Fernández López et al. Malar J (2015) 14:356 DOI 10.1186/s12936-015-0891-0 RESEARCH Open Access Imported malaria including HIV and pregnant woman risk groups: overview of the case of a Spanish city 2004–2014 María Fernández López1,2*†, Jose Manuel Ruiz Giardín1†, Juan Víctor San Martín López1, Jerónimo Jaquetti3, Isabel García Arata3, Carolina Jiménez Navarro4 and Noemi Cabello Clotet5 Abstract Background: Arrival of inmigrants from malaria endemic areas has led to a emergence of cases of this parasitic dis- ease in Spain. The objective of this study was to analyse the high incidence rate of imported malaria in Fuenlabrada, a city in the south of Madrid, together with the frequent the lack of chemoprophylaxis, for the period between 2004 and 2014. Both pregnant women and HIV risk groups have been considered. Methods: Retrospective descriptive study of laboratory-confirmed malaria at the Fuenlabrada University Hospital, in Madrid, during a 10-year period (2004–2014). These data were obtained reviewing medical histories of the cases. Rel- evant epidemiological, clinical and laboratory results were analysed, with focus on the following risk groups: pregnant women and individuals with HIV. Results: A total of 185 cases were diagnosed (90.3 % Plasmodium falciparum). The annual incidence rate was 11.9/100,000 inhabitants/year. The average age was 30.8 years (SD: 14.3). Infections originating in sub-Saharan Africa comprised the 97.6 % of the cases. A total of 85.9 % were Visiting Friends and Relatives. Only a 4.3 % completed adequate prophylaxis. A total of 14.28 % of the fertile women were pregnant, and 8 cases (4.3 %) had HIV. None of them in these special groups completed prophylaxis. Conclusions: The incidence rate in Fuenlabrada is higher than in the rest of Spain, due to the large number of immi- grants from endemic areas living in the municipality. However, the results are not representative of all the country. It seems to be reasonable to implement prevention and pre-travel assessment programs to increase chemoprophylaxis. Pregnancy tests and HIV serology should be completed for all patients to improve prophylactic methods. Keywords: HIV, Inmigrants, Malaria, Pregnancy, Public health, VFRs Background at risk of suffering from this disease. The WHO estimates Malaria is the most common and lethal parasitic disease that 198 million cases of malaria occurred worldwide in in the world and one of the most important public health 2013 and the disease led to 584,000 deaths. The worst problems. According to data from the World Health scenery can be found in the WHO African Region, where Organization (WHO), malaria is endemic in 104 coun- approximately a 90 % of all of the malaria deaths occur; tries, which suggests that half of the world’s population is children under 5 years in this area account for a 78 % of all the deaths [1]. Spain has 46.5 million inhabitants [2] and is defined as *Correspondence: [email protected] “the port of entry to Europe from Africa”. The large num- †María Fernández López and Jose Manuel Ruiz Giardín have contributed equally to the article and both should be considered as first author ber of immigrants arriving in the country from malaria 1 Department of Internal Medicine, Fuenlabrada University Hospital, endemic areas has led to a rise of this parasitic disease Fuenlabrada, C/Camino del Molino, 2, Zip Code 28942 Fuenlabrada, cases in the last years. Madrid, Spain Full list of author information is available at the end of the article © 2015 Fernández López et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons. org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Fernández López et al. Malar J (2015) 14:356 Page 2 of 9 The last reported autochthonous case of malaria in malaria were reported (between 350 and 400 cases a Spain was in 1961, while malaria was officially declared year), although due to under-reporting, the total number eradicated in 1964. In October 2010, one case of autoch- of imported cases is thought to be higher. In 2013, 143 thonous malaria due to Plasmodium vivax was diagnosed cases were reported, with an accumulated incidence rate in Aragon, north-eastern Spain. However, and due to the of 2.24 cases/100,000 inhabitants [6] (considering in the presence of the vector Anopheles atroparvus in Spain, denominator the registered population of Madrid from autochthonous malaria is not an unexpected fact [3]. In 2013 census). In 2014, between January and June, 53 addition, sporadic autochthonous transmission of vec- cases of malaria were reported [16]. tor-borne diseases in continental Europe is possible; this Regarding the municipality of Fuenlabrada, it has a fact could