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Background: The efficacy of albendazole therapy in patients with parenchymal neurocysticercosis (NCC) is suboptimal. Plasma levels of albendazole sulfoxide (ASOX), the active metabolite of albendazole, are highly variable among patients. We hypothesized that high ASOX plasma levels during albendazole therapy may be associated with an increased antiparasitic efficacy., Methods: ASOX plasma levels were measured at treatment day 7 in 118 patients with parenchymal NCC enrolled in a treatment trial. The relationships between increasing ASOX plasma levels with the proportion of cysts resolved and the proportion of patients with complete cyst resolution (evaluated by 6-month brain magnetic resonance) were assessed., Results: There was a trend toward a higher proportion of cysts resolved and a higher proportion of patients cured with increasing quartiles of ASOX plasma levels. In patients with 3 or more brain cysts, the regression analysis adjusted by the concomitant administration of praziquantel (PZQ) showed a 2-fold increase in the proportion of cysts resolved (risk ratio [RR], 1.98; 95% confidence interval [CI], 1.01-3.89; P = .048) and 2.5-fold increase in the proportion of patients cured (RR, 2.45; 95% CI, .94-6.36; P = .067) when ASOX levels in the highest vs the lowest quartile were compared. No association was found in patients with 1-2 brain cysts., Conclusions: We suggest an association between high ASOX plasma levels and increased antiparasitic efficacy in patients with parenchymal NCC. Nonetheless, this association is also influenced by other factors including parasite burden and concomitant administration of PZQ. These findings may serve to individualize and/or adjust therapy schemes to avoid treatment failure., (© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Objective: To characterize the prevalence and clustering of multimorbidity in four diverse geographical settings in Peru., Methods: Multimorbidity, defined as having ≥2 chronic conditions, was studied in adults aged ≥35 years in four diverse settings in Peru: Lima, Tumbes, and urban and rural Puno. Six of these conditions (alcohol disorder, asthma, chronic obstructive pulmonary disease, depression, diabetes, and hypertension) were cataloged as objectively ascertained chronic conditions and paired in dyads to explore clusters of multimorbidity., Results: We analyzed data from 2890 adults, mean age 55.2 years, 49% males. Overall, 19.1% of participants had multimorbidity, ranging from 14.7% in semi-urban Tumbes to 22.8% in Lima. The dyads with the highest coexistence (approximately 20%) were observed in hypertension and diabetes in Tumbes, whereas the dyads with lowest coexistence (approximately 1%) were those involving asthma in all study sites. In terms of clusters, Tumbes showed a predominance of hypertension and diabetes, urban and rural Puno a predominance of depression and alcohol disorders, and Lima a higher degree of coexistence of all of the six conditions than in the other clusters., Conclusion: Multimorbidity is common and the pattern of clusters is highly heterogeneous. The conditions to prioritize will vary in each setting., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2019.)

Background: Bacillus Calmette-Guerin (BCG) scar formation is considered a visual marker of vaccination and cell-mediated immune response. This study characterized the association between pregnancy and birth characteristics with BCG scar formation., Study Design: Pregnant women were enrolled prospectively. Infants were followed up for the first 6 months of life, and the diameter of the BCG scar was recorded. Marginal models were fitted to assess the association of BCG scar diameter with pregnancy and birth characteristics using linear regressions with generalized estimating equations., Results: A total of 307 infants were enrolled, of whom 19.2% (59/307) were of low birth weight. Among those with known gestational age, 7.1% were preterm births (21/295). Overall, 98.7% (303/307) of infants developed a BCG scar. BCG scar trends in a tropical environment, such as the Amazon, differ from the trends evidenced in the capital of Peru. For every additional week of gestational age, the mean scar diameter increased by 0.1 mm (95% confidence interval [CI]: 0.02, 0.24; p  = 0.017). Maternal illness during pregnancy impacted BCG scar size, as the infants of mothers who self-report fever had a smaller scar diameter (1 mm, 95% CI: 0.5, 1.8 mm; p  = 0.001)., Conclusion: The immune reaction to the BCG vaccination is affected by gestational age at birth and systemic inflammatory episodes during pregnancy., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

The Millennium Development Goals (MDGs) are a set of 8 aims adopted by the United Nations to create a more peaceful, prosperous, and just world. Four MDGs directly concern public health, and public health schools should be involved in meeting them. The Johns Hopkins University-directed Fogarty Global Infectious Disease Research Training Program in Peru and Bolivia, funded by the Fogarty International Center of the National Institutes of Health, has spanned nearly 3 decades and provides a case study of how low-resource interventions can help meet MDGs., (© 2019 American Medical Association. All Rights Reserved.)

Our results highlight for the first time that a significant proportion of cell doublets in flow cytometry, previously believed to be the result of technical artifacts and thus ignored in data acquisition and analysis, are the result of biological interaction between immune cells. In particular, we show that cell:cell doublets pairing a T cell and a monocyte can be directly isolated from human blood, and high resolution microscopy shows polarized distribution of LFA1/ICAM1 in many doublets, suggesting in vivo formation. Intriguingly, T cell-monocyte complex frequency and phenotype fluctuate with the onset of immune perturbations such as infection or immunization, reflecting expected polarization of immune responses. Overall these data suggest that cell doublets reflecting T cell-monocyte in vivo immune interactions can be detected in human blood and that the common approach in flow cytometry to avoid studying cell:cell complexes should be re-visited., Competing Interests: JB, MP, CL, DW, Rd, YJ, MB, VS, GS, JG, SP, GP, AW, DV, BG, RT, Ad, RG, MS, RT, KL, PV, AS, BP No competing interests declared, (© 2019, Burel et al.)

Background: Kidney health needs to be studied in low- and middle-income countries with populations living at high altitude and undergoing urbanization. We studied whether greater level of urbanization was associated with worse kidney function and higher hemoglobin was associated with worse kidney function at high altitude. Methods: Cross-sectional analysis of population-based studies in Peru including five sites at different altitude above the sea level and urbanization level (in decreasing order of urbanization): Lima (sea level), Arequipa (2335 m), urban Puno (3825 m), Tumbes (sea level), and rural Puno (3825 m). The exposures were urbanization and altitude as per study site, and hemoglobin (g/dL). The outcome was the estimated glomerular filtration rate (eGFR). Results: Four thousand two hundred eight people were studied: mean age was 57.4 years (standard deviation: 12.4) and 51.9% were women. In comparison to rural Puno, eGFR was similar in Lima; in comparison to rural Puno, Arequipa, urban Puno, and Tumbes had worse eGFR, for example, in Arequipa, β = -8.07 (95% confidence interval [CI]: -10.90 to -5.24). Intermediate (β = -8.60; 95% CI: -10.55 to -6.66) and high (β = -11.21; 95% CI: -14.19 to -8.24) altitude were negatively correlated with eGFR when only urban places were analyzed. At high altitude, there was a trend for a negative association between hemoglobin and eGFR: β = -1.09 (95% CI: -2.22 to 0.04). Conclusions: Apparently, higher altitude and level of urbanization, except for one highly urbanized site, were associated with worse kidney function. Our findings suggest that some of the adverse impact of high altitude on kidney function has been balanced by the lower risk conferred by rural environments.

Triatomine vectors transmit Trypanosoma cruzi, the etiological agent of Chagas disease in humans. Transmission to humans typically occurs when contaminated triatomine feces come in contact with the bite site or mucosal membranes. In the Southern Cone of South America, where the highest burden of disease exists, Triatoma infestans is the principal vector for T. cruzi. Recent studies of other vector-borne illnesses have shown that arthropod microbiota influences the ability of infectious agents to colonize the insect vector and transmit to the human host. This has garnered attention as a potential control strategy against T. cruzi, as vector control is the main tool of Chagas disease prevention. Here we characterized the microbiota in T. infestans feces of both wild-caught and laboratory-reared insects and examined the relationship between microbial composition and T. cruzi infection using highly sensitive high-throughput sequencing technology to sequence the V3-V4 region of the 16S ribosomal RNA gene on the MiSeq Illumina platform. We collected 59 wild (9 with T. cruzi infection) and 10 lab-reared T. infestans (4 with T. cruzi infection) from the endemic area of Arequipa, Perú. Wild T. infestans had greater hindgut bacterial diversity than laboratory-reared bugs. Microbiota of lab insects comprised a subset of those identified in their wild counterparts, with 96 of the total 124 genera also observed in laboratory-reared insects. Among wild insects, variation in bacterial composition was observed, but time and location of collection and development stage did not explain this variation. T. cruzi infection in lab insects did not affect α- or β-diversity; however, we did find that the β-diversity of wild insects differed if they were infected with T. cruzi and identified 10 specific taxa that had significantly different relative abundances in infected vs. uninfected wild T. infestans (Bosea, Mesorhizobium, Dietzia, and Cupriavidus were underrepresented in infected bugs; Sporosarcina, an unclassified genus of Porphyromonadaceae, Nestenrenkonia, Alkalibacterium, Peptoniphilus, Marinilactibacillus were overrepresented in infected bugs). Our findings suggest that T. cruzi infection is associated with the microbiota of T. infestans and that inferring the microbiota of wild T. infestans may not be possible through sampling of T. infestans reared in the insectary., Competing Interests: The authors have declared that no competing interests exist.

