HEALTH — LETTER

Severe falciparum (14% parasite load), was obtunded at pres- in sub-Saharan are directly attribut- in entation and required intravenous quinine able to malaria.7 Australia resettles more despite reported predeparture therapy and resuscitation. Overall, 15 of the humanitarian per capita than any 20 children treated before departure other nation8 and many are from malaria- antimalarial treatment required hospital admission, despite our endemic regions. Predeparture antimalarial Sarah Cherian, Joanna M Fagan, selective non-admission policy for uncom- treatment should reduce the number of Aesen Thambiran, Janet Geddes and plicated P. falciparum malaria. No child had clinical episodes of malaria presenting David Burgner long-term sequelae and all had parasitologi- within Australia, but the efficacy of this cal cure at Day-28 follow-up. unproven intervention warrants prospective TO THE EDITOR: Predeparture screening Possible explanations for these apparent study. Importantly, documented predepar- and treatment for Plasmodium falciparum failures of predeparture treatment include: ture antimalarial treatment should not dis- malaria is increasingly administered to (i) incorrect documentation of treatment; tract health care providers from considering humanitarian refugees from malaria- (ii) poor compliance; (iii) lack of supervi- this potentially life-threatening in a endemic areas immediately before resettle- sion; and (iv) inactive or expired medica- febrile child recently migrated from a ment in Australia. It is undertaken by the tion. Delays in departure must also be malaria-endemic area. International Organization for Migration considered at assessment, as these allow Acknowledgements: We thank Dr Ronan Murray (IOM), under contract from the Department potential re-infection — in this cohort, the for his helpful advice and input into this manu- of Immigration and Multicultural Affairs time between treatment and migration was script. (DIMA).1 Combination therapy (usually an poorly documented. Subsequent clinical artemisinin derivative in combination with Sarah Cherian, Telethon Research Fellow presentation in WA ranged from 24 to 31 (Refugee Health)1 and MSc candidate2 another drug, or chloroquine) is used for 3 The Medical Journal of Australia ISSN: days0025-729X after treatment 4/ in Africa (in cases where Joanna M Fagan, Nurse both adults and children. The first dose (of 3 documentation was available). As all chil- Aesen Thambiran, Medical Director what is usually18 December a 3–5-dose 2006 treatment185 11/12 course)611-611 ©The Medical Journal of Australiadren were2006 not treated at a single centre Janet Geddes, Paediatric Infectious Diseases is supervised, and written documentation of 2 www.mja.com.au offshore, these cases are likely to reflect and Refugee Health Fellow the treatment should accompany the refugee David Burgner, Senior Lecturer1 and Paediatric Refugee health — Letter more widespread and multifactorial issues to Australia.1 Giving predeparture antima- Infectious Diseases Physician2 about the effectiveness of predeparture anti- larial treatment has the potential benefit of 1 School of Paediatrics and Child Health, malarial management. reducing the incidence of malaria after University of Western Australia, Perth, WA. Another concern is the rise of multidrug- arrival, as well as reducing the risk of local 2 Princess Margaret Hospital for Children, resistant strains of P. falciparum, particularly transmission in malaria-receptive areas of Perth, WA. Australia. throughout sub-Saharan Africa and South- 3 Migrant Health Unit, North Metropolitan Area East . Combination therapy with artem- Health Service, Perth, WA. Onshore health assessments are per- isinin derivatives is now recommended by [email protected] formed in about 80% of humanitarian refu- the World Health Organization as first-line 1. Humanitarian Business Process Section, Australian gees resettled in Western Australia (A 2 Thambiran, Medical Director, Migrant treatment. However, many of the patients Government Department of Immigration and Multi- in this cohort received treatment with cultural Affairs. Health screening protocols for refu- Health Unit, Perth, WA, personal communi- gee and special humanitarian program entrants to pyrimethamine–sulphadoxine and artesu- cation). Between August 2005 and March Australia from east and west Africa. Version 1.4. nate, despite reported high levels of parasite Canberra: DIMA, 2006: 1-10. 2006 — a period of increased offshore 3 predeparture management of malaria (in resistance. IOM protocols are evolving in 2. Pan American Health Organization. Position of an attempt to reflect the rapidly changing WHO’s Roll Back Malaria Department on malaria line with DIMA/IOM policy in response, treatment policy. http://www.paho.org/English/AD/ multidrug-resistance patterns in these DPC/CD/mal-who-position-paper.htm (accessed presumably, to the increasing burden of 1 imported malaria in refugees coming to malaria-endemic regions. A recent Ugan- July 2006). 3. Greenwood BM, Bojang K, Whitty CJ, Targett GA. Australia) — 336 African refugee children were dan study reported high Day-28 cure rates with artemether–lumefantrine (despite a rel- Malaria. Lancet 2005; 365: 1487-1498. screened on arrival in WA. Thirty-two chil- 4. Piola P, Fogg C, Bajunirwe F, et al. Supervised dren (9.5%) with P. falciparum malaria were atively complex dosing schedule) because of versus unsupervised intake of six-dose artemether- 4 identified, of whom 20 (10 Burundian, eight lower drug resistance. lumefantrine for treatment of acute, uncomplicated These cases highlight the continuing need Plasmodium falciparum malaria in Mbarara, Congolese and two Sudanese) had received Uganda: a randomised controlled trial. Lancet 2005; predeparture antimalarial medications. for comprehensive and timely onshore 365: 1467-1473. Eleven children who presented in a 3-week assessment (including malaria screening), 5. Snow RW, Guerra CA, Noor AM, et al. The global irrespective of predeparture treatment. distribution of clinical episodes of Plasmodium fal- period had all been treated at a single centre ciparum malaria. Nature 2005; 434: 214-217. in Kenya with pyrimethamine–sulphadox- P. falciparum malaria remains a major glo- 6. John CC. Malaria. In: Rudolph C, Rudolph A, edi- ine and artesunate, according to sighted bal cause of morbidity and mortality — tors. Rudolph’s pediatrics. 21st ed. New York: IOM documentation. Of the remaining nine there were an estimated 515 million clinical McGraw-Hill, 2003: 1136-1143. children, some had transited through coun- in 2002, with 70% occurring in 7. Rowe AK, Rowe SY, Snow RW, et al. The burden of 5 malaria mortality among African children in the year tries other than Kenya, but not all had Africa. P. falciparum has a significant case- 2000. Int J Epidemiol 2006; 35: 691-704. 6 complete documentation. Three children fatality rate (up to 20% in cerebral malaria ), 8. United Nations High Commissioner for Refugees. presented with malaria parasite loads rang- even when managed appropriately. It results Refugees by numbers. 2006 edition. Geneva: 3 UNHCR, 2005. http://www.unhcr.org/cgi-bin/texis/ ing from 6% to 14% within 7–10 days of in 1–2 million deaths each year, mainly of vtx/basics/opendoc.htm?tbl=BASICS&id= arrival in WA. One child had severe malaria children, and about 18% of all child deaths 3b028097c (accessed Nov 2006). ❏

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