Question about Malaria tablets (not for doctors)

[gingernut]

I am deliberately posing this question in this forum, as I would like the opinion of professional pilots and cabin crew, and not that of medics.

I am seeking the answer to a few questions, raised recently by a consultation I had with a patient. I have to be a little cagey, as I am bound by rules of patient confidentiality.

Here are my questions:

a) Is it common for international airlines to issue their staff antimalarial prophylaxis? (Malaria tablets in particular).

b) How do airlines work out which drug for which patient?

c) How do they monitor and record side effects and adverse reactions?

d) How do they link in with AME/GP? (Record keeping/PMH etc.)

e) Do pilots take MEFLOQUINE (Larium), and if not, how are they informed about the risks of (?) less effective medication.

As far as I know, mefloquine is contra-indicated in those performing precision activities.

I am well aware of the indications/cautions/contra-indications/side effects of each drug, I am more interested in the systems that are in place to ensure efficacy and safety.

I am specifically interested because I have an interest in travel medicine and aviation.

Thanks in manticipation.

[Flypuppy]

I can only answer you last point about Meflaquin/Larium. Aircrew are specifically banned from using this drug. There is something in the AIC about it, I'll see if I can find the relevant text.

[earnest]

a) Is it common for international airlines to issue their staff antimalarial prophylaxis? (Malaria tablets in particular).

Yes. (I think health and safety rules, plus liability, require this, although I suggest you verify the legal side).

b) How do airlines work out which drug for which patient?

Usual guidelines as used by medical profession or advisors to the travel industry, with some modifications (see below).

c) How do they monitor and record side effects and adverse reactions?

They can't. Crew are advised to take medication under medical guidance and this includes the reporting of side FX. Health wise, crew belong to their GP, not their the company or even their AME. Standard medical ethics/protocol I think.

d) How do they link in with AME/GP? (Record keeping/PMH etc.)

As above, ie they don't, unless specialist advice is required (eg adverse reactions or drug sensitivities to recommended prophylaxis).

e) Do pilots take MEFLOQUINE (Larium), and if not, how are they informed about the risks of (?) less effective medication.As far as I know, mefloquine is contra-indicated in those performing precision activities.

They don't take mefloquine (or at least they are not supposed to). AICs (UK) are issued to cover medical topics like these, and they are usually repeated in company standard procedures and aircrew notices, which are usually mandatory. (By that I mean the banning of larium is mandated, not the taking of the prophylaxis. You can only take the horses to the water . . )
Some companies have supplies of the recommended drugs at their bases that can be picked up by crews flying to areas of risk, and specify which prophylactic regime is recommended for the various geographical areas.


I am well aware of the indications/cautions/contra-indications/side effects of each drug, I am more interested in the systems that are in place to ensure efficacy and safety.

Hope this helps.

[Captain Airclues]

gingernut

The company that I work for does not issue antimalaria drugs or give advice. However, I am well aware of the side-effects of the various drugs.

When I started longhaul flying 35 years ago, I took the decision to take precautions against being infected rather than risk the effects of long term drug use. I know that the docs won't agree with this, but it's worked for me (so far!).

Airclues

[gingernut]

Cheers chaps.

Flypuppy, thanks for the advice, I never thought of that ! My area of expertise is medicine, not flying ! (Have a ppl though). I'll have a root through the stuff in the briefing room.

Earnest, thanks for the answers. It would appear that any link between patient (pilot/cabin crew), company and GP appears to rely on the patient creating the links, which I guess would work under most circumstances, I'm just a little concerned about when things go wrong, eg drug interaction or adverse reaction. I'm not actually sure that linking in with the GP, (if ethical) would improve safety anyway - it would depend on the GP's information system. (Most are pretty dire to say the least).

Captain airclues, thanks for your honest reply. Glad to see you are taking non-pharmalogical precautions - these are often neglected by most travellers. I guess it would be a waste of time lecturing you about the benefits of chemical prophylaxis, it looks like you've made up your mind on the basis of available information! I guess, to be honest, if I was in your situation I would probably have to think long and hard about the issues ! Never trust a drug company vs malaria is biggest killer in the world

[Captain Airclues]

gingernut

As a longhaul pilot I would have had to take these drugs continuously for the last 35 years. Could you tell me what research has been carried out into the effects of long term antimalarial drug use? In particular how many people who took part in the research had been taking the drugs for 35 years, and what percentage of those people had any form of liver damage? How did this compare with the number of unprotected people who contracted malaria? I would be interested to know the rersults of any research as I am often asked for advice by my younger colleagues.

Airclues

[OzExpat]

I've worked in the tropics for the last 19 years. When I first got here, it was suggested that I take a Chloroquin tablet once a week - pick a day and stick to it. I picked a day but found that I'd keep forgetting, so finally gave up the whole idea after two months.

Almost as soon as I started taking Chloroquin, I was told that it was better not to take anything. It was suggested to me that, no matter what you take as a preventative, it was still possible to get malaria. Therefore, taking any tablets for it was only going to mask the symptoms until it hit really hard. The thinking here, at the time - and even now - is that it's better to get the earliest symptoms, so that treatment can begin at the earliest stage.

If you've been using the "top shelf" stuff as a preventative treatment and still get Malaria - it happens - what is left to attack the malaria when you get it? Thus, it was always seen as important to use only Chloroquin, or something equally mild, as a preventative and also for initial treatment. That way, you can always go up to some stronger treatment, if necessary.

