Malaria is a very serious condition that is common in some tropical countries. It is important that you take measures to reduce your risk of infection when you travel to these areas. This leaflet gives general information about malaria and how to avoid it. You should always see a doctor or nurse before travelling to a country with a malarial risk. They are provided with up-to-date information about the best antimalarial medication for each country.
What is malaria?
Malaria is a serious infection. It is common in tropical countries such as parts of Africa, Asia and South America. Malaria is a disease caused by a parasite called Plasmodium that lives in mosquitoes. A parasite is a living thing that lives in, or on, another living organism. The plasmodium parasite is passed to humans from a mosquito bite.
There are four types of plasmodium that cause malaria. These are called Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale and Plasmodium malariae. Most cases of malaria brought into the UK are due to Plasmodium falciparum. This type of malaria is also the most likely to result in severe illness and/or death.
Most infections occur in travellers returning to the UK (rather than visitors coming to the UK). The risk of getting malaria is greatest if you do not take antimalarial medication or do not take it properly. People who take last-minute holidays and those visiting friends or relatives abroad have been shown to be the least likely to take antimalarial medication.
In 2013, 1,501 people in the UK developed malaria which had been caught whilst abroad. Seven people died. Malaria can kill people very quickly if it is not diagnosed promptly.
The most common symptom of malaria is a high temperature (fever). Malaria can also cause muscle pains, headaches, diarrhoea and a cough.
Note: if you feel unwell and have recently visited an area in which there is malaria, you should seek prompt medical advice, even if you have taken your antimalarial medication correctly.
Preventing malaria - four steps
There is an ABCD for prevention of malaria. This is:
- Awareness of risk of malaria.
- Bite prevention.
- Antimalarial medication - Chemoprophylaxis (taking antimalarial medication exactly as prescribed).
- Prompt Diagnosis and treatment.
Awareness of the risk of malaria
The risk varies between countries and the type of trip. For example, back-packing or travelling to rural areas is generally more risky than staying in urban hotels. In some countries the risk varies between seasons - malaria is more common in the wet season. The main type of parasite and the amount of resistance to medication vary in different countries. Although risk varies, all travellers to malaria-risk countries should take precautions to prevent malaria.
The mosquitoes which transmit malaria commonly fly from dusk to dawn and therefore evenings and nights are the most dangerous time for transmission.
You should use an effective insect repellent on clothing and any exposed skin. Diethyltoluamide (DEET) is safe and the most effective insect repellent and can be sprayed on to clothes. It lasts up to three hours for 20%, up to six hours for 30% and up to 12 hours for 50% DEET. There is no further increase in duration of protection beyond a concentration of 50%. When both sunscreen and DEET are required, DEET should be applied after the sunscreen has been applied. DEET can be used on babies and children over 2 months of age. In addition, DEET can be used, in a concentration of up to 50%, if you are pregnant. It is also safe to use if you are breast-feeding. If you have sensitive skin you may find DEET irritating. Insecticides containing picaridin are a useful alternative.
If you sleep outdoors or in an unscreened room, you should use mosquito nets impregnated with an insecticide (such as pyrethroid). The net should be long enough to fall to the floor all round your bed and be tucked under the mattress. Check the net regularly for holes. Nets need to be re-impregnated with insecticide every six to twelve months (depending on how frequently the net is washed) to remain effective. Long-lasting nets, in which the pyrethroid is incorporated into the material of the net itself, are now available and can last up to five years.
If practical, you should try to cover up bare areas with long-sleeved, loose-fitting clothing, long trousers and socks - if you are outside after sunset - to reduce the risk of mosquitoes biting. Clothing may be sprayed or impregnated with permethrin, which reduces the risk of being bitten through your clothes.
Sleeping in an air-conditioned room reduces the likelihood of mosquito bites, due to the room temperature being lowered. Doors, windows and other possible mosquito entry routes to sleeping accommodation should be screened with fine mesh netting. You should spray the room before dusk with an insecticide (usually a pyrethroid) to kill any mosquitoes that may have come into the room during the day. If electricity is available, you should use an electrically heated device to vaporise a tablet containing a synthetic pyrethroid in the room during the night. The burning of a mosquito coil is not as effective.
Herbal remedies have not been tested for their ability to prevent or treat malaria and are therefore not recommended. Likewise, there is no scientific proof that homoeopathic remedies are effective in either preventing or treating malaria and they are also not recommended.
