Thorn Tree on Malaria

Hi, Enough people have been writing various "facts" about the risks and benefits of various anti-malarial meds that I thought it would be a good time to break out the pharmacology books and write something out. Specifically, I will address mefloquine (larium) and doxycycline. Both are good medicines to protect against malaria (and especially chloroquine resistant malaria). Both have good and bad points. Furthermore, there is a ton of misinformation floating around on this site and among backpackers on the road (as best as I can tell, a good deal of this misinformation originates in Australia, or at least a number of Aussies have told me things that their doctors have said that are not true). I want to emphasize that either med is vastly superior to not taking anything, and hoping for the best. Malaria is very deadly, and it kills fast-- especially when you haven't been exposed to malaria since birth and your ancestors haven't lived in malaria zones for thousands and thousands of years. You should always remember that in many malaria zones, help is not just around the corner. There is no 911 to call, no ambulance with flashing lights screaming across the landscape to save you, and in the day or 2 or 3 that it may take to get you to a hospital, you can easily die. Also, these meds do not protect you 100%, and the best thing you can and should always do is not be bitten by mozzies, which is a different topic. Finally, the disclaimer-- the following is not an all-inclusive discussion, and though I don't think I've made any mistakes, like the good American that I am, I deny all responsibility for everything, so don't sue me. If you are a child, are pregnant, or have the potential of becoming pregnant while on these meds (ie are female and fertile), you should talk to a doctor since these meds might not be the right choice for you. Prophylaxis regimes: Mefloquine-- 1 tab (250mg) each week, starting one week before travel and continuing 4 weeks after exiting the malaria zone. Doxycycline-- 1 tab (100mg) each day, starting ~2 days before travel and ending 4 weeks after leaving the malaria zone. Both medicines are well absorbed provided you don't have some stomach problem like diarrhea/vomiting. Since compliance is always an issue, mefloquine is easier because it is only once a week and has a long half life. Unlike other tetracyclines, doxycycline is absorbed very well from the gut even if it is taken with milk or calcium/aluminum containing things (I forgot about this and I think at some point I said you couldn't take doxy with milk to someone in the past). Both meds should be taken with a full glass of water and with food. Additionally, doxy is irritating and after taking the med, one should maintain an upright position (don't go to sleep) for ~1 hour to decrease the chance that it will reflux back up. Just to mention, doxy is one of the drugs used to treat traveller's diarrhea, so using it daily to protect against malaria will also help to prevent traveller's diarrhea. Lastly, taking the meds faithfully and not stopping until 4 weeks after exiting the malaria zone is incredibly incredibly important and cannot be over- emphasized. Contraindications: All this is direct quotes from the USPDI Drug Information Handbook for the Health Care Professional (aka the drug bible). Mefloquine--- "Risk- benefit should be considered when the following medical problems exist: 1) Epilepsy or history of Seizure disorder?2) First or second degree heart block 3) History of Psychiatric disorders ?4) Sensitivity to mefloquine, quinidine, quinine, or related medications 5) Caution is also required in any patient whose occupation requires fine coordination and spatial discriminations, such as airline pilots or neurosurgeons (this is probably where there whole thing about not scuba diving while on mefloquine comes from. In my opinion, it doesn't make a lot of sense. As any scuba diver knows, all medicines and environmental factors can influence what happens to you during a dive. If you find that you are dizzy, light headed, or are having trouble concentrating when taking this med, you shouldn't dive (ie exercise caution). The same goes for doxycycline, which can also cause dizziness and lightheadedness. I, and a number of other people I know, have gone diving without any problem while on mefloquine, and you shouldn't pass up the opportunity to go diving either. )" The long-term use of mefloquine is unknown, and if you are going to be using it for over a year, you should get an eye exam and some basic lab tests (since at high dosages in rats it has caused retinal degeneration and lens opacity (not reported in humans though.)) Doxycycline--- Tetracycline meds have a wide range of problems, but some are much more common for one type of tetracycline med vs another, and not all apply to doxy, so I'll only list the more likely ones for doxy. "Risk-benefit should be considered when the following medical problems exist: 1) Hepatic ([liver] function impairment 2) Hypersensitivity to tetracyclines, or ‘caine-type? local anesthetics (e.g. lidocaine, procaine)" Side-Effects: Mefloquine: Most side-effects (gastrointestinal disturbances, headache, dizziness, extrasystoles, syncope/fainting) are dose related, and occur with an incidence not much higher than for placebo or other antimalarial meds when taken at phophylactic dosages. 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. Treatment dosage is 1250mg once, which is 5 times the weekly prophylactic dosage! This is where a lot of the mefloquine confusions and scary rumor originate. "Those indicating need for medical attention-- Incidence rare-- Bradycardia (slow heartbeat); neuropsychiatric toxicity (anxiety, confusion, seizures, hallucinations, mental depression, psychosis, or restlessness)?.Those indicating need for medical attention only if they continue or are bothersome-- Incidence more frequent—CNS toxicity (difficulty concentrating, dizziness, headache, insomnia, lightheadedness, vertigo); gastrointestinal distrubances (abdominal or stomach pain, diarrhea, loss of appetite, nausea, or vomiting); visual disturbances" From what I have seen, the most common side- effect of mefloquine is vivid dreams. These tend to occur the night that the tablet is taken, and are not necessarily nighmares, just vivid dreams. Doxycycline: "Those indicating need for medical attention-- Incidence more frequent-- Discoloration of infants? or children's teeth; photosensitivity (increased sensitivity of skin to sunlight)�Encidence rare—benign intracranial hypertension (anorexia, headache, vomiting, papilledema, visual changes, bulging of fontanel in infants); hepatotoxicity ([liver toxicity] abdominal pain, nausea and vomiting, yellowing skin); pancreatitis (abdominal pain, nausea and vomiting)�Ehose indicating need for medical attention only if they continue or are bothersome-- Incidence more frequent-- CNS toxicity (dizziness, lightheadedness, or unsteadiness); gastrointestinal disturbances (cramps or burning of the stomach, diarrhea, nausea or vomiting); photosensitivity (increased sensitivity to sunlight)�Encidence less frequent-- Fungal overgrowth [including yeast infections] (itching of the rectal or genital areas, sore mouth or tongue); hypertrophy of the papilla (darkening or discolored tongue)." Since doxy is an antibiotic, it alters the normal bacterial flora of your gut and other places, and can lead of overgrowth of various bacteria/fungus species that are not affected by doxy. This can cause diarrhea (C. dificile for example), fungal infections, and yeast infections. Drug interactions: The following is a list of some of the generic names of medications that interact with mefloquine or doxy. Mefloquine: beta-blockers, calcium channel blockers (both are beta blockers and calcium channel blockers are meds that slow the heart rate and are frequently used to treat high blood pressure), quinidine, quinine (this is very important if you are taking mefloquine and still manage to develop malaria, since treating the malaria with quinine can be dangerous in this situation), choroquine, valproic acid, and oral typhoid vaccine (it can decrease the effectiveness of the vaccine if you are taking the vaccine and mefloquine at the same time). Doxycycline: Barbituates, Carbamazepine, Phenytoin, cholestramine, Colestipol, estrogen-containing oral contraceptives (concurrent long-term use with tetracyclines may result in reduced contraceptive reliability and increased incidence of breakthrough bleeding), penicillins, vitamin A. Just to say it, there are case reports for all sorts of other side-effects that have possibly been caused by these (and all) meds. A case report basically means that one or a few people have had problem X while taking medicine Y. It doesn't always mean that one caused the other, and does mean that the problem is incredibly rare. If it is a serious problem, it will have been listed above, even if it is incredibly rare As you can see, both these meds are associated with all sorts of side-effects, ranging from fairly frequent to very rare in incidence. In fact, if you take out the paperwork from any medicine, you will find a lengthy list of side- effects that will scare the hell out of you and make you think that you should avoid taking the drug. Look at the label for acetominphen, asprin, or any common cold remedy for example. Just because it is reported doesn't mean that the side-effect will happen to you, and even if it does, one must weigh the risk of the possible consequence of not taking the medicine. What you should probably pay more attention to is the risk-benefit (contraindication) list, as this is where you are more likely to get yourself into trouble by taking a medication. I hope this long thing helps everyone and clears up some of the misconceptions about anti-malarial meds. Please, someone save this so when the whole debate starts up again in another few weeks, I won't have to type everything out again. If you have any questions, I can try and answer them. So can your doctor, or if possible, an infectious disease specialist. Marc

(the_real_choman@hotmail.com)

Hi, The following is taken from my ~monthly e-mail updates to all my friends/family: "On larium dreams: the anti-malaria med causes very vivid dreams. Not nightmares, but normal dreams that are much more vivid and blend with reality to the point were often one wakes up and goes about the day not realizing that the dream didn't happen. A scary dream can really be bad.... In Cintsa(South Africa) I had a larium dream-- I don't remember most of it, but in the end, I was playing in a huge rugby game in SA, with thousands of drunk SA people screaming on. Why the coach decided to play the small American guy is beyond me. But the ball popped out of the scrum at my feet so I picked it up and started running. I was getting the shit beat out of me (literally-- I felt every hit), but I didn't seem to go down. I dove across the line and scored. The crowd went wild. I threw my arms up in joy and woke up. I was so happy I had to tell Kathrine so I woke her up. She had an upset look and said she had lost her baby. She had been 7 months pregnant and didn't know it. She had a miscarriage. But she still decided to marry the guy, who she didn't know. She was trying to decide whether or not to change her last name. She thought that maybe she would just hyphenate it. The funniest larium dream I had was when I was in Tanzania. The dean of UCLA Med was having a huge party and everyone was invited. I decided that it sounded like good fun and bought a ticket to fly home. At the party, over wine and cheese, I was telling people that I was traveling around Africa. They were all amazed and asked why I had decided to come home, it must have been expensive, and that was the end of my trip right? I said, "no, I'm going back." They couldn't believe I had spent all the money for a round trip ticket. Then it hit me. I knew I hadn't thought it through properly. I had forgotten to buy a return ticket and didn't have enough money to fly back. But Max(my travel bud in East Africa) was waiting in Zanzibar for me to continue the trip. Damn. I was so surprised (you know that feeling of shock when you realize you've made a really really big mistake?) I started laughing and woke up, unable to stop laughing." This isn't to say that all larium dreams are fun and good. Nothing is more scary than when someone is chasing you and you can't move. Or when you have a dream that your sister died and wake up assuming this is just part of your life without realizing it was a dream for half of the day. The good thing about larium dreams is that they almost completely (in my experience) go away after the first few weeks. Also, you become pretty good at controlling/enjoying your dreams after the first few?. Marc

(the_real_choman@hotmail.com)

Are you a Medically qualified prof.?

