Eradicating Atherosclerotic Events by Targeting Early Subclinical Disease: It Is Time to Retire the Therapeutic Paradigm of Too Much, Too Late.

Recent decades have seen spectacular advances in understanding and managing atherosclerotic cardiovascular disease, but paradoxically, clinical progress has stalled. Residual risk of atherosclerotic cardiovascular disease events is particularly vexing, given recognized lifestyle interventions and powerful modern medications. Why? Atherosclerosis begins early in life, yet clinical trials and mechanistic studies often emphasize terminal, end-stage plaques, meaning on the verge of causing heart attacks and strokes. Thus, current clinical evidence drives us to emphasize aggressive treatments that are delayed until patients already have advanced arterial disease. I call this paradigm "too much, too late." This brief review covers exciting efforts that focus on preventing, or finding and treating, arterial disease before its end-stage. Also included are specific proposals to establish a new evidence base that could justify intensive short-term interventions (induction-phase therapy) to treat subclinical plaques that are early enough perhaps to heal. If we can establish that such plaques are actionable, then broad screening to find them in early midlife individuals would become imperative-and achievable. You have a lump in your coronaries! can motivate patients and clinicians. We must stop thinking of a heart attack as a disease. The real disease is atherosclerosis. In my opinion, an atherosclerotic heart attack is a medical failure. It is a manifestation of longstanding arterial disease that we had allowed to progress to its end-stage, despite knowing that atherosclerosis begins early in life and despite the availability of remarkably safe and highly effective therapies. The field needs a transformational advance to shift the paradigm out of end-stage management and into early interventions that hold the possibility of eradicating the clinical burden of atherosclerotic cardiovascular disease, currently the biggest killer in the world. We urgently need a new evidence base to redirect our main focus from terminal, end-stage atherosclerosis to earlier, and likely reversible, human arterial disease.

Effectiveness and safety of probiotics as adjuvants in the eradication of Helicobacter pylori. Systematic review and meta-analysis / Efectividad y seguridad del uso de probióticos como adyuvantes en la erradicación de Helicobacter pylori. Revisión sistemática y metaanálisis

Abstract Introduction: Adding probiotics to triple and quadruple therapies has been proposed to improve their effectiveness in the eradication of Helicobacter pylori, but there is controversy about their usefulness. Objective: To assess the effectiveness and safety of probiotics as adjuvants in triple or quadruple therapies for H. pylori eradication in adults. Materials and methods: Systematic review and meta-analysis. Randomized clinical trials (RCTs) assessing the effectiveness and safety of probiotics as adjuvant therapy in combination with triple and quadruple therapies for the eradication of H. pylori in adults and published in English or Spanish between January 2010 and May 2020 were searched in the Embase, Ovid Medline, Cochrane Library, and LILACS databases. Regarding the meta-analysis, a fixed-effects model was used to calculate the pooled measure (OR and RR) of the effectiveness and safety of using adjuvant probiotics in triple and quadruple therapy. Results: Twelve RCTs were included (1 091 patients in total): 9 assessed triple therapy, 2 assessed quadruple therapy, and 1 assessed both triple and quadruple therapy. In the case of triple therapy, the use of adjuvant probiotics was more effective than placebo: 79.4% vs. 71.1%, (OR=1.42; 95%CI: 1.05-2.09), but in the case of quadruple therapy, their use did not increase effectiveness. The most widely used probiotic was Lactobacillus reuteri, with an eradication rate of 77.9% (95%CI: 70.5-84.19) versus 66.8% (95%CI: 58.8-74.2) for placebo. Probiotics decreased the occurrence of adverse effects in both triple therapy (OR=0.50; 95%CI: 0.28-0.90) and quadruple therapy (OR=0.26; 95%CI: 0.09-0.74). Conclusions. Adjuvant probiotics improve the effectiveness of triple therapy to eradicate H. Pylori by 8.5%, but the final effectiveness is <90%. Furthermore, their use does not increase the effectiveness of quadruple therapy. However, the use of these microorganisms reduces the adverse effects of these therapies.

Resumen Introducción. Se ha propuesto agregar probióticos a las terapias triples y cuádruples para mejorar su efectividad en la erradicación de Helicobacter pylori, pero existe controversia sobre su utilidad. Objetivo. Evaluar la efectividad y seguridad del uso adyuvante de probióticos en la terapia triple o cuádruple para la erradicación de H. pylori en adultos. Materiales y métodos. Revisión sistemática y metaanálisis. Se realizó una búsqueda en Embase, Ovid Medline, Cochrane Library y LILACS de ensayos clínicos aleatorizados (ECA) publicados en inglés o español entre enero de 2010 y mayo de 2020 que evalúan la efectividad y seguridad de usar probióticos como terapia coadyuvante en combinación con la terapia triple o cuádruple en la erradicación de H. pylori en adultos. En el metaanálisis se utilizó un modelo de efectos fijos para calcular la medida combinada (OR y RR) de efectividad y seguridad de los probióticos coadyuvantes en terapia triple y cuádruple. Resultados: Se incluyeron 12 ECA (1 091 pacientes en total): 9 evaluaron terapia triple; 2, terapia cuádruple, y I, terapia triple y cuádruple. En la terapia triple el uso coadyuvante de probióticos fue más efectivo que el uso de placebo: 79.4% vs. 71.1% (OR=1.42; IC95%: 1.05-2.09), pero en la terapia cuádruple, su uso no aumentó la efectividad. El probiótico más utilizado fue Lactobacillus reuteri, con una tasa de curación de 77.9% (IC95%: 70.5-84.19) versus 66.8% (IC95%: 58.8-74.2) del placebo. Los probióticos disminuyeron la ocurrencia de efectos adversos tanto en terapia triple (OR=0.50; IC95%: 0.28-0.90) como en cuádruple (OR=0.26; IC95%: 0.09-0.74). Conclusiones. El uso coadyuvante de probióticos mejora la efectividad de la terapia triple para erradicar H. Pylori en un 8.5%, pero la efectividad final es <90%. Además, su uso no aumenta la efectividad de la terapia cuádruple. No obstante, el uso de estos microorganismos disminuye los efectos adversos de estas terapias.

