Malaria and mountaineering

Posted by Stephanie Mackie, Jeremy Windsor and Paul Richards on 08/03/2010
Make sure you don't take malaria to altitude.

Spectacular landscapes, amazing climbs and virgin peaks … many of us travel far and wide for these unforgettable mountain experiences. Whilst most come back with a sun tan and some jealousy-inducing shots of high peaks in sunny climes, a few bring back something a lot more dangerous: malaria.

In 2007, 1,548 people in the UK were diagnosed with malaria1. On average between 5 and 15 die each year despite the best efforts of the NHS. Even for those who survive, malaria is an unpleasant business. Days of fevers, chills and joint pains leave you wiped out for weeks. For many, the diagnosis of malaria will come as a complete surprise. Don’t suffer from ignorance – read on!

Malaria is an infectious disease passed on by the bites of female anopheles mosquitoes. It is found widely in tropical regions including many popular mountaineering destinations in Asia, Latin America, and Africa2. Many mountaineers who pass through tropical lowland areas before, or in the early parts, of an expedition will be at risk. Imagine what it would be like at 3,000, 4,000 or 5,000m when malaria strikes. Sounds scary? It is! But in many cases, malaria is preventable, even in a challenging mountain environment. A simple A, B, C, D approach3 can help:

A – Be AWARE of the risk
Make sure you are aware of the risks involved in your journey by first visiting a travel clinic or your GP surgery for advice. Try to do this at least 6 weeks before departure since it allows enough time for a “test” dose of your preferred anti-malarial tablet. If possible, provide your GP with a detailed plan of where you are going and for how long – in many countries only certain regions pose a risk. It’s often been said that the anopheles mosquito doesn’t survive above 1,500m. In most cases this is true, but there are reports of some surviving at 3,000m or higher! Importantly, even if you plan to spend most of your time at altitude, part of your expedition will pass through lowland areas at some stage. One bite is enough to acquire malaria!

B – Stop mosquitoes BITING you
Bite prevention is possibly the most important part of protecting yourself from malaria. Anti-malarial tablets are effective but even they can’t work 100% of the time. If the mosquito doesn’t bite you in the first place, you won’t get infected with malaria!

Preventing mosquito bites is common sense. The best strategy is to limit how much of your body is accessible to mosquitoes. Keep covered up with long trousers and full sleeves wherever possible. Unless you want to add gloves and a balaclava, you’ll need something to protect the skin on your hands and face too. DEET is an effective insect repellent which can be found in a range of liquids, sprays, creams and sticks. Preparations containing 50% DEET are most effective and will need fewer applications. Higher concentrations are not usually recommended except for the most heavily insect infested areas. DEET works well on skin but can eat into plastics and some synthetic fabrics – so keep it away from watch straps and technical kit!

The mosquitoes which carry malaria are predominantly active at dawn and dusk, so one of the best ways to prevent bites is to sleep under a bed net, especially one treated with an insecticide such as permethrin6. Many places in tropical areas will supply bed nets; however it is sensible to have your own. These can often be found in travel shops and chemists and cost only £10-£20 – a good investment! It’s also worth using a “knock-down” spray before going to bed as this will kill any insects already in the room.

Sleeping under a net is easy to do if you are staying in a guesthouse, hotel or mountain hut, however it’s a lot more difficult if you are camping or bivvying. In these situations use a tent with an insect mesh door, cover as much skin as possible7, avoid areas close to stagnant water and use generous amounts of DEET to exposed skin when outside your mosquito net protection!

C – Take appropriate medicines to prevent malaria (CHEMOPROPHYLAXIS)
If you’re going to an area where there is a high risk of malaria, you should be taking an anti-malarial medication. At present there are a number of medicines available which can help protect you from developing the disease. Your choice will depend upon the region you are visiting, your current and past health, and any personal preferences you might have. Although all of these are generally considered safe, they do have side effects and it is important to think about which ones are manageable and which could cause you problems. Most anti-malaria medicines need to be started before entering an at risk area. Because of this, seek advice early so that you can make sure you begin to take the tablets at the right time.

 

At present, five different medicines are recommended for preventing malaria3:

  • Malarone (atovaquone-proguanil)
    Allegedly, fewest side effects. Only needs to be taken 2 days before and 1 week after exposure. Expensive, may occasionally cause nausea and headache. The safety of malarone in long-term use is not yet known.
     
  • Doxycycline
    Provides protection against gastroenteritis, is cheap and has few side effects. Can be started on arrival. May cause thrush, sometimes makes the skin more sensitive to sunlight, can cause stomach upset.
     
  • Mefloquine
    Only taken once a week, relatively cheap, usually well tolerated. Needs to be taken 1 week before departure. May be linked to serious psychiatric side effects in susceptible individuals. Can make seizures more likely. Some side effects can be confused with altitude illnesses such as AMS.
     
  • Chloroquine
    Cheap, can be taken for extended periods of time. Very widespread resistance – seldom used alone, may cause headache, stomach upset, or itching.
     
  • Proguanil
    Usually well tolerated. Very widespread resistance – seldom used alone, may cause mouth ulcers and diarrhoea.

Apart from malarone, most anti-malarial medication needs to be continued for four weeks after returning from a high risk area.

Doses
 

Drug

Dose

Frequency

Duration

Malarone (atovaquone-proguanil)

250mg

(atovaquone),

 plus 100mg (proguanil)

Once daily

1-2 days before entering an at-risk area, throughout stay, and 1 week after leaving.

Mefloquine

250mg

Once weekly

1 week before entering an at-risk area, throughout stay, and 4 weeks after leaving.

