Source: Stager K, Legros F, Krause G, et al. Imported malaria in children in industrialized countries, 1992–2002. Emerg Infect Dis. 2009;15(2):185–190; doi:10.3201/eid1502.080712A multinational group of investigators evaluated the epidemiology of imported malaria in children ≤18 years of age in 11 industrialized countries, identified trends and risk groups, and ranked destinations according to malaria risk for children. Data from 1992 to 2002 were collected directly from the 11 countries’ health authorities. Imported malaria was defined as parasitologically confirmed malaria that had been acquired in a disease-endemic area, diagnosed after clinical disease had developed and when the person was in an industrialized country where the disease was not endemic. Data from the United Nations World Tourism Organization was used to estimate the total numbers of travelers to malaria-endemic countries; the investigators assumed that 1 of 10 travelers was <18 years of age.A total of 17,009 cases of imported malaria were reported. The frequency of reported malaria in different age groups ranged from 13.5% (for children 0–2 years old) to 18.1% (15–17 years old). Greater than 75% of cases were reported from France (6,618), the UK (3,816), and the US (2,614). More than 50% of all imported malaria world-wide was imported from Africa, principally West Africa. Plasmodium falciparum accounted for 70% of all cases. The case-fatality ratio for all countries was <0.4%. Less than 20% of infected children had taken malaria chemoprophylaxis. In the US, cases were most often imported from Central America and South America, followed by West and East Africa and Asia. In the US, P falciparum accounted for 47% of cases, P vivax 38%, P ovale 2.5%, and P malaria 4.8%. Among US children, there were four deaths among the 1,225 cases.The authors recognize limitations of the study included underreporting, missing data, inadequate surveillance systems, and differing malaria case definitions (clinical vs laboratory-confirmed cases). They caution that many immigrants think the partial immunity acquired while living in the endemic county will protect them during a return trip and are not aware that the immunity wanes within six months. Practitioners need to ensure that their patients take malaria chemoprophylaxis when traveling to malaria-endemic areas.Dr Dinerman has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.This study is a reminder of the importance of providing pre-travel advice on malaria prevention and remaining aware of the possibility of malaria in children returning to the US from endemic areas. Malaria continues to be one of the most important and devastating infectious diseases in developing areas of the world, responsible for one million deaths each year, mostly from sub-Saharan Africa.1 Malaria is the 3rd leading cause of global mortality in children younger than 5 years of age (see AAP Grand Rounds, August 2005;14:22–232). Malaria is the most common cause of fever (59%) in patients with a systemic febrile illness after travel to endemic countries.3 (See also AAP Grand Rounds, October 2007;18:43–44.4)The diagnosis should be considered in the febrile child returning from an area with known transmission. Symptoms of malaria are generally non-specific, including fever, chills, weakness, nausea, vomiting, diarrhea, headache, dizziness, myalgia, and cough. Pediatricians needing assistance with the diagnosis or management of suspected cases can call the CDC Malaria Hotline at (770) 488–7788 to consult with a specialist. Additionally, concise treatment guidelines are available online at http://www.cdc.gov/Malaria/pdf/treatmenttable.pdf.To enhance malaria surveillance in the US, be aware that malaria is a nationally notifiable disease. Cases should be reported to the state and local health department which forwards the information to the National Malaria Surveillance System (NMSS) managed by the CDC’s Division of Parasitic Diseases.International travel offers children a potentially culturally enriching and life-enhancing experience. As this study demonstrates, however, it is not without risk. While the authors emphasize malaria chemoprophylaxis for travelers to endemic malaria regions, we believe clinicians should also stress the importance of primary prevention of mosquito-borne diseases by using long-sleeved shirts and long pants, insect repellents, and mosquito netting.Although malaria is not currently a vaccine-preventable disease, increased funding and research have led to the development of several promising candidate vaccines which are currently undergoing large-scale clinical trials.5,6