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Information for the Public: Preventing Malaria in the Pregnant Woman

Know Your Risk of Malaria

Malaria is a serious illness transmitted by the bite of an infective mosquito. Pregnant women traveling to Africa, Central and South America, parts of the Caribbean, Asia (including South Asia, Southeast Asia, and the Middle East), Eastern Europe, and the South Pacific may be at risk for this potentially deadly disease.

All travelers to areas with malaria transmission, including pregnant women, should protect themselves from malaria by taking an antimalarial drug and by preventing mosquito bites. Despite the risk, most travelers can avoid becoming ill with malaria by taking these precautions.

Caution: Travel to a Malaria Risk-area During Pregnancy is NOT Recommended

• During your pregnancy, you should not travel to an area with malaria unless travel cannot be postponed. If you get malaria, you may become more ill than a woman who is not pregnant would become.

• Malaria is a major risk to your pregnancy. The very high fevers, shaking chills, and rigors that occur with malaria frequently cause premature birth, miscarriage, and stillbirth.

• If you must travel, take an antimalarial drug (a drug to prevent malaria) and prevent mosquito bites to reduce, but not eliminate, the risk of developing malaria. Your health care provider will need to prescribe your antimalarial drug. Another section below has information on preventing mosquito bites.

• Experience with the recommended antimalarial drugs indicate that they are safe to take while pregnant—safer for you and your pregnancy than getting malaria would be. Depending on which countries you will travel to, your health care provider will recommend either chloroquine or mefloquine. Experience with chloroquine and limited experience with mefloquine indicates that they are safe to take during pregnancy, including the first trimester.

• Pregnant women should NOT take the following antimalarial drugs: atovaquone/proguanil, doxycycline, or primaquine. These drugs are either not safe to take during pregnancy or we don't currently have enough information to judge their safety.

To find out if your travel will take you into an area with malaria:

• Visit CDC's Traveler's Health website at http://wwwn.cdc.gov/travel
• Go to the online malaria map application at http://www.cdc.gov/malaria/risk_map/

Find Out Which Antimalarial Drug is Recommended for You

• Antimalarial drugs are only available by prescription through a health care provider.
• You should be prescribed either chloroquine or mefloquine depending on the area of the world in which you are traveling and any other medical conditions you may have.
• Find the drug below; read the directions for use and side effects. If you have any questions about the drug recommended, call your health care provider or pharmacist.

Antimalarial Drug Warnings and Instruction

• Take your antimalarial drug exactly on schedule. Missing or delaying doses may increase your risk of getting malaria.
• For the best protection against malaria, it is important to continue taking your drug as recommended after leaving the malaria-risk area (4 weeks for mefloquine and chloroquine). Otherwise, you can develop malaria.
• Overdosage (taking too much of an antimalarial drug) can be fatal. Keep drugs in childproof containers out of the reach of children to prevent accidental poisoning.
• Buy your drugs before traveling overseas. Drugs purchased overseas may not be made according to United States standards and may not be effective. They may also be dangerous, contain the wrong drug or an incorrect amount of active drug, or be contaminated.

  Halofantrine (also called Halfan) is widely used overseas to treat malaria. CDC recommends that you do not take Halfan because of serious heart-related side effects, including deaths.

  You should avoid using antimalarial drugs that are not recommended unless you have been diagnosed with life-threatening malaria and no other treatment options are available.

• Most antimalarial drugs are well-tolerated; most travelers do not need to stop taking their drug because of side effects. However, if you are particularly concerned about side effects, discuss the possibility of starting your drug early (3-4 weeks in advance of your trip) with your health care provider. If you cannot tolerate your drug, ask your doctor to change your medication.

Pregnant women traveling to malaria-risk areas in South America, Africa, South Asia, Tajikistan, Asia, and the South Pacific should take mefloquine as their antimalarial drug.

Mefloquine (brand name Lariam™ and generic)

Directions for use

• The adult dosage is 250 mg (one tablet) once a week.
• Take the first dose at least 2 weeks before arrival in the malaria-risk area.
• Take your dose once a week, on the same day of the week, while in the risk area.
• Take your dose once a week for 4 weeks after leaving the risk area.
• Take the drug on a full stomach with a full glass of liquid.

Side Effects and Warnings

The most common side effects reported by travelers taking mefloquine include headache, nausea, dizziness, difficulty sleeping, anxiety, vivid dreams, and visual disturbances. Mefloquine has rarely been reported to cause serious side effects, such as seizures, depression, and psychosis. These serious side effects are more frequent with the higher doses used to treat malaria; fewer occurred at the weekly doses used to prevent malaria. Mefloquine is eliminated slowly by the body and thus may stay in the body for a while even after the drug is discontinued. Therefore, side effects caused by mefloquine may persist weeks to months after the drug has been stopped.

