Severe imported malaria in adults

Severe malaria is characterized by the presence of asexual forms of Plasmodium falciparum in the blood and the presence of one or more OMS 2000 criterion. Imported malaria is defined as malarial infection acquired in an endemic country (often in sub-Saharan Africa) and treated in France. The largest patient group includes African patients, long-term residents in France, coming back from a vacation in their native country. In non-immunized adults, severe malaria causes multiple organe failure such as severe Gram-negative sepsis, with variable degrees of altered mental status. Severe sepsis is treated in an intensive care unit (mechanically assisted ventilation, kidney dialysis, vasoconstrictors...). Intravenous quinine is the reference treatment, but artemisinin derivatives (arthemeter and artesunate) are the most rapidly acting antimalarial drugs.     

Severe imported Plasmodium falciparum malaria, France, 1996-2003

Little is known about severe imported Plasmodium falciparum malaria in industrialized countries where the disease is not endemic because most studies have been case reports or have included <200 patients. To identify factors independently associated with the severity of P. falciparum, we conducted a retrospective study using surveillance data obtained from 21,888 P. falciparum patients in France during 1996-2003; 832 were classified as having severe malaria. The global case-fatality rate was 0.4% and the rate of severe malaria was ≈3.8%. Factors independently associated with severe imported P. falciparum malaria were older age, European origin, travel to eastern Africa, absence of chemoprophylaxis, initial visit to a general practitioner, time to diagnosis of 4 to 12 days, and diagnosis during the fall-winter season. Pretravel advice should take into account these factors and promote the use of antimalarial chemoprophylaxis for every traveler, with a particular focus on nonimmune travelers and elderly persons.     

Severe malaria attack is associated with high prevalence of Ascaris lumbricoides infection among children in rural Senegal

In human populations, the concomitance of various parasitic infections can induce modifications of the specific immune response to each pathogen and thus induce changes in their clinical expression. Several studies, however, have produced conflicting results. To study the hypothesis that there is an association between helminthiasis and the occurrence of severe malaria a prospective case-control study was carried out in a rural zone of Senegal where 105 presumptive severe malaria attacks were studied in 2001 and 2002. Following parasitological control the cases were divided into two groups: A (severe malaria) with severe symptoms and parasite density >5000 parasites/microl (n = 64) and B (other causes) with severe symptoms and negative or weak parasite density (n = 41). In group A the prevalence of Ascaris lumbricoides infection was higher in cases of severe malaria than in controls, odds ratio (OR) = 9.95 (95% CI 3.03-32.69). Similar but not significantly different results were observed between patients in group B and their controls, OR = 2.47 (95% CI 0.95-6.38).     

Control of malaria in Africa: from the eradication of malaria to the control of malaria

The control strategies usually recommended in Africa south of the Sahara have not been followed by a lasting decline in the endemic level of the disease in the rural environment. The set-backs of the eradication period have revealed the need to redefine control objectives and strategies adapted to each type of malaria. Systematic chemotherapy for attacks of fever is a strategy that can be proposed in all circumstances; it avoids mortality from malaria; it can be carried out in the field on a country scale. The other means of control, directed against the parasites and the vectors, may be used depending of the specific situation in each country and on each type of malaria. Malaria control has to be integrated into the basic health system of each country, and we need to improve health education and develop primary health care. We must continue with our efforts to develop new antimalarial drugs, insecticides and vaccines; urgent steps must be taken to train malariologists capable of adapting the new techniques to the actual situation in the field. It is by associating socioeconomic development with the control means as a whole that we shall be able to control the various types of malaria and to reach out towards the objective of health for all by the year 2000.