The American Journal of Tropical Medicine and Hygiene - Volume 83, Issue 2, August 2010

Recent interest in global health among medical students has grown drastically, and many students now spend time abroad conducting short-term research projects in low-resource settings. These short-term stints in developing countries present important ethical challenges to US-based students and their medical schools as well as the institutions that host such students abroad. This paper outlines some of these ethical issues and puts forth recommendations for ethically mindful short-term student research.

This report describes how Nigeria, a country that at one time had the highest number of cases of dracunculiasis (Guinea worm disease) in the world, reduced the number of cases from more than 653,000 in 1988 to zero in 2009, despite numerous challenges. Village-based volunteers formed the foundation of the program, which used health education, cloth filters, vector control, advocacy for safe water, voluntary isolation of patients, and monitored program interventions and cases reported monthly. Other factors in the program's success were strong governmental support, advocacy by a former head of state of Nigeria, technical and financial assistance by The Carter Center, the U.S. Centers for Disease Control and Prevention, the United Nations Children's Fund, the World Health Organization, and many other partners and donors. The estimated cost of the Nigerian program during 1988–2009 is $37.5 million, not including funding for water supply projects or salaries of Nigerian governmental workers.

The African Society of Human Genetics (AfSHG), founded in 2003 with its inaugural meeting in Accra, Ghana, 1 has the stated missions of (1) disseminating information about human genetics research in Africa, (2) establishing a mentorship network providing educational resources, including the development of appropriate technology transfer, (3) providing advocacy for human genetic research in Africa, and (4) encouraging collaborative research. Despite its young age, the AfSHG has developed a strong cadre of active researchers, both within and outside of Africa, with more than 400 members (from 16 countries across Africa as well as 8 other countries), and has held six successful meetings, five in Africa and one in the United States.

Although some malaria-control programs are beginning to combine insecticide-treated nets (ITNs) and indoor residual spraying (IRS), little is known about the effectiveness of such combinations. We use a mathematical model to compare the effectiveness of ITNs and IRS with dichlorodiphenyltrichloroethane (DDT) or bendiocarb, applied singly and in combination, in an epidemiological setting based in Namawala, Tanzania, with Anopheles gambiae as the primary vector. Our model indicates that although both IRS (with DDT) and ITNs provide personal protection, humans with only ITNs are better protected than those with only IRS, and suggests that high coverage of IRS with bendiocarb may interrupt transmission, as can simultaneous high coverage of ITNs and IRS with DDT. When adding a second vector-control intervention, it is more effective to cover the unprotected population first. Although our model includes some assumptions and approximations that remain to be addressed, these findings should be useful for prioritizing and designing future field research.

New photomap of Anopheles (Nyssorhynchus) darlingi Root, 1926, is described for a population from Guajará-Mirim, State of Rondonia, Brazil. The number of sections in the previous A. darlingi reference map was maintained and new subsections were added to the five chromosome arms. Breakage points of paracentric inversions had been previously incorporated into the photomap of this species. An additional inversion is reported, called 3Lc, totaling 14 inversions in the A. darlingi chromosome arms. The proposed photomap is potentially useful for further evolutionary studies in addition to physical and in silico chromosome mapping using A. darlingi genomic and transcriptome sequences. Furthermore, in our attempt to compare sections of the 2R chromosome arm of A. darlingi with Anopheles funestus, Anopheles stephensi, and Anopheles gambiae, we found great differences in the arrangement of the polytene chromosome bands, which are consistent with the known phylogenetic divergence of these species.

