• 10-year assessment of treatment outcome among Cambodian refugees with sputum smear-positive tuberculosis in Khao-I-Dang, Thailand.

      Sukrakanchana-Trikham, P; Puéchal, X; Rigal, J; Rieder, H L; Médecins sans Frontières Tuberculosis Programme, Khao-I-Dang, Prachinburi, Thailand. (International Union Against Tuberculosis and Lung Disease, 1992-12)
      Tuberculosis control among displaced persons is fraught with difficulties to ensure adherence of patients to treatment for a prolonged period of time. In the Khao-I-Dang camp for Cambodian refugees an approach with daily, directly observed treatment throughout the course of 6 months duration was chosen to address the problem. Of a total 929 patients with sputum smear-positive tuberculosis who were enrolled from 1981 to 1990, 5.0% died, 75.5% completed treatment and were bacteriologically cured with a day-to-day adherence of more than 98%, none failed bacteriologically, 19.2% were transferred to another camp where continuation of treatment was guaranteed, and only 0.4% absconded from treatment. These data suggest that the approach to tuberculosis control in this refugee camp was very effective in cutting the chain of transmission of tuberculosis in a highly mobile population and in reducing substantially unnecessary morbidity and mortality.
    • [A foci of Schistosomiasis mekongi rediscovered in Northeast Cambodia: cultural perception of the illness; description and clinical observation of 20 severe cases]

      Biays, S; Stich, A H; Odermatt, P; Long, C; Yersin, C; Men, C; Saem, C; Lormand, J D; Médecins sans Frontières, Suisse. Odermatt_Biays@hotmail.com (Wiley-Blackwell, 1999-10)
      RésuméLa découverte en 1992 d'une population présentant des signes cliniques d'hypertension portale très évoluée a permis la redécouverte d'un foyer de bilharziose 'oublié' pendant plus de vingt ans dans la province de Kracheh au nord-est du Cambodge. Des éléments de la perception culturelle de la maladie par la population et des observations cliniques sur la morbidité grave provoquée par Schistosoma mekongi sont présentés. Les entretiens avec les patients et la population des villages alentours révèlent que la bilharziose a de lourdes conséquences psychosociales: angoisse de la mort, infirmité, invalidité. Les symptômes sont bien identifiés et auraient augmenté ces vingt dernières années. Ils font l'objet de dénominations et de traitements traditionnels spécifiques. Les descriptions cliniques de 20 patients illustrent la pathologie grave observée dans l'hôpital de Sambour, au nord de la province de Kracheh. Elles montrent le pouvoir pathogène de S. mekongi aux différents âges de la vie (de 7 à 58 ans): cachexie, hépatosplénomégalie, retard de croissance et pubertaire, décompensation d'hypertension portale avec ascite et rupture de varices oesophagiennes. L'efficacité du traitement à ces stades avancés de la maladie est inconstant: le suivi des patients sur 30 mois montre que 5 d'entre eux sont décédés, 5 se sont améliorés puis ont récidivés, 3 étaient dans des états stationnaires et 5 se sont nettement améliorés, 2 ont été perdus de vus. Les observations cliniques et les entretiens montrent qu'une pathologie très sévère, aux graves conséquences individuelles et communautaires, est présente dans la province de Kracheh. Cette maladie est liée à une infection par S. mekongi mais l'aggravation des symptômes par d'éventuelles infections associées est à préciser. A un stade avancé de la maladie le pronostic vital est très réservé même après traitement. Ces observations démontrent l'importance d'une intervention globale à long-terme sur toute la population touchée, à des degrés divers, par cette maladie. SUMMARY: In 1992 a foci of Schistosomiasis mekongi was rediscovered in the province of Kracheh in Northeast Cambodia. Severe clinical signs due to portal hypertension, which were frequently observed in this population, allowed the discovery of this 'forgotten' focus. Elements of the perception of the population and clinical observations of 20 severe cases due to S. mekongi infections are presented. Interviews with patients and villagers of the area of Kracheh showed severe psychosocial impact including fear from death, infirmity and invalidity. The symptoms of schistosomiasis were well known by the population and were reported to have increased in frequency in the last two decades. They have received traditional names and specific traditional treatment. (ABSTRACT TRUNCATED)
    • A Survey on Vaccine Efficacy in the City of Bongor (Chad) and its Operational Consequences for the Vaccination Program

