Early warning and response system for dengue outbreaks: Moving from research to operational implementation in Mexico.

Dengue disease epidemics have increased in time and space due to climatic and non-climatic factors such as urbanization. In the absence of an effective vaccine, preventing dengue outbreak relies on vector control activities. Employing computerized tools to predict outbreaks and respond in advance has great potential for improving dengue disease control. Evidence of integrating or implementing such applications into control programs and their impact are scarce, and endemic countries demand for experience sharing and know-how transfer. Mexico has extensive experience of pre-validated EWARS (Early Warning And Response System), a tool that was developed in 2012 as part of a collaboration with the Special Program for Research and Training in Tropical Diseases Unit (TDR) at the World Health Organization and used at national level. The advancement of EWARS since 2014 and its stepwise integration into the national surveillance system has increased the appreciation of the need for integrated surveillance (including disease, vector and climate surveillance), and for linking inter-institutional and trans-sectoral information for holistic epidemiological intelligence. The integration of the EWARS software into the national surveillance platform in Mexico was a remarkable milestone and a successful experience. This manuscript describes the implementation process of EWARS in Mexico, which started in 2012 and further demonstrates benefits, threats, and opportunities of integrating EWARS into existing national surveillance programs.

The elimination of trachoma as a public health problem in Mexico: From national health priority to national success story.

INTRODUCTION: Mexico was the first country in the Americas and the third in the world to eliminate trachoma as a public health problem, as validated by the WHO in 2017. OBJECTIVE: To describe the critical elements that favored the elimination of trachoma as a public health problem in Mexico and the public health impact of this success. METHODOLOGY: A revision and compilation of data and information contained in the dossier presented by the country to PAHO/WHO to obtain the validation of trachoma elimination as a public health problem was conducted by a group of delegates from the national and local trachoma prevention and control program. Data from the national and local surveillance systems and reports of actions conducted after achieving the elimination goal were also included. Critical elements that favored the achievement of the elimination goal from 1896 to 2019 were extracted. RESULTS: Mexico reached the elimination of trachoma in 2016 obtaining the validation in 2017. 264 communities were no longer endemic and 151,744 people were no longer at risk of visual impairment or possible blindness due to trachoma. The key to the success of this elimination process was primarily the local leadership of health authorities with sustained funding for brigades, increased access to potable water and sanitation, and key alliances with indigenous authorities, health authorities, and government institutions that contributed to the achievement of the goal. The SAFE strategy started implementation in Mexico in 2004 as a comprehensive package of interventions. SAFE stands for surgery, antibiotics, facial cleanliness, and improvement of the environmental conditions. These actions impacted drastically on the number of new cases trachmatous trichiasis (TT) and trachomatous inflammation-follicular (TF), which decreased from 1,794 in 2004 to zero in 2016. CONCLUSIONS: The elimination of trachoma as a public health problem in Mexico is a true success story that may serve as a model example for the elimination of other neglected infectious diseases in the Americas.

The Early Warning and Response System (EWARS-TDR) for dengue outbreaks: can it also be applied to chikungunya and Zika outbreak warning?

BACKGROUND: In the Americas, endemic countries for Aedes-borne diseases such as dengue, chikungunya, and Zika face great challenges particularly since the recent outbreaks of CHIKV and ZIKV, all transmitted by the same insect vectors Aedes aegypti and Ae. albopictus. The Special Program for Research and Training in Tropical Diseases (TDR-WHO) has developed together with partners an Early Warning and Response System (EWARS) for dengue outbreaks based on a variety of alarm signals with a high sensitivity and positive predictive value (PPV). The question is if this tool can also be used for the prediction of Zika and chikungunya outbreaks. METHODOLOGY: We conducted in nine districts of Mexico and one large city in Colombia a retrospective analysis of epidemiological data (for the outbreak definition) and of climate and entomological data (as potential alarm indicators) produced by the national surveillance systems for dengue, chikungunya and Zika outbreak prediction covering the following outbreak years: for dengue 2012-2016, for Zika 2015-2017, for chikungunya 2014-2016. This period was divided into a "run in period" (to establish the "historical" pattern of the disease) and an "analysis period" (to identify sensitivity and PPV of outbreak prediction). RESULTS: In Mexico, the sensitivity of alarm signals for correctly predicting an outbreak was 100% for dengue, and 97% for Zika (chikungunya data could not be obtained in Mexico); the PPV was 83% for dengue and 100% for Zika. The time period between alarm and start of the outbreak (i.e. the time available for early response activities) was for Zika 4-5 weeks. In Colombia the sensitivity of the outbreak prediction was 92% for dengue, 93% for chikungunya and 100% for Zika; the PPV was 68% for dengue, 92% for chikungunya and 54% for Zika; the prediction distance was for dengue 3-5 weeks, for chikungunya 10-13 weeks and for Zika 6-10 weeks. CONCLUSION: EWARS demonstrated promising capability of timely disease outbreak prediction with an operational design likely to improve the coordination among stakeholders. However, the prediction validity varied substantially across different types of diseases and appeared less optimal in low endemic settings.

