Malaria prophylaxis

and Martina Feichter, medical editor and biologist

Sophie Matzik is a freelance writer for the medical team.

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Martina Feichter studied biology with an elective subject pharmacy in Innsbruck and also immersed herself in the world of medicinal plants. From there it was not far to other medical topics that still captivate her to this day. She trained as a journalist at the Axel Springer Academy in Hamburg and has been working for since 2007 - first as an editor and since 2012 as a freelance writer.

More about the experts All content is checked by medical journalists.

Malaria prophylaxis is the term used to describe measures that are intended to prevent an infection with malaria or the outbreak of the disease. Above all, this includes preventing the bite of the anopheles mosquito - the carrier of the malaria pathogens - (exposure prophylaxis). One can also take preventive malaria medication, which is supposed to prevent an outbreak of disease in the event of a possible infection (chemoprophylaxis). There is currently no malaria vaccination. Read everything you need to know about malaria prophylaxis here.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. B50B51B54B52B53

Malaria prophylaxis options

In principle, there are two ways of preventing malaria in an infectious disease risk area: exposure prophylaxis (avoiding mosquito bites) and medical malaria prophylaxis (chemoprophylaxis, precautionary use of malaria medication). When "malaria prophylaxis" is generally spoken of, it usually means drug-based malaria prophylaxis. It is generally advisable in countries with a high risk of infection.

In areas with a lower risk of malaria, so-called standby therapy may be sufficient: the malaria medication is only carried in an emergency when travelers go to remote areas (with poor medical care). If the traveler develops possible symptoms of malaria, they can use them to treat themselves - as recommended by a doctor before departure. If malaria is actually involved, this early self-treatment can significantly improve the prognosis.

The German Society for Tropical Medicine and Global Health e.V. (DTG) regularly publishes current recommendations as to which type of malaria prophylaxis is advisable in which countries.

There are rapid malaria tests that provide guidance on the question "Do I have malaria?" Within a few minutes. can give. The DTG advises travelers against such rapid tests because the result is not necessarily reliable. Only trained personnel should use such rapid tests in exceptional cases in remote regions.

Malaria prophylaxis: Avoid mosquito bites

The malaria pathogen is transmitted through the bite of the crepuscular / nocturnal anopheles mosquito. An effective mosquito repellent is therefore part of the malaria prophylaxis. To do this, you should heed the following advice:

• Stay in mosquito-proof rooms in the evening and at night if possible (rooms with air conditioning and mosquito screens in front of the windows and doors).
• Sleep under a mosquito net. For additional protection, you should impregnate the mosquito net with an insecticide (active ingredient permethrin). You can also buy nets that have already been pre-impregnated.
• Wear light-colored clothing that covers the skin (long pants, socks, tops with long sleeves). If possible, impregnate clothing with an insecticide or buy pre-impregnated clothing.
• In high-risk areas, it can also make sense to wear a large but airy headgear. You can also attach a mosquito net to the brim.
• Use mosquito repellants on bare skin (see below). It should be applied 20 to 30 minutes after sunscreen is applied.

Mosquito repellants

Repellents are applied directly to the skin in the form of sprays, ointments or creams. They only offer protection from a bite to the area of ​​skin that has been directly treated with the product.

Most repellants indicate how long the protection against insect bites lasts after the product has been applied. The main factor here is the concentration of the active ingredient. Usually the effectiveness is several hours. However, this information is only partially reliable. For example, if you are in hot areas with a tropical climate and you sweat a lot, the insect repellent will wash off much more quickly with the sweat. In areas where there is a risk of malaria, you should therefore reapply repellants for malaria prophylaxis earlier than indicated.

Effect and active ingredients of the repellants

Repellants are different from insecticides in that they don't kill insects. The substances contained in repellants either have a deterrent effect on mosquitoes or cover up the body odor in such a way that the bloodsuckers can no longer perceive people. Various repellants are available for purchase in Germany.

Not all products that are sold as repellants in pharmacies or drugstores are also suitable for protection against the anopheles mosquito. Therefore, ask specifically for repellants for malaria prophylaxis when buying.

