INVITED ARTICLE

TRAVEL MEDICINE

Charles D. Ericsson and John F. Modlin, Section Editors

Prevention of Malaria in Children

Philip R. Fischer1 and Ralf Bialek2
1

Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota; and 2Institute for Tropical Medicine, University Hospital, Tuebingen, Germany

Malaria kills 1 million children each year and is also a major

cause of illness, health care visits, and hospitalizations in many
areas of the world [1]. Although 2.4 billion people on the planet
live under the threat of malaria, most of the morbidity and
mortality with the disease is seen in sub-Saharan Africa [2, 3].
Like residents of regions where malaria is endemic, children
traveling in such areas are also at risk. Each year, 1000 cases
of malaria are imported into the United States [4] and 7000
are imported into Europe [5]; cases in children are well documented [6, 7] and comprise 5%10% of imported cases in
some unpublished reports.
Worldwide efforts to combat malaria have moved from the
unsuccessful eradication attempts of the 1950s through the control efforts of the 1980s to the current Roll Back Malaria program (http://www.rbm.who.int) [8]. Spurred by widespread
publicity and fueled by newly mobilized resources, current control efforts have increased the optimism that malaria can be
subdued. However, what can be done now to prevent malaria
in children? Specific interventions are possible to avoid malaria
infection, to prevent malaria illness, and to preempt malariaassociated mortality. These measures are easily implemented
for children whose families have the resources to travel to areas
where malaria is endemic, and similar efforts, when affordable,
could benefit young residents of these regions.
Received 3 July 2001; revised 1 October 2001; electronically published 2 January 2002.
Reprints or correspondence: Dr. Philip R. Fischer, Pediatric and Adolescent Medicine, Mayo
Clinic, 200 First Street SW, Rochester, MN 55905 (fischer.phil@mayo.edu).
Clinical Infectious Diseases 2002; 34:4938
 2002 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2002/3404-0011$03.00

AVOIDING MALARIA INFECTION

The majority of cases of malaria are acquired via a bite from
an infected mosquito, although some cases are acquired transplacentally or via transfusion of blood products. Generally, to
avoid malaria infection, a child must avoid being bitten by an
infected mosquito. This can be accomplished by choosing appropriate times and places for activities, controlling the physical
environment, blocking mosquitoes access to the skin, repelling
mosquitoes from the skin, and killing mosquitoes near the
child. Table 1 outlines practical advice about mosquito avoidance for traveling children.
Malaria is transmitted by female anopheline mosquitoes,
which bite either outdoors or indoors during evening and night
hours. Thus, a child should spend the evening and night hours
in a mosquito-free environment, such as inside a house with
screened windows and closed doors. When they are in areas of
endemicity, travelers should schedule activities so that children
are not outside during evening hours, when anopheline mosquitoes are most likely to bite. In some areas, malaria transmission is seasonal, and elective trips could be planned for the
dry season, when transmission is less common.
Mosquitoes spend their lives in and around standing water.
Human living areas should be free of persistent puddles and
open water-containers. In some areas, small fish that feed on
insect larvae are kept in fountains and water storage containers
as a means of mosquito control [9].
Given that mosquitoes and children do end up sharing the
same living areas, physical barriers should be used to block the
access of mosquitoes to childrens skin. Skin should be covered
with clothing (lightweight for comfort and light-colored to be
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Although malaria kills 1 million children each year, preventive measures can be effective in limiting the mortality and
morbidity associated with malaria. Mosquito bites can be avoided by use of appropriate environmental control and use of
protective clothing, bed nets, repellents, and insecticide. Chemoprophylaxis is a mainstay of malaria prevention, and new,
effective agents are increasingly available. Rapid, accurate diagnosis and effective medical treatment can help people who
become ill with malaria despite their preventive efforts. With careful attention to preventive efforts, malaria should be
extremely rare in travelers; similarly, broader implementation of preventive measures could decrease the burden of malaria
on residents in areas where it is endemic.

Table 1.

Practical advice for avoiding malaria infection.

Proactive protective actions

Schedule a visit to an area where malaria is endemic during
seasons of low transmission
Plan to spend evenings and nights in closed buildings
Impregnate clothes and bed nets with insecticide
Protective actions in area of endemicity
Eliminate standing water near housing
Cover skin with long-sleeved shirt and long pants or dress
Use bed nets
Apply concentrated DEET to skin, avoiding oral and ocular
contamination
NOTE.
mide.

