Disease threats in Somalia.

During this time of war and famine in Somalia, disease threats are encyclopedic both for Somalis and visitors. Malnutrition will amplify the magnitude and severity of endemic tropical infectious diseases. Necessary crowding around life-saving food distribution centers could turn focal infectious disease outbreaks into large epidemics.

In vitro growth inhibition of Plasmodium falciparum by sera from different regions of the Philippines.

Sera from different malaria endemic regions of the Republic of the Philippines were compared for their ability to inhibit growth of Plasmodium falciparum in vitro. Dialyzed serum was added to synchronous cultures containing schizonts for either the total 48 hr test period or only the last 24 hr in order to analyze the effects on erythrocytic invasion and intraerythrocytic growth, respectively. Reduction in 3H-hypoxanthine uptake was used to determine the percent of inhibition compared to nonimmune serum. One hundred seventy sera from Mindanao and Palawan in the South, the centrally located island of Mindoro, and Luzon in the North, were tested against 4 P. falciparum strains from the Philippines and 1 from Africa. Indirect fluorescent antibody titers were not predictive of inhibition. Inhibition of merozoite invasion rather than intraerythrocytic parasite growth is suggested by this study. Generally, sera were more inhibitory to parasite strains from the same geographical area than to those from more remote areas.

Epidemiology of HIV infection among prostitutes in the Philippines.

Between 1985 and 1987, examinations for human immune deficiency virus (HIV) antibody were done on 25,392 prostitutes working in 64 cities throughout the Philippines. The country-wide seropositivity rate among prostitutes based on this sample was 0.8/1,000. Of the HIV cases, 85% were working in just two cities whose prostitute populations comprised 50% of the total sample. The average incidence rate for the same two cities after 1 year was 2.3/1,000. HIV antibody-positive women were enrolled in a case-control study to determine demographic and epidemiologic risk factors. This study involving 34 HIV-positive prostitutes and 61 randomly selected negative control prostitutes did not reveal any risk factors related to sexual or other types of behavior. A history of genital warts, a history of abnormal vaginal discharge, and cytomegalovirus antibody were significantly more frequent in the HIV-positive cases than in the controls; however, by logistic regression analysis, only an abnormal vaginal discharge was independently associated with HIV infection. Absence of any evidence of transmission by blood transfusion or i.v. drug abuse suggests that HIV was introduced by the heterosexual route.

Drug resistant tuberculous meningitis in the Philippines: report of a case.

A fatal case of tuberculous meningitis caused by a multiply-resistant tubercle bacillus is described, the first such case from Southeast Asia. Increased efforts to isolate Mycobacterium tuberculosis from the cerebrospinal fluid and determine the extent and pattern of drug resistance are necessary if the high mortality from this disease is to be reduced.

Rapid diagnosis of tuberculous meningitis by using an enzyme-linked immunosorbent assay to detect mycobacterial antigen and antibody in cerebrospinal fluid.

Rapid diagnostic tests for tuberculous meningitis are urgently needed because delayed treatment increases the already high mortality rate of this disease. Direct acid-fast staining of cerebrospinal fluid is the only quick method generally available, but it lacks sensitivity. Therefore, we evaluated the use of an enzyme-linked immunosorbent assay (ELISA) to mycobacterial antigen and antibody in the cerebrospinal fluid of 29 patients with proven tuberculous meningitis, 83 patients with nontuberculous central nervous system infections, and 15 normal controls. The specificity of the test was 96%; the four false-positive results all occurred in patients with bacterial meningitis. Fifteen (52%) of 29 patients with tuberculous meningitis had either a positive antigen or antibody ELISA test, which was significantly more than the number of patients testing positive by direct staining (two of 29 positive; P less than .01). We therefore recommend using an ELISA to detect antigen and antibody but caution that because of limited sensitivity a negative test result does not exclude the diagnosis of tuberculous meningitis.

A serologic survey of rice-field leptospirosis in Central Luzon, Philippines.

Although human cases of leptospirosis have been reported from the Philippines, there is a lack of data on its prevalence. We therefore surveyed three rice-farming villages for the presence of leptospiral antibody. Out of 155 sera tested, 63 (43.6%) tested positive using the standard microagglutination test. Antibodies were more frequent in men than women (48 vs. 31%, respectively, p less than 0.01), and less common in the elderly. Exposure to leptospires occurs frequently in rice farmers, and leptospirosis is likely to be an underdiagnosed cause of both mild and severe febrile illness in the Philippines.

Tourniquet application after cobra bite: delay in the onset of neurotoxicity and the dangers of sudden release.

