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Nosocomial myiasis is a rare event that has a higher incidence in the hospitals of poor and developing countries. The presence of nosocomial myiasis reflects the need for improved medical facilities and increased awareness among healthcare personnel. Severely ill patients are more susceptible, such as those with impaired consciousness, paralysis, and underlying diseases. The two cases here in described represent the first report of nosocomial myiasis in the Kurdistan Province, in Western Iran and one of them is the first report of myiasis involving a COVID-19-infected patient. The causal agent was Lucilia sericata. The taxonomical identification of the larvae of the second and third instar was based on the morphology of the cephaloskeleton, anterior spiracles, and peritreme plaques.

We conducted a retrospective cohort study of children who had chronic fascioliasis in the highlands of Peru to determine triclabendazole treatment efficacy. Children passing Fasciola eggs in stool were offered directly observed triclabendazole treatment (>1 doses of 10 mg/kg). Parasitologic cure was evaluated by using microscopy of stool 1–4 months after each treatment. A total of 146 children who had chronic fascioliasis participated in the study; 53% were female, and the mean ± SD age was 10.4 ± 3.1 years. After the first treatment, 55% of the children achieved parasitologic cure. Cure rates decreased after the second (38%), third (30%), and fourth (23%) treatments; 17 children (11.6%) did not achieve cure after 4 treatments. Higher baseline egg counts and lower socioeconomic status were associated with triclabendazole treatment failure. Decreased triclabendazole efficacy in disease-endemic communities threatens control efforts. Further research on triclabendazole resistance and new drugs to overcome it are urgently needed.

Fasciola hepatica is highly prevalent in the highlands of Peru. School-age children have the greatest risk of infection. Mass treatment of at-risk populations has been proposed to control the infection and prevent complications. However, the decreasing effectiveness of triclabendazole raises concerns regarding this strategy. Previous studies reported aggregation of Fasciola infection among family members. This study aimed to determine the risk of fascioliasis among household members living with Fasciola-infected children identified through school-based testing. We conducted a cross-sectional study including adult members of households where children with and without fascioliasis were identified. Demographic, epidemiological, and socioeconomic information was collected. One blood sample was drawn to test for Fasciola antibodies, and three stool samples were collected for microscopy for Fasciola ova. We tested 326 adults from 213 households. Of these adult subjects, chronic fascioliasis (24 of 326, 7.4%) was the most common helminth infection. Thirty-nine subjects (12.7%) tested positive for Fasciola antibodies. Combining microscopy and serum antibody tests, 13.2% (43 of 326) had evidence of Fasciola infection. One third (104 of 326, 31.9%) of the participants lived with at least one child infected with Fasciola hepatica. Adults with fascioliasis were four times more likely to live with an infected child. Poverty and diet were associated with increased risk of Fasciola infection. Adults with fascioliasis were significantly more likely to live with Fasciola-infected children.

Purpose of the review This review aims to critically assess current knowledge about the epidemiology, diagnosis, and management of Fasciola infection in humans. Recent findings Fascioliasis is an emerging neglected zoonotic infection affecting the health and wellbeing of human populations. The burden of infection is unclear, and studies have shown the geographic expansion of fascioliasis in human and livestock likely related to climate change. The infection can be asymptomatic or present in acute or chronic forms. Regardless of the presentation, fascioliasis can be associated with long-term complications such as anemia and malnutrition. Early in the infection, antibody testing is the only tool available for diagnosis confirmation. In the chronic forms serology and stool microscopy are helpful. Other tests such as antigen detection and PCR-based methods including isothermal tests have shown promising results. Triclabendazole is the only drug available to treat Fasciola infection. However, reports of resistant infections in livestock and human threaten the clinical care and control of the infection in endemic areas. Summary Fascioliasis is an emerging infection around the world with an uncertain burden. Lack of standardization of diagnostic testing and treatment alternatives hinder treatment and control of the infection.

ObjectiveThe severe acute respiratory syndrome-Coronavirus-2 (SARS-CoV-2) has caused a pandemic claiming more than 4 million lives worldwide. Overwhelming Coronavirus-Disease-2019 (COVID-19) respiratory failure placed tremendous demands on healthcare systems increasing the death toll. Cost-effective prognostic tools to characterize COVID-19 patients’ likely to progress to severe hypoxemic respiratory failure are still needed.DesignWe conducted a retrospective cohort study to develop a model utilizing demographic and clinical data collected in the first 12-hours admission to explore associations with severe hypoxemic respiratory failure in unvaccinated and hospitalized COVID-19 patients.SettingUniversity based healthcare system including 6 hospitals located in the Galveston, Brazoria and Harris counties of Texas.ParticipantsAdult patients diagnosed with COVID-19 and admitted to one of six hospitals between March 19th and June 31st, 2020.Primary outcomeThe primary outcome was defined as reaching a WHO ordinal scale between 6-9 at any time during admission, which corresponded to severe hypoxemic respiratory failure requiring high-flow oxygen supplementation or mechanical ventilation.ResultsWe included 329 participants in the model cohort and 62 (18.8%) met the primary outcome. Our multivariable regression model found that lactate dehydrogenase (OR 2.36), qSOFA score (OR: 2.26), and neutrophil to lymphocyte ratio (OR:1.15) were significant predictors of severe disease. The final model showed an area under curve (AUC) of 0.84. The sensitivity analysis and point of influence analysis did not reveal inconsistencies.ConclusionsOur study suggests that a combination of accessible demographic and clinical information collected on admission may predict the progression to severe COVID-19 among adult patients with mild and moderate disease. This model requires external validation prior to its use.STRENGTHS AND LIMITATIONS OF THIS STUDY⍰Our study utilized objective and measurable demographic and clinical information regularly available in healthcare settings even among patients unable to communicate.⍰Our primary outcome corresponds to WHO ordinal score which would allow compare our results to other studies and in other settings.⍰Our model could serve as an effective point of service tool during early admission to assist in clinical management and allocation of resources to unvaccinated patients.⍰Our study is a retrospective study of unvaccinated COVID19 patients, and validation of our prediction model in the rest of our study population is still needed.⍰In addition, testing our model in a more recent cohort after emergence of new SARS-CoV-2 variants will be needed to assess its robustness.

