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MALARIA – AS AN IMPORTED DISEASE
Javed Sethi
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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?
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Travelling70 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
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EpidemiologyAt risk areas include Africa, South America,
Indian Subcontinent, Far East1600 cases per year of malaria notified
between 2003 to 2008 in travellers returning to UK
Visiting family or friends > holiday makers83% have not taken prophylaxis
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MalariaMost common imported tropical disease85 deaths from 2000 to 2008Our role as GPs – in care of the acutely illand in promoting health and preventing
disease
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MalariaPlasmodium, by a mosquito bite- AnophelesMultiplies in liver and then attacks the RBCsFever, nausea, shivering, headache and may
result in multi-organ failure or even deathDormant in liver for months
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Causes
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Risk assessmentOur responsibility under GMSPreventative measures – identify risks and
those at riskAssessment with a questionnaire and face to
face appointmentTravel to visit family accounts 18%Destination, length of stay, accomodation,
healthcare, budget and insuranceAge, comorbidities, cultural beliefs
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Post assessment adviceGeneral and specific adviceExplain disease transmissionChemoprophylaxisPrevention adviceEnsure understandingSign post travellers to www.travax.nhs.uk,
www.fitfortravel.nhs.uk
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Clinical featuresIntermittent fever with rigors and sweatingHeadache, malaise, myalgia and anorexiaFlu like symptomsChildren can present with vague symptomsIncubation period is 6 daysMay manifest in 6 months or suspect for upto
12 months in travellers from high risk areasComplications occur with parasitaemia (> 2%
blood cells parasitized)
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ComplicationsImpaired conciousnessSeizuresRenal impairmentAcidosisHypoglycaemiaPulmonary oedemaDIC, HaemoglobinuriaShock
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InvestigationsDiscuss with microbiologistThick and Thin blood filmsRepeat in 12 to 24 hours3 negative films make diagnosis unlikelyMalarial parasitic antigenFBCNotifiable diseaseMalaria reference laboratoryRelatives/travelling group should be informed
that they may be at risk
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TreatmentFalciparum malariaUncomplicated:Quinine and doxycycline for 5 to 7 daysAtovaqoune-proguanil for 3 daysComplicated:IV quinineMefloquine (side effects)Chloroquine (resistance)
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TreatmentNon falciparum malariaChloroquine for 3 days thenPrimaquine for 14 days to treat hypnozoite
stage
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PreventionRisk of exposure versus side effects of
chemoprophylaxis.Awareness of riskPrevention of BitesChemoprophylaxisDiagnosis and treatment
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Prevention of BitesBite from dusk to dawn, peak at 02:00 amRepellants - Diethyltoluamide 50%Advisory Committee on Malaria Prevention
recommend it in pregnancy, breast feeding, children
Insecticides Mosquito netsClothing, Electric heated devices
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Drug Advantages
Disadvantage
Dose Side effects
Proguanil Well tolerated
Resistance 200 mg 1 wk before and 4 wks after
GI upset
Chloroquine Pregnancy and breast feeding
Exacerbate Myasthenia,Psoriasis
300mg wkly and 4 wks later
GI upset and headache
Mefloquine 2nd and third trimester, weekly dose
CI in depression and epilepsy
250mg weekly begin 3 wks before til 4 wks
Neuropsychiatric problems
Doxycycline Cheap, started close to departure
Photosensitivity, CI in <12
100mg OD 2 days before and 4 wks later
Oesophagitis, photosensitivity
Atovaquone/proguanil
Short course
Expensive 250/100mg, 2 days before til 7 days after
GI upset and headache
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ChemoprophylaxisPrimaquine:Effective prophylactic against hynozoite
stageNot recommended by ACMPHaemolysis in patients with G6PD deficiency
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ProphylaxisCausal prophylaxis is against liver stage as it
takes 7 days to developTo be taken for 7 days afterSuppressive prophylaxis is against the red
cell stage and is taken 4 weeks after Give travellers written informationNot on NHSTo buy over the counter or private
prescription
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Precautions in special conditions with antimalarialsPregnancy, BreastfeedingEpilepsyAnticoagulantsG6PD deficiencyImmunosuppressionSickle cell diseaseLiver disease, Renal impairmentPorphyria
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MYTH: I used to live in Africa so I am immune to Malaria
FACT: Nobody is 100% immune and partial immunity fades