- Email: [email protected]
Eritrean and Sudanese migrants presenting with malaria in Israel
Travel Medicine and Infectious Disease (2011) 9, 303e305
Available online at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/tmid
COMMENTARY
Eritrean and Sudanese migrants presenting with malaria in Israel Lisa Saidel-Odes a,*, Klaris Riesenberg a, Francisc Schlaeffer a, Rozalia Smolyakov a, Mike Kafka b, Abraham Borer a,c a Infectious Diseases Institute, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 151, Beer-Sheva 84101, Israel b Hematology Laboratory, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 151, Beer-Sheva 84101, Israel c Infection Control and Hospital Epidemiology Unit, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 151, Beer-Sheva 84101, Israel
Received 17 November 2010; received in revised form 18 September 2011; accepted 19 September 2011 Available online 28 October 2011
KEYWORDS Malaria; Eritrea; Sudan; Plasmodium falciparum; Plasmodium vivax
Summary In Israel, a malaria-free country, we have noticed lately an increase of hospital admissions with malaria, parallel to the rise in the number of Eritrean and Sudanese migrants. Eritrea and Sudan are malaria-endemic countries; Plasmodium falciparum accounts for 85 e90% and Plasmodium vivax accounts for 10e15% of malaria species in these areas. We aimed to describe the features of malaria in this migrant population by conducting a retrospective descriptive study of Eritrean and Sudanese migrants admitted with malaria during 1/2009 e4/2010. Patient files were reviewed for demographics, clinical data, laboratory tests, treatment and outcome. 101 patients (mean age 24.9 (SD 5.6) years; 86.1% males) with malaria were identified. 87.1% were infected with P. vivax, 6% with P. falciparum, and 6.9% had both. All presented with pyrexia. None had respiratory or cerebral complications. Mean length of hospitalization was 2.49 (SD 1.5) days. No treatment failures or complications were observed. We conclude that in countries with waves of migrants from malaria-endemic areas, onset of fever should raise suspicion of malaria. Contrary to the known dominance of P. falciparum among malaria species in Eritrea and Sudan, the vast majority of migrants presented with P. vivax. The region of P. vivax acquisition remains unclear. ª 2011 Elsevier Ltd. All rights reserved.
* Corresponding author. Infectious Diseases Institute, Soroka University Medical Center, P.O. Box 151, Beer-Sheva 84101, Israel. Tel.: þ972 8 640 0370; fax: þ972 8 640 3534. E-mail addresses: [email protected] (L. Saidel-Odes), [email protected] (K. Riesenberg), [email protected] (F. Schlaeffer), [email protected] (R. Smolyakov), [email protected] (M. Kafka), [email protected] (A. Borer). 1477-8939/$ - see front matter ª 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.tmaid.2011.09.003
304
L. Saidel-Odes et al.
Introduction
IRB approval
Each year 300e500 million people worldwide are infected with malaria, causing approximately 1 million deaths.1 Transmission of malaria has increased in recent years in many countries where it was once eradicated or well controlled.2e5 Spain has reported a high number of natives from malaria-endemic countries with an increase in the incidence rate of malaria.3,6 This can pose a diagnostic challenge to physicians and laboratory technicians who do not have experience with malaria. Israel is a malaria-free country; all cases are imported by Israeli travelers to or migrants from malaria-endemic areas. Eritrea and Sudan are malaria-endemic countries; Plasmodium falciparum accounts for 85e90% and Plasmodium vivax accounts for 10e15% of malaria species in these areas.7 Lately we have noticed an increase of admissions to our hospital with malaria, parallel to the rise in number of Eritrean and Sudanese illegal migrants. Eritreans travel (by foot) from Eritrea to Israel via Ethiopia, Sudan and Egypt, while Sudanese travel through Egypt only. Our aims were to identify specific epidemiological characteristics of malaria among Eritrean and Sudanese migrants to Israel and to evaluate response to treatment.
The study protocol # 10524 was approved by the Soroka University Medical Center Helsinki committee, April 2010.
