Clinical Review

Investigation and treatment of imported malaria in non-endemic countries

BMJ 2013; 346 doi: (Published 21 May 2013) Cite this as: BMJ 2013;346:f2900
  1. Christopher J M Whitty, consultant physician and professor of international health121,
  2. Peter L Chiodini, consultant parasitologist1, director and honorary professor2,
  3. David G Lalloo, professor of tropical medicine3
  1. 1Hospital for Tropical Diseases, London WC1E 6JB, UK
  2. 2PHE Malaria Reference Laboratory, London School of Hygiene and Tropical Medicine, London, UK
  3. 3Liverpool School of Tropical Medicine, Liverpool, UK
  1. Correspondence to: C J M Whitty christopher.whitty{at}

Summary points

  • Malaria is a common cause of fever in people returning from the tropics

  • Falciparum malaria is potentially fatal unless treated early, and patients over 65 years are at particular risk

  • In most cases, vivax malaria can be treated with chloroquine in the outpatient setting

  • Resistance to antimalarial drugs used to treat falciparum malaria is widespread

  • Artesunate is the drug of choice for severe malaria, but if this is not available do not delay treatment with quinine

Every year, several thousand people with malaria arrive in non-endemic countries, and about 1600 arrive in the United Kingdom alone. Case fatality in the UK, as elsewhere, is around 1% overall but varies by age and previous exposure to malaria.1 2 3 This rate is similar to that seen in endemic countries, but the age profile of deaths is very different. In Africa mortality is highest in young children, but in imported cases it is highest in older patients, especially those over 65 years.4 5 6 If malaria is treated early, with widely available drugs before it becomes severe, death is avoidable and a full recovery almost guaranteed. Late presentation carries a higher risk of death. The management of severe malaria is a medical emergency. This review describes how to recognise and diagnose malaria, the current treatment of uncomplicated malaria, and the management of patients with severe disease. It concentrates on adults and recent advances relevant to non-endemic high resource countries such as Europe and North America. Different challenges arise in low resource endemic settings and are not covered in this review.

Sources and selection criteria

We searched the Cochrane Library and PubMed for recent relevant trials and observational studies on imported malaria. The search was supplemented where relevant by data from the UK Malaria Reference Laboratory and expert opinion from the PHE Advisory Committee on …

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