Malaria Prophylaxis for Indonesia

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QUESTION

I have been working a 4-week rotation between the USA and East Kalimantan (Borneo) for about 2 years. While on Borneo, I am in the jungle much of the time. I have never contracted malaria. I am embarrassed to say I thought I had been inoculated for malaria when I first started working here. I just spent 10 days in a hospital last month fighting a blood degenerating viral infection not unlike hemophiliac dengue. Is there a preferred Rx I should take for malaria? I have no allergies to medicines that I am aware of. I am 57 year-old male.

ANSWER

Given the amount of time you spend in rural areas of Borneo, you probably should consider anti-malarial medication to prevent infection. There are three types of drug which are recommended against malaria in Indonesia: atovaquone-proguanil (sold as Malarone), mefloquine (sold as Lariam) and doxycycline. Each has pros and cons: Malarone and doxy have to be taken every day, while Lariam is only taken weekly, which might make it more convenient. However, both doxy and Lariam should be taken for a full 4 weeks after leaving the malarial area, while Malarone is only taken for a week after leaving.

In my opinion, Malarone has the fewest and mildest side effects (though some people complain of upset stomachs and disturbed sleep patterns), while doxycycline is sometimes a problem in the tropics since it can cause sun sensitivity. Lariam is not recommended for people with a history of mental illness, and has been reported to have psychiatric side effects, including nightmares, hallucinations and even altered behavior. Of the three, Malarone is the most expensive, and doxycycline usually the cheapest.

In terms of taking them long term, I don’t know of any studies that look at long term usage of Malarone (it is expensive enough that I doubt anyone takes it for very long trips!), while people do safely take doxycycline for periods of several months, and Peace Corps volunteers and American expats routinely take Lariam for periods of several years.

Of course, many people living long term in malarial areas do not find it convenient to take pills to prevent malaria, and focus on other preventative measures, mainly revolving around killing mosquitoes and avoiding being bitten. Sleeping under a long-lasting insecticide treated bednet is one such method, which is cheap, easy and very effective.

Incidentally, the area you are in is interesting from a malaria point of view since it is one of the few places where transmission of Plasmodium knowlesi occurs. This is a type of malaria which was thought to be only present in macaque monkeys, until human cases started becoming more prevalent a few years ago. Now it is considered a “human” type of malaria, and an emerging threat in south-east Asia. It’s important to be aware of it as the mosquitoes which transmit it tend to be forest-dwelling (since that is where the macaques live), and although very easily treated with chloroquine or other anti-malarials, an infection can progress rapidly into quite severe disease.

If you suspect you might have malaria at any point, therefore, it is crucial to get out and get tested at a clinic or hospital, where they can promptly treat you if you test positive. Be aware also that if tested via microscopy, P. knowlesi can often be confused with P. malariae or P. vivax; while the initial treatment is likely to be the same for all three, if you had P. vivax you might be told about taking an additional medication, called primaquine, to prevent future relapses, whereas relapses do not occur with P. knowlesi.

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!

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.

Post-infection Malaria Medication

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QUESTION

My daughter has recently returned from a trip to Borneo. Even with aggressive preventive anti-mosquito behaviour (long sleeves/pants, deet applications and mosquito netting) but not anti-malarial medication, she received over 30 bites. She is now exhibiting some symptoms (body aches, headache and severe fatigue). She has an appointment at the doctors in 2 days time. Is there some kind of post-trip medication (like doxycycline) she can take as a precaution even if the malarial test comes back negative at this early of a time. Thanks.

ANSWER

The important thing to note here is that if your daughter has symptoms of malaria, then she should be diagnosed and, if positive, treated with medication aimed at curing active malaria. Doxycycline is NOT a drug used for the treatment of malaria, so there is no point taking it if she is already exhibiting symptoms.

Furthermore, some types of malaria found in Borneo (notably P. falciparum and P. knowlesi) can become more severe very quickly – 2 days may be too long to wait. If you live in an area where malaria transmission occurs, you may be able to buy a self-testing kit (also known as a rapid diagnostic test, or RDT) for malaria in a local pharmacy. Otherwise, if your daughter’s symptoms get worse, you should take her to an emergency room and explain her travel history and subsequent risk of having malaria.

