Claire Panosian

Peritonitis caused by Mycobacterium kansasii in a patient undergoing continuous ambulatory peritoneal dialysis.

Mycobacterium kansasii was isolated from the peritoneal fluid, peritoneal biopsy, and the Tenckhoff catheter of a 62-year-old woman undergoing continuous ambulatory peritoneal dialysis (CAPD) who presented with the clinical picture of peritonitis. To the best of our knowledge, this is the first case of CAPD-associated peritonitis caused by M kansasii. Routine susceptibility tests using standard concentrations of isoniazid indicated isoniazid resistance; however, the organism was inhibited in vitro by a higher concentration of this drug. The patient responded to combination therapy with isoniazid and rifampin, as well as removal of the catheter. This report emphasizes the importance of mycobacterial cultures, in certain circumstances, in patients with CAPD-associated peritonitis and the utility of quantitative in vitro susceptibility testing.

Economic Access to Effective Drugs for Falciparum Malaria

The increasing death toll from drug-resistant falciparum malaria is cause for international concern. In 2002, the US Agency for International Development commissioned the Institute of Medicine (IOM) to recommend global actions to ensure the broadest possible access to new, effective antimalarial treatments. In a report issued in 2004, the IOM Committee on Economics of Antimalarial Drugs recommended a global subsidy of 300 million dollars to 500 million dollars per year to replace increasingly ineffective drugs with coformulated artemisinin combination treatments to be distributed through public and private channels in affected areas. This approach allows the existing market to support the switch to new drugs and keeps treatment costs for consumers at levels similar to the current price of chloroquine. The leverage of an international subsidy of combination therapy can also discourage the distribution of monotherapies (such as solo artemisinins), the use of which might foster increasing resistance to antimalarial drugs in the future.

The Affordable Medicines Facility-malaria: killing it slowly

In 2002, we served on a committee for the Institute of Medicine of the US National Academy of Sciences that was asked to recommend measures for getting new and eff ective, but relatively expensive, artemisininbased antimalarials to poor populations. People were still buying chloroquine because it was cheap and available, but it was becoming less eff ective because of parasite resistance, and malaria mortality was increasing. At that time, artemisinin derivatives were highly eff ective but no other drugs in the pipeline were expected to be as good. Then, as now, most people sought malaria treatment in the private sector. Rapid diagnostic tests were available but were expensive and low quality, and WHO’s recommendation for fever in malaria-endemic areas was presumptive treatment with an antimalarial drug. The threat of resistance to artemisinin was heightened by widespread use of artemisinin mono therapies across Asia and Africa, and WHO’s entreaties to manufacturers to cease production of monotherapies were largely ignored. Only after serious deliberation on the pros and cons of making artemisinin combination treatments (ACTs), which reduce the chances that drug-resistant parasites would arise and spread, widely available—in line with WHO guidelines—did the committee recommend a subsidy to producers to make the life-saving drugs inexpensive. After a further 5 years of discussion, a fi rst phase of the Aff ordable Medicines Facility—malaria (AMFm), designed by many organisations working under the Roll Back Malaria Partnership, was hosted by the Global Fund to Fight AIDS, Tuberculosis and Malaria. AMFm was funded by the UK’s Department for International Development, UNITAID, the Bill & Melinda Gates Foundation, and the Canadian Government. In The Lancet, Sarah Tougher and colleagues report the results of an independent evaluation of an 18-month AMFm pilot in seven countries (Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania [including Zanzibar], and Uganda). In the six pilots where the programme was implemented to a substantial degree, AMFm met or exceeded benchmarks for availability, price, and market share of quality-assured ACTs. In private for-profi ts, quality-assured ACT market share at baseline ranged from 2% to 12%. There were increases in all pilots, exceeding 30 percentage points in fi ve pilots. Over 87% of quality-assured ACTs sold in this sector at endpoint were AMFm co-paid in all pilots except Niger. For comparison, executives at multinational drug companies queried before the launch of AMFm indicated that for the launch of a new product in a developing country, a market share of about 10% at 1 year and 20% at 2 years would be considered successful. Price declines in the private for-profi t sector, which accounted for between 49% and 92% of market share in these countries, ranged from US

CommentThe Affordable Medicines Facility—malaria: killing it slowly

1·28 to

ANIMAL BITES AND SCRATCHES

4·82 per dose, at an average subsidy cost to donors of a dollar per adult dose. Although AMFm had less eff ect on the public sector where there were substantial delays in ordering drugs and implementing the programme, in four countries the public sector purchased AMFmsubsidised ACTs from the private sector to avoid stockouts. AMFm was also successful in reducing relative market share of artemisinin monotherapy in the two countries where artemisinin monotherapies, which could accelerate the spread of resistance, were signifi cant in the market at baseline. The original AMFm design, already modifi ed in phase 1, must be—and can be—further aligned with the changing needs of malaria control. Declines in malaria incidence in some parts of the world, particularly east Africa, have shrunk the malaria caseload, but the need for prompt malaria treatment near the household remains. Resistance to artemisinin, which had not been detected at the time of the Institute of Medicine Published Online October 31, 2012 http://dx.doi.org/10.1016/ S0140-6736(12)61843-1

Saving lives, buying time: economics of malaria drugs in an age of resistance.

