Resort & Urban Areas: Minimal
risk and antimalarial drugs not recommended. The use of insect repellents is recommended
as this will also minimise the risk of other diseases from bites such as Dengue.
Inland Forested areas: The benign vivax form of malaria exists and is
sensitive to Chloroquine.
Day Trips: Antimalarial drugs not required (malarial mosquito is only active
from dusk to dawn. Insect repellents should be used for reasons as above.
Lombok: The risk of serious falciparum malaria exists and appropriate antimalarial
drugs recommended. (Mefloquine or doxycycline)
Minimisation of exposure to mosquitoes
Stringent measures to prevent mosquito contact reduce the risk of contracting
malaria by ten fold.
- Minimise night time outside activities.
- Avoid dark coloured clothing as it attracts
mosquitoes as do perfume, cologne & after-shave.
- Clothing to cover arms and legs in the
evenings. NB. It is common for mosquitoes to attack leg/ankle region.
- Use of mosquito repellents. The most
effective mosquito repellent is (DEET). "Rid" or "Muskol". It is
effective for 3 to 4 hours when applied to clothing or skin. It needs to be spread evenly
and completely over all exposed skin. Repellents containing more than 20% DEET should be
avoided in infants and young children. (see also Children's dosage for antimalarials).
Untreated travellers in proximity to treated ones are more apt to be bitten.
- Mosiguards:- Ankle and wrist bands
impregnated with DEET, mosquito nets impregnated with permethrin are available from TMVC,
MASTA, camping stores and some chemists.
- DEET repellents should be kept well away
from plastics, including cameras, as it will dissolve them
Dengue & Dengue haemorrhagic fever
The "Dengue" mosquito ( Aedes aegpti ) prefers to feed on humans and
has invaded urban tropical environment of many countries including Australia. It is
considered the most important mosquito spread viral disease in the world
Severe headache, bone & muscle pain, high fever and rash usually occur 4-6 days after
an infected bite. There is no vaccination available so avoiding bites is essential.
Anyone suspected of being infected with Dengue, especially the haemorrhagic form
(large bruises on skin, bleeding gums or blood from nose or bowel) should seek medical
assistance immediately. If untreated or inappropriately treated Dengue haemorrhagic fever
can be fatal. *2
Rabies has occurred on the islands of Java, Timor & Lombok but the Island of Bali
is rabies free
Medical Kit: Panadol, sunscreens, sunburn cream, antihistamines, antiseptic
(Betadine), antifungal (tinea and thrush), diarrhoea medications (antibiotic, gastrolyte
if taking children), bandages and dressings, condoms.
Heat and Humidity: Plenty of drinks rich in mineral salts (fruit and vegetable
juices, clear soups and even a little table salt) are recommended. Daily showering, loose
cotton clothing and talcum powder will reduce heat rash. Risk of severe sunburn needs
Shoewear: Shoes and clothing should be examined before use - particularly in the
morning - as snakes tend to rest in them. ... Leather goods made from inadequately treated
skins may contain anthrax spores causing life threatening skin sores.
Accident Prevention: Traffic accidents are a leading cause of accidents among
travellers. Vehicles are often unroadworthy. Unfamiliarity with roads, poor condition of
roads and drunk drivers add to the dangers. Kuta beach in bali is considered a dangerous
beach for swimming and on average 6 tourists drown each year.
Plane Trip: Drink plenty of fluids, exercise legs, avoid excessive alcohol &
Travel Insurance: Travel insurance should cover not only medical & hospital
expenses but also costs due to general accidents, medical evacuation, loss of luggage
& money, as well as delays due to strikes.
Sexually Transmitted Disease: There is a high risk of HIV in developing countries
(NB. 42% of those already infected with HIV being women 1*). Also most travellers
contracting STD had not planned to have sexual contact whilst away. (coerced by the
culture and or alcohol) Local condoms are unreliable . There is no evidence that HIV or
any other sexually transmitted infections are acquired from insect bites.
Treatment of Illness
Management of Diarrhoea
Because diarrhoea is so common it is important to be aware of how to manage it if
Most travellers do not develop dehydrating diarrhoea; almost any beverage coupled
with a source of salt (eg., salted crackers) suffices for hydrating most ill travellers
Bottled or canned beverages, tea, broth, foods such as rice, bananas, papaya (pawpaw),
potatoes and dry biscuits are tolerated best. Children with diarrhoea are of special
concern (see Travelling with children).
