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

Study on the use and effectiveness of malaria preventive measures reported by employees of chinese construction companies in Western Africa in 2021

BACKGROUND

As malaria continues to be a significant global public health concern, especially in Sub-Saharan Africa, Chinese workers in Africa are at increased risk of malaria. The effectiveness of malaria prevention measures implemented by Chinese companies and workers is a question that may correlate with the malaria infection rate in this population. This study explored the use and effectiveness of malaria prevention measures for Chinese employees in West Africa to provide a reference for companies and individuals on improving malaria prevention and control.

METHODS

Using a cross-sectional approach, we surveyed 256 participants in 2021, mainly from Nigeria, Mali, Côte d'Ivoire, Ghana, Guinea, Sierra Leone, and Senegal in West Africa. The survey duration is from July to the end of September 2021. We selected two companies from the 2020 ENR "World's Largest 250 International Contractors" list, which featured 6 Chinese companies, all of which are state-owned and have a 61.9% market share in Africa. The participants were Chinese workers with more than a year of work experience in construction companies in Africa. A 20-minute WeChat-based structured online questionnaire was used to obtain information on malaria infection status and malaria prevention measures. Descriptive statistical analysis, chi-square test, principal components analysis, and ordinal logistic regression analysis are used to analyze the data obtained. The difference in Statistical significance was set at P < 0.05.

RESULTS

Ninety six (37.5%) participants contracted malaria more than once within a year. The principal components analysis found a low correlation between public and individual preventive measures. No significant correlation was found between public preventive measures and malaria infection (p > 0.05), while standardized use of mosquito nets (P = 0.016) and pesticide spraying (P = 0.047) contributed significantly to fewer malaria infections at the individual level, but the removal of vegetation around houses (P = 0.028) at the individual level related to higher malaria infection.

CONCLUSIONS

In our sample of Chinese construction workers going to Africa, some individual preventive measures had a stronger association with malaria prevention than a variety of public environmental measures. Furthermore, individual and public preventive measures were not associated with each other. Both of these findings are surprising and require further investigation in larger and more diverse samples. This- study provides important clues about the challenges that risk reduction programs face for migrant workers from China and elsewhere.

Chikungunya: risks for travellers

RATIONALE FOR REVIEW

Chikungunya outbreaks continue to occur, with changing epidemiology. Awareness about chikungunya is low both among the at-risk travellers and healthcare professionals, which can result in underdiagnosis and underreporting. This review aims to improve awareness among healthcare professionals regarding the risks of chikungunya for travellers.

KEY FINDINGS

Chikungunya virus transmission to humans occurs mainly via daytime-active mosquitoes, Aedes aegypti and Aedes albopictus. The areas where these mosquitoes live is continuously expanding, partly due to climate changes. Chikungunya is characterized by an acute onset of fever with joint pain. These symptoms generally resolve within 1-3 weeks, but at least one-third of the patients suffer from debilitating rheumatologic symptoms for months to years. Large outbreaks in changing regions of the world since the turn of the 21st century (e.g. Caribbean, La Réunion; currently Brazil, India) have resulted in growing numbers of travellers importing chikungunya, mainly to Europe and North America. Viremic travellers with chikungunya infection have seeded chikungunya clusters (France, United States of America) and outbreaks (Italy in 2007 and 2017) in non-endemic countries where Ae. albopictus mosquitoes are present. Community preventive measures are important to prevent disease transmission by mosquitoes. Individual preventive options are limited to personal protection measures against mosquito bites, particularly the daytime-active mosquitos that transmit the chikungunya virus. Candidate vaccines are on the horizon and regulatory authorities will need to assess environmental and host risk factors for persistent sequelae, such as obesity, age (over 40 years) and history of arthritis or inflammatory rheumatologic disease to determine which populations should be targeted for these chikungunya vaccines.

