g logo nhs blue

Guidelines for malaria prevention in travellers from the UK 2017

General issues

  • The Advisory Committee on Malaria Prevention (ACMP) prophylaxis guidelines are intended for UK-based visitors to malaria endemic areas and may not be appropriate for use by those residing in endemic areas
  • It is recommended that health professionals stick to using one resource for country specific malaria recommendations to optimise consistency of advice. Although other sources of advice are available, healthcare professionals working in England, Wales or Northern Ireland are advised to use the ACMP guidelines as their preferred source of guidance for malaria prevention
  • While these guidelines deal with malaria, malaria prevention is only one aspect of pre-travel advice. An overall risk assessment-based package of travel health advice should be provided to the traveller. Guidance on risk assessment can be obtained from the Yellow Book, NaTHNaC and TRAVAX
  • Emphasise to the traveller the ABCD of malaria prevention:
    • awareness of risk
    • bite prevention
    • chemoprophylaxis
    • diagnose promptly and treat without delay
  • Emphasise that while no regimen is 100% effective, the combination of preventive measures advised will give significant protection against malaria

Clinical symptoms and signs of malaria

Non-specific symptoms of malaria

  • Fever/sweats/chills
  • Malaise (vague discomfort)
  • Myalgia (muscle pain, tenderness)
  • Headache
  • Diarrhoea
  • Cough

Major features of severe or complicated falciparum malaria in adults

  • Impaired consciousness or seizures 
  • Renal impairment (oliguria < 0.4ml/kg bodyweight per hour or creatinine >265μmol/l) 
  • Acidosis (pH <7.3) 
  • Hypoglycaemia (<2.2mmol/l) 
  • Pulmonary oedema or acute respiratory distress syndrome (ARDS) 
  • Haemoglobin ≤8g/dl 
  • Spontaneous bleeding/disseminated intravascular coagulation 
  • Shock (algid malaria) 
  • Haemoglobinuria (without G6PD deficiency) 

Major features of severe or complicated malaria in children 

  • Impaired consciousness or seizures 
  • Respiratory distress or acidosis (pH <7.3) 
  • Hypoglycaemia 
  • Severe anaemia 
  • Prostration (inability to sit or stand) 
  • Parasitaemia >2% red blood cells parasitised

Measures to prevent mosquito bites

  • Effective bite prevention should be the first line of defence against malarial infection
  • For some destinations, ACMP advises awareness of risk and bite prevention for malaria prevention and does not recommend chemoprophylaxis. Practitioners are strongly advised that whether or not chemoprophylaxis is also recommended, the benefits from using bite prevention measures are emphasised to travellers. Furthermore, their role in protecting against infection with other vector-borne diseases should also be mentioned


  • ACMP recommends DEET-based insect repellents as concentrations over 20% give a longer duration of protection than currently available formulations of other agents. If DEET is not tolerated (or is not available), an alternative preparation should be used, but few are as effective as high concentrations of DEET


  • As a guide, duration of protection is 1 to 3 hours for 20%, up to 6 hours for 30% and up to 12 hours for 50% DEET. There is no further increase in duration of protection beyond a concentration of 50%
  • DEET is not recommended for infants below the age of 2 months
  • ACMP advice on use of DEET for protection from mosquito bites:
    • DEET is suitable for all individuals over the age of 2 months (unless allergic)
    • 50% has the longest duration of action, and needs fewer applications per day
    • there is no current evidence that any group (including pregnant women and small children) is at increased risk from using 50% DEET
  • Lower concentrations are available:
    • they need more frequent application and may not be as effective as 50%
    • care must be taken to re-apply or use a higher concentration DEET preparation if mosquito biting occurs after their use
    • lower concentrations are not suitable for individuals who may expect prolonged exposure, such as that encountered by backpackers and expedition travellers
    • ACMP considers concentrations below 20% inappropriate in almost any circumstance
  • DEET applications can damage some plastic watch straps, watch 'glasses' and plastic jewellery; these items should not be allowed to come into contact with DEET
  • The user should ensure that repellents are not ingested or inhaled and do not come into contact with their eyes or mouth. Repellents should be used only on exposed areas of skin
DEET and sunscreen
  • Repellent activity will reduce more quickly than that of a sunscreen if reapplying only sunscreen on top and repellent will therefore usually need to be reapplied on top of a sunscreen
  • When both sunscreen and DEET are required, DEET should be applied after the sunscreen. 30 to 50 SPF sunscreen should be applied to compensate for DEET-induced reduction in SPF. Sunscreen is not required from dusk to dawn

