Successfully reported this slideshow.

Malaria in Haiti Symposia - The CRUDEM Foundation

1,854 views

Published on

Malaria in Haiti Symposia, presented in Milot, Haiti at Hôpital Sacré Coeur.

CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.

Published in: Health & Medicine
  • Be the first to comment

Malaria in Haiti Symposia - The CRUDEM Foundation

  1. 1. Anthony  Karabanow,  MD  
  2. 2. Hai$    Each  year,  Haiti  reports    ~30,000  confirmed  cases  to   PAHO    200,000  cases  are  thought  to  occur  annually    Occurs  mostly  during  the  rainy  season:       Primary  peak  November  to  January  
  3. 3. Prevalence  in  Hai$    Emerging  Infectious  Diseases  Journal  (Volume  13,   Number  10–October  2007):     Survey  of  714  persons  in  Artibonite  Valley  during  high   malaria  season     Prevalence  of  3.1%  by  PCR     14.2%  prevalence  amongst  febrile  persons  
  4. 4. Malaria  a.er  Jan  12    JAMA.  2010;303(20):2028-­‐2029:     From  Jan  12  to  Feb  25,  CDC  received  reports  of  11   laboratory-­‐confirmed  cases  of  P.  falciparum  malaria   acquired  in  Haiti     7  emergency  responders,  3  Haitian  residents,  1  US   traveler     2  of  the  emergency  responders  required  transfer  to  the   US  for  ICU  care  
  5. 5. Biology    Vector:  female  Anopheles  mosquito    After  inoculation,  sporozoites  go  to  liver  in  1  to  2  hrs    Liver  stage  is  asymptomatic    Incubation  period  is  12  to  14  days  for  Pf    Symptomatic  stage  is  RBC  stage  
  6. 6. Biology    Why  is  P.falciparum  so  virulent?     CYTOADHERENCE    AND  SEQUESTRATION  
  7. 7. Biology    P.  falciparum  expresses  “knobs”  on  the  surface  of   infected  RBCs    Knobs  mediate  cytoadherence  to  endothelial  cells    Leads  to:     Small  infarcts     Capillary  leakage     Organ  dysfunction  
  8. 8. Clinical  disease    MALARIA  IS  A  NON-­‐SPECIFIC  FEBRILE  ILLNESS  
  9. 9. Severe  malaria    Severe  parasitemia  (>5%)    Organ  dysfunction:      CNS  disease      ARDS     Circulatory  collapse       Renal  failure     Hepatic  failure       DIC     Severe  anemia       Hypoglycemia  
  10. 10. Clinical  disease    Greatest  risk  for  severe  disease:     Children     Pregnant  women     Non-­‐immune  individualized     Immunocompromised  
  11. 11. Clinical  disease  
  12. 12. PHYSICAL  EXAM                                                                          VIDEO  
  13. 13. CNS  disease    Impaired  consciousness    Delirium    Seizures    More  common  in  children    If  untreated,  usually  fatal    With  treatment,  mortality  is  15-­‐20%  
  14. 14. Malarial  re$nopathy    MALARIAL  RETINOPATHY:  A  NEWLY   ESTABLISHED  DIAGNOSTIC  SIGN  IN  SEVERE   MALARIA      Am.  J.  Trop.  Med.  Hyg.,  75(5),  2006,  pp.  790-­‐797  
  15. 15. Macular  whitening  
  16. 16. White  re$nal  vessels  
  17. 17. Re$nal  hemorrhage  
  18. 18. Proposed  algorhythm  
  19. 19. ARDS    Non-­‐cardiogenic  pulmonary  edema:     Parasite  sequestration  in  lungs     SIRS  
  20. 20. ARDS  
  21. 21. Renal  failure    Pathogenesis:     Parasite  sequestration  in  renal  microcirculation     Hemolysis  (“blackwater  fever”    ATN)     Hypovolemia  
  22. 22. Blackwater  fever  
  23. 23. Anemia    Pathogenesis:     Hemolysis     Cytokine  suppression  of  hematopoiesis  
  24. 24. Severe  anemia  
  25. 25. Hypoglycemia    Pathogenesis:     Increased  host  glucose  consumption     Quinine  induced  
  26. 26. Metabolic  acidosis    Pathogenesis:     Tissue  shock  –  sequestered  parasites,  hypovolemia     Impaired  renal/hepatic  lactate  clearance  
  27. 27. Diagnosis    Microscopy  (gold  standard)    Rapid  Diagnostic  Tests  (RDTs)    PCR  
  28. 28. Microscopy    Has  sensitivity  of  5  –  10  parasites/microL    Thick  smears     Measure  parasite  density    Thin  smears     Identification  of  malarial  species  
  29. 29. Iden$fica$on  $ps    Infected  RBCs  are  of  normal  size    Ring  forms  are  commonly  seen     Located  at  periphery  of  RBCs     Multiple  rings  per  RBCs  may  be  present    Schizonts,  trophozoites  are  rarely  seen    Gametocytes  have  banana  shape  
  30. 30. Calcula$ons    Count  parasites  until  200  WBCs  have  been  seen    Parasite  density  (#/microL)  =     (#  parasites)  x  (WBC  count  /  200)    %  Parasitemia  =     (Parasite  density)  /  WBC  
  31. 31. RDTs    Detect  malaria  antigens:     P.  falciparum  LDH     Histidine-­‐rich  protein  2  
