Role of the SEAMEO TROPMED Network in health human resources development. Southeast Asian Ministers of Education Organization. Tropical Medicine and Public Health.

The Southeast Asian Ministers of Education Organization (SEAMEO) is a chartered international organization for the promotion of regional cooperation in education, science, technology and culture. The Regional Tropical Medicine and Public Health Network (TROPMED) operates through four specialized Centers in Indonesia, Malaysia, the Philippines and Thailand, with a coordinating unit, the TROPMED Central Office in Bangkok, Thailand. In line with the overall mission of SEAMEO, the role of TROPMED is to promote health and to prevent or control disease, thus improving the quality of life of people in the Asia-Pacific Region. Toward this end, SEAMEO TROPMED serves to facilitate the strengthening of national and institutional capabilities in research and training through postgraduate academic programs; short-term training courses; scientific fora; publications and information dissemination and as such, has been in the mainstream of health human resources development since its inception in 1967. To date, a total of 3,353 TROPMED alumni have benefited from training in 26 regular course offerings; of these, 1,596 were females and 1,757, males. From 1991 to 1995, a total of 434 key health personnel have attended short-term training courses, with increasing attendance from Cambodia, Lao PDR and Vietnam. TROPMED's effectiveness comes from the collective strength of and the spirit of cooperation among its host institutions and partners. Faced with a health scenario of both developing and developed economies, SEAMEO TROPMED aims to further its role as an international forum for health development thus, addressing the need for effective strategies for health sector reform and advocacy of relevant health, environmental and development policies through its various programs and activities.

The epidemiologic study of geriatric patients at siriraj geriatric clinic.

A retrospective study was designed to explore the epidemiology of geriatric patients at Siriraj Geriatric Clinic organised by the department of Preventive and Social Medicine, both in terms of social and medical aspects. A total of 854 patients were recruited with a male to female ratio of 1 : 1.6 and an average age of 67.1 + 6.1 years in 1985 and two years more in 1995 ranging from 60-90 years. The majority of the patients were married (62.1%), achieved secondary school (47.5%) and depended on pensions (46.4%). The average number of family member actually living in the same house was 4.0 + 2.7. The number of those who smoked cigarettes, drank alcohol and consumed tonic food were 29.1 percent, 41.7 percent and 48.7 percent respectively, while multivitamins were taken most in the tonic food category (31.7%). Regarding the prevalence of clinical complaints, arthralgia was the most common problem (58.3%) followed by amnesia (51.5%). Those who lived in a single family tended to be economically poorer than those who lived as an extended family, and they tended to work outdoors during the pre-retirement period. Being unable to take the bus was the most common disability among instrumental activity of daily living (IADL) while the elderly aged 71 years or more were found more among those who failed to perform each aspect of instrumental activity of daily living, especially in self-drug administration with the highest odds ratio of 19.5 (95% confidence interval 2.4-884.9). As far as systemic complaints were concerned, the elderly aged 71 years or more were found to suffer more significantly from hearing loss and urinary system symptoms with an odds ratio of 2.4 (95% confidence interval 1.5-3.7) and 2.1 (95% confidence interval 1.0-4.4) sequentially. When considering the impact of clinical complaints to the IADL, those of visual abnormality, hearing loss, urinary symptoms, amnesia and insomnia were found more frequently in those patients with impaired IADL that was statistically significant. The elderly with three chronic diseases or more or who were regularly taking three types of drugs or more would be disabled in terms of IADL, with odds ratios of 1.8 (95% confidence interval 1.1-2.9) and (95% confidence interval 1.8-6.4) respectively.

A symposium on containment of mefloquine-resistant falciparum malaria in Southeast Asia with special reference to border malaria.

Important questions related to the factors responsible for and contributing to the origin and spread of multi-drug resistant falciparum malaria at the Thai-Cambodian and Thai-Myanmar border areas are discussed, including the current geographical distribution of multi-drug resistance and the prevention and control of this phenomenon. Specific recommendations are made on epidemiological surveillance, drug deployment, vector control, and the problem of migration which plays a major role in the dissemination of resistant parasite populations. The recent advent of mefloquine resistance of P. falciparum in Thailand may serve as fair warning in the absence of stern measures for preventing the occurrence of resistance to the next and currently last line of antimalaria drugs, especially those with a long half-life, in areas with intensive, uncontrolled malaria transmission, such as tropical Africa.

Drug resistant malaria, with special reference to Thailand.

