The impact of Chagas disease control in Latin America: a review

Discovered in 1909, Chagas disease was progressively shown to be widespread throughout Latin America, affecting millions of rural people with a high impact on morbidity and mortality. With no vaccine or specific treatment available for large-scale public health interventions, the main control strategy relies on prevention of transmission, principally by eliminating the domestic insect vectors and control of transmission by blood transfusion. Vector control activities began in the 1940s, initially by means of housing improvement and then through insecticide spraying following successful field trials in Brazil (Bambui Research Centre), with similar results soon reproduced in S?o Paulo, Argentina, Venezuela and Chile. But national control programmes only began to be implemented after the 1970s, when technical questions were overcome and the scientific demonstration of the high social impact of Chagas disease was used to encourage political determination in favour of national campaigns (mainly in Brazil). Similarly, large-scale screening of infected blood donors in Latin America only began in the 1980s following the emergence of AIDS. By the end of the last century it became clear that continuous control in contiguous endemic areas could lead to the elimination of the most highly domestic vector populations - especially Triatoma infestans and Rhodnius prolixus - as well as substantial reductions of other widespread species such as T. brasiliensis, T. sordida, and T. dimidiata, leading in turn to interruption of disease transmission to rural people. The social impact of Chagas disease control can now be readily demonstrated by the disappearance of acute cases and of new infections in younger age groups, as well as progressive reductions of mortality and morbidity rates in controlled areas. In economic terms, the cost-benefit relationship between intervention (insecticide spraying, serology in blood banks) and the reduction of Chagas disease (in terms of medical and social care and improved productivity) is highly positive. Effective control of Chagas disease is now seen as an attainable goal that depends primarily on maintaining political will, so that the major constraints involve problems associated with the decentralisation of public health services and the progressive political disinterest in Chagas disease. Counterbalancing this are the political and technical cooperation strategies such as the "Southern Cone Initiative" launched in 1991. This international approach, coordinated by PAHO, has been highly successful, already reaching elimination of Chagas disease transmission in Uruguay, Chile, and large parts of Brazil and Argentina. The Southern Cone Initiative also helped to stimulate control campaigns in other countries of the region (Paraguay, Bolivia, Peru) which have also reached tangible regional successes. This model of international activity has been shown to be feasible and effective, with similar initiatives developed since 1997 in the Andean Region and in Central America. At present, Mexico and the Amazon Region remain as the next major challenges. With consolidation of operational programmes in all endemic countries, the future focus will be on epidemiological surveillance and care of those people already infected. In political terms, the control of Chagas disease in Latin America can be considered, so far, as a victory for international scientific cooperation, but will require continuing political commitment for sustained success.     

Decline in diarrhea mortality and admissions after routine childhood rotavirus immunization in Brazil: a time-series analysis

Background

In 2006, Brazil began routine immunization of infants <15 wk of age with a single-strain rotavirus vaccine. We evaluated whether the rotavirus vaccination program was associated with declines in childhood diarrhea deaths and hospital admissions by monitoring disease trends before and after vaccine introduction in all five regions of Brazil with varying disease burden and distinct socioeconomic and health indicators.

Methods and Findings

National data were analyzed with an interrupted time-series analysis that used diarrhea-related mortality or hospitalization rates as the main outcomes. Monthly mortality and admission rates estimated for the years after rotavirus vaccination (2007–2009) were compared with expected rates calculated from pre-vaccine years (2002–2005), adjusting for secular and seasonal trends. During the three years following rotavirus vaccination in Brazil, rates for diarrhea-related mortality and admissions among children <5 y of age were 22% (95% confidence interval 6%–44%) and 17% (95% confidence interval 5%–27%) lower than expected, respectively. A cumulative total of ∼1,500 fewer diarrhea deaths and 130,000 fewer admissions were observed among children <5 y during the three years after rotavirus vaccination. The largest reductions in deaths (22%–28%) and admissions (21%–25%) were among children younger than 2 y, who had the highest rates of vaccination. In contrast, lower reductions in deaths (4%) and admissions (7%) were noted among children two years of age and older, who were not age-eligible for vaccination during the study period.

