- Email: [email protected]
AN ISOTHIAZOLE THIOSEMICARBAZONE IN THE TREATMENT OF VARIOLA MAJOR IN MAN
1068
vascular accident; a 25-year-old female with chronic myocarditis who died of pulmonaryoedema 17 hours after admission; and a 27-year-old female who died in circulatory collapse a few minutes after coming to hospital before adequate replacement therapy could be given.
AN ISOTHIAZOLE THIOSEMICARBAZONE IN THE TREATMENT OF VARIOLA MAJOR IN MAN A Controlled Clinical Trial and
Discussion
Our experience with this large series of patients with cholera indicates that, despite a higher incidence of certain complications such as hypoglyceemia and centralnervous-system dysfunction in children, the disease is generally similar in children and adults in its clinical manifestations and response to adequate replacement
A. RAMACHANDRA RAO M.B. Madras HEALTH
Summary Cholera in children is in most respects similar to cholera in adults. An approach to therapy utilising clinical criteria combined with measurement of stool volume to determine fluid requirements, and the prompt correction of acidosis as well as sodium chloride and potassium deficits, has been used in a series of 769 patients treated in Dacca, East Pakistan. The mortality was less than 1% in both children and adults. Similar results have been obtained with this method at an isolated field treatment centre. We thank the nursing staff of the Pakistan-SEATO Cholera Research Laboratory for their excellent work and the following physicians who contributed to the care of the patients: Dr. J. Ahmed, Dr. A. K. M. J. Alam, Dr. M. M. Ali, Dr. K. M. Ally, Dr. R. K. Barui, Dr. J. Cole, Dr. Z. Haque, Dr. M. S. Islam, Dr. A. S. M. M. Rahman, Dr. M. Rahman, and Dr. M. S. Zoha. This work was supported in part by Research Agreement
no.
196802 between the National Institutes of
Health, Bethesda, Maryland, U.S.A., and the Pakistan-SEATO Cholera Research Laboratory. Requests for reprints should be addressed to Dr. John Lindenbaum, First Medical Division, Bellevue Hospital, 462 First Avenue, New York, New York, U.S.A. REFERENCES
Bullock, W. E., Phillips, R. A. (1965) Lancet, ii, 132. Carpenter, C. C. J., Mitra, P. P., Sack, R. B., Dans, P. E., Wells, S. A., Chaudhuri, R. N. (1965) ibid. i, 726. Wallace, C. K., Mitra, P. P., Sack, R. B., Mondal, A., Wells, S. A., Dans, P. E., Lewis, G. W., Chaudhuri, R. N. (1965) in Proceedings of the Cholera Research Symposium; p. 190. Washington. Gordon, R. S., Jr, Ahmed, J., Akbar, R., Alam, A. K. M. J., Ali, M., Baru, R. K., Greenough, W. B., III, Islam, M. R., Islam, M. S., Khan, A. Q., Lindenbaum, J., Rahman, A. S. M. M., Zoha, M. S. (1964) E. Pakistan med. J. 8, 10. Feeley, J. C., Greenough, W. B., III, Sprinz, H. S., Oseasohn, R. O (1966) Ann. intern. Med. (in the press). Greenough, W. B., III (1965) in Current Therapy; p. 7. Philadelphia and
OFFICER,
CORPORATION OF MADRAS
JAMES A. MCFADZEAN M.D.
Glasg.
HEAD OF THE DIVISION OF EXPERIMENTAL MAY
therapy. Clinical estimates of dehydration, without the use of direct measurements of hasmoconcentration, such as specific gravity, were found to be adequate in estimating fluid requirements, an approach that has also been used successfully in adults in Calcutta (Carpenter, Mitra et al. 1965). The results obtained in the present series did not depend on the presence of modern hospital facilities or readily available expert consultation. Similar therapeutic success has been obtained in a treatment centre located on a barge near Matlab Bazar in East Pakistan (Gordon et al. 1966) where patients are treated by young Pakistani physicians and nurses trained in our Dacca hospital wards. Cholera cots, intravenous fluids, tetracycline, and a stethoscope are available, but there are no laboratory facilities other than those for bacteriological diagnosis. During the 19-month period ending in June, 1965, 496 patients with documented V. cholerae infection were admitted. There were 4 deaths, a mortality-rate for the entire group of 0-81%; in 268 patients below the age of 10, there were 2 deaths (0-75%).
Laboratory
Investigations
& BAKER, LTD.,
CHEMOTHERAPY,
DAGENHAM
KUMARI KAMALAKSHI RESEARCH
B.Sc. ASSISTANT, INDIAN COUNCIL
FOR MEDICAL RESEARCH
THE activity of ’M&B7714’ (4-bromo-3-methylisothiazole-5-carboxaldehyde thiosemicarbazone) in experimental pox infections has been described by Slack, Wooldridge, McFadzean, and Squires (1964), Rao, McFadzean, and Squires (1965), and Westwood et al. (1966). The compound was effective against neurovaccinia and rabbit pox when administered shortly before the death of the control animals and so we decided to carry out a clinical trial of M & B 7714 in variola-major infections in man. Under the auspices of the Indian Council of Medical was assessed for therapeutic Research, M & B 7714 in with activity patients smallpox admitted to the Infectious Diseases Hospital, Madras. 1293 patients were
investigated. Controlled Clinical Trial PLAN OF TRIAL
Patients Patients were those who had been admitted to the Infectious Diseases Hospital, Tondiarpet, Madras, with smallpox. In most cases, diagnosis was clinical, but in doubtful cases this was confirmed by laboratory methods-by the demonstration of elementary bodies in smears stained by Gutstein’s technique and/or by the culture of the variola virus on the chorioallantoic membrane of the chick embryo. All patients were admitted to the trial, except: patients with hamiorrhagic smallpox (types 1 and 2) and variola sine-eruptione (type 12) (see figure);patients who were admitted during the scabbing stage; and patients who had been treated with other drugs which may have had antiviral activity. The following patients were subsequently excluded from the trial-those admitted moribund and treated but who died within 24 hours of admission and those admitted and treated but who subsequently died, before discharge, from causes other than smallpox. Smallpox cases were classified as to variety and type by the standard technique used in the hospital (see figure).