International travel contributes to the global spread of antimicrobial resistance. Travelers' diarrhea exacerbates the risk of acquiring multidrug-resistant organisms and can lead to persistent gastrointestinal disturbance post-travel. However, little is known about the impact of diarrhea on travelers' gut microbiomes, and the dynamics of these changes throughout travel. Here, we assembled a cohort of 159 international students visiting the Andean city of Cusco, Peru and applied next-generation sequencing techniques to 718 longitudinally-collected stool samples. We find that gut microbiome composition changed significantly throughout travel, but taxonomic diversity remained stable. However, diarrhea disrupted this stability and resulted in an increased abundance of antimicrobial resistance genes that can remain high for weeks. We also identified taxa differentially abundant between diarrheal and non-diarrheal samples, which were used to develop a classification model that distinguishes between these disease states. Additionally, we sequenced the genomes of 212 diarrheagenic Escherichia coli isolates and found those from travelers who experienced diarrhea encoded more antimicrobial resistance genes than those who did not. In this work, we find the gut microbiomes of international travelers' are resilient to dysbiosis; however, they are also susceptible to colonization by multidrug-resistant bacteria, a risk that is more pronounced in travelers with diarrhea.

Stunting, defined as height-for-age Z score equal to or lower than -2, is associated with increased childhood mortality, cognitive impairment, and chronic diseases. The aim of the study was to investigate the relationship between linear growth, intestinal damage, and systemic inflammation in infants at risk of stunting. We followed up 78 infants aged 5-12 months living in rural areas of Peru for 6 months. Blood samples for biomarkers of intestinal damage (intestinal fatty-acid-binding protein [I-FABP] and zonulin) and systemic inflammation (interleukin-1beta, interleukin-6, tumor necrosis factor alpha [TNF-alpha], soluble CD14, and lipopolysaccharide-binding protein [LBP]) and fecal samples for microbiome analysis were collected at baseline and closure of the study. The children's growth and health status were monitored through biweekly home visits by trained staff. Twenty-one percent of the children became stunted: compared with non-stunted children, they had worse nutritional parameters and higher levels of serum I-FABP at baseline. The likelihood of becoming stunted was strongly associated with an increase in sCD14 over time; LBP and TNF-alpha showed a trend toward increase in stunted children but not in controls. The fecal microbiota composition of stunted children had an increased beta diversity compared with that of healthy controls throughout the study. The relative abundance of Ruminococcus 1 and 2, Clostridium sensu stricto, and Collinsella increased in children becoming stunted but not in controls, whereas Providencia abundance decreased. In conclusion, stunting in our population was preceded by an increase in markers of enterocyte turnover and differences in the fecal microbiota and was associated with increasing levels of systemic inflammation markers.

Fascioliasis is a zoonotic trematode infection that is endemic in the highlands of Peru. Chronic fascioliasis can be asymptomatic and remain undiagnosed for years. Chronic malnutrition in children, as manifested by stunting, leads to delayed cognitive development and lost productivity. We hypothesized that fascioliasis is among the factors associated with stunting in children from endemic areas. We conducted a cross-sectional study among children attending pre-school and school in 26 communities in the Anta province in the Cusco region of Peru. We conducted interviews to collect information on demographic, socioeconomic, and medical history. Blood was collected and tested for complete cell count and FAS2 ELISA for Fasciola antibodies. Three stool samples per participant were tested for parasites by Kato-Katz and Lumbreras rapid sedimentation methods. Chronic fascioliasis was determined by the presence of ova in stool. Children’s height, weight, and age were recorded and used to calculate height for age Z scores (HAZ). Three thousand children participated in the study. Nine percent (264) of children had at least one positive test for Fasciola infection, 6% (164) had chronic fascioliasis, and 3% (102) had only positive antibody tests. The median HAZ was -1.41 (IQR: -2.03 to -0.81) and was similar in males and females. Twenty six percent (776) of children had stunting with HAZ < -2. Children with chronic fascioliasis had a lower median HAZ than children without Fasciola (-1.54 vs. -1.4, p = 0.014). History of treatment for malnutrition, history of treatment for anemia, having other helminths in stool, lower socioeconomic score, living at a higher elevation, and fewer years of schooling of both parents were associated with a lower HAZ score. In a multiple regression analysis, older age and a lower socioeconomic score were associated with a lower HAZ score. While fascioliasis and other helminths were associated with lower HAZ, they were not independent of the socioeconomic score., Author summary Fasciola infection is endemic in the highlands of Peru. Children in the highlands are particularly affected. The effect of chronic fascioliasis on children’s long-term health and development, particularly the impact on nutrition, is not well defined. In this large epidemiologic study, we evaluated the association of chronic Fasciola infection with chronic malnutrition. Children with chronic Fasciola, defined as finding Fasciola eggs in stool, had a lower height for age Z score than those without Fasciola. A lower poverty score, fewer years of education of parents, and higher house elevation were also associated with stunted growth.