Results
Methods
There were 101 patients identified with malaria, 88/101 (87.1%) were infected with P. vivax, 6% with P. falciparum, and 6.9% had both species. Demographic characteristics are shown in Table 1. 87/101 (86.1%) were male; the mean age was 24.9 5.6 years. All patients presented with pyrexia. None had respiratory or cerebral complications. Other signs and symptoms included: chills in 77/88 (87.5%), headache in 40/73 (54.8%), myalgia in 18/71 (25.4%), abdominal cramps in 17/89 (19.1%), and vomiting in 13/101 (12.9%) of the patients. Table 2 summarizes the laboratory characteristics on admission. Patients with P. falciparum were treated with mefloquine (750 mg stat, then 500 mg 6e12 h later or 1250 mg as a single dose). Patients with P. vivax were treated with chloroquine (1 g salt, then 0.5 g after 6 h, then 0.5 mg daily 2 days) or mefloquine (dose as above) followed by two weeks of primaquine (30 mg daily).9 Mean length of hospitalization (SD) was 2.49 (1.5) days. No treatment failures or complications were noted during the hospitalization period.
Acquisition of cases
Discussion
The study was performed at a 1000-bed tertiary-care teaching hospital in southern Israel. We identified retrospectively all adult Eritrean and Sudanese patients admitted with malaria during the study period of January 2009 through April 2010 from the records of the Hematology Laboratory.
Malaria continues to be a world-wide problem, and not only in endemic areas. Population movements around the world should alert us to the possibility of imported infectious diseases, including malaria. Most publications address the issue of malaria in migrants to malarial areas10,11; very few refer to malaria in migrants to malaria-free regions.3,6 In malaria-free countries, malaria should be suspected in patients presenting with fever who have arrived or returned from malaria-endemic areas in the past six weeks.12 It is very important to diagnose the type of plasmodium causing the disease. This cannot be based solely on the region of acquisition. Contrary to the known dominance of P. falciparum among malaria species in Eritrea and Sudan, the vast majority of our patients presented with P. vivax. There are possible explanations for this finding, though the precise geographical location of P. vivax acquisition remains unclear:
Microbiologic identification Malaria was diagnosed according to routine laboratory procedures: microscopic examination of stained blood films8 and a rapid antigen detection method BinaxNow Malaria (Inverness Medical, Maine, USA).
Measures Data were abstracted using a structured questionnaire covering demographic background including age, gender, country of origin, and travel route to Israel; clinical symptoms including fever, influenza-like symptoms, musculoskeletal, gastrointestinal, respiratory and neurological symptoms; physical examination findings; laboratory data including a complete blood count, renal function tests, bilirubin, lactate dehydrogenase, and urinalysis; antimalarial treatment administered and clinical outcome.
Statistical analysis Data were analyzed using the SPSS software (SPSS inc., version 15). Differences between categorical variables were analyzed by the Chi-square test.
1. Migrants with P. falciparum malaria may have died from the disease on their travel route. Table 1 Demographic population.
characteristics
of
patient
Variable
Number (%)
Patients Male Female Age, years (mean SD) Country of origin Eritrea Sudan
106 87 (86.1%) 14 (13.9%) 24.9 5.6 89 (88.1%) 12 (11.9%)
Eritrean and Sudanese migrants presenting with malaria in Israel Table 2
Laboratory characteristics.
Variable
Value (mean SD)
Hemoglobin Reticulocyles % WBCs Platelets Glucose Urea Creatinine LDH Total bilirubin
11.3 g/dl 2.3 3.9 1.9 6146 103/ml 2549 103 124.7 103/ml 59.3 103 101 mg/dl 19.7 31.87 mg/dl 7.9 0.72 mg/dl 0.16 716 u/l 259 1.5 mg/dl 0.9
2. Sudanese and Eritrean migrants might have been treated for malaria while in malaria-endemic areas but not treated with primaquine for the liver dormant hypnozoites, therefore those who had P. vivax malaria in the past relapsed. 3. Although Egypt in considered a malaria-free country, this might be inaccurate and it is possible that P. vivax malaria was acquired while traveling through this country. Of note, there have been cases of malaria in Israeli soldiers who served in Sinai in the 1970s.13 Our hospital is the only one available in the south of Israel (excluding the port of Eilat area), so that all migrants in the south of the country presenting with malaria are referred to us. Treatment failure in the first month after admission (the minimal time period in which they reside in the south of the country) would lead to readmission to our hospital. None of the patients that we treated was readmitted in that time period. We have shown in all our patients that prompt diagnosis and treatment led to full recovery without complications. We therefore recommend that a blood film be examined immediately in migrants presenting with fever. Similarly, travelers returning from malaria-endemic areas and presenting with fever should alert the emergency room physician about the possibility of malaria.
Conflict of interest All authors declare that they have no conflict of interest and no financial disclosure.
305
Acknowledgments This work was presented in part at the 50th Interscience Conference on Antimicrobial Agents and Chemotherapy [Abstract P-1125], Boston, Massachusetts, USA, September 12e15, 2010.
