Chemoprophylaxis use and the risk of malaria in travelers to Nepal

Abstract

Background: Malaria transmission in Nepal is focal and seasonal. Based on data in returning travelers the risk of malaria is low. Sources of advice give contradictory information regarding the need for chemoprophylaxis. As a result, a degree of confusion exists among visitors. The aim of this study was to describe chemoprophylactic practices among travelers to Nepal and to document differences in advice according to its source and the country in which it was given. Methods: A questionnaire survey of tourists attending the CIWEC Clinic Travel Medicine Center, Kathmandu between June 2000 and May 2001. Resident expatriates and indigenous Nepalese were excluded. Results: Completed questionnaires were obtained from 1,303 respondents. Two hundred and eighty-eight respondents were taking chemoprophylaxis specifically for their trip to Nepal (22%), whereas 958 were not. Travelers from the United Kingdom and Denmark were significantly more likely, and those from the United States and Germany significantly less likely, to be taking chemoprophylaxis. Most travelers sought pretravel advice (71%), and all sources were more likely to advise them not to take chemoprophylaxis than to take it. However, travelers advised by a family practitioner were significantly more likely to be taking chemoprophylaxis than those advised by a travel medicine specialist. Of those taking chemoprophylaxis, 53% were doing so for a visit to the Terai alone, 33% for all areas of Nepal, and 6% for the Kathmandu Valley. Nine different chemoprophylactic regimes were in use. Six hundred and forty respondents who were not taking chemoprophylaxis had been advised that it was not necessary; 276 had made the choice themselves; and 131 had been taking chemoprophylaxis but had stopped while in Nepal. Twenty-eight of these respondents had stopped because of side effects. The most common reason for choosing not to take chemoprophylaxis was either the occurrence of side effects or the fear of them (31%). Conclusions: The variable and ultimately low risk of contracting malaria in Nepal has resulted in a lack of consensus and a wide range of opinion regarding the need for chemoprophylaxis. There is a need for clarification and tighter definition of the malaria risk faced by travelers to Nepal to avoid unnecessary chemoprophylaxis use while protecting those at significant risk.