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1.  Imported malaria and high risk groups: observational study using UK surveillance data 1987-2006 
BMJ : British Medical Journal  2008;337(7661):103-106.
Objective To examine temporal, geographic, and sociodemographic trends in case reporting and case fatality of malaria in the United Kingdom.
Setting National malaria reference laboratory surveillance data in the UK.
Design Observational study using prospectively gathered surveillance data and data on destinations from the international passenger survey.
Participants 39 300 cases of proved malaria in the UK between 1987 and 2006.
Main outcome measures Plasmodium species; sociodemographic details (including age, sex, and country of birth and residence); mortality; destination, duration, and purpose of international travel; and use of chemoprophylaxis.
Results Reported cases of imported malaria increased significantly over the 20 years of the study; an increasing proportion was attributable to Plasmodium falciparum (P falciparum/P vivax reporting ratio 1.3:1 in 1987-91 and 5.4:1 in 2002-6). P vivax reports declined from 3954 in 1987-91 to 1244 in 2002-6. Case fatality of reported P falciparum malaria did not change over this period (7.4 deaths per 1000 reported cases). Travellers visiting friends and relatives, usually in a country in Africa or Asia from which members of their family migrated, accounted for 13 215/20 488 (64.5%) of all malaria reported, and reports were geographically concentrated in areas where migrants from Africa and South Asia to the UK have settled. People travelling for this purpose were at significantly higher risk of malaria than other travellers and were less likely to report the use of any chemoprophylaxis (odds ratio of reported chemoprophylaxis use 0.23, 95% confidence interval 0.21 to 0.25).
Conclusions Despite the availability of highly effective preventive measures, the preventable burden from falciparum malaria has steadily increased in the UK while vivax malaria has decreased. Provision of targeted and appropriately delivered preventive messages and services for travellers from migrant families visiting friends and relatives should be a priority.
doi:10.1136/bmj.a120
PMCID: PMC2453297  PMID: 18599471
2.  Risk of malaria in British residents returning from malarious areas. 
BMJ : British Medical Journal  1990;300(6723):499-503.
OBJECTIVES--To identify which British residents travelling abroad are at greatest risk of malaria infection, and to determine the efficacy of malaria chemoprophylaxis for preventing P falciparum infections in tropical Africa. DESIGN--Prospective cohort study (case-base linkage) with routine national surveillance systems. Denominators (base population) were obtained from monitoring a random sample of returning British travellers with the international passenger survey. Numerators (cases) were obtained from reports of malaria infections in British residents, through the Malaria Reference Laboratory network. SETTING--International passenger survey conducted at passport control of international airports in Britain. Malaria reports received nationally were collated centrally in London. SUBJECTS--2948 British residents (0.2%) returning to Britain in 1987 randomly selected and questioned and 1052 British residents with microscopically confirmed malaria infections in 1987, whose case reports were reviewed and on whom additional data were collected by postal survey. MAIN OUTCOME MEASURES--Annual incidence subdivided by categories of risk. Chemoprophylactic efficacy for east and west Africa by principal regimens and compliance. RESULTS--Annual rates of reported infection per 100,000 travellers to Oceania were 4100; to west and east Africa were 375 and 172 respectively; to Latin America, the Far East, and the Middle East were 12, 2, and 1 respectively. Immigrants visiting friends and relatives in Ghana and Nigeria were at greatest risk (1303 and 952 per 100,000 respectively) in west Africa. Business travellers to Kenya experienced the highest attack rates in east Africa (465 per 100,000). Age-sex specific attack rates varied by region. No prophylaxis was reported to have been used by 23% of British visitors to west Africa, 17% to east Africa, 46% to central or southern Africa, and 58% visiting south Asia. The efficacy of chloroquine plus proguanil against P falciparum infection was 73% and 54% in west and east Africa respectively. Lower values were obtained for chloroquine alone and proguanil alone. The efficacy of Maloprim (pyrimethamine-dapsone) was 61% in west Africa, but only 9% in east Africa. Visitors to west Africa who did not comply with their chemoprophylactic regimen were at a 2.5-fold higher risk of infection than fully compliant users. Non-compliant visitors to east Africa had similar rates of infection as non-drug users. CONCLUSIONS--In 1987 chloroquine plus proguanil was the preferred chemoprophylactic regimen for P falciparum infection in Africa; antimalarial drugs must be taken regularly to be effective.
PMCID: PMC1662322  PMID: 2107927
3.  Risk factors for mortality from imported falciparum malaria in the United Kingdom over 20 years: an observational study 
Objectives To determine which travellers with malaria are at greatest risk of dying, highlighting factors which can be used to target health messages to travellers.
Design Observational study based on 20 years of UK national data.
Setting National register of malaria cases.
Participants 25 054 patients notified with Plasmodium falciparum malaria, of whom 184 died, between 1987 and 2006.
Main outcome measures Comparison between those with falciparum malaria who died and non-fatal cases, including age, reason for travel, country of birth, time of year diagnosed, malaria prophylaxis used.
