Malaria prevention and prophylaxis

Malaria prevention and prophylaxis

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DAN receives many inquiries from members regarding malaria. Indeed malaria has become an increasing problem due to drug resistance. As divers venture deeper into the African tropics they incur increasing risk of contracting malaria. Lack of medical facilities, transportation and communication add additional complexity to managing this medical emergency.

Three DAN members have required evacuation by air over the last three years due to malaria. Understanding malaria prophylaxis and general preventative measures is therefore of the utmost importance. The following section covers the most important considerations in selecting and using malaria prophylactic measures and medications. The treatment of malaria, which is complex and requires close medical supervision, falls outside the scope of this document.

The three commandments of malaria prevention and survival are:
1. Do not get bitten
2. Seek immediate medical attention if you suspect malaria
3. Take “the pill” (anti-malaria tablets/propftylaxis)

Do not get bitten

  • Stay indoors from dusk to dawn
  • If you have to be outside between dusk and dawn – cover up: long sleeves, trousers, socks, shoes (90% of mosquito bites occur below the knee)
  • Apply DEET containing insect-repellent to all exposed areas of skin, repeat four-hourly
  • Sleep in mosquito-proof accommodation: Air-conditioned, proper mosquito gauze, buildings/tents treated with pyrethrum-based insect repellent/insecticide
  • Burn mosquito coils/mats
  • Sleep under an insecticide impregnated (Permacote®/Peripel®) mosquito net (very effective)

Seek immediate medical attention if you suspect malaria

  • Any flu-like illness starting 7 days or more after entering a malaria endemic area is malaria until proven otherwise
  • The diagnosis is made on a blood smear or with an ICT finger prick test
  • One negative smear/ICT does NOT exclude the diagnosis (repeat smear/ICT diagnosis is made, another illness is diagnosed or the patient recovers spontaneously – i.e. from ordinary influenza)

Take “the pill”

There are several dangerous myths regarding malaria prophylaxis:

  • Prophylaxis does not make the diagnosis more difficult
  • It does protect against the development of cerebral malaria
  • Is not 100% effective – hence the importance of avoiding bites
  • Not all anti-malaria medication is safe for diving
  • Malaria is often fatal – making prophylaxis justified
  • Anti-malaria drugs, like all drugs, have potential side-effects, but the majority of side-effects decrease with time
  • Serious side-effects are rare and can be avoided by careful selection of a tablet or combination of tablets to suit your requirements (Country, region and season)

The following drugs are available for the prevention of malaria:

Doxycycline (Vibramycin® or Cyclido or Doryx®)

Used extensively in the prevention of Chloroquine resistant malaria. About 99% effective. Not officially recommended for use in excess of 8 weeks for malaria prevention, but it has been used for as long as three years with no reported adverse side effects. Offers simultaneous protection against tick-bite fever.

Dosage: 100mg after a meal daily starting 1 to 2 days before exposure until 4 weeks after exposure. Doxycycline should be taken with plenty of non-alcholic liquid.

Side effects: nausea, vomiting, diarrhoea, allergy, photosensitisation. May cause vaginal thrush infections and reduces the efficacy of oral contraceptives.

Use in pregnancy: unsafe (as is scuba diving). Also, avoid during breast feeding and in children younger than 8 years of age.

Doxycycline is DAN’s first choice recommendation for divers in areas with choloquine resistance/”resistant malaria”.

Chloroquine (Nivaquine ® or Daramal ® or Plasmaquine ®):

Contains only chloroquine. Must be taken in combination with Proguanil (Paludrine ®)

Dosage: 2 tablets weekly starting one week before exposure until 4 weeks after leaving the endemic area Contra-indications: known allergy, epilepsy

Side effects: headache, nausea & vomiting, diarrhoea, rashes, may cause photosensitivity (sunburn – prevention, apply sun block)

Use in pregnancy: safe (note scuba diving is not considered safe during pregnancy)

Proguanil (Paludrine®)

Must be taken in combination with chloroquine (Nivaquine® or Daramal® or Plasmaquine®) Dosage: 2 tablets every day starting one week prior to exposure until 4 weeks after

