Artemisinin combination therapy mass drug administration in a setting of low malaria endemicity: programmatic coverage and adherence during an observational study in Zanzibar.

BACKGROUND: Mass drug administration (MDA) appears to be effective in reducing the risk of malaria parasitaemia. This study reports on programmatic coverage and compliance of MDA using artemisinin-based combination therapy (ACT) in four shehias (smallest administration unit) that had been identified as hotspots through Zanzibar's malaria case notification surveillance system. METHODS: Mass drug administration was done in four shehias selected on the basis of: being an established malaria hot spot; having had mass screening and treatment (MSaT) 2-6 weeks previously; and exceeding the epidemic alert threshold of 5 cases within a week even after MSaT. Communities were sensitized and MDA was conducted using a house-to-house approach. All household members, except pregnant women and children aged less than 2 months, were provided with ACT medicine. Two weeks after the MDA campaign, a survey was undertaken to investigate completion of ACT doses. RESULTS: A total of 8816 [97.1% of eligible; 95% confidence interval (CI) 96.8-97.5] people received ACT. During post MDA surveys, 2009 people were interviewed: 90.2% reported having completed MDA doses; 1.9% started treatment but did not complete dosage; 4.7% did not take treatment; 2.0% were absent during MDA and 1.2% were ineligible (i.e. infants <2 months and pregnant women). Main reasons for failure to complete treatment were experience of side-effects and forgetting to take subsequent doses. Failure to take treatment was mainly due to fear of side-effects, reluctance due to lack of malaria symptoms and caregivers forgetting to give medication to children. CONCLUSION: Mass drug administration for malaria was well accepted by communities at high risk of malaria in Zanzibar, with high participation and completion rates. Further work to investigate the potential of MDA in accelerating Zanzibar's efforts towards malaria elimination should be pursued.

Praziquantel efficacy and long-term appraisal of schistosomiasis control in Pemba Island.

OBJECTIVE: To determine whether praziquantel (PZQ) has retained its efficacy against Schistosoma haematobium on Pemba Island after 20 years of mass administration--albeit discontinuous--and to analyse retrospectively the performance of schistosomiasis control programmes. METHODS: A sample of Pemba schoolchildren was examined before and after PZQ treatment by urine filtration, macro- and micro-haematuria and viability of excreted eggs. RESULTS: Although 5% of treated children continued to pass some eggs in the urine up to the seventh week after PZQ administration, none of these eggs was viable, indicating an effective schistosomicidal activity followed by a slow release of dead eggs from host tissues. CONCLUSION: No signs of PZQ resistance could be detected in the population under study. An overall retrospective analysis of schistosomiasis control activities in Pemba Island revealed that mass drug administration is clearly effective in reducing infection prevalence, but soon after interruption of drug distribution prevalence returns rapidly to pre-intervention levels.

A comparative trial of a single-dose ivermectin versus three days of albendazole for treatment of Strongyloides stercoralis and other soil-transmitted helminth infections in children.

A randomized trial carried out in rural Zanzibar comparing a single dose of 200 micrograms/kg of ivermectin and 400 mg/day for three days of albendazole for treatment of strongyloidiasis and other intestinal nematodes is described. In 301 children with Strongyloides stercoralis infection, treatment with ivermectin or albendazole resulted in cure rates of 83% and 45%, respectively. While both drugs were very effective against Ascaris lumbricoides, Trichuris trichiura was cured only in 11% (ivermectin) and 43% (albendazole) of the subjects, although the mean eggload was reduced by 59% and 92%, respectively. Ivermectin was ineffective against hookworms, while albendazole resulted in a cure rate of 98%. No severe side effects were recorded and mild side effects were of transient nature for both treatments. Therefore, ivermectin provides a safe and a highly effective single dose treatment for S. stercoralis and A. lumbricoides, while it is not an alternative for the treatment of T. trichiura and hookworm infections.

