Effect of preventive supplementation with ready-to-use therapeutic food on the nutritional status, mortality, and morbidity of children aged 6 to 60 months in Niger: a cluster randomized trial

CONTEXT

Ready-to-use therapeutic foods (RUTFs) are an important component of effective outpatient treatment of severe wasting. However, their effectiveness in the population-based prevention of moderate and severe wasting has not been evaluated.

OBJECTIVE

To evaluate the effect of a 3-month distribution of RUTF on the nutritional status, mortality, and morbidity of children aged 6 to 60 months in Niger.

DESIGN, SETTING, AND PARTICIPANTS

A cluster randomized trial of 12 villages in Maradi, Niger. Six villages were randomized to intervention and 6 to no intervention. All children in the study villages aged 6 to 60 months were eligible for recruitment.

INTERVENTION

Children with weight-for-height 80% or more of the National Center for Health Statistics reference median in the 6 intervention villages received a monthly distribution of 1 packet per day of RUTF (92 g [500 kcal/d]) from August to October 2006. Children in the 6 nonintervention villages received no preventive supplementation. Active surveillance for conditions requiring medical or nutritional treatment was conducted monthly in all 12 study villages from August 2006 to March 2007.

MAIN OUTCOME MEASURES

Changes in weight-for-height z score (WHZ) according to the World Health Organization Child Growth Standards and incidence of wasting (WHZ <-2) over 8 months of follow-up.

RESULTS

The number of children with height and weight measurements in August, October, December, and February was 3166, 3110, 2936, and 3026, respectively. The WHZ difference between the intervention and nonintervention groups was -0.10 z (95% confidence interval [CI], -0.23 to 0.03) at baseline and 0.12 z (95% CI, 0.02 to 0.21) after 8 months of follow-up. The adjusted effect of the intervention on WHZ from baseline to the end of follow-up was thus 0.22 z (95% CI, 0.13 to 0.30). The absolute rate of wasting and severe wasting, respectively, was 0.17 events per child-year (140 events/841 child-years) and 0.03 events per child-year (29 events/943 child-years) in the intervention villages, compared with 0.26 events per child-year (233 events/895 child-years) and 0.07 events per child-year (71 events/1029 child-years) in the nonintervention villages. The intervention thus resulted in a 36% (95% CI, 17% to 50%; P < .001) reduction in the incidence of wasting and a 58% (95% CI, 43% to 68%; P < .001) reduction in the incidence of severe wasting. There was no reduction in mortality, with a mortality rate of 0.007 deaths per child-year (7 deaths/986 child-years) in the intervention villages and 0.016 deaths per child-year (18 deaths/1099 child-years) in the nonintervention villages (adjusted hazard ratio, 0.51; 95% CI, 0.25 to 1.05).

CONCLUSION

Short-term supplementation of nonmalnourished children with RUTF reduced the decline in WHZ and the incidence of wasting and severe wasting over 8 months.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00682708.

The dynamics of measles in sub-Saharan Africa

Although vaccination has almost eliminated measles in parts of the world, the disease remains a major killer in some high birth rate countries of the Sahel. On the basis of measles dynamics for industrialized countries, high birth rate regions should experience regular annual epidemics. Here, however, we show that measles epidemics in Niger are highly episodic, particularly in the capital Niamey. Models demonstrate that this variability arises from powerful seasonality in transmission-generating high amplitude epidemics-within the chaotic domain of deterministic dynamics. In practice, this leads to frequent stochastic fadeouts, interspersed with irregular, large epidemics. A metapopulation model illustrates how increased vaccine coverage, but still below the local elimination threshold, could lead to increasingly variable major outbreaks in highly seasonally forced contexts. Such erratic dynamics emphasize the importance both of control strategies that address build-up of susceptible individuals and efforts to mitigate the impact of large outbreaks when they occur.