Doxycycline

100mg

Once daily

1-2 days before entering an at-risk area, throughout stay, and 4 weeks after leaving.

Chloroquine + proguanil

(only where there is little drug resistance)

300mg

(chloroquine),

plus 200mg (proguanil)

Once weekly (chloroquine),

once daily

(proguanil)

1 week before entering an at-risk area, throughout stay, and 4 weeks after leaving.

Chloroquine

(only where there is no drug resistance)

300mg

Once weekly

1 week before entering an at-risk area, throughout stay, and 4 weeks after leaving.

Proguanil

(only where there is no drug resistance)

200mg

Once daily

1 week before entering an at-risk area, throughout stay, and 4 weeks after leaving.

 

 

Also remember:
Although it is often possible to buy anti-malaria tablets at your destination, the counterfeiting of drugs is a massive problem in many parts of the world8. It is very difficult for even a trained pharmacist to distinguish confidently between those that are genuine and those that are fake. If in doubt, buy your anti-malarial medicine before leaving the UK.

Whilst chloroquine and proguanil are available over the counter at your local pharmacy, the others require a prescription. Your medications are best kept in hand luggage in order to reduce the risk of loss or damage. If you can, store some spares somewhere safe, just in case.

Don’t forget - malaria can occur if tablets are missed or stopped too soon.

Finish the course!

Although rumours abound of strange and exotic ways of preventing malaria - from Marmite to homeopathy - most of them don’t work3. It’s worth bearing in mind that if you do get ill and need medical assistance, many insurance companies will not look kindly on travellers who have chosen not to take adequate precautions to prevent the disease.

D – If you become unwell and are at risk of malaria, get DIAGNOSED and TREATED quickly
By its very nature, mountaineering is a sport that often takes us far away from big cities, well-equipped hospitals and trained medical staff. One of the most important aspects of staying healthy in the mountains is recognising when you or other members of your group are in danger. Malaria is no exception.

If you are planning to travel through an area where you might be exposed to malaria, it makes sense to know the signs and symptoms of the disease before you go. The combination of a fever and a headache in a high risk area is a sign that malaria may be developing. At altitude, don’t assume that someone with a headache has acute mountain sickness (AMS). Malaria can be an aggressive disease and can spread quickly, affecting the brain and other vital organs. If you suspect malaria then a rapid descent and transfer to medical care is vital.

Nowadays easy-to-use diagnostic kits are available to help with the diagnosis but have proved less reliable than expected in field use.

Warning signs you may have malaria9:

• Fever, especially alternating hot and cold
• Headache
• Muscle pain
• Cough
• Diarrhoea and abdominal pain

For travel in very remote areas it is worth carrying “back up” medicines. For trips where you will be more than 24 hours away from medical back up, “standby emergency medicines” can be lifesavers. The medicine chosen for emergency malaria treatments are different from the ones used for prevention. At present, three different regimens are commonly recommended for UK travellers: co-artemether, malarone, and quinine combined with doxycycline3. It is important to discuss with your GP whether you’ll need emergency medicines, and if so, how to use them.

Malaria is a serious illness which is widespread across much of the world. But it doesn’t need to stop you enjoying breathtaking mountains in some of the most remote areas in the world. With a little planning and thought, the risk of malaria can be greatly reduced – so before your next trip, remember the ABCD, and get good medical advice well before you go.

 

More information
More information is available from your GP or travel clinic, as well as online at:

National Travel Health Network and Centre

fitfortravel

UK Health Protection Agency

 References:

1. HPA. Malaria imported into the United Kingdom in 2007: Implications for those advising travellers. In: Health Protection Report [serial online] 2008 [cited 5 March 2009]; 2(17): news.
2. World Health Organisation. Country list: Yellow fever vaccination requirements and recommendations; and malaria situation [document on the internet]. Geneva: World Health Oragnisation; 2008 [cited 5 March 2009]. Available from: http://www.who.int/ith/countries/2008_country_list.pdf
3. Chiodini P, Hill D, Lalloo D, Lea G, Walker E, Whitty C and Bannister B. Guidelines for malaria prevention in travellers from the United Kingdom. London, Health Protection Agency, January 2007.
4. Fradin SM, Day JF. Comparative efficacy of insect repellents against mosquito bites. N Engl J Med. 2002 July 4; 347:13-18.
5. Choi, H.W., Breman, J.G., Teutsch, S.M., Liu, S., Hightower, A.W. and Sexton, J.D., 1995. The effectiveness of insecticide-impregnated bed nets in reducing cases of malaria infection: a meta-analysis of published results. Am J Trop Med Hyg, 1995; 52(5): 377-382.
6. Gupta RK, Sweeney AW, Rutledge LC, Cooper RD, Frances SP, Westrom DR. Effectiveness of controlled-release personal-use arthropod repellents and permethrin-impregnated clothing in the field. J Am Mosq Control Assoc. 1987 Dec;3(4):556-60.
7. Dondorp AM, Newton PN, Mayxay M, Van Damme W, Smithuis FM, Yeung S, Petit A, Lynam AJ, Johnson A, Hien TT, McGready R, Farrar JJ, Looareesuwan S, Day NP, Green MD, White NJ. Fake antimalarials in Southeast Asia are a major impediment to malaria control: multinational cross-sectional survey on the prevalence of fake antimalarials. Trop Med Int Health. 2004 December;9:1241-6.
8. National Travel Health Network and Centre. Travel health information sheet: malaria [document on the internet]. London: NaTHNaC; 2007 [cited 5 March 2009]. Available from: http://www.nathnac.org/travel/factsheets/malaria.htm

 



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