The American Journal of Tropical Medicine and Hygiene - Current Issue

Healthcare workforce shortages are continuing to increase worldwide with more profound deficits seen in rural communities in both developed and developing countries. These deficits impede progress towards heath equity and global health initiatives including the 2030 Sustainable Development Goals. Medical training has supported the idea that having a rural background influences future practice in rural settings. With a majority of global health experiences taking place in rural settings, there is an opportunity for health profession programs to take advantage of expanding global health education to encourage future practice in rural settings and address inequalities in workforce distribution.

Chagas disease remains a major impediment to sustainable socioeconomic development in Latin America. Transplacental transmission explains the persistence of transmission in urban areas, in non-endemic regions, and in areas with an established interrupted vectorial transmission. One of every five cases of congenital Chagas disease in the world occurs in Colombia and Venezuela. The massive migration of impoverished populations from neighboring Venezuela has worsened the situation creating a humanitarian crisis in Northeastern Colombia, including the Sierra Nevada de Santa Marta. The prevalence of Chagas infection among pregnant women in these areas is higher than the national average, and the public health resources are insufficient. This perspective discusses the associated increased morbidity and mortality of congenital Chagas in this region, where stigmatization contributes to the impression among health authorities and the general population that it affects indigenous communities only. The monitoring and control of congenital Chagas disease in the Sierra Nevada of Santa Marta is a public health necessity that demands urgent and effective interventions.

The neglected tropical diseases Zika, Ebola, and Lassa fever (LF) have all been noted to cause some degree of hearing loss (HL). Hearing loss is a chronic disability that can lead to a variety of detrimental effects, including speech and language delays in children, decreased economic productivity in adults, and accelerated cognitive decline in older adults. The objective of this review is to summarize what is known regarding HL secondary to these viruses. Literature for this review was gathered using the PubMed database. Articles were excluded if there were no data of the respective viruses, postinfectious complications, or conditions related to survivorship. A total of 50 articles were included in this review. Fourteen articles discussing Zika virus and subsequent complications were included. Across these studies, 56 (21.2%) of 264 Zika-infected individuals were found to have HL. Twenty-one articles discussing Ebola virus and subsequent complications were included, with 190 (5.7%) of 3,350 Ebola survivors found to have HL. Fifteen additional articles discussing LF and subsequent complications were included. Of 926 individuals with LF, 79 (8.5%) were found to have HL. These results demonstrate a relationship between HL and infection. The true prevalence is likely underestimated, however, because of lack of standardization of reporting and measurement. Future studies of viral sequelae would benefit from including audiometric evaluation. This information is critical to understanding pathophysiology, preventing future cases of this disability, and improving quality of life after survival of infection.

Buruli ulcer is an infectious disease provoking chronic, disabling skin ulcers in mammals and humans. Buruli ulcer is caused by Mycobacterium ulcerans, an environmental mycobacterium synthesizing a toxin called mycolactone responsible for the pathogenicity. The reservoirs and the modes of transmission of M. ulcerans remain elusive, limiting the prophylaxis capabilities in rural areas in endemic countries. In Australia, several studies have demonstrated the probable role of possums as reservoirs. In Côte d’Ivoire, some studies have speculated on the potential role of grasscutters in the transmission cycle of M. ulcerans. In this study, we detected M. ulcerans–specific sequences in rectal contents and spleens collected in wild grasscutters hunted in Buruli ulcer–endemic area in Côte d’Ivoire, but not in farmed negative control animals and in domesticated animals, namely, pigs, goats, cattle, and dogs, living in close contact with the local population. Some grasscutters exhibited the same sequence pattern in the feces and spleen. These observations confirm the asymptomatic gut carriage of M. ulcerans in this mammal species. Moreover, these observations suggest the dissemination of M. ulcerans from the gut to the spleen in grasscutters. These observations suggest that, in some mammals, M. ulcerans is not only an inoculated pathogen but also a translocating invasive pathogen.

We report a case of a 13-year-old immunocompetent male with multifocal tubercular osteomyelitis involving several spinal segments, small bones of the hands, and the scalp, who started with progressively back pain and enlarging painful swelling on the palms of hands, fatigue, and irregular fever. All the hand lesions were firm, mildly tender, and covered by ulcerated skin with serous discharge from the site. Magnetic resonance showed lesions of the right fifth metacarpal, of the right intermediate phalanx of the fourth finger, of the left second metacarpal, and of most vertebral bodies of the cervical, dorsal, lumbar, and sacral spine. The nucleic acid amplification test and the final culture from the drainage of the hands’ lesion were positive for Mycobacterium tuberculosis. The patient received a standard antitubercular treatment for 12 months with clinical improvement.

This article’s goal is to assess the perspectives of private providers on current and future public–private engagement in Metro Manila, a city of 13 million using semistructured interviews with a convenience sample of 18 private physicians. Our study found that private providers perceived their clientele as loyal and their services as distinct from public services, with unique attractions of convenience and quality of service. They saw value in engaging with the public sector for knowledge exchange, access to public-sector commodities, and access to public sector assistance with public health tasks related to tuberculosis (TB). However, their proposed ways of engaging were more centered on the private sector role, in ways that are not currently being pursued by the public sector. It is of the utmost importance to recognize that private provider perspectives are essential to build effective engagement models and, thus, to reach all clients with quality TB care.

