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Studies have shown elevated blood lead levels (BLL) in residents of remote communities in the Amazon, yet sources of lead exposure are not fully understood, such as lead ammunition consumed in wild game.Data was collected during two cross-sectional studies that enrolled 307 individuals in 26 communities. Regression models with community random effects were used to evaluate risk factors for BLLs, including diet, water source, smoking, sex, age, and indigenous status. The All-Ages Lead Model (AALM) from the Environmental Protection Agency (EPA) was used to estimate background and dose from wild game consumption.Indigenous status and wild game consumption were associated with increased BLLs. Indigenous participants had 2.52 μg/dL (95% CI: 1.95-3.24) higher BLLs compared to non-indigenous. Eating wild game was associated with a 1.41 μg/dL (95% CI: 1.20-1.70) increase in BLLs. Two or more portions per serving were associated with increased BLLs of 1.66 μg/dL (95% CI: 1.10-2.57), compared to smaller servings. Using the AALM, we estimate background lead exposures to be 20 μg/day with consumption of wild game contributing 500 μg/meal. Lastly, we found a strong association between BLLs and mercury exposure.Consumption of wild game hunted with lead ammunition may pose a common source of lead exposure in the Amazon. Communities that rely on wild game and wild fish may face a dual burden of exposure to lead and mercury, respectively.

I.AbstractBackgroundMethylmercury (MeHg) is an environmental pollutant of global public health concern. MeHg is associated with immune dysfunction but the underlying mechanisms are unclear. The most common route of MeHg exposure is through consumption of fatty fish that contain beneficial n-3 polyunsaturated fatty acids (PUFA) that may protect against MeHg toxicity.ObjectivesTo better inform individual costs and benefits of fish consumption, we aimed to identify candidate epigenetic biomarkers of biological responses that reflect MeHg toxicity and PUFA protection.MethodsWe profiled genome-wide DNA methylation using Illumina Infinium MethylationEPIC BeadChip in whole blood from N=32 individuals from Madre de Dios, Peru. Madre de Dios has high artisanal and small-scale gold mining activity, which results in high MeHg exposure to nearby residents. We compared DNA methylation in N=16 individuals with high (>10 µg/g) vs. N=16 individuals with low (ResultsWe identified hypomethylated (i.e., likely activated) genes and promoters in high vs. low MeHg-exposed participants linked to Th1/Th2 immune imbalance, decreased IL-7 signaling, and increased marginal zone B cells. These three pathways are feasible mechanisms for MeHg-induced autoimmunity. In addition, we identified candidate epigenetic biomarkers of PUFA-mediated protection: hypomethylated enhancer binding sites for retinoid X receptor (RXR) and retinoic acid receptor α (RARα). Last, we observed hypomethylated enhancer and promoter binding sites for glucocorticoid receptor (GR), which is associated with developmental neurotoxicity, and transcription factor 7-like 2 (TCF7L2), which is associated with type 2 diabetes (T2D) risk.DiscussionHere, we identify a set of candidate epigenetic biomarkers for assessing individualized risk of autoimmune response and protection against neurotoxicity due to MeHg exposure and fish consumption. In addition, our results may inform surrogate tissue biomarkers of early MeHg exposure-related neurotoxicity and T2D risk.

Deforestation, artisanal and small-scale gold mining (ASGM), and the rapid development related to highway expansion cause opportunities for toxic trace element exposure in the Amazon region of Madre de Dios (MDD), Peru, one of the most biologically diverse places in the world. The objective of this study was to assess the exposure to arsenic, cadmium, lead, and mercury among adults in Madre de Dios. In total, 418 adult (18+ years) participants in the Investigacion de Migracion, Ambiente, y Salud (IMAS) (Migration, Environment, and Health Study) participated in this study. Consent, survey data, and biospecimens were collected between August and November 2014. Nail elements were measured by inductively coupled plasma sector field mass spectrometry. Differences by selected individual and household characteristics and local land uses were tested using one-way ANOVAs and linear mixed models. Adults in ASGM-affected areas had higher nail arsenic and nail cadmium than their non-ASGM counterparts. Higher household fish consumption was positively associated with nail mercury and nail lead. The results indicate that adult exposure to arsenic, cadmium, lead, and mercury is heterogeneous across Madre de Dios, and the exposures related to ASGM communities and fish consumption suggest that exposures from artisanal and small-scale mining are environmentally widespread. Further investigation is warranted to ascertain potential health impacts.

