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To facilitate understanding of the advances in health care in Nicaragua since 1979, this discussion examines them within a historical framework. Nicaragua was occupied by US marines almost continuously from 1909-33. In 1933, their withdrawal left in power the US backed National Guard and the 1st dictator, Anastasio Somoza Garcia. Health conditions under the Somoza regime are difficult to evaluate because lack of data and underreporting were the norm. The health care system under Somoza was administered by 23 separate agencies, including the National Social Security Institute (INSS), a national Ministry of Health, independent local health ministries, and autonomous public hospital governing boards. On July 19, 1979, the dictatorship was overthrown in a popular uprising. Somoza left behind a foreign debt of 1.6 billion dollars, which the Sandinista Front for National Liberation (FSLN) needed to honor to qualify for needed loans. Following Somoza's defeat, the new government faced the problem of how to care for the tens of thousands of persons wounded and how to distribute the aid and medical supplies coming in from other countries. The key to achieving these tasks was popular participation and organization. By the early part of 1980, the new government was addressing more directly the organization of the health care system. Unlike the fragmented services under Somoza, health care in the new Nicaragua fell under the control of a unified Ministry of Health (MINSA). In 1980, the FSLN initiated an intensive campaign against illiteracy, 100,000 young Nicaraguans, called "brigadistas," were trained and sent around the country to teach basic reading and writing. In addition, 1 out of 10 was trained in elementary health principles. They were responsible for educating others about hygiene and basic sanitation as well as distributing antimalarial medication. 5 popular Health Campaigns were waged during 1981 against polio; measles, diphtheria, pertussis, and tetanus; rabies; poor sanitation; and malaria. Since women and children make up about 75% of the population, maternal and child health is a priority. The Sandinistas' approach to diarrhea and dehydration, a major cause of morbidity and mortality in children, has been the creation of over 200 oral rehydration units. The purpose of these units, in addition to the oral replacement of an appropriate salt and glucose solution, is to educate health care workers about the prevention and treatment of diarrheal disease. The education of health care workers also has been a priority. With increased access to health services, there is a chronic shortage of supplies and personnel and capital to build new facilities. International aid has been very important to health. Diverting funds away from Nicaraguan destabilization and toward social needs here in the US would have a positive impact on health services for the people of both Nicaragua and the US.
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PMID:Health care in Nicaragua: a social and historical perspective. 659 13

Decreased sensitivity and incipient resistance of Plasmodium falciparum strains to chloroquine have been reported from Mto-wa-Mbu, in the north-east of the United Republic of Tanzania. In this locality the population had been exposed to chloroquine pressure for about two decades, in the form of medicated salt and through easy availability of the drug itself. In an attempt to find out whether such chemosuppression had influenced the immune response of the population, two seroepidemiological surveys were carried out in March 1981 and March 1982; the second survey was performed to confirm the results obtained in the first one. The humoral immunological response was measured by the immunofluorescent antibody technique. In the absence of information on the immunological profile that existed in the area prior to the introduction of chloroquine in 1960, the results of the present surveys were compared with those obtained in another locality in the north-east of the United Republic of Tanzania in 1967, and in the West Kiang district of Gambia in 1965. The two areas used for comparison exhibited a malaria endemicity similar to that prevailing in Mto-wa-Mbu prior to the introduction of the medicated salt. The results from Mto-wa-Mbu showed a significantly lower proportion of subjects with positive titres and a lower geometric mean titre in all age groups.A reduction in the humoral immunological response might be explained by the drug pressure that has been exerted in the area for many years. The depressed immune response found at Mto-wa-Mbu, however, was so marked that other factors may have contributed to its establishment.In view of the importance of these findings, it is recommended that further, longitudinal serological studies be conducted in the field to assess the effects of chemosuppression on the immune response of the protected populations.
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PMID:Incipient resistance of Plasmodium falciparum to chloroquine among a semi-immune population of the United Republic of Tanzania. 2. The impact of chloroquine used as a chemosuppressant on the immune status of the population. 676 Oct 4

