Malaria knowledge and utilization of chemoprophylaxis in the UK population and in UK passengers departing to malaria-endemic areas.

BACKGROUND: The burden of imported malaria is predominantly in travellers visiting friends and relatives (VFR) in sub-Saharan Africa. The failure of this group to use chemoprophylaxis is recognized as the most important risk factor for the high incidence of disease. Understanding the reasons for failure to follow national recommendations may relate to knowledge, risk perception, cost, and peer pressure. Research into these variables is critical to understand and change practices in this group and this study was designed to explore whether knowledge, risk perception and prophylaxis use differs between travellers' to various destinations and the rest of the UK population. METHODS: Two face-to-face questionnaire surveys were conducted to collect information on demographics, malaria knowledge, source, and quality of pre-travel advice, past travel experience and perceived malaria threat. One was an IPSOS survey of individuals representative of the UK population. The other was a departure lounge survey (Civil Aviation Authority (CAA)) of passengers departing to malarious regions detailing destinations and use of chemoprophylaxis. RESULTS: Around a quarter of the 1,991 UK population surveyed had previously travelled to a malarious area. Five-hundred departing passengers were interviewed, of which 80% travelled for leisure (56% VFR's) and 42% were travelling to West Africa. Malaria knowledge among the UK population (score 58.6) was significantly lower than that of individuals who had previously travelled or were travelling (63.8 and 70.7 respectively). Malaria knowledge was similar in individuals who had and had not sought pre-travel advice and travellers using and not using chemoprophylaxis for their journey. Leisure travellers to Ghana and Nigeria were predominantly VFRs (74%), whilst 66% of travellers to Kenya were tourists. Despite similar high knowledge scores and perceived (>90%) threat of the lethality of malaria in the three groups, chemoprophylaxis use in Nigerians (50%) was substantially lower than in passengers departing to Kenya (78%) and Ghana (82%). More frequent annual return visits were made to Nigeria (72%) than to Ghana (38%) or Kenya (23%). CONCLUSION: Travellers had more malaria knowledge than the non-travelled UK population. Malaria knowledge, perceived threat, travel experience, and quality of pre-travel advice appear unrelated to the use of chemoprophylaxis in passengers. Reducing malaria in VFR travellers will require strategies other than improving malaria knowledge and enhancing malaria risk awareness

Imported malaria among people who travel to visit friends and relatives: is current UK policy effective or does it need a strategic change?

BACKGROUND: The proportion of all imported malaria reported in travellers visiting friends and relatives (VFRs) in the UK has increased over the past decade and the proportion of Plasmodium falciparum malaria affecting this group has remained above 80% during that period. The epidemiological data suggest that the strategies employed in the UK to prevent imported malaria have been ineffective for VFRs. This paper attempts to identify possible reasons for the failure of the malaria prevention strategy among VFRs and suggest potential alternatives. METHODS: A review of the current UK malaria prevention guidelines was undertaken and their approach was compared to the few data that are available on malaria perceptions and practices among VFRs. RESULTS: The current UK malaria prevention guidelines focus on educating travellers and health professionals using messages based on the personal threat of malaria and promoting the benefits of avoiding disease through the use of chemoprophylaxis. While malaria morbidity disproportionately affects VFRs, the mortality rates from malaria in VFRs is eight times, and severe disease eight times lower than in tourist and business travellers. Recent research into VFR malaria perceptions and practices has highlighted the complex socio-ecological context within which VFRs make their decisions about malaria. These data suggest that alternative strategies that move beyond a knowledge-deficit approach are required to address the burden of malaria in VFRs. DISCUSSION: Potential alternative strategies include the use of standby emergency-treatment (SBET) for the management of fevers with an anti-malarial provided pre-travel, the provision of rapid diagnostic testing and treatment regimen based in general-practitioner surgeries, and urgent and walk-in care centres and local accident and emergency (A&E) departments to provide immediate diagnosis and accessible ambulatory treatment for malaria patients. This latter approach would potentially address some of the practical barriers to reducing the burden of malaria in VFRs by moving the process nearer to the community