Contra-indications: known allergy to Proguanil. Interactions with Warfarin (an anti-coagulant incompatible with diving)

Side-effects: heartburn (tip: take after a meal, with a glass of water and do not lie down shortly after taking Proguanil) mouth ulcers (tip: take folic acid tablets 5mg per day if this occurs) loose stools (self-limiting – no treatment required)

Use in pregnancy: safe but must be taken with folic acid supplement. 5mg per day (note scuba diving is not considered safe during pregnancy)

The combination of chloroquine & Proguanil is about 65% effective falciparum malaria. Although not a first choice, its relative safety and limited side effects may justify its use in certain individuals.

Atovaquone / Proguanil (Malarone ® ; Malanil ®)

Registered in South African as a causal prophylaxis in February 2004. Safety in diving has not been established. Preliminary data suggests it may be safe for pilot and divers.

Effective against Malaria isolates that are resistant to other drugs.

Controlled studies have shown a 98% overall efficacy of Atovaquone / Proguanil in the prevention of P. falciparum malaria

Dosage: 1 Tablet daily for adults, starting 24 – 48 hours prior to arrival in endemic area, during exposure in endemic areas and for 7 days after leaving the endemic area only.

Dose should be taken at the same time each day with food or a milky drink.

Contra-indications: Known allergy to Proguanil or Atovaquone or renal impairment (i.e., significant renal disease is likely to be incompatible with diving). Safety in children < 11kg has not been established.

Side-effects: Heartburn (Tip: Take after a meal, with a glass of water & do not lie down shortly after taking Proguanil); mouth ulcers. To date Atovaquone has been well tolerated and the most common adverse reaction being headache.

Use in Pregnancy: Safety in pregnancy and lactating women has not been established. (Note: SCUBA diving is not considered safe during pregnancy)

The safety of Malanil has not been confirmed in diving. Accordingly, even though preliminary data suggests that it may be safe, we are not able to recommend it. Doxycycline remains the first choice for divers diving in Africa where there is resistance to chloroquine.

Mefloquine (Lariam® or Mefliam®)

About 90% effective Dosage: one tablet per week.

Side effects: may cause drowsiness, vertigo, joint aches and interfere with fine motor co- ordination (making it difficult to exclude DCI in some cases)

Pregnancy: probably safe in early pregnancy and may be used with confidence after the first trimester of pregnancy. May be used in breast feeding and babies weighing more than 5kg.

Mefloquine is considered unsafe for divers and pilots. It is contra-indicated in epilepsy but us a good first choice for other travellers

Pyrimethamine/Dapasone (Maloprim® or Deltaprim®/Malzone®)

No longer regarded as effective but still recommended in Zimbabwe

Sulfadoxine and Pyrimethamine (Fansidar®)

No longer used as a prophylactic.

Quinine (Lennon-Quinine Sulphate®)

Not used for prophylaxis but is the backbone in the treatment of moderate and severe malaria. Serious side-effects are not uncommon during treatment.

Arthemeter (Cotexin®)

fte “Chinese drug”. Available in some areas of Africa. Not for prophylaxis. Used in combination with other drugs in the treatment of mild to moderate malaria.

Halofantrine (Halfan)

Not used for prophylaxis and best avoided for treatment.

Recommended malaria drug prophylaxis in DAN Southern African region (Africa and Indian Ocean islands)

malaria

* In situations where the risk of contracting malaria is low, (e.g. in cities, air conditioned hotel or when rainfall has been low, etc.) the traveller may be advised to take no drug prophylaxis but stand-by treatment mus t be carried unless medical care is readily available. Personal protection against bites must be adhered to at ALL TIMES.

