Malaria … The Real Story

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
* Approximately 2.7 million people die each year from malaria, most of which are
* Cerebral malaria has a fatality rate of approximately 20%.
* Children below 5 years, the elderly, or the immuno-compromised are at greatest
* 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,,, 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
* 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
* 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

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

Copyright © 2002 Kim Patra