Am I more susceptible to malaria?

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QUESTION

I contracted common malaria, vivax?, when i was 20 yrs old from long visit to Papua NewGuinea, 1970. Returned to USA and was treated with chloro, primaquine drugs and really no problems since treatment.

Now going to Thailand for week, Chiang Mai and region. If bitten by local malarial mosq. am i more likely to recur? And should I certainly choose prophylaxis? thnx

ANSWER

If you were treated successfully with chloroquine and primaquine then there is no reason for your malaria to reoccur. Since it has been a long time since you had malaria, you probably also don’t have any antibodies against the parasite in your system anymore; this just means you don’t have any extra immunity against P. vivax (which you might have done if you had returned to a malaria area, and particularly one with the same strain of P. vivax as that which infected you, within a few months or years of being infected the first time), but it doesn’t mean you will be any more susceptible than someone who never had malaria.

In terms of where you are going, the city of Chiang Mai itself is not considered to have malaria transmission, but the areas surrounding it are, particularly as you get closer to the Burmese border. As such, if you will be travelling in rural and/or forested areas, you might want to consider taking prophylactic medication (and other preventative measures, like sleeping under a long-lasting insecticide treated bednet).

Thailand unfortunately has seen the emergence of resistance to a couple widely used prophylactic measures, namely chloroquine and mefloquine (sold as Lariam), so these are not appropriate preventative medicine in this region. Instead, you should consider taking doxycycline or atovaquone-proguanil (sold as Malarone).

Treatment of Malaria

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QUESTION

How is malaria treated?

ANSWER

Malaria can be a severe, potentially fatal disease (especially when caused by Plasmodium falciparum) and treatment should be initiated as soon as possible.

Patients who have severe P. falciparum malaria or who cannot take oral medications should be given the treatment by continuous intravenous infusion.

Most drugs used in treatment are active against the parasite forms in the blood (the form that causes disease) and include:

  • chloroquine
  • atovaquone-proguanil (Malarone®)
  • artemether-lumefantrine (Coartem®)
  • mefloquine (Lariam®)
  • quinine
  • quinidine
  • doxycycline (used in combination with quinine)
  • clindamycin (used in combination with quinine)
  • artesunate (not licensed for use in the United States, but available through the CDC malaria hotline)

In addition, primaquine is active against the dormant parasite liver forms (hypnozoites) and prevents relapses. Primaquine should not be taken by pregnant women or by people who are deficient in G6PD (glucose-6-phosphate dehydrogenase). Patients should not take primaquine until a screening test has excluded G6PD deficiency.

How to treat a patient with malaria depends on:

  • The type (species) of the infecting parasite
  • The area where the infection was acquired and its drug-resistance status
  • The clinical status of the patient
  • Any accompanying illness or condition
  • Pregnancy
  • Drug allergies, or other medications taken by the patient

If you have or suspect you have malaria, you should contact your doctor immediately.

Malarone and Mefloquine for Malaria

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QUESTION

Which drug is better for kids for anti-malaria – Malarone or Mefloquine. I have heard about lot of side-effects of Mefloquine. So, which is a safer drug out of these two or is there any other drug with no side-effects? Is it important to take anti-malaria pills keeping in mind the side-effects?

ANSWER

Both drugs are considered safe for children, though Malarone (atovaquone-proguanil) should not be given to pregnant women or those nursing a child under 5kg. Malarone is also available in a pediatric form in some places, where the dose is reduced specifically for prescription to children under 40kg in weight. Personally, I took both Malarone and mefloquine (as Lariam) when I was a child, and experienced no side effects from either, though certainly many more people do report side effects from mefloquine, including disturbed sleep and hallucinations, or increased anxiety, and it is therefore not recommended for people with a history of psychiatric illness or disorders.

If this does not apply to you or your children, then it really is a matter of preference, cost and practicality. Malarone is generally more expensive than Lariam, needs to be taken every day, but only needs to be taken a few days before departing for the malarial area and for only one week after you return. Lariam, on the other hand, is only taken weekly (which can be an advantage with small children), but needs to be started 2 weeks before travel and for 4 weeks afterwards, which can make it less convenient for short trips.

