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Malaria among Recently Arrived East African Refugees
Epi-X Posting: Malaria among Recently Arrived Burundian Refugees
In the past week, CDC has become aware of at least 10 cases of malaria among a group of approximately 1600 Burundian refugees who have resettled from Tanzania to the United States since May 2007. At least 3 of these cases have met the definition of severe malaria. The purpose of this Epi-X posting is to inform states of the problem and to encourage prompt presumptive malaria therapy for this entire population of refugees.
Refugee population background
Tanzania cares for over 270,000 refugees, the largest refugee population in Africa. The majority of the Tanzanian refugee population is from Burundi and is sheltered in camps in the northwestern part of the country. In FY 2007 and FY 2008, 10,000 Burundian refugees are expected to be resettled in the U.S. Since May, more than 1600 refugees have arrived to the U.S., with an additional 600 expected in the next 3 months.
Summary of known malaria cases
Among refugees who have become ill with malaria in this group, the earliest date of arrival was May 30, 2007. The earliest reported onset of illness was June 8, 2007. The cases have been reported from 7 states (North Dakota, Washington, Oregon, New York, Illinois, Texas, and Tennessee) and include at least four hospitalizations. Of the eight cases for which species is known, all are caused by Plasmodium falciparum, the species that causes the most severe clinical manifestations of malaria. No deaths have been reported to date.
Current pre-departure therapy for malaria
Among refugees from sub-Saharan Africa resettling to the United States, a single dose of sulfadoxine-pyrimethamine (SP) is given as presumptive therapy within 3 days before departure. Because of increasing SP resistance in East Africa, the International Organization for Migration (IOM), which screens and treats most U.S.-bound refugees, has been implementing improved pre-departure therapy with artemesinin combination therapy (ACT, i.e., Coartem®).
Because of the cases reported here, IOM has accelerated implementation of this regimen among refugees resettling from Tanzania and anticipates that by Saturday, July 7, 2007, all refugees from Tanzania who are eligible for ACT will have received a full course prior to departure. Therefore, refugees arriving in the United States on or after July 10, 2007, will have received ACT prior to departure.
Presumptive malaria treatment for asymptomatic Burundian refugees
Refugees who arrived before July 10, 2007, and who do not have documentation of pre-departure therapy with an ACT regimen should undergo presumptive treatment on arrival per the following guidelines:
- For refugees weighing 5 kilograms (11 pounds) or more, the medication of choice for presumptive post-arrival treatment of malaria is atovaquone-proguanil (Malarone®). This antimalarial is recommended because it is highly effective for treatment of P. falciparum. The standard treatment regimen is effective, short, simple, and well tolerated.
- Infants who weigh less than 5 kilograms (11 pounds) should not receive presumptive therapy for malaria but should have testing for malaria if they have signs or symptoms of the disease.
- Pregnant women, lactating women, and persons with other contraindications (e.g., allergy or hypersensitivity to medications) should not receive presumptive therapy. These individuals should undergo diagnostic testing and receive directed treatment if they are found to have malaria. Referral to a specialist may be necessary.
Refugees undergoing presumptive therapy with atovaquone-proguanil should receive the following weight-based regimen (pediatric tab = 62.5 mg atovaquone/25 mg proquanil; adult tab = 250 mg atovaquone/100 mg proguanil):
- 5-8 kg: 2 pediatric tabs once a day for 3 days
- 9-10 kg: 3 pediatric tabs once a day for 3 days
- 11-20 kg: 1 adult tab once a day for 3 days
- 21-30 kg: 2 adult tabs once a day for 3 days
- 31-40 kg: 3 adult tabs once a day for 3 days
- >40 kg: 4 adult tabs once a day for 3 days
Atovaquone-proguanil should be taken with food or a milk drink. For persons weighing 11 kilograms or more who experience gastrointestinal symptoms with therapy, the daily dose may be divided in two and given twice a day.
Evaluation and treatment of refugees with symptoms of malaria
Untreated malaria can progress rapidly. Any refugee from an area endemic for malaria who has signs or symptoms of malaria should be promptly evaluated by a physician with experience in malaria. The CDC Malaria Hotline (770-488-7788) is available between 8:00 AM and 4:30 PM Eastern Time to assist in the diagnosis and management of patients with malaria. In addition, emergency consultation is available after hours at 770-488-7100. More information on malaria is available at http://www.cdc.gov/malaria .
Guidance for State Refugee Health Coordinators
Most of the recently arrived Burundi refugees identified so far with malaria had an onset of disease within 2 weeks of arrival in the United States. Therefore, CDC encourages that presumptive therapy for refugees without documentation of ACT therapy prior to departure be initiated as soon as possible after arrival.
CDC recommends the following:
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Locate all Burundian refugees who have arrived in your state from May 1, 2007, to present.
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Follow the presumptive malaria treatment guidance outlined above.
CDC will be contacting affected states in separate Epi-X postings and will provide lists of recent Burundian refugee arrivals to assist with follow-up. Refugee health coordinators whose Epi-X digital certificates have expired should contact the EpiX HelpDesk at 877-GET-EPIX (877-438-3749) or epixhelp@cdc.gov.
Reporting of malaria to public health agencies
Clinicians caring for refugees are reminded that malaria is a nationally notifiable disease and is reportable in all U.S. states. Thus, any case of malaria should be promptly reported to the local or state public health department. The CDC Malaria Hotline (see above) can also assist clinicians with reporting cases of malaria.
Further information
By means of Epi-X, CDC will provide additional information as it becomes available. For further information, please contact one of the following:
- BK Kapella, MD, MS, BKapella@cdc.gov, 404-639-3448
- Paul Arguin, MD, Parguin@cdc.gov, 770-488-4257
- Gregory Armstrong, MD, GArmstrong@cdc.gov, 404-639-4443