Elsevier Editorial System(tm) for Transactions of the Royal Society of Tropical Medicine and Hygiene Manuscript Draft Manuscript Number: TRSTMH-D-06-00270R2 Title: 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 Article Type: Full Length Article Section/Category: Keywords: malaria, prophylaxis, Africa, travel, travellers, migrant Corresponding Author: Mr thierry pistone, MD Corresponding Author's Institution: CHU Bordeaux First Author: thierry pistone, MD Order of Authors: thierry pistone, MD; philippe guibert, MD; denis malvy, PhD; Khaled Ezzedine, PhD; marie-catherine receveur, MD; martin danis, PhD; frederic gay, MD; M Siriwardana; bernard larouze, MD; olivier bouchaud, PhD Manuscript Region of Origin: Abstract: An observational prospective cohort study assessed malaria risk perception, knowledge and prophylaxis practices among individuals of African ethnicity living in Paris and traveling 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 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 TA (33%) than in TC (7%). The availability of a malaria vaccine was mentioned by 62% of VFR with frequent confusion between yellow fever vaccine and

malaria prevention. Twenty-nine percent took adequate chemoprophylaxis with complete adherence, more among TC (41%) than TA (13%). Effective anti-vector protection measures used were bed nets (16%), wearing long clothes at night (14%) and air conditioning (9%) with no differences between the study groups except in the use of impregnated bed nets by 11% of TC and none of TA. 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.

COVER LETTER Oct, 16 2006

Dear Ms Scott,

Please find two versions of our revised manuscript ref TRSTMH-D-06-00270R1 : one

with the changes shown (Malafric_ethnic220906), and the other one without these indications

(Malafric_Ethnic161006). In addition, you will find a response to each query of the editor

and detailed revision notes. All authors have seen and agree with these modifications. We

hope that this new version of our article will be suitable for publication in the Transactions.

Sincerely yours.

Thierry Pistone, MD

Cover Letter

RESPONSE TO EDITOR’S QUERIES As requested, 1/ the paper has been significantly shortened to 2227 words. 2/ Figure 1 has been removed 3/ Repetitions between text and tables were removed as recommended. It has been clarified that, for data shown in tables 2 and 3, no statistically significant differences were observed between the two groups and, therefore, they were combined for the analyses. 4/ The discussion has been significantly shortened. In particular, some superfluous statements were removed. As mentioned by reviewer #2, we precised in the discussion the limit of our methods. The conclusion has been re-written. 5/ The p value of 1 in table 1 has been corrected.

REVISION NOTES RESPONSE TO EDITOR’S QUERIES As requested, 1/ the paper has been significantly shortened to 2227 words. 2/ Figure 1 has been removed 3/ Repetitions between text and tables were removed as recommended. It has been clarified that, for data shown in tables 2 and 3, no statistically significant differences were observed between the two groups and, therefore, they were combined for the analyses. 4/ The discussion has been significantly shortened. In particular, some superfluous statements were removed. As mentioned by reviewer #2, we precised in the discussion the limit of our methods. The conclusion has been re-written. 5/ The p value of 1 in table 1 has been corrected. INTRODUCTION Last paragraph We replaced the Last paragraph by “Therefore, we assessed malaria risk perception, knowledge and prophylaxis practices in pre-departure VFR at two travel agencies and two travel clinics in Paris. We also evaluated prophylactic practices in VFR upon return from their country of origin in sub-Saharan Africa”. RESULTS Page 6 Paragraph 1 We removed “ As summarized in figure 1” “ The median delay between return and phone call was 20 days, with no difference between TC and TA groups.” Paragraph 2 We removed “ As shown in Table 1, the TC and TA pre-travel groups were similar in terms of age, sex, birthplace (sub-Saharan Africa or France) and reason for travel. However, the TC group had a lower social class, travelled more to West Africa, less frequently on previous travel but for a longer length of stay compared to the TA group.” “ The most recent attack occurred on average 7 years ago.”

