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Epilepsy in a focus of onchocerciasis in Burkina Faso
First, Malawi’s strategy has
yet, involved DOT apart from the initial intensive phase treatment in hospital. Second, the Chinese strategy seems to have relied on a resource capacity (technical, financial, and human) that is orders of magnitude greater than that available in Malawi. Thus TB suspects were initially referred to the county radiographer for screening by fluoroscopy, and only those with suspicious fluoroscopic findings proceeded to sputum submission for smear microscopy. Furthermore, every dose of the drug regimen was supervised by a village doctor on an outpatient basis (drug regimen: 2 months of streptomycin, isoniazid, pyrazinamide and rifampicin twice a week followed by 4 months of isoniazid and rifampicin three times a week). Malawi’s human resources are so restricted that its TB-control programme has only one qualified doctor on its permanent staff, and the cadre of clinicians (clinical officers and medical assistants) who might not,
as
to China’s village doctors are already heavily committed and unlikely to be able to supervise treatment on an outpatient basis nationally without a substantial increase in their numbers. On the grounds of financial restraint, Malawi has been denied antituberculous regimens containing rifampicin throughout. Further, Malawi has been unable to maintain its national quota of two Odelka cameras for mass miniature radiography screening, and would be hard-pushed to guarantee the consumables required (eg, continuous electricity supply) at district level to allow fluoroscopy for all TB suspects. Third, the strategy used in Malawi showed cure rates of 75-80% in the mid-1980s, which fell to 60-70% in the 1990s (national TB programme reports, 1992-95). This fall in cure rates coincided with increasing HIV seroprevalence levels that are unheard of in China.
approximate
*S Bertel Squire,
Anthony
interviewed. Those people with at least two episodes of seizures were considered to be epileptic. These people were examined by a neurologist. Five villages were screened and 1424 subjects examined, of whom 1062 were 15 years old above. and Among these, positive skin-snip for onchocerciasis were found in 135 people. There were 16 epileptics identified, two of whom had a positive skin-snip for onchocerciasis.
The prevalence of epilepsy in this area is 1-5% (95% CI 0-9-2-3%), which is little different from a non-endemic area for onchocerciasis surveyed earlier, where we found a prevalence of 1-06%. The prevalences of onchocerciasis in
the epileptic and non-epileptic groups were not significantly different (p=0-67, Fisher’s exact tests). In this study, no association between onchocerciasis and epilepsy was demonstrated. *J K
Faculté des Sciences de la Santé, Ouagadougou, Burkina Faso, Direction du Programme de Dévolution, Ministère de la Santé, Ouagadougou, and *Institut de Neurologie Tropicale, Faculté de Médecine, 2 Rue Du Docteur Marcland, 87025 Limoges, France
1
2
3
D Harries
*Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK; and Department of Medicine, College of Medicine, Chichiri, Blantyre, Malawi
4 5
1
China Tuberculosis Control Collaboration. Results of directly observed short-course chemotherapy in 112 842 Chinese patients with smear-positive tuberculosis. Lancet 1996; 347: 358-62.
Epilepsy in
a
focus of onchocerciasis in
Burkina Faso have noted a possible association between onchocerciasis and epilepsy in western Uganda,’-3 and a WHO expert committee on onchocerciasis control has suggested studies to clarify the relation between the two diseases.4 Burkina Faso, was a hyperendemic area for onchocerciasis in the 1970s (prevalence more than 60%) but since the Onchocerciasis Control Programme (OCP), the prevalence and incidence has greatly decreased. Currently, onchocerciasis exists at a hypoendemic level.4 We studied the prevalence of epilepsy in a focus of onchocerciasis in collaboration with an ongoing survey carried out by the National Team Against Onchocerciasis in villages bordering the river Bougouriba. After doing a census of the village population for the diagnosis of onchocerciasis, we used OCP methodology (two skin-snips taken from iliac crests of each villager were examined after 30 min incubation in distilled water for the presence and number of Onchocerca volvulus microfilariae; a second microscopic reading was done 24 h later for all negative samples; and a control examination was performed by another technician on each sample). Adhering to the WHO protocol for the diagnosis of the main neurological diseases in developing countries, all villagers aged 15years and above were
SiR-Reports
836
Kabore, J W Cabore, Z Melaku, M Druet-Cabanac,
P M Preux
Ovuga E, Kipp W, Mungherera M, Kasoro S. Epilepsy and retarded growth in a hyperendemic focus on onchocerciasis in rural Western Uganda. East Afr Med J 1992; 69: 554-57. Kilian AHD. Onchocerciasis and epilepsy. Lancet 1994; 343: 983. Kipp W, Kasoro S, Burnham G. Onchocerciasis and epilepsy in Uganda. Lancet 1994; 343: 183-84. WHO Expert Committee on Onchocerciasis. Onchocerciasis and its control. WHO Tech Rep Ser 1995: no 852. Schoenberg BS. Clinical neuroepidemiology in developing countries: neurology with few neurologists. Neuroepidemiology 1987; 3: 143-53.
