Manejo de neoplasias oncohematológicas en el contexto de la pandemia de COVID-19: recomendación de expertos / Management of oncohematological neoplasms in the COVID-19 pandemic: experts recommendation

RESUMEN La pandemia por COVID-19 originado por el Coronavirus 2 causante de síndrome respiratorio agudo severo (SARS-CoV-2) es causante de una crisis de salud pública a nivel global. Muchos reportes indican resultados desalentadores en pacientes con cáncer respecto a la población general. Por ello, los expertos en el manejo de neoplasias oncohematológicas del Instituto Nacional de Enfermedades Neoplásicas, hospitales nacionales y una clínica privada de Lima Metropolitana han desarrollado recomendaciones obtenidas por consenso para continuar con el manejo de pacientes con neoplasias oncohematológicas en forma segura ante la coyuntura de pandemia.

ABSTRACT The ongoing COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a global public health crisis. Many reports indicate disappointing results in cancer patients compared to the general population. Therefore, experts in the management of oncohematological malignancies from the National Institute of Neoplastic Diseases, national hospitals and a private clinic in Metropolitan Lima have developed recommendations obtained by consensus to continue with the management of patients with oncohematological neoplasms safely in the face of the pandemic.

Diagnóstico y tratamiento del cáncer de mama HER2+: Guía de Práctica Clínica de la Sociedad Peruana de Cancerología / Diagnosis and treatment of HER2 + breast cancer: Clinical Practice Guide of the Peruvian Society of Cancerology

RESUMEN Introducción. En Perú, el cáncer de mama representa el tipo de cáncer más frecuente en mujeres y el sexto tipo de cáncer más letal en la población general. La sobreexpresión del receptor del factor de crecimiento epidérmico (HER2+) ocurre en 20% a 30% de los cánceres de mama, y se asocia con tumores más agresivos, con mayor recurrencia y mayor mortalidad. Objetivo. Elaborar un conjunto de recomendaciones basadas en evidencias para el diagnóstico y tratamiento del cáncer de mama HER2+, con la finalidad de contribuir a reducir la mortalidad, progresión de la enfermedad y mejorar la calidad de vida. Métodos. Se conformó un panel de especialistas clínicos y metodólogos, quienes identificaron preguntas clínicas relevantes sobre el diagnóstico y tratamiento del cáncer de mama HER2+. Se desarrolló una búsqueda sistemática de GPC en Medline (PubMed), y en organismos elaboradores y recopiladores. Para la formulación de recomendaciones, el panel de especialistas discutió la evidencia y elementos del contexto de implementación de la recomendación, siguiendo la metodología propuesta por el Ministerio de Salud del Perú. Resultados. Se priorizó nueve preguntas clínicas. Se formuló un total de 25 recomendaciones clínicas. Conclusiones. Se elaboró una GPC basada en evidencias, a través de un proceso sistemático, riguroso y transparente desarrollado por un equipo multidisciplinario.

ABSTRACT Introduction. In Peru, breast cancer represents the most common type of cancer in women and the sixth most lethal type of cancer in the general population. Overexpression of the epidermal growth factor receptor (HER2 +) occurs in 20% to 30% of breast cancers, and is associated with more aggressive tumors, with greater recurrence and greater mortality. Objective. Prepare a set of evidence-based recommendations for the diagnosis and treatment of HER2 + breast cancer, in order to help reduce mortality, disease progression and improve quality of life. Methods. A panel of clinical specialists and methodologists was formed, who identified relevant clinical questions about the diagnosis and treatment of HER2 + breast cancer. A systematic search for CPGs was carried out in Medline (PubMed), and in developing and compiling agencies. For the formulation of recommendations, the panel of specialists discussed the evidence and elements of the context of implementation of the recommendation, following the methodology proposed by the Ministry of Health of Peru. Results. Nine clinical questions were prioritized. A total of 25 clinical recommendations were made. Conclusions. An evidence-based CPG was developed through a systematic, rigorous and transparent process developed by a multidisciplinary team.

