Since 1997

​Malaria

Malaria is a perennial concern to travellers in Africa. Of all the questions DAN receives, malarial prophylaxis is one of the most common. Safety of medication while diving and drug resistance considerations are the most pressing issues.

As divers venture deeper into the African tropics the risk of contracting malaria increases proportionally. Lack of medical facilities, transportation and communication add additional complexity to managing this medical emergency. Understanding malaria prophylaxis and general preventative measures is therefore of the utmost importance. The following section covers the most important considerations in selecting and using malaria prophylactic measures and medications.

The medical treatment of malaria, which is complex and requires close medical supervision, falls outside the scope of this document.  If you think that you may have malaria or are concerned about unexplained symptoms after visiting a malaria area, contact DAN immediately.
The three most important guidelines regarding malaria prevention and survival are: 
  • Do Not Get Bitten
  • Seek Immediate Medical Attention If You Suspect Malaria
  • Take “The Pill” (Anti-Malaria Tablets / Prophylaxis) 

Do Not Get Bitten

  • Stay indoors from dusk to dawn 
  • If you have to be outside between dusk and dawn – cover up:
    • Long sleeves, trousers, socks, shoes (90% of mosquito bites occur below the knee)
  • Apply a 30% DEET containing insect-repellent to all exposed areas of skin, repeat four-hourly 
  • Sleep in mosquito-proof accommodation: 
    • Air-conditioned, and / or well maintained mosquito gauze 
    • Buildings / tents, regularly treated with a pyrethroid-based insect repellent / insecticide 
    • Burn mosquito coils / mats
    • Sleep under a pyrethroid insecticide (Vital Protection AM1® / Permacote® / Peripel®) impregnated mosquito net (very effective)
      • Vital Protection AM2® can be sprayed on to clothing to keep away mosquitoes and ticks.

Seek Immediate Medical Attention If you Suspect Malaria

  • Any ‘flu-like illness starting 7 days or more after entering a malaria endemic area is malaria until proven otherwise.
  • The diagnosis is made on a blood smear or rapid malaria antigen finger prick test. 
  • One negative blood smear / rapid test does NOT exclude the diagnosis:
    • Repeat the smear / rapid test until the diagnosis is made, another illness is conclusively diagnosed or spontaneous recovery occurs e.g., from influenza. 

Take “The Pill 

Malaria chemoprophylaxis (Pills) is 90% effective in the prevention of malaria in non-immune travellers. Untreated Plasmodium falciparum (“Cerebral”) malaria is 100% fatal. Go figure…

There are several dangerous myths regarding malaria prophylaxis. Please note that: 
  • Prophylaxis does not make the diagnosis more difficult Prophylaxis does not make the treatment more difficult
  • Prophylaxis does not make you / the mosquito / the parasite ‘resistant’…
  • Does no more “...damage to your liver / eyes / kidneys / immunity / fertility..” than the beer /  G&T / etc. etc consumed after a good dive…
  • Etc. etc.

However

  • Prophylaxis is not 100% effective - hence the importance of always avoiding bites 
  • Prophylaxis does protect against the development of cerebral malaria even if you  become ill in spite of taking prophylaxis.
  • Not all anti-malaria medication is safe with diving, hence the need to consult a medical practitioner with a knowledge of malaria as well as diving well in advance to travelling to a malaria risk area. 

Anti-Malaria Drugs, Like All Drugs, Have Potential Side-Effects

  • The majority of side-effects decrease with time.
  • Serious side-effects are rare and can be avoided by careful selection of a tablet  to suit your requirements (Country, region and season).

Drugs For The Prevention of Malaria

All three options are equally effective in the prevention of malaria but mefloquine is NOT considered safe in diving. 

Doxycycline (Doximal® or Vibramycin® or Cyclidox® or Doryx®, etc.)   

  • Not officially recommended for use in excess of 8 weeks for malaria prevention, but it has been used for as long as three years with no reported adverse effects in the treatment of acne. Offers simultaneous protection against tick-bite fever and even traveller’s diarrhoea.
  • Dosage: 100mg daily after a meal starting 1 - 2 days before exposure. Must be continued for 4 weeks after exposure. Doxycycline should be taken on a full stomach with plenty of non-alcoholic liquid. 
  • Side effects: Heartburn, nausea, vomiting, diarrhoea, allergy, photosensitisation. May cause vaginal thrush and may reduce the efficacy of oral contraceptives.  Tip: To reduce the chances of heartburn, nausea and vomiting take the daily dose after a meal, with plenty of liquid and NOT before bed-time or diving…
  • Contraindications: Pregnancy; breastfeeding; children < 8 years
  • Use in Pregnancy: Unsafe (As is SCUBA DIVING)
 Doxycycline is DAN Southern Africa’s agent of choice for divers diving in Sub-Saharan Africa as well as other areas with chloroquine resistance / “resistant malaria”. 

