Enfoque terapéutico profiláctico para reducir la morbilidad por paludismo en la mujer embarazada / Prophylactic therapeutic approach to reduce malaria morbidity among pregnant women

Introducción: La infección por malaria durante el embarazo es un importante problema de salud en la mayoría de las regiones tropicales. Esta condición puede tener incidencia negativa tanto en la gestante como en el feto. Objetivo: Indagar en el impacto del tratamento preventivo intermitente con el medicamento antimalárico sulfadoxina-pirimetamina en la mujer embarazada. Métodos: Se realizó una revisión bibliográfica en la base de datos Medline/Pub Med y en artículos relevantes relacionados al tema de los últimos cinco años. Además, se tomó como referencia las guías para el tratamiento de malaria de la Organización Mundial de la Salud, verisón 2016-2017. Análisis y síntesis de los resultados: Durante el período 2015-2017 no se lograron avances significativos en la reducción del número de enfermos palúdicos. No obstante, se señala la anemia como causa de mortalidad en el curso de la malaria. También, se destacan los nuevos enfoques y compromisos para reducir la morbilidad atribuible al paludismo en la mujer embarazada en sus tres vertientes: tratamiento eficaz de los casos de paludismo, el uso de mosquiteros tratados con insecticidas, y la utilización del tratamiento preventivo intermitente con el antimalárico sulfadoxina-pirimetamina a partir del segundo trimestre del embarazo. La indicación de este tratamiento inlcuye mínimo dos dosis del fármaco antipalúdico, con un intervalo de un mes entre cada dosis, con independencia de que las embarazadas muestren o no síntomas de la enfermedad. Conclusiones: Esta intervención para prevenir el paludismo en el embarazo es una cuestión prioritaria en la iniciativa de salud materna, infantil y reproductiva; además, ayuda a mejorar y aumentar la cobertura de las medidas de control de esta enfermedad durante la gestación(AU)

Introduction: Malaria infection during pregnancy is an important health problem in most tropical regions. This condition may have a negative incidence on pregnant women and fetuses. Objective: Inquire into the effect of the intermittent preventive treatment with the malarial sulfadoxine / pyrimethamine in pregnant women. Methods: A bibliographic review was conducted in the database Medline / PubMed and in relevant papers about the topic published in the last five years. The Guidelines for the Treatment of Malaria 2016-2017 of the World Health Organization were also used as reference. Analysis and synthesis of results: Significant progress was not achieved in reducing the number of malaria patients in the period 2015-2017. However, anemia is reported as the cause of mortality during the course of malaria. New approaches and commitments are proposed to reduce malaria-related morbidity among pregnant women, namely effective treatment of malaria cases, use of insecticide-treated mosquito nets, and intermittent preventive treatment with the antimalarial sulfadoxine / pyrimethamine as of the second quarter of pregnancy. Indication of this treatment includes at least two doses of the malarial, with a separation of one month between the doses, regardless of whether the pregnant women have symptoms of the disease. Conclusions: The intervention to prevent malaria during pregnancy is a first-priority aspect of the mother, child, reproductive health initiative. It also helps improve and broaden the coverage of measures for the control of this disease during pregnancy(AU)

Plasmodium falciparum infection in pregnant women attending antenatal care in Luanda, Angola / Infecção por Plasmodium falciparum em mulheres grávidas em consultas pré-natal em Luanda, Angola

INTRODUCTION: Malaria during pregnancy remains a serious public health problem. The aim of this study was to establish the prevalence and possible risk factors for malaria in pregnant women attending antenatal care at Augusto Ngangula Specialized General Hospital in Luanda, Angola. METHODS: Pregnant women (679 total) who attended antenatal care from April to September 2008 were included in the study after signing informed consent. For each participant, the social-demographic profile and malaria and obstetric histories were investigated via a questionnaire. Diagnosis was made by optic microscopy, and hemoglobin concentration measured. The associations between age, parity, gestational age, residence, schooling, malaria during gravity, anemia and treatment with incidence of Plasmodium falciparum infection were analyzed through logistic regression. RESULTS: During the period of study, 74 (10.9%) out of 679 women were infected by P. falciparum. The average concentration of hemoglobin was 11.1 ± 0.07g/dL, and there were significant associations between the history of malaria during pregnancy, P. falciparum infection (p<0.01) and anemia at the time of observation (p<0.001). CONCLUSIONS: Previous history of malaria during pregnancy represents a risk factor for current infection and anemia was an important complication associated with malaria, even in women who were treated with sulfadoxine-pyrimethamine during pregnancy.