      Luthi, J; Kessler, W; Boelaert, M; Médecins sans Frontières, Bruxelles, Belgique. (Published by WHO, 1997)
      A measles epidemic occurred in the city of Bongor, Chad, from 22 September 1993 to 26 June 1994. A total of 792 patients were hospitalized, with a case fatality rate of 5.2%. After the epidemic, the district management team evaluated the expanded programme on immunization (EPI). Through a cluster survey the attack rate was estimated to be 29.1% (95% confidence interval (CI) = 20.4-37.8%) for the age group 12-59 months (n = 206). For this same age group, the measles immunization coverage was estimated to be 44.2% (95% CI = 34.6-53.8%) and the vaccine efficacy 9.5% (95% CI = 0-41.5%). Several flaws in the logistic handling of the vaccines and especially in the cold chain were identified. These results indicated a serious management problem in the EPI, which the district team then immediately started to rectify. The method used to estimate the immunization coverage and efficacy in the study is rapid and low cost. Also, it is feasible at the district level and permits identification of management problems in the EPI.
    • Acceptability and Utilisation of Services for Voluntary Counselling [corrected] and Testing and Sexually Transmitted Infections in Kahsey Abera Hospital, Humera, Tigray, Ethiopia.

      Reilley, B; Hiwot, Z G; Mesure, J; Medecins sans Frontieres USA, 333 Seventh Avenue, 2nd floor 1001-5004, New York, USA. (2004-07)
      OBJECTIVES: A study was conducted to assess the acceptability and utilization of voluntary counselling and testing (VCT) and sexually transmitted infection (STI) services in Kahsey Abera Hospital, Humera. METHODS: Retrospective data was taken from hospital consultation logbooks from January 2002 to February 2003, and focus group discussions were conducted in March 2003 in the community. RESULTS: While the services were known and utilization is increasing, important misconceptions about the medical services, disease transmission, and STI treatment persist. Although hospital care was generally considered of high quality, persons often go to pharmacies to self-treat for STIs due to concerns about confidentiality, and the stigma of HIV deters many from wanting to know their serostatus. CONCLUSIONS: Additional education is needed on HIV/AIDS, STIs, and the medical services provided. Education may make use of community health workers or outreach workers in a small group where participants can feel comfortable to ask sensitive questions. HIV/AIDS treatment is planned for the near future and may be significant in reducing HIV/AIDS stigma.
    • Accessibility of diagnostic and treatment centres for visceral leishmaniasis in Gedaref State, northern Sudan.

      Gerstl, S; Amsalu, R; Ritmeijer, K; Médecins Sans Frontières Holland, Amsterdam, The Netherlands. sgerstl@aol.com (Wiley-Blackwell, 2006-02)
      OBJECTIVE: To evaluate the accessibility of visceral leishmaniasis (VL) treatment. METHOD: Community-based study using in-depth qualitative interviews and focus group discussions with key informants, as well as quantitative questionnaires with 448 randomly selected heads of households in nine representative villages in three geographical sub-regions. RESULTS: Despite the high incidence of the disease, most people in Gedaref State know little about VL, and help at a treatment centre is usually sought only after traditional remedies and basic allopathic drugs have failed. Factors barring access to treatment are: lack of money for treatment and transport, impassability of roads, work priorities, severe cultural restrictions of women's decision-making power and distance to the next health center. CONCLUSIONS: To provide more VL patients with access to treatment in this highly endemic area, diagnostic and treatment services should be decentralized. Health education would be a useful tool to rationalise people's health-seeking behaviour.
    • Accuracy of MUAC in the detection of severe wasting with the new WHO growth standards.