.....no further words needed......

you didn't mention treatment if taking, for example, larium but you still get malaria. My notes from a tropical deseases institute says don't treat with halfan(halofantrine) but use a complicated combination of quinine plus tetracycline or doxycycline or fansidar from day 3. Any comments?

good job, a little bit overdone maybe, but it stresses the coorect points. ancestors will only help if they develloped sickle cell trait. otherwise, even born in a malareous area and thoroughly exposed, when you leave the scene for more than two years, your resistance is almost back to zero. unfortunately a cause of death for quite some people who spent years in europe (etc) and then return to their roots (africa, asia,..) halfan is okay when you have an ecg machine at hand. qt interval should be less thasn .40 seconds. halfan is NOT recommended as stand-by treatment. it interveres more than other anti malarials with heart action (increases the risk of arrhythmias). i carry artemisinine as a stand by treatment and try to get malarone (good for the person, not that good for the public health). but these two drugs are only recommended for moderate attacks.i use mefloquine as profylaxis (since 1989 on and off), no problems. quinine is still the life saver in most of these cases.

Having also done some fairly serious searching about the malaria: what would people pay for a six month vaccine? (Yes, there IS a malaria vaccine, and has been for many years.)

The malaria vaccine has not been shown to be effective. There have been several **experimental** vaccines, but the best has not been sufficiently effective to put through the licensing process. The fact that malaria is caused by a protozoan makes developing a vaccine difficult. P.S. Folks should try to reply to this post so that LP keeps it up on the board

I would recommend that anyone visiting malaria areas have a look at the following website : www.travelclinic.co.za . This website will contain the most up-to-date info on malaria - alternatively contact Dr Andrew Jamieson on e- mail malaria@mweb.co.za .

(woodb.kny@pixie.co.za)

So, lets see. In response to all the great discussions I stirred up on the Africa and on the SE Asia site-- My qualifications for better or worse are: 1) BA in Immunology from The University of California, Berkeley 2) 3 weeks of the loony bin (the reason I have so much time to write all this stuff-- given the choice of hanging out on the psych ward and risking being attacked by a manic patient, or hiding in the library, what would you do?) and 1 week of opthomology away from getting my MD from the University of California, Los Angeles 3) I have a pretty good infectious disease background. 4) I learned my pharmacology from Dr. Lou Ignarro, Nobel Prize winner from the past year, and outstanding teacher. 5) I extended medical school by a year to travel/do rotations in other countries. I ran a pediatric ward at a rural hosptial in Swaziland last year during the short rains and treated _a lot_ of malaria (probably more than most US doctors ever will see). I've seen many of the complications. I've seen cerebral malaria. I've watched 3 people develop the dreaded "blackwater fever," aka acute renal failure, and die b/c they did not have access to dialysis. I actually don't think my qualifications are important, as I purposely directly quoted and referenced most of what I wrote so that everyone could look it up for themselves if they wanted to. I could just as easily be an English teacher or a garbage collector; the facts themselves are referenced and accurate. Just to stress again, everyone going to a malaria zone should be on a prophylactic drug. I know lots of people say they did fine without anything, and didn't get malaria. Some possible reasons: 1) they are lucky 2) maybe they didn't actually expose themselves to malaria (maybe they spent their time in a city for example) 3) maybe they were very dilligent with anti-mozzie protection-- long pants/sleeves, DEET, mozzie nets, etc-- though all it takes is one bite to get malaria (just to put it in perspective, 40-60% of the people in Mozambique are chronic carriers of P. falciparum, so you can guess how many of the mosquitoes have malaria....) 4) Maybe the sample is biased-- travellers who get malaria tend to die if they don't get treated within a few days-- so you mostly read the postings from those who managed one way or another not to get malaria. To address the question of drug resistance, and if we should be using cetain drugs for prophylactic purposes. Mefloquine resistance is felt to come from the exposure of P. falciparum to quinine, and not the exposure of the parasite to mefloquine. Mefloquine (and several other anti-malarial meds) is an analog of quinine, and quinine is the gold standard for treating complicated malaria. It is used like one would give out chewing gum to children during the malaria season (rainy season). Thus, the widespread use of quinine is felt to be the source of the spotty mefloquine resistance seen in parts of the world. I'm not sure I fully believe this, but you can find references to this in most major ID books, and in journal articles. Doxycycline (and all cyclines) is an antibiotic that is most commonly used to treat _acne_, certain sexually transmitted diseases, atypical bacterial respiratory infections, and some unusual bacterial infections. It is very commonly used in animal feed to increase the rate of growth of the livestock (Some nations, such as GB, have outlawed this use, but less civilized places like the US still allow it to be used in feed). This, and the indiscriminant use of this wide-spectrum abx in humans has led to widespread resistance of many species of pathogens to this group of antibiotics. Resistance is transmitted by plasmids, and some species like Strep pneumo and Group A strep, which used to be highly susceptible, are now resistant to the cyclines. Because of all the resistance, the cyclines are mostly used for acne treatment, and the treatment of atypical bacterial infections these days. As an aside, if you don't have acne and you tell a doctor-friend that you've been taking a cycline, you'll probably get them to raise an eyebrow since they'll immediately think you must have an STD like chlamydia. For the big bad bacterial infections, doxy has never been, and will never be, a first-line drug, so this lessens the impact of the above. As far as the long-term use of doxy goes, its long-term effects are not known, but at the same time, I haven't heard anything bad happening if you take it long-term. What this means is no one has done any studies on the long-term effects of the cyclines, so everyone says you should be careful if you are planning to use them for more than a year. They say this to cover their asses, plain and simple. To address the statement someone made about the existence of malaria vaccines: over the years there have been a number of malaria "vaccines." They all work the same way-- a possible vaccine is developed and everyone in the lab gets very excited. They then all volunteer to be used as lab rats to test the efficacy of the vaccine. They innoculate themselves with malaria after being vaccinated, wait a bit, then throw a big party to celebrate the sucess of their new vaccine that will bring them all sorts of money. During the party, someone starts to feel a bit hot. Then someone else starts to feel a bit feverish. Pretty soon, everyone is in the hospital being treated for active malaria. I'm not joking. THERE IS NO EFFECTIVE VACCINATION FOR MALARIA AT THIS TIME, AND DUE TO THE COMPLEXITY OF THE PARASITE, THERE WILL NOT BE AN EFFECTIVE VACCINE FOR MALARIA IN THE NEAR FUTURE, IF EVER! Malaria is a very complicated parasite, and scientists have consistantly been foiled at developing a vaccine. Someone mentioned that the often irrational fear of larium originated in GB and not Australia. This wouldn't surprise me. Medicine in Commonwealth Nations is, in general, different than medicine in the States. I hate to say it, but I was not impressed by the time I spent at a very good hosptial in GB (it has nothing to do with the doctors; mostly just the system). I hear from Aussie doctor-friends that things are much better over in their part of the world. Several doctors (I assume) have raised a very interesting medical situation. What to do with someone who was on mefloquine but develops malaria? Why this is a problem: mefloquine has a very long half life and is present in significant levels for weeks after one stops taking it (13-33 day half life for elimination). Mefloquine is an analog of quinine, the work-horse drug for treating resistant malaria. Quinine and all its analogs (meflquine, quinidine, and others) also exert effects on the heart's electrical conduction system-- they are anti-arrythmic drugs. They increase something called the QT interval on the EKG, which I won't try to explain. You can imagine that if you take both quinine and mefloquine, the effect on the heart's conduction will be more pronounced than just taking one of these meds, and this is true. Thus, there is a very real risk of giving someone quinine if they are also on mefloquine-- arrythmias (irregular heart rhythms), and death. Sometimes, someone who hasn't been on mefloquine, and who develops malaria, will be treated with quinine. A dosage of mefloquine will be administered to assure cure. Since the mefloquine is given after the quinine, it is recommended to wait 12 hours after the last dose of quinine, so that the quinine has been cleared from the sytem. No problem. Obviously, you can't wait a over a month for the mefloquine to clear if someone develops malaria while taking this med for preventive purposes. This situations is one of those things that infectious diseaase specialists are around to deal with. I can't tell you what to do from personal experience, and most ID doctors in the US would probably have to look it up in a book. To quote from the USPDI, "patients taking weekly mefloquine prophylaxis may be found to have mefloquine-resistant malaria that requires treatment with quinine; because mefloquine has a very long half-life [approximately 20 days], it will remain in the body long after the drug has been discontinued. Although there is insufficient information available, it is recommended that if quinine must be given that the patient be hospitalized, if possible, and monitored for QT prolongation and possible rhythm disturbances. Seizure activity may also be potentiated in these patients. In patients considered to be at high risk for a seizure, additional precautions and interventions may be indicated." There are a number of other possible medications that can be used in this situation besides quinine. Practically, one should remember that most malaria is found in the developing (or in many cases as I like to call it, the undeveloping) world. You won't find modern terciary care hospitals, with all sorts of cardiac monitoring and ICU capacity. You won't find a wide assortment of these more exotic medications. Often you won't be able to travel/get evacuated to a place that has the above. Quinine, the work-horse anti-malarial, which is a very good drug with some very bad possible side-effects, is about all you will find frequently. Given the choice of dying from malaria, or risking the quinine, you'll end up on quinine and hope for the best. The following is taken from two ID books, which any doctor (or anyone for that matter) curious about the subject should refer. They also give a good (and simple) discussion on how to choose a prophylactic drug, and what to do for children, pregnant women, etc. My references: _Currrent Therapy of Infectious Disease_ by Schlossberg and _Principles and Practice of Infectious Diseases_ by Mandell, Dolin, and Bennett. Halofantrine, not available in the US, is an analog to quinine. Usually P. falciparum will also be resistant to Halofantrine if it is resistant to mefloquine. It was not very effective in a study of malaria along the borders of Thailand, and it is a fairly dangerous drug, associated with QT interval prolongation and death in individuals who have received this drug and mefloquine or quinine at the same time. It should not be used in individuals who were taking mefloquine for prophylaxis. Artemisinin, or IV artesunate, is another option. This drug is becoming popular in Africa and SE Asia. It is well tolerated and leads to rapid reduction in parasitemia and fever. Unfortunately, when used alone, it is associated with a very high rate of recrudescence, and should not be used as a monotherapy. In the above senario of someone who gets malaria while on mefloquine prophylaxis, mefloquine would not be an option in a combined therapy. Drugs that could be used include doxy or pyrimethamine-sulfadoxine (Fansidar), added after initial artemisinin therapy. Anyone who is fails quinine or mefloquine therapy should be treated by an infectious disease expert, who can decide the appropriate drug combination and regime. Finally, some numbers I found in Mandell's book: mefloquine, when used at theraputic dosages for active malaria, is associated with severe neuropsychiatric adverse reactions (psychosis, seizures) 10-60 times as frequenctly as when the drug is used at dosages for malaria prophylaxis. The incidence of drug related complications during treatment for active malaria was estimated to be 1:215 to 1:1700 users. Someone asked why they were on the same dosage of mefloquine even though they weighed 2x that of their girlfriend. The dosage of mefloquine is based on weight up to 45kg. Beyond that, the dosage is the same for everyone. Yes, your girlfriend probably had more adverse side-effects than you did because the drug concentration in her body was higher (though this isn't the only possibility). And yes, you were both given the proper recommended dosages of mefloquine. Marc

