Injectable antimalaria therapy in tropical Africa; iatrogenic disease and waste medical resources

Contamination of medicine injection paraphernalia used by registered medical practitioners in south India: an ethnographic study

While considerable attention has been directed at the important role of intravenous drug use in the spread of human immunodeficiency virus (HIV) and hepatitis B, little research to date has been conducted on the role of medicine injections in disease transmission. This is the case despite the fact that (a) the number of medicine injections is several orders of magnitude greater than injections of illegal drugs and (b) the networks of people potentially affected by contaminated medicine injection paraphernalia is far wider. In this article we examine the medicine injecting practices of a random sample of 40 registered medical practitioners (RMP) who have not had formal training in allopathic medicine (do not have MBBS or MD degrees) in Tamil Nadu, India. Attention is drawn to: (a) the lack of vigilance practitioners exercise in maintaining hygienic needles and syringes, (b) their perceptions of what constitutes acceptable hygienic procedure and (c) how patients respond in contexts where they are able to purchase disposable needles and syringes directly from practitioners or from the open market prior to visiting a practitioner. Study results are a cause for alarm and indicate widespread contamination of injection paraphernalia as well as common reuse of disposable needles. The study was confined to RMPs and the researchers strongly suggest that future studies of MBBS trained doctors practising in the public and private sectors be carried out. A structured observation instrument developed to record needle and syringe contamination during the process of injection administration is provided.

Intramuscular loading dose of quinine for falciparum malaria: pharmacokinetics and toxicity

In a study of intramuscular injection of quinine eight adults with moderately severe falciparum malaria resistant to chloroquine were treated with quinine dihydrochloride, being given a loading dose of 20 mg salt (16.7 mg base)/kg followed by three or four eight hourly maintenance doses of 10 mg salt (8.3 mg base)/kg injected into the anterior thigh. All patients responded to treatment. Fever and parasite clearance times (mean (SD) 60 (23) h and 53 (22) h respectively) were comparable with those obtained with intravenous quinine. The mean peak plasma quinine concentration of 11.0 mg/l (34.4 mu mol/l) [corrected] was reached a median of five hours after administration of the loading dose. In all patients plasma quinine concentrations exceeded the high minimum inhibitory concentration for Plasmodium falciparum malaria prevalent in Thailand within four hours of the start of treatment but did not cause toxicity other than mild cinchonism. When intravenous infusion is not possible an intramuscular quinine loading dose is an effective means of starting treatment in patients with moderately severe falciparum malaria who cannot swallow tablets.