Mosquito-Borne Malaria

Outbreaks of locally transmitted cases of malaria in the United States have been small and relatively isolated, but the
potential risk for the disease to re-emerge is present due to the abundance of competent vectors, especially in the southern
states. At the request of the states, CDC assists in these investigations of locally transmitted mosquito-borne malaria.

“Airport” Malaria
“Airport” malaria refers to malaria caused by infected mosquitoes that are transported rapidly by aircraft from a malaria-
endemic country to a non-endemic country. If the local conditions allow their survival, they can bite local residents who
can thus acquire malaria without having traveled abroad.

Congenital Malaria
In congenital malaria, infected mothers transmit parasites to their child during pregnancy before or during delivery.
Therefore, though congenital transmission is rare, health-care providers should be alert to the diagnosis of malaria in ill
neonates and young infants, particularly those with fever. During evaluation, health-care providers should obtain a complete
and accurate travel and residency history on the patient and close relatives. Patients should be asked about transfusion of
blood products. The absence of recent foreign travel or a long interval between immigration of the mother and the birth of
the infant being examined should not discourage clinicians from obtaining blood films on the patient to rule out a potentially
life-threatening but treatable infection.

Transfusion-Transmitted Malaria
Transfusion-transmitted malaria is rare in the United States, but it is a potential severe complication in blood recipients. On
average, only one case of transfusion-transmitted malaria occurs in the United States every 2 years. Because no approved
tests are available in the United States to screen donated blood for malaria, prevention of transfusion-transmitted malaria
requires careful questioning of prospective donors.

Needle stick injury

Accidental transmission can occur among drug addicts who share syringes and needles.

Microscopy
Rapid Diagnostic Test
Indirect Fluorescent Antibody Test
ADVANTAGE
Microscopy is an established,
relatively simple technique that is
familiar to most laboratorians. Any
laboratory that can perform routine
hematology tests is equipped to
perform a thin and thick malaria
smear. Within a few hours of
collecting the blood, the microscopy
test can provide valuable information.
First and foremost it can determine
that malaria parasites are present in the
patient’s blood. Once the diagnosis is
established – usually by detecting
parasites in the thick smear – the
laboratorian can examine the thin
smear to determine the malaria species
and the parasitemia, or the percentage
of the patient’s red blood cells that are
infected with malaria parasites. The
thin and thick smears are able to
provide all 3 of these vital pieces of
information to the doctor to guide the
initial treatment decisions that need to
be made acutely.
High-quality malaria microscopy is
not always immediately available in
every clinical setting where patients
might seek medical attention.
Although this practice is discouraged,
many healthcare settings either save
blood samples for malaria microscopy
until a qualified person is available to
perform the test, or send the blood
samples to commercial or reference
laboratories. These practices have
resulted in long delays in diagnosis.
The laboratories associated with these
health-care settings may now use an
RDT to more rapidly determine if their
patients are infected with malaria.
Malaria antibody detection is
performed using the indirect
fluorescent antibody (IFA) test. The
IFA procedure can be used to
determine if a patient has been infected
with Plasmodium. Because of the time
DISADVANTAGE
Microscopy results are only as reliable
as the laboratories performing the
tests. In the United States, there are, on
average, 1700 cases of malaria
diagnosed and reported each year.
Thus, the average laboratorian does
not perform this test regularly, and
may not be maintaining optimal
proficiency.
The use of the RDT does not eliminate
the need for malaria microscopy. The
RDT may not be able to detect some
infections with lower numbers of
malaria parasites circulating in the
patient’s bloodstream. Also, there is
insufficient data available to determine
the ability of this test to detect the 2
less common species of malaria, P.
ovale and P. malariae. Therefore all
negative RDTs must be followed by
microscopy to confirm the result. In
addition, all positive RDTs also should
be followed by microscopy. The
currently approved RDT detects 2
different malaria antigens; one is
specific for P. falciparum and the other
is found in all 4 human species of
malaria. Thus, microscopy is needed
to determine the species of malaria that
was detected by the RDT. In addition,
microscopy is needed to quantify the
proportion of red blood cells that are
infected, which is an important
prognostic indicator.
Species-specific testing is available for
three of the four human species: P.
falciparum, P. vivax, and P. malariae.
P. ovale antigens are not always
readily available and so antibody
testing is not performed routinely.
required for development of antibody Cross reactions often occur between
and also the persistence of antibodies, Plasmodium species and Babesia
serologic testing is not practical for species.
routine diagnosis of acute malaria.
However, antibody detection may be
useful for: Screening blood donors
involved in cases of transfusion-
induced malaria when the donor’s
parasitemia may be below the
detectable level of blood film
examination Testing a patient, usually
from an endemic area, who has had
repeated or chronic malaria infections
for a condition known as tropical
splenomegaly syndrome Testing a
patient who has been recently treated
for malaria but in whom the diagnosis
is questioned.