Neurocysticercosis is a parasitic brain disease caused by the larval form (Cysticercus cellulosae) of Taenia solium and is the leading cause of preventable epilepsy worldwide. However, the pathophysiology and relation to the wide range of clinical features remains poorly understood. Axonal swelling is emerging as an important early pathological finding in multiple neurodegenerative diseases and as a cause of brain injury, but has not been well described in neurocysticercosis. Histological analysis was performed on human, rat and porcine NCC brain specimens to identify axonal pathology. Rat infection was successfully carried out via two routes of inoculation: direct intracranial injection and oral feeding. Extensive axonal swellings, in the form of spheroids, were observed in both humans and rats and to a lesser extent in pigs with NCC. Spheroids demonstrated increased immunoreactivity to amyloid precursor protein and neurofilament indicating probable impairment of axonal transport. These novel findings demonstrate that spheroids are present in NCC which is conserved across species. Not only is this an important contribution toward understanding the pathogenesis of NCC, but it also provides a model to analyze the association of spheroids with specific clinical features and to investigate the reversibility of spheroid formation with antihelminthic treatment., (© 2018 International Society of Neuropathology.)

Background: Active case-finding among contacts of patients with tuberculosis is a global health priority, but the effects of active versus passive case-finding are poorly characterised. We assessed the contribution of active versus passive case-finding to tuberculosis detection among contacts and compared sex and disease characteristics between contacts diagnosed through these strategies., Methods: In shanty towns in Callao, Peru, we identified index patients with tuberculosis and followed up contacts aged 15 years or older for tuberculosis. All patients and contacts were offered free programmatic active case-finding entailing sputum smear microscopy and clinical assessment. Additionally, all contacts were offered intensified active case-finding with sputum smear and culture testing monthly for 6 months and then once every 4 years. Passive case-finding at local health facilities was ongoing throughout follow-up., Findings: Between Oct 23, 2002, and May 26, 2006, we identified 2666 contacts, who were followed up until March 1, 2016. Median follow-up was 10·0 years (IQR 7·5-11·0). 232 (9%) of 2666 contacts were diagnosed with tuberculosis. The 2-year cumulative risk of tuberculosis was 4·6% (95% CI 3·5-5·5), and overall incidence was 0·98 cases (95% CI 0·86-1·10) per 100 person-years. 53 (23%) of 232 contacts with tuberculosis were diagnosed through active case-finding and 179 (77%) were identified through passive case-finding. During the first 6 months of the study, 23 (45%) of 51 contacts were diagnosed through active case-finding and 28 (55%) were identified through passive case-finding. Contacts diagnosed through active versus passive case-finding were more frequently female (36 [68%] of 53 vs 85 [47%] of 179; p=0·009), had a symptom duration of less than 15 days (nine [25%] of 36 vs ten [8%] of 127; p=0·03), and were more likely to be sputum smear-negative (33 [62%] of 53 vs 62 [35%] of 179; p=0·0003)., Interpretation: Although active case-finding made an important contribution to tuberculosis detection among contacts, passive case-finding detected most of the tuberculosis burden. Compared with passive case-finding, active case-finding was equitable, helped to diagnose tuberculosis earlier and usually before a positive result on sputum smear microscopy, and showed a high burden of undetected tuberculosis among women., Funding: Wellcome Trust, Department for International Development Civil Society Challenge Fund, Joint Global Health Trials consortium, Bill & Melinda Gates Foundation, Imperial College National Institutes of Health Research Biomedical Research Centre, Foundation for Innovative New Diagnostics, Sir Halley Stewart Trust, WHO, TB REACH, and IFHAD: Innovation for Health and Development., (Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Assessing Mycobacterium tuberculosis (TB) viability by fluorescein diacetate (FDA) microscopy can predict TB culture results, treatment response and infectiousness. However, diverse methods have been published. We aimed to optimise FDA microscopy, minimising sputum processing, biohazard and complexity for use in resource-constrained settings., Methods and Results: Optimization: Patients with smear-positive pulmonary TB before treatment and healthy control participants provided sputa. These were divided into equal aliquots that were tested directly or after NaOH centrifuge-decontamination. Each aliquot was cultured and used to prepare slides (n = 80). FDA microscopy used: 1 or 3 drops of sputum; with/out acid-alcohol wash; with/out phenol sterilization; with 0/30/60 seconds KMnO4 quenching. Control samples all had negative culture and microscopy results. FDA microscopy had higher sensitivity when performed directly (without centrifuge-decontamination) on 1 drop of sputum (P<0.001), because 3 drops obscured microscopy. Acid-alcohol wash and KMnO4 quenching made bacilli easier to identity (P = 0.005). Phenol sterilization did not impair microscopy (P>0.1). Validation: The 2 protocols that performed best in the optimization experiments were reassessed operationally by comparing duplicate slides (n = 412) stained with KMnO4 quenching for 30 versus 60 seconds. FDA microscopy results were similar (P = 0.4) and highly reproducible, with 97% of counts agreeing within +/-1 logarithm. Storage: Smear microscopy slides and aliquots of the sputum from which they were made were stored for 4 weeks. Twice-weekly, paired slides (n = 80) were stained with freshly prepared versus stored FDA and read quantitatively. Storing sputum, microscopy slides or FDA solution at 4°C or room temperature had no effect on FDA microscopy results (all P>0.2). Cost: Material costs for each slide tested by FDA microscopy using reagents purchased locally were USD $0.05 and required the same equipment, time and skills as auramine acid-fast microscopy., Conclusions: We recommend a simple, bio-secure protocol for FDA microscopy that provides sensitive and repeatable results without requiring centrifugation., Competing Interests: All the authors declare that they have no competing interests exist in relation to this publication. The corresponding author had full access to all study data and was responsible for the decision to publish.

Background: The majority of tuberculosis transmission occurs in community settings. Our primary aim in this study was to assess the association between exposure to community venues and multidrug-resistant (MDR) tuberculosis. Our secondary aim was to describe the social networks of MDR tuberculosis cases and controls., Methods: We recruited laboratory-confirmed MDR tuberculosis cases and community controls that were matched on age and sex. Whole-genome sequencing was used to identify genetically clustered cases. Venue tracing interviews (nonblinded) were conducted to enumerate community venues frequented by participants. Logistic regression was used to assess the association between MDR tuberculosis and person-time spent in community venues. A location-based social network was constructed, with respondents connected if they reported frequenting the same venue, and an exponential random graph model (ERGM) was fitted to model the network., Results: We enrolled 59 cases and 65 controls. Participants reported 729 unique venues. The mean number of venues reported was similar in both groups (P = .92). Person-time in healthcare venues (adjusted odds ratio [aOR] = 1.67, P = .01), schools (aOR = 1.53, P < .01), and transportation venues (aOR = 1.25, P = .03) was associated with MDR tuberculosis. Healthcare venues, markets, cinemas, and transportation venues were commonly shared among clustered cases. The ERGM indicated significant community segregation between cases and controls. Case networks were more densely connected., Conclusions: Exposure to healthcare venues, schools, and transportation venues was associated with MDR tuberculosis. Intervention across the segregated network of case venues may be necessary to effectively stem transmission., (© The Author(s) 2018. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Norovirus is a leading cause of acute gastroenteritis worldwide. Routine norovirus diagnosis requires stool collection. The goal of this study was to develop and validate a noninvasive method to diagnose norovirus to complement stool diagnostics and to facilitate studies on transmission., Methods: A multiplex immunoassay to measure salivary immunoglobulin G (IgG) responses to 5 common norovirus genotypes (GI.1, GII.2, GII.4, GII.6, and GII.17) was developed. The assay was validated using acute and convalescent saliva samples collected from Peruvian children <5 years of age with polymerase chain reaction (PCR)-diagnosed norovirus infections (n = 175) and controls (n = 32). The assay sensitivity and specificity were calculated to determine infection status based on fold rise of salivary norovirus genotype-specific IgG using norovirus genotype from stool as reference., Results: The salivary assay detected recent norovirus infections and correctly assigned the infecting genotype. Sensitivity was 71% and specificity was 96% across the evaluated genotypes compared to PCR-diagnosed norovirus infection., Conclusions: This saliva-based assay will be a useful tool to monitor norovirus transmission in high-risk settings such as daycare centers or hospitals. Cross-reactivity is limited between the tested genotypes, which represent the most commonly circulating genotypes., (© The Author(s) 2018. Published by Oxford University Press for the Infectious Diseases Society of America.)

