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PubMed2004

Epidemiology of Andean cutaneous leishmaniasis: incrimination of Lutzomyia ayacuchensis (Diptera: psychodidae) as a vector of Leishmania in geographically isolated, upland valleys of Peru.

The southernmost limit of the distribution of endemic Andean cutaneous leishmaniasis (CL), commonly known as Uta, is localized in the western Andean valleys of Ayacucho, Peru. This area is completely isolated from other regions endemic for this disease. Identification of the insect vector for Andean CL was carried out by combining entomologic and parasitologic approaches. Two Lutzomyia species were captured: Lutzomyia ayacuchensis and Lu. noguchii. The former species was considered responsible for transmission of Leishmania because 1) there was a coincidence in space and time between the presence of this insect and the distribution of Andean CL, 2) it was shown to be highly anthropophilic, 3) Leishmania parasites of the subgenus Viannia were detected by a specific polymerase chain reaction assay, 4) promastigotes isolated from this insect were shown by multilocus enzyme electrophoresis and molecular karyotyping to belong to the same deme of Leishmania (Viannia) peruviana as the one circulating in humans living in the study area, and 5) the complete cycle of L. (V.) peruviana was observed in experimental infections of Lu. ayacuchensis. Parasite and vector homogeneity found in Ayacucho contrasted with the heterogeneity reported for other areas endemic for Andean CL. The potential influence of ecologic determinants on this geographically isolated area is discussed.

Altitude↗
PubMedDate not supplied

[Hyperendemicity of human fasciolosis in the Mantaro Valley, Peru: factors for infection with Fasciole hepatica].

A sample of 206 children (between 1 and 16 years-old) in Huertas (n = 110) and Julcán (n = 96) districts of the Mantaro Valley, Peru, were studied with a clinico-epidemiological interview, serology and fecal parasitologic tests to describe the prevalence and analyze risk factors of infection by Fasciola hepatica (Fh). Fh prevalence by fecal examinations in Huertas (H) was 28.3% and Julcán (J), 12.6%. Using serological tests, the prevalences were: for H, 36.3% and for J, 22.7%. Univariate analysis showed a significant association between Fh infection and 3 variables in H: living near small streams (OR= 4.8; P < 0.05) or farms (OR= 2.88; P < 0.05) and the habit of drinking hot herbal drinks "emolientes" (OR= 2.92; P < 0.05); and in other 3 variables in J: having a single room per house (OR= 21.0; P < 0.05), defecating in the fields (OR= 4.77; P < 0.05), history of taking antiparasitic medication in the last six months (OR= 4.61; P < 0.05). Multivariate analysis, applied to the whole set of data revealed as possible risk factors for infection with Fh: the habit of drinking "emolientes" (OR= 5.16; P < 0.05) and living near small streams (OR= 17.22; P < 0.05) or in farms (OR= 8.13; P < 0.05). According to these results one of the most important and less recognized risk factors is the habit of drinking "emolientes". Due to the clinical importance of human fascioliasis, we conclude that its presence in the Mantaro Valley is an important public health problem, effective early diagnosis would allow rapid treatment and avoidance of the serious impairment brought by chronic infection.

Adolescent↗
PubMed2004

The value of counting BCG scars for interpretation of tuberculin skin tests in a tuberculosis hyperendemic shantytown, Peru.

SETTING: The tuberculin skin test (TST) is widely used as a diagnostic or screening test for Mycobacterium tuberculosis infection and disease. A peri-urban shantytown in the desert hills of south Lima, Peru, highly endemic for tuberculosis, and where bacille Calmette-Guérin (BCG) vaccine had been given in multiple doses until 1995. OBJECTIVE: To analyze the effect of multiple BCG vaccines on TST in a community-based setting. DESIGN: Point-prevalence survey of TST reactions of 572 people aged 6-26 years from 255 households. TST reactions were compared to the observed number of BCG scars and other potential risk factors (age, living with a TST-positive person, and contact with active tuberculosis). RESULT: People with two or more scars had significantly larger reactions, even after adjusting for potential risk factors. The adjusted population attributable fraction of being TST-positive and having two or more BCG scars was 26%. CONCLUSION: There is no demonstrated benefit of repeat BCG vaccination. We therefore recommend that physicians take into consideration the number of BCG scars when interpreting the TST and that programs give no more than one BCG vaccination.

Adolescent↗
PubMed2004

Implementation and initial evaluation of a Web-based nurse order entry system for multidrug-resistant tuberculosis patients in Peru.

