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• How It Spreads
• Where Malaria Occurs
• World Malaria Day 2024
• Clinical Guidance: Malaria Diagnosis & Treatment in the U.S.
• Clinical Features
• Clinical Testing and Diagnosis
• Malaria Risk Assessment for Travelers

Choosing a Drug to Prevent Malaria

• How to Report a Case of Malaria
• Public Health Strategy
• Malaria's Impact Worldwide
• Communication Resources

At a glance

• Drugs to prevent malaria differ by country of travel.
• Counsel patients to use personal protective measures along with malaria chemoprophylaxis.
• Consider contraindications and drug-drug interactions when prescribing a malaria prophylaxis.
• Consider the timing of when to start and stop chemoprophylaxis. Some medications require patients take them weeks in advance of travel and continued after leaving the malaria-endemic area.

Medication shortage

Mefloquine shortage‎, considerations, considerations when choosing a drug for malaria prophylaxis:.

• Recommendations for drugs to prevent malaria differ by country of travel and can be found in CDC's Yellow Book chapter on Malaria Prevention Information, by Country. Recommended drugs for each country are listed in alphabetical order and have comparable efficacy in that country.
• When used correctly malaria chemoprophylaxis is very effective. Using multiple prevention strategies together offer additional protection. Counsel patients on the use of personal protective measures, (i.e., insect repellent, long sleeves, long pants, sleeping in a mosquito-free setting or using an insecticide-treated bed net) along with malaria chemoprophylaxis.
• For all medicines, also consider the possibility of drug-drug interactions with other medicines that the person might be taking as well as other medical contraindications, such as drug allergies.
• When several different drugs are recommended for an area, the following table might help in the decision process.
• CDC has replaced the Malaria Prevention Country Tables with the Yellow Book 2024 chapter on Malaria Prevention Information, by Country . You can find the same information regarding chemoprophylaxis by country or region.

Drug/Dosage

Reasons that might make you consider using this drug

Reasons that might make you avoid using this drug

Atovaquone/Proguanil (Malarone)

Begin 1 – 2 days before travel, daily during travel, and for 7 days after leaving.

Adults: 1 adult tablet daily.

Children: 5-8 kg: ½ pediatric tablet daily. >8-10 kg: ¾ pediatric tablet daily. >10-20 kg: 1 pediatric tablet daily. >20-30 kg: 2 pediatric tablets daily. >30-40 kg 3 pediatric tablets daily. >40 kg and over: 1 adult tablet daily.

• Good for last-minute travelers because the drug is started 1-2 days before traveling to an area where malaria transmission occurs
• Some people prefer to take a daily medicine
• Good choice for shorter trips because you only have to take the medicine for 7 days after traveling rather than 4 weeks
• Very well tolerated medicine – side effects uncommon
• Pediatric tablets are available and may be more convenient
• Cannot be used by women who are pregnant or breastfeeding a child less than 5 kg
• Cannot be taken by people with severe renal impairment
• Tends to be more expensive than some of the other options (especially for trips of long duration)
• Some people (including children) would rather not take a medicine every day

Chloroquine

Begin 1 – 2 weeks before travel, once/week during travel, and for 4 weeks after leaving.

Adults: 300 mg base (500 mg salt), once/week.

Children: 5 mg/kg base (8.3 mg/kg salt) (maximum is adult dose), once/week.

• Some people would rather take medicine weekly
• Good choice for long trips because it is taken only weekly
• Some people are already taking hydroxychloroquine chronically for rheumatologic conditions. In those instances, they may not have to take an additional medicine
• Can be used in all trimesters of pregnancy
• Cannot be used in areas with chloroquine or mefloquine resistance
• May exacerbate psoriasis
• Some people would rather not take a weekly medication
• For trips of short duration, some people would rather not take medication for 4 weeks after travel
• Not a good choice for last-minute travelers because drug needs to be started 1-2 weeks prior to travel

Doxycycline

Begin 1 – 2 days before travel, daily during travel, and for 4 weeks after leaving.

Adults: 100 mg daily.

