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Revista P eruana de P arasitología Prevalence of helminths a nd intestinal protozoa in the Amazon region of San Mar tín, P eru, using a multititechniq ue appr oach V olumen 19 , Número 1 , Año 201 1 ISSN 2219-0848 (V ersión Electrónica) a,b b c a a, Vicente Maco , Catherine de Beaumont , Charles Robinson , Angelica T erashima , Luis A. Marcos a Eduardo Gotuzzo . , Prevalencia de helmint os y pro tozoarios intestinales en la r egión amazónica de San Mar tín, P erú, usando múltiples técnicas coprológicas a. Institute of T ropical Medicine Alexander von Humboldt, Cayetano Heredia University, Lima, P eru b. Division of Inf ectious Diseases, Department of Medicine, Albert Einstein College of Medicine, N ew Y ