Adverse drug reactions to chloroquine/hydroxychloroquine in combination with azithromycin in COVID-19 in-patients: data from intensive pharmacovigilance in Morocco, 2020

In Morocco, chloroquine/hydroxychloroquine + azithromycin have been used off-label for COVID-19 treatment. This study aimed to describe the distribution, nature and seriousness of the adverse drug reactions (ADRs) associated with the two drug combinations in COVID-19 in-patients. We conducted a prospective observational study based on intensive pharmacovigilance in national COVID-19 patients' management facilities from April 1 to June 12, 2020. Hospitalized patients treated with chloroquine/hydroxychloroquine + azithromycin and who experienced ADRs during their hospital stay were included in the study. The causality and seriousness of the ADRs were assessed using the World Health Organization-Uppsala Monitoring Centre method and the agreed criteria in the ICH guideline (E2A) respectively. A total of 237 (51.7%) and 221 (48.3%) COVID-19 in-patients treated respectively with chloroquine + azithromycin and hydroxychloroquine + azithromycin experienced 946 ADRs. Serious ADRs occurred in 54 patients (11.8%). Gastrointestinal system was most affected both in patients taking chloroquine + azithromycin (49.8%) or hydroxychloroquine + azithromycin (54.2%), followed by nervous system and psychiatric. Eye disorders were more frequent in patients receiving chloroquine + azithromycin (10.3%) than those receiving hydroxychloroquine + azithromycin (1.2%). Cardiac ADRs accounted for 6.4% and 5.1% respectively. Chloroquine + azithromycin caused more ADRs by patients than hydroxychloroquine + azithromycin (2.6 versus 1.5 ADRs/patient). Causality assessment was possible for 75.7% of the ADRs. Diabetes was identified as a risk factor for serious ADRs (ORa 3.56; IC: 95% 1.5-8.6). The off-label use of the two drug combinations in COVID-19 in-patients according to the national therapeutic protocol seems to be safe and tolerable. ADRs were mainly expected. However, precaution should be taken in using the drugs in diabetic patients to prevent the risk of serious ADRs.

Assessment of soil erosion rates in a Mediterranean cultivated and uncultivated soils using fallout 137Cs

Fallout radionuclides, such as ¹³⁷Cs, have been recognized as a valuable means for studying soil erosion processes. In this study, the ¹³⁷Cs technique was used to assess soil erosion magnitude and to investigate the effectiveness of terrace cultivations in the High Atlas of Morocco, particularly, the Ourika watershed. ¹³⁷Cs depth distribution profiles were established along slope gradients associated with land use considering cereal crop, arboriculture and native forests. Along the slope gradient, depth distribution profiles highlight dissimilarities reflecting differences in land use, topographic roughness, soil particle distribution and stoniness. ¹³⁷Cs inventory decreases exponentially with depth and its penetration increases along the slope. It becomes higher at the bottom of the slope, with penetration reaching 30 cm. ¹³⁷Cs mass activity and inventory significantly decrease in cultivated terraces, compared to native forest. Although the pattern of ¹³⁷Cs gain/loss varied according to topography, soil properties and vegetation cover, showing eroding and aggrading profiles, most samples had ¹³⁷Cs values lower than the reference value, suggesting net-loss of soil as a consequence of erosion processes. The net erosion rates were estimated about 8.5 and 6.0 t ha^-1 yr^-1 in cereal crop and arboriculture agrosystems, respectively, whereas in the forest, the net erosion rate was lower at about 4.2 t ha^-1 yr^-1. Soil loss on agricultural terraces is not significantly above tolerable erosion rates for Morocco (<7 t ha^-1 yr^-1), particularly for arboriculture terraces. A strong correlation was observed between ¹³⁷Cs and both soil organic carbon and slope gradient, in uncultivated area, whereas, there was no correlation for cultivated terraces. Terraced arboriculture systems should be encouraged for better soil preservation against water erosion in the Ourika watershed.

Evaluation of the Yield of Histopathology in the Diagnosis of Lymph Node Tuberculosis in Morocco, 2017: Cross-Sectional Study

BACKGROUND

The frequency of occurrence of extrapulmonary tuberculosis (EPTB) has been increasing globally over the last two decades. In Morocco, EPTB cases account for 46% of the patients reported with a new episode of tuberculosis (TB). Lymph node TB (LNTB) is the most common form of EPTB. In line with the guidelines of the National TB Program, the diagnosis is mainly based on clinical evidence, including histopathology.

