Not all severe malaria cases are severe: Is it time to redefine severity criteria for malaria in non-endemic regions?

BACKGROUND: The current definition of severe malaria in non-endemic areas follows WHO criteria, which mainly target children in malaria-endemic areas, potentially misclassifying cases in non-endemic regions. We assessed the performance of a modified severe malaria classification criteria within our patient cohort. METHODS: A cohort study of patients managed for malaria in a non-endemic setting (2005-2023) was analyzed. We classified patients into severe malaria (SM) using WHO 2013 criteria except for hyperparasitemia, where 2 % threshold was applied. Patients with SM were distinguished as very severe malaria (VSM) when presenting at least one of the following conditions: parasitemia >10 %, pulmonary edema, impaired consciousness, seizures, renal failure, metabolic acidosis or hyperlactatemia, shock or hypoglycemia. In patients with SM and no criteria for VSM, less severe malaria (LSM) was defined by: 2-10 % parasitemia, hyperbilirubinemia, prostration, anemia or minor bleeding. The primary composite outcome was death or the need for a life-saving intervention, as analyzed in the three comparative groups. Secondary outcome was the prevalence of co-infections. RESULTS: Among 506 patients with malaria, 176 (34.8 %) presented with SM. A total of 37 (7.3 %) patients developed a life-threatening condition, namely death (n = 4) and/or the need for life-saving interventions (n = 34). All fatalities and 33 out of the 34 life-saving interventions occurred in the VSM group. Patients in LSM group did not develop any life-threatening conditions. As to co-infections, 28 (5.5 %) patients had a community-acquired co-infection, with no differences between groups (p = 0.763). CONCLUSIONS: Severity criteria definitions would benefit from a review when assessing patients with malaria in non-endemic areas. Within the spectrum of SM, patients reclassified as LSM have a low risk of developing a life-threatening condition and present low co-infection incidence and could benefit from management out of intensive care units and a restrictive use of empirical antibiotics.

Assessing viral metagenomics for the diagnosis of acute undifferentiated fever in returned travellers: a multicenter cohort study.

BACKGROUND: Up to 45% of febrile returning travellers remain undiagnosed after a thorough diagnostic work-up, even at referral centres. Although metagenomic next-generation sequencing (mNGS) has emerged as a promising tool, evidence of its usefulness in imported fever is very limited. METHODS: Travellers returning with fever were prospectively recruited in three referral clinics from November 2017 to November 2019. Unbiased mNGS optimised for virus detection was performed on serum samples of participants with acute undifferentiated febrile illness (AUFI), and results were compared to those obtained by reference diagnostic methods (RDM). RESULTS: Among 507 returned febrile travellers, 433(85.4%) presented with AUFI. Dengue virus (n = 86) and Plasmodium spp. (n = 83) were the most common causes of fever. 103/433(23.8%) AUFI remained undiagnosed at the end of the follow-up.Metagenomic next-generation sequencing unveiled potentially pathogenic microorganisms in 196/433(38.7%) AUFI. mNGS identifications were more common in patients with a shorter duration of fever (42.3% in ≤5 days vs 28.7% in >5 days, P = 0.005). Potential causes of fever were revealed in 25/103(24.2%) undiagnosed AUFI and 5/23(21.7%) travellers with severe undiagnosed AUFI. Missed severe aetiologies included eight bacterial identifications and one co-infection of B19 parvovirus and Aspergillus spp.Additional identifications indicating possible co-infections occurred in 29/316(9.2%) travellers with AUFI, and in 11/128(8.6%) travellers with severe AUFI, who had received a diagnosis through RDM. The most common co-infections detected in severe AUFI were caused by Gram-negative bacteria. Serum mNGS was unable to detect >50% of infectious diagnoses achieved by RDM and also yielded 607 non-pathogenic identifications. DISCUSSION: mNGS of serum can be a valuable diagnostic tool for selected travellers with undiagnosed AUFI or severe disease in addition to reference diagnostic techniques, especially during the first days of symptoms. Nevertheless, mNGS results interpretation presents a great challenge. Further studies evaluating the performance of mNGS using different sample types and protocols tailored to non-viral agents are needed.

