Patterns of malaria indices across three consecutive seasons in children in a highly endemic area of West Africa: a three times-repeated cross-sectional study.

OBJECTIVES: To study the manifestations of Plasmodium infection, and its relations with the malaria disease, especially when comparing dry and rainy seasons in a hyperendemic area of West Africa. METHODS: The study was carried out in an area where malaria transmission is high, showing important seasonal variations. One thousand children, representing the total child population (1-12 year old), were observed transversally at the end of three consecutive seasons (dry/rainy/dry). The usual indicators, such as parasite density, splenomegaly, anaemia, or febrile disease were recorded and analysed. RESULTS: The prevalence of Plasmodium falciparum was high in all age groups and seasons, constantly around 60%. The high transmission season (rainy) showed higher rates of anaemia and spleen enlargement and, in the youngest children only, higher parasite densities. There were also differences between the two dry seasons: in the first one, there was a higher rate of fever than in the second one (p < 0.001). Low parasite density (<2,000 p/µl) was never associated with fever during any season, raising some concern with regard to the usefulness of parasite detection. The possible origins of fever are discussed, together with the potential usefulness of analyzing these indices on a population sample, at a time when fever incidence rises and malaria is one potential cause among others. The distinction to be made between the Plasmodium infection and the malaria disease is highlighted. CONCLUSIONS: These data confirm previous hypotheses of a strong difference in malaria infection and disease between dry and rainy seasons. The most relevant seasonal indicator was not mainly parasite rate and density but anaemia, spleen enlargement, prevalence and possible origin of fever. RECOMMENDATIONS: In any situation (i.e. fever or not) and especially during the dry season, one must consider that detection of parasites in the blood is only evidence of a Plasmodium infection and not necessarily of a malaria disease. In such a situation, it seems suitable to obtain, through national malaria teams, a well-defined situation of transmission and prevalence of Plasmodium infection following zones and seasons, in order to adapt control strategies. For researchers, a systematic management of data separately for dry and rainy season appears mandatory.

A "reverse pharmacology" approach for developing an anti-malarial phytomedicine.

A "reverse pharmacology" approach to developing an anti-malarial phytomedicine was designed and implemented in Mali, resulting in a new standardized herbal anti-malarial after six years of research. The first step was to select a remedy for development, through a retrospective treatment-outcome study. The second step was a dose-escalating clinical trial that showed a dose-response phenomenon and helped select the safest and most efficacious dose. The third step was a randomized controlled trial to compare the phytomedicine to the standard first-line treatment. The last step was to identify active compounds which can be used as markers for standardization and quality control. This example of "reverse pharmacology" shows that a standardized phytomedicine can be developed faster and more cheaply than conventional drugs. Even if both approaches are not fully comparable, their efficiency in terms of public health and their complementarity should be thoroughly considered.

Use of herbal remedies in the management of sleeping sickness in four northern provinces of Angola.

ETHNOPHARMACOLOGICAL RELEVANCE: This study reports for the first time on the use of folk medicine to treat sleeping sickness and its symptoms in four endemic provinces in northern Angola. By interviewing both traditional practitioners and confirmed patients, it highlights reasons to recourse to folk medicine, the plant species used for this affection as well as arises awareness about the use of particular plants showing potential risks. AIM OF THE STUDY: The aims of this explorative study were three-fold. Firstly, it informed on access to, and use of plant-based medicine as first-choice treatment by infected persons. Secondly, it aimed at collecting comprehensive data from patients and traditional healers on herbal remedies in order to identify plant species used in the management of the disease. Thirdly, it served as contribution for primary indication of potential risk of use associated with the studied plants and their preparation. MATERIALS AND METHODS: The study was conducted in 4 endemic provinces of Angola, namely Bengo, Zaire, Kwanza Norte and Uíge. We explored the use of herbal remedies by conducting structured and semi-structured interviews within two distinct study populations. The first group comprises 30 patients who had been diagnosed for trypanosomiasis and treated by the reference treatment. The second group included 9 traditional practitioners who had already treated sleeping sickness. The plants that were cited during the interviews were collected during field walks under supervision of a traditional healer, then authenticated and deposited at the National Herbarium in Luanda. RESULTS: Of the 30 included patients, 12 (40%) had turned to folk medicine in the management of trypanosomiasis and related symptoms. 7 medicinal plants were reported by this group. Considering the key motivation to consult a traditional practitioner, two main factors accounted for half of the cases: "past experience with folk medicine" and "family habit". Out of 9 traditional practitioners' interviewees, 26 medicinal plants were cited. Roots and leaves were the most used plant parts, and decoction was the common mode of preparation. Evidence for antitrypanosomal activity in the scientific literature was found for 56% (17 of 30) of the identified plant species. The most cited plant was Crossopteryx febrifuga (UR = 6). Some of the cited plants, as for example Aristolochia gigantea, raised concern about potential toxicity. CONCLUSIONS: With 40% of infected persons having turned first to folk medicine before consulting a medical doctor, this explorative study points out that plant-based medicines play an important role in local dynamics of health care. It highlights the need for primary assessment of potential risk of use related to the herbal recipes, and for reporting it to the concerned population. This first ethnobotanical study on trypanosomiasis in endemic provinces of Angola provides information on 30 plants, of which some had been identified as promising for further pharmacological research. Our results provide a first step towards the validation and valorization of Angolan herbal remedies for sleeping sickness.

