Malaria in Southeast AsiaOne of the most commonly asked questions by first-time travellers to Southeast Asiais "Should I take malarials?". Its a simple question, with a complicated answer, bestsummed up as "it depends". Heres ten pointers that we hope will help you make amore informed decision regarding malarials and travel to Southeast Asia..1) Talk to a travel doctor.Malaria is a serious disease which kills over one million people every year,and the best place to start is with a doctor who is a travel specialist. Your localmedical practitioner or family doctor may not have the expertise nor experience togive you an accurate opinion on what you should be doing. "Travellers MedicalCentres" are a growing niche which you should avail yourself of.If you talk to your doctor, mention Asia and they lunge for the prescription book,without even asking where in Asia you are considering going, then you need to geta more informed opinion.Talking of a more informed opinion, we talked to a tropical medicine specialist weveknown for years and heres what he had to say:"Generally travel medical doctors try to individualise it with the patient and theirtrip, rather than adopt a "cookbook" approach and a risk assessment model workswell here. Basically the factors to be considered and discussed with a clientenquiring about malaria tabs are:- the country itself and overall level of risk which includes "official"recommendations from organisations e.g.. WHO- areas travelled to within the country (esp urban or rural) as risks will vary here.This includes level of remoteness and access to medical care- duration of travel- season of travel i.e. wet / dry- style of travel - on a spectrum of rock bottom to 5-star.
- the clients own compliance with mosquito avoidance measures- the clients own wishes regarding what level of risk is acceptable -- some want tobe "covered for everything" whilst some others dont want tablets even if theyregoing to a high risk area.Its a moveable feast and not cast in stone. For example:- Previous blanket recommendations for needing prophylaxis for anywhere inIndia were recently relaxed about one to two years ago. However a recent increasein cases amongst tourists in Goa forced a rethink.- there is good evidence that due to climate change, malaria in Kenya is nowoccurring at higher altitudes (incl. Nairobi!) at areas and elevations previouslyconsidered malaria free.I think the main message is that the decision to take or not take malariaprevention needs to be made by the client after consultation with atravel medicine provider."Now heres some other points about the disease you should consider.2) Malarials do not immunise you from malariaThis is a common misconception. To quote the WHO: "No antimalarialprophylactic regimen gives complete protection". Malarials do not protectyou 100% from malaria, rather they give you more time to get to a medical centrewhere you will still need to seek further medical treatment. This is certainly the casewith doxycycline -- one of the more commonly prescribed medications.3) An ounce of prevention is worth a pound of cureListen to your Grandma -- An ounce of prevention is worth a pound of cure.The best way to avoid being afflicted by malaria is to avoid being bitten by mosquitosand there are a number of simple steps one can take to dramatically reduce thechances of being bitten. These include:
a) Use a permethrin impregnated mosquito netb) Use mosquito repellent containing DEETc) Dress sensibly -- wear long pants and sleeves at dawn and dusk.d) Use mosquito coils or other anti-mosquito devices (e.g.., citronella) as asecondary control.e) If you are prone to being bitten, lean towards accommodation that can be sealedup -- air-con with no slatted windows nor open eaves.f) Watch out for rooms with bucket showers/toilets. These tend to have bucketsofstagnant water -- a mozzies beach resort -- in the bathroom.g) Dont sleep naked in a swamp.4) Prevention protects you from other nastiesAnother potentially fatal disease spread by mosquitos is dengue fever. It should bea far bigger concern to travellers than malaria, but as theres no pills to sell to"protect" you from it, you hear far less about it from the medical industry. Infollowing the steps outlined in point 3 above, youll also protect yourself fromdengue fever.5) The need for malarials is dependent on where you are goingThe US Centre for Disease Control (CDC), an organisation which tends to err on thecautious side, suggests the following areas have malaria risks:Cambodia: Risk throughout the country, including risk in the temple complex atAngkor Wat. No risk in Phnom Penh and around Lake Tonle Sap.Laos: Risk throughout the country, except no risk in the city of Vientiane.Thailand: Risk in rural areas that border Cambodia, Laos, and Burma. Risk in KoPha Ngan. No risk in cities and no risk in major tourist resorts. No risk in Bangkok,Chiang Mai, Chiang Rai, Pattaya, Phuket and Ko Samui.Vietnam: Rural only, except no risk in the Red River delta and the coastal plainnorth of the Nha Trang. No risk in Hanoi, Ho Chi Minh City, Da Nang, Nha Trang,Qui Nhon, and Haiphong.The WHO makes the following recommendations:Cambodia: Throughout the year in the whole country except in Phnom Penh andclose around Tonle Sap. Risk within the tourist area of Angkor Wat is limited.
