Malaria affects between 300 and 500 million people a year, resulting in over 3 million deaths. Morbidity and mortality are the greatest in children and pregnant women and travelers. There is increasing incidence of chloroquine-resistant strains of Plasmodium faciparum (CRPF) and P. vivax worldwide. A greater effort needs to be made to reach pregnant women who may be returning to a malaria endemic area to see family and friends.
What is the incidence of malaria in pregnant travelers? Preliminary data from the CDC surveillance program during 1997-1999 demonstrates that 3810 cases of malaria were reported to the CDC; of these, 2313 were men, 1279 were women and the sex was not known in 218 people. Sixty-three of the women were reported to be pregnant; 25 of the women were US residents; 36 were foreign residents; others of unknown status (M. Parise, 2000, personal communication).
These data suggest that the highest risk of malaria in pregnant travelers is in those women returning to an endemic area to see their family(18/25 US residents). Travel medicine practitioners should promote chemophylaxis in this high-risk group. Most cases of malaria were acquired in Africa and most cases were falciparum plasmodium. According to the data collected most of the pregnant travelers did not take, or took inappropriate, prophylaxis for the area of destination (20/25 US residents); 47 of the women were hospitalized. Complications during treatment included adult respiratory distress syndrome, renal failure and anemia. None of the cases was fatal.
Malaria acquired during pregnancy has severe consequences. If a woman is pregnant or plans to become pregnant and cannot defer travel to a high-risk area, appropriate chemoprophylaxis is essential. Pregnancy is associated with an increased susceptibility to malaria both during pregnancy and during the postpartum period (Diagne et al., 2000). Pregnancy increases susceptibility and clinical severity of falciparum malaria in women both with and without existing immunity, i.e. women living in and traveling to endemic areas. A pregnant traveler visiting an endemic area is at significant risk for malaria infection and its devastating consequences for her and her fetus.
Most of the studies on malaria occurring during pregnancy have been done on pregnant women living in endemic areas. These studies have demonstrated that women living in such areas have an increased susceptibility to P. falciparum infection during pregnancy when compared with local women who are not pregnant. The increase in susceptibility appears to be more during the first pregnancy and to diminish, in some studies, with subsequent pregnancies. For individuals living in endemic areas protective immunity is acquired during childhood. The increased susceptibility to malaria for women during pregnancy has been thought to be due to sequestration of the parasites in the placenta and suppression of selected components of the immune system, associated with the increased production of several hormones and other proteins (Fried and Duffy, 1996; Diagne et al., 1997; Duffy and Fried, 1999; Nahlen, 2000).
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