Chapter 8 Advising Travelers with Specific Needs

Lin H. Chen

Long-term travelers and expatriates in malarious areas are at risk for severe malaria throughout their stay, but sometimes they do not recognize the continued need for reducing risk through prophylaxis and personal protective measures. Even those with knowledge of the need for preventive practices may be unable to adhere to them or may opt to discontinue them. Guidelines for malaria prevention might be interpreted as focusing on preventing Plasmodium falciparum malaria in short-term travelers. Optimal malaria prevention in long-term travelers poses dilemmas because of diverse traveler characteristics and itineraries (including traveling in and out of malarious areas), the heterogeneous quality of and access to medical care, and the limited reports on long-term safety and efficacy of antimalarial drugs. Moreover, parasite resistance, seasonality, and the intensity of transmission evolve with environmental and population alterations.

For this discussion, long-term travelers are defined as nonimmune travelers staying in malaria-endemic countries for ≥6 months. A review summarized published data on the risk of malaria in long-term travelers, evidence for personal protective measures, and safety and tolerability of malaria prophylaxis during long-term use (Box 8-05).

INDIVIDUALIZED RISK CONSIDERATIONS

Some travelers have preconceived notions about malaria prevention for their long-term journey or stay in an endemic region that may shape their acceptance of standard recommendations. Even when educational efforts appear successful in convincing such travelers to take prophylaxis, they often meet other travelers or locals who convince them that the medication is either not necessary or is in some way detrimental to their health. Additionally, adherence to malaria prophylaxis among Peace Corps volunteers was associated with forgetting the medication, fear of long-term adverse effects, and experiencing adverse events attributed to the drug. Nonetheless, taking a detailed assessment of the traveler’s risk and attitude may help the clinician determine the traveler’s likelihood of adherence to preventive actions during long-term travel. Consider asking about the following:

• Traveler’s beliefs regarding personal protective measures
• Traveler’s knowledge and preferences toward continuous prophylaxis
• Travel characteristics, including the quality of accommodations, activities, and social support and network
• Economic considerations
• Destination-specific infrastructure, including medical service, access to high-quality care, medication supply, and availability of repellents, insecticides, and nets

PRACTICAL RECOMMENDATIONS

Personal Protective Measures

Preventing malaria in all travelers is a complex issue and particularly so for long-term travelers and expatriates, who require personalized expert advice. For long-term travelers and expatriates, malaria prevention must stress the role of personal protective measures as an adjunct to prophylaxis, including adapting behaviors to minimize mosquito exposure, staying in housing with screened windows and doors, using air conditioning, sleeping under an insecticide-treated bed net, applying insecticide sprays in the residence, managing the environment to reduce vector breeding, using effective repellent, and wearing long sleeves and pants when practical (Box 8-06).

Malaria Prophylaxis

Prophylaxis decreases the risk of illness, hospitalization, and death. However, some travelers may disregard prophylaxis recommendations. Working with the traveler to overcome his or her concerns, providing insight into the severity of malaria, and deriving a feasible and sensible prophylaxis plan are recommended (Box 8-07). For example, a long-term traveler or expatriate based in a malaria-endemic country with highly seasonal or geographically focal malaria transmission may rely primarily on personal protective measures at some times and target periods of prophylaxis during the transmission season or when venturing into endemic areas. However, a traveler who will be staying in an area of high continuous malaria transmission should continue to use malaria prophylaxis for the entire stay.

Another scenario that may arise and merits discussion with long-term travelers is whether they should continue malaria prophylaxis if they develop fever during travel. Rapid diagnostic tests are unreliable for self-diagnosis in travelers because most travelers are not able to use and read the test correctly. (In the United States, rapid diagnostic tests are only approved for laboratory use.) Because fever has numerous possible causes besides malaria, travelers should continue their recommended prophylaxis provided that they are tolerating it well. In addition, they should be tested for malaria even if taking prophylaxis. Clearly the possibility of other treatable causes of fever should be explored. Travelers who will be >24 hours from adequate medical care should consider carrying a full course of malaria medication for emergency self-treatment when malaria is suspected, regardless of whether they take continuous prophylaxis. Travelers who might self-administer treatment should be told that they still require follow-up care as soon as they are able to access it.

Unfortunately, in many countries malaria is a frequent diagnosis in people who do not have malaria. In addition to receiving unnecessary treatment, long-term travelers and expatriates who are misdiagnosed with malaria may stop taking their prophylaxis because they erroneously believe that it did not work. It is difficult to relay such a concept during the pretravel consult, but the attempt should be made.

SUMMARY

Recommendations for malaria prevention in all travelers must be personalized. Tailoring advice by assessing the traveler’s preferences and concerns and determining the traveler’s possible adherence, along with education regarding malaria, will likely result in better adherence than simply prescribing a course of prophylaxis. The following messages should be conveyed to the long-term traveler regarding malaria prevention:

• Adherence to prophylaxis in high-risk areas is essential.
• Use of personal protective measures, such as bed nets and screens, is critical (as many will not use repellents long term).
• Reliable medical facilities at the destination should be located as soon as feasible.
• Data support the safety of long-term use of prophylaxis.
• Supplies of antimalarial drugs should be brought from home, because poor-quality drugs (substandard, falsified, or counterfeit) are prevalent in malaria-endemic countries.
• Fever is a worrisome sign, and malaria must be considered and ruled out (see Chapter 5, Fever in Returned Travelers).
• A medical evacuation insurance policy should be purchased if the traveler will be in an area with inadequate medical facilities.
• Although individual use of rapid diagnostic tests is not advised, carrying standby treatment with follow-up medical care may be appropriate for some.
• Presumptive antirelapse therapy may be appropriate for exposure in areas with intense P. vivax transmission (after a normal level of G6PD is documented).
• Misconceptions regarding malaria are pervasive in malaria-endemic countries among expatriates and local residents, and long-term travelers should trust health advice only from reputable and respected sources.

BIBLIOGRAPHY

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Perspectives sections are written as editorial discussions aiming to add depth and clinical perspective to the official recommendations contained in the book. The views and opinions expressed in this section are those of the authors and do not necessarily represent the official position of CDC.