Selective ambulatory management of Plasmodium falciparum malaria in paediatric refugees

A Scoping Review of the Health of African Immigrant and Refugee Children

Migration is a growing phenomenon around the world, including within the African continent. Many migrants, especially African children, face challenges related to health and social inclusion and can face increased health risks. A systematic scoping review of available literature on the health of African migrant children across the globe was conducted to offer insight into these health risks. The review was conducted over a 15-month period from January 2019 to April 2020, yielding 6602 articles once duplicates were removed. This search included electronic databases, reference lists of articles reviewed, and searches of libraries of relevant organisations. A total of 187 studies met the inclusion criteria, of which 159 were quantitative, 22 were qualitative, and 6 used mixed methods. The findings reveal decreased health in this population in areas of nutrition, infectious diseases, mental health, birth outcomes, sexual and reproductive health, physical and developmental health, parasitic infections, oral health, respiratory health, preventative health, endocrine disorders, health care services, and haematological conditions. The findings offer insights into factors influencing the health of African immigrant and refugee children. Further studies, especially qualitative studies, are needed to determine barriers to service access after migration and to investigate other underexplored and overlooked health concerns of African migrant children, including pneumonia and child maltreatment.

Management and prevention of imported malaria in children. Update of the French guidelines

Since the 2007 French guidelines on imported Falciparum malaria, the epidemiology, treatment, and prevention of malaria have changed considerably requiring guidelines for all Plasmodium species to be updated. Over the past decade, the incidence of imported malaria has decreased in all age groups, reflecting the decrease in the incidence of malaria in endemic areas. The rates of severe pediatric cases have increased as in adults, but fatalities are rare. The parasitological diagnosis requires a thick blood smear (or a rapid immunochromatographic test) and a thin blood film. Alternatively, a rapid antigen detection test can be paired with a thin blood film. Thrombocytopenia in children presenting with fever is highly predictive of malaria following travel to a malaria-endemic area and, when detected, malaria should be strongly considered. The first-line treatment of uncomplicated P. falciparum malaria is now an artemisinin-based combination therapy (ACT), either artemether-lumefantrine or artenimol-piperaquine, as recommended by the World Health Organization in endemic areas. Uncomplicated presentations of non-falciparum malaria should be treated either with chloroquine or ACT. The first-line treatment of severe malaria is now intravenous artesunate which is more effective than quinine in endemic areas. Quinine is restricted to cases where artesunate is contraindicated or unavailable. Prevention of malaria in pediatric travelers consists of nocturnal personal protection against mosquitoes (especially insecticide-treated nets) combined with chemoprophylaxis according to the risk level.

Malaria in Sydney, Australia: Lessons learned from case management

AIM

To evaluate the clinical presentation and profile of malaria cases diagnosed at a tertiary children's hospital in Australia

METHODS

A retrospective file review of children diagnosed with malaria at the Children's Hospital Westmead from 1 January 2000 to 31 December 2010.

RESULTS

During the 11-year study period, 40 children were diagnosed with malaria; 30 (75%) presented with fever; 14 (35%) complained of nausea, vomiting or abdominal pain; and eight (20%) were completely asymptomatic. The median time between arrival in Australia and malaria diagnosis was 32 (range 4-434) days. Sixteen (40%) were refugees from sub-Saharan Africa, six (15%) were immigrants from South-East Asia, and seven (18%) recently travelled to or visited friends and family in malaria-endemic areas. Most (68%) cases had Plasmodium falciparum; Plasmodium vivax was identified in four cases with exposures in India and Papua New Guinea; one had mixed P. falciparum and P. vivax infection.

CONCLUSION

Malaria signs and symptoms were non-specific, with an absence of fever in a quarter of cases. Diagnostic vigilance is required in all children with potential malaria exposure in the preceding year. Asymptomatic parasitaemia should be considered in recent migrants from malaria-endemic areas.

Malaria: an update for physicians

Malaria remains the most important parasitic infection in humans. There have been significant advances in the treatment of both nonsevere and severe malaria with the advent of artemisinin combination therapies and parenteral artesunate, but the optimum supportive management of severe malaria is unclear. A broadly acceptable therapy for the prevention of relapses in Plasmodium vivax infection has not been discovered. Globally, the priority remains to prevent infection in the vulnerable, to move toward elimination where feasible, and to ensure that effective treatment is available to all. In developed settings, prevention of infection and its early recognition are crucial.

Factors associated with the performance of a blood-based interferon-γ release assay in diagnosing tuberculosis

Background

Indeterminate results are a recognised limitation of interferon-γ release assays (IGRA) in the diagnosis of latent tuberculosis (TB) infection (LTBI) and TB disease, especially in children. We investigated whether age and common co-morbidities were associated with IGRA performance in an unselected cohort of resettled refugees.

Methods

A retrospective cross-sectional study of refugees presenting for their post-resettlement health assessment during 2006 and 2007. Refugees were investigated for prevalent infectious diseases, including TB, and for common nutritional deficiencies and haematological abnormalities as part of standard clinical screening protocols. Tuberculosis screening was performed by IGRA; QuantiFERON-TB Gold in 2006 and QuantiFERON-TBGold In-Tube in 2007.