INTRODUÇÃO: A malária na gravidez continua a ser um grave problema de saúde pública. O objetivo deste estudo foi determinar a prevalência e possíveis fatores de risco para a malária, em mulheres grávidas que foram atendidas em consultas pré-natal, no Hospital Geral Especializado Augusto Ngangula, em Luanda, Angola. MÉTODOS: De abril a setembro de 2008, 679 mulheres grávidas foram envolvidas no estudo após consentimento informado. O perfil sócio demográfico e história de malária e obstetrícia foram investigados através de um questionário. O diagnóstico foi efetuado por microscopia óptica e determinou-se ainda as concentrações da hemoglobina. Através da regressão logística foi analisada a associação entre a idade, paridade, tempo de gestação, residência, escolaridade, malária durante a gravidez, anemia e tratamento com a infecção por Plasmodium falciparum. RESULTADOS: Setenta e quatro (10,9%) das 679 mulheres estavam infectadas com P. falciparum. O valor médio da concentração da hemoglobina foi de 11,1 ± 0,07g/dL, encontrando-se uma associação significativa entre história de malária na gravidez e infecção por P. falciparum (p<0,01) e anemia no momento da observação (p<0.001). CONCLUSÕES: A história de malária anterior na gravidez foi um fator de risco para uma infecção atual e a anemia uma complicação importante associada à malária, mesmo em mulheres que receberam tratamento durante a gravidez com sulfadoxina-pirimetamina.

Disseminated toxoplasmosis in an immunocompetent patient from Peruvian Amazon / Toxoplasmosis diseminada en un paciente inmunocompetente procedente de la Amazonía peruana

We report a case of severe toxoplasmosis in an immunocompetent patient, characterized by pneumonia, retinochoroiditis, hepatitis and myositis. Diagnosis was confirmed by serology, T. gondii in thick blood smear and presence of bradyzoites in muscle biopsy. Treatment with pyrimethamine plus sulfadoxine was successful but visual acuity and hip extension were partially recovered. This is the first case report of severe toxoplasmosis in an immunocompetent patient from Peru.

Reportamos un caso de toxoplasmosis severa en un paciente inmunocompetente caracterizado por neumonía, retinocoroiditis, hepatitis y miositis. El diagnóstico fue confirmado por serología, el hallazgo de T. gondii en gota gruesa y la presencia de bradizoitos en biopsia muscular. El tratamiento con pirimetamina mas sulfadoxina fue exitoso pero solo hubo una parcial recuperación de la agudeza visual y de la capacidad de extensión de la cadera. Este es el primer reporte de un caso de toxoplasmosis severa en el Perú.

Caracterización clínica y radiológica del compromiso pulmonar por toxoplasmosis aguda diseminada en nueve pacientes inmunocompetentes / Clinical and radiological characterization of the pulmonary commitment for acute toxoplasmosis disseminated in nine immunocompetents patients

La toxoplasmosis aguda en el individuo inmunocompetente generalmente tiene un comportamiento benigno y autolimitado. Sin embargo, en pacientes provenientes de área selvática se han presentado casos severos de compromiso visceral, el más frecuente de ellos, el pulmonar. Se realizó la descripción clínica y radiológica de nueve individuos miembros de las fuerzas militares de Colombia, con toxoplasmosis aguda y compromiso pulmonar. El 55% de los casos presentó disnea clase funcional II/IV; 33% clase funcional III/IV y tan sólo 1/9 pacientes presentó clase funcional IV/IV. La imagen radiológica más común fue la consolidación pulmonar unifocal o multifocal (66%), y en menor frecuencia la presencia de infiltrados reticulares, reticulonodulares y derrame pleural. La totalidad de los pacientes evolucionaron en forma satisfactoria, dos de ellos con necesidad de soporte con ventilación mecánica no invasiva.

