Knowledge, attitudes and practices of business travelers regarding malaria risk and prevention

Identifying and characterizing high-risk populations in pilot malaria elimination districts in Madagascar: a mixed-methods study

BACKGROUND

In Madagascar, the districts of Antsirabe II, Faratsiho and Antsiranana I have relatively low malaria incidence rates and have been selected by the National Malaria Control Programme for pilot elimination strategies. The districts have residual transmission despite increasing coverage and quality of malaria services. This study sought to identify priority subpopulations at highest risk for malaria and collect information on intervention preferences and methods that will inform subnational tailoring of malaria service delivery.

METHODS

This mixed methods study employed (i) a quantitative malaria risk factor assessment in Antsirabe II and Faratsiho comprising a test-negative frequency matched case-control study and a qualitative risk factor assessment in Antsiranana I; and (ii) a qualitative formative assessment in all three districts. For the case-control study, a mixed effects logistic regression was used with age, sex and district included as fixed effects and health facility included as a random effect. The qualitative risk factor assessment used semi-structured interview guides and key informant interviews. For the qualitative formative assessment in the three districts, a summary report was generated following semi-structured interviews and focus group discussions with high-risk populations (HRPs) and stakeholders.

RESULTS

In Antsirabe II and Faratsiho districts, rice agriculture workers, outdoor/manual workers, particularly miners, and those with jobs that required travel or overnight stays, especially itinerant vendors, had higher odds of malaria infection compared to other (non-rice) agricultural workers. In Antsiranana I, respondents identified non-rice farmers, mobile vendors, and students as HRPs. Risk factors among these groups included overnight stays and travel patterns combined with a lack of malaria prevention tools. HRPs reported treatment cost and distance to the health facility as barriers to care and expressed interest in presumptive treatment and involvement of gatekeepers or people who have influence over intervention access or participation.

CONCLUSIONS

The study results illustrate the value of in-depth assessments of risk behaviours, access to services and prevention tools, surveillance and prevention strategies, and the involvement of gatekeepers in shaping subnational tailoring to reach previously unreached populations and address residual transmission in elimination settings.

Knowledge, attitudes, and practices about malaria in travelers to risk areas in Peru

BACKGROUND

Travelers from international airports who travel to endemic countries know the knowledge, attitudes, and practices (KAP) about malaria; however, it is still unknown to interprovincial travelers who go to the endemic regions of Peru. The objective is to determine the level of KAP about malaria among Peruvian travelers to risk areas.

METHODS AND PRINCIPAL FINDINGS

This are an analytical cross-sectional study of 277 passengers from a bus station in a low-risk area of malaria in Peru, whose destination was an intermediate/high-risk area during February-March 2018. Absolute and relative frequencies of personal variables associated with the trip and KAP were estimated.

RESULTS

Less than 50% know the main symptoms of malaria and at what time of day there is a greater risk of becoming infected. Five out of ten people knew which practices were preventive against contagion, and four out of ten answered that the treatment can be given in a health establishment, pharmacy, or by some healer.

CONCLUSIONS

Travelers to malaria endemic areas have a low level of knowledge and practice (39.7%) as well as an inadequate preventive attitude (35.4%) against malaria.

Knowledge of the Sexual Transmission of Zika Virus and Preventive Practices Against Zika Virus Among U.S. Travelers

Individuals are often at increased risk of acquiring infectious disease while traveling. We sought to understand knowledge, attitudes and practices (KAP) regarding Zika virus among travelers from the United States. A total of 1043 study participants were recruited from a probability-based internet panel. Participants self-reported their knowledge of Zika infection and modes of transmission, and identified actions they had taken to prevent Zika infection and transmission including actions to prevent unintentional pregnancy since becoming aware of the Zika virus. Logistic regression was used to model the odds of taking preventive actions against Zika infection with adjustment for potential confounding factors. Knowledge of the sexual transmissibility of Zika virus significantly increased the odds of taking a preventive action against Zika infection, especially condom use or sexual abstention. Participants reported preferences for receiving information about Zika from private doctors and from the Internet. Discrepancies between where travelers seek information about Zika and how they would like to receive information regarding Zika were also found. These findings suggest that improving targeted messaging through online media may increase awareness of the sexual transmissibility of Zika as well as improve health communications with U.S. travelers. Travelers who are unaware of potential disease risks are less likely to adopt personal protective measures to protect themselves and reduce disease spread. Thus, future work should focus on improving communication and providing education to adopt effective prevention strategies while traveling.

Malaria standby emergency treatment (SBET) for travellers visiting malaria endemic areas: a systematic review and meta-analysis

BACKGROUND

Malaria prevention methods for travellers to low or moderate malaria risk areas vary and remain controversial. Standby emergency treatment (SBET) for malaria is one possible strategy increasingly recommended since 1988 with little evidence on its effectiveness or how it is truly being used.