Results

Complete data were available on 1130 refugees, of whom 573 (51%) were children less than 17 years and 1041 (92%) were from sub-Saharan Africa. All individuals were HIV negative. A definitive IGRA result was obtained in 1004 (89%) refugees, 264 (26%) of which were positive; 256 (97%) had LTBI and 8 (3%) had TB disease. An indeterminate IGRA result was obtained in 126 (11%) refugees (all failed positive mitogen control). In multivariate analysis, younger age (linear OR  = 0.93 [95% CI 0.91–0.95], P<0.001), iron deficiency anaemia (2.69 [1.51–4.80], P = 0.001), malaria infection (3.04 [1.51–6.09], P = 0.002), and helminth infection (2.26 [1.48–3.46], P<0.001), but not vitamin D deficiency or insufficiency, were associated with an indeterminate IGRA result.

Conclusions

Younger age and a number of common co-morbidities are significantly and independently associated with indeterminate IGRA results in resettled predominantly African refugees.

Disparities exist in the availability of outpatient malaria treatment in Maryland, USA

BACKGROUND

Prior review of pediatric malaria cases in the Washington, DC area raised concern that there may be systematic barriers to the timely procurement of antimalarial medications for those patients being treated for malaria as outpatients. We hypothesized that the local availability of antimalarial medications was not consistent across communities of differing socioeconomic status.

METHODS

We administered a blinded telephone questionnaire to pharmacists in the Maryland suburbs of Washington, DC and assessed the in-stock availability of antimalarial medication. Pharmacies were stratified into categories of population risk, disease incidence, and income.

RESULTS

Pharmacies in high-income ZIP codes were more likely to stock first-line therapy medications (93%, p = 0.03) than pharmacies in moderate-income, low-incidence, low-risk ZIP codes (50%). Moderate-income ZIP codes with high-malaria incidence and a high-risk population (67%, p = 0.35) were no more likely to stock first-line antimalarial medications than pharmacies in moderate-income, low-incidence, low-risk areas (50%). In all, only four (9%) pharmacies stocked quinine. Many pharmacists stated the reason for this discrepancy was that they believed the Food and Drug Administration (FDA) had "pulled quinine off the market."

CONCLUSIONS

In the United States, disparities exist in the availability of outpatient-antimalarial medications. We recommend that a complete outpatient treatment course is dispensed, or the availability of the medication at the pharmacy that the patient will use is verified prior to departure from the clinic or emergency department. Pharmacists and physicians should be aware that the FDA restrictions on the use of quinine sulfate do not apply to its use for the treatment of malaria.

The case for outpatient treatment of Plasmodium falciparum malaria in a selected UK immigrant population

UK guidance recommends that all patients with falciparum malaria be admitted to hospital, although a number of cohort studies in the developed world demonstrate that outpatient treatment of falciparum malaria is feasible and safe in selected patients. We review the literature on outpatient treatment in developed countries and present local data from East London where a selected immigrant population were successfully treated as outpatients. Although it is premature to claim that outpatient treatment of falciparum malaria is safe in all selected patients, we conclude it is time for a large UK-based safety study or randomised trial to dispel the belief that all patients with uncomplicated Plasmodium falciparum must be admitted to hospital.

The Australasian Society for Infectious Diseases guidelines for the diagnosis, management and prevention of infections in recently arrived refugees: an abridged outline

About 13,000 refugees are currently accepted for migration into Australia each year, many of whom have spent protracted periods living in extremely disadvantaged circumstances. As a result, medical practitioners are increasingly managing recently arrived refugees with acute and chronic infectious diseases. The Australasian Society for Infectious Diseases has formulated guidelines for the diagnosis, management and prevention of infection in newly arrived refugees. This article is an abridged version of the guidelines, which are available in full at <http://www.asid.net.au>. All refugees should be offered a comprehensive health assessment, ideally within 1 month of arrival in Australia, that includes screening for and treatment of tuberculosis, malaria, blood-borne viral infections, schistosomiasis, helminth infection, sexually transmitted infections, and other infections (eg, Helicobacter pylori) as indicated by clinical assessment; and assessment of immunisation status, and catch-up immunisations where appropriate. The assessment can be undertaken by a general practitioner or within a multidisciplinary refugee health clinic, with use of an appropriate interpreter when required. The initial assessment should take place over at least two visits: the first for initial assessment and investigation and the second for review of results and treatment or referral.

The Needs of Children in Natural or Manmade Disasters

Disasters have been described as “events of sufficient scale, asset depletion, or numbers of victims to overwhelm medical resources” [1] or as “a serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses that exceed the ability of the affected community or society to cope using its own resources” [2]. Importantly, that definition goes on to state: “A disaster is a function of the risk process. It results from the combination of hazards, conditions of vulnerability and insufficient capacity or measures to reduce the potential negative consequences of risk.”