Utilidad de los diálogos deliberativos para la formulación de recomendaciones de guías de práctica clínica / Use of Deliberative Dialogues for the Formulation of Recommendations for Clinical Practice Guidelines

RESUMEN En el presente artículo se reporta la experiencia obtenida por el Instituto Nacional de Salud de Perú, en la utilidad del desarrollo de diálogos deliberativos para la formulación de recomendaciones, como uno de los componentes del proceso de adaptación de Guías de Práctica Clínica basadas en evidencia, utilizando el sistema GRADE (por sus siglas en ingles: Grading of Recommendations, Assessment, Development and Evaluations). Describe los temas de salud pública que fueron deliberados y la participación de los actores implicados con un enfoque multidisciplinario. Presenta los aspectos que fueron tomados en cuenta de forma previa y durante los diálogos. Finalmente, propone los desafíos que serán abordados en las siguientes experiencias a fin de optimizar estos procesos y colaborar en la interacción entre las evidencias científicas y el valor agregado que otorgan los actores implicados a través de su experiencias, perspectivas y conocimientos para el desarrollo de recomendaciones en salud.

ABSTRACT This study reports the experience obtained by the National Institute of Health of Peru in the use of deliberative dialogues for the formulation of recommendations as one of the stages of the process of adaptation of evidence-based clinical practice guidelines using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system. Using a multidisciplinary approach, this study describes: 1. the public health problems addressed in the dialogues; 2. the role of the involved parties; 3. the parameters that were considered before and during the discussions; 4. the challenges for optimizing these dialogues and stimulating the interaction between scientific evidence and the added value provided by the involved parties through their experiences, perspectives, and knowledge for the development of recommendations in health.

Intervenciones para prevenir la aparición de sobrepeso y obesidad en niños menores de cinco años / Interventions to prevent the development of overweight and obesity in children younger than five years

RESUMEN La obesidad infantil representa uno de los mayores problemas de salud pública a nivel mundial. En el presente artículo se exponen las intervenciones para prevenir el sobrepeso y obesidad en niños menores de cinco años. Las intervenciones dirigidas a prevenir la obesidad en infantes fueron: promoción de la lactancia materna, vigilancia del crecimiento del niño y promoción de una adecuada alimentación complementaria, a través de la consejería nutricional con enfoque de alimentación responsiva, brindadas en distintos escenarios como el centro de salud o basados en el hogar a través de visitas domiciliarias. Las intervenciones dirigidas a prevenir obesidad en los preescolares incluyen las intervenciones con componentes de actividad física y nutrición que involucren activamente a los padres. La calidad de la evidencia de la mayoría de estudios es alta debido a que proviene de ensayos clínicos controlados, revisiones sistemáticas y metaanálisis. Todas estas intervenciones se realizan o podrían ser replicadas en nuestro país, mediante una adecuada contextualización.

ABSTRACT Childhood obesity is one of the most severe public health problems worldwide. The present study describes the interventions used to prevent overweight and obesity in children younger than 5 years. The objective of the interventions was to stimulate breastfeeding, monitor the child's growth, and promote adequate complementary feeding by means of nutritional counseling using a responsive feeding approach in different settings, including health centers and residences. The interventions included physical activity and nutritional counseling, with the active participation of the parents. The quality of evidence from most studies was high because the evidence was derived from controlled clinical trials, systematic reviews, and meta-analyses. All interventions were conducted or could be replicated in Peru by adequate contextualization.

[Use of Deliberative Dialogues for the Formulation of Recommendations for Clinical Practice Guidelines]. / Utilidad de los diálogos deliberativos para la formulación de recomendaciones de guías de práctica clínica.

This study reports the experience obtained by the National Institute of Health of Peru in the use of deliberative dialogues for the formulation of recommendations as one of the stages of the process of adaptation of evidence-based clinical practice guidelines using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system. Using a multidisciplinary approach, this study describes: 1. the public health problems addressed in the dialogues; 2. the role of the involved parties; 3. the parameters that were considered before and during the discussions; 4. the challenges for optimizing these dialogues and stimulating the interaction between scientific evidence and the added value provided by the involved parties through their experiences, perspectives, and knowledge for the development of recommendations in health.

En el presente artículo se reporta la experiencia obtenida por el Instituto Nacional de Salud de Perú, en la utilidad del desarrollo de diálogos deliberativos para la formulación de recomendaciones, como uno de los componentes del proceso de adaptación de Guías de Práctica Clínica basadas en evidencia, utilizando el sistema GRADE (por sus siglas en ingles: Grading of Recommendations, Assessment, Development and Evaluations). Describe los temas de salud pública que fueron deliberados y la participación de los actores implicados con un enfoque multidisciplinario. Presenta los aspectos que fueron tomados en cuenta de forma previa y durante los diálogos. Finalmente, propone los desafíos que serán abordados en las siguientes experiencias a fin de optimizar estos procesos y colaborar en la interacción entre las evidencias científicas y el valor agregado que otorgan los actores implicados a través de su experiencias, perspectivas y conocimientos para el desarrollo de recomendaciones en salud.

