Malaria Acquired in Haiti - 2010
2008, a total of 1,298 cases of malaria in the United States were reported
provisionally to CDC, and 527 (40.6%) were caused by P. falciparum; all
but two of the malaria cases were imported. Most imported cases are in travelers returning to the United
States from areas in Africa, Asia, and the Americas where malaria transmission
is known to occur. Of the four Plasmodium
species that routinely infect humans (P. falciparum, P. vivax, P.
malariae, and P. ovale), P. falciparum causes the most severe
disease and highest mortality.
caused by Plasmodium falciparum infection is endemic in Haiti, and the
principal mosquito vector is Anopheles albimanus, which frequently bites
outdoors. Although each year Haiti reports approximately 30,000 confirmed cases
of malaria to the Pan American Health Organization, as many as 200,000 cases
might occur annually.
January 12, 2010, a 7.0 magnitude earthquake struck Haiti. According to the Haitian government,
approximately 200,000 persons were killed, and 500,000 were left homeless. These displaced persons who are living
outdoors or in temporary shelters as well as thousands of emergency responders
in Haiti are at substantial risk for malaria.
January 12 - February 25, 2010, CDC received reports of 11 laboratory-confirmed
cases of P. falciparum malaria in 11 persons returning from Haiti.
Patients included seven emergency responders (six U.S. military personnel, one
nonmilitary emergency responder), one U.S. traveler and 3 Haitian citizens who
traveled to the US, including one adoptee. Two of the military personnel required intensive care.
was indicated for the seven emergency responders and the lone U.S. traveler.
Six of these eight patients (including the two hospitalized military personnel)
reported nonadherence to the recommended malaria medication regimen. Adherence
status was unknown for the remaining two patients.
traveling to Haiti should receive chemoprophylaxis. Chemoprophylaxis, although highly effective in preventing
malaria, is not 100% effective.
Therefore, if fever develops in persons taking chloroquine or other
antimalarials for chemoprophylaxis, they still should be evaluated for malaria
infection with a diagnostic test.
medications are started <1 week before departure, or while already in Haiti,
either atovaquone-proguanil or doxycycline are recommended.
- Use of weekly
chloroquine requires receiving the initial dose 1 week before departure.
- Use of weekly
mefloquine requires receiving the initial dose 2 weeks before departure.
- Mosquito avoidance
measures should be taken, such as using mosquito repellent, wearing protective
clothing, and sleeping under an insecticide-treated mosquito net.
currently recommends microscopic examination of blood smears for malaria
diagnosis. Three negative malaria smears spaced 12--24 hours apart are needed
to rule out malaria. Rapid diagnostic tests for malaria can remain positive up
to 3 weeks after treatment and should not be used to assess treatment failure
in a patient with malaria.
with laboratory-confirmed P. falciparum malaria acquired in Haiti should
receive treatment according to CDC guidelines.
- Uncomplicated malaria
can be treated with one of the following regimens: chloroquine,
artemether-lumefantrine, atovaquone-proguanil, or the combination of quinine
and doxycycline, tetracycline, or clindamycin.
- In patients with
confirmed malaria who report adherence to chemoprophylaxis in Haiti, a change
to a different drug than that taken for chemoprophylaxis is recommended for
- Consider switching
patients with uncomplicated, laboratory-confirmed malaria from chloroquine
treatment to other recommended drugs after any indication of poor response to
chloroquine such as increasing parasite density 24 hours after starting
treatment, persistent parasitemia 48 hours after starting treatment, or
- Severe malaria
requires treatment with intravenous quinidine and one of the following:
doxycycline, tetracycline, or clindamycin. Intravenous artesunate also is
available from CDC for use in the United States as part of an investigational
CDC. Health information for
travelers to Haiti. Atlanta, GA: US Department of Health and Human Services,
CDC; 2010. http://wwwnc.cdc.gov/travel/destinations/haiti.aspx
Accessed March 2, 2010.
Do Parents Remain Concerned about Vaccine Safety?|
In the March 2010 issue of Pediatrics, Freed et al,
conducted an Internet survey in 2009 assessing parental vaccine safety
concerns. Parents were enrolled if
they had children living in the household <= 17 years of age. Outcome
measures included opinions on vaccine safety and whether or not a vaccine that
a physician recommended was refused. |
Ninety percent of the 1552 parents that responded to the
survey agreed that vaccines are a good way to protect their child from
disease. Eighty-eight percent
follow their physician's recommendations regarding vaccines. However, 11.5% had refused at least one
vaccine that their physician recommended.
