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Malaria Content Supplied by NHS Choices
Introduction

Malaria is a serious tropical disease spread by mosquitoes. If it isn't diagnosed and treated promptly, it can be fatal.

A single mosquito bite is all it takes for someone to become infected.

Symptoms of malaria

It's important to be aware of the symptoms of malaria if you're travelling to areas where there's a high risk of the disease. Symptoms include:

Symptoms usually appear between 7 and 18 days after becoming infected, but in some cases the symptoms may not appear for up to a year, or occasionally even longer.

Read more about the symptoms of malaria.

When to seek medical attention

Seek medical help immediately if you develop symptoms of malaria during or after a visit to an area where the disease is found.

You should still seek medical help even if it's several weeks, months or a year after you return from travelling.

If there's a possibility you have malaria, a blood test will be carried out to confirm whether or not you're infected.

You should receive the results of your blood test on the same day. If you have malaria, treatment will be started straight away.

What causes malaria

Malaria is caused by a type of parasite known as Plasmodium. There are many different types of Plasmodia parasites, but only five cause malaria in humans.

The Plasmodium parasite is mainly spread by female Anopheles mosquitoes, which mainly bite at dusk and at night. When an infected mosquito bites a human, it passes the parasites into the bloodstream.

Malaria can also be spread through blood transfusions and the sharing of needles, but this is very rare.

Read more about the causes of malaria and how it's spread.

Malaria risk areas

Malaria is found in more than 100 countries, mainly in tropical regions of the world, including:

  • large areas of Africa and Asia
  • Central and South America
  • Haiti and the Dominican Republic
  • parts of the Middle East
  • some Pacific islands

The 2014 World Malaria Report, published by the World Health Organization (WHO), estimates there were 198 million cases of malaria worldwide and 584,000 deaths in 2013.

Malaria is not found in the UK, although about 1,586 travellers were diagnosed with the disease after returning to the UK in 2014, and three people died.

The Fit for Travel website has more information about the risk of malaria in specific countries.

Preventing malaria

Many cases of malaria can be avoided. An easy way to remember is the ABCD approach to prevention:

  • Awareness of risk - find out whether you're at risk of getting malaria before travelling
  • Bite prevention - avoid mosquito bites by using insect repellent, covering your arms and legs, and using an insecticide-treated mosquito net
  • Check whether you need to take malaria prevention tablets - if you do, make sure you take the right antimalarial tablets at the right dose, and finish the course
  • Diagnosis - seek immediate medical advice if you develop malaria symptoms, as long as up to a year after you return from travelling

Speak to your GP if you're planning to visit an area where there's a malaria risk. It may be recommended that you take antimalarial tablets to prevent infection.

Read more about preventing malaria.

Treating malaria

If malaria is diagnosed and treated promptly, virtually everyone will make a full recovery. Treatment should be started as soon as the diagnosis has been confirmed.

Antimalarial medication is used to both treat and prevent malaria. Which type of medication is used and the length of treatment will depend on:

  • the type of malaria
  • the severity of your symptoms
  • where you caught malaria
  • whether you took an antimalarial to prevent malaria
  • whether you're pregnant

In some cases, you may be prescribed emergency standby treatment for malaria before you travel. This is usually if there's a risk of you becoming infected with malaria while travelling in a remote area with little or no access to medical care.

Read more about treating malaria.

Complications of malaria

Malaria is a serious illness that can get worse very quickly. It can be fatal if not treated promptly.

It can also cause serious complications, including:

  • severe anaemia - where red blood cells are unable to carry enough oxygen around the body, leading to drowsiness and weakness
  • cerebral malaria - in rare cases, the small blood vessels leading to the brain can become blocked, causing seizures, brain damage and coma

The effects of malaria are usually more severe in pregnant women, babies, young children and the elderly. Pregnant women in particular are usually advised not to travel to malaria risk areas.

Read more about the complications of malaria.


Symptoms of malaria

Symptoms of malaria can develop as quickly as seven days after you're bitten by an infected mosquito.

Typically, the time between being infected and when symptoms start (incubation period) is 7 to 18 days, depending on the specific parasite you're infected with. However, in some cases it can take up to a year for symptoms to develop.

