COVAX - Time to reconsider the strategy and its target.

COVAX, the international initiative supporting COVID-19 vaccination campaigns globally, is budgeted to be the costliest public health initiative in low- and middle-income countries, with over 16 billion US dollars already committed. While some claim that the target of vaccinating 70% of people worldwide is justified on equity grounds, we argue that this rationale is wrong for two reasons. First, mass COVID-19 vaccination campaigns do not meet standard public health requirements for clear expected benefit, based on costs, disease burden and intervention effectiveness. Second, it constitutes a diversion of resources from more cost-effective and impactful public health programmes, thus reducing health equity. We conclude that the COVAX initiative warrants urgent review.

Suppressive, curative, and prophylactic potentials of an antimalarial polyherbal mixture and its individual components in Plasmodium berghei-Infected mice.

ETHNOPHARMACOLOGICAL RELEVANCE: Malaria remains one of the most prevalent infectious diseases in tropical regions of the world, particularly in sub-Saharan Africa, where it remains epidemiologically holoendemic. The absence of effective vaccines and Plasmodium resistance to antimalarial drugs have been the major challenges to malaria control measures. An alternative strategy could be the application of validated and standardized herbal formulations. AIM OF THE STUDY: To evaluate the antimalarial activity of a polyherbal mixture (APM) and compare it to those of its individual constituent plants. METHODS: APM consisted of stem barks of Mangifera indica (MI), Azadirachta indica (AI), Nauclea latifolia (and roots, NL) and roots of Morinda lucida (ML). Dihydroartemisinin-piperaquine (DHP) and pyronaridine-artesunate (PA) served as positive controls. Antimalarial activity was evaluated using suppressive, curative and prophylactic assays in mice infected with Plasmodium berghei. RESULTS: All the herbal mixtures, individually and in combination, showed significant (p < 0.05) antiplasmodial activities in the various assays. They produced considerable parasite suppression (>50%), substantial clearance (>70%), and notable prophylaxis (>60%, except for NL: 35%). APM (95.4-98.7%) and AI (92%), respectively, elicited greater and comparable suppression relative to DHP (88%) and PA (87.3%). However, all the herbal decoctions, individually (72-93.6%) and in combination (82.5-91%), showed lower parasite clearance than DHP (100%) and PA (99.5%). Meanwhile, APM showed relatively greater suppression and prophylaxis than its constituent plants, suggesting that the combination produced synergistic or additive effects. CONCLUSION: These findings could substantiate the use of these plants, singly or in combination, as traditional remedies for malaria. Further studies are recommended to evaluate their clinical usefulness.

Rare mutations in Pfmdr1 gene of Plasmodium falciparum detected in clinical isolates from patients treated with anti-malarial drug in Nigeria.

BACKGROUND: Plasmodium falciparum, the deadliest causative agent of malaria, has high prevalence in Nigeria. Drug resistance causing failure of previously effective drugs has compromised anti-malarial treatment. On this basis, there is need for a proactive surveillance for resistance markers to the currently recommended artemisinin-based combination therapy (ACT), for early detection of resistance before it become widespread. METHODS: This study assessed anti-malarial resistance genes polymorphism in patients with uncomplicated P. falciparum malaria in Lagos, Nigeria. Sanger and Next Generation Sequencing (NGS) methods were used to screen for mutations in thirty-seven malaria positive blood samples targeting the P. falciparum chloroquine-resistance transporter (Pfcrt), P. falciparum multidrug-resistance 1 (Pfmdr1), and P. falciparum kelch 13 (Pfk13) genes, which have been previously associated with anti-malarial resistance. RESULTS: Expectedly, the NGS method was more proficient, detecting six Pfmdr1, seven Pfcrt and three Pfk13 mutations in the studied clinical isolates from Nigeria, a malaria endemic area. These mutations included rare Pfmdr1 mutations, N504K, N649D, F938Y and S967N, which were previously unreported. In addition, there was moderate prevalence of the K76T mutation (34.6%) associated with chloroquine and amodiaquine resistance, and high prevalence of the N86 wild type allele (92.3%) associated with lumefantrine resistance. CONCLUSION: Widespread circulation of mutations associated with resistance to current anti-malarial drugs could potentially limit effective malaria therapy in endemic populations.

