Jonathan O’Keeffe, Medical Director, SeaDrill • Nov 2018
Over the last 8 years I’ve advised many organisations with regard to their malaria prevention strategy. Malaria is an unpredicatable infectious disease. Some people, having been exposed to the malaria parasite for many years, may develop a partial immunity and it can be a mild to moderate illness resembling flu but for others it is a life threatening 100% preventable illness. Ambiguous severity and consequnces is one reason for the stories from travellers as to why they do or don’t take malaria preventive medication (also known as chemoprophylaxis) when the visit malarious countries.
People give a list of reasons for not taking an antimalarial medication and they roughly fit into the ‘I never take a tablet or a vaccine if I don’t have to’ narrative. At first glance this may seem a very sensible rule of thumb. Top reason for not taking an antimarial is the ‘risk of side effects from the medication’. Slightly lower down the list is the argument ‘I know a guy who had Malaria ‘x’ times (substitute your own value here). He never took anything and he’s still alive to tell the tale’ or ‘If I get a fever, I can always treat myself’ or ‘Malaria is completely treatable so why should I worry’. Next excuse down in terms of misdirected logic is ‘I lived in ‘X’ (substitute your own malaria endemic location here) a few years back and I developed immunity. Final versions of the same argument include ‘Antimalaria medications can make you go crazy’ or ‘prevention is not 100% effective’ or lowest on the list of credible arguments and bordering on the conspiracy theory end of the spectrum of arguments is ‘it’s just another way of BigPharma making more money through fear mongery’.
Although I may sound dismissive of people’s genuine concern not to put themselves in harms way by taking a medication with potential health side effects, I don’t wish to be. The mistake people make in relation to malaria prevention is not to conduct a proper informed risk:benefit analysis where they weigh up the potential for (usually very mild) side effects versus the risk of a neurological complication or death. We have a natural tendancy to believe we will be the one to get the side effect but we never believe we will be the one to contract the fatal disease. Good risk assessments are a composite of the frequency of the incident times the impact. Side effects of antimalarials are infrequent (roughly 10% of people will get one) and the impact of these is mostly minor and almost always reversible. Side effects of a case of Falciparum Malaria are guaranteed and the impact is almost always severe or fatal for a business traveller or expatriate.
From an institutional, organisational or company perspective the main mistake we make is to provide insufficient information to our travellers or workers to help them take an informed decision. Getting travellers to fill a form prior to travel saying they are ready to travel but we don’t check their understanding of the risk’s involved is not enough. Raising travel risk awareness is a continuous activity that requires resources. It should involve a multichannel campaign using presentations, testimonials, e-learning, leaflets/mailshots, travel alerts and other targetted methods. As a topic, Malaria prevention should be a very high priority for any organisation sending people to Africa or parts of Asia. It invoves education and raising employee awareness of the risk especially malaria symptoms, offering them access to travel health advice and chemoprophylaxis, a well defined link to a reliable diagnostic service while abroad if they become sick and monitoring for fever for up to a year on return home. These days a company may be held liable or part responsible if they do not take the risk of harm from malaria seriously enough to implement a proper programme.
Doctor heal thy self – I travel to subsaharan Africa regularly. I once took mefloquine (weekly tablet) for two years without more than vivid dreams (quite nice really!) I took doxycycline (cheap and daily) and got heartburn and had to avoid the sun for fear of a photo-sensitive rash. I’ve taken numerous courses of Malarone (the slightly more expensive daily one) over the last 15 years without adverse complication. I’ve never had malaria. Every couple of years I am involved in the case investigation for a co-worker or a colleague who invariably did not complete their own risk:benefit assessment and who died as a result.
Take malaria prevention seriously at both a company and a personal responsiblity level. It can be a mild illness for some but it also kills many. Don’t buy into anecdote over evidence. Implement a Malaria prevention strategy. Protect your organisation, protect yourself.