28 May 2003
By Dr. Ted Lankester
This can seem a confusing topic for many aid workers; even for doctors and nurses. Most advice is directed towards the short-term traveller, so here are some guidelines for those going away for a month or longer. It is based on information from the WHO, UK Advisory Committee on Malaria Prevention, our experience at InterHealth in caring for members of 180 NGOs and from other reliable sources.
Here is a simple tour:
FIRST - Avoid getting bitten. That means mozzie nets, DEET based insect repellent, cover-up and loads of common sense. Easy - but very dangerous - to forget.
SECOND - Take an effective antimalarial.
The rest of this section applies to Sub Saharan Africa - far and away the most risky areas for most of us. Always make sure you read the Patient Information Leaflet because not all side effects and reasons for not taking them are listed below.
You have 3 choices:
1. Mefloquine or Lariam. Not necessarily the big bad L. Lariam is effective and 3 people out of 5 have no significant side effects. You can always trial it for 3 weeks before going as three quarters of side effects will show up in that time. You should avoid it if you have ever been significantly depressed or anxious, have patches of insomnia, epilepsy, liver problems and any abnormalities in your heart rhythm or conduction. Our impression is that those with very steady temperaments ie the non-moody amongst us seem to do better on it. The dose is 250mg weekly and you start 3 to 4 weeks before entering and continue for 4 weeks after returning from a malarious area. Many people have taken mefloquine for many years and there are no legitimate reasons for stopping providing you have no side effects and you get your liver function tests checked say every year: occasionally it causes them to become abnormal. It can be used in the middle and latter thirds of pregnancy but not while breastfeeding or in the first third of pregnancy.
2. Doxycycline. This is almost as effective as mefloquine. Although an antibiotic most people can take this long term without serious side effects- indeed many younger people use this long term for acne. The dose is 100mg daily starting 1 or 2 days before and continuing for 28 days after leaving mozzie-land. The most important side effect is sun burn- up to 40% of people using this may sunburn more easily meaning you need to stick to the shade or use sunblock. Its essential to swallow doxy with plenty of fluid and in an upright position or your gullet will suffer. It makes thrush more likely in some women. Doxy can't be used in pregnancy or when breastfeeding. There is no upper time limit on its use but it is worth reviewing any symptoms every 6 months and chatting with a medical advisor if you are getting any obvious side effects- and having a more thorough review after 2 years.
3. Malarone. This is fairly new. It's not yet proved itself as the wonder drug but it's got a lot of big advantages - apart from its price. It seems to work as well as mefloquine in trials so far. Side effects are few, but because it contains some proguanil there is the possibility it can cause mouth ulcers and some thinning of the hair. The dose is one tablet daily and you can start it just 1 or 2 days before going to a malarious area and then continue for only 7 days after leaving. In the arcane world of UK drug licensing it is currently recommended for up to 28 days but many aid workers have been on this much longer term, some for up to 2 years. It should not be used in pregnancy or breastfeeding
And then there is chloroquine and proguanil (Paludrine). These are no longer sufficiently effective to use in Sub Saharan Africa (SSA)- though pregnant women in their first third of pregnancy have no safe alternative. Otherwise if you are taking C plus P in SSA consider changing to a more effective antimalarial as soon as possible.
Maloprim or Deltaprim. This is still widely used in Zimbabwe, Zambia and other surrounding countries. However there is increasing resistance and it can no longer be recommended as a main line antimalarial.
Other parts of the world? - more complicated - you will need to get specialist advice.
Before signing off two other important things to mention:
1. Self testing kits eg Rapimal. These can be very useful in detecting Falciparum malaria. They are hard to use on your own especially if you are shaking or feeling ill. We recommend them for couples, families and groups living or travelling off the beaten path or where local lab facilities are not reliable.
2. Standby treatment kits. Malaria can kill in 12 to 24 hours. If you will be 12 hours or more from a reliable doctor or lab or from a health facility that can reliably give you correct treatment take a kit with you. But before self-diagnosing or self-treating always try and get medical advice and if symptoms persist after self-treatment make sure you get the best possible medical care available.
This short piece is about prevention - treatment is of course vital but you will have to wait to hear about that until another time - unless you want to order a copy of the Travellers Good Health Guide. (Ted Lankester, Sheldon Press 2002). This and a full range of antimalarials and health supplies are available from InterHealth: email email@example.com, telephone +44 20 7902 9000 or look at the website www.interhealth.org.uk
For agencies or individuals who receive other services or supplies from InterHealth or for whom InterHealth acts as travel health/medical advisor we have an arrangement with Glaxo Smith Kline who have generously made Malarone (and Combivir for Post-Exposure Prophylaxis of HIV) available at greatly reduced cost for those working in Least Developed Countries.
Thanks for reading this - Safe travelling ...
(Neither the writer, InterHealth nor Aid Workers Network can take any responsibility for adverse events which may arise from any of the advice or recommendations given above)
Ted Lankester is Director of Health Care Services and Senior Physician at InterHealth, a UK based medical charity which acts as health advisor to relief and development organisations, mission agencies, churches and other not-for-profit organisations. For more information visit www.interhealth.org.uk
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Aid Workers Exchange 28-MAY-03 ISSN 1478-5137