DEET, N,N-diethyl m-toluamide or N,N-diethyl-3-methylbenza-

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PREVENTING MALARIA DISEASE

After the host is bitten by an infective mosquito, malaria parasites remain in the circulation for 30 min before gaining
entry into hepatocytes. There, the parasites develop for at least
11.5 weeks before returning to the circulatory system to infect
RBCs and cause symptoms of malaria disease; some strains of
species other than Plasmodium falciparum, however, can persist
in the liver for months to years. Newer prophylactic medications, such as atovaquone-proguanil and primaquine, are able
to kill the parasites effectively before they return from the liver
to the blood system. Most chemoprophylactic agents, however, act by maintaining a concentration in the circulating blood
adequate to prevent the infection from becoming established in
RBCs. Thus, the infection is aborted before symptoms develop.
Chemoprophylaxis has been used effectively for decades, but
the increasing resistance of Plasmodium to medications has
limited the effectiveness of chemoprophylactic regimens used
in the past [22]. In areas of endemicity, chemoprophylactic
efforts have been hindered by cost and programmatic difficulties. Nonetheless, mosquito avoidance and chemoprophylaxis are the mainstays of malaria prevention for children traveling from areas where malaria is not endemic to areas where
it is.
Figure 1 shows countries and areas where there is risk of
acquiring malaria. As displayed in the figure, the selection of the
appropriate antimalarial medication should be individualized according to the patterns of resistance in the geographical region
where exposure is anticipated. The Web sites of the Centers for
Disease Control and Prevention (http://www.cdc.gov) and the
World Health Organization (http://www.who.int) give specific
guidance. In general, chloroquine is the first choice for che-

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less attractive to insects). Sleeping children should be surrounded by bed nets. Nets to fit various sizes and styles of beds
are available through the Internet, for example at the Travel
Medicine Web site (http://www.travmed.com).
Clothes and bed nets can be impregnated with an insecticide
to increase their effectiveness in protecting children. Products
such as 0.5% permethrin can be sprayed on clothes and nets
to moisten them; the material should then be allowed to air
dry for at least 6 h before use. Even if laundered, the impregnated clothes will remain insecticidal for 26 weeks [10]. Impregnated nets seem to retain their protective ability for 612
months and have been shown to decrease overall malaria mortality and morbidity in communities [11].
Applied topically to skin, chemical repellents are effective in
reducing the number of mosquito bites received. DEET (N,Ndiethyl m-toluamide or N,N-diethyl-3-methylbenzamide) is the
gold standard; it has proven its safety and effectiveness for 140
years [12, 13]. Nonetheless, 13 serious adverse neurologic events
have occurred concurrent with DEET use. Details of these cases
were not fully recorded, but at least some were related to oral
ingestion or overapplication of DEET [14]. Despite myths to
the contrary, high concentrations of DEET have not been linked
to adverse effects, but higher concentrations have longer durations of effectiveness [15]. Children can safely apply DEET
in concentrations of 30%, which will provide 46 h of repellent activity. Use of newer formulations of DEET (such as
those incorporating DEET into liposomes) extends the duration
of protection to 12 h. DEET in any form is toxic if ingested
orally, and ocular contact will irritate the eyes and should be
avoided. Therefore, DEET should not be applied to the hands,
forearms, or faces of young children. DEET-containing repellents can interact with concurrently applied sunscreens to limit
sunscreen effectiveness by 34% [16], but the insect-repellent
efficacy of DEET is unchanged by concurrent sunscreen use [17].
No insect repellent has yet been identified that is more effective than DEET [12]. Natural products that contain cit-

ronella have only a short-term (30 min) effect in repelling

mosquitoes. Some perfumed repellents might actually attract
mosquitoes. A new topical insect repellent, 1-pipetidinecarboxylic acid, 2-(2-hydroxyethyl)-,1-methylpropylester (trade name,
Bayrepel [Bayer]), is under development, and its effectiveness
is similar or superior to that of DEET in field studies. Its use
is recommended by the World Health Organization [18], and
it has been licensed in several countries for use on children
aged 12 years. Safety studies have not yet been performed for
younger children.
Environmental insecticides, such as those released by slowly
burning coils, seem to decrease indoor mosquito populations
by 50%75% [19, 20], but some cases of airway irritation have
been reported with the use of these products [21]. Ultrasonic
buzzers and devices that electrocute insects have not been found
to reduce bites from infected mosquitoes [19]. Community
spraying of insecticides is expensive but effective in limiting
mosquito populations.

