Malaria remains a major source of morbi-mortality among travellers. In 2007, a consensual multicenter Primary Care-Hospital shared guideline on travel-prior chemoprophylaxis, diagnosis and clinical management of imported malaria was set up in the Barcelona North Metropolitan area. The aim of the study is to assess the evolution of malaria cases in the area as well as its clinical management over the 10 years of its implementation.
A total of 190 malaria cases, all them imported, have been recorded. The overall estimated malaria crude incidence was of 0.47 cases per 10,000 population/year (95% CI 0.34-0.59) with a slight significant positive slope especially at the expense of an increase in Indian sub-continent Plasmodium vivax cases. The number of patients who attended the pre-travel consultation was low (13.7%) as well as those with prescribed chemoprophylaxis (10%). Severe malaria was diagnosed in 34 (17.9%) patients and ICU admittance was required in 2.6% of them. Organ sequelae (two renal failures and one post-acute distress respiratory syndrome) were recorded in 3 patients at hospital discharge, although all three were recovered at 30 days. None of the patients died. Patients complying with severity criteria were significantly males (p = 0.04), came from Africa (p = 0.02), were mainly non-immigrant travellers (p = 0.01) and were attended in a hospital setting (p < 0.001). The most frequently identified species was Plasmodium falciparum (64.2%), P. vivax (23.2%), Plasmodium malariae (1.6%) and Plasmodium ovale (1.1%). Those patients diagnosed with P. falciparum malaria came more often from sub-Saharan Africa (p < 0.001) and those with P. vivax came largely from the Indian sub-continent (p = 0.003). Among the 126 patients in whom an immunochromatographic antigenic test was performed, the result was interpreted as falsely negative in 12.1% of them. False negative results can be related to cases with <1% parasitaemia.
After 10 years of surveillance, a moderate increase in malaria incidence was observed, mostly P. vivax cases imported from the Indian sub-continent. Although severe malaria cases have been frequently reported, none of the patients died and organ sequelae were rare. Conceivably, the participation of the Primary Care and the District and Third Level Hospital professionals defining surveillance, diagnostic tests, referral criteria and clinical management can be considered a useful tool to minimize malaria morbi-mortality.

1.Malaria is the tropical disease most commonly imported into the UK, with 1300-1800 cases reported each year, and 2-11 deaths. 2. Approximately three quarters of reported malaria cases in the UK are caused by Plasmodium falciparum, which is capable of invading a high proportion of red blood cells and rapidly leading to severe or life-threatening multi-organ disease. 3. Most non-falciparum malaria cases are caused by Plasmodium vivax; a few cases are caused by the other species of plasmodium: Plasmodium ovale, Plasmodium malariae or Plasmodium knowlesi. 4. Mixed infections with more than one species of parasite can occur; they commonly involve P. falciparum with the attendant risks of severe malaria. 5. There are no typical clinical features of malaria; even fever is not invariably present. Malaria in children (and sometimes in adults) may present with misleading symptoms such as gastrointestinal features, sore throat or lower respiratory complaints. 6. A diagnosis of malaria must always be sought in a feverish or sick child or adult who has visited malaria-endemic areas. Specific country information on malaria can be found at http://travelhealthpro.org.uk/. P. falciparum infection rarely presents more than six months after exposure but presentation of other species can occur more than a year after exposure. 7. Management of malaria depends on awareness of the diagnosis and on performing the correct diagnostic tests: the diagnosis cannot be excluded until more than one blood specimen has been examined. Other travel related infections, especially viral haemorrhagic fevers, should also be considered. 8. The optimum diagnostic procedure is examination of thick and thin blood films by an expert to detect and speciate the malarial parasites. P. falciparum and P. vivax (depending upon the product) malaria can be diagnosed almost as accurately using rapid diagnostic tests (RDTs) which detect plasmodial antigens. RDTs for other Plasmodium species are not as reliable. 