Misuse of Artemisinin Combination Therapies by Clients of Medicine Retailers Suspected to Have Malaria Without Prior Parasitological Confirmation in Nigeria.

BACKGROUND: Prompt and effective case detection and treatment are vital components of the malaria case management strategy as malaria-endemic countries implement the testing, treating and tracking policy. The implementation of this policy in public and formal private sectors continue to receive great attention while the informal private retail sector (mostly the patent and propriety medicine vendors [PPMVs]) where about 60% of patients with fever in Nigeria seek treatment is yet to be fully integrated. The PPMVs sell artemisinin combination therapies (ACTs) without prior testing and are highly patronized. Without prior testing, malaria is likely to be over-treated. The need to expand access to diagnosis in the huge informal private health sector among PPMVs is currently being explored to ensure that clients that patronize retail drug stores are tested before sales of ACTs. METHODS: A cross-sectional multistage study was conducted among 1279 adult clients, 20 years and above, who purchased malaria medicines from 119 selected PPMVs in five administrative areas (States) of Nigeria, namely: Adamawa, Cross River, Enugu, Lagos and Kaduna, as well as the Federal Capital Territory, Abuja. Exit interviews using a standard case report questionnaire was conducted after the purchase of the antimalarial medicine and thick/thin blood smears from the clients' finger-prick were prepared to confirm malaria by expert microscopy. RESULTS: Of the 1279 clients who purchased malaria medicines from the PPMV outlets, 107 (8.4%) were confirmed to have malaria parasites. The malaria prevalence in the various study areas ranged from 3.5% to 16%. A high proportion of clients in the various study sites who had no need for malaria medicines (84%-96.5%) purchased and used antimalarial medicines from the PPMVs. This indicated a high level of over-treatment and misuse of antimalarials. Common symptoms that are widely used as indicators for malaria such as, fever, headache, and tiredness were not significantly associated with malaria. Nausea/vomiting, poor appetite, chills, bitter taste in the mouth and dark urine were symptoms that were significantly associated with malaria among the adult clients (P<.05) but not fever (P=.06). CONCLUSION: Misuse of ACTs following overtreatment of malaria based on clinical diagnosis occurs when suspected cases of malaria are not prior confirmed with a test. Non-testing before sales of malaria medicines by PPMVs will perpetuate ACT misuse with the patients not benefiting due to poor treatment outcomes, waste of medicines and financial loss from out-of-pocket payment for unneeded medicines.

Factors contributing to anaemia after uncomplicated falciparum malaria in under five year-old Nigerian children ten years following adoption of artemisinin-based combination therapies as first-line antimalarials.

BACKGROUND: Artemisinin-based combination therapies (ACTs) have remained efficacious treatments of acute falciparum malaria in many endemic areas but there is little evaluation of factors contributing to the anaemia of acute falciparum malaria following long term adoption of ACTs as first-line antimalarials in African children. METHODS: Malarious <5 year-olds randomized to artemether-lumefantrine, artesunate-amodiaquine or dihydroartemisinin-piperaquine treatments were followed up clinically for 6 weeks. Anaemia was defined as haematocrit <30%; Malaria-attributable fall in haematocrit (MAFH) as the difference between haematocrit 28-42 days post- and pre-treatment; Total MAFH (TMAFH) as the difference between days 28-42 haematocrit and the lowest haematocrit recorded in the first week post-treatment initiation; Drug-attributable fall in haematocrit (DAFH) as the difference between MAFH and TMAFH; Early appearing anaemia (EAA) as haematocrit <30% occurring within 1 week in children with normal haematocrit pre-treatment. Predictors of anaemia pre-treatment, EAA, MAFH or DAFH >4% were evaluated by stepwise multiple logistic regression models. Survival analysis and kinetics of DAFH were evaluated by Kaplan-Meier estimator and non-compartment model, respectively. RESULTS: Pre-treatment, 355 of 959 children were anaemic. Duration of illness >2 days and parasitaemia ≤10,000 µL-1 were independent predictors of anaemia pre-treatment. EAA occurred in 301 of 604 children. Predictors of EAA were age ≤ 15 months, history of fever pre-treatment and enrolment haematocrit ≤35%. The probabilities of progression from normal haematocrit to EAA were similar for all treatments. MAFH >4% occurred in 446 of 694 children; its predictors were anaemia pre-treatment, enrolment parasitaemia ≤50,000 µL-1, parasitaemia one day post-treatment initiation and gametocytaemia. DAFH >4% occurred in 334 of 719 children; its predictors were history of fever pre-and fever 1 day post-treatment initiation, haematocrit ≥37%, and parasitaemia >100,000 µL-1. In 432 children, declines in DAFH deficits were monoexponential with overall estimated half-time of 2.2d (95% CI 1.9-2.6). Area under curve of deficits in DAFH versus time and estimated half-time were significantly higher in non-anaemic children indicating greater loss of haematocrit in these children. CONCLUSION: After ten years of adoption of ACTs, anaemia is common pre-and early post-treatment, falls in haematocrit attributable to a single infection is high, and DAFH >4% is common and significantly lower in anaemic compared to non-anaemic Nigerian children. TRIAL REGISTRATION: Pan African Clinical Trial Registry (PACTR) [ PACTR201709002064150, 1 March 2017 ].