CONCLUSIONS/RECOMMENDATIONS

Travellers planning to visit destinations with active CHIKV circulation should be advised about the risk for chikungunya, prevention strategies, the disease manifestations, possible chronic rheumatologic sequelae and, if symptomatic, seek medical evaluation and report potential exposures.

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.

Factors Affecting Pre-Travel Health Seeking Behaviour and Adherence to Pre-Travel Health Advice: A Systematic Review

BACKGROUND

Recent years have seen unprecedented growth in international travel. Travellers are at high risk for acquiring infections while abroad and potentially bringing these infections back to their home country. There are many ways to mitigate this risk by seeking pre-travel advice (PTA), including receiving recommended vaccinations and chemoprophylaxis, however many travellers do not seek or adhere to PTA. We conducted a systematic review to further understand PTA-seeking behaviour with an ultimate aim to implement interventions that improve adherence to PTA and reduce morbidity and mortality in travellers.

METHODS

We conducted a systematic review of published medical literature selecting studies that examined reasons for not seeking PTA and non-adherence to PTA over the last ten years. 4484 articles were screened of which 56 studies met our search criteria after full text review.

RESULTS

The major reason for not seeking or non-adherence to PTA was perceived low risk of infection while travelling. Side effects played a significant role for lack of adherence specific to malaria prophylaxis.

CONCLUSIONS

These data may help clinicians and public health providers to better understand reasons for non-adherence to PTA and target interventions to improve travellers understanding of potential and modifiable risks. Additionally, we discuss specific recommendations to increase public health education that may enable travellers to seek PTA.

Malaria Surveillance - United States, 2016

PROBLEM/CONDITION

Malaria in humans is caused by intraerythrocytic protozoa of the genus Plasmodium. These parasites are transmitted by the bite of an infective female Anopheles species mosquito. The majority of malaria infections in the United States occur among persons who have traveled to regions with ongoing malaria transmission. However, malaria is occasionally acquired by persons who have not traveled out of the country through exposure to infected blood products, congenital transmission, laboratory exposure, or local mosquitoborne transmission. Malaria surveillance in the United States is conducted to provide information on its occurrence (e.g., temporal, geographic, and demographic), guide prevention and treatment recommendations for travelers and patients, and facilitate transmission control measures if locally acquired cases are identified.

PERIOD COVERED

This report summarizes confirmed malaria cases in persons with onset of illness in 2016 and summarizes trends in previous years.

DESCRIPTION OF SYSTEM

Malaria cases diagnosed by blood film microscopy, polymerase chain reaction, or rapid diagnostic tests are reported to local and state health departments by health care providers or laboratory staff members. Case investigations are conducted by local and state health departments, and reports are transmitted to CDC through the National Malaria Surveillance System (NMSS), the National Notifiable Diseases Surveillance System (NNDSS), or direct CDC consultations. CDC reference laboratories provide diagnostic assistance and conduct antimalarial drug resistance marker testing on blood samples submitted by health care providers or local or state health departments. This report summarizes data from the integration of all NMSS and NNDSS cases, CDC reference laboratory reports, and CDC clinical consultations.

