Infectious disease. Combating emerging viral threats

Most approved antiviral therapeutics selectively inhibit proteins encoded by a single virus, thereby providing a “one drug-one bug” solution. As a result of this narrow spectrum of coverage and the high cost of drug development, therapies are currently approved for fewer than ten viruses out of the hundreds known to cause human disease. This perspective summarizes progress and challenges in the development of broad-spectrum antiviral therapies. These strategies include targeting enzymatic functions shared by multiple viruses and host cell machinery by newly discovered compounds or by repurposing approved drugs. These approaches offer new practical means for developing therapeutics against existing and emerging viral threats.

Consumer response and satisfaction to prepackaged antimalarial drugs for children in Aba, Nigeria

In July 2003, a consortium of three USAID partners launched a project to promote the correct use of color-coded, age-specific, prepackaged drugs (PPDs) to treat malaria promptly in preschool-aged children in Aba, Abia State, Nigeria. A 3-pronged promotional approach included training of patent medicine vendors (PMVs), home visits by community health promoters, and mass media. Five hundred seventy respondents were interviewed in February-March 2004. People heard about the PPDs from medicine sellers (33.4%), health workers (24.3%), the electronic mass media (18.4%), and friends or relatives (13.5%). Most children (81.1%) took Robaquine (chloroquine-CQ), while 108 (18.9%) took Fansidar (sulphadoxine-pyrimethamine-SP). The median amount paid for Robaquine was 50 naira (dollars 0.36) and for Fansidar, 80 naira (dollars 0.57). Respondents rated the effectiveness of the PPD treatment as very effective (86.8%). Most respondents had something positive to say about the drug (94.9%) and the packaging (93.8%). Only 19.5%) had a complaint about either the drug or the packaging. Overall, 454 (83.9%) received the correct age-appropriate packet. Continuing education is needed for the PMVs to ensure that they obtain accurate age information about the child and sell the age-specific packet. Underdosing is just as serious a concern as overdosing in Nigeria where parasite resistance is rapidly developing for both drugs.

Consumers stated and revealed preferences for community health workers and other strategies for the provision of timely and appropriate treatment of malaria in southeast Nigeria

Background

The African Heads of State meeting in Abuja, Nigeria on Roll Back Malaria adopted effective treatment of malaria nearer the home as one of the strategies for malaria control in Africa. A potentially effective strategy for bringing early, appropriate and low cost treatment of malaria closer to the home is through the use of community health workers (CHWs). There is paucity of information about people's actual preferences for CHWs and how stated preferences relates to revealed preferences for both the CHW strategy and other strategies for improving the timeliness of malaria treatment in not only Nigeria but in many malaria endemic countries.

Objectives

To determine peoples' stated and actual preferences for different strategies for improving the timeliness and appropriateness of treatment of malaria before and after the implementation of a community health workers (CHW) strategy in their community.

Methods

A prospective study was undertaken in a rural malaria holo-endemic Nigerian community. A questionnaire was used to collect information on health-seeking from householders before (first survey) and after (second survey) implementation of a CHW malaria treatement strategy.

Results

The consumers mostly preferred the CHW strategy over self-treatment in the homes and other strategies of treatment. The use of community health workers (CHWs) increased from 0% to 26.1% (p < 0.05), while self-treatment in the homes decreased from 9.4% to 0% (p < 0.05) after the implementation of the CHW strategy. Use of patent medicine dealers also decreased from 44.8% to 17.9% (p < 0.05) after CHW strategy was implemented.

Conclusion

Community health workers can be used to improve and ensure timely and appropriate treatment of malaria. The CHW strategy could also be sustained since it was preferred and used by consumers over self-treatment in the homes as well as other strategies for improving treatment. Hence, the CHW strategy is a feasible and promising method of improving home-management of uncomplicated malaria.

The costs of changing national policy: lessons from malaria treatment policy guidelines in Tanzania

OBJECTIVE

To document the cost incurred by the Tanzanian government by changing the policy on first-line treatment of malaria, from chloroquine to sulfadoxine-pyrimethamine.

METHODS

Costs were analysed from the perspective of the Ministry of Health and included all sources of funding. Costs external to the public health sector (e.g. private and community costs) were not included. The base case analysis adopted an incremental rather than a full cost approach, assuming that an organizational infrastructure was already in place. However, specific attention was paid to the burden placed on National Malaria Control Program staff. We also costed activities planned but not implemented to estimate the total expense for an 'ideal' process.

