Preventative Medication for Malaria in Dominican Republic

by

QUESTION

I just read the CDC recommended medicines for preventing malaria and I am confused. It gives the pros and cons for taking one drug over another. My husband and I are in excellent health, we need our td boosters. Our 15 year old is current in his vaccinations. We will be in D.R. for 2.5 weeks near Jarabacoa then Rio San Juan. We will be on a missionary trip. What medicine should be take in your opinion before hand?

ANSWER

Apart from some basic differences, particularly regarding which forms of malaria they are effective and against, and in what areas of the world, the choice of which anti-malarial to take mostly comes down to personal preferences. So, for example, in most of Africa, malaria is resistant to chloroquine, so this drug is not recommended for travellers; conversely, in parts of Thailand, malaria is resistant to mefloquine, so likewise, if travelling to those areas, you would need to pick another drug.

Having said that, in the Dominican Republic the malaria is sensitive to all forms of anti-malarial drugs, so you don’t have to worry about that. Between the four main types of drug you can take (atovaquone-proguanil, doxycycline, mefloquine and chloroquine), there are significant differences in price, frequency and duration of taking the tablets and side effects, all of which may influence your decision to take one over another. They are all roughly equal in terms of their efficacy in preventing malaria, apart from when resistance is an issue, as I’ve mentioned.

Of the four, chloroquine and mefloquine are taken weekly, while atovaquone-proguanil (often sold as Malarone) and doxycycline are taken daily. Some people prefer the convenience of only having to take a pill every week, but the disadvantage is that these both have to be started 2 weeks before you travel, whereas the daily medications can be started the day before you leave. While Malarone only needs to be taken for one week after returning from your trip, the others should be taken for a full four weeks, to ensure that malaria does not surface once you’re back.

All have some reported side effects, but in my experience, Malarone has the fewest and the most mild, though some people report upset stomachs and disturbed sleep. Chloroquine also has some potential gastrointestinal side effects and can also produce itching, which is a particularly common side effect in people of African descent. The tablets have a metallic taste which some people find unpleasant.

Doxycycline is also an antibiotic, which means it can also help prevent other infections while travelling, though one of its common side effects is sun sensitivity, which may make it less suitable for travelling in tropical areas (personally I have not experienced this side effect, though I have known many people who have).

Mefloquine (sold as Lariam) is not recommended for people with a history of mental illness, and is known to have psychiatric side effects, including nightmares, hallucinations and even altered behavior (again, my whole family took Lariam during one trip, and no one experienced any such side effects, but you should be aware of the possibilities).

Another important factor to consider is price: doxycycline is usually the cheapest drug, and Malarone the most expensive (could be as much as $100 for each of you, for enough to cover the 2.5 week trip, plus a week of tablets once you get back), with the others somewhere in between.

Again, ultimately the choice usually comes down to what factors are important to you and your personal preference. I tend to pay the extra for Malarone since I prefer the convenience of starting the pills right before I leave, and only taking them for a week when I return. Furthermore, when I am away, I am usually working outside, and so would rather not risk the potential sun sensitivity side effect of doxycycline. You should also talk with your doctor about what is usually available in your area from local pharmacies, as they may not carry the full selection of choices.

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).

Malaria Prophylaxis for Indonesia

by

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 Pills Vietnam

by

QUESTION

I am travelling from Hanoi to Ho Chi Minh city via Haalong Bay, Hue and Hoi An, all are Costal areas. Should I take Malarone? I would prefer not to as I am trying to get pregnant.

ANSWER

In Vietnam, costal areas north of Nha Trang are considered malaria-free, as are the cities of Hanoi and Ho Chi Minh city. As such, it is only rural and costal areas closer to Ho Chi Minh city where you might be at risk. One option you have is to take mefloquine (Lariam) – it is safe to take while pregnant (or trying to get pregnant), and is effective in most areas of Vietnam. There is resistance to mefloquine in the Mekong Delta region, but it doesn’t sound like you will be travelling there, so this shouldn’t be a problem.

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.

How is Malaria Treated

by

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.

Malaria in Myanmar (Burma)

by

QUESTION

Is Malaria an issue in Myanmar where I am going in June?

ANSWER from Malaria.com Editor

YES. Malaria is a risk in all rural areas of the country below 1,000 meters of altitude (anything below 3300 feet). Rangoon/Yangon and Mandalay do not have malaria.

You should take medication to prevent malaria (prophylaxis) throughout your stay, and also protect yourself from getting bitten by mosquitoes if you are travelling to risk areas for malaria. Personal protection measures including sleeping under an insecticide treated bednet, wearing insect repellent and wearing long-sleeved clothing, especially in the evenings, early morning and throughout the night, which is when the mosquitoes that transmit malaria are active and feeding.

