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Efficacy of co-administration of albendazole and diethylcarbamazine against geohelminthiases: a study from south india
Tropical Medicine and International Health
Efficacy of co-administration of albendazoleand diethylcarbamazine against geohelminthiases:a study from South India
T. R. Mani1, R. Rajendran1, A. Munirathinam1, I. P. Sunish1, S. Md. Abdullah2, D. J. Augustin2and K. Satyanarayana1
1 Centre for Research in Medical Entomology (Indian Council of Medical Research), Madurai, India2 Department of Public Health & Preventive Medicine, Government of Tamil Nadu, Chennai, India
The efficacy of single-dose combination drug therapy with diethylcarbamazine (DEC) plus albendazole(ALB), and single-drug therapy with DEC alone against geohelminths was compared as part of a mass drugadministration (MDA) for elimination of filariasis. This study was conducted in two blocks of VillupuramDistrict of Tamil Nadu State, India, covering a population of 321 000 including about 100 000 children1–15 years of age. Prevalence and intensity of geohelminth infection were determined by the Kato–Katztechnique immediately before and 3 weeks after the MDA. A pre-treatment cross-sectional survey wasundertaken in 18 statistically selected villages out of 204 villages, including 646 school children. About60% were infected with one or more geohelminths. The overall prevalence rates were 53.9%, 12.4% and5.7% for Ascaris lumbricoides, hookworms and Trichuris trichiura, respectively. Combination therapy(DEC + ALB) produced a cure rate of 74.3% and an egg reduction rate of 97.3% for geohelminths, whichwere higher than the corresponding rates (30.4% and 79.0%) observed in the single drug therapy arm withDEC alone. The odds of cure with combination therapy were significantly higher for roundworm(5.3 times) and hookworms (3.5 times), then odds of cure with DEC alone. Both therapies were equallyeffective against trichuriasis, recording cure rates >77% and egg reduction rates >83%. In combinationtherapy, 53.5% of the children noticed expulsion of worms after MDA, while in single drug therapy only20.9% did. Our study indicated that MDA of combination therapy was operationally feasible at thecommunity level, and it may secure higher community compliance because of its perceived benefits andenhanced efficacy against geohelminths than single-drug therapy.
keywords geohelminths, albendazole, diethylcarbamazine, ascariasis, trichuriasis, hookworms
correspondence Dr K. Satyanarayana, Centre for Research in Medical Entomology, 4, Sarojini Street,Chinna Chokkikulam, Madurai 625 002, India. E-mail: [email protected]
diethylcarbamazine (DEC) and this is being attempted in
India as a new initiative in a pilot programme (Ramaiah
Large-scale chemotherapy plays a vital role in the control
et al. 2000). Several antihelmintic drugs, especially when
of many parasitic infections such as lymphatic filariasis
given in combination, have a significant antifilarial effect
(LF), onchocerciasis, schistosomiasis and intestinal ne-
providing a number of good tools to control filariasis
matode infections (Savioli et al. 1997). The greatest
(Turner & Michael 1997). Two new drugs, ivermectin
successes were through the development of single-dose
(IVR) and albendazole (ALB), when combined with DEC,
therapy and mass treatment control programmes for a
have been shown to be highly effective in the management
number of diseases (Stephenson & Wiselka 2000).
of microfilariasis because of lymphatic filarial worms
Currently, the most practical and feasible method for
(Ottesen et al. 1999). Hence, the revised elimination
the control of LF is the rapid reduction of microfilarial
strategy for LF is designed to break the chain of
load in the community by mass annual single dose of
transmission in populations exposed to the risk of
Tropical Medicine and International Health
T. R. Mani et al. Albendazole + DEC against geohelminthiases
infection by administering a single dose of two drugs,
2000, as a part of a large-scale MDA programme for
annually for 5–6 years (Karam & Ottesen 2000).
filariasis control/elimination in 12 districts, covering a
Consequent upon the formation of the Global Alliance
population of about 27 million. During the fourth round
to Eliminate Lymphatic Filariasis, free supply of alben-
(March 2001), the Tamil Nadu Government decided to co-
dazole tablets was announced by WHO and SmithKline
administer ALB along with DEC in six districts, covering a
Beecham for mass chemotherapy along with DEC towards
population of about 14 million. However, the Villupuram
filariasis elimination [World Health Organization (WHO)
District along with five other districts received DEC alone.
