Malaria in illegal Chinese immigrants, Italy. (Dispatches).A cluster of 22 imported malaria cases, 21 caused by Plasmodium falciparum Plasmodium fal·cip·a·rum n. A protozoan that causes falciparum malaria. , was observed among illegal Chinese immigrants in northern Italy Northern Italy comprises of two areas belonging to NUTS level 1:
********** The recent increase of population movements is paralleled by an increase in imported malaria cases in Europe, where malaria is not endemic (1,2). In Italy, migrants and foreign-born people visiting relatives represent an increasing proportion of imported malaria cases (3). Most cases are in persons from malaria-endemic areas. They rarely develop complications because of their semi-immune status and because early diagnosis is usually made on the basis of travel history (4). We describe an unprecedented cluster of malaria cases in immigrants from China. Most of the immigrants originated from the province of Zhe Jiang, which is free from indigenous falciparum malaria fal·cip·a·rum malaria n. Malaria caused by Plasmodium falciparum and characterized by severe malarial paroxysms that recur about every 48 hours and often by acute cerebral, renal, or gastrointestinal manifestations. (Allan Schapira, pers. commun.); therefore, they had no immunity to the infection. Case Reports During the summer of 2000, several Chinese immigrants were admitted to hospitals in northern and central Italy Central Italy is a geographic area in Italy that encompasses four of the country's 20 autonomous regions:
n. 1. The protozoan (Plasmodium vivax) that causes the most common form of malaria. 2. Vivax malaria. infection. The major epidemiologic and clinical characteristics of the 22 cases are listed (Table). All but one were in immigrants arriving for the first time in Italy. A detailed travel history was obtained from half the patients. Communication was extremely difficult, as none could speak any European language or Arabic, and none was accompanied by family members. Even when translators were used, information was incomplete and incoherent, because of fear of deportation. In most cases the area of origin was the province of Zhe Jiang. These patients reported that at least 3 months had lapsed between their departure from China and arrival in Italy. Traveling by land and sea, these immigrants visited several malarious areas of Southeast Asia Southeast Asia, region of Asia (1990 est. pop. 442,500,000), c.1,740,000 sq mi (4,506,600 sq km), bounded roughly by the Indian subcontinent on the west, China on the north, and the Pacific Ocean on the east. and eastern and western Africa. Long stops of several weeks in Laos, Thailand, Myanmar, Bangladesh, Pakistan, Kenya, Tanzania, Ivory Coast Ivory Coast: see Côte d'Ivoire. , or Cameroon were reported. In at least two cases, Italy was not the country of arrival in Europe: one patient entered France first and another entered Switzerland before being transferred to Italy. Most patients were young adult men. None reported having taken malaria chemoprophylaxis chemoprophylaxis /che·mo·pro·phy·lax·is/ (-pro?fi-lak´sis) prevention of disease by means of a chemotherapeutic agent. che·mo·pro·phy·lax·is n. Disease prevention by use of chemicals or drugs. or adopting other malaria preventive measures. Some had had previous febrile febrile /feb·rile/ (feb´ril) pertaining to or characterized by fever. feb·rile adj. Of, relating to, or characterized by fever; feverish. episodes, which had occurred outside Italy and had been treated with unspecified drugs. It was almost invariably in·var·i·a·ble adj. Not changing or subject to change; constant. in·var  i·a·bil impossible to define the lag between onset of current symptoms and the
time patients sought care at hospital. The time to diagnosis in hospital
was longer than 24 hours in 50% of the cases, and it was longer for the