Children: ≥8 years old: 2.2 mg/kg (maximum is adult dose) daily.

• Tends to be the least expensive antimalarial
• Some people are already taking doxycycline chronically for prevention of acne. In those instances, they do not have to take an additional medicine
• Doxycycline also can prevent some additional infections (e.g., Rickettsiae and leptospirosis) and so it may be preferred by people planning to do lots of hiking, camping, and wading and swimming in fresh water
• Cannot be used by pregnant women and children <8 years old
• Some people would rather not take a medicine every day
• Women prone to getting vaginal yeast infections when taking antibiotics may prefer taking a different medicine
• Persons planning on considerable sun exposure may want to avoid the increased risk of sun sensitivity
• Some people are concerned about the potential of getting an upset stomach from doxycycline

Begin 1 – 2 weeks before travel, weekly during travel, and for 4 weeks after leaving.

Adults: 228 mg base (250 mg salt), weekly.

Children: ≤9 kg: 4.6 mg/kg base (5 mg/kg salt), weekly. >9-19 kg: ¼ tablet weekly. >19-30 kg: ½ tablet weekly. >30-45 kg: ¾ tablet weekly. >45 kg: 1 tablet weekly.

• Can be used during pregnancy
• Cannot be used in areas with mefloquine resistance
• Cannot be used in patients with certain psychiatric conditions
• Cannot be used in patients with a seizure disorder
• Not recommended for persons with cardiac conduction abnormalities
• Not a good choice for last-minute travelers because drug needs to be started at least 2 weeks prior to travel

Begin 1 – 2 days prior to travel, daily during travel, and for 7 days after leaving

Adults: 30 mg base (52.6 mg salt), daily

Children: 0.5 mg/kg base (0.8 mg/kg salt) up to adult dose daily

• It is one of the most effective medicines for preventing P. vivax and so it is a good choice for travel to places with > 90% P. vivax
• Cannot be used in patients with glucose-6-phosphatase dehydrogenase (G6PD) deficiency
• Cannot be used in patients who have not been tested for G6PD deficiency
• There are costs and delays associated with getting a G6PD test done; however, it only has to be done once. Once a normal G6PD level is verified and documented, the test does not have to be repeated the next time primaquine is considered
• Cannot be used by pregnant women
• Cannot be used by women who are breastfeeding unless the infant has also been tested for G6PD deficiency
• Some people are concerned about the potential of getting an upset stomach from primaquine

Tafenoquine (Arakoda TM )

Begin daily for 3 days prior to travel, weekly during travel, and for 1 week after leaving.

Adults only: 200 mg per dose.

• One of the most effective drugs for prevention of P. vivax malaria, but also prevents P. falciparum
• Good choice for shorter trips because you only have to take the medicine once, 1 week after traveling rather than 4 weeks
• Good for last-minute travelers because the drug is started 3 days before traveling to an area where malaria transmission occurs
• There are costs and delays associated with getting a G6PD test done; however, it only has to be done once. Once a normal G6PD level is verified and documented, the test does not have to be repeated the next time tafenoquine is considered
• Cannot be used by children
• Not recommended in those with psychotic disorders

Malaria is a serious disease caused by a parasite that infects the Anopheles mosquito. You get malaria when bitten by an infective mosquito.

For Everyone

Health care providers, public health.

Travel tips for what AAA says will be the busiest Memorial Day weekend in 20 years

WEST QUINCY, Mo. (WGEM) - AAA expects 43.8 million travelers to travel 50 miles or more from home this Memorial Day weekend.

“We haven’t seen Memorial Day weekend travel numbers like these in almost 20 years,” said Paula Twidale, senior vice president of AAA Travel. “We’re projecting an additional one million travelers this holiday weekend compared to 2019, which not only means we’re exceeding pre-pandemic levels but also signals a very busy summer travel season ahead.”

Local police are urging drivers to be safe on the road this Memorial Day weekend.

Quincy Police Pro-Act Officer Amber Haistings, said the department will have extra patrols out this weekend.

She said it is important for drivers to be prepared before they hit the road. This includes inspecting your car’s tire pressure and checking the oil. She said it is also a good idea to pack some extra food and blankets in case an emergency happens on the road.

