Rev. Soc. Bras. Med. Trop. vol.10 número6

EXPERIENCE IN BRAZIL WITH THE USE OF AVAILABLE

SHISTOSOM ICIDES IN MASS TREATM ENT CAM PAIGNS

Aluizio Prata*

I N T R O D U C T I O N

M ass t r e a t m e n t f o r sch ist o so m ia si s id e a l ly r e f er s t o t h e u n iv e r sal t r e a t m e n t o f w h o le p o p u la t io n s li v i n g in e n d e m ic ar e as, h o w e v e r as n o n t o x i c d r u gs ar e n o t y e t a v a ila b le f o r sc h ist o so m ia sis, t r e a t m e n t sh o u ld n o t a p p ly t o ali m e m b e r s o f su ch c o m m u n it ie s as w it h m alar ia. V i a n n a M a r t in s1 5 d e f in e s i t as b e in g a sim u lt a n e o u s o r a l m o st si m u lt a n e o u s t r e a t m e n t o f a .la r ge n u m b e r o f p eo p le r e p r e se n t at iv e o f a p o p u la t io n . A l t h o u g h t h e la ck o f sin gle d o se t h e r a p y in t h e p ast m ad e it d i f f i c u l t t o e st a b lish m ass t r e a t m e n t f o r sc h ist o so m ia sis, p r o gr am m e s h ave b een ca r r ie d o u t w h ic h c o u ld b e co n sid e r - ed as m ass t r e a t m e n t s, r e a ch in g lar ge m e m b e r s o f p e o p le i n f e ct e d b y

Schistosoma

in a w e ll d e f in e d p o p u la t i o n .

Pr o gr am e s o f M ass Tr e a t m e n t in B r a zil

Antimony compounds.

H e r a ld o M a c ie l14 f i r st u sed a n t i m o n y c o m p o u n d s in B r a zil f o r m ass t r e a t m e n t o f sch i st o so m ia sis. H e t r e a t e d 1 .0 6 3 sa ilo r s ( 9 % o f t h e B r a zil ia n N a v y ) in t h e p e r io d o f 1 9 2 3 — 1 9 2 8 . Ta r t a r e m e t ic w as u se d in a t o t al d o se o f 0 .9 5 g in t r a v e n o u sly a d m in ist e r e d o ver a p e r io d o f t en d a y s. H e c la im e d 9 2 % su ccess in t h e r a p y .

In 1 9 4 3 , t r e a t m e n t o f sch i st o so m ia sis b eca- m e c o m p u l so r y in t h e v il la ge o f Ca t e n d e in t h e st at e o f Pe r n a m b u c o 1 0 . Se v e n t h o u san d p e o p le w er e e x a m in e d an d 4 ,1 7 1 w er e f o u n d t o h ave

Schistosoma

eggs in t h e ir st o o ls. In t h e p e r io d o f 1 9 4 3 t o 1 9 4 7 , 3 ,5 3 9 p e o p le st ar t ed t r e a t ­ m e n t o f w h ic h 3 ,3 3 4 co m p le t e d it . T h e d r u g u se d w as t a r t a r e m e t ic. O n ly o n e d eat h w as r e p o r t e d . A l t h o u g h t h i s f o r m o f t r e at m e n t w as n o t w id e ly a cce p t e d in t h e p e r io d o f 1 9 4 9 t o 1 9 5 2 , 5 8 2 m o r e p e o p le w e r e t r e at e d . Th e e f f i c a c y o f t h is t h e r a p y w as assessed b y st o o l e x a m in a t io n s in t h e t h r e e m o n t h s f o l lo w i n g t h e r a p y , a n d si x t y f o u r p e r ce n t o f t r e at ed p a t ie n t s w e r e f o u n d t o h ave n e gat ive st o o ls.

