Malaria Prevention

malaria-prevention Malaria is a potentially fatal disease transmitted by mosquito bites in malarial zones, usually near water. Left untreated, it can kill in a day.

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What is Malaria?

Malaria is a potentially fatal blood borne disease caused by the injection of the Plasmodium parasite into the bloodstream of the host via the anticoagulant/ saliva in the mouthparts of the Anopheles mosquito.

Malaria has afflicted humanity since before recorded history, and drugs to treat it are recorded in Traditional Chinese Medical texts from over 4000 years ago. The Anopheles mosquito which transmits the infection thrives in marshy areas and it was formerly believed that the “bad air” there = “mal aria” was the cause of the disease. This is close to the truth, but not quite correct.

Who is susceptible?

Anyone bitten. Babies and pregnant women are particularly badly affected but anyone bitten can acquire the disease. Some immunity/ tolerance can occur over many years with multiple infections. This is not ideal medicine, but does explain in part the apparent indifference to being bitten by some local people in Malaria zones. The availability or otherwise of local Malaria prevention or treatment are equally likely explanations to the more relaxed attitude of some local people to Malaria, relative to that of overseas visitors.

What is the incubation period?

The interval between mosquito bite and onset of symptoms (incubation period) is between 7 to 30 days.

What are the types of Malaria?

Plasmodium vivax, ovale and malariae are responsible for the main non-lethal types of Malaria and P. falciparum is the type that can kill in a day or so. P. vivax and P. ovale, having a liver stage in their life cycle can re-surface after months or years, with episodic chills and fevers. Pregnant women are especially susceptible to P.falciparum and this infection has grave implications for mother and foetus.

What happens with uncomplicated Malaria?

Classically, (but uncommonly) the patient goes through a number of recurring stages:
First a stage of chills and shivering, then a stage of fever, headache, vomiting and sometimes febrile seizures in young children. Then intense sweating followed by the fever breaking and recovery, leaving the patient exhausted

Basically, patients get a mixture of all of the above plus aches and pains and malaise.
One can see how Malaria is easily misdiagnosed as Influenza in the UK especially away from main cities. Fewer overseas travellers are seen away from the major cities.
Over time the presence of an enlarged spleen, and jaundice may prompt the doctor to ask about overseas travel.

What is Severe Malaria?

Severe malaria occurs when serious organ failure complicates the picture. It is commonly due to P. falciparum. Severe malaria is a medical emergency and should be treated urgently and aggressively in a Teaching Hospital especially if occurring in a pregnant woman. With Cerebral Malaria the patient may behave very oddly and may convulse and enter coma, often in a few hours. Red cells break down rapidly causing profound anaemia and acute renal failure from the red cell sludge. The patient’s life hangs in the balance.

How do Mosquitos track us down?

Mostly they follow a plume of gasses we produce, the main one is in fact Carbon Dioxide.

NO amount of perfume or smelly things you can apply can disguise the fact that you are breathing out CO2.

Mosquitos only have wee little brains but they know their CO2. Strong aromatic oils put them off biting once they alight but they will keep exploring places where you have not applied these.

How effective is antimalarial drug prevention?

Antimalarial drugs taken for prophylaxis by travellers are very effective in general but can delay the appearance of malaria symptoms by weeks or months, long after the traveller has left the malaria-endemic area. (This can happen particularly with P. vivax and P. ovale, both of which can produce dormant liver stage parasites; the liver stages may reactivate and cause disease months after the infective mosquito bite.)

Returned travellers should always remind their health-care providers of any travel in areas where malaria occurs during the past 12 months.

How can I prevent Malaria?

Avoid travel to Malarial zones in the rainy season.
Cover up exposed skin especially at dusk when more mosquitoes are about.
Use DEET impregnated mosquito nets over your bed in heavily infected areas.
Use DEET mosquito repellent on exposed skin.
Use an appropriate Malaria prevention tablet.

What about strong aromatic oils?

In high enough doses, applied VERY frequently eg hourly, these can be quite effective.
Most travellers prefer the convenience of DEET applied less often.

What are the tablet Malaria prevention options?

Atovaquone/Proguanil (Malarone)

What is good about it?

  • Start 1 – 2 days before the trip
  • Finish a week after you leave, rather than take it for a month
  • Ideal for last minute short trips
  • No sunshine interaction
  • Take one a day
  • Covers Chloroquine resistant Malaria

What is bad about it?

  • Expensive
  • Take one a day

Chloroquine

What is good about it?

  • Taken weekly, ideal for longer trips to lower risk areas where there is NO resistant P. falciparum
  • Safe in all trimesters of pregnancy

What is bad about it?

  • P. falciparum resistance common. You can die quickly
  • Must take for a month after you leave the area
  • Can flare up psoriasis
  • NOT ideal for short last minute trips AS must be started 1 – 2 weeks prior to departure

Doxycycline

What is good about it?

  • One a day
  • Start 2 days before departure
  • Some activity for traveller’s diarrhoea prevention
  • Cheap
  • Patient may be on it already for acne

What is bad about it?

  • MUST not be allowed to stay in the oesophagus: ie must be washed down, or oesophageal ulceration may occur
  • Fairly intense sunburn can occur if taking this. CAN avoid by avoiding the sun but this seems to miss the whole point of the holiday…. Strong Sunblock can prevent this sunburn, as can sensible sun restriction eg 11 am till 2- 3 pm
  • Vaginal thrush in women
  • Can cause diarrhoea and other tummy upset
  • Only partial protection against STDs eg Chlamydia, so patient may be unaware of “holiday souvenirs”

Mefloquine (Lariam)

What is good about it? (VERY LITTLE, REALLY)

  • Taken once a week
  • Safe in pregnancy if you do not develop convulsions or insanity
  • Good for long term trips if you are tolerant of it
  • Good news: only 1% develop fits or major psychiatric disturbances

What is bad about it?

  • Sadly, 1% develop fits or major psychiatric disturbances
  • Need to commence 2 weeks prior to departure
  • Need to take for 4 weeks after leaving the area
  • Bad for patients with heart conduction defects

Where does Malaria now occur?

WHO Malaria map (http://www.cdc.gov/malaria/map/index.html).

What about a Malaria vaccine?

Don’t hold your breath.

What do I do if I think I may have caught it?

Do NOT wait till you get home if you have flu-like symptoms in a Malaria zone, whether taking Malaria prevention or not.

Remember the local doctors at your holiday location may not be whizz kids on some UK conditions but they beat us hands down on their own local diseases. Check with your Hotel or the UK Embassy and SEE A DOCTOR.

What is available from Askthedoctoruk?

For the last 12 years the Medical Director has only had occasion to recommend Malarone.
So Malarone it is.

What is the Malarone preventative dose?

One a day for 2 days prior to arrival and a week after departure.
The pack size is 12, so for a week’s holiday you will need two packets.

Price List

Medication Strength per dose Pack size Price £
Malarone up to 1 week trip 250mg 15 55
Malarone 2 week trip 250mg 24 74
Malarone 3 week trip 250mg 30 90