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BackgroundThe WHO recommended 1200mg/day of fluconazole (FCZ) in the induction phase of cryptococcal meningitis (CM) in HIV prior to 2018 in regions where amphotericin-B (AMB) was unavailable. A 2-stage AMB-controlled, dose-escalation study to determine the maximum tolerated dose and the safety/efficacy of an induction-consolidation strategy of higher doses FCZ (1200mg-2000mg/day), adjusted for weight and renal function (eGFR)in adults with CM was undertaken.MethodsIn Stage-1, three induction doses of FCZ (1200mg/day, 1600mg/day and 2000mg/day) were tested in sequential cohortsand compared with AMB in a 3:1 ratio. A particular dose was not tested in Stage 2 if there were significant predetermined safety or efficacy concerns. In Stage-2, the 1200mg dose was excluded per protocol because of increased mortality, and participants were randomised to 1600mg, 2000mg FCZ or AMB in a 1:1:1 ratio.FindingsOne hundred and sixty eight participants were enrolled with 48, 50, and 48 in the AMB, 1600mg and 2000mg cohorts. The Kaplan Meier proportion for mortality (90% CI) at 10 and 24 weeks for AMB was 17% (10, 29) and 24% (15, 37), compared to 20% (12, 32) and 30% (20, 43) for 1600mg, and 33% (23, 46) and 38% (27, 51) for 2000mg/day FCZ. With the exception of a higher incidence of gastrointestinal side effects in the 2000mg cohort, both induction doses of FCZ were safe and well tolerated. There were no life-threatening changes in electrocardiogram QTc which were similar across all doses of FCZ and AMB. The median (IQR) change in log10 cryptoccal colony forming units (CFU) from week 0 to week 2 was -8(-4.1,-1.9) for AMB; -2.5(-4.0, -1.4) for 1600mg FCZ and -8 (-3.2, -1.0) for 2000mg FCZ. The proportion (90% CI) CSF CM negative at 10 weeks was 81%(71,90) for AMB; 56%(45,69) for 1600mg FCZ and 60%(49,73) for 2000mg FCZ.InterpretationInduction phase weight and renal-adjusted doses of 1600mg and 2000mg/day FCZ for CM were safe and well tolerated except for increased GI side effects in the 2000mg/day dose, and had similar times to achieve CSF sterilization, but took significantly longer than AMB. The WHO recommended 1200mg FCZ was associated with a high mortality. While not statistically significant, mortality was numerically lower in the AMB compared to 1600mg and 2000mg FCZ These data make a case for a phase 3 study of higher doses of FZC.

En países con elevada endemia tuberculosa, las personas están muy cerca a esta enfermedad a lo largo de toda su vida. Sea porque algún familiar o amigo desarrolla la enfermedad o porque en el devenir de la vida experimenta la infección o la enfermedad. En el caso del médico o profesional de la salud, seguramente su cercanía será mayor, y preferentemente si se dedica a actividades de prevención y control en tuberculosis. En este artículo se exponen las experiencias cercanas con la tuberculosis desde nuestra infancia, como estudiante de medicina, médico, investigador, salubrista y docente universitario, donde el profesional pasa situaciones afectivas personales, temas de limitaciones de conocimiento, limitaciones en el diagnóstico, hasta ejecución de investigaciones sobre problemas locales y generando respuestas en la prevención y control. Seguramente es una experiencia común en profesionales de salud que en el día a día enfrentan esta endemia, de la cual cada vez conocemos más, pero se nos hace muy difícil su control.

Abstract Background To evaluate the mortality in hospitalized patients with tuberculous meningitis and describe factors associated with an increased risk of mortality. Methods Retrospective study of hospitalized patients with tuberculous meningitis between 2006 and 2015 in Peru performing a generalized linear regression to identify factors predictive of in-hospital mortality. Results Of 263 patients, the median age was 35 years, 72.6% were men, 38% were positive for HIV upon admission, 24% had prior TB infections and 2.3% had prior MDR-TB infections. In-hospital mortality was 30.4% of all study patients with a final diagnosis of TBM. When multivariable analysis was applied, significant associations with in-hospital mortality were seen among patients with HIV (RR 2.06; Confidence Interval 95% (95% CI) 1.44–2.94), BMRC II (RR 1.78; 95% CI 1.07–2.97), BMRC III (RR 3.11; 95% CI 1.78–5.45) and positive CSF cultures (RR 1.95; 95% CI 1.39–2.74). Conclusions In-hospital mortality is higher among patients with HIV infections, age over 40 years, positive CSF TB culture and BMRC stage II or III.

