Clinical, geographical, and temporal risk factors associated with presentation and outcome of vivax malaria imported into the United Kingdom over 27 years: observational study

Abstract

Objective: To examine temporal and geographical trends, risk factors, and seasonality of imported vivax malaria in the United Kingdom to inform clinical advice and policy.

Design: Observational study.

Setting: National surveillance data from the UK Public Health England Malaria Reference Laboratory, data from the International Passenger Survey, and international climactic data.

Participants: All confirmed and notified cases of malaria in the UK (n=50,187) from 1987 to 2013, focusing on 12,769 cases of vivax malaria.

Main outcome measures: Mortality, sociodemographic details (age, UK region, country of birth and residence, and purpose of travel), destination, and latency (time between arrival in the UK and onset of symptoms).

Results: Of the malaria cases notified, 25.4% (n=12,769) were due to Plasmodium vivax, of which 78.6% were imported from India and Pakistan. Most affected patients (53.5%) had travelled to visit friends and relatives, and 11.1% occurred in tourists. Imported P vivax is concentrated in areas with large communities of south Asian heritage. Overall mortality was 7/12,725 (0.05%), but with no deaths in 9927 patients aged under 50 years. Restricting the analysis to those aged more than 50 years, mortality was 7/2798 (0.25%), increasing to 4/526 (0.76%) (adjusted odds ratio 32.0, 95% confidence interval 7.1 to 144.0, P<0.001) in those aged 70 years or older. Annual notifications decreased sharply over the period, while traveller numbers between the UK and South Asia increased. The risk of acquiring P vivax from South Asia was year round but was twice as high from June to September (40 per 100,000 trips) compared with the rest of the year. There was strong seasonality in the latency from arrival in the UK to presentation, significantly longer in those arriving in the UK from South Asia from October to March (median 143 days) versus those arriving from April to September (37 days, P<0.001).

Conclusions: Travellers visiting friends and family in India and Pakistan are most at risk of acquiring P vivax, and older patients (especially those >70 years) are most at risk of dying; these groups should be targeted for advice before travelling. The risk of acquiring vivax malaria is year round but higher during summer monsoons, masked by latency. The latency of time to clinical presentation of imported vivax malaria in the UK is highly seasonal; seasonal latency has implications for pretravel advice but also for the control of malaria in India and Pakistan. A reduced incidence of vivax malaria in travellers may mean further areas of South Asia can be considered not to need malaria chemoprophylaxis.

Fig 1 All reported cases of Plasmodium vivax malaria in the United Kingdom, 1987-2013, and passenger numbers to India and Pakistan

Fig 2 Annual cases of Plasmodium vivax imported from India and Pakistan per 100 000 trips, 1993-2013

Fig 3 Total number of cases with vivax malaria diagnosed per month in the United Kingdom, 1987-2013 and quarterly passenger numbers between the UK and India and Pakistan, 1993-2013

Fig 4 Latency between arrival in United Kingdom and onset of symptoms, by month of arrival in UK, 1987-2013

Fig 5 Latency between arrival in United Kingdom and onset of symptoms, by month of arrival in UK, for India, Pakistan, and rest of world, 1987-2013

Fig 6 Average monthly rainfall in India and Pakistan, 1990-2009. Adapted using open database data from the Climactic Research Unit, University of East Anglia