High dermatophyte contamination levels in hairdressing salons of a West African suburban community.

Tinea capitis is a dermatophyte infection of scalp is commonly spread by currently infected patients, asymptomatic carriers or by fomites, such as hairdressing tools. However, studies on the risk factors of Tinea capitis remain scarce. The aim of this study was to evaluate the dermatophytes contamination level of the hairdressing tools to which hairdressing salon customers are exposed in Sirakoro-Méguétana, a suburb of Bamako, the capital city of Mali. A total of 41 hairdressing tools were sampled in five hairdressing salons. Two anthropophilic dermatophytes species, Microsporum audouinii (53.3%) and Trichophyton soudanense (46.7%), were cultured from 30 (73.2%) samples. This first study, addressing hairdressing salons dermatophyte contamination, revealed a strikingly high contamination of hairdressing tools with dermatophyte propagules, which exposes hairdressing salons customers to an important dermatophytosis risk. The sterilisation of hairdressing tools is central to preventing dermatophytoses spreading. Appropriate community information and hairdressers training should be implemented in this view.

Fc gamma receptor IIa-H131R polymorphism and malaria susceptibility in sympatric ethnic groups, Fulani and Dogon of Mali.

It has been previously shown that there are some interethnic differences in susceptibility to malaria between two sympatric ethnic groups of Mali, the Fulani and the Dogon. The lower susceptibility to Plasmodium falciparum malaria seen in the Fulani has not been fully explained by genetic polymorphisms previously known to be associated with malaria resistance, including haemoglobin S (HbS), haemoglobin C (HbC), alpha-thalassaemia and glucose-6-phosphate dehydrogenase (G6PD) deficiency. Given the observed differences in the distribution of FcγRIIa allotypes among different ethnic groups and with malaria susceptibility that have been reported, we analysed the rs1801274-R131H polymorphism in the FcγRIIa gene in a study of Dogon and Fulani in Mali (n = 939). We confirm that the Fulani have less parasite densities, less parasite prevalence, more spleen enlargement and higher levels of total IgG antibodies (anti-CSP, anti-AMA1, anti-MSP1 and anti-MSP2) and more total IgE (P < 0.05) compared with the Dogon ethnic group. Furthermore, the Fulani exhibit higher frequencies of the blood group O (56.5%) compared with the Dogon (43.5%) (P < 0.001). With regard to the FcγRIIa polymorphism and allele frequency, the Fulani group have a higher frequency of the H allele (Fulani 0.474, Dogon 0.341, P < 0.0001), which was associated with greater total IgE production (P = 0.004). Our findings show that the FcγRIIa polymorphism might have an implication in the relative protection seen in the Fulani tribe, with confirmatory studies required in other malaria endemic settings.

[Epidemiology of cutaneous leishmaniasis in five villages of Dogon country, Mali]. / Épidémiologie clinique et parasitologique de la leishmaniose cutanée dans cinq villages du Pays Dogon, Mali.

The epidemiology of the cutaneous leishmaniasis (CL) with Leishmania major is poorly documented in Mali. Following reports of CL in the tourist areas of the Dogon country (Bandiagara Escarpment), a joint French and Malian bio-clinical team conducted a field study from 16 to 27 January, 2010. The population of 5 villages has been examined by a dermato-infectiologist and cases were selected by visual inspection of skin lesions. Smears and biopsies (from the lesions) and venous blood were obtained from suspected cases of CL. Diagnosis was performed by light microscopy, in vitro cultures, serology and molecular biology. Fifty patients with skin lesions have been examined. Twenty-one have been suspected as CL. At least one sample was obtained from 18 patients. The lesions were predominantly old, more or less scarring and secondary infected. A skin smear was performed for 15 patients, a skin biopsy for 14 patients: smears and cultures were all negative. The PCR (Leishmania spp.) made on 14 biopsies was positive for 12 patients (86%). The low amount of amplified DNA obtained did not allow the sequencing and identification of the species of Leishmania. Western blot (WB) serology was positive in 11 cases out of 12 (92%). This investigation showed the presence of cutaneous leishmaniasis in Bandiagara. A further investigation is required during transmission period (September-October) to confirm the presence of Leishmania major epidemic in Dogon country.

