Transactions of the Royal Society of Tropical Medicine and Hygiene

Editorial Board

2010-02-01

Successes and challenges in global immunization efforts

Alexandra M. Hay — 2010-02-01

Vaccination is one of the most cost-effective health interventions and has become a major part of the strategy towards achieving Millennium Development Goal (MDG) 4, the reduction in deaths of children under 5 years of age by two-thirds (between 1990 and 2015). Immunization can become an even more effective health intervention when combined with other health services and treatments relevant to the particular population being targeted. Child Health Days supported by UNICEF are an example of linked interventions, when people are offered vaccinations along with other services such as vitamin A supplementation, nutritional screening, deworming tablets, oral rehydration salts and distribution of insecticide-treated bed nets.

Atypical manifestations of chikungunya infection

Senaka Rajapakse, Chathuraka Rodrigo, Anoja Rajapakse — 2010-02-01

Summary: Chikungunya fever is a viral infection transmitted to humans by the bite of infected mosquitoes. Typical chikungunya virus (CHIKV) infection results in an acute febrile illness characterized by severe joint pain and rash. Although chikungunya is generally not considered life threatening, atypical clinical manifestations resulting in significant morbidity have been documented, especially during epidemics. This review describes atypical manifestations following CHIKV infection reported in the literature, categorized as neurological, cardiovascular, skin, ocular, renal and other manifestations. The importance of vertical transmission from an infected mother resulting in neonatal infection is also highlighted. CHIKV infection can result in severe illness needing intensive care, with significant mortality. While there are many deaths reported which are directly attributable to CHIKV infection, background mortality is also increased during epidemics. In this context, considering CHIKV infection a benign and non fatal illness has to be revisited.

Human plague occurrences in Africa: an overview from 1877 to 2008

Simon Neerinckx, Eric Bertherat, Herwig Leirs — 2010-02-01

Summary: Plague remains a public health concern worldwide, but particularly in Africa. Despite the long-standing history of human plague, it is difficult to get a historical and recent overview of the general situation. We searched and screened available information sources on human plague occurrences in African countries and compiled information on when, where and how many cases occurred in a centralised database. We found records that plague was probably already present before the third pandemic and that hundreds of thousands of human infections have been reported in 26 countries since 1877. In the first 30 years of the 20th century, the number of human cases steadily increased to reach a maximum in 1929. From then on the number decreased and fell below 250 after 1945. Since the 1980s, again increasingly more human infections have been reported with the vast majority of cases notified in East Africa and Madagascar. We show that public health concerns regarding the current plague situation are justified and that the disease should not be neglected, despite the sometimes questionability of the numbers of cases. We conclude that improving plague surveillance strategies is absolutely necessary to obtain a clear picture of the plague situation in endemic regions.

Child age or weight: difficulties related to the prescription of the right dosage of antimalarial combinations to treat children in Senegal

A. Souares, R. Lalou, P. Senghor, J.Y. Le Hesran — 2010-02-01

Summary: Less than a year after the introduction of amodiaquine (AQ)/sulfadoxine-pyrimethamine (SP) as the first-line antimalarial treatment in Senegal, our study aimed to assess patients’ drug intake and check its correspondence with nurses’ prescription-adherence, the national guidelines regimen and theoretical dosage. The study was conducted at five health centers. Children aged 2–10 years who were prescribed AQ/SP by the nurse were recruited. At day 3, caregivers were questioned about treatment adherence. We collected information about nurses’ prescriptions and conducted in-depth interviews on prescription patterns. Among the 289 children who were recruited, 35.3% took less than 80% of the prescribed doses. Nevertheless, 47.7% and 83.7% respectively for AQ and SP received a dosage higher than the theoretical dosage. Age-weight discrepancy leads to overprescribing drugs: nurses acknowledged using the child's age more often than weight to determine the dosage if the child has a low weight. Under and overdosing are not only due to patient practices but causes related to national guidelines and health staff practices. For successful implementation and utilization of antimalarial combinations in Africa, countries should really focus on nurses’ training. National guidelines should also be based on national average weight instead of international tables.