Multicenter Pivotal Clinical Trial of Urine Malaria Test for Rapid Diagnosis of Plasmodium falciparum Malaria.

The need to expand malaria diagnosis capabilities alongside policy requirements for mandatory testing before treatment motivates exploration of noninvasive rapid diagnostic tests (RDTs). We report the outcome of the first cross-sectional, single-blind clinical performance evaluation of a urine malaria test (UMT) for diagnosis of Plasmodium falciparum malaria in febrile patients. Matched urine and finger-prick blood samples from participants ≥2 years of age with fever (axillary temperature of ≥37.5°C) or with a history of fever in the preceding 48 h were tested with UMT and microscopy (as the gold standard). BinaxNOW (Pf and Pan versions) blood RDTs were done to assess relative performance. Urinalysis and rheumatoid factor (RF) tests were conducted to evaluate possible interference. Diagnostic performance characteristics were computed at 95% confidence intervals (CIs). Of 1,800 participants screened, 1,691 were enrolled; of these 566 (34%) were febrile, and 1,125 (66%) were afebrile. Among enrolled participants, 341 (20%) tested positive by microscopy, 419 (25%) were positive by UMT, 676 (40%) were positive by BinaxNOW Pf, and 368 (22%) were positive by BinaxNow Pan. UMT sensitivity among febrile patients (for whom the test was indicated) was 85%, and specificity was 84%. Among febrile children ≤5 years of age, UMT sensitivity was 93%, and specificity was 83%. The area under the receiver-operator characteristic curve (AUC) of UMT (0.84) was not significantly different from that of BinaxNOW Pf (0.86) or of BinaxNOW Pan (0.87), indicating that the tests do not differ in overall performance. Gender, seasons, and RF did not impact UMT performance. Leukocytes, hematuria, and urobilinogen concentrations in urine were associated with lower UMT specificities. UMT performance was comparable to that of the BinaxNOW Pf/Pan tests, making UMT a promising tool to expand malaria testing in public and private health care settings where there are challenges to blood-based malaria diagnosis testing.

Cost-Effectiveness and Validity Assessment of Cyscope Microscope, Quantitative Buffy Coat Microscope, and Rapid Diagnostic Kit for Malaria Diagnosis among Clinic Attendees in Ibadan, Nigeria.

Background. Unavailability of accurate, rapid, reliable, and cost-effective malaria diagnostic instruments constitutes major a challenge to malaria elimination. We validated alternative malaria diagnostic instruments and assessed their comparative cost-effectiveness. Method. Using a cross-sectional study design, 502 patients with malaria symptoms at selected health facilities in Ibadan between January and April 2014 were recruited consecutively. We examined malaria parasites using Cyscope®, QBC, and CareStart™ and results were compared to light microscopy (LM). Validity was determined by assessing sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Costs per hour of use for instruments and turnaround time were determined. Result. Sensitivity of the instruments was 76.0% (CareStart), 95.0% (Cyscope), and 98.1% (QBC). Specificity was 96.0% (CareStart), 87.3% (Cyscope), and 85.5% (QBC). PPV were 65.2%, 67.5%, and 84.7%, while NPV were 93.6%, 98.6%, and 99.4% for CareStart, Cyscope, and QBC with Kappa values of 0.75 (CI = 0.68-0.82) for CareStart, 0.72 (CI = 0.65-0.78) for Cyscope, and 0.71 (CI = 0.64-0.77) for QBC. Average cost per hour of use was the lowest ($2.04) with the Cyscope. Turnaround time was the fastest with Cyscope (5 minutes). Conclusion. Cyscope fluorescent microscope had the shortest turnaround time and is the most cost-effective of all the malaria diagnostic instruments evaluated.

