Archive for June, 2008

OMNI Postings of 6/30/08

Posted by Paul Rega, MD — published on June 30th, 2008
On this date in 1859, Charles Blondin became the 1st person to cross Niagara Falls on a tightrope.  Afterwards, he went to City Hall to receive an award, but tripped as he went up the stairs.

But I digress…

1)  Experts agree that TTE does not have the sensitivity and specificity to diagnose PE.  However, a recent study suggests that some values are more sensitive and specific for PE than previously thought.  For example, the ratio of right ventricular to left ventricular (RV/LV) end diastolic dimension was the most accurate predictor for PE, with a sensitivity and specificity of 66% and 77%, respectively.
2)  For those of you who are interested in the proper PPE for responding to weapons of mass destruction, NIOSH has come up with recent guidelines.  This is especially important for those of you who are involved with EMS and who run ERs. You know who you are.
3)  Here are the latest (2005) stats for ER visits in the U.S.  For example, 15% of patients were seen within 15 minutes.  85% of those were Dr. W’s patients.
4)  This is an LA times article on hospital mistakes that, by law, have to be reported.  There were 1,002 cases of serious medical harm disclosed by California hospitals between July 2007 and May of this year.  Examples include bedsores, operating on the wrong body part, and dropping cigarette ashes into a laceration while suturing.
5)  USA Today has come up with a story on the cost of universal health care in Taxachussetts.  The percentage of uninsured adults has dropped by nearly half, from 13% to 7%.  Costs have climbed to $625 million the first year, up from estimates of $472 million.  Monthly premiums for those who qualify for the partially subsidized program went up an average of 9.4% going into the second year of the program. For higher income residents who buy coverage without a state subsidy, the average premium increase was 5.1%.
Paul R.
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categories: Emergency Medicine

TTE & PE

Posted by Paul Rega, MD — published on June 30th, 2008

Medical News Today, 6/30/08:  US clinicians have identified two transthoracic echocardiography (TTE) markers that are sensitive for the detection of pulmonary embolism (PE) in patients.Patients suspected of having PE are often examined using TTE for signs of thrombosis or other diagnoses, with multiple echo indices linked to the presence of PE, explain Joseph Lodato and colleagues, from the University of Chicago Medical Center in Illinois.

Noting that TTE alone is not sensitive or specific enough for detecting PE, the team investigated whether any of the individual echo indices had greater predictive accuracy than the others.

The researchers examined a raft of TTE indices in 67 patients, aged an average of 58 years, with suspected PE, within 48 hours of a gold standard computed tomography (CT) scan.

Overall, 61% of patients were given a CT-confirmed diagnosis of PE.

Although patients with PE tended to have more echo indices than those without (2.4 vs 1.5), this difference did not reach significance and eight patients with CT-confirmed PE had no echo markers for PE.

The ratio of right ventricular to left ventricular (RV/LV) end diastolic dimension was the most accurate predictor for PE, with a sensitivity and specificity of 66% and 77%, respectively.

The “McConnell sign” - defined as RV-free wall hypokinesis or akinesis plus normokinesia or hyperkinesia of the RV apex - had the highest specificity for PE, at 96%, but poor sensitivity, at just 16%.

Tricuspid regurgitation (TR) velocity, a suggested echo index for PE, did not significantly differ between patients with and without PE (270 vs 294 m/sec).

PE diagnosis was not significantly predicted by the presence of RV/LV area ratio, intraventricular septal shift, pulmonary artery diameter, or the “60/60 sign” of TR velocity <3.9 m/sec plus pulmonary artery acceleration of <60 m/sec.

"A thorough understanding of the echocardiographic findings in PE may aid in raising the clinical suspicion of this diagnosis and prompt definitive diagnostic testing," Lodato et al write in the journal Echocardiography.

They conclude: “Our study identifies a number of echocardiographic parameters that should prompt the physician to suspect PE and order the appropriate diagnostic test for the patient.”

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categories: Emergency Medicine

NIOSH PPE Guidelines for Emergency Personnel

Posted by Paul Rega, MD — published on June 30th, 2008

PPE.  “Attention Emergency Responders: Guidance on Emergency Responder Personal  Protective Equipment (PPE) for Response to CBRN Terrorism Incidents.”  NIOSH/CDC. June 2008.

http://www.cdc.gov/niosh/docs/2008-132/pdfs/2008-132.pdf

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categories: Emergency Medicine

ER Stats (2005)

Posted by Paul Rega, MD — published on June 30th, 2008

Emergency Department Visits

(Data are for U.S. for year indicated)

Number of visits: 115.3 million

Number of injury-related visits: 41.9 million

Number of visits per 100 persons: 39.6

Most commonly diagnosed condition: contusion with intact skin surface

Percent of visits with patient seen in less than 15 minutes: 15

Average time spent in emergency department: 3.3 hours

Percent of visits resulting in hospital admission: 12

Percent of visits resulting in transfer to higher level or specialized care needed: 1

Source: National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary, Tables 1, 11, 13, 22, 25

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categories: Emergency Medicine

The “ooops” are out-ed in California hospitals

Posted by Paul Rega, MD — published on June 30th, 2008

LA Times, 6/30/08:  Last October, a technician at the children’s hospital at Stanford University improperly connected a ventilator hose, accidentally pumping too little oxygen into a 9-day-old infant’s lungs.

A month later, technicians at Dominican Hospital in Santa Cruz unintentionally placed a CT scan of one patient into the electronic file of another, leading physicians to remove the wrong person’s appendix.

Last March, Virginia Fahres, 76, died at Pomona Valley Hospital Medical Center in Pomona after a nurse gave her two drugs, neither of which her doctor had prescribed.

Those incidents were among 1,002 cases of serious medical harm disclosed by California hospitals between July 2007 and May of this year. The disclosures are the first under a state law that requires hospitals to inform health regulators of all substantial injuries to their patients.

Officially called “adverse events,” those accidents are also known as “never events” because they are considered preventable, and many safety experts say they should never happen. California patients are being injured at a rate of about 100 a month, according to data compiled by the state Department of Public Health.

“I think the never events are a wake-up call to everyone about the safety of California hospitals,” said Beth Capell, a lobbyist for Health Access California, a consumer group.

Revelations of such errors have led lawmakers and hospital associations in at least seven states to protect patients from having to pay for the cost of care that went awry. In Sacramento, an assemblyman proposed a ban on reimbursing hospitals for the types of injuries tracked by the state. But when lobbyists for doctors and hospitals objected, he scaled it back to cover far fewer errors.

Four million people were admitted to California hospitals last year. State investigators found some errors occurred because hospitals failed to follow safeguards designed specifically to prevent harm.

Last July at UC San Diego Medical Center, a patient died after a nurse incorrectly programmed a medicine pump that then delivered more than twice the appropriate dose of a specialized blood pressure drug. Regulators found that the hospital’s administration had been warned earlier by its own safety committee that “errors continue to occur” with that type of pump but had not taken sufficient corrective action, according to a state probe.

UC San Diego officials said they have since held repeat drills with staffers who treat patients with Flolan and examined every step in the process.

Dr. Angela Scioscia, the center’s senior medical director, said the public reporting requirement is “a great opportunity to make rapid improvements” because hospitals can learn from one another’s problems. “We don’t want people to be afraid when they come into hospitals, because they are becoming safer and safer all the time,” Scioscia said.

Under the 2006 disclosure law by state Sen. Elaine Alquist (D-Santa Clara), hospitals must inform state regulators of every occurrence of 28 different types of dangerous mistakes. Those include deaths during labor, medication errors, suicide attempts and sexual assaults.

The public health department has until 2015 to begin posting the information on the Internet, although officials said they hope to begin publishing it earlier. The most recent figures available cover the 10 months since July 2007. In that time, 466 patients developed bedsores so severe that the dead skin formed a crater or rotted through to the muscle or bone.

Another 145 patients had foreign objects such as surgical equipment left in their bodies. Thirty-four died while under anesthesia. In 41 surgeries, doctors performed the wrong procedure or operated on the wrong body part or on the wrong patient.

So far, the state Department of Public Health has levied $25,000 fines against 10 hospitals that reported adverse events. Officials said other investigations are still under way.

One hospital, Scripps Memorial in La Jolla, was fined twice for two errors that occurred last November with the same patient. First, as the patient was recovering from surgery, she was given a painkiller that is not supposed to be used after operations. When she went into respiratory arrest, the pharmacist provided a corrective medication at a dose 10 times too weak to be effective.

The patient survived. State investigators discovered that the hospital’s pharmacists had not been properly instructed in the use of 10 medications, including the corrective drug, that the hospital stocked for emergencies.

The ventilator error at Stanford’s Lucile Packard Children’s Hospital occurred because a therapist had assembled the machine by following a diagram that had been drawn backward. Dr. Christy Sandborg, the hospital’s chief of staff, said the medical team quickly noticed that the ventilator wasn’t working correctly and stopped using it. The child recovered, she said, and the hospital has made changes to prevent future occurrences.

Overcrowded emergency rooms are another factor behind patient injuries. A 2006 study found that California had fewer emergency rooms per resident than any other state.

At Kaiser Foundation Hospital San Jose in March, staffers left a patient waiting in the emergency room for more than an hour after a test showed that his blood sugar was higher than the maximum measurable with a glucometer. The medics determined that he needed immediate care, but all 25 treatment bays were full. He passed out in the waiting room and died from heart failure.

