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1 Malaria Epidemiology, diagnosis and risk of resurgence Eskild Petersen Professor, MD, DMSc Department of Infectious Diseases Aarhus University Hospital, Skejby Specialist of Infectious Diseases and Tropical Medicine ESCMID Online Lecture Library Twins, Liberia
2 When pa8ents are admi:ed we seldom know immediately what the diagnosis is We must decide Which samples for analysis, isola8on or not High risk pa8ent based on travel history (West Africa) Treatment to be started before a clear diagnosis We do this based on History and physical examina8on Laboratotory tes8ng and RDTs (Rapid Diagnos8c tests) Geography of travel and earlier life (migra8on) ESCMID Online Lecture Library
3 ESCMID Online Lecture Library
4 You have now excluded a haemorrhagic fever What can cause fever and Disseminated Intervascular Coagula8on? Sep8cemia both gr+ and gr- Leptospirosis Malaria Dengue, Yellow fever CCHF, Alkhurma Hemorrhagic Fever Biochemistry (Hb, WBC, Thrc, CRP, liver- and kidney parameters, BS, Malaria microscopy or rapid test, DIC parameters), blood culrure Blood pressure, pulse, resp. rate or O 2 satura8on, p- lactate Treatment? ESCMID Online Lecture Library An8bio8cs? Malaria drugs?
5 Case fatality rate s Overall P.falciparum ( ) 1.3 Range in Europe Switzerland ESCMID Online Lecture Library Phillips-Howard et al. BMJ : Christen et al. Am J Trop Med Hyg 2006;75:
6 3 pa8ents died = 5.3% (3/56) ESCMID Online Lecture Library
7 Global distribu8on of malaria ESCMID Online Lecture Library
8 e r u t c e r L o e h t n i u l a n O by D I M C S E Pre control y r a r b i L
9 2788 cases diagnosed since 2011 Yemen 16th April imported cases in 2013 World Malaria Report 2013 Malaria, the present chalenge Several cases in the International City 26th June imported cases in 2011 ESCMID Online Lecture Library 12 April cases reported in autochthonous cases
10 Authonous tramsission of P.vivax eastern Oman Malaria - Oman (02): comment Oman interrupted malaria transmission in 2004 and maintained it un8l September 2007, when a focus of local transmission (with 4 cases) was detected in Dakhiliya governorate. Secondary cases occurred in North Sharqiya governorate in 2010, North Sharqiya and Dakhiliya in 2011, and North and South Sharqiya and North Ba8nah in The number of imported cases started to show a decrease from 2029 in 2012 to 1440 cases in Of the total 1451 cases recorded in 2013, the majority (99.24 percent) were interna8onally imported except for 11 secondary cases. hbp:// Immigrants from the Asian subcon8nent being asymptoma8c gametocyte carriers ESCMID Online Lecture Library star8ng a limited local transmission. Gene8c fingerprin8ng needed to determine if it is a single or mul8ple introduc8on.
11 P.falciparum are imported from Africa and P.vivax from Asia ESCMID Online Lecture Library
12 Malaria in Europe A ques8on of climate change? Finland Germany Poland The Netherlands Armenia, Azerbaijan Greece ESCMID Online Lecture Library
13 Malaria in Greece 2012 hbp:// hbp://ecdc.europa.eu/en/press/news/lists/news/ecdc COMMUNICABLE DISEASE THREATS REPORT CDTR Week 37, 9-15 September 2012 All users This weekly bulle8n provides updates on threats monitored by ECDC. I. Execu8ve summary EU Threats Malaria - Greece Opening date: 31 May 2012 Latest update: 7 September 2012 Since June 2012, eight autochthonous cases of malaria, caused by Plasmodium vivax infec8on, have been reported from Greece. Local control measures have been implemented in accordance with na8onal guidelines. Update of the week No addi8onal autochthonous cases were reported since the last update. ESCMID Online Lecture Library Livadas GA & Sphangos JC. Malaria in Greece ( ). Pyrsos, Athen Vol. 2. p. 259, table CXLVI
14 hbp:// fe2d- 476c ff4cb1b568&ID=912 Three P. vivax cases reported in 2013, none in 2014 ESCMID Online Lecture Library In the outbreak over?
15 Long latency P. vivax (P. vivax hibernans) ESCMID Online Lecture Library White NJ. Determinants of relapse periodicity in Plasmodium vivax malaria. Malaria J 2011;10:97
16 P. vivax - different phenotypes IN: White NJ. Determinants of relapse periodicity in Plasmodium vivax malaria. Malaria J 2011;10:97 ESCMID Online Lecture Library Bray & Garnham. Br Med Bull 1982;38:117-22
17 P. vivax haplotypes Temperate zone P.vivax Miao M et al. BMC Evol Biol. 2012;12:22.
18 The malaria team, Liberia Diagnosis of malaria
19 Malaria: thick blood films Dry the slide, and it can be send by mail
20
21 Plasmodium falciparum thin blood films Ring forms Ring forms Schizont - early Schizont - late Schizont - burst Schizont - burst Gametocyte Gametocytes
22
23 Microscopy and limita8ons of rapid tests Centers managing pa8nts with malaria must be able to provide round the clock malaria microscopy of thick and thin blood films and parasite density calcula8ons. Rapid tests may be false nega8ve in cases with very high P.falciparum density?? (Gillet et al. Malaria J 2009; 8:271 ) (HRP2 dele8on in parts of South America) Variant P. ovale (Tordrup et al. Malaria J 2011;10:15) P.knowlesi HRP2 based tests will be nega8ve sensi8vity variable with other tests hbp:// research- publica8ons/rdt_round3/en/index.html
24 Use a rapid test which include pan Plasmodial an8gen ie. LDH or Aldolase
25 Which method should we use? Detec8on levels of different diagnos8c methods: Rapid tests 200 parasites per mm 3 WHO 2011 Microscopy 5 parasites per mm 3 (experienced microscopist) Petersen E et al Am J Trop Med Hyg 1996;55: PCR 0.5 parasites per mm 3 Gama BE et al. Exp Parasitol Mar 2; [Epub]
26 The development of immunity to malaria Semi- immune
27 Conclusion Previous malaria endemic areas s8ll have the mosquitoes and thus have transmission poten8al Asymptoma8c gametocyte carriers from endemic areas cons8tute a constant risk in areas with transmission poten8al Diagnosis of asymptoma8c carriers is a challenge because of the low parasite density in semi- immunes
28 Thank you ques8ons? Aarhus University Hospital Skejby - Thank you very much -
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