Imported Pediatric Malaria
Abstract and Commentary
By Philip R. Fischer, MD, DTM&H
Dr. Fischer is Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
Dr. Fischer reports no financial relationship to this field of study.
Synopsis: A retrospective survey shows that imported pediatric malaria continues to occur. Children most at risk are those traveling to visit friends and relatives, especially in West Africa, without being provided effective chemoprophylaxis.
Source: Hickey PW, Cape KE, Masuoka P, et al. A local, regional, and national assessment of pediatric malaria in the United States. J Travel Med 2011;18:153-160.
A retrospective review of pediatric malaria at a Washington, DC, children's hospital identified 98 cases over 8 years from 1999 to 2006. Their mean age was 9.6 years. Approximately half of the children were long-term U.S. residents who had visited friends or relatives in their country of origin, and most of the others were recent immigrants. Eighty-five percent of these children had been exposed to malaria in West Africa. Only 6% reported having been properly adherent to an effective malaria chemoprophylaxis regimen. Seventeen of the children were initially diagnosed with something other than malaria, but 82% of patients were accurately diagnosed as having malaria on the day they presented for care. The mean duration of symptoms prior to diagnosis was 5 days (range 1-30). One child recovered following cardiac arrest, 19% required intensive care, and all survived.
The authors then reviewed the Pediatric Health Information System database and identified 306 children with malaria at 40 large American children's hospitals from January 2003 to June 2008. P. falciparum accounted for the majority of infections. The hospitals' charges for the care of these 306 children totaled $5.3 million ($17,519 per patient).
Imported malaria continues to be diagnosed among children in the United States, as well as in Europe.1,2 In the United States during 2009, there were 1,484 reported cases of malaria, and 16% of these cases were among those younger than 18 years of age.3 Of these pediatric cases, 89% occurred after travel in Africa, and 73% were in children who had traveled to visit friends and relatives; only 4% reported adherence to an accepted anti-malarial chemoprophylaxis regimen.3
While important, malaria is not the most common problem occurring in returned travelers. Of 1,591 children presenting for health care in 19 countries following travel to 218 destinations, 28% had diarrhea, 25% had skin conditions, 23% had fever (8% of the total with malaria), and 11% had respiratory illnesses.4 When compared to adults presenting for post-travel care, children presented sooner following travel, required more hospitalizations, more often lacked pre-travel care, and more often had traveled to visit friends and relatives.4
So, what are the practical implications of these new data? First, realizing that the majority of sick returned pediatric travelers and the majority of patients with imported malaria had traveled to visit friends and relatives, we should expand our pre-travel efforts specifically directed toward these travelers.5 Second, realizing that most of these travelers did not take appropriate chemoprophylaxis, we should identify ways of both bringing these travelers into contact with pre-travel care and ensuring that they apply appropriate preventive efforts. How might this be accomplished? Strategies should be developed to engage travelers who are not currently presenting for pre-travel care. Current practices could be supplemented with new efforts focused on immigrant populations (those most likely to take children to other countries to visit friends and relatives). A goal would be to reach into communities with good pre-travel interventions. This could be facilitated by including questionnaires about future travel plans in community clinic and primary care practice health maintenance visits.6
Malaria still happens among children in the United States. Imported malaria most commonly occurs in those children who traveled to visit friends and relatives, especially in West Africa. Malaria diagnoses are frequently delayed in the United States, and imported malaria is associated with significant morbidity and cost. These are not new messages, but these old findings (reported in Travel Medicine Advisor in 2003, 2006, and 2009) are again confirmed by new data. What will be done to better prevent imported pediatric malaria? A new Pediatric Interest Group of the International Society of Travel Medicine is seeking to work in and beyond the travel medicine community to improve pre-travel care of children.7
- Garbash M, Round J, Whitty CJ, et al. Intensive care admissions for children with imported malaria in the United Kingdom. Pediatr Infect Dis J 2010;29:1140-1142.
- Elmansouf L, Dubos F, Dauriac A, et al. Evaluation of imported pediatric malaria management in northern France. Med Mal Infect 2011;41:145-151.
- Mali S, Tan KR, Arguin PM. Malaria surveillance — United States. 2009. MMWR Surveill Summ 2011;60:1-15.
- Hagmann S, Neugebauer R, Schwartz E, et al. Illness in children after international travel: Analysis from the GeoSentinel Surveillance Network. Pediatrics 2010;125:e1072-e1080.
- Hagmann S, Schlagenhauf P. Prevention of imported pediatric malaria — travel medicine misses the bull's eye. J Travel Med 2011;18:151-152.
- Hagmann S, Reddy N, Neugebauer R, et al. Identifying future VFR travelers among immigrant families in the Bronx, New York. J Travel Med 2010;17:193-196.
- Pediatric Interest Group, International Society of Travel Medicine. Available at: www.istm.org/WebForms/Members. Accessed Aug. 27, 2011.