Results Mortality increased steadily with age, with a case fatality of 25/548 (4.6%) in people aged >65 years, adjusted odds ratio 10.68 (95% confidence interval 6.4 to 17.8), P<0.001 compared with 18–35 year olds. There were no deaths in the ≤5 year age group. Case fatality was 3.0% (81/2740 cases) in tourists compared with 0.32% (26/8077) in travellers visiting friends and relatives (adjusted odds ratio 8.2 (5.1 to 13.3), P<0.001). Those born in African countries with endemic malaria had a case fatality of 0.4% (36/8937) compared with 2.4% (142/5849) in others (adjusted odds ratio 4.6 (3.1 to 9.9), P<0.001). Case fatality was particularly high from the Gambia. There was an inverse correlation in mortality between region of presentation and number of cases seen in the region (R2=0.72, P<0.001). Most delay in fatal cases was in seeking care.
Conclusions Most travellers acquiring malaria are of African heritage visiting friends and relatives. In contrast the risks of dying from malaria once acquired are highest in the elderly, tourists, and those presenting in areas in which malaria is seldom seen. Doctors often do not think of these as high risk groups for malaria; for this reason they are important groups to target in pre-travel advice.
doi:10.1136/bmj.e2116
PMCID: PMC3314185  PMID: 22454091
4.  Declining incidence of malaria imported into the UK from West Africa 
Malaria Journal  2008;7:235.
Background
Two thirds of all falciparum malaria cases reported in the United Kingdom (UK) are acquired in West Africa (WA). To ensure recommendations and guidelines for malaria prophylaxis in travellers to West Africa correlate to the risk of infection, a study was undertaken to examine recent trends and predict future patterns of imported malaria acquired by UK residents visiting West Africa and West African visitors to the UK between 1993 and 2006.
Methods and Results
Using passenger numbers and malaria surveillance reports, the data revealed a 2.3-fold increase in travel to West Africa with a five-fold increase in travelers visiting friends and relatives (VFR). Malaria incidence fell through the study period, the greatest decline noted in VFR with a fall from 196 cases/1,000 person-years to 52 cases/1,000 person-years, 9.8% per year p < 0.0001. The risk for travellers from the UK visiting for other reasons declined 2.7 fold, at an annual decrease of 7.0%, with the incidence in West African visitors to the UK falling by 2.3 fold, a rate of 7.9% annually.
Discussion
The reduction in incidence among all three groups of travellers may be explained by several factors; changing chemoprophylaxis usage and/or increased travel in urban areas where malaria risk has declined over the past decade, or widespread reduction in malaria transmission in West Africa.
Conclusion
With the reduction in malaria incidence seen in both visitors to and from West Africa, the most rational explanation for these findings is a fall in malaria transmission in West Africa, which may require a change in chemoprophylaxis policy for UK travelers over the next 5–10 years.
doi:10.1186/1475-2875-7-235
PMCID: PMC2613412  PMID: 19000299
5.  Validation of malaria surveillance case reports: implications for studies of malaria risk. 
STUDY OBJECTIVE--The aim of the study was to investigate the quality of national malaria surveillance reports in the United Kingdom. DESIGN--Persons with malaria reported to the Malaria Reference Laboratory (MRL) in 1987 were contacted by post to verify existing records with respect to key variables. The MRL data set was then analysed for inaccuracies. SETTING--The study was confined to UK residents. PARTICIPANTS--602 persons with malaria in 1987 responded (53%). MEASUREMENTS AND MAIN RESULTS--Review of case reports showed few missing data except for duration of residence in the UK, detailed chemoprophylactic regimens, and compliance. There were more missing surveillance data in reports of ethnic minority groups, principally in dates of travel (p = 0.008) and chemoprophylaxis use (p less than 0.0001). Patient recall in the survey was at variance with the surveillance reports in dates of travel and onset of infection, chemoprophylaxis use, and in compliance. Surveillance reports overestimated the number of days between leaving a malarious area and onset of symptoms (by 9 d for P falciparum and by 24 d for P vivax), and underestimated the delay between onset and diagnosis of P falciparum by 3 d. Over 50% of patients who had recalled the use of chloroquine, proguanil, pyrimethamine/dapsone, and pyrimethamine had not been recorded as having taken these drugs on the surveillance reports. Reported compliance also differed between the two data sets. CONCLUSIONS--It is recommended that research units test the quality of their surveillance data before embarking on analytical studies used to generate health policy guidelines.
PMCID: PMC1060626  PMID: 2370506
6.  The incidence of malaria in travellers to South-East Asia: is local malaria transmission a useful risk indicator? 
Malaria Journal  2010;9:266.
Background
The presence of ongoing local malaria transmission, identified though local surveillance and reported to regional WHO offices, by S-E Asian countries, forms the basis of national and international chemoprophylaxis recommendations in western countries. The study was designed to examine whether the strategy of using malaria transmission in a local population was an accurate estimate of the malaria threat faced by travellers and a correlate of malaria in returning travellers.
Methods
Malaria endemicity was described from distribution and intensity in the local populations of ten S-E Asian destination countries over the period 2003-2008 from regionally reported cases to WHO offices. Travel acquired malaria was collated from malaria surveillance reports from the USA and 12 European countries over the same period. The numbers of travellers visiting the destination countries was based on immigration and tourism statistics collected on entry of tourists to the destination countries.
Results
In the destination countries, mean malaria rates in endemic countries ranged between 0.01 in Korea to 4:1000 population per year in Lao PDR, with higher regional rates in a number of countries. Malaria cases imported into the 13 countries declined by 47% from 140 cases in 2003 to 66 in 2008. A total of 608 cases (27.3% Plasmodium falciparum (Pf)) were reported over the six years, the largest number acquired in Indonesia, Thailand and Korea. Four countries had an incidence > 1 case per 100,000 traveller visits; Burma (Myanmar), Indonesia, Cambodia and Laos (range 1 to 11.8-case per 100,000 visits). The remaining six countries rates were < 1 case per 100,000 visits. The number of visitors arriving from source countries increased by 60% from 8.5 Million to 13.6 million over the 6 years.