Background: Although malaria control investments worldwide have resulted in dramatic declines in transmission since 2000, progress has stalled. In the Amazon, malaria resurgence has followed withdrawal of Global Fund support of the Project for Malaria Control in Andean Border Areas (PAMAFRO). We estimate intervention-specific and spatially-explicit effects of the PAMAFRO program on malaria incidence across the Loreto region of Peru, and consider the influence of the environmental risk factors in the presence of interventions. Methods: We conducted a retrospective, observational, spatial interrupted time series analysis of malaria incidence rates among people reporting to health posts across Loreto, Peru between the first epidemiological week of January 2001 and the last epidemiological week of December 2016. Model inference is at the smallest administrative unit (district), where the weekly number of diagnosed cases of Plasmodium vivax and Plasmodium falciparum were determined by microscopy. Census data provided population at risk. We include as covariates weekly estimates of minimum temperature and cumulative precipitation in each district, as well as spatially- and temporally-lagged malaria incidence rates. Environmental data were derived from a hydrometeorological model designed for the Amazon. We used Bayesian spatiotemporal modeling techniques to estimate the impact of the PAMAFRO program, variability in environmental effects, and the role of climate anomalies on transmission after PAMAFRO withdrawal. Findings: During the PAMAFRO program, incidence of P. vivax declined from 42.8 to 10.1 cases/1000 people/year. Incidence for P. falciparum declined from 14.3 to 2.5 cases/1000 people/year over this same period. The effects of PAMAFRO-supported interventions varied both by geography and species of malaria. Interventions were only effective in districts where interventions were also deployed in surrounding districts. Further, interventions diminished the effects of other prevailing demographic and environmental risk factors. Withdrawal of the program led to a resurgence in transmission. Increasing minimum temperatures and variability and intensity of rainfall events from 2011 onward and accompanying population displacements contributed to this resurgence. Interpretation: Malaria control programs must consider the climate and environmental scope of interventions to maximize effectiveness. They must also ensure financial sustainability to maintain local progress and commitment to malaria prevention and elimination efforts, as well as to offset the effects of environmental change that increase transmission risk. Funding: National Aeronautics and Space Administration, National Institutes of Health, Bill and Melinda Gates Foundation. © 2023 The Author(s)

Introduction The Taenia solium tapeworm is responsible for cysticercosis, a neglected tropical disease presenting as larvae in the body of a host following taenia egg ingestion. Neurocysticercosis (NCC), the name of the disease when it affects the human central nervous system, is a major cause of epilepsy in developing countries, and can also cause intracranial hypertension, hydrocephalus and death. Simulation models can help identify the most cost-effective interventions before their implementation. Modelling NCC should enable the comparison of a broad range of interventions, from treatment of human taeniasis (presence of an adult taenia worm in the human intestine) to NCC mitigation. It also allows a focus on the actual impact of the disease, rather than using proxies as is the case for other models. Methods This agent-based model is the first model that simulates human NCC and associated pathologies. It uses the output of another model, CystiAgent, which simulates the evolution of pig cysticercosis and human taeniasis, adding human and cyst agents, including a model of cyst location and stage, human symptoms, and treatment. CystiHuman also accounts for delays in the appearance of NCC-related symptoms. It comprises three modules detailing cyst development, seizure probability and timing, and intracranial hypertension/hydrocephalus, respectively. It has been implemented in Java MASON and calibrated in three endemic villages in Peru, then applied to another village (Rica Playa) to compare simulation results with field data in that village. Results and discussion Despite limitations in available field data, parameter values found through calibration are plausible and simulated outcomes in Rica Playa are close to actual values for NCC prevalence and the way it increases with age and cases with single lesions. Initial simulations further suggest that short-term interventions followed by a rapid increase in taeniasis prevalence back to original levels may have limited impacts on NCC prevalence.

