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Malaria in Tunisian Military Personnel after Returning from External Operation

Malaria in Tunisian Military Personnel after Returning from External Operation Hindawi Publishing Corporation Malaria Research and Treatment Volume 2013, Article ID 359192, 3 pages http://dx.doi.org/10.1155/2013/359192 Clinical Study Malaria in Tunisian Military Personnel after Returning from External Operation 1 1 1 1 1 2 Fa\da Ajili, Riadh Battikh, Janet Laabidi, Rim Abid, Najeh Bousetta, Bouthaina Jemli, 1 1 2 1 Nadia Ben abdelhafidh, Louzir Bassem, Saadia Gargouri, and Salah Othmani Department of Internal Medicine, Military Hospital of Tunis, 1008 Montefl ury, Tunisia Department of Parasitology, Military Hospital of Tunis, 1008 Montefl ury, Tunisia Correspondence should be addressed to Fa¨ıda Ajili; faida1977@yahoo.fr Received 24 December 2012; Revised 21 April 2013; Accepted 27 April 2013 Academic Editor: Neena Valecha Copyright © 2013 Fa¨ıda Ajili et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Malaria had been eliminated in Tunisia since 1979, but there are currently 40 to 50 imported cases annually. Soldiers are no exception as the incidence of imported malaria is increasing in Tunisian military personnel aeft r returning from malaria-endemic area, often in Sub-Saharan Africa. Methods. We retrospectively analyzed the clinical and biological presentations, treatment, and outcomes of 37 Tunisian military personnel hospitalized at the Department of Internal Medicine, the Military Hospital of Tunis, between January 1993 and January 2011, for imported malaria. eTh clinical and laboratory features were obtained from the medical records and a questionnaire was filled by the patients about the compliance of malaria prophylaxis. Results. Thirty- sevenmalepatients,withameanageof41years,weretreatedformalariainfection.Twenty-twoweredueto Plasmodium falciparum. The outcome was favourable for all patients, despite two severe access. The long-term use of chemoprophylaxis has been adopted by only 21 (51%) of expatriate military for daily stresses. Moreover, poor adherence was found in 32 patients. Conclusion.Theriskof acquiring malaria infection in Tunisian military personnel can largely be prevented by the regular use of chemoprophylactic drugs combined with protective measures against mosquito bites. 1. Introduction currently between 40 and 50 annual cases of imported malaria. Plasmodium falciparum is the origin of the majority Malaria is one of the most widespread infectious diseases of of the cases [3, 4]. Soldiers are no exception, as malaria our time. According to the latest WHO estimates, there were represents a common risk threatening sometimes the vital about 219 million cases of malaria in 2010 and an estimated prognosis in military dealing with external operation. eTh 660 000 deaths. Africa is the most aeff cted continent: about returned infected militaries are a source of parasite and may 90% of all malaria deaths occur there. lead to the reappearance of malaria in countries where it was eTh last few years were marked by an increasing number previously eradicated. It essentially reflects a misapplication of imported malaria supported by the increasing number of of prophylactic measures. international travel in association with the important influx The aim of this paper is to review the literature about of immigrants from malaria-endemic countries especially imported malaria in soldiers and to assess the compliance from the Sub-Saharan Africa [1]. Malaria burden is difficult of malaria prophylaxis among the soldiers in our military to estimate, especially in low-income countries where data hospital in the department of internal medicine during the collection and reporting quality are poor. Data emerging period from January 1993 to January 2011. from WHO reports just estimate malaria incidence and mort- ality, reporting malarial cases and malarial death from the dif- 2. Patients and Methods ferent WHO regions, collected by ministries of health of dif- ferent countries. These data do not reflect the real inci- The malaria prophylaxis was based on mefloquine at a dose of dence in the general population [2]. In Tunisia, we declare 250 1 tab/week began a week before departure and continued 2 Malaria Research and Treatment during the stay and 4 weeks aeft r return