The other thing to consider, finally, is where you are going—some forms of malaria found in south-east Asia are resistant to mefloquine, meaning it is not a suitable anti-malarial for travel in those areas, so Malarone would be a better choice in that circumstance. Both mefloquine and Malarone are suitable for travel in all other malarial areas.

How to Prevent Malaria

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QUESTION

How to prevent malaria?

ANSWER

There are a number of ways to prevent malaria. These can be placed into two categories: medication and vector protection.

For medication, there are drugs you can take to prevent the malaria parasite from developing after someone is bitten by an infected mosquito. These drugs are known as “chemoprophylaxis.”

There are several different kinds, such as doxycycline, mefloquine (marketed as Lariam), atovaquone-proguanil (marketed as Malarone) and chloroquine—the type you use depends on the type of malaria present in the area. For example, in much of Africa and India, malaria is resistant to chloroquine, so this cannot be used as a prophylactic. In parts of Thailand, resistance to mefloquine has emerged. However, if the appropriate type of prophylaxis is used, it is very effective against malaria.

The problem is that these drugs have not been tested for long-term use, can be expensive and may have side-effects. Therefore they are of limited use for people who live in areas where malaria is endemic, and are more appropriate for travelers who are in malarial areas for short amounts of time. However, anti-malarial medication may be used in a very specific way for people at particularly high-risk for malaria, such as pregnant women and young children. In these cases, the high-risk individuals receive a dose or series of doses of malaria medication in order to prevent malaria. This form of prevention is known as intermittent preventive therapy (IPT).

Vector prevention involves protecting oneself against getting bitten by mosquitoes. This can involve wearing long-sleeved clothing in the evenings and at night, when malaria mosquitoes are most active, or wearing insect repellent on exposed skin. Indoor residual spraying, whereby repellent and insecticides are sprayed inside the house, can also be used to bring down the number of mosquitoes.

Another very effective technique for preventing malaria is to sleep under a long-lasting insecticide-treated bednet. The mesh acts as a barrier against the mosquitoes, and the insecticide impregnated in the mesh further repels the mosquitoes and prevents them from biting through the mesh.

Malaria Treatments

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QUESTION

What are the of different types of antimalaria drugs?

ANSWER

Most drugs used in treatment are active against the parasite forms in the blood (the form that causes disease) and include:

  • chloroquine
  • atovaquone-proguanil (Malarone®)
  • artemether-lumefantrine (Coartem®)
  • artesunate-pyronaridine (Pyramax®)
  • dihydroartemisinin-piperaquine (Duo-Cotecxin®)
  • mefloquine (Lariam®)
  • quinine (given intravenously, this is recommended first-line treatment for severe, complicated malaria)
  • quinidine
  • doxycycline (used in combination with quinine)
  • clindamycin (used in combination with quinine)

All of the treatments above which combine an artemisinin-derivative (such as artemether, artesunate or dihydroartemisinin) in combination with another anti-malarial are called the artemisinin-based combination therapies (ACTs) and are collectively recommended by the World Health Organisation as the first line medication against uncomplicated malaria.

In addition, primaquine is active against the dormant parasite liver forms (hypnozoites) and prevents relapses. Primaquine should not be taken by pregnant women or by people who are deficient in G6PD (glucose-6-phosphate dehydrogenase). Patients should not take primaquine until a screening test has excluded G6PD deficiency.

Treatment and Management of Malaria Parasite

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QUESTION

What are the treatments and management of malaria?

ANSWER

Treatment is actually part of the strategy for managing malaria, so I will come back to that later. The other main ways in which malaria is controlled is through prevention, diagnosis (followed by treatment if necessary) and education.

1) Prevention:

There are a number of ways to prevent malaria. These can be placed into two categories: medication and vector protection.

For medication, there are drugs you can take to prevent the malaria parasite from developing after someone is bitten by an infected mosquito. These drugs are known as “chemoprophylaxis.”

