Malaria Prophylaxis – Delaware

by

QUESTION

Where can I get vaccinated for malaria in Wilmington, DE?

ANSWER

Currently there is no vaccine for preventing malaria.  However, 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 being 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.

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.

Check the “Malaria Overview” section of malaria.com for a map showing where malaria is found, and for appropriate  preventive treatment. You can also look at the CDC website and consult your physician before traveling.

At what age can you get malaria?

by

QUESTION

What age do you get malaria?

ANSWER

Malaria is transmitted by the bite of an infected mosquito, and therefore any one living  where malaria is present, at any age,  is susceptible. To prevent malaria,  sleep under a long-lasting insecticide treated bednet; make sure it is re-dipped in insecticide every year or so to maintain its efficacy. The mosquitoes which transmit malaria tend to feed at night, and so protecting yourself and your home during the evening, night and early morning is crucial. Maintaining good screens on all windows and doors can be a very effective way of preventing mosquitoes from entering, and in many parts of the world, people spray inside with insecticides to reduce the number of mosquitoes yet further. Wearing long-sleeved clothing at night and in the evenings can also prevent bites.

Pregnant women though, due to changes to the mother’s immune system and also perhaps due to the physiology of the placenta, are very vulnerable to malaria. There is also the risk (up to 33% in some studies) that malaria will pass directly from the mother to the baby, either through the placenta or in blood during childbirth—this is called “congenital malaria,” and can manifest as early as 1 day after delivery but a late as months after. The symptoms are similar to that of adult malaria, with fever, anaemia, lethargy, etc.

Even if the unborn baby does not get congenital malaria, it can be effected by its mother having malaria during pregnancy, with possible low birth weight, anaemia and even spontaneous abortion—abortion rates due to malaria can vary between 15-70%.

Given these negative effects, it is very important to protect pregnant women against malaria, and bednet distribution schemes in many places target these women. In high transmission settings, women may also be offered intermittent preventive therapy (IPT) which consists of at least two doses of anti-malarial medication, usually once during the second and once during the third trimester.

Malaria Prevention

by

QUESTION

How can I protect myself from being infected with malaria?

ANSWER

There are many ways to prevent from getting infected with malaria. Some methods are more appropriate if you live in a malarial area, others are more for travellers to malarial areas, who are not staying long term. MALARIA.com has a comprehensive page dedicating to malaria prevention and protection.

Malaria in Namibia

by

QUESTION

could you please let me know, whether or not a malaria prophylaxe injection is necessary for a 3-weeks trip by car in Namibia, starting mid August.

ANSWER

It depends on where you are going in Namibia. According to the US Centers for Disease Control, malaria is transmitted in Namibia in the provinces of  Kunene, Ohangwena, Okavango, Omaheke, Omusati, Oshana, Oshikoto, and Otjozondjupa and in the Caprivi Strip. As such, if you are travelling to any of these areas, you should consider taking medication to prevent malaria. Three types of medication are considered equally effective in these regions: atovaquone-proguanil (Malarone), mefloquine (Lariam) and doxycycline. Which one you decide to take is mainly a matter of personal preference, based on details such as how often you will need to take a tablet (every day for Malarone and doxy, once a week for Lariam), how long you want to take the medication (Malarone is started the day before your trip, and should be taken for a week after, doxy is also started 1-2 days before travelling but must be taken for 4 weeks after returning and Lariam is started 2 weeks before travelling and for 4 weeks afterwards) and price (Malarone is the most expensive, and doxy usually the cheapest). In addition, each has different potential side effects (Malarone usually has the fewest; doxy can result in sun sensitivity, and Lariam may have psychiatric side effects, and is not recommended for anyone with a history of mental illness).

Doxycycline After Malaria Diagnosis

by

QUESTION

My daughter is 24 and in rural Uganda for 4 months. She has been diagnosed with malaria (plasmodium falciparum) and is taking treatment now. Treatment is 3 tablets of Neosidar tablets contain of sulfadoxine BP and of pyrimethamine followed tonight and for the next 3 days by 4 tablets of Lumarten in the morning and at bedtime with milk. Lumarten is a mix of artemether and lumefantrine. Her doctor in Entebbe recommended she should stop taking doxycycline: “the doxy is like a lock on the door, and now someone has broken the lock, so it’s better to treat the malaria as it comes (while still using nets, bug spray, long sleeves, etc. to avoid bites) rather than keep taking the doxy every day.”

Should she stop taking doxycycline and should she be taking the Lumarten with milk? Thank you very much.

ANSWER

I am not personally familiar with Lumarten, but these antimalarials are often taken with food. Of more concern is that she has been given a sulfadoxine-pyramethamine treatment—these are no longer recommended as first line treatment against malaria, and so she should just take the artemisinin-based combination therapy (artemether-lumefantrine is such a combination therapy).