or doxycycline 200 mefloquine 250 divided into 3 doses at 8 h (3 then 2 then 1 at adoseof1tablet/day startedonthe dayofdeparture tablet) or artemether + lumefantrine (Coartem) 6 taken in and continued during the stay and 4 weeks aeft r return. eTh total over 3 days at the following times: H0, H8, H24, H36, soldiers were educated to respect the recommendations for H48, and H60. Under malaria treatment, the clinical course malaria prophylaxis that is the protection against mosquito was quickly favorable with a thermal defervescence and a bites (mosquito nets, repellents, impregnated clothing and disappearanceofsymptomsinlessthanfourdaysin35cases coils). Aeft r returning from a mission in endemic countries (94%). There were no deaths among the patients included in (Rwanda, Cambodia, the Democratic Republic of Congo, thestudy.Sideeeff ctsofmalariatreatmentwerereportedin14 Cote d’Ivoire), we detected 37 cases of malaria. A question- patients (38%). They were mostly digestive disorders such as naire was filled by all the patients and they gave notification nausea vomiting, diarrhea, dizziness, or rash. We have noted whether they stopped prophylaxis or not, their adherence to no cases of relapses in our series. the treatment, and the reasons of the noncompliance. The diagnosis of malaria was so mentioned in front of 4. Discussion an infectious syndrome confirmed by testing gout thick. All patients underwent blood samples including parasitological Most of the published studies have assessed the noncom- test (thick blood smear), a biological assessment (hemato- pliance aeft r returning from malaria-endemic areas, either logical blood sample, liver and kidney blood tests, balance through questionnaires filled in by travelers [ 5–7]orsick inflammatory), and clinical monitoring (temperature, neuro- patients or through prophylaxis plasma concentration in sick logical status). patients. Military in mission in an endemic country, prophy- lactic treatment noncompliance was estimated between 63.4 and 54.7% in different series [ 8–10]. 3. Results McCarthy and Coyle [11] had analyzed the effect of eTh patients were all male with an average age of 41 years. eTh malaria chemoprophylaxis drug use in potential travelers. long-term use of chemoprophylaxis has been adopted by only eTh authors concluded that potential travelers were more 21 (51%) of expatriate military for daily stresses. Moreover, tolerant of taking prophylaxis if associated with no or mild poor adherencewas foundinthe questionnaireof32patients. adverse events and least tolerant of mild squeals from malaria The fears were iatrogenic risk of impotence infertility in all the and severe drug related events. non-compliant soldiers. This poor compliance of prophylaxis Ourstudy hadevaluated thecompliancewithmalaria resulted in 37 malaria cases in the Tunisian Armed Forces prophylaxis of military travelers by a questionnaire and aer ft returning from a mission in endemic countries. showed their noncompliance or poor adherence to this treat- Patients were received initially in the emergency depart- ment. Such preventative measures in our military even if they ment aer ft returning from the malaria-endemic area. All were poor, they have participated in the development of these patients had a thin/thick blood smear in the parasitological clinical forms less serious in our series. Soldiers were not laboratory of our hospital. No confirmation was made else- aware of the severity of the malaria disease and even 20 of where. This test allowed the diagnosis of malaria in all the them declared their noncompliance to the malaria prophyl- cases. No patient was treated without conrm fi ation by this axis; others may be hiding the truth regarding their compli- test. ance. The patients were then transferred to the internal med- The limits of our study were the missing of the practice of icine department. Clinically, the malaria was dominated by a blood sampling regarding the concentration of doxycycline high fever in all patients. Twenty patients (54%) had nausea or mefloquine, the retrospective character, and the monocen- and/or vomiting, headache and arthralgia. Thrombocytope- tric study as some asymptomatic soldiers may probably be nia was constant. Six patients (16%) had severe thrombocy- detected for malaria elsewhere with a great delay. 