No abstract

During May 4, 2007–February 29, 2008, the United States resettled 6,159 refugees from Tanzania. Refugees received pre-departure antimalarial treatment with sulfadoxine-pyrimethamine (SP), partially supervised (three/six doses) artemether-lumefantrine (AL), or fully supervised AL. Thirty-nine malaria cases were detected. Disease incidence was 15.5/1,000 in the SP group and 3.2/1,000 in the partially supervised AL group (relative change = –79%, 95% confidence interval = –56% to –90%). Incidence was 1.3/1,000 refugees in the fully supervised AL group (relative change = –92% compared with SP group; 95% confidence interval = –66% to –98%). Among 39 cases, 28 (72%) were in refugees < 15 years of age. Time between arrival and symptom onset (median = 14 days, range = 3–46 days) did not differ by group. Thirty-two (82%) persons were hospitalized, 4 (10%) had severe manifestations, and 9 (27%) had parasitemias > 5% (range = < 0.1–18%). Pre-departure presumptive treatment with an effective drug is associated with decreased disease among refugees.

More than 50,000 refugees are resettled to the United States annually, many from areas highly endemic for parasites. Some of these infections present little clinical consequence after migration, but others are responsible for morbidity and mortality. The Centers for Disease Control and Prevention has issued predeparture presumptive treatment and postarrival medical guidelines for the management of parasites. Although these guidelines are evidence based, there remain significant challenges to presumptive treatment programs in refugees. Gaps in the evidence continue; resettling populations are continually changing, thus altering the epidemiology; and there are logistical and cost barriers to fully implementing recommendations. This article will review the evolution and status of current guidelines, as well as identify gaps and challenges to full implementation. It is imperative for clinicians serving this population to be familiar with interventions received by refugees, since previous treatment will impact screening, diagnostic evaluation, and treatment decisions.