A brief review on features of falciparum malaria during pregnancy.

Malaria in pregnancy is a serious public health problem in tropical areas. Frequently, the placenta is infected by accumulation of Plasmodium falciparum-infected erythrocytes in the intervillous space. Falciparum malaria acts during pregnancy by a range of mechanisms, and chronic or repeated infection and co-infections have insidious effects. The susceptibility of pregnant women to malaria is due to both immunological and humoral changes. Until a malaria vaccine becomes available, the deleterious effects of malaria in pregnancy can be avoided by protection against infection and prompt treatment with safe, effective antimalarial agents; however, concurrent infections such as with HIV and helminths during pregnancy are jeopardizing malaria control in sub-Saharan Africa.

A brief review on features of falciparum malaria during pregnancy

Malaria in pregnancy is a serious public health problem in tropical areas. Frequently, the placenta is infected by accumulation of Plasmodium falciparum-infected erythrocytes in the intervillous space. Falciparum malaria acts during pregnancy by a range of mechanisms, and chronic or repeated infection and co-infections have insidious effects. The susceptibility of pregnant women to malaria is due to both immunological and humoral changes. Until a malaria vaccine becomes available, the deleterious effects of malaria in pregnancy can be avoided by protection against infection and prompt treatment with safe, effective antimalarial agents; however, concurrent infections such as with HIV and helminths during pregnancy are jeopardizing malaria control in sub-Saharan Africa

Imported malaria in pregnant women: A retrospective pooled analysis.

BACKGROUND: Data on imported malaria in pregnant women are scarce. METHOD: A retrospective, descriptive study of pooled data on imported malaria in pregnancy was done using data from 1991 to 2014 from 8 different collaborators in Europe, the United States and Japan. National malaria reference centres as well as specialists on this topic were asked to search their archives for cases of imported malaria in pregnancy. A total of 631 cases were collated, providing information on Plasmodium species, region of acquisition, nationality, country of residence, reason for travel, age, gestational age, prophylactic measures and treatment used, as well as on complications and outcomes in mother and child. RESULTS: Datasets from some sources were incomplete. The predominant Plasmodium species was P. falciparum (78.5% of cases). Among the 542 cases where information on the use of chemoprophylaxis was known, 464 (85.6%) did not use chemoprophylaxis. The main reason for travelling was "visiting friends and relatives" VFR (57.8%) and overall, most cases of malaria were imported from West Africa (57.4%). Severe anaemia was the most frequent complication in the mother. Data on offspring outcome were limited, but spontaneous abortion was a frequently reported foetal outcome (n = 14). A total of 50 different variants of malaria treatment regimens were reported. CONCLUSIONS: Imported cases of malaria in pregnancy are mainly P. falciparum acquired in sub-Saharan Africa. Malaria prevention and treatment in pregnant travellers is a challenge for travel medicine due to few data on medication safety and maternal and foetal outcomes. International, collaborative efforts are needed to capture standardized data on imported malaria cases in pregnant women.

Does the use of alcohol-based hand gel sanitizer reduce travellers' diarrhea and gastrointestinal upset?: A preliminary survey.

INTRODUCTION: Use of alcohol-based hand sanitizer is recommended by the CDC to reduce the risk for travellers' diarrhoea, but its effectiveness has not been assessed. MATERIALS AND METHODS: We investigated the potential protective effect of hand sanitizer use on the occurrence of diarrhoea and/or vomiting in 200 international travellers, who were returning home, at an international airport. We also conducted a knowledge, aptitude and practice survey about hand gel use among international travellers consulting for pre-travel advice at a specialized clinic. RESULTS: 200 returning travellers were included of which 32.5% declared having used alcohol-based hand sanitizer during travel. Travellers who used hand sanitizer reported diarrhoea and vomiting significantly less frequently than those who did not (17% vs. 30%, OR = 0.47; 95% CI [0.21-0.97], p = 0.04). A total of 257 travellers consulting for pre-travel advice were included. A majority of travellers knew that hand sanitizer may be used for hand hygiene and had already used hand sanitizer; 72% planned to bring hand sanitizer during their next travel. CONCLUSIONS: Use of hand sanitizer is highly acceptable by travellers and is associated with a reduction in the incidence of travellers' diarrhoea and/or vomiting.

Family compliance with counseling for children traveling to the tropics.