Detection of NS1 protein from dengue virus in excreta and homogenates of wild-caught Aedes aegypti mosquitoes using monoclonal antibodies.

Dengue fever is one of the most devastating infectious diseases worldwide. Development of methods for dengue virus (DENV) detection in mosquitoes to assess prevalence as a preliminary screen for entomological surveillance in endemic regions of DENV will certainly contribute to the control of the disease. A monoclonal antibody against the NS1 (nonstructural protein 1) viral protein was generated using recombinant NS1 protein and used to detect and analyze DENV in both excreta and total homogenates from Aedes aegypti mosquitoes. Results demonstrated expression of NS1 in excreta of DENV laboratory-infected mosquitoes and homogenates from field mosquitoes infected with DENV. The immunodetection method reported here represents a first-line strategy for assessing the prevalence of DENV in mosquitoes, for entomological surveillance in endemic regions of dengue. Detection of DENV prevalence in field mosquitoes could have an impact on vector surveillance measures to interrupt dengue transmission.

Validation of the Early Warning and Response System (EWARS) for dengue outbreaks: Evidence from the national vector control program in Mexico.

BACKGROUND: During 2017, twenty health districts (locations) implemented a dengue outbreak Early Warning and Response System (EWARS) in Mexico, which processes epidemiological, meteorological and entomological alarm indicators to predict dengue outbreaks and triggers early response activities. Out of the 20 priority districts where more than one fifth of all national disease transmission in Mexico occur, eleven districts were purposely selected and analyzed. Nine districts presented outbreak alarms by EWARS but without subsequent outbreaks ("non-outbreak districts") and two presented alarms with subsequent dengue outbreaks ("outbreak districts"). This evaluation study assesses and compares the impact of alarm-informed response activities and the consequences of failing a timely and adequate response across the outbreak groups. METHODS: Five indicators of dengue outbreak response (larval control, entomological studies with water container interventions, focal spraying and indoor residual spraying) were quantitatively analyzed across two groups ("outbreak districts" and "non-outbreak districts"). However, for quality control purposes, only qualitative concluding remarks were derived from the fifth response indicator (fogging). RESULTS: The average coverage of vector control responses was significantly higher in non-outbreak districts and across all four indicators. In the "outbreak districts" the response activities started late and were of much lower intensity compared to "non-outbreak districts". Vector control teams at districts-level demonstrated diverse levels of compliance with local guidelines for 'initial', 'early' and 'late' responses to outbreak alarms, which could potentially explain the different outcomes observed following the outbreak alarms. CONCLUSION: Failing timely and adequate response of alarm signals generated by EWARS showed to negatively impact the disease outbreak control process. On the other hand, districts with adequate and timely response guided by alarm signals demonstrated successful records of outbreak prevention. This study presents important operational scenarios when failing or successding EWARS but warrants investigating the effectiveness and cost-effectiveness of EWARS using a more robust designs.

Identifying urban hotspots of dengue, chikungunya, and Zika transmission in Mexico to support risk stratification efforts: a spatial analysis.