In 2004, Sudan adopted artesunate + sulfadoxine/pyrimethamine (SP) combination as the first-line drug, in response to the high level of falciparum resistance to antimalarials. In 2007, a molecular study on antimalarial resistance linked genes, pfcrt, pfmdr1, pfdhfr, pfdhps, and pfATPase6, was conducted on 198 isolates from central and eastern Sudan. We observed a high frequency of point mutations at almost all loci analyzed, mainly of pfcrt 76T (72.7%), pfdhfr 51I (75.3%), and pfdhfr 108N (72.7%) alleles. The MARK III in vitro test for chloroquine sensitivity in 45 P. falciparum isolates showed that 37.8% of the isolates were low resistant and 6.7% were fully resistant. This study represents the most recent molecular investigation on antimalarial resistance in this area after the adoption of artemisinin-based combination therapy (ACT), and underlines the importance of the analysis of SP resistance evolution to monitor the efficacy of ACT therapy in endemic areas.

In 2003, 44 U.S. Marines were evacuated from Liberia with either confirmed or presumed Plasmodium falciparum malaria. An outbreak investigation showed that only 19 (45%) used insect repellent, 5 (12%) used permethrin-treated clothing, and none used bed netting. Adherence with weekly mefloquine (MQ) was reported by 23 (55%). However, only 4 (10%) had serum MQ levels high enough to correlate with protection (> 794 ng/mL), and 9 (22%) had evidence of steady-state kinetics (MQ carboxy metabolite/MQ > 3.79). Tablets collected from Marines met USP identity and dissolution specifications for MQ. Testing failed to identify P. falciparum isolates with MQ resistance. This outbreak resulted from under use of personal protective measures and inadequate adherence with chemophrophylaxis. It is essential that all international travelers make malaria prevention measures a priority, especially when embarking to regions of the world with high transmission intensity such as west Africa.

“Good doctors are of no use without good discipline. More than half the battle against disease is not fought by doctors, but by regimental officers. It is they who see that the daily dose of mepacrine (anti-malarial chemoprophylactic drug used in WW II) is taken…if mepacrine was not taken, I sacked the commander. I only had to sack three; by then the rest had got my meaning.”

—Lieutenant General William Slim (1891–1970), Burma Campaign, 1943

The combined efficacy of a long-lasting insecticidal net (LLIN) and a carbamate-treated plastic sheeting (CTPS) or indoor residual spraying (IRS) for control of insecticide-resistant mosquitoes was evaluated in experimental huts in Burkina Faso. Anopheles gambiae from the area is resistant to pyrethroids and to a lesser extent, carbamates. Relatively low mortality rates were observed with the LLIN (44%), IRS (42%), and CTPS (52%), whereas both combinations killed significantly more mosquitoes (~70% for LLIN + CTPS and LLIN + IRS). Blood feeding by An. gambiae was uninhibited by IRS and CTPS compared with LLIN (43%), LLIN + CTPS (58%), and LLIN + IRS (56%). No evidence for selection of the kdr and ace-1R alleles was observed with the combinations, whereas a survival advantage of mosquitoes bearing the ace-1R mutation was observed with IRS and CTPS. The results suggest that the combination of the two interventions constitutes a potential tool for vector-resistance management.

Severe rhabdomyolysis (creatine phosphokinase = 29,400U/L) developed in a 16-year-old boy from Manaus, Brazil, after he started treatment with chloroquine for infection with Plasmodium vivax. Treatment led to myoglobinuria and acute renal failure. After hemodialysis, the patient improved and a muscle biopsy specimen showed no myophosphorylase or deaminase deficiency. This case of rhabdomyolysis associated with P. vivax infection showed no comorbidities. The pathogenesis is still unclear.

Although rhabdomyolysis is generally reported as a complication of Plasmodium falciparum malaria, leading to metabolic and renal complications, 1 it has been reported in a patient with P. vivax infection with myoadenylate deaminase deficiency. 2 We report a case in a patient without typical muscle enzyme deficiencies in which severe rhabdomyolysis developed while the patients was being treated with chloroquine for a confirmed P. vivax infection.

