Is there Malaria in South Africa?

Yes

Malaria is endemic in certain areas of South Africa

Through good malaria control efforts, the disease is now restricted to certain districts in three provinces; namely the north-eastern KwaZulu-Natal, parts of Mpumulanga and Limpopo. These areas have conditions that are suitable for malaria transmission.

Malaria occurs mainly in low altitude areas but occasionally has been found in high altitude areas within these provinces. On rare occasions malaria is contracted near the Molopo river in the North-West Province and Orange River in the Northern Cape Province (Department of Health, 2009)

It is a seasonal disease. Low transmission periods are between May and September.

Will I see mosquitoes while I'm in South Africa?

Yes.

However, not all mosquitoes carry the malaria parasite.

The mosquitoes which do carry the malaria parasite belong to the anopheles group. The mosquitoes which carry the parasites in malaria endemic areas generally bite between dusk and dawn.

Remember the "ABC" of Malaria prevention

1. Awareness – be aware of the risk
2. Bite prevention – avoid being bitten by mosquitoes, take the necessary precautions
3. Chemoprophylaxis – use prophylaxis to protect yourself against malaria when necessary
4. Diagnosis - insist on diagnostic tests if fever develops a week or more after exposure to malaria
5. Effective – malaria treatments are available and it is important to get the appropriate treatment specific to your circumstances

A: Awareness of malaria risk: what is my risk of getting malaria in South Africa?

Malaria risk is not evenly distributed within South Africa.The risk of being bitten with an infected mosquito depends on the time of year you are travelling, where you are travelling to, if you will be in the area between dusk and dawn, and if you are in a high risk group (refer to Table 1).  Table 1 provides information on the malaria risk in South Africa and the recommended precautions

Table 1: Summary of malaria risk periods and recommended precautions

What is my risk of getting malaria in countries neighbouring South Africa?

According to the World Health Organisation, the malaria situation in countries neighbouring South Africa is listed below (WHO, 2012).

Table 2: Malaria risk in countries neighbouring South Africa

B: Avoid mosquito bites: what precautions can I take when entering a malaria endemic area?

These are some of the precautionary measures you can take to avoid being bitten by mosquitoes:

• Mosquitoes which carry malaria generally bite between dusk and dawn.
• Close windows and doors and remain indoors during this time.
• Use insect repellent on exposed skin. Lotions and spray options are available.
• Spray your accommodation with an aerosol insecticide.
• Wear long-sleeved, light-coloured clothing, long trousers and socks.
• Sleep under a bednet (preferably impregnated with an approved insecticide) or in a netted tent or use screens to prevent mosquitoes from flying in.

C: Compliance with Chemoprophylaxis, when indicated: what should I do about chemoprophylaxis?

Chemoprophlyaxis are medicines which help to reduce the chances of getting ill with malaria. These medicines must be taken according to the instructions given by your local medical practitioner/pharmacist.

• If a person travels to a malaria area, it is important to find out if they require chemoprophylaxis
• Chemoprophylaxis should be used in conjunction with personal protection measures against mosquito bites.
• There are different types of chemoprophylaxis available which have different modes of action. The choice of drug to take should be tailored to the individual (South African Department of Health, 2009; Baker, 2009).
• You should always consult your local travel doctor or general practitioner for advice on chemoprophylaxis well in advance before travelling. The South African Department of Health has listed the available chemoprophylaxis in their Guidelines for the Prevention of malaria in South Africa (Department of Health (2009) Guidelines for the Prevention of Malaria in South Africa). These include mefloquine, doxycycline and atovaquone-proguanil. See guidelines for information on how to take these medicines.

D: Early Detection of malaria

Malaria symptoms may only develop 10-14 days after an infective mosquito bite.

• If a person has taken chemoprophylaxis, this period might be even longer. This can reduce suspicion of malaria to the detriment of the patient, especially as many people believe that prophylaxis is a guarantee against malaria.
• Non-specific flu-like symptoms are common presenting symptoms of malaria. Some of these include: fever, rigors, headache, sweating, fatigue, myalgia (back and limbs), abdominal pain, diarrhoea, appetite loss, nausea and vomiting, cough. In young children, malaria may present with fever, lethargy, poor feeding and vomiting.
• You should seek immediate medical attention if you have flu-like symptoms for up to six months after visiting a malaria area.

E: Effective treatment

There are drugs to treat malaria and it must be treated as a medical emergency. A high index of suspicion must be practiced. High-level resistance precludes the use of chloroquine for falciparum malaria (Department of Health, 2009).

• If you have flu-like symptoms, inform your doctor that you have visited a malaria area, so that prompt diagnosis can be made.
• Stand- by treatment: If you are planning on travelling to remote locations outside South Africa where there is limited access to proper medical care, the World Health Organisation advises carrying appropriate malaria treatment medication for self-administration (WHO, 2010).This is called stand-by emergency treatment. You should consult your medical doctor about this.

