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To prevent future epidemics, enhanced quality assurance is essential., Because of instability in eastern Afghanistan, new refugees crossed into the federally administered tribal areas of northwestern Pakistan in 2002. In 2003, we investigated an epidemic of Plasmodium falciparum malaria in 1 of the camps. Incidence was 100.4 cases/1,000 person-years; in other nearby camps it was only 2.1/1,000 person-years. Anopheline mosquitoes were found despite an earlier spray campaign. Documented clinical failures at the basic health unit prompted a drug resistance survey of locally manufactured sulfadoxine-pyrimethamine used for routine treatment. The in vivo failure rate was 28.5%. PCR analysis of the P. falciparum dihydrofolate reductase and dihyropteroate synthase genes showed no mutations associated with clinical failure. However, chemical analysis of the drug showed that it was substandard. As global incidence decreases and epidemics become more of a threat, enhanced quality assurance of control interventions is essential.

Although most malaria occurs in Africa and Asia, it is also found in travelers returning from malaria-endemic regions (1). In the United States in 2005, a total of 1,528 cases of malaria were diagnosed, an increase of 15% from the previous year (2). In the United Kingdom in 2006, a total of 1,758 malaria cases were reported (3). In each country, malaria prophylaxis was inadequate for 75%–80% of patients (2,3). Most cases of malaria in travelers occur sporadically as single cases. We describe a cluster of Plasmodium falciparum malaria cases among a group of US citizens returning from East Africa.

Since 1963, reported malaria transmission in Haiti has been restricted to Plasmodium falciparum. However, screening of Haitian refugees in Jamaica in 2004, by microscopic examination, identified P. falciparum, P. vivax, and P. malariae. PCR confirmed the P. malariae and P. falciparum but not P. vivax infections. DNA sequencing and rRNA gene sequences showed transmission of P. malariae. This report confirms that P. malariae is still being transmitted in Haiti.