Malaria Case Report

Case Report:   An 18 years old male university student

visited the Health Unit complaining of unexplained high fever for 2 – 3 days. On

physical examination, he had flu-like symptoms. His body temperature is about 38.2º. However, after a complete history taking, he revealed a history of visiting to

Nigeria for a camping a week before.  

He was anxious about malaria infection and this agreed with the comments of the

physician-in-charge. A complete blood count on this patient was performed. \ The result show normal appearance

accepted for presentation of malarial parasite in red blood cell.  He was

diagnosed for vivax malarial infection and referred to the nearby hospital for proper

treatment.

If you were an epidemiologist, How to investigate this problem?

Malaria surveyMalaria survey

Definition: field study in

endemic areas to find out the

magnitude of malaria problems

and ecological factors related

to endemicity (host-agent-

environment)

StepsSteps::

1.1.PlanningPlanning

2.2.PreparationPreparation

3.3.Implementation &interpretation:Implementation &interpretation:

Vector study: Vector study: types of mosquito, density, species, types of mosquito, density, species,

life span, choices to host resting habits, life span, choices to host resting habits,

breeding habits, resistance to insecticides.breeding habits, resistance to insecticides.

MalaroimetricMalaroimetric indicesindices

A-Human:

1-splenic index (non specific):

the percentage of children

between 2-9 years showing

enlargement of spleen,

excluding other causes of

spleenomegaly (Bilharisiasis

and Leshmania).

2-gametocyte index (specific):

the percentage of the host

having gametocytes in their

blood.

3-infant parasitic index (specific):

the percentage of the infants below

the age of one year showing

malaria parasites in their blood. It

is the most sensitive index for

recent infection.

B-Vector Indices:

•1.Oocyte index: percentage of oocyte in the stomach wall of female anopheles.

•2.Sporosoite index: percentage of female anopheles having sporozoite index in their salivary glands.

In a village in Upper Egypt, an increasing number of cases of high fever with rigors, severe

headache and body aches.

By specific investigations, these cases were confirmed to be

malaria

What are the most important preventive measures that should

be done in this situation?

PreventionPrevention

General prevention:General prevention:

1- Sanitary environment 1- Sanitary environment such as filling small such as filling small collection of water to eliminate breeding places.collection of water to eliminate breeding places.

2- Eradication of breeding spaces2- Eradication of breeding spaces biologically by biologically by ducks and frogs and chemically by spraying of ducks and frogs and chemically by spraying of crude oil and larvicides on water surface.crude oil and larvicides on water surface.

3-Destruction of adult mosquitoes 3-Destruction of adult mosquitoes by spraying of by spraying of screened living and sleeping quarters with a liquid screened living and sleeping quarters with a liquid aerosol .aerosol .

4- 4- in endemic area use screen ,bed nets, animal in endemic area use screen ,bed nets, animal barrier between breeding places and habitation.barrier between breeding places and habitation.

5- personal protection against mosquito bites 5- personal protection against mosquito bites ((the first linethe first line):):

• avoid outdoor exposure between dusk and dawn.avoid outdoor exposure between dusk and dawn.• Wearing long loose clothing after dusk with light Wearing long loose clothing after dusk with light

color.color.• Avoid perfumes and colognes.Avoid perfumes and colognes.• Use effective insect repellents.Use effective insect repellents.• Using knock- down sprays or plug in vaporizing Using knock- down sprays or plug in vaporizing

devices indoor.devices indoor.• Using mosquito net and insecticides treated bed Using mosquito net and insecticides treated bed

nets.nets.

6- Health education of the public for the mode of 6- Health education of the public for the mode of transmutation, protection from exposure transmutation, protection from exposure and importance of treatment.and importance of treatment.

7- Blood donors with positive history should be 7- Blood donors with positive history should be avoidedavoided

Control Control

A-Cases:

1-Early case finding1-Early case finding by laboratory examination of by laboratory examination of

clinically suspected persons and by periodic clinically suspected persons and by periodic

survey.survey.

2-2-NotifictionNotifiction to local health office. to local health office.

3- 3- Isolation isIsolation is not required. not required.

appropriate therapy should be started immediately:

• Delay it can have serious or fatal consequences.

• It is complex and should be infectious disease physician.

