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Locally acquired malaria is rare in the US; however, in 2023, cases were reported in Florida, Texas, Maryland, and Arkansas. Prompt diagnosis and treatment of malaria are essential to prevent severe malaria disease. This article details malaria and offers treatment guidelines. [ABSTRACT FROM AUTHOR]

After the lifting of COVID-19 restrictions, international travel has demonstrated recovery to prepandemic levels. Travel, particularly to tropical regions, can be associated with contracting various infectious diseases. For this reason, collecting a travel history is a necessity when assessing any patient with vague infectious symptoms, most notably fever. Early suspicion, identification, and treatment of tropical illnesses can be lifesaving. This case study concerns a patient who recently traveled to Africa and is under evaluation for fever in the emergency department. The proper approach to the febrile traveler and the pathophysiology, diagnosis, and treatment of malaria are reviewed. [ABSTRACT FROM AUTHOR]

Malaria in child travelers caused by Plasmodium ovale spp. is less well characterized than malaria due to other Plasmodium species. Commonly used diagnostic tests often lack adequate sensitivity to identify P. ovale spp., and a missed diagnosis may have serious consequences. We present a case series of eight children in the United States with P. ovale malaria, all of whom had traveled to or immigrated from malaria-endemic areas. Two children developed clinical malaria, including one with severe malaria; two had isolated splenomegaly; and four were asymptomatic siblings of the children with splenomegaly. Seven of the eight children had negative blood smear readings, and the diagnosis was made by polymerase chain reaction testing. Two children had concurrent P. malariae infection despite presumptive antimalarial treatment before immigration. These findings suggest a need for reconsideration of screening and diagnostic evaluation for P. ovale malaria in high-risk groups.

The Intergovernmental Panel on Climate Change has reported that the prevalence of vector-borne diseases has increased in recent decades and that the prevalence of malaria, Lyme disease, dengue, and, in particular, West Nile virus infection are expected to increase further if control measures are not strengthened. (1)(2) This review article summarizes the epidemiology, various clinical manifestations, and management strategies of these vector-borne diseases with increasing prevalence both in the United States and worldwide., (© American Academy of Pediatrics, 2024. All rights reserved.)

Background Children who develop malaria after returning to a setting in which the disease is not endemic are at high risk for critical delays in diagnosis and initiation of antimalarial therapy. We assessed the clinical impact of the implementation of malaria rapid diagnostic testing (RDT) on the management of children with malaria at an urban US children's hospital that serves a large immigrant population. Methods This was a retrospective cohort study of all children diagnosed with laboratory-confirmed malaria at the Children's Hospital of Philadelphia (CHOP) between 2000 and 2014. RDT using a US Food and Drug Administration–approved immunochromatographic assay was introduced at CHOP on August 1, 2007. We compared clinical management and outcomes of patients with malaria diagnosed before and after RDT introduction. Results We analyzed 82 pediatric malaria cases (32 before and 50 after RDT implementation). The majority of these patients had traveled to West Africa (91.5%) and were infected with Plasmodium falciparum (80.5%). The mean time to a positive result decreased from 10.4 to 0.9 hours (P <.001) after the introduction of RDT for patients with P falciparum. The mean time to antimalarial therapy decreased from 13.1 to 6.9 hours (P =;.023) in hospitalized patients. We found no significant reduction in the mean number of clinical signs of severe malaria between 0 and 48 hours of hospitalization and no difference in the need for exchange transfusion, time to resolution of parasitemia, or length of hospital stay. Conclusions Implementation of RDT for malaria was associated with shorter times to malaria diagnosis and initiation of antimalarial therapy. The results of this study support RDT in the optimal management of patients with malaria who present in settings in which the disease is not endemic. [ABSTRACT FROM AUTHOR]

Purpose: We describe here the case of a 40-year-old Nigerian male with severe Plasmodium falciparum malaria successfully treated with investigational intravenous (IV) artesunate. Summary: A 40-year-old Nigerian male was admitted to the medical intensive care unit for the treatment of severe malaria. The patient presented with the classic malaria paroxysm and altered mental status and was in acute renal failure. A blood parasite, thick and thin smear was performed revealing positive ring forms on smear which are characteristic of Plasmodium falciparum, with an estimated parasitemia of 2%. Per the Centers for Disease Control and Prevention (CDC) guidelines, the recommended treatment for severe malaria is with IV quinidine, the only Food and Drug Administration (FDA)-approved medication available for the treatment of severe malaria in the United States. However, quinidine was not immediately available, including from surrounding hospitals. As a result, the infectious diseases physician and pharmacist decided to contact the CDC to initiate the process for obtaining IV artesunate, an investigational drug only available via a FDA-approved Investigational New Drug (IND) protocol. Artesunate was flown into Houston later that night, and this drug was administered successfully to the patient. Patient responded to treatment and was discharged from the hospital on day 4. Conclusion: A patient with severe falciparum malaria was successfully treated with investigational artesunate procured from the CDC. [ABSTRACT FROM AUTHOR]

