The nutrition transition in the Venezuelan Amazonia: increased overweight and obesity with transculturation.

OBJECTIVES: Amerindians have a particularly high propensity to overweight and obesity as they change lifestyle and experience a nutrition transition. The aim of this study was to evaluate the effects of transculturation on nutritional status in three Amazonian Amerindian villages. METHODS: Nutritional status was assessed in 232 volunteers: 65 Yanomami from an isolated village and 167 Guahibo subjects from villages with intermediate and high levels of transculturation. RESULTS: There was a significant pattern of decreasing stunting and increasing overweight and obesity across the gradient of transculturation. From the jungle Yanomami to the intermediate and transculturated Guahibo, stunting was respectively 72, 55, and 39%, and children /adult overweight was 0, 3/44, and 15/89%. These anthropometric-based patterns were confirmed by bioimpedance vector analysis. CONCLUSIONS: Transculturation in these Amerindian populations is associated with an increase in overweight and obesity coexisting with undernourished children.

Anaemia and malaria in Yanomami communities with differing access to healthcare.

Inequitable access to healthcare has a profound impact on the health of marginalised groups that typically suffer an excess burden of infectious disease morbidity and mortality. The Yanomami are traditionally semi-nomadic people living in widely dispersed communities in Amazonian Venezuela and Brazil. Only communities living in the vicinity of a health post have relatively constant access to healthcare. To monitor the improvement in the development of Yanomami healthcare a cross-sectional survey of 183 individuals was conducted to investigate malaria and anaemia prevalence in communities with constant and intermittent access to healthcare. Demographic and clinical data were collected. Malaria was diagnosed by microscopy and haemoglobin concentration by HemoCue. Prevalence of malaria, anaemia, splenomegaly, fever and diarrhoea were all significantly higher in communities with intermittent access to healthcare (anaemia 80.8% vs. 53.6%, P<0.001; malaria 18.2% vs. 6.0%, P=0.013; splenomegaly 85.4% vs.12.5%, P<0.001; fever 50.5% vs. 28.6%, P=0.003; diarrhoea 30.3% vs.10.7% P=0.001). Haemoglobin level (10.0 g/dl vs. 11.5 g/dl) was significantly associated with access to healthcare when controlling for age, sex, malaria and splenomegaly (P=0.01). These findings indicate a heavy burden of anaemia in both areas and the need for interventions against anaemia and malaria, along with more frequent medical visits to remote areas.

Malaria diagnosis under field conditions in the Venezuelan Amazon.

To improve practical, accurate diagnosis of malaria in the Amazon rainforest of Venezuela, two rapid diagnostic tests (RDT) (OptiMAL-IT) and FalciVax) and a laboratory light microscope, used in the field with a battery-operated head lamp as an external light source, were evaluated against the standard laboratory microscope procedure for malaria detection. One hundred and thirty-six Yanomami patients were studied for the presence of malaria parasites. Thirty-three patients (24%) were positive for malaria (Plasmodium falciparum, P. vivax, P. malariae). Twenty-one (64%) of the positive patients had <100 parasites/microl. Both RDTs showed poor sensitivity (24.2% for OptiMAL-IT) and 36.4% for FalciVax) but good specificity (99% both for OptiMAL-IT) and FalciVax). Field and laboratory microscopy showed sensitivities of 94% and 91%, respectively. The kappa coefficient was 0.90, indicating a high agreement between field and laboratory microscopy. We conclude that (i) adequate slide reading cannot be substituted by either of the two RDTs in the Venezuelan Amazon and (ii) the use of a light source such as that described above makes slide reading more feasible than hitherto in remote areas without electricity.

Polymorphism in the gene encoding the apical membrane antigen-1 (AMA-1) of Plasmodium falciparum. X. Asembo Bay Cohort Project.

We have investigated the genetic diversity of the gene encoding the apical membrane antigen-1 (AMA-1) in natural populations of Plasmodium falciparum from western Kenya and compared it with parasite populations from other geographic regions. A total of 28 complete sequences from Kenya, Thailand, India, and Venezuela field isolates were obtained. The genetic polymorphism is not evenly distributed across the gene, which is in agreement with the pattern reported in earlier studies. The alleles from Kenya exhibit 20 and 30% more polymorphism than that found in Southeast Asia and Venezuelan alleles, respectively. Based on the gene genealogies derived from sequencing data, no evidence for allele families was found. We have found evidence supporting limited gene flow between the parasite populations, specifically, between the Southeast Asian and Venezuelan isolates; however, no alleles could be linked to a specific geographic region. This study reveals that positive natural selection is an important factor in the maintenance of genetic diversity for AMA-1. We did not find conclusive evidence indicating intragenic recombination is important in the generation of the AMA-1 allelic diversity. The study provides information on the genetic diversity of the AMA-1 gene that would be useful in vaccine development and testing, as well as in assessing factors that are involved in the generation and maintenance of the genetic diversity in P. falciparum.