RESULTS

CDC received reports of 2,078 confirmed malaria cases with onset of symptoms in 2016, including two congenital cases, three cryptic cases, and one case acquired through blood transfusion. The number of malaria cases diagnosed in the United States has been increasing since the mid-1970s. However, in 2015 a decrease occurred in the number of cases, specifically from the region of West Africa, likely due to altered travel related to the Ebola virus disease outbreak. The number of confirmed malaria cases in 2016 represents a 36% increase compared with 2015, and the 2016 total is 153 more cases than in 2011, which previously had the highest number of cases (1,925 cases). In 2016, a total of 1,729 cases originated from Africa, and 1,061 (61.4%) of these came from West Africa. P. falciparum accounted for the majority of the infections (1,419 [68.2%]), followed by P. vivax (251 [12.1%]). Fewer than 2% of patients were infected by two species (23 [1.1%]). The infecting species was not reported or was undetermined in 10.8% of cases. CDC provided diagnostic assistance for 12.1% of confirmed cases and tested 10.8% of specimens with P. falciparum infections for antimalarial resistance markers. Of the U.S. resident patients who reported reason for travel, 69.4% were travelers who were visiting friends and relatives. The proportion of U.S. residents with malaria who reported taking any chemoprophylaxis in 2016 (26.3%) was similar to that in 2015 (26.6%), and adherence was poor among those who took chemoprophylaxis. Among the 964 U.S. residents with malaria for whom information on chemoprophylaxis use and travel region were known, 94.0% of patients with malaria did not adhere to or did not take a CDC-recommended chemoprophylaxis regimen. Among 795 women with malaria, 50 were pregnant, and one had adhered to mefloquine chemoprophylaxis. Forty-one (2.0%) malaria cases occurred among U.S. military personnel in 2016, a comparable proportion to that in 2015 (23 cases [1.5%]). Among all reported cases in 2016, a total of 306 (14.7%) were classified as severe illnesses, and seven persons died. In 2016, CDC analyzed 144 P. falciparum-positive and nine P. falciparum mixed species samples for surveillance of antimalarial resistance markers (although certain loci were untestable in some samples); genetic polymorphisms associated with resistance to pyrimethamine were identified in 142 (97.9%), to sulfadoxine in 98 (70.5%), to chloroquine in 67 (44.7%), to mefloquine in six (4.3%), and to atovaquone in one (<1.0%). The completeness of key variables (e.g., species, country of acquisition, and resident status) was 79.4% in 2016 and 75.7% in 2015.

INTERPRETATION

The number of reported malaria cases in 2016 continued a decades-long increasing trend and is the highest since 1972. The importation of malaria reflects the overall increase in global travel trends to and from areas where malaria is endemic; a transient decrease in the acquisition of cases, predominantly from West Africa, occurred in 2015. In 2016, more cases (absolute number) originated from regions of the world with widespread malaria transmission. Since the early 2000s, worldwide interventions to reduce malaria have been successful; however, progress has plateaued in recent years, the disease remains endemic in many regions, and the use of appropriate prevention measures by travelers remains inadequate.

PUBLIC HEALTH ACTIONS

The best way to prevent malaria is to take chemoprophylaxis medication during travel to a country where malaria is endemic. Malaria infections can be fatal if not diagnosed and treated promptly with antimalarial medications appropriate for the patient's age and medical history, the likely country of malaria acquisition, and previous use of antimalarial chemoprophylaxis. In 2018, two tafenoquine-based antimalarials were approved by the Food and Drug Administration (FDA) for use in the United States. Arakoda was approved for use by adults for chemoprophylaxis and is available as a weekly dosage that is convenient during travel, which might improve adherence and also can prevent relapses from P. vivax and P. ovale infections. Krintafel was approved for radical cure of P. vivax infections in those >16 years old. In April 2019, intravenous artesunate became the first-line medication for treatment of severe malaria in the United States. Because intravenous artesunate is not FDA approved, it is available from CDC under an investigational new drug protocol. Detailed recommendations for preventing malaria are available to the general public at the CDC website (https://www.cdc.gov/malaria/travelers/drugs.html). Health care providers should consult the CDC Guidelines for Treatment of Malaria in the United States and contact the CDC's Malaria Hotline for case management advice when needed. Malaria treatment recommendations are available online (https://www.cdc.gov/malaria/diagnosis_treatment) and from the Malaria Hotline (770-488-7788 or toll-free at 855-856-4713). Persons submitting malaria case reports (care providers, laboratories, and state and local public health officials) should provide complete information because incomplete reporting compromises case investigations and efforts to prevent infections and examine trends in malaria cases. Adherence to recommended malaria prevention strategies is low among U.S. travelers; reasons for nonadherence include prematurely stopping after leaving the area where malaria was endemic, forgetting to take the medication, and experiencing a side effect. Molecular surveillance of antimalarial drug resistance markers (https://www.cdc.gov/malaria/features/ars.html) enables CDC to track, guide treatment, and manage drug resistance in malaria parasites both domestically and internationally. More samples are needed to improve the completeness of antimalarial drug resistance analysis; therefore, CDC requests that blood specimens be submitted for all cases of malaria diagnosed in the United States.