(the_real_choman@hotmail.com)

Couldn't do it better, even with my medical biology background... I hope this post wil stay here very long....and that from now on the TT will remain clear of all those fuzzy questions about malaria which end up being the same again and again (about 1 in 10 postings at the moment I think), and that we can now talk about travelling......

While we have some quality information here, what is the official story about lifelong immunity and/or lifelong re-occuring lethargy or depression after surviving a full malaria attack? ` ` ` ` ` `

Malaria; 4 main species affect humans: falciparum (the dangerous one), vivax, ovale and malariae.(the last three are in general less serious although they can also make you quite sick). Malaria is transmitted by female anopheles mosquitoes. There are roughly 400 species of which around 60 are involved in the transmission of human malaria. Each species has e.g. its specific biting pattern (early after sunset, around midnight, between 2 and 4 a.m, etc.) Just assume between sunset minus 1 hour and sunrise plus 1 hour) Remember that malaria can be transmitted by blood transfusion as well. Resistance to malaria develops over the years with regular exposure. Infants suffer most because their resistance is zero for a start (once their fetal haemoglobine has been replaced by normal haemoglobine) If not regularly exposed, one loses his or her immunity. Apparently 2 year of non-exposure reduces your resistance to almost zero. If the red blood cells have the sickling characteristic (trait) the person is more or less protected against the severe effects of malaria (especially in infancy), because the parasites don't have much appetite in these abnormal cells. Also people lacking the Duffy blood group are protected against Vivax (hence hardly any vivax in West Africa and Afro-Americans), Also fetal haemoglobine protects Relapses: Caused by activation of "sleeping" parasites in the liver (not affected by the primary treatment).. Falciparum: mostly up to one year, rarely up to two years, very rarely up to four years after the primary infection. Vivax: Different relapse patterns in different parts of the world. Ovale: Less relapses than Vivax. Mostly spontaneous recovery after a short period. Malariae. Relapses are possible long after the primary infection. They are common in the first year and then follow at long intervals, but there have been reports of parasites in the blood up to 52 years after the primary infection, without major symptoms. Uncomplicated recovery is the rule. However, cerebral damage in various degrees is possible in cases of cerebral malaria.

Life being what it is,many people cannot take Mefloquin for 1-2 or 3 years while in Africa. Some friends of mine lived there for such period of time and stop the threatment after 6 months or a little more due to side effects and serious one. Others stopped also for the same reasons and personnaly developped a side affect after one week and nothing serious... Those that I know,stopped taken the medication,and decided to take their chances and of course got Malaria,but working in Cities were properly threated. I personnaly nearly quit,which I did not.Was there for only 2 months. Bought also ounce there Sulfate Quinine as well as Fansidar. And honestly what are my options for my second trip which will last up to two years if not three? I ALSO THINK THAT YOU CANNOT PREVENT YOURSELF OF A MOSQUITOE BIT.....over such a period. What is therefore to your opinion a good method of fighting Malaria??? In West Africa. I bou

(gatienp@hotmail.com)

are not as life-threatening as suggested here. They are only so if not caught and treated early, and that doesn't mean you have to treat it the very moment you notice symptoms. Obviously, however, if you're in a place where there is no medical treatment, you need to get yourself to a place where there is. I know many people from around the globe who have had malaria once and felt like absolute hell for a period of time but are fine. Many scientists who live in these areas and work for long periods of time consider getting the disease to be preferable to taking highly toxic medications or using toxic repellents for long periods. The majority of people who die from malaria are those without the opportunity for treatment or who don't seek it early on.

Thanks for the information. I honestly thought myself that the whole panoply of drugs,Deet,Mosquitoe Net etc is for those travelling through infected areas. Those residing will take certain precautions but first will reassure themselves of immediate proper threatment if required. I was in Lom? Togo last Fall for 2 months and beside changing a few window screens of my appartment,vaporizing a spray in the whole house 2 hours before going to bed WAS ENOUGH. Of course I was not running around town at night either. It is all a question of common sense and to be alert. Can you give me infos on Sulfate Quinine as well as Fansidar? I won't be taken Lariam anymore since side effects still persists after being back since 4 months. They are sold over the counter in West Africa in most pharmacy. Are they still effective in those countries where Malaria is endemic?. Thank you in advance

"m" why do you presume that a "Repellent" is "highly toxic"? ` DEET, a recommended repellent, "keeps mosquitoes away but does not kill them" -- unlike Pyrethrin, a recommended mosquito insecticide -- that is extracted from Chrysanthemum Flowers. Is your assumption based on some toxicological studies or simply the opinion that any commercially processed "chemical" is "toxic", and anything extracted from "natural" sources is non-toxic? I am confused. ` ` ` ` ` ` `

As per instructructions on DEEP WOOD 95 % DEET,it is toxic. It is also a very effective repellent with such a concentration.No African Woman will get near you.... It is not my idea of a repellent. I threw a few bottles away and forgot the whole idea. Seriously it is highly toxic but I think it is related to someone drinking the product and I'm no expert.

smack the fuckers with a rolled up newspaper.

CAN ANYONE TELL ME WHERE I CAN GET DEET BASED MOSQUITO REPELLENT IN THE U.K.?, AS I DON'T SEEM TO BE ABLE TO FIND ANY. WE ARE GOING TO THE GAMBIA IN APRIL.

I've taken Larium for a year and stopped. The drug gave me vivid dreams the evening after taking it and heart burn if I didn't eat with it. It worked well. Note that I got malaria anyway. It came on gradually and I overlooked it before getting sick. I treated the malaria with Halfan which cured it promptly. When I got home to Can. the tropical Doc told me tat Halfan in combination with Larium stops your heart 1/20 of the time and can be fatal. I no longer take Larium simply because I live here and a net at night for sleeping and trousers worn in the evening is better.

http://www.geocities.com/TheTropics/6913//lariam.htm No need to waffle on further

http://www.geocities.com/TheTropics/6913/lariam.htm (one less slash)

Does anyone have any information on Artenam? My wife took it last year when we were in Tanzania and she had Malaria and it worked superbly. However it doesn't seem to get mentioned anywhere.

