Assessment of knowledge about malaria among patients reported with fever: a hospital-based study

BACKGROUND & OBJECTIVES: Knowledge about malaria, attitude and health seeking behaviour of fever patients attending Medicine Out Patient Department at Safdarjang Hospital, New Delhi were studied from June to August 2003. METHODS: Cross-sectional survey comprising 200 fever cases was done with prestructured and pretested questionnaire. Data on sociodemographic profile, history of fever, health seeking behaviour, etc were recorded. RESULTS: About 83% of fever cases did not approach the doctor even after three days of onset of fever symptom, 25.5% tried self medication and 20.5% approached chemists for treatment. Knowledge about causes and prevention of malaria was found to be inadequate in the study subjects. INTERPRETATION & CONCLUSION: Knowledge about malaria is poor even in persons residing in urban localities and proper health education is required for successful control of malaria. Information, education and communication activities are indicated to create awareness among the community.     

Malaria control and fever management in Henan Province, China, 1992

Henan Province, which once had the highest malaria prevalence in China, had only 318 reported cases in 1992. Our purpose was to investigate this late 'consolidation phase' of malaria control in Henan with reference to malaria surveillance. We conducted a questionnaire survey of village doctors in Shang Shi Qiao Township during the transmission period of 1992. Of the 732 recorded fever cases, 16 were probable malaria cases by clinical and treatment response criteria, but only one received a full course of antimalarials. Of the 732 patients, 61% had fever every day, 37% went for treatment the first day, 52% waited 2–3 days and 10% waited longer. One hundred and twenty‐eight patients took self‐medication before seeing the doctor. Blood examination was carried out in 526 (71%) fever cases but only four were positive, all for Plasmodium vivax . Our findings highlight problems relating to patient behaviour and motivation of village doctors, malaria treatment, surveillance and microscopy, rural migration, economic development and malaria transmission. All need to be considered for reforming the malaria control strategy in Henan Province.     

Clinical predictors of malaria and other febrile illnesses in children under five on Pemba Island, Tanzania

Under the current guidelines of presumptive treatment of all children with reported fever, the risk of over-prescribing antimalarial drugs and missing other important causes of fever, like acute respiratory tract infection (ARI), is substantial. Clinical algorithms have been shown to be useful in diagnosing malaria, but often with differing results, due to regional variations. We set out to explore the clinical features associated with malaria compared with other febrile illnesses and specifically severe malaria with ARI in children under five in Pemba. Two hundred and seven children aged six months to five years presenting to a hospital clinic with fever were studied in Pemba. Clinical findings were related to the presence of malaria parasitaemia. Malaria accounted for 67.7% of the febrile episodes investigated. Five symptoms and signs, including pallor, drowsiness, splenomegaly, fever duration and no chest crackles, could accurately predict a case of malaria with a sensitivity of 91.3% and specificity of 53% and positive predictive value of 80.3%. Several clinical features were found to differentiate severe malaria from ARI. These results confirm that clinical algorithms can increase the diagnostic accuracy of malaria, although not sufficiently to replace microscopy, and by promoting the use of clinical skills other treatable causes of febrile illnesses may be identified.These findings could have implications in optimizing treatment and malaria control in children on Pemba.     

Chloroquine-resistant malaria in Jos, Nigeria

A 16-year-old Nigerian boy who had lived all his life in a malaria endemic region presented with continuing fever after what would ordinarily be accepted as adequate treatment for malaria. He went on to develop cerebral malaria, recovering only after administration of quinine.     

Malaria morbidity,treatment-seeking behaviour,and mortality in a cohort of young children in rural Burkina Faso