3 3 topenia (platelets<30×10 /mm ). Hepatic cytolysis was According to WHO, the malaria elimination terminology found in 75% of cases and a biological inflammatory syn- should be adopted when referring to the interruption of local drome in 90% of cases with a mean CRP = 80 mg/L, br fi ino- mosquito-borne malaria transmission and the reduction gen average = 6 g/L, and an average sedimentation rate = to zero of the incidence of infection caused by human 60 mm in H1. malaria parasites in a defined geographical area as a result of The majority of patients (35 cases, 94%) showed no deliberate efforts, but continued measures to prevent reest- admission severity criteria adopted by WHO [1]but2patients ablishment of transmission are required. who developed cerebral malaria (one case) and severe renal In Tunisia, malaria was eliminated since 1979; malaria failure with acute tubular necrosis (one case). remains topical in Tunisia because of the persistence of ano- Plasmodium (P.) falciparum was the most frequent species pheles and the coexistence of a potential reservoir of parasites (22 cases, 60%) seen in patients returned from Rwanda and consisting of imported cases of the disease. From 1999 to Democratic Republic of Cong, followed by P. ovalae (10 cases, 2006, 98 cases of imported malaria were diagnosed at the 27%) returned from Democratic Republic of Congo, P. vivax Pasteur Institute of Tunis, which lists about 30% of national (4 cases, 10%) in Cote D’Ivoire, and P. malariae (a case, 2%) cases [3]. No military studies had been published in this eld fi . in Cambodia. eTh re arefourtypes of humanmalaria: P. falciparum, Parasitemia ranged between 3 and 6%. It exceeded P. vivax, P. malariae, and P. ovale [12]. In our series, P. 5% in 4 patients. All patients received a treatment with falciparum was the most frequent species (22 cases, 60%), Malaria Research and Treatment 3 followed by P. ovalae (10 cases, 27%), P. vivax (4 cases, 10%), [6] J. E. Touze, J. M. Debonne, and J. P. Boutin, “Current situation and future perspectives for malaria prophylaxis among trav- and P. malariae (a case, 2%). P. falciparum and P. vivax are the ellers and military personnel,” Bulletin de l’Academie Nationale most common but P. falciparum is themostfatal if nottreated de Medecine,vol.191,no. 7, pp.1293–1303,2007. within 24 hours [13, 14]. [7] T.Debord, P. Eono,J.L.Rey,and R. Roue, ´ “Infectious hazards In P. vivax and P. ovale infections, patients having recov- in military personnel in operations,” Mede ´ cine et Maladies ered from the rfi st episode of illness may sueff r several addi- Infectieuses,vol.26, no.3,pp. 402–407, 1996. tional attacks aeft r months or even years without symptoms. [8] L.Ollivier, R. Michel,M.P.Carlottietal.,“Chemoprophylaxis Relapses occur because P. vivax and P. ovale have dormant compliance in a French battalion aer ft returning from malaria- liver stage parasites that may reactivate [15]. We have noted endemic area,” Journal of Travel Medicine,vol.15, no.5,pp. 355– no cases of relapses in our series. 357, 2008. Concerning our military, they have performed their mis- [9] R. Lessells, M. E. Jones, and P. D. Welsby, “A malaria outbreak sion in countries where P. falciparum was the dominant spe- following a British military deployment to Sierra Leone,” Jour- cies.Meantimetodiagnosis of malariawas relatively short24 nal of Infection, vol. 48, no. 2, pp. 209–210, 2004. hours (6 H–4 days) since all soldiers returning from a mission [10] N. Resseguier, V. MacHault, L. Ollivier et al., “Determinants in an endemic country were screened and this explains also of compliance with malaria chemoprophylaxis among French the rarity of severe cases in our series and the good response soldiers during missions in inter-tropical Africa,” Malaria to the treatment. Because of parasite resistance to antimalarial Journal,vol.9,no. 1, article41, 2010. drugs conventionally used, monotherapy is now banned in [11] A. E. McCarthy and D. Coyle, “Determining utility values the treatment of uncomplicated P. falciparum. Chloroquine related to malaria and malaria chemoprophylaxis,” Malaria has been for nearly 40 years, the rst fi -line drug eeff ctive, Journal,vol.9,no. 1, article92, 2010. easy to use, and inexpensive that permitted the control of [12] C. Godet, G. le Moal,M.H.Rodieretal.,“Imported malaria: malaria and its mortality. eTh emergence of resistance and