Conclusions

After the introduction of rotavirus vaccination for infants, significant declines for three full years were observed in under-5-y diarrhea-related mortality and hospital admissions for diarrhea in Brazil. The largest reductions in diarrhea-related mortality and hospital admissions for diarrhea were among children younger than 2 y, who were eligible for vaccination as infants, which suggests that the reduced diarrhea burden in this age group was associated with introduction of the rotavirus vaccine. These real-world data are consistent with evidence obtained from clinical trials and strengthen the evidence base for the introduction of rotavirus vaccination as an effective measure for controlling severe and fatal childhood diarrhea. Please see later in the article for the Editors'' Summary     

The potential economic value of a Trypanosoma cruzi (Chagas disease) vaccine in Latin America

Background

Chagas disease, caused by the parasite Trypanosoma cruzi (T. cruzi), is the leading etiology of non-ischemic heart disease worldwide, with Latin America bearing the majority of the burden. This substantial burden and the limitations of current interventions have motivated efforts to develop a vaccine against T. cruzi.

Methodology/Principal Findings

We constructed a decision analytic Markov computer simulation model to assess the potential economic value of a T. cruzi vaccine in Latin America from the societal perspective. Each simulation run calculated the incremental cost-effectiveness ratio (ICER), or the cost per disability-adjusted life year (DALY) avoided, of vaccination. Sensitivity analyses evaluated the impact of varying key model parameters such as vaccine cost (range: $0.50–$200), vaccine efficacy (range: 25%–75%), the cost of acute-phase drug treatment (range: $10–$150 to account for variations in acute-phase treatment regimens), and risk of infection (range: 1%–20%). Additional analyses determined the incremental cost of vaccinating an individual and the cost per averted congestive heart failure case. Vaccination was considered highly cost-effective when the ICER was ≤1 times the GDP/capita, still cost-effective when the ICER was between 1 and 3 times the GDP/capita, and not cost-effective when the ICER was >3 times the GDP/capita. Our results showed vaccination to be very cost-effective and often economically dominant (i.e., saving costs as well providing health benefits) for a wide range of scenarios, e.g., even when risk of infection was as low as 1% and vaccine efficacy was as low as 25%. Vaccinating an individual could likely provide net cost savings that rise substantially as risk of infection or vaccine efficacy increase.

Conclusions/Significance

Results indicate that a T. cruzi vaccine could provide substantial economic benefit, depending on the cost of the vaccine, and support continued efforts to develop a human vaccine.     

Low prevalence of rotavirus and high prevalence of norovirus in hospital and community wastewater after introduction of rotavirus vaccine in Nicaragua

Rotavirus (RV) and norovirus (NoV) are major causes of pediatric diarrhea and are altogether associated with approximately 800,000 deaths in young children every year. In Nicaragua, national RV vaccination program using the pentavalent RV5 vaccine from Merck was implemented in October 2006. To determine whether RV vaccination decreased the overall number of RV infections, we investigated the occurrence of RV and NoV in wastewater in the city of León from July 2007 to July 2008 and compared these data with pre-vaccination data. The major finding was the low prevalence of RV compared to NoV in all sampling points (11% vs 44%, p<0.05), and that RV concentration was lower as compared to NoV. RV was observed mainly during the rainy season (July-September), and the majority of all RV detected (6/9) belonged to subgroup (SG) I. The partial VP7-gene obtained from one RV positive sample was similar (99% nt identity) to a G6 VP7-gene of bovine origin and similar to the corresponding gene of the vaccine strain (98%). Furthermore RV G-types 2 and 4 were found in the incoming wastewater. NoV strains were detected throughout the year, of which a majority (20/21) were of genotype GII.4. We conclude that the introduction of RV vaccination reduced the transmission of RV in the community in Nicaragua. However, the burden of diarrhea in the country remains high, and the high prevalence of NoVs in hospital and municipal wastewater is noteworthy. This study highlights the need for further assessment of NoV following RV vaccine introduction.     