Fascioliasis is a zoonotic infection linked to significant economic losses in the livestock industry. Infection prevalence and estimated financial burden vary across locations owing to different diagnostic tests used. The accuracy of liver condemnation to estimate the prevalence and costs of fascioliasis has seldom been evaluated. We performed a pilot study to determine the prevalence and burden of Fasciola hepatica infection among cattle slaughtered at the municipal abattoir in the Anta province of the Cusco highlands in Peru. We compared liver condemnation with bile microscopy for the diagnosis of infection and prediction of carcass weight. Data were collected from 2009 slaughtered cattle for 1 year. The overall prevalence of Fasciola infection by bile microscopy was 62.5% (1247/2009). A higher prevalence was observed after the rainy season from March to August than from September to February (p

Fascioliasis is a foodborne trematode endemic worldwide. Children under 15 years have the highest prevalence of infection. We hypothesized that acute fascioliasis would be associated with more pronounced cytokine changes than in children with chronic disease or no helminth infections. To test this hypothesis, 33 children who live in the Peruvian highlands were classified into 3 groups: acute fascioliasis, and chronic fascioliasis and no helminth infection. Type Th1, Th2 and Th17 cytokines were measured in plasma by cytometric bead array. Children with acute infection had higher levels of IL-5 and IL-17 compared with controls (p

School-age children bear the highest burden of fascioliasis in endemic countries. Few studies have addressed Fasciola in preschool children. We performed a secondary data analysis using two Fasciola databases from Cusco, Peru, comparing preschoolers with elementary school children. We included 2,630 children, 50% were female, the median age was 8.4 years (interquartile range [IQR] 6.1–10.5), and 15% (396/2,630) were < 5 years of age. Children < 5 years were less likely to be infected with Fasciola hepatica (P = 0.008) and Hymenolepis nana (P < 0.001) and more likely to have anemia (P < 0.001) and a lower median height for age Z (HAZ) score (P = 0.002). Fascioliasis was less common in younger children, but this group may be at higher risk for chronic complications caused by fascioliasis.

Ayahuasca (Banisteriopsis caapi) is a jungle vine with hallucinogenic properties used in ancient ritual celebrations in countries of the Amazon basin. The vine is ingested as a concoction, also called ayahuasca, and prepared by combining it with other botanicals such as the shrub Psychotria viridis or the liana Diplopterys cabrerana. The active ingredients of ayahuasca include the hallucinogen dimethyltryptamine and potent inhibitors of the monoamine oxidase-A (MAO) that prevent its degradation. Ayahuasca may have therapeutic effects in psychiatric illnesses such as substance abuse and depression. It decreased dependence symptoms, cravings and use among cocaine users. Acute and chronic ayahuasca use decreased depression, anxiety, and panic symptoms...

Fasciola hepatica is the most widely distributed trematode-affecting humans. The Andes Mountains are highly endemic for fascioliasis. We report results of a cross-sectional study evaluating the epidemiology of Fasciola among children in 26 agricultural communities in the Cusco region of Peru. Children 3 to 16 years old were enrolled in preschools and schools. Blood from participants was tested for complete blood counts, transaminases, and Fasciola antibodies. Stool samples were tested for Fasciola and other parasites. A total of 2,515 children were included in the analysis and the mean age was 9.6 years (+/-3.6). Ten percent (253) of the children had at least one positive test for Fasciola, 6% had chronic infection, and 0.4% acute infection. The rest of the subjects had only antibodies against Fasciola. The prevalence of infection varied from 0% to 20% between communities. Children with evidence of Fasciola exposure were older, lived at higher altitudes, and had a lower socioeconomic status than children without infection. The logistic regression analysis showed that children from Ancahuasi district, older children, and children with higher measures of poverty were more likely to have Fasciola exposure. Fascioliasis is common in the Cusco region and associated with poverty. However, the distribution varies markedly between communities.

PURPOSE OF REVIEW: This review aims at describing the latest research in Fasciola epidemiology, diagnosis, treatment, and control in endemic countries. RECENT FINDINGS: The geographic distribution and range of reservoirs for Fasciola hepatica continues to expand. The impact of fascioliasis goes beyond human disease to affect food security and income in developed and developing countries. Promising serologic and molecular methods to diagnose fascioliasis have been described, but are not widely available. Triclabendazole remains the only highly active medication to treat human and livestock infected with juvenile and adult forms of Fasciola spp. Efforts to control fascioliasis may be hindered by the emergence of resistance to triclabendazole among livestock and subsequently in humans. SUMMARY: Increased awareness and surveillance are likely to uncover the real distribution and burden of fascioliasis in human. Research into new drugs or adjuvants to tackle the emerging resistance to triclabendazole is imperative to treat and control Fasciola infection.

Myiasis is the infestation by dipterous fly larvae in humans and animals. The larvae can infect living or necrotic tissue involving the skin, nasopharynx, genitourinary, and gastrointestinal tracts. The accidental ingestion of eggs causes infection of the intestinal tract. We report a case of intestinal myiasis caused bySarcophagaspp. larvae in a two-year-old child from Limatambo province in the Cusco region of Peru. Live larvae were identified incidentally in this child’s stool sample during the study screening forStrongyloides stercoralis. The child did not have any constitutional or abdominal symptoms. The morphological examination of the specimen under magnification revealedSarcophagaspp. larvae. We performed a literature review of publications reporting intestinal myiasis caused bySarcophagaspp. and discussed key aspects of this infestation.

