<trans-abstract xml:lang="de" xmlns="http://www.w3.org/1999/xhtml">

<p>U Hrvatskoj je malarija iskorijenjena 1964. godine, a u sljedećim godinama importirano je oko deset slučajeva godišnje, najčešće se radilo o hrvatskim radnicima migrantima, posebice pomorcima. Oko 80 % registriranih slučajeva zarazilo se u Africi zbog nepravilne primjene kemoprofilakse. Cilj ovoga istraživanja bio je utvrditi incidenciju malarije hrvatskih pomoraca od 2004. do 2014. godine, istražiti jesu li pravilno uzimali kemoprofilaksu te je li im malarija priznata kao profesionalna bolest. Da bismo odgovorili na ta pitanja, analizirali smo epidemiološku anketu Hrvatskoga zavoda za javno zdravstvo, koju su ispunili pacijenti, te smo pregledali epidemiološka izvješća i nacionalni Registar profesionalnih bolesti. U promatranom razdoblju ukupno su 102 osobe oboljele od malarije, od kojih je 25 pomoraca. Sedamnaest pomoraca nije uzimalo kemoprofilaksu uopće, a osam ih je uzimalo, ali ne prema uputama. Također, nikomu od njih malarija nije priznata kao profesionalna bolest prema hrvatskom zakonodavstvu niti ima informacija jesu li svoja prava ostvarili na bilo koji drugi način. Sve to jasno upućuje na zaključak da pomorci i njihovi poslodavci trebaju biti bolje informirani o dobrobitima preventivnih mjera i o svojim radnim pravima.</p>
</trans-abstract>

U Hrvatskoj je malarija iskorijenjena 1964. godine, a u sljedećim godinama importirano je oko deset slučajeva godišnje, najčešće se radilo o hrvatskim radnicima migrantima, posebice pomorcima. Oko 80 % registriranih slučajeva zarazilo se u Africi zbog nepravilne primjene kemoprofilakse. Cilj ovoga istraživanja bio je utvrditi incidenciju malarije hrvatskih pomoraca od 2004. do 2014. godine, istražiti jesu li pravilno uzimali kemoprofilaksu te je li im malarija priznata kao profesionalna bolest. Da bismo odgovorili na ta pitanja, analizirali smo epidemiološku anketu Hrvatskoga zavoda za javno zdravstvo, koju su ispunili pacijenti, te smo pregledali epidemiološka izvješća i nacionalni Registar profesionalnih bolesti. U promatranom razdoblju ukupno su 102 osobe oboljele od malarije, od kojih je 25 pomoraca. Sedamnaest pomoraca nije uzimalo kemoprofilaksu uopće, a osam ih je uzimalo, ali ne prema uputama. Također, nikomu od njih malarija nije priznata kao profesionalna bolest prema hrvatskom zakonodavstvu niti ima informacija jesu li svoja prava ostvarili na bilo koji drugi način. Sve to jasno upućuje na zaključak da pomorci i njihovi poslodavci trebaju biti bolje informirani o dobrobitima preventivnih mjera i o svojim radnim pravima.


