April 25th was World Malaria Day. Malaria is found most often
in Africa, Southern Asia, Central America, and South America, and is relatively
rare in the United States.
Malaria is caused by a bite from a parasite-infected mosquito. Symptoms of
malaria can include fever, chills, sweats, body aches, and muscle pain. Fever
that goes away and comes back is fairly common. Nausea, vomiting, abdominal
pain, backache, and dark urine are also possible symptoms. More severe forms
involving altered mental status and organ involvement typically require
hospitalization. Left untreated, malaria can be fatal.
According to the Centers for Disease Control and Prevention:
--3.4 billion people live in areas at risk of malaria transmission in 106
countries and territories.
--The World Health Organization estimates that in 2012, malaria caused 207
million clinical episodes, and 627,000 deaths.
--About 1,500 cases of malaria are diagnosed in the United States annually,
mostly in returned travelers.
Dr. Phil Seidenberg, who spent five years living and working in Zambia as
Global Rescue’s African Regional Medical Director, has treated many malaria
patients in the course of his career. Dr. Seidenberg points out that significant
global progress has been made with malaria over the past decade, with better
control of malaria and fewer deaths from malaria for multiple reasons. We spoke
with Dr. Seidenberg and posed five common questions that travelers may have
about the risks, prevention and treatment of malaria.
1. How do I know if malaria is an issue where I’m traveling?
For updated information on countries with malaria, use the resources available
through either the Center for Disease Control (CDC) or the World Health Organization
(WHO). Both of these organizations have maps with malaria risk levels indicated
by country, and for regions within countries as well. Global Rescue members can
contact Global Rescue for specific malaria advice.
Travelers headed to Africa should be aware that, while progress has been made
in controlling malaria on the continent, an estimated 91% of deaths from
malaria in 2010 were in the African Region (CDC). According to the WHO, in
recent years, four countries have been certified by WHO as having eliminated
malaria: the United Arab Emirates (2007), Morocco (2010), Turkmenistan (2010),
and Armenia (2011).
It is important to consider the time of year of your travel. If a country has
malaria, there is usually some seasonality to it. Typically malaria follows the
rainy season, and is particularly active in the middle to the late part of the
rainy season when water is pooling in areas; standing water allows
malaria-carrying mosquito larva to populate.
Another consideration is how rural will your travel be, because in general
malaria is more common in rural areas. In locations around the world where
there is greater control, such as in capital cities, travelers will likely face
less risk. However, if travelers are planning on rural travel and there is
malaria in these countries, they need to be well informed and take preventive
measures.
2. Who are the people greatest at risk?
Anyone who is not native to an area certainly faces an increased susceptibility
to malaria. There is a level of tolerance that develops over time in those who
are born and live in areas with malaria. A look at global statistics shows that
greater than 75% of people who die from malaria are kids under five years old.
If you are thinking of bringing kids along to areas with malaria, it is not a
definite no-no but it is something to weigh carefully because the kids are the
ones who do more poorly. The elderly are the next at-risk population, and the
third class of traveler at an increased risk is pregnant women.
3. If I go to a malarial area, should I take medication?
There are anti-malarial prophylactic medications (preventative therapies) that
one can take. It is important to note, however, that none of these treatments
is 100 percent effective. You should seek advice from your regular healthcare
provider, or a provider experienced in travel medicine to help decide which of
these medications might be best for your individual health profile.
The primary recommendation I usually give is to choose a simple option such as
Doxycycline, which is available everywhere. It needs to be taken only one to
two days prior to travel, and the dose is just 100 milligrams once a day. It is
contraindicated for kids younger than eight, mainly for cosmetic reasons
because it stains teeth. Doxycycline is not a first choice medication for
pregnant women, but may be okay to use during pregnancy in certain situations.
The major side effect with its use is sun sensitivity. It causes a small number
of people to burn really quickly and often the locations with malaria are sunny
and tropical. Doxycyline can also be used for skin infections and, among other
things, as treatment for some types of pneumonia, so it is in many ways useful
to have in a travel case.