The initial symptoms of malaria are flu-like and include:

  • a high temperature (fever)
  • headache
  • sweats
  • chills
  • vomiting

These symptoms are often mild and can sometimes be difficult to identify as malaria.

With some types of malaria, the fever occurs in 48-hour cycles. During these cycles, you feel cold at first with shivering. You then develop a fever, accompanied by severe sweating and fatigue. These symptoms usually last between 6 and 12 hours.

Other symptoms of malaria can include:

  • muscle pains
  • diarrhoea
  • generally feeling unwell

The most serious type of malaria is caused by the Plasmodium falciparum parasite. Without prompt treatment, this type could lead to you quickly developing severe and life-threatening complications, such as breathing problems and organ failure.

Read more about the complications of malaria.

Seeking medical advice

Seek medical advice immediately if you develop symptoms of malaria during or after a visit to an area where the disease is found.

You should still seek medical help even if it's several weeks, months or a year after you return from travelling.


Causes of malaria

Malaria is caused by the Plasmodium parasite. The parasite can be spread to humans through the bites of infected mosquitoes.

There are many different types of plasmodium parasite, but only five types cause malaria in humans.

These are:

  • Plasmodium falciparum - mainly found in Africa, it's the most common type of malaria parasite and is responsible for most malaria deaths worldwide
  • Plasmodium vivax - mainly found in Asia and South America, this parasite causes milder symptoms than Plasmodium falciparum, but it can stay in the liver for up to three years, which can result in relapses
  • Plasmodium ovale - fairly uncommon and usually found in West Africa, it can remain in your liver for several years without producing symptoms
  • Plasmodium malariae - this is quite rare and usually only found in Africa
  • Plasmodium knowlesi - this is very rare and found in parts of southeast Asia

How malaria is spread

The plasmodium parasite is spread by female Anopheles mosquitoes, which are known as "night-biting" mosquitoes because they most commonly bite between dusk and dawn.

If a mosquito bites a person already infected with malaria, it can also become infected and spread the parasite on to other people. However, malaria can't be spread directly from person to person.

Once you're bitten, the parasite enters the bloodstream and travels to the liver. The infection develops in the liver before re-entering the bloodstream and invading the red blood cells.

The parasites grow and multiply in the red blood cells. At regular intervals, the infected blood cells burst, releasing more parasites into the blood. Infected blood cells usually burst every 48-72 hours. Each time they burst, you'll have a bout of fever, chills and sweating.

Malaria can also be spread through blood transfusions and the sharing of needles, but this is very rare.


Antimalarial medication

Antimalarial medication is used to prevent and treat malaria.

You should always consider taking antimalarial medicine when travelling to areas where there's a risk of malaria. Visit your GP or local travel clinic for malaria advice as soon as you know when and where you're going to be travelling.

It's very important to take the correct dose and finish the course of antimalarial treatment. If you're unsure, ask your GP or pharmacist how long you should take your medication for.

Preventing malaria

It's usually recommended you take antimalarial tablets if you're visiting an area where there's a malaria risk as they can reduce your risk of malaria by about 90%.

The type of antimalarial tablets you will be prescribed is based on the following information:

  • where you're going
  • any relevant family medical history
  • your medical history, including any allergies to medication
  • any medication you're currently taking
  • any problems you've had with antimalarial medicines in the past
  • your age
  • whether you're pregnant

You may need to take a short trial course of antimalarial tablets before travelling. This is to check that you don't have an adverse reaction or side effects. If you do, alternative antimalarials can be prescribed before you leave.

Types of antimalarial medication

The main types of antimalarials used to prevent malaria are described below.

Atovaquone plus proguanil

  • dosage - the adult dose is one adult-strength tablet a day. Child dosage is also once a day, but the amount depends on the child's weight. It should be started one or two days before your trip and taken every day you're in a risk area, and for seven days after you return.
  • recommendations - a lack of clear evidence means this antimalarial shouldn't be taken by pregnant or breastfeeding women. It's also not recommended for people with severe kidney problems.
  • possible side effects - stomach upset, headaches, skin rash and mouth ulcers.
  • other factors - it can be more expensive than other antimalarials, so may be more suitable for short trips.