Relevance of screening for Chagas and viral hepatitis in Bolivian migrants

Objectives: Given the scarcity of data regarding prevalence of various infectious diseases in Latin-American countries, our study aims to assess the burden of T. cruzi, S. stercoralis, HIV and viral hepatitis in Latin-American migrants, with a focus on Bolivian migrants.MethodsWe performed a retrospective observational study of 565 screening evaluations in adults (≥18 years) carried out at our International Healthcare referral service in Barcelona. We reviewed structured clinical records and microbiological results of patients attended between February 2012 and April 2015.ResultsThe median age was 35 years and 74% were women. Of the population screened, 87% were of Bolivian origin. We found a 48% prevalence of T. cruzi, 16% of S. stercoralis, 0.2% of HIV, 0.2% HBV and 0.2% HCV.ConclusionsThese results support the relevance of screening for T. cruzi and S. stercoralis in Bolivian migrants but challenge the pertinence of systematic screening for HBV in this population. (AU)

Objetivos: Dada la escasez de datos con relación a la prevalencia de diversas enfermedades infecciosas en los países iberoamericanos, el objetivo de nuestro estudio fue evaluar la carga de T. cruzi, S. stercoralis, VIH y hepatitis vírica en los emigrantes iberoamericanos, con especial atención en los emigrantes bolivianos.MétodosEstudio observacional retrospectivo de 565 cribados en adultos (≥ 18 años) realizado en nuestro servicio de Servicio de Salud Internacional en Barcelona. Revisamos los registros clínicos estructurados y los resultados microbiológicos de los pacientes asistidos entre febrero de 2012 y abril de 2015.ResultadosLa edad media fue de 35 años y el 74% fueron mujeres. El origen boliviano representó el 87% de la población cribada. Encontramos una prevalencia de 48% de T. cruzi, 16% de S. stercoralis, 0,2% de VIH, 0,2% de VHB y 0,2% de VHC.ConclusionesEstos resultados respaldan la relevancia del cribado de T. cruzi y S. stercoralis en migrantes bolivianos, aunque cuestiona la pertinencia del cribado sistemático de VHB en esta población. (AU)

Recomendaciones para el cribado de enfermedad infecciosa, salud mental y mutilación genital femenina en pacientes inmigrantes atendidos en Atención Primaria / Recommendations for the screening for infectious diseases, mental health, and female genital mutilation in immigrant patients seen in Primary Care

La salud de la población inmigrante puede mejorarse si ciertas condiciones de salud se identifican de una forma temprana a través de la implementación de un programa de cribado. Este documento presenta las recomendaciones obtenidas en el marco del proyecto Cribado en población inmigrante (CRIBMI), cuyo objetivo es implementar un programa de cribado de enfermedades infecciosas (VIH, VHB, VHC, tuberculosis, estrongiloidiasis, esquistosomiasis y enfermedad de Chagas), así como mutilación genital femenina (MGF) y salud mental (SM) entre la población inmigrante a nivel de Atención Primaria. Las recomendaciones se basaron en: procedencia de países endémicos para estrongiloidiasis, esquistosomiasis y enfermedad de Chagas; umbral de prevalencia en el país de origen del 1% para VIH, 2% para VHC, VHB y una incidencia de > 50 casos/100.000 habitantes para tuberculosis activa en migrantes con menos de 5 años en Europa. Explorar el riesgo de MGF se recomienda en mujeres que proceden de países donde esta práctica es habitual. La evaluación de SM se recomienda a personas que vienen de áreas en conflicto o alta tensión