Malaria Surveillance - United States, 2015

PROBLEM/CONDITION

Malaria in humans is caused by intraerythrocytic protozoa of the genus Plasmodium. These parasites are transmitted by the bite of an infective female Anopheles species mosquito. The majority of malaria infections in the United States occur among persons who have traveled to regions with ongoing malaria transmission. However, malaria is occasionally acquired by persons who have not traveled out of the country through exposure to infected blood products, congenital transmission, laboratory exposure, or local mosquitoborne transmission. Malaria surveillance in the United States is conducted to provide information on its occurrence (e.g., temporal, geographic, and demographic), guide prevention and treatment recommendations for travelers and patients, and facilitate transmission control measures if locally acquired cases are identified.

PERIOD COVERED

This report summarizes confirmed malaria cases in persons with onset of illness in 2015 and summarizes trends in previous years.

DESCRIPTION OF SYSTEM

Malaria cases diagnosed by blood film microscopy, polymerase chain reaction, or rapid diagnostic tests are reported to local and state health departments by health care providers or laboratory staff members. Case investigations are conducted by local and state health departments, and reports are transmitted to CDC through the National Malaria Surveillance System (NMSS), the National Notifiable Diseases Surveillance System (NNDSS), or direct CDC consultations. CDC reference laboratories provide diagnostic assistance and conduct antimalarial drug resistance marker testing on blood samples submitted by health care providers or local or state health departments. This report summarizes data from the integration of all NMSS and NNDSS cases, CDC reference laboratory reports, and CDC clinical consultations.

RESULTS

CDC received reports of 1,517 confirmed malaria cases, including one congenital case, with an onset of symptoms in 2015 among persons who received their diagnoses in the United States. Although the number of malaria cases diagnosed in the United States has been increasing since the mid-1970s, the number of cases decreased by 208 from 2014 to 2015. Among the regions of acquisition (Africa, West Africa, Asia, Central America, the Caribbean, South America, Oceania, and the Middle East), the only region with significantly fewer imported cases in 2015 compared with 2014 was West Africa (781 versus 969). Plasmodium falciparum, P. vivax, P. ovale, and P. malariae were identified in 67.4%, 11.7%, 4.1%, and 3.1% of cases, respectively. Less than 1% of patients were infected by two species. The infecting species was unreported or undetermined in 12.9% of cases. CDC provided diagnostic assistance for 13.1% of patients with confirmed cases and tested 15.0% of P. falciparum specimens for antimalarial resistance markers. Of the U.S. resident patients who reported purpose of travel, 68.4% were visiting friends or relatives. A lower proportion of U.S. residents with malaria reported taking any chemoprophylaxis in 2015 (26.5%) compared with 2014 (32.5%), and adherence was poor in this group. Among the U.S residents for whom information on chemoprophylaxis use and travel region were known, 95.3% of patients with malaria did not adhere to or did not take a CDC-recommended chemoprophylaxis regimen. Among women with malaria, 32 were pregnant, and none had adhered to chemoprophylaxis. A total of 23 malaria cases occurred among U.S. military personnel in 2015. Three cases of malaria were imported from the approximately 3,000 military personnel deployed to an Ebola-affected country; two of these were not P. falciparum species, and one species was unspecified. Among all reported cases in 2015, 17.1% were classified as severe illnesses and 11 persons died, compared with an average of 6.1 deaths per year during 2000-2014. In 2015, CDC received 153 P. falciparum-positive samples for surveillance of antimalarial resistance markers (although certain loci were untestable for some samples); genetic polymorphisms associated with resistance to pyrimethamine were identified in 132 (86.3%), to sulfadoxine in 112 (73.7%), to chloroquine in 48 (31.4%), to mefloquine in six (4.3%), and to artemisinin in one (<1%), and no sample had resistance to atovaquone. Completion of data elements on the malaria case report form decreased from 2014 to 2015 and remains low, with 24.2% of case report forms missing at least one key element (species, travel history, and resident status).