Time is of the essence: exploring a measles outbreak response vaccination in Niamey, Niger

The current World Health Organization recommendations for response during measles epidemics focus on case management rather than outbreak response vaccination (ORV) campaigns, which may occur too late to impact morbidity and mortality and have a high cost per case prevented. Here, we explore the potential impact of an ORV campaign conducted during the 2003-2004 measles epidemic in Niamey, Niger. We measured the impact of this intervention and also the potential impact of alternative strategies. Using a unique geographical, epidemiologic and demographic dataset collected during the epidemic, we developed an individual-based simulation model. We estimate that a median of 7.6% [4.9-8.9] of cases were potentially averted as a result of the outbreak response, which vaccinated approximately 57% (84563 of an estimated 148600) of children in the target age range (6-59 months), 23 weeks after the epidemic started. We found that intervening early (up to 60 days after the start of the epidemic) and expanding the age range to all children aged 6 months to 15 years may lead to a much larger (up to 90%) reduction in the number of cases in a West African urban setting like Niamey. Our results suggest that intervening earlier even with lower target coverage (approx. 60%), but a wider age range, may be more effective than intervening later with high coverage (more than 90%) in similar settings. This has important implications for the implementation of reactive vaccination interventions as they can be highly effective if the response is fast with respect to the spread of the epidemic.

Unacceptably high mortality related to measles epidemics in Niger, Nigeria, and Chad

BACKGROUND

Despite the comprehensive World Health Organization (WHO)/United Nations Children's Fund (UNICEF) measles mortality-reduction strategy and the Measles Initiative, a partnership of international organizations supporting measles mortality reduction in Africa, certain high-burden countries continue to face recurrent epidemics. To our knowledge, few recent studies have documented measles mortality in sub-Saharan Africa. The objective of our study was to investigate measles mortality in three recent epidemics in Niamey (Niger), N'Djamena (Chad), and Adamawa State (Nigeria).

METHODS AND FINDINGS

We conducted three exhaustive household retrospective mortality surveys in one neighbourhood of each of the three affected areas: Boukoki, Niamey, Niger (April 2004, n = 26,795); Moursal, N'Djamena, Chad (June 2005, n = 21,812); and Dong District, Adamawa State, Nigeria (April 2005, n = 16,249), where n is the total surveyed population in each of the respective areas. Study populations included all persons resident for at least 2 wk prior to the study, a duration encompassing the measles incubation period. Heads of households provided information on measles cases, clinical outcomes up to 30 d after rash onset, and health-seeking behaviour during the epidemic. Measles cases and deaths were ascertained using standard WHO surveillance-case definitions. Our main outcome measures were measles attack rates (ARs) and case fatality ratios (CFRs) by age group, and descriptions of measles complications and health-seeking behaviour. Measles ARs were the highest in children under 5 y old (under 5 y): 17.1% in Boukoki, 17.2% in Moursal, and 24.3% in Dong District. CFRs in under 5-y-olds were 4.6%, 4.0%, and 10.8% in Boukoki, Moursal, and Dong District, respectively. In all sites, more than half of measles cases in children aged under 5 y experienced acute respiratory infection and/or diarrhoea in the 30 d following rash onset. Of measles cases, it was reported that 85.7% (979/1,142) of patients visited a health-care facility within 30 d after rash onset in Boukoki, 73.5% (519/706) in Moursal, and 52.8% (603/1,142) in Dong District.

CONCLUSIONS

Children in these countries still face unacceptably high mortality from a completely preventable disease. While the successes of measles mortality-reduction strategies and progress observed in measles control in other countries of the region are laudable and evident, they should not overshadow the need for intensive efforts in countries that have just begun implementation of the WHO/UNICEF comprehensive strategy.

High sensitivity and specificity of the Pastorex® latex agglutination test for Neisseria meningitidis serogroup A during a clinical trial in Niger

There is a great need for a rapid diagnostic test to guide vaccine choice during outbreaks of meningococcal meningitis in resource-poor countries. During a randomised clinical trial conducted during an epidemic of Neisseria meningitidis serogroup A in Niger in 2003, the sensitivity and specificity of the Pastorex latex agglutination test for this serogroup under optimal field conditions were assessed, using culture and/or PCR as the gold standard. Results from 484 samples showed a sensitivity of 88% (95% CI 85-91%) and a specificity of 93% (95% CI 90-95%). Pastorex could be a good alternative to current methods, as it can be performed in a local laboratory with rapid results and is highly specific. Sensitivity can be improved with prior microscopy where feasible. A study specifically to evaluate the Pastorex test under epidemic conditions, using laboratories with limited resources, is recommended.