Drug resistance of malaria parasites is a major problem confronting efforts to treat and control malaria. Starting with chloroquine, the emergence of resistance to other drugs has led to multi-drug resistance patterns that pose increasing threats for the future. This report reviews work carried out over the past decades at the Hospital for Tropical Diseases, Bangkok, which monitors patients from many areas, including the Thai-Cambodian border, which harbors the world's most severe multi-drug resistant Plasmodium falciparum.

Rice-powder salt solution in the treatment of acute diarrhea in young children.

Dehydration is the most common cause of death in diarrheal patients. Early oral rehydration therapy (ORT) can prevent or reverse dehydration from diarrhea in almost almost all cases. Shortages of oral rehydration salt (ORS) packets in certain areas remain a major problem of the Diarrheal Diseases Control Program of Thailand. To find an effective solution that can be prepared locally, a randomized trial of oral rehydration solutions was conducted. A rice-powder salt solution containing rice-power 30 g/l and salt 3.5 g/l (RPSS) was evaluated in a group (n = 23) of infants and young children aged between 4 months and 5 years with mild or moderate dehydration from acute watery diarrhea, and the results were compared with those who received WHO recommended glucose electrolyte solution (WHO-ORS) (n = 21), and glycine supplemented WHO-ORS (G-ORS) (n = 20). The efficacies of WHO ORS and G-ORS were found to be similar. The RPSS was found to be more effective than WHO-ORS and G-ORS as shown by a significantly lower stool frequency, lower rate of stool output, a significantly shorter duration of diarrhea, and a smaller intake of rehydration fluid. Promotion of the effective rice-salt solution could increase early implementation of ORT in many rural communities.

Pharmacokinetics of primaquine in healthy volunteers.

The pharmacokinetics of primaquine were investigated in 8 healthy subjects (4 males and 4 females). The volunteers received 15 mg base of primaquine daily for 14 days. The results showed that the concentration-time profiles in whole blood and in plasma were similar. The mean values (+/- SD) of area under the curve (AUC) of the last dose were significantly decreased when compared to the values of the first dose both in whole blood and in plasma (909.96 +/- 603.07, 1,147.05 +/- 684.8 ng.hr/ml respectively in whole blood with p = 0.007 and 1,255.11 +/- 531.59, 1,603.66 +/- 505.45 ng.hr/ml respectively in plasma with p = 0.023). The decrease in the concentration-time profile of the last dose was due to enhancement of drug elimination with significant increase in clearance after the last dose (4.871 +/- 1.741 and 6.443 +/- 2.514 ml/min/kg respectively in whole blood with p = 0.007, 3.199 +/- 1.197 and 4.422 +/- 2.068 ml/min/kg respectively in plasma with p = 0.016).

In vitro sensitivity of Plasmodium falciparum to sulfadoxine and pyrimethamine.

An in vitro microtechnique of Rieckmann et al., (1978) modified by Yisunsri and Rieckmann (1980) using 3 media; Waymouth, Waymouth plus 10% human serum, and RPMI was assessed to determine the sensitivity of P. falciparum to sulfadoxine, pyrimethamine and its combination. The study confirmed the synergism between sulfadoxine and pyrimethamine. There was no interaction between media and drug tested. MIC1 and MIC2 of sulfadoxine in different media showed significant difference (p less than 0.001). No significant difference was observed in MIC1 and MIC2 of pyrimethamine in the three media used (p greater than 0.05). For sulfadoxine-pyrimethamine combination, MIC1 and MIC2 in Waymouth alone and plus 10% human serum showed no significance (p greater than 0.05) while in RPMI showed positive correlation (p less than 0.001). MIC1 might be more applicable for clinical evaluation than MIC2. At present Waymouth medium with 5% patient serum, is considered to be the most suitable for testing sensitivity of malarial parasites.

Effects of antimalarial drugs on human natural killer cell activity.

Separation of null cell fraction from the other cellular components of human peripheral blood obtained from normal healthy individuals was effected through the Ficoll-Hypaque density gradient centrifugation, carbonyl iron phagocytosis-magnet application, E-rosette forming and binding to 19S-EAC respectively. The null cells were used as effector cells in the cytotoxic assay. The spontaneous cell-mediated cytotoxicity assay was employed and the highly NK-sensitive K562 labelled with Na251 CrO4 were used as targets. The null cell fraction was divided into several portions to allow for normal control, diluent control and tests. The test portions were those exposed to the various antimalarial drugs employed. It was observed that the T cell, B cells and null cell fractions accounted for 72%, 18% and 10% of the total lymphocyte population respectively. The mean cytotoxicity generated by the natural killer subset was 63%. The antimalarial drugs/drug combination used were chloroquine, quinine, pyrimethamine and sulfadoxine/pyrimethamine combination. Concentrations used were their respective minimal inhibitory concentration (MIC) and corresponding 5 X MIC. The inhibitory effects on natural killer cell activity of these drugs were observed. The possible reasons for these observations are discussed.

