“The best laid plans” do those who have been given malaria … · Whitman TJ et al. An Outbreak of Plasmodium falciparum Malaria in U.S. Marines Deployed to Liberia Am J Trop

“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