BACKGROUND: Effective Aedes aegypti control is limited, in part, by the difficulty in achieving sufficient intervention coverage. To maximise the effect of vector control, areas with persistently high numbers of Aedes-borne disease cases could be identified and prioritised for preventive interventions. We aimed to identify persistent Aedes-borne disease hotspots in cities across southern Mexico. METHODS: In this spatial analysis, geocoded cases of dengue, chikungunya, and Zika from nine endemic Mexican cities were aggregated at the census-tract level. We included cities that were located in southern Mexico (the arbovirus endemic region of Mexico), with a high burden of dengue cases (ie, more than 5000 cases reported during a 10-year period), and listed as high priority for the Mexican dengue control and prevention programme. The Getis-Ord Gi*(d) statistic was applied to yearly slices of the dataset to identify spatial hotspots of each disease in each city. We used Kendall's W coefficient to quantify the agreement in the distribution of each virus. FINDINGS: 128 507 dengue, 4752 chikungunya and 25 755 Zika clinical cases were reported between Jan 1, 2008, and Dec 31, 2016. All cities showed evidence of transmission heterogeneity, with a mean of 17·6% (SD 4·7) of their total area identified as persistent disease hotspots. Hotspots accounted for 25·6% (SD 9·7; range 12·8-43·0) of the population and 32·1% (10·5; 19·6-50·5) of all Aedes-borne disease cases reported. We found an overlap between hotspots of 61·7% for dengue and Zika and 53·3% for dengue and chikungunya. Dengue hotspots in 2008-16 were significantly associated with dengue hotspots detected during 2017-20 in five of the nine cities. Heads of vector control confirmed hotspot areas as problem zones for arbovirus transmission. INTERPRETATION: This study provides evidence of the overlap of Aedes-borne diseases within geographical hotspots and a methodological framework for the stratification of arbovirus transmission risk within urban areas, which can guide the implementation of surveillance and vector control. FUNDING: USAID, the US Centers for Disease Control and Prevention, the Canadian Institutes of Health Research, International Development Research Centre, Fondo Mixto CONACyT (Mexico)-Gobierno del Estado de Yucatan, and the US National Institutes of Health. TRANSLATION: For the Spanish translation of the abstract see Supplementary Materials section.

Vector competence of Aedes aegypti and Culex quinquefasciatus from the metropolitan area of Guadalajara, Jalisco, Mexico for Zika virus.

Zika virus (ZIKV) is a mosquito-borne pathogen discovered in the late 40's in Uganda during a surveillance program for yellow fever. By 2014 the virus reached Eastern Island in the Americas, and two years later, the virus spread to almost all countries and territories of the Americas. The mosquito Aedes aegypti has been identified as the main vector of the disease, and several researchers have also studied the vector competence of Culex quinquefasciatus in virus transmission. The aim of the present study was to evaluate the vector competence of Ae. aegypti and Cx. quinquefasciatus in order to understand their roles in the transmission of ZIKV in Guadalajara, Jalisco, Mexico. In blood feeding laboratry experiments, we found that Ae. aegypti mosquitoes showed to be a competent vector able to transmit ZIKV in this area. On the other hand, we found that F0 Cx. quinquefasciatus mosquitoes are refractory to ZIKV infection, dissemination and transmission.

Urban and semi-urban mosquitoes of Mexico City: A risk for endemic mosquito-borne disease transmission.

Since past century, vector-borne diseases have been a major public health concern in several states of Mexico. However, Mexico City continues to be free of endemic mosquito-borne viral diseases. The city is the most important politic and economic state of Mexico and one of the most important city of Latin America. Its subtropical highland climate and high elevation (2240 masl) had historically made the occurrence of Aedes species unlikely. However, the presence of other potential disease vectors (Culex spp, Culiseta spp), and the current intermittent introductions of Aedes aegypti, have revealed that control programs must adopt routine vector surveillance in the city. In this study, we provide an updated species list from a five-years of vector surveillance performed in Mexico City. A total of 18,553 mosquito larvae were collected. Twenty-two species from genus Culex, Aedes, Culiseta, Anopheles, Lutzia and Uranotaenia were observed. Nine new mosquito records for the city were found. Ae. albopictus was recorded for the first time in Mexico City. Interestingly, a new record, Ae. epactius was the most frequent species reported. Cx. pipiens quinquefasciatus exhibited the highest number of individuals collected. We detected six areas which harbor the highest mosquito species records in the city. Cemeteries included 68.9% of our collection sites. Temporarily ponds showed the highest species diversity. We detected an increasing presence of Ae. aegypti, which was detected for three consecutive years (2015-2017), predominantly in the warmer microclimates of the city. We found a possible correlation between increasing temperature and Ae. aegypti and Ae. albopictus expanding range. This study provides a starting point for developing strategies related to environmental management for mosquito control. The promotion of mosquito control practices through community participation, mass media and education programmes in schools should be introduced in the city.