      Fernández, M A L; Delchevalerie, P; Van Herp, M; Medical Department, Brussels Operational Center, Doctors Without Borders, Brussels, Belgium. miguel.angel.luque@brussels.msf.org (2010-07)
      OBJECTIVES: The objectives of this study were to estimate the accuracy of using mid-upper-arm circumference (MUAC) measurements to diagnose severe wasting by comparing the new standards from the World Health Organization (WHO) with those from the US National Center for Health Statistics (NCHS) and to analyze the age independence of the MUAC cutoff values for both curves. METHODS: We used cross-sectional anthropometric data for 34,937 children between the ages of 6 and 59 months, from 39 nutritional surveys conducted by Doctors Without Borders. Receiver operating characteristic curves were used to examine the accuracy of MUAC diagnoses. MUAC age independence was analyzed with logistic regression models. RESULTS: With the new WHO curve, the performance of MUAC measurements, in terms of sensitivity and specificity, deteriorated. With different cutoff values, however, the WHO standards significantly improved the predictive value of MUAC measurements over the NCHS standards. The sensitivity and specificity of MUAC measurements were the most age independent when the WHO curve, rather than the NCHS curve, was used. CONCLUSIONS: This study confirms the need to change the MUAC cutoff value from <110 mm to <115 mm. This increase of 5 mm produces a large change in sensitivity (from 16% to 25%) with little loss in specificity, improves the probability of diagnosing severe wasting, and reduces false-negative results by 12%. This change is needed to maintain the same diagnostic accuracy as the old curve and to identify the children at greatest risk of death resulting from severe wasting.
    • Adherence to a Combination of Artemether and Lumefantrine (Coartem) in Kajo Keji, Southern Sudan.

      Depoortere, E; Salvador, E T C; Stivanello, E; Bisoffi, Z; Guthmann, J P; Epicentre, 42 bis boulevard Richard Lenoir, 75011 Paris, France. evelyn.depoortere@brussels.msf.org (Published by: Maney Publishing, 2004-09)
    • Adherence to a Six-Dose Regimen of Artemether-Lumefantrine for Treatment of Uncomplicated Plasmodium Falciparum Malaria in Uganda.

      Fogg, C; Bajunirwe, F; Piola, P; Biraro, S; Checchi, F; Kiguli, J; Namiiro, P; Musabe, J; Kyomugisha, A; Guthmann, J P; et al. (Published by: American Society of Tropical Medicine and Hygiene, 2004-11)
      Measuring baseline levels of adherence and identifying risk factors for non-adherence are important steps before the introduction of new antimalarials. In Mbarara in southwestern Uganda, we assessed adherence to artemether-lumefantrine (Coartem) in its latest World Health Organization blister formulation. Patients with uncomplicated Plasmodium falciparum malaria were prescribed artemether-lumefantrine and received an explanation of how to take the following five doses at home. A tablet count was made and a questionnaire was completed during a home visit. Among 210 analyzable patients, 21 (10.0%) were definitely or probably non-adherent, whereas 189 (90.0%) were probably adherent. Age group was not associated with adherence. Lack of formal education was the only factor associated with non-adherence after controlling for confounders (odds ratio = 3.1, 95% confidence interval [CI] = 1.1-9.7). Mean lumefantrine blood levels were lower among non-adherent (n = 16) (2.76 microg/mL, 95% CI = 1.06-4.45) than among adherent (n = 171) (3.19 microg/mL, 95% CI = 2.84-3.54) patients, but this difference was not statistically significant. The high adherence to artemether-lumefantrine found in our study suggest that this drug is likely to be very effective in Mbarara provided that patients receive clear dosage explanations.
    • Adherence to antiretroviral therapy assessed by drug level monitoring and self-report in cameroon

