Examples of tropical disease control in the humanitarian medical programmes of MSF and Merlin.

Humanitarian medical programmes in the tropics have the opportunity to provide beacons of good practice. The use of modern drugs and diagnostics, a lack of bureaucracy, adequate budgets, motivated staff and well-functioning supply lines all contribute to the success of this approach. At a joint meeting of the Royal Society of Tropical Medicine, the London School of Hygiene and Tropical Medicine, Médecins Sans Frontières and Merlin, new data were presented on the outcomes of recent humanitarian programmes to control malaria (Ethiopia), human African trypanosomiasis (south Sudan), Lassa fever (Sierra Leone) and tuberculosis (Tomsk, former USSR).

Elevated blood selenium levels in the Brazilian Amazon.

Contaminated fish poses a difficult challenge throughout the world, on the one hand, fish is a very nutritious food source, while on the other hand it accumulates many toxic substances, including mercury (Hg). As part of our efforts in the Brazilian Amazon to maximize nutritional input from fish consumption, a dietary mainstay, and minimize toxic risk, we have been studying the role of selenium (Se), an essential element, that may influence the distribution of Hg in the body and influence Hg neurotoxicity. Se, which is naturally present in the soil, is ingested through consumption of various foods, notably fish, mammals and certain plants. The objectives of the present study were: (i) evaluate whole blood Se (B-Se) and Hg (B-Hg); (ii) characterize B-Se variations with respect to socio-demographic and dietary variables; and (iii) examine the relation between B-Se and B-Hg. A total of 236 persons from six riparian communities of the Tapajós River Basin, a tributary of the Amazon, participated in this study. Whole blood Se and Hg were measured and interview administered questionnaires were used to obtain data on socio-demographic variable, smoking and drinking habits, and fish and fruit consumption. The results show that B-Se are in the upper normal range (median=284.3 microg/L, range=142.1-2029.3 microg/L). No individuals presented B-Se deficiency, but 9 participants from the same extended family had relatively high B-Se levels, potentially a threat to their health. B-Se varied between communities, was significantly higher among alcohol drinkers and farmers, but not associated with age, sex or tobacco consumption. A significant positive relation between B-Se and B-Hg was noted, independently of the overall fish consumption. B-Se increased with consumption of Peacock bass (Cichla sp.), a piscivorous fish species, and coconut pulp (Cocos nucifera L.). The B-Se intercommunity variations may reflect geographic differences in local soil Se levels as well as traditional land use practices in the different ecosystems of the Tapajós River Basin. In this population with relatively high exposure to Hg, Se may play an important role. Further studies should examine, in this region, the sources of Se, its transmission through the terrestrial and aquatic ecosystem and its role with respect to human health.

Development of a National Consensus for Tactical Emergency Medical Support (TEMS) Training Programs--Operators and Medical Providers.

INTRODUCTION: Tactical teams are at high risk of sustaining injuries. Caring for these casualties in the field involves unique requirements beyond what is provided by traditional civilian emergency medical services (EMS) systems. Despite this need, the training objectives and competencies are not uniformly agreed to or taught. METHODS: An expert panel was convened that included members from the Departments of Defense, Homeland Security, Justice, and Health and Human Services, as well as federal, state, and local law-enforcement officers who were recruited through requests to stakeholder agencies and open invitations to individuals involved in Tactical Emergency Medical Services (TEMS) or its oversight. Two face-to-face meetings took place. Using a modified Delphi technique, previously published TEMS competencies were reviewed and updated. RESULTS: The original 17 competency domains were modified and the most significant changes were the addition of Tactical Emergency Casualty Care (TECC), Tactical Familiarization, Legal Aspects of TEMS, and Mass Casualty Triage to the competency domains. Additionally, enabling and terminal learning objectives were developed for each competency domain. CONCLUSION: This project has developed a minimum set of medical competencies and learning objectives for both tactical medical providers and operators. This work should serve as a platform for ensuring minimum knowledge among providers, which will serve enhance team interoperability and improve the health and safety of tactical teams and the public.