Socios En Salud uses directly observed therapy to treat a majority of the multidrug-resistant tuberculosis in Peru. The nurses play an important role in this community-based model as the patients' primary care givers. Since nurses, rather than physicians, are involved in patients' daily care, we developed a nurse-order entry system to test whether such a system would improve the accuracy and quality of medication data. We compared regimen information from patient electronic medical records, paper charts and pharmacy records. After a two-month training period on the new system, we conducted the trial for 52 days in two of Lima's six geographic treatment areas, and re-reviewed the three sources of medication data. We measured the error rates after the trial period and found there was no significant difference in the control group's (Lima Este), error rate (8.6% vs. 6.9%, P=0.66) after the trial. The intervention group (Lima Callao), however, showed a significant drop in the error rate (17.4% vs. 3.1%, P=0.0074) after the same time interval. Additionally, the nurse expressed satisfaction with the order entry system and its ease of use. The decrease in error rates and user satisfaction regarding the system are promising measures of our order entry system's success.

Antitubercular Agents↗
PubMed2004

Reproductive tract infections in rural women from the highlands, jungle, and coastal regions of Peru.

OBJECTIVE: To define the prevalences and manifestations of reproductive tract infections (RTIs) in rural Peruvian women. METHODS: During 1997-98, we visited 18 rural districts in coastal, highlands, and jungle regions of Peru. We administered standardized questionnaires and pelvic examinations to members of women's community-based organizations; and collected vaginal fluid for pH, amine odour, Gram stain, microscopy, and culture for Trichomonas vaginalis; cervical specimens for Chlamydia trachomatis, Neisseria gonorrhoeae; human papilloma virus (HPV) by polymerase chain reaction (PCR) assays, and blood for syphilis serology. FINDINGS: The 754 participants averaged 36.9 years of age and 1.7 sex partners ever; 77% reported symptoms indicative of RTIs; 51% and 26% reported their symptoms spontaneously or only with specific questioning, respectively. Symptoms reported spontaneously included abnormal vaginal discharge (29.3% and 22.9%, respectively). One or more RTIs, found in 70.4% of participants, included bacterial vaginosis (43.7%), trichomoniasis (16.5%), vulvovaginal candidiasis (4.5%), chlamydial infection (6.8%), gonorrhoea (1.2%), syphilis seropositivity (1.7%), cervical HPV infection (4.9%), and genital warts or ulcers (2.8%). Of 715 adequate Pap smears, 7 revealed cancer, 4 high-grade squamous intra-epithelial lesions (SIL) and 15 low-grade SIL. Clinical algorithms had very low sensitivity and predictive values for cervical infection, but over half the women with symptoms of malodorous vaginal discharge, signs of abnormal vaginal discharge, or both, had bacterial vaginosis or trichomoniasis. CONCLUSION: Overall, 77% of women had symptoms indicative of RTIs, and 70% had objective evidence of one or more RTIs. Women with selected symptoms and signs of vaginal infection could benefit from standard metronidazole therapy.

Adolescent↗
PubMed2004

Variation in the costs of delivering routine immunization services in Peru.

OBJECTIVE: Estimates of vaccination costs usually provide only point estimates at national level with no information on cost variation. In practice, however, such information is necessary for programme managers. This paper presents information on the variations in costs of delivering routine immunization services in three diverse districts of Peru: Ayacucho (a mountainous area), San Martin (a jungle area) and Lima (a coastal area). METHODS: We consider the impact of variability on predictions of cost and reflect on the likely impact on expected cost-effectiveness ratios, policy decisions and future research practice. All costs are in 2002 prices in US dollars and include the costs of providing vaccination services incurred by 19 government health facilities during the January-December 2002 financial year. Vaccine wastage rates have been estimated using stock records. FINDINGS: The cost per fully vaccinated child ranged from 16.63-24.52 U.S. Dollars in Ayacucho, 21.79-36.69 U.S. Dollars in San Martin and 9.58-20.31 U.S. Dollars in Lima. The volume of vaccines administered and wastage rates are determinants of the variation in costs of delivering routine immunization services. CONCLUSION: This study shows there is considerable variation in the costs of providing vaccines across geographical regions and different types of facilities. Information on how costs vary can be used as a basis from which to generalize to other settings and provide more accurate estimates for decision-makers who do not have disaggregated data on local costs. Future studies should include sufficiently large sample sizes and ensure that regions are carefully selected in order to maximize the interpretation of cost variation.

Child, Preschool↗
PubMed2004

Environmental temperature, cholera, and acute diarrhoea in adults in Lima, Peru.