Background: Individuals' self-perceptions of weight often differ from objective measurements of body fat. This study aimed to 1) measure agreement between self-perceptions of weight and objective measurement of body fat by bioelectric impedance analysis (BIA) among Peruvian adults; and 2) quantify the association between body fat and a) baseline self-perceptions of weight and b) whether a participant underestimated their weight status., Methods: Longitudinal data from the CRONICAS Cohort Study of 3181 Peruvian adults aged 35-years and older were used. BIA measurements of body fat were categorized across four nominal descriptions: low weight, normal, overweight, and obese. Kappa statistics were estimated to compare BIA measurements with baseline self-perceptions of weight. To quantify the association between body fat over time with both baseline self-perceptions of weight and underestimation of weight status, random effects models, controlling for socioeconomic and demographic covariates, were employed., Results: Of the 3181 participants, 1111 (34.9%) were overweight and 649 (20.4%) were obese at baseline. Agreement between self-perceived and BIA weight status was found among 43.1% of participants, while 49.9% underestimated and 6.9% overestimated their weight status. Weighted kappa statistics ranged from 0.20 to 0.31 across settings, suggesting poor agreement. Compared to perceiving oneself as normal, perceiving oneself as underweight, overweight, or obese was associated with - 4.1 ( p  < 0.001), + 5.2 ( p  < 0.001), and + 8.1 ( p  < 0.001) body fat percentage points, respectively. Underestimating one's weight status was associated with having 2.4 ( p  < 0.001) body fat percentage points more than those not underestimating only after adjusting for demographic and socioeconomic covariates., Conclusions: Half of study participants were overweight or obese. There was poor agreement between self-perceptions of weight with BIA measurements of body fat, indicating that individuals often believe they weigh less than they actually do. Underestimating one's weight status was associated with having more body fat percentage points, but was only statistically significant after adjusting for demographic and socioeconomic characteristics. Further research should be conducted to investigate how self-perceptions of weight can support clinical and public health interventions to curb the obesity epidemic., Competing Interests: This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects of the CRONICAS Cohort Study were approved by the institutional review boards of the Universidad Peruana Cayetano Heredia, the Asociación Benéfica PRISMA in Lima, Peru, and the Johns Hopkins University in Baltimore, USA. Written informed consent was obtained from all subjects.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Feeding of infant formula using contaminated bottles may be an important transmission pathway of enteric pathogens during early life. Determinants of suboptimal bottle hygiene and the feasibility and acceptability of intervention strategies have not been well assessed. We evaluated the extent of bottle contamination, its contributing factors, and options for promoting improved bottle hygiene in a Peruvian shantytown. During Phase 1, we sampled from bottles and caregiver hands ( n = 48) and processed for enumeration of total coliform and Escherichia coli colony-forming units. A semi-structured questionnaire captured bottle use and hygiene practices. Phase 2 involved the identification of candidate practices to recommend to caregivers. Phase 3 consisted of a behavioral trial in which 14 caregivers were educated about improved practices for bottle disinfection and later reported on their experiences implementing them. Fecal bacteria were detected in 43.8% of bottles sampled during Phase 1 and in 21.7% of hands. Caregivers overall did not use effective methods for disinfecting bottles, displayed misunderstandings surrounding hygienic practices, and few had ever discussed bottle hygiene with a health provider. Findings from the behavioral trial indicated that the improved practice of brushing the bottle with dish detergent for 30 seconds after every use is preferable to boiling the bottle for several minutes daily as caregivers reported that the brush was simple to use, efficient, and practical. The promotion of a bottle brush and detergent is a feasible and acceptable intervention strategy in peri-urban settings, and future research should evaluate its long-term effectiveness for reducing bottle contamination.

Cysticercosis is a parasitic disease that frequently involves the human central nervous system (CNS), and current treatment options are limited. Oxfendazole, a veterinary medicine belonging to the benzimidazole family of anthelmintic drugs, has demonstrated substantial activity against the tissue stages of Taenia solium and has potential to be developed as an effective therapy for neurocysticercosis. To accelerate the transition of oxfendazole from veterinary to human use, the pharmacokinetics, safety, and tolerability of oxfendazole were evaluated in healthy volunteers in this phase 1 first-in-human (FIH) study. Seventy subjects were randomly assigned to receive a single oral dose of oxfendazole (0.5, 1, 3, 7.5, 15, 30, or 60 mg oxfendazole/kg body weight) or placebo and were followed for 14 days. Blood and urine samples were collected, and the concentrations of oxfendazole were measured using a validated ultraperformance liquid chromatography mass spectrometry method. The pharmacokinetic parameters of oxfendazole were estimated using noncompartmental analysis. Oxfendazole was rapidly absorbed with a mean plasma half-life ranging from 8.5 to 11 h. The renal excretion of oxfendazole was minimal. Oxfendazole exhibited significant nonlinear pharmacokinetics with less than dose-proportional increases in exposure after single oral doses of 0.5 mg/kg to 60 mg/kg. This nonlinearity of oxfendazole is likely due to the dose-dependent decrease in bioavailability that is caused by its low solubility. Oxfendazole was found to be well tolerated in this study at different escalating doses without any serious adverse events (AEs) or deaths. There were no significant differences in the distributions of hematology, biochemistry, or urine parameters between oxfendazole and placebo recipients. (This study has been registered at ClinicalTrials.gov under identifier NCT02234570.)., (Copyright © 2019 American Society for Microbiology.)

Taenia solium is known to cause human cysticercosis while T. saginata does not. Comparative in vitro and in vivo studies on the oncosphere and the postoncospheral (PO) forms of T. solium and T. saginata may help to elucidate why cysticercosis can occur from one and not the other. The aim of this study was to use in vitro culture assays and in vivo models to study the differences in the development of the T. solium and T. saginata oncosphere. Furthermore, this study aimed to evaluate the expression of cytokines and metalloproteinases (MMPs) in human peripheral blood mononuclear cells (PBMCs), which were stimulated by these oncospheres and PO antigens. T. solium and T. saginata activated oncospheres (AO) were cultured in INT-407 and HCT-8 intestinal cells for 180 days. The T. solium began to die while the T. saginata grew for 180 days and developed to cysticerci in INT-407 cells. Rats were inoculated intracranially with AO and PO forms of either T. saginata or T. solium. Rats infected with T. solium AO and PO forms developed neurocysticercosis (NCC), while those infected with the T. saginata did not. Human PMBCs were stimulated with antigens of AO and PO forms of both species, and the production of cytokines and metalloproteinases (MMPs) was measured. The T. solium AO antigen stimulated a higher production of IL-4, IL-5, IL-13, IFN-γ, and IL-2 cytokines compared to T. saginata AO. In the PO form, the T. saginata PO antigen increased the production of IL-4, IL-5, IL-13, IFN-γ, IL-1β, IL-6, IL-10, TNF-α and IL-12 cytokines compared to T. solium, suggesting that this global immune response stimulated by different forms could permit survival or destruction of the parasite depending of their life-cycle stage. Regarding MMPs, T. solium AO antigen stimulated a higher production of MMP-9 compared to T. saginata AO antigen, which may be responsible for altering the permeability of intestinal cells and facilitating breakdown of the blood-brain barrier during the process of invasion of host tissue., Competing Interests: The authors have declared that no competing interests exist.

The pig is the natural intermediate host of Taenia solium , a parasite causing significant burden of disease in both humans and pigs. Porcine cysticercosis is traditionally detected via tongue palpation and slaughterhouse meat inspection, both with limited sensitivity. Serum antibody detection has a better performance; however, it does not discriminate past from present infection. Serum antigen detection can demonstrate viable infection and gives a good estimate of parasitic load. This study evaluated a sandwich antigen-detection ELISA using monoclonal antibodies (MoAbs) 158C11 and 60H8 for the diagnosis of viable cysticercosis in pigs. Serum samples were used from 35 naturally T. solium cysticerci-infected pigs, 31 cysticercosis-negative pigs, and 22 pigs with Taenia hydatigena infection (to assess cross-reactions). Positive cysticercosis samples were subcategorized at necropsy according to parasitic burden as mild (1-10 viable cysts, n = 10), moderate (11-100 cysts, n = 5), or severe infection (more than 100 cysts, n = 20). This Ag-ELISA showed a sensitivity of 82.9% and a specificity of 96.8% when not considering cross-reactions with T. hydatigena . Hundred percentage of severely infected, 80% of moderately infected, and 50% of mildly T. solium -infected pigs tested positive. Twenty of 22 pigs with only T. hydatigena infections were positive, with 13 reaching saturating levels in the ELISA. The Ag-ELISA revealed the presence of live cysts and is, thus, a fairly reliable test to monitor experimental infection, response to treatment, and follow-up in animal models of cysticercosis. It should, however, be carefully interpreted when used in regions where T. hydatigena is endemic in pigs.

