title: A comparison of compliance rates with anti-vectorial protective measures during travel to regions with dengue or chikungunya activity, and regions endemic for Plasmodium falciparum malaria.
abstract: BACKGROUND
  There is limited information on compliance rates with anti-vectorial protective measures (AVPMs) during travel to countries with risk of dengue and chikungunya. We evaluated differences in mosquito exposures, and factors associated with AVPM compliance in travellers going to countries where the principal mosquito-borne infectious disease threat is falciparum malaria and those where risk of dengue or chikungunya predominates.
  
  
  METHODS
  Department of Defence beneficiaries with planned travel to regions where the predominant mosquito-borne infection is falciparum malaria, and those with predominantly dengue or chikungunya risk, were included. Regions were divided into three groups: 'high-risk falciparum malaria', 'low-risk falciparum malaria' and 'chikungunya/dengue risk'. Demographics, trip characteristics, arthropod exposure and AVPM compliance were captured using pre- and post-travel surveys. Skin repellent compliance was defined as self-reported use, categorized as 'often/every day'. A logistic regression model was used to estimate factors associated with AVPM compliance.
  
  
  RESULTS
  183 (9%), 185 (9%) and 149 (7%) travelled to high and low falciparum malaria risk regions, and chikungunya/dengue risk regions, respectively. Overall, 53% (95% CI: 48-57%) and 16% (95% CI: 12-19%) were compliant with repellent use on skin and clothing, respectively. Daytime bites were reported more frequently in chikungunya/dengue risk regions than high malaria risk regions (37% vs. 10%), while night time bites were frequently in high malaria risk regions (53% vs 20%; P < 0.001). Compliance with skin repellents was associated with female gender [RR: 1.54 (95% CI: 1.05-2.28)], observing mosquitoes during travel [RR: 2.77 (95% CI: 1.76-4.36)] and travel during the rainy season [RR: 2.45 (95% CI: 1.66-3.71)]).
  
  
  CONCLUSIONS
  Poor AVPM compliance was observed in the overall cohort. Compliance with skin repellent use was associated with female gender, observing mosquitoes and travelling during the rainy season, and was not associated with the risk of malaria or chikungunya/dengue at the travel destination.
authors.affiliation: Department of Preventive Medicine and Biostatistics, Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.|Division of Infectious Diseases, Naval Medical Center Portsmouth, Portsmouth, VA, USA.|Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA.
authors.forename: Tahaniyat
authors.initials: T
authors.lastname: Lalani
authors.affiliation: San Antonio Uniformed Services Health Education, Fort Sam Houston, TX, USA.
authors.forename: Heather
authors.initials: H
authors.lastname: Yun
authors.affiliation: Department of Preventive Medicine and Biostatistics, Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
authors.forename: David
authors.initials: D
authors.lastname: Tribble
authors.affiliation: Department of Preventive Medicine and Biostatistics, Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.|Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA.|Walter Reed National Military Medical Center, Bethesda, MD, USA.
authors.forename: Anuradha
authors.initials: A
authors.lastname: Ganesan
authors.affiliation: Madigan Army Medical Center, Tacoma, WA, USA.
authors.forename: Anjali
authors.initials: A
authors.lastname: Kunz
authors.affiliation: Department of Preventive Medicine and Biostatistics, Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.|Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA.|Madigan Army Medical Center, Tacoma, WA, USA.
authors.forename: Mary
authors.initials: M
authors.lastname: Fairchok
authors.affiliation: Landstuhl Regional Medical Center, Landstuhl, Germany.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Schnaubelt
authors.affiliation: Department of Preventive Medicine and Biostatistics, Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.|Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA.
authors.forename: Jamie
authors.initials: J
authors.lastname: Fraser
authors.affiliation: Department of Preventive Medicine and Biostatistics, Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.|Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA.
authors.forename: Indrani
authors.initials: I
authors.lastname: Mitra
authors.affiliation: Division of Infectious Diseases, Naval Medical Center Portsmouth, Portsmouth, VA, USA.
authors.forename: Karl C
authors.initials: KC
authors.lastname: Kronmann
authors.affiliation: San Antonio Uniformed Services Health Education, Fort Sam Houston, TX, USA.
authors.forename: Timothy
authors.initials: T
authors.lastname: Burgess
authors.affiliation: Department of Preventive Medicine and Biostatistics, Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.|Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA.|Naval Medical Center of San Diego, San Diego, CA, USA.
authors.forename: Robert G
authors.initials: RG
authors.lastname: Deiss
authors.affiliation: Enteric Diseases Department, Naval Medical Research Center, Silver Spring, MD, USA.
authors.forename: Mark S
authors.initials: MS
authors.lastname: Riddle
authors.affiliation: Naval Medical Center of San Diego, San Diego, CA, USA.|DoD HIV/AIDS Prevention Program, Naval Health Research Center, San Diego, CA, USA.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Johnson
mesh_terms: D000962:Antimalarials / Q000627:therapeutic use*; D018890:Chemoprevention / Q000379:methods; D065632:Chikungunya Fever / Q000517:prevention & control*; D003715:Dengue / Q000517:prevention & control*; D005260:Female; D006801:Humans; D007299:Insect Bites and Stings / Q000517:prevention & control*; D007302:Insect Repellents / Q000627:therapeutic use; D016778:Malaria, Falciparum; D008297:Male; D010349:Patient Compliance / Q000706:statistics & numerical data*; D014195:Travel; D014330:Tropical Medicine
chemical_list: D000962:Antimalarials; D007302:Insect Repellents
keywords: Anti-vectorial protective measures; chikungunya; compliance; dengue; malaria