Malaria is only found in the eastern side of South Africa, Northern KwaZulu Natal, Swaziland and along the Mozambique border. Our route is designed to avoid affected area so there is no need for concern.
However, if you are traveling else where, either before or after your time with us, you might want to read up a little more about the disease...

Facts
Malaria is a public health problem in 90 countries affecting at least 300 million people. Tropical Africa accounts for 90% of these cases. Estimates of malaria mortality vary from 1,5 to 3 million deaths a year.

The Plasmodium genus of protozoal parasites is the causative agent of malaria. Human malaria is caused by 4 species : P. falciparum, P. malariae, P. vivax, P. ovale. P. falciparum is the predominant species and the one that causes the most serious disease. This is also the species that has given rise to the new drug resistant strains that are emerging.

The Plasmodium parasites are highly specific with female Anopheles mosquitoes as the vectors and man as the only vertebrate host. The parasites have a complex life cycle that is split between the host and the vector.

The South African Situation
Incidence associated with climatic conditions and influx of migrants from neighboring countries.

Chloroquine resistance necessitated continuing changes in chemoprophylaxis.

90 - 95 % of the locally contracted cases are due to P. falciparum.

Prophylaxis against Malaria
1) Precautionary measures against Malaria
Mosquitoes feed between dusk and dawn in doors and outdoors.
- remain indoors
-at night, wear long-sleeved clothing, long trousers and socks
-insect repellent
-stay in well-constructed, well-maintained buildings in the best developed part of town
-close windows and doors
-mosquito proof net treated with permethrin from time to time and edges tucked in
-spray house / tent inside
-use mosquito mats etc.
-treat clothes with an insecticide registered for this, permethrin.

2) Taking of anti-malaria drugs
Chloroquine-resistant vs Chloroquine-sensitive areas

Could still contract Malaria in spite of prophylactic medication. Contact doctor if any flu-like symptoms start. Tell the doctor of the possibility of Malaria. He would not look for it if you do not tell him / her !!! Symptoms of infection can occur up to 6 months after leaving a malaria area !

Recommendations for SA
High risk area : Drugs from October to May
Intermediate risk area : Drugs from October to May only for high risk people
( Children < 5 years, pregnant, Immuno-compromised )
Low risk area : No drugs
Factors influencing the selection of drugs
Patient factors
-Children / infants
-Breast feeding
-Pregnancy / lactation
-Porphyria
-Epilepsy
-Chronic illness : Liver disease may result in drugs becoming toxic. Patients on cardiac medication can only take certain drugs
-Sensitivity to Sulph drugs : Persons sensitive for Sulphas, should not take Fansidar or Maloprim
-Exposure to sunlight : Exposure for long periods to sunlight can cause
photosensitivity and should use sunscreens

Environmental factors
- duration of stay : Extended use of chloroquine can cause retinal damage, 6 monthly ophtalmiological check-up recommended Mefloquine ( Larium ) should not be used for longer than a year. Doxycycline should not be used for longer than 3 months.

-Type of accommodation : greater risk in tent vs. building
-Time of year : In southern Africa Malaria is seasonal, although in certain areas such as Mozambique and the Zambezi Valley, there is a risk of contracting the disease throughout the year

Comments on drugs used for chemoprophylaxis;
Seriousness of side-effects should be weighed up against the risk of contracting malaria.

Chloroquine ( Daramal )
Cheap, without prescription, safe in pregnancy / lactation, safe in
children. Used with caution in patients with epilepsy, cardiac or renal
disease. Usually well tolerated.
Side-effects : headache, nausea / vomiting, diarrhea, pruritis ( itch ),
skin eruptions and itching of palms, soles, impaired vision
Serious side-effects are rare, but periodic eye examinations are necessary
if used for long periods.

Proguanil ( Paludrine )
Best tolerated, very good safety and can be used in pregnancy and children. Rarely cause side effects.
Side-effects:
Mild gastric intolerance, vomiting, abdominal discomfort, mouth ulcers, skin reactions, hair loss.