Provide an overview about childhood diarrhea burden and prevention interventions with demonstrated impact in reducing disease risk. Diarrhea incidence and mortality in children is declining around the world. A few pathogens cause most of the burden (rotavirus, norovirus, Shigella, enterotoxigenic E. coli, Campylobacter, and Cryptosporidium). Available rotavirus vaccines have demonstrated to significantly decrease diarrhea hospital admissions and mortality. WASH interventions, especially point of use water safety improvements and handwashing, are effective in decreasing diarrhea burden. Early and exclusive breastfeeding prevents early childhood diarrhea. Diarrhea in children under 5 years old is still among the most important causes of mortality in middle- and low-income countries. However, diarrhea complications and deaths are preventable. Vaccines, water, sanitation, and hygiene (WASH) and breastfeeding are effective and affordable interventions. Future research should determine the effectiveness of combining these interventions and address problems in implementation and integration of interventions.

Latin America is among the highly endemic regions for cystic echinococcosis (CE). In Peru, an estimated 1,139 disability-adjusted life years are lost annually from surgical treatment of CE. This is comparable with the combined total for Argentina, Brazil, Uruguay, and Chile. The prevalence of human infection has been investigated in the central Peruvian Andes, but there are no community-based screening data from other regions of Peru. We carried out a population survey in January 2015 using abdominal ultrasound to estimate the prevalence of abdominal CE in the Canas and Canchis provinces, in the Cusco region of Peru. Among 1,351 subjects screened, 41 (3%) had CE. There was significant variation between communities with similar socioeconomic features in a small geographical area. A history of CE was reported by 4.1% of the screened subjects, among whom 30.3% still had CE on ultrasound. Among patients reporting previous CE treatment, 14.9% had CE in active stages. Limited education, community of residence, and knowing people with CE in the community were associated with CE. These results demonstrate a significant burden of CE in the region and suggest the need for further investigations, control activities, and optimization of clinical management for CE in this area.

In Cusco, Peru, and South America in general, there is a dearth of travelers' diarrhea (TD) data concerning the clinical features associated with enteropathogen-specific infections and destination-specific risk behaviors. Understanding these factors would allow travel medicine providers to tailor interventions to patients' risk profiles and travel destination. To characterize TD etiology, evaluate region-specific TD risk factors, and examine relationships between preventive recommendations and risk-taking behaviors among medium- to long-term travelers' from high-income countries, we conducted this case-case analysis using 7 years of prospective surveillance data from adult travelers' presenting with TD to a physician in Cusco. At the time of enrollment, participants provided a stool sample and answered survey questions about demographics, risk behaviors, and the clinical features of illness. Stool samples were tested for norovirus (NV), bacteria, and parasites using conventional methods. Data obtained were then analyzed using case-case methods. NV (14%), enterotoxigenic Escherichia coli (11%), and Campylobacter (9%), notably ciprofloxacin-resistant Campylobacter, were the most frequently identified pathogens among adults with TD. Coinfection with multiple enteropathogens occurred in 5% of cases. NV caused severe disease relative to other TD-associated pathogens identified, confining over 90% of infected individuals to bed. Destination-specific risk factors include consumption of the local beverage "chicha," which was associated with Cryptosporidium infection. Preventive interventions, such as vaccines, directed against these pathogens could significantly reduce the burden of TD.

Strongyloides stercoralis affects 30-100 million people worldwide. The burden is underestimated because of the paucity of studies, limited geographical areas surveyed, and poor quality of diagnostic tests. This study aimed at determining the epidemiology of strongyloidiasis using sensitive microscopy testing in rural populations living at different altitudes in Cusco, Peru. Data were collected from subjects aged > 3 years living in Quellouno (elevation 2,600 ft) and Limatambo (elevation 8,379 ft) districts. Subjects provided one fresh stool sample and answer a standardized questionnaire. Fresh stool was tested on site using the Baermann's test and agar plate culture. Formalin-preserved stool was tested by rapid sedimentation. Eighty percent (585/715) of eligible subjects consented to participate; after excluding subjects with missing data, 65% (462/715) were included. Fifty-five percentage were female; the median age was 33 years (interquartile range 13-52), and 72% had government health insurance. Half had intestinal parasites, and Strongyloides was the most common (24.5%) followed by Giardia (15.5%), Blastocystis (14.9%), and hookworm (11.5%). The agar plate culture detected more cases of Strongyloides than Baermann's or sedimentation tests. Strongyloides infection was more common at low altitude (26.4%) than at high altitude (18.6%), but the difference was not statistically significant (P = 0.08). Older age, walking barefoot, bathing in rivers/streams, and using municipal sewage were associated with strongyloidiasis. Strongyloides was the most prevalent parasite in the areas studied and was associated with demographic, socioeconomic, and sanitary factors.

Hymenolepis nana is the most common cestode infection in the world. However, limited information is available regarding its impact on affected populations. We studied the epidemiology and symptoms associated with hymenolepiasis among children 3-16 years old in 16 rural communities of the highlands of the Cusco region in Peru. Information on demographics, socioeconomic status, symptoms as reported by parents, and parasitological testing was obtained from the database of an ongoing Fasciola hepatica epidemiologic study. A total of 1,230 children were included in the study. Forty-five percent were infected with at least one pathogenic intestinal parasite. Giardia spp. (22.9%) was the most common, followed by Hymenolepis (17.4%), Fasciola (14.1%), Ascaris lumbricoides (6.1%), and Strongyloides stercoralis (2%). The prevalence of Hymenolepis infection varied by community, by other parasitic infections, and by socioeconomic status. However, only years of education of the mother, use of well water, and age less than 10 years were associated with Hymenolepis infection in the multivariate analysis. Hymenolepis nana infection was associated with diarrhea, jaundice, headaches, fever, and fatigue. Children with > 500 eggs/g of stool were more likely to have symptoms of weight loss, jaundice, diarrhea, and fever. Hymenolepis nana infection and age were the only factors retained in the multivariate analysis modeling diarrhea. Hymenolepiasis is a common gastrointestinal helminth in the Cusco region and is associated with significant morbidity in children in rural communities. The impact caused by the emergence of Hymenolepis as a prevalent intestinal parasite deserves closer scrutiny.