be appreciated after the occurrence of several population of 200,312 inhabitants living in 39.21 km2, emerging vector-borne disease outbreaks in different with a 13.6 % of immigrants (January, 2015) [17]. It is one countries in Europe [4]. of the regions of the community of Madrid with the high- In 2012, according to data from the National Network est number of reported cases of malaria, due to the fact of Epidemiological Vigilance of the National Centre of that a large number of immigrants from endemic areas Epidemiology (Red Nacional de Vigilancia Epidemi- have settled in here [18]. This city, in the south of Madrid, ológica del Centro Nacional de Epidemiología), 484 cases is where the presented study was focused. were reported to the WHO, all of which were imported cases, been caused mainly by Plasmodium falcipa- Objective rum [5]. In 2013, the incidence rate in Spain was 1.25 The main objectives of this study are to evaluate the high cases/100,000 inhabitants [6]. incidence rate of this parasitic disease in this Spanish In Spain, most of the imported malaria cases affect city (a non-endemic area), together with the description immigrants who live in Spain and travel to their home of the sociodemographic, epidemiological and clinical countries to visit their friends and relatives (Visiting characteristics of the cases of malaria diagnosed in the Friends and Relatives, VFR). This risk group represents Fuenlabrada University Hospital for a 10 years period an important percentage of the imported malaria cases (from its opening in June 2004 until June 2014). In addi- described in most of the studies about this matter [7–9]. tion, the lack of chemoprophylaxis is also analysed. Two In these cases, the high risk of malaria can be attributed risk groups are taken into account in the study: pregnant to various factors. In one hand, they do not receive pre- women and Human Immunodeficiency Virus (HIV). travel assessment. On the other, there is a low percep- tion of risk due to a sense of immunity against infection. Methods And finally, there are cultural and/or language barriers. As it has been already described in the Introduction sec- In addition, sometimes the travel is not planned, with tion, the study is focused on the municipality of Fuen- people having to travel rapidly to their home countries labrada. The malaria cases under analysis were all of to attend to a specific event [10]. Usually, they travel to those diagnosed between June 2004 and June 2014 in the rural areas and stay there for long periods of time [10, Fuenlabrada University Hospital. This centre attends the 11]. Traveller Visiting Friends and Relatives, who are whole population of the city, ant it has 350 beds. descendents of immigrants born in a non-endemic zone, In the municipality of Fuenlabrada, there were a total represent a special population [12]. Most of them are of 27,187 registered foreigners (13.6 %), with the follow- children who travel to the home countries of their par- ing distribution: Romanian (22.5 %), Moroccan (16.2 %), ents and who do not possess natural semi-immunity Nigerian (8.9 %), Chinese (7 %), Colombian (4.6 %), and against malaria [7, 10, 11, 13]. In fact, they sometimes Equatoguinean (4.4 %) [17]. The Sub-Saharan African suffer severe malaria. population registered in Fuenlabrada is 4377 inhabitants. The Community of Madrid is in the centre of Spain. Approximately a 14 % of the Sub-Saharan population in It has almost 6.5 million inhabitants and a 14.28 % of the Community of Madrid lives in the municipality of immigrant population (930,366 foreign inhabitants are Fuenlabrada [14]. It is important to emphasize that many registered). Romanians are the most numerous (22.6 %), foreigners are not legally registered and this number is followed by Moroccans (9 %) and other African nation- higher within the Sub-Saharan population. alities (3 %) [14]. Malaria has been a mandatory report- The study was performed as a descriptive retrospective ing disease in Madrid since 1995, when the responsibility survey performed in the Fuenlabrada University Hospital. of the surveillance programmes in Spain was transferred The clinical history numbers of the cases were provided from the national govern to the regional governs [15]. by the Departments of Microbiology and Preventive However, it has always been a mandatory reporting dis- Medicine. The database was completed and designed in a ease in Spain. Between 2004 and 2013, 1214 cases of retrospective manner after reviewing the clinical history Fernández López et al. Malar J (2015) 14:356 Page 3 of 9 of the cases. The usage of these clinical histories was microbiological criteria (i.e.