Diagnosis of congenital toxoplasmosis: prenatal and neonatal evaluation of methods used in Toulouse University Hospital and incidence of congenital toxoplasmosis

The aim of this study was to determine the incidence of congenital toxoplasmosis (CT) and to assess the performances of prenatal and neonatal diagnoses. From 1994-2005, in Toulouse University Hospital, France, amniocentesis was performed on 352 pregnant women who were infected during pregnancy. All women were treated with spiramycin and pyrimethamine-sulfadoxine when prenatal diagnosis was positive. Among the 275 foetuses with follow-up, 66 (24 percent) were infected. The transmission rates of Toxoplasma gondii were 7 percent, 24 percent and 59 percent in the first, second and third trimesters, respectively. The sensitivity and specificity of PCR on amniotic fluid (AF) were 91 percent and 99.5 percent, respectively. One case was diagnosed by mouse inoculation with AF and six cases were diagnosed by neonatal or postnatal screening. The sensitivity and specificity of PCR on placentas were 52 percent and 99 percent, respectively. The sensitivity of tests for the detection of specific IgA and IgM in cord blood was 53 percent and 64 percent, respectively, and specificity values were 91 percent and 92 percent. In conclusion, PCR performed on AF had the highest levels of sensitivity and specificity for the diagnosis of CT. This permits an early diagnosis of most cases and should be recommended.

Resistência à sulfadoxina-pirimetamina em Maputo, Moçambique: presença de mutações nos genes dhfr e dhps do Plasmodium falciparum / Sulfadoxine-pyrimethamine resistance in Maputo, Mozambique: presence of mutations in the dhfr and dhps genes of Plasmodium falciparum

Foram analisadas a freqüência e distribuição de mutações nos genes dihidrofolato redutase e dihidropteroato sintetase do Plasmodium falciparum, usando a metodologia de reação em cadeia da polimerase e polimorfismos de hidrólise por enzimas de restrição, em amostras de sangue infectado proveniente de crianças moçambicanas, residentes em Maputo. A análise foi feita antes e 7 dias após o tratamento com sulfadoxina-pirimetamina (S/P). Os resultados mostraram a ocorrência de mutações pontuais nos genes estudados e a presença de combinações de três alelos em dhfr (51Ile, 59Arg e 108Asn) e do quintúplo mutante (dhfr 51Ile, 59Arg, 108Asn e dhps 437Gly, 540Glu), ambas situações associadas à falha terapêutica no sétimo dia após tratamento com S/P. Esses achados mostram a importância de se estudar a resistência à S/P em Moçambique, e como os marcadores moleculares de resistência aos antimaláricos podem fornecer dados importantes para a política nacional de controlo da malária.

The frequency and distribution of mutations in Plasmodium falciparum, dihydrofolate reductase and dihydropteroate synthase genes were analyzed, using the polymerase chain reaction and restriction fragment length polymorphism methodology, in infected blood samples from Mozambican children living in Maputo, before and seven days after treatment with sulfadoxine/pyrimethamine (S/P). The results showed the occurrence of point mutations in the genes studied and the presence of combinations of three alleles in dhfr (51Ile, 59Arg and 108Asn) and "quintuple" mutant (dhfr 51Ile, 59Arg, 108Asn and dhps 437Gly, 540Glu). Both of these situations were associated with seven-day therapeutic failure, following treatment with S/P. These findings show the importance of studying S/P resistance in Mozambique, and how molecular markers for antimalarial resistance can provide important data for national malaria control policy.

Effects of antifolates - co-trimoxazole and pyrimethamine-sulfadoxine - on gametocytes in children with acute, symptomatic, uncomplicated, Plasmodium falciparum malaria

Antimalarial drugs including the antifolate, pyrimethamine-sulfadoxine (PS), can modulate the prevalence and intensities of gametocytaemia following treatment of acute malaria infections. They may also directly influence the transmission and spread of drug insensitivity. Little is known of the effects of co-trimoxazole (Co-T), another antifolate antimalarial, on gametocytes in children with acute malaria infections. We compared the effects of Co-T and PS on the prevalence and intensities of gametocytaemia and gametocyte sex ratios in 102 children aged 0.5-12 years presenting with acute and uncomplicated falciparum malaria. Compared to pre-treatment, both drugs significantly increased gametocyte carriage post-initiation of treatment. However, gametocyte carriage was significantly lower on day 14 in those treated with Co-T than PS. Significant increase in gametocytaemia with time occurred in PS - but not Co-T-treated children. Kaplan-Meier survival curve of the cumulative probability of remaining gametocyte-free in children who were agametocytaemic at enrolment showed that by day 7 of follow up, children treated with PS had a significantly higher propensity to have developed gametocytes than in Co-T-treated children (Log-rank statistic 5.35, df = 1, P = 0.02). Gametocyte sex ratio changes were similar following treatment with both drugs. PS and Co-T treatment of acute malaria infections in children from this endemic area is associated with significant increases in prevalence and intensities of gametocytaemia but these effects are more marked in those treated with PS than Co-T.