<div xmlns="http://www.w3.org/1999/xhtml">
<p>Malaria is a life-threatening tropical infectious disease caused by parasites of the genus <italic>Plasmodium</italic> entered into humans by the bite of female <italic>Anopheles</italic> mosquitoes (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_1">1</a>). Almost half of the world’s population is at risk of contracting malaria. The World Health Organization (WHO) estimates that the number of clinical malaria cases worldwide was 229 million in 2019 (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_2">2</a>). The highest number of cases and deaths was recorded in Africa. Malaria killed 409,000 people in 2019, mostly children aged under 5 years (67 %) (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_2">2</a>).</p>
<p>Malaria is prevented by chemoprophylaxis, vaccination, bite-avoidance, and vector control. Currently, no malaria vaccine is commercially available for travellers, and repellents are considered the most important measure to prevent infection. In high-risk destinations chemoprophylaxis is strongly advised (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_3">3</a>–<a ref-type="bibr" href="#j_aiht-2021-3597_ref_4">4</a>). Even though vector control (draining wetlands and use of insecticides to destroy mosquitoes) has successfully eradicated the disease in many countries, it remains a major problem in poor subtropical and tropical areas (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_2">2</a>, <a ref-type="bibr" href="#j_aiht-2021-3597_ref_5">5</a>–<a ref-type="bibr" href="#j_aiht-2021-3597_ref_7">7</a>).</p>
<p>In Croatia, malaria was officially eradicated in 1964 (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_8">8</a>–<a ref-type="bibr" href="#j_aiht-2021-3597_ref_10">10</a>), but no autochthonous infections have been recorded since 1958 (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_9">9</a>). A retrospective study of the incidence of malaria in Croatia (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_8">8</a>) between 1987 and 2006 reported 201 cases, mostly in seamen (70 %), workers in tropical countries, and tourists.</p>
<p>Croatia has about 30,000 seafarers, 70 % of whom sail under foreign flags (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_9">9</a>). Traveling to different parts of the world and the characteristic way of life on board exposes them to infections to which they would rarely be exposed in their countries of origin. According to the 2006 Maritime Labour <italic>Convention</italic> and Croatian regulations (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_11">11</a>–<a ref-type="bibr" href="#j_aiht-2021-3597_ref_13">13</a>), every seafarer must have a valid medical certificate to perform duties at sea. Malaria infection in seafarers is a major public health problem (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_14">14</a>–<a ref-type="bibr" href="#j_aiht-2021-3597_ref_16">16</a>), with the incidence from 500 to 1,000 a year worldwide (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_14">14</a>), and prevention should be based on antimalarial prophylaxis taking into account its benefits and risks, including side effects and the actual risk of developing infection in tropical ports.</p>
<p>The aim of our retrospective cohort study was to investigate the incidence of malaria in Croatia from 2004 to 2014, determine the share of infected seafarers, and establish how many of them took chemoprophylaxis. Considering that an infectious disease contracted at work is considered occupational (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_17">17</a>), our secondary aim was to see whether seafarers with malaria exercised their right to claim occupational disease with their employer and/or health insurance.</p>
<sec id="j_aiht-2021-3597_s_001">
<div>METHODS</div>
<p>Our analysis relied on data collected from epidemiological journals registering malaria cases in Croatia and questionnaires completed by malaria patients from 2004 to 2014, which are available in the archive of the Croatian Institute of Public Health (CIPH) epidemiology service. The questionnaires contain personal and other demographic information (gender, age, education, occupation) and information about how the patient contracted malaria, in which country, how severe the symptoms were, whether they used prophylaxis (specific drug, according to which scheme, how regularly, and for how long), and whether they received antimalarial treatment upon return home. We then compared the obtained data with those from the CIPH Register of Infectious Diseases and the Register of Occupational Diseases. The use of these data was approved by the ethics committees of CIPH and the University of Zagreb School of Medicine.</p>