1999]. About 40 million persons worldwide were expected
Thus, the fourth round MDA by the Government of Tamil
to be covered by two-drug yearly mass drug administration
Nadu during the month of March 2001 was the first round
(MDA) in the year 2001 by national programmes with two
for our new study. Two blocks, Tirukoilur and Mugaiyur
or three options for drug choices, including DEC + ALB
from Villupuram District with 204 villages and a popula-
(WHO 2001). The national programmes were expected to
tion of 321 000 (including about 100 thousand children
cover 80–90% population for five to six MDAs in this
between 1 and 15 years of age), were selected for this
endeavour, which may ultimately lead to elimination of LF,
project. The health system distributed the drugs. All
and the current status was reviewed (Das et al. 2001;
community members aged 1 year and above were targeted
for drug consumption, after a well-orchestrated health
Intestinal helminth infections are widespread, causing
education campaign in all the 12 districts. Tirukoilur Block
nutritional deficiencies and impaired childhood cognitive
was assigned for co-administration of two drugs and
development (Stephenson & Wiselka 2000). In India, most
Mugaiyur block was assigned for the administration of a
pre-school children are underweight and stunted, with
single drug (DEC) alone. In order to have baseline data for
intestinal helminth infestation being one of the contribu-
the two blocks, 24 villages from Tirukoilur and 27 villages
ting factors (Awasthi & Pande 1997). The availability of
from Mugaiyur (total of 51 villages) were screened and
drugs such as DEC and ALB, which have antihelmintic and
nine index villages were selected from each block, using
antifilarial properties, opens the possibility of integrating a
statistical considerations based on population size of the
geohelminth control programme with a filariasis control
villages. Representation was given to small, medium sized
programme, where these nematodes occur concurrently
and big villages in this selection. The baseline survey on
(Beach et al. 1999; Ananthakrishnan & Das 2001). Single
geohelminths was conducted in these 18 index villages by
doses of albendazole (600 mg) in combination with DEC
including all 18 primary schools in the area, whose
(6 mg/kg) proved to have both long-term effectiveness in
students had never been treated against helminths by any
decreasing microfilaraemia and adult filarial worm antigen
community-based programme. Within a given school,
levels in Wuchereria bancrofti infections (Ismail et al.
children aged 9–10 years were selected by a simple random
1998). Combination drug therapy with DEC + ALB has
sampling technique, to draw the necessary numbers
been suggested as a comprehensive measure to control both
(20–50) from children of that age group.
intestinal helminths and LF because of the ‘ancillary
A total of 321 school children (177 boys and 144 girls)
benefits’ of ALB and the resultant enhanced compliance of
were enlisted from Tirukoilur Block for baseline prevalence
the population at risk (Ottesen et al. 1999). However, the
assessment prior to DEC + ALB intervention. Similarly, a
current technical data does not clearly reveal the efficacy of
total of 325 school children (180 boys and 145 girls) were
the combination of DEC + ALB over DEC alone, although
examined to assess the prevalence rate for geohelminthiasis
control of intestinal worms and filariasis together, partic-
from Mugaiyur Block prior to intervention with DEC
ularly in children, could have a higher cost benefit (Das &
alone. After explaining the purpose of the study and
Pani 2000). Therefore, a two-arm community-based
obtaining informed consent from headmasters and parents,
research study was undertaken to examine the impact of
numbered sterile vials along with spatula were given to
co-administration of DEC + ALB on the prevalence and
enrolled school children, who were asked to bring a stool
intensity of intestinal helminthic infections and filarial
sample on the following day. During the distribution of the
transmission and infection in one arm, and DEC alone in
vials, the amount of stool sample needed and the collection
the other arm. The data pertaining to intestinal helminths
method by using the spatula were explained to them. Stool
are presented in this communication.
