In Quebec, refugees are typically dispersed in family groups to smaller communities or metropolitan-area suburbs throughout the province. For the group studied, the host communities were relatively small (median population 60 000, range 18 000–1.5 million).23
For almost 40% of the group, the communities had populations of less than 100 000 and no tertiary-care hospital.
During the 5 weeks after arrival of the refugees, the McGill University Centre for Tropical Diseases received 36 requests for laboratory confirmation and many telephone consultations for diagnosis and treatment of malaria. Of the 36 submitted slides, 15 were confirmed as positive, 11 for Plasmodium falciparum
(parasitemia [proportion of blood cells containing parasites] range 0.3%–7%).22
The refugees had been airlifted from camps in Tanzania but originated from Burundi (52%), the Democratic Republic of the Congo (39%), Rwanda (5%) and Tanzania (4%). Of the 221 studied, 124 were male and 97 female. The mean age was 17 (range < 1–51) years; more than half (128/221) were 15 years of age or younger. The mean stay in a refugee camp was 3.1 (range 1–7) years. Of the 221 refugees, 161 (73%) had had at least 1 episode of clinical malaria and a variety of treatments while in the refugee camps. Few (38 [17%]) had taken malaria prophylaxis in the camps, and the regimens had been suboptimal (e.g., chloroquine or sulfadoxine– pyrimethamine).24,25
Bed nets had not been used.
Of the 221 refugees, 87 (39%) had had symptoms compatible with malaria (), for which they had sought medical care at hospitals or clinics, during their first 3– 4 months in Canada. No significant differences other than pregnancy existed between these 87 refugees and the other 134. Most had sought care within 30 days of arrival (median 14, range 2– 118 days). The median duration of symptoms before care was sought was 3.5 (range 1– 10) days. Complete or partial medical records were obtained for 66 of the 87 refugees and for 2 asymptomatic adults whose children were found to have malaria. There were no major demographic differences between these 68 subjects and the 21 whose records could not be reviewed.
According to the medical records, malaria was investigated by thin and thick smears in 55 of the 68 subjects; no record of a malaria smear could be found for the other 13. Malaria testing was requested for all 21 refugees presenting with “classic” malaria symptoms (high fever, chills and headache) but not for 3 of the 11 refugees with “flu-like” symptoms, 5 of the 19 children with gastrointestinal complaints or the 1 woman with a spontaneous abortion.
A probable diagnosis of malaria was made by primary laboratories for 20 of the 68 refugees whose records were available for review (). Most reports (15/20) stated simply “malaria” or “malaria species”; the remainder identified P. falciparum. Parasitemia was estimated in only 5 of the reports: mean 1.8% ± 2%, range 0.001%– 5%. Three-quarters of the 20 probable diagnoses were confirmed by the McGill University Centre for Tropical Diseases: as P. falciparum (11), P. ovale (2) and mixed P. falciparum/P. ovale (2) infections. Of the 15 confirmed cases, 7 were in children 15 years of age or younger, 6 of whom had “classic” malaria symptoms. In 3 of the 5 false-positive cases, the symptoms were also typical for malaria; the other 2 refugees were pregnant women. Only 1 person (an adult) with the classic triad of fever, chills and headache had a negative smear and an unconfirmed diagnosis. Most of the remaining negative smears were from people with “flu-like” symptoms, gastrointestinal complaints or weakness. From the medical records, appropriate therapy was verified in only 10 of the 15 confirmed cases; at least 3 of the 5 patients with a false-positive initial diagnosis received antimalarial drugs inappropriately.
Fig. 1: Laboratory investigation for possible malaria among 87 African refugees in Quebec who sought health care because of symptoms compatible with malaria. P = Plasmodium. *Includes 2 asymptomatic adults whose children were found to have malaria.
Malaria infection was documented by PCR in 48 of the 210 refugees who provided a blood sample for the study (23%; 95% confidence interval [CI] 17%–29%). Of the 13 for whom malaria testing had never been requested, 3 (23%; 95% CI 6%– 54%) were PCR-positive for P. falciparum. Of the 19 for whom a negative malaria smear had been reported but not confirmed, 9 (47%; 95% CI 25%– 71%) were PCR-positive for P. falciparum. The rate of parasite detection among the 134 refugees who had not sought medical care during their first 3– 4 months in Canada was 18% (95% CI 12%– 26%).