References 1. Arguin PM, Steele SF. Malaria. In: Brunette GW, editor. CDC health information for international travel 2010. The Yellow Book. Spain: Elsevier Mosby; 2009. p. 128e43. 2. McNeely DF, Chu A, Lowe S, Layton M. Malaria surveillance in New York city: 1991e1996. Int J Infect Dis 1998;2:132e6. 3. Millet JP, Garcia de Olalla P, Carrillo-Santisteve P, Gasco ´n J, Trevin ˜o B, Mun ˜oz J, et al. Imported malaria in a cosmopolitan European city: a mirror image of the world epidemiological situation. Malar J 2008;7:56. 4. Schlagenhauf P, Steffen R, Loutan L. Migrants as a major risk group for imported malaria in European countries. J Travel Med 2003;10:106e7. 5. Schwartz E. Malaria in Israelecan severe malaria related morbidity and mortality be prevented? Harefuah 2002;141: 699e701. 762, 761. 6. Rey S, Zuza I, Martı´nez-Monde ´jar B, Rubio JM, Merino FJ. Imported malaria in an area in southern Madrid, 2005e2008. Malar J 2010;9:290. 7. Tan KR, Mali S, Arguin PM. Malaria risk information and prophylaxis, by country. In: Brunette GW, editor. CDC health information for international travel 2010. The Yellow Book. Spain: Elsevier Mosby; 2009. p. 143e59. 8. Warhurst DC, Williams JE. Laboratory diagnosis of malaria. J Clin Pathol 1996;49:533e8. 9. Center for Disease Control and Prevention. Guidelines for treatment of malaria in the United States. http://www.cdc. gov/malaria/resources/pdf/treatmenttable.pdf (accessed 15.05.11). 10. Khamsiriwatchara A, Wangroongsarb P, Thwing J, Eliades J, Satimai W, Delacollette C, et al. Respondent-driven sampling on the ThailandeCambodia border. I. Can malaria cases be contained in mobile migrant workers? Malar J 2011;10:120. 11. Sheehy SH, Angus BJ. Malaria: severe, life-threatening. Clin Evid 2011. pii: e0913, (Online). 12. Humar A, Keystone J. Evaluating fever in travelers returning from tropical countries. BMJ 1996;312:953e6. 13. Rachmilewitz D. Increased incidence of malaria in Sinai and its prevention. Herefuah 1973;84:199e200.
Available online at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/tmid
COMMENTARY
Eritrean and Sudanese migrants presenting with malaria in Israel Lisa Saidel-Odes a,*, Klaris Riesenberg a, Francisc Schlaeffer a, Rozalia Smolyakov a, Mike Kafka b, Abraham Borer a,c a Infectious Diseases Institute, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 151, Beer-Sheva 84101, Israel b Hematology Laboratory, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 151, Beer-Sheva 84101, Israel c Infection Control and Hospital Epidemiology Unit, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 151, Beer-Sheva 84101, Israel
Received 17 November 2010; received in revised form 18 September 2011; accepted 19 September 2011 Available online 28 October 2011
KEYWORDS Malaria; Eritrea; Sudan; Plasmodium falciparum; Plasmodium vivax
Summary In Israel, a malaria-free country, we have noticed lately an increase of hospital admissions with malaria, parallel to the rise in the number of Eritrean and Sudanese migrants. Eritrea and Sudan are malaria-endemic countries; Plasmodium falciparum accounts for 85 e90% and Plasmodium vivax accounts for 10e15% of malaria species in these areas. We aimed to describe the features of malaria in this migrant population by conducting a retrospective descriptive study of Eritrean and Sudanese migrants admitted with malaria during 1/2009 e4/2010. Patient files were reviewed for demographics, clinical data, laboratory tests, treatment and outcome. 101 patients (mean age 24.9 (SD 5.6) years; 86.1% males) with malaria were identified. 87.1% were infected with P. vivax, 6% with P. falciparum, and 6.9% had both. All presented with pyrexia. None had respiratory or cerebral complications. Mean length of hospitalization was 2.49 (SD 1.5) days. No treatment failures or complications were observed. We conclude that in countries with waves of migrants from malaria-endemic areas, onset of fever should raise suspicion of malaria. Contrary to the known dominance of P. falciparum among malaria species in Eritrea and Sudan, the vast majority of migrants presented with P. vivax. The region of P. vivax acquisition remains unclear. ª 2011 Elsevier Ltd. All rights reserved.