METHODS

A systematic review and meta-analysis were performed based on a structured search in Embase, Medline, PubMed, Cochrane and Web of Science on 7 September 2018. The primary outcome was the overall prevalence of SBET use in travellers, and secondary outcomes were the proportion carrying SBET, the response to fever [use of SBET, health facility attendance and use of malaria rapid diagnostic test (mRDT)], adverse events to SBET and the proportion using SBET incorrectly (incorrect dosage/duration). The pooled SBET use prevalence was analysed using a random effects model. A descriptive summary was done to present secondary outcomes. The study protocol was registered with PROSPERO CRD42018103703.

RESULTS

A total of 11 studies were eligible for inclusion among the 1027 titles identified by our search. The studies included 7/11 prospective cohort studies that recruited pre-travel clinic attendees in Europe and 4/11 cross-sectional studies, of which 3 recruited travellers at airports before their return home from Southeast Asia and Africa and 1 from an employee registry including long-term travellers. The overall pooled prevalence of SBET use among the 26 403 travellers was 2.5% (95% confidence interval, 1.1-4.3%; range, 0.4-10.8%). There was significant variation in the proportion of travellers carrying SBET medication (40-100%), the proportion of travellers with appropriate response to fever (23-100%), adverse events (0-33%) and incorrect dosage/duration of SBET (0-100%).

CONCLUSION

Adherence to the proposed recommendations for SBET use, notably the response to fever, was poor. If the use of SBET is to be pursued, modifications to the current SBET strategy should be considered, such as better selection of travellers at higher risk for malaria and the potential addition of mRDTs.

Low adherence with national travel medicine recommendations in Belgian expatriate children: A retrospective analysis

BACKGROUND

Expatriates (expats) from European countries regularly migrate to low-income countries where infectious diseases are more prevalent. Little evidence exists however on pediatric expatriates' compliance with preventive measures related to infectious diseases. This study aims to evaluate compliance in Belgian expat-children.

METHODS

Data of 135 Belgian expat-children, visiting the Institute of Tropical Medicine (Antwerp, Belgium), were collected from clinical notes, laboratory results and from a web-based immunization-register. Information on routine vaccinations, yellow fever, hepatitis A, rabies, typhoid fever, meningococcal ACW₁₃₅Y, Japanese encephalitis, BCG vaccine and anti-malaria chemoprophylaxis was collected.

RESULTS

Overall, 87% of expat-children were up-to-date with their routine vaccinations. Although all children were eligible for hepatitis A, typhoid and rabies vaccination, only 8-21% were fully vaccinated. Only 29 and 61% of eligible children were vaccinated against meningococcal (ACW₁₃₅Y) or yellow fever respectively. Finally, only 10% of children who lived in malaria-endemic-areas, reported chemoprophylaxis-use.

CONCLUSION

Although routine vaccination coverage in expat-children seems adequate, additional preventive measures are often needed. Whether this is due to lack of high-quality health care-access, fear of side-effects or insufficient knowledge about the risks/available preventive measures, remains elusive. Nevertheless, expats seem to constitute a separate risk-group for infectious diseases and destination-related health issues.

Business travel-associated illness: a GeoSentinel analysis

Background

Analysis of a large cohort of business travelers will help clinicians focus on frequent and serious illnesses. We aimed to describe travel-related health problems in business travelers.

Methods

GeoSentinel Surveillance Network consists of 64 travel and tropical medicine clinics in 29 countries; descriptive analysis was performed on ill business travelers, defined as persons traveling for work, evaluated after international travel 1 January 1997 through 31 December 2014.

Results

Among 12 203 business travelers seen 1997-2014 (14 045 eligible diagnoses), the majority (97%) were adults aged 20-64 years; most (74%) reported from Western Europe or North America; two-thirds were male. Most (86%) were outpatients. Fewer than half (45%) reported a pre-travel healthcare encounter. Frequent regions of exposure were sub-Saharan Africa (37%), Southeast Asia (15%) and South Central Asia (14%). The most frequent diagnoses were malaria (9%), acute unspecified diarrhea (8%), viral syndrome (6%), acute bacterial diarrhea (5%) and chronic diarrhea (4%). Species was reported for 973 (90%) of 1079 patients with malaria, predominantly Plasmodium falciparum acquired in sub-Saharan Africa. Of 584 (54%) with malaria chemoprophylaxis information, 92% took none or incomplete courses. Thirteen deaths were reported, over half of which were due to malaria; others succumbed to pneumonia, typhoid fever, rabies, melioidosis and pyogenic abscess.

Conclusions

Diarrheal illness was a major cause of morbidity. Malaria contributed substantial morbidity and mortality, particularly among business travelers to sub-Saharan Africa. Underuse or non-use of chemoprophylaxis contributed to malaria cases. Deaths in business travelers could be reduced by improving adherence to malaria chemoprophylaxis and targeted vaccination for vaccine-preventable diseases. Pre-travel advice is indicated for business travelers and is currently under-utilized and needs improvement.