Laos: Throughout the year in the whole country except in Vientiane.Thailand: Throughout the year in rural, especially forested and hilly, areas of thewhole country, mainly towards the international borders. There is no risk in cities(e.g. Bangkok, Chiang Mai, Pattaya), Samui island and the main tourist resorts ofPhuket island. However, there is a risk in some other areas and islands.Vietnam: Malaria risk exists in the whole country, excluding urban centres, the RedRiver delta, and the coastal plain areas of central Vietnam. High-risk areas are thehighland areas below 1 500 m. south of 18?N, notably in the 4 central highlandsprovinces Dak Lak, Dak Nong, Gia Lai and Kon Tum, Binh Phuoc province, and thewestern parts of the coastal provinces, Quang Tri, Quang Nam, Ninh Thuan andKhanh Hoa.6) Malarials can have nasty side effectsThere are four main types of malarials which are prescribed for travel to Asia.They are atovaquone/proguanil (brand name Malarone), doxycycline, mefloquine(brand name Larium) and primaquine. While the majority of travellers take thesewithout problem, each of these can have serious side-effects, including:Atovaquone/proguanilStomach pain, nausea, vomiting, and headache.DoxycyclineSun sensitivity, nausea, stomach pain and vaginal yeast infection. More inconvenientthan a touch of sunburn is that doxycycline can render the birth-control pillineffective. If you are using doxycycline and dont have plans for baby travellers onyour immediate horizon, then you will need to use alternative birth controlmeasures.MefloquineThe most common side effects include headache, nausea, dizziness, difficultysleeping, anxiety, vivid dreams, and visual disturbances. Rarer, more serious sideeffects include seizures, depression, and psychosis. Weve personally seenindividuals bearing the brunt of these side effects and would never suggest anyonetake this profilactic for travel in Asia.
PrimaquineStomach cramps, nausea, and vomiting. Primaquine can also cause an hemolysis(bursting of the red blood cells) in G6PD deficient persons, which can be fatal.That all sounds pretty terrible, but then theres the effects of catchingmalariawhich you need to weight these against:Shaking chills, headaches, muscle aches, tiredness, nausea, vomiting, and diarrhoea.May also cause anaemia and jaundice. Infection with one type ofmalaria,Plasmodium falciparum, if not promptly treated, may cause kidney failure,seizures, mental confusion, coma, and death.7) Many mosquitos are malarial resistantMalaria is an adapting disease and certain areas are resistant to some malarials.To again quote from the CDC:CambodiaThe provinces of Preah Vihear, Siemreap, Oddar Meanchey, Banteay Meanchey,Battambang, Pailin, Koh Kong, and Pursat bordering Thailand are mefloquineresistant -- use only atovaquone/proguanil or doxycycline.All other areas you can use atovaquone/proguanil, doxycycline, mefloquine orprimaquine.No risk in Phnom Penh and Tonle Sap.LaosThe provinces of Bokeo, Luang Nam Tha, Salavan and Champassak, along with theareas along the Thai and Burmese borders are all mefloquine resistant -- use onlyatovaquone/proguanil or doxycycline.All other areas you can use atovaquone/proguanil, doxycycline, mefloquine orprimaquine.No risk in Vientiane.ThailandAll of Thailand is mefloquine resistant, use only atovaquone/proguanil ordoxycycline.No risk in cities and no risk in major tourist resorts. No risk in Bangkok, Chiang Mai,Chiang Rai, Pattaya, Phuket and Ko Samui.
VietnamThe southern and central part of Vietnam, including rural areas of the provinces ofTay Ninh, Song Be, Lam Dong, Ninh Thuan, Khanh Hoa, Dak Lak, Gia Lai, and KonTum are all mefloquine resistant -- use only atovaquone/proguanil or doxycycline.All other areas you can use atovaquone/proguanil, doxycycline, mefloquine orprimaquine.No risk in Hanoi, Ho Chi Minh City, Da Nang, Nha Trang, Qui Nhon, and Haiphong.To boil all that down, if you are going to take malarials, dont take mefloquine as itdoesnt cover the entirety of any one of the above countries.8) Malarials are expensivePurchased in the west, malarials can be very expensive. While were notsuggesting theres any profiteering going on (perish the thought), there is a definatefinancial incentive for the pharmaceutical industry to convince you to purchase thepills before you leave home. If youre comfortable using generic medication,malarials are far more affordable in Asia than in the west,so consider spendingyour money in Asia.9) Chances are youll be fineYoure far more likely to have a motorbike accident, have your bag stolen orcontract dengue fever than you are to come into contact with malaria. While the localpopulation has some degree of inherited resistance to the disease, there arethousands of foreigners living in Asia who have no such resistance. Very very few ofthese foreigners, who live in Asia for years, take malarials on a regular basis.10) Our personal experienceFor what its worth, in our over ten years of living and travelling absolutely all overthe region, weve:Been involved in three motorcycle accidentsHad some piece of luggage stolen at least three timesKnow of at least half a dozen people who have had dengue fever
Have known not a single person who has contracted malariaHave seen two people (including a Travelfish staffer) totally freak out as a result oftaking mefloquine.In conclusion, if youre planning on stopping by just the main tourist hotspots,using repellent and a mosquito net, dressing sensibly and never sleeping naked in aswamp, then chances are you probably dont need to take malarials. On the otherhand, if youre planning on spending a lot of time trekking in remote areas andhanging out in border zones, dont plan to use a mosquito net or repellent andalmost certainly plan to sleep in a swamp in your birthday suit once or twice, thenavailing yourself of a course of malarials would be a prudent decision.One last point -- if you do decide to take malarials, make sure you take the fullcourse of pills. If you cut it short youre contributing to drug resistant strains ofmalaria and also endangering yourself.