Background: Low-density asymptomatic Plasmodium infections are prevalent in endemic areas, but little is known about their natural history. The trajectories of these infections and their propensity to fluctuate to undetectable densities can affect detection in clinical trials and field studies. We aimed to classify the natural history of these infections in a high transmission area over 29 days., Methods: In this longitudinal cohort study, we enrolled healthy, malaria-asymptomatic, afebrile, adults (age 18-59 years) and older children (age 8-17 years) in Katakwi District, Uganda, who were negative for Plasmodium infection on rapid diagnostic tests. Participants were instructed to self-collect one dried blood spot (DBS) per day for a maximum of 29 days. We excluded people if they were pregnant or taking antimalarials. During weekly clinic visits, staff collected a DBS and a 4 mL sample of venous blood. We analysed DBSs by Plasmodium 18S rRNA quantitative RT-PCR (qRT-PCR). We classified DBS by infection type as negative, P falciparum, non-P falciparum, or mixed. We plotted infection type over time for each participant and categorised trajectories as negative, new, cleared, chronic, or indeterminate infections. To estimate the effect of single timepoint sampling, we calculated the daily prevalence for each study day and estimated the number of infections that would have been detected in our population if sampling frequency was reduced., Findings: Between April 9 and May 20, 2021, 3577 DBSs were collected by 128 (40 male adults, 60 female adults, 12 male children, and 16 female children) study participants. 2287 (64%) DBSs were categorised as negative, 751 (21%) as positive for P falciparum, 507 (14%) as positive for non-P falciparum, and 32 (1%) as mixed infections. Daily Plasmodium prevalence in the population ranged from 45·3% (95% CI 36·6-54·1) at baseline to 30·3% (21·9-38·6) on day 24. 37 (95%) of 39 P falciparum and 35 (85%) of 41 non-P falciparum infections would have been detected with every other day sampling, whereas, with weekly sampling, 35 (90%) P falciparum infections and 31 (76%) non-P falciparum infections would have been detected., Interpretation: Parasite dynamics and species are highly variable among low-density asymptomatic Plasmodium infections. Sampling every other day or every 3 days detected a similar proportion of infections as daily sampling, whereas testing once per week or even less frequently could misclassify up to a third of the infections. Even using highly sensitive diagnostics, single timepoint testing might misclassify the true infection status of an individual., Funding: US National Institutes of Health and Bill and Melinda Gates Foundation., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Nigeria is one of the countries in the world with the highest burden of malaria, accounting for a quarter of all cases in Africa. According to the Centers for Disease Control and Prevention, microscopic examination remains the gold standard for laboratory confirmation of malaria. However, the policy and practice of presumptive treatment of malaria for all febrile illnesses has been widely advocated in sub-Saharan Africa. Presumptive management of fevers and/or other symptoms of malaria results in over-diagnosis, and consequently overtreatment. This article discusses the overtreatment of malaria as practiced in Nigeria and other African regions against standard treatment guidelines, highlights a wide range of its associated effects on patients and proffers possible solutions to curb the unethical practice of malaria overtreatment., Competing Interests: The authors declare no competing interests., (Copyright: Emmanuel Temitope Anjorin et al.)

This case study examined current trends in the prevalence of vector-borne diseases and the impact of climate change on disease distribution. Our findings indicate that the dynamics of the Anopheles mosquito population in particular has changed dramatically in the past decade and now poses an increasing threat to human populations previously at low risk for malaria transmission. Given their geographic location and propensity for sustaining vector-borne disease outbreaks, southeastern states are particularly vulnerable to climate-induced changes in vector populations. We demonstrate the need to strengthen our hospital and laboratory infrastructure prior to further increases in the incidence of vector-borne diseases by discussing a case of uncomplicated malaria in a patient who arrived in one of our hospitals in Louisiana. This case exemplifies a delay in diagnosis and obtaining appropriate treatment in a timely manner, which suggests that our current health care infrastructure, especially in areas heavily affected by climate change, may not be adequately prepared to protect patients from vector-borne diseases. We conclude our discussion by examining current laboratory protocols in place with suggestions for future actions to combat this increasing threat to public health in the United States.

Return to international travel in the COVID-19 pandemic recovery period is expected to increase the number of patients with imported malaria in the United States (US). Malaria prevention in travelers and preparedness for timely diagnosis and appropriate treatment are key to minimize imported malaria morbidity and mortality. Intravenous artesunate (IVAS) is now available from commercial distributors in the US for the treatment of severe malaria. Hospitals and pharmacists should have a plan for malaria treatment, including stocking artemether-lumefantrine for uncomplicated malaria, and stocking or planning for rapid procurement of IVAS for the treatment of severe malaria., Competing Interests: Potential conflicts of interest. All other authors report no potential conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest., (Published by Oxford University Press on behalf of Infectious Diseases Society of America 2023.)

Malaria infection remains a potential health threat to U.S. service members located in or near endemic areas due to duty assignment, participation in contingency operations, or personal travel. In 2022, a total of 30 active and reserve component service members were diagnosed with or reported to have malaria, a 42.9% increase from the 21 cases identified in 2021. Over half of the malaria cases in 2022 were caused by Plasmodium falciparum (53.3%; n=16) and one-sixth (16.7%; n=5) were attributed to P vivax. The remaining 9 cases were associated with other or unspecified types of malaria. Malaria cases were diagnosed or reported from 19 different medical facilities-15 in the U.S. and 1 each from Germany, Africa, South Korea, and Japan. Of the 28 cases with a known location of diagnosis, 9 (32.1%) were reported from or diagnosed outside the U.S.

From April 24 to 26, 2013, the Armed Forces Health Surveillance Center and the U.S. Africa Command cosponsored the inaugural meeting of the West Africa Malaria Task Force in Accra, Ghana. The meeting's purpose was to identify common challenges, explore regional and transcontinental collaborations, and to share knowledge about best practices in the fight against malaria in West Africa. Military representatives from Benin, Burkina Faso, Ghana, Liberia, Niger, Nigeria, Senegal, and Togo participated in the Task Force; various U.S. Government agencies were also represented, including the Department of Defense, the Centers for Disease Control and Prevention, and the Agency for International Development. African nation participants presented brief overviews of their military's malaria prevention and control measures, surveillance programs, diagnostic capabilities, and treatment regimens emphasizing gaps within existing programs. Representatives from U.S. agencies discussed activities and capabilities relevant for the region, challenges and lessons learned regarding malaria, and highlighted opportunities for enhanced partnerships to counter malaria in West Africa. This article summarizes the major conclusions of the Task Force meeting, identifies relevant focus areas for future Task Force activities, and outlines opportunities for further inclusion of West African militaries to improve regional malaria surveillance and control efforts. [ABSTRACT FROM AUTHOR]

