The IDI [Immigration Directorate Instructions, Feb 2007] states that malaria prophylaxis should be provided on request for pregnant women and children under 5.

2. The HPA also states [p82] that a limited period of prophylaxis of four to six weeks may be appropriate in some circumstances to allow pregnant women and young children returning to their country of origin to settle and arrange for future healthcare but not appropriate in general for individuals returning to their country of origin.

However, detainees are a special group. They are likely to be destitute on return  and therefore  prophylaxis is vital to allow them to settle and find shelter.  Children have often been born here [therefore no natural immunity] to mothers who have been here long enough [more than a few months] to have lost much of their natural immunity so that no  significant protection will have  been passed transplacentally or via the breast milk.

Note that the IDI states [p14] that time should be allowed for malaria prophylaxis to take effect before removal. On page 13 of the IDI is stated  that removal directions  “should be dependent  on any pre-departure element of such [preventive] treatment being completed.”  It has been argued that people have been detained too late to allow enough time for prophylaxis.

Use BNF [p355 current], HPA, or Nathnac country pages and IDI for prophylaxis for individual countries.

In practice, most of the time we are asked for advice for detainees being removed to Subsaharan Africa where, apart from Lesotho, some parts of South Africa, Ethiopia, Namibia, and Botswana,  the risk is very high with very widespread chloroquine resistance.   

Therefore we are usually only dealing with 2 antimalarials for prophylaxis, MEFLOQUINE and  MALARONE, as doxycline is contraindicated in pregnant women and childre  under 12 and chloroquine  and proguanil are ineffective in chloroquine resistant areas.

[If chloroquine and proguanil can be used, they should be started 1 week prior to departure. They can be used at any age and in pregnancy.  Chloroquine is contraindicated if there is a history of epilepsy and extra folic acid should be given with proguanil in pregnancy.]

MALARONE [proguanil with atovaquone] can only be used for prophylaxis in children weighing 11kg or more. HPA [p41] state s “DO NOT USE” under 11kg.

When Yarl's Wood asked the malarial helpline about giving malarone to a 10kg child they were told they would be giving it off licence. The GMC advice on off licence drugs is that they shouldn’t be given if a licenced alternative is available.  Malarone should be started 24 hours prior to arrival at destination. Note that the BNF [p359 current] states under “Cautions diarrhea or vomiting [reduced absorption of atovaquone];’… Malarone is not recommended in pregnancy.

MEFLOQUINE can be used in children of 6kg or more and over 3 months of age, and in pregnancy.
BNF [p358current] states under contraindications “ Avoid for prophylaxis if history of psychiatric disorders [including depression] or convulsions.“

However, mefloquine is NOT licenced for use in pregnancy. The current BNF [p355] states that the manufacturer advises that prophylaxis with mefloquine in pregnancy should “be avoided as a matter of principle” but that studies including in the first trimester have been reassuring. The HPA [p 66] states that ‘..it is generally agreed that Mefloquine may be advised in the second and third trimesters of pregnancy ……….its use may also be justified in the first trimester after taking expert advice.” Because of these obvious doubts it has been possible to delay removals until after the first trimester.

The HPA [p65] says that …,the pregnant traveller must be informed of the risks which malaria presents and the risks and benefits of anti malarial prophylaxis.” The IDI [p13] states that medical advice on preventive measures including  advice leaflets, should be made available to detainees as soon as possible.

If a pregnant woman has a history of depression or other psychiatric disorders or fits, we have  successfully argued that she cannot  be removed during pregnancy to a chloroquine resistant area.   Recently Medical Justice volunteer doctors said that a pregnant woman with prior suicidal ideation [mentioned 5 times in the current Yarl's Wood notes] should not be given mefloquine.  She WAS given mefloquine and after release was sectioned under the Mental Health Act.  

Mefloquine should be started at least 2 and a half weeks before travel.

Nathnac states ‘Mefloquine is ideally begun 2-3 weeks before departure to reach effective blood levels, and evaluate for adverse side effects. This is particularly important for first time users”,  After 3 doses about 75% of adverse reactions will have occurred. [Nursing travel journal and ‘roll back malaria’]. The IDI [page 17] table from the HPA /ACMP [Advisory committee on malaria prophylaxis] says that mefloquine has a half life of 21 days indicating that 3 weeks is the recommended time between prescription and removal.

Last minute mefloquine is not recommended. The IDI p20 states that ‘Mefloquine is generally  started with a 2-3 week window to determine tolerance if it has not been used before.” [ Note Nathnac states that 2-3 weeks also needed to reach effective blood levels]. The HPA [p76] section on last minute travellers states ….’it would be sensible to avoid mefloquine for last minute prophylaxis if the traveller has not taken and tolerated mefloquine in the past.’ [Note the  slightly misleading  paragraph in the BNF [p354] ‘Length of prophylaxis‘ which has been used to  claim that mefloquine can be given 1-2 days prior to departure.]

NOTES:

1.Although some drug company websites state that mefloquine should be given at least a week prior to travel, none of the guidelines give this advice.  We have successfully opposed removal after 1 week of mefloquine. ‘Roll back malaria‘ states that efficacy is compromised by starting 1 week prior to departure .  

2. Intermittent preventive therapy [IPT] for pregnant women is available in some countries but is considered only adequate for partially immune women, ie those who live there and is not suitable for those who have been here for more than a few months and have lost most of their immunity.]

CHILDREN <6KG in weight or < 3 months of age CANNOT TAKE MEFLQUINE and therefore cannot safely be removed to a chloroquine resitant area.  [Malarone cannot be used under 11KG]

ASPLENIC people are advised not to travel to malarial areas [particular risk]. HPA p 70.
People with SICKLE CELL DISEASE [who may also be asplenic] are particularly at risk and there is a consensus among a group of haematologists that they should not be removed to malarial areas.

BED NETs : The IDI ACMP Appendix [p20] states that “All should be given an advice leaflet [on mosquito bite avoidance and the need for prompt medical attention if febrile] and a bed net [one per person being repatriated].  However p14 of the IDI states that it is the detainees‘ responsibility to obtain them. We have been asking for bed nets for the long term in addition to  short term prophylactic medication.  [4-6 weeks] which is particularly necessary for detainees  who will usually be returning destitute and without shelter. [see above]

 

03/08/09