Fr o m 1 9 5 1 o n w ar d s, Se t t e 18 se t u p a lo n g t e r m f o l lo w - u p t o assess t r e a t m e n t o f sc h ist o so ­ m iasis in Cat e n d e . He r e v ie w e d 1 ,0 9 4 t r e at e d p a t ie n t s a n d co m p a r e d t h e m w it h a sim ila r gr o u p o f n o n t r e a t e d p a t ie n t s; h e f o u n d t h a t 4 0 % o f t h e t r e a t e d gr o u p st ill p assed eggs in st o o ls as co m p a r e d t o 6 6 % in t h e c o n t r o l gr o u p . Li v e r f u n c t io n t e st s w er e b e t t e r in t h e t r e at e d gr o u p , an d o n l y 1 .7 % o f p at ie n t s p r o gr e sse d t o t h e h e p a t o sp l e n i c f o r m as co m p a r e d t o 9 % in t h e n o n t r e at e d gr o u p . Si n c e h ist o p a t h o lo gica l e x a m in a t io n s h ad b een ca r r ie d o u t as a r o u t in e in t h o se w h o d ie d in t h e ar ea b ef o r e an d af t e r in t r o d u t io n o f c o m p u l so r y t h e r a p y f o r sch ist o

-Internacional Conference on Schistosomiasis Cairo, October 18-25, 1975

Organized by the Ministry of Health of Egypf

356

Rev. Soc. Bras. Med. Trop.

Vol. X N?6

so m iasis, it w as p o ssib le t o a n a ly se t h e p r e vale n - ce o f sc h i st o so m o t ic le sio n s in t h e p o p u la t io n , It w as f o u n d t h a t su ch le sio n s w er e p r e v a le n t in t h e o r d e r o f 1 6 .5 % b ef o r e t r e a t m e n t an d 1 1 .5 % a f t e r t r e at m e n t . A s f a r as h e p a t ic f i b r o si s is co n ce r n e d , it s p r e v ale n ce w as 5 .4 % b e f o r e t r e at m e n t an d 1 .3 % af t e r t r e a t m e n t A l t h o u g h t h is d a t a ar e v e r y im p o r t a n t , h is c o n t r o l gr o u p s w er e t o o sm a ll (so m e t im e s o n l y 2 5 cases) t o e n ab le u s t o d r a w a n y d e f i n it e co n c lu si o n s. I t is n o t e w o r t h y t h a t in t h e v illa ge o f Cat e n d e , t o ge t h e r w it h t h e c o m p u l so r y t r e a t m e n t f o r sch ist o so m ia sis, a h y gie n e e d u c a t io n cam p a ign w as se t u p an d m o l u sci ci d e s w er e i n t r o d u ce d , a lt h o u gh t h e se m e asu r e s w e r e n o t c o n t i n u e d 1 8 .

A f t e r t h e d isco v e r y o f an e n d e m ic ar ea in t h e t o w n o f A r a x á , St a t e o f M in as G e r a is, ali t h o se p assin g

Schistosoma

eggs in st o o l s w er e t r e at e d u sin g n e o -an t im o sa n . A y e a r lat e r , Ro d r igu e s d a Si l v a 1 9 sh o w e d t h a t 8 5 % o f t r e at ed p a t ie n t s w er e st i ll p assin g eggs in t h e ir st o o ls. Su c h a h igh p r e va le n ce o f p o sit iv e st o o l e x a m in a t io n s c o u ld w e ll b e e x p la in e d h o w e v e r b y e it h e r r e -i n f e ct io n o r f a ilu r e in t h e r a p y . T h e sam e h igh p r e v a le n ce o f p o sit iv e st o o l e x a m in a ­ t io n s a f t e r t r e a t m e n t w as f o u n d in t h e v il la ge o f

Re d e n ção , in t h e st at e o f Ce ar á. Ro d r i gu e s d a Sil v a co m m e n t in g o n t h is sa y s t h a t r e -in f e ct io n m ay w e ll e x p la in t h e h igh p r e v ale n ce o f p o sit iv e st o o l e x a m in a t io n s in p a t ie n t s t r e at e d in Re d e n ­ ção , w h er e as in A r a x á f a ilu r e in t h e r a p y c o u ld w ell be t h e ca se 2 1 . N e o -a n t im o sa n h o w e v e r w as su cc e sf u ll y u se d in Fo r d la n d ia , in t h e st at e o f Pará. O n e h u n d r e d a n d t h i r t y p a t ie n t s o u t o f a p o p u la t io n o f 2 .0 0 0 w e r e t r e a t e d in t h e p e r io d o f 1 9 5 4 t o 1 9 5 6 an d in 1 9 6 2 o n l y 1 9 p a t ie n t s w er e f o u n d t o p ass sch ist o so m a eggs in t h e ir st o o ls. Th e se w er e t r e a t e d 9 , an d n o w Fo r d l a n ­ d ia is n o lo n ge r an e n d e m ic ar ea.

