The World Health Organization (WHO) estimates that 228 million cases of malaria occurred worldwide in 2018, with approximately 405 000 deaths, 67% of which were in children under 5 years old, mostly in sub-Saharan Africa (WHO, 2019a). WHO advises that international travellers are at risk of malaria infection in 87 countries worldwide, mainly in Africa, Asia and Latin America. WHO recommends that before visiting malaria risk areas, travellers should consult their national disease control centres, or other institutions offering travel advice, for information regarding malaria prevention measures (WHO, 2019b).
Malaria is a severe and potentially life-threatening febrile illness caused by infection with the parasite Plasmodium. This parasite is spread by the bite of a female Anopheles mosquito in tropical and sub-tropical regions of the world. There are five species of Plasmodium that cause malaria in humans: P. falciparum (responsible for the most dangerous type of malaria and the most likely to be fatal), P. vivax, P. ovale, P. malariae and P. knowlesi (Public Health England [PHE], 2019a).
Malaria does not currently occur naturally in the UK, but continues to be a significant, preventable risk for UK travellers visiting malaria-endemic countries (PHE, 2019b).
Malaria in UK travellers
In 2018, a total of 1683 cases of imported malaria were reported in the UK. This included six malaria deaths, all from P. falciparum acquired in Africa. The majority of UK malaria cases were reported in England with a total of 1597 cases, 52 cases were reported in Scotland, 23 in Wales and 11 in Northern Ireland. The reason for travel was known for 925 cases and out of these; 738 travellers (85% of cases) had visited family in their country of origin, also known as visiting friends and relatives or VFR travellers (PHE, 2019a).
This is consistent with previous reports of malaria in UK travellers. Between 2002 and 2013 a total of 17 811 cases of imported malaria were reported in the UK, with the majority of cases in VFR travellers who were infected with falciparum malaria during visits to sub-Saharan Africa (Behrens et al, 2015). This profile of imported malaria in VFR travellers is similar in other European countries, such as France (Behrens et al, 2015; Kendjo et al, 2019).
Other reasons for travel given by the 2018 UK malaria cases (when travel history was known) included the following (PHE, 2019b):
- Armed forces
- Business/professional
- Children visiting parents abroad
- Civilian/air crew
- Holiday.
Malaria guidelines
PHE is an executive agency of the Department of Health and Social Care and is a publicly funded, not-for-profit organisation. They provide evidence-based, professional, scientific expertise and support to various organisations, including central government, the NHS, Parliament and the general public. They also provide guidance and support for health professionals advising UK travellers on malaria prevention. This is in the form of the online document: Guidelines for malaria prevention in travellers from the UK. These guidelines are freely available on PHE's website (PHE, 2019a).
The PHE guidelines (2019a) provide country-specific malaria recommendations, including malaria prevalence maps, advice for special risk travellers like pregnant women, and contain a frequently asked questions section. All current country-specific information corresponds with the malaria advice available on the National Travel Health Network and Centre's TravelHealthPro individual Country Information pages (TravelHealthPro, 2019a).
These practical guidelines, developed by PHE's Advisory Committee on Malaria Prevention, are updated and reissued annually. If significant changes in the distribution or behaviour of the malaria parasite, new drugs or anti-mosquito measures need to be considered, the guidelines will also be updated as required (PHE, 2019a).
PHE recommend health professionals use one resource for country-specific malaria recommendations to optimise consistency of advice. PHE recognise other sources of advice are available, but advise health professionals working in England, Wales or Northern Ireland to use PHE guidelines as their preferred source. It is important to note that they have been expressly devised for UK health professionals advising UK travellers, and may not be appropriate for residents of malaria endemic areas (PHE, 2019a).
The last major update of the guidelines was in 2017, when PHE published a significant revision of country recommendations (TravelHealthPro, 2019b).
After the major revision of country recommendations in the 2017 guidelines, fewer changes were necessary for the 2018 update, published on 3 January 2019 (TravelHealthPro, 2019b). Changes to the 2018 guidelines included the following (TravelHealthPro, 2019b):
- The manufacturer's update to the Summary of Product Characteristics for mefloquine adding insomnia to list of psychiatric symptoms that must be regarded as prodromal for a more serious event
- Additional information concerning atovaquone/proguanil and the use in pregnancy when there is no alternative appropriate antimalarial option
- Update of country recommendations for Paraguay
- Temporary recommendations for Bangladesh, Cape Verde and South Africa previously issued since the last publication in 2017.