Serum quinine concentrations were determined in 51 children with uncomplicated falciparum malaria and 22 controls. Quinine 10 mg salt/kg was given one-hour, two-hour, four-hour intravenously in group A (14 patients, 5 controls), group B (12 patients, 6 controls), Group C (10 patients, 6 controls) and given orally in group D (15 patients, 5 controls). In malaria patients, the highest serum quinine levels were observed at the end of intravenous infusion and by the 4th hour after oral medication. Mean of the peaks of the drug concentrations of the 4 schedules were not significantly different, ranging from 22 to 28 n mol/ml. Serum concentrations in the patients were significantly higher than those of the controls. The total clearance of quinine in the patients were approx. 1 ml/min/kg, which was significantly less than those of the controls. The total apparent volume of distribution of the drug was similarly reduced. In patients it was about 0.8 litre/kg. The elimination half times of quinine ranged from 9 to 11 hours, whereas the value in the controls ranged from 3 to 7 hours. Side effects of quinine were not observed.
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PMID:Serum quinine concentrations following the initial dose in children with falciparum malaria. 676 56

Iron in food is classified as belonging to the haem pool, the nonhaem pool, and extraneous sources. Haem iron is derived from vegetable and animal sources with varying bioavailability. Hookworm infestation of the intestinal tract affects 450 million people in the tropics. Schistosoma mansoni caused blood loss in 7 Egyptian patients of 7.5- 25.9 ml/day which is equivalent to a daily loss of iron of .6-7.3 mg daily urinary loss of iron in 9 Egyptian patients. Trichuris trichiura infestation by whipworm is widespread in children with blood loss of 5 ml/day/worm. The etiology of anemia in children besides iron deficiency includes malaria, bacterial or viral infections, folate deficiency and sickle-cell disease. Severe infections cause profound iron-deficiency anemia in children in central American and Malaysia. Plasmodium falciparum malaria-induced anaemia in tropical Africa lowers the mean haemoglobin concentration in the population by 2 g/dI, causing profound anaemia in some. The increased risk of premature delivery, low birthweight, fetal abnormalities, and fetal death is directly related to the degree of maternal anemia. Perinatal mortality was reduced from 38 to 4% in treated anemic mothers. Mental performance was significantly lower in anemic school children and improved after they received iron. Supplements of iron, soy-protein, calcium, and vitamins given to villagers with widespread malnutrition, iron deficiency, and hookworm infestation in Colombia reduced enteric infections in children. Severe iron-deficiency anemia was treated in adults in northern Nigeria by daily in Ferastral 10 ml, which is equivalent to 500 mg of iron per day. Choloroquine, folic acid, rephenium hydroxynaphthoate, and tetrachlorethylene treat adults with severe iron deficiency from hookworm infestation in rural tropical Africa. Blood transfusion is indicated if the patient is dying of anaemia or is pregnant with a haemoglobin concentration 6 gm/dl. In South East Asia, mg per day prevented iron-deficiency anaemia in pregnancy. Field-trials on nutritional iron deficiency include an acidified milk formula plus ferrous sulphate for infants; biscuits with added bovine hemoglobin for children in Chile; sugar plus sodium ferric EDTA in Guatemala; salt with ferric orthophosphate and sodium acid sulphate in India; and Salt with ferrous sulphate plus sodium hexametaphosphate.
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PMID:Iron deficiency in the tropics. 704 57