[Interventions to prevent the development of overweight and obesity in children younger than five years]. / Intervenciones para prevenir la aparición de sobrepeso y obesidad en niños menores de cinco años.

Childhood obesity is one of the most severe public health problems worldwide. The present study describes the interventions used to prevent overweight and obesity in children younger than 5 years. The objective of the interventions was to stimulate breastfeeding, monitor the child's growth, and promote adequate complementary feeding by means of nutritional counseling using a responsive feeding approach in different settings, including health centers and residences. The interventions included physical activity and nutritional counseling, with the active participation of the parents. The quality of evidence from most studies was high because the evidence was derived from controlled clinical trials, systematic reviews, and meta-analyses. All interventions were conducted or could be replicated in Peru by adequate contextualization.

La obesidad infantil representa uno de los mayores problemas de salud pública a nivel mundial. En el presente artículo se exponen las intervenciones para prevenir el sobrepeso y obesidad en niños menores de cinco años. Las intervenciones dirigidas a prevenir la obesidad en infantes fueron: promoción de la lactancia materna, vigilancia del crecimiento del niño y promoción de una adecuada alimentación complementaria, a través de la consejería nutricional con enfoque de alimentación responsiva, brindadas en distintos escenarios como el centro de salud o basados en el hogar a través de visitas domiciliarias. Las intervenciones dirigidas a prevenir obesidad en los preescolares incluyen las intervenciones con componentes de actividad física y nutrición que involucren activamente a los padres. La calidad de la evidencia de la mayoría de estudios es alta debido a que proviene de ensayos clínicos controlados, revisiones sistemáticas y metaanálisis. Todas estas intervenciones se realizan o podrían ser replicadas en nuestro país, mediante una adecuada contextualización.

[Contribution of Peru in initiatives to promote global health security]. / Contribución del Perú en las iniciativas para promover la seguridad sanitaria mundial.

This article describes the concept of global health security and its development over time. It emphasizes the need to control challenges against global health such as those produced by biologic agents both natural and intentional. It presents world initiatives that have developed during the last two decades and the contribution of Peru to the Global Health Security Agenda (GHSA) and the Monitoring and Evaluation Framework. In order to accelerate the implementation of the International Health Regulations Peru has played an important role to accelerate the implementation of International Health Regulations (IHR), participating with a group of countries, World Health Organization (WHO), and GHSA in the creation of the Joint External Evaluation Tool (JEE).

[Use of evidence in heath policies and programs contributions of the instituto nacional de salud]. / Uso de la evidencia en políticas y programas de salud aportes del instituto nacional de salud.

This article analyzes some examples about how the Ministry of Health of Peru has used evidence for policy and program formulation, implementation and evaluation. It describes the process by which health budget programs are based and strengthened with scientific evidence. Provides an overview about how the development of clinical guidelines methodology is facilitating the generation of high quality evidence based clinical guidelines.It presents some examples of specific information needs of the Ministry of Health to which the Instituto Nacional de Salud has responded, and the impact of that collaboration. Finally, the article proposes future directions for the use of research methodology especially relevant for the development and evaluation of policy and programs, as well as the development of networks of health technology assessment at the national and international level.

[El niño phenomenon and natural disasters: public health interventions for disaster preparedness and response]. / Fenómeno el niño y desastres naturales: intervenciones en salud pública para la preparación y respuesta.

This article reviews public health interventions for preparedness and response to natural disasters within the context of El Niño phenomenon using systematic reviews and a review of revisions with emphasis on vector-borne diseases, water-borne diseases, malnutrition, heat stress, drought, flood-associated diseases, mental health problems, vulnerability of the physical health-system infrastructure, as well as long-term policies aimed at protecting the populations of these cases. Environmental interventions were identified, including vector control, chemoprophylaxis, immunization, and intradomiciliary water treatment. While these finds are based primarily on systematic reviews, it is necessary to evaluate the benefit of these interventions within the population, according to the context of each region.