B y 1 9 5 6 , 1 5 ,0 0 0 p a t ie n t s in t h e N o r t h e a st o f B r a zil h ad b ee n t r e at e d b y t h e M in ist r y o f H e a lt h t h r o u gh a n a t io n a l ca m p a ig n 2 0 ; 1 0 ,0 0 0 m o r e w er e t r e at e d in 1 9 5 7 2 2 . Th e d r u gs u sed w er e: 1) N e o -an t im o san in a t o t al d o se o f 1 m l (8 .5 m g Sb +++) p er k g. b .w . in t r a m u scu la r - ly o v e r a p e r io d o f 12 d a y s; 2 ) A n t i m o n y d im e r cap t o su ccin at e in a d o se o f 4 0 m g/ k g.b .w . ín t r a m u sc u la r l y o v e r si x d a y s; 3 ) So d i u m a n t i ­ m o n y I glu co n a t e in a d o se o f 17 m g/ k g.b .w . in t r av e n o u sly o ve r si x d a y s. A b o u t 8 0 % o f p at ien t s co m p le t e d t r e a t m e n t an d o n l y o n e d eat h w as r e p o r t e d 2 0 . T h e cu r e r at e w as assessed b y f o u r st o o l e x a m in a t io n s in t h e f o u r m o n t h s f o l lo w i n g t r e a t m e n t an d w as f o u n d t o b e 7 0 % 1 6 . T h i s t r e am e n t w as ca r r ie d o u t b y lo cal cl i n i c s, o n e o f t h e m (It a p o r a n g a ) h ad

6 ,0 0 0 p at ie n t s. Ro d r i gu e s d a Si l v a 22 a n a ly sin g t h e r e su lt s o f t h i s ca m p a ig n st r e sse d t h a t t h e e ld e r l y gr o u p o f t r e at e d p a t i e n t s p r e se n t e d h igh e r r at es o f n e gat iv e st o o l s. In It a p o r a n ga t h e r at e o f p o sit iv e st o o l e x a m in a t io n s d r o p p e d f r o m 7 8 .5 % t o 5 9 .5 % .

In t h e p e r io d 1 9 6 2 t o 1 9 7 1 , 8 2 ,2 7 6 m o r e p a t ie n t s w er e t r e at e d b y t h e M i n ist r y o f H e a lt h ; t h is f ig u r e d o e s n o t ín c lu d e p a t ie n t s t r e a t e d b y h e alt h se r v ice s in d i f f e r e n t St a t e s o f t h e co u n - t r y 9 . Th e r e su lt s h o w e v e r o f t h i s ca m p a ign h ave n o t y e t b een an alise d .

Fr e i t a s9 c r i t i c i ze d go v e r n m e n t a l p r o gr a m m e s f o r t h e c o n t r o l a n d t r e a t m e n t o f sc h ist o so m ia sis in B r a zi l — m ass t r e a t m e n t in c lu d e d - c h ie f ly b e cau se o f l a c k o f c o n t i n u i t y .

K l o e t ze l 13 t r e a t e d 1 1 2 y o u n gst e r s w it h an a n t i m o n ia l d r u g in t h e v ill a ge o f G a m e le ir a , in t h e St a t e o f Pe r n a m b u co . G a m e le ir a h as 5 ,0 0 0 i n h a b it a n t s an d is lo ca t e d in an e n d e m ic ar ea. A 9 0 % d e cr e ase in st o o l e gg e x c r e t io n w as f o u n d a f t e r o n e y e a r o f t r e a t m e n t .

Fo l l o w i n g D a v is' c o n c e p t o f m ass ch e m o t h e - r a p y sp e c i f c t o an age gr o u p . Pr a t a

et ai1,

f r o m 1 9 5 2 t o 1 9 7 3 t r e at e d 1 ,6 7 9 n a v y t r a in e e s in t h e st at e o f Bah ia. A l i t h o se w h o j o in e d t h e N a v y d u r i n g t h a t t im e w e r e in v e st igat e d b y st o o l e x a m in a t io n an d r e ct al b io p sy , a n d t h o se w h o w er e f o u n d t o be p o sit iv e w er e a llo ca t e d t o d if f e r e n t sch e m e s o f t e a t m e n t . M o r e t h an 2 0 sch e d u le s w er e u se d an d t h e cu r e r at e w as la r ge ly d e p e n d a n t o n t h e k i n d o f sch e m e u se d .