In terms of the doxycycline, I do not understand the doctor’s advice. There is no harm in continuing to take doxycycline after having malaria, and in fact it might prevent re-infection! Of course this depends on how long she is still in Uganda for—the doxy must be taken for four weeks after leaving the malarial area, so if she is returning home soon, she should weigh up the continued preventive benefit against the inconvenience of a long continuation of taking the medication. In general, I don’t like the doctor’s attitude that your daughter should just accept continuing infections with malaria, and “treat them as they come.” It’s much better to use all available methods for prevention. One thing to consider is that dairy products inhibit the uptake of doxycycline, so if your daughter was also taking her doxy with milk (some doctors mistakenly advise this, to prevent stomach upsets when taking the medication), that might have been one reason why she still got infected.

How is Malaria Prevented?

by

QUESTION

What are the methods to prevent malaria?

ANSWER

Malaria prevention consists of a combination of mosquito avoidance measures and chemoprophylaxis. Although very efficacious, none of the recommended interventions are 100% effective.

Mosquito Avoidance Measures

  • Because of the nocturnal feeding habits of Anopheles mosquitoes, malaria transmission occurs primarily between dusk and dawn.
  • Contact with mosquitoes can be reduced by remaining in well-screened areas, using mosquito bed nets (preferably insecticide-treated nets), using a pyrethroid-containing flying-insect spray in living and sleeping areas during evening and nighttime hours, and wearing clothes that cover most of the body.
  • All travelers should use an effective mosquito repellent.
  • The most effective repellent against a wide range of vectors is DEET (N,N-diethylmetatoluamide), an ingredient in many commercially available insect repellents. The actual concentration of DEET varies widely among repellents. DEET formulations as high as 50% are recommended for both adults and children older than 2 months of age (see the Protection Against Mosquitoes, Ticks, and Other Insects and Arthropods section later in this chapter). DEET should be applied to the exposed parts of the skin when mosquitoes are likely to be present.
  • In addition to using a topical insect repellent, a permethrin-containing product may be applied to bed nets and clothing for additional protection against mosquitoes.

Chemoprophylaxis

  • All currently recommended primary chemoprophylaxis regimens involve taking a medicine before travel, during travel, and for a period of time after leaving the malaria endemic area. Beginning the drug before travel allows the antimalarial agent to be in the blood before the traveler is exposed to malaria parasites.
  • Presumptive antirelapse therapy (also known as terminal prophylaxis) uses a medication towards the end of the exposure period (or immediately thereafter) to prevent relapses or delayed-onset clinical presentations of malaria caused by hypnozoites (dormant liver stages) of P. vivax or P. ovale. Because most malarious areas of the world (except the Caribbean) have at least one species of relapsing malaria, travelers to these areas have some risk for acquiring either P. vivax or P. ovale, although the actual risk for an individual traveler is difficult to define. Presumptive anti-relapse therapy is generally indicated only for persons who have had prolonged exposure in malaria-endemic areas (e.g., missionaries, volunteers).
  • In choosing an appropriate chemoprophylactic regimen before travel, the traveler and the health-care provider should consider several factors. The travel itinerary should be reviewed in detail and compared with the information on where malaria transmission occurs within a given country (see the Malaria Risk Information and Prophylaxis, by Country, section later in this chapter) to determine whether the traveler will actually be traveling in a part of the country where malaria occurs and if significant antimalarial drug resistance has been reported in that location.
  • The resistance of P. falciparum to chloroquine has been confirmed in all areas with P. falciparum malaria except the Caribbean, Central America west of the Panama Canal, and some countries in the Middle East. In addition, resistance to sulfadoxine–pyrimethamine (e.g., Fansidar) is widespread in the Amazon River Basin area of South America, much of Southeast Asia, other parts of Asia, and in large parts of Africa. Resistance to mefloquine has been confirmed on the borders of Thailand with Burma (Myanmar) and Cambodia, in the western provinces of Cambodia, in the eastern states of Burma (Myanmar), on the border between Burma and China, along the borders of Laos and Burma, and the adjacent parts of the Thailand–Cambodia border, as well as in southern Vietnam.
  • Additional factors to consider are the patient’s other medical conditions, medications being taken (to assess potential drug–drug interactions), the cost of the medicines, and the potential side effects.
      The medications recommended for chemoprophylaxis of malaria may also be available at overseas destinations. However, combinations of these medications and additional drugs that are not recommended may be commonly prescribed and used in other countries. Travelers should be strongly discouraged from obtaining chemoprophylactic medications while abroad. The quality of these products is not known, and they may not be protective and may be dangerous. These medications may have been produced by substandard manufacturing practices, may be counterfeit, or may contain contaminants. Additional information on this topic can be found in an FDA document

Purchasing Medications Outside the United States

    .