Uso de la evidencia en políticas y programas de salud aportes del instituto nacional de salud / Use of evidence in heath policies and programs contributions of the instituto nacional de salud

RESUMEN En el presente artículo se analizan algunos ejemplos del uso de evidencia generada por el Instituto Nacional de Salud (INS) que el Ministerio de Salud del Perú ha realizado en los últimos años en la formulación, implementación y evaluación de las políticas y programas. Presenta el proceso por el cual los programas presupuestales se sustentan y fortalecen a partir de la evidencia. Describe el progreso en el desarrollo de una metodología para generar guías de calidad a partir de la mejor evidencia disponible para orientar la práctica clínica. Presenta algunos ejemplos de requerimientos de evidencia del Ministerio de Salud al Instituto Nacional de Salud y su impacto en política. Por último, propone direcciones futuras respecto a metodologías de investigación especialmente relevantes para el desarrollo y evaluación de políticas y el fortalecimiento de redes de evaluación de tecnologías en el ámbito nacional e internacional.

ABSTRACT This article analyzes some examples about how the Ministry of Health of Peru has used evidence for policy and program formulation, implementation and evaluation. It describes the process by which health budget programs are based and strengthened with scientific evidence. Provides an overview about how the development of clinical guidelines methodology is facilitating the generation of high quality evidence based clinical guidelines.It presents some examples of specific information needs of the Ministry of Health to which the Instituto Nacional de Salud has responded, and the impact of that collaboration. Finally, the article proposes future directions for the use of research methodology especially relevant for the development and evaluation of policy and programs, as well as the development of networks of health technology assessment at the national and international level.

Contribución del Perú en las iniciativas para promover la seguridad sanitaria mundial / Contribution of Peru in initiatives to promote global health security

RESUMEN El artículo describe el concepto de la seguridad sanitaria mundial, su evolución en el tiempo y discute la importancia de enfrentar los problemas que amenazan la salud global producidas por agentes biológicos de manera natural, accidental o intencional. Asimismo, presenta las iniciativas surgidas en las últimas dos décadas en el mundo, y el rol del Perú en el desarrollo de la Agenda para La Seguridad Sanitaria Mundial o Global Health Security Agenda (GHSA) y la Alianza para las Evaluaciones Externas. Al respecto, el Perú ha cumplido un papel importante participando con un grupo de países, la Organización Mundial de la Salud (OMS) y la GHSA en el proceso de desarrollo de un instrumento de evaluación externa conjunta denominado Joint External Evaluation Tool (JEE) con el objetivo último de acelerar la implementación del Reglamento Sanitario Internacional (RSI).

ABSTRACT This article describes the concept of global health security and its development over time. It emphasizes the need to control challenges against global health such as those produced by biologic agents both natural and intentional. It presents world initiatives that have developed during the last two decades and the contribution of Peru to the Global Health Security Agenda (GHSA) and the Monitoring and Evaluation Framework. In order to accelerate the implementation of the International Health Regulations Peru has played an important role to accelerate the implementation of International Health Regulations (IHR), participating with a group of countries, World Health Organization (WHO), and GHSA in the creation of the Joint External Evaluation Tool (JEE).

Fenómeno el niño y desastres naturales: intervenciones en salud pública para la preparación y respuesta / El niño phenomenon and natural disasters: public health interventions for disaster preparedness and response

RESUMEN El presente artículo realiza una revisión de las intervenciones en salud pública para la preparación y respuesta ante desastres naturales en el contexto del fenómeno El Niño (FEN) a partir de revisiones sistemáticas y una revisión de revisiones con énfasis en las enfermedades transmitidas por vectores, transmitidas por el agua, malnutrición, estrés térmico, sequías, enfermedades asociadas a inundaciones, problemas de salud mental, vulnerabilidad de la infraestructura física de los servicios de salud, así como de las políticas a largo plazo orientadas a proteger a la población en estos casos. Se identificaron intervenciones ambientales, como el control de vectores, quimioprofilaxis, vacunación y tratamiento intradomiciliario de agua. Si bien estos hallazgos se basan principalmente en revisiones sistemáticas, es necesario evaluar el beneficio de estas intervenciones en la población, de acuerdo con la realidad de cada región.

ABSTRACT This article reviews public health interventions for preparedness and response to natural disasters within the context of El Niño phenomenon using systematic reviews and a review of revisions with emphasis on vector-borne diseases, water-borne diseases, malnutrition, heat stress, drought, flood-associated diseases, mental health problems, vulnerability of the physical health-system infrastructure, as well as long-term policies aimed at protecting the populations of these cases. Environmental interventions were identified, including vector control, chemoprophylaxis, immunization, and intradomiciliary water treatment. While these finds are based primarily on systematic reviews, it is necessary to evaluate the benefit of these interventions within the population, according to the context of each region.