Health implications of chronic hepatosplenomegaly in Kenyan school-aged children chronically exposed to malarial infections and Schistosoma mansoni

2010-02-01

Abstract: Hepatosplenomegaly among school-aged children in sub-Saharan Africa is highly prevalent. Two of the more common aetiological agents of hepatosplenomegaly, namely chronic exposure to malaria and Schistosoma mansoni infection, can result in similar clinical presentation, with the liver and spleen being chronically enlarged and of a firm consistency. Where co-endemic, the two parasites are thought to synergistically exacerbate hepatosplenomegaly. Here, two potential health consequences, i.e. dilation of the portal vein (indicative of increased portal pressure) and stunting of growth, were investigated in a study area where children were chronically exposed to malaria throughout while S. mansoni transmission was geographically restricted. Hepatosplenomegaly was associated with increased portal vein diameters, with enlargement of the spleen rather than the liver being more closely associated with dilation. Dilation of the portal vein was exacerbated by S. mansoni infection in an intensity-dependent manner. The prevalence of growth stunting was not associated with either relative exposure rates to malarial infection or with S. mansoni infection status but was significantly associated with hepatosplenomegaly. Children who presented with hepatosplenomegaly had the lowest height-for-age Z-scores. This study shows that hepatosplenomegaly associated with chronic exposure to malaria and schistosomiasis is not a benign symptom amongst school-aged children but has potential long-term health consequences.

Mycetoma in children in Sudan

A.H. Fahal, A.H. Abu Sabaa — 2010-02-01

Summary: We report on 722 children with confirmed mycetoma seen at the Mycetoma Research Centre, Khartoum, Sudan during May 1991 to March 2009. There were 531 males (73.5%) and 191 females (26.5%) with an age range of 4–17 years (mean 13.7±2.9 years); most were students. The majority of patients were from Central and Western Sudan. The disease duration ranged between 6 months and 14 years (mean 2.27±2.12 years). Most of the patients had eumycetoma (79.1%). The clinical course was typical in the majority of the patients. Family history of mycetoma was reported in 15% of patients. The foot was affected most, followed by knee, hand, head and neck, chest wall and buttocks. In the foot, the metatarsal bones and calcaneum were affected most. Cytological and ultrasonic examinations of the lesions and histological examination of the surgical biopsies were the cornerstone in the diagnosis of mycetoma. Combined medical treatment and surgical excision was the standard treatment. Disease recurrence after surgical excision was reported in 17.9% of patients. The morbidity rate in this study was high, and it had led to high school dropout and many socioeconomic impacts on patients, families and community. Children with mycetoma need psychological support to identify and to treat their psychosocial problems.

Intestinal helminths and protozoa in children in pre-schools in Kafue district, Zambia

2010-02-01

Summary: Intestinal parasitic infections are among the most widespread of human infections in developing countries, and children are the most vulnerable. The aim of this study was to determine the prevalence of the protozoa Cryptosporidium and Giardia, as well as prevalence and intensity of intestinal helminths in children attending pre-school or day-care centres in Kafue District, Zambia. Single stool samples were collected from 403 children from 10 pre-schools and were subjected to duplicate Kato–Katz thick smears to identify and quantify helminths. A commercial immunofluorescence kit was used to identify Cryptosporidium- and Giardia-positive samples. The overall prevalence of helminth infection was 17.9%. Ascaris lumbricoides was found in 12.0%, hookworm in 8.3%, Taenia spp. in 0.9%, Hymenolepis nana in 0.6% and Schistosoma mansoni in 0.3%. The overall prevalence of Cryptosporidium and Giardia was 28.0 and 29.0%, respectively, with more girls infected with Giardia (33.8%) than boys (22.7%) (P=0.02). Significant differences in infections with A. lumbricoides and Cryptosporidium were observed between the various pre-schools (P < 0.001). These findings indicate that intestinal parasites are prevalent in children enrolled in pre-schools in Zambia. Future studies should explore local factors associated with transmission of these infections, and consequently provide the necessary health education to parents and teachers.

