The Following Drugs Are Available for the Prevention of Malaria:

(1) DOXYCYCLINE (Vibramycin® or Cyclidox® or Doryx®, etc.):

Used extensively in the prevention of chloroquine resistant Malaria. About 99% effective. Not officially recommended for use in excess of 8 weeks for Malaria prevention, but it has been used for as long as three years with no reported adverse effects. Offers simultaneous protection against tick-bite fever.

Dosage: 100mg daily after a meal starting 1 - 2 days before exposure until 4 weeks after exposure. Doxycycline should be taken with plenty of non-alcoholic liquid.

Side effects: Nausea, vomiting, diarrhoea, allergy, photosensitisation. May cause vaginal thrush and may reduce the efficacy of oral contraceptives.

Contraindications: Pregnancy; breastfeeding; children < 8 years

Use in Pregnancy: Unsafe (Note: SCUBA diving is not considered safe during pregnancy) 

Doxycycline is DAN Southern Africa’s agent of choice for divers diving in Sub Saharan Africa as well as other areas with chloroquine resistance / “resistant Malaria”.

(2)  ATOVAQUONE / PROGUANIL (Malanil ®; Malarone ®)

Registered in South African as a causal prophylaxis in February 2004. Although safety in diving has not been confirmed, many divers are using it with no reported adverse effects. The side-effect profile does not pose undue risk as long as the medication is commenced at least 24 hours before diving to avoid an inadvertent allergic response or untoward side-effects manifesting during or shortly after a dive. Some increased sensitivity to motion sickness has been reported anecdotally. Preliminary data suggests it is safe for pilots.

Controlled studies have shown a 98% overall efficacy of Atovaquone / Proguanil in the prevention of P. falciparum Malaria

Dosage: 1 Tablet daily for adults, starting 24 – 48 hours prior to arrival in endemic area, during exposure in endemic areas and for 7 days after leaving the endemic area only. Dose should be taken at the same time each day with food or a milky drink.

Contra-indications: Known allergy to Proguanil or Atovaquone or renal impairment (i.e., significant renal disease is likely to be incompatible with diving).

Paediatric Malanil®: This is available for children between 12kg and 40kg. Safety in children < 11kg has not been established.

Side-effects: Heartburn (Tip: Take after a meal, with a glass of water & do not lie down shortly after taking Atovaquone / Proguanil); mouth ulcers. To date Atovaquone has been well tolerated and the most common adverse reaction being headache.

Use in Pregnancy: Safety in pregnancy and lactating women has not been established. (Note: SCUBA diving is not considered safe during pregnancy)

(3) Mefloquine (Lariam® or Mefliam®)

About 90% effective against chloroquine resistant malaria. Convenient dosing schedule.

Dosage: One tablet /week.

Side effects: May cause drowsiness, vertigo, joint aches and interfere with fine motor coordination (Making it difficult to exclude DCI in some cases).

Use in Pregnancy: Probably safe in early pregnancy and may be used with confidence after the first trimester of pregnancy. May be used in breast feeding and babies weighing more than 5kg.

NOTE: Mefloquine is considered unsafe for divers & pilots. It is contra-indicated in epilepsy but is a good first choice for other travellers.

(4) CHLOROQUINE plus PROGUANIL

a. Chloroquine (Nivaquine® or Daramal® or Plasmaquine®):>

Contains only chloroquine. Must be taken in combination with Proguanil (Paludrine®

Dosage: 2 tabs weekly starting one week before exposure until 4 weeks after leaving the Malaria endemic area.

Contra-indications: Known allergy, epilepsy

Side effects: Headache, nausea & vomiting, diarrhoea, rashes; may cause photosensitivity (sunburn; prevention – apply sun block

Use in Pregnancy: Safe. (Note: SCUBA diving is not considered safe during pregnancy)

b. Proguanil (Paludrine®):

Must be taken in combination with Chloroquine (Nivaquine® or Daramal® or Plasmaquine®)

Dosage: 2 Tablets every day starting one week prior to exposure until 4 weeks after.>

Contra-indications: Known allergy to Proguanil. Interactions with Warfarin (An anticoagulant / blood thinning agent -- that is incompatible with diving)

Side-effects: Heartburn (Tip: Take after a meal, with a glass of water & do not lie down shortly after taking Proguanil); mouth ulcers (Tip: Take Folic acid tablets 5mg per day if this occurs); loose stools  (self limiting – no treatment required

Use in Pregnancy: Safe - but must be taken with Folic acid supplement: 5mg per day. (Note: SCUBA diving is not considered safe during pregnancy)
NOTE: The combination of Chloroquine & Proguanil is about 65% effective for resistant falciparum malaria. Although not a first choice, its relative safety and limited side-effects may justify its use in certain individuals. It MAY be of use in Malaria areas outside of Sub-Saharan Africa and is available as a combination pill, Savarin®, in certain Francophone countries
 

NOTE: Proguanil on its own is no longer available in South Africa making this combination obsolete.