Randomisation The hospital maintains a single admission-register, in which all cases, irrespective of the infectious disease, are recorded in the order of their admittance to the hospital and given a serial hospital number. Admissions into the register are made by" non-technical clerks. Those cases of smallpox with " odd hospital numbers were allocated to the drug group and those
—
-
London. -
Gordon, R. S., Jr, Rosenberg, I. S., Davies, B. I., Benenson, A. S (1964) Lancet, i, 355.
DR. LINDENBAUM AND OTHERS:
REFERENCES—continued
Kobari, K. (1965) in Proceedings of the Cholera Research Symposium; p. 212. Washington. Lindenbaum, J., Greenough, W. B., III, Benenson, A. S., Oseasohn, R., Rizvi, S., Saad, A. (1965) Lancet, i, 1081. Mondal, A. (1965) in Proceedings of the Cholera Research Symposium; p. 213. Washington. Monsur, K. A. (1963) Bull. Wld Hlth Org. 28, 387. Wallace, C. K. (1966) Bull. Calcutta, Sch. trop. Med. (in the press). — Fabie, A. E., Mangubat, O., Velasco, E., Juinio, C., Phillips, R. A. (1964) Bull. Wld Hlth Org. 30, 795. Watten, R. H., Morgan, F. M., Songkhla, Y., Vanikiati, B., Phillips, R. A. (1959) J. clin. Invest. 38, 1879.
1069 treated with the drug. In schedule VII, only children under 12 years were treated, and therefore the maximum possible dose administered was 60 g. The age/dosage schedule was as follows: -
Since analyses of the separate schedules schedules are taken together in this report.
were
similar all the
Definitions
’
Classification of Smallpox (Madras scheme)
with " even " numbers were allocated to the placebo group, by the resident medical officer. The relevant course of tablets or suspension was then dispensed in separate containers labelled with the name of the patient along with instructions regarding administration, by the resident medical officer who was not concerned any further with the trial. Nowhere-either on the case sheet or on the dispensing container-was the hospital number or the treatment entered. Neither the observer, nor the nurses giving treatment, had access to this number, or to thmethod of treatment and thus as far as was possible the personal bias was eliminated in the study of the progress of the patient. Patients with smallpox were, however, given a smallpox serial number for reference purposes. Treatments M & B 7714.-The patients admitted to the trial in schedules l-lll were given the drug in tablet form, each tablet containing 0-5 g. In schedules iv-vn the tablets were replaced by an aqueous-type suspension, each 5 ml. of which contained 1 g. of the drug. Placebo.-The inert tablets and suspension used in all schedules were made as identical’ as possible to the drug preparations in appearance, smell, and taste. Treatment was given by the nurse in charge of the ward as per instructions, and immediate entries were made on the respective bedside records. During the trial, seven different dosage schedules were evaluated:
Vaccinated.-Those who had a visible mark of vaccination done at one time or other in their life (but not during the incubation period of the present attack) or those who had evidence of an attack of smallpox previously. Unvaccinated.-Those persons who had never been vaccinated; who were said to have been vaccinated but had no visible marks; or who were vaccinated for the first time during the incubation period of the current illness. Day of disease.-The day on which the patient became.unwell was taken as day 1 of the disease. Criteria for the Assessment The following criteria were applied in assessing the effect of the drug: (1) The fatality-rate (total and with reference to the vaccinial status, clinical type, age, and the " day of disease" on
admission). (2) The effect on the course of disease. This was undertaken only in patients admitted on or before the 4th day of the TABLE I-FATALITY-RATES IN THE TWO
GROUPS,
WITH REFERENCE TO
VACCINIAL STATUS
disease and was assessed by (a) the number of afebrile patients; (b) the mean number of febrile days; (c) the mean maximum height of temperature reached on any one day; and (d) the mean day to complete scabbing of lesions. Results
patients in the trial, 601 were controls and 692 had treatment with either tablets or suspension of Of 1293
M&B7714.
Fatality-rates The fatality-rates of the two groups were 23-3% (140 of 601) in the control group and 22-4% (155 out of 692) in the drug-treated group. Table i shows the fatality-rate with reference to out
Schedule
iv
was
an
uncontrolled trial, all
cases
being
TABLE II-FATALITY-RATE WITH REFERENCE TO AGE AND CLINICAL TYPE
(VACCINATED PATIENTS)
1070 TABLE III-FATALITY-RATE WITH REFERENCE TO AGE AND CLINICAL TYPE
vaccinial status. In the vaccinated patients the rate in the control group was 3-7% and in the drug-treated group it was 1 9 % ; in unvaccinated patients the fatality-rate in the control group was 34-5% and in the drug-treated group it was 34-7%. There is no statistically significant difference between these figures. Tables 11 (vaccinated) and III (unvaccinated) give the fatality-rates with reference to clinical type and age of the
patients.