The effects of environmental temperature, presence and severity of El Niño, presence of cholera in the community, and interactions among these variables on the number of adult diarrhoeal patients attending the Hospital Nacional Cayetano Heredia in Lima, Peru, during 1991-1998, were evaluated. During 1991-1996, an increased number of visits to the hospital due to acute diarrhoea in the warmer months was observed. This periodic pattern was altered in 1997, when rising of the environmental temperature was observed in Lima secondarily associated with a strong El Niño event. A multivariate model was built in which environmental temperature and interaction between environmental temperature and presence of cholera predicted the number of adult patients with acute diarrhoea attending the Hospital Nacional Cayetano Heredia. Monitoring of environmental temperature and presence of cholera may be used as a warning system to predict epidemics of diarrhoea in adults, which may have a tremendous impact on healthcare strategies and management of health services in general.

Acute Disease↗
PubMed2004

[Excessive subcutaneous gnathostomosis after a six months stay in Peru. Successful treatment with albendazole].

A 27-year-old female primatologist returned from a trip to Peru with painful swellings on the right jaw, the mandible and at the axillary gland. Later on her right upper arm and forearm showed big, painful swellings with reddish stripes, while the former swellings gradually disappeared. Finally the back of the right hand, the right forefinger and the left forearm showed the same swellings. Diagnosis was established by the evidence of special antibodies against Gnathostoma spinigerum. Two courses of a 4-week treatment with albendazole cured the patient.

Adult↗
PubMed2005

Drug resistance profiles of Mycobacterium tuberculosis isolates: five years' experience and insight into treatment strategies for MDR-TB in Lima, Peru.

SETTING: Lima, Peru. OBJECTIVE: To describe drug resistance profiles of TB isolates from patients at risk for multidrug-resistant tuberculosis (MDR-TB), and to consider the implications of these findings for treatment. DESIGN: Descriptive study of drug susceptibility testing (DST) results for TB isolates from 1680 patients referred for suspicion of MDR-TB between 1996 and 2001. RESULTS: Of 1680 isolates tested, 1144 (68%) were resistant to at least one anti-tuberculosis drug and 926 (55%) were MDR-TB strains. Of 926 MDR isolates, 50 (5%) were resistant to INH and RMP alone, while 367 (40%) were resistant to at least five first-line drugs. We identified 146 unique drug resistance profiles, the most common of which accounted for 11% of drug-resistant isolates. The annual prevalence of isolates with resistance to at least five first-line drugs rose significantly during the study period, from 29% to 37% (P = 0.00086). CONCLUSIONS: This is a group of patients with TB disease among whom the prevalence of a broad spectrum of often highly drug-resistant strains appears to be increasing over time. A single standardized retreatment regimen may be inadequate to cure most patients. Capacity for drug sensitivity testing is essential for development of multiple standardized retreatment or individualized treatment regimens and epidemiological surveillance for planning.

Drug Resistance, Bacterial↗
PubMed2005

Randomized, double-blind, phase III, pivotal field trial of the comparative immunogenicity, safety, and tolerability of two yellow fever 17D vaccines (Arilvax and YF-VAX) in healthy infants and children in Peru.

We conducted a randomized, double-blind, phase III yellow fever (YF) vaccine trial among 1,107 healthy children in Sullana in northern Peru. The safety and efficacy (by measurement of geometric mean neutralizing antibody titer responses) were determined for two YF vaccines, ARILVAX (n = 738) and YF-VAX(R) (n = 369). Serocon-version rates were higher (94.9%) in ARILVAX than in YF-VAX (90.6%) recipients. The two-sided 95% confidence interval (YF-VAX-ARILVAX) was (-12.8% to -2.5%), indicating that the higher seroconversion rate for Arilvax was significant. Post-vaccination (30-day) mean log(10) neutralization indices were found to be similar for both products: 1.32 for ARILVAX and 1.26 for YF-VAX (P = 0.1404, by analysis of variance). A similar number of subjects in each group reported at least one adverse event (AE); 441 (59.8%) for ARILVAX versus 211 (59.9%) for YF-VAX. Most (591; 96.7%) of these were of a mild nature and resolved without treatment. There were no treatment-related serious AEs. This is the first randomized, double-blind comparison of two YF vaccines in a pediatric population; both vaccines were shown to be highly immunogenic and well-tolerated.

Antibodies, Viral↗
PubMed1992

Host records and tissue locations for Diplostomum mordax (metacercariae) inhabiting the cranial cavity of fishes from Lake Titicaca, Peru.

