Falciparum Malaria in European Tourists to the Dominican Republic

Dispatches
Falciparum Malaria in European Tourists
to the Dominican Republic
Tomas Jelinek,* Manuel Corachan,† Martin Grobusch,‡
Gundel Harms-Zwingenberger,§ Herwig Kollaritsch,¶
Joachim Richter,# and Bernd Zieger** for TropNetEurop††
*Ludwig-Maximilians-University, Munich, Germany; †Sección de Medicina
Tropical, Hospital Clinic, Barcelona, Spain; ‡Medizinische Klinik mit
Schwerpunkt Infektiologie, Virchow-Klinikum, Berlin, Germany; §Institut für
Tropenmedizin, Berlin, Germany; ¶University of Vienna, Austria;# Heinrich-
Heine-University, Düsseldorf, Germany; **Institut für Tropenmedizin,
Städtische Kliniken Dresden-Friedrichstadt, Dresden, Germany;
††European Network on Imported Infectious Disease Surveillance
Thirteen cases of falciparum malaria acquired by Europeans in the Dominican
Republic occurred from June 1999 to February 2000. The cases were identified by the
European Network on Imported Infectious Disease Surveillance (TropNetEurop).
Malaria, falciparum malaria in particular,
All but three patients (two Spanish, one
represents a serious health hazard to travelers to
Austrian) were Germans (Table). All had
disease-endemic areas. As international air
traveled to Punta Cana, a town in the eastern tip
travel to tropical destinations has become more
of the Dominican Republic, or to nearby beach
popular, imported cases have also increased in
resorts. Excursions were made only to the
countries where malaria is not endemic (1-3). The
nearest town, Higüey, which was not considered
importance of appropriate drug prophylaxis has
malarious. The patients were not required to and
been stressed repeatedly (4).
did not receive malaria chemoprophylaxis for this
Like most countries in the Caribbean, large
journey and did not practice exposure precau-
parts of the Dominican Republic are considered
tions. Within 1-2 weeks after their return,
low risk for falciparum malaria (5). In general,
patients visited general practitioners or emer-
only border regions to Haiti and provinces in the
gency rooms, reported fever, and were hospital-
northwest have been associated with endemicity.
ized after diagnoses of falciparum malaria were
This pattern has been reversed recently: starting
established by blood films. For all patients, the
with an index patient in June 1999, 12 additional
clinical course was uneventful, and drug
European patients acquired falciparum malaria
treatment was successful (Table).
in the Dominican Republic from November 1999
The clustering of cases during a compara-
through February 2000. The cases were
tively short time suggests a change in the
identified and reported within TropNetEurop, a
epidemiologic situation in the Dominican Repub-
sentinel surveillance network of clinical sites
lic and may herald future outbreaks among
throughout Europe whose goal is to monitor
tourists. According to information from the
imported infectious diseases. The network has a
Dominican Republic, malaria cases increased in
reporting system at sentinel clinics throughout
1999 after Hurricane George: as of November 20,
Europe, known for its speed of reporting (usually
1999, 3,003 cases had been reported, compared to
within few days of diagnosis) and for members’
2,000 cases for all of 1998. In the eastern part of
sites that serve as regional referral centers.
the country, an outbreak of falciparum malaria
among the local population was noted and traced
back to Haitians working in construction. With
Address for correspondence: Tomas Jelinek, University of
anopheline vectors and abundant breeding sites
Munich, Department of Infectious Diseases and Tropical
Medicine, Leopoldstr. 5, 80802 Munich, Germany; fax: (x49)-
in that area, transmission of falciparum malaria
89-336112; e-mail: jelinek@lrz.uni-muenchen.de.
is easy (6). Current recommendations for visitors
Vol. 6, No. 5, September–October 2000
537
Emerging Infectious Diseases

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Dispatches
Table. Patients with falciparum malaria from the Dominican Republic
Month/year
No.
Sexa
Age
Nationality
presentation
Journey
Therapy
1
F
26
German
06/99
2
M
28
German
11/99
14 days in Punta Cana (honeymoon with #3)
Mefloquine
3
F
28
German
11/99
14 days in Punta Cana (honeymoon with #2)
Mefloquine
4
F
34
German
11/99
7 days in Punta Cana
Mefloquine
5
F
28
Spanish
11/99
7 days in Punta Cana
Chloroquine
6
F
45
German
11/99
14 days in Punta Cana
Atovaquone/
proguanil
7
M
27
German
11/99
Flight assistant, overnight stays in Puerto
Quinine
Plata (October) and Punta Cana (November)
8
F
30
German
11/99
10 days in Punta Cana
Mefloquine
9
F
47
Austrian
12/99
14 days in Punta Cana
Quinine
10
F
28
Spanish
12/99
6 days in Punta Cana
Chloroquine
11
F
30
German
12/99
10 days in Punta Cana
Mefloquine
12
F
31
German
12/99
16 days in Punta Cana
Chloroquine
13
M
24
German
02/00
10 days in Punta Cana
Quinine
aF = female; M = male.
to the Dominican Republic should include an
TropNetEurop receives financial support from Dr.
antimalaria strategy and strict adherence to
Democh Maurmeier Stiftung and Förderprogramm für
personal protection measures against mosquito
Forschung und Lehre der Medizinischen Fakultät, Ludwig-
Maximilians-University, Munich, Germany.
bites.
For 1998, official statistics from the World
Dr. Jelinek is head of the Research Group for Im-
Tourism Organization put the number of visitors
ported Diseases at the Department of Infectious Diseases
from Germany to the Dominican Republic at
and Tropical Medicine, University of Munich. His re-
366,599 (7). Corresponding numbers from
search interests include molecular mechanisms of drug
Austria and Spain are 30,017 and 110,782,
resistance in falciparum malaria, mechanisms of immu-
nity to malaria, and the epidemiology of imported infec-
respectively. If these numbers were used as the
tious diseases.
basis for a crude denominator, the annual
incidence of falciparum malaria in tourists to the
east coast of the Dominican Republic would be
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Emerging Infectious Diseases
538
Vol. 6, No. 5, September–October 2000

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