Immunisations and malaria prophylaxis

If you are heading somewhere exotic and developing you will of course need to head down to a clinic and get a variety of jabs before disappearing. Most of the important ones will be boosters of shots you probably had as a child. There are several others, but it is worth thinking twice about being sold on having the 'whole package' - it all depends on where you are going and how you feel about the risk.

Many a traveller goes to a clinic and says they're going to somewhere like Brazil or Thailand (or equally mainstream), the nurse types 'Thailand' into a computer (experience suggests not all health professionals have first-hand experience or knowledge of travel health or pragmatism) and next thing they know they have a bill for $100s, a very painful arm, 10s of very expensive pills and coverage for some very bizarre diseases of which the risk of are small compared to other risks.

Nevertheless, it is important to warn against the foolhardy approach and 'I'll take the risk' attitude you might find travellers on the road with (normally regarding Malaria). You'll also note things have tried to be kept as simple and concise as possible tackling a very big subject.

A word to the wise... the following information is taken from various sources, some medical, some not, most third party. No one connected with this site is a doctor and therefore the information in this section should be taken with that consideration in mind. However, this is a good place to start and is evidence of how we have slowly unraveled the mystery of travel health and especially Malaria medication.

As for malaria... a quick guide to prevention when travelling

As for malaria, there's little point getting too into the subject as it's a minefield. The thing is, you ask a doctor and no matter where you are going you seem to get a doomsday scenario and prescribed Lariam or similar at great cost. Most of the time, in hindsight, it seems and is unnecessary. It is important to note where you will be in any country as often high risk malaria is centred on small/fringe (jungle/forest) areas rather than cities or the whole country.

Different preventative drugs can and are recommended in various parts of the world due to prevalence and resistance [to normally -quine based drugs], but there are essentially five core malaria prophylaxis: Atovaquone/Proguanil (Malarone), Chloroquine, Doxycycline, Mefloquine (Lariam) and Primaquine. All of which have pros and cons - good overview here -, but with some treatments pros come at high costs or other sideeffects. The cheaper and more generic choices are Chloroquine [which is often combined with Proguanil] and Doxycycline. These both can be started only a few days before needed and need to be taken for 4 weeks after you have left an at risk area (so to cover yourself for 1 day would need a 4 week + 1 day course). They are typically taken daily. Doxycycline is typical go to drug for backpackers as it is the cheapest  and available at low cost in larger Asia and African cities (obviously buy from a reputable looking pharmacy and get advice on usage / side effects - Boots in Bangkok price (6months worth) at about US$60).

With a reputation for causing nightmares Mefloquine (Larium/Vibramycin) is a taken only weekly (but needs to be started 2 weeks before and 4 after). Despite the reputation not everyone reacts badly, but there are now pockets of Mefloquine resistant-malaria and more modern drugs are now normally recommended. The final options are typically the better and most frequently recommended, but most expensive. Primaquine and Malarone/Malanil (Atovaquone/Proguanil) are both daily and need only be taken for 7 days after risk. Malarone is suitable for children and well tolerated with side effects uncommon. It can't be taken for more than 90 days, which is just as well as it is pretty [read: very] expensive. Primaquine like Doxycycline is easy to find over the counter abroad cheaply in less developed countries, but like Doxycycline has a reputation of causing upset stomachs.

It is really worth mentioning that there is a ton of misinformation floating around on the net and among backpackers on the road.

It needs to be emphasised that any medication listed in this section is vastly superior to not taking anything, and hoping for the best. Some Malaria strains are deadly and kill fast (90% of malaria deaths are children under the age of five, mainly in sub-Saharan Africa) - especially when you haven't been exposed to malaria since birth.

So in what areas am I at risk from Malaria? The blanket answer is that a 'risk' exists in almost all countries in Asia (below Mongolia/Kazakhstan), Africa and Latin America with the notable exceptions of Libya, Chile, Tunisia and Uruguay. If you want to see 'the map' take a look at the somewhat paranoid CDC Malaria page. However, this 'risk' really does vary and to colour an entire country red due to a sometimes localised and seasonal risk is kind of missing the mark. Whereas a serious risk may exist in a pocket of a country (say Thailand), there are many, many other regions where very little or no risk exists. So research carefully.

Take for example Nepal; Kathmandu and a normal trekking circuit poses no risk from malaria, but due to a risk in the lower lying parts of the country the whole country often gets a warning. The same can be said for Latin America outside of the Amazon basin, which is often bypassed by travellers or visited for only a few days.

Travel to rural areas always involves more potential exposure to malaria than in the larger cities. For example, the capital cities of the Manila, Bangkok and Colombo are essentially malaria-free. However, as noted, malaria is present in many other places (especially rural areas) of these countries. By contrast in West Africa, Ghana and Nigeria have malaria throughout the entire country. However, the risk will always be lower in the larger cities where independent travellers tend to focus their travels since these act as the main transport hubs.

Of the 3500 types of mosquito (20 more are discovered every year) only a few carry killer diseases such as Malaria. The female (it would have to be!) Anopheles malarial mosquito bites mainly between 2300 and 0400 at night. This is when it is particularly important not to get bitten. Also worth mentioning is the Aedes mosquito (spreading dengue and yellow fever) bites during the day. Both feed at ground level so cover up your ankles with a little repellent. No Malaria medication protects you 100%, and the best thing you can and should always do is not get bitten, which is a different topic.

Keep in mind that many of the reported problems with Mefloquine occur at dosages used for the treatment of active malaria, and not the prevention of malaria. The treatment dosage is 1250mg once, which is 5 times the weekly prophylactic dosage! This is where a lot of the Mefloquine confusions and scary rumours originate.

The most common side effect of Mefloquine is vivid dreams. These tend to occur the night the tablet is taken, and are not necessarily nightmares, just vivid dreams. For Doxycycline it is photosensitivity (increased sensitivity of skin to sunlight) and for Doxycycline and an upset stomach. Make sure you are taking the right medication for the region you are travelling in especially if really off the beaten track or in West/Central Africa. Again... it is quite possible to visit a country with a malarial risk and never get anywhere near that risk area (Cambodia, Bolivia, Thailand, South Africa, Iran, Namibia, China, Burma, Nepal - there are loads of them!).

Why bother going to all this hassle/cost?

Once in a while, you will meet travellers who refuse to take prophylactics, either because they want to acquire resistance to malaria or else because they believe there is a homeopathic cure for this killer disease. Unfortunately (especially in Africa), they think they are being very clever.

For the record, travellers can't acquire effective resistance to malaria and if anyone knows of a homeopathic cure, please let us [and the medical profession] know. It is personal choice what you do but, especially in East/West Africa not using a prophylactic drug when in a high risk areas for long periods is risking your life in a manner both unnecessarily (the drugs are cheap in Africa/Asia) and foolishly. Equally pills aside the most important thing is to always sleep under a treated net when in high risk regions.