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Malaria

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Malaria is transmitted by mosquitoes that usually bite from dusk to dawn. Symptoms can develop as early as six days or as late as several months after exposure. Early malaria symptoms are flu like, such as head/body aches and generally feeling tired and unwell. Untreated, it can cause complications including anaemia, seizures, mental confusion, kidney failure and coma. It can be fatal.

Prevalance of Malaria in Indonesia

Malaria is present in most of Indonesia. Chloroquine-resistant P. falciparum malaria is present.

There is no malaria in:

• Jakarta
• Main resort areas of Bali or the island of Java (except for Menorah Hills in central Java, risk exists there)
• Urban areas in Sumatra, Kalimantan, Sulawesi and Nusa Tenggara Barat

There is malaria in:

• All rural areas in Sumatra, Kalimantan, Nusa Tenggara Barat and Sulawesi
• Areas of Bali outside the main resort areas
• All areas of eastern Indonesia including Papua, Nusa Tangara, Timur, Maluku and Maluku Utara
• Lombok

Malaria is a potential problem in almost all areas outside the main metropolitan centers in Indonesia. It is more effective and healthier to rely more on anti-mosquito measures than on anti-parasite drugs. Be aware of these points:

• Malaria is spread by mosquitoes, so any measures that reduce mosquito bites reduce the risk of contracting malaria and other illnesses such as dengue fever.
• For prophylactic drugs to be effective, they must be taken regularly according to the recommended schedule.
• Prophylactic medication does NOT offer absolute protection.
• Exceeding the recommended dose of prophylactic medication does not increase its effectiveness and will increase the risk of side effects, which may (rarely) be serious. Before certain types of malaria prophylaxis are prescribed, a doctor's examination and laboratory tests are advised.

Simple Self-Protection Measures to Prevent Malaria

• Prevent mosquito bites.
• Chemoprophylaxis

1. Correct use of mosquito netting will greatly reduce the incidence of bites. For added protection of up to 3 months or longer, netting can be soaked in a 1% solution of permethrin or other repellent/insecticide. If staying in a malarious area, curtains should be treated in a similar manner.

2. Mosquito coils (obat anti nyamuk) and "knockdown spray" containing pyrethroids should be used in cool dark places where mosquitoes lurk.

3. Avoid use of dark-colored clothing, perfumes and colognes in the evening and at night.

4. An effective mosquito repellent should be used on exposed skin and clothing. DEET (diethylmethylbenzamide) is an effective safe component of good repellents. Actual concentrations of DEET varies widely between different manufacturers and can be as high as 90% (too high for safety). Choose a repellent with between 30-45% DEET (unless pregnant, in which case the concentration should be < 35%) and take the following precautions:

• Apply sparingly and only to exposed skin
• Never apply high concentrations to skin (use those for clothing)
• Do not inhale or swallow or get it in eyes or mucous membranes
• Do not apply to hands that may touch eyes or mouth
• Do not apply to wounds, rashes, or abrasions
• Wash repellent off after coming indoors to stay
• If skin starts to burn, wash repellent off and seek medical advice

DEET-based repellents should last for up to 4 hours.

Although mosquitoes can bite through cloth it is still better to cover up.

5. Mosquitoes breed in standing water. Clear the neighborhood of ponds & pits and cover all water containers and any objects that can trap rainwater.

Anti-malaria chemoprophylaxis

There are many drugs used for malaria prophylaxis and medical opinion differsas to the best medications to use. Malaria in indonesia is resistant to the medication chloroquine.

• If visiting malarial areas, use a medication to prevent chloroquine-resistant P. falciparum malaria. These include:
  
• Atovaquone plus proguanil (Malarone® and generics)
• Doxycycline (many brands and generics)
• Mefloquine (Lariam® and generics)

Continue malarial prophylaxis while exposed to malaria. Stopping the medication while still exposed leaves you susceptible again to the dangerous consequences of malaria.

As well as this difference of opinion, the situation is further complicated by the increasing emergence and spread of resistance to some anti-malaria prophylactics, especially with respect to P. falciparum and P. vivax. You should be aware of the recommendations current in your home country, and that advice can be 'fine-tuned' by the experience of doctors locally. AEA's recommendations are based on up-to-date personal experience, clinical experience with patients, and reference to the most recent publications by specialist advisory bodies in South East Asia, the UK and Australia.

