The American Journal of Tropical Medicine and Hygiene - Volume 83, Issue 3, September 2010

The objective of this study was to compare acute and chronic undernutrition rates before and after the introduction of a food-supplementation program as an adjunct to routine health care for children of migrant workers in the Dominican Republic. The cross-sectional study was conducted in five rural communities in the Dominican Republic. Children 18 years and younger were eligible if they received routine health care from local mobile clinics. Data were obtained before (2005) and after (2006) initiation of a food-supplementation program. χ2 or Fisher exact tests were used for analysis. Among 175 children in 2005, 52% were female, and 59% were < 5 years of age (mean age = 5.3 years). Among 148 children in 2006, 48% were female, and 57% were < 5 years of age (mean age = 5.6 years). Acute undernutrition rates decreased from 40% to 23% (P = 0.001) after initiation of the food-supplementation program. Rates of chronic undernutrition decreased from 33% to 18% after the initiation of the food-supplementation program (P = 0.003). Food supplementation in the context of routine health-care visits improved the nutritional status of children, and it warrants further exploration as a way to reduce childhood undernutrition in resource-scarce areas.

Limited objective data are available for the prevalence of peripheral neuropathy (PN) among antiretroviral (ART)–treated human immunodeficiency virus (HIV)–infected patients in resource-limited settings. A validated neuropathy-screening tool was integrated into routine ART visits at an HIV clinic in Mombasa, Kenya. Diagnosis of PN required at least one symptom and either abnormal vibratory sensation or deep tendon reflex bilaterally. Among 102 consecutively screened patients, 63% were women, 62% were receiving ART for ≤ 1 year, and 86% were receiving a stavudine (D4T)–based regimen. Thirty-seven (36%) had PN. Univariate analysis showed that current D4T use was protective against PN (P = 0.03) and older age was a marginal risk factor (P = 0.05). Multivariate analysis showed that older age was a risk factor for neuropathy (P = 0.04). Peripheral neuropathy was common, particularly among older HIV-infected adults in Kenya. The protective association with current D4T use likely represents survivor effect bias. Longitudinal studies using this screen will help further characterize PN in resource-limited settings.

Recent concerns regarding antiepileptic drug (AED) availability in Zambia led us to conduct a study in the Lusaka and Southern Provinces to quantify the availability and cost of AEDs and assess determinants. Among 111 pharmacies, almost one-half did not carry AEDs (N = 54; 49.1%). Available AEDs were phenobarbitone (21; 18.9%), carbamazepine (27; 24.3%), valproic acid (4; 3.6%), and phenytoin (3; 2.7%). Adult out-of-pocket monthly costs ranged from US $7 to $30. Pediatric syrups were universally unavailable. Interviews revealed several barriers to AED provision, including that handling phenobarbitone (historically the most affordable AED) has become increasingly difficult because of newly enforced regulatory requirements. Personal communications with epilepsy-care providers in other low income countries suggest that this problem may be widespread. Improved enforcement of existing drug regulations may be contributing to the AED shortage. Social programs aimed at encouraging people with epilepsy to come “out of the shadows” must be preceded by improved AED access.

The aim of this study was to describe the current status of diabetes care in an urban diabetes clinic in Malawi and the prevalence of human immunodeficiency virus (HIV) in this population, investigating possible associations between HIV and diabetes. A systematic prospective survey of patients attending the diabetes clinic at a teaching hospital in Blantyre, Malawi was conducted. Six hundred twenty patients were assessed. Seventy-four percent had glycosylated hemoglobin (HbA1C) > 7.5%. Systolic blood pressure was > 140 mm Hg in 52% of patients. Hypertension was more common in patients with raised creatinine (P < 0.003), retinopathy (P = 0.01), and stroke (P < 0.0002). Microvascular complication rates were high, specifically nephropathy (34.7%), retinopathy (34.7%), and neuropathy (46.4%). HIV seroprevalence was 13.7%. HIV-positive subjects had a lower body mass index (BMI) and lower fasting blood sugar, and they were more likely to have albuminuria (48.0% versus 33.3%; P < 0.05). Control of glycemia and hypertension were poor, and microvascular complications were common. Nephropathy in diabetic patients may be affected by HIV status.

The aim of this study was to identify whether there was a relationship between the distance that people have to carry water home and ill health. We conducted a systematic review for papers that reported on the association between diarrheal risk and distance. Six papers were identified for inclusion in the meta-analysis. These were all observational studies, and only two reported effect sizes that adjusted for possible confounding. Multiple different types of water sources supplied the study communities. The combined odds ratio (OR) showed a significant increase in illness risk in people living farther away from their water source (OR = 1.45; 95% confidence interval [CI] = 1.04–1.68). There is a need for better designed studies to further elucidate the health impacts on having to carry water home.