Doxycycline (also known as Vibramycin-D)

  • dosage - the dose is 100mg daily as a tablet or capsule. You should start the tablets two days before you travel and take them each day you're in a risk area, and for four weeks after you return.
  • recommendations - not suitable for pregnant or breastfeeding women, children under the age of 12 (because of the risk of permanent tooth discolouration), people who are sensitive to tetracycline antibiotics, or people with liver problems.
  • possible side effects - stomach upset, heartburn, thrush, and sunburn as a result of light sensitivity. It should always be taken with food, preferably when standing or sitting.
  • other factors - it is relatively cheap. If you take doxycycline for acne, it will also provide protection against malaria as long as you're taking an adequate dose. Ask your GP.

Mefloquine (also known as Lariam)

  • dosage - the adult dose is one tablet weekly. Child dosage is also once a week, but the amount will depend on their weight. It should be started three weeks before you travel and taken all the time you're in a risk area, and for four weeks after you get back.
  • recommendations - it's not recommended if you have epilepsy, seizures, depression or other mental health problems, or if a close relative has any of these conditions. It's not usually recommended for people with severe heart or liver problems.
  • possible side effects - dizziness, headache, sleep disturbances (insomnia and vivid dreams) and psychiatric reactions (anxiety, depression, panic attacks and hallucinations). It's very important to tell your doctor about any previous mental health problems, including mild depression. Don't take this medication if you have a seizure disorder.
  • other factors - if you haven't taken mefloquine before, it's recommended you do a three-week trial before you travel to see whether you develop any side effects.

Chloroquine and proguanil

A combination of antimalarial medications called chloroquine and proguanil is also available, although these are rarely recommended nowadays because they're largely ineffective against the most common and dangerous type of malaria parasite, Plasmodium falciparum.

However, chloroquine and proguanil may occasionally be recommended for certain destinations where the Plasmodium falciparum parasite is less common than other types, such as India and Sri Lanka.

Treating malaria

If malaria is diagnosed and treated promptly, a full recovery can be expected. Treatment should be started as soon as a blood test confirms malaria.

Many of the same antimalarial medicines used to prevent malaria can also be used to treat the disease. However, if you've taken an antimalarial to prevent malaria, you shouldn't take the same one to treat it. This means it's important to tell your doctor the name of the antimalarials you took.

The type of antimalarial medicine and how long you need to take it will depend on:

  • the type of malaria you have
  • where you caught malaria
  • the severity of your symptoms
  • whether you took preventative antimalarial tablets
  • your age
  • whether you're pregnant

Your doctor may recommend using a combination of different antimalarials to overcome strains of malaria that have become resistant to single types of medication.

Antimalarial medication is usually given as tablets or capsules. If someone is very ill, it will be given through a drip into a vein in the arm (intravenously) in hospital.

Treatment for malaria can leave you feeling very tired and weak for several weeks.

Emergency standby treatment

In some cases, you may be prescribed emergency standby treatment for malaria before you travel. This is usually if there's a risk of you becoming infected with malaria while travelling in a remote area with little or no access to medical care.

Examples of emergency standby medications include:

  • atovaquone with proguanil
  • artemether with lumefantrine
  • quinine plus doxycycline
  • quinine plus clindamycin

Your GP may decide to seek advice from a travel health specialist before prescribing emergency standby treatment.

Read more about emergency treatment for malaria.

Antimalarials in pregnancy

If you're pregnant, it's advisable to avoid travelling to areas where there's a risk of malaria.

Pregnant women have an increased risk of developing severe malaria, and both the baby and mother could experience serious complications.

It's very important to take the right antimalarial medicine if you're pregnant and unable to postpone or cancel your trip to an area where there's a malaria risk.

Some of the antimalarials used to prevent and treat malaria are unsuitable for pregnant women because they can cause side effects for both mother and baby.

The list below outlines which medications are safe or unsafe to use while pregnant:

  • mefloquine - not usually prescribed during the first trimester of pregnancy, or if pregnancy is a possibility during the first three months after preventative antimalarial medication is stopped. This is a precaution, even though there's no evidence to suggest mefloquine is harmful to an unborn baby.
  • doxycycline - never recommended for pregnant or breastfeeding women as it could harm the baby.
  • atovaquone plus proguanil - not generally recommended during pregnancy or breastfeeding because research into the effects is limited. However, if the risk of malaria is high, they may be recommended if there's no suitable alternative.

