The Practice Nurse at Stockbridge Blue Practice in Edinburgh, Scotland, (twinned with Ndirande in Blantyre, Malawi) regularly gives malaria prevention advice to patients travelling to malaria high-risk countries. Twinning Project team member, Jemma, consulted Amiko Hippisley before visiting Malawi in November. In this post, Amiko reviews routine procedure.
“Regarding our antimalarial advice we give to patients, I’ve learned as I’ve gone along but also use the Travax Travel health web-site for professionals (www.travax.scot.nhs.uk), which is done by SCIEH, based in Glasgow and updated daily (you need an ID & password). Their sister travel web-site for the public is www.fitfortravel.scot.nhs.uk, which I give out to patients. They are easy to use, with an A-Z index, so you click on the country and then click on ‘malaria map’ which gives a key guide, as antimalarial prophylaxis can vary within a country, depending on which region. www.malariahotspots.co.uk is also a very useful and easy to use web-site for the public & health professionals.
Our patients fill out a travel form prior to their appointment and they get a single, double or triple appointment, depending on how many vaccines they need and how many countries they’re visiting for antimalarial advice and prescription. The PN goes through the patient’s notes and computer records to see what vaccines they’re up-to-date with and which ones or boosters they need, prior to seeing the patient. I have Travax up on the screen during the consultation, as it’s better for the patient to visualise the country & malarious areas for their travels.
If they only need OTC (over the counter) tablets – chloroquine (daily) and/or proguanil (weekly), they are advised to buy them from the chemist. They don’t need to remember the name/s, as the pharmacist will know what tablets are required. I advise that proguanil can cause some patients to feel a bit nauseous but that’s better than contracting malaria. If they need a private prescription, which we charge £14.00 for (prescription & admin charge), we write them out for the patient but the GP signs it. They are advised of the ‘double charge’, as the patient then needs to buy the tablets from the chemist also.
The OTC tablets are not effective in areas where the private tablets are required but the private tablets will also work in the areas where OTC tablets are needed. This is due to the malaria resistance in the mosquitos in the milder areas.
The 3 choices of private tablets are:-
1. Malarone (atovaquone/proguanil), which is the most favoured because it has the least side-effects and is needed for a much shorter time. It is a daily tablet, that is taken from 1-2 days before entry in to the malarious area, daily whilst there & then for a week after leaving the area. They are the most expensive option. Cost ~£1.60 per tablet. It is the newest tablet to the market but has been out many years now. Licensed for 36 days but can be prescribed for up to 6 months, if required.
2. Doxycycline 100 mg tablet. Also daily but taken from about a week before, during and for a month after. The benefit is that it is a broad spectrum antibiotic but has the side-effect of interfering with the pill and also causes skin photosensitivity. High SPF is advised. It can aalso cause oesophagitis/gastritis in some cases, so needs to be taken with a good amount of food or after meals! Prices for this one vary a lot from chemist to chemist, so it’s worth shopping around! Licensed for 3 months but can be prescribed for much longer.
3. Mefloquine/Lariam. This costs about the same as malarone but is a weekly tablet, so works out a lot cheaper. It potentially has the worst side-effects (neuro-psychiatric) and there’s a lot of scare-mongering about it but it only affects about 15% of people. Can be prescribed long-term.
When prescribing these, we need to take in to account things like allergy to certain components of the tablets, epilepsy, contraception use, pregnancy, mental history, other medical conditions, etc. We always have to be on our toes so as not to make a mistake.
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