Eldryd Parry

Endomyocardial Fibrosis: Still a Mystery after 60 Years

The pathologist Jack N. P. Davies identified endomyocardial fibrosis in Uganda in 1947. Since that time, reports of this restrictive cardiomyopathy have come from other parts of tropical Africa, South Asia, and South America. In Kampala, the disease accounts for 20% of heart disease patients referred for echocardiography. We conducted a systematic review of research on the epidemiology and etiology of endomyocardial fibrosis. We relied primarily on articles in the MEDLINE database with either “endomyocardial fibrosis” or “endomyocardial sclerosis” in the title. The volume of publications on endomyocardial fibrosis has declined since the 1980s. Despite several hypotheses regarding cause, no account of the etiology of this disease has yet fully explained its unique geographical distribution.

Prevalence and associated factors of atopic dermatitis symptoms in rural and urban Ethiopia

Background Allergic diseases, including atopic dermatitis (AD), are increasingly becoming a clinical problem in developing countries.

Allergic Complications of Meningococcal Disease I—Clinical Aspects

Out of 717 patients with meningococcal disease 53 showed one or more of the three allergic complications: 47 (6·6%) developed arthritis, 12 (1·7%) developed cutaneous vasculitis, and 6 developed episcleritis. These complications, which were often multiple, occurred six to nine days after the beginning of the illness and three to six days after the start of successful antibiotic therapy. Those patients with severe systemic disease were prone to the complications. Histological and bacteriological study of the arthritis and vasculitis showed that these lesions were probably not due to persisting infection and suggested that they might be due to immune complex disease.

Working together to rebuild health care in post-conflict Somaliland

In 1991, the Somali National Movement fighters recaptured the Somaliland capital city of Hargeisa after a 3-year civil war. The government troops of the dictator General Mohamed Siad Barre fled south, plunging most of Somalia into a state of anarchy that persists to this day. In the north of the region, the redeclaration of independence of Somaliland took place on May 18, 1991. Despite some sporadic civil unrest between 1994 and 1996, and a few tragic killings of members of the international community, the country has enjoyed peace and stability and has an impressive development record. However, Somaliland continues to await international recognition. The civil war resulted in the destruction of most of Somalilands health-care facilities, compounded by mass migration or death of trained health personnel. Access to good, affordable health care for the average Somali remains greatly compromised. A former medical director of the general hospital of Hargeisa, Abdirahman Ahmed Mohamed, suggested the idea of a link between Kings College Hospital in London, UK, and Somaliland. With support from two British colleagues, a fact-finding trip sponsored by the Tropical Health and Education Trust (THET) took place in July, 2000, followed by a needs assessment by a THET programme coordinator. Here, we describe the challenges of health-care reconstruction in Somaliland and the evolving role of the partnership between Kings College Hospital, THET, and Somaliland within the context of the growing movement to link UK NHS trusts and teaching institutions with counterparts in developing countries.

Proximity of the home to roads and the risk of wheeze in an Ethiopian population

Background: There is widespread public concern that exposure to road vehicle traffic pollution causes asthma, but epidemiological studies in developed countries have not generally confirmed a strong effect and may have underestimated the risk as a result of relatively high and widespread exposure to traffic in everyday life. Aims: To investigate the effect of living close to a traffic bearing road on the risk of wheezing in Jimma, Ethiopia where road traffic is generally low and restricted to a limited network of roads. Methods: Data have been previously collected on respiratory symptoms, allergic sensitisation, and numerous demographic and lifestyle factors in a systematic sample of inhabitants of Jimma town. In 2003 the homes of these people were retraced; the shortest distance to the nearest surfaced road, and traffic flows on these roads were measured. Results: Distance measurements were collected for 7609 (80%) individuals. The overall prevalence of wheeze was similar in those living within 150 m of a road compared to those living further away (3.9% v 3.7%), but among the 3592 individuals living within 150 m, the risk of wheeze increased significantly in linear relation to proximity to the road (adjusted odds ratio = 1.17 per 30 m proximity, 95% CI 1.01 to 1.36). This relation was stronger, though not significantly so, for roads with above median traffic flows. Conclusion: These findings indicate that living in close proximity to road vehicle traffic is associated with an increased risk of wheeze, but that other environmental factors are also likely to be important.

Peri-partum Cardiac Failure

The syndrome of peri-partum cardiac failure (PPCF) has been studied in 224 women seen in three years in Zaria, in northern Nigeria. A very high proportion were rural Hausa patients. There was a seasonal peak in July, and the incidence was about one per cent of deliveries. The risk increased with both age and parity. Symptoms began most commonly in the second week after delivery, and admission was commonest in the fourth. Typical signs of cardiac failure were found, and pulsus alternans, atrio-ventricular valvular incompetence, transient systemic hypertension and splenomegaly were common. The chest radiograph showed marked cardiomegaly, and extrasystoles and inverted T waves were often present in the electrocardiogram (ECG). Hypoalbuminaemia was common. Digoxin and diuretics were rapidly effective, causing a mean weight loss of 29 per cent in 15 days, resolution of hypertension, and a fall in the cardio-thoracic ratio (CTR) from 61 to 53 per cent. During the first year after diagnosis, the CTR became normal in 82 per cent of patients, and the ECG in 60 per cent. PPCF recurred, again with the same seasonal variation, after 19 per cent of subsequent pregnancies. During follow up for two to five years, 22 per cent of the women became hypertensive, and 11 per cent died. The prognosis was worst in those with an arrhythmia, hypertension, sustained cardiomegaly or aged 30 or more. Asymtomatic post-partum hypertension (PPHT) was found in 61 per cent of normal Hausa women, with a seasonal peak in May, especially in those with hypertension during pregnancy or labour, and twin pregnancies. Peri-partum cardiac failure may be due to the combined pressure load of PPHT, the volume load from eating the customary sodium-rich kanwa, and the cardiovascular demands of heat, both climatic and traditionally self-imposed.