<p>The data were analysed using descriptive statistics and the chi-squared test for differences in the use of chemoprophylaxis between seafarers and other malaria patients.</p>
</sec>
<sec id="j_aiht-2021-3597_s_002">
<div>RESULTS</div>
<p>Between 2004 and 2014, a total of 102 cases of malaria were recorded (89 men, 8 women, and 5 undetermined), of which 25 among seafarers (24.5 %, all men). Other patients were skilled workers, university degree workers, and military staff of various professions. For 12 people there were no data on education or occupation (<a ref-type="table" href="#T1">Table 1</a>).</p>
<table-wrap id="T1" position="float">
<label>Table 1</label>
<caption><p>Distribution of malaria patients by education and occupation between 2004 and 2014</p></caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th valign="top" align="left">Professional qualifications/occupation</th>
<th valign="top" align="center">N</th>
<th valign="top" align="center">%</th>
</tr>
</thead>
<tbody>
<tr>
<td valign="top" align="left">Skilled worker</td>
<td valign="top" align="center">31</td>
<td valign="top" align="center">30.39</td>
</tr>
<tr>
<td valign="top" align="left">University degree workers</td>
<td valign="top" align="center">25</td>
<td valign="top" align="center">24.51</td>
</tr>
<tr>
<td valign="top" align="left"><bold>Seafarers</bold></td>
<td valign="top" align="center"><bold>25</bold></td>
<td valign="top" align="center"><bold>24.51</bold></td>
</tr>
<tr>
<td valign="top" align="left">Active military personnel</td>
<td valign="top" align="center">6</td>
<td valign="top" align="center">5.88</td>
</tr>
<tr> 
<td valign="top" align="left">Unemployed</td>
<td valign="top" align="center">3</td>
<td valign="top" align="center">2.94</td>
</tr>
<tr>
<td valign="top" align="left">Unknown</td>
<td valign="top" align="center">12</td>
<td valign="top" align="center">11.76</td>
</tr>
<tr>
<td valign="top" align="left">Total</td>
<td valign="top" align="center">102</td>
<td valign="top" align="center">100.00</td>
</tr>
</tbody>
</table>
</table-wrap>
<p>The highest incidence was recorded in 2012 and 2013, whereas no incidence among seafarers was recorded in 2008 and 2009 (<a ref-type="fig" href="#F1">Figure 1</a>).</p>
<figure id="F1" position="float" fig-type="figure">
<h2>Figure 1</h2>
<figCaption><p>Incidence of malaria cases imported in Croatia between 2004 and 2014</p></figCaption>
<img xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="graphic/j_aiht-2021-72-3597_fig1.jpg" src="https://sciendo-parsed.s3.eu-central-1.amazonaws.com/64708e5371e4585e08a9fecd/j_aiht-2021-72-3597_fig1.jpg?X-Amz-Algorithm=AWS4-HMAC-SHA256&amp;X-Amz-Date=20240718T023742Z&amp;X-Amz-SignedHeaders=host&amp;X-Amz-Expires=18000&amp;X-Amz-Credential=AKIA6AP2G7AKP25APDM2%2F20240718%2Feu-central-1%2Fs3%2Faws4_request&amp;X-Amz-Signature=ca42778d4c0715514226205bde3d14458ddd1b142ff5c286f1acc933659a7ef4" class="mw-100"/>
</figure>
<p><a ref-type="table" href="#T2">Table 2</a> shows the distribution of infected seafarers by endemic areas. Most were infected with <italic>Plasmodium falciparum</italic> (N=13; <a ref-type="table" href="#T3">Table 3</a>) and 21 were hospitalised, while four did not provide this information. Twelve were hospitalised in Croatia, two in Africa, one in Ukraine, and six did not provide this information. One sailor received outpatient treatment in Africa.</p>
<table-wrap id="T2" position="float">
<label>Table 2</label>
<caption><p>Distribution of seafarers with malaria by areas of infection</p></caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th valign="top" align="left">Endemic area</th>
<th valign="top" align="center">Number of infected seafarers</th>
</tr>
</thead>
<tbody>
<tr>
<td valign="top" align="left">Ivory Coast</td>
<td valign="top" align="center">5</td>
</tr>
<tr>
<td valign="top" align="left">Nigeria</td>
<td valign="top" align="center">4</td>
</tr>
<tr>
<td valign="top" align="left">Mozambique</td>
<td valign="top" align="center">1</td>
</tr>
<tr>
<td valign="top" align="left">Cameroon</td>
<td valign="top" align="center">2</td>
</tr>
<tr>
<td valign="top" align="left">Congo</td>
<td valign="top" align="center">1</td>
</tr>
<tr>
<td valign="top" align="left">Equatorial Guinea</td>
<td valign="top" align="center">2</td>
</tr>
<tr>
<td valign="top" align="left">Angola</td>
<td valign="top" align="center">3</td>
</tr>
<tr>
<td valign="top" align="left">Gana</td>
<td valign="top" align="center">2</td>
</tr>
<tr>
<td valign="top" align="left">Sierra Leone</td>