Treatment for multidrug-resistant tuberculosis (MDR TB) is associated with adverse events (AE). Patients treated with an MDR TB regimen in Hospital Nossa Senhora da Paz, Cubal, Angola, were prospectively enrolled from May 2013 to July 2015. Baseline characteristics, AE, and clinical and microbiological outcomes were recorded. A total of 216 patients were treated with an MDR TB regimen and 179 (82.9%) patients developed at least one AE. The most common AE were elevation of liver enzymes (46.8% of patients), elevated creatinine (44.4% of patients), and ototoxicity (40.7% of patients). Previous TB treatment was associated with the occurrence of AE (OR 4.89, 95% CI: 2.09–11.46, P < 0.001) and months on treatment was associated to severe AE (OR 1.11 95% CI: 1.04–1.18, P = 0.001). Successful treatment was achieved in 117 (54.2%) patients. Incidence of AE was associated with an unsuccessful outcome (OR 1.23, 95% CI: 1.09–1.40, P = 0.001). Patients treated with MDR TB treatment frequently experience AE, and these are related with previous TB treatment and duration of treatment. Given the high percentage of patients experiencing AE and the low treatment success rates, more effective and less toxic drugs to treat MDR TB are urgently needed.

We aimed to investigate the epidemic situation of tuberculosis (TB) in prisons in the central region of China. Tuberculosis screening was carried out in two prisons in middle China. A sum of 3,459 prisoners accepted chest X-ray examination; 40 of them were diagnosed as active TB patients. The active TB prevalence (1,156/105) was significantly higher than that of the province and China’s general population (P < 0.01). As for gender, TB prevalence in men’s prison (1,589/105) was higher than that in the women’s prison (946/105). Nevertheless, the risk of having TB in women’s prison was much higher than that in the men’s prison when compared with the TB prevalence from the province (women: OR = 2.37, 95% CI: 1.34, 4.22; men: OR = 1.53, 95% CI: 0.90, 2.60) and the China’s general population (women: OR = 3.30, 95% CI: 2.15, 5.09; men: OR = 2.06, 95% CI: 1.29, 3.30). In view of the severe epidemic situation of TB in prisons, integrating medical resources to establish a consummate and effective management system is necessary.

Enteric fever is a major public health concern in endemic areas, particularly in infrastructure-limited countries where Salmonella Paratyphi A has emerged in increasing proportion of cases. We aimed to evaluate a method to detect Salmonella Typhi (S. Typhi) and Salmonella Paratyphi A (S. Paratyphi A) in febrile patients in Bangladesh. We conducted a prospective study enrolling patients with fever > 38°C admitted to two large urban hospitals and two outpatient clinics located in Dhaka, Bangladesh. We developed and evaluated a method combining short culture with a new molecular assay to simultaneously detect and differentiate S. Typhi and S. Paratyphi A from other Salmonella directly from 2 to 4 mL of whole blood in febrile patients (n = 680). A total of 680 cases were enrolled from the four participating sites. An increase in the detection rate (+38.8%) in S. Typhi and S. Paratyphi A was observed with a multiplex polymerase chain reaction (PCR) assay, and absence of non-typhoidal Salmonella detection was reported. All 45 healthy controls were culture and PCR negative, generating an estimated 92.9% of specificity on clinical samples. When clinical performance was assessed in the absence of blood volume prioritization for testing, a latent class model estimates clinical performance ≥ 95% in sensitivity and specificity with likelihood ratio (LR) LR+ > 10 and LR− < 0.1 for the multiplex PCR assay. The alternative method to blood culture we developed may be useful alone or in combination with culture or serological tests for epidemiological studies in high disease burden settings and should be considered as secondary endpoint test for future vaccine trials.

In 2017–18, a large-scale cholera outbreak swept Yemen. We calculated the number of culture-confirmed cases from the suspected cases and diagnosis testing records. We estimate 184,248 confirmed cholera cases between April 2017 and the end of 2017, and the reproduction number of 2.2 with 95% CI of [2.1, 2.3] during the initial stage. We find a significantly (nonlinear) positive association between the reproduction number (R t ) and precipitation, explained 13% of transmissibility changes, with one unit (mm) increment in precipitation leading to an increment of 20.1% in R t . We find a significantly (nonlinear) negative association between the R t and cumulative Google Trends index (GTI), explained 62% of transmissibility changes, with one unit increment in cumulative GTI leading to a drop of 0.03% in R t .

Subject to a high burden of diarrheal diseases, Afghanistan is also susceptible to climate change. This study investigated the spatiotemporal distribution of diarrheal disease in the country and how associated it is with climate variables. Using monthly aggregated new cases of acute diarrhea reported between 2010 and 2016 and monthly averaged climate data at the district level, we fitted a hierarchical Bayesian spatiotemporal statistical model. We found aridity and mean daily temperature were positively associated with diarrhea incidence; every 1°C increase in mean daily temperature and 0.01-unit change in the aridity index were associated with a 0.70% (CI: 0.67%, 0.73%) increase and a 4.79% (CI: 4.30%, 5.26%) increase in the risk of diarrhea, respectively. Average annual temperature, on the other hand, was negatively associated, with a 3.7% (CI: 3.74%, 3.68) decrease in risk for every degree Celsius increase in annual average temperature. Temporally, most districts exhibited similar seasonal trends, with incidence peaking in summer, except for the eastern region where differences in climate patterns and population density may be associated with high rates of diarrhea throughout the year. The results from this study highlight the significant role of climate in shaping diarrheal patterns in Afghanistan, allowing policymakers to account for potential impacts of climate change in their public health assessments.