Mefloquine ( Larium )
Should not be used for > 1 year. The following people should not take it :
-Pregnant women or 3 months before conception ( 1/2 life of 42 days )
-Children < 15 kg
-Patients with history of epilepsy or psychiatric disorders
-Cardiac conduction abnormalities
-Depression
-People requiring fine motor control such as pilots, scuba divers, mountaineers
-Patients on Beta Blockers, Ca Channel Blockers, Digitalis or Anti-depressant therapy
Side-effects :
-Dizziness or disturbance of balance
-Gastro-intestinal disturbances
Less frequent effects are :
-Headache, myalgia, feeling of weakness, visual disturbance
-Palpitations, bradycardia, irregular pulse and extrasystoles, AV block
-Hair loss, rash or pruritis
-Convulsions
-Psycological changes, eg. depressive mood, confusion, anxiety, hallucinations, paranoid reactions
-Drop in White blood cells and Platelets

If Mefloquine is used for prophylaxis, Halofantrine should not be used for treatment since it may lead to potencially fatal prolongation of the QTC interval ( Heart conduction abnormality )

Doxycycline
Well tolerated
Side-effects : Nausea and vomiting, Photosensitivity, skin reactions, vaginal candidiasis
Contra-indicated in pregnancy, breastfeeding and children < 8 years as it can seriously damage tooth development. Should not be used for longer than 3 months.

Drugs for Standby Treatment
Sulfadoxine-pyrimethamine
Taken as a single dose. Cannot be taken by patients allergic to Sulphas

Quinine
Only if person cannot take Sulfadoxine-pyrimethamine. Should not be used without medical supervision.
Side-effects :
Mild hearing impairment, tinnitis, headache, nausea, visual disturbances (up to 70 % of patients), Arrhythmias, hypoglycemia. Quinine toxicity could be confused with cerebral malaria.

Halofantrine
Should be taken on an empty stomach. Course could be repeated after 1 week.
Not to be taken if mefloquine was used
Note to be taken in patients with known family history of QTC prolongation.

Important points:
Can contract it, in spite of taking prophylactic medication, up to 6 months
after visiting an area.
Inform your doctor.

Symptoms :
- Fever
- Rigors
- Headaches
- Sweating
- Tiredness
- Myalgia
- Abdominal Pain
- Diarrhea
- Lost of appetite
- Low blood pressure
- Nausea
- Slight jaundice
- Cough
- Enlarged liver and Spleen

Subject: How to Protect Yourself from Mosquito Bites

Malaria is transmitted by the bite of an infected mosquito; these mosquitoes usually bite between dusk and dawn. If possible, remain in doors in a screened or air-conditioned area during the peak biting period. If out-of-doors, prevent mosquito bites by wearing long-sleeved shirts, long pants, and hats; apply insect repellent to exposed skin. Use insect that contain DEET (diethylmethyltoluamide) for the best .

When using repellent with DEET, follow these precautions:
Read and follow the directions and precautions on the product label.

Use only when outdoors and wash skin with soap and water after coming indoors.

Do not breathe in, swallow, or get into the eyes. (DEET is toxic if wallowed.) If using a spray product, apply DEET to your face by spraying our hands and rubbing the product carefully over the face, avoiding eyes and mouth.

Do not put repellent on wounds or broken skin.

Higher concentrations of DEET may have a longer repellent effect however, concentrations over 50% provide no added protection.

Timed-release DEET products may have a longer repellent effect thaniquid products.

DEET may be used on adults, children, and infants older than 2onths of age. Protect infants by using a carrier draped with mosquito netting with an elastic edge for a tight fit.

Children under 10 years old should not apply insect repellent themselves.

Do not apply to young children's hands or around eyes and mouth.

Details on how to protect yourself from insects and how to use repellents.

Travellers should take a flying-insect spray or mosquito oils on their trip to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide, these insecticides quickly kill flying insects, including mosquitoes.
If you are not staying in well screened or air-conditioned rooms, you should take additional precautions, including sleeping under mosquito netting (bed nets). Bed nets sprayed with the insecticide permethrin areore effective permethrin both repels and kills mosquitoes. In the Unitedtates, permethrin is available as a spray or liquid (e.g. Permanone) toreat clothes and bed nets. Bed nets may be purchased that have already been treated with permethrin. Permethrin or another insecticide,eltamethrin, may be purchased overseas to treat bed nets and clothes.

Protection against Mosquitoes and Other Arthropods

Although vaccines or chemoprophylactic drugs are available against vector-borne diseases such as yellow fever and malaria, travelers still should be advised to use repellents and other general protective measures against biting arthropods.

The effectiveness of malaria chemoprophylaxis is variable, depending on patterns of resistance and compliance with medication, and no similar preventive measures exist for other mosquito-borne diseases such asengue. For many vector-borne diseases, no specific preventives area available.

General Preventive Measures

The principal approach to prevention of vector-borne diseases is avoidance.

Tick- and mite-borne infections characteristically are diseases "place whenever possible, known foci of disease transmission should avoided. Although avoiding rural locations can prevent many vector-borne infections, certain mosquito- and midge-borne arboviral and parasitic infections are transmitted seasonally, and simple changes itinerary can greatly reduce risk for acquiring them.