There is no substitute for taking prophylactic malaria medicine; it might be that if your daughter had started taking prophylactic medicine as soon as she started receiving multiple mosquito bites, then she may have been protected to some degree. However, malaria has a latent period, and so she would have had to continue taking the medication for a period of time after returning home as well – with doxycycline, this means taking the drug for a further four weeks.

Current Status of Malaria

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QUESTION:

What is the current status on malaria? And does P.knowlesi spp. pose a greater threat compared to the others? Does the number malaria cases increase every year globally? Is P. knowlesi spp. more dangerous than the others and why?

ANSWER:

I’ll answer your question about Plasmodium knowlesi first. So far, it is considered a relatively minor source of malaria in humans, as its natural host are macaque monkeys and so it is usually thought of as a “zoonotic” disease.Between 2000-2008, there were only been about 400 reported cases of P. knowlesi, all restricted to south-east Asia, and mainly Borneo. These figures are low compared to other forms of malaria, such as P. falciparum, which in Africa alone accounts for millions of cases a year, and close to a million fatalities. However, there are some causes for concern with regards to P. knowlesi.

First of all, it appears to be an emerging human infection; the first cases were traced back to the 1960s, with the number of cases increasing in recent years. While some of this increase is likely the result of higher accuracy diagnosis and awareness about malaria, it is also hypothesised that the increasing population density in forested areas of south-east Asia may also be leading to greater numbers of people being exposed to this parasite. Secondly, although easily treated with anti-malarial drugs, the life cycle of P. knowlesi is such that it reproduces very rapidly in the human host, causing cycles of fever every 24 hours (a so-called “quotidian fever”). This means that the infection can progress rapidly, becoming severe in a matter of days, and therefore requiring prompt treatment. Finally, although locally restricted to south-east Asia, P. knowlesi has become the dominant form of malaria in some of these areas, notably Sarawak. As such, although currently not a major source of malaria in the global human population, it is locally important to public health and moreover, more research is needed to determine why the number of cases has been on the rise.

As for your questions about the status of malaria globally, the number of cases annually is estimated to be around 250 million. The vast majority of these are in Africa. Over 700,000 people, mainly children under five, die from malaria each year. As for whether the number of cases is increasing or decreasing, this is hard to determine. For one, a large number of cases are not reported every year, making accurate estimates difficult. Secondly, the world’s population is growing, and it is growing at the greatest rate in Africa, where the majority of malaria cases occur. As such, even if the proportion of people with malaria decreases over time, due to health initiatives such as distributing long-lasting insecticide treated bednets or free treatment, the total number of cases may still rise. Another problem we face in the fight against malaria is climate change: as the world’s patterns of rainfall and temperatures change, new areas become susceptible to malaria transmission, putting more people at risk. However, what is very encouraging is that deaths from malaria seem to be decreasing on a global scale.

Malaria No More is an organisation dedicated to eliminating deaths from malaria by the year 2015; more information about their methods and some of their success stories can be found on the Malaria No More website.

Of Macaques and Men

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Plasmodium knowlesi —a new challenge in the Roll Back Malaria Program?

Deforestation oil palm Malaysia

Oil palm plantation in Malaysia: Such land-use change may be affecting malaria transmission. Photo courtesy of Yusmar Yahaya (http://www.flickr.com/photos/leafbug/4880638055/sizes/m/)

Mention of malaria often conjures images of infants hospitalized in Africa. Although most deaths from malaria are children under 5 in sub-Saharan Africa, there are many different types of malaria that put over half of the world’s population at risk in subtropical and tropical regions worldwide.

There have historically been four species of Plasmodium parasites that cause malaria humans.  P. falciparum is the most lethal species that infects humans, whereas P. vivax is the most widespread.  P. vivax and P. ovale also cause clinical symptoms and decreased economic potential in certain regions.

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