Visiting Friends

Malaria Prophylaxis

Last week, we saw that Malaria is the biggest risk for any traveler in Africa. Hundreds of millions of people get it each year. 627,000 people, mostly children or people with weakened immune systems, society’s most vulnerable, die of it.

Asking an African traveler about anti-malarial prophylaxis is like asking a Frenchman about wine. Every missionary or development worker feels passionately about their favorite drug because, “It saved my life!” (Author’s disclosure: Coartem rocks! Dying to awesome in three days…)

This post is not medical advice. Malaria prevention depends on both the geographical place you are going (because the disease in various places has different resistance to different medicines), and your own health. Before Visiting Friends, get the advice of a physician who specializes in tropical medicine.

The Basics

Malaria is caused by a parasite passed from person to person by mosquitoes. The female mosquito bites an infected person, sucking their blood and becoming infected herself. Then she bites another person. The juices she injects in preparation to suck blood contains the malaria parasites, infecting the second victim.

The classic symptoms of malaria are fevers & chills, and shakes & weakness. These symptoms come and go in a cycle, with several days between bouts.

The fevers are extreme, with the patient drenched in a soaking sweat. They feel like they are burning up and throw off all their covers. Ten minutes later, they are freezing and cannot get warm enough, no matter how many blankets are piled on them.

The shakes are so bad that a patient cannot hold a glass of water without it violently sloshing over the sides. The weakness prevents even the most common activities.

Other symptoms of malaria include flu-like symptoms such as headache, fever, joint pain, vomiting, anemia, and jaundice. Bad cases may include convulsions.

In Africa and other tropical regions, malaria is endemic and many people are infected. They go about their business between bouts, but huge amounts of productivity are lost as they suffer. The poor must often try to function even during active symptoms because if they do not work, they will not eat. It is not uncommon in many places to see people bundled up in coats even on warm days, attempting to keep their symptoms under control.

Prevention

The best defense is a good offense, and the best cure for malaria is to never get infected in the first place. Pyrethroid-treated nets, insect repellent, and staying indoors around dusk are all three effective prevention techniques.

Pyrethroid-treated nets have been credited with saving about 250,000 children in the first decade of the 21^st century. They are inexpensive and cost-effective, but need replaced every year or two. The nets hang over the bed, suspended from the ceiling or bed posts, and drape all the way around it, preventing mosquitoes from getting in during the night to bite.

Learn how to use your net with the light on, before you get into bed in the dark. My first night in Africa was spent wrapped in a cocoon-like mass of netting. I was safe from mosquitoes, but nearly strangled. Used properly, nets are low-hassle and work well.

Insect repellent is also useful, especially if you have to be out and about near dusk. DEET is extremely effective against mosquitoes, while at the same time being relatively safe. They may buzz, but they will not land and bite. It is often difficult to find insect repellent in Africa, so this is something you should bring with you. The small bottles that are manually applied are more space-efficient in luggage than the larger aerosol sprays.

Lastly for prevention, simply stay indoors as much as possible at dusk. Don’t leave doors and windows open. You may find that the friends you are visiting take pride in having gone to what you might consider great lengths to mosquito-proof their residence. This shows that they care about their family and guests.

Prophylaxis

A malaria prophylaxis is any of several drugs that are taken as a preventative. Each of the drugs is mostly effective, and each has various side-effects. Some drugs are ineffective in some areas due to drug-resistance. An expert in tropical medicine can help sort out the best options on an individual basis.

Common prophylaxis include Doxycycline, Malarone, Lariam (mefloquine), and Primaquine. Doxycycline is perhaps the most common in Africa, where it is inexpensive and generally available. Its major side-effect is sensitivity to sunshine; long-term use also increases susceptibility to thrush (oral Candida). Malarone has few side effects, but must be taken with food to avoid an upset stomach; it is also expensive. Lariam is falling out of favor because of psychiatric side-effects, which can be severe in some cases. Primaquine requires a genetic test before use because some people (most often of African or southern European descent) can have a serious blood reaction.

It is extremely important to continue taking prophylaxis upon your return until advised otherwise by your doctor. Malaria parasites hide out in the liver and can emerge long after your trip is over. The extended treatment (often 3-4 weeks) is intended to completely rid your body of the parasite.

A vaccine for malaria has long been the holy grail of tropical medicine. Only recently has a candidate vaccine, Mosquirix, finally proven both safe and effective. It is expected to become available in the next several years. Mosquirix is about 50% effective, which could save hundreds of thousands of lives a year in Africa.

Cure

If you suspect you might have malaria, seek treatment by a tropical medicine specialist, not a general practitioner. Simple malaria is harder to diagnose than to cure; Coartem is easy to administer and is often distributed in packaging designed for low-literacy field use. In a small number of cases or if left untreated, malaria can have serious complications requiring rapid medical intervention.

HINT: Stress, such as long-distance travel, can bring onset of malaria symptoms. Seasoned travelers often stop by the pharmacy before leaving a developing region and pick up a malaria test kit and a curative dose of Coartem, “just in case”. Both are only a handful of dollars in Africa, but can be two or even more orders of magnitude more expensive in the United States. Always consult a physician if you think you have malaria, but the self-test kit can quickly help remove doubt.