Monkeypox virus infections in low-risk groups during the 2022-23 global outbreak: An analysis of the WHO global report.

Introduction: In the 2022-23 Mpox outbreak, cases also occurred in children, adolescents, and adults aged 50 years and older, for whom the risk of transmission is low and whose epidemiological characteristics are less known, compared to high-risk groups such as young adults. Here we describe the epidemiological characteristics of Mpox in children, adolescents and adults aged 50 years and older in the global Mpox outbreak. Methods: A retrospective study on laboratory-confirmed surveillance data of Mpox cases reported to World Health Organization (WHO) was conducted. Case data from WHO's 2022-23 Mpox Outbreak: Global Trends from 1 January 2022 to 1 September 2023 was used for our analysis. We included cases reported by WHO with data on age (children [range, 0 to 9 years], adolescents [range, 10 to 17 years], adults 50 to 59 years, and adults 60 years and older), gender, WHO region, hospital admission, and intensive care unit admission. Results: Until September 01, 2023, data from 89,752 cases of Mpox have been reported to WHO. Of all the reported cases, 1124 (1.3%), 6296 (7.0%) and 1501 (1.6%) were children and adolescents, adults aged 50-59 years, and adults aged 60 years or older, respectively, and the proportion varied among WHO regions. There was a high proportion of cases among population aged 0-17 years, adolescents (256 [66.3%]) from the region of the Americas and girls aged 0-9 years [127 (46.7%)] from the African region. Men aged 50-59 years (3495 [57.2%] vs. 2553 [41.8%] cases from the region of the Americas and the European region, respectively) and men aged 60-69 years (639 [60.0%] vs. 607 [48.4%] from the region of the Americas and the European region) were most affected, compared to other age groups and women. Among children, adolescents, and adults aged 50 years or older, a low proportion of cases developed some complications and required hospital admission, and some cases were admitted to the intensive care unit. Conclusions: Epidemiological evidence of Mpox in these low-risk groups highlights the risk of wider community transmission. Therefore, while efforts continue to control the global outbreak of Mpox in high-risk groups, it is also necessary to ensure that these low-risk groups have access to timely health care and vaccination.

Monkeypox Outbreak in Peru.

Monkeypox (Mpox) is a zoonotic disease caused by the Orthopoxvirus monkeypox virus (MPXV). Since 1970, outbreaks of MPXV have occurred in several Sub-Saharan African countries. However, from May 2022 to April 2023, recent outbreaks of Mpox occurred in several countries outside of Africa, and these cases quickly spread to over 100 non-endemic countries on all continents. Most of these cases were found in the region of the Americas and the Europe region. In Latin America, the highest all-age Mpox rates per million inhabitants were in Peru, Colombia, Chile, and Brazil. Given its global impact, Mpox was declared as an international Public Health Emergency by WHO in July 2022. MPXV infection disproportionately affects men who have sex with men and members of the HIV-infected population. Vaccination is the current strategy for controlling and preventing Mpox in high-risk groups. In this context, Peru has the fourth-highest number of Mpox cases in Latin America and faces significant challenges in disease control. Because of this, in this review, we discuss the epidemiology, public health indicators, and prevention of Mpox in the 2022 Peru outbreak so that health authorities can join forces to control MPXV transmission.

SIR-SI model with a Gaussian transmission rate: Understanding the dynamics of dengue outbreaks in Lima, Peru.

INTRODUCTION: Dengue is transmitted by the Aedes aegypti mosquito as a vector, and a recent outbreak was reported in several districts of Lima, Peru. We conducted a modeling study to explain the transmission dynamics of dengue in three of these districts according to the demographics and climatology. METHODOLOGY: We used the weekly distribution of dengue cases in the Comas, Lurigancho, and Puente Piedra districts, as well as the temperature data to investigate the transmission dynamics. We used maximum likelihood minimization and the human susceptible-infected-recovered and vector susceptible-infected (SIR-SI) model with a Gaussian function for the infectious rate to consider external non-modeled variables. RESULTS/PRINCIPAL FINDINGS: We found that the adjusted SIR-SI model with the Gaussian transmission rate (for modelling the exogenous variables) captured the behavior of the dengue outbreak in the selected districts. The model explained that the transmission behavior had a strong dependence on the weather, cultural, and demographic variables while other variables determined the start of the outbreak. CONCLUSION/SIGNIFICANCE: The experimental results showed good agreement with the data and model results when a Bayesian-Gaussian transmission rate was employed. The effect of weather was also observed, and a strong qualitative relationship was obtained between the transmission rate and computed effective reproduction number Rt.