Porcine cysticercosis is an endemic parasitic disease caused by infection with Taenia solium that is found predominantly in developing countries. In order to aid in the development of simple diagnostic approaches, identification and characterization of potential new antigens for immunodiagnostic purposes is desired. The cysteine protease family has previously been found to have important immunodiagnostic properties. These proteases are expressed as zymogens which contain a signal peptide, pro-peptide, and an active domain. Subsequent catalytic cleavage of the pro-peptide converts these zymogens into enzymes. With the use of bioinformatic tools we identified an active domain of a novel cathepsin L-like cysteine protease (TsolCL) in the T. solium genome. The TsolCL gene includes 705 nucleotides (nt) within a single intron and a 633 nt exonic sequence encoding an active protein of 211 amino acids. Sequence alignment and phylogenetic analysis suggest that the TsolCL gene is closely related to genes found in Echinoccocus granulosus and E. multiloculars. In addition, TsolCL was found to have a 61.9%-99.0% similarity to other cathepsin L proteins found in other helminths and mammals. We cloned, expressed, purified, and characterized the recombinant active TsolCL (27 kDa) using the baculovirus-insect cell expression system. TsolCL showed cysteine protease enzymatic activity with the capacity to hydrolyze the Z-Phe-Arg-AMC substrate as well as bovine serum albumin. However, TsolCL was not able to hydrolyze human immunoglobulin. In addition, TsolCL has cathepsin L conserved amino acid residues in the catalytic site (Gln8, Cys14, His159, Asn179 and Trp181) and the motif GCNGG. Using ELISA, TsolCL was able to distinguish circulating IgG antibodies between healthy animals and naturally infected pigs with cysticercosis, showing a moderate sensitivity of 83.33% (40/48; 95% CI: [69.8%-92.5 %]), and a specificity of 83.78% (31/37; 95% CI: [67.9%-93.8%]). In conclusion, a novel cathepsin L-like cysteine protease from a T. solium metacestode was expressed successfully in Baculovirus system and was evaluated as a candidate antigen to diagnose porcine cysticercosis using the ELISA immunoassay., (Copyright © 2019 Elsevier B.V. All rights reserved.)

The pork tapeworm, Taenia solium , is among the leading causes of preventable epilepsy in the world and is common in rural areas of developing countries where sanitation is limited and pigs have access to human feces. Prior studies in rural villages of Peru have observed clusters of T. solium cysticercosis among pigs that live near human tapeworm carriers. Such spatial analyses, however, have been limited by incomplete participation and substandard diagnostic tests. In this study, we evaluated the association between necropsy-confirmed cysticercosis in pigs and their distance to T. solium tapeworm carriers in six villages in northern Peru. A total of six (1.4%) tapeworm carriers were detected using copro-antigen enzyme-linked immunosorbent assay and seven of 10 (70%) pigs belonging to the tapeworm carriers were found with viable cyst infection on necropsy. This was significantly greater than the prevalence of viable cyst infection among pigs living < 500 m (11%) and > 500 m (0.5%) from a tapeworm carrier ( P < 0.001 for distance trend). Similar statistically significant prevalence gradients were observed after adjustment for possible confounders and for other pig-level outcomes including infection with > 10 viable cysts, degenerated cyst infection, and serological outcomes. This investigation confirms that porcine cysticercosis clusters strongly around tapeworm carriers in endemic rural regions of northern Peru and supports interventions that target these hotspots.

Neurocysticercosis (NCC) is a helminth infection affecting the central nervous system caused by the larval stage (cysticercus) of Taenia solium. Since vascular alteration and blood-brain barrier (BBB) disruption contribute to NCC pathology, it is postulated that angiogenesis could contribute to the pathology of this disease. This study used a rat model for NCC and evaluated the expression of two angiogenic factors called vascular endothelial growth factor (VEGF-A) and fibroblast growth factor (FGF2). Also, two markers for BBB disruption, the endothelial barrier antigen and immunoglobulin G, were evaluated using immunohistochemical and immunofluorescence techniques. Brain vasculature changes, BBB disruption, and overexpression of angiogenesis markers surrounding viable cysts were observed. Both VEGF-A and FGF2 were overexpressed in the tissue surrounding the cysticerci, and VEGF-A was overexpressed in astrocytes. Vessels showed decreased immunoreactivity to endothelial barrier antigen marker and an extensive staining for IgG was found in the tissues surrounding the cysts. Additionally, an endothelial cell tube formation assay using human umbilical vein endothelial cells showed that excretory and secretory antigens of T. solium cysticerci induce the formation of these tubes. This in vitro model supports the hypothesis that angiogenesis in NCC might be caused by the parasite itself, as opposed to the host inflammatory responses alone. In conclusion, brain vasculature changes, BBB disruption, and overexpression of angiogenesis markers surrounding viable cysts were observed. This study also demonstrates that cysticerci excretory-secretory processes alone can stimulate angiogenesis., (© 2018 Wiley Periodicals, Inc.)

Cystic echinococcosis (CE) is a parasitic zoonosis caused by the larval stage of the tapeworm Echinococcus granulosus . Detection of the adult stage in the canine definitive host is essential for estimating infection rates, surveillance and monitoring of CE control programs. This study sought to develop and validate a coproantigen sandwich enzyme-linked immunosorbent assay (copro-ELISA), based on antibodies against E. granulosus -soluble membrane antigens (EGMA), that is capable of distinguishing infected and noninfected dogs. Anti- E. granulosus polyclonal immunoglobulin G antibodies were obtained from rabbit antiserum against EGMA. Optimization of the test was performed with 51 positive and 56 negative stool samples of canine echinococcosis. Specificity, sensitivity, cross-reactivity, intra- and inter-assay precision, and over time detection were evaluated. According to the receiver operating characteristic analysis, the diagnostic sensitivity and specificity were 96.1% (CI: 85.9-99.6) and 98.2% (CI: 89.5-100), respectively. Negative and positive predictive values were 96.5% (CI: 91.7-100) and 98% (CI: 94.1-100), respectively. No cross-reactivity with Taenia hydatigena , Dipylidium caninum , or Toxocara canis was observed. Intra- and inter-assay repeatability showed values of less than 15% of the variation coefficient. The over time detection was from 20 to 27 days postinfection with E. granulosus . The copro-ELISA based on EGMA detection offers a simplified in-house development of diagnostic testing. This assay showed high specificity and sensitivity and had no cross-reactivity with other parasites. Further studies and development of this test in a kit format may be useful for the detection of active infection in dogs living in CE endemic regions.

Although pyrazinamide (PZA) is a key component of first- and second-line tuberculosis treatment regimens, there is no gold standard to determine PZA resistance. Approximately 50% of multidrug-resistant tuberculosis (MDR-TB) and over 90% of extensively drug-resistant tuberculosis (XDR-TB) strains are also PZA resistant. pncA sequencing is the endorsed test to evaluate PZA susceptibility. However, molecular methods have limitations for their wide application. In this study, we standardized and evaluated a new method, MODS-Wayne, to determine PZA resistance. MODS-Wayne is based on the detection of pyrazinoic acid, the hydrolysis product of PZA, directly in the supernatant of sputum cultures by detecting a color change following the addition of 10% ferrous ammonium sulfate. Using a PZA concentration of 800 µg/ml, sensitivity and specificity were evaluated at three different periods of incubation (reading 1, reading 2, and reading 3) using a composite reference standard (MGIT-PZA, pncA sequencing, and the classic Wayne test). MODS-Wayne was able to detect PZA resistance, with a sensitivity and specificity of 92.7% and 99.3%, respectively, at reading 3. MODS-Wayne had an agreement of 93.8% and a kappa index of 0.79 compared to the classic Wayne test, an agreement of 95.3% and kappa index of 0.86 compared to MGIT-PZA, and an agreement of 96.9% and kappa index of 0.90 compared to pncA sequencing. In conclusion, MODS-Wayne is a simple, fast, accurate, and inexpensive approach to detect PZA resistance, making this an attractive assay especially for low-resource countries, where TB is a major public health problem., (Copyright © 2019 Alcántara et al.)

Background: Congenital Trypanosoma cruzi infection accounts for an estimated 22% of new cases of Chagas disease in Latin America. However, neonatal diagnosis is challenging, as 9-month follow-up for immunoglobulin G testing is poor, quantitative polymerase chain reaction (qPCR) analysis is not routinely performed, and the micromethod misses ≥40% of congenital infections., Methods: Biorepository samples from new mothers and their infants from Piura, Peru, (an area of nonendemicity), and Santa Cruz, Bolivia (an area of endemicity) were accessed. Infant specimens were assessed using the micromethod, qPCR analysis, and a trypomastigote excretory secretory antigen (TESA) blot for detection of immunoglobulin M (IgM)-specific shed acute phase antigen (SAPA) bands, using qPCR as the gold standard., Results: When compared to qPCR, IgM TESA blot was both sensitive and specific for congenital Chagas disease diagnosis. Cumulative sensitivity (whether only 4 bands or all 6 bands were present) was 80% (95% confidence interval [CI], 59%-92%). Specificity was 94% (95% CI, 92%-96%) in the area of endemicity and 100% in the area of nonendemicity. SAPA bands occurred sequentially and in pairs, and parasite loads correlated highly with the number of SAPA bands present. The micromethod detected infection in fewer than half of infected infants., Conclusions: The IgM TESA blot for detection of SAPA bands is rapid, relatively inexpensive, and more sensitive than the micromethod and may be a useful point-of-care test for detection of congenital T. cruzi infection.