Myiasis is the infestation by dipterous larvae. The larvae can infect intact or decaying tissue including the skin or epithelial surfaces of the orbits, nose, and genitourinary and gastrointestinal tracts. We report a case of primary obligatory nasal myiasis byOestrus ovisin a 56-year-old man from Cusco in Peru. He presented with nasal pruritus, congestion, and sneezing white “cottony” material. The material was identified asO. ovislarvae. A literature review of publications reporting nasal myiasis caused byO. ovisis presented.

The normal physiologic changes during pregnancy contribute to nutritional, metabolic, and immunologic adjustments, which can have an impact on the presentation of several diseases. New onset seizures during pregnancy and the postpartum can be attributed to several etiologies. Patient demographic data as well as personal and social histories are key in determining the etiology of new onset seizures. Neurocysticercosis (NCC), a commonly overlooked etiology, must be included in the differential diagnosis of patients with new onset seizures coming from NCC endemic areas. The diagnosis is based on a combination of clinical findings, exposure history, imaging, and serology. We present two cases of patients with NCC that became symptomatic during pregnancy or postpartum period. We will review the epidemiology, clinical manifestations, and management of NCC in pregnancy.

Many cestode species are transmitted through the food supply. Cestode human infections occur worldwide but are more prevalent where sanitation, water supply, hygiene, and food handling practices are suboptimal. Food-borne species relevant to humans include Taenia solium, Taenia saginata, Diphyllobothrium spp., Hymenolepis nana, Echinococcus granulosus, and Spirometra spp. The life cycle of these species include an intestinal tapeworm and a tissue larval stage. Humans may be affected by one or both parasite stages depending on the infecting parasite. The clinical manifestation of cestode infections can be severe and disabling, like in seizure disorders caused by T. solium neurocysticercosis and complicated surgical interventions to treat cystic echinococcosis. However, some other may cause mild symptoms or subclinical infections but compromise income and food security like with T. saginata. The treatment of the tapeworm stage is with praziquantel, but the management of cestode larval infection is complex and is usually challenging to clinicians. The prevention of cestode infection involves personal hygiene, clean water, and high food safety standards including food inspection. Thoroughly freezing and cooking animal products may interrupt transmission of some cestodes.

Objective. To evaluate the prevalence of soil-transmitted helminth infections, anemia, and malnutrition among children in the Paucartambo province of Cusco region, Peru, in light of demographic, socio-economic, and epidemiologic contextual factors. Methods. Children from three to twelve years old from six communities in Huancarani district in the highlands of Peru were evaluated for helminth infections, anemia, and nutritional status. Data collected included demographic variables, socioeconomic status, exposures, complete blood counts, and direct and sedimentation stool tests. Results. Of 240 children analyzed, 113 (47%) were infected with one or more parasites. Giardia (27.5%) and Fasciola (9.6%) were the most commonly identified organisms. Eosinophilia was encountered in 21% of the children. Anemia (48.8%) was associated with age (3-4 vs 5-12 years old; odds ratio (OR): 5.86; 95% confidence interval (CI): 2.81-12.21). Underweight (10%) was associated with male sex (OR: 5.97; CI: 1.12-31.72), higher eosinophil count (OR: 4.67; CI: 1.31-16.68) and education of the mother (OR: 0.6; CI: 0.4-0.9). Stunting (31.3%) was associated with education of the mother (OR: 0.83; CI: 0.72-0.95); wasting (2.7%) was associated with higher eosinophil count (OR: 2.75; CI: 1.04-7.25). Conclusions. Anemia and malnutrition remain significant problems in the Peruvian highlands. These findings suggest that demographic factors, socio-economic status, and possibly parasitic infections intertwine to cause these health problems.

Background Travelers receive medical advice from a variety of sources, including travel agencies. The aim of this study is to describe the quality of pre-travel advice provided by travel agencies in Cuzco to travelers interested in visiting malaria and yellow fever endemic areas. Methods Trained medical students posed as tourists and visited travel agencies in Cuzco requesting travel advice for a trip to the southern Amazon of Peru, recording advice regarding risk and prevention of malaria and yellow fever. Results A total of 163 registered travel agencies were included in the study. The mean proposed tour duration was 6.8 days (±1.4 days) with a median time to departure of 3 days and a median tour cost of 805 US dollars (USD) [interquartile range (IQR) 580–1,095]. Overall, 45% employees failed to mention the risk for any illness. Eighteen percent of the employees acknowledged risk of malaria and 53% risk of yellow fever. However, 36% denied malaria risk and 2% denied risk of yellow fever in the region. The price of tours from travel agencies that did not mention any health risk was significantly lower [1,009.6 ± 500.5 vs 783.9 ± 402 USD, t (152) = 3, p

Fasciola hepatica is the most widely distributed trematode infection in the world. Control efforts may be hindered by the lack of diagnostic capacity especially in remote endemic areas. Polymerase chain reaction (PCR)–based methods offer high sensitivity and specificity but require expensive technology. However, the recombinase polymerase amplification (RPA) is an efficient isothermal method that eliminates the need for a thermal cycler and has a high deployment potential to resource-limited settings. We report on the characterization of RPA and PCR tests to detect Fasciola infection in clinical stool samples with low egg burdens. The sensitivity of the RPA and PCR were 87% and 66%, respectively. Both tests were 100% specific showing no cross-reactivity with trematode, cestode, or nematode parasites. In addition, RPA and PCR were able to detect 47% and 26% of infections not detected by microscopy, respectively. The RPA adapted to a lateral flow platform was more sensitive than gel-based detection of the reaction products. In conclusion, the Fasciola RPA is a highly sensitive and specific test to diagnose chronic infection using stool samples. The Fasciola RPA lateral flow has the potential for deployment to endemic areas after further characterization.

