MALARIA: Malarone in pregnancy

Amy Norton : Feb 16, 2011
NEW YORK (Reuters Health) - Pregnant women who take the anti-malarial drug Malarone during their first trimester might not be increasing their baby's risk of birth defects, a new study suggests.
Most anti-malaria drugs -- including this one -- are not approved for use in pregnancy. So when pregnant women want to travel to malaria-ridden regions, they face a huge problem: should they take preventive medicines that haven't been proven safe for the fetus?
In general, experts advise all pregnant women to avoid traveling to countries where malaria is common, since the infection itself may be dangerous to the mother and fetus.
The new study, published in the Archives of Internal Medicine, is the first to look at pregnant women's use of Malarone -- known generically as atovaquone-proguanil -- and the risk of birth defects.
So the researchers say it is too soon to declare the drug safe for the small number of pregnant women who might need to take it.
The cheapest and mostly widely used anti-malaria drug, called chloroquine, is considered safe during pregnancy. But resistance to that drug has become common worldwide.
Another anti-malaria drug, the antibiotic doxycycline, is known to have adverse effects on the fetus.
In the new study, researchers looked at data on nearly 571,000 births in Denmark between 2000 and 2008. Overall, 2 to 3 out of every 100 newborns had a birth defect.
Among the 149 women who used Malarone at some point during the first trimester, roughly one of every hundred had a baby with a birth defect.
The findings offer some reassurance that the drug is not linked to any large risk of birth defects, said lead researcher Dr. Bjorn Pasternak, of Statens Serum Institute in Copenhagen.
Still, since only a small number of women in the study took Malarone during early pregnancy, the findings cannot rule out the possibility of some risk, Pasternak said.
"We believe it is far too soon to declare this drug to be safe for use in pregnancy," he told Reuters Health in an email.
Malarone is not inexpensive -- it costs close to $200 for 24 pills. The number of pills a woman would have to take depends on how long she stays in the malaria region.
Caused by a mosquito-borne parasite, malaria is widespread (the technical term is "endemic") in large areas of Africa, Asia and South and Central America, where it kills about 1 million people a year.
An estimated 10,000 to 30,000 travelers develop malaria every year, and about 150 die.
http://www.reuters.com/article/2011/02/16/us-malaria-drug-idUSTRE71F66K20110216?feedType=RSS&feedName=healthNews

MALARIA: risk warning to last-minute holidaymakers

18 January 2011

 Malaria falciparum, transmitted by this type of mosquito, can prove fatal if left untreated

 

Travel websites offering late deals to destinations where malaria is a risk should carry clear warnings, say experts.The call comes from doctors who had to treat three patients in a week, all of them UK citizens who had returned from "winter sun" holidays to The Gambia.All three patients, in their 40s and 50s, had booked their holidays with the same travel website. None had sought proper medical advice before travelling. If they had, they would have been told that malaria is endemic in the Western African country they were travelling to and advised of the need to take appropriate precautions.

Simple measures like covering up the skin by wearing long-sleeved shirts and trousers and using insect repellent, as well as taking malaria prevention tablets, can help avoid infection with the parasite that causes the disease that is transmitted by mosquito bites.
The three patients that the doctors at the James Cook University Hospital in Middlesbrough treated all had the most serious form of malaria - falciparum malaria.
One of the doctors, John Widdrington, said in a letter to the British Medical Journal: "Many travel websites and holiday brochures, including the website used by our patients, make no specific reference to the risk of contracting malaria.
"Travel websites need to include explicit messages about taking medical advice and effective chemoprophylaxis before travelling to malaria endemic areas.
"We've now written to the UK travel trade association Abta to flag this up to them."
He said part of the problem was people leaving the planning of their holidays until the last minute.
"The time to think about what health precautions you may need to take is before you book."
Some malaria tablets need to be taken for a couple of weeks before travelling to an affected area, for example.
"And as well as doing your own research about the area you will be travelling to, make sure you leave yourself enough time to see a doctor, either your own GP or one at a travel clinic, for advice," he said.
A spokeswoman from Abta said most travel websites did carry information about the risks of malaria, but that this was not always "upfront".
She said there was also an onus on the consumer to check properly for advice.
"When people are in a hurry not everybody will look in true depth and do all the research they need to.
"We recommend travellers follow Foreign Office advice," she said.
http://www.bbc.co.uk/news/health-12216682

MALARIA: Can Malaria Be Beaten?

