13. Otros

Denney, JA., Capanni, F., Herrera, P., Dulanto, A., Roldan, R., Paz, E., Jaymez, AA., Chirinos, EE., Portugal, J., Quispe, R., Brower, RG., Checkley, W.; INTENSIVOS Cohort Study.

BMJ Open. 2015 Jan 16;5(1)

Abstract

INTRODUCTION:

Mechanical ventilation is a cornerstone in the management of critically ill patients worldwide; however, less is known about the clinical management of mechanically ventilated patients in low and middle income countries where limitation of resources including equipment, staff and access to medical information may play an important role in defining patient-centred outcomes. We present the design of a prospective, longitudinal study of mechanically ventilated patients in Peru that aims to describe a large cohort of mechanically ventilated patients and identify practices that, if modified, could result in improved patient-centred outcomes and lower costs.

METHODS AND ANALYSIS:

Five Peruvian intensive care units (ICUs) and the Medical ICU at the Johns Hopkins Hospital were selected for this study. Eligible patients were those who underwent at least 24 h of invasive mechanical ventilation within the first 48 h of admission into the ICU. Information on ventilator settings, clinical management and treatment were collected daily for up to 28 days or until the patient was discharged from the unit. Vital status was assessed at 90 days post enrolment. A subset of participants who survived until hospital discharge were asked to participate in an ancillary study to assess vital status, and physical and mental health at 6, 12, 24 and 60 months after hospitalisation, Primary outcomes include 90-day mortality, time on mechanical ventilation, hospital and ICU lengths of stay, and prevalence of acute respiratory distress syndrome. In subsequent analyses, we aim to identify interventions and standardised care strategies that can be tailored to resource-limited settings and that result in improved patient-centred outcomes and lower costs.

ETHICS AND DISSEMINATION:

We obtained ethics approval from each of the four participating hospitals in Lima, Peru, and at the Johns Hopkins School of Medicine, Baltimore, USA. Results will be disseminated as several separate publications in different international journals.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

KEYWORDS:

EPIDEMIOLOGY

Ballard, SB., Reaves, EJ., Luna, CG., Silva, ME., Rocha, C., Heitzinger, K., Saito, M., Apaza, S., Espetia, S., Blazes, DL., Tilley, DH., Guzmán, RC., Gilman, RH., Bausch, DG.

PLoS One. 2015 Jul 10;10(7)

Abstract

BACKGROUND:

Successful vaccination strategies against norovirus will require understanding the burden of disease and relevant genotypes in populations. However, few data are available from cohort studies of adults living in low- and middle-income countries (LMIC).

MATERIALS AND METHODS:

We conducted a nested case-control study within a Peruvian military cohort to characterize the burden of norovirus infection, predominant genotypes, and associated symptoms from 2004 through 2011. Randomly selected case and control stools were tested for norovirus, bacteria, and parasites. The odds ratio of the association between norovirus infection and diarrhea was estimated using multiple logistic regression and co-infection adjusted attributable fractions were calculated.

RESULTS:

Of the 3,818 cohort study participants, 624 developed diarrhea. Overall and norovirus-associated diarrhea incidence rates were 42.3 and 6.0 per 100 person-years, respectively. The most prevalent norovirus genogroup was GII (72.5%, 29/40), which was associated with diarrhea (AOR 3.4, 95% CI: 1.3-8.7, P = 0.012). The co-infection adjusted GII attributable fraction was 6.4%.

DISCUSSION:

Norovirus was a frequent cause of diarrhea in an adult population followed longitudinally in an LMIC setting. Vaccine strategies should consider targeting adults in endemic settings and special populations that could serve as community transmission sources.

Patil, CL., Turab, A., Ambikapathi, R., Nesamvuni, C., Chandyo, RK., Bose, A., Islam, MM., Ahmed, AM., Olortegui, MP., de Moraes, ML., Caulfield, LE.; MAL-ED network.

