Prevention

The short answer

For most travelers I see, I prescribe Malarone (atovaquone-proguanil). It's the cleanest option — best tolerated, simplest schedule, fewest hassles.

I switch to doxycycline when cost matters or the trip is long. I reach for mefloquine only in a few specific situations.

This is the framework I actually use in clinic, not a textbook comparison.

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Why Malarone is my default

When a patient walks in and asks "what should I take?", my opening assumption is Malarone. I've prescribed it hundreds of times.

Tolerability is the main reason. A drug the patient stops taking on day three because of nausea provides zero protection. Malarone is the best-tolerated of the three — most patients report mild stomach upset at worst.

The schedule is short. One tablet daily, starting one day before, ending one week after. The week-after window is the part that actually gets followed. With doxycycline you go four weeks. With mefloquine, four more weekly doses.

No screening branches. No psychiatric history check, no diving exclusion, no age cutoff under 8. Almost every adult is a candidate.

Speed. A patient who walks in three days before departure can start tomorrow. The other two need a longer runway.

The downside is cost — about CHF 50–80 per week of trip. For a 10-day Tanzania safari, that's small change. For a six-month research stay, it becomes prohibitive. That's where I switch.

When I switch to doxycycline

Cost-driven. Specifically when:

• The trip is long (months, not weeks). Daily Malarone for half a year tips many patients to skipping prophylaxis entirely. A doxycycline tablet costs about 20 cents.
• The traveler is a backpacker who specifically asks for it. Cost-sensitive, generally healthy, and the bonus protection against leptospirosis and African tick-bite fever is genuinely useful for adventure travel.
• Malarone isn't an option because of severe kidney problems.

What I tell every doxy patient:

• Take with a full glass of water. Don't lie down for half an hour after.
• SPF 50 every day, hats, long sleeves where you can. Doxycycline makes you sunburn faster.
• Continue four weeks after leaving the malaria area. The rule that gets broken most.
• You can scuba dive on it. The "doxy is bad for divers" myth comes from confusion with mefloquine.

When I reach for mefloquine

Three situations:

• Long trips where weekly dosing is the difference. Six months in rural Africa. Daily dosing isn't sustainable; weekly is.
• Pregnancy in the second or third trimester when travel is unavoidable.
• Patients who already know it works for them — long-term expats and aid workers who tolerate the weekly schedule.

The hard rule: no mefloquine for any patient with a personal psychiatric history. Even mild depression years ago counts. Same for seizure disorder or cardiac conduction problems. Rare neuropsychiatric reactions happen disproportionately to people with vulnerable history.

I also have patients take their first 2–3 doses at home before departure. Any unusual dreams, anxiety, or mood change, we switch them to Malarone before they leave Switzerland.

Quick scenarios

• 10-day Tanzania safari — Malarone. Don't overthink it.
• 6-month research trip in West Africa — Mefloquine, after psych screen and 3-week home trial.
• Pregnancy — Specialist consult. If past first trimester: mefloquine.
• Children — Under 8, no doxycycline. Pediatric Malarone from 5 kg is the cleanest answer.
• Diver — Doxy or Malarone. Mefloquine is out.
• History of depression — Malarone for short trips, doxy for long ones. Mefloquine off the table forever.
• 4-week Southeast Asia backpacker — Doxycycline.

Two questions that come up every time

What if I miss a dose? Take it as soon as you remember the same day. Skip if you've passed into the next day's window. Never double up.

What if I get sick anyway? Prophylaxis reduces malaria risk by ~90%, not 100%. Any fever during or in the three months after travel to a malaria area gets a malaria blood test, immediately. Even if you took every dose perfectly. Non-negotiable.

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If your trip involves complications — pregnancy, kids, complex medical history, immunosuppression — book a consultation. The 30 minutes is worth it.