Other repellents

  • Please see full guideline on guidance for other repellents (e.g. 3-ethlyaminopropionate, icaridin, oil of citronella, p-menthane 3,8 diol)


  • If sleeping outdoors or in unscreened accommodation, insecticide-treated mosquito nets should be used. Protective efficacy for travellers has been estimated at 50%
  • Mosquito bed nets must be free of tears and should be tucked in under the mattress. Insecticide (pyrethroid)-impregnated bed nets improve protection because they help to prevent (a) biting through the net on parts of the body touching the net, (b) mosquitoes surviving long enough near a net to find any tears in the net which may exist (c) diversion of mosquitoes from someone under a net to someone in the same room without a net


  • Within the limits of practicality, cover up with loose-fitting clothing, long sleeves, long trousers and socks if out of doors after sunset, to minimise accessibility to skin for biting mosquitoes


  • The ACMP strongly advises against the following:
    • herbal remedies
    • homoeopathy
  • There is no evidence for the following strategies:
    • electronic buzzers
    • vitamin B1
    • vitamin B12
    • garlic
    • savoury yeast extract spread
    • tea tree oil
    • bath oils


  • Recommendations for antimalarials should be appropriate for the destination and tailored to the individual, taking into account possible risks and benefits to the traveller. As part of an individual stringent risk assessment it is essential that a full clinical history is obtained, detailing current medication, significant health problems and any known drug allergies. For a suggested risk assessment template see Appendix 2 of the full guideline
  • Travellers should ensure that the medication required for their chemoprophylaxis is obtained from a reputable source in the UK before they travel

The drugs

  • For further information on drug actions, dosages, side-effects, interactions, and contraindications, please refer to the BNF and the summary of product characteristics (SmPCs) for individual drugs 
  • The SmPCs and the BNF should be consulted as required when recommending malaria chemoprophylaxis
  • Information on drugs should be read in conjunction with the full guideline sections on:
    • drug resistance
    • recommended dose regimens
    • additional information on the use of antimalarial agents in special groups, including those with medical conditions
  • Anybody from the UK, including members of the public, can report any suspected side effects from malaria medicines via the Yellow Card Scheme on the Medicines and Healthcare products Regulatory Agency (MHRA) website: www.mhra.gov.uk. Attacks of malaria that occur in individuals prescribed malaria prophylaxis should also be reported via this system

Prophylactic regimens against malaria in adults

    • These drugs are not listed in order of preference
    • The preferred prophylaxis is determined by a full risk assessment for each individual traveller 
Prophylactic regimens against malaria in adults
Regimen Dose for chemoprophylaxis Usual amount for tablet (mg) 

Areas of chloroquine-resistant P. falciparum


One tablet weekly



One tablet/capsule daily 


Atovaquone-proguanil combination preparation 

One tablet daily 

250 (atovaquone) plus 100 (proguanil) 

Areas of little chloroquine resistance; poorly effective where extensive resistance


Two tablets weekly

155 (base) 





Two tablets daily 


  • See full guideline for doses of prophylactic antimalarials in children
Emergency standby treatment for adults

Situation for use

Standby treatment regimen

Usual amount per tablet

Adult dose

Chloroquine or multi-drug resistant falciparum malaria

Artemether plus lumefantrine combination preparation

20 mg artemether plus 120 mg lumefantrine

4 tablets initially, followed by 5 further doses of 4 tablets each given at 8, 24, 36, 48 and 60 hours.

Total 24 tablets over a period of 60 hours


Tablets should be taken with food to enhance drug absorption

Chloroquine or multi-drug resistant falciparum malaria

Atovaquone plus proguanil combination preparation

250 mg atovaquone plus 100 mg proguanil

4 tablets as a single dose on each of three consecutive days

Chloroquine or multi-drug resistant falciparum malaria

Quinine plus doxycycline

300 mg quinine 100 mg doxycycline

Quinine 2 tablets 3 times a day for 3 days, accompanied by 1 tablet of doxycycline twice daily for 7 days


Quinine plus clindamycin

300 mg quinine 150 mg clindamycin

Quinine 2 tablets 3 times a day for 5–7 days

Clindamycin 3 tablets (450 mg) 3 times a day for 5 days

* Please see Appendix 3 of full guideline for Emergency standby medication traveller information leaflet which can be copied and pasted for use.
Pregnant travellers should avoid malarious areas. If that is not possible, quinine plus clindamycin is the only regimen to be used in pregnancy.

