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.

Malaria Prophylaxis and Getting Pregnant

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QUESTION

I will be traveling to the Ivory Coast for two weeks. I will be staying with my in-laws in the city in very clean conditions with a/c etc. I am a strict vegetarian so I will be bringing most of my food and will have access to clean water. I myself grew up in an undeveloped nation so I am used to precautions needed to prevent illness. However, mosquitoes do seem to love to bite me.

I sadly just had a miscarriage and want to try to conceive again within the next month. My doctor has prescribed Atovaquone-Proguanil for me. I am concerned about taking the drug since my body is recovering and as I said I want to try to conceive upon returning. How long will this drug stay in my system? Does it effect fertility or a fetus? Do the benefits outweigh the risks? How likely it is that I wouldn’t show signs of malaria until much later after potentially conceiving? I am also concerned of the emotional side effects of the medicine coupled with my recent loss.

Thank you for any information.

ANSWER

Firstly I am very sorry for your loss.    Your doctor prescribed Atovaquone-Proguanil  which is a first class  drug to prevent malaria.  Some people do experience  side effects but many do not. It is recommended to take the pill at the same time each day and with food or a milky drink.  Start taking the drug 1-2 days before you arrive and continue for a week afterwards. The drug should be out of your system within a few days after stopping it. Don’t try to conceive until after that.  While I do not know how long ago you had the miscarriage, WHO and UNICEF recommend waiting around 6 months before trying again, so that your body (and emotions) can recover fully.

Besides taking Atovaquone-Proguanil, be sure to protect yourself from mosquito bites; protect you legs and arms by wearing long sleeves and trousers/long skirt, avoid being out during dawn and dusk when mosquitoes like to feed, use an insect repellent (you can try citronella if you are worried about chemicals), and if the house isn’t screened (or even if it is), sleep under a long acting insecticide treated bed net.   Enjoy your trip and take care.

Malaria Infection Even With Prevention

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QUESTION

Can you still get infected with Malaria even when taking a preventative such as doxycycline or Malarone?

ANSWER

Yes, no prophylactic medication is 100% effective though both Malarone and doxycycline are usually over 90% effective, when taken properly. It is important to make sure each tablet is taken approximately at the same time each day, and in the case of Malarone, it is important to take it with some fatty food as this assists in absorption. Conversely, doxycycline should not be taken within 6 hours of consuming dairy products, as the calcium present in milk can prevent uptake of doxycycline. For these reasons, it is important to also use other methods of preventing malaria, such as sleeping under a long-lasting insecticide treated bednet.

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).

Do I need malaria tablets to live in Nigeria?

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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.

Malaria Pills Taken with Other Drugs

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QUESTION

Can malaria pills be taken with other vaccines or medications?

ANSWER

Malaria pills can be taken with most other medications, though this may vary with the type of prophylaxis (medication to prevent malaria) that you take, and there may be some specific combinations which are not recommended, so be sure to consult with a doctor about specific drug interactions. For example, Malarone (atovaquone-proguanil) is known to interact with anticoagulant drugs such as warfarin and aspirin, though depending on the dose it may be possible to take both, as long as the patient is carefully monitored.

If you are planning to travel to a malarial area, you will likely need to get a prescription before being able to get prophylaxis, so you should take that opportunity to talk to the nurse or physician about your specific medications and whether they will interact.

Severe Head Pain with Malaria

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QUESTION

Can severe head pain be a symptom of mistreated malaria? My son just returned from an 8 month trip to Ghana. He had malaria 3 times and typhoid 1 time. He is now dealing with a severe head pain in his frontal lobe.

He took doxycycline every day and when he got really sick, he took Coartem. He was finally sent home because they couldn’t figure out why he has such severe head pains. Where do we go from here? He has an MRI scheduled and an appointment with an Infectious Disease Doctor. I am afraid they will not know what to do to help him. I am seeking more advice. Hopeful…CT

ANSWER

Severe head pain is not associated with mistreated malaria, nor indeed is considered a possible lasting effect of malaria infection. You are doing the right thing by going to see a doctor, including one who is an infectious disease specialist—I hope they also have experience with tropical medicine, since in the US and Europe, many very well-trained doctors are still not very familiar with the types of infections which are more commonly observed in the tropics.

Your son was right to take Coartem when he had malaria, but do you know whether he went to a clinic for diagnosis first? The symptoms of malaria are very general, such as fever, chills, nausea and aches, and many people in malarial areas (particularly visitors) often assume they have malaria when in fact their symptoms could be caused by a number of other things.

Secondly, doxycycline is considered a very effective preventive medication against malaria, but only if taken properly. Since doxycycline can cause mild stomach upset, many people take it with milk, which can lessen these symptoms; however, the calcium in the milk can bind to the drug, preventing successful absorption and reducing its efficacy as a malaria preventive.

If your son had a diet high in diary products or took antacids while in Ghana, this could explain why he suffered several malarial episodes. Alternatively, if he took the drug regularly and correctly, and particularly if he did not seek diagnosis via blood test from a clinic, that may be an indication that he wasn’t suffering from malaria at all, and other causes should be explored.

Finally, one of the very well-described side effects of doxycycline is its tendency to cause people to become very sun sensitive. While this usually manifests itself in skin sensitivity, it could also be that your son has become more visually sensitive to light, which in itself could lead to severe headaches. I hope he feels better soon!

Can Child Be Affected by Mother’s Malaria

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QUESTION
If the baby’s mother has malaria, can it affect the child?

ANSWER

If the mother is pregnant when she gets malaria, particularly if it is her first pregnancy and particularly if she has never had malaria before, the effects on both the mother and child can be very serious. For the mother, this is because her immune system changes when she gets pregnant. This leaves her more vulnerable to the effects of malaria, including anaemia.

The most dangerous type of malaria, P. falciparum, also seems very able to infect cells in the placenta, leading to a higher intensity infection, and also reducing oxygen delivery to the baby. This, combined with the mother’s illness and anaemia, can lead to low birth weight, anaemia and other complications in the child once it is born. Malaria can also pass through the placenta, or be transferred to the baby through blood during childbirth, resulting in “congenital malaria”; that is, malaria which has been passed from mother to infant. Since newborns have inexperienced immune systems, malaria in the first days or weeks of life, and especially if the child is already low birth weight, can be very dangerous.

As such, a lot of effort has gone to finding ways to prevent malaria in pregnancy and to treat women who do get malaria while pregnant to prevent negative effects both to her and her unborn child. These efforts mainly involve the distribution of long-lasting insecticide treated bednets, and in some places also include the administration of intermittent preventive therapy, where women are given periodic doses of anti-malarials during pregnancy to protect against the disease.

Mefloquine

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QUESTION

My son, 7 years old, took Mefloquine course for malaria prevention last year. We are travelling to INdia again this year. Does he and myself need to repeat the anti-malaria pills again this year?

ANSWER

Yes. You need to take anti-malarial preventative medication every time you go back to a malarial area. It is also important to continue taking the drug for the required amount of time before and after returning from your trip—in the case of mefloquine, you need to start taking it two weeks before you depart for the malarial area, and then continue you taking it for 4 weeks after you get back. This ensures that if you are exposed to malaria at the beginning or end of your trip, you are still adequately protected.

If you have some time, we at Malaria.com would be very grateful if you would take a minute or two to answer our malaria survey that we are conducting about our readers’ experiences with anti-malarials, and particularly their side effects.

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.