Multiplex polymerase chain reaction (PCR) platforms have enhanced understanding of intestinal pathogens in low- and middle-income countries (LMICs). However, few such studies have been performed in Latin America, where poverty, poor sanitation, and undernutrition persist. Multiplex PCR (BioFire, Salt Lake City, UT) was used to identify viral, bacterial, and parasitic pathogens in stool collected on day 1 and 31 from children aged 6 to 35 months with acute, non-bloody diarrhea in two locations (rural and urban) in Guatemala. We analyzed correlation between pathogens and clinical, demographic, and socioeconomic variables; described patterns of pathogen acquisition, persistence, and clearance over the 30-day period; and calculated population attributable fractions (PAFs) for diarrheal causation for individual pathogens. We analyzed 316 subjects (144 urban; 172 rural) enrolled between March 2015 and January 2016. Rural subjects had significantly more malnutrition, animal exposure, and unimproved water/sanitation infrastructure. The majority of subjects had multiple pathogens/sample (4.8 rural and 2.7 urban). Few meaningful correlates were identified between individual pathogens and clinical, demographic, or environmental variables. Escherichia coli pathotypes, Shigella, Campylobacter, and Giardia had high rates of persistence between initial and 30-day follow-up. Statistically significant adjusted PAFs were identified for Campylobacter (14.9%, 95% CI: 3.2–23.1), norovirus (10.2%, 95% CI: 0.4–17.1), sapovirus (7.6%, 95% CI: 2.3–10.9), and adenovirus 40/41 (5.6%, 95% CI: 0.3–8.7). These observations further characterize the diversity and complexity of enteric pathogens in children in LMICs. Patterns of chronic symptomatic and asymptomatic infection among Latin American children are similar to those observed in other LMIC regions. Findings have direct implications for practitioners treating individuals with acute infectious diarrhea and should inform regional public health strategies.

Campylobacter jejuni is the leading bacterial cause of diarrhea worldwide. A capsular polysaccharide (CPS) conjugate vaccine is under development and requires determination of the valency. However, distribution of CPS types circulating globally is presently poorly described. We aimed to determine whether CPS type distribution in Peru differs from that in other endemic regions. We used a multiplex polymerase chain reaction (PCR) assay for the detection of CPS encoding genes capable of distinguishing all 35 CPS types on Campylobacter isolates in two prospective communities based studies conducted in cohorts of children less than 59 months of age in Peru. Results showed that CPS type HS4 complex was the most prevalent, followed by HS3 complex and HS15. Differences in CPS type for symptomatology were not statistically significant. Most subjects demonstrated repeated infections over time with different CPS types, suggesting that CPS types may confer of a level of homologous protective immunity. In this dataset, some differences in CPS type distribution were observed in comparison to other low-middle income countries. Further studies need to be conducted in endemic areas to increase our knowledge of CPS type distribution and guide vaccine development.

Infectious diarrhea cases have increased during the past years in the Anhui Province of China, but little is known about its spatial cluster pattern and associated socioeconomic factors. We obtained county-level total cases of infectious diarrhea in 105 counties of Anhui in 2016 and computed age-adjusted rates. Socioeconomic factors were collected from the Statistical Yearbook. Hot spot analysis was used to identify hot and cold spot counties for infectious diarrhea incidence. We then applied binary logistic regression models to determine the association between socioeconomic factors and hot spot or cold spot clustering risk. Hot spot analysis indicated there were both significant hot spot (29 counties) and cold spot (18 counties) clustering areas for infectious diarrhea in Anhui (P < 0.10). Multivariate binary logistic regression results showed that infectious diarrhea hot spots were positively associated with per capita gross domestic product (GDP), with an adjusted odds ratio (AOR): 3.51, 95% CI: 2.09–5.91, whereas cold spots clustering were positively associated with the number of medical staffs (AOR: 1.18, 95% CI: 1.08–1.29) and negatively associated with the number of public health physicians (AOR: 0.27, 95% CI: 0.09–0.86). We identified locations for hot and cold spot clusters of infectious diarrhea incidence in Anhui, and the clustering risks were significantly associated with health workforce resources and the regional economic development. Targeted interventions should be carried out with considerations of regional socioeconomic conditions.

Improving access to safe and affordable sanitation facilities is a global health priority that is essential for meeting the United Nation’s Sustainable Development Goals. To promote the use of improved sanitation in rural and low-income settings, plastic latrine slabs provide a simple option for upgrading traditional pit latrines. The International Finance Corporation/World Bank Selling Sanitation program estimated that plastic slabs would have a 34% annual growth, with a market size of US$2.53 million in Kenya by 2017. In this study, we examined the commercial viability of these plastic latrine slabs in rural Kenya by evaluating a financing and distribution model intervention, documenting household slab sales to date, and assessing consumer exposure and perceptions. We also determined household willingness to pay through a real-money auction with 322 households. We found that no households in our study area had purchased the plastic slabs. The primary barriers to slab sales were limited marketing activities and low demand compared with the sales price: households were willing to pay an average of US$5 compared with a market price of US$16. Therefore, current household demand for the plastic latrine slabs in rural Kenya is too low to support commercial distribution. Further efforts are required to align the price of plastic latrine slabs with consumer demand in this setting, such as additional demand creation, product financing, and public sector investment.