This paper investigates the factors that motivate decisions of settler colonists to engage in off-farm employment (OFE) in the Northern Ecuadorian Amazon (NEA). Overall, OFE, as a type of population mobility, may increasingly become a dominant demographic factor in rural frontier regions. Although OFE decisions are primarily a matter of individual choice, factors associated with the farm household and the local community also play key roles in this decision-making. This paper applies a multilevel conceptual framework and uses a multinomial, multilevel statistical model to study OFE in the NEA in 1999 as a result of factors at the individual, farm household, and community levels. The results show important differences between OFE participation choices in personal characteristics, human capital, farm household life cycle, land use, land management, farm environmental conditions, transportation accessibility, community size, and structure of local labor markets. The paper also identifies the effects of policy-relevant variables on choices to engage in OFE in local community, other rural, or urban areas of destination.

Immunization programs have leveraged decades of research to maximize oral polio vaccine (OPV) response. Moving toward global poliovirus eradication, the WHO recommended phased OPV-to-IPV replacement on schedules in 2012. Using the MAL-ED prospective birth cohort data, we evaluated the influence of early life exposures impacting OPV immunization by measuring OPV response for serotypes 1 and 3.Polio neutralizing antibody assays were conducted at 7 and 15 months of age for serotypes 1 and 3. Analyses were conducted on children receiving ≥3 OPV doses (n = 1449). History of vaccination, feeding patterns, physical growth, home environment, diarrhea, enteropathogen detection, and gut inflammation were examined as risk factors for non-response [LogSerotype 1 seroconversion was significantly higher than serotype 3 (96.6% vs. 89.6%, 15 months). Model results indicate serotypes 1 and 3 failure was minimized following four and six OPV doses, respectively; however, enteropathogen detection and poor socioeconomic conditions attenuated response in both serotypes. At three months of age, bacterial detection in stool reduced serotype 1 and 3 LogUnder real-world conditions, improved vaccination coverage and socio-environmental conditions, and reducing early life bacterial exposures are key to improving OPV response and should inform polio eradication strategies.

Successful immunization programs have diminished parental fear of diseases and increased fear of vaccines. Children with nonmedical exemptions to school immunization requirements are at increased risk of acquiring and transmitting disease. We explored differences in vaccine attitudes, beliefs, and information sources among parents of exempt and vaccinated children.Self-administered surveys were mailed to 780 parents of children with nonmedical exemptions (cases) and 1491 parents of fully-vaccinated children (controls).Vaccines most often refused by exempt children were varicella (49%) and hepatitis B (30%). The most common reason for claiming exemptions was vaccine might cause harm (57%). Parents of vaccinated children were less likely than parents of exempt children to report concern about vaccine safety, question the need for immunization, and oppose immunization requirements. Nearly 25% of parents of vaccinated children reported that children get more immunizations than are good for them and 34% expressed concern that children's immune systems could be weakened by too many immunizations. Both groups received information from health care professionals; parents of exempt children were more likely to also consult other sources.Our findings support the need for improved methods to communicate vaccine safety information. Further studies to explore vaccine safety concerns among parents are needed.

The mechanism of high altitude effect on tuberculosis (TB) infection has not been fully established. We previously reported a lower positive tuberculin skin test (TST) prevalence in high altitude villages compared with sea level communities in Peru. In this study, four additional communities were tested to assess whether decreased TB transmission was also in urban environments at high altitude. TST results from 3,629 individuals in nine communities were analyzed using generalized estimating equations to account for community clustering. Positive TST prevalence was not significantly different between the urban highland and the urban non-highland communities after adjusting for age, household contacts with a TST-positive person or a TB case, and presence of a Bacillus Calmette-Guérin vaccination scar. The effect of population concentration and increased contact with active TB overwhelmed the protective effect of altitude in urban highlands. Highland cities require the same preventive efforts against TB as non-highland communities.