Malaria is a tropical disease that affects millions of travellers every single year, yet there is so much confusion around antimalarial protection that almost half of travellers leave themselves at risk. The big question is how important are antimalarials when you travel and should you take them when you do?
Travelling the world is an amazing journey, filled with wondrous sights, amazing experiences and exciting adventures. It has its highs and lows, its good times and its bad times and a whole array of issues that divide and bring together travellers of every nationality, creed and description, but the one thing that unites all backpackers in a cohesive whole of seething hatred, the one thing all world travellers agree on, is that mosquitoes are a bloody pain in the arse!
Most of the time they are an irritation, leaving us with annoying and sometimes painfully itchy welts on our skin and causing most of us to spray clouds of chemicals all over ourselves as we get the DEET spray out and sleep under permethrin coated nets, but depending on where you travel there can be a much more serious side to the mosquito issue too. Malaria.
This isn’t one of the happiest travel related topics, but it is one of the most important ones, and one that I get a lot of questions and emails about. Malaria is an issue that scares a lot of potential backpackers, often through a lot of misinformation and lack of education on the topic as much as any practical concerns about the disease. This is especially true when it comes to taking antimalarial tablets to protect themselves. Anti malarial medication, or prophylaxis as it is technically called, has been the cause of debate amongst travellers for a long time now, do you need to take it or don’t you? Are the side effects worth it?
Well the simple answer is yes, if you are travelling in an area that is a high risk and especially if you are spending an extended amount of time there. But the debate is often far more complex than that.
What is malaria?
Malaria is a potentially fatal disease that is spread exclusively through the bite of the female Anopheles mosquito. It is caused by a parasite called Plasmodium, which multiply in the liver and then affect red blood cells.
There are essentially four primary types of plasmodium parasites that affect humans.
- Plasmodium Falciparum,
- Plasmodium Vivax,
- Plasmodium Malariae,
- Plasmodium Ovale.
There is also plasmodium knowlesi found in macaques which is a cause of zoonotic malaria in humans and is found in in South East Asia.
Basically speaking, the top two – falciparum and vivax – are the most common and are unfortunately also the most dangerous in humans. Malaria is prevalent throughout tropical and sub tropical regions, and outbreaks of various intensities and length are common in many countries throughout these regions, so the ‘danger zones’ can often wax and wane.
Symptoms of malaria.
Symptoms of malaria include sever flu like symptoms such as shivering, coldness, a dull muscular ache, mild to severe fever, rash, headaches, diarrhoea and vomiting. They can occur anytime, most often up to fifteen days after the actual bite but can in some people take up to 4 weeks.
When to seek medical attention.
The big danger of these initial symptoms is that they can be very difficult to actually recognise as malaria, and if not treated promptly it does have the potential to cause serious long term damage to the liver or even be fatal. Diagnosis can only be made by health professionals taking a blood sample so it is important that you get yourself to adequate medical facilities as soon as possible if you suspect you have contracted the disease.
If you develop any of the above symptoms during or after your trip, even if it is a few months after, then go and get a blood test from your GP, specialist nurse, travel clinic or nearest medical facility as soon as possible.
What vaccines or medications are available?
There is no vaccine. A little blunt but true nonetheless. There are current clinical trials that are testing some potential vaccinations that are expected to publish results in 2015, but at the moment the only way to protect yourself against malaria is by minimising the risk as much as possible, and that involves taking anti malarial medication. There are a range of antimalarial prophylaxis available, and they are used to both prevent and to treat malaria.
Atovaquone plus Proguanil (also known as Malarone and a variety of brand names).
This is a common and popular anti malarial due to the fact that it has relatively few and mild side effects compared to others. Possible side effects include headaches, mouth ulcers, rash and sometimes intestinal upset. It is not recommended for pregnant women during the first trimester or those with kidney problems. The adult dose is one tablet taken once a day every day you are travelling, and the child dose is also once a day but at a lesser strength. It should be started two days before you travel and for a week after you return. It is also relatively expensive compared to other anti malarial tablets so may be useful on shorter trips.
Mefloquine (also known as Lariam and a variety of brand names).
