likely to be more than 24 hours away from medical care. Self-
medication should beavoidedif medical help is accessible.
In order to avoid excessive self-medication, the traveller
should be provided withwritten instructionsthat urgent
medical attention should be sought if fever ( 38 °C or more)
develops 7 days (or more) after arriving in a malarious area
and that self-treatment is indicated if medical help is not
available within 24 hours of fever onset.
In view of the continuing emergence of resistant strains
and of the different regimens required for different areas
expert advice should be sought on the best treatment course
for an individual traveller. A drug used for chemoprophylaxis
should not be considered for standby treatment for the same
traveller.Malaria prophylaxis, specific recommendations
Where a journey requires two regimens, the regimen for the
higher risk area should be used for the whole journey. Those
travelling to remote or little-visited areas may require expert
advice. See alsoRecommended regimens for prophylaxis
against malaria(p. 387 ).Important
Settled immigrants (or long-term visitors) to the UK may be
unaware thatany immunity they may have acquired while
living in malarious areas is lost rapidlyafter migration to
the UK, or that any non-malarious areas where they lived
previouslymay now be malarious.Malaria, treatment
Advice for healthcare professionals
A number of specialist centres are able to provide advice on
specific problems.
PHE (Public Health England) Malaria Reference Laboratory
( 020 )7637 0248(fax) (prophylaxis only)www.malaria-
reference.co.uk
National Travel Health Network and Centre0845 602 6712
Monday and Friday: 9 – 11 a.m. and 1 – 2 p.m, Tuesday to
Thursday: 9 – 11 a.m. and 1 – 3 : 30 p.m.travelhealthpro.org.uk/
Travel Medicine Team, Health Protection Scotland
(registered users of Travax only)www.travax.nhs.uk(for
registered users of the NHS Travax website only) ( 0141 ) 300
1100 (weekdays 2 – 4 p.m. only)
Birmingham ( 0121 )424 2358
Liverpool ( 0151 )705 3100
London0845 155 5000(treatment)
Oxford ( 01865 )225 430Advice for travellers
Hospital for Tropical Diseases Travel Healthline ( 020 ) 7950
7799 http://www.fitfortravel.nhs.uk
WHO advice on international travel and healthwww.who.
int/ith
National Travel Health Network and Centre (NaTHNaC)
http://www.travelhealthpro.org.uk/Treatment
Recommendations on the prophylaxis and treatment of
malaria reflect guidelines agreed by UK malaria specialists.
Choice will depend on the age of the child.
If the infective species isnot known, or if the infection is
mixed, initial treatment should be as forfalciparum malaria
with quinine p. 397 ,Malarone®(atovaquone with proguanil
hydrochloride p. 394 ), orRiamet®(artemether with
lumefantrine p. 393 ). Falciparum malaria can progress
rapidly in unprotected individuals and antimalarial
treatment should be considered in those with features of
severe malaria and possible exposure, even if the initial
blood tests for the organism are negative.Falciparum malaria (treatment)
Falciparum malaria (malignant malaria) is caused by
Plasmodium falciparum. In most parts of the worldP.
falciparumis now resistant to chloroquine p.^395 which
should not therefore be given for treatment. Quinine,
Malarone®(atovaquone with proguanil hydrochloride), or
Riamet®(artemether with lumefantrine) can be given by
mouth if the child can swallow and retain tablets and there
are no serious manifestations (e.g. impaired consciousness);
quinine should be given by intravenous infusion if the child
is seriously ill or unable to take tablets. Mefloquine p. 396 is
now rarely used for treatment because of concerns about
resistance.
Oralquinine is well tolerated by children although the
salts are bitter. Quinine is given by mouth together with or
followed by clindamycin p. 327 [unlicensed indication] or, in
children over 12 doxycycline p. 352.
If the parasite is likely to be sensitive, pyrimethamine with
sulfadoxine as a single dose [unlicensed] may be given
(instead of either clindamycin or doxycycline) together with,
or after, a course of quinine.
Alternatively,Malarone®,orRiamet®may be given
instead of quinine. It is not necessary to give clindamycin,
doxycycline, or pyrimethamine with sulfadoxine after
Malarone®orRiamet®treatment.
If the child is seriously ill or unable to swallow tablets, or if
more than 2 % of red blood cell are parasitized, quinine
should be given byintravenous infusion[unlicensed] (until
patient can swallow tablets to complete the 7 -day course
together withorfollowed by eitherdoxycycline in children over
12 years, or clindamycin).
Specialist advice should be sought in difficult cases (e.g.
very high parasite count, deterioration on optimal doses of
quinine, infection acquired in quinine-resistant areas of
south east Asia) because intravenousartesunatemay be
available for‘named-patient’use.
Pregnancy
Falciparum malaria is particularly dangerous in pregnancy,
especially in the last trimester. The treatment doses of oral
and intravenous quinine (including the loading dose) can
safely be given in pregnancy. Clindamycin [unlicensed
indication] should be given for 7 days with or after quinine.
Doxycycline should be avoided in pregnancy (affects teeth
and skeletal development in fetus); pyrimethamine with
sulfadoxine, Malarone®, and Riamet®are also best avoided
until more information is available. Specialist advice should
be sought in difficult cases (e.g. very high parasite count,
deterioration on optimal doses of quinine, infection acquired
in quinine-resistant areas of south east Asia) because
intravenous artesunate may be available for‘named patient’
use.
Non-falciparum malaria (treatment)
Non-falciparum malaria is usually caused byPlasmodium
vivaxand less commonly byP. ovaleandP. malariae.P.
knowlesiis also present in the Asia-Pacific region.
Chloroquine is the drug of choice for the treatment of non-
falciparum malaria (but chloroquine-resistantP. vivaxhas
been reported in the Indonesian archipelago, the Malay
Peninsula, including Myanmar, and eastward to Southern
Vietnam).
For the treatment of chloroquine-resistant non-falciparum
malaria,Malarone®[unlicensed indication], quinine, or
Riamet®[unlicensed indication] can be used; as with
chloroquine, primaquine p. 396 should be given for radical
cure.
Chloroquine alone is adequate forP. malariaeandP.
knowlesiinfections but in the case ofP. vivaxandP. ovale,a
radical cure(to destroy parasites in the liver and thus prevent
relapses) is required. This is achieved with primaquine
[unlicensed] given after chloroquine.392 Protozoal infection BNFC 2018 – 2019
Infection5