RESULTS

Total costs were Tsh 795 million (USD 813,743), with the largest proportion accounted for by training. Costs of the policy change process were equivalent to about 4% of annual government and donor expenditure on malaria and to about 1% of overall public expenditure on health. A number of planned activities were not implemented; including these would bring the total cost to Ts 880 million (USD 896,130).

CONCLUSION

On top of extra costs for the drugs themselves, a change in treatment policy requires time, resources and substantial management capacity at national and local level. A better understanding of these issues and the costs involved benefits countries planning and implementing policy change.

Should chloroquine be laid to rest?

Chloroquine (CQ) has been the front line antimalarial drug due to its efficacy, low cost and scanty side effects, until resistance has evolved. Although its use has been officially discontinued in most malaria-affected countries, it is still widely used. Practical and pharmacological considerations indicate that it could be still used in semi-immune adults and that more efficient treatment protocols could be devised to treat even patients infected with CQ-resistant parasite strains. Since its antimalarial activity is pleiotropic, drug resistance may be due to different mechanisms, each amenable to reversal by drug combination.

A cost-effectiveness analysis of three antimalarial treatments for acute, uncomplicated Plasmodium falciparum malaria in Mumbai, India

BACKGROUND

Malaria is a major public health problem representing 2.3% of the overall global disease burden. The cost of treatment of malaria continues to rise as older drugs and insecticides become less effective and are replaced by more effective, but also more expensive products.

METHODS

A post-hoc pharmacoeconomic analysis (direct and indirect costs only) of three antimalarials, chloroquine, mefloquine and co-artemether, was carried out to address the problem of switch to a more expensive first-line antimalarial in the face of growing chloroquine resistance.

RESULTS

From the perspective of a large public hospital, it was seen that in an area of high grade chloroquine resistance, the total expenditure on patients who fail chloroquine would exceed the excess expenditure on mefloquine when the RII + RIII resistance exceeded 9%.

CONCLUSIONS

Switch to a more expensive drug like mefloquine as a first-line option would be cost-effective when the moderate-severe chloroquine resistance exceeded 9%.

Therapeutic efficacy of chloroquine or amodiaquine in combination with sulfadoxine-pyrimethamine for uncomplicated falciparum malaria in Papua New Guinea

Resistance of Plasmodium falciparum to chloroquine is widespread in Papua New Guinea. At a meeting in Port Moresby in October 1997, it was decided to explore a possible change of the current first-line treatment of uncomplicated malaria with chloroquine alone (amodiaquine for children under five years) to chloroquine or amodiaquine in combination with sulfadoxine-pyrimethamine (S-P). To assess the therapeutic efficacy of the new drug combination in Papua New Guinea, a study was carried out in 1998-1999 at five hospital outpatient departments. From the 513 patients enrolled for the study, 95 defaulted from follow-up. Of the remaining 418, 399 (95.5%) had an adequate clinical response (ACR). Out of the 19 patients who did not have an ACR, 3 (0.7% of the total) developed severe signs in the first 24 hours and were treated in hospital; they were regarded as early treatment failures. The remaining 16 did not complete the study on the basis of various exclusion criteria but were not excluded from the analysis. From these results it was concluded that the combination was effective and a decision was taken in May 2000 to introduce the two-drug combination regimens as the standard first-line treatment of uncomplicated malaria, including falciparum malaria, in Papua New Guinea.

Vendor-to-vendor education to improve malaria treatment by private drug outlets in Bungoma District, Kenya

BACKGROUND

Private outlets are the main suppliers of uncomplicated malaria treatment in Africa. However, they are so numerous that they are difficult for governments to influence and regulate. This study's objective was to evaluate a low-cost outreach education (vendor-to-vendor) programme to improve the private sector's compliance with malaria guidelines in Bungoma district, Kenya. The cornerstone of the programme was the district's training of 73 wholesalers who were equipped with customized job aids for distribution to small retailers.

METHODS

Six months after training the wholesalers, the programme was evaluated using mystery shoppers. The shoppers posed as caretakers of sick children needing medication at 252 drug outlets. Afterwards, supervisors assessed the outlets' knowledge, drug stocks, and prices.

RESULTS

The intervention seems to have had a significant impact on stocking patterns, malaria knowledge and prescribing practices of shops/kiosks, but not consistently on other types of outlets. About 32% of shops receiving job aids prescribed to mystery shoppers the approved first-line drug, sulfadoxine-pyremethamine, as compared to only 3% of the control shops. In the first six months, it is estimated that 500 outlets were reached, at a cost of about $8000.