Abstract Background TB transmission in healthcare facilities is an important public health problem, especially in the often-overcrowded settings of HIV treatment scale-up. The problem is compounded by the emergence of drug resistant TB. Natural ventilation is a low-cost environmental control measure for TB infection control where climate permits that is suited to many different areas in healthcare facilities. There are no published data on the effect of simple structural modifications to existing hospital infrastructure to improve natural ventilation and reduce the risk of nosocomial TB transmission. The purpose of this study was to measure the effect of simple architectural modifications to existing hospital waiting and consulting rooms in a low resource setting on (a) improving natural ventilation and (b) reducing modelled TB transmission risk. Methods Room ventilation was measured pre- and post-modification using a carbon dioxide tracer-gas technique in four waiting rooms and two consulting rooms in two hospitals in Lima, Peru. Modifications included additional windows for cross-ventilation (n = 2 rooms); removing glass from unopenable windows (n = 2); creation of an open skylight (n = 1); re-building a waiting-room in the open air (n = 1). Changes in TB transmission risk for waiting patients, or healthcare workers in consulting rooms, were estimated using mathematical modelling. Results As a result of the infrastructure modifications, room ventilation in the four waiting rooms increased from mean 5.5 to 15; 11 to 16; 10 to 17; and 9 to 66 air-changes/hour respectively; and in the two consulting rooms from mean 3.6 to 17; and 2.7 to 12 air-changes/hour respectively. There was a median 72% reduction (inter-quartile range 51–82%) in calculated TB transmission risk for healthcare workers or waiting patients. The modifications cost

La COVID-19, en los escasos seis meses de su presencia, ha provocado una crisis sanitaria mundial, con mayor impacto en los países más pobres. En la actualidad, existe un mejor conocimiento de la clínica de esta enfermedad y su relación con los fenómenos fisiopatológicos; sin embargo, dada la alta letalidad, el mayor enfoque de su manejo se ha orientado hacia el paciente hospitalizado o crítico. Esta información y experiencia se comparte con el fin de lograr reforzar una mejor atención a las personas afectadas por la COVID-19 desde sus primeros síntomas en el hogar, especialmente en estos momentos de amplia transmisión en la comunidad, donde los servicios de salud están seriamente limitados en recursos humanos y materiales. El objetivo es: i) evitar complicaciones más allá de las causadas por la propia evolución de la enfermedad; ii) determinar el momento adecuado para la referencia del paciente al hospital y reducir la letalidad; iii) reforzar el aislamiento de los casos; y iv) posiblemente, disminuir la progresión a una enfermedad severa. Incluye el manejo luego del alta hospitalaria, así como recomendaciones para considerar si los servicios de salud colapsan; indicaciones sobre cuándo dar de alta al paciente para que regrese al trabajo, y destaca la importancia del telemonitoreo para el éxito de este manejo en el contexto epidemiológico actual.

La letalidad por COVID-19 así como su rápida diseminación son responsables de la actual crisis mundial; por ello, desde un inicio se buscaron medicamentos con acción antiviral frente a este agente. Es imposible, por ahora, saber qué persona en estado leve desarrollará una elevada carga viral o tiene una predisposición a desarrollar una respuesta extremada del sistema inmune, pero un tratamiento temprano en los casos leves no sólo garantizaría una mayor eficacia, sino que se evitarían los casos severos. En la actualidad no se dispone de ensayos clínicos, doble ciego, aleatroizados, ni metaanálisis para tomar decisiones seguras; mientras tanto, la pandemia avanza en nuestro país, generando dolor y muerte. En este contexto, en el Perú, las sociedades científicas han manifestado la necesidad del uso de medicamentos antivirales, aún con poca evidencia, basado en la probabilidad de éxito previo a un tratamiento, por sus efectos in vitro y por sus efectos clínicos tempranos, tales como: cloroquina, hidroxicloroquina, azitromicina, lopinavir, ritonavir. De esta manera, en el país desde el 29 de marzo de 2020, se dispone de una norma técnica del Ministerio de Salud, que facilita el uso de estos a nivel nacional para los casos moderados y severos. Consideramos que bajo un sistema estructurado, los centros de primer nivel de atención podrían tratar los casos leves de COVID-19. Nuestro país, a través de las estrategias de prevención y control de TB y de ITS/VIH/SIDA, tiene experiencia en el manejo de programas de tratamiento en dicho nivel. Los costos serán menores que los requeridos en el fortalecimiento del tercer nivel de atención.

Cough is a characteristic symptom of tuberculosis, is the main cause of transmission, and is used to assess treatment response. We aimed to identify the best measure of cough severity and characterize changes during initial tuberculosis therapy. We conducted a prospective cohort of recently diagnosed ambulatory adult patients with pulmonary tuberculosis in two tertiary hospitals in Lima, Peru. Pre-treatment and five times during the first two months of treatment, a vibrometer was used to capture 4-hour recordings of involuntary cough. A total of 358 recordings from 69 participants were analyzed using a computer algorithm. Total time spent coughing (seconds per hour) was a better predictor of microbiologic indicators of disease severity and treatment response than the frequency of cough episodes or cough power. Patients with prior tuberculosis tended to cough more than patients without prior tuberculosis, and patients with tuberculosis and diabetes coughed more than patients without diabetes co-morbidity. Cough characteristics were similar regardless of HIV co-infection and for drug-susceptible versus drug-resistant tuberculosis. Tuberculosis treatment response may be meaningfully assessed by objectively monitoring the time spent coughing. This measure demonstrated that cough was increased in patients with TB recurrence or co-morbid diabetes, but not because of drug resistance or HIV co-infection.