The effects of tourniquet application were prospectively studied in 36 hospitalized patients who developed neurotoxic symptoms after bites by the Philippine cobra (Naja naja philippinensis). Tourniquets had been applied in 94% of cases and delayed the onset of symptoms. Four patients were asymptomatic prior to the release of their tourniquet and in 11 patients symptoms worsened precipitously. Most importantly, 4 patients developed complete respiratory paralysis requiring artificial ventilation on its removal. Medical personnel seeing patients after a possible cobra bite should remove any tourniquet very gradually with both specific therapy and ventilatory support at hand. We recommend tourniquet application in the Philippines only after the bite of a definitely identified cobra and when removal can take place under controlled hospital conditions.

Praziquantel pharmacokinetics and side effects in Schistosoma japonicum-infected patients with liver disease.

Praziquantel undergoes extensive first-pass hepatic biotransformation, but there is little information on its disposition or toxicity when administered to patients with liver disease. To define the influence of liver disease on the pharmacokinetics of praziquantel, we administered it orally to 30 patients with proven Schistosoma japonicum infection whose liver disease was carefully assessed as being severe, moderate, or absent. Both the peak plasma concentration of praziquantel and the bioavailability (measured as the area under the plasma concentration time curve) were significantly greater in the two groups of patients with liver disease (P less than .005), as were the concentrations of the two identified metabolites of praziquantel. Mild side effects were associated with high peak concentrations of praziquantel, but a syndrome of severe abdominal pain followed by bloody diarrhea was not. Our results indicate that the side effects and bioavailability of praziquantel are increased in the presence of liver disease.

Placebo-controlled trial of intravenous penicillin for severe and late leptospirosis.

The effect of a 7-day course of intravenous penicillin (6 million units/day) on severe, advanced leptospirosis was examined in a randomised, placebo-controlled, double-blind trial involving 42 patients. Every measurable aspect of the disease was favourably affected by penicillin. Fever lasted more than twice as long in the placebo group (11.6 [SD 8.34] days vs 4.7 [4.19] days, p less than 0.005), and by the fourth day after starting penicillin more than half the treatment group, but only 1 of 19 in the placebo group, were afebrile (p less than 0.005). Creatinine rises persisted more than thrice as long in the patients receiving only placebo (8.3 [8.46] days vs 2.7 [1.90] days; p less than 0.01). Penicillin also shortened the hospital stay and prevented leptospiruria. Intravenous penicillin should be given to patients with severe leptospirosis, even if therapy can be begun only late in the course of their disease.

Amodiaquine less effective than chloroquine in the treatment of falciparum malaria in the Philippines.

Amodiaquine was compared to chloroquine in two groups of Filipino patients with uncomplicated falciparum malaria. Every patient received 25 mg/kg of base orally given over three days. In a hospital study, all eight patients receiving chloroquine cleared their parasitemia by day 6, but six of eight patients receiving amodiaquine failed to clear parasitemia and in four patients there was no response at all (RIII resistance); this difference was significant (P less than 0.01). In a village based study, there was initial clearing of parasitemia in each patient. However, recrudescent infection occurred in all five patients receiving amodiaquine (RI resistance). Five of six falciparum infections were sensitive to chloroquine, while parasitemia reappeared in one patient. In this village, resistance to amodiaquine was significantly more common than resistance to chloroquine (P less than 0.05). To our knowledge, this is the first report of amodiaquine being substantially worse than chloroquine in the treatment of Plasmodium falciparum infection.

Rehydration and maintenance therapy of cholera patients in Jakarta: citrate-based versus bicarbonate-based oral rehydration salt solution.

We compared the therapeutic efficacy of a World Health Organization standard bicarbonate-based oral rehydration salt solution (BBORS) with a citrate-based oral rehydration solution (CBORS) in a randomized, double-blind, controlled trial in 130 dehydrated patients with cholera aged three to 82 years. On admission the 70 patients who received CBORS and the 60 who received BBORS were similar except that the serum CO2 content (mmol/liter) was significantly lower in the CBORS group (10.8 +/- 3.6 vs. 12.5 +/- 5.3). The incidence of vomiting postadmission (41% vs. 62%, respectively), the stool output during the first 24 hr (4,252 +/- 3,900 ml vs. 6,025 +/- 4,389 ml, respectively), and the time until the patients' conditions were considered normal (38.9 +/- 14.5 hr vs. 46.3 +/- 22.7 hr, respectively) were all significantly less in the CBORS group. The serum CO2 content increased more rapidly during the first 48 hr in the CBORS group (87% +/- 74% vs. 61% +/- 68% for the BBORS group); 23% of the patients receiving CBORS and 35% of the patients receiving BBORS were considered oral-therapy treatment failures. The results indicate that CBORS was superior to BBORS for rehydration and maintenance therapy of hospitalized cholera patients in Jakarta.