Spur cell anaemia and acute haemolysis in patients with hyperreactive malarious splenomegaly. Experience in an isolated Yanomamo population of Venezuela.

A prospective study, aimed to investigate the aetiology of an unusual clustering of cases of severe acute haemolytic anaemia affecting a high percentage of the adult population, was carried out in two isolated Yanomamo communities of the Upper Orinoco basin in Venezuela. Twenty-six patients with active or recent episodes of severe haemolysis were evaluated. All of them exhibited massive liver and spleen enlargement and fulfilled the diagnostic criteria of the hyperreactive malarious splenomegaly (HMS) syndrome. In four cases with advanced non-alcohol-related chronic liver disease, hypersplenism, severe haemolytic anaemia and acanthocytosis, the characteristic clinical and laboratory findings of spur cell anaemia were documented. Chronic infection by the HBV and HCV was present in three of them. However, in most of the 22 additional HMS cases, the acute haemolytic condition appeared associated with the occurrence of a cold agglutinin-mediated autoimmune response. The clustering of a significant number of cases of severe acute haemolysis in HMS patients from this small isolated aboriginal community is most unusual, and represents a serious complicating factor for a population already beleaguered by a high prevalence of malaria due to multiresistant strains of Plasmodium falciparum. Moreover, the coexistence of HMS and severe chronic HBV or HCV infection may further aggravate the course of the haemolytic disorder, because of the occurrence of spur cell anaemia.

High dose artesunate in combination with mefloquine: pharmacovigilance in the Venezuelan Amazon.

Forty-six patients in a remote health post of Amazonas, Venezuela, accidentally received artesunate in a dose of 10 mg/kg/day combined with mefloquine. This corresponds to the upper limit of the therapeutic range recommended by the WHO (2-10 mg/kg/day). Side effects were retrospectively investigated and a pharmacovigilance report was written. The main side effects were vomiting and diarrhea. Four patients developed complications with signs of dehydration. It is suggested to re-assess the therapeutic range of artesunate when given in combination with mefloquine and to establish a worldwide centralized antimalarial toxicity reporting system.

Assessment of routine malaria diagnosis in the Venezuelan Amazon.

The quality of routine malaria diagnosis is a crucial topic of malaria control. The aim of this assessment was to monitor and evaluate the quality of routine malaria diagnosis in Amazonas (Venezuela) and to improve the quality control system. The traditional non-blinded quality control system was found to be overburdened with diagnostic samples. A modified sampling system with fewer samples to be tested was proposed. Expert microscopists blindly double-checked 1000 slides and 550 rapid diagnostic tests (RDT) (OptiMAL-IT) from health posts (HP). For Plasmodium vivax, HP microscopy and OptiMAL-IT showed sensitivies of 86% and 63%, respectively. For P. falciparum, HP microscopy and OptiMAL-IT showed sensitivities of 68% and 89%, respectively. Both methods lost accuracy when fewer parasites occurred in the sample. HP microscopists from different municipalities displayed significant differences in diagnostic quality. Overall, quality of routine malaria diagnosis in the Venezuelan Amazon is good but not optimal. The change from the traditional non-blinded quality control system to blinded cross-checking of a minimal selection of samples is - comparatively - a low cost intervention with possibly high impact on the quality of routine malaria diagnosis. The introduction of RDTs should be discussed carefully in order not to displace an existing network of HP microscopists.

Community-randomized trial of lambdacyhalothrin-treated hammock nets for malaria control in Yanomami communities in the Amazon region of Venezuela.

We conducted a community-randomized controlled trial in an area of moderate malaria transmission in the Amazon region, southern Venezuela, home of the Yanomami indigenous ethnic group. The aim was to compare the malaria incidence rate in villages with lambdacyhalothrin-treated hammock nets (ITHN) or with placebo-treated hammock nets (PTHN). In both arms of the study, intensive surveillance for early case detection was maintained and prompt malaria treatment was administered. Baseline data were collected before the intervention and a population of around 924 Yanomami was followed for 2 years. Despite the recent introduction of nets in the Yanomami villages and the adverse natural conditions in the area, the nets were accepted enthusiastically by the study population, used conscientiously and looked after carefully. The malaria incidence rate per thousand person-years at risk was 114.6 in the IHTN group and 186.8 in the PTHN group. The adjusted rate ratios indicated that ITHN prevent 56% [IRR: 0.44, 95% confidence interval (CI): 52-59%] of new malaria cases. ITHN reduced the prevalence of parasitaemia by 83% [relative risks (RR): 0.17, 95% CI: 47-100%], according to a cross-sectional survey carried out during the high transmission season. The prevalence of splenomegaly and anaemia was too low to detect any possible reduction as a result of ITHN. The main conclusion of the present study is that ITHN can reduce malaria incidence in the area and it is the most feasible method for malaria control in a forested area where indigenous villages are scattered over a large territory. This is the first community-level epidemiological trial to show that ITHN are highly effective against malaria transmitted by Anopheles darlingi.