first cases occurring at each hospital.The clinical picture on admission to hospital was that of a nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik) 1. not due to any single known cause. 2. not directed against a particular agent, but rather having a general effect. nonspecific 1. febrile illness. The parasite density was >10% in 8 (38.1%) of 21 falciparum malaria cases. In 7 (33.3%) of 21 falciparum cases, the criteria for complicated and severe disease (5) were met. One patient died, and another had neurologic sequelae sequelae Clinical medicine The consequences of a particular condition or therapeutic intervention after recovering from cerebral malaria. Patient 6 was admitted to hospital for headache and fever. His condition deteriorated in 24 hours, with the development of coma and hyperbilirubinemia. He was transferred to an intensive care unit 36 hours after admission. Malaria diagnosis was made 48 hours after admission and specific treatment immediately started. He died on the fourth hospital day from multi-organ failure. The autopsy confirmed massive malaria infection in the brain, lungs, heart, kidneys, spleen spleen, soft, purplish-red organ that lies under the diaphragm on the left side of the abdominal cavity. The spleen acts as a filter against foreign organisms that infect the bloodstream, and also filters out old red blood cells from the bloodstream and decomposes , and intestine. Patient 15 had a diagnosis of cerebral malaria (convulsions Convulsions Also termed seizures; a sudden violent contraction of a group of muscles. Mentioned in: Heat Disorders , impaired consciousness), acute renal failure acute renal failure Acute kidney failure Nephrology An abrupt decline in renal function, triggered by various processes–eg, sepsis, shock, trauma, kidney stones, drug toxicity-aspirin, lithium, substances of abuse, toxins, iodinated radiocontrast. , and adult respiratory distress Respiratory distress A condition in which patients with lung disease are not able to get enough oxygen. Mentioned in: Lung Cancer, Non-Small Cell syndrom. He received intravenous quinine quinine (kwī`nīn', kwĭnēn`), white crystalline alkaloid with a bitter taste. Before the development of more effective synthetic drugs such as quinacrine, chloroquine, and primaquine, quinine was the specific agent in the treatment of , doxycycline doxycycline /doxy·cy·cline/ (dok?se-si´klen) a semisynthetic broad-spectrum tetracycline antibiotic, active against a wide range of gram-positive and gram-negative organisms; used also as d. calcium and d. hyclate. , and exchange transfusion exchange transfusion n. The removal of most of a patient's blood followed by introduction of an equal amount from donors. Also called substitution transfusion, total transfusion. , and was discharged in apparently good health 24 days after admission. He was readmitted I week later with a neurologic syndrome that required a 7-day hospital stay. The final diagnosis was acute psychosis psychosis (sīkō`sĭs), in psychiatry, a broad category of mental disorder encompassing the most serious emotional disturbances, often rendering the individual incapable of staying in contact with reality. , which was considered a consequence of the previous episode of cerebral malaria. Patients 10 and 20 had cerebral malaria. They were both treated with intravenous quinine, doxycycline, and exchange transfusion and recovered. Patient 12 also had cerebral malaria, was treated with intravenous quinine and clindamicin, and recovered. Patient 7 had acute anemia and received a blood transfusion blood transfusion, transfer of blood from one person to another, or from one animal to another of the same species. Transfusions are performed to replace a substantial loss of blood and as supportive treatment in certain diseases and blood disorders. in addition to quinine and doxycycline. Uncomplicated cases received either quinine or mefloquine mefloquine /mef·lo·quine/ (mef´lo-kwin) an antimalarial effective against chloroquine-resistant strains of Plasmodium falciparum and P. vivax; used as the hydrochloride salt. , and all recovered. Patient 11 left the hospital on the same day of admission, without completing his malaria treatment course. Conclusions Malaria is a reemerging problem in Italy, with more then 5,000 cases reported from 1986 to 1996 (6). Most cases are imported and present as sporadic disease (Med.) a disease which occurs in single and scattered cases. See the Note under Endemic, a. os> See also: Sporadic . The only major cluster of malaria, reported by Orlando and colleagues, was caused by the practice of sharing injection equipment among drug addicts (7). We describe an unprecedented cluster of imported malaria in Chinese clandestine immigrants. Although Italy is a natural point of arrival for immigrants to Europe, it is unlikely that the cluster was limited to Italy: at least two of our patients visited other European countries before entering Italy. This cluster