it
(UNVACCINATED)
37-5% (116/309). For the group over 20 years the mortality in the controls was 35-7% (5/14) and 48-6% (17/35) in the drug-treated group. The average day of the disease on admission was 7-3. Consideration of the admissions up to and including day 4 shows a fatality-rate in the control group of 32-4% (12/37) and in the drug-treated group of 20% (13/65). If one considers these according to vaccinial status, in the vaccinated group the mortality-rate was nil in the controls and 3-8% (1/26) in the drug-treated group. Among unvaccinated patients the mortality in the control group was 50% (12/24) and in the drug-treated group it was 30-8% (12/39). l Effect on Course of Disease The following analyses were only undertaken on results from patients admitted on or before the 4th day of disease. The number of afebrile patients.-Table m shows the number of afebrile patients in the groups. There were none in types 3-5, 9% in the drug-treated unvaccinated types 6-8, and in types 9-11 there were only small was
’
J
In the vaccinated
patients with modified varieties (types there were no deaths in either group but 9-11, figure) in the flat varieties (types 3-5) the deaths were 5/5 in the control group and 3/7 in the drug-treated group. In types 6-8 (ordinary varieties) the fatality-rate in the control group was 2-1% (3/144) and in the drug-treated group it was 1-2% (2/172). In the unvaccinated patients, there were no deaths in the modified varieties in either group while in the " flat " varieties the fatality-rate in the control group was 100% (33/33) and in the drug-treated group it was 94-1% (48/51). In clinical types 6-8 the mortality-rate in the control group was 28-7% (99/345) and in the drug-treated group it was 27-3% (102/373). In the vaccinated patients (table 11) consideration of the age group 0-20 shows a mortality-rate in the control group of 4-3% (4/92) compared with 1% (1/100) for the drug-treated group. For patients aged 0-5 the figures are 33-3% (4/12) for the control group and 8-3% (1/12) for the drug-treated group. For patients aged more than 20 the figures are 3 2 °o (4/126) in the control group and 2-5% (4/160) in the drug-treated group. In the unvaccinated patients in the 0-20 age-group (table in) the mortality-rate was 34-4% (127/369) in the control group and 33’5% (133/397) in the drug-treated group. In the 0-5 group the mortality in the control group was 40-3% (112/278) and in the drug-treated group see
TABLE IV-DETAILS AMONG SURVIVORS OF AFEBRILE
numbers. The mean number of febrile days.-Table m also shows the mean number of febrile days and these were less in1 the drug-treated group both in the vaccinated and in thei unvaccinated. The mean maximum height of temperature on any one day. -Table iv also shows the mean maximum height of temperature reached on any one day. Little difference was observed. The mean days to complete scabbing.-Table v shows the mean number of days to scabbing. In the ordinary variety scabbing occurred earlier in the drug-treated group compared to the controls but the difference is of doubtful
significance. Toxic
Manifestations of the Drug
Nausea and
vomiting
were seen
in
some cases
but the
CASES, MEAN NUMBER OF FEBRILE DAYS AND MEAN MAXIMUM HEIGHT OF TEMPERATURE IN PATIENTS ADMITTED ON OR BEFORE THE 4TH DAY OF DISEASE
1071 TABLE V-THE MEAN DAYS TO COMPLETE SCABBING OF LESIONS
were
the
found during administration of the drug of increased serum-bilirubin.
or
during
period
Virological
Tests
Limited experiments (carried out by Dr. E. A. Boulter of the Microbiological Research Establishment, Porton, Wiltshire) early in the trial had indicated a striking reduction in the viral concentration of scabs from patients receiving the drug, in comparison with scabs from control
patients.
of administration of the drug on these grounds warranted. 6 patients, however, did refuse to accept the drug due to persistent vomiting. In some cases, prior administration of ’Stemetil’ (prochlorperazine) reduced the incidence of vomiting. There were 4 cases of allergic dermatitis, all of which responded to antihistamine treatment. 18 patients, in the drug-treated group, had " clinical jaundice " but there were no biochemical manifestations of liver damage (see below).
stopping
was not
During tests were
Clinical Laboratory Investigations the course of the trial a number of
Further scabs were examined from 16 control and 16 treated patients at roughly comparable stages and with the same clinical type of disease. Measured quantities of scabs were ground with sand and suspended in McIlvaines buffer pH 7-2 with 1% horse serum, and then titrated on the chorioallantoic membranes of eggs using the method of Westwood et al. (1957). The results are given in table vii. Scabs from half the treated group had a reduced titre of virus compared with the controls. Analysis of the figures by the Fisher-Behrens test showed that the difference in the figures just failed to reach significance. Other investigations undertaken by Dr. Boulter included titrations of haemagglutinin-inhibiting and neutralising TABLE VII-TITRATION OF VARIOLA VIRUS IN CRUSTS FROM SMALLPOX
PATIENTS
laboratory
done.
Serum-levels Serum-levels of M & B 7714 were estimated on a number of patients receiving tablets and these showed that only very low concentrations were obtained. Treatment with the drug in suspension, however, showed that form gave higher concentrations (table vi). In no investigation, however, was there a close correlation between dose and serum-concentration.
Tests for Drug Toxicity Red and white blood-cell counts were done at frequent regular intervals in both groups of patients; no abnormal changes were detected. Urine samples were also regularly examined. It was later seen during administration of larger doses of the drug that there were a number of cases of " clinical jaundice ", usually on the third or fourth day after the start of treatment and reaching a maximum between 5 and 11
days after
commencement
of
treatment.