Estimation of the cost of large-scale school deworming programmes with benzimidazoles

A. Montresor, A.F. Gabrielli, A. Diarra, D. Engels — 2010-02-01

Abstract: This study estimates the cost of distributing benzimidazole tablets in the context of school deworming programmes: we analysed studies reporting the cost of school deworming from seven countries in four WHO regions.The estimated cost for drug procurement to cover one million children (including customs clearance and international transport) is approximately US$20000.The estimated financial costs (including the cost of training of personnel, drug transport, social mobilization and monitoring) is, on average, equivalent to US$33000 per million school-age children with minimal variation in different countries and continents.The estimated economic costs of distribution (including the time spent by teachers, and health personnel at central, provincial and district level) to cover one million children approximately corresponds to US$19000. This study shows the minimal cost of school deworming activities, but also shows the significant contribution (corresponding to a quarter of the entire cost of the programme) provided by health and education systems in endemic countries even in the case of drug donations and donor support of distribution costs.

Estimating the burden of disease and the economic cost attributable to chikungunya, Andhra Pradesh, India, 2005–2006

T. Seyler, Y. Hutin, V. Ramanchandran, R. Ramakrishnan, P. Manickam, M. Murhekar — 2010-02-01

Summary: To estimate the burden and cost of chikungunya in India, we searched for cases of fever and joint pain in the village of Mallela, Andhra Pradesh, and collected information on the demography, signs, symptoms, healthcare utilization and expenditure associated with the disease. We estimated the burden of the disease using disability-adjusted life years (DALYs). We estimated direct and indirect costs and made projections for the district and state using surveillance data corrected for under-reporting. On average, from December 2005 to April 2006, each of the 242 cases in the village led to a burden of 0.0272 DALYs (95% CI 0.0224–0.0319) and a cost of US$37.50 (95% CI 30.6–44.3). Overall, chikungunya in Mallela led to 6.57 DALYs and a loss of US$9100. Out-of-pocket direct medical costs accounted for 68% of the total. From January to December 2006 the burden for Kadapa district was 160 DALYs (cost: US$290 000). Over the same period the burden for Andhra Pradesh was 6600 DALYs (cost: US$12 400 000). While the burden was moderate, costs were high and mostly out of pocket.

Estimating the healthcare burden of osteomyelitis in Uganda

2010-02-01

Summary: Chronic osteomyelitis is a considerable healthcare burden in many developing countries, but this burden is poorly quantified. To estimate the clinical burden of osteomyelitis we systematically sampled the medical records of orthopaedic clinics at five hospitals in Uganda. To estimate the surgical burden of osteomyelitis we reviewed the diagnosis in 9354 operations conducted during a 1 year period at the same five hospitals. Of 1844 outpatients with a documented diagnosis sampled over 1 year, 187 (10%) had osteomyelitis. Only 20% of those with osteomyelitis were older than 20 years, whereas this age group accounted for 52% of patients with another orthopaedic diagnosis or no diagnosis (P<0.001). Osteomyelitis was diagnosed in 325 (3.5%) of the surgical operations; in 32% of these operations the patients were children aged between 10 and 14 years. The tibia was the bone most frequently involved (31%), and sequestrectomy was the most frequent surgical procedure (60%). These findings suggest that osteomyelitis disproportionately affects the young, and is a burden on both clinical and surgical services. To decrease this burden in populations with limited resources, improved diagnosis and more timely treatment of acute osteomyelitis is needed.

Household and microeconomic factors associated with malaria in Mpumalanga, South Africa

2010-02-01

Summary: A household matched case–control study design was used to explore associations between household characteristics and malaria risk in seven study towns in the hypoendemic area of Mpumalanga Province, South Africa. Controls were identified from neighboring households of each case. Principle component analysis was used to calculate a wealth index for households to allow comparison across socioeconomic groups. Conditional univariate and multiple logistic regression analyses were used to assess associations between household malaria risk and potential risk factors. Univariate analysis demonstrated an increased household malaria risk for people living in mud-walled houses compared with those in brick dwellings (OR=5.10, 95% CI 2.03–12.80, P=0.001). Multivariate analysis confirmed the association between malaria risk and mud-wall construction (OR=6.12, 95% CI 2.26–16.59, P=0.001) and demonstrated an association with opening windows after retiring to sleep (OR=4.01, 95% CI 1.32–12.18, P=0.014). An inverse association between household wealth, third (OR=0.24, 95% CI 0.09–0.65, P=0.005) and fourth quartiles (OR=0.27, 95% CI 0.10–0.79, P=0.016), and malaria risk was observed. Associations found here include increased household malaria risk and mud-wall construction, the practice of opening of windows at night and relative household poverty. Education campaigns targeting risk behavior may reduce malaria risk, but economic development is a more important intervention.