Association of HLA alleles with Plasmodium falciparum severity in Malian children.

Pre-erythrocytic immunity to Plasmodium falciparum malaria is likely to be mediated by T-cell recognition of malaria epitopes presented on infected host cells via class I and II major histocompatibility complex (MHC) antigens. To test for associations of human leukocyte antigen (HLA) alleles with disease severity, we performed high-resolution typing of HLA class I and II loci and compared the distributions of alleles of HLA-A, -B, -C and -DRB1 loci in 359 Malian children of Dogon ethnicity with uncomplicated or severe malaria. We observed that alleles A*30:01 and A*33:01 had higher frequency in the group of patients with cerebral disease compared to patients with uncomplicated disease [A*30:01: gf = 0.2031 vs gf = 0.1064, odds ratio (OR) = 3.17, P = 0.004, confidence interval (CI) (1.94-5.19)] and [A*33:01: gf = 0.0781 vs gf = 0.0266, 4.21, P = 0.005, CI (1.89-9.84)], respectively. The A*30:01 and A*33:01 alleles share some sequence motifs and A*30:01 appears to have a unique peptide binding repertoire compared to other A*30 group alleles. Computer algorithms predicted malaria peptides with strong binding affinity for HLA-A*30:01 and HLA-A*33:01 but not to closely related alleles. In conclusion, we identified A*30:01 and A*33:01 as potential susceptibility factors for cerebral malaria, providing further evidence that polymorphism of MHC genes results in altered malaria susceptibility.

[Neuromeningeal cryptococcosis in Mali]. / La cryptococcose neuro-méningée au Mali.

Cryptococcal meningitis is the most common fatal central nervous system infection in AIDS patients in Sub-Saharan Africa. The purpose of this prospective study conducted from March 2003 to February 2004 in the internal medicine and infectious diseases departments of the Point G University Hospital Center was to investigate the clinical, prognostic and epidemiological profile of Cryptococcus neoformans infection in patients hospitalized for brain and meningeale infection (BMI). Diagnosis of neuromeningeal cryptococcosis (NMC) was based on positive identification of Cryptococcus by direct exam of the cebrospinal fluid (CSF) after India ink staining and/or culture on Sabouraud medium without actidione. During the study period, a total of 569 patients were hospitalized including 235 (41.3%) with HIV infection. Overall C. neoformans was identified in 14 patients. Median patient age was 39 +/- 8 years. There was a male preponderance with a sex ratio of 1.8 (9 men/5 women). Patients with BMI were HIV-positive in 85.7% of cases (n=12) and HIV-negative in 14.3% (n=2). The overall and HIV-specific prevalence of BMI was 2.5% and 5.1% respectively. The CD4 lymphocyte count was between I and 49 cells/mm3 in 64.3% of cases. The main clinical symptoms were cephalea in 85.7% of cases, altered consciousness in 50% and nausea/vomiting in 35.7%. Neurological manifestations (hemiparesis and cranial nerve deficit) were noted in 14.3%. HIV infection is the main purveyor of NMC in Mali. The actual incidence of cryptococcosis is unclear due to the poor sensitivity of diagnostic techniques. This study highlights diagnostic difficulties related to clinical polymorphism and poor technical facilities. Agglutination testing of blood and CSF is recommended, but mortality remains.

[Obstacles to laboratory diagnosis of malaria in Mali--perspectives]. / Problématique du diagnostic biologique du paludisme au Mali--perspectives.

