Preventing malaria in four steps
There is an ABCD for prevention of malaria. This is:
- Awareness of risk of malaria.
- Bite prevention.
- Antimalarial medication - Chemoprophylaxis (taking antimalarial medication exactly as prescribed).
- Prompt Diagnosis and treatment.
Clinical Editor's note
December 2017 - Dr Hayley Willacy has recently read that Public Health England's (PHE) guidance to travellers about malaria has been updated - see Further reading and references below. Between 2000 and 2015 the number of cases of malaria dropped worldwide, with the majority of cases from Africa and Asia regions. Changes to the risk level and/or malaria prevention recommendation have been made for 41 countries as a result. In some areas, including some countries in Asia, parts of the Caribbean, and Central and South America, the malaria risk is now deemed to be below the threshold for which preventative measures are considered necessary. The PHE recommends that clinicians strongly advise travellers planning to visit Africa that the malaria situation there remains serious and requires rigorous application of preventive measures.
Awareness of the risk of malaria
The risk varies between countries and the type of trip. For example, back-packing or travelling to rural areas is generally more risky than staying in urban hotels. In some countries the risk varies between seasons - malaria is more common in the wet season.
The main type of parasite and the amount of resistance to medication vary in different countries. Although risk varies, all travellers to malaria-risk countries should take precautions to prevent malaria.
The mosquitoes which transmit malaria commonly fly from dusk to dawn and therefore evenings and nights are the most dangerous time for transmission.
You should use an effective insect repellent on clothing and any exposed skin. Diethyltoluamide (DEET) is safe and the most effective insect repellent and can be sprayed on to clothes. It lasts up to three hours for 20%, up to six hours for 30% and up to 12 hours for 50% DEET. There is no further increase in duration of protection beyond a concentration of 50%. When both sunscreen and DEET are required, DEET should be applied after the sunscreen has been applied. DEET can be used on babies and children over 2 months of age. In addition, DEET can be used, in a concentration of up to 50%, if you are pregnant. It is also safe to use if you are breast-feeding. If you have sensitive skin you may find DEET irritating. Insecticides containing picaridin are a useful alternative.
If you sleep outdoors or in an unscreened room, you should use mosquito nets impregnated with an insecticide (such as pyrethroid). The net should be long enough to fall to the floor all around your bed and be tucked under the mattress. Check the net regularly for holes. Nets need to be re-impregnated with insecticide every six to twelve months (depending on how frequently the net is washed) to remain effective. Long-lasting nets, in which the pyrethroid is incorporated into the material of the net itself, are now available and can last up to five years.
If practical, you should try to cover up bare areas with long-sleeved, loose-fitting clothing, long trousers and socks - if you are outside after sunset - to reduce the risk of mosquitoes biting. Clothing may be sprayed or impregnated with permethrin, which reduces the risk of being bitten through your clothes.
Sleeping in an air-conditioned room reduces the likelihood of mosquito bites, due to the room temperature being lowered. Doors, windows and other possible mosquito entry routes to sleeping accommodation should be screened with fine mesh netting. You should spray the room before dusk with an insecticide (usually a pyrethroid) to kill any mosquitoes that may have come into the room during the day. If electricity is available, you should use an electrically heated device to vaporise a tablet containing a synthetic pyrethroid in the room during the night. The burning of a mosquito coil is not as effective.
Herbal remedies have not been tested for their ability to prevent or treat malaria and are therefore not recommended. Likewise, there is no scientific proof that homeopathic remedies are effective in either preventing or treating malaria and they are also not recommended.
Antimalarial medication (chemoprophylaxis) helps to prevent malaria. The best medication to take depends on the country you visit. This is because the type of parasite varies between different parts of the world. Also, in some areas the parasite has become resistant to certain medicines.
There is a possibility of antimalarials that you may buy in the tropics or over the internet, being fake. It is therefore recommended that you obtain your antimalarial treatment from your doctor's surgery, a pharmacist or a travel clinic. Medications to protect against malaria are not funded by the NHS. You will need to buy them, regardless of where you obtain them.
So now you can buy this medication over-the-counter, what might the benefits be? Well first, you should save some money.— Michael Stewart, Getting malaria tablets from your pharmacist
The type of medication advised will depend upon the area to which you are travelling. It will also depend on:
- Any health problems you have.
- Any medication you are currently taking.
- The length of your stay.
- Any problems you may have had with antimalarial medication in the past.
Names of medications often used are chloroquine, doxycycline, proguanil, atovaquone and mefloquine.
You should seek advice for each new trip abroad. Do not assume that the medication that you took for your last trip will be advised for your next trip, even to the same country. There is a changing pattern of resistance to some medicines by the parasites. Doctors, nurses, pharmacists and travel clinics are updated regularly on the best medication to take for each country.
You must take the medication exactly as advised. This usually involves starting the medication up to a week or more before you go on your trip. This allows the level of medicine in your body to become effective. It also gives time to check for any side-effects before travelling. It is also essential that you continue taking the medication for the correct time advised after returning to the UK (often for four weeks). The most common reason for malaria to develop in travellers is because the antimalarial medication is not taken correctly. For example, some doses may be missed or forgotten, or the tablets may be stopped too soon after returning from the journey.
What are the side-effects with antimalaria tablets?
Antimalarial medication is usually well tolerated. The most common side-effects are minor and include feeling sick (nausea) or diarrhoea. However, some people develop more severe side-effects. Therefore, always read the information sheet which comes with a particular medicine for a list of possible side-effects and cautions. To reduce possible side-effects, it is usually best to take the medication after meals.
If you are taking doxycycline then you need to use a high-factor sunscreen. This is because this medication makes the skin more sensitive to the effects of the sun.
Around 1 in 20 people taking mefloquine may develop headaches or have problems with sleep.
Note: medication is only a part of protection against malaria. It is not 100% effective and does not guarantee that you will not get malaria. The advice above on avoiding mosquito bites is just as important, even when you are taking antimalarial medication.
Further reading and references
Malaria: guidance, data and analysis; Public Health England
World Malaria Report; World Health Organization, 2012
Fairhurst RM, Nayyar GM, Breman JG, et al; Artemisinin-resistant malaria: research challenges, opportunities, and public health implications. Am J Trop Med Hyg. 2012 Aug87(2):231-41.
Malaria Reference Laboratory Website; Public Health England
Malaria; NICE CKS, November 2016 (UK access only)
Guidelines for malaria prevention in travellers from the UK: 2017; Public Health England (2017)
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