- Antimotility drugs ('stoppers'). Since most
diarrhoeal illnesses last only a few days, these drugs may be very helpful in relieving
diarrhoea and cramps. Do not use if high fever or blood in motions. Do not use in children
under 6, and be cautious in children under 12. Adult Dosage: loperamide (Imodium) -2
capsules (each 2 mg) followed by 1 cap after each unformed stool. (maximum 8 caps per
- Antibiotics. Diarrhoea with high fever, distressing
symptoms or blood in motions:
A single dose of two tablets of any of the following drugs
should be effective. If response is not dramatic after 12 hours continue 1 tab twice a day
for a further 3 days. (Norfloxacin 400mg, ciprofloxacin 500mg , doxycycline 100mg,
- Prolonged diarrhoea greater than 10
days and without fever:
A bowel parasite "giardiasis" is the commonest cause. The best treatment is
tinidasole (Fasigyn) - 4 x 500mg tablets (2g) in a single dose. Metronidazole 400mg three
times a day for 5 days is an alternative. If this is not completely effective amoebic
dysentery is a possibility. Tinidazole (Fasigyn) - 4 x 500mg tablets (2g) daily for 3
successive days should be effective.
When diarrhoea is prolonged and with fever seek medical
Antibiotics to prevent Diarrhoea.
This is reasonable for short trips (less than 3 weeks). Indications include persons
- Inflammatory bowel disease, Immunocompromised persons
including individuals who have had their spleen removed or poorly
functioning spleen (eg Hodgkin's lymphoma).
- Insulin dependant diabetics
- Persons on strong H2 blockers or proton pump
inhibitors.(Losec, Somac, Zantac)
- Business travellers whose purpose of the trip would be
ruined will often chose this option. - Norfloxacin 400mg daily, Ciprofloxacin 500mg daily
or Bactrim 1 DS daily could be used. Doxycycline is less effective.
Azithromycin is useful for pregnant women and children ** WHO
Poisonous snakes occur in many parts of the world. As for snake bite within Australia
the general principles of
- immediately apply a firm broad bandage
- immobilise the limb with a splint
- leave the bandage and splint in place until medical care and
Early diagnosis and treatment of malaria
Any fever developing after 8 days or upon return
(particularly within the first 3 months) may be due to malaria. You should consult a
doctor, voice your suspicion of malaria, and ask for a blood film to be done. You should
do so within 48 hours of onset of fever, or earlier if you are more than moderately
Remember No malarial prevention drug gives 100% protection
Antimalarial Drugs & Common side effects ... Childrens dosages
Chloroquine: Minor side effects such as stomach upset
and blurred vision occur frequently. These can lessened by taking tablets with food, or
taking half the dose on 2 occasions each week. They are safe in pregnant women and
children in correct doses. Pruritus (itch) in dark skin individuals is common. . If you
have had generalised psoriasis, chloroquine and other chloroquine-like drugs, including
primaquine, quinidine and proguanil should be avoided. Retinal changes including eye
damage and blindness may occur after prolonged use but on the usual 300mg per week dose it
would take 6-7 years.
- a combination of atovaquone and proguanil in a single tablet, is a new
addition for malaria prevention. Its use has been approved for treatment and
prevention of malaria (TGA-Australia) since November 2001. It is particularly useful where malaria is
resistant to chloroquine and mefloquine (Larium). On evidence to date, it appears
to be very safe and effective, but is expensive.
For prevention of malaria, Malarone is taken once a day,
starting 1 day before entering malarial risk area and continuing for 1 week after leaving the
malarious area. It should be taken with food or milk. This regime is simple
and suited to business & frequent travellers. Nb. When Malarone is used for malaria prevention, side
effects are uncommon . However, nausea, vomiting, abdominal pain, and diarrhoea
occur when higher doses of the drug are used for treatment. Convulsions and rash
have rarely been reported.
Doxycycline: It is an alternative to mefloquine for short-term travellers.
Doxycycline at 100 mg/day is approved for a period of up to 8 weeks only (NHMRC 1994) but
is probably safe for longer use. Side Effects include thrush, stomach & bowel upsets,
(particularly if medication is taken on an empty stomach) and sunlight sensitivity. The
exaggerated sunburn reaction may be minimised by avoidance of sunlight, using sunscreen
and taking the drug in the evening. Drinking copious quantities of water after swallowing the
drug is recommended to reduce heartburn. Using Doxycycline may make the
Contraceptive pill unreliable. The Therapeutic guidelines 2002 states that: "A
second form of contraception is not necessary, but may be offered." & "Women
who develop breakthrough bleeding might consider using barrier methods for the
duration of antibiotic therapy". Discuss this
matter with your doctor.
Mefloquine: Side-effects ('Lariam') Minor side
effects such as nausea, vomiting, heartburn and loose stools occur in about 20% of users,
but this is no more frequent than with other antimalarials and usually subside with
continued use. Taking ½ tab twice a week with food, and drinking copious water with medication will
help reduce these.
Unfortunately mefloquine frequently produces annoying
adverse neurological effects such as insomnia, vivid dreams, dizziness, mental clouding,
anxiety and coordination problems. These are sufficient to interfere with daily activities
in up to 10% of users and are probably aggravated by use of alcohol and cannabis.