As in past years, most holiday travelers are expected to travel by car – more than 38 million of them, according to AAA. The organization advises motorists hoping to avoid the worst traffic to leave metropolitan areas early Thursday and Friday and to stay off the roads between 3 p.m. and 7 p.m. Sunday and Monday.

“We haven’t seen any pullback in travel since the pandemic. Year after year, we have seen these numbers continue to grow,” AAA spokesperson Aixa Diaz said. “We don’t know when it’s going to stop. There’s no sign of it yet.”

The American Red Cross recommends the following travel tips when you are on the road:

• Be well-rested and alert, use your seat belts, observe speed limits and follow the rules of the road.
• If you plan on drinking alcohol, designate a driver who won’t drink.
• Give your full attention to the road. Avoid distractions such as cell phones.
• Use caution in work zones. There are lots of construction projects underway on the highways.
• Don’t follow other vehicles too closely.
• Make frequent stops.
• Clean your vehicle’s lights and windows to help you see, especially at night. Turn your headlights on as dusk approaches, or during inclement weather. Don’t overdrive your headlights.
• Don’t let your vehicle’s gas tank get too low. If you have car trouble, pull as far as possible off the highway.
• Carry a Disaster Supplies Kit in your trunk.
• Let someone know where you are going, your route and when you expect to get there. If your car gets stuck along the way, help can be sent along your predetermined route.

Officer Haistings said Quincy Police will be looking out for distracted drivers and those under the influence.

She said common distractions are phones and even trying to eat while you drive.

She said fatigue can also be a concern, especially on long road trips.

“If you are tired while you are driving, maybe make sure you have two drivers, so one can sleep while the other one is driving and switch. Or if you don’t have somebody else with you, pull over to a safe area where you could rest your eyes for a bit,” Haistings said.

She said it’s also a good idea to leave early. It not only helps you beat traffic but gives you extra time to get to your destination.

According to AAA, drivers this weekend can expect similar gas prices as last year when the national average was roughly $3.57. Pump prices rose this spring but have held somewhat steady in recent weeks.

Copyright 2024 WGEM. All rights reserved.

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Norfolk Southern will pay $15 million fine as part of federal settlement over Ohio derailment

FILE - Debris from a Norfolk Southern freight train lies scattered and burning along the tracks on Feb. 4, 2023, the day after it derailed in East Palestine, Ohio. A federal judge has signed off Tuesday, May 21, 2024, on the $600 million class action settlement over last year’s disastrous Norfolk Southern derailment in eastern Ohio, but many people who live near East Palestine are still wondering how much they will end up with out of the deal. (AP Photo/Gene J. Puskar, File)

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The federal government agreed to a $15 million fine for Norfolk Southern over last year’s disastrous derailment in East Palestine, Ohio, and the railroad promised to pay more than $500 million to complete the efforts to improve safety that it announced after the crash and address community health concerns.

Residents who had to evacuate their homes after the derailment were generally underwhelmed by the deal the Environmental Protection Agency and Justice Department announced Thursday that doesn’t include any criminal charges. This federal settlement comes two days after a federal judge signed off on the railroad’s $600 million class action settlement with residents whose lives were disrupted.

In addition to the civil penalty, Norfolk Southern agreed to pay $235 million in past and future cleanup costs — on top of what they’ve already paid for cleanup — and set up a $25 million health care fund to pay for 20 years of medical exams in the community. The railroad will also pay about $30 million for long-term monitoring of drinking water, groundwater and surface water in the area. The agreement also says the railroad will pay $244 million for previously promised railroad improvements through 2025.

Many East Palestine residents feel this settlement doesn’t do nearly enough to a company that just reported a $527 million profit in the fourth quarter of last year and $53 million in the first quarter after the derailment costs. The railroad’s CEO received $13.4 million in total compensation last year.

“Honestly, no amount can ever make this right, but it should be at least enough to hurt them a little bit. I’m sure that’s not going to hurt their bottom line at all,” Jami Wallace said.

