Do I really need to take antimalarials for this trip?

December 4, 2023 11:42 AM

Going to Costa Rica for 2 weeks at the end of the month. I have all my recommended vaccines but don't really want to take the malaria pills. Without getting alarmist about this, what is your experience or where can I find better information?

Up to date on all my shots - in the last 30 days I've had my COVID and flu shots, just finished the typhoid vaccine, and have received two doses of Twinrix (Hep A and B).

I'm pro-vaccine, I just don't really want to take the antimalarials for the trip. I have them already, and they were fully covered by insurance so I'm not out any money, I just don't want to deal with the side effects. I can get nauseous fairly easily, and in general have strong reactions to new medications - if something's on the "less common list" of side effects, I can reliably get at least one.

I have 30% DEET lotion, a stack of mosquito repellent bracelets for wrists and ankles that could be exposed (beyond long sleeve / pants - I mean, limited science here but why not).

My thinking here is this - people just kind of pop down there all the time without even getting the general vaccines mentioned above. Whether planned or last-minute cheap flights, there are I'm sure tons of tourists who don't take the malaria pills.

So... thoughts? I'm sure this question is more like "can I feel okay about not taking them". Otherwise healthy and have moderate risk tolerance, and good employer-provided medical insurance and Canadian healthcare.

posted by mireille to Health & Fitness (20 answers total)

This seems like a situation where the sensible advice is "talk to your doctor, who knows your history" rather than take a poll of strangers on the internet.

But for what it's worth, the NHS in the UK documents the circumstances under which they recommend chemoprophylaxis. This includes Costa Rica specific advice (e.g. a map and a warning about a recent outbreak) and general guidelines about how to estimate and reduce your risk.
posted by caek at 11:56 AM on December 4, 2023 [1 favorite]

I don't mean this in a trite way, but I think you have to figure out if you'd be ok with getting malaria. Like if the worst consequence happened would you consider that an annoyance or a disaster? If an annoyance then go for it. If a disaster THEN you need figure out how likely it is to actually happen, a question I will leave to others.

Oh whether you take them or not, mosquitos are super annoying so if you plan to be sitting in one place during your mosquito exposure time, take a themacell too. They work great.
posted by If only I had a penguin... at 12:00 PM on December 4, 2023 [6 favorites]

If they recommend you take it, you should take it. A small inconvenience to avoid malaria. I've known two people who had it and it's nothing to take lightly. What is your concern about taking them? I just did a round in March when I went to Ghana. Was hardly an issue and I'm extremely sensitive to most medication.
posted by simonelikenina at 12:00 PM on December 4, 2023 [2 favorites]

Which part of the country are you going?

The majority of the country will likely be in the dry season by the end of the month - so it will presumably be slightly less buggy, though I guess it would depend how soon the dry season starts this year. I looked at the CDC info page, and even in the rainy season, malaria is mostly around Limon (the Caribbean side).

Worth noting that the most common strain right now in CR is the strain that causes the majority of malaria deaths world-wide. This strain can kill really quickly - sadly, in my time in West Africa I was in the vicinity of multiple malaria-induced deaths -it's bad. You don't want to risk it.

In short, if you're not going to the Caribbean side, probably fine, based on the CDC page. If you are though, I wouldn't risk it - I've taken Malarone (at one point, for a year straight), have a number of colleagues who have taken it as well, it's a fairly well-tolerated drug.
posted by coffeecat at 12:03 PM on December 4, 2023 [2 favorites]

It looks like the annoyance vs. disaster outcome depends on how quickly you diagnose and get treatment. So you need to be willing to.drop everything and go to your local tropical disease clinic if you have any symptoms within the 3 months following your trip.
posted by If only I had a penguin... at 12:04 PM on December 4, 2023 [1 favorite]

My first reaction was going to be 'why anitmalarials?' because up until recently antimalarials weren't recommended in CR unless you were up by the Nicaraguan border. Apparently this has changed and there was a recent outbreak in Limón :( It still depends on where you're traveling, though, so depending on your itinerary you might be off the hook.

