Treatment of imported malaria in an ambulatory setting: prospective studyCommentary: Should patients with imported malaria routinely be admitted?

We respond to the paper by D’Acremont et al, ‘Treatment of imported
malaria in an ambulatory setting: prospective study,” and the commentary
by Whitty et al. We wish to add to the debate, principally supporting
D’Acremont and hopefully addressing some of Whitty et al’s concerns.

We are the sole providers of care to a large group of non-immune
expatriates and ‘semi-immune’ Mozambicans in Maputo, diagnosing malaria by
means of rapid antigen testing and microscopy. We confine this letter to
discussion of non-immune patients with falciparum malaria.

Given the lack of adequate high level care facilities in Maputo, we
have of necessity had to devise a treatment protocol that involves the
ambulatory management of uncomplicated falciparum malaria. Severe or
complicated cases, as adjudged by WHO criteria, are immediately commenced
on intravenous quinine and evacuated to South Africa. This luxury is not
available to uncomplicated cases. Our uncomplicated cases, by contrast,
have all been administered ambulatory treatment with a six dose course of
co-artemether (artemether-lumefantrine). None of these cases was admitted,
all having been followed up as outpatients in our clinic.

To date seventy five non-immune patients with uncomplicated
falciparum malaria have received ambulatory treatment with co-artemether.
No other anti-malarial treatment agent has been used on any of our
uncomplicated cases. Using this system of management we have achieved a
100% cure rate in uncomplicated falciparum malaria, as judged by parasite
clearance and lack of further episodes of clinical malaria. Of necessity,
as sole providers of care, we would have been made aware of any further
episodes of malaria. No patient who received ambulatory treatment
deteriorated or required additional or ‘rescue treatment’: all made a full
and uneventful recovery free of sequelae.

We would point out that our treatment protocol permitted ambulatory
treatment of patients with parasitaemias of up to 5%, provided no other
sign of severe or complicated malaria was present. D’Acremont et al
declined ambulatory treatment with a 2% parasitaemia; our WHO criteria
were otherwise similar to, but more comprehensive than D’Acremont et al’s.

We suspect that our results, currently being prepared for detailed
publication, are due to the use of a combination treatment that contains
an artemisinin, the known efficacy and rapidity of action of artemether
preventing progression to severe or complicated malaria. The action of the
artemisinins in the early stages of the erythrocytic phase of parasite
development, an advantage not enjoyed by mefloquine, may also be a
critical factor in the prevention of progression and help explain our
results.

Dr Stephen Toovey

Medical director

Netcare Travel Clinics,
South Africa

Dr Andrew Jamieson

Medical director

Netcare Travel Clinics,
South Africa

Competing interests:

ST has been reimbursed by Novartis, manufacturers of co-artemether,
for attending a conference and has received a fee for speaking.