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Item type:Publication, El Niño/Southern Oscillation (ENSO) and stunting in children under 5 years in Peru: a double-difference analysis(Elsevier, 2020-04-01)Background The 1997–98 El Niño/Southern Oscillation (ENSO) was one of the most important natural disasters in 20th century Peru, associated with heavy rainfall and flooding. It affected 502 000 people, ruined 944 km of roads, and damaged 580 health centres and 956 schools. Almost a quarter of all people affected (23%) came from Piura, in the northwest of Peru. In this study, we assessed the association between the 1997–98 ENSO and growth stunting in children younger than 5 years on Peru's north coast. Methods We analysed Peruvian Demographic and Health Survey (DHS) data, from 1996 and 2000, using a double-difference approach. Our primary outcome was childhood growth stunting, and our exposure was the ENSO phenomenon. The exposed group was from Peru's Piura coast, and the unexposed group was from southern coastal regions, which were less affected by the events associated with ENSO 1997–98. First, we conducted a regional comparison. Secondly, we used propensity score matching (PSM) to explore similarities between the exposed and non-exposed groups. We then estimated adjusted prevalence ratios (PR) of childhood growth stunting using generalised linear models. Finally, we conducted a subanalysis by childhood age. Findings We studied 2270 and 1349 children younger than 5 years from 1996 and 2000, respectively. Regression without matching showed a PR of 1·37 (95% CI 0·93–2·01), and a PSM regression 1-to-2 PR of 1·45 (0·66–3·18), obtaining a PR greater than 1 but with a confidence interval that included the null value. Furthermore, we found a possible effect on children aged 0–11 months. In the regressions without PSM, analysis for this age group showed a PR of 2·48 (1·11–5·54); whereas, after PSM 1-to-2, the PR was 2·69 (1·03–7·03); alternative PSM was also consistent with these results. Analysis of the other age groups yielded results that were not statistically significant. Interpretation Our results suggest that the ENSO phenomenon could have increased childhood stunting on the coast of Piura. More specifically, children who were aged 0 to 11 months during the worst and most disruptive period of the El Niño phenomenon were at increased risk of growth stunting. Our results were consistent with and without PSM. Factors that might have contributed to our results include increased childhood morbidity with concurrent reductions in maternal and familial access to health care, and diminished household incomes due to El Niño's devastating effects during the disaster period. Our findings outline a need to prevent harm to people and their health during weather and natural events associated with ENSO. Specifically, there is a need for childhood-focused social protection systems, especially during critical stages of growth and development. Childhood-focused social protection and delivery systems will be instrumental in preventing downstream effects of similar climatic events. Funding Fogarty 2D43 TW007393. - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Peru – progress in health and sciences in 200 years of independence(Elsevier, 2021-12-20)Peru celebrates 200 years of independence in 2021. Over this period of independent life, and despite the turbulent socio-political scenarios, from internal armed conflict to economic crisis to political instability over the last 40 years, Peru has experienced major changes on its epidemiological and population health profile. Major advancements in maternal and child health as well as in communicable diseases have been achieved in recent decades, and today Peru faces an increasing burden of non-communicable diseases including mental health conditions. In terms of the configuration of the public health system, Peru has also strived to secure country-wide optimal health care, struggling in particular to improve primary health care and intercultural services. The science and technology infrastructure has also evolved, although the need for substantial investments remains if advancing science is to be a national priority. Climate change will also bring significant challenges to population health given Peru's geographical and microclimates diversity. Looking back over the 200-years of independence, we present a summary of key advances in selected health-related fields, thus serving as the basis for reflections on pending agendas and future challenges, in order to look forward to ensuring the future health and wellbeing of the Peruvian population. Resumen translated El Perú cumple 200 años de independencia en 2021. Durante estos dos siglos de vida independiente, junto con periodos sociales y políticos turbulentos, incluyendo un conflicto armado interno, hiperinflación y la inestabilidad política de los últimos 40 años, el Perú ha experimentado importantes cambios en su perfil epidemiológico con repercusiones directas en la salud de la población. En las últimas décadas, los indicadores de salud materno-infantil y de las enfermedades transmisibles muestran mejoría importante, pero el país se enfrenta de manera simultánea a una carga