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Travel Medicine and Infectious Disease (2014) xx, 1e5
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/tmid
Imported malaria at Buraidah Central Hospital, Qassim, Saudi Arabia: A retrospective analysis Imad R. Musa a, Gasim I. Gasim b, Amin O. Eltoum a, Ishag Adam b,c,* a
Buraiadah Central Hospital, Qassim, Saudi Arabia Qassim College of Medicine, Qassim University, Saudi Arabia c Faculty of Medicine, University of Khartoum, Sudan b
Received 8 December 2013; received in revised form 10 April 2014; accepted 17 April 2014
KEYWORDS Plasmodium falciparum; Vivax; Imported malaria; Severe; Treatment
Summary Background: Malaria is a major threat to global health and it is a widespread throughout tropical and subtropical countries with an increasing risk to travellers. Methods: A retrospective analysis was conducted to investigate the epidemiology of imported malaria at Buraidah in Qassim region, Saudi Arabia during the period of January 2010 through April 2013. Results: There were 46 imported malaria cases. These cases were Plasmodium vivax (89.1%), Plasmodium falciparum (0.02%) and were mixed in 4 cases. Their age range between 14 and 54 and the mean was 29.7 years. Around three quarter (71.2%) of the patients were males. Most of the patients were Indian (54.3%) and Pakistani (23.9%). Over half (54.3%) of the patients had severe malaria, mainly severe anaemia, jaundice and hypotension. There was no mortality among the patients. Conclusions: Most of the detected malaria cases in this setting were among expatriates, particularly from the Indian subcontinent, while the predominant species was P. vivax. More than 50% of the cases presented with severe malaria. ª 2014 Elsevier Ltd. All rights reserved.
Introduction Malaria is a major threat to global health. It is estimated to affect 154e289 million people with around 610 000e97 1000 deaths [1], most of these case are in tropical and
subtropical countries with increasing risk to travellers [1e4]. With exception of Gizan and Asir region, malaria is not endemic in Saudi Arabia [5e7]. However, some imported malaria cases were observed in non-malarious areas in Saudi Arabia [8]. World Health Organization (WHO) figures showed
* Corresponding author. Faculty of Medicine, University of Khartoum, Sudan. E-mail addresses:
[email protected],
[email protected] (I. Adam). http://dx.doi.org/10.1016/j.tmaid.2014.04.006 1477-8939/ª 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Musa IR, et al., Imported malaria at Buraidah Central Hospital, Qassim, Saudi Arabia: A retrospective analysis, Travel Medicine and Infectious Disease (2014), http://dx.doi.org/10.1016/j.tmaid.2014.04.006
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I.R. Musa et al. Table 1
WHO characteristics of severe malaria.
Cerebral malaria
Hyperparasitemia
Repeated generalized convulsions impaired consciousness Pulmonary oedema
Severe anaemia
Renal failure
Hypoglycaemia
Circulatory collapse
Unusual bleeding and/or disseminated intravascular coagulation Acidaemia/acidosis
Macroscopic haemoglobinuria Prostration and weakness
Hyperpyrexia Hyperbiliribunemia
Impaired consciousness or unrousable coma not explained by any other cause, with a Glasgow score 9. Prostration, i.e. generalized weakness so that the patient is not able to walk, or sit up unless being assisted Failure to feed Multiple convulsions e more than two episodes with in 24 h >2% parasitized erythrocytes or >250 000 parasites/ml (in non-immune individuals) 2 seizures observed within 24 h Rousable mental condition The acute lung injury score is measured on the ground of radiographic densities, extent of hypoxaemia, and positive end-expiratory pressure Haematocrit < 15% or haemoglobin 10 000/ml Urine output < 400 ml/24 h in adults ( 265 mmol/l (>3.0 mg/dl) inspite of adequate volume restoration Whole blood glucose concentration < 2.2 mmol/l ( 5 years of age ( 10 C Spontaneous bleeding from any of gums, nose, gastrointestinal tract, or laboratory proof of disseminated intravascular coagulation Arterial pH < 7.25 or acidosis (plasma bicarbonate < 15 mmol/l) Haemolysis not secondary to glucose-6-phosphate dehydrogenase deficiency Generalized weakness to extent that the patient is not able to walk or sit up unless being assisted Core body temperature > 40 C Total bilirubin >43 mmol/l (>2.5 mg/dl)
that in 2011 the numbers of imported cases of malaria formed nearly all the cases detected in Saudi Arabia where the total number approached 3000 cases [6]. In fact, all the of the Arabian Gulf countries have high hospitality and high vulnerability with regard to malaria as they receive continuously large numbers of imported malaria cases among the big influx of expatriates coming from the Indian subcontinent, and sub-Saharan Africa [9]. Malaria is a notifiable disease in Saudi Arabia requiring the treating doctors at the public hospitals and other private hospitals to report cases to the Vector Control Center, of the Ministry of Health [10]. The fast growth of international travel from endemic areas of malaria is an important risk for imported malaria infection [11] and the Kingdom of Saudi Arabia is as the rest of the gulf countries where expatriates from endemic areas in Africa and Asia are recruited. Qassim area is an agricultural and industrial area that attracts skilled and non-skilled manpower from different places, and hence increases the chance of imported malaria. The aims of this study were to describe the epidemiology of imported malaria diagnosed at Buraidah Central Hospital, Qassim Region, Saudi Arabia.