Revision Notes

We added “ The table 1 summarizes social and demographic characteristics of TC and TA pre-travel groups of VFR. VFR from the TC group had a lower social level, a longer stay in France and had travelled less frequently to Africa.” Page 7 and 8 Section “Malaria risk perception and knowledge of malaria causes” Page 7 Paragraph 2 We removed “ Answers to open-ended questions concerning health risk perceptions and knowledge of malaria transmission were not statistically different between TC and TA ptre-travel groups. The two groups were combined for the analyses, as shown in Table 2. Malaria, mentioned by almost 50% of VFR in both groups, was by far the most frequent health concern. When VFR who considered malaria as a health concern were asked “why”, two thirds mentioned “ inevitable destiny” and one fourth said “mosquito bites are impossible to prevent”. When VFR who did not consider malaria as a health concern were asked “why”, 44% cited the availability of chemoprophylaxis and 22% the availability of a “malaria vaccine” whereas 25% based their conviction on the fact they had never suffered a malaria attack.”. We added “ Answers to open-ended and closed-ended questions were mostly not statistically different between TC and TA pre-travel groups. Therefore, both groups were combined for the analyses (tables 2 and 3). Concerning health risk perceptions and knowledge of malaria transmission (Table 2), malaria, mentioned by almost 50% of VFR in both groups, was by far the most frequent health concern.” “ As shown in table 3, which summarizes general knowledge on malaria, 13 %….” Paragraph 3 We removed “ Responses to six closed-ended questions on general malaria knowledge were not statistically different between TC and TA pret-travel groups, as shown in Table 3.” “ Vaccine availability and the need to be vaccinated against malaria were mentioned by a high percentage of the pre-travel population (35% and 62%, respectively). Skin repellent and bed nets were considered good protection by a large percentage of the VFR.” Paragraph 4 We removed “ When asked whether wearing long clothes at night is good protection against malaria, 52% (99/191) of the VFR said yes, more (p<0.05) in the TC group (58%, 71/122) than in the TA group (40%, 28/69). “ We added “ Regarding prevention, nearly two-third of the VRF considered that they have to be vaccinated against malaria before travelling and 52% (99/191) that wearing long clothes at night is good protection against malaria, more (p<0.05) in the TC group (58%, 71/122) than in the TA group (40%, 28/69).”

Page 8 Paragraph 5 We replaced “ No differences were observed between the TA and TC groups” by “ …with no differences between TC and TA groups “. Page 9 Section “Prophylaxis planned before departure” Paragraph 1 We replaced “ …intended drugs were…” by “ …intended regimen was…” Section « Malaria prophylaxis practices in post-travel population » Paragraph 1 We removed “ The most frequently used chemoprophylaxis was the association chloroquine plus proguanil (45%, 48/106)”. We added “ …including 15% who used chloroquine alone.” DISCUSSION Page 10 Paragraph 1 We added “relatively” good overall knowledge. We replaced “largely” by “high rate of” inadequate… We replaced “ belief that transmission is possible with water, poor personal hygiene or sun exposure” by “ inadequate knowledge on transmission modes of malaria. We removed “Examples of such barriers include lower perceived risk of malaria attacks especially after return, absence of the drug after return to France, and the fact that two thirds of VFR considered malaria a fatality and one in ten thought transmission is possible with water, poor personal hygiene or sun exposure” We added “Numerous factors seemed to hinder the use of adequate protective measures such as lower perceived risk of malaria attacks especially after return, absence of the drug after return to France, fatality and inadequate knowledge on transmission modes of malaria.” We removed “ Moreover, incorrect belief in the existence of a vaccine against malaria --even after the TC advice-- may be an additionnal factor to hinder the use of adequate protective measures in VFR. Qualitative analysis suggests this belief might stem from frequent confusion between

the yellow fever vaccine and malaria prevention, especially the belief that the yellow fever vaccine works against malaria too.” We added “ Moreover, incorrect belief that the yellow fever vaccine works against malaria too - even after the TC advice - may be an additional factor to hinder the use of adequate protective measures in VFR”. Paragraph 2 We removed “ According to a survey of 23 000 conducted by the French Public Institute on Health Economy, 22% of French residents declare a renouncement of health care due to financial reasons (CREDES, 1999).”