Gametocitemia de Plasmodium falciparum según la respuesta terapéutica a sulfadoxina-pirimetamina y cloroquina en dos municipios de Antioquia, Colombia / Gametocyte levels in response to differing malaria treatments in two municipalities of Colombia

Se ha informado que el número de gametocitos circulantes de Plasmodium falciparum está influenciado por aspectos como el nivel de endemicidad de la zona, la clase de esquizonticidas sanguíneos usados y la respuesta terapéutica a ellos. En Colombia son muy pocos los trabajos que han evaluado estas relaciones. Mediante un diseño experimental, se evaluó la gametocitemia (variable efecto) en función del nivel endémico de dos municipios de Antioquia, del tratamiento (sulfadoxina-pirimetamina y sulfadoxina-pirimetamina más cloroquina) y de la respuesta terapéutica (adecuada y fallida). Se estudiaron 148 pacientes con malaria por P. falciparum no complicada. La gametocitemia varía en función del tiempo de padecimiento de la malaria actual (mayor en Turbo que en Zaragoza) y esta variable debe controlarse para eliminar la aparente diferencia en las gametocitemias por municipio. No se hallaron diferencias estadísticamente significativas en la gametocitemia (porcentaje de pacientes con gametocitos circulantes y cantidad de ellos por microlitro) según el tratamiento y la respuesta terapéutica, aunque los niveles de gametocitos son mayores en los pacientes tratados sólo con sulfadoxinapirimetamina, respecto a quienes recibieron sulfadoxina-pirimetamina más cloroquina. Tampoco hubo diferencias en la gametocitemia según el sexo ni la edad de los pacientes, ni se halló correlación de ella con la parasitemia asexual. La diferencia en el nivel de gametocitemia encontrada entre los municiios de Turbo y Zaragoza parece estar influida por el tiempo transcurrido entre el inicio de los síntomas y la instauración del tratamiento.

Plasmodium falciparum gametocyte levels are influenced by level of regional endemicity, the antimalarial treatment, and the therapeutic response of patients. Few previous studies have related these factors in Colombia. Here, gametocytaemia was evaluated with respect to two treatment schemes (sulfadoxine/pyrimethamine and sulfadoxine/pyrimethamine plus chloroquine), the patient response (adequate or failure), and the locality (two areas of varying case frequency). One hundred forty-eight residents of Turbo and Zaragoza (Antioquia), all with uncomplicated malaria, were evaluated. The gametocytaemia and the rates of clinical malaria at the beginning of treatment were greater in Turbo than in Zaragoza. No statiscally significant differences in the gametocytaemia by treatment schemes or therapeutic responses were noted, although the patients who received SP had more gametocytes than those treated with SP+CQ. Gametocytaemia was not correlated with asexual parasitemia or sex and age of patient. The difference in the level of gametocytaemia between Turbo and Zaragoza appears to be influenced by the time elapsed between the appearance of symptoms and the beginning of treatment.

Associations of antifolate resistance in vitro and point mutations in dihydrofolate reductase and dihydropteroate synthetase genes of Plasmodium falciparum.

