The Michigan Infectious Disease Society agrees with the CDC and IDSA statements regarding the Influenza A (H1N1) outbreak these last several days. Please go to their links found on this web page for the most up to date guidelines and information.
From Dr. Keystone’s talk at U of M, March 24, 2001, I recorded the following:
- What is the risk of malaria in persons who do not take chemoprophylaxis in visiting certain areas of the world for > 1 month — Mexico and Central America 1:10,000; S.E. Asia 1:1,000; Africa 1:50, and Oceania 1:5;
- 3% of persons taking mefloquine discontinue the drug; 1:200-500 have neuropsychiatric problems; seizures and psychosis occur in 1:10,000-13,000 persons on the medication.
- Mefloquine is the only drug used as chemoprophylaxis for the pregnant woman; there are some data to suggest pregnancy increases attraction of mosquitoes;
- There is a self diagnostic test for malaria available outside of the U.S.; the sensitivity and specificity in trials were > 90%, however, clinical experience suggests travelers don’t use the test correctly;
- MalaroneÒ is a relatively new anti-malarial with a cure rate of ³ 98% in non-immune persons with malaria; the dose is 4 tabs/day x 3 days in adults and 1-3 tabs/day x 3 days in children; the medication may induce vomiting so an antiemetic may be needed as well.
Clinical and laboratory guidelines have been recently published for use of HIV—1 drug resistance testing as part of treatment management; AIDS 2001; 15: 309-320.
From the 3rd Surgeon Symposium on Clinical Implications of HIV Drug Resistance — Frankfurt, Germany, February, 2001
From Clifford Lane, NIH: HIV infection is characterized by the development of immunodeficiency occurring simultaneously with an increase in immune activation. Use of IL-2 may expand T-cell pool and extend half-life of CD4 cells. The clinical benefit of this strategy remains to be demonstrated.
From C. Craig of Roche Discovery, England: The level of unbound protease inhibitor (PI) is associated with antiretroviral activity, and because most PIs are highly protein bound, the level of protein in serum may have a significant effect on the efficiency of PIs in vivo. Alpha-acid glycoprotein provides the greatest contribution to PI protein binding. Use of serum in drug testing to assay antiretroviral activity of PIs may underestimate the role of serum proteins in vivo.
Treatment options for persons who have failed all 3 currently available classes of antiretroviral agents are extremely limited. A trial of amprenavir and lopinavir/r as part of lopinavir/r Easy Access Program showed moderate viral suppression and immunologic recovery for patients with documented treatment failure with all 3 classes of available agents.
Data from Wayne State/Detroit Medical Center (R. MacArthur) were presented which examined use of ritonovir-boosted indinavir in highly experienced HIV-infected patients. Using retrospective chart review of 17 patients, at 24 weeks after initiating the combination therapy, 5 patients achieved full virologic response and 6 patients had a partial response. However, 4/17 patients had confirmed or probable episodes of nephrolithiasis, with 2 of 4 discontinuing the regimen.
In terms of defining resistance, the final analysis of the HAVANA trial was presented by B. Clotet of Spain. These data, using 326 patients with first, second or third drug failure, demonstrated that, at week 24, individuals who had genotypic testing and access to expert opinion had a significant difference in viral load below detection and HIV-1 RNA reduction compared with those who did not receive genotypic testing and/or expert opinion.
Discussing transmission of resistant virus, R. Comacho of Portugal demonstrated a prevalence of 16.7% (9/54) primary resistance mutations in newly HIV-infected patients. Similarly, O. Donoso of Spain showed resistant genotypes in 14/130 (10.8%) therapy-naïve HIV-infected persons in 18 outpatient clinics in Spain.
As evidenced by an outbreak earlier in 2001 in Seattle/King County, Washington, susceptible young adults may continue to sustain disease transmission caused by measles virus. In this recent outbreak, 42% of the reported cases were 29-39 years of age. The age cohort currently between 27 and 44 years of age may be particularly vulnerable because: 1) they were enrolled in public school before the implementation of effective school immunization laws requiring proof of immunity; 2) they may have been vaccinated before 12 months of age, thus circulating maternal antibody could have blunted the immune response to vaccine; or 3) waning immunity from receiving only one measles vaccine [Ed. Note: This latter reason is unlikely; the 1989-1991 national outbreak showed that waning measles immunity from a single vaccination is a very uncommon cause of susceptibility. It is far more likely that primary vaccine failure (~ 5% following a single dose of vaccine) occurred].
While only smallpox has been completely eradicated as a cause of human diseases, there are 10 other diseases on their way out. These diseases include those caused by polio, measles, and hepatitis B viruses, as well as maternal/neonatal tetanus. Preventive treatments are available but proper financing will be required. In order to eradicate polio by 2005, approximately $1 billion is needed to remove pockets of infection in 20-30 countries. Measles could be eliminated by 2010 at a (today’s) cost of $3 billion. To achieve elimination of hepatitis B virus infection by 2010-2015 will cost between $3 billion to $5 billion. Controlling maternal/neonatal tetanus disease by 2005 is possible with an additional sum of $130 million in aid.
A video about Malaria Continue reading…