Porto Alegre, December 19, 2024.
One of the reasons for consulting an infectious disease specialist is the need for guidance on malaria prevention (prophylaxis) when planning a vacation trip to a malaria-endemic area of the planet. This text is a response to a consultation by a family organizing a vacation trip to South Africa.
The information presented here refers to a specific destination, during a specific period, with a specific itinerary and specifically planned activities. However, this information can be used for other trips regarding non-pharmacological measures and the use of repellent, after considering and adjusting other vacation, tourism, or short-term work trip plans. The use of medications for malaria prevention, chemoprophylaxis, is a controversial subject without consensus among different countries. The Brazilian Ministry of Health does not recommend chemoprophylaxis for travelers from non-endemic areas to malaria-endemic areas, whether these trips are within the country or abroad.
Topics covered in the text
1 — Stay in a malaria area
2 — Predominant local malaria type
3 — Malaria prophylaxis
4 — Summary of recommendations
1 — Stay in a malaria area
The malaria area included in this trip's itinerary is exclusively Kruger National Park. The figures below show that this park is the only malaria area in South Africa. A 4-day stay is planned for this location.
Malaria Risk in Kruger National Park
Kruger National Park is a seasonal malaria area with medium to high risk. The high-risk period is from September to May. The planned stay during this trip falls within the highest risk period.
This vacation trip to South Africa will begin on 12/22/2024 and return on 01/03/2025, with a total stay of approximately 15 days, depending on flight schedules.
2 - Predominant Local Malaria Type
The CDC in Atlanta and the World Health Organization report that the predominant malaria in Kruger National Park is caused by _Plasmodium falciparum_. The incubation period for this species is 8 to 12 days, according to the Malaria Treatment Guide in Brazil, Ministry of Health, 2020.
3 - Malaria Prophylaxis for Travelers
Malaria prophylaxis can be achieved through general measures, vaccination, and chemoprophylaxis. General measures are unanimously recommended. Vaccination is not currently indicated for travel contexts. Regarding medication use, there is no global consensus. The use of drugs for prevention remains controversial. North American and European countries recommend chemoprophylaxis; the Brazilian Ministry of Health does not.
Due to the extensive distribution of diagnostic and treatment networks for malaria in Brazil, chemoprophylaxis is not indicated for travelers within national territory according to the Malaria Treatment Guide in Brazil, page 62, 2020. As chemoprophylaxis is not fully effective, and given the existing network in Brazil, early clinical and etiological diagnosis of malaria and prompt treatment are considered better options than unsatisfactory chemoprophylaxis. Similarly, other countries that are endemic areas for malaria adopt strategies similar to those used in Brazil. However, it is common for countries where malaria is not endemic to recommend chemoprophylaxis for their citizens traveling to endemic areas in Brazil and also to Kruger National Park, our current focus of clarification. I am unaware of other national recommendations that indicate malaria chemoprophylaxis for Brazilians traveling to other countries where the disease is endemic.
The Brazilian Ministry of Health does not have specific published guidelines on malaria prophylaxis for travelers to South Africa. However, some professionals choose to base their recommendations on international guidelines, such as those from the CDC. In this regard, for areas including the Mopani and Vhembe districts in Limpopo Province, the Ehlanzeni district in Mpumalanga Province, and the Mkhanyakude district in KwaZulu-Natal Province, as well as Kruger National Park, the CDC recommends chemoprophylaxis including atovaquone-proguanil, doxycycline, or mefloquine.
High-risk situations for malaria transmission:
- Destinations including areas with high levels of malaria transmission and/or transmission in urban perimeters
- Activities from sunset to dawn
- Accommodation allowing contact with mosquitoes: sleeping outdoors, in camps, boats, or precarious dwellings without mosquito protection
- Travel period longer than the disease's incubation period, i.e., staying in the location longer than the minimum incubation period of the disease (seven days for falciparum malaria)
- Travel near the beginning or end of the rainy season
- Destinations up to 1,000 m altitude
- Access to the health system at the destination more than 24 hours away
The family in question fits some of these situations. Thus, at the end of the text, I will summarize the recommended recommendations for this family based on the information presented above.
High risk of severe disease:
- Individuals from areas where malaria is not endemic
- Children under 5 years of age
- Pregnant women
- Elderly
- Splenectomized individuals
- People with immunodeficiency
- Neoplasms under treatment
- Transplant recipients
Regarding the items above, the family that consulted an infectologist only fits the first item.
General measures for protection against insect bites are:
- Ask tour guides and local people about the peak activity time for malaria mosquitoes, from sunset to dawn
- Wear light-colored and long-sleeved clothing during high-exposure activities
- Use barrier measures such as screens on doors and windows, air conditioning, and use of mosquito nets impregnated with long-lasting insecticide
- Bring and use DEET-based repellent (N-N-diethylmetatoluamide) which should be applied to exposed areas of the skin, following the manufacturer's instructions. For children under 2 years of age, the use of repellent is not recommended without medical guidance. For children between 2 and 12 years old, use concentrations up to 10% DEET, no more than three times a day, avoiding prolonged use.
4 - Summary of Recommendations and Final Considerations
The recommendations presented above do not apply to the entire stay in South Africa; they apply only to the 4 days of stay in Kruger National Park.
Avoid activities outside the hotel from sunset to dawn. During this period, try to stay indoors in mosquito-free accommodations. Ask tour guides and local people about the peak activity time for malaria mosquitoes, from sunset to dawn. During this conversation, take the opportunity to ask if there have been any recently acquired malaria cases in the park. Also ask about the best places for care in case someone in the family develops a fever. Where do people in the region consult when they develop a fever? When is malaria suspected? What is the name, phone number, address of the health institution? How far is it, in time and kilometers?
Wear light-colored and long-sleeved clothing during high-exposure activities. And on exposed areas of the skin, use DEET-based repellent.
I recommend that you reserve the last days of the total trip time for your stay in Kruger National Park to take advantage of the 1-week incubation period that is usually the incubation period for falciparum malaria, more prevalent in the region. If contracting malaria is inevitable, it is better to diagnose and treat EARLY (IMMEDIATELY) here in Porto Alegre upon return from the trip.
And upon return, for a period of 1 or 2 months, in case of fever in any family member, consult immediately, informing that you have been in a malaria-endemic area.
Malaria is one of the diseases controlled by the Ministry of Health and its local representatives such as the State and Municipal Health Secretariat. Thus, antimalarial medications and their dispensing are in accordance with the Malaria Program. Even knowing that they are not available for prophylaxis in Brazil, I contacted the Porto Alegre SMS which also informed that the Brazilian Ministry of Health does not recommend chemoprophylaxis for malaria; however, it recommends the other preventive measures presented above.
References
Yellow Fever Vaccine & Malaria Prevention Information, by Country, CDC Yellowbook. Mark Gershman, Rhett Stoney (Yellow Fever) Holly Biggs, Kathrine Tan (Malaria)
South Africa, CDC Yellowbook. Lucille Blumberg, Amy Herman-Roloff
Brasil. Ministério da Saúde. Guia de Tratamento da Malária. 2020.
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