INTERPRETATION

The decrease in malaria cases from 2014 to 2015 is associated with a decrease in imported cases from West Africa. This finding might be related to altered or curtailed travel to Ebola-affected countries in in this region. Despite progress in reducing malaria worldwide, the disease remains endemic in many regions, and the use of appropriate prevention measures by travelers is still inadequate.

PUBLIC HEALTH ACTIONS

The best way to prevent malaria is to take chemoprophylaxis medication during travel to a country where malaria is endemic. As demonstrated by the U.S. military during the Ebola response, use of chemoprophylaxis and other protection measures is possible in stressful environments, and this can prevent malaria, especially P. falciparum, even in high transmission areas. Detailed recommendations for preventing malaria are available to the general public at the CDC website (https://www.cdc.gov/malaria/travelers/drugs.html). Malaria infections can be fatal if not diagnosed and treated promptly with antimalarial medications appropriate for the patient's age and medical history, the likely country of malaria acquisition, and previous use of antimalarial chemoprophylaxis. Health care providers should consult the CDC Guidelines for Treatment of Malaria in the United States and contact the CDC's Malaria Hotline for case management advice when needed. Malaria treatment recommendations are available online (https://www.cdc.gov/malaria/diagnosis_treatment) and from the Malaria Hotline (770-488-7788 or toll-free at 855-856-4713). Persons submitting malaria case reports (care providers, laboratories, and state and local public health officials) should provide complete information because incomplete reporting compromises case investigations and efforts to prevent infections and examine trends in malaria cases. Compliance with recommended malaria prevention strategies is low among U.S. travelers visiting friends and relatives. Evidence-based prevention strategies that effectively target travelers who are visiting friends and relatives need to be developed and implemented to reduce the numbers of imported malaria cases in the United States. Molecular surveillance of antimalarial drug resistance markers (https://www.cdc.gov/malaria/features/ars.html) has enabled CDC to track, guide treatment, and manage drug resistance in malaria parasites both domestically and internationally. More samples are needed to improve the completeness of antimalarial drug resistance marker analysis; therefore, CDC requests that blood specimens be submitted for all cases diagnosed in the United States.

Tour leaders with detailed knowledge of travel-related diseases play a key role in disease prevention

In Taiwan, group tours are a popular mode of international travel; hence, group tour leaders must ensure traveler safety and health. This study identified factors influencing tour leaders' willingness to recommend pretravel medical consultation and vaccination.A cross-sectional questionnaire survey was administered to tour leaders from January 2011 to December 2012. Multivariate logistic regression analyses were performed to estimate the odds ratios of having a positive attitude and willingness based on different knowledge scores of the tour leaders after adjustments for age, sex, education level, and seniority.Tour leaders with a more detailed knowledge of both travel-related infectious and noninfectious diseases demonstrated a higher willingness to receive vaccination. They believed that consultation at travel clinics before travel can improve travelers' health (P < .05).This study supports the importance and effectiveness on educating tour leaders' knowledge about travel-related diseases to improve health care for travelers.

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.

