>Newsletters>March 2005>Diving & Malaria

Indonesia Scuba Diving Newsletter

Malaria Prophylaxis and Diving

By Dr Frans Cronje (Divers Alert Network Southern Africa) & Dr Albie De Frey (Worldwide Travel Medical Consultants)

DAN receives many inquiries from members regarding malaria. Indeed, malaria has become an increasing problem due to drug resistance. As divers venture deeper into the tropics they incur increasing risk of contracting malaria. 3 of our diving destinations - Malaysia, Indonesia and Burma - have malarial areas, but the main problem is in travelling to other malarial areas, often in other countries, shortly before or after your diving holiday. 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 3 Commandments of malaria prevention and survival are:

1. Do Not Get Bitten
2. Seek Immediate Medical Attention If You Suspect Malaria
3. Take 'The Pill' (Anti-Malaria Tablets / Prophylaxis)

1. Do Not Get Bitten

• Stay indoors from dusk to dawn
• Apply DEET containing insect-repellent to all exposed areas of skin, repeat 4-hourly
• Sleep in mosquito-proof accommodation:
  • Air-conditioned, proper mosquito gauze
  • Buildings / tents treated with pyrethrum-based insect repellent / insecticide
• Burn mosquito coils / mats
• Sleep under an insecticide impregnated (Permacote® / Peripel®) mosquito net (very effective)

2. 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 with an ICT finger prick test. One negative smear / ICT does NOT exclude the diagnosis (repeat smear / ICT until diagnosis is made, another illness is diagnosed or the patient recovers spontaneously - e.g. from ordinary flu).

3. Take 'The Pill'

There are several dangerous myths regarding malaria prophylaxis. Please note that:

• Prophylaxis does not make the diagnosis more difficult
• It does protect against the development of cerebral malaria
• Is not 100% effective - hence the importance of avoiding bites
• Not all anti-malarials are safe with diving
• Malaria is often fatal - making prophylaxis justified

Anti-malaria drugs, like all drugs, have potential side-effects, but the majority of side-effects decrease with time.

Serious side-effects are rare and can be avoided by careful selection of a tablet or combination of tablets to suit your requirements (region and season).

Drugs Available for Malaria Prevention

1. Chloroquine (Nivaquine® or Daramal® or Plasmaquine®):

Contains only chloroquine. Must be taken in combination with Proguanil (Paludrine®)

Dosage: 2 tabs weekly starting 1 week before exposure until 4 weeks after leaving the malaria endemic area.

Contra-indications: Known allergy, epilepsy

Side effects: Headache, nausea & vomiting, diarrhoea, rashes; may cause photosensitivity (sunburn; prevention - apply sun block)

Use in Pregnancy: Safe. (Note: Scuba diving though is not considered safe during pregnancy)

2. Proguanil (Paludrine®):

Must be taken in combination with Chloroquine (Nivaquine® or Daramal® or Plasmaquine®)

Dosage: 2 Tablets every day starting 1 week prior to exposure until 4 weeks after.

Contra-indications: Known allergy to Proguanil. Interactions with Warfarin (an anti-coagulant -- that is incompatible with diving)

Side-effects: Heartburn (Tip: take after a meal, with a glass of water & do not lie down shortly after taking Proguanil); mouth ulcers (Tip: Take Folic acid tablets 5mg per day if this occurs); loose stools (self limiting - no treatment required)

Use in Pregnancy: Safe - but must be taken with folic acid supplement: 5mg per day. (Note: Scuba diving is not considered safe during pregnancy)

The combination of Chloroquine & Proguanil is about 65% effective. It is DAN's second choice for malaria prophylaxis in areas of resistant malaria and a first choice in areas of low or absent resistance due to the benign side-effect profile of the drugs.

3. Doxycycline (Vibramycin® or Cyclidox® or Doryx®, etc.):

Used extensively in the prevention of resistant malaria. About 99% effective. Used alone or in combination with chloroquine. Not officially recommended for use in excess of 8 weeks for malaria prevention, but it has been used for as long as 3 years with no reported adverse effects. Offers simultaneous protection against tick-bite fever and cholera.

Dosage: 100mg daily starting 1 - 2 days before exposure until 4 weeks after exposure.

Side effects: Nausea, vomiting, diarrhoea, allergy, photo-sensitisation. May cause vaginal thrush infections and reduces the efficacy of oral contraceptives.

Use in Pregnancy: Unsafe (as is scuba diving). Also avoid during breast feeding and in children < 8 years

Doxycycline is DAN's first choice recommendation for divers diving in areas with chloroquine resistance / resistant malaria.

4. Mefloquine (Lariam® or Mefliam®):

About 90% effective.

Dosage: 1 tablet / week.

Side effects: May cause drowsiness, vertigo, joint aches and interfere with fine motor co-ordination (making it difficult to exclude DCI in some cases).

Pregnancy: Probably safe in early pregnancy and may be used with confidence after the first trimester of pregnancy. May be used in breast feeding and babies weighing more than 5kg.

Lariam is considered unsafe for divers & pilots. It is contra-indicated in Epilepsy but is a good first choice for other travellers.

5. Sulfadoxine & Pyrimethamine (Fansidar®):

No longer used as prophylactic.

Used as first-line treatment in mild malaria as a single dose in isolated areas while en route to definitive care. Efficacy is variable.

Contra-indicated in known sulphonamide allergy.

6. Quinine (Lennon-Quinine Sulphate®):

Not used for prophylaxis but is the backbone in the treatment of moderate and severe malaria. Serious side-effects are not uncommon during treatment.

7. Arthemeter (Cotexin®):

The "Chinese drug", available in some areas. Not for prophylaxis. Used in combination with other drugs in the treatment of mild to moderate malaria.

8. Halofantrine (Halfan):

Not used for prophylaxis. Can cause serious interactions with other anti-malarials.

Efficacy variable.

If you think that you may have malaria or are concerned about unexplained symptoms after visiting a malaria area, contact DAN immediately on 0800 020111 or +27 (0)11 242 0112.

There are some amazing diving frontiers where protecting yourself is not only wise but also gives you the peace of mind to enjoy your dream dive adventure such as West Papua Province in New Guinea:

West Papua diving sites