Hycanthone

— T h e gr ea t ad v an t age o f h y ca n - t h o n e t h e r a p y h as b een t h e p o ssib i li t y o f a sin gle d o se t h e r a p y , m a k i n g i t su it a b le f o r m ass t r e a t m e n t 8 .

P i za 1 7 , in t h e St a t e o f Sã o Pa u lo , h as t h e lar ge st se r ies o f t r e at e d p a t ie n t s w it h h y c a n ­ t h o n e , an d so f a r 6 1 ,4 6 1 p a t ie n t s h ave b een t r e at e d . T h e i n it ia l sch e d u le r e co m m e n d e d b y t h e cam p a ign a ga in st sc h i st o so m ia si s in t h is st at e w as 3 m g/ k g.b .w . b u t la t e r r e d u ce d t o 2 .5 m g/ k g. b .w . A l t h o u g h t h i s ca m p a ign is st i ll in p r o gr e ss, it s r e su lt s h ave n o t y e t b een assessed . A c o m p l ic a t i n g f a c t o r is t h a t in t e r n a i i m m ig r a t i o n is r e sp o n sib le f o r t h e e ve r in cr e a- sin g e x t e n t o f e n d e m ic ar ea in t h e st at e o f Sã o Pau lo . A c c o r d i n g t o t h e se le c t io n a n d gu id a n ce im m ig r a n t se r v ice , a t least 3 6 ,0 0 0 n e w sc h i st o ­ so m ia sis p a t ie n t s m o v e d t o Sã o Pa u lo in t h e p e r io d o f 1 9 7 3 -1 9 7 4 .

NOV-DEZ/ 76

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Th e r e ar e h o w e v e r n o a v a ila b le d a t a o n t h e r e su lt s o f t h is t r e at m e n t .

Bin a an d Pr a t a 3 t r e at e d 2 1 1 sc h i st o so m a t ic p a t ie n t s l iv i n g in V a r ze a N o v a , an ar ea w h er e t r an sm issio n o f t h e d isease w as lo w . T h e age ran ge w as 2 -7 4 y e ar s an d 15 p a t ie n t s h ad t h e h e p a t o sp le n ic f o r m o f t h e d ise ase , w h ile 1 9 6 had t h e h e p a t o -in t e st in a l f o r m . H y c a n t h o n e w as u se d in a sin gle d o se o f 2 .5 m g/ k g. b .w . in t r a m u sc u l a r ly . O n l y p r e gn an t w o m e n an d t w o o t h e r p a t ie n t s w it h c o n t r a i n d ic a t i o n s w e r e n o t t r eat ed . Sid e e f f e ct s w e r e n au se a, v o m it in g , a n o r e x i a , d izzin e ss, h e ad ach e , d r o w sin e ss, sleep - n ess a n d p a in a t t h e sit e o f t h e in j e ct io n . H o w e y e r t h e y w er e o n l y m il d o r m o d e r at e an d n o t la st in g m o r e t h a n 2 4 h o u r s. In o n l y 4 p at ie n t s w er e p o sit iv e st o o ls f o u n d in f iv e e x a m in a t io n s a f t e r f iv e m o n t h s o f t r e a t m e n t , an d in o n l y o n e a f t e r 1 6 m o n t h s.

