If you are travelling, it is essential to find out whether there is a risk of malaria in the place or places you are going. If there is, you can avoid getting the disease by taking steps to avoid mosquito bites, and in some cases by taking antimalarial medication. Malaria can be a life-threatening illness, so it is extremely important to consider prevention before travelling to an at-risk area.
Preventing malaria in four steps
There is an ABCD for prevention of malaria. This is:
- Awareness of risk of malaria.
- Bite prevention.
- Chemoprophylaxis. This means taking antimalarial medication to prevent the disease.
- Diagnosis should be made promptly and treatment started quickly. Seek medical attention urgently if you become unwell after travelling to a high-risk area.
Malaria is a serious infection, so prevention is crucial. See the separate leaflet called Malaria for more information about the types of malaria, transmission, the malaria parasite, symptoms of malaria and treatment.
Awareness of the risk of malaria
Before travelling, it is very important to find out if there is a risk of malaria in the place or places you are going. You can find this out on the Fitfortravel website, or from your travel clinic or pharmacist. The risk varies between countries and can depend on 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. In other countries, the risk varies depending on which part of the country you visit. One part of the country may be an area where there is a risk, and in other areas there is no or low risk. Often in high mountainous areas there is no risk, whilst in lower warmer areas there may be higher risk. The mosquito involved thrives in warm, humid conditions, so places with this sort of climate tend to be high-risk areas.
- Risk is particularly high in Africa, much of Asia and parts of South America.
- Western Europe and the United States of America are not areas of risk.
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.
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You should use an effective insect repellent on clothing and any exposed skin. Diethyltoluamide (DEET) is safe, 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%. Because 50% DEET lasts longer, you do not need to apply it so often. It is also more effective in this higher concentration. 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 breastfeeding. 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, ideally 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 also available and can last approximately three 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 also 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.
To find out whether there is a risk of malaria in any country you're visiting, and whether you need to take antimalarial tablets, visit the NHS Fitfortravel site.
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 pharmacist or a travel clinic. Pharmacists can now provide the full range of antimalarial medications, so there's no need to see your GP or practice nurse for a prescription. Medications to protect against malaria are not funded by the NHS. You will need to buy them, regardless of where you obtain them.Feature
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.
- Whether you are pregnant or breastfeeding.
- Age (some medicines cannot be used in children).
Names of medications which may be used are:
- Chloroquine (or hydroxychloroquine if you already take this for another condition).
- Atovaquone and proguanil combination.
You should seek advice for each new trip abroad. Do not assume that the medication 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 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. This will vary depending on the individual medicine but is likely to be between one and four weeks. Because of the way the parasite infects your blood, it can still be spreading in your blood several weeks after being bitten. It is important to take your medicines for the correct amount of weeks after leaving an affected country, in order to prevent this.
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 antimalarial tablets?
Antimalarial medication is usually well tolerated. The most common side-effects are minor and include headaches, 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.
A few people taking mefloquine may develop headaches or have problems with sleep (including difficulty sleeping or abnormal dreams). Mood may be affected.
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
Guidelines for malaria prevention in travellers from the UK 2018; Public Health England Annual report, January 2019
Malaria: guidance, data and analysis; Public Health England
World Malaria Report 2018; World Health Organization, November 2018
NHS Fit For Travel: Travel health information for people travelling abroad from the UK; Health Protection Scotland
Tickell-Painter M, Maayan N, Saunders R, et al; Mefloquine for preventing malaria during travel to endemic areas. Cochrane Database Syst Rev. 2017 Oct 3010:CD006491. doi: 10.1002/14651858.CD006491.pub4.
Malaria; NICE CKS, November 2017 (UK access only)
Chen-Hussey V, Behrens R, Logan JG; Assessment of methods used to determine the safety of the topical insect repellent N,N-diethyl-m-toluamide (DEET). Parasit Vectors. 2014 Jun 37:173. doi: 10.1186/1756-3305-7-173.