Death from rheumatic heart disease in rural Ethiopia.

In their Seminar, Jonathan Carapetis and colleagues (July 9, p 155) identify the need for more and better data on acute rheumatic fever (ARF) and rheumatic heart disease (RHD), particularly in low-income and middle-income countries. In rural Ethiopia, the prevalence of RHD in schoolchildren is about 4·6 per 1000 and recent research showed a mean age at death of 25·9 years in hospital inpatients. Secondary prophylaxis with a regular injection of penicillin every 3 or 4 weeks is a proven and the most cost-effective approach to the control of ARF and RHD, since primary prophylaxis is difficult to establish and vaccine development is still years away. At Dabat Health Centre in the North Gondar Administrative Zone, Ethiopia, patients with ARF and RHD have been enrolled in a follow-up and secondary prevention programme since 1998. Patients are included after seeking health care because of symptomatic ARF or RHD. In April, 2005, a survey was done to assess mortality and patients’ reasons for defaulting from follow-up. Patients or their family members were traced by trained staff and were interviewed at their homes. A pretested and validated questionnaire was used. Defaulting was defined as no return to follow-up for more than 6 consecutive months (follow-up intervals varied since the start of the programme). 43 patients have been enrolled in the secondary prevention programme in the past 7 years, of whom 34 defaulted and nine still attended. Of the 34 patients who had not been seen at follow-up, 16 families were traced and interviewed; among these, eight patients had already died. Of the nine attending patients, eight families could be traced and two patients had died during follow-up. The overall mortality rate in patients with RHD was 125·3 per 1000 personyears (95% CI 67·4–232·9) since the start of follow-up, and the mean age at death was 22·0 years (2·7). We assumed that RHD was the cause of death in patients previously diagnosed with the disorder. The mortality rate from RHD could be an overestimate because other causes of death could not be established (eg, by verbal autopsy), and the low proportion of successfully traced patients (55·8%) could have introduced selection bias. However, according to our data, there is no reason to assume that the nonrespondents showed a different mortality rate. Our results suggest an annual mortality rate of 12·5% in patients with RHD in this community, which contrasts strikingly with the annual mortality rate of 1·5% used in a further report by Carapetis and colleagues to estimate the current worldwide annual mortality (233 000–294 000) from RHD. Our results show that this povertyrelated disease is an unrestrained killer of young adults. We also show how precarious and difficult follow-up can be for rural people, even when care and regular penicillin prophylaxis are given through trained staff near the homes of the patients. The only effective way to reduce the significant death toll of RHD is through population-based disease registries integrated into an easily accessible, comprehensive primary healthcare structure which ensures regular secondary prophylaxis after the first episode of ARF. This is the theory; in practice, as we have found, it is difficult to achieve.

Meningococcal antigen in diagnosis and treatment of group A meningococcal infections

Meningococcal antigen was measured by countercurrent immunoelectrophoresis in the blood and cerebrospinal fluid of 200 patients with group A meningococcal meningitis. Antigen was detected in the blood of 27 (13.5 per cent) patients. These patients had a worse prognosis and a higher incidence of allergic complications, such as arthritis and vasculitis, about 5 days after the start of antibiotic treatment. Antigen was found in the CSF of 129 (67.5 per cent) patients); antigen often persisted in the cerebrospinal fluid despite antibiotic treatment before admission. A combination of immunoelectrophoresis and routine bacteriologic study was used in the diagnosis of 162 (84.8 per cent) patients with meningococcal meningitis. High levels of antigen and a slow antigen disappearance were associated with neurologic damage. The antigen is stable and may be detected from specimens of cerebrospinal fluid dried on filter paper.

Trial of Chloramphenicol for Meningitis in Northern Savanna of Africa

In a controlled trial chloramphenicol proved as effective and much cheaper than penicillin for the treatment of group A meningococcal meningitis in Zaria, Nigeria. A short course of five days cured most patients. Adults and older children were soon able to take chloramphenicol by mouth, which reduced the cost and simplified treatment. It is suggested that chloramphenicol is a suitable alternative to sulphonamides for the treatment of meningococcal meningitis in those parts of Africa where the organism is sulphonamide-resistant.

Tropical medicine for the 21st century

The specialty of tropical medicine originated from the needs of the colonial era and is removed from many of the health care requirements of tropical countries today. Tropical medicine concentrates on parasitic diseases of warm climates, although other infections and diseases related to poverty rather than climate dominate medicine in developing countries challenged by population pressure, civil strife, and migration. In the new century, tropical medicine would best be absorbed into the specialty of infectious diseases, which should incorporate parasitic diseases, travel medicine, and sexually transmitted diseases. Pressing questions for health care and research in developing countries concern the provision of appropriate services for problems such as HIV/AIDS, tuberculosis, sexually transmitted diseases, and injuries. The question of how to provide appropriate clinical care in resource poor settings for the major causes of morbidity and premature mortality has been neglected by donors, academic institutions, and traditional tropical medicine.