In our last edition we looked at the threat of malaria and attempts to control it. We stressed the need for travellers to Africa to be well informed beforehand. In part two Sue Walmsley focuses on practical advice for prevention.

Each year 2000 people return to the UK with malaria. Some die, and those who survive the agonies of sweats, shivers and splitting headaches will tell you they will gladly pay anything to avoid going down with the disease again.

However, by following sound advice you can cut the risks to virtually nothing. Countless numbers of visitors to Africa protect themselves against malaria every year by following a few simple guidelines:

1. Know the risks.

When planning your trip contact an organisation such as the British Airways Travel Clinic or the Medical Advisory Services for Travellers Abroad (MASTA), a database validated by the London School of Hygiene and Tropical Medicine. They will provide a comprehensive report on all health risks in the individual countries you plan to visit.

MASTA classifies Africa as Zone C, denoting high risk of transmission. By comparison India is Zone B. However, the World Health Organisation (WHO) points out that Africa is a big place and that there are local variations. Malaria is also highly seasonal.

MASTA categorises Kenya, Tanzania and Malawi as high-risk areas. It also indicates chloroquine resistance in those three countries, as well as in Zimbabwe and South Africa. So obtain local information to find out about the risks you face.

2. Get expert medical advice - early.

All travellers should consult their general practitioner about three months before departure. He will follow WHO guidelines regarding the prophylactic regime to prescribe and give guidance on side-effects and symptoms of malaria.

A Bristol doctor stressed that travellers must take more responsibility for their own health by being as accurate as possible about their itinerary: "I would start by asking my patients what type of holiday they were planning. If they were going backpacking, the advice I would give them would be different to that if they were going on a luxury cruise," he said.

It is particularly important to fully understand and be able to recognise the early symptoms of malaria. Get your doctor's advice on this. Travellers who ask their tour operator or travel agent for guidance on the subject should not be surprised to be referred to specialist advisors. There is at least one case on record of a tour operator being sued after recommending a particular prophylactic that was not effective.

3. Take the right prophylactic.

Both the WHO and MASTA are unequivocal in their recommendations for African travel; mefloquine (Lariam) is the first choice of drug, with proguanil (Paludrine) and chloroquine (Nivoquine/Avloclor) as the second option. As a cure for malaria, MASTA recommends treatment with quinine sulphate and Fansidar.

This whole-hearted support for Lariam may surprise those who have been following the worldwide debate over allegations of its harmful side-effects. These range from nausea, insomnia, bad dreams and depression to panic attacks and suicidal tendencies.

The Bristol doctor said he would make sure people were aware of the potential side effects but stressed that, in some parts of Africa, the increase in chloroquine resistance means Lariam is the only effective prophylactic.

Further support for Lariam comes from Dr. Alan Spira of the Travel Medicine Centre in Beverly Hills, USA. His paper "Malaria and the Lariam controversy" claims that "the risk of serious neuropsychiatric side-effects are approximately one in 13,000 - the same as that of chloroquine, which has been used for decades. Aspirin has a 7% rate of adverse drug reactions, which is above that of Lariam, yet no-one sensationalises the dangers of Aspirin," he said.

MASTA states that one in 140 people can experience unpleasant side-effects usually occuring within the first two or three doses.

The price of prophylactics in the UK varies depending on the product, which dispensary makes up the prescription and whether you are eligible for free medication under the National Health Service.

Mr Joel Hirst, a pharmacist with the Bristol-based group Pharmacy Plus said Lariam was only available on private prescription and would cost about 25 for eight tablets. You need to take one tablet per week two weeks prior to departure, one a week while on holiday and one a week for four weeks after returning home.

If you were buying Avloclor and Paludrine, the combination of tablets required would be about 16 for a two-week holiday. These prophylactics are available without a doctor's prescription. However, Mr Hirst stressed that anyone buying over the counter should read the instructions carefully and take the full course.

Another prophylactic which is marketed in the UK under the brand names of Maloprim and Malosone is available only on private prescription at just 6. In Zimbabwe it is known as Deltaprim and is recommended by many local doctors and pharmacists. The drug has been championed by Bulawayo, Zimbabwe, pharmacist Mr Peter Rollason who has battled for years to get it reinstated after the National Pharmaceutical Association removed it from the British National Formulary. Questions about the drug's main ingredients arose over 20 years ago when it reportedly resuld in the death of a user. Studies later showed the death was probably due to an overdose but the drug still remains blacklisted.