Poor hand hygiene and food handling put consumers of restaurant and street food at risk of enteric disease, especially in low-income countries. This study aimed to collect hygiene indicators from a nationally representative sample of restaurants and street food vendors. The field team collected data from 50 rural villages and 50 urban administrative units (mahallas). We explored restaurant service staff, cook, and food vendor hygiene practices (N = 300 restaurants and 600 street food vendors), by observing hygiene facilities, food handling, and utensil cleaning. A qualitative assessment explored perceptions of hygiene related to food handling. During restaurant spot checks, 91% (273/300) had soap and water at handwashing location for customers but in only 33% (100) at locations convenient for restaurant staff. Among street food–vending stalls, 11% (68/600) had soap and water when observed. During 90-minute structured observations, cooks used soap to wash hands on 14/514 (3%) of occasions before food preparation, 6/82 (8%) occasions after cutting fish/meat/vegetables, 3/71 (4%) occasions before serving food, and 0/49 (0%) occasions) before hand-mashing food/salad preparation; no street food vendors washed hands with soap during these food-handling events. Most of the qualitative study participants perceived that customers select a vendor based on tastiness of the food, whereas no one mentioned the importance of food hygiene. The study demonstrates widespread poor hygiene and food-handling practices in restaurants and among food vendors. Based on our study findings, we proposed a food premises Hygiene Investigation Model to create action plans to improve food safety.

To address water and hygiene infrastructure deficiencies in health-care facilities (HCFs) in Siaya County, Kenya, portable water stations, soap, and water treatment products were provided to 109 HCFs in 2005. In 2011 and again in 2016, we interviewed staff in 26 randomly selected HCFs, observed water sources, water stations, and tested source and stored water for chlorine residual and Escherichia coli. Of 26 HCFs, 22 (85%) had improved water supplies, and 22 (85%) had functioning handwashing and drinking water stations, but < 50% provided soap or water treatment. Thirteen (50%) of 26 source water samples yielded E. coli; 24 (92%) of 26 stored water samples yielded no E. coli, including nine with residual chlorine and nine untreated samples from sources yielding no E. coli. Eleven years after implementation, 85% of HCFs continued to use water stations that protected water from recontamination. Sustainable provision of soap and water treatment products could optimize intervention use.

A previously healthy young man presented with a chronic cavitary pulmonary infection that began while in Goa, India. Burkholderia pseudomallei was cultured from sputum samples. The infection fully resolved after prolonged antibiotic treatment. Other than traveling during the monsoon season, extensive use of well-water for water-pipe smoking of cannabis was identified as a possible risk factor for infection. This is one of the first reports of travel-associated melioidosis from India. Genomic and immunological characterization suggested that the B. pseudomallei isolate collected from the reported case exhibited limited similarity to other B. pseudomallei strains.

Leptospirosis is the leading cause of zoonotic morbidity and mortality globally, yet little is known about the immune mechanisms that may contribute to pathogenesis and severe disease. Although neutrophils are a key component of early immune responses to infection, they have been associated with tissue damage and inflammation in some febrile infections. To assess whether neutrophils contribute to the pathogenesis observed in severe leptospirosis, we quantitated levels of neutrophil activation markers in patients with varying disease severities. Hospitalized leptospirosis patients had significantly higher levels of toll-like receptors 2 and 4 (TLR2 and TLR4, respectively) on peripheral neutrophils than healthy controls, with the highest levels detected in patients with organ dysfunction. We observed no significant differences in other neutrophil baseline activation markers (CD62L and CD11b) or activation capacity (CD62L and CD11b levels following stimulation), regardless of disease severity. Our results provide preliminary evidence supporting the hypothesis that higher initial bacterial loads or inadequate or delayed neutrophil responses, rather than TLR-driven inflammation, may drive severe disease outcomes.

Leishmaniasis is a vector-borne disease caused by protozoan parasites of the Leishmania genus. In Australia, leishmaniasis is an imported disease that is presenting itself at increased rates because of international travel, the influx of immigrants, and deployment of military operations to endemic regions. Although Leishmania species are morphologically indistinguishable, there is a strong correlation between some causative species of leishmaniasis and the subsequent response to the treatments available and patient outcome. Consequently, identification of the infective species is imperative as misidentification can result in the administering of an ineffective drug. The aim of this study was to develop a simple diagnostic tool with high sensitivity and specificity, which is capable of detecting the presence of the parasite and accurately differentiating the causative species in question. Using the advantageous properties of the maxi-circle kinetoplast DNA, a polymerase chain reaction (PCR)-restriction fragment length polymorphism (RFLP) targeting the ND7 gene was developed for the analysis of imported cases of human leishmaniasis in Australia. Designed as a dual analysis, concurrent PCR of Leishmania maxi-circle DNA and digestion with two separate enzymes (NlaIII and HpyCH4IV), this study provides an appraisal on 24 imported cases of leishmaniasis between 2008 and 2017. Five Leishmania species were reported, with members of the Viannia subgenus being the most common. The implementation of novel diagnostic procedures for leishmaniasis such as the one reported here is needed to establish a gold standard practice for the diagnosis and treatment of leishmaniasis.

