MALARIA (swamp fever, malaria)

Malaria is an infectious disease caused by a parasite (called Plasmodium) transmitted by the bite of the Anopheles mosquito. There are four different types of which Malaria falciparum is the most dangerous and the most widespread. The incubation period – the time between an infecting bite and the appearance of the disease – varies from ten days to four weeks (rarely several months).

The symptoms include attacks of fever, but can initially be quite similar to influenza. If adequate treatment is not started in time, an attack may sometimes result in death within a few days.

Where does malaria occur? Map: www.who.int/ith - disease distribution maps.

Malaria only occurs in those areas in which Anopheles mosquitoes are present : in the tropics and in a large number of subtropical areas. From a height of 1.500 to 2.500 m onwards, depending on temperature and climate, Anopheles mosquitoes are either rare or non-existent. In most big cities there is little or no risk at all of infection, except in Africa where a real risk exists. Risk also exists in the suburbs of the big cities in Asia (e.g. in India). In a number of areas the risk varies strongly according to the season.

How can malaria be prevented?

q It is very important to avoid mosquito bites : the Anopheles mosquito only bites between dusk and dawn, is rather small and hardly makes any noise.

Þ In the evening wear light-coloured clothing which covers your arms and legs as much as possible. Apply repellent cream with a DEET basis (20 to 50%, for children and pregnant women preferably 20 to 30%) to the uncovered parts of your body e.g. Care-Plus^® DEET, Moustimug^â, Z-stop^â, Anti-M^â, OTC-repellent^â etc. and repeat this every four to six hours (DEET 20-30% only gives protection for 4 to 6 hours, a higher percentage of DEET 40-50% will protect for 8 hours - it will most often not protect you all night long!). Non containing DEET repellents were less examined; products based on the citrodiol extracts of eucalyptus oil (Care-Plus^® Natural, Mosegor^®/Mosiguard^®),picaridine (Care-Plus^® Repel-it; Parazeet) and "IR3535" (has no long action against the Anopheles mosquito) are however excellent safe products.

Þ Sleep in rooms that leave no access to mosquitoes, (mosquito nets on the sills, electrically-warmed anti-mosquito plates, airco does not always hamper mosquitos from biting) or sleep under a mosquito net impregnated with permethrine or deltamethrine hung over the bed with the edges tucked under the mattress. If these measures are carried out correctly, the risk of malaria will be reduced by 80 to 90%.

q The intake of pills as prevention : There is no drug efficient enough to prevent malaria 100%, which means that quite often a combination of measures is preferable. Also the drugs used have changed over the years. Moreover, the advantages and disadvantages of drugs should be considered against the risk of malaria infection. These risks are dependent on the visited country, and on the region, the season, the duration of your stay and the kind of trip (see www.itg.be). Some people might be troubled by the side effects while taking antimalarial drugs. These are usually mild and are not always a reason to stop taking the pills. Sometimes it may be necessary to change to another type of medication due to intestinal problems, allergic reactions or other intolerance symptoms. Therefore it is the doctor who can best decide for each individual which drug to use. This explains why individuals from the same group may end up taking different drugs.

For areas with resistance against chloroquine or fansidar (ZONE C on the malaria map):