Self-diagnosis of malaria by travellers: a cohort study on the use of malaria rapid diagnostic tests provided by a Swiss travel clinic

Background

The WHO recommends that all suspect malaria cases be tested before receiving treatment. Rapid diagnostic tests (RDT) for malaria can be performed reliably by community health workers with no formal medical background and thus, RDTs could also be provided to travellers for self-diagnosis during visits to endemic regions.

Methods

RDTs were proposed during pre-travel consultations to pre-defined categories of travellers. A training run on their own blood was performed and, if carried out correctly, the traveller was given a written procedure on how to perform the test and act on its result. The travellers were then proposed to buy a malaria RDT kit and were interviewed upon their return.

Results

From February 2012 to February 2017, 744 travellers were proposed RDTs and 692 performed the training run (one could not complete it due to a hand tremor). Among the 691 subjects included, 69% travelled to moderate- or low-risk areas of malaria, 18% to high-risk areas and 13% to mixed-risk areas. The two most frequent categories of travellers to whom RDTs were proposed were long-term travellers (69%) and those travelling to remote areas (57%). 543 travellers (79%) were interviewed upon return. During their trip, 17% (91/543) had a medical problem with fever and 12% (65/543) without fever. Among 91 febrile patients, 57% (52/91) performed an RDT, 22% (20/91) consulted immediately without using the test, and 21% (19/91) did neither. Four RDTs (4/52; 8%) were positive: 2 in low-risk and 2 in high-risk areas (0.7% attack rate of self-documented malaria). Two travellers could not perform the test correctly and attended a facility or took standby emergency treatment. Four travellers with negative results repeated the test after 24 h; all were still negative. Carrying RDTs made travellers feel more secure, especially when travelling with children.

Conclusions

1/6 travellers experienced fever and 4/5 of those reacted appropriately: more than half used RDTs and a quarter consulted immediately. Four travellers (including 2 from low-risk areas) diagnosed themselves with malaria and self-treated successfully. This strategy allows prompt treatment for malaria in high-risk groups and may avoid over-diagnosis (and subsequent inappropriate treatment) of malaria on-site.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-017-2079-2) contains supplementary material, which is available to authorized users.

Day-to-Day Population Movement and the Management of Dengue Epidemics

Dengue is a growing public health problem in tropical and subtropical cities. It is transmitted by mosquitoes, and the main strategy for epidemic prevention and control is insecticide fumigation. Effective management is, however, proving elusive. People’s day-to-day movement about the city is believed to be an important factor in the epidemiological dynamics. We use a simple model to examine the fundamental roles of broad demographic and spatial structures in epidemic initiation, growth and control. We show that the key factors are local dilution, characterised by the vector–host ratio, and spatial connectivity, characterised by the extent of habitually variable movement patterns. Epidemic risk in the population is driven by the demographic groups that frequent the areas with the highest vector–host ratio, even if they only spend some of their time there. Synchronisation of epidemic trajectories in different demographic groups is governed by the vector–host ratios to which they are exposed and the strength of connectivity. Strategies for epidemic prevention and management may be made more effective if they take into account the fluctuating landscape of transmission intensity associated with spatial heterogeneity in the vector–host ratio and people’s day-to-day movement patterns.

Pre-Travel Medical Preparation of Business and Occupational Travelers: An Analysis of the Global TravEpiNet Consortium, 2009 to 2012

The aim of the study was to understand more about pre-travel preparations and itineraries of business and occupational travelers.

Methodologies for measuring travelers' risk perception of infectious diseases: A systematic review

Numerous studies in the past have stressed the importance of travelers' psychology and perception in the implementation of preventive measures. The aim of this systematic review was to identify the methodologies used in studies reporting on travelers' risk perception of infectious diseases. A systematic search for relevant literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. There were 39 studies identified. In 35 of 39 studies, the methodology used was that of a knowledge, attitude and practice (KAP) survey based on questionnaires. One study used a combination of questionnaires and a visual psychometric measuring instrument called the 'pictorial representation of illness and self-measurement" or PRISM. One study used a self-representation model (SRM) method. Two studies measured psychosocial factors. Valuable information was obtained from KAP surveys showing an overall lack of knowledge among travelers about the most frequent travel-associated infections and associated preventive measures. This methodological approach however, is mainly descriptive, addressing knowledge, attitudes, and practices separately and lacking an examination of the interrelationships between these three components. Another limitation of the KAP method is underestimating psychosocial variables that have proved influential in health related behaviors, including perceived benefits and costs of preventive measures, perceived social pressure, perceived personal control, unrealistic optimism and risk propensity. Future risk perception studies in travel medicine should consider psychosocial variables with inferential and multivariate statistical analyses. The use of implicit measurements of attitudes could also provide new insights in the field of travelers' risk perception of travel-associated infectious diseases.