In 2002, we served on a committee for the Institute of Medicine of the US National Academy of Sciences that was asked to recommend measures for getting new and eff ective, but relatively expensive, artemisininbased antimalarials to poor populations. People were still buying chloroquine because it was cheap and available, but it was becoming less eff ective because of parasite resistance, and malaria mortality was increasing. At that time, artemisinin derivatives were highly eff ective but no other drugs in the pipeline were expected to be as good. Then, as now, most people sought malaria treatment in the private sector. Rapid diagnostic tests were available but were expensive and low quality, and WHO’s recommendation for fever in malaria-endemic areas was presumptive treatment with an antimalarial drug. The threat of resistance to artemisinin was heightened by widespread use of artemisinin mono therapies across Asia and Africa, and WHO’s entreaties to manufacturers to cease production of monotherapies were largely ignored. Only after serious deliberation on the pros and cons of making artemisinin combination treatments (ACTs), which reduce the chances that drug-resistant parasites would arise and spread, widely available—in line with WHO guidelines—did the committee recommend a subsidy to producers to make the life-saving drugs inexpensive. After a further 5 years of discussion, a fi rst phase of the Aff ordable Medicines Facility—malaria (AMFm), designed by many organisations working under the Roll Back Malaria Partnership, was hosted by the Global Fund to Fight AIDS, Tuberculosis and Malaria. AMFm was funded by the UK’s Department for International Development, UNITAID, the Bill & Melinda Gates Foundation, and the Canadian Government. In The Lancet, Sarah Tougher and colleagues report the results of an independent evaluation of an 18-month AMFm pilot in seven countries (Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania [including Zanzibar], and Uganda). In the six pilots where the programme was implemented to a substantial degree, AMFm met or exceeded benchmarks for availability, price, and market share of quality-assured ACTs. In private for-profi ts, quality-assured ACT market share at baseline ranged from 2% to 12%. There were increases in all pilots, exceeding 30 percentage points in fi ve pilots. Over 87% of quality-assured ACTs sold in this sector at endpoint were AMFm co-paid in all pilots except Niger. For comparison, executives at multinational drug companies queried before the launch of AMFm indicated that for the launch of a new product in a developing country, a market share of about 10% at 1 year and 20% at 2 years would be considered successful. Price declines in the private for-profi t sector, which accounted for between 49% and 92% of market share in these countries, ranged from US

Human antiprotozoal therapy: past, present, and future.

1·28 to

Vertebral Osteomyelitis After Intravesical Administration of Bacille Calmette-Guérin

4·82 per dose, at an average subsidy cost to donors of a dollar per adult dose. Although AMFm had less eff ect on the public sector where there were substantial delays in ordering drugs and implementing the programme, in four countries the public sector purchased AMFmsubsidised ACTs from the private sector to avoid stockouts. AMFm was also successful in reducing relative market share of artemisinin monotherapy in the two countries where artemisinin monotherapies, which could accelerate the spread of resistance, were signifi cant in the market at baseline. The original AMFm design, already modifi ed in phase 1, must be—and can be—further aligned with the changing needs of malaria control. Declines in malaria incidence in some parts of the world, particularly east Africa, have shrunk the malaria caseload, but the need for prompt malaria treatment near the household remains. Resistance to artemisinin, which had not been detected at the time of the Institute of Medicine Published Online October 31, 2012 http://dx.doi.org/10.1016/ S0140-6736(12)61843-1

Saving Lives, Buying Time

If you or your child is bitten or scratched by an animal, the wound can get infected. Clean the wound right away and get medical help as soon as possible. Even if the animal is your family pet, you should follow these steps: 1. Wash the wound well with soap and water. 2. Put pressure on the area to stop the bleeding. 3. When bleeding stops, put an antibiotic cream, such as Neosporin, on the wound. 4. Cover the bite or scratch with a clean bandage. 5. Get medical help the same day if possible. Ì Many bites are puncture wounds that can become infected if not cleaned well. Ì If any stitches are needed, they must be done within the first 12 hours after a bite. Human bites should receive the same first aid and prompt medical attention as an animal bite. Your child will be given a tetanus vaccine if he or she has not had one in the past 5 years. An adult needs the vaccine every 10 years. Follow the treatment your doctor orders. Each day, until the wound heals, remove the bandage and check the wound. Clean the wound with soap and water and put on a clean bandage until the wound heals. دحأ لبق نم شدخلا وأ ضعلل كلفط وأ تنأ تضرعت اذإ ىلعي يصرحا .ىودعلل حرجلا ضرعتي دقف ،تاناويحلا ةيبطلا ةدعاسملا ىلع لوصحلاو روفلا ىلع حرجلا فيظنت ىتح ةيلاتلا تاوطخلا عابتا كِيلع يغبني .نكمي ام عرسأب :ةرسلأل ةفيللأا تاناويحلا نم ناويحلا ناك ول