The malaria medication controversy


Is its prevention worse than the disease?

This theme has run wild lately with regard to malaria, and it is time to set the record straight. Let’s look at the facts and calm the excitement with some common sense.

To understand why we need protection against malaria, let’s understand what we are fighting. Malaria is a potentially fatal disease spread by mosquito bites. It’s found through much of the world but primarily in the tropics. It infects 300 million to 550 million people (yes, that is one-third to one-half billion people, about seven times the number of those suffering from AIDS) and kills between one and three million annually.

There are four species of this parasite which affect mankind. The most dangerous is called Falciparum, but the most common form is called Vivax, which can hibernate for months to years in the liver.

Travelers visiting areas where malaria exists can avoid this disease with just two tools: personal protective measures against mosquito bites and appropriate malaria preventive medication, officially known as “chemoprophylaxis.”

The medication is taken to avoid dying from malaria and to reduce serious infection; no medication confers 100% protection against infection. Because of the life cycle of the parasite, any antimalarial medication must be taken for a set period of time after leaving the risk area.

In the United States, we have four medications available to us for prevention (it is a different story for the treatment of malaria as a disease): chloroquine, mefloquine, doxycycline and atovaquone-proguanil. Let’s dissect each of these in turn and learn about them.

Chloroquine (Aralen®) has been around for over half a century and was once the standard drug for preventing malaria. Unfortunately, it now only works in a few regions of the world such as Central America and parts of the Middle East.

It is taken weekly, beginning two weeks before arrival in the malarious area and continued throughout the trip until four weeks after having left the risk area. It is generally safe and can be used in pregnancy but can be fatal in overdosages, particularly with children.

Mefloquine (Lariam®) has also been around for decades and is a highly effective antimalarial, but resistance to this drug is now recognized, particularly in Southeast Asia.

It is the most convenient of the four, being taken only once a week, starting two weeks before arrival in the malarious area and continued throughout the trip until four weeks after having left the risk area.

This medication has an unfortunately bad reputation because of its potential side effects. Approximately one in 200 users develop sleep disturbances or emotional instability. It is forbidden in those who have a seizure disorder or psychiatric problems.

Doxycycline (Vibramycin®) is an antibiotic, often used by dermatologists for acne control. It is a very good medication to prevent malaria and can be started right at the beginning of the trip instead of two weeks in advance. It must be taken daily throughout the exposure period and continued for four additional weeks after leaving the risk area.

The potential problems with this medication are the risk of yeast infection in women, ulcers and phototoxicity from sun exposure, plus it cannot be taken by pregnant women nor children.

Atovaquone-Proguanil (Mala-rone®) is the newest antimalarial but is actually two old drugs which when combined is very effective.

Like doxycycline it is taken daily, but instead of having to continue for four weeks after leaving the risk area you merely take it for one week after. The shorter course leads to a higher likelihood that a traveler will actually take the medication correctly and fully. It is very safe and very gentle and has become the medication of choice in my full-time travel and tropical medicine clinic, especially for short-term travel.

In other parts of the world, such as Great Britain, a drug called Paludrine (proguanil + chloroquine) is used, but, while very safe, it is not very effective and they have a higher death rate from malaria because of this.

Amazingly, travelers have been told by other travelers on the road not to take malaria medication and have been infected or have died as a result. This is not worth it!

There is a place for each of these, but thought and time is necessary to figure out which is best for you when you travel. Please consult with a specialist in travel or tropical medicine before your journey.

Healthy Travels!

Dr. Spira is medical director of the Travel Medicine Center (131 N. Robertson Blvd., Beverly Hils, CA 90211; visit www.healthytravel.com).

Next month in this column — a few words on Economy Class Syndrome from Dr. Larry G. Baratta.