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MALARIA - AFGHANISTAN ex BAHAMAS (GREAT EXUMA)
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International Society for Infectious Diseases
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Date: Thu 17 April 2008
From: Martin Tepper <tepper.ml@forces.gc.ca>
Malaria in a Canadian Forces member, likely acquired in Great Exuma, Bahamas
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A Canadian Forces (CF) member stationed in Kandahar, Afghanistan
since 7 Aug 2008, departed Afghanistan on 13 Jan 2008, and transited
through a non-malarious area in the Persian Gulf before arriving in
Great Exuma/Bahamas (GE/B) on 16 Jan 2008 via Miami. He stayed in
GE/B from 16 to 23 Jan 2008 at an upscale resort. Reportedly he had
little outdoor activity during twilight hours and took no personal
insect discipline measures (or malaria chemoprophylaxis). He departed
GE/B on 24 Jan 2008 and arrived back in Afghanistan on 5 Feb 2008
having stayed in Paris from 25 Jan to 2 Feb 2008 and transited
through the same Persian Gulf area of the outbound trip.
He developed symptoms on 31 Jan 2008 and was diagnosed with
_Plasmodium falciparum_ (Pf) infection by the CF medical unit in
Kandahar. A malaria smear was performed by CF laboratory technicians
and photomicrographs of the smear were confirmed as Pf at the McGill
University Centre for Tropical Diseases in Montreal. He was treated
for his infection and recovered. His fellow travellers are reported
to have not developed malaria. The case was reported to the Public
Health Agency of Canada (PHAC) on 11 Feb 2008; PHAC subsequently
reported the case to the Bahamian public health authority and to PAHO
(Pan American Health Organisation).
While the geographic exposure site for this case cannot be
"perfectly" ascribed, we felt at the time and continue to feel that
the most likely exposure site was in GE/B using the following lines
of reasoning:
- the malarious season in Afghanistan, including in Kandahar is
usually taken as May to November (according to the WHO); hence,
invoking an exposure in Afghanistan would entail a very long
incubation period for Pf of at least 60 days. If exposure was in
GE/B, the incubation period is between 7 and 15 days.
- while in Afghanistan, the patient took malaria chemoprophylaxis as
per the CF protocol; in his specific case, this entailed the use of
mefloquine weekly during the malarious season followed by terminal
prophylaxis with primaquine ending on 24 Dec 2007.
- no other cases of Pf malaria have been reported among CF members in
the Kandahar area in the 2006 and 2007 malaria seasons (the CF has
operated in the Kandahar area since the fall of 2005); this would
entail approximately 35 000 person-months of exposure.
- Pf had been reported in GE/B as late as August 2007 resulting in a
recommendation for chemoprophylaxis by PHAC and the US Centers for
Disease Control and Prevention (the US CDC recommendation was
rescinded in December 2007).
- the recently reported German case of Pf, well ascribed to exposure
in GE/B, indicates that some risk, although likely small, for Pf
transmission currently exists in GE/B.
It is likely that this CF case described above was an indicator of
continuing Pf risk in GE/B.
--
Martin Tepper, MD, MHSc, FRCPC
Chief, Communicable Disease Control Program
Directorate Force Health Protection (D FHP)
Canadian Forces Health Services Group Headquarters (CF H Svcs Gp HQ)
Department of National Defence (DND)
1745 Alta Vista Drive, Room 360
Ottawa, Ontario, CANADA
K1A 0K6
<tepper.ml@forces.gc.ca>
Steve Schofield, PhD
Senior Advisor, Public Health Entomology
Directorate Force Health Protection
Department of National Defence
Ottawa, Ontario, CANADA
[This case illustrates the need for systematic search of carriers to
avoid an outbreak like the one seen in Jamaica over the past 18
months.
We agree with the judgment expressed in the statement that it is
highly unlikely that the patient's _P. falciparum_ infection
originated in Afghanistan. First, because of the long incubation
period even if the patient were non-compliant during his stay in
Afghanistan; and second, because _P. falciparum_ should be entirely
sensitive to mefloquine in Afghanistan. We thank Drs. Tepper and
Schofield for providing information. - Mod.EP]
[see also:
Malaria - Germany ex Bahamas: (Great Exuma) 20080416.1369
2007
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Malaria - Bahamas (Exuma islands) (02): alert lifted 20071215.4029
Malaria - Bahamas (Exuma islands) 20070823.2771
2006
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Malaria - Bahamas (Exuma Islands) (02) 20060921.2698
Malaria - Bahamas (Exuma Islands) 20060620.1705]
...................................lm/ep/mj/lm
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