Conclusion
The intensity of malaria transmission particularly sub-national activity did not correlate with the risk of travellers acquiring malaria in the large numbers of arriving visitors. It is proposed to use a threshold incidence of > 1 case per 100,000 visits to consider targeted malaria prophylaxis recommendations to minimize use of chemoprophylaxis for low risk exposure during visits to S-E Asia. Policy needs to be adjusted regularly to reflect the changing risk.
doi:10.1186/1475-2875-9-266
PMCID: PMC2959067  PMID: 20920352
7.  Chemoprophylaxis and Malaria Death Rates 
Emerging Infectious Diseases  2006;12(3):447-451.
Malaria chemoprophylaxis increases the survival of nonimmune travelers.
To determine the effect of chemoprophylaxis on the case-fatality rate of malaria, we analyzed all cases of Plasmodium falciparum malaria in nonimmune persons reported from 1993 to 2004 in Germany. In univariate and multivariate logistic regression analysis, we determined the effect of age, sex, chemoprophylaxis, chemoprophylactic regimen, compliance for chemoprophylactic regimen, exposure prophylaxis, country of infection, and year of reporting on the outcome. Of 3,935 case-patients, 116 (3%) died of malaria. Univariate analysis showed significant associations with death for chemoprophylaxis with chloroquine plus proguanil compared to no chemoprophylaxis. The multivariate model showed that patients who had taken chemoprophylaxis were less likely to die compared to those who had not taken chemoprophylaxis, adjusted for patient age and reporting year. The study demonstrated that chemoprophylaxis significantly reduced fatality rates among nonimmune malaria patients and supports the importance of existing guidelines for malaria prevention.
doi:10.3201/eid1203.050736
PMCID: PMC3291437  PMID: 16704783
malaria; chemoprophylaxis; CFR; chloroquine; plasmodium falciparum; research
8.  Declining incidence of imported malaria in the Netherlands, 2000-2007 
Malaria Journal  2010;9:300.
Background
To describe the epidemiology and trends of imported malaria in the Netherlands from 2000 through 2007.
Methods
Based on national surveillance data regarding all reported infections of imported malaria, diagnosed 2000 through 2007, incidence and trends of imported malaria in the Netherlands were estimated. Travellers statistics were used to estimate incidence, and data on malaria chemoprophylaxis prescriptions were used to estimate the number of unprotected travellers.
Results
Importation of malaria to the Netherlands is declining even as more travellers visit malaria-endemic countries. On average, 82% were acquired in sub-Saharan Africa, and 75% were caused by Plasmodium falciparum. The overall incidence in imported falciparum malaria fell from 21.5 to 6.6/10,000 of unprotected travellers. The percentage of unprotected travellers rose from 47% to 52% of all travellers. The incidence of imported falciparum infections is greatest from Middle and West Africa, and decreased from 121.3 to 36.5/10,000 travellers. The import of malaria from this region by immigrants visiting friends and relatives (VFR) decreased from 138 infections in 2000, to 69 infections in 2007.
Conclusion
The annual number of imported malaria shows a continuing declining trend, even with an increasing number of travellers visiting malaria endemic countries. VFR import less malaria than previously, and contribute largely to the declining incidence seen. The decline is not readily explained by increased use of chemoprophylaxis and may reflect a reduced risk of infection due to decreasing local malaria transmission as observed in some malaria endemic areas. Nevertheless, the increasing number of unprotected travellers remains worrisome.
doi:10.1186/1475-2875-9-300
PMCID: PMC2988037  PMID: 21029424
9.  The spatial and temporal patterns of falciparum and vivax malaria in Perú: 1994–2006 
Malaria Journal  2009;8:142.
Background
Malaria is the direct cause of approximately one million deaths worldwide each year, though it is both preventable and curable. Increasing the understanding of the transmission dynamics of falciparum and vivax malaria and their relationship could suggest improvements for malaria control efforts. Here the weekly number of malaria cases due to Plasmodium falciparum (1994–2006) and Plasmodium vivax (1999–2006) in Perú at different spatial scales in conjunction with associated demographic, geographic and climatological data are analysed.
Methods
Malaria periodicity patterns were analysed through wavelet spectral analysis, studied patterns of persistence as a function of community size and assessed spatial heterogeneity via the Lorenz curve and the summary Gini index.
Results
Wavelet time series analyses identified annual cycles in the incidence of both malaria species as the dominant pattern. However, significant spatial heterogeneity was observed across jungle, mountain and coastal regions with slightly higher levels of spatial heterogeneity for P. vivax than P. falciparum. While the incidence of P. falciparum has been declining in recent years across geographic regions, P. vivax incidence has remained relatively steady in jungle and mountain regions with a slight decline in coastal regions. Factors that may be contributing to this decline are discussed. The time series of both malaria species were significantly synchronized in coastal (ρ = 0.9, P < 0.0001) and jungle regions (ρ = 0.76, P < 0.0001) but not in mountain regions. Community size was significantly associated with malaria persistence due to both species in jungle regions, but not in coastal and mountain regions.