This is a tablet that is taken once a week. It should be started three weeks before you travel and four weeks after you get back. Serious side effects are rare, but do include depression, anxiety, psychosis and seizures, insomnia, panic attacks and hallucinations amongst others. Mefloquine has gained quite a bad reputation because of these side effects, but the benefits of taking the anti malarial outweigh the risks. Many people take this medication quite safely, but the side effects if you are susceptible to them are sever, so it is strongly recommended that you do a three week trial at least a month before you travel to test if you develop any side effects.
Doxycycline (also known as Vibramycin D and a variety of brand names).
This is a capsule taken daily. You should start the course two days before you travel and take it for a month after you return. This is popular because it is relatively cheap compared to other anti malarial tablets and the side effects are not as severe. It can cause increased susceptibility to sunburn in some people, as well as heartburn, stomach upset and thrush, and is not recommended for pregnant women or children under 12 at all. It can also reduce the effectiveness of combined hormone contraceptives such as the pill.
Chloraquine (also known as Avloclor and and a variety of brand names).
This is one of the most common anti malarials and the normal dose is 2 tablets once a week, started one week before you leave, throughout your trip and for 4 weeks afterwards. There are a wide variety of potential side effects which may include nausea, diarrhoea, headache, rashes, skin itch, blurred vision, hair loss, dizziness, mood change, sun sensitivity or seizures. Those with kidney or liver disease should be assessed carefully before taking this medication and it is normally not recommended for long term use.
Proguanil (also known as chlorguanide, chloroguanide and and a variety of brand names).
The normal dose is a 200mg tablet daily and is generally safe for long term, extended use. One or two doses should be taken before departure, continued throughout your trip and for 4 weeks afterwards. It is very important to complete the course. Side effects may include: anorexia, nausea, diarrhoea, constipation, skin itch and mouth ulcers.
This list is not comprehensive and does not include the variety of combinations or brand names available in other countries. Some countries and regions have developed varying degrees of resistance to some, so not all prophylaxis will be recommended for all areas. It is essential you speak to your GP or nurse practitioner who will be able to use your medical history and clinical judgement to determine which drug is right for you as an individual.
Do you need to take them?
There are a number of things you need to consider about your own individual trip and circumstances as to what the answer will be, but to be honest this is a personal decision that you will have to take for yourself. All I can do as a health professional is give you all the facts, the pros and cons, then recommend you take them if the situation warrants it; but the final decision on the risk management is down to you.
The first thing you should do is weigh up the risk of where you are going. The excellent malaria map at the Centre of Disease Control (CDC) website or the malaria maps for specific countries at the Fit For Travel website are both excellent resources for finding up to date and current information on high, medium or low risk areas, or where there are currently any outbreaks of the disease.
When you know what your destination or destinations are, ask yourself these questions.
- Are you travelling in a tropical country where malaria is present?
- Are you travelling in parts of that country or countries where the risk of contracting malaria is high?
- Will you be spending more time in the high risk parts of each country such as rural regions, than you are in the lower risk regions such as major cities?
- Are you in a high risk group? (Such as volunteers or those spending significant amounts of time in rural areas for trekking or activities for example).
The more ‘yes’ answers you get to these questions, the more likely it is that you should take some form of anti malarial tablet, conversely the less ‘yes’ answers you have, the more likely it is you won’t need them.
You should also assess how much risk you will be in. If you are travelling for an extended period in rural or jungle areas, especially near bodies of water, or are working or volunteering for extended periods in areas where malaria is present everywhere, then you will be at significantly more risk of contracting the disease than if you were simply in a major city for a few days and your exposure to malarial areas limited, and you should act accordingly.
Basically speaking, if you are travelling in a tropical country (usually a red zone on a malaria map) or an area where malaria is present everywhere, and you are in a high risk group or staying in that area for a long time, then it is strongly recommended that you take anti malarial medication.
If you are travelling through a country or region where malaria is only present in small areas, and your exposure to these areas is limited, then it isn’t always necessary to take prophylaxis.