Metacercariae of Diplostomum mordax were found in the cranial cavity of Orestias agasii, Orestias olivaceous, Orestias luteus, and Basilichthys bonariensis, fishes from Lake Titicaca, Peru. Metacercariae were not found in Oncorhynchus mykiss introduced into the lake during 1939 and 1940. Compression of neural tissue within and on the surface of the brain was observed in all infected fishes. Metacercariae migrating into the cerebrum and cerebellum of the piscine host caused hemorrhaging, cell necrosis, inflammation, fiber formation, and nerve fiber disruption. The presence of D. mordax in B. bonariensis and the 3 species of Orestias constitute new host records. Infections in the cerebrum and cerebellum add new information on specific parasite location.

Animals↗
PubMed2005

Validation of a rapid method for detection of M. tuberculosis resistance to isoniazid and rifampin in Lima, Peru.

SETTING: Treatment of multidrug-resistant tuberculosis (MDR-TB) is often based on drug susceptibility testing (DST) results; for this reason, rapid, simple DST methods are sought which could be applied in resource-poor countries. One such method is a nitrate reductase colorimetric assay known as the Griess method. In Peru, where the incidence rate of TB is among the highest in South America, the National Institute of Health recently undertook the validation and implementation of the direct Griess method. OBJECTIVE: To describe the process of validation and implemention of the direct Griess method at the Peruvian National Institute of Health. DESIGN: Prospective study comparing the sensitivity and specificity of the direct Griess method with the Löwenstein-Jensen proportion method in determining resistance to isoniazid (INH) and rifampin (RMP) among clinical isolates. RESULTS: Among 192 specimens, the sensitivity and specificity of the Griess method for detection of INH resistance was 99.1% and 100%, respectively. For identification of RMP resistance, the sensitivity and specificity was 93.5% and 100%, respectively. CONCLUSIONS: In addition to its high sensitivity and specificity and rapid turn around time, the Griess method uses simple, inexpensive reagents and requires minimal laboratory space and technical expertise, thus providing an ideal screening tool for resource-poor settings with high rates of MDR-TB.

Colorimetry↗
PubMedDate not supplied

[Prevalence of entero-parasitosis in one Andean community in the Province of Victor Fajardo, Ayacucho, Peru].

The objectives of the study were to find out the prevalence and distribution of entero-parasitism and determine the prevalence of coproantigens of Taenia solium in the Andean community of Huancapi, Province of Victor Fajardo, Ayacucho, Peru. In the observational, transversal-descriptive study carried out between July and September 2000, by the Ritchie and Ziehl-Neelsen methods, modified by Cryptosporidium sp., samples of feces from 312 persons of the general population were examined. In addition, the presence of coproantigens of T. solium was investigated by the ELISA method. 77.88% (243) were positive to one or more entero-parasites. The prevalence for each protozoan specie is: 66.99% for Entamoeba coli; 12,50% for Iodamoeba butschlii; 10.90% for Chilomastix mesnili and 10.57% for Giardia lamblia; for the helminthes it was: 4.49% for Ascaris lumbricoides; 3.52% for Hymenolepis nana and 1.28% for Trichuris trichiura. Coproantigens of T. solium were detected in 3.52% of the samples. The prevailing commensal protozoan indicate that there are deficiencies in the basic sanitary services, particularly in water for domestic consumption. Huancapi is a new endemic zone for infection by T. solium.

Adolescent↗
PubMed2005

Tuberculosis skin testing, anergy and protein malnutrition in Peru.

SETTING: Malnutrition and intestinal parasites cause immunosuppression. This may cause false-negative tuberculin skin tests (TST) and failure to identify tuberculosis (TB) infection. OBJECTIVE: To assess factors associated with TST positivity and anergy in disadvantaged communities in Peru. DESIGN: A study of 212 randomly selected adults: 102 in a rural Amazonian village and 110 shanty town residents in urban Lima. RESULTS: Respectively 52% and 53% of urban and rural jungle populations were TST-positive. Using simultaneous tetanus and candida skin tests, 99% had at least one positive skin test. Generalised anergy was therefore rare, despite frequent intestinal parasitic infection, including 34% helminth infection prevalence in the jungle. TST positivity was associated with age (P = 0.001), known TB contact (P = 0.02) and poor household ventilation (P = 0.007). TST positivity was not significantly associated with crowding, reported past TB, single/multiple BCG vaccination, income, intestinal parasites, dietary factors, body mass index or body fat. Individuals with lower anthropometric body protein, as measured by corrected arm muscle area, were less likely to be TST-positive (P = 0.02), implying that protein malnutrition caused tuberculin-specific anergy. CONCLUSION: These results identify the importance of household ventilation for community TB transmission and add to the evidence that protein malnutrition suppresses TB immunity, causing false-negative TST results.