CyberKnife Stereotactic Radiosurgery in brain metastases: A report from Latin America with literature review

Background and aim

Stereotactic radiosurgery is increasingly being employed for the treatment of brain metastases, both as an adjuvant to surgical resection, and also as a primary treatment modality. The aim of this study is to evaluate overall survival and local control in patients with brain metastases treated with CyberKnife Stereotactic Radiosurgery (CKRS), due to the lack of evidence reported in Latin America.

Cryptic species in marine polychaete and their independent introduction from North America to Europe

The vast body of ballast water carried across oceans by freight ships represents a major source for the introduction of foreign species into marine ecosystems. The worm Marenzelleria viridis, originally found only in North America, appeared in estuaries of the North Sea in 1979 and 6 years later also in the Baltic, where it has developed into a major faunal element. Two competing hypotheses are discussed here: either both populations owe their presence to a single introductory event in the North Sea, or each population originated from a separate introduction. Our phylogeographic analysis of Baltic, North Sea and American Marenzelleria, based on mitochondrial 16S rDNA sequences (326- bp segment) of 98 individuals from 17 localities on the North American, North Sea, and Baltic coasts not only favors the two-event hypothesis, but also separates the locations of origin for the introductions. Eighteen mitochondrial genotypes were identified altogether. In agreement with allozyme data, three lineages were identified: genotypes assigned to the same lineage differed from each other by up to 5 point mutations, and those assigned to different lineages differed by up to 17. The existence of three morphologically indistinguishable, and thus cryptic, species is therefore suggested. The individuals from the Baltic Sea probably originated from the Atlantic coast of the United States between Chesapeake Bay and Georgia, and the North Sea populations may stem from the U.S. coast region north of Chesapeake Bay to Nova Scotia. Despite their similar morphologies, the two European Marenzelleria species may differ ecologically with respect to their preference for habitat salinity. Assuming that transport via ballast water occurs quite frequently, we hypothesize that both European cryptic species of Marenzelleria may originally have been introduced to both the North Sea and the Baltic Sea but that neither of them was able to proliferate in both water bodies owing to their differential physiological performances at high and low salinities.      

Invasive pneumococcal disease in Portugal prior to and after the introduction of pneumococcal heptavalent conjugate vaccine

The rates of invasive pneumococcal disease (IPD), serotype distribution and antimicrobial susceptibility prior to and after the introduction of the heptavalent pneumococcal conjugate vaccine in Portuguese children were evaluated. The changes in incidence of IPD in children under 1 year old between the two periods of the study was not significant (P=0.53), despite the 21% decline. In children under 18 years old there was a 27.7% decrease in vaccine serotypes. All nonvaccine serotypes increased 71.4%. The decrease in vaccine serotypes was more impressive during the first year of life (-54.8%) than for children between 1 and 5 years of age (-19.1%). Among children under 1 year old, penicillin nonsusceptible isolates declined between the two periods of the study (47.2% vs. 25.0%) (P=0.03), as did those of cefotaxime and ceftriaxone nonsusceptible isolates. No changes were observed for isolates nonsusceptible to tetracycline and macrolides. The serotypes of these nonsusceptible isolates differed after the introduction of vaccine (P=0.01). Multiresistance increased 57.1% after the introduction of vaccine. Multiresistant isolates with vaccine serotype declined 42.9% (P<0.001), and nonvaccine serotypes appeared during the vaccination period (P<0.001). These findings suggest a replacement of vaccine serotypes by nonvaccine serotypes, mainly among nonsusceptible isolates.     

Prevalence of Helicobacter pylori infection in Latin America and the Caribbean populations: A systematic review and meta-analysis