cada vez mayor de enfermedades no transmisibles y de salud mental. En cuanto a los sistemas de salud pública, se han realizado esfuerzos por aumentar la cobertura y calidad de la atención de salud en todo el país, apostándose en particular por mejorar la atención primaria. La ciencia y tecnología relacionadas con la salud también han mejorado, aunque si se quiere que la ciencia sea una prioridad nacional, son necesarias inversiones sustanciales. El cambio climático traerá importantes desafíos para la salud de la población, dada la diversidad geográfica y de microclimas del país. Para conmemorar los 200 años de vida independiente del Perú, presentamos un resumen de avances clave en diversas áreas y temas relacionados con la salud. Este repaso sirve como base para reflexionar sobre agendas y desafíos pendientes y futuros, con el fin de asegurar la salud y el bienestar de la población peruana en las próximas décadas. - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Study protocol: Improving response to malaria in the Amazon through identification of inter-community networks and human mobility in border regions of Ecuador, Peru and Brazil(BMJ Publishing Group, 2024-04-15)Understanding human mobility’s role in malaria transmission is critical to successful control and elimination. However, common approaches to measuring mobility are ill-equipped for remote regions such as the Amazon. This study develops a network survey to quantify the effect of community connectivity and mobility on malaria transmission. Methods We measure community connectivity across the study area using a respondent driven sampling design among key informants who are at least 18 years of age. 45 initial communities will be selected: 10 in Brazil, 10 in Ecuador and 25 in Peru. Participants will be recruited in each initial node and administered a survey to obtain data on each community’s mobility patterns. Survey responses will be ranked and the 2–3 most connected communities will then be selected and surveyed. This process will be repeated for a third round of data collection. Community network matrices will be linked with each country’s malaria surveillance system to test the effects of mobility on disease risk. Ethics and dissemination This study protocol has been approved by the institutional review boards of Duke University (USA), Universidad San Francisco de Quito (Ecuador), Universidad Peruana Cayetano Heredia (Peru) and Universidade Federal Minas Gerais (Brazil). Results will be disseminated in communities by the end of the study. - Some of the metrics are blocked by yourconsent settings
Item type:Publication, The Lancet Countdown South America: Increasing Health Opportunities by Identifying the Gaps in Health and Climate Change Research(Elsevier Ltd, 2023-10-01)South America is experiencing the effects of climate change, including extreme weather events and changes in temperature and precipitation patterns. These effects interact with existing social vulnerabilities, exacerbating their impact on the health and wellbeing of populations. This viewpoint highlights four main messages from the series, which presented key gaps from five different perspectives of health and climate. First, there is an overall need for local analyses of priority topics to inform public policy, which include national and sub-national evidence to adequately strengthen responses and preparedness for climate change hazards and address relevant social vulnerabilities in South American countries. Second, research in health and climate is done in silos and the intersection is not clear in terms of responsibility and leadership; therefore, transdisciplinary research and action are key. Third, climate research, policies, and action need to be reflected in effective funding schemes, which until now are very limited. For adaptation and mitigation policies to be effective, they need a robust and long-term funding scheme. Finally, climate action is a big opportunity for healthier and more prosperous societies in South America, taking the advantage of strategic climate policies to face the challenges of climate change and tackle existing social inequities. - Some of the metrics are blocked by yourconsent settings
Item type:Publication, The Impact of Sustained Malaria Control in the Loreto Region of Peru: A Retrospective, Observational, Spatially-Varying Interrupted Time Series Analysis of the PAMAFRO Program(Elsevier Ltd, 2023-04-01)Background: Although malaria control investments worldwide have resulted in dramatic declines in transmission since 2000, progress has stalled. In the Amazon, malaria resurgence has followed withdrawal of Global Fund support of the Project for Malaria Control in Andean Border Areas (PAMAFRO). We estimate intervention-specific and spatially-explicit effects of the PAMAFRO program on malaria incidence across the Loreto region of Peru, and consider the influence of the environmental risk factors in the presence of interventions. Methods: We conducted a retrospective, observational, spatial interrupted time series analysis of malaria incidence rates among people reporting to health posts across Loreto, Peru between the first epidemiological week of January 2001 and the last epidemiological week