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Published Date: 2007-01-12 00:00:00
Subject: PRO/EDR> Malaria - EU ex India (Goa)
Archive Number: 20070112.0150

MALARIA - EUROPEAN UNION EX INDIA (GOA)
********************
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Date: 11 Jan 2007
From: ProMED-mail <promed@promedmail.org>
Source: Eurosurveillance weekly release, Vol.12, Iss.1, 11 Jan 2007 [edited]
<http://www.eurosurveillance.org/ew/2007/070111.asp#2>

An increase in numbers of malaria cases has
recently been reported in travellers returning
from India, in particular from the state of Goa,
on the west coast. These cases have been reported
to the European Network on Imported Infectious
Disease Surveillance (TropNetEurop,
<http://www.tropnet.net>). In the past 2 years,
there have been no reports of malaria in European
travellers to Goa. However, since late November
2006, the malaria surveillance map of the network
has shown an unusually intensive signal from
India [1], indicating an increase in the number
of malaria reports from that region, including Goa.
By 10 Jan 2007, 8 patients had been reported: 2
in Germany, 4 in Denmark, and 2 in Sweden. With
the exception of 2 Danish cases, all patients
travelled independently of one another. The 2
German patients, one of the Swedish patients and
one of the Danish patients stayed in Goa for 2-3
weeks and had not visited other regions within India.
Germany cases 1 and 2.
---------------
The 2 German patients developed severe malaria
and were treated in an intensive care unit with
artesunate/doxycycline. Both travellers (a woman
in her 50s and a man in his 40s), travelling
independently, spent 14 days at 2 popular coastal
resorts in Goa. Neither took any malaria
chemoprophylaxis. One traveller developed a
hyperparasitaemia of 25 percent, both had signs
of cerebral malaria and acute renal failure. They
were admitted to the hospital on 10 and 11 Dec
2006 respectively, and made a full recovery.
Sweden case 1.
--------
A Swede in his 40s travelled to Goa for 2.5 weeks
in November-December 2006. He visited a beach in
northern Goa and stayed in a beach hotel. He
slept under a mosquito net but without air
conditioning. He did not take any malaria
chemoprophylaxis, in accordance with the Swedish
recommendations for travellers to that area [2].
Five days after his return to Sweden, he
developed a sudden fever, was diagnosed with a
probable pneumonia and treated with
amoxicillin/clavulanic acid for 3 days. With no
improvement in his condition he was admitted to
hospital seven days later, where a diagnosis of
Plasmodium falciparum monoinfection with 0.4
percent parasitaemia was made. This diagnosis was
delayed because travel history had not been
obtained earlier. The patient was treated with
mefloquine and made an uneventful recovery.
Sweden case 2.
--------
A Swede in her 50s visited Goa for a 2-week
holiday in November-December 2006, and did not
take any malaria chemoprophylaxis. Staying in a
coastal area in Goa, she travelled for 3 days to
an area 300 km inland. She developed symptoms the
day before her return to Sweden. On her return
she visited her general practitioner twice, and a
diagnosis of bronchitis was made and treatment
with amoxicillin/clavulanic acid started. The
patient was admitted to hospital with a fever of
40 deg C, hypotensive thrombocytopenia and
hyponatraemia, diagnosis with _P. falciparum_
malaria and a 1.5 percent parasitaemia, 16 days
after her return. Malaria treatment was initiated
with quinine and proguanil/atovaquone. Her
condition gradually improved and she was discharged from hospital a week later.
Denmark case 1.
----------
A Dane in his 60s visited Goa for a 2-week
holiday in December 2006. He stayed in Goa but
visited a waterfall in an area east of Goa. His
hotel accommodation in Goa had no air
conditioning and no mosquito net. In accordance
with the Danish travel recommendations at the
time [3] he did not take any malaria
chemoprophylaxis. He developed symptoms of fever
and headache 9 days after his return to Denmark,
and was admitted to a local hospital 3 days
later. Two days later, he was diagnosed with _P.
falciparum_ malaria, 0.3 percent parasitaemia,
and transferred to an infectious disease ward. On
admission he had eye muscle paresis but with a
normal cerebral magnetic resonance imaging scan,
and thrombocytopenia. Because of these
complications, he was started on intravenous
quinine followed by mefloquine, and made an uneventful recovery.
