COMMENTARY

Travel to West Africa? Don't Neglect Malaria Prevention

Ruth Namuyinga, MD, MPH

Disclosures

December 10, 2014

Editorial Collaboration

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Hello. I'm Dr Ruth Namuyinga, an Epidemic Intelligence Service officer in the Division of Parasitic Diseases and Malaria at CDC. I'm pleased to speak with you as part of the CDC Expert Video Commentary Series on Medscape. Today I will review some strategies that clinicians can employ to help prevent malaria in patients who are traveling to West Africa this holiday season.

Malaria is endemic in Sierra Leone, Liberia, and Guinea, the three countries hardest hit by the ongoing Ebola epidemic. Both Ebola virus disease and malaria present with similar symptoms of fever, chills, vomiting, and diarrhea. Preventing malaria infection in travelers to West Africa will not only save lives but will minimize the time and resources necessary to rule out possible Ebola infection. Returning home without fever or other symptoms suggestive of Ebola will also be reassuring to patients and the American public.

As the holiday season draws near, US clinicians should pay particular attention to preventing malaria infection among travelers to West Africa. The winter holidays are a popular time for the immigrant West African community in the United States to travel to their home countries to visit family and friends. Their children may also travel with them because of the long school break.

Immigrants from malaria-endemic countries may consider themselves partially or completely immune to malaria and believe that if they are infected, their symptoms will be mild and easily treatable with medicines acquired while abroad. However, these travelers should know that any immunity they may have acquired while growing up in a malaria-endemic country eventually dissipates after moving away, making them just as vulnerable to malaria as people who grew up in nonendemic countries. Their children and spouses who may accompany them on the trip may also have no immunity against malaria. And depending on the destination, not all of the medicines that are available overseas to treat malaria may be appropriate or effective.

It is important for clinicians to ask patients with links to Sierra Leone, Liberia, or Guinea whether they have any upcoming travel plans and make them aware that the CDC has issued Level 3 travel warnings for those three countries, advising against nonessential travel, and the US Department of State issued a travel advisory for travelers returning from the three countries. If patients say that travel cannot be avoided or postponed, clinicians should be sure to provide guidance to reduce the potential for spread of Ebola virus disease and to prevent malaria infection.

Malaria is highly preventable with the appropriate antimalarial drug taken before, during, and for a period of time after returning from a malaria-endemic area. For West Africa, three effective antimalarial drugs can be prescribed: Malarone (atovaquone and proguanil), doxycycline, or mefloquine (which is the one drug of the three that can also be used in pregnancy). Dosing of antimalarial drugs for infants and children is based on body weight. A complete list of malaria prophylaxis with the appropriate dosing is outlined under CDC: Malaria and Travelers.

Approximately 1500 cases of malaria, including five deaths, are reported in the United States each year because of travel to areas of malaria transmission. In the vast majority of these cases, an antimalarial drug was either not taken at all, the drug was not appropriate for the destination, or the drug was not taken according to directions.

Symptoms of malaria are nonspecific and may be confused with the early symptoms of Ebola virus disease. Besides fever, malaria can also present with shaking chills, sweats, nausea, vomiting, diarrhea, headache, body ache, and fatigue. Symptoms can progress, causing kidney failure, lung damage, coma, and death. The incubation period for malaria varies from 7 to 30 days. The shorter periods are most often seen with Plasmodium falciparum, the predominant type of malaria found in West Africa.

Should a traveler from a malaria-endemic area return with fever, a blood smear should be ordered immediately and read the same day to test for malaria parasites. There are new CDC guidelines on the malaria website for performing malaria diagnostic testing on patients also suspected of having Ebola infection.

In summary, clinicians should exercise extra vigilance in preventing malaria among travelers to West Africa, given the ongoing Ebola epidemic in that region.

Web Resources

Cullen KA, Arguin PM; Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC). Malaria surveillance — United States, 2011. MMWR Surveill Summ. 2013;62:1-17.

Guidance for Malaria Diagnosis in Patients Suspected of Ebola Infection in the United States

Recommendations for Immigrants from Malaria-Endemic Countries Planning to Return "Home" to Visit Friends and Relatives

Malaria

Choosing a Drug to Prevent Malaria

Malaria Fact Sheets, Brochures, and Posters

Travel Health Notices

US Department of State Travel Alerts and Warnings

Ebola Outbreak - Going to West Africa?

Ebola Outbreak - Recently in West Africa?

Ruth Namuyinga, MD, MPH, is an Epidemic Intelligence Service officer assigned to the Malaria Branch in the Center for Global Health at the Centers for Disease Control and Prevention in Atlanta, Georgia, where she provides technical support to the President's Malaria Initiative, provides consultations for malaria cases, and is involved in malaria operational research internationally. She recently returned from Sierra Leone where she provided epidemiologic support for the Ebola response. Dr Namuyinga received her medical degree at Makerere University College of Health Sciences in Uganda and completed her specialty training in preventive medicine at Johns Hopkins Bloomberg School of Public Health.

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