Kaiser officials said that since his death, patients who need immediate care have been kept in the triage area under nursing supervision. The hospital said it also established a system to call in extra medical help when its emergency room is overwhelmed.

Doctors and hospitals warned against equating all adverse events with mistakes.
Debby Rogers, the vice president for quality and emergency services at the California Hospital Assn, said someone with a fractured neck might develop a pressure sore while resting on a backboard awaiting surgery. Treating the sore would require moving the patient, potentially paralyzing them by exacerbating the fracture, she said.

“We would like to think we can prevent all of them, but we can’t,” Rogers said.

Kathleen Billingsley, the deputy public health director in charge of regulating healthcare facilities in California, said that overall, “the hospitals are very responsive” about reporting injuries.

Dr. Donald Berwick, the president of the Institute for Healthcare Improvement, a Massachusetts nonprofit, said the number of mistakes is certainly much higher than what California hospitals have disclosed. His institute has estimated that as many as 15 million patients nationwide are harmed each year in hospitals.

“It will always be true that the vast majority of incidents are never reported,” Berwick said.

Maine, Massachusetts, Pennsylvania and New York have restricted payments for avoidable medical errors. Hospital associations in Minnesota, Washington and Vermont have pledged never to bill patients for the costs of botched care, according to the National Conference of State Legislatures.

Starting in October, the federal Centers for Medicaid and Medicare Services will stop reimbursing hospitals for eight kinds of mistakes, including bedsores, objects left in patients, and infections acquired during surgery or from catheters.

In April, Assemblyman Mike Feuer (D-Los Angeles) introduced legislation to bar medical providers from seeking payment in cases involving any of the adverse events that California hospitals must report.

But the hospitals’ and doctors’ associations objected that the bill, AB 2146, could result in denial of payment even when the damage was not their fault, or occurred when they were repairing an injury caused by another medical provider.

Last week, Feuer rewrote the bill so that the state MediCal program would no longer reimburse hospitals for the same preventable errors that Medicare refuses to pay for.

Feuer said he hopes that cutting payments will prod hospitals to be more careful.

“There’s a widespread recognition,” he said, “that the ‘never’ list is too long.”

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categories: Emergency Medicine

The Cost of Universal Health Insurance in Massachusetts

Posted by Paul Rega, MD — published on June 30th, 2008

USA Today, 6/30/08:  Self-employed Patricia Pelletier says she has better health insurance than she did before Massachusetts became the first state to require almost all residents have coverage, but it’s costing her more.

The plan she now buys, through a system set up by the state, covers more, she says, but her monthly premium is going up from $422 to $615 in August.

“I almost fell on the floor,” says Pelletier, 55, of Newbury. “Costs are getting out of control.”

Tuesday marks the one-year anniversary of the deadline for most Massachusetts residents to carry health coverage. Those who don’t face tax penalties. Since the program began, the percentage of uninsured adults has dropped by nearly half, from 13% to 7%, according to studies cited by the state.

Yet the Massachusetts experiment, enacted in 2006 by a Republican governor in a Democratic state, still faces a huge challenge — costs.

Most of the newly insured are lower income residents who qualify for low- or no-cost coverage through the state and there were more uninsured than the state anticipated. Both factors pushed costs to $625 million the first year, up from estimates of $472 million, according to figures from the state agency overseeing the program.

In the fiscal year that starts Tuesday, the governor has requested $869 million for the program, up from 2006 estimates of $725 million.

Monthly premiums for those who qualify for the partially subsidized program went up an average of 9.4% going into the second year of the program, state figures show. For higher income residents who buy coverage without a state subsidy, such as Pelletier, the average premium increase was 5.1%.

As both presidential candidates outline their own health proposals — and several states consider insurance expansion efforts — Massachusetts’ health care law is both touted as an example to copy nationally and criticized as a model to avoid.

“Some will say it’s an overwhelming success story. Others will say it has cost somewhat more than expected, so we can’t afford to expand coverage,” says Drew Altman, president of the non-partisan Kaiser Family Foundation, which studies health policy. “The truth is somewhere in the middle.”

The new insurance law in Massachusetts is being felt keenly in hospitals, doctor’s offices and clinics, like the Revere Family Health Center, about 15 minutes from Cambridge. Cambridge Health Alliance, which runs this center and 20 others, says their clinics have seen a 16% increase in visits since the expanded program helped many patients get insurance.

Center Director Somava Stout says insured patients are more likely to come in for preventive care. For some, insurance has meant survival.

Kathleen Richard, who is battling thyroid cancer, is among them. “She would not be alive today if she didn’t have insurance,” says Stout.

Without insurance, Stout says, it would have been difficult, if not impossible, to get Richard the complex surgery she needed. Until she became ill, Richard, 55, always worked and had insurance. Her illness caused her to lose her job and her coverage.

Her cancer was discovered after an emergency visit in 2005 to Cambridge Hospital, which has since helped Richard sign up for several different types of subsidized coverage through the state.

“When you go from having insurance, then having nothing, it’s very frightening,” says Richard, whose cancer is now in remission. “It’s such a plus not to have to worry about insurance.”

The first priority of the Massachusetts effort was to broaden coverage so that residents such as Richard could be insured, says Jon Kingsdale, head of the independent state agency that oversees the program. Tackling costs would come later.

“The way to do this is to make the moral commitment to cover everybody,” Kingsdale says. That forces “the political leadership, doctors, hospitals and health insurers to grapple with how to make this affordable. I don’t know any other way to get America to confront this very tough problem.”

The state has 355,000 newly insured residents, as of April, according to the journal Health Affairs, a leading chronicle of health policy, which recently outlined the success and challenges of the effort.

January figures cited by the state show most of the newly insured qualify for help: 37% are eligible for free state-subsidized coverage, 17% are in an expanded Medicaid program, and 14% only pay for part of their coverage.

Only 7% of the newly insured bought it on their own without a subsidy. The remaining 25% signed up through their jobs.

A bill before the state Legislature aims to save money through a variety of efforts, Kingsdale says, including increasing the use of electronic medical records.

“The state made a great commitment, a heroic commitment,” says Assaad Sayah, chief of emergency medicine at Cambridge Hospital. “Is it perfect? No. I’m not sure any system in the world is perfect. But it’s better than what we had before.”

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categories: Emergency Medicine

The repercussions on recent FDA actions

Posted by Paul Rega, MD — published on June 30th, 2008

Wall Street Journal 6/30 reports that “beleaguered pharmaceutical-industry executives” are halting an increasing number of drug-development projects because of “a tough new regulatory climate.”

According to Schering-Plough Corp. Chief Executive Fred Hassan, “an intensifying focus on safety, and a diminished tolerance for side effects at the Food and Drug Administration (FDA), have dramatically lowered the odds that [two drug projects the company recently stopped] would make it to market — at least not without a lot of extra time and money.” The director of the FDA’s Center for Drug Evaluation and Research, Janet Woodcock, M.D., “denies that the agency has become ‘more conservative’ about drug safety,” but in 2007, “the FDA approved just 19 new medicines, the fewest in 24 years, and announced about 75 new or revised ‘black-box’ warnings about potential side effects,…twice the number in 2004.”

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categories: Emergency Medicine

Omni Posting of 6/29/08

Posted by Paul Rega, MD — published on June 29th, 2008
On this date in 1992, two major earthquakes hit southern California.  Well, actually,  there was one true earthquake measuring 7.4.  The other was really Luciano Pavarotti banging into the wall as he was trying to find the bathroom at 3 AM.
But I digress…
1)  This is a MedScape case of an infant with vomiting and bruising who presents to the ER.  There is a nice differential of vomiting contained in the discussion.
2)  There’s a drug that may be of help in slowing the rate of aortic expansion in people with Marfan’s.  It’s called Losartan.
3)  Imagine doing a blood test to check for occult traumatic brain injury in kids.  That’s in the works and the researchers claim that this will something that will be used in ERs.  A blood test!  Amazing!  Pretty soon they’ll have a blood test to help diagnose PE!  (Only kidding!)
4)  This is about a new management technique for a group of patients you rarely see in the ER.  The claim is that you attach a neurostimulation unit near the occipital nerves and it will reduce the incidence of debilitating attacks for those with chronic migraines.  The results of the research have not been published as yet, so it cannot be substantiated whether the electrical unit attracted lightning strikes as well as diminishing the incidence of headaches.
Now a series of abstracts about bladder scanners.  I was soo-oo-o excited when I found these , I wet my pants!
1)  This one from Singapore (Yes, they have bladder problems even there!) concludes that their scanner should replace a straight cath.
2)  This is also positive for the scanner.  It minimizes the risk of infection and urethral trauma while increasing patient satisfaction.
3)  This was a rather negative opinion on the scanner.  Since it was a post-surgical population, the applying of a probe on the belly increased patient discomfort.  In addition, the staff wasn’t that competent (reading between the lines.)  For the researchers, the tool didn’t seem to be sensitive enough to estimate volume.  But I’m not sure if we care about the quantitative results.  All we would want is to know “Is there residual or isn’t there?”  If there is, then you cath.
4)  This was an in-patient population.  Ultrasound scanning of the bladder to measure residual urine volume reduced the frequency of catheterization by 38% as compared with the patients on intermittent catheterization, with 17.4 catheters saved for each patient.  Which makes me think:  Buy 1 or 2 for the hospital and the ER can use it on the few cases it gets per month.
5)  This abstract compares 2 types of bladder scanners.  While they’re both comparable in estimating residual volume, the BME-150A can also sweep floors, clean out ashtrays, and diaper the baby on the maid’s day off.
6)  Scanning also worked in post-partum women in Norway.

