Barriers to malaria prevention among immigrant travelers in the United States who visit friends and relatives in sub-Saharan Africa: A cross-sectional, multi-setting survey of knowledge, attitudes, and practices

Abstract

Background Despite achievements in the reduction of malaria globally, imported malaria cases to the United States by returning international travelers continue to increase. Immigrants to the United States from sub-Saharan Africa (SSA) who then travel back to their homelands to visit friends and relatives (VFRs) experience a disproportionate burden of malaria illness. Various studies have explored barriers to malaria prevention among VFRs and non-VFRstravelers to the same destinations with other purpose for travel-but few employed robust epidemiologic study designs or performed comparative analyses of these two groups. To better quantify the key barriers that VFRs face to implement effective malaria prevention measures, we conducted a comprehensive community-based, cross-sectional, survey to identify differences in malaria prevention knowledge, attitudes, and practices (KAP) among VFRs and others traveling to Africa and describe the differences between VFRs and other types of international travelers. Methods and findings Three distinct populations of travelers with past or planned travel to malaria-endemic countries of SSA were surveyed: VFRs diagnosed with malaria as reported through a state health

Malaria Surveillance — United States, 2017

“…Among U.S. civilians, those traveling to visit friends and relatives are the most common group to acquire malaria, and they are less likely than other types of travelers to have taken any chemoprophylaxis (24.1% compared with 35.2%, among VFR and non-VFR travelers, respectively). Although pretravel health consultations are necessary to obtain prescription antimalarial medications tailored for the person's age, pregnancy status, destination country, preferences (e.g., daily or weekly drug regimen), tolerability of potential side effects (e.g., sun sensitivity for doxycycline and neuropsychiatric disorders for mefloquine), and cost, many travelers do not seek pretravel consultations (67,68). In addition, because antimalarial medications are often not covered by insurance, out-of-pocket costs can prevent U.S. travelers from initiating chemoprophylaxis (69)(70)(71).…”

“…However, persons traveling for the purpose of VFR made up approximately 60% of U.S. civilian patients in 2017; targeting malaria prevention efforts to this group could protect U.S. civilians from acquiring malaria. The insight from recent work to address malaria prevention among VFR travelers suggests that the motivations, situations, and health care environments for VFR travelers are complex, and improving access and adherence to malaria prevention, especially chemoprophylaxis, will require a multifaceted approach (68,(70)(71)(72). Health care disparities for immigrant communities and limited access to travel clinics that are knowledgeable about and can provide specialized care for their unique needs are barriers to preventive pretravel care.…”

“…Traveling at the last minute for a family illness or death also can limit their ability to acquire malaria chemoprophylaxis ( 71 ). VFR travelers, compared with non-VFR travelers, had statistically longer durations of travel (7 weeks versus 3.8 weeks) ( 68 ). Insurance policies, especially Medicaid, which covers a large proportion of low-income immigrants, often have dispensing policies that limit the number of days for which a medication can be dispensed, and many insurance policies do not offer a prescription override for a vacation (i.e., allowing a prescription to be filled for more than a 30-day supply) ( 70 ).…”

“…In one study, cross-sectional surveys were conducted among U.S. resident travelers in four different categories: 1) VFR travelers in the community settings, 2) VFR travelers with recent malaria diagnoses, 3) VFR travelers attending a travel clinic, and 4) non-VFR travelers attending a travel clinic. The study objectives were to assess and compare malaria prevention knowledge, attitudes, and practices among these groups ( 68 ). The findings indicated that even among those who obtained chemoprophylaxis medications at a travel clinic, VFR travelers were less likely to adhere to the medication regimen (83.0%) compared with non-VFR travelers (98.7%).…”

“…The findings indicated that even among those who obtained chemoprophylaxis medications at a travel clinic, VFR travelers were less likely to adhere to the medication regimen (83.0%) compared with non-VFR travelers (98.7%). VFR travelers with recent malaria diagnoses were less concerned about malaria risk than other groups of VFRs and were more likely to have taken five or more previous trips to sub-Saharan Africa ( 68 ). This suggests that having taken previous trips that did not result in malaria decreased the perception of risk for a malaria infection overall.…”