Author Correction: Zika Virus in Salivary Glands of Five Different Species of Wild-Caught Mosquitoes from Mexico.

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has not been fixed in the paper.

Early warning and response system (EWARS) for dengue outbreaks: Recent advancements towards widespread applications in critical settings.

BACKGROUND: Dengue outbreaks are increasing in frequency over space and time, affecting people's health and burdening resource-constrained health systems. The ability to detect early emerging outbreaks is key to mounting an effective response. The early warning and response system (EWARS) is a toolkit that provides countries with early-warning systems for efficient and cost-effective local responses. EWARS uses outbreak and alarm indicators to derive prediction models that can be used prospectively to predict a forthcoming dengue outbreak at district level. METHODS: We report on the development of the EWARS tool, based on users' recommendations into a convenient, user-friendly and reliable software aided by a user's workbook and its field testing in 30 health districts in Brazil, Malaysia and Mexico. FINDINGS: 34 Health officers from the 30 study districts who had used the original EWARS for 7 to 10 months responded to a questionnaire with mainly open-ended questions. Qualitative content analysis showed that participants were generally satisfied with the tool but preferred open-access vs. commercial software. EWARS users also stated that the geographical unit should be the district, while access to meteorological information should be improved. These recommendations were incorporated into the second-generation EWARS-R, using the free R software, combined with recent surveillance data and resulted in higher sensitivities and positive predictive values of alarm signals compared to the first-generation EWARS. Currently the use of satellite data for meteorological information is being tested and a dashboard is being developed to increase user-friendliness of the tool. The inclusion of other Aedes borne viral diseases is under discussion. CONCLUSION: EWARS is a pragmatic and useful tool for detecting imminent dengue outbreaks to trigger early response activities.

Spatio-temporal coherence of dengue, chikungunya and Zika outbreaks in Merida, Mexico.

Response to Zika virus (ZIKV) invasion in Brazil lagged a year from its estimated February 2014 introduction, and was triggered by the occurrence of severe congenital malformations. Dengue (DENV) and chikungunya (CHIKV) invasions tend to show similar response lags. We analyzed geo-coded symptomatic case reports from the city of Merida, Mexico, with the goal of assessing the utility of historical DENV data to infer CHIKV and ZIKV introduction and propagation. About 42% of the 40,028 DENV cases reported during 2008-2015 clustered in 27% of the city, and these clustering areas were where the first CHIKV and ZIKV cases were reported in 2015 and 2016, respectively. Furthermore, the three viruses had significant agreement in their spatio-temporal distribution (Kendall W>0.63; p<0.01). Longitudinal DENV data generated patterns indicative of the resulting introduction and transmission patterns of CHIKV and ZIKV, leading to important insights for the surveillance and targeted control to emerging Aedes-borne viruses.

Improved tools and strategies for the prevention and control of arboviral diseases: A research-to-policy forum.