The Malaria Evolution in South Asia (MESA) International Center for Excellence in Malaria Research (ICEMR) was established by the US National Institutes of Health (US NIH) as one of 10 malaria research centers in endemic countries. In 10 years of hospital-based and field-based work in India, the MESA-ICEMR has documented the changing epidemiology and transmission of malaria in four different parts of India. Malaria Evolution in South Asia-ICEMR activities, in collaboration with Indian partners, are carried out in the broad thematic areas of malaria case surveillance, vector biology and transmission, antimalarial resistance, pathogenesis, and host response. The program integrates insights from surveillance and field studies with novel basic science studies. This is a two-pronged approach determining the biology behind the disease patterns seen in the field, and generating new relevant biological questions about malaria to be tested in the field. Malaria Evolution in South Asia-ICEMR activities inform local and international stakeholders on the current status of malaria transmission in select parts of South Asia including updates on regional vectors of transmission of local parasites. The community surveys and new laboratory tools help monitor ongoing efforts to control and eliminate malaria in key regions of South Asia including the state of evolving antimalarial resistance in different parts of India, new host biomarkers of recent infection, and molecular markers of pathogenesis from uncomplicated and severe malaria.

Each year, malaria causes an estimated 500,000 deaths worldwide. Most of these deaths occur in Africa and disproportionally affect children younger than five years worldwide. Human malarial disease is caused by protozoan parasites of the genus Plasmodium. The primary means of infection is through the bite of a female Anopheles mosquito. The incidence of malaria in the United States has increased since 2011, in conjunction with the increase in worldwide travel. An estimated 2,000 cases of malaria occur annually in the United States. All travelers to malaria-endemic regions should be prescribed prophylaxis. Malaria has a broad range of clinical presentations. Travelers who have symptoms of malaria should seek medical attention as soon as possible. All febrile travelers who have recently returned from a malarious area should be evaluated for malaria. The accurate, timely, and species-specific diagnosis of malaria is essential for successful treatment. Direct microscopy of Giemsa-stained blood smears is the reference standard for laboratory diagnosis. Rapid testing for malaria has emerged as an important adjunctive diagnostic modality. Malaria treatment is determined by individual patient factors and geography. The World Health Organization recommends treating uncomplicated cases of malaria with artemisinin combination therapy, except in the first trimester of pregnancy. Severe malaria is mainly caused by Plasmodium falciparum. Children, pregnant patients, and people who are not from endemic regions are at highest risk of severe malaria. Intravenous artesunate is the treatment of choice for severe malaria.

Importance: Malaria is caused by protozoa parasites of the genus Plasmodium and is diagnosed in approximately 2000 people in the US each year who have returned from visiting regions with endemic malaria. The mortality rate from malaria is approximately 0.3% in the US and 0.26% worldwide., Observations: In the US, most malaria is diagnosed in people who traveled to an endemic region. More than 80% of people diagnosed with malaria in the US acquired the infection in Africa. Of the approximately 2000 people diagnosed with malaria in the US in 2017, an estimated 82.4% were adults and about 78.6% were Black or African American. Among US residents diagnosed with malaria, 71.7% had not taken malaria chemoprophylaxis during travel. In 2017 in the US, P falciparum was the species diagnosed in approximately 79% of patients, whereas P vivax was diagnosed in an estimated 11.2% of patients. In 2017 in the US, severe malaria, defined as vital organ involvement including shock, pulmonary edema, significant bleeding, seizures, impaired consciousness, and laboratory abnormalities such as kidney impairment, acidosis, anemia, or high parasitemia, occurred in approximately 14% of patients, and an estimated 0.3% of those receiving a diagnosis of malaria in the US died. P falciparum has developed resistance to chloroquine in most regions of the world, including Africa. First-line therapy for P falciparum malaria in the US is combination therapy that includes artemisinin. If P falciparum was acquired in a known chloroquine-sensitive region such as Haiti, chloroquine remains an alternative option. When artemisinin-based combination therapies are not available, atovaquone-proguanil or quinine plus clindamycin is used for chloroquine-resistant malaria. P vivax, P ovale, P malariae, and P knowlesi are typically chloroquine sensitive, and treatment with either artemisinin-based combination therapy or chloroquine for regions with chloroquine-susceptible infections for uncomplicated malaria is recommended. For severe malaria, intravenous artesunate is first-line therapy. Treatment of mild malaria due to a chloroquine-resistant parasite consists of a combination therapy that includes artemisinin or chloroquine for chloroquine-sensitive malaria. P vivax and P ovale require additional therapy with an 8-aminoquinoline to eradicate the liver stage. Several options exist for chemoprophylaxis and selection should be based on patient characteristics and preferences., Conclusions and Relevance: Approximately 2000 cases of malaria are diagnosed each year in the US, most commonly in travelers returning from visiting endemic areas. Prevention and treatment of malaria depend on the species and the drug sensitivity of parasites from the region of acquisition. Intravenous artesunate is first-line therapy for severe malaria.