Has the economic crisis led to a new risk profile for international travellers?

INTRODUCTION

The economic world crisis has led to the migration of European workers to developing countries with a high incidence of infectious diseases. The objective of this study was to assess whether this context has produced an increase in the risks to international travellers for work reasons (TWR).

METHODS

Observational, retrospective study. The study population included TWR who were attended before travelling at an International Health Unit in the year 2007 (the year before the initiation of the European crisis) and in the year 2012 (when the structural crisis was established). A comparative socioeconomic analysis was performed as well as an analysis of the risk factors present in both groups.

RESULTS

In 2007 and 2012 a total of 9,197 travellers were attended. Of these, there were 344 TWR (3.4%); 101 TWR (2.8%) in 2007 and 243 TWR (4.5%) in 2012 (p<0.001). The average age of the travellers was 38.1 years (SD: 10.57). The most common destination was Sub-Saharan Africa, in 164 (47.6%) of the cases. Malaria chemoprophylaxis was prescribed to 152 travellers (44%) and 80 presented comorbidity (23.25%). The TWR from 2012 presented a significantly greater age (p=0.05), more comorbidity (p=0.018) and a greater proportion of stays in rural areas (p=0.0009) for longer time periods (p=0.001).

CONCLUSIONS

At 5 years from the start of the economic crisis, there was a change in the profile of TWR. Their number has increased significantly, as has the proportion who present risk factors for contracting imported diseases. The International Health Units should adapt to these new circumstances and adopt preventive measures for this population.

Pharmaceutical care model to assess the medication-related risks of travel

BACKGROUND

People are at greater risk of health problems when travelling and a significant number of travel-related health problems are associated with the effects of travel on pre-existing chronic diseases. Medications play a key role in the management of these conditions. However, there is a notable lack of research evaluating the potential medication-related risks associated with travel.

OBJECTIVE

To apply a systematic pharmaceutical care model developed to evaluate potential pharmaceutical risks (PPRs) and pharmaceutical care issues (PCIs) in travellers.

SETTING

Adult travellers leaving Cairns International Airport, Australia, for an international destination.

METHOD

A cross-sectional survey using semi-structured interviews, including a systematic medication history, followed by the application of a pharmaceutical care model to evaluate each participant for PPRs and PCIs.

MAIN OUTCOME MEASURE

Evaluation of standard clinical and travel-related PPRs and PCIs.

RESULTS

Medications for chronic diseases were being taken by 47.7% of the 218 travellers interviewed. Although 75.2% of participants presented with no PPRs, a total of 274 PCIs were identified across 61.5% of the participants, with an average of 2.04 PCIs per participant. The most prevalent PCIs related to the inadequate precautions taken by some travellers visiting malaria-endemic regions. Although 91 participants recognised that they were travelling to malaria-endemic regions, 65.9% of these participants were not using malarial chemoprophylaxis, and only 16.5% were using chemoprophylaxis that fully complied with standard recommendations. The second most prevalent PCI was the need for 18.8% of participants to be educated about their medications. Other PCIs identified have the potential to increase the risk of acute, travel-related conditions, and complicate the care of travellers, if they inadvertently became unwell while overseas.

CONCLUSION

PPRs and PCIs were not identified in all participants. However, the impact of many of the identified medication-related issues could be substantial to the traveller. This study represents the novel application of a pharmaceutical care model to identify potential PPRs and PCIs in travellers that may not be identified by other pre-travel risk assessment methods.

Risk factors for UK Plasmodium falciparum cases

BACKGROUND

An increasing proportion of malaria cases diagnosed in UK residents with a history of travel to malaria endemic areas are due to Plasmodium falciparum.

METHODS

In order to identify travellers at most risk of acquiring malaria a proportional hazards model was used to estimate the risk of acquiring malaria stratified by purpose of travel and age whilst adjusting for entomological inoculation rate (EIR) and duration of stay in endemic countries.

RESULTS

Travellers visiting friends and relatives and business travellers were found to have significantly higher hazard of acquiring malaria (adjusted hazard ratio (HR) relative to that of holiday makers 7.4, 95% CI 6.4-8.5, p < 0. 0001 and HR 3.4, 95% CI 2.9-3.8, p < 0. 0001, respectively). All age-groups were at lower risk than children aged 0-15 years.

CONCLUSIONS

These estimates of the increased risk for business travellers and those visiting friends and relatives should be used to inform programmes to improve awareness of the risks of malaria when travelling.

Business travelers: vaccination considerations for this population

Illness in business travelers is associated with reduced productivity on the part of the employee as well as the employer. Immunizations offer a reliable method of preventing infectious diseases for international business travelers. The authors review the travel patterns of business travelers, available data on illnesses they encounter, their potential travel-associated risks for vaccine-preventable diseases and recommendations on immunizations for this population. Routine vaccines (e.g., measles, tetanus and influenza) should be reviewed to assure that they provide current coverage. The combined hepatitis A and hepatitis B vaccine with a rapid schedule offers options for those with time constraints. Other vaccine recommendations for business travelers need to focus on their destinations and activities and underlying health, taking into account the concept of cumulative risk for those with frequent travel, multiple trips or long stays.

