and your child will need to start taking them before travel. Dosages for infants and children usually have to be specially prepared; allow your pharmacist sufficient time to prepare your prescriptions.
Find Out Which Antimalarial Drug is Right for Your Child
Your health care provider will decide which antimalarial drug is the right one for your child. Some drugs may not be effective in some countries in the world. A medical condition may prevent your child from taking a particular antimalarial drug. In addition, children’s dosages are based on their age and weight and need to be carefully calculated.
Antimalarial Warnings and Instructions
- Give your child their antimalarial drug exactly on schedule. Missing or delaying doses may increase their risk of getting malaria.
- For the best protection against malaria, your child should continue taking their drug as recommended after leaving the malaria-risk area (4 weeks for mefloquine, doxycycline, or chloroquine; 7 days for atovaquone/proguanil or primaquine). Otherwise, they can develop malaria.
- Overdosage (taking too much of an antimalarial drug) can be fatal. Keep drugs in childproof containers out of the reach of children.
- Buy your drugs before traveling overseas. Drugs purchased overseas may not be made according to United States standards and may not be effective. They may also be dangerous, contain the wrong drug or no active drug, or be contaminated.
- Halofantrine (also called Halfan) is widely used overseas to treat malaria. CDC recommends that you and your child not use Halfan because of serious heart-related side effects, including deaths.
- You should avoid using antimalarial drugs that are not recommended unless your child has been diagnosed with life-threatening malaria and no other treatment options are available.
- Most antimalarial drugs are well-tolerated; most travelers do not need to stop taking their drug because of side effects. However, if you are particularly concerned about side effects, discuss the possibility of starting your drug early (3-4 weeks in advance of your trip) with your health care provider. If you cannot tolerate the drug, ask your doctor to change your medication.
Antimalarial Drug Information
Infants and children traveling to malaria-risk areas in Africa, South America, the Indian Subcontinent, Tajikistan, Asia, and the South Pacific should be given one of the following antimalarial drugs (listed alphabetically):
- atovaquone/proguanil
- doxycycline
- mefloquine
- primaquine (in special circumstances).
Atovaquone/proguanil (Brand Name: Malarone™)
Atovaquone/proguanil is a combination of two drugs, atovaquone plus proguanil, in one tablet. It is available in the United States as the brand name, Malarone.
Your child’s health care provider will prescribe atovaquone/proguanil based on your child’s weight . Note: Atovaquone/proguanil should not be used to prevent malaria in infants that weigh less than 11 pounds (5 kilograms).(Updated December 22, 2006).
Directions for Use
- Give the first dose of atovaquone/proguanil 1 to 2 days before travel to the malaria-risk area.
- Give atovaquone/proguanil once a day during travel in the malaria-risk area.
- Give atovaquone/proguanil once a day for 7 days after leaving the malaria-risk area.
- Give the dose at the same time each day and have your child take the pill after a meal or with milk. Atovaquone/proguanil is better absorbed if taken with food or a milky drink.
Side Effects and Warnings
The most common side effects reported by travelers taking atovaquone/proguanil are stomach pain, nausea, vomiting, and headache. Most people taking this drug do not have side effects serious enough to stop taking it; If your child cannot tolerate atovaquone/proguanil, see their health care provider for a different antimalarial drug.
Travelers Who Should NOT Take Atovaquone/proguanil to Prevent Malaria
- children weighing less than 11 pounds (5 kilograms) (Updated December 22, 2006)
- pregnant women
- women breast-feeding infants weighing less than 11 pounds (5 kilograms) (Updated December 22, 2006)
- patients with severe renal impairment (severe kidney disease)
- patients allergic to atovaquone or proguanil
Doxycycline (Many Brand Names and Generic Brands Are Available)
Doxycycline is related to the antibiotic tetracycline.
Directions for Use
- Your child’s health care provider will prescribe doxycycline based on your child’s weight.
- Give the first dose of doxycycline 1-2 days before travel to the malaria-risk area.
- Give doxycycline once a day, at the same time each day, while in the risk area.
- Give doxycycline once a day for 4 weeks after leaving the risk area.
Side Effects and Warnings
One of the most common side effects reported in children taking doxycycline includes sunburning faster than normal (sun sensitivity). To prevent sunburn, your child should avoid midday sun, wear a high SPF sunblock, long-sleeved shirts, long pants, and a hat.
Doxycycline may cause nausea and stomach pain. Give your child the drug after a meal and have them drink a full glass of liquid. They should not lie down for 1 hour after taking the drug to prevent reflux of the drug (stomach contents backing up into the esophagus).
Most children taking doxycycline do not have side effects serious enough to stop taking it. If your child cannot tolerate doxycycline, see their health provider. Other drugs are available.
Travelers Who Should Not Take Doxycycline
- children under the age of 8 years; teeth may become permanently stained.