Atovaquone / Proguanil (Malanil®; Malarone®) 

  • This is the youngest kid on the malaria prophylaxis block and also the most expensive.
  • It’s main advantage is that it can be stopped 7 days after leaving the malaria risk area.
  • The side-effect profile is much the same as for the other two options.
  • It was previously considered unsafe in pilots and divers but has now been documented to be safe in pilots, subject to the usual provisos for the use of medication in pilots. In addition it has been used by many divers without serious documented adverse events and although safety in diving has not been formally studied and documented, it can be considered as an option if used with caution.
    • Some additional sensitivity to motion sickness has been reported anecdotally.
Dosage: 1 Tablet daily for adults, starting 24 – 48 hours prior to arrival in a malaria endemic area, for the duration of stay  in the region and for only 7 days after leaving the endemic area. Dose should be taken at the same time each day with food or a milky drink. 

Contra-indications: Known allergy to proguanil or atovaquone or renal impairment (NOTE: significant kidney disease is likely to be incompatible with diving). Safety in children < 11kg has not been established. 

Side-effects: Heartburn (Tip: See safety tip as for doxycycline.); mouth ulcers. The most commonly reported side-effects are headache and abdominal discomfort.

Use in Pregnancy: Safety in pregnancy and lactating women has not been established. (Note: SCUBA DIVING is not considered safe during pregnancy)  

Mefloquine (Lariam® or Mefliam®) 

  • A cost effective option for non-divers with a  convenient dosing schedule. 
  • Dosage: One tablet  per week, commencing one week prior to entering the malaria area
  • Side effects: May cause drowsiness, vertigo, joint aches and interfere with fine motor co-ordination (Making it difficult to exclude DCI in some cases).   It is contra-indicated in persons with ANY history of neuro-psychiatric illness and epilepsy as  well as anyone with heart rhythm abnormalities.
  • Use in Pregnancy: Mefloquine is now the drug of choice in all three trimesters of pregnancy. May be used in breast feeding and babies weighing more than 5kg. (However: Pregnancy is NOT compatible with scuba diving.)
Mefloquine is considered unsafe for divers & pilots. The following medication is NOT appropriate as malaria prophylaxis for a variety of well-documented, scientific reasons: 
Pyrimethamine / Dapsone (Maloprim® or Deltaprim® / Malazone®). No longer regarded as effective.  
Chloroquine (Nivaquine®, many other trade names). Not used for prophylaxis on its own or in combination with proguanil (Paludrine®) anywhere in Sub-Saharan Africa.
Homeopathic medication. There is not a single homeopathic or ‘natural’ compound on the market that has been shown to prevent or treat malaria effectively. Avoid at all cost.  
Quinine (Lennon-Quinine Sulphate®). Not used for prophylaxis but is still the backbone in the treatment of moderate and severe malaria in South Africa. Serious side-effects are not uncommon during treatment.
Sulfadoxine & Pyrimethamine. (Fansidar®). No longer used as prophylactic 
Halofantrine (Halfan®). Not used for prophylaxis and must be avoided as treatment because of resistance and serious side-effects.
Artemether (Cotexin®, many other trade names). The “Chinese wonder drug”. Available in some areas of Africa. It must NOT be used  for prophylaxis. It is used in combination   with other drugs in the treatment of mild to moderate malaria, never on its own!  

Notes

  1. Prophylaxis significantly reduces the incidence of malaria and slows the onset of serious symptoms of malaria. 
  2. All anti-malaria drugs excluding Mefloquine are considered compatible with diving.
  3. Like with all other medication, anti-malaria drugs should be tried and tested on land well in advance – three weeks in the case of mefloquine if it had not been used before. 
  4. If unpleasant side-effects occur, please consult your doctor or DAN
  5. Whether or not you take prophylaxis, be vigilant about potential malarial symptoms. Malaria can present in many ways – any febrile illness during or after a stay in a malaria area must be considered to be malaria until conclusively proven otherwise. Always inform your doctor that you have been in a malaria area. Symptoms may present within 7-14 days from first exposure until six weeks and rarely even months after leaving a malaria area.
  6. No single medication is 100% effective and barrier mechanisms / personal protection against bites (e.g. mosquito repellents, nets, protective clothing, not going outdoors from dusk to dawn) must be applied. 
  7. The following groups of travellers are considered at increased risk of contracting serious malaria: Pregnant women, babies and children under the age of 5 years, the immune compromised, travellers without a spleen and the elderly.
​The above mentioned recommendations are based on material supplied by the National Department of Health, WHO and The Travel Doctor.