Denmark case 2.
----------
A Dane in his 20s travelled to Goa for a 2-week
holiday in November 2006, and stayed in a tourist
hotel. He did not take any chemoprophylaxis. His
symptoms developed in early December, one week
after his return to Denmark, and he was admitted
to hospital 3 days later with a low grade fever.
Microscopy revealed a parasitaemia of 1 percent.
He was treated with mefloquine with rapid
clinical response and cleared his parasitaemia uneventfully.
Denmark case 3 and 4.
---------
Two men in their 20s travelled together to India
for 3 weeks from mid-October to the beginning of
November 2006. They visited Punjab, Goa, Delhi
and Mumbai. Both took chloroquine tablets only.
The Danish Statens Serum Institut considers
chloroquine-only prophylaxis to be insufficient
for malarious areas in India and recommends
taking both chloroquine and proguanil [3]. Both
men developed fever, headache and
gastrointestinal symptoms on the last day of
their holiday. One of the patients was diagnosed
that day with _P. falciparum_ malaria by
microscopy and was successfully treated with
proguanil/atovaquone (4 tablets per day for 3
days). The diagnosis was confirmed by Binax NOW
antigen test. The 2nd patient initially tested
negative by microscopy for malaria on 3
consecutive days while still taking chloroquine,
but his blood tested positive 6 weeks after onset
of symptoms, and he was successfully treated with proguanil/atovaquone.
Comment from TropNetEurop
--------
Goa, a popular winter resort for European
tourists who visit beach hotels and resorts along
the coast, has previously been considered to be
very low-risk for malaria infection for
travellers. It appears that this cluster of cases
of imported falciparum malaria, acquired in the
area to the north of Panaji, the capital of Goa,
has coincided with a period of intense rainfall
(50 percent above average) in the Goan and
Konokan region since October 2006 [4]. This may
be the cause of increased vector breeding and
transmission during the current rainy season.
The risk of infection will presumably decline
with the coming dry season. Currently, however,
there may be increased risk of malaria
transmission and therefore all travellers who
intend to visit this region of India are advised
to use mosquito bite avoidance measures. Visitors
may consider using WHO type IV prevention [5],
which is mosquito bite prevention plus
chemoprophylaxis with atovaquone/proguanil,
doxycycline, or mefloquine, or they may consider
travelling with emergency standby treatment.
Anyone who becomes unwell while on holiday or
shortly after their return should seek medical
attention promptly. Falciparum malaria can be a
life-threatening illness. The diagnosis can only
be made if a careful travel history is taken, and
testing done early, even for regions where
malaria is not normally recognised. The risk in
Goa will be monitored and we expect transmission
to cease as the rainy season ends in early 2007.
Changes made in recommendations for travellers in
some EU member states In December 2006, Denmark�s
Statens Serum Institut changed its malaria advice
until further notice, as a precautionary measure.
Until there is information on possible
chloroquine resistance, the new recommendation
for Danish travellers to Goa is type IV
chemoprophylaxis, as described above [3].
Previously no chemoprophylaxis was advised.
In Sweden, no changes in the general
recommendations for travellers have been made [2]
but the Swedish Institute for Infectious Disease
Control has informed about the Goa cases on their
home page and sent a letter to all departments of
Infectious Diseases and Infectious Disease
Control. In this letter it is stated that: "Until
we know more about the present malaria situation,
malaria prophylaxis can be considered for
travellers visiting Goa. The drugs that might be
used are Malarone, Lariam (mefloquine) or
doxycycline". In addition, there have been
several news spots on this topic on the national television.