Serum-
bilirubin began to increase within the first 3 days of treatment and reached a maximum value of between 4-11 and 9-4 mg. per 100 ml. 5-8 days after the commencement of treatment (6 g. twice daily for 5 days). In the few patients in which estimations were continued for a sufficient period, pre-treatment values were attained about 20 days after commencement of therapy. No increase in
serum-glutamic-oxaloacetic-transaminase, serum-glutamic-pyruvic-transaminase, or serum-alkaline-phosphatase TABLE VI-SERUM-CONCENTRATION AFTER INGESTION OF M EITHER AS SUSPENSION OR AS TABLETS
&
B
7714
*
Taking " negative " =0
antibodies and the titration of virus as determined by pock counts and heemagglutination in the virasmic stage of the disease. These revealed no information of significance. Discussion
suggest that M & B 7714 may, to some slight extent, have influenced the mortality-rate in the vaccinated patients, the mean number of febrile days, the time to scabbing, and the virus titre in the scabs. None of the findings was statistically significant, however, and for all practical purposes the compound has no role in the treatment of smallpox. It might be argued that the disease process in most patients in the trial had advanced well beyond the stage at which a therapeutic agent could possibly be of value. The most important toxic feature of the compound in this trial was the increase in unconjugated bilirubin. This was not, however, associated with any abnormality in liver-function tests or any other abnormality or upset. When the drug was withdrawn, the serum-bilirubin returned to normal. The most likely explanation was that the compound interferes with conjugation of bilirubin with glucuronic acid, and thus with excretion. The results
presented
1072
Summary This paper reports the therapeutic assessment in smallpox of ’ M & B 7714 ’ (4-bromo-3-methylisothiazole5-carboxaldehyde thiosemicarbazone) in a controlled double-blind trial on 1293 patients with smallpox. Assessment was made by fatality-rate (with reference to vaccinial status, clinical type, age, and day of disease on admission), the numbers of afebrile cases, the mean number of febrile days, the mean maximum height of temperature reached on any one day, and the mean day to complete scabbing of lesions. There was evidence that the drug had some beneficial effect but none of the findings
statistically significant. Apart from the increase in serum-bilirubin with high doses, some nausea and vomiting, and 4 cases of allergic dermatitis, the drug in this therapeutic trial did not present any significant toxic factors.
was
We thank the Indian Council for Medical Research under whose the clinical trials were undertaken, and especially to Dr. C. Pandit for his guidance and valuable suggestions, and the Government of India, Government of Madras, and the Commissioner of the Corporation of Madras for permission to undertake these trials; the director of the Microbiological Research Establishment, Porton Down, for facilities for carrying out a number of aspects of this investigation; and Miss Lalitha, the medical and nursing staff of the Infectious Diseases Hospital, Tondiarpet, Madras, and Mr. K. Corbett and the staff of the research group of May & Baker Ltd. for their assistance.
auspices
Requests for reprints should be addressed to Dr. J. May & Baker Ltd., Dagenham, Essex.
A. McFadzean,
REFERENCES
R., McFadzean, J. A., Squires, S. (1965) Ann. N.Y. Acad. Sci. 130, 118. Slack, R., Wooldridge, K. R. H., McFadzean, J. A., Squires, S. (1964) Nature, Lond. 204, 587. Westwood, J. C. N., Bowen, E. T., Boulter, E. A. (1966) Unpublished. Phipps, P. H., Boulter, E. A. (1957) J. Hyg., Camb. 55, 123.
Rao,
A.
-
ASSESSMENT OF AN ISOTHIAZOLE THIOSEMICARBAZONE IN THE PROPHYLAXIS OF CONTACTS OF VARIOLA MAJOR A. RAMACHANDRA RAO M.B. Madras HEALTH
OFFICER, CORPORATION OF MADRAS
G. D. W. MCKENDRICK M.A., B.M. Oxon., M.R.C.P. CONSULTANT
PHYSICIAN,
ST.
ANN’S HOSPITAL,
TOTTENHAM
L. VELAYUDHAN
KUMARI KAMALAKSHI
M.B. Madras
B.Sc.
ASSISTANT RESEARCH OFFICER
RESEARCH ASSISTANT
INDIAN COUNCIL FOR MEDICAL RESEARCH
Hamre
al. (1950) showed that certain thiosemicarbaactive against vaccinia virus and the search for more active compounds led to the development of 4-bromo3-methylisothiazole-5-carboxaldehyde thiosemicarbazone M & B 7714 ’) (Caton et al. 1965, Slack et al. 1964). This compound had a clear-cut activity against neurovaccinia and smallpox in mice when given orally (Rao et al. 1965), but a controlled therapeutic trial in smallpox in man was disappointing (Rao et al. 1965, Rao et al. 1966). Testing a similar compound, 1-methylisatin 3-thiosemicarbazone (methisazone), Bauer et al. (1963) showed a striking prophylactic effect when the drug was given in the incubation period. We decided to carry out a controlled, double-blind, prophylactic trial in smallpox contacts in the hope that administration of M & B 7714 during the et
zones were
TABLE I-THE DISTRIBUTION OF CONTACTS WITH INCIDENCE OF SMALLPOX RELATED TO AGE
incubation period might lessen the attack rate or modify the severity of the illness should smallpox be contracted. Methods
people studied were all the family contacts of smallpox patients (the index cases) admitted to the Infectious Diseases Hospital, Tondiarpet, Madras, India between February, 1964, and April, 1965, who showed no evidence of previous successful vaccination or of previous smallpox. It was felt that a much more accurate assessment of any prophylactic effect would be obtained by using only previously unprotected contacts, approximately 30% of whom could be expected to get smallpox. The definition of unvaccinated was as given by Rao et al. (1966). With the numbers involved a strict surveillance of contacts became possible. For the purposes of the trial the hospital day was defined as being 24 hours from 4 P.M. During an evening visit to the hospital all index cases admitted during the preceding 24-hour period were seen, addresses were checked, and any visiting relatives were interviewed. The next morning the families were visited at home by a team consisting of a doctor, a nurse, and a health inspector and any unprotected family contacts were accepted for the trial. Where there were more than two such contacts they were accepted in order of age. The name, age, date of vaccination (not usually done by the first visit), and degree of exposure were recorded and contacts were allotted in strict rotation to a previously prepared randomised schedule as a result of which they received either suspension A or suspen7714 sion B. The active suspension contained 1 g. of M & B was as identical 5 ml. and the control per suspension (placebo) as possible in colour and taste. Although the trial set out to be double-blind this proved impossible in practice since the active suspension produced nausea and vomiting in some people. The greatest care was The
therefore taken to ensure that no member of the team knew to which group, control or drug, the next unprotected contact would be allotted. In this way no bias could enter into a decision whether or not to accept a contact in whom the evidence of previous successful vaccination was doubtful. After TABLE II-THE RELATIONSHIP BETWEEN THE DAY OF DISEASE OF THE
INDEX CASE WHEN TREATMENT WAS STARTED AND THE INCIDENCE OF SMALLPOX
vascular accident; a 25-year-old female with chronic myocarditis who died of pulmonaryoedema 17 hours after admission; and a 27-year-old female who died in circulatory collapse a few minutes after coming to hospital before adequate replacement therapy could be given.