Jeremy Laurance 05 Aug 2010 The Independent
When I see a packet of malaria pills I think of that famous Clint Eastwood line from Dirty Harry, delivered as he pointed his .44 magnum at a bank robber and neither of them could remember how many shots he had fired, or whether there was still one left in the chamber. "The question you have got to ask yourself is: do I feel lucky? Well, do ya, punk?"Actually, I do. Lucky enough not to have to take the nasty, expensive little things on my periodic visits to Africa and other malarial parts of the world. Now I find myself being asked to reconsider after X Factor star Cheryl Cole's unpleasant encounter with a mosquito in Tanzania. Such is the power of celebrity.I based my view on a Lancet paper published in the 1990s by London's Hospital for Tropical Diseases which assessed the chances of contracting malaria, for those not taking prophylactic drugs, at 0.6 per cent for an average two-week holiday in East Africa. The authors described this as "high" and in public health terms I suppose it is - the Health Protection Agency points out that more than 1,500 people are diagnosed with malaria in the UK each year having acquired it abroad.But it didn't seem high to me - and I disliked the way commercial travel clinics pushed expensive injections and other protective measures at frightened travellers without quantifying the risks. So for the last 15 years I have followed a rough rule of thumb: if I am slumming it or travelling into the bush, I take the pills; if I am staying in four-star hotels in town, I don't bother. My impression is that many regular visitors to Africa do the same. Public health doctors may demur - and Ms Cole's story undoubtedly strengthens their case. She had spent only six days in Tanzania and had, reportedly, taken anti-malarial drugs that provide 90 per cent protection. How unlucky is that?Doubly unlucky because - and this is the real story about malaria - in many parts of the world it is declining, rapidly. About 2.5 billion people live in malarial areas around the globe, and the disease kills almost a million of them every year, mostly children. Changes in the incidence of the disease may go unnoticed by tourists but have huge significance for the local population. Now Cheryl Cole, who first visited Tanzania last year on a charity expedition to Mount Kilimanjaro, has helped focus attention on their plight in a way she could hardly have anticipated.In coastal Kenya, not far from where she was holidaying, cases of severe malaria in children have fallen 90 per cent in the last five years. Similar falls have been reported from other locations across Africa and the world.In certain islands in the Philippines malaria has been eliminated. Mexico is said to be close to eradication, and some countries in Central and South America are moving in the same direction. Morocco was recently declared malaria-free by the World Health Organisation, helping boost the tourist trade there.Sub-Saharan Africa, which bears 70 per cent of the disease burden, presents a much tougher challenge. Yet even here there have been spectacular advances, as in coastal Kenya. Last week, the African Leaders Malaria Alliance announced that malaria cases and deaths had been cut by up to 80 per cent in 10 African countries since 2000, including Ethiopia, Ghana, Rwanda, Zambia and Zanzibar.Among malaria specialists, where gloom prevailed a decade ago, the buzzword now is "elimination": no more malaria deaths by 2015 and no more malaria a decade or two after that. As the Lancet noted last month, "previously cautious malariologists, released from a 40-year collective depression... have been invigorated."How has this change of heart come about? Some call it the Bill Gates effect. Almost three years ago, the world's biggest philanthropist threw down a challenge to the global health community to eliminate malaria in his lifetime. Sceptics responded that his dream would only be realised if he were cryo-preserved. Yet his call had a galvanising effect.The Foundation that he leads with his wife, Melinda, has not only given grants of dizzying size to the search for a malaria vaccine, the distribution of bed nets and other measures, it has also brought a new vigour to the entire aid industry. Its speed and flexibility leaves larger bureaucracies like the UN standing, and where it goes others follow. It has been described as a new type of multilateral organisation, introducing entrepreneurial flair to a sector submerged in red tape.Some complain