Control of Bancroftian filariasis by integrating therapy with vector control using polystyrene beads in wet pit latrines.

In the town of Makunduchi, Zanzibar, wet pit latrines provided breeding places for Culex quinquefasciatus and there were few other mosquito breeding places available. The adult mosquito population in bedrooms was monitored for a year and found to consist almost entirely of Cx quinquefasciatus of which 2.45% carried infective larvae of Wuchereria bancrofti. It was estimated that each person received about 24,993 bites per year, of which 612 were potentially infective. After a year of baseline data collection, polystyrene beads were expanded in boiling water and applied to form floating layers on all infested pits. Subsequently the adult mosquito population declined remarkably so that the estimated number of bites per person per year was only about 439. To retain control, surveillance for newly wet pits continued to be necessary. Initially the microfilarial rate in the human population was 49.5%, with many cases of filarial disease. The microfilarial rate was reduced to 10.3% by mass treatment with diethylcarbamazine, with no sign of resurgence a year after treatment. The infective rate among mosquitoes was reduced to 0.41% and the combined effect of the vector and microfilarial control was to reduce the number of infective bites per person per year by 99.7%.

Estimation of the infectious reservoir of Plasmodium falciparum in natural vector populations based on oocyst size.

A method for determining the infectious reservoir of malaria (K) and vector survival rate (P) by measuring oocyst size and discriminating between the most recent and other infections is described. In the laboratory the mean diameter of 3 d oocysts in Anopheles gambiae, kept at 26 degrees C, was 11.5 microns and the mean diameter at day 5 was 24.5 microns. Oocyst sizes in wild caught mosquitoes from southern Tanzania, that had fed on the occupants of bed nets with holes in the sides, were more variable. 2060 A. gambiae s.l. and 1982 A. funestus were examined for oocysts 3 d after feeding; 796 and 654 oocysts from the 153 and 170 infected females, respectively, were measured. Because of misclassification errors, the use of a simple cut-off model, in which all oocysts less than 17.5 microns in diameter were considered to have arisen from the most recent feed, was thought to overestimate K and underestimate P. A statistical model which allows for overlap in the oocyst size distributions is described. Estimates of the infectious reservoir derived from this model were 2.8% for A. gambiae s.l. and 4.2% for A. funestus, and the estimated survival rates per gonotrophic cycle were 65.5% and 52.9%, respectively. The utility of measuring oocyst size in naturally infected mosquitoes is discussed.

Insecticide-impregnated bed nets reduce malaria transmission in rural Zanzibar.

There has been concern that impregnated bed nets are an insufficiently powerful method to control malaria in areas with very high perennial transmission, as in the humid lowland parts of tropical Africa. We carried out a 'cross-over' trial among children under 5 years of age in 2 villages in rural Zanzibar. In 1989, one village was supplied with newly permethrin-impregnated bed nets whereas the other served as unprotected control. In 1992, when those nets had lost their insecticidal activity and were badly torn, the village which had previously been the control was given newly impregnated bed nets. Each time, reinfection with Plasmodium falciparum was measured after initially clearing the parasites by administering a therapeutic dose of sulfadoxine/pyrimethamine. The introduction of bed nets led to a 74-78% reduction in the weekly rate of reinfection with malaria parasites, in all age groups. The nets apparently also affected perceived clinical symptoms, haemoglobin levels, and the mosquito sporozoite rate.

The scope and limitations of laparoscopic ovarian biopsy in the diagnosis of secondary amenorrhea.

Laparoscopically directed ovarian biopsy has been evaluated in 39 cases of secondary amenorrhea. The definite diagnosis was achieved in 29 cases. In 10 cases, ovarian histopathology alone was insufficient, and the estimations of gonadotropins were essential for the final diagnosis. The scope and limitations of this procedure for the differential diagnosis of premature ovarian failure and hypothalamic-pituitary lesions are discussed.

Evaluation of Host Resistance and Soil Fumigation for the Management of Black Root Rot of Tobacco in Ontario.

