Travel Medicine and Infectious Disease (2014) 12, 303e304
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/tmid
EDITORIAL
Malaria chemoprophylaxis compliance program: Thinking inside the box The challenges and pitfalls of long-term adherence with malaria chemoprophylaxis are highlighted in the paper by Cunningham et al. [1] in this special issue of Travel Medicine and Infectious Disease. The authors show that malaria prevention in expatriates is associated with low levels of adherence, high levels of reported malaria cases and reviewed chemoprophylaxis long term use. Despite these drawbacks, success in the fight against malaria has been illustrated by the reduction of its global morbidity and mortality. For international organizations, one of the biggest challenges is the non-immune population of travelers going to malaria locations. Long-term compared to short-term travelers are more likely to become infected by Plasmodium falciparum malaria or Plasmodium vivax malaria (OR Z 1.5 and OR Z 2.44 respectively) [2]. The risk of getting malaria has been proven to be almost 100% by using a statistical probability of being infected by sporozoites if the stay in the malaria endemic area >4 weeks assuming 10 bites per night and 1% of bites being infective [3]. For non-immunes, this risk can be mitigated by the use of chemoprophylaxis as an additional measure to awareness, bite prevention and early diagnosis and treatment; combining all four key elements of a comprehensive malaria control program. Clinical trials show that all three forms of malaria chemoprophylaxis have high efficacy rates with >92% being reported for mefloquine, >92% for doxycycline, and >98% for combination atovaquone plus proguanil [4e6]. Compliance to medication is a complex phenomenon but it can be approached in an innovative way that would involve adherence and motivator enablers to overcome the common causes of non-compliance. A number of studies have demonstrated that inadequate compliance to prescribed medication regimens result in increased morbidity and mortality from a wide variety of illnesses, as well as increased health-care costs, and diminished economic returns not only for organizations but also individuals [7]. For the protection of non-immune personnel assigned to malaria locations, companies and institutions should “think http://dx.doi.org/10.1016/j.tmaid.2014.06.003 1477-8939/ª 2014 Elsevier Ltd. All rights reserved.
inside the box” of their malaria control program. They can apply an in-depth organizational structuring of the malaria program elements, especially chemoprophylaxis compliance, and include a verification component that will strengthen the program adherence and effectiveness. In that regard, sets of measures targeting non immunes travelers should be adequately defined with verification and reporting mechanisms and have them embedded in the sending organizations’ systems to achieve program success. They can include: 1. Awareness and training of the travelers delivered in a comprehensive manner with documented and verified education sessions before, during and after assignments. The established channels and messages should communicate the risk of malaria and the needs for combined personal measures. It is also important to include defined company approach for delivery of services and supplies, in addition to program expectations. Detailed information on high risk malaria region allows informed choices on chemoprophylaxis taking. By-in can be obtained by the workers signing an attestation form at the time of their training with the understanding that they can be randomly tested for compliance and have the choice to be reassigned to a malaria free region [8]. The focus of the communication should not only target factors for noncompliance but also enablers addressing identified barriers. 2. Bite prevention measures for the individuals exposed outdoors from dusk to dawn repellents [9] and impregnated clothing with use of impregnated bed nets and environmental vector control measures (indoor residual spraying, mosquito proof facilities and larva control measures) at operations and lodging sites, reducing personnel exposure to mosquito bites. 3. Supply to travelers of malaria chemoprophylaxis recommended by the World Health Organization [10] and national disease prevention organizations. Supportive measures for chemoprophylaxis compliance should include subsidized provision of the medicines, individual
304 counselling for the choice of medicines and their combination with group and individual sessions on long term use, potential side effects and ability to change medication with medical oversight. The use of tests verifying the presence of malaria preventive medicines in the urine is an effective enabler for malaria chemoprophylaxis compliance and targeted education. Beside the laboratory methods in place, Mefloquine and Proguanil field strip tests are currently available and doxycycline test development is ongoing [11]. 4. Availability of services for early diagnosis and treatment in endemic areas, during travel through a 24/7 malaria hotline and a stand by treatment delivered while leaving the malaria locations. Successful malaria control program, including chemoprophylaxis for travelers assigned by their organization in endemic areas depends on clearly stated Company expectations, effective and periodic verification of all program components at the individual and system levels, including testing for use of malaria chemoprophylaxis where possible, and as conducted by Companies in the oil and gas sector [8]. Reporting of noncompliance, malaria episodes and deaths with fit for purpose educative interventions should consistently be applied with adequate executive level engagement. Individual, operations and executive commitment in program implementation are essential for effective compliance of adequately designed program components and successfully protect the safety and health of personnel assigned in malaria locations.
Conflict of interest statement None declared.