Conclusion
Overall, findings highlight the importance of highly refined spatial and temporal data on malaria incidence together with demographic and geographic information in improving the understanding of malaria persistence patterns associated with multiple malaria species in human populations, impact of interventions, detection of heterogeneity and generation of hypotheses.
doi:10.1186/1475-2875-8-142
PMCID: PMC2714521  PMID: 19558695
10.  Global malaria connectivity through air travel 
Malaria Journal  2013;12:269.
Background
Air travel has expanded at an unprecedented rate and continues to do so. Its effects have been seen on malaria in rates of imported cases, local outbreaks in non-endemic areas and the global spread of drug resistance. With elimination and global eradication back on the agenda, changing levels and compositions of imported malaria in malaria-free countries, and the threat of artemisinin resistance spreading from Southeast Asia, there is a need to better understand how the modern flow of air passengers connects each Plasmodium falciparum- and Plasmodium vivax-endemic region to the rest of the world.
Methods
Recently constructed global P. falciparum and P.vivax malaria risk maps, along with data on flight schedules and modelled passenger flows across the air network, were combined to describe and quantify global malaria connectivity through air travel. Network analysis approaches were then utilized to describe and quantify the patterns that exist in passenger flows weighted by malaria prevalence. Finally, the connectivity within and to the Southeast Asia region where the threat of imported artemisinin resistance arising is highest, was examined to highlight risk routes for its spread.
Results
The analyses demonstrate the substantial connectivity that now exists between and from malaria-endemic regions through air travel. While the air network provides connections to previously isolated malarious regions, it is clear that great variations exist, with significant regional communities of airports connected by higher rates of flow standing out. The structures of these communities are often not geographically coherent, with historical, economic and cultural ties evident, and variations between P. falciparum and P. vivax clear. Moreover, results highlight how well connected the malaria-endemic areas of Africa are now to Southeast Asia, illustrating the many possible routes that artemisinin-resistant strains could take.
Discussion
The continuing growth in air travel is playing an important role in the global epidemiology of malaria, with the endemic world becoming increasingly connected to both malaria-free areas and other endemic regions. The research presented here provides an initial effort to quantify and analyse the connectivity that exists across the malaria-endemic world through air travel, and provide a basic assessment of the risks it results in for movement of infections.
doi:10.1186/1475-2875-12-269
PMCID: PMC3766274  PMID: 23914776
11.  Patterns of Plasmodium vivax and Plasmodium falciparum malaria underscore importance of data collection from private health care facilities in India 
Malaria Journal  2009;8:227.
Background
This study describes patterns of falciparum and vivax malaria in a private comprehensive-care, multi-specialty hospital in New Delhi from July 2006 to July 2008.
Methods
Malarial morbidity by Plasmodium species (Plasmodium falciparum, Plasmodium vivax, or Plasmodium sp.) was confirmed using microscopy and antigen tests. The influence of seasonal factors and selected patient demographics on morbidity was evaluated. The proportions of malaria cases caused by P. falciparum at the private facility were compared to data from India's National Vector Borne Disease Control Programme (NVBDCP) during the same period for the Delhi region.
Results
In New Delhi, P. faciparum was the dominant cause of cases requiring treatment in the private hospital during the period examined. The national data reported a smaller proportion of malaria cases caused by P. falciparum in the national capital region than was observed in a private facility within the region. Plasmodium vivax also caused a large proportion of the cases presenting clinically at the private hospital during the summer and monsoon seasons.
Conclusion
The proportion of P. falciparum malaria cases tends to be greatest during the post-monsoon season while the proportion of P. vivax malaria cases tends to be greatest in the monsoon season. Private hospital data demonstrate an under-reporting of malaria case incidences in the data from India's national surveillance programme during the same period for the national capital region.
doi:10.1186/1475-2875-8-227
PMCID: PMC2766385  PMID: 19822005
12.  Epidemiology and clinical features of vivax malaria imported to Europe: Sentinel surveillance data from TropNetEurop 
Malaria Journal  2004;3:5.
Background
Plasmodium vivax is the second most common species among malaria patients diagnosed in Europe, but epidemiological and clinical data on imported P. vivax malaria are limited. The TropNetEurop surveillance network has monitored the importation of vivax malaria into Europe since 1999.
Objectives
To present epidemiological and clinical data on imported P. vivax malaria collected at European level.
Material and methods
Data of primary cases of P. vivax malaria reported between January 1999 and September 2003 were analysed, focusing on disease frequency, patient characteristics, place of infection, course of disease, treatment and differences between network-member countries.
Results
Within the surveillance period 4,801 cases of imported malaria were reported. 618 (12.9%) were attributed to P. vivax. European travellers and immigrants were the largest patient groups, but their proportion varied among the reporting countries. The main regions of infection in descending order were the Indian subcontinent, Indonesia, South America and Western and Eastern Africa, as a group accounting for more than 60% of the cases. Regular use of malaria chemoprophylaxis was reported by 118 patients. With 86 (inter-quartile range 41–158) versus 31 days (inter-quartile range 4–133) the median symptom onset was significantly delayed in patients with chemoprophylaxis (p < 0.0001). Common complaints were fever, headache, fatigue, and musculo-skeletal symptoms. All patients survived and severe clinical complications were rare. Hospitalization was provided for 60% and primaquine treatment administered to 83.8% of the patients, but frequencies varied strongly among reporting countries.