AN ISOTHIAZOLE THIOSEMICARBAZONE IN THE TREATMENT OF VARIOLA MAJOR IN MAN A Controlled Clinical Trial and
Discussion
Our experience with this large series of patients with cholera indicates that, despite a higher incidence of certain complications such as hypoglyceemia and centralnervous-system dysfunction in children, the disease is generally similar in children and adults in its clinical manifestations and response to adequate replacement
A. RAMACHANDRA RAO M.B. Madras HEALTH
Summary Cholera in children is in most respects similar to cholera in adults. An approach to therapy utilising clinical criteria combined with measurement of stool volume to determine fluid requirements, and the prompt correction of acidosis as well as sodium chloride and potassium deficits, has been used in a series of 769 patients treated in Dacca, East Pakistan. The mortality was less than 1% in both children and adults. Similar results have been obtained with this method at an isolated field treatment centre. We thank the nursing staff of the Pakistan-SEATO Cholera Research Laboratory for their excellent work and the following physicians who contributed to the care of the patients: Dr. J. Ahmed, Dr. A. K. M. J. Alam, Dr. M. M. Ali, Dr. K. M. Ally, Dr. R. K. Barui, Dr. J. Cole, Dr. Z. Haque, Dr. M. S. Islam, Dr. A. S. M. M. Rahman, Dr. M. Rahman, and Dr. M. S. Zoha. This work was supported in part by Research Agreement
no.
196802 between the National Institutes of
Health, Bethesda, Maryland, U.S.A., and the Pakistan-SEATO Cholera Research Laboratory. Requests for reprints should be addressed to Dr. John Lindenbaum, First Medical Division, Bellevue Hospital, 462 First Avenue, New York, New York, U.S.A. REFERENCES
Bullock, W. E., Phillips, R. A. (1965) Lancet, ii, 132. Carpenter, C. C. J., Mitra, P. P., Sack, R. B., Dans, P. E., Wells, S. A., Chaudhuri, R. N. (1965) ibid. i, 726. Wallace, C. K., Mitra, P. P., Sack, R. B., Mondal, A., Wells, S. A., Dans, P. E., Lewis, G. W., Chaudhuri, R. N. (1965) in Proceedings of the Cholera Research Symposium; p. 190. Washington. Gordon, R. S., Jr, Ahmed, J., Akbar, R., Alam, A. K. M. J., Ali, M., Baru, R. K., Greenough, W. B., III, Islam, M. R., Islam, M. S., Khan, A. Q., Lindenbaum, J., Rahman, A. S. M. M., Zoha, M. S. (1964) E. Pakistan med. J. 8, 10. Feeley, J. C., Greenough, W. B., III, Sprinz, H. S., Oseasohn, R. O (1966) Ann. intern. Med. (in the press). Greenough, W. B., III (1965) in Current Therapy; p. 7. Philadelphia and
OFFICER,
CORPORATION OF MADRAS
JAMES A. MCFADZEAN M.D.
Glasg.
HEAD OF THE DIVISION OF EXPERIMENTAL MAY
therapy. Clinical estimates of dehydration, without the use of direct measurements of hasmoconcentration, such as specific gravity, were found to be adequate in estimating fluid requirements, an approach that has also been used successfully in adults in Calcutta (Carpenter, Mitra et al. 1965). The results obtained in the present series did not depend on the presence of modern hospital facilities or readily available expert consultation. Similar therapeutic success has been obtained in a treatment centre located on a barge near Matlab Bazar in East Pakistan (Gordon et al. 1966) where patients are treated by young Pakistani physicians and nurses trained in our Dacca hospital wards. Cholera cots, intravenous fluids, tetracycline, and a stethoscope are available, but there are no laboratory facilities other than those for bacteriological diagnosis. During the 19-month period ending in June, 1965, 496 patients with documented V. cholerae infection were admitted. There were 4 deaths, a mortality-rate for the entire group of 0-81%; in 268 patients below the age of 10, there were 2 deaths (0-75%).
Laboratory
Investigations
& BAKER, LTD.,
CHEMOTHERAPY,
DAGENHAM
KUMARI KAMALAKSHI RESEARCH
B.Sc. ASSISTANT, INDIAN COUNCIL
FOR MEDICAL RESEARCH
THE activity of ’M&B7714’ (4-bromo-3-methylisothiazole-5-carboxaldehyde thiosemicarbazone) in experimental pox infections has been described by Slack, Wooldridge, McFadzean, and Squires (1964), Rao, McFadzean, and Squires (1965), and Westwood et al. (1966). The compound was effective against neurovaccinia and rabbit pox when administered shortly before the death of the control animals and so we decided to carry out a clinical trial of M & B 7714 in variola-major infections in man. Under the auspices of the Indian Council of Medical was assessed for therapeutic Research, M & B 7714 in with activity patients smallpox admitted to the Infectious Diseases Hospital, Madras. 1293 patients were
investigated. Controlled Clinical Trial PLAN OF TRIAL
Patients Patients were those who had been admitted to the Infectious Diseases Hospital, Tondiarpet, Madras, with smallpox. In most cases, diagnosis was clinical, but in doubtful cases this was confirmed by laboratory methods-by the demonstration of elementary bodies in smears stained by Gutstein’s technique and/or by the culture of the variola virus on the chorioallantoic membrane of the chick embryo. All patients were admitted to the trial, except: patients with hamiorrhagic smallpox (types 1 and 2) and variola sine-eruptione (type 12) (see figure);patients who were admitted during the scabbing stage; and patients who had been treated with other drugs which may have had antiviral activity. The following patients were subsequently excluded from the trial-those admitted moribund and treated but who died within 24 hours of admission and those admitted and treated but who subsequently died, before discharge, from causes other than smallpox. Smallpox cases were classified as to variety and type by the standard technique used in the hospital (see figure).
