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The ongoing COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a global public health crisis. Many reports indicate disappointing results in cancer patients compared to the general population. Therefore, experts in the management of oncohematological malignancies from the National Institute of Neoplastic Diseases, national hospitals and a private clinic in Metropolitan Lima have developed recommendations obtained by consensus to continue with the management of patients with oncohematological neoplasms safely in the face of the pandemic., La pandemia COVID-19 originado por el Coronavirus 2, agente causal del síndrome respiratorio agudo severo (SARS-CoV-2) ha desencadenado una crisis de salud pública a nivel global. Muchos reportes indican resultados desalentadores en pacientes con cáncer respecto a la población general. Por ello, los expertos en el manejo de neoplasias oncohematológicas del Instituto Nacional de Enfermedades Neoplásicas, hospitales nacionales y una clínica privada de Lima Metropolitana han desarrollado recomendaciones obtenidas por consenso para continuar con el manejo de pacientes con neoplasias oncohematológicas en forma segura ante la coyuntura de pandemia.

This study reports the experience obtained by the National Institute of Health of Peru in the use of deliberative dialogues for the formulation of recommendations as one of the stages of the process of adaptation of evidence-based clinical practice guidelines using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system. Using a multidisciplinary approach, this study describes: 1. the public health problems addressed in the dialogues; 2. the role of the involved parties; 3. the parameters that were considered before and during the discussions; 4. the challenges for optimizing these dialogues and stimulating the interaction between scientific evidence and the added value provided by the involved parties through their experiences, perspectives, and knowledge for the development of recommendations in health.En el presente artículo se reporta la experiencia obtenida por el Instituto Nacional de Salud de Perú, en la utilidad del desarrollo de diálogos deliberativos para la formulación de recomendaciones, como uno de los componentes del proceso de adaptación de Guías de Práctica Clínica basadas en evidencia, utilizando el sistema GRADE (por sus siglas en ingles: Grading of Recommendations, Assessment, Development and Evaluations). Describe los temas de salud pública que fueron deliberados y la participación de los actores implicados con un enfoque multidisciplinario. Presenta los aspectos que fueron tomados en cuenta de forma previa y durante los diálogos. Finalmente, propone los desafíos que serán abordados en las siguientes experiencias a fin de optimizar estos procesos y colaborar en la interacción entre las evidencias científicas y el valor agregado que otorgan los actores implicados a través de su experiencias, perspectivas y conocimientos para el desarrollo de recomendaciones en salud.

Utilidad de las pruebas de detección de antígeno urinario para un diagnóstico rápido de legionelosis

Existe amplia controversia acerca del mecanismo de acción del levonorgestrel como anticonceptivo oral de emergencia; numerosas organizaciones, tanto científicas como de la sociedad civil, muestran su disconformidad con su uso, debido a su posible acción como inductor de aborto. Con el objetivo de evaluar la evidencia científica disponible sobre los mecanismos de acción del levonorgestrel utilizado como anticonceptivo oral de emergencia (AOE), se realizó una revisión sistemática en las bases de datos Medline y Cochrane Library donde se encontró 444 artículos; después de revisar los resúmenes, se seleccionó 22 artículos, los cuales fueron evaluados a texto completo. Se encontró que el principal mecanismo de acción del levonorgestrel, a las dosis recomendadas como AOE, es la inhibición o retraso de la ovulación; no afecta a los espermatozoides en su capacidad de migración ni de penetración al óvulo. No se ha demostrado alteraciones morfológicas ni moleculares en el endometrio que puedan interferir con la implantación del huevo fecundado. No existe evidencia científica actual disponible que sustente que el uso de levonorgestrel como AOE sea abortivo. There is wide controversy about the mechanism of action of the levonorgestrel used for emergency oral contraception, and many organizations, both scientific as well as from the civil society, show their discrepancy with its use, due to its possible action as an abortion- inducer. In order to evaluate the scientific evidence available on the mechanisms of action of the levonorgestrel used for emergency oral contraception (EOC), a systematic revision was performed in the Medline and Cochrane library databases. We found 444 articles. After reviewing the abstracts, we selected 22 articles, whose complete texts were evaluated. We found that the main mechanism of action of the levonorgestrel, given at the doses recommended for EOC, is the inhibition or retardation of the ovulation, it doesn’t affect the spermatozoa in their migration or egg-penetration capacities. No morphological or molecular alterations in the endometrium that could interfere with the implantation of the fertilized egg have been demonstrated. There is no actual scientific evidence available supporting that the use of levonorgestrel for EOC is abortive.

