BNF for Children 2011-2012

332 5.4.1 Antimalarials BNFC 2011–20125 InfectionsAsplenia Asplenic children (or those with severesplenic dysfunction) are at particular risk of severemalaria. If travel to malarious areas is unavoidable,rigorous precautions are required against contractingthe disease.Renal impairment Avoidance (or dosage reduction)of proguanil is recommended since it is excreted by thekidneys. Malarone c should not be used for prophylaxisin children with estimated glomerular filtration rate lessthan 30 mL/minute/1.73 m 2 . Chloroquine is only partiallyexcreted by the kidneys and reduction of the dosefor prophylaxis is not required except in severeimpairment. Mefloquine is considered to be appropriateto use in renal impairment and does not require dosagereduction. Doxycycline is also considered to be appropriate.Pregnancy Travel to malarious areas should beavoided during pregnancy; if travel is unavoidable,effective prophylaxis must be used. Chloroquine andproguanil can be given in the usual doses duringpregnancy, but these drugs are not appropriate formost areas because their effectiveness has declined,particularly in sub-saharan Africa; in the case of proguanil,folic acid 5 mg daily should be given. The centreslisted on p. 329 should be consulted for advice onprophylaxis in chloroquine-resistant areas. Althoughthe manufacturer advises that mefloquine should notbe used during pregnancy, particularly in the first trimester,unless the potential benefit outweighs the risk,studies of mefloquine in pregnancy (including use inthe first trimester) indicate that it can be considered fortravel to chloroquine-resistant areas. Doxycycline iscontra-indicated during pregnancy. Malarone c shouldbe avoided during pregnancy unless there is no suitablealternative.Breast-feeding Prophylaxis is required in breast-fedinfants; although antimalarials are present in milk, theamounts are too variable to give reliable protection.October), Kyrgystan (but low risk in south-west, seebelow), Libya, most tourist areas of Turkey (but low riskin Adana and border with Syria, see below), Uzbekistan(extreme south-east only):chemoprophylaxis not recommended but avoidmosquito bites and consider malaria if fever presentsLow risk Risk low in Armenia (June–October), Azerbaijan(southern border areas, June–September), Egypt(El Faiyum only, June–October), Iran (northern borderwith Azerbaijan, May–October; variable risk in ruralsouth-east provinces; see below), rural north Iraq(May–November), Kyrgystan (south-west, May–October),north border of Syria (May–October), Turkey(plain around Adana and east of there, border withSyria, March–November):preferablychloroquine or (if chloroquine not appropriate) proguanilhydrochlorideVariable risk Risk variable and chloroquine resistancepresent in Afghanistan (below 2000 m, May–November),Iran (rural south-east provinces, March–November, seealso Low Risk above), Oman (remote rural areas only),Saudi Arabia (south-west and rural areas of westernregion; no risk in Mecca, Medina, Jeddah, or highaltitudeareas of Asir Province), Tajikistan (June–October),Yemen (no risk in Sana’a):chloroquine + proguanil hydrochloride or (ifchloroquine + proguanil not appropriate and childover 12 years) doxycyclineSpecific recommendationsWhere a journey requires two regimens, the regimen forthe higher risk area should be used for the wholejourney. Those travelling to remote or little-visitedareas may require expert advice.Risk may vary in different parts of a country—checkunder all risk levelsImportant Settled immigrants and their carers (orlong-term visitors) to the UK may be unaware thatthey will have lost some of their immunity and alsothat the areas where they previously lived may nowbe malariousNorth Africa, the Middle East, and CentralAsiaVery low risk Risk very low in Algeria, Egypt (but lowrisk in El Faiyum, see below), Georgia (south-east, July–Sub-Saharan AfricaNo chemoprophylaxis recommended for Cape Verde(some risk on São Tiago) and Mauritius (but avoidmosquito bites and consider malaria if fever presents)Very high risk Risk very high (or locally very high)and chloroquine resistance very widespread in Angola,Benin, Botswana (northern half, November–June), BurkinaFaso, Burundi, Cameroon, Central African Republic,Chad, Comoros, Congo, Democratic Republic of theCongo (formerly Zaïre), Djibouti, Equatorial Guinea,Eritrea, Ethiopia (below 2000 m; no risk in AddisAbaba), Gabon, Gambia, Ghana, Guinea, Guinea-Bissau,Ivory Coast, Kenya, Liberia, Madagascar, Malawi, Mali,Mauritania (all year in south; July–October in north),Mozambique, Namibia (all year along Kavango andKunene rivers; November–June in northern third),Niger, Nigeria, Principe, Rwanda, São Tomé, Senegal,Sierra Leone, Somalia, South Africa (low-altitude areasof Mpumalanga and Limpopo Provinces, KrugerNational Park, and north-east KwaZulu-Natal as farsouth as Jozini), Sudan, Swaziland, Tanzania, Togo,Uganda, Zambia, Zimbabwe (all year in Zambezi valley;