- Area: 2,345,410 km2
- Population: 62,660,000 inhabitants (estimate dated June 2006)
- Official language: French
- Currency: Congolese Franc since June 17, 1998 (on January 6, 2005, 1 US dollar = CDF 417)
- Border countries: Angola (Cabinda), Congo, Central African Republic, Sudan, Rwanda, Burundi, Uganda, Tanzania, Zambia and Angola
- Capital: Kinshasa (3-6 million inhabitants)
- Main cities: Mbuji-Mayi, Matadi, Kisangani, Lubumbashi, Mbandaka, Kikwit, Gbadolite and Kolwezi.

The country is largely composed of a central basin, drained by the Congo and its affluents.
In the Western part of the country, the topography (600 to 900 m) is composed of Mayombe and the Cristal Mountains. In the South, the Katanga plateaus reach an altitude of 1,500m, while the country’s highest summits are found in the East, in Kivu (Rwenzori Mountains, which reach 5,019m and the Virunga volcanic range, reaching over 3,000m).
In the basin, the DRC enjoys an equatorial climate that is always hot and humid. The climate turns tropical in the Northern part of the country and in the Southern part from the 5th parallel.
However, because of the vast surface area of this subcontinent, significant variations are observed, with a dry season that increases from the West to the East and from the North to the South (Fig. 2). When it exists, this dry season runs from May through August.

Resistance to chloroquine

According to Moran et al., resistance to chloroquine apparently appeared in the DRC in 1982, at the Eastern border, and, from there, it evidently spread throughout the entire country (22). Delacollette et al. confirm that in 1982, three Americans, members of the Peace Corps working in Kivu, contracted a chloroquine-resistant malaria (20).
Resistance is mentioned in 1985 by Ngimbi et al., in a study conducted in Kinshasa in 1984: out of 101 patients treated with chloroquine at a dose of 25 mg/kg given over three days, the rate of recovery was 95%. A strain was confirmed to be resistant in vitro (11). 
The same year, in an in vivo and in vitro study carried out in Kinshasa and Mbuji-Mayi, Phuc Nguyen-Dinh et al. did not observe any resistance (09). However, in 1986, they observed a level of resistance in vitro of 82% (13).
In vivo in 1988, Paluku et al. observed levels of sensitivity to chloroquine at a dose of 25 mg/kg over three days of 92% in children under 5 years old in Equador and of 44% only in Kinshasa (13). In 1989, the same authors observed sensitivity in vivo of 53.5 % in Kisangani, 19.5% in Bas-Congo and 55.5% in Bandundu (17).
In 1997, in vivo sensitivity to chloroquine at a dose of 25 mg/kg over three days was still 61%. It was 55% in 2003 (53); this inefficacy most likely explains that in Kinshasa and Kivu, regular treatment with chloroquine during pregnancy no longer prevents dysmaturity or low birth weight (54, 55).

Resistance to other antimalarial drugs

1. Amodiaquine:
No data published.

2. Quinine:
In 1989, in vivo sensitivity to quinine was 93.9% in Kisangani, 91.5% in Bas-Congo and 97.6% in Bandundu (17). 
Out of 34 children hospitalized with severe malaria and treated intravenously with quinine, fever clearance time was 44.1 hours and parasite clearance time was 59.6 hours (18).
In vitro, no plasmodium strain was found to be resistant to quinine (09).

3. Mefloquine:
No data published.

4. Halofantrine:
The study carried out by Mashako et al. in 1990 covered only 54 pediatric cases treated with halofantrine. Efficacy was 100%, fever clearance time was 18 hours and parasite clearance time was 37 hours (25).

5. The sulfadoxine-pyrimethamine combination:
In 1989, Paluku et al. observed an efficacy of the sulfadoxine-pyrimethamine combination in 95.8% of cases in Kisangani, 97.8% in Bas-Congo and 100% in Bandundu (17).
In 2003, Kazadi et al. noted 7.5% failures out of 333 treatments with the sulfadoxine-pyrimethamine combination for uncomplicated Plasmodium falciparum malaria (53).
 
