[Assessment of the management of cases of fever and malaria by general practitioners in the central Highlands of Madagascar, 2009-2010]. / Évaluation de la prise en charge des cas de fièvre et du paludisme par des médecins communautaires dans les Hautes Terres centrales de Madagascar, 2009-2010.

The aim of this study was to determine the frequency of confirmed malaria among patients with fever in the central Highlands of Madagascar, the clinical utility of treating this fever, and the involvement of community general practitioners in improving malaria management. This descriptive, prospective study took place from July 1, 2009, through June 30, 2010. Patients consulting for fever were classified into 2 groups: the first (G1) included all children younger than 5 years and the second group (G2) children 5 years or older and adults. In G1, 1383 cases of fever included 145 (10.5%) confirmed cases of malaria. The corresponding numbers in G2 were 1172 and 276 (23.5%). The prevalence of malaria was highest between December and May. In G1, the main clinical signs associated with a positive rapid diagnostic test (RDT) were pallor, jaundice, seizures, and failure to eat. In G2, a positive RDT was associated with pallor, coma, and jaundice. Treatment of patients with positive RDTs was based on quinine (51%) or artemisinin-based combination therapy (49%). Malaria remains endemic in the central Highlands of Madagascar. Efforts should be undertaken to improve prescription of antimalarial drugs.

[Implementation of the hypertension network in Mali (RHYTM)]. / Mise en place du réseau hypertension du Mali (RHYTM).

In view of the rising prevalence of arterial hypertension and its complications throughout sub-Saharan Africa including in rural areas, the Association of the Rural Doctors of Mali asked its NGO partner, Sant6 Sud, for assistance in setting up a medical network dedicated to hypertension. This report describes the implementation of the Mali Hypertension Network (French acronym, RHYTM) that involved three stages, i.e., physician training, development of appropriate protocols and field trials. The physician training stage was carried out over a one-week period and covered all the aspects of hypertension. In the second stage international guidelines were used as a basis for development of appropriate protocols for the rural setting. Field trials were conducted in the villages to verify the feasibility of the protocols and functionality of the network. Treatment of hypertension depends mainly on lifestyle and dietetic measures with emphasis on reducing salt intake. Drug treatment is based primarily on first-intention use of thiazidic diuretics. Management of this chronic pathology runs up against socio-cultural, economic and logistic obstacles. These problems are discussed and possible solutions are proposed. This preliminary experience will provide epidemiologic and clinical data on a sample population including more than 80000 people and explore the possibility of extending the network to other zones in this area of Africa.

[For front-line community-based general practitioners]. / Pour une médecine générale communautaire en première ligne.

In the past thirty years considerable effort has been devoted to delivering basic health services to rural populations. However the quality of care remains poor. One problem is that the absence of general practitioners working at the community level has resulted in health care systems without doctors. This "missing-link" situation is inconsistent with the availability of a large number of young fully trained medical doctors who graduated from Medical Schools in West African countries and Madagascar. Based on examples in Mali and Madagascar, the authors of this article attempt to show the advantages of a new concept, i.e., community-based general practitioners. These practitioners would not only provide a front-line medical presence but also combine the principles of primary health care (PHC) and family medicine (FM) into a single practice. For this approach to be successful a number of obstacles would have to be overcome and several indispensable accompanying measures would have to be implemented. The goal would be to establish a familiar front-line healthcare provider that village communities could trust.

[Treatment of epilepsy in rural areas in Mali]. / Traitement des épileptiques en milieu rural au Mali.

Epilepsy is a public health problem in Africa due to prevalence and social exclusion. We report a follow-up protocol for epileptic patients treated at home in rural areas of Mali. The objectives were: education for the patient, family, and village leaders in orders to achieve good compliance, uninterrupted supply of generic phenobarbitol, follow-up visits once a month for one year then every two months if good compliance with a country physician with delivery of phenobarbitol in sufficient quantity to reach the next visit, verification of correct drug dosage and use, supervision of treatment effect. After two years, the follow-up visits showed that 57.4% of the patients had been seizure free for at least 24 months (more than 4 monthly seizures before treatment). Rate of seizures decreased in 15.7% of the patients. Results were excellent with no seizures, clear physical, psychic and social improvement (work, married life, school attendance). Very few side effects were observed. There were no cases of poisoning. The management scheme is very cost effective: 1.5 USD per month per patient, including phenobarbitol and implementation. There is a need for anti-epilepsy programs in Africa which should be implemented on the local (rural medicalisation), national and international level ("Epilepsy out of the shadows" campaign).

Treatment with phenobarbital and monitoring of epileptic patients in rural Mali.

OBJECTIVE: To assess the efficacy of phenobarbital treatment for epileptic patients in rural Mali. METHODS: Epileptic patients were treated at home with phenobarbital at daily dosages ranging from 50 mg for children to 200 mg for adults and their condition was monitored. Advice was given to patients, their families, and the village authorities in order to achieve compliance. An uninterrupted supply of generic phenobarbital was provided and a rural physician made two follow-up visits to each village to ensure that the drug was taken in the correct doses. The physician gave information to the population, distributed the phenobarbital in sufficient quantities to cover the periods between visits, and monitored the patients' responses to treatment. During the first year the physician visited the patients every two months. The frequency of visits was subsequently reduced to once every four months. FINDINGS: In the six months preceding treatment the average rate of seizures among patients exceeded four per month. After a year of treatment, 80.2% of the patients experienced no seizures for at least five months. A total of 15.7% of patients experienced a reduction in seizures. In many cases no further seizures occurred and there were improvements in physical health, mental health and social status. There were very few side-effects and no cases of poisoning were reported. The cost of treatment per patient per year was 7 US dollars for generic phenobarbital and 8.4 US dollars for logistics. CONCLUSION: Low doses of phenobarbital were very effective against epilepsy. However, there is an urgent need for programmes involving increased numbers of physicians in rural areas and, at the national level, for the inclusion of epilepsy treatment in the activities of health care facilities. Internationally, an epilepsy control programme providing free treatment should be developed.