BACKGROUND: Antifolate antimalarials like sulfadoxine-pyrimethamine are used as second-line treatment for Plasmodium falciparum malaria patients who fail to respond to chloroquine. The efficacy of the sulfa-pyrimethamine combination in the treatment is also compromised by the development of resistance in the parasite. Resistance to these drugs has been shown to encode with point mutations in dihydrofolate reductase and dihydropteroate synthetase genes. SETTINGS: An experimental study. MATERIAL AND METHODS: Forty clinical isolates collected from different geographical locations in India were used to assess the relationships between resistance to sulfadoxine-pyrimethamine (SP) and mutations in P. falciparum dihydrofolate reductase (DHFR) and dihydropteroate synthetase (DHPS). In vitro drug susceptibility and mutation-specific polymerase chain reaction (PCR) assays were also done. RESULTS: It was observed that a number of isolates possessed mutant genotypes and showed low sensitivity to SP in vitro. Of the 40 clinical isolates studied, 87.5% had DHFR and 15% had DHPS gene mutations. As observed from PCR results, 55( (22/40) presented double mutation of DHFR Arg-59 and Asn-108 and 32.5 % (13/40) had single mutant type allele of Asn-108. Of the 40 isolates, 10 % (4/40) presented doubly mutated forms of DHPS Phe-436 and Thr-613 and single mutant type allele Gly-581 was detected in 5 % (2/40) isolates. Parasites carrying double or single mutant forms of DHFR/DHPS showed elevated minimum inhibitory concentration (MIC) values of both pyrimethamine (760-6754 nM; r=0.69) and sulfadoxine (108 - 540 micro M; r=0.87) when compared to sensitive and resistant strains. CONCLUSION: Though there was a correlation between molecular techniques and in vitro drug sensitivity profiles, the relevance of these findings to the clinical efficacy of SP combination drugs needs to be established by controlled clinical trials.

Drug resistant falciparum malaria and the use of artesunate-based combinations: focus on clinical trials sponsored by TDR.

Antimalarial drug resistance has now become a serious global challenge and is the principal reason for the decline in antimalarial drug efficacy. Malaria endemic countries need inexpensive and efficacious drugs. Preserving the life spans of antimalarial drugs is a key part of the strategy for rolling back malaria. Artemisinin-based combinations offer a new and potentially highly effective way to counter drug resistance. Clinical trials conducted in African children have attested to the good tolerability of oral artesunate when combined with standard antimalarial drugs. The cure rates of the different combinations were generally dependent on the degree of resistance to the companion drug. They were high for amodiaquine-artesunate, variable for sulfadoxine/pyrimethamine-artesunate, and poor for chloroquine-artesunate.

Assessment of therapeutic efficacy of chloroquine and sulphadoxine-pyrimethamine in uncomplicated falciparum malaria.

A standardised protocol has been developed by World Health Organization (CDS/RBM/2002) to assess the efficacy of common antimalarials in the treatment of clinically manifested infection with uncomplicated P. falciparum malaria for areas with low to moderate transmission. The therapeutic efficacy protocol is based on clinical and parasitological responses of the patients and it has the purpose of determining the practical efficacy of the drug regimen in study areas with the ultimate objective of ascertaining its continued usefulness or the necessity for replacing it in the routine treatment. Present study has been conducted at seven sites--Kathiatali and Simonabasti of District Nowgaon, Assam; Sonapur and Boko of District Kamrup, Assam; Keonjhar Town, Padampur and Basudebpur of District Keonjhar, Orissa. In order to reduce the patient recruitment time, health centre close to well-defined community was identified to conduct the activities at peak malaria season by selecting local pockets and organising mobile clinics. Microscopically confirmed cases of P. falciparum were enrolled according to the criteria for inclusion and exclusion. Treatment with recommended drug was given under supervision and a follow-up schedule at various intervals for 28 days was maintained. In chloroquine (CQ) study areas, wherever patients showed treatment failure, they were treated with second line drug--sulphadoxine-pyrimethamine (SP) combination and then followed-up as per study protocol. It was observed that 30% cases showed treatment failure to CQ in District Nowgaon, where revised drug policy has already been introduced. In Kamrup district, treatment failure with CQ was found to be less than 25%, which denotes the said regimen is still effective. Almost all the patients from Padampur and Basudebpur of District Keonjhar responded to CQ, treatment failure was noticed only in two patients (3%). The antifolate combination found to be fully effective as second line and also as first line wherever revised drug policy has been introduced.

A safety and efficacy trial of artesunate, sulphadoxine-pyrimethamine and primaquine in P falciparum malaria.