- children allergic to doxycycline or other tetracyclines
- pregnant women
- Very limited safety data exists on the use of doxycycline by breast-feeding women. Most experts consider the likelihood of harmful effects to be remote.
Mefloquine (Brand Name Lariam™ and Generic)
Directions for Use
- Your child’s health care provider will prescribe mefloquine based on your child’s weight.
- Give the first dose of mefloquine 1 week before travel to the malaria-risk area.
- Give the drug once a week, on the same day of the week, while in the risk area.
- Give mefloquine once a week for 4 weeks after leaving the malaria-risk area.
- Mefloquine should be given on a full stomach after a meal.
Side Effects and Warnings
The most common side effects reported by travelers taking mefloquine include headache, nausea, dizziness, difficulty sleeping, anxiety, vivid dreams, and visual disturbances. Mefloquine has rarely been reported to cause serious side effects, such as seizures, depression, and psychosis. These serious side effects are more frequent with the higher doses used to treat malaria; fewer occurred at the weekly doses used to prevent malaria.
Mefloquine is eliminated slowly by the body and thus may stay in the body for a while even after the drug is discontinued. Therefore, side effects caused by mefloquine may persist weeks to months after the drug has been stopped.
Most children taking mefloquine do not have side effects serious enough to stop taking the drug. (Other antimalarial drugs are available if your child cannot tolerate mefloquine; see your health care provider.)
Children Who Should NOT Take Mefloquine
If your child has a condition that is listed below, they should not take mefloquine and you should ask their health care provider for a different antimalarial drug:
- persons with active depression or a recent history of depression
- persons with a history of psychosis, generalized anxiety disorder, schizophrenia, or other major psychiatric disorder
- persons with a history of seizures (does not include the type of seizure caused by high fever in childhood)
- persons allergic to mefloquine
- Mefloquine is not recommended for persons with cardiac conduction abnormalities (for example, an irregular heartbeat).
Primaquine
If your child cannot take other antimalarial drugs and if your health care provider thinks it is necessary, primaquine may be used to prevent malaria while the child is in the malaria-risk area.
Directions for Use
Note: Children must be tested for G6PD deficiency (glucose-6-phosphate-dehydrogenase) and have a documented G6PD level in the normal range before primaquine use. G6PD is an enzyme; your health care provider will do a blood test to find out if your child has a high enough level of this enzyme to safely take primaquine. Primaquine can cause a bursting of the red blood cells (hemolysis) which can be fatal, if your child is deficient in G6PD.
- Your child’s health care provider will prescribe primaquine based on your child’s weight.
- Give the first dose 1-2 days before travel to the malaria-risk area.
- Give primaquine once a day, at the same time each day, while in the risk area.
- Give primaquine once a day for 7 days after leaving the risk area.
Side Effects and Warnings
The most common side effects reported by travelers taking primaquine include stomach cramps, nausea, and vomiting.
If your child has a condition listed below, they should not take primaquine and you should ask their health care provider for a different drug:
- persons with G6PD deficiency
- persons who have not had a blood test for G6PD deficiency
- pregnant women (the fetus may be G6PD deficient, even if the mother’s blood test is in the normal range)
- women breast-feeding infants unless the infant has a documented normal G6PD level
- persons allergic to primaquine
- Do not share primaquine with others; they may be G6PD deficient and suffer bursting of their red blood cells, which can be fatal.
Chloroquine Phosphate (Brand Name Aralen™ and Generics)
Travelers to malaria-risk areas in Mexico, Haiti, the Dominican Republic, and certain countries in Central America, the Middle East, and Eastern Europe should take chloroquine as their antimalarial drug. (Hydroxychloroquine sulfate is available as an alternative; see below.)
Directions for Use
- Your child’s health care provider will prescribe chloroquine based on your child’s weight.
- Give the first dose of chloroquine 1 week before arrival in the malaria-risk area.
- Give the dose once a week, on the same day of the week, while in the risk area.
- Give the dose once a week for 4 weeks after leaving the risk area.
- Chloroquine should be taken on a full stomach to lessen the risk of nausea and stomach upset.
Side Effects and Warnings
The most common side effects reported by travelers taking chloroquine include nausea and vomiting, headache, dizziness, blurred vision, and itching. Chloroquine may worsen the symptoms of psoriasis. Most children taking chloroquine do not have side effects serious enough to stop taking the drug. Other antimalarial drugs are available; see their health care provider
Note: In malaria-risk areas where chloroquine is the recommended drug but chloroquine cannot be taken, atovaquone/proguanil, doxycycline, mefloquine, or primaquine would also be effective and can be used as your child’s antimalarial drug.