BACKGROUND: The number of people, both adults and children, traveling abroad, is on the rise. Some seek counseling at travel medicine centers before departure. METHODS: A prospective study was conducted among children <16 years visiting a travel medicine center in Marseille, France, from February 2010 to February 2011. Parents were contacted by telephone 4 weeks after their return, and asked about compliance with pre-travel advice. RESULTS: One hundred sixty-seven children were evaluated after their trip. Compliance with immunizations, malaria chemoprophylaxis, and food-borne disease prevention was 71, 66, and 31%, respectively. Compliance with malaria chemoprophylaxis varied significantly with destination, and was higher for African destinations. Significant features associated with poor compliance with chemoprophylaxis were a trip to Asia or the Indian Ocean, age <5 years, and a monoparental family. Compliance with prevention of food- and water-borne diseases was higher in children < 2 years of age. CONCLUSIONS: A ≥ 80% compliance with pre-travel counseling in children traveling overseas was achieved only for drinking bottled water, using repellents, a routine vaccine update, and yellow fever immunization.

Field evaluation of rapid diagnostic tests for malaria in Yaounde, Cameroon.

Rapid diagnostic tests (RDTs) are affordable, alternative diagnostic tools. The present study aimed to evaluate RDTs available in Cameroon and compare their characteristics to follow the parasitological response of patients for 28 days. Malaria diagnosis was assessed in 179 febrile patients using conventional microscopy as the reference method. Parascreen detects both Plasmodium falciparum-specific histidine-rich protein 2 (Pf HRP-2) and Pan-specific plasmodial lactate dehydrogenase (pLDH) in all four human Plasmodium spp. Diaspot is based on the detection of Pf HRP-2. OptiMAL-IT (pLDH specific for P. falciparum and pLDH for all four human Plasmodium spp.) was assessed for comparison. The reliability of RDTs was evaluated by calculating the sensitivity, specificity, positive predictive value, negative predictive value, false-positive rate, false-negative rate, and likelihood ratio. The clinical outcome of 18 children treated with atovaquone-proguanil and followed for 28 days was evaluated using microscopy and RDTs. Of 179 samples, 133 (74.3%) were pure P. falciparum-positive smears, 4 (2.2%) pure P. malariae-positive smears, and 42 (23.5%) negative smears. Parascreen and Diaspot had high sensitivity (>92%) and positive predictive values (>94%). The specificities for Parascreen and Diaspot were 81.0% and 90.5%, respectively. The false-positive rates and the false-negative rates were 19.0% and 4.5% for Parascreen and 9.5% and 8.3% for Diaspot, respectively. Most false-negatives occurred in samples with low parasitaemia (<500 asexual parasites/µL). The performance of RDTs was better at higher parasitaemia (>500 asexual parasites/µL). Four pure P. malariae were only detected by the pan-Plasmodium bands of Parascreen and OptiMAL-IT. In blood samples from patients treated and followed-up for 28 days, HRP2-based RDTs remained positive in most samples until Day 28. Despite negative smears, OptiMAL-IT remained positive in several patients until Day 7 but was negative in all patients from Day 14 onwards. RDTs can improve the management of febrile patients. The validity, ease of use, and cost of HRP2-based tests were comparable. However, one of the current weaknesses of the RDT-based strategy using the tests available in Cameroon is inadequate sensitivity for low parasitaemia. In some cases, RDT results may require correct interpretation based on clinical history, clinical examination, and microscopic diagnosis.

Demographics, health and travel characteristics of international travellers at a pre-travel clinic in Marseille, France.

With the aim to identify at-risk individuals among a cohort of international travellers, 3442 individuals who sought advice at Marseille travel health centre in 2009 were prospectively included. Demographics, travel characteristics, chronic medical conditions, vaccinations and antimalarial chemoprophylaxis were documented. Chronic medical conditions were reported by 11% of individuals, including hypertension (39%), asthma (20%), thyroid disease (15%) and depression (13%). 4% reported taking a daily medication, and psychotropic and cardiovascular medications were the most commonly used. Older travellers (≥60 years) accounted for 10% of the travellers and the prevalence of chronic medical conditions was 27% in this group. Individuals aged 15 years or less accounted for 13% of the travellers. Age, last minute travel (17%) and neurological and psychiatric diseases were the most frequent factors that influenced Yellow fever vaccination and malaria chemoprophylaxis, with more than one tenth of the travellers reporting at least one risk factor for which adjusted advice may be necessary. Migrants visiting their relatives in their origin country accounted for 14% of travellers and 73% of this group travelled with their family including young children. We demonstrate that a significant proportion of travellers are at-risk (43%) because of their travel conditions (VFR), their age, or their health status, and should be targeted for risk reduction strategies.