of December 2016. Model inference is at the smallest administrative unit (district), where the weekly number of diagnosed cases of Plasmodium vivax and Plasmodium falciparum were determined by microscopy. Census data provided population at risk. We include as covariates weekly estimates of minimum temperature and cumulative precipitation in each district, as well as spatially- and temporally-lagged malaria incidence rates. Environmental data were derived from a hydrometeorological model designed for the Amazon. We used Bayesian spatiotemporal modeling techniques to estimate the impact of the PAMAFRO program, variability in environmental effects, and the role of climate anomalies on transmission after PAMAFRO withdrawal. Findings: During the PAMAFRO program, incidence of P. vivax declined from 42.8 to 10.1 cases/1000 people/year. Incidence for P. falciparum declined from 14.3 to 2.5 cases/1000 people/year over this same period. The effects of PAMAFRO-supported interventions varied both by geography and species of malaria. Interventions were only effective in districts where interventions were also deployed in surrounding districts. Further, interventions diminished the effects of other prevailing demographic and environmental risk factors. Withdrawal of the program led to a resurgence in transmission. Increasing minimum temperatures and variability and intensity of rainfall events from 2011 onward and accompanying population displacements contributed to this resurgence. Interpretation: Malaria control programs must consider the climate and environmental scope of interventions to maximize effectiveness. They must also ensure financial sustainability to maintain local progress and commitment to malaria prevention and elimination efforts, as well as to offset the effects of environmental change that increase transmission risk. Funding: National Aeronautics and Space Administration, National Institutes of Health, Bill and Melinda Gates Foundation. - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Prevalence of and Factors Associated with Childhood Anaemia in Remote Villages of the Peruvian Amazon: A Cross-Sectional Study and Geospatial Analysis(Oxford University Press, 2023-08-01)Background: Anaemia is a public health problem in Peru. In the Loreto region of the Amazon, ≥50% of children may be anaemic, although insufficient information exists for rural villages. Methods: To generate more data about childhood anaemia in the Peruvian Amazon, haemoglobin was measured as part of a trachoma survey in 21 randomly selected villages. All children 1–9 y of age from 30 randomly selected households per village were recruited. Anaemia was classified according to the World Health Organization guidelines and a socio-economic status (SES) index was created for each household using principal component analysis. Spatial autocorrelation was determined using Moran’s I and Ripley’s K function. Results: Of 678 children with complete haemoglobin data, 25.4% (95% confidence interval [CI] 21.2 to 30.1) had mild-or-worse anaemia and 22.1% (95% CI 15.6 to 30.3) had moderate-or-worse anaemia. Mild-or-worse anaemia was more common among children whose primary source of drinking water was surface water (prevalence ratio [PR] 1.26 [95% CI 1.14 to 1.40], p<0.001) and who were in the lowest SES tercile (PR 1.16 [95% CI 1.02 to 1.32], p=0.021). Moderate-or-worse anaemia was more common among boys (PR 1.32 [95% CI 1.09 to 1.60], p=0.005). No evidence of geospatial clustering was found. Conclusions: Remote villages of the Amazon would benefit from interventions for childhood anaemia and the poorest households would have the most to gain. Integrating anaemia screening into neglected tropical diseases surveys is an opportunity to use public health resources more efficiently. - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Network Profile: Improving Response to Malaria in the Amazon Through Identification of Inter-Community Networks and Human Mobility in Border Regions of Ecuador, Peru, and Brazil(2023-11-30)Objectives Understanding human mobility’s role on malaria transmission is critical to successful control and elimination. However, common approaches to measuring mobility are ill-equipped for remote regions such as the Amazon. This study develops a network survey to quantify the effect of community connectivity and mobility on malaria transmission. Design A community-level network survey Setting We collect data on community connectivity along three river systems in the Amazon basin: the Pastaza river corridor spanning the Ecuador-Peru border; and the Amazon and Javari river corridors spanning the Brazil-Peru border. Participants We interviewed key informants in Brazil, Ecuador, and Peru, including from indigenous communities: Shuar, Achuar, Shiwiar, Kichwa, Ticuna, and Yagua. Key informants are at least 18 years of age and are considered community leaders. Primary outcome Weekly, community-level malaria incidence during the study period. Methods We measure community connectivity across the study area using a respondent driven sampling design. Forty-five communities were initially selected: 10 in Brazil, 10 in Ecuador, and 25 in Peru. Participants were recruited in each initial node and