Anti-malaria prophylaxis comes in 3 grades according to personal resistance:

1. No resistance: Chloroquine alone is adequate for prophylaxis.
2. Chloroquine resistance: This occurs in many places in Indonesia, particularly South Eastern Kalimantan, East Maluku, Lombok, and Flores. If chloroquine is used, it should be supplemented with Proguanil.
3. Antifolate resistance: This is emerging in South East Asia, Papua and other islands of East Indonesia. The parasite is resistant to chloroquine and fansidar.

General rules for anti-malaria prophylaxis

2. The use of mefloquine (larium) is hotly debated but polarized. The author believes this drug is useful for short-term prophylaxis and as a stand-by treatment. Prolonged use should happen only after consultation with your medical advisor.

3. Always check for medication allergies. Fansidar should not be taken if a patient is allergic to sulfa drugs. Some patients, especially those of Asian or Mediterranean origin, should be tested for G6PD deficiency.

4. Prophylaxis should commence 1-2 weeks prior to travel to establish effective blood levels, to establish a routine of regular intake of medication, and to make sure that any early side effects occur while near adequate medical support and not in a remote area. Medication intake should continue for 4 weeks after returning from malarious areas, with the exception of doxycycline.

5. Doxycycline (vibramycin) is a reasonable daily alternative for short stays of up to 6 weeks and can be supplemented with weekly chloroquine. It should not be taken by children whose permanent teeth are not complete or by pregnant women.

6. Some authorities recommend that people traveling through or working in a malarious area start taking Vitamin B supplements two weeks beforehand, as there is evidence that metabolites of Vitamin B cause an odor that discourages Anopheles mosquitoes.

7. Always have enough medicine to last for the duration of your stay, as specific medication may not be available in remote areas.

Recommendations for prophylaxis

ALWAYS check side-effects and contra-indications before taking and DO NOT SELF-PRESCRIBE.

For healthy adults:

1. Doxycyline (vibramycin) is an alternative for short stays of about 2-6 weeks. 100 mg once a day with food, starting 2 days before and finishing 2 weeks after exiting malarious area.

or

2. Mefloquine (larium) 250 mg (1 tablet) once a week, before, during, and for 4 weeks after exposure. Do not use Fansimef (fansidar plus mefloquine) for prophylaxis. Do not use if any history of convulsions, depressive illness or cardiac conditions. ALWAYS check its use with a doctor before taking.

or

3. Chloroquine and Proguanil for longer stays;

Chloroquine 2x 150 mg tablets once a week, same time each week

Proguanil 2x 100 mg tablet once a day, same time each day

both starting 2 weeks before and finishing 4 weeks after exiting.

For pregnant women:

Malaria can cause intrauterine fetal death, miscarriage, congenital infection, premature labor and pre-eclamptic toxemia.

We strongly advise women who are pregnant or trying to become pregnant not to go to a malarious area (anywhere outside metropolitan Jakarta, Bandung, Yogya, Surabaya and Bali).

Doxycycline is contraindicated in pregnancy. Proguanil is considered safe, and chloroquine is considered safe but alone constitutes insufficient protection. Mefloquine is not known to be safe in the 1^st trimester but has been used in the 2^nd and 3^rd trimesters without known problems so far.

For children:

In this group the emphasis is on bite prevention. Antimalarials for children must be prescribed by a pediatrician and doses individualized.

Chloroquine phosphate / chloroquine sulfate: 50 mg chloroquine base per tablet: DOSE: 5.0 mg / kg / week up to maximum adult dose

Chloroquine sulfate syrup (Nivaquine syrup): 25 mg chloroquine base per 5 ml syrup; DOSE: 1.0 ml / kg / week (measure accurately using a syringe)

Proguanil syrup: 3 mg /kg/day.

IF SICK WITH A FEVER AFTER VISITING A MALARIOUS AREA, ALWAYS GIVE THE DOCTOR A TRAVEL HISTORY AND IF ASK HIM / HER IF YOU COULD HAVE MALARIA.

Malaria: Additional information on Malaria and Cerebral Malaria

Additional info on Malaria from the US Center for Disease Control

If you have medical-related questions about living in Indonesia to ask of medical professionals, see Ask the Experts.

We trust this information will assist you in making correct choices regarding your health and welfare. However, it is not intended to be a substitute for personalized advice from your medical advisor.

Our appreciation to Dr. Rene de Jongh of International SOS, An AEA Company who has contributed this article in response to a growing health threat faced by expatriates in Indonesia.

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