OMNI Posting of 6/28/08

Posted by Paul Rega, MD — published on June 28th, 2008
While acquainting myself with a new elderly patient, I asked, ‘How long have you been bedridden?’ After a look of complete confusion, she answered…’Why, not for about twenty years — when my husband was alive.’ (Tip of the hat to Beth Keil for the joke.
But I digress… 

This MMWR report summarizes U.S. malaria cases in persons with onset of illness in 2006 and summarizes trends during previous years. CDC received reports of 1,564 cases of malaria among persons in the United States with onset of symptoms in 2006, six of which were fatal.  This is something to add to your differential when seeing a patient with fever and a curious travel history. 
This is a MMWR map of malaria cases on a state-by-state basis.  There were 29 cases in Ohio and 20 cases in Michigan in 2006.  Way to go, Ohio!!!
This is a no-brainer case report.  What’s important is that this variation of the disease includes a treatment necessity that is not used with the other variations.  It’s the addition of antibiotics — penicillin usually.
We’re up to over 800 cases of salmonella infection from the much-maligned tomato.  Six in Ohio and 4 in Michigan.  Way to go again, Ohio!!!!!!!  The second link is a map of where the cases are located.
For you obsessive-compulsives among you, here is a CDC breakdown of the causes of unintentional deaths by percentage from 1999-2005.  Over the years the most significant increase was seen with falls followed by  poisoning.  The third largest increase was with watching “The View” 5 days a week.
Paul R.
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categories: Emergency Medicine

MMWR: Malaria - State by State, 2006

Posted by Paul Rega, MD — published on June 28th, 2008

 

1

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categories: Emergency Medicine

Malaria Surveillance — United States, 2006

Posted by Paul Rega, MD — published on June 28th, 2008

 

Sonja Mali, MPH
Stefanie Steele, MPH
Laurence Slutsker, MD
Paul M. Arguin, MD
Division of Parasitic Diseases National Center for Zoonotic, Vector-Borne, and Enteric Diseases

 

Corresponding author: Sonja Mali, MPH, Division of Parasitic Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases, CDC, 4770 Buford Hwy., N.E., MS F-22, Atlanta, GA 30341. Telephone: 770-488-7757; Fax: 770-488-4465; E-mail: smali@cdc.gov.

 

Abstract

MMWR:  June 20, 2008 / 57(SS05);24-39

Problem/Condition: Malaria in humans is caused by intraerythrocytic protozoa of the genus Plasmodium (i.e., P. falciparum, P. vivax, P. ovale, and P. malariae). These parasites are transmitted by the bite of an infective female Anopheles species mosquito. The majority of malaria infections in the United States occur among persons who have traveled to areas with ongoing malaria transmission. In the United States, cases can occur through exposure to infected blood products, congenital transmission, or local mosquitoborne transmission. Malaria surveillance is conducted to identify episodes of local transmission and to guide prevention recommendations for travelers.

Period Covered: This report summarizes cases in persons with onset of illness in 2006 and summarizes trends during previous years.

Description of System: Malaria cases confirmed by blood film or polymerase chain reaction (PCR) are mandated to be reported to local and state health departments by health-care providers or laboratory staff members. Case investigations are conducted by local and state health departments, and reports are transmitted to CDC through the National Malaria Surveillance System (NMSS), National Notifiable Diseases Surveillance System (NNDSS), and direct CDC consultations. Data from these reporting systems serve as the basis for this report.

Results: CDC received reports of 1,564 cases of malaria among persons in the United States with onset of symptoms in 2006, six of which were fatal. This is an increase of 2.4% from the 1,528 cases reported for 2005. P. falciparum, P. vivax, P. malariae, and P. ovale were identified in 39.2%, 17.6%, 2.9%, and 3.0% of cases, respectively. Ten patients (0.6%) were infected by two or more species. The infecting species was unreported or undetermined in 36.6% of cases. Compared with 2005, the largest increases in cases were from Asia (16.0%). Based on estimated volume of travel, the highest estimated relative case rates of malaria among travelers occurred among those returning from West Africa. Of 602 U.S. civilians who acquired malaria abroad and for whom chemoprophylaxis information was known, 405 (67.3%) reported that they had not followed a chemoprophylactic drug regimen recommended by CDC for the area to which they had traveled. Seventeen cases were reported in pregnant women, among whom only one reported taking chemoprophylaxis precautions. Six deaths were reported; five of the persons were infected with P. falciparum and one with P. malariae.

Interpretation: Despite the 2.4% increase in cases from 2005 to 2006, the numbers of malaria cases remained relatively stable during 2001–2006. No change was detected in the proportion of cases by species responsible for infection. U.S. civilians traveling to West Africa had the highest estimated relative case rates. In the majority of reported cases, U.S. civilians who acquired infection abroad had not adhered to a chemoprophylaxis regimen that was appropriate for the country in which they acquired malaria.

Public Health Actions: Additional investigations were conducted of the six fatal cases that occurred in the United States. Persons traveling to a malarious area should take one of the recommended chemoprophylaxis regimens appropriate for the region of travel and use personal protection measures to prevent mosquito bites. Any person who has been to a malarious area and who subsequently has a fever or influenza-like symptoms should seek medical care immediately and report their travel history to the clinician; investigation should always include blood-film tests for malaria, with results made available immediately. Malaria infections can be fatal if not diagnosed and treated promptly. CDC recommendations concerning malaria prevention are available at http://wwwn.cdc.gov/travel/contentdiseases.aspx#malaria or by calling the CDC Malaria Branch on weekdays (telephone: 770-488-7788; Monday–Friday, 8:00 A.M.–4:30 P.M. EST); during evenings, weekends, and holidays, call the CDC Director’s Emergency Operations Center (telephone: 770-488-7100), and ask to page the person on call for the Malaria Branch. Recommendations concerning malaria treatment are available at http://www.cdc.gov/malaria/diagnosis_treatment/treatment.htm or by calling the CDC Malaria Hotline.

Introduction

 

Malaria in humans is caused by infection with one or more species of Plasmodium (i.e., P. falciparum, P. vivax, P. ovale, and P. malariae) that can infect humans. The infection is transmitted by the bite of an infective female Anopheles species mosquito. Malaria remains a devastating global problem, with an estimated 350–500 million cases and 1 million deaths occurring annually, 80% of them in sub-Saharan Africa (1). Forty-nine percent of the world’s population lives in areas where malaria is transmitted (e.g., 109 countries in parts of Africa, Asia, the Middle East, Eastern Europe, Central America and South America, the Caribbean, and Oceania) (1). Before the 1950s, malaria was endemic throughout the southeastern United States; an estimated 600,000 cases occurred in 1914 (2). During the late 1940s, a combination of improved housing and socioeconomic conditions, water management, vector-control efforts, and case management interrupted malaria transmission in the United States. Since then, malaria case surveillance has been maintained to detect locally acquired cases that could indicate the reintroduction of transmission and to monitor patterns of resistance to antimalarial drugs. Anopheline mosquitoes remain seasonally present in all states and territories except Hawaii.

The majority of reported cases of malaria diagnosed each year in the United States are imported from regions where malaria transmission is known to occur, although congenital infections and infections resulting from exposure to blood or blood products are also reported in the United States. In addition, occasionally a limited number of cases are reported that might have been acquired through local mosquitoborne transmission (3).

State and local health departments and CDC investigate malaria cases acquired in the United States, and CDC analyzes data from imported cases to detect trends in acquisition. This information is used to guide malaria prevention recommendations for international travelers.

The signs and symptoms of malaria illness vary, but the majority of patients have fever. Other common symptoms include headache, back pain, chills, increased sweating, myalgia, nausea, vomiting, diarrhea, and cough. The diagnosis of malaria should always be considered for persons with these symptoms who have traveled to an area with known malaria transmission. Malaria also should be considered in the differential diagnosis of persons who have fever of unknown origin, regardless of their travel history. Untreated P. falciparum infections can rapidly progress to coma, renal failure, pulmonary edema, and death. This report summarizes malaria cases reported to CDC among persons with onset of symptoms in 2006.

Methods

Data Sources

 

Malaria case data are reported to the National Malaria Surveillance System (NMSS) and the National Notifiable Diseases Surveillance System (NNDSS) (4). Although both systems rely on passive reporting, the numbers of reported cases might differ because of differences in collection and transmission of data. A substantial difference between the data collected in these two systems is that NMSS receives more detailed clinical and epidemiologic data regarding each case (e.g., information concerning the area to which the infected person has traveled). Malaria cases can be reported to CDC through NMSS, NNDSS, or direct consultation with CDC; therefore, cases identified through these various paths are compared and compiled, duplicates are eliminated, and cases are analyzed. This report presents data on the aggregate of cases reported to CDC through all reporting systems.

