Malaria: The facts for determining good practice

RCN Travel Health Forum and the British Travel Health Association Joint Conference and Exhibition
Monday 8 December 2008

Conference summary by JANE POWELL, GlaxoSmithKline (GSK) Travel Health. The conference and exhibition were wholly sponsored by GSK and Jane attended in her role as Brand Manager.

In early December the RCN Travel Health Forum (THF) and the British Travel Health Association (BTHA) held a joint conference dedicated to the prevention of malaria. It may have been a cold winter morning in London, but the delegates were undaunted in their quest to learn more about this tropical disease and, with 140 attendees and experts in the field sharing their knowledge, the house was full.

Opening address

Following the THF Chair Sandra Grieve's opening remarks, Dr Peter Carter OBE, Chief Executive & General Secretary of the RCN, welcomed delegates to the study day and spoke about the current period of changes and challenges the THF was experiencing. This was mainly due to the merger with four other RCN forums uniting to form a Public Health Forum and the ever-changing global threat of infectious diseases, exemplified by the recent cholera outbreak in Zimbabwe. Dr Carter highlighted that there was a clear need for educational initiatives and further study days to support nurses during this challenging period.

Information and resources on malaria

The first speaker of the day was Jane Chiodini, Travel Health Specialist Nurse, who had succumbed to a winter virus and had effectively lost her voice. She proceeded stoically and came prepared, presenting her slides with speech bubbles against the background music of The Tremeloes hit Silence is Golden. However, what her presentation lacked in volume, it certainly made up for in content. She provided attendees with a valuable overview of the resources available nationally and internationally on malaria prevention, including:

Other websites such as:

Educational materials:

Jane Chiodini also underlined the importance of referring to these and similar resources regularly in order to stay abreast of travel health developments, such as the newly emerging malaria strain in humans called Plasmodium knowlesi.

Knowledge, attitudes and practices of African visiting friends and relatives (VFRs)

Penny Neave, Health Protection Specialist and Health Strategist at the HPA, explored the challenges associated with offering travel health advice to VFRs - a notoriously difficult sector of the population to reach and treat who:

Penny explained that reluctance to take antimalarials has led to VFR men being twice as likely to die from malaria infection as women and reiterated the importance of recommending chemoprophylaxis: about half of the fatal cases of imported malaria occur in travellers who had taken no chemoprophylaxis.

Ultimately, it is important to remember when working with Africans or African VFRs that this group is not homogenous. Indeed, wide-ranging cultural preferences and socioeconomic factors will shape behaviour of each traveller.

Grappling with mosquitoes!

In the next session, Dr Nigel Hill, an entomologist from the London School of Hygiene and Tropical Medicine, assessed bite prevention methods available for travellers. He emphasised that they should be evaluated in terms of suitability in different circumstances and efficacy, recommending:

Dr Hill then briefly discussed the methods that he wouldn't recommend to travellers because they have been shown to be ineffective, including:

Malaria in returning travellers

In the final morning session, Dr Nick Beeching, Senior Lecturer and Clinical Lead in Infectious Diseases from the Liverpool School of Tropical Medicine, reviewed the latest trends in imported malaria rates. In particular, he highlighted that, although initially it was thought that incidence would decline from the 1950s onwards, malaria is currently resurgent.

Dr Beeching explained that the biggest problems preventing the successful treatment of malaria cases are delays in presentation and delays in diagnosis and treatment. For instance, he recalled three deaths from malaria in Liverpool that were caused by delays in diagnosis. A history of travel should always be recorded, and doctors and nurses investigating illness in travellers returning from malaria endemic regions should always consider malaria as a possible diagnosis until it can be excluded.

With regards to the treatment of malaria infection, Dr Beeching urged delegates to:

One of the most recent and important developments that Dr Beeching discussed was the identification of Plasmodium knowlesi, a new form of malaria originally found in monkey hosts, but now recognised to cause disease in humans. It is prevalent in Thailand and Malaysia, and is now emerging in travellers returning from these areas to Europe.

Case scenarios and Q&A session

Following lunch and an opportunity to visit the exhibition where various resources available to the delegates were demonstrated, Dr Nick Beeching chaired a panel discussion and interactive session with Diane Parsons, Senior Nurse at InterHealth, representing the THF and Claire Wong, Travel Health Nurse Specialist from NaTHNaC, representing the BTHA. They considered case studies of travellers visiting four at-risk areas (Goa, Guinea, the Caribbean and South America), which illustrated that:

I'll never get malaria

Tim Beacon, Director of the Outdoor Experience, emphasised the importance of assessing travellers' risk of exposure to malaria during adventure travel and that awareness and preparation were crucial for prevention. He reiterated the importance of:

When he was a young traveller, Tim recalled, vital information regarding malaria prevention was unavailable. This led to many of his friends contracting malaria because they were unaware of the risks. Today, he said, there was no excuse for travellers to be unaware of malaria and how to prevent it, but he still thought there was a need for education.

The role of pharmacists in malaria advice

In the following session, Professor Larry Goodyer, Head of the School of Pharmacy at De Montfort University, described the current provision of travel health advice - especially on malaria - as delivered by community pharmacists. He explored the role pharmacists can play in advising travellers on malaria prevention, including:

Malaria: advice for children and young people

The final session of the day saw Dr Delane Shingadia, a consultant in paediatric infectious diseases at London's Great Ormond Street Hospital, discussing the challenges faced in the prevention of malaria in children and young people. In particular, he focused on the following points:

Dr Shingadia went on to acknowledge that the source of pre-travel advice in VFR populations is often not clear, with risk factors associated with this group different to the general population. Often VFRs will travel to at-risk areas while pregnant, with children or while unwell with multiple other illnesses. They also frequently arrange travel at the last minute with little time to seek professional advice - and many simply don't ask for advice at all.

At the close of the meeting Dr John Davies, Chair of the BTHA, and Sandra Grieve underlined that malaria is a preventable disease that should be at the forefront of travel health advice for people visiting endemic regions of the world. The high turnout for the event illustrated the desire for up-to-date knowledge as well as the importance of continuing education and sharing best practice in travel health.

*Hill N, Lenglet A et al. (2007) "Plant based insect repellent and insecticide treated bed nets to protect against malaria in areas of early evening biting vectors: double blind randomised placebo controlled clinical trial in the Bolivian Amazon", BMJ 2007;335(7628):1023.