Malaria

Question:
I will be diving near an island off Madagascar in ten days. Since malaria if of great concern there, I have been advised to take Mefloquine (Lariam) 250 mg. tablets once each week beginning in a few days prior to departure date; then, take one tablet each of the three weeks I will be in Madagascar (and perhaps in South Africa) and then again upon return to the U.S., I will take a tablet each week for another four weeks. I have also been advised that I could take Doxyclycline 100mg ( But I just found out from a recent traveler to Madagascar, that Lariam pills are more effective there.)
Could you kindly advise what current information there might be regarding Lariam and diving? After taking each tablet, how long should I wait before diving?

Answer:
In general, Divers Alert Network recommends that all travelers to malarious areas follow established guidelines to prevent malaria. The serious health risk represented by malaria cannot be overemphasized. Prophylaxis is essential and includes both the prevention of mosquito bites and drug prophylaxis. The malaria parasite, a protozoan, is transmitted to humans by the bite of an infected Anopheles mosquito, usually between dusk and dawn.

Personal protection is the best way to prevent malaria and other insect transmitted diseases. This means staying in well screened areas while indoors, wearing clothes that cover most of the body when outdoors and using mosquito nets for sleeping. Insect sprays and repellents for clothing, tents and nets should be used as well as personal repellents containing at least 30 percent DEET. Stronger concentrations can be used with caution.

Drug prophylaxis and measures to prevent mosquito bites are necessary for divers to tropical malarious areas and divers should discuss their travel plans with a physician well before departure. Recommendations may differ from various countries, reflecting the differences in approach and availability of medicines. All of the drugs used for prophylaxis are considered safe and well tolerated.

However, there have been no studies conducted on any medication use and diving; and for that reason there are no scientific data that would allow a blanket recommendation for..., or against the use of a particular drug. Issues of diving fitness while using anti-malarials are generally based on the presence of side effects.

As with any drug, side effects and toxic reactions may occur which may compromise the safety of a dive, and/or create issues of diagnostic problems associated with possible decompression illness. The seriousness of malaria, nonetheless, warrants tolerating temporary side effects. If a diver is unable to take preventive medications against malaria because of side effects, the trip should be canceled, as the risk is too great that malaria will occur.

Regardless of preventive measures employed, malaria may still be contracted. Malaria may not develop until long after the trip, and prophylaxis must be continued for an appropriate length of time. If flu-like symptoms (any illness with chills, fever and headache) develop during a trip in malarious areas or within several months after the last exposure, obtain medical attention immediately.

From the CDC: Prevention

Mefloquine (Lariam®) is the recommended drug for most travelers to risk areas in:
Cambodia, except in the western provinces bordering Thailand. (See doxycycline.)
Indonesia
Lao People's Democratic Republic
Malaysia
Myanmar (Burma)
Viet Nam
Philippines, in the following provinces: Luzon, Basilian, Mindoro, Palawan, Mindanao, and the Sulu Archipelago (for other Philippine provinces, see chloroquine)
Mefloquine dosages: Mefloquine is a prescription drug sold in the United States under the brand name Lariam®. The adult dosage is 250 mg (one tablet), taken once a week. Mefloquine should be taken 1 week before arrival in the malaria risk area, once a week while in the malaria risk area, and once a week for 4 weeks after leaving the malaria risk area.
Mefloquine side effects: Minor side effects, such as nausea, dizziness, and difficulty sleeping, usually do not last long and do not require stopping the drug. Travelers who experience serious side effects should see a physician.
Mefloquine should NOT be used by travelers with a known allergy to mefloquine and is not recommended for use by travelers with a history of epilepsy, severe psychiatric disorders, or cardiac conduction abnormalities.

Doxycycline is the recommended drug for most travelers to risk areas in:
Cambodia: western provinces bordering Thailand (for other malaria risk areas, see mefloquine)
Thailand: areas bordering Cambodia and Myanmar (Burma)
Doxycycline dosages: Doxycycline is a prescription drug sold in the United States. The adult dosage is 100 mg once a day. This drug should be taken 1 or 2 days before entering malaria risk area, once a day while there, and once a day for 4 weeks after leaving the malaria risk area.
Doxycycline side effects: photosensitivity (the risk of sunburn occurring more quickly and more severely than normal), yeast infections, nausea and vomiting.
Doxycycline should not be taken during pregnancy, by children under 8 years old or before going to bed.