Randomisation The hospital maintains a single admission-register, in which all cases, irrespective of the infectious disease, are recorded in the order of their admittance to the hospital and given a serial hospital number. Admissions into the register are made by" non-technical clerks. Those cases of smallpox with " odd hospital numbers were allocated to the drug group and those
—
-
London. -
Gordon, R. S., Jr, Rosenberg, I. S., Davies, B. I., Benenson, A. S (1964) Lancet, i, 355.
DR. LINDENBAUM AND OTHERS:
REFERENCES—continued
Kobari, K. (1965) in Proceedings of the Cholera Research Symposium; p. 212. Washington. Lindenbaum, J., Greenough, W. B., III, Benenson, A. S., Oseasohn, R., Rizvi, S., Saad, A. (1965) Lancet, i, 1081. Mondal, A. (1965) in Proceedings of the Cholera Research Symposium; p. 213. Washington. Monsur, K. A. (1963) Bull. Wld Hlth Org. 28, 387. Wallace, C. K. (1966) Bull. Calcutta, Sch. trop. Med. (in the press). — Fabie, A. E., Mangubat, O., Velasco, E., Juinio, C., Phillips, R. A. (1964) Bull. Wld Hlth Org. 30, 795. Watten, R. H., Morgan, F. M., Songkhla, Y., Vanikiati, B., Phillips, R. A. (1959) J. clin. Invest. 38, 1879.
1069 treated with the drug. In schedule VII, only children under 12 years were treated, and therefore the maximum possible dose administered was 60 g. The age/dosage schedule was as follows: -
Since analyses of the separate schedules schedules are taken together in this report.
were
similar all the
Definitions
’
Classification of Smallpox (Madras scheme)
with " even " numbers were allocated to the placebo group, by the resident medical officer. The relevant course of tablets or suspension was then dispensed in separate containers labelled with the name of the patient along with instructions regarding administration, by the resident medical officer who was not concerned any further with the trial. Nowhere-either on the case sheet or on the dispensing container-was the hospital number or the treatment entered. Neither the observer, nor the nurses giving treatment, had access to this number, or to thmethod of treatment and thus as far as was possible the personal bias was eliminated in the study of the progress of the patient. Patients with smallpox were, however, given a smallpox serial number for reference purposes. Treatments M & B 7714.-The patients admitted to the trial in schedules l-lll were given the drug in tablet form, each tablet containing 0-5 g. In schedules iv-vn the tablets were replaced by an aqueous-type suspension, each 5 ml. of which contained 1 g. of the drug. Placebo.-The inert tablets and suspension used in all schedules were made as identical’ as possible to the drug preparations in appearance, smell, and taste. Treatment was given by the nurse in charge of the ward as per instructions, and immediate entries were made on the respective bedside records. During the trial, seven different dosage schedules were evaluated:
Vaccinated.-Those who had a visible mark of vaccination done at one time or other in their life (but not during the incubation period of the present attack) or those who had evidence of an attack of smallpox previously. Unvaccinated.-Those persons who had never been vaccinated; who were said to have been vaccinated but had no visible marks; or who were vaccinated for the first time during the incubation period of the current illness. Day of disease.-The day on which the patient became.unwell was taken as day 1 of the disease. Criteria for the Assessment The following criteria were applied in assessing the effect of the drug: (1) The fatality-rate (total and with reference to the vaccinial status, clinical type, age, and the " day of disease" on
admission). (2) The effect on the course of disease. This was undertaken only in patients admitted on or before the 4th day of the TABLE I-FATALITY-RATES IN THE TWO
GROUPS,
WITH REFERENCE TO
VACCINIAL STATUS
disease and was assessed by (a) the number of afebrile patients; (b) the mean number of febrile days; (c) the mean maximum height of temperature reached on any one day; and (d) the mean day to complete scabbing of lesions. Results
patients in the trial, 601 were controls and 692 had treatment with either tablets or suspension of Of 1293
M&B7714.
Fatality-rates The fatality-rates of the two groups were 23-3% (140 of 601) in the control group and 22-4% (155 out of 692) in the drug-treated group. Table i shows the fatality-rate with reference to out
Schedule
iv
was
an
uncontrolled trial, all
cases
being
TABLE II-FATALITY-RATE WITH REFERENCE TO AGE AND CLINICAL TYPE
(VACCINATED PATIENTS)
1070 TABLE III-FATALITY-RATE WITH REFERENCE TO AGE AND CLINICAL TYPE
vaccinial status. In the vaccinated patients the rate in the control group was 3-7% and in the drug-treated group it was 1 9 % ; in unvaccinated patients the fatality-rate in the control group was 34-5% and in the drug-treated group it was 34-7%. There is no statistically significant difference between these figures. Tables 11 (vaccinated) and III (unvaccinated) give the fatality-rates with reference to clinical type and age of the
patients.