Myanmar/Burma is known to have strains of malaria which are resistant to certain medications; specifically, chloroquine resistance is widespread, while some areas in addition have malaria which is resistant to mefloquine (sold as Lariam). As such, the CDC recommends atovaquone-proguanil (sold as Malarone) or doxycycline if you will be travelling in the provinces of Bago, Kachin, Kayah, Kayin, Shan, and Tanintharyi. In all other areas of the country, mefloquine should also be considered as an option.

Answer from Malaria.com medical advisor

For anyone planning a trip abroad its important to know the health risks in your destination. Malaria is an especially important concern for anyone traveling to tropical or subtropical regions. Here’s what I found on the CDC Travelers’ Health website. I find this is the best place to look for this information.

  • Areas of Burma with Malaria: Rural areas throughout the country at altitudes
  • If you will be visiting an area of Burma with malaria, you will need to discuss with your doctor the best ways for you to avoid getting sick with malaria. Ways to prevent malaria include the following:
  • Taking a prescription antimalarial drug.
  • Using insect repellent and wearing long pants and sleeves to prevent mosquito bites. Sleeping in air-conditioned or well-screened rooms or using bednets.
  • Some areas of Burma have resistance to certain antimalarial drugs.

See the malaria information for Burma to find out which antimalarial drug is appropriate for the area you plan to visit in Burma.

Relapsing Malaria

by

QUESTION

I’m constantly on malaria drugs, fall ill every 2 weeks and always diagnosed with malaria.I’m getting really fed up and need a permanent solution to all of this. I want to live a healthy life and I’m tired of being on malaria drugs. How do I overcome malaria permanently?

ANSWER

It is very unusual to be reinfected so constantly with malaria. First of all, how are you getting diagnosed? You should be getting a blood test, and not relying on symptoms only; the symptoms of malaria are very general and it could be that you are suffering from something else entirely.

The two main methods for accurate diagnosis are blood smear and rapid diagnostic test. The blood smear is used throughout the world, but can sometimes miss light infections (though if you feel sick, your infection is likely heavy enough to be detected by this method). The problem is that it requires a trained technician to take the sample, prepare it properly, and read it thoroughly and accurately. In my experience, many clinics, especially if they are rushed and busy, will not take the time to read a blood slide properly, and will just diagnose malaria without looking. This is really bad!

It is very important to be properly diagnosed, so you can get the correct treatment, and if you don’t have malaria, you can be diagnosed for something else. The second kind of diagnostic is a rapid diagnostic test, or RDT. This looks for antibodies to malaria in your blood, and is very sensitive and quick. In an ideal world, you should try to have both done, to cross-check the results.

The next thing is to check whether you are receiving the correct treatment for the type of malaria that you have (if you are positively diagnosed with malaria). In many parts of the world, malaria has become resistant to some of the main medications used against it. Notably, this is the case in many places with Plasmodium falciparum, the most dangerous kind of malaria, which has become resistant to chloroquine in many parts of the world, to sulfadoxine-pyrimethamine (sold as Fansidar in many places) and also to mefloquine (sold as Lariam) in some places. As such, the World Health Organisation NEVER recommends these treatments be given as first line drugs against P. falciparum malaria—instead, they recommend artemisinin-combination therapies (ACTs), such as Alu, Coartem or Duo-Cotecxin. If you have been diagnosed with P. falciparum, you must try to take these kinds of drugs first. No resistance to ACTs has been reported, so if you take the full dose correctly, as prescribed by your doctor (and check to make sure the drugs are not expired), then you should be cured of malaria.

However, treatment does not stop you from getting infected again, and this is where prevention comes it. Preventing malaria is a cornerstone of control efforts. Since malaria is transmitted by a mosquito, preventing mosquitoes from entering the house, and particularly stopping them from biting you at night, is crucial. Screening all doors and windows can help stop mosquitoes from getting in, and in high transmission areas, many people will also spray inside their houses every once in a while with insecticides to kill any lingering insects.

In addition, sleeping under a long-lasting insecticide treated bednet can drastically reduce the number of mosquitoes that are able to bite you at night. If you already have a net, it may be worth re-dipping it in insecticide (usually permethrin) to make sure it is still working effectively. The mosquitoes that transmit malaria feed at night, so if you are walking around outside in the evenings or at night, it is important to try to wear long-sleeved clothing, to prevent them from accessing your skin.

All of these efforts will help prevent you from getting malaria again in the future.

Malaria Fever

by

QUESTION

My Father aged 65 years was diagnosed with 2 types of malaria almost a week back. he has been given medicines but temperature is fluctuating and not coming down. all other organs are functionining properly except platelet count which is little less.

Now he has been suggested new medicines for a duration of 14 days.
How fast can he recover from this malaria and when will the fever come down?