References [1] Cunningham J, Horsley J, Patel D, Tunbridge A, Lalloo DG. Compliance with long-term malaria prophylaxis in British expatriates. Travel Med Infect Dis 2014;12(4):341e8.
Editorial [2] Lim PL, Han P, Chen LH, MacDonald S, Pandey P, Hale D, Schlagenhauf P. Expatriates ill after travel: results from the Geosentinel Surveillance Network. BMC Infect Dis 2012;12: 386. [3] Knobloch J. Long-term malaria prophylaxis for travelers. J Travel Med 2004;11(6):374e8. [4] Tan KR, Magill AJ, Parise ME, Arguin PM. Doxycycline for malaria chemoprophylaxis and treatment: report from the CDC expert meeting on malaria chemoprophylaxis. Am J Trop Med Hyg 2011;84(4):517e31. [5] Recommendations for the prevention of malaria among travelers. MMWR Recomm Rep e Morb Mortal Wkly Rep Recomm Rep/Cent Dis Control 1990;39(RR-3):1e10. [6] Schlagenhauf P, Adamcova M, Regep L, Schaerer MT, Rhein HG. The position of mefloquine as a 21st century malaria chemoprophylaxis. Malar J 2010;9:357. [7] Utzinger J, Tozan Y, Singer BH. Efficacy and cost-effectiveness of environmental management for malaria control. Trop Med Int Health e TM IH 2001;6(9):677e87. [8] Diara M, Nowosiwsky A, Harmen S, Burke N, Alilio M. Enabling factors for improved malaria chemoprophylaxis compliance. Am J Trop Med Hyg 2012;87(5):960e1. [9] Lupi E, Hatz C, Schlagenhauf P. The efficacy of repellents against Aedes, Anopheles, Culex and Ixodes spp. e a literature review. Travel Med Infect Dis 2013;11(6):374e411. [10] Malaria Policy Advisory Committee to the WHO: conclusions and recommendations of March 2013 meeting. Malar J 2013; 12:213. [11] Fusai TETA, Moreau J-M, Lichtenberger J-M. Tetrapal e a new technique for malaria drug testing in urine SPE international conference on health, safety, and environment in oil and Gas exploration and production. Nice: France Society of Petroleum Engineers; 2008.
Malick Diara* Susan Ngunjiri ExxonMobil Medicine and Occupational Health Department, United States *Corresponding author. E-mail address: [email protected] (M. Diara) 2 June 2014
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/tmid
EDITORIAL
Malaria chemoprophylaxis compliance program: Thinking inside the box The challenges and pitfalls of long-term adherence with malaria chemoprophylaxis are highlighted in the paper by Cunningham et al. [1] in this special issue of Travel Medicine and Infectious Disease. The authors show that malaria prevention in expatriates is associated with low levels of adherence, high levels of reported malaria cases and reviewed chemoprophylaxis long term use. Despite these drawbacks, success in the fight against malaria has been illustrated by the reduction of its global morbidity and mortality. For international organizations, one of the biggest challenges is the non-immune population of travelers going to malaria locations. Long-term compared to short-term travelers are more likely to become infected by Plasmodium falciparum malaria or Plasmodium vivax malaria (OR Z 1.5 and OR Z 2.44 respectively) [2]. The risk of getting malaria has been proven to be almost 100% by using a statistical probability of being infected by sporozoites if the stay in the malaria endemic area >4 weeks assuming 10 bites per night and 1% of bites being infective [3]. For non-immunes, this risk can be mitigated by the use of chemoprophylaxis as an additional measure to awareness, bite prevention and early diagnosis and treatment; combining all four key elements of a comprehensive malaria control program. Clinical trials show that all three forms of malaria chemoprophylaxis have high efficacy rates with >92% being reported for mefloquine, >92% for doxycycline, and >98% for combination atovaquone plus proguanil [4e6]. Compliance to medication is a complex phenomenon but it can be approached in an innovative way that would involve adherence and motivator enablers to overcome the common causes of non-compliance. A number of studies have demonstrated that inadequate compliance to prescribed medication regimens result in increased morbidity and mortality from a wide variety of illnesses, as well as increased health-care costs, and diminished economic returns not only for organizations but also individuals [7]. For the protection of non-immune personnel assigned to malaria locations, companies and institutions should “think http://dx.doi.org/10.1016/j.tmaid.2014.06.003 1477-8939/ª 2014 Elsevier Ltd. All rights reserved.