Fifty-four percent of those surveyed were concerned about adverse
events. Newer vaccines appeared to be more of a concern to parents (HPV and the
conjugated meningococcal vaccine). Other specific vaccine refusals were MMR and
percent of the parents felt they should have the right to refuse vaccines for
school entry. Eleven percent believed children did not need to be vaccinated
for diseases that are no longer common and >1 in 5 believe that some
vaccines cause autism in healthy children.
The bottom line is that we still need to continue to educate
families about vaccine preventable diseases vaccines as well as the safety
record of vaccines. Physicians
remain a trusted source of information for families.
Dealing with Parental Refusal to Vaccinate|
This AAP webpage offers useful guidance and downloadable
documents, including a parental Refusal to Vaccinate Form.|
Take Part in Our Vaccine Survey
A Message from David Berman, D.O.
Pediatric Infectious Disease Program
All Children's Specialty Physician
|All physicians are encouraged to complete the brief survey regardless of your opinion regarding
childhood vaccination. If enough responses are received, the anonymous results will
be presented at the Annual Suncoast Pediatric Conference (Sarasota, Florida) in
Thank you for your participation.
Vaccine and Influenza Resource Links|
Vaccine information from the Centers for Disease
Control and Prevention|
Influenza H1N1 Resources for Pediatricians
For guidance documents:
Information for Healthcare Professionals:
Oseltamivir Safety in Children < 12 Months of Age for Treatment of
Oseltamivir has been reported to cause CNS toxicity in
7-day-old rats with a single super dose of 1000 mg/kg dose. However, this is
not seen in adult animals. This adverse outcome may be secondary to the
immature blood-brain barrier in juvenile rats.|
A retrospective study was done to compare neurologic adverse
events that occurred with oseltavmivir compared to the adamantanes (amantadine
and rimantadine) in children <12 months of age.
Fifteen academic centers participated between
2000-2006. Data was collected for
adverse events occurring within 30 days of oseltamivir. There were a total of
180 patients included in the study.
There was not a statistical difference between oseltamivir
and the adamantanes regarding abnormal neurologic events. Two patients had a
seizure and one patient had seizure-like activity. Investigators deemed these events unrelated to the antiviral
medication. Of the 3 patients, one had pertussis and influenza co-infection and
had seizure-like movements on day 2 of amantadine. The second patient had
respiratory failure and the first seizure occurred prior to oseltamivir. The last patient had a seizure during
amantadine treatment but had an underlying history of seizures. One death occurred within 30 days in a
patient that received oseltamivir. This patient had life-support withdrawn by
the family due to the history of pre-existing interstitial lung disease and
failure to thrive.
This is the largest report of oseltamivir use in children
<12 months of age. There is a prior publication from Japan of 103 children
treated with oseltamivir. In these children there was no mortality or
In the current study, there was a broad dosing range among
oseltamivir-treated patients (1-7mg/kg/dose). This emphasizes the importance of
additional pharmacokinetic data to determine the most appropriate dose.
Currently, the Collaborative Antiviral Study Group is conducting a prospective
pharmacokinetic and safety study among the pediatric population < 2 years of
Pediatric Infectious Disease Journal 2010;
Risk Factors for the Development of Herpes Zoster Following Varicella
This study was aimed to investigate effects of chronic
medical conditions, race, and recent vaccination on the risk of developing
herpes zoster (HZ) in children that had received one prior dose of varicella
vaccine. A prior publication in 1998 in adults suggested the risk of HZ in
African-American adults was 1/3 that of Caucasians. |
In this current study, cases were identified from a cohort
of members of the Southern California Kaiser Permanente (SCKP) Health
Plan. With this health system,
there is an opportunity to evaluate outcomes in patients of all races since
there is equal access for all that participate in SCKP.