Many people have no side effects, so maybe you could just try medicating for a day or two while you're still safe at home, as an experiment?
posted by eraserbones at 12:06 PM on December 4, 2023 [1 favorite]

Others will have better advice on Costa Rica specifically, but I wanted to mention my experience with Malorone. I took a three-week course a couple of months ago on a trip to East Africa, and had no side effects. A lot of the time, I didn't even take it with food or milk. Ordinarily, I'm a fairly sensitive person, so I kept my eyes peeled for anything weird going on with my body or health, but didn't see any impact. It is supposed to be a lot easier to tolerate than the previous generation of malaria drugs.
posted by Atrahasis at 12:13 PM on December 4, 2023 [1 favorite]

Response by poster: So... I had gone to a travel clinic at my pharmacy who provided all of the information and the vaccines and the prescriptions based on the specific regions I'll be visiting. I was kind of hoping it was a bit of overkill - they also gave me antibiotics in case I developed severe diarrhea (I don't think that's even how you'd treat it, now that I read about it?), and steroid cream for mosquito bites, and honestly it seemed like way more than the average traveler would even bother with. I think this is coming a bit from so many vaccines in a single month - and I like vaccines, they're a privilege! - but of course I'm just kind of feeling rough from all of that and didn't want new medications to make me feel terrible on the trip.

Thanks all for the recommendations and thoughts - I had been kind of hoping for "nah, you're good" permission, but I'll try taking one before I leave (even before I'm supposed to) and see how it goes. Good to know that they're more tolerated than what I've heard of in the past.
posted by mireille at 12:28 PM on December 4, 2023

So I’ll give my 2 cents on this- I was a Peace Corps volunteer in West Africa. I was supposed to take anti malaria le (mefloquine, then doxy after the mefloquine messed with me mentally). However I didn’t really get many bites at my site and I hated the upset stomach that came with doxy so I stopped taking it. I got malaria. It was so bad that I couldn’t walk and had a 103.something fever. It was the most miserable I’ve ever felt, with a real fear of “will I be ok?”

I fully recovered and these are my take aways
- I never want to have malaria again
- if I needed to be med evac’d or even brought to a hospital I was glad the US government was going to foot the bill (bc I was a PC volunteer)
- if you’re going to risk it, have a rapid test already packed in your bag (buy it in country)
- travel home with extra rapid tests because
- testing and treating for malaria is really expensive in the US
- malaria is a PUBLIC health issue. When you get malaria, that’s not the end of transmission. Mosquitos bite you and then bite other people who get sick and who may not have the same access to treatment as you do.
- I can’t speak to the specific areas of where you are traveling

(Re: diarrhea, the antibiotics would help treat it if it’s bacteria that’s causing it. You don’t really die of diarrhea, but rather dehydration caused by it. Treating diarrhea is a combo of stoping the diarrhea and staying hydrated, with various ways to solve either.)
posted by raccoon409 at 1:20 PM on December 4, 2023 [8 favorites]

Oh, and after I recovered I switched to taking macarons. I stayed adherent to the medication for the rest of my time in Peace Corps, with little to no side effects
posted by raccoon409 at 1:21 PM on December 4, 2023 [1 favorite]

*malarone! I would have been much better with taking it daily if it had been a macaron!
posted by raccoon409 at 3:15 PM on December 4, 2023 [15 favorites]

My hiking buddies and I went to Mount Arenal, Monte Verde, and Playa Esterillos Este for 10 days in Feb this year. We none of us even considered taking anti-malarials. Once we got there, mosquitoes were not in evidence. Mount Arenal was too cold; Monte Verde, too windy, and the beach was too dry. FWIW I took choloroquine for 2 years as a Peace Corps volunteer in Mali, suffered no side effects and never got malaria.
posted by olopua at 3:34 PM on December 4, 2023

I only ever got the wild but not necessarily bad dreams. Take the pills. Any side effects are better than malaria and peeing out your butt for way too long. Oh, that was too graphic? Definitely take the meds.
posted by atomicstone at 4:06 PM on December 4, 2023 [2 favorites]

I'll go against the grain here and provide a counterpoint to the "better safe than sorry" theme. It really heavily depends on where you plan on visiting.