9. Most patients treated for P. falciparum malaria should be admitted to hospital for at least 24 h as patients can deteriorate suddenly, especially early in the course of treatment. In specialised units seeing large numbers of patients, outpatient treatment may be considered if specific protocols for patient selection and follow up are in place. 10. Uncomplicated P. falciparum malaria should be treated with an artemisinin combination therapy (Grade 1A). Artemether-lumefantrine (Riamet(®)) is the drug of choice (Grade 2C) and dihydroartemisinin-piperaquine (Eurartesim(®)) is an alternative. Quinine or atovaquone-proguanil (Malarone(®)) can be used if an ACT is not available. Quinine is highly effective but poorly-tolerated in prolonged treatment and should be used in combination with an additional drug, usually oral doxycycline. 11. Severe falciparum malaria, or infections complicated by a relatively high parasite count (more than 2% of red blood cells parasitized) should be treated with intravenous therapy until the patient is well enough to continue with oral treatment. Severe malaria is a rare complication of P. vivax or P. knowlesi infection and also requires parenteral therapy. 12. The treatment of choice for severe or complicated malaria in adults and children is intravenous artesunate (Grade 1A). Intravenous artesunate is unlicensed in the EU but is available in many centres. The alternative is intravenous quinine, which should be started immediately if artesunate is not available (Grade 1A). Patients treated with intravenous quinine require careful monitoring for hypoglycemia. 13. Patients with severe or complicated malaria should be managed in a high-dependency or intensive care environment. They may require haemodynamic support and management of: acute respiratory distress syndrome, disseminated intravascular coagulation, acute kidney injury, seizures, and severe intercurrent infections including Gram-negative bacteraemia/septicaemia. 14. Children with severe malaria should also be treated with empirical broad spectrum antibiotics until bacterial infection can be excluded (Grade 1B). 15. Haemolysis occurs in approximately 10-15% patients following intravenous artesunate treatment. Haemoglobin concentrations should be checked approximately 14 days following treatment in those treated with IV artemisinins (Grade 2C). 16. Falciparum malaria in pregnancy is more likely to be complicated: the placenta contains high levels of parasites, stillbirth or early delivery may occur and diagnosis can be difficult if parasites are concentrated in the placenta and scanty in the blood. 17. Uncomplicated falciparum malaria in the second and third trimester of pregnancy should be treated with artemether-lumefantrine (Grade 2B). Uncomplicated falciparum malaria in the first trimester of pregnancy should usually be treated with quinine and clindamycin but specialist advice should be sought. Severe malaria in any trimester of pregnancy should be treated as for any other patient with artesunate preferred over quinine (Grade 1C). 18. Children with uncomplicated malaria should be treated with an ACT (artemether-lumefantrine or dihydroartemisinin-piperaquine) as first line treatment (Grade 1A). Quinine with doxycycline or clindamycin, or atovaquone-proguanil at appropriate doses for weight can also be used. Doxycycline should not be given to children under 12 years. 19. Either an oral ACT or chloroquine can be used for the treatment of non-falciparum malaria. An oral ACT is preferred for a mixed infection, if there is uncertainty about the infecting species, or for P. vivax infection from areas where chloroquine resistance is common (Grade 1B). 20. Dormant parasites (hypnozoites) persist in the liver after treatment of P. vivax or P. ovale infection: the only currently effective drug for eradication of hypnozoites is primaquine (1A). Primaquine is more effective at preventing relapse if taken at the same time as chloroquine (Grade 1C). 21. Primaquine should be avoided or given with caution under expert supervision in patients with Glucose-6-phosphate dehydrogenase deficiency (G6PD), in whom it may cause severe haemolysis. 22. Primaquine (for eradication of P. vivax or P. ovale hypnozoites) is contraindicated in pregnancy and when breastfeeding (until the G6PD status of child is known); after initial treatment for these infections a pregnant woman should take weekly chloroquine prophylaxis until after delivery or cessation of breastfeeding when hypnozoite eradication can be considered. 23. An acute attack of malaria does not confer protection from future attacks: individuals who have had malaria should take effective anti-mosquito precautions and chemoprophylaxis during future visits to endemic areas.