Estimating transmission intensity for a measles epidemic in Niamey, Niger: lessons for intervention

The objective of this study is to estimate the effective reproductive ratio for the 2003-2004 measles epidemic in Niamey, Niger. Using the results of a retrospective and prospective study of reported cases within Niamey during the 2003-2004 epidemic, we estimate the basic reproductive ratio, effective reproductive ratio (RE) and minimal vaccination coverage necessary to avert future epidemics using a recent method allowing for estimation based on the epidemic case series. We provide these estimates for geographic areas within Niamey, thereby identifying neighbourhoods at high risk. The estimated citywide RE was 2.8, considerably lower than previous estimates, which may help explain the long duration of the epidemic. Transmission intensity varied during the course of the epidemic and within different neighbourhoods (RE range: 1.4-4.7). Our results indicate that vaccination coverage in currently susceptible children should be increased by at least 67% (vaccine efficacy 90%) to produce a citywide vaccine coverage of 90%. This research highlights the importance of local differences in vaccination coverage on the potential impact of epidemic control measures. The spatial-temporal spread of the epidemic from district to district in Niamey over 30 weeks suggests that targeted interventions within the city could have an impact.

Late vaccination reinforcement during a measles epidemic in Niamey, Niger (2003-2004)

Low measles vaccination coverage (VC) leads to recurrent epidemics in many African countries. We describe VC before and after late reinforcement of vaccination activities during a measles epidemic in Niamey, Niger (2003-2004) assessed by Lot Quality Assurance Sampling (LQAS). Neighborhoods of Niamey were grouped into 46 lots based on geographic proximity and population homogeneity. Before reinforcement activities, 96% of lots had a VC below 70%. After reinforcement, this proportion fell to 78%. During the intervention 50% of children who had no previous record of measles vaccination received their first dose (vaccination card or parental recall). Our results highlight the benefits and limitations of vaccine reinforcement activities performed late in the epidemic.

Ceftriaxone as effective as long-acting chloramphenicol in short-course treatment of meningococcal meningitis during epidemics: a randomised non-inferiority study

BACKGROUND

In sub-Saharan Africa in the 1990s, more than 600,000 people had epidemic meningococcal meningitis, of whom 10% died. The current recommended treatment by WHO is short-course long-acting oily chloramphenicol. Continuation of the production of this drug is uncertain, so simple alternatives need to be found. We assessed whether the efficacy of single-dose treatment of ceftriaxone was non-inferior to that of oily chloramphenicol for epidemic meningococcal meningitis.

METHODS

In 2003, we undertook a randomised, open-label, non-inferiority trial in nine health-care facilities in Niger. Participants with suspected disease who were older than 2 months were randomly assigned to receive either chloramphenicol or ceftriaxone. Primary outcome was treatment failure (defined as death or clinical failure) at 72 h, measured with intention-to-treat and per-protocol analyses.

FINDINGS

Of 510 individuals with suspected disease, 247 received ceftriaxone, 256 received chloramphenicol, and seven were lost to follow-up. The treatment failure rate at 72 h for the intention-to-treat analysis was 9% (22 patients) for both drug groups (risk difference 0.3%, 90% CI -3.8 to 4.5). Case fatality rates and clinical failure rates were equivalent in both treatment groups (14 [6%] ceftriaxone vs 12 [5%] chloramphenicol). Results were also similar for both treatment groups in individuals with confirmed meningitis caused by Neisseria meningitidis. No adverse side-effects were reported.

INTERPRETATION

Single-dose ceftriaxone provides an alternative treatment for epidemic meningococcal meningitis--its efficacy, ease of use, and low cost favour its use. National and international health partners should consider ceftriaxone as an alternative first-line treatment to chloramphenicol for epidemic meningococcal meningitis.

Epidemiological patterns of meningococcal meningitis in Niger in 2003 and 2004: under the threat of N. meningitidis serogroup W135