that Gates is seeking to replicate the world domination he achieved with Microsoft in another, albeit altruistic, sphere. These critics say the new entrepreneurial aid business he has spawned is undemocratic, overly powerful, and is leading to empire- building, wasteful competition, fragmentation and duplication. Why should Bill Gates decide which sorts of vaccines get developed? they ask.There is no denying, however, the impact of Gates's interest on the bottom line. Today's funding for malaria, from all sources, exceeds $10bn (£6.3bn) - a hundredfold increase in little more than a decade. Celebrities from Senegalese musician Youssou N'Dour to David Beckham have joined the cause. Politicians Bill Clinton and Tony Blair have become involved through their respective aid foundations, followed by a growing queue of corporate donors and public figures who bring clout, profile and funding. This week, Andrew Mitchell, the International Development Secretary, published the UK's business plan for malaria, opening a consultation on the best ways of supporting the fight against the disease.Malaria - for so long the poor relation to Aids in terms of global attention, despite claiming more lives in many countries - is suddenly glamorous.The tools for elimination are to hand. More than 200m insecticide-treated bed nets have been distributed since 2000, and are estimated to have saved 1m lives, according to the Roll Back Malaria Partnership. Ban ki-Moon, the UN Secretary General, said that with the delivery of a further 150m bed nets by the end of this year "universal coverage of malaria prevention can be achieved". Vast funds have been invested in indoor spraying against mosquitoes, in distributing more effective artemesinin-based drugs against the disease, and in developing a vaccine, with one candidate, made by the UK-based pharmaceutical manufacturer GlaxoSmithKline, in final (phase III) human trials.But meeting Gates's challenge will be a tough task. Optimists, such as Sir Richard Feachem of the Malaria Elimination Group, point to the "shrinking map" of malaria, which included the US and the UK in 1900 (when malaria was endemic in the Kent marshes). Today, 108 countries in the world are malaria-free. One hundred countries have continuing malaria transmission, and of these, 39 are embarked upon malaria elimination. The remaining 61 are striving to control malaria, but it is Feachem's hope that they too can be persuaded to switch to a policy of elimination.The task is immense. In 2008, malaria killed 863,000 people. Almost 90 per cent of those who died were in Africa, and of those, almost 90 per cent were children under five, according to the WHO. Children are especially vulnerable because they have undeveloped immune systems; the WHO estimates the disease kills 3,000 children a day.The world has been striving to eliminate malaria for more than half a century - with faint success. The Global Malaria Eradication Programme was launched in 1955 but it quickly became apparent that its ambition was not achievable in sub-Saharan Africa. In the late Sixties the strategy switched from eradication to long-term control; people with fever caused by the disease were treated with the then standard drug, chloroquine. But as resistance to the drug grew, malaria deaths rose through the 1970s and 1980s. By the early 1990s the strategy was recognised as a disaster.Throughout the 1990s, as nations wrung their hands over Aids, efforts were made to refocus attention on malaria. The world's health ministers launched a global declaration in Amsterdam in 1992 to control the disease, with a focus on Africa. The latest drive against the disease began 10 years ago, when leaders of countries across Africa signed a declaration in Abuja, Nigeria to "halve the malaria mortality for Africa's people by 2010". Initially progress was slow; there were reports that instead of declining, malaria was rising, by up to half in some areas. Accurate figures were hard to come by, and estimates were distrusted. What is not in dispute, however, is that over the last three years things have moved much more quickly, and more consistently in the right direction. The huge rise in the importation of bed nets and artemesinin drugs has saved millions of lives.Controlling malaria has come to be seen as good business, not just good charity. The disease is estimated to cost Africa $12bn a year - 1.3 per cent of its economic growth. If that sum could be saved, it would constitute the biggest boost to health and