The use of parasite lactate dehydrogenase isoenzyme-based visual test for the speciation of Plasmodium Falciparum and Plasmodium vivax infections

Parasite specific lactate dehydrogenase (LDH) isoenzyme coated OptiMAL test strips were used to diagnose Plasmodium falciparum and p. vivax infections in one hundred clinically suspected malaria patients attending the Clinical Research Unit for Malaria, Defence Services General Hospital, Mingaladon during May to September 1999. Traditional microscopic examination was carried out in parallet to observe the sensitivity and specificity of the LDH-based OptiMAL test. the interpretation of the results by LDH-based test strips took only five minutes, whereas microscopic examination took thrity minutes. The sensitivities and specificities of pLDH-based OptiMAL test were 89.47 per cent and 100.0 per cent for P. falciparum; 100.0 per cent and 96.43 per cent for P.vivax respectively. Due to the rapid detection and speciation, prompt treatment was made without any delay.

Intervention study to improve the misuse of artemisinin and its derivatives at a township in Myanmar

Intervention study to remove the misuse of Artemisinin and its derivatives was conducted in Myeik township. Workshops to use Artemisinin compound together with Mefloquine was conducted for doctors, basic health workers and drug dealers separately. Mefloquine tablets that are to be used together with Artemisinin compounds were made available with low price at hospital cost sharing shop, meditrade government clinic and rural health centres. Assessment was done on doctors, basic health workers and drug dealers on how they improve their knowledge on the use of Artemisinin compounds before and 6 months after intervention. Assessment was also done on 100 consecutive patients who had been treated in hospital and another 100 who had been treated outside the hospital before and after intervention. After intervention all doctors and basic health workers, had improved the knowledge of Artemisinin and 90 percent and 36.5 percent of them can give proper dosage of these drugs. All the doctors change their attitude and use combined therapy on all of their patients. Among the general practitioners all 100 percent did use combined therapy, but the patients did not come regularly for 3 day treatment as the cost of first visit is high and patients get better after 24 hours. These are the main reasons for the failure. Ninety-four percent of the drug dealers cannot keep simple records for the sale of these compounds. Only 3.6 percent of the Artemisinin compound bought from the drug dealers continue to buy Mefloquine. This include 46 percent of the patients who bought from the drug store and received referral tickets with necessary instruction to use combined drug therapy. This findings is also supported from the study on ex-patients. We conclude that special strip tablets are required so that all Artemisinin compounds are sold with Mefloquine all in one packet. It is also necessary to enforce the existing Food and Drug Act so that we can give more rigid training to drug dealers.

The effect of antimalarials on reticulocyte count of patients with falciparum malaria

One hundred and eleven adult patients who attended North Okkalapa General Hospital for uncomplicated falciparum malaria were chosen for the study. They were treated with dihydroartemisinine (Cetexin), quinine, artesunate tablets and artemether injection. Fifty nine adult male and female without malaria were chosen as controls. They were treated with sulfadoxine-pyrimethamine, quinine and artesunate. Thick and thin blood films were taken from the patients daily and were stained and counted for malaria parasites. Packed cell volume (PCV), WBC count and reticulocyte count were also done. Among the patients treated with drugs, there was a significant fall in the mean reticulocyte count (number concentration and number fraction) at day 3. But the reticulocytes were raised back to normal at days 7 and 14. There was no significant changes in the mean packed cell volume (PCV) and mean level of total WBC count of the patients in all 4 groups. Among normal controls treated with artesunate tablets, there was also a significant fall in the mean reticulocyte count at day 3 but the mean reticulocytes count was also raised back to normal at days 7 and 14. Among normal controls treated with quinine and sulfadoxine-pyrimethamine tablets, there was no significant fall in the mean reticulocyte count. And there was no significant changes in PCV and WBC count in all 3 groups of controls. The fall in reticulocyte counts can be due to part of the disease malaria as well as to the drug including quinine and not singly to artemisinine therapy alone.

