Domestic Refugee Health Screening Guidance
Malaria Screening
Last updated: July 2022
On this page:
Minnesota malaria screening recommendations
Microlearning series: Malaria
Labs
Best practices
Background and epidemiology
Resources
Minnesota malaria screening recommendations
- Refugees from sub-Saharan Africa who received pre-departure treatment with a recommended antimalarial drug or drug combination do not need further evaluation or treatment for malaria unless they have signs or symptoms of disease.
- Symptomatic individuals should be tested for malaria and treated as indicated.
- Offer post-arrival treatment (preferred) or conduct screening for refugees from sub-Saharan Africa with no documentation of pre-departure treatment, if within 3 months of U.S. arrival. Presumptive treatment is contraindicated for the following groups:
- Pregnant women in their first trimester of pregnancy
- Infants weighing < 5 kilograms (kg)
- Those with a known allergy to the medication being used
- Refugees from areas other than sub-Saharan Africa are not routinely presumptively treated or tested, unless specifically directed. Refugees with signs or symptoms who have been in endemic areas should be evaluated promptly for malaria: CDC: Where Malaria Occurs.
Microlearning series: Malaria
This video (under 5 minutes) is meant to serve as a summary of malaria screening guidance and resources for providers completing the refugee health screening and all those serving new arrivals.
Refugee Health Microlearning Series: Malaria Transcript (PDF)
Labs
- PCR is preferred in asymptomatic individuals, as it is more sensitive, and helpful in species determination.
- If PCR is not available, blood smears (3 separate blood films taken at 12- to 24- hour intervals) should be examined.
- A rapid diagnostic test (RDT) should only be used in conjunction with blood smears, as it has the lowest sensitivity.
Best practices
- When presumptive treatment for malaria is deemed necessary, atovaquone-proguanil (Malarone™) and artemether-lumefantrine are the medications of choice in the United States. Additional information on the treatment of malaria can be found on CDC: Malaria.
- Any individual who tests positive for malaria (Plasmodium spp.) must be reported to MDH within one working day: Reporting Malaria (Plasmodium spp.).
- Some hematologic or physical examination findings in screening of asymptomatic individuals, such as thrombocytopenia or splenomegaly, are associated with malaria in individuals from highly endemic areas. Malaria should be considered in the differential diagnosis of refugees with these clinical signs, even when lacking other common symptoms such as fever. High rates of splenomegaly have been observed in Congolese refugees, and CDC has issued specific guidance for this population at Unresolved Splenomegaly in Recently Resettled Congolese Refugees ― Multiple States, 2015–2018.
Background and epidemiology
Malaria is a febrile illness caused by several protozoan species in the genus Plasmodium. The parasite is transmitted to humans by bites from infected Anopheles genus mosquitoes. The risk of malaria is highest in the tropical and sub-tropical regions of the world. Although local transmission of malaria frequently occurred in Minnesota over 100 years ago, all of the cases reported in Minnesota residents in recent years have been imported infections acquired abroad.
Although global malaria incidence has declined over the past 10 years, an estimated 229 million new cases of malaria occurred worldwide in 2019, with 94% of them in Africa (World Health Organization: World Malaria Report 2020). The acute clinical consequences of infection and disease are most severe in persons who have no malaria immunity (also called tolerance); as a result, in highly endemic areas, young children account for most malaria deaths. Although five species of malaria routinely infect humans, the burden and consequences of Plasmodium falciparum predominate. Among those with no immunity, P. falciparum infection may lead to severe morbidity or mortality within hours of onset of symptoms.
In the late 1990s, concerns about the high prevalence of Plasmodium infection in refugees from sub-Saharan Africa led the Centers for Disease Control and Prevention (CDC) to recommend that all refugees departing for the United States from malaria-endemic areas in sub-Saharan Africa receive presumptive therapy for malaria. These recommendations were issued in May 1999 to organizations and clinicians performing pre-departure examinations and management (“panel physicians”). Presently, CDC recommends presumptive, pre-departure ACT (artemether-lumefantrine [Coartem™]) for refugees departing out of sub-Saharan Africa. This presumptive therapy is completed no sooner than 5 days before departure and is administered and documented as directly observed therapy (CDC: Recommendations for Pre-departure Presumptive and Directed Treatment for P. falciparum Infection for Refugees from sub-Saharan Africa).
Since 2010, an average of 50-60 cases of malaria have been reported in Minnesota residents each year. The majority of cases likely acquired malaria in Africa with Liberia, Nigeria, and Kenya being the most commonly reported exposure locations.
Among refugees who arrived in Minnesota from 2009-2019, 1,498 (7%) were tested for malaria at their post-arrival Refugee Health Assessment (RHA). The majority of refugees were not tested for malaria due to the recommendation not to test asymptomatic arrivals from regions outside of sub-Saharan Africa, or arrivals from sub-Saharan who had been treated presumptively overseas. Among those tested for malaria, only nine (1%) tested positive. Among the nine who tested positive, five were infected P. falciparum and four with P. vivax. All nine were subsequently treated for malaria infection.
Malaria Infection among Primary Refugees to Minnesota by Region of Origin, 2009-2019
| Region of Origin* | Received RHA** | Tested for Malaria (%)*** | Positive and Treated (%)**** |
|---|---|---|---|
| East Asia/Pacific | 38 | 9 (24%) | 0 (0%) |
| Eastern Europe | 778 | 58 (7%) | 0 (0%) |
| Latin America/Caribbean | 223 | 22 (10%) | 0 (0%) |
| North Africa/Middle East | 1,368 | 61 (5%) | 0 (0%) |
| South/Southeast Asia | 8,531 | 334 (4%) | 5 (1%) |
| Sub-Saharan Africa | 9,129 | 1,014 (11%) | 4 (<1%) |
| Total | 20,067 | 1,498 (7%) | 9 (1%) |
*Based on MDH's world regions
**Refugee Health Assessment (RHA): health screening done in U.S., usually within 90 days of U.S. arrival
***% among those who received RHA
****% among those screened for malaria
Resources
- Malaria
MDH staff are available to provide clinical consultation regarding testing and diagnosis of malaria and other mosquito-transmitted diseases. Call 651-201-5414 for a clinical consultation. - CDC: Clinical Testing and Diagnosis for Malaria