Doxycycline pills
Photo credit – Norm and Debra
This is a guest post by Phil from Phil in the blank.
Travelers, from their own experiences and the second hand tales of others, share opinions on everything from the best place to stay to the hard-to-find restaurant that has $2 plates of delicious food.
They also share their opinions on a range of travel health issues.
Sometimes these opinions are well-informed. Other times, they are incomplete or worse, just plain wrong. Three of the most controversial travel health issues are malaria prophylactics, the rabies vaccine and traveler’s diarrhea.
In this post, I will address the differing opinions on these topics and provide a recommendation for each one.
Before I get started, let me first say that I am not a doctor. The following recommendations are based on a collection of current research from a variety of sources.
That said, you should arrange for a travel health consultation if you plan on traveling to a tropical or developing world area. A doctor at a travel health clinic can provide reliable advice that is tailored to your destination.
Malaria Prophylactics
While there is not yet a malaria vaccine available, there are several medications that can be taken as a prophylactic. Almost every traveler I meet has an opinion on which one to take or whether to take them at all.
At least one of the prophylactics – mefloquine, also known as Lariam – is notorious for its possible side effects.
Another is an antibiotic – doxycycline – with its own set of possible side effects.
A third, Malarone, has fewer possible side effects, but it’s a daily tablet and it’s the most expensive of the three.
The prophylactic decision is further complicated by the fact that there are different strains of malaria. It is foolish to think of malaria as one disease that is the same throughout the world.
You might not have taken a prophylactic during your trip to Asia. Perhaps malaria was endemic at your destination but not widespread and the strain present was the milder plasmodium vivax or plasmodium ovale. You made it through your trip malaria-free.
Now you are planning a trip to West Africa and you’re thinking malaria is no big deal.
Except malaria is more widespread in West Africa and the dominant strain is plasmodium falciparum, the most virulent strain and the one responsible for most cases of severe and cerebral malaria, which can kill you.
The dreaded mosquito
Photo credit – wild_turkey5300
All of this is to say that malaria prevention – and treatment – depends on your specific destination. There is no one-size-fits-all strategy. Instead, take the following course of action:
- Use this table from the CDC to see what strain (if any) of malaria is present and what prophylactic is recommended.
- Have a consultation at a travel health clinic and talk about the different options with a doctor several weeks before your trip.
- If you are taking a prophylactic, test it out before hand and make sure you don’t have significant side effects. Keep in mind that if you are taking mefloquine, it needs to be taken several weeks before your trip anyways for it to be effective.
- Carry a backup treatment option. While it is unlikely, you can get malaria even if you are taking a prophylactic.
I came down with malaria while taking mefloquine in northern Benin. If it wasn’t for a round of coartem (a good emergency standby treatment for plasmodium falciparum), I might have been in big trouble – early treatment is critical and in this case, the nearest clinic was almost a day away.
Rabies Vaccine
Few travelers get the rabies vaccine. It is a costly series of injections and even with the vaccine, you still need to get additional injections if you are bitten or scratched by an animal.
never handle grounded bats
Photo credit - Wordyeti
Most travelers reason that rabies is rare and you still need post-exposure treatment regardless of whether you have the vaccine, so why go through the trouble?
While it’s true that the vaccine does not confer immunity, it buys you time in the event that you are bitten or scratched by an animal. Timely treatment is critical in rabies cases and it certainly doesn’t hurt to extend the grace period.
Perhaps more importantly, the vaccine removes the most difficult step of post-exposure treatment: the administration of rabies immune globulin (RIG). RIG is expensive and it’s not well-stocked by every clinic.
If you’ve been vaccinated, you won’t need the RIG booster as part of your treatment.
Personally, I have never elected to have the rabies vaccine. But I’m rarely around animals and I spend most of my time in cities.
While most travelers you meet may say, “skip it,” you should review your itinerary and talk to a doctor at a travel health clinic before making a decision on whether or not to get the rabies vaccine.
Traveler’s Diarrhea
Traveler’s diarrhea and its various incarnations (“Delhi belly,” “Montezuma’s revenge,” etc.) afflict almost every traveler at one point or another.
Whether it’s from undercooked food or unfiltered water, you may find yourself making some unwanted trips to the bathroom if you’re traveling in the developing world.
Most cases of traveler’s diarrhea last a couple of days before going away on their own. During this time, many people will pop a few doses of Imodium, considering it a form of treatment.
travel health
Photo credit - meddygarnet
Imodium slows down your gut, meaning less trips to the bathroom and presumably, greater comfort, but it doesn’t treat traveler’s diarrhea – it merely helps you manage the symptoms.
Furthermore, there is some evidence that suggests Imodium may prolong the illness. By slowing down your gut, it’s possible that the offending bacteria stays in your GI tract longer.
If you are battling traveler’s diarrhea and you need to board a bus for a long voyage, by all means, take some Imodium, but don’t expect it to cure the illness.
