A retrospective review of malaria cases seen in a non-endemic area of South Africa☆
Introduction
Malaria continues to pose a special risk for travelers to endemic areas. However, malaria may not always be recognized or properly treated in non-endemic areas due to the low frequency of occurrence. As a result, there is usually limited experience among health care workers in detecting parasites and treating malaria cases. This disease has significant morbidity and mortality in Africa, with one in every four childhood deaths in Africa attributed to it.1 Malaria is a preventable disease if all the measures to prevent the disease are put in place.2
Seasonal malaria occurs from November to May each year [summer months] in parts of South Africa predominantly in the areas bordering Mozambique.3, 4 In most cases patients who present with malaria in a non-endemic area have a travel history to an endemic area.5 The city of Pretoria lies in the non-endemic or seasonal malaria region of South Africa. It should be noted that although South Africa is not an entirely malaria free country, the majority of the provinces in South Africa are non-endemic. With this in mind, it is noteworthy to mention that challenges are faced by laboratory technologists in non-endemic areas including Pretoria. This is important as we seek to eliminate malaria in most regions of the world.
In view of the infrequent presentation, the challenge is detecting malaria parasites and treating patients promptly and adequately. Additional challenges are related to the skill and experience of the laboratory technologists and microscopists in non-endemic areas which may result in failure to detect parasites when examining blood smears. Sensitive assays like rapid antigen tests may be needed to screen for malaria prior to confirmation with a blood smear. These are available but need to be used by experienced personnel. Treatment should usually follow the national guidelines. However, clinicians in non-endemic areas may not be familiar with the treatment options available. National guidelines for the treatment of malaria in South Africa issued by the Department of Health6 are summarized in Table 1. The guidelines include Coartem® as the first line treatment for uncomplicated malaria acquired anywhere in Sub-Saharan Africa and in these guidelines Quinine (plus Doxycycline or Clindamycin) remains the gold standard for the treatment of severe malaria.6 Artemether lumefantrine combination is only registered currently for the treatment of drug resistant malaria in endemic areas in patients weighing less than 65 kg. An off label use of Coartem in non-immunes and those >65 kg has also been recommended.7 However, these national guidelines are outdated and there is an urgent need to revise and make them uniform for the country.
This study was based on a review of blood specimens submitted to Dr George Mukhari (DGM) Hospital, which is a tertiary teaching hospital near Pretoria, South Africa almost 300 km from the nearest malaria transmission area.
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Materials and methods
The study was approved by the research and ethics committee of the University of Limpopo (Medunsa Campus). All specimens submitted to the medical microbiology laboratory for malaria investigations between May 2003 and May 2006 were included in the study. Hospital records of patients who had plasmodial infection and were clinically diagnosed as having malaria were reviewed for clinical data. The treatment administered to each patient was compared to South African national treatment guidelines.6
Results
A total of 516 specimens were received in the microbiology laboratory during the study period and 211/516 (41%) were found to be malaria smear positive. Of these, 97% were P. falciparum, 2% were Plasmodium malariae and 1% was Plasmodium ovale. There were no mixed infections in this study. The number of cases of malaria has increased over the past three years and the increase was significant for children [p = 0.005]; this breakdown is shown in Fig. 1. However, the cases diagnosed in the
Discussion
Malaria is an important infectious disease among returning travelers even in other parts of the world5, 8, 9 and in non-endemic areas children and adults both lack acquired immunity and are thus at equal risk of acquiring malaria. In this study, we found an increase in the number of cases of malaria diagnosed over the study period [3 years], although the number of cases reported in the inter-seasonal period did not increase. The increase in the number of malaria cases was statistically
Conclusion
In a non-endemic malaria region like Pretoria, South Africa, awareness of malaria is important as it occurs sporadically and yet may be fatal27 Malaria is being diagnosed mainly in returning visitors from the neighboring countries particularly Mozambique. Giemsa stained smears remain the gold standard of diagnosis and speciation, however, it is worth noting that an additional 8% of the patients were diagnosed by using the HRP2 antigen. A proportion of this may reflect diagnosis in patients
Conflicts of interest declaration
The authors of this paper declare that that they have no conflict of interest, financial or otherwise that may influence the manuscript.
Acknowledgements
We would like to thank staff at the Microbiology Laboratory and the clerks at the Dr George Mukhari Hospital, GaRankuwa, Pretoria for assisting in access to laboratory and hospital records.
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The results of this study have been presented at a conference Federation of Infectious Disease Society of Southern Africa held in Cape Town, Spier Hotel on 28 October 2007.