702

Antimicrobial drugs advised in pharmacies in Brazil for children with acute respiratory infections SIR,-Dr Khallaf and colleagues (July 27, p 248) report prescribing patterns from Egyptian pharmacies for children with acute respiratory illnesses and raise the possibility of using pharmacy personnel as counsellors for early referral of children with symptoms of acute lower respiratory tract infections. We have studied thirty-three pharmacies serving low-income families in Fortaleza, Brazil. 1 untrained counter worker at each pharmacy was interviewed and asked which medicines they would recommend for a 2-year-old child with: cough only, cough and fever, or cough, fever, and difficulty in breathing. 3 recommended antibiotics for children with cough, 20 for cough plus fever, and 14 for children with cough, fever, and difficulty in breathing. Of antibiotics mentioned co-trimoxazole was the most common (34 times). Other drugs recommended included cough preparations, analgesics, and bronchodilators. Dipyrone was recommended for fever in eleven pharmacies despite its well-known side-effects.! Thus, in contrast to the Egyptian findings, we found that pharmacy attendants routinely recommend antimicrobial drugs. Early detection of severe cases of lower respiratory infection is very important in reducing mortality among young children in developing countries.2 In many areas of Brazil where public health facilities are few and far between, private pharmacies are often the only alternative for those seeking treatment. Since the World Health Organisation has already suggested that antibiotics could be prescribed by health workers at first-level facilities (eg, community health workers), the involvement of retail pharmacy staff, after adequate training, in the prescribing of antibiotics should be considered.3 Training may not only adjust sales practices to the needs of people but also involve pharmacies in the early referral of severe cases to

health

centres.

This study was funded by the Toyota Foundation. Kanji for his comments. Maternal and Child Epidemiology Unit, Department of Epidemiology and Population Sciences, London School of Hygiene and Tropical Medicine, London WC1 E 7HT, UK, and Department of Social Medicine, Federation University of Pelotas, Pelotas, R.G.Sul, Brazil

of both vaccines and

see

which

one

is suitable for India in the

longterm. As a health economist, I was aware of the higher costs of IPV but the immune response of IPV has been demonstrated in South India (T. J. John, personal communication). In 1989,was contracted by Resources for Child Health Project (REACH), funded by USAID, to be part of the team doing a cost-effectiveness study of the two vaccines in John’s study population, and I thought I was taking part in a major decision. I was disheartened to find the study very biased in favour of OPV; the data collection was poor, with an estimation of cost alone, and effectiveness was not taken into consideration. The pilot study showed IPV to be very expensive. This was publicised as cost-effectiveness analysis whereas it was in fact a cost analysis-and an inaccurate one. A study in Senegal demonstrated the higher cost-effectiveness of IPV1 when cost, efficacy, and effectiveness (efficacy plus acceptance) of the two vaccines were compared. A major aid agency such as USAID should be aware of the dangers of producing results without assessing their validity since this could have tragic effects in India, if that country’s Government makes decisions on the basis of such a study. In view of the efficacy of IPV, the continuing so-called cost-effectiveness study should be reviewed and assessed by expert health economists lest erroneous results are given to the Government of India. Department of Public Health Medicine, Glamorgan Health Authority, Pontypridd, Mid Glamorgan CF37 1 LA, UK Mid

RUBY KAUL

We thank Mr Najmi 1. Moulia-Pelat JP, Garenne M, Schlumberger more expensive? Lancet 1988; ii: 1424.

M, Diouf B. Is inactivated poliovaccine

Anti-CD4 therapy of acute rejection in long-term renal allograft recipients CHIZURU MISAGO WALTER FONSECA

1. Editorial. Analgesics, agranulocytosis, and aplastic anaemia. Lancet 1986; ii: 899-900. 2. World Health Organisation. Programme for control of acute respiratory infections: guidelines for management of research activities (document ARI/RES/89.1). Geneva: WHO, 1989. 3. WHO/UNICEF. Basic principles for control of acute respiratory infections in children in developing countries. Geneva: WHO, 1986.

Use of inactivated

the vaccine progeny virus also spreads to non-vaccinees, extending immunity to a wider population at no extra cost. Cost comparison alone would certainly show that OPV costs far less than IPV in respect of dose, administration, and amount needed to establish and maintain adequate immunity. However, a stringent cost-effectiveness analysis should examine all the costs and benefits

or oral poliovirus vaccine in India

SIR,-Dr Samuel and his colleagues (Aug 10,

p 343) have the demonstrated of successfully immunogenic efficacy intradermal inactivated poliovirus vaccine (IPV) in 15 subjects in South India. However, decision making on the use of poliovirus vaccines, especially in a large, poor country such as India, needs to be based on a stringent cost-effectiveness analysis of IPV and the oral vaccine (OPV). Both vaccines have risks and benefits but those of one should be weighed against those of the other. IPV has been successful in countries where it is used exclusively but these countries are economically developed-they are small with very good national health programmes that cover the entire population and ensure administration of primary vaccination and regular boosters. OPV is being used nationally in India, not only for economic reasons but also for immunological reasons it confers both humoral and intestinal immunity much faster than IPV and it establishes itself in the alimentary tract, blocking infection with the virus (A. Sabin, personal communication). The other added benefit is that

SIR,-Acute rejection can occur even in the longest functioning transplants. "Late" rejections (over 1 year post-

renal

transplantation are more resistant to corticosteroid or pan-T-cell antibody therapy, the failure-rate being about 35% compared with less than 10% for rejections in the early post-transplantation.1,2 Anti-CD4 monoclonal antibodies (mAb) have been reported to prevent or to delay the onset of allograft rejection in experimental models and have been used to prevent acute rejection in transplant recipients.3-5 Their capacity to combat established rejection has yet to be demonstrated. In a pilot study we have evaluated monoclonal anti-CD4 MAX.16H5 (used successfully in rheumatoid arthritis6) in the treatment of acute rejection in long-term renal allograft recipients. In five patients (1-5-6 years post transplant) with histologically and immunologically confirmed severe acute rejection the MAX. 16H5 was infused intravenously on three consecutive days at a dose of 0-6 mg/kg daily. All but one patient (prednisone/ azathioprine) was on triple drug basic immunosuppression. Biopsies were done before and 20-22 days after rejection therapy and fme-needle aspiration biopsies (FNAB) were done before and one to four times (one on day 7) after therapy. Six other patients with histologically and immunologically confirmed acute rejection 1.5-8 years post transplant received only 3 x1g methylprednisolone as bolus therapy. All eleven patients were treated between September, 1990, and May, 1991. The decision to give anti-CD4 or methylprednisolone depended on the patients’ agreement to antibody therapy and to the frequent biopsies. The infusion of anti-CD4 resulted in a sharp reduction of peripheral blood T cell expressing the CD4 antigen (in four out of five patients the count fell below 5% of pretreatment level). The first T cells expressing the CD4 antigen at normal density were