samples were collected in the morning of the next day andtransported to the laboratory and examined by the Kato–Katz technique, following World Health Organization
(WHO) recommendations (WHO 1993), to assess the
The Villupuram District of Tamil Nadu state was covered
prevalence of geohelminthiasis, species profile and
by three MDAs by single-dose DEC alone from 1998 to
Tropical Medicine and International Health
T. R. Mani et al. Albendazole + DEC against geohelminthiases
Microscopy of nematode eggs was used to diagnose a
therapy and single-drug therapy were evaluated for cure
helminthic infection, while the concentration of those eggs
rate for the three nematodes studied. Egg counts (epg + 1)
was used to estimate the intestinal worm burden in the
were transformed to common log for statistical application
host. The prevalence rate was expressed as the percentage
and are reported as the GM. The egg reduction rate was
of subjects found positive for any of the three geohelm-
expressed as the percentage GM epg reduction, i.e.
inths, viz. roundworm (Ascaris lumbricoides), hookworms
percentage fall in geometric mean epg counts. Pre- and
(Ancylostoma duodenale and Necator americanus) and
post-treatment prevalences for each geohelminths within
whipworm (Trichuris trichiura). The intensity of geo-
the two arms were compared using the chi-square test.
helminth infections was defined as eggs per gram (epg) of
Cure rates were tested by calculating log odds ratio
faeces and the mean epg was calculated as the geometric
between the two treatment arms, and Student’s t-tests
mean (GM) intensity by using the following formula:
were conducted on transformed values of intensities of
GM epg values to measure the significance of the egg
output reduction within each treatment group.
log(epg + 1) is the sum of the logarithms of each
individual epg, one egg was added to each count to permit
calculation of the logarithm in case of epg ¼ 0, and ‘n’ the
number of subjects investigated. The GM controls for thedrift in epg among untreated subjects and takes into
Among the 646 stool samples examined from the two
account the over-dispersed nature of the egg counts. In this
treatment groups of school children, the overall prevalence
procedure all children were included for calculations,
of geohelminths at enrolment was 53.9% for Ascaris,
including those without any eggs in their stool sample,
12.4% for hookworms, and 5.7% for Trichuris; 59.6% of
similar to the procedure adapted by earlier workers
all school children examined had one or more geohelmin-
(Kightlinger et al. 1995). The threshold proposed for use
thic infections. All infections were of light intensity
by a WHO Expert Committee in 1987 for the classes for
according to the WHO classification. Of the 385 infected
intensity for each helminth in stools were followed to
individuals, 79.2% had a single infection and 20.8% had
determine the classes of intensity of infections (Montresor
mixed infections. Among 77 children who had mixed
et al. 1998). According to this, light intensity infection was
infection, dual infection constituted 95% and 5% triple
defined as having < 5000 epg for roundworm, < 2000 epg
infection. Ascaris lumbricoides with hookworms was the
for hookworms and < 1000 for whipworm.
predominant dual infection (67.5%) followed by Ascaris
Three weeks after MDA (post-treatment), 541 (83.7%)
plus Trichuris (28.4%). Hookworms plus Trichuris
of the 646 children surveyed before the MDA were tested
again to assess the impact of MDA on intestinal worm
In the combination therapy group (DEC + ALB), the
burden. In order to compensate for the loss of sample
prevalence of geohelminths was 60.4%, while it was
because of examination schedules, sickness and absentee-
58.8% in single drug therapy group (Table 1). The two
ism, 131 children were selected as a replacement (age- and
treatment groups did not differ significantly, except the
sex-matched bench-mates of missing children, from among
prevalences of hookworms (16.5% vs. 8.3%; P < 0.005;
those who had participated in the MDA but who were not
Table 1). Whipworm infection was comparatively rare in
covered for stool examination in the baseline studies
both treatment groups with 5.0% and 6.8% prevalence,
earlier) bringing the total to 672 for post-MDA evaluation.