* Corresponding author. Infectious Diseases Institute, Soroka University Medical Center, P.O. Box 151, Beer-Sheva 84101, Israel. Tel.: þ972 8 640 0370; fax: þ972 8 640 3534. E-mail addresses: [email protected] (L. Saidel-Odes), [email protected] (K. Riesenberg), [email protected] (F. Schlaeffer), [email protected] (R. Smolyakov), [email protected] (M. Kafka), [email protected] (A. Borer). 1477-8939/$ - see front matter ª 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.tmaid.2011.09.003
304
L. Saidel-Odes et al.
Introduction
IRB approval
Each year 300e500 million people worldwide are infected with malaria, causing approximately 1 million deaths.1 Transmission of malaria has increased in recent years in many countries where it was once eradicated or well controlled.2e5 Spain has reported a high number of natives from malaria-endemic countries with an increase in the incidence rate of malaria.3,6 This can pose a diagnostic challenge to physicians and laboratory technicians who do not have experience with malaria. Israel is a malaria-free country; all cases are imported by Israeli travelers to or migrants from malaria-endemic areas. Eritrea and Sudan are malaria-endemic countries; Plasmodium falciparum accounts for 85e90% and Plasmodium vivax accounts for 10e15% of malaria species in these areas.7 Lately we have noticed an increase of admissions to our hospital with malaria, parallel to the rise in number of Eritrean and Sudanese illegal migrants. Eritreans travel (by foot) from Eritrea to Israel via Ethiopia, Sudan and Egypt, while Sudanese travel through Egypt only. Our aims were to identify specific epidemiological characteristics of malaria among Eritrean and Sudanese migrants to Israel and to evaluate response to treatment.
The study protocol # 10524 was approved by the Soroka University Medical Center Helsinki committee, April 2010.
Results
Methods
There were 101 patients identified with malaria, 88/101 (87.1%) were infected with P. vivax, 6% with P. falciparum, and 6.9% had both species. Demographic characteristics are shown in Table 1. 87/101 (86.1%) were male; the mean age was 24.9 5.6 years. All patients presented with pyrexia. None had respiratory or cerebral complications. Other signs and symptoms included: chills in 77/88 (87.5%), headache in 40/73 (54.8%), myalgia in 18/71 (25.4%), abdominal cramps in 17/89 (19.1%), and vomiting in 13/101 (12.9%) of the patients. Table 2 summarizes the laboratory characteristics on admission. Patients with P. falciparum were treated with mefloquine (750 mg stat, then 500 mg 6e12 h later or 1250 mg as a single dose). Patients with P. vivax were treated with chloroquine (1 g salt, then 0.5 g after 6 h, then 0.5 mg daily 2 days) or mefloquine (dose as above) followed by two weeks of primaquine (30 mg daily).9 Mean length of hospitalization (SD) was 2.49 (1.5) days. No treatment failures or complications were noted during the hospitalization period.
Acquisition of cases
Discussion
The study was performed at a 1000-bed tertiary-care teaching hospital in southern Israel. We identified retrospectively all adult Eritrean and Sudanese patients admitted with malaria during the study period of January 2009 through April 2010 from the records of the Hematology Laboratory.
Malaria continues to be a world-wide problem, and not only in endemic areas. Population movements around the world should alert us to the possibility of imported infectious diseases, including malaria. Most publications address the issue of malaria in migrants to malarial areas10,11; very few refer to malaria in migrants to malaria-free regions.3,6 In malaria-free countries, malaria should be suspected in patients presenting with fever who have arrived or returned from malaria-endemic areas in the past six weeks.12 It is very important to diagnose the type of plasmodium causing the disease. This cannot be based solely on the region of acquisition. Contrary to the known dominance of P. falciparum among malaria species in Eritrea and Sudan, the vast majority of our patients presented with P. vivax. There are possible explanations for this finding, though the precise geographical location of P. vivax acquisition remains unclear:
Microbiologic identification Malaria was diagnosed according to routine laboratory procedures: microscopic examination of stained blood films8 and a rapid antigen detection method BinaxNow Malaria (Inverness Medical, Maine, USA).
Measures Data were abstracted using a structured questionnaire covering demographic background including age, gender, country of origin, and travel route to Israel; clinical symptoms including fever, influenza-like symptoms, musculoskeletal, gastrointestinal, respiratory and neurological symptoms; physical examination findings; laboratory data including a complete blood count, renal function tests, bilirubin, lactate dehydrogenase, and urinalysis; antimalarial treatment administered and clinical outcome.
Statistical analysis Data were analyzed using the SPSS software (SPSS inc., version 15). Differences between categorical variables were analyzed by the Chi-square test.