If possible, reschedule your bus trip, go to the bathroom as often as needed, rest as much as possible, and rehydrate with water and oral rehydration salts (you can buy these at any pharmacy for less than $1).
If you have persistent or severe diarrhea, you may need to take an antibiotic like ciprofloxacin (talk to a doctor at a travel health clinic about self-administering this medication if you have not done so before).
If you are having other symptoms besides diarrhea, or you are seeing blood or mucous in your stool (gross, I know), you should go to a clinic – there is a chance you have something beyond a simple bacterial infection.
Hopefully, this post has provided some insight into some of the more controversial travel health issues. It does not intend to say that you shouldn’t seek advice from other travelers or that anecdotal evidence from the tales of others is worthless.
What it does intend to say is that if you are traveling to a tropical or developing world area for the first time, you should have a conversation with a doctor who specializes in travel health.
If you are prepared, most travel health issues will never come up, and if they do, you’ll know how to deal with them.
Bio: Phil Paoletta is currently traveling through West Africa teaching people how to draw camels. You can keep up with his wanderings at his blog Phil in the Blank. He also blogs about travel health at Sick on the Road and travel safety at My Travel Safety.
Great post, loads of useful info. As you say, all these things are relative to the situation and person taking the drug. I’ve taken Lariam as an anti-malarial and am one of those people who don’t get side effects – other than it giving me incredibly awesome trippy dreams
Hey Laurence,
Be grateful your dreams were only trippy!! I had some paralyzing nightmares when I took it. Exactly, each situation, each trip is different and should be assessed on its own terms.
Thanks for the informative article Phil. I’ll be honest, when I see a post named “3 Controversial Travel Health Topics” I was expecting a bunch of quack info, but was pleasantly surprised that was not the case
I think the one thing left to mention about rabies immune globulin is that it is a blood based product. That means if you’re in a place where the health care, and blood supply may be suspect (most places you might be concerned about rabies), you may be putting yourself at risk again.
Also, rabies is fatal if not treated (with or without vaccine).
As always, talk to your doc or local travel health center before heading out!
Thanks, Dustin. Yeah, good addition there regarding RIG. And you’re right – there’s only been a handful of people that have survived without post exposure treatment.
Thanks for the information! These health problems can really put a damper on traveling.
Thanks for the great info Phil. When I was going to the Amazon in Ecuador, the locals (pharmacists included) swore by the use of Vitamin B as a prophylactic for malaria prevention. So, that’s what I went with. Any evidence that Vitamin is effective in this way?
That seems like a dangerous recommendation to me. There is no evidence that vitamin B prevents malaria. Some people think that taking it helps ward off mosquitos, thus preventing bites. People say the same thing about garlic. Bottom line, though, it’s not a prophylactic.
Useful info! When I went to Rwanda I was given Malrone. I didn’t even have an option when I got it prescribed. I was in Spain and that’s what they gave me. I didn’t have any side effects but have heard of people getting sick from it.
Was that at a travel health clinic? Normally, they will discuss the drug with respect to your destination. It also might have depended on your time frame. Lariam, for example, needs to be taken several weeks in advance.
Phil, thanks for the excellent information. All three topics you covered are important ones for the international traveler.
Malaria prophylaxis is extremely important for travelers to endemic areas, especially where P. falciparum is present. Around 1,400 people are diagnosed with malaria in the US every year, and almost all did not take prophylactic meds while traveling abroad.
The rabies vaccine was not generally recommended except for travelers who would be handling animals or caving (due to the high risk of bat exposure). However, this thinking is changing and now many travel docs are recommending this vaccine more frequently. Remember, while the most common vector for rabies in the US is bats, in Africa it’s unvaccinated dogs.
For Travelers’ Diarrhea, the only thing I would mention is that two doses of cipro twelve hours apart is enough to wipe out the illness in most cases.
Thanks for the great article. Keep up the good work. Love your website.
PS- Here’s a link to an article on malaria that some might find helpful:
http://journals.lww.com/smajournalonline/Fulltext/2005/12000/Malaria-Primer-for-Clinicians-in-the-United-States.12.aspx#
WEll researched and brilliantly argued. Certainly some great points for discussion.
Personally, as others have said, it is personal choice and horses for courses when it comes to illness prevention but there are side effects thyat have to be weighed up when deciding.
Hi Phil, Thats a very insightful article which removes some of the things that people take for granted. For example very few people actually knew that there are various strains of plasmodium in different regions and that you need to talk to a doctor about the effective prophylactic medication.
In short, would you say the travellers diarrhoea is entirely caused by bacteria or can change of diet and even cooking ingredients result to the same. In which case the traveller would resort back to their normal self once they get home?
Hi Phil, I think it’s a good thing to bring these items under people’s attention every now and then.
I will be taking Malarone to the wildparks in South Africa next month. It’s the only tablet my insurance covers, but would have chosen it otherwise as well. Have also taken the rabies shots, even though these were the only shots my insurance did not cover. I will spend part of my trip in remoter areas, and will be working with animals as well. Just thought the risk too high not to take them.