Treatment of quinine resistant falciparum malaria in Thai children.

A study was carried out to assess the efficacy of a modified 7 day course of quinine in children with falciparum malaria, in comparison with those of a 7 day course of quinine at standard dosage and a combination of a 7 day course of quinine and sulfadoxine-pyrimethamine, and in relation to the MIC, and to the serum levels of quinine during the course of treatment. Seventy seven children aged 2 years to 12 years with falciparum malaria were randomly treated with one of the 3 regimens. Group I, quinine 10 mg base per kg body wt. 8 hourly for 7 days, 21 of 28 cases (75%) were cured, while 6 cases (21%) showed RI and 1 case (4%) RII failure. Group II, quinine 10 mg base per kg body wt. 8 hourly for the first 4 days then 15 mg base per kg body wt. 8 hourly for the next 3 days, 20 of 23 cases (87%) were cured, while 3 cases (13%) showed RI failure. Group III, quinine 10 mg base per kg body wt. 8 hourly for 7 days and then sulfadoxine 30 mg per kg body wt. and pyrimethamine 1.5 mg per kg body wt., 16 of 26 cases (62%) were cured and 10 cases (38%) showed RI failure. The cure rates in the 3 groups were not statistically different. The three groups had similar serum quinine concentration profiles. Treatment with quinine was successful in cases in which serum quinine levels could be maintained above MIC for 7 days. There was no additional effect of sulfadoxine-pyrimethamine on quinine.

Treatment of falciparum malaria with intra muscular quinine in a rural area of Thailand.

The study was carried out in 32 adult cases of falciparum malaria who had nausea and vomiting. All patients were admitted in Chomboeng Crown Prince Hospital, Ratchaburi Province, during April-December 1981. Patients were treated with 600 mg of quinine dihydrochloride intramuscularly every 8 hours until nausea and vomiting subsided and the drug could be given orally. Quinine was given 8 hourly for 7 days. Parasites were cleared from the blood by D3 in 26 cases, and by D5 in 4 cases. Fever was cleared in a mean of 2.8 days after the treatment. In the other 2 cases, intravenous quinine was given instead of intramuscular quinine on D2 and D3 respectively and parasitaemia was cleared within D7 in both cases. In 13 cases, serum quinine concentrations were measured prior to the first injection of quinine, then 4 hours, and 8 hours later. In other 6 cases, the measurements were carried out prior to the first injection and 4 hours later only. In 5 patients, quinine was present in the baseline blood sample. In the other 14 patients, mean serum quinine concentration at 4 hours was 19.43 n mol/ml. The mean serum quinine concentration at 8 hours in 8 patients was 22.0 n mol/ml. Therapeutic serum concentrations can be attained by intramuscular injection of quinine.

Serum quinine concentrations following the initial dose in children with falciparum malaria.

Serum quinine concentrations were determined in 51 children with uncomplicated falciparum malaria and 22 controls. Quinine 10 mg salt/kg was given one-hour, two-hour, four-hour intravenously in group A (14 patients, 5 controls), group B (12 patients, 6 controls), Group C (10 patients, 6 controls) and given orally in group D (15 patients, 5 controls). In malaria patients, the highest serum quinine levels were observed at the end of intravenous infusion and by the 4th hour after oral medication. Mean of the peaks of the drug concentrations of the 4 schedules were not significantly different, ranging from 22 to 28 n mol/ml. Serum concentrations in the patients were significantly higher than those of the controls. The total clearance of quinine in the patients were approx. 1 ml/min/kg, which was significantly less than those of the controls. The total apparent volume of distribution of the drug was similarly reduced. In patients it was about 0.8 litre/kg. The elimination half times of quinine ranged from 9 to 11 hours, whereas the value in the controls ranged from 3 to 7 hours. Side effects of quinine were not observed.

Sulfadoxine-pyrimethamine resistant falciparum malaria in Thai children.