OBJECTIVE: To describe the pattern of fever-associated morbidity, treatment-seeking behaviour for fever episodes, and cause-specific mortality in young children of a malaria-holoendemic area in rural Burkina Faso. METHODS: In a longitudinal community-based intervention study, 709 representative children aged 6-31 months were followed daily over 6 months (including the main malaria transmission period) through village-based field staff. RESULTS: Of 1848 disease episodes, 1640 (89%) were fever episodes, and of those, 894 (55%) were attributed to malaria (fever + > or =5000 parasites/microl). Eighty-five percent of fever episodes were treated, mainly with chloroquine and paracetamol, 69% of treatments took place in households, 16% in local health centres, 13% in villages, and 1% in hospitals. Treatment-seeking in a health centre or hospital was associated with accessibility and disease severity. Cerebral malaria and malnutrition-associated diarrhoea were the most frequently diagnosed causes of death. While most children with a post-mortem diagnosis of diarrhoea had not received any treatment, children who died of malaria had often received insufficient treatment. In particular, there was a lack of an appropriate second-line treatment at formal health services after chloroquine treatment had failed to resolve symptoms. CONCLUSIONS: These findings call for more effective prevention and treatment of malaria, malnutrition and diarrhoea in rural African communities, as well as for better supervision of existing malaria treatment guidelines in formal health services.     

A case of falciparum malaria successfully treated with intravenous artesunate

The case was a 28-year-old Japanese female who was considered to be infected with malaria in India. She manifested fever in Tokyo, Japan, and was brought to Toho University Hospital due to continuous high fever and severe thrombocytopenia. Ring forms at 11% of her RBCs and ICT Malaria P.f/P.v test was also positive for Plasmodium falciparum diagnosis. Not only the high parasitemia and delay of the diagnosis (6 days after the onset of fever), but also her DIC status required prompt and proper treatment. The diagnosis of severe malaria was strongly considered, and intravenous Artesunate (a qinghaosu derivative) was decided to be administered to the patient. After the four series of administration, mefloquine was subsequently given to prevent recrudescence. Parasite clearance time and fever clearance time were 24 hours and 108 hours, respectively. Thrombocytopenia was improved shortly after the treatment, but then anemia was once worsened with following gradual improvement. No other significant side effects were observed and no recrudescence occurred up to 8 months after her discharge. In Japan, very few cases treated with intravenous Artesunate were reported and our results showed its safe and excellent effect for a Japanese malaria patient.     

Short report: Q fever and Plasmodium falciparum malaria co-infection in a patient returning from the Comoros archipelago

Although Plasmodium falciparum malaria and Q fever are both prevalent in Africa, there have been no reports of co-infection to date. We report a case who returned from the Comoros archipelago diagnosed by serologic analysis as well as detection of Coxiella burnetii DNA in acute-phase serum. Thus, Q fever may be associated with malaria infection in travelers returning from disease-endemic countries. This diagnosis should be considered when the response to malaria treatment is incomplete.     

Trial of pyrethroid impregnated bednets in an area of Tanzania holoendemic for malaria. Part 3. Effects on the prevalence of malaria parasitaemia and fever.

Children aged 1-10 in five villages were contacted fortnightly. Their axillary temperatures, reports of fevers and blood slides were taken. Following the introduction of permethrin impregnated nets into two estate villages the slide positivity for falciparum malaria declined markedly. In traditional villages the introduction of impregnated nets had less convincing effects than in the estate villages and DDT spraying had no perceptible effect on malaria. Over all villages there was a clear relationship between axillary temperature greater than 37.4 degrees C, reports of fever and high parasitaemia. We defined malaria fever in this way, and found in some cases significant reductions in occurrence of such fever following some time after introduction of permethrin impregnated nets. No such effects were found with lambdacyhalothrin nets or with DDT spraying.     

LECTURES ON THE THEORY AND PRACTICE OF MEDICINE;: NOW IN COURSE OF DELIVERY AT THE THEATRE OF ANATOMY AND MEDICINE,WEBB-STREET,SOUTHWARK

Treatment of typhus fever; treatment of the complications; causes of relapse. INTERMITTENT FEVER; specific causes; action of malaria; symptoms of this fever; divisions; diagnosis; complications; state of the spleen; dropsy; treatment of intermittent fever.     