Expatriates ill after travel: results from the Geosentinel Surveillance Network

Background

Expatriates are a distinct population at unique risk for health problems related to their travel exposure.

Methods

We analyzed GeoSentinel data comparing ill returned expatriates with other travelers for demographics, travel characteristics, and proportionate morbidity (PM) for travel-related illness.

Results

Our study included 2,883 expatriates and 11,910 non-expatriates who visited GeoSentinel clinics ill after travel. Expatriates were more likely to be male, do volunteer work, be long-stay travelers (>6 months), and have sought pre-travel advice. Compared to non-expatriates, expatriates returning from Africa had higher proportionate morbidity (PM) for malaria, filariasis, schistosomiasis, and hepatitis E; expatriates from the Asia-Pacific region had higher PM for strongyloidiasis, depression, and anxiety; expatriates returning from Latin America had higher PM for mononucleosis and ingestion-related infections (giardiasis, brucellosis). Expatriates returning from all three regions had higher PM for latent TB, amebiasis, and gastrointestinal infections (other than acute diarrhea) compared to non-expatriates. When the data were stratified by travel reason, business expatriates had higher PM for febrile systemic illness (malaria and dengue) and vaccine-preventable infections (hepatitis A), and volunteer expatriates had higher PM for parasitic infections. Expatriates overall had higher adjusted odds ratios for latent TB and lower odds ratios for acute diarrhea and dermatologic illness.

Conclusions

Ill returned expatriates differ from other travelers in travel characteristics and proportionate morbidity for specific diseases, based on the region of exposure and travel reason. They are more likely to present with more serious illness.

Malaria prevention knowledge, attitudes, and practices (KAP) among international flying pilots and flight attendants of a US commercial airline

BACKGROUND

In 2010, malaria caused approximately 216 million infections in people and 655,000 deaths. In the United States, imported malaria cases occur every year, primarily in returning travelers and immigrants from endemic countries. In 2010, five Plasmodium falciparum malaria cases occurred among crew members of one US commercial airline company (Airline A). This investigation aimed to assess the malaria prevention knowledge, attitudes, and practices (KAP) of Airline A crew members to provide information for potential interventions.

METHODS

The web link to a self-administered on-line survey was distributed by internal company communications to Airline A pilots and flight attendants (FA) eligible for international travel. The survey collected demographic information as well as occupation, work history, and malaria prevention education.

RESULTS

Of approximately 7,000 nonrandomly selected crew members, 220 FA and 217 pilots completed the survey (6%). Respondents correctly identified antimalarial medication (91% FA, 95% pilots) and insect repellents (96% FA, 96% pilots) as effective preventive measures. While in malaria-intense destinations, few FA and less than half of pilots always took antimalarial medication (4% FA, 40% pilots) yet many often spent greater than 30 minutes outdoors after sundown (71% FA, 66% pilots). Less than half in both groups always used insect repellents (46% FA, 47% pilots). Many respondents were unaware of how to get antimalarial medications (52% FA, 30% pilots) and were concerned about their side effects (61% FA, 31% pilots).

CONCLUSION

Overall, FA and pilots demonstrated good knowledge of malaria prevention, but many performed risky activities while practicing only some recommended malaria preventive measures. Malaria prevention education should focus on advance notification if traveling to a malaria-endemic area, how to easily obtain antimalarial medications, and the importance of practicing all recommended preventive measures.

The role of standby emergency medication for falciparum malaria: current opinion

Travellers to malaria-endemic destinations are at risk of significant disease and, sometimes, death. Current malaria protection strategies, including chemoprophylaxis, can never be completely effective. In some cases, protective measures are discontinued or misapplied while the risk of infection still exists. In others, suboptimal measures are used, or even no measures at all, because of poor information or inappropriate risk-benefit assessment. In very rare cases, inexplicable failure of prophylaxis occurs. If malaria is contracted whilst abroad the danger to the individual is often further compounded by a lack of high-quality medical facilities and an uncertain supply of effective drugs for treatment. The advent of newer, well tolerated, drugs for treating malaria provides an opportunity to review the role of standby emergency self-medication in travellers visiting or staying (for work or other reasons) in areas where there is a risk of contracting malaria. This article was prepared following a meeting convened in London on Africa Malaria Day in 2002, in which the current opinions of experts in travel medicine and specifically malaria were discussed. It reviews opinion on the current effectiveness and acceptance of prevention strategies, as well as the role of standby emergency medication for falciparum malaria.