# high risk people include babies and children under 5 years, pregnant woman, elderly people (and greater than 65 years), people with suppressed immunity (e.g. diabeties, etc)

Notes:

  1. The above mentioned recommendations were compiled from material supplied by the National Department of Health and Worldwide Travel Medical Consultants.Prohpylaxis significantly reduces the incidence of malaria and slows the onset of serious symptoms of malaria
  2. All anti-malaria drugs excluding Mefloquine are considered compatible with diving
  3. Like with all other medications, anti-malaria drugs should be tried and tested on land well in advance
  4. If unpleasant side-effects occur, please consult your diving doctor
  5. Whether or not you take prophylaxis, be paranoid about malerial Malaria can presrnt in many ways varying from fever or diarrhoea to flu-like symptoms. Always inform your doctor that you have been in a malaria area. Symptoms can start within 7 to 14 days from first exposure until 30 days (and rarely even months) after leaving a malaria area.
  6. No single medication is 100% effective and barrier mechanisms (personal protection against bites e.g. mosquito repellents, nets, protective clothing, not going outdoors from dusk to dawn) must be
  7. Any strange symptom occurring during or within 6 weeks of leaving a malaria area should be regarded with suspicion and requires medical

If you think that you may have malaria or are concerned about unexplained symptoms after visiting a malaria area, contact DAN immediately on 0800 020111 or +27(0)11 242 0112.

Frans J Cronjé, MBChB(Pret), BSc(Hons) Aerosp Med
Albie De Frey, MBChB(Pret)
Hermie C Britz, MBChB(Pret), BSc(Hons) Aerosp Med

Anyone for Sardines?

Anyone for Sardines?
The cliff faced wild coast

Jean Marx took himself off to experience the sardine run this year. This is what he learned.  In a world of countless stories of been there done that, people often go to extremes to find that something special or new. I have been diving for a long time and have been all around the globe in search of that new, special place – from the Galapagos to the Coral Sea, and most places in between. Yet I had often heard about the sardine run, but never got round to experiencing it. As with most things in life – this X file syndrome that it’s out there – we often overlook what is right on our doorstep

Text and images by Jean Marx

Earlier this year, I went on a Tiger Shark weekend to Umkomaas, organized by Prestige Dive School. The operator that we used was Blue Rush. They specialize in shark encounters and the sardine run. The owners, Dietmar and Raffaella, are a very interesting couple. Dietmar is Austrian and able to speak 7 languages while Raffaella (Raffa) is an Italian lady that knows her way around sharks. We had an awesome experience gaining good footage of Tiger and Blacktip sharks. On one dive we saw dolphin and humpback whales and suddenly the conversation started veering towards the sardine run. Raffa said that she would bring some photos to dinner that evening. That night, we were in high spirits after a very exciting day when the photo album came out -images of breaching whales, dolphin surfing waves and frantic bird action. I decided that this year I was going, come hell or high water.

Humpback whale breaching

Unfortunately high water came. Massive torrential floods hit the South Coast. Visibility was down to zero and with 4 meter swells there was no chance of getting out to sea. I was very disappointed but kept on watching the forecasts.

I saw a forecast that showed a potential break in the weather and phoned Dietmar in Port St Johns, where Blue Rush was based for the 2008 run. The Sea was calming down and most importantly the visibility was improving. I was on the plane the next day on my way to the Wild Coast where Dietmar and Raffa were hosting a group of Italians for the week.

Ideally I should have taken 2 cameras. I prepped a Nikon D200 with 10.5mm fisheye for underwater. On the trip I met a famous photographer Carlo Mari who was testing the D3 for Nikon. He kindly lent me his D300 for boat-based shooting. The best lens for this being something in the 70mm-200mm range.

Gannets diving for sardines

Black tip shark

The sardine run happens every year between May and July. There are many theories why the sardines “migrate”, but no scientific proof. One of the accepted theories is that changes in the frontal system, move cold water from the Agulhas Bank northwards and the sardines see this occurrence as an extension of their habitat. The run begins in deep water off the East Coast, or Wild Coast, of South Africa and then moves on to the Kwazulu Natal coastline. The continental shelf defines the sardine run experience to be had. Along the East Coast the continental shelf is very close to shore and it gets deep very quickly. This is where you will find the classic “bait ball” where predators surround a group of sardines. On the Kwazulu Natal coast, where it is very shallow, you will find a lot of shark activity resulting in the “doughnut” formation. This is where a shark is surrounded by sardines and it looks like a doughnut from the air. This is also where the sardines will get pushed up to shore on occasion. This activity is not really dived but promises some opportunity with big schools of game fish also joining the hunt.