I have loads of questions about malaria. Some may seem stupid, perhaps, to the medically qualified. But it seems to me that so much of the advice assumes medical knowledge, even training, which most people simply do not have. [How many people know what is meant by the word 'prophylaxis' for example? yet all articles / posts ever written about malaria assume understanding of that word......] I may have to be in Arusha, Tanzania, for a year, by the way, which is why I am highly interested to find out as much as possible...... But: for example, How exactly does malaria work? Why would it ever not work in a particular individual's case ? Do all Africans who inhabit malarial regions religiously take Lariam or whatever all their lives ? If not, how come they don't all contract and die from malaria? Or perhaps they do suffer from it to a greater or lesser extent ? How does Lariam work? Why does it sometimes not work? What is the likelihood of it not working in any individual's case? If one does get malaria,{specifically, of the sort that one would get in Arusha} what are the likely effects of it? Can treatment 'cure' it completely, or is it true that one's liver is permanently damaged and may suffer relapses even years later, attributable to the disease ? If one gets bitten by a single malarial mosquito, does that mean that one inevitably contracts malaria? Once one has been bitten by one malarial mosquito, do additional bites by the same or other mosquitoes make things worse? or is the malaria just going to go ahead and do its thing anyway ??? I have never been to a malarial region before, but I have been to mosquito areas such as the south of France / Italy and the Caribbean. In all of them I find that however much I soak myself in deet and wear long trousers / sleeved shirts and so on, still I get quite badly bitten by mosquitoes. Is it true that some people, in particular, celtic origin people, do attract mosquitoes more than do others ? I knew someone in the Caribbean who claimed never to be be bitten by mosquitoes, whilst his wife often was....... If I am correct that I am more susceptible to the attentions of mosquitoes than are most people, is that a factor that should reasonably lead me to conclude that contracting malaria is so inevitable that I simply should not go to Tanzania in the first place ??

Children in Africa get malaria several times and pick up a semi-immunity after having had it several times [unless it kills them]. Many of the adults in tropical Africa have low-level malaria but it is asymptomatic because they have become semi-immune to it.

The type of malaria that is in Africa [Plasmodium falciparum] does not relapse, unless you get infected.
again from another mosquito bite.

People vary in their attractiveness to [Anopheles] mosquitoes but this isn't possible to classify along ethnic lines. This is an individual thing and is not exactly predictable. Mosquitoes at home [warm temperate area] love me, but the ones in Central America seemed to like other people better [sorry I have no observations from Africa]. Some people say that vitamin B12 helps, and others recommend to not eat any sugar.

Artenam (artemesinin) is an excellent treatment for malaria. It is not widely used because it is too expensive for most of the locals. I found it at just a few pharmacies around Moshi for about US$10-12, that's a fortune for the Tanzanians. Resistance is increasing to this drug and it's not approved for use in the US.

Is Marc or any other health professional type still around? I see that one isn't supposed to take some of these antimalarials if one has seizures or has psychiatric disorders.

I do not get seizures but take an anti-seizure/mood stabilizing medication, Depakote. Do you know anything about this interacting with antimalarials? Also, I'm bipolar (manic depressive) and have various neuroses to content with. Will antimalarials set me off, make me crazy?

I will be spending a few weeks in a West African city soon for business. Advice would be appreciated. I'm not sure whether we will be making forays out of the city.

Hi,
It is me again, now Doctor Marc Chodos, MD, starting my residency training in orthopaedic surgery at Johns Hopkins Medical Center.
First, I would like to mention something that no one ever talks about. If you don't take mefloquine with lots of water, it can get stuck in your esophagus. I don't know if it is a physical or chemical irritation, but it can be quite painful to swallow (or breath if it gets stuck near the diaphram level) for several days after this happens. I've seen it twice now, and it happened to me while on Mt Kilimanjaro. Make sure you have a glass of water handy when taking mefloquine.
In response to questions about artenam, I mentioned in a previous response that it has a very high failure rate when used alone. Please refer to response post #9: "Artemisinin, or IV artesunate, is another option. This drug is becoming popular in Africa and SE Asia. It is well tolerated and leads to rapid reduction in parasitemia and fever. Unfortunately, when used alone, it is associated with a very high rate of recrudescence, and should not be used as a monotherapy. In the above senario of someone who gets malaria while on mefloquine prophylaxis, mefloquine would not be an option in a combined therapy. Drugs that could be used include doxy or pyrimethamine-sulfadoxine (Fansidar), added after initial artemisinin therapy."
In response to post #25, I agree that people build up resistance to grossly symptomatic malaria over time b/c of their immune system, but I would argue that they are not asymptomatic. Anemic children walking around with a hemoglobin level of 9 or less may be normal in parts of Africa, but I am certain it leads to more insidious long-term issues.
In response to the post before this one, no you should not use mefloquine if you have bipolar disorder. Stick with doxy, or malarone (if you can find/afford it).
I just returned from SE Asia (Singapore, Malaysia, Thailand, Cambodia, Vietnam, and Laos) over 3 months during the dry season. Very hot. Not very many mozzies, except in certain areas (Chiang Mai, Laos, Cambodia, during the day at Koh Tao). I started the trip on mefloquine until I entered Cambodia. I never had any side effects to it, and actually didn't even notice that I was taking it (unfortunately, no cool dreams to report).
I was tipped off that malarone was available in Bkk, but I could not find it after extensively searching a number of hospitals and pharmacies. Mefloquine is available, at a cost of ~50-55 baht per pill (1$=39 baht). Doxy is widely available too, and is cheap.
I switched to doxy when I entered the Thai-Cambodian border region (mefloquine resistance reported in the border areas of Thailand). I had minimal problems taking the doxy, and took one or two dosages late (>8hrs after I was supposed to). This is actually pretty good compliance, but you can see that mefloquine is much easier in this regard since it is only once per week. I used mostly SPF 15, 25, or 30 waterproof sunblock. Of note, in most of the world sunblock is imported and very expensive. Moreover, it is quite difficult to find waterproof sunblock. IMO water resistant sunblock is useless since you will sweat it off, or wash it off readily. I always get burned with water-resistant sunblock, even if I reapply it frequently. What I am trying to say is that you should bring along plenty of extra suntan lotion (SPF30, or definitely >SPF15; and waterproof) when you leave home. In case you are wondering, my skin tone is about the same as someone from Greece, Southern Italy, Israel, etc. I found that I burned quickly without suntan lotion while taking doxy. Yet, I tend to burn in the equatorial regions anyway unless I have built up a good tan, so.... I met several people that had gotten burned quite badly b/c they didn't use suntan lotion and didn't know they should use it while on doxy (either b/c they forgot or the doctor didn't tell them). I also met some people who didn't use suntan lotion for whatever reason, took doxy, and didn't burn. Skin tone and sun exposure are everything here.
Both medicines, plus the fact that I am very good about anti-mozzie precations-- wearing pants, long sleeves, DEET (>30% for face and sometimes upper extremity exposed regions, and I usually use small amounts of 100% DEET for exposed areas, especially lower extremity-- feet if wearing sandles, sometimes arms if wearing short sleeves, neck, ears), using a mozzie net, and not wandering around extensively at night-- seem to have been effective at preventing me from getting malaria again.
In short, regardless of which medicine you choose, anti-malarial prophylaxis is important and effective.
MD Chodos, MD

It seems from all this that the thing to do is take lariam, cover up & use DEET. And then seek treatment at the earliest opportunity if infected. But what are the symptoms (i.e. how does a person know they've been infected?) and is 'treatment' self-medication or do you need to go to a hospital? I'm travelling with kids so would be interested to know what signs & symptoms to look for. Thanks

Good to see an intelligent discussion of this subject. It's been a while since I checked into the Thorn Tree, and I remember wildly argumentative posts, with superbly unqualified people doling out advice on one drug or another. For my 2 cents....I took larium over a period of @ 6 months, while traveling through SE Asia. I also managed to contract malaria anyway. No one drug is going to be able to protect you completely, and no drug claims to be able to. For general info, malaria is NOT PLEASANT. I lost @ 14 lbs in as many days, had fevers over 105(F), shakes and mild hallucinations. It took me 6 days just to get to a town that had basic hospital services (trekking near the Tibetan border at the time). Would I ever go to a malarial zone without preventative meds? No way. Why risk it? Sure, you may not get it, but if you do, believe me, it really sucks.

Me again.
My malaria experiences will be different since all the malaria I've seen has been in the local population, all of whom have some degree of resistance to it after repeated exposures.
Any fever is malaria until proven otherwise in a malarial zone. During the wet season, just about anything can be malaria. I remember one case where the mother came in with her 12 year old boy, saying that he hadn't had much of an appetite for the last week. She said he was on anti-seizure medicine and thought that maybe the dosage needed to be adjusted. I ran a malaria smear (despite the "are you an idiot?" looks the nurse gave me) and it was 3+ malaria (smears are read on a scale of 1 to 4, 4+ being a very high parasite load).
One of my friends got malaria in the Congo a few years ago, despite taking what I think was larium (I think bad diarrhea might interfere with absorbing the medicines so the actual blood level might be low despite good compliance-- he had an ameoba for weeks). He said it felt like being run over by a train-- fever, chills, sweats, malaise, aches....It hit him very hard and very quickly.
So you can see that the presentation can vary quite a bit from person to person.
This brings up the point of a first aid kit. It is my opinion that the only two absolutely necessary things to have in a first aid kit are a thermometer and oral rehydration salts (ORS). If you don't feel right, the thermometer will help you decide if it is serious or not (ie do you have a fever?). The ORS can save your life if you have severe stomach problems like diarrhea/vomiting-- it is dehydration that'll kill you. Anything else in a first aid kit is nice to have, but superfluous in the end. I can't think of much else that will help to save your life; most things in first aid kits are really comfort things. You can always improvise when push comes to shove.
If you have a fever and don't feel right for whatever reason, and you are or have fairly recently been in a malarial zone, you should see a doctor to get tested for malaria. It is simple to do, cheap in Africa, and you'll get great service (any traveler/westerner will immediately be at the front of the line in all the rural clinics and hospitals I've seen). You don't self-treat malaria, especially without diagnosing it first.
Marc

Thank you Dr. Chodos! And all the congratulations in the world on your new MD!

