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References A COMPARISO OF 1. Haupt H.A., RO\"ere GO. Anabolic steroids- a redew of the literature. Am {Sports Mrd 198-1; 12: -I69-J8.l. MEBENDAZOLE AND 2. \V"tlson JD. Androgen abuse by athletes. Endocr Rn' 1988; 9: 181-199. 3. Elashoff JD, Jacknow AD, Sham SG, Braunstein GO. Effects of anabolic·androgenic steroids IN TREATING on muscular strength. Ann Intern Med 1991; 115: 387·393. 4. Yesalis CE, Bahrke ~. Anabolic-androgenic steroids - current issues. Sports Med 1995; 19: 32("3-W. CHILDREN WITH TRICHURIS 5. Yesalis CE, Buckley WE, Anderson WA, et al. Athletes' projections of anabolic steroid use. elm Sports Afed 1990; 2: 155-171. TRlCHIURA I FECTIO I 6. Perry HM, Wright 0, Littlepage B:":C. Dying to be big: a fe\,jew of anabolic steroid use. Br I Sport, Med 1992; 26, 259-26I. DURBAN, SOUTH AFRICA 7. Buckley WE, Yesalis eE, Friedl CE, Anderson WA, Strelt Al, Wright lE. Estimated prevalence of anabolic steroid use among male high school seniors. JAMA 1988; 260: 34-l1-J.4..t5. 8. Windsor K Dumitru D. Prevalence of anabolic steroid use by male and female adolescents. Med Sci Sports Exn" 1989; 21: 494-197. TFHG Jackson, SR Epstein, E Gouws, RF Cheetham 9. Tanner SM, Miller DW, Alongi C. Anabolic steroid use by adolescents: prevalence, motives, and knowledge of risks. CIin / Sport Mtd 1995; 5: 1 115. 10. Melia P, Pipe A, Greenberg L The use of anabolic·androgenic steroids by Canadian tudents. Clm I Sport Med 1996; 6, 9-H. 11. Korkia P. Anabolic steroid use in adolescents. Sports Ext7Cise and InJury 1996; 2.: 136-1 Objective. To compare the efficacy of mebendazole 500 mg 12. Hickson RC, Ball KL .. Falduto MT. Adverse effects of anabolic steroids. Med Toxieol Adt't'TSf and aIbendazole 400 mg single-close treatments of Trichuris Drug Exp 1989; 4, 254-271. 13. Goldberg L. Adverse effects of anabolic steroids. lAMA 1996; 276, 257. trichiura infection in children in the Durban area of KwaZulu- 14. Johnson M, Jay ~,Shoup B, Rickert V. Anabolic steroid use in adolescent males. Pediatrics atal, South Africa. 1989; 83: 921-92-1. 15. Bumett KF, Kleinman ME. Psychological characteristics of adolescent steroid users. Design. A single-blind randomised trial in children with a Adolescence 1994; 29: 81-89. 16. DuRant RH. Rickert VI. Ashworth CS. !':ewman C. Slavens G. Use of multiple drugs among documented moderate infection of T. mchiura. Ova were adolescents who use anabolic steroids. N Engl / Med 1993; 328: 97...2-926. counted in stool specimens before and 10 days after 17. Middleman A, DuRant RH...:\.nabolic steroid use and associated health risk behaviours. Sport, Med 1996; 21(-1): 251-255. treatment by the formal-ether concentration method. 18. Nemechek PM. Anabolic steroid users - another potential risk group for HIV infection. .\1 Engl I Med 1991; 325, 357. Setting. Two shelters for abandoned and orphaned children 19. Van der Merwe PI, Kruger HSl. Drugs in sport: results of the past 6 years of dope testing in in Durban. South Africa. S Afr Med 11992; 820 151-153. 20. lidestad SD, Lambert MJ. Schwellnus MP. A survey to determine types and dosages of Participants. inety-six children aged between 2 and 12 anabolic androgenic steroids used by competiti\'e body builders in South Africa. SA /ollrnal of Sports Medicine 1994; 1(2): 24-2 . years. 21. 5chwellnus ~{P, Lambert MI.. TOOd ~iP,. ]uritz.P1. Androgenic anabolic steroid use in matric pupils. A survey of prevalence of use in the western Cape. 5 Afr Med / 1992; 82: 154-1- . Outcome measures. The number of children who showed 22 Todd MP. The use of anabolic steroids by high school pupils in Cape Town: a survey. reduced T. trichiura ova counts after the treatments, and Submitted in partial fulfilment of the requirements for a BSc Hons degree in the Department of Mathematical Statistics, L'niver5ity of Cape Town, 1991. reductions in ova counts, both expressed as percentages. 23. Yesalis CE. Incidence of anabolic steroid use: a discussion of methodological issues. In: Yesalis C, ed. Anabolic Steroids in Sport and ExerCise. Champalgn, Ill: Human Kinetics Statistical analysis using the Wilcoxon 2-sample test and the Publishers. 1993; -19-70. chi-square test. 24. Smart R, Blair ~. Test-retest reliability and validity information for a high .school drug use programme. Drug Alcohol Depend 1978; 3, 265-271. Results. Eighty-two children completed the trial; 42 received 25. Nilsson S. Androgenic anabolic steroid use among male adolescents in Falkenberg. Eur JGin Ph:mnDcol 1995; 48, 9-11. mebendazole and 40 albendazole. Of the mebendazole group 26. World Health Organisation. Meetmg on Research InitlQtive on Drugs and Sports 1993. Geneva: 85% showed a reduction in T. trichiura ova count, compared WHO. 7-11 lune 1993. 27. Wang MQ Yesalis CE. Fitzhugh EC, 8uckley WE. Desire for weight gam and potential risks with 75% of children who received albendazole. of adolescent males using anabolic steroids. Percept Mot Skills 1994; 78: 267-274. Mebendazole treatment was associated with a median 28. Goldberg L, Elliot DL, Clarke GN, et al. The Adolescents Training and Learning to Avoid Steroids (ATLAS) prevention programme. Background and results of a model intervention. percentage reduction in ova count of 72.2%, which Arch PediD/r Adoles< Med 1996; 1500 713-721. significantly exceeded the 44.1% reduction after albendazole