Five Anopheles marajoara Galvão and Damasceno populations, representing diverse ecological conditions, were sampled throughout Colombia and analyzed using nine hypervariable DNA microsatellite loci. The overall genetic diversity (H = 0.58) was lower than that determined for some Brazilian populations using the same markers. The Caquetá population (Colombia) had the lowest gene diversity (H = 0.48), and it was the only population at Hardy–Weinberg equilibrium. Hardy–Weinberg disequilibrium in the remaining four populations was probably caused by the Wahlund effect. The assignment analyses showed two incompletely isolated gene pools separated by the Eastern Andean cordillera. However, other possible geographical barriers (rivers and other mountains) did not play any role in the moderate genetic heterogeneity found among these populations (F ST = 0.069). These results are noteworthy, because this species is a putative malaria vector in Colombia.

Catches of Anopheles gambiae and An. arabiensis with the Ifakara Tent Trap-model B (ITT-B) correlate better with human landing catches than any other method but fail to reduce the proportion of blood-fed mosquito caught, which indicates that users are exposed to bites during collection. An improved C model (ITT-C) was developed and evaluated by comparing with ITT-B in semi-field and full-field conditions in southern Tanzania. The sensitivity of the ITT-C was approximately two times that of the ITT-B: relative rate (95% confidence interval) = 1.92 (1.52–2.42), 1.90 (1.48–2.43), and 2.30 (1.54–3.30) for field populations of An. arabiensis, Culex spp., and Mansonia spp., respectively. The ITT-C caught 73% less blood-fed An. arabiensis than the ITT-B in open field experiments and none in semi-field experiments, which confirmed that the C design is a safe trapping method. Validation of ITT-C by comparison with human landing catches and parasitologic measures of human infection status may be necessary to confirm that this design produces consistent and epidemiologically meaningful results.

The African malaria mosquito, Anopheles gambiae, inhabits diverse environments including dry savannas, where surface waters required for larval development are absent for 4–8 months per year. Under such conditions, An. gambiae virtually disappears. Whether populations survive the long dry season by aestivation (a dormant state promoting extended longevity during the summer) or are reestablished by migrants from distant locations where larval sites persist has remained an enigma for over 60 years. Resolving this question is important, because fragile dry season populations may be more susceptible to control. Here, we show unequivocally that An. gambiae aestivates based on a demographic study and a mark release–recapture experiment spanning the period from the end of one wet season to the beginning of the next. During the dry season, An. gambiae was barely detectable in Sahelian villages of Mali. Five days after the first rain, before a new generation of adults could be produced, mosquito abundance surged 10-fold, implying that most mosquitoes were concealed locally until the rain. Four days after the first rain, a marked female An. gambiae s.s. was recaptured. Initially captured, marked, and released at the end of the previous wet season, she has survived the 7-month-long dry season. These results provide evidence that An. gambiae persists throughout the dry season by aestivation and open new questions for mosquito and parasite research. Improved malaria control by targeting aestivating mosquitoes using existing or novel strategies may be possible.

Vector competence, the probability that a vector will transmit a pathogen after feeding on an infected host, is known to vary among vector species, populations, days since feeding, and temperature during the extrinsic incubation period. However, the extent of spatio-temporal variability and consistency in vector competence of populations is not known. We examined vector competence of Culex pipiens Linnaeus and Cx. restuans Theobald mosquitoes for West Nile virus collected over 3 years from 17 sites to measure spatial and temporal scales of variation in vector competence. We found extreme variation with 0–52% of mosquitoes transmitting West Nile virus at a single site between different sampling periods, and similar variation across populations. However, we also found that within a smaller geographic range, vector competence varied somewhat synchronously, suggesting that environmental and population genetic factors might influence vector competence. These results highlight the spatio-temporal variability in vector competence and the role of local processes.

The Aedes aegypti densovirus (AeDNV) has previously shown potential in mosquito control. To improve its efficacy as a biopesticide, the gene for an excitatory insect-specific toxin from Buthus martensii Karsch (BmK IT1) was inserted into the AeDNV genome and cloned into pUCA plasmid. The coding sequence for green fluorescent protein was ligated to the C-terminus of the BmK IT1 gene as a screening marker. Recombinant and helper plasmids were cotransfected into C6/36 cells; wild-type viruses were the controls. The recombinant viruses were identified and quantified by real-time polymerase chain reaction and exposed to Ae. albopictus larvae for the evaluation of its bioinsecticidal activity. LT50 and LD50 bioassays showed that the recombinant AeDNV had stronger and faster pathogenic effects on Ae. albopictus than the wild-type virus. This is the first report on the recombinant AeDNA containing the insect-specific toxin, BmK IT1, which may be used to develop a novel type of insecticide.