Introducción. La tuberculosis es un problema de salud pública en nuestro país. Los pacientes afectados tardan en acceder a los servicios de salud entre otros factores por el estigma y discriminación social que se tiene de esta enfermedad en la población. Además, el estigma tiene impacto en la relación social y familiar de los pacientes afectados. El objetivo del presente estudio fue cuantificar el estigma en estudiantes de la facultad de medicina de una universidad pública. Métodos. Se realizó un estudio observacional, descriptivo y transversal. Se aplicó un cuestionario previamente validado a estudiantes de los tres primeros años de la facultad de medicina, con la finalidad de cuantificar el estigma a la tuberculosis. Resultados. Se aplicó el cuestionario a 505 estudiantes de la facultad de medicina. El 39% de la población estudiantil mostró un moderado y gran estigma frente a las personas afectadas por tuberculosis; asimismo, el 38% mostró un leve estigma y 23% no presentó estigma frente a esta enfermedad. Conclusiones. Existe moderado y gran estigma en 39% de los estudiantes de la facultad de medicina estudiados.

Objectives. To determine the level of stigma related to HIV/AIDS and its association with adherence to antiretroviral therapy (HAART). Materials and methods. A cross-sectional study that included adult patients which were part of the HAART program during at least 6 months. Stigma was defined as the loss of value of the person infected with HIV according to Berger scale and treatment adherence as the correct consume of medications which were measured with the Simplified Medication Adherence Questionnaire. Poisson regression test was used to calculate the prevalence ratios (PR) of associated factors. Results. The results of 339 surveys were analyzed. 74% were male and the median age was 39 years (Interquartile Range [IQR]: 16). High stigma was found in 25,4% of respondents, moderate in 47,5%. A reduction of 10 points in the Berger scale was associated with an increase of 5% in adherence to HAART in men (adjusted PR [aPR]: 0.95; 95% confidence interval [CI]: 0.91-0.99), and 7% in women (aPR: 0.92; 95% CI: 0.87–0.98). Conclusions. There is a high level of stigma related to HIV/AIDS and is associated with the lack of adherence to HAART according to gender. We recommend interventions aimed at reducing stigma related to status disclosure in women and related to public attitudes in men.

Accidents caused by urticating or poisonous setae from lepidoptera caterpillars are known as erucism. These accidents are produced by accidental contact, especially in children, with bristles on the insect’s body surface, connected to venom glands. Symptoms may be local or systemic, with deadly clinical presentations. The accident caused by Lonomia spp. caterpillars can trigger bleeding disorders, which is considered the most severe type of erucism. The case of a 5-year-old girl is reported. She was from the town of Villarondos, in the Peruvian Amazon, department of Huánuco, who accidentally knelt down on caterpillar bristles, and subsequently experienced hemolytic anemia, plateletopenia, and coagulation disorder. The diagnosis was made based on the medical history, clinical manifestation, laboratory examination results, and response to antilonomic serum. The clinical, laboratory, and therapeutic aspects of erucism due to Lonomia spp. are discussed.

Chikungunya is an arthropod-borne virus transmitted by Aedes mosquito bites. A viral mutation has allowed Aedes albopictus to become the preferred vector extending the geographic spread of the condition. The virus causes an acute febrile illness occasionally followed by a chronic rheumatic condition causing severe impairment. The diagnosis is usually confirmed with serology. No specific treatment is currently available. This article reviews the condition with emphasis on his dissemination in the Americas. Keywords: Chikungunya, Alphavirus, Epidemics

BACKGROUND:We previously reported increased unstimulated blood levels of interferon-gamma in persons with latent tuberculosis infection (LTBI) in the United States, suggesting enhanced immune activation in LTBI. To investigate this further in a TB-endemic setting, we assessed interferon-gamma levels in persons with and without LTBI in Peru. METHODS:We analyzed data from patients with and without a recent type 1 (spontaneous) acute myocardial infarction (AMI) who were enrolled from two public hospital networks in Lima, Peru, and underwent LTBI testing using the QuantiFERON® TB Gold In-tube (QFT) assay. Participants with a positive QFT test were defined as having LTBI, whereas participants with a negative QFT test were defined as non-LTBI. Unstimulated interferon-gamma was quantified via enzyme-linked immunosorbent assay in the QFT nil-tube, which does not contain antigens. We compared unstimulated interferon-gamma levels between LTBI and non-LTBI groups using the Wilcoxon rank sum test. We used proportional odds modeling for multivariable analysis. RESULTS:Data from 214 participants were included in this analysis. Of those, 120 (56%) had LTBI. There were no significant differences in age, sex and comorbidities between LTBI and non-LTBI participants, except for recent AMI that was more frequent in LTBI. LTBI participants had higher unstimulated interferon-gamma levels compared to non-LTBI participants (median, interquartile range; 14 pg/mL, 6.5-52.8 vs. 6.5 pg/mL, 4.5-15; P