1. Migrants with P. falciparum malaria may have died from the disease on their travel route. Table 1 Demographic population.
characteristics
of
patient
Variable
Number (%)
Patients Male Female Age, years (mean SD) Country of origin Eritrea Sudan
106 87 (86.1%) 14 (13.9%) 24.9 5.6 89 (88.1%) 12 (11.9%)
Eritrean and Sudanese migrants presenting with malaria in Israel Table 2
Laboratory characteristics.
Variable
Value (mean SD)
Hemoglobin Reticulocyles % WBCs Platelets Glucose Urea Creatinine LDH Total bilirubin
11.3 g/dl 2.3 3.9 1.9 6146 103/ml 2549 103 124.7 103/ml 59.3 103 101 mg/dl 19.7 31.87 mg/dl 7.9 0.72 mg/dl 0.16 716 u/l 259 1.5 mg/dl 0.9
2. Sudanese and Eritrean migrants might have been treated for malaria while in malaria-endemic areas but not treated with primaquine for the liver dormant hypnozoites, therefore those who had P. vivax malaria in the past relapsed. 3. Although Egypt in considered a malaria-free country, this might be inaccurate and it is possible that P. vivax malaria was acquired while traveling through this country. Of note, there have been cases of malaria in Israeli soldiers who served in Sinai in the 1970s.13 Our hospital is the only one available in the south of Israel (excluding the port of Eilat area), so that all migrants in the south of the country presenting with malaria are referred to us. Treatment failure in the first month after admission (the minimal time period in which they reside in the south of the country) would lead to readmission to our hospital. None of the patients that we treated was readmitted in that time period. We have shown in all our patients that prompt diagnosis and treatment led to full recovery without complications. We therefore recommend that a blood film be examined immediately in migrants presenting with fever. Similarly, travelers returning from malaria-endemic areas and presenting with fever should alert the emergency room physician about the possibility of malaria.
Conflict of interest All authors declare that they have no conflict of interest and no financial disclosure.
305
Acknowledgments This work was presented in part at the 50th Interscience Conference on Antimicrobial Agents and Chemotherapy [Abstract P-1125], Boston, Massachusetts, USA, September 12e15, 2010.
References 1. Arguin PM, Steele SF. Malaria. In: Brunette GW, editor. CDC health information for international travel 2010. The Yellow Book. Spain: Elsevier Mosby; 2009. p. 128e43. 2. McNeely DF, Chu A, Lowe S, Layton M. Malaria surveillance in New York city: 1991e1996. Int J Infect Dis 1998;2:132e6. 3. Millet JP, Garcia de Olalla P, Carrillo-Santisteve P, Gasco ´n J, Trevin ˜o B, Mun ˜oz J, et al. Imported malaria in a cosmopolitan European city: a mirror image of the world epidemiological situation. Malar J 2008;7:56. 4. Schlagenhauf P, Steffen R, Loutan L. Migrants as a major risk group for imported malaria in European countries. J Travel Med 2003;10:106e7. 5. Schwartz E. Malaria in Israelecan severe malaria related morbidity and mortality be prevented? Harefuah 2002;141: 699e701. 762, 761. 6. Rey S, Zuza I, Martı´nez-Monde ´jar B, Rubio JM, Merino FJ. Imported malaria in an area in southern Madrid, 2005e2008. Malar J 2010;9:290. 7. Tan KR, Mali S, Arguin PM. Malaria risk information and prophylaxis, by country. In: Brunette GW, editor. CDC health information for international travel 2010. The Yellow Book. Spain: Elsevier Mosby; 2009. p. 143e59. 8. Warhurst DC, Williams JE. Laboratory diagnosis of malaria. J Clin Pathol 1996;49:533e8. 9. Center for Disease Control and Prevention. Guidelines for treatment of malaria in the United States. http://www.cdc. gov/malaria/resources/pdf/treatmenttable.pdf (accessed 15.05.11). 10. Khamsiriwatchara A, Wangroongsarb P, Thwing J, Eliades J, Satimai W, Delacollette C, et al. Respondent-driven sampling on the ThailandeCambodia border. I. Can malaria cases be contained in mobile migrant workers? Malar J 2011;10:120. 11. Sheehy SH, Angus BJ. Malaria: severe, life-threatening. Clin Evid 2011. pii: e0913, (Online). 12. Humar A, Keystone J. Evaluating fever in travelers returning from tropical countries. BMJ 1996;312:953e6. 13. Rachmilewitz D. Increased incidence of malaria in Sinai and its prevention. Herefuah 1973;84:199e200.