Any views or advice please on use of Wormwood as an alternative to conventional malarial prophylactics.
Going to Namibia in August for a couple of weeks.
Previous experience of Mefloquine and Doxy unpleasant and
have heard of Wormwood as an option.
Many thanks is advance

Molly,
You'd have to do a medline search (go to a search engine, look up "medline" and find a free medline site), but I double there have been any randomized, double blinded studies on wormwood. I have a vague recollection from my childhood herb-growing days that wormwood was one of the ingredients in bootleg whiskey that made you go blind. You'd have to check on that one too, because the memory is pretty vague.
Marc

Thanks Marc
If I find out anything useful, I will post it here

Re 19 - Hazel - I get my Deet in Millets. 50% seems to work OK. Remember it's easy to get bitten through thin clothing and who wears anything else in the tropics.

A question for you docs, pharmecists and wannabemedics - does much Deet get absorbed through the skin with repeated use and have any studies been done on the effects of absorbed Deet? It's pretty mean stuff. If it dissolves plastic, what on earth is it doing to my body? No, I know I'm not made of plastic ......

Re 17 - Jean Pierre - lashings of Deet in my experience do not deter African women who think we stink anyway. They're usually too focussed on the pay-off to worry about a little olfactory annoyance. If it bothers you, overlay the Deet with a generous amount of Lynx spray deoderant - 'Africa' is my favourite variety.

Re 21 - Sheldon - brilliant net site. Highly informative and the best coverage of malaria preventatives and treatments I have seen. Personally, I wouldn't touch Mefloquine/Larium with Jean Pierre's. I have made many trips to Africa and have taken precautions against being bitten in preference to prophelactics. But after reading these sites, I'm having a rethink.

Hello - another qualified MD here (Board certified professor of Emergency Medicine in California with experience in travel med in US and abroad). I find Marc's postings thorough and informative, and appreciate his view that experience in the medical field is NOT a substitute for doing one's homework (looking up the facts). I appreciate that Marc has worked in a malaria-heavy part of Africa...thus far my first-hand experience has been limited to SE Asia. One thing I'd like to add is that Malarone (atovaquone plus proguanil, to which Marc alluded briefly) is a good alternative for treatment of Malaria acquired while on mefloquine (Lariam). The curative dose is 1 gm atovaquone plus 400 mg proguanil (4 pills of Malarone) daily for 3 days. It's not available in the U.S., but I'm told it can be bought in Europe. I don't know if or where it can be found in Africa, but it HAS been studied with excellent results in sub-Saharan countries. It's also a reasonable alternative for prophylaxis (adult dose = 250 mg atovaquone + 100 mg proguanil daily). The following 2 abstracted references are worth reading:


TITLE: Malarone (atovaquone and proguanil hydrochloride): a review of its clinical development for treatment of malaria. Malarone Clinical Trials Study Group.
AUTHORS: Looareesuwan S; Chulay JD; Canfield CJ; Hutchinson DB
AUTHOR AFFILIATION: Department of Clinical Tropical Medicine, Bangkok Hospital for Tropical Diseases, Faculty of Tropical Medicine, Mahidol University, Thailand.
SOURCE: Am J Trop Med Hyg 1999 Apr;60(4):533-41
CITATION IDS: PMID: 10348225 UI: 99275981

ABSTRACT: The continuing spread of drug-resistant malaria emphasizes the need for new antimalarial drugs. Atovaquone is a broad-spectrum antiprotozoal drug with a novel mechanism of action, via inhibition of parasite mitochondrial electron transport, and a favorable safety profile. Early studies with atovaquone alone for treatment of malaria demonstrated good initial control of parasitemia but an unacceptable rate of recrudescent parasitemia. Parasites isolated during recrudescence after treatment with atovaquone alone were resistant to atovaquone in vitro. The combination of atovaquone and proguanil is synergistic in vitro, and clinical studies demonstrated enhanced efficacy of the combination compared to either drug alone for treatment of malaria. Malarone, a fixed-dose combination of 250 mg of atovaquone and 100 mg of proguanil hydrochloride, is available in many countries for treatment of acute, uncomplicated malaria caused by Plasmodium falciparum. At the recommended dose (in adults, four tablets once a day for three days), the overall cure rate was > 98% in more than 500 patients with falciparum malaria. In four randomized, controlled clinical trials, treatment with atovaquone and proguanil hydrochloride was significantly more effective than mefloquine (Thailand), amodiaquine (Gabon), chloroquine (Peru and the Philippines) or chloroquine plus pyrimethamine/sulfadoxine (Philippines). In clinical trials where the comparator drug was highly effective, treatment with atovaquone and proguanil hydrochloride was equally effective. Parasites isolated during recrudescence after treatment with the combination of atovaquone and proguanil were not resistant to atovaquone in vitro. The most commonly reported adverse events in clinical trials (abdominal pain, anorexia, nausea, vomiting, diarrhea and coughing) occurred with similar frequency in patients treated with a comparator drug. Malarone is a safe and effective new agent for treatment of malaria.


TITLE: Randomised placebo-controlled study of atovaquone plus proguanil for malaria prophylaxis in children.
AUTHORS: Lell B; Luckner D; Ndjave M; Scott T; Kremsner PG
AUTHOR AFFILIATION: Research Unit, Albert Schweitzer Hospital, Lambarene, Gabon.
SOURCE: Lancet 1998 Mar 7;351(9104):709-13
CITATION IDS: PMID: 9504515 UI: 98163043

ABSTRACT: BACKGROUND: The combination of atovaquone and proguanil is highly effective and safe for the treatment of Plasmodium falciparum malaria. We aimed in this randomised, double-blind, placebo-controlled study to assess the efficacy and safety of this combination for malaria prophylaxis. METHODS: 320 children who lived in a hyperendemic area for P falciparum malaria were stratified by weight and randomly assigned atovaquone plus proguanil or placebo once daily for 12 weeks. All children received initial curative treatment with atovaquone and proguanil before the start of chemosuppression. We recorded adverse events daily and collected thick blood smears once a week. The primary endpoint was a positive blood smear. FINDINGS: 25 of 140 children in the placebo group and none of the 125 children in the atovaquone plus proguanil group had positive smears during chemosuppression (p<0.001). Adverse events during the chemosuppression phase did not differ between the groups. INTERPRETATION: The combination of atovaquone plus proguanil is a highly effective and well-tolerated chemosuppressive antimalarial in children. This drug combination could replace current regimens.


Again, thanks to Marc for the good work...and best of luck in residency.

I lost my life due to tt!

does anyone have any knowledge re a new repellant product now on the market, produced by Bayer. it's called AUTAN Active and claims to be better than DEET (smells better, better for the skin) and lasts 70% longer? available at Boots in UK for £5.

also, what is the approx shelf life of say a 95% DEET repellant. would a spray purchased 18 months+ ago still be effective now?

in response to post #19, in UK you can buy DEET products at Blacks and YHA stores.

Thanks for all the informative info, so now I will take anti-malarials (was not going to) but I recently came off depression medication (Ibelieve the depression was situational) and just worry about my head going screwy again:) Which of the meds are better to take for this???
Thanks in advance

Okay, I read all 40 posts. Please advise for my situation. I will be traveling backpacker style all over SE Asia/Indian Sub-continent/China/Siberia/Moscow etc. for 18 months. I will be in and out of high, medium, and low risk malaria regions for the first 10 months. I have been prescibed Lariam and told to take continuously. Do you agree with this? Should I limit my intake to the high risk zones? Expense is another issue here. Can I get reliable Lariam in BKK without an Rx? I will of course be taking all the bite precautions as well. What do you think?

Thanks for your help and excuse my separate post on TT (twas before I saw this post). Cheers!

Okay, I read all 40 posts. Please advise for my situation. I will be traveling backpacker style all over SE Asia/Indian Sub-continent/China/Siberia/Moscow etc. for 18 months. I will be in and out of high, medium, and low risk malaria regions for the first 10 months. I have been prescibed Lariam and told to take continuously. Do you agree with this? Should I limit my intake to the high risk zones? Expense is another issue here. Can I get reliable Lariam in BKK without an Rx? I will of course be taking all the bite precautions as well. What do you think?

Thanks for your help and excuse my separate post on TT (twas before I saw this post). Cheers! Please email me at kirkandjenn@bigworld.com

Just a quickie: What level of psych problems constitute a contraindication for mefloquine? Eg occasional episodes of sub-clinical depression. I have also heard that the people most likely to suffer from psychiatric problems on this drug are those with 'type A' personalities. Is this true?

I heard this, incidentally, from a medical student friend about to go to Tanzania on an elective so this isn't just a 3rd hand rumour, although I am usually a UK dweller, which is where all the stories about Larium side-effects seem to be most prevalent.

Thanks

Thanks for all the *very* useful info, Marc and everyone else. I'm very, very glad you took the trouble to post this. Best of luck on your residency.

Do not interfere in the affairs of dragons, because you are crunchy and taste good with ketchup.

Actually, another question: How easy is it to pick up Malaria tablets "on the road"? I am already in South America and if the standards (quality, effectivity) are the same, I would prefer to pick up Mefloquine somewhere in Chile or Bolivia, instead of having someone bring it from Europe (which would however be possible). So, does anyone have experiences or recommendations on this procedure? Can the medication be prescribed in any hospital in that region or do I have to go to a specific institution? Thanks in advance for your help and in general for the informative posts on here!

All I want to know is - do I need to take malaria meds to do a 2 day trek from Chang Mai? And if so, which one?