it
(UNVACCINATED)
37-5% (116/309). For the group over 20 years the mortality in the controls was 35-7% (5/14) and 48-6% (17/35) in the drug-treated group. The average day of the disease on admission was 7-3. Consideration of the admissions up to and including day 4 shows a fatality-rate in the control group of 32-4% (12/37) and in the drug-treated group of 20% (13/65). If one considers these according to vaccinial status, in the vaccinated group the mortality-rate was nil in the controls and 3-8% (1/26) in the drug-treated group. Among unvaccinated patients the mortality in the control group was 50% (12/24) and in the drug-treated group it was 30-8% (12/39). l Effect on Course of Disease The following analyses were only undertaken on results from patients admitted on or before the 4th day of disease. The number of afebrile patients.-Table m shows the number of afebrile patients in the groups. There were none in types 3-5, 9% in the drug-treated unvaccinated types 6-8, and in types 9-11 there were only small was
’
J
In the vaccinated
patients with modified varieties (types there were no deaths in either group but 9-11, figure) in the flat varieties (types 3-5) the deaths were 5/5 in the control group and 3/7 in the drug-treated group. In types 6-8 (ordinary varieties) the fatality-rate in the control group was 2-1% (3/144) and in the drug-treated group it was 1-2% (2/172). In the unvaccinated patients, there were no deaths in the modified varieties in either group while in the " flat " varieties the fatality-rate in the control group was 100% (33/33) and in the drug-treated group it was 94-1% (48/51). In clinical types 6-8 the mortality-rate in the control group was 28-7% (99/345) and in the drug-treated group it was 27-3% (102/373). In the vaccinated patients (table 11) consideration of the age group 0-20 shows a mortality-rate in the control group of 4-3% (4/92) compared with 1% (1/100) for the drug-treated group. For patients aged 0-5 the figures are 33-3% (4/12) for the control group and 8-3% (1/12) for the drug-treated group. For patients aged more than 20 the figures are 3 2 °o (4/126) in the control group and 2-5% (4/160) in the drug-treated group. In the unvaccinated patients in the 0-20 age-group (table in) the mortality-rate was 34-4% (127/369) in the control group and 33’5% (133/397) in the drug-treated group. In the 0-5 group the mortality in the control group was 40-3% (112/278) and in the drug-treated group see
TABLE IV-DETAILS AMONG SURVIVORS OF AFEBRILE
numbers. The mean number of febrile days.-Table m also shows the mean number of febrile days and these were less in1 the drug-treated group both in the vaccinated and in thei unvaccinated. The mean maximum height of temperature on any one day. -Table iv also shows the mean maximum height of temperature reached on any one day. Little difference was observed. The mean days to complete scabbing.-Table v shows the mean number of days to scabbing. In the ordinary variety scabbing occurred earlier in the drug-treated group compared to the controls but the difference is of doubtful
significance. Toxic
Manifestations of the Drug
Nausea and
vomiting
were seen
in
some cases
but the
CASES, MEAN NUMBER OF FEBRILE DAYS AND MEAN MAXIMUM HEIGHT OF TEMPERATURE IN PATIENTS ADMITTED ON OR BEFORE THE 4TH DAY OF DISEASE
1071 TABLE V-THE MEAN DAYS TO COMPLETE SCABBING OF LESIONS
were
the
found during administration of the drug of increased serum-bilirubin.
or
during
period
Virological
Tests
Limited experiments (carried out by Dr. E. A. Boulter of the Microbiological Research Establishment, Porton, Wiltshire) early in the trial had indicated a striking reduction in the viral concentration of scabs from patients receiving the drug, in comparison with scabs from control
patients.
of administration of the drug on these grounds warranted. 6 patients, however, did refuse to accept the drug due to persistent vomiting. In some cases, prior administration of ’Stemetil’ (prochlorperazine) reduced the incidence of vomiting. There were 4 cases of allergic dermatitis, all of which responded to antihistamine treatment. 18 patients, in the drug-treated group, had " clinical jaundice " but there were no biochemical manifestations of liver damage (see below).
stopping
was not
During tests were
Clinical Laboratory Investigations the course of the trial a number of
Further scabs were examined from 16 control and 16 treated patients at roughly comparable stages and with the same clinical type of disease. Measured quantities of scabs were ground with sand and suspended in McIlvaines buffer pH 7-2 with 1% horse serum, and then titrated on the chorioallantoic membranes of eggs using the method of Westwood et al. (1957). The results are given in table vii. Scabs from half the treated group had a reduced titre of virus compared with the controls. Analysis of the figures by the Fisher-Behrens test showed that the difference in the figures just failed to reach significance. Other investigations undertaken by Dr. Boulter included titrations of haemagglutinin-inhibiting and neutralising TABLE VII-TITRATION OF VARIOLA VIRUS IN CRUSTS FROM SMALLPOX
PATIENTS
laboratory
done.
Serum-levels Serum-levels of M & B 7714 were estimated on a number of patients receiving tablets and these showed that only very low concentrations were obtained. Treatment with the drug in suspension, however, showed that form gave higher concentrations (table vi). In no investigation, however, was there a close correlation between dose and serum-concentration.
Tests for Drug Toxicity Red and white blood-cell counts were done at frequent regular intervals in both groups of patients; no abnormal changes were detected. Urine samples were also regularly examined. It was later seen during administration of larger doses of the drug that there were a number of cases of " clinical jaundice ", usually on the third or fourth day after the start of treatment and reaching a maximum between 5 and 11
days after
commencement
of
treatment.
Serum-
bilirubin began to increase within the first 3 days of treatment and reached a maximum value of between 4-11 and 9-4 mg. per 100 ml. 5-8 days after the commencement of treatment (6 g. twice daily for 5 days). In the few patients in which estimations were continued for a sufficient period, pre-treatment values were attained about 20 days after commencement of therapy. No increase in
serum-glutamic-oxaloacetic-transaminase, serum-glutamic-pyruvic-transaminase, or serum-alkaline-phosphatase TABLE VI-SERUM-CONCENTRATION AFTER INGESTION OF M EITHER AS SUSPENSION OR AS TABLETS
&
B
7714
*
Taking " negative " =0
antibodies and the titration of virus as determined by pock counts and heemagglutination in the virasmic stage of the disease. These revealed no information of significance. Discussion
suggest that M & B 7714 may, to some slight extent, have influenced the mortality-rate in the vaccinated patients, the mean number of febrile days, the time to scabbing, and the virus titre in the scabs. None of the findings was statistically significant, however, and for all practical purposes the compound has no role in the treatment of smallpox. It might be argued that the disease process in most patients in the trial had advanced well beyond the stage at which a therapeutic agent could possibly be of value. The most important toxic feature of the compound in this trial was the increase in unconjugated bilirubin. This was not, however, associated with any abnormality in liver-function tests or any other abnormality or upset. When the drug was withdrawn, the serum-bilirubin returned to normal. The most likely explanation was that the compound interferes with conjugation of bilirubin with glucuronic acid, and thus with excretion. The results
presented
1072
Summary This paper reports the therapeutic assessment in smallpox of ’ M & B 7714 ’ (4-bromo-3-methylisothiazole5-carboxaldehyde thiosemicarbazone) in a controlled double-blind trial on 1293 patients with smallpox. Assessment was made by fatality-rate (with reference to vaccinial status, clinical type, age, and day of disease on admission), the numbers of afebrile cases, the mean number of febrile days, the mean maximum height of temperature reached on any one day, and the mean day to complete scabbing of lesions. There was evidence that the drug had some beneficial effect but none of the findings
statistically significant. Apart from the increase in serum-bilirubin with high doses, some nausea and vomiting, and 4 cases of allergic dermatitis, the drug in this therapeutic trial did not present any significant toxic factors.
