Student travel health and the role of universities and health clinics in New Zealand to prevent imported infections: a cross-sectional study.

BACKGROUND: Tertiary students are at risk of acquiring infectious diseases during overseas travel as they visit low-income countries, have low perceptions of risk and are unlikely to access travel health advice. Some will visit friends and relatives abroad, a group identified as disproportionately affected by imported infections. There is no national student travel health policy in NZ. This study aimed to explore travel health training of university-based health providers; academics' practices and perceptions of travel health; reasons for travel and countries visited by NZ university students, their travel health uptake and factors affecting decision making about this. METHODS: A cross-sectional study consisting of surveys sent in 2014 to university clinics, senior academics and students. RESULTS: Surveys were completed by 251 respondents. Three of nine clinicians had only undertaken a short course in travel health. Competing resources and time constraints in health clinics were amongst the barriers to providing optimal services. Of the senior academics, only 14% were able to confirm their university collaborated with health clinics. Sixty seven percent of students were unaware that clinics provided travel health services and 19% had or intended to seek professional travel health advice. CONCLUSIONS: A national policy is warranted involving all stakeholders, utilizing innovative technologies to increase uptake of student travel health services.

Imported infections: What information should be collected by surveillance systems to inform public health policy?

BACKGROUND: International travel carries the risk of imported diseases, which are an increasingly significant public health problem. There is little guidance about which variables should be collected by surveillance systems for strategy-based surveillance. METHODS: Surveillance forms for dengue, malaria, hepatitis A, typhoid and measles were collected from Australia and New Zealand and information on these compared with national surveillance forms from the UK and Canada by travel health experts. Variables were categorised by information relating to recent travel, demographics and disease severity. RESULTS: Travel-related information most commonly requested included country of travel, vaccination status and travel dates. In Australia, ethnicity information requested related to indigenous status, whilst in New Zealand it could be linked to census categories. Severity of disease information most frequently collected were hospitalisation and death. CONCLUSIONS: Reviewing the usefulness of variables collected resulted in the recommendation that those included should be: overseas travel, reason for travel, entry and departure dates during the incubation period, vaccination details, traveller's and/or parents' country of birth, country of usual residence, time resident in current country, postcode, hospitalisation and death details. There was no agreement about whether ethnicity details should be collected. The inclusion of these variables on surveillance forms could enable imported infection-related policy to be formulated nationally and internationally.

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.

"You're losing your Ghanaianess": understanding malaria decision-making among Africans visiting friends and relatives in the UK.

BACKGROUND: In the UK, the majority of imported malaria infections occur in the London area among UK residents of African origin who travel to Africa visiting friends and relatives (VFRs). Effective malaria prevention measures are available but there is little understanding of the factors that enhance and constrain their use among VFRs. METHODS: Semi-structured interviews were undertaken with Africans resident in London who visited friends and relatives in Nigeria and Ghana (n = 20) and with African VFRs recently treated for malaria (n = 6). Data collection took place between December 2007 and February 2011. Information on migration patterns and travel of respondents was collected and the data were analysed using a framework analysis approach. RESULTS: Knowledge of the link between mosquitoes and malaria was high. Factors influencing the use of mosquito avoidance methods included knowledge about the local environment, perceptions of the inevitability of contracting malaria, and a desire to fit with the norms of host families. Previous experience of bed nets, and the belief that more modern ways of preventing mosquito bites were available deterred people from using them. Chemoprophylaxis use was varied and influenced by: perceptions about continuing immunity to malaria; previous experiences of malaria illness; the cost of chemoprophylaxis; beliefs about the likely severity of malaria infections; the influence of friends in the UK; and, the way malaria is perceived and managed in Nigeria and Ghana. Malaria treatment was considered by many to be superior in Nigeria and Ghana than in the UK. A conceptual framework was developed to illustrate the manner in which these factors interact to affect malaria decisions. CONCLUSIONS: The use of malaria prevention among VFRs needs to be understood not only in terms of individual risk factors but also in relation to the context in which decisions are made. For VFRs, malaria decisions are undertaken across two distinct social and environmental contexts and within the structural constraints associated with each. Strategies for reducing the burden of malaria among VFRs that ignore this complexity are likely to face challenges. New approaches that take account of contextual as well as individual factors are required.

Challenges facing providers of imported malaria-related healthcare services for Africans visiting friends and relatives (VFRs).

