Long-term exposure to malaria risk - How to protect yourself?

I spent almost 5 years working in and out of Africa on various consulting assignments. I travelled to Kenya, Tanzania, Uganda, Madagascar, Malawi, South Africa, Zambia, Nigeria, Ghana and Sudan for work and also visited Mozambique, Zimbabwe, Egypt and Morocco for holidays.

I was not living there full time but travelling every week on Sunday and returning home to Dubai for the weekend. Repeat. Every week. Often, I would chose to spend the weekend there too.

Although I wasn't exposed to the full-time risk of malaria that living there poses the reality is that it only takes one mosquito bite to be infected.

At the beginning, as much as I was totally excited to spend so much time in Africa, I did not want to overlook the risks associated with this and many other diseases. The GP or the tropical units at the hospitals are used to dealing with vacationing people who are exposed for a short period of time only and are unclear and contradictory when it comes to long-term exposure. So I got several messages, contradicting advice, confusing instructions and simply unrealistic recommendations.

If you have ever travelled to a malaria risk area you will have been prescribed the typical malaria tablets available in your country, something that is one of the most universally accepted form of prevention. And you will also know that nothing really protects you from malaria but only helps you recover if you are infected.

You would think, what is the issue then if there are tablets one can take?

The answer is two fold.

On one hand, the side effects of some of the tablets are simply unacceptable. You may feel dizzy, confused and most likely will have trouble sleeping with surreal nightmares and hallucinations. That is pretty much the norm for almost everyone. Regardless of what the information sheet tells you, these are all very common and at least one of my travel party members had that every time we travelled somewhere. Do you want your holiday be ruined by feeling ill for a couple of days every week (most tablets are taken weekly)

On the other hand if you want to avoid these side effects you can take the famous Malarone tablets which have much less side effects but cost a small fortune so are not really an option if you are travelling for an extended period of time (I used to pay euro 50 per packet which coveres you for less than a week's worth of travel). Not to mention that the drug being quite new, the long-term side effects are unclear. 

Malarone never gave me relevant side effects but it is not great for the liver. And who can afford euro 300 per month on malaria tablets? Not to mention that they were not available in Dubai where I was living so had to smuggle them into the country. Not a viable solution.

So trying to weight the alternatives I found myself in a lose-lose situation where no option was really a valid one for the long term. Did I really want to put my body through the processing of so much chemical madness for years to come?

Given the answer was a rotund No I had to be creative with the solution.

After a few weeks of Malarone while I was exploring the reality on the ground and asking the locals what they did I realised that these are the best steps to reduce the risk of catching malaria:

1. Wear long sleeves. No matter what the temperature outside was I was always wearing long sleeves. The only way to truly avoid malaria is to simply avoid being bitten so, logically, avoiding exposed parts is the only way. And not every fabric is born the same way, thin cotton or silk are not going to rpevent a mosquito from biting you, malaria prone areas have smart and adapted mosquitoes who can deal with this adn bite you through the clothes. Same applies for very tight leggings or alike which only offer mild protection
2. Wear socks. Again, the easiest way to get bitten is while sitting in an office with holes on the wall and mosquitoes dancing in the air. You can't see your ankles and mosquitoes are quite keen on that part of the body so wearing socks eliminates that risk too. No matter what the weather was like, I always wore closed shoes and socks, thick ones, mosquitoes can pierce through the thin stocking like socks
3. Create a halo of mosquito repellent. Mosquito repellent is extremely toxic so I did not want to constantly spray it on my remaining exposed parts or when I was sitting by the beach/pool when wearing socks and long sleeves was not an option so whenever possible, I sprayed it around myself to create a physical barrier, on the desk and chair, on my clothes, on the mosquito net
4. Sleep under the mosquito net. Always. Be consistent and anal about it. Make sure the net is tucked under the bed once you are inside and check for any holes of any size which are an entrance for the tiny mosquitoes. Mosquito nets save lives in Africa and it is such a simple item. Most of the bites I used to get back home were always while asleep. High end hotels will usually not have mosquito nets because they constantly spray the rooms and have AC (see next point) but if you are in the bush or in a more basic accommodation make use of them
5. Turn the AC on. Mosquitoes don't like cold areas so if you have it, turn it on and try to set it at a lower temperature than usual to keep them away
6. Use mosquito spray sparingly. I always made sure to carry portable plug-in mosquito repellent which I plugged in even at high-end hotels like Hilton, Serena, etc. because even high-end hotels cannot control every single room it is best to be safe than sorry. Many hotels provide mosquito spray, I almost always sprayed the room with a good amount before leaving for dinner. Because these things are also toxic you don't want to be there when you push a large amount into the air. And if I did not have a bottle in the room I would cal the hotel to come spray in the evening. Most hotels will be able to do so
7. Last but not least, spray mosquito repellent on yourself. There are several brands and options available in the market but if you are going to a truly plush and tropical area where mosquitoes are everywhere the only repellents that will really keep them away are the ones which contain DEET. In some countries DEET is limited by law to 20% content only, I tried to stock on this type of repellent in Africa where the limit can go as far as 50% and whenever possible I sprayed it on my clothes not on my skin because this is really toxic. But be careful, if you spray it on your clothes it may damage them. Avoid delicate fabrics because the DEET will indeed melt certain fabrics like plastic of silk, I have seen it.

Why is the obvious measure, aka spraying mosquito repellent, the last resource?

Repellent is very toxic and if you are constantly keeping it in contact with your skin you will damage it, no kidding so if possible, avoid it. Obviously, if you are by the beach or in an extremely hot place where long sleeves and socks are not an option by all means use it but try to minimise it.

Given that I was in Africa and in high risk areas for so long I carried mosquito repellent with me everywhere, it was one of the staple items in my purse. Even today, when I have not worked in Africa for 3 years, I still carry it in my bag because I realised that with my innate obsession with less travelled places malaria remains a risk in many places in Asia and South America too.

What are your tricks for long-term exposure to malaria?