Predictors of the failure of treatment with pyrimethamine-sulfadoxine in children with uncomplicated falciparum malaria

The prevalence of pyrimethamine-sulfadoxine (PS)-resistant Plasmodium falciparum malaria has been increasing in sub-Saharan Africa or other parts of the world in the last one or two decades. The factors that identify children at risk of treatment failure after being given PS were evaluated in 291 children with acute, symptomatic, uncomplicated, P. falciparum malaria. The children took part in four antimalarial drug trials between July 1996 and July 2004 in a hyperendemic area of southwestern Nigeria. Following treatment, 64 (22%) of 291 children failed treatment by day 7 or 14. In a multivariate analysis, an age < or = 1.5 years (AOR=2.9, 95% CI 1.3-6.4, P = 0.009) and presence of fever (AOR = 3.3, 95% CI 1.28-7.14, P = 0.01) were independent predictors of the failure of treatment with PS at presentation. Following treatment, delay in parasite clearance >3 days (AOR = 2.56, CI 1.19-5.56, P = 0.016) was an independent predictor of the failure of treatment with PS. In addition, compared with the children who had no fever then, children with fever three or more days after starting treatment were more likely to be treatment failures. These findings may have implications for malaria control efforts in some sub-Saharan African countries where treatment of malaria disease depends almost entirely on PS monotherapy, and for programmes employing PS or PS-based combination therapy.     

Diagnostic accuracy and case management of clinical malaria in the primary health services of a rural area in south-eastern Tanzania

Malaria control continues to rely on the diagnosis and prompt treatment of both suspected and confirmed cases through the health care structures. In south-eastern Tanzania malaria is one of the leading causes of morbidity and mortality. The absence of microscopic examination in most of the health facilities implies that health workers must rely on clinical suspicion to identify the need of treatment for malaria. Of 1558 randomly selected paediatric consultations at peripheral health facilities throughout Kilombero District, 41.1% were diagnosed by the attending health worker as clinical malaria cases and 42.5% prescribed an antimalarial. According to our malaria case definition of fever or history of fever with asexual falciparum parasitaemia of any density, 25.5% of all children attending the health services had malaria. This yielded a sensitivity of 70.4% (IC95% = 65.9-74.8%) and a specificity of 68.9% (IC95% = 66.2-71.5%). Accordingly, 30.4% of confirmed cases left with no antimalarial treatment. Among malaria-diagnosed patients, 10% were underdosed and 10.5% were overdosed. In this area, as in many African rural areas, the low diagnostic accuracy may imply that the burden of malaria cases may be overestimated. Greater emphasis on the functioning and quality of basic health services in rural endemic areas is required if improved case management of malaria is to help roll back this scourge.     

Etiology and outcome of fever after a stay in the tropics

BACKGROUND: Information on epidemiology and prognosis of imported fever is scarce and almost exclusively limited to hospital settings. METHODS: From 2000 to 2005, all travelers presenting at our referral outpatient and inpatient centers with ongoing fever within 12 months after a stay in the tropics were prospectively followed. Case definitions and treatment were based on international recommendations. Outcome was assessed by at least 1 follow-up consultation or telephone call within 3 months after initial contact. RESULTS: A total of 1842 fever episodes were included, involving 1743 patients. Regions of exposure were mainly sub-Saharan Africa (68%) and the Southeast Asia-Pacific region (12%). Tropical diseases accounted for 39% of all cases and cosmopolitan infections for 34%. Diagnosis often remained unknown (24%). The pattern of tropical diseases was mainly influenced by the travel destination, with malaria (35%, mainly Plasmodium falciparum) and rickettsial infection (4%) as the leading diagnoses after a stay in Africa; dengue (12%), malaria (9%), and enteric fever (4%) after travel to Asia; and dengue (8%) and malaria (4%) on return from Latin America. Disease pattern varied also according to the category of travelers, the delay between exposure and fever onset, and the setting. Hospitalization was required for 503 fever episodes (27%). Plasmodium falciparum malaria accounted for 36% of all admissions and was the only tropical cause of death (5 of 9 patients). Fever of unknown cause had invariably a favorable outcome. CONCLUSION: The clinical spectrum of imported fever is highly destination specific but also depends on other factors. Plasmodium falciparum malaria was the leading cause of mortality in the study population.     