[Rice fortification to correct micronutrient deficiency in children 6-59 months old]. / Fortificación del arroz para corregir la deficiencia de micronutrientes en niños de 6 a 59 meses de edad.

OBJECTIVE: To carry out a systematic review of the literature on the effectiveness of fortified rice consumption in terms of increasing levels of iron and other micro-nutrients in children aged 6-59 months, with a view to evaluating its usefulness as a public health intervention. METHODS: A search was conducted in MEDLINE, Embase, Cochrane Library, and LILACS databases. The review included randomized clinical trials (RCTs) that assessed the consumption of fortified rice, compared with a placebo or other forms of intervention, in terms of enhanced levels of iron and other micronutrients. The CONSORT® checklist was used to assess methodological quality. The risk of bias in the studies was assessed using the Cochrane® Collaboration methodology. RESULTS: Seven RCTs were included in the review. All the studies showed significant improvements in indicators of nutritional iron status in the intervention groups, without reporting adverse effects. There was no evidence of improvement in vitamin A levels or in anthropometric indicators of weight and height as a secondary result of the intervention. The included studies showed moderate methodological quality. CONCLUSIONS: Rice fortification was an effective intervention strategy to correct iron deficiency in children under age 5. For implementation as a public health measure, local studies are needed to assess its effectiveness in long-term and large-scale interventions.

Fortificación del arroz para corregir la deficiencia de micronutrientes en niños de 6 a 59 meses de edad / Rice fortification to correct micronutrient deficiency in children 6-59 months old

Objetivo. Realizar una revisión sistemática de la literatura sobre la eficacia del consumo de arroz fortificado en el incremento de los niveles de hierro y otros micronutrientes en niños de 6 a 59 meses de edad, con la finalidad de evaluar su utilidad como intervención de salud pública. Métodos. La búsqueda se realizó en las bases de datos Medline, Embase, The Cochrane Library y LILACS. Se incluyeron ensayos clínicos aleatorizados (ECA) que evaluaron el consumo de arroz fortificado comparado con placebo u otras formas de intervención sobre la mejora de los niveles de hierro y otros micronutrientes. Para evaluar la calidad metodológica, se utilizó la lista de verificación CONSORT®. El riesgo de sesgo de los estudios se evaluó según la metodología de la Colaboración Cochrane®. Resultados. Se incluyeron siete ECA en la revisión. Todos los estudios mostraron mejoras significativas en indicadores del estado nutricional de hierro en los grupos intervenidos, sin reportar efectos adversos. No se evidenció mejoría en los niveles de vitamina A, ni en los indicadores antropométricos de peso y talla como resultado secundario de la intervención. Los estudios incluidos mostraron calidad metodológica moderada. Conclusiones. La fortificación del arroz representó una estrategia de intervención eficaz para corregir la deficiencia de hierro en la población infantil menor de cinco años. Su implementación como medida de salud pública requiere estudios locales que evalúen su efectividad en intervenciones a largo plazo y en mayor escala.

Objective. To carry out a systematic review of the literature on the effectiveness of fortified rice consumption in terms of increasing levels of iron and other micro­nutrients in children aged 6-59 months, with a view to evaluating its usefulness as a public health intervention. Methods. A search was conducted in MEDLINE, Embase, Cochrane Library, and LILACS databases. The review included randomized clinical trials (RCTs) that assessed the consumption of fortified rice, compared with a placebo or other forms of intervention, in terms of enhanced levels of iron and other micronutrients. The CONSORT® checklist was used to assess methodological quality. The risk of bias in the studies was assessed using the Cochrane® Collaboration methodology. Results. Seven RCTs were included in the review. All the studies showed significant improvements in indicators of nutritional iron status in the intervention groups, without reporting adverse effects. There was no evidence of improvement in vitamin A levels or in anthropometric indicators of weight and height as a secondary result of the intervention. The included studies showed moderate methodological quality. Conclusions. Rice fortification was an effective intervention strategy to correct iron deficiency in children under age 5. For implementation as a public health measure, local studies are needed to assess its effectiveness in long-term and large-scale interventions.

International study to evaluate PCR methods for detection of Trypanosoma cruzi DNA in blood samples from Chagas disease patients.