 

Question:
I would be grateful if your medical director could supply me with the recommendations regarding the use of Malarone as malaria prophylaxis when diving. I have a patient who is planning a diving holiday in Kenya. Thank you very much for your help.

Answer:
My impression was that Malarone was indicated for treatment of acute uncomplicated falciparum malaria and not for chemoprophylaxis where Paludrine (AstraZeneca) is usually used.
I would not recommend anyone undergoing treatment, with this or any other product for that matter, for malaria to dive.
as for its use in prophylaxis, there is, to my knowledge, no relevant literature on its use as a prophylaxis during diving holidays.
the usual recommendations, which are not completely problem free, is doxycycline but avoid the sun or Lariam but beware of GI and psychotropic effects. the best is the use of repellents and nets but be aware to the small but definitely present risk of infection.

Question:
I would like your advice please. I am going to the Cocos Islands off Costa Rica in October/November of this year. However, before going out to the islands, I will be spending four days on the main land Costa Rica visiting the forest and volcanoes. I believe that this is a Malaria area and I would appreciate your advice as to what precautions I could take, bearing in mind that some of the malarial prevention drugs appear to have a bad record when combined with diving.

Answer:
Chloroquine is the drug of choice in the Costa Rica Region but you must see your Gp as he/she may consider another preperation more suitable in your case.
Be aware that these medications all have side effects, especially the drug Mefloquine which can present with side effects closely resembling Decompression Sickness.
However the best solution is to avoid getting bitten through the use of insect repellants, clothing, netting and insect sprays.

 

MALARIA PREVENTION AND PROPHYLAXIS
By Dr Frans Cronje (Divers Alert Network Southern Africa)
& Dr Albie De Frey (Worldwide Travel Medical Consultants)

DAN receives many inquiries from members regarding malaria. Indeed, malaria has become an increasing problem due to drug resistance. As divers venture deeper into the African tropics they incur increasing risk of contracting malaria. Lack of medical facilities, transportation and communication add additional complexity to managing this medical emergency. Three DAN members have required evacuation by air over the last three years due to malaria. Understanding malaria prophylaxis and general preventative measures is therefore of the utmost importance. The following section covers the most important considerations in selecting and using malaria prophylactic measures and medications. The treatment of malaria, which is complex and requires close medical supervision, falls outside the scope of this document. If you think that you may have malaria or are concerned about unexplained symptoms after visiting a malaria area, contact DAN immediately on 0800 020111 or +27(0)11 254 1112.
The Three Commandments of malaria prevention and survival are :
(1) Do Not Get Bitten
(2) Seek Immediate Medical Attention If You Suspect Malaria
(3) Take "The Pill" (Anti-Malaria Tablets / Prophylaxis)

 

(1) DO NOT GET BITTEN

- Stay indoors from dusk to dawn
- If you have to be outside between dusk and dawn - cover up : Long sleeves, trousers, socks, shoes (90%) of mosquito bites occur below the knee)
- Apply DEET containing insect-repellent to all exposed areas of skin, repeat four-hourly
- Sleep in mosquito-proof accommodation :
- Air-conditioned, proper mosquito gauze
- Buildings / tents treated with pyrethrum-based insect repellent / insecticide
- Burn mosquito coils / mats
- Sleep under an insecticide impregnated (Permacote® / Peripel®) mosquito net (very effective)

 

(2) SEEK IMMEDIATE MEDICAL ATTENTION IF YOU SUSPECT MALARIA

- Any flu-like illness starting 7 days or more after entering a malaria endemic area is malaria until proven otherwise.
- The diagnosis is made on a Blood smear or with an ICT finger prick test,
- One negative smear / ICT does NOT exclude the diagnosis (Repeat smear / ICT until diagnosis is made, another illness is diagnosed or the patient recovers spontaneously - e.g. from ordinary flu)

