Malaria Prophylaxis Recommendations

Risk Assessment and Drug Selection Algorithm

The Centers for Disease Control and Prevention recommends using chloroquine 300 mg base weekly for chloroquine-sensitive areas, or atovaquone-proguanil, doxycycline, or mefloquine for chloroquine-resistant regions 1, 2, 3
For chloroquine-resistant areas, the American Society of Tropical Medicine and Hygiene suggests choosing from three first-line options based on patient factors: atovaquone-proguanil, doxycycline 100 mg daily, or mefloquine 250 mg weekly 1, 2
Doxycycline 100 mg daily is an alternative for mefloquine-resistant areas, but is contraindicated in pregnancy and children <8 years 1, 2
Mefloquine 250 mg weekly is effective but has neuropsychiatric side effects in 0.01%-higher; avoid in those with seizure history, psychiatric disorders, or need for precision movements 1, 4, 2

The Centers for Disease Control and Prevention recommends starting chloroquine/mefloquine 1-2 weeks before travel, continuing weekly during travel, and for 4 weeks after leaving the malarious area 1, 6, 3
Doxycycline should be started 1-2 days before travel, continued daily during travel, and for 4 weeks after departure 1
Atovaquone-proguanil can be started 1-2 days before travel and continued for only 7 days after leaving 2

The American College of Obstetricians and Gynecologists recommends that pregnant women use chloroquine as the safest option; carry Fansidar for presumptive self-treatment if fever develops and medical care unavailable 1, 7
Children <15 kg should use chloroquine; mefloquine and doxycycline are contraindicated 1, 7

The Centers for Disease Control and Prevention advises never stopping prophylaxis early: continue for full 4 weeks post-exposure (except atovaquone-proguanil at 7 days) even if you feel well 1, 2
Mefloquine neuropsychiatric effects occur in first three doses (70% of cases); discontinue immediately if severe mood changes, hallucinations, or seizures develop 4
Doxycycline photosensitivity can be severe and prolonged; avoid excessive sun exposure 4

The World Health Organization recommends primaquine 30 mg base daily during the last 2 weeks of the 4-week post-exposure prophylaxis period to prevent relapses of P. vivax and P. ovale 9, 8
Mandatory G6PD testing is required before primaquine use; contraindicated in pregnancy 8

The American Society of Tropical Medicine and Hygiene suggests combining chemoprophylaxis with mosquito avoidance measures, such as remaining in well-screened areas between dusk and dawn, using DEET-containing repellents, wearing long sleeves and pants after sunset, sleeping under permethrin-treated bed nets, and applying permethrin spray to clothing 2, 3, 6