Malaria Surveillance - United States, 2014

PROBLEM/CONDITION

Malaria in humans is caused by intraerythrocytic protozoa of the genus Plasmodium. These parasites are transmitted by the bite of an infective female Anopheles mosquito. The majority of malaria infections in the United States occur among persons who have traveled to regions with ongoing malaria transmission. However, malaria is occasionally acquired by persons who have not traveled out of the country through exposure to infected blood products, congenital transmission, laboratory exposure, or local mosquitoborne transmission. Malaria surveillance in the United States is conducted to identify episodes of local transmission and to guide prevention recommendations for travelers.

PERIOD COVERED

This report summarizes cases in persons with onset of illness in 2014 and trends during previous years.

DESCRIPTION OF SYSTEM

Malaria cases diagnosed by blood film, polymerase chain reaction, or rapid diagnostic tests are reported to local and state health departments by health care providers or laboratory staff. Case investigations are conducted by local and state health departments, and reports are transmitted to CDC through the National Malaria Surveillance System, National Notifiable Diseases Surveillance System, or direct CDC consultations. CDC conducts antimalarial drug resistance marker testing on blood samples submitted by health care providers or local or state health departments. Data from these reporting systems serve as the basis for this report.

RESULTS

CDC received reports of 1,724 confirmed malaria cases, including one congenital case and two cryptic cases, with onset of symptoms in 2014 among persons in the United States. The number of confirmed cases in 2014 is consistent with the number of confirmed cases reported in 2013 (n = 1,741; this number has been updated from a previous publication to account for delayed reporting for persons with symptom onset occurring in late 2013). Plasmodium falciparum, P. vivax, P. ovale, and P. malariae were identified in 66.1%, 13.3%, 5.2%, and 2.7% of cases, respectively. Less than 1.0% of patients were infected with two species. The infecting species was unreported or undetermined in 11.7% of cases. CDC provided diagnostic assistance for 14.2% of confirmed cases and tested 12.0% of P. falciparum specimens for antimalarial resistance markers. Of patients who reported purpose of travel, 57.5% were visiting friends and relatives (VFR). Among U.S. residents for whom information on chemoprophylaxis use and travel region was known, 7.8% reported that they initiated and adhered to a chemoprophylaxis drug regimen recommended by CDC for the regions to which they had traveled. Thirty-two cases were among pregnant women, none of whom had adhered to chemoprophylaxis. Among all reported cases, 17.0% were classified as severe illness, and five persons with malaria died. CDC received 137 P. falciparum-positive samples for the detection of antimalarial resistance markers (although some loci for chloroquine and mefloquine were untestable for up to nine samples). Of the 137 samples tested, 131 (95.6%) had genetic polymorphisms associated with pyrimethamine drug resistance, 96 (70.0%) with sulfadoxine resistance, 77 (57.5%) with chloroquine resistance, three (2.3%) with mefloquine drug resistance, one (<1.0%) with atovaquone resistance, and two (1.4%) with artemisinin resistance.

INTERPRETATION

The overall trend of malaria cases has been increasing since 1973; the number of cases reported in 2014 is the fourth highest annual total since then. Despite progress in reducing global prevalence of malaria, the disease remains endemic in many regions and use of appropriate prevention measures by travelers is still inadequate.