Estimating Excess Mortality Due to Prostate, Breast, and Uterus Cancer during the COVID-19 Pandemic in Peru: A Time Series Analysis.

During the COVID-19 pandemic, most of the deaths in Peru were related to COVID-19; however, cancer deaths have also been exacerbated in the first months of the pandemic. Despite this, excess mortalities of prostate, breast, and uterus cancer are not available by age group and region from January to December 2020. Therefore, we estimated the excess deaths and excess death rates (per 100,000 habitants) due to prostate, breast, and uterus cancer in 25 Peruvian regions. We did a time series analysis. Prostate, breast, and uterus cancer death data for 25 Peruvian regions were retrieved during the COVID-19 pandemic in 2020, as well as data for up to 3 years prior (2017-2019) from the Sistema Informatico Nacional de Defunciones at the Ministry of Health of Peru. Deaths in 2020 were defined as observed deaths. The expected deaths (in 2020) were estimated using the average deaths over 3 preceding years (2017, 2018 and 2019). Excess mortality was calculated as the difference between observed mortality and expected mortality in 2020. We estimated that the number of excess deaths and the excess death rates due to prostate, breast, and uterus cancer were 610 deaths (55%; 12.8 deaths per 100,000 men), 443 deaths (43%; 6 deaths per 100,000 women), and 154 deaths (25%; 2 deaths per 100,000 women), respectively. Excess numbers of deaths and excess death rates due to prostate and breast cancer increased with age. These excess deaths were higher in men aged ≥ 80 years (596 deaths (64%) and 150 deaths per 100,000 men) and women aged 70-79 years (229 deaths (58%) and 15 deaths per 100,000 women), respectively. In summary, during the COVID-19 pandemic, there were excess prostate and breast cancer mortalities in 2020 in Peru, while excess uterus cancer mortalities were low. Age-stratified excess death rates for prostate cancer and breast cancer were higher in men ≥ 80 years and in women ≥ 70 years, respectively.

Characteristics of Respiratory Syncytial Virus versus Influenza Infection in Hospitalized Patients of Peru: A Retrospective Observational Study.

Respiratory syncytial virus (RSV) and influenza infections are important causes of respiratory illness associated with hospitalizations in children in Peru; however, comparisons of RSV and influenza hospitalization across all age groups are not available in Peru. Therefore, we conducted an observational, retrospective study between May 2015 and October 2021 using hospitalization from RSV and influenza infection data obtained from SUSALUD (open data) in Peru to compare the baseline characteristics of sex, age, region, and infection type. For the study, 2696 RSV-infected and 1563 influenza-infected hospitalized patients from different age groups were included. Most hospitalizations from RSV infection and the influenza virus occurred in children <5 years of age (86.1% vs. 32.2%, respectively). Compared with influenza infection, RSV infection was less likely to occur in individuals ≥5 years of age (adjusted odds ratio (aOR) = 0.07; 95% confidence interval (CI), 0.06−0.08; p < 0.0001; compared to <5 years of age), and more likely to occur in highlands (aOR = 1.75; 95% CI, 1.46−2.07; p < 0.0001, compared to coast region), and jungle region (aOR = 1.75; 95% CI, 1.27−2.41; p = 0.001, compared to coast region). Among the respiratory complications, RSV pneumonia was less likely to occur between different age groups (aOR = 0.29; 95% CI, 0.22−0.37; p < 0.0001, compared to <5 years of age), compared with influenza pneumonia. These findings on the RSV-hospitalization and its complications are helpful for health services planning and may increase awareness of the Peruvian population's RSV and influenza disease burden.

Ocular Fungal Infections.

Fungal infections of the eye continue to be an important cause of ocular morbidity and loss of vision, particularly in the developing world [...].

COVID-19, Non-Communicable Diseases, and Behavioral Factors in the Peruvian Population ≥ 15 Years: An Ecological Study during the First and Second Year of the COVID-19 Pandemic.