 

Malaria Fever and Recovery

by

QUESTION

My 21 year old daughter spent 4 months on a study abroad program in Dakar. A week before returning home she started having night fevers and would complain of retrosternal pain and rib and neck and shoulder pain. The next day she would be fine.

The episodes came every other day and eventually it occurred to her that it might be malaria. It was evening so she went to a pharmacy for a rapid diagnostic test which they didn’t have but they felt she had malaria based on her symptoms and gave her a 3 day course of artesunate-mefloquine.

She returned to the United States and a day after taking her last dose, she was seen by a physician and tests were done which showed that she had contracted Plasmodium falciparum malaria. Other than the smears, all her lab tests and CXR were normal and there were no abnormal findings on physical exam, in fact she was the picture of health.

We were told that she was cured and that no follow up was necessary and that she could continue with her planned trip to Thailand the next day. About 6 hours before boarding the plane to Bangkok she developed fever of 100.9 but had absolutely no other symptoms or pain. About an hour later she had a bout of diarrhea. She had one more low grade fever on the flight (99.8). I spoke to another physician who seems more familiar with malaria and was told that she is not actually cured and may continue to have episodic fevers and symptoms for a while or it’s possible she was just suffering from an ordinary garden variety gastrointestinal bug.

I have many questions. I understand that her malaria is the most virulent type. How is it that all her lab work and physical exam is normal 1 day after completing treatment? Can we expect it to remain normal? What causes the episodic fevers if she is supposedly cured? She is on doxycycline again prophylactically (which she was on in Senegal) while in Thailand. Should she be on something else since she did contract malaria on doxycycline? (She took it religiously). Thanks for any advice. She will be seeing a physician in Bangkok ASAP, but since I won’t be there to ask questions, I am hoping you can give me some answers. Your site is the best information I have found on malaria.

ANSWER

Many thanks for the comprehensive information you have provided regarding your daughter’s condition. Even though your daughter did have the most virulent form of malaria, she was very smart to seek treatment relatively promptly, and lucky to receive appropriate medication (artemisinin-based combination therapies, such as artesunate-mefloquine, are recommended by the World Health Organization as first-line treatment against malaria). It is likely due to this prompt and effective action that her lab tests and blood parameters were all normal so soon after treatment; had she waited longer for treatment, the consequences could have been much more severe. No resistance to this medication has been detected in Africa as of yet, so she should be fully cured and thus her health should remain stable; a blood smear, where her blood is examined under a microscope, can determine this; this is a very standard procedure so could easily be carried out in Thailand if she wants.

Fever is a side effect of the body’s immune system responding to a disease threat, so it is not uncommon for some symptoms to carry on after treatment. In addition, mild side effects of anti-malarial medication can often mimic the symptoms of malaria itself, including fever and nausea.

Given also the (entirely reasonable) possibility of an additional, unrelated stomach bug, I suspect that your daughter has successfully beaten off this malaria attack, and while she should remain vigilant if similar symptoms arise again, her health in the future should not be adversely affected at all by this episode.

Also, as mentioned briefly above, medical professionals in Thailand should be well equipped to diagnose and treat malaria if she suspects she has been reinfected. It is worth noting that malaria in south-east Asia has shown signs of resistance to mefloquine (as well as other drugs, such as chloroquine and sulfadoxine-pyrimethamine), so if she does require treatment while there, she should make sure the medication they provide does not contain any of the afore-mentioned compounds.

Regarding doxycycline, it’s great that your daughter took it religiously—that is certainly the first step towards protection. Randomized placebo controlled trials have shown it is between 92-96% effective in preventing P. falciparum malaria, which is very good, but obviously not 100% perfect – even when taken perfectly, some infections do occur. In addition, there is some data which suggests that dairy products, taken together with doxycycline, may limit  the uptake of the drug. This is rarely communicated to patients, who are instead contrarily told sometimes that taking the pills together with dairy products can reduce side effects! As such, please let your daughter know that she should avoid dairy products for 2-3 hours around the time she takes her doxycycline.

Malaria in Ivory Coast

by

QUESTION

I am going to work in the Ivory Coast on an oil and gas platform out at sea I will be in the Ivory Coast for about 30 Days and home for 26 Days and back in the Ivory Coast for 30 Days this could go on for a couple of years. What would you suggest that I take for anti malaria? Would O need a prescription or can I get it from the chemist?

ANSWER
You usually need a prescription to get anti-malarials. None of the available anti-malarials are really recommended for long-term use, except possibly for doxycycline, and since that one requires you to take for four weeks after you have left the malarial area, you might find yourself taking a pill every day for several years! Some people on doxycycline experience sun sensitivity as a side effect, which means it might not be the best choice for people working outdoors in the tropics.