Black root rot of tobacco, caused by the soilborne fungus Thielaviopsis basicola, is a serious problem in many tobacco (Nicotiana tabacum L.)-growing regions of the world. In Ontario, the disease is favored by cool, wet soil conditions and heavy textured or poorly drained soils. Yield loss can be severe under these conditions and fumigants containing chloropicrin are used extensively for controlling the disease. Usually, fumigants control the disease reasonably well, but they are costly and could cause a negative environmental impact. A 2-year study was conducted to evaluate the performance of resistant (AC Gayed) and moderately susceptible (Delgold) tobacco cultivars and soil fumigation to black root rot. T. basicola reduced yield of the susceptible Delgold cultivar. The interaction between genotype and fumigation was significant for most traits examined, indicating that the two genotypes responded differently. Orthogonal comparisons indicate that yield from nonfumigated AC Gayed was higher than that of nonfumigated Delgold. Yield of nonfumigated AC Gayed was also not significantly different from the yield of AC Gayed treated either with Vorlex Plus (1,3-dichloropropene+methyl isothiocyanate) or with Vorlex Plus CP (1,3-dichloropropene+methyl isothiocyanate+chloropicrin). In contrast, the yield of nonfumigated Delgold was lower than Delgold treated with Vorlex Plus CP.

Multiple metastatic calcifications detected by bone scintigraphy and demonstrated by CT.

Metastatic calcifications according to histopathologic and scintigraphic findings have been well-defined. The authors report a postoperative case of hyperparathyroidism with multiple metastatic calcifications in the lung, kidney, stomach, heart, and vessels that were primarily detected by bone scintigraphy and demonstrated by CT. Tc-99m MDP bone scintigraphy showed a markedly increased accumulation of radioactivity diffusely throughout the lung, left ventricular wall, both kidneys, and the gastric cardia and body. In the lung, plain films showed almost normal lung. CT, however, demonstrated patchy, slightly increased densities in the lung bilaterally. Cardiac CT indicated a considerably increased density of the ventricular myocardium and remarkable calcification in or near the atrioventricular septum or annulus fibrosus. Upper abdominal CT demonstrated increased densities diffusely throughout the gastric mucosa and renal cortex. Only vascular calcifications were depicted by plain films. Using both bone scintigraphy and CT provides accurate information about each lesion and each tissue, allowing precise diagnosis of even a questionable lesion in the early stage of metastatic calcification. Early diagnosis and early therapy offer the best chance for cure or palliative therapy.

Epidemiology of streptococcus group A in school aged children in Pemba.

BACKGROUND: In Pemba (Zanzibar) all the risk factors which favour Group A Streptococci spreading, infections and late sequelae are present, though GAS epidemiology is unknown. OBJECTIVE: To determine the prevalence of GAS pharyngeal carriers among school-aged-children. DESIGN: Community-based cross sectional study, carried out at the end of the dry season (January-February 2001). SETTING: Eight primary schools over the four Pemba districts were included in the study. SUBJECTS AND METHODS: Two thousand two hundred and eighty six children aged 7-10 years were selected by random sampling and submitted to throat-swab after informed consent. Swabs were processed according to the "Lennette Manual of Clinical Microbiology" 7th Ed. Isolated were tested for antibiotic susceptibility toward penicillins, erythromycin, clindamycin, josamycin, cloramphenicol, levofloxacin, rifampin and tetracyclines. RESULTS: Twenty seven point six percent of school-aged children harboured beta-haemolytic Streptococci in their pharynx; most of the isolates were serologically identified as non Group A streptococci group C and G represented more than 70% of all strains, 38.8% of whom were identified as group G; the prevalence of group A streptococci carriers among healthy children all over the island was 8.6%; group A streptococci isolates were sensitive to all the antibiotic tested, except tetracyclines, towards which 83.2% of strains were resistant. CONCLUSION: This is the first research in the field of bacteriology carried out in Pemba. According to the epidemiology of group A streptococci and to the environmental and underlying factors which predispose to late group A streptococci sequelae, we suggest to consider antibiotic treatment for children presenting with sore throat with fever and swollen cervical lymphonodes without cough or coryza.