Knowledge, attitudes, and practices toward malaria risk and prevention among frequent business travelers of a major oil and gas company

BACKGROUND

Despite significant morbidity and mortality among business travelers due to malaria, very little has been published on knowledge, attitudes, and practices (KAP) toward malaria risk. The aim of this study was to assess KAP among frequent international business travelers (FBT) and to identify recommendations for improving malaria prevention that could be applied to the wider FBT community in occupational health.

METHODS

A retrospective web-based survey was conducted in 2005 among self-registered FBT of an oil and gas company based in the Netherlands.

RESULTS

The survey was completed by 328 of the 608 self-registered FBT (54%). Fifty-four percent of respondents had visited a high-risk area for malaria. Most respondents (96%) were experienced travelers; the majority (71%) sought health advice before their trip and made use of a company health resource. Fever was recognized as a malaria symptom by all FBT; travel to high-risk malaria areas was correctly identified by 96%, and 99% of these travelers adhered to use of adequate personal protective measures. The proportion of travelers carrying appropriate anti-malaria drug regimen was positively associated with receiving company advice among FBT traveling to high-risk destinations (RR = 2.10, 95% CI: 1.21-3.67), but not for those traveling to low- or no-risk destinations. Only 8% (14) of those going to a high-risk area were not carrying malaria prophylaxis. One in five of FBT traveling to no-risk areas were unnecessarily carrying malaria prophylaxis.

CONCLUSIONS

The majority of KAP results were excellent. We postulate that a company culture with a strong focus on health, safety, security, and environment can positively contribute to high KAP scores. Notwithstanding the excellent findings, this study also provides a cautionary tale for company health functions against overprescribing of malaria prophylaxis. It demonstrates the need for constant review and audit of adherence to quality criteria.

A cohort study of risk factors for malaria among healthcare workers in equatorial Guinea: stay away from the ground floor

BACKGROUND

Nonimmune long-term travelers to sub-Saharan Africa are at a high risk of contracting malaria. Most previous studies described risk factors and spatial distribution only in short-term travelers. This study describes the epidemiology and spatial distribution of malaria cases among expatriate healthcare workers in Equatorial Guinea.

METHODS

We conducted a cohort study evaluating the risk factors for malaria among healthcare personnel working in a hospital in Bata, Equatorial Guinea. Demographic data were recorded for all workers, and the spatial distribution of malaria cases within the hospital perimeters was determined.

RESULTS

During 2008 noncomplicated falciparum malaria was diagnosed in 13/102 workers (12.75%). On univariate analysis, the factors negatively associated with the risk of contracting malaria were living above the first floor and being older than 30 years. This association remained significant in multivariate analysis [hazard ratio (HR) = 0.24, 95% confidence interval [CI] = 0.06-0.91 for subjects living above the first floor and HR = 0.14, 95% CI = 0.04-0.52 for subjects above 30 years old]. Males and smokers had increased risk of contracting malaria on univariate analysis. However, this association was not significant in multivariate analysis (HR = 3.37, 95% CI = 0.87-13.1 and HR = 3.12, 95% CI = 0.83-11.75, for univariate and multivariate analysis, respectively). Low compliance with malaria prevention guidelines was observed in the study cohort.

CONCLUSIONS

Living on the ground floor of apartment buildings in sub-Saharan Africa, as opposed to living on the top floors, confers an increased risk of acquiring malaria in long-term travelers with low compliance to prophylaxis. These findings should be discussed in advance with people intending to stay in sub-Saharan Africa for an extended period of time. The association between belonging to a younger age group and an increased risk of acquiring malaria, and the marginally significant increased risk of malaria in males and smokers, can probably be explained by increased exposure to malaria vectors. The compliance of healthcare workers with malaria prophylaxis is extremely low, as was previously described for other long-term residents.

Illness in long-term travelers visiting GeoSentinel clinics

Length of travel appears to be associated with health risks. GeoSentinel Surveillance Network data for 4,039 long-term travelers (trip duration >6 months) seen after travel during June 1, 1996, through December 31, 2008, were compared with data for 24,807 short-term travelers (trip duration <1 month). Long-term travelers traveled more often than short-term travelers for volunteer activities (39.7% vs. 7.0%) and business (25.2% vs. 13.8%). More long-term travelers were men (57.2% vs. 50.1%) and expatriates (54.0% vs. 8.9%); most had pretravel medical advice (70.3% vs. 48.9%). Per 1,000 travelers, long-term travelers more often experienced chronic diarrhea, giardiasis, Plasmodium falciparum and P. vivax malaria, irritable bowel syndrome (postinfectious), fatigue >1 month, eosinophilia, cutaneous leishmaniasis, schistosomiasis, and Entamoeba histolytica diarrhea. Areas of concern for long-term travelers were vector-borne diseases, contact-transmitted diseases, and psychological problems. Our results can help prioritize screening for and diagnosis of illness in long-term travelers and provide evidence-based pretravel advice.

Knowledge and use of measures to reduce health risks by corporate expatriate employees in western Ghana

BACKGROUND

Expatriate corporate workers stationed in remote regions of developing countries with limited health care resources are at substantial risk for a variety of infectious diseases.

