Protection against malaria
BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7171.1508 (Published 28 November 1998) Cite this as: BMJ 1998;317:1508All rapid responses
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Here in the states, we have received very little news about the
devastating psychiatric side effects of mefloquine, and the rate of these
side effects is underestimated in the literature. Therefore, U.S. doctors
follow the CDC recommendations which prefer mefloquine, without even being
aware that in other countries this drug has a reputation for causing
serious depression, paranoia, and even suicide.
I had always freely prescribed mefloquine for travellers without
warning them about possible consequences, and took it myself on a trip to
India. For a previous trip, I had used doxycyline with no ill effect at
all. On this trip, I experienced nausea, headache, loss of appetite, and
emotional lability to the degree that my travel plans had to be changed.At
the time, I didn't think of the little pill I took once a week as the
possible culprit. In fact, it wasn't until years later upon reading press
releases from Britain that I recognized my symptoms were side effects of
the drug. They persisted for at least six months upon discontinuing the
drug, which is not surprising given the very long action of mefloquine.
We also do not know enough about the interactions of it with other
drugs, especially oral contraceptives which may potentiate its action.
Therefore, I am much more cautious now and prescribe alternative
approaches such as doxycyline whenever appropriate. I have never heard of
proguanil, and do not find it in the main reference books for U.S. drugs,
the Physician's Desk Reference.
Competing interests: No competing interests
Viewing the short lesson of the week on malaria prophylaxis, it
strikes me once more how regional preferences affect the choice of malaria
prophylaxis.
British travellers are currently in the invidious position of choosing
between mefloquine, which has a terrifying reputation, and the relatively
ineffective combination of chloroquine and proguanil. Passing reference is
made to Maloprim, which is indicated for few destinations.
Why is doxycycline, an antimalarial propylaxis deemed important by the
rest of the world, not even mentioned? There is good clinical evidence
that doxycycline is an effective malaria prophyaxis, and it has the
advantage of not being tainted by media reports.
Interestingly, I note that America steadfastly still ignores the existence
of proguanil, further perpetuating another anachronistic regional
idiosyncrasy.
Competing interests: No competing interests
Malaria - missed opportunities for prevention
EDITOR – We applaud Abi Berger on his compendium (A, B, C, D) of
measures available for protecting travellers against the ravages of
malaria infection.1 The particular emphasis on compliance with
appropriate drug regimens should however not detract from the importance
of strict adherence to effective measures for preventing mosquito contact
and bites. No drug measures are 100% effective and in low transmission
malaria areas the risk of adverse events attributed to chemoprophylaxis
may well exceed the benefit of avoided infections.2,3
Conversely, although the World Health Organization advocates
protection against mosquito bites as the "first-line of defence against
malaria", the basis for this recommendation has until recently been
questionable.4 Evidence for a protective effect against malaria of skin-
applied insect repellents, air-conditioners, fans, coils, vaporising mats,
and long-sleeved clothing has been largely speculative and based on
extrapolation from indirect evidence of decreased vector feeding with use
of these measures.
The rise of "evidenced-based medicine, widely publicised reports of
encephalopathic reactions in children associated with the most widely used
insect repellent, N,N-diethyl-3-methylbenzamide (DEET), and the carefree
ambience and nonchalance of many travellers has resulted in neglect of
personal protection measures (PPM).
This is exemplified by a postal survey of visitors to the Kruger
National Park, South Africa, during the seasonal high-risk period. More
than 95% (7034/7387) of tourists provided responses to the section
investigating use of PPM. Thirteen percent of these travellers (912/7034)
used no PPM and only 17.1% (n=1209) used four or more effective measures
while 27.1% (n=1907), 22.2% (n=1565), and 20.5% (n=1441) used one, two and
three effective PPM, respectively. Neglect of PPM use was positively
associated with non-use of drug measures, with 17.3% of tourists that were
not using drug measures neglecting PPM use compared to 11.9% of those on
chemoprophylaxis (Chi-square=28.24, p=0.000).
The most commonly used PPM were skin-applied insect repellents
(90.3%, n=5525), long-sleeved clothing (46.0%, n=2815), socks and shoes
(38.8%, n=2374), coils (27.0%, n=1651) and vaporising mats (17.6%,
n=1076). Specific effective PPM were little used, particularly knockdown
insecticides (9.0%, n=548), bed-nets (1.5%, 49) and insecticide
impregnation of clothing (0.2%, n=12). There were individual travellers
who relied upon ineffective measures, including ultrasonic buzzers (n=12),
alcohol consumption (n=9), Vitamin B12 and garlic ingestion (n=4).
Two important recent papers have bearing on malaria prevention advice
offered to travellers by medical professionals. A review of DEET toxicity
revealed only two case-reports of systemic toxicity following topical
application in adults and only 13 case-reports of encephalopathic toxicity
in children despite 40 years of extensive use.5 Secondly, a questionnaire
survey of more than 100 000 European tourists to East Africa found that
air-conditioned rooms (Chi-square=4.01, p=0.045) and clothing which covered arms
and legs (Chi-square=5.25, p=0.022) effectively reduced the risk of malaria.6
Regular use of all or some of the four most important PPM, viz. air-
conditioned room and/or bed net, adequate clothing, insecticides and/or
coils, and repellents, reduced the risk of malaria to approximately 50%
compared to no use (multivariate Chi-square=8.47, p=0.037).
Geographic knowledge of the distribution and prevalence of malaria
and drug-resistant malaria should be used to determine the type and indeed
the necessity of malaria chemoprophylaxis. Travel health advisors however
are obliged to advocate the correct use of proven personal protection
measures against mosquito bites for malaria prevention.
David N Durrheim
Consultant in Communicable Disease Control
Mpumalanga Department of Health
Private Bag X11285
Nelspruit 1200, South Africa
Peter A Leggat
Associate Professor and Deputy Head
School of Public Health and Tropical Medicine
James Cook University
Townsville
Queensland 4811 Australia
Both authors have contributed to the conception and preparation of
this document, there is no conflict of interest and the manuscript has not
been offered for publication elsewhere.
References
1 Berger A. Protection against malaria. BMJ 1998; 317: 1508.
2 Steffen R, Behrens RH. Travellers' malaria. Parasitology today
1992; 8: 61-66.
3 Durrheim DN, Braack LEO, Waner S, Gammon S. Risk of malaria in
visitors to the Kruger National Park, South Africa. J Travel Med 1998; 5:
173-177.
4 World Health Organization. International travel and health:
vaccination requirements and health advice. Geneva: WHO, 1998.
5 Fradin MS. Mosquitoes and mosquito repellents: a clinicians
guide. Ann Intern Med 1998; 128: 931-940.
6 Schoepke A, Steffen R, Gratz N. Effectiveness of personal
protection measures against mosquito bites for malaria prophylaxis in
travelers. J Travel Med 1998; 5: 188-192.
Competing interests: No competing interests