The subfamily Triatominae currently consists of 154 species, most of them being of great importance for public health because they are considered potential vectors of the protozoan Trypanosoma cruzi, the etiologic agent of Chagas disease. In addition to their epidemiological importance, these insects are considered important biological models for cell studies because they have peculiar characteristics in their cells, for example, persistence of the nucleolus during spermatogenesis. This phenomenon is characterized by the presence of the nucleolus or nucleolar corpuscles during all phases of meiosis. To date, all knowledge is restricted to the study of the presence/absence of the nucleolus during the triatomine meiosis, so the present work aimed to analyze if this persistent nucleolar material has transcriptional activity. Analysis of the meiotic metaphases of Rhodnius montenegrensis and Panstrongylus megistus by using fluorochrome acridine orange made it possible to characterize the presence of RNA in the nucleolar material. Thus, it was demonstrated, for the first time, that the persistent nucleolar material during triatomine meiosis is transcriptionally active, supporting the hypothesis of the relationship between nucleolar persistence during meiosis of these insects and the formation of the chromoid body, an organelle responsible for the support of all transcriptional activities during spermiogenesis.

Chagas disease is a public health problem caused by the Trypanosoma cruzi, and the T. cruzi I (TcI) and T. cruzi II (TcII) groups are considered important genotypes from the clinical point of view. Currently, the groups need to be molecularly analyzed for their identification; thus, we cytogenetically analyzed these groups with the objective of developing more accessible techniques for the characterization of these parasites. TcI and TcII groups were differentiated by nucleus characterization with lacto-acetic orcein (TcI—nucleus with positive heteropycnosis and TcII—nucleus with negative heteropycnosis), emphasizing the importance of the application of this technique for epidemiological and clinical studies of Chagas disease.

Angiostrongyliasis, caused by the Angiostrongylus cantonensis roundworm, became reportable in the state of Hawaii in 2007. We confirmed 82 reported cases between 2007 and 2017. There was a median of seven cases per year, and the majority (57%) of cases occurred between January and April. Most (83%) cases were found on the island of Hawaii, with geographic information system (GIS) analysis identifying hot spots on the east side of the island. However, cases were identified on the other major islands as well, suggesting the risk of exposure is present statewide. Comparisons of cases from 2007 to 2017 with cases from previous assessments found no statistical differences in cerebrospinal fluid results, peripheral blood results, or ages of cases. However, differences in geographic distribution of the cases were statistically significant. Improved testing and increasing awareness of the disease have contributed to our efforts to better understand the general risk factors and modes of transmission present in Hawaii and also helped improve our prevention efforts, although we still do not fully understand the specific causes of cases being concentrated in certain parts of the state over others. Continued outreach efforts, including public forums and publication of preliminary clinical guidelines, aim to inform and improve our public health response and efforts to prevent angiostrongyliasis.

Control of schistosomiasis presently relies largely on preventive chemotherapy with praziquantel through mass drug administration (MDA) programs. The Schistosomiasis Consortium for Operational Research and Evaluation has concluded five studies in four countries (Côte d’Ivoire, Kenya, Mozambique, and Tanzania) to evaluate alternative approaches to MDA. Studies involved four intervention years, with final evaluation in the fifth year. Mass drug administration given annually or twice over 4 years reduced average prevalence and intensity of schistosome infections, but not all villages that were treated in the same way responded similarly. There are multiple ways by which responsiveness to MDA, or the lack thereof, could be measured. In the analyses presented here, we defined persistent hotspots (PHS) as villages that achieved less than 35% reduction in prevalence and/or less than 50% reduction in infection intensity after 4 years of either school-based or community-wide MDA, either annually or twice in 4 years. By this definition, at least 30% of villages in each of the five studies were PHSs. We found no consistent relationship between PHSs and the type or frequency of intervention, adequacy of reported MDA coverage, and prevalence or intensity of infection at baseline. New research is warranted to identify PHSs after just one or a few rounds of MDA, and new adaptive strategies need to be advanced and validated for turning PHSs into responder villages.

Cystic echinococcosis (CE) is a chronic, complex, and overlooked zoonotic disease caused by Echinococcus granulosus. In humans, it may result in a wide spectrum of clinical manifestations depending on the type of complications, ranging from asymptomatic infection to fatal disease. The primary complications and risk factors associated with CE are not well defined. We performed a retrospective, observational study of inpatients diagnosed with CE from January 1998 to December 2017 in the public health-care system of western Spain. Five hundred and six cases were analyzed. More than half of the patients (302 [59.7%]) were asymptomatic, and the diagnoses were made incidentally. A total of 204 (40.3%) patients had complications associated with CE; 97 (47.5%) were mechanical, 62 (30.4%) were infectious, 15 (7.3%) were immunoallergic, and 30 (14.7%) involved a combination of complications. Mortality was higher in patients with mechanical complications (9.4%) than in patients with infectious complications (5.6%) and in patients with allergic complications (0%) (odds ratio = 19.7, 95% CI, 4.3–89.1, P < 0.001). In summary, CE frequently results in complications, especially in the liver in younger patients and, regardless of other variables, such as size or stage of cyst. Mechanical problems and superinfection are the most frequent complications. CE is an obligatory diagnosis in patients with urticarial or anaphylactoid reactions of unknown cause in endemic areas.