Malaria cases confirmed by blood film or polymerase chain reaction (PCR) among civilians and military personnel are identified by health-care providers or laboratories. Each confirmed malaria case is reported to local or state health departments and to CDC on a uniform case-report form that contains clinical, laboratory, and epidemiologic information.* CDC reviews all report forms received and requests additional information from the provider or the state, if necessary (e.g., when no recent travel to a malarious country is reported). Other cases are reported by telephone to CDC directly by health-care providers, usually when they are seeking assistance with diagnosis or treatment. Information regarding cases reported directly to CDC is shared with the relevant state health department. All cases that have been reported as acquired in the United States are investigated further, including all induced and congenital cases and possible introduced or cryptic cases. Information derived from uniform case-report forms is entered into a database and analyzed annually.

A case rate for each country was estimated using estimates of travel volume for U.S. travelers to each country where cases of malaria were acquired and the number of cases among U.S. travelers attributable to each country. Data used to estimate country-specific relative case rates were extrapolated from World Tourism Organization estimates of annual numbers of U.S. travelers to specified countries (5). Estimated relative case rates were determined by dividing the individual country-specific case rate by the median individual country-specific case rate.

Definitions

 

The following definitions are used in this report:

  • U.S. residents: Persons living in the United States, including civilians and U.S. military personnel, regardless of legal citizenship.
  • Foreign residents: Persons who do not meet the definition of U.S. residents.
  • U.S. civilians: U.S. residents, excluding U.S. military personnel.
  • Laboratory criteria for diagnosis: Demonstration of malaria parasites on blood film or by PCR.
  • Confirmed case: Symptomatic or asymptomatic infection that occurs in a person in the United States or one of its territories who has laboratory-confirmed (by microscopy or PCR) malaria parasitemia, regardless of whether the person has had previous episodes of malaria while in other countries. A subsequent episode of malaria is counted as an additional case if the indicated Plasmodium species differs from the initially identified species. A subsequent episode of malaria occurring in a person while in the United States could indicate a relapsing infection or treatment failure resulting from drug resistance if the indicated Plasmodium species is the same species identified previously.

 

This report also uses terminology from recommendations of the World Health Organization (6). Definitions of the following terms are included for reference:

  • Autochthonous malaria:
    — Indigenous. Mosquitoborne transmission of malaria in a geographic area where malaria occurs regularly.
    — Introduced. Mosquitoborne transmission of malaria from a person with an imported case in an area where malaria does not occur regularly.
  • Imported malaria: Malaria acquired outside a specific area. In this report, imported cases are those acquired outside the United States and its territories.
  • Induced malaria: Malaria acquired through artificial means (e.g., blood transfusion or by using shared common syringes).
  • Relapsing malaria: Recurrence of disease after it has been apparently cured. In malaria, true relapses are caused by reactivation of dormant liver-stage parasites (hypnozoites) found in P. vivax and P. ovale.
  • Cryptic malaria: A case of malaria for which epidemiologic investigations fail to identify a plausible mode of acquisition. (Cryptic malaria cases are primarily identified in countries where malaria is not endemic.)

Laboratory Diagnosis

 

Early and prompt diagnosis of malaria requires that physicians obtain a travel history from every febrile patient. Malaria should be included in the differential diagnosis of every febrile patient who has traveled to a malarious area. If malaria is suspected, a Giemsa-stained film of the patient’s peripheral blood should be examined for parasites as soon as possible. Thick and thin blood films must be prepared correctly because diagnostic accuracy depends on blood-film quality and examination of the film by experienced laboratory personnel (7).† Certain reference laboratories and health departments have the capacity to perform PCR diagnosis of malaria, although PCR diagnosis generally is reserved for cases for which blood-film diagnosis of malaria or species determination is inadequate.

Results

General Surveillance

 

For 2006, CDC received 1,564 reports of cases of malaria occurring among persons in the United States and its territories, representing a 2.4% increase from the 1,528 cases reported with a date of onset in 2005 (7). A total of 713 cases occurred among U.S. residents, and 217 cases occurred among foreign residents; resident status was not known for 634 cases. The number of cases increased during 1980–2000 among U.S. residents; however, during 2001–2006, the number of cases plateaued (Table 1).

Plasmodium Species

 

Of the 1,564 cases reported in 2006, the infecting Plasmodium species was identified and reported in only 991 (63.4%) cases. P. falciparum and P. vivax make up the majority of infections and were identified in 61.8% and 27.7% of infected persons of known species infection, respectively. The number of reported cases of P. falciparum and P. vivax remained relatively stable during 2004–2006 (Table 2). Among 909 cases for which both the region of acquisition and the infecting species were known, P. falciparum accounted for 65.8% of infections acquired in Africa, 22.5% in the Americas, 9.3% in Asia, and 4.5% in Oceania (Table 3). Infections attributed to P. vivax accounted for 4.3% acquired in Africa, 58.3% in the Americas, 61.5% in Asia, and 72.7% in Oceania.

Region of Acquisition and Diagnosis

 

All cases were reported as imported cases. Of 1,140 imported cases for which the region of acquisition was known, 793 (69.6%) were acquired in Africa, 205 (18.0%) in Asia, 120 (10.5%) in the Americas, and 22 (1.9%) in Oceania (Table 3). West Africa accounted for 563 (71.0%) cases acquired in Africa, and India accounted for 121 (59.0%) cases acquired in Asia. In the Americas, a combined total of 82 (68.3%) cases were acquired in Central America and the Caribbean (The Bahamas, Belize, Costa Rica, Dominican Republic, El Salvador, Guatemala, Haiti, Honduras, Jamaica, and Nicaragua), followed by 27 (22.5%) cases in South America (Bolivia, Brazil, Ecuador, Guyana, Peru, and Suriname) and 11 (9.2%) cases in Mexico. Information regarding region of acquisition was missing for 424 (27.7%) imported cases. Among U.S. civilians, a small but steady increase (16%) in cases acquired in Asia occurred from 2005 to 2006.

In the United States, six state health departments accounted for 47.8% of the reported cases: California (n = 185), New York City (n = 174), Texas (n = 129), Georgia (n = 90), New Jersey (n = 87), and Illinois (n = 82) (Figure 1). Compared with 2005, the states with the most significant change in number of reported malaria cases in 2006 were Georgia and Alaska. The number of cases reported in Georgia increased from 54 cases in 2005 to 90 cases in 2006, and Alaska reported an increase from eight cases in 2005 to 23 cases in 2006; all cases occurred among U.S. military personnel, all of whom had traveled to Afghanistan.

Imported Malaria by Resident Status

 

Of 930 imported malaria cases of known resident status, 713 (76.7%) occurred among U.S. residents, and 217 (23.3%) occurred among residents of other countries. Of the 713 imported cases, 511 (71.7%) were acquired in Africa, 116 (16.3%) were acquired in Asia, and 42 (5.9%) were acquired in Central America and the Caribbean (Table 4). Of the 217 imported cases among foreign residents, 131 (60.4%) were acquired in Africa. Of patients with foreign cases for whom purpose of travel was known, 76 (58%) identified as being a recent immigrant or refugee, and 22 (17%) reported visiting friends and relatives in the United States.

Relative Case Rates Among U.S. Residents

 

In 2006, the countries with the lowest estimated case rates of malaria among U.S. travelers (among countries that reported cases) were The Bahamas and Jamaica, both of which had been considered nonendemic countries but experienced malaria outbreaks in 2006 (Figure 2). Examples of other countries with low estimated relative case rates include Mexico, Vietnam, Costa Rica, and Thailand. For many of these countries, malaria risk areas are concentrated in small parts of the country. Examples of countries with estimated relative case rates in the middle range include India, Honduras, Haiti, and Kenya, which have malaria transmission occurring more homogenously throughout the country. Estimated relative case rates were highest in countries in West Africa and Oceania, including Nigeria, Ghana, Papua New Guinea, and Vanuatu. These high estimated case rates not only reflect widespread transmission areas but also likely reflect higher transmission intensity.

Interval Between Arrival and Illness

 

Both the interval between date of arrival in the United States and onset of illness and the infecting Plasmodium species were known for only 622 (39.8%) of the imported malaria cases (Table 5). Symptoms began before arrival in the United States for 40 (6.4%) persons and after arrival for 582 (93.6%) persons. Clinical malaria occurred <30 days after arrival in 384 (89.5%) of the 429 persons with P. falciparum cases and in 69 (54.3%) of the 127 P. vivax cases (Table 5). Six (1.0%) of 622 persons became ill with an infection with P. vivax or P ovale >1 year after returning to the United States.

Imported Malaria Among U.S. Military Personnel

 

In 2006, 50 cases of imported malaria were reported among U.S. military personnel. Information on infecting species was known for 38 cases: 33 cases of P. vivax, four cases of P. falciparum, and one case of P. malariae. Among the 38 cases with known infecting species, 33 patients had reported taking chemoprophylaxis, of whom 19 (57.5%) had taken the correct CDC-recommended antimalarial drug for the specific region of travel; only one patient reported adherence to the prescribed drug regimen. These cases were reported by state health departments and do not include all cases reported through malaria surveillance activities conducted by the U.S. Department of Defense.