BACKGROUND:Meningitis caused by Mycobacterium tuberculosis is a major cause of morbidity and mortality worldwide. We evaluated the performance of cerebrospinal fluid (CSF) testing with the GeneXpert MTB/RIF assay versus traditional approaches for diagnosing tuberculosis meningitis (TBM). METHODS:Patients were adults (n = 37) presenting with suspected TBM to the Hospital Nacional Dos de Mayo, Lima, Peru, during 12 months until 1st January 2015. Each participant had a single CSF specimen that was divided into aliquots that were concurrently tested for M. tuberculosis using GeneXpert, Ziehl-Neelsen smear and culture on solid and liquid media. Drug susceptibility testing used Mycobacteria Growth Indicator Tube (MGIT 960) and the proportions method. RESULTS:81% (30/37) of patients received a final clinical diagnosis of TBM, of whom 63% (19/30, 95% confidence intervals, CI: 44-80%) were HIV-positive. 22% (8/37, 95%CI: 9.8-38%), of patients had definite TBM. Because definite TBM was defined by positivity in any laboratory test, all laboratory tests had 100% specificity. Considering the 30 patients who had a clinical diagnosis of TBM: diagnostic sensitivity was 23% (7/30, 95%CI: 9.9-42%) for GeneXpert and was the same for all culture results combined; considerably greater than 7% (2/30, 95%CI: 0.82-22%) for microscopy; whereas all laboratory tests had poor negative predictive values (20-23%). Considering only the 8 patients with definite TBM: diagnostic sensitivity was 88% (7/8, 95%CI: 47-100%) for GeneXpert; 75% (6/8, 95%CI: 35-97%) for MGIT culture or LJ culture; 50% (4/8, 95%CI 16-84) for Ogawa culture and 25% (2/8, 95%CI: 3.2-65%) for microscopy. GeneXpert and microscopy provided same-day results, whereas culture took 20-56 days. GeneXpert provided same-day rifampicin-susceptibility results, whereas culture-based testing took 32-71 days. 38% (3/8, 95%CI: 8.5-76%) of patients with definite TBM with data had evidence of drug-resistant TB, but 73% (22/30) of all clinically diagnosed TBM (definite, probable, and possible TBM) had no drug-susceptibility results available. CONCLUSIONS:Compared with traditional culture-based methods of CSF testing, GeneXpert had similar yield and faster results for both the detection of M. tuberculosis and drug-susceptibility testing. Including use of the GeneXpert has the capacity to improve the diagnosis of TBM cases.

In order to determine the association between the number of formal urban public transport routes and the situation of tuberculosis (TB) in each district of Lima, a correlational analysis and linear regression model between the two variables was performed. Also determined were the number of public transport routes most likely to transmit TB, the areas of greatest activity of these routes and a mapping of these routes. There is a positive correlation between the number of formal routes through each district of Lima and the situation of tuberculosis; a percentage of the TB situation could be explained by the number of public transport routes. Of the 404 formal routes that run through Lima, 147 (36.4%) are routes of greater probability of transmission of TB. Public transport should be considered in the ongoing fight against TB.

Introduction Cough is a key symptom of tuberculosis (TB) as well as the main cause of transmission. However, a recent literature review found that cough frequency (number of coughs per hour) in patients with TB has only been studied once, in 1969. The main aim of this study is to describe cough frequency patterns before and after the start of TB treatment and to determine baseline factors that affect cough frequency in these patients. Secondarily, we will evaluate the correlation between cough frequency and TB microbiological resolution.Methods This study will select participants with culture confirmed TB from 2 tertiary hospitals in Lima, Peru. We estimated that a sample size of 107 patients was sufficient to detect clinically significant changes in cough frequency. Participants will initially be evaluated through questionnaires, radiology, microscopic observation drug susceptibility broth TB-culture, auramine smear microscopy and cough recordings. This cohort will be followed for the initial 60 days of anti-TB treatment, and throughout the study several microbiological samples as well as 24 h recordings will be collected. We will describe the variability of cough episodes and determine its association with baseline laboratory parameters of pulmonary TB. In addition, we will analyse the reduction of cough frequency in predicting TB cure, adjusted for potential confounders.Ethics and dissemination Ethical approval has been obtained from the ethics committees at each participating hospital in Lima, Peru, Asociación Benéfica PRISMA in Lima, Peru, the Universidad Peruana Cayetano Heredia in Lima, Peru and Johns Hopkins University in Baltimore, USA. We aim to publish and disseminate our findings in peer-reviewed journals. We also expect to create and maintain an online repository for TB cough sounds as well as the statistical analysis employed.

