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Update: Chloroquine-Resistant Plasmodium falciparum -- Africa

The first confirmed cases of chloroquine-resistant Plasmodium falciparum acquired in Africa were reported in 1978 (1) and occurred in non-immune travelers who had been in East Africa for relatively short periods of time. These reports of chloroquine-prophylaxis or treatment failures were substantiated by serial parasitologic and clinical observations of each infection and, when available, in-vitro confirmation of drug resistance. CDC continues to monitor the status of chloroquine-resistant P. falciparum malaria in East Africa (2). Recent reports document that the transmission of resistant parasites is now occurring more widely in Africa than was previously described (2).

During the past year, confirmed chloroquine-resistant infections have been described from specific areas in Zambia (3) and Sudan (4); previously, Kenya, Tanzania, Uganda, Madagascar, and the Comoros Islands were acknowledged to have transmission of chloroquine-resistant P. falciparum. It remains unclear whether these countries have nationwide transmission of disease and whether contiguous countries are similarly affected. In addition, a few apparent chloroquine-resistant infections have been reported in Malawi and northeastern Zaire. It may now be prudent to advise travelers to these specific suspect areas that they may be at risk of acquiring chloroquine-resistant malaria. While such anecdotal reports may reflect the spread of chloroquine-resistant P. falciparum in Africa, they require further confirmation; great caution should be exercised in interpreting case reports of drug-resistant malaria.

Studies in several West African countries, as well as a recent assessment of drug susceptibility of P. falciparum infections in western and central Zaire, have failed to demonstrate chloroquine-resistance (5). These experiences emphasize the importance of rigorously applying accurate drug-susceptibility testing procedures and adhering to the accepted World Health Organization definitions of drug resistance (6).

Since health professionals frequently advise travelers of health risks that may be incurred during travel, they should be aware of the changing distribution of chloroquine-resistant malaria in Africa. CDC has published recommendations for malaria chemoprophylaxis for travelers to affected areas of East Africa (2); Fansidar* (sulfadoxine 500 mg plus pyrimethamine 25 mg) one tablet weekly PLUS chloroquine 300 mg (base) once weekly is currently recommended. Weekly doses of Fansidar and chloroquine may be taken together on the same day. It should be noted, however, that this combination may not be completely effective in preventing episodes of symptomatic malaria, as prophylaxis failures with sulfonamide-antifolate combination drugs have occurred (7,8). Travelers should be advised that any acute febrile illness may be malaria and that medical attention should be sought, regardless of whether chemoprophylaxis is being taken.

Further updates of this rapidly evolving situation will be published as accurate information becomes available. An expanded discussion of the recommendations for the prophylaxis of malaria is available in Prevention of Malaria in Travelers, 1982 (9). Reported by Malaria Br, Div of Parasitic Diseases, Center for Infectious Diseases, CDC.

References

  1. CDC. Chloroquine-resistant malaria acquired in Kenya and Tanzania--Denmark, Georgia, New York. MMWR 1978;27:463-4.

  2. CDC. Revised recommendations for malaria chemoprophylaxis for travelers to East Africa. MMWR 1982;31:328-30.

  3. Kofi Ekue JM, Ulrich A, Njelesani EK. Plasmodium malaria resistant to chloroquine in a Zambian living in Zambia. Br Med J 1983;286:1315-6.

  4. Al Tawil N, Akood MA. Response of falciparum malaria to a standard regimen of chloroquine in Khartoum province, Sudan. World Health Organization, WHO/MAL/83.991.

  5. CDC. Unpublished data.

  6. Bruce-Chwatt LJ, ed. Chemotherapy of malaria, 2nd ed. World Health Organization, Geneva, 1981.

  7. Markwalder KA, Meyer HE. Possible sulfadoxine-pyrimethamine resistance in Plasmodium falciparum malaria from Kenya (letter). Trans R Soc Trop Med Hyg 1982;76:281.

  8. Stahel E, Degremont A, Lagler U. Pyrimethamine/sulfadoxine resistant falciparum malaria acquired at Dar es Salaam, Tanzania (letter). Lancet 1982;1:1118-9.

  9. CDC. Prevention of malaria in travelers 1982. MMWR 1982; 31;1S-28S.



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