Sublingual sugar for hypoglycaemia in children with severe malaria: a pilot clinical study.

BACKGROUND: Hypoglycaemia is a poor prognostic indicator in severe malaria. Intravenous infusions are rarely feasible in rural areas. The efficacy of sublingual sugar (SLS) was assessed in a pilot randomized controlled trial among hypoglycaemic children with severe malaria in Mali. METHODS: Of 151 patients with presumed severe malaria, 23 children with blood glucose concentrations < 60 mg/dl (< 3.3 mmol/l) were assigned randomly to receive either intravenous 10% glucose (IVG; n = 9) or sublingual sugar (SLS; n = 14). In SLS, a teaspoon of sugar, moistened with a few drops of water, was gently placed under the tongue every 20 minutes. The child was put in the recovery position. Blood glucose concentration (BGC) was measured every 5-10 minutes for the first hour. All children were treated for malaria with intramuscular artemether. The primary outcome measure was treatment response, defined as reaching a BGC of >or= 3.3 mmol/l (60 mg/dl) within 40 minutes after admission. Secondary outcome measures were early treatment response at 20 minutes, relapse (early and late), maximal BGC gain (CGmax), and treatment delay. RESULTS: There was no significant difference between the groups in the primary outcome measure. Treatment response occurred in 71% and 67% for SLS and IVG, respectively. Among the responders, relapses occurred in 30% on SLS at 40 minutes and in 17% on IVG at 20 minutes. There was one fatality in each group. Treatment failures in the SLS group were related to children with clenched teeth or swallowing the sugar, whereas in the IVG group, they were due to unavoidable delays in beginning an infusion (median time 17.5 min (range 3-40).Among SLS, the BGC increase was rapid among the nine patients who really kept the sugar sublingually. All but one increased their BGC by 10 minutes with a mean gain of 44 mg/dl (95%CI: 20.5-63.4). CONCLUSION: Sublingual sugar appears to be a child-friendly, well-tolerated and effective promising method of raising blood glucose in severely ill children. More frequent repeated doses are needed to prevent relapse. Children should be monitored for early swallowing which leads to delayed absorption, and in this case another dose of sugar should be given. Sublingual sugar could be proposed as an immediate "first aid" measure while awaiting intravenous glucose. In many cases it may avert the need for intravenous glucose.

The plant pathogen Pseudomonas aeruginosa triggers a DELLA-dependent seed germination arrest in Arabidopsis.

To anticipate potential seedling damage, plants block seed germination under unfavorable conditions. Previous studies investigated how seed germination is controlled in response to abiotic stresses through gibberellic and abscisic acid signaling. However, little is known about whether seeds respond to rhizosphere bacterial pathogens. We found that Arabidopsis seed germination is blocked in the vicinity of the plant pathogen Pseudomonas aeruginosa. We identified L-2-amino-4-methoxy-trans-3-butenoic acid (AMB), released by P. aeruginosa, as a biotic compound triggering germination arrest. We provide genetic evidence that in AMB-treated seeds DELLA factors promote the accumulation of the germination repressor ABI5 in a GA-independent manner. AMB production is controlled by the quorum sensing system IQS. In vitro experiments show that the AMB-dependent germination arrest protects seedlings from damage induced by AMB. We discuss the possibility that this could serve as a protective response to avoid severe seedling damage induced by AMB and exposure to a pathogen.