A range of health-related and behavioral risk factors are associated with COVID-19 incidence and mortality. In the present study, we assess the association between incidence, mortality, and case fatality rate due to COVID-19 and the prevalence of hypertension, obesity, overweight, tobacco and alcohol use in the Peruvian population aged ≥15 years during the first and second year of the COVID-19 pandemic. In this ecological study, we used the prevalence rates of hypertension, overweight, obesity, tobacco, and alcohol use obtained from the Encuesta Demográfica y de Salud Familiar (ENDES) 2020 and 2021. We estimated the crude incidence and mortality rates (per 100,000 habitants) and case fatality rate (%) of COVID-19 in 25 Peruvian regions using data from the Peruvian Ministry of Health that were accurate as of 31 December 2021. Spearman correlation and lineal regression analysis was applied to assess the correlations between the study variables as well as multivariable regression analysis adjusted by confounding factors affecting the incidence and mortality rate and case fatality rate of COVID-19. In 2020, adjusted by confounding factors, the prevalence rate of obesity (ß = 0.582; p = 0.037) was found to be associated with the COVID-19 mortality rate (per 100,000 habitants). There was also an association between obesity and the COVID-19 case fatality rate (ß = 0.993; p = 0.014). In 2021, the prevalence of obesity was also found to be associated with the COVID-19 mortality rate (ß = 0.713; p = 0.028); however, adjusted by confounding factors, including COVID-19 vaccination coverage rates, no association was found between the obesity prevalence and the COVID-19 mortality rate (ß = 0.031; p = 0.895). In summary, Peruvian regions with higher obesity prevalence rates had higher COVID-19 mortality and case fatality rates during the first year of the COVID-19 pandemic. However, adjusted by the COVID-19 vaccination coverage, no association between the obesity prevalence rate and the COVID-19 mortality rate was found during the second year of the COVID-19 pandemic.

Analysis of Excess All-Cause Mortality and COVID-19 Mortality in Peru: Observational Study.

During the COVID-19 pandemic, an excess of all-cause mortality has been recorded in several countries, including Peru. Most excess deaths were likely attributable to COVID-19. In this study, we compared the excess all-cause mortality and COVID-19 mortality in 25 Peruvian regions to determine whether most of the excess deaths in 2020 were attributable to COVID-19. Excess deaths were calculated as the difference between the number of observed deaths from all causes during the COVID-19 pandemic (in 2020) and the number of expected deaths in 2020 based on a historical from recent years (2017-2019). Death data were retrieved from the Sistema Informatico Nacional de Defunciones (SINADEF) at the Ministry of Health of Peru from January 2017 to December 2020. Population counts were obtained from projections from Peru's Instituto Nacional de Estadística e Informática (INEI). All-cause excess mortality and COVID-19 mortality were calculated by region per 100,000 population. Spearman's test and linear and multiple regression models were used to estimate the correlation between excess all-cause mortality and COVID-19 mortality per 100,000 population. Excess all-cause death rates varied widely among regions (range: 115.1 to 519.8 per 100,000 population), and COVID-19 mortality ranged between 83.8 and 464.6 per 100,000 population. There was a correlation between the all-cause excess mortality and COVID-19 mortality (r = 0.90; p = 0.00001; y = 0.8729x + 90.808; R2 = 0.84). Adjusted for confounding factors (mean age in the region, gender balance, and number of intensive care unit (ICU) beds), the all-cause excess mortality rate was correlated with COVID-19 mortality rate (ß = 0.921; p = 0.0001). These findings suggest that most of the excess deaths in Peru are related to COVID-19. Therefore, these findings can help decision-makers to understand the high COVID-19 mortality rates in Peru.

Excess all-cause deaths stratified by sex and age in Peru: a time series analysis during the COVID-19 pandemic.

