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Odyssean Malaria in South Africa (2014-2023): An In-Depth Review
Estimated Read Time: 4 minutes, 30 seconds
Estimated Listening Time: 6 minutes, 43 seconds
Originally Published: July 2023
Source: Public Health Bulletin
Type of article: Summary of Report or Analysis
MedED Catalogue Reference: MDRA002
Category: Reports & Analysis
Cross-reference: Infectious & Tropical Diseases
Keywords: Odyssean Malaria, malaria, Anopheles Mosquito, endemic-malaria, cryptic malaria
1. Odyssean malaria is a malaria infection caused by a malaria-parasite-infected mosquito that has been inadvertently transported to a non-endemic area via transport links such as sea, air, rail, or road.
2. While uncommon, the number of cases of infection resulting from odyssean malaria during the period under investigation in this Review ( 2014-2023) represents an increase over previous periods.
3. Odyssean malaria has a higher-than-average mortality rate, in part due to late diagnosis and treatment.
4. With increased travel from endemic regions, including Zimbabwe and Mozambique, particularly following holiday periods, healthcare providers must be alert to the possibility of malaria infection in patients with no history of travel.
Report Overview & Importance | The Context | Study Design | Findings | Recommendations | Conclusion | Access the Report
Overview & Importance
As travel to malaria-endemic regions, both locally and in neighbouring areas, increases, an understanding and awareness of odyssean malaria are crucial for improving patient outcomes and developing effective public health initiatives.
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The Context
In South Africa, malaria transmission is typically restricted to the regions of Limpopo, Mpumalanga, and KwaZulu-Natal, where the heat, humidity and higher rainfall are most favourable to the vectors of human malaria - the Anopheles mosquitoes.
However, there are cases where malaria occurs outside of these areas and where direct infection by the Anopheles mosquito is not obvious. These cryptic cases can include person-to-person transmission through infected blood or tissue or nosocomial transmission via contaminated materials or fluids. The Anopheles mosquito can also be imported to a non-endemic area via transportation links like air, road, rail, or sea. This is what is referred to as odyssean malaria, also known as airport, suitcase, minibus, or taxi-rank malaria.(pg1)
While instances of Odyssean malaria are relatively uncommon, during the ten years under investigation in this Review, there was a noted increase in its occurrence, particularly in Gauteng Province. This highlights the importance of increasing awareness of this form of transmission.
Below follows a summary of the findings of the Odyssean Malaria in South Africa (2014-2023): An In-Depth Review published in the latest Public Health Bulletin South Africa ( July 2024)
This is by no means a complete reflection of the review findings, and a link to the full Review is below.
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Study Design
For the purposes of the Review, odyssean malaria was defined as :
The investigators identified a case as odyssean malaria when epidemiological investigations were unable to determine an apparent mode of infection other than where mosquitoes may have inadvertently traveled to non-endemic areas through road, rail or other modes of transport.
The study method used for the Review was a descriptive analysis of all investigations conducted between 2014 and 2023 and included clinical and laboratory records, site visits and assessments and patient interviews. Entomological investigations for adult mosquitoes and larvae in potential aquatic breeding sites were conducted at index houses and other places of interest. Only cases investigated by personnel from the National Institute for Communicable Diseases ( NICD) were included.
A summary of the findings of the review is as follows: (pg3,4,5,7)
- Ninety-nine cases of odyssean malaria were determined in the period under investigation, 97 of which were laboratory-confirmed cases, and two were probable cases
- The cases occurred in 27 clusters, most within the same household. Four of the clusters occurred within game lodges or reserves
- The majority of cases were due to infection by P. falciparum (98%)
- Three of the cases were reported among pregnant women
- The majority of the cases (69%) were among adults aged 18 years and older
- Seventeen deaths were recorded from infection by odyssean malaria. This reflects a case fatality of 17%, approximately 17 times higher than the national fatality rate for malaria in SA
- Most of the cases were reported in December, January, March, and May, which relate to the holiday seasons in the region
- The vast majority of the cases were reported in Gauteng Province (GP) (84% ), with the North West Province (NW) recording the next highest infection rate at 7%
- Within GP, the cities of Johannesburg and Tshwane accounted for most of the reported cases
The review made several recommendations, including that healthcare workers consider testing for malaria in any patient who presents with unexplained febrile illness, especially if it is accompanied by thrombocytopenia.
Furthermore, the investigators recommended wider use of point-of-care rapid diagnostic malaria tests in settings where routine laboratory diagnosis is delayed or unavailable, such as in primary care settings.
Cases of odyssean malaria are inevitable due to the high and ever-increasing volume of road, rail and air traffic from malaria-risk areas. This dynamic, coupled with the increase of artemisinin resistance on the continent and the ability of the parasites to avoid detection via rapid-testing kits, makes the cases of imported and odyssean malaria of increasing significance.
Although outbreaks are uncommon, the review highlights the need for healthcare practitioners to consider malaria as a differential diagnosis in patients who present with unexplained fever and thrombocytopenia, even in the absence of travel history.
Odyssean malaria will remain a risk in SA’s non-endemic provinces until malaria is eliminated in the region.
Report Download: Odyssean Malaria in South Africa (2014-2023): An In-Depth Review. Public Health Bulletin South Africa, July 2024 (PDF)
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