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Low efficacy of the combination artesunate plus amodiaquine for uncomplicated falciparum malaria among children under 5 years in Kailahun, Sierra Leone.
Tropical Medicine and International Health. 2006 Jul; 11(7):1017-1021.In 2004, Sierra Leone adopted artesunate plus amodiaquine as first-line antimalarial treatment. We evaluated the efficacy of this combination in Kailahun, where a previous study had shown 70.2% efficacy of amodiaquine in monotherapy. Method and outcome classification of the study complied with WHO guidelines. Children 6--59 months with uncomplicated malaria were followed-up for 28 days. PCR genotyping was used to distinguish recrudescence from reinfection. Reinfections were reclassified as cured. Of 172 children who were referred to the study clinic, 126 satisfied inclusion criteria and were enrolled. No early treatment failures were reported. The day 14, efficacy was 98.2% (95% CI: 93.8--99.8). Of 65 recurrent parasitaemias analysed by PCR, 17 were recrudescences. The PCR-adjusted day 28 efficacy was 84.5% (95% CI: 76.4--90.7). All true failures occurred in the last 8 days of follow-up. Of 110 children who completed the 28-day follow-up, 54 (49.1%) experienced a novel infection. The efficacy of this combination was disappointing. The high reinfection rate suggested little prophylactic effect. In Kailahun a more efficacious combination might be necessary in the future. The efficacy of AS + AQ needs to be monitored in Kailahun and in the other regions of Sierra Leone. (author's)
Efficacy of chloroquine, sulfadoxine-pyrimethamine and amodiaquine for treatment of uncomplicated Plasmodium falciparum malaria among children under five in Bongor and Koumra, Chad. [Efficacité de la chloroquine, de l'association sulfadoxine-pyriméthamine et de l'amodiaquine dans le traitement du paludisme à Plasmodium falciparum non compliqué chez les enfants de moins de cinq ans à Bongor et Koumra, au Tchad]
Transactions of the Royal Society of Tropical Medicine and Hygiene. 2006 May; 100(5):419-426.We report two 28-day in-vivo antimalarial efficacy studies carried out in the urban centres of Bongor and Koumra, southern Chad. We assess chloroquine (CQ), sulfadoxine--pyrimethamine (SP) and amodiaquine (AQ) to treat Plasmodium falciparum uncomplicated malaria. Methods and outcome classification complied with latest WHO guidelines. Out of the 301 and 318 children aged 6-59 months included in Bongor and Koumra, respectively, 246 (81.7%) and 257 (80.8%) were eligible for analysis. In Bongor and Koumra, the 28-day PCR-adjusted failure rates for CQ were 23.7% (95% CI 14.7--34.8%) and 32.9% (95% CI 22.1--45.1%), respectively, and those for SP were 16.3% (95% CI 9.4--25.5%) and 4.3% (95% CI 1.2--10.5%). AQ failure rates were 6.4% (95% CI 2.1--14.3%) and 2.2% (95% CI 0.3--7.6%). The current use of CQ in Bongor and Koumra is questionable, and a more efficacious treatment is needed. Considering the reduced efficacy of SP in Bongor, AQ seems to be the best option for the time being. Following WHO recommendations that prioritize the use of artemisinin-based combinations, artesunate plus amodiaquine could be a potential first-line treatment. Nevertheless, the efficacy of this combination should be evaluated and the change carefully prepared, implemented and monitored. (author's)
Efficacy and safety of artemether-lumefantrine (Coartem) tablets (six-dose regimen) in African infants and children with acute, uncomplicated falciparum malaria.