BACKGROUND: In this study, we estimated excess all-cause deaths and excess death rates during the COVID-19 pandemic in 25 Peruvian regions, stratified by sex and age group. DESIGN: Cross-sectional study. SETTING: Twenty-five Peruvian regions with complete mortality data. PARTICIPANTS: Annual all-cause official mortality data set from SINADEF (Sistema Informático Nacional de Defunciones) at the Ministry of Health of Peru for 2017-2020, disaggregated by age and sex. MAIN OUTCOME MEASURES: Excess deaths and excess death rates (observed deaths vs expected deaths) in 2020 by sex and age (0-29, 30-39, 40-49, 50-59, 60-69, 70-79 and ≥80 years) were estimated using P-score. The ORs for excess mortality were summarised with a random-effects meta-analysis. RESULTS: In the period between January and December 2020, we estimated an excess of 68 608 (117%) deaths in men and 34 742 (69%) deaths in women, corresponding to an excess death rate of 424 per 100 000 men and 211 per 100 000 women compared with the expected mortality rate. The number of excess deaths increased with age and was higher in men aged 60-69 years (217%) compared with women (121%). Men between the ages of 40 and 79 years experienced twice the rate of excess deaths compared with the expected rate. In eight regions, excess deaths were higher than 100% in men, and in seven regions excess deaths were higher than 70% in women. Men in eight regions and women in one region had two times increased odds of excess death than the expected mortality. There were differences in excess mortality according to temporal distribution by epidemiological week. CONCLUSION: Approximately 100 000 excess all-cause deaths occurred in 2020 in Peru. Age-stratified excess death rates were higher in men than in women. There was strong excess in geographical and temporal mortality patterns according to region.

Use of Smartphones for the Detection of Uterine Cervical Cancer: A Systematic Review.

Little is known regarding the usefulness of the smartphone in the detection of uterine cervical lesions or uterine cervical cancer. Therefore, we evaluated the usefulness of the smartphone in the detection of uterine cervical lesions and measured its diagnostic accuracy by comparing its findings with histological findings. We conducted a systematic review to identify studies on the usefulness of the smartphone in detecting uterine cervical lesions indexed in SCOPUS, MEDLINE/PubMed, Cochrane, OVID, Web of Science, and SciELO until November 2020. The risk of bias and applicability was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A total of 16 studies that evaluated the usefulness of the smartphone in the detection of uterine cervical lesions based on the images clicked after visual inspection with acetic acid (VIA), Lugol's iodine (VILI), or VIA/VILI combination were included in the study. Five studies estimated diagnostic sensitivity and specificity, nine described diagnostic concordance, and five described the usefulness of mobile technology. Among the five first studies, the sensitivity ranged between 66.7% (95% confidence interval (CI); 30.0-90.3%) and 94.1% (95% CI; 81.6-98.3%), and the specificity ranged between 24.0% (95% CI; 9.0-45.0%) and 85.7% (95% CI; 76.7-91.6%). The risk of bias was low (20%), and the applicability was high. In conclusion, the smartphone images clicked after a VIA were found to be more sensitive than those following the VILI method or the VIA/VILI combination and naked-eye techniques in detecting uterine cervical lesions. Thus, a smartphone may be useful in the detection of uterine cervical lesions; however, its sensitivity and specificity are still limited.

Ocular Sporotrichosis.

Sporotrichosis is a subacute or chronic mycosis predominant in tropical and subtropical regions. It is an infection of subcutaneous tissue caused by Sporothrix fungus species, but occasionally resulting in an extracutaneous condition, including osteoarticular, pulmonary, nervous central system, and ocular disease. Cases of ocular sporotrichosis are rare, but reports have been increasing in recent decades. Ocular infections usually occur in hyperendemic areas of sporotrichosis. For its classification, anatomic criteria are used. The clinical presentation is the infection in the ocular adnexal and intraocular infection. Ocular adnexa infections include palpebral, conjunctivitis, and infections of the lacrimal sac. Intraocular infection includes exogenous or endogenous endophthalmitis. Most infections in the ocular adnexal have been reported in Brazil, China and Peru, and intraocular infections are limited to the USA and Brazil. Diagnosis is performed from Sporothrix isolation in the mycological examination from ocular or skin samples. Both sporotrichosis in the ocular adnexa and intraocular infection can mimic several infectious and non-infectious medical conditions. Ocular adnexa infections are treated with potassium iodide and itraconazole. The intraocular infection is treated with amphotericin B. This review describes the clinical findings and epidemiological, diagnosis, and treatment of ocular sporotrichosis.

Association between Obesity and COVID-19 Mortality in Peru: An Ecological Study.

