Options for mitigating the risk of contracting Malaria in travellers visiting Malaria endemic areas in Southern Africa.
I will focus on the species of malaria parasites applicable to the traveler coming to Sub Saharan Africa, and more specifically to Southern Africa. Although there are many species of the Plasmodium parasite, some of which only affect humans , and some zoonotic infections, the most common here is Plasmodium falciparum, and in much smaller numbers P. vivax and P. ovale. The latter two do not typically cause disease as severe as P. falciparum, but they do cause reoccurring malaria.
Treatment and prevention of any disease pivots around risk management, and weighing up pros and cons of taking the drugs vs not taking them. Typically the malaria endemic areas in South Africa are still lower risk areas than the tropics, and for people living there it is not practical to be on prophylactic medication permanently. Typically they (and their family physician) know the symptoms of Malaria, and early diagnosis and treatment is sufficient. For a person travelling to a malaria area, prevention is almost always better than cure, especially seeing that onset of symptoms is 7-14 days after exposure, and the person might well be back in his home country where Malaria will almost certainly not be on the top of the differential diagnosis when he/she presents with flulike symptoms to a healthcare provider.
The most proactive steps to take in minimising your risk of contracting malaria and treating it early are:
1. Chemoprophylaxis
2. DEET spray in the evening on exposed limbs, clothing and mozzy net.
3. Barriers - mozzy net, long sleeves at night.
4. Repellent in room where you sleep - Thermocell is the best invention since sliced bread. I typically have one burning when I sit on a bushpig bait in the sugarcane up here in Northern KZN. (By the way, to touch on another thread, it makes a great gift for your PH)
5. Rapid test - these R50 finger prick tests are available at most pharmacies, and are quite accurate to diagnose malaria. Please note, that should the test be negative and you have fevers, headache, rigors, and other symptoms please go and consult your doctor. It is possible that you can still have malaria, and he will use a laboratory test of sorts to diagnose it, as well as look for tick-bite fever and other diseases.
6. Have meds on hand to treat. Coartem is the the first line treatment, and consists of a short 3 day coarse of medication.
Again, here I would like to mention that should you test positive and take the treatment whilst on your safari, it is still advisable to consult a doctor to review your health and look at basic bloods. We are all aware from the hunting books written by the explorers of yesteryear, how many people died from complicated malaria, then referred to as blackwater fever. Malaria can be detrimental to your kidneys and liver and it can develop into fatal cerebral malaria. Even though most cases are successfully treated on a outpatient basis, one must always take the necessary caution in doing so.
Regarding Malaria chemoprophylaxis, I try to prescribe according to what a px tolerated well in the past, if they had used before and then according to side effect profile and drug interactions.
In that sence Malarone and Doxycycline are best tolerated, and Mefloquine has the most contraindications, especially with any neurotropic/ psychotropic drugs on board - this includes sleeping tablets, sedatives, antidepressants and alcohol. It is also a known culprit for myocardial toxicity when potenciated by a whole lot of drugs it interacts with. In my opinion Mefloquine should be reserved for use in pregnancy, as it is the safest drug (Category B) then.
To deviate slightly, Permethrin wash to impregnate clothes with is, heaven knows why, not available in SA, so I usually use the sprays to help repell ticks and pepperticks, but they still often get to you in droves when you walk in the bush. For that reason I’m quite partial to Doxycycline, serving a duel purpose in acting as Malaria prophylaxis and treating rickettsia at the same time if you continue it for 2-4 weeks after exposure. The only time I’m reluctant to give Doxycycline is in pxs with very light type 1 or 2 skin, as sun sensitivity is a common problem there. At times Doxycycline is also used in malaria treatment, but not as a first line therapy.
Malarone again has the advantage that it only needs to be taken 2 days prior to travel and 7 days after travel, and in addition can be used to treat uncomplicated plasmaquin resistant falciparum malaria.
When spending the time and money on an African safari, it is always advised to start a test dose of the prophylaxis well in advance of your travels. I usually suggest one month. This allows for you to see if you experience any side effects, and if the side effects are severe enough, to change to a different form of prophylaxis.
Just as an interesting aside, maybe just a word of caution re Ciprofloxacin and the other fluoroquinolones mentioned in the thread. My wife is a physiotherapist, and she sees quite a lot of patients with achilles and shoulder tendinitis and cruciate ligament injuries after having been on a course of them. Last year I fell on a buffalo hunt and tore my right posterior cruciate ligament 4 weeks after being on Levofloxacin. Likewise a well known PH in Zambia/Zimbabwe did the same a few years ago after losing his balance when he stepped of the Land Cruiser into an elephant track in Zambia. That was also a few weeks after a dose of Levofloxacin. As active outdoorsmen it is something to just keep in mind. In that sence a combination of Doxycycline and Metronidazole is safer cover for a dysentery/ amoeba/ shigella/ salmonella infection, the only downside that you cant enjoy a cold beer or two on the metronidazole.
Hope the bit of info is useful.