Tratamiento cuádruple con doxiciclina, furazolidona, bismuto e inhibidor de bomba de protones sigue siendo efectivo frente al Helicobacter pylori en nuestra población

Nuestro objetivo es determinar si el tratamiento para Helicobacter pylori (HP) con doxiciclina, furazolidona, bismuto y un inhibidor de bomba de protones mantiene su efectividad en nuestra población. Se realizó un estudio retrospectivo, no aleatorio, realizado en una clínica privada de Lima, Perú. Se obtuvo la información de la historia clínica digital. Se incluyó a pacientes con el diagnóstico de infección por HP por biopsia y/o test rápido de la ureasa, obtenidos al realizar una endoscopía entre enero 2017 a octubre 2022. Debían haber recibido el tratamiento cuádruple en estudio o un esquema triple alternativo con amoxicilina, levofloxacino e inhibidor de bomba de protones y tener una prueba de aliento para HP en el lapso de 1 a 6 meses después del tratamiento. El esquema cuádruple con furazolidona logró la erradicación en 117/122 casos (95,9%) mientras que el triple con levofloxacino en 5/16 (31,2%) cuando se usó por 7 dias y en 22/38 (57,9%) cuando se usó por 10 días, siendo las diferencias altamente significativas (p>0,001). En conclusión, el tratamiento cuádruple con furazolidona mostró alta efectividad, mientras que el triple con levofloxacino no alcanzó niveles aceptables.

Our objective is to determine the effectiveness of a therapeutic regimen for helicobacter pylori that includes a proton pump inhibitor, doxycycline, furazolidone and bismuth in our location. We carried out a retrospective study, non-randomized, in a private hospital in Lima, Peru. Patients with biopsy and/or rapid urease test proven helicobacter pylori infection after an endoscopy, from January 2017 to October 2022 were included. They received the therapeutic regimen of the study or an alternative triple regimen with a proton pump inhibitor, amoxicillin and levofloxacin and were followed with a urea breath test within 1 to 6 months upon completion of therapy. The quadruple therapy with furazolidone obtained success in 117/122 cases (95.9%) while the triple therapy with levofloxacin only in 5/16 (31.2%) when used for 7 days and 22/38 (57.9%) when used for 10 days, a statistically significant difference with p<0.001. Conclusion: Quadruple therapy with furazolidone reached high effectiveness in our location, while triple therapy with levofloxacin was not an acceptable alternative.

Hepatitis C mortality trends in Mexico from 2001 to 2017.

INTRODUCTION AND OBJECTIVES: We aimed to analyze the trends of total and sex-stratified mortality from hepatitis C virus (HCV) and to estimate the proportion of non-alcoholic liver disease deaths in Mexico attributable to HCV from 2001-2017. MATERIALS AND METHODS: Using the mortality multiple-cause dataset, we selected the codes for acute HCV and chronic HCV to analyze trends from 2001 to 2017. We then estimated the proportion of HCV-related deaths out of non-alcoholic chronic liver disease deaths, by including in the denominator: other acute and chronic viral hepatitis, malignant neoplasm of the liver, liver failure, chronic hepatitis, fibrosis, and cirrhosis of the liver, and other inflammatory diseases of the liver. Average percent change (APC) for trends, overall and by sex, were estimated using Joinpoint regression. RESULTS: The trend in crude mortality rate significantly increased from 2001-2005 (APC 18.4%; 95%CI=12.5, 24.5; p value<0.001), and then significantly decreased from 2013-2017 (APC -6.5%; 95%CI=-10.1, -2.9; p value<0.001). Stratified by sex women experienced a more rapid decline in the 2014-2017 period than men. CONCLUSIONS: HCV mortality seems to have started to decrease, but much remains to be done in terms of prevention, diagnosis, and timely access to treatment.

Tratamiento de primera línea para erradicación de Helicobacter pylori: todavía una terapia eficaz / First-line treatment for eradication of Helicobacter pylori: Still an effective therapy

Resumen Objetivo: Este estudio tiene como objetivo principal determinar la respuesta al esquema de tratamiento de primera línea con triple terapia estándar (amoxicilina, claritromicina, omeprazol), para erradicación de Helicobacter pylori en una determinada población, para determinar si este esquema propuesto en guías internacionales es aún una opción adecuada para pacientes en una determinada región de Costa Rica. Métodos: Se realizó una búsqueda en el servicio de gastroenterología del Hospital San Francisco de Asís, Grecia, Alajuela, Costa Rica; de todos los pacientes con infección por Helicobacter pylori y que recibieron tratamiento de primera línea con triple terapia (amoxicilina, claritromicina y omeprazol) por 14 días, en el periodo comprendido entre febrero 2017 a febrero 2019, incluyendo para el análisis solamente en los que se contaba con una prueba confirmatoria posterior a tratamiento, ya fuera por antígeno fecal de H. pylori o biopsia convencional. Resultados: Se identificaron un total de 369 casos. El diagnóstico se realizó con biopsia en el 96,4% de los pacientes. La respuesta al tratamiento de primera línea se alcanzó en un 90.5% corroborada por antígeno fecal en el 92.1% de los casos. Conclusiones: Este estudio muestra que la terapia triple con amoxicilina, claritromicina e Inhibidor de bomba de protones por 14 días mantiene un adecuado nivel de eficacia. Sin embargo, hay que tomar en cuenta que estos datos son únicamente de un área de atracción determinada y puede que no reflejen la realidad de todo el país.

Abstract Aim: The main objective of this study is to determine the response to the firstline treatment regimen with triple standard therapy (amoxicillin, clarithromycin, omeprazole), to eradicate Helicobacter pylori in a certain population. The goal is to determine if the proposed regimen in international guidelines services is still a suitable option for patients in a certain region of Costa Rica. Methods: The study took place in San Francisco de Asís Hospital, Grecia, Alajuela, Costa Rica. All patients with a Helicobacter pylori infection that were given first- line treatment with triple therapy (amoxicillin, clarithromycin and omeprazole) for its eradication for 14 days, in the period between February of 2017 and February of 2019, were included in the study. Results: A total of 369 cases were identified. The diagnosis was made with biopsy in 96.4% of patients. Response to first-line treatment was achieved in 90.5% corroborated by fecal antigen in 92.1% of all cases. Conclusions: This study shows that triple therapy with amoxicillin, clarithromycin and omeprazole for 14 days maintains an adequate level of efficacy. However, it must be considered that these results are from a specific area and may not reflect the reality of the entire country.