moprophylaxis for children going to areas where malaria is still

sensitive to chloroquine. Mefloquine is generally a good option
for children traveling to areas where chloroquine-resistant malaria is prevalent; atovaquone-proguanil and (for children 8
years of age) doxycycline are good alternative choices. Children
who must travel to areas where there is mefloquine-resistant
malaria would usually receive atovaquone-proguanil or, if they
are 8 years old, doxycycline.
Table 2 notes medications effective in chemoprophylaxis and
details about recommended dosages. Clearly, the use of any
preventive medication must be customized on the basis of the
childs age, size, and health. There are not good data to specify
the duration of chemoprophylaxis in children, but continuous
use for 12 years is probably safe.
Chloroquine, a 4-aminoquinolone, was once the mainstay
of malaria chemoprophylaxis but has become less useful as the
parasites have developed resistance to its effects. As noted on
figure 1, its usefulness is limited to a few areas of Latin America,
the Mideast, and Asia. Chloroquine is rapidly absorbed and
becomes more concentrated in RBCs than in plasma. Approximately one-half is secreted in the urine, and the other one-

half is biotransformed by the liver; metabolites are important

to the prophylactic effect, and the half-life is 610 days [23].
Toxicity is unusual with the dosages given as prophylaxis, but
pruritus is sometimes seen, especially in Africans and AfricanAmericans. There is some concern that the cumulative doses
achieved after 5 years of continual prophylaxis might be associated with a retinopathy and, therefore, periodic retinal examinations are sometimes recommended for children receiving
long-term prophylaxis. Chloroquine is generally safe for most
children. Overdosing, however, can be dangerous, and attention
should be paid to pill safety and the avoidance of inadvertent
ingestion of pills.
The addition of proguanil, given daily, to chloroquine, given
weekly, provides an effective prophylactic regimen in some parts
of the world. Nonetheless, malaria with increasing resistance
to this regimen has extended to East Africa and other areas,
and this combination of prophylaxis is no longer a first-line
choice for chemoprophylaxis. In addition, proguanil is not licensed for use in the United States. It is generally safe for
children, but transient hair loss, mouth sores, and mild gastrointestinal symptoms have been associated with its use.
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Figure 1. Map showing countries and regions where malaria occurs. The risk of malaria, however, is not uniform throughout the shaded areas.
The Web sites of the Centers for Disease Control and Prevention (http://www.cdc.gov) and the World Health Organization (http://www.who.int) give
specific information identifying which parts of some countries actually are areas where malaria is endemic.

Table 2.

Chemoprophylactic agents for malaria.

Agent(s)

Dosage

Comments

5 mg/kg weekly; maximum dose, 300 mg; begin

1 week before exposure, continue 4 weeks
after exposure

Mostly effective in Central America

Chloroquine plus proguanil

Chloroquine as above; proguanil 4 mg/kg daily (or

3 mg/kg per day in 2 divided doses); maximum
dose, 200 mg

Increasing resistance has been noted

Mefloquine

5 mg/kg weekly; maximum dose, 250 mg; begin

12 weeks before exposure and continue 4
weeks after exposure

Effective in Africa, Asia, South America; no limits

to the age or size of the patient; do not administer
if the patient has seizures, dysrhythmia, or psychiatric problems

Atovaquone plus proguanil

1 pediatric pill (1/4 of an adult pill) per 10 kg daily;

maximum dose, 4 pediatric pills (1 adult pill);
begin 12 days before exposure and continue
7 days after exposure

Alternative to mefloquine; dosage, 250 mg atovaquone 100 mg proguanil per adult pill

Doxycycline

2 mg/kg daily, maximum 100 mg

Ineffective near some of the border areas of Thailand; do not administer if patient is !8 years old;
alternative to mefloquine

Primaquine

0.5 mg/kg daily; maximum dose, 30 mg

Not yet recommended; there is some risk if the

patients G6PD level is low

Tafenoquine

Pending

Studies in progress; there is some risk if the

patients G6PD level is low

NOTE.

G6PD, glucose-6-phosphate dehydrogenase.