Chloroquine combined with proguanil is suitable during pregnancy, but it is rarely used as it's not very effective against the most common and dangerous type of malaria parasite.


Complications of malaria

Malaria is a serious illness that can be fatal if not diagnosed and treated quickly. Pregnant women, babies, young children and the elderly are particularly at risk.

The Plasmodium falciparum parasite causes the most severe malaria symptoms and most deaths.

As complications of severe malaria can occur within hours or days of the first symptoms, it's important to seek urgent medical help as soon as possible.

Anaemia

The destruction of red blood cells by the malaria parasite can cause severe anaemia.

Anaemia is a condition where the red blood cells are unable to carry enough oxygen to the body's muscles and organs, leaving you feeling drowsy, weak and faint.

Cerebral malaria

In rare cases, malaria can affect the brain. This is known as cerebral malaria, which can cause your brain to swell, sometimes leading to permanent brain damage. It can also cause fits (seizures) or coma.

Other complications

Other complications that can arise as a result of severe malaria include:

Malaria in pregnancy

The World Health Organization (WHO) recommends that pregnant women should avoid travelling to areas where there's a risk of malaria.

If you get malaria while pregnant, you and your baby have an increased risk of developing serious complications, such as:

Visit your GP if you're pregnant and travelling to a high-risk area. They may recommend taking antimalarial medication.

Read more about taking antimalarials while pregnant.


Preventing malaria

There's a significant risk of getting malaria if you travel to an affected area. It's very important you take precautions to prevent the disease.

Malaria can often be avoided using the ABCD approach to prevention, which stands for:

  • Awareness of risk - find out whether you're at risk of getting malaria
  • Bite prevention - avoid mosquito bites by using insect repellent, covering your arms and legs, and using a mosquito net
  • Check whether you need to take malaria prevention tablets - if you do, make sure you take the right antimalarial tablets at the right dose, and finish the course
  • Diagnosis - seek immediate medical advice if you have malaria symptoms, including up to a year after you return from travelling

These are outlined in more detail below.

Being aware of the risks

To check whether you need to take preventative malaria treatment for the countries you're visiting, see the Fit for Travel or National Travel Health Network and Centre (NaTHNaC) websites.

It's also important to visit your GP or local travel clinic for malaria advice as soon as you know where you're going to be travelling.

Even if you grew up in a country where malaria is common, you still need to take precautions to protect yourself from infection if you're travelling to a risk area.

Nobody has complete immunity to malaria, and any level of natural protection you may have had is quickly lost when you move out of a risk area.

Preventing bites

It's not possible to avoid mosquito bites completely, but the less you're bitten, the less likely you are to get malaria.

To avoid being bitten:

  • Stay somewhere that has effective air conditioning and screening on doors and windows. If this isn't possible, make sure doors and windows close properly.
  • If you're not sleeping in an air-conditioned room, sleep under an intact mosquito net that's been treated with insecticide.
  • Use insect repellent on your skin and in sleeping environments. Remember to reapply it frequently. The most effective repellents contain diethyltoluamide (DEET) and are available in sprays, roll-ons, sticks and creams.
  • Wear light, loose-fitting trousers rather than shorts, and wear shirts with long sleeves. This is particularly important during early evening and at night, when mosquitoes prefer to feed.

There's no evidence to suggest homeopathic remedies, electronic buzzers, vitamins B1 or B12, garlic, yeast extract spread (such as Marmite), tea tree oils or bath oils offer any protection against mosquito bites.

Antimalarial tablets

There's currently no vaccine available that offers protection against malaria, so it's very important to take antimalarial medication to reduce your chances of getting the disease.

However, antimalarials only reduce your risk of infection by about 90%, so taking steps to avoid bites is also important.

When taking antimalarial medication:

  • make sure you get the right antimalarial tablets before you go - check with your GP or pharmacist if you're unsure
  • follow the instructions included with your tablets carefully
  • depending on the type you're taking, continue to take your tablets for up to four weeks after returning from your trip to cover the incubation period of the disease

Check with your GP to make sure you're prescribed a medication you can tolerate. You may be more at risk from side effects if you:

If you've taken antimalarial medication in the past, don't assume it's suitable for future trips. The antimalarial you need to take depends on which strain of malaria is carried by the mosquitoes and whether they're resistant to certain types of antimalarial medication.