Children in the Peruvian Amazon Basin are at risk of soil-transmitted helminths (STH) infections. This study aimed to determine the prevalence of STH infection in children from a rural Amazonian community of Peru and to elucidate epidemiological risk factors associated with its perpetuation while on a school-based deworming program with mebendazole. Stool samples of children aged 2–14 years and their mothers were analyzed through direct smear analysis, Kato–Katz, spontaneous sedimentation in tube, Baermann’s method, and agar plate culture. A questionnaire was administered to collect epidemiological information of interest. Among 124 children, 25.8% had one or more STH. Individual prevalence rates were as follows: Ascaris lumbricoides, 16.1%; Strongyloides stercoralis, 10.5%; hookworm, 1.6%; and Trichuris trichiura, (1.6%). The prevalence of common STH (A. lumbricoides, T. trichiura, and hookworm) was higher among children aged 2–5 years than older children (31.6% versus 12.8%; P = 0.01). In terms of sanitation deficits, walking barefoot was significantly associated with STH infection (OR = 3.28; CI 95% = 1.11–12.07). Furthermore, STH-infected children more frequently had a mother who was concomitantly infected by STH than the non-STH–infected counterpart (36.4% versus 14.1%, P = 0.02). In conclusion, STH infection is highly prevalent in children from this Amazonian community despite routine deworming. Institutional health policies may include hygiene and sanitation improvements and screening/deworming of mothers to limit the dissemination of STH. Further studies are needed to address the social and epidemiological mechanics perpetuating these infections.

Mass deworming of school-aged children with anthelmintics has been recognized as an effective approach for reducing the burden of soil-transmitted helminth (STH) infections. However, the consequences of this intervention on nontargeted parasite populations sharing the same gastrointestinal niche are unclear. We conducted a cross-sectional survey among three primary schools in Sululta town, Ethiopia, to examine the association between students’ histories of deworming treatment in the past 6 months and the prevalence of cestode and protozoan infections. An interviewer-led questionnaire administered to parents provided information on sociodemographic factors, and deworming status was ascertained from school records. Stool samples were collected from 525 children for microscopic examination. The independent associations of “any cestode” (positive either for Hymenolepis nana or Taenia spp. eggs) and “any protozoan” (positive either for Giardia lamblia or Entamoeba histolytica/Entamoeba dispar) with history of deworming were examined using logistic regression. Overall, 25.9% of children were infected with at least one intestinal parasite of which H. nana was the most common. In multivariate analyses, deworming in the past 6 months was positively associated with increased odds of both “any protozoan” and “any cestode” infections; the latter reached statistical significance (AOR = 1.83, 95% CI: 0.69–4.86, P = 0.220, AOR = 3.82, 95% CI: 1.17–12.73, P = 0.029, respectively). If this observed association is causal, a greater understanding of interspecies interactions within the gastrointestinal niche may elucidate possible consequences of mass deworming treatments against STHs on coexisting nontargeted parasites.

The Awa indigenous people of Ecuador live in remote areas and were included in health programs only recently. The first screening for parasitic infections in the Awa communities was implemented in the context of community epidemiology. During the site visits in each community, the health-care staff collected the samples for stool microscopy and serology for Strongyloides. A total of 705 individuals consented for the study, representing 40% of the Awa population living in the targeted communities; 184 (26%) participants supplied a stool sample. Giardia intestinalis was found in about 11% of samples. Prevalence of Ascaris lumbricoides and Trichuris trichiura was 54.9% and 36.9%, respectively. No hookworm eggs were found. In addition, Strongyloides stercoralis larvae were found in eight individuals (4.3%), whereas serology was positive in 22.7% of the individuals tested. The community-based approach resulted in an impressive participation. There was a high prevalence of parasites associated with relevant morbidity.

Geophagy, the craving and purposive consumption of earth, is commonly reported during pregnancy. To date, most studies of geophagy have been cross-sectional and have not assessed its relationship with HIV infection. Therefore, to concurrently examine proposed etiologies of geophagy, a cohort of 371 women with mixed HIV status from Nyanza region, Kenya were recruited in late pregnancy and interviewed about pica at nine time points, through 21 months postpartum. Nutritional status (hemoglobin concentration and food insecurity), physical health (HIV infection and gastrointestinal distress), and psychosocial health (depression and perceived stress) were also repeatedly assessed. Prevalence of geophagy was greatest during pregnancy and decreased significantly postpartum. In a two-level hierarchical linear model, a one-unit increase in average hemoglobin (g/dL) was associated with a 35% decrease in the odds of geophagy. The adjusted odds ratios (CI) of geophagy were 3.98 (2.99, 5.29), 2.54 (1.13, 5.69), and 1.68 (1.15, 2.44) times higher if a woman was pregnant, reported diarrhea in the prior 24 hours, or was HIV positive, respectively. The adjusted odds ratio of geophagy was 1.61 (1.06, 2.45) times higher if a woman reported geophagy during childhood. Our results lend greatest plausibility to the protection hypothesis (i.e., that geophagy occurs in response to compromised immunity and/or infection). Given the high prevalence of geophagy, clinicians should regularly screen for the behavior and measure inflammatory biomarkers before treating geophagy with iron supplements, which can exacerbate some infections.