Se reporta el caso de un recién nacido varón, producto de embarazo de 36 semanas, con diagnóstico de neumonía congénita y examen confirmatorio de infección por el virus de la influenza A (H1N1), sin ningún otro tipo de contacto sospechoso. La madre ingresó al hospital con insuficiencia respiratoria y antecedente de proceso gripal de cinco días de evolución, durante los primeros días de la pandemia en el Perú. Por la evolución grave del proceso respiratorio, se le administró ventilación mecánica para luego ser sometida a cesárea por sufrimiento fetal agudo y oligoamnios. Se confirmó en la madre infección por el virus de la influenza A H1N1 epidémico y tuberculosis pulmonar.We report the case of a male newborn, product of a 36 week pregnancy, with diagnosis of congenital pneumonia and with a confirmatory test for influenza A (H1N1) virus, without any other suspicious contact. The mother was admitted to the hospital with respiratory failure and the history of a flu-like episode of 5 days of evolution, during the first days of the pandemic in Peru. Due to the severe evolution of the respiratory process, assisted ventilation was given to her and then a cesarean section was performed due to acute fetal distress and oligoamnios. The mother was later confirmed as a case of epidemic influenza A (H1N1) and pulmonary tuberculosis.

Se describe el caso de un varón de 47 años, con tiempo de enfermedad de dos días, caracterizado por pérdida de fuerza progresiva, simétrica y ascendente de miembros inferiores, se realizó punción lumbar luego de la tomografía cerebral y electromiografía lo cual evidenció polirradiculopatía motora pura con patrón axonal, compatible con el síndrome de Guillain Barré. Posteriormente, recibió cuatro sesiones de plasmaféresis, con mejoría clínica significativa desde la segunda sesión. Debido al antecedente epidemiológico se solicitó set para Brucellas, con rosa de Bengala positivo, se inició tratamiento antibiótico con rifampicina y doxiciclina, además de rehabilitación. Tres meses después el paciente mejoró completamente. La importancia del tratamiento temprano con plasmaféresis y determinar su diagnóstico etiológico hacen que el pronóstico del síndrome de Guillain Barré sea favorable.We describe a case of a 47 years old male, with a history of 2 days of progressive, ascendant, symmetrical weakness in the lower extremities; a lumbar puncture was performed after the brain CT scan, as well as an electromyography, evidencing pure motor polyradiculopathy with axonal pattern, compatible with Guillain Barre syndrome. Afterwards, he received four plasmapheresis sessions, with clinical improvement from the second session. Due to his epidemiological background, Brucella set testing was done. Rose Bengal was positive, antibiotic treatment with rifampin and doxicicline was initiated, as well as rehabilitation. Three months later the patient recovered completely. The relevance of early treatment with plasmapheresis and the definition of the etiologic diagnosis determine that the prognosis of the Guillain Barre syndrome is favorable.

El manejo del paciente con tuberculosis (TB) a nivel institucional, que garantice la disminución del riesgo de transmisión, una adecuada vigilancia al tratamiento, y optar por medidas de soporte social, esta convirtiéndose en una propuesta para el manejo de pacientes con TB multidrogo resistente (TB MDR) y extensivamente resistente a drogas (TB XDR) y en especial en el manejo de casos que no cumplan con un tratamiento adecuado o tengan condiciones sociales que pongan en riesgo su adecuado seguimiento. Se plantean algunas estrategias que ya han sido utilizadas exitosamente en otros países cuya implementación debe ser valorada a nivel local.

Para afrontar la pandemia por la nueva Influenza A (H1N1) se requiere de un adecuado manejo de los casos, en ese sentido, la Sociedad Peruana de Enfermedades Infecciosas y Tropicales ha desarrollado una guía que se resume en este artículo. Se detalla el diagnóstico clínico y flujos para la toma de decisiones, el manejo terapéutico y las consideraciones a tener en cuenta para casos graves y situaciones especiales, como es el caso de las gestantes.