The sensitivity of Plasmodium falciparum strains to chloroquine was tested in one locality in the north-east of the United Republic of Tanzania, where a chloroquine-medicated salt project has been implemented for chemosuppression for many years, and where large amounts of the drug have been available during the last decade for the treatment of malaria infections.Single doses of chloroquine (5 or 10 mg of base/kg of body weight) failed to clear P. falciparum trophozoites in asymptomatic parasite carriers selected from the school population. In comparison, clearance had been obtained easily ten years previously with 5 mg of base/kg of body weight in several localities in the area.A total dose of 25 mg of base/kg of body weight given over a 3-day period succeeded in clearing asexual parasites from the peripheral blood by day 3 in all instances. Asexual parasites were not found again during the nine days following administration of the drug.All the schoolchildren who had received 5 or 10 mg of base/kg of body weight at the beginning of the trial were treated with a further 20 mg of base/kg of body weight at the end of the 7-day observation period. Asexual parasites reappeared in the blood of some of these children 7-10 days after the second administration of the drug.Using the in vitro microtechnique, incomplete schizont inhibition was observed in 3 out of 21 cases at a chloroquine concentration of 1.14 mumol/litre of blood, which is the discriminating dosage for resistance at RI level.No cases of retinopathy related to the prolonged use of chloroquine were detected among the 221 residents who had spent more than 16 consecutive years in the locality.
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PMID:Incipient resistance of Plasmodium falciparum to chloroquine among a semi-immune population of the United Republic of Tanzania. 1. Results of in vivo and in vitro studies and of an ophthalmological survey. 704 90

Patients with uncomplicated hyperparasitemic falciparum malaria are usually given parenteral antimalarial treatment to prevent a progression to vital organ dysfunction and death. Since the oral artemisinin derivatives are more rapidly effective than other antimalarial drugs, we compared oral artesunate (4 mg/kg/day for three days with mefloquine 25 mg/kg on the second day) with an intravenous quinine loading dose (20 mg of salt/kg initially then 10 mg/kg every 8 hr, followed by mefloquine 25 mg/kg) in an open paired randomized trial in 60 patients with acute falciparum malaria and greater than 4% parasitemia, but no evidence of vital organ dysfunction. There were no deaths and none of the patients progressed to develop severe malaria. Oral artesunate treatment resulted in shorter median [range] times to fever clearance (19 hr [4-45] versus 47 hr [4-107]) (P < 0.0001), parasite clearance (36 hr [18-61] versus 82 hr [36-104]) (P < 0.0001), and discharge from the hospital (25 hr [12-44] versus 58 hr [24-115]) (P < 0.0001). There was no toxicity attributable to artesunate. The cure rates by day 28 were 70% (19 of 27) and 39% (11 of 27) in the artesunate and quinine groups, respectively (relative risk = 1.7; 95% confidence interval = 1.0-3.0). Oral artesunate was simpler, cheaper, safer, and more effective than intravenous quinine for the treatment of uncomplicated hyperparasitemia.
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PMID:Oral artesunate in the treatment of uncomplicated hyperparasitemic falciparum malaria. 748 11

Following invasion by the malaria parasite there appear in the parasitized erythrocyte new ("induced") permeation pathways that mediate the transport of a wide variety of small solutes. Although anion-selective, these pathways have a significant cation permeability and cause a substantial increase in the basal leak of cations into and out of the infected cell. In this study of human erythrocytes infected in vitro with Plasmodium falciparum it was shown that the transport of monovalent cations (Rb+ and choline), but not that of a nonelectrolyte (sorbitol) or a monovalent anion (lactate), via the malaria-induced pathways is strongly dependent on the nature of the anion in the suspending medium. Substitution of NO3- for Cl- resulted in a 4-6-fold increase in the unidirectional influx and efflux of Rb+, and a 2-3-fold increase in the influx of choline via the induced pathways. By contrast, replacement of Cl- with NO3- caused a slight (although not significant) decrease in the malaria-induced influx of sorbitol and lactate. Hemolysis experiments with a range of K+ salts revealed that the net influx of K+ into infected cells showed the same novel anion dependence as seen for the unidirectional flux of Rb+ and choline, with hemolysis occurring much faster in iso-osmotic KNO3 and KSCN solutions than in KCl, KBr, or KI solutions. Hemolysis in the corresponding Na+ salt solutions was very much slower, consistent with the induced pathways being selective for K+ over Na+, and raising the possibility that the efflux of cell K+ via these pathways may play a role in host cell volume regulation. A number of models that would account for the anion dependence of malaria-induced cation transport are considered.
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PMID:Novel anion dependence of induced cation transport in malaria-infected erythrocytes. 759 35