Rational case management of malaria with a rapid diagnostic test, Paracheck Pf®, in antenatal health care in Bangui, Central African Republic.

BACKGROUND: Both treatment and prevention strategies are recommended by the World Health Organization for the control of malaria during pregnancy in tropical areas. The aim of this study was to assess use of a rapid diagnostic test for prompt management of malaria in pregnancy in Bangui, Central African Republic. METHODS: A cohort of 76 pregnant women was screened systematically for malaria with ParacheckPf® at each antenatal visit. The usefulness of the method was analysed by comparing the number of malaria episodes requiring treatment in the cohort with the number of prescriptions received by another group of pregnant women followed-up in routine antenatal care. RESULTS: In the cohort group, the proportion of positive ParacheckPf® episodes during antenatal clinics visits was 13.8%, while episodes of antimalarial prescriptions in the group which was followed-up routinely by antenatal personnel was estimated at 26.3%. Hence, the relative risk of the cohort for being prescribed an antimalarial drug was 0.53. Therefore, the attributable fraction of presumptive treatment avoided by systematic screening with ParacheckPf® was 47%. CONCLUSIONS: Use of a rapid diagnostic test is useful, affordable and easy for adequate treatment of malaria in pregnant women. More powerful studies of the usefulness of introducing the test into antenatal care are needed in all heath centres in the country and in other tropical areas.

[Pandemic influenza A (H1N1 virus) on Futuna Island in the Pacific, from August to September 2009]. / Pandémie de grippe A (virus H1N1) à Futuna, île du pacifique, d'août à septembre 2009.

OBJECTIVE: The aim of this study is to report the observation of the pandemic of influenza A (H1N1 virus) from August to September 2009 on the island of Futuna, in a context of isolated island that may mimic an environment closed. METHOD: We conducted a prospective observational study of influenza-like illness, from the first confirmed case of influenza A on the island until the end of the epidemic wave. RESULTS: From August 15 to September 20, 2009, 1536 cases of influenza syndrome were identified. The estimate of the overall clinical attack rate was 36 %. The evolution of the epidemic shows an explosion of new cases of influenza A and subsequently a rapid decline of the epidemic. The spread of the infection was made by contiguity, jumping from one city to another. The cumulative number of cases by age group shows that the majority of cases were children and young adults under the age of 20 years. The most frequent symptoms were cough, rhinorrhea, headache, myalgia or asthenia, and fever. CONCLUSION: This study, despite these limitations, shows an explosive epidemic of influenza A, which can be explained by the circulation of virus that has been fostered by gatherings of public and closed environment. Age group classification shows that majority of cases were young, in contrast to seasonal influenza, but the symptoms were alike. This study highlights the difficulties to manage an epidemic surveillance system at high level and given the quick spread of the disease.

Pattern of the Antimalarials Prescription during Pregnancy in Bangui, Central African Republic.

Introduction. The aim of this study was to identify the antimalarials prescribed during the pregnancy and to document their timing. Method. From June to September 2009, a survey was conducted on 565 women who gave birth in the Castors maternity in Bangui. The antenatal clinics cards were checked in order to record the types of antimalarials prescribed during pregnancy according to gestational age. Results. A proportion of 28.8% ANC cards contained at least one antimalarial prescription. The commonest categories of antimalarials prescribed were: quinine (56.7%), artemisinin-based combinations (26.8%) and artemisinin monotherapy (14.4%). Among the prescriptions that occurred in the first trimester of pregnancy, artemisinin-based combinations and artemisinin monotherapies represented the proportions of (10.9%) and (13.3%). respectively. Conclusion. This study showed a relatively high rate (>80%) of the recommended antimalarials prescription regarding categories of indicated antimalarials from national guidelines. But, there is a concern about the prescription of the artemisinin derivatives in the first trimester of pregnancy, and the prescription of artemisinin monotherapy. Thus, the reinforcement of awareness activities of health care providers on the national malaria treatment during pregnancy is suggested.

Relatively low prevalence of peripheral and placental Plasmodium infection at delivery in bangui, central african republic.

Introduction. The aim of this study was to estimate the prevalence of malaria among women giving birth in Bangui. Association between sociodemographic characteristics of those women and malaria, as well as prevention compliance (use of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTsp) and insecticide-treated bed nets (ITNs)), was analyzed. Methods. During September 2009, a survey was conducted on 328 women who gave birth at two main maternities of Bangui. Information was obtained by standardized questionnaire about sociodemographic criteria, IPTsp, other antimalarial treatment, and use of bet nets. Smears prepared from peripheral and placental blood were analysed for malaria parasites. Findings and Discussion. Positive results were found in 2.8% of thick peripheral blood smears and in 4.0% of placental slides. A proportion of 30.5% of the women had received at least two doses of IPTsp during the current pregnancy. Only a proportion of 42.4% of this study population had ITNs. Multigravid women were less likely to use IPTsp and ITNs. However, use of IPTsp was associated with personal income and secondary or university educational status. Hence, although this relatively prevalence was observed, more efforts are needed to implement IPTsp and ITNs, taking into account sociodemographic criteria.

