G321(P) Rationalising our diagnostic approach to malaria in children in the paediatric accident & emergency department

Introduction Fever in the returned traveller is a common presentation. Traditionally, guidelines suggest three blood films to rule out malaria however with advances in rapid diagnostic tests (RDTs), sensitivities have improved. RDTs were introduced in 2015 as part of malaria screening in our hospital. Recent data suggest that in travellers to low risk countries, in whom there is a low clinical suspicion of malaria, a single negative RDT issufficient to exclude malaria. We audited our current diagnostic approach with the aim of rationalising our guideline. Methods The audit was approved by the local clinical governance department. All children who received malaria screens between 1 st January 2015 and 31 st December 2017 were identified and retrospective data collected from electronic patient records. Data collected included; demographics; type, number of malaria screen and their results; duration and destination of travel. Risk of malaria was stratified in accordance with the NHS fitfortravel website and Centres for Disease Control data. Statistical analysis was carried out using Microsoft Excel. Results Between 2015–2017, 132 children were investigated for malaria. The median age was 3 years old. 53% of the children (n=70) travelled to a low risk country, mostly to Bangladesh (n=63). Two cases of falciparum malaria were diagnosed from travellers to high risk areas in Africa. RDTs were consistently carried out from August 2017 on all initial malaria screens with blood-film. Only 31% of tests complied with the guideline, receiving 3 malaria screens. 48% received 1 screen and 21% received 2 screens. There was no correlation between the number of screens and whether malaria was the most likely diagnosis (Fisher’s Exact test p=0.15) or the malaria risk in the destination of travel (p=0.36). Conclusion Malaria was very rare in our population. Most travellers returned from a destination of low risk. There was a lack of consistency in the number of malaria screens performed. We proposed a modified guideline based on risk stratification from the destination of travel and the clinical presentation of the child. We encourage clinicians to consider other causes of fever in well children who travelled to low risk countries and suggest a single RDT with blood film would be sufficient to rule out malaria in this group.