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“The best laid plans”
Do those who have been given malaria prophylaxis use it
correctly?
Jane Chiodini MSc RGN RM FFTM RCPS(Glasg)
Joint Conference of the Faculty of Travel Medicine and Faculty of Occupational Medicine. Tuesday 11th September 2012
Photo credit James Gathany
Outline of this session
• Setting the scene
• What do we mean by malaria prophylaxis?
• The evidence – What are the problems
– Who is having difficulty
• Strategies from the literature
• Tips and solutions
To set the scene –
malaria and UK travellers
©National Geographic
Malaria – the key facts
• Malaria is a life-threatening disease caused by parasites that are transmitted to people through the bites of infected mosquitoes.
• In 2010, malaria caused an estimated 655 000 deaths (with an uncertainty range of 537 000 to 907 000), mostly among African children.
• Malaria is preventable and curable. • Increased malaria prevention and control
measures are dramatically reducing the malaria burden in many places.
• Non-immune travellers from malaria-free areas are very vulnerable to the disease
when they get infected.
http://www.who.int/malaria/world_malaria_report_2011/en/ WHO Malaria Fact sheet No. 94 – April 2012
http://www.who.int/mediacentre/factsheets/fs094/en/index.html#
UK malaria cases 1992 - 2011
http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1317133806543
Health Protection Agency Malaria Reference Laboratory data http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Malaria/EpidemiologicalData/
Malaria Imported to the UK 2009 2010 2011
Plasmodium falciparum 1179 1263 1149
Plasmodium vivax 205 350 416
Plasmodium ovale 69 99 77
Plasmodium malariae 36 37 31
Mixed infections 6 12 4
TOTAL 1495 1761 1677
Number of DEATHS 6 7 8
6 falciparum 2 vivax
Who is getting malaria? ……. UK Malaria Cases 2011
VFR travellers
Holiday travellers
Business travellers
Health Protection Agency Malaria Reference Laboratory data
Year Chemoprophylaxis not taken by
2005 78%
2007 83%
2009 84%
2011 84%
Health Protection Agency Malaria Reference Laboratory data www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Malaria/EpidemiologicalData
Why do they get malaria? Malaria cases, all ages and prophylaxis by year
Every case of malaria in a traveller represents a failure:
• of public health and the travel industry to promote awareness of the risk
• of the traveller to seek pre-travel health advice
• of the health care provider to provide appropriate advice
• of the traveller to adhere to appropriate recommendations for preventing infection
Keystone J, Kozarsky P. in Schlagenhauf-Lawlor P. Travelers’ Malaria 2nd Edn. Ch 26: 288-393
F A I L U R E
What do we mean by malaria prophylaxis?
A
B C D
UK Guidance
• New guidelines will be available online later this year
• Go to www.malaria-reference.co.uk or www.hpa.org.uk and search on malaria
Chiodini P, Hill D, Lalloo D et al. Guidelines for malaria prevention in travellers from the United Kingdom. London, Health Protection Agency, 2007
Individuals’ knowledge
Important to be aware of guidance and have good standards of practice
Chiodini J, Boyne L, Stillwell A, Grieve S. Travel health nursing: career and competence development, RCN guidance. RCN:London 2012 Chiodini JH et al. Recommendations for the practice of travel medicine. Travel Med Infect Dis. 2012 May;10(3):109-28.