administered a survey to obtain data on each community’s mobility patterns. Survey responses were ranked and the 2-3 most connected communities were then selected and surveyed. This process was repeated for a third round of data collection. Community network matrices will be linked with eadch country’s malaria surveillance system to test the effects of mobility on disease risk. Findings To date, 586 key informants were surveyed from 126 communities along the Pastaza river corridor. Data collection along the Amazon and Javari river corridors is ongoing. Initial results indicate that network sampling is a superior method to delineate migration flows between communities. Conclusions Our study provides measures of mobility and connectivity in rural settings where traditional approaches are insufficient, and will allow us to understand mobility’s effect on malaria transmission. Strengths and Limitations Strength: Community networks are unmeasured in rural areas of the Amazon, but have been shown to capture human mobility in other regions of the world. Strength: Our design captures social, economic, and human wellbeing connectivity and migration in key indigenous communities along the Peru-Ecuador border as well as in the most important confluence for the Amazon River located in the Brazil-Peru-Colombia tri-country intersection. Strength: Our design quantifies cross-border human mobility between communities, as well as the magnitude, timing, duration, and reason for mobility, which provides actionable information for malaria control and elimination programs in the region Limitation: Migration decisions occur at individual and household levels that are coupled with environmental change and seasonality, meaning that our measures of community mobility may not be stable over time and we may be subject to ecological fallacy by inferring individual risk from community networks. Limitation: Our study relies on passive surveillance to test the community network/human mobility link with malaria. However, there exist cases that are asymptomatic, unreported (i.e., treated with traditional medicines), or that occur in our community network but are reported elsewhere. The extent of these cases can significantly increase uncertainty. Funding This work was supported by the US National Institutes of Health (R01 AI51056; William K. Pan, PI) and by a grant from the Duke Climate and Health Initiative (William Pan, PI). PRC-U was supported by CONCYTEC through the PROCIENCIA program under the call entitled “Science, Technology and Innovation Thesis and Internships” according to the contract PE501081617-2022. AGL, CSC, EJA and PRC-U were sponsored by Emerge, the Emerging Diseases Epidemiology Research Training grant D43 TW007393 awarded by the Fogarty International Center of the US National Institutes of Health. Competing Interests We declare no conflicts - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Spotted fever group rickettsiae in black rats, pets, and humans in Zungarococha community, A rural area in the surroundings of Iquitos, Peru(Elsevier BV, 2025-01-01)Rickettsiae are a family of ectoparasite-borne bacteria that can produce high morbidity and mortality among humans. There are scarce data on rickettsial ecology in rural areas of the Peruvian Amazon basin, where seroprevalence has not been determined, and the identities of animals acting as reservoirs of these bacteria are not known. We conducted a cross-sectional study in Zungarococha (between 2019 and 2021), a rural community located approximately 20 km away from Iquitos city. Blood samples were collected from humans (175), dogs (123), and cats (12). Blood samples and tissues were collected from black rats (84). Finally, we collected fleas from dogs and cats (222), ticks from dogs (91), and mites from black rats (32). Blood samples from humans, dogs, cats, and black rats were analyzed by indirect immunofluorescence assays (IFA) to detect IgG antibodies against rickettsias. We screened ectoparasites and black rat tissues by real-time-PCR (qPCR). Positive ectoparasites were further assessed by PCR and DNA amplicon sequencing. Non-parametric tests were used to evaluate factors associated with being seropositive among human adults. IgG seroprevalences were 38.3 %, 58.5 %, 16.7 % and 48.1 % among humans, dogs, cats, and rats, respectively. Among humans, only male gender was statistically associated with having IgG antibodies against Rickettsia spp. (p-value=0.049, chi-square test). Different ectoparasites were identified, including Ctenocephalides felis from cats and dogs, Rhipicephalus sanguineus s.l. from dogs, and Laelaps nuttalli from black rats. Rhipicephalus sanguineus s.l. (2/91 ticks) and Ct. felis (53/56 fleas and 55/55 flea pools) were qPCR-positive for Rickettsia spp. Recovered genetic material from 53 Ct. felis was sequenced and all were identified as Rickettsia asembonensis. All tissue samples from black rats were negative by qPCR. Humans, dogs, cats, and black rats are exposed to spotted fever group rickettsiae in rural areas surrounding Iquitos. As reported in urban areas, R. asembonensis is the main Rickettsia species circulating in rural areas surrounding Iquitos and Ct. felis appears to be the main vector.2