Abstract and Introduction
Abstract
The concept of 'standby emergency treatment' (SBET) describes the strategy where travelers carry an emergency malaria treatment for self-administration when no medical attention is available or for use under medical supervision after a confirmed malaria diagnosis, and raises many issues for discussion. International guidelines vary on the topic, and there is controversy regarding the appropriate niche for this imperfect strategy. There are situations when SBET can supplement chemoprophylaxis with mosquito bite prevention and for some travelers, particularly those visiting minimal malaria risk areas, carriage of SBET and concomitant anti-mosquito bite measures can constitute the main antimalaria strategy. A strong argument in support of equipping travelers with a quality effective antimalarial treatment as part of their travel medical kit is the global proliferation of counterfeit antimalarials, a situation that is increasing in Africa but is especially prevalent in Asia where more than 50% of artemisinin products are fake. New developments such as improved rapid malaria tests and their wider distribution together with the availability of effective, well-tolerated malaria treatments, such as atovaquone/proguanil, artemether/lumefantrine and a new artemisinin combination dihydroartemisin/piperaquine, which is licensed in Europe for uncomplicated malaria, suggest that it is time to revisit and re-evaluate this strategy for travelers.
Introduction
According to the World Tourism Organization, there were approximately 940 million arrivals worldwide in 2010, of which approximately 180 million were arrivals in to malaria endemic areas.[101] Travelers need effective strategies against malaria. The current options are personal measures against mosquito bites, use of chemoprophylaxis and for some travelers the carriage of a standby emergency treatment (SBET) as a supplement to personal protection. One of the controversies in contemporary policy of malaria protection in travelers is protection in low-risk malaria endemic areas, where the risk of adverse reactions to malaria chemoprophylaxis outweighs the risk of malaria infection.[1] In these situations, the use of SBET becomes an attractive alternative strategy to continuous chemoprophylaxis.
Prevention of malaria is hampered by incorrect behavior. Studies show that correct use of protective strategies by travelers is poor. One analysis of imported malaria cases showed that more than 60% of those who acquired malaria did not use a chemoprophylaxis.[2] Even in those who use chemoprophylaxis, there is a failure rate, that is, malaria infection despite chemoprophylaxis, of up to 10% due to the development of parasite resistance and imperfect adherence to dosage schedules on the part of the traveler. Adherence to personal protection measures against mosquito bites is even poorer with fewer than 10% of travelers using an appropriate combination of measures (appropriate antimosquito measures include the use of repellents, insecticide-treated clothing, impregnated bed nets or air conditioning).[3] As a result of failed prevention, travelers acquire malaria each year with an associated case fatality rate of between 0.5 and 5%.[4–6] WHO data show that 6244 cases of malaria were imported in Europe in 2010, and this is considered to be an underestimation,[102] and 1688 imported cases were reported in the USA in 2010.[7] Analyses of risk factors associated with severe malaria and malaria deaths in travelers[5–9,102] highlight the following:
Species: most deaths (93–100%) are due to Plasmodium falciparum malaria;[5,7]
Age and sex: deaths occur mainly in older individuals with a predominance in men;[10–13]
Delay in the diagnosis of malaria;
Delay in the treatment of malaria;
Use of inadequate or incorrect treatment.
SBET is considered to be a safety net for travelers, and the appropriate use of SBET could eliminate many of the risk factors mentioned above.
Expert Rev Anti Infect Ther. 2012;10(5):537-546. © 2012 Expert Reviews Ltd.
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