Health on the Road: Malaria

They buzz then bite.  It hurts.  It itches.  It reddens and welts.  If you’re particularly unfortunate, it turns into disease and requires treatment.  But what about avoiding it altogether?   What should you know about preventing and treating malaria while travelling?  

A ubiquitous disease that affects millions and kills hundreds of thousands of people every year, it’s mosquito-borne Malaria that can be the mosquito in every traveller’s bowl of hearty soup.   Egregious and disabling when contracted, there’s one thing that divides travellers almost universally: to medicate, or not to medicate? 

We spend countless hours dousing ourselves in chemically-infused DEET, sleeping under permethrin-coated nets and avoiding mosquito bites at great length.  However, debate and confusion occur when anti-malarial medication forms part of the discussion.    

I’m fortunate, touch wood, to have avoided the dreaded curse of Malaria to this day despite having spent ample time in endemic zones over the years.  I medicated, then I didn’t, a constant game of trial and error before I became a nurse. 

The simple mention of Malaria can evoke fear in potential travellers, sometimes through lack of education and misinformation, but enough to turn some off travel altogether.  It’s ergo an important subject to discuss. 

Equipped with sound knowledge and a decent understanding, particularly about prevention but also symptoms and treatment, you’ll be well armed to travel in malarial zones without an almighty fear weighing you down along with the 200 bottles of DEET based repellent buried in your luggage.    

So, let’s take a detailed look at Malaria and prophylactic medication (aka preventative drugs), ideally to avert further debate and to gain some clarity. 

DISCLAIMER I am not a qualified medical practitioner, nor do I profess to be.  I am a nurse, though, and work in the healthcare industry.  The information contained here within is based on knowledge obtained from reliable and published clinical sources, relayed in my voice.  However, advice from a qualified local medical doctor is always recommended when symptoms are of concern and persist.    

What is Malaria? 

It’s a disease that’s spread almost exclusively through the noxious bite of the female Anopheles mosquito, a mosquito that hunts for human prey from dusk to dawn.  The saliva of the mosquito contains parasites called Plasmodium, organisms that, when introduced to human blood via a bite, cause disease.  The parasites travel to the liver via the circulatory system (veins and arteries), where they multiply and infect erythrocytes (red blood cells, the cells responsible for transporting oxygen throughout the human body).   

In terms of those that affect humans, there are four, listed here from most to least dangerous:

• Plasmodium Falciparum,
• Plasmodium Vivax,
• Plasmodium Malariae, and
• Plasmodium Ovale.

There is a fifth parasite, known as Plasmodium Knowlesi, which is found primarily in macaques.  It’s rare that it causes disease in humans.  It’s the first two – Plasmodium Falciparum and Plasmodium Vivax – that are the most prevalent. 

Plasmodium Falciparum is also the most dangerous, with serious life-threatening complications always a risk following contraction. 

Where is Malaria found? 

It’s a challenge to exclusively define the parameters of malarial zones as outbreaks can occur, often in regions of a country not previously affected.  However, if you’re travelling in a tropical or sub-tropical zone of the world, you can (almost) safely assume there will be a risk of malaria, ranging from mild to high. 

Rather than list each country and its associated risk here, I’d recommend taking the time to review an interactive world map to determine if your next destination presents a risk.

In general, malaria is endemic to the following world regions:

• Central America and (parts of) the Caribbean,
• (Parts of) South America,
• Sub-Saharan African and (areas of) the Middle East,
• Central, South, East and South-East Asia, and
• (A few) Pacific Islands.       

Symptoms of Malaria

If you are not taking chemoprophylaxis (preventative medication), have been bitten while travelling in an affected region and start to feel unwell, then there is a chance you could be infected with malaria.  Note that infection can also (sometimes) occur while taking certain preventative medications; some of them provide partial protection and can mask symptoms. 

These are the key symptoms of a malarial strain, presenting anywhere from 14 days to four weeks following a bite, and can occur in various combinations:

• Flu-like symptoms (like shivering and dull muscular aches),
• Mild to severe fevers (above 37.9 degrees Celsius),
• Skin rashes,
• Headaches,
• Diarrhoea, and
• Vomiting.

These are classified as mild.  However, more complicated symptoms do exist and occur as a result of Falciparum, particularly when treatment is not sought. 

When Should Medical Attention Be Sought?  

The symptoms listed in the previous section are general and can also be indicative of other illnesses and disease processes, posing a danger to those travellers averse to seeking medical attention.  However, malaria is a serious thing.  In 2016 alone, 445,000 people died from the disease.   

If left untreated, the parasite can cause significant damage to your liver (responsible for many fundamental functions in the human body, like excreting waste, generating vital products and storing others) and can even result in death. 

If you’re travelling in a region of the world that’s affected by Malaria, you’ve been bitten and some of the symptoms I mentioned above present, then you need to seek medical attention.  Diagnosis can only occur when a blood sample is taken, through identification of the parasite during the screening process. 

Even if you’ve been taking preventative medication and it’s more than four weeks following a bite, it’s best to get tested.  Don’t leave it until you get home – it may be too late.