Objective To revise the available evidence on the cost-effectiveness of antiviral regimens for treatment of chronic hepatitis B. Material and methods We performed a systematic revision on MEDLINE, LILACS NICE and COCHRANE databases, searching for economic evaluations of antiviral regimens for treatment of chronic hepatitis B. We included original studies, systematic revisions and management guidelines including information on the cost-effectiveness of this treatment. We registered the characteristics and results of the retrieved documents. Results We obtained 29 original papers, 4 revision articles and 4 management guidelines. Most of these publications have been done in the last 5 years. There was conflict of interest in 73% of original articles, due to authors working for the pharmaceutical industry. 93% of articles that evaluate the cost-effectiveness of giving treatment for chronic hepatitis B against management of its complications find that it is indeed cost-effective to give antiviral treatment. 3/6 studies that evaluate lamivudine against other drugs find it as a dominant strategy, 3/5 find entecavir as the dominant strategy, 1/1 find tenofovir dominant, ¼ find conventional interferon as dominant and none of them find adefovir or pegylated interferon as dominant strategies. Conclusions We consider that the available evidence suggests that to give antiviral treatment for chronic hepatitis B is a cost-effective intervention for many health systems, including ours. It has varying indexes of cost-effectiveness according to the evaluated regimens. Ideally , we should perform local economic evaluations in this issue.

We assessed whether mutations in the Plasmodium falciparum multidrug-resistance gene 1 (pfmdr1) (C1034S, D1042N, and Y1246D) would predict treatment outcome during a 28-day in vivo treatment trial in the Peruvian Amazon. Mefloquine (MQ) was compared with mefloquine-artesunate (MQ-AS) in a randomized, multi-clinic protocol for the first time in the Americas. Of 115 patients enrolled in the in vivo arm, 97 patients were eligible for molecular analysis. All 97 patients remained parasite-free during 28 days of follow-up (MQ, n = 46; MQ-AS, n = 51), indicating 100% clinical efficacy of the MQ and MQ-AS treatment regimens. The reported MQ-sensitive alleles (C1034, D1042, and Y1246) were present in 48.5% (n = 47) of the cases, whereas 49 isolates (50.5%) contained the D1246 mutation reported to confer MQ resistance in vitro. However, neither this mutation nor a double mutation (S1034, D1246; n = 16) was predictive of MQ treatment outcome.

Eight genotypes of Plasmodium falciparum were detected after analysing blood samples obtained from 30 Peruvian jungle-dwelling patients in Loreto, a high transmission area for P. falciparum, using amplification of the polymorphic marker gene GLURP (glutamate-rich protein). Genotypes I (GLURP450) and VIII (GLURP800) were the most common ( 15 30 and 13 30 , respectively). This single copy gene snowed 15 patients to be infected with a single genotype of P. falciparum; the other 15 were infected with mixed genotypes, one of them with 4 genotypes. These findings are compatible with a high genetic complexity of P. falciparum. Further investigations are needed, using this and other markers, in order to design malaria control measures in Peru.

¿Son efectivos los repelentes contra mosquitos para prevenir enfermedades transmitidas por vectores?