Here's some info on Malarone, a new (in the US) medicine combination for preventing or treating malaria. This is all condensed from _The Medical Letter on Drugs and Therapeutics_ Vol 42 Issue 1093 pp 109-111 (11/27/00) "Atovaquone/Proguanil (Malarone) for Malaria." The Medical Letter is a non-profit unbiased review letter regarding drugs and therapeutic regimes (they have a web site: www.medletter.com). They conclude that malarone is expensive, must be taken daily, and that the data on prophylaxis of travelers using malarone is limited. They feel that mefloquine [larium] is generally preferred as a first line drug for the prophyaxis of malaria in the traveler population.
-Malarone is approved by the FDA for both prophylaxis and treatment of malaria.
-COST compared to other meds, for enough med to take as prophylaxis for a 2 wk trip (for doxy this is 1-2 days prior entering a malaria zone, and continuing for one month after leaving (46 pills). For mefloquine, this is 1-2 wks prior to entering the zone and continuing for one month after (8 pills). For Malarone, this is 1-2 days prior to enterin the malarial zone, and continuing for _1 wk_ after leaving (23 pills). Note that since malarone is a per day drug, it is much more expensive than the other two options for a long trip.)
Mefloquine: $63.38
Malarone: $103.48
Doxycycline: $3.66 (generic)
-Atovaquone works by depolarizing the parasitic mitochondria, unlike all other antimalarials. This novel mechanism of action likely explains why there is no known resistance to it. Proguanil has an active metabolite that inhibits parasitic dihydrofolate reductase. It potentiates atovaquone.
-Malarone is effective against all forms of P falciparum and P malariae. It is effective against the blood, but not the liver forms of P vivax and P ovale.
-Atovaquone is poorly absorbed from the gut, but is better taken up if the med is taken with a fatty meal. It has a 2-3 day half live and is excreted unchanged in the stool. Proguanil is rapidly absorbed, concentrated in red blood cells, metabolized by the liver, and excreted in the urine. It has a 12-21 hour half life. Thus, malarone should be taken once per day with a meal.
-Clinical Trials: 6 published studies (917 patients)for the _TREATMENT_ of P falciparum malaria comparing malarone to mefloquine (100% vs 86%), amodiaquine (98% vs 81%), chlorquine+pyrimethamine-sulfadoxine(Fansidar) (100% vs 88%); quinine+tetracycline, Fansidar, or halofantine (as effective).
2 randomized double blind trial for prophylaxis of 515 semi-immune adults (living in endemic regions) using malarone vs placebo: 98-100% effective vs 48-63%. Similar study of 320 semi-immune children: 100% vs 82% effective.
-Two randomized double-blind trials of 1998 non-immune _TRAVELERS_ comparing malarone to mefloquine or chloroqine+proguanil (no placebo group): 100% vs 100% vs 99% effective. The amount of exposure to malaria is questionable since there was no placebo. Finally, 1 double blind trial in 297 non-immune _TRAVELERS_ who moved to Irian Jaya of malarone vs placebo: 1/148 on malarone infected with P falciparum vs 23/149 on placebo; 3/148 on malarone infected with P vivax vs 16/149 on placebo.
-Malarone is generally well tolerated. SIDE EFFECTS include abdominal pain, nausea, vomiting, diarrhea, headache, and rash. Also mild elevations in liver enzymes. Side effects worse at treatment dosages as opposed to the lower prophylaxis dosages (as is true with all antimalarial meds). Proguanil is considered safe during pregnancy; the safety of atovaquone during pregnancy is unknown.
-Taking tetracycline, metoclopramide (reglan), or rifampin (rifadin) at the same time as malarone will reduce the plasma concentrations of atovaquone by 40-50%. Proguanil has no known drug interactions.
-The review concludes that "Malarone may be as effective as mefloquine for prevention and treatment of chloroquine-resistant P falciparum malaria, but data on prophylaxis of non-immune _TRAVELERS_, such as those from the USA, are limited. Malarone is expensive and must be taken daily for prophylaxis; mefloquine [larium] is generally preferred.

Sorry guys, I'm just posting to make sure this brilliant thread doesn't disappear from this site.

An excellent thread; wish I'd come across it sooner.

I've contracted malaria twice while taking larium. The first time (6 years ago) I chalked it up to all the intestinal parasites which presumably interfered with absorbing the mefloquine, but this last time I was healthy right up to the day I went down with malaria. The doctor I saw (in Mali) said it's pretty common when taking larium.

My question is about the drug he prescribed: arsiquinoforme, made in France. His feeling was that if you've got malaria you take the drug for three days and by definition you are cured. I am less confident. Any ideas, comments, suggestions?

Thanks.

Mark

quickie: is malarone available through the nhs in britain and if not, where can i get it en route overland to india/thailand? cheers for any replies

Dear Marc ,

i think it is very interesting to read about your med. things but I would like to remind you that some of us are not englishspoken (?) so please: use some chapters so it is so much easier to follow what, when and how , okay?

remember:enter x 2..

Marc: Thank you for your excellent posts about malaria on the Thorn Tree. I was feeling dizzy with all the
misinformation out there.

I specifically want to ask you about your information that you can get Mefloquine in BKK for approx
50 baht/pill. I was quoted $20/pill in California yesterday! My husband and I are going to be
travelling for a year, and our trip will start in BKK.

To buy this pill, will I need a doctor's prescription? Did you get the pills because of medical contacts,
or can anyone go up to a pharmacy and get it? This information will make such a difference in our
financial situation. Also, do you have any more info on whether Maladrone is available now?

Thanks you once again for your help in this matter.

Firstly my congratulations to everyone who has contributed to this thread. I wish I had seen it before boring you all with another newbie post about Doxy/Lariam :-)

One nugget of info that I haven't seen addressed yet: does anyone know any stats for the relative chance of experiencing severe side-effects from either drug (esp. photo-sensitivity with Doxy)?

Cheers folks..... George

OK, I know I said ONE nugget of information - but I think some of you qualified medical folks can help me out here. I'm going to be travelling in Malaysia, Thailand, Vietnam, Laos and Cambodia over a 6 month period. As far as I can tell Mefloquine is recommended for all but the Thai border areas.

I'm going to moving in and out of malarial areas so my questions are: i) when would you recommend starting treatment and ii) is my assumption that Doxy would be the most effective/generate least side-effects? By this I mean would it be better to stick with Doxy the whole time OR start Mefloquine and shift to Doxy for Thai border areas.

Any comments welcome. Keep up the quality posts people!
Cheers, George

P.S. CreamSoda - wise words, will have to remember that :))

Brilliant!
To Mark, or anybody else that know:
After reading all this, I think the new Malarone is my thing (border ares in Thailand)
Is it possible to go to a docktor in Bangkok and get Malarone?
What about the Netherlands? (stopping there om my way, og think I have time to go see a doctor

First, I was told by an ID doc at Harbor-UCLA that you can get malarone in BKK, but I searched extensively (not extensively enough) and couldn't find any.
Many people have been asking me about SE Asia and what med to use. First, when the CDC says the "border regions of Thailand," it is because they don't expect people to venture into the surrounding areas. I would consider Cambodia, Laos, and ex-Burma to be areas where one could potentially be exposed to mefloquine-resistant malaria. Don't think of it as a few-kilometer strip of land surrounding all of the Thai border areas that is bad.
Without any scientific evidence to back this up, I would suggest 1) using either doxy or malarone 100% of the time, or 2) using using mefloquine until the day before reaching a mefloquine-resistant region (MRR), and then switching to doxy or malarone. Stay on this medication until you have been out of the MRR for the recommended amount of time (4 wks for doxy or 1 wk for malarone). At that point you could then switch back to malarone, and repeat the above everytime you entered another MRR. In practice (especially if you should use doxy), unless you are traveling for extensive periods of time, you will end up starting your trip on mefloquine and finishing on something else.
Marc

When I was working at a safari lodge in Zimbabwe, management's suggestion for those with Lariam issues was to advise people to make sure that they were drinking lots of water (at least 5 litres a day), and that they should try splitting their weekly into one half pill every half week.
Is this reasonable?

I used Malarone while traveling in Cambodia as there is depression in my family and doxy gives me yeast problems. With my insurance I was able to purchase it at a reasonable price in the US. They gave me 1 months worth or 30 pills but I only needed it for 2 days before, 4 days there and 7 after so one persrciption did for 2 people.

I didn't notice any terrible side effects, except for feeling a little spacy about 20 minutes after taking it. I just took it before going to sleep. Make sure you have food with you to take it with. One night I got caught without food as the resturants were closed and the next day I had very slight abdominal pain (not enough to keep me from doing anything though). For the record I didn't get malaria.

I would really appreciate hearing from you helpful MDs out there if there is any new info on this anti-malarial.

Thanks.

http://www.hindustantimes.com/nonfram/020201/detFOR30.asp

This is an article covering the effects of Triclosan on Malaria parasites.



Honor among Bodhisattvas !

As far as I know, you cannot find Malarone in SE-Asia,I`ve asked some doctors and in pharmacies, in Europe you can buy it even without prescription in pharmacies.

good to see some fact based inf here!
i have a Q that i was not able to get an answer for: i have heard that taking vit b (either b12 or b complex) can help with keeping the mozzies away. my doc said it was rubbish, and that she has never heard of this (she's an infectious dis xpet). does anybody know if this is true or where the rumor originated?
im heading of for vietnam/laos in april- so this is important (and yes, im also taking my pills)

Ok, some brief questions as this is a really useful post...
I've had malaria. The doctor gave me quinine/chloroquine as curative. It worked but affected my eyesight very badly - tunnel vision, instability, etc. If I take quinine-based as profylactic, will this work?
I've taken larium in past but had depressive side-effects. Will this recurr if I take it again? Is it more likely to increase in severity and become paermanent if I continue to take it?
My mother has a heart condition ( a hole) which I do not want to get tested for as I don't want to know. But, is malarone OK to take if I do have any heart problems?

Honest, I'm not making this list of medical woes up and need advice for a 4 month trip to SE Asia (Malaysia, Vietnam, Laos Thailand) where I don't want to allways be within 24 hours of a doctor...