Overdiagnosis and overtreatment of malaria in children in a secondary healthcare centre in Sekondi-Takoradi, Ghana.

Overdiagnosis and overtreatment of malaria is a major problem in children in malaria-endemic countries. This retrospective study identified children who were admitted with fever and were treated with or without anti-malarial medications and discharged at the Paediatric Unit of the Effia-Nkwanta Regional Hospital. The medical records of all children were searched, retrieved and assessed. A total of 1160 records from children (age range, 0-12 years) were reviewed and evaluated. Of the total number, 21.3% had laboratory confirmed malaria, 38.4% were malaria negative, while 40.3% had no malaria tests performed. In addition, the results showed that 4.5% of the laboratory confirmed malaria positive cases were not given anti-malarial medication while 84.1% of the malaria negative cases were given these incorrectly. Furthermore, 78.2% of the children with no malaria tests were prescribed anti-malarial medication. The presumptive diagnosis of malaria should be abandoned and the installation of a functional laboratory services promoted.

Genotypes of Cryptosporidium spp. and Enterocytozoon bieneusi in Human Immunodeficiency Virus-Infected Patients in Lagos, Nigeria.

Molecular characterization of Cryptosporidium spp. and Enterocytozoon bieneusi has improved our understanding of the transmission of both organisms in humans. In this study, to infer possible infection sources, Cryptosporidium spp. and E. bieneusi in fecal specimens from 90 HIV-infected patients attending antiretroviral clinics in Lagos, Nigeria were detected and genotyped by PCR and DNA sequencing. Cryptosporidium spp. and E. bieneusi were identified in four and five patients, respectively, including the occurrence of subtype IeA11T3G3 of Cryptosporidium hominis in two patients, subtype IIcA5G3k of Cryptosporidium parvum in one patient, and Type IV of E. bieneusi in four patients. Among the remaining positive patients, one had mixed infection of Cryptosporidium meleagridis and C. hominis and one had mixed E. bieneusi genotypes. These data highlight a possible difference in major transmission routes (anthroponotic vs. zoonotic) between Cryptosporidium spp. and E. bieneusi in HIV+ patients in the study area.

Factors associated with risk of malaria infection among pregnant women in Lagos, Nigeria.

BACKGROUND: Pregnant women living in an area of stable malaria transmission such as Lagos, Nigeria, have been identified as being at an increased risk of the effects of malaria infection. In this area, most of the infections are asymptomatic which means they are overlooked and untreated much to the detriment of the mother and her foetus. The reality of scaled-up malaria interventions with long-lasting insecticide treated nets, vector control, artemisinin combination therapy (ACT) and intermittent preventive treatment of malaria pregnancy (IPTp) using sulphadoxine pyrimethamine (SP) is that it is also essential to determine the risk factors at play in these kinds of circumstances. This study was aimed at identifying the factors associated with risk of malaria infection in pregnant women in Lagos, Southwest Nigeria. METHODS: Demographic information and malaria prevention practices of the pregnant women studied were captured using structured questionnaire. Microscopy was used to establish malaria infection, species identification and parasite density. Relative risk and multivariate logistic regression analysis were used to compare factors associated with malaria in pregnant women. RESULTS: Malaria microscopy details, demographic information and malaria prevention practices of the pregnant women were obtained using a structured questionnaire. The prevalence of malaria using peripheral blood from 1,084 pregnant women that participated in the study was 7.7%. Plasmodium falciparum (P. falciparum) was seen in 95.2% of the cases as either mixed infection with P. malariae (3.6%) or as a mono infection (91.6%). Malaria preventive practices associated with a significant reduction (P<0.05) in the malaria infection was the use of insecticide sprays (RR = 0.36, 95 C.I. 0.24-0.54), and the combined use of insecticide spray and insecticide-treated nets (ITN) (RR= 6.53, 95% C.I. 0.92-46.33). Sleeping under ITN alone (RR = 1.07, 95% C.I. 0.55-2.09) was not associated with significant reduction in malaria infection among the study participants with malaria parasitaemia. Young maternal age (<20years) (RR = 2.86, 95% C.I. 1.48 - 5.50), but not primigravidity (RR = 1.36, 95% C.I. 0.90-2.05), was associated with an increased risk of malaria infection during pregnancy. After a multivariate logistic regression, young maternal age (OR = 2.61, 95% C.I. 1.13 - 6.03) and the use of insecticide spray (OR = 0.38, 95% C.I. 0.24-0.63) were associated with an increase and a reduction in malaria infection, respectively. CONCLUSION: Malaria prevalence was low among the pregnant women studied. Young maternal age and non-usage of insecticidal spray were the main factors associated with an increased risk of malaria infection among pregnant women in Lagos, Nigeria.