6. Artemisinine derivatives:
No data published.

According to Karch et al., the anopheline fauna of Kinshasa comprises seven species: Anopheles gambiae is the species encountered most frequently (93.3%) and is responsible for one bite per person per night (b/p/night) in the city, against 26 in rural areas. The average annual inoculation rate is 197 infested bites per person per year (ib/p/year). Anopheles funestus, Anopheles paludis, Anopheles Hancocki, Anopheles coustani, Anopheles brunnipes and Anopheles nili are much more rare (29).
Coene has shown that in the city of Kinshasa, Culex mosquitoes are responsible for 121 b/p/night and Anopheles gambiae are responsible for 5.1 b/p/night. In rural areas, Anopheles gambiae is responsible for 13.3 b/p/night and Anopheles funestus is responsible for 2.4 b/p/night. The other species play a much smaller role: Anopheles nili (0.4 b/p/night), Anopheles brunnipes (0.7 b/p/night), Anopheles paludis (0.4 b/p/night) and Anopheles hancocki (0.2 b/p/night) (27).
In Bandundu, Karch and Mouchet have shown that Anopheles paludis is the most prevalent (55.1%), followed by Anopheles gambiae (27.8%), Anopheles funestus (11.2%), Anopheles moucheti (4.4%) and Anopheles nili (1.5%) (33).
According to Bafort, Anopheles marshalli apparently plays a role in malaria transmission in the Eastern part of the country (10).
Anopheles gambiae (68.3%), Culex (28.1 %) and Anopheles funestus (28.1 %) larvae have been isolated in the ponds of Kivu. Anopheline density is greater as the pond is shadier (59, 60).

In Kinshasa, using coils to fight mosquitoes inside homes has not proved effective: Coene et al. demonstrated that this practice was lowering the rate of bites by only 18% to 30% (16).
On the other hand, on the Bateke Plateaus near Kinshasa, the persistent use of insecticide-treated mosquito nets for beds has caused the number of Anopheles gambiae to drop by 94% and the number of ib/p/year to drop by 98% (37).

Malaria is an especially difficult burden for the populations in the Democratic Republic of the Congo.
Accordingly, an annual average of nine febrile illnesses have been observed per person in children under 5 years old and four febrile illnesses per person in those over 5 years old. Fever-related mortality in children under 5 years old is 3 p. 1000 (Health for All Project, 1985).
Malaria infection is found in 37% of primigravida and in 24% of all pregnant women (13).
Meuris et al. have shown that 18% of pregnant women with a malaria infection give birth to  low birth-weight newborns (35). 

Families respond as best they can, spending approximately 25% of their income: 85.6% buy coils, 55.5% use aerosol insecticides and 38.6% have mosquito nets for beds (28). Forty-four percent of children receive presumptive treatment for malaria when they have a fever (36).

From 1952 to 1961, Belgium had an average of 35 cases of malaria imported from Zaire (former name of the Democratic Republic of the Congo) each year, with extremes of seven in 1958 and 79 in 1952 (05). From 1985 to 1995, the annual average was 289 cases, with extremes of 208 in 1985 and 423 in 1994 (50).

More recently, a study conducted concerning missionaries in the Northeastern part of the county showed that 62% of them were taking a chemical prophylaxis: either chloroquine alone (25.8%), chloroquine-proguanil combination (45.2%), chloroquine-pyrimethamine combination (3.2%), mefloquine alone (3.2%), pyrimethamine alone (3.2%), proguanil alone (19.4%), or pyrimethamine-dapsone combination (1.6%) (47).   

In its 2006 edition of health recommendations for travelers, the Institut français de veille sanitaire (French Health Watch Institute) classifies the Democratic Republic of the Congo in group three of “countries with a high prevalence of resistance to chloroquine or multiple resistance” (63). 
This means that the recommended chemical prophylaxis is:
- for adults: atovaquone-proguanil combination, mefloquine or doxycycline;
- for pregnant women: atovaquone-proguanil combination or mefloquine;
- for children: atovaquone-proguanil combination, mefloquine or doxycycline, at doses suitable for their weight (weight-related dose).
Of course, simple measures of individual protection against anopheline bites are to be remembered: skin repellants and persistent insecticide-treated mosquito nets for beds. 
Prophylaxis for malaria is no longer needed in the mountainous regions of the country (Kivu) above 1,800 meters.
In the rest of the country, chemical prophylaxis is not necessary for short stays of less than seven days, if mosquito-protection rules are followed carefully and if you are able, during the months following return to a malaria-free area, to visit a doctor immediately in the event of a fever, informing him or her of your travels to a malaria-stricken area.

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