Conclusions
TropNetEurop data can contribute to the harmonization of European treatment policies.
doi:10.1186/1475-2875-3-5
PMCID: PMC385246  PMID: 15003128
13.  The knowledge, attitudes and practices of wintersun vacationers to the Gambia toward prevention of malaria: is it really that bad? 
Malaria Journal  2014;13:74.
Background
Each year clusters of imported malaria cases are observed in Dutch wintersun vacationers returning from The Gambia. To gain more insight in the travel health preparation and awareness of these travellers, the knowledge, attitudes and practices (KAP) of this travel group was studied by analysing the data of the Continuous Dutch Schiphol Airport Survey.
Methods
In the years 2002 to 2009 a questionnaire-based survey was conducted at the Dutch Schiphol Airport with the aim to study the KAP, i.e. accuracy of risk perception (“knowledge”), intended risk-avoiding behaviour (“attitude”) and use of personal protective measures and malaria chemoprophylaxis (“practice”) toward prevention malaria in travellers to The Gambia. Travellers to other high-risk destinations served as controls.
Results
The KAP of travellers to The Gambia toward prevention of malaria was significantly better than that observed in other travellers. Trend analyses indicated that attitude improved over time in both groups but knowledge did not change. Only in travellers to high-risk countries other than The Gambia significant increases in protection rates were observed over time.
Conclusions
The KAP of travellers to The Gambia toward prevention of malaria was better than that observed in travellers to destinations other than The Gambia. Trend analyses revealed a significant improvement of intended risk avoiding behaviour but not in protection rates or risk perception.
doi:10.1186/1475-2875-13-74
PMCID: PMC3939397  PMID: 24581328
Malaria; Traveller; Travel; Risk; Knowledge; Attitude; Practice; KAP; VFR; Gambia; Tourist
14.  Spatiotemporal Dynamics and Demographic Profiles of Imported Plasmodium falciparum and Plasmodium vivax Infections in Ontario, Canada (1990–2009) 
PLoS ONE  2013;8(9):e76208.
We examined malaria cases reported to Ontario’s public health surveillance systems from 1990 through 2009 to determine how temporal scale (longitudinal, seasonal), spatial scale (provincial, health unit), and demography (gender, age) contribute to Plasmodium infection in Ontario travellers. Our retrospective study included 4,551 confirmed cases of imported malaria reported throughout Ontario, with additional analysis at the local health unit level (i.e., Ottawa, Peel, and Toronto). During the 20-year period, Plasmodium vivax accounted for 50.6% of all cases, P. falciparum (38.6%), Plasmodium sp. (6.0%), P. ovale (3.1%), and P. malariae (1.8%). During the first ten years of the study (1990–1999), P. vivax (64% of all cases) was the dominant agent, followed by P. falciparum (28%); however, during the second ten years (2000–2009) the situation reversed and P. falciparum (55%) dominated, followed by P. vivax (30%). The prevalence of P. falciparum and P. vivax cases varied spatially (e.g., P. falciparum more prevalent in Toronto, P. vivax more prevalent in Peel), temporally (e.g. P. falciparum incidence increased during the 20-year study), and demographically (e.g. preponderance of male cases). Infection rates per 100,000 international travellers were estimated: rates of infection were 2× higher in males compared to females; rates associated with travel to Africa were 37× higher compared to travel to Asia and 126× higher compared to travel to the Americas; rates of infection were 2.3–3.5× higher in June and July compared to October through March; and rates of infection were highest in those 65–69 years old. Where exposure country was reported, 71% of P. falciparum cases reported exposure in Ghana or Nigeria and 63% of P. vivax cases reported exposure in India. Our study provides insights toward improving pre-travel programs for Ontarians visiting malaria-endemic regions and underscores the changing epidemiology of imported malaria in the province.
doi:10.1371/journal.pone.0076208
PMCID: PMC3786973  PMID: 24098780
15.  Epidemiological and Clinical Features of Plasmodium falciparum Malaria in United Nations Personnel in Western Bahr el Ghazal State, South Sudan 
PLoS ONE  2013;8(1):e55220.
Western Bahr el Ghazal State is located in northwestern South Sudan, which is a tropical area subject to Plasmodium falciparum malaria epidemics. The aim of this study is to explore the epidemiological and clinical features of Plasmodium falciparum malaria in United Nations personnel stationed in this area. From July 2006 to June 2009, epidemiological data and medical records of 678 patients with Plasmodium falciparum malaria at the U.N. level 2 hospital were analyzed. The U.N. personnel were divided into individuals not immune to Plasmodium falciparum and individuals semi-immune to Plasmodium falciparum. The patients were divided into a chemoprophylaxis group (non-immune individuals who complied with the chemoprophylaxis regimen, 582 cases) and a no/incomplete chemoprophylaxis group (non-immune individuals who either did not fully comply with chemoprophylaxis or did not use it at all and semi-immune individuals who did not use chemoprophylaxis, 96 cases). Overall morbidity was about 11.3%. There was a significant difference in the morbidity of semi-immune and non-immune individuals (1.3% vs. 15.1%, P<0.001). Out of the total, 82.9% of cases occurred during the rainy season. The incidence of fever in the chemoprophylaxis group was significantly lower than in the no/incomplete chemoprophylaxis group (36.8% vs. 96.9%, P<0.001). Significant differences were observed between the two groups with respect to all other malaria-like symptoms except gastrointestinal symptoms, serum glucose level, platelet count, and alanine aminotransferase level. The incidence of complications was 1.2% (chemoprophylaxis group) and 44.8% (no/incomplete chemoprophylaxis group).The most common complication was thrombocytopenia, which was seen in 40.6% of the no/incomplete chemoprophylaxis group. In summary, Plasmodium falciparum malaria mainly occurred in rainy season. Gastrointestinal symptoms are an important precursor of malaria. Blood smears and rapid diagnostic tests should be performed after the onset of gastrointestinal symptoms. Appropriate chemoprophylaxis is necessary for reducing the severity of malaria.
