Évaluation des pratiques dans la prise en charge du paludisme d’importation de l’enfant dans la région Nord–Pas-de-Calais

Management of imported malaria in the emergency department: Adequacy compared to guidelines, and impact of the SARS-CoV-2 pandemic

OBJECTIVES

Adequacy of imported malaria management with respect to guidelines in emergency departments (ED) is low. We aimed to identify factors associated with this non-compliance, and a potential impact of the SARS-CoV-2 pandemic.

PATIENTS AND METHODS

Patients presenting with imported malaria at the ED of the hospital of Melun (France), from January 1, 2017 to February 14, 2022 were retrospectively included.

RESULTS

Among 205 adults and 25 children, biological criteria of severity were fully assessed in 10% of cases; lactates (40%) and blood pH (21%) levels were the main missing variables. Of 74 patients (32%) with severe malaria, 13 were misclassified as uncomplicated malaria. The choice and dosage of treatment were adequate in 85% and 92% of cases, respectively. Treatment conformity was lower in severe malaria cases than in non-severe malaria cases (OR 0.15 [95% CI 0.07-0.31]), with oral treatment in 17 patients with severe malaria; conformity was higher in the intensive care unit (OR 4.10 [95% CI 1.21-13.95]). Patients with severe malaria were more likely to start treatment within 6hours than patients with uncomplicated malaria (OR 1.97 [95% CI 1.08-3.43]), as were patients infected by P.falciparum compared to other species (OR 4.63 [95% CI 1.03-20.90]). Consulting during the SARS-CoV-2 pandemic was the only organizational factor associated with a lower probability of adequate management (OR 0.42 [95% CI 0.23-0.75]).

CONCLUSION

Initial evaluation of malaria severity and time to treatment administration could be improved. These have been adversely impacted by the SARS-CoV-2 pandemic.

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.

Knowledge gaps in the diagnosis and management of patients with tropical diseases presenting to Canadian emergency departments: are the gaps being met?

OBJECTIVE

We conducted a needs assessment to identify knowledge gaps in the management of tropical diseases by Canadian emergency physicians and identify available, related continuing medical education (CME) resources.

METHODS

A literature review was conducted to summarize challenges in the management of commonly encountered tropical diseases. An anonymous online survey was administered to Canadian emergency physicians using the Canadian Association of Emergency Physicians survey deployment service in July and August 2012. The survey identified self-reported gaps in knowledge and assessed knowledge using case-based vignettes. A list of CME resources was generated from a review of major academic emergency medicine journals, online cases, and conference topics from emergency medicine associations during 2010-2011. Two independent reviewers assessed the relevance of the resources; differences were resolved by consensus.

RESULTS

From 635 citations, 47 articles were selected for full review; the majority (66%) were retrospective chart reviews, few (10.6%) had an emergency medicine focus, and fewer still were Canadian (8.5%). In total, 1,128 surveys were distributed, and 296 (27%) participants were included in the study. Most respondents reported "no" (52.4%) or "some" (45.9%) training in tropical medicine. Most (69.9%) rated their comfort in managing patients with tropical diseases as "low." Few (11.1%) respondents reported a tropical disease being misdiagnosed or mismanaged; 44.1% indicated malaria. The perceived need for further training was high (76.7%). Conference workshops were the most highly requested CME modality, followed by case studies and podcasts. Correct answers to case vignettes ranged from 30.7 to 58.4%. Although 2,038 CME titles were extracted from extensive searches, only 6 were deemed relevant.

CONCLUSIONS

Most Canadian emergency physicians have had minimal training in tropical diseases, reported a low comfort level in their management, and identified a high need for CME opportunities, which are lacking.