BACKGROUND: In many non-malarious countries, imported malaria disproportionately affects Africans visiting friends and relatives (VFRs). Most previous research has focused on understanding the knowledge, attitudes and practices of these travellers, but has not examined the quality of prevention, diagnosis and treatment services provided. The aim of this study was to understand the perspective of providers of malaria-related healthcare services to VFRs about factors impacting on the quality of these and to make recommendations about improvements. METHODS: Thirty semi-structured interviews were conducted with practice nurses providing pre-travel health advice (n = 10), general practitioners (GPs) (n = 10), hospital consultants (n = 3), and community pharmacists (n = 7) working in areas of London with large African communities and a relatively high burden of imported malaria. A thematic analysis of the results was undertaken. RESULTS: Time constraints in GPs' surgeries and competing priorities, lack of confidence in issuing advice on mosquito avoidance, the cost of chemoprophylaxis and travel at short notice prevented the provision of adequate malaria prevention advice. Long GP waiting times, misdiagnoses, lack of disclosure by VFRs about recent travel, and the issue of where malaria treatment should be provided were raised as potential barriers to diagnosis and treatment. CONCLUSIONS: Some issues raised by respondents are relevant to all travellers, irrespective of their reason for travel. The challenge for healthcare providers to reduce the burden of imported malaria in VFRs is to provide services of sufficient quality to persuade them to adopt these in preference to those with which they may be familiar in their country of birth. Although no single intervention will significantly lower the burden of imported malaria, addressing the issues raised in this research could make a significant impact.

Barriers to malaria control in rural south-west Timor-Leste: a qualitative analysis.

BACKGROUND: Malaria is an important health problem in Timor-Leste. Although funding has been provided to reduce the burden of this disease, few studies have investigated whether this has improved malaria-related knowledge, management of symptoms, and treatment in rural communities. The aim of this study was to explore the perceptions and practices undertaken in relation to all aspects of malaria control by members of two rural communities in Timor-Leste. METHODS: A qualitative study was undertaken in two rural hamlets in Timor-Leste. Research methods included transect walks, focus groups and semi-structured interviews. Content analysis was used to identify themes. RESULTS: The location of the hamlets near rice fields, leaking taps, inadequate water supplies and dumping of waste from the local hospital provided opportunities for mosquitoes to breed. Most participants were aware of the link between mosquitoes and malaria, but a lack of control over their environment was a major barrierto preventing malaria. The distribution ofbed nets had occurred once, and was the only intervention undertaken bythe National Malaria Control Programme. However, limiting the distribution of bed nets to pregnant women and children aged under 5 years had resulted in some focus group respondents believing that only those in these groups could be affected by malaria. Self-diagnosis and home treatmentwere common. Treatment for unresolved infections depended on access to transport funds, and belief in the power of traditional healers. CONCLUSION: Improvements in infrastructure, empowerment of rural communities, and better access to treatment are recommended if the incidence of malaria is to be reduced throughout the country.

Does public subsidy of the cost of malaria chemoprophylaxis reduce imported malaria? A comparative policy analysis.

BACKGROUND: Chemoprophylaxis is recommended for at-risk travellers visiting malaria endemic regions. The majority of travellers with imported malaria have not used this, and travellers visiting friends and relatives have the largest burden of malaria and the lowest compliance to chemoprophylaxis. In 1995, the UK's Department of Health (DH) implemented a policy to make travellers fully responsible for the cost when purchasing chemoprophylaxis. This policy was not implemented in three Primary Care Trusts (PCTs) in London due to concern about the potential increase of imported malaria in their residents, and they maintained the public subsidy. An impact evaluation of the policy change was undertaken to determine if the continued subsidy reduced the incidence of imported malaria in one of the boroughs where the subsidy was maintained when compared to a borough where no subsidy was provided. METHODS: Between 2007 and 2010 prescriptions for malaria chemoprophylaxis were collected from pharmacy records and PCTs, and all cases of imported malaria reported from the tertiary hospital in each of the two boroughs were compared. RESULTS: The dispensed chemoprophylaxis prescriptions were nearly 8.8 times higher in Lambeth (where subsidized drugs were provided), than in Hackney. A Poisson model revealed significantly fewer reports of imported malaria per capita were made in Lambeth compared to Hackney (p = 0.042). CONCLUSIONS: The difference in malaria reports between the boroughs only just reached statistical significance, despite the considerable difference in chemoprophylaxis prescribing between the boroughs. Some travellers may not consider using chemoprophylaxis, irrespective of the cost. Regular evaluations of the recent policy changes in areas where malaria is subsidized will be important.