prevention should strengthened,” Medecine et Maladies Infec- the extension of Plasmodium falciparum and P. vivax to this tieuses, vol. 34, no. 11, pp. 546–549, 2004. molecule are sometimes multiplied by a factor of vfi e and [13] F. Bruneel, L. Hocqueloux, C. Alberti et al., “The clinical spec- more, the malaria mortality [16]. Chloroquine has lost its trum of severe imported falciparum malaria in the intensive place in the arsenal therapeutic or prophylactic against P. care unit: report of 188 cases in adults,” American Journal of falciparum [15, 17]. The best available treatment, particularly Respiratory and Critical Care Medicine,vol.167,no. 5, pp.684– for malaria P. falciparum, is a combination drug including 689, 2003. artemisinin (ACT) [10, 11]. Tunisia adopted the combination [14] R. Petrognania, E. Peytela, C. Ponchela, J. P. Carpentiera, and therapy recommended by WHO to prevent resistance [4]. J. M. Sa¨ıssyb, “Severe imported malaria in adults,” Mede ´ cine et Maladies Infectieuses, vol. 36, no. 10, pp. 492–498, 2006. [15] M. Bernabeu, G. P. Gomez-Perez, S. Sissoko et al., “Plasmodium 5. Conclusion vivax malaria in Mali: a study from three different regions,” Malaria Journal,vol.11, no.1,article 405, 2012. The noncompliance of the of preventive measures, mainly, [16] A. E. Frosch,M.Venkatesan, andM.K.Laufer, “Patternsof chemoprophylaxis during the stay and return of soldiers from chloroquine use and resistance in sub-Saharan Africa: a sys- malaria-endemic areas, is partially the origin of these cases tematic review of household survey and molecular data,” of malaria. Awareness of the military and a strengthening of Malaria Journal, vol. 10, no. 1, article 116, 2011. their health education before and during the stay are needed [17] M. C. Henry and C. Rogier, “Evaluation du paludisme et de la to reduce the incidence of this infection which may involves lutte antivectorielle,” Mede ´ cine Tropicale,vol.69, no.2,p.117, serious life-threatening in patients. References [1] World Malaria Report, 2011. [2] B. Autino, A. Noris, R. Russo, and F. Castelli, “Epidemiology of malaria in endemic areas,” Mediterranean Journal of Hematol- ogy and Infectious Diseases,vol.4,no. 1, ArticleIDe2012060, [3] K. Aoun, E. Siala, D. Tchibkere et al., “Imported malaria in Tunisia: consequences on the risk of resurgence of the disease,” Mede ´ cine Tropicale,vol.70, no.1,pp. 33–37, 2010. [4] S. Belhadj, O. Menif, E. Kaouech et al., “Paludisme d’importa- tion en tunisie: bilan de 291 cas diagnostiques ´ al ` ’hop ˆ ital La Rabta de Tunis (1991–2006),” Revue Francophone des Labora- toires, vol. 38, no. 399, pp. 95–98, 2008. [5] A. L. Fontanet, S. Houze, ´ A. Keundjian et al., “Efficacy of anti- malarial chemoprophylaxis among French residents travelling to Africa,” Transactions of the Royal Society of Tropical Medicine and Hygiene,vol.99, no.2,pp. 91–100,2005. 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Malaria in Tunisian Military Personnel after Returning from External Operation

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Hindawi Publishing Corporation
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Copyright © 2013 Faïda Ajili et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Publishing Corporation Malaria Research and Treatment Volume 2013, Article ID 359192, 3 pages http://dx.doi.org/10.1155/2013/359192 Clinical Study Malaria in Tunisian Military Personnel after Returning from External Operation 1 1 1 1 1 2 Fa\da Ajili, Riadh Battikh, Janet Laabidi, Rim Abid, Najeh Bousetta, Bouthaina Jemli, 1 1 2 1 Nadia Ben abdelhafidh, Louzir Bassem, Saadia Gargouri, and Salah Othmani Department of Internal Medicine, Military Hospital of Tunis, 1008 Montefl ury, Tunisia Department of Parasitology, Military Hospital of Tunis, 1008 Montefl ury, Tunisia Correspondence should be addressed to Fa¨ıda Ajili; faida1977@yahoo.fr Received 24 December 2012; Revised 21 April 2013; Accepted 27 April 2013 Academic Editor: Neena Valecha Copyright © 2013 Fa¨ıda Ajili et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Malaria had been eliminated in Tunisia since 1979, but there are currently 40 to 50 imported cases annually. Soldiers are no exception as the incidence of imported malaria is increasing in Tunisian military personnel aeft r returning from malaria-endemic area, often in Sub-Saharan Africa. Methods. We