OBJECTIVE

This study aimed to evaluate the yield of histopathology testing in the diagnosis of LNTB.

METHODS

This cross-sectional, prospective study was conducted among patients with cervical lymph node who were enrolled in the study from November 2016 to May 2017 in three regions of Morocco. We compared the outcomes of histopathological testing with those of bacteriology. Sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) of histopathology testing were calculated. Culture and Xpert tests were used as the gold standard Laboratoty Testing.

RESULTS

A total of 262 patients were enrolled in this study. The Se, Sp, PPV, and NPV of histopathology testing were 95.6% (129/135), 64.6% (82/127), 74.1% (129/174), and 93.2% (82/88), respectively, in the presence of granuloma with or without caseous necrosis and were 84.4% (114/135), 74.8% (95/127), 78.1% (114/146), and 81.9% (95/116), respectively, in the presence of granuloma with caseous necrosis. The granuloma with caseous necrosis was associated with increased PPV and Sp of histopathology testing (P&lt;.05).

CONCLUSIONS

The presence of the granuloma with caseous necrosis in the histopathological examination had significantly improved the yield of histopathology testing for the diagnosis of LNTB. The findings recommend to maintain histopathology testing in establishing the LNTB diagnosis and to explore other techniques to improve it.

Outbreak Investigation of a Multipathogen Foodborne Disease in a Training Institute in Rabat, Morocco: Case-Control Study

Background

On June 18, 2017, the public health service was alerted about 43 students in the training institute in Rabat who were admitted to the emergency room for acute gastroenteritis following the uptake of a meal a day before.

Objective

This study aimed to investigate the foodborne disease outbreak by confirming the outbreak, identifying the source of contamination, and recommending control measures.

Methods

We conducted a case-control study. Cases and controls were selected in a ratio of 1:1. We defined a case as any member of the training institute who attended the Ramadan buffet in the institute’s restaurant and who had presented, in the weekend of June 16 to 20, 2017, symptoms of diarrhea or vomiting with at least one of the following signs: abdominal pain, fever, headache, nausea, and dizziness. A control was defined as anyone who attended the Ramadan buffet in the institute’s restaurant but had not presented any symptoms from June 16 to 20, 2017. We conducted a bivariate and multivariable analysis. Stools of ill students were collected, and a food specimen was collected for bacterial testing.

Results

A total of 50 cases and 50 controls were selected. Among the cases, males were predominant (43/50, 86%); the median age was 21 years. A total of 47 cases sought medical care. There were no hospitalizations and no deaths. The episode was short with an estimated average incubation period of 9 hours. The epidemic curve oriented toward a common source of contamination. Among food items, briwates were strongly associated with the illness with an odd ratio of 14.23 (95% CI 5.04-40.04; P<.001). Laboratory testing of briwates showed presence of Escherichia coli O157 and Staphylococcus aureus.

Conclusions

This foodborne disease outbreak was likely caused by briwates that was contaminated with S aureus and E coli. We recommended strengthening hygiene measures. Food handling techniques should be taught as part of continuous professional development for food handlers.

Prevalence of uncontrolled blood pressure in Meknes, Morocco, and its associated risk factors in 2017

Background

Uncontrolled high blood pressure (UBP) can lead to various cardiovascular complications causing an estimated nine million deaths per year worldwide. In Meknes, epidemiologic data on UBP are scarce, depriving programs from evidence-based information that would allow a better management of hypertension. Hence, we aimed to assess UBP prevalence in hypertensive patients treated in Meknes and identify UBP-associated risk factors.

Methods

Between November and December 2017, we conducted a cross-sectional study enrolling 922 hypertensive patients managed at Meknes’s primary health care facilities using the multistage sampling method. We interviewed patients face to face to collect their socio-demographic-characteristics, lifestyle behaviours, clinical parameters and the triad care system-patient-physician. Another questionnaire was self-administered by physicians to characterize therapeutic inertia. A multivariate logistic regression analysis highlighted the risk factors associated with UBP.