was
We thank the Indian Council for Medical Research under whose the clinical trials were undertaken, and especially to Dr. C. Pandit for his guidance and valuable suggestions, and the Government of India, Government of Madras, and the Commissioner of the Corporation of Madras for permission to undertake these trials; the director of the Microbiological Research Establishment, Porton Down, for facilities for carrying out a number of aspects of this investigation; and Miss Lalitha, the medical and nursing staff of the Infectious Diseases Hospital, Tondiarpet, Madras, and Mr. K. Corbett and the staff of the research group of May & Baker Ltd. for their assistance.
auspices
Requests for reprints should be addressed to Dr. J. May & Baker Ltd., Dagenham, Essex.
A. McFadzean,
REFERENCES
R., McFadzean, J. A., Squires, S. (1965) Ann. N.Y. Acad. Sci. 130, 118. Slack, R., Wooldridge, K. R. H., McFadzean, J. A., Squires, S. (1964) Nature, Lond. 204, 587. Westwood, J. C. N., Bowen, E. T., Boulter, E. A. (1966) Unpublished. Phipps, P. H., Boulter, E. A. (1957) J. Hyg., Camb. 55, 123.
Rao,
A.
-
ASSESSMENT OF AN ISOTHIAZOLE THIOSEMICARBAZONE IN THE PROPHYLAXIS OF CONTACTS OF VARIOLA MAJOR A. RAMACHANDRA RAO M.B. Madras HEALTH
OFFICER, CORPORATION OF MADRAS
G. D. W. MCKENDRICK M.A., B.M. Oxon., M.R.C.P. CONSULTANT
PHYSICIAN,
ST.
ANN’S HOSPITAL,
TOTTENHAM
L. VELAYUDHAN
KUMARI KAMALAKSHI
M.B. Madras
B.Sc.
ASSISTANT RESEARCH OFFICER
RESEARCH ASSISTANT
INDIAN COUNCIL FOR MEDICAL RESEARCH
Hamre
al. (1950) showed that certain thiosemicarbaactive against vaccinia virus and the search for more active compounds led to the development of 4-bromo3-methylisothiazole-5-carboxaldehyde thiosemicarbazone M & B 7714 ’) (Caton et al. 1965, Slack et al. 1964). This compound had a clear-cut activity against neurovaccinia and smallpox in mice when given orally (Rao et al. 1965), but a controlled therapeutic trial in smallpox in man was disappointing (Rao et al. 1965, Rao et al. 1966). Testing a similar compound, 1-methylisatin 3-thiosemicarbazone (methisazone), Bauer et al. (1963) showed a striking prophylactic effect when the drug was given in the incubation period. We decided to carry out a controlled, double-blind, prophylactic trial in smallpox contacts in the hope that administration of M & B 7714 during the et
zones were
TABLE I-THE DISTRIBUTION OF CONTACTS WITH INCIDENCE OF SMALLPOX RELATED TO AGE
incubation period might lessen the attack rate or modify the severity of the illness should smallpox be contracted. Methods
people studied were all the family contacts of smallpox patients (the index cases) admitted to the Infectious Diseases Hospital, Tondiarpet, Madras, India between February, 1964, and April, 1965, who showed no evidence of previous successful vaccination or of previous smallpox. It was felt that a much more accurate assessment of any prophylactic effect would be obtained by using only previously unprotected contacts, approximately 30% of whom could be expected to get smallpox. The definition of unvaccinated was as given by Rao et al. (1966). With the numbers involved a strict surveillance of contacts became possible. For the purposes of the trial the hospital day was defined as being 24 hours from 4 P.M. During an evening visit to the hospital all index cases admitted during the preceding 24-hour period were seen, addresses were checked, and any visiting relatives were interviewed. The next morning the families were visited at home by a team consisting of a doctor, a nurse, and a health inspector and any unprotected family contacts were accepted for the trial. Where there were more than two such contacts they were accepted in order of age. The name, age, date of vaccination (not usually done by the first visit), and degree of exposure were recorded and contacts were allotted in strict rotation to a previously prepared randomised schedule as a result of which they received either suspension A or suspen7714 sion B. The active suspension contained 1 g. of M & B was as identical 5 ml. and the control per suspension (placebo) as possible in colour and taste. Although the trial set out to be double-blind this proved impossible in practice since the active suspension produced nausea and vomiting in some people. The greatest care was The
therefore taken to ensure that no member of the team knew to which group, control or drug, the next unprotected contact would be allotted. In this way no bias could enter into a decision whether or not to accept a contact in whom the evidence of previous successful vaccination was doubtful. After TABLE II-THE RELATIONSHIP BETWEEN THE DAY OF DISEASE OF THE
INDEX CASE WHEN TREATMENT WAS STARTED AND THE INCIDENCE OF SMALLPOX