Chemoprophylaxis Use Among U.S. Civilians

 

Information concerning chemoprophylaxis use and travel area was known for 602 (90.8%) of the 663 U.S. civilians who had imported malaria. Of these 602 patients, 405 (67.3%) had not taken any chemoprophylaxis. Of the 197 patients who did report taking malaria chemoprophylaxis, 58 (29.4%) had not taken a CDC-recommended drug for the area visited, whereas 131 (20.9%) had taken a CDC-recommended drug (7). Data for the specific drug taken were missing for the remaining eight (4.1%) travelers. A total of 58 (44.3%) patients receiving CDC-recommended chemoprophylaxis reported taking mefloquine; 36 (27.5%) had taken doxycycline; 25 (19.1%) had taken atovaquone-proguanil; and eight (6.1%) who had traveled only in areas where chloroquine-resistant malaria has not been documented had taken chloroquine. Of the 131 persons taking a CDC-recommended malaria chemoprophylaxis for the travel region, only 52 (40.0%) reported adherence to the prescribed drug regimen.

Malaria Infection After Recommended Prophylaxis Use

 

A total of 220 patients (including 136 U.S. civilians, 41 persons in the U.S. military, eight foreign residents, and 35 persons for whom information regarding status was missing) contracted malaria after taking a recommended antimalarial drug for chemoprophylaxis. Of these, 76 (34.5%) reported complete adherence with the drug regimen, and 104 (47.3%) reported nonadherence; adherence was unknown for the remaining 40 (18.2%). Information regarding infecting species was available for 178 (80.9%) patients who had taken a recommended antimalarial drug; the infecting species was undetermined for the remaining 42 patients.

Cases Caused by P. vivax or P. ovale

Among the 220 patients who received a diagnosis of malaria after recommended chemoprophylaxis use, 70 (31.8%) had cases that were caused by P. vivax, and 10 (4.5%) had cases caused by P. ovale. Among the 80 total cases of P. vivax or P. ovale, 41 (51.2%) occurred >45 days after arrival in the United States. These cases were consistent with relapsing infections and do not indicate primary prophylaxis failures. Information on 19 cases was insufficient (i.e., missing data regarding symptom onset or return date) to assess whether the infection was a relapse infection. A total of 20 cases occurred <45 days after the patient returned to the United States; 10 each caused by P. vivax and P. ovale. Nine of the 20 patients did not adhere to their malaria chemoprophylaxis regimen; information regarding drug regimen adherence was missing for four cases. Seven patients reported adherence with an antimalarial chemoprophylaxis regimen. Of these seven, three patients had traveled to Africa, two of whom reported taking atovaquone-proguanil as malaria chemoprophylaxis and one who reported taking doxycycline. Two patients had traveled to Asia; one had traveled to India and had taken primaquine, and one had traveled to Iraq and taken mefloquine for chemoprophylaxis. The remaining two patients had traveled to Central America and South America; one patient had traveled to Peru and took doxycycline, and one had traveled to Honduras and taken mefloquine for chemoprophylaxis. Possible explanations for these cases include inappropriate dosing, unreported nonadherence to the regimen, malabsorption of the drug, or emerging parasite resistance.

Cases Caused by P. falciparum and P. malariae

Ninety-four cases of malaria were reported among persons who had taken a recommended antimalarial drug for chemoprophylaxis, including 78 cases of P. falciparum and 16 of P. malariae. Of the 78 P. falciparum cases among those who reported taking a recommended antimalarial drug, all except one case was acquired in Africa. Forty-three (55.1%) patients reported nonadherence to the antimalarial drug regimen; adherence information was not available for 14 cases. In 21 (26.9%) cases, patients reported adherence with malaria chemoprophylaxis, all of whom had traveled to Africa. Fourteen patients reported taking mefloquine, three doxycycline, one primaquine, and three took atovaquone-proguanil. Of the 16 P. malariae cases, 11 were acquired in Africa, four in Asia, and one in the Caribbean. Five patients reported nonadherence to the antimalarial drug regimen, and no adherence information was available for five cases. For the remaining six cases, patients reported adhering to the drug regimen; three took mefloquine, two took doxycycline, and one took atovaquone-proguanil.

Cases of Mixed-Species Infection

Among the 220 patients who had taken a recommended malaria chemoprophylaxis, four had a mixed Plasmodium species infection. Three patients had traveled to Africa, two of whom had a mixed infection of P. vivax and P. falciparum, and one who had P. vivax and P. ovale infections. All three patients had taken atovaquone-proguanil for malaria chemoprophylaxis; however, one had not completed the drug regimen, and no adherence information was available for the remaining two. The patient with the fourth mixed-infection case (P. ovale and P. falciparum) had traveled to Papua New Guinea and also did not complete the malaria chemoprophylaxis drug regimen.

Purpose of Travel

 

Purpose of travel to areas in which malaria is endemic was reported for 617 (86.5%) of the 713 U.S. civilians with imported malaria. Though travelers could report multiple reasons for travel, the largest proportion (50.9%) represented persons who had visited friends or relatives in malarious areas; the second and third highest proportions, 9.9% and 7.4%, represented persons who had traveled as missionaries or as tourists, respectively (Table 6).

Malaria in Children

 

Of the 1,445 cases for whom age was known, 280 (19.4%) cases occurred in persons aged <18 years. Among these, 113 (40.4%) cases occurred among U.S. civilian children, 78 (27.9%) occurred among children of foreign citizenship, and for 89 (31.8%) cases, resident status was unknown.

Ninety-four (83.1%) of the cases among U.S. civilian children for whom country of exposure was known were attributable to Africa. Of the 113 cases among U.S. civilian children, six (5.3%) of the children were aged <24 months, 24 (21.2%) were aged 24--59 months, 40 (35.4%) were aged 5--12 years, and 24 (21.2%) were aged 13--17 years. Among 75 patients for which reason for travel was known, 74 were reported as visiting friends and relatives; the remaining patient was reported as a being a tourist. Among the 88 cases for whom chemoprophylaxis information was known, 30 (34%) patients reported taking chemoprophylaxis, of whom 18 (60%) had taken a correct regimen; only three (16.7%) reported complete adherence.

Malaria During Pregnancy

 

A total of 17 cases of malaria were reported among pregnant women in 2006, representing 3.4% of cases among women. Eight (47.0%) of the 17 cases occurred among U.S. civilians, five of whom had traveled to Africa and three of whom had traveled to countries in Central America and South America. The five women who traveled to Africa were reported as visiting friends and relatives; the three women who traveled to Central America and South America were reported as being tourists. Of the eight cases of malaria reported among U.S. civilian pregnant women, only one (12.5%) woman reported taking malaria chemoprophylaxis; however, she reported taking an inappropriate medication. No information was available on the birth outcomes of the pregnant women.

Deaths Attributed to Malaria

 

Six deaths attributable to malaria were reported in 2006 and are described in the following case reports:

Case 1

On March 20, a man aged 47 years from Thailand arrived in New York City and developed fever and lethargy. He had a medical history of alcoholic cirrhosis, ascites, spontaneous bacterial peritonitis, and diabetes. On March 21, the patient was admitted to the hospital and had symptoms of a chronically ill person, with fever, jaundice, and a distended abdomen. The initial diagnosis was hepatic encephalopathy and spontaneous bacterial peritonitis; peripheral blood smears were ordered to determine whether a concurrent malaria infection was present. The patient was intubated, received mechanical ventilation, and was treated with ceftriaxone, ampicillin/sulbactam, clindamycin, and dexamethasone. The blood smear was positive for P. malariae by microscopy, which was subsequently confirmed by PCR. Doxycycline and quinidine gluconate were added to the regimen within 24 hours of admission. The patient experienced renal failure and died on March 25, 2006.

Case 2

On March 30, a woman aged 65 years returned to Arizona from a 17-day tour of Kenya and Tanzania. Malaria prophylaxis had been prescribed, but the entire regimen was not completed. On June 7, the woman experienced fever and chills. On June 9, she sought treatment at an emergency room; she was evaluated, received intravenous fluids, and was sent home. On June 12, the patient returned to the hospital with the same symptoms as well as nausea and syncope. A peripheral blood film revealed P. falciparum infection; the patient was administered oral quinine and doxycycline. On June 13, she experienced a decreased level of consciousness, necessitating intubation and mechanical ventilation. She died the same evening.

Case 3

On June 29, a girl aged 2 years who recently had emigrated from Nigeria was hospitalized in Boston, Massachusetts, for fever, vomiting, diarrhea, and scleral icterus. Peripheral blood films obtained on admission were positive for P. falciparum, with 1.4% parasitemia; she was administered oral atovaquone-proguanil. On June 30, her parasitemia increased to 26.7%, and she was transferred to the pediatric intensive care unit for an exchange transfusion and continuous quinidine infusion plus intravenous clindamycin. By July 2, the parasitemia had resolved, but the patient experienced acute respiratory distress syndrome. The patient was intubated and mechanical ventilation was initiated; she died on July 3, 2006.

Case 4

On July 28, a man aged 59 years returned from a month-long trip to Ghana. The patient also traveled regularly to India twice per year for mission work; his most recent trip had been in January 2006. He did not take malaria prophylaxis routinely while in India and did not take malaria prophylaxis while traveling to Africa. The evening he returned to the United States, he experienced a high fever and went to an urgent care center, where he received a diagnosis of community-acquired pneumonia and was treated with azithromycin. The patient’s symptoms persisted and progressed to include vomiting and melena. He sought medical attention again on August 1; a peripheral blood film revealed P. falciparum with 10% parasitemia. He was administered oral mefloquine and transferred to a hospital intensive care unit (ICU), where he was treated with quinine and doxycycline. Within 24 hours, he experienced respiratory distress and was intubated. Quinidine gluconate was recommended, and exchange transfusion was initiated; however the patient died before quinidine gluconate could be administered. The patient died on August 3, 2006.