OBJECTIVE: To determine effectiveness and safety of the combination of artesunate, sulphadoxine + pyrimethamine and primaquine in the treatment of P falciparum malaria. DESIGN: A hospital based prospective study. SETTING: Base Hospital, Moneragala. METHODS: In 30 P falciparum infected patients admitted to the hospital, blood was taken for estimation of haemoglobin, white cell counts, and serum levels of aspartate aminotransferase, alanine aminotransferase, bilirubin and creatinine. They were administered artesunate, sulphadoxine + pyrimethamine (S + P) and primaquine on day 0 (artesunate 4 mg/kg, sulphadoxine 25 mg/kg, pyrimethamine 1.25 mg/kg and primaquine 0.75 mg/kg), and only artesunate on days 1 and 2 (artesunate 4 mg/kg each day). Blood was examined for malarial parasites, and patients were assessed on days 1, 2, 7, 14, 21 and 28. Patients assessed the severity of selected symptoms. Biochemical analyses were done on day 0 and repeated on days 7 and 28. RESULTS: Eight patients presented with fever which resolved in 7 patients in 48 hours. Asexual parasites were cleared in 80% of the 30 patients within 24 hours of treatment and in all 30 by day 7. Gametocytaemia cleared in all patients by day 14. There were no adverse effects experienced by the patients. The white cell and differential counts, liver enzymes and creatinine levels were within normal limits on all follow up days. CONCLUSIONS: The combination of artesunate, S + P and primaquine was found to be effective and safe in the treatment of uncomplicated P falciparum malaria.

Treatment of uncomplicated Plasmodium falciparum malaria in Myanmar: a clinical decision analysis.

This study was undertaken to compare cost-effectiveness of three drug regimes for treatment of uncomplicated falciparum malaria in Myanmar. The alternative regimens in this study were chloroquine (CQ), sulphadoxine-pyrimethamine (SP) and mefloquine (MFQ) along with their therapeutic efficacy in Myanmar. The study was performed by modeling a clinical decision tree based on a hypothetical 1,000 adult uncomplicated falciparum malaria cases. Key variables were (i) three drug regimes: CQ, SP and MFQ, (ii) three categories of therapeutic efficacy of each drug: adequate clinical response (ACR), early treatment failure (ETF) and late treatment failure (LTF) according to the 1996 WHO protocol, and (iii) compliance with each drug. In structuring the model, necessary assumptions were made. The cost effectiveness was measured as cost per case cured and cost per case prevented death related to the provided drug, from the provider's perspective. According to the present price and therapeutic efficacy, SP is the most cost effective drug for a case cured in all three categories of efficacy (US$ 0.12 per case cured in ACR, US$ 0.38 per case cured in ETF and US$ 0.54 per case cured in LTF). For a case prevented death, CQ is most cost effective in all three categories (US$ 0.58 per case prevented death in the ACR, US$ 2.14 per case prevented death in the ETF and US$ 2.51 per case prevented death in the LTF). The lowest cost effective regimen is MFQ for both indicators of effectiveness at the present price and therapeutic efficacy. A sensitivity analysis was performed for sensitive values.

The use of personal protective measures in control of malaria in a defined community.

Malaria is one of the main health problems in the non-immune immigrant workers and army personnel of the malaria endemic areas in Myanmar. Due to changes in the vector bionomics and multiresistant strains of P. falciparum, chemoprophylaxis alone is not an effective means of control of malaria in them. So it is envisaged that the combined used of personal protective measures (deltamethrin impregnated bed-nets, scalves and hand-bands) and the chemoprophylaxis will be an effective means of control of malaria in the define group of people. The study also intended to find out the side effects of the deltamethrin and feasibility and acceptability of methods by the users. The study was conducted in Theini Township, Northern Shan State, from March to November 1993. The study population consisted of all ages of both sexes 554 and 440 persons in the test and control groups respectively. At the initial phase of the study, malaria infected persons from both the groups were treated. The experimental group received personal protective measures with impregnation of bed-nets using 25 mg ai/m2 of deltamethrin at 4 monthly intervals and the scarves and hand-bands at twice the concentration of the insecticides at monthly intervals. Chemoprophylaxis was given to both the groups at weekly intervals using age adjusted dosage of Pyrixine tablet (sulfadoxine-pyrimethamine). The parasitological, entomological, and epidemiological indices were collected at two month intervals in both the groups. The study clearly showed the impact of personal protective measures and chemoprophylaxis on malaria infection in the studied subjects. During the study period, the out patient malaria cases of the test group was 6% to 11.2% and that of the control group was 12% to 21.6% in Theini Hospital. The reinfection rate of the test group (0.9 to 4.7%) was also significantly lower than the control group (6.1 to 14.3%) from July to November. Acceptance of the treated bed-nets, scarves and hand-bands was high and good compliance was found in the follow up. The results of the study clearly showed that malaria can be controlled effectively in the defined group of persons for a malaria transmission season by using chemoprophylaxis and personal protective measures.