CONCLUSIONS

Changing private sector knowledge and practices is widely acknowledged to be slow and difficult. The vendor-to-vendor programme seems a feasible district-level strategy for achieving significant improvements in knowledge and practices of shops/kiosks. However, alternate strategies will be needed to influence pharmacies and clinics. Overall, the impact will be only moderate unless national policies and programmes are also introduced.

Very high risk of therapeutic failure with chloroquine for uncomplicated Plasmodium falciparum and P. vivax malaria in Indonesian Papua

Chloroquine remains the first-line therapy for uncomplicated malaria in Indonesia. Among a series of trials of chloroquine for malaria on this archipelago conducted since 1990, we now report the highest risk of therapeutic failure yet observed. A clinical trial of standard chloroquine therapy for uncomplicated malaria at Arso PIR V in northeastern Indonesian Papua was conducted during 1995. We enrolled 104 non-immune subjects infected with Plasmodium falciparum (n = 55), P. vivax (n = 29), or P. falciparum plus P. vivax (n = 20) and administered supervised standard chloroquine therapy (10 + 10 + 5 mg/kg at 24-hour intervals). The 28-day cumulative incidence of therapeutic failure was 95% for P. falciparum, 84% for P. vivax, and 100% for mixed infections. Only one subject each for P. falciparum and P. vivax remained free of parasites at day 28. All recurrent parasitemias occurred with whole blood levels of chloroquine plus desethylchloroquine exceeding 100 ng/ml. These findings document almost complete failure of chloroquine against P. falciparum or P. vivax near the northeastern coast of Indonesian Papua.

An economic comparison of chloroquine and sulfadoxine-pyrimethamine as first-line treatment for malaria in South Africa: development of a model for estimating recurrent direct costs

The relative cost-effectiveness of chloroquine (CQ) and sulfadoxine-pyrimethamine (SP) as first-line antimalarial therapy in southern Africa is of great interest to policymakers, clinicians and researchers in the subregion. A model was developed to access the cost-effectiveness of replacing CQ with SP as first-line treatment in Mpumalanga, South Africa, where malaria is seasonal and the population is non-immune. In-vivo drug resistance levels were used to derive a 'resistance variable' for each drug, which was used to compare the costs to the public healthcare provider associated with either therapeutic option. Costs including drugs, staff time, transport, maintenance, utilities, training and consumables were determined and subjected to Monte Carlo simulation and subsequent analysis to generate an average cost-effectiveness ratio (ACER) with confidence intervals for each drug. SP was found to be 4.8 (95% CI 3.3-6.7) times more cost-effective than CQ in Mpumalanga at 1997 resistance levels and costs, despite the far greater cost per treatment course of SP (US$ 4.02 as opposed to US$ 0.22 for CQ) in South Africa. At the price of SP in Kenya and Uganda (US$ 0.47-4.80 per treatment course), the ACER for SP does not change materially, increasing to between 5.1 and 5.6. Resistance emerged as the factor that most influenced the ACER of a specific drug. Indirect costs, compliance, changes in effectiveness and costs over time and costs of adverse events were not included in the model owing to paucity of data and logistical difficulties. Since most of these are likely to be similar in both drug models, the relative ACER is unlikely to be significantly altered by their inclusion.

Perception of chloroquine efficacy and alternative treatments for uncomplicated malaria in children in a holoendemic area of Tanzania: implications for the change of treatment policy

Prior to policy change from chloroquine (CQ) to sulphadoxine/pyrimethamine (S/P; Fansidar) we assessed the perception of CQ efficacy and the alternative treatment options for malaria in children among parents/guardians (N=527) of under-fives attending first level health facilities on account of fever. It was hypothesized that the long experience with CQ and its antipyretic effect (lacking in S/P) might impede acceptance of S/P for wider use as first-line drug. Malarial fevers in children were most commonly treated with CQ (92.8%), followed by quinine (60.7%) and S/P (28.7%). A 63.2% knew the reasons for non-response to antimalarial treatment, and only 50% were aware that CQ could fail to treat malaria, and 57.1% knew alternative treatment options, namely quinine (52.2%) and S/P (20.5%). Generally, decreased efficacy of CQ had been noticed, and quinine was prescribed for both suspected and proven CQ failures in first level health facilities and the district hospital. S/P was judged to be more effective than quinine, but too strong for children, and was the least known drug in the study area. All formulations of S/P cost more per dose for a child and an adult than CQ. The implications of these findings on the change of malaria treatment policy are discussed.