Case 5

On October 17, a woman aged 75 years who was a resident of India arrived in Arizona to attend a family wedding. On October 19, she was taken to the hospital because of fever, disorientation, and decreased level of consciousness. Her medical history included a neurogenic bladder, necessitating self-catheterization, and cerebral malaria. The initial diagnosis was pyelonephritis, and she was treated with intravenous ceftriaxone in the ICU. On October 20, a peripheral blood film revealed P. falciparum; quinine and doxycycline were added to the treatment regimen. The patient experienced renal failure and acute respiratory distress syndrome and was intubated on the October 23. She experienced a nosocomial blood stream infection, and antibiotics were continued; however, her condition continued to deteriorate. The patient was discharged to hospice care and died on November 11, 2006.

Case 6

Case 6 was reported as case 2 in the CDC malaria surveillance report published in 2007 (7). However, the actual date of onset was April 19, 2006, not 2005 as previously reported.

On April 19, a man aged 55 years was taken to an ED with a 4-day history of fever, emesis, and epigastric pain. He was a resident of the United States but had traveled to Uganda, his country of origin, for 3 months and had returned on April 12. He had not taken malaria prophylaxis. On admission, he had sinus tachycardia and a temperature of 100.3ºF (37.9ºC). Routine laboratory analysis was significant only for thrombocytopenia (platelet count: 19,000/µL). A differential diagnoses list was generated, including malaria, dengue fever, and Chikungunya fever; no additional evaluations were performed. The patient’s symptoms improved with antiemetics, normal saline, and pain control. He was discharged with a tentative diagnosis of dengue fever. Four days later, on April 23, he died abruptly. Samples sent to CDC were positive for P. falciparum by PCR but negative for other suspected pathogens.

Discussion

 

A total of 1,564 cases of malaria were reported to CDC for 2006, representing an increase from the total number of cases reported in 2005. The number of cases with no information regarding residential status or clinical information increased from 2005 to 2006, from 325 unidentified cases to 634 unidentified cases (7). Excluding the cases with no information on residence status, the percentage of U.S. resident cases was relatively stable from 2000 to 2006.

Although during 2002–2006, the number of cases acquired from specific regions overall was stable, the proportion of cases from Asia increased slightly but steadily. Flux in the number of cases acquired in a specific region can be affected by many factors, including the amount of transmission occurring in the region, adherence to preventive measures (e.g., mosquito avoidance and chemoprophylaxis) by travelers, the purpose of travel that predominates in that country (e.g., business travel or adventure travel), and the volume of travel to those countries.

Of the 1,564 imported cases, 634 (40.5%) cases did not have information available regarding residential status, and 424 (27.1%) did not have information regarding travel history. An increase in the number of cases that do not have residential and clinical information available decreases the accuracy with which the data reflect trends in malaria surveillance in the United States. Vigilance needs to be exercised by local and state health departments, health-care providers, and other health personnel to provide accompanying information regarding malaria cases when submitting cases through the various reporting systems to CDC.

In the Caribbean region, the endemic transmission of malaria ended in the mid-1960s, except in the island of Hispaniola, which includes the countries of Dominican Republic and Haiti (8). In 2006, three cases of malaria in the United States were reported from the Caribbean region; two in U.S. travelers and one in a foreign visitor. Two of the three cases were acquired from Jamaica and one from The Bahamas (Great Exuma Island); all were caused by P. falciparum. Although these countries were not considered risk areas for malaria, the islands remained at risk for reintroduction because of the tropical climate, presence of viable vectors, and close proximity to countries where malaria is still endemic. As a result, CDC issued recommendations on June 16, 2006, and December 4, 2006, for chloroquine chemoprophylaxis for persons traveling to Great Exuma, The Bahamas, and Kingston, Jamaica, respectively. Through several interventions, including active case finding and treatment and mosquito-control strategies, the outbreak in Great Exuma seemed to be controlled. CDC rescinded chemoprophylaxis recommendations for travelers to Great Exuma on September 19, 2006 (9). However, additional cases have occurred in travelers, and chemoprophylaxis recommendations have been reinstated. In Jamaica, similar strategies to contain the outbreak have been used; however, rare cases continue to be identified in Kingston.§ Fortunately, these occasional cases do not present a substantial ongoing risk to travelers, and routine chemoprophylaxis is no longer recommended. Both of these outbreaks demonstrate the importance of the constant vigilance of health-care providers and rapid response by public health officials for effective containment strategies to avoid widespread reintroduction of malaria in nonendemic areas.

U.S. military personnel usually are on long-term prophylaxis for malaria to adequately protect them for the duration of their deployment in malaria-endemic regions. In regions where P. vivax or P. ovale infections predominate, primaquine is recommended in addition to the chemoprophylactic regimen to prevent relapsing malaria infection (10). The U.S. Army recommends that U.S. soldiers being deployed in regions where P. vivax infections predominate should take mefloquine or doxycycline as the primary prophylactic drug, followed by primaquine for 2 weeks before their return to the United States (11,12). In 2006, 19 of 25 soldiers who had long-term (>1 year) deployments in Afghanistan had not taken primaquine terminal prophylaxis after their course of doxycycline as prescribed by the U.S. Army. Of the remaining six soldiers who had taken both doxycycline and primaquine chemoprophylaxis, only one soldier reported adherence to the entire regimen.

One purpose of malaria surveillance is to identify prophylaxis failures that might indicate emergence of drug resistance. However, approximately 82% of imported malaria cases among U.S. residents for whom information regarding prophylaxis use was available occurred among persons who were either not taking prophylaxis or were taking a non-CDC recommended prophylaxis regimen. Based on available information, the majority of patients who apparently received an appropriate medication and had onset of symptoms within 45 days, reported nonadherence with their chemoprophylactic regimen or provided insufficient information to make a determination regarding adherence. Because CDC does not actively seek serum drug levels from patients who report adherence with a recommended regimen, differentiating among inaccurate reporting of adherence, malabsorption of the antimalarial drug, and emerging drug resistance is not possible. No conclusive evidence indicates a single national or regional source of infection in this group of patients or the failure of a particular chemoprophylactic regimen. Health-care providers are encouraged to contact CDC quickly when chemoprophylaxis failure is suspected to enable CDC to measure serum drug levels of the antimalarial drugs in question and parasite from the patient to evaluate for possible drug resistance.

Of the six fatal cases that occurred in the United States in 2006, four of the patients reported taking no chemoprophylaxis while traveling to areas where malaria is endemic; information on chemoprophylaxis use for the remaining two cases was not available. One patient substantially delayed seeking care, five had substantial delays in establishing a diagnosis, and three patients experienced a delay in receiving appropriate treatment. These findings underscore the importance of patients adhering to correct chemoprophylaxis and promptly seeking medical care if symptoms develop, as well as the importance of physicians considering malaria in the differential diagnosis of fever in a person who has returned from travel. A previous review of deaths attributed to malaria in the United States indicated that failure to take or adhere to recommended antimalarial chemoprophylaxis, promptly seek medical care for posttravel illness, and promptly diagnose and treat suspected malaria all contributed to fatal outcomes (13).

As in previous years, people who traveled to visit friends and relatives experienced the majority of malaria cases in 2006. Foreign-born U.S. civilians need to be aware that acquired immunity wanes quickly when malaria exposure is interrupted and that they need to take prophylaxis when returning to malarious areas. Additionally, children of foreign-born U.S. civilians who are born in the United States are not immune to malaria and are highly vulnerable to infection (14). In this summary, approximately three fourths of the children with malaria whose reason for travel was to visit friends and relatives abroad had not been taking any chemoprophylaxis or had been taking an incorrect medication for chemoprophylaxis.

Seventeen cases were reported in pregnant women, a 21% increase from 2005. Among U.S. civilians who were pregnant, only one of eight women (12.5%) reported taking chemoprophylaxis. This proportion is much lower than the percentage of total U.S. civilians with malaria who took chemoprophylaxis. Malaria during pregnancy among women who are not immune poses a high risk for both maternal and perinatal morbidity and mortality (15). Pregnant travelers should be counseled to avoid travel to malarious areas. If deferral of travel is impossible, these women should be informed that the risks from malaria greatly outweigh those associated with prophylaxis and that safe chemoprophylaxis regimens are available and should be emphasized. Information for pregnant travelers is available at http://wwwn.cdc.gov/travel/contentmalariapregnantpublic.aspx.

Signs and symptoms of malaria are often nonspecific, but fever usually is present. Other symptoms include headache, chills, increased sweating, back pain, myalgia, diarrhea, nausea, vomiting, and cough. For prompt diagnosis, malaria must be included in the differential diagnosis of illness in a febrile patient with a history of travel to a malarious area. Clinicians should ask all febrile patients for a travel history, including international visitors, immigrants, refugees, migrant laborers, and other international travelers.