In September 2019, PHE published an update of their UK malaria prevention guidelines. Changes to the updated guidelines are minor (TravelHealthPro, 2019a) and include (PHE, 2019a):
- Uzbekistan and Paraguay were declared to be free of malaria by the WHO in 2018, followed by Algeria and Argentina in May 2019. The country recommendations table has been amended accordingly to reflect this
- Greater attention to application of insect repellent is required, as there is evidence that many travellers do not apply it correctly
- Community-based participatory work with travellers VFR has been shown to identify barriers to malaria prevention and help implement suitable protective interventions for this important group.
Malaria is spread by the bite of a female Anopheles mosquito in tropical and sub-tropical regions of the world
Useful resources
| Malaria Reference Laboratory Advisory Service for Health Professionals The Malaria Reference Laboratory provides reference and diagnostic parasitology of malaria, with surveillance of all imported malaria reported in the UKDoctors, practice nurses and other health professionals can email their malaria prophylaxis and risk assessment queries to the Malaria Reference Laboratory using their malaria risk assessment form: https://www.gov.uk/government/publications/malaria-risk-assessment-formIf possible, forms should be completed electronically and emailed to: phe.malproph@nhs.netThe Malaria Reference Laboratory will reply within 3 working days |
| National Travel Health Network and Centre (NaTHNaC) Advice Line for Health Professionals Telephone: +44 (0)845 602 6712Opening timesMornings: Monday to Friday 09:00–11:00. Afternoons: Mondays and Fridays 13:00–14:00. Tuesdays, Wednesdays and Thursdays 13:00–15:30NaTHNaC is unable to take calls from the general public |
| NaTHNaC TravelHealthPro website: https://travelhealthpro.org.uk/ |
| NHS. Malaria prevention: https://www.nhs.uk/conditions/malaria/prevention/ |
| Public Health England. Malaria in the UK: annual report: www.gov.uk/government/publications/malaria-in-the-uk-annual-report |
| Public Health England. Malaria: information for people travelling overseas: www.gov.uk/government/publications/malaria-information-for-people-travelling-overseas |
| TravelHealthPro. Malaria Factsheet: https://travelhealthpro.org.uk/factsheet/52/malaria |
| TravelHealthPro. Risk assessment/risk management checklist: https://travelhealthpro.org.uk/factsheet/61/risk-assessment–risk-management-checklist |
| World Health Organization. Malaria: https://www.who.int/en/news-room/fact-sheets/detail/malaria |
Pregnancy
The guidelines do not currently recommend use of atovaquone/proguanil as an anti-malarial in pregnancy due to limited data. However, they do not advise that atovaquone/proguanil is contraindicated in pregnancy. They state: ‘if there are no other appropriate options, its use may be considered in the second and third trimesters after careful risk assessment. Folic acid 5 mg daily should be taken for the length of time that atovaquone/proguanil is taken in pregnancy’ (PHE, 2019a).
Risk assessment
Malaria advice is an intrinsic part of a comprehensive travel risk assessment process, which should also encompass vaccine, food and water hygiene advice, and be tailored to the individual's specific requirements.
UK travellers to regions with a risk of malaria should be reminded (regardless of whether or not antimalarials have been recommended) of the importance of trying to avoid mosquito bites. Currently designated ‘low risk’ areas, with a recommendation for bite prevention plus awareness of risk, still have a potential for malaria, so any symptoms, such as fever or flu-like illness, should be investigated as a medical emergency.
Travellers should be aware of the importance of reporting symptoms for up to a year after travel to malaria endemic areas.
Conclusion
Practice nurses are at the forefront of UK malaria prevention as they are often the primary source of information for many UK travellers. Practice nurses are in a unique position as trusted and accessible community health professionals. UK travellers who may not perceive themselves as at significant risk of malaria, such as VFR travellers, can be more receptive to advice and information from practice nurses regarding malaria.
By following current PHE malaria prevention guidelines, practice nurses are promoting current evidence-based recommendations and offering travellers appropriate malaria prevention strategies, a prime function of their public health role.
KEY POINTS:
- Malaria continues to be a preventable risk for UK travellers visiting endemic countries
- UK travellers visiting friends and family in sub-Saharan Africa are at significant risk of malaria
- Public Health England malaria prevention recommendations change quickly—practice nurses should be familiar with real-time online resources
- Bite avoidance and symptom awareness are crucial components of any malaria prevention strategy
CPD reflective practice:
- In which group of UK travellers are the majority of UK malaria cases consistently reported? How could you increase awareness of malaria in this group?
- Which anti-malarial can be considered in the second and third trimester of pregnancy, if mefloquine is contraindicated and the pregnant traveller feels travel is unavoidable?
- Why is mosquito bite avoidance and symptom awareness a crucial component of malaria prevention?