development in the continent's history. Eradicating disease boosts productivity, creates markets and stabilises governments.The future, however, is anything but certain. Though the 90 per cent fall in children with severe malaria on the Kenyan coast is impressive, the reasons are not obvious. Malaria has been in decline in this area for at least 15 years and some have suggested climate change is a factor. Meanwhile it is rising in upland areas around Mount Kenya, where incidence was previously low. Professor Robert Snow, who reported the Kenyan figures in The Lancet, said malaria had changed "from a major cause of childhood illness and death to a relatively minor problem" on Kenya's coast. But it was simplistic to attribute it to more bed nets and better drugs. "The truth is probably much more complex," he wrote.Critics also question the notion of "universal coverage" with bed nets - expected in Ethiopia and southern Sudan this year and everywhere in early 2011. How many nets can you hang in a small hut occupied by a large family? Some older children are always likely to go without. There have been distribution problems too: the rush to freight in bed nets has left thousands of them sitting in warehouses because there was no means of transporting them over the final miles.Malaria is concentrated around the equator, the "middle, wet bit" of Africa, with just seven countries accounting for two thirds of all cases: the Democratic Republic of Congo, Ethiopia, Kenya, Nigeria, southern Sudan, Tanzania and Uganda. While there have been gains in some, others such as Nigeria have done less well. With a population of 120 million, Nigeria contributes heavily to the global malaria burden.Even where success has been achieved, there is no guarantee it will be permanent. Zanzibar, the island off Tanzania that has become a luxury tourist destination, has eliminated malaria twice before but each time it has been re-imported from the mainland. Kenya has also slipped back, and in Congo the uncertainties multiply.Constant vigilance is essential. That requires stable, committed government. It is not always available. In Uganda, grants worth over $350m were suspended by the Global Fund over allegations of corruption (which are currently before the courts). In Tanzania a grant worth over $100m from the Global Fund was discovered unclaimed last year because it lacked a single signature.Countries worst affected by the disease have been reluctant to buy the new artemesinin-based drugs because of their cost. At $1 to $2 a dose, they are 10 times more expensive than chloroquine. Though funded by aid programmes today, governments wonder for how long that funding will last. There are fears about resistance too, signs of which have emerged on the Thai-Cambodian border. If the artemesinin drugs lose their potency, there is nothing else immediately in the pharmaceutical locker.Eradication may be the only way to combat resistance. The most taxing question, however, and one which divides the malaria community, is what penalties may follow success? Chris Drakeley, director of the Malaria Centre at the London School of Hygiene and Tropical Medicine, points out that enormous funds are required to eliminate the last few cases of a disease - witness polio, still defying efforts to wipe it from the planet."If malaria drops down the Top 10 list of worst diseases, what justification is there for putting in vast resources to eliminate it? In a situation where malaria had been controlled to a low level for a decade, you would have a large group of children with no immunity to the disease. The impact of an outbreak could then be devastating. There is an argument that some level of malaria is quite good - it maintains a level of immunity in the population."The best hope for the future is a vaccine. No disease has ever been eliminated without a vaccine. But malaria is not caused by a simple virus - it is an organism (a parasite) with a nucleus that is more complex than a virus.The front runner is GlaxoSmithKline's RTSS vaccine, currently being tested in 14,000 children in 11 African countries, with results due in 2012. Early trials suggested that it provided 30-50 per cent protection - far from perfect, but a lot better than nothing.Scientists are optimistic that it will provide a useful further weapon against malaria. But there will be many years yet of fighting before the war can be declared won.
http://www.independent.co.uk/life-style/health-and-families/features/can-malaria-be-beaten-2043383.html

