I simply want to add from personal experience that Larium (Mefloquine) gave me major psychiatric problems, but in 1992 when I took it, no one knew that it would have an effect on those who suffer from depression. So if you do suffer from depression or take SSRIs, Larium is a definite no-no.

My son is working for an NGO in Ethiopia at present and has been there for 5 months and returns in a month's time. He has to take an antimalarial for a longer course of treatment than many of you holiday makers, and this is the advice from the Tropical Medicine Department at the University Hospital of Mulhouse (France).

Up to a month's stay, Larium.
Up to two months' stay, Malarone
Up to six months stay, Doxycycline.

He is a water engineer and has had to work at the cholera outbreak area of Moyale on the Kenyan/Ethiopian border, and was glad that he's taking Doxycycline because it's the antibiotic of choice to treat cholera!

Whichever medicine you chose, please remember to take it regularly when you are out there and to continue and finish the course once you return home. Bon voyage!!

Lariam can have serious psychiatric effects in otherwise "normal" people. I've seen it happen; I get the impression that such side effects are much more common than is reported in "official" documents. It also stays in your system for several weeks, so if it makes you go nuts, you are $%#@ed.

I don't get these recommendations. Lariam's pre and post-travel requirements (sometimes a month or more) seem to make it suboptimal for short term use.

Doxycycline can have some nasty side-effects (sun sensitivity, GI problems, etc.).

IME (I am not an MD), Malarone has the fewest side effects and can be stopped if you get serious side effects. Malarone and doxycycline must be taken daily (verus weekly for mefloquine), but that's no big deal.

There's always the option of taking nothing, taking precautions not to get bitten, and then treating any suspected infection (make sure to have at least a full treatment regimen with you). That's a discussion that one should probably have with a travel medicine specialist.

Aside from the usual headache, nausea, etc. mefloquine's side effects can range from nothing (my experience) to violent dreams, anxiety, irritability, aggressive behavior (a friend had those 4) to psychosis, seizures, and delirium.

http://www.fda.gov/cder/foi/label/20...lbl_Lariam.pdf

I'm no expert, but I always thought that one needed to consider side effects and region (some strains of malaria are better prevented with different medicines), not so much length of stay.

Makes sense, though I believe Malarone and Doxycycline are supposedly good for prophylaxis of all strains of malaria. The other drugs are more limited.

Lots of info here: http://www.cdc.gov/malaria/travel/drugs_hcp.htm

Yes, I think that is correct (again, Im not an MD). Before traveling to such far and distant places I do consult with an infectious disease specialist who has a travel medicine practice in addition to their regular practice. On the more recent trips they have given me Malarone which I seem to tolerate well. Mrs GF is allergic to it unfortunately. With Malarone he told me that it would prevent vivax malaria and keep me from dying from falcipirum malaria. While in Zambia a few years ago I got very ill from what turned out to be food poisoning. But for a while as we were on the phone with doctors in Jo'burg and Philly they were concerned I had falcipirum malaria even though I was on the Malarone. That would be consistent with what my local doc told me (they have both types in Zambia).

FWIW, both my wife and I took mefloquine for our last trip, and neither one of us had any problems with it. But it definitely has an eye-opening list of side effects that are possible (although they're supposedly more common in the dosage levels to treat malaria, rather than preventative). I'm not sure if the side effects are really more common than the official numbers as ralfp thinks, or whether it's just that you hear about them more because of the nature of the side effects. I'll have to admit though that at the time I was debating whether I really wanted to take it, especially since the area we were travelling in we probably didn't *really* need it, but I'm glad to know that we seem to tolerate it, because we'll need something again for a future trip.

Actually, I know several people who had non-trivial (but not severe) reactions to Lariam, though I don't recall having any problems with it (I've taken it twice, each time for about 8 weeks). Small sample size -> not statistically significant.

From a google search: in one study "Neuropsychiatric adverse events were found in 29% of the subjects, with 19% being considered "moderate or severe." On the other hand, the Army claims rates of 1 in 2,000 to 1 in 30,000 (PDF)

As far as I can see, the only benefit of Lariam over Malarone, excluding cost and any specific contraindications, is the once weekly (vs. once daily) dosing.

