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Study to Document Pre Admission Risk Factors for Development of Severe Malaria and the SpectrumEB YunusSM is a medical emergency, which needs immediatemanagement in a hospital setup. The differentdurations, which were documented by this study fromthe onset to hospital admission, will provide someimportant insight. These durations: onset of illness,severe symptoms, impaired consciousness,prostration, travel time, and hospital stays are allfound to be in appropriately prolonged leading todelay in starting specific management. The delay maybe important contributing factor to influence theoutcome. The travel time to hospital was found to becomparatively less if the commuter mechanism of thecountry is considered. Therefore the delays arepossibly due to lack of awareness about the conditionand consequences. Other authors in this region ofAsia also observed this 9 . Even one can speculate thislack of awareness is also prevailing amongst thepracticing and operational health care personnel. AKAP study is needed to describe the situationprevailing among people and professionals.Detail examination of different durations by differentcategories of hospitals provided that these are moreprolong in THC. This is possibly because of the factthat patients developing complications over time andmore serious cases are used to seek admission at THCand or being referred from PHCs and SHCs. Butsurprisingly the travel time was lowest at the SHCsthat should be supposed to be in between PHCs andTHCs. This needs further study. But all the durationswere found to be significantly different betweendifferent categories of hospitals saving duration ofprostration.Most of the patients had more than one types orpresentation of SM, types as described by WHO. Butout of these in descending order the most frequenttypes were: Severe prostration, Hypoglycemia,Unarousable coma, Convulsion, Severe anemia,Impaired consciousness, Hyperpyrexia andHyperparasitemia. But in a small number of casesjaundice, abnormal behavior, pulmonary edema,shock and DIC/bleedings were also present. Therewas a striking difference between the THC and PHCsfor different types with SHCs in betweenencountering most of the types that the other twolacked in this series. But it was found that moresevere types like unarousable coma and impairedconsciousness were more frequent at THC. Thisfeature emphasizes that the center of attention for SMmanagement should be more focused to SHCsthrough making them more efficient in all respect.The outcome data revealed that the case fatality washighest at THC followed by SHCs. This is lowest atthe PHCs. As more severe cases with more serioustypes were conglomerated naturally and or by referralto THC and SHCs obviously the fatality rate washigher. So these centers should be upgraded andrefurnished so that critical cases can be appropriatelyand comprehensively managed. A good number ofcases, with insignificant difference between allcategories of hospitals, left the hospital before theattainment of outcome. So outcome of these caseswere unknown and therefore acting as an artefact forgeneral implication of outcome data. Theinterpretation of those therefore needs somereservation for this reason.Conclusion :It can be concluded that more awareness andorientation training are needed both for thecommunity and the professionals working in theendemic zone to ensure early diagnosis and prompttreatment. Secondary Health Care Hospitals shouldbe more equipped for handling severe malaria casesand Chittagong Medical College Hospital should memade as a center of excellence for the same as it is theonly Tertiary Health Care Provider at the perimeter ofthe malaria endemic zone of Bangladesh. Malariaissue should be incorporated in National MCHprogram. Further studies are needed to explore thesituation critically.Acknowledgement & Conflicts of InterestThis study was supported by Research GroupStrengthening Grant of Tropical Disease ResearchWing of World Health Organization and wascollaborated by Malaria and Parasitic DiseasesControl Unit of Directorate General of HealthServices of Bangladesh. The authorities and staffs ofthe study site hospitals deserve special mentioning forthe continued help. There was no conflict of interest.87
Journal of Bangladesh College of Physicians and Surgeons Vol. 22, No. 3, <strong>September</strong> <strong>2004</strong>References1. M&PDC Unit of DGHS and WHO. (1994). Recommendationsof the workshop on "Malaria Clinical Case Definition - Theiruse for Early Diagnosis and Prompt Treatment (EDPT) andEpidemiological surveillance".2. Rhaman MR, Faiz MA, Das JC, Yunus EB: A prospectivedocumentation of prognostic factors of severe malaria amongadult patients in Chittagong Medical College Hospital,Bangladesh. JCMCTA 1996;7(S3):32-45.3. Faiz MA, Rhaman MR, Hussain MA, Rashid HU: Factorscontributing to outcome in cerebral malaria. Bang Med ResCourt Bull (in press).4. Brundfand GH: Roll Back Malaria answering the call. 1998http://rbm.who.int/docs/rbm brochure.htm5. Luxemburg C, Riccf F, Nostcn F, Raimond D, Bathed S, WhiteNJ:The epidemiology of severe malaria in an area of lowtransmission in Thailand. Trans R See Trop Med Hyg91 : 256-626. Brown N: Severe malaria in children at Port Moresby GeneralHospital, Papua New Guinea. Trop Geogr Med 1995; 47 : 107-10.7. Kool KL, Tan WL, Eng P, Ong YY: Malaria requiring intensivecare. Ann Acad Med Singapore 1995 May 27 : 353-7.8. Grag RK, Karak B, Misra S: Neurological manifestations ofmalaria : an update. Neurol India 1999 Jun 47 : 85-919. Kochar D, Kumawat BL, Karan S, Kochar SK, Karan AgarwalRP: Severe and complicated malaria in Bikaner, WesternIndia. Southeast Asian J Trop Med Public Health 1997; 28(2): 259-267.88
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