H y c a n t h o n e , in a sin gle i n t r a m u sc u l a r d o se o f 3 .3 m g/ k g o f b o d y w e igh t , w as u sed t o t r e a t 5 9 7 p e r so n s in t h e e n d e m ic v il la ge o f Ca n a b r a v a in t h e st at e o f Ba h ia 4 . Ei g h t y t h r e e p er ce n t o f t h e t o t al p o p u la t i o n w as t r e at e d , le a v in g o n ly 7 % o f p a t ie n t s w it h Sc h ist o so m ia si s n o t t r e at e d . Tr e a t m e n t w as giv e n t o t h e w h o le gr o u p o ve r t w o d a y s, t h e d r u g b e in g w e ll t o le r a t e d w it h t h e f r e q u e n cy an d i n t e n sit y o f t o x i c r e a ct io n s an d sid e e f f e c t s si m il a r t o t h o se o b se r v e d in V a r ze a N o va. A f t e r f i v e st o o l e x a m in a t io n s 14 m o n t h s lat er , 1 5 2 p a t ie n t s (2 5 .5 % ) w er e st ill p assin g eggs in st o o ls. N in e t y t w o p o sit iv e p a t ie n t s w er e t h e n r e -t r e at e d w it h h y c a n t h o n e u si n g t h e sam e sch e d u le . Th e r e w as o n e d eat h p r o b a b ly cau se d b y t o x i c h e p a t it is. T h e f i r st st o o l e x a m in a t io n af t e r t h e se co n d t r e a t m e n t w as n egat iv e in 7 7 % o f t h e p at ie n t s, in co m p a r iso n w it h t h e 9 3 ,7 % af t e r t h e f i r st o n e . T h i s su gge st s t h e p o ssib il it y o f a cq u ir e d r e sist an ce. Th e f i n a l st o o l e x a m in a ­ t io n 3 8 m o n t h s a f t e r t h e i n it ia l t r e a t m e n t , sh o w e d 1 9 % o f p a t ie n t s p assin g eggs, T h i s p e r ce n t age is c o n sid e r a b ly b e t t e r t h an t h e p r e -t r e a t m e n t v a lu e o f 4 6 .3 % , an d a p p lie s f o r ali ages (see gr a p h ).

Si m i l a r r e su lt s w er e o b t a in e d b y A g u ir r e

et

at

in t h e st at es o f Ri o d e Ja n e i r o an d Ri o G r a n d e d o N o r t e 1 .

Ka t z

et all

1 t r e at e d 7 6 0 p a t ie n t s in t h e v il la ge o f B a l d im in t h e st at e o f M in as Ge r ais. O n ly 1 6 p r e gn an t w o m e n an d a n o t h e r 2 2 p at ie n t s w it h se r io u s c o n c u r r i n g d isease w er e n o t t r e at e d . H y c a n t h o n e w as u se d in a sin gle d o se o f 2 .5 m g/ k g b .w . i n t r a m u sc u la r l y . Si d e e f f e ct s w e r e n au se a, v o m it i n g , a n o r e x i a , m u scle p ain , h e ad a ch e , d izzin e ss, an d t e n d e r n e ss at t h e sit e o f in j e c t i o n , b u t t h e y w e r e m ild t o m o d e r a ­

t e a n d d isap p e ar e d in 2 4 h o u r s. T h e p e r ce n t age cu r e a f t e r t h r e e n egat iv e st o o l e x a m in a t io n s w as 9 5 .6 % . K a t z st r e sse d t h e f a c t t h a t h e h ad a lr e a d y t r e a t e d m o r e t h an 9 ,0 0 0 p a t ie n t s w it h - o u t f a t a li t y o r even j a u n d ic e .

Th e r e f o r e in t h e p ast f iv e y e ar s m o r e t h an 1 0 0 ,0 0 0 p e o p le h ave b een t r e at ed as p a r t o f co n t r o l l e d t h e r a p e u t ic p r o gr a m m e s, an d t h e m a n u f a c t u r e r s o f h y ca n t h o n e cla im e d t h a t b y Ju n e 1 9 7 5 , 4 3 3 ,0 1 8 p a t ie n t s h ad b een t r e at e d

ín Br a zil.

Oxamniquine —

B i n a an d Pr a t a 5 t r e at ed 7 5 c h ild r e n aged f r o m 3 t o 12 y e a r s in Ta q u a r e n d i in t h e St a t e o f Bah ia. T h i s is an e n d e m ic ar ea b u t w h e r e t r a n sm issio n h as b een p r e ve n t e d .

