{"id":1161,"date":"2016-10-07T14:24:54","date_gmt":"2016-10-07T14:24:54","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=1161"},"modified":"2017-08-21T10:47:27","modified_gmt":"2017-08-21T10:47:27","slug":"primary-care-corner-with-geoffrey-modest-md-malaria-prophylaxis-twice-a-week-with-atovaquone-proguanil","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/10\/07\/primary-care-corner-with-geoffrey-modest-md-malaria-prophylaxis-twice-a-week-with-atovaquone-proguanil\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Malaria Prophylaxis Twice a Week With Atovaquone-proguanil?"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest<\/strong><\/p>\n<p>Overall, the results are pretty miserable for medication adherence to malaria prophylaxis in long-term travelers to malaria-infested areas. A recent article found that twice-a-week prophylaxis with atovaquone \u2013 proguanil (Malarone) was very effective (see doi: 10.1093\/jtm\/taw064).<\/p>\n<p>Details:<\/p>\n<ul>\n<li>An observational study was conducted in two sites in West Africa: the jungle in Angola and a medical station in Equatorial Guinea.<\/li>\n<li>Angola: 14 male expatriates, median age 24, working in the jungles of Angola for 16 months. During the first six months, all refused malaria prophylaxis, and eight developed malaria, 2 with severe cases. They then accepted twice weekly AP (atovaquone-proguanil), given through directly-observed therapy.<\/li>\n<li>Equatorial Guinea: 108 medical staff and families (50% male, age range 1.5 to 71 with 28 &lt; 12 years old, mean stay 19.5 months. 49 declined malaria prophylaxis, 40 received mefloquine, in 19 heard about the Angola experience and decided to take twice-weekly AP.<\/li>\n<li>Overall, 122 people were included in the study. 63 did not take prophylaxis, 40 took mefloquine, and 33 took AP twice-weekly.<\/li>\n<\/ul>\n<p>Results:<\/p>\n<ul>\n<li>No prophylaxis: 16 cases of malaria: 11.7 per thousand person-months (1368 months at risk)<\/li>\n<li>Mefloquine: two cases per 1000 person-months (983 months at risk)<\/li>\n<li>AP twice-weekly: zero cases per 391 person-months (391 months at risk)<\/li>\n<li>Either treatment was associated with a 20-fold decreased odds of malaria infection compared to no prophylaxis, OR = 0.05 (0.006 \u2013 0.42), p= 0.006.<\/li>\n<\/ul>\n<p>Commentary:<\/p>\n<ul>\n<li>Malaria in general, and falciparum in particular, is a huge international problem, with ramifications for travelers:\n<ul>\n<li>97 countries have continuing risk of malaria transmission. These countries are visited by more than 125 million international travelers per year<\/li>\n<li>At least 10,000 cases of travel-associated malaria occur annually, mostly in those who did not take malaria chemoprophylaxis.<\/li>\n<li>Malaria is still the leading cause of hospitalization in ill-returning febrile travelers<\/li>\n<li>Malaria remains the leading cause of death from infectious diseases among travelers<\/li>\n<li>Travel to sub-Saharan Africa has both a heavy burden of Plasmodium falciparum, as well as most deaths from malaria.<\/li>\n<li>There are three approved options for malaria chemoprophylaxis in sub-Saharan Africa: mefloquine weekly, doxycycline daily, and AP daily.<\/li>\n<\/ul>\n<\/li>\n<li>Travelers spending more than a few weeks in a malarial zone often do not take prophylaxis. It was quite striking in this study that the 45% of the participants not taking prophylaxis were in fact medical personnel.<\/li>\n<li>Although not formally studied, AP has the potential for long-term of prophylaxis given the long half-life of atovaquone of 50 to 84 hours, though proguanil is only 14 to 20 hours, with some suggestive data that weekly dosing may be adequate.<\/li>\n<li>AP is in some ways the most appealing regimen, given its very low side effect profile vs. mefloquine or doxycycline, but is quite expensive. The weekly costs are approximately:\u00a0 AP daily $50,\u00a0mefloquine once a week $10, doxycycline daily $18.<\/li>\n<li>This was not a large randomized controlled trial, but the numbers are quite impressive. I think at this point it is wise to recommend the standard approved treatments, but given the high likelihood for non-adherence, I personally will offer the option (as a second-tier option) of the twice-a-week AP therapy for those who are reluctant to take AP daily because of either cost (which then becomes $14\/week and comparable to the other options), or concerns about effectiveness, or other concerns about taking daily medications.<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Malaria Prophylaxis Twice a Week With Atovaquone-proguanil?  [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/10\/07\/primary-care-corner-with-geoffrey-modest-md-malaria-prophylaxis-twice-a-week-with-atovaquone-proguanil\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-1161","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1161","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=1161"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1161\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=1161"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=1161"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=1161"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}