Imported malaria remains a public health concern in the United States, but the health impact on children and the financial costs to society have not been well defined. Inpatient and outpatient malaria cases diagnosed at Children's National Medical Center (CNMC) in Washington, DC over an 8-year period are retrospectively reviewed. Cases are mapped against Census Bureau population data. These observations are compared with the national burden of pediatric malaria, including both disease severity and cost, by reviewing inpatient malaria cases in the Pediatric Health Information System (PHIS), January 2003 to June 2008. At CNMC, malaria most commonly affects children who traveled to West Africa to visit friends and relatives. Poor adherence to prophylaxis and self-treatment with antimalarial medications were commonly identified. Mapping demonstrates case clustering in communities with large sub-Saharan African populations. The cumulative incidence (CI) of malaria at CNMC of 9.0 per 10,000 admissions is 7.6 times the national average. The CI of malaria at PHIS hospitals is 1.2 per 10,000 admissions with an average cost of $17,519. Malaria is a preventable disease for which the risk to life and costs of treatment are significant. Patterns of risk can be used by health planners to target prevention strategies at the community level. In regions with a high density of immigrants, particularly from sub-Saharan Africa, physicians must be aware of the risk, understand recommended prophylaxis and treatment regimens, and advocate for their appropriate use in the community. [ABSTRACT FROM AUTHOR]

The article describes the case of a 31-year-old African-American female who was brought to the emergency department (ED) due to a headache. According to her roommate, she found the patient lying on the living floor in a pool of vomit. She adds that the patient continued to have persistent pain and worsening nausea with vomiting after being discharged from the urgent care center the day before.

The article offers information on the Standards for Reporting of Diagnostic Accuracy (STARD) and Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) techniques for evaluating the quality and reporting, related to the diagnostic accuracy studies in tuberculosis (TB), human immunodeficiency virus (HIV) and malaria. It mentions that TB, HIV and malaria are the causes of mobility and mortality. It offers information on the use of rapid diagnostic tests (RDT) in malaria control programmes. It states that the point-of-care (POC) test was not successful for TB. It states that the Global Fund to Fight AIDS, TB and Malaria allotted 15.6 billion dollars to fight diseases in the U.S. It mentions that STARD report includes, data collection, blinding and reference standard test.

This article looks at the treatment of malaria in the United States, offering clinicians practical recommendations for the diagnosis and treatment of the disease. The article offers biological and epidemiologic information. Symptoms of severe malaria are outlined. The importance of taking a travel history is emphasized. Treatment options are covered for the different species. Antimalarial drugs are listed with indications, dosages, potential adverse effect and comments. A malaria treatment algorithm is presented. The study concludes that malaria is a diagnostic and treatment challenge in the U.S. and that failure to diagnose and treat promptly has resulted in malaria deaths.

On May 17, 2022, the Massachusetts Department of Public Health (MDPH) Laboratory Response Network (LRN) laboratory confirmed the presence of orthopoxvirus DNA via real-time polymerase chain reaction (PCR) from lesion swabs obtained from a Massachusetts resident. Orthopoxviruses include Monkeypox virus, the causative agent of monkeypox. Subsequent real-time PCR testing at CDC on May 18 confirmed that the patient was infected with the West African clade of Monkeypox virus. Since then, confirmed cases* have been reported by nine states. In addition, 28 countries and territories, † none of which has endemic monkeypox, have reported laboratory-confirmed cases. On May 17, CDC, in coordination with state and local jurisdictions, initiated an emergency response to identify, monitor, and investigate additional monkeypox cases in the United States. This response has included releasing a Health Alert Network (HAN) Health Advisory, developing interim public health and clinical recommendations, releasing guidance for LRN testing, hosting clinician and public health partner outreach calls, disseminating health communication messages to the public, developing protocols for use and release of medical countermeasures, and facilitating delivery of vaccine postexposure prophylaxis (PEP) and antivirals that have been stockpiled by the U.S. government for preparedness and response purposes. On May 19, a call center was established to provide guidance to states for the evaluation of possible cases of monkeypox, including recommendations for clinical diagnosis and orthopoxvirus testing. The call center also gathers information about possible cases to identify interjurisdictional linkages. As of May 31, this investigation has identified 17 § cases in the United States; most cases (16) were diagnosed in persons who identify as gay, bisexual, or men who have sex with men (MSM). Ongoing investigation suggests person-to-person community transmission, and CDC urges health departments, clinicians, and the public to remain vigilant, institute appropriate infection prevention and control measures, and notify public health authorities of suspected cases to reduce disease spread. Public health authorities are identifying cases and conducting investigations to determine possible sources and prevent further spread. This activity was reviewed by CDC and conducted consistent with applicable federal law and CDC policy. ¶ ., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Objectives: Most children in the United States who visit the emergency department (ED) with fever have minor illnesses not requiring treatment or hospitalization. However, when a child has recently immigrated or traveled abroad, internationally acquired severe systemic infections (ISSIs) must be considered. We sought to describe children who have traveled internationally and present to the ED with a complaint of fever and to determine risk factors associated with ISSIs in these patients., Methods: We conducted a retrospective study of children younger than 18 years who presented to 2 pediatric EDs in Bronx, NY (June 2007 to May 2017). Patients were included if they had both fever within 24 hours and international travel within 30 days. We compared groups using bivariate analyses and created a prediction model for ISSIs using multivariable logistic regression., Results: Of the 353 children included, 44 (12%) had ISSI: 25 (57%), malaria; 6 (14%), dengue; and 13 (30%), bacteremia. Eight (18%) of those with ISSI presented with fever to another medical provider in the week prior but did not receive bloodwork. Four variables were independently associated with ISSIs: headache (odds ratio [OR], 21.7; 95% confidence interval [CI], 6.8-69.3), travel to Africa or Asia (OR, 18.8; 95% CI, 4.8-73.2), platelets of 150,000/μL or less (OR, 15.1; 95% CI, 4.7-48.6), and alanine aminotransferase level of 30 IU/L or greater (OR, 8.9; 95% CI, 3.1-25.3)., Conclusions: Children who travel internationally and present with fever upon return are at substantial risk for developing ISSIs. The diagnosis of ISSIs is often overlooked, but certain risk factors have the potential to aid clinicians., Competing Interests: Disclosure: There are no conflicts of interests to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Congenital malaria is a condition that can be acquired during pregnancy or perinatally at the time of delivery by transplacental transmission of parasitized maternal erythrocytes. Because of its rare incidence in the United States, it is most frequently missed as a differential diagnosis by physicians when evaluating a febrile infant born to an immigrant mother. Timely diagnosis for physicians is also a challenge when there is no recent history of travel. Pediatric emergency department physicians hence must obtain a thorough history and elicit any exposure to malaria in the past when evaluating a febrile infant. We report a case of an 18-day male infant with congenital malaria and no maternal history of travel and febrile illnesses during pregnancy., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: In 2016, the Centers for Disease Control and Prevention and the Government of Nigeria initiated the Malaria Frontline Project in Kano and Zamfara States. The project goal is to improve the quality and coverages of malaria interventions adapting polio program strategy. We conducted a baseline assessment of malaria interventions., Methods: Twenty-four primary health centers per State were selected using probability sampling. Health workers (HW) were purposively sampled to assess their knowledge of national malaria control guidelines. Clients were selected for exit interview to assess health workers´ adherence to the national guidelines. WHO cluster methodology was used to survey heads of household and women of reproductive age on knowledge of malaria prevention, Long Lasting Insecticidal Net (LLIN) ownership and use., Results: Of the 158 HW interviewed, 94.3% knew the correct criteria for malaria diagnosis, 86.1% reported using artemisinin-based therapy to treat uncomplicated malaria. About 45% of HW reported prescribing artemisinin-based combination therapy (ACT) for uncomplicated malaria in first trimester of pregnancy and 39% prescribed quinine. Only 73.9% of fever cases were referred to laboratory as recommended by the national guideline. Households with one LLIN per 2 persons (Kano: 27.1%; Zamfara: 30.0%), LLIN use (Kano: 70.8%; Zamfara: 81.6%) and IPTp1 (Kano: 38.6%; Zamfara: 33.3%)., Conclusion: most clinicians have knowledge of national guidelines, but fewer adhere to guidelines in practice. Population LLIN ownership, LLIN use among pregnant women and IPTp are lower than the national targets of 58%, 83% and 75% respectively for 2016. We recommend improving health workers´ technical capacity and adherence to national malaria guidelines., (©Adefisoye Oluwaseun Adewole et al.)

