[HIV, only the tip of the iceberg in Burundi]

In Burundi, like in many other resource-limited settings, HIV sector is mainly financed by international funding (IF). Through this way, HIV-infected people may have access to care, antiretroviral therapy and opportunistic infections medications free of charge. In addition, IF can also contribute to major the HIV-health care professionals (HCP) salary. Indeed, because of dramatically low incomes, public sector HCP move frequently through the country or migrate towards foreign countries, attracted by higher salaries and better working environment. To date, relatively large funding became available in some settings for HIV-care. Through illustrative examples from the field in Burundi, we are discussing why consequences are, in many cases, a worsening of inequities and disorganization of the public health sector, instead of leading this latter one towards a global improvement. Furthermore, we are suggesting that HIV-programs per se are not sufficient to provide a proper management of the epidemic at a global scale.

Dengue type 3 virus infections in European travellers returning from the Comoros and Zanzibar, February-April 2010

In late February-early April 2010, five cases of dengue fever were diagnosed in returning travellers in Europe in EurotravNet sites in Sweden and France in patients with travel history to the Comoros and/or Zanzibar, Tanzania. Four cases were non-complicated dengue fever and one case dengue hemorrhagic fever. Three patients were viraemic at the time of diagnosis and infected with Dengue type 3 virus. An estimated 100 million cases of dengue fever and 250,000 cases of dengue haemorrhagic fever occur annually worldwide [1]. The past 20 years have seen a dramatic geographic expansion of epidemic dengue fever from Southeast Asia to the South Pacific Islands, the Caribbean, and the Americans. An increasing number of reports of dengue fever and associated illness among travellers to dengue virus–infected areas paralleled the changing epidemiology of dengue in local populations [1]. In 2010 (until 14 April), five cases of dengue fever including one case of dengue haemorrhagic fever, have been reported from EurotravNet sites in France and Sweden, in four travellers returning from the Comoros and one traveller returning from Zanzibar, Tanzania. EurotravNet, the Network for travel medicine and tropical diseases of the European Centre for Disease Control consists of 14 core sites in nine European countries and participants monitor travel related infectious diseases in Europe (www.eurotravnet.eu).

Dengue type 3 virus infections in European travellers returning from the Comoros and Zanzibar, February-April 2010

In late February-early April 2010, five cases of dengue fever were diagnosed in returning travellers in Europe in EurotravNet sites in Sweden and France in patients with travel history to the Comoros and/or Zanzibar, Tanzania. Four cases were non-complicated dengue fever and one case dengue hemorrhagic fever. Three patients were viraemic at the time of diagnosis and infected with Dengue type 3 virus.

Vaccination in adults with auto-immune disease and/or drug related immune deficiency: results of the GEVACCIM Delphi survey

INTRODUCTION

There are insufficient data regarding the efficacy and safety of vaccination in patients with auto-immune disease (AID) and/or drug-related immune deficiency (DRID). The objective of this study was to obtain professional agreement on vaccine practices in these patients.

METHODS

A Delphi survey was carried out with physicians recognised for their expertise in vaccinology and/or the caring for adult patients with AID and/or DRID. For each proposed vaccination practice, the experts' opinion and level of agreement were evaluated.

RESULTS

The proposals relating to patients with AID specified: the absence of risk of AID relapse following vaccination; the possibility of administering live virus vaccines (LVV) to patients not receiving immunosuppressants; the pertinence of determining protective antibody titre before vaccination; the absence of need for specific monitoring following the vaccination. The proposals relating to patients with DRID specified that a 3-6 month delay is needed between the end of these treatments and the vaccination with LVV. There is no contraindication to administering LVV in patients receiving systemic corticosteroids prescribed for less than two weeks, regardless of their dose, or at a daily dose not exceeding 10mg of prednisone, if this involves prolonged treatment. Out of 14 proposals, the level of agreement between the experts was "very good" for eleven, and "good" for the remaining three.

CONCLUSION

Proposals for vaccine practices in patients with AID and/or DRID should aid with decision-making in daily medical practice and provide better vaccine coverage for these patients.

[Should there be a specific management for HIV infected-immigrants in France?]