Argemone mexicana decoction for the treatment of uncomplicated falciparum malaria.

A prospective, dose-escalating, quasi-experimental clinical trial was conducted with a traditional healer using a decoction of Argemone mexicana for the treatment of malaria in Mali. The remedy was prescribed in three regimens: once daily for 3 days (Group A; n=23); twice daily for 7 days (Group B; n=40); and four times daily for the first 4 days followed by twice daily for 3 days (Group C; n=17). Thus, 80 patients were included, of whom 80% were aged<5 years and 25% were aged<1 year. All presented to the traditional healer with symptoms of malaria and had a Plasmodium falciparum parasitaemia>2000/microl but no signs of severe malaria. The proportions of adequate clinical response (ACR) at Day 14 were 35%, 73% and 65% in Groups A, B and C, respectively (P=0.011). At Day 14, overall proportions of ACR were lower in children aged<1 year (45%) and higher in patients aged>5 years (81%) (P=0.027). Very few patients had complete parasite clearance, but at Day 14, 67% of patients with ACR had a parasitaemia<2000/microl. No patient needed referral for severe disease. Only minor side effects were observed. Further research should determine whether this local resource could represent a first-aid home treatment in remote areas.

Beyond the myth of expensive clinical study: assessment of traditional medicines.

Clinical studies with human subjects represent the only assessment of effectiveness and safety that can translate into medical practice, and national or local health policy. There are several reasons why traditional medicines (in fact medicinal plants and other alternative or complementary medicines) should be subjected to more clinical research with patient observation and follow-up: firstly, this would help to select products of interest for further investigations in ethnopharmacology; secondly, it could translate into immediate recommendations for the population using the assessed local treatments. Contrary to a commonly held myth, clinical studies can be conducted at relatively low cost, if one works with local/regional research institutes and with doctoral students, focusing on meaningful clinical measures rather than sophisticated laboratory analyses. This paper describes special designs of clinical studies, appropriate for traditional medicines and tested in the field, including: the retrospective treatment-outcome population survey, the prognosis- outcome method (with modern physicians observing progress of patients treated by a traditional healer), the dose-escalating prospective study (detecting a dose-response phenomenon in humans). It is suggested that this approach offers the best cost-effective course of action for obtaining maximal benefits from traditional medicines, especially those used for treating endemic diseases.

Malaria treatment in remote areas of Mali: use of modern and traditional medicines, patient outcome.

Use of official health services often remains low despite great efforts to improve quality of care. Are informal treatments responsible for keeping a number of patients away from standard care, and if so, why? Through a questionnaire survey with proportional cluster samples, we studied the case histories of 952 children in Bandiagara and Sikasso areas of Mali. Most children with reported uncomplicated malaria were first treated at home (87%) with modern medicines alone (40%), a mixture of modern and traditional treatments (33%), or traditional treatment alone (27%). For severe episodes (224 cases), a traditional treatment alone was used in 50% of the cases. Clinical recovery after uncomplicated malaria was above 98% with any type of treatment. For presumed severe malaria, the global mortality rate was 17%; it was not correlated with the type of treatment used (traditional or modern, at home or elsewhere). In the study areas, informal treatments divert a high proportion of patients away from official health services. Patients' experience that outcome after standard therapeutic itineraries is not better than after alternative care may help to explain low use of official health services. We need to study whether some traditional treatments available in remote villages should be considered real, recommendable first aid.

Intellectual property rights, benefit-sharing and development of "improved traditional medicines": A new approach.