There are several different kinds, such as doxycycline, mefloquine (marketed as Lariam), atovaquone-proguanil (marketed as Malarone) and chloroquine—the type you use depends on the type of malaria present in the area. For example, in much of Africa and India, malaria is resistant to chloroquine, so this cannot be used as a prophylactic. In parts of Thailand, resistance to mefloquine has emerged. However, if the appropriate type of prophylaxis is used, it is very effective against malaria.

The problem is that these drugs have not been tested for long-term use, can be expensive and may have side-effects. Therefore they are of limited use for people who live in areas where malaria is endemic, and are more appropriate for travelers who are in malarial areas for short amounts of time. However, anti-malarial medication may be used in a very specific way for people at particularly high-risk for malaria, such as pregnant women and young children. In these cases, the high-risk individuals receive a dose or series of doses of malaria medication in order to prevent malaria. This form of prevention is known as intermittent preventive therapy (IPT).

Vector prevention involves protecting oneself against getting bitten by mosquitoes. This can involve wearing long-sleeved clothing in the evenings and at night, when malaria mosquitoes are most active, or wearing insect repellent on exposed skin. Indoor residual spraying, whereby repellent and insecticides are sprayed inside the house, can also be used to bring down the number of mosquitoes.

Another very effective technique for preventing malaria is to sleep under a long-lasting insecticide-treated bednet. The mesh acts as a barrier against the mosquitoes, and the insecticide impregnated in the mesh further repels the mosquitoes and prevents them from biting through the mesh.

2) Diagnosis

Diagnosis is considered a crucial step in controlling malaria, since it ensures that people are receiving correct medication, whether for malaria or for another condition which is causing their symptoms. Currently, the most commonly observed form of diagnosis is through microscopy of thick and thin blood films, which can be stained if necessary. These should be read by a qualified technician to determine both the species of malaria infection and the intensity of parasitaemia (number of parasites in the blood).

More recently, other methods for diagnosis have emerged. These include the use of rapid diagnostic tests (RDTs) which utilize a drop of blood applied to a reagent strip which very quickly reacts to show whether the patient is infected with malaria. While considered generally more sensitive than blood films, some RDTs don’t test for all types of malaria parasite, and many require that the reagents be kept cold in order for the test to be effective, which can be a problem in some developing countries.

Perhaps the most sensitive test for malaria is through PCR, which can theoretically detect a single malaria parasite in a drop of blood, and also determine the species. However, measures of infection intensity require an alternative form of PCR, called real-time PCR, which can be technologically challenging. All forms of PCR require a lot of expensive equipment and reagents, trained technicians and take several hours to run.

3) Treatment

Malaria treatment can be determined based on the diagnostic results, as well as other factors, such as:

  • The area where the infection was acquired and its drug-resistance status
  • The clinical status of the patient
  • Any accompanying illness or condition
  • Pregnancy
  • Drug allergies, or other medications taken by the patient

Most uncomplicated (i.e. not severe) cases of P. falciparum can be treated with oral medication, such as artemisinin-based combination therapies (ACTs). Artemisinin is given in combination with another anti-malarial drug in order to prevent resistance from developing in the parasite. Patients who have complicated (severe) P. falciparum malaria or who cannot take oral medications should be given the treatment by continuous intravenous infusion, with quinine recommended by WHO as the first-line treatment.

Other drugs, which are used in some settings, are considered second-line or alternative forms of treatment. These include:

  • chloroquine (very rarely used for P. falciparum, due to widespread resistance)
  • atovaquone-proguanil (Malarone®)
  • mefloquine (Lariam®)
  • quinine
  • quinidine
  • doxycycline (used in combination with quinine)
  • clindamycin (used in combination with quinine)

In addition, primaquine is active against the dormant parasite liver forms (hypnozoites) and prevents relapses, for patients with P. vivax or P. ovale malaria. Primaquine should not be taken by pregnant women or by people who are deficient in G6PD (glucose-6-phosphate dehydrogenase). Patients should not take primaquine until a screening test has excluded G6PD deficiency.

4) Education

Through education, people living in at-risk areas for malaria transmission can learn about ways to prevent the disease (see above), as well as what to do if they suspect they are infected (i.e. seek diagnosis). Similarly, education is important for travellers visiting malarial areas, so they know the best ways in which to avoid being infected.

