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Objective—To evaluate the impact of zinc supplementation on the clinical course, stool weight, duration of diarrhoea, changes in serum zinc, and body weight gain of children with acute diarrhoea. Design—Randomised double blind controlled trial. Children were assigned to receive zinc (20 mg elemental zinc per day) containing multivitamins or control group (zinc-free multivitamins) daily in three divided doses for two weeks. Setting—A diarrhoeal disease hospital in Dhaka, Bangladesh. Patients—111 children,3 to 24 months old, below 76% median weight for age of the National Center for Health Statistics standard with acute diarrhoea. Children with severe infection and/or oedema were excluded. Main outcome measures—Total diarrhoeal stool output,duration of diarrhoea, rate of weight gain, and changes in serum zinc levels after supplementation. Results—Stool output was 28% less and duration 14% shorter in the zinc supplemented group than placebo (p = 0.06). There were reductions in median total diarrhoeal stool output among zinc supplemented subjects who were shorter (less than 95% height for age), 239 v 326 g/kg (p < 0.04), and who had a lower initial serum zinc (< 14 mmol/l), 279 v329 g/kg (p < 0.05); a shortening of mean time to recovery occurred (4.7 v6.2 days,p < 0.04) in those with lower serum zinc. There was an increase in mean serum zinc in the zinc supplemented group (+2.4 v˛0.3 µmol/l, p < 0.001) during two weeks of supplementation,and better mean weight gain (120 v30 g, p < 0.03) at the time of discharge from hospital. Conclusions—Zinc supplementation is a simple, acceptable, and aVordable strategy which should be considered in the management of acute diarrhoea and in prevention of growth faltering in children specially those who are malnourished. (Arch Dis Child 1997;77:196‐200)

Seventeen adult patients with acute Plasmodium falciparum malaria, admitted to the Hospital for Tropical Diseases, were studied. Serial measurements of the serum concentration of C-reactive protein, serum amyloid A protein, and percentage parasitaemia were determined, together with initial measurement of serum electrolytes, liver function, haemoglobin, white cell and platelet counts. Initial C-reactive protein and serum amyloid A concentrations were increased (C-reactive protein mean 49.0 mg/l serum amyloid A 28 mg/l) falling towards the normal range by the seventh day of treatment. There was a significant correlation between the pretreatment parasite count and clinical and laboratory markers of inflammation. C-reactive protein and serum amyloid A concentrations correlated inversely with the serum sodium. These results indicate that measurement of acute phase reactants such as C-reactive protein and serum amyloid A may prove valuable in assessing the severity of P falciparum malaria, and in following the response to antimalarial treatment.

Health professionals need to educate travellers about the dangers of malaria and the importance of prophylaxis There was a large increase in the number of cases of falciparum malaria imported into the United Kingdom and reported to the malaria reference laboratory in the first quarter of 1998.1 The two factors cited to explain this increase were unusually heavy rains in east Africa and a reduction in the use of the most effective antimalaria drug, mefloquine.1 At the same time there was an increase in the number of cases of severe malaria in the United Kingdom.1 During December 1997 and January 1998 this hospital treated five patients for severe malaria and gave advice on a further 20 patients with malaria who had been admitted to intensive care units throughout England. Of the 25 patients, 13 were male (median adult age 50; range 23 to 85) and two were children. Twenty two of those treated were of European origin. Altogether 20 patients had travelled to east Africa (16 to Kenya and at least six of these to Mombasa); five had travelled to west Africa. Median parasitaemia was 16% (range 1.1% to 60%). Ten patients (40%) had taken no prophylaxis; one of these was a Kenyan man of Asian origin who was on holiday in the United Kingdom. Prophylactic drugs had been prescribed for 15 patients: 11 had been prescribed proguanil and chloroquine, two had been prescribed mefloquine, and two had been prescribed other drugs. Nine of the 15 had not taken the drugs as prescribed. Thus 19 of the 25 (76%) had taken either inadequate doses or no prophylactic drugs. The cost to the NHS for intensive care for these patients exceeded £160 000 ($256 000). We report on …

EDITOR,—The adverse events reported by P J Barrett and colleagues in travellers taking mefloquine, who were recruited to the study when seeking telephone advice,1 were subjectively much more severe and disabling than those described in a study from Swiss, Swedish, and American researchers published around the same time2. Schlagenhauf …

EDITOR—The health risks associated with international travel range from minor symptoms to severe morbidity and death. In 2000, residents of the United Kingdom made 56.8 million visits abroad, 3.3 times the number made in 1980. Of all visits abroad, 72% were to countries in the European Union and 9% were to North America. Beaches, bites, bugs, and boils (Credit: SHANE PARTRIDGE/REX) Hand in hand with an increase in travel we can expect a similar increase in travel related …

Editor—Croft and Garner’s interpretation of their systemic review of controlled studies involving mefloquine cannot qualify as evidence based.1 They have selected two outcome measures, non-compliance and withdrawal, as proxy markers for drug tolerance without any evidence of correlation of this behaviour to tolerability. In Orht’s study,2 which makes up 43% of the mefloquine group withdrawals, four of the seven withdrawals were because soldiers were redeployed and the remaining three were because of protocol failures3 and concurrent fever, none of which was obviously related to tolerability. In clinical studies where subjects were at no risk of malaria the threshold and reason for withdrawal from prophylaxis may be different from those of travellers, whom the authors claim will behave similarly despite a different risk of malaria. The author’s argument that a symptom based outcome is less objective than a withdrawal based outcome when measuring tolerability is subjective. The claim that poor compliance or withdrawal from mefloquine is more likely to leave travellers incompletely protected compared with other regimens is unsupported and selectively used to discredit mefloquine. Their study and others3 confirm that mefloquine is an effective antimalarial prophylactic drug. To restrict its use to the fittest and healthiest travellers on the basis of differences in undefined withdrawal rates in non-travellers because no current studies define its true tolerability is naive. An important issue, which the authors have failed to acknowledge, is that the tolerability of any prophylactic regimen needs to be counterbalanced by the risks of morbidity and mortality associated with the disease it is used against. Under the banner of an evidence based analysis the authors have used a limited dataset, which is arguably inadequate for meta-analysis, to reflect their personal preferences on the indications for mefloquine prophylaxis.