 

(3) TAKE "THE PILL"

There are several dangerous myths regarding malaria prophylaxis. Please note that:
- Prophylaxis does not make the diagnosis more difficult
- It does protect against the development of cerebral malaria
- Is not 100% effective - hence the importance of avoiding bites
- Not all anti-malarials are safe with diving
- Malaria is often fatal - making prophylaxis justified
- Anti-malaria drugs, like all drugs, have potential side-effects, but the majority of side-effects decrease with time.
- Serious side-effects are rare and can be avoided by careful selection of a tablet or combination of tablets to suit your requirements (region and season).

 

THE FOLLOWING DRUGS ARE AVAILABLE FOR THE PREVENTION OF MALARIA

(1) Chloroquine (Nivaquine® or Daramal® or Plasmaquine®):
Contains only chloroquine. Must be taken in combination with Proguanil (Paludrine®)
Dosage: 2 tabs weekly starting one week before exposure until 4 weeks after leaving the malaria endemic area.
Contra-indications : Known allergy, epilepsy
Side effects: Headache, nausea & vomiting, diarrhoea, rashes; may cause photosensitivity (sunburn; prevention - apply sun block)
Use in Pregnancy: Safe. (Note: SCUBA diving is not considered safe during pregnancy)

(2) Proguanil (Paludrine®):
Must be taken in combination with Chloroquine (Nivaquine® or Daramal® or Plasmaquine®)
Dosage: 2 Tablets every day starting one week prior to exposure until 4 weeks after.
Contra-indications: Known allergy to Proguanil. Interactions with Warfarin (an anti-coagulant -- that is incompatible with diving)
Side-effects: Heartburn (Tip: take after a meal, with a glass of water & do not lie down shortly after taking Proguanil); mouth ulcers (Tip: Take Folic acid tablets 5mg per day if this occurs); loose stools (self limiting - no treatment required)
Use in Pregnancy: Safe - but must be taken with Folic acid supplement: 5mg per day. (Note: SCUBA diving is not considered safe during pregnancy)
The combination of Chloroquine & Proguanil is about 65% effective. It is DAN's second choice for malaria prophylaxis in areas of resistant malaria and a first choice in areas of low or absent resistance due to the benign side-effect profile of the drugs.

(3) Doxycycline (Vibramycin® or Cyclidox® or Doryx®, etc.):
Used extensively in the prevention of resistant malaria. About 99% effective. Used alone or in combination with chloroquine. Not officially recommended for use in excess of 8 weeks for malaria prevention, but it has been used for as long as three years with no reported adverse effects. Offers simultaneous protection against tick-bite fever and cholera.
Dosage: 100mg daily starting 1 - 2 days before exposure until 4 weeks after exposure.
Side effects: Nausea, vomiting, diarrhoea, allergy, photosensitisation. May cause vaginal thrush infections and reduces the efficacy of oral contraceptives.
Use in Pregnancy: Unsafe (as is SCUBA DIVING). Also avoid during breast feeding and in children < 8 years
Doxycycline is DAN's first choice recommendation for divers diving in areas with chloroquine resistance / resistant malaria.

(4) Mefloquine (Lariam® or Mefliam®) :
About 90% effective.
Dosage: One tablet /week.
Side effects: May cause drowsiness, vertigo, joint aches and interfere with fine motor co-ordination (making it difficult to exclude DCI in some cases).
Pregnancy: Probably safe in early pregnancy and may be used with confidence after the first trimester of pregnancy. May be used in breast feeding and babies weighing more than 5kg.
Lariam is considered unsafe for divers & pilots. It is contra-indicated in Epilepsy but is a good first choice for other travellers.

(5) Pyrimethamine / Dapsone (Maloprim® or Deltaprim® / Malazone®):
No longer regarded as effective. Still recommended in Zimbabwe.

(6) Sulfadoxine & Pyrimethamine. (Fansidar®):
No longer used as prophylactic.
Used as first-line treatment in mild malaria as a single dose in isolated areas while en route to definitive care. Efficacy is variable.
Contra-indicated in known sulphonamide allergy.