inside the box” of their malaria control program. They can apply an in-depth organizational structuring of the malaria program elements, especially chemoprophylaxis compliance, and include a verification component that will strengthen the program adherence and effectiveness. In that regard, sets of measures targeting non immunes travelers should be adequately defined with verification and reporting mechanisms and have them embedded in the sending organizations’ systems to achieve program success. They can include: 1. Awareness and training of the travelers delivered in a comprehensive manner with documented and verified education sessions before, during and after assignments. The established channels and messages should communicate the risk of malaria and the needs for combined personal measures. It is also important to include defined company approach for delivery of services and supplies, in addition to program expectations. Detailed information on high risk malaria region allows informed choices on chemoprophylaxis taking. By-in can be obtained by the workers signing an attestation form at the time of their training with the understanding that they can be randomly tested for compliance and have the choice to be reassigned to a malaria free region [8]. The focus of the communication should not only target factors for noncompliance but also enablers addressing identified barriers. 2. Bite prevention measures for the individuals exposed outdoors from dusk to dawn repellents [9] and impregnated clothing with use of impregnated bed nets and environmental vector control measures (indoor residual spraying, mosquito proof facilities and larva control measures) at operations and lodging sites, reducing personnel exposure to mosquito bites. 3. Supply to travelers of malaria chemoprophylaxis recommended by the World Health Organization [10] and national disease prevention organizations. Supportive measures for chemoprophylaxis compliance should include subsidized provision of the medicines, individual
304 counselling for the choice of medicines and their combination with group and individual sessions on long term use, potential side effects and ability to change medication with medical oversight. The use of tests verifying the presence of malaria preventive medicines in the urine is an effective enabler for malaria chemoprophylaxis compliance and targeted education. Beside the laboratory methods in place, Mefloquine and Proguanil field strip tests are currently available and doxycycline test development is ongoing [11]. 4. Availability of services for early diagnosis and treatment in endemic areas, during travel through a 24/7 malaria hotline and a stand by treatment delivered while leaving the malaria locations. Successful malaria control program, including chemoprophylaxis for travelers assigned by their organization in endemic areas depends on clearly stated Company expectations, effective and periodic verification of all program components at the individual and system levels, including testing for use of malaria chemoprophylaxis where possible, and as conducted by Companies in the oil and gas sector [8]. Reporting of noncompliance, malaria episodes and deaths with fit for purpose educative interventions should consistently be applied with adequate executive level engagement. Individual, operations and executive commitment in program implementation are essential for effective compliance of adequately designed program components and successfully protect the safety and health of personnel assigned in malaria locations.
Conflict of interest statement None declared.
References [1] Cunningham J, Horsley J, Patel D, Tunbridge A, Lalloo DG. Compliance with long-term malaria prophylaxis in British expatriates. Travel Med Infect Dis 2014;12(4):341e8.
Editorial [2] Lim PL, Han P, Chen LH, MacDonald S, Pandey P, Hale D, Schlagenhauf P. Expatriates ill after travel: results from the Geosentinel Surveillance Network. BMC Infect Dis 2012;12: 386. [3] Knobloch J. Long-term malaria prophylaxis for travelers. J Travel Med 2004;11(6):374e8. [4] Tan KR, Magill AJ, Parise ME, Arguin PM. Doxycycline for malaria chemoprophylaxis and treatment: report from the CDC expert meeting on malaria chemoprophylaxis. Am J Trop Med Hyg 2011;84(4):517e31. [5] Recommendations for the prevention of malaria among travelers. MMWR Recomm Rep e Morb Mortal Wkly Rep Recomm Rep/Cent Dis Control 1990;39(RR-3):1e10. [6] Schlagenhauf P, Adamcova M, Regep L, Schaerer MT, Rhein HG. The position of mefloquine as a 21st century malaria chemoprophylaxis. Malar J 2010;9:357. [7] Utzinger J, Tozan Y, Singer BH. Efficacy and cost-effectiveness of environmental management for malaria control. Trop Med Int Health e TM IH 2001;6(9):677e87. [8] Diara M, Nowosiwsky A, Harmen S, Burke N, Alilio M. Enabling factors for improved malaria chemoprophylaxis compliance. Am J Trop Med Hyg 2012;87(5):960e1. [9] Lupi E, Hatz C, Schlagenhauf P. The efficacy of repellents against Aedes, Anopheles, Culex and Ixodes spp. e a literature review. Travel Med Infect Dis 2013;11(6):374e411. [10] Malaria Policy Advisory Committee to the WHO: conclusions and recommendations of March 2013 meeting. Malar J 2013; 12:213. [11] Fusai TETA, Moreau J-M, Lichtenberger J-M. Tetrapal e a new technique for malaria drug testing in urine SPE international conference on health, safety, and environment in oil and Gas exploration and production. Nice: France Society of Petroleum Engineers; 2008.
Malick Diara* Susan Ngunjiri ExxonMobil Medicine and Occupational Health Department, United States *Corresponding author. E-mail address: [email protected] (M. Diara) 2 June 2014