All children in the class were requested to report sightingof expelled worms after MDA, at the first survey itself, in
Reported participation and side reactions
the school. While collecting the post-MDA stool samples,a questionnaire was used to enquire whether they noticed
All the children covered in this study reported that they
expulsion of worms in stools after the MDA. The
consumed drugs assigned to their families and the local
proportion of children who had perceived the benefit of
health workers covered a small number who missed
MDA by way of seeing expulsion of worms in stools after
MDA, during mop-up operations in the schools. A
receiving MDA, were computed for each arm and were
separate questionnaire survey on about 850 households
compared. The difference in the prevalence rates for each
indicated that about 80% of the families participated in
geohelminth between pre- and post-treatment values was
this 5-day MDA (17–21 March 2001) programme, by
expressed as percentage of pre-treatment value and was
reporting consumption of tablets distributed by the
referred to as cure rate. Thus, the efficacy of combination
health system, in both arms. There were no major
Tropical Medicine and International Health
T. R. Mani et al. Albendazole + DEC against geohelminthiases
Table 1 Baseline prevalence and intensity of geohelminths
*Significantly different. Eggs per gram of stool.
adverse side reactions, although mild side-effects such as
very effective against Trichuris, each inducing cure rates
fever, giddiness and vomiting were reported in about 9%
>77% and egg reduction rates > 83%.
of participants which could be managed by the local
The odds of cure for Ascaris in DEC + ALB therapy was
health authorities. These details are being reported
5.3 times the odds of cure in DEC alone arm and the odds
ratio was significant (P < 0.001; not shown in table). Similarly, the odds of cure in the combination therapy armfor any of three helminths (5.7 times; P < 0.01) and
hookworms (3.5 times; P < 0.001) was higher than the
The prevalence and GM epg counts before and after
odds of cure in the single-drug arm.
treatment and the cure and egg reduction rates are given inTable 2. Within each arm the prevalences of individual
parasites came down significantly after the MDA, exceptfor DEC alone arm for hookworms. This is despite
A greater proportion (53.5%) of school children perceived
significantly greater prevalence for hookworms in the pre-
the benefits of expulsion of worms after the co-adminis-
treatment period in the combination therapy arm. The cure
tration of DEC + ALB and noticed expulsion of worms
rates were significantly higher in the combined therapy arm
after MDA, while only one-fifth (20.9%) gave such a
for Ascaris, hookworms and any of three worms, but not
history in DEC alone treatment group.
so for Trichuris, for which both arms were equallyeffective. The GM epg values in both arms were signifi-
cantly reduced after therapy, except for the DEC alone armfor hookworms. This pattern on intensity of worm burden
Control of filariasis in India had taken a new turn with the
was similar to the observations on the reduction of
introduction of single-dose, two-drug (DEC + ALB) mass
prevalences and both parameters behaved in a similar
administration by the Government of India on a pilot scale,
fashion. Though there were significant reductions in the
with donation of ALB by SmithKline Beecham through
GM epg in both arms, except for hookworms in the DEC
WHO (WHO 1999). We had an opportunity to study and
alone arm, there were substantial differences in the
report the role of DEC + ALB on filariasis and intestinal
magnitude of egg count reduction (egg reduction rate) for
geohelminths control, against the DEC alone arm, prob-
various parasites. The figures for any of three worms and
ably reporting for the first time from this region.
for Ascaris were similar with 18–20% difference in favour
Our data reveal that the study population of this area
of combined therapy (Table 2). Extreme patterns were seen
was infested at a moderate level, the prevalence of soil-
for hookworms on the one hand and whipworm on the
transmitted helminthiasis being about 60%. The intensity
other, the latter did not show any difference between the
of helminth infections was comparatively low and all
arms, where as in the case of hookworms a 58% difference
children had light infections according to WHO criteria. In
was observed between the two arms, registering very
general, there was higher prevalence of ascariasis and
strong benefits for combined therapy. On the whole,
low prevalence of hookworms infection and trichuriasis.