There is a gap in the epidemiological data on obesity and COVID-19 mortality in low and middle-income countries worst affected by the COVID-19 pandemic, including Peru. In this ecological study, we explored the association between body mass index (BMI), the prevalence of overweight and obesity, and the COVID-19 mortality rates in 25 Peruvian regions, adjusted for confounding factors (mean age in the region, mean income, gender balance and number of Intensive Care Unit (ICU) beds) using multiple linear regression. We retrieved secondary region-level data on the BMI average and prevalence rates of overweight and obesity in individuals aged ≥ 15 years old, from the Peruvian National Demographics and Health Survey (ENDES 2020). COVID-19 death statistics were obtained from the National System of Deaths (SINADEF) from the Peruvian Ministry of Health and were accurate as of 3 June 2021. COVID-19 mortality rates (per 100,000 habitants) were calculated among those aged ≥ 15 years old. During the study period, a total of 190,046 COVID-19 deaths were registered in individuals aged ≥ 15 years in 25 Peruvian regions. There was association between the BMI (r = 0.74; p = 0.00001) and obesity (r = 0.76; p = 0.00001), and the COVID-19 mortality rate. Adjusted for confounding factors, only the prevalence rate of obesity was associated with COVID-19 mortality rate (ß = 0.585; p = 0.033). These findings suggest that as obesity prevalence increases, the COVID-19 mortality rates increase in the Peruvian population ≥ 15 years. These findings can help to elucidate the high COVID-19 mortality rates in Peru.

Sex differences in the incidence, mortality, and fatality of COVID-19 in Peru.

BACKGROUND: There is a worrying lack of epidemiological data on the sex differential in COVID-19 infection and death rates between the regions of Peru. METHODS: Using cases and death data from the national population-based surveillance system of Peru, we estimated incidence, mortality and fatality, stratified by sex, age and geographic distribution (per 100,000 habitants) from March 16 to November 27, 2020. At the same time, we calculated the risk of COVID-19 death. RESULTS: During the study period, 961894 cases and 35913 deaths were reported in Peru. Men had a twofold higher risk of COVID-19 death within the overall population of Peru (odds ratio (OR), 2.11; confidence interval (CI) 95%; 2.06-2.16; p<0.00001), as well as 20 regions of Peru, compared to women (p<0.05). There were variations in incidence, mortality and fatality rates stratified by sex, age, and region. The incidence rate was higher among men than among women (3079 vs. 2819 per 100,000 habitants, respectively). The mortality rate was two times higher in males than in females (153 vs. 68 per 100,000 habitants, respectively). The mortality rates increased with age, and were high in men 60 years of age or older. The fatality rate was two times higher in men than in women (4.96% vs. 2.41%, respectively), and was high in men 50 years of age or older. CONCLUSIONS: These findings show the higher incidence, mortality and fatality rates among men than among women from Peru. These rates vary widely by region, and men are at greater risk of COVID-19 death. In addition, the mortality and fatality rates increased with age, and were most predominant in men 50 years of age or older.

Sex differences in COVID-19 fatality rate and risk of death: An analysis in 73 countries, 2020-2021.

There is a worrying lack of epidemiological data on the sex differential in COVID-19 fatality rates. We examined the Global Health 50/50 tracks of sex-disaggregated infection and mortality COVID-19 data from 73 countries through May 20, 2021. We compared the infection fatality rate (IFR) in men vs. women and risk of death from COVID-19 by country. Of all cases in 73 countries, 42,933,757 were in women and 40,187,894 in men; 1,274,663 men and 971,899 women died. The IFR was higher in males (3.17%) than in women (2.26%). The IFR in males vs. females varied from country to country, and it was higher in men in Brazil, Yemen, Mexico, Ecuador, Scotland, Peru, Guatemala, North Macedonia and Afghanistan. Overall, men had a higher odd of death from COVID-19 (OR, 1.22; 95% CI, 1.13-1.32; =0.00001) and in 49 countries, compared to women. Men in Albania and Guatemala had twice the risk of death from COVID-19. Our findings show higher fatality rates among men than among women. These rates vary widely by country, and men have a higher odd of death from COVID-19.

Decrease in the prevalence of hepatitis B and D virus infections in an endemic area in Peru 23 years after the introduction of the first pilot vaccination program against hepatitis B.