Existen pocos estudios que reporten datos acerca de autopsias de pacientes con VIH en Sudamérica y ninguno que documente los resultados post mórtem en los pacientes con VIH/SIDA en el Perú. Objetivos: Determinar el espectro de las infecciones oportunistas y las causas de mortalidad en pacientes VIH-positivos en un hospital público en Lima. Asimismo, se revisa la información clínico-epidemiológica con respecto a la infección con VIH en el Perú. Materiales y métodos: Se incluyeron en este análisis retrospectivo, 16 autopsias relacionadas con VIH del Hospital Dos de Mayo, realizadas entre 1999-2004. Resultados: La causa primaria de la muerte fue establecida en 12 pacientes: uno murió de neoplasia y 11 de enfermedades infecciosas, incluyendo tres con infección pulmonar, siete con infección diseminada, y dos con infección del sistema nervioso central (un caso presentó patología dual). Las infecciones oportunistas fueron identificadas en 14 casos, incluyendo citomegalovirus, histoplasmosis, criptococcosis, toxoplasmosis, neumonía por Pneumocistis, aspergilosis, tuberculosis, virus de la varicela-zoster y criptosporidiosis. Catorce pacientes tenían por lo menos una enfermedad relacionada con el SIDA que no había sido sospechada clínicamente ni diagnosticada antes de la muerte. Por otra parte, 82% de los diagnósticos considerados de significancia clínica importante, no habían sido sospechados antes de la muerte. Conclusiones: El espectro y la frecuencia de ciertas infecciones oportunistas reportadas en el presente estudio lo diferencia de otros estudios de autopsias realizados en Sudamérica; destacando la importancia de realizar necropsias en VIH/SIDA en países de recursos limitados, con el fin de observar los patrones locales específicos de la enfermedad.

Mixed Cryptosporidium infections were detected in 7 of 21 patients with a diagnosis of rare Cryptosporidium canis or C. felis infections; 6 patients were infected with 2 Cryptosporidium spp. and 1 patient with 3 species. Mixed infections may occur more frequently than previously believed and should be considered when assessing cryptosporidiosis.

During 1999 to 2000, we identified HIV-infected persons with new episodes of tuberculosis (TB) at 10 hospitals in Lima-Peru and a random sample of other Lima residents with TB. Multidrug-resistant (MDR)-TB was documented in 35 (43%) of 81 HIV-positive patients and 38 (3.9%)of 965 patients who were HIV-negative or of unknown HIV status (p < 0.001). HIV-positive patients with MDR-TB were concentrated at three hospitals that treat the greatest numbers of HIV-infected persons with TB. Of patients with TB, those with HIV infection differed from those without known HIV infection in having more frequent prior exposure to clinical services and more frequent previous TB therapy or prophylaxis. However, MDR-TB in HIV-infected patients was not associated with previous TB therapy or prophylaxis. MDR-TB is an ongoing problem in HIV-infected persons receiving care in public hospitals in Lima and Callao; they represent sentinel cases for a potentially larger epidemic of nosocomial MDR-TB.

Introducción: Presentamos los resultados de la ejecución del Plan TBCero, que con un enfoque sociopolítico se desarrolla en la jurisdicción del centro de salud de San Cosme, distrito de La Victoria. Esta es un área de elevado riesgo de transmisión de TB (AERT-TB), que presenta la más alta tasa de incidencia de TB del Perú, y donde las condiciones como el trabajo informal, daños psicosociales, pobreza, altas tasas migratorias, hacinamiento y tugurización han dificultado el éxito de diversas intervenciones. Metodología: Desde Marzo del 2009 se viene implementando el Plan TBCero con un modelo de abordaje integral, sistémico y humanizado que se fundamenta en la incidencia sobre los determinantes sociales de la salud (DSS) y la Atención Primaria de Salud (APS). Está conducido por la DISA V Lima Ciudad y la Municipalidad Distrital de La Victoria (MLV) con la participación de las personas afectadas por la TB. Tiene 6 componentes: incidencia política, atención clínica de las personas/familias/comunidades afectadas, manejo de factores asociados (VIH, daños psicosociales, laborales), salud y seguridad de los servidores de salud, promoción y comunicación en salud y gestión del plan. Dentro de ello, se desarrolla la Estrategias DATOS (Detección, análisis y tratamiento observado socialmente), que permite fortalecer la estrategia DOTS en las AERT-TB. Resultados: Incremento en un 130% del porcentaje de SRI, disminución del porcentaje de abandono (83 %), disminución en 20% de la tasa de incidencia de TB, humanización de la atención familiar/comunitaria, y participación del gobierno local de La Victoria (MLV) con la formulación y ejecución de políticas públicas saludables. Se sugiere la aplicación del modelo en otras AERT-TB del país y/o del mundo.