To carry out a systematic review of the literature on the effectiveness of fortified rice consumption in terms of increasing levels of iron and other micro-nutrients in children aged 6-59 months, with a view to evaluating its usefulness as a public health intervention.A search was conducted in MEDLINE, Embase, Cochrane Library, and LILACS databases. The review included randomized clinical trials (RCTs) that assessed the consumption of fortified rice, compared with a placebo or other forms of intervention, in terms of enhanced levels of iron and other micronutrients. The CONSORT® checklist was used to assess methodological quality. The risk of bias in the studies was assessed using the Cochrane® Collaboration methodology.Seven RCTs were included in the review. All the studies showed significant improvements in indicators of nutritional iron status in the intervention groups, without reporting adverse effects. There was no evidence of improvement in vitamin A levels or in anthropometric indicators of weight and height as a secondary result of the intervention. The included studies showed moderate methodological quality.Rice fortification was an effective intervention strategy to correct iron deficiency in children under age 5. For implementation as a public health measure, local studies are needed to assess its effectiveness in long-term and large-scale interventions.

Se realizó una búsqueda sistemática para identificar publicaciones sobre la seguridad ante la exposición de raticidas que contienen Salmonella para humanos y animales. Se consideraron publicaciones a texto completo que incluían descripción de su metodología y la presentación adecuada de sus resultados. De 545 publicaciones recuperadas, 47 se revisaron a texto completo de las que se seleccionaron 12. En seis se reportan casos de salmonelosis en humanos, incluso casos fatales, asociados a la exposición a versiones anteriores de estos raticidas. El único ensayo clínico encontrado reporta una mayor frecuencia de diarrea y fiebre en el grupo que ingirió Salmonella contenida en Biorat® (presentación comercial actual); sin embargo, la diferencia no fue estadísticamente significativa, pero el ensayo presentó problemas metodológicos. Las cepas de Salmonella enteritidis contenidas en una versión anterior (Ratin®) y en la versión actual corresponden a la misma variedad (Danysz) y fagotipo (6a), y están cercanamente relacionadas según la técnica de electroforesis en gel de campo pulsado (PFGE). No se reporta efectos patógenos de esta Salmonella para las diferentes especies de animales ensayadas; sin embargo, se encontraron limitaciones en la metodología empleada. Se concluye que la Salmonella enteritidis contenida en versiones anteriores de raticidas produjo enfermedad en humanos por lo que fue prohibida su comercialización y que existiría un riesgo potencial de la versión actual por contener una bacteria muy similar y por no tener evidencia suficiente que garantice su seguridad. Son necesarios estudios bien diseñados por instituciones sin conflicto de interés, antes de su aplicación en salud pública o agricultura. We conducted a systematic search of the literature to identify publications on the safety of exposure to Salmonella-based rodenticides by humans and animals. We included full-text publications that described the methods and presented their results satisfactorily. Of 545 publications retrieved, 47 were reviewed in full text and from those 12 were selected. Six reports featured cases of salmonellosis in humans, with fatal cases, associated with exposure to previous versions of this type of rodenticide. A clinical trial reported an increased frequency of diarrhea and fever in the group that ingested Biorat ® (the current commercial form) containing Salmonella, however the difference from the control group was not significant, but the trial had methodological problems. Strains of Salmonella enteritidis from an earlier version of the rat poison (Ratin®) and those in the current version correspond to the same variety (Danyzs) and phage type (6a), and were found to be closely related using the technique of pulsed field gel electrophoresis (PFGE). No pathogenic effects of this Salmonella were reported in different animal species tested; however, we found limitations in the methodology. We conclude that the Salmonella enteritidis contained in earlier rat poison formulations produced illness in humans so that its commercialization was prohibited, and that there would be a potential risk with the present formulation because it contains a very similar bacteria, and because there is not sufficient evidence to guarantee its safety. Well-designed studies still need to be done by institutions that do not have a conflict of interest before it can be applied in the areas of public health and agriculture.