Latest Malaria Research
• To determine which travellers with malaria are at greatest risk of dying
• 20 year observational study based on UK national data
• 25,054 patients with Plasmodium falciparum malaria of whom 184 died between 1987 and 2006
Checkley et al. BMJ 2012 http://www.bmj.com/content/344/bmj.e2116
Results
• The highest cases of were malaria were seen in VFRs but they were far less likely to die
• Overall case fatality was 3.0% in tourists compared with 0.32% in VFRs
• Mortality increased with age, with the elderly almost ten times more likely to die than those aged 18-35 years
• Death rate among tourists is particularly high when returning from a ‘winter sun’ holiday in the Gambia
Checkley et al. BMJ 2012 http://www.bmj.com/content/344/bmj.e2116
Learning from the Results
For tourists, poor uptake of malaria tablets and low
awareness of the dangers of malaria may well be factors
for death from malaria
A B C D
Checkley et al. BMJ 2012 http://www.bmj.com/content/344/bmj.e2116
Conclusions • Those of African heritage who are VFRs are far more
likely to get malaria due to poor prophylaxis uptake, but tourists travelling from Europe, especially on winter sun holidays in Africa are far more likely to die from the disease once acquired, with the risk increasing further in older tourists
• Pre travel advice needs to include importance of taking malaria tablets and prompt presentation for treatment
• Make holidaymakers more aware malaria is common, fatal and needs early diagnosis
Checkley et al. BMJ 2012
Occupational travellers
“Those travelling overseas for work”
Heterogeneous group
Covers a variety of professions
Ranges from short-term city based business executives to expatriates
Patel D. Occupational travel. Occupational Medicine : in depth review 2011; 61(1), 6-18 http://occmed.oxfordjournals.org/content/61/1/6.full.pdf+html
Occupational travellers • Appear well informed regarding malaria risk
– But comply poorly with preventive measures
• Compliance in expatriates – Is particularly poor – Decreases over time
• Reasons for non-compliance – Presumed immunity – Forgetfulness – Conflicting advice – Concerns over side effects – Daily medication
Patel D. Occupational travel. Occupational Medicine : in depth review 2011; 61(1), 6-18 http://occmed.oxfordjournals.org/content/61/1/6.full.pdf+html
Business Travellers
• Business travellers are well informed regarding
– mode of transmission
– the risk of malaria at specific destinations
• Business travellers had poor knowledge regarding
– localized risk of transmission
– anti-mosquito measures
– details of malaria symptoms
– incubation time
Weber R, Schlagenhauf P, Amsler L et al. Knowledge, Attitudes and Practices of Business Travellers Regarding Malaria Risk and Prevention J Travel Med 2003; 10:219-224
• Business travellers need to have better knowledge on
– when, where and how malaria infection can be prevented
– why personal protection measures and chemoprophylaxis after travel were so important
• Emphasis needs placing on
– Informing travellers regarding risk areas
– Anti-mosquito measures
– Symptoms
– Chemoprophylaxis
– Standby treatment
Business Travellers
Weber R, Schlagenhauf P, Amsler L et al. Knowledge, Attitudes and Practices of Business Travellers Regarding Malaria Risk and Prevention J Travel Med 2003; 10:219-224
The military traveller
• 225 US marines deployed to Liberia for 10 days in 2003
– 36% P.falciparum attack rate in those on land
• 55% compliance with mefloquine prophylaxis
• 45% used insect repellent
• 12% used permethrin-treated clothing
• Bed nets not available
Whitman TJ et al. An Outbreak of Plasmodium falciparum Malaria in U.S. Marines Deployed to Liberia Am J Trop Med Hyg. 2010 August 5; 83(2): 258-265 and Fukuda MM. Editorial: Malaria in the US Armed Forces: A Persistent but Preventable Threat. MSMR Vol. 19 No.1 Jan 2012.
Was the solution already known?
“Good doctors are of no use without good discipline. More than half the battle against
disease is not fought by doctors, but by regimental officers….….if mepacrine was not
taken, I sacked the commander.
I only had to sack three; by then the rest had got my meaning”
Lt.General William Slim, British Army, 1943
The Military Traveller
• 1170 Swedish soldiers in Liberia 2004 to 2006
– 7000 person-months’ malaria exposure
• No cases of P.falciparum malaria
• Why not?