Nomadic pastoralists are among the world’s hardest-to-reach and least served populations. Pastoralist communities are difficult to capture in household surveys because of factors including their high degree of mobility over remote terrain, fluid domestic arrangements, and cultural barriers. Most surveys use census-based sampling frames which do not accurately capture the demographic and health parameters of nomadic populations. As a result, pastoralists are “invisible” in population data such as the Demographic and Health Surveys (DHS). By combining remote sensing and geospatial analysis, we developed a sampling strategy designed to capture the current distribution of nomadic populations. We then implemented this sampling frame to survey a population of mobile pastoralists in southwest Ethiopia, focusing on maternal and child health (MCH) indicators. Using standardized instruments from DHS questionnaires, we draw comparisons with regional and national data finding disparities with DHS data in core MCH indicators, including vaccination coverage, skilled birth attendance, and nutritional status. Our field validation demonstrates that this method is a logistically feasible alternative to conventional sampling frames and may be used at the population level. Geospatial sampling methods provide cost-affordable and logistically feasible strategies for sampling mobile populations, a crucial first step toward reaching these groups with health services.

In low-resource settings, many children are severely ill at arrival to hospital. The risk factors for mortality among such ill children are not well-known. Understanding which of these patients are at the highest risk could assist in the allocation of limited resources to where they are most needed. A cohort study of severely ill children treated in the resuscitation room of the pediatric emergency department at Queen Elizabeth Central Hospital in Malawi was conducted over a 6-month period in 2017. Data on signs and symptoms, vital signs, blood glucose levels, and nutritional status were collected and linked with in-hospital mortality data. The factors associated with in-hospital mortality were analyzed using multivariable logistic regression. Data for 1,359 patients were analyzed and 118 (8.7%) patients died. The following factors were associated with mortality: presence of any severely deranged vital sign, unadjusted odds ratio (UOR) 2.6 (95% CI 1.7–4.0) and adjusted odds ratio (AOR) 3.2 (95% CI 2.0–5.0); severe dehydration, UOR 2.6 (1.4–5.1) and AOR 2.8 (1.3–6.0); hypoglycemia glycemia (< 5 mmol/L), UOR 3.6 (2.2–5.8) and AOR 2.7 (1.6–4.7); and severe acute malnutrition, UOR 5.8 (3.5–9.6) and AOR 5.7 (3.3–10.0). This study suggests that among severely sick children, increased attention should be given to those with hypo/low glycemia, deranged vital signs, malnutrition, and severe dehydration to avert mortality among these high-risk patients.

A chronic kidney disease of unknown etiology (CKDu) has been killing workers in Central America. Occupational heat stress is thought to play an important role. Leptospirosis and hantavirus have been suggested as additional possible risk factors. In a case–control study in a Nicaraguan mining community, a structured survey was administered to adults, and biological measurements and specimens were taken. Serum was analyzed for antibodies to Leptospira and hantavirus. Before statistical analysis, a board-certified nephrologist determined final case and control status based on serum creatinine and other laboratory values. Multivariable analysis was by logistic regression. In sensitivity analyses, cases were restricted to those diagnosed with CKDu in the previous 3 years. Of 320 eligible participants, 112 were classified as presumptive cases, 176 as controls and 32 as indeterminant. The risk of CKDu in those ever having worked in mining or construction was 4.4 times higher than in other participants (odds ratio = 4.44, 95% CI: 1.96–10.0, P = 0.0003). Eighty-three (26%) of the 320 participants were seropositive for at least one tested strain of Leptospira. No evidence of a causal link between leptospirosis or hantavirus and CKDu was found. The sensitivity analyses provide some evidence against the hypotheses that leptospirosis or hantavirus leads to CKDu within a few years. A major limitation was the impossibility of determining the absolute or relative timing of infection and CKDu onset. A prospective cohort design, with repeated collection of specimens over several years, could yield clearer answers about infections as potential etiologic agents in CKDu.

To explore the educational practices of antenatal care providers toward pregnant women with sickle cell disease (SCD) and sickle cell trait (SCT), a survey was conducted among selected doctors and midwives who provide antenatal care at the outpatient clinic of the Obstetric Department of the Korle-Bu Teaching Hospital, Accra, Ghana. The study explored their practices of screening for and patient education about SCD and SCT. Of the 102 respondents, 100(98%) stated that they were knowledgeable in the medical and genetic aspects of the disease. Regarding screening, 82(80.4%) reported mandatory screening for SCD, 9(8.8%) did not offer screening as routine, and 11(10.8%) gave patients the choice. The majority (93.1%) always informed patients when the test was positive but health-care providers less than six years experience were less likely to communicate SCT status to patients without the trait (odds ratio [OR] = 0.41, 95% CI [0.18–0.93]). Nurses/midwives were less likely to tell patients their carrier status (OR = 0.25, 95% CI [0.10–0.59]). There was also variation in referral practices for genetic counseling, with 26.5% always referring, 28.4% never doing so, and 45.1% only referring if the patient had questions. This may affect patients’ awareness of this genetic condition. Therefore, continuous medical education on SCD/SCT and standardization of counseling may help inform couples’ family planning choices and reduce the burden of the disease on future generation and health care.

