Rapid diagnostic tests for the home-based management of malaria, in a high-transmission area

Rapid diagnostic tests (RDT) are sometimes recommended to improve the home-based management of malaria. The accuracy of an RDT for the detection of clinical malaria and the presence of malarial parasites has recently been evaluated in a high-transmission area of southern Mali. During the same study, the cost-effectiveness of a 'test-and-treat' strategy for the home-based management of malaria (based on an artemisinin-combination therapy) was compared with that of a 'treat-all' strategy. Overall, 301 patients, of all ages, each of whom had been considered a presumptive case of uncomplicated malaria by a village healthworker, were checked with a commercial RDT (Paracheck-Pf). The sensitivity, specificity, and positive and negative predictive values of this test, compared with the results of microscopy and two different definitions of clinical malaria, were then determined. The RDT was found to be 82.9% sensitive (with a 95% confidence interval of 78.0%-87.1%) and 78.9% (63.9%-89.7%) specific compared with the detection of parasites by microscopy. In the detection of clinical malaria, it was 95.2% (91.3%-97.6%) sensitive and 57.4% (48.2%-66.2%) specific compared with a general practitioner's diagnosis of the disease, and 100.0% (94.5%-100.0%) sensitive but only 30.2% (24.8%-36.2%) specific when compared against the fulfillment of the World Health Organization's (2003) research criteria for uncomplicated malaria. Among children aged 0-5 years, the cost of the 'test-and-treat' strategy, per episode, was about twice that of the 'treat-all' (U.S.$1.0. v. U.S.$0.5). In older subjects, however, the two strategies were equally costly (approximately U.S.$2/episode). In conclusion, for children aged 0-5 years in a high-transmission area of sub-Saharan Africa, use of the RDT was not cost-effective compared with the presumptive treatment of malaria with an ACT. In older patients, use of the RDT did not reduce costs. The question remains whether either of the strategies investigated can be made affordable for the affected population.

Ethnopharmacology and malaria: New hypothetical leads or old efficient antimalarials?

New treatments are urgently needed to curb and eradicate malaria in developing countries. As most people living in malarial endemic areas use traditional medicine to fight this disease, why have new treatments not emerged recently from ethnopharmacology-oriented research? The rationale and limitations of the ethnopharmacological approach are discussed in this paper, focusing on ethnopharmacology methodologies and techniques used for assessing botanical samples for their antimalarial properties. Discrepancies often observed between strong ethnopharmacological reputation and laboratory results are discussed, as well as new research perspectives.

Decreasing clinical efficacy of chloroquine in Ankazobe, Central Highlands of Madagascar

The clinical efficacy of chloroquine was assessed in the Primary Health Centre of Ankazobe, Central Highlands of Madagascar. This study shows an increase in the level of chloroquine resistance with the appearance of early treatment failures and RIII resistance. Furthermore, the prevalence of clinical treatment failures is approaching the level of 25%, at which WHO recommends a change of first-line drug.

A clinical trial of 'AM', a Ugandan herbal remedy for malaria

BACKGROUND

Mortality and morbidity from malaria is still high in Africa, and may further increase as resistance to antimalarial drugs spreads. Many people rely on herbal medicines as the first line of treatment. Yet there has been very little clinical research into their effectiveness.

METHODS

Patients being treated for malaria at a herbalists' clinic in South-West Uganda were followed up and their response to a particular herb, 'AM', was monitored. Eighty-eight patients were enrolled; 72 were followed up for at least 2 days, and were questioned about side-effects. Nineteen patients infected with Plasmodium falciparum had initial parasite counts sufficiently high for parasite clearance to be assessed.

RESULTS

No severe adverse reactions were observed, although about 50 per cent experienced minor side-effects. Although complete parasite clearance was achieved in only one case, the geometric mean of parasite counts had declined significantly by day 7. There was also a marked symptomatic improvement in 17 of the 19 patients.