I've had malaria - no. 29, hideous fever, slightly greenish vomit, and the most APALLING belly pain EVER, apparantly it makes you're spleen swell up and believe me it feels like it. I wouldn't mess about with self-miedication, but if its going to take you more than a day to get to a doctor then start the medication on the way.
Quick questions:
i) Is quinine completely pointless in SE Asia?
ii) If you've had side-effects from Lariam once, are you likely to get them whenever you take it?
iii) Do the side effects get worse if you continue using it or do they stay as they are?

I've had mildly nasty side effects from Lariam and swapped to quinine, hence the malaria, very stupid I know, but would take Lariam agian if the side effects wouldn't worsen.

I've also had very bad side effects with quinine used as a curative- tunnel vision and unstable vision - likely to recur if I take quinine again?

First, all it takes in one mozzie to get malaria (or to ruin your night.) I don't know if vitamin B, or garlic, or other things like that keep the mozzies away. I haven't seen any studies, but most people I've talked to say they are old wive's tales. Even if they work, I would be shocked if they were very effective. In summary, they probably won't hurt you, but I wouldn't soley rely on them to prevent bites, malaria, or other mozzie-transmitted illnesses.
Quinine is very toxic. It should never be used to prevent malaria. It, by itself, or in combination with other meds, is incredibly effective at treating malaria-- really the gold standard world-wide. This comes at a price. First, quinine causes birth defects as it crosses the placenta (deafness, limb abnormalities, visual defects; and it can induce delivery). It can cause agranulocytosis (death of white blood cells that fight infections), bleeding problems, it is toxic to the liver, it can cause irregular heart rhythms and death, it is toxic to the nervous system and can cause seizures, delirium, coma, etc, it is toxic to the eyes, and can cause peripheral field visual defects (which may incompletely recover) or blindness....
The most common side-effect of quinine at treatment dosages is "cinchonism," a group of symptoms that include blurred vision/changes in color vision, headaches, nausea and vomiting, ringing/buzzing in the ears, and temporary loss of hearing. This is felt to be dose related, and is well described. Finally, quinine can cause diarrhea, and abdominal pain, in addition to nausea and vomiting.
In short, DON'T USE QUININE FOR PROPHYLAXIS.
Marc

This is a great post -- thanks for everyone's information, and thanks especially to Marc. A couple of posters had the same question I had, which didn't get answered: if one has a history of depression (I took Wellbutrin to help my ADD and situational depression, have been off it for a couple months), is it best to avoid Larium? And also, which medications are best for long-term (ie more than 6 months) use? I will be in South Asia (India, Nepal, Sri Lanka) for 8 months. Thanks... BB

Ive just been given a 'paludrine/avloclor travel pack'from the chemist in the uk as Im off to sri lanka for three weeks-will this do the job?
p.s.I had a very bad reaction to larium 6years ago which put me off the drug.

I think most doctors would advise you to avoid mefloquine if you have a history of depression. Does that mean that everyone with a history of depression (I don't know what you mean by "situational" depression-- everyone feels down at times-- after the death of a loved one, a break-up, etc, but the normal mourning process (or bereavement) would not meet the axis 1 definition of major depression.) will freak out on mefloquine? Of course not. Most people will probably be totally fine using mefloquine. But no one is going to be stupid enough to tell you that you'll be ok. From the medical-legal viewpoint, it isn't worth it­ Not unlike avoiding penicillin in people with "penicillin allergies," even though you think it is very very unlikely that this specific person has a true allergy to penicillin.
As far as long term use of antimalarials go (assuming the malaria will be sensitive to mefloquine), I personally would chose mefloquine since it is a once-a-week drug. I think it would be much harder to take a med everyday, but that's just me. I would imagine that malarone will be too expensive at this point for most people to use long term. Doxy is tried and true, and would be my second choice. Though if I were a woman and could possibly get pregnant, I might rethink this since tetracycline drugs and pregnancy are not a good combination.
Again, like most things in medicine, there are not hard and fast rules. Ask 10 people, and you'll likely get several different (and contradictory) answers that are all valid.
Marc

Yes, the yucky but tolerable side effects of larium tend to decrease/disappear over time.
marc

Marc, thanks for your response. By situational depression (that was the medical term), I mean that I was unhappy with my life but my reaction to it went off into medical depression (mind-body affecting one another). Anyway, I am most interested in doxy, but had a question about the pregnancy question -- I will not be looking to get pregnant while taking malaria drugs and it is highly unlikely that it will happen by accident (as I am a lesbian), however, I am planning on getting pregnant at some point in the next five years or so. Would doxy affect my longterm chances of getting pregnant or having a healthy baby? Or is it just while I am taking the drug? Also, I believe Malarone is covered by my insurance (Blue Cross) and I wonder what the side effects/longterm usage effects would be. Also, is Larium less toxic because you only take it once a week? I would actually have an easier time remembering to take something every day than every week, but I'd rather do it every week if it gave me awful side effects. Whew... didn't mean to write a novel... Anyway, thanks a lot for your help!

Keep-alive post - the longer this thread stays the better!

Firstly, thanks Marc and everyone for finally producing some independent and useful info and discussions. Particularly thanx to Dr Dave (no.39) for shedding some light on the Malarone issue which I have been hunting for info about for ages. I second the question asked in no.69, as I will probably be planning a pregnancy within the next five years. I will only be taking malaria meds for 2 months-ish, but I wonder if there are any known long term effects for future children from any of the drugs? Have any studies been done on this? I'm still trying to decide which ones to take for my trip to East and Southern Africa. Also, are malaria pills needed in Egypt?

Good info - LP keep this one please.

I had Lariam for 6 weeks (2 weeks before, 4 weeks after visit) in SE Asia (Indonesia). It worked well for me, apart from slight lightheadness. No vivid dreams (well, I never remember my dreams anyway...).
I completely agree that anti-malaria drug is better to have than to suffer a higher risk of getting malaria.

Unfortunatly it seems like I am a person who attracts mosquitoes (if I walk in a forest next to another person, guess who will have the most bites afterwards?). ;-)
My guess is that sweating and blood veins close to the skin could be attractive to mosquitoes?

BTW, I got bitten on the hands and on the ankles by mozzies, those parts are not easy to protect.
It also seems like the mozzies in Asia make no noise (as the blood suckers in the nordic countries).

The half life of doxycycline is short so it should be completely out of your system in a matter of days. Add in a month or two or three more since you don't know if you are pregnant for a little bit after you get pregnant (ie so you are certain to not have gotten pregnant while taking doxy), and you can be pretty certain that the doxycycline you previously took will not have an effect on your pregnancy. You don't need to wait 5 years.
Marc

It seems slightly ridiculous that we have to post this way in order to keep a thread going, but since this is one of the most even-handed, knowledgeble discussions of malaria pills that i've seen on TT, i'm going to vote for it again.

Thanks, Marc!

Firstly, I want to say thanks to Marc for all of the wonderful advice and info you have posted.

Secondly, my question(s)...
I will be travelling in West Africa (Senegal, Mali, Burkina Faso, Cote D'Ivoire, Ghana, Togo, and Benin) for about 2 and a half months. I just spoke to my travel doc who recommended that I take Larium, but from reading about all the side effects, I think I would prefer to take something else.

I know my other options would be Malarone and Doxy. Malarone is expensive and I'd rather carry it as a standby treatment (do I need to get a doc prescription for it?) I used Doxy when I travelled in South East Asia without any side effects, except for the last few weeks or so while I was in Indonesia and contracted some kind of stomach virus (I suspect from something I ate), and stopped taking Doxy. I didn't contract Malaria. If this was to happen again while I'm travelling in West Africa, what should I do (as the risks of contracting Malaria are higher in W Africa than SE Asia)? Start using another anti-malarial, or continue taking doxy regardless? Also, are there statistics that show Larium or Doxy as more effective than the other (for this specific region)? I've read many stories about how Larium users still contract Malaria. If the statistics are similar or are favorable to either one, I'll choose to take that one instead. (I haven't been able to find many stories, or specifically any "horror" stories with Doxy, except that my travelling partner had a horrible sunburn, possibly second degree, while taking doxy.)

Please advise...

Thanks for your help!

(Dunno if you know about vaccinations but I just received my yellow fever and meningococcal shots and am currently experiencing stiff neck and joints, tingly sensations and slight sharp pains in my head - is this normal!? I asked my travel doc and she said I'm not supposed to have any side effects from the vaccinations!)

So often professionals horde knowledge or assume that it takes a degree to make an informed decision. Thanks for sharing.

Square eyes....Its taken me three hours to scour the internet for the most up to date info on Malaria preventation for Africa. This had been the most useful info so far. Thanks - keep checking in Marc, you're a star!

My doctor and the Travel Clinic in the UK gave me contradictary advice recommending two different medications. I've checked the 'fitfortravel.scot.nhs.uk' website and various other medical sites. Any recommendations for authoritive advice in the UK? It seems so hard to get advice you can trust. And is malarone available here? ( did i miss that in the 70 odd posts!)..

Q2. Doxycycline increases the risk of sunburn.Right. Does that mean it will be easier to get a suntan too? :-)

Should someone post a new 'question' and point people towards this discussion? I went through all the previous pages on the TT before I found this!

I'd just like to add my thanks to all concerned. I'm off to the Amazon in a few weeks and like the prev poster hav had all manner of problems getting good advice - especially from my local heath board here in the uk. This post has been a godsend, lets keep it live.

Excellent information. no I can go talk to my doctor with at least a little knowledge of the risks and cures.

thank you and keep this thread alive,

Happy trails

Hi folks,

Once again, thanks to Dr. Marc and others for such a useful discussion. Great post.