Genetic structure of Plasmodium falciparum and elimination of malaria, Comoros archipelago.

The efficacy of malaria control and elimination on islands may depend on the intensity of new parasite inflow. On the Comoros archipelago, where falciparum malaria remains a major public health problem because of spread of drug resistance and insufficient malaria control, recent interventions for malaria elimination were planned on Moheli, 1 of 4 islands in the Comoros archipelago. To assess the relevance of such a local strategy, we performed a population genetics analysis by using multilocus microsatellite and resistance genotyping of Plasmodium falciparum sampled from each island of the archipelago. We found a contrasted population genetic structure explained by geographic isolation, human migration, malaria transmission, and drug selective pressure. Our findings suggest that malaria elimination interventions should be implemented simultaneously on the entire archipelago rather than restricted to 1 island and demonstrate the necessity for specific chemoresistance surveillance on each of the 4 Comorian islands.

Rabies exposure in international travelers: do we miss the target?

BACKGROUND: Little data exist about the spatial distribution of the risk for travelers of being injured by a potentially rabid animal. METHODS: Over the last 14 years, animal-associated injuries in 424 international travelers presenting to a travel medicine clinic in Marseille, southern France, were investigated. RESULTS: The majority of cases were reported from North Africa (41.5%) and Asia (22.2%). Most countries where at-risk injuries occurred (Algeria, Morocco, Tunisia, Thailand, and Turkey) were those for which travelers do not usually seek advice at a specialized travel clinic, because these countries are not at risk for specific travel-associated diseases like malaria or yellow fever. The probability of travelers being attacked by each animal species varied significantly according to the destination country. Dogs were more frequently involved in Algeria, cats in Tunisia and the Middle East, and non-human primates in sub-Saharan Africa, Madagascar, and Asia. CONCLUSIONS: We suggest that rabies pre-exposure vaccination should be offered to individuals traveling regularly to North Africa to visit their relatives and who are at high risk of exposure to potentially rabid animal attacks. Pre-travel advice when addressing rabies prevention should consider the specific epidemiology of animal-related injuries in the traveled country, as well as the traveler's characteristics. Travelers should be advised about which species of animal are potentially aggressive in their destination country so that they can more easily avoid risk-contacts.

Common health hazards in French pilgrims during the Hajj of 2007: a prospective cohort study.

BACKGROUND: The majority of published studies on Hajj-related diseases were based on hospitalized patient cohorts. METHODS: A total of 545 Hajj pilgrims from Marseille were enrolled in a prospective epidemiological study to evaluate the incidence of common health hazards. They were administered a questionnaire before traveling addressing demographic factors and health status indicators and a post-travel questionnaire about travel-associated diseases. RESULTS: Respondents had a median age of 61 years and originated mainly from North Africa (81%). A significant proportion of individuals had chronic medical disorders such as walking disability (26%), diabetes mellitus (21%), and hypertension (21%). A total of 462 pilgrims were administered a questionnaire on returning home. A proportion of 59% of travelers presented at least one health problem during the pilgrimage and 44% of the cohort attended a doctor during travel; 3% were hospitalized. Cough was the main complaint among travelers (attack rate of 51%), followed by headache, heat stress, and fever. Few travelers suffered diarrhea and vomiting. Cardiovascular diseases, neurological disorders, trauma, skin and gastrointestinal problems were not frequently observed in our survey, suggesting that their prevalence among the causes of admission to Saudi hospitals reflects a bias of selection. Cough episodes were significantly more frequent in individuals >55 years. We also evidenced that women were more likely to present underlying chronic cardiovascular disorder and diabetes compared to men and that they more frequently suffered from cough episodes associated with fever during the Hajj. CONCLUSIONS: Health risks associated with the Hajj in our experience are much more related to crowding conditions than to travel. Our work suggests that the studies performed in Saudi specialized units probably overestimate the part of certain diseases within the spectrum of Hajj-associated diseases. Our results also suggest that old female Hajjes should be considered as a high-risk population and that preventive measures should be reinforced before departing for Saudi Arabia.