Mefloquine, a quinoline-methanol compound, is effective

against malaria in most travel destinations, with the exception
of some regions near Thailands borders with Cambodia and
Myanmar. It is rapidly absorbed, and absorption might be improved by taking it with a meal [23]. It is generally available
only in tablet form and has a taste that many children do not
enjoy. There are anecdotal reports that taking mefloquine after
eating and administration with either a cola drink or chocolate
seem helpful for some children. Emesis within 30 min of ingestion should prompt a second administration of the entire
dose. Mefloquine seems to have an adverse reaction profile that
is similar in children and in adults, but the exact risks for mild
side effects are not well understood, especially in young children. In adults, bothersome effects (nausea, vomiting, insomnia, vivid dreams) occur in 10%15% of those who receive
it, and serious neuropsychiatric side effects have also been reported; !5% of individuals treated need to discontinue treatment because of side effects. Comparative studies suggest that
the frequency of side effects with mefloquine is similar to that
with other preventive antimalarial regimens [24]. Serious adverse reactions are less likely with prophylactic than with curative dosages. Mefloquine does affect cardiac conduction and
can lower the seizure threshold. It should not be administered
to children with psychiatric problems or abnormalities of cardiac rhythm. Children who require anticonvulsant therapy and
children aged !5 years who have a history of febrile seizures
should also avoid mefloquine.
The mixed combination of atovaquone and proguanil, re-

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cently released into the US market, adds an additional agent

to the chemoprophylactic armamentarium. Atovaquone inhibits the parasites mitochondrial electron transport, and proguanil acts on folate to hinder DNA synthesis by the parasite.
This combination product does have some effect during the
liver stage of malaria (causal prophylaxis), so it can be discontinued just a week after the traveling child leaves the area
of endemicity. It is effective and safe in children residing in
areas of endemicity [25] and in nonimmune adult travelers
[22], but detailed studies in pediatric travelers have not been
done. Pending further study, it is not yet recommended for
children who weigh !10 kg.
Doxycycline is contraindicated in children aged !8 years because of possible staining of developing teeth and because of
theoretical concerns about interference with bone growth. It
should be taken with plenty of liquid because inadequate swallowing of capsules can lead to esophageal irritation. Photosensitivity occurs in some children who are receiving doxycycline,
so use of sunscreen that blocks both ultraviolet A and B radiation is advised for children who are receiving this agent.
Primaquine, an 8-aminoquinoline, has been used for decades
to treat persistent hepatic infection with Plasmodium vivax and
Plasmodium ovale. Recently, it has been proposed as causal
prophylaxis for all forms of malaria. If it were to be used, one
would need to rule out glucose-6-phosphate dehydrogenase
(G6PD) deficiency in the child, because the use of primaquine
in children with this deficiency can cause hemolytic crises. Pri-

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Chloroquine

to be seen how successful new immunizations will be, both in

residents of areas of endemicity and in visitors to malarial
regions of the world.

PREEMPTING MALARIA MORTALITY

In areas where malaria is endemic, efforts at mass chemoprophylaxis have not proved successful. This was primarily due to
programmatic problems that limited compliance with the distribution and regular administration of weekly medication. Because of ineffective prophylaxis and incomplete mosquito control measures, the emphasis in developing countries was placed
on prompt evaluation and treatment of febrile children who
possibly had malaria. Significant decreases in malaria-related
morbidity and mortality have not been achieved.
Nonetheless, the idea of administering early presumptive
treatment to avert serious complications of malaria is appealing.
In travelers who are careful to avoid mosquitoes when visiting
areas where the risk of acquiring malaria is relatively low, the
risk of side effects from chemoprophylactic medications might
be about the same as or even greater than the risk of suffering
adversely from malaria. In such cases, one might suggest that
chemoprophylaxis be withheld and that presumptive curative
therapy be readily available. The German Society of Tropical
Medicine and the Swiss Working Group on Travel Medicine
are now recommending this approach for travelers to low-risk
areas (i.e., parts of Thailand, Mexico, Peru, the Middle East,
and some other areas), and this is consistent with the World
Health Organization recommendations for travelers to low-risk
areas. In the United States, the Centers for Disease Control and
Prevention still recommends standard chemoprophylaxis.
However, dependence on presumptive treatment as a means
of preventing malaria-induced morbidity and mortality requires that diagnostic methods be accurate and that therapeutic
interventions be available and rapidly effective. Clinical findings
(e.g., fever, pallor, and splenomegaly) alone have not been completely sensitive or specific in the detection of malaria, but
presumptive treatment by parents has sometimes been shown
to reduce mortality among children in areas of endemicity [30].
Blood tests that use rapid antigen-detection techniques have
been similarly incompletely reliable in field situations [31]. Even
in the United States, appropriate diagnostic evaluation of children with malaria is often delayed [32]. Therapeutic interventions are possible, but there can be some morbidity already by
the time malaria is suspected and treated. Options for presumptive treatment include chloroquine (for travelers to some
limited geographic areas), mefloquine, the combination of atovaquone and proguanil, and quinine, but the side effects associated with therapeutic dosages and compliance challenges
can limit the proportion of patients who complete therapy.