Monitoring delagil (chloroquine) efficacy against imported Plasmodium vivax strains

The efficiency of P. vivax malaria treatment with delagil (chloroquine) was evaluated in 122 patients, including 82 cases in Moscow and the Moscow region. The origin of the cases was malaria endemic areas in Asia, Africa, the Pacific Region, South America, and Transcaucasia. Forty other cases were imported malaria cases (secondary to imported ones), detected in Moscow and the Moscow region. Standard treatment with delagil (2.5 g) resulted in clinical improvement during 3 days in the majority of cases. Initial signs of degradation of asexual stages of P. vivax--kernels of nucleus, refinement of cytoplasm and its vacuolization, aggregation of pigment in isolated instances, its pushing out from cytoplasm--were observed after 1-2 hours after administration of delagil. Thereafter, parasite degradation was increasing, and it disappeared within 48 hours. Disappearance of fever slowed down in a few cases. However, degradation of parasites occurred during the same period among the rest of cases. It can not be excluded that fever was determined by the pyrogenic effect of remnants of degraded parasites and by the products of destroyed infected erythrocytes. It is probable that the findings of gametocytes, not completely degraded after disappearance of asexual forms in conjunction with prolonged fever, could result in a wrong conclusion of drug resistance. Negative results of microscopy and nested PCR on the last day of treatment, as well as in the following 10 days and absence of complains during 45 days, suggest the absence of resistance to delagil in P. vivax strains imported from different regions of the world. It is also probable that the literature on P. vivax resistance to chloroquine is limited to sporadic cases.     

Malaria infection in children in tropical rainforest: assessments by women of Ugbowo Community in Benin City,Nigeria

ObjectiveTo examine how mothers recognize malaria infection in children aged less than five and five years, frequency and duration of the infection in these children as well as measures used to reduce exposure of children to mosquito bites, and to discuss the possibilities of designing a strategy that involves mothers in management and control of malaria infection.MethodsThe data were originated from personal interviews which involved mothers in the Ugbowo Community in Benin City, Nigeria who were selected using multi-stage systemic random sampling technique. The data were analyzed qualitatively and by use of percentages, arithmetic mean and bar chart.ResultsThe results showed that all the interviewees believed that children got malaria infection along with fever or fever and other symptoms. Approximately 30% of interviewee recognized malaria infection through fever and cough while 1% by fever and vomiting. Approximately 72% of the interviewees claimed that their children had malaria infection every three months and 16% claimed that their children had the infection every month. Most of the interviewees reported that the length of time from recognition of malaria symptoms on their children to treatment was between one and three days. Most of the interviewees used insecticide treated bed nets to reduce their children's exposure to mosquito bites and few used mosquito repellent ointment.ConclusionsFor malaria management strategy to be effective and sustainable, it is important to empower women with more knowledge on detection of malaria symptoms and they should be involved in planning and designing the strategy.     

Season, fever prevalence and pyrogenic threshold for malaria disease definition in an endemic area of Mali

BACKGROUND: Modelling malaria parasitaemia as function of fever has been proposed as best alternative to estimate the attributable fraction of malaria fever and the sensitivity and specificity of different case definitions of malaria disease. OBJECTIVES: To determine the prevalence of fever and its relation to malaria parasitaemia and to establish a pyrogenic threshold for malaria disease in the area. METHODS: We conducted two cross-sectional surveys in children of 6 months to 9 years of age (2434 during the rainy season of 1993 and 2353 during the dry season of 1994) randomly selected from 21 areas of Bandiagara district, Mali. RESULTS: The relationship between fever and Plasmodium falciparum parasitaemia depends strongly on the season, thus affecting the malaria-attributable fraction of fever cases and the sensitivity and specificity of malaria case definitions. The overall proportion of fever attributable to malaria parasitaemia was 33.6% during the rainy season and 23.3% during the dry season, with the highest proportion occurring among the youngest children. The cut-off value, where the sensitivity curve crosses the specificity curve, was around 3200 pf/microl for all age categories during the rainy season and 200 pf/microl during the dry season. CONCLUSIONS: Malaria remains a main cause of fever in this area of Mali. The pyrogenic threshold of parasitaemia depends strongly on the season, and different cut-off levels of parasitaemia should be used during the two seasons to define malaria cases in this area.     

