Malaria: Questions and answers for travellers

Dr Jane Wilson-Howarth, author of The Essential Guide to Travel Health, answers travellers’ questions about malaria

Dr Jane Wilson-Howarth
08 July 2010

Whenever I speak at travel shows, people always want to know about malaria. So this issue I’ve put together some of the most frequently asked questions I receive about the disease so you can be better informed before your big trip.

What are the side effects of malaria tablets?

This is probably everyone’s biggest concern, perhaps because the press has made so much of the occasionally disastrous side effects. The truth is that all antimalarials – indeed, any medicine that has some therapeutic effect – has the potential to cause side effects, and all antimalarials will produce side effects in some people.

The trick is to find out which particular ones are recommended for your intended destination and to see if they suit you. The most common side effects are queasiness, loss of appetite and nausea, but these problems are less likely to be troublesome if the tablets are taken on a full stomach.

Doxycycline in particular is one that can not only cause the quease but also needs to be washed down with plenty of water.

Can Lariam make you mad?

Lariam (mefloquine) is unusual in being capable of altering the way you feel. It can make people feel low in mood and can cause vivid dreams. Most people will not experience this effect, but if you notice it during the first three doses, I would recommend changing to an alternative tablet.

In the past, before this alarming side effect was well recognised, people would go abroad and blame feelings of depression on jetlag or culture shock, and – in the absence of advice from a friendly GP – would go on taking Lariam; a few travellers became quite ill.

Their tales made the press in a big way and have done a lot to undermine the good that this preparation does since, if it suits you, it is effective; personally, it is my favourite antimalarial. It also happens to give the best protection against the dangerous forms of malaria – the sort that can kill within 24 hours of the first symptom.

These days nurses and doctors who prescribe Lariam screen their patients carefully and tell people to try three doses before departure; this doesn’t need to be done each time you travel – if it suited you once, it will be all right again.

I’ve been recommended Lariam for travel in Africa – is there an alternative?

Lariam is still the most effective antimalarial for people travelling to sub-Saharan Africa, if they can tolerate it. It is taken weekly. Alternatives are daily doxycycline, which causes queasiness in about 25% of takers and can make the skin extra-sensitive to sunburn, and Malarone, which is less effective than Lariam but generally low on side effects. This, too, commonly causes nausea and it can precipitate mouth ulcers; it is also very expensive.

I want to take my kids on safari – will they be OK on malaria tablets?

My entire family took Lariam on a trip to southern Africa and all felt well on it. My children were then seven and 12. Parents must be very cautious if planning to take small children to malarious Africa.

Little’uns can get very ill with cerebral malaria and can become critical within hours. It is also difficult to get babies to take effective antimalarials. Chloroquine syrup exists but it is so bitter that it is completely unpalatable, and not effective enough for Africa any more

The new Malarone paediatric tablets are a godsend but don’t help to solve the other challenge: getting the children to cover up and apply repellent at dusk.

Spraying permethrin insecticide on long clothes put on at 5pm will help kids avoid mosquito bites.

Wearing long, loose clothes that have been treated in this way means very little skin is left exposed so the child doesn’t need to have much repellent applied to their skin.

Will malaria pills give me complete protection against malaria?

No. Properly taken pills will usually protect but, if they fail, they will slow the disease process so that you have time to get to hospital. It is important to protect yourself from mosquito bites.

I have heard taking anti-malarials might make it more difficult to diagnose malaria. Is this true?

Not really. But they do stop you dying.

I’m pregnant – can I take malaria tablets?

Pregnant women (quite rightly) worry about any drugs they take, and it is best to avoid as many unnecessary medicines as possible. However, pregnant women are more at risk of becoming dangerously ill with falciparum malaria (the most dangerous form) than non-pregnant women – some research has suggested that pregnant women are more attractive to malarious mosquitoes.

Therefore, if you are pregnant – or planning a pregnancy – it’s important to consider whether going to a malarious destination is sensible. If the journey is essential then take advice from a travel clinic.

Doxycycline cannot be taken during pregnancy or while breast feeding. Lariam is being prescribed more and more in pregnancy and is probably safe, or at least a safer option that risking malaria.

The medicines that have long been given to pregnant travellers are the combination of chloroquine and Paludrine, with a folic acid supplement. This regime is still protective in much of Asia and South America, but it is not really good enough for sub-Saharan Africa.

Do malaria tablets interfere with any other drugs?

Not many, but if you take prescribed medicines remind the doctor who prescribes the antimalarial in case there is an interaction. Doxycycline probably reduces the efficacy of the contraceptive pill for the first three weeks of taking it – but only for these first three weeks.

Most medicines interfere with warfarin. People with epilepsy should not take Lariam or chloroquine; these medicines interfere with antiepileptic drugs and can increase the chances of having a fit. Lariam and chloroquine can cause problems in some people on some kinds of medicines used to control the rhythm of the heart, including beta-blockers and digoxin.

And people taking Malarone should avoid grapefruit juice! It inhibits the drug’s metabolism, so could increase the chances of Malarone becoming toxic.

What else do antimalarial tablets protect you against?

Most antimalarials only protect you against the four types of malaria (Plasmodium falciparum, P. vivax, P. ovale and P. malariae) that affect humans.

Taking precautions against being bitten, of course, protects you against a host of other nasty infections. Doxycycline, being a broad-spectrum antibiotic, gives some additional protection against travellers’ diarrhoea and various other bacterial infections.

I’m taking a one-year career break. Can I stay on malaria tablets for that long?

There is no limit to the length of time for which you can take Paludrine, and you can take chloroquine safely for about seven years. Lariam – if it suits you – is alright for two years or so.

Doxycycline isn’t licensed for long-term use in malaria prophylaxis but this group of medicines is tried and tested, and often prescribed long term for acne. Malarone is a new drug and so far doctors are not giving it for more than three months.

I’ve heard there is a Chinese herbal drug that works against malaria.

Artemether, which is extracted from the wormwood weed, has been used in Chinese medicine for 3,000 years. Its antimalarial properties were recognised and it has been used in treating severe malaria in hospitals in Thailand, Kenya and elsewhere for some years.

Recently, though, a new formulation – in combination with another drug, lumefantrine – was launched as Riamet tablets, which are available in the UK. These can be carried as a cure should malaria strike.

What are the best sources of information on malaria?

The antimalarial you take will depend upon your personal medical history, so it’s wise to discuss your plans with your nurse or a private travel clinic. The type of medication also depends on your destination – for more information, check out the following:

A help line gives malaria information in a long country-by-country list that cannot be short-circuited, so it can take a long time to hear your destination.

Hospital for Tropical

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  • Dr Jane Wilson-Howarth is a GP who has done research on malarious mosquitoes in Indonesia and bat malarias in Peru and Madagascar. She is the author of Bugs, Bites & Bowels (Cadogan), Shitting Pretty (Travelers’ Tales), Your Child’s Health Abroad (Bradt) and Lemurs of the Lost World (Impact Books).

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