Pages 10 and 11 Paragraph 3 We removed “ Previous studies regarding adherence to malaria prophylaxis in VFR are few in number and limited by bias because they just studied VFR hospitalized with imported malaria (Bouchaud et al., 2005; Boutin et al., 2005; Castelli et al., 1999; CNRMI, 1999; Froude et al., 1992; Makdoembaks et al., 2000; Schultz, 1998; Shah et al., 1998). Scolari et al. (2002) published the only study that included quantitative analysis of malaria prophylaxis used by African immigrants free from malaria. Only 17.6% of the illegal African immigrants interviewed in this study sought pre-travel advice before past visits to Africa and only 4% of them completed chemoprophylaxis (29% after pre-travel advice). Compared with Scolari et al. (2002), the rate of adequate chemoprophylaxis (including adherence) among European travellers was higher and calculated as 46% by Hamer et al. (2004), 63% by Laver et al (2001) and 57% by Steffen et al. (1990). The main objective of pre-travel advice to travellers of African ethnicity in travel clinics should be to reach equivalent or even better rates of adequate chemoprophylaxis than the rates observed by European travellers.” We added “ As expected, the rate of adequate malaria chemoprophylaxis (29%) was higher in our study population of VFR than the rate of chemoprophylaxis (adequate or not) completed during the visit by imported malaria cases previously investigated (4% to 11%) (Bouchaud et al., 2005; Boutin et al., 2005; Castelli et al., 1999; Froude et al., 1992; Schultz, 1998; Shah et al., 1998). But, the rate we observed among VFR was lower compared with rates (35% to 63%) observed among European travelers to malaria endemic countries. (Malvy et al., 2006; Hamer et al., 2004; Laver et al., 2001; Steffen et al., 1990). This result is consistent with the higher perception of malaria as a health risk among European travelers as compared with our study population (Hamer et al., 2004; Toovey et al.,2004) (70 and 80% versus 50%).”

Page 11 Paragraph 4 We added “ We did not find significant differences between TC and TA groups concerning malaria risk perception and knowledge of the disease. Nevertheless, interpretation of these findings is limited by the relatively small number of VFR investigated. Further, even if we have carefully selected the population as described in the methods section, we cannot exclude the fact that few subjects were misclassified.” We removed “ We postulate that these better knowledge of prophylactic measures and chemoprophylaxis usage in the TC group, which has on average a lower social class than the TA group, reflect the impact of pre-travel medical advice in travel clinics. However, the design of our study did not allow us to formally prove this issue.” We added “ These observations suggest the positive impact of pre-travel consultation in travel clinics concerning the implementation of adequate prophylactic measures.” Paragraph 5 We removed “ In our study, malaria was the most frequent health concern, as nearly half of VFR considered themselves at risk for malaria. Hamer et al. (2004) and Toovey et al. (2004) have reported higher rates of health concern in European tourists, as 70 to 80% of whom considered themselves at high risk for malaria.” Page 12 Paragraph 6 We replaced “ Our findings regarding malaria prophylaxis” by “ The drugs used by our study population for malaria prophylaxis” Paragraph 7 We removed “ Three-quarters of pre-travel VFR correctly cited the role of mosquito bites in malaria transmission, and the same proportion considered bed nets efficient protection. These figures are lower than those reported in a study by Govere et al. (2000), which found that 92% of the African community of Mpumalanga Province (South Africa) mentioned mosquito bites as the cause of malaria. In contrast, the poor use of bed nets and skin repellent, as declared by VFR interviewed after return, are similar to observations reported in rural communities from endemic areas like Zimbabwe, where 82% of interviewed individuals reported failure to adopt any individual protection measures against malaria (Vundule et al., 1993).” CONCLUSION We replaced the conclusion by : “ Our findings regarding representations, somewhat limited knowledge on malaria and the inadequate prophylactic practices we identified in VRF, demonstrate the need for public health strategies better adapted to this high-risk population. Culturally-targeted messages and media coverage have to be developed, and chemoprophylaxis reimbursement needs to be considered by the French Public Health System. This should be done in collaboration with health workers in travel medicine, anthropologists and health education professionals.”