ObjectiveTo describe the prevalence of Helicobacter pylori (H. pylori) infection in Latin Americaand the Caribbean (LAC), through systematic review and meta-analysis by age groups and gender.MethodsSystematic review and meta-analysis of the population-based observational epidemiological studies carried out in LAC, focused on the prevalence of H. pylori and published until March, 2018. The databases utilized in the search were MEDLINE, SCIELO andPUBMED. The prevalence described in the meta-analysis and 95% confidence intervals were estimated by the random effects model, and weighted by the size of the study.ResultsThe 22 selected studies were carried out in 14 countries of LAC, and included 24,178 individuals. The studies were conducted between 1987 and 2012, and all were representative of at least one city. The prevalence of H. pylori infection was 57.57% (CI95%:50.43;64.72) for all ages; in children and adolescents the prevalence was 48.36% (CI95%:38.03;58.70) and in adults 69.26%(CI95%:64.54;76.99). No differences were observed regarding sex.ConclusionPrevalence of H. pylori infection in LAC is high for all age groups. These data reinforce the necessity of actions towards the prevention and treatment of H. pylori infection for all age groups. Treating H pylori infection in young ages probably will reduce gastric cancer incidence in the future.     

The neglected tropical diseases of Latin America and the Caribbean: a review of disease burden and distribution and a roadmap for control and elimination

The neglected tropical diseases (NTDs) represent some of the most common infections of the poorest people living in the Latin American and Caribbean region (LAC). Because they primarily afflict the disenfranchised poor as well as selected indigenous populations and people of African descent, the NTDs in LAC are largely forgotten diseases even though their collective disease burden may exceed better known conditions such as of HIV/AIDS, tuberculosis, or malaria. Based on their prevalence and healthy life years lost from disability, hookworm infection, other soil-transmitted helminth infections, and Chagas disease are the most important NTDs in LAC, followed by dengue, schistosomiasis, leishmaniasis, trachoma, leprosy, and lymphatic filariasis. On the other hand, for some important NTDs, such as leptospirosis and cysticercosis, complete disease burden estimates are not available. The NTDs in LAC geographically concentrate in 11 different sub-regions, each with a distinctive human and environmental ecology. In the coming years, schistosomiasis could be eliminated in the Caribbean and transmission of lymphatic filariasis and onchocerciasis could be eliminated in Latin America. However, the highest disease burden NTDs, such as Chagas disease, soil-transmitted helminth infections, and hookworm and schistosomiasis co-infections, may first require scale-up of existing resources or the development of new control tools in order to achieve control or elimination. Ultimately, the roadmap for the control and elimination of the more widespread NTDs will require an inter-sectoral approach that bridges public health, social services, and environmental interventions.     

Wartime evacuation and mortality from childhood leukaemia in England and Wales in 1945-9.

OBJECTIVE--To discover whether the wartime government evacuation of children from London and other population centres to rural districts was associated with any increase in childhood leukaemia. DESIGN--Observational study of mortality from leukaemia among the childhood population of England and Wales in relation to the unique population movements during the second world war. The 476 rural districts of England and Wales were ranked according to the ratio of government evacuees (two thirds of them children) to local children in September 1941. The districts were divided into three categories, each with similar numbers of children in 1947 but with different ratios of evacuees to local children ("low," "intermediate," "high"). Mortality from childhood leukaemia was examined in these three rural categories in 1945-9. Urban areas were also examined according to their exposure to evacuees. SETTING--Local authority areas of England and Wales. SUBJECTS--Children aged under 15. RESULTS--47% excess of leukaemia at ages 0-14 years occurred in 1945-9 in the rural "high" category for evacuees relative to the "low" category, with a significant trend across the three categories. There were increases in both the 0-4 and 5-14 year age groups, but these were larger in the older age group. Rates 25% lower than average occurred in rural areas with few evacuees. CONCLUSION--These findings suggest that wartime evacuation increased the incidence of childhood leukaemia in rural areas and that other forms of population mixing may have contributed to the increases in past decades. Overall, they add to the appreciable evidence for an infective basis in childhood leukaemia.     

A new species and a new combination in Stelis (Pleurothallidinae-Orchidaceae) from South America

Stelis duckei, of the Crocodeilanthe group, is described from the state of Ceará, Brazil. The new species is morphologically similar to S. speciosa, but can be distinguished by its longer ramicauls, wider leaves, and obtuse lip with a ridge-like callus at the base. The new combination Stelis speciosa is also provided here.     