The following children should not take chloroquine; you should ask their health care provider for a different drug:
- patients allergic to chloroquine
Hydroxychloroquine Sulfate (Brand Name: Plaquenil™)
Hydroxychloroquine sulfate is an alternative to chloroquine phosphate, although less evidence exists on its effectiveness as an antimalarial drug.
Directions for Use
- Your child’s health care provider will prescribe hydroxychloroquine sulfate based on your child’s weight.
- Give the first dose 1 week before arrival in the malaria-risk area.
- Give the dose once a week, on the same day of the week, while in the risk area.
- Give the dose once a week for 4 weeks after leaving the risk area.
- Give hydroxychloroquine sulfate after a meal to lessen nausea and stomach upset.
Side Effects and Warnings
Nausea and vomiting, headache, dizziness, blurred vision, difficulty sleeping, and itching have been reported with hydroxychloroquine sulfate use. Minor side effects usually do not require stopping the drug. Hydroxychloroquine sulfate may worsen the symptoms of psoriasis. Other antimalarial drugs are available; see your health care provider.
Note: In malaria-risk areas where hydroxychloroquine sulfate is the recommended drug but hydroxychloroquine sulfate cannot be taken, atovaquone/proguanil, doxycycline, mefloquine, or primaquine are also effective and can be used as your child’s antimalarial drug.
Protect Yourself from Mosquito Bites
Malaria is transmitted by the bite of an infected mosquito; these mosquitoes usually bite between dusk and dawn. To avoid being bitten, remain indoors in a screened or air-conditioned area during the peak biting period. If out-of-doors, wear long-sleeved shirts, long pants, and hats. Apply insect repellent (bug spray) to exposed skin.
Choosing an Insect Repellent
For the prevention of malaria, CDC recommends an insect repellent with DEET (N, N-diethyl-m-toluamide) as the repellent of choice. Many DEET products give long-lasting protection against the mosquitoes that transmit malaria (the anopheline mosquitoes).
A new repellent is now available in the United States that contains 7% picaridin (KBR 3023). Picaridin may be used if a DEET-containing repellent is not acceptable to the user. However, there is much less information available on how effective picaridin is at protecting against all of the types of mosquitoes that transmit malaria. Also, since the percent of picaridin is low, this repellent may only protect against bites for 1-4 hours.
At this time, use of other repellents is not recommended for the prevention of malaria because there is insufficient data on how well they protect against the mosquitoes that transmit malaria.
Precautions When Using Any Repellent
- Read and follow the directions and precautions on the product label.
- Use only when outdoors and thoroughly wash off the repellent from the skin with soap and water after coming indoors.
- Do not breathe in, swallow, or get repellent into the eyes or mouth. If using a spray product, apply to your face by spraying your hands and rubbing the product carefully over the face, avoiding eyes and mouth.
- Never use repellents on wounds or broken skin.
- Pregnant women should use insect repellent as recommended for other adults. Wash off with soap and water after coming indoors.
- Repellents may be used on infants older than 2 months of age.
- Children under 10 years old should not apply insect repellent themselves. Do not apply to young children’s hands or around their eyes and mouth.
Using Repellents With DEET
- Do not get repellent containing DEET into the mouth. DEET is toxic if swallowed.
- Higher concentrations of DEET may have a longer repellent effect; however, concentrations over 50% provide no added protection.
- Timed-release DEET products, which are micro-encapsulated, may have a longer repellent effect than liquid DEET products. Re-apply as necessary, following the label directions.
Using Repellents With Picaridin
- Spray enough picaridin repellent to slightly moisten skin.
- Reapply repellents with picaridin (7% picaridin is the only product currently available in the United States) every 3 to 4 hours. Do not apply more than 3 times a day.
- Picaridin repellent causes moderate eye irritation. Avoid contact with eyes. If in eyes, wash with water for 15 to 20 minutes.
Other Recommended Anti-mosquito Measures
- Travelers should take a flying insect spray on their trip to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
- Travelers not staying in well-screened or air-conditioned rooms should sleep under bed nets (mosquito nets), preferably nets treated with the insecticide permethrin. Permethrin both repels and kills mosquitoes as well as other biting insects and ticks. In the United States, permethrin is available as a spray or a liquid (e.g. Permanone™). Pre-treated nets, permethrin or another insecticide deltamethrin, are available overseas.
For information on ordering insecticide-treated bed nets: http://www.travmed.com, phone 1-800-872-8633, fax: 413-584-6656; or http://www.travelhealthhelp.com, phone 1-866-621-6260. - Protect infants (especially infants under 2 months of age not wearing insect repellent) by using a carrier draped with mosquito netting with an elastic edge for a tight fit.
- Clothing, shoes, and camping gear, can also be treated with permethrin. Treated clothing can be repeatedly washed and still repel insects. Some commercial products (clothing) are now available in the United States that have been pretreated with permethrin.