The study of human intestinal pathogens has been limited by the lack of methods for the long-term culture of primary human intestinal epithelial cells (PECs). The development of infection models with PECs would allow a better understanding of host-parasite interactions. The objective of this study was to develop a novel method for prolonged in vitro cultivation of PECs that can be used to study Cryptosporidium infection. We isolated intact crypts from human intestines removed during weight loss surgery. The fragments of intestinal layers were cultivated with culture medium supplemented with growth factors and antiapoptotic molecules. After 7 days, the PECs formed self-regenerating cell clusters, forming villi that resemble intestinal epithelium. The PECs proliferated and remained viable for at least 60 days. The cells expressed markers for intestinal stem cells, epithelial cells, and mature enterocytes. The PECs were infected with Cryptosporidium . In contrast to older models in which parasite numbers decay, the burden of parasites increased for >120 h. In summary, we describe here a novel method for the cultivation of self-regenerating human epithelial cells from small intestinal crypts, which contain both intestinal stem cells and mature villus cells. We present data that suggest these cells support Cryptosporidium better than existing cell lines. PECs should provide an improved tool for studying host-parasite interactions involving Cryptosporidium and other intestinal pathogens.

Fasciola hepatica is the most widely distributed trematode infection in the world. Control efforts may be hindered by the lack of diagnostic capacity especially in remote endemic areas. Polymerase chain reaction (PCR)–based methods offer high sensitivity and specificity but require expensive technology. However, the recombinase polymerase amplification (RPA) is an efficient isothermal method that eliminates the need for a thermal cycler and has a high deployment potential to resource-limited settings. We report on the characterization of RPA and PCR tests to detect Fasciola infection in clinical stool samples with low egg burdens. The sensitivity of the RPA and PCR were 87% and 66%, respectively. Both tests were 100% specific showing no cross-reactivity with trematode, cestode, or nematode parasites. In addition, RPA and PCR were able to detect 47% and 26% of infections not detected by microscopy, respectively. The RPA adapted to a lateral flow platform was more sensitive than gel-based detection of the reaction products. In conclusion, the Fasciola RPA is a highly sensitive and specific test to diagnose chronic infection using stool samples. The Fasciola RPA lateral flow has the potential for deployment to endemic areas after further characterization.

Triclabendazole is reported to be highly effective in treatment of human fascioliasis. We present 7 of 19 selected cases of human fascioliasis referred to our center in the Cusco region of Peru that failed to respond to triclabendazole. These were mostly symptomatic adults of both sexes that continued passing Fasciola eggs in the stool despite multiple treatments with 2 doses of triclabendazole at 10 mg/kg per dose. We documented the presence of eggs by rapid sedimentation and Kato Katz tests after each treatment course. We found that repeated triclabendazole courses were not effective against fascioliasis in this group of people. These findings suggest that resistance to triclabendazole may be an emerging problem in the Andes., Author Summary Fascioliasis is a zoonotic food borne trematode infection with a wide distribution. The complex epidemiology of this infection makes control efforts difficult. The paucity of drugs available for treatment may further hinder their success. Triclabendazole, the only first line drug for Fasciola, has been used for many years in the livestock industry. Resistant livestock Fasciola infections have emerged in developing and developed countries. However, most human trials report triclabendazole efficacies close to 100% after a few doses. Only a few cases of triclabendazole treatment failure have been published. We document 7 patients infected with Fasciola hepatica in Cusco–Peru that failed several treatment courses with triclabendazole. This raises concerns regarding preparedness to address resistant parasite infections and calls for more research to find new medications and tools to evaluate resistance.

Background Increasing numbers of travelers are visiting high altitude locations in the Andes. The epidemiology of acute mountain sickness (AMS) among tourists to high altitude in South America is not well understood. Methods A cross‐sectional study to evaluate the epidemiology, pre‐travel preparation, and impact of AMS among travelers to Cusco, Peru (3,400 m) was performed at Cusco's International Airport during June 2010. Foreign travelers, 18 years or older, staying 15 days or less, departing Cusco were invited to participate. Demographic, itinerary, and behavioral data were collected. The Lake Louise Clinical score (LLCS) was used to assess AMS symptoms. Results In total, 991 travelers participated, median age 32 years (interquartile range 25–49), 55.5% female, 86.7% tourists, mostly from the United States (48.2%) and England (8.1%). Most (76.7%) flew from sea level to Cusco and 30.5% visited high altitude in the previous 2 months. Only 29.1% received AMS advice from a physician, 19% recalled advice on acetazolamide. Coca leaf products (62.8%) were used more often than acetazolamide (16.6%) for prevention. AMS was reported by 48.5% and 17.1% had severe AMS. One in five travelers with AMS altered their travel plans. Travelers older than 60 years, with recent high altitude exposure, who visited lower cities in their itinerary, or used acetazolamide were less likely to have AMS. Using coca leaf products was associated with increased AMS frequency. Conclusions AMS was common and adversely impacted plans of one in five travelers. Acetazolamide was associated with decreased AMS but was prescribed infrequently. Other preventive measures were not associated with a decrease in AMS in this population. Pre‐travel preparation was suboptimal.