retrospectively analyzed the clinical and biological presentations, treatment, and outcomes of 37 Tunisian military personnel hospitalized at the Department of Internal Medicine, the Military Hospital of Tunis, between January 1993 and January 2011, for imported malaria. eTh clinical and laboratory features were obtained from the medical records and a questionnaire was filled by the patients about the compliance of malaria prophylaxis. Results. Thirty- sevenmalepatients,withameanageof41years,weretreatedformalariainfection.Twenty-twoweredueto Plasmodium falciparum. The outcome was favourable for all patients, despite two severe access. The long-term use of chemoprophylaxis has been adopted by only 21 (51%) of expatriate military for daily stresses. Moreover, poor adherence was found in 32 patients. Conclusion.Theriskof acquiring malaria infection in Tunisian military personnel can largely be prevented by the regular use of chemoprophylactic drugs combined with protective measures against mosquito bites. 1. Introduction currently between 40 and 50 annual cases of imported malaria. Plasmodium falciparum is the origin of the majority Malaria is one of the most widespread infectious diseases of of the cases [3, 4]. Soldiers are no exception, as malaria our time. According to the latest WHO estimates, there were represents a common risk threatening sometimes the vital about 219 million cases of malaria in 2010 and an estimated prognosis in military dealing with external operation. eTh 660 000 deaths. Africa is the most aeff cted continent: about returned infected militaries are a source of parasite and may 90% of all malaria deaths occur there. lead to the reappearance of malaria in countries where it was eTh last few years were marked by an increasing number previously eradicated. It essentially reflects a misapplication of imported malaria supported by the increasing number of of prophylactic measures. international travel in association with the important influx The aim of this paper is to review the literature about of immigrants from malaria-endemic countries especially imported malaria in soldiers and to assess the compliance from the Sub-Saharan Africa [1]. Malaria burden is difficult of malaria prophylaxis among the soldiers in our military to estimate, especially in low-income countries where data hospital in the department of internal medicine during the collection and reporting quality are poor. Data emerging period from January 1993 to January 2011. from WHO reports just estimate malaria incidence and mort- ality, reporting malarial cases and malarial death from the dif- 2. Patients and Methods ferent WHO regions, collected by ministries of health of dif- ferent countries. These data do not reflect the real inci- The malaria prophylaxis was based on mefloquine at a dose of dence in the general population [2]. In Tunisia, we declare 250 1 tab/week began a week before departure and continued 2 Malaria Research and Treatment during the stay and 4 weeks aeft r return or doxycycline 200 mefloquine 250 divided into 3 doses at 8 h (3 then 2 then 1 at adoseof1tablet/day startedonthe dayofdeparture tablet) or artemether + lumefantrine (Coartem) 6 taken in and continued during the stay and 4 weeks aeft r return. eTh total over 3 days at the following times: H0, H8, H24, H36, soldiers were educated to respect the recommendations for H48, and H60. Under malaria treatment, the clinical course malaria prophylaxis that is the protection against mosquito was quickly favorable with a thermal defervescence and a bites (mosquito nets, repellents, impregnated clothing and disappearanceofsymptomsinlessthanfourdaysin35cases coils). Aeft r returning from a mission in endemic countries (94%). There were no deaths among the patients included in (Rwanda, Cambodia, the Democratic Republic of Congo, thestudy.Sideeeff ctsofmalariatreatmentwerereportedin14 Cote d’Ivoire), we detected 37 cases of malaria. A question- patients (38%). They were mostly digestive disorders such as naire was filled by all the patients and they gave notification nausea vomiting, diarrhea, dizziness, or rash. We have noted whether they stopped prophylaxis or not, their adherence to no cases of relapses in our series. the treatment, and the reasons of the noncompliance. The diagnosis of malaria was so mentioned in front of 4. Discussion an infectious