Nasser A. Al-Hamdan

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J Vector Borne Dis 46, December 2009, pp. 313–314Hospital-acquired malaria associated with dispensing diluted heparinsolutionNasser A. Al-HamdanFaculty of Medicine, King Fahad Medical City, Riyadh, Saudi ArabiaKey words Heparin solution – hospital-acquired – malaria – Saudi ArabiaTransmission of malaria, a mosquito-borne proto-zoan disease, naturally acquired by exposure to bitesof infective female Anopheles spp has also been docu-mented to be through blood and organ transplantfrom infected persons, and accidental infection ofdrug users or medical personnel was reported1. Thisreport implicates a probable mean of transmission ofmalaria associated with inappropriate dispensing ofdiluted heparin solution.Seven cases of malaria in children aged 3–5.5 yr dueto Plasmodium falciparum, were reported from adistrict hospital in Riyadh region, in central SaudiArabia, where local malaria transmission is non-existent. Later on two more children from the sametown were admitted to another hospital with samediagnosis. All cases were chloroquine-resistant andwere successfully treated with quinine. Extensive en-tomological surveys in the town, including the hos-pital, failed to trap anopheline mosquitoes. All chil-dren, except one (a 2.5-year old Sudanese girl), wereSaudi, who neither had been to a malarious area, norreceived blood transfusion. None of the family mem-bers of the Saudi cases suffered from a recent febrileillness. There were no cases of malaria in the hospi-tal among Saudis other than those in the paediatricward. The Sudanese girl, the index case, was admit-ted to the hospital with fever soon after arrival fromSudan.Interviews with the parents of the eight Saudi casesrevealed three common epidemiological character-istics. First, all cases had history of a recent admis-sion to the same hospital for acute gastroenteritis orbronchopneumonia 9 to 16 days prior to the secondadmission, when diagnosis of malaria was made. Sec-ond, the first admission of all cases coincided withadmission of at least a case of malaria in the sameward. Third, the patients were admitted to differentrooms and all of them received medications througha fixed cannula. In the same month there was an un-explained cause of a fatal fever in a 2-month old girlwith congenital heart disease, who had fulfilled allthe above mentioned three epidemiological charac-teristics. However, diagnosis of malaria was notconsidered on admission. There were no cases ofmalaria in the hospital among Saudis other than thosein the paediatric ward.We concluded that malaria was acquired during thefirst admission. Thorough review of medical proce-dures and direct observation of nursing practices re-vealed that heparin solution used to flush cannula wasused to be diluted by nurses inside the paediatric wardin a 500 ml bottle of normal saline. The bottle is usedfor three days and then discarded. Disposable syringeand needle supposed to be used for each patient. Anurse should have diluted heparin from the bottle foranother patient. Red blood cells infected with P.falciparum parasite, must have remained in the tip ofthe needle and dropped inside the bottle. Thus, con-taminated, the bottle became a common source forinfection with malaria. Malaria cases stopped appear-ing soon after we stopped this practice and supervisedunit dosing of heparin. Conceivably, it is possibly thatother cases of malaria as well as cases of other seri- J  VECTOR  BORNE  DIS  46, DECEMBER 2009 314ous diseases with longer incubation periods could haveoccurred due to nurses’ malpractice.Malaria transmission through heparin locks for chil-dren in paediatric ward was reported from other hos-pital in Riyadh in Saudi Arabia2. Accidental self-inoculation with infected blood, even subcutaneously,has been well-documented to have resulted in ma-laria in doctors, laboratory workers and nurses3–7.Our observation probably gives an alternative expla-nation for the so called “baggage malaria”, a termcoined by Castelli et al8 as an explanation for crypticmalaria in Italy. It is important to ask about historyof recent hospitalization, intravenous medication onadmission and concurrent admission of malaria casesin the ward, during the investigation of unexplainedoccurrence of malaria case(s) in a non-malarious area.AcknowledgementThe author appreciates the support from Field Epi-demiology Training Programme of Ministry ofHealth, and the cooperation of the nurses in the hos-pital where the investigation was done.References1. Gilles HM. Epidemiology of malaria. In: Gilles HM,Warrel DA, editors. Bruce-Chwatt’s essential malariol-ogy. III edn. London: Edward Arnold 1983; p.124–64.2. Abulrahi HA, Bohlega EA, Fontaine RE, Al-SeghayerSM, Al-Ruwais AA. Plasmodium falciparum malariatransmitted in hospital through heparin locks. Lancet1997; 349: 23–5.3. Bending M, Maurice P. Malaria: a laboratory risk.Postgrad Med J 1980; 56: 344–5.4. Borsch G, Odendahl J, Sabin G, Ricken D. Malaria trans-mission from patient to nurse (letter).  Lancet 1982; 2:1212.doi: 10.1016/S0140-6736(82)91219–3.5. Burne J. Malaria by accidental inoculation (letter). Lan-cet 1970; 3: 936.6. Cannon N, Dismukes W, Walker S. Malaria acquired byaccidental needle puncture (letter). JAMA 1972; 222:1425.7. Piro S, Sammud M, Badi S, Al Ssabi L. Hospital-acquiredmalaria transmitted by contaminated gloves. J HospInfect 2001; 47: 156–8.8. Castelli F, Caligaris S, Matteelli A, Chiodera A, CarosiG, Fausti G. ‘Baggage Malaria’ in Italy; cryptic malariaexplained? Trans R Soc Trop Med Hyg 1993; 87: 394.Corresponding author: Dr Nasser Al-Hamdan,  6858 Al-Tarafyah St., Al-Mohamadyah, Riyadh 12361-4717,Saudi Arabia.E-mail: nalhamdan@kfmc.med.sa; hamdannasser@hotmail.comReceived: 24 August 2009 Accepted in revised form: 7 September 2009

Hospital-acquired malaria associated with dispensing diluted heparin solution

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