Likewise, Lariam must be taken for four weeks after leaving the malarial area, but is only taken weekly, so it might be more convenient. Lariam is unsuitable for people with certain psychiatric disorders, and many people report side effects such as anxiety and increased aggression. Moreover, I am not sure what the recommendations are regarding long term use.

Malarone (atovaquone-proguanil) is convenient in that it only has to be taken for one week after leaving a malarial area, but again it is a daily pill, and while it probably has the least number of side effects, it is also the most expensive, and could be prohibitively so for long term use.

So, as you can see, there are pros and cons with all the main forms of preventive anti-malarial medications! Since you will be working out at sea, I actually wonder how great the risk of malaria actually is—the mosquitoes which carry the malaria parasite require stagnant freshwater in order to breed, and so if the platform does not contain these areas of still freshwater and if you are sufficiently off-shore so that mosquitoes cannot fly readily from the mainland, you may actually find there is not very much malaria there, and you will only be at risk if and when you visit the mainland.

In those cases, you could look into taking Malarone or another type of medication to protect you when you are on the mainland. In addition, for peace of mind, while on the rig you could use other types of prevention against malaria, such as sleeping under a long-lasting insecticide treated bednet at night and taking care not to be bitten by any mosquitoes that might be around.

As such, I would advise you trying to find out how far the platform is from the mainland and whether there is known malarial risk there. If there is, then you should talk to your doctor about the above anti-malarial drugs and decide which one would be best for you, if any—like bednets, there are also measures you can take to protect yourself from mosquitoes which can also be very effective is used regularly and correctly.

Do I need malaria tablets to live in Nigeria?

by

QUESTION

Do I need malaria tablets to live in Nigeria? I was born and bred in the UK and want to go back to live in Nigeria for about 2 years, do I need malaria tablets?

ANSWER

It is not usually recommended to take malaria tablets for long periods of time (i.e. more than a few months). People living for extended periods in areas with malaria should focus on other methods of prevention, such as sleeping under a long-lasting insecticide-treated bednet.

The mosquitoes that carry malaria, Anopheles, feed mostly in the evenings and at night, so it is particularly important to protect yourself during these times. Screening windows and doors tightly can help prevent mosquitoes form entering, as can air conditioning inside the house (it makes the climate less suitable for the mosquitoes).

In many parts of Africa, insecticide is sometimes sprayed indoors, again to prevent mosquitoes from being inside the house. Personal protection is also important; wearing long-sleeved clothing, particularly at dawn, dusk and at night, can prevent mosquitoes from biting you, as can wearing mosquito repellent, particularly kinds containing the chemical DEET.

Regarding tablets to prevent malaria, if you really want to pursue this option, the only medication which is recommended for long-term use is doxycycline, but you should consult with your doctor about its suitability for periods of longer than 6 months, and they should also explain to you the possible side effects associated with taking it.

While the above mentioned forms of prevention should be the mainstay of your efforts to avoid malaria, it is also important to know what the symptoms are and what to do if you suspect you might be infected.

Malaria is characterized by high fever, chills, aches and nausea most commonly, and if you think you may be infected, you should immediately go to a doctor or a clinic for diagnosis. The doctor/clinician should take a blood sample and either look at it under a microscope to look for malaria parasites or they will use a drop of blood in a rapid diagnostic test. In both cases, you should only take medication to treat malaria if you are positively diagnosed.

Socio-Economic and Environmental Conditions Contributing to Malaria

by

QUESTION

what socio-economic and environmental conditions contribute to the disease?

ANSWER

Malaria transmission requires the presence of Anopheles mosquitoes; as such, conditions which favor the growth and persistence of these mosquitoes will also be hotspots for malaria transmission, provided the climate is also sufficiently warm for the development of the parasite within the mosquito.

Rural areas without sophisticated water and sanitation systems often utilize streams or ponds for everyday water needs; if these produce stagnant patches of water, they can be an ideal location for the development of mosquito larvae. Similarly, if rural farmers dig canals or ditches to irrigate their fields, these can become breeding areas. Urban areas tend to have less standing water, apart from cisterns, so in many cases transmission is less prevalent in urbanized locations. As a further socio-economic factor, preventing mosquitoes from entering the house and biting people is  key way to prevent infection. Rich people in malarial areas may be more able to have fully screened houses, possibly even with air-conditioning, which will prevent mosquitoes from establishing in the house. They may also be more likely to have access to a long-lasting insecticide treated bednet, which further reduces mosquito bites, and also access to accurate diagnostic screening and treatment, if they do happen to get infected.

All of these factors contribute to making malaria burden highest in some of the world’s poorest areas, with the highest levels of mortality in sub-Saharan Africa.