  32. 32. Op$MAL  assay  
  33. 33. Op$MAL  assay  
  34. 34. Problems  with  RDTs    Decreased  sensitivity  at  low  parasitemia    Cannot  quantify  parasitemia    Positive  test  despite  parasite  clearance    Higher  cost  
  35. 35. PCR    Can  detect  as  few  as  1  to  5  parasites/microL    Cannot  quantify  infection    Costly    Requires  specialized  equipment  and  trained  staff  
  36. 36. Treatment    Good  news:  P.  falciparum  malaria  in  Haiti  is   chloroquine  sensitive    Bad  news:    P.  falciparum  malaria  in  Haiti  can  still   prove  fatal  
  37. 37. CQ  resistance?    Emerging  Infectious  Disease  Journal  (Volume  15,   Number  5–May  2009):     821  persons  screened  for  malaria  at  Hopital  Albert   Schweitzer  between  2006-­‐7     79  persons  tested  positive  for  P.  falciparum     PCR  analysis  detected  5  cases  of  CQ  resistance  
  38. 38. Uncomplicated  malaria    Parasitemia  <  5%    No  evidence  of  organ  dysfunction    Able  to  take  PO    General  rule:    Malaria  can  be  fatal.  If  in  doubt  of   degree  of  severity,  always  treat  more  aggressively  
  39. 39. Chloroquine    Adults:    600  mg  base  (=1000  mg  salt)  po  immediately,   followed  by  300  mg  base  (=500  mg  salt)  po  at  6,  24,   and  48  hours.  Total  dose:  1500  mg  base  (=2500  mg   salt).      Children:    10  mg  base/kg  po  immediately,  followed  by   5  mg  base/kg  po  at  6,  24,  and  48  hours.  Total  dose:  25   mg  base/kg.    
  40. 40. Management  of  severe  malaria    Treat  the  parasitemia    Treat  the  organ  dysfunction  
  41. 41. Chloroquine    10  mg  base/kg  in  isotonic  fluid  by  constant-­‐rate  IV   infusion  over  8  hours,  followed  by  15  mg/kg  given   over  the  next  24  hours.                                                                                or    5  mg  base/kg  in  isotonic  fluid  by  constant-­‐rate  IV   infusion  over  6  hours,  every  6  hours,  for  a  total  of  5   doses  (i.e.  25  mg  base/kg  continuously  over  30  hours).  
  42. 42. Quinine    Loading  dose:    20  mg  salt/kg  of  body  weight  diluted  in   10  ml  isotonic  fluid/kg  by  IV  infusion  over  4  hours    Maintenance  dose:    8  hours  after  the  start  of  the   loading  dose,  10  mg  salt/kg,  over  4  hours.    Repeat  maintenance  dose  every  8  hours  
  43. 43. Cerebral  malaria    Follow  the  Glasgow/Blantyre  scores    LP  to  r/o  bacterial  meningitis    Seizure  management  (NOT  PROPHYLAXIS):     Diazepam  0.4  mg/kg  IV/PR     Lorazepam  0.1  mg/kg  IV  
  44. 44. ARDS     May  need  mechanical  ventilation     Avoid  volume  overload  leading  to  cardiogenic   pulmonary  edema  
  45. 45. Renal  failure    Infuse  isotonic  saline  to  maintain  euvolemia    Dialysis  as  necessary  
  46. 46. Anemia    Exchange  transfusion  are  of  uncertain  value    Transfuse  for  Hg  <  7  or  compatible  symptoms    Diuretics  often  NOT  needed  as  pts  are  usually   hypovolemic  
  47. 47. Hypoglycemia    Follow  blood  sugars  routinely    Use  IVF  with  D5  routinely    Consider  in  pts  with  MS  changes  
  48. 48. Other    Bacteremia  (enteric,  esp  Salmonella)  is  a  common   complication  of  severe  malaria     Consider  blood  cultures  and  antibiotic  therapy  for   decompensated  patients    DVT  prophylaxis    Nutrition  via  NGT    Fever  control    
  49. 49. Preven$on    ITN    IRS    IPT    Larval  control    Repellants    ?  vaccine  
  50. 50. Malaria  elimina*on  on  Hispaniola    The  Lancet  Infectious  Diseases  May  2010:    What  is  needed  for  malaria  elimination  on   Hispaniola?  
  51. 51. Eliminate  the  human  reservoir    Establish  active  case  detection  around  patients   identified  passively  through  health  systems  to  detect   asymptomatic  infections    Mass  detection  and  treatment  of  infection,   particularly  during  the  extended  dry  season  
  52. 52. Prevent  transmission    Targeted  insecticide-­‐treated  mosquito  nets,  indoor   residual  spraying,  or  larval  habitat  management   around  foci  of  infection  identified  through  passive  to   active  case  detection  
  53. 53. Mobilize  community    To  seek  diagnosis  and  treatment  for  all  fevers    To  understand  and  support  the  elimination  effort  
  54. 54. Ini$a$ve    Carter  Center  launched  initiative  to  eradicate  malaria   in  Haiti/DR  by  2010    Will  likely  cost  $200  million  

×