PUBLIC HEALTH ACTION

Completion of data elements on the malaria case report form increased slightly in 2014 compared with 2013, but still remains unacceptably low. In 2014, at least one essential element (i.e., species, travel history, or resident status) was missing in 21.3% of case report forms. Incomplete reporting compromises efforts to examine trends in malaria cases and prevent infections. VFR travelers continue to be a difficult population to reach with effective malaria prevention strategies. Evidence-based prevention strategies that effectively target VFR travelers need to be developed and implemented to have a substantial impact on the number of imported malaria cases in the United States. Fewer U.S. resident patients reported taking chemoprophylaxis in 2014 (27.2%) compared with 2013 (28.6%), and adherence was poor among those who did take chemoprophylaxis. Proper use of malaria chemoprophylaxis will prevent the majority of malaria illnesses and reduce risk for severe disease (https://www.cdc.gov/malaria/travelers/drugs.html). Malaria infections can be fatal if not diagnosed and treated promptly with antimalarial medications appropriate for the patient's age and medical history, likely country of malaria acquisition, and previous use of antimalarial chemoprophylaxis. Recent molecular laboratory advances have enabled CDC to identify and conduct molecular surveillance of antimalarial drug resistance markers (https://www.cdc.gov/malaria/features/ars.html) and improve the ability of CDC to track, guide treatment, and manage drug resistance in malaria parasites both domestically and globally. For this effort to be successful, specimens should be submitted for all cases diagnosed in the United States. Clinicians should consult CDC Guidelines for Treatment of Malaria in the United States and contact the CDC Malaria Hotline for case management advice, when needed. Malaria treatment recommendations can be obtained online at https://www.cdc.gov/malaria/diagnosis_treatment/ or by calling the Malaria Hotline at 770-488-7788 or toll-free at 855-856-4713.

Using WeChat official accounts to improve malaria health literacy among Chinese expatriates in Niger: an intervention study

BACKGROUND

Malaria is the main health risk for Chinese expatriates working in Niger. Health education is a recommended intervention for prevention of malaria among non-immune travellers and expatriate workers. It is urgent to develop an effective and feasible way for these populations to obtain information about the prevention and treatment of malaria.

METHODS

An individually randomized, unblinded, controlled trial was used to evaluate the effectiveness of using WeChat official accounts for health education to improve malaria health literacy among Chinese expatriates in Niger. A total 1441 participants completed a baseline malaria health literacy questionnaire and were randomly assigned to an intervention or comparison group in a ratio of 1:1. From July to October 2014, 50 malaria prevention and treatment messages were sent to the intervention group; 50 health news messages were concurrently sent to the control group. Both groups completed the malaria health literacy questionnaire again 4 months after the start of the education intervention. A questionnaire addressing satisfaction with the health education programme was completed by the intervention group. Malaria morbidity data for 2013 and 2014 were also collected.

RESULTS

At baseline, participant health literacy rates were 58.29, 62, 54, and 34% for skills, knowledge, practice, and attitude, respectively. After the intervention, rates for all four aspects of malaria literacy were above 70%. There was greater change in knowledge, attitude, practice, skills, and overall health literacy among the intervention group compared with the controls, with a statistically significant difference (p < 0.01). This was especially true for acquisition of malaria-related knowledge, practice and attitude; comprehensive intervention practices; and, correct use of rapid diagnostic tests (p < 0.001). The reported malaria morbidity during the study period decreased from 23.72 to 15.40%. Participants reported high levels of satisfaction with the WeChat health education programme with over 80% stating that they would continue to follow the programme.

CONCLUSIONS

The present health education intervention, via a WeChat official account, for the prevention and treatment of malaria among non-immune travellers and expatriate workers proved to be an effective, sustainable, feasible, and well accepted strategy for improving malaria health literacy among Chinese expatriates in Niger.

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.

Malaria Surveillance - United States, 2013

PROBLEM/CONDITION

Malaria in humans is caused by intraerythrocytic protozoa of the genus Plasmodium. These parasites are transmitted by the bite of an infective female Anopheles mosquito. The majority of malaria infections in the United States occur among persons who have traveled to regions with ongoing malaria transmission. However, malaria is also occasionally acquired by persons who have not traveled out of the country through exposure to infected blood products, congenital transmission, laboratory exposure, or local mosquitoborne transmission. Malaria surveillance in the United States is conducted to identify episodes of local transmission and to guide prevention recommendations for travelers.

PERIOD COVERED

This report summarizes cases in persons with onset of illness in 2013 and summarizes trends during previous years.