Accepted 14 lan 1998. (P = 0.024). Conclusian. The mebendazole 500 mg single-close therapy was more efficacious than the albendazole 400 mg single­ dose therapy in treating T. trichiura infection in these children.

S Afr Med J1998; 88: 880-883.

Medical Research Council, Durban TFHG Jackson, PhD SR Epstein, MedTech (SA) E Gouws. MSc jansse1l-Cilag, PO Box 785939, Sand/on, 2146 RF Cheetham, MSc

July 199 , VO!. 0.7 SAMJ , ORIGINAL ARTICLES

Trichuriasis is an extensive worldwide health problem with microscope, and dilute Lugol's iodine was used as a stain. The estimates indicating that some 500 million people are infected counts were expressed as eggs per gram of stool. Ninety-six with Trichuris,' Although found in all communities, parasitic children with a moderate infection (5 - 70 ova per cover slip on diseases tend to be associated with poverty, and one estimate low power) were selected for the trial. of the prevalence of T. trichiuYa infections in school-going children in a peri-urban area of KwaZulu- latal is 47%-' TreatInent and follo-w-up Intestinal parasitic infections impact on morbidity widely. These children then received either a single 500 mg dose of has been associated with protein energy mebendazole (Vermox; Janssen-Cilag) or a single 400 mg dose malnutrition,' which in turn has behavioural and cognitive of albendazole (Zental; SmithKline Beecham). The drugs were effects. In a Jamaican study by Simeon et ai' it was shown that packaged identically and administered under the supervision T. trichiura infection combined with poor nutritional status had of a clinician in a single-blind manner according to a an adverse effect on school performance. Trichuriasis has also randomisation schedule prepared by the Janssen Research possibly been linked with poor attention in school-going Foundation, Belgium. The staff supervising the children were children.' T. trichillYa infection is one of the most difficult asked to note any adverse experiences reported by them, parasitic infections to treat effectively. For example, Hall and particularly during the 24-hour period following drug aharS found that although albendazole initially appeared to administration.Ten days after treatment stool collections were inhibit ova production, it was later resumed. Results of other repeated and 1 g duplicate samples of each specimen were investigations also support the fact that trichuriasis is more processed for quantitative T. trichiura ova counts, as above. difficult to treat than other parasitic infections such as and hookworm.·.7 Statistics Mebendazole and albendazole are both In order to show a 25% difference in parasite reduction carbamate drugs. Mebendazole has a broad spectrum of between the two treatment groups, with 80% power and activity, including trichuriasis, hookworm, significance at the 5% level, 80 children were required to ascariasis, enterobiasis, strongyloidiasis and tapeworm. The complete the study. The distribution of the ova counts, as well drug is not absorbed from the host's intestine to any significant as the percentage reduction in ova counts, deviated degree and appears to work by irreversibly blocking significantly from normality and so the results were uptake in the parasite, leading to depletion of the parasite summarised in terms of medians and interquartile ranges. The glycogen, decreased formation of adenosine triphosphate and significance of the difference between groups was assessed cell death.· Albendazole has a similar spectrum of activity to using the Wilcoxon 2-sample test. The chi-square test was used mebendazole, but its mode of action differs in that it is to compare the groups with respect to the percentage of absorbed from the host's intestine.· children showing a reduction in ova burden. Mebendazole has been available as a multiple daily dose formulation on the South African market for many years. The Ethical approval advent of the single-dose regimen for mebendazole and the This study was approved by the Postgraduate (Ethics) availability of albendazole for human treatment prompted the Committee of the Faculty of Medicine, University of atal, decision to conduct this comparative trial in South Africa. Durban.