1

Table 1. Characteristics of Travel clinic (TC) and Travel agency (TA) pre-travel groups

of travellers of African ethnicity.

Total

N= 191

n (%)

TC group

N = 122

n (%)

TA group

N= 69

n (%)

p value

Age (mean, in years) 37.8 37.9 37.70 0.91

Male 111 (58%) 72 (59%) 39 (57%) 0.74

African born 180 (94%) 112 (92%) 68 (99%) 0.11

French citizenship 51 (27 %) 36 (29 %) 15 (22%) 0.34

Travel for family visit 162 (85%) 104 (85%) 58 (84%) 0.99

High 23 (12%) 13 (11%) 10 (14%)

Medium 81 (42%) 42 (34%) 39 (57%)

Social class

Low 87 (46%) 67 (55%) 20 (29%)

0.002

Mean length of stay

in France (years)

15.7 16.7 14.1 0.03

once every

1-3 yr

84 (44%) 41 (34%) 43 (62%)

once every

4-7 yr

33 (17%) 24 (20%) 9 (13%)

last trip

>8 yr ago

31 (16%) 25 (20%) 6 (9%)

Frequency

of previous

travel

to Africa

never 43 (23%) 32 (26%) 11 (16%)

0.001

Length of visit

(median, in days)

33 44 25 0.001

West Africa 132 (69%) 92 (75%) 40 (58%)

Central Africa 54 (28%) 28 (23%) 26 (38%)

Location

of country

visited Indian Ocean 5 (3%) 2 (2%) 3 (4%)

0.04

Table

2

Table 2. Analysis of main themes evoked in answers by travellers of African ethnicity to

open-ended questions concerning health risk perceptions and knowledge of malaria

transmission §

Analysis of main themes Pre-travel

population

n (%*)

“What are your health

concerns?” (N=191)

Malaria 89 (47%)

Food and waterborne diseases 49 (26%)

None 45 (24%)

AIDS 13 (7%)

Meningitis 10 (5%)

“For you, why malaria is a

health concern?” (N=102)

Inevitable destiny 68 (67%)

Mosquito bites impossible to

prevent

26 (25 %)

“For you, why is malaria not

a health concern?” (N=89)

Availability of

chemoprophylaxis

39 (44%)

Availability of a vaccine 20 (22%)

Never had malaria attack 2 (24%)

“For you, how is malaria

transmitted?” (N=191)

Mosquito bites 141 (74 %)

Water or poor personal hygiene 12 (7%)

Sun exposure 7 (4%)

§ no statistically significant difference between the travel clinic and the travel agency groups * More than one answer is possible to each question. Total % for each question may be >100%

3

Table 3. Analysis of answers by travellers of African ethnicity to six closed-ended questions

concerning general malaria knowledge §

General malaria knowledge

Yes

n (%)

No

n (%)

Do not know n (%)

“Is it possible to get malaria in the country

you are travelling to?”

166 (87%) 4 (2%) 21 (11%)

“ Is there a vaccine against malaria?” 67 (35%) 49 (26%) 75 (39%)

“Does one have to be vaccinated against malaria

before travelling?”

119 (62%) 38 (20%) 34 (18%)

“Are skin repellents a good protection against malaria?” 114 (60%) 36 (19%) 41 (21%)

“Is sleeping under a bed-net a good protection

against malaria?”

145 (76%) 25 (13%) 21 (11%)

§ : no statistically significant difference between the travel clinic and the travel agency groups

4

Table 4. Chemoprophylaxis practices reported by TC and TA post-travel groups of travellers

of African ethnicity.