ETHNOPHARMACOLOGICAL RELEVANCE: Protection of intellectual property rights and benefit-sharing are key issues for all ethnopharmacological research. The International Society of Ethnobiology has produced helpful guidelines on access and benefit-sharing which are widely viewed as a "gold standard" but the question remains how best to apply these guidelines in practice. Difficult questions include ownership of traditional knowledge, making appropriate agreements, and how appropriately to share benefits. MATERIALS AND METHODS: We present the case study of the development of an "improved traditional medicine" for malaria in Mali and we report how benefit-sharing was applied in this case. RESULTS: The knowledge about the selected plant came independently from several families and traditional healers. The IPR approach was to recognise that this traditional knowledge belongs to the people of Mali and was used for their benefit in developing a new "improved traditional medicine" (ITM). The traditional healer whose method of preparation was used, and who collaborated in clinical trials, did not request any financial reward but asked for the ITM to be named after him. The most sustainable benefit for the community was sharing the results of which preparation of which medicinal plant seemed to be the most effective for treating malaria. Attempts at providing a health centre and training a health worker for the village did not prove to be sustainable. CONCLUSIONS: Respect for intellectual property rights and benefit-sharing are possible even in a context where the knowledge is not owned by a clearly identified person or group of people. The most sustainable benefits are intangible rather than material: namely recognition, improved knowledge about which traditional treatment is the best and how to prepare and take it.

Home treatments alone or mixed with modern treatments for malaria in Finkolo AC, South Mali: reported use, outcomes and changes over 10 years.

BACKGROUND: In 2003, a study in Mali showed that 87% of episodes of uncomplicated malaria were first treated at home. We investigated whether treatment-seeking patterns in Mali had changed 10 years later. METHODS: In 2013, we repeated the retrospective treatment-outcome study on 400 children with presumed malaria in the same area. RESULTS: Most children with reported uncomplicated malaria were still first treated at home (76% [196/258] in 2013 vs 85% in 2003; p=0.006), rather than in modern health centres (20% [52/258] in 2013 vs 12% in 2003; p=0.01). Overall, 58% of children with uncomplicated malaria were treated with herbal medicine alone, a significant increase from 24% 10 years earlier (p<0.001). This was associated with an increase in use of Argemone mexicana decoction from 8% to 26% (p<0.001), with a reported cure or improvement in 100% of cases among those aged >5 years. For severe malaria, first treatment was sought less often from a traditional healer compared with 10 years earlier (4% vs 32%; p<0.001) and more often from a modern health centre (29% vs 17%; p=0.04). CONCLUSIONS: Two trends that emerged are that there is a greater use of modern health facilities for treatment of severe malaria, and a greater use of traditional medicine alone for treatment of uncomplicated malaria.

Rapid assessment of alternative medicine through a comparison of the expected and observed progress of patients: a feasibility study of the prognosis/follow-up method.

OBJECTIVE AND METHOD: To test an unusual research design in assessing alternative care, in a classic Arabic medicine clinic in Mauritania. The need for a common language between alternative and standard (modern) practitioners, as well as patients, led to the development of a relative patient progress scale. Patient-observed progress under alternative treatment was compared to expected progress (prognosis) by alternative and standard practitioners. RESULTS: With a follow-up rate of 55 of 80 patients, alternative and standard practitioners had 86% agreement in judging patient progress (kappa = 0.46). Sixty-two percent (62%) of patients progressed as well or better than expected with standard medicine, according to standard practitioners. Classic Arabic medicine was found to be safe; standard practitioners observed signs of imminent danger in two patients only, one of whom was referred to the modern hospital, and the other not, by his own will. In the course of this study, CAM and standard practitioners started a weekly joint consultation. CONCLUSION: The prognosis/follow-up method is useful for the assessment of alternative medicine, especially when a study with a control group is impractical. It provides practitioners from different medical systems with elements of a common language. It may facilitate collaboration and appropriate referral between alternative and standard practitioners.

Reverse pharmacology for developing an anti-malarial phytomedicine. The example of Argemone mexicana.

