Emergence of Plasmodium ovale malaria among the French Armed Forces in the Republic of Ivory Coast: 20 years of clinical and biological experience.

BACKGROUND: French military surveillance identified an increase in Plasmodium ovale attacks among soldiers in Ivory Coast. This emergence and the low sensitivity of biological tests raise the question of a possible role of P. ovale variant species. METHODS: Epidemiological data about P. ovale attacks from 1993 to 2012 were studied; the species diagnosis was based on a thin blood smear and/or a quick diagnostic test. Clinical and biological features in soldiers hospitalized in 2 French military hospitals were also reviewed. Malaria polymerase chain reaction followed by genotyping was performed when available. RESULTS: French military physicians declared 328 P. ovale attacks over the 20-year study. A peak of incidence occurred in 2005. Among patients with positive blood smears, the quick diagnostic test was positive in 33 of 101 tests performed. The hospital study showed that symptoms and biological changes were not specific, which made diagnosis challenging: fever, anemia, and thrombocytopenia were not present in 20%, 71%, and 23% of the 45 confirmed cases, respectively. It was possible to perform molecular investigations on 19 clinical isolates: 18 were classic haplotypes with additional polymorphism and 1 was variant. CONCLUSIONS: This emergence of P. ovale malaria enabled a good description to be made in nonimmune patients. The lack of sensitivity of both clinical features and quick diagnostic tests suggests an underestimation. Reasons for this outbreak are especially intense exposure to the vectors and the insufficient efficacy of doxycycline against P. ovale. The polymorphism of classic haplotypes of P. ovale rather than variant forms could be involved.

[Risk of nosocomial infection in Intertropical Africa. Part 4: prevention]. / Le risque nosocomial en Afrique Intertropicale. Partie 4: prévention.

Nosocomial infections have long been neglected in Sub-Saharan Africa, even though their prevalence is higher than in developed countries. Recently, however, this major public health problem has been the focus of a growing number of recommendations not only from the World Health Organization but also from some national health ministries. Because of the numerous limitations especially in financial resources in these regions, priority must be given to the implementation of simple and cost-effective measures. Accordingly the greatest efforts must be devoted to educating healthcare workers and patients about the importance of handwashing, eliminating unnecessary injections and transfusions, performing the latter acts in aseptic conditions, isolating patients with communicable diseases, handling waste products safely, and using antimicrobials properly. Amid the daunting health issues facing Sub-Saharan Africa, implementing these inexpensive measures that could save the lives of thousands of patients and healthcare workers appears easy. However it will require a cultural revolution. The keys to success will be changing the organizational culture, developing a commitment to prevention and evaluating performance regularly.

[Risk of nosocomial infection in intertropical Africa--part 2: patient infection]. / Le risque nosocomial en Afrique intertropicale partie 2: les infections des patients.

Patients admitted to hospitals in tropical Africa are at increased risk for nosocomial infection. However accurate description of this risk is difficult due to a lack of published data in the literature. The main promoting factors are poor health care facilities, high microbial levels in the hospital and community environment and generally uncertain health status. Most available information is about neonatal infection. The increasing number of reports involving multiresistant bacteria is evidence of poor hospital sanitation. Infections involving operative incision sites, tuberculosis and respiratory virus transmission are grossly underestimated. Infections transmitted by the parenteral route are probably decreasing due to more widespread use of disposal equipment and adequate transfusion safety measures. Epidemics involving viral hemorrhagic fever are rare but highly publicized events that attest to daily neglect of nosocomial risk factors in some health care facilities

[Risk of nosocomial infection in intertropical Africa--part 3: health care workers]. / Le risque nosocomial en Afrique intertropicale. Partie 3: les infections des soignants.

Parts of the nosocomial infections issue are the professionally-acquired infections of health care workers. This problem is widely neglected in sub-Saharan Africa, and little is known on the subject, in spite of the high prevalence of blood-borne infections such as HIV or hepatitis B and C, and air-borne diseases like tuberculosis. Besides, unsafe practices and accidents like blood exposures are more frequent than in western countries. This is due to the lack of political concern, of safer equipment and of specific teachings. Most of this severe infections' treatments are long, difficult or unavailable in Subsaharan Africa. The loss of contaminated health care workers can then become devastating for their family and the fragile health care structures of those developing countries. Finally, one should not underestimate the risk of infection transmission from health care provider to patient, like in several past outbreaks of Ebola hemorrhagic fever.