The malaria eradication campaign in Colombia, 1959-1979 / La campaña de erradicación de la malaria en Colombia, 1959-1979

Introduction: In the mid-fifties, Colombia adopted and implemented the Malaria Eradication Campaign (MEC), which has not been evaluated yet in the country. Objective: To evaluate the results achieved during the attack and consolidation phases of the MEC regarding malaria transmission in Colombia between 1959 and 1979. Materials and methods: We conducted a descriptive and retrospective study based on the malariometric and operational results of the MEC in Colombia from 1959 to 1979 compiled from the archives of the Ministry of Public Health. We used the criteria defined by the WHO Expert Committee on Malaria. The information was stored, tabulated, and analyzed based on the malariometric indicators we developed. Results: In the short-term eradication period (1959-1969), a reduction of 94% (4,172) in transmission was achieved during the first year of the attack phase (1959) while in the last year (1962), there was an 88% (8,426) reduction of the accumulated load of cases compared to the annual average of the 1950s (71,031). These low levels of transmission were maintained until the end of 1969. During the intensification period of control of the eradication (1970-1979), there was an increase in malaria endemicity and a resurgence of the epidemic transmission. Due to financial problems affecting the regularity of the operations, Colombia was unable to sustain the results and achieve an interruption of transmission, which resulted in a resurgence of cases during the attack and consolidation phases. Conclusions: The campaign did not achieve the goal of interrupting malaria transmission in the national territory but there was marked control in areas of medium and low intensity.

Introducción. A mediados de la década de 1950, el país adoptó e implementó la Campaña de Erradicación de la Malaria (CEM), sin que hasta ahora se haya hecho su evaluación. Objetivo. Evaluar los resultados alcanzados en las fases de ataque y consolidación de la campaña de erradicación de la malaria en Colombia, entre 1959 y 1979. Materiales y métodos. Se hizo un estudio descriptivo y retrospectivo de los resultados "malariométricos" y operacionales de la CEM en Colombia entre 1959 y 1979 a partir de los datos recopilados de los archivos del Ministerio de Salud Pública. Se utilizaron los criterios establecidos por la Organización Mundial de la Salud (OMS) relacionados con las fases de un programa de erradicación de malaria. Se almacenó, tabuló y analizó la información, y se elaboraron y aplicaron indicadores malariométricos. Resultados. En el periodo de erradicación a corto plazo (1959-1969), durante el primer año de la fase de ataque (1959), se alcanzó una reducción de la transmisión del 94 % (4.172) y, en el último año (1962), una disminución del 88 % (8.426) en la carga acumulada de casos comparada con el promedio anual de la década del 50 (71.031); estos bajos niveles de transmisión se mantuvieron hasta finales de 1969. En el periodo de intensificación del control para la erradicación (1970-1979), se produjo un incremento de la endemia y resurgió la transmisión epidémica. Debido a problemas financieros que afectaron la regularidad de la operación para mantener los resultados, y no habiéndose logrado la interrupción de la transmisión, se observó un resurgimiento de casos en las fases de ataque y consolidación. Conclusiones. La campaña no logró la meta de interrupción de la transmisión de la malaria en el territorio nacional, pero sí se consiguió un acentuado control en áreas de mediana y baja intensidad.

La campaña de erradicación de la malaria en Colombia, 1959-1979 / The malaria eradication campaign in Colombia, 1959-1979

Introducción. A mediados de la década de 1950, el país adoptó e implementó la Campaña de Erradicación de la Malaria (CEM), sin que hasta ahora se haya hecho su evaluación. Objetivo. Evaluar los resultados alcanzados en las fases de ataque y consolidación de la campaña de erradicación de la malaria en Colombia, entre 1959 y 1979. Materiales y métodos. Se hizo un estudio descriptivo y retrospectivo de los resultados "malariométricos" y operacionales de la CEM en Colombia entre 1959 y 1979 a partir de los datos recopilados de los archivos del Ministerio de Salud Pública. Se utilizaron los criterios establecidos por la Organización Mundial de la Salud (OMS) relacionados con las fases de un programa de erradicación de malaria. Se almacenó, tabuló y analizó la información, y se elaboraron y aplicaron indicadores malariométricos. Resultados. En el periodo de erradicación a corto plazo (1959-1969), durante el primer año de la fase de ataque (1959), se alcanzó una reducción de la transmisión del 94 % (4.172) y, en el último año (1962), una disminución del 88 % (8.426) en la carga acumulada de casos comparada con el promedio anual de la década del 50 (71.031); estos bajos niveles de transmisión se mantuvieron hasta finales de 1969. En el periodo de intensificación del control para la erradicación (1970-1979), se produjo un incremento de la endemia y resurgió la transmisión epidémica. Debido a problemas financieros que afectaron la regularidad de la operación para mantener los resultados, y no habiéndose logrado la interrupción de la transmisión, se observó un resurgimiento de casos en las fases de ataque y consolidación. Conclusiones. La campaña no logró la meta de interrupción de la transmisión de la malaria en el territorio nacional, pero sí se consiguió un acentuado control en áreas de mediana y baja intensidad.

Introduction: In the mid-fifties, Colombia adopted and implemented the Malaria Eradication Campaign (MEC), which has not been evaluated yet in the country. Objective: To evaluate the results achieved during the attack and consolidation phases of the MEC regarding malaria transmission in Colombia between 1959 and 1979. Materials and methods: We conducted a descriptive and retrospective study based on the malariometric and operational results of the MEC in Colombia from 1959 to 1979 compiled from the archives of the Ministry of Public Health. We used the criteria defined by the WHO Expert Committee on Malaria. The information was stored, tabulated, and analyzed based on the malariometric indicators we developed. Results: In the short-term eradication period (1959-1969), a reduction of 94% (4,172) in transmission was achieved during the first year of the attack phase (1959) while in the last year (1962), there was an 88% (8,426) reduction of the accumulated load of cases compared to the annual average of the 1950s (71,031). These low levels of transmission were maintained until the end of 1969. During the intensification period of control of the eradication (1970-1979), there was an increase in malaria endemicity and a resurgence of the epidemic transmission. Due to financial problems affecting the regularity of the operations, Colombia was unable to sustain the results and achieve an interruption of transmission, which resulted in a resurgence of cases during the attack and consolidation phases. Conclusions: The campaign did not achieve the goal of interrupting malaria transmission in the national territory but there was marked control in areas of medium and low intensity.