Most travelers taking mefloquine do not have side effects serious enough to stop taking the drug. (Other antimalarial drugs may be available if you cannot tolerate mefloquine; see your health care provider.)

Travelers Who Should Not Take Mefloquine

The following travelers should not take mefloquine and should ask their health care provider for a different antimalarial drug:

• persons with active depression or a recent history of depression
• persons with a history of psychosis, generalized anxiety disorder, schizophrenia, or other major psychiatric disorder
• persons with a history of seizures (does not include the type of seizure caused by high fever in childhood)
• persons allergic to mefloquine
• Mefloquine is not recommended for persons with cardiac conduction abnormalities (for example, an irregular heartbeat)
• Persons traveling to areas where mefloquine-resistant malaria exists

Pregnant women traveling to malaria-risk areas in Mexico, Haiti, the Dominican Republic, and certain countries in Central America, the Middle East, and Eastern Europe should take either chloroquine or hydroxychloroquine sulfate as their antimalarial drug.

Chloroquine phosphate (brand name Aralen™ and generics)

Pregnant women traveling to malaria-risk areas in Mexico, Haiti, the Dominican Republic, and certain countries in Central America, the Middle East, and Eastern Europe should take either chloroquine or hydroxychloroquine sulfate as their antimalarial drug.

Directions for use

• The adult dose is 500 mg chloroquine phosphate once a week.
• Take the first dose of chloroquine 1 week before arrival in the malaria-risk area.
• Take your dose once a week, on the same day of the week, while in the risk area.
• Take your dose once a week for 4 weeks after leaving the risk area.
• Chloroquine should be taken on a full stomach to lessen the risk of nausea and stomach upset.

Side Effects and Warnings

The most common side effects reported by travelers taking chloroquine include nausea and vomiting, headache, dizziness, blurred vision, and itching. Chloroquine may worsen the symptoms of psoriasis. Most travelers taking chloroquine do not have side effects serious enough to stop taking the drug. Other antimalarial drugs are available; see your health care provider.

The following travelers should not take chloroquine and should ask their health care provider for a different drug:

• persons allergic to chloroquine
• persons traveling to areas where chloroquine-resistant malaria exists

Hydroxychloroquine sulfate/ brand name Plaquenil®

Hydroxychloroquine sulfate is an alternative to chloroquine phosphate.

Directions for use

• The adult dosage is 400 mg once a week.
• Take the first dose 1 week before arrival in the malaria-risk area.
• Take your dose once a week, on the same day of the week, while in the risk area.
• Take the dose once a week for 4 weeks after leaving the risk area.
• Take hydroxychloroquine sulfate on a full stomach to lessen nausea and stomach upset.

Side Effects and Warnings

Nausea and vomiting, headache, dizziness, blurred vision, difficulty sleeping, and itching have been reported with hydroxychloroquine sulfate use. Minor side effects usually do not require stopping the drug. Hydroxychloroquine sulfate may worsen the symptoms of psoriasis. Other antimalarial drugs are available; see your health care provider.

The following travelers should not take hydroxychloroquine and should ask their health care provider for a different drug:

• persons allergic to hydroxychloroquine
• persons traveling to areas where chloroquine-resistant malaria exists

Pregnant women should NOT take doxycycline, primaquine, or atovaquone/proguanil to prevent malaria. These drugs are either not safe to take during pregnancy or we don't currently have enough information to judge their safety.

Know the Signs and Symptoms of Malaria

You can still get malaria despite taking an antimalarial drug and using protection against mosquito bites. Although taking an antimalarial drug greatly reduces your chances of getting malaria, no antimalarial drug is 100% effective. You should be alert for the flu-like symptoms of malaria; symptoms can include fever, shaking chills, headache, muscle aches, and tiredness. Nausea, vomiting, and diarrhea may also occur.

Malaria symptoms can occur at least six to nine days after being bitten by an infected mosquito. Therefore, fever in the first week of travel in a malaria-risk area is unlikely to be malaria; however, ill travelers should still seek immediate medical care and any fever should be promptly evaluated.

If you become ill with a fever or flu-like illness while traveling in a malaria-risk area and up to 1 year after returning home, seek immediate medical care. Delaying treatment can lead to serious complications such as loss of your pregnancy, coma, kidney failure, and death. Tell your health care provider that you are pregnant, where you have been traveling, and that you have been exposed to malaria.

Self-treatment

Malaria can be a fatal disease if not treated quickly.

Travelers who will be more than 24 hours from professional medical care during their trip should ask their health care provider about a self-treatment drug. If you develop fever or other flu-like illness, and professional medical care is not available within 24 hours, take your self-treatment drug and seek medical care immediately after self-treatment.