A very common active ingredient in repellants for malaria prophylaxis is DEET (N, N-diethyl-m-toulamide or diethyptoluamide for short). It is highly effective and has been tried and tested for many years. According to the DTG, corresponding repellants should contain DEET in a concentration of 30 to 50 percent.

However, DEET should not be used during pregnancy, breastfeeding or in babies. It must not be applied over large areas to small children. DEET is not recommended at all for injured or sensitive skin. Also avoid contact between DEET and plastics (sunglasses, handbag, etc.). These can dissolve through the active ingredient.

Another common repellant agent against malaria mosquitoes is icaridin. It is less well researched, but offers protection comparable to DEET. In addition, the risk of side effects is lower (better skin tolerance), the smell is more pleasant and contact with plastics is not a problem. Icaridin can also be used during pregnancy and breastfeeding. For effective malaria prophylaxis, repellants should contain icaridin in a concentration of 20 to 30 percent.

Various plant-based repellants or with essential oils (tea tree oil, citronella, etc.) are also available for malaria prophylaxis. They are considered to be more compatible with the environment and your own health. However, their duration of action is shorter than that of classic repellants (with DEET or Icaridin). In addition, essential oils can irritate the skin and mucous membranes, especially when exposed to strong sunlight.

Drug malaria prophylaxis

For drug-based malaria prophylaxis (chemoprophylaxis), drugs such as those used to treat malaria can be used. The way the preparations work is that they either disrupt the metabolism of the pathogens (plasmodia) or prevent the pathogens from multiplying. If the drugs are taken preventively as part of chemoprophylaxis, it is not the infection itself that is prevented, but the onset of the disease.

It is best to buy malaria drugs in Germany. In many malaria areas there are deceptively real-looking but ineffective counterfeits of the preparations in circulation. In addition, some health insurance companies reimburse the malaria prophylaxis costs for purchases in Germany.

According to the DTG, the following drugs are available for malaria prophylaxis:

• Atovaqoun / Proguanil: Preparations with a fixed combination of these two active ingredients are suitable for malaria prophylaxis and emergency self-treatment as well as for the treatment of uncomplicated tropic malaria and other forms of malaria.
• Mefloquine: For malaria prophylaxis, this active ingredient can be used in regions with a high risk of malaria. With some restrictions it can also be used there for malaria therapy. It is not recommended for emergency self-treatment (among other things because of the possible side effects). Mefloquine is the only drug that pregnant women are allowed to take for malaria prophylaxis.
• Doxycycline: An antibiotic that is also effective against malaria pathogens. It is effective and well tolerated. It is therefore recommended in some countries as well as by the World Health Organization (WHO) and the DTG for malaria prophylaxis (as an alternative to atovaquone / proguanil or mefloquine). This use is not officially permitted in Germany. In justified individual cases, however, a doctor can also prescribe doxycycline in this country to prevent malaria ("off-label").

The drug-based malaria prophylaxis does not offer 100 percent protection against infection. You should therefore also heed the above-mentioned tips against mosquito bites (exposure prophylaxis).

All of the above drugs require a prescription, so they can only be obtained from the pharmacy upon presentation of a doctor's prescription. Which medication is best suited for malaria prophylaxis in individual cases and how it is dosed and used should be discussed with the doctor as part of a travel consultation. When choosing a suitable remedy, the doctor will primarily consider the following points:

• holiday destination
• duration of the stay
• Age of the traveler
• possible pregnancy
• any previous illnesses
• possible use of medication (such as anticoagulants or birth control pills)
• possible intolerance to certain active ingredients

Depending on the active ingredient, taking medication for malaria prophylaxis must be started a certain time before entering the malaria risk area. In addition, you have to take the drug for some time after your return. Early withdrawal can lead to a late outbreak of malaria!

Discuss malaria prophylaxis with your doctor at an early stage! Then there is enough time to start taking a malaria drug in good time and possibly switch to another drug if you cannot tolerate this first drug.