CONCLUSIONS

AM appears safe, although it is not always well tolerated. Significant symptomatic improvement and a reduction of parasite counts were observed in patients taking AM. There is a need for further research, such as a randomized controlled trial, to assess the efficacy of this treatment.

The impact of multiple drug therapy on leprosy disabilities

In an overview of controlled trials, it is shown that bactericidal drugs increase the short-term risk of Type I reactions, but prevent the long-term development of new impairments caused by bacterial proliferation. Clinical experience suggests that the clofazimine component of multiple drug therapy (MDT) has reduced the incidence of Type II reactions or erythema nodosum leprosum (ENL). The principal impact of MDT, compared with monotherapy, has been to reduce the duration of active disease, thus preventing the deterioration of disability scores. Reduction of population disability rates is mainly achieved by earlier detection and treatment. MDT has a number of indirect benefits such as improved compliance, decreased cost, and increased motivation and availability of leprosy workers. However, MDT must be supplemented by other measures to prevent and treat disabilities.

Tobacco control programmes for universities: a feasibility study

BACKGROUND

University may be a good time for smoking cessation, because younger, lighter smokers are more successful at stopping.

METHODS

An initial survey of 4141 students at Cambridge and Anglia Polytechnic universities identified the prevalence of smoking; questionnaires were given to smokers asking about desire to stop. Some respondents were invited to a discussion, but very few came. Those wanting to quit were sent a second questionnaire about what help they wanted. On National No Smoking Day, 101 students were interviewed about "stop smoking' advertisements, and those wanting to stop smoking were offered different forms of help. Lastly, student union welfare officers at 54 universities in the United Kingdom were interviewed over the telephone, about what motivation and support they provide for students to stop smoking, and what more they would consider providing.

RESULTS

Prevalence of smoking varied according to university, subject studied and sex. Desire to quit varied with subject studied, duration of habit and amount smoked. Some "stop smoking' TV adverts were widely remembered, but their motivational impact remains unclear. Most of those wanting to stop found it difficult, but few requested help unless approached directly. Only books were widely used, and innovative ones seemed most popular. Few student unions provided effective encouragement or help for students to stop smoking. Most said they would consider doing more.

CONCLUSIONS

There is a need for smoking cessation programmes at universities. More research is needed on ways of motivating those who do not want to stop. "Direct marketing' of books seems the best way of reaching those who want to stop. The effectiveness of different books needs to be evaluated. There is great potential for improving the quality, quantity and availability of cessation aids through student unions.

Bronchoalveolar lavage fluid neutrophils increase after corticosteroid therapy in smokers with idiopathic pulmonary fibrosis

Patients with idiopathic pulmonary fibrosis (IPF) are often cigarette smokers and are often being treated with corticosteroids at the time of bronchoalveolar lavage. We addressed the question of whether or not the bronchoalveolar lavage fluid (BALF) neutrophil content of patients with IPF undergoes changes in smokers different from those in nonsmokers after institution of corticosteroids. Eighteen patients were studied (10 smokers and 8 nonsmokers). Fourteen patients (6 smokers and 8 nonsmokers) were treated orally with prednisone. The histologic assessment of alveolar inflammation and inflammatory small airways disease was no different in smokers than in nonsmokers. None of the smokers treated with prednisone had pathologic evidence of emphysema in addition to IPF. Five of 6 smokers showed an increase in BALF neutrophils after 3 months of prednisone (p less than 0.05), whereas the nonsmokers' BALF neutrophils decreased or remained unchanged. This increase in BALF neutrophils in smokers was not associated with concomitant or subsequent clinical deterioration but, in fact, with clinical improvement after 3 months of therapy. These data indicate that the combination of cigarette smoking and corticosteroid therapy influences the BALF neutrophil content in patients with IPF and suggest that interval changes in BALF neutrophil content may not reflect the status of the inflammatory process or structural derangements in the lungs of some patients with IPF.