BACKGROUND: Research has been conducted on interventions to control dengue transmission and respond to outbreaks. A summary of the available evidence will help inform disease control policy decisions and research directions, both for dengue and, more broadly, for all Aedes-borne arboviral diseases. METHOD: A research-to-policy forum was convened by TDR, the Special Programme for Research and Training in Tropical Diseases, with researchers and representatives from ministries of health, in order to review research findings and discuss their implications for policy and research. RESULTS: The participants reviewed findings of research supported by TDR and others. Surveillance and early outbreak warning. Systematic reviews and country studies identify the critical characteristics that an alert system should have to document trends reliably and trigger timely responses (i.e., early enough to prevent the epidemic spread of the virus) to dengue outbreaks. A range of variables that, according to the literature, either indicate risk of forthcoming dengue transmission or predict dengue outbreaks were tested and some of them could be successfully applied in an Early Warning and Response System (EWARS). Entomological surveillance and vector management. A summary of the published literature shows that controlling Aedes vectors requires complex interventions and points to the need for more rigorous, standardised study designs, with disease reduction as the primary outcome to be measured. House screening and targeted vector interventions are promising vector management approaches. Sampling vector populations, both for surveillance purposes and evaluation of control activities, is usually conducted in an unsystematic way, limiting the potentials of entomological surveillance for outbreak prediction. Combining outbreak alert and improved approaches of vector management will help to overcome the present uncertainties about major risk groups or areas where outbreak response should be initiated and where resources for vector management should be allocated during the interepidemic period. CONCLUSIONS: The Forum concluded that the evidence collected can inform policy decisions, but also that important research gaps have yet to be filled.

Zika Virus in Salivary Glands of Five Different Species of Wild-Caught Mosquitoes from Mexico.

Zika virus (ZIKV) is a mosquito-borne pathogen, and Aedes aegypti has been identified as the main vector of the disease. Other mosquito species in the Aedes and Culex genera have been suggested to have the potential for being competent vectors based on experimental exposition of mosquitoes to an infectious blood meal containing ZIKV. Here, we report the isolation in cell culture of ZIKV obtained from different body parts of wild-caught female mosquitoes (Ae. aegypti, Ae. vexans, Cx. quinquefasciatus, Cx. coronator, and Cx. tarsalis) and whole male mosquitoes (Ae. aegypti and Cx. quinquefasciatus) in Mexico. Importantly, this is the first report that shows the presence of the virus in the salivary glands of the wild-caught female mosquitoes species, Cx. coronator, Cx. tarsalis, and Ae. vexans. Our findings strongly suggest that all the species reported herein are potential vectors for ZIKV.

Detection of Zika virus in Aedes mosquitoes from Mexico.

Background: We report on the results of an entomovirological surveillance system of Aedes populations performed by the Ministry of Health of the central state of San Luis Potosí, Mexico. Methods: Indoor adult Aedes aegypti and Aedes albopictus pools collected at San Martín, Tamazunchale, Ciudad Valles, Metlapa, Ebano, Tamuin and Axtla during the dry season of 2016 were examined for the presence of dengue (DENV), chikungunya (CHIKV) and Zika (ZIKV) viruses using real-time PCR. Results: Both Ae. aegypti and Ae. albopictus were found to be infected with ZIKV in the absence of confirmed symptomatic human cases. Conclusions: The entomovirological surveillance system analysed here identified both Ae. aegypti and Ae. albopictus infected with ZIKV which triggered an immediate aggressive vector control campaign.

Taking innovative vector control interventions in urban Latin America to scale: lessons learnt from multi-country implementation research.

Prior to the current public health emergency following the emergence of chikungunya and Zika Virus Disease in the Americas during 2014 and 2015, multi-country research investigated between 2011 and 2013 the efficacy of novel Aedes aegypti intervention packages through cluster randomised controlled trials in four Latin-American cities: Fortaleza (Brazil); Girardot (Colombia), Acapulco (Mexico) and Salto (Uruguay). Results from the trials led to a scaling up effort of the interventions at city levels. Scaling up refers to deliberate efforts to increase the impact of successfully tested health interventions to benefit more people and foster policy and program development in a sustainable way. The different scenarios represent examples for  a 'vertical approach' and a 'horizontal approach'. This paper presents the analysis of a preliminary process evaluation of the scaling up efforts in the mentioned cites, with a focus on challenges and enabling factors encountered by the research teams, analysing the main social, political, administrative, financial and acceptance factors.

Repellency of 29 Synthetic and Natural Commercial Topical Insect Repellents Against Aedes aegypti (Diptera: Culicidae) in Central Mexico.

