Establishment of a multisite umbrella cohort study protocol to describe the epidemiology and aetiologies of acute undifferentiated febrile illness in Latin America.

INTRODUCTION: Acute undifferentiated febrile illnesses (AUFIs) impose a large burden in the tropics. Understanding of AUFI's epidemiology is limited. Insufficient diagnostic capacity hinders the detection of outbreaks. The lack of interconnection in healthcare systems hinders timely response. We describe a protocol to study the epidemiology and aetiologies of AUFI and pathogen discovery in strategic areas of Latin America (LA). METHODS AND ANALYSIS: Global Infectious Diseases Network investigators comprising institutions in Colombia, Dominican Republic, México, Perú and the USA, developed a common cohort study protocol. The primary objective is to determine the aetiologies of AUFI at healthcare facilities in high-risk areas. Data collection and laboratory testing for viral, bacterial and parasitic agents are performed in rural and urban healthcare facilities and partner laboratories. Centralised laboratory and data management cores deploy diagnostic tests and data management tools. Subjects >6 years with fever for <8 days without localised infection are included in the cohort. They are evaluated during the acute and convalescent phases of illness. Study personnel collect clinical and epidemiological information. Blood, urine, nasal or pharyngeal swabs and saliva are collected in the acute phase and blood in convalescent phase. Specimens are banked at -80°C. Malaria, dengue and COVID-19 are tested onsite in the acute phase. The acute-phase serum is PCR tested for dengue, chikungunya, Venezuelan equine encephalitis, Mayaro, Oropouche, Zika, and yellow fever viruses. Paired convalescent and acute serum antibody titters are tested for arbovirus, Leptospira spp, and Rickettsia spp. Serum is used for viral cultures and next-generation sequencing for pathogen discovery. Analysis includes variable distributions, risk factors and regression models. Laboratory results are shared with health authorities and network members. ETHICS AND DISSEMINATION: The protocol was approved by local ethics committees and health authorities. The results will be published in peer-reviewed journals. All study results are shared with local and regional health authorities.

Risk factors for acute mountain sickness in travellers to Cusco, Peru: coca leaves, obesity and sex.

BACKGROUND: Acute mountain sickness (AMS) may occur after rapid ascents to altitudes >2500 m. Cusco (3350 m) in Peru is a popular destination for altitude inexperienced travellers. This study aimed at evaluating the incidence and risk factors for AMS among a cohort of foreign Spanish language students in Cusco. METHODS: We performed a cohort study among young healthy foreign Spanish language students arriving to Cusco between 2012 and 2016. Consenting students answered an enrollment questionnaire on demographics, travel history and intended AMS preventive behaviour within 48 h of arrival. At 4-5 days after enrollment participants answered a second questionnaire about actual preventive behaviour before symptoms and the development of symptoms compatible with AMS during their first 48 h in Cusco. We used the 2018 Lake Louise Scoring System for AMS diagnosis. Participants with headache and a score ≥ 3 were considered to have AMS. RESULTS: We enrolled 142 language students, the median age was 21 years (interquartile range 20-25) and 57% were female. Participants decreased physical activity (38%), increased fluid intake (34%), drank coca leaf tea (34%), took acetazolamide (16%) and acclimatized at a lower altitude (6%) to prevent AMS. Thirty-nine percent had AMS. In the multivariate analysis, obesity [odds ratio (OR) 14.45 (2.33-89.6)] and female sex [OR 4.32 (1.81-10.28)] were associated with increased risk of AMS. Taking acetazolamide [OR 0.13 (0.03-0.56)] was associated with decreased AMS risk. Consumption of coca leaf tea was not associated with decreased risk of AMS. CONCLUSIONS: In our cohort, AMS affected two out of five travellers. Obesity and female sex were associated with increased risk. Drinking coca leaf tea for prevention did not decrease the risk of AMS. Acetazolamide prophylaxis was associated with decreased risk of AMS.

Prevalence and Risk Factors for Human Cystic Echinococcosis in the Cusco Region of the Peruvian Highlands Diagnosed Using Focused Abdominal Ultrasound.

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

Acute mountain sickness impact among travelers to Cusco, Peru.

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

Excessive alcohol consumption increases risk taking behaviour in travellers to Cusco, Peru.