  • Emergency standby treatment should be recommended for those taking chemoprophylaxis and visiting remote areas where they are unlikely to be within 24 hours of medical attention. It is intended for those travellers who believe that they may have malaria and is not a replacement for chemoprophylaxis
  • Individuals for whom emergency standby treatment is advised must be provided with written instructions for its use. In particular, they must be informed about symptoms suggesting possible malaria, including fever of 38°C and above, indications for starting the standby treatment, how to take it, expected side-effects and the possibility of drug failure
  • Standby emergency treatment should be started if it is impossible to consult a doctor and/or reach a diagnosis within 24 hours of the onset of fever. Medical attention should be sought as soon as possible for full assessment and to exclude other serious causes of fever. This is particularly important as many illnesses other than malaria may present with fever
  • The traveller should complete the standby treatment course and recommence their antimalarial chemoprophylaxis 1 week after taking the first treatment dose, except in the case of mefloquine prophylaxis, which should be resumed at least twelve hours after the last treatment dose if quinine was used for standby treatment. Antipyretics should be used to treat fever. A second full treatment dose of the antimalarial should be taken if vomiting occurs within 30 minutes of taking it (half-dose if vomiting occurs after 30–60 minutes). The agent used for emergency standby treatment should be different from the drugs used for chemoprophylaxis, both to minimise drug toxicity and due to concerns over drug resistance


  • Suspected malaria is a medical emergency
  • Consider malaria in every ill patient who has returned from the tropics in the previous year, especially in the previous three months
  • Fever on return from the tropics should be considered to be malaria until proven otherwise. Malaria cannot be diagnosed with certainty by clinical criteria alone. Suspected cases should be investigated by obtaining a blood film diagnosis as a matter of urgency
  • There is no need to wait for fever spikes before taking blood; this only delays diagnosis and the fever pattern seldom conforms to text book periodicity, especially in the case of Plasmodium falciparum
  • An EDTA-anticoagulated venous blood sample should be taken. The sample should be received in the laboratory within one hour of being taken as falciparum malaria may increase in severity over a few hours and the morphology of malaria parasites in EDTA deteriorates over time

Resources for treatment advice


  • Malaria is a statutorily notifiable disease in England and Wales and the clinician caring for the patient must complete a notification form. In Scotland, malaria is not on the list of notifiable diseases but Plasmodium is on the list of notifiable organisms
  • The Malaria Reference Laboratory (MRL) reporting form should also be completed and sent to the MRL separately or along with referred specimens

Special groups (medical conditions)

Smoking cessation

  • Chloroquine or mefloquine should not be used in those taking sustained-release bupropion hydrochloride as the chances of seizure may be increased


  • Pregnant women are advised to avoid travel to malarious areas
  • In the event that travel is unavoidable, the pregnant traveller must be informed of the risks which malaria presents and the risks and benefits of antimalarial chemoprophylaxis
  • Pregnant women have an increased risk of developing severe malaria and a higher risk of fatality compared to non-pregnant women
  • Diagnosis of falciparum malaria in pregnancy can be particularly difficult as parasites may not be detectable in blood films due to sequestration in the placenta
  • Expert advice is required at an early stage if malaria is suspected in a pregnant woman. Complications, including severe anaemia, hypoglycaemia, jaundice, renal failure, hyperpyrexia and pulmonary oedema, may ensue. The result may be miscarriage, premature delivery, maternal and/or neonatal death
  • Congenital malaria is rare, but occurs more commonly with P. vivax than with the other malaria parasites of humans
  • Avoidance of mosquito bites is extremely important in pregnancy as pregnant women are particularly attractive to mosquitoes. Ideally, pregnant women should remain indoors between dusk and dawn. If they have to be outdoors at night they should adhere rigorously to bite precautions
  • DEET should be used in a concentration of not more than 50%. DEET has a good safety record in children and pregnancy but ingestion should be avoided
  • Chloroquine and proguanil: safe in all trimesters of pregnancy. Their major disadvantage is the relatively poor protection they give in many geographical areas due to the presence of drug-resistant P. falciparum. Pregnant women taking proguanil should receive supplementation with 5 mg folic acid daily for at least the first trimester
  • Mefloquine: caution advised
  • Doxycycline: contraindicated in pregnancy
  • Atovaquone/proguanil: lack of evidence on safety in pregnancy