In Mexico, the use of repellents to prevent insects from landing and biting is a common practice. However, variation in the efficiency of natural and synthetic repellents has been observed. In this study, we evaluated the repellency and protection time of 16 synthetic and 13 natural-based commercial products against Aedes aegypti (L.) from an endemic dengue area (Jojutla, Morelos) in Central Mexico. The "arm exposure" cage test was used to assess the efficacy of the repellents. Tests were conducted by three adult volunteers. Results showed that DEET (N, N-Diethyl-3-methylbenzamide) repellents provided the highest protection and duration times against Ae. aegypti. However, low repellency and short-time protection was observed (when compared with the manufacturers' protection times). Natural-based products did not repel (either landing or biting) mosquitoes for >30 min. These results show that most of the repellent products did not provide satisfactory levels of personal protection against mosquito bites. Frequent reapplication of repellents (synthetic and natural-based) may compensate for their short duration of action. Repellent efficacy data must be integrated into the decision-making process for an optimal response to the local (or specific region) situation.

Dengue Contingency Planning: From Research to Policy and Practice.

BACKGROUND: Dengue is an increasingly incident disease across many parts of the world. In response, an evidence-based handbook to translate research into policy and practice was developed. This handbook facilitates contingency planning as well as the development and use of early warning and response systems for dengue fever epidemics, by identifying decision-making processes that contribute to the success or failure of dengue surveillance, as well as triggers that initiate effective responses to incipient outbreaks. METHODOLOGY/PRINCIPAL FINDINGS: Available evidence was evaluated using a step-wise process that included systematic literature reviews, policymaker and stakeholder interviews, a study to assess dengue contingency planning and outbreak management in 10 countries, and a retrospective logistic regression analysis to identify alarm signals for an outbreak warning system using datasets from five dengue endemic countries. Best practices for managing a dengue outbreak are provided for key elements of a dengue contingency plan including timely contingency planning, the importance of a detailed, context-specific dengue contingency plan that clearly distinguishes between routine and outbreak interventions, surveillance systems for outbreak preparedness, outbreak definitions, alert algorithms, managerial capacity, vector control capacity, and clinical management of large caseloads. Additionally, a computer-assisted early warning system, which enables countries to identify and respond to context-specific variables that predict forthcoming dengue outbreaks, has been developed. CONCLUSIONS/SIGNIFICANCE: Most countries do not have comprehensive, detailed contingency plans for dengue outbreaks. Countries tend to rely on intensified vector control as their outbreak response, with minimal focus on integrated management of clinical care, epidemiological, laboratory and vector surveillance, and risk communication. The Technical Handbook for Surveillance, Dengue Outbreak Prediction/ Detection and Outbreak Response seeks to provide countries with evidence-based best practices to justify the declaration of an outbreak and the mobilization of the resources required to implement an effective dengue contingency plan.

Alarm Variables for Dengue Outbreaks: A Multi-Centre Study in Asia and Latin America.

BACKGROUND: Worldwide, dengue is an unrelenting economic and health burden. Dengue outbreaks have become increasingly common, which place great strain on health infrastructure and services. Early warning models could allow health systems and vector control programmes to respond more cost-effectively and efficiently. METHODOLOGY/PRINCIPAL FINDINGS: The Shewhart method and Endemic Channel were used to identify alarm variables that may predict dengue outbreaks. Five country datasets were compiled by epidemiological week over the years 2007-2013. These data were split between the years 2007-2011 (historic period) and 2012-2013 (evaluation period). Associations between alarm/ outbreak variables were analysed using logistic regression during the historic period while alarm and outbreak signals were captured during the evaluation period. These signals were combined to form alarm/ outbreak periods, where 2 signals were equal to 1 period. Alarm periods were quantified and used to predict subsequent outbreak periods. Across Mexico and Dominican Republic, an increase in probable cases predicted outbreaks of hospitalised cases with sensitivities and positive predictive values (PPV) of 93%/ 83% and 97%/ 86% respectively, at a lag of 1-12 weeks. An increase in mean temperature ably predicted outbreaks of hospitalised cases in Mexico and Brazil, with sensitivities and PPVs of 79%/ 73% and 81%/ 46% respectively, also at a lag of 1-12 weeks. Mean age was predictive of hospitalised cases at sensitivities and PPVs of 72%/ 74% and 96%/ 45% in Mexico and Malaysia respectively, at a lag of 4-16 weeks. CONCLUSIONS/SIGNIFICANCE: An increase in probable cases was predictive of outbreaks, while meteorological variables, particularly mean temperature, demonstrated predictive potential in some countries, but not all. While it is difficult to define uniform variables applicable in every country context, the use of probable cases and meteorological variables in tailored early warning systems could be used to highlight the occurrence of dengue outbreaks or indicate increased risk of dengue transmission.