Practices of Chemoprophylaxis

(adequate or not)

Total

N= 106

n (%)

TC* group

N=64

n (%)

TA** group

N=42

n (%)

Chloroquine + Proguanil 48 (45%) 42 (65%) 6 (14%)

Chloroquine alone 16 (15%) 3 (5%) 13 (31%)

Mefloquine 12 (11%) 8 (13%) 4 (10%)

Others 4 (4%) 2 (3%) 2 (5%)

None 26 (25%) 9 (14%) 17 (40%)

Total 106 (100%) 64 (100%) 42 (100%)

* Travel clinic group; ** Travel agency group

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

T. Pistonea,b,c,*, P. Guibertb, D. Malvyb,c, K. Ezzedinec, M.C. Receveurb, M. Danisb, F.

Gayb, M. Siriwardanaa, B. Larouzéa, O. Bouchaudb,d

a INSERM, UMR-S 707, Paris, F-75012; Université Pierre et Marie Curie-Paris 6 ; UMR-S

707, Paris, F-75012

b Société de Médecine des Voyages, Paris, France

c Centre René Labusquière, Tropical Medicine Branch, EA 3677, Université Victor Segalen

Bordeaux 2, France

d Institut de Médecine et d’Epidémiologie Appliquées -Fondation Internationale Léon Mba ;

Hôpital Avicenne, Université Paris Nord, France,

All authors are MD/

Running title: Malaria prophylaxis among travellers of African parentage

*Corresponding author: Thierry Pistone, Service de Medecine Interne et des Maladies

Tropicales, Hôpital Saint-Andre, CHU Bordeaux, France; Fax: 33 (0) 5 56 79 47 86;

E-mail 1: thierry.pistone@chu-bordeaux.fr E-mail 2: thierry.pistone@wanadoo.fr

Word count (Abstract): 200 Word count (Article): 2227

Authors role in the research:

T.P.: analysis, data interpretation, writing and revision of manuscript

P.G.: design of study, data collection, analysis, interpretation and revision of manuscript

M.D., F.G.: design of study, analysis and interpretation of data

O.B., B.L., D.M., K.E., M.C.R., M.S.: data interpretation and revision of the manuscript

Manuscript

2

Summary

An observational prospective cohort study assessed malaria risk perception, knowledge and

prophylaxis practices among individuals of African ethnicity living in Paris and traveling 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 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 TA (33%) than in TC (7%). The availability of a malaria vaccine

was mentioned by 62% of VFR with frequent confusion between yellow fever vaccine and

malaria prevention. Twenty-nine percent took adequate chemoprophylaxis with complete

adherence, more among TC (41%) than TA (13%). Effective anti-vector protection measures

used were bed nets (16%), wearing long clothes at night (14%) and air conditioning (9%) with

no differences between the study groups except in the use of impregnated bed nets by 11% of

TC and none of TA. 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.

Keywords: malaria, Africa, travel, travellers, prophylaxis, migrant

3

Introduction

Among Western countries, France has the highest incidence of imported malaria cases

due to its historical links with French-speaking parts of Africa. The steady rise in imported

malaria in France since the 1990s, acquired primarily in Africa, results in 6000 to 7000 cases

and at least 20 avoidable deaths per year (Boutin et al., 2005). Imported malaria costs the

French Public Health Insurance System around € 25 million annually (Pistone et al., 2003).

Immigrants comprise less than 10% of France's population but contribute more than 70% of

imported malaria cases in the country (INSEE, 2005). Previous studies have shown that the

residents of Western countries most strongly affected by imported malaria are travellers of

African ethnicity who visit friends and relatives (VFR) in their country of origin (Shah et al.,

1998; Schultz, 1998; Castelli et al., 1999; Cleary et al., 2003 and Boutin et al., 2005). Thus,

VFR are considered a high-risk group for imported malaria, and malaria prevention among

these travellers should be improved by disseminating better information about malaria risk

perception, knowledge and prophylaxis.