Immigrants living in France account for one third of new cases of infection and are a target population for prevention. Care givers should adapt their management practice, taking into account this population's specificities which are not restricted to cultural differences but include major socioeconomic factors. In addition to training on alien rights and basic sociocultural knowledge, care-givers (especially clinicians) must spend more time with the patient (especially at the beginning of the relationship) and accept sharing the "medical power" with other people with a better knowledge of other aspects of the patients' life in addition to the medical one. As in other chronic diseases, mediation is one of the available tools with evident benefits for any patient. Assuming compliance is the same for migrants as for other patients, using this mediation will warrant therapeutic success.

Malaria risk perception, knowledge and prophylaxis practices among travellers of African ethnicity living in Paris and visiting their country of origin in sub-Saharan Africa

An observational prospective cohort study assessed malaria risk perception, knowledge and prophylaxis practices among individuals of African ethnicity living in Paris and travelling to their country of origin to visit friends or relatives (VFR). The study compared two groups of VFR who had visited a travel clinic (TC; n=122) or a travel agency (TA; n=69) before departure. Of the 47% of VFR citing malaria as a health concern, 75% knew that malaria is mosquito-borne and that bed nets are an effective preventive measure. Perception of high malaria risk was greater in the TA group (33%) than in the TC group (7%). The availability of a malaria vaccine was mentioned by 35% of VFR, with frequent confusion between yellow fever vaccine and malaria prevention. Twenty-nine percent took adequate chemoprophylaxis with complete adherence, which was higher among the TC group (41%) than the TA group (12%). Effective antivector protection measures used were bed nets (16%), wearing long clothes at night (14%) and air conditioning (8%), with no differences between the study groups except in the use of impregnated bed nets (11% of the TC group and none of the TA group). Media coverage, malaria chemoprophylaxis repayment and cultural adaptation of preventive messages should be improved to reduce the high rate of inadequate malaria prophylaxis in VFR.

Serratia marcescens prosthesis infection successfully treated with meropenem after imipenem failure

A 78-year-old woman developed an early knee-prosthesis infection due to multiresistant Serratia marcescens that was successfully treated with high-dose meropenem, after failure of a long-term therapy combining imipenem and multiple surgical interventions. Because of its lower neurotoxicity, meropenem might be preferred to imipenem/cilastatin for the treatment of osteo-articular infections due to multiresistant Gram-negative bacilli in the elderly.

Escherichia coli native valve endocarditis

Among 36 cases of Escherichia coli native valve endocarditis (NVE) that met Duke criteria (31 cases in the literature between 1909 and 2002, and five cases seen in Paris, France), the urinary tract was the most common portal of entry. The majority (72.2%) of cases developed in elderly females. Overall, the proportion of patients aged > 70 years rose from 5.3% in 1982 to 22.9% in 2002. Persistent E. coli bacteraemia in the elderly in the absence of cardiac risk-factors may be a sign of NVE and should prompt an investigation by echocardiography.

Tuberculosis in HIV-infected patients: a comprehensive review

The incidence of tuberculosis (TB) is currently increasing in HIV-infected patients living in Africa and Asia, where TB endemicity is high, reflecting the susceptibility of this group of patients to mycobacteria belonging to the TB group. In this population, extension of multiple resistance to anti-tuberculous drugs is also a matter of anxiety. HIV-induced immunosuppression modifies the clinical presentation of TB, resulting in atypical signs and symptoms, and more frequent extrapulmonary dissemination. The treatment of TB is also more difficult to manage in HIV-infected patients, particularly with regard to pharmacological interactions secondary to inhibition or induction of cytochrome P450 enzymes by protease inhibitors with rifampicin or rifabutin, respectively. Finally, immune restoration induced by highly active anti-retroviral therapy (HAART) in developed countries may be responsible for a paradoxical worsening of TB manifestations.

Epidemiology and clinical features of vivax malaria imported to Europe: sentinel surveillance data from TropNetEurop

BACKGROUND

Plasmodium vivax is the second most common species among malaria patients diagnosed in Europe, but epidemiological and clinical data on imported P. vivax malaria are limited. The TropNetEurop surveillance network has monitored the importation of vivax malaria into Europe since 1999.

OBJECTIVES

To present epidemiological and clinical data on imported P. vivax malaria collected at European level.

MATERIAL AND METHODS

Data of primary cases of P. vivax malaria reported between January 1999 and September 2003 were analysed, focusing on disease frequency, patient characteristics, place of infection, course of disease, treatment and differences between network-member countries.