Rapid accurate laboratory diagnosis is necessary for effective malaria management. In Mali, meeting this prerequisite is impeded by underuse of laboratory diagnosis by clinicians, absence of qualified laboratory facilities in some locations, and poor continuous professional education of laboratory technicians. The twofold aim of this investigation was to perform quality control of thick smear readings made by laboratory technicians in 1998 and 1999 and to study the feasibility and diagnostic value of two rapid diagnostic tests (RDT), i.e., ParaSight and OptiMAL, in comparison with the thick smear technique in the period from 1998 to 2003. Quality control of thick smear readings indicated a 56% false positive rate with 49.3% concordance between laboratory technician readings and the reference centre. Trials using RDT showed that the OptiMAL test was more efficient with 97.2% sensibility, 95.4% specificity and 93% concordance in comparison with thick smear. A program of training, refresher courses, and regular didactic supervision (quality control) for laboratory technicians has been set up in Mali under the sponsorship of the "Fondation Mérieux" (ACTION BIOMALI) and the President's Malaria Initiative (PMI). These institutions provide funding for training as well as equipment and consumables in all public medical laboratories in Mali. The thick smear method is still being used as the reference technique, but use of RDT is to be implemented at all levels of the health care pyramid.

[Development of anti-malarial vaccines and need for clinical trials in accordance with international standards in South Africa]. / Le développement de vaccins antipaludiques et la nécessité des essais cliniques conformes aux normes internationales en Afrique.

In the 20th century malaria remains a major problem of public health in sub-Saharan Africa. This haemosporidium discovered in Africa by Laveran in 1880, kills one child every 30 seconds which amounts to three "tsunami" flowing each year into the African continent. The current international solidarity raises new hopes as regards the possibility to suppress the morbidity effects on the population's health condition. In order to be efficient, today's strategies (impregnated mosquito nets, intermittent preventive treatments, artemisinin based combination therapy) should reach at least 80% of the targeted population (pregnant women and children). By 2025, the uncontrolled urbanization of the African population and the social disorders will make a new population a target for malaria. The new data of functional genomics and proteonics open new avenues of research for new mechanisms, new therapeutics and vaccine targets and new tools of diagnosis and prognosis. The current candidate vaccines of the first generation have allowed the development of African competences in clinical trials of international standard. Although they represent scientific advances they will not resolve the problem of public health. Research on candidate vaccines of 2nd and 3rd generation remains a challenge for the international scientific community. Africa should play a determining role in this process. Scientific information on the field remains essential for these generations of new anti-malarial vaccines. The ethical aspects regarding those clinical trials and actions of public health and research remain an universal necessity Deontology and ethics are two complementary approaches for the good practice of medicine and research of a good practitioner. For the protection and advantages of the patient and/or volunteer of the research are the cornerstones of the ethical approach. The scientific quality of a research protocol submitted to an independent research ethics committee and the volunteer 's informed consent are universal ethical obligations. For the quality of ethics observance in a country reflects best the quality of the efficiency of its research system and its democracy.

[Neuromeningeal cryptococcosis in non-HIV patients to CHU ward of Point G in Bamako (Mali): 3 case report]. / Cryptococcose neuroméningée chez des patients VIH négatif au CHU du Point G de Bamako (Mali): à propos de trois observations cliniques.

We report 3 clinical observations of neuromeningeal cryptococcosis which occurred without any immunodepression related to HIV infection. Our patients were male. They did not present any particular medical history indicating a diagnosis of cryptococcosis. Nevertheless we found a professional exposure to the risk of inhalation of C. neoformans capsules. The diagnosis was based on presence of encapsulated yeast of Cryptococcus in the direct exam by China ink and culture on Sabouraud medium. CD4 lymphocytic count was done in two patients (case 1:899 cells/mm3; case 2:347 cells/mm3). Idiopathic lymphocytopenia was noted in one case. Co-morbidity of 5. pneumoniae meningitis was reported in one patient (case 3). Treatment was based on injectable amphotericin B in monotherapy (case 1), followed by perfusion of fluconazole cure (case 2). Case 3 was treated by perfusion of amphotericin B associated with ceftriaxone (case 2). No secondary prophylactic treatment was administered. Evolution was favorable after follow-up of 5 years (case 1) and of 4 years (case 2). The third patient died during hospitalization.

'Lactomassilus timonensis,' a new anaerobic bacterial species isolated from the milk of a healthy African mother.

We here report the main characteristics of a new anaerobic bacterial genus and species 'Lactomassilus timonensis,' strain Marseille-P4641T (CSUR = P4641), isolated by microbial culturomics from the milk of a 35-year-old healthy lactating mother from Mali.