Malaria treatment in South Africa

Malaria is a notifiable disease in South Africa. According to the South African Department of Health (2009), the current recommended treatment for uncomplicated malaria in South Africa (Department of Health, 2009) is as follows:

• For patients over one year of age and non-pregnant patients: fixed dose artemisinin-based combination, artemether + lumefantrine. If artemeter + lumefantine is not available, quinine + doxycycline is recommended while patients are under observation;
• For children ≤ 1 year and all pregnant patients: quinine + clindamycin.

References

• Department of Health (2009) Guidelines for the treatment of malaria in South Africa. Click here http://www.doh.gov.za/docs/factsheets/guidelines/malaria/treatment/2009guidelines-a.pdf
• Department of Health (2009) Guidelines for the Prevention of malaria in South Africa http://www.doh.gov.za/docs/factsheets/guidelines/prevention_malaria09.pdf
• Department of Health (2007) Travel Health Information Booklet for Travellers within South Africa
• Baker, L. (2009) Malaria Prophylaxis: make the right choice for travelers with special circumstances. South Afr J Epidemiol Infect. 24 (4). http://www.sajei.co.za/SAJEI/article/view/193/212
• Blumberg, L. (2010) The 2010 FIFA World Cup: Communicable disease risks and advice for visitors to South Africa. Journal of Travel Medicine.17 (3). 150-152 http://dx.doi.org/10.1111/j.1708-8305.2010.00413.x
• World Health Organisation. International Travel Health (2012)

Common Myths

"It is better not to take any prophylaxis, as it masks the symptoms and makes diagnosis difficult"

This is incorrect. Prophylactic drugs suppress parasite development, and therefore, even if not totally effective (due to partial drug resistance or non-compliance), symptoms tend to take longer to appear, may be less severe at first and development of complications is retarded. In the complete absence of drugs, parasites are able to multiply at phenomenal rates, and malaria can quickly progress, and lead to severe complications and death.

"There is this new deadly strain of malaria"

Cerebral malaria is not a new strain; it is a complication of untreated P. falciparum malaria. Early diagnosis and appropriate treatment should ensure that no one gets cerebral malaria.

"Malaria cannot be cured"

Malaria can indeed be cured with the appropriate drugs. Due to drug resistance to certain drugs, it is important to use the recommended drugs for the specific area.

Also, because most common drugs only deal with the blood and not the liver stages of the disease, the two malaria species that have dormant liver stages (vivax and ovale) may relapse. If the parasite species is not identified correctly, or if there were two species present in the blood, of which one was missed, malaria can recur, sometimes many months later. However, once the species has been correctly identified, the liver stage can be successfully treated with primaquine.

"Prophylaxis need only be taken while in a malaria area"

The drugs that we have to prevent malaria are known as blood schizontocides, which means that they work on the parasite once it enters the red blood cells. This does not occur until 10-14 days after being bitten by an infected mosquito. If the drug is stopped before the parasites reach the blood cells, there will not be enough in the blood to kill the parasites and the prophylaxis will fail. It is therefore extremely important to continue taking prophylaxis for four weeks after leaving a malaria area. Atovaquone-proguanil is an exception in that it acts primarily on the tissue stage and therefore one needs only to continue the course for seven days after leaving the area"The drugs are worse than the disease"

Antimalarials, like any other drug, do have side effects in some people, and in varying degrees. However only 15-20% of people experience side effects, and these are usually tolerable, with severe adverse reactions being rare. Malaria is potentially fatal and causes severe illness and discomfort which could land you in hospital and out of action for weeks.

"If I take an antimalarial, there will be nothing left to treat me if I do get malaria"

There are numerous different drugs and drug regimes available for the fast and effective treatment of malaria. The use of one chemoprophylactic, does not exclude the future use of another antimalarial should the need arise.

"I will be visiting the area outside of the malaria season, so I do not need prophylaxis"

Although transmission decreases during the "off" season, infective mosquitoes may still be active in the off season, just in lower concentrations. One still needs to take protective measures aginst mosquito bites, but not necessarily chemoprophylaxis.

"Drinking Gin and Tonic or Rum will prevent mosquitoes from biting me, and will safeguard me against contracting malaria"

There is no scientific evidence that either will protect you against mosquito bites. Malaria is a potentially fatal disease that requires proper preventative measures to be implemented.

"I wasn't bitten, can I stop taking my prophylaxis?"

The female Anopheles mosquito is not known as 'the silent killer' for nothing. She does not buzz around your head at night, irritating you. You may not be aware of her presence at all. The reaction to her bite may also not be as pronounced as it is with other bloodsucking insects and you may be unaware of having been bitten.

This guide, updated in October 2013, has been prepared by the Malaria Research Programme, of the Medical Research Council in South Africa.

Disclaimer: The information is provided to inform you about the malaria situation in South Africa. We do not offer clinical advice in this guide and you should always consult your travel doctor for travel related medical advice specific to your needs. (Updated May 2010)