Since the Neisseria meningitidis serogroup W135 epidemic in Burkina Faso in 2002, the neighbouring countries dread undergoing outbreaks. Niger has strongly enhanced the microbiological surveillance, especially by adding the polymerase chain reaction (PCR) assay to the national framework of the surveillance system. During the 2003 epidemic season, 8113 clinically suspected cases of meningitis were notified and nine districts of the 42 crossed the epidemic threshold, while during the 2004 season, the number of cases was 3521 and four districts notified epidemics. In 2003 and 2004, serogroup A was identified in most N. meningitidis from cerebrospinal fluid (CSF) specimens (89.7% of 759 and 87.2% of 406, respectively). Although serogroup W135 represented only 8.3% of the meningococcal meningitis in 2003 and 7.9% in 2004, and was not involved in outbreaks, it was widespread in various areas of the country. In the regions that notified epidemics, the proportion of serogroup W135 was tiny while it exceeded 40% in several non-epidemic regions. Despite the wide distribution of W135 serogroup in Niger and the fears expressed in 2001, the threat of a large epidemic caused by N. meningitidis W135 seems to have been averted in Niger so far. There is no clear indication whether this serogroup will play a lasting role in the epidemiology of meningococcal meningitis or not. As early as in the 1990s, a significant but transient increase in the incidence of N. meningitidis serogroup X was observed. Close microbiological surveillance is crucial for monitoring the threat and for identifying at the earliest the serogroups involved in epidemics.

Outbreaks of serogroup X meningococcal meningitis in Niger 1995-2000

In the African meningitis belt, the recurrent meningococcal meningitis epidemics are generally caused by serogroup A. In the past 20 years, other serogroups have been detected, such as X or W135, which have caused sporadic cases or clusters. We report here 134 meningitis cases caused by Neisseria meningitidis serogroup X that occurred in Niamey between 1995 and 2000. They represented 3.91% of the meningococcal isolates from all CSF samples, whereas 94.4% were of serogroup A. Meningococcal meningitis cases were detected using the framework of the routine surveillance system for reportable diseases organized by the Ministry of Public Health of Niger. The strains were isolated and determined by the reference laboratory for meningitis in Niamey (CERMES) and further typed at the WHO collaborating center of the Pharo in Marseille and at the National Reference Center for the Meningococci at the Institut Pasteur. Reference laboratories in Marseille and Paris characterized 47 isolates having the antigenic formula (serogroup:serotype:sero-subtype) X:NT:P1.5. Meningitis cases due to meningococcus serogroup X did not present any clinical or epidemiological differences to those due to serogroup A. The seasonal incidence was classical; 93.3% of the cases were recorded during the dry season. The mean age of patients was 9.2 years (+/- 6 years). The sex ratio M/F was 1.3. Case fatality rate was 11.9% without any difference related to age or sex. The increasing incidence of the serogroup X was not related to the decrease of serogroup A, but seemed cyclic, and evolved independently of the recurrence of both serogroups A and C.

Polymerase chain reaction assay and bacterial meningitis surveillance in remote areas, Niger

To compensate for the lack of laboratories in remote areas, the national reference laboratory for meningitis in Niger used polymerase chain reaction (PCR) to enhance the surveillance of meningitis caused by Neisseria meningitidis, Streptococcus pneumoniae, and Haemophilus influenzae. PCR effectively documented the wide geographic spread of N. meningitidis serogroup W135.

Are anti-Chlamydia pneumoniae antibodies prognosis indicators for peripartum cardiomyopathy?

BACKGROUND

The authors recently pointed out an epidemiological relation between specific anti-Chlamydia pneumoniae antibodies and peripartum cardiomyopathy in Niamey (Republic of Niger).

DESIGN

In this work, they studied the prognosis value of such specific antibodies.

METHODS

The serological status for specific IgG, IgA and IgM anti-C. pneumoniae antibodies of 50 African women (age, mean+/-SD = 30.2 +/- 7 years) hospitalized in Niamey, with peripartum cardiomyopathy, was determined at the time of diagnosis. The diagnosis was categorized as 'complete remission' (13 patients, age = 29.3 +/- 6.5 years, observation delay = 27 months), 'incomplete remission' (27 patients, age = 30.7 +/- 7.6 years, observation delay = 14 months) and 'deceased' (10 patients, age = 30.3 +/- 6.2 years, observation delay = 13 months). The control group comprised 27 African women (age = 25.2 +/- 4.6 years), living in the same area. The Mann-Whitney and Fisher's exact tests were used for the statistical comparison.

RESULTS

The dilution of IgG specific anti-C. pneumoniae antibodies was higher (P = 0.047) in the 'incomplete remission' compared with 'complete remission'. The dilution of IgA specific anti-C. pneumoniae antibodies was higher (P = 0.033) in the patients with a severe evolution ('deceased' + 'incomplete remission') compared with 'complete remission'. There was no significant difference between patients in 'complete remission' compared with 'controls'.