The risks associated with alcohol intoxication are rarely discussed during pre-travel counselling. However, alcohol immoderation abroad may increase the exposure to health risks. Few studies have addressed alcohol consumption and risk taking behaviour in travellers to South America. From October to December of 2004, travellers leaving the city of Cusco in Peru were asked to fill out anonymous questionnaires regarding demographics, self-reported alcohol consumption, illness and risk behaviour for sexually-transmitted infection (STI) and travellers diarrhoea. Most travellers (87.2%) consumed alcohol and 20.4% reported inebriation in Cusco. Those admitting inebriation were more likely to be male, single

Background. Demographics, preferences on health care, and regional differences in pre-travel advice guidelines may influence the preparation of travelers to developing countries. Methods. A secondary data analysis of the database of a travelers' health survey conducted in Cusco in 2002 was performed. Data from those whose place of residence was North America or Western Europe were selected. Illness rates, vaccinations, prophylactic medication use, and general recommendations on disease prevention were compared between the two groups. Results. Data from 1,612 North Americans (NAM) and 3,590 Western Europeans (EUR) were analyzed. NAM were older, stayed longer in Cusco, and had less experience traveling to developing countries (p < 0.01). They reported being ill more often than EUR (58% vs 42%, p < 0.01). Diarrhea was more frequent among EUR (55.6% vs 46.7%, p < 0.01), and acute mountain sickness (AMS) was more frequent among NAM (52.8% vs 35.2%, p < 0.01). EUR sought advice from health care professionals (67.1% vs 52.0%, p < 0.01) and travel medicine practitioners (45.8% vs 37%, p < 0.01) more often. NAM used prophylactic medications more often (53% vs 48.6%, p = 0.00) and received a lower mean number of vaccines (1.97 ± 1.68 vs 2.63 ± 1.49; t-test 14.02, p < 0.01). Advice on safe sex and alcohol consumption was low in both groups, especially among NAM. Conclusions. Pre-travel preparation and travel-related illnesses varied between NAM and EUR. Improving consistency of pre-travel preparation based on the best evidence should become a priority among different national bodies providing travel medicine recommendations.

Background Sexual networking in popular tourist destinations is a problem worldwide. In Peru, locals sexually interacting with travelers bridge high-risk groups, the general population, and travelers. Methods A cross-sectional study was conducted in Cuzco about sexual behavior among young Peruvians who admitted having sex with travelers. A subgroup of the participants had serologic testing for Chlamydia trachomatis, Herpes simplex virus (HSV) type 2, and Treponema pallidum. Results Eighty-eight subjects volunteered for blood sampling. Their mean age was 22.9 years (±4.1) and 53.4% were male. The majority were single (86.2%), but 12.6% had a stable relationship. The median number of sexual partners in the 3 months prior to the study was 2 [interquartile range (IQR): 1–4]. During that period, 43.1% reported foreign partners, 28.4% reported foreign and Peruvian partners, 17% reported Peruvian partners, and the remaining 11.5% reported combinations of Peruvian, foreign, and sex workers partners. The median number of foreign partners in the 12-month period prior to the study was 4 (IQR: 2–8). Only 25.3% reported consistent condom use. Alcohol (69%) and drugs (36.8%) were commonly used before sexual activity. Seventy-eight percent tested positive for HSV type 2, 25% for C trachomatis, and 1.1% for T pallidum. Conclusions The core group of young Peruvians we report on demonstrated a high-risk sexual behavior and a high prevalence of sexually transmitted infections. Our results underscore the need for education on safer sex practices among this group and among travelers.

Traditional risk factors do not explain the individual differences in susceptibility to travelers' diarrhea (TD) among the increasing number of travelers to the developing world. Single-nucleotide polymorphisms of the genes encoding for lactoferrin and interleukin 8 (IL-8) have been linked to susceptibility to TD. Subjects with mutations of the FUT2 gene are immune to norovirus infection. The recognition of individual variations in susceptibility to TD will aid in risk stratification of travelers to the developing world. Diagnosis is usually syndromic, but improved diagnostic methods are in development. Quinolones have been the mainstay of antibiotic treatment, but azithromycin (for resistant organisms) and rifaximin (for noninvasive organisms) may provide advantages. Transcutaneous vaccines for the major Escherichia coli enteropathogens are in development. In the future, travel advice, prophylactic medication regimens, and standby treatment for TD will be better tailored to each patient's specific risk factors.