EPA Administrator Michael Regan said the fine is the largest allowed under the Clean Water Act, and the railroad agreed to continue paying all of the cleanup costs. Plus he said Norfolk Southern committed to meaningful safety improvements

“This settlement is historic in many ways and will begin to make up for some of the damage caused to the residents of East Palestine. And it would absolutely push the industry in the direction that we would like for the industry to go,” Regan said. “Again, if some of these provisions that we’ve secured and locked in had been in place, we may not even be where we are today. ”

But the railroad won’t face criminal charges, and this latest settlement won’t add anything to Norfolk Southern’s roughly $1.7 billion in total costs related to the derailment because the Atlanta-based company was already anticipating those costs.

Neither this federal settlement nor the class action settlement seem like enough to Krissy Ferguson.

“Slaps on the wrist. A $15 million fine? And I can never go back to my home again?” Ferguson said.

But resident Misti Allison said it is encouraging to see the investigations and lawsuits against the railroad start to wrap up, and the cleanup is expected to be done sometime later this year.

“I think this is a great step, but let’s continue to make sure the community is made whole,” Allison said.

Many in the small town near the Ohio-Pennsylvania border are eager to put the derailment behind them, but fears about the possibility of developing cancer down the road hang over residents. Allison said she wants to make sure health needs are addressed. But this federal settlement primarily includes only money for exams while the class action settlement includes money for health problems that developed over the past year. Neither deal addresses potential long-term health problems that might develop.

The safety improvements Norfolk Southern promised include adding about 200 more trackside detectors to spot overheating bearings. It has also promised to invest in more than a dozen advanced inspection portals that use an array of cameras to take hundreds of pictures of every passing railcar.

A bill in Congress that would require Norfolk Southern and the rest of the major freight railroads to make more significant changes has stalled , although the industry has promised to make improvements on its own.

Norfolk Southern officials said they believe the relatively small size of this settlement reflects how much the railroad has already done, including paying $780 million in cleanup costs and providing $107 million in aid to residents and the communities affected.

“We are pleased we were able to reach a timely resolution of these investigations that recognizes our comprehensive response to the community’s needs and our mission to be the gold standard of safety in the rail industry,” CEO Alan Shaw said. “We will continue keeping our promises and are invested in the community’s future for the long haul.”

After Thursday’s announcement, the only remaining federal investigation is the National Transportation Safety Board’s probe into the cause of the Feb. 3, 2023, derailment. That agency plans to announce its conclusions at a hearing in East Palestine on June 25 . Republicans in Congress have said they might be willing to look at rail safety reforms after that report.

Ferguson said it feels like Norfolk Southern is rushing to resolve things before the NTSB report comes out. U.S. Sen. JD Vance and Ohio Attorney General Dave Yost said in a joint statement that they think the government should have waited to settle.

“The residents of East Palestine deserve full compensation to account for the hardships they have faced in the months since the derailment, but they also deserve the full truth about why the derailment and vent and burn occurred,” the statement said. “With its decision to reach a settlement now, the DOJ may have sacrificed its opportunity to use the NTSB’s findings to impose maximum leverage on those responsible for any potential wrongdoing.”

The NTSB has said previously that the derailment was likely caused by an overheating bearing that wasn’t caught in time by the trackside detectors the railroad relies on to spot mechanical problems. The head of the NTSB also said that the five tank cars filled with vinyl chloride didn’t need to be blown open to prevent an explosion because they were actually starting to cool off even though the fire continued to burn around them.

The railroad is still working to resolve a lawsuit Ohio filed against it after the derailment.

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What to Know About the I.C.C. Prosecutor’s Request for Warrants for Israeli and Hamas Leaders

The International Criminal Court prosecutor requested arrest warrants for Prime Minister Benjamin Netanyahu of Israel and Hamas leaders. Here is a closer look at the court and the warrant.

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By Emma Bubola and Charlie Savage

The prosecutor of the International Criminal Court said on Monday that he had requested arrest warrants for war crimes and crimes against humanity for Prime Minister Benjamin Netanyahu of Israel and the leaders of Hamas. Here’s a closer look at the court and the warrants.

