Malaria: chemoprophylaxis and other ounces of prevention

If you are concerned about malaria (a reasonable concern, as the consequences of infection are sufficiently grave that even a small risk of contraction is significant), then here's what i have to say about that:

Mosquito prevalence
Traveling in October or later (i.e. after monsoon), in major cities (Delhi) and smaller ones (Haridwar, Uttarkashi) in north western India, i only saw mosquitos in the evening around sunset. At that time they were common, but not overwhelming hordes (as i have experienced in many areas of the US). All of the hotels i stayed in (which ranged from very western/modern to middling) had screened windows. If your accomodations are more... porous, you may want to take mosquito netting, but it was completely unnecessary for me.
Doxycycline is one of the cheapest and safest malaria chemoprophylaxis pharmaceuticals, especially the monohydrate (not hyclate) variant. It can cause some nausea (i experienced this just once) and should not be taken within a couple hours of consuming dairy or calcium tablets, but is best taken with some food. The main consideration is that it can make you much more sensitive to sun, so you will need to take precautions against too much exposure (which is a good idea, anyway). This same medication is taken for extended periods for severe acne and is pretty safe, but of course all medications have their risks. You will need one 100 mg pill a day, starting a couple days before potential exposure to malaria and continuing for a month after the last potential exposure. The hyclate form of doxycycline is similar to the monohydrate, but is considered (with relatively little evidence) to cause a bit more nausea if it is taken without food. Both forms must not be taken with calcium or iron (that means dairy, mostly).

Big pharma will try to charge you over $100 to fill your prescription of generic doxycycline (nevermind any costs involved in getting said prescription; there are some advantages to having a physician as a close relative). Here are some tips:

  • You can grab online "discount coupons" (e.g. at goodRx) that cost you nothing. My understanding of these is that these are wholesale accounts and for some reason pharmacies are required to let you buy at that price if you present the information.
  • The prices after discount will not likely be what is represented on these online webpages, and you're on your own in spite of their published "help line" phone numbers, which lead to (surprise!) an operator ready to enroll you in a program. Anyway, it makes sense to shop around at different pharmacies, and this is complicated by the fact that you can't find out the discount price until you have presented your prescription. In my case i went first to Publix (big supermarket chain in south/central Florida) because it's close, not a drug store, and was supposed to be tied for cheapest (goodRx told me it would be around $70). Well, even though the discount code gave me about $40% off what the good gougers people of Publix where going to charge, it was still over $200 for the ~100 pills i needed! The second place i tried was CVS, and although i have reason to think Walgreens may be somewhat cheaper still, i went ahead and filled the prescription there because (1) the CVS pharmacist was so helpful, (2) the price so much cheaper than Publix pharmacy, and (3) Walgreens is a cancerous blight on the Earth (with CVS not far behind, alas). Total cost was still over $100, so let's say ~$1 a pill. The monohydrate was about $30 cheaper (the pharmacist looked up both for me, bless her), and i preferred that form, anyway.
  • But here's the important tip: i walked into a small chemist's shop (i.e. pharmacy) in Uttarkashi, India. This is nowhereville, a town with as many ruminants and beasts of burden as people just 80 kilometers from Tibet. I asked about doxycycline and he pulled out a bottle. Price: 10¢ a pill. No prescription necessary. If you want to use chemoprophylaxis, do yourself a favor and buy a minimum quantity of doxycycline monohydrate in the US, or none at all if you like, and hit a chemist's shop first thing in India to pick up your bottle. Boom! If a penny saved is a penny earned, you've earned yourself a night or two in a nice hotel. The kicker is that the small print on the bottles of pills CVS charged me dearly for states that they were manufactured in Goa, India. That's a hell of a markup...
    BTW, if you suffer from asthma, you might also ask the chemist about steroid inhalers. Out of curiosity, i did, and my eyes bugged out as he pulled out four different modern formulations, all for less than $10 apiece. To quote the aforementioned "family physician", "Isn't it wonderful what capitalism and a cartel can do?"


More effective than trying to kill the parasitic malaria before they can become entrenched in your body is preventing them from getting inside. This is where long clothing comes in, and it will also protect you from things the pills can't, like dengue fever and a whole panoply of mosquito-transmitted nasties, with the additional advantage of protecting you from the sun and the grime (livestock in the streets, etc...). The weather can be pretty warm in the NW plain during October, but it's not so overpowering that long sleeve shirts and pants are a problem.

Mosquitos will try to bite you right through your clothing, which is where permethrin comes in: it's pretty neat stuff. If you are worried at all about insect-vectored diseases, it's probably worth buying a bottle at a local livestock supply (if you live in a rural area) or online. You can buy the 10% formula intended for treating livestock and dilute it and treat a whole bag full of clothes, or pay about the same amount for a similar volume of premixed 0.5% stuff specifically sold for treating clothing, and treat one outfit. This is a compound based on the compound in chrysanthemums (the flowers) that kills insects. You soak your clothes (and any soft baggage, i'd suggest*) in it, let them dry, and then they repel and/or kill vermin of the invertebrate kind that contact them for the next month or few — even after several washes. It's considered generally safe for humans, and in fact the main reason it can't be used directly on your skin is that enzymes in your skin would break it down too quickly for it to be useful. It isn't supposed to damage synthetics, but make sure you don't buy a formula with petroleum distillates as inactive ingredients: you want the mix with pure water. Permethrin is very popular with hikers in tick-infested areas of the US. *It will also kill any bed bugs that try to hitch a ride and come in contact, so that's a bonus.

Permethrin won't keep the 'skeeters from landing on your skin and biting you, though. There is a newish compound called picaridin that is as effective as DEET (the only effective repellent compound approved for use in the US until relatively recently) and possibly less smelly/harsh. You can also get high-tech dispersions of DEET that have minimal odor and 8 hours of effect. Either one is fine.

In retrospect, my exposure to mosquitos was much less than i had expected, so the chemoprophylaxis was probably an unnecessary precaution. Given the same circumstances of traveling week(s) after monsoon is over in the northern plain and Himalayan foothills, staying in well-enclosed rooms, wearing long sleeves, pants and a hat treated with permethrin with repellent applied most days, and being indoors during most of the high activity dawn and dusk hours, the risk of mosquito bites is very low.

Hopefully this is enough detail to smooth the path for other travelers.