Travel health update

Guidelines for prevention of malaria in UK travellers; Travel and Flu websites from Sanofi Pasteur; Important changes to ACMP malaria guidelines

GUIDELINES FOR PREVENTION OF MALARIA IN UK TRAVELLERS

Guidelines for practitioners advising travellers visiting malaria endemic areas have been available for some time and published in journals such as the BMJ. However in 2007, a completely new publication was written taking the form of an A5 sized book, which was very attractive both visually and practically and created a comprehensive and, importantly, a far more user-friendly document for all healthcare professionals. Written by the Health Protection Agency (HPA) Advisory Committee for Malaria Prevention (ACMP), the guidelines were available both in hard copy and electronic format. On 22 August 2013, a revision of these guidelines was published, written again by ACMP, now part of Public Health England (PHE).

My first impression is the difference in the look! Formatted as an A4 PDF, with no illustrations (apart from a few charts and maps), it is only available as an electronic download - perhaps this is a sign of the times. However, having got over the shock, I’ve found it to be just as user friendly as the previous edition, more cost effective to print out a paper copy if needed, possibly easier to read as well.

As with the previous edition, the Executive summary on page 6 suggests that the guidelines may be of use to prospective travellers who wish to read about the options for themselves.

Below is a summary of some of the significant changes to affect your day-to-day practice when advising travellers who need malaria prevention. However, I would strongly recommend reading the UK Malaria Guidelines for a fuller explanation before acting on any of the information below. Printing off charts such as the malaria chemoprophylaxis dosages for both adults and children could provide a useful aide memoir in your consultation.

NEW TRAVEL AND FLU WEBSITES FROM SANOFI PASTEUR MSD

Two new ‘fun to use’ websites have been launched by SPMSD. The travel health site www.areyouready2go.co.uk has been developed with the intention of saving us time in a travel consultation with plenty of helpful information for the traveller to read in this easy to navigate website. Still to be launched is a section entitled ‘My records,’ which will provide a record of previous vaccinations and include the capability to set up e mail or text reminder for the next appointment. SPMSD also plans to build a section for information specific for health care professionals (HCPs), including information about SPMSD vaccines, e learning travel related content and some useful links.

The flu website http://www.flu-protect.co.uk/ provides a range of information for HCPs including those in occupational health and private companies, as well as for patients. I particularly liked the education provided about how the immune system works – see http://www.flu-protect.co.uk/hcp/how-immune-system-works A cold versus flu checker is available to help the user possibly determine whether the symptoms are flu or not – this checker is also available as a ‘free’ app for iPhone – a handy tool to possibly cut down on unnecessary surgery appointments during the flu season. See https://itunes.apple.com/us/app/flu-vs-cold/id642793824?mt=8

IMPORTANT CHANGES TO ACMP MALARIA GUIDELINES

• Additional information about a fifth species of Plasmodium, P. knowlesi: this species is very rarely imported at present, but is capable of producing severe illness. Within the malaria lifecycle, P.knowlesi divides inside the red cell very rapidly over 24 hours, more rapidly than other species, resulting in faster progression of the illness
• Additional information has been added on bite prevention. The repellent DEET is reportedly used worldwide by approximately 200 million people each year; studies have concluded that there is a low risk of adverse effects when DEET is applied according to product directions. DEET is useful as a clothing repellent but its duration on clothing is shortened due to its volatility. Most of the nets now available are long-lasting impregnated nets. In these products the pyrethroid is incorporated into the material of the net itself or bound to it with a resin.
• The advice to patients purchasing their own supplies of malaria chemoprophylaxis has changed to include the warning ‘those purchasing antimalarial drugs over the internet to ensure that they are dealing with a bona fide supplier or web site’
• Chloroquine tablets contain 155mg chloroquine base therefore the adult dose of chloroquine, 310mg, is 2 tablets (weekly). There is a very clear table setting out the dose steps for chloroquine syrup for children, explaining that this differs in its chloroquine base to chloroquine tablets.
• ACMP advises that children can be given atovaquone/proguanil from 5kg in weight. A child weighing 5-8 kg should be given 0.125% of the adult dose (half a paediatric tablet) and children weighing from >8 to 10kg should be given 0.188% of the adult dose (three-quarters of a paediatric tablet).
• Chemoprophylaxis in female patients
  • Removal of recommendation for additional contraceptive precautions when taking doxycycline but a reminder that if the traveller suffers vomiting or diarrhoea, the usual additional precautions should be observed
  • Doxycycline is best avoided for antimalarial prophylaxis during pregnancy. However, if required before 15 weeks’ gestation it should not be withheld if other options are unsuitable. The course of doxycycline, including the 4 weeks after travel, must be completed before 15 weeks’ gestation
  • Additional information is included for breast feeding: the ACMP concludes, based on current evidence, that doxycycline should not be used in breast feeding unless other options are unsuitable and its use is felt to be essential.
  • ACMP advises against the use of atovaquone/proguanil for antimalarial chemoprophylaxis in pregnancy. However, if there are no other options, its use may considered in the second and third trimesters after careful risk assessment. If it is used in pregnancy, a folate supplement should also be given
  • Mefloquine should be used with caution in first trimester, but can be used in all trimesters for travellers to high risk regions
• Detailed country by country advice for 117 different countries has been provided in a table. Risk of malaria and recommendations for chemoprophylaxis have been revised for some countries and/or geographical areas, and some geographical areas of risk have been re-defined. Both NaTHNaC and Health Protection Scotland (HPS) have representation on the Advisory Committee for Malaria Prevention in UK travellers (ACMP). HPS, through the Scottish Malaria Advisory Group, produces country recommendations and accompanying maps which are updated on an ongoing basis; in some instances, there may be differences between the ACMP (and NaTHNaC) and HPS guidance. Health professionals are encouraged to be consistent in their choice of resource, and are assured that if they follow either standard their travellers will be receiving expert advice based on evidence-based recommendations’.
• The section on students and children at boarding school includes new suggestions for specific written instructions/advice for parents
• Advice for travellers leaflets are now available in Bengali, Gujarati, Punjabi and Urdu as well as English

Reference

Chiodini PL, Field VK, Hill DR, Whitty CJM and Lalloo DG. Guidelines for malaria prevention in travellers from the United Kingdom. London, Public Health England, July 2013.

• For links to all the information on malaria mentioned above and more, go to http://www.janechiodini.co.uk/education/malaria/