Symptoms of Malaria but Tests Negative

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QUESTION

My sister has been suffering from fever from past 22 days temperature varying from 102-106 with chills shivering, headache, body pain,nausea and muscle ache but tested negative for malaria. She also tested negative for dengue, swine flu, hiv, and many others.  So out of frustration we gave her mefloc 250 and she seems to be responding. She is still having fever that is after 12 hrs of medication but the temprature is ranging between 98-100 and there is no headache and no chills and shivers.  Now we are confused how to confirm that it is really malaria and when will the fever stop completely. Should we shift her to a some other hospital at present she is in Pune.

ANSWER

The diagnosis of malaria is confirmed by observing parasites on a blood smear.  There are also Rapid Diagnostic Tests (RDT) that can be done with a pin prick of blood, but the blood smear is the definitive test. It is possible, that in your sister’s case,  a proper malaria test was not done or not interpreted correctly, and she does have malaria and it is responding to the medicine.   Alternatively it could be that your sister does not have malaria, but suffers from another problem that coincidentally is resolving itself at the same time the anti-malarial medicine is given.  It is hard to determine exactly what is wrong, but the good news is that she is getting better.

Sometimes medicine is given on presumption of illness which is what happened in your sister’s case. However, if someone has uncomplicated falciparum malaria, (most prevalent in India)  WHO recommends Artemisimin Combined Therapy (ACT), which uses an artemisinin compound with another anti malarial, such as mefloquine, not mefloquine alone.  If your sister’s fever returns, make sure to have a blood smear taken to see if it is malaria or not, and if so what kind of malaria it is, to better tailor her medicine.

Anti Malaria Tablets – When to Start

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QUESTION

I am due to travel to South Goa on 27th October 2012. It is 9th Oct now. It says I should start taking my tablets 1 week before traveling, however I was wondering if it was okay to start taking them now so my body can get used to the side affects before I travel. I do not want to be ill all the time whilst I am away.

ANSWER

Yes, you do need to take preventive medicine against malaria when visiting India and it is best to follow instructions given by your doctor or the drug insert. For India,  the US Center for Disease Control (CDC)  recommends Malarone (Atovaquone/proguanil), Doxycycline and Mefloquine as drugs to prevent malaria.

Malarone  needs to be started 1-2 days before travel to a malarial area, taken daily and continued for 7 days after leaving the area.

Doxycycline needs to be started 1-2 days before travel, is taken daily and needs to be continued for 4 weeks after leaving malarial areas.

Mefloquine needs to be started 2 weeks before travel, is taken weekly, and needs to be continued for 4 weeks after leaving.

Chloroquine is NOT recommended for India because of resistance, so it is not effective.

Medicine for Malaria

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QUESTION

is rotam and maladar malaria medicine?

ANSWER

I have never heard of Rotam, but Maladar is the brand name of a combination sulfadoxine-pyrimethamine, and is used to treat malaria. However, it should be noted that it is not recommended by the World Health Organization as a first-line treatment option, due to concerns about drug resistance, and also lack of efficacy against certain types of malaria.

Instead, first-line recommended treatment is of an artemisinin-based combination therapy, or ACTs, which combine an artemisinin derivative (such as artesunate, artemether or dihyrdoartemisinin) with another anti-malarial drug, such as lumefantrine, piperaquine or mefloquine. Common brand names include Coartem, Lonart and Duo-Cotecxin.

Preventative Medication for Malaria in Dominican Republic

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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

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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).

Antimalarial Drugs During pPregnancy

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QUESTION

What is the safest antimalarial drug to be used by a pregnant woman in her second trimester?

ANSWER

With regards to treating malaria, intravenous artesunate (or quinine, if artesunate is not available) should be used for the treatment of severe/complicated Plasmodium falciparum malaria. Signs of severe and/or complicated malaria include impaired consciousness, organ failure, abnormal bleeding, hypoglycemia, severe anemia and/or inability to ingest medication orally. Treatment for uncomplicated malaria (where the above signs are absent) in pregnant women is usually chloroquine for P. vivax, P. ovale, P. knowlesi and P. malariae, as well as for P. falciparum if there are no reports of this parasite being resistant to chloroquine in the area. In places where P. falciparum is resistant to chloroquine, quinine and clindamycin should be used to treat this parasite in pregnant women.

As for preventative anti-malarials (chemoprophylaxis), if a pregnant woman is travelling to an area where only P. vivax, P. ovale, P. knowlesi, P. malariae or chloroquine-sensitive P. falciparum is transmitted, then she should take chloroquine to prevent malaria. In areas where P. falciparum is resistant to chloroquine, mefloquine is also suitable during pregnancy. Note that in some areas of south-east Asia, there are areas where P. falciparum is resistant to mefloquine, which may prevent its suitability as a prophylactic in this region. Preventing malaria during pregnancy is crucial, since the mother, particularly if it is her first baby, is especially vulnerable to the parasite. Moreover, malaria can have a negative impact on the fetus.

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 Pills Vietnam

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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.

How is Malaria Prevented?

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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

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Malaria in Ivory Coast

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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.