Malarone is another great option. It is a very good, safe medication and very
well-tolerated, although a little bit more difficult to find outside of travel
clinics. Malarone is taken daily, and needs to be started only one to two days
before travel. Side effects are minimal. Importantly, Malarone consists of a
two-drug punch that greatly reduces the chance of contracting a resistant
malarial strain. This medication cannot be used by pregnant women. Malarone is
more expensive than the other options, and since it is taken daily, cost could
be a factor for some, especially on longer trips.
A third option is mefloquine, or Lariam. It is preferred by some people because
it is taken on a weekly, not daily, basis. Lariam, which is safe for pregnant
women, must be started at least two to three weeks before travel, and continued
for up to four weeks upon completion of travel. While it is less expensive than
some other options, Lariam has been shown to have more side effects than any
other anti-malarial drug. However, many travelers use Lariam and are just fine.
People always ask about Lariam because they hear about people reporting crazy
dreams. Psychotic side effects are anecdotal, never really proven, but there is
enough anecdotal evidence that typically I suggest other options first.
4. Are there other steps I can take or products to help protect against
malaria?
Definitely. Take precautions such as wearing long sleeves, using DEET
repellants to ward off mosquitoes, and sleeping under netting. Most countries
typically have mosquito nets in stores and even supermarkets, but if you’re
concerned that you won’t be able to find them, it is a good idea to buy them in
advance. The insecticide treated nets are really the ones to use. People
sometimes pre-treat their clothing, too.
It is important to know that the two peaks for malaria transmission are right
at dusk and then right before sunrise. These are times when the mosquitoes are
a little bit more active and more people are in contact with active mosquitoes,
which is probably why transmission occurs most frequently between those two
periods. Be especially cautious at these times.
5. What do I do if I’m traveling and I think that I may have malaria?
The first step is to determine if you have malaria. In most African capital
cities, you can go into almost any pharmacy and pick up a Rapid Diagnostic Test
(RDT). It involves a simple finger prick, a few drops of blood, and a 15-minute
wait for results. RDTs are part of the reason that malaria is under control,
because we are no longer indiscriminately treating kids and people with fevers
that are not malaria. Be cautious about the expiration dates, however, and do
not buy anything that has expired. The RDTs are no different for kids versus
adults. Another option is to go to a clinic. Almost any clinic operating in
malarial countries will be able to do a very quick blood smear or a Rapid
Diagnostics Test, too.
What do you do if you have malaria? Most hospitals in malarial countries are
more than capable of diagnosing and treating malaria. For treatment, the WHO
recommends Artemisinin Combination Therapy, or ACT. However, do not assume that
ACT is necessarily what you will receive. Absolutely ask for ACT by name. Most
healthcare providers should know what that means, even though there are
different trade names in some parts of the world. It is worth knowing that for
almost all simple malaria, even complicated malaria, artemisinin compounds are
the ones to use. Those that only have single artemisinin are, over time, quite
bad for our malaria treatment options because the parasite develops resistance
early. (Emerging artemisinin resistance is a major concern, according to the
WHO, in certain areas of the world.) The combination therapy hits the parasite
with two active medications working against it.
For severe malaria, usually defined by altered mental status or organ
dysfunction, in some places they are starting to do artemisinin IV drips. This
approach has been shown to be better than good old quinine, which still is very
effective. But typically if someone were hospitalized with severe malaria,
quinine versus artesunate are the only real options for treatment.
It is extremely important to be vigilant upon returning home. First, if
travelers are taking a prophylactic that requires them to continue to take it
for a few weeks afterwards, they must make sure to do that. Second, and even
more dangerous in my view, is that it is hard to get malaria diagnosed in the
States unless someone really thinks about it. In fact, this happened to friends
of mine when they came back with their kids from Africa. It is an easy thing
for a lab to take a look at a blood smear under with a microscope, but when
medical professionals don’t ever see malaria that often, they’re not going to
think about it. So, if someone comes back, gets sick and they’re worried about
malaria, they need to really be careful that they tell whoever is seeing them,
“By the way, I was in Haiti. Can you check me for malaria?” It could be a
couple of months before travelers should consider themselves no longer at risk
after returning home.
Again, it is always a good idea for travelers to check in with their primary
care provider or a travel medicine professional before traveling for a detailed
discussion of their risk for malaria.