<td valign="top" align="center">3</td>
</tr>
<tr>
<td valign="top" align="left">Zambia, Burkina Faso</td>
<td valign="top" align="center">1</td>
</tr>
<tr>
<td valign="top" align="left">Unknown</td>
<td valign="top" align="center">1</td>
</tr>
</tbody>
</table>
</table-wrap>
<table-wrap id="T3" position="float">
<label>Table 3</label>
<caption><p>Distribution of seafarers and other malaria patients by infectious organism</p></caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th valign="top" align="left">Type of <italic>Plasmodium</italic></th>
<th valign="top" align="center">Seafarers N</th>
<th valign="top" align="center">Others N</th>
</tr>
</thead>
<tbody>
<tr>
<td valign="top" align="left">Unknown</td>
<td valign="top" align="center">10</td>
<td valign="top" align="center">38</td>
</tr>
<tr>
<td valign="top" align="left"><italic>P. ovale or P. vivax</italic></td>
<td valign="top" align="center">1</td>
<td valign="top" align="center">2</td>
</tr>
<tr>
<td valign="top" align="left"><italic>P. falciparum</italic></td>
<td valign="top" align="center">13</td>
<td valign="top" align="center">39</td>
</tr>
<tr>
<td valign="top" align="left"><italic>P. falciparum and P. ovale</italic></td>
<td valign="top" align="center">1</td>
<td valign="top" align="center">1</td>
</tr>
<tr>
<td valign="top" align="left"><italic>P. falciparum and P. vivax</italic></td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">1</td>
</tr>
</tbody>
</table>
</table-wrap>
<p>Of the 25 seafarers, one 33-year-old died. He had stayed in Nigeria for six months before infection.</p>
<p>Of the total of 102 patients, only 24 took chemoprophylaxis (8 of 25 seafarers and 16 of 79 others), while 69 reported taking none at all (17 of 25 seafarers and 52 of 79 others), and nine did not provide this information. Upon return, only 9 of the 24 patients who took chemoprophylaxis continued taking prophylaxis. Three were taking mefloquine tablets for two, four, or six weeks. Two were taking atovaquone/proguanil tablets, one for three and the other for 28 days. Two were taking 100 mg doxycycline tablets, one for several days, the other for 1 month, while one person continued with the unknown medication for only two days. No difference in the frequency of prophylaxis was observed between seafarers and others (chi-squared=3.933; df=2; P=0.14).</p>
<p>Prophylaxis taken by eight seafarers before and during the voyage included mefloquine, atovaquone/proguanil, and doxycycline tablets. However, all admitted not to have strictly followed instructions for use.</p>
<p>Upon return, only three seafarers continued taking their medication but not long enough, according to guidelines (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_18">18</a>). All reported to the national epidemiology register and were instructed to follow antimalarial measures. Of 25 sick seafarers, 24 answered in the questionnaire that they did not take any antimalarial measures, such as household inspection and spraying with insecticide and medical examination. Only one seafarer reported spraying the household with insecticide and took medical examination.</p>
<p>As for our secondary aim, none of the sick seafarers exercised their right to claim occupational disease. Only one malaria case was claimed and recognised as occupational in 2014, but not by a seafarer.</p>
</sec>
<sec id="j_aiht-2021-3597_s_003">
<div>DISCUSSION</div>
<p>The results of this ten-year retrospective cohort study has showed a large drop in malaria incidence among seafarers and a drop in prevalence compared to all recorded patients with respect to earlier reports (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_8">8</a>–<a ref-type="bibr" href="#j_aiht-2021-3597_ref_10">10</a>). As expected, most were infected in Africa by <italic>P. falciparum</italic>, which is in line with other reports (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_2">2</a>, <a ref-type="bibr" href="#j_aiht-2021-3597_ref_8">8</a>, <a ref-type="bibr" href="#j_aiht-2021-3597_ref_9">9</a>, <a ref-type="bibr" href="#j_aiht-2021-3597_ref_16">16</a>, <a ref-type="bibr" href="#j_aiht-2021-3597_ref_19">19</a>–<a ref-type="bibr" href="#j_aiht-2021-3597_ref_22">22</a>). It has also showed some weaknesses in the system of recording, prevention, and follow-up of malaria cases in the country. Some countries have a better recording system, most notably great seafaring nations with frequent cases of imported malaria, such as Spain, France, United Kingdom, Germany, and Italy. Poland and Lithuania have a similar problem with reporting as Croatia, because many seafarers sail under foreign flags and are treated for malaria in the ports of call, which is not recorded in national databases (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_19">19</a>–<a ref-type="bibr" href="#j_aiht-2021-3597_ref_20">20</a>).</p>