RESULTS

Within the surveillance period 4,801 cases of imported malaria were reported. 618 (12.9%) were attributed to P. vivax. European travellers and immigrants were the largest patient groups, but their proportion varied among the reporting countries. The main regions of infection in descending order were the Indian subcontinent, Indonesia, South America and Western and Eastern Africa, as a group accounting for more than 60% of the cases. Regular use of malaria chemoprophylaxis was reported by 118 patients. With 86 (inter-quartile range 41-158) versus 31 days (inter-quartile range 4-133) the median symptom onset was significantly delayed in patients with chemoprophylaxis (p < 0.0001). Common complaints were fever, headache, fatigue, and musculo-skeletal symptoms. All patients survived and severe clinical complications were rare. Hospitalization was provided for 60% and primaquine treatment administered to 83.8% of the patients, but frequencies varied strongly among reporting countries.

CONCLUSIONS

TropNetEurop data can contribute to the harmonization of European treatment policies.

[Imported malaria in 2000 in 2 northern Paris hospitals]

The number of travellers in malaria striken areas increases each year (2). The risk of infection is high in Sub-Saharan Africa, but appropriate chemoprophylaxis can reduce the morbidity and mortality rate of malaria. Half of the samples of malaria cases received by the National reference centre of malaria chemosensibility (CNRCP) for chemosensibility analysis came from two hospitals in the north of Paris: Bichat Claude Bernard in Paris and Delafontaine in Saint-Denis. In 2000, quite all the malaria cases (n = 387) observed at the Bichat and Delafontaine Hospitals came from Africa (99%). Plasmodium falciparum remains the most represented (87.6%) species, with an average parasitic density of 0.3%. Patients with P falciparum came for medical advice on the tenth day after return (median, extremes 0-174 days). More than half of the patients (58%) did not take any medication for chemoprophylaxis and even if they took some, it was irregular or inappropriate. The most used drug chemoprophylaxis is the association of chloroquine and proguanil or Savarine. In 15% of the cases, the travellers took chloroquine as a prophylaxis and 4% other medicine not recommended by the French authorities. An average of 43.7% of these travellers took inappropriate chemoprophylaxis. In total, 27 chemoprophylaxis failures are reported. Some patients (22%) have already taken self treatment which was readjusted during admission at hospital. The first treatment of malaria in 2000 was monotherapy with quinine (P. falciparum) and chloroquine (P. ovale, malariae, vivax). The treatment associations in case of suspicious resistance were quinine + doxycycline and atovaquone + proguanil. Treatment failure was infrequent and resulted above all from a bad observance. More information should be given to travellers as well as doctors about recommendations and treatments.

Profile and evolution of the chemosusceptibility of falciparum malaria imported into France in 2000

In 2000, the chemosusceptibility of imported malaria was stable in France. All countries of infection considered, the bi-resistance to chloroquine and cycloguanil has not changed from 1996 to 2000. The monotherapy using quinine or mefloquine remains the first-line treatment to falciparum malaria. Resistance to these two antimalarials is rare in Africa and has not evolved over the past 15 years.

A simple clinical and paraclinical score predictive of CD4 cells counts below 400/mm3 in HIV-infected adults in Dakar University Hospital, Senegal

In industrialized countries the decision to start co-trimoxazole (CMX) prophylaxis of HIV-related opportunistic infections is based on the CD4+ cell count. The value of CMX prophylaxis has also been demonstrated in Africa, where CD4+ cell counts are rarely available. We therefore developed a simple score predictive of a threshold CD4+ cell count (400/mm3) below which CMX prophylaxis is indicated. In a retrospective cross-sectional study, we collected clinical and biological data on 211 HIV-infected patients recruited from January 1996 through January 1998 at Fann University Hospital in Dakar, Senegal. Several variables were identified as being predictive of a CD4+ cell count below 400/mm3 by stepwise logistic regression. Each variable was weighted according to its regression coefficient, as follows: male sex (+1), weight loss (+2), body mass index < 22 (+2), herpes zoster (+4), tuberculin induration < 5 mm (+3) and haemoglobin < or = 10 g/dL (+1). A score of > or = 4 (sum of weights) selected patients with CD4+ cell counts below 400/mm3 with a sensitivity of 98% and a negative predictive value of 83%. Such a score should be applicable in the African context and should facilitate the management of HIV-infected patients, especially the prescription of CMX prophylaxis.