doi:10.1371/journal.pone.0055220
PMCID: PMC3555950  PMID: 23372839
16.  The changing pattern of imported malaria in British visitors to Kenya 1987-1990. 
Following a sudden increase of imported malaria from Kenya in December 1989-January 1990, an investigation was set up to identify risk factors for travellers' malaria. A questionnaire asking for details of travel patterns and compliance with prophylaxis was sent to cases reported over the 6-month Kenyan winter period. Quarterly malaria attack rates between January 1987 and June 1991 were calculated and linked to meteorological conditions in Mombasa. The number of travellers to Kenya has doubled in the 4 years studied and the quarterly rates varied 4-fold over this period. There was no clear seasonal pattern of malaria in travellers, nor was there any clear relation of malaria to coastal rainfall. Compliance with chemoprophylaxis was poor, with only 16% of cases using currently advised regimens. While the annual malaria attack rate per 10,000 travellers decreased by 37% over the study period, the total numbers of malaria cases imported from Kenya rose by 61%, reflecting the increase in the numbers of travellers to the region. As the popularity of East Africa as a tourist destination continues to increase, Kenya will remain an important and significant source of malaria imported into the UK.
PMCID: PMC1293905  PMID: 8459379
17.  Plasmodium vivax malaria relapses at a travel medicine centre in Rio de Janeiro, a non-endemic area in Brazil 
Malaria Journal  2012;11:245.
Background
Malaria is a potentially severe disease widely distributed in tropical and subtropical regions worldwide. Clinically, the progression of the disease can be life-threatening if it is not promptly diagnosed and properly treated. Through treatment, the radical cure of Plasmodium vivax infection can be achieved, thus preventing potential relapses and the emergence of new cases outside the Amazon region in Brazil. Surveillance for therapeutic failure in non-endemic areas is advantageous, as it is unlikely that recurrence of the disease can be attributed to a new malaria infection in these regions.
Methods
An observational study of 53 cases of P. vivax and mixed (P. vivax and Plasmodium falciparum) malaria was conducted at a travel medicine centre between 2005 and 2011 in Rio de Janeiro and a descriptive analysis of the potential factors related to recurrence of P. vivax malaria was performed. Groups with different therapeutic responses were compared using survival analysis based on the length of time to recurrence and a set of independent variables thought to be associated with recurrence.
Results
Twenty-one relapses (39.6%) of P. vivax malaria were observed. The overall median time to relapse, obtained by the Kaplan-Meier method, was 108 days, and the survival analysis demonstrated an association between non-weight-adjusted primaquine dosing and the occurrence of relapse (p < 0.03). Primaquine total dose at 3.6 mg/kg gave improved results in preventing relapses.
Conclusions
A known challenge to individual cure and environmental control of malaria is the possibility of an inappropriate, non-weight-based primaquine dosing, which should be considered a potential cause of P. vivax malaria relapse. Indeed, the total dose of primaquine associated with non-occurrence of relapses was higher than recommended by Brazilian guidelines.
doi:10.1186/1475-2875-11-245
PMCID: PMC3416703  PMID: 22839416
Plasmodium vivax malaria; Relapse; Therapeutic failure; Weight-based dosing
18.  Malaria Epidemiology in Mersin Province, Turkey from 2002 to 2011 
Iranian Journal of Parasitology  2013;8(2):296-301.
Background
Malaria is an infectious disease caused by Plasmodium spp. with high morbidity and mortality in human in tropical and subtropical regions. In recent years, number of malaria cases has been significantly reduced because of fight with the disease in Turkey. This study intended to investigate the malaria epidemiology in Mersin Province from 2002 to 2011 using data from the provincial Public Health Directorate.
Methods
Over ten years, 303573 blood samples were taken from the people by active and passive surveillance methods and blood smears were prepared. Smears were stained with Giemsa and examined under the microscope.
Results
Totally, 73 people including 44 male and 29 female were positive in terms of Plasmodium spp. It was determined that P. vivax observed in 67 cases while P. falciparum in 6 cases. Cases were mainly observed in 15 to 44 years old range, showed an increase between June-September periods and a significant decrease after 2006. Out of the 73 malaria cases, 54 cases were from Mersin Province and 13 cases were imported from another province of Turkey. Six cases were transmitted from abroad.
Conclusion
These results provide information about malaria epidemiology in an endemic area in Turkey and contribute its prevention in Mersin Province.
PMCID: PMC3724156  PMID: 23914244
Malaria; Epidemiology; Plasmodium; Turkey
19.  Malaria in the United Kingdom 
British Medical Journal  1974;2(5921):707-711.
Over the past decade the United Kingdom had the second highest number of cases of imported malaria among European countries. There has been a substantial rise in recorded cases of malaria during the past three years though some of it may be due to improved notification. Fatal cases of malaria in visitors to Africa have averaged 6.5% of reported infections due to Plasmodium falciparum. Attacks of vivax malaria may occur several months after travellers return from a malarious country.