A current analysis of chemotherapy strategies for the treatment of human African trypanosomiasis.

Despite the recent advances in drug research, finding a safe, effective, and easy to use chemotherapy for human African trypanosomiasis (HAT) remains a challenging task. The four current anti-trypanosomiasis drugs have major disadvantages that limit more widespread use of these drugs in the endemic regions of sub-Saharan Africa. Pentamidine and suramin are limited by their effectiveness against the only first stage of Trypanosoma brucei gambiense and Trypanosoma brucei rhodesiense, respectively. In addition, melarsoprol and eflornithine (two second stage drugs) each have disadvantages of their own. The former is toxic and has increasing treatment failures while the latter is expensive, laborious to administer, and lacks efficacy against T. b. rhodesiense. Furthermore, melarsoprol's toxicity and decreasing efficacy are glaring problems and phasing out the drug as a frontline treatment against T. b. gambiense is now possible with the emergence of competent, safe combination chemotherapies such as nifurtimox-eflornithine combination treatment (NECT). The future of eflornithine, on the other hand, is more promising. The drug is useful in the context of combination chemotherapy and potential orally administered analogues. Due to the limits of monotherapies, greater emphasis should be placed on the research and development of combination chemotherapies, based on the successful clinical tests with NECT and its current use as a frontline anti-trypanosomiasis treatment. This review discussed the current and future chemotherapy strategies for the treatment of HAT.

Comparative study of entero-parasitic infections among HIV sero-positive and sero-negative patients in Lagos, Nigeria.

BACKGROUND: Intestinal parasites are endemic in many parts of the world where HIV infection is also widespread. Previous studies had shown that the spectrum of opportunistic and common endemic parasitic infections with HIV vary in different regions and usually reflect the infections prevalent in these regions. This present study was aimed at comparing the prevalence and types of intestinal parasitic infections in HIV sero-positive and sero-negative patients in Lagos. MATERIALS AND METHODS: Venous blood and stool samples of 1080 patients, recruited from three health care institutions were screened for HIV infection and intestinal parasites using HIV-1, HIV-2 rapid tests, direct wet mount with saline/iodine and formol-ether technique, respectively. RESULTS: Results showed that 6% (65/1080) of patients were sero-positive for HIV infection. In addition, 23.3% (252/1080) patients were infected with intestinal parasites and 33.8% (22/65) of patients with HIV had intestinal parasites co-infections. The prevalence of Entamoeba histolytica/Entamoeba dispar, Entamoeba coli, Iodamoeba butschilii, Giardia intestinalis, and Hookworm were statistically significantly higher among HIV sero-positive patients as compared to the HIV sero-negative patients. In addition, HIV sero-positive patients had higher odds of mixed intestinal parasites than the HIV sero-negative patients (9.1% versus 3.9%; adjusted OR 2.05, 95% CI, 1.14-3.72, P=0.021). CONCLUSION: In this study population, HIV sero-positive patients were more likely to have intestinal parasitic infections. The study underscores the public health significance of intestinal parasitic infections in HIV infected individuals.

Parasitologic Assessment of Two-Dose and Monthly Intermittent Preventive Treatment of Malaria during Pregnancy with Sulphadoxine-Pyrimethamine (IPTP-SP) in Lagos, Nigeria.