Slightly off the topic of prophylactics, but I have a quick question: I've just recovered from malaria, contracted in Northern Mozambique and treated successfully with Fansidar. I've had conflicting advice from people regarding drinking after this ? some say I shouldn't drink for up to 7 weeks, to give the liver chance to recover fully; others say it's no problem to get straight back on the beer. A minor point I know, but does anyone out there know the true story regarding drinking after malaria?

Cheers,

rob

Searched high and low for comprehensive information about malaria and all I got were contradictions, both from local medical clinics that deal specifically with people going overseas and the internet. so all my thanks to you Marc. I have been reading TT for 2 weeks now and came across this my chance. Anyway to post it in an easier to find place for others?

Most smiles are started by another smile!

Artemisia absinthium (wormwood) is the critical herb in absinthe and contains thujone.

Absinthe originally became popular in France because of its use by French soldiers posted to north and west Africa who used it as a malarial treatment. The anecdotal evidence at the time was such that the French military authorities encouraged the consumption of absinthe and it was widely believed to be at least partly successful.

And no - it doesn't make you go blind. Absinthe, I mean.

This may be silly but I must ask it ...

I am not hugely confident in Lariam. I have read a lot of bad press on it and, whether justified or not, I do not think that I would be confident taking it. Does one think that this would affect its side-effects? If it is not to be taken when suffering from depression, may this mean that feelings of unease when taking it could have an effect???

Comments would be grand.

Matt

it says on the british national formulary web site that some western provinces of cambodia (and thai/cambodia border) have malaria that is resistant to larium (mefloquine).

any one know which provinces and how prevalent this resistance is?

Great thread! Even the doctors in the clinic here have been giving me contradictory information.
One question: If the dosage is the same for everyone over 45 KG, but I have VERY strong reactions to all drugs (I weigh 48 KG) and am generally given a lower dosage than most adults (including anesthesia during surgery), should I consider taking a lower dosage of melfoquine? (Example: if I take an antihistamine or even a pain killer, I need half the normal dosage for it to be effective without causing side effects).
It seems like the basic idea here is that each person has to weigh the pros and cons of each for himself. I for one have a very sensitive stomach as well as a constant battle with vaginal thrush. Even taking a one week dosage of antibiotics does me in and I could not imagine taking even a "mild" antibiotic continually for 6 months. So melfoquine it is for me with the expectation of no side effects.


Most smiles are started by another smile!

please respond ASAP--I leave within a week!
MARC,

Thanks for all of the great information. However, I'm still unclear about how important it is to avoid larium if one has/had depression and panic disorder. I'm a 30 year old woman living in northern California. I've been taking anti-depressants for most of the last 13 years (currently wellbutrin, effexor, trazodone) and get depressed without meds, but am not currently depressed because I'm on medication.

I'm going to Thailand for 5 weeks; two of which I'll be in the Northeast between Chiang Mai and the Golden Triangle.
What do you suggest taking? A FAST response is much APPRECIATED. thank you.

For the previous poster: please refer to my answer in posting #67. I would suggest that you not use larium for all the various reasons outlined above.
Marc

This is one of the longest and best documented threads on the LonelyPlanet Thorn tree. Very interesting indeed.
Let me just ad a topic for discussion :

*** the use of Artemisinine and it's derivatives like Artemether, Artesunate, ... ***

There are some points I's like to stress :

- these drugs are currently only recommended to treat actual Malaria, not as preventive medication. Allthough it would probably work, but there are fears of getting resistance to these drugs. More research is needed.
- these drugs are very effective. In many studies at least as effective as the alternatives, often more effective. But in general with very few to no side effects. But ... what about recrudescence ? This is indeed possible, but then again ... retreatment is possible, and as mentioned in other posts, the combination with other drugs.
- it is important to respect the dose prescribed. In the past some companies distributed packages with tablets/vials containing a dose that was later considered to be rather small.
- the drugs exist in tablets, and vials for intramuscular injections. The choice of the most appropriate form can be made by the physician. The advantage is that in general no perfusion is needed. Ofcourse it can be needed for other reasons at the beginning of the treatment, but there is often no need for a sustained perfusion. This makes this drug easier to use in areas where perfusions are hard to find.
- its effective against malaria that is resistant to many other drugs
- there are very little to no side effects. This doesn't mean the drugs is free of them, but certainly when compared to other drugs (like ofcourse Mefloquine) it's "toxicity profile" is very interesting indeed
- the product is not "new", it is just "less known". In fact it has been used in China for a very long time. It took quite a while before "western interest" arose. This was needed however, since the available products in China were not always of good quality. Belgian companies decided to invest in reliable production facilities complying with the most stringent American or European laws. Nowadays, these companies still distribute high quality artemisinine derivatives ... but their succes was copied in other countries. A recent article in The Lancet I believe states that some tablets found on the market contained a smaller dose , or a poorer quality drug. This is not the case with the European product
- these drugs are not always easy to find. There should be no problem in south east Asia and in large parts of Africa. In the US and in Western Europe however, these drugs are not readily available at the moment. Larger hospitals with a tropical disease unit usually know where these drugs can be obtained.
- the cost when bought in Asia / Africa is usually lower then Lariam, but might be higher than Quinine
- some physicians believe that people travelling to medium risk countries, not travelling in a fashion that rapid medical attention is hard to find, and not willing to take Lariam because of various reasons, can decide NOT to take any preventive drugsn but leave home with their own supply of artemisinin derivatives. If they then develop a medical problem that even remotely looks like Malaria, they will seek medical attention. If malaria is present, or in case of the slightest doubt, they can then take the treatment. The tricky part is ofcourse : how well can travellers themselves feel symptoms, how fast can medical care be found, ... so this is maybe not an ideal solution. But for some situations and some people, this "Lariam avoiding strategy" is worth considering. In that case this "considering" should include a personal visit to an experienced physician in a travel clinic to discuss positive and negative implications.
- in some African countries special forms are available for children, including a syrup.

Dear Doctor Mark,
thanks for your useful info and explanation about anti-malaria drugs. I'll probably spend one year and more in Mumbai (working) and I wonder what long-term expats can take against malaria. Once I used to take chlorochina and proguanyle together and I had some side-effects (my stomach) and I wonder what can I do now: at the hospital of my home town in Italy they have told me that Mumbai is quite safe for malaria, but I don't believe it is so safe.
Thank you in advance,
Clara

Klaretta

to the operators,
please never delete all this information!!!!

Thanks doctor Marc for such an effort to clarify some doubts about Malaria.
Next month I have plans for a short trip in the Amazon forest, and after reading all feel better and more councious about the disease.

I hope you're still checking in on this it's the best resource I've found on the web anywhere - you deserve an award.

I'm off to South America in October and then Africa (Southern) after three months in Oz. I don't want to take Larium, I have a friend who's been left with severe depression and forgetfulness and other problems since he took it. I reckon doxycycline is my best option. Two problems - I'm on the contraceptive pill (Dianette) will that have any effect ? Also I've had suspected salmonella three years ago, and a couple of severe food poisoning incidents since then (last one last month). I still have ocasional stomach upsets. The doctor had me taking gaviscon (antacid) and maxalon but now I'm feeling better taking a probiotic supplement (acidophillus somethingorother). As it's an antibiotic will doxycycline make my stonach problems worse/better or is it down to pure luck ? Hope you can help, my doctor doesn't seem well up on the subject !

Thanks for all your advice

Very informative. Again, Marc, your efforts are widely appreciated!

malaprim and cloroquin? I have done my best to scan the info on the last 90 posts, but not see this get a mention - is that just because it is just not worth mentioning? I grew up in africa, and only made a half hearted attempt to take malaria pills when i went to the Zambezi valley (deltaprim was the flavour at the time). Anyway I never got malaria. I have now been living in the UK for 3 years, returning home once a year, and being aware of the fact that whatever resistance my system may have built up, would now be zero. So I take malaprim and cloroquin and it suffices (even in the Zambezi valley). Now, I intend to travel around central and south america and would like to know how these two drugs stand up to the competition or should I start contemplating the tougher stuff (doxycycline, larium and mefloquine). (and these are the only competition from what I can glean from the info on this post - correct??).

I swear by halfan!!!So take it people.

Wow. what else is there to say? I got malaria in Malawe. Felt a car sickness one day. Hallucinated the next day and was in a hospital by the third. The doctors (one from Malawe, the other from France, I think) told me they considered it very mild and to continue the Mefloquine. I don't remember halfan or any other medication.

One thing that my doctor did notice back in the US was my enlarged liver. Marc, have you heard of such side effects from malaria?

It's not the travel, but to go. ~Jaroga, 22 Malawe

I used malarone for 7 days in Cambodia and felt it was a good altrnative. It did make me sleepy and I did follow the directions for eating it with food. I took it at night. It didn't make me feel crazy of get sunburned or a yeast infection. Also insurance covers it quite nicely in the US, making it cheaper than Larium by the pill.

my question. Is there any new info on side its effects? If I went back to SEA I would like to use malarone again .


I also want to mention I've also seen info about the use of Artemesia annua derivitives, especially In VN as a treatment, rather than profilaxis for malaria. I've used a combination of the herb artemesia annua and grapefruit seed extract to protect against parasites and other bacteria on foodwhile traveling and I've found it a very effective preventative. The herbal form is active in your gut but is not asorbed so doesn't effect your whole system. I can't quite see how it would prevent malaria in this form, but it sure works for parasites. I've used traveling in mexico and all over SEA. I used to get everything- giardia, amoebas the whole gamut- now I don't get anything even eating street food. There a company called Nutribiotic that carries it in the US.

Long live this thread Happy Travels!