At one of the many international conferences he has addressed on the subject, Mr Rollason has described Deltaprim as "ideally suited" to Zimbabwe's conditions. "Far too many visitors are spending more money than necessary on drugs which aren't as appropriate as Deltaprim," he has advised.

Whilst Deltaprim is recommended for Zimbabwe, Chloroquine and udrine are generally preferred in South Africa. Such regional variations stress the need for expert guidance.

In addition to malaria prophylactics, vaccinations for diseases such as typhoid, cholera and yellow fever may be recommended depending on your African destination. It is also not unusual for a malaria prophylatic prescription to be accompanied by one for Hepatitis. Some vaccinations are free, such as polio, tetanus and diptheria while others such as yellow fever cost about 21 which is payable at your doctor's surgery.

Both WHO and MASTA are unanimous in stressing that no prophylactic is 100% effective, so the best way to avoid malaria is by not getting bitten.

4. Cover exposed skin after dusk.

Long-sleeved shirts with button collars and cuffs and slacks are recommended. Mosquitos are particularly attracted to feet and ankles so both should be well covered.

5. Use a repellant.

Repellents may be purchased as a cream, in stick form or as an aerosol spray. They should be used on all exposed skin, but must be applied carefully to the face. It is a good idea to follow makers' recommendations and test for skin sensitivity before use.

6. Sleep behind screens.

If your room or tent has good screens these may be sufficient, provided that the enclosed space and all hidden areas are sprayed and the room kept shut for some time before retiring. An impregnated bed net may be even safer as long as the enclosed space is sprayed and the edges well tucked in under the mattress.

7. Use a deterrent.

Mosquitos do not like a strong current of moving air so overhead fans and air conditioning can deter them. Vapour pads can also be effective, but they too depend upon the availability of electricity. Smoke coils don't need a power source but like vapour pads, require relatively still air for the fumes to circulate fully. It is therefore unwise to rely solely on such deterrents.

8. Act on any possible symptoms.

Symptoms are fever, shivering, aching joints and headaches. At the slightest suspicion consult a doctor as early treatment could greatly reduce the possibility of more serious consequences.

There are encouraging reports from the USA, where the military has developed the first vaccine against malaria. Scientists at the Walter Reed Army Medical Centre have begun small field trials of the vaccine in Gambia. If this proves effective it will have far-reaching implications in the fight to eradicate malaria worldwide.

Bristol-based Sue Walmsley worked in southern Africa for three years without contracting malaria. For their assistance in compiling this article, Travel Africa wishes to thank Dr Shiva Murgasampillay of the WHO African Region, the London School of Hygiene and Tropical Medicine, and Violette Kee-Tui, reporting from Zimbabwe. For details of your nearest British Airways Travel Clinic call (01276) 685040; MASTA can be reached on (0891) 224100.

READER'S EXPERIENCE

"We have been to Kenya four times. In 1993 I was prescribed Lariam, which cost £33. I was ill and lost half a stone in one morning. Suffered mild diarrhoea and vomitting after each tablet. In 1997 I took Avlocor and Paludrine. One week after returning I was severely ill with malaria, with one week in hospital. My husband used Lariam for three visit with no side-effects." - Ann Green, Cheshire

"In May 1996 my wife and I undertook a canoeing safari on the Zambezi. We both took anti-malarial tablets as prescribed by our doctors. I took Lariam (20 for eight tablets) and my wife took a combination of Chloroquin and Malaprin. In November I became quite ill - headaches, intense shivering, fever and aching joints. I informed my health centre about the Zambezi trip but this was discounted because of the time lapse. My condition worsened and after three weeks blood samples showed serious anaemia but revealed no evidence of the malarial parasite. The anaemia gradually improved but I was off work for six weeks. I was not referred to the Tropical Diseases Hospital and it was only after several weeks that my doctor seemed to take seriously the possibility of malaria. I am sure that greater awareness of malaria on the part of my health centre may have diagnosed my condition earlier and perhaps my treatment would have been more appropriate."

- The Revd Alec Brown, Cheshire

Published in Travel Africa Edition Two: Winter 1997/8.Text is subject to Worldwide Copyright (c)