Malaria is one of the top 10 leading causes of death in Uganda. Short-term medical missions (STMMs) to address unmet medical needs in lower-resource settings are increasingly common. Th is study evaluates correlations between patient and clinician variables and accurate malaria diagnosis by providers on STMMs to Uganda. We surveyed 18 U.S. providers and performed a retrospective chart review of 246 patients seen by those providers on STMMs in Uganda between 2016 to 2017. All providers recorded their clinical level of suspicion for patients who met inclusion criteria, following which a rapid diagnostic test (RDT) was performed. Fift y-four percent of the patients tested positive for malaria. Level of provider accuracy ranged widely from 30.0% to 95.5% correct. Our fi ndings reaffirm that signs and symptoms of malaria are too nonspecifi c to be used alone without diagnostic testing by STMM providers. Pre-departure STMM training on malaria diagnosis is a necessity. [ABSTRACT FROM AUTHOR]

The authors discuss the major health problems facing the U.S. involving the emergence of malaria with focus on the early diagnosis and policies on treatment of the disease. They cite the need for health care providers to follow the common National Health Guidelines for treatment of malaria based on the drug policy 2013. They also outline the administration of artemisinin derivatives in pregnant women with severe malaria and the efforts made to produce an effective vaccine against malaria.

Malaria is a common infection world-wide, which carries significant risk of morbidity and mortality. Health care providers in the United States may lack experience in recognizing and treating this disease. The pathophysiology of malaria differs during pregnancy, resulting in increased risk for serious morbidity and mortality for the woman and her fetus. Screening for risk factors, especially immigration from and travel to endemic countries, is critical. Symptoms of malaria can mimic influenza-type illnesses, causing delay in diagnosis. Consultation with an infectious disease specialist and hospitalization may be required for appropriate testing and treatment. Chemoprophylaxis and counseling regarding methods to reduce risk are important components of prevention. The US Centers for Disease Control and Prevention and the World Health Organization have established protocols for treatment and are helpful resources for clinicians. A team approach to care based on the woman's stage of illness and recovery, can involve midwives, physicians, specialists and others., (© 2021 by the American College of Nurse-Midwives.)