combined therapy registered higher egg reduction rates
Intensity as measured by GM epg was very low and
except for Trichuris, and the same pattern was noted for
different from other developing countries. Hall & Holland
cure rates derived from prevalences. Both treatments were
(2000) have reported that school children from Mexico,
Tropical Medicine and International Health
T. R. Mani et al. Albendazole + DEC against geohelminthiases
Madagascar, Myanmar, Nigeria, and Kenya bear a heavy
burden of infection and considerable morbidity because ofthe soil-transmitted helminthiases. The heaviest worm
burden of Ascaris in the world was reported fromMadagascar (Kightlinger et al. 1995). The GM epg value
was 675 for Ascaris in 1–10-year-old children, with an
increase with age and 10-year-old children in Madagaskar
had a GM epg value of 7161, against the very low value
(< 25 GM epg) in our study. Srinivasan et al. (1987)
observed very high prevalence (92%) but with moderate
intensity of hookworms infection (> 2000 epg) in 4% of
infected patients in South India, compared with highintensity in Nigeria (Udonsi 1984). In Nigeria, 58% of
children studied had hookworm infection and 60% hadepg counts of 10 000 or more. In the present communi-
cation, data on boys and girls and on the predisposition of
some children with higher egg output after therapy were
not taken up and these will be communicated separately.
There are limited studies comparing the efficacy of
DEC + ALB with other drugs for geohelminths control.
Ismail & Jayakody (1999) studied this combination in the
treatment of trichuriasis in Sri Lanka and Njenga et al.
(1999) in Kenya. Our current report contributes informa-
tion along with the filariasis control programme in Tamil
Nadu, India, which involves a large number of children.
The co-administration of DEC and ALB was clearly more
effective than DEC alone against Ascaris and hookworm
infections, both in terms of cure rate (74.3% vs. 30.8%;
89.5% vs. 26.0%) and egg reduction rate (96.6% vs.
76.6%; 94.2% vs. 36.1%). The pattern of results in 541
children who were examined at both the points (541 vs.
541) were similar to the results mentioned above for the
larger sample (646 vs. 672) given in Table 2. The cure rates
for Ascaris (71.4 vs. 34.0 for 541 children as against
74.3 vs. 30.8 in the larger sample) and any of three worms
(73.4 vs. 39.6 against 74.3 vs. 30.4) were similar for both
samples. Likewise, the egg reduction rates for Ascaris (91.3
vs. 76.4 as against 96.6 vs. 76.6) and for any of three
worms (94.1 vs. 78.5 as against 97.3 vs. 79.0) were similar,
hence the results for the followed-up sample (541 vs. 541)
and those for the replacement sample (646 vs. 672) were
similar. Some drop-out children returned for the post-
treatment survey, bringing the total to 672. High cure rates
and egg reduction rates of Ascaris and hookworm infection
with a single dose of ALB have been reported in many
studies (Albonico et al. 1994; Norhayati et al. 1997).
As far as trichuriasis is concerned, both treatment
regimens, viz. DEC + ALB and DEC alone produced very
similar cure rates (81.6% vs. 77.3%) and almost the same
egg reduction rates (84.0% vs. 85.6%). This shows that
addition of ALB to DEC produced no appreciable impact
on T. trichuris infection, unlike higher efficacies observed
Tropical Medicine and International Health
T. R. Mani et al. Albendazole + DEC against geohelminthiases
for the other two geohelminths. Similar findings on the
treatment for intestinal nematodes ‘good value’ even if
effect of ALB on trichuriasis have also been recorded in
25% of the children (community) are infected. The instant
Bangladesh (Hall & Nahar 1994), in Guatemala (Watkins
deworming effect of DEC + ALB may help secure higher
& Pollitt 1996) and in Thailand (Sukontason et al. 2000).