(7) Quinine (Lennon-Quinine Sulphate®):
Not used for prophylaxis but is the backbone in the treatment of moderate and severe malaria. Serious side-effects are not uncommon during treatment.

(8) Arthemeter (Cotexin®):
The "Chinese drug". Available in some areas of Africa. Not for prophylaxis. Used in combination with other drugs in the treatment of mild to moderate malaria but it is not registered in South Africa at present.

(9) Halofantrine (Halfan):
Not used for prophylaxis. Can cause serious Interactions with other anti-malarials.
Efficacy variable.

 

 

RECOMMENDED MALARIA DRUG PROPHYLAXIS IN DAN SOUTHERN AFRICA REGION (AFRICA & INDIAN OCEAN ISLANDS)
AREAMALARIARECOMMENDED DRUGS
Kruger Park
Eastern Tvl
Northern Tvl
Kwazulu
(excluding Ingwavuma & Ubombo)
Low: June to October / low rainfall
High: Hot wet seasons November to May
High risk persons : Chloroquine & Proguanil
Low risk persons: Nothing -see below.
Chloroquine & Proguanil
Ingwavuma & UbomboThroughout the yearChloroquine & Proguanil
Doxycycline or Mefloquine
* Nothing
SwazilandThroughout the year in lowveld areasChloroquine & Proguanil
Doxycycline or Mefloquine
* Nothing
ZimbabweMainly November to June in areas below 1200m and throughout the year in the Zambezi valleyChloroquine & Proguanil
Doxycycline or Mefloquine
* Nothing
Angola
Comoros
Kenya
Madagascar
Malawi
Mozambique
Zaire
Throughout the yearChloroquine & Proguanil
Doxycycline or Mefloquine
* Nothing
BotswanaMainly November to June in the northern parts of the country (eg. Okavango)Chloroquine & Proguanil
Doxycycline or Mefloquine
* Nothing
NamibiaMainly November to June in northern rural areas (eg. Ovambo, Kavango & Etosha)Chloroquine & Proguanil
Doxycycline or Mefloquine
* Nothing
ZambiaMainly November to June in areas below 1200m and throughout the year in the Zambezi valleyChloroquine & Proguanil
Doxycycline or Mefloquine
* Nothing
SeychellesNo malaria 
MauritiusOnly benign forms of malaria in the northChloroquine in northern areas
* Nothing

* In situations where the risk of contracting malaria is low, ( e.g. in cities, air condconditioned hotel or when rainfall has been low, etc.) the traveller may be advised to take no drug prophylaxis but standby treatment must be carried unless medical care is readily available. Personal protection against bites must be adhered to at ALL TIMES.

E High risk people include babies & children under 5 years, pregnant women, elderly people (> 65 years), people with suppressed immunity (e.g. diabetics, etc.)

 

NOTES:

(1) Prophylaxis significantly reduces the incidence of malaria and slows the onset of serious symptoms of malaria.

(2) All anti-malaria drugs excluding Lariam (Mefloquine) are considered compatible with diving.

(3) Like with all other medication, anti-malaria drugs should be tried and tested on land well in advance.

(4) If unpleasant side-effects occur, please consult your diving doctor, DAN: +27(0)11 254 1112 or 0800 020111 or WORLDWIDE TRAVEL MEDICAL CONSULTANTS: (011) 888-7488

(5) Whether or not you take prophylaxis, be paranoid about malarial symptoms. Malaria can present in many ways varying from fever, diarrhoea to flu-like symptoms. Always inform your doctor that you have been in a malaria area. Symptoms can start within 7-14 days from first exposure until 30 days (and rarely even months) after leaving a malaria area.

(6) No single medication is 100% effective and barrier mechanisms / personal protection against bites (e.g. mosquito repellents, nets, protective clothing, not going outdoors from dusk to dawn) must be applied.

(7) Any strange symptom occurring during or within 6 weeks of leaving a malaria area should be regarded with suspicion and requires medical attention.