Background: The detection of Trypanosoma cruzi genetic material in clinical samples is considered an important diagnostic tool for Chagas disease. We have previously demonstrated that PCR using clot samples yields greater sensitivity than either buffy coat or whole blood samples. However, phenol-chloroform DNA extraction from clot samples is difficult and toxic. The objective of the present study was to improve and develop a more sensitive method to recover parasite DNA from clot samples for the diagnosis of Chagas disease., Methodology/principal Findings: A total of 265 match pair samples of whole blood-guanidine (GEB) and clot samples were analyzed; 150 were from Chagas seropositive subjects. DNA was extracted from both whole blood-guanidine samples, using a previously standardized methodology, and from clot samples, using a newly developed methodology based on a combination of the FastPrep technique and the standard method for GEB extraction. A qPCR targeting the nuclear satellite sequences was used to compare the sample source and the extraction method. Of the 150 samples from Chagas positive individuals by serology, 47 samples tested positive by qPCR with DNA extracted by both GEB and clot, but an additional 13 samples tested positive only in DNA extracted from clot. No serology-negative samples resulted positive when tested by qPCR., Conclusions: The new methodology for DNA extraction from clot samples improves the molecular diagnosis of Chagas disease., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Oxfendazole (methyl [5-(phenylsulphinyl)-1H benzimidazole-2-yl] carbamate) has a particularly long metabolic half-life in ruminants, and its metabolite fenbendazole also has anthelminthic action. A very limited number of drugs are available for the treatment of some zoonotic helminth infections, such as neurocysticercosis and echinococcosis. More recent work has expanded oxfendazole's nonclinical safety profile and demonstrated its safety and bioavailability in healthy human volunteers, thus advancing the possibility of a new and greatly needed option for antiparasitic treatment of geohelminths and tissue parasites. Areas covered: The present article reviews evidence supporting the safety and efficacy of oxfendazole against both gut and tissue dwelling helminths in animals, as well as more recent safety and pharmacokinetic data supporting its potential for use in human parasitoses. Expert commentary: The pharmacokinetics, safety, and wide spectrum of efficacy of oxfendazole are consistently demonstrated in intestinal helminth infections of animals as well as in tissue dwelling larval cestode and trematode infections in diverse animal species. Now supported by first-in-human safety and pharmacokinetic data, oxfendazole becomes a promising alternative to the limited portfolio of antiparasitic drugs available to treat helminthic diseases of humans.

Quantitative polymerase chain reaction (qPCR) for Toxoplasma gondii multicopy genes has emerged as a promising strategy for sensitive detection of parasite DNA. qPCR can be performed from blood samples, which are minimally invasive to collect. However, there is no consensus about what type of blood specimen yields the best sensitivity. The development of a novel protocol for qPCR detection of T. gondii using blood clot, involving an appropriate DNA extraction method and the use of an internal amplification control to monitor the reaction is presented in the current study. Assays directed to the B1 and REP529 genes were performed in spiked specimens of whole blood, guanidine-ethylenediaminetetraacetic acid blood, and clot. The clot-based qPCR was shown to be more sensitive when compared with other types of specimens, detecting five and 0.05 T. gondii genomes, using B1 and REP529 targets, respectively. Finally, a comparative analysis with samples from HIV patients with clinical suspicion of toxoplasmosis was performed, demonstrating the detection of four positive suspected cases with clots compared with only one using guanidine-ethylenediaminetetraacetic acid blood. The high analytical sensitivity and the cost-effective advantages offered by clot supports this methodology as a good laboratory tool to monitor parasite burden.

Aims: Prognostic thresholds to identify new type 2 diabetes mellitus (T2DM) cases using the HOMA-IR have not been defined. We studied the HOMA-IR performance to identify incident T2DM cases and to assess if the thresholds varied according to urbanization and altitude in Peru., Methods: Longitudinal analysis. The outcome was incident T2DM cases: self-report diagnosis and fasting glucose. The exposure was the HOMA-IR. Receiver operating characteristic (ROC) curves were plotted, and the area under the ROC curve (AUC) was estimated with 95% confidence intervals (95% CIs). Results are presented overall and stratified by study site (Lima, Tumbes, urban Puno, and rural Puno), rurality (urban, semiurban, and rural), and altitude (low and high)., Results: A total of 3120 participants (mean age: 55.6 years, 51.2% females) contributed data to this analysis. The median baseline HOMA-IR was 1.7 (IQR 1.0-2.9), with median values ranging from 1.1 in rural Puno to 2.0 in Lima and Tumbes ( p < 0.001). Overall for incident T2DM, the AUC was 0.69 (95% CI: 0.64-0.74) with an empirical threshold of 2.8 yielding a positive likelihood ratio of 2.30 and a negative one of 0.61; the positive and negative predictive values were 14.6% and 95.7%, respectively. The empirical thresholds varied within the variables of interest, for example, from 0.9 in urban Puno to 2.9 in Lima., Conclusions: Using the HOMA-IR to identify incident T2DM cases seems to yield moderate accuracy. The HOMA-IR could help improve identifying people at high risk of T2DM.

Pneumonia is one of the major causes of child mortality, yet with a timely diagnosis, it is usually curable with antibiotic therapy. In many developing regions, diagnosing pneumonia remains a challenge, due to shortages of medical resources. Lung ultrasound has proved to be a useful tool to detect lung consolidation as evidence of pneumonia. However, diagnosis of pneumonia by ultrasound has limitations: it is operator-dependent, and it needs to be carried out and interpreted by trained personnel. Pattern recognition and image analysis is a potential tool to enable automatic diagnosis of pneumonia consolidation without requiring an expert analyst. This paper presents a method for automatic classification of pneumonia using ultrasound imaging of the lungs and pattern recognition. The approach presented here is based on the analysis of brightness distribution patterns present in rectangular segments (here called "characteristic vectors") from the ultrasound digital images. In a first step we identified and eliminated the skin and subcutaneous tissue (fat and muscle) in lung ultrasound frames, and the "characteristic vectors"were analyzed using standard neural networks using artificial intelligence methods. We analyzed 60 lung ultrasound frames corresponding to 21 children under age 5 years (15 children with confirmed pneumonia by clinical examination and X-rays, and 6 children with no pulmonary disease) from a hospital based population in Lima, Peru. Lung ultrasound images were obtained using an Ultrasonix ultrasound device. A total of 1450 positive (pneumonia) and 1605 negative (normal lung) vectors were analyzed with standard neural networks, and used to create an algorithm to differentiate lung infiltrates from healthy lung. A neural network was trained using the algorithm and it was able to correctly identify pneumonia infiltrates, with 90.9% sensitivity and 100% specificity. This approach may be used to develop operator-independent computer algorithms for pneumonia diagnosis using ultrasound in young children., Competing Interests: The authors have declared that no competing interests exist.

Background: Chronic lung disease is a leading contributor to the global disease burden; however, beyond tobacco smoke, we do not fully understand what risk factors contribute to lung function decline in low-income and middle-income countries., Methods: We collected sociodemographic and clinical data in a randomly selected, age-stratified, sex-stratified and site-stratified population-based sample of 3048 adults aged ≥35 years from four resource-poor settings in Peru. We assessed baseline and annual pre-bronchodilator and post-bronchodilator lung function over 3 years. We used linear mixed-effects models to assess biological, socioeconomic and environmental risk factors associated with accelerated lung function decline., Results: Mean±SD enrolment age was 55.4±12.5 years, 49.2% were male and mean follow-up time was 2.36 (SD 0.61) years. Mean annual pre-bronchodilator FEV 1 decline was 30.3 mL/year (95% CI 28.6 to 32.0) and pre-bronchodilator FVC decline was 32.2 mL/year (30.0 to 34.4). Using multivariable linear mixed-effects regression, we found that urban living, high-altitude dwelling and having hypertension accounted for 25.9% (95% CI 15.7% to 36.1%), 21.3% (11.1% to 31.5%) and 15.7% (3.7% to 26.9%) of the overall mean annual decline in pre-bronchodilator FEV 1 /height 2 , respectively. Corresponding estimates for pre-bronchodilator FVC/height 2 were 42.1% (95% CI% 29.8% to 54.4%), 36.0% (23.7% to 48.2%) and 15.8% (2.6% to 28.9%) of the overall mean annual decline, respectively., Conclusion: Urbanisation, living at high altitude and hypertension were associated with accelerated lung function decline in a population with low daily smoking prevalence., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Occurrence of Chagas disease and arbovirus coinfections is unknown, despite the vast co-endemic areas throughout the Americas. This study examined the proportion of individuals positive for Trypanosoma cruzi and coinfections with dengue, chikungunya, and Zika viruses in Machala, Ecuador (January 2014-December 2015). Chagas seropositivity was evaluated with five commercially available assays. Dengue infections were identified by nonstructural protein 1 rapid test and enzyme linked immunosorbent assay (ELISA), immunoglobulin M ELISA, and reverse transcription PCR (RT-PCR); chikungunya and Zika infections were identified by RT-PCR. Of 658 individuals, six were positive for T. cruzi (0.91%), including one T. cruzi /dengue coinfection and one T. cruzi /chikungunya/dengue coinfection. The clinical manifestations of coinfected individuals corresponded to severe dengue and dengue with warning signs, respectively. We observed discrepant results by using the Hemagen Chagas kit and the rapid test Chagas Detect Plus (false positives: 3.9% and 15.4%), highlighting the need to assess diagnostic assays in geographic regions with distinct taxonomic units of T. cruzi.