[Dynamics of Egg Excretion of Schistosoma haematobium in a Longitudinal Cohort Under Treatment with Praziquantel over a Five-Year Period in Kalifabougou, Mali]. / Dynamique de l'excrétion ovulaire de Schistosoma haematobium dans une cohorte de Kalifabougou (Mali) sous traitement par le praziquantel (PZQ) durant cinq ans.

This study aim was to evaluate the dynamics of Schistosoma haematobium eggs excretion after the scaling up of "Mass Drug Administration" (MDA) with praziquantel (PZQ) from 2011 to 2016 in a cohort of volunteers living in the village of Kalifabougou, Mali. We conducted a cross-sectional study on 676 volunteers in May 2011 niched in cohort study from 696 volunteers aged three months to 25 years. The eggs of Schistosoma haematobium (Sh) were tested by urine filtration technique, Soil-transmitted helminth and Schistosoma mansoni by the Kato-Katz technique. Maximal MDA/ PZQ population coverage was 83% in 2015 and no MDA/PZQ n 2014. A total of 676 volunteers was included in this prospective cohort. The prevalence rate of Sh showed a significate decreasing from 2011, 2013 to 2014 with respectively 10.2% [95% CI=10.04-10,18], 5.32% [95% CI=5.30-5.33], and 5.25% [95% CI=524.-5.31], followed by an increase to 10.6% [95% CI = 10.47-10.63] in 2015 and a significative decrease in 2016 to 5.4% [95% CI=3.5-7,3]. Children aged from six to 10 years and mostly boys were more infected with Sh, then could serve of parasite reservoir. MDA with PZQ remains an effective strategy for schistosomiasis control against Sh in Kalifabougou. Additional studies on MDA/PZQ average treatment covering human-water contact behaviors and population migration are necessary to understand the persistence of the 5% annual prevalence rate of egg shedding in the cohort of volunteers periodically treated with PQZ. Testing eggs shed viability will be also an added value.

L'objectif de cette étude était d'évaluer la dynamique de l'excrétion ovulaire de Schistosoma haematobium (Sh) après la mise à échelle du « traitement de masse ¼ (TDM) avec le praziquantel (PZQ) de 2011 à 2016 dans une cohorte de volontaires vivant dans le village de Kalifabougou au Mali. Nous avons conduit une étude transversale sur 676 volontaires au mois de mai 2011 nichée dans une étude de cohorte de 695 volontaires, âgés de 3 mois à 25 ans et suivis de 2011 à 2016. Les œufs de Sh ont été recherchés par la technique de filtration d'urines et ceux des géo helminthes et de Schistosoma mansoni avec le Kato-Katz. Le taux de couverture maximum de la population cible de Kalifabougou en TDM/PZQ était de 83 % en 2015 et il n'a pas eu de TDM/PZQ en 2014. Le taux de prévalence de Sh montrait une réduction significative entre 2011, 2013 et 2014 avec respectivement 10,20 % [95 % CI = 10,04-10,18]- 5,32 % [95 % CI = 5,30- 5,33], et 5,25 % [95 % CI = 5,24-5,31], suivi d'une augmentation à 10,60 % [95 % CI = 10,47-10,63] en 2015 et d'une baisse significative en 2016 à 5,40 % [95 % CI = 3,5-7,3]. Les enfants âgés de six à dix ans, et majoritairement les garçons, seraient plus infectés par Sh, et pourraient servir de réservoir de parasites. Le TDM avec le PZQ reste une stratégie efficace pour le contrôle de la schistosomose à Sh à Kalifabougou. Des études complémentaires sur la couverture moyenne en TDM-PZQ, les comportements de contact homme-eau et les mouvements de population sont nécessaires pour comprendre la persistance du taux de prévalence annuel de 5 % de l'excrétion ovulaire dans la cohorte de volontaires traités périodiquement par le PQZ. Un test de viabilité des œufs excrétés serait aussi une valeur ajoutée.

[Persistent neurological sequelae due to cerebral malaria in a cohort of children from Mali]. / Séquelles neurologiques persistantes dues au paludisme cérébral dans une cohorte d'enfants au Mali.