So far, I've never needed anything stronger than Chloroquin. I know that I've been lucky in this regard, but this is still the "fact of life" as I see it, in this part of the world. Probably just a case of horses for courses.

Hope this helps.

[FlyMD]

Policy at all my operators to date was to issue about 6 doses of Lariam (or whatever drug was popular at the time), not for preventative consumption, but as an emergency help in case of malaria outbreak.
Otherwise, information was given out about proper behavior in the tropics (long sleeves at sundown, etc..).
The best part was the handout of a good bug-repellant (cream and aerosol) at every briefing for a flight with a tropical destination.
Last but not least, we always insisted on the best availble hotel, as soon as it was in Africa or similar: good air-conditioning goes a long way towards preventing bug-bites..

Privately, I have taken regular doses of Lariam on a trip to Kenya. I had to interrupt the treatment, because 2 weekly pills of Lariam completely destroyed my digestive system...
As far as which drug you can take in a high-risk situation, it's a matter of personal experience, but don't forget to ask your doctor about it...

I would be really scared top take those drug on a regular basis, because I feel that it's pretty strong stuff, and long-term effects are potentially dangerous...

[gingernut]

Captain airclues, don't know of the studies first hand. I guess the clinical question is "does the risk of taking long term prophylaxis outweigh the benefits."

I should imagine that any studies performed will be retrospective, ie looking back in time, and as such, will not be that robust, in terms of clinical evidence.

If you wish to know of any studies, I could have a search through the medical databases, but it will be in a couple of weeks time, as I am off on hols !

[SRB]

I posed the very same questions about long term malaria prophlaxis to a professor who specialised in these things before I started longhaul flying to East Africa. He pointed out that very long term prophlaxis was nothing new, and that people had been taking such drugs for years at a time, sometimes tens of years.

He quoted examples such as VSO workers, career diplomats, ex-pat business men etc. He said the incidence of long term damage was very low and reminded me that chloroquine had been around for donkeys years, and taken by ex-pats and locals for as long . This provides a good statistical argument to encourage long term prophylaxis, even for folk such as Capt Airclues who may need to take the drugs on and off for very long periods of time.

I'm always surprised when intelligent, logical people use arguments along the llines of, "If the drug is not the best for the job, or not 100% effective, then what is the point?" That, to me, is like refusing to wear a seatbelt that may be a bit frayed at the edges, concentrating instead on driving more safely. Malaria is, as gingernut points out, the world's biggest killer disease. (You can substitute the mosquito into that quote by an IRA terrorist: "We only have to be lucky once. You have to be lucky all the time.")

I remember reading that taking anti-malarials that are not the first choice drugs may still reduce the virulence of the disease, which goes against Oz Expat's argument. I have not read anywhere (reputable) that has suggested the taking of 2nd choice drugs can hinder the treatment of malaria. Someone may correct me on this as I don't have the appropriate scientific papers to hand.

I'm an aviation medic and professional pilot and I take the prophylaxis. It won't guarantee I won't catch malaria, but anything that stacks the odds in my favour gets my vote.

Keeping the little critters away from us in the first place is, as has already been stated, still the first line of defence.

[BroomstickPilot]

Gingernut,

I am not professional aircrew, (at least, not yet).

However, I am certain I was bitten by mosquitoes actually during a BA night flight back from Calcutta a couple of years ago, (despite the air conditioning).

If you frequent Malarial areas it is a certainty that you are going to get bitten, (I certainly did) and some of the mosquitoes that bite you are certain to be of Malaria carrying species.

The point I wish to make is that trying to avoid Malaria merely by avoiding getting bitten, in my view, just isn't an adequate method of avoiding the disease.

Best regards,

BroomstickPilot

[timzsta]

Having done a few trips to the Gulf & one to W Africa when I was in the Navy I certainly remember well the malaria tablets dilemma.

Gulf deployments - malaria tablets for Oman only. Advised to take 2 weeks before the start visit to a month after (which often meant most of the deployment). Dont want to take them - sign to say as such. Ttook a small tablet daily and a larger one weekly. Larger ones made people sleepy (an issue when taking £200m of the Queens property through the Straits of Hormuz). Interesting thought - anyone done a study on effects of taking malaria tablets and NAPS (Nerve Agent Pre-treatment set) tablets (vis a vee Gulf War Syndrome).

Sierra Leone (2000) there was a much higher risk of Malaria. Again the drugs made people sleepy. I was working as a Fighter Controller (again not good to be falling asleep). All aircrew, FCs and ATC guys were given different drugs to the rest of the ships company. Still had the problem of the sleepy ones though. So us FCs and ATC boys used to try and take the sleepy ones prior to going to sleep so as to avoid the problems. Kept on them until 1 month after getting back, and definetely did notice I felt more "awake" after coming off the drugs.

An aside from Micheal Caine'a autobiography. In Korea as a soldier the medics gave him 2 pieces of advice - take malaria tablets and dont go with the local girls (or you will get the clap). So he took his malaria tablets and kept his trousers on. Most of his mates forgot to take their malaria tablets and took their trousers off and suffered no ill effects. Poor old Micheal came down with a severe case of Malaria and was rushed to hospital (which goes to show doesnt it).

My general thought is - I wouldnt like to have to take these drugs permanently. Life is hard enough as it is, without spending 1 day a week walking about like a zombie. But then you might get malaria.

Hope my thoughts of some help.