Background: Community-acquired pneumonia remains the leading cause of death in children worldwide, and current diagnostic guidelines in resource-poor settings are neither sensitive nor specific. We sought to determine the ability to correctly diagnose radiographically confirmed clinical pneumonia when diagnostics tools were added to clinical signs and symptoms in a cohort of children with acute respiratory illnesses in Peru., Methods: Children < 5 years of age with an acute respiratory illness presenting to a tertiary hospital in Lima, Peru, were enrolled. The ability to predict radiographically confirmed clinical pneumonia was assessed using logistic regression under four additive scenarios: clinical signs and symptoms only, addition of lung auscultation, addition of oxyhemoglobin saturation (Spo 2 ), and addition of lung ultrasound., Results: Of 832 children (mean age, 21.3 months; 59% boys), 453 (54.6%) had clinical pneumonia and 221 (26.6%) were radiographically confirmed. Children with radiographically confirmed clinical pneumonia had lower average Spo 2 than those without (95.9% vs 96.6%, respectively; P < .01). The ability to correctly identify radiographically confirmed clinical pneumonia using clinical signs and symptoms was limited (area under the curve [AUC] = 0.62; 95% CI, 0.58-0.67) with a sensitivity of 66% (95% CI, 59%-73%) and specificity of 53% (95% CI, 49%-57%). The addition of lung auscultation improved classification (AUC = 0.73; 95% CI, 0.69-0.77) with a sensitivity of 75% (95% CI, 69%-81%) and specificity of 53% (95% CI, 49%-57%) for the presence of crackles. In contrast, the addition of Spo 2 did not improve classification (AUC = 0.73; 95% CI, 0.69-0.77) with a sensitivity of 40% (95% CI, 33%-47%) and specificity of 72% (95% CI, 68%-75%) for an Spo 2  ≤ 92%. Adding consolidation on lung ultrasound was associated with the largest improvement in classification (AUC = 0.85; 95% CI, 0.82-0.89) with a sensitivity of 55% (95% CI, 48%-63%) and specificity of 95% (95% CI, 93%-97%)., Conclusions: The addition of lung ultrasound and auscultation to clinical signs and symptoms improved the ability to correctly classify radiographically confirmed clinical pneumonia. Implementation of auscultation- and ultrasound-based diagnostic tools can be considered to improve diagnostic yield of pneumonia in resource-poor settings., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Neurocysticercosis (NCC), the infection of the human central nervous system (CNS) with larval cysts of Taenia solium causes widespread neurological morbidity. Animal models are crucial for studying the pathophysiology and treatment of NCC. Some drawbacks of current NCC models include differences in the pathogenesis of the model and wild-type parasite, low rates of infection efficiency and lack of reproducibility. We describe a novel porcine model that recreates infection in the CNS with high efficiency. Activated oncospheres, either in a high (45,000-50,000) or low (10,000) dose were inoculated in the common carotid artery of 12 pigs by ultrasound-guided catheterization. Following oncosphere injection, either a high (30 mL) or low (1-3 mL) volume of saline flush was also administered. Cyst burden in the CNS was evaluated independently according to oncosphere dose and flush volume. Neurocysticercosis was achieved in 8/12 (66.7%) pigs. Cyst burden in the CNS of pigs was higher in the high versus the low oncosphere dose category (median: 4.5; interquartile ranges [IQR]: 1-8 and median: 1; IQR: 0-4, respectively) and in the high versus the low flush volume category (median 5.5; IQR: 1-8 and median: 1; IQR: 0-2, respectively), although not statistically different. All cysts in the CNS were viable, whereas both viable and degenerated cysts were found in the musculature. Carotid injection of activated oncospheres in pigs is effective in reproducing NCC. Oncosphere entry into the CNS by way of vasculature mimics wild-type infection, and provides a useful alternative for future investigations on the pathogenesis and antiparasitic treatment of NCC.

Background: The prevalence of and factors associated with ideal cardiovascular health (ICH) by sociodemographic characteristics in Peru is not well known., Methods: The American Heart Association's ICH score comprised 3 ideal health factors (blood pressure, untreated total cholesterol and glucose) and 4 ideal health behaviours (smoking, body mass index, high physical activity and fruit and vegetable consumption). ICH was having 5 to 7 of the ideal health metrics. Baseline data from the Center of Excellence in Chronic Diseases, a prospective cohort study in adults aged ≥35 years in 4 Peruvian settings, was used (n=3058)., Results: No one met all 7 of ICH metrics while 322 (10.5%) had ≤1 metric. Fasting plasma glucose was the most prevalent health factor (72%). Overall, compared with ages 35-44 years, the 55-64 years age group was associated with a lower prevalence of ICH (prevalence ratio 0.54, 95% CI 0.40 to 0.74, P<0.001). Compared with those in the lowest tertile of socioeconomic status, those in the middle and highest tertiles were less likely to have ICH after adjusting for sex, age and education (P<0.001)., Conclusion: There is a low prevalence of ICH. This is a benchmark for the prevalence of ICH factors and behaviours in a resource-poor setting., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Ehrlichia spp. are emerging infectious pathogens, especially in the Americas. Although Ehrlichia canis is primarily a parasite of dogs, polymerase chain reaction-confirmed human infections have been reported from Mexico, Venezuela, and Costa Rica. This study reports the presence of E. canis DNA in 13.7% of 205 dogs from urban areas in Peru and of those, five were analyzed for phylogenetic variation using the Tandem Repeat Protein 36 (TRP36) gene. The use of the TRP36 gene for such analysis was validated against 16S rRNA and heat shock protein genes using Shannon's entropy bioinformatic approach. When compared with other E. canis strains previously reported, three unique and novel E. canis strains were detected. In addition, the TRP36 amino acid tandem repeat sequences of the Peruvian strains share close similarity to an E. canis strain detected from four human blood bank samples in Costa Rica. This study reports for the first time domestic dogs infected with E. canis strains closely related to a zoonotic strain, which may be of public health concern as dogs can be chronically infected with this pathogen.

Interspecies transmission of pathogens is an unfrequent but naturally occurring event and human activities may favour opportunities not previously reported. Reassortment of zoonotic pathogens like influenza A virus can result from these activities. Recently, swine and birds have played a central role as "mixing vessels" for epidemic and pandemic events related to strains like H1N1 and H5N1. Unsafe practices in poultry markets and swine farms can lead to interspecies transmission, favouring the emergence of novel strains. Thus, understanding practices that lead to interspecies interactions is crucial. This qualitative study aimed to evaluate poultry processing practices in formal and informal markets and the use of leftovers by swine farmers in three Peruvian cities: Lima (capital), Tumbes (coastal) and Tarapoto (jungle). We conducted 80 direct observations at formal and informal markets and interviewed 15 swine farmers. Processors slaughter and pluck chickens and vendors and/or processors eviscerate chickens. Food safety and hygiene practices were suboptimal or absent, although some heterogeneity was observed between cities and chicken vendors versus processors. Both vendors (76%) and processors (100%) sold the chicken viscera leftovers to swine farmers, representing the main source of chicken viscera for swine farms (53%). Swine farmers fed the chicken viscera to their swine. Chicken viscera cooking times varied widely and were insufficient in some cases. Non-abattoired poultry leads to the sale of poultry leftovers to small-scale swine farms, resulting in indirect but frequent interspecies contacts that can lead to interspecies transmission of bacterial pathogens or the reassortment of influenza A viruses. These interactions are exacerbated by suboptimal safety and hygiene conditions. People involved in these activities constitute an at-risk population who could play a central role in preventing the transmission of pathogens between species. Educational interventions on hygiene and food safety practices will be important for reducing the risk of interspecies influenza transmission., (© 2018 Blackwell Verlag GmbH.)