Results

UBP prevalence was 73% with a mean age of 61±11 years (mean±standard deviation) and a male/female ratio of 1/3. Risk factors associated with UBP were: therapeutic inertia (adjusted odds ratio to other variables (AOR) = 18.2, 95% CI [8.35–39.84]), drug non-adherence (AOR = 1.8, 95% CI [1.07–3.04]), obesity/overweight (AOR = 1.6, 95% CI [1.03–2.58]), unemployment (AOR = 1.9, 95% CI [1.09–3.01]), low income (AOR = 2.6, 95% CI [1.01–6.86]), family history of hypertension (AOR = 1.5, 95% CI [1.07–2.08]) and male sex (AOR = 1.6, 95% CI [1.04–2.58]).

Conclusion

UBP prevalence is high in Meknes. Prevention should firstly focus on raised awareness of hypertensive patients’ self-care management. Secondly, health professionals should better comply to the guidelines of anti-hypertensive treatments. Lastly, health professionals should frequently be reminded to reach therapeutic goals to overcome therapeutic inertia.

Innovative Approaches to Improve Public Health Practice in the Eastern Mediterranean Region: Findings From the Sixth Eastern Mediterranean Public Health Network Regional Conference

Public health professionals in the Eastern Mediterranean region (EMR) have limited access to continuing education, including workshops and conferences in public health. Held under the theme Innovative Approaches: Adapting to the Current EMR Context, the Eastern Mediterranean Public Health Network (EMPHNET) organized and conducted the Sixth EMPHNET Regional Conference from March 26 to 29, 2018. This paper summarizes the key activities including workshops, roundtable discussions, oral and poster presentations, keynote speeches, and side meetings. Before the opening, 5 preconference workshops were held: “Field Epidemiology Training Program (FETP) Accreditation,” “Innovative Public Health Surveillance,” “Human and Animal Brucellosis,” “Rapid Response Teams,” and “Polio Transition and Routine Immunization.” The conference hosted 6 roundtable discussions: “Consolidation of the FETP Network,” “One Health to Achieve Global Health Security,” “Polio Eradication Efforts and Transition Planning for Measles Elimination,” “Mobile Data Collection and Other Innovative Tools to Enhance Decision Making,” “Confronting Candida auris: An Emerging Multidrug-resistant Global Pathogen,” and “Functioning and Sustainable Country Public Health Emergency Response Operation Framework.” One of the conference’s key objectives was to provide a space for FETP residents, graduates, and public health professionals to showcase achievements. A total of 421 abstracts were submitted and after professional review, 34.9% (147/421) were accepted (111 for oral presentations and 36 for poster presentations) and published by Iproceeding. The conference met the primary objectives of showcasing the public health accomplishments and contributions of the EMR, encouraging the exchange of ideas and coordination among stakeholders, and engaging cross-sectoral workforce in producing recommendations for approaching regional and global health concerns. Moreover, the conference presented a unique opportunity for FETPs and other public health professionals from the Mediterranean region to present their significant scientific work and also facilitated networking among professionals. EMPHNET strives to continue to present similar exchange opportunities for public health professionals in the region.

Assessment of a new instrument for detecting preventable adverse drug reactions

BACKGROUND

Pharmacovigilance centres (PVCs) in the World Health Organization (WHO) Programme for International Drug Monitoring have demonstrated their ability to detect preventable adverse drug reactions (ADRs) in their databases. In this field, there is no gold-standard method for detecting medication errors and evaluating ADR preventability. Therefore, we developed, from existing tools, a preventability assessment method: the 'P Method' (PM).

OBJECTIVE

To present the PM and to evaluate its inter-rater reliability.

METHODS

The PM includes 20 explicit criteria for assessing ADR preventability. This approach is based on identification of any potentially preventable risk factor that increases the likelihood of ADR occurrence. The outcome of the preventability assessment results in one of three possible scores: 'preventable', 'non-preventable' or 'not assessable'. The PM was tested in a multicentre study involving nine national PVCs. Two experienced reviewers at each participating PVC independently analysed the preventability of 183 ADRs, applying the PM.

RESULTS

The overall agreement between all reviewers for assessment of ADR preventability was 'fair', with a kappa value of 0.27 [95 % confidence interval (CI) 0.21-0.40]. The level of agreement between reviewer pairs ranged from 'slight', with a kappa value of 0.12 (95 % CI -0.03 to 0.27), to 'substantial', with a kappa value of 0.69 (95 % CI 0.48-0.89).

CONCLUSION

The analysis of the agreements and disagreements between reviewers highlighted where improvements might be made. Given that no standard assessment tool exists in the WHO Programme, the transparency of the assessment process in this method provides a substantial basis for further development and for support in signalling possible preventability.