Institutional tuberculosis (TB) transmission is an important public health problem highlighted by the HIV/AIDS pandemic and the emergence of multidrug- and extensively drug-resistant TB. Effective TB infection control measures are urgently needed. We evaluated the efficacy of upper-room ultraviolet (UV) lights and negative air ionization for preventing airborne TB transmission using a guinea pig air-sampling model to measure the TB infectiousness of ward air.For 535 consecutive days, exhaust air from an HIV-TB ward in Lima, Perú, was passed through three guinea pig air-sampling enclosures each housing approximately 150 guinea pigs, using a 2-d cycle. On UV-off days, ward air passed in parallel through a control animal enclosure and a similar enclosure containing negative ionizers. On UV-on days, UV lights and mixing fans were turned on in the ward, and a third animal enclosure alone received ward air. TB infection in guinea pigs was defined by monthly tuberculin skin tests. All guinea pigs underwent autopsy to test for TB disease, defined by characteristic autopsy changes or by the culture of Mycobacterium tuberculosis from organs. 35% (106/304) of guinea pigs in the control group developed TB infection, and this was reduced to 14% (43/303) by ionizers, and to 9.5% (29/307) by UV lights (both p < 0.0001 compared with the control group). TB disease was confirmed in 8.6% (26/304) of control group animals, and this was reduced to 4.3% (13/303) by ionizers, and to 3.6% (11/307) by UV lights (both p < 0.03 compared with the control group). Time-to-event analysis demonstrated that TB infection was prevented by ionizers (log-rank 27; p < 0.0001) and by UV lights (log-rank 46; p < 0.0001). Time-to-event analysis also demonstrated that TB disease was prevented by ionizers (log-rank 3.7; p = 0.055) and by UV lights (log-rank 5.4; p = 0.02). An alternative analysis using an airborne infection model demonstrated that ionizers prevented 60% of TB infection and 51% of TB disease, and that UV lights prevented 70% of TB infection and 54% of TB disease. In all analysis strategies, UV lights tended to be more protective than ionizers.Upper-room UV lights and negative air ionization each prevented most airborne TB transmission detectable by guinea pig air sampling. Provided there is adequate mixing of room air, upper-room UV light is an effective, low-cost intervention for use in TB infection control in high-risk clinical settings.

The current understanding of airborne tuberculosis (TB) transmission is based on classic 1950s studies in which guinea pigs were exposed to air from a tuberculosis ward. Recently we recreated this model in Lima, Perú, and in this paper we report the use of molecular fingerprinting to investigate patient infectiousness in the current era of HIV infection and multidrug-resistant (MDR) TB.All air from a mechanically ventilated negative-pressure HIV-TB ward was exhausted over guinea pigs housed in an airborne transmission study facility on the roof. Animals had monthly tuberculin skin tests, and positive reactors were removed for autopsy and organ culture for M. tuberculosis. Temporal exposure patterns, drug susceptibility testing, and DNA fingerprinting of patient and animal TB strains defined infectious TB patients. Relative patient infectiousness was calculated using the Wells-Riley model of airborne infection. Over 505 study days there were 118 ward admissions of 97 HIV-positive pulmonary TB patients. Of 292 exposed guinea pigs, 144 had evidence of TB disease; a further 30 were tuberculin skin test positive only. There was marked variability in patient infectiousness; only 8.5% of 118 ward admissions by TB patients were shown by DNA fingerprinting to have caused 98% of the 125 characterised cases of secondary animal TB. 90% of TB transmission occurred from inadequately treated MDR TB patients. Three highly infectious MDR TB patients produced 226, 52, and 40 airborne infectious units (quanta) per hour.A small number of inadequately treated MDR TB patients coinfected with HIV were responsible for almost all TB transmission, and some patients were highly infectious. This result highlights the importance of rapid TB drug-susceptibility testing to allow prompt initiation of effective treatment, and environmental control measures to reduce ongoing TB transmission in crowded health care settings. TB infection control must be prioritized in order to prevent health care facilities from disseminating the drug-resistant TB that they are attempting to treat.

Institutional transmission of airborne infections such as tuberculosis (TB) is an important public health problem, especially in resource-limited settings where protective measures such as negative-pressure isolation rooms are difficult to implement. Natural ventilation may offer a low-cost alternative. Our objective was to investigate the rates, determinants, and effects of natural ventilation in health care settings.The study was carried out in eight hospitals in Lima, Peru; five were hospitals of "old-fashioned" design built pre-1950, and three of "modern" design, built 1970-1990. In these hospitals 70 naturally ventilated clinical rooms where infectious patients are likely to be encountered were studied. These included respiratory isolation rooms, TB wards, respiratory wards, general medical wards, outpatient consulting rooms, waiting rooms, and emergency departments. These rooms were compared with 12 mechanically ventilated negative-pressure respiratory isolation rooms built post-2000. Ventilation was measured using a carbon dioxide tracer gas technique in 368 experiments. Architectural and environmental variables were measured. For each experiment, infection risk was estimated for TB exposure using the Wells-Riley model of airborne infection. We found that opening windows and doors provided median ventilation of 28 air changes/hour (ACH), more than double that of mechanically ventilated negative-pressure rooms ventilated at the 12 ACH recommended for high-risk areas, and 18 times that with windows and doors closed (p < 0.001). Facilities built more than 50 years ago, characterised by large windows and high ceilings, had greater ventilation than modern naturally ventilated rooms (40 versus 17 ACH; p < 0.001). Even within the lowest quartile of wind speeds, natural ventilation exceeded mechanical (p < 0.001). The Wells-Riley airborne infection model predicted that in mechanically ventilated rooms 39% of susceptible individuals would become infected following 24 h of exposure to untreated TB patients of infectiousness characterised in a well-documented outbreak. This infection rate compared with 33% in modern and 11% in pre-1950 naturally ventilated facilities with windows and doors open.Opening windows and doors maximises natural ventilation so that the risk of airborne contagion is much lower than with costly, maintenance-requiring mechanical ventilation systems. Old-fashioned clinical areas with high ceilings and large windows provide greatest protection. Natural ventilation costs little and is maintenance free, and is particularly suited to limited-resource settings and tropical climates, where the burden of TB and institutional TB transmission is highest. In settings where respiratory isolation is difficult and climate permits, windows and doors should be opened to reduce the risk of airborne contagion.