The risks associated with alcohol intoxication are rarely discussed during pre-travel counselling. However, alcohol immoderation abroad may increase the exposure to health risks. Few studies have addressed alcohol consumption and risk taking behaviour in travellers to South America. From October to December of 2004, travellers leaving the city of Cusco in Peru were asked to fill out anonymous questionnaires regarding demographics, self-reported alcohol consumption, illness and risk behaviour for sexually-transmitted infection (STI) and travellers diarrhoea. Most travellers (87.2%) consumed alcohol and 20.4% reported inebriation in Cusco. Those admitting inebriation were more likely to be male, single, <26 years old, and travelling alone or with friends. Travellers who admitted inebriation and fell ill while in Cusco were more likely to seek medical attention, change itinerary, and report decreased satisfaction with the trip experience. In the multivariate analysis, inebriation was independently associated with reporting higher numbers of unsafe food choices, illicit drug use, and risky sexual activity. It is concluded that alcohol intoxication during travel was associated with increased risk taking behaviour for common travel related conditions. Although travel related illnesses were not associated with inebriation, some markers of illness severity were more often reported by those who admitted intoxication. Risk for heavy alcohol use abroad should be assessed during the pre-travel visit in certain groups and appropriate counselling should be provided.

Pre-travel preparation for Cusco, Peru: a comparison between European and North American travelers.

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

Self-reported health problems among travelers visiting Cuzco: a Peruvian Airport survey.

Travel related illnesses are a concern among travelers visiting developing countries. These illnesses affect the travelers' plans and the local tourism industry. Few data on travel related illnesses are available from tourist destinations. Foreign travelers answered a self-administered questionnaire on health issues at the departures area of Cuzcos' International Airport between August and November 2002. Self-reported travel related illnesses that occurred during the travelers stay in Cuzco were compared with demographic and risk factors. The total number of participants was 5988. Their mean age was 35.4 years (SD 11.4), and slightly over half were female. The most common countries of residence were the United States (23.5%) and the United Kingdom (20%). The median length of stay in Cuzco was 5 days (IQR: 4-7 days). Pre-travel advice was received by 93.6% of the participants. Half (47.6%) of the participants became ill while in Cuzco. The most common illnesses reported were diarrhea (49.8%), altitude sickness (43.2%), and upper respiratory infections (21.7%). Most participants who reported an illness treated themselves (75.5%), and only 22.1% sought medical attention. It is concluded that a significant burden of disease is observed in travelers to Cuzco. Self-medication is very common and apparently preferred over formal medical attention.

Risk factors associated with diarrhea among international visitors to Cuzco, Peru.

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

Pretravel health advice among international travelers visiting Cuzco, Peru.

BACKGROUND: Cuzco, a Peruvian city of historical interest located 3,326 m above sea level, is a frequent destination for tourists. We conducted a descriptive study to assess the extent and sources of pretravel health advice received by international travelers before their arrival to Cuzco. METHODS: Data were collected as part of a health survey among travelers. Between August and November 2002, travelers between 15 and 65 years old were invited to fill out a questionnaire in the departing area of Cuzco's international airport. RESULTS: A total of 5,988 travelers participated. The mean age was 35.4 years (SD 11.4 yr); 50.6% were female and 50.8% were single. Tourism was the reason for traveling in 90.2% of the participants, and 89.3% of them were traveling with companions. Pretravel health information was received by 93.6%. The median number of information sources was two, with books (41.5%), travel medicine clinics (38.8%), the Internet (23.3%), and general practitioners (22.7%) as the main sources. Most frequently received recommendations were about safe food and water consumption (85%), use of insect repellents (66.0%), sunburn protection (64.4%), and condom use (22%). Only 16.5% took medication to prevent altitude sickness, and 14.2% took medication to prevent traveler's diarrhea. Variables independently associated with receiving pretravel health information from a health care professional were female gender, country of residence other than the United States, length of stay in Cuzco > 7 days, length of stay in other Peruvian cities > 7 days, tourism as the main reason for visiting Cuzco, traveling with companions, and consulting of more than one source of information. CONCLUSIONS: Most travelers arriving to Cuzco had received pretravel health information, and the majority obtained it from more than one source. Recommendations addressed for specific health risks, such as altitude sickness prophylaxis, were received by few travelers.