Malaria has been with us for a very long time. Prehistoric
man is thought to have suffered from malaria, and it has been
recorded in the ancient Egyptian tabloids. Malaria was named
as such during the Roman times when marshes once surrounded
the City of Rome, and the disease was thought to have come
on bad winds ( “Mal-Aria” or “Bad Air”).
One of the commonest travel queries put to me must be the
malaria question. “Do I really need to take malaria
prophylaxis (preventative)?” As we go on you will see
that answer is not as easy as a simple “yes” or
“no”. Many variables must be considered before
making the decision to medicate travellers, and this potentially
fatal disease must never be taken lightly.
I am often bemused by conversations between seasoned travellers,
or by the reels of confident answers on travel forum pages,
to people posing the malaria prophylaxis question. Advise
such as “ the locals don’t take preventative,
so why should we”, or “ I’ve been there
4 times, never got malaria, and never took any tablets”.
What do these statements actually mean? As for the first statement,
“the locals” have a certain level of natural immunity
to the local strain of malaria, however they do still get
the disease, and yes, sometimes they die. The person who made
the second statement (and those like him), is assuming that
if you get away disease free 4 times, that the disease does
not exist, or, that if the disease did exist then 100% of
visitors would be affected. This demonstrates the ignorance
of gamblers.
A few statistics should bring the reality home to those that
may have become complacent about this troublesome disease.
* 300 – 500 million cases of malaria are reported worldwide
each year. Most cases
are in Sub-Saharan Africa; however some regions within Indonesia
are high-risk
zones.
* Approximately 2.7 million people die each year from malaria,
most of which are
children.
* Cerebral malaria has a fatality rate of approximately 20%.
* Children below 5 years, the elderly, or the immuno-compromised
are at greatest
risk.
* Pregnant women are at greater risk of contracting the disease,
and the disease is
more progressive once the woman is infected.
* During the Japanese invasion of Papua New Guinea in the
1940’s, 60% of
casualties were not from warfare, but from epidemic malaria.
So What is malaria?
Malaria is a disease caused by a small protozoan microorganism,
(a little larger than a bacteria), that is transmitted to
humans by the saliva of the Anopheles mosquito. It is an infectious
disease, however it does require a vector (carrier) to transmit
the disease. (ie. you cannot catch malaria from another person
by touching, kissing etc, but you could be infected by a mosquito
that has bitten that infected person). There are four types
of malaria in all, however in Indonesia we are generally dealing
with only the Vivax, and Falciparum malarias. Once a host
has been bitten by an infected mosquito, the malaria organism
infects and destroys the red blood cells and invades the liver
of its host. The Falciparum malaria is a more severe form
of the disease, however the Vivax malaria may remain dormant
in the liver for as long as 5 years.
What are the symptoms of malaria?
Generally someone suffering from malaria will present with
one or more of the following symptoms:
* Cough.
* Flu like symptoms.
* Fatigue (Tired all the time).
* Malaise (weak).
* Shaking chills.
* Athralgia (Joint pains).
* Paroxysmal fevers and sweats (swinging fever, followed by
sweating episode).
In most cases, the victim will have travelled to a malaria
risk zone within the past month or so. Vivax malaria however,
may present over a year after original exposure to the disease.
In Indonesia high risk zones for Malaria are all Islands East
of Bali (Lombok, Sumba, Sumbawa, The Gilles), and recent reports
show sporadic outbreaks in rural areas of East and Central
Java. (I have never quite understood why the pesky little
mozzies that spread this disease never packed their bags and
hoped on a boat to start a new epidemic in Bali…..but
evidently they never have !!).
What should I do if I think I have malaria?
Consult the nearest clinic or travel health centre. Malaria
needs professional diagnosis and treatment. Diagnosis should
not be delayed until the end of your holiday, or until it
fits into your travel plans. Should you experience any of
the above symptoms, you should not assume that you have malaria
and self medicate, unless you are many, many miles away from
medical facilities. If you are planning such travel you should
consult a travel health centre before your departure to organise
prophylaxis and emergency treatment until medical help can
be summoned.
How can I prevent malaria?
Make sure that you are informed, and aware of the travel
risks to the particular area that you are visiting. There
are many informative web sites (CDC, travelhealth.com, tripprep.com),
however they do tend to bag Indonesia as region rather than
zone high-risk areas within the archipelago. Other factors
to be taken into consideration when making the decision to
recommend malaria prophylaxis are:
* What type of accommodation will you use? 5 star, middle
of the road or
backpacker?
* How long will you travel for? A weekend vacation, or a 6-month
long trek?