PMCID: PMC1611114  PMID: 4604717
20.  Vivax malaria and bacteraemia: a prospective study in Kolkata, India 
Malaria Journal  2013;12:176.
Background
Falciparum malaria increases the risk for bacteraemia, whereas the relationship between vivax malaria and bacteraemia is not clear. Data from a prospective fever surveillance study in Kolkata, India were reanalysed for the potential association between Plasmodium vivax malaria and bacteraemia.
Methods
Patients of all ages presenting with fever of three days or more to a project health outpost were invited to participate. A blood film and blood culture was performed on presentation. Treatment and referral were provided according to national guidelines. The case fraction and incidence of malaria, bacteraemia, and co-infection were calculated.
Results
3,371 participants were enrolled during a one-year study period, of whom 93/3,371 (2.8%) had malaria (89/93 [95.7%] Plasmodium vivax) and 256 (7.6%) bacteraemia. There were 154 malaria, 423 bacteraemia and 10 P. vivax-bacteremia coinfection episodes per 100,000/year. Among the malaria-bacteraemia co-infections, all were vivax malaria and 5/6 (83%) bacteria isolated were Gram-negative (one S. Typhi, one S. Paratyphi A, three other Gram-negative). Bacteraemia occurred in 6/89 (6.7% [95%CI: 3.1-13.9%]) of P. vivax cases versus 250/3,278 (7.6% [95% CI: 6.7-8.6%]) without Plasmodium infection (p=0.76).
Conclusions
While an increased risk was not demonstrated, concomitant bacteraemia occurs frequently in vivax malaria in an area with a high background incidence of bacteraemia, and should be considered in cases of vivax malaria with severe manifestations.
doi:10.1186/1475-2875-12-176
PMCID: PMC3691654  PMID: 23721247
Bacteraemia; Falciparum malaria; Vivax malaria
21.  Severity of imported malaria: protective effect of taking malaria chemoprophylaxis 
Malaria Journal  2013;12:265.
Background
Although chemoprophylaxis remains an important strategy for preventing malaria in travellers, its effectiveness may be compromised by lack of adherence. Inappropriate use of chemoprophylaxis is likely to increase the risk of acquiring malaria, but may probably also worsen the severity of imported cases. The aim of this study was to assess the impact of use of malaria chemoprophylaxis on clinical features and outcome of imported malaria.
Methods
Demographic, clinical and laboratory data of patients included in the Rotterdam Malaria Cohort between 1998 and 2011 were systematically collected and analysed. Patients were classified as self-reported compliant or non-compliant users or as non-users of chemoprophylaxis. Severe malaria was defined using the 2010 WHO criteria.
Results
Details on chemoprophylaxis were available for 559 of the 604 patients, of which 64.6% were non-users, 17.9% were inadequate users and 17.5% reported to be adequate users. The group of non-users was predominated by patients with African ethnicity, partial immunity and people visiting friends and relatives. The majority contracted Plasmodium falciparum malaria. In contrast, compliant users acquired non-falciparum malaria more frequently, had significant lower P. falciparum loads on admission, shorter duration of hospitalization and significant lower odds for severe malaria as compared with non-users. Patients with P. falciparum malaria were more likely to have taken their chemoprophylaxis less compliantly than those infected with non-P. falciparum species. Multivariate analysis showed that self-reported adequate prophylaxis and being a partially immune traveller visiting friends and relatives was associated with significantly lower odds ratio of severe malaria. In contrast, age, acquisition of malaria in West-Africa and being a non-immune tourist increased their risk significantly.
Conclusions
Compliant use of malaria chemoprophylaxis was associated with significantly lower odds ratios for severe malaria as compared with non-compliant users and non-users of chemoprophylaxis. After correction for age, gender and immunity, this protective effect of malaria chemoprophylaxis was present only in individuals who adhered compliantly to use of chemoprophylaxis. Patients with P. falciparum malaria were more likely to have used their chemoprophylaxis less compliantly than patients with non-P. falciparum malaria who were more likely to have contracted malaria in spite of compliant use of chemoprophylaxis.
doi:10.1186/1475-2875-12-265
PMCID: PMC3734097  PMID: 23902640
Malaria; Travellers; Prophylaxis; Plasmodium falciparum; Travel; Outcome; Import; Severe; Atovaquone; Proguanil; Mefloquine; Immunity
22.  Increasing Plasmodium falciparum malaria in southwest London: a 25 year observational study 
Archives of Disease in Childhood  2002;86(6):428-430.
Aims: To identify changes in the presenting number and species of imported malaria in children in southwest London.
Methods: A prospective single observer study over 25 years (1975–99) of all cases of paediatric malaria seen at St George's Hospital.
Results: A confirmed diagnosis was made in 249 children (56% boys; 44% girls; median age 8.0 years). Of these, 53% were UK residents and 44% were children travelling to the UK. A significant increase was noted in the number of cases over the 25 years (1975–79: mean 4.8 cases/year; 1990–99: mean 13.7 cases/year). Over the 25 years Plasmodium falciparum was seen in 77%, P vivax in 14%, P ovale in 6%, and P malariae in 3% of cases. P falciparum had increased in frequency (1975–79: P falciparum 50%, P vivax 50%; 1990–99: P falciparum 82%, P vivax 6%), associated with an increase in the proportion of children acquiring their infection in sub-Saharan Africa. Median time between arrival in the UK to the onset of fever was: P falciparum, 5 days; P ovale, 25 days; P malariae, 37 days; and P vivax, 62 days. Median time interval between the onset of fever to commencement of treatment was 4 days. This had not improved over the 25 year period. Only 41% of UK resident children presenting to hospital had taken prophylaxis and the overall number of symptomatic children taking no prophylaxis was increasing.