MALARIA: travellers at risk; UK statistics

The singer was initially diagnosed with exhaustion after collapsing during a photoshoot for her forthcoming record release on Saturday. She was admitted to a Surrey hospital after her condition worsened considerably the next day.
"Cheryl hadn't been feeling herself for about a week [after returning on 22 June]. She was feeling tired and listless. "During Sunday afternoon, Cheryl went downhill quickly. She was sweating and shaking and in a bad way."
Her spokesman said: "Cheryl Cole is currently in hospital, being treated for malaria. Following doctors' advice she will be cancelling all work commitments for the next week."
The 27-year-old singer went to Tanzania for a break from her work three weeks ago. Doctors believe she got malaria because of being bitten by a mosquito there. British tourists increasingly travel to countries where malaria is prevalent and every year about 2,000 Britons return home with malaria, making the UK one of the biggest importers of malaria in the industrialised world. An average of nine people die each year from malaria in the UK.
Malaria is transmitted by an infected mosquito and it only takes one bite from an infected mosquito to produce the disease. The most severe form of malaria (Plasmodium falciparum) is on the increase amongst British travellers. A preventable infection, malaria can be fatal if left untreated.
http://www.guardian.co.uk/culture/2010/jul/06/cheryl-cole-malaria-reports

BIOTERRORISM: antibiotic resistant organism

The efficiency of antibiotics is decreasing due to the spread of a bacterial gene conferring high levels of drug resistance. Photograph: Murdo Macleod for the Guardian
International travel and medical tourism have led to the rapid, global spread of drug-resistant bacteria that may presage the end of antibiotics and leave doctors struggling to treat infected patients, scientists warn today.
A new gene conferring high levels of resistance to almost all antibiotics has been found to be widespread in forms of gut bacteria that can cause potentially life-threatening pneumonia and urinary tract infections.
In just three years, says Professor Tim Walsh of Cardiff University who discovered the gene, it has grown in prevalence from being rarely observed at all to existing in between 1% and 3% in patients with Enterobacteriaceae infections in India.
"It is absolutely staggering," said Walsh. "Because of international travel, globalisation and medical tourism, [the gene] now has the opportunity to go anywhere in the world very quickly."
Walsh's paper on the spread of drug-resistant bacteria containing the gene appears today in the Lancet infectious diseases journal.
He and his colleagues have found NDM-1 (New Delhi metallo-beta-lactamase) 1 positive bacteria not only in India and Pakistan but also in the UK. Some of the infected British patients had travelled to India for kidney or bone marrow transplants, dialysis, pregnancy care or burns treatment, while others had undergone cosmetic surgery.
Walsh says it is not possible to know how widespread the bacteria now is in the UK. The Health Protection Agency has issued an alert, but doctors report only those cases they treat.
Alarmingly, there are only two antibiotics that still work against NDM 1-producing bacteria, and the likelihood is that they will also be overcome before long.
"In many ways, this is it," he said. "This is potentially the end. There are no antibiotics in the pipeline that have activity against NDM 1-producing Enterobacteriaceae."
Even if scientists started work immediately on discovering new antibiotics against the threat, he added, there will be nothing available soon.
"We have a bleak window of maybe 10 years, where we are going to have to use the antibiotics we have very wisely, but also grapple with the reality that we have nothing to treat these infections with.
"It is the first time it has got to this stage with these type of bacteria."
Walsh and his colleagues' work also shows that the NDM 1-producing bacteria are widespread not only in hospitals but quite probably in the wider community in India, where contamination of drinking water allows gut-borne bugs to be transmitted easily. Drug-resistant bacteria could also potentially be passed from one person to another in the UK, he said.
Ten years ago, scientists believed the greatest threat from drug-resistant infections involved what are known as Gram-positive bacteria, which include the so-called superbug MRSA (methicillin-resistant staphylococcus aureus).
But now, says the Lancet paper, clinical microbiologists increasingly agree that multidrug-resistant Gram-negative bacteria, which thrive in the gut, pose the greatest risk to public health.
Not only is the genes' resistance to antibiotics growing more rapidly, but there are fewer new drugs to fight them.
Walsh discovered the NDM 1 gene after investigating the case of a patient in Sweden who was admitted to hospital in India infected with Klebsiella pneumoniae and E. coli bacteria.
The gene made the bacteria resistant to the group of antibiotics called carbapenems. The carbapenems are normally kept for emergencies and used when bacteria is found to be resistant to more commonly prescribed antibiotics.
The gene is carried on a plasmid, a small section of DNA that can move from one bug to another, passing on drug-resistance as it goes. These have, according to the paper, "an alarming potential to spread and diversify among bacterial populations."
Walsh says: "The plasmids are highly promiscuous."
Given the likely worldwide spread of these multidrug-resistant bacteria, the paper says: "It is disturbing … to read calls in the popular press for UK patients to opt for corrective surgery in India with the aim of saving the NHS money.
"As our data shows, such a proposal might ultimately cost the NHS substantially more than the short-term saving and we strongly advise against such proposals."
In a commentary in the journal, Johann Pitout from the University of Calgary in Canada calls for patients who have received medical treatment in India to be screened before they are admitted for care back home. He warns that medical tourism, fuelling the spread, could grow in India by 30% every year over the next five years.
http://www.guardian.co.uk/science/2010/aug/11/antibiotics-efficiency-drug-resistant-bacteria