Use of a histidine-rich protein 2-based rapid diagnostic test for malaria by health personnel during routine consultation of febrile outpatients in a peripheral health facility in Yaounde, Cameroon.

The role of a rapid diagnostic test (RDT) in the case management of Plasmodium falciparum malaria infections has not been determined in Africa. Our study was conducted during November 2007-January 2008 to assess test accuracy of an RDT in the management of febrile outpatients in a peripheral urban health facility in Cameroon. We found the overall sensitivity to be 71.4% and a specificity of 82.2%; the positive predictive value and negative predictive value were 73.8% and 80.4%, respectively. False-negative and false-positive cases represented 11.8% and 10.5% of all febrile patients. Malaria alone (31.3%) was the first cause of fever; 33.5% of fever cases were of unknown origin. Acute respiratory infections were common among children 0-2 years of age (25.5%) and decreased with age. The risk of having a clinical failure with the presumptive treatment of febrile children was seven times greater than that of the RDT-oriented management (relative risk = 6.8, 95% confidence interval = 0.88-53.4, P = 0.03) because of the delay of appropriate treatment of non-malarial febrile illness. Our results suggest that the RDT may be of limited utility for children greater than five years of age and adults and that diagnosis based on microscopic examination of blood smears should be recommended for these patient populations, as well as in areas of low transmission.

Knowledge, attitudes, and practices of French travelers from Marseille regarding rabies risk and prevention.

OBJECTIVE: To assess the awareness of the mode of rabies transmission, travel-associated rabies risk, and adequate preventive measures among French travelers. METHODS: Three hundred travelers were administered a detailed questionnaire prior to pretravel advice, addressing their knowledge, attitudes, and practices (KAP) with respect to animal-related injuries and rabies risk. Two hundred and nine were administered a post-travel questionnaire by telephone, addressing the occurrence of contacts with animals during travel. RESULTS: Countries visited were at risk for rabies in 84.7% of the cases. Only 6.7% of travelers knew that the risk of rabies was important, while 40.1% considered it moderate or low. Dog bites appeared to be a well-known mode of transmission of rabies. By contrast, licks on broken skin or contamination of the mucous membrane with saliva (10%) and scratches (0.7%) were rarely known. Cats (23.7%), foxes (28.3%), monkeys (10.3%), and bats (5.0%) were rarely mentioned as possible rabies vectors. Only 50.7% of travelers were aware of the preventive vaccination. Approximately 57.6% of individuals traveling to rabies-endemic countries presented to the clinic less than 21 days before departing, rendering a complete preventive vaccination against rabies unfeasible. Immediate washing of the injury with water and soap was mentioned by only 3.0% of individuals and self-disinfection with antiseptics by 21.3%. Of those who traveled in a rabies-risk country, 3.8% declared that they had been attacked by animals; however, none was injured. Animal encounters were frequent with dogs (53.8%), monkeys (39.5%), bats (17.9%), and cats (15.4%). CONCLUSIONS: The KAP of French travelers with regard to travel-associated rabies risk need to be improved, particularly regarding the prevention of animal bites, postbite measures, and their urgency.

Multinormal in vitro distribution model suitable for the distribution of Plasmodium falciparum chemosusceptibility to doxycycline.

The distribution and range of 50% inhibitory concentrations (IC(50)s) of doxycycline were determined for 747 isolates obtained between 1997 and 2006 from patients living in Senegal, Republic of the Congo, and Gabon and patients hospitalized in France for imported malaria. The statistical analysis was designed to answer the specific question of whether Plasmodium falciparum has different phenotypes of susceptibility to doxycycline. A triple normal distribution was fitted to the data using a Bayesian mixture modeling approach. The IC(50) geometric mean ranged from 6.2 microM to 11.1 microM according to the geographical origin, with a mean of 9.3 microM for all 747 parasites. The values for all 747 isolates were classified into three components: component A, with an IC(50) mean of 4.9 microM (+/-2.1 microM [standard deviation]); component B, with an IC(50) mean of 7.7 microM (+/-1.2 microM); and component C, with an IC(50) mean of 17.9 microM (+/-1.4 microM). According to the origin of the P. falciparum isolates, the triple normal distribution was found in each subgroup. However, the proportion of isolates predicted to belong to component B was most important in isolates from Gabon and Congo and in isolates imported from Africa (from 46 to 56%). In Senegal, 55% of the P. falciparum isolates were predicted to be classified as component C. The cutoff of reduced susceptibility to doxycycline in vitro was estimated to be 35 microM.