Con el objetivo de determinar la asociación entre el número de rutas formales de transporte público urbano y la situación de la tuberculosis (TB) en cada distrito de Lima, se realizó un análisis correlacional y un modelo de regresión lineal entre ambas variables. Asimismo, se determinó el número de rutas de transporte público de mayor probabilidad de transmisión de TB, las zonas de mayor circulación de dichas rutas y un mapeo de estas. Existe una correlación positiva entre el número de rutas formales que recorren cada distrito de Lima y la situación de TB; un porcentaje de la situación de TB podría ser explicada por el número de rutas de transporte público. De las 404 rutas formales que recorren Lima Metropolitana, 147 (36,4%) son rutas de mayor probabilidad de transmisión de TB. El transporte público debería ser considerado en la lucha actual contra la TB

Con el objetivo de determinar la asociación entre el número de rutas formales de transporte público urbano y la situación de la tuberculosis (TB) en cada distrito de Lima, se realizó un análisis correlacional y un modelo de regresión lineal entre ambas variables. Asimismo, se determinó el número de rutas de transporte público de mayor probabilidad de transmisión de TB, las zonas de mayor circulación de dichas rutas y un mapeo de estas. Existe una correlación positiva entre el número de rutas formales que recorren cada distrito de Lima y la situación de TB; un porcentaje de la situación de TB podría ser explicada por el número de rutas de transporte público. De las 404 rutas formales que recorren Lima Metropolitana, 147 (36,4%) son rutas de mayor probabilidad de transmisión de TB. El transporte público debería ser considerado en la lucha actual contra la TB

La Cystoisospora belli, antes denominada Isospora belli, es el agente etiológico de la cystoisosporiasis, una infección oportunista que afecta a pacientes inmunodeprimidos, caracterizada por diarrea crónica y pérdida ponderal. La incidencia de diarrea crónica por este agente, en pacientes infectados por el VIH, ha disminuido considerablemente. Ello gracias al advenimiento de la terapia antirretroviral de gran actividad (TARGA), con la que se ha logrado mejorar la respuesta inmunológica del paciente y disminuir su carga viral. Se presentan seis casos de cystoisosporiasis recurrente y refractaria en pacientes con infección por VIH, en quienes se diagnosticó cystoisosporiasis pese a que previamente se encontraban recibiendo profilaxis con trimetropin/sulfametoxazol (TMP/SMX). Cinco de ellos evolucionaron de manera tórpida y fallecieron, a pesar de una buena respuesta al TARGA (adecuado incremento de CD4 y disminución de la carga viral hasta rangos indetectables), y de tratamiento con TMP/SMX por vía oral y otros medicamentos de segunda línea.

La Cystoisospora belli, antes denominada Isospora belli, es el agente etiológico de la cystoisosporiasis, una infección oportunista que afecta a pacientes inmunodeprimidos, caracterizada por diarrea crónica y pérdida ponderal. La incidencia de diarrea crónica por este agente, en pacientes infectados por el VIH, ha disminuido considerablemente. Ello gracias al advenimiento de la terapia antirretroviral de gran actividad (TARGA), con la que se ha logrado mejorar la respuesta inmunológica del paciente y disminuir su carga viral. Se presentan seis casos de cystoisosporiasis recurrente y refractaria en pacientes con infección por VIH, en quienes se diagnosticó cystoisosporiasis pese a que previamente se encontraban recibiendo profilaxis con trimetropin/sulfametoxazol (TMP/SMX). Cinco de ellos evolucionaron de manera tórpida y fallecieron, a pesar de una buena respuesta al TARGA (adecuado incremento de CD4 y disminución de la carga viral hasta rangos indetectables), y de tratamiento con TMP/SMX por vía oral y otros medicamentos de segunda línea.