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To assess the validity of clinical criteria, we investigated 2096 outpatients diagnosed as malaria cases by nurses at a rural health subcentre in a highly endemic area of Papua New Guinea. 73% of the children < 10 years old had a positive blood slide for any species of Plasmodium and 32% had > or = 10,000 P. falciparum parasites per microL. For adults the frequencies were 51% and 9%, respectively. Stepwise logistic regression identified spleen size, no cough, temperature, no chest indrawing, and normal stools as significant predictors for a positive blood slide in children; no cough and normal stools predicted a positive blood slide in adults. Fever, no cough, vomiting, and enlarged spleen were significant predictors for a P. falciparum parasitaemia > or = 10,000/microL in children; in adults the only predictor was vomiting. In children the association of no cough and enlarged spleen had the best predictive value for a positive blood slide, and a temperature > or = 38 degrees C had the best predictive value for a P. falciparum parasitaemia > or = 10,000 microL. In adults, no major symptom had a good predictive value for a positive blood slide but vomiting had the best predictive value for a P. falciparum parasitaemia > or = 10,000/microL. When microscopy is not available, these findings can help in areas of high endemicity to determine which patients with a history of fever are most likely to have malaria and, more importantly, for which patients another diagnosis should be strongly considered.
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PMID:Malaria: how useful are clinical criteria for improving the diagnosis in a highly endemic area? 799 31

Pneumonia and malaria are common causes of childhood morbidity and mortality in many developing countries and simple guidelines have been proposed to facilitate their diagnosis by relatively unskilled health workers. We have studied children in The Gambia attending out-patient and under-five clinics with clinically suspected pneumonia (cough or difficulty in breathing and a raised respiratory rate) during periods of high or low malaria transmission. During a period of high malaria transmission, 33% of these children had radiological evidence of pneumonia (with or without malaria parasitaemia) compared to 38% who had malaria parasitaemia, no radiological evidence of pneumonia and no other obvious cause of fever. Corresponding figures during a period of low malaria transmission were 48% and 6% respectively. The clinical overlap between pneumonia and malaria has important implications for case management strategies and evaluation of disease-specific interventions in regions in which both pneumonia and malaria are prevalent.
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PMID:Overlap in the clinical features of pneumonia and malaria in African children. 829 67

The study, which is based on data from a household level health survey conducted in early 1993 in the rural areas of the districts of Western Area and Port Loko of Sierra Leone, examines the coverage of an Expanded Program on Immunization (EPI), infant and child mortality, and disease symptoms in children who died under age five in the study area. The results of the study indicated that the infant and child mortality rate per thousand live births declined from about 162 in the mid 1980s to about 77 in 1993. This decline was associated with immunization coverage which considerably increased by 1993, reaching as high as above 60% of the eligible children. The study further reveals that the major symptoms of disease at the time of death of an infant or a child were fever, cough, troubled breathing, and diarrhea in that order. While fever and cough could reflect the persistence of malaria and pneumonia-two major causes of infant and child deaths not covered by existing EPI-the study also revealed that many children failed to take full doses of immunization. Similarly, inadequate coverage of domiciliary oral rehydration therapy (ORT) might have been the reason of high incidence of diarrhea-related deaths. Simple medical technologies to eliminate many of the existing major causes of infant and child mortality in rural Sierra Leone are now available. Perhaps, a strengthened primary health care service, including an extensive rural health care network, aimed at eliminating these diseases, would go a long way in reducing infant and child mortality to irreducible minimum.
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PMID:Immunization coverage and child mortality in two rural districts of Sierra Leone. 877 43

A 2-year prospective audit on the profile and outcome of malaria cases admitted to a general hospital was performed. Fifty-six cases were seen from January 1991 to December 1992, 52 of which were due to monoinfections with Plasmodium vivax. The main presenting complaints were fever, chills, sweats, myalgia, dry cough and headache. A significant percentage had anaemia (64.3%), thrombocytopaenia (57.1%), hyponatraemia (42.9%), and liver dysfunction (44.7%). Diagnosis rests on the demonstration of parasites in stained peripheral blood smears. None of the patients developed major complications. A high index of suspicion of malaria must be maintained in the medical evaluation of all patients and in particular, of returning travellers.
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PMID:Malaria: an audit of 56 cases admitted to a hospital. 894 52