Changing the first line drug for malaria treatment--cost-effectiveness analysis with highly uncertain inter-temporal trade-offs

Access to effective treatment would substantially reduce the burden of malaria in sub-Saharan Africa, but resistance to chloroquine, the most commonly used first line drug, is now widespread. There has been considerable debate over the level of chloroquine resistance at which a new first line drug should be adopted. Two issues make this an extremely complex decision: it involves trade-offs in costs and health outcomes over time; and many of the parameters are uncertain. A modelling approach was identified as appropriate for addressing these issues. The costs and effects of changing from chloroquine to sulphadoxine-pyrimethamine (SP) as the first line drug were modelled over 10 years, allowing for growth in drug resistance. Probabilistic sensitivity analysis was used to allow for the high levels of parameter uncertainty. The optimal year of switch was highly dependent on both empirical values, such as initial resistance and resistance growth rates, and on subjective values, such as the time preferences of policy-makers. It was not possible to provide policy-makers with a definitive threshold resistance level at which to switch, but the model can be used as an analytical tool to structure the problem, explore trade-offs, and identify areas for which data are lacking.

East African Network for Monitoring Antimalarial Treatment (EANMAT). Monitoring antimalarial drug resistance within National Malaria Control Programmes: the EANMAT experience

The National Malaria Control Programme (NMCP), organized within the Ministry of Health (MoH), is an essential component for the planning, execution and coordination of malaria control activities. As effective case management remains the mainstay of malaria control in almost every African country, antimalarial drug resistance is a major barrier to the implementation of effective malaria control policies. In order to function effectively, these units must have an efficient surveillance system which can provide reliable and current estimates of the severity of drug resistance. Without this information, it is impossible for the MoH to design and promote a rational antimalarial policy, but because of limited resources, especially of people and expertise, most NMCPs have been unable to initiate and manage such a system. The need for collaborative partnerships between the MoH and the research community prompted the establishment of the East Africa Network for Monitoring Antimalarial Treatment (EANMAT). EANMAT has attempted to bring together the complimentary skills of malaria researchers and MoH staff in four east African countries. After 3 years of operation, data generated by EANMAT have been used to review and modify national malaria treatment policies in Kenya, Uganda, Rwanda and Tanzania. This new approach, which forges a closer working relationship between the research and policy communities, has effectively built capacity around the complex of surveillance, interpretation and use of evidence within a policy environment. The added-value of this approach is that the research community has learned to appreciate the constraints of policy development, and that the control community has established the need to build capacity and ownership of research evidence. Networks similar to EANMAT should be encouraged elsewhere in Africa to engender similar partnerships: to assist the development of rational treatment policies, and thus more effective malaria chemotherapy leading to significant lowering of malaria morbidity and mortality.

Treatment of childhood fevers and other illnesses in three rural Nigerian communities

The seeking of healthcare for childhood illnesses was studied in three rural Nigerian communities of approximately 10,000 population each. The aim was to provide a baseline understanding of illness behaviour on which to build a programme for the promotion of prepackaged chloroquine and cotrimoxazole for early and appropriate treatment of childhood fevers at the community level. A total of 3117 parents of children who had been ill during the 2 weeks prior to interview responded to questions about the nature of the illness and the actions taken. Local illness terms were elicited, and the most prevalent recent illness and the actions taken. Local illness terms were elicited, and the most prevalent recent illnesses were 'hot body' (43.9 per cent), malaria, known as iba (17.7 per cent), and cough (7.4 per cent). The most common form of first-line treatment was drugs from a patent medicine vendor or drug hawker (49.6 per cent). Only 3.6 per cent did nothing. Most who sought care (77.5 per cent) were satisfied with their first line of action, and did not seek further treatment. The average cost of an illness episode was less than US$2.00 with a median of US$1.00. Specifically, chloroquine tablets cost an average of US 29 cents per course. Analysis found a configuration of signs and symptoms associated with chloroquine use, to include perception of the child having malaria, high temperature and loss of appetite. The configuration positively associated with antibiotic use consisted of cough and difficult breathing. The ability of the child's care-givers, both parental and professional, to make these distinctions in medication use will provide the foundation for health education in the promotion of appropriate early treatment of childhood fevers in the three study sites.

