Malaria I.
I.However, since November 2004, CDC has received reports of three malaria cases in U.S. travelers returning from areas in La Altagracia and Duarte provinces (Figure) previously considered nonmalarious. An additional 14 cases of malaria in La Altagracia Province, in the far eastern region of the country, have been reported in European and Canadian travelers. This report describes three of these 17 malaria cases and summarizes the overall investigation, which led to expansion of CDC recommendations for chloroquine prophylaxis to include all of La Altagracia and Duarte provinces.
The MoH investigation included active case detection and entomologic investigations in La Altagracia and Duarte provinces. In Duarte Province, officials confirmed that no other cases had been reported during 2003--2004. Nonetheless, MoH is taking precautionary measures, including enhanced surveillance. In La Altagracia Province, MoH surveillance data have identified an increase in cases of malaria beginning in November 2004 among migrant workers in the Bavaro Zone, 10 miles from the Punta Cana resort area. MoH intensified control measures in the Bavaro Zone, which include 1) presumptive treatment of all construction and hotel workers by using directly observed therapy with chloroquine and primaquine, and 2) mosquito control through residual and spatial insecticide spraying and application of larvicide to suspected breeding sites. Measures instituted in the Punta Cana resort area include intensified surveillance and larvicide application.
This is an officialCDC Health Advisory
Distributed via Health Alert NetworkNovember 30, 2004, 15:15 EST (03:15 PM EST)CDCHAN-00217-04-11-30-ADV-N
Revised Recommendations for Malaria Prophylaxis
in Dominican Republic
CDC has received reports of 2 cases of malaria in November 2004 in U.S. travelers to
the Dominican Republic whose visits were limited to Punta Cana (La Altagracia
Province) and San Francisco de Macoris (Duarte Province). During the same period at
least 2 more cases have been reported in European travelers who visited Punta Cana.
CDC has recommended malaria prophylaxis for travelers to rural areas in the Dominican
Republic but not for travel to resorts. In light of these reports, as a precautionary
measure, CDC is expanding the recommendations to include chloroquine prophylaxis for
travelers to all areas in La Altagracia Province, including the Punta Cana area, and also
to all areas of Duarte Province. The Ministry of Health in the Dominican Republic has
implemented malaria control measures, including intensified surveillance, prompt case
management, and intensive mosquito control activities. CDC will continue to monitor the
situation and provide updates on these recommendations.
Health care providers needing assistance with diagnosis or management of suspected
cases of malaria should call the CDC Malaria Hotline: 770-488-7788 (M-F, 8am-4:30 pm,
eastern time). For emergency consultation after hours, call: 770-488-7100 and request
to speak with a CDC Malaria Branch clinician.
In rural areas of the Dominican Republic, P. falciparum malaria is endemic, with the highest risk in the far western region of the country, and prophylactic medication with chloroquine is recommended for incoming travellers. Conversely, urban and resort areas in the Dominican Republic have been considered nonmalarious, and prophylactic medication has not been recommended for persons travelling to these areas(1). However, since November 2004, the Centers for Disease Control and Prevention (CDC) has received reports of three malaria cases in U.S. travellers returning from areas in La Altagracia and Duarte provinces previously considered nonmalarious. An additional 14 cases of malaria in La Altagracia Province, in the far eastern region of the country, have been reported in European and Canadian travellers. This report describes three of these 17 malaria cases and summarizes the overall investigation, which led to expansion of CDC recommendations for chloroquine prophylaxis to include all of La Altagracia and Duarte provinces.
Prevention and Control Measures
On 24 November, CDC expanded its recommendations for chloroquine prophylaxis for travellers to the Dominican Republic to include all of La Altagracia and Duarte provinces, in addition to rural areas countrywide(2). The revised recommendations advise clinicians and travellers about the expanded malaria risk area so that any febrile persons who have visited these areas will receive prompt diagnosis and treatment to avoid severe complications. Major networks of blood collection agencies and the Food and Drug Administration also were contacted. Similar alerts were issued by health officials in Europe and by the Public Health Agency of Canada.
The MoH investigation included active case detection and entomologic investigations in La Altagracia and Duarte provinces. In Duarte Province, officials confirmed that no other cases had been reported during 2003-2004. Nonetheless, MoH is taking precautionary measures, including enhanced surveillance. In La Altagracia Province, MoH surveillance data have identified an increase in cases of malaria beginning in November 2004 among migrant workers in the Bavaro Zone, 10 miles from the Punta Cana resort area. MoH intensified control measures in the Bavaro Zone, which included: 1) presumptive treatment of all construction and hotel workers by using directly observed therapy with chloroquine and primaquine, and 2) mosquito control through residual and spatial insecticide spraying and application of larvicide to suspected breeding sites. Measures instituted in the Punta Cana resort area include intensified surveillance and larvicide application.
MMWR Editorial Note
This report describes an outbreak of malaria in areas in the Dominican Republic previously thought to be nonmalarious. P. falciparum is the only malaria parasite in the Dominican Republic and has remained susceptible to chloroquine. Because P. falciparum malaria can be rapidly fatal, travellers should be aware of risk areas so that they can take appropriate preventive measures; clinicians should consider malaria in their diagnosis and treatment of febrile illness in travellers. Malaria can be prevented by taking an antimalarial drug and by preventing mosquito bites. Chloroquine is the recommended drug for malaria prevention for persons travelling to the Dominican Republic and is highly efficacious and well tolerated by most travellers. To prevent mosquito bites, travellers should use insect repellent containing up to 50% DEET and wear long-sleeved clothing; if not staying in screened or air-conditioned housing, they should sleep under a net, preferably one treated with insecticide. Rapid intervention is crucial for ill travellers with suspected malaria(3). In nearly all cases in this outbreak, delays in diagnosis and treatment occurred; in certain cases, delays contributed to serious illness.