How to Chemically Prevent and Treat Malaria

Once diagnosed by a healthcare professional, then treatment usually consists of a course of medication (taken by mouth unless it’s very serious) as well as symptom management.  Hospitalisation can be required, to monitor symptoms, provide relief from symptoms when they persist and ensure compliance with treatment, but it’s often limited to cases of Falciparum.       

The medication that’s used to prevent Malaria is often also used to treat it.  Here are the most common antimalarial medications.   

Atovaquone and Proguanil (commonly branded as Malarone among others) – prevention and treatment

Relatively friendly with few mild side effects, it’s a popularly prescribed antimalarial.  It contains a mixture of two antimalarial medications in one tablet.  It should be taken daily, commenced two days before arriving in the affected zone and continued for one-week post-departure from danger.  If you are pregnant and in the first trimester or have kidney problems, then it’s best to avoid taking it.  It’s expensive, so perhaps best used for short trips.  It’s primarily used against Falciparum. 

Mefloquine (Commonly branded as Lariam among others) – prevention and treatment

It’s a controversial tablet, one that’s gained a lot of negative attention over the years.  It’s taken once a week, three weeks before departure and for a month upon leaving the affected zone.  Although rare, serious mental problems can occur as side effects: severe anxiety, hallucinations, depression, restlessness, confusion and suicidal ideation.  The benefits of this antimalarial outweigh the risks, and side effects should be noted during the three-week period prior to arrival in the affected zone.  Consult medical attention if any of these symptoms start.  It’s also quite expensive.      

Doxycycline (Commonly branded as Monodox among others) – prevention 

It’s been my antimalarial of choice for many years, in the instances I’ve opted to use one.  It’s a single tablet taken once a day, started two days before arriving in the malarial zone and continued for four weeks following departure.  There are side effects, most of which are mild, none of which I experienced, including increased sensitivity to sunburn, gastrointestinal (bowel) irritation (resulting in diarrhoea) and thrush.  It can be used for extended periods.  It’s cheap, which is perhaps why it’s often the choice of antimalarial among budget conscious backpackers.   

Chloroquine (Commonly known as Aralen among others) – prevention and treatment 

It’s used to treat all forms of Malaria and is one of the more popularly prescribed chemoprophylaxis.  I’m not sure why, as it comes with a whole host of potential side effects: nausea, diarrhoea, headaches, mood changes, light sensitivity, skin irritation, blurred vision, hair loss, dizziness and seizures to name a few.  As a preventative, it should be used once a week, starting a week before arrival in the danger zone, continued throughout the stay and taken for four weeks following departure.    

Proguanil (Commonly known as chlorguanide and chloroguanide) – prevention and treatment 

It’s a tablet that’s taken daily, started two days before arrival in the malarial zone, continued throughout the stay and used for four weeks post-departure.  There are some mild effects, not limited to anorexia, constipation, diarrhoea, nausea and mouth ulcers. 

It should be noted that there are other options, combinations of drugs and brand names available, depending on the country in which you see a doctor to get the prescription.  If you are going to use antimalarials as a preventative measure, then it’s important you specify the zones you’ll be visiting, as some countries have developed resistance to certain medications, rendering them useless in protecting you against Malaria.  Speak openly and honestly with the travel practitioner you see, so they can best protect you against the risk, should you choose to follow this path. 

Is There a Vaccination against Malaria? 

Historically, no vaccination against malaria has been available.  This is still the case, however in 2017 the World Health Organisation announced that a vaccine, currently being tested in clinical trials, will be used in three heavily affected African nations: Ghana, Kenya and Malawi.  The RTS,S vaccine provides partial protection against malaria in young children, a population particularly vulnerable to the ill effects of the disease.  

Although only a trial, its development is promising for the future, particularly given the unlikelihood that mosquitoes will ever be eradicated.  

How to Avoid Malaria 

There are various tried, tested and effective measures – used by long-term locals in affected zones – that should always be adopted by you while travelling in regions where Malaria poses a threat to your health.  Preventing Malaria, after all, is far better than trying to cure it. 

Wear loose fitting, light coloured cotton (or other soft) clothing, ideally articles that cover your legs and arms.  This is a key ingredient to avoiding a dreaded, parasite-laden mosquito bite.  Mosquitoes are attracted to dark colours, so any hue close to white, worn during the hours from dusk to dawn, will serve you well.  

This is particularly important while going out and about after dark (before going to bed where you’ll be protected by other barriers).  Use this tactic in tandem with the next item, and you’ll almost certainly avoid a bite.   

Diethyltoluamide (DEET) based repellents are highly effective agents at protecting you and your skin against mosquito – and other insect – bites.  It is a chemical but it’s been tested and proven to be safe (even in children) when applied correctly.  

It works by forming a vapour barrier on the surface of the skin.  The barrier repels mosquitoes, deterring them from landing.  

The percentage of DEET present equates to the length of coverage you’ll receive.  For example, 7% DEET will cover you for two hours while 98.25% DEET will give protection for up to 10 hours, an effective barrier to last the duration of your sleep.  

