Trends in imported malaria during the COVID-19 pandemic, Spain ( plus Redivi Collaborative Network)

Introduction: The COVID-19 pandemic has caused disruptions in prevention and management strategies for malaria globally. Currently, data analysing trends in travel-related infections during the pandemic years are scarce. The objective of this analysis was to describe the epidemiological and clinical characteristics of patients with imported malaria within the +Redivi network in Spain, focusing on yearly trends from pre-pandemic years to date. Methods: Cases recorded in +Redivi from October 2009 to December 2021 were analysed and patients with a diagnosis of malaria (standard diagnostic methods using thick/thin peripheral blood smears, with/without a malaria rapid diagnostic test and/or Plasmodium spp. polymerase chain reaction) were identified. The total number of malaria cases, cases according to type of patient and severe cases, per year, were analysed. Results: In total, 1751 cases of malaria (1751/26601, 6.6%) were identified. The majority occurred in males (1041, 59.5%), median age was 36.3 (interquartile range: 27-44.7) years and most occurred in visiting friends and relatives (VFR)-immigrants (872, 49.8%). Most infections were acquired in sub-Saharan Africa (1.660, 94.8%) and were due to Plasmodium falciparum (81.3%). There were 64 cases of severe malaria (3.7%) and 4 patients died (0.2% mortality, all in pre-pandemic years). A significant increase in cases of severe malaria was observed during the study period (P<0.001) (attributable to the increase in 2021). There were 16/93 severe cases in 2021 (17.2%), all due to Plasmodium falciparum, (compared with <= 5% in previous years), which mainly occurred in travellers and VFR-immigrants (10/16, 62.5% and 5/16, 31.3%, respectively). Conclusions: After an initial decline associated with travel restrictions due to the ongoing COVID-19 pandemic, an increase in imported malaria and a significant increase in cases of severe malaria was observed. Patients with imported malaria may present and/or be diagnosed late during this public health crisis and health care professionals should be alerted to the recent increase in severe cases.