ANSWER

When patients are given the appropriate treatment against malaria, the fever is usually reduced very quickly and the patient will start to recover after a few days. The right kind of treatment depends on the severity of the infection and the type (or, in your father’s case, types) of malaria the patient is infected with.

If your father was infected with P. falciparum alongside another type of malaria (probably P. vivax, P. malariae or P. ovale), then he should have first received an artemisinin-based combination therapy (ACT) drug first. These drugs combine artemisinin or a derivative (such as artemether, artesunate or dihydroartemisinin) with another anti-malarial, such as lumefantrine. Common brand names of these ACTs include Coartem, Alu and Duo-Cotecxin.

There are no reported cases of resistance to these combination therapies at present, so if your father continued to feel sick after completing this treatment, he should be re-tested for malaria; it is possible that the malaria parasites were killed, and his continuing fever was an after effect either of the medication or just an indication that the body was recovering from the infection.

If he was re-tested and found positive, then other second-line drugs can be prescribed. However, it is important to note that malaria is resistant to chloroquine in many areas, and so this drug is not suitable for treatment in these places. Similarly, resistance is widespread to sulfadoxine-pyrimethamines, such as Fansidar, and in south-east Asia, P. falciparum is also resistant to mefloquine (Lariam) in some cases. As such, your father’s doctor should be careful to prescribe him an appropriate treatment for the area in which he is living.

In addition, if your father was found to be co-infected with either P. vivax or P. ovale, then there is a chance of later relapse into malaria again, weeks or even months after the initial infection has been treated. This is because the parasites in these types of malaria can form dormant stages in the liver, where they escape being killed by the normal forms of treatment. In this case, your father should ask about the possibility of being treated with primaquine; the course is normally 14 days, so it may be that this is what his doctors have currently given him. If so, this will kill the dormant liver stages and prevent relapse. Prior to taking primaquine, patients should be tested for G6DP deficiency, as patients with this condition may become dangerously anaemic when they take primaquine.

Can’t Get Rid of Malaria

by

QUESTION

Each and every month I am suffering from malaria ..Treatment is also going on but I am unable to get rid of it.

ANSWER

It is very unusual to be reinfected so constantly with malaria. First of all, how are you getting diagnosed? You should be getting a blood test, and not relying on symptoms only; the symptoms of malaria are very general and it could be that you are suffering from something else entirely. The two main methods for accurate diagnosis are blood smear and rapid diagnostic test. The blood smear is used throughout the world, but can sometimes miss light infections (though if you feel sick, your infection is likely heavy enough to be detected by this method). The problem is that it requires a trained technician to take the sample, prepare it properly, and read it thoroughly and accurately. In my experience, many clinics, especially if they are rushed and busy, will not take the time to read a blood slide properly, and will just diagnose malaria without looking. This is really bad! It is very important to be properly diagnosed, so you can get the correct treatment, and if you don’t have malaria, you can be diagnosed for something else. The second kind of diagnostic is a rapid diagnostic test, or RDT. This looks for antibodies to malaria in your blood, and is very sensitive and quick. In an ideal world, you should try to have both done, to cross-check the results.

The next thing is to check whether you are receiving the correct treatment for the type of malaria that you have (if you are positively diagnosed with malaria). In many parts of the world, malaria has become resistant to some of the main medications used against it. Notably, this is the case in many places with Plasmodium falciparum, the most dangerous kind of malaria, which has become resistant to chloroquine in many parts of the world, to sulfadoxine-pyrimethamine (sold as Fansidar in many places) and also to mefloquine (sold as Lariam) in some places. As such, the World Health Organisation NEVER recommends these treatments be given as first line drugs against P. falciparum malaria – instead, they recommend artemisinin-combination therapies (ACTs), such as Alu, Coartem or Duo-Cotecxin. If you have been diagnosed with P. falciparum, you must try to take these kinds of drugs first. No resistance to ACTs has been reported, so if you take the full dose correctly, as prescribed by your doctor (and check to make sure the drugs are not expired), then you should be cured of malaria.

However, treatment does not stop you from getting infected again, and this is where prevention comes it. Preventing malaria is a cornerstone of control efforts. Since malaria is transmitted by a mosquito, preventing mosquitoes from entering the house, and particularly stopping them from biting you at night, is crucial. Screening all doors and windows can help stop mosquitoes from getting in, and in high transmission areas, many people will also spray inside their houses every once in a while with insecticides to kill any lingering insects. In addition, sleeping under a long-lasting insecticide treated bednet can drastically reduce the number of mosquitoes that are able to bite you at night. If you already have a net, it may be worth re-dipping it in insecticide (usually permethrin) to make sure it is still working effectively. The mosquitoes that transmit malaria feed at night, so if you are walking around outside in the evenings or at night, it is important to try to wear long-sleeved clothing, to prevent them from accessing your skin. All of these efforts will help prevent you from getting malaria again in the future.