Screening for childhood lead poisoning in the industrial region of Fez, Morocco

The study objectives were to estimate lead poisoning prevalence among children living next to an industrial area, to compare it to that in a control population, and to establish clinical and biological follow-up of the poisoned children. This is a descriptive cross-sectional study including 150 children (exposed and unexposed) performed between January 2012 and April 2013. It was meant to determine blood lead levels (BLLs) in children considered to be an exposed population (EP N 90), living in the industrial area Ain Nokb Fez compared with BLLs of children of other areas belonging to the same city supposed to be unexposed [UP (N = 60)]. A sociodemographic questionnaire was obtained, and a blood lead analysis was performed. Clinical and biological follow-up has been performed of poisoned children. The sample consisted of 90 EP children with an average age of 6.82 ± 3.32 years and male-to-female sex ratio (SR) of 1.5 and 60 UP children with an average age of 6.45 ± 3.29 years and an SR of 1.2. Among the 150 children recruited, the average of BLLs was 58.21 ± 36 µg/L (18-202.3 μg/L). The average of BLLs in EP children (71 ± 40 µg/L) was statistically greater (p < 0.0001) than that registered in UP children (38 ± 13 µg/L). All poisoned children belonged to the EP group at a prevalence of 21.1 %. The clinical and biological examinations of poisoned children showed a few perturbations such as anemia, hypocalcaemia, and deficiencies in magnesium and iron. No renal disease or objective neurological disorders were observed. In the follow-up of the children with BLL ≥100 µg/L (19 cases). BLL monitoring showed a significant decrease in average of blood concentration ranging from 136.75 ± 32.59 to 104.58 ± 32.73 µg/L (p < 0.0001) and in lead poisoning prevalence (p < 0.001), which decreased to 7.8 % from 21.1. Our study showed a high prevalence of lead poisoning (21.1 %) in EP children. The relocation of the industrial site associated with corrective and preventive measures has contributed to a decrease of exposure and lead poisoning prevalence in the aforementioned population.

Prognostic factors of Atractylis gummifera L. poisoning, Morocco

In Morocco, acute Atractylis gummifera L. poisoning represents the leading cause of death by plant poisoning especially for children. All cases received in the Moroccan poison control centre from January 1981 to December 2009 (n = 467) were included in a retrospective study of the characteristics and risk factors of A. gummifera L. poisoning. The most vulnerable age group was children (63.4% of cases). Most cases were due to accidental exposure (75.5%), but some were from therapeutic use (18.1%) or attempted abortion (7.4%). Patients presented with moderate poison severity signs (grade 2) in 22.3% of cases or severe signs (grade 3) in 21.0%. The mortality rate was 39.2%. The majority of deaths (81.1%) occurred in children aged < 15 years following accidental exposure. Multivariate logistic regression analysis revealed that risk factors for mortality were coma (OR = 20.5); hepatitis (OR = 52.7) and rural residence (OR = 7.26), while gastric decontamination was a protector factor (OR = 0.26).

The involvement of Pharmacovigilance Centres in medication errors detection: a questionnaire-based analysis

OBJECTIVES

This study assesses the ability of Pharmacovigilance Centres (PVCs) to detect medication errors (ME) and to proceed to building Patient Safety (PS) via their information networks and to underline the limits for this challenge.

METHODS

This was an exploratory study conducted in PVCs members of the World Health Organization International Drug Monitoring network. A questionnaire specifically designed for the needs of the study was sent to a network via a confidential email system. The questionnaire asked for information, progress and improvement made by PVCs in PS and ME.

RESULTS

Among the 88 countries, 21 answered. Reporting of Adverse Drug Reactions (ADRs) by health care professionals (HCP) is mandatory for 42% of PVCs. 100% of countries receive reports from HCP, 66% from patients and 24% from PCCs. ADRs reports are received by all communications means. There is an heterogeneity between countries regarding PVCs and PS activities. Among them, 4 PVCs have the prime activity of PS organization.

CONCLUSION

PVCs are able to detect and analyze ME. There is a need to coordinate efforts between countries to optimize ME detection, and its analysis. Bridges need to be built linking PVCs, PCCs and PS organizations in order to avoid duplication of workload.

[Pesticide poisoning in Moroccan children: epidemiological and prognostic aspects (1990-2008)]

OBJECTIVE

The purpose of this paper is to describe the epidemiological profile of<np pagenum="196"/> acute pesticide poisoning in children (APP) treated by the Moroccan Poison Control Center (CAPM) and to analyze death cases in order to determine factors predictive of severity.