Brazilian registry for the elimination of hepatitis C in dialysis units: a call to action for Nephrology / Registro brasileiro para eliminação da hepatite C nas unidades de diálise: um chamado para a Nefrologia

Abstract Infection by the hepatitis C virus is more prevalent in patients on dialysis than in the general population in Brazil, and has been associated with worse outcomes. Current therapy for hepatitis C is highly effective, safe, and widely available in Brazil, with coverage provided to dialysis patients with chronic kidney disease, which makes the elimination of hepatitis C a viable target. The Brazilian Society of Nephrology, the Brazilian Society of Hepatology, and the Brazilian Liver Institute developed the "Brazilian Registry for the Elimination of Hepatitis C in Dialysis Units". This project aims to identify, treat, and monitor the response to treatment of patients on chronic dialysis infected with the hepatitis C virus in Brazil. This article presents the issue and invites Brazilian nephrologists to rally around the achievement of a significant goal.

Resumo A infecção pelo vírus da hepatite C é mais prevalente em pacientes em diálise do que na população geral no Brasil e implica um pior prognóstico. O tratamento atual para hepatite C é altamente eficaz, seguro e disponível no país, inclusive para a população de pacientes crônicos em diálise, o que torna a eliminação do vírus da hepatite C uma meta viável. A Sociedade Brasileira de Nefrologia, a Sociedade Brasileira de Hepatologia e o Instituto Brasileiro do Fígado desenvolveram o "Registro Brasileiro para Eliminação da Hepatite C nas Unidades de Diálise". O projeto visa identificar pacientes em diálise crônica com vírus da hepatite C no Brasil, além de tratar e monitorar a resposta virológica após o tratamento. Este breve artigo apresenta o problema e convida os nefrologistas brasileiros a unirem forças nesse objetivo comum.

Shifting to foot-and-mouth disease-free status without vaccination: Application of the PROMETHEE method to assist in the development of a foot-and-mouth national program in Uruguay.

Foot-and-mouth disease (FMD) is highly contagious, and the introduction of FMD virus in countries free of the disease can result in large epidemics, similar to those observed in the United Kingdom, Japan, and Uruguay. Many countries or regions of South America are recognized as "FMD-free with vaccination" or "FMD-free without vaccination." Uruguay has been certified as FMD-free with vaccination, and the transition to the status of FMD-free without vaccination has been discussed among the stakeholders of the Ministry of Livestock Agriculture and Fisheries (MGAP in Spanish). This study illustrates how the Preference Ranking Organization Method for Enrichment Evaluation (PROMETHEE) can identify and rank alternative actions to be used in the national FMD program in Uruguay. It uses multiple-criteria decision analysis (MCDA) to structure the problem comprehensively. This helps to identify critical issues and potential solutions when planning a national FMD program for a country with a disease-free without vaccination status. The analysis highlighted the following perspectives: i) the importance of communication strategies as the country changes to "FMD-free without vaccination" status, as well as potential challenges such as a lack of trust in government; ii) the importance of enhancing epidemiological capacity and data management to allocate resources better and provide feedback from the surveillance system; iii) the need to re-evaluate the animal health compensation strategy to stimulate biosecurity and disease reporting; and iv) the importance of assisting the backyard pig sector given the risks it carries and the complexity of dealing with because of its informality, the educational status of its owners, and the lack of formal assistance by veterinary services. The results suggests that the MCDA approach could be a useful tool for animal health agencies when planning a program to eliminate FMD (as well as other diseases) in a structured way because it helps to identify which alternatives would yield more effective results and it helps to address future challenges.

Measles: a millennial itch in the COVID-19 era. / Sarampión: un prurito milenario en tiempos de COVID-19.

Measles is a viral disease with an ample clinical spectrum that can range from fever, cough and rash, to death. It is the most contagious human disease known. In the last 50 years, mainly due to vaccination, its mortality has decreased by more than 90%. However, in the last five years the cases of Measles have increased significantly, causing 144,000 deaths in 2019. In Mexico, the arrival of COVID-19 represents a serious threat to immunization programs because it converges in time with the worst measles outbreak since 1994.

El sarampión es una enfermedad viral de amplio espectro clínico que puede ir desde fiebre, tos y exantema, hasta la muerte. Es la enfermedad humana más contagiosa que se conoce. En los últimos 50 años, y en esencia gracias a la vacunación, su mortalidad se redujo en más del 90%. Sin embargo, en el último quinquenio han ido en aumento los casos de sarampión y en 2019 ocasionaron 144,000 decesos. Para México, la llegada de la COVID-19 representa una grave amenaza a los programas de inmunización, pues coincide con el momento en que se registra el peor brote de sarampión desde 1994.

A erradicação da poliomielite em quatro tempos / La erradicación de la poliomielitis en cuatro tiempos / Poliomyelitis eradication in four stages

O objetivo deste artigo é rever o "estado da arte" dos avanços, obstáculos e estratégias para atingir a erradicação global da pólio. As ações de controle da poliomielite iniciaram na década de 1960 com o advento das duas vacinas antipoliomielíticas, a vacina oral da pólio (VOP) e a vacina inativada da pólio (VIP). No período de 1985 a 2020, são implementadas estratégias para atingir a meta de erradicação do poliovírus selvagem (WPV). Após o sucesso da interrupção da transmissão autóctone do WPV na região da Américas, foi lançada a meta da erradicação global. Descrevemos o processo de erradicação em quatro tempos: (1) O advento das vacinas VIP e VOP iniciou a era do controle da poliomielite; (2) A utilização massiva e simultânea da VOP teve impacto significativo sobre a transmissão do poliovírus selvagem no final da década de 1970 no Brasil; (3) Políticas públicas (nacionais e internacionais) decidem pela erradicação da transmissão autóctone do poliovírus selvagem nas Américas e definem as estratégias epidemiológicas para interromper a transmissão; e (4) A implantação das estratégias de erradicação interrompeu a transmissão autóctone do WPV em quase todas as regiões do mundo, exceto no Paquistão e Afeganistão, onde, em 2020, cadeias de transmissão do WPV1 desafiam as estratégias de contenção do vírus. Por outro lado, a persistência e a disseminação da circulação do poliovírus derivado da VOP, em países com baixa cobertura vacinal, somadas às dificuldades para substituir a VOP pela VIP constituem, atualmente, os obstáculos para a erradicação a curto prazo. Finalmente, discutimos as estratégias para superar os obstáculos e os desafios na era pós-erradicação.

