Readers' questions are answered as examples of general problems commonly met in practice. It is a good rule in medicine that only their own doctors know the patient well enough to pontificate on the case as there are often other factors unknown to strangers.
Two years ago my wife and I spent three weeks touring the hill tracts of southeast Bangladesh near the border with Myanmar. One evening we had dinner at a friends and a fellow guest told me she was a medical officer with a large UN programme in Bangladesh. We talked about the incidence of malaria in the country and the government's irradication programme. I was surprised when she told me that other than the practical measures described in your article (July 20) she took no antimalarial drugs. Her approach was that if she developed the symptoms of malaria she would immediately start a therapeutic course of Malaron. What are your views on this somewhat unorthodox approach and would you recommend it? Michael Pickett, Crawley
Anti-malarial drugs are recommended for Bangladesh. It might be safe for people whose visit will be confined to a five star hotel in Dhaka City not to take them, but even this would be a risk that I would not be prepared to take myself. Nor do I recommend your friend's type of regime to my patients.
In most parts of Bangladesh the usually recommended drugs are proguanil and chloroquine (better known by their tradenames Paludrine and Avloclor Navaqine). People who are going to go into the hills need Larium mefloquine or doxycline or Malarone. The difficulty with doxycline is that it makes many peoples' skin extremely sensitive to sun. I have seen people who have only been exposed to sun for a short time but who still suffered horrific sunburn.
Malarone is a combination of atovaquone and proguanil. Last time I went to the Indian sub continent about 18 months ago I took Malarone. Malorone is the best there is in that there is least resistance to it and the dose regime is so simple - one daily starting 48 hours before reaching the area, daily while there and continuing for seven days after coming home. Even people of my age can remember to take it.
As you know Lariam causes a comparatively high incidence of neurological or psychological disturbance (see the last question). It should not be prescribed for any patient with a history of psychological troubles or neurological problems such as seizures. Nor should it be given to those with a family history of this type of trouble. I don't even prescribe Lariam for those patients who could be prescribed as creative and highly strung
Two of my patients have died of malaria. Sorry as I was as both were good friends I was relieved that neither had been following the advice of the practice on anti malarial precautions. One was a man who lived in Kenya for most of the year and had been born there. He sickened and died suddenly. Unfortunately he was always convinced that his lifetime travelling around Africa had given him immunity. The other was the managing director of one of the country's larger companies. He had been told locally that as he was moving only from smart office to smarter hotel in a capital city he didn't have to bother. "English doctors are so fussy" the locals had advised. He never returned.
The symptoms of malaria are so diverse that it would be unfair to blame anti malarials for making it a difficult disease to diagnose. Local doctors in many overseas countries have the habit, perhaps a wise one, of considering all unexplained symptoms accompanied by fever as malaria. Your friend should remember that the majority of deaths of British travellers to malarial zones are now ex-patriots returning for a holiday in their original country.
Is it necessary to take anti-malaria tablets for a trip to South Africa taking in Johannesburg and Cape Town and along part of the Garden route? There will be a weekend game drive in a park near Johannesburg and the holiday is in late November/December. Are any other vaccinations or tablets required? I am a well-controlled type II diabetic on metformin and glyclazide tablets. Does this alter the advice in any way? Jennifer Kay, Liverpool
Johannesburg, Cape Town and the Garden Route would be safe but the Kruger Park for example is not. I would suggest that anyone visiting a game park and going beyond the confines of the cities should check with one of the MASTA travel clinics - tel. 0906 550 1402 (calls cost £1 a minute), www.masta.org is their web site. The malarial zones of South Africa are defined by rivers and by the different provinces so that a good map when interpreting up to date information is needed.
Before going to South Africa you should be fully protected against typhoid and hepatitis A. You are already rather late for complete hepatitis A prevention as two injections of a vaccine, such as Havrix or Hepatyrix, should have a six to twelve month interval between them. Fortunately the first injection will give some protection, but not of course immediately. Presumably you have already been protected against diphtheria. I always recommend that any of my patients who are going abroad should have a polio booster - very easy - only a drop of the vaccine on a lump of sugar. The need for hepatitis B depends on your lifestyle, if you are likely to become very affectionate with someone you meet on holiday it is a good precaution. I used to recommend it to all my patients who lived in exotic spots, we forget that we are unusual in North West Europe in not as yet having endemic hepatitis B. Likewise rabies. In this practice we routinely give those living in many other parts of the world rabies protection, but don't usually recommend it to those going on a holiday.
