MALARIA – AS AN IMPORTED DISEASE

1. MALARIA – AS AN IMPORTED DISEASE JavedSethi

2. Which type of malarial plasmodium is the most common? • What is the incubation period? • Is the antimalarial prophylaxis on NHS prescriptions? • Which antimalarial is safe in pregnancy?

3. Travelling • 70 million trips in 2007 compared to 30 million in 1987 • 6% fall in visits abroad, but yet large numbers travel • 1 in 10 seek medical advice

4. Epidemiology • At risk areas include Africa, South America, Indian Subcontinent, Far East • 1600 cases per year of malaria notified between 2003 to 2008 in travellers returning to UK • Visiting family or friends > holiday makers • 83% have not taken prophylaxis

5. Malaria • Most common imported tropical disease • 85 deaths from 2000 to 2008 • Our role as GPs – in care of the acutely ill and in promoting health and preventing disease

7. Malaria • Plasmodium, by a mosquito bite- Anopheles • Multiplies in liver and then attacks the RBCs • Fever, nausea, shivering, headache and may result in multi-organ failure or even death • Dormant in liver for months

9. Causes

10. Risk assessment • Our responsibility under GMS • Preventative measures – identify risks and those at risk • Assessment with a questionnaire and face to face appointment • Travel to visit family accounts 18% • Destination, length of stay, accomodation, healthcare, budget and insurance • Age, comorbidities, cultural beliefs

11. Post assessment advice • General and specific advice • Explain disease transmission • Chemoprophylaxis • Prevention advice • Ensure understanding • Sign post travellers to www.travax.nhs.uk, www.fitfortravel.nhs.uk

12. Clinical features • Intermittent fever with rigors and sweating • Headache, malaise, myalgia and anorexia • Flu like symptoms • Children can present with vague symptoms • Incubation period is 6 days • May manifest in 6 months or suspect for upto 12 months in travellers from high risk areas • Complications occur with parasitaemia (> 2% blood cells parasitized)

13. Complications • Impaired conciousness • Seizures • Renal impairment • Acidosis • Hypoglycaemia • Pulmonary oedema • DIC, Haemoglobinuria • Shock

14. Investigations • Discuss with microbiologist • Thick and Thin blood films • Repeat in 12 to 24 hours • 3 negative films make diagnosis unlikely • Malarial parasitic antigen • FBC • Notifiable disease • Malaria reference laboratory • Relatives/travelling group should be informed that they may be at risk

15. Treatment • Falciparum malaria • Uncomplicated: • Quinine and doxycycline for 5 to 7 days • Atovaqoune-proguanil for 3 days • Complicated: • IV quinine • Mefloquine (side effects) • Chloroquine (resistance)

16. Treatment • Non falciparum malaria • Chloroquine for 3 days then • Primaquine for 14 days to treat hypnozoite stage

17. Prevention • Risk of exposure versus side effects of chemoprophylaxis. • Awareness of risk • Prevention of Bites • Chemoprophylaxis • Diagnosis and treatment

18. Prevention of Bites • Bite from dusk to dawn, peak at 02:00 am • Repellants - Diethyltoluamide 50% • Advisory Committee on Malaria Prevention recommend it in pregnancy, breast feeding, children • Insecticides • Mosquito nets • Clothing, • Electric heated devices

20. Chemoprophylaxis • Primaquine: • Effective prophylactic against hynozoite stage • Not recommended by ACMP • Haemolysis in patients with G6PD deficiency

21. Prophylaxis • Causal prophylaxis is against liver stage as it takes 7 days to develop • To be taken for 7 days after • Suppressive prophylaxis is against the red cell stage and is taken 4 weeks after • Give travellers written information • Not on NHS • To buy over the counter or private prescription

22. Precautions in special conditions with antimalarials • Pregnancy, Breastfeeding • Epilepsy • Anticoagulants • G6PD deficiency • Immunosuppression • Sickle cell disease • Liver disease, • Renal impairment • Porphyria

23. MYTH: I used to live in Africa so I am immune to Malaria • FACT: Nobody is 100% immune and partial immunity fades