Another thing to consider is the potential side effects of each medication. This is the big issue amongst many long term travellers and one of the big reasons some travellers don’t take them. For some people, this is the right choice too as the side effects (ranging from hallucinations to depression and anxiety amongst many others) can be severe in a small percentage of people and the cons of taking the medication outweigh the pros. Even mild side effects such as sensitivity to sunlight or nausea or diarrhoea can make taking the medication unpleasant at best and not worth it if the exposure risk is minimal.
The best thing to do is to go and speak to your GP or even better a specialist travel nurse at a travel clinic. Researching is essential but can only get you so far. Speak to the professionals who will be able to examine you and tailor this advice on your specific medical history as well as your own unique individual needs.
Any good examination and prescription should take into account a wide range of factors including (but not limited to):
- Your destination (or destinations) as some antimalarial medication will not be suitable in all areas,
- Your potential risk of exposure,
- Your age and general health,
- Relevant medical history (both yours and your family history – if relevant)
- Any allergies that you may have,
- Current or recent medication regimes (including birth control),
- Other physical factors such as pregnancy.
Go at least 6 weeks (preferably longer) before you plan to start your trip, as this will allow you time to get the right information and make an informed decision, and also take a three week short course of anti malarials (if you have never taken them before) to see if you develop any side effects. Trust me, the last thing you want to do is leave it until the last moment and then find out you are having severe panic attacks and seeing pink elephants on the night train to Mumbai once you are on your travels!
Mosquito avoidance and prevention measures.
Regardless of whether you decide to take antimalarials or not, and regardless of whether the country or region you are travelling in has malaria in all or just some areas, you should always – in every circumstance and without fail – use a variety of preventative measures to stop the little buggers from biting you in the first place! Never has the expression prevention is better than a cure been more apt, because if they can’t bite you, they can’t infect you! Luckily there are a whole variety of ways to help you do this.
Air conditioning, screening and nets.
Air conditioned hotel rooms are generally safe from mosquito bites provided that windows are left shut. They are not completely bug free, but they are more secure than most rooms. If you are staying somewhere without air conditioning, check that windows or doors have at least mesh insect screens on them. If your accommodation has none of these and you are essentially at risk, then you should try and sleep under a mosquito net where you can. These are available to buy almost everywhere, and if you buy one in the UK before you go, it should already be pre treated with permethrin, a solution that kills insects on contact. If your net is old or you cannot be sure if it has been pre treated, then you can get permethrin solution to soak it in. Nets should be treated like this every six months.
DEET sprays are extremely effective at repelling mosquitoes and other biting insects. Clinical evidence suggest they are very safe. There are a variety of strengths right up to 100% but it is generally not necessary or recommended to use a concentration any greater than 50% DEET. You should apply repellents to all exposed skin when outside and reapply regularly as needed dependent on the strength you are using.
Repellents containing natural ingredients are also popular among many backpackers who may not like the idea of using a load of chemicals, but evidence suggests that whilst some do work, they do not work for as long as DEET based products and need to be reapplied more regularly.
Loose fitting, light cotton clothing should be worn. Cover up as much skin as is comfortable. Long trousers and at least a T shirt is best. Malarial mosquitoes are more active at night, particularly at dusk and dawn, so it is wise to cover up more during these times.
Coils and plug in devices.
Mosquito coils release an insecticide when burned and are effective if sitting outside on a balcony. They should not be used indoors. Electronic plug in devices are available to use inside, and release an insecticide spray.
You can start to see why it is such a confusing issue for many people, as the very personal choice of whether to take antimalarial prophylaxis or not is based on a risk assessment of a wide variety of factors, and whilst as a medical professional I can advise, inform and recommend airing on the side of caution, I cannot and would never try to force you to take them. That decision is wholly down to you.
I hope that this short article has at least provided you with some of the information or answers you need, but no article can be completely thorough especially in a diverse a field as health care issues. So please if you have any questions please feel free to ask me below or email me if you prefer. Remember I am here to help and offer advice to all first time or even experienced backpackers out there. I am a qualified nurse as well as a backpacker and I will do my best to help, or at least point you in the right direction if I can’t.