OBJECTIVES: To describe the frequency of HTLV-1 infection among offspring of mothers who had presented with HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP), strongyloidiasis, or asymptomatic HTLV-1 infection, and to identify factors associated with HTLV-1 infection. METHODS: In a descriptive study, records were reviewed of HTLV-1-positive women and their offspring who had been tested for HTLV infection at a public hospital in Lima, Peru, from 1989 to 2003. Sons and daughters of women who had presented with strongyloidiasis, HAM/TSP, or asymptomatic infection were eligible for this study. RESULTS: Three hundred seventy subjects were included: 279 were the offspring of 104 mothers presenting with HAM/TSP, 58 were the offspring of 22 mothers with strongyloidiasis, and 33 were the offspring of 26 asymptomatic mothers. Mean age of the offspring at the time of testing was 26 years (standard deviation 12). Nineteen percent of the offspring tested positive for HTLV-1: 6% (2/33) of those with asymptomatic mothers, 19% (52/279) among the offspring of mothers with HAM/TSP, and 31% (18/58) among the offspring of mothers presenting with strongyloidiasis On multiple logistic regression analysis, three factors were significantly associated with HTLV-1: (a) duration of breast-feeding (odds ratio [OR] = 15.1; [4.2-54.1] for 12 to 24 months versus less than 6 months breast-feeding); (b) clinical condition of the mother (OR = 8.3 [1.0-65.3] for HAM/TSP and OR = 11.5 [1.4-98.4] for strongyloidiasis in comparison with offspring of asymptomatic mothers); and (c) transfusion history (OR = 5.5 [2.0-15.2]). CONCLUSIONS: In addition to known risk factors for HTLV-1 transmission (duration of breast-feeding and history of blood transfusion), maternal HAM/TSP and strongyloidiasis were associated with seropositivity among offspring of HTLV-1-infected mothers.OBJETIVOS: Describir la frecuencia de la infección por HTLV-1 en los hijos e hijas de madres diagnosticadas con mielopatía/paraparesia espástica tropical asociada con el HTLV-1 (M/PET-HTLV-1), estrongiloidiasis o infección asintomática por HTLV-1, e identificar los factores asociados con la infección por HTLV-1. MÉTODOS: Para este estudio descriptivo se revisaron los registros de mujeres positivas a HTLV-1 y de sus hijos evaluados con pruebas para la infección por HTLV en un hospital público de Lima, Perú, entre 1989 y 2003. Eran elegibles para este estudio los hijos y las hijas de las mujeres que se presentaron con estrongiloidiasis, M/PET-HTLV-1 o infección asintomática. RESULTADOS: En el estudio participaron 370 personas: 279 hijos de 104 madres con M/PET-HTLV-1, 58 hijos de 22 madres con estrongiloidiasis y 33 hijos de 26 madres asintomáticas. La edad promedio de los participantes en el momento de su prueba para HTLV era de 26 años (desviación estándar: 12 años). De las personas estudiadas, 19% resultaron positivas a la infección por HTLV-1: 6% (2/33) de los hijos de madres asintomáticas, 19% (52/279) de los hijos de madres con M/PET-HTLV-1 y 31% (18/58) de los hijos de madres con estrongiloidiasis. Según el análisis de regresión logística múltiple, tres factores se asociaron significativamente con la infección por HTLV-1: a) duración de la lactancia materna por 12_24 meses (razón de posibilidades [odds ratio, OR] = 15,1; intervalo de confianza de 95% [IC95%]: 4,2 a 54,1, frente a la lactancia materna por menos de 6 meses); b) que la madre presentara M/PET-HTLV-1 o estrongiloidiasis (OR = 8,3; IC95%: 1,0 a 65,3 y OR = 11,5; IC95%: 1,4 a 98,4, respectivamente, en comparación con los hijos de madres asintomáticas); y c) los antecedentes de haber recibido una transfusión sanguínea (OR = 5,5; IC95%: 2,0 a 15,2). CONCLUSIONES: Además de los factores de riesgo de la transmisión de la infección por HTLV-1 conocidos (duración de la lactancia materna y antecedentes de transfusión sanguínea), el diagnóstico materno de M/PET-HTLV-1 y el de estrongiloidiasis se asociaron significativamente con la infección por HTLV-1 en los hijos de madres seropositivas.

Fasciola hepatica is a zoonotic infection with a worldwide distribution. Autochthonous cases have not been reported in the Amazon region of Peru. Operculated eggs resembling F. hepatica were identified in the stools of five out of 215 subjects in a remote indigenous community of the Peruvian jungle. Polymerase chain reaction targeting Fasciola hepatica cytochrome oxidase subunit 1 (COI) gene and sequencing of the products confirmed Fasciola infection.

Giardia duodenalis is one of the most commonly identified parasites in stool samples. Although relatively easy to treat, giardiasis can be difficult to detect as it presents similar to other diarrheal diseases. Here, we present a recombinase polymerase amplification-based Giardia (RPAG) assay to detect the presence of Giardia in stool samples. The RPAG assay was characterized on the bench top using stool samples spiked with Giardia cysts where it showed a limit-of-detection nearly as low as the gold standard polymerase chain reaction assay. The RPAG assay was then tested in the highlands of Peru on 104 stool samples collected from the surrounding communities where it showed 73% sensitivity and 95% specificity against a polymerase chain reaction and microscopy composite gold standard. Further improvements in clinical sensitivity will be needed for the RPAG assay to have clinical relevance.

The objective of this study was to determine the risk factors for travelers' diarrhea (TD) reported by visitors to Cuzco, Peru. In this cross-sectional study, self-administered questionnaires looking at perceived occurrence of health problems and pre-travel health advice were obtained from departing travelers at Cuzco's International Airport between August and November 2002. A total of 5,988 travelers participated in the study. The mean age was 35 years, and 51% were women. The prevalence of TD was 24%. Factors associated with TD in the multivariable analysis were use of antibiotic prophylaxis (OR: 3.20), vaccination against cholera (OR: 1.44), history of advice for safe food and water consumption (OR: 1.46), being younger than 35 years of age (OR: 1.37), being a resident of the United States (OR: 1.28), not staying in hotels in Cuzco (OR: 1.13), and number of unsafe food or beverages consumed (OR: 1.04). Remaining in Cuzco < 1 week was a protective factor (OR: 0.58). TD is common among travelers to Cuzco. This study suggests that conventional recommendations are not invariably effective at decreasing TD.