Clinical Updates
14 May 2008
Change in malaria chemoprophylaxis recommendations: Costa Rica, South Africa and Viet Nam and updated recommendations for Goa
The Health Protection Agency Advisory Committee on Malaria Prevention (ACMP) recently reviewed recommendations for travellers to Costa Rica, South Africa, Viet Nam and Goa, India. After considering the current epidemiology, risk of malaria transmission and patterns of drug resistance in these countries, the ACMP has revised its recommendations for UK travellers.
Costa Rica
The revised recommendations for Costa Rica are [1]:
- There is a risk of malaria in Limon Province except for the city of Limon (Puerto Limon).
- There is a low risk in the rest of the country in rural areas below 500m.
The recommended chemoprophylaxis for risk areas is chloroquine. Chemoprophylaxis is not recommended for the areas of Costa Rica that are low risk, however travellers should be aware of the small risk of malaria.
South Africa
The revised recommendations for South Africa are [2]:
- There is a high risk of malaria in South Africa in the low altitude areas of Mpumalanga and Limpopo which border Mozambique and Zimbabwe. This includes Kruger National Park. The areas bordering these are low risk.
- There is also a high risk of malaria in northeast KwaZulu-Natal as far south as Jozini and a low risk between Jozini and Richards Bay.
Chloroquine resistance is widespread. The recommended chemoprophylaxis for low altitude areas of Mpumalanga and Limpopo which border Mozambique and Zimbabwe and in KwaZulu-Natal as far south as Jozini is mefloquine, doxycycline or atovaquone/proguanil (Malarone™).
Chemoprophylaxis is not recommended for the areas of South Africa that are low risk, as listed above, however travellers should be aware of the small risk of malaria.
Viet Nam
The revised recommendations for Viet Nam are as follows:
- There is a high risk of malaria in rural areas of Viet Nam.
- There is a very low risk in cities, the coast between Ho Chi Minh and Hanoi, and the Mekong River delta until the border area with Cambodia.
Chloroquine resistance is widespread in Viet Nam. There also is evidence of mefloquine resistance in malaria areas of the southern part of the country in the provinces of Tay Ninh, Lam Dong, Dac Lac, Gia Lai, and Kon Tum. The recommended chemoprophylaxis in the areas with mefloquine resistance is atovaquone/proguanil (Malarone™) or doxycycline.
The recommended chemoprophylaxis for all other risk areas is atovaquone/proguanil (Malarone™), doxycycline or mefloquine.
Chemoprophylaxis is not recommended for cities, the coast between Ho Chi Minh and Hanoi, nor for the Mekong River delta until the border area with Cambodia. However, travellers should be aware of the small risk of malaria.
Goa
In March 2007 the Health Protection Agency (HPA) reported on a cluster of Plasmodium falciparum malaria cases in travellers from the UK who had visited Goa between December 2006 and March 2007 [3,4]. Cases were also seen in other European travellers to Goa [5]. Since 2007, enhanced surveillance of malaria imported into the UK has identified 117 cases in travellers returning from India and several of these cases occurred in travellers from the UK who had returned from Goa [6]. In view of these findings the recommendations for chemoprophylaxis for travellers visiting Goa remain unchanged and are:
- There is a risk of malaria in the Indian state of Goa. Chloroquine resistance is present. The recommended chemoprophylaxis for Goa is chloroquine plus proguanil. Alternatives are mefloquine, doxycycline or atovaquone/proguanil (Malarone™).
The NaTHNaC Country Information Pages for these countries have been updated.
Advice for travellers
Travellers to areas where malaria is a risk are advised to take appropriate malaria chemoprophylaxis and insect bite avoidance measures.
All travellers should be aware of the signs and symptoms of malaria and should seek immediate medical attention if they develop a fever of 38°C [100°F] or higher more than one week after being in a malaria risk area, or who develop any symptoms suggestive of malaria within a year of return.
References
1. Redman C, Genasi F, Boyne L, Smith K. Helping define the areas of malaria risk in Costa Rica. Health Protection Scotland Weekly Report. 42 No.2008/3. Available at: http://www.documents.hps.scot.nhs.uk/ewr/pdf2008/0803.pdf
2. Department of Health, South Africa: Malaria Treatment Guidelines [draft] 5 December 2007
3. Health Protection Agency. Cluster of malaria cases from northern Goa – update. Health Protection Report [serial online] 2007; 1(10). Available at http://www.hpa.org.uk/hpr/archives/2007/hpr1007.pdf
4. NaTHNaC Clinical Updates. Cluster of malaria cases from northern Goa - update. 9 March 2007. [Accessed 14 May 2008]. Available at http://www.nathnac.org/pro/clinical_updates/malaria_Goa
5. Jelinek T, Behrens R, Bisoff Z, et al. Recent cases of falciparum malaria imported to Europe from Goa, India, December 2006-January 2007. Eurosurveill (serial online] 2007 [accessed 14 May 2008]; 12(10):E070111.1. Available at http://www.eurosurveillance.org/ew/2007/070111.asp#1
6. Health Protection Agency. Revised malaria prevention guidelines for travellers to Goa, India. Health Protection Report. 2 (15); 11 April 2008 . Available at http://www.hpa.org.uk/hpr/archives/2008/news1508.htm#goa [accessed 14 May 2008]
Links
NaTHNaC Clinical Update: Cluster of Plasmodium falciparum malaria cases from northern Goa – update
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