Previous studies on VFR may suffer from recruitment bias because they focused on

patients with malaria attack. This problem seems to have been avoided in two recent

investigations - one (Scolari et al., 2002) of African migrants attending a public health clinic in

Italy and one (Morgan et al., 2005) of migrants living in London. However, neither study

investigated VFR shortly before departure and immediately after return, the times when the

most accurate data on prophylaxis knowledge and practice can be obtained.

Therefore, we assessed malaria risk perception, knowledge and prophylaxis practices

in pre-departure VFR at two travel agencies and two travel clinics in Paris. We also evaluated

prophylactic practices in VFR upon return from their country of origin in sub-Saharan Africa.

4

Population and Methods

This observational prospective survey was conducted in Paris over an 8-month period

(January to August 1998), evaluating VFR who visited their country of origin in sub-Saharan

Africa for more than 7 days. Travellers were recruited on a volunteer basis by an investigator

at two travel clinics (within Pitié-Salpêtrière and Bichat University Hospitals, Paris) after a

pre-travel consultation (TC group) and in two travel agencies specializing in flights to sub-

Saharan Africa after ticket purchase (TA group). Travellers recruited at both sites (TC and TA

groups) and travellers of TA group who intended to visit a travel clinic were not included in

the study.

The study had a pre-travel and post-travel phase and was based on interviews using a

standardised questionnaire with open- and closed-ended questions.

The pre-travel interviews, carried out face-to-face by the same investigator, provided

information on social and demographic characteristics, knowledge and risk perception of

malaria and planned prophylaxis practices. The study population was divided in eight socio-

economic levels according to the Public Institute of French Demography (INSEE) and

recoded into three social classes: low (working class, unskilled employees), medium (skilled

employees, technicians) or high (engineers, senior executives, company managers). Frequency

of previous travel to Africa was classified into four groups: high (every 1 to 3 years),

intermediate (every 4 to 7 years), low (every 8 years or more), or never since first arrival in

France.

In the post-travel phase, the same investigator interviewed by phone the travellers at

most 10 days after their presumed date of return to Paris using a second standardised

questionnaire concerning malaria prophylaxis practices, including chemoprophylaxis and anti-

vector measures. Reproducibility of pre- and post-travel questionnaires was tested by phone.

5

Both questionnaires were prospectively given twice within a 7-day interval among a

randomised subset (15%) of the two groups and compared to assess validity.

Answers to open-ended questions were analyzed by identifying main themes and their

frequency of appearance in the interviews. Malaria chemoprophylaxis adherence scores were

calculated according to WHO specifications (WHO, 2005) as follows: percentage of days on

malaria chemoprophylaxis adherence during travel and 30 days after. Chemoprophylaxis was

considered “adequate” for a given destination if the choice of drug, dosage and adherence

were in accordance with the French national guidelines established by the Ministry of Health

in 1998 (CSHPF, 1998).

The study was approved by the Consultative Committee for Protection of Persons in

Biological Research of the Pitié-Salpêtrière University Hospital, AP-HP, Paris, France.

Data entry, data management and univariate analysis were carried out using Epi Info

6.04 software (CDC, Atlanta, GA, USA). Differences were considered as significant if p was

less than 0.05.

6

Results

Study population

One hundred and ninety one VFR were recruited and interviewed before their trip,

122 (64%) in the TC group and 69 (36%) in the TA group. For both groups, the median delay

between interview and departure was 7 days. Forty-four travellers returned after the survey

deadline (August 10, 1998) and were not considered in the analysis. Of the 147 remaining, we

were able to contact 106 (72%; 64 TC and 42 TA) for phone interviews after their return to

France. These individuals comprised the study population for the post-travel phase. The pre

and post-travel groups did not differ significantly in terms of gender, age, nationality, travel

frequency, professional class, and social and demographic characteristics (data not shown,

available on request).

The table 1 summarizes social and demographic characteristics of TC and TA pre-

travel groups of VFR. VFR from the TC group had a lower social level, a longer stay in France

and had travelled less frequently to Africa. Travel destinations were linked to the country of

origin. The most visited countries were Mali, Senegal, Ivory Coast, Cameroon for the TC

group and Ivory Coast, Democratic Republic of Congo, Mali, Congo for the TA group. Ten

percent (19/191) of all VFR visited Africa for the funeral ceremony of a relative. In the pre-

travel population, 25% (48/191) of the VFR declared a history of malaria attack.