Stavudine- and nevirapine-related drug toxicity while on generic fixed-dose antiretroviral treatment: incidence, timing and risk factors in a three-year cohort in Kigali, Rwanda

2010-02-01

Summary: This cohort study was conducted to report on the incidence, timing and risk factors for stavudine (d4T)- and nevirapine (NVP)-related severe drug toxicity (requiring substitution) with a generic fixed-dose combination under program conditions in Kigali, Rwanda. Probability of ‘time to first toxicity-related drug substitution’ was estimated using the Kaplan-Meier method and Cox-proportional hazards modeling was used to identify risk factors. Out of 2190 adults (median follow-up: 1.5 years), d4T was replaced in 175 patients (8.0%) for neuropathy, 69 (3.1%) for lactic acidosis and 157 (7.2%) for lipoatrophy, which was the most frequent toxicity by 3 years of antiretroviral treatment (ART). NVP was substituted in 4.9 and 1.3% of patients for skin rash and hepatotoxicity, respectively. Use of d4T 40mg was associated with increased risk of lipoatrophy and early (<6 months) neuropathy. Significant risk factors associated with lactic acidosis and late neuropathy included higher baseline body weight. Older age and advanced HIV disease increased the risk of neuropathy. Elevated baseline liver tests and older age were identified as risk factors for NVP-related hepatotoxicity. d4T is associated with significant long-term toxicity. d4T-dose reduction, increased access to safer ART in low-income countries and close monitoring for those at risk are all relevant strategies.

Baseline characteristics, response to and outcome of antiretroviral therapy among patients with HIV-1, HIV-2 and dual infection in Burkina Faso

2010-02-01

Summary: In an urban district hospital in Burkina Faso we investigated the relative proportions of HIV-1, HIV-2 and HIV-1/2 among those tested, the baseline sociodemographic and clinical characteristics, and the response to and outcome of antiretroviral therapy (ART). A total of 7368 individuals (male=32%; median age=34 years) were included in the analysis over a 6 year period (2002–2008). The proportions of HIV-1, HIV-2 and dual infection were 94%, 2.5% and 3.6%, respectively. HIV-1-infected individuals were younger, whereas HIV-2-infected individuals were more likely to be male, have higher CD4 counts and be asymptomatic on presentation. ART was started in 4255 adult patients who were followed up for a total of 8679 person-years, during which time 469 deaths occurred. Mortality differences by serotype were not statistically significant, but were generally worse for HIV-2 and HIV-1/2 after controlling for age, CD4 count and WHO stage. Among severely immune-deficient patients, mortality was higher for HIV-2 than HIV-1. CD4 count recovery was poorest for HIV-2. HIV-2 and dually infected patients appeared to do less well on ART than HIV-1 patients. Reasons may include differences in age at baseline, lower intrinsic immune recovery in HIV-2, use of ineffective ART regimens (inappropriate prescribing) by clinicians, and poor drug adherence.

Reliability of rapid testing for hepatitis B in a region of high HIV endemicity

2010-02-01

Summary: Hepatitis B (HBV) and HIV co-infection is common in resource-poor settings. A recent study from Malawi revealed poor correlation between hepatitis B surface antigen (HBsAg) point-of-care tests and reference tests in patients co-infected with HIV. We studied a cohort of 300 Malawian adults entering a treatment programme for HIV. Sera were tested for HBsAg first using the Determine rapid test and re-tested using a commercial enzyme immunoassay (EIA). All tests were done under optimal conditions in Liverpool, UK. Sera from all 25 patients positive for HBsAg using the rapid test and from 50 who were negative, were re-tested using the EIA, with complete concordance of results. The κ correlation was 1, specificity 100% (93–100%) and sensitivity 100% (86–100%) compared to the reference test. Patients had advanced immune suppression (mean CD4=175 cells×106/l). In a non-field setting, the results of point-of-care Determine rapid hepatitis B tests appear reliable in patients with HIV-1 co-infection.