syndrome confirmed by testing gout thick. All patients underwent blood samples including parasitological Most of the published studies have assessed the noncom- test (thick blood smear), a biological assessment (hemato- pliance aeft r returning from malaria-endemic areas, either logical blood sample, liver and kidney blood tests, balance through questionnaires filled in by travelers [ 5–7]orsick inflammatory), and clinical monitoring (temperature, neuro- patients or through prophylaxis plasma concentration in sick logical status). patients. Military in mission in an endemic country, prophy- lactic treatment noncompliance was estimated between 63.4 and 54.7% in different series [ 8–10]. 3. Results McCarthy and Coyle [11] had analyzed the effect of eTh patients were all male with an average age of 41 years. eTh malaria chemoprophylaxis drug use in potential travelers. long-term use of chemoprophylaxis has been adopted by only eTh authors concluded that potential travelers were more 21 (51%) of expatriate military for daily stresses. Moreover, tolerant of taking prophylaxis if associated with no or mild poor adherencewas foundinthe questionnaireof32patients. adverse events and least tolerant of mild squeals from malaria The fears were iatrogenic risk of impotence infertility in all the and severe drug related events. non-compliant soldiers. This poor compliance of prophylaxis Ourstudy hadevaluated thecompliancewithmalaria resulted in 37 malaria cases in the Tunisian Armed Forces prophylaxis of military travelers by a questionnaire and aer ft returning from a mission in endemic countries. showed their noncompliance or poor adherence to this treat- Patients were received initially in the emergency depart- ment. Such preventative measures in our military even if they ment aer ft returning from the malaria-endemic area. All were poor, they have participated in the development of these patients had a thin/thick blood smear in the parasitological clinical forms less serious in our series. Soldiers were not laboratory of our hospital. No confirmation was made else- aware of the severity of the malaria disease and even 20 of where. This test allowed the diagnosis of malaria in all the them declared their noncompliance to the malaria prophyl- cases. No patient was treated without conrm fi ation by this axis; others may be hiding the truth regarding their compli- test. ance. The patients were then transferred to the internal med- The limits of our study were the missing of the practice of icine department. Clinically, the malaria was dominated by a blood sampling regarding the concentration of doxycycline high fever in all patients. Twenty patients (54%) had nausea or mefloquine, the retrospective character, and the monocen- and/or vomiting, headache and arthralgia. Thrombocytope- tric study as some asymptomatic soldiers may probably be nia was constant. Six patients (16%) had severe thrombocy- detected for malaria elsewhere with a great delay. 3 3 topenia (platelets<30×10 /mm ). Hepatic cytolysis was According to WHO, the malaria elimination terminology found in 75% of cases and a biological inflammatory syn- should be adopted when referring to the interruption of local drome in 90% of cases with a mean CRP = 80 mg/L, br fi ino- mosquito-borne malaria transmission and the reduction gen average = 6 g/L, and an average sedimentation rate = to zero of the incidence of infection caused by human 60 mm in H1. malaria parasites in a defined geographical area as a result of The majority of patients (35 cases, 94%) showed no deliberate efforts, but continued measures to prevent reest- admission severity criteria adopted by WHO [1]but2patients ablishment of transmission are required. who developed cerebral malaria (one case) and severe renal In Tunisia, malaria was eliminated since 1979; malaria failure with acute tubular necrosis (one case). remains topical in Tunisia because of the persistence of ano- Plasmodium (P.) falciparum was the most frequent species pheles and the coexistence of a potential reservoir of parasites (22 cases, 60%) seen in patients returned from Rwanda and consisting of imported cases of the disease. From 1999 to Democratic Republic of Cong, followed by P. ovalae (10 cases, 2006, 98 cases of imported malaria were diagnosed at the 27%) returned from Democratic Republic of Congo, P. vivax Pasteur