The prosecutor is accusing both sides of war crimes.

The court’s prosecutor, Karim Khan, said in a statement that he was applying for arrest warrants for Yahya Sinwar, Mohammed Deif and Ismail Haniyeh of Hamas because he had “reasonable grounds to believe” that they were responsible for war crimes and crimes against humanity, which included “the killing of hundreds of Israeli civilians” in the Hamas-led Oct. 7 attacks in Israel, and the taking of at least 245 hostages.

Mr. Khan said that the Hamas officials “planned and instigated the commission of crimes” on that day, and that they “have acknowledged their responsibility for those crimes” through their actions, such as personal visits to hostages shortly after their kidnapping.

The prosecutor cited accusations of murder, extermination, hostage-taking, and acts of sexual violence as war crimes. He also said he had reasonable grounds to believe the officials were responsible for acts of torture and cruel treatment.

Mr. Khan also said that he had requested arrest warrants for Mr. Netanyahu and Israel’s defense minister, Yoav Gallant, because there were reasonable grounds to believe that they bore responsibility for war crimes and crimes against humanity, including the starvation of civilians as a weapon of war and “intentionally directing attacks against a civilian population.”

Mr. Khan said that these crimes were committed “as part of a widespread and systematic attack against the Palestinian civilian population.” He also said that in his office’s view, some of the crimes “continue to this day.”

“International law and the laws of armed conflict apply to all,” he said. “No foot soldier, no commander, no civilian leader — no one — can act with impunity. Nothing can justify willfully depriving human beings, including so many women and children, the basic necessities required for life. Nothing can justify the taking of hostages or the targeting of civilians.”

The International Criminal Court was set up under a 1998 treaty, but the U.S. and Israel aren’t members.

The International Criminal Court is an international court that has jurisdiction to prosecute people for war crimes, genocide and crimes against humanity.

It was established in 2002 as a standing body to investigate those crimes under a 1998 treaty known as the Rome Statute. Previously, the United Nations Security Council had set up ad hoc tribunals to address atrocities in specific places, like the former Yugoslavia and Rwanda.

The I.C.C. is based in The Hague, a Dutch city that has long been a center for international law and justice. It is separate from the International Court of Justice, an international tribunal also in The Hague which is an arm of the United Nations and handles civil disputes between countries. The latter is currently weighing a claim brought by South Africa that Israel is conducting a genocide in Gaza . Israel has strongly denied the accusation.

Many democracies joined the International Criminal Court, including close American allies like Britain. The court has recognized Palestine as a member since 2015.

But neither Israel nor the United States is a member. The United States, which conducts numerous military operations abroad, has taken the position that the court should not exercise jurisdiction over citizens from countries that are not parties to the treaty.

That position, however, has been tested by Russia’s invasion of Ukraine. Russia is not a member, but Ukraine is. Last year, the court issued arrest warrants for President Vladimir V. Putin and another Russian official, saying they bore individual criminal responsibility for the abduction and deportation of Ukrainian children in the wake of Russia’s full-scale invasion of Ukraine in 2022. After a lengthy internal debate, President Biden ordered the U.S. government to share evidence of Russian war crimes with the court.

The arrest warrants have the immediate effect of limiting travel for targets.

Mr. Khan’s request for warrants must still be approved by judges on the court. If they are issued, the warrants would put both the Israeli officials and Hamas leaders at risk of being arrested and sent to The Hague for trial if they travel to one of the court’s 124 member nations , which include most European countries.

Presumably they would not go to countries that would arrest and extradite them, in which case they may never stand trial. But the effective travel restrictions would function as a kind of punishment in and of themselves.

“Israel will be more isolated after this action,” said Stephen Rapp, a former U.S. ambassador at large who headed the Office of Global Criminal Justice in the State Department. He said that if the arrest warrants go ahead, the named officials “will find it hard to travel to two-thirds of the world.”