Severe imported malaria is an important problem in European countries, where approximately 8,000 cases of Plasmodium falciparum malaria are reported each year. Although the World Health Organization recommends intravenous artesunate (IVA) as the treatment of choice for severe malaria in areas of low transmission, it is rarely used in Europe, because it is not yet available as a drug manufactured under Good Manufacturing Practices. We report a series of eight imported severe falciparum malaria cases treated with IVA combined with intravenous quinine (IVQ). This combined therapy was found to be efficacious, safe, and well-tolerated. The only observed death occurred in a young man who presented 10 days after the onset of symptoms. IVA plus IVQ treatment seems to be an acceptable approach, because the legal risks in using an unlicensed drug for treating a severe malaria case denies the patient the possibility of being treated with the most effective regimen.

The Grand Cayman population of Aedes aegypti is highly resistant to DDT and pyrethroid insecticides. Glutathione transferase, cytochrome P450, and esterase levels were increased in the Grand Cayman population relative to a susceptible laboratory strain, but synergist studies did not implicate elevated insecticide detoxification as a major cause of resistance. The role of target site resistance was therefore investigated. Two substitutions in the voltage-gated sodium channel were identified, V1016I in domain II, segment 6 (IIS6) (allele frequency = 0.79) and F1534C in IIIS6 (allele frequency = 0.68). The role of the F1534C mutation in conferring resistance to insecticides has not been previously established and so a tetraplex polymerase chain reaction assay was designed and used to genotype mosquitoes that had been exposed to insecticides. The F1534C mutation was strongly correlated with resistance to DDT and permethrin.

Morphological differentiation of mosquitoes in the subgenera Culex (Culex) and Culex (Phenacomyia) in Guatemala is difficult, with reliable identification ensured only through examination of larval skins from individually reared specimens and associated male genitalia. We developed a multiplexed polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay to identify common Cx. (Cux.) and Cx. (Phc.). Culex (Cux.) chidesteri, Cx. (Cux.) coronator, Cx. (Cux.) interrogator, Cx. (Cux.) quinquefasciatus, Cx. (Cux.) nigripalpus/Cx. (Cux.) thriambus, and Cx. (Phc.) lactator were identified directly with a multiplexed primer cocktail comprising a conserved forward primer and specific reverse primers targeting ribosomal DNA (rDNA). Culex nigripalpus and Cx. thriambus were differentiated by restriction digest of homologous amplicons. The assay was developed and optimized using well-characterized specimens from Guatemala and the United States and field tested with unknown material from Guatemala. This assay will be a valuable tool for mosquito identification in entomological and arbovirus ecology studies in Guatemala.

More than 5,000 diarrheal cases per year receive medical care at the National Children's Hospital of Costa Rica, and nearly 5% of them require hospitalization. A total of 173 Escherichia coli strains isolated from children with diarrhea were characterized at the molecular, serologic, and phenotypic level. Multiplex and duplex polymerase chain reactions were used to detect the six categories of diarrheagenic E. coli. Thirty percent (n = 52) of the strains were positive, indicating a high prevalence among the pediatric population. Enteropathogenic E. coli and enteroinvasive E. coli pathotypes were the most prevalent (21% and 19%, respectively). Pathogenic strains were distributed among the four E. coli phylogenetic groups A, B1, B2, and D, with groups A and B1 the most commonly found. This study used molecular typing to evaluate the prevalence of diarrheagenic E. coli reported in Costa Rica and demonstrated the importance of these pathotypes in the pediatric population.

Bartonella species are being recognized as important bacterial human and canine pathogens, and are associated with multiple arthropod vectors. Bartonella DNA extracted from blood samples was obtained from domestic dogs in Algiers, Algeria. Polymerase chain reaction (PCR) and DNA sequence analyses of the ftsZ gene and the 16S-23S intergenic spacer region (ITS) were performed. Three Bartonella species: Bartonella vinsonii subsp. berkhoffii, Bartonella clarridgeiae, and Bartonells elizabethae were detected infecting Algerian dogs. To our knowledge, this study is the first report of detection by PCR amplification of Bartonella in dogs in North Africa.

