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Epidemiologic Notes and Reports Malaria in Travelers Returning from Kenya: Failure of Self-Treatment with Pyrimethamine/Sulfadoxine

In August 1988, seven (88%) of eight U.S. citizens returning to Pennsylvania from a tour of western Kenya developed symptoms of malaria. Onset of symptoms occurred 10-74 days (median: 12 days) after arrival in the zone endemic for malaria. The travelers stayed 1 month in an area within 100 miles of Lake Victoria. Each took pyrimethamine 12.5 mg divided by apsone 100 mg (Maloprim*) orally once a week starting 10 days before arrival at this site. All eight were exposed to mosquitoes at night, and all used insecticide and mosquito netting for protection. None of the eight had had malaria before this trip. Each of the seven experienced fever, followed by chills, rigors, and diaphoresis. Five of the seven became ill while still in Kenya. In one of these five, symptoms resolved spontaneously within 2 days of onset; the other four took presumptive oral therapy with pyrimethamine 75 mg/sulfadoxine 1.5 g (FansidarR, 3 tablets) 2 days before returning to the United States. One of these four had symptom resolution after therapy with FansidarR. One of the three travelers whose symptoms persisted after FansidarR therapy had a therapeutic level of sulfadoxine (57 ppm) on her return to the United States.

Blood smears were examined for all three travelers who remained symptomatic after FansidarR therapy, as well as for two additional travelers who became ill after returning to the United States. All five had blood smears diagnostic of Plasmodium falciparum malaria. All five were treated successfully with quinine and tetracycline. Reported by: Div of Field Svcs, Epidemiology Program Office; Malaria Br, Div of Parasitic Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Malaria is endemic in large areas of sub-Saharan Africa, New Guinea, Latin America, and Asia. Travelers to areas with endemic malaria in sub-Saharan Africa and New Guinea are at particular risk for malaria even when recommended precautions such as mosquito netting, insecticides, and chemoprophylaxis are used. Approximately 150 U.S. travelers annually are diagnosed with P. falciparum malaria on return from abroad; most have visited sub-Saharan Africa (1). Resistance of P. falciparum to chloroquine extends throughout sub-Saharan Africa, and resistance to sulfa drugs and pyrimethamine has also been reported (2).

Prophylactic use of Maloprim and other pyrimethamine/sulfa compounds against malaria is not recommended for U.S. travelers. Rather, adults traveling to sub-Saharan locations where malaria is endemic should take chloroquine salt, 500 mg orally once each week (3). Travelers to these areas who have no history of sulfonamide intolerance should also take with them three FansidarR tablets. If symptoms of malaria occur while the traveler is far from medical assistance, these three tablets of FansidarR should be taken in a single oral dose as therapy for presumed malaria.

P. falciparum malaria can sometimes persist despite the use of appropriate therapy. Because of increased travel by U.S. citizens, primary-care physicians will continue to have a role not only in prevention but also in diagnosis and treatment of malaria in returning travelers.

References

  1. Lobel HO, Campbell CC, Schwartz IK, Roberts JM. Recent trends in the importation of malaria caused by Plasmodium falciparum into the United States from Africa. J Infect Dis 1985; 152:613-7.

  2. Lobel HO, Campbell CC. Malaria prophylaxis and distribution of drug resistance. In: Strickland GT, ed. Clinics in tropical medicine and communicable diseases. Vol 1. London: Saun ders, 1986:225-42.

  3. CDC. Health information for international travel, 1988. Atlanta: US Department of Health and Human Services, Public Health Service, 1988:15-61,94-103; HHS publication no. (CDC)88-8280. *Use of trade names is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services.

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