CONCLUSIONS

At the time of peripartum cardiomyopathy diagnosis the specific IgG and IgA anti-C. pneumoniae antibodies are of prognosis value: a high dilution is more often associated with a poor prognosis. This is the first identified prognosis factor during the precocious evolution of peripartum cardiomyopathy.

Emergence of complex and diverse CRF02-AG/CRF06-cpx recombinant HIV type 1 strains in Niger, West Africa

On the basis of partial env and gag subtyping, we documented that the majority of HIV-1 strains circulating in Niger were CRF02-AG (54.3%) or CRF06-cpx (18.1%) and that 9% of the samples were possible recombinants between CRF02 and CRF06. To determine in more detail the precise structure of these viruses we sequenced the full-length genomes for three such strains (97NE-003, 00NE-036, and 00NE-095). From the bootscan and phylogenetic tree analysis it is evident that the new viruses are the result of recombination events between CRF02-AG and CRF06-cpx strains. Importantly, each virus had a different complex recombinant structure with multiple breakpoints, leading to viruses with complex mosaic patterns.

Predominance of CRF02-AG and CRF06-cpx in Niger, West Africa

A total of 110 HIV-1-positive samples obtained in 1997 (n = 44) and 2000 (n = 66) were genetically characterized in the V3-V5 envelope region and the p24 gag region. The majority of the strains were CRF02-AG (54.3%) or CRF06-cpx (18.1%) in env and gag. More than 9% of the samples were recombinants between CRF02 and CRF06; 9 were CRF06 in env but CRF02 in gag, and for one sample the opposite was seen. Overall for 23 (20.9%) samples, the subtype designation was different between env and gag, and in 20 of these 23 samples a CRF was involved in the recombination event. No significant differences were seen between subtype distributions in 1997 and 2000, except that the proportion of recombinants increased from 13.6% in 1997 to 27.2% in 2000.

[Chlamydia pneumoniae and acute respiratory tract infections in breast-feeding infants: simultaneous mother-child serological study in Niamey (Niger)]

The age and the origin of Chlamydia pneumoniae primary infection in Sahelian areas are unknown. To evaluate the prevalence of C. pneumoniae antibodies, the authors studied the serological status of C. pneumoniae-, C. psittaci- and C. trachomatis-specific antibodies of 50 mother-child couples using the microimmunofluorescence technique. Children were 10 to 34 month-old (18,1 6,2, mean SD), breast-fed and hospitalized with acute respiratory tract infections in Niamey (republic of Niger). Specific C. pneumoniae IgG antibodies were present in 46/48 (95.8%) children, IgA in 32/48 (66.6%). In the mothers, specific C. pneumoniae IgG antibodies were present in 40/48 (83.3%), IgA in 31/48 (64.6%). The specific IgM antibodies were steadily absent in mothers and children. In the mother-child couples, 38/46 (79.2%) had specific C. pneumoniae IgG antibodies and 23/47 (48.9%) had IgA. The prevalence of specific C. pneumoniae IgG and IgA antibodies is very high in this population. These results point out that C. pneumoniae primary infection is very precocious in this paediatric population and is very different from American, Asian and European reports. A mother-child direct contamination during the first months of life in this breast-feeding pediatric population is discussed.

[Value of malaria prophylaxis in surgical intervention in a malaria endemic zone , Niamey, Niger]

One hundred patients were included in a randomised trial to identify surgical factors inducing malaria and assess the impact of chloroquine prophylaxis in Niamey where resistance to the drug is moderate. Thick smears were positive in 19 patients without prophylaxis (37%) versus 7 under chloroquine (15%). Factors influencing malaria were surgical intervention lasting more than 1 hour and general anaesthesia. Chloroquine prophylaxis was significantly efficient under such circumstances.

[Behavioral disorders after treatment with isoniazid]

Isoniazid, efficient antituberculosis drug, can provoke neuropsychiatric manifestations at certain patients. Two mechanisms of action for isoniazid-related psychosis are kept by the majority of authors: pyridoxin deficiency isoniazid toxicity, molecule near chemically to iproniazid, powerful IMAO (monoamine oxydase inhibitor). The predisposing factors are: slow acetylator, diabetes, hepatic insufficiency, old age, alcoholism. Family and personal history of mental illness are also predisposing factors. We report here the observation of a 53-year-old man presented with psychotic symptoms suspected to be relation with isoniazid. The favorable evolution after the definitive stop of isoniazid therapy is in favor of this hypothesis. Although rare, the neuropsychiatric symptoms during tuberculosis treatment by isoniazid, the possibility of iatrogenic etiology must be evoked. Isoniazid, antituberculosis very used in Africa, is mentioned by several authors like the cause of psychiatric disorders. Pyridoxin deficiency seems to play a role of trigger. Supplementation with vitamin B6 during the treatment by isoniazid must be therefore systematic to warm these unrests.

