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