If the recommended antimalarial drug cannot be taken, pregnant women and their health care providers should contact the Centers for Disease Control Malaria Hotline at 770-488-7788 for advice on alternative antimalarial drugs and a self-treatment regimen, if needed. Pregnant women should not travel to a malaria-risk area without appropriate antimalarial drug therapy.

Take Your Antimalarial Drug While Breast-feeding

If you are breast-feeding, a very small amount of chloroquine or mefloquine will be passed into your breast milk. This small amount of drug will not harm your infant, but it won't be enough drug to protect him or her against malaria. Children taken to a malaria-risk area should have their own antimalarial drug.

Women who are breastfeeding infants weighing less than 5 kg (11 pounds) should not take atovaquone/proguanil as their antimalarial drug. Primaquine should not be given to a breastfeeding woman unless both she and her infant have a documented normal G6PD level. Very limited data on doxycycline indicates that it is probably safe to use during breast-feeding and the chance of a problem developing is remote.

Children of any age can get malaria; infants traveling to an area with malaria risk need to be given their own antimalarial. See your pediatrician 4 to 6 weeks ahead of travel to allow time for vaccinations to take effect and malaria drug doses to be made by a pharmacist.

For more information, see Preventing Malaria in Infants and Children (Information for the Public).

Protect Yourself from Mosquito Bites

Malaria is transmitted by the bite of an infective mosquito; these mosquitoes usually bite at night (between dusk and dawn). To avoid being bitten, remain indoors in a screened or air-conditioned area during the peak biting period. If out-of-doors, wear long-sleeved shirts, long pants, and hats. Apply insect repellent (bug spray) to exposed skin.

Choosing an Insect Repellent

For the prevention of malaria, CDC recommends use of one of four types of insect repellents.

• DEET (Chemical Name: N,N-diethyl-m-toluamide or N,N-diethly-3-methyl-benzamide). Products containing DEET include but are not limited to: Off!, Cutter, Sawyer and Ultrathon.
• Picaridin (KBR 3023, aka Bayrepel, and icaridin outside the US, Chemical Name: 2-(2-hydroxyethyl)-1-piperidinecarboxylic acid 1-methylpropyl ester ) Products containing picaridin include but are not limited to: Cutter Advanced, Skin so Soft Bug Guard Plus and Autan (outside the US)
• Oil of Lemon Eucalyptus or PMD (Chemical Name: para-menthane-3,8-diol) the synthesized version of oil of lemon eucalyptus. Products containing OLE and PMD include but are not limited to: Repel
• IR3535 (Chemical Name: 3-[N-Butyl-N-acetyl]-aminopropionic acid, ethyl ester) Products containing IR3535 include but are not limited to: Skin so Soft Bug Guard Plus Expedition

In general, higher concentrations of the active ingredient provide longer duration of protection. Products with ≤10% active ingredient may offer only limited protection, often from 1-2 hours. Products that offer sustained release or controlled release (micro-encapsulated) formulations, even with lower active ingredient concentrations, may provide longer protection times. Studies suggest that concentrations of DEET above ~50% do not offer a marked increase in protection time against mosquitoes (e.g. DEET efficacy tends to plateau at around 50%). Regardless of what product is used, if travelers start to get mosquito bites they should reapply the repellent according to the label instructions or remove themselves from the area with mosquitoes if possible.

Precautions When Using Any Repellent

• Read and follow the directions and precautions on the product label.
• Use only when outdoors and thoroughly wash off the repellent from the skin with soap and water after coming indoors.
• Do not breathe in, swallow, or get repellent into the eyes or mouth. If using a spray product, apply to your face by spraying your hands and rubbing the product carefully over the face, avoiding eyes and mouth.
• Never use repellents on wounds or broken skin.
• Pregnant women should use insect repellent as recommended for other adults. Wash off with soap and water after coming indoors.
• Repellents may be used on infants older than 2 months of age.
• Children under 10 years old should not apply insect repellent themselves. Do not apply to young children's hands or around their eyes and mouth.

Other Recommended Anti-mosquito Measures

• Travelers should take a flying insect spray on their trip to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
• Travelers not staying in well-screened or air-conditioned rooms should sleep under bed nets (mosquito nets), preferably nets treated with the insecticide permethrin. Permethrin both repels and kills mosquitoes as well as other biting insects and ticks. In the United States, permethrin is available as a spray or a liquid (e.g. Permanone™). Pre-treated nets, permethrin or another insecticide deltamethrin, are available overseas.
• Protect infants (especially infants under 2 months of age not wearing insect repellent) by using a carrier draped with mosquito netting with an elastic edge for a tight fit.

Clothing, shoes, and camping gear, can also be treated with permethrin. Treated clothing can be repeatedly washed and still repel insects. Some commercial products (clothing) are now available in the United States that have been pretreated with permethrin.