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      Does public subsidy of the cost of malaria chemoprophylaxis reduce imported malaria? A comparative policy analysis

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          Abstract

          Background

          Chemoprophylaxis is recommended for at-risk travellers visiting malaria endemic regions. The majority of travellers with imported malaria have not used this, and travellers visiting friends and relatives have the largest burden of malaria and the lowest compliance to chemoprophylaxis. In 1995, the UK’s Department of Health (DH) implemented a policy to make travellers fully responsible for the cost when purchasing chemoprophylaxis. This policy was not implemented in three Primary Care Trusts (PCTs) in London due to concern about the potential increase of imported malaria in their residents, and they maintained the public subsidy. An impact evaluation of the policy change was undertaken to determine if the continued subsidy reduced the incidence of imported malaria in one of the boroughs where the subsidy was maintained when compared to a borough where no subsidy was provided.

          Methods

          Between 2007 and 2010 prescriptions for malaria chemoprophylaxis were collected from pharmacy records and PCTs, and all cases of imported malaria reported from the tertiary hospital in each of the two boroughs were compared.

          Results

          The dispensed chemoprophylaxis prescriptions were nearly 8.8 times higher in Lambeth (where subsidized drugs were provided), than in Hackney. A Poisson model revealed significantly fewer reports of imported malaria per capita were made in Lambeth compared to Hackney (p = 0.042).

          Conclusions

          The difference in malaria reports between the boroughs only just reached statistical significance, despite the considerable difference in chemoprophylaxis prescribing between the boroughs. Some travellers may not consider using chemoprophylaxis, irrespective of the cost. Regular evaluations of the recent policy changes in areas where malaria is subsidized will be important.

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          Most cited references13

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          Malaria risk perception, knowledge and prophylaxis practices among travellers of African ethnicity living in Paris and visiting their country of origin in sub-Saharan Africa.

          An observational prospective cohort study assessed malaria risk perception, knowledge and prophylaxis practices among individuals of African ethnicity living in Paris and travelling to their country of origin to visit friends or relatives (VFR). The study compared two groups of VFR who had visited a travel clinic (TC; n=122) or a travel agency (TA; n=69) before departure. Of the 47% of VFR citing malaria as a health concern, 75% knew that malaria is mosquito-borne and that bed nets are an effective preventive measure. Perception of high malaria risk was greater in the TA group (33%) than in the TC group (7%). The availability of a malaria vaccine was mentioned by 35% of VFR, with frequent confusion between yellow fever vaccine and malaria prevention. Twenty-nine percent took adequate chemoprophylaxis with complete adherence, which was higher among the TC group (41%) than the TA group (12%). Effective antivector protection measures used were bed nets (16%), wearing long clothes at night (14%) and air conditioning (8%), with no differences between the study groups except in the use of impregnated bed nets (11% of the TC group and none of the TA group). Media coverage, malaria chemoprophylaxis repayment and cultural adaptation of preventive messages should be improved to reduce the high rate of inadequate malaria prophylaxis in VFR.
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            Barriers to uptake and adherence with malaria prophylaxis by the African community in London, England: focus group study.

            Rates of imported malaria in the UK and other European countries are increasing, and particularly the more serious Plasmodium falciparum malaria. This study investigated beliefs about malaria and barriers to the uptake and adherence to malaria prophylaxis experienced by African descent individuals in inner London who have low rates of use of malaria prophylaxis and high risks of P. falciparum malaria. Five focus groups conducted with 44 volunteers of African origin living in south London. Transcripts were analysed qualitatively. Failure to access the drugs prior to travel was influenced by perceptions of malaria as a low threat, non-serious and easily treatable, and a belief that they were vaccinated or somehow not at personal risk, together with concerns about side effects of the drugs, dislike of the taste and disbelief by some participants of the drugs effectiveness. Health service barriers included the cost of drugs, waiting times for appointments and uncertainty regarding appropriate medication. Adherence to the prophylaxis was hindered by difficulties in remembering complex regimes, a lack of understanding of the rationale for continuing the drugs after return to the UK and the practice of leaving drugs for relatives in Africa. However, there was some variability in beliefs and practices that appeared to be associated with socio-economic status, prior experience of malaria and the local organisation and delivery of primary care travel services. Much non-adherence is 'intentional' and reflects both beliefs common to all travellers and the particular circumstances and experiences of migrants of African descent. However, there was considerable variability in beliefs and practices among participants that reflects the heterogeneity within the West African community in their socio-economic position and circumstances. Changing behaviours requires a multi-dimensional approach involving community-based health promotion that targets the beliefs of this ethnic group and health service measures.
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              Estimating unreported malaria cases in England: a capture-recapture study.

              A capture-recapture study was undertaken to estimate the incidence and likely total burden of malaria cases in England. Cases diagnosed by the national Malaria Reference Laboratory (MRL) between July 2003 and December 2004 were matched with cases reported to Hospital Episode Statistics using demographic, geographical, parasitological, and temporal information. A total of 3861 cases were recorded in one or both datasets; the 'unknown population' was estimated as 746 cases (95% CI 677-822) giving a total of 4607 cases (95% CI 4446-4767) over 18 months. Eighty-four percent (95% CI 83-85) of cases were recorded in one or both datasets. Fifty-six percent (95% CI 54-58) of cases were captured by the MRL surveillance system; ascertainment for Plasmodium falciparum and London cases was higher at 66% and 62%, respectively. Improving case ascertainment will facilitate effective measures to reduce the burden of this preventable disease in the UK.
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                Author and article information

                Journal
                Malar J
                Malar. J
                Malaria Journal
                BioMed Central
                1475-2875
                2013
                12 July 2013
                : 12
                : 238
                Affiliations
                [1 ]Department of Community Health Development, AUT University, Auckland, New Zealand
                [2 ]Department of Biostatistics, AUT University, Auckland, New Zealand
                [3 ]Hospital for Tropical Diseases, Mortimer Market, & London School of Hygiene and Tropical Medicine, London, UK
                Article
                1475-2875-12-238
                10.1186/1475-2875-12-238
                3723845
                23848986
                489efc69-9e26-41a6-9224-afd7efdec77f
                Copyright ©2013 Neave et al.; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 23 April 2013
                : 1 July 2013
                Categories
                Research

                Infectious disease & Microbiology
                imported malaria,chemoprophylaxis,subsidized costs,evaluation

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