      Kouanfack, Charles; Laurent, Christian; Peytavin, Gilles; Ciaffi, Laura; Ngolle, Maguy; Nkene, Yvette Mawamba; Essomba, Claudine; Calmy, Alexandra; Mpoudi-Ngolé, Eitel; Delaporte, Eric; et al. (2008-06-01)
      OBJECTIVES: To compare adherence to antiretroviral therapy using drug level monitoring and self-report and to explore the relation between these 2 methods and viral load measurements. METHODS: Sixty patients received a fixed-dose combination of nevirapine, stavudine, and lamivudine in a clinical study in Cameroon. Adherence was assessed every 6 months until month 36 by nevirapine minimal plasma concentration and self-report. Plasma HIV-1 viral load was determined at the same time. Analyses included 159 complete observations. RESULTS: The proportion of patients labeled as "adherent" was significantly lower using nevirapine monitoring (88.7%, 95% confidence interval [CI]: 82.7 to 93.2) than self-report (97.5%, CI: 93.7 to 99.3; P = 0.002). Virologic failure was associated with the nevirapine concentration (adjusted odds ratio [aOR] = 4.43; P = 0.018) but not with the self-reported adherence (aOR = 0.84; P = 0.9). As compared with the virologic outcome, the sensitivity of nevirapine level monitoring for predicting inadequate adherence was 20.5%, the specificity was 91.7%, the positive predictive value was 44.4%, and the negative predictive value was 78.0%. For self-report, the respective values were 2.6%, 97.5%, 25.0%, and 75.5%. CONCLUSIONS: Drug level monitoring provided a more reliable estimate of adherence than self-report. This method could be used in research settings. Operational research is required to define how to improve the accuracy of the self-report method because it is the most feasible method in clinical practice.
    • Adherence to antiretroviral therapy in patients enrolled in a comprehensive care program in Cambodia: a 24-month follow-up assessment

      Spire, Bruno; Carrieri, Patrizia; Sopha, Pal; Protopopescu, Camelia; Prak, Narom; Quillet, Catherine; Ngeth, Chanchhaya; Ferradini, Laurent; Delfraissy, Jean-François; Laureillard, Didier; et al. (2008-05)
      BACKGROUND: The long-term maintenance of antiretroviral therapy (ART) remains an important issue, especially in limited-resource settings where additional barriers exist. A cross-sectional study was performed 24 months after ART initiation for patients treated in Cambodia in order to estimate the prevalence and identify determinants of non-adherence. METHODS: Adults receiving ART for 24 +/- 2 months were considered eligible for the study. Self-reported non-adherence was defined according to an algorithm based on six items. The questionnaire also assessed ART-related side effects and HIV disclosure. HIV-1 RNA plasma viral load was measured using real-time PCR. Multivariate rare events logistic regression analysis was used to identify independent factors associated with non-adherence. RESULTS: A total of 346 patients participated in the study. At 24 months, 95% of patients were adherent, 80% had HIV RNA <40 copies/ml and 75% had CD4+ T-cell counts >200 cells/mm3. Virological success was significantly higher in adherent patients than in non-adherent patients (81% versus 56%, P=0.021). Living in a rural area, limited HIV disclosure and perceived lipodystrophy were independently associated with non-adherence. CONCLUSIONS: At 24 months, adherence to ART was high and explained positive virological outcomes. In order to maintain adherence and long-term virological benefits, special attention should be given to patients living in rural areas, those with lipodystrophy-related symptoms and others who express difficulties disclosing their condition to close family members.
    • Adherence to the combination of sulphadoxine-pyrimethamine and artesunate in the Maheba refugee settlement, Zambia.

      Depoortere, E; Guthmann, J P; Sipilanyambe, N; Nkandu, E; Fermon, F; Balkan, S; Legros, D; Epicentre, Paris, France. evelyn.depoortere@msf.be (Wiley-Blackwell, 2004-01)
      Artemisinin-based combination therapy (ACT) is one strategy recommended to increase cure rates in malaria and to contain resistance to Plasmodium falciparum. In the Maheba refugee settlement, children aged 5 years or younger with a confirmed diagnosis of uncomplicated falciparum malaria are treated with the combination of sulphadoxine-pyrimethamine (1 day) and artesunate (3 days). To measure treatment adherence, home visits were carried out the day after the last treatment dose. Patients who had any treatment dose left were considered certainly non-adherent. Other patients' classification was based on the answers to the questionnaire: patients whose caretakers stated the child had received the treatment regimen exactly as prescribed were considered probably adherent; all other patients were considered probably non-adherent. Reasons for non-adherence were assessed. We found 21.2% (95% CI [15.0-28.4]) of the patients to be certainly non-adherent, 39.4% (95% CI [31.6-47.6]) probably non-adherent, and 39.4% (95% CI [31.6-47.6]) probably adherent. Insufficient explanation by the dispenser was identified as an important reason for non-adherence. When considering the use of ACT, the issue of patient adherence remains challenging. However, it should not be used as an argument against the introduction of ACT. For these treatment regimens to remain efficacious on a long-term basis, specific and locally adapted strategies need to be implemented to ensure completion of the treatment.
    • Adults receiving HIV care before the start of antiretroviral therapy in sub-Saharan Africa: patient outcomes and associated risk factors