Intermittent preventive treatment of malaria with sulphadoxine-pyrimethamine (IPTP-SP) is a key strategy in the control of malaria in pregnancy. However, reports of increasing level of resistance to SP using nonpregnant populations have made it imperative for the continuous monitoring of the efficacy of SP in pregnant women. This study assessed using microscopy, monthly dosing and the standard two-dose regimen among 259 pregnant women attending antenatal clinics in Lagos, Nigeria that consented 122 in the two-dose arm (Arm A) and 137 in the monthly dose arm (Arm B). Baseline parasitaemia in the two groups was 5 (4.1%) and 3 (2.2%) in Arms A and B, respectively. Few of the women developed parasitaemia after the initial SP dose in Arms A 4 (3.3%) and B 2 (1.5%). However, none of the women had malaria infection after the second dose in both Arms. Although IPTP-SP is suggestive of protecting the women from malaria infection, there was no significant difference observed between the two dosing schemes.

Molecular surveillance of drug-resistant Plasmodium falciparum in two distinct geographical areas of Nigeria.

Drug resistance against P. falciparum has been recognized as the crucial obstacle to curbing mortality and morbidity from malaria. We therefore determined the baseline distribution of pfcrt and pfmdr1 genes associated with resistance to chloroquine and pfdhfr gene associated with resistance to pyrimethamine in P. falciparum isolates collected from two geographically distinct areas of Nigeria. We use RT-PCR assays and sequencing to determine the prevalence of these mutations. The combined prevalence of pfcrt T76 mutation in the two sites was 92.3% with 86% from Osogbo compared to 93% from Lafia. Sequencing analysis of the (Pfcrt) K76T haplotype (amino acids 72-76) revealed CVIET as the only resistance haplotype present in the two areas. The frequency of pfmdr1 polymorphisms was higher in Lafia (39%) compared to that in Osogbo (35%) and the combined prevalence from the two sites was 45.5%. The prevalence of the pfdhfr triple mutant alleles was high in both locations. The Osogbo vs Lafia prevalence for pfdhfr mutations was 84% vs 91%, 88% vs 87% and 96% vs 96% for I51, R59 and N108, respectively. None of the samples from the two locations had the T108 mutation. The combined prevalence of pfcrt and pfmdr1 in Osogbo and Lafia was 44.2% with a risk ratio of 0.4164 while the combined prevalence of pfcrt, pfmdr1 and pfdhfr was 40.4% with a risk ratio of 1.081. These results strongly suggest the widespread distribution of CQ and pyrimethamine resistance without any marked distinction between the two locations.

Strongyloides stercoralis and the immune response.

The immune system is a highly evolved network of cells and molecules that can distinguish between invading pathogens and the body's own cells. But helminths, in their complex forms, are capable of down-regulating host immunity, protecting them from being eliminated and also minimizing severe pathology in the host. This review focuses on Strongyloides stercoralis and the immune responses in immunocompetent and/or immunocompromised individuals. It also highlights the implications for diagnosis/treatment and draws attention to an emerging public health disease. The solution to reducing the prevalence of strongyloidiasis remains on the effectiveness of pre-emptive measures in endemic communities, increased awareness, prompt early diagnosis as well as timely treatment.

Prevalence of malaria in pregnant women in Lagos, South-West Nigeria.

Prevalence rates reported for malaria in pregnancy in Nigeria vary considerably. The accuracy of results of malaria diagnosis is dependent on training, experience, and motivation of the microscopist as well as the laboratory facility available. Results of training programmes on malaria microscopy have shown low levels of sensitivity and specificity of those involved in malaria diagnosis routinely and for research. This study was done to ascertain the true prevalence of malaria in pregnancy in Lagos, South-West Nigeria. A total of 1,084 pregnant women were recruited into this study. Blood smears stained with Giemsa were used for malaria diagnosis by light microscopy. Malaria infection during pregnancy presents mostly as asymptomatic infection. The prevalence of malaria in this population was 7.7% (95% confidence interval; 6.2-9.4%). Factors identified to increase the risk of malaria infection include young maternal age (< 20 years), and gravidity (primigravida). In conclusion, this study exposes the over-diagnosis of malaria in pregnancy and the need for training and retraining of laboratory staffs as well as establishing the malaria diagnosis quality assurance programme to ensure the accuracy of malaria microscopy results at all levels.

Dracunculiasis--the saddle is virtually ended.