Sixty-eight children with uncomplicated falciparum malaria admitted to the Hospital for Tropical Diseases in Bangkok during April-December 1980 were randomly divided into 3 groups and given 3 regimens. Group 1 of 27 cases were treated with a single dose of sulfadoxine 20 mg per kg body wt and pyrimethamine 1.0 mg per kg body wt. Two cases (7.4%) were cured (S) while 4 cases (14.8%) showed RI failure, 17 cases (63.0%) RII failure and 4 cases (14.8) RIII failure. In Group 2, 18 cases were treated with a single dose of sulfadoxine 30 mg per kg body wt and pyrimethamine 1.5 mg per kg body wt. Two cases (11.1%) were cured (S), while 7 cases (38.9%) showed RI failure, 7 cases (38.9%) RII failure and 2 cases (11.1%) RIII failure. In Group 3, 23 cases were treated with quinine 10 mg base per kg body wt 8 hourly for 5 days plus sulfadoxine 20 mg per kg body wt and pyrimethamine 1.0 mg per kg body wt, single dose given with the last dose of quinine. Thirteen cases (56.5%) were cured (S), while 10 cases (43.5%) showed RI failure.

Pathophysiology of malaria.

The pathophysiology of malaria infection is presented from animal studies and the various manifestations occurring in human cases. Maegraith (1974) proposed the concept of a chain reaction of physiological processes that leads to the disease following malarial infection. It may be seen that the malaria parasites first damage the infected red blood cells directly and then initiate a chain reaction of nonspecific inflammatory processes and later on immunological responses aggravating further the inflammatory reactions. Because of ther interdependence in nature of these changes as suggested by Maegraith in 1977 it is usually difficult to clearly identify these three mechanisms.

Treatment of falciparum malaria with sulfalene-pyrimethamine versus sulfadoxine-pyrimethamine.

The study was carried out in 89 uncomplicated falciparum malaria adult cases admitted to Paholpol-Phayuhasena Hospital, Kanchanaburi Province, Thailand, during July 1979 and March 1980. The patients were divided alternatively into 2 groups. Group I, 46 patients, were treated with a single dose of 1000 mg sulfalene and 50 mg pyrimethamine (2 tablets of Metakelfin). Group II, 43 patients, were treated with 1000 mg sulfadoxine and 50 mg pyrimethamine (2 tablets of Fansidar). The parasitemia was cleared within 7 days in 7 cases (15.2%) of group I and in 11 cases (25.6%) of group II. The results of both groups are not statistically significant. It is concluded that the success rate of Fansidar in the treatment of falciparum malaria is decreasing in Thailand and Metakelfin can be used in the treatment of falciparum malaria either alone in mild cases or in combination with quinine as an alternative to Fansidar.

Treatment of giardiasis in children with quinacrine, metronidazole, tinidazole and ornidazole.

One hundred and twenty four children with symptomatic and parasitologically confirmed giardiasis were treated in a comparative trial. The dosage of antigiardia drug was adjusted to the body surface area of the patients from the adult basic dosage as 100 mg of quinacrine t.i.d. for 5 days, 200 mg of metronidazole t.i.d. for 7 days, 2 gm of metronidazole once, 2 gm of tinidazole once or 2 gm of ornidazole once. They were hospitalized for follow-up for 30 days. The parasitological follow-up consisted of daily examination of stool specimens. Reinfections were unlikely. The rates of success were: a 5-day course of quinacrine, cured all of them, 20 patients; a 7-day course of metronidazole, 12 of 20; metronidazole, single dose, 11 of 21; tinidazole, single dose, 18 of 21; ornidazole, single dose, 21 of 22; placebo, none of 20. After a single dose, 5 patients had transient elevation of transaminases, one patient in each of metronidazole and tinidazole group 3 patients in ornidazole group. A 5-day course of quinacrine gave excellent result but the drug is not widely marketed. Ornidazole or tinidazole were more effective, both of them were recommended as a drug of choice as single dose therapy, however transient increase of transaminases may occur in some cases.

A study on the diagnostic methods for Trichomonas vaginalis infection.

A comparison of the sensitivity of the wet smear, Papanicolaou's stained smear, and culture in Cystein-Peptone-Liver-Maltose (CPLM) medium for the diagnosis of T. vaginalis infection was undertaken in 1, 197 female subjects, both with and without gynaecological disorders. The wet smear method gave 15.5% positives, culture method, 16.5% positives and Papanicolaou's stained smear 6.7% positives. All positive cases by Papanicolaou's method or wet smear method were positive by the culture method. These findings indicate that the wet smear and culture in CPLM medium were better than the Papanicolaou's method.