Malaria chemoprophylaxis — DTM&H MCQ
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Correct answer: B — Atovaquone-proguanil with strict bite avoidance advice
The correct answer is B, atovaquone-proguanil with strict bite avoidance advice. Ghana is a high-transmission chloroquine-resistant falciparum area, so effective chemoprophylaxis plus rigorous bite avoidance is mandatory throughout the visit. Mefloquine is unsuitable here because she has both epilepsy and a prior severe neuropsychiatric reaction, and UK guidance treats epilepsy and mefloquine intolerance as contraindications to its use. Atovaquone-proguanil is not associated with neuropsychiatric or seizure-provoking effects and is a standard alternative for short-trip travellers to chloroquine-resistant West Africa who cannot take mefloquine. It is licensed for short-term use (up to 28 days), fitting her 3-week itinerary, and can be started only 1 to 2 days before travel. Why the other options are wrong: C. Mefloquine started 3 weeks before travel: contraindicated by her epilepsy and by her documented severe neuropsychiatric reaction; mefloquine can lower seizure threshold and precipitate further neuropsychiatric toxicity. E. Chloroquine weekly during travel: chloroquine is also contraindicated in epilepsy, and in any case gives no useful protection against the chloroquine-resistant falciparum malaria prevalent in Ghana. A. Primaquine without G6PD testing: primaquine causes haemolysis in G6PD deficiency, so G6PD status must always be checked before use; it is also not a first-line prophylactic agent in UK practice. D. Standby artemether-lumefantrine instead of prophylaxis: standby treatment is reserved for remote areas with delayed medical access and never replaces chemoprophylaxis on a high-risk rural itinerary during the rainy season. Key point: both chloroquine and mefloquine are contraindicated in epilepsy, making atovaquone-proguanil (with strict bite avoidance) the appropriate choice for chloroquine-resistant destinations like Ghana.
Reference: UK Health Security Agency, Guidelines for malaria prevention in travellers from the UK (updated 2025), chemoprophylaxis choice and epilepsy contraindications section, https://www.gov.uk/government/publications/malaria-prevention-guidelines-for-travellers-from-the-uk