Verbal autopsy uses a caretaker interview to determine the cause of death. We conducted a study of the major causes of child death in Namibia to determine the validity of this method. A questionnaire, including signs and symptoms of the diagnoses of interest was administered to the caretaker in 135 deaths of children < 5 years old who were identified from hospital records. The 243 diagnoses included malnutrition (77), diarrhoea (73), pneumonia (36), malaria (33), and measles (24). Sensitivity and specificity of various algorithms of reported signs and symptoms were compared to the medical diagnoses. An algorithm for malnutrition (very thin or swelling) had 73 per cent sensitivity and 76 per cent specificity. An algorithm for cerebral malaria (fever, loss of consciousness or convulsion) had 72 per cent sensitivity and 85 per cent specificity, while for all malaria deaths the same algorithm had low sensitivity (45 per cent) and high specificity (87 per cent). For diarrhoea, loose or liquid stools had high sensitivity (89 per cent), but low specificity (61 per cent). Cough with dyspnoea or tachypnoea had 72 per cent sensitivity and 64 per cent specificity. An algorithm for measles (age > or = 120 days, rash) had 71 per cent sensitivity and 85 per cent specificity. The study results suggest verbal autopsy data can be useful to ascertain the leading causes of death in childhood, but may have limitations for health impact evaluation.
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PMID:Validation study of a verbal autopsy method for causes of childhood mortality in Namibia. 900 66

Early passive case finding and treatment compliance are the cornerstones of tuberculosis (TB) control programs. As human behavior plays a critical role in both strategies, a better understanding of it is important for the planning and implementation of a successful TB programme, especially for the health education component, Our qualitative study in Uasin Gishu, Kenya, aimed at a better understanding of the community's beliefs and perceptions of TB, recognition of early symptoms and health-seeking behavior. Five focus groups with a total of 49 people were held: on with hospitalized TB patients, two with rural and two with urban participants. Tuberculosis is well known in the communities and many vernacular names for the disease exist. TB is perceived as a contagious, 'sensitive' disease difficult to diagnose and treat. Community members believe that TB should be diagnosed and treated in a hospital or by a medical doctor and not at the peripheric level. TB treatment is perceived as long, agonising and cumbersome. Traditional treatment is considered a valid alternative to modern treatment, believed to be as effective and much shorter. Initial symptoms such as cough and fever are often overlooked and/or confused with malaria or a common cold. Symptoms associated with the disease refer to the later stage of TB. TB is attributed to causes such as smoking, alcohol, hard work, exposure to cold and sharing with TB patients. Many participants believe TB is hereditary. Prolonged self-treatment and consultation with the traditional health sector as well as the social stigma attached to the disease increase patient's delay. Only after symptoms persist for some time and/or the suspect's health deteriorates, are modern health services consulted. These social conditions necessitate culturally sensitive health education, taking into account local perceptions of TB.
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PMID:From their own perspective. A Kenyan community's perception of tuberculosis. 929 51

The World Health Organization (WHO) in 1993 developed the integrated management of childhood illness (IMCI) draft algorithm which offers guidelines upon the diagnosis and treatment of acute respiratory infections, diarrhea, malaria, measles, ear infections, and malnutrition, as well as immunization status. During a 14-month study period, 1795 children aged 2 months to 5 years were enrolled in the study from the outpatient pediatric clinic of Siaya District Hospital in western Kenya, of whom 52% were male and the median age was 13 months. 51% of the children complained of having fever, 22% of having a cough, and 11% of having diarrhea. 86% of the main complaints were directly addressed by the IMCI algorithm. 1210 children had Plasmodium falciparum infection and 1432 met the WHO definition for anemia. The sensitivities and specificities for classification of illness by a minimally trained health worker using the IMCI algorithm compared to diagnosis by the physician were: pneumonia, 97% sensitivity and 49% specificity; dehydration in children with diarrhea, 51% and 98%, respectively; malaria, 100% and 0%; ear problem, 98% and 2%; nutritional status, 96% and 66%; and need for referral, 42% and 94%. Detection of fever by placing a hand upon the forehead was 91% sensitive and 77% specific. Considerable clinical overlap was observed between pneumonia and malaria, and between malaria and malnutrition. Study findings led to some changes in the IMCI algorithm.
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PMID:Evaluation of an algorithm for integrated management of childhood illness in an area of Kenya with high malaria transmission. 952 16