Prevalence of antibodies against hepatitis E virus among urban and rural populations in Venezuela.

Antibodies against hepatitis E virus (HEV) were detected in sera by a synthetic peptide-based enzyme immunoassay (EIA) from different populations in Venezuela. Antibodies against HEV were found in 1.6% (3/184) of urban pregnant woman (Caracas), in 3.9% (8/204) of rural populations (San Camilo, Edo Apure), and in 5.4% (12/223) of rural Amerindians (Padamo, Edo Amazonas). Positivity was confirmed by a neutralization EIA based on the use of competing soluble free peptides. The prevalence of antibodies in the Amerindian group was significantly higher than in urban pregnant women. No relation was found between age and HEV prevalence in rural populations. Three of 21 positive sera were also weakly positive by Western blot for IgM antibodies. This result, together with the low optical density values observed by EIA, suggested that the presence of antibodies in these sera reflects past infections. Based on these results, Venezuela does not seem to be highly endemic for hepatitis E. This is the first report of serological evidence of infection by HEV in South America.

Extensive multiple test centre evaluation of the VecTest malaria antigen panel assay.

To determine which species and populations of Anopheles transmit malaria in any given situation, immunological assays for malaria sporozoite antigen can replace traditional microscopical examination of freshly dissected Anopheles. We developed a wicking assay for use with mosquitoes that identifies the presence or absence of specific peptide epitopes of circumsporozoite (CS) protein of Plasmodium falciparum and two strains of Plasmodium vivax (variants 210 and 247). The resulting assay (VecTest Malaria) is a rapid, one-step procedure using a 'dipstick' test strip capable of detecting and distinguishing between P. falciparum and P. vivax infections in mosquitoes. The objective of the present study was to test the efficacy, sensitivity, stability and field-user acceptability of this wicking dipstick assay. In collaboration with 16 test centres world-wide, we evaluated more than 40 000 units of this assay, comparing it to the standard CS ELISA. The 'VecTest Malaria' was found to show 92% sensitivity and 98.1% specificity, with 97.8% accuracy overall. In accelerated storage tests, the dipsticks remained stable for > 15 weeks in dry conditions up to 45 degrees C and in humid conditions up to 37 degrees C. Evidently, this quick and easy dipstick test performs at an acceptable level of reliability and offers practical advantages for field workers needing to make rapid surveys of malaria vectors.

Estudio del efecto de ivermectina en helmintos intestinales en comunidades yanomamis del Alto Orinoco Estado Amazonas Venezuela / Study of effect of ivermectin in helminths intestinal in communities yanomami of High Orinoco State Amazonas Venezuela

Altas prevalencia de infecciones helmínticas intestinales han sido observadas entre la población amerindia de la Amazonía venezolana, siendo ascaris lumbricoides, trichuris trichiura y los anquilostomídes los helmintos más frecuentes en estas poblaciones. Una muestra de heces de individuos de la etnia Yanomami, de la región de Ocamo, Alto Orinoco, fue examinada para helmintos instestinales mediante la técnica de Kato-Katz, para determinar el efecto de la ivermectina sobre los parásitos antes mencionados, después de una dosis de éste fármaco. La droga tuvo un efecto importante sobre A. lumbricoides y T. trichiura, reduciendo la prevalencia y la carga parasitaria, a los 15 días después del tratamiento, de 64,70 a 7,56 por ciento, la prevalencia, y de 6.422,32 a 995,50 huevos/g de heces a la carga parasitaria para A. lumbricoides. Para T. trichiura, la prevalencia disminuyó de 89,07 a 45,38 por ciento y la carga parasitaria se redujo de 2.495 a 549,96 huevos/g de heces. No hubo un efecto significativo sobre los anquilostomídeos. Dos meses después del tratamiento, hubo un incremento de la prevalencia de T. trichiura a niveles pre-tratamiento (80,67 por ciento), mientras que la carga parasitaria se mantuvo reducida (615,73 huevos/g de heces). La prevalencia y la carga parasitaria de A. lumbricoides no se incrementó (9,24 por ciento; 478,39 huevos/g de heces). Los resultados de este estudio muestran que el tratamiento con invermectina tiene un efecto apreciable sobre la prevalencia y la carga parasitaria de estas infecciones helmínticas