<p>What raises the greatest concern, however, is that almost two-thirds of all patients (seafarers included) do not observe chemoprophylaxis at all. Only eight seafarers in our study took chemoprophylaxis before and during their stay in endemic areas, and only three continued to take it upon return. Furthermore, none was taking it in accordance with standards of care, which shows a decline from the earlier twenty-year report (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_8">8</a>). Studies from other countries confirm poor compliance of seafarers with instructions for use of antimalarial drugs (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_19">19</a>–<a ref-type="bibr" href="#j_aiht-2021-3597_ref_22">22</a>). One Polish study (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_20">20</a>) concluded that even though information about correct use of prophylaxis was publicly available on the Internet, as was pre-travel medical counselling, people traveling to tropical countries were still poorly informed, which increases the risk of them contracting malaria.</p>
<p>According to the Croatian Act on the list of occupational diseases, malaria contracted during work is considered an occupational disease (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_17">17</a>), yet it has not been reported in the Croatian Register of Occupational Diseases as such for any seafarer between 2004 and 2014 (<a ref-type="bibr" href="#j_aiht-2021-3597_ref_23">23</a>).</p>
<p>Our study is limited to data provided by the Croatian Institute of Public Health, which are incomplete and separated from occupational disease reporting, as we cannot claim with certainty that none of the seafarers exercised their right to claim occupational disease with foreign insurers, but we can reasonably establish that no such information has been recorded in Croatia. And this is perhaps the central conclusion of our study: there is no system which constantly monitors seafarers and their health and links national and international disease databases. In addition, further research should include occupational health and labour law issues.</p>
<p>In the meantime, education about safety at work and prevention measures needs to be improved, such as through continuing education on tropical infectious diseases and their symptoms and through clearly instructing all migrant workers how to take prophylaxis. A multidisciplinary approach to the issue is important, and it should involve cooperation between occupational medicine specialists, employer representatives, epidemiologists, and seafarers.</p>
<table-wrap id="T4" position="float">
<label>Table 4</label>
<caption><p>Distribution of seafarers and other malaria patients by whether they took prophylaxis</p></caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th valign="top" align="left">Has chemoprophylaxis been taken before this disease?</th>
<th valign="top" align="center">Seafarers N</th>
<th valign="top" align="center">Others N</th>
</tr>
</thead>
<tbody>
<tr>
<td valign="top" align="left">No data</td>
<td valign="top" align="center">0</td>
<td valign="top" align="center">9</td>
</tr>
<tr>
<td valign="top" align="left">Yes</td>
<td valign="top" align="center">8</td>
<td valign="top" align="center">16</td>
</tr>
<tr>
<td valign="top" align="left">No</td>
<td valign="top" align="center">17</td>
<td valign="top" align="center">52</td>
</tr>
</tbody>
</table>
</table-wrap>
</sec>
</div>

Malaria among Croatian seafarers between 2004 and 2014: evaluation of chemoprophylaxis use and occupational disease reporting

Institution for Health Care, Occupational and Sports Medicine dr. Fani Žunić Pedisić

Archives of Industrial Hygiene and Toxicology

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Malarija među hrvatskim pomorcima u razdoblju 2004.‒2014.: evaluacija primjene kemoprofilakse i prijave profesionalne bolesti

U Hrvatskoj je malarija iskorijenjena 1964. godine, a u sljedećim godinama importirano je oko deset slučajeva godišnje, najčešće se radilo o hrvatskim...

Malaria among Croatian seafarers between 2004 and 2014: evaluation of chemoprophylaxis use and occupational disease reporting

Article Category: Original article

Published Online: Dec 30, 2021

Page range: 295 - 298

Received: Oct 01, 2021

Accepted: Dec 01, 2021

DOI: https://doi.org/10.2478/aiht-2021-72-3597

© 2021 Heinz-Elmar Tenorth, published by Sciendo

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.