Safety of tamoxifen SIR-I am concerned that Choo (Feb 17, p 458)’ should echo the "unease" of unspecified critics who believe that tamoxifen deserves "a much fairer assessment" than it is apparently expected to receive at the hands of the International Agency for Research on Cancer (IARC) during the Monographs meeting (Feb 13-20) to assess whether tamoxifen might be carcinogenic. Who are these critics? Why should they be pressing for tamoxifen to be treated any differently from any of the 800 other drugs, chemicals, and exposures that have been evaluated for their carcinogenicity in the Monographs programme over the past 20 years? Who exactly, your readers may wonder, is exposed to "the danger that tamoxifen might be replaced uncritically by [an antioestrogen] that is thought to be safer but for which there is much less human data on toxicity and effectiveness"? But let us take the item at face value. It is not enough to say that the carcinogenicity of tamoxifen should not be evaluated because it saves the lives of many women with breast cancer (which it obviously and mercifully does). Noone is seriously suggesting that tamoxifen should be withdrawn for the treatment of breast cancer even if it were adjudged to be a human carcinogen by IARC. Many drugs in the chemotherapeutic arsenal are classed as carcinogens
by IARC, including azathioprine, chlorambucil, methylCCNU, cyclosporin, cyclophosphamide, melphalan, MOPP, and other combined chemotherapy regimens that include alkylating agents-not to speak of radiotherapy. These treatments will continue to be prescribed as long as doctors and their patients judge that the benefit is worth the risk-
yet, involved DOT apart from the initial intensive phase treatment in hospital. Second, the Chinese strategy seems to have relied on a resource capacity (technical, financial, and human) that is orders of magnitude greater than that available in Malawi. Thus TB suspects were initially referred to the county radiographer for screening by fluoroscopy, and only those with suspicious fluoroscopic findings proceeded to sputum submission for smear microscopy. Furthermore, every dose of the drug regimen was supervised by a village doctor on an outpatient basis (drug regimen: 2 months of streptomycin, isoniazid, pyrazinamide and rifampicin twice a week followed by 4 months of isoniazid and rifampicin three times a week). Malawi’s human resources are so restricted that its TB-control programme has only one qualified doctor on its permanent staff, and the cadre of clinicians (clinical officers and medical assistants) who might not,
as
to China’s village doctors are already heavily committed and unlikely to be able to supervise treatment on an outpatient basis nationally without a substantial increase in their numbers. On the grounds of financial restraint, Malawi has been denied antituberculous regimens containing rifampicin throughout. Further, Malawi has been unable to maintain its national quota of two Odelka cameras for mass miniature radiography screening, and would be hard-pushed to guarantee the consumables required (eg, continuous electricity supply) at district level to allow fluoroscopy for all TB suspects. Third, the strategy used in Malawi showed cure rates of 75-80% in the mid-1980s, which fell to 60-70% in the 1990s (national TB programme reports, 1992-95). This fall in cure rates coincided with increasing HIV seroprevalence levels that are unheard of in China.
approximate
*S Bertel Squire,
Anthony
interviewed. Those people with at least two episodes of seizures were considered to be epileptic. These people were examined by a neurologist. Five villages were screened and 1424 subjects examined, of whom 1062 were 15 years old above. and Among these, positive skin-snip for onchocerciasis were found in 135 people. There were 16 epileptics identified, two of whom had a positive skin-snip for onchocerciasis.