Cysticercosis is a worldwide parasitic disease of humans and pigs principally caused by infection with the larvae of the pork tapeworm Taenia solium. Through the use of the recently-made-available T. solium genome, we identified a gene within a novel 1448 bp ORF that theoretically encodes for a 433 amino acid-long protein and predicted to be an α-enolase closely related to enolases of other flatworms. Additional bioinformatic analyses revealed a putative plasminogen-binding region on this protein, suggesting a potential role for this protein in pathogenesis. On this basis, we isolated the mRNA encoding for this presumptive enolase from T. solium metacestodes and reverse-transcribed it into cDNA before subsequently cloning and expressing it in both E. coli (rEnoTs) and insect cells (rEnoTsBac), in a 6xHis tagged manner. The molecular weights of these two recombinant proteins were ∼48 and ∼50 kDa, respectively, with the differences likely attributable to differential glycosylation. We used spectrophotometric assays to confirm the enolase nature of rEnoTs as well as to measure its enzymatic activity. The resulting estimates of specific activity (60.000 U/mg) and K m (0.091 mM) are quite similar to the catalytic characteristics of enolases of other flatworms. rEnoTs also exhibited high immunogenicity, eliciting a strong polyclonal antibody response in immunized rabbits. We subsequently employed rEnoTsBac for use in an ELISA aimed at discriminating between healthy pigs and those infected with T. solium. This diagnostic assay exhibited a sensitivity of 88.4% (95% CI, 74.92%-96.11%) and a specificity of 83.7% (95% CI: 69.29%-93.19%). In conclusión, this study reports on and enzymatically characterizes a novel enolase from T. solium metacestode, and shows a potential use as an immunodiagnostic for porcine cysticercosis., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Trypanosoma cruzi causes Chagas disease in the Americas. The outcome of infection ranges from lifelong asymptomatic status to severe disease. Relationship between T. cruzi lineage (TcI-TcVI) infection history and prognosis is not understood. We previously described peptide-based lineage-specific enzyme-linked immunosorbent assay (ELISA) with trypomastigote small surface antigen (TSSA)., Methods: A novel rapid diagnostic test (RDT; Chagas Sero K-SeT) that incorporates a peptide that corresponds to the TSSA II/V/VI common epitope was developed and validated by comparison with ELISA. Patients from Bolivia and Peru, including individuals with varying cardiac pathology, and matched mothers and neonates, were then tested using Chagas Sero K-SeT., Results: Chagas Sero K-SeT and ELISA results, with a Bolivian subset of cardiac patients, mothers, and neonates, were in accord. In adult chronic infections (n = 121), comparison of severity class A (no evidence of Chagas cardiomyopathy) with class B (electrocardiogram suggestive of Chagas cardiomyopathy) and class C/D (decreased left ventricular ejection fraction; moderate/severe Chagas cardiomyopathy) revealed a statistically significant increase in Chagas Sero K-SeT reactivity with increasing severity (χ2 for trend, 7.39; P = .007). In Peru, Chagas Sero K-SeT detected the sporadic TcII/V/VI infections., Conclusions: We developed a low cost RDT that can replace ELISA for identification of TSSA II/V/VI immunoglobulin G. Most importantly, we show that response to this RDT is associated with severity of Chagas cardiomyopathy and thus may have prognostic value. Repeated challenge with T. cruzi infection may both exacerbate disease progression and boost the immune response to the TSSApep-II/V/VI epitope.

Rationale: Platelets may interact with the immune system in tuberculosis (TB) to regulate human inflammatory responses that lead to morbidity and spread of infection., Objectives: To identify a functional role of platelets in the innate inflammatory and matrix-degrading response in TB., Methods: Markers of platelet activation were examined in plasma from 50 patients with TB before treatment and 50 control subjects. Twenty-five patients were followed longitudinally. Platelet-monocyte interactions were studied in a coculture model infected with live, virulent Mycobacterium tuberculosis (M.tb) and dissected using qRT-PCR, Luminex multiplex arrays, matrix degradation assays, and colony counts. Immunohistochemistry detected CD41 (cluster of differentiation 41) expression in a pulmonary TB murine model, and secreted platelet factors were measured in BAL fluid from 15 patients with TB and matched control subjects., Measurements and Main Results: Five of six platelet-associated mediators were upregulated in plasma of patients with TB compared with control subjects, with concentrations returning to baseline by Day 60 of treatment. Gene expression of the monocyte collagenase MMP-1 (matrix metalloproteinase-1) was upregulated by platelets in M.tb infection. Platelets also enhanced M.tb-induced MMP-1 and -10 secretion, which drove type I collagen degradation. Platelets increased monocyte IL-1 and IL-10 and decreased IL-12 and MDC (monocyte-derived chemokine; also known as CCL-22) secretion, as consistent with an M2 monocyte phenotype. Monocyte killing of intracellular M.tb was decreased. In the lung, platelets were detected in a TB mouse model, and secreted platelet mediators were upregulated in human BAL fluid and correlated with MMP and IL-1β concentrations., Conclusions: Platelets drive a proinflammatory, tissue-degrading phenotype in TB.

Introduction: Tuberculosis (TB) is a significant cause of morbidity and mortality worldwide. The patient compliance with the long treatment regimens is essential for successful eradication. Pyrazinamide (PZA) shortens these regimens from 9 to 6 months, and therefore, improves treatment completion rates. Although PZA is a first-line medication for the treatment of TB, no simple or reliable assay to determine PZA resistance is yet available. In the presence of PZA, only susceptible Mycobacterium tuberculosis strains release pyrazinoic acid (POA). Therefore, the measurement and quantification of released POA is an indicator of PZA resistance., Methods: Two electrochemical sensors were constructed and tested with alternative working electrodes in conjunction with a portable potentiostat to measure the current produced when a potential difference of 2 V is applied to varying concentrations of POA in controlled solutions., Results: The large (13.2 mm) electrochemical sensor was able to detect POA at a minimum concentration of 40 μM to a statistically significant level (P = 0.0190). Similar graphical trends were obtained when testing the electrochemical sensor in the supernatant of a negative microscopic observation drug susceptibility assay culture, irrespective of the presence of PZA., Conclusion: Inexpensive and reusable electrochemical sensors with a portable potentiostat are a promising tool for the detection of POA, a biomarker of PZA susceptible M. Tuberculosis., Competing Interests: There are no conflicts of interest

Background: The changes in body composition markers (weight, fat mass, lean mass, and BMI) over time can be associated with TB treatment outcome among HIV-infected patients. The aim of this study was to investigate whether changes in fat mass and lean mass were associated with the treatment response among patients with HIV infection and pulmonary tuberculosis., Materials and Methods: This was a prospective cohort study. Data from HIV-infected patients commencing TB therapy were analyzed. This included body weight measurement using bioimpedance equipment at baseline, one month, and two months after starting TB treatment., Results: The study was conducted in 125 patients, 17 patients (13.6%) died during treatment, of which 5 died during the first month of treatment, 4 during the second month and 8 after the second month. The group of patients with good response, increased their weight by 1.3 kg (p <0.001) at the end of the first month of TB treatment and 2.6 kg in the second month (p <0.001), and body fat increase was 1.2 Kg (p <0.001) and 2.3 kg (p <0.001), the first and second month respectively. The group of patients who died had lost 2.1 kg fat mass after the first month (p <0.001) and 3.7 kg in the second month (p <0.001)., Conclusions: Our results show that the weight change during TB treatment (increased fat mass) helps us predict therapeutic response. Weight loss during the first month of starting therapy should be evaluated thoroughly to identify the probable cause of treatment failure., Competing Interests: Conflict of interest: The authors declare that they have no competing interests.

To reduce transmission of tuberculosis (TB) in resource-limited countries where TB remains a major cause of mortality, novel diagnostic tools are urgently needed. We evaluated the fractional concentration of exhaled nitric oxide (FeNO) as an easily measured, noninvasive potential biomarker for diagnosis and monitoring of treatment response in participants with pulmonary TB including multidrug resistant-TB in Lima, Peru. In a longitudinal study however, we found no differences in baseline median FeNO levels between 38 TB participants and 93 age-matched controls (13 parts per billion [ppb] [interquartile range (IQR) = 8-26] versus 15 ppb [IQR = 12-24]), and there was no change over 60 days of treatment (15 ppb [IQR = 10-19] at day 60). Taking this and previous evidence together, we conclude FeNO is not of value in either the diagnosis of pulmonary TB or as a marker of treatment response.