A n o r al su sp e n sio n o f o x a m n iq u in e w as u se d in sin gle d o se o f 1 5 -2 5 m g/ k g b .w . T w e n t y o n e p er ce n t o f t h e p a t ie n t s h ad o n e o r m o r e o f t h e f o l lo w i n g sid e e f f e ct s: d izzin e ss, d r o w sin e ss, n au sea an d o c c a si o n a lly v o m it i n g, b u t t h e y d isap p e ar e d sp o n t a n e o u sly in o n e t o t w o h o u r s. T h e cu r e r at e w as 8 8 % . A n o t h e r gr o u p o f 3 1 3 p at ie n t s w it h t h e h e p at o -sp le n ic f o r m o f sch i st o so m ia sis w as t r e at ed b y t h e sam e a u t h o r s in M ir an gab a. ( B a h ia ) , w h er e t h e r e is also n o t r a n sm issio n o f sc h ist o so m ia sis. O x a m ­ n iq u in e w as u se d in ca p su le f o r m f o r a d u lt s in a d o se 1 2 ,5 — 1 5 m g/ k g b .w ., an d in su sp e n sio n f o r m f o r c h ild r e n in a d o se o f 2 0 m g/ k g b .w . Fi f t y si x p e r ce n t o f p a t ie n t s h ad o n e o r m o r e o f t h e f o l l o w i n g sy m p t o m s: d izzin e ss, d r o w si­ n ess, h e ad ach e , n au se a ( 7 .3 4 % ) , v o m it in g ( 2 .8 5 % ) . Th e se sid e e f f e ct s d isap p e ar e d in t h e f o l lo w i n g t w o h o u r s a f t e r t r e a t m e n t . T h e cu r e r at e w as assessed b y f iv e st o o l e x a m in a t io n s in t h e si x m o n t h s f o l l o w i n g t r e a t m e n t , an d 8 4 % o f p at ie n t s w e r e f o u n d t o h ave n egat iv e st o o l e x a m in a t io n s.

T h e sam e a u t h o r s t r e at e d 2 8 6 p a t ie n t s in t h e e n d e m ic ar ea o f Bo a Esp e r a n ça in t h e st at e o f Bah ia. Th e n u m b e r o f p a t ie n t s t r e at ed r ep r esen - t ed 8 7 .7 % o f t h e w h o le p o p u la t i o n an d 1 1 .4 % o f t h e m h ad a sever e f o r m o f t h e d isease. O x a m n iq u i n e d o se w as t h e sam e an d sid e e f f e ct s w e r e sim ila r t o p r e v i o u sl y r e p o r t ed in

M ir an gab a.

-PREVALENCEOF SCHISTOSOMIASIS MEASURED BY

THE PRESENCE OF EG6S IN STOOLS, BEFORE AND AFTER

TREATM ENT, ACCORDING TO AGE GROUPS

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b an ce s: o n e b e cam e aggr e ssive a n d t h e o t h e r p r e se n t ed p e r ce p t u al d ist u r b a n ce s. A p a r t f r o m t h e se t w o p a t ie n t s, sid e e f f e c t s w e r e m il d an d t r a n si e n t n o t r e q u i r i n g m e d ic a t io n . Ev a lu a t io n is st ill in p r o gr e ss, b u t so f a r 8 7 .2 % o f p a t ie n t s sh o w n e gat iv e st o o ls.

K a t z an d Z i c k e r 1 2 , u si n g a sin gle o r al d o se o f o x a m n i q u i n e o f 2 0 m g/ k g b .w . f o r c h ild r e n an d 1 5 m g/ b .w . f o r a d u lt s, t r e a t e d 2 2 0 p a t ie n t s in t h e v ill a g e o f Pe r i Per i in t h e st at e o f M in as Ge r ais. Sid e e f f e c t s w e r e m il d an d t h e a u t h o r s r e co m m e n d t h e d r u g f o r t h e t r e a t m e n t o f c o m m u n it i e s. T h e cu r e r at es assessed b y 2 -4 st o o ls e x a m in a t io n s f o u r m o n t h s a f t e r t h e r a p y w er e f o u n d t o b e 6 5 ,5 % f o r c h il d r e n an d 8 2 .4 % f o r a d u lt s.

T h e m a n u f a ct u r e r s st a t e d t h a t b y Ju n e 1 9 7 5 o x a m n i q u i n e h ad b een giv e n t o m o r e t h an 1 0 0 ,0 0 0 p a t ie n t s w it h o u t f a t a l i t y o r even j a u n d i ce .

In c o n c lu si o n , a p a r t f r o m t h e t w o cases o f n e u r o p sh y c h ia t r i c d ist u r b a n ce s r e p o r t e d b y Co u r a e t a l, n o se r io u s c o m p l ic a t i o n h as b een o b se r v e d w it h o x a m n iq u i n e .