Comparison of the effect of combinations of parentral artemisinin derivatives (I/M artemether, I/V artesunate) plus oral mefloquine with intravenous quinine plus oral tetracycline on patients with cerebral malaria: A multicentre trial (Preliminary Report)

In order to find out the best drug combination for treatment of cerebral malaria at less equipped hospitals, 105 cases of cerebral malaria belonging to Mawlamyine, Pyin Oo Lwin and North Okkalapa hospitals were studied in a controlled trial of three regimens. (1) Intramuscular artemether total dose 480 mg plus mefloquine 750 mg in a single dose given through nasogastric tube at day 0. (2) Intravenous artesunate total dose 240 mg plus mefloquine 750 mg as in regimen 1. (3) Intravenous quinine dighdrochloride 600 mg in 180 ml infusion of dextrose saline given over 4 hours. The dose is repeated every 8 hours until the patient can swallow the tablets. Then oral quinine sulphate tablets were given 600 mg 8 hourly. Total period of quinine therapy is 7 days. Tetracycline 250 mg capsules were given 6 hourly for 7 days (started via nasogastric tube while the patient is unconscious). There was no significant difference in overall mortality rate, mean parasite clearance time, mean fever clearance time and mean time to regain consiousness between the three groups. Thus quinine-tetracycline (if necessary to supplement with artemether-mefloquine at 48 hours if the patient failed to respond to initial treatment) is suggested, as the drug of first choice for the management of cerebral malaria in Myanmar.

The effect of combination of chloroquine with sulfadoxine pyrimethamine on patients with uncomplicated falciparum malaria

The effect of chloroquine, sulfadoxine- pyrimethamine and chloroquine plus sulfadoxine-pyrimethamine were studied on 97 patients with uncomplicated falciparum malaria. 53. 1 per cent of the patients were resistant to chloroquine at R2 and R3 level. Among patients treated with sulfadoxine- pyrimethamine, 25 per cent were resistant to the same level. But, when chloroquine is combined with sulfadoxine-pyrimethamine only 12.1 per cent of the patients were resistant at R2 level. There were no patients who were resistant at R3 level to the combined drugs. All the patients were free from toxicity that can be related to the two drugs. Apart from simple additive effect, there may also have the potentiating effect of combining two drugs. Hence for a developing country like Myanmar with the problem of multidrug resistance, this method of treatment may be considered for semi-immune patients with uncomplicated falciparum malaria.

Pharmacokinetics of mefloquine in uncomplicated plasmodium falciparum malaria patients in Myanmar

With the aim to study the pharmacokinetic basis underlying the therapeutic outcome of mefloquine in malaria patients, a single oral dose of 1000 mg mefloquine hydrochloride (Mepha) was administered to 24 patients with acute uncomplicated falciparum malaria and 10 healthy volunteers and was followed-up till day 42. The drug serum levels at various time intervals were analysed by a Waters HPLC and the pharmacokinetic profile studied. The study shows that although Myanmar malaria patients had a slower rate of absorption (T1/2ab = 6.38 + 0.60 hour; Tmax =1.31 + 0.12 days), the peak serum level reached was much higher (Cmax = 2.24 + 0.05 ug/ml) than those of the westerners.

Prevalence of hypoglycaemia in untreated patients with falciparum malaria

Two hundred and four consecutive patients with P. falciparum malaria who attended Tharrawaddy Civil Hospital during 1990 and 1991 malaria seasons were studied. The factors such as age group, sex, parasite density, body temperature, presence of pregnancy and clinical categories of the patients were related to the plasma glucose level of the patients, 180 plasm samples from the patient's attendants and 54 plasma samples from patients with P. vivax malaria who attended to the same hospital were also included in the study as controls. High percentage of patients with hypoglycaemia (< 40 mg/dl) was present in patients with cerebral malaria, patients with high parasite density and women with pregnancy. But there was no significant difference between these groups of patients and controls. Hypoglycaemia in falciparum malaria may be multi-factorial and not due to single cause.

The Effect of oral artesunate versus quinine on patients who are resistant to chloroquine and sulfadoxine pyrimethamine