Purpose: Body composition is known to influence the development and progression of chronic respiratory diseases (CRDs). We sought to characterize the unique anthropometric phenotypes that present with asthma, chronic obstructive pulmonary disease (COPD), and chronic bronchitis across four distinct settings in Peru., Methods: We collected sociodemographic, clinical history, and spirometry data from 2959 participants from Lima, Tumbes, and rural and urban Puno. We compared the prevalence of CRDs among different study sites and described disease phenotypes. We used single and multivariable linear regression to model the influence of CRD status on various descriptors of body composition., Results: Overall prevalence of CRDs varied across sites with the highest prevalence of asthma in Lima (14.5%) and the highest prevalence of COPD in rural Puno (9.9%). Measures of body composition also varied across sites, with highest mean body mass index (BMI) in Lima (28.4 kg/m 2 ) and the lowest mean BMI in rural Puno (25.2 kg/m 2 ). Participants with COPD had the lowest mean fat mass index (FMI) (10.5 kg/m 2 ) and waist circumference (88.3 cm), whereas participants with asthma had the highest mean FMI (14.5 kg/m 2 ), and waist circumference (94.8 cm). In multivariable analysis, participants with COPD had a lower waist circumference (adjusted mean - 2.97 cm, 95% CI 4.62 to - 1.32 cm) when compared to non-CRD participants., Conclusions: Our findings provide evidence that asthma and chronic bronchitis are more likely to be associated with obesity and higher fat mass, while COPD is associated with being underweight and having less lean mass.

Setting: There remains a lack of effective and inexpensive diagnostic tools for active tuberculosis (TB) disease. Testing immune responses to proteins secreted by Mycobacterium tuberculosis, such as MPT64, may be a diagnostic option., Objective: To evaluate the sensitivity and specificity of a patch test using MPT64 for the diagnosis of active TB disease., Design: This randomised, double-blind, placebo-controlled, prospective study in Lima, Peru, involved 55 healthy controls and 457 symptomatic individuals referred for routine TB testing by the National TB Control Programme. All subjects underwent a comprehensive diagnostic workup, and received an active patch on one arm and a placebo patch on the opposite arm, which were read after 4 days., Results: Eighty-one (18%) of the symptomatic participants were classified as having definite TB, while an additional 98 (21%) had probable TB. The patch tests performed the same in both groups, with a sensitivity of 27% and specificity of 74%. The area under the receiver operating characteristic curve was 0.495 (95%CI 0.425-0.565)., Conclusions: Contrary to existing literature, the MPT64 patch was not sensitive and specific to detect active TB. Given the potential of the test, understanding possible differences in the protein source or underlying genetic factors should be explored further.

The relative fitness of drug-resistant versus susceptible bacteria in an environment dictates resistance prevalence. Estimates for the relative fitness of resistant Mycobacterium tuberculosis ( Mtb ) strains are highly heterogeneous and mostly derived from in vitro experiments. Measuring fitness in the field allows us to determine how the environment influences the spread of resistance. We designed a household structured, stochastic mathematical model to estimate the fitness costs associated with multidrug resistance (MDR) carriage in Mtb in Lima, Peru during 2010-2013. By fitting the model to data from a large prospective cohort study of TB disease in household contacts, we estimated the fitness, relative to susceptible strains with a fitness of 1, of MDR- Mtb to be 0.32 (95% credible interval: 0.15-0.62) or 0.38 (0.24-0.61), if only transmission or progression to disease, respectively, was affected. The relative fitness of MDR- Mtb increased to 0.56 (0.42-0.72) when the fitness cost influenced both transmission and progression to disease equally. We found the average relative fitness of MDR- Mtb circulating within households in Lima, Peru during 2010-2013 to be significantly lower than concurrent susceptible Mtb If these fitness levels do not change, then existing TB control programmes are likely to keep MDR-TB prevalence at current levels in Lima, Peru., (© 2018 The Authors.)

Background: Sapovirus is one of the primary viral causes of acute gastroenteritis (AGE), especially where rotavirus vaccination has been implemented. The characteristics and impact of natural infection at the community level, however, have not been well documented., Methods: Stool samples were analyzed from 100 children randomly selected from a community-based birth cohort study in Peru. All diarrheal and 1 nondiarrheal stools collected trimonthly from children up to age 2 years (n = 1669) were tested for sapovirus detection. Viral shedding duration was determined by testing additional weekly samples (n = 440) collected before and after a sapovirus-positive sample., Results: The incidence of sapovirus infection in the first and second years of life was 4.3 and 11.1 per 100 child-months, respectively. By age 2 years, 82% of children had at least 1 sapovirus infection, and 64% had at least 1 sapovirus-associated diarrhea episode. The median shedding period was 18.5 days. In 112 of 175 infections, 14 genotypes from 4 genogroups (GI, GII, GIV, and GV) were determined. Among genogroups, GI were more frequently found in symptomatic infections than in asymptomatic infections (odds ratio, 3.1; 95% confidence interval, 1.3-7.4). Fifty-nine children had serial sapovirus infections, but only 3 had repeated infection of the same genotype., Conclusions: Sapovirus was frequently detected in children with AGE at the community level during the first 2 years of life. Serial sapovirus infections by multiple genotypes in a child suggest genotype-specific immunity from each infection, which needs to be taken into account for vaccine development.

Objective: To determine whether the concentration and distribution of immune markers in paired oral samples were similar., Study Type: Clinical research., Study Design: Cross-sectional study., Methods: Paired saliva and oral secretions (OS) samples were collected. The concentration of immune markers was estimated using Luminex multiplex assay (Thermo Fisher Scientific, Waltham, MA). For each sample, the concentration of respective immune markers was normalized to total protein present and log-transformed. Median concentrations of immune markers were compared between both types of samples. Intermarker correlation in each sampling method and across sampling methods was evaluated., Results: There were 90 study participants. Concentrations of immune markers in saliva samples were significantly different from concentrations in OS samples. Oral secretions samples showed higher concentrations of immunoregulatory markers, whereas the saliva samples contained proinflammatory markers in higher concentration., Conclusion: The immune marker profile in saliva samples is distinct from the immune marker profile in paired OS samples., Level of Evidence: 2b. Laryngoscope, 128:E214-E221, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Cough frequency, and its duration, is a biomarker that can be used in low-resource settings without the need of laboratory culture and has been associated with transmission and treatment response. Radiologic characteristics associated with increased cough frequency may be important in understanding transmission. The relationship between cough frequency and cavitary lung disease has not been studied., Methods: We analyzed data in 41 adults who were HIV negative and had culture-confirmed, drug-susceptible pulmonary TB throughout treatment. Cough recordings were based on the Cayetano Cough Monitor, and sputum samples were evaluated using microscopic observation drug susceptibility broth culture; among culture-positive samples, bacillary burden was assessed by means of time to positivity. CT scans were analyzed by a US-board-certified radiologist and a computer-automated algorithm. The algorithm evaluated cavity volume and cavitary proximity to the airway. CT scans were obtained within 1 month of treatment initiation. We compared small cavities (≤ 7 mL) and large cavities (> 7 mL) and cavities located closer to (≤ 10 mm) and farther from (> 10 mm) the airway to cough frequency and cough cessation until treatment day 60., Results: Cough frequency during treatment was twofold higher in participants with large cavity volumes (rate ratio [RR], 1.98; P = .01) and cavities located closer to the airway (RR, 2.44; P = .001). Comparably, cough ceased three times faster in participants with smaller cavities (adjusted hazard ratio [HR], 2.89; P = .06) and those farther from the airway (adjusted HR, 3.61;, P = .02). Similar results were found for bacillary burden and culture conversion during treatment., Conclusions: Cough frequency during treatment is greater and lasts longer in patients with larger cavities, especially those closer to the airway., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: High body mass index (BMI) and blood pressure (BP) are major contributors to the high burden of non-communicable diseases in adulthood. Individual high-risk and population approaches for prevention require newer strategies to target these risk factors and focusing on the family to introduce prevention initiatives appears as a promising scenario. Characterisation of the relationship between BMI and BP among the adult members of a given family merits evaluation. We conducted a secondary analysis of an implementation study in Tumbes, Peru, benefiting from data derived from families with at least one adult offspring., Methods: The exposures of interest were the BMI, systolic BP (SBP) and diastolic BP (DBP) of the mother and father. The outcomes were the BMI, SBP and DBP of the offspring. Mixed-effects linear regression models were conducted., Results: The mean age of the offspring, mothers and fathers was 29 (SD: 9.5), 54 (SD: 11.8) and 59 (SD: 11.6) years, respectively. Father's BMI was associated with a quarter-point increase in offspring BMI, regardless of the sex of the offspring. Mother's BMI had a similar effect on the BMI of her sons, but had no significant effect on her daughters'. Mother's SBP was associated with almost one-tenth of mmHg increase in the SBP of the adult offspring. There was no evidence of an association for DBP., Conclusions: In families with adult members, the higher the parents' BMI and SBP, the higher their adult offspring's levels will be., (© 2018 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.)