Transactions of the Royal Society of Tropical Medicine and Hygiene. 2005; 99:459-467.Approximately one million children die from malaria each year. A recently approved artemisinin-based tablet, Coartem (co-artemether), comprising artemether 120 mg plus lumefantrine 20 mg, given in four doses, provides effective antimalarial treatment for children in many sub-Saharan countries. However, this regimen is considered insufficient for non-immune infants and in areas where multidrug-resistant Plasmodium falciparum predominates. This open-label study assessed the efficacy and safety of co-artemether administered to 310 African children weighing 5—25 kg, with acute, uncomplicated falciparum malaria. Six doses of coartemether were given over 3 days, with follow-up at 7, 14 and 28 days. Treatment rapidly cleared parasitemia and fever. The overall 28-day cure rate was 86.5%, and 93.9% when corrected by PCR for reinfection. Cure rates at 7 and 14 days exceeded 97.0% (uncorrected) and, on day 28, were similar in infants (5 -<10 kg) previously exposed to malaria infection (partially immune: 88.6% uncorrected; 93.3% corrected), and in those who were non-immune (82.5% uncorrected; 95.0% corrected). Adverse events were mostly mild. There was no electrocardiographic evidence of cardiotoxicity. The co-artemether six-dose regimen, treating acute uncomplicated falciparum malaria in African children, achieved rapid parasite clearance and a high cure rate. Treatment was generally safe and well tolerated. (author's)
In: While the world sleeps: writing from the first twenty years of the global AIDS plague, edited by Chris Bull. New York, New York, Thunder's Mouth Press, 2003. 401-412.Public concern over the global AIDS epidemic, particularly in Africa, has grown enormously in recent years, but there is considerable debate about what the international community can and should do about it. Especially controversial has been the high cost of antiretroviral drugs used to extend the lives of people with AIDS. The pharmaceutical companies that make these drugs price them beyond reach of the world's poor, but in November 2001 at the WTO meeting in Doha, Qatar, these companies were forced to accede to pressure from developing-country governments, nongovernmental organizations, and activists, and allow poor governments to adjust certain rigid patent rules applying to vaccines and drugs in order to protect public health. Despite this apparent triumph of international pressure, far more needs to be done. A coalition of governments and nongovernmental organizations, led by the UN, recently launched the Global Fund Against AIDS, Tuberculosis, and Malaria (referred to here as the Global Fund), and its performance will test how well such a global institution can confront the most serious health crises of our time, and perhaps in all of human history. (excerpt)
Bronchodilators and other medications for the treatment of wheeze-associated illnesses in young children.
[Unpublished] 1993. , [iv], 37 p. (WHO/ARI/93.29)The World Health Organization's (WHO) Programme for the Control of Acute Respiratory Infections (ARIs) reviewed the literature to provide this background paper on available drugs for the treatment of wheeze, the common causes of wheeze, and the pathogenesis and pathophysiology of asthma and bronchiolitis. It focuses on children in countries with a high infant mortality rate and where bacterial pneumonia is a major public health problem. When health providers manage wheeze in children, they must consider the fact that bacterial pneumonia is the leading cause of respiratory death in young children in developing countries. Even health providers in developed countries should consider bacterial pneumonia as the cause of wheeze. These providers tend to associate viral infections with wheeze. Many children with an ARI have combined viral and bacterial infections. About 50% of outpatient cases with confirmed Haemophilus influenzae and Streptococcus pneumoniae bacteremic pneumonia have wheeze. The first bronchodilator physicians should use to manage acute episodes of wheeze is a beta-2 adrenergic agent, e.g., salbutamol. Financial limitations will restrain the likelihood of long-term preventive therapy of acute episodes of wheeze caused by asthma. The best prophylactic options for asthma-related recurrent wheeze are sodium cromoglycate and inhaled corticosteroids. The leading therapeutic drugs for treating acute asthma include an inhaled beta-2 adrenergic agent with oral corticosteroids if needed. This treatment will achieve bronchodilatation and reversal of the airway narrowing caused by mucosal edema, by mucus hypersecretion, and by smooth muscle spasm. Long-term beta agonist therapy alone will not reduce airway inflammation. Allergen avoidance can also protect against recurrent wheeze in some cases. The annexes include tables on the presentation and dosage of bronchodilators and other drugs for the treatment of wheeze in children aged 0-5 and on bronchodilators and other drugs for the treatment of wheeze in the WHO list of essential drugs.