deserves some discussion. First, malaria prevention in travelers requires active medical interventions and personal motivation for both chemoprophylaxis and prevention of contact with the vector (8). Clandestine migrants are unlikely to receive such medical attention, and none of our patients reported having taken malaria prophylaxis Malaria prophylaxis is the prevention of malaria. Rationale Malaria is thought to be one of the oldest infectious diseases, evolving around 10000 years ago. The development of virulence in the parasite has been demonstrated using genomic mapping of samples from this . Second, falciparum malaria in nonimmune persons is potentially fatal and thus needs to be diagnosed and treated early. A diagnostic delay almost certainly occurred among these immigrants, mainly because clandestine immigrants are unlikely to seek prompt medical attention. Although this could not be confirmed, the high parasite density at admission to hospital is an indirect indicator. After hospital admission, diagnostic delay was higher for the first cases and decreased thereafter: in the absence of an alert system each hospital had to learn for itself about the possibility of malaria in Chinese immigrants. Third, travelers from non-malarious areas pose a difficult diagnostic dilemma to health-care providers, who require a detailed travel history to raise the suspicion of malaria. Language barriers and fear of deportation made this step very difficult in our case list. Even when translators were used, patients were still very reluctant to provide the details of their trip to Italy because of their illegal status. It is also possible that they indeed did not know details about the trip. The clinical consequence of the factors mentioned above was that at hospital admission cases were more severe than average. The rate of severe malaria in the cluster was 33%, which is much higher than the rates of 1.3% in immigrants and 9.2% in nonimmune Italians recently reported for Lombardy region (9). One patient died, and another one had acute psychosis as a consequence of cerebral malaria. Italy, from which malaria was eradicated in the 1950s, is susceptible to the reintroduction Noun 1. reintroduction - an act of renewed introduction intro, introduction, presentation - formally making a person known to another or to the public of the disease because the vector, mainly Anopheles Anopheles: see mosquito. labranchiae, is still present at high densities (10). P. vivax malaria vivax malaria n. Malaria in which the paroxysms recur every third day, counting inclusively, and are induced by the release of merozoites and their invasion of new red blood cells. Also called tertian malaria. transmitted by indigenous vectors has recently been documented in Maremma Maremma (märām`mä), coastal area in Tuscany, central Italy, along the Tyrrhenian Sea and extending E to the Apennines. A flourishing region in Etruscan and early Roman times, it became marshy and was largely abandoned in the Middle Ages , Italy (11). Italian vectors have been found to be refractory to infection by strains of P. falciparum from tropical Africa Tropical African rain forests are tropical moist forests of semi-deciduous varieties distributed across nine West African countries -- Benin, Ghana, Guinea Bissau, Guinea, Ivory Coast, Liberia, Nigeria, Sierra Leone and Togo. in in-vitro studies (12). However, the risk of reintroduction of P. falciparum strains from Asia, where local vectors are more closely related to the Mediterranean ones, is basically unknown. Malaria in Chinese immigrants may represent an emerging problem in Europe, one which might increase the rate of severe disease and death from imported falciparum malaria. Interventions to raise awareness of the malaria risk among the Chinese community of clandestine immigrants may not be feasible. To limit the risk for severe disease and death, local health structures in the countries of arrival need to be alert to the possible risk of malaria in febrile illegal immigrants even if they are not coming from classical high-risk areas. This cluster was reported to TropNetEurop, a network which has sentinel clinics throughout Europe, and GaoSentinel, a similar network mainly made up of centers in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. . A local reporting system could have helped in this specific situation to quickly generate awareness of the outbreak.