I’ve always used DEET-based repellents and have rarely been bitten.     

Mosquitoes are great at detecting heat.  By using air conditioning, you lower the temperature of the room and your skin, which makes you less a target than if you were to sleep in an airless hot, humid room.  

When there is a breeze, often created by air conditioners and certainly by fans, the environment becomes more challenging in which for mosquitoes to fly.  

Air conditioners also create a dry atmosphere in a room or enclosed space, again deterring mosquitoes who thrive in moist environments (such as beside lakes).  When they're switched on, with sealed windows and doors (as best as possible), another obstacle is created that mosquitoes need to overcome.  

It’s not always possible to get a room with a fan or air conditioner, so ensure at least one of the following measures is present and used.   

It’s ideal if windows are lined with some sort of fine netted screens, seemingly impenetrable to mosquitoes, especially those burdened by a belly full of blood.  This is not easy to achieve – or find – in the developing world, where other life priorities often take precedence.  

Even if windows are sealed by screens, extra layers of protection should always be used: bed nets act as mechanical and chemical barriers, deterring and even killing the little blighters.  Most nets – especially those sold in the developed world like the USA, Canada, the UK, Europe and Australia – are impregnated with permethrin, an insecticide that kills mosquitoes shortly after contact.  

I have always carried one with me for the instances one is absent from the ceiling above my bed at a hostel, hotel, bed and breakfast or other lodging. 

It’s a hard thing to avoid: a shower dripping continually with droplets that pool on the floor; a hotel beside a beautiful lake (such as Lake Malawi); or a really humid environment during monsoon.  

Water is everywhere, and mosquitoes lay their eggs in it, particularly when it is stagnant.  In fact, they depend on water for survival, thriving in it and using it for multiple purposes.  

The closer you stay to water, the likelier it is you’ll be exposed to a greater concentration of mosquitoes, particularly when it is humid.  I’m not saying you should avoid water sources in malarial zones, but you need to take extra precautions in these environments to avoid being bitten.   

Should Antimalarials Be Used, Then?  

So, the question remains: should you be taking a mouth full of chemicals while travelling in malarial zones, simply to try and avoid the curse of Malaria?  In reality, there is no simple answer.  As you’ve perhaps noted by now, it’s a multi-faceted disease with lots of associated processes and risks.  Taking antimalarials needs to be a personal decision, one that is well informed by thorough research and investigation. 

Your body is your temple, and whether you flood it with chemicals is a decision that should be made by you.  However, as a health professional, I advise you to fill your mind with as much professional level knowledge as possible.  Ask travel doctors and nurses for the facts, weigh up the pros and cons, then make a truly informed decision.  The risk management is ultimately up to you. 

There are steps involved in arriving at a decision, and questions you should be asking yourself before making it.  Review the map at the Centre of Disease Control, the link to which I provided above under ‘Where is Malaria Found?’.  Find out what type of risk is inherent to the country or region you’ll be visiting.  If it’s low, then perhaps no chemoprophylaxis (preventative medication) is required; non-medical avoidance strategies may be enough to protect you.  However, if the risk is high, then maybe one of the medications mentioned above may be advisable. 

I always ask myself the following questions before travelling to an affected zone, and would encourage my patients and you to do the same:

• Am I travelling to a zone of the world affected by Malaria?
• Is there a high risk of contracting Malaria in the region I’ll be visiting? 
• Will I be spending a significant amount of time in a high-risk area (as do volunteers)?

If you answer yes to a few of these questions, then it’s perhaps best you consider using an antimalarial medication.  If you answer no to most of these, then avoidance strategies may be enough to protect you. 

Think carefully about what you plan to do, and where you plan to do it.  Extended high-risk exposure is unsafe, such as volunteering in rural areas near water where Falciparum is abundant.  Jungle trekking, staying in rural areas and being near stagnant water where Malaria is present puts you at a greater risk of contracting the disease. 

If you don’t know what you’ll be doing because you prefer to travel spontaneously, then perhaps consider taking some antimalarials with you from home.  At least then you’ll have the option to use them if the situation arises.  The best-case scenario is that you end up not requiring them, subsequently disposing of them safely when appropriate.

Preventing and Treating Malaria While Travelling (Personally)

Personally, these days, I no longer use antimalarials.  I’m vigilant when traveling in danger zones, covering up and protecting myself in the period when mosquitoes are most prevalent.  It’s a personal choice I’ve made.  I travel a lot, and I want to ensure no resistance occurs.  In the instance I do one day contract malaria, I want to ensure the medication used to treat me is effective.  However, each person should make the decision based on his or her own knowledge, values and beliefs. 

Know what the dangers are and make an informed decision based on your sound knowledge and reasoning. 

I hope this article has been somewhat useful in answering a few of the questions that had been lurking inside.  It’s nearly impossible to be completely comprehensive when discussing healthcare issues, particularly in one article.  If you have any questions, then please don’t hesitate to get in contact.  I’m always happy to discuss healthcare matters on an individual basis.  Alternatively, contact your healthcare provider, and open a line of enquiry.  No question, in terms of health, is stupid. 

Safe malaria-free travels.