Epidemiologic Notes and Reports
Malaria in Travelers Returning from Kenya: Failure
of Self-Treatment with Pyrimethamine/Sulfadoxine
In August 1988, seven (88%) of eight U.S. citizens returning to
Pennsylvania from a tour of western Kenya developed symptoms of
malaria. Onset of symptoms occurred 10-74 days (median: 12 days)
after
arrival in the zone endemic for malaria. The travelers stayed 1
month
in an area within 100 miles of Lake Victoria. Each took
pyrimethamine
12.5 mg divided by apsone 100 mg (Maloprim*) orally once a week
starting 10 days before arrival at this site. All eight were
exposed to
mosquitoes at night, and all used insecticide and mosquito netting
for
protection. None of the eight had had malaria before this trip.
Each of the seven experienced fever, followed by chills, rigors,
and
diaphoresis. Five of the seven became ill while still in Kenya. In
one
of these five, symptoms resolved spontaneously within 2 days of
onset;
the other four took presumptive oral therapy with pyrimethamine 75
mg/sulfadoxine 1.5 g (FansidarR, 3 tablets) 2 days before returning
to
the United States. One of these four had symptom resolution after
therapy with FansidarR. One of the three travelers whose symptoms
persisted after FansidarR therapy had a therapeutic level of
sulfadoxine (57 ppm) on her return to the United States.
Blood smears were examined for all three travelers who remained
symptomatic after FansidarR therapy, as well as for two additional
travelers who became ill after returning to the United States. All
five
had blood smears diagnostic of Plasmodium falciparum malaria. All
five
were treated successfully with quinine and tetracycline.
Reported by: Div of Field Svcs, Epidemiology Program Office;
Malaria
Br, Div of Parasitic Diseases, Center for Infectious Diseases, CDC.
Editorial Note
Editorial Note: Malaria is endemic in large areas of sub-Saharan
Africa, New Guinea, Latin America, and Asia. Travelers to areas
with
endemic malaria in sub-Saharan Africa and New Guinea are at
particular
risk for malaria even when recommended precautions such as mosquito
netting, insecticides, and chemoprophylaxis are used. Approximately
150
U.S. travelers annually are diagnosed with P. falciparum malaria on
return from abroad; most have visited sub-Saharan Africa (1).
Resistance of P. falciparum to chloroquine extends throughout
sub-Saharan Africa, and resistance to sulfa drugs and pyrimethamine
has
also been reported (2).
Prophylactic use of Maloprim and other pyrimethamine/sulfa
compounds
against malaria is not recommended for U.S. travelers. Rather,
adults
traveling to sub-Saharan locations where malaria is endemic should
take
chloroquine salt, 500 mg orally once each week (3). Travelers to
these
areas who have no history of sulfonamide intolerance should also
take
with them three FansidarR tablets. If symptoms of malaria occur
while
the traveler is far from medical assistance, these three tablets of
FansidarR should be taken in a single oral dose as therapy for
presumed
malaria.
P. falciparum malaria can sometimes persist despite the use of
appropriate therapy. Because of increased travel by U.S. citizens,
primary-care physicians will continue to have a role not only in
prevention but also in diagnosis and treatment of malaria in
returning
travelers.
References
Lobel HO, Campbell CC, Schwartz IK, Roberts JM. Recent trends in
the
importation of malaria caused by Plasmodium falciparum into the
United
States from Africa. J Infect Dis 1985; 152:613-7.
Lobel HO, Campbell CC. Malaria prophylaxis and distribution of
drug
resistance. In: Strickland GT, ed. Clinics in tropical medicine and
communicable diseases. Vol 1. London: Saun ders, 1986:225-42.
CDC. Health information for international travel, 1988. Atlanta:
US
Department of Health and Human Services, Public Health Service,
1988:15-61,94-103; HHS publication no. (CDC)88-8280.
*Use of trade names is for identification only and does not imply
endorsement by the Public Health Service or the U.S. Department of
Health and Human Services.
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