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maquine is not yet generally accepted as a prophylactic agent

but does have potential for preventive use [26].
Tafenoquine, also an 8-aminoquinoline, is a newer investigational antimalarial agent. As resistance to other prophylactic
agents increases, tafenoquine holds promise as a potential future addition to the antimalarial armamentarium. Like primaquine, it should only be used in children without G6PD
deficiency. A study in adolescents in an area of endemicity
showed a protective effect that persisted for 7 weeks after a 3day course of tafenoquine [27], which suggests that this agent
might have protective activity in short-term travelers who are
treated only before traveling.
Other antimalarial agents have been used in the past but are
not currently recommended as prophylactic agents. These other
agents are either inadequately effective (pyrimethamine and
azithromycin) or potentially toxic to children (sulfadoxine can
cause Stevens-Johnson syndrome, amodiaquine can suppress
bone marrow activity, and halofantrine can cause cardiac
rhythm disturbance).
The real hope for malaria control rests with the pursuit of
an effective vaccination. Initial efforts were disappointing, but
new methods of immunization hold potential for success. The
Spf66 vaccine includes amino acid sequences from 3 asexual
blood-stage proteins that are linked by repeat sequences from
the circumsporozoite protein. This product was developed in
South America and initially seemed to be effective there. In
field trials in other areas where different strains of Plasmodium
species were endemic, however, it was much less effective. Overall, there have been 9 clinical trials of this vaccine, which have
found that it has no statistically significant efficacy in decreasing
the rates of malaria infection or severe outcomes of malaria.
In the South American studies, there was a suggestion of a
decrease in episodes of malaria due to P. falciparum, but this
finding was not replicated elsewhere [28]. There have been 4
studies of a sporozoite-stage vaccine that uses a peptide sequence from a protein found on the surface of sporozoites.
None of these studies found that the vaccine had a significant
effect on the incidence of malaria [28].
The life cycle of malarial parasites is complex, and the human
immune response to malaria has not been completely characterized. Even as the malaria genome is decoded, it seems that
successful vaccines will involve multiple antigens that affect
various stages of the parasite life cycle [29]. Vaccines can target
pre-erythrocytic stages in a way that would prevent infection
from becoming established, erythrocytic stages to moderate the
actual course of the infection, and gametocyte stages to block
subsequent transmission of parasites. DNA-based vaccines are
currently being evaluated, as are various combinations of priming and boosting vaccination strategies. Clinical studies involving children have been launched in West Africa. It remains

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Newer rapid-acting antimalarial regimens that involved products such as the combination of artemether and lumefantrine
[33] might make even presumptive self-treatment more reliably
effective.
In addition, as much as possible, ready access to competent
medical care for ongoing monitoring and management must
be assured. For travelers to Africa, presumptive therapy cannot
replace chemoprophylaxis as the mainstay of malaria prevention among children, especially because of the high risk of P.
falciparum malaria and because these diagnostic, therapeutic,
and management issues have not been resolved. Whether or
not a pediatric traveler received chemoprophylaxis while in an
area where malaria is endemic, any febrile illness in such a child
should stimulate a prompt and thorough evaluation by a competent medical-care professional.
In conclusion, efforts aimed at the prevention of malaria in
children must be multifaceted. Insect avoidance is essential and
can prevent the acquisition of a malaria infection. Chemoprophylaxis is effective and usually well tolerated; this serves as a
means of preventing symptomatic malaria illness. Rapid treatment of symptomatic malaria is useful in limiting malarias
morbidity and mortality among travelers who have breakthrough malaria despite preventive efforts. At the same time,
children residing in areas where malaria is endemic continue
to suffer and die at alarming rates. Global efforts to combat
malaria are critical, and continued efforts to perfect an effective
vaccine are essential.