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2 destinations with malaria risk, and 2 without, that surprise travelers

Malaria is a parasite that is spread through the bite of an infected mosquito.

Malaria is an illness caused by a parasite that is spread through the bite of an infected mosquito. While malaria is the leading cause of death due to infection for travelers returning from tropical destinations, it is usually prevented by anti-malarial drugs and mosquito-avoidance measures. I discuss both of these in detail with patients heading to the highest risk zones: sub-saharan Africa and some pacific islands ( 90% of malaria cases occur in these regions). Other destinations where the disease is present in certain risk areas include parts of South Asia, Haiti, Dominican Republic, Southeast Asia, Central America and South America).

From what I've observed in practice, here are the places to which people travel and they are surprised when I produce the malaria map:

1. Punta Cana: Most of the Dominican Republic has either little or no risk of malaria, but the easternmost region (including Punta Cana) is an area of risk where taking preventative medicine is worth considering. While Hispanola (the island which is divided into Haiti and the Dominican Republic) is an intermediate risk zone for malaria, many of my clients are heading to resorts that use mosquito control measures and have well-screened, air-conditioned accommodation. That can greatly decrease the risk, and as a result we do not see waves of travelers returning to Canada with the disease. I find that among my colleagues the opinion about whether to recommend pills or just mosquito avoidance is split. The risk to resort travelers is low but not zero, so I generally present the options and let the traveler decide.

2. Victoria Falls (Zimbabwe) and Kruger Park (South Africa): I've seen plenty of great itineraries for South African trips. Travelers can choose to enjoy the beautiful city of Cape Town, visit elephants near Port Elizabeth, tour coastal wineries, and then camp for a few nights in or around Kruger Park to snap some photos of the magnificent wildlife. Some package trips also fly people to Victoria Falls, where they will spend a night or two in Botswana, Zimbabwe or Zambia before returning to South Africa or flying home. While South Africa is mostly malaria-free, the zone around Kruger Park is a risk area, as is the area around Victoria Falls.

3. Cambodia: This destination is a good news story. The 2019 World malaria report from WHO states that in 2018 Cambodia reported its first year ever of no malaria deaths. While much of the country is still considered a risk zone, a trip to Siem Reap and a cruise down the Mekong poses very little risk. Bug spray and protective clothing are all I recommend for dealing with mosquitoes for such itineraries.

4. The Vietnamese Coast: While much of the interior area of Vietnam is considered an area of risk for malaria, the popular route along the country's gorgeous coast (including Ha Long Bay, Hue and Da Nang) is not. Neither Ho Chi Minh City nor Hanoi pose a risk of the disease, either. As a result, most travelers going to Vietnam do not need to take preventative medication for malaria.

Often the important question is not whether a traveler is going to a country with malaria risk, but whether they will be going to the region of risk, and if so, for how long and in what type of accommodation. Since the mosquitoes that carry malaria bite from dusk until dawn, day trips into affected areas carry little to no risk. The same can be said for travelers who plan to stay indoors from dusk until dawn in well-screened, air-conditioned structures. Some tra

velers going to low-risk areas for short periods elect to use avoidance measures such as an effective insect repellent and protective clothing, then stay vigilant for any signs of malaria (which look very much like the flu: fever, muscle aches, chills). Whether or not a traveler used anti-malarial medication during their trip, seeking a test for possible infection is important if there are any of these signs, even if the trip ended months ago. Malaria can rapidly destroy red blood cells and organs, and the best chance of recovery is treatment in the early stages.

The changing situation: COVID-19 and the impact on eradicating malaria

The risk of malaria to travelers is my area of specialty, but of far greater concern worldwide is how the disease and its impact of people who live in affected countries is evolving. On one hand, due to COVID-19 malaria control measures are being suspended and access to diagnosis and treatment are restricted in countries with a high burden of the disease. The World Health Organization estimates that, if nothing is done to ensure supplies continue to get to where they are needed, deaths from malaria could double those reported in 2018. The 2019 World malaria report from the WHO indicates that, even before the pandemic, the WHO African region had a slowing malaria mortality reduction rate (the rate at which deaths from malaria are decreasing). Even with current levels of funding, which are the greatest in history, it is unlikely that the goal of reducing malaria incidents and deaths by 40% from 2015 levels will be reached. On the other hand, new treatments including a vaccine and malaria-blocking microbes are showing promise. Hopefully scientists and the nations that fund them can use the lessons in collaboration we've learned during the pandemic to work as one team towards eradicating malaria entirely.

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