No studies have quantified the impact of pre-culture antibiotic use on the recovery of individual blood-borne pathogens or on population-level incidence estimates for Streptococcus pneumoniae. We conducted bloodstream infection surveillance in Thailand during November 2005–June 2008. Pre-culture antibiotic use was assessed by reported use and by serum antimicrobial activity. Of 35,639 patient blood cultures, 27% had reported pre-culture antibiotic use and 24% (of 24,538 tested) had serum antimicrobial activity. Pathogen isolation was half as common in patients with versus without antibiotic use; S. pneumoniae isolation was 4- to 9-fold less common (0.09% versus 0.37% by reported antibiotic use; 0.05% versus 0.45% by serum antimicrobial activity, P < 0.01). Pre-culture antibiotic use by serum antimicrobial activity reduced pneumococcal bacteremia incidence by 32% overall and 39% in children < 5 years of age. Our findings highlight the limitations of culture-based detection methods to estimate invasive pneumococcal disease incidence in settings where pre-culture antibiotic use is common.

Buruli ulcer (BU), a disease caused by Mycobacterium ulcerans, leads to the destruction of skin and sometimes bone. Here, we report a case of severe multifocal BU with osteomyelitis in a 6-year-old human immunodeficiency virus (HIV)-negative boy. Such disseminated forms are poorly documented and generally occur in patients with HIV co-infection. The advent of antibiotic treatment with streptomycin (S) and rifampin (R) raised hope that these multifocal BU cases could be reduced. The present case raises two relevant points about multifocal BU: the mechanism of dissemination that leads to the development of multiple foci and the difficulties of treatment of multifocal forms of BU. Biochemical (hypoproteinemia), hematological (anemia), clinical (traditional treatment), and genetic factors are discussed as possible risk factors for dissemination.

The diagnostic value of enzyme-linked immunosorbent assay (ELISA) was evaluated when blood specimens of 92 patients suspected of brucellosis underwent the ELISA (IgM and IgG), standard tube agglutination (SAT), and 2-mercaptoethanol (2-ME) tests and blood cultures; 38 sera from non-brucellosis patients and 34 sera from blood donors were also subjected to ELISA, SAT, and 2-ME tests. SAT was able to pinpoint only 23 (25%), whereas ELISA confirmed the etiology in 56 (60.9%; P < 0.001) patients with brucellosis, including 31 culture-confirmed cases. The sensitivity and specificity of ELISA were 100% and 71.31%, respectively. Because they were confirmed by ELISA, the diagnosis could never be excluded with SAT in 33 cases. ELISA has been found to be more sensitive in acute (28% higher sensitivity; P < 0.02) and chronic (55% higher sensitivity; P < 0.01) cases. For accurate diagnosis in suspected brucellosis cases detection, we recommend both ELISA IgM and IgG tests. ELISA IgG and 2-ME tests seem to be promising tools in judging prognosis.

The tuberculin skin test (TST) quantifies cell-mediated immunity to tuberculosis antigens. Helminths suppress cell-mediated immunity, so we studied the effect of helminth infection and deworming on the TST in a randomized, double-blind, placebo-controlled study in an indigenous Amazon community (N = 195). Stool microscopy diagnosed helminths in 98% and co-infection with multiple species in 24% of study subjects. The TST was positive (≥ 10 mm) for 49%, and responses increased with age (P < 0.001), Bacille Calmette Guerin (BCG) vaccination (P = 0.01), and tuberculosis contact (P = 0.05). TST results had no association with helminth-egg concentrations, species, or co-infections (all P > 0.1). One month after deworming with albendazole (three daily 400-mg doses), helminths were reduced, but 63% remained infected with helminths. Albendazole did not cause a change in TST size (P = 0.8) or positivity (P = 0.9) relative to placebo. Thus, TST reactions were unaffected by albendazole therapy that partially cured intestinal helminth infections, and TST interpretation was unaffected by high-burden helminth infections and co-infection with multiple helminth species.