Antimalarial medicine advice to travellers following psychosis scare

When student Alana Cutland fell to her death from a light aircraft over Madagascar, the island was shocked.

The 19-year-old student was returning from a research project in the north of the country on July 25, when she fell from the aircraft which was supposed to be carrying her home.

More shocking still was the fact that her death is being investigated in connection to common antimalarial drugs.

Police investigating her death are working to the theory that she jumped while delusional from an adverse reaction to anti-malaria pills.

Malaria is one of the most widespread life-threatening diseases on the planet. Chances are if you've travelled to the tropics or sub-Saharan Africa you will have been advised to take anti-malaria medicines.

Carried by mosquitoes, Unicef estimates around 3.2 billion people – almost half of the world's population – live in areas at risk of the malaria parasite. It is responsible for around half a million deaths a year.

However, the preventable disease is cheaply and easily treated. In many countries malaria medicines such as choloquine are for sale to travellers over the counter.

Due to the widespread area in which the malaria is endemic there are a range of medicines developed to combat it. Like any disease there are a range of treatments with an equally diverse range of pros and cons.

However in 2013, one particularly common was medicine flagged for adverse neuropsychiatric effects. Mefloquine which was used in various branded medicines was given an upgraded warning by the American FDA "due to risk of serious psychiatric and nerve side effects."

The drug which was widely prescribed in to US armed forces and overseas personnel was issued with a "boxed warning, the most serious kind of warning about these potential problems".

Following Cutland's death Lariam pills - a branded form of the medicine - were found in the student's luggage. Lariam has previously been linked to suicide and psychotic episodes in travellers.

Travellers on the medicines would often complain of "malarial dreams" or nightmares, with others having more extreme psychotic reactions. In 2012 it was implicated in a psychotic episode in US Army Sgt. Robert Bales, who was found guilty of the murder of eleven Afghan civilians.

However, though these disturbing side effects have been recognised. The chance of a traveller suffering from the episodes as a result of mefloquine is still extremely low.

"Acute psychiatric events are not uncommon in the general population (2% per year)," said Prof Ron Behrens of the London School of Hygiene and Tropical Medicine, saying that the psychiatric events are just as likely to be brought about from other environmental factors while travelling.

"Foreign travel is considered, to increase this risk, as is the use of psychoactive drugs and/or alcohol taken during travel."

Mefloquine is commonly prescribed for travellers to Madagascar as prevention against falciparum malaria, said Behrens.

A spokesperson from the Ministry of Health confirmed that "It [mefloquine] is not currently being sold in New Zealand although it is still classed as approved - meaning it would only be funded in a hospital setting."

In New Zealand mefloquine is still prescribed in two forms, including Lariam.

However last November this medication was updated by the New Zealand ministry of health with a warning that Lariam "may have sudden serious mental problems," and that it should not be prescribed to people who are currently depressed or have a history of serious mental illnesses.

The Ministry of Foreign Affairs and Trade advises those visiting effected areas to obtain malaria medicines, saying that the biggest danger to travellers is returning undiagnosed.

"In general malaria is a curable disease provided it is diagnosed and treated promptly.

"If you feel unwell during your trip or in the first three weeks after your return, you are advised to seek immediate medical advice and tell the doctor about your travel."

From 2003 until 2016 there were 533 cases of imported malaria in travellers returning to New Zealand. According to Pharmac , Papua New Guinea accounts for 25% of these cases.
India (18.6%) is second for imported malaria cases, with the Solomon Islands(8.8%), Indonesia(6.1%) and Vanuatu(5.9%) being the most common destinations for Kiwi travellers contracting malaria.