Published Date: 2000-07-13 23:50:00
Subject: PRO/EDR> Malaria, vivax - Germany ex Greece
Archive Number: 20000713.1158

MALARIA, VIVAX - GERMANY EX GREECE
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A ProMED-mail post
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Date: 11 Jul 2000 19:15:27 +0200
From: Tomas Jelinek <jelinek@lrz.uni-muenchen.de>
Source: TropNetEurop, Martin Grobusch (Charite, Berlin, Germany) [edited]

Two cases of _Plasmodium vivax_ malaria imported from Greece
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On 6 Jul 2000, a German couple (female, 45 years; male 48 years) developed
almost simultaneously an acute febrile illness with chills, fatigue and
headache. On 9 Jul 2000 (on day 3 of there illness) they presented
themselves to the local hospital. On admission, physical examination was
inconspicuous, apart from multiple insect bites on the ankles of both
patients. Laboratory results on admission revealed an elevated LDH and
pronounced thrombopenia but a low white cell count, thus being suggestive
of malaria. Thick film readings revealed _Plasmodium vivax_ parasitaemia of
less than 0.5 % in both patients, a diagnosis which was subsequently
confirmed by expert microscopists from the Bernhard Nocht Tropical
Institute in Hamburg.
The past medical history of both was empty. From [Jun] 19 to 26, the couple
had spent a one-week holiday in Kassandra, Chalkidiki, Greece [Greek
Macedonia south of Thessaloniki] in a tourist resort. During this sojourn,
they undertook a day trip to Sarti but stayed in the surroundings of the
hotel for the rest of the time.
Travel history of the past 5 years comprised several trips within Europe
(but not to coastal areas of Turkey) a brief trip to South Africa in 1995
and a holiday in Kenya in 1980. The air plane on which the two were
travelling back home from Thessaloniki to Dusseldorf on a direct flight did
not visit any malaria-endemic area at least for the last ten days, but
probably not for much longer. To our present knowledge, there are no direct
flights from malaria-endemic areas into Thessaloniki airport. To our
knowledge, there is no evidence so far of a local outbreak.
Malaria eradication was completed in the 50ies [1950s] of this century
throughout Greece.

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[Greece was previously a malaria-endemic country with transmission of both
_P.vivax_ and _P.falciparum_ The last recorded indigenous case was in 1974,
but the local _Anopheles_ vectors, _An. superpictus_ and _An. labranchiae_,
are able to transmit malaria.
We have no other reports on cases from Greece whether in tourists or
inhabitants. The incubation period in the human host is 12 to 17 days which
fits with the time of the visit to Greece. The infections most probably
were transmitted by the same mosquito as both patients developed symptoms
simultaneously.
The maturation time in the mosquito is 16 days at 20C and 8 to 10 days at
28C. The most probable explanation is infection from an asymptomatic
carrier of _P.vivax_ gametocytes, who infected the mosquito sometime in the
beginning of June. Infection during the 1995 visit to South Africa is a not
likely explanation partly because of the long time since the visit but
mostly because it is almost impossible that recrudescence should happen
simultaneously after five years.
Recent outbreaks in The Dominican Republic and Malaysia have been due to
migrant workers carrying parasites initiating limited local transmission.
We do not know whether this is the case here. Comments from authorities in
Greece are appreciated. For the following months febrile tourists from the
Chalkidiki area, Greece, should routinely have a blood film examined for
malaria parasites. -Mod.EP]
.................................................ep/ds
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