In 1991, Peru launched the first vaccination program against hepatitis B in children aged under 5 years in the hyperendemic [hepatitis B virus (HBV) and hepatitis D virus (HDV)] province of Abancay. We conducted a cross-sectional study to determine the prevalence of HBV and HDV infections, 23 years after the launch of the vaccination program, as well as the post-vaccine response against hepatitis B in terms of prevalence of hepatitis B surface antibody (anti-HBs ≥10 mUI/ml). Among 3165 participants aged from 0 to 94 years, the prevalence rates of hepatitis B surface antigen (HBsAg), and hepatitis B core antibody (total anti-HBc) were 1.2% [95% confidence interval (CI) 0.85-1.64%], and 41.67% (95% CI 39.95-43.41%), respectively. The prevalence rate of anti-HBs at protective levels (≥10 mUI/ml) in individuals who HBsAg and anti-HBc negative was 66.36% (95% CI 64.15-68.51%). The prevalence rate of HBsAg in children aged <15 years was nil, and among adult HBsAg carriers, the prevalence of hepatitis D antibody (anti-HDV) was 5.26% (2/38; 95% CI 0.64-17.74). These findings showed that HBV prevalence has changed from high to low endemicity, 23 years following implementation of the vaccination program against hepatitis B, and HDV infection was not detected in those aged <30 years.

PCR performance for the diagnosis of cutaneous leishmaniasis caused by Leishmania viannia complex using biopsy samples, compared with exudate samples from skin lesions on filter paper.

BACKGROUND: Cutaneous leishmaniasis (CL) is generally diagnosed by molecular methods, including PCR, using biopsy samples, skin scrapings and clinical exudates. In this study, we assessed the PCR performance for diagnosis of CL using skin of biopsy samples vs PCR of skin lesion exudate samples on filter paper and compared the diagnostic concordance of PCR using both sampling methods. METHODS: We assessed the PCR performance using 80 skin biopsy samples and 80 filter paper samples containing exudates from skin lesions obtained from 74 patients with clinical suspicion of CL in Cusco, Peru. RESULTS: : PCR using skin biopsy samples had superior diagnostic accuracy compared with filter paper PCR (62.5% [50/80] vs 38.7% [31/80], respectively; p˂0.005) and the diagnostic concordance between both sampling methods was 'moderate' (kappa coefficient=0.50, 95% CI 0.98 to 1.0). CONCLUSIONS: PCR using biopsy samples remains the standard for diagnosis of CL.

Seroepidemiology of hepatitis A, B, C, D and E virus infections in the general population of Peru: A cross-sectional study.

BACKGROUND: Viral hepatitis (hepatitis A, B, C, D and E) remains a public health problem in Peru, with a high disease burden. There are limited data on the prevalence of viral hepatitis at a national level, and none reported for over two decades. In this study, the prevalence rates of hepatitis A (HAV), B (HBV), C (HCV), D (HDV) and E virus (HEV) infections in the Peruvian population were determined to provide updated baseline data that would help guide the development of strategies aimed at reducing the transmission of viral hepatitis in Peru. METHODS: We conducted a cross-sectional, population-based study in the 25 regions of Peru. The study included participants of both sexes, aged 15-69 years, who had lived for >6 months in a specific region of Peru. Serum samples were analyzed by ELISA for anti-HAV (IgG), anti-HBs ≥10 mUI/ml, anti-HCV, anti-HDV and anti-HEV (IgG) antibodies, and by chemiluminescence for the HBV surface antigen (HBsAg) and antibodies against the core HBV antigen (anti-HBc IgM and IgG). RESULTS: In a total of 5183 study participants, the prevalence rates of anti-HAV (IgG), HBsAg, total anti-HBc IgG, anti-HBs ≥10 mUI/ml, anti-HCV and anti-HEV (IgG) were 98.4% [95% confidence interval (CI) 98.0-98.7), 0.4% (95% CI 0.21-0.55), 10.1% (95% CI 9.4-11.0), 60% (95% CI 58.5-61.2), 0.1% (95% CI 0.02-0.25), and 14% (95% CI 13.1-15.0%), respectively. The prevalence of anti-HDV among HBsAg carriers was 15% (3/20). CONCLUSIONS: The prevalence of HAV and HEV in the population aged 15-69 years in Peru is high, while the prevalence of HBV and HDV has changed from intermediate to low endemicity level and the prevalence of HCV is low. These findings would prove useful in the development of new strategies aimed at reducing the transmission of viral hepatitis in Peru, with a view to ultimately eliminating these infections in the future.