Ideal sardine conditions comes with good visibility and calm seas. But the chances to see the sardines improves with colder water and a SW wind that helps blow the sardines closer to shore. Expect a long day at sea, a lot of swimming and getting in and out of the boat numerous times in order to keep up with the ever-moving sardines.

The best indication of sardine action is Cape Gannets circling in the air and then and diving into the water. Just before they reach the water they pull their wings back like a fighter jet. It is quite strange to hear a loud crack and then be suddenly looking at a bird with a sardine in its mouth 10 meters under the water. The truth is, once you get into the water, you don’t know what to expect. There can be absolutely nothing or only sardines that are being targeted by the Gannets. Hopefully there are big predators too, like dolphin or shark. We saw only common dolphin but bottlenose are seen. The sharks that you can encounter are mostly dusky ,copper and blacktip with the occasional Zambezi thrown in for good measure. The dolphin hunt by blowing bubbles and using their sonar to keep the sardines together. They then hit the ball at great speed. Sharks are normally present but will patrol the fringes and bottom of the ball for a snack. The real jackpot is when Bryde’s or Minke Whales start feeding. Penguins and cape fur seals can also make an appearance. There were sightings of sailfish and even false killer whales joining the hunt this year, but these sightings are rare.

So basically your day is spent looking for sardine action. But the activity that you can see from the boat is an action movie in its own right. Humpback Whales breaching, super pods of between 500-1000 dolphin, birds such as cape gannets, cormorants and gulls are abundant with the odd albatross patrolling the skies. If all this activity fails, the scenery of the Wild Coast is wild to say the least. Massive cliffs mark the ragged shoreline where the continuous pounding of the waves has created caves and eerie shapes in the rock. Waterfall Bluff is one of only 4 waterfalls in the world that fall directly into the sea.

I think all divers will agree that diving is like a lucky dip and we gladly take what gift Neptune will show us. The only difference is with the Sardine run, Santa joins the party with a big sleigh of goodies.

The Southern Red Sea

The Southern Red Sea
Playful Dolphins at Dolphin reef

The “Deep South”, as it is sometimes referred to, must be one of the best kept secrets in the Red Sea. Yes it may be further to travel, but that is little to sacrifice for world-renowned encounters with friendly dolphins, wall diving (which must be some of the best in the world), forests of soft coral covering every inch of reef, perfect conditions and visibility that stretches on forever. It is further to travel but, to me, the ultimate benefit of being further away was the fact that 4 days went by before we saw another boat on the same reef as us.

Text and Images by Paul Hunter

After a disappointing trip to the Northern Red sea I was hesitant to return. I had placed the Red Sea on a pedestal. Yes the conditions were perfect and the visibility awesome but there was nothing to see from a fish life perspective. I have to admit though that the two wrecks we did, the Thistlegorn and the Dunraven, were unbelievable and an experience of a life-time.

One of the few times we saw other dive boats on the reefs we were diving

After much persuasion, I was convinced to return. But this time hundreds of kilometres south; the Deep South. I was told that the reefs were what the north was like 15 years ago. I joined a group of about 20 people most of whom are underwater photographers and good friends. This definitely added to the experience of the trip.

Let’s face it travelling to Egypt and the Red Sea is an adventure unlike anywhere else in the world. There is something mystical about the place, I think it has something to do with a history dating back thousands of years. A time of Pharaohs and Gods and a civilization ahead of it’s time. It was time to return to Egypt and the Red Sea.

Driving through Marsa Alam en-route to the harbour I soon realised that this once small fishing village on the western coast of the Red Sea is blooming into a Riviera. It is destined to become another Sharm El Sheik as a top diving destination. Marsa Alam is located some 250km south of Hurghada. Since the opening of its international airport in 2001 this small village has become more popular and accessible. In some way, i wanted to be selfish and stop progress so this place and the unspoilt reefs can remain just as they are.