All patients with diabetes should remember that their need for hypoglycaemic treatment will vary with changes in stress level, diet, exercise regimes and temperature. As you have non insulin dependent type 2 diabetes you shouldn't suffer from any of these problems. However don't put a strain on your cardiovascular system by going wild with a sudden flush of enthusiasm for violent exercise especially if the weather is both hot and muggy.
During the past five years I have travelled from Australia to Bangladesh - working mainly in health programs in the northern rural areas. Each year I have used the Mefloquine drug to combat malaria. In taking the preventative medication I have followed the instructions carefully - taking the tablet a week before arriving in the malaria risk area and then once a week until the course of tablets is completed - usually in my case for a period of five weeks. Each year I have noticed that some 12 days after taking the first tablet I have been extremely poorly with fever, headaches and severe flu-like symptoms which last for three to four days. With taking these tablets am I literally giving myself a bad dose of malaria for my body to fight - or am I allergic to the tablets? This reaction is so debilitating that it is quite difficult to work for a few days and I would be interested to know if you could suggest an alternate course of prevention for me. Steve Parker, Adelaide
Lariam mefloquine was a great advance in anti malarials when it was first introduced as it extended the range of malaria that was sensitive to anti-malarials. I used to take it myself before Malarone was available. Unfortunately it can have serious side effects for those who are over sensitive, have psychological, or psychiatric problems (or even if there is a family history of these) or any neurological complaints. It should always be taken for at least two or three weeks before the visit starts not only to ward off malaria but to check for unwanted side effects. Lesser symptoms than actual psychological breakdown are not unusual, but these tend to be more in the nature of headaches, tummy upsets, loss of sleep and lack of precision of movement. Some doctors suggest that those taking Lariam shouldn't drive or work machinery for three weeks except with the upmost caution. I should switch to Malarone and think of any additional cost as a holiday expense.
Given the current hot weather and the potential for global warming to give us more hot summers, should we be worried that malaria will become a problem in Britain? Marilyn Frayn, Newport
In the 19th century malaria used to be a problem in Britain, that is why those living in Lincolnshire were known as yellow bellies. They had haemolytic jaundice as the result of malaria caught from the mosquitoes living on the marshes and fens. England, like Italy before Mussolini dealt with the problem, had similar difficulties. The only cases of malaria which have been reported in this country in the last thirty of forty years, other than those caught abroad, have been reported near airports presumably from mosquitoes that have been stowaways. If our temperatures were to be regularly at the current levels, and our fens reverted to wet lands, I should have thought the return of malaria would be a possibility.
Two of my colleagues tell scary stories of having had nightmares and hallucinations on a malaria drug called Larium. One of them persisted with the course of tablets because he was afraid of the consequences if he did not. He also had a skin rash reaction. The other stopped after the first week and just made sure he was well covered up whilst travelling in Asia. Is this drug commonly prescribed and are there any alternatives? I am planning a trip to the Far East next year. Sally May Willson, Edinburgh
Yes. Malarone is the obvious alternative to Lariam. It is very dangerous to take Lariam if it induces hallucinations. It is known for its ability to cause a psychotic breakdown in those carrying the genes that could make their psyche vulnerable. Anyone taking Lariam who suffers from any form of changes in mood, either irrational depression or over elation, hallucinations, or I would suggest even skin reactions which are known side effect should discontinue it at once and adopt an alternative anti-malarial regime.
Whatever the prophylactic medicinal regime taken to prevent malaria remember to follow the other precautions in a malarial zone, such as mosquito nets over the bed and or mosquito guards in front of the windows, wearing long sleeved shirts, long trousers, using insect repellents such as DEET and never forgetting that shady spots by day are as dangerous as dusk when night approaches.