MALARONE^® : for an adult: 1 tablet daily, starting 1 day before arrival in the malaria risk area until 7 days after leaving risk area. Malarone^® should be taken preferably during a meal or with milk, every day at the same time. It may be taken for several months (= much longer than the 4 weeks stated in the product leaflet; but keep the high price in consideration). Malarone^Ò can be given to children from 5 kg, in an adapted dose. Malarone^Òshould not be given to pregnant women or breast feeding women. Efficiency of > 95 %.
DOXYCYCLINE: for an adult 1 tablet of 100 mg or ½ tablet of 200 mg daily, 1 day before arrival in the malaria risk area until 4 weeks after leaving risk area; doxycycline should be taken with plenty of liquid or during a meal, every day at the same time. May be taken for several months. Doxycycline must not be given to children < 8 years or pregnant women. Doxycycline can sometimes cause fungal infections of the mouth and the genitals and may give rise to phototoxic rash (sun allergy). Efficiency of > 95 %.
LARIAM^®: 1 tablet per week, on a fixed day, during the evening meal, until 4 weeks after return or after leaving risk area. Lariam^Ò is not given to children who weigh less than 5 kg. Lariam^Òcan be given to pregnant women from the second trimester of their pregnancy on. Only in well-defined, specific situations can the drug be taken from the first trimester of pregnancy. Efficiency of > 95 %. (less effective in some isolated areas of Thailand, Myanmar and Cambodia).
1. CONTRAINDICATIONS to be discussed with the doctor
- depression, psychiatric problems, episodes of anxiety - epilepsy - heart arrhythmia’s		- previous intake not well tolerated - pregnancy (or planned) or during the first trimester of pregnancy
2. START : 3 tablets should be taken before departure
If never taken previously and sufficient time before departure :	Classic	If taken previously and well tolerated and no time before departure, only in case of high malaria risk
“Test tolerance” : = 1 tablet per week 2-3 weeks before departure = at least 3 tablets before departure	Take 1 tablet per week, at least 2 week(s) before departure or take 1 tablet per day during 2 days, at least 1 week before departure (medication build up) and then 1 tablet per week	Take 1 tablet per day for 3 consecutive days just before departure (medication build up), and then 1 tablet per week
3. POSSIBLE SIDE EFFECTS:
The majority of people can take Lariam^® without any problem	Possible side effects : severe dizziness, insomnia, nightmares, HUNTED FEELING, sensation of shortness of breath, FROM unusual mood swings TO depression, depressive feelings, inexplicable anxiety, headache, cardiac palpitations, and rarely gastro-intestinal complaints (75% of side effects appear after taking 3 tablets, 95% after 6 tablets; the risk of side effects decreases with the duration of tolerance; delayed side effects are possible and can be caused by stress, fatigue and/or insomnia).		Extremely rare : epilepsy, hallucination (1/10.000)
May be taken for many months and several years if necessary	Consider stopping Lariam^® if too troublesome and switch to another schedule. If possible discuss this with an experienced doctor		Stop immediately and definitively
4. ALTERNATIVES: Malarone: 1 tablet per day. When switching from a different prophylaxis to Malarone during or after a stay in a malaria region (or when one has forgotten to take 1 or 2 pills), Malarone should always be continued until at least 4 weeks after the switch - this means Malarone sometimes must be taken longer than the prescribed 7 days after leaving the malaria region: ·  Switch ³ 3 weeks before departure: once daily for the rest of the stay  - until 7 days after leaving the risk area · Switch < 3 weeks before departure: once daily until 4 weeks after the switch · Switch after departure (=after leaving the risk area); once daily for another 4 weeks Malarone has an efficiency of > 95% and can easily be used during several months (taking into consideration the high price).
Doxycycline (1 tablet of 100 mg or ½ tab. of 200 mg /day, to be started 1 day before departure until 4 weeks after return), to be discussed with the doctor. Not for children under the age of 8 and pregnant women. Doxycycline should be taken in a sitting position, with plenty of liquid, or during the meal (ulcer in the oesophagus).  Can cause fungal infections of the mouth and the genitals and photosensitivity (excessive skin reaction after sun exposure). Doxycycline is > 95 % effective and can be taken for several months.

NB. The combination of Nivaquine and Paludrine is no longer used (Paludrine is no longer available; this combination is insufficiently effective).

These medications are only available on doctor’s prescription.

In case of fever during or after a stay in the tropics, you must seek competent medical aid as quickly as possible.

Finally, as no drug is 100% effective in preventing malaria, it is important that if an attack of fever occurs in the first three months after your return from the tropics, a malaria infection should be considered as a possibility despite the correct use of the drug prescribed. However, it is reassuring to know that malaria, provided it is recognised in time, is easy to treat without any danger of recurrent attacks. The belief that "once malaria always malaria" is totally untrue.