[Blackwater fever in adults with sickle cell anemia. Two fatal cases]

Blackwater fever is characterized by severe intravascular hemolysis with renal failure caused by recurrent use of quinine for prophylaxis. Once described in European patients, sporadic cases have been reported more and more often in autochthonous Africans and Asians. Newer antimalarials including aminoalchohol mefloquine, and halofantrine have also been implicated in Blackwater fever. In this report we describe two cases of blackwater fever involving patients with sickle cell anemia (HbSS). Symptoms including fever, acute hemolytic anemia, emesis, back pain, and hemoglobinuria were characteristic of blackwater fever. Both patients died. Although the underlying mechanism of blackwater fever remains unclear, a likely explanation is an immunoallergic reaction to quinine. Association with glucose-6-phosphate dehydrogenase deficiency has often been reported. Our cases suggest that blackwater fever may also be correlated with hemoglobinopathy such as HbSS.

[Chlamydia infection and peripartum dilated cardiomyopathy in Niger]

Peripartum cardiac failure due to cardiomyopathy is common in sub-saharan Africa. The etiology is unknown. This study was performed in Niger to assess a possible relationship between peripartum cardiomyopathy and Chlamydia. A total of 50 African women presenting peripartum cardiomyopathy underwent testing for infection by Chlamydia pneumoniae, Chlamydia trachomatis, and Chlamydia psittaci. The inclusion criteria were cardiac failure during the last three months of pregnancy or first 6 months postpartum with echocardiographic evidence of dilated cardiomyopathy. Similar testing was carried out in a control group of 25 African women from the same geographical location without cardiac disease. Detection of specific IgG, IgA and IgM antibodies was performed using the microimmunofluorescence technique. The cut-off values were > or = 1/32 for specific IgG antibody and > or = 1/16 for specific IgA and IgM antibody. Statistical comparison of the patient and control groups was achieved using the chi 2 test. For Chlamydia pneumoniae, 48 patients (96 p. 100) versus 20 controls (80 p. 100) controls were positive for IgG antibodies (p < 0.025) and 39 patients (80 p. 100) versus 14 controls (56 p. 100) were positive for IgA antibodies (p < 0.05). No patient or control demonstrated IgM antibodies for Chlamydia pneumoniae. For Chlamydia trachomatis and Chlamydia psittaci, differences in positive rates were not statistically significant. This is the first study demonstrating infection in patients with peripartum cardiomyopathy. The possible role of Chlamydia pneumoniae is discussed.

[Acute intoxication with "sobi-lobi" (Datura). Four cases in Niger]

The datura (Datura stramonium, Datura metel) belongs to a group of plants from the solanacies variety and can be the cause of voluntary intoxication. In Nigher, its flowers and seeds are used for their hallucinogenic properties. Its alcaloïds have an atropine-like effect. We are reporting here the first four cases of voluntary intoxication among teenagers in Niamey (Republic of Niger). The symptoms, which happened to be identical for the four patients, lead us quickly towards the possibility of a collective intoxication. During the questioning, the patients admitted they had smoked the plant's dried flowers, but also they drunk an herbal tea mixed with datura seeds. Symptoms are comparable to that of intoxications caused by atropine. Neurological signs are the main symptoms (agitation, delirium, disorientation, hallucination, mydriasis, retention of urine...). The others noticeable signs are: fever, dry mouth, tachycardia, thirstiness. The evolution was favourable as the patients left the hospital between D2 and D4. Those clinical features are compared to the literature items, which are inexistent in western Africa. The prognosis may be fatal, especially for the child and during massive intoxications meant to be autolystic or toxicomaniac. The recovery when possible leads usually to no sequels however sever the clinical picture is. The consultation of the population enabled us to comprehend that datura is known and consumed for its hallucinogenic proprieties. The therapeutic guidance is described and prevention suggested.