MALARIA: personal experience and review

To watch children slip into the potentially fatal clutches of malaria is terrifying. It's the speed of the descent from good health to serious illness that is so frightening: at dawn they are fine, by dusk they could be in a coma, from which they might never wake. I know this because several years ago I was there – panic-stricken – watching my then eight-year old son, his mind drowning in delirium and his young body teetering on the brink of collapse.
He begged me to 'Just let me close my eyes for a bit, mum', and, desperate, I pleaded with him to stay awake. His decline took less than six hours. In the end he was fine – it meant an emergency airlift, an admission to hospital where he was administered artemisinin (a drug derived from the plant Artemesia annua) intravenously, and four long recuperative weeks out of school, but he did make a full recovery. We were lucky, luckier than the parents of the estimated 5,000 children that die from malaria every day.
Malaria is the world's biggest killer. It affects almost 500 million people a year and takes the lives of nearly 3 million – mostly in Africa, where a child is estimated to die from the disease every 30 seconds, at an estimated cost to the economy of more than £6bn a year.
Despite its much publicised Roll Back Malaria Partnership, the World Health Organisation has had limited success in 20 years. The only real impact the programme has had on the disease is through the introduction of insecticide-treated nets (ITNs), which are an effective prophylactic, particularly for children, when used correctly (but which remain heavily taxed in much of Africa).
Most of the world's millions of malaria sufferers are still not benefiting from life-saving drugs nearly five years after the WHO urged their widespread use. Since 2001, the UN health agency has recommended countries switch to artemisinin-based combination drugs (or ACTs) to treat malaria, which has become resistant to conventional medicines, like chloroquine.
The majority of sufferers understand very little about the disease or how it is transmitted (by the female mosquito, which must be pregnant, and which only bites between dusk and dawn).
Ronald Ross, a British doctor born in India, discovered it was the mosquito that transmitted malaria. Until then the popular theory was that foul-smelling gases emitted from swampy soils caused the disease – the word 'malaria' comes from the Italian, 'bad air'. The mortality rate at the time – over a million deaths a year – was reduced to less than 10,000 during the 1950s as a direct result of education and the eradication schemes initiated by Ross. Since the 60s, though, the disease has been on the increase – in 1960 only 10% of the world's population was at risk; that figure now stands at over 40%.
Today, as a result of poor vector control, global warming and intercontinental travel, malaria infects one in 10 of the world's population. It is present in over 100 countries (including eastern Europe, Russia and Turkey), visited by more than 125 million tourists every year, up to 30,000 of whom fall ill when they get home. Last year 1,754 Britons contracted malaria abroad – 1,300 of them the deadliest strain, Plasmodium falciparum (or cerebral malaria). Eleven of them died.
Poverty and poor education compound the problem of malaria in third-world countries, elevating mortality rates. Astonishingly, ignorance of the disease – despite the press coverage it receives and the access to world-class medicine – is a factor in first-world infection, too. Most British travellers who were infected with malaria last year admitted to failing to take correctly – or at all – oral malarial prophylaxis when visiting areas where the disease is endemic.
An investigation conducted earlier this year in the UK found that travellers who sought advice from alternative health centres (complaining that drugs prescribed by their GPs made them feel nauseous) were being offered 'dangerous' advice on malaria prevention and given unproven homoeopathic remedies. Conventional drugs prescribed by GPs are a combination of chloroquine and proguanil, mefloquine (Lariam), doxycycline and Malarone.