Conclusion: Imported childhood P falciparum malaria is increasing in southwest London associated with increasing travel from sub-Saharan Africa. Over the 25 year period there has been no improvement in chemoprophylaxis rates or time to diagnosis.
doi:10.1136/adc.86.6.428
PMCID: PMC1763015  PMID: 12023177
23.  Imported Malaria in Children in Industrialized Countries, 1992–2002 
Emerging Infectious Diseases  2009;15(2):185-191.
Children account for a considerable proportion of cases imported to the United States and Europe.
Children account for an appreciable proportion of total imported malaria cases, yet few studies have quantified these cases, identified trends, or suggested evidence-based prevention strategies for this group of travelers. We therefore sought to identify numbers of cases and deaths, Plasmodium species, place of malaria acquisition, preventive measures used, and national origin of malaria in children. We analyzed retrospective data from Australia, Denmark, France, Germany, Italy, Japan, the Netherlands, Sweden, Switzerland, the United Kingdom, and the United States and data provided by the United Nations World Tourism Organization. During 1992–2002, >17,000 cases of imported malaria in children were reported in 11 countries where malaria is not endemic; most (>70%) had been acquired in Africa. Returning to country of origin to visit friends and relatives was a risk factor. Malaria prevention for children should be a responsibility of healthcare providers and should be subsidized for low-income travelers to high-risk areas.
doi:10.3201/eid1502.080712
PMCID: PMC2657617  PMID: 19193261
pediatric; malaria; children; travel; research
24.  Imported malaria to Northern Ireland: improving surveillance for better intervention 
The Ulster medical journal  2006;75(2):129-135.
Malaria is a preventable disease, which is under notified in the UK. This study sought to evaluate the current surveillance arrangements in Northern Ireland (NI), describe the epidemiology of malaria and make appropriate recommendations.
A case was defined as a resident or visitor to NI with laboratory confirmed malaria, diagnosed by the NI haematology laboratories and/or the Malaria Reference Laboratory (MRL) from 1998–2003. Laboratory data were compared with notifications and hospital admission data.
One hundred and fourteen laboratory cases were identified compared with 63 notifications received by the regional surveillance centre. Six cases were associated with two episodes of malaria reflecting recurrence and or reinfection. P. falciparum was the most common infection with two fatalities reported; this was particularly associated with travel to West Africa. Most cases were associated with short visits to malarious areas. Thirty-three percent of all cases did not take prophylaxis and, of those that did, approximately half were taking a prophylactic regime appropriate to the region visited.
This study highlights the need for improved surveillance of malaria in order to capture risk factors and other relevant information to inform public and professional education. This would facilitate increasing local awareness, enhancing prescription of and compliance with appropriate chemoprophylaxis and enabling early diagnosis and treatment of malaria.
PMCID: PMC1891728  PMID: 16755943
25.  Malaria resurgence risk in southern Europe: climate assessment in an historically endemic area of rice fields at the Mediterranean shore of Spain 
Malaria Journal  2010;9:221.
Background
International travel and immigration have been related with an increase of imported malaria cases. This fact and climate change, prolonging the period favouring vector development, require an analysis of the malaria transmission resurgence risk in areas of southern Europe. Such a study is made for the first time in Spain. The Ebro Delta historically endemic area was selected due to its rice field landscape, the presence of only one vector, Anopheles atroparvus, with densities similar to those it presented when malaria was present, in a situation which pronouncedly differs from already assessed potential resurgence areas in other Mediterranean countries, such as France and Italy, where many different Anopheles species coexist and a different vector species dominates.
Methods
The transmission risk was assessed analysing: 1) climate diagrams including the minimum temperature for Plasmodium falciparum and Plasmodium vivax development; 2) monthly evolution of the Gradient Model Risk (GMR) index, specifying transmission risk period and number of potential Plasmodium generations; 3) ecological characteristics using remote sensing images with the Eurasia Land Cover characteristics database and the monthly evolution of the Normalized Difference Vegetation Index (NDVI); 4) evaluation of A. atroparvus population dynamics.
Results
Climatological analyses and GMR index show that a transmission risk presently exists, lasting from May until September for P. falciparum, and from May until October for P. vivax. The GMR index shows that the temperature increase does not actually mean a transmission risk increase if accompanied by a precipitation decrease reducing the number of parasite generations and transmission period. Nevertheless, this limitation is offset by the artificial flooding of the rice fields. Maximum NDVI values and A. atroparvus maximum abundance correspond to months with maximum growth of the rice fields.
Conclusions
The Ebro Delta presents the ecological characteristics that favour transmission. The temperature increase has favoured a widening of the monthly potential transmission window with respect to when malaria was endemic. The combined application of modified climate diagrams and GMR index, together with spatial characterization conforms a useful tool for assessing potential areas at risk of malaria resurgence. NDVI is a good marker when dealing with a rice field area.
doi:10.1186/1475-2875-9-221
PMCID: PMC2924348  PMID: 20673367

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