METHODS

A survey was carried out among expatriates working at a large power plant construction site in western Ghana in 1998 to evaluate their use of pretravel medical services, current knowledge, and behavioral practices in relation to food- and waterborne disease prevention, diarrhea, malaria, respiratory infections, alcohol use, and high-risk sexual activity. An anonymous, structured, and pretested questionnaire was used.

RESULTS

The response rate was 42 of 60 (70%). Most respondents were men (39 of 42, 93%) with previous international construction experience. Adherence to food and water safety recommendations decreased with time. Expatriates (15 of 23, 65%) from developed countries reported at least one episode of diarrhea, whereas no expatriates (0 of 9) from resource-poor countries reported diarrhea (p < 0.001). Use of malaria chemoprophylaxis deteriorated with increasing duration of time on the job site. None of the expatriates (0 of 9) who had been on the site for more than a year was still taking an antimalarial compared to those who had been there for 3 months or less (13 of 16) (p < 0.01). Forty-three percent (18 of 42) of the respondents reported having had a respiratory infection in the past 3 months. Only 38% (15 of 39) received preplacement education on human immunodeficiency virus (HIV) risk. A higher proportion of those who received pretravel HIV education used condoms always (4 of 5) than those who did not receive HIV education (1 of 5).

DISCUSSION

The use of health advice and preventive measures was generally low among the expatriate corporate survey respondents. Adherence to preventive measures declined with the increase in length of stay. Corporations need to develop appropriate health promotion strategies targeting their expatriates in developing countries.

Connaissances et perceptions du paludisme chez 103 voyageurs à destination intertropicale consultant le centre de conseil aux voyageurs du centre hospitalier universitaire de Bordeaux, France

OBJECTIVE

Malaria is increasing worldwide due to the emergence and spread of drug resistant strains. As globalization in business and commerce and appetites for more adventurous travel increase, more people from non-endemic countries are being exposed to malaria. The management of travelers before departure or returning from visiting endemic countries with malaria is a challenge, both for exposed individuals and for physicians, considering the weak knowledge of the disease.

METHODS

A survey was conducted among French individuals traveling to endemic areas to evaluate their knowledge and perception of malaria. An observational study using guided questionnaires was made on 103 travelers recruited in the Bordeaux University Hospital travel clinic, France.

RESULTS

The findings of the survey were consistent with previously reported data concerning the knowledge of signs and symptoms of malaria, as well as with the global level of knowledge on the disease, and with the number of travelers not understanding the mode of infection appropriately. Irrelevant data was reported concerning the typical pattern of the disease, the objectives of malaria management for travelers, and the attention given to the most susceptible groups: children, pregnant women, and immuno-compromised individuals.

CONCLUSION

Our findings show a link between gender and adhesion to prophylactic measures, and an inverse gradient in the subgroup of frequent overseas travelers, between knowledge and risk perception of illness.

Spanish travelers to high-risk areas in the tropics: airport survey of travel health knowledge, attitudes, and practices in vaccination and malaria prevention

OBJECTIVE

To evaluate travel health knowledge, attitudes, and practices on vaccination and malaria prevention among Spanish travelers to the tropics.

METHODS

A cross-sectional survey was carried out in the departure lounge of the two main Spanish international airports in the summer of 2004. A questionnaire was administered to 1,206 Spanish citizens traveling to high-risk areas of tropical South America, 635 travelers (52.6%); Southeast Asia, 251 (20.8%); Sub-Saharan Africa, 181 (15.0%), and the Indian subcontinent, 139 (11.6%). Risk areas were defined according to published sources. Travelers were asked about their attitudes to travel vaccines and malaria prophylaxis and whether they had received either or both on this or previous trips. Adequate malaria prophylaxis was considered as the correct drugs for the destination as indicated by the World Health Organization.

RESULTS

Fifty-eight percent of travelers were male and the mean age was 38 years. Thirty-six percent were traveling to tropical areas for the first time. The main reason for travel was tourism (82%) or business (12%). The mean time preparing the trip was 39 days; 73% looked for information a mean of 19 days in advance and 54% were advised in travelers' clinics. Fifty-five percent received no travel vaccines. A total of 48.1% of tourists and 30.1% of business travelers were vaccinated (p<0.00006). The most frequent vaccines administered were as follows: typhoid fever, 32%; yellow fever, 29%; tetanus-diphtheria, 24%; and hepatitis A, 14%. Malaria prophylaxis was taken by 422 travelers including mefloquine (44%), atovaquone-proguanil (17%), chloroquine (16%), chloroquine-proguanil (15%), doxycycline (3%), and unknown (5%).

CONCLUSIONS

More than half of travelers to risk areas received no vaccinations before the trip. More than a third of travelers to Sub-Saharan Africa received no malaria prophylaxis.