• Most strains of p. falciparum are resistant to chloroquine. If the species cannot be identified with confidence the patient should be treated as the most serious type.

D- International measures for travelers :

Checklist for travelers to malarious

areas:

1.Risk for malaria :

Higher in sub-Saharan Africa than other part

in the world.

No vaccine is currently available (vaccine under trial).

Appropriate chemoprophylaxis and anti-mosquito measures will help prevention.

2.Personal protective measures3.chemoprophylaxis: a) Primary prophylaxis

Drug Usage Before travel

During travel

After travel

chloroquine weekly 1-2 weeks

continue 4 week

mefloquine weekly continue 4 week

doxycycline Daily1-2 days

continue 4 week

Atovaquone\ proguanil

Daily continue 7 days

Travel to areas with out chloroquine resistant strain:

1-Chloroquine once –a-week. 2-Hydroxychloroquine

3- Mefloquine, doxycycline,Atovaquone\ proguanil

Travel to areas with chloroquine resistant p.falciparum:

Mefloquine,Doxycycline,Atovaquone\ proguanil

Travel to areas with mefloquine resistant p.falciparum:

Atovaquone\ proguanil, doxycycline,

B) Terminal prophylaxis: To prevent relapse that may occur 4years or

more after chemoprophylaxis.

Primaquine to prevent relapse with p.vivax and p.ovale

For 14 days after the travelers has left the malaria endemic areas.

4.In case of illness: the traveler should be

informed about mild symptoms warned that delay in treatment is fatal.

Tetanus Tetanus

At 4 o`clock in the after noon of April 20, 2009 a young married women 25 years old had an accident by her car . She was left bleeding in the road for 2 hours until the ambulance came and took her to the hospital.

The doctor examined her and the wound in the back of her head was dressed then she was dismissed from the hospital. After a week she exhibited all the symptoms of tetanus ; had rigid neck and muscle spasm especially in her face . She asked the doctor and was referred to the fever hospital.

•What is the causative organism?•What are the modes of transmission ?•What is the prevention of tetanus?•What is the steps of control of the

case ?

• Causative agent:Causative agent:

Clostridium tetaniClostridium tetani, a gram positive anaerobic spore , a gram positive anaerobic spore forming organisms.forming organisms.

• Reservoir:Reservoir:

The natural habitat of the organisms are in The natural habitat of the organisms are in the soil the soil contaminated by excreta of herbivorous animalscontaminated by excreta of herbivorous animals e.g. e.g. horses, cattle, sheep and goats and sometimes man. horses, cattle, sheep and goats and sometimes man.

Incubation period:Incubation period: 3- 21 days3- 21 days although it may range although it may range from from one day to several months one day to several months depending on the depending on the character, extent and location of the wound. character, extent and location of the wound. Most cases Most cases occur within 14 days.occur within 14 days.

• Mode of transmission:Mode of transmission:

• 1.1. Infection of wounds Infection of wounds::

• By spores introduced to the punctured By spores introduced to the punctured wounds contaminated with soil, street wounds contaminated with soil, street dust or animal faeces through laceration, dust or animal faeces through laceration, burns, or trivial unnoticed wounds. burns, or trivial unnoticed wounds.

• The presences of necrotic tissues and or The presences of necrotic tissues and or foreign bodies favor anaerobic organisms foreign bodies favor anaerobic organisms to produce toxins.to produce toxins.

• Intravenous drug use is an independent Intravenous drug use is an independent risk factor for tetanus in the absence of risk factor for tetanus in the absence of acute injuriesacute injuries

• 2.2. Post operative surgical tetanus: Post operative surgical tetanus:

- - Contaminated instruments or defectively sterilized Contaminated instruments or defectively sterilized catgut catgut

- contaminated wounds by dust containing spores.- contaminated wounds by dust containing spores.

3.3. Puerperal sepsis: Puerperal sepsis: Using contaminated Using contaminated instruments in labor or abortion.instruments in labor or abortion.

4.4. Tetanus neonatorum: Tetanus neonatorum:

--by contaminated hands with soil by contaminated hands with soil

- Contaminated instruments for cutting the cord - Contaminated instruments for cutting the cord (scissor or knife) (scissor or knife)

-Using contaminated dressing or fomites to cover the -Using contaminated dressing or fomites to cover the stumpstump..