Improving adherence to malaria treatment for children: the use of pre-packed chloroquine tablets vs. chloroquine syrup

Malaria is a major cause of morbidity and mortality among children under five in sub-Saharan Africa. Prompt diagnosis and adequate treatment of acute clinical episodes are essential to reduce morbidity and prevent complications and mortality. In many countries, chloroquine syrup is the mainstay of malaria treatment for children under five. Not only is syrup more expensive than tablets, adherence to the prescribed dose at home is a problem because mothers use wrongly sized measuring devices or have difficulty with the instructions. We investigated the impact of introducing pre-packed tablets for children on adherence to treatment and compared the total cost of the tablets with that of syrup. Children aged 0--5 years diagnosed with malaria at the clinic over a 6-week period received either pre-packed tablets or syrup by random assignment. The principal caregivers were interviewed at home on day 4 after attending the clinic. Of the 155 caregivers given pre-packed tablets, 91% (n=141) adhered to the recommended dosage, while only 42% (n=61) of 144 who were provided syrup did. Only 20% of caregivers who received syrup used an accurate 5 ml measure. The cost of treatment with tablets was about one-quarter that of syrup and 62% (n=96) of caregivers preferred tablets. Pre-packed chloroquine tablets are a viable alternative to syrup.

Impact of prepackaging antimalarial drugs on cost to patients and compliance with treatment

OBJECTIVE

To examine the extent to which district health teams could reduce the burden of malaria, a continuing major cause of mortality and morbidity, in a situation where severe resource constraints existed and integrated care was provided.

METHODS

Antimalarial drugs were prepackaged into unit doses in an attempt to improve compliance with full courses of chemotherapy.

FINDINGS

Compliance improved by approximately 20% in both adults and children. There were 50% reductions in cost to patients, waiting time at dispensaries and drug wastage at facilities. The intervention, which tended to improve both case and drug management at facilities, was well accepted by health staff and did not involve them in additional working time.

CONCLUSION

The prepackaging of antimalarials at the district level offers the prospect of improved compliance and a reduction in the spread of resistance.

A randomized, parallel-group study in Mumbai (Bombay), comparing chloroquine with chloroquine plus sulfadoxine-pyrimethamine in the treatment of adults with acute, uncomplicated, Plasmodium falciparum malaria

A major problem in the control of malaria is the development of resistance, of the parasites to the existing drugs and of the vectors to insecticides. With few new drugs in the pipeline, in an era of declining resources, it is imperative to make judicious use of the existing antimalarials. In the city of Mumbai, resistance exists to chloroquine (CQ) and to sulfadoxine-pyrimethamine (SP). Use of a combination of CQ with SP would theoretically slow down the development of resistance to each of the drugs and increase their useful lives. The effectiveness of this combination in the treatment of adults from Mumbai, who had acute, uncomplicated Plasmodium falciparum malaria, was compared with that of CQ alone. The combination was found to be significantly more effective, in terms of 28- or 42-day cure rates, and to be more cost-effective.

Economic impact of febrile morbidity and use of permethrin-impregnated bed nets in a malarious area II. Determinants of febrile episodes and the cost of their treatment and malaria prevention

The objective of this study is to determine the effect of permethrin insecticide-treated bed net (PITN) use on the incidence of febrile episodes and on household malaria expenses in Benin. Over the course of one year, 208 randomly selected PITN user and non-user households were visited weekly to determine expenditures on febrile morbidity and its treatment, and to monitor spending on malaria prevention. Multivariate analyses were performed to distinguish the effects of PITN use from other important determinants of morbidity, such as malaria-related beliefs and practices, income, and other socio-economic variables. Results from the logistic regression analysis show that the use of PITNs decreases the risk of febrile episodes by 34% in children living in the rural zone. Multiple regression analysis reveals that PITN use does not reduce prevention and treatment expenses. These expenses are significantly associated with women's income. This report also discusses other factors associated with febrile morbidity and malaria-related expenditures.

Comparative efficacy and safety of chloroquine and alternative antimalarial drugs: a meta-analysis from six African countries

OBJECTIVE

To evaluate the safety and efficacy of the currently used antimalarial drugs in six African countries.

DESIGN

A meta-analysis.

MAIN OUTCOME MEASURES

The role of efficacy, safety and cost on the selection of antimalarial drugs.

