Malaria Home > Malaria and Travelers >

Information for Health Care Providers: Preventing Malaria in the Pregnant Woman

Malaria is transmitted to humans by the bite of an infected female Anopheles mosquito. All travelers to malaria-risk areas, including pregnant women, should take an antimalarial drug to prevent malaria. Malaria is always a serious disease and may be a deadly illness. Inform your patients that fever or flu-like illness, either while traveling or after returning home (for up to 1 year or more) may be malaria and that they should seek immediate medical attention.

Health care providers (HCP) can find information about malaria risk areas, prophylaxis medications, and anti-mosquito measures on the CDC Travelers' Health website: http://wwwn.cdc.gov/travel. The website contains both general traveler’s health precautions plus malaria-specific information. IN addition, the current Health Information for International Travel (the Yellow Book) may be viewed.

Caution Against Travel to a Malaria Risk-area during Pregnancy

Malaria in pregnancy carries significant morbidity and mortality for both the mother and the fetus. Pregnant women should be advised to avoid travel to malarious areas if possible. Women who do choose to go to malarious countries can reduce their risk of acquiring malaria by using several preventive approaches, including personal protection to avoid infective mosquito bites (see section below) and using prophylactic malaria medication as directed. No preventive method is 100% effective; pregnant women who develop symptoms of malaria should immediately seek professional medical care from providers knowledgeable in the care of pregnant women in tropical areas.

Provide Antimalarial Drug Warnings and Instructions for Use

Advise patients that antimalarial drugs are most effective if taken exactly on schedule without skipping doses and that their drug should be continued post-travel for the most complete protection. Antimalarial drugs should be purchased before travel; drugs purchased overseas may not be manufactured 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 (marketed as Halfan) is widely used overseas to treat malaria. CDC does not recommend the use of Halfan because of serious cardiac complications, including deaths. Travelers should be advised to avoid Halfan unless they have been diagnosed with life-threatening malaria and no other options are immediately available.

Overdosage of antimalarial drugs can be fatal. Parents should be advised to keep drugs in childproof containers out of the reach of children.

Antimalarial Drug Information

Mefloquine (Brand Name Lariam™ and Generic Drug)

Pregnant women traveling to chloroquine-resistant malaria-risk areas in South America, Africa, the Indian subcontinent, Tajikistan, Asia, and the South Pacific should take mefloquine as their antimalarial drug. Mefloquine is currently the only medication recommended for malaria chemoprophylaxis in areas with chloroquine-resistant P. falciparum. A review of mefloquine use in pregnancy from clinical trials and reports of inadvertent use of mefloquine during pregnancy suggest that its prophylactic use during the second and third trimesters of pregnancy is not associated with adverse fetal or pregnancy outcomes. More limited data suggest it is also safe to use during the first trimester.

Mefloquine primary prophylaxis should begin 2 weeks before travel to malarious areas. It should be continued once a week, on the same day of the week, during travel to malarious areas, and for 4 weeks after the travelers leaves such areas.

Adverse Reactions and Contraindications

Mefloquine has been associated with rare serious adverse reactions ( e.g. psychoses or seizures) at prophylactic doses; these reactions are more frequent with the higher doses used for treatment. Other side effects that occur with prophylactic doses include gastrointestinal disturbance, headache, insomnia, abnormal dreams, visual disturbances, depression, anxiety disorder, and dizziness. Other more severe neuropsychiatric disorders occasionally reported during post-marketing surveillance include sensory and motor neuropathies (including parasthesia, tremor, and ataxia), agitation or restlessness, mood changes, panic attacks, forgetfulness, confusion, hallucinations, aggression, paranoia, and encephalopathy. On occasions, psychiatric symptoms have been reported to continue long after mefloquine has been stopped.

During prophylactic use, if psychiatric symptoms such as acute anxiety, depression, restlessness, or confusion occur, these may be considered prodromal to a more serious event. In these cases, the drug must be discontinued and an alternative drug substituted.