Institute of Tunis, which lists about 30% of national (4 cases, 10%) in Cote D’Ivoire, and P. malariae (a case, 2%) cases [3]. No military studies had been published in this eld fi . in Cambodia. eTh re arefourtypes of humanmalaria: P. falciparum, Parasitemia ranged between 3 and 6%. It exceeded P. vivax, P. malariae, and P. ovale [12]. In our series, P. 5% in 4 patients. All patients received a treatment with falciparum was the most frequent species (22 cases, 60%), Malaria Research and Treatment 3 followed by P. ovalae (10 cases, 27%), P. vivax (4 cases, 10%), [6] J. E. Touze, J. M. Debonne, and J. P. Boutin, “Current situation and future perspectives for malaria prophylaxis among trav- and P. malariae (a case, 2%). P. falciparum and P. vivax are the ellers and military personnel,” Bulletin de l’Academie Nationale most common but P. falciparum is themostfatal if nottreated de Medecine,vol.191,no. 7, pp.1293–1303,2007. within 24 hours [13, 14]. [7] T.Debord, P. Eono,J.L.Rey,and R. Roue, ´ “Infectious hazards In P. vivax and P. ovale infections, patients having recov- in military personnel in operations,” Mede ´ cine et Maladies ered from the rfi st episode of illness may sueff r several addi- Infectieuses,vol.26, no.3,pp. 402–407, 1996. tional attacks aeft r months or even years without symptoms. [8] L.Ollivier, R. Michel,M.P.Carlottietal.,“Chemoprophylaxis Relapses occur because P. vivax and P. ovale have dormant compliance in a French battalion aer ft returning from malaria- liver stage parasites that may reactivate [15]. We have noted endemic area,” Journal of Travel Medicine,vol.15, no.5,pp. 355– no cases of relapses in our series. 357, 2008. Concerning our military, they have performed their mis- [9] R. Lessells, M. E. Jones, and P. D. Welsby, “A malaria outbreak sion in countries where P. falciparum was the dominant spe- following a British military deployment to Sierra Leone,” Jour- cies.Meantimetodiagnosis of malariawas relatively short24 nal of Infection, vol. 48, no. 2, pp. 209–210, 2004. hours (6 H–4 days) since all soldiers returning from a mission [10] N. Resseguier, V. MacHault, L. Ollivier et al., “Determinants in an endemic country were screened and this explains also of compliance with malaria chemoprophylaxis among French the rarity of severe cases in our series and the good response soldiers during missions in inter-tropical Africa,” Malaria to the treatment. Because of parasite resistance to antimalarial Journal,vol.9,no. 1, article41, 2010. drugs conventionally used, monotherapy is now banned in [11] A. E. McCarthy and D. Coyle, “Determining utility values the treatment of uncomplicated P. falciparum. Chloroquine related to malaria and malaria chemoprophylaxis,” Malaria has been for nearly 40 years, the rst fi -line drug eeff ctive, Journal,vol.9,no. 1, article92, 2010. easy to use, and inexpensive that permitted the control of [12] C. Godet, G. le Moal,M.H.Rodieretal.,“Imported malaria: malaria and its mortality. eTh emergence of resistance and prevention should strengthened,” Medecine et Maladies Infec- the extension of Plasmodium falciparum and P. vivax to this tieuses, vol. 34, no. 11, pp. 546–549, 2004. molecule are sometimes multiplied by a factor of vfi e and [13] F. Bruneel, L. Hocqueloux, C. Alberti et al., “The clinical spec- more, the malaria mortality [16]. Chloroquine has lost its trum of severe imported falciparum malaria in the intensive place in the arsenal therapeutic or prophylactic against P. care unit: report of 188 cases in adults,” American Journal of falciparum [15, 17]. The best available treatment, particularly Respiratory and Critical Care Medicine,vol.167,no. 5, pp.684– for malaria P. falciparum, is a combination drug including 689, 2003. artemisinin (ACT) [10, 11]. Tunisia adopted the combination [14] R. Petrognania, E. Peytela, C. Ponchela, J. P. Carpentiera, and therapy recommended by WHO to prevent resistance [4]. J. M. Sa¨ıssyb, “Severe imported malaria in adults,” Mede ´ cine et Maladies Infectieuses, vol. 36, no. 10, pp. 492–498, 2006. [15] M. Bernabeu, G. P. Gomez-Perez, S. Sissoko et al., “Plasmodium 5. Conclusion vivax malaria in Mali: a study from three different regions,” Malaria Journal,vol.11, no.1,article 405, 2012. The noncompliance of the of preventive measures, mainly, [16] A. E. 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