Problem/condition: Malaria in humans is caused by intraerythrocytic protozoa of the genus Plasmodium. These parasites are transmitted by the bite of an infective female Anopheles species mosquito. The majority of malaria infections in the United States occur among persons who have traveled to regions with ongoing malaria transmission. However, malaria is occasionally acquired by persons who have not traveled out of the country through exposure to infected blood products, congenital transmission, nosocomial exposure, or local mosquitoborne transmission. Malaria surveillance in the United States is conducted to provide information on its occurrence (e.g., temporal, geographic, and demographic), guide prevention and treatment recommendations for travelers and patients, and facilitate rapid transmission control measures if locally acquired cases are identified., Period Covered: This report summarizes confirmed malaria cases in persons with onset of illness in 2017 and trends in previous years., Description of System: Malaria cases diagnosed by blood film microscopy, polymerase chain reaction, or rapid diagnostic tests are reported to local and state health departments through electronic laboratory reports or by health care providers or laboratory staff members. Case investigations are conducted by local and state health departments, and reports are transmitted to CDC through the National Malaria Surveillance System (NMSS), the National Notifiable Diseases Surveillance System (NNDSS), or direct CDC consultations. CDC reference laboratories provide diagnostic assistance and conduct antimalarial drug resistance marker testing on blood samples submitted by health care providers or local or state health departments. This report summarizes data from the integration of all cases from NMSS and NNDSS, CDC reference laboratory reports, and CDC clinical consultations., Results: CDC received reports of 2,161 confirmed malaria cases with onset of symptoms in 2017, including two congenital cases, three cryptic cases, and two cases acquired through blood transfusion. The number of malaria cases diagnosed in the United States has been increasing since the mid-1970s; in 2017, the number of cases reported was the highest in 45 years, surpassing the previous peak of 2,078 confirmed cases reported in 2016. Of the cases in 2017, a total of 1,819 (86.1%) were imported cases that originated from Africa; 1,216 (66.9%) of these came from West Africa. The overall proportion of imported cases originating from West Africa was greater in 2017 (57.6%) than in 2016 (51.6%). Among all cases, P. falciparum accounted for the majority of infections (1,523 [70.5%]), followed by P. vivax (216 [10.0%]), P. ovale (119 [5.5%]), and P. malariae (55 [2.6%]). Infections by two or more species accounted for 22 cases (1.0%). The infecting species was not reported or was undetermined in 226 cases (10.5%). CDC provided diagnostic assistance for 9.5% of confirmed cases and tested 8.0% of specimens with P. falciparum infections for antimalarial resistance markers. Most patients (94.8%) had symptom onset <90 days after returning to the United States from a country with malaria transmission. Of the U.S. civilian patients who reported reason for travel, 73.1% were visiting friends and relatives. The proportion of U.S. residents with malaria who reported taking any chemoprophylaxis in 2017 (28.4%) was similar to that in 2016 (26.4%), and adherence was poor among those who took chemoprophylaxis. Among the 996 U.S. residents with malaria for whom information on chemoprophylaxis use and travel region were known, 93.3% did not adhere to or did not take a CDC-recommended chemoprophylaxis regimen. Among 805 women with malaria, 27 reported being pregnant. Of these, 10 pregnant women were U.S. residents, and none reported taking chemoprophylaxis to prevent malaria. A total of 26 (1.2%) malaria cases occurred among U.S. military personnel in 2017, fewer than in 2016 (41 [2.0%]). Among all reported cases in 2017, a total of 312 (14.4%) were classified as severe malaria illnesses, and seven persons died. In 2017, CDC analyzed 117 P. falciparum-positive and six P. falciparum mixed-species samples for antimalarial resistance markers (although certain loci were untestable in some samples); identification of genetic polymorphisms associated with resistance to pyrimethamine were found in 108 (97.3%), to sulfadoxine in 77 (69.4%), to chloroquine in 38 (33.3%), to mefloquine in three (2.7%), and to atovaquone in three (2.7%); no specimens tested contained a marker for artemisinin resistance. The data completeness of key variables (species, country of acquisition, and resident status) was lower in 2017 (74.4%) than in 2016 (79.4%)., Interpretation: The number of reported malaria cases in 2017 continued a decades-long increasing trend, and for the second year in a row the highest number of cases since 1971 have been reported. Despite progress in malaria control in recent years, the disease remains endemic in many areas globally. The importation of malaria reflects the overall increase in global travel to and from these areas. Fifty-six percent of all cases were among persons who had traveled from West Africa, and among U.S. civilians, visiting friends and relatives was the most common reason for travel (73.1%). Frequent international travel combined with the inadequate use of prevention measures by travelers resulted in the highest number of imported malaria cases detected in the United States in 4 decades., Public Health Actions: The best way to prevent malaria is to take chemoprophylaxis medication during travel to a country where malaria is endemic. Adherence to recommended malaria prevention strategies among U.S. travelers would reduce the numbers of imported cases; reasons for nonadherence include prematurely stopping after leaving the area where malaria was endemic, forgetting to take the medication, and experiencing a side effect. Travelers might not understand the risk that malaria poses to them; thus, health care providers should incorporate risk education to motivate travelers to be adherent to chemoprophylaxis. Malaria infections can be fatal if not diagnosed and treated promptly with antimalarial medications appropriate for the patient's age, medical history, the likely country of malaria acquisition, and previous use of antimalarial chemoprophylaxis. Antimalarial use for chemoprophylaxis and treatment should be informed by the most recent guidelines, which are frequently updated. In 2018, two formulations of tafenoquine (i.e., Arakoda and Krintafel) were approved by the Food and Drug Administration (FDA) for use in the United States. Arakoda was approved for use by adults for chemoprophylaxis; the regimen requires a predeparture loading dose, taking the medication weekly during travel, and a short course posttravel. The Arakoda chemoprophylaxis regimen is shorter than alternative regimens, which could possibly improve adherence. This medication also might prevent relapses. Krintafel was approved for radical cure of P. vivax infections in those aged >16 years and should be co-administered with chloroquine (https://www.cdc.gov/malaria/new&#95;info/2020/tafenoquine&#95;2020.html). In April 2019, intravenous artesunate became the first-line medication for treatment of severe malaria in the United States. Artesunate was recently FDA approved but is not yet commercially available. The drug can be obtained from CDC under an investigational new drug protocol. Detailed recommendations for preventing malaria are available to the general public at the CDC website (https://www.cdc.gov/malaria/travelers/drugs.html). Health care providers should consult the CDC Guidelines for Treatment of Malaria in the United States and contact the CDC's Malaria Hotline for case management advice when needed. Malaria treatment recommendations are available online (https://www.cdc.gov/malaria/diagnosis&#95;treatment) and from the Malaria Hotline (770-488-7788 or toll-free 855-856-4713). Persons submitting malaria case reports (care providers, laboratories, and state and local public health officials) should provide complete information because incomplete reporting compromises case investigations and efforts to prevent infections and examine trends in malaria cases. Molecular surveillance of antimalarial drug resistance markers (https://www.cdc.gov/malaria/features/ars.html) enables CDC to track, guide treatment, and manage drug resistance in malaria parasites both domestically and internationally. More samples are needed to improve the completeness of antimalarial drug resistance analysis; therefore, CDC requests that blood specimens be submitted for any case of malaria diagnosed in the United States., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