INTRODUCTION: Several neurological complications are associated with cerebral malaria (CM). However, few long-term data from childhood survivors have been published. METHODS: A cross-sectional study was carried out in Mali among children followed from 1999 to 2002 after serious and complicated malaria. Our aim was to evaluate the persistent neurological sequelae associated with CM. RESULTS: This study concerned 101 subjects who had had CM. Mean age was 5.6+/-3.6 years. Twenty-eight children presented persistent neurological sequelae (27.7p.cent). Among them eight (7.9p.cent) children had developed these sequelae just after CM and 20 (19.8p.cent) a few months later: headaches, mental retardation, speech delay, bucco-facial dyspraxia, diplegia and frontal syndrome (one case each), dystonia (two cases), epilepsy (five cases) and behavior and attention disorders (15 cases). CONCLUSIONS: In this study, we show that neurological signs due to CM can persist in the long run. Long-term follow-up and proper management after CM are essential.

[In vitro cultivation of fields isolates of Plasmodium falciparum in Mali]. / Culture in vitro d'isolats de terrain de Plasmodium falciparum au Mali.

Malaria immunology, molecular biology and pathogenicity studies often require the adaptation of Plasmodium falciparum field isolates to continuous in vitro cultivation. For this purpose we have established propagation protocols of asexual erythrocytic stages of P. falciparum samples from malaria patients or asymptomatic carriers in Mali. The parasites were grown in standard culture medium supplemented by human serum and in a culture medium without human serum but supplemented by AlbuMax 1. The candle jar environment and tissue culture flasks gassed with 5% CO2, 5% O2 and 90% N2 obtained from a portable gas mixer were used. Protocols for parasite cultivation in a resource-poor setting were developed. These protocols were successfully applied to fresh isolates in Mali as well as to blood samples frozen in liquid nitrogen and shipped to a laboratory in U.S.A.

P. falciparum malaria prevalence among blood donors in Bamako, Mali.

AIM: Malaria parasite is usually transmitted to humans by Anopheles mosquitoes but it can also be transmitted through blood transfusion. Usually malaria transmission is low in African urban settings. In West Africa where the P. falciparum is the most predominant malaria species, there are limited measures to reduce the risk of blood transfusion malaria. The aim of this study was to evaluate the prevalence of P. falciparum malaria carriage among blood donors in the National Blood Center of Bamako, capital city of Mali. METHODS: The study was conducted using a random sample of 946 blood donors in Bamako, Mali, from January to December 2011. Screening for malaria was performed by thick smear and rapid diagnostic test (RDT). Blood group was typed by Beth-Vincent and Simonin techniques. RESULTS: The frequency of malaria infection was 1.4% by thick smear and 0.8% by the RDT. The pick prevalence of P. falciparum malaria was in rainy season, indicating a probable high seasonal risk of malaria by blood transfusion, in Mali. The prevalence of P. falciparum infection was 2% among donors of group O the majority being in this group. CONCLUSION: There is a seasonal prevalence of malaria among blood donors in Bamako. A prevention strategy of transfusion malaria based on the combination of selection of blood donors through the medical interview, promoting a voluntary low-risk blood donation and screening all blood bags intended to be transfused to children under 5, pregnant women and immune-compromised patients during transmission season using thick smear will reduce the risk of transfusion malaria in Mali.

Spleen enlargement and genetic diversity of Plasmodium falciparum infection in two ethnic groups with different malaria susceptibility in Mali, West Africa.