El objetivo de este artículo es revisar el "estado de la cuestión" de los avances, obstáculos y estrategias para alcanzar la erradicación global de la polio. Las acciones de control de la poliomielitis se iniciaron en la década de 1960, con el advenimiento de las dos vacunas antipoliomielíticas, la vacuna oral de la polio (VOP) y la vacuna inactivada de la polio (VIP). En el período de 1985 a 2020, se implementan estrategias para alcanzar la meta de la erradicación del virus de la polio salvaje (WPV). Tras el éxito de la interrupción de la transmisión autóctona del WPV en la región de las Américas, se lanzó la meta de la erradicación global. Describimos el proceso de erradicación en cuatro tiempos: (1) El advenimiento de las vacunas VIP y VOP inició la era del control de la poliomielitis; (2) La utilización masiva y simultánea de la VOP tuvo un impacto significativo sobre la transmisión del virus de la polio salvaje, al final de la década de 1970, en Brasil; (3) Políticas públicas (nacionales e internacionales) deciden la erradicación de la transmisión autóctona del virus de la polio salvaje en las Américas y definen las estrategias epidemiológicas para interrumpir la transmisión; y (4) La implantación de las estrategias de erradicación interrumpió la transmisión autóctona del WPV en casi todas las regiones del mundo, excepto en Paquistán y Afganistán, donde, en 2020, cadenas de transmisión del WPV1 desafían las estrategias de contención del virus. Por otro lado, la persistencia y la diseminación de la circulación del virus de la polio, derivado de la VOP, en países con baja cobertura de vacunas, sumadas a las dificultades para substituir la VOP por la VIP constituyen, actualmente, los obstáculos para la erradicación a corto plazo. Finalmente, discutimos las estrategias para superar los obstáculos y los desafíos en la era poserradicación.

This article's objective is to review the "state of the art" in the progress, obstacles, and strategies for achieving global polio eradication. Poliomyelitis control measures began in the 1960s with the advent of two vaccines, the oral polio vaccine (OPV) and the inactivated polio vaccine (IPV). From 1985 to 2020, strategies were implemented to reach the goal of eradication of wild poliovirus (WPV). Following the success with the interruption of indigenous WPV transmission in the Americas, the goal of global eradication was launched. We describe the process of eradication in four historical stages: (1) The advent of the inactivated and oral polio vaccines launched the age of poliomyelitis control; (2) The massive and simultaneous use of OPV had a significant impact on WPV transmission in the late 1970s in Brazil; (3) Domestic and international public policies set the goal of eradication of indigenous WPV transmission in the Americas and defined the epidemiological strategies to interrupt transmission; and (4) The implementation of eradication strategies interrupted indigenous WPV transmission in nearly all regions of the world except Pakistan and Afghanistan, where in 2020 the WPV1 transmission chains have challenged the strategies for containment of the virus. Meanwhile, the persistence and dissemination of circulation of OPV-derived poliovirus in countries with low vaccination coverage, plus the difficulties in replacing OPV with IPV, are currently the obstacles to eradication in the short term. Finally, we discuss the strategies for overcoming the obstacles and challenges in the post-eradication era.

Caracterización del paludismo como enfermedad endémica en Ecuador / Characterization of the malaria like endemic illness in Ecuador

RESUMEN Fundamento: el paludismo como problema de salud pública mundial, afecta a un elevado número de personas cada año. Congruente con evaluaciones de la Organización Mundial de la Salud y la Organización Panamericana de la Salud, cada año se presentan entre 50 y 100 millones de casos de la enfermedad. Objetivo: caracterizar el paludismo como enfermedad endémica en Ecuador. Métodos: se realizó una revisión bibliográfica de un total de 23 artículos en las bases de datos Scopus, Latindex y SciELO, mediante un gestor de búsqueda y administrador de referencias Endnote, de ellos 22 corresponden a los últimos cuatro años, 12 corresponden a artículos en diferentes revistas electrónicas y sitios web especializados en el tema y 11 a informes y documentos de organizaciones mundiales, de los cuales se utilizaron 72 citas seleccionadas para la revisión. Resultados: los diferentes documentos relacionados con las estadísticas, destacan el incremento del paludismo en diferentes áreas del planeta, por lo cual se intencionan acciones que contribuyen a su disminución e incluso erradicación, sin embargo en Ecuador, en los últimos dos años los resultados son desfavorables en este sentido. Conclusiones: es evidente que los directivos de la salud pública y factores comunitarios de cada país afectado por paludismo, deben asumir un enfoque preventivo que vele por los problemas de salud de las comunidades y favorezca el medio ambiente, fomenten en iniciativas que promuevan mayor responsabilidad ambiental a favor de erradicarla. En el caso de Ecuador, se muestran resultados desfavorables que tienden al incremento de esta enfermedad.

ABSTRACT Background: the malaria as problem of world public health, affects a high number of persons every year. Coherent with evaluations of the World Health Organization and the Pan-American Health Organization, between 50 and 100 million cases of the illness are presented every year. Objective: to characterize the malaria as an endemic illness in Ecuador. Methods: a bibliographical review of a whole of 23 articles was carried out in the Scopus, Latindex and SciELO databases, by means of a search engine and Endnote references manager, of them 22 correspond to last four years, 12 correspond to articles in different electronic magazines and web sites specializing in the topic and 11 to reports and documents of world organizations, of which 72 quotations selected for the review were used. Results: the different documents related to the statistics, emphasize the increase of the malaria in different areas of the planet, for which actions that contribute to its decrease and even eradication are carried out, nevertheless in Ecuador, in the last two years the results are unfavorable in this sense. Conclusions: it is clear that the managers of the public health and community factors of every country affected by malaria, must assume a preventive approach that looks over the problems of health of the communities and favors the environment, they encourage in initiatives that promote major environmental responsibility in favor of eradicating it. In case of Ecuador, there appear unfavorable results that tend to the increase of this illness.

A Review of Traditional Vaccine-Preventable Diseases and the Potential Impact on the Otolaryngologist.

