Imported Malaria in Guatemalan Soldiers Returning from the Democratic Republic of the Congo –Guatemala, 2011

Author (s): 

María L. Müller, L. Ortíz-Batsche, M. Castellanos, A. Díaz-Artiga, N. Padilla

Background: Outbreaks of imported malaria are of public health concern due to the threat of introduction of drug-resistant strains where no antimalarial resistance is reported. We investigated a suspected case of malaria in a Guatemalan soldier returning from an eight-month deployment in the Democratic Republic of the Congo (DRC), where chloroquine-resistant (CQR) Plasmodium falciparum is documented. Upon returning in June 2011, he remained in non-malaria-endemic areas and presented thirty days later with fever. The soldier’s battalion had received mefloquine prophylaxis. Methods: Febrile illness work-up included thick-blood smear and Polymerase Chain Reaction (PCR) assay for P. falciparum detection. To identify additional infections and risk factors, we interviewed all battalion members regarding malaria symptoms, adherence to chemoprophylaxis and personal protection measures. We obtained blood samples for thick blood smears and PCR. On PCR-positives, we detected chloroquine-resistant (CQR) strains through P. falciparum chloroquine-resistance transporter (Pfcrt) gene sequencing. We calculated risk ratios (RR) and 95% confidence intervals. Results: We interviewed and obtained blood samples from 144 soldiers (96%). Besides the index patient, no additional soldiers reported fever. P. falciparum monoinfection was confirmed in the suspected case. PCR assays identified one additional sub-clinical infection with parasite density below microscopic detection level. Pfcrt sequencing demonstrated chloroquine-sensitivity in the two. Illness was associated with taking mefloquine for less than 8 days upon return (RR 22.3 [1.1,451.0]). Conclusions: Chemoprophylaxis compliance in soldiers serving in DRC should be encouraged. As result of this investigation, routine PCR and thick blood smear screening for P. falciparum, including CQR strains, among soldiers returning from DRC was established. This will allow for prompt detection and treatment of infected soldiers, and prevent local transmission of potentially drug-resistant strains. Keywords: Malaria/etiology; Malaria/prevention & control; Risk Factors; Risk-Taking; Travel; Humans; Guatemala; Democratic Republic of the Congo

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