Regression analysis of changes in blood pressure with oral contraceptive use.

Measurements of blood pressure were obtained on 2,673 women from East Boston, Massachusetts, an urban, working class neighborhood, in surveys conducted in both 1973 and 1976-1977. Of these, 927 women participated in a third survey in 1978. The women were 16 to 49 years of age in 1973, premenopausal throughout the study, and not on blood pressure medication. Regression analyses were performed of blood pressure change between the first and second as well as between the second and third surveys on initial blood pressure, age, weight, and patterns of oral contraceptive use. For systolic pressure the effect of starting oral contraceptive use was an increase of 4.1 mmHg (p less than 0.0001), while the effect of discontinuing use relative to continued use was a 4.4 mmHg decrease (p less than 0.0001). These changes were not affected by duration of use or time since last use among past users. For diastolic pressure the average effect of starting use between surveys was an insignificant 1.0 mmHg increase, but diastolic pressure level seemed to increase with duration of use (0.5 mmHg/year, p = 0.0009). The effect of discontinuing use relative to continued use was a drop of 2.7 mmHg in diastolic pressure (p = 0.0004), which was uninfluenced by time since last use.

Comparison of immunity to malaria in Sudan and Indonesia: crisis-form versus merozoite-invasion inhibition.

Immunity to falciparum malaria was compared in two populations from malarious areas of southern Sudan and Flores, Indonesia. In Sudan, splenomegaly in adults was rare and anti-plasmodium indirect fluorescent antibody (IFA) titers were low to moderate, 1:1,280 being the modal titer. Sudanese serum was profoundly inhibitory to cultured Plasmodium falciparum, reducing incorporation of radiolabeled hypoxanthine by 63-93% and severely retarding intraerythrocytic parasite development, resulting in moribund crisis-form parasites and virtually no healthy schizonts. In Flores, 64% of the serum donors had splenomegaly greater than or equal to Hackett spleen grade 4 or 5, and the modal IFA titer was 1:10,240. Sera from Indonesia did not retard intraerythrocytic parasite development, but inhibited merozoite erythrocyte invasion 22-87%. Anti-merozoite activity did not correlate with IFA titers. The differences in principal modes of anti-parasitic activity suggest that immunity to malaria in Sudan is based on cell-mediated immune mechanisms associated with crisis forms, merozoite neutralization being of secondary importance. In contrast, malaria immunity in Flores appears to be principally based on anti-merozoite antibody, which does not cause crisis forms and allows for development of reduced numbers of healthy schizonts. This less efficient mechanism may lead to a continuous low-grade parasitemia, which could explain the high specific malaria antibody titers and adult splenomegaly in Flores as compared to Sudan. This latter approach to immunity, being less efficient than the former, apparently results in chronic malaria infections with associated high Ig titers and splenomegaly.

Prolonged incubation improves the micro-scale in-vitro test for drug sensitivity of Plasmodium falciparum.

In the standard micro-scale in-vitro test for detecting resistance of Plasmodium falciparum to chloroquine, isolates are incubated for 24-28 h in medium that does not contain serum. The effect of prolonging incubation to 48 h and of adding human AB serum to the culture medium of P falciparum from Irian Jaya, Indonesia was studied. Addition of serum was not associated with any advantages or disadvantages. Production of schizonts was increased when incubation was prolonged. This facilitated reading of the malaria smears and interpretation of the results. The percentage of successful tests (greater than or equal to 20 schizonts/200 asexual parasites in control wells) increased from 31% at 28 h incubation to 94% at 48 h. Among the 7 (44%) isolates which were chloroquine-resistant in vivo, only 1 met the criteria for a positive test at 28 h incubation, but at 48 h all 7 did. To achieve optimum results from the micro-scale in-vitro test in Jayapura, Irian Jaya, isolates should be incubated for 48 h.

Hearing impairment in meningococcal meningitis.

Hearing affection as a sequel of meningococcal meningitis and its relation to age, sex, severity and duration of disease was studied in Cairo, Egypt during the period December 1966--December 1973. The total incidence of impaired hearing in the 775 cases was 5.8%. This incidence was higher in the younger age groups, females, severe cases of meningitis and in patients who received specific therapy shortly after the onset of signs and symptoms of the disease. The aetiology of hearing impairment in meningitis was reviewed.