[Congenital malaria. Parasitological and serological studies in Niamey (Niger)]

Congenital malaria is defined as the presence of Plasmodium parasites in the erythrocytes of newborns less than seven days old. The aim of this study was to determine the incidence of congenital malaria and its possible clinical consequences. We carried out a prospective survey in Niamey, the capital of Niger (600,000 inhabitants) from July to September 1993. Niamey is in an area of mesoendemic malaria and this period of the year corresponds to the rainy season, when malaria transmission is maximal. Ninety mothers and their newborns were included. We assessed the clinical status of the mother and child at the time of the delivery, and took blood smears to check for parasitemia and blood samples to check for antimalaria antibodies by indirect immunofluorescence (IIF). The placenta was not examined. Clinical signs of malaria (fever, splenomegaly, anemia and jaundice) were absent in all mothers and children and 88 of the 90 children had normal birth weights. Plasmodium falciparum was the only parasite detected, with 49 of the 90 mothers and 12 of the 90 newborns having positive blood smears. Serological tests detected the presence of antimalaria antibodies in 73 of the 90 mothers (81.1%) and 68 of the 90 newborns (75.5%). Thus, we found no cases of congenital malaria with clinical signs in this study, despite the high frequency of parasites and antimalaria antibodies. The reasons for this absence of cases of congenital malaria with symptoms are discussed.

Postpartum cardiac failure in Sudanese-Sahelian Africa: clinical prevalence in western Niger

Postpartum cardiac failure (PPCF) is the most frequent clinical form of heart failure in hospitalized women in Sudanese-Sahelian Africa. We have previously studied this disease in a hospital setting. Although the incidence is relatively high in rural areas, no systematic field study has been carried out. In this report, we describe a retrospective study conducted in the western part of Niger in July-August 1991. Sixty-two villages were visited and a thorough search for patients was initiated (from a population of 79,941 inhabitants, 19,941 females 14-40 years of age, corrected census of 1988). Twenty-eight patients from 27 villages were included. The subject patients were those presenting with predefined symptoms (dyspnea and cough) and physical signs (edema of the legs) of congestive heart failure during the six-month period following delivery. Apart from arterial hypertension and previous PPCF, diagnosis of another cardiac disease was an exclusion criterion. The prevalence of PPCF was 1.40 per 1,000 females of child-bearing age. The clinical profiles of these cases were in accordance with those of a previous study in 1989 carried out at Niamey Hospital. These results were a mean +/- SD age of 28 +/- 7 years, multiparity (mean = 4 children), poor socioeconomic status, postpartum ablutions with hot water, and a high sodium intake. This is the first study on the clinical prevalence of PPCF in a Sudanese/Sahelian population living in a rural area.

Nutritional status and plasma trace elements in peripartum cardiomyopathy. A comparative study in Niger

BACKGROUND

Peripartum cardiomyopathy is a frequent condition of unknown origin in Sahelian West Africa.

OBJECTIVE

To identify the nutritional and trace-elements status, plasma concentrations of albumin, pre-albumin (trans-thyretin), retinol binding protein, copper, selenium and zinc were assayed in 35 African women living in a Sahelian area, hospitalized in the Hôpital national, Niamey (Republic of Niger) with peripartum cardiac failure due to peripartum cardiomyopathy.

METHODS

Plasma albumin was assayed by an automatic method; pre-albumin and retinol binding protein by radial immunodiffusion (Mancini's method); and plasma copper, selenium and zinc by neutron activation and particle-induced X-ray emission. The results were compared with those for a control group of African women living under the same conditions but without peripartum cardiac failure.

RESULTS

Plasma albumin and pre-albumin were lower in patients with peripartum cardiomyopathy than they were in controls (P < 0.001). For retinol binding protein, the difference was not statistically significant. The plasma concentrations of selenium and zinc were lower in patients than they were in controls (48 +/- 25 versus 77 +/- 16 ng/ml and 0.90 +/- 0.21 versus 1.17 +/- 0.25 micrograms/ml, respectively, P < 0.001) whereas that of copper was higher (2.03 +/- 0.37 versus 1.23 +/- 0.20 micrograms/ml, P < 0.001). The mean zinc: copper ratio was lower in patients than it was in controls (0.44 versus 0.95).

CONCLUSION

Such differences may be aetiological factors or biological consequences of the peripartum cardiac failure due to cardiomyopathy. Nutritional abnormalities may play a role in the pathophysiology of the disease.