Malaria chemoprophylaxis — DTM&H MCQ

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A traveller to West Africa asks about malaria chemoprophylaxis. She has a history of depression managed with sertraline and wants to avoid neuropsychiatric side effects. The area has chloroquine-resistant P. falciparum. What is the most appropriate prophylaxis?

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Correct answer: C — Atovaquone-proguanil daily

The correct answer is C, Atovaquone-proguanil daily. In chloroquine-resistant P. falciparum areas such as West Africa, UK malaria prevention guidance (UKMEAG/TravelHealthPro) lists atovaquone-proguanil, doxycycline and mefloquine as effective options, but mefloquine carries a well-documented risk of neuropsychiatric adverse effects and is contraindicated in patients with current or past depression, anxiety, or other psychiatric disorders. Atovaquone-proguanil has a favourable neuropsychiatric side-effect profile, making it the appropriate first-line choice for this traveller with a depression history on sertraline. It is taken once daily, started one to two days before travel and continued for only seven days after return, which also supports adherence compared with other agents. Why the other options are wrong: D. Mefloquine 250 mg weekly: contraindicated in patients with a history of depression or other psychiatric illness because it can precipitate or worsen anxiety, depression, psychosis and seizures, exactly the risk this patient wants to avoid. A. Doxycycline 100 mg daily: effective against chloroquine-resistant falciparum but causes photosensitivity, oesophagitis and vaginal candidiasis, and offers no specific psychiatric-history advantage over atovaquone-proguanil, making it a reasonable but not the most appropriate choice here. B. Chloroquine plus proguanil: chloroquine resistance is now near-universal across sub-Saharan Africa, so this combination provides inadequate protection in West Africa. E. Primaquine 30 mg daily: not used as first-line primary prophylaxis for P. falciparum in UK guidance; it targets liver hypnozoites (relevant to P. vivax/ovale) and requires G6PD testing before use. Key point: in a patient with psychiatric history travelling to a chloroquine-resistant P. falciparum area, mefloquine is contraindicated, so atovaquone-proguanil is the preferred prophylaxis.

Reference: NaTHNaC/TravelHealthPro (UKHSA UK Malaria Expert Advisory Group, UKMEAG), Malaria factsheet, https://travelhealthpro.org.uk/factsheet/52/malaria