Adolescent↗
PubMed2005

Does traditional medicine use hamper efforts at tuberculosis control in urban Peru?

Decades of social and political unrest have contributed to the urbanization of the population of Peru with large-scale migration from rural Andean and Amazonian communities to overcrowded shantytowns around Lima. We administered a face-to-face survey questionnaire to 116 patients with suspected and proven tuberculosis (TB) in northern Lima to determine the extent to which the use of traditional therapies from indigenous regions persists and the impact of any such use on TB control. Sixty-three percent of participants reported some form of self-treatment prior to presentation to the National Tuberculosis Program; 52% of them used traditional remedies. Symptom duration was longer among self-remedy users than non-users (median = 25 versus 15 days; P = 0.07) and among those exclusively using western remedies rather than traditional remedies (median = 30 versus 15 days; P = 0.01). We thus found no evidence that use of traditional remedies has an appreciable effect on diagnostic delay in Lima.

Adult↗
PubMedDate not supplied

[Multiple sclerosis in Peru. A clinical-epidemiological description of a series of patients].

INTRODUCTION: In Peru up to recent years multiple sclerosis (MS) was considered a very rare disorder. AIM. To report clinical, epidemiological and ancillary test results of an MS cases series. PATIENTS AND METHODS: Description of a retrospective cohort of 55 patients studied in HNCH and a private neurological center in Lima between 1993-2004. Clinical records, laboratory and MRI tests were reviewed with Mc Donald's criteria. RESULTS: There were 55 cases (36 women). Mean age was forty. 65% were born in Lima, 27% have foreign ancestor up to third generation. 42 cases were definite MS and 13 possible MS. The most frequent form of MS was RRMS (49.1%). Early symptoms were optic neuritis, motor and sensitive complaints; in the follow up cerebelar symptoms, increase of motor compromise and sphincteric disturbance were showed. Brain and spine MRI were positive in 27 cases and 17 cases respectively. VEP were abnormal in 53% of cases, just one case had cerebrospinal fluid (CSF) compatible with MS. Mode of EDSS was 6.5. Immunomodulators were used in 30% of cases. Survival at 10 and 20 years of disease were 87% and 45% respectively. CONCLUSION: Our study shows than optic neuritis is an important early symptom and CSF study is commonly negative in patients with MS. Survival is shorter than other reports. Other features resembled previous international reports. To have foreign ancestors could be a risk factor for MS in this group.

Adolescent↗
PubMedDate not supplied

[Thiabendazole for the control of Strongyloides stercoralis infection in a hyperendemic area in Peru].

Strongyloides stercoralis infection is a disease caused by an intestinal parasite. This helminth is highly prevalent in tropical and subtropical areas. The preferred treatment is ivermectin, and thiabendazole as a second option available in certain Peruvian institutions. The purpose of the study was to assess the efficacy and tolerability of thiabendazole (25 mg/kg/day) administered twice a day (after meals) for three days in individuals with S. stercoralis chronic infection. The study was conducted at Hospital de La Merced, Province of Chanchamayo, Peru (endemic area), during a 90 day period. The study included 32 individuals (22 female and 10 male, average age +/- SD = 9.31 +/- 8.11 years) with a diagnosed S. stercoralis infection. Follow up tests were eosinophil count, hematocrit, agar plate feces culture, and Baermann technique modified by Lumbreras. Healing rate was 90.6%. The average eosinophil count in healed patients significantly decreased (1168 to 665 eosinophils/cc, p=0.006) as compared to the treatment failure group, which showed a slight increase (618 to 897 eosinophils/cc, p=0.125). Hematocrit increased in both groups (2% and 3%, respectively). Adverse effects were headache, dizziness, and epigastralgia in 6.2% of individuals. It was concluded that the studied scheme showed a high effectiveness rate and was well tolerated. Therefore this scheme may be taken into account for control programs of this parasite in hyperendemic areas.

Adolescent↗
PubMed2005

[Chagas disease in Peru: congenital transmission].

American Trypanosomosis is an important parasitic infection in Peru. Human cases, reservoirs and vectors have been showed in two known geographic areas in the endemic zones: southwestern and northern and northeastern regions of the country; however vectors belonging to the three genera of triatominae: Triatoma, Panstrongylus and Rhodnius have been collected in almost all the territory. The serological surveys in blood banks in the southwestern region is 2-6% and human cases found out of the endemic areas show the possibility of congenital cases. The study of the prevalence is starting. This preliminary study performed on 3000 pregnant of Arequipa shows serological positives in 22 (0.7%) and only a newborn positive at IgM. This result indicates a probable low rate of congenital transmission and necessary to perform more studies.

Adult↗