Imported Malaria in Italy: Epidemiologic and Clinical Studies

Imported malaria in a Singapore hospital: clinical presentation and outcome

OBJECTIVE

To evaluate the clinical presentation and outcome of imported malaria.

METHODS

A retrospective chart review was conducted of patients with imported malaria admitted to the Communicable Disease Centre (CDC), Singapore (a 130-bed tertiary referral center) from January 1992 to December 1993. An imported case was defined as a smear-positive infection that was acquired in another country.

RESULTS

Among 200 malaria patients hospitalized at CDC, 168 imported cases (137 males and 31 females, 131 nonresidents and 37 residents) were studied. The mean age was 31.6 6 10.5 years. The countries visited were India (49.4%), Indonesia (16.7%), and Bangladesh (13%). Five patients had chemoprophylaxis and 36 patients had experienced previous malaria infection. The predominant symptoms were fever (97.6%), chills (79.2%), and rigors (67.9%). Hepatomegaly was detected in 56 (33.3%) and splenomegaly in 49 patients (29.2%). Plasmodium vivax was present in 132 patients, Plasmodium falciparum in 29, and mixed P. vivax and P. falciparum in 7 patients. Parasitemia ranged from 0.1% to 8.0%. Of the vivax cases, 130 were treated with chloroquine, followed by primaquine in 123 patients. Quinine was given to 36 patients (29 falciparum malaria and 7 mixed infections). Median time to fever defervescence was 2 days. Complications occurred in three patients (2 with shock and 1 with pulmonary edema). According to World Health Organization gravity criteria, body temperature over 40 degrees C was detected in six patients, bilirubinemia higher than 50 mmol/L in nine, parasitemia over 5% in five, glycemia less than 2.2 mmol/L in two patients. There were five relapses. No death was recorded.

CONCLUSION

Plasmodium vivax is the most common cause of imported malaria, with the majority acquired from the Indian subcontinent. Only a few patients presented with severe malaria.

Clinicoepidemiological study of imported malaria in travelers and immigrants to Madrid

BACKGROUND

The number of Spanish travelers visiting malaria endemic areas, and the number of immigrants from malarial countries arriving in Spain are continuously increasing. However, little information about imported cases in Spain is available.

METHODS

A prospective clinicoepidemiological study of imported cases of malaria diagnosed at a referral teaching hospital in Madrid, Spain.

RESULTS

Of the 160 patients, sixty (37.5%) were immigrants and 100 (62.5%) Spanish nationals. Malaria was acquired in Africa by 98.3% of immigrants and in 83.0% of travelers. Falciparum malaria accounted for 71.8% of the cases, P. vivax for 11.9%, P. ovale for 10.6% and P. malarie for 5. 0%. Eleven (6.9%) patients, all immigrants, were asymptomatic. Severe complications were recorded in 17 (10.6%): 7, severe anemia; 3, cerebral malaria; 2, renal failure; 1, spontaneous splenic rupture; 1, acute pulmonary edema; 1, sepsis; 1, acute cerebrovascular accident; and 1, disseminated intravascular coagulation. There were no fatal cases. Among the 100 Spanish nationals, 44% did not follow any prophylaxis, 29% followed a correct prophylaxis, 27% were considered defaulters, and 39% took self-treatment without cure.

CONCLUSIONS

There is a changing pattern of imported malaria in Madrid, with one third occurring in immigrants and two thirds in nationals. This data provides information about the reemergence of imported malaria to Europe.

Severe and complicated Falciparum malaria in Italian travelers

Imported malaria has been an important public health problem in Western countries in the last 20 years, since international travel has become an increasing habit for nonimmune populations and since chemoresistance to most antimalarial drugs has been spreading throughout the world. Moreover, immigration from African and Asian countries has been rapidly increasing, especially in Italy in the last few years. Malaria had been widespread in Italy in the past, but no new autochthonous cases have been reported since 1961. Nonetheless the number of reported cases throughout the country has been steadily growing because of imported malaria1-3 in nonimmune travelers as well as in immigrants from tropical countries. In our experience as well as according to other statistics, the vast majority of patients have Plasmodium falciparum malaria acquired in Africa.4,5 The clinical spectrum of this disease is wide, and severe cases are frequently observed, including a few fatal cases, which, although rare, are highlighted by mass media and impress the public opinion.5-8 The purpose of this study was to examine the clinical spectrum of malaria, with particular interest in severe falciparum malaria, and to define the frequency of this phenomenon and epidemiologic characteristics of patients who experience it as a life-threatening disease.

Malaria Imported by Travelers: The Israeli Experience

Indigenous malaria has been successfully eradicated in North America, Europe, and a few other previously endemic locations. Extensive antimalarial programs, improvement of health care services, and advances in socioeconomic development have all contributed to one of the most significant achievements in public health of the 20th century.1 Nevertheless, a new malaria transmission pattern is increasingly seen in these areas nowadays. The constantly mounting movement of travelers from developed countries to the tropics and the affluent immigration to the industrialized world from countries where malaria has remained endemic are responsible for the emergence of imported malaria.2 Most physicians who studied medicine in developed countries, although familiar with the classic presentation of the disease, have rarely seen a single case of malaria during training and believe that it is an exotic illness existing elsewhere. It is important therefore to characterize the demographic and clinical features of imported malaria, which is practically the only malaria now seen in the industrialized world, and to make it more familiar to health care providers. This need is further emphasized by the emerging problem of drug-resistant malaria, which may be atypical in patients who had received inappropriate prophylaxis. In Israel malaria is almost exclusively an imported disease. It occurs in Israelis who visit or work in endemic areas and in immigrants, invariably from Ethiopia. The majority of Ethiopian immigrants arrived in two waves in 1985 and 1991 and do not represent an ongoing malaria problem.3 The features of the disease in this population were extensively reported elsewhere.3,4 In the present report we examine the characteristics of malaria imported to Israel by travelers.