Prompt treatment of suspected malaria is essential because persons with P. falciparum infection are at risk for experiencing life-threatening complications soon after onset of illness. Ideally, therapy for malaria should be initiated immediately after the diagnosis has been made. Treatment should be determined on the basis of the infecting Plasmodium species, the probable geographic origin of the parasite, the parasite density, and the patient’s clinical status (15). If malaria is suspected but cannot be confirmed or malaria is confirmed but species determination is not possible, antimalarial treatment that is effective against P. falciparum should be initiated. Resistance of P. falciparum to chloroquine occurs worldwide, with the exception of a limited number of geographic regions (e.g., Central America). Therefore, therapy for presumed P. falciparum malaria should entail the use of a drug effective against such resistant strains (16).

The findings in this report are subject to at least two limitations. First, although malaria is a notifiable disease in the United States, malaria case counts are obtained through passive surveillance systems and from individual reporting from health-care professionals treating persons with malaria. Therefore, only cases that are diagnosed by health-care or laboratory workers and reported to state and local health departments and to CDC are included, possibly resulting in an underestimate of disease incidence. Second, the completeness of reporting to the surveillance system might vary by reporting group and by year, which limits the amount of information that can be learned from each case.

Health-care providers should be familiar with prevention, recognition, and treatment of malaria and are encouraged to consult appropriate sources for malaria prevention and treatment recommendations (Table 7). Physicians seeking assistance with the diagnosis or treatment of patients with suspected or confirmed malaria should call CDC’s Malaria Branch (telephone: 770-488-7788; Monday–Friday, 8:00 AM–4:30 PM EST); call CDC’s Emergency Operations Center (telephone: 770-488-7100) during evenings, weekends, and holidays (ask to page person on call for Malaria Branch); or visit CDC’s website at http://www.cdc.gov/malaria/diagnosis_treatment/treatment.htm. These resources are intended for use by health-care providers only.

Detailed recommendations for the public for preventing malaria are available online at http://wwwn.cdc.gov/travel/contentdiseases.aspx#malaria. In addition, biannually, CDC publishes recommendations in Health Information for International Travel (commonly referred to as The Yellow Book) (17), which is available and updated frequently on CDC’s website at http://wwwn.cdc.gov/travel; The Yellow Book also can be purchased online from Elsevier at http://www.elsevierhealth.com or by telephone (800-545-2522).

CDC provides assistance for diagnostic parasitology through DPDx (Laboratory Identification of Parasites of Public Health Concern), a project developed and maintained by CDC’s Division of Parasitic Diseases. DPDx (available at http://www.dpd.cdc.gov/dpdx) provides free Internet-based laboratory diagnostic assistance (i.e., telediagnosis) to laboratorians and pathologists in suspected parasitic disease cases, such as malaria. Digital images captured from diagnostic specimens can be submitted for consultation through e-mail. Telediagnosis assistance by CDC is available during regular business hours. Because laboratories can transmit images to CDC and obtain a rapid response (with average time ranging from minutes to several hours) to their inquiries, this system allows efficient diagnosis of challenging cases and rapid dissemination of information. As of January 2008, approximately 49 public health laboratories in 46 states and Puerto Rico had the ability to perform telediagnosis. Implementation of telediagnosis at public health laboratories receives full assistance from CDC, including training of personnel in digital imaging techniques. The DPDx website also contains reference material with images, text, and videos on approximately 100 different species of parasites with information (including laboratory diagnosis, geographic distribution, clinical features, treatment, and life cycles) available for each parasite.

Acknowledgments

 

This report is based, in part, on data reported from state, territorial, and local health departments; health-care providers; and laboratories.

References

 

  1. Guinovart C, Navia MM, Tanner M, et al. Malaria: burden of disease. Curr Mol Med 2006;6:137–40.
  2. Pan American Health Organization. Report for registration of malaria eradication from United States of America. Washington, DC: Pan American Health Organization; 1969.
  3. CDC. Multifocal autochthonous transmission of malaria—Florida, 2003. MMWR 2004;53:412–3.
  4. CDC. National notifiable diseases surveillance system. CDC; 2008. Available at http://www.cdc.gov/ncphi/disss/nndss/nndsshis.htm.
  5. World Tourism Organization. Yearbook of tourism statistics. 2006 ed. Madrid, Spain: World Tourism Organization. Available at http://www.unwto.org/pub/doc/UNWTO_pub_cat_06_en.pdf.
  6. World Health Organization. Terminology of malaria and of malaria eradication: report of a drafting committee. Geneva, Switzerland: World Health Organization; 1963:32.
  7. CDC. Malaria surveillance—United States, 2005. MMWR 2007;56 (No. SS-6).
  8. Pan American Health Organization. Status of malaria eradication in the Americas, 18th report. PAHO CSP 18/7. Washington, DC: Pan American Health Organization; 1970. Available at http://hist.library.paho.org/english/gov/csp/18_7.pdf.
  9. CDC. Malaria—Great Exuma, Bahamas, May–June 2006. MMWR 2006;55;1013–6.
  10. Baird JK, Hoffman SL. Primaquine therapy for malaria. Clin Infect Dis 2004;39:1336–45.
  11. Ciminera P, Brundage J. Malaria in U.S. military forces: a description of deployment exposures from 2003 through 2005. Am J Trop Med Hyg 2007;76:275–9.
  12. Croft AM, Darbyshire AH, Jackson CJ, van Thiel PP. Malaria prevention measures in coalition troops in Afghanistan. JAMA 2007;297: 2197–200.
  13. Newman RD, Parise ME, Barber AM, Steketee RW. Malaria-related deaths among U.S. travelers, 1963–2001. Ann Intern Med 2004; 141:547–55.
  14. Fulford M, Keystone JS. Health risks associated with visiting friends and relatives in developing countries. Curr Infect Dis Rep 2005;7:48–53.
  15. Griffith KS, Lewis LS, Mali S, Parise ME. Treatment of malaria in the United States: a systematic review. JAMA 2007;297:2264–76.
  16. Baird JK. Effectiveness of antimalarial drugs. N Engl J Med 2005; 352:1565–77.
  17. CDC. Health information for international travel, 2008. Atlanta, GA: US Department of Health and Human Services, Public Health Service, CDC; 2007.
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categories: Emergency Medicine

Baby Bruising

Posted by Paul Rega, MD — published on June 28th, 2008

Medscape, 6/25/08 (http://www.medscape.com/viewarticle/575987)

From Medscape Emergency Medicine:  Cases in Pediatric Emergency Medicine
Spontaneous Bruising in a 2-Month-Old  CME/CE
Posted 06/25/2008
by Ghazala Q. Sharieff, MD
A 2-month-old female came to the emergency department (ED) with her parents, who said she had a low-grade fever, congestion, nasal discharge, and was “pulling at her ears.” She was born at 33 weeks gestational age and was admitted for 13 days. She was not intubated during this time, however, and was discharged when her weight stabilized. The patient had been doing well until this ED visit. There were no ill contacts. She was subsequently diagnosed with a left otitis media and started on amoxicillin. The next day, projectile vomiting developed and she was returned to the ED 2 days later with 2 additional episodes of vomiting, an episode of bloody diarrhea, and decreased oral intake. The parents also reported a rash that developed in the ED during this visit. Physical examination revealed a temperature of 97.7 degrees F rectally, heart rate of 130 breaths per minute, and respiratory rate of 36 breaths per minute. Tympanic membranes were normal bilaterally. The skin examination initially revealed no lesions; however, while the patient was being held for a blood draw, an ecchymotic area developed on the right scapula, right forearm, and also in the bilateral inguinal folds. Laboratory findings revealed a normal complete blood count and normal coagulation studies. However, because of the spontaneous bruising, the child was transferred to the ED of the local children’s hospital for further evaluation. Their examination confirmed the above pattern of bruising and in addition, another bruise had developed above the patient’s left ankle. The parents denied any history of trauma or history of easy bruising or bleeding. However, they did report a family member who received blood transfusions on a yearly basis for an unknown reason. Repeat laboratory data were obtained and revealed a white blood cell count of 10.8, hematocrit of 25.1, and platelets of 530. Prothrombin time (PT) was 10.7, and partial thromboplastin time (PTT) was 19. Chemistry panel and liver function tests were normal. The baby ate well in the ED, and hematology was consulted. Because of the spontaneous bruising, clinicians advised that a blood culture be obtained and that the patient be given a dose of ceftriaxone in case she had early disseminated intravascular coagulopathy. The patient had no further bruising in the ED and was discharged home with next-day hematology follow-up.

The next day, the patient was returned to the pediatric ED because of persistent vomiting. While no new bruising was found at this visit, the ED physician ordered head computed tomography (CT) because of the complaints of vomiting and bruising. The CT scan revealed a left parietal subdural hemorrhage. In addition, there were small bilateral frontal subdural fluid collections that were suspicious for old subdural hematomas. Repeat coagulation studies were within normal limits. The patient was admitted to the trauma service for observation, and a child protective services report was filed because of the suspicion of inflicted injury. She subsequently had an unremarkable hospital visit and was discharged in the care of a foster parent while the case underwent additional investigation.