Early Hg mobility in cultivated tropical soils one year after slash-and-burn of the primary forest, in the Brazilian Amazon.

In the Brazilian Amazon, forest conversion to agricultural lands (slash-and-burn cultivation) contributes to soil mercury (Hg) release and to aquatic ecosystem contamination. Recent studies have shown that soil Hg loss occurs rapidly after deforestation, suggesting that Hg mobility could be related to the massive cation input resulting from biomass burning. The objective of this research was to determine the effects of the first year of slash-and-burn agriculture on soil Hg levels at the regional scale of the Tapajós River, in the state of Pará, Brazilian Amazon. A total of 429 soil samples were collected in 26 farms of five riparian communities of the Tapajós basin. In September 2004, soil samples were collected from primary forest sites planned for slash-and-burn cultivation. In August 2005, one year after the initial burning, a second campaign was held and the exact same sites were re-sampled. Our results showed that total Hg levels in soils did not change significantly during the first year following slash-and-burn, suggesting no immediate release of soil Hg at that point in time. However, an early Hg mobility was detected near the surface (0-5 cm), reflected by a significant shift in Hg distribution in soil fractions. Indeed, a transfer of Hg from fine to coarser soil particles was observed, indicating that chemical bonds between Hg and fine particles could have been altered. A correspondence analysis (CA) showed that this process could be linked to a chemical competition caused by cation enrichment. The regional dimension of the study highlighted the prevailing importance of soil types in Hg dynamics, as shown by differentiated soil responses following deforestation according to soil texture. Confirming an early Hg mobility and indicating an eventual Hg release out of the soil, our results reinforce the call for the development of more sustainable agricultural practices in the Amazon.

A comparison of liposomal amphotericin B with sodium stibogluconate for the treatment of visceral leishmaniasis in pregnancy in Sudan.

OBJECTIVES: Little is known about the treatment of visceral leishmaniasis (VL) in pregnancy, especially in resource-poor settings. We present a series of pregnant women with VL treated with either sodium stibogluconate or liposomal amphotericin B (AmBisome), or both, in eastern Sudan over 16 months. METHODS: We did a retrospective analysis of all pregnant VL patients treated in the Médecins sans Frontières (MSF) Um el Kher centre between January 2004 and April 2005. We diagnosed VL with laboratory confirmation of clinical suspects, and recorded the outcomes of treatment for pregnant women and their foetuses. We carried out a manual search of relevant publications and a systematic search of the literature in the MEDLINE database. RESULTS: We treated 23 women with sodium stibogluconate, 4 with AmBisome and sodium stibogluconate and 12 with AmBisome alone. There were 13 (57%) spontaneous abortions in the sodium stibogluconate monotherapy group, and none in either of the other two groups. All spontaneous abortions occurred in the first two trimesters. All patients, except one in the sodium stibogluconate group who defaulted, were discharged as cured in good clinical condition. CONCLUSIONS: AmBisome treatment for VL appears to be safe and effective for pregnant women and their foetuses. We recommend the use of AmBisome as first-line treatment for these patients.

Itraconazole in the treatment of New World mucocutaneous leishmaniasis.

BACKGROUND: A well-tolerated oral drug is required for the treatment of mucocutaneous leishmaniasis (MCL). Current parenteral treatment regimens with pentavalent antimonials are associated with marked toxicity and significant rates of relapse. AIM: To evaluate the efficacy and tolerability of high-dose itraconazole for the treatment of MCL. METHODS: An uncontrolled treatment study was performed in 13 Ecuadorian patients with MCL. Each patient received a daily dosage of 400 mg of itraconazole for a minimum of 3 months. RESULTS: All 13 subjects responded to itraconazole during the first month of treatment, but by 12 months after treatment the complete resolution of MCL lesions was observed in only three (23%) subjects. No adverse effects of treatment were reported. Response to treatment was associated with a short evolution of the disease and mild to moderate disease severity. CONCLUSION: Prolonged and high-dose treatment regimens with itraconazole are not effective for the treatment of the majority of patients with MCL.