[Diagnosis of imported malaria in France]. / Diagnostic du paludisme d'importation en France.

The need for diagnosis of imported malaria is frequent in France. Diagnosis biological tools are different, according methods, sensitivity, interpretation and costs. Strategies for their use could be stratified according locally available methods, and experience of the practician.

[Risk of noscomial infection in intertropical Africa--part 1: background]. / Le risque nosocomial en Afrique intertropicale--partie 1: le contexte.

Nosocomial infection is a risk in any health care setting. A review of recent medical literature shows that there is a paucity of information on nosocomial infection in intertropical Africa. Often misunderstood or denied, nosocomial infection is in reality an underestimated public health problem at most medical facilities even university hospital centers. However most hospitals are confronted with the same financial, structural and logistics difficulties, with limited training and awareness about hospital hygiene among caregivers, and with situations bringing together contagious infections with susceptible subjects. Assessment of the risks for patients and caregivers is a necessary prerequisite for implementing measures to control nosocomial infections in intertropical Africa.

[Rapid immunochromatographic tests for detection of malaria: principles and strategies for use]. / Tests immunochromatographiques rapides de détection du paludisme, principes et stratégies d'utilisation.

Malaria is a parasitological emergency requiring safe quick accurate diagnosis so that appropriate therapy can be implemented. A number of rapid diagnostic tests based on detection of HRP2 Ag, enzymes, LDH or aldolase are now available. However the use of these tests is restricted to trained, experienced staff in special situations. The purpose of this report is to describe the different tests on the market and clarify the limitations for their use.

[Achievement quality evaluation of pretransfusion bedside test]. / Evaluation de la qualité de réalisation des tests de concordance ultime au lit du patient.

As far as transfusions accidents are concerned, immunological causes are frequent. Pretransfusion Bedside Compatibility Tests (PBCT) are the last chance to avoid them. However low data are disponible on the quality their realisation is achieved. The aim of the study is to evaluate the quality level of achievement of these tests, in HIA Laveran Hospital (Marseille Armees, France). During 13 months, from november 2001 to december 2002, we systematically analysed PBCT after use (analysis rate 91%). Three kinds of errors have been noticed: Technical errors, understanding errors and both. Overall mistake rate was 10.4% (1632 tests analysed). In the same time, a complementary formation was dispensed to users responsible of misfits. This formation was successful, decreasing the overall mistake rate from 22.8% (november 2001) to 10.7% (december 2002). This study is an evidence of the importance to evaluate achievement quality of PBCT and shows how efficient can be simple correction methods.

[Pathogenic approach of thrombopenia in dengue and its hemorrhagic complications]. / Approche pathogénique de la thrombopénie dans la dengue et dans ses complications hémorragiques.

Dengue is a frequent viral infection in the intertropical countries. The frequency and the severe forms of this infection are a real problem of public health. The haemorrhagic forms of the disease are constantly associated with thrombocytopenia. Its pathophysiology is still unclear. Among the different hypothesis, immune mechanisms play the main role. The authors discussed here the responsibility of the binding of immune complexes and the role of cytokines.

[Djibouti, history of 2 epidemics of cholera: 1993-1994]. / Djibouti, histoire de deux épidémies de choléra: 1993-1994.

When two cholera epidemics broke out in Djibouti, respectively in 1993 and 1994, Bioforce was obliged to intervene. The first time, three goals were pursued: setting up a rehydration centre in a tent, organizing epidemiological surveillance and training local personnel in treatment and diagnosis techniques. The next year, the epidemic followed serious flooding. The epidemiological analysis showed that cholera had become endemic in the poor neighbourhoods of the town and that epidemic break-outs were favoured by contaminated surface water and disturbances in the distribution of drinking water. The epidemic of 1997, likewise following flooding, only confirmed this point of view.

[Diagnostic difficulties and current clinical aspects of Plasmodium falciparum malaria upon returning from a chemoresistance area]. / Difficultés diagnostiques et aspects cliniques actuels du paludisme à Plasmodium falciparum au retour d'une zone de chimiorésistance.