Methods Settings Study population This is a retrospective study which was conducted at Buraidah Central Hospital, Saudi Arabia which serves as a tertiary referral center, where it involved all patients with imported malaria admitted to the above mentioned hospital from the 1st January 2010 to the 30th April 2013. Buraidah Central Hospital is the main hospital assigned to admit patients with malaria in Qassim region. Data were retrieved from the medical files for age, gender, nationality, year and month of admission. Malaria was diagnosed by thick and thin peripheral blood films stained with Giemsa. Then the malaria parasite species causing malaria, severity, and the outcomes were documented.
Definitions The hospital regimens for treating malaria, depends on the type of the plasmodium and the severity of malaria according the WHO criteria, 2000. Imported malaria was defined as per the WHO criteria [12], as an infection that was acquired outside the area where the case was diagnosed. Mixed malaria is defined as an infection caused by mixed Plasmodium species [e.g. Plasmodium vivax and Plasmodium Table 2 Characteristics of patients and outcome of the imported malaria. The variable
The frequency
The mean (SD) of the age, year Number (%) of Male gender P. vivax Severe Malaria
29.7 (1.3) 43 (93.5%) 41 (89.1%) 25 (54.3)
Please cite this article in press as: Musa IR, et al., Imported malaria at Buraidah Central Hospital, Qassim, Saudi Arabia: A retrospective analysis, Travel Medicine and Infectious Disease (2014), http://dx.doi.org/10.1016/j.tmaid.2014.04.006
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A retrospective analysis of imported malaria
Fig. 1
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Map showing the origin of imported malaria to Buraiadah Central Hospital, Kingdom Saudi Arabia.
falciparum]. Moreover relapsing malaria is defined as recurrence of P. vivax parasitaemia after more than 28 days of initiation of a treatment course with chloroquine [12,13]. Severe P. falciparum malaria in children and adults is defined depending on the WHO criteria [14,15], Table 1.
Treatment In case of uncomplicated P. falciparum malaria infection, oral artesunate-sulfadoxineepyrimethamine regimen is used as first line therapy and artemetherelumefantrine as a second-line therapy. Artesunate and quinine were the first line and second-line therapy for severe cases followed by doxycycline, or clindamycin for total elimination of infection and primaquine for eradication of gametocytes. Ethical considerations Ethical approval was obtained from the medical education and research centre in Qassim area, and from Buraidah Central hospital’s administration, and all the information were reviewed synonymously without revealing identity.
Results Demographic characteristics There were 46 cases of malaria out of a total admission of 23 208 for other illnesses during the same period. Ages ranged between 14 years and 54 years with a mean age of
29.7 1.3. Forty three (93.5) of the cases were males, Table 2.
Type of malaria While the vast majority of these cases were P. vivax (41, 89.1%), P. falciparum was identified in one case (2.2%), and four (8.7%) were mixed infections. The patients were Indian (25, 54.3%), Pakistani (11, 23.9%), Sudanese (5, 10.9%), Ethiopian (2, 4.3%), and Afghanistan (1, 2.2%) and there were two Saudi patients, Fig. 1. The highest numbers of cases in a single month were detected in August where 9 (19.6%) cases were detected followed by March and October with 6 (13%) cases in each.