All U.S.-bound refugees from sub-Saharan Africa receive presumptive antimalarial treatment before departing for the United States. Among U.S.-bound Congolese refugees, breakthrough malaria cases and persistent splenomegaly have been reported. In response, an enhanced malaria diagnostic program was instituted. Here, we report the prevalence of plasmodial infection among 803 U.S.-bound Congolese refugees who received enhanced diagnostics. Infections by either rapid diagnostic test (RDT) or PCR were detected in 187 (23%) refugees, with 78 (10%) by RDT only, 35 (4%) by PCR only, and 74 (9%) by both. Infections identified by PCR included 103 monoinfections (87 Plasmodium falciparum, eight Plasmodium ovale, seven Plasmodium vivax, and one Plasmodium malariae) and six mixed infections. Splenomegaly was associated with malaria detectable by RDT (odds ratio: 1.8, 95% CI: 1.0-3.0), but not by PCR. Splenomegaly was not strongly associated with parasitemia, indicating that active malaria parasitemia is not necessary for splenomegaly.

Tropical splenomegaly is often associated with malaria and schistosomiasis. In 2014 and 2015, 145 Congolese refugees in western Uganda diagnosed with splenomegaly during predeparture medical examinations underwent enhanced screening for various etiologies. After anecdotal reports of unresolved splenomegaly and complications after U.S. arrival, patients were reassessed to describe long-term clinical progression after arrival in the United States. Post-arrival medical information was obtained through medical chart abstraction in collaboration with state health partners in nine participating states. We evaluated observed splenomegaly duration and associated clinical sequelae between 130 case patients from eastern Congo and 102 controls through adjusted hierarchical Poisson models, accounting for familial clustering. Of the 130 case patients, 95 (73.1%) had detectable splenomegaly after arrival. Of the 85 patients with records beyond 6 months, 45 (52.9%) had persistent splenomegaly, with a median persistence of 14.7 months (range 6.0-27.9 months). Of the 112 patients with available results, 65 (58.0%) patients had evidence of malaria infection, and the mean splenomegaly duration did not differ by Plasmodium species. Refugees with splenomegaly on arrival were 43% more likely to have anemia (adjusted relative risk [aRR]: 1.43, 95% CI: 1.04-1.97). Those with persistent splenomegaly were 60% more likely (adjusted relative risk [aRR]: 1.60, 95% CI: 1.15-2.23) to have a hematologic abnormality, particularly thrombocytopenia (aRR: 5.53, 95% CI: 1.73-17.62), and elevated alkaline phosphatase (aRR: 1.57, 95% CI: 1.03-2.40). Many patients experienced persistent splenomegaly, contradicting literature describing resolution after treatment and removal from an endemic setting. Other possible etiologies should be investigated and effective treatment, beyond treatment for malaria and schistosomiasis, explored.

Evaluates malaria in US Marines returning from Somalia and their compliance with chemoprophylaxis. Study of consecutive sample of 106 US Marines diagnosed with malaria; Identification of incidence and clinical features of imported malaria.

Pretravel consultation is important and effective in preventing the spread of malaria. Travelers to high-risk malaria-endemic areas should receive antimalarial advice: a combination of mosquito avoidance measures and chemoprophylaxis. Malaria prevention can be complex owing to the individual characteristics of the traveler, travel destination, duration of stay, and type of travel. Health care providers need to obtain a complete travel history on all returned travelers with clinical infectious features and with a history of travel or migration from malaria-endemic areas. Considering the diagnosis of malaria in febrile travelers with risk factors increases the likelihood of a timely diagnosis and treatment., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The MSMR has been publishing the results of surveillance studies of malaria since 1995. The standard MSMR case definition uses Medical Event Reports and records of hospitalizations in counting cases of malaria. This report summarizes the performance of the standard MSMR case definition in estimating incident cases of malaria from 2015 through 2017. Also explored was the potential surveillance value of including outpatient encounters with diagnoses of malaria or positive laboratory tests for malaria in the case definition. The study corroborated the relative accuracy of the MSMR case definition in estimating malaria incidence and provided the basis for updating the case definition in 2019 to include positive laboratory tests for malaria antigen within 30 days of an outpatient diagnosis.

In 2014, panel physicians from the International Organization for Migration (IOM), who conduct Department of State-required predeparture examinations for U.S.-bound refugees at resettlement sites in Uganda, noticed an unusually high number of Congolese refugees with enlarged spleens, or splenomegaly. Many conditions can cause splenomegaly, such as various infections, liver disease, and cancer. Splenomegaly can result in hematologic disturbances and abdominal pain and can increase the risk for splenic rupture from blunt trauma, resulting in life-threatening internal bleeding. On CDC's advice, panel physicians implemented an enhanced surveillance and treatment protocol that included screening for malaria (through thick and thin smears and rapid diagnostic testing), schistosomiasis, and several other conditions; treatment of any condition identified as potentially associated with splenomegaly; and empiric treatment for the most likely etiologies, including malaria and schistosomiasis. CDC recommended further treatment for malaria with primaquine after arrival, after glucose-6-phosphate dehydrogenase testing, to target liver-stage parasites. Despite this recommended treatment protocol, 35 of 64 patients with available follow-up records had splenomegaly that persisted beyond 6 months after resettlement. Among 85 patients who were diagnosed with splenomegaly through abdominal palpation or ultrasound at any point after resettlement, 53 had some hematologic abnormality (leukopenia, anemia, or thrombocytopenia), 16 had evidence of current or recent malaria infection, and eight had evidence of schistosomiasis. Even though primaquine was provided to a minority of patients in this cohort, it should be provided to all eligible patients with persistent splenomegaly, and repeated antischistosomal therapy should be provided to patients with evidence of current or recent schistosomiasis. Given substantial evidence of familial clustering of cases, family members of patients with known splenomegaly should be proactively screened for this condition., Competing Interests: All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Compared with other plasmodium species which cause human malaria, Plasmodium malariae is considered to be relatively infrequent and milder, although recent reports indicate that its prevalence and impact have been under-estimated. A 23-month-old boy, born and previously living in a refugee camp in Liberia who presented with P. malariae 6 weeks after arrival in the USA, is reported. Despite ostensibly effective anti-malarial treatment with artemether/lumefantrine and two courses of hydrochloroquine, he experienced recurrent parasitaemia, refractory anaemia and splenomegaly over a 6-month period; the symptoms resolved after he received atovaquone/proguanil. It is hypothesised that the recrudescing clinical malaria in this case was related to the long pre-erythrocytic phase unique to P. malariae, and potentially also to a proportion of the parasites being drug-resistant.