Lower respiratory tract infections (LRTIs) are the leading cause of deaths in children < 5 years old worldwide, particularly affecting low-resource settings such as Aweil, South Sudan. In these settings, diagnosis can be difficult because of either lack of access to radiography or clinical algorithms that overtreat children with antibiotics who only have viral LRTIs. Point-of-care ultrasound (POCUS) has been applied to LRTIs, but not by nonphysician clinicians, and with limited data from low-resource settings. Our goal was to examine the feasibility of training the mid-level provider cadre clinical officers (COs) in a Médecins Sans Frontières project in South Sudan to perform a POCUS algorithm to differentiate among causes of LRTI. Six COs underwent POCUS training, and each subsequently performed 60 lung POCUS studies on hospitalized pediatric patients < 5 years old with criteria for pneumonia. Two blinded experts, with a tiebreaker expert adjudicating discordant results, served as a reference standard to calculate test performance characteristics, assessed image quality and CO interpretation. The COs performed 360 studies. Reviewers rated 99.1% of the images acceptable and 86.0% CO interpretations appropriate. The inter-rater agreement (κ) between COs and experts for lung consolidation with air bronchograms was 0.73 (0.63–0.82) and for viral LRTI/bronchiolitis was 0.81 (0.74–0.87). It is feasible to train COs in South Sudan to use a POCUS algorithm to diagnose pneumonia and other pulmonary diseases in children < 5 years old.

There is insufficient evidence on whether dengue rapid diagnostic tests (dRDTs) influence clinical decisions in endemic areas. Therefore, our objective was to evaluate the impact of dRDTs on the prescription of antibiotics and anti-inflammatory drugs by physicians in a dengue-endemic area in Colombia. A retrospective cohort study was conducted with 330 patients in Cali, Colombia, between January 2012 and December 2017. The exposure was defined by the result of the dRDT. The outcomes were prescription of antibiotics and anti-inflammatory drugs after results of dRDT. Incidence and RR with 95% CIs were estimated. Multivariate logistic regression models were fitted separately for each outcome. Antibiotics were prescribed in 3% exposed and 14% unexposed. Anti-inflammatory drugs were prescribed in 1.2% exposed and 7.9% unexposed. A positive dRDT reduced the prescription of anti-inflammatories (AdjOR: 0.06, 95% CI: 0.008–0.5) but, by itself, had no effect on antibiotics (AdjOR: 1.1, 95% CI: 0.2–6); however, in hospitalized patients, a positive result reduced the probability of antibiotic prescription (AdjOR: 0.02, 95% CI: 0.00–0.8). Despite limitations of current dRDTs, they influence treatment decisions. Further studies are needed to assess the effect of dRDTs in patient outcomes and health-care costs.

A 43-year-old man was admitted to the intensive care unit and diagnosed with yellow fever. He presented with refractory bleeding, extreme hyperferritinemia, and multiple organ dysfunction syndrome, requiring renal replacement therapy, mechanical ventilation, and treatment with vasoactive drugs. Because the bleeding did not respond to fresh-frozen plasma administration, the patient received therapeutic plasma exchange, which was accompanied by a marked improvement of the clinical and biochemical parameters, including a significant decline in serum ferritin levels.

Zika virus (ZIKV) serological diagnostics are compromised in areas where dengue viruses (DENV) co-circulate because of their high levels of protein sequence homology. Here, we describe the characterization of a Zika blockade-of-binding ELISA (Zika BOB) and a Zika microneutralization assay (Zika MN) for the detection of ZIKV nonstructural protein 1 (NS1)–specific antibodies and ZIKV neutralizing antibodies, respectively. Zika BOB and Zika MN cutoffs were established as 10 and 100 endpoint titers, respectively, using samples collected pre- and post-virologically confirmed ZIKV infection from subjects living in DENV-endemic areas. Specificity of the assays was equally high, whereas sensitivity of Zika BOB was lower than that of Zika MN, especially in samples collected > 6 months post-infection. Immunosurveillance analysis, using combined results from both Zika BOB and Zika MN, carried out also in DENV-endemic regions in Colombia, Honduras, Mexico, and Puerto Rico before (2013–2014) and after (2017–2018) ZIKV introduction in the Americas suggests unapparent ZIKV seroprevalence rates ranged from 25% to 80% over the specified period of time in the regions investigated.

This article describes, for the first time, the role of the nasal mucosa (NM) as the initial site for the Histoplasma capsulatum mycelial-to-yeast transition. The results highlight that yeasts may arrive to the cervical lymph nodes (CLN) via phagocytes. Bats and mice were intranasally infected with H. capsulatum mycelial propagules and they were killed 10, 20, and 40 minutes and 1, 2, and 3 hours after infection. The NM and the CLN were monitored for fungal presence. Yeasts compatible with H. capsulatum were detected within the NM and the CLN dendritic cells (DCs) 2–3 hours postinfection, using immunohistochemistry. Histoplasma capsulatum was re-isolated by culturing at 28°C from the CLN of both mammalian hosts 2–3 hours postinfection. Reverse transcription-polymerase chain reaction assays were designed to identify fungal dimorphism, using mycelial-specific (MS8) and yeast-specific (YPS3) gene expression. This strategy supported fast fungal dimorphism in vivo, which began in the NM 1 hour postinfection (a time point when MS8 and YPS3 genes were expressed) and it was completed at 3 hours (a time point when only the YPS3 transcripts were detected) in both bats and mice. The presence of intracellular yeasts in the nasal-associated lymphoid tissue (NALT), in the NM nonassociated with the NALT, and within the interdigitating DCs of the CLN suggests early fungal dissemination via the lymph vessels.