The high resistance to malaria in the nomadic Fulani population needs further understanding. The ability to cope with multiclonal Plasmodium falciparum infections was assessed in a cross-sectional survey in the Fulani and the Dogon, their sympatric ethnic group in Mali. The Fulani had lower parasite prevalence and densities and more prominent spleen enlargement. Spleen rates in children aged 2-9 years were 75% in the Fulani and 44% in the Dogon (P<0.001). There was no difference in number of P. falciparum genotypes, defined by merozoite surface protein 2 polymorphism, with mean values of 2.25 and 2.11 (P=0.503) in the Dogon and Fulani, respectively. Spleen rate increased with parasite prevalence, density and number of co-infecting clones in asymptomatic Dogon. Moreover, splenomegaly was increased in individuals with clinical malaria in the Dogon, odds ratio 3.67 (95% CI 1.65-8.15, P=0.003), but not found in the Fulani, 1.36 (95% CI 0.53-3.48, P=0.633). The more susceptible Dogon population thus appear to respond with pronounced spleen enlargement to asymptomatic multiclonal infections and acute disease whereas the Fulani have generally enlarged spleens already functional for protection. The results emphasize the importance of spleen function in protective immunity to the polymorphic malaria parasite.

[Epidemiology of schistosomiasis in the periurban area of Sotuba, 10 years mass treatment began in Mali]. / Épidémiologie des schistosomoses dans le village périurbain de Sotuba, dix années après la mise à échelle du traitement de masse au Mali.

OBJECTIVE: The objective of this work was to describe the epidemiology of schistosomiasis 10 years after mass administration of praziquantel began in Sotuba, Mali. METHODOLOGY/RESULTS: This observational cross-sectional survey in Sotuba, a periurban village in the Bamako district, took place from July to September 2010 and collected stool and urine samples from residents at least one year old. Kato-Katz (for stool) and urine filtration techniques were used to detect Schistosoma mansoni and S. hæmatobium eggs, respectively. Overall, 335 urine samples and 300 stool samples were examined. The prevalence rate was 5.4% (18/335) for S. hæmatobium and 8.7% (26/300) for S. mansoni. Excretion of these eggs was most frequent in the 6-15 year-old group: 4.8% (16/335) for S. hæmatobium and 7.7% (23/300) for S. mansoni. Snails of the Biomphalaria pfeifferi and Bulinus truncatus species were the intermediate hosts, captured in the fields at water contact points. The principal clinical symptoms reported by participants were abdominal pain 27.2% (61/169) and headaches 23.2% (52/169). CONCLUSION: Despite the implementation of mass drug administration in Mali a decade ago, our results show that schistosomiasis transmission continues in Sotuba. Assessment of the risk factors for this persistent transmission is strongly needed.

[Lice in Mali: frequency of infestation, genotyping, infection rate and case management]. / Poux au Mali: fréquence de portage, génotypage, taux d'infection et prise en charge.

OBJECTIVES: Because lice-transmitted infections are a real public health problem, epidemiological studies in different ecoclimatic zones of Africa are useful. This article aims to describe the frequency of lice infestation, their genotypes, and their infection by pathogens in the regions of Koulikoro and Mopti. METHODOLOGY: A cross-sectional survey allowed us to collect lice from rural populations. Techniques of molecular biology (real-time PCR, standard PCR, and genotyping) were used for analysis of lice samples. RESULTS: Infestation rates were 57% (12/21) among subjects in Diankabou, in the Sahelian zone; 91% (39/43) in Doneguebougou, and 86% (59/69) in Zorocoro, in a savanna zone. The overall lice infestation rate in the samples in the three localities was 83% (110/133). Real-time PCR showed 3% (4/92) of Acinetobacter baumanii but no B. quintana in Diankabou. Phylogenetic analysis of the mitochondrial gene (Cytb) showed that head lice in Mali belong to genotype C. CONCLUSIONS: The high frequency of lice infestation in the study population indicates that it would be useful to conduct national epidemiological surveys to estimate the magnitude of this public health problem.

Doctoral training of African scientists.

There are two principal rationales for doctoral training of African scientists in health: 1) these scientists are essential for the nations of sub-Saharan Africa to define and implement their own health priorities, and 2) the research they perform is essential for development. However, this training is difficult because of its expense (> $20,000 per year), because many developed country mentors are unaware of the realities of research in sub-Saharan Africa, and because major differences in salary provide a financial disincentive to return. We describe a training strategy that reduces attrition because it is linked to the investigators' responsibilities before and after training, and to home country priorities. This strategy requires a close relationship between the developing country (on-site) and developed country (off-site) mentors, with joint participation in the selection and funding process, followed by course work and short-term, independent projects off-site that lead to a thesis project in the developing country, and subsequently to a defined professional position in the developing country after completion of the doctoral degree. For this strategy to succeed, the developed country mentor must have both field experience and investigative expertise; the developing country mentor must have an understanding of modern biology, as well as clinical and epidemiologic experience. In addition, we would like to emphasize that the long-term retention of these talented, highly-trained individuals requires a similar long-term commitment by their developed country mentors, well beyond the short term of most research funding.