The differentiation of malaria from other causes of fever in the absence of microscopy is notoriously difficult. Clinical predictors of malaria have been studied in an area of low and unstable transmission on the western border of Thailand. In 1527 children aged 2-15 years who were followed prospectively for 7 months, 82% (1254) had at least one febrile episode. Malaria caused 24% (301) of the first febrile episodes (Plasmodium falciparum 128, P. vivax 151, P. malariae 1, mixed infections with P. falciparum and P. vivax 21). Each malaria case was matched with the next child of similar age presenting to the dispensary with another cause of fever. Clinical symptoms or signs associated with a final diagnosis of malaria were: confirmed fever (> or = 38 degrees C) (odds ratio [OR] 1.6, 95% confidence interval [95% CI] 1.4-1.9), headache (OR 1.5, 95% CI 1.3-1.9), muscle and/or joint pain (OR 2.0, 95% CI 1.6-2.8), nausea (OR 1.7, 95% CI 1.4-2.3), clinical anaemia (OR 1.4, 95% CI 1.3-3.3), palpable spleen (OR 1.3, 95% CI 1.1-1.7), palpable liver (OR 1.4, 95% CI 1.1-2.1), absence of cough (OR 1.6, 95% CI 1.4-2.0), and absence of diarrhoea (OR 1.5, 95% CI 1.2-2.4). None of these signs alone or in combination proved a good predictor of malaria. The best diagnostic algorithms (history of fever and headache without cough, and history of fever with an oral temperature > or = 38 degrees C [sensitivity 51% for both, specificity 72 and 71%, respectively]) would result in prescription of antimalarial drugs in 28-29% of the non-malaria febrile episodes, and only 49% of the true malaria cases. Thus half of the potentially life-threatening P. falciparum infections would not be treated. Although multivariate analysis identified vomiting, confirmed fever, splenomegaly and hepatomegaly as independent risk factors for a diagnosis of falciparum malaria, use of these signs to differentiate falciparum from vivax malaria, and thus to determine antimalarial treatment, was insufficiently sensitive or specific. Malaria diagnosis should be confirmed by microscopical examination of a blood slide or the use of specific dipstick tests in areas of low transmission where highly drug-resistant P. falciparum coexists with P. vivax.
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PMID:Clinical features cannot predict a diagnosis of malaria or differentiate the infecting species in children living in an area of low transmission. 969 50

South Sudan has 5 million inhabitants and has been fighting a war of independence with North Sudan since 1959. The hostilities have totally disrupted the society and its government. In this region, international nongovernmental organizations (NGOs) are cooperating in relief activities in Operation Life Line, providing assistance to semi-nomadic pastoral tribes such as the Nuers and the Dinkas. The NGO Doctors Without Borders assisted in fighting a major epidemic of kala azar in the late 1980s; it cost some 200,000 lives, half of the Nuers' total population. The report of these doctors flying to different spots in the South of the country recounted how medical consultations were carried out under trees where possible. Kala azar was treated with ampules of Pentostam, and brucellosis patients were picked from the waiting group. Tuberculosis, whose indications are heavy coughing and expectoration, was also rampant. The abscess of a woman caused by a human bite was treated under local anesthesia with ketamine. The team had examined 70 patients by midday. In Duar, a site where Doctors Without Borders has treated 20,000 kala azar patients, basic health care and vaccinations were performed. In a marshy region, the Dinkas allow their livestock to graze, and there is a small but acceptable clinic in this location to which 3 patients with cerebral malaria were admitted by noon. There were also many TB patients. The doctors prescribed routine medications before conducting further examinations.
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PMID:[Sudan, through the back door]. 985 45

The continuing spread of drug-resistant malaria emphasizes the need for new antimalarial drugs. Atovaquone is a broad-spectrum antiprotozoal drug with a novel mechanism of action, via inhibition of parasite mitochondrial electron transport, and a favorable safety profile. Early studies with atovaquone alone for treatment of malaria demonstrated good initial control of parasitemia but an unacceptable rate of recrudescent parasitemia. Parasites isolated during recrudescence after treatment with atovaquone alone were resistant to atovaquone in vitro. The combination of atovaquone and proguanil is synergistic in vitro, and clinical studies demonstrated enhanced efficacy of the combination compared to either drug alone for treatment of malaria. Malarone, a fixed-dose combination of 250 mg of atovaquone and 100 mg of proguanil hydrochloride, is available in many countries for treatment of acute, uncomplicated malaria caused by Plasmodium falciparum. At the recommended dose (in adults, four tablets once a day for three days), the overall cure rate was > 98% in more than 500 patients with falciparum malaria. In four randomized, controlled clinical trials, treatment with atovaquone and proguanil hydrochloride was significantly more effective than mefloquine (Thailand), amodiaquine (Gabon), chloroquine (Peru and the Philippines) or chloroquine plus pyrimethamine/sulfadoxine (Philippines). In clinical trials where the comparator drug was highly effective, treatment with atovaquone and proguanil hydrochloride was equally effective. Parasites isolated during recrudescence after treatment with the combination of atovaquone and proguanil were not resistant to atovaquone in vitro. The most commonly reported adverse events in clinical trials (abdominal pain, anorexia, nausea, vomiting, diarrhea and coughing) occurred with similar frequency in patients treated with a comparator drug. Malarone is a safe and effective new agent for treatment of malaria.
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PMID:Malarone (atovaquone and proguanil hydrochloride): a review of its clinical development for treatment of malaria. Malarone Clinical Trials Study Group. 1034 25


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