J Health Popul Nutr. 2015 May 1;34

Abstract

We report the infant feeding experiences in the first month of life for 2,053 infants participating in «Malnutrition and Enteric Infections: Consequences for Child Health and Development» (MAL-ED). Eight sites (in Bangladesh, India, Nepal, Pakistan, Brazil, Peru, South Africa, Tanzania), each followed a cohort of children from birth (by day 17), collecting detailed information on infant feeding practices, diet and illness episodes. Mothers were queried twice weekly regarding health status, breastfeeding and the introduction (or no) of non-breast milk liquids and foods. Here, our goal is to describe the early infant feeding practices in the cohort and evaluate factors associated with termination of exclusive breastfeeding in the first month of life. With data from enrollment to a visit at 28-33 days of life, we characterized exclusive, predominant or partial breastfeeding (using a median of 6-9 visits per child across the sites). Only 6 of 2,053 infants were never breastfed. By one month, the prevalences of exclusive breastfeeding were < 60% in 6 of 8 sites, and of partial breastfeeding (or no) were > 20% in 6 of 8 sites. Logistic regression revealed that prelacteal feeding (given to 4-63% of infants) increased the likelihood of partial breastfeeding (Odds Ratio (OR): 1.48 (95% confidence interval (CI): 1.04, 2.10), as did the withholding of colostrum (2-16% of infants) (OR: 1.63:1.01, 2.62), and being a first-time mother (OR: 1.38:1.10, 1.75). Our results reveal diversity across these sites, but an overall trend of early transition away from exclusive breastfeeding in the first month of life. Interventions which introduce or reinforce the WHO/UNICEF Ten Steps for Successful Breastfeeding are needed in these sites to improve breastfeeding initiation, to reinforce exclusive breastfeeding and delay introduction of non-breast milk foods and/or liquids.

Rothstein JD, Leontsini E, Olortegui MP, Yori PP, Surkan PJ, Kosek M.

Am J Trop Med Hyg. 2015 Sep;93(3)

Abstract

The gap between the efficacy and the effectiveness of household water treatment in reducing diarrhea-related morbidity indicates the need for a better understanding of the determinants of long-term behavior change. To explore the barriers to drinking water chlorination in the Peruvian Amazon, where diarrhea is endemic among under-5 children, we conducted qualitative research with 23 caregivers from peri-urban communities of Iquitos, Peru. Our inquiry drew on the Transtheoretical Model of behavior change and the Integrated Behavioral Model for Water, Sanitation, and Hygiene to identify the most relevant contextual, psychosocial, and technological determinants of initial action and long-term adoption of chlorination. Our findings suggest that the decision to try out this practice resulted from the combined effect of knowledge of chlorination benefits and product availability and affordability. Progress from action to adoption was influenced by caretakers’ understanding of dosage, the packaging of chlorine products, knowledge and skills for multipurpose laundry bleach, the taste of treated water, and reinforcement. This analysis suggests that a focus on these determinants and the household domain may help to improve the sustainability of future intervention efforts.

Francis, ER., Kuo, CC., Bernabe-Ortiz, A., Nessel, L., Gilman, RH., Checkley, W., Miranda, JJ., Feldman, HI., CRONICAS Cohort Study Group.

BMC Nephrol. 2015 Jul 24;16

Abstract

BACKGROUND:

The silent progression of chronic kidney diseases (CKD) and its association with other chronic diseases, and high treatment costs make it a great public health concern worldwide. The population burden of CKD in Peru has yet to be fully described.

METHODS:

We completed a cross sectional study of CKD prevalence among 404 participants (total study population median age 54.8 years, 50.2 % male) from two sites, highly-urbanized Lima and less urbanized Tumbes, who were enrolled in the population-based CRONICAS Cohort Study of cardiopulmonary health in Peru. Factors potentially associated with the presence of CKD were explored using Poisson regression, a statistical methodology used to determine prevalence ratios.

RESULTS:

In total, 68 participants (16.8 %, 95 % CI 13.5-20.9 %) met criteria for CKD: 60 (14.9%) with proteinuria, four (1%) with eGFR < 60 mL/min/1.73 m2 , and four (1%) with both. CKD prevalence was higher in Lima (20.7 %, 95 % CI 15.8-27.1) than Tumbes (12.9 %, 95 % CI 9.0-18.5). Among participants with CKD, the prevalence of diabetes and hypertension was 19.1 % and 42.7 %, respectively. After multivariable adjustment, CKD was associated with older age, female sex, greater wealth tertile (although all wealth strata were below the poverty line), residence in Lima, and presence of diabetes and hypertension.

CONCLUSIONS:

The high prevalence rates of CKD identified in Lima and Tumbes are similar to estimates from high-income settings. These findings highlight the need to identify occult CKD and implement strategies to prevent disease progression and secondary morbidity.

Ganoza CA, Matthias MA, Saito M, Cespedes M, Gotuzzo E, Vinetz JM.

PLoS Negl Trop Dis. 2010 Feb 23;4(2):e612.

Renal carriage and shedding of leptospires is characteristic of carrier or maintenance animal hosts. Sporadic reports indicate that after infection, humans may excrete leptospires for extended periods. We hypothesized that, like mammalian reservoir hosts, humans develop asymptomatic leptospiruria in settings of high disease transmission such as the Peruvian Amazon.

Asymptomatic renal colonization of leptospires in a region of high disease transmission is common, including among people without serological or clinical evidence of recent infection. Both pathogenic and intermediate Leptospira can persist as renal colonization in humans. The pathogenic significance of this finding remains to be explored but is of fundamental biological significance.