Plasmodium falciparum entered into the Peruvian Amazon in 1994, sparking an epidemic between 1995 and 1998. Since 2000, there has been sustained low P. falciparum transmission. The Malaria Immunology and Genetics in the Amazon project has longitudinally followed members of the community of Zungarococha (N = 1,945, 4 villages) with active household and health center-based visits each year since 2003. We examined parasite population structure and traced the parasite genetic diversity temporally and spatially. We genotyped infections over 5 years (2003-2007) using 14 microsatellite (MS) markers scattered across ten different chromosomes. Despite low transmission, there was considerable genetic diversity, which we compared with other geographic regions. We detected 182 different haplotypes from 302 parasites in 217 infections. Structure v2.2 identified five clusters (subpopulations) of phylogenetically related clones. To consider genetic diversity on a more detailed level, we defined haplotype families (hapfams) by grouping haplotypes with three or less loci differences. We identified 34 different hapfams identified. The F(st) statistic and heterozygosity analysis showed the five clusters were maintained in each village throughout this time. A minimum spanning network (MSN), stratified by the year of detection, showed that haplotypes within hapfams had allele differences and haplotypes within a cluster definition were more separated in the later years (2006-2007). We modeled hapfam detection and loss, accounting for sample size and stochastic fluctuations in frequencies overtime. Principle component analysis of genetic variation revealed patterns of genetic structure with time rather than village. The population structure, genetic diversity, appearance/disappearance of the different haplotypes from 2003 to 2007 provides a genome-wide "real-time" perspective of P. falciparum parasites in a low transmission region.

There is wide controversy about the mechanism of action of the levonorgestrel used for emergency oral contraception, and many organizations, both scientific as well as from the civil society, show their discrepancy with its use, due to its possible action as an abortion- inducer. In order to evaluate the scientific evidence available on the mechanisms of action of the levonorgestrel used for emergency oral contraception (EOC), a systematic revision was performed in the Medline and Cochrane library databases. We found 444 articles. After reviewing the abstracts, we selected 22 articles, whose complete texts were evaluated. We found that the main mechanism of action of the levonorgestrel, given at the doses recommended for EOC, is the inhibition or retardation of the ovulation, it doesn't affect the spermatozoa in their migration or egg-penetration capacities. No morphological or molecular alterations in the endometrium that could interfere with the implantation of the fertilized egg have been demonstrated. There is no actual scientific evidence available supporting that the use of levonorgestrel for EOC is abortive.

Community acquired pneumonia (CAP) is a major public health problem, being the most affected the pediatric population. The aim of this study was to compare the etiology, clinical and radiological features of CAP in under- five-year-old children.Children have been attended at the Practice or Emergency Room from Puno and Lima health facilities. Twelve pathogens were studied using cultures (bacterial and viral), reaction polymerase chain to S. pneumoniae and H. influenzae, enzyme-linked immunosorbent assay for M. pneumoniae and indirect immunofluorescence test for C. pneumoniae and viruses (nasal and pharyngeal swabs).One hundred and ninety three children were enrolled with clinical and radiological confirmation of pneumonia between July and November 2006. At least one pathogen was identified in 123 (63.7%) of 193 patients. Fifty five percent had viral infection, 21% bacterial infection and 12% presented viral and bacterial co-infection. The most frequent etiologic agents were respiratory syncytial virus (38.3% from all, 69.8% of viral pneumonias) and S. pneumoniae (18.6% from all, 90% from bacterial pneumonias). In Lima, the cases of severe pneumonia predominated. The association of pneumonia with wheezing was reported in Lima, however, it hasn't been reported in Puno.We found a pathogen in 63.7% of the patients and there were no differences in the proportion and distribution of different identified etiological agents between Lima and Puno health facilities, whose ecological and climatic features are very different. The association of pneumonia with wheezing was only reported in Lima.