South Dakota Department of Health
CDC Advisory 00217
This is an official
CDC Health Advisory
Distributed via Health Alert Network
November 30, 2004, 15:15 EST (03:15 PM EST)
CDCHAN-00217-04-11-30-ADV-N
Revised Recommendations for Malaria Prophylaxis
in Dominican Republic
CDC has received reports of 2 cases of malaria in November 2004 in U.S. travelers to the Dominican Republic whose visits were limited to Punta Cana (La Altagracia Province) and San Francisco de Macoris (Duarte Province). During the same period at least 2 more cases have been reported in European travelers who visited Punta Cana. CDC has recommended malaria prophylaxis for travelers to rural areas in the Dominican Republic but not for travel to resorts. In light of these reports, as a precautionary measure, CDC is expanding the recommendations to include chloroquine prophylaxis for travelers to all areas in La Altagracia Province, including the Punta Cana area, and also to all areas of Duarte Province. The Ministry of Health in the Dominican Republic has implemented malaria control measures, including intensified surveillance, prompt case management, and intensive mosquito control activities. CDC will continue to monitor the situation and provide updates on these recommendations.
Malaria in the Dominican Republic
Updated: January 31, 2006
The Public Health Agency of Canada (PHAC) continues to recommend malaria prophylaxis (medication) and the use personal insect protective measures against mosquito bites for travel to rural areas of the Dominican Republic AND to all areas, including resort areas, within the province of La Altagracia. The Public Health Agency of Canada (PHAC) continues to recommend malaria prophylaxis (medication) and the use of personal insect protective measures (e.g., repellants) against mosquito bites for travel to all rural areas of the Dominican Republic.
Additionally, in light of the evidence of ongoing malaria transmission in and around tourist resort areas within the province of La Altagracia , the Public Health Agency of Canada in consultation with the Malaria Sub-Committee of the Committee to Advise on Tropical Medicine and Travel (CATMAT) has expanded its recommendations as follows:
For travel to rural areas of the country AND to all areas within the province of La Altagracia (including resort areas):
The Agency recommends malaria prophylaxis (medication) and the use personal insect protective measures against mosquito bites.
The tourist resort destinations of Punta Cana and Bavaro are located within the province of La Altagracia.
Note : While chloroquine is the malaria drug of choice for the Dominican Republic , atovaquone / proguanil (Malarone ?), doxycycline and mefloquine are as effective as chloroquine and readily available.
How to prevent malaria infection
Two important measures can help you prevent malaria infection: avoiding mosquito bites and using effective anti-malarial medications.
Personal Measures to Avoid Mosquitoes
Female Anopheles mosquitoes bite mainly during the evening and night. Using personal insect protective measures will reduce your risk of being bitten by these mosquitoes.
stay in well-screened or completely enclosed, air-conditioned accommodation;
sleep under insecticide-treated bed nets;
wear clothing that reduces the amount of exposed skin; wear long-sleeved shirts (tightly weaved material, sleeves down, buttoned/zipped up, tucked into pants) and long pants (tucked into socks or footwear);
light-coloured clothing may be less attractive to some mosquitoes and make mosquitoes more noticeable;
use DEET-based products as repellents on exposed skin. The higher the concentration of DEET in the repellent formulation, the longer the duration of protection. However, this relation reaches a plateau at about 30% to 35%. DEET formulations that are "extended duration" (ED), such as polymers, are generally considered to provide longer protection times, and may be associated with less DEET absorption. Formulations over 30% are not currently available in Canada , although they are available internationally, including in the United States . It should be noted, however, that products sold outside Canada have not been evaluated by Health Canada . Most repellents containing "natural" products are effective for shorter durations than DEET and for this reason are not considered the preferred products for protecting against mosquito bites.
Regulatory agencies in western nations may differ regarding the recommended maximum concentration and application rates of DEET, especially for children. The Committee to Advise on Tropical Medicine and Travel (CATMAT) is satisfied that, for travel outside of Canada where the risk of malaria outweighs the risk of any important adverse reaction to DEET, the threshold for use of DEET should be low.
CATMAT recommends that concentrations of DEET up to 35% can be used by any age group.
For children, alternative personal protective measures, such as mosquito nets treated with insecticide, should be the first line of defense, especially for infants less than 6 months of age. Portable mosquito nets, including self-standing nets, placed over a car seat, a crib, playpen, or stroller help protect against mosquitoes. However, as a complement to the other methods of protection, the judicious use of DEET should be considered for children of any age. Recent medical literature from Canada suggests that DEET does not pose a significant or substantial extra risk to infants and children.
DEET/sunscreen combination products are not generally recommended, because DEET can decrease the efficacy of sunscreens. As well, sunscreens should be used liberally and often while DEET should be used sparingly and only as often as required. If application of both is necessary, the Canadian Dermatology Association recommends that the sunscreen be applied first and allowed to penetrate the skin for 20 minutes, prior to applying DEET.
These precautions will also help to prevent other mosquito-borne infections such as dengue fever.