community compliance in the forthcoming MDAs, from
In a study in Sri Lanka, a significantly higher cure rate
56.5% in the second MDA in 1998 (Ramaiah et al. 2000)
(79.3%) and egg reduction rate (93.8%) was recorded
and 80% reported consumption of drugs in this study for
against trichuriasis, when ALB and IVR were co-adminis-
the fourth MDA in 2001. Community co-operation has
tered, compared with ALB alone or ALB + DEC (Ismail &
been found to be very encouraging when the LF elimin-
Jayakody 1999). In some studies, ALB alone produced a
ation programme was integrated with control of intestinal
low cure rate but higher egg reduction rate for trichuriasis
helminth infections (WHO 2000a) and benefits regarding
(Bartoloni et al. 1993; Albonico et al. 1994; Norhayati
improvement of community acceptance and co-operation
et al. 1997). High cure (67.4%) and egg reduction rates
in filariasis control programmes were forecast by Mey-
(87.0%) were also reported against trichuriasis with ALB
rowitsch & Simonsen (2001) when studying DEC treat-
in Thailand (Jongsuksuntigul et al. 1993) and a very high
ment and worm expulsion in children. The instant
cure rate (90.5%) was reported by Jagota (1986) in India.
deworming of children after ALB treatment created
In a small-scale field-based clinical trial in Kenya with
immense confidence in the community (WHO 2000a). This
21–22 children in each group, 67.4%, 71.1%, 78.8% cure
was also reflected in our study among school children, who
rates for intestinal helminths were obtained among persons
reported worm expulsions with enthusiasm. We have a
treated with DEC, ALB and a combination of the two
built-in control group with DEC alone to nullify errors, if
drugs, respectively, 6 months after treatment (Njenga et al.
any, in this kind of self-reporting by school children.
1999). In this study, the identity of helminths was not
Ottesen has stated in a meeting (WHO 2000b) that
specified and therefore we cannot directly compare data.
children stand to benefit most from the LF elimination
However, our combined therapy arm recorded similar cure
efforts. This is also the case with geohelminth control, as the
heaviest infections with worms typically occur among
Treatment with DEC alone has significant therapeutic
children aged between 5 and 14 years (Savioli et al. 1992;
effects on some enteric parasites including Ascaris (Turner
Ananthakrishnan & Das 2001) and this age group is
& Michael 1997). Our current study has also brought out
therefore most likely to benefit from treatment (Hall et al.
additional information on the efficacy of DEC against
1997).Childhood is the period when most filariasis infec-
geohelminths in a public health scale intervention. In
tion is acquired, often as much as one-third children
single-dose DEC treatment, although the cure rate was low
becoming infected before age 5 (Witt & Ottesen 2001).
in Ascaris infection (30.8%), the egg reduction was more
Sunish et al. (2002) also emphasized this aspect and
evident (76.6%). Similar results were recently reported in
proposed measurement of new infections in children
26 Tanzanian children using single-dose DEC, with 60.2%
reflected by childhood antigenaemia prevalence (CAP) as an
reduction of egg output, 7.7% cure rate for Ascaris
important indicator of a successful filariasis control pro-
infection and 10 children (38.5%) noticing expulsion of
gramme. These reviews indicate that the combined strategy
worms within 2 days after therapy (Meyrowitsch &
(DEC + ALB) for multiple disease (filariasis and geohelm-
Simonsen 2001). In our study, expulsion of worms was
inths) control can benefit children immensely and could be
noticed by 20.9% of children in DEC alone arm.
implemented in a cost-effective manner at the community
Single-dose DEC therapy could produce equivalent cure
level, as suggested by Beach et al. (1999), Cline et al. (2000)
(> 77%) and egg reduction rates (> 84%), as combination
and Stephenson & Wiselka (2000). Our results indicate that
therapy for T. trichuris. However, DEC alone gave a poor
future compliance for the overall filariasis control pro-
cure (26%) and egg reduction rate (36%) for hookworm
gramme could be improved and/or sustained because of the
infection and was definitely inferior to combination drug
higher perceived benefits felt by the beneficiary community,
therapy. Co-administration of ALB with DEC enhanced
and will help in reducing the time period required for the
most of the properties of DEC alone (> 74%) and its
control/elimination of filariasis, apart from substantial
benefits were perceived by more people (32.6%).
benefits for control of geohelminthiases.