Dracunculiasis is a preventable parasitic disease that for many years has affected poor communities without a safe portable water supply. Transmission is basically limited among the nomadic in remote rural settings. Most countries, including Asia, are declared free from the Guinea worm disease restraining the burden of transmission to Africa especially Sudan, Ghana, Mali, Nigeria and Niger. This review focuses mainly on the progress made so far by the Global Guinea Worm Eradication Programme championed by the Carter Center, Centers for Disease Control and Prevention, World Health Organisation, The United Nations Children's Fund and the individual efforts of endemic nations through their National Guinea Worm Eradication Programme aimed towards total global Guinea worm eradication.

Adverse reactions following annual ivermectin treatment of onchocerciasis in Nigeria.

OBJECTIVES: This study aims to document and underscore the need to monitor adverse reactions following repeated ivermectin treatment under the current dispensation of the implementation of the Community-directed Treatment with Ivermectin (CDTI) Program. As communities are empowered to distribute ivermectin, monitoring of adverse reactions by health care professionals is important in achieving the onchocerciasis control objectives through mass ivermectin therapy. METHODS: Eight hundred and ninety subjects from 204 randomly selected households (based on cluster of households) were interviewed using structured questionnaires and in-depth interviews. Responses concerning the adverse effects of ivermectin at the first and sixth rounds were obtained using self-report and treatment records. RESULTS: Of the 890 individuals, 40.67% presented with adverse reactions at the first round of treatment (TX(1)). This was reduced to 15.06% at the sixth (TX(6)) round of treatment. Pains in joints were more frequently reported at TX(1) and TX(6), 22.7% and 8.5%, respectively. CONCLUSION: The relatively mild adverse reaction rates observed at TX(1) did not affect future participation in community treatment with ivermectin, due to adequate community mobilization with health education messages. The current CDTI program has a good chance of achieving the onchocerciasis control program's objectives in Shao, Kwara State, Nigeria.

Use of CD-ROM MEDLINE by medical students of the College of Medicine, University of Lagos, Nigeria.

BACKGROUND: Use of information technology in information acquisition, especially MEDLINE on CD-ROM and online, has been evaluated in several localities and regions, especially in the advanced countries. Use of MEDLINE on CD-ROM is still very poor among the medical students of the University of Lagos, Lagos, Nigeria, due to lack of awareness, insufficient personal computers, nonperiodic training, and the high cost of using the facility. Due to financial constraints, MEDLINE online and sufficiently-networked computer systems are not available. OBJECTIVE: To report on the situation in Nigeria, a developing country, so as to compare the current awareness of searching MEDLINE on CD-ROM among the medical students at the University of Lagos with the awareness of their overseas' counterparts. This is the first step toward setting up an online PubMed search as well as expanding the computer systems and network. METHODS: Essentially based on cross-sectional proportional sampling using structured questionnaires, in-depth interviews, and focus-group discussions among the medical students and library staff. The study involved the medical students in their second year to sixth (final) year of study. RESULTS: Of the 250 students interviewed, 130 (52%) were aware of MEDLINE on CD-ROM searches as a means of information retrieval. Only 60 (24%) had used MEDLINE on CD-ROM-2% had used MEDLINE on CD-ROM more than 9 times; 4%, 7 to 9 times; 8%, 4 to 6 times; and 10%, 1 to 3 times. Of the students who used MEDLINE on CD-ROM search, 22% used it in preparing for examinations, 24% in research, 6% in patient care, and 26% in preparation of assignments and clinical cases. Lack of awareness (52%) and cost of undertaking MEDLINE on CD-ROM search (46%) were identified as important factors that discouraged the use of MEDLINE on CD-ROM. CONCLUSION: Though the above factors were recognized as important, it was concluded that the reasons for the poor use of MEDLINE on CD-ROM are multifactorial. Poor use of MEDLINE on CD-ROM could be attributed to these critical underlying factors: nonavailability of networked personal computers, which should be connected to a central server; lack of mandatory assignments to the medical students that would specifically require use of MEDLINE on CD-ROM; financial constraints on the university management; and infrequent periodic orientation on use of MEDLINE on CD-ROM. It was therefore suggested that the number of personal computers should be increased and that the library staff should periodically train the preclinical and clinical medical students in searching MEDLINE on CD-ROM. These steps would enable the medical students to benefit from online PubMed searching when it becomes fully operational in the future.