METHODS RESULTS Subjects and stool specimens Patient cLaracteristics One hundred and seventy-five children between the ages of One hundred and fifty-three (88%) of the 175 children screened 2 and 12 years (mean 8 years) were screened for this study. were positive for T. trichiura infection; only 9 children were free The children lived in one of two shelters for abandoned and of parasites. Eleven other parasite species were identified, with orphaned children in the Durban area of KwaZulu- atal, Giardia dllodenalis (63% of children), Entamo~ba coli (31%) and South Africa. Initial screening was performed to determine Ascaris and Entamoeba histolytica/dispar (both 17%) being the which children were infected with T. trichillYa. Stool specimens next most common parasites identified. Most (71%) of the .. were collected in 30 ml plastic screw-cap stool jars and •• faecal samples were formed, 24% were semi-formed, and the preserved in 10% formal-saline. Formed stool specimens were remaining 5% were fluid. Of the 96 children who had an covered with preservative; in the case of a semi-formed stool appropriate level of T. trichiura infection and who entered the an equal volume of 10% formal-saline was added to the jar. trial, 14 either were unable to provide a post-treatment stool One-gram samples were then processed in duplicate by means specimen or were lost to follow-up. Eighty-two children were of the formal-ether concentration method. Total egg counts therefore included in the analysis, of whom 42 received were performed on the concentrate using a compound ORIGINAL ARTICLES

mebendazole and 40 albendazole. TO adverse events were produce a statistically significant reduced ova count of 0% in reported in either group. T. trichillTa-infected individuals. Good efficacy in treating T. tricllillTa infection was reported Ova counts by Abadib when he treated subjects from Unjung Pandang, Indonesia, with a single 500 mg dose of mebendazole. He The randomisation schedule achieved comparable baseline reported a cure rate of 78% and an ova reduction rate of 93%. counts for each treatment, and these are summarised together A study conducted previously in South Africa with the with percentage reductions in counts in Table 1. Frequency of mebendazole 500 mg single-dose regimen showed a 100% cure ova count reduction was 36/42 ( 6%) after treatment with rate for trichuriasis in a small number of children with low ova mebendazole and 30/40 (75%) after albendazole (P = 0.054). 1 counts ' The percentage reduction after mebendazole (72%) was The effects and implications of untreated parasitic infections significantly greater (P =0.024) than after albendazole (44%). in children, such as trichuriasis, are wider than may initially be apparent. Three studies among Kenyan schoolchildren have Table I. Pre- and post-treatment ova counts (eggs per gram of shown improved growth, appetite and spontaneous physical stool) activity after treatment of their mixed parasitic infections,