Species complexes in Hericium (Russulales, Agaricomycota) and a new species - Hericium rajchenbergii - from southern South America

Species of the genus Hericium are generally recognized by macro morphology of their basidiomes, while they are very similar in the microscope. As a result, species boundaries are not always clear, and many collections are subsumed under incorrect names. We report on a thorough phylogenetic analysis based on ITS sequences to clarify the application of the most common names in the genus. H. alpestre, H. americanum, and H. erinaceus cannot readily be distinguished by their ITS sequences alone, while they are kept separate by characters from substrate preferences, geographical distribution, and macro morphology. A neotype is selected for H. alpestre. A well supported clade includes H. coralloides together with other, unnamed taxa. One of these, H. rajchenbergii from Argentina, is here described as new to science.     

New species and a new combination in Myrtaceae from northeastern South America

Three new species of Myrtaceae (Calyptranthes bracteata, Eugenia gonglycocarpa, andMyrcia rupta) from northeastern South America are described and illustrated, and a new combination (Eugenia tetramera) is proposed. The closed-calyx and the completely or partially fused cotyledons ofMyrcia rupta, unusual features for the genus, are discussed and compared with related species inMyrcia andMarlierea.     

Development of morbidity in hemolytic disease of the newborn after the introduction of immune prophylaxis at the Rostock blood exchange center from 1970 to 1980

The development of morbus haemolyticus neonatorum morbidity is demonstrated by referring to the example of the "exchange centre" in Rostock after using anti-D-immunprophylaxis for more than 10 years. The level achieved is compared with findings in international studies. The main cause for rest morbidity consists in omitting indicated immunoprophylaxis. Further progress in reducing the morbidity of morbus haemolyticus neonatorum can only be achieved by keeping physicians informed about the deleterious consequences of anti-D-immunisation having occurred.     

Growth in utero,blood pressure in childhood and adult life,and mortality from cardiovascular disease.

In national samples of 9921 10 year olds and 3259 adults in Britain systolic blood pressure was inversely related to birth weight. The association was independent of gestational age and may therefore be attributed to reduced fetal growth. This suggests that the intrauterine environment influences blood pressure during adult life. It is further evidence that the geographical differences in average blood pressure and mortality from cardiovascular disease in Britain partly reflect past differences in the intrauterine environment. Within England and Wales 10 year olds living in areas with high cardiovascular mortality were shorter and had higher resting pulse rates than those living in other areas. Their mothers were also shorter and had higher diastolic blood pressures. This suggests that there are persisting geographical differences in the childhood environment that predispose to differences in cardiovascular mortality.     

A new species,new combinations,and a new name in Acanthaceae from northern South America

A new species of Acanthaceae (Ruellia saülensis) is described and illustrated from French Guiana, and three new combinations (Justicia potarensis, J. flaviflora, andJ. tobagensis) and one new name (Justicia coppenamensis) are proposed. The new species is compared to its closest relative (Ruellia rubra), and a justification of the transfers is provided.     

Decreased thrombotic mortality and morbidity after valvular cardiac surgery as a consequence of adequate coumarin anticoagulation. A retrospective study in 516 patients.

Two almost identical groups of 258 patients each who underwent surgery for the substitution of one or more than one cardiac valve were taken into consideration. After surgery all patients, with the exception of those who received a porcine allograph, were given coumarin drugs for 1 year for thrombosis prophylaxis. In the first group of patients operated in 1972 and 1973 the laboratory follow-up and the therapeutic range were neither constant nor uniform. In the case of the second group, which included patients operated in 1974 and 1975, adequate laboratory follow-up and constantly adequate therapeutic ranges were always kept. This retrospective study has shown a statistically significant decrease in mortality due to thromboembolism and to unknown causes in the second group of patients (x2 = 8,313, "p" less than 0,0025). A decrease of the non-lethal embolic complications was also noted in the second group of patients (x2 = 6,813, "p" less than 0,0025). On the other hand, bleeding complications were greater in the second group of patients (x2 = 3,485, "p" less than 0,05) and this was interpreted as secondary to the higher anticoagulation administered to the latter patients. The results indicate that an adequate coumarin anticoagulation seems able to decrease the incidence of lethal or non-lethal thromboembolic complications after cardiac valve replacement significantly.