Geographical concentration of falciparum malaria treated in the UK and delay to treatment with artesunate in severe cases: an observational study

Abstract

ObjectivesTo quantify geographical concentration of falciparum malaria cases in the UK at a hospital level. To assess potential delay-to-treatment associated with hub-and-spoke distribution of artesunate in severe cases.DesignObservational study using national and hospital data.Setting and participants3520 patients notified to the Malaria Reference Laboratory 2008–2010, 34 patients treated with intravenous artesunate from a tropical diseases centre 2002–2010.Main outcome measuresGeographical location of falciparum cases notified in the UK. Diagnosis-to-treatment times for intravenous artesunate.ResultsEight centres accounted for 43.9% of the UK's total cases; notifications from 107 centres accounted for 10.2% of cases; 51.5% of hospitals seeing malaria notified 5 or fewer cases in 3 years. Centres that saw <10 cases/year treat 26.3% of malaria cases; 6.1% of cases are treated in hospitals seeing <2 cases/year. Concentration of falciparum malaria was highest in Greater London (1925, 54.7%), South East (515, 14.6%), East of England (402, 11.4%) and North West (192, 5.4%). The North East and Northern Ireland each notified 5 or fewer cases per year. Median diagnosis-to-treatment time was 1 h (range 0.5–5) for patients receiving artesunate in the specialist centre; 7.5 h (range 4–26) for patients receiving it in referring hospitals via the hub-and-spoke system (p=0.02); 25 h (range 9–45) for patients receiving it on transfer to the regional centre from a referring hospital (p=0.002).ConclusionsMost UK hospitals see few cases of falciparum malaria and geographical distances are significant. Over 25% of cases are seen in hospitals where malaria is rare, although 60% are seen in hospitals seeing over 50 cases over 3 years. A hub-and-spoke system minimises drug wastage and ensures availability in centres seeing most cases but is associated with treatment delays elsewhere. As with all observational studies, there are limitations, which are discussed.

Malaria in the returning older traveler

“…Significant delays from diagnosis to treatment were only seen in regional centers who did not have artesunate on site. The fact that treatment promptly followed diagnosis in specialist centers is generalisable to our study, which was performed in two tertiary referral centers, and therefore we can assume that our delays in treatment were due to delay in diagnosis [ 24 ].…”

“…This, and the fact that the study was conducted in only two centers, means that caution must be taken with generalizing results. However, even in settings that would expect to see even fewer presentations of imported infection, it is important for physicians to remain alert to the possibility; a large study in the UK showed that while most UK cases are seen in hospitals which see a lot of malaria cases, 25 % of falciparum malaria is seen in centers which see less than one malaria patient a month, and 6 % in hospitals that see fewer than two cases per year [ 24 ]. Furthermore case-notes reviews have their limitation; the non-documentation of questions relating to travel history and use of malaria prophylaxis were taken to mean that these questions were not asked, which may not be the case.…”

Geographical and temporal trends in imported infections from the tropics requiring inpatient care at the Hospital for Tropical Diseases, London – a 15 year study

“…10 , 11 This decline in patients admitted with malaria may also reflect greater access to specialist care elsewhere and the increased availability of artemisinin based therapies which used to be only available in specialist centres. 12 Artemisinin based regimes are markedly more effective than older quinine based regimes, particularly in the most unwell patients and wider access to these drugs may have resulted in a reduced need for transfer to a specialist unit.…”

UK malaria treatment guidelines 2016

“…29 26% of UK malaria cases are seen in centres with less than 10 cases a year. 36 Patients with falciparum malaria (or a mixed infection which includes falciparum parasites) can be divided into those with uncomplicated and those with severe or complicated disease (Box 3). Assessment of the patient should include careful clinical evaluation and review of investigations for the features of severe malaria detailed below.…”