In the UK, chloroquine and proguanil can be bought over the counter from local pharmacies. However, you should seek medical advice before buying it as it's rarely recommended nowadays. For all other antimalarial tablets, you'll need a prescription from your GP.

Read more about antimalarial medication, including the main types and when to take them.

Get immediate medical advice

You must seek medical help straight away if you become ill while travelling in an area where malaria is found, or after returning from travelling, even if you've been taking antimalarial tablets.

Malaria can get worse very quickly, so it's important that it's diagnosed and treated as soon as possible.

If you develop symptoms of malaria while still taking antimalarial tablets, either while you're travelling or in the days and weeks after you return, remember to tell the doctor which type you have been taking. The same type of antimalarial shouldn't be used to treat you as well.

If you develop symptoms after returning home, visit your GP or a hospital doctor and tell them which countries you've travelled to in the last 12 months, including any brief stopovers.

'I was so weak, I couldn't even pick up a glass'

Unlike many travellers, Alex Beard was careful to take precautions against getting bitten by a malaria-carrying mosquito.

She went to Africa armed with insect repellent, a mosquito net and antimalarial tablets. But after several months travelling, her precautions lapsed.

"I'd been studying in Ghana for about 4.5 months," she says. "My best friend and I decided to travel back to England by land. We stopped in Burkina Faso. I'd been feeling a bit ill for a while, but I just put it down to an upset stomach and feeling tired, and ignored it.

"We were in a small rural village, miles from anywhere, when I started to feel very ill. I had a stabbing pain in my side and I found it really hard to breathe. I took painkillers and didn't tell anyone about it. I can be very stubborn. But eventually I was so weak I couldn't even pick up a glass."

Alex's friend realised something was wrong. She took her to the village's tiny medical centre. "The doctor sent me off for a blood test, which they did at the vet's. There I was, surrounded by pictures of sheep and goats. I thought I was losing my mind. I kept fainting."

Back at the medical centre, the doctor told Alex she had Plasmodium falciparum malaria, the most dangerous kind. But she found it very hard to understand what was being said.

"We don't speak French, so they had to tell us about seven times before we understood. Eventually they resorted to doing impressions of mosquitoes. We thought we knew the classic signs of malaria, and I didn't have them. I just couldn't believe it."

The doctor gave Alex a bag of pills. She had to take 15 pills every day for three days. He also gave her pills to take in case she relapsed. As there was no hospital, all Alex could do was go back to her hostel, take the pills and hope for the best.

She spent three days drifting in and out of consciousness with a high fever, unable to walk or move. Then she felt well enough to travel to the nearest city so she could be nearer better medical facilities in case she got worse.

Alex rested for four days, then carried on travelling for the next three months. She suffered two relapses and took her pills, which stopped the disease again. But when she got home, she continued to suffer.

"I was in and out of hospital having severe night sweats and speech problems. I had really bad sickness and severe stomach problems. I had to go back for regular blood tests, which didn't show any sign of the parasites, but I was still ill. It took me about 18 months to get over it and I now have irritable bowel syndrome as a result of malaria."

Alex says British travellers should take malaria prevention as seriously as possible. "When you're somewhere for so long, malaria protection doesn't seem too important," she says. "I was sleeping outside my mosquito net because it was too hot and I must have missed taking some pills. I kick myself for it now.

"We're so lucky to have easy access to these antimalarials. Millions of people die from malaria in the developing world. Find out what you need and stick to your regime. It'll only take a few seconds out of your day."

'Malaria nearly killed me'

Mo Kanneh nearly died after catching one of the most severe forms of malaria during a trip to Sierra Leone.

He didn't take antimalarial medication, believing the course he had taken for a previous trip to the West African country still protected him.

But he fell ill soon after returning to the UK and spent two weeks fighting for his life in hospital.

A chaplain was even called to give Mo his last rites after doctors feared he would not survive.

"I was told I could have died," says Mo. "Compared to what I went through, the potential mild discomfort of taking antimalarial pills is nothing."