Despite the availability of standard treatment guidelines for malaria in Pakistan adherence to protocols by prescribers is poor. This descriptive, cross-sectional study aimed to explore the perceptions and knowledge of prescribers in Islamabad and Rawalpindi cities towards adherence to standard treatment guidelines for malaria. A questionnaire was distributed to a random sample of 360 prescribers; 64.7% were satisfied with the available antimalarial drugs and 41.3% agreed that antimalarial drugs should only be prescribed after diagnostic testing. Only half the prescribers had the guidelines available in their health facility. Almost all the prescribers (97.7%) agreed that there was a need for more educational programmes about the guidelines. Most prescribers were unaware of the correct standard treatment regimen for Plasmodium falciparum and P. vivax malaria. There were no differences in knowledge between males and females, but prescribers having more experience, practising as general practitioners and working in private health-care facilities possessed significantly better knowledge than their counterparts.
معارف ومدركات محرري الوصفات الطبية حول الالتزام بالدلائل الإرشادية العلاجية المعيارية للملاريا: دراسة مقارنة مستعرضة من باكستان
مديحة مالك، محمد عزمي أحمد حسالي، عسرول أكمل شافعي، أزهر حسين
على الرغم من توافر الدلائل الإرشادية العلاجية المعيارية للملاريا في باكستان فإن التزام محرري الوصفات بها سيء. وتستهدف هذه الدراسة الوصفية المستعرضة استقصاء مدركات ومعارف محرري الوصفات الطبية في مدينتي إسلام آباد وراولبندي حول الالتزام بالدلائل العلاجية المعيارية للملاريا. وقد وزع الباحثون استبياناً على عينة عشوائية تضم 360 من محرري الوصفات الطبية، واتضح أن 64.7% منهم كانوا راضين بالأدوية المتوافرة المضادة للملاريا، وأن 41.3% موافقون على أن الأدوية المضادة للملاريا ينبغي أن لا توصف إلا بعد إجراء اختبار تشخيصي. ولم تكن الدلائل الإرشادية متوافرة إلا عند نصف المرافق الصحية التي يعمل بها محررو الوصفات الطبية. وكان جميع محرري الوصفات الطبية تقريباً (97.7%) موافقين على الحاجة لمزيد من البرامج التعليمية حول الدلائل الإرشادية، وكان معظم محرري الوصفات الطبية غير مطلعين على النظام العلاجي المعياري الصحيح للمتصوّرة المنجلية والمتصوّرة النشيطة. ولم يكن هناك اختلاف في المعارف بين الذكور والإناث، إلا أن محرري الوصفات ذوي الخبرة الأكثر، والذين يمارسون باعتبارهم أطباء عامين ويعملون في مرافق الرعاية الصحية الخاصة يمتلكون معارف أفضل من غيرهم من الزملاء.
Connaissances et perceptions des prescripteurs concernant les guides thérapeutiques normalisés pour le paludisme et le respect de ces derniers : étude transversale comparative menée au Pakistan.
Malgré la disponibilité de guides thérapeutiques normalisés pour le paludisme au Pakistan, le respect des protocoles de soins par les prescripteurs est médiocre. La présente étude descriptive et transversale visait à explorer les connaissances des prescripteurs dans les villes d’Islamabad et de Rawalpindi concernant les guides thérapeutiques normalisés pour le paludisme et leurs perceptions du respect de ces guides. Un questionnaire a été distribué à un échantillon aléatoire de 360 prescripteurs ; 64,7 % étaient satisfaits des médicaments antipaludiques disponibles et 41,3 % convenaient que les antipaludéens devaient être prescrits uniquement après un test diagnostique. Seule la moitié des prescripteurs possédaient les guides thérapeutiques sur leur lieu de travail. Presque tous les prescripteurs (97,7 %) convenaient que davantage de programmes d’éducation sur ces guides étaient nécessaires. La plupart des prescripteurs ignoraient les bons schémas thérapeutiques types pour le paludisme à Plasmodium falciparum et P. vivax. Aucune différence n’a été observée entre les connaissances des hommes et des femmes. Toutefois, les prescripteurs chevronnés, ceux exerçant comme médecins généralistes et travaillant dans des établissements de soins de santé privés avaient de bien meilleures connaissances que leurs confrères.

暂无摘要。