Classical pharmacology has been the basis for the discovery of new chemical entities with therapeutic effects for decades. In natural product research, compounds are generally tested in vivo only after full in vitro characterization. However drug screening using this methodology is expensive, time-consuming and very often inefficient. Reverse pharmacology, also called bedside-to-bench, is a research approach based on the traditional knowledge and relates to reversing the classical laboratory to clinic pathway to a clinic to laboratory practice. It is a trans-disciplinary approach focused on traditional knowledge, experimental observations and clinical experiences. This paper is an overview of the reverse pharmacology approach applied to the decoction of Argemone mexicana, used as an antimalarial traditional medicine in Mali. A. mexicana appeared as the most effective traditional medicine for the treatment of uncomplicated falciparum malaria in Mali, and the clinical efficacy of the decoction was comparable to artesunate-amodiaquine as previously published. Four stages of the reverse pharmacology process will be described here with a special emphasis on the results for stage 4. Briefly, allocryptopine, protopine and berberine were isolated through bioguided fractionation, and had their identity confirmed by spectroscopic analysis. The three alkaloids showed antiparasitic activity in vitro, of which allocryptopine and protopine were selective towards Plasmodium falciparum. Furthermore, the amount of the three active alkaloids in the decoction was determined by quantitative NMR, and preliminary in vivo assays were conducted. On the basis of these results, the reverse pharmacology approach is discussed and further pharmacokinetic studies appear to be necessary in order to determine whether these alkaloids can be considered as phytochemical markers for quality control and standardization of an improved traditional medicine made with this plant.

Whole-Genome Shotgun Sequence of Arthrospira platensis Strain Paraca, a Cultivated and Edible Cyanobacterium.

Here we report the whole-genome shotgun sequence of a Peruvian strain of Arthrospira platensis (Paraca), a cultivated and edible haloalkaliphilic cyanobacterium of great scientific, technical, and economic potential.

Pre-hospital risk factors for inpatient death from severe febrile illness in Malian children.

BACKGROUND: Inpatient case fatality from severe malaria remains high in much of sub-Saharan Africa. The majority of these deaths occur within 24 hours of admission, suggesting that pre-hospital management may have an impact on the risk of case fatality. METHODS: Prospective cohort study, including questionnaire about pre-hospital treatment, of all 437 patients admitted with severe febrile illness (presumed to be severe malaria) to the paediatric ward in Sikasso Regional Hospital, Mali, in a two-month period. FINDINGS: The case fatality rate was 17.4%. Coma, hypoglycaemia and respiratory distress at admission were associated with significantly higher mortality. In multiple logistic regression models and in a survival analysis to examine pre-admission risk factors for case fatality, the only consistent and significant risk factor was sex. Girls were twice as likely to die as boys (AOR 2.00, 95% CI 1.08-3.70). There was a wide variety of pre-hospital treatments used, both modern and traditional. None had a consistent impact on the risk of death across different analyses. Reported use of traditional treatments was not associated with post-admission outcome. INTERPRETATION: Aside from well-recognised markers of severity, the main risk factor for death in this study was female sex, but this study cannot determine the reason why. Differences in pre-hospital treatments were not associated with case fatality.

Is parasite clearance clinically important after malaria treatment in a high transmission area? A 3-month follow-up of home-based management with herbal medicine or ACT.

Argemone mexicana (AM), a validated herbal medicine for uncomplicated malaria, seems to prevent severe malaria without completely clearing parasites in most patients. This study, in a high transmission area of South Mali, explores whether residual parasitaemia at day 28 was associated with subsequent malaria episodes and/or anaemia. Three hundred and one patients were randomly assigned to AM or artesunate/amodiaquine as first line treatment, of whom 294 were followed up beyond the standard 28 days, to 84 days. From day 29 to day 84, there were no significant differences between treatment groups in new clinical episodes of uncomplicated malaria (0.33 vs 0.31 episodes/patient), severe malaria (< 6% per month of patients aged ≤ 5 years) or moderate anaemia (hematocrit < 24%: 1.1% in both groups at day 84). Total parasite clearance at day 28 was not correlated with incidence of uncomplicated or severe malaria or of moderate anaemia over the subsequent two months. Total parasite clearance at day 28 was not clinically important in the context of high transmission. If this finding can be confirmed, some antimalarials which are clinically effective but do not completely clear parasites could nevertheless be appropriate in high transmission areas. Such a policy could be tested as a way to delay resistance to artemisinin combination therapies.

Argemone mexicana decoction versus artesunate-amodiaquine for the management of malaria in Mali: policy and public-health implications.