In the United States, the gold standard for malaria diagnosis is microscopic blood smear examination. Because malaria is not endemic in the United States, diagnostic capabilities may be limited, causing delays in diagnosis and increased morbidity and mortality. A survey of the malaria diagnostic practices of U.S. laboratories was conducted from June to July 2017; members of the American Society for Microbiology's listserv received a questionnaire inquiring about malaria diagnostic test availability, techniques, and reporting. Results were assessed using the Clinical and Laboratory Standards Institute (CLSI) guidelines for malaria diagnostics. After excluding incomplete and duplicate responses, responses representing 175 laboratories were included. Most labs (99%) received at least one specimen annually for malaria diagnosis, and 31% reported receiving only 1 to 10 specimens. The majority (74%) diagnosed five or fewer cases of malaria per year. Most (90%) performed blood smears on-site. Two-thirds (70%) provided initial blood smear results within 4 h. Although diagnostic testing for malaria was available 24/7 at 74% (141) of responding laboratories, only 12% (17) met criteria for analysis and reporting of malaria testing, significantly more than reported in a similar survey in 2010 (3%; P < 0.05). The majority of laboratories surveyed had the capability for timely diagnosis of malaria; few comply with CLSI guidelines. Inexperience may factor into this noncompliance; many laboratories see few to no cases of malaria per year. Although reported adherence to CLSI guidelines was higher than in 2010, there is a need to further improve laboratory compliance with recommendations., (Copyright © 2018 American Society for Microbiology.)

The article presents a report from the U.S. Centers of Disease Control and Prevention (CDC) involving the diagnosis of plasmodium knowlesi (P. knowlesi), a rare form of simian malaria, in a U.S. traveler in 2008. Details of a 50-year-old woman and long-time U.S. resident who returned to the Philippines to visit relatives are presented. Her malaria symptoms upon return included headache, fever, and chills. She was treated with atovaquone-proguanil and primaquine.

Reviews a case of congential malaria. Analysis of the case, involving an infant in Nassau County, New York; Review of the patients symptoms and treatment; Investigation by the Nassau County Department of Health revealing that the patient's mother had emigrated to the United States from Guatemala; Negative blood sample taken from the mother; Importance of having medical health history available in a patients native language.

Summarizes the investigation of a case of Plasmodium vivax malaria diagnosed during September 1995 in Michigan. Indications of the findings; Possible sources of infection; Imported malaria; Treatment.

Among 1,683 persons in the United States who developed malaria following international travel during 2012, more than half acquired disease in one of 16 countries in West Africa. Since March 2014, West Africa has experienced the world's largest epidemic of Ebola virus disease (Ebola), primarily affecting Guinea, Sierra Leone, and Liberia; in 2014, approximately 20,000 Ebola cases were reported. Both Ebola and malaria are often characterized by fever and malaise and can be clinically indistinguishable, especially early in the course of disease. Immediate laboratory testing is critical for diagnosis of both Ebola and malaria, so that appropriate lifesaving treatment can be initiated. CDC recommends prompt malaria testing of patients with fever and history of travel to an area that is endemic for malaria, using blood smear microscopy, with results available within a few hours. Empiric treatment of malaria is not recommended by CDC. Reverse transcription-polymerase chain reaction (RT-PCR) testing is recommended to diagnose Ebola. During the Ebola outbreak in West Africa, CDC received reports of delayed laboratory testing for malaria in travelers returning to the United States because of infection control concerns related to Ebola. CDC reviewed documented calls to its malaria consultation service and selected three patient cases to present as examples of deficiencies in the evaluation and treatment of malaria among travelers returning from Africa during the Ebola epidemic.

The article reports on the approval of BinaxNOW Malaria Test, the first malaria rapid diagnostic tests (RDT), by the U.S. Food and Drug Administration in the U.S. The use of RDT can decrease the amount of time required to determine whether a patient is infected with malaria. Meanwhile, the BinaxNOW Malaria Test is not approved for use by patients, but for use by hospital and commercial laboratories. Moreover, the manufacturer is seeking a Clinical Laboratory Improvement Amendments waiver.

This article presents news from the U.S. Centers for Disease Control and Prevention (CDC). The CDC reports that the U.S. Food and Drug Administration (FDA) has approved the BinazNOW Malaria test which is the first malaria rapid diagnostic test (RDT) available in the U.S. Made by Inverness Medical Professional Diagnostics, the test is approved for use by hospitals and commercial laboratories but not for individual physicians or patients. The test detects two different malaria antigens but it does not eliminate the need to examine blood smears.