Introduction A majority of otolaryngologists have not had direct experience with many vaccine-preventable diseases since the creation of national vaccination programs. Despite the elimination of endemic transmission of some of these diseases in the United States, outbreaks can occur anywhere and still pose a threat to public health around the world. Recent outbreaks and changing trends in exemption rates indicate that it is important for physicians to maintain a working knowledge of how these diseases present and of the recommended treatment guidelines. Objectives This review will evaluate the current state of vaccination rates, vaccine exemption rates and disease incidence in the United States and in the world. It will also examine the clinical presentation and treatment recommendations of these diseases. Data Synthesis United States estimated vaccination rates, vaccine exemption rates and vaccine-preventable disease incidences were obtained from data compiled by the Centers for Disease Control and Prevention. World vaccination rates and disease incidences were obtained from the World Health Organization databases, which compile official figures reported by member states. A PubMed literature review provided information on the current state of vaccination exemptions and outbreaks in the United States. Conclusion Vaccination and vaccine exemption rates continue to put the United States and many areas of the world at risk for outbreaks of vaccine-preventable diseases. Clinical guidelines should be reviewed in the event of a local outbreak.

A Review of Traditional Vaccine-Preventable Diseases and the Potential Impact on the Otolaryngologist

Abstract Introduction A majority of otolaryngologists have not had direct experience with many vaccine-preventable diseases since the creation of national vaccination programs. Despite the elimination of endemic transmission of some of these diseases in the United States, outbreaks can occur anywhere and still pose a threat to public health around the world. Recent outbreaks and changing trends in exemption rates indicate that it is important for physicians to maintain a working knowledge of how these diseases present and of the recommended treatment guidelines. Objectives This review will evaluate the current state of vaccination rates, vaccine exemption rates and disease incidence in the United States and in the world. It will also examine the clinical presentation and treatment recommendations of these diseases. Data Synthesis United States estimated vaccination rates, vaccine exemption rates and vaccine-preventable disease incidences were obtained from data compiled by the Centers for Disease Control and Prevention. World vaccination rates and disease incidences were obtained from the World Health Organization databases, which compile official figures reported by member states. A PubMed literature review provided information on the current state of vaccination exemptions and outbreaks in the United States. Conclusion Vaccination and vaccine exemption rates continue to put the United States and many areas of the world at risk for outbreaks of vaccine-preventable diseases. Clinical guidelines should be reviewed in the event of a local outbreak.

Intervenciones en salud pública: bases conceptuales para la determinación de objetivos y evaluación / Public health interventions: conceptual basis for the determination of objectives and evaluation

RESUMEN Este artículo tiene como objetivo difundir conceptos relevantes en el diseño de intervenciones sanitarias. Teniendo en cuenta que la evidencia epidemiológica y la potencia del instrumental disponible o composición tecnológica de control son fundamentales para la determinación de una escala de objetivos en salud pública: extinción; erradicación; eliminación; control o reducción de niveles de exposición o control de la transmisión natural; reducción o prevención de ocurrencia de epidemias; limitación del daño y reducción de la mortalidad. El factor limitante para el logro de estos objetivos debe estar dado por la epidemiología de la enfermedad, que puede estar determinada por inaccesibilidad y/o patrones excepcionales de transmisión, dificultades operacionales e insuficiencia de medios, pero no por la inaplicación del conocimiento existente.

ABSTRACT This article aims to disseminate relevant concepts in the design of health interventions. Taking into account that the epidemiological evidence and the strength of the available instruments or technological control composition are fundamental for the determination of a scale of public health objectives: extinction, eradication, elimination, control or reduction of levels of exposure or control of natural transmission, reduction or prevention of the occurrence of epidemics, limitation of damage and reduction of mortality. The limiting factor for achieving these objectives must be given by the epidemiology of the disease, which may be determined by inaccessibility or exceptional patterns of transmission, operational difficulties, and insufficient means, but not by the inapplicability of existing knowledge.

[Epidemiologic study of leprosy in Brazil: reflections on elimination goalsEstudio epidemiológico de la lepra en el Brasil: reflexión sobre las metas de eliminación]. / Estudo epidemiológico da hanseníase no Brasil: reflexão sobre as metas de eliminação.

OBJECTIVE: To describe the epidemiological profile of leprosy in Brazil in the period from 2005 to 2015 and describe the behavior of leprosy indicators in relation to the goals established by the World Health Organization (WHO) for elimination of this disease. METHOD: The study was performed using data from the Ministry of Health websites. The following indicators were assessed: prevalence, overall coefficient of detection, coefficient of detection according to age (< 15 years or ≥ 15 years), cure rate, and proportion of cases with WHO grade 2 disability. RESULTS: During the study period, the prevalence of leprosy cases was stable at a medium level (1.00 to 4.99/10 000 population), with decreasing national trend. However, the national trend was not observed in the Northeast, North, and Midwest regions. The coefficient of new cases in individuals < 15 years of age decreased from 2005 to 2015 in all regions. A marked decrease was detected in the proportion of new cases with grade 2 disability, especially in the South and Southeast. The North was the only region with increase in this indicator. The rate of leprosy cure in Brazil has not changed since 2005, having remained within the 75-90% range regardless of age group. CONCLUSION: There was improvement (reduction) in the main leprosy indicators in Brazil from 2005 to 2015. Even though Brazil did not eradicate leprosy, this goal will likely be reached in 2020 if the current parameters are maintained. Leprosy control policies should be adapted to the reality of each Brazilian region, given the heterogeneous distribution of prevalence.

OBJETIVOS: Describir el perfil epidemiológico de la lepra en el Brasil en el período 2005-2015 y verificar cómo se comportan los indicadores brasileños en relación con las metas establecidas por la Organización Mundial de la Salud (OMS) para la eliminación de esa enfermedad. MÉTODOS: La investigación se realizó a partir de los datos disponibles en los sitios del Ministerio de Salud. Los indicadores evaluados fueron los datos de prevalencia, los coeficientes de detección general y por grupo etario (<15 o ≥ 15 años), el porcentaje de curación y la discapacidad de grado 2. RESULTADOS: En el período del estudio, el coeficiente de prevalencia de casos de lepra se mantuvo en un nivel promedio (de 1,00 a 4,99/10 000 habitantes), con una tendencia nacional decreciente. Sin embargo, en las regiones del nordeste, norte y centro-oeste no se observó ese comportamiento. El coeficiente de casos nuevos en menores de 15 años disminuyó entre el 2005 y el 2015 en todas las regiones. El coeficiente de detección de casos nuevos con diagnóstico de discapacidad de grado 2 tuvo una reducción significativa, principalmente en las regiones del sur y del sudeste; el norte del país fue la única región donde aumentó ese coeficiente. El porcentaje de curación de la lepra en el Brasil no ha cambiado desde el 2005 y se considera regular (de 75% a 90%), independientemente del grupo de edad. CONCLUSIÓN: Los principales indicadores de lepra se redujeron en el período del estudio. Aunque no se haya erradicado la lepra en el Brasil, esa meta deberá alcanzarse en el 2020 si se mantienen los parámetros. Se recomienda adaptar la política de atención a la lepra a la realidad de cada región brasileña, en vista de que la prevalencia de la enfermedad presenta una distribución heterogénea.