– All instructed prior to deployment to use DEET and bed nets
– Chemoprophylaxis encouraged by command and health personnel
– Soldiers took tablets together at the same time of day
Andersson H et al. Well tolerated chemoprophylaxis uniformly prevented Swedish soldiers from Plasmodium falciparum malaria in Liberia, 2004-2006. Mil Med. 173, 12:1194. 2008 and Fukuda MM. Editorial: Malaria in the US Armed Forces: A Persistent but Preventable Threat. MSMR Vol. 19 No.1 Jan 2012
Why travellers get malaria
• Not seeking advice
• Not taking advice
• Data on not taking tablets or completing the course
• Taking herbal and homeopathic remedies
• Receiving poor advice'
1. Chiodini J. Malaria prevention advice in a primary care setting. Travel Medicine and Infectious Disease. 2009; 7: 165-168
Example of poor advice received by travellers in a primary care setting
1997 2006
Mosquito nets 84% 83%
Impregnation of mosquito nets 38% 38%
Insect repellents 97% 92%
DEET 49% 75%
Eucalyptus based repellents 12% 17%
Air conditioned/screened accommodation
39% 62%
Insect repellent room sprays 49% 53%
Mosquito coils / heating mats 60% 39%
Chiodini J. Malaria prevention advice in a primary care setting. Travel Medicine and Infectious Disease. 2009; 7: 165-168
Other providers of advice – travel agents and pharmacist
• While travel agents’ health knowledge on some topics is adequate, in other areas it is inconsistent (1)
• With few exceptions, the travel industry has not taken the responsibility of educating itself and its clients about the risk of malaria associated with travel (2)
• Improving the safety and accuracy of pharmacists’ advice would increase significantly travellers’ access to reliable health information (3)
1. Ivatts SL et al. J Travel Med 1999: 6; 76-80 2. Keystone J, Kozarsky P. in Schlagenhauf-Lawlor P. Travelers’ Malaria 2nd Edn. Ch 26: 288-393 3. Toovey S. . J Travel Med 2006: 13(3): 161-165
Factors impacting on imported malaria
Increase in numbers of travellers to malarious areas
Increase in malaria transmission in various destinations
Increase in drug resistance
Keystone J, Kozarsky P. in Schlagenhauf-Lawlor P. Travelers’ Malaria 2nd Edn. Ch 26: 288-393
Lack of understanding by
many travellers of the risk and serious nature of the illness
Resultant disinclination of travellers to seek pre-travel health advice and to adhere to recommendations
Factors particularly apply to VFRs and long term travellers
PAST PRESENT
Resolving the problem?
Resolving the problem?
Travellers’ malaria is a failure
• Major cause of this is failure is lack of adherence to prevention measures
• Source of the problem can be found in analysing the Health Belief Model, so too can the solution
• Key to the solution is identifying innovative and creative ways of communicating health advice to travellers so that they will be convinced of their vulnerability and will take responsibility for disease prevention
• Education must be patient centred
Keystone J, Kozarsky P. in Schlagenhauf-Lawlor P. Travelers’ Malaria 2nd Edn. Ch 26: 288-393
Health Belief Model applied to Malaria
Individual Perception Modifying Factors Likelihood of Action
Perceived susceptibility to malaria
Seriousness of malaria
Age, sex, ethnicity Personality
Socio-economics Knowledge
Perceived threat of malaria
Cues to action • Targeted education to the individual on malaria • Symptoms of disease • Medical information on malaria
Perceived benefits vs barriers to behavioural
change e.g. Peer pressure, misinformation, the ‘know alls’!
