Malaria is a potentially fatal tropical disease spread by mosquitoes that is still largely misunderstood by many travellers. This ultimate guide is here to give all backpackers all the information they need to protect themselves against malaria on their gap year and understand the importance of antimalarials.
Malaria is an potentially fatal yet entirely preventable mosquito borne illness, yet despite this almost half of travellers to at risk regions don’t protect themselves adequately enough. According to the World Health Organisation there were 212 million new cases of malaria worldwide in 2015, with 429,000 malaria deaths, with Africa accounting for 90% of those cases and 92% of deaths.
In 2016 alone a total of 1,618 cases of Malaria were reported in travellers bringing Malaria back into the UK from at risk areas, and of those cases 6 were fatal.
Of the 65.7 million UK travellers who head abroad regularly every single year that number may not seem like much, but since it can only take a single bite from an infected mosquito to contract malaria for every single one of those travellers in an at risk area it is essentially a role of the dice every day they are travelling.
Despite a lot of progress in treating and preventing malaria it is still a significant risk for any traveller heading out on their gap year, but with the right information, knowledge and preparation travellers can make fully informed decisions about protecting themselves from this disease.
What Is Malaria?
Malaria is a tropical disease caused by a parasite known as Plasmodium. This parasite is spread by the bite of an infected female Anopheles mosquitoes which most commonly bite between dusk and dawn.
There are four primary types of plasmodium parasite that cause malaria in humans, but plasmodium falciparum, mainly found in Africa, is the most deadly.
Once you’re bitten by an infected mosquito the parasite enters the bloodstream and travels to the liver. The malaria infection incubates in the liver and then re-enters the bloodstream and invades the red blood cells.
What Are The Symptoms Of Malaria?
Symptoms of malaria include sever flu like symptoms such as shivering, chills, coldness, a dull muscular ache, mild to severe fever, rash, headaches, diarrhoea and vomiting.
The big problem with symptoms of malaria is that many of them are very general and common to a wide variety of other bugs and viruses, and this is the reason that it is very often misdiagnosed. You can develop one symptom or all, and there is no general pattern.
They can also occur anytime, most often up to fifteen days after the actual bite but can in some people take up to 4 weeks. Help should be sought if symptoms are developed up to a year after being in a high risk area as if they are not recognised and treated promptly, malaria does have the potential to cause serious long term damage to the liver or even be fatal.
Where Am I At Risk Of Contracting Malaria?
About half the worlds population is at risk from malaria, which occurs primarily in tropical and subtropical regions where it is hot and humid. These conditions allow both the Anopheles mosquito can survive and the malaria parasites can complete their growth cycle, which they cannot do below 20°C. Essentially the at risk zone sweeps across the center of the world map near the equator.
It is important to remember that even in countries where malaria is present, there may be different risk factors in different parts of that same country and in other parts transmission may not occur at all.
For much more detailed information on specific risk status for different regions, the CDC has a world malaria map and Fit For Travel have excellent malaria maps for specific countries. These are the best resources for finding out for yourself whether the places you are heading to have a high risk or low to no risk of malaria.
How To Avoid Contracting Malaria.
Official NHS advice on avoiding malaria follows a simple A,B,C,D approach.
- Awareness of risk – Being aware of the risks involved and how to protect yourself is the most important aspect of protecting yourself. Speak to a professional in a travel clinic or GP surgery and find out whether you’re at risk of getting malaria before travelling.
- Bite prevention – avoid mosquito bites as much as possible using as many methods as possible.
- Check whether you need to take malaria prevention tablets – if you do,make sure you take the right antimalarial tablets at the right dose, and finish the course.
- Diagnosis – seek immediate medical advice if you develop any symptoms of malaria, as long as up to a year after you return from travelling.
In certain circumstances there is also a fifth letter, E, added to the procedural advice.
- Emergency Standby Treatment – If you are travelling somewhere remote or where medical facilities aren’t easily available or accessible, then you may have the option of carrying a course of emergency standby treatment.
Mosquito Bite Prevention.
One of the best ways to reduce the risk of contracting malaria, or any other mosquito borne disease such as zika, dengue, Japanese encephalitis or a whole host of others, is making sure that you aren’t bitten in the first place. Or at the very least taking steps to reduce the risk as much as possible.
Wearing the right clothes.
Wearing the right clothes is essential when trying to prevent mosquito bites. The official advice is often to wear long sleeve tops and long trousers, particularly between the hours of 9pm and 5am which is when the female Anopheles mosquito (the breed that carries malaria) bites, and particularly when near bodies of water or hot and humid environments.
It is also a good idea to use clothing that has a strong thick weave (which makes it less likely that mosquitoes can bite through it) and is also treated with permanent insect repellent. There are a range of brands that sell clothing like this.