RESULTS

The comparative efficacy study showed that amodiaquine (with > 90% cure rate) was superior to chloroquine and sulphadoxine-pyrimethamine at seven days schedule. The efficacy of amodiaquine was also observed to be comparable to that of mefloquine and halofantrine. The parasite clearance time (PCT) of these drugs ranged between two days and a week and the fever clearance time (FCT) was within 48 hours. The recrudescence rate at D14-D21 was found to be 12-17% in chloroquine and amodiaquine, while sulphadoxine-pyrimethamine showed a trend similar to halofantrine and mefloquine (0-12% recrudescence rate). Similarly, a big difference was also noted in the cost of the different antimalarial drugs. The pharmacokinetic data, however, showed that they are of similar profile, except in adverse features and contraindications, and values like their half-life (t1/2) where the long (t1/2) in drugs like sulphadoxine-pyrimethamine endows them with suppressive-cure feature, especially against recrudescent strains. Nevertheless, as these data are obtained from resident population in Africa, who however naive are exposed to few malaria challenges in their life, the results should not be directly extrapolated to total non immunes such as visitors from Europe.

CONCLUSION

The choice of alternative antimalarial drugs should be mainly based on their relative efficacy, safety and cost.

A trial of Fansidar plus chloroquine or Fansidar alone for the treatment of uncomplicated malaria in Gambian children

Chloroquine can no longer be recommended as the first-line treatment for uncomplicated malaria in several parts of Africa because of the increasing prevalence of chloroquine resistance. However, chloroquine was a highly effective treatment for malaria not only because of its ability to kill parasites quickly but also because it is an anti-inflammatory drug. Therefore, we have investigated whether Fansidar (pyrimethamine/sulfadoxine) plus chloroquine is a more effective treatment for uncomplicated malaria than Fansidar alone. Four hundred and five Gambian children with uncomplicated Plasmodium falciparum malaria were studied in a randomized controlled trial. Significantly more children treated with Fansidar alone, compared to those treated with Fansidar plus chloroquine (19/203 vs. 2/202; P < 0.001), returned to the clinic with persistent symptoms during the first 3 d after treatment. Three children who had received Fansidar alone had fits, but none of the children treated with Fansidar plus chloroquine did so. At the day 7 follow-up, the parasite failure rate in the Fansidar alone group was 3/198 (1.5%), whilst in the Fansidar plus chloroquine group it was 3/201 (1.5%). At the day 28 follow-up, there was still no significant difference between the parasite failure rate in the Fansidar alone group (15/150; 10.0%) and the Fansidar plus chloroquine group (7/141; 5.0%) and the mean packed cell volume (PCV) in the 2 groups was similar. Thus, a combination of Fansidar plus chloroquine was a more effective symptomatic treatment than Fansidar given alone, but neither the parasite cure rate nor the PCV was enhanced by use of the combination.

A comparison of amodiaquine and chloroquine in the treatment therapy of falciparum malaria in Kenya

During June to August 1989, 158 symptomatic outpatients with P. falciparum malaria were randomly treated with either amodiaquine or chloroquine 25 mg/kg, divided over three days. Amodiaquine (Camoquin, Parke-Davis) was significantly more effective in terms of the rate of parasite clearance, 2.4 versus 3.1 days; parasite clearance day 7; 87% versus 41%; and clinical amelioration, 98% versus 68%. Moreover, this study demonstrates the lack of therapeutic toxicity of amodiaquine. Globally, tolerance was better with amodiaquine than with chloroquine; in particular, cutaneous side effects were less frequent with amodiaquine. There was no evidence of granulocyte or gross hepatic toxicity. These results suggest that WHO recommendations concerning amodiaquine should be questioned. In view of its low cost, demonstrated efficacy and lack of proven therapeutic toxicity, amodiaquine should be considered as a viable replacement for chloroquine in areas with high levels of clinical chloroquine failure.

Management of malaria before and after introduction of a treatment protocol at the Eldoret District Hospital

A prospective study on the management of suspected malaria using a protocol on a general medical ward during the months of February and March, 1992 was done and the results compared with those of a retrospective study covering the months of November and December, 1991. The retrospective analysis showed that 78 (65%) from a total of 120 patients received antimalarial drugs despite negative or absent blood smears for malarial parasites. In 41 (34%) of the 120 patients, the first line treatment given was quinine. In the prospective study the overall quinine use dropped sharply to 19% from 54% in the retrospective study. 94 (49%) from a total of 193 patients with suspected malaria had negative blood smears of whom only 8 (4%) received quinine while 63 (33%) did not receive any antimalarial therapy and 38 of these 63 patients ended up with different final diagnoses; the remaining 25 were observed on no antimalarial treatment and discharged home feeling well. These results emphasize the need for proper diagnosis of malaria and suggest that chloroquine is still acceptable and effective as a first line drug for proven cases of malaria in adult patients in Eldoret. Unnecessary quinine use is discouraged as the drug is more expensive with more toxic effects compared to chloroquine.