Malaria risk perception and knowledge in pre-travel population

Malaria risk perception and knowledge of malaria causes

Of 191 VFR in the pre-travel population, 49% (94/191) considered themselves at risk

for contracting malaria, including 17% (32/191) who considered themselves at high-risk.

Perception of high malaria risk was greater (p<0.05) in the TA group (33%, 23/69) than in the

TC group (7%, 9/122).

7

Answers to open-ended and closed-ended questions were mostly not statistically

different between TC and TA pre-travel groups. Therefore, both groups were combined for

the analyses (tables 2 and 3). Concerning health risk perceptions and knowledge of malaria

transmission (Table 2), malaria, mentioned by almost 50% of VFR in both groups, was by far

the most frequent health concern. When VFR were asked how malaria is transmitted, 25%

failed to mention mosquito bites, instead providing incorrect responses such as water

transmission, poor personal hygiene and sun exposure. As shown in table 3, which summarizes

general knowledge on malaria, 13 % of VFR did not know they could catch malaria in the

country they will be visiting.

Regarding prevention, nearly two-third of the VFR considered that they have to be

vaccinated against malaria before travelling and 52% (99/191) that wearing long clothes at

night is good protection against malaria, more (p<0.05) in the TC group (58%, 71/122) than in

the TA group (40%, 28/69). When asked “Do you know malaria prophylaxis measures?”, the

VFR mentioned “drugs” (59%, 113/191), “Nivaquine®” (chloroquine) (31%, 59/191) and

“bed net” (24%, 46/191) with no differences between TC and TA groups. In response to the

question “Do you have to take tablets against malaria up to 1 month after return to France?”,

65% (124/191) of VFR said "yes", more (p<0.05) in the TC group (72%, 88/122) than in the

TA group (52%, 36/69).

Prophylaxis planned before departure

Ninety-four percent (179/191) of VFR planned to use a chemoprophylaxis, more (p<

0.05) in the TC group (98%, 119/122) than in the TA group (87%, 60/69). In 59% (113/191)

of the VFR - more frequently (p<0.05) in the TC group (69%, 84/122) than in the TA group

(42%, 29/69) - the intended regimen was adequate for the country they were visiting.

8

In the pre-travel population, 51% (97/191) of both TC and TA travellers intended to use at

least one anti-vector measure (bed nets, long clothes or repellents). However, the planned use

of bed nets was higher (p < 0.05) in the TC group (58%, 71/122) than in the TA group (32%,

22/69). Fifty-six percent (107/191) of VFR intended to use skin repellents and 10% (19/191)

electric diffusers.

Malaria prophylaxis practices in post-travel population

As shown in Table 4, 75% (80/106) of the post-travel population said they had used a

chemoprophylaxis (adequate or not), including 15% who used chloroquine alone.

Chemoprophylaxis use was more frequently reported (p<0.05) in the TC group (87%, 55/64)

than in the TA group (59%, 25/42). The median score of chemoprophylaxis adherence was

higher (p<0.05) in the TC group (93%, 51/55) than in the TA group (62%, 15/24).

Adequate chemoprophylaxis practices - correct drug, dosage and adherence including

after return - were reported by 29% (31/106) of the post-travel population, more (p<0.05) in

the TC group (41%, 26/64) than in the TA group (13%, 5/42). Our qualitative analysis of post-

travel interviews identified three reasons for inadequate chemoprophylaxis after return:

insufficient malaria risk perception, negligence and absence of the drug after return to France,

often because the drugs were left for relatives in Africa.

Use of the following anti-vector protection measures were reported by the post-travel

population: bed nets (16%, 17/106), long clothes in the evening (14%, 15/106), air

conditioning (9%, 9/106), skin repellent (7%, 7/106) and mosquito coil (4%, 4/106). There

was no significant difference between TC and TA responses except for the use of impregnated

bed nets by 11% (7/64) of the TC group and none of the TA group.