Discussion

The differential diagnosis of vomiting infants is quite large but includes the following:

  • Infections: Urinary tract infections, otitis media, meningitis, gastroenteritis;
  • Head injury;
  • Intracranial mass or hydronephrosis;
  • Intra-abdominal pathology: Pyloric stenosis, appendicitis, malrotation with volvulus, Hirschsprung’s disease, intussusception, esophageal stenosis/atresia, necrotizing enterocolitis, peritonitis;
  • Renal disease;
  • Gastroesophageal reflux;
  • Metabolic diseases: Inborn errors of metabolism, congenital adrenal hyperplasia;
  • Drug ingestions: Digoxin, iron, aspirin, theophylline, lead; and
  • Post-tussive, especially following pertussis or respiratory syncytial virus.

Child maltreatment occurs in all socioeconomic groups and there is an increased incidence if the following variables are present:

  • Domestic violence;
  • Parental substance abuse;
  • Parental mental illness/antisocial personality;
  • Social isolation;
  • Poverty;
  • Animal abuse; and
  • History of the parent being abused.

Most cases of child abuse occur in children less than 3 years of age, with about one third of victims less than age 3 years, one third between 6 months and 3 years, and one third less than 6 months of age. Children less than 4 years of age are at increased risk for physical abuse because of their verbal or physical inability to resist abuse, increased time that is spent with their direct caregiver, and their increased need for assistance with activities of daily living.

Psychosocial Characteristics of Abuser and Abused

Characteristics of the abusive caregiver include:

  • Aberrant childhood nurture or abuse;
  • Previous loss of child to foster care or avoidable death;
  • Fear of injuring child;
  • Violent behaviors towards others;
  • Substance abuser;
  • Mental illness (particularly depression) or poor impulse control;
  • Young mental age; and
  • Unrealistic expectations of the child.

Families who are socially isolated, who have an insufficient support system, or those with financial or marital stress are also at risk for child abuse.

Characteristics of the abused child include:

  • Premature birth;
  • Neonatal separation;
  • Multiple birth;
  • Congenital defect/mental retardation;
  • Difficult temperament; and
  • Any condition that interferes with parent-child bonding.

Diagnostic Testing

According to a study of bruising in children with fatal inflicted head injuries, 21% of the victims had no external bruises, yet they all had internal hemorrhage, generally intracranial hemorrhage.[2] Once there is suspicion for inflicted injury, a head CT should be obtained and a skeletal survey performed in children less than 2 years of age.

Laboratory studies should include a platelet count, PT, and PTT if contusions or hematomas are present. This prevents the accused or their lawyers from claiming that the patient had chronic bleeding disorders.

It is often difficult to diagnose retinal hemorrhages in an active infant and therefore an ophthalmology consultation may be warranted. All cases of suspected abuse need to be reported to the appropriate authorities.

Warning Signs

There are several red flags that should alert the healthcare professional to the possible diagnosis of nonaccidental injury. These include injuries that are incompatible with the patient’s history or a persistently changing history; circumferential burns, bruises, and/or fractures that are found in various stages of healing; and delays in seeking medical care.

It is imperative that the provider know normal developmental landmarks:

1 month old: May begin to track at the end of the month;
4 months old: Starts to roll;
6 months old: Can sit unsupported;
9 months old: Crawls, cruises on furniture, develops the pincer response; and
12 months old: Starts to walk.

Knowledge of the above can help providers identify histories that are inconsistent with the developmental age of the child. For example, the 1-month-old baby who rolls off the changing table or the 6-month-old who crawls to the iron and burns both palms would cause suspicion.

In contrast, providers should be aware of other conditions that can mimic abuse, such as Mongolian spots, erythema multiforme, hemophilia, and alternative medicine practices, including coin-rubbing (practiced mainly by Vietnamese immigrants, causing linear ecchymoses) and cupping (practiced by Eastern European immigrants, producing circular lesions as a result of placing heated a hemispheric object on the skin).

Nonaccidental head trauma is the leading cause of traumatic death and serious head injuries in infants less than 12 months of age. In a study of pediatric abusive head trauma, the perpetrators were father (37%), mother’s boyfriend (20.5%), female babysitter (17.3%), and mother (12.6%).[1]

Shaken baby syndrome (SBS) or shaken impact syndrome occurs when there is intracranial hemorrhage as the result of severe shaking of an infant. The infant typically lacks any external injuries and has retinal hemorrhages. The immediate management consists of airway control and management of elevated intracranial pressure.

Conclusion

It is important to keep head injury in the differential diagnosis of infants who present with isolated vomiting. In this case, the combined history of bruising and vomiting was a red flag that led the emergency physician to suspect child abuse. This case was extremely difficult because bruising developed in the ED itself and therefore nonaccidental trauma was not initially considered.

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categories: Emergency Medicine

Losartan & Marfan’s

Posted by Paul Rega, MD — published on June 28th, 2008

Medical News Today, 6/27/08

Link:  Drug Treatment For Marfan Syndrome Looks Promising
“A small study in 18 patients assessing the effectiveness of the drug losartan for treating Marfan syndrome in children has yielded encouraging results. Reporting in the June 26 issue of The New England Journal of Medicine, Johns Hopkins researchers showed that losartan-a compound used for years to treat high blood pressure-slowed the enlargement of the aorta, the most life-threatening defect associated with Marfan syndrome.”

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categories: Emergency Medicine

BioMarkers for Kids’ Silent Brain Trauma

Posted by Paul Rega, MD — published on June 28th, 2008

Medical News Today, 6/28/08 (http://www.medicalnewstoday.com/articles/112952.php):  “Axela Inc announced plans to use the dotLab® System in a study of childhood brain injury at Children’s Hospital of Pittsburgh of UPMC. The dotLab System will be used as a research tool to screen high-risk infants for unsuspected brain injury in an emergency department (ED) setting. The project will study candidate biomarkers for shaken baby syndrome (SBS) and other types of brain injury.

Rachel Berger, MD, MPH, a pediatrician and researcher at the Child Advocacy Center at Children’s Hospital, an assistant professor of pediatrics at the University of Pittsburgh School of Medicine and an associate director of the Safar Center for Resuscitation Research said, “The data we generated on Axela’s dotLab System correlated strongly with results obtained as part of our previous studies using an ELISA. This platform continues to be the only system, to our knowledge, that has the capability of measuring serum biomarker concentrations in an ED setting.” Berger added, “We are very encouraged with the continued improvement Axela has made to this assay. Axela’s ability to incrementally add new markers to enhance the same consumable throughout the study will enable a valuable and needed testing format for the ED assessment of these small children.”

This ongoing research is part of a grant proposal entitled, Novel Approaches to Screening for Inflicted Childhood Neurotrauma.

“Not only does our platform promise solutions to screen for childhood brain injury,” said Rocky Ganske, President and CEO of Axela, “but the current test now takes less than 20 minutes to complete using less than two drops of blood - capabilities that will potentially open a new level of care and diagnostics to neonatal and pediatric patients around the world. Our test requires less time, labor, and analysis and is less cumbersome than current methods in an ED setting.” Ganske added, “We are excited about the next phase of this trial of almost 1,000 children including the addition of new sites based on outcomes. We look forward to correlating this data with current imaging methods, and continuing to positively impact Dr. Berger’s already significant body of research in silent brain injury…”

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categories: Emergency Medicine

Zapping occipital nerves to aid chronic migrainers

Posted by Paul Rega, MD — published on June 28th, 2008

Medical News Today, 6/28/08 (http://www.medicalnewstoday.com/articles/113053.php):

“Medtronic, Inc. announced that data from a multicenter, prospective, randomized, singleblinded, Controlled investigational study using its neurostimulation system to stimulate the occipital nerves as a potential approach to treating medically refractory chronic migraines will be presented during a late-breaking session at the annual scientific meeting of the American Headache Society (AHS) tomorrow in Boston. This study, called Occipital Nerve Stimulation for the Treatment of Intractable Migraine (ONSTIM), included patients who have regularly experienced 15 or more headache days per month that were not responsive to conventional medical therapies.

The ONSTIM study, sponsored by Medtronic and conducted under an investigational device exemption (IDE), collected electronic diary data from 66 patients from nine centers who were followed for three months. The data to be reported at the AHS meeting include the average change in the number of headache days per month, overall pain intensity and the responder rate based on at least a 50 percent reduction in headache days per month or at least a threepoint reduction in overall pain intensity.

“The ONSTIM results suggest that occipital nerve stimulation, or ONS, may be a promising therapy option for individuals who have not had success in treating their chronic migraine and as a result are living with the painful and often debilitating symptoms,” said Dr. Joel R. Saper, M.D., founder and director of the Michigan Head Pain and Neurological Institute, Ann Arbor, Mich., and principal investigator for the ONSTIM study. “While ONS for chronic migraine requires additional clinical evaluation, our early experience in this study is encouraging and indicates that ONS could possibly help some chronic migraine patients who have exhausted other treatment options.”

In the study, thin lead wires were placed under the skin near the occipital nerves, which arise from the spinal cord and branch out across the back of the head carrying sensory signals from that region to the brain. The leads were connected to an implanted Medtronic neurostimulator that delivered controlled electrical pulses to the occipital nerves. Patients were randomized to three groups to receive: either a neurostimulator and have the ability to control the level of stimulation; or a neurostimulator as part of a device control group; or only standard medical management instead of an ONS implant. A positive response was defined as at least a 50 percent reduction in the number of headache days in a month, or a reduction in the pain intensity of at least three points on a standard 010 pain scale. In addition to evaluating the efficacy of ONS therapy, the ONSTIM trial was designed to follow patients out to three years related to safety.”

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categories: Emergency Medicine