As a resident in Africa, I questioned my own doctor about the efficacy and side effects of these drugs. He dismissed chloroquine and proguanil as almost useless, since the parasite has been shown – in this region anyway – to have developed significant resistance to the combination. Lariam, he said, can cause serious neurological disturbances in as many as one in 10 people. Doxycycline increases photosensitivity, which means patients must be prepared to stay out of the sun. It can also interfere with the potency of oral contraception. Malarone, the most recent anti-malarial to be registered, is considered both effective and relatively easily tolerated, but expensive.
Without exception, all short-term visitors to a malarious area should seek advice from the experts (which include the London School of Hygiene and Tropical Medicine, the WHO and the Health Protection Agency) on malarial prophylaxis beforehand. The situation, however, is more complicated for expatriates living in endemic areas, partly because of the risk associated with long-term use of chemoprophylaxis and partly because there is limited data available on the sustained use of some drugs.
The Health Protection Agency suggests that 'the risk of serious side effects associated with long-term prophylactic use of chloroquine and proguanil is low. However, anyone who has taken chloroquine regularly for over five years and requires further prophylaxis should be screened twice-yearly for early retinal changes'. Even before these changes become apparent, there could be other intolerable side effects: my husband, for example, is unable to take proguanil (Paludrine) as it gives him appallingly bad mouth ulcers, which render him unable to eat.
Research suggests there is no increased risk of serious side effects with long-term use of mefloquine (Larium), assuming a person can tolerate it in the short term. Experience of doxycycline in long-term use is limited, though the available data is reassuring (however, like mefloquine, it must be avoided during pregnancy). In many parts of the world, oral prophylaxis is not a guaranteed form of protection; Plasmodium falciparum is increasingly resistant to various antimalarial drugs (indeed my son was on a chloraquine/proguanil combination when he contracted this particularly virulent strain of the disease). As the WHO warns, no antimalarial prophylactic regimen gives complete protection.
Those travelling to malarious areas for extended periods of time (over six months) – or living there (particularly in the case of women, who may become pregnant, and young children) – need to balance the risk of infection against the benefits and side effects of oral prophylaxis; sometimes taking a pill daily gives a false sense of security and might result in laziness when it comes to other prophylactic measures – sleeping under nets, for example, spraying rooms or burning mosquito coils at night.
http://www.guardian.co.uk/money/2008/mar/19/expat-finance-malaria-prevention

MALARIA: Control across the Limpopo

Zimbabwe and South Africa's Limpopo province are working on an agreement to eliminate malaria on both sides of the Limpopo River.Top malaria scientist Professor Maureen Coetzee said: "They are in the middle of drafting a trans-Limpopo malaria control application."The health department in Limpopo, which borders on Zimbabwe, reported an increase in malaria cases in December in the Vhembe and Mopani districts.Zimbabwe's malaria programme has suffered setbacks in control and research, said Richard Tren, director of Africa Fighting Malaria."For many years Zimbabwe had an excellent malaria control programme and now it is down to almost zero," he said.The National Institute of Health Research (formerly the Blair Research Institute), which does malaria research, has lost many of its staff and much of its resources.Tren said: "Since 2000 the malaria control programme has broken down."This could present a threat to Zimbabwe's neighbours, since people travel with the parasite.
http://www.fightingmalaria.org/news.aspx?id=1438