      Bastard, Mathieu; Nicolay, Nathalie; Szumilin, Elisabeth; Balkan, Suna; Poulet, Elisabeth; Pujades-Rodriguez, Mar (Lippincott Williams & Wilkins, 2013-12-15)
      Gaining understanding of the period before antiretroviral therapy (ART) is needed to improve treatment outcomes and to reduce HIV transmission. This study describes the cascade of enrollment in HIV care, pre-ART follow-up, and predictors of mortality and lost to follow-up (LTFU) before ART initiation.
    • Anthropometry and Clinical Features of Kashin-Beck Disease in Central Tibet.

      Mathieu, F; Begaux, F; Suetens, C; De Maertelaer, V; Hinsenkamp, M; Médecins Sans Frontières, Département Médical, Bruxelles, Belgium. (Springer, 2001)
      We compared two different populations living in central Tibet with the purpose of establishing standard values for different anthropometric parameters in a rural population. Later on, these values were used as references for a similar study on a KBD population. One group (KBD) (n=1,246) came from the endemic areas, and the other group, serving as the control population (n=815), came from non-endemic areas. Both groups included children and adults and were of the Mongoloid type; they were farmers or semi-nomads. Height, weight, segment length, joint perimeter, joint diameter, joint movement were recorded. Also more subjective information such as general feeling of tiredness, rapid fatigue at work, work limitation, joint pain, muscle weakness, muscular atrophy, dwarfism, flatfoot, and waddling gate was also collected. Those variables were compared between the two groups.
    • Antibiotic Sensitivity of Endemic Shigella in Mbarara, Uganda.

      Legros, D; Ochola, D; Lwanga, N; Guma, G; Epicentre, Kampala, Uganda. (1998-03)
      We analysed the chimio-sensitivity to antibiotics of endemic strains of Shigella isolated in Mbarara district, southwest Uganda. Twenty four strains were isolated, of which none was sensitive to cotrimoxazole and eight (33.4%, 95% CI [15.6-55.3]) to ampicillin, the two antibiotics recommended to treat dysentery during non epidemic periods in Uganda. Two isolates were resistant to nalidixic acid and none was resistant to the fluoroquinolones (Ciprofloxacin, Norfloxacin). It is concluded that the results of this survey could be used to facilitate the elaboration of a new treatment protocol to treat endemic dysentery cases in Uganda.
    • Antimalarial efficacy of chloroquine, amodiaquine, sulfadoxine-pyrimethamine, and the combinations of amodiaquine + artesunate and sulfadoxine-pyrimethamine + artesunate in Huambo and Bie provinces, central Angola.

