Malaria and VFRs The role of travel medicine Dr Jane N Zuckerman WHO Collaborating Centre for Reference, Research & Training in Travel Medicine Academic Centre for Travel Medicine & Vaccines Royal Free Travel Health Centre University College Medical School

UK Travellers 2012 The number of visits abroad by UK residents fell by 0.5% in 2012, from 56.8 million in 2011 to 56.5 million. There is no clear evidence that the fall is driven by people living in any particular part of the UK. Holiday visits, which account for nearly two thirds of visits abroad, fell by 1.8% while both business visits and visits to friends or relatives grew. Source: International Passenger Survey (IPS) - Office for National Statistics

UK residents' visits abroad by purpose Visits (thousands) HolidayBusiness Visit Friends or RelativesMiscellaneous ,2365,1624,1001, ,1335,2974,4571, ,1875,6144,6742, ,8086,1134,9382, ,7656,8795,5022, ,1387,1666,0043, ,3068,0336,4524, ,0238,1616,5984, ,6858,8727,1784, ,6708,2207,7273, ,9028,0737,8703, ,1977,8928,5273, ,9128,1409,7993, ,1758,55610,6483, ,2879,10211,9633, ,4379,01812,2142, ,5318,92012,3922, ,4926,88711,5921, ,4226,63910,8501, ,8196,84611,5941, ,1736,95611,7971,612 Source: Office For National Statistics

UK residents visits abroad by purpose 1992 to 2012 Source: International Passenger Survey (IPS) - Office for National Statistics

Public Health England Malaria Report 2013 There were 1,378 cases of malaria reported in ill returned travellers to the UK in 2012, including two deaths. This is a decrease from the 1,677 cases reported in As in previous years, the majority (73%) were caused by the potentially life-threatening Plasmodium falciparum and were acquired in Africa. This high proportion of Plasmodium falciparum reflects the fact that most malaria imported into the UK is acquired in Africa. Where region of travel was specified; 49% (669/1,378) of P.falciparum cases originated from West Africa. Among UK malaria cases, where reason for travel was known, over 70% were visiting friends and relatives and the majority of these travellers had not taken malaria prophylaxis.

Malaria Report 2013 Probably reflects greater travel to malaria-endemic areas. This high proportion of falciparum malaria reflects the fact that most malaria imported to the UK is acquired in West Africa. The group who continue to be at highest risk of contracting malaria are those visiting friends and relatives. This group are more likely to acquire malaria for a number of reasons, including: not seeking or being unable to access appropriate medical advice before travel, receiving poor advice, not adhering to advice, or not perceiving themselves to be at risk because the destination is familiar to them.

Imported malaria cases and deaths United Kingdom:

Year*P.falciparumP.vivaxP.ovaleP.malariaeMixedP unspecifiedTotalDeaths

Imported malaria cases by species and region of travel, United Kingdom: 2012 Geographic area *P.falciparumP.vivaxP.ovaleP.malariaeMixed P unspecified Total West Africa East Africa Central Africa Southern Africa North Africa Africa - unspecified Asia§ Far East/SE Asia Central/South America Middle East Oceania Not given Total

Imported malaria cases by reason for travel, United Kingdom: 2011 Population group*P.falciparumP.vivaxP.ovaleP.malariaeMixedP unspecifiedTotal Visiting family in country of origin Holiday travel Foreign visitor ill while in UK New entrant Business/professional travel UK citizen living abroad Foreign student studying in the UK Civilian sea/air crew British armed services Children visiting parents living abroad Other Not stated Total

Some Evidence Where the history of taking anti-malarial medication was obtained, 84 %of cases had not taken prophylaxis. Of those who had malaria diagnosed in the UK, where ethnicity was known, 136 were reported as white British, compared with 938 who were reported as African or of African descent and 395 reported as Asian or of Asian descent. The burden of falciparum malaria in particular falls heavily on those of African ethnicity, and this group is important to target in pre-travel advice. Some groups are at particular risk of acquiring malaria and are not being reached by health messages about the importance of anti-malarial prophylaxis. HPA Malaria Report 2012

Malaria and UK Travellers Under-reporting of malaria cases in the UK is known. A capture-recapture study estimated that the surveillance system captured 56% of cases. Ethnic minority travellers visiting friends and relatives are at particular risk of acquiring malaria Once acquired the risk for mortality is significantly higher in holiday travellers. There is a strong association between increasing age and mortality. Therefore elderly travellers should be considered a particular risk group.

VFRs & Travel Health More migrant families travel to countries of their ethnic origin, where malaria is endemic, contributing to the increasing incidence of imported malaria Failure to comply with prophylaxis or to seek travel health advice mostly explains the increased risk of exposure and cases of malaria in travellers, particularly those visiting friends and relatives. Historically, the problem for travel health practitioners recommending malaria prophylaxis for travel to Africa and Asia has been the adverse publicity regarding this treatment. In addition, many people visiting friends and relatives underestimate their risk of exposure to travel related illness, especially malaria, despite not having lived in an endemic area for many years. This is a dangerous presumption. Other reasons for the reported increase include inaccessibility of travel health advice, over the counter purchase of inappropriate prophylaxis, and purchase of inexpensive (and sometimes counterfeit prophylaxis) at the destination.

UK Travel Patterns With travel predicted to grow to nearly 1.6 billion international arrivals by 2020, travellers will be at increased risk of exposure. The increase in cases of imported malaria is not unexpected. It reflects the increase in the number of visits abroad together with a 150% increase in UK residents travelling to malaria endemic areas during the past decade. One notable change is that with improved vector control in Asia, most cases are now acquired in Africa. As severe acute respiratory syndrome showed, 21st century threats to global public health and travel are inextricably interlinked, and they present ready opportunities for the rapid spread of infectious disease Although people visiting friends and relatives are at particular risk & form the largest group returning with malaria, business and holiday travel also account for a percentage of cases.

What Can We Do? A significant decrease in imported cases of P vivax reported after travel to the Indian subcontinent, a result of successful vector eradication in many urban areas. Pursuing a similar policy and achieving the millennium goals in Africa may reduce the incidence of malaria in endemic areas and improve the health of populations, while also reducing the risk of malaria to travellers, all of which may negate the necessity for prophylaxis in the future. What else can we do? Healthcare practitioners involved in advising travellers about preventing malaria should follow the clear and concise guidelines on malaria prevention for UK travellers. Studies of people visiting friends and relatives aimed at identifying the pertinent factors such as cultural beliefs, knowledge, and attitude towards malaria prevention would help understand how best to impart health education through targeted communication and the use of innovative techniques.