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Decreasing incidence of imported malaria in the Netherlands and Europe
- Perry J van Genderen, Dennis A. Hesselink, and Jacob M. Bezemer (18 July 2008)
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Imported malaria in High Risk Groups
- Edward Green, Rohit Bazaz and Steve T. Green (23 July 2008)
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Perry J van Genderen, Consultant Internal Medicine and Tropical diseases Harbour Hospital, Haringvliet 2, 3011TD Rotterdam, The Netherlands, Dennis A. Hesselink, and Jacob M. Bezemer
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Editor, With great interest we read the observational study of Smith and colleagues. (1) They examined trends in incidence of imported malaria in the United Kingdom between 1987 and 2006. In the 20-year study period a significant increase of the incidence of falciparum malaria was reported, whereas the number of vivax malaria cases decreased steadily over the years. The reported increase in falciparum malaria in the UK does not correspond with our own observations on imported malaria in the Netherlands during recent years. We examined all consecutive malaria cases in the Harbour Hospital and Institute for Tropical diseases in Rotterdam, the Netherlands between January 1, 1999 and January 1, 2008. The number of falciparum cases clearly decreased after the year 2000 from 40 patients in 2001 to 20 in 2007. Imported malaria with non-falciparum species also declined in this observational period. Interestingly, the same evolution of imported malaria has been noted in the Netherlands as a whole, where official malaria notifications have decreased from 569 cases in 2000 to 210 cases in 2007.(2,3) Moreover, this trend is not restricted to the Netherlands alone. The WHO data on imported malaria in most European countries show that reported falciparum malaria cases are declining over the past years. (4) Compatible with the UK experience, also in the Netherlands travelers to Ghana and Nigeria account for about half of all imported falciparum cases, suggesting considerable overlap in countries of acquisition of malaria. (3) From table 1 in the paper by Smith and colleagues, it appears that during the last five years of the study period numbers of falciparum malaria cases have decreased compared with the 1996-2001 time period. This is supported by the number of imported falciparum malaria cases in 2007, as reported by the WHO for the UK, (4) that has not been so low since 1994. Since the authors used a linear regression for analysis of linear trend over a much longer period of 20 years, this newly evolving trend of decreasing incidence rates since 2001 may have been lost. International travel is still on the rise and the incidence of malaria does not decline dramatically over the world in general. (5) Decreased incidence rates of imported malaria in the Netherlands and most European countries may suggest that travelers to malaria endemic regions are nowadays better prepared against the transmission of Plasmodium species by mosquito bites, either by adhering more strictly to personal protective measures like insect repellants and/or a more compliant intake of newer and more convenient chemoprophylactic drugs like atovaquone/proguanil. Jacob M. Bezemer, M.Sc. Dennis A. Hesselink, M.D., Ph.D. Perry J.J. van Genderen, M.D., Ph.D. Reference: (1) Adrian D Smith, David J Bradley, Valerie Smith, Marie Blaze, Ron H Behrens, Peter L Chiodini and Christopher J M Whitty Imported malaria and high risk groups: observational study using UK surveillance data 1987- 2006 BMJ 2008;337; a120 (2) van der Eerden LJM , Bosman A , Visser LG . Afname van importmalaria, een overzicht van 2002. Infectieziekten Bulletin 2003 Dec 12 ; 14 : 419 – 423 . (Dutch) (3) Government report on infectious diseases in the Netherlands. (Dutch) [http://www.rivm.nl/cib/binaries/StaatvanInfectieziekten2007_tcm92- 53097.pdf] (Accessed 2008 July 17) (4) WHO data on malaria: [http://data.euro.who.int/cisid] (Accessed 2008 July 10) (5) World Health Organization and UNICEF: World Malaria Report 2005 Roll Back Malaria 2005 [http://www.rbm.who.int/wmr2005/html/exsummary_en.htm] (Accessed 2008 July 10) Competing interests: None declared |
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Edward Green, SpR Infectious Diseases Royal Hallamshire Hospital, Glossop Road, Sheffield, S102JF, Rohit Bazaz and Steve T. Green
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Sir, Smith et al. revealed the disproportionate burden of imported malaria in ethnic minority groups who have visited friends and relatives in their country of origin. Their study also showed that where the reason for travelling was known, those who had been on holiday to a malarious area accounted for only 15% of imported falciparum malaria cases, but nearly half (46%) of the deaths occurred in this group.(1) Previous studies have shown that during face-to-face consultations, travel agents provide health advice inconsistently and only mention health risks when prompted.(2) We recently reviewed travel brochures from 27 British tour operators which featured holidays to malarious African countries. Of the 27, in only 12 did we find any mention of malaria or the advisability of malaria prophylaxis. Only four brochures mentioned malaria on the same page as a holiday to a recognised malarious region. Such literature would be an ideal place to target advice to travellers, and these results show that this opportunity is being missed. More generally, these findings suggest that the travel industry is failing to take the risk of malaria to travellers of whatever variety sufficiently seriously. We note that there is no specific guidance given by the Association of British Travel Agents (ABTA) to tour operators regarding malaria.(3) Also, the airline industry trade association, the International Air Transport Association (IATA), advises member airlines on disinfection of aircraft to remove insects, but no recommendations regarding the offering of health advice to passengers.(4) Accordingly, people travelling independently to visit relatives in malarious countries are unlikely to be exposed to any relevant health advice at all prior to travelling. We believe that the travel industry has an obligation to improve the quantity and quality of malaria advice it provides in its brochures and other promotional publications, with particular emphasis on malaria prevention where appropriate. For independent travellers, malaria advice should be provided by the airline, for example on the ticket itself. This would help target those travelling on business or visiting friends and family in their country of origin. 1. Imported malaria and high risk groups: observational study using UK surveillance data 1987-2006. Smith et al. BMJ 2008 Jul 3;337:a135. doi: 10.1136/bmj.a135. 2. Provision of health information by British travel agents. Grabowski P, Behrens RH. Trop Med Int Health. 1996 Oct;1(5):730-2. 3. ABTA Code of Conduct 2008, section 2F 4. IATA “Health Tips for Travellers”. http://www.iata.org/Whip/_Files/WgId_0073/HEALTH%20TIPS.pdf Competing interests: None declared |
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