Study of cutaneous leishmaniasis in the State of Campeche (Yucatan Peninsula), Mexico, over a period of two years / Estudio de la leishmaniasis cutánea en el estado de Campeche (Península de Yucatán), México, por un periodo de dos años

Objective. To study cutaneous leishmaniasis (CL), in the Calakmul municipality of the Campeche State, during two years. Materials and methods. Individuals with skin lesions were evaluated. Aspirates taken from the lesions were cultured, PCR was performed to diagnose the Leishmania species. Results. The culture detected 42% of the samples. PCR diagnosed CL in 76% of the samples; of those 38% were from children and 62% from adults. 89% of the patients were infected with L. mexicana; 14.4% with Mexican strains of L. mexicana; 7% with L. braziliensis; 3.6% with L. mexicana and L. braziliensis. The most affected villages with CL were Dos Lagunas Sur with 12.3%, La Mancolona with 6.5% and La Guadalupe with 2.2% of prevalence, respectively. After the treatment with Glucantime, 96% of the patients were healed. Conclusion. CL is an important public health concern in Calakmul, and the parasite causing it belongs to Leishmania mexicana and Leishmania braziliensis complexes.

Objetivo. Estudiar la leishmaniasis cutánea en Calakmul, Campeche, México, durante dos años. Material y métodos. Se estudiaron individuos con lesiones cutáneas, se tomaron aspirados y se inocularon medios de cultivo; se realizó la técnica de PCR para identificar la especie de Leishmania. Resultados. Los cultivos detectaron 42% de las muestras. Con la PCR se amplificaron 76% de las muestras, 38% fueron tomadas de niños y 62% de adultos. En 89% de las muestras positivas se identificó Leishmania mexicana, en 14.4% cepas mexicanas de L. mexicana, en 7% L. braziliensis y en 3.6% L. mexicana y L. braziliensis. En Dos Lagunas Sur se encontró una prevalencia de 12.3%, en La Mancolona 6.5% y en La Virgen 2.2%. Del total de los pacientes, 96% se curó con Glucantime. Conclusion. La leishmaniasis cutánea es un problema de salud pública en Calakmul y las especies causantes pertenecen a los complejos Leishmania mexicana y Leishmania braziliensis.

Study of cutaneous leishmaniasis in the State of Campeche (Yucatan Peninsula), Mexico, over a period of two years.

OBJECTIVE: To study cutaneous leishmaniasis (CL), in the Calakmul municipality of the Campeche State, during two years. MATERIALS AND METHODS: Individuals with skin lesions were evaluated. Aspirates taken from the lesions were cultured, PCR was performed to diagnose the Leishmania species. RESULTS: The culture detected 42% of the samples. PCR diagnosed CL in 76% of the samples; of those 38% were from children and 62% from adults. 89% of the patients were infected with L. mexicana; 14.4% with Mexican strains of L. mexicana; 7% with L. braziliensis; 3.6% with L. mexicana and L. braziliensis. The most affected villages with CL were Dos Lagunas Sur with 12.3%, La Mancolona with 6.5% and La Guadalupe with 2.2% of prevalence, respectively. After the treatment with Glucantime, 96% of the patients were healed. CONCLUSION: CL is an important public health concern in Calakmul, and the parasite causing it belongs to Leishmania mexicana and Leishmania braziliensis complexes.