DESCRIPTION OF SYSTEM

Malaria cases diagnosed by blood film, polymerase chain reaction, or rapid diagnostic tests are mandated to be reported to local and state health departments by health care providers or laboratory staff. Case investigations are conducted by local and state health departments, and reports are transmitted to CDC through the National Malaria Surveillance System, National Notifiable Diseases Surveillance System, or direct CDC consultations. CDC conducted antimalarial drug resistance marker testing on blood samples submitted to CDC by health care providers or local/state health departments. Data from these reporting systems serve as the basis for this report.

RESULTS

CDC received 1,727 reported cases of malaria, including two congenital cases, with an onset of symptoms in 2013 among persons in the United States. The total number of cases represents a 2% increase from the 1,687 cases reported for 2012. Plasmodium falciparum, P. vivax, P. malariae, and P. ovale were identified in 61%, 14%, 3%, and 4% of cases, respectively. Forty (2%) patients were infected by two species. The infecting species was unreported or undetermined in 17% of cases. Polymerase chain reaction testing determined or corrected the species for 85 of the 137 (62%) samples evaluated for drug resistance marker testing. Of the 904 patients who reported purpose of travel, 635 (70%) were visiting friends or relatives (VFR). Among the 961 cases in U.S. civilians for whom information on chemoprophylaxis use and travel region was known, 42 (4%) patients reported that they had initiated and adhered to a chemoprophylaxis drug regimen recommended by CDC for the regions to which they had traveled. Thirty-six cases were reported in pregnant women, none of whom had adhered to chemoprophylaxis. Among all reported cases, approximately 270 (16%) were classified as severe illnesses in 2013. Of these, 10 persons with malaria died in 2013, the highest number since 2001. In 2013, a total of 137 blood samples submitted to CDC were tested for molecular markers associated with antimalarial drug resistance. Of the 100 P. falciparum-positive samples, 95 were tested for pyrimethamine resistance: 88 (93%) had genetic polymorphisms associated with pyrimethamine drug resistance, 74 (76%) with sulfadoxine resistance, 53 (53%) with chloroquine resistance, one (1%) with atovaquone resistance, none with mefloquine drug resistance, and none with artemisinin resistance.

INTERPRETATION

The overall trend of malaria cases has been increasing since 1973; the number of cases reported in 2013 is the third highest annual total since then. Despite progress in reducing the global burden of malaria, the disease remains endemic in many regions, and the use of appropriate prevention measures by travelers is still inadequate.

PUBLIC HEALTH ACTIONS

Completion of data elements on the malaria case report form increased slightly in 2013 compared with 2012, but still remains unacceptably low. This incomplete reporting compromises efforts to examine trends in malaria cases and prevent infections. VFRs continue to be a difficult population to reach with effective malaria prevention strategies. Evidence-based prevention strategies that effectively target VFRs need to be developed and implemented to have a substantial impact on the numbers of imported malaria cases in the United States. Fewer patients reported taking chemoprophylaxis in 2013 (32%) compared with 2012 (34%), and adherence was poor among those who did take chemoprophylaxis. Proper use of malaria chemoprophylaxis will prevent the majority of malaria illness and reduce the risk for severe disease (http://www.cdc.gov/malaria/travelers/drugs.html). Malaria infections can be fatal if not diagnosed and treated promptly with antimalarial medications appropriate for the patient's age and medical history, the likely country of malaria acquisition, and previous use of antimalarial chemoprophylaxis. Recent molecular laboratory advances have enabled CDC to identify and conduct molecular surveillance of antimalarial drug resistance markers (http://www.cdc.gov/malaria/features/ars.html). These advances will allow CDC to track, guide treatment, and manage drug resistance in malaria parasites both domestically and globally. For this to be successful, specimens should be submitted for all cases diagnosed in the United States. Clinicians should consult the CDC Guidelines for Treatment of Malaria and contact the CDC's Malaria Hotline for case management advice, when needed. Malaria treatment recommendations can be obtained online (http://www.cdc.gov/malaria/diagnosis_treatment) or by calling the Malaria Hotline (770-488-7788 or toll-free at 855-856-4713).