Diagnosis, treatment of malaria in returning US travelers hampered during Ebola outbreak
Fear of infection during the height of the Ebola outbreak may have delayed diagnosis and treatment of malaria among travelers returning to the United States from the affected region, according to case data highlighted in MMWR.
These delays often were the result of health care and lab workers refusing to handle the patients’ blood until reassured there would be no risk for Ebola transmission, the CDC researchers wrote.
“During the Ebola outbreak in West Africa, CDC received reports of delayed laboratory testing for malaria in travelers returning to the United States because of infection control concerns related to Ebola,” they wrote. “Both Ebola and malaria are often characterized by fever and malaise and can be clinically indistinguishable, especially early in the course of disease. Immediate laboratory testing is critical for diagnosis of both Ebola and malaria, so that appropriate lifesaving treatment can be initiated.”
The researchers reviewed calls to its malaria consultation service during the outbreak and selected three cases emblematic of diagnosis and treatment failures. These cases were adults returning to the U.S. from Africa in either March or May 2015. When seeking medical care, each reported fever and other symptoms related to both malaria and Ebola.
The first case, a man aged 34 years, called emergency medical services a week after returning to the U.S. Although placed in isolation and given oral medications for his fever, blood drawn for testing had to be sent to a state laboratory due to the local laboratory’s concerns of exposure. Results received from the state lab confirmed malaria and ruled out Ebola; however, hyperparasitemia could not be confirmed because hospital staff members were uncomfortable placing the IV catheter needed for blood smear microscopy. After transfer to another hospital, the patient completed oral therapy and was discharged 3 days later.
The second case, a man aged 69 years, developed subjective fever a day before returning to the U.S. from Kenya. After difficulties receiving weekend treatment or testing from an urgent-care and ED, the patient visited another ED where he was placed in isolation after reporting his history of travel to Africa. Medical assessment was suspended for 4 hours until hospital staff members were assured there was no risk for Ebola transmission associated with travel to Kenya, and the patient was discharged later that morning.
The final case, a woman aged 31 years, visited an ED after travel from Sierra Leone. The hospital laboratory refused to conduct any diagnostics until confirmation that the woman was not infected with Ebola, a process that involved clinicians, the state health department and CDC. Hours after arrival, a malaria test only approved for laboratory use by the FDA was performed at bedside, with no further tests conducted until a negative Ebola reverse transcription PCR result was confirmed 9 hours after admission. The patient eventually was diagnosed with urinary tract infection, but a malaria smear was never performed.
Although the prevalence of cases such as these is unknown, the researchers said they illustrate the occurrence of practices that could be detrimental to a patient’s outcome and, going forward, should be avoided.
“Malaria evaluation should be prioritized in febrile persons who traveled to malaria-endemic areas regardless of travel to an Ebola-affected country,” the researchers wrote. “Timely and immediate education is needed for health care providers and laboratory managers to encourage adherence to guidelines for evaluation and management of malaria in the febrile traveler to prevent poor outcomes.” – by Dave Muoio
Disclosure: The researchers report no relevant financial disclosures.