Severity Out of these 46 patients, 25 (54.3%) patients had severe malaria, mainly severe anaemia (17), jaundice (4) and hypotension (4).
Treatment Patients with uncomplicated malaria were treated with chloroquine/þ primaquine and sulfadoxine-pyrimethamine in the P. vivax and P. falciparum malaria, respectively. All patients with severe malaria received quinine and doxycycline (followed by primaquine in case with P. vivax). There was no death.
Please cite this article in press as: Musa IR, et al., Imported malaria at Buraidah Central Hospital, Qassim, Saudi Arabia: A retrospective analysis, Travel Medicine and Infectious Disease (2014), http://dx.doi.org/10.1016/j.tmaid.2014.04.006
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Discussion The study showed that imported malaria was identified clinical entity in this setting. Saudi Arabia is a non-endemic area for malaria. However due to an increase in international transportation, imported malaria has become a significant clinical and public health issue [11]. This study describes the status of imported malaria cases in Qassim region where it depicts that a total number 46 cases were detected with P. vivax being the most frequently identified strain (41 cases), followed by P. falciparum (1 case). This trend is consistent with other epidemiological studies carried in the region [8,16]. The predominance of male gender found in this study can be attributed to the fact that males are the main work recruits in Saudi Arabia, a finding that has been pointed to by Khan et al. [16], while the mean age of study population was 29.7 1.3 a finding which is more or less similar to what Al-Tawfiq et al. have found [8]. The predominant species were P. vivax a thing that can easily be explained on looking to the origin of most of the cases, where they are originating from the Indian subcontinent where vivax is endemic [17]. The investigators found that most of the cases appeared in August where about 9 cases were seen, a thing that can be attributed to the season of peak transmission in countries from which most of the cases originated such as India, Pakistan, Sudan, and Ethiopia during which time most of the employees return back to KSA following their summer vacation [18e21] and they have no history of travelling to the southern part of Saudi Arabia. It worth mentioning that about 54% of the cases fulfilled the WHO criteria for severe malaria and three of them needed admission to the intensive care unit although falciparum malaria comprised not more than 11% of the infections, a finding that adds to other researchers findings of severe malaria caused by vivax infection [22e26]. It is prudent to mention that P. vivax possess a liver stage as one of it’s life cycle components which are called hypnozoites, and the only means to eliminate these hypnozoites is the use of an 8-aminoquinoline (currently only primaquine), a thing that requires compliance with a long regimen along with care to avoid those at risk of haemolysis due to the frequently encountered genetic polymorphism, glucose-6-phosphate dehydrogenase deficiency. Risk of reintroduction of P. vivax into malaria free areas but still containing competent Anopheles vectors is increased as persons carrying hypnozoites are undetectable until they become symptomatic from activation of the hypnozoites. There for, a conceptual change is to be found if proper management of vivax malaria and a good estimation to its clinical threat, the risk of exposure to it, the enduring threat after travel, or by prescribing ineffective chemoprophylaxis are to take place and lead to reduction in travellers hazards of suffering potentially dangerous clinical attacks that are difficult to manage and treat [27]. It is possible that some case might have been missed either by being treated as out- patients/ self treatment or being admitted to another hospital (e.g. pediatrics specialist hospital),though the common route for such cases is Buraidah central hospital. Perhaps the cases of uncomplicated malaria were self-treated and they did not come to the hospital treatment for uncomplicated vivax malaria includes Chloroquine and primaquine according to
I.R. Musa et al. regimens used in Saudi Arabia [28]. This regimen proved efficient, where 37 of the cases were cured. Quinine dihydrochloride was used in 6 cases of severe malaria followed by Doxycycline as per the protocol in Saudi Arabia albeit recent evidence supports the use Artesunate [28e30]. It worth noting that artesunate has not been used to treat uncomplicated P. vivax malaria.
Conclusions Most of the detected malaria cases in Qassim region were among expatriates, particularly from the Indian subcontinent, while the predominant species were vivax. More than 50% of the cases presented with severe malaria.
Conflict of interest Authors declare no conflict of interest.
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