Presumptive Treatment to Reduce Imported Malaria among Refugees from East Africa Resettling in the United States

Abstract

During May 4, 2007–February 29, 2008, the United States resettled 6,159 refugees from Tanzania. Refugees received pre-departure antimalarial treatment with sulfadoxine-pyrimethamine (SP), partially supervised (three/six doses) artemether-lumefantrine (AL), or fully supervised AL. Thirty-nine malaria cases were detected. Disease incidence was 15.5/1,000 in the SP group and 3.2/1,000 in the partially supervised AL group (relative change = –79%, 95% confidence interval = –56% to –90%). Incidence was 1.3/1,000 refugees in the fully supervised AL group (relative change = –92% compared with SP group; 95% confidence interval = –66% to –98%). Among 39 cases, 28 (72%) were in refugees < 15 years of age. Time between arrival and symptom onset (median = 14 days, range = 3–46 days) did not differ by group. Thirty-two (82%) persons were hospitalized, 4 (10%) had severe manifestations, and 9 (27%) had parasitemias > 5% (range = < 0.1–18%). Pre-departure presumptive treatment with an effective drug is associated with decreased disease among refugees.

Mass administration of the antimalarial drug mefloquine to Guantánamo detainees: a critical analysis

“…2008). Among the motivations for administering PPT to dislocated persons arriving in the USA is that such patients typically face barriers to accessing medical care after their arrival and that US clinicians may have limited clinical experience with malaria, thus contributing to delays in diagnosis (Phares et al. 2011).…”

“…2010). Today, in conformity with WHO recommendations, the treatment of choice for PPT is the ACT Coartem ® (Phares et al. 2011).…”

“…The primary justification for the use of PPT has typically been on clinical grounds and not for public health purposes. Despite posing a theoretical risk of autochthonous transmission, no local cases of malaria transmission have been linked to refugee resettlement in the USA (Phares et al. 2011).…”

“…PPT is frequently justified, particularly among refugees and other dislocated populations to which detainee populations might be compared (Stauffer et al 2008). Among the motivations for administering PPT to dislocated persons arriving in the USA is that such patients typically face barriers to accessing medical care after their arrival and that US clinicians may have limited clinical experience with malaria, thus contributing to delays in diagnosis (Phares et al 2011). Neither of these rationales should be applicable among detainees held at Guantá namo, where ample and timely medical care was presumably available, provided by military healthcare providers familiar with the clinical and laboratory diagnosis and management of the disease (Scsepko 2002, DoD 2007.…”

“…The use of mefloquine for this purpose finds no precedent in the literature on PPT (Slutsker et al 1995;Miller et al 2000;Barnett 2004;CDC 2010), and researchers at WRAIR have even emphasised that mefloquine will 'likely not find use' for this indication among 'asymptomatic, otherwise healthy' persons 'due to its association with adverse CNS events at therapeutic doses' (Milner et al 2010). Today, in conformity with WHO recommendations, the treatment of choice for PPT is the ACT Coartem Ò (Phares et al 2011).…”