Dolphin on Dolphin reef
Dolphin on Dolphin reef

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Clown fish in anemone

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Spectacular soft corals

Dolphin Reef, as its name describes, is home to a very large pod of friendly Dolphin. It’s a shallow horse-shoe shaped reef structure, basically in the middle of nowhere. I would highly recommend this experience to anybody who is in the near vicinity of this magical place. To spend time with these highly intelligent mammals and in such an awesome environment is a once-in-a-life-time must. From the time I hit the water it was almost a sensory overload swimming with them; from their high pitched clicking sounds bouncing off my body to being surrounded by no less than 10 dolphins at a time. The more we wanted to interact with them the more they seemed to want to interact with us. I was unsure if they were used to interaction with people or were just unafraid of us as they came right up to me, swimming continually around me in circles or from straight up from below. The interaction was surreal and I’m still unsure who was having more fun; them or us. We must have spent 90 minutes in the water with them before we had to call for the boats to pick us up as we were all exhausted.

The Red Sea and ship wrecks are synonymous so this trip would not be complete without at least one wreck dive. The Abu Galawa Wreck is not a big wreck. In fact it’s only a sailboat, and it lies at the base of the reef on its starboard side in 18m of water. The wreck is very picturesque and great for photographers and the opportunity should not be missed. The boat is mostly intact, except for decking and the upper structure. The inside is filled with a massive shoal of glassfish. I have tried to find out more about this wreck but to no avail. The only information I have is from the guides who told us that’s it’s an American sailboat that sank in 2002.

Small yacht that had collided with reef now an awesome wreck

Diversity, diversity and more diversity is something this trip had from the start and St John’s Cave was no different. From the surface it looks like somebody went to work on the reef with a pizza cutter. I could make out the myriad of tunnels which form an underwater maze through the reef. With our boat moored on the southern side of the reef we were informed that there were two openings to the north which would lead us into the tunnel system. At this stage I must point out that we were extremely lucky as our captain and dive guides gave us a lot of freedom. The captain was very flexible in terms of the different dive locations and the dive guides let us do our own thing. This helped with the bunch of photographers onboard and went a long way in keeping the peace. The dive on this reef was another highlight for me. What we found while diving here was unbelievable. There were deep cracks in the coral plate which provided us with tunnels to navigate and explore. These same cracks allowed shafts of light to penetrate right down to the seabed. It was mesmerising and cathedral-like to witness. What a pleasure to photograph these scenes. Although some of these cracks were narrow to swim through I never felt unsafe or lost as the cracks always opened up to bigger caverns or to the sea again.

Cathedral light at St Johns Caves

Wall diving
Endless visibility and wall dives

Thousands of Goldies surround the reefs

Wonderful Wall diving. With famous names like St Johns and Elphinestone on the agenda, to mention a few, I knew the wall diving was going to be good. To be honest, the wall diving exceeded my expectations. The walls were covered from top to bottom with pristine hard and soft corals. In some places there were forests of soft coral on the wall. This made for awesome underwater photographic opportunities. We were very fortunate that we never really had strong currents on our dives. This meant we could do the dives at our own pace and really get to enjoy some of the wonders on these reefs. Elphinestone lived up to its name as a magical dive site with unbelievable corals and a large variety of fish life. Another good reason to visit this location is the possibility of seeing Oceanic Whitetip shark. Unfortunately we did not get to see any this time, but that is nature and what will keep me coming back.

The phrases: unspoilt, secluded, diverse and some of the best diving I have ever done, sum up my experience. This is really a special place to visit and dive – one which I will highly recommend. If you are looking for an adventure with unspoilt reefs and secluded dive sites this is the place for you. It’s far away from the hustle and bustle of the north. I would also recommend doing this trip on a liveaboard as many of the locations are too far for day trips. With calm surface conditions, visibility that stretches forever and pristine reefs this trip is well worth it.

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