New guidelines for malaria prophylaxis in Angkor Wat?!
 

This weekend my husband and I went to a travel medicine clinic to get vaccinations for our upcoming trip to Bangkok, Hanoi and Siem Reap. I was positive that the doctor would prescribe a malaria prophylaxis for Siem Reap. However, he told us that last year the guidelines changed and malaria prophylaxis is no longer recommended for tourists staying in hotels in Siem Reap and only doing day trips to Angkor Wat/temples (in other words, returning to the Siem Reap hotel to sleep at night). I was wondering if anyone else has been given this advice by their travel MD?

what does the CDC say???.....i guess i would question this advice

This is unusual advice. The cdc still considers all of Cambodia outside of PP to be malarial risk. Also, the idea that you are not exposed to mosquitoes with just day trips to the temples is naive. I encountered some mosquitoes at the temples, but many more in the evenings in Siem Reap. Many eating establishments are indoor/outdoor, and while they often have mosquito coils buring, you are still likely to get bitten. It is not as if the temples were in a malarial risk area and the town is not. Even in air-conditioned hotel rooms, you will still encounter mosquitoes that get in when the door is opened, even briefly.

Are you in the US or elsewhere? Have you checked your own country's guidelines for malaria prophylaxis?

I just checked the UK website, http://www.fitfortravel.scot.nhs.uk/...s/cambodia.htm and their advice is the same as the cdc's: Angkor and the surrounding areas are all considered malarial risk.

From the CDC site:

http://wwwn.cdc.gov/travel/destinationCambodia.aspx

"Malaria risk area in Cambodia: Risk throughout the country, including risk in the temple complex at Angkor Wat. No risk in Phnom Penh and around Lake Tonle Sap."

How many bites do you need at the temple to get malaria? I would ask him to show you the guidelines that have changed. ((*))

Are thge mosquitoes aware that they are not supposed to bite hotel guests. Can they read room reservations? Are guest house residents potential bitees?

The whole thing about Malaria prophylaxis is that the regimen is far less stressful than contracting malaria.

Perhaps the room key has some magic powers a la garlic and vampires.

JMGJD-this is not an attack on you. It is a dismal attempt to poke fun at one more travel clinic giving questionable advice.

JMGJD, if it were me (and it isn't) I'd call the Travel Clinic and tell them you've done some more reading on the topic and have not been able to find new guidelines for the Angkor Wat area that do not recommend malaria prophylaxis. Indeed, all of the major travel medicine sites continue to recommend it. (Give them the cdc reference) Ask for the reference on the "new guidelines" and ask for a re-appointment (at no charge to you) to discuss this matter with the doctor.

PLEASE note this is not advise, only a passing comment:

I was told by a doctor who works in a field clinic for Doctors without Borders that there is no malaria risk in Siem Reap or the temples in the IMMEDIATE vicinity, including Angkor Wat. His story is that the particular mosquitos carrying malaria have moved up in altitude and are now only to be found in the Kulen Mountain area. So those going to Koh Ker, Bang Melea or Kbal Spean, etc would be at a much greater risk.

Just anecdotal info; not to be taken as advise. I don't know if any of this is true.

Regardless of whether you're taking the prophylaxis, you've got to keep mosquitos off you as you are at much higher risk of getting dengue fever than malaria in Siem Reap proper.

I have just come from our local Travel Clinic here in Victoria, Canada and have been given a perscription for Malarone for our visit to Siem Reap. I have every confidence in the doctors at our local facility so Malarone it is.

Hi, Lori, thanks for your comments. I have periodically heard similar comments from locals. I've not heard that the malarial mosquitoes are moving to higher elevations, though. That would be unusual.

Let me give some data that is worth thinking about. The recommendations from the cdc WHO and other governmental bodies are made on the basis of reported cases in various areas. Since as a short-term visitor, you are more susceptible to a malarial infection than a local is (has to do with developed resistance), recomendations are made on that basis.

In malarial areas, there are often waxing and waning of numbers of cases. In some locales this appears to be due to wet season/dry season difference, though this is not particularly a factor in Cambodia. because of this natural waxing and waning, such public health bodies are reluctant to change guidelines on the basis of short-term numbers.

In addition, there has been recent movement of various tropical illnesses (for instance an outbreak of Chikungunya fever, a mosquito borne illness in Italy). While there are many factors that are involved in this, international travel and global warming appear to be two factors.

There is a recent report that Plasmodium knowlesi, a malarial parasite previously thought only to affect monkeys, has now been identified as a human pathogen. It is a deadly type of malarial, and it has been identified in Borneo and parts of peninsular Malaysia. There is some concern that it has been confused in the past with a more benign type of malaria, Plasmodium malariae.