Here is the CDC website for Costa Rica and malaria. The CDC only recommends antimalarials for Limon and Alajuela provinces. I can't imagine being MORE conservative than the CDC recommendations on this topic.

Costa Rica is remarkably diverse in terms of geography for such a small country. You've got tropical beaches just a couple hours drive from cool highlands and everything in between. (Northern Pacific beaches are even noticeably different than southern Pacific beaches.) If you are visiting coffee plantations in the highlands, not many mosquitoes there.

Many people don't know much about Costa Rica and default to thinking of it as a generic, tropical, developing country.

I tend to be very conservative on this sort of thing, but would feel comfortable visiting anything other than Limon without taking the antimalarials. For Alajuela, I would probably only consider taking them if I planned on visiting the lower laying areas closer to the coast. (Much of Alajulea is higher elevation and not really tropical.)

Source - I lived in Costa Rica for 6 months. (In Alajuela province.) I do not remember mosquitoes being a problem while I lived there, and I am usually the first to get bit.
posted by pineapplerunner at 5:30 PM on December 4, 2023 [1 favorite]

I took Malarone for two years straight and never had a single side effect - in fact, I chose to pay $7 per pill out of pocket *because* it has such a drastically lower incidence of side effects, compared to other types of prophylaxis. Is there any reaction in particular you’re worried about?
posted by rrrrrrrrrt at 5:52 PM on December 4, 2023

FWIW, the Canadian government only recommends antimalarials for "Alajuela Province near the border with Nicaragua and Limón Province".
posted by ssg at 6:06 PM on December 4, 2023

Re: the antibiotics, most travelers diarrhea is caused by bacteria and you’ll be VERY grateful to have that azithromycin on hand if it happens to you. I’ve never before prayed so sincerely for sweet merciful death.
posted by jesourie at 10:08 PM on December 4, 2023 [1 favorite]

I lived in/near a malarial zone for several months and my family opted not to take antimalarials, but I would if I was going on vacation for two weeks, because you'll be feeling both really sick and like you really wasted your time if you get malaria a few days in.
posted by bluedaisy at 10:13 PM on December 4, 2023

Where are you going in Costa Rica? There are maps available to where malaria is or is not a risk. a href="https://travelhealthpro.org.uk/country/58/costa-rica#Malaria">This site says "low risk" in Limon Province (Caribbean shore) and "very low risk" everywhere else. So you should be fine with DEET and covering.

Re: diarrhea. Yes. Have the pills on hand. However be mindful, that anti-bacterials kill the bacterial flora inside your gut so you have the opposite problem quickly (eating some yoghurt is recommended for this kind of constipation.)
posted by Dotty at 5:51 AM on December 5, 2023

If you go the no prophylaxis route, make sure to have some option for protecting yourself from mosquitos while sleeping (simple screened tent, treated mosquito net). I was a Peace Corps Volunteer in West Africa and never got malaria, took doxycycline for the entire time. There was another volunteer near me who was sleeping without a mosquito net (assume she was taking prophylaxis, not sure though) and got malaria. If the side effects are the issue you could ask your doctor for advice on which antimalarials are less likely to cause side effects.

I did travel in Africa a fair amount for work later after PC as well for a few weeks at a time and am not sure if I took antimalarials consistently for those trips. But as others have said, getting malaria isn't fun so no need to risk it if you think you could just take the pills.
posted by knownfossils at 9:11 AM on December 5, 2023