Fever in the Returned Traveler — Malaria Testing — Clinical Pathway: Emergency Department

Fever In the Returned Traveler — Emergency Department

Malaria Testing

Malaria testing is recommended for all Afghan refugees and returned travelers from malaria-endemic areas presenting with fever.
Note: P. vivax and P. ovale have a latent phase and can present months to years later.

Epic order:

  • Blood Parasite Exam
  • G6PD (in Afghan refugees because of a high prevalence of G6PD deficiency)

Blood Parasite Exam
  • Includes a rapid diagnostic test (RDT) BinaxNOW Malaria (1 hr TAT)
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  • Blood smear, thin (4 hr TAT) and thick (8 hr TAT)
  • RDT detects presence of plasmodium antigen
    • If negative and child meets all other discharge criteria, may discharge home while awaiting blood smear results
    • If positive and non-ICU admission possible, await thin blood smear results (which measures % parasitemia) before determining PICU vs. floor
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  • Children with thin blood smears with > 5% parasitemia require PICU admission
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  • Parasitemia will be repeated every 4 hrs per the CHOP Malaria Protocol, but only first parasitemia needs to result in the ED
If Non-falciparum Malaria
P. vivax or P. ovale is Detected
  • Send qualitative G6PD testing to guide medication dosing for anti-relapse treatment (primaquine or tafenoquine) due to risk of hemolytic anemia in individuals with G6PD deficiency.

Additional Information About the BINAX now RDT Test

  Sensitivity Specificity
Plasmodium falciparum 99.7% 94.2-100%
Plasmodium vivax 93.5% 99.8%
Plasmodium malariae
Plasmodium ovale		 43-75% 99%

Test has some cross-reactivity with rheumatoid factor and human anti-mouse antibody (HAMA)
Test may be “false-positive” after recent prior malaria treatment, highest risk at day 14 (98.2%) and decreases over time (day 21 (94.6%), day 28 (92.0%), and day 35 (73.5%)).

Note: A positive RDT test does not rule out co-infection, complete infectious work as indicated.
Some children living in endemic areas can have low levels of parasitemia that are not the etiology of their fever or other presenting complaints.

Criteria for Severe Malaria

Send PT/PTT/INR immediately if not already sent. Review lab work, including CBC, BMP, UA, coagulation studies, parasitemia count. Determine if child meets criteria for severe malaria.

Child has a positive malaria test and severe malaria as defined by one or more of the following CDC criteria:

  • Hyperparasitemia (> 5%)
  • Cerebral malaria; defined as impairment of consciousness, seizures, coma, or other neurologic abnormalities
  • Severe anemia (Hb < 7 g/dL)
  • Hemoglobinuria
  • Pulmonary edema or acute respiratory distress syndrome (ARDS)
  • Disseminated intravascular coagulation (DIC)
  • Circulatory shock
  • Acute kidney injury
  • Metabolic acidosis
  • Hypoglycemia

CHOP Severe Malaria Treatment Protocol