For those of you with an interest in the techinal aspects of this, "Plasmodium knowlesi Malaria in Humans Is Widely Distributed and Potentially Life Threatening" was just published in Clinical Infectious Diseases 2008;46:165–171. The whole article is available on the web without registration.

My thanks to Nutrax on the Lonely Planet board for this information on Plasmodium knowlesi.

Oh, and I forgot to thank Lori for her comment about dengue. Day and night, you need to do what you can to prevent mosquito bites.

Research pays off.

I dropped off my Malarone Rx at the pharmacy yesterday, and when I went to pick it up they told me that my insurance co. had rejected it and recommended Lariam instead, so they had the doctor change the Rx.

I knew that the CDC had not mentioned Lariam, so I made them look it up and sure enough, there is a resistance to mefloquine in Camodia and Burma, right where I'm going!!

The pharmacist says he gives out much much more Lairam then Malarone, and did not know that. If I had just blindly taken the Lariam, it would have been for no reason!

My doctor is trying to get an excption from PacifiCare today, they are usually pretty good about it. If not, I will pay the $200+ myself and try to get reimbursed when I get back.

It pays to be anal sometimes.

Lynnie

I took my prescription to Costco, and got 38 Malarone for $56.

I don't know if it is because we are on Medicare and AARP, but you might check it out. I'm not sure you need to be a member of Costco to get meds. ((*))

Good idea Jed, If Pacific Care doesn't come thru I will check out Costco. I'm a member

bottom line imo, better safe than sorry....

Lynnie, good for you for doing your research!

Costco has the lowest prices on Malarone in the US. If your insurance doesn't cover it, go there.

Most doctors and pharmacists have little info about travel medicine. While you always have to be vigilant and informed to get the best medical care, that is doubly true in the area of travel medicine.

I recently learned that in the state of Georgia, the membership discount places must fill prescriptions for EVERYONE who asks (this comes from one of the consumer TV specials on 'where are the cheapest drugs'). Membership is not required - by state law. (Georgia is not usually a leader in such things, so my guess is many other states do this also!).

Kathie I've downloaded the article and it's both fascinating and scary as all get out.

I don't get mosquitos moving to higher elevations either unless it was to get at some water that's there year round.

They certainly didn't ALL move up there. Read Kristina's report...they are everywhere!

I agree Lynnie, it's good to be anal about all aspects of your health care, especially when traveling in developing countries. Everyone should participate as actively as you did in the medical decisions being made around them.

Lori, I know what you mean about the article. Scary stuff.

We opted to go ahead and take the Malarone. We felt it was better to be safe than sorry. I'm glad we did...and I would encourage you to do the same, for what it's worth.

just out of interest... am adding the sentence taken from our local equivalent to the CDC... the tropical medicine institute in Antwerp Belgium

the adivce they give for Siem Reap is as follows: "in Siem Riep itself: the risk is low or non-existent, but there is a malaria risk in the neighbourhood of the city, and also limited risk in the region of Angkor Wat, when staying in this area, malaria tablets are necessary. People visiting these temples during the day and who return to their luxury hotel at night do not need to take malaria tablets. They need to carry a mosquito repellent to apply to their skin in case they are unable to get back before evening (due to e.g. illness, car failure, etc)"

still think i'll take some malarone along just in case (incidentally would not recommend taking Lariam to anyone... took it years ago in Senegal and never again... too many sideeffects)

Thanks, brusselschap for another source on this. As most people who go to the temples spend time at the temples at sunrise and sunset, they are at the temples when malarial mosquitos are most active.

agreed :-)

Don't forget about the dengue which is as big a problem as malaria. You are at the temples all day when the dengue bugs are out. You need the DEET regardless; it's your only protection against dengue

I've been on Malarone twice...two trips, back-to-back years to Ghana. Personally, I refuse to take Larium...I've heard too many horror stories... along with one from a young woman I met...some years ago... while waiting in the Bangkok airport for a flight. She has permanent liver damage from taking Larium. And yes, of course, one can have reactions to anything, but there's just been too much negative stuff that I've heard about Larium over many years.
If anyone has Kaiser Permanente medical insurance(California) and I've seen it in Hawaii, well Kaiser has an excellent medical travel department.I've used both the one in San Diego...before we got our own L.A. one...and our L.A. one.
You just tell them the countries you're going to visit and they send out a packet of info on what you need to take and should take. I got all shots and Malarone there and the Malarone cost me, from what I can remember, between $10-$20...for a 3-week supply. The shots were free. I didn't even need an appointment...it was just walk-in. They had the shots ready at the sight I had chosen. Happy Travels!

I would also be very careful about taking larium. I know of two cases who had severe psychotic episodes that landed them in the hospital for weeks and others who have had life threatening side effects.

Gloria,
Am I the only one who thinks Larium has been too accessible in LA?