Drug malaria prophylaxis: side effects

All drugs used for malaria prophylaxis can have side effects. The type and likelihood of such undesirable effects depend on the active substance:

The combination of active ingredients Atovaqoun / Proguanil can temporarily cause nausea, indigestion and headaches. Psycho-vegetative side effects such as dizziness, palpitations, insomnia, unusual dreams and depression are less common.

Mefloquine can cause psycho-vegetative side effects such as nightmares, depressive mood, anxiety, restlessness and confusion. Epileptic seizures and psychotic symptoms (such as hallucinations) are less common (depending on the dosage and the individual tendency to such symptoms). The drug must therefore not be taken for any psychiatric illness or for many neurological illnesses (such as convulsions). Mefloquine should be used with great caution in the event of certain changes in the heart rate (conduction disorders in the heart).

Because of these possible risks, since mid-2013 doctors should only prescribe mefloquine after they have filled out a checklist to inquire about possible contraindications and have issued the traveler with a patient passport.

If you develop psychological symptoms such as acute anxiety, depression, restlessness, or confusion while taking mefloquine, discontinue the drug immediately and take another anti-malarial drug instead.

Doxycycline can make the skin more sensitive to UV light, which is why you should avoid prolonged sunbathing while taking it. Other possible side effects are ulcers of the esophagus (when taking doxycycline with too little water), nausea (when taking on an empty stomach), indigestion, vaginal thrush and increased liver values.

Children under eight years of age, pregnant and breastfeeding women are not allowed to use doxycycline. In addition, the antibiotic must not be taken with dairy products.

Malaria prophylaxis: standby therapy

The so-called standby therapy enables you to start malaria treatment on your own in an emergency. Doctors also speak of "emergency self-treatment (NSB)". To do this, you will take a malaria medication with you on the trip to an area with a low risk of malaria, which a doctor has prescribed for you individually and explained how to use it. You can take it if:

• You develop a fever (> 38 degrees Celsius, measured in the armpit) seven days or more after your first visit to an area with a low risk of malaria
• this fever lasts more than 24 hours and
• You cannot contact a doctor within 48 hours.

These precise guidelines are intended to prevent someone from taking malaria medication in the event of temporary fever attacks from other causes.

The dosage of medication for emergency self-treatment is based on an intake schedule that your doctor has recommended before you travel, depending on your age, height, weight and risk. If you do not have such a personal schedule to hand, you must dose carefully. In children, for example, much smaller amounts are effective than in adults. Too high doses are also associated with more severe side effects.

The "emergency self-treatment" is really only intended for emergencies and does not replace a doctor's visit! Even if you have already started taking the malaria medication independently, you should see a doctor (preferably a tropical medicine) as soon as possible - at the latest after your return to Germany.

Malaria prophylaxis: cost

All malaria prophylaxis and treatment drugs require a prescription.In the last few years, some health insurers have started to reimburse the cost of medical malaria prophylaxis in addition to some travel vaccinations. Inquire at your health office in advance whether it is possible to cover the costs.

Why is there no malaria vaccination?

So far, no malaria vaccine has been developed that could prevent infection with a high degree of probability. This is mainly due to the fact that there are several types of malaria pathogens and these are also divided into different subtypes. This is why it is so difficult to develop a vaccine that works against all known pathogens.

The researchers are still working on a vaccination against malaria. The vaccine candidate RTS, S from a British pharmaceutical company is being tested. It contains a protein from the pathogen causing the dangerous tropical malaria (Plasmodium falciparum) as well as an active enhancer. The malaria vaccine is intended to prepare the immune system for a possible infection and quickly render the pathogen harmless after it has penetrated. However, the success rate is not as good as hoped. This vaccine is therefore not very suitable as a malaria prophylaxis for travelers. Some researchers believe that it could at least reduce child mortality from malaria in Africa.

Until greater progress is made in vaccine development, the following applies especially to travelers: An effective malaria prophylaxis consists in avoiding bites by the anopheles mosquito as far as possible and, if necessary, taking malaria medication as a preventive measure!

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