Plague is a vector-borne, highly virulent zoonotic disease caused by the bacterium Yersinia pestis. It persists in nature through transmission between its hosts (wild rodents) and vectors (fleas). During epizootics, the disease expands and spills over to other host species such as humans living in or close to affected areas. Here, we investigate the effect of large-scale climate variability on the dynamics of human plague in the western United States using a 56-year time series of plague reports (1950–2005). We found that El Niño Southern Oscillation and Pacific Decadal Oscillation in combination affect the dynamics of human plague over the western United States. The underlying mechanism could involve changes in precipitation and temperatures that impact both hosts and vectors. It is suggested that snow also may play a key role, possibly through its effects on summer soil moisture, which is known to be instrumental for flea survival and development and sustained growth of vegetation for rodents.

A retrospective, matched case-control study was conducted in Jamaica's Western Regional Health Authority (WRHA). Forty-three individuals developing clinical leptospirosis between January 2005 and December 2007 (i.e., cases) were age and neighborhood matched to 89 controls. Odds ratios (OR) and associated 95% confidence intervals (CIs) and the relative excess risk due to interaction (RERI) were calculated. Cases had increased odds of contact with rodents OR 3.52, goats OR 3.38, and being engaged in outdoor labor OR 5.30. Knowledge of leptospirosis and indoor work was protective, OR 0.39 and OR 0.16, respectively. Positive RERI values were noted for joint exposure to rodents and goats (RERI 5.54), outdoor labor and goats (RERI 6.97), and outdoor labor and rodents (RERI 30.59). Our results suggest a synergistic effect of occupational and environmental exposures on clinical human leptospirosis from the WRHA. Knowledge of the disease and its risk factors allows for protection from the disease.

We evaluated the incidence, severity, and duration of reactional states in 139 multibacillary (MB) leprosy patients in the first 2 years after the completion of the 1 year regimen of multidrug therapy (MDT) currently recommended by the World Health Organization (WHO) and compared those findings with 295 MB leprosy patients treated with the same regimen previously recommended for 2 years. During the first year after the completion of 1 year MDT, patients experienced 1 or more reactional states 27% of the time, the vast majority being lepra type 1 reactions (reversal reactions, RR), whereas patients who received 2 year MDT experienced a reactional state during that time period only 8% of the time (P < 0.001). Furthermore, during the first year after the completion of therapy, and during the first 2 years, both the number of reactional states and reversal reactions were significantly (P ≤ 0.004) more frequent, severe, of longer duration, and more commonly associated with neuritis.

In the United States, the American dog tick, Dermacentor variabilis (Say) is considered an important biological vector of Francisella tularensis, the etiologic agent of tularemia. In this study, we evaluated the vector efficiency of nymphal D. variabilis infected as larvae with differing clades and subspecies (A1b, A2, and type B) of F. tularensis. In all cases, D. variabilis larvae were able to acquire, maintain, and transstadially transmit F. tularensis. Significant replication of the bacteria also occurred in infected nymphs. Transmission of F. tularensis to Swiss Webster mice was not observed with A1b, and low rates were observed with A2 (8.0%) and type B (13.5%). Negative effects on tick survivorship were also observed for A1b, A2, and type B infections. Our results provide evidence of a high fitness cost and low transmission rates during the immature stages, suggesting that D. variabilis may play a limited role in enzootic maintenance of F. tularensis.

Rocky Mountain spotted fever (RMSF) is the most common tick-borne illness in Tennessee. Little is known about the occurrence of R. rickettsii, the causative agent, in ticks in Tennessee. To better understand the prevalence and distribution of rickettsial agents in ticks, we tested 1,265 Amblyomma, Dermacentor, and Ixodes adult and nymphal ticks. Additionally, we tested 231 Amblyomma americanum larvae. Ticks were collected from 49 counties from humans, wild animals, domestic canines, and flannel drags. Spotted fever group rickettsiae (SFGR) DNA was detected by polymerase chain reaction (PCR) in 32% of adult and nymphal ticks. A total minimum infection rate of 85.63 was found in larval pools tested. Three rickettsial species, Rickettsia montana, Rickettsia amblyommii, and Rickettsia cooleyi were identified by molecular analysis. Rickettsia rickettsii was not detected. This study suggests that some RMSF cases reported in Tennessee may be caused by cross-reactivity with other SFGR antigenically related to R. rickettsii.