The patients who attended the out patients cllinic of Thayarwaddy Civil Hospital and North Okkalapa General Hospital were treated with chloroquine (600 mg base at days 0 and 1 and 300 mg base at day 2). To those who failed to clear the parasites at 72 hours were treated with 3 tablets of sulfadoxine pyrimethamine (each containing 500 mg sulfadoxine and 25 mg pyrimethamine). To those who failed again to clear the parasites at 72 hours were treated with one of the following drugs at alternate sequence. (1) 50 mg Artesunate tablets were given twice a day for 5 days orally. The initial dose was double. (2) Quinine sulphate tablets 600 mg 3 times per day given orally for 7 days. Total 60 patients were studied.In both groups of patients parasites were cleared at 72 hours and at day 4. The parasite clearance time and fever clearance time of the patients treated with the two different drugs were not statistically different. All patients treated with artesunate can tolerate the drug and were free from side effects that can be related to the drug. Out of 18 patients who were followed till day 28,6 patients recrudesced at days between 21 and 28. Among the patients treated with quinine 50 percent failed to complete the drug course. Out of 10 patients who were followed till day 28, one patient recrudesced at day 21. We conclude that Artesunate or quinine alone are effective but may not be useful for treatment of drug resistant malaria.

Plasma level of quinidine in Myanmar patients with falciparum malaria

Plasma level of quinidine on 14 adult male falciparum malaria patients were studied. The patients consisted of 7 with low level of parasites in blood and 7 with high level of parasites ( > 5 percent RBC parasitised). All the patients received infusion of quinidine 15 mg/kg body weight diluted in 500 cc normal saline as initial loading dose, followed by infusion 7.5 mg/kg body weight 8 hourly for another two doses and than followed by oral quinidine 7.5 mg/kg 3 times a day for 7 days. Plasma for quinidine estimation was collected at the following hours: 0,1,2,4,6,9,12,36,48 hours and on days. 3,4 and 7 of the study period. In patients with low level of parasites, the maximum plasma quinidine level reached the peak 6.8 ug/ml onthe 4th day of treatment. After the first dose of treatment, it reached 4.3 ug/ml at 2nd hour. Among patients with high level of parasites, the maximum plasma quinidine concentration was 6.6 ug/ml and this concentration was obtained at 9th hour after the first dose. The mean plasma concentration of the 2 groups was not statistically different.

The effect of intramuscular loading dose of quinine on Myanmar patients (children and adults) with falciparum malaria

The effect of three doses of intramuscular quinine followed by oral quinine on ten adults and ten children with falciparum malaria (half of each group were highly parasitised) were studied. There were no complications associated with this method of therapy. the level of serum quinine in all the adults reached above the minimal inhibitory concentration (MIC) from the 2nd hour of the drug administration. So this method of administration should be recommended for severely ill patients before referral to hospitals. Anong the children, eight responded well to the therapy and the serum quinine level rose above MIC level from the second hour as in adults. There were two patients who failed to respone to the treatment. One had persistantly high level of quinine and was misdiagnosed as a case of cerebral malaria instead of quinine toxicity. He responded well when quinine was omitted and replaced with mefloquine. Another child had persistantly low level of quinine. He developed cerebral sings and symptoms and also responded well to mefloquine. Thus it is suggested that the level of serum quinine should be monitroed in children if possible, or toxicity ot quinine should be watched.

Concentration method of detecting Plasmodium falciparum using microcentrifuge and heparinised capillary tubes

Sixty malaria patients were studied. Thick blood films were prepared from the finger tips of the patients as usual to detect malaria parasites in blood. A sample of blood is also collected from the same finger tip with heparinised capillary tubes at the same time. The tubes were centrifuged at 10,000 rpm for 5 minutes. The capillary tube was then broken into 3 pieces. One at upper part of the red cell column just below the white cells and another at the base of the red cell column. Blood collected from these two samples were stained together with samples from finger tips using usual standard procedure for the detection of malaria parasites. Blood collected from the uppermost part of red cell column yield the highest parasite density. The use of capillary tube is not an extraburden to the work load of the malaria unit and special instruments are also not necessary. This method may help in the detection of patients with low level of parasites in peripheral blood.

Widal agglutination test reaction in patients with fallciparum malaria

Serum samples from 115 patients with falciparum malaria who attended Tharyarwady Civil Hospital during summer and rainy seasons of 1991 were studied. Of these, 71 patients were followed at Day (7) of admission to the hospital. the sera were tested by tube agglutination for antibodies against H and O suspension of enteric fever organisms (Salmonella typhi, Salmonella paratyphi A and Salmonella paratyphi B). 3 samples of sera collected from patients with parasite density (1+) and suffering from uncomplicated malaria showed agglutination titre + 1/40 to 0 and H antigens of Salmonella typhi. One serum sample collected from a patient with parasite density (2+) and suffering from uncomplicated malaria showed agglutination titre + 1/40 to 0