During the years 2002-2008, 122 children were diagnosed with
HZ that were <12 years of age. Control subjects without HZ during the
same time period were matched 5:1 ratio to each case. The investigators found the risk of HZ among
African-American children was 40% of that among Caucasian children and 30% of
that among Asian children. These
results may support a hypothesis of genetic differences in immunity to
Pediatric Infectious Disease Journal
Are We Following Recommendations for Newborns Exposed to
As we all know, the risk for developing chronic hepatitis B
infection in infants is very high (about 90%) following maternal-infant
transmission. A study was
conducted in Switzerland to evaluate the compliance with recommended procedures
of exposed infants. |
Records were reviewed to determine hepatitis B testing from
four sites over a two-year period (2005 and 2006). 26,750 (98.6%) women were
tested for hepatitis B. 194 women were HBsAg positive (0.73%). 53 were excluded from the study. Of
the remaining 141 women, 84% were foreign born. If the infant was Swiss born, then they were more likely to
complete timely immunization than if they were foreign born. 98.6% of newborns
received active and passive anti-HBV immunization within 24 hours of birth. Of
the HBsAg-exposed infants, 83% completed vaccine with 2 further doses but this
was not done in a timely fashion. Delay of the 2nd dose was observed
Breakdown from the 4 sites:
17% did not complete the hepatitis B vaccine series
35% completed the series but not in a timely fashion
48% completed the series as recommended
As far as following recommendations for serologic follow-up,
only 38% were tested at all and 22% were tested in a timely fashion.
The good news: no chronically infected child was identified.
However, this study further reinforces the importance of long-term follow-up in
infants born to mothers infected with hepatitis B.
Reminders need to be sent to physicians for recommended
procedures in managing infants born to hepatitis B-infected mothers. The other important point in this
study from the four Swiss hospitals was that 0.73% of the mothers were HBsAg
Pediatric Infectious Disease Journal
Hyperbaric Oxygen Therapy (HBOT) in Pediatric Infectious Disease
Some pediatric patients with chronic decubitus ulcers and/or
refractory osteomyelitis may benefit from HBOT. One role of HBOT in the healing
process is to create a high oxygen gradient from the periwound area to the
hypoxic wound center to stimulate neoangiogenesis and promote wound
healing. We have patients that
have benefited from HBOT in combination with surgical debridement and
antibiotics. Benefits of HBOT also
include enhancement of oxidative killing of bacteria, enhanced collagen production
and deposition, and potentiation of antibiotics. |
The Cochrane Collaboration found 26 studies examining HBOT
role in management of chronic wound healing. Only 5 studies were considered
rigorous to be considered for full review. The Undersea and Hyperbaric Medical Society (UHMS) has
approved specific indications for HBOT. These include air or gas embolism,
decompression sickness, gas gangrene, crush injuries, intracranial abscess,
necrotizing soft tissue infections, radiation necrosis, compromised skin grafts
and refractory osteomyelitis.
HBOT is not without risk. Adverse events are rare but have
been reported. They include barotrauma to sinuses (<2%), ears (2-4%), and
lungs (pneumothorax <1 in 1 million). Patients with myopia may have a
temporary exacerbation and generalized seizures may occur in 0.03% of
patients. Therefore, it is very
important to only consider HBOT for the approved indications. Children treated with HBOT may only be
cared for by a certified and experienced physician in HBOT and wound
management. It is the combination of interventions (HBOT, wound
debridement, and antibiotics) that allow for healing to occur. Chronic fatigue,
lyme disease, fibromyalgia, and autism are not approved for HBOT.
Domestic Medical Screening for Haitian Orphan Parolees
The Department of Health and Human Services has made
recommendations for medical screening for orphaned children from Haiti entering
the United States under humanitarian parole status.
The initial medical screening should include:
Assessing for symptoms of communicable disease and trauma
Past medical history of tuberculosis and HIV should be solicited if
possible medication and immunization history if available.
If the child has fever, the physician should have high
clinical suspicion for malaria, dengue, and S. typhi
Lab screening should include:
CBC, HIV testing, malaria smear (if symptomatic),
leptospirosis serology (if symptomatic), dengue serology (if symptomatic),
stool (ova and parasite on three consecutive mornings regardless of symptoms)
- If GI symptoms are present, send for stool culture, Giardia,
Cryptosporidium, rotavirus, and strongyloides (if eosinophilia is present)
- RPR (if positive, then FTA-ABS or MHA-TP)
- Hepatitis B surface antigen
- Tuberculin skin testing (TST) or interferon-gamma release
assay (2-14 years of age)-some experts prefer TST in children < 5years of
There are low vaccine coverage rates in Haitian orphans. It
may be preferred to reimmunize children presumptively. It is acceptable to
perform serologic evaluation of concentrations of antibodies to vaccines
(examples: measles, mumps, rubella, polio, hepatitis A, tetanus and diphtheria).