Malaria Prevention

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QUESTION

What is malaria and the preventive measures?

ANSWER

Malaria is a disease caused by single-celled parasites of the genus Plasmodium. There are currently five species which cause disease in humans, and while each is slightly different, they all act in basically the same way, and cause similar symptoms. Of the five, the most dangerous is Plasmodium falciparum, which can lead to death in a matter of days if not treated promptly.

In terms of prevention, the same basic methods are used to prevent all types of malaria. These can be placed into two categories: medication and vector protection.

For medication, there are drugs you can take to prevent the malaria parasite from developing after someone is bitten by an infected mosquito. These drugs are known as “chemoprophylaxis.”

There are several different kinds, such as doxycycline, mefloquine (marketed as Lariam), atovaquone-proguanil (marketed as Malarone) and chloroquine—the type you use depends on the type of malaria present in the area. For example, in much of Africa and India, malaria is resistant to chloroquine, so this cannot be used as a prophylactic. In parts of Thailand, resistance to mefloquine has emerged. However, if the appropriate type of prophylaxis is used, it is very effective against malaria.

The problem is that these drugs have not been tested for long-term use, can be expensive and may have side-effects. Therefore they are of limited use for people who live in areas where malaria is endemic, and are more appropriate for travelers who are in malarial areas for short amounts of time. However, anti-malarial medication may be used in a very specific way for people at particularly high-risk for malaria, such as pregnant women and young children. In these cases, the high-risk individuals receive a dose or series of doses of malaria medication in order to prevent malaria. This form of prevention is known as intermittent preventive therapy (IPT).

Vector prevention involves protecting oneself against getting bitten by mosquitoes. This can involve wearing long-sleeved clothing in the evenings and at night, when malaria mosquitoes are most active, or wearing insect repellent on exposed skin. Indoor residual spraying, whereby repellent and insecticides are sprayed inside the house, can also be used to bring down the number of mosquitoes.

Another very effective technique for preventing malaria is to sleep under a long-lasting insecticide-treated bednet. The mesh acts as a barrier against the mosquitoes, and the insecticide impregnated in the mesh further repels the mosquitoes and prevents them from biting through the mesh.

Affected by Lariam… How to Help?

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QUESTION

Five years ago my husband was working in Africa. To get protection against malaria, he took Lariam. Since then, he became strange, poor sleep, constant depression, insecurity and distrust, inability to concentrate, forgetfulness, anger, strange behavior.

I insisted to see a doctor, but he refuses, saying that this is the problem of diabetes (he has type 2 diabetes) and stress at work.We living 12 years together, I can clearly see it’s more than that.
I tried many different things to prove that he was effected by Lariam to get help. But it did not work. All that I got “I m not crazy.” He’s not but not normal either. it’s ruining our family and lives. We have 2 kids.

Is there any method for establishing the presence of problems (blood test, etc.)?  I was hoping that after he stopped taking Lariam he will feel better. It took 4 years, but no significant changes. How to help him, and is it possible?

ANSWER

Thank you for your question—I am sorry to hear that your husband has been so negatively affected by Lariam. His symptoms are certainly consistent with some of the more unpleasant side-effects of mefloquine (the generic name for Lariam), which have been well reported over the years, and which many sufferers claim have continued long after they have stopped taking the drug.

Lariam was the anti-malarial drug of choice for the US military for many years, and a significant number of servicemen returning from Somalia and Iraq have reported back to the Army’s Surgeon General’s office regarding their on-going psychological symptoms. You can read a report about some of these Lariam cases here.

Roche, the pharmaceutical company that makes Lariam, has recently conceded some of the severe side effects that are associated with the drug, and “Lariam-induced psychosis” is a valid medical diagnosis for people who present with symptoms of paranoia, aggression, anger, hallucinations and other psychological side effects. As such, I think it is important for your husband to realise that you don’t think he is crazy, but that he might be suffering from the late-lasting after effects of a medication, similar effects to that felt by hundreds of US servicemen and other people who have taken Lariam.