Twelve cases of cerebral malaria due to plasmodium falciparum, treated with loading dose of quinine (20 mg/kg salt in 500 ml of 5% glucose infused IV in 4 hrs) are compared with eleven age and sex matched cases treated with conventional dose of 10 mg/kg. The parasite clearance rate was significantly faster in loading dose group. There was no difference in recovery time: the interval between the initiation of treatment to full recovery of consciousness in both groups. One patient had pretreatment hypoglycaemia and two cases in the conventional dose group developed hypoglycaemia during therapy. One patient died in conventional dose group due to multi-organ failure. Two litres blood exchange transfusion was also tried for this case. Mild cinchonism occurred in two cases after loading dose while this was observed only in one case in conventional dose group. There was no significant hypotension or ECG changes in any patient. Loading dose of quinine seems to be well tolerated and may clear parasitaemia faster in case of malaria due to Plasmodium falciparum (PF).
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PMID:Experience on loading dose--quinine therapy in cerebral malaria. 786 10

The prevelance of IDA in industrialized countries has declined in recent decades, but there has been little change in the worldwide prevalence. IDA is currently estimated to affect more than 500 million people. Recent studies have indicated that anemia per se, the most common manifestation of iron deficiency, is less important from a public health standpoint than liabilities associated with tissue iron deficiency. The most important of the latter are an impairment in psychomotor development and cognitive function in infants and preschoolers, a deficit in work performance in adults, and an increase in the frequency of low birth weight, prematurity, and perinatal mortality in pregnancy. There have been several recent advances in combatting nutritional iron deficiency. One of the major problems has been in distinguishing iron deficiency from other causes of anemia seen epidemiologically such as malaria, HIV infection, chronic inflammation, hemoglobinopathies, and protein energy malnutrition. When combined with serum ferritin and hemoglobin determinations, the serum transferrin receptor assay is a valuable addition in epidemiologic surveys because it provides a quantitative measure of functional iron deficiency and it distinguishes true IDA from the anemia of chronic disease. The most difficult challenge is to develop effective methods of supplying iron to large segments of a population. Supplementation with iron tablets is suitable for only brief periods of need such as during pregnancy. The poor compliance with existing supplementation programs is believed to be due mainly to the gastrointestinal side effects of oral iron which can be eliminated by the use of a gastric delivery system. The most effective long-term strategy is to increase the intake of bioavailable iron in the diet. The customary approach has been to fortify a food staple such as wheat, rice, sugar, or salt, and thereby increase the iron intake of the entire population. However, because of concerns about the risk of cancer and heart disease in individuals with high iron stores, there is an increasing reluctance to supply iron to individuals who do not require it. A more effective strategy is to fortify food vehicles that are targeted to segments of the population at greatest risk of iron deficiency such as infants and school children. Because of the strong inhibitory properties of diets in regions of the world where iron deficiency is most prevalent, the use of NaFeEDTA has important advantages for food fortification.
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PMID:Iron deficiency: the global perspective. 788 26

By dynamic modeling based on Ross & MacDonald's mathematical model, the characteristics of rapid transmission of malaria and slow transmission of filariasis was compared. The dynamic mechanism showed that the infection efficiency in filariasis, namely, the probability of becoming infected in man by one infective bite of mosquito, was much lower than that in malaria; hence the vectorial capacity or transmission velocity in filariasis was also markedly lower than that in malaria. Since the intensity of infection i.e. the microfilaria density can largely affect the infection efficiency in filariasis, drug treatment, especially using DEC-medicated salt can reduce the intensity of infection and the infection efficiency, thus interrupting transmission finally. However, for malaria, only when the measures for mosquito vector control (including mosquito proofing) are taken as a priority to reduce the vectorial capacity or transmission velocity, malaria can then be controlled subsequently. These theoretical analyses are being demonstrated by the practice for malaria and filariasis control in our country, which could also be used as a theoretical base for enlightening the successful filariasis control strategies in our country.
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PMID:[Comparison of the transmission dynamics and the control effects between malaria and filariasis by using mathematical model]. 816 40


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