Imported Malaria
Abstract & Commentary
By Philip Fischer, MD, DTM&H, Professor of Pediatrics, Division of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
Dr. Fischer reports no financial relationship relevant to this field of study.This article originally appeared in the August 2006 issue of Travel Medicine Advisor. It was edited by Frank Bia, MD, MPH, and peer reviewed by Mary-Louise Scully, MD. Dr. Bia is Professor of Medicine and Laboratory Medicine; Co-Director, Travel Medicine and International Travelers' Clinic, Yale University School of Medicine, and Dr. Scully works for the Sansum-Santa Barbara Medical Foundation Clinic, Santa Barbara, CA. Dr. Bia is a consultant for Pfizer and Sanofi Pasteur, and receives funds from Johnson & Johnson. Dr. Scully reports no financial relationships relevant to this field of study.
Synopsis: Malaria continues to occur among returned travelers in the United States. Careful attention to appropriate use of chemoprophylaxis would prevent most cases.
Source: CDC. Malaria in Multiple Family Members —Chicago, Illinois, 2006. MMWR Morb Mortal Wkly Rep. 2006;55:645-648.
A family of 7 visited the parents' native country of Nigeria in late 2005 and early 2006. Three of the children had febrile illnesses in Nigeria and were successfully treated with a variety of medications. Two weeks after returning to Chicago, 4 of the children developed fever and headache; they were treated with antipyretics and amoxicillin. Three days later, 3 of the 4 children were noted to be jaundiced and still febrile. All 5 children were smear positive for Plasmodium falciparum and were treated as inpatients; 3 in an intensive care unit for complicated malaria. One of the children had significant hemolysis and severe metabolic acidosis requiring intubation. Another required red cell transfusion for anemia. Two of the children with complicated malaria had sickle cell disease, and the other children had sickle cell trait. The parents were asymptomatic, but were treated with mefloquine, without laboratory testing for malaria. All 7 family members recovered.
Commentary
All 5 children in the unfortunate family reported in MMWR became ill with malaria shortly after visiting friends and relatives in Nigeria. Similarly, more than half of cases of malaria reported in the United States in 2004 were in individuals who had traveled to visit friends and relatives.1
The experience of the family with malaria points out several specific areas for improvement in medical care. First, general education directed towards the lay public, especially those traveling to visit friends and relatives, would be useful. Sixty-five percent of cases of imported malaria in the United States in 2004, were in individuals who, like the family from Illinois, took no chemoprophylaxis.1 Perhaps those of us who practice travel medicine should seek opportunities, through the media or through travel agencies, to educate travelers about the need for preventive malaria medications.
Second, health care professionals must give accurate advice about the availability and use of malaria medicines. The family from Chicago had contacted their local health department about malaria medications prior to their trip. They were informed that malaria medications were available, but were left thinking that the medicines were only for curative treatment. Health care providers and advisors must be clear in answering questions so as to let concerned travelers know that preventive medications are both available and advisable.
Third, when chemoprophylaxis is prescribed, it should be appropriate for the region of travel. In 2004, 10% of cases of imported malaria were in travelers who had used non-CDC-recommended prophylaxis regimens.1 Hence, those who prescribe should be up-to-date with current recommendations for chemoprophylaxis. Health care providers can readily obtain access to print, phone, and e-mail advice about malaria prevention, diagnosis, and treatment.1
In addition, when the Chicago children became ill with fever and headache 2 weeks after returning from Nigeria, they were advised to use antipyretics and amoxicillin. The published report contains no mention of malaria having been considered as a diagnostic possibility at the time of initial presentation. Travel history should be obtained when caring for patients with fever. Fortunately, the family continued to seek medical help as the illness progressed.
Once diagnosed with malaria, the ill members of the family from Chicago received appropriate therapy. Of the 4 fatal cases of malaria in the United States in 2004, 2 were initially treated with chloroquine despite recent travel in areas of Africa where chloroquine--resistant malaria is common. Another was in a patient who was initially hospitalized in an intensive care unit in an area of the United States where intravenous quinine and quinidine were unavailable. It is essential that appropriate curative therapy be initiated when malaria is diagnosed.
There is general acceptance among the medical community that sickle hemoglobinopathy protects from malaria. Indeed, sickle trait is 90% protective against severe malaria. Nonetheless, as demonstrated by the family from Illinois, malaria-associated anemia is often severe in individuals with sickle cell disease,1 and malaria can occur in patients who have sickle trait.
The recent CDC review of malaria imported into the United States in 2004,1 included mention of a fatal case of P. vivax malaria in a 69-year-old man with underlying medical conditions. Similarly, a case of P. vivax cerebral malaria was recently reported from Turkey.2 Non-falciparum malaria parasites can indeed cause severe disease or be part of a mixed malaria infection.
There were 3 cases of congenital malaria in the United States in 2004 as well.1 The mothers had been in Guatemala, India, and Nigeria during their pregnancies, and one had symptomatic malaria at the time of delivery. The infants presented with fever and anemia at 2, 5, and 5.5 weeks of age.
The CDC received 1324 reports of malaria in the United States in 2004.1 Awareness of these cases and of the Illinois family with malaria reminds us that malaria continues to be a problem in returned travelers and immigrants in the United States. Most cases are associated with lack of chemoprophylaxis. Also, appropriate diagnosis and treatment are sometimes delayed. While improving the care of departing and returned travelers in the United States, we must also continue our efforts to deal with malaria in endemic regions where more than 1,000,000 children die of malaria each year.
References
- Skarbinski J, et al. Malaria Surveillance — United States, 2004. MMWR Surveill Summ. 2006;55:23-37.
- Ozen M, et al. Cerebral Malaria Owing to Plasmodium vivax: Case Report. Ann Trop Paediatr. 2006;26:141-144.
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