Likelihood of behavioural change will be affected
by the personality of the individual and by the quality of advice they
receive
Risk communication
• Is central to effective decision making in modern healthcare
• Is not straightforward, but there are some simple rules for the clear presentation of risk
– Be honest about what we know
– Be honest about what we do not know
– Explore people’s understanding, reactions and opinions about this information
Thomson R, Edwards A, Grey J. Risk communications in the clinical consultation. Clinical Medicine 2005; 5: 465-469
Communication is
key
Travel clinic communication and non-adherence to malaria chemoprophylaxis
• Important to have a clear structure
• Take a proactive approach to eliciting and responding to concerns
• Highlighting key issues
• Managing the flow of information
• Facilitating shared decision making
• Being creative in problem solving
Farquharson L, Noble L, Behrens R. Travel Medicine and Infectious Disease 2011; 9, 278-283
Good encounters
Prioritises malaria at the outset
But your big risk, of course is
malaria
Information about risk is understandable
You’ll be bitten once every day by an infected
mosquito
Personal teaching
www.janechiodini.co.uk
Mick - patient with malaria
Video clip on patient with malaria from ‘Help I caught it abroad’ Broadcast on ITV and ITV 2 http://specialeditionfilms.com/
Patient information book for traveller to read in waiting room prior to consultation, covers basics of malaria prevention advice with less on chemoprophylaxis, allowing
more time to focus on this aspect within the appointment
Available from the tools section on www.janechiodini.co.uk
Training and videos
Malaria course includes an animated lifecycle of the malaria parasite and a
video of malaria prevention consultation – all available at
www.janechiodini.co.uk under tab ‘Malaria Matters’
A
B
C D
A = Awareness of Risk
What do you
know about
malaria?
You cannot get malaria from dirty food and drinks
Malaria is not sexually transmitted
There is NO vaccine to protect against malaria
Homoeopathic and herbal remedies are not effective in preventing or treating malaria
Electric buzzers do not work
There is no evidence that bath oils, garlic capsules, vitamin B12, yeast extracts are effective in bite prevention
First measure - dispelling the myths!
Maps found at www.travax.nhs.uk and www.fitfortravel.nhs.uk
B = Bite prevention
To see is to remember To do is to understand
Confucius
D = Diagnosis
Prompt action for diagnosis and treatment are ESSENTIAL
Key messages for diagnosis
• Malaria is very serious
• You can die from this disease
• Essential you seek medical help immediately
• Malaria presents like a flu like illness – report that you have been abroad
• This is one time when you must never think “I don’t like to bother the doctor!”
C = Chemoprophylaxis and Compliance
Individualised malaria leaflets
Short Message Service (SMS) to improve chemoprophylaxis compliance?
• Not demonstrated to improve compliance but further study recommended (1)
• Such services seem to be an effective tool for increasing compliance with vaccination schedules (2)
1. Ollivier et al (2009) Malaria Journal 8:236 2. Vilella et al (2004) Preventive Medicine 38;4:503-9
Personal actions
Standby Emergency Treatment
Pros
• Fake antimalarials “out there”
• Useful where no adequate medical services (diagnosis and treatment)
Cons
• Much drug unused
• Instructions on seeking help within 24 hours may not be followed
• The illness may not be malaria, delaying diagnosis of other serious conditions
Schlagenhauf P, Petersen E. Standby emergency treatment of malaria in travelers: experience to date and new developments. Expert Rev Anti Infect Ther. 2012 May;10(5):537-46. http://www.ncbi.nlm.nih.gov/pubmed/22702318
In the consultation
• Having sufficient time is crucial for best practice
Chiodini J, Boyne L, Stillwell A, Grieve S. Travel health nursing: career and competence development, RCN guidance. RCN:London 2012 http://www.rcn.org.uk/__data/assets/pdf_file/0006/78747/003146.pdf
In conclusion
• Advisers must be knowledgeable
• Advice must centre on ABCD
• Be realistic and patient centred
• Sufficient time is crucial
• Good communication skills are essential
• www.hpa.org.uk
• www.malaria-reference.co.uk
• http://www.who.int/topics/malaria/en/
• http://malaria.wellcome.ac.uk/
• http://malaria.lshtm.ac.uk/
• http://malaria.lshtm.ac.uk/malaria-module
• www.malariahotspots.co.uk
• www.nathnac.org
• www.travax.nhs.uk
• www.fitfortravel.nhs.uk
• www.fco.gov.uk
• www.travelhealth.co.uk/businesstravel/advice/index.html
• www.janechiodini.co.uk
Useful weblinks