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.

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.

Malaria Prophylaxis in Ghana, Africa

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QUESTION

My husband will be traveling to Ghana soon. We have Mefloquine and Primaquine. Which one do you think is best for prophylaxis in Ghana? He also has Fansidar, but we understand it’s best not to use this for prophylaxis. Thank you for your help!

ANSWER

There are positives and negatives associated with both of these medications. Mefloquine is recommended for travelers in Ghana (whereas the Centers for Disease Control does not explicitly recommend primaquine for this area, since primaquine is particularly effective against Plasmodium vivax malaria, which is almost completely absent from West Africa), and only has to be taken once a week (primaquine must be taken daily).

A disadvantage with mefloquine is that you must start taking it 2 weeks before your trip, whereas primaquine can be started as little as 1-2 days before travel; mefloquine is also not recommended for people with a history of psychiatric or mental problems, as it can cause severe side effects. Even healthy individuals often report disturbing dreams or increased agression/anxiety while taking mefloquine. However, one major disadvantage to primaquine is that you must be tested for G6DP deficiency prior to taking it – your husband may have already done this, prior to being prescribed the drug. People with G6DP deficiency should not take primaquine.

Overall, the decision comes down to personal preference, though from a disease perspective, mefloquine would probably be the better choice for travel to Ghana, given the higher prevalence of P. falciparum malaria in this region, as opposed to P. vivax. Other options to consider would be atovaquone-proguanil (Malarone – expensive, taken daily, but very effective and very well tolerated by most people, with very low side effects) or doxycycline (very cheap, taken daily, is an antibiotic so can prevent some other infections but often results in sun sensitivity, which can be a problem in the tropics). Both of these can be started 1-2 days before arriving in the malarial area.

After you come back, I would be very grateful if you could take our malaria medication side effects survey, as we are very interested in hearing from our readers what their experiences with malaria prophylaxis and treatment have been.

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 Prevention

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QUESTION

What are the ways in which you can prevent yourself from being infected with malaria?

ANSWER

Malaria prevention consists of a combination of mosquito avoidance measures (since malaria is transmitted by infected mosquitoes) and chemoprophylaxis (medication to prevent the establishment of malaria in your body, if you do get bitten). 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 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 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.

Paludrine/Avloclor Anti Malaria Travel Pack

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QUESTION

Is this anti malaria travel pack suitable for Borneo?

ANSWER

This kit is NOT appropriate for preventing malaria in Borneo. Avloclor contain chloroquine phosphate, and some types of malaria present in Borneo are resistant to chloroquine.

The CDC recommends that travelers to Malaysian or Indonesian Borneo should use atovaquone-proguanil (Paludrine contains proguanil, but the drug Malarone contains the combination of proguanil and atovaquone in one pill), mefloquine (sold under the brand name Lariam) or doxycycline.

Each of these different types of prophylaxis (preventative medication) has its advantages and disadvantages: Malarone is very expensive but many people consider it to have the fewest side effects; Lariam has been associated with severe side effects and is not recommended for people with a history of mental illness, but only needs to be taken once a week (the others require a daily pill); and doxycycline is cheap but may produce sun sensitivity.

When you return from your trip, please take a moment to share your experiences with anti-malarial medication by taking our malaria survey. We will compile all the results and post them on MALARIA.com, so visitors to the site can be informed about the preferences and side effects experienced by other members of the public who have used different forms of prophylaxis.

Malaria Medicine for Pregnant Women

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QUESTION

What medicine can be given to a pregnant woman who has malaria?

ANSWER

The type of anti-malarial that should be given to a pregnant women depends on the type of malaria they have, its severity and how long she has been pregnant. Chloroquine, quinine and artemisinin-derivatives can be given during all trimesters, but in many places malaria is resistant to chloroquine.

In general, the World Health Organisation recommends ACTs (artemisinin-based combination therapies) as the first line treatment against uncomplicated malaria. Mefloquine and pyrimethamine/sulfadoxine are able to be given the second and third trimesters; again, in some areas, resistance to mefloquine has been detected. Moreover, some people are allergic to sulfas, and so pyrimethamine/sulfadoxine would not be appropriate for these patients. Primaquine, doxycycline and halofantrine are contraindicated during pregnancy.

Malaria Prophylaxis in Pakistan

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QUESTION

Do I need antimalarials if i am returning to my home country in pakistan after two years?

ANSWER

That depends on where you will be going in Pakistan and how long you are planning on staying. Malaria is a risk at all areas under 2,500m of altitude. However, antimalarials are not recommended to be taken on a long-term basis, so if you are relocating home permanently and will be in an area at risk of malaria transmission, you should look into other preventative measures. This includes sleeping under a long-lasting insecticide-treated bednet at night, which prevents infected mosquitoes from biting you, and also potentially spraying indoors to kill mosquitoes. Making sure all rooms are well-screened can also keep mosquitoes out, and wearing long-sleeved clothing and insect repellent on exposed skin will further reduce bites. If you suspect you might have malaria (for example if you experience high fever, particularly coming in cycles interspersed with chills), you should immediately visit a doctor or clinic to test for malaria, so you can receive prompt and accurate treatment.

If you are staying in Pakistan for a short period of time (< 6 weeks) you could certainly consider taking an anti-malarial drug to prevent malaria. Doxycycline, mefloquine (sold as Lariam) and atovaquone-proguanil (sold as Malarone) are all recommended as appropriate prophylactic medications against malaria in Pakistan.