Estudo epidemiológico da hanseníase no Brasil: reflexão sobre as metas de eliminação / Epidemiologic study of leprosy in Brazil: reflections on elimination goals / Estudio epidemiológico de la lepra en el Brasil: reflexión sobre las metas de eliminación

RESUMO Objetivos Descrever o perfil epidemiológico da hanseníase no Brasil no período de 2005 a 2015 e verificar como os indicadores brasileiros estão se comportando em relação às metas estipuladas pela Organização Mundial da Saúde (OMS) para eliminação dessa doença. Métodos A pesquisa foi realizada a partir dos dados disponíveis nos sites do Ministério da Saúde. Foram avaliados os indicadores: dados de prevalência, coeficientes de detecção geral e conforme grupo etário (< 15 anos ou ≥ 15 anos), porcentagem de cura e grau 2 de incapacidade. Resultados No período do estudo, o coeficiente de prevalência dos casos de hanseníase manteve-se em patamar médio (de 1,00 a 4,99/10 000 habitantes), com tendência nacional decrescente. Entretanto, esse comportamento não foi observado nas regiões Nordeste, Norte e Centro-Oeste. O coeficiente de casos novos em indivíduos com menos de 15 anos apresentou diminuição entre 2005 e 2015 em todas as regiões. O coeficiente de detecção de casos novos diagnosticados com grau 2 de incapacidade teve redução significativa, principalmente nas regiões Sul e Sudeste; o Norte do país foi a única região com aumento desse coeficiente. O percentual de cura de hanseníase no Brasil, independentemente da faixa etária, não sofreu alteração desde 2005, sendo considerado regular (75% a 90%). Conclusão Os principais indicadores de hanseníase apresentaram redução no período do estudo. Embora o Brasil não tenha erradicado a hanseníase, essa meta deverá ser alcançada em 2020 caso sejam mantidos os parâmetros. Recomenda-se adaptar a política de atenção à hanseníase à realidade de cada região brasileira, visto que a prevalência da doença apresenta distribuição heterogênea.

ABSTRACT Objective To describe the epidemiological profile of leprosy in Brazil in the period from 2005 to 2015 and describe the behavior of leprosy indicators in relation to the goals established by the World Health Organization (WHO) for elimination of this disease. Method The study was performed using data from the Ministry of Health websites. The following indicators were assessed: prevalence, overall coefficient of detection, coefficient of detection according to age (< 15 years or ≥ 15 years), cure rate, and proportion of cases with WHO grade 2 disability. Results During the study period, the prevalence of leprosy cases was stable at a medium level (1.00 to 4.99/10 000 population), with decreasing national trend. However, the national trend was not observed in the Northeast, North, and Midwest regions. The coefficient of new cases in individuals < 15 years of age decreased from 2005 to 2015 in all regions. A marked decrease was detected in the proportion of new cases with grade 2 disability, especially in the South and Southeast. The North was the only region with increase in this indicator. The rate of leprosy cure in Brazil has not changed since 2005, having remained within the 75-90% range regardless of age group. Conclusion There was improvement (reduction) in the main leprosy indicators in Brazil from 2005 to 2015. Even though Brazil did not eradicate leprosy, this goal will likely be reached in 2020 if the current parameters are maintained. Leprosy control policies should be adapted to the reality of each Brazilian region, given the heterogeneous distribution of prevalence.

RESUMEN Objetivos Describir el perfil epidemiológico de la lepra en el Brasil en el período 2005-2015 y verificar cómo se comportan los indicadores brasileños en relación con las metas establecidas por la Organización Mundial de la Salud (OMS) para la eliminación de esa enfermedad. Métodos La investigación se realizó a partir de los datos disponibles en los sitios del Ministerio de Salud. Los indicadores evaluados fueron los datos de prevalencia, los coeficientes de detección general y por grupo etario (<15 o ≥ 15 años), el porcentaje de curación y la discapacidad de grado 2. Resultados En el período del estudio, el coeficiente de prevalencia de casos de lepra se mantuvo en un nivel promedio (de 1,00 a 4,99/10 000 habitantes), con una tendencia nacional decreciente. Sin embargo, en las regiones del nordeste, norte y centro-oeste no se observó ese comportamiento. El coeficiente de casos nuevos en menores de 15 años disminuyó entre el 2005 y el 2015 en todas las regiones. El coeficiente de detección de casos nuevos con diagnóstico de discapacidad de grado 2 tuvo una reducción significativa, principalmente en las regiones del sur y del sudeste; el norte del país fue la única región donde aumentó ese coeficiente. El porcentaje de curación de la lepra en el Brasil no ha cambiado desde el 2005 y se considera regular (de 75% a 90%), independientemente del grupo de edad. Conclusión Los principales indicadores de lepra se redujeron en el período del estudio. Aunque no se haya erradicado la lepra en el Brasil, esa meta deberá alcanzarse en el 2020 si se mantienen los parámetros. Se recomienda adaptar la política de atención a la lepra a la realidad de cada región brasileña, en vista de que la prevalencia de la enfermedad presenta una distribución heterogénea.

Manejo de la infección por Helicobacter pylori: apreciación crítica de la literatura / Treatment of the Helicobacter pylori Infection: A Critical Appraisal of the Literature

Introducción: la infección por Helicobacter pylori es un problema de salud pública, dada su relación con cáncer gástrico. El incremento de la resistencia bacteriana limita la erradicación efectiva, a pesar del empleo de diferentes esquemas de tratamiento. Métodos: revisión de la literatura en la base de datos Pubmed/Medline entre el 1 de enero de 2015 y el 31 de diciembre de 2016 sobre el manejo del Helicobacter pylori. Resultados: se incluyeron 26 artículos. La terapia secuencial sobresale como opción de tratamiento de primera línea para escenarios como Colombia. La implementación de coadyuvantes puede influir en las tasas de erradicación. Los estudios de epidemiología local y costo-efectividad son escasos. Conclusiones: el uso y conocimiento adecuado de los esquemas de manejo puede disminuir los costos para el sistema, la resistencia antimicrobiana y favorecer la erradicación de patógenos. Se requieren estudios para generar recomendaciones locales.