An update on malaria prevention, diagnosis and treatment for the returning traveller

The diagnosis of malaria needs to be considered for every returning traveller with a fever. Compliance with prevention, both pharmaceutical and non-pharmaceutical, is essential for every traveller. New tests for diagnosis are now available. Treatment options have recently expanded to include the artemisinin derivatives that used to be unavailable in the western countries.

Health information given by Swiss travel agencies

BACKGROUND

Many of the 1 million Swiss traveling to tropical or subtropical countries book their trip through travel agencies every year. These agencies are thus an important source of information about malaria and other important health risks and little is known about the appropriate health information provided by these.

METHOD

A study was conducted to assess health-related information in members of the Swiss Federation of Travel Agencies in the metropolitan area of Zurich, Switzerland. A covert investigator (F.M.S.) visited these agencies and requested information on a package holiday for 2 or 3 weeks to Kenya. Following an in-person interview, the investigator recorded any health-related information provided on a pretested form. If none was mentioned, the agent was prompted using a standardized procedure.

RESULTS

A total of 88 agencies were visited. Spontaneous health advice was given in 44% of all visits. After prompting, 99% of all travel agents mentioned preventive measures against malaria, but only 69% indicated the need for vaccinations against other diseases. Spontaneous advice on malaria risk and vaccinations was better than advice given upon prompting. One fifth of all travel agents neither mentioned malaria prevention measures spontaneously nor recommended seeing a health specialist.

CONCLUSIONS

Overall, travel medicine knowledge of travel agents in the Zurich area needs improvement as many tended to draw attention to health risks only when prompted. Attitude, personal knowledge, and experience of individual travel agents were key to the health information given. Up-to-date and readily available information on health risks should be provided to travel agencies and structured training given in collaboration with health professionals.

Prospective analysis of parasitic infections in Canadian travelers and immigrants

BACKGROUND

International travel is associated with increased risk of vector-borne illnesses, particularly malaria. The objective of this study was to prospectively assess the relative frequency of parasitic diseases in Canadian travelers and to characterize demographic and travel-related predictors of these infections.

METHODS

Data on Canadians and new immigrants who crossed international borders and were seen in the Tropical Disease Unit of Toronto General Hospital between November 1997 and June 2003 were prospectively collected and entered into the GeoSentinel Surveillance Network database.

RESULTS

Of 3,528 returned Canadian travelers and new immigrants in the database, 1,010 had a parasitic infection diagnosed. Mean age of the 3,528 travelers was 37.3 years, and 42.6% were male. Those diagnosed with parasitic infections were more likely than the remaining cohort to have been traveling for the purpose of immigration (21.1% vs 7.1%, p < 0.001), or visiting friends and relatives (VFR) (17.9% vs 11.8%, p < 0.01). Common parasitic infections included nonhistolytica amebiasis (N= 209), malaria (N= 143), cutaneous larva migrans (N= 105), giardiasis (N= 74), and schistosomiasis (N= 48).

CONCLUSIONS

Parasitic infections occurred in 29% of Canadian travelers. New immigrants and VFRs are at increased risk for malaria, as well as protozoal and helminthic infections.

Travelers' knowledge, attitudes and practices on the prevention of infectious diseases: results from a study at Johannesburg International Airport

BACKGROUND

Although Johannesburg International Airport (JIA) acts as a hub for travel into Africa, little was known of the knowledge, attitudes, and practices (KAP) with respect to infectious disease prevention of departing travelers.

METHODS

The study was conducted among departing passengers at JIA from August to October 2003. Travelers aged at least 18 years, resident in non-malarious developed countries and departing from JIA for risk destinations, were given either a malaria (Q-mal, n=219) or vaccine-preventable disease (Q-vac, n=200) questionnaire. European Travel Health Advisory Board traveler KAP questionnaires were used.

RESULTS

African destinations accounted for 99% of the total. Traveler mean age was 42 years, with 30% aged 50 years or above. Leisure (42%) and business (37%) were the commonest travel reasons; 8% of subjects were visiting friends or relatives. Forty-six per cent of travelers prepared for their trip at least 1 month in advance; 86% had sought pre-travel health advice, with travel clinics and the Internet being rated highest by travelers for quality of advice. World Health Organization immunization guidelines were followed poorly: only 37% and 27%, respectively, of travelers had demonstrable proof of protection against hepatitis A and B, with 40% of all Q-vac travelers unable to produce a vaccination certificate. Of travelers to yellow fever- endemic countries, 76% were able to produce a valid vaccination certificate; 22% of travelers to countries not endemic for yellow fever had nevertheless been specifically immunized against yellow fever for their journeys. Forty-nine per cent of Q-mal travelers carried either no or inappropriate antimalarials.

CONCLUSIONS

Considerable deficiencies in KAP were documented with regard to travel vaccinations and malaria protection in travelers departing JIA. Improved vaccine uptake and antimalarial prescribing are required for travelers to Africa.