Disabling side effects sufficient to recommend the cessation of mefloquine occur in 0.5%
of users. However despite this, some 5 - 10% of users will stop the drug. Consequently
any person requiring a clear mind and good co-ordination should not use mefloquine. This may involve travellers to high altitude and definitely those contemplating aqualung
(scuba) diving. Other contra indications include persons with a history of seizures, neuro-psychiatric disorder, the first 3 months of pregnancy and those with cardiac
conduction problems. Women are advised to use contraceptives during and for 3 months after
administration of mefloquine.
Mefloquine is probably best commenced 3 -4 weeks before
entering a malarious area as it takes this long to build up to satisfactory blood levels.
(half life of 21 days). Also this provides time to detect those travellers that
develop unacceptable side-effects and thus enable a change in medication.
Commencing 1 or 2 weeks before departure is
A recent report involving soldiers taking mefloquine 250mg daily for 3 days to enable a
quick build up in blood levels was surprisingly well tolerated.
US authorities are prepared to use mefloquine for up to 2 years continuously in Peace
Corps Volunteers overseas.
Serious neuropsychological side effects can occur when mefloquine is used in high doses.
(click important note )
see also Malarial misconceptions: http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/ccdr-rmtc/00vol26/26s2/26s2n_e.html or copy
Proguanil: One of the safest antimalarial drugs. Mouth ulcers is an annoying complication in up to
37% of travellers. (when taken with Chloroquine). Proguanil is taken 2 tabs daily,
starting 1 day before entering malarial area and continuing for 4 weeks after
leaving the area.
Chloroquine is taken 2 tabs weekly
. Confusing your tablets could be deadly.
Contrarily to WHO recommendations, Australian travel physicians mostly limit the use of Chloraquine + Proguanil,
to travellers unable to take mefloquine or doxycycline.
Stand by Treatment
Since malaria can become life-threatening within a short time you should not delay
seeking medical attention. Travellers who are likely to be more than 24 hours away from
medical help, are often given one or more treatment courses of the following to take with
Business persons & Frequent Travellers
Some travellers make
frequent short stops to endemic areas, over a prolonged period of time. Such travellers may
eventually choose to reserve chemoprophylaxis for high-risk areas only. Malarone
may be the most useful malarial prevention drug here, as it only needs to be
taken for 1 week after leaving the malarial area. When antimalarial drugs are
not used, rigorous self-protection measures against mosquito bites should be
employed and they should be prepared for an
attack of malaria: they should always carry a course of antimalarials for stand-by
emergency treatment, seek immediate medical care in cases of fever, and take
self-treatment if medical help is not available.*(*p 135 WHO 2002 year book
Standby malarial treatment:
- Malarone (Atovaquone +
Proguanil) - The dosage is 4 tabs daily for 3 days with food and is now considered the drug of choice. (but
expensive approx $100 Aus).
- Riamet (Co-artemether which contains
artemether 20mg and lumefantrine 120mg) - 4 tablets twice a day 3 days.
Advantage of being very quick acting.
Fansidar (3 tablets for an adult)
- becoming less reliable
Mefloquine for adults > 65kg, 3 tablets followed 6-8
hours later by another 1 tablet (high side effects & no longer
Quinine (adult dose 600 mg three times a day for 7 days) -
see also WHO year book (Stand by
(Nb. If taking malarone for prevention, a supply of
Riamet should be taken)
ICT Malaria P.f/P.v test
- This test, provides a
realistic alternative for people in this category, particularly those who have had
significant side-effects from either mefloquine or doxycycline. This test detects circulating antigens of falciparum malaria. A finger prick blood sample
gives a result in 5 minutes. For Plasmodium falciparum infection the test is close to 100%
reliable, but false positives can occur (rheumatoid factor, previously treated
malaria in the last month). For vivax malaria reliabilty is very low. The test is stable at 37 degrees C for 4 months. Cost approx $30 for 2 test kit.
NB. The test is very reliable in experienced hands but reliability in a sick
febrile traveller (self testing) is questionable.
Preventive drugs should be continued after treatment for
malaria. As serious neurological side effects may occur when mefloquine is used in
the high doses needed for treatment, it should only be used in a true emergency situation
when medical attention is not available. Standby use of mefloquine is not recommended for
persons already taking mefloquine for malarial prevention.
(click important note ) -- Also see Full Information
Travel Checklist & Medical Kit
Examination after travel: It is advisable (if not essential) to visit your
local doctor promptly if you
** page 203, Manual of Travel Medicine
- suffer from a chronic disease, such as cardiovascular disease, diabetes
mellitus, chronic respiratory disease;
- experience illness in the weeks following their return home, particularly
if fever, persistent diarrhoea, vomiting, jaundice, urinary disorders, skin
disease or genital infection occurs;
- consider that you may have been exposed to a serious infectious disease while
- have spent more than 3 months in a developing country.