9

Discussion

Our findings highlight the paradoxical coupling of relatively good overall knowledge of

malaria transmission and a high rate of inadequate malaria prophylaxis in VFR. Numerous

factors seemed to hinder the use of adequate protective measures such as lower perceived risk

of malaria attacks especially after return, absence of the drug after return to France, fatality

and inadequate knowledge on transmission modes of malaria. These inadequate perceptions

agree with the African social representation and knowledge of malaria reported in surveys

performed in sub-Saharan Africa by several authors (Gessler et al., 1995; Morgan et al., 2005;

Nuwaha, 2002; Vundule et al., 1993). Moreover, incorrect belief that the yellow fever vaccine

works against malaria too - even after the TC advice - may be an additional factor to hinder

the use of adequate protective measures in VFR.

As suggested by Morgan et al. (2005), drug cost could also hamper adherence to

prophylaxis. In this respect, Pistone et al. (2003) showed that reimbursing French travelers in

West Africa for chloroquine plus proguanil malaria chemoprophylaxis could be cost-effective

for the French Public Health Insurance System. Further economic and sociological studies

should be conducted to assess the impact of drug cost on recourse to chemoprophylaxis of

VFR.

As expected, the rate of adequate malaria chemoprophylaxis was higher in our study

population of VFR (29%) than the rate of chemoprophylaxis (adequate or not) completed

during the visit by imported malaria cases previously investigated (4% to 11%) (Bouchaud et

al., 2005; Boutin et al., 2005; Castelli et al., 1999; Froude et al., 1992; Schultz, 1998; Shah et

al., 1998). But, the rate we observed among VFR was lower compared with rates (35% to

63%) observed among European travelers to malaria endemic countries (Malvy et al., 2006;

Hamer et al., 2004; Laver et al., 2001; Steffen et al., 1990). This result is consistent with the

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higher perception of malaria as a health risk among European travelers (Hamer et al., 2004;

Toovey et al.,2004) as compared with our study population (70 and 80% versus 50%).

We did not find significant differences between TC and TC groups concerning malaria

risk perception and knowledge of the disease. Nevertheless, interpretation of these findings is

limited by the relatively small number of VFR investigated. Further, even if we have carefully

selected the population as described in the methods section, we cannot exclude the fact that

few subjects were misclassified. We identified several differences between VFR in the two

groups. The TC group showed greater knowledge of prophylactic measures (pre-travel

population) and higher rates of chemoprophylaxis use, including adequate regimens and better

adherence (post-travel population). In addition, the differences between the two groups

highlight greater knowledge among TC group (pre-travel population) of two prophylactic

measures - duration of chemoprophylaxis after return to France and use of long-sleeved

clothing at night. These observations suggest the positive impact of pre-travel consultation in

travel clinics concerning the implementation of adequate prophylactic measures.

The drugs used by our study population for malaria prophylaxis emphasise the

persistent common knowledge of chloroquine as a “well-known” chemoprophylactic drug

even though its usage is no longer recommended as an efficient stand-alone drug for

chemoprophylaxis in Africa. The wide use in Africa, for decades, of chloroquine for malaria

prophylaxis and treatment, as well as its cheap price, probably contribute to this persistent and

inadequate practice.

Conclusions

Our findings regarding representations, somewhat limited knowledge on malaria and

the inadequate prophylactic practices we identified in VRF, demonstrate the need for public

health strategies better adapted to this high-risk population. Culturally-targeted messages and

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media coverage have to be developed, and chemoprophylaxis reimbursement needs to be

considered by the French Public Health System. This should be done in collaboration with

health workers in travel medicine, anthropologists and health education professionals.

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Conflicts of interest statement

The authors have no conflicts of interest concerning the work reported in this paper.

Acknowledgements We thank Dr Paul Kretchmer (San Francisco Edit) for assistance in the revision of the English.

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