Resurgence of malaria and drug resistance in plasmodium falciparum and plasmodium vivax species in Bombay.

Malaria had been well controlled in Bombay, through control of mosquito breeding sites and legal provisions. However in the past 2-3 years there has been a marked increase in incidence of malaria in Bombay. The objective of the present study was to assess the incidence of drug resistance of malarial parasite to standard drugs. The study was an outpatient study, but drug administration was supervised, blood smear was read by experienced technicians counting at least 100 fields. Follow up was done upto day 14 as beyond that, smear positivity due to reinfection cannot be ruled out. Two hundred cases; 56 of P. falsiparum, 139 of P. vivax and 5 with mixed infection were investigated. The public health department strategy of administering single dose of (10 mg/kg) chloroquine found to be largely effective in the past was now found to be only partially effective, with 20/56 Pl. falciparum, 7/139 P. vivax and 1/5 mixed infection cases showing smear positive on day 6 or day 14. These patients, resistant to single dose chloroquine, were then treated with full dose of (25 mg/kg) chloroquine. Three out of 20 cases of P. falciparum and 1/7 P. vivax cases did not respond to full dose (25 mg/kg) of chloroquine. These 3 chloroquine resistant cases of P. falciparum responded to Sulfadoxinepyrimethamine while the single case of chloroquine resistant P. vivax did not respond to quinine or sulfadoxinepyrimethamine.

Prevention of Plasmodium falciparum malaria by Fansimef and Lariam in the northeastern part of Thailand.

Two studies were conduct in Thailand in order to find appropriate falciparum malaria prophylactic drug regimens. The first study was done during June - September 1987 with 363 soldiers who received Fansimef (MSP) 1 tab/week (group 1), 337 soldiers who received MSP 1 tab/2 week (group 2) and 165 soldiers who received chloroquine 300 mg base weekly plus Fansidar 1 tab/week (group 3). At the end of the study there were 9 and 13 falciparum malaria episodes in groups 1 and 2, respectively, with incidence rates of 0.8 and 1.8 cases/100 person-months (P-M). In group 3, the corresponding values were 30 episodes and an incidence of 7.2/100 P-M. For the second study which lasted from October 1987 - January 1988 in the same area, 498 soldiers were given Fansimef 1/2 tab/week (group 4), 499 soldiers were given Lariam 1/2 tab/week (group 5) and 247 soldiers were given chloroquine plus Fansidar (group 6). Thirty malaria episodes were found in group 4, for an incidence of 2.0/100 P-M. In group 5, 23 episodes were found, for an incidence of 1.6/100 P-M. In group 6, 74 episodes occurred, ie an incidence of 12.2/100 P-M. The incidence rates of malaria among Fansimef 1 tab weekly, Fansimef half dose weekly or Lariam half dose weekly were not significantly different but were different from chloroquine plus Fansidar groups. Adverse events in each group were mild.

Mefloquine monitoring in acute uncomplicated malaria treated with Fansimef and Lariam.

Mefloquine levels were compared between Plasmodium falciparum malaria patients with sensitive response and those with treatment failure who received 3 drug regimens of mefloquine (46 patients with MSP 3 tablets (Fansimef), 38 and 34 with mefloquine (Lariam) 750 mg and 1,250 mg). Mefloquine concentrations on Day-1 in any regimens in patients with treatment failure were significantly lower than those from the sensitive response, whereas there was no difference in the concentrations on Day-7. However, MIC values of mefloquine prior to drug treatment were comparable in both groups. The study suggests that pre-treatment in vitro sensitivity testing was a non-reliable indicator of clinical outcome. Mefloquine concentration on the first day after treatment is a better predictor of the treatment outcome.