Efficacy of mefloquine and sulfadoxine-pyrimethamine for the treatment of uncomplicated Plasmodium falciparum infection in Machinga District, Malawi, 1998.

In response to the spread of chloroquine-resistant Plasmodium falciparum, Malawi changed its first-line antimalarial drug in 1993 from chloroquine to sulfadoxine-pyrimethamine (SP). Surveillance data has suggested that resistance to SP may be increasing. We compared the efficacy of SP with a potential successor, mefloquine (MQ). By use of a modified World Health Organization in vivo protocol, children infected with P. falciparum were randomized to receive SP (sulfadoxine 25 mg/kg) or MQ (15 mg/kg). We observed combined RII and RIII parasitologic failures of 20.0 and 22.0% in the SP and MQ arms, respectively. Among those in the MQ arm, the relative hazard of failing with a Day 2 drug level < 500 ng/mL was 10.6 times higher than those with levels > or = 500 ng/mL. Given the decreased efficacy of the first-line antimalarial drug and the high failure rates of MQ at this lower dosage, Malawi should consider assessing the efficacy and feasibility of alternative drugs to treat uncomplicated falciparum malaria.

Use of malaria prevention measures by North American and European travelers to East Africa.

BACKGROUND: The use of preventive measures, including effective chemoprophylaxis, is essential for protection against malaria among travelers. However, data have shown that travelers and medical advisors are confused by the lack of uniform recommendations and numerous prophylactic regimens of varying effectiveness that are used. METHODS: To assess the use and type of preventive measures against malaria, we conducted a cross-sectional study in 1997 among travelers departing from the Nairobi and Mombasa airports in Kenya with European destinations. RESULTS: Seventy-five percent of the travelers studied were residents of Europe and 25% were residents of North America; all stayed less than 1 year, and visited malarious areas. Most travelers, 97.1%, were aware of the risk and 91.3% sought pretravel medical advice. Although 95.4% used chemoprophylaxis and/or antimosquito measures, only 61.7% used both regular chemoprophylaxis and two or more antimosquito measures. Compliance with chemoprophylaxis was lowest amongst those who used a drug with a daily, as opposed to, a weekly dosing schedule, stayed more than 1 month, attributed an adverse health event to the chemoprophylaxis, and were less than 40 years of age. Among US travelers, 94.6% of those taking chemoprophylaxis were taking an effective regimen, that is, mefloquine or doxycycline. Only 1.9% used a suboptimal drug regimen, such as chloroquine/proguanil. Among European travelers, 69% used mefloquine or doxycycline, and 25% used chloroquine/proguanil. Notably, 45.3% of travelers from the UK used chloroquine/proguanil. Adverse events were noted by 19.7% of mefloquine users and 16.4% of travelers taking chloroquine/proguanil. Neuropsychologic adverse events were reported by 7.8% of users of mefloquine and 1.9% of those taking chloroquine/proguanil. The adverse events, however, had a lesser impact on compliance than frequent dosing schedule. CONCLUSIONS: Health information should be targeted to travelers who are likely to use suboptimal chemoprophylaxis or may be noncompliant with prophylaxis. Uniform recommendations for effective chemoprophylaxis with simple dosing schedules are necessary to reduce rates of malaria among travelers to Africa.

School-associated violent deaths in the United States, 1992 to 1994.

OBJECTIVES: To conduct the first nationwide investigation of violent deaths associated with schools in the United States, to quantify the risk of school-associated violent death, and to identify epidemiologic features of these deaths. DESIGN: Descriptive case series. SETTING: United States, July 1, 1992, through June 30, 1994. METHODS: School-associated violent deaths were identified by study collaborators and through 2 online news databases. Police reports, medical examiners' records, and interviews with police and school officials provided detailed information about each case. RESULTS: In a 2-year period, 105 school-associated violent deaths were identified. The estimated incidence of school-associated violent death was 0.09 per 100 000 student-years. Students in secondary schools, students of minority racial and ethnic backgrounds, and students in urban school districts had higher levels of risk. The deaths occurred in communities of all sizes in 25 different states. Homicide was the predominant cause of death (n = 85 [80.9%]), and firearms were responsible for a majority (n = 81 [77.1%]) of the deaths. Most victims were students (n = 76 [72.4%]). Both victims and offenders tended to be young (median ages, 16 and 17 years, respectively) and male (82.9% and 95.6%, respectively). Approximately equal numbers of deaths occurred inside school buildings (n = 31 [29.5%]), outdoors but on school property (n = 37 [35.2%]), and at off-campus locations while the victim was in transit to or from school (n = 37 [35.2%]). Equal numbers of deaths occurred during classes or other school activities (n = 46 [43.8%]) and before or after official school activities (n = 46 [43.8%]). CONCLUSIONS: School-associated violent deaths were more common than previously estimated. The epidemiologic features of these deaths were similar to those of homicides and suicides that occur elsewhere. A comprehensive approach that addresses violent injury and death among young people at school and elsewhere in the community is suggested.