      Guthmann, J P; Ampuero, J; Fortes, F; Van Overmeir, C; Gaboulaud, V; Tobback, S; Dunand, J; Saraiva, N; Gillet, P; Franco, J; et al. (Elsevier, 2005-07)
      We studied three antimalarial treatments in Caala and Kuito, Angola, in 2002 and 2003. We tested chloroquine (CQ), amodiaquine (AQ) and sulfadoxine-pyrimethamine (SP) in Caala, and AQ, SP and the combinations AQ+artesunate (AQ+AS) and SP+artesunate (SP+AS) in Kuito. A total of 619 children (240 in Caala, 379 in Kuito) with uncomplicated Plasmodium falciparum malaria were followed-up for 28 days, with PCR genotyping to distinguish recrudescence from reinfection. PCR-corrected failure proportions at day 28 were very high in the CQ group (83.5%, 95% CI 74.1-90.5), high in the SP groups (Caala: 25.3%, 95% CI 16.7-35.8; Kuito: 38.8%, 95% CI 28.4-50.0), around 20% in the AQ groups (Caala: 17.3%, 95% CI 10.0-27.2; Kuito: 21.6%, 95% CI 14.3-30.6) and very low in the artemisinin-based combination groups (1.2%, 95% CI 0.0-6.4 for each combination AQ+AS and SP+AS). These results show that CQ and SP are no longer efficacious in Caala and Kuito and that the moderate efficacy of AQ is likely to be compromised in the short term if used as monotherapy. We recommend the use of AQ with AS, though this combination might not have a long useful therapeutic life because of AQ resistance.
    • Antimalarial efficacy of sulfadoxine-pyrimethamine, amodiaquine and a combination of chloroquine plus sulfadoxine-pyrimethamine in Bundi Bugyo, western Uganda.

      Checchi, F; Piola, P; Kosack, C; Ardizzoni, E; Klarkowski, D; Kwezi, E; Priotto, G; Balkan, S; Bakyaita, N; Brockman, A; et al. (Wiley-Blackwell, 2004-04)
      We report below an in vivo antimalarial efficacy study conducted in 2002 in Bundi Bugyo, a district of western Uganda housing a large displaced population. We tested sulfadoxine-pyrimethamine (SP), amodiaquine (AQ) and the combination chloroquine plus SP (CQ + SP). A total of 268 children with uncomplicated Plasmodium falciparum malaria were followed-up for 28 days according to WHO recommendations, with PCR genotyping to distinguish late recrudescences from re-infections. PCR-adjusted failure proportions at day 28 were 37.0% (34/92, 95% CI 27.1-47.7) in the SP group, 20.6% (14/68, 95% CI 11.7-32.1) in the AQ group and 22.8% (18/79, 95% CI 14.1-33.6) in the CQ + SP group. Early failures were particularly frequent in the SP group (15.2%). Clearance of gametocytes was slower in the SP and CQ + SP groups than in the AQ group. This study suggests that, in Bundi Bugyo, CQ + SP (Uganda's first-line regimen) will need to be replaced by a more efficacious regimen. Across Uganda, the deployment of SP containing combinations may not be a feasible long-term strategy. For Bundi Bugyo, we recommend a combination of artesunate and AQ. Our study also confirms previous findings that resistance is considerably underestimated by 14-day follow-ups. Antimalarial policy decisions should therefore be based on 28-day studies, with PCR adjustment to distinguish re-infections.
    • Artesunate + amodiaquine and artesunate + sulphadoxine-pyrimethamine for treatment of uncomplicated malaria in Democratic Republic of Congo: a clinical trial with determination of sulphadoxine and pyrimethamine-resistant haplotypes.

      Swarthout, T D; van den Broek, I; Kayembe, G; Montgomery, J; Pota, H; Roper, C; Médecins Sans Frontières, London, UK. (Wiley-Blackwell, 2006-10)
      We undertook a trial of artesunate + amodiaquine (AS + AQ) and artesunate + sulphadoxine-pyrimethamine (AS + SP) in 180 children of age 6-59 months with uncomplicated malaria in Democratic Republic of Congo. Children were randomly allocated to receive 3 days observed treatment of AS + AQ (n = 90) or 3 days of AS + SP (n = 90). Primary efficacy outcomes were 28-day parasite recurrence rates, and recrudescence rates were adjusted by genotyping to distinguish new infection and recrudescence. In addition, we determined the prevalence of molecular markers of resistance to sulphadoxine and pyrimethamine. Day 28 parasite recurrence rates were 16.9% (14/83; 95% CI: 9.5-26.7) in the AS + AQ group and 34.6% (28/81; 95% CI: 24.3-46.0) in the AS + SP group (P = 0.009). After PCR correction, recrudescence rates were 6.7% (5/74; 95% CI: 2.2-15.1) for AS + AQ and 19.7% (13/66; 95% CI: 10.9-31.3) for AS + SP (P = 0.02). There was no significant difference between the two arms in time to parasite clearance, fever clearance and gametocyte clearance. Parasite genotyping showed high frequencies of dihydrofolate reductase (dhfr) and dihydropteroate synthase (dhps) molecular SP-resistance markers, with 57% of the samples showing more than three mutations linked to SP resistance, and 27% with triple-dhfr/double-dhps haplotype, confirming that SP treatment failure rates are likely to be high. AS + AQ had significantly higher efficacy than AS + SP. These results contributed to the subsequent change to AS + AQ as first-line regimen in the country. Efforts to properly implement the new protocol and maintain adherence at acceptable levels should include health staff and patient sensitization. The 6.8% recrudescence rate indicates that AS + AQ should be monitored closely until a more effective artemisinin combination therapy regimen is needed and can be introduced.
    • Artesunate and sulfadoxine-pyrimethamine combinations for the treatment of uncomplicated Plasmodium falciparum malaria in Uganda: a randomized, double-blind, placebo-controlled trial.