Travelers should be advised that exposure to arthropod bites can be minimized by modifying patterns of activity or behavior. Some mosquitoes are most active in twilight periods at dawn and dusk or in the evening. Avoidance of outdoor activity during these periods can reduce risk of exposure. Wearing long-sleeved shirts, long pants, and hats minimizes areas of exposed skin. Shirts should be tucked in.

Repellent supplied to clothing, shoes, tents, mosquito nets, and other gear will enhance protection. When exposure to ticks or biting insects is a possibility, travellers should be advised to tuck their pants into their socks and to wear boots or sandals. Permethrin-based repellents applied as directed (see the following section, Repellents") will enhance protection.

Travelers should advised to inspect themselves and their clothing for ticks, both during outdoor activity and at the end of the day. Ticks are detected more easily on light-colored or white clothing. Prompt removal of attached ticks can prevent some infections.

When accommodations are not adequately screened or air conditioned, bed nets are essential to provide protection and comfort. Bed nets should be tucked under mattresses and can be sprayed with a repellent, such as permethrin. The permethrin will be effective for several months if the bed net is not washed. Aerosol insecticides and mosquito coils can help to clear rooms of mosquitoes however, some coils contain dichlorodiphenyl-richloroethane (DDT) and should be used with caution repellents:

Travelers should be advised that permethrin-containing repellents (e.g., Permanone or deltamethrin) are recommended for use on clothing, shoes, bed nets, and camping gear. Permethrin is highly effective as an insecticide and as a repellent. Permethrin-treated clothing repels and kills ticks, mosquitoes, and other arthropods and retains this effect after repeated laundering. There appears to be little potential for toxicity from permethrin-treated clothing. The insecticide should be reapplied after very five washings.

Most authorities recommend repellents containing N,N-diethylmetatoluamide (DEET) as an active ingredient. DEET repels mosquitoes, ticks, and other arthropods when applied to the skin or clothing. In general, the more DEET repellent contains, the longer time it can protect against mosquitoes. However, there appears to be no added benefit of concentrations greater than 50%. A microencapsulated, sustained-release formulation can have a longer period of activity than liquid formulations at the same concentrations. Length of protection also varies with ambient temperature,mount of perspiration, any water exposure, abrasive removal, and other factors.

No definitive studies have been published about what concentration of DEETs safe for children. No serious illness has arisen from use of DEET according the manufacturer's recommendations. DEET formulations as high as 50% are recommended for both adults and children 2 months of age. Lower concentrations are not as long lasting, offering short-term protection only and necessitating more frequent reapplication.

Repellent product that do not contain DEET are not likely to offer the same degree protection from mosquito bites as products containing DEET. Non-DEET repellents have not necessarily been as thoroughly studied as DEET and may not be safer for use on children. Parents should choose the type and concentration of repellent to be used by taking into account the amount of time that a child might be outdoors, exposure to mosquitoes, and the risk mosquito-transmitted disease in the area. The recommendations for DEET in pregnant women do not differ from those for non-pregnant adults.

EET is toxic when ingested and may cause skin irritation in sensitive persons. High concentrations applied to skin can cause blistering. However, because DEET is so widely used, a great deal of testing has been and over the long history of DEET use, very few confirmed incidents of toxic reactions to DEET have occurred when the product is used properly.

Travelers should be advised that the possibility of adverse reactions to DEET will be minimized if they take the following precautions:

Use enough repellent to cover exposed skin or clothing. Do not apply repellent to skin that is under clothing. Heavy application is not to achieve protection. If repellent is applied to clothing, wash treated clothing before wearing again.

Do not apply repellent to cuts, wounds, or irritated skin.

After returning indoors, wash treated skin with soap and water.

Do not spray aerosol or pump products in enclosed areas.

Do not apply aerosol or pump products directly to the face. Spray our hands and then rub them carefully over the face, avoiding eyes and mouth.

When using repellent on a child, apply it to your own hands and the rub them on your child. Avoid the child's eyes and mouth and apply sparingly around the ears.

Do not apply repellent to children's hands. (Children tend to put their hands in their mouths.)

Do not allow children under ten years old to apply insect repellent to themselves have an adult do it for them. Keep repellents out of reach of children.

Protect infants two months of age and under by using a carrier raped with mosquito netting with an elastic edge for a tight fit.

Bed nets, repellents containing DEET, and permethrin should be purchased before traveling and can be found in hardware, camping, sporting goods, and military surplus stores. Overseas, permethrin or anothernsecticide, deltamethrin, may be purchased to treat bed nets and clothes.

Dr Neil van Tonder (bvtond@iafrica.com)