Mefloquine is contraindicated for use by travelers with a known hypersensitivity to mefloquine or related compounds (e.g. quinine and quinidine) and in persons with active depression, a recent history of depression, generalized anxiety disorder, psychosis, schizophrenia, or other major psychiatric disturbances. Mefloquine is contraindicated in persons with a history of seizures (not including the type of seizure caused by high fever in childhood). It should be used with caution in persons with psychiatric disturbances or a previous history of depression. A review of available data suggests that mefloquine may be used for persons concurrently on beta blockers, if they have no underlying arrhythmia. However, mefloquine is not recommended for persons with cardiac conduction abnormalities. Any traveler receiving a prescription for mefloquine must also receive a copy of the FDA Medication Guide which can be found at the FDA website: http://www.fda.gov/cder/foi/label/2003/19591s191bl_Lariam.pdf (PDF format only)

Chloroquine (brand name Aralen™ and generic drug)

Pregnant women traveling to chloroquine-sensitive malaria-risk areas in Mexico, the Caribbean, and certain countries in Central America, the Middle East, and Eastern Europe may take either chloroquine or hydroxychloroquine sulfate (Plaquenil™) as their antimalarial drug. Chloroquine has been used for decades with no documented increase in birth defects.

In areas where chloroquine-resistant P. falciparum has not been reported, either chloroquine phosphate or hydroxychloroquine sulfate (Plaquenil) may be used. Less evidence exists on hydroxychloroquine sulfate’s effectiveness as an antimalarial drug.

Chloroquine primary prophylaxis should begin 1-2 weeks before travel to malarious areas. It should be continued once a week, on the same day of the week, during travel to malarious areas and for 4 weeks after a traveler leaves such areas.

Pregnant women unable to take chloroquine should take mefloquine; this drug is also effective against chloroquine-sensitive P. falciparum.

Adverse Reactions and Contraindications

Side effects that can occur include gastrointestinal disturbance, headache, dizziness, blurred vision, insomnia, and pruritus, but generally these effects do not require that the drug be discontinued. High doses of chloroquine, such as those used to treat rheumatoid arthritis, have been associated with retinopathy; this serious side effect appears to be extremely unlikely when chloroquine is used for routine weekly malaria prophylaxis. Chloroquine and related compounds may exacerbate psoriasis.

Other Antimalarial Drugs

• Doxycycline and primaquine are contraindicated during pregnancy.
• Atovaquone/proguanil (Malarone™) is currently not recommended for use by pregnant women to prevent malaria.
• For advice on prophylaxis for pregnant women who cannot take the recommended antimalarial drug for their malaria-risk area, contact the CDC Malaria Hotline at 770-488-7788.

Prescribe Antimalarial Drugs if Traveling While Breast-feeding

Nursing mothers should be advised to take the usual dose of antimalarial drug. The small amount of medication in breast milk will not harm the infant nor be enough to protect the child against malaria. Therefore, the breast-feeding child needs his or her own prophylaxis.

Because safety data is not yet available, atovaquone/proguanil is not currently recommended for women breast-feeding infants <5 kg. Primaquine should not be prescribed for a breast-feeding woman unless both she and her infant have a documented normal G6PD level. Very limited data is available on the use of doxycycline in lactating women; most experts consider the theoretical possibility of adverse events to be remote.

Advise nursing mothers to carefully wash insect repellent off their hands and breast skin before holding and nursing their infants.

See Preventing Malaria in Infants and Children (Information for Health Care Providers) for additional information.

Educate Your Patients on the Signs and Symptoms of Malaria

Advise your patients that they can still contract malaria despite prophylaxis and anti-mosquito measures. Inform travelers that fever or flu-like illness, either while traveling or after returning home (for up to 1 year or more), may be malaria and that they should seek immediate medical attention.

Self-treatment

Malaria can be effectively treated early in the course of the disease; however, delay of appropriate treatment can have serious or even fatal consequences. Travelers who choose not to take an antimalarial drug or who are on a less than effective regimen (chloroquine in a chloroquine-resistant risk area) or who may be in very remote areas can be given a self-treatment course.

Contact the Centers for Disease Control and Prevention Malaria Hotline at 770-488-7788 for advice on a self-treatment regimen for pregnant women.

Advise Your Patients to Protect Themselves from Mosquito Bites

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.