Rotavirus genotype G4P[8] and enteric adenovirus in HIV-positive patients with and without diarrhoea in São Paulo State, Brazil

2010-02-01

Summary: The present study was carried out in order to identify rotavirus and enteric adenovirus in HIV-positive patients with and without diarrhoea, collected in a pre- and early highly active antiretroviral therapy era. Rotavirus was detected in 2.5% (3/118) and adenovirus in 14.4% (17/118) of the samples from patients without diarrhoea. In the patients with diarrhoea, rotavirus was identified in 1.5% (2/133) and adenovirus in 7.5% (10/133). These findings suggest no increased frequency of virus excretion in HIV-infected patients with diarrhoea. The genotype G4P[8] was characterized in all positive rotavirus samples, and this is the first report of rotavirus molecular characterization in HIV-positive patients in Brazil.

Chromoblastomycosis in Sarawak, East Malaysian Borneo

Felix Boon Bin Yap — 2010-02-01

Summary: A retrospective study was conducted to determine the clinical characteristics and treatment outcomes of 11 new patients with a histological diagnosis of chromoblastomycosis at Sarawak General Hospital, Malaysia, between 1996 and 2008. The majority (81.8%) were males, and the median age at presentation was 40 years. Over half the patients were farmers. All the patients had irregular verrucous lesions, mostly on the lower limbs (90.9%), and had initially been misdiagnosed. The mean duration of the lesions was 13.8 years. Oral terbinafine and itraconazole were administered to all the patients; clinical cure was seen in 54.5%, and partial response in 18.2%. Concomitant electrocautery and cryotherapy were only effective for small lesions.

Cutaneous larva migrans: a neglected disease and possible association with the use of long socks

2010-02-01

Summary: Cutaneous larva migrans is a common parasitic skin disease that can be easily prevented by wearing ‘protective’ footwear. However, this has been under-emphasized in terms of what constitutes the protective footwear. Even though the disease resolves spontaneously, the significant duration of the disease along with severity of pruritus make treatment unavoidable. Here, we present a very long-standing creeping eruption, which puzzled many attending clinicians handling the case, and the possibility of long socks as a causal effect on the development of cutaneous larva migrans infection.

Plagiarism

Alan C. Jackson, Allan R. Ronald, Israel Steiner — 2010-02-01

In a recent issue of the Transactions of the Royal Society of Tropical Medicine and Hygiene, Uneke and Ogbonna published a review article on treatment impact of malaria and HIV co-infection in pregnancy in Africa. In the same issue, correspondence from Brentlinger et al. (with 10 co-authors) provides excellent detailed documentation of plagiarism in the review article from at least 16 previously published review articles and research reports. In an extensive supplementary table Brentlinger et al. showed 34 excerpts of text from source papers without text identified as a quotation; in the majority, the source paper was not even referenced in the same paragraph (19/34=56%). Brentlinger et al. requested that the paper be retracted after reviewing the online electronic version and they disagreed with the decision to proceed with print publication. In their response letter Uneke and Ogbonna indicate that “authorship was well attributed as much as possible” and they state that a “review that is scientifically sound is likened to ‘honey’ formed by the honey bees from a combination of nectar from the flowers of various plants.” Finally, the Editor-in-Chief, Bo Drasar, wrote that “when material has been electronically published it remains available and it is not possible to delete material from circulation” and “in the interest of openness and for the avoidance of doubt” he proceeded to publish the review article and also the letter by Brentlinger et al. and the response letter by Uneke and Ogbonna. He did not refute in any way the allegation of plagiarism and failed to address the abundant evidence provided in the supplementary table of Brentlinger et al.

Plagiarism: editor's response

Bo Drasar — 2010-02-01

Plagiarism is a serious matter and undermines the credibility of authorship. In this edition of the Transactions Jackson and his co-authors express their disagreement with my handling of a recent case.

Editorial Board statement

B.D. Drasar — 2010-02-01

The Editorial Board wishes it to be known that it condemns plagiarism. We are aware that the article by Uneke and Ogbonna is plagiarised and note the actions that have been taken to give this offence the widest possible exposure. We are fully cognisant of the problem of removing materials once published on the internet but wish to designate the article as ‘Withdrawn because of Plagiarism’.