Staying in the right accommodation.
Staying in any room or accommodation that is fully sealed with air conditioning or insect repellent screens on any windows or doors significantly (but not completely) reduces the chances of mosquitoes getting around you to bite you in the first place.
Be careful of standing water.
Mosquitoes lay their eggs in stagnant or still water, so if you are staying near any old air con units that may have pooled water, swimming pools that aren’t cleaned regularly, large puddles or anywhere that water has collected then take extra precautions.
Using a net.
A good mosquito net that has been fully treated with permethrin has been statistically proven to significantly reduce the chances of being bitten by a mosquito, and sleeping under one when you are in a high risk malarial area is always a good idea.
There are a variety of insect repellents and brands available to travellers, but not all of them are equal, or even effective.
The only repellents that are clinically recommended are those which contain 20% to 50% of the active ingredients DEET, Picaridin, PMD or IR3535.
DEET is the gold standard for mosquito and other biting insect prevention and although some travelers do not like the idea of putting chemicals on their skin clinical evidence suggest that it is the single most effective option and very safe, and is the primary repellent recommended by the Advisory Committee For Malaria Prevention In Travellers (ACMP) for areas with a high risk of malaria.
Repellents containing Picaridin, a synthetic molecule based on a chemical found naturally in black pepper plants, are a good alternative to DEET.
Research suggests that repellents containing at least 20% Picaridin can repel mosquitoes as well as DEET can, but will need to be reapplied more regularly, every 4 to 6 hours. Like DEET, any concentration less than 20% is not considered effective, so always use concentrations between 20% and 50%.
PMD Oil of Lemon Eucalyptus.
PMD (p Menthane – 3, 8 – diol) is a natural by product of the distillation process of the leaves of the Lemon Eucalyptus tree, and Oil of Lemon Eucalyptus is a refined oil with a minimum of 64% PMD, which is the active ingredient that works effectively as a repellent.
This is not to be confused with the ‘natural repellents’ lemon oil, lemon essential oil, lemon eucalyptus essential oil or any other alternative, as none of these are approved or recommended in countries with disease carrying mosquitoes.
This is because whilst PMD is present in these repellents, it is not present in a large enough quantity to be considered effective.
PMD Oil of Lemon Eucalyptus has at least 64% PMD, and this provides similar protection to DEET against Aedes, Culex and Anopheles mosquitoes, and it is a good natural alternative to DEET. The only problem is that it does not last as long and will need to be reapplied more often. Every 4 – 6 hours instead of the 6 – 8 needed for DEET.
IR3535 is a synthetic amino acid that has been shown to be effective against several types of mosquitoes that carry Zika, Dengue and other diseases, but is not as effective as DEET at the same percentage and needs to be applied more regularly. It is also not recommended where malaria is a risk factor as it is not effective against Anopheles mosquitoes.
You should apply repellents to all exposed skin when outside and reapply regularly as needed dependent on the strength you are using.
What doesn’t work.
A lot of people swear by a variety of alternative methods for avoiding mosquito bites including herbal remedies, homeopathy, buzzers, vitamin supplements, garlic, tea tree oil and many more. There may be some anecdotal evidence from other travellers but let me be clear, there is no scientific or clinical evidence that any of these methods work at all and as a medical professional I cannot recommend any of them as a method to prevent or treat malaria.
If you are travelling to an area with a high risk of malaria then on top of the preventative methods above, you will probably also need to take antimalarial prophylaxis.
Antimalarials are generally very highly recommended by travel health professionals in areas that are at high risk of malaria. They don’t stop you from getting bitten by infected mosquitoes which is why other preventative measures are still important, and they do not prevent infection from the parasite either. What they do is suppress the symptoms of the disease and kill the parasites in the liver or as they reenter the blood stream, essentially killing the disease before it affects you.
Do You Really Need Antimalarials?
Whether you take antimalarials or not is a personal decision that every individual traveller must make for themselves.
It is extremely important that all travellers visit a Travel Clinic or speak to their GP, Nurse Specialist or Pharmacist before they go as travel health professionals will take into account a variety of factors on whether they will recommend antimalarials or not, and will know the latest updates on outbreaks, medications and disease resistance in mosquitoes.
Travel health professionals will take into account various factors, including but not limited to:
- Is malaria present in the destination?
- Whether the destination (or areas within that destination) is high risk or low to no risk.
- The amount of time spent in at risk areas.
- The type of travel and activities you will do when you are there.
- If you are in a high risk activity group (volunteering, spending significant amount of time in rural areas, hiking).
- If you are in a high risk personal group (young children, pregnant women, the elderly).
- Any relevant medical history.
- Any allergies.
- Any current conditions or medication.
- Any problems with antimalarials in the past.
- And other individual factors.
Very basically speaking, if you are spending any amount of time in a high risk area and a travel health professional recommends you take antimalarials, then you should take that recommendation as a strong one.
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.
But it is essential that you seek qualified medical advice before you make that decision.
Types Of Antimalarial.
There are a variety of antimalarials available under an even wider variety of brand names, but the primary medications are:
The main types of antimalarials used to prevent malaria are described below.
Atovaquone plus Proguanil (also known as Malarone).
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, women who are breastfeeding 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 dependent on the childs weight. It should be started two days before you travel and taken for a week after you return, and is recommended for periods of 28 days but can be used for up to a year. It is also relatively expensive compared to other anti malarial tablets so may be useful on shorter trips.
Mefloquine (also known as Lariam).
This is a tablet that is taken as a 250 mg tablet once a week. The child dosage is again the same frequency but dependent on weight. It should be started three weeks before you travel, taken throughout travel through an at risk area 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, an it is not recommended for anyone with a past medical history of heart or liver problems, epilepsy, seizures, depression or other mental health issues. Mefloquine has gained quite a bad reputation because of these side effects, but the benefits of taking the anti malarial outweigh the risks for many who are not subsceptible to them. Many people take this medication quite safely, but the side effects if you are susceptible to them are severe, so it is strongly recommended that you do a three week trial at least two months before you travel to test if you develop any side effects.
Doxycycline (also known as Vibramycin D).
This is a 100mg capsule taken daily. You should start the course two days before you travel, every day you are travelling and for a month after you return.
This is one of the most popular antimalarials because it is relatively cheap compared to other anti malarial tablets and the side effects – for those that do get them, not everyone will – are not as severe as others.
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 is also not recommended for those who are allergic to tetracycline antibiotics or those with liver problems.It can also reduce the effectiveness of combined hormone contraceptives such as the pill.
Chloraquine And Proguanil.
This combination of antimalarials are rarely recommended because they are largely ineffective against the most common and dangerous type of malaria parasite, Plasmodium falciparum. They are sometimes recommended for destinations where this parasite is not as common such as India or Sri Lanka.
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.
Stand By Emergency Treatment (SBET).
This is not common for the average traveller but can be prescribed to those in certain at risk groups such as volunteers, medics working in relief areas or those working in remote areas where there is little or remote access to medical facilities but the risk of malaria is high. If you are in one of these at risk groups then your GP or practice nurse will discuss these options with you.
Examples of emergency standby medications include:
- Atovaquone with Proguanil
- Artemether with Lumefantrine
- Quinine plus Doxycycline
- Quinine plus Clindamycin.
This medication will be given on top of your preventative antimalarials and are not a replacement for them. They are to be taken if you start to develop symptoms of malaria up to a week after being in a malarial area and cannot get to a medical facility. You should still seek medical assistance as soon as possible.
Your SBET medication will be prescribed specifically for you as an individual and are not suitable for anyone else, likewise you should not take mediction prescribed for someone else. Your GP or nurse will discuss the specifics with you based on your individual needs.
What About The Side Effects?
One of the primary reasons most travellers give for not taking antimalarials when they should be is fear of the side effects, and there are so many exagerations, half truths and misinformation out there that these fears are rarely justified.
All medications have potential side effects. All of them. Antimalarials are no different.
Some of the side effects of some antimalarials – Lariam in particular – are pretty serious, but it is extremely important to remember two things about that.
First, not every antimalarial is the same. Just because one antimalarial has a specific side effect that doesn’t mean others will.
Second, the word ‘potential’ is very important. Just because there is a potential for side effects that does not mean everyone will get them, and for those that do that does not mean they will automatically be severe.
In fact many people won’t get side effects at all, and for the few that do the majority of those will only suffer very mild to moderate symptoms.
So when you weigh that up against the chances of getting malaria, it isn’t all that bad after all. So if you are headed to a high risk area and a medical professional strongly recommends that you take antimalarials, don’t let fear and misinformation stop you from listening to that advice.
Is There A Vaccine For Malaria?
No. Not yet. Not for widespread use anyway.
The WHO has for the first time approved a vaccine specifically for children in at risk areas, known as RTS, S, or the brand name Mosquirix, but this is not yet in widespread use nor as of yet recommended for general use for travellers.
There are currently ongoing clinical trials to test a variety of malaria vaccines that can be used on a wider scale and the results do look promising, but at the moment the efficacy is not good enough to consider the vaccine ready.
Right now the only way to protect yourself against malaria is by minimising the risk of being bitten as much as possible, and taking anti malarial medication in high risk areas.
Malaria is a potentially fatal yet constantly underestimated tropical disease, and one that many travellers are at risk of around the world. Having the right knowledge, taking the right precautions and listening to medical professionals advice on the importance of antimalarials are all essential in reducing and negating the risk as much as possible.
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