* Are you a seasoned traveller or first time away from home?
* How old are you? Children under 9 as well as females that
may be pregnant or
breast feeding face special considerations.
So, once that malaria risk has been assessed, preventative
action must be taken. The best way to avoid the disease is
to avoid the carrier. Don’t get bitten by the mozzies
and you won’t get the disease. Ways to avoid this are:
* As this particular mosquito bites between the dusk and
dawn hours, be
particularly cautious during these times.
* Avoid the use of dark coloured clothing and perfumes. Both
attract the mosquito.
Choose long sleeved, light coloured attire, and use Citronella
rather than
perfume.
* Wear a personal insect repellent with a concentration of
DEET 30% - 45%
(diethylmethylbenzamide). Pregnant women should use a concentration
of 35%
or less. Higher concentrations of this lotion should be used
on clothing rather than
directly on the skin.
* Use a good knockdown spray in your room before retiring.
* Mosquito nets are useful especially for babies and small
children.
* There is some evidence that taking Vitamin B supplements
may repel the
anopheles mosquito, however this is inconclusive, and should
not alone be relied
upon as a preventative.
* There are some rather unconventional methods, such as wearing
pet flea collars
around ankles and legs. This is not recommended and can cause
severe local
reactions.
Assuming that our traveller has been assessed as warranting
medication for his travels, let’s look at the options
available:
* Doxycycline is actually an antibiotic, and belongs the
Tetracycline group. This is
still probably a favourite of mine for malaria prophylaxis,
due to it’s short
pre-dosing time, and low incidence of side effects. Doxycycline
needs to be taken
only 2 days before departure, and 3 weeks after leaving the
risk area. It needs to
be taken daily (adult dose 100mg), and the side effects may
include increased
sun sensitivity (you burn easily in the sun, therefore wear
a good sunscreen), and
as with all antibiotics may encourage fungal growth especially
in females
(vaginal thrush). This drug should not be used in children
under 9 years of age,
pregnant or breast-feeding mothers as is interferes with bone
formation. Doxycy
cline may interfere with the action of oral contraceptives,
so women on the
contraceptive pill should take extra precautions. Some people
report gastro-
intestinal disturbances with this drug; this can be avoided
by taking the
medication with food.
* Chloroquine has been used for many years, and for this reason
we find that
many strains of malaria are resistant to this drug. Chloroquine
resistance has
been reported through most risk zones in Indonesia, therefore
it would be unwise
to choose this drug as your first line of defense.
* Larium (mefloquine) is an excellent long-term prophylaxis,
as it needs to be
taken only once a week. It does need to be taken 2 weeks before
and 4 weeks
after leaving the risk zone. Some people do report experiencing
nightmares, sleep
disturbances or mood changes while on this drug. In these
cases the drug should
be stopped, and another form of prophylaxis employed. It should
not be taken by
any person with existing neuropsychiatric disorders (seizures,
psychosis etc), or
any person suffering from heart conduction disorders (especially
those currently
on beta-blockers). Note: any person taking mefloquine that
contracts malaria,
should never be treated with Halofantrine. Instant death may
follow due to
cardiac arrhythmia.
* Malarone (Atovaquone and proguanil) is the “new kid
on the block” of malaria
prophylaxis. Its main draw back is the price. It can cost
you almost an airline ticket
to purchase enough of this drug to last you a long holiday!
Malarone does have to
be taken on a daily basis, however needs to be started only
one day before travel
and only 7 days after travel to risk areas. Malarone is generally
well tolerated with
few side effects; it should be taken at the same time each
day with milk.
Unfortunately Malarone is not as yet produced in Indonesia.
Why take these drugs even after you have left the high-risk
area? ….as I mentioned before, the malaria plasmodium
enters a liver phase where it may escape the effects of the
anti-malarial drug. Taking the malaria prophylaxis weeks after
possible exposure will catch these ….we hope! It is
wise to remember that NO MALARIA PROPHYLAXIS gives 100% protection
from the disease. Should you suffer from any symptoms suggestive
of malaria, even as long as 12 months or more after leaving
a risk zone, you should contact you doctor immediately.
… ..And to all our readers travelling for the long
school holidays, be safe, be happy, and don’t forget
the fly spray !!
Kim Patra is a qualified Registered Nurse / Midwife, and
mother of three, who has been living and working in Bali for
past 15 years. She has assisted many traveller (... and others)
either as a flying medical escort or just a voice on the end
of the phone! Kim is happy to discuss any health concerns
that your may have. Her e-mail contact is info@chcbali.com