Arlington, Virginia, Partnership for Child Health Care, 1995. , 11,  p. (Trip Report; BASICS Technical Directive: 008-GU-01-015; USAID Contract No. HRN-6006-Q-08-3032)As part of a series of activities designed to reduce morbidity and mortality from acute respiratory infections in children under the age of 5 in Guatemala, a consultant from the BASICS (Basic Support for Institutionalizing Child Survival) program visited Guatemala in 1995 to analyze, modify, and field test the protocol developed by the USAID Mission to document the degree to which drugs prescribed for pneumonia are available in the community through the private sector. This field report provides background information and describes the current situation in Guatemala in terms of availability of drugs in the public sector through the Ministry of Health, the Drogueria Nacional, municipalities, and the Pan American Health Organization. Relevant activities in the private sector are also described, including the for-profit businesses as well as services provided by UNICEF, the European Union, and nongovernmental organizations. A brief overview of one health area gives an example of the current situation. The result of this consultancy visit was the determination that the situation merited adjustment of the originally requested study and that the survey as designed would likely require modification and application within target communities. Included among the appendices is the original protocol developed for assessing community drug availability.
Prevention of tuberculosis in children. Detection and chemotherapy of infectious cases of tuberculosis.
CHILDREN IN THE TROPICS. 1992; (196-197):60-9.Prevention of tuberculosis (TB) in children in developing countries involves 3 interventions: detection and treatment of sources of infection, i.e., adults with pulmonary TB; BCG vaccination of newborns to prevent primary infection and its complications; and prophylactic treatment of newly infected infants. The first element of prevention is reviewed here. In less developed areas, detection and diagnosis of TB entails education of the public and of health providers so that people with chronic cough have sputum sent to regional laboratories for microscopic examination. Rarely, x-ray facilities may also be used. Quality control of laboratory work and universal coverage are essential. The proportion of actual cases of TB diagnosed by microscopy ranges from 5 to 10% in African and Latin American countries to 25% in Asian countries, depending on the prevalence of TB, the age structure of the population, and the quality of the laboratories. Calculated rates of detection are 60-90% however. There are 3 types of infectious TB cases; new cases with smear-positive pulmonary TB (80-90%), previously treated cases who are true or false failures or relapses, and chronic TB cases who probably have resistant organisms. In developing countries, the last group will probably not receive second-line drugs because of the cost, but will be treated with isoniazid alone and are considered unlikely to recover. At the end of standardized treatment, there are 6 classes of patients: cured cases, probable cures, failures or relapses, decreased, lost to follow-up, and move to another district for care. World Health Organization objectives for rate of cure will probably be modified in given countries due to financial limitations.
ESSENTIAL DRUGS MONITOR. 1991; (11):10-1.Most health professionals in developing and developed countries consider oral rehydration therapy (ORT) to be the most effective treatment for diarrhea. An estimated 1,500 million episodes of diarrhea occur annually and 3 million of these results in death of children <5 years old. Caretakers must give increased amounts of fluids (rice water, tea, and gruel) to children with diarrhea to prevent dehydration. If they become dehydrated, caretakers must take them to a health workers so he/she can assess and treat them with oral rehydration solution (ORS) or, in the case of severe dehydration, rehydrate them intravenously. Drugs should not be used to treat diarrhea cases. Nevertheless, surveys in 4 Asian nations indicated that drug use ranged from 22-68% of diarrhea episodes and ORS use ranged only from 9-21%. Drug use is very expensive. In fact, Peru spent >US$2 million on antidiarrheals in 1988- 1989. Further, drugs often make up >40% of health care costs in developing countries, so ORS use reduces these costs. Indeed drug us deflects from correct case management of diarrhea. In addition, drugs have no proven value for acute diarrhea. They do not decrease the fluid loss responsible for death and may even have serious side effects, such as central nerve depression and gastrointestinal toxicity. If health workers suspect cholera or dysentery, however, they can administer effective and relatively inexpensive antibiotics. Since the early 1980s, almost all developing countries had a national control of diarrheal disease program. In several countries, hospital admission rates for diarrhea fell 61% and the case fatality rate fell 71% after ORT introduction. Some hospitals have even saved as much as 60% in costs due to these declines. WHO has a book available which covers rational use of drugs in managing acute diarrhea in children.