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Need for Malaria Prophylaxis by Travelers to Areas With Chloroquine-Resistant Plasmodium falciparum

On April 12, 1985, new recommendations for malaria prophylaxis were published by CDC in response to evidence that weekly use of pyrimethamine/sulfadoxine (Fansidar) for malaria prophylaxis was associated with fatal cutaneous reactions in 1/18,000 to 1/26,000 users (1). These revised recommendations emphasized the weekly use of chloroquine or amodiaquine as the mainstay of chemoprophylaxis and suggested that the weekly prophylactic use of Fansidar be limited to travelers at very high risk of exposure to chloroquine-resistant Plasmodium falciparum, mainly longer-term travelers to eastern and central Africa. It was further recommended that short-term (3 weeks or less) travelers to areas with chloroquine-resistant P. falciparum carry three tablets (adult dose) of Fansidar to take presumptively in the event of a febrile illness when professional medical care is not readily available. Finally, the importance of personal protection from mosquito contact by use of insect repellants, insect sprays, nets, and screens was stressed.

To date, 60 cases of P. falciparum infection have been reported to CDC, with onset of illness in 1985 among U.S. travelers who acquired their infection in Kenya, where chloroquine-resistant P. falciparum is widely prevalent. Review of the preventive measures taken by these 60 persons revealed that chemoprophylaxis had been used by 46 (77%). Thirty-nine (65%) persons had used chloroquine alone weekly for prophylaxis. Weekly prophylaxis with Fansidar and chloroquine had been used by seven (12%). Of concern is that only four (24%) of 17 malaria patients investigated who had traveled to Kenya after April 1985 were aware of the recommendation for presumptive treatment with Fansidar. Furthermore, only seven (41%) of these 17 had used insect repellants.

The current recommendations are more complicated than before because they reflect an effort to balance the risks and benefits of prophylactic regimens for travelers to various areas. It is essential that health-care providers and travelers consider the possibility that a febrile illness may be malaria, even when chloroquine prophylaxis has been used. Further, it is important that the three-tablet adult treatment dosage of Fansidar and the indications for its use are explained thoroughly to travelers because responsibility is placed on them to recognize a potential malaria infection and, if necessary, treat themselves while abroad.

The current CDC guidelines for malaria prophylaxis for travelers (1,2) contain detailed recommendations for travelers to different destinations, taking into account the risk of malaria infection. Health-care providers are encouraged to report all malaria patients to state and local health departments, with particular attention to travel histories and chemoprophylaxis. CDC continues to monitor both the level of implementation of the current recommendations and their effect on the occurrence of P. falciparum infections in U.S. travelers. Reported by Malaria Br, Div of Parasitic Diseases, Center for Infectious Diseases, Div of Quarantine, Center for Prevention Svcs, CDC.

References

  1. CDC. Revised recommendations for preventing malaria in travelers to areas with chloroquine-resistant P. falciparum. MMWR 1985;34:185-90.

  2. CDC. Health information for international travel 1985. Atlanta, Georgia: Public Health Service, U.S. Department of Health and Human Services; publication no. (CDC) 85-8280.

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