Showing him the above document, or many other reports of people will long-lasting Lariam side-effects, might help him realise this is not about being crazy, but about side effects over which he had no control. If he is willing to see a psychiatrist, with the understanding that what he is experiencing is not his fault at all, then you might be able to find some solutions to his behavioural changes.

 

Malaria in Borneo, Indonesia

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QUESTION

We fly to Borneo tomorrow and have been very stupid not thinking about Malaria medication. Can someone quickly tell if I should take medication when there and also what type would be best to take?

Thank you for your help.

ANSWER

Yes! Malaria prophylaxis is recommended for trips to Indonesian Borneo, particularly rural areas. Recommended forms of prophylaxis are Malarone (atovaquone-proguanil), doxycycline and Lariam (mefloquine). The first is the most expensive, but has the fewest side effects, the second is the cheapest but can induce sun sensitivity and needs to be taken for 4 weeks after returning home and the third only requires one pill a week (the others are taken daily) but side effects can be severe and disturbing, including vivid dreams, impaired consciousness and hallucinations.

I am less familiar with south-east Asia, but I know in Africa doxycycline is readily available, for very little money, at local pharmacies. Therefore if you don’t have time to get the necessary anti-malarials before you leave, don’t panic! You may well be able to buy them in-country, particularly if you stop in Jakarta or another major city on your way. Check expiry dates and make sure the drugs are in the original packaging before you purchase though, as counterfeit drugs are distressingly prevalent. Also, do not buy chloroquine (or indeed any anti-malarial not listed above)—malaria in Borneo has been reported to be resistant to chloroquine and so this is not an appropriate anti-malarial for this area.

Please consider sharing your experiences with whichever prophylactic you choose when you return from your trip. We at MALARIA.com are trying to compile data on people’s experiences with malaria prophylactics and treatment medication, and we would be very grateful if you would take our malaria survey. Thank you!

Please also use other preventative measures against malaria while you are in Borneo—sleeping underneath an insecticide-treated bednet and wearing long-sleeved clothing in the evenings and at night, plus applying insect-repellent to exposed skin, can all help to reduce the incidence of mosquito bites and thus the risk of contracting malaria. Plus, avoiding insect bites will probably improve your enjoyment of the trip as a whole!

How to Protect from Malaria

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QUESTION

How can I protect my body from malaria?

ANSWER

There are a number of ways to prevent malaria. These can be placed into two categories: medication and vector protection.

For medication, there are drugs you can take to prevent the malaria parasite from developing after someone is bitten by an infected mosquito. These drugs are known as “chemoprophylaxis”.

There are several different kinds, such as doxycycline, mefloquine (marketed as Lariam), atovaquone-proguanil (marketed as Malarone) and chloroquine—the type you use depends on the type of malaria present in the area. For example, in much of Africa and India, malaria is resistant to chloroquine, so this cannot be used as a prophylactic. In parts of Thailand, resistance to mefloquine has emerged. However, if the appropriate type of prophylaxis is used, it is very effective against malaria.

The problem is that these drugs have not been tested for long-term use, can be expensive and may have side-effects. Therefore they are of limited use for people who live in areas where malaria is endemic, and are more appropriate for travelers who are in malarial areas for short amounts of time. However, anti-malarial medication may be used in a very specific way for people at particularly high-risk for malaria, such as pregnant women and young children. In these cases, the high-risk individuals receive a dose or series of doses of malaria medication in order to prevent malaria. This form of prevention is known as intermittent preventive therapy (IPT).

Vector prevention involves protecting oneself against getting bitten by mosquitoes. This can involve wearing long-sleeved clothing in the evenings and at night, when malaria mosquitoes are most active, or wearing insect repellent on exposed skin. Indoor residual spraying, whereby repellent and insecticides are sprayed inside the house, can also be used to bring down the number of mosquitoes.

Another very effective technique for preventing malaria is to sleep under a long-lasting insecticide-treated bednet. The mesh acts as a barrier against the mosquitoes, and the insecticide impregnated in the mesh further repels the mosquitoes and prevents them from biting through the mesh.