We assessed whether mutations in the Plasmodium falciparum multidrug-resistance gene 1 (pfmdr1) (C1034S, D1042N, and Y1246D) would predict treatment outcome during a 28-day in vivo treatment trial in the Peruvian Amazon. Mefloquine (MQ) was compared with mefloquine-artesunate (MQ-AS) in a randomized, multi-clinic protocol for the first time in the Americas. Of 115 patients enrolled in the in vivo arm, 97 patients were eligible for molecular analysis. All 97 patients remained parasite-free during 28 days of follow-up (MQ, n = 46; MQ-AS, n = 51), indicating 100% clinical efficacy of the MQ and MQ-AS treatment regimens. The reported MQ-sensitive alleles (C1034, D1042, and Y1246) were present in 48.5% (n = 47) of the cases, whereas 49 isolates (50.5%) contained the D1246 mutation reported to confer MQ resistance in vitro. However, neither this mutation nor a double mutation (S1034, D1246; n = 16) was predictive of MQ treatment outcome.

En el presente artículo se analizan algunos ejemplos del uso de evidencia generada por el Instituto Nacional de Salud (INS) que el Ministerio de Salud del Perú ha realizado en los últimos años en la formulación, implementación y evaluación de las políticas y programas. Presenta el proceso por el cual los programas presupuestales se sustentan y fortalecen a partir de la evidencia. Describe el progreso en el desarrollo de una metodología para generar guías de calidad a partir de la mejor evidencia disponible para orientar la práctica clínica. Presenta algunos ejemplos de requerimientos de evidencia del Ministerio de Salud al Instituto Nacional de Salud y su impacto en política. Por último, propone direcciones futuras respecto a metodologías de investigación especialmente relevantes para el desarrollo y evaluación de políticas y el fortalecimiento de redes de evaluación de tecnologías en el ámbito nacional e internacional. This article analyzes some examples about how the Ministry of Health of Peru has used evidence for policy and program formulation, implementation and evaluation. It describes the process by which health budget programs are based and strengthened with scientific evidence. Provides an overview about how the development of clinical guidelines methodology is facilitating the generation of high quality evidence based clinical guidelines.It presents some examples of specific information needs of the Ministry of Health to which the Instituto Nacional de Salud has responded, and the impact of that collaboration. Finally, the article proposes future directions for the use of research methodology especially relevant for the development and evaluation of policy and programs, as well as the development of networks of health technology assessment at the national and international level.

Se evaluó la frecuencia de mutaciones en los genes pfCRT y DHFR/DHPS del Plasmodium falciparum asociados a la resistencia a cloroquina y sulfadoxina-pirimetamina en 83 cepas provenientes de los distritos Esmeralda y Machala ubicados en las fronteras entre Ecuador-Perú y Ecuador-Colombia durante el año 2002. Se empleó la reacción en cadena de polimerasa (PCR) convencional y sus variantes. El gen pfCRT presentó más de 90% de muestras mutantes en Esmeralda y Machala. Para el gen DHFR, el 90% de las cepas fueron muestras mutantes en Esmeralda, tres fueron mutaciones dobles y una triple; en Machala se encontró 25% de formas mutantes simples y 75% de formas mixtas (formas silvestres/mutantes). En conclusión, la resistencia a cloroquina se ha fijado en las cepas portadoras de la mutación K76T pfCRT, mientras que la impronta genética a la resistencia a pirimetamina está en evolución, principalmente en el distrito de Esmeralda The frequency of mutations in pfCRT and DHFR/DHPS genes of Plasmodium falciparum associated with resistance to chloroquine and sulfadoxine-pyrimethamine was evaluated in 83 strains from the districts of Esmeralda and Machala, located on the borders of Ecuador-Peru and Ecuador-Colombia in 2002. Polymerase chain reaction (PCR), conventional and its variants, was used. Mutations in the pfCRT gene were found in more than 90% of the samples from Esmeralda and Machala. For the DHFR gene, 90% of the strains were mutant samples from Esmeralda, 3 were double mutations and 1 was a triple mutation. In Machala, 25% were simple mutant forms and 75% mixed mutant forms (wild forms/mutant). In conclusion, resistance to chloroquine has been fixed in strains carrying K76T pfCRT mutation, whereas genetic imprinting for resistance to pyrimethamine is evolving, particularly in the district of Esmeralda