Mental Health Recommendations
Consider potential mental health and developmental issues in
all Haitian orphans.
For further recommendations see the detailed document:
Department of Health and Human Services
Perinatal HIV-1 Infected Children Born to Low Risk Mothers
Who Tested Antibody Negative During Pregnancy
This article reviews 3 cases of HIV-1 infected infants born
to low risk mothers who tested HIV-1 antibody negative during the 1st
trimester of pregnancy. We have had the same experience in our infectious
disease group. Although the rate
of perinatal HIV infection has dropped dramatically in the United States, there
still remain children born with perinatal infection. The current guidelines
recommend HIV-1 testing of all pregnant women during the first trimester.
Recommended repeat testing should be carried out during the 3rd
trimester for a subset of pregnant women (however, there is a statement that
testing may be considered for all pregnant women).
The subset of women included for third trimester testing:
IV drug users and partners
Multiple sexual partners
Women that receive care in jurisdictions with higher
The three case presentations in this report (all low risk
mothers testing HIV negative in 1st trimester):
5-month-old infant presents with FTT, adenopathy,
thrombocytopenia, and anemia. The mother acquired infection from the patient's
father who was HIV positive but did not disclose to the mother.
- 5-month-old infant presents with Pneumocystis jiroveci
pneumonia (PCP). The mother
acquired the disease from the patient's father who was involved in a bisexual
- 3-month-old infant presents with Pneumocystis jiroveci
pneumonia (PCP). The father was
subsequently diagnosed with AIDS.
These 3 cases occurred in Ohio, a state that does not have
an elevated incidence of HIV or AIDS as per 2006 CDC report. These cases demonstrate that infection
may occur later in pregnancy and go undetected. Repeat testing during the 3rd trimester may
potentially prevent 46 infant infections annually. The pediatrician should continue to remain vigilant
regarding HIV testing in any infant suspected to have HIV infection despite
negative maternal testing.
Pediatric Infectious Disease Journal
Severe Isoniazid-Associated Liver Injuries Among Persons
Being Treated for Latent Tuberculosis Infection-United States 2004-2008
4% of the U.S. population has latent tuberculosis infection (LTBI). Because
LTBI can progress to active disease, CDC recommends testing and treatment of
LTBI for persons in certain groups. Since the 1960s, 6 to 9 months of
isoniazid (INH) has been the mainstay of treatment for latent tuberculosis
infection (LTBI), but its application has been limited by concerns about the
toxicity of INH and the long duration of treatment. To quantify the frequency of severe adverse events (SAEs)
associated with LTBI treatment, the CDC began a national project to monitor
SAEs associated with treatment for LTBI.
2004--2008, 17 SAEs in persons who received INH therapy for LTBI and had
experienced severe liver injury were reported to the CDC through the CDC's
passive surveillance system. Two persons were children (11 and 14 years old), 5
persons were between 16 and 35 years and 10 persons were older than 35
years. Five patients, including
one child, underwent liver transplantation. Five adults died, including one
liver transplant recipient.
Timing of SAEs:
of the 17 SAEs occurred beyond the third month of therapy, indicating that
INH-associated liver injury is possible anytime during the treatment course.
This finding was in contrast to an earlier study that found 10 of 11 episodes
of INH-induced hepatotoxicity occurred during the first 3 months of therapy.
The CDC obtained further information on 10 of the 15
cases with LTBI. SAE symptoms
began in the 10 patients 1 to 7 months after INH initiation. All patients were monitored according
to current guidelines (i.e., monthly clinical evaluation, including symptom
screening and physical examination, and two patients were selected for
additional laboratory monitoring.
SAE diagnosis was prompted by symptoms, not laboratory values.