Chemoprophylaxis prior to conception

  • If a female traveller is planning to conceive during a visit to a destination with a high risk of contracting chloroquine-resistant falciparum malaria, expert advice should be sought. Use of mefloquine may be considered after careful risk assessment
  • Those travellers who plan to become pregnant after taking antimalarials and who wish to do so with minimal antimalarial drug present, may elect to observe the following time intervals after completing the course, before attempting to conceive:
    • mefloquine: 3 months
    • doxycycline: 1 week
    • atovaquone/proguanil: 2 weeks


  • Nursing mothers should wash repellents off their hands and breast skin prior to handling infants
  • Mefloquine: experience suggests safe to use during lactation
  • Doxycycline: contraindicated
  • Atovaquone/proguanil: not recommended because of the absence of data however, can be used when breast-feeding if there is no suitable alternative antimalarial
  • Nursing mothers should be advised to take the usual adult dose of antimalarial appropriate for the country to be visited. The amount of medication in breast milk will not protect the infant from malaria. Therefore, the breastfeeding child needs his or her own prophylaxis (see full guideline for paediatric doses)


  • Travellers should ensure their INR (International Normalised Ratio) is stable and within the therapeutic range prior to departure and they have adequate supplies of their anticoagulant for the whole trip. Changes in diet and alcohol intake can affect the INR
  • Patients on warfarin may have underlying cardiovascular disease and may be on cardiovascular medication. Interactions with other medication together with the individuals' medical history should be taken into account when deciding on appropriate malaria chemoprophylaxis
  • Chloroquine: no interaction between warfarin and chloroquine documented in the BNF, although there is a caution in the SPC for chloroquine
  • Proguanil: an isolated report of an enhanced effect of warfarin when taken together with proguanil
  • Mefloquine: not considered to be a problem for those taking warfarin
  • Doxycycline: anticoagulant effect of coumarins (including warfarin) is possibly enhanced by tetracyclines
  • Atovaquone/proguanil: unknown whether there are interactions between atovaquone/proguanil and warfarin, although there has been an isolated report of an enhanced effect of warfarin when taken together with proguanil (see above under proguanil)
  • Advice for travellers needing malaria chemoprophylaxis who are taking warfarin:
    • travellers should inform their anticoagulant clinic and start taking their malaria tablets 2–3 weeks prior to their departure
    • a baseline INR should be checked prior to starting chemoprophylaxis, and re-checked after 1 week of taking chemoprophylaxis to determine whether or not the warfarin dosage needs to be adjusted
    • the traveller must check with their anticoagulant clinic to see if their INR is appropriate for travel. If a traveller is away for a long period of time the INR should be checked at intervals at the destination
    • self-monitoring of the INR may be suitable for some travellers, but must be under the supervision of an anticoagulant clinic
    • once chemoprophylaxis has been completed, the INR should be checked again to re-stabilise anticoagulant therapy

New oral anticoagulants (NOAC)

  • Dabigatran etexilate, rivaroxaban and apixaban are the most commonly available NOAC. They do not interact with food, do not require laboratory monitoring and have a lower potential for drug interactions than the coumarins
  • There is relatively limited experience of antimalarial chemoprophylactic use those taking NOAC
  • Apixaban and rivaroxaban are substrates of CYP3A4 and p-glycoprotein. Dabigatran is a substrate of p-glycoprotein. Mefloquine inhibits CYP3A4 and p-glycoprotein, so could increase NOAC plasma concentrations which might lead to an increased bleeding tendency. Atovaquone may produce minor inhibition of CYP3A4. The effect of proguanil on this enzyme is unknown
  • Neither atovaquone nor proguanil inhibits p-glycoprotein
  • If doubt exists after following this guideline, take expert advice from an anticoagulant clinic


  • A history of febrile convulsions only does NOT contraindicate use of any of the currently available malaria chemoprophylactic drugs. The following advice applies to travellers with epilepsy where restrictions DO apply
  • In epilepsy:
    • doxycycline or atovaquone/proguanil can be used
    • chloroquine: unsuitable
    • mefloquine: unsuitable

Other conditions

  • See full guideline on the prevention of malaria for the following medical conditions:
    • glucose 6-phosphate dehydrogenase deficiency
    • immunocompromised travelers (e.g. transplant patients, people with with HIV/AIDS)
    • liver disease
    • renal impairment
    • splenectomy
    • acute porphyri

full guideline from…

Chiodini PL, Patel D, Whitty CJM and Lalloo DG. Guidelines for malaria prevention in travellers from the United Kingdom, 2017 London: Public Health England. 
First included: October 2001, updated December 2017.