[Resistance of Plasmodium falciparum to antimalarial drugs: impact on malaria pre-elimination in Madagascar]. / Résistance de Plasmodium falciparum aux antipaludiques: impact sur la pré-élimination du paludisme à Madagascar.

The purpose of this review was to provide up-to-date information on the resistance of Plasmodium falciparum to the main antimalarials used in Madagascar and to assist implementation of the malaria control and elimination program. In 2006, the failure rate for chloroquine treatment was 44% (n = 300) and was comparable to the rate observed in continental Africa. Most treatment failures occurred after the first week of follow-up. P. falciparum resistance to chloroquine appeared to be special in Madagascar with only 3.2% of isolates showing in vitro resistance (n = 372, 7 sentinel sites) and less than 1% harbouring mutant parasites within the Pfcrt gene. Conversely, the Pfmdr1 N86Y point mutation was found in 64.3% (n = 174) of isolates in 2006 and in 51.7% (n = 343) in 2007. Failure of combined sulfadoxine-pyrimethamine therapy, i.e., the recommended intermittent preventive treatment for malaria during pregnancy, and in vitro resistance to pyrimethamine were rare. However, the Pfdhfr 51I/59R/108N allele showed consistently high prevalence levels reaching 33.3% in 2008. Moreover, the single Pfdhfr 164L mutant allele, a haplotype unique to Madagascar, was discovered in 2006 and showed prevalence rates up to 30% in some locations (southeast) in 2008. Up to now, the quadruple mutant allele Pfdhfr 51I/59R/108N/164L has not been observed. Susceptibility to the other antimalarials tested appeared excellent but the number of isolates showing in vitro susceptibility to artemisinin derivatives has been fallen in recent years and this decline may herald a decrease in the efficacy of these drugs.

[Collaboration between traditional and modern medicines: prospectives of structuring a combined care system for traumatology cases]. / Articolazione tra medicina tradizionale e medicina convenzionale in Mali: prospettive per la strutturazione di un sistema di presa in carico congiunto dei casi di traumatologia ortopedica.

The Italian NGO Terra Nuova (TN) is implementing a project with the aim of promoting collaboration between traditional and conventional medicines within orthopedic traumatology in Mali. The study is supporting the project to formulate rightly the proposal of a joint system of managing traumatology cases. It has the purpose of analysing the ability of the two healthcare systems and identifying the training needs of the respective operators in this field, in order to draw interventions that can improve their therapeutic practice. The research uses quantitative and qualitative methods for data collection and is structured in three under-studies. The study points out a great use of the traditional medicine for traumatology cases, a good ability of the traditional care system to manage such cases, even though some aspects need improvements, and a diffused availability of conventional health workers to collaborate with traditional ones, since the former recognise their own incapability in this field. The study suggest that valorizing strengths and emending weakness of both healthcare systems in managing traumatology cases, will allow the TN intervention to structure and test collaboration between the two medicines with effective prospects for public health.

[Assessment of sulfadoxine-pyriméthamine (Fansidar, Paludar) efficacy in patients with uncomplicated malaria in Madagascar: preliminary study to propose a simplified study protocol]. / Surveillance de l'efficacité de sulfadoxine-pyriméthamine (Fansidar, Paludar) pour le traitement de l'accès palustre à Madagascar: proposition d'un protocole simplifié.

To alleviate the insufficient number of experienced medical teams invited to and accepting to monitor the effectiveness of drugs prescribed to patients with a diagnosis of uncomplicated malaria and to insure the surveillance of the susceptibility of P. falciparum to current antimalarials used in Madagascar, there is a need to draw a feasible study protocol carefully discussed with them. We carried out a preliminary study in two rural areas and assessed the efficacy of sulfadoxine-pyrimethamine (SP) for curing uncomplicated P. falciparum malaria, with a simplified protocol based on the principle of observational study. A single dose of SP was given on day 0 with paracetamol. The persons to whom the drugs were administered accepted two other interventions of one member of the medical teams on day 14 and day 28. Nineteen patients, 3-63 years old, fulfilled the follow-up. The efficacy of this combination was noted for the 19 persons. Our results show that P. falciparum strains are susceptible to SP. Since SP will be used in intermittent preventive treatment in pregnant women in Madagascar, one way to delay the occurrence of SP resistant parasites will be (a) to avoid massive use of SP for the non pregnant persons and (b) to monitor susceptibility of P. falciparum to SP as part of pilot studies using standard WHO protocol (which is not really easy for most of the peripheral health facilities--with the follow-up procedures with clinical examination and parasitological control at Days 0, 1, 2, 3, 7, 14, 21 and 28), and routinely with simplified protocol such as the analytical observational study illustrated in this present study. Limit and advantage of observational study are discussed.