Integrated programmes for simultaneous treatment of
In our study, the odds of cure with combination therapy
multiple diseases appear to be an efficient and cost-effective
were significantly higher than odds of cure with DEC alone
approach for addressing geohelminthiasis (Beach et al.
for roundworm (5.3 times) and hookworms (3.5 times).
1999). Periodic mass treatment is warranted when the
This was also true for odds of cure (5.7 times) for any of
prevalence of intestinal nematodes in school children
three geohelminths, between arms, giving a distinct
exceeds 50%, although Guyatt (1999) considers mass
advantage to combination therapy. The combination
Tropical Medicine and International Health
T. R. Mani et al. Albendazole + DEC against geohelminthiases
resulted in enhanced efficacy of the broad-spectrum
Cline BL, Savioli L & Neira M (2000) Introduction: opportunities
activity against geohelminths, especially against Ascaris
to work together: intestinal helminth control and programmes
and hookworms, and a greater proportion of school
to eliminate lymphatic filariasis. Parasitology 121, S3–S4.
children (53.5% against 20.9%) under the combination
Das PK & Pani SP (2000) Towards elimination of lymphatic
drug therapy of DEC + ALB perceived the benefits of
filariasis in India: problems, challenges, opportunities and newinitiatives. Journal of International Medical Science Academy
deworming. These positive factors could in turn lead to
greater participation and sustained compliance at higher
Das PK, Ramaiah RD, Vanamail P et al. (2001) Placebo-controlled
level by the community in forthcoming MDAs.
community trial of four cycles of single-dose diethylcarbamazineor ivermectin against Wuchereria bancrofti infection andtransmission in India. Transactions of the Royal Society of
Tropical Medicine and Hygiene 95, 336–341.
The study was partly supported financially by WHO/TDR,
Guyatt HL (1999) Mass chemotherapy and school-based anthel-
Geneva (ID No. A00257). This project was cleared by the
mintic delivery. Transactions of the Royal Society of Tropical
Ethical Committee of the CRME, Madurai, for protection
of human rights. The authors are grateful to Dr R. Reuben,
Hall A & Holland C (2000) Geographical variation in Ascaris
lumbricoides fecundity and the implication for helminth control.
former Director of CRME, for her constant encouragement
and guidance throughout the study. The critical comments
Hall A & Nahar Q (1994) Albendazole and infections with Ascaris
on the manuscript by Dr V. Kumaraswami, Deputy
lumbricoides and Trichuris trichiura in children in Bangladesh.
Director, TRC, Chennai, are gratefully acknowledged. The
Transactions of the Royal Society of Tropical Medicine and
authors also wish to express their thanks to the staff of
Department of Public Health & Preventive Medicine (DPH
Hall A, Orinda V, Bundy DAP et al. (1997) Promoting child health
& PM), Tamil Nadu, for their kind co-operation in
through helminth control – a way forward? Parasitology Today
conducting the field work. We acknowledge the technical
assistance of Shri S. Anbusivam and Shri C. Sundararaju
Ismail MM & Jayakody RL (1999) Efficacy of albendazole and its
and other staff members of Tirukoilur and Headquarters of
combinations with ivermectin or diethylcarbamazine (DEC) in
CRME, Madurai. We thank the school teachers, head-
the treatment of Trichuris trichiura infections in Sri Lanka. Annals of Tropical Medicine and Parasitology 93, 501–504.
masters, parents and students who have made this study a
Ismail MM, Jayakody RL, Weil GJ et al. (1998) Efficacy of single
pleasant experience. We appreciate the excellent help
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Handekzeme (HE) zählen zu den häufigsten Hauterkrankungen, wobei sie jedoch keine Differentialdiagnose erfordern. Der Schweregrad kann von sehr leichten Ausprägungen bis zu schweren chronischen Fällen reichen, die eine lang dauernde Krankschreibung erforderlich machen können und teilweise therapierefraktär sind. Chronische Handekzeme sind mit hohen Kosten und mit einem erheblichen Verlus
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