Albendazole Mebendazole I 15 which included T. trichillra. l- An important finding among (median (median Jamaican schoolchildren was that the children most likely to (interquartile (interquartile range» range» P-value benefit from treatment were those with poor nutritional status and heavy T trichiuTa infections.'· Both in South Africa and Pre-treatment 1 045 (626 - 1 548) 899 (583 - 2 051) S Post-treatment 567 (184 - 948) 278 (71 - 605) 0.054 elsewhere it has been shown that treatment of parasitic Reduction 44% (7 -72%) 72% (33 - 89%) 0.024 infections can have a positive effect on children's cognitive processes."· Simeon et aU showed particular benefit in children who were undernourished. Owing to the wide implications of , the DISCUSSIO control or elimination of gastro-intestinal infections such as The results presented here indicating different efficacies trichuriasis is of paramount importance in the upliftrnent of between mebendazole and albendazole in treating socially and economically disadvantaged communities. In view T trichillra infection are reflected elsewhere in the literature."JO of the type of communities where T trichillTa is most prevalent, In a comparative trial using the same dose regimens as this the treatment of this parasitic infection must take into account study, Albonico et a]9 showed mebendazole to be significantly not only efficacy of the medication but also its availability and superior to albendazole for both cure rate (P < 0.01) and cost. Both at the time of undertaking this research and when percentage ova reduction (P < 0.001) in children infected with reporting these results mebendazole 500 mg was available T. trichillra in Zanzibar. In a comparative study using 400 mg of without a doctor's prescription, making it simpler to either mebendazole or albendazole, Bartoloni et al.' showed administer and more accessible, while albendazole 400 mg was mebendazole to have a higher cure rate than albendazole available only on prescription in South Africa. The price of the (60% v. 33%), while albendazole was reported to have a higher two products was comparable. Our results showed both drugs ova reduction rate than mebendazole (45.7% v. 15%). However, to be safe; however, mebendazole was shown to have superior only 25 children with T. trichillra infection participated in the efficacy in treating T. trichillTa infections in this group of study, which may have contributed to the inconsistent results. children. In a study using higher doses of both mebendazole and albendazole (600 mg and 1 g, respectively), Holzer and Frey" We thank Dr B Bhana, Mrs CB Anderson and Mr F Sumad for reported that both drugs had enhanced cure rates in T. trichillra their help and assistance with the practical aspects of this trial. This infection. Albendazole cured 90% of subjects and mebendazole study could not have been undertaken without the co-operation of the two children's shelters where subjects were recruited. In this 93°/0 • Several authors have studied either mebendazole or regard we would like to thank Mr M Chili, Sr L Mkhize and Mrs V zimande from the Othandweni Home in Lamontville, Durban, albendazole in an open fashion in the treatment of trichuriasis. and Mrs N Malahleha, Mr P Ndlovu and Mr S Ngcobo from the Ramalingam et alIi treated patients with 400 mg, 600 mg Ol" 800 Sinethemba Street Shelter in Durban. This project was supported 1mB mg albendazole a a single dose. The ova reduction rates on by a research grant from Janssen-Cilag, South Africa, and by the day 21 were 39°'0, 85°0 and 73°/0 , respectively, and the cure rate Medical Research Council. varied between 20°0 and 61°0, again with the best result in the 600 mg group. In comparison to these results, Hall and Nahar' References

reported that single doses of 600 mg or 00 mg albendazole 1. Cooper ES, Bundy DAP. Trichuriasis_ In: Pawlowski Z5, ed. BaiIIlue's Clinical TropIcal .\fe'dlcmc' and Communicable' D,seQse':>. Val 1. Intr?stlnQI Helminth Infections. 1':ew York­ were ineffecti\Oe and that -lOO mg for 5 days was required to Academic Press, 1QS7 630.