  

• Prophylaxis in wound managementProphylaxis in wound management

• Tetanus prophylaxis in wounded person Tetanus prophylaxis in wounded person is based on: is based on:

• Careful assessment of the wound weather Careful assessment of the wound weather clean or contaminated, clean or contaminated,

• The immunization status of the person.The immunization status of the person.

• Management of woundManagement of wound

• Cleaning of wound, surgical debridement Cleaning of wound, surgical debridement if required and proper dose of antibiotics if required and proper dose of antibiotics (penicillin).(penicillin).

• Those who have been completely Those who have been completely immunizedimmunized

• Minor and uncontaminated woundsMinor and uncontaminated wounds require a booster dose of toxoid if more require a booster dose of toxoid if more than 10 years have passed since last than 10 years have passed since last dose was given.dose was given.

• For major and contaminated woundsFor major and contaminated wounds a a single booster injection of tetanus toxoid single booster injection of tetanus toxoid should be given in the day of injury for should be given in the day of injury for those who not received tetanus toxoid those who not received tetanus toxoid since 5 years.since 5 years.

Persons who are non immunizedPersons who are non immunized or or those who have not completed their those who have not completed their primaryprimary immunizationimmunization

• Require a dose of toxoid as soon as Require a dose of toxoid as soon as possible and require TIG or ATS in case of possible and require TIG or ATS in case of contaminated major wound, separate contaminated major wound, separate syringes and separate sites must be syringes and separate sites must be used.used.

• If ATS of animal origin is used, it is If ATS of animal origin is used, it is essential to do sensitivity l.D test. essential to do sensitivity l.D test.

Control:Control:

CaseCase– Early case findingEarly case finding– NotificationNotification to local health office to local health office– Isolation:Isolation: No need for isolation but the No need for isolation but the

patient should be hospitalized for patient should be hospitalized for management.management.

– Release Release after cure.after cure.– Treatment: Treatment:

• Specific treatment TIG 1M in dose of 3000 Specific treatment TIG 1M in dose of 3000 - 6000 IU. - 6000 IU.

• If TIG is not available, ATS (equine) in a If TIG is not available, ATS (equine) in a single large dose given IM preceded single large dose given IM preceded by hypersensitivity test by hypersensitivity test

• Metronidazole I.V in large doses should be Metronidazole I.V in large doses should be given 7-14 days.given 7-14 days.

• The wound should be debrided widely and The wound should be debrided widely and excised if possible.excised if possible.

• careful attention to provide an adequate careful attention to provide an adequate airway and to control muscle spasmairway and to control muscle spasm

ContactsContacts

Investigation of contacts and source of infection Investigation of contacts and source of infection to determine the circumstances of injuryto determine the circumstances of injury

Outbreak measuresOutbreak measures

Not applicable except for rare cases as clusters Not applicable except for rare cases as clusters of Intravenous drug users.of Intravenous drug users.

Case of tetanus neonatorum

On Tuesday 2005, a boy was born in a country in rural area. His umbilical cord was cut with a knife and the stump was dressed with olive oil.

After a week the baby could not feed and suckle. There was episodes of convulsion and stiffness. His mother took him to the doctor and the doctor referred him to the fever hospital.

What is the features of the confirmed case?What is the mode of transmition in this case?How could we prevent it and protect the mother?

Case Definition:Suspected case:•Any death of unknown cause between 3 to 28 days of life.Confirmed Case:Neonatal tetanus is diagnosed on clinical findings and does not depend upon laboratory confirmation. A confirmed case is any infant with:•A normal ability to suck and cry during the first 2 days of life•History of poor feeding or inability to such between the ages of 3 and 28 daysEpisodes of convulsions or stiffness (i.e. jerking of the muscles).

Mode of transmission:

The disease occurs through introduction of tetanus spores via the umbilical cord during delivery.

Prevention of tetanus neonatorum

•Vaccination of mothers by TT during pregnancy

•Health education of mother about the importance of

vaccination during pregnancy.

•Sanitation of the place of deliveries, sterilization of

all instrument used in deliveries and all articles,

scissors, scalpel used in cutting the cord,

•Using sterilized catgut in ligation of the cord.

•Using sterile dressing in covering the stump.

Thank you