The warrant request represents one of the harshest condemnations of Israel’s strategy in its war against Hamas and its campaign’s toll on Gaza’s civilian population. But Mr. Rapp said that Israel “has proved itself sort of immune to international pressure, ” and it was unclear whether the prosecutor’s actions would have an impact on its strategy in Gaza.

The I.C.C. cannot try defendants in absentia . It also has no police force, relying on member states to arrest fugitives and transfer them to The Hague.

In the case of Mr. Putin, the judges approved the request within weeks.

The prosecutor is accusing Israeli officials of intentionally targeting civilians and using starvation as a weapon.

Mr. Khan said that he believed Israeli officials were responsible for intentionally attacking civilians, but he largely focused on allegations of starvation, and extermination or murder “including in the context of deaths caused by starvation.”

For months, Israel has been criticized for the scale of civilian deaths, but Israeli officials have blamed Hamas for the toll, accusing the armed group of using civilians as a shield, its fighters deliberately hiding among and beneath noncombatants.

Under the laws of war, it can be lawful to pull the trigger knowing that some civilian bystanders are likely to be killed, so long as the harm to innocents is deemed to be necessary and proportionate to striking a legitimate military target.

Mr. Rapp, the former U.S. ambassador, said that prosecutors’ greater emphasis on accusations that Israeli officials have restricted the transfer of critical supplies of food and medicine to civilians may be because that issue is “relatively simple” compared to second-guessing targeting decisions.

“The humanitarian rules are very strict,” he said, adding that a state which conducts a military operation in an area of which it controls the perimeter must ensure that civilians have the means of survival.

“If you look at the black letter of international law in this area, it is actually very, very clear,” he said.

Israel’s foreign minister denounced the warrant applications.

Neither Mr. Netanyahu nor Mr. Gallant immediately commented on the decision.

Israel’s foreign minister, Israel Katz, said that he had ordered the immediate establishment of a special committee aimed at fighting the decision, which he said “was intended first and foremost to tie the hands of the State of Israel and deny it the right of self-defense.”

The “scandalous” prosecutor’s decision, he said, “is a frontal attack without restraint on the victims of Oct. 7 and our 128 hostages in Gaza.”

In a statement on Telegram, Hamas condemned the warrant requests against its leaders. It said that the prosecutor should demand the arrest not only of Mr. Netanyahu and Mr. Gallant but of all “leaders, officers and soldiers who participated in crimes against the Palestinian people.”

Because of an editing error, an earlier version of this article said that the United States and Israel hadn’t signed the treaty that set up the International Criminal Court. They signed, but are not members.

How we handle corrections

Emma Bubola is a Times reporter based in London, covering news across Europe and around the world. More about Emma Bubola

Charlie Savage writes about national security and legal policy. More about Charlie Savage

Our Coverage of the Israel-Hamas War

News and Analysis

Israel’s military battled deeper into Rafah  in the southern Gaza Strip, expanding its offensive into the city and driving more people out of it, while Israel faced growing international pressure and isolation over its war against Hamas.

Despite recent diplomatic blows, Israeli leaders are focused on their public , which still largely views the war with Hamas in Gaza as an existential conflict.

William J. Burns, the C.I.A. director, who has been the lead American negotiator in efforts for a cease-fire in Gaza, plans to travel to Europe for talks with his Israeli counterpart  to try to revive the stalled discussions over a pause in the fighting and the release of hostages.

Israeli forces retrieved the bodies of three Oct. 7 Hamas attack victims  in an overnight operation in northern Gaza, the Israeli military said, further heightening fears for the fate of the remaining hostages held in Gaza.

U.S. Military Aid Project: The Pentagon predicted that a stream of humanitarian aid would be arriving in Gaza via the floating pier, but little relief has reached the besieged strip .

Ari Emanuel’s Condemnation: The media executive Ari Emanuel condemned Israel’s conservative prime minister,  Benjamin Netanyahu, for his leadership since the Hamas attack of Oct. 7, a conspicuous statement from one of Hollywood’s most powerful figures.

Amal Clooney Weighs In: The prominent human rights lawyer was on a panel that recommended arrest warrants  for leaders of Israel and Hamas. She had been criticized earlier for not speaking out on the war.