No changes in the general recommendations for
travellers have been made in Germany. In
addition, the recent cluster of malaria cases
imported from Goa has also prompted the Advisory
Committee for Malaria Prevention in United
Kingdom Travellers (ACMP) to issue temporary
change to its recommendations. The ACMP advises
that travel advisors should highlight the risk of
malaria, instruct on the use of mosquito bite
avoidance measures [6], and recommend malaria
chemoprophylaxis to those travellers who will be
visiting Goa, particularly areas north of Panaji,
and who will be remote from medical care. This
advice remains in effect until further notice as
the situation is clarified. The recommended
chemoprophylaxis is chloroquine plus proguanil.
Alternatives are mefloquine, atovaquone plus proguanil, or doxycycline.
[Reported by:
T Jelinek /1 (<jelinek@bctropen.de>), R Behrens
/2, Z Bisoffi /3, A Bjorkmann /4, J Gascon /5, U
Hellgren /6, E Petersen /7, T Zoller /8 on behalf
of TropNetEurop, the European Network on Imported
Infectious Disease Surveillance R H Andersen /9, Anders Blaxhult /10,
1 Berlin Center for Travel & Tropical Medicine, Berlin, Germany;
2 Hospital for Tropical Diseases, London, UK;
3 Centro per le Malattie Tropicali, Ospedale S. Cuore, Negrar (Verona), Italy;
4 Karolinska Hospital, Department of Medicine,
Unit of Infectious Diseases, Stockholm;
5 Seccion de Medicina Tropical, Hospital Clinic, Barcelona, Spain
6 Department of Infectious Diseases, Karolinska
University Hospital Huddinge, Stockholm
7 Department of Infectious Diseases, Aarhus
University Hospital, Skejby, Aarhus, Denmark
8 Medizinische Klinik mit Schwerpunkt
Infektiologie, Charite/Campus Virchow-Klinikum, Berlin, Germany;
9 Statens Serum Institut, Copenhagen, Denmark;
10 Swedish Institute for Infectious Disease Control, Stockholm, Sweden.]
Acknowledgements:
Thomas Zoller Charite hospital, Berlin, Germany;
Johan Iversen, Department of Infectious Diseases,
Hvidovre Hospital, Denmark; Toke Barfod,
Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark.
References:
1. TropNetEurop Friends & Observers Sentinel
Surveillance Report: November 2006. Map on p. 3.
<http://www.tropnet.net/reports_friends/pdf_reports_friends/nov06_dengue2006_friends.pdf>
2. Rekommendationer f�r malariaprofylax. 2006.
(in Swedish)
<http://www.smittskyddsinstitutet.se/upload/Publikationer/Malariaprofylax-2006.pdf>
3. Aendrede anbefalinger for malariaprofylakse
for rejsende til Goa i Indien. 22 Dec 2006. (in
Danish only). <http://www.ssi.dk/sw174.asp?PAGE=2&ArtNo=3478761>
4. Rainfall maps, India Meteorological
Department.
<http://www.imd.ernet.in/section/hydro/dynamic/seasonal-rainfall.htm>
5. Country list; Vaccination requirements and
malaria situation. In: International travel and
health publication. Geneva: World Health
Organization; 2005.
<http://whqlibdoc.who.int/publications/2005/9241580364_country_list.pdfa>
6. The National Travel Health Network and Centre
(NaTHNaC). Insect bite avoidance. London:
NaTHNaC, 2006. <http://www.nathnac.org/pro/factsheets/iba.htm>
--
ProMED-mail
<promed@promedmail.org>
[This is an authoritative summary of the _P.
falciparum_ cases imported to Europe from Goa,
India so far with a comment on changes in
recommendations for malaria chemoprophylaxis for
visitors to Goa. The question is, when it is
possible to abandon recommending this
chemophrophylaxis? Data on surveillance of
malaria in the Indian population are badly
needed, and ProMED looks forward to the comments
of the Indian Ministry of Health. - Mod.EP]

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