Malaria is one of the major fears facing most travellers deciding to travel the world and a source of massive confusion regarding treatment and prevention.
Do I take prevention or not? Most of us have all heard the stories of: “I took anti-malarial medication and still got malaria” or “I have never taken the medication and never got malaria”.
These are all common tales from friends and family, but the decision to take Malaria prophylaxis ultimately rests with you and your doctor. Here I will try to simplify some Malaria information so you can better plan your travels….
What is Malaria?
Malaria is an infectious disease spread by mosquitoes that carry the protozoan called Plasmodium. Plasmodium passes into the blood stream through a mosquito bite, from where it first infects the liver and then the red blood cells. It is only transmitted by the female Anopheles mosquito, which is most active in the early morning and evening, but bites the whole night.
There are four different kinds of malaria that regularly infect people:
• Plasmodium falciparum
• Plasmodium Vivax
• Plasmodium malariae
• Plasmodium ovale
Each of these strains varies in their severity and in their distribution across the globe. Out of these four, Plasmodium falciparum and Plasmodium vivax are the most common and Plasmodium falciparum is usually the most serious.
What are the first signs of being infected?
The symptoms of malaria usually only appear after about 1 week to a month after being bitten, but can even appear later in those who have taken anti-malarial medication. It usually presents as flu-like symptoms such as headache, swinging fevers, joint pain and shivering, and less often with vomiting, jaundice (yellow colour of the skin) or seizures. The swinging fever is typical of malaria with periods of coldness followed by a sweating fever.
• Any neurological change such as seizures, abnormal posturing, decreased consciousness
• Problems with breathing
• Severe anaemia –not easy to diagnose unless at a doctor, but patient may look severely pale.
When to see a doctor:
Anyone who suspects they may have malaria should see a doctor as soon as they can, even the doctors! It is necessary to make an accurate diagnosis of malaria, which is done on a blood sample at a laboratory. This ensures you are treating the correct illness, helps to bring down the problem of resistance, and gets you the right help early on.
Malaria is often curable but unless treated early it can rapidly complicate to infect your brain (cerebral Malaria), cause kidney failure, low blood sugar, an inability to clot your blood (coagulopathy) and shock.
Do not be afraid of foreign doctors here- the doctors in the malaria areas are often well equipped to treat this disease and have plenty of experience! If you are no longer in a malaria area make sure you tell the doctor treating you that you have been travelling to one.
Primary prevention of malaria is by preventing infection by the plasmodium by wearing long sleeves and long pants at high-risk times, by sleeping in a mosquito free room or under a mosquito net and by using insect repellent.
Malaria can also be prevented by taking prophylaxis tablets, before, during and after your stay in a high-risk area. The CDC recommends that if travelling to low risk areas to only use preventative measures and that no medication should be prescribed.
The tablets are as follows and all need to be prescribed by a doctor or travel clinic:
o Chloroquine: This medication can still be used where the parasite is not resistant, but resistance is widespread and increasing. Start taking 1-2 weeks before travel to malaria area, by taking one tablet each week and for 4 weeks after leaving. Price ±$ 30 per 100 tablets
o Atovaquone –proguanil: Begin taking 1-2 days before travel to malaria areas, by taking one tablet at the same time each day. Take with food. Price: ± $60 for 12 tablets. Not many side effects.
o Doxycycline: begin by taking 1-2 days before reaching the malaria area and take daily until 4 weeks after leaving the area. Can cause abnormal tanning in response to the sun. Cost: Cheap, and can be taken long term. Price: ± $40 for 100 tablets. This is the tablet I would recommend for people travelling overland who will be in the areas for extended periods of time.
o Hydroxyl-chloroquine sulphate: Can be used in place of Chloroquine, but only in Quinine sensitive areas. Start taking 1-2 weeks before travel to the area, take weekly on the same day and for 4 weeks after leaving the area. Price: ±$ 50 for 100 tablets.
o Mefloquine: Use in mefloquine sensitive areas and begin 2 weeks before reaching the area. Has got psychiatric side effects, and not for use with cardiac abnormalities. Price: ± $150 for 100 tablets.
o Primaquine: Can be used for prophylaxis, but only on short trips to areas with mostly P. Vivax malaria. Start 1-2 days before travel to area and take daily at the same time until 7 days after leaving the area. Price: ± $60 for 100 tablets (two tablets needed for one dose).
Where will I be traveling?
(see more detailed information at: http://www.cdc.gov/malaria/travelers/country_table/a.html)
Image: Map of the malaria distribution in Africa (www.who.int)
• Types: P. falciparum (majority), P. malariae, P. Ovale, P. Vivax
• Prevention medication:
o Atovaquone – proquanil
• There is widespread resistance to Quinine (yes, unfortunately Gin&Tonic no longer works)
• Types: Mostly P. vivax, also P. falciparum
o Primaquine in Bolivia, Panama, Paraguay.
o Chloroquine in Belize
• Resistance to Chloroquine in most areas.
South-Eastern Asia and Middle East:
• Types: P. vivax, P. falciparum, P. Malariae, P. ovale(rare)
• Resistance to Chloroquine
The treatment of malaria is different from the prophylaxis, as mostly tablets need to be combined for effective treatment. This should be started as soon as possible after the diagnosis is made, or if you are travelling remotely you should carry a few days’ treatment on you and start as soon as you suspect malaria. This should just be emergency treatment to cover the time it will take you to get to a doctor.
The best treatment against P. falciparum is an artemisinin based therapy known as ACT. Treatment should be managed by a medical professional and all drugs prescribed should be by a doctor (even the few days emergency medication you carry with you)
What to pack:
• Pack long-sleeved tops to wear in the evenings and a pair of trousers to cover your legs.
• Insect repellent for your skin
• Insect repellent for fabrics and paints (see http://www.vitalprotection.co.za/) – these last up to 3 months on fabric and can be used for your clothes, tent and mosquito net.
• Malaria prophylaxis tablets if you decide to take them.
• Rapid malaria test kits – these small packets contain a rapid malaria test that can be used by testing blood from a finger prick. If you will be travelling to remote areas – ask your travel clinic about these and learn how to use it.
• 3-4 days emergency malaria treatment as prescribed by your doctor if you will be travelling to remote areas.
Should I immunise?
There is currently no immunisation against malaria, but a few are in the pipe-line.
Whatever you decide regarding malaria prevention, remember that although prophylaxis is not 100% effective it may help to prevent any serious complications from severe malaria. I hope this helps clear things up and good luck travelling!
*Please note that this advice may change and that the opinion of your doctor should take precedence. You should please consult your doctor if you are pregnant as the management changes or if you have any medical allergies.