Scrub typhus is a rickettsial disease transmitted to humans through the bite of chigger mites infected with Orientia tsutsugamushi, and is an endemic disease in Taiwan. To elucidate the molecular epidemiology of O. tsutsugamushi, the complete open reading frame of the 56-kDa type-specific antigen gene sequence of strains isolated from scrub typhus patients were determined and analyzed. A total of 116 isolates of O. tsutsugamushi were successfully isolated from patients infected in diverse geographic origins including Taiwan and three offshore islets, Kinmen, Matsu, and Penghu between May 2006 and December 2007. Sequence analysis revealed that 22 distinct sequence types could be identified that were broadly distributed in different clusters of the phylogenetic tree. Most of the isolates belong to Karp, Kawasaki, and Kuroki genotypes and are closely related to strains from Thailand, Japan, and Korea, whereas unique isolates different from other countries were also found in Taiwan. Distinct seasonal distributions were found in different sequence types. Some sequence types caused disease in the cold season, whereas others caused disease in the warm season.

Dengue is an acute emerging infectious disease transmitted by Aedes mosquitoes and has become a serious global public health problem. In mainland China, a number of large dengue outbreaks with serious consequences have been reported as early as 1978. In the three decades from 1978 to 2008, a total of 655,324 cases were reported, resulting in 610 deaths. Since the 1990s, dengue epidemics have spread gradually from Guangdong, Hainan, and Guangxi provinces in the southern coastal regions to the relatively northern and western regions including Fujian, Zhejiang, and Yunnan provinces. As the major transmission vectors of dengue viruses, the biological behavior and vectorial capacity of Aedes mosquitoes have undergone significant changes in the last two decades in mainland China, most likely the result of urbanization and global climate changes. In this review, we summarize the geographic and temporal distributions, the serotype and genotype distributions of dengue viruses in mainland China, and analyze the current status of surveillance and control of vectors for dengue transmission.

During the past two decades, Dengue virus-3 (DENV-3) has re-emerged in the Western Hemisphere causing significant epidemics of dengue fever (DF) and dengue hemorrhagic fever (DHF). In an effort to understand the molecular evolution of DENV-3 and their relationships to other DENV-3 circulating in the western hemisphere, we conducted a phylogenetic study on DENV-3 isolates made between 2002 and 2007 in the metropolitan area of Medellín, Colombia. An unexpected co-circulation of two different variants of DENV-3 subtype III during at least 5 years in Medellín was found. In addition, a more complete analysis of DENV-3 viruses isolated in other South American regions revealed the existence of three different subtype III lineages, all derived from independent introductions. This study documents significant genetic diversity of circulating viruses within the same subtype and an unusual capacity of the population of this city to support continuous circulation of multiple variants of dengue virus.

Dengue represents an important public health issue in many tropical areas, leading to high morbidity and the employment of substantial health resources. Even though the number of fatalities related to dengue is unknown, several reports warn about the potential occurrence of severe infections and even death. The clinical spectrum of dengue is highly variable, ranging from a mild flu-like syndrome to severe disease, with shock and hemorrhage. The occurrence of bacterial superinfection, or coinfection, in patients with dengue has been noted by some authors, but the available information comes from anecdotic reports. In this study, we show the clinical and anatomopathological data of a patient infected with dengue, who subsequently died of acute multi-organic failure related to Staphylococcus aureus infection. The autopsy revealed a severe disseminated staphylococcal disease and confirmed dengue infection.

Traditional study designs do not identify acute asymptomatic or pre-symptomatic dengue virus (DENV) infections, thus limiting our understanding of immunologic and viral factors that modulate infection outcome. In the 2006 and 2007 dengue seasons, we conducted a pilot index cluster study in Managua, Nicaragua, in which 442 persons living within 50 meters of 22 index cases identified through an ongoing pediatric cohort study were evaluated for DENV infection. Post-enrollment and pre-enrollment DENV infections were confirmed in 12 (2.7%) and 19 (4.3%) contacts, respectively. Five (42%) post-enrollment infections were asymptomatic, and DENV-2 was identified in 9 (75%) infections. Phylogenetic analysis with full-length DENV genomic sequence from contacts, index cases, and cohort dengue cases indicated focal transmission and infection outside the local area. We demonstrate the feasibility of identification of acute asymptomatic and pre-symptomatic cases in urban Latin America, the first report of such a study in the Americas, and identify age and concomitant immunity to DENV of contacts as a key factor in index cluster study design.