Elsevier

The Lancet

Volume 349, Issue 9044, 4 January 1997, Pages 23-25
The Lancet

Early Report
Plasmodium falciparum malaria transmitted in hospital through heparin locks

https://doi.org/10.1016/S0140-6736(96)03508-8Get rights and content

Summary

Background

After a community investigation had implicated hospital admission as a shared feature of a cluster of acute Plasmodium falciparum malaria (AFM) cases in Riyadh, Saudi Arabia, we began an in-hospital investigation to determine the method of transmission.

Methods

We investigated all AFM patients admitted to one paediatric hospital for any reason from December, 1991, to April, 1992. We classified AFM as locally acquired (LAFM) if during the month before AFM onset the patient had not visited a malarious area, and as hospital acquired (HAFM) if the LAFM patient had been admitted to hospital during that month. We compared exposures of HAFM cases with those of other patients sampled from the same wards. We observed nursing practices and investigated by anonymous questionnaire how nurses administered parenteral drugs.

Findings

Of 21 LAFM cases, 20 (95%) had a previous hospital admission (exposure admission) compared with 15 (25%) of 61 other patients (p<0·001; x2 test). During the exposure admission, all HAFM patients had occupied the same room as, or a room adjacent to, an AFM patient; 14 (23%) of 60 other patients occupied the same room or rooms adjacent to an AFM patient (p<0·001, χ2). 90% of HAFM patients received infusions through a heparin lock during the exposure admission, compared with 49% of 120 general patients (p<0·001, χ2). 10% of nurses admitted to using one syringe for more than one heparin lock and 50% filled syringes with enough heparin for three to ten heparin locks.

Interpretation

P falciparum was transmitted between patients when single syringes were used on heparin locks of sequential patients. This practice would easily transmit other blood-borne agents.

Introduction

Nosocomial malaria usually involves single incidents of transmission to individual patients or hospital staff by accidental needle-stick injuries, blood transfusions, or organ transplants.1 The only reported outbreak of nosocomial malaria involved six patients on a medical ward in Venezuela.2 In February, 1992, we detected nine otherwise unrelated children with Plasmodium falciparum malaria who had neither left Riyadh, Saudi Arabia nor received blood transfusions. Riyadh city and the surrounding desert within 600 km are non-malarious. No anopheline mosquitoes were found near the children's houses or in suitable breeding spots elsewhere in Riyadh. The mean monthly temperature was 13−8°C. A community case-control study implicated hospital admission for another reason within a month before malaria onset. We report our investigation to determine the method of transmission in the most frequently implicated hospital.

Section snippets

Methods

The hospital is a 352-bed public paediatric hospital. Children (1 month to 12 years old) requiring treatment of acute medical conditions are admitted to wards 2A and 3A. Each of these wards has nine rooms with four or five beds in each room.

We identified malaria cases from December 7, 1991, to April 23, 1992, from regional malaria surveillance reports and infection-control records in the hospital and two other public hospitals in Riyadh. In the hospital, we made daily ward rounds for new

Results

We detected 41 AFM cases, including 21 LAFM and 20 IFM. The mean age of both LAFM and IFM patients was 2·7 years, and the male to female ratio for both was 2/1. LAFM appeared as an outbreak from weeks 1 to 13 of 1992 (figure).

During the month before AFM onset, 20 (95%) of the LAFM patients had an admission for another condition to wards 2A or 3A, and were thus classified as HAFM. By contrast, 15 (25%) of 61 patients admitted to these wards during week 1 of the investigation (χ2 34·5, 1 df,

Discussion

Our epidemiologic findings suggest strongly that P falciparum was accidentally propagated among hospital patients. Intervals from exposure to onset were within the range of the incubation period of P falciparum. Exposure was linked in time and space to source malaria patients. Heparin locks were identified as a portal of exit and entry. The nurses' admission of using single syringes on the heparin locks of sequential patients provides the mechanism of transfer of infected erythrocytes from one

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