Absence of relationships between selected human factors and natural infectivity of Plasmodium falciparum to mosquitoes in an area of high transmission.

The effects of sex, age of the human host, patency of asexual and sexual stages and seasonality on infectiousness of Plasmodium falciparum to mosquitoes were investigated in a rural village in southern Tanzania between 1992 and 1994. Villagers from randomized subgroups of households were surveyed for malaria parasites. Gametocyte and trophozoite prevalences were age dependent and fluctuated without any clear pattern of seasonality. A sample of 107 participants, selected to include an excess of gametocyte carriers, slept under bednets with holes cut into the sides for 3 weeks. A total of 3837 Anopheles gambiae s.l. and 5403 A. funestus recovered from these bednets, was examined for all oocysts 5-7 days after feeding or for oocysts less than 17.5 microns in diameter 2-3 days after feeding. Additional blood slides from participants were taken twice weekly. The 5-7 day oocyst rates were 12.1% in A. gambiae s.l. and 10.9% in A. funestus and 2-3 day rates were 3.6 and 4.9%, respectively. The higher rates using the former method were attributed to previous infection. There were strong correlations in the levels of infection in both vectors when they fed on the same hosts. However, patent gametocytaemia was only weakly associated with the development of oocysts in the mosquito. Infectiousness was not related to host age, sex, or the season.

Genetic characterization of the malaria parasite Plasmodium falciparum in the transmission from the host to the vector.

The present study followed a Plasmodium falciparum population through its life-cycle at the level of individual hosts and vectors. The aim was to determine to what extent genotypes of the parasite that were found in the host were transmitted to the vector. Mosquitoes were collected that had fed on people sleeping under mosquito nets with holes. Genes determining 2 highly polymorphic merozoite surface proteins, MSP-1 and MSP-2, were used to characterize the parasite by PCR at different stages of the life-cycle. The parasite genotypes found in the host were compared to the genotypes of the oocyst stages after transmission to the mosquitoes. The results show that there was no significant correlation in the rate of oocyst-positive mosquitoes and the presence of parasites in the blood samples. For MSP-1, most of the parasites characterized in the human blood by PCR fragment size were also found afterwards in the oocyst-stage (22 of 29; MSP-2: 17 of 36). This study indicates that there is no selective transmission of distinct genotypes to the vector. In addition, the frequencies of the allelic families of both genes are similar in the blood samples and in the oocysts for the whole population.

Soil-transmitted nematode infections and mebendazole treatment in Mafia Island schoolchildren.

In August 2000, a cross-sectional study was performed to assess the prevalence and intensity of soil-transmitted nematode infections in schoolchildren on Mafia Island. Hookworm infection was widespread (72.5% prevalence) whereas Trichuris trichiura was less prevalent (39.7%) and Ascaris lumbricoides was present at a low prevalence (4.2%), mainly in urban areas. In a subsample of the study population, both Necator americanus and Ancylostoma duodenale were found, although N. americanus was more prevalent. This survey was followed by a parasitological evaluation of mebendazole treatment using a single, 500-mg dose. The data on outcome were used for comparison with those from recent studies of similar treatment regimens in the neighbouring island of Pemba, Zanzibar, where periodic chemotherapy with mebendazole to schoolchildren has been implemented as part of a helminth-control programme since 1994. A higher efficacy of mebendazole against hookworm infection was found in Mafia Island (where a cure 'rate' of 31.3% and an egg-reduction 'rate' of 78.1% were recorded) when compared with that observed in Pemba Island, possibly indicating that hookworms may be developing mebendazole resistance on Pemba Island as a result of intense exposure to the drug there.