Community pyrimethamine-sulfadoxine use and prevalence of resistant Plasmodium falciparum genotypes in Mali: a model for deterring resistance.

Pyrimethamine-sulfadoxine (PS, Fansidar; Hoffman-LaRoche, Basel, Switzerland) is now the first-line antimalarial therapy in parts of Africa with high rates of chloroquine-resistant Plasmodium falciparum. With PS resistance increasing and no suitably inexpensive and effective third antimalarial drug available, strategies for delaying the spread of PS resistance in Africa are needed. Community PS usage was measured in two Malian villages, one rural and one periurban, and prevalence of pyrimethamine-resistant P. falciparum genotypes was determined at these sites and two urban sites. The prevalence of resistant genotypes was 22.6% (n = 84) in the periurban village where PS was available from multiple sources and large stocks of PS were observed, and 13.5% (n = 89) and 23.4% (n = 77) in a large town and a city, respectively, where PS is widely available. No pyrimethamine-resistant genotypes (n = 58) were detected in Kolle, a rural village with a community-supported dispensary and clinic where PS is used sparingly and no PS was available in pharmacies or markets. The high rates of pyrimethamine resistant genotypes concurrent with higher PS usage argue for a policy of judicious PS use in Mali and in similar settings. A possible model for slowing the spread of drug-resistant malaria is illustrated by the example of the Kolle clinic.

Chloroquine treatment of uncomplicated Plasmodium falciparum malaria in Mali: parasitologic resistance versus therapeutic efficacy.

Whether and when to replace chloroquine with other antimalarial drugs is an urgent public health question in much of Africa, where Plasmodium falciparum, which is increasingly resistant to chloroquine, continues to kill millions each year. Antimalarial drug efficacy has traditionally been measured as parasitologic resistance, but recent guidelines use both clinical and parasitologic criteria to monitor therapeutic efficacy. To assess the new efficacy protocol, we measured parasitologic and therapeutic outcomes in 514 patients treated with chloroquine for uncomplicated P. falciparum malaria in Mali. There was a general agreement between parasitologic and therapeutic outcomes at two sites, with 13-17% parasitologic resistance rates and 10-15% treatment failure rates. However, the new protocol overestimated early treatment failure rates (21-71% of cases classified as early treatment failure had sensitive or RI parasitologic responses), particularly where resistance was rare, and missed low-level parasitologic resistance. Modifications of the protocol for monitoring antimalarial therapeutic efficacy are recommended.

Pyrimethamine-sulfadoxine efficacy and selection for mutations in Plasmodium falciparum dihydrofolate reductase and dihydropteroate synthase in Mali.

To assess pyrimethamine-sulfadoxine (PS) efficacy in Mali, and the role of mutations in Plasmodium falciparum dihydrofolate reductase (DHFR) and dihydropteroate synthase (DHPS) in in vivo PS resistance, 190 patients with uncomplicated P. falciparum malaria were treated with PS and monitored for 56 days. Mutation-specific polymerase chain reactions and digestion with restriction endonucleases were used to detect DHFR and DHPS mutations on filter paper blood samples from pretreatment and post-treatment infections. Only one case each of RI and RII level resistance and no cases of RIII resistance or therapeutic failure were observed. Post-PS treatment infections had significantly higher rates of DHFR mutations at codons 108 and 59. No significant selection for DHPS mutations was seen. Pyrimethamine-sulfadoxine is highly efficacious in Mali, and while the low level of resistance precludes assessing the utility of molecular assays for in vivo PS resistance, rapid selection of DHFR mutations supports their role in PS failure.