The prevalence of epilepsy in this area is 1-5% (95% CI 0-9-2-3%), which is little different from a non-endemic area for onchocerciasis surveyed earlier, where we found a prevalence of 1-06%. The prevalences of onchocerciasis in
the epileptic and non-epileptic groups were not significantly different (p=0-67, Fisher’s exact tests). In this study, no association between onchocerciasis and epilepsy was demonstrated. *J K
Faculté des Sciences de la Santé, Ouagadougou, Burkina Faso, Direction du Programme de Dévolution, Ministère de la Santé, Ouagadougou, and *Institut de Neurologie Tropicale, Faculté de Médecine, 2 Rue Du Docteur Marcland, 87025 Limoges, France
1
2
3
D Harries
*Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK; and Department of Medicine, College of Medicine, Chichiri, Blantyre, Malawi
4 5
1
China Tuberculosis Control Collaboration. Results of directly observed short-course chemotherapy in 112 842 Chinese patients with smear-positive tuberculosis. Lancet 1996; 347: 358-62.
Epilepsy in
a
focus of onchocerciasis in
Burkina Faso have noted a possible association between onchocerciasis and epilepsy in western Uganda,’-3 and a WHO expert committee on onchocerciasis control has suggested studies to clarify the relation between the two diseases.4 Burkina Faso, was a hyperendemic area for onchocerciasis in the 1970s (prevalence more than 60%) but since the Onchocerciasis Control Programme (OCP), the prevalence and incidence has greatly decreased. Currently, onchocerciasis exists at a hypoendemic level.4 We studied the prevalence of epilepsy in a focus of onchocerciasis in collaboration with an ongoing survey carried out by the National Team Against Onchocerciasis in villages bordering the river Bougouriba. After doing a census of the village population for the diagnosis of onchocerciasis, we used OCP methodology (two skin-snips taken from iliac crests of each villager were examined after 30 min incubation in distilled water for the presence and number of Onchocerca volvulus microfilariae; a second microscopic reading was done 24 h later for all negative samples; and a control examination was performed by another technician on each sample). Adhering to the WHO protocol for the diagnosis of the main neurological diseases in developing countries, all villagers aged 15years and above were
SiR-Reports
836
Kabore, J W Cabore, Z Melaku, M Druet-Cabanac,
P M Preux
Ovuga E, Kipp W, Mungherera M, Kasoro S. Epilepsy and retarded growth in a hyperendemic focus on onchocerciasis in rural Western Uganda. East Afr Med J 1992; 69: 554-57. Kilian AHD. Onchocerciasis and epilepsy. Lancet 1994; 343: 983. Kipp W, Kasoro S, Burnham G. Onchocerciasis and epilepsy in Uganda. Lancet 1994; 343: 183-84. WHO Expert Committee on Onchocerciasis. Onchocerciasis and its control. WHO Tech Rep Ser 1995: no 852. Schoenberg BS. Clinical neuroepidemiology in developing countries: neurology with few neurologists. Neuroepidemiology 1987; 3: 143-53.
Safety of tamoxifen SIR-I am concerned that Choo (Feb 17, p 458)’ should echo the "unease" of unspecified critics who believe that tamoxifen deserves "a much fairer assessment" than it is apparently expected to receive at the hands of the International Agency for Research on Cancer (IARC) during the Monographs meeting (Feb 13-20) to assess whether tamoxifen might be carcinogenic. Who are these critics? Why should they be pressing for tamoxifen to be treated any differently from any of the 800 other drugs, chemicals, and exposures that have been evaluated for their carcinogenicity in the Monographs programme over the past 20 years? Who exactly, your readers may wonder, is exposed to "the danger that tamoxifen might be replaced uncritically by [an antioestrogen] that is thought to be safer but for which there is much less human data on toxicity and effectiveness"? But let us take the item at face value. It is not enough to say that the carcinogenicity of tamoxifen should not be evaluated because it saves the lives of many women with breast cancer (which it obviously and mercifully does). Noone is seriously suggesting that tamoxifen should be withdrawn for the treatment of breast cancer even if it were adjudged to be a human carcinogen by IARC. Many drugs in the chemotherapeutic arsenal are classed as carcinogens
by IARC, including azathioprine, chlorambucil, methylCCNU, cyclosporin, cyclophosphamide, melphalan, MOPP, and other combined chemotherapy regimens that include alkylating agents-not to speak of radiotherapy. These treatments will continue to be prescribed as long as doctors and their patients judge that the benefit is worth the risk-