Table. Epidemiologic and clinical characteristics of 22 Chinese
immigrants with malaria in Italy
Day/
Sex, mo of
age Countries initial Malaria
No. (yrs) Origin visited visit species
1 M, 24 Na Pakistan 1/7 Pf
2 F, 20 Na Na 3/7 Pf
3 M, 26 Na Na 3/7 Pf
4 M, 20 Zhe Laos, 5/7 Pf
Jiang Myanmar,
Bangladesh,
Pakistan, East
Africa
5 M, 29 Souther Pakistan, 5/7 Pf
n China Myanmar,
Thailand
6 M, 23 Na Vietnam, 17/7 Pf
Cambodia,
Kenya
7 M, 19 Zhe Pakistan, Ivory 19/7 Pf
Jiang Coast
8 M, 33 Na Pakistan 20/7 Pv
9 M, 23 Na Na 20/7 Pf
10 F, ? Na Pakistan 21/7 Pf
11 M, 26 Na Na 22/7 Pf
12 M, 28 Na Tanzania 22/7 Pf
13 F, 28 Na Na 26/7 Pf + Po
14 M, 24 Zhe Laos, 27/7 Pf
Jiang Myanmar,
Bangladesh,
Pakistan, East
Africa
15 M, 25 Zhe Laos, 28/7 Pf
Jiang Myanmar,
Bangladesh,
Pakistan, East
Africa
16 M, 22 Zhe East Africa 28/7 Pf
Jiang
17 M, 18 Na Myanmar, 2/8 Pf
Bangladesh,
Pakistan, Ivory
Coast, France
18 F, 19 Souther Kenya 6/8 Pf
n China
19 M, 29 Na Pakistan 7/8 Pf
20 F, 24 Zhe Ivory Coast 6/9 Pf
Jiang
21 M, 29 Southern Pakistan, 11/9 Pf
China Ivory Coast
22 M, 18 Na Cameroon 15/11 Pf
Days
Sex, until
age Parasite hospita Clinical signs
No. (yrs) density l dx (a) & symptoms
1 M, 24 <1% 0 Uncomplicated
2 F, 20 15% 0 Uncomplicated
3 M, 26 15% 0 Uncomplicated
4 M, 20 <1% 2 Uncomplicated
5 M, 29 <1% 1 Uncomplicated
6 M, 23 20% 2 Severe
7 M, 19 3% 2 Severe
8 M, 33 [Nd.sup.2] 0 [Nd.sup.3]
9 M, 23 2.5% 0 Uncomplicated
10 F, ? 20% 3 Severe
11 M, 26 <1% 0 Uncomplicated
12 M, 28 11% 4 Severe
13 F, 28 10% 3 Severe
14 M, 24 <1% 0 Uncomplicated
15 M, 25 15% 8 Severe
16 M, 22 <1% 0 Uncomplicated
17 M, 18 <1% 1 Uncomplicated
18 F, 19 1% 11 Uncomplicated
19 M, 29 1% 0 Uncomplicated
20 F, 24 17% 2 Severe
21 M, 29 <1% 0 Uncomplicated
22 M, 18 <1% 0 Uncomplicated
Sex,
age
No. (yrs) Treatment Outcome
1 M, 24 Quinine + Resolved
Doxycycline
2 F, 20 Mefloquine Resolved
3 M, 26 Mefloquine Resolved
4 M, 20 Quinine + Resolved
Doxycycline
5 M, 29 Quinine + Resolved
Doxycycline
6 M, 23 Quinine + Death
Doxycycline
7 M, 19 Quinine + Resolved
antifolics;
transfusion
8 M, 33 Chloroquine Resolved
9 M, 23 Mefloquine Resolved
10 F, ? Quinine + Resolved
Doxycycline
Exchange
transfusion
11 M, 26 Quinine Self
discharge
d
12 M, 28 Quinine + Resolved
Clindamicin
13 F, 28 Quinine + Resolved
Doxycycline
Primaquine
14 M, 24 Quinine + Resolved
Doxycycline
15 M, 25 Quinine + Neurologi
Doxycycline c sequelae
Exchange
transfusion
16 M, 22 Quinine Resolved
17 M, 18 Quinine + Resolved
Doxycycline
18 F, 19 Quinine + Resolved
Doxycycline
19 M, 29 Quinine + Resolved
Doxycycline
20 F, 24 Quinine + Resolved
Doxycycline
Exchange
transfusion
21 M, 29 Quinine + Resolved
Doxycycline
22 M, 18 Mefloquine Resolved
(a) A value of 0 indicates diagnosis on the day of admission.
F = female; M = male; dx = diagnosis; mo = month; Na = not assessed;
Nd = not determined in a case of Plasmodium vivax infection; Pv = P.
vivax; Pf = P. falciparum; Po = P. ovale.