CO M M EN T S

M ass t r e a t m e n t o f sc h i st o so m ia si s in t h e p ast w as d o n e c a u t io u sly w it h a n t i m o n y c o m p o u n d s an d lar ge n u m b e r s o f p a t ie n t s w e r e t r e at e d b y t h e M in ist r y o f H e a lt h t h r o u gh h e alt h cl i n i c s. T o x i c i t y o f a n t i m o n y c m p o u n d s, lo n g t er m t h e r a p y , d i f f i c u l t y in in j e c t i n g t h e d r u g a n d t h e p o ssib i li t y o f r e -i n f e c t io n h in d e r e d t h e p i l o t p r o j e ct s. Fu r t h e r m o r e p a t ie n t s co -o p e r a t e d p o o r l y a n d t h e m ass t r e a t m e n t in t h e v il l a g e o f Ca t e n d e le f t d o u b t s as t o t h e a p p l i c a b i l i t y o f t h i s k in d o f t r e a t m e n t in B r a zil .

T h i s si t u a t i o n w a s n o t alt e r e d b y t h e u se o f N ir id a zo le o n ce it w as f o u n d t h a t lar ge n u m b e r s o f p a t i e n t s p a r t i c u la r l y t h o se w it h h e p at o sp le

-n o m e ga ly - co m p la i -n e d o f v a r i o u s -n e u r o lo gica l sy m p t o n s.

D u r i n g t h e last si x y e a r s h o w e v e r , t h e in t r o d u c t i o n o f sin gle d o se t h e r a p y h as m ad e e asie r m ass t r e a t m e n t o f sch ist o so m ia sis. H y - ca n t h o n e h as b een u se d in v a r i o u s p i l o t p r o j e ct s a n d at p r e se n t e t w o v e r y lar ge co m p a ign s are st ill in p r o gr e ss. U n f o r t u n a t e ly w it h t h e t r e a t ­ m e n t o f m o r e cases r e p o r t s o f sever e t o x i c h e p a t it is h ave a p p e a r e d 2 an d t h e p o ssib i li t y o f r e sist an ce a f t e r t h e f i r st d o se , t o ge t h e r w it h a ccu sa t io n s o f t e r a t o g e n ic, ca r c in o ge n i c an d m u t a ge n ic e f f e ct s - a lt h o u gh n o t su b st an - t ia t e d 2 4 , — h ave r e d u ce d t h e u se o f h y ca n t h o n e as a d r u g f o r m ass t r e a t m e n t . H o w e v e r it h as b een u se d in t h i s w a y in B r a zi l w it h m o r e t h a n 1 0 0 ,0 0 0 p at ie n t s.

O x a m n iq u i n e in o r a l f o r m r aise d o p t im ism as a su i t a b le d r u g f o r m ass t r e a t m e n t o f sch i st o so m ia sis, b u t so f a r it h as o n l y b een u sed in p i l o t p r o j e ct s.

Pe r h ap s w e ar e n o t f a r a w a y f r o m in t r o d u - c i n g m ass t r e a t m e n t f o r sc h ist o so m ia sis as f o r m alar ia. T h i s is n o t p o ssib le w it h h y ca n t h o n e a n d as y e t w e d o n o t k n o w w h e t h e r it w ill be p o ssib le w it h o x a m n i q u i n e ; w e m a y h ave t o a w a it t h e e m e r ge n ce o f a n e w d r u g.

It is e v id e n t t h a t m ass t r e a t m e n t o f sc h i st o ­ so m ia sis is t h e b e st f o r m o f t r e a t m e n t in a n o n e n d e m ic ar ea, as w as seen in Fo r d la n d ia w h e r e t h e d isease w as e r ad ica t e d b y sp e c i f ic t r e at ­ m e n t , an d in V a r ze a N o v a w h e r e it w as co n t r o - led .

T h e B r a zil ia n e x p e r ie n ce sh o w s t h a t d u r in g t h e lo n g t e r m , t r e a t m e n t m a y d e cr e ase t h e p r e vale n ce o f t h e d isease even in e n d e m ic ar eas - a l t h o u g h it is d i f f i c u l t t o assess it in t e r m s o f t h e ge n er al c o n t r o l o f t h e d isease.

I t ap p e ar s t h a t t r e a t m e n t o f sc h ist o so m ia sis p r e ve n t s t h e ap p e a r a n ce o f se r io u s f o r m s o f t h e d isease.

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