Pierre Landry

Treatment of imported malaria in an ambulatory setting: prospective studyCommentary: Should patients with imported malaria routinely be admitted?

# Treatment of imported malaria in an ambulatory setting: prospective study {#article-title-2} Many specialists in tropical medicine consider that patients with imported malaria, at least those with Plasmodium falciparum malaria, should be admitted to hospital, as complications can develop quickly.1 In Switzerland, patients with malaria who lack signs of severe disease are treated as outpatients, because empirical observations of patients with imported malaria show that death is usually due to a delay in diagnosis rather than complications during treatment.2 We conducted a prospective study in the outpatient clinic of a university hospital to assess the safety of treating imported malaria in an ambulatory setting. We conducted our study from January 1990 to July 2000. At study entry we used predefined clinical and laboratory criteria (table) to determine if patients with malaria required admission to hospital. If no criteria were met, ambulatory treatment was considered appropriate. Patients received the first dose of drugs under supervision and were kept under surveillance for one hour before being sent home with instructions. Follow up was at the attending doctors discretion: clinical and parasitological assessments were performed daily until symptoms resolved and one blood slide was clear of parasites. View this table: Predefined clinical and laboratory criteria for admission of patients with malaria to hospital and number of patients primarily admitted to hospital with the condition Overall, 165 (17%) of 958 patients with fever were positive for parasites; 113 (69%) had P falciparum . Seventy one (43%) of the 165 were first generation immigrants and none was white; and 135 (82%) had travelled to Africa. Median age was 33.7 (range … Correspondence to: C J M Whitty

Rabies Postexposure Prophylaxis in Routine Practice in View of the New Centers for Disease Control and Prevention and World Health Organization Recommendations

BACKGROUND New recommendations for rabies postexposure prophylaxis (PEP) were published by the Centers for Disease Control and Prevention and the World Health Organization in 2010. In view of these new recommendations, we investigated the adequacy of rabies PEP among patients consulting our travel clinic. METHODS A retrospective analysis of the files of all patients who consulted for rabies PEP at the Travel Clinic of the University Hospital in Lausanne, Switzerland, between January 2005 and August 2011 was conducted. RESULTS A total of 110 patients who received rabies PEP were identified. The median age of the patients was 34 years (range, 2-79 years), and 53% were women. Ninety subjects were potentially exposed to rabies while travelling abroad. Shortcomings in the management of these patients were (1) late initiation of rabies PEP in travelers who waited to seek medical care until returning to Switzerland, (2) administration of human rabies immunoglobulin (HRIG) to only 7 of 50 travelers (14%) who sought care abroad and for whom HRIG was indicated, and (3) antibody levels <0.5 IU/mL in 6 of 90 patients (6.7%) after 4 doses of vaccine. CONCLUSIONS Patients do not always receive optimal rabies PEP under real-life conditions. A significant proportion of patients did not develop adequate antibody levels after 4 doses of vaccine. These data indicate that the measurement of antibody levels on day 21 of the Essen PEP regimen is useful in order to verify an adequate immune response.

Mefloquine at the crossroads? Implications for malaria chemoprophylaxis in Europe.

Since its introduction to the market in 1985, mefloquine has been used for malaria chemoprophylaxis by more than 35 million travellers. In Europe, in 2014, the European Medicines Agency (EMA) issued recommendations on strengthened warnings, prescribing checklists and updates to the product information of mefloquine. Some malaria prevention advisors question the scientific basis for the restrictions and suggest that this cost-effective, anti-malarial drug will be displaced as a first-line anti-malaria medication with the result that vulnerable groups such as VFR and long-term travellers, pregnant travellers and young children are left without a suitable alternative chemoprophylaxis. This commentary looks at the current position of mefloquine prescribing and the rationale of the new EMA recommendations and restrictions. It also describes the new recommendations for malaria prophylaxis that have been adapted by Switzerland, Germany, Austria and Italy where chemoprophylaxis use is restricted to high-risk malaria-endemic areas.

Compliance to live oral Ty21a typhoid vaccine, and its effect on viability.

BACKGROUND Concerns have been expressed that in travelers the efficacy of the live oral Ty21a typhoid vaccine Vivotif could be lower than reported, maybe due to a lack of compliance. The purpose of this study was to examine the level of compliance with the recommendations regarding dosing, timing of dosing with respect to food intake, and storage. METHODS Travelers were randomized into two groups: one received oral information only, and the second, a combination of oral and written information. Four criteria of compliance were applied to travelers: 3 capsules needed to be swallowed (criterion 1) on day 1, 3 and 5 (criterion 2), at least 1 hour before or 2 hours after a meal (criterion 3) and the vaccine had to be kept refrigerated (2-8 degrees C) (criterion 4). Compliance was evaluated using three different methods: a questionnaire, pill counting, and electronic monitoring using the Medication Event Monitoring System (MEMS). Storage conditions were checked by temperature tags, and viability of the vaccine was assessed by culturing the content of remaining capsules. RESULTS The data of 115 travelers were analyzed. All the travelers took the 3 capsules. Compliance to all four criteria was complete in 68% of travelers according to the questionnaire, and 53% according to the MEMS (p =.05). Sixty-seven percent of all the doses intervals were of 48 hours +/- 6 hours, 12% being shorter than 36 hours and 7% longer than 60 hours. Eighty-seven travelers (76%) took their capsules on each alternate day. The method of information had no significant impact on compliance. Forty-two percent of tags showed exposure to temperature over 10 degrees C for more than 24 hours. Yet, no difference could be found in the viability of the vaccine compared with controls. CONCLUSIONS Most travelers take their 3 capsules on alternate days, but many did not follow the other recommendations. Electronic monitoring of compliance provides more accurate results than questionnaires. Emphasis must be put on motivating the travelers to take the vaccine as recommended.