METHOD

the study is based on a retrospective study of all cases of APP collected by the CAPM over a period of eighteen years (January 1990 to December 2008). Univariate analysis was performed to identify risk factors.

RESULTS

2,672 cases of childhood poisoning by pesticide were collected. The mean age was 5.6 ± 4.57 years. The sex ratio was 1.12. The cause of poisoning was accidental in 87.1% of cases, followed by attempted suicide (12.1%). Organophosphates were the most frequent poison (50.7%), followed by alpha-chloralose (26.5%). The case fatality rate was 3.3%. Mortality was attributed to organophosphates in 30 cases, followed by inorganic derivatives (7 cases) and carbamates (6 cases). A univariate analysis comparing survivors and groups who died showed that rural origin (p = 0.04), voluntary circumstances (p = 0.001), and the type of chemical class of pesticide (p &lt; 0.001) significantly influence fatal poisoning.

CONCLUSION

Acute pesticide poisoning among children is a reality in Morocco. Preventive measures may be needed.

[Management of scorpion sting in Morocco]

Scorpion stings are the first cause of poisoning, and represent between 30 and 50% of all cases reported to the Moroccan Poison Control Centre. Concerned by the size of the problem, we have paid special attention to this pathology. Through retrospective and prospective studies, it has been possible to determine the nature and the chronology of clinical stages, as well as the epidemiological, clinical and therapeutic factors of gravity. On this basis, we worked out a new management to provide support for patients. This management will standardize support provided at the national level, and will reduce the number of lethal case and rationalize spending by reviewing medication, transfer of patients and hospital care. This standardization is an essential component of the national strategy against scorpion poisoning. Other components include training of medical staff, awareness campaigns, and information systems to monitor lethal cases. A survey over five years shows a reduction in the number of lethal cases and rationalization of costs. Medical care provided rests upon the distinction between patients stung by scorpions and patients actually poisoned. The first category of patients will be monitored up to four hours after the scorpion sting, while poisoned patients will be transferred to an intensive care unit.

[Reactive airways dysfunction syndrome (Brooks syndrome)]

INTRODUCTION

Although the existence of classical occupational asthma is well known and described after fairly prolonged exposure to moderate levels of air-contaminators, authentic asthma can be provoked by rapid single inhalation of a high dosed corrosive gas: this is Brooks' syndrome.

OBSERVATION

A 30 year-old woman, without respiratory past history and no atopy presented with post-toxic asthma following a single accidental inhalation of hydrochloric acid. The diagnosis was established on the 8 criteria of Brooks and the clinical outcome remained stable with, however, excellent response to the inhalation of broncho-dilatators during asthma attacks.

COMMENTS

The relationship with the accidental inhalation may have been ignored by the victim. The outcome of this syndrome is good in 50% of cases; in 25% the symptomatology worsens and in the remaining 25% it remains stable.

Phenotypic and genomic analyses of human strains belonging or related to Bifidobacterium longum, Bifidobacterium infantis, and Bifidobacterium breve

A numerical analysis based on phenotypic characteristics (89 enzymatic tests and 49 carbohydrate acidification tests), in which experimental strips from Biomerieux-API, La Balme les Grottes, France, were used, was performed to characterize 82 new isolates belonging or related to Bifidobacterium longum, Bifidobacterium infantis, and Bifidobacterium breve. A total of 72 strains were isolated from child or adult feces, and the other strains were obtained from human vaginas and bronchi. In this study we also included 38 type and reference strains that were representative of all species of the genus Bifidobacterium and 6 strains belonging to the genus Lactobacillus. DNA-DNA relationships between B. longum and B. infantis were determined by using 19 strains related to these species, as determined by the numerical analysis. The degree of DNA binding was determined by the S1 nuclease method. The phenotypic study revealed that there were six main clusters, which were subdivided into nine subclusters. Subcluster Va contained the type strains of B. longum and B. infantis. The DNA-DNA relatedness values of some of the new isolates were very similar to the DNA-DNA relatedness values of the type strain of B. longum. On the basis of these data, it was difficult to isolate B. infantis strains and then to define B. infantis as a single species separated from B. longum. Subclusters IVb to IVf comprised reference strains of B. breve. Cluster III and subcluster Ia were not identified.