Tropical traveller and Malaria

Question 1

What are the key questions you should ask in a risk assessment before a patient travels?

Answer 1

Where are you going? (urban or rural)
How long for?
What will you be doing there?
When are you going?
Past medical history- epilepsy, increased age, pregnancy, comorbidities, immunosuppression
Drug history

Question 2

What groups of people are at greater risk of malaria?

Answer 2

healthcare workers, military, those working with animals, sex tourism

Question 3

Outline how you would prevent malaria (ABCD)

Answer 3

A- awareness of risk
B- bite avoidance- DEET, mosquito nets (citronella is not recommended
C- chemoprophylaxis- before, during and after, consider S/E, cost and contraindications
D- diagnose early- fever up to 6-12months after return could be malaria.

Question 4

Outline some malaria prophylaxis that may be prescribed

Answer 4

Atovaquone+proguanil=Malorone 1 tablet/day (CI in pregnancy, renal failure and is expensive)
Mefloquine (Larium)- start 2-3 weeks prior to travel and for 4 weeks after return, 1 tablet/day (suitable in pregnancy)
Doxycycline- 1tablet/day, cheap, (CI pregnancy)
Chloroquin (+/- proguanil)- only for N.Africa, middle east and central asia

Question 5

What is a suitable standby treatment for malaria?

Answer 5

Coartem (Artemether/lumefantrine) for acute uncomplicated malaria.

Question 6

Name some conditions associated with travel that can be vaccinated against?

Answer 6

Yellow fever- live vaccine- not for immunocompromised
Meningococcal ACWY
Polio
Hep A (2 doses 6 months apart)
Typhoid
Rabies (3 doses - day 0, 7 and 21- for Africa, asia)

Question 7

How is rabies transmitted?

Answer 7

through animal bites

- if you develop symptom you will die

Question 8

What group of people are less likely to seek pre-travel advice?

Answer 8

Those visiting family and friends- they are therefore more likely to experience fever

Question 9

Which part of the world are you more likely to return with a systemic febrile illness?

Answer 9

Africa/South East Asia

Question 10

Which part of the world are you more likely to return with acute diarrhoea?

Answer 10

South Central Asia, Central America

Question 11

Which part of the world are you more likely to return with a dermatological condition?

Answer 11

Caribbean (cutaneous larvae migrans)

South America

Question 12

In a patient returning from abroad what are the most common causes of fever?

Answer 12

Malaria (P.falciparum)
Dengue (viral)
Mononucleosis
Enteric fever
Rickettsia

Question 13

What are the 3 major clinical syndromes among returning travellers?

Answer 13

GI disease
Systemic febrile illness
Dermatological disease

Question 14

What is the most common cause of fever in returning travellers?

Answer 14

Malaria

Question 15

What is the most common dermatological disease in patients returning from the Caribbean?

Answer 15

Cutaneous Larvae migrans

Question 16

What is the most common parasitic disease to cause diarrhoea?

Answer 16

Giardia

Question 17

What is the most common bacterial disease to cause diarrhoea?

Answer 17

Campylobacter

Question 18

What’s the most likely malaria causative agent?

Answer 18

P.falciparum

Question 19

What are the symptoms of malaria?

Answer 19

fever, riggers, vomiting, headache, arthralgia, malaise (cough and diarrhoea too)

Question 20

How is malaria diagnosed?

Answer 20

Blood film and antigen testing PCR

Question 21

How do you treat P.falciparum?

Answer 21

Non-severe: Artemesinin combination therapy PO
Malorone or quinine (with doxycycline or clindamycin)
Severe: IV artesunate or quinine

Question 22

How do you treat P.vivax?

Answer 22

PO ACT or chloroquine
followed by primaquine to eliminate hypnozoite stage
(NB check for G6PD deficiency prior to primaquine)

Question 23

What sort of fever do you get with P.vivax and P.ovale?

Answer 23

tertian fever- day 1 and 3

Question 24

which malaria is more severe: P.vivax or P.falciparum?

Answer 24

P.falciparum