I am starting this brief description reminding you that we live in an endemic area for the aforementioned disease which is being transmitted throughout the year, although there are periods when the risk of getting it is especially high (obvious outbreaks of malaria right after the two rain seasons). 

The period most struck by malaria infections extends from December to June, that is during and after humid months as well as corresponding to the hottest season of the year. Taking this into account, I strongly advice you against the idea of not taking the prophylaxis. Malaria may be mortal in its most acute form (cerebral malaria) caused by plasmodium falciparum. 

Obviously, it is important to use a mosquito net when sleeping, for the feeding time for the mosquitoes lasts from dusk until dawn. 

This is my personal opinion on the issue of preventive medicines: 

1) Lariam (Mefloquina) is an excellent medicine; its effectiveness reaches 95%. From my point of view it is the best choice, taking into consideration its effectiveness and lack of serious side-effects for the prophylactic doses (one tablet a week). Let me tell you not to be afraid of nor hold every word of the instruction booklet attached to the very medicine. Many of the side-effects written there are so rare to be counted on the fingers of one hand. The only problems which volunteers reported to me during the last few years were: vague abdominal disturbances mostly in the day of taking the tablet, sharp and laborious dreams (although I’ve never heard about real nightmares), in rare cases- sleeplessness and vertigoes during the day. 

However, this is the medicine which saved many from malaria, causing little problems. As far as I remember, the British guidelines suggest starting the prophylaxis 2 weeks before the journey. The reason is that the side-effects occur mostly after taking the second dose. In case the very rare and more complicated side-effects occurred, it is better to be still at home and allow oneself some time to consult the doctor. In Italy though, it is still recommended to start the prophylaxis 1 week before the journey. 

On the return to Italy, it is advised to continue the prophylaxis for another 4 weeks, to protect oneself against so called ‘airport malaria’, which the unfortunate ones may get from a mosquito imprisoned in an aircraft coming back to Europe (the incubation period for plasmodium falciparum is around 1 month). According to the British guidelines, Lariam may be taken continuously without any problems for at least 6 months. In Italy though, it is recommended only for the stays not exceeding 3 months. 

For longer stays, any prophylaxis should be suspended. If one gets malaria afterwards, they will receive normal treatment. In fact, after such period of time, the drug’s protection decreases due to a certain resistance of the parasite to the low doses, whereas the side-effects remain. Moreover, after one semester, the volunteers are likely to acquire kind of semi-immunity due to the previous repetitive contacts with the sting of the mosquito and, as a result, the eventual attack of malaria would be of less acute consequences. 

2) Malarone (association of atovaquone and proguanil) is a great medicine and even overtakes Lariam in terms of the protection. The prophylaxis should be initiated 2 days before journey and continued for one week after return. 

The problem with Malarone is that its use is authorized in Great Britain (and I think also in Italy) only for 28 days. Malarone has to be taken on a daily basis (one tablet every day).

Together with a bit elevated price, it might be considered a drawback by some people. On the other hand, this medicine is very tolerable and I have never heard any complaints on side-effects from the volunteers who decided to use it. 

3) Some have chosen the doxiciclina, which is recognized in various international guidelines and it seems like it hasn’t lost its validity (the protection rate is not very clear, though). The prophylaxis with doxiciclina should be started one week before journey and continued for 4 weeks after return. You can use it for the maximum period of 6 months. 

The dose is 100 mg (1 tablet), one time a day. Yet, this drug may bring you series of side-effects: the most frequent ones are charged to the digestive tract (vomiting, diarrhea, sensation of abdominal stretching, anorexia). Usually the gastroenterological disturbances are more acute when the medicine is mixed with milk, so we recommend to those who take the drug not to drink it. Another problem sometimes reported by the volunteers is the photosensitivity: the patient may develop skin rashes when exposed to the sun. Because of that, we suggest protecting oneself with long sleeves and cap. 

4) The association of chloroquine and proguanil is no longer advisable, because the percentage of parasite’s resistance to it became too high. 5) In rare cases, when volunteers would like to come to Chaaria with small children, we must remind that the prophylaxis is necessary and of double importance in the pediatric age, because children are especially prone to acute forms of malaria, potentially mortal. The prophylaxis should be assumed also by pregnant women. 

Although there are some antimalaric substances in the maternal milk, their quantity varies a lot and one cannot rely on it. In the pediatric age, the best choice is Lariam. You can be provided with further detailed instructions on the usage in any pharmacy or medical offices. As an alternative product for children may serve the association of pirimetamine and dapsone, but I have no experience on that. 

I remember that Lariam may be teratogenic (harmful to foetus), so it is better to avoid pregnancy for three consecutive months after the suspension of its use. I hope the information will help you decide which medicine to choose. I didn’t say a word about homeopathic medicine and the products of herbal medicine, because I have no data to do it. I simply don’t know anything about them and I leave the choice to you. 

Br Beppe 

Ps. You don’t need to take any vaccinations against cholera, because its protection is low. I don’t recommend the prophylaxis against meningococcal meningitis too, which happens sporadically, and when it does, I can provide you with necessary medicines here, in Chaaria.