Antimalarial medication (chemoprophylaxis) helps to prevent malaria. The best medication to take depends on the country you visit. This is because the type of parasite varies between different parts of the world. Also, in some areas the parasite has become resistant to certain medicines.
There is a possibility of antimalarials that you may buy in the tropics or over the internet, being fake. It is therefore recommended that you obtain your antimalarial treatment from your doctor's surgery, a pharmacist or a travel clinic. Medications to protect against malaria are not funded by the NHS. You will need to buy them, regardless of where you obtain them.
The type of medication advised will depend upon the area to which you are travelling. It will also depend on:
- Any health problems you have.
- Any medication you are currently taking.
- The length of your stay.
- Any problems you may have had with antimalarial medication in the past.
You should seek advice for each new trip abroad. Do not assume that the medication that you took for your last trip will be advised for your next trip, even to the same country. There is a changing pattern of resistance to some medicines by the parasites. Doctors, nurses, pharmacists and travel clinics are updated regularly on the best medication to take for each country.
You must take the medication exactly as advised. This usually involves starting the medication up to a week or more before you go on your trip. This allows the level of medicine in your body to become effective. It also gives time to check for any side-effects before travelling. It is also essential that you continue taking the medication for the correct time advised after returning to the UK (often for four weeks). The most common reason for malaria to develop in travellers is because the antimalarial medication is not taken correctly. For example, some doses may be missed or forgotten, or the tablets may be stopped too soon after returning from the journey.
What are the side-effects with antimalarial medication?
Antimalarial medication is usually well tolerated. The most common side-effects are minor and include feeling sick (nausea) or diarrhoea. However, some people develop more severe side-effects. Therefore, always read the information sheet which comes with a particular medicine for a list of possible side-effects and cautions. To reduce possible side-effects, it is usually best to take the medication after meals.
If you are taking doxycycline then you need to use a high-factor sunscreen. This is because this medication makes the skin more sensitive to the effects of the sun.
Around 1 in 20 people taking mefloquine may develop headaches or have problems with sleep.
Note: medication is only a part of protection against malaria. It is not 100% effective and does not guarantee that you will not get malaria. The advice above on avoiding mosquito bites is just as important, even when you are taking antimalarial medication.
Symptoms of malaria (to help with prompt diagnosis)
Symptoms are similar to flu. They include:
- High temperature (fever).
- Joint pains.
- Being sick (vomiting).
- Sometimes, being unable to think/speak clearly because of fever or mental confusion (delirium).
These symptoms may take a week or more to develop after you have been bitten by a mosquito. Occasionally, it takes a year for symptoms to develop.
This means that you should suspect malaria in anyone with a feverish illness who has travelled to a malaria-risk area within the past year, especially in the previous three months.
- Pregnant women are at particular risk of severe malaria and should, ideally, not go to malaria-risk areas. Full discussion with a doctor is advisable if you are pregnant and intend to travel. Many antimalarial medications are safe in pregnancy but a few should be avoided.
- Chloroquine and proguanil are safe all through pregnancy.
- Mefloquine, should be avoided in the first twelve weeks.
- Doxycycline and Malarone® (atovaquone combined with proguanil) should be avoided altogether.
- Non-pregnant women taking mefloquine should avoid becoming pregnant. You should continue with contraception for three months after the last dose.
- You may have a restricted choice of antimalarial medication if you have epilepsy, chronic kidney disease, some forms of mental illness or some other uncommon illnesses. This may be due to your condition, or to possible interactions with other medication that you may be taking.
- If you do not have a spleen (if you have had it removed) or your spleen does not work well, you have a particularly high risk of developing severe malaria. Ideally, you should not travel to a malaria-risk country. However, if travel is essential, every effort should be made to avoid infection and you should be very strict about taking your antimalarial medication.
- Travellers going to remote places far from medical facilities sometimes take emergency medication with them. This can be used to treat suspected malaria until proper medical care is available.
Further reading & references
- Guidelines for malaria prevention in travellers from the UK; Public Health England, December 2016
- Freedman DO, Chen LH, Kozarsky PE; Medical Considerations before International Travel. N Engl J Med. 2016 Jul 21;375(3):247-60. doi: 10.1056/NEJMra1508815.
- Malaria; Fitfortravel, Health Protection Scotland
- Malaria; World Health Organization, 2014 (updated 2016)
- Shretta R, Avancena AL, Hatefi A; The economics of malaria control and elimination: a systematic review. Malar J. 2016 Dec 12;15(1):593.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient Platform Limited has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Colin Tidy
Dr Helen Huins