One other is that Larium/mefloquine is still indicated for mothers nursing young infants (in chloroquine-resistant areas) while there is insufficient data on Malarone/atovaquone+proguanil excretion in breastmilk to recommend its use currently:

http://wwwn.cdc.gov/travel/yellowBoo...laria.aspx#647

Just to clarify, the schedule for the drugs I mentioned relates to those going to work/stay in an infected area, and do not cover the pre-post drug taking periods.

And there will always be folk who don't fall within the statistics quoted - even more proof that statistics are not always to be believed!!

Just a comment to those who consider buying meds in the country they are visiting or off the internet, please make sure that your source of supply is reliable, because medication counterfeiting is big business .............

One more item to note on Malarone. I had a trip to Singapore not too long ago and I didn't plan on heading down to Indonesia, but ended up going to Bintan - where I got bit by a mosquito. My travel doc suggested that I take a course of Malarone even though I was back in the States the very next day. She said that Malarone is not approved for after exposure, but that it can sometimes help.

For what it's worth, I did not contract malaria - but of course I can't confirm it that was because of the Malarone or not. YMMV

Many expats have died from Malaria in East Africa - I know first hand because I lived there for several years. The deadliest strains of malaria are found in East Africa.

Malaria has to be visually diagnosed by mircoscope by a lab technician/doctor - and in its initial stages can be very hard to impossible to detect. Many health centers have badly trained professionals on staff. Imagine being a days travel from a proper health facility.

FWIW - Some large African cities (e.g. Nairobi) have a little to no Malaria because it isn't typically found at higher altitudes.

I never used anything (and traveled to very remote places) but was always very careful about using bednets/deet and knew what signs to look for/was prepped.

With proper precautions you have little to worry about though. In short: take Malarone.

Most of the above posters have good points, and each traveler's situation is different, hence the excellent advice to consult with a travel medicine specialist prior to travel, even if you choose not to take prophylaxis.

I'm a family physician, have studied travel medicine, and I've done a lot of volunteer medical aid work overseas, but for most US-based physicians (myself included) the tropical diseases are so rare it's difficult to keep current in that field. Even the best lab can miss malaria on a blood smear because it is so rare.

The various medications have differing side effects, allergy profiles, and interactions with other medications the patient may be taking. Patients with impaired kidney or liver function need dosage adjustments or different meds. Nursing moms, babies and children, people with psychiatric history or history of seizure disorders all need consideration in deciding on the best treatment. Where you will travel, how long, and the nature of your activities factor into the decision. All very individualized, so I can't make any blanket recommendations.

Two very important points:

Prevention is better than prophylaxis and treatment - use DEET, wear longs sleeves, etc - though I favor prophylaxis too.

Almost all the malaria deaths in the US are in people who were not timely diagnosed, usually due to failure to mention their travel history (and failure of the doc to ask), so the possibility of malaria was not considered. TELL your doctor! Usually, these patients did not take prophylaxis either, but even if you do take the medications, they are not 100% protective. Therefore, IMHO, any traveler returning from a malarious area who presents with fever should be considered to have malaria until proven otherwise.

Personally, I take Lariam (mefloquine) starting one week before travel and persisting for 4 weeks after return. I buy artisinate overseas in case I do contract falciparum malaria, as it is difficult to impossible to obtain it in the US, and time is of the essence in successful treatment.

As pointed out above, malaria (and TB too) are far and away the numbers 1 and 2 killer diseases worldwide, so take it seriously. I've treated hundreds of malaria cases (all overseas, none in the US) and seen more than a few deaths from the disease.

That second part is important. Don't trust a GP (or any other MD) without experience in these matters to prescribe appropriate malaria prophylaxis (or other travel-related meds). I've been given incorrect drugs even after visiting a doc specifically for a trip. I had to correct the MD and tell her that her source of info was incorrect.

I pay for a subscription medical information service that I can check online or loaded on my smartphone. Even having studied travel medicine, it changes too quickly to memorize, and new alerts arise in different areas almost daily. I rarely advise or prescribe for an individual patient without checking these resources first - or preferably with the patient, in the exam room, on my laptop.

Actually, that's good advice for many other areas of medicine too - not just travel medicine...