      Priotto, G; Kabakyenga, J K; Pinoges, L; Ruiz, A; Eriksson, T; Coussement, F; Ngambe, T; Taylor, W R J; Perea, W; Guthmann, J P; et al. (Elsevier, 2008-01-25)
      Drug-resistant malaria is spreading in Africa. The few available drugs might be safeguarded if combined with an artemisinin derivative. We investigated the efficacy, safety, and tolerability of 2 combinations of artesunate with sulfadoxine-pyrimethamine (SP) in a mesoendemic region in Uganda with SP resistance, from September 1999 to June 2000. In a randomized, double-blind, placebo-controlled trial, 420 children aged 6-59 months with uncomplicated Plasmodium falciparum malaria were assigned SP alone (25 mg/kg sulfadoxine, 1.25 mg/kg pyrimethamine) or combined with artesunate (AS; 4 mg/kg/d) for either 1 d (SPAS1) or 3 d (SPAS3). Children were followed-up for 28 d. Day 14 cure rates were 84.6% (99/117) with SPAS3 and 61.9% (73/118) with SPAS1 compared with 55.8% (86/154) with SP. Corresponding day 28 results were 74.4% (87/117) and 45.2% (52/115) compared with 40.5% (62/153). A significant improvement was obtained with the addition of 3 d, but not 1 d, of artesunate (risk ratio [RR] = 1.5, 95% CI 1.3-1.8 at 14 d and RR = 1.8, 95% CI 1.5-2.3 at 28 d). Both AS regimens achieved significantly faster parasite clearance and lower gametocyte carriage. All drug regimens were well tolerated, but SP alone was ineffective. Treatment efficacy improved with SPAS3 but the cure rate at day 28 was modest. The combinations were well tolerated and safe. In areas where SP resistance is prevalent other combinations should be considered.
    • Artesunate versus quinine in the treatment of severe falciparum malaria in African children (AQUAMAT): an open-label, randomised trial

      Dondorp, Arjen M; Fanello, Caterina I; Hendriksen, Ilse C E; Gomes, Ermelinda; Seni, Amir; Chhaganlal, Kajal D; Bojang, Kalifa; Olaosebikan, Rasaq; Anunobi, Nkechinyere; Maitland, Kathryn; et al. (2010-11-08)
      Severe malaria is a major cause of childhood death and often the main reason for paediatric hospital admission in sub-Saharan Africa. Quinine is still the established treatment of choice, although evidence from Asia suggests that artesunate is associated with a lower mortality. We compared parenteral treatment with either artesunate or quinine in African children with severe malaria.
    • Association between older age and adverse outcomes on antiretroviral therapy: a cohort analysis of programme data from nine countries.

      Greig, Jane; Casas, Esther C; O'Brien, Daniel P; Mills, Edward J; Ford, Nathan; Médecins Sans Frontières, London, UK. jane.greig@london.msf.org (2012-07-31)
      Recent studies have highlighted the increased risk of adverse outcomes among older patients on antiretroviral therapy (ART). We report on the associations between older age and adverse outcomes in HIV/AIDS antiretroviral programmes across 17 programmes in sub-Saharan Africa.