BACKGROUND: A century after its discovery, Chagas disease still represents a major neglected tropical threat. Accurate diagnostics tools as well as surrogate markers of parasitological response to treatment are research priorities in the field. The purpose of this study was to evaluate the performance of PCR methods in detection of Trypanosoma cruzi DNA by an external quality evaluation. METHODOLOGY/FINDINGS: An international collaborative study was launched by expert PCR laboratories from 16 countries. Currently used strategies were challenged against serial dilutions of purified DNA from stocks representing T. cruzi discrete typing units (DTU) I, IV and VI (set A), human blood spiked with parasite cells (set B) and Guanidine Hidrochloride-EDTA blood samples from 32 seropositive and 10 seronegative patients from Southern Cone countries (set C). Forty eight PCR tests were reported for set A and 44 for sets B and C; 28 targeted minicircle DNA (kDNA), 13 satellite DNA (Sat-DNA) and the remainder low copy number sequences. In set A, commercial master mixes and Sat-DNA Real Time PCR showed better specificity, but kDNA-PCR was more sensitive to detect DTU I DNA. In set B, commercial DNA extraction kits presented better specificity than solvent extraction protocols. Sat-DNA PCR tests had higher specificity, with sensitivities of 0.05-0.5 parasites/mL whereas specific kDNA tests detected 5.10(-3) par/mL. Sixteen specific and coherent methods had a Good Performance in both sets A and B (10 fg/µl of DNA from all stocks, 5 par/mL spiked blood). The median values of sensitivities, specificities and accuracies obtained in testing the Set C samples with the 16 tests determined to be good performing by analyzing Sets A and B samples varied considerably. Out of them, four methods depicted the best performing parameters in all three sets of samples, detecting at least 10 fg/µl for each DNA stock, 0.5 par/mL and a sensitivity between 83.3-94.4%, specificity of 85-95%, accuracy of 86.8-89.5% and kappa index of 0.7-0.8 compared to consensus PCR reports of the 16 good performing tests and 63-69%, 100%, 71.4-76.2% and 0.4-0.5, respectively compared to serodiagnosis. Method LbD2 used solvent extraction followed by Sybr-Green based Real time PCR targeted to Sat-DNA; method LbD3 used solvent DNA extraction followed by conventional PCR targeted to Sat-DNA. The third method (LbF1) used glass fiber column based DNA extraction followed by TaqMan Real Time PCR targeted to Sat-DNA (cruzi 1/cruzi 2 and cruzi 3 TaqMan probe) and the fourth method (LbQ) used solvent DNA extraction followed by conventional hot-start PCR targeted to kDNA (primer pairs 121/122). These four methods were further evaluated at the coordinating laboratory in a subset of human blood samples, confirming the performance obtained by the participating laboratories. CONCLUSION/SIGNIFICANCE: This study represents a first crucial step towards international validation of PCR procedures for detection of T. cruzi in human blood samples.

Plasmodium falciparum genetic diversity maintained and amplified over 5 years of a low transmission endemic in the Peruvian Amazon.

Plasmodium falciparum entered into the Peruvian Amazon in 1994, sparking an epidemic between 1995 and 1998. Since 2000, there has been sustained low P. falciparum transmission. The Malaria Immunology and Genetics in the Amazon project has longitudinally followed members of the community of Zungarococha (N = 1,945, 4 villages) with active household and health center-based visits each year since 2003. We examined parasite population structure and traced the parasite genetic diversity temporally and spatially. We genotyped infections over 5 years (2003-2007) using 14 microsatellite (MS) markers scattered across ten different chromosomes. Despite low transmission, there was considerable genetic diversity, which we compared with other geographic regions. We detected 182 different haplotypes from 302 parasites in 217 infections. Structure v2.2 identified five clusters (subpopulations) of phylogenetically related clones. To consider genetic diversity on a more detailed level, we defined haplotype families (hapfams) by grouping haplotypes with three or less loci differences. We identified 34 different hapfams identified. The F(st) statistic and heterozygosity analysis showed the five clusters were maintained in each village throughout this time. A minimum spanning network (MSN), stratified by the year of detection, showed that haplotypes within hapfams had allele differences and haplotypes within a cluster definition were more separated in the later years (2006-2007). We modeled hapfam detection and loss, accounting for sample size and stochastic fluctuations in frequencies overtime. Principle component analysis of genetic variation revealed patterns of genetic structure with time rather than village. The population structure, genetic diversity, appearance/disappearance of the different haplotypes from 2003 to 2007 provides a genome-wide "real-time" perspective of P. falciparum parasites in a low transmission region.