The incidence and clinical aspects of malaria in patients returning from chemoresistance areas were evaluated by means of two studies. The first one was a prospective study of 145 subjects back from a 4 months' stay in Gabon and who had complied with an appropriate chemoprophylaxis regimen. Twelve of these subjects were found to have particulate P. falciparum antigens on the 3rd day following their return. Spontaneous negativation of parasitaemia was observed in 10 cases, whereas 2 subjects were about to develop a malarial attack. Forty-five days after the return home, 5 new cases of malarial attack and 3 cases of anaemia had occurred, although none of these 8 patients had haematozoa on the 3rd day. In the second study 31 patients admitted to hospital in 1987 were reviewed. The following clinical syndromes were detected: malarial attacks with high parasitaemia in 6 cases, malarial attacks with low or undetectable parasitaemia in 5 cases, anaemia, thrombocytopenia or pancytopenia in 5 cases, and febrile alteration of the general condition in 3 cases. Two aspects of malaria were identified: "malaria infection" with a latent and asymptomatic parasitic infestation likely to disappear spontaneously or to turn into "malaria disease". The latter has protean manifestations, but bouts of fever with low parasitaemia and blood disorders are predominant.

[Evaluation of the OptiMal test in the diagnosis of imported malarial outbreak]. / Evaluation du test OptiMal dans le diagnostic des accès palustres d'importation.

The OptiMal test is an immuno-chromatographic dipstick test that permits indiscriminate detection of Plasmodium falciparum and other species of human malaria. The purpose of this study was to evaluate the efficacy of the test for diagnosis of imported malaria. A total of 244 patients with a presumptive diagnosis of imported malaria in France were included during the study period. The reference test, i.e., combined thick and thin blood films, demonstrated infection by Plasmodium falciparum in 58 cases, Plasmodium vivax in 12, P. ovale in 8 and Plasmodium malariae in 2. The OptiMal test detected only 46 of the 55 Plasmodium falciparum cases. The sensitivity of the test for diagnosis of that species was 80%, its specificity was 98%, and its positive and negative predictive values were 95 and 93% respectively. Parsitemia studies showed poor test reliability for densities lower than 150/ul. Detection of other species was accurate in 21 out of 22. The results of this study demonstrate that the current version of the OptiMal test should be used with great caution for the diagnosis of malarial infection in hospital practice.

[Suspected epidemic at a hospital in Senegal]. / Suspicion d'épidémie dans un hopital Sénégalais.

Most outbreaks of noscomial infection are detected by means of molecular biological testing. However Euclidian distance is a rapid, reliable alternative if facilities for molecular biological testing are unavailable, as at the Principal Hospital in Dakar, Senegal. Over the 7 month period from 01/10/98 to 31/04/99, 110 of the 1033 blood cultures specimens collected in a group of 2360 children hospitalized in pediatric departments A and B of the Principal Hospital were found to be positive for Burkholderia cepacia. This high incidence suggested the possibility of an epidemic. This likelihood was further increased by evidence showing that all strains exhibited the same biotype and by results of pulsed-field electrophoresis (CHEF Mapper, Spel digestion) indicating that bacteria was of clonal origin. These findings were entirely consistent with those obtained by Euclidian distance but excessive mortality was not observed in the children involved. Testing of environmental specimens demonstrated the presence of the same strains in respirators and catheters. The most feasible hypothesis to account for these findings is environmental contamination resulting in mucocutaneous contamination of patients. Hemoculture containers were probably contaminated during handling.

[American pulmonary histoplasmosis. Prospective study with 232 soldiers after a 2-year assignment in Guiana]. / Histoplasmose pulmonaire americaine. Etude prospective chez 232 militaires ayant effectue un sejour de 2 ans en Guyane.

The purpose of this report is to describe the results of a prospective study on pulmonary histoplasmosis in French Guiana. Chest radiographs were performed in 232 French legionnaires returning from a two-year assignment in French Guiana. Further examinations were performed in a total of 8 subjects in whom chest radiographs demonstrated the presence of nodules in the lungs. No evidence of cancer or tuberculosis was found. Findings confirmed histoplasmomas in two cases and demonstrated probable histoplasmosis nodules in 6 cases including three involving calcified lesions. Five of these eight patients had been in high-risk rain forest environments. Pulmonary histoplasmosis should be considered as a possible diagnosis in subjects returning from endemic zones. Confirmation depends on a spectrum of findings. Calcified nodules require only radiographic surveillance with follow-up at six months. Non-calcified nodules require further investigation including CT-scan, bronchoscopy, and serological tests. Surgical biopsy may be necessary to achieve exact histological and mycological identification of the lesion and is recommended in smokers.