Introduction: Helicobacter pylori (H. pylori) infection is a public health problem due to its relationship with gastric cáncer The escalation of antibiotic resistance hampers an effective eradication, despite the availability of treatment options. Methods: A review of the literature was performed in the database PubMed between 01/01/2015 and 31/31/2016. Results: Twenty six articles were included. Sequential therapy stands out as a first line therapy for scenarios such as Colombia. The implementation of adjuvants may have a positive impact on eradication rates. Local epidemiólogo- and cost-effectiveness studies are scarce. The results were analized by erradication therapies, coadyuvant treatment, guidelines and outcomes non mentioned in the guidelines. Conclusions: The correct use and knowledge of the different treatment options could reduce the costs for the health systems, the antibiotics resistance and could favor pathogen eradication. Further studies are required for establishing local recommendations.

Infección por Cystoisospora belli en pacientes con VIH: análisis de casos con diferente evolución clínica / Cystoisospora belli infection in HIV patients: analysis of cases with different clinical evolution

Resumen Introducción: La infección por Cystoisospora belli es una de las causas más frecuentes de diarrea acuosa en pacientes con infección por VIH y ocasiona altas tasas de morbilidad y mortalidad. Métodos: Se realizó un estudio retrospectivo en pacientes infectados con VIH y diarrea por C. belli. Características clínicas y de laboratorio fueron recolectadas mediante el análisis de historias clínicas. Resultados: Se identificaron siete casos. Cuatro presentaron diarrea recurrente a pesar de recibir profilaxis secundaria con cotrimoxazol y tratamiento específico, dos de los cuales tuvieron buena respuesta viral e inmunológica al tratamiento anti-retroviral de gran actividad (TARGA) al momento del diagnóstico y tratamiento antiparasitario. Mientras que, los tres restantes no recibían profilaxis, tampoco TARGA (dos de ellos), pero respondieron bien al tratamiento. Conclusiones: C. belli es causa importante de diarrea en pacientes VIH con TARGA y profilaxis, pudiendo tener distinta evolución clínica. Sugerimos que la infección persistente puede ser debido al fallo farmacológico por causas intrínsecas o extrínsecas al parásito, o a defectos en la restauración del sistema inmune intestinal, o ambos.

Introduction: Cystoisospora belli infection is one of the most important causes of watery diarrhea in patients with HIV and causes high rates of morbidity and mortality. Methods: A retrospective study was conducted in patients with HIV and diarrhea by C. belli. Clinical and laboratory characteristics were collected by analyzing clinical records. Results: Four had recurrent diarrhea despite receiving secondary prophylaxis with cotrimoxazole and specific treatment, two of which had a good viral and immunological response to highly active antiretroviral therapy (HAART) at the time of diagnosis and antiparasitic treatment. While the remaining three did not receive prophylaxis, neither did HAART (two of them), but they responded well to treatment. Conclusions: C. belli is an important cause of diarrhea in HIV patients on HAART and prophylaxis, being able to have different clinical evolution. We suggest that persistent infection may be due to drug failure by intrinsic or extrinsic to the parasite causes, or to defects in restoration of the intestinal immune system, or both.

Efectividad de un nuevo régimen simplificado en la erradicación de Helicobacter pylori. Estudio prospectivo realizado en una clínica privada de Lima Metropolitana / New simplified regimen for Helicobacter pylori eradication achieves high effectiveness. Prospective study in a private clinic in Lima, Peru

RESUMEN Objetivo: Determinar la efectividad de dos nuevos esquemas para el tratamiento de Helicobacter pylori frente al esquema triple convencional de amoxilina, claritromicina y un inhibidor de bomba de protones. Materiales y métodos: Estudio prospectivo, no aleatorio, realizado en una clínica privada de Lima, Perú. Los pacientes con infección por Helicobacter demostrada por endoscopia con biopsia y/o test de la ureasa, recibieron uno de tres tratamientos en estudio y fueron examinados mediante el test del aliento con urea C14, entre 1 y 6 meses después. Resultados: El tratamiento triple convencional solo logró la erradicación en 49/68 casos (71,2%) y el cuádruple con doxiciclina, metronidazol, bismuto y esomeprazol lo hizo en 52/62 casos (83,9%) siendo esta diferencia no significativa (p>0,1). El esquema simplificado de doxiciclina, furazolidona y bismuto logró curar a 79/83 pacientes (95,2%) superando a los dos anteriores con valor significativo (p<0,005 y p<0,05 respectivamente). Conclusiones: El tratamiento triple convencional para Helicobacter no está alcanzando niveles aceptables de efectividad en nuestra institución. Esto enfatiza la necesidad de buscar nuevas alternativas; por lo que sería útil validar con nuevos estudios los buenos resultados logrados por el régimen Simplificado de doxiciclina, furazolidona y bismuto que aquí presentamos

ABSTRACT Objective: To determine the effectiveness of two new therapeutic regimes for Helicobacter pylori versus triple therapy that includes a proton pump inhibitor, amoxicillin and clarithromycin. Materials and methods: prospective study, non-randomized, in a private Hospital in Lima, Peru. Patients with biopsy and/or rapid ureasa test proven Helicobacter pylori infection received one of the three therapeutic regimens and were followed with a urea breath test 1 to 6 months upon completion of therapy. Results: Triple therapy achieved eradication in 49/68 of cases (71.2%); quadruple therapy (doxycycline + metronidazole + bismuth + esomeprazole) in 52/62 (83.9%), and the simplified regimen with doxycycline + furazolidone + bismuth, obtained success in 79/83 of cases (95.2%). Statistically significant difference with p<0.005 and p<0.05 respectively. Conclusion: Triple therapy against Hp does not achieve acceptable effectiveness in our institution. This highlights the need to look for new therapeutic options, being the simplified regime (doxycycline, furazolidone and bismuth) used in the current study a good option, requiring further studies for validation.