Immigrant health status may be improved if certain health conditions are identified early through the implementation of a screening program. This document presents the recommendations resulting from the Screening in immigrant population project (CRIBMI) aimed at implementing a screening program for infectious diseases (HIV, HBV, HCV, tuberculosis, strongyloidiasis, schistosomiasis and Chagas disease), as well as female genital mutilation and mental health (MH) in migrant population at Primary Care level. Screening recommendations were based on: coming from an endemic country for strongyloidiasis, schistosomiasis, and Chagas diseases; on a threshold level of prevalence for HIV (> 1%), HBV (> 2%), and HCV (> 2%), and on incidence (> 50 cases/100,000-inhabitants) for active tuberculosis in immigrants with < 5 years in Europe. Exploring the risk of FGM is recommended in women from countries where this practice is prevalent. Evaluation of MH status is recommended for people from areas of conflict and violence

Geographic analysis and estimation of hepatitis C cases in migrant populations living in Spain: is a country-based screening strategy appropriate?

Background: Spain needs to increase the number of new known cases in order to achieve the goal of eliminating hepatitis C virus (HCV) by 2030. The aim of this study was to estimate the number of HCV cases among the migrant population in Spain and propose different scenarios for micro-elimination strategies, targeting the most relevant migrant groups. Methodology: this epidemiological and demographic cross-sectional descriptive study employed a systematic approach to estimate the number of migrants infected by HCV in Spain. Estimates are based on demographic data and details the size of the foreign-born population living in every Spanish province and the anti-HVC+ prevalence rates in their respective countries of origin. Results: in Spain, there are 100,268 estimated cases of anti-HCV+ among the total adult migrant population who live in the country. The estimated cases of anti-HCV+ among migrants from moderate-high endemic countries with a prevalence of ≥ 2%, > 3%, > 4% and > 5% are 48,979, 48,029, 24,176 and 15,646, respectively. The anti-HCV+ endemic countries (≥ 2%) that contribute to the highest number of estimated cases in Spain are Romania, Italy, Pakistan, Ukraine, Senegal, Russia and Nigeria. The autonomous communities with the highest prevalence and number of estimated anti-HCV+ cases among migrant population are Catalonia, Valencian Community, Madrid and Andalusia, respectively. Conclusion: these data show the need to establish HCV screening strategies for the migrant population in Spain and, particularly, in the most affected areas. The strategy should target those migrant communities with a higher prevalence and a higher number of estimated cases, such as people from Eastern Europe, Sub-Saharan Africa and Pakistan

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Infiltración de los ligamentos uterosacros con un anestésico local de larga duración en pacientes sometidas a histerectomía vaginal / Infiltration of the uterosacral ligaments with a long-acting local anesthetic in patients undergoing vaginal hysterectomy

Objetivo: Conocer si la infiltración de los ligamentos uterosacros con un anestésico de vida media larga, al practicar una histerectomía vaginal, disminuye la utilización de otras formas de analgesia postoperatoria con posible morbilidad. Sujetos y métodos: Ensayo clínico controlado y aleatorizado y a doble ciego con 2 grupos de pacientes. Al grupo de estudio (45 pacientes) se le inyectaron 5 ml de ropivacaína al 0,75% en cada ligamento uterosacro durante la intervención. Al grupo control no se le realizó ninguna inyección paracervical. Se valoró el dolor postoperatorio a las 2 h del inicio de la anestesia, a las 2.30, 3.30, 13.30 y 25.30. En los casos en que la valoración de la Escala Visual Analógica (EVA) era superior a 3, se practicaba una analgesia epidural considerada de rescate. Resultados: El grupo de estudio no precisó anestesia epidural de rescate en el 68,9% de las pacientes, frente al 43,6% del grupo control (p = 0,027). Conclusiones: Infiltrar los ligamentos uterosacros con un anestésico local de larga duración en las pacientes sometidas a histerectomía vaginal disminuye la necesidad de emplear analgesia de rescate, que es cara y tiene efectos secundarios adversos