Additionally, three patients had no putative predictors of liver injury,
indicating that careful monitoring is needed regardless of the patient's risk
recommended treatment for LTBI:
treatment remains a key component of the TB elimination strategy in the US. One
study estimated that LTBI treatment prevented 4,000 - 11,000 TB cases in 2002 in
the US, substantially reducing the burden of TB.
an equally effective, better-tolerated regimen is developed, 9 months of INH
therapy remains the mainstay of LTBI treatment. Efficacy and safety have not been established for other
treatment regimens, such as 4 or 6 months of rifampin, 3 months of INH and
rifampin (the preferred regimen in the United Kingdom, or 3 months of
once-weekly INH and rifapentine, a regimen currently under investigation.
Advice for medical providers:
Patients receiving INH for LTBI therapy should
be monitored according to American Thoracic Society (ATS)/CDC recommendations
because of the risk for drug-induced hepatoxicity.
- Existing recommendations
emphasize the careful selection of candidates for LTBI testing and treatment
based on risk for infection. Persons who are not at risk for TB infection
should not undergo testing for LTBI.
- Monthly clinical
monitoring, including a brief physical examination, for the signs and symptoms
of LTBI treatment--associated adverse events is recommended for all patients.
- Patients who have HIV
infection, patients who have chronic liver disease, pregnant women, women in
the immediate postpartum period (≤3 months after delivery), and patients who
use alcohol regularly should be considered for baseline laboratory hepatic
- Although baseline
laboratory testing is not routinely indicated in older persons, it may be
considered on an individual basis, especially for patients who are taking
medications for chronic medical conditions.
- Routine laboratory
testing is indicated for patients whose baseline testing is abnormal and other
persons at risk for hepatic disease.
- An evaluation including
laboratory testing should be obtained upon the first sign or symptom of a
possible adverse event. Providers should educate patients to discontinue
treatment immediately, even before an evaluation is conducted.
- In the absence of
symptoms, INH should be discontinued if aminotransferase values are five times
the upper limit of normal.
- In the presence of
symptoms, INH should be discontinued if aminotransferase values are three times
the upper limit of normal.
- No more than a 1-month supply of INH at a time
should be prescribed, and treatment should be combined with careful clinical
liver injury is an idiosyncratic drug-induced reaction in patients of any age
treated with INH, including those with or without a putative predictor for
INH-associated liver injury.
liver injury can occur even in the absence of symptoms.
- Patients receiving INH therapy for LTBI should
be told categorically by medical providers to stop taking their medication
immediately if they have symptoms such as nausea, vomiting, abdominal
discomfort, or unexplained fatigue and to contact their providers for further
- Report possible
INH-associated SAEs to their respective health departments and to the Food and
Drug Administration's MedWatch (https://www.accessdata.fda.gov/scripts/medwatch).
American Thoracic Society. An official ATS statement: Hepatotoxicity of
Antituberculosis Therapy. Am J Respir Crit Care Med 2006;174:935--52.
Pediatrics Tuberculosis Collaborative Group. Targeted tuberculin skin
testing and treatment of latent tuberculosis infection in children and
adolescents. Pediatrics 2004;114:1175--201
tuberculin skin testing and treatment of latent tuberculosis infection. MMWR
|David M. Berman, D.O.|
Juan Dumois III, M.D.
Shirley Jankelevich, M.D.
Allison Messina, M.D.
Dale Bergamo, M.D.
Patricia Emmanuel, M.D.
Jorge Lujan-Zilbermann, M.D.
Carina A. Rodriguez, M.D.
Katie Namtu, Pharm.D.
All Children's Hospital
Tampa General Hospital
Bayfront Bay Place Nursery
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|What is the Value of Commercial Influenza Assays for
Detecting Pandemic Influenza A (H1N1) in Pediatrics?|
Investigators from Children's Hospital of Boston collected
nasopharyngeal specimens using two swabs from each patient in children
up to 18
years of age. Two test kits were used. One kit was Binax NOW and the
Flu A/B, which is a direct fluorescent antibody. Polymerase Chain
Reaction (PCR) was used as the
Even though the specificity of each test was >99%, both
tests had poor sensitivity for the Pandemic H1N1 (BinaxNOW 59.6% and DFA
57.3%). Therefore, it is important to remember
that your rapid testing may not rule out infection with Pandemic H1N1.
much more sensitive.
Pediatric Infectious Disease Journal