Mo hopes his story will raise awareness about the risks of malaria in UK residents visiting friends and family in their country of origin.

Immunity to malaria

In 2010, 61% of the 1,700 cases of malaria reported in the UK were in people who had travelled to a malaria region in their country of origin.

Many people mistakenly think they are immune to diseases such as malaria because they have previously lived in a malaria region.

However, immunity is quickly lost when someone moves to a malaria-free country like the UK.

Mo thought the antimalarial pills he had taken on his previous trip to Sierra Leone 10 months earlier would give him immunity.

He also thought that his genes provided some protection against the mosquito-borne parasite.

Both his brother and grandmother, who live in Sierra Leone, had had malaria and made a full recovery after developing only mild symptoms.

Mosquito bites

Mo flew out on April 11 2013 to join the rest of his family for the funeral of his mother, who had died unexpectedly from a heart attack.

"Her death was such a shock," he says. "In the rush of making last minute travel arrangements, antimalarials were low down on my to-do list."
He spent a week in the country travelling between Freetown and his ancestral home attending ceremonial events in honour of his mother.
"I didn't take any precautions at all," says Mo, an online marketing manager from east London. "No mosquito net, no mosquito repellent.
"I remember being bitten a few times but we had so many things to deal with that malaria was the last thing on my mind."
Back in the UK

On his return to the UK, Mo says he felt "absolutely fine", apart from a complete loss of appetite, which he put down to grieving.
"In a week, I probably managed to eat one banana and a couple of bowls of soup," he says.
By the end of his first week back, Mo quickly began experiencing symptoms including sweats, muscle ache, severe headaches and breathing difficulties.
"It dawned on me that it might be malaria but I wasn't too worried," he says. "I thought it would be cured easily with a few tablets."
As his breathing worsened, he called for an ambulance and was taken to Homerton University Hospital, in east London, on April 24.
A blood test confirmed malaria. However, it was not just any malaria. Mo had been infected with plasmodium falciparum, the most deadly form of malaria.
Found mainly in Africa, almost all deaths from malaria are due to the plasmodium falciparum parasite.
Intensive care

Mo was placed in intensive care. "A doctor said he was going to put me to sleep for a few hours to insert a tube to help me breathe," he says.
The next thing Mo remembers is waking up nine days later in St Thomas' Hospital, in central London, hooked up to life-support equipment.
"It was a complete shock," he says. "I had tubes and needles going in and out of me. I couldn't speak because there was a large tube in my mouth."
The drama of the previous nine days - his family's distress, the chaplain's prayers, moving hospital - were revealed to him over the following days.
"When I woke up, the medical staff, family and friends helped me piece together the past nine days.
"It was very upsetting to be told that I had come close to dying.
"The malaria parasite had been attacking my lungs and they were filling up with fluid.
"Pint after pint of brown fluid was being pumped out. The doctors feared I was going to drown in this fluid."
In falciparum malaria, fluid can accumulate in the lungs and cause severe breathing problems.
"My family was told that the outlook wasn't good and that they should be prepared for the possibility that I wasn't going to make it.
"We had only just buried our mother and now they were being told I was probably going to die."
In case Mo didn't make it through the night, a hospital chaplain was called to administer his last rites.
Transfer to St Thomas'

With his condition deteriorating by the day, a medical team from St Thomas' came to Homerton to assess his condition.
It was decided that Mo should be transferred to St Thomas' where they would try to beat the malaria parasite using different drugs.
By the time Mo woke up after his nine-day blackout, the parasite level had dropped significantly, his lungs had cleared and he was able to breathe unaided.
He remained at St Thomas' under close supervision for another five days until the parasite had virtually disappeared from his blood.
"The staff at St Thomas' saved my life, for which I will forever be grateful," says Mo. "They were fantastic."
After two weeks in hospital, Mo was discharged on May 8 and spent the following two weeks recovering at home.
"I had lost about two stone and I still felt weak," he says. "I still had difficulty breathing. Even going to the bathroom was a struggle."
He has since made a full recovery and a subsequent blood test showed that the malaria parasite was no longer present in his system.
"A near death experience makes you realise life can be taken away from you at a moment's notice," says Mo.
"If I've taken anything away from this experience, it's never to take your health for granted."

 
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