July 199 ,Vo!. , '0."7 SAMJ , ORIGINAL ARTICLES

2. Kvalsvig ID, Cooppan RM, Connolly KJ. The effects of parasite infections on cognitive processes in children. Ann Trop Med Parasitol1991; 85: 551·568. EXPRESSION OF SCHIZOPHRENIA 3. Stevenson lS. Impact of Helminth Infections on Human Nutrition. London: TayIar & Francis, 1987. IN BLACK XHOSA-SPEAKING AND 4. Simeon DT, Grantham-McGreggor SM, Wong MS. infection and cognition in children: results of a randomized . Parasitology 1995; 110: -l57­ .64. WHITE ENGLISH-SPEAKING 5. Hall A, Nahar Q. Albendazole and infections with Ascaris lumbncoides and Trichuris triclliuTI1 in children in Banglade::;h. Trans R 50c Trop Med Hyg 199.+; 88: 110-112. SOUTH AFRICANS 6. Abadi K. Single dose mebendazole therapy for soil-transmitted . Am / Trop Med Hyg 1985; 34, 129·133. 7. Bartoloni A, Guglielmetti P, Canedni G, et al. Comparati\·e efficacy of a single -400 mg dose of albendazole or mebendazole in the treatment of infections in K Ensink, BA Robertson, 0 Ben-Arie, P Hodson, C Tredoux children. Trap Ceogr Med 1993; 45: 11-4-116. 8. Dollery C, ed. Therapeutic Drugs. 1st ed. Edinburgh: Churchilllivingstone, 1991: A31, M12. 9. Albonico M, Smith PG, Hall A, Chwaya HM, Alawi KS, Savioli L. A randomized Objective. To inv:estigate whether schizophrenia manifests controlled trial comparing mebendazole and albendazole against Ascaris, Trichuris and hookworm infections. Trans R 50c Trap Med Hyg 199-1; 8S: 385-589. itself differently in Xhosa-speaking South Africans, 10. Holzer BR, Frey FJ. Differential efficacy of mebendazole and albendazole against but not for Trichuris trichiura infestations. Eur I Clin Pharmacal 1987; compared with English-speaking white South Africans. 32, 635·637. 11. Ramalingam S, Sinniah B, Krishnan U. Albendazole, an effective single dose, broad Design. A comparative study·of the presentation of spectrum anthelmintic drug. Am I Trop Med Hyg 1983; 32: 984·989. schizophrenia in two groups of patients. 12. Evans AC, Hollmann AW, De Preez l. Mebendazole 500 mg for single·dose treatment of nematode infestation. 5 Aft Med J 1987; 72: 665-667. Settings and subjects. A sample of 63 patients (43 Xhosa­ 13. Adams EJ, Stephenson lS, latham MC, Kinoti SN. Physical activity and growth of Kenya school children with hookworm, Trichuris trichiura and Ascaris lumbricoides speaking and 20 English-speaking) admitted to a large infections are improved after treatment with albendazole. J Nutr 199-1; 124: 1199-12.06. psychiatric hospital for the first time with a diagnosis of 1-4. Stephenson lS, Latham MC, Adams El. Kinoti SN, Pertet A. Weight gain of Kenyan school children infected with hookworm, Trichuris trichiura and Ascaris lumbricoides is schizophrenia. improved following once- or twice-yearly treatment with albendazole. I Nutr 1992; 123, 656·665. Outcome measures. The Present State Examination (PSE) was 15. Stephenson lS, Latham MC, Adams EJ, Kinoti SN, Pertet A. Physical fitness, growth and appetite of Kenyan school boys with hookworm, Trichuris trichiura and Ascaris used to confirm the clinical diagnosis of schizophrenia. lumbricoides infections are improved four months after a single dose of albendazole. I The Relatives' Rating of Symptoms and Social Behaviour Nutr 1993; 123, 1036·10.6. 16. Simeon DT, Grantham-McGreggor SM, Callender JE, Wong MS. Treatment of Trichuris (KAS-R) was used to obtain information on the behavioural trichiura infections improves growth, spelling scores and school attendance in some and emotional expression of schizophrenia. children. J Nutr 1995; 125: 1 75-1 3. Results. A significantly higher prevalence of aggressive and Accepted 14]an 1998. disruptive behaviour was reported by relatives of Xhosa­ speaking patients with schizophrenia of recent onset compared with English-speaking patients. The PSE elicited significantly more delusions of persecution, sexual and fantastic delusions, self-neglect and irritability in the Xhosa­ speaking patients. Canclusion. Significant differences in the presentation of schizophrenia, but not its core symptoms, were identified in . Xhosa-speaking blacks and English-speaking whites.

5 AIr M£d J199 ; 88, 883-887.

Significant differences in the presentation, course and outcome of schizophrenia have been documented in many societies,I.> but have received surprisingly little attention in South Africa. Given the misuse of social and cultural differences for political purposes, many South African researchers have been critical of

Department of Psychiatry, University ofCape Town ..• • K Ensink, BSocSc Hons (psych), MA (Clin Psych) BA Robertson, MB ChB, Dipl Psych, MD C Tredoux, BA Hons (Psych), MA, PhD FaCIlity ofMedicine, Queen's University, Kingston, Ontario, Canada o Ben-Arie, MB ChB, DPM, FRC Psych, FRCPC Valkertberg Hospital, Cape Tourn P Hodson, MB ChB, MRCP, FF Psych