A classic way of delaying drug resistance is to use an alternative when possible. We tested the malaria treatment Argemone mexicana decoction (AM), a validated self-prepared traditional medicine made with one widely available plant and safe across wide dose variations. In an attempt to reflect the real situation in the home-based management of malaria in a remote Malian village, 301 patients with presumed uncomplicated malaria (median age 5 years) were randomly assigned to receive AM or artesunate-amodiaquine [artemisinin combination therapy (ACT)] as first-line treatment. Both treatments were well tolerated. Over 28 days, second-line treatment was not required for 89% (95% CI 84.1-93.2) of patients on AM, versus 95% (95% CI 88.8-98.3) on ACT. Deterioration to severe malaria was 1.9% in both groups in children aged 5 years) and 0% had coma/convulsions. AM, now government-approved in Mali, could be tested as a first-line complement to standard modern drugs in high-transmission areas, in order to reduce the drug pressure for development of resistance to ACT, in the management of malaria. In view of the low rate of severe malaria and good tolerability, AM may also constitute a first-aid treatment when access to other antimalarials is delayed.

[Knowledge of traditional healers on malaria in Kendi (Bandiagara) and Finkolo (Sikasso) in Mali ]. / La prise en charge du paludisme par les therapeutes traditionnels dans les aires de sante de Kendie (Bandiagara) et de Finkolo (Sikasso) au Mali.

The survey has been carried out in the context of the project "Traditional Practices and Primary Health Care", developed by the Traditional Medicine Department (DMT) of the INRSP and the Swiss Ngo Antenna Technologies, with the support of Aidemet Ngo. The objective was to evaluate the knowledge, attitudes and practices of traditional healers on uncomplicated and severe malaria, in the perspective of collaboration between traditional and modern medicine for the optimal care of the critical cases. The investigation has been conducted from January to February 2003 in the health areas of Kendié (Bandiagara District, Mopti Region) and Finkolo (Sikasso District and Region). The interviews concerned in total 79 traditional healers, 9 of which were women. The survey showed that the traditional healers have a good knowledge of the symptomatology of uncomplicated and severe malaria, and their diagnosis corresponds with that of the health workers who do not have access to laboratory analyses. On the other hand, the traditional etiology doesn't always correspond with the modern one, even if the traditional healers mention, among the causes of malaria, the mosquito bites. Most treatments were based on plant substances. We identified 66 medicinal species in total. The majority of them had already been studied for anti-plasmodial activity. We therefore investigated 8 of these plants, which had not previously been thoroughly studied. Extracts of different parts of these plants were tested on standard chloroquine-resistant strains of Plasmodium falciparum; the most active plants were Argemone mexicana, Securinega virosa, Spondias mombin and Opilia celtidifolia, with IC50 ranging from 1.00 to 4.01 microg/ml.

The cpcB-cpcA locus as a tool for the genetic characterization of the genus Arthrospira (Cyanobacteria): evidence for horizontal transfer.

To investigate the genetic diversity of the genus Arthrospira and to compare it with other cyanobacteria, sequences of 670 nt from the phycocyanin operon were determined for 23 natural, cultivated or commercial strains of Arthrospira and compared with sequences from 20 other non-Arthrospira cyanobacterial strains. The sequenced DNA fragment comprises the last 255 nt of cpcB, the cpcB-cpcA spacer and the first 304 nt of cpcA. The resulting phylogenetic tree confirms that the genus Arthrospira is not related to Spirulina. So far, cpcB-cpcA data suggest that the closest relative of Arthrospira is Planktothrix. Based on this locus, the genus Arthrospira consists of three genetically clustered lineages. However, the distribution of nucleotide substitutions indicates that these three lineages are not the result of a simple cladogenesis characterized by the accumulation of independent substitutions. Instead, the observed clustering is the result of horizontal transfers of blocks of sequences. Analysis of the distribution of substitutions in the sequenced fragment indicates a point of intragenic recombination close to the stop codon of cpcB. The capacity of exchange of genetic material among strains probably explains why morphology and geographical origin do not correlate with the cpcB-cpcA clusters. Nevertheless, this study shows for the first time that the genus Arthrospira, represented here by cultivated and wild specimens, is clearly monophyletic. Moreover, the cpcB-cpcA DNA fragment, comprising both highly and moderately variable regions, allows (1) a strict differentiation of the taxon Arthrospira from other cyanobacteria (using the coding regions only) and (2) the study of relationships inside Arthrospira (using both the coding and non-coding regions).