河南省1990～2005年疟疾疫情及防治效果评价

目的 分析河南省1990～2005年疟疾流行情况，评价疟疾防治措施及防治效果。 方法 收集河南省1990～2005年疟疾流行、防治措施、防治效果及媒介监测、发热病人血检、血清学调查资料进行统计分析。 结果 16年间河南省共进行传播休止期治疗80.27万人次，流行季节服药治疗76.43万人次，治疗疟疾现症病人和疑似病人43 891人次。1990～1992年和1996～1999年共用杀虫剂处理蚊帐133.28万顶，保护人群199.93万人次。发热病人血检1 121.61万人次，阳性率为0.10%（11 213/1 121.61），占全部报告病例的29.01%。1990～2000年间接荧光抗体试验（IFAT）检测34 846人次，阳性率为3.30%（1 149/34 846）。1993～1999年调查当地居民71 234人次，带虫率为0.40%（286/71 234）。河南省主要的疟疾传播媒介为中华按蚊和嗜人按蚊，叮人习性分别为0.060 8和0.314 3，媒介能量嗜人按蚊是中华按蚊的22.4倍。1990～2005年全省共报告疟疾病例38 654例，平均年发病率为2.62/10万，其中1992年发病318例，当年发病率为0.37/10万，为历史最低点。70.05%（27 076/38 654）的病例分布在嗜人按蚊和中华按蚊共存的复合媒介地区。 结论 河南省疟疾防治措施得当，有效控制疟疾发病，但部分地区疫情不稳定，局部暴发点不断出现，疟疾控制工作仍十分艰巨。     

Efficacy of chloroquine in febrile Plasmodium falciparum infected children in Mewat region of Haryana

During 1996, Mewat region of Gurgaon district in Haryana experienced high incidence of Plasmodium falciparum malaria, assuming epidemic proportion in large number of villages affected by floods. Mortality due to fever was also high. In vivo 7 days study amongst 32 febrile P. falciparum infected children of 1 to 14 years age group in flood affected villages of Ferozpur Jhirka Community Health Centre of Mewat region was carried out. All the 32 cases showed good response to chloroquine suggesting that drug was effective and useful as first line of treatment, reducing severity of P. falciparum infection and resolving fever due to infection of the species. The study also indicated that chloroquine was an effective drug in controlling epidemic situation and mortality in areas of high incidence of P. falciparum. Pyrogenic stimulus was variable among different developmental stages of P. falciparum and suggestive of the need of earliest possible initiation of anti-malaria treatment, community based fever survey and blood smear examination. Increase in incidence of fever in an endemic community, particularly in children, should be considered as an indicator of impending outbreak of P. falciparum malaria. Effectiveness of diagnostic and control measures taken can be evaluated on the basis of incidence of malaria particularly due to P. falciparum infection and also incidence of fever in an endemic community.     

广东省嗜人按蚊分布区疟疾防治后期监测方法研究

目的　探讨嗜人按蚊分布区疟疾防治后期流行病学特点和简化疟疾监测方法的可行性。　方法　选择广东省有嗜人按蚊分布的 12个市、县作为观察点。每个市、县重点抓“三热”病人血检、现症病人根治和媒介按蚊监测。对输入性病例疫点不作任何处理 ,只进行现症病人根治 ;对原发和输入继发病例除现症病人根治外 ,病人家属需进行假定性治疗。结果　广东省 12个嗜人按蚊分布区的市、县 ,4年居民平均血检率为 0 .5 4 % ,疟原虫平均阳性率为 0 .35 % ,血检数量虽然由人口总数的 5 %减少至 0 .5 4 % ,但每年疟疾年发病率都是稳中有降 ,没有暴发流行点出现。广东省嗜人按蚊吸血习性通过加权校正 ,吸人血比例为 6 8.2 % ,吸牛血比例为 31.8%。 4年所发现的 16 78例疟疾病例均呈散发性 ,平均每个疫点仅 1.14个 ,各病例之间无必然联系。　结论　在广东省嗜人按蚊分布区疟疾防治后期 ,疟疾的监测方法完全可以简化为只进行“三热”病人血检和现症病人根治。血检数量为人口总数的 0 .5 %较为适宜