Malaria is one of the greatest health problems in the world, with an estimated 207 million cases in 2012 (1). The number of deaths is uncertain owing to inadequate diagnosis and reporting, but has been estimated at between 473 000 and 1.2 million per year. More than 80 % of these occur in sub-Saharan Africa (1, 2).
The European Centre for Disease Control and Prevention (ECDC) registered 5 482 cases of malaria in Europe in 2011 (3). The patients were mainly infected in sub-Saharan Africa and south-east Asia. Imported malaria is most frequently due to the potentially malignant Plasmodium falciparum, and according to figures from the global surveillance system for travel-related infectious diseases (GeoSentinel), falciparum malaria accounted for 5 % of 17 228 cases of travel-related disease in 2009 (4). Infection in Europe is highly unusual in modern times, but 61 cases of vivax malaria contracted in Greece were reported in 2011 (3).
During the period 2004 – 2013, 28 – 88 cases of malaria were reported annually in Norway to the Reporting System for Infectious Diseases (MSIS) (5). The highest number was recorded in 2013, with 88 cases distributed among 18 of Norway’s 19 counties. Nord-Trøndelag was the only county in which no cases of malaria were reported. By way of comparison, 27 – 48 cases of systemic meningococcal disease were reported during the same period (5). As many as 57 – 75 % of the malaria cases diagnosed in Norway are caused by P. falciparum (5).
Atovaquone-proguanil or mefloquine are usually recommended as prophylaxis in connection with travel to malaria areas. According to figures from the Norwegian Prescription Register, 23 787 prescriptions for atovaquone-proguanil and 4 011 for mefloquine were issued in Norway in 2012 (6). There has been a gradual increase in the annual number of prescriptions for atovaquone-proguanil over the past decade, with 8 430 more prescriptions in 2012 than in 2005, while the annual number of prescriptions for mefloquine has remained unchanged.
In Norway, African immigrants are the group who most frequently contract malaria, because they often travel to endemic areas without using prophylaxis (7). Our experience is that people who originate from malaria-endemic areas find the disease troublesome but seldom dangerous, because of immunity, and do not take into account that they have lost their immunity to malaria. Tourists, people on foreign postings and other travellers are also at risk of infection. It is therefore important for all population groups to be aware of the risk of malaria (7).
Malaria symptoms are non-specific in the early phase, and may be misdiagnosed as influenza, gastroenteritis or other acute fevers with general symptoms in the form of nausea, vomiting, diarrhoea, headache, backache, muscular pain or cough (8).
In cases of falciparum malaria or the rare type of malaria that is due to Plasmodium knowlesi, the disease can rapidly develop into serious illness where emergency treatment may save the patient’s life. A malaria patient who is generally affected to the extent of being incapable of swallowing tablets, has signs of vital organ dysfunction or a high parasite count (> 2 – 4 %), has severe malaria (8). Pregnant women and small children are at particular risk of more rapid development of the disease and a more serious course (9).
Malaria is diagnosed by means of Giemsa-stained thin- and thick-film blood film smears that reveal the type of Plasmodium and parasitaemia (percentage of red blood cells infected). Antigen tests constitute a supplement that can rapidly detect whether the patient has malaria and should therefore be available at all hospitals, especially those without malaria microscopy expertise. There are many different malaria rapid diagnostic tests (RDTs) with varying sensitivity and specificity (10). All tests have a generally lower sensitivity to species other than P. falciparum.
Patients with suspected malaria must take a test without delay. If falciparum malaria is detected, the patient must be treated and put under surveillance in hospital where drugs for intravenous treatment must be available in case the disease takes a severe course. Detailed guidelines for malaria treatment in Norway have been published previously in the Journal of the Norwegian Medical Association (11) and in Nasjonal faglig retningslinje for bruk av antibiotika i sykehus [National guidelines for the use of antibiotics in hospitals], published by the Norwegian Directorate of Health in 2013 (12).
The object of the present study was to investigate preparedness and procedures for the diagnosis and treatment of malaria at Norwegian hospitals.