Acknowledgment We are indebted to Piero Olliaro and Allan Schapira for providing useful information on the epidemiology of malaria in China. The activities of the Regional Referral Center for Travel Related Diseases are partly supported by grants from the Regione Lombardia. Dr. Matteelli is responsible for the Centre for International Health at the University Hospital of Brescia. He has field experience as an associate malariologist with the World Health Organization. References (1.) Legors F, Danis M. Surveillance of malaria in European Union European Union (EU), name given since the ratification (Nov., 1993) of the Treaty of European Union, or Maastricht Treaty, to the European Community countries. Eurosurveillance 1998;3:45-7. (2.) Muentener P, Schlagenhauf P, Steffen R. Imported malaria (1985-95): trends and perspectives. Bull World Health Organ 1999;77:560-6. (3.) Sabatinelli G, Romi R, Majori G. Malaria epidemiological situation and assessment of the malaria reintroduction risk in Italy. Giornale Italiano di Malattie Infettive 1998;4:71-87. (4.) Castelli F, Matteelli A, Caligaris S, Gulletta M, El-Hamad I, Scolari C, et al. Malaria in migrants. Parassitologia 1999; 41:261-5. (5.) World Health Organisation. Severe falciparum malaria. Trans R Soc Trop Mad Hyg 2000;94(Suppl 1):S1-S74. (6.) Sabatinelli G, Majori G. La sorveglianza epidemiologica della malaria in Italia e aggiornamento ag·gior·na·men·to n. pl. ag·gior·na·men·tos The process of bringing an institution or organization up to date; modernization. [Italian, from aggiornare, to update : a- della casistica nazionale al 1996. Giornale Italiano di Medicina Tropicale 1996;1:23-7. (7.) Orlando G, Marini V, Esposito R, Rancati M, Cargnel A, Almaviba M. An outbreak of P. falciparum malaria among drug addicts. Revista Iberica de Parasitologia 1982;1:(Suppl 1):S399. (8.) Croft A. Malaria: prevention in travelers. BMJ BMJ n abbr (= British Medical Journal) → vom BMA herausgegebene Zeitschrift 2000;321:154-60. (9.) Matteelli A, Colombini P, Gulletta M, Castelli F, Carosi G, for the SIRL study group. Epidemiological features and case management practices of imported malaria in northern Italy 1991 - 1995. Trop Med Int Health 1999;4:653-7. (10.) Romi R, Pierdominici G, Severini C. Status of malaria vectors in Italy. J Mad Entomol 1997;34:263-71. (11.) Baldari M, Tamburro A, Sabatinelli G, Romi R, Severini C, Cuccagna G, et al. Malaria in Maremma, Italy. Lancet 1998; 351:1246-7. (12.) Ramsdale CD, Coluzzi M. Studies on the infectivity of tropical African strains of Plasmodium falciparum to some southern European vectors of malaria. Parassitologia 1975;52:109-11. Alberto Matteelli, * Alberto Volonterio, ([dagger]) Maurizio Gulletta, * Laura Galimberti, ([double dagger double dagger n. A reference mark (  ) used in printing and writing. Also called diesis.Noun 1. ]) Stefania Maroccolo,' Giovanni Gaiera, ([paragraph]) Gloria Giani, (#) Maurizio Rossi, ** Nicoletta Dorigoni, ([double dagger]) Luca Bellina, * Giovanna Orlando, (#) Zeno Bisoffi, ([section]) and Francesco Castelli * * University of Brescia The first phase goes back to 1964, when the chamber of commerce (Camera di Commercio) of Brescia tried to create a biennial degree course of engineering; unfortunately the cost was too high. , Brescia, Italy; ([dagger]) Ospedale Niguarda-Ca Granda, Milano, Italy; ([double dagger]) University of Milano, Milano, Italy; ([section]) Institute for Tropical Medicine tropical medicine, study, diagnosis, treatment, and prevention of certain diseases prevalent in the tropics. The warmth and humidity of the tropics and the often unsanitary conditions under which so many people in those areas live contribute to the development and , Negrar, Italy; ([paragraph]) [Ospedale San Raffaele San Raffaele may refer to:
Address for correspondence: Alberto Matteelli, Institute of Infectious and Tropical Diseases, University of Brescia, Piazza Spedali Civili, 1 B 25125 Brescia, Italy; fax: 39-030-303061; e-mail: forleo@master.cci.unibs.it |
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