malaria alert

by Jenny Bryan and Matt Brooker

Malaria is perhaps the greatest health hazard for people travelling to tropical countries and there is no vaccine against the mosquito-borne parasite that causes the disease. When visiting areas where malaria is known to be prevalent you will need to protect yourself: the only sure way to avoid malaria is to avoid mosquito bites.

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medication

The primary defence against malaria is against mosquitoes: sensible clothing, the use of insect repellents and mosquito nets (see travel bugs). There is no 100% effective anti-malarial drug but they do greatly reduce the risk of contracting the disease. Your GP, local travel clinic or MASTA (see help and info) will have up-to-date information and will be able to advise of the appropriate drug for your trip. The drug recommended will depend upon:

• Areas you are visiting – affected regions include parts of Central and South America, Africa, and Central and South East Asia. The effectiveness of drugs varies depending on the region as the malaria-causing parasites differ.
• Duration of your stay – the level of risk is directly proportional to the length of stay.
• Types of trip – backpackers are at a higher risk as they may visit a number of different regions and are more likely to have close contact with mosquitoes e.g. trekking and accommodation without protective screens and air-conditioning.
• Physical condition – perversely, whilst pregnant travellers are limited as to which drugs they should take, they are at greater risk of contracting malaria (possibly due to giving off more CO2 which attracts mosquitoes). If contracted, malaria is more likely to cause serious illness in immuno-suppressed travellers (these include pregnant women and young children).

By getting current medical advice well in advance of your trip, you give yourself the opportunity to obtain best course of medication for your situation. It's worth noting that advice given in the UK may well conflict with that given in other countries due to differing drug-resistance patterns in different countries.

commonly used drugs

• chloroquine (Avloclor, Nivaquine): started one week before entering an endemic area, two tablets are taken weekly during the visit, and continued for four weeks after leaving.
• proguanil (Paludrine): used as an alternative to chloroquine and also started one week before entering an endemic area, two tablets are taken daily during the visit, and continued for four weeks after leaving. In countries where there is some resistance to chloroquine, proguanil and chloroquine are both taken.
• mefloquine (Lariam): in areas where there is high resistance to chloroquine, it is started at least one week, and preferably two to three weeks, before entering an endemic area, one tablet is taken weekly during the visit, and continued for four weeks after leaving.
• maloprim: taken with chloroquine as an alternative to mefloquine for travellers in Australasia and the Pacific islands where there is malaria. Started one week before entering an endemic area, one tablet is taken weekly during the visit, and continued for four weeks after leaving.
• atovaquone/malorone (Malarone): once-a-day tablet with the advantage that it can be started the day before arriving in a country where malaria is endemic and only needs to be taken for one week after leaving.
• doxocycline (Vibramycin): recommended when travelling in countries where there is significant resistance to other anti-malarial drugs, or for those people who cannot take other agents. Treatment should start a few days before entering an endemic area and be continued for four weeks after leaving.

side effects

Anti-malarial drugs have side effects, like many other medicines. It is advisable to take all of these drugs after meals to help minimise side effects.

Chloroquine and proguanil may cause gastric upset and are best taken at night, after the last meal. People with epilepsy should not take chloroquine, and proguanil can affect the dose of blood thinning agents that people require, so this should be discussed with a doctor. Mouth ulcers can be a problem when chloroquine and proguanil are taken together.

Doxycycline may cause the skin to become extra-sensitive to the sun. Be careful not to take it on an empty stomach last thing at night, or to lie down for half an hour after you have taken it, and always wash it down with a glass of water.

People tend to be most concerned about the possibility of hallucinations and other psychiatric problems if they take mefloquine. Research carried out by MASTA and the London School of Hygiene and Tropical Medicine (see help and info) suggested that about 1 in 140 people (approx 0.7%) taking mefloquine will experience temporarily disabling neuropsychiatric side effects. These tend to occur after the first few doses. People are advised to start treatment two to three weeks before travelling so that alternative treatment can be used if problems do arise.

symptoms and treatment

The symptoms of malaria include headache, depression, chills with sweating and fever. The incubation period for malaria is usually a minimum of a week after the infected bite.

The first rule is to seek professional medical help immediately in all suspected cases of malaria. If you have been in an affected region for a week or more and develop flu-like symptoms or fever, even up to a year after returning home, assistance should be sought straight away and you should tell your doctor that you have been travelling in a malaria risk area. Any delay could be costly. In certain instances this is not possible and first aid must be applied – this should however only be used as an interim measure until medical help is available.

Self-treatment kits for emergency first aid are available for those who will be in an infected area for over a week and may find themselves more than 24 hours from medical treatment. Professional advice should be sought when choosing a kit to ensure the full details for use are explained. Some licensed drugs are available specifically for self-treatment kits but often they consist of the same drugs that are prescribed for prevention. It is crucial that the "emergency" drug is not the same drug you are taking as preventative medication.

Each year, about 2,000 travellers develop malaria after entering or returning to the UK and on average nine cases are fatal. All too often the disease could have been avoided. By taking steps to avoid mosquito bites and the use of protective medication, the risk of contracting malaria can be minimised and travellers can concentrate on enjoying their trips.

help and info

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organisations

Hospital for Tropical Diseases – Department of Travel Medicine
Mortimer Market
Capper Street
London WC1E 6JD
Switchboard: 020 7387 9300
Travel clinic: 020 7388 9600
Website: www.uclh.org/services/htd/index.shtml
Travellers Healthline Advisory Service: 09061 33 77 33 (calls are charged at 50p per minute and should last on average 7-8 minutes.)
Fax-back Info Service: 09061 991 992 (calls are charged at £1.50 per minute and should last on average no longer than 2 minutes)
Provides pre-travel advice, including up-to-date information on anti-malarials and prophylatic drugs, consultant led clinics and post-tropical screening.

HPA Malaria Reference Laboratory (formerly PHLS)
London School of Hygiene and Tropical Medicine
Keppel Street
London WC1E 7HT
Malaria Prevention Advice Line: 09065 508 908 (24 hours, £1 per min)
Website: www.lshtm.ac.uk
Malaria prevention guidelines: www.hpa.org.uk/infections/topics_az/malaria/guidelines.htm
Provides in-depth information and advice to travellers on malaria prevention.

MASTA (Medical Advisory Services for Travellers Abroad)
Moorfield Road
Yeadon
Leeds LS19 7BN
Tel: 0113 238 7575 (note: MASTA do not accept personal travel enquiries by phone)
Travellers' Health Line (for MASTA Health Brief): 0906 550 1402 (£1 per min; calls from mobiles may be higher)
E-mail: enquiries@masta.org
Website: www.masta.org
Aims to raise the awareness of health issues associated with travel. Services include up-to-date information about immunisations and anti-malarials, an online search facility to find your nearest MASTA associated travel clinic, a health library with travel advice, factsheets and news, and a chat room. Also produce a Health Brief, which gives personalised immunisation and anti-malaria advice for a specific journey. The website includes advice on staying well when you're away from home, including info on immunisation and antimalarials.

websites

Backpacking Travel Advice
www.travelindependent.info/b4yougo.htm
This site, created by a traveller for other travellers, contains a host of information aimed at backpackers. Whilst the writer points out that he is not a doctor, the site contains some useful advice 'from the horse's mouth'.

MASTA
www.masta.org/travel-health/disease-risks.asp?group=2&dis_id=4
Comprehensive information from the MASTA website about malaria risk, bite avoidance, diagnosis and treatment.

Preventing Malaria
www.preventingmalaria.info/prevention/index.htm
Details of the drugs available as prevention against malaria and other steps that you can take to avoid getting bitten.

Travel Doctor
www.traveldoctor.co.uk/malaria.htm
Contains a map of malaria endemic areas, and information about malaria prevention, symptoms and treatment.

reading

Health Advice for Travellers by Department of Health
For those planning to travel abroad, this gives detailed information on health precautions, reciprocal health agreements, and vaccinations. It contains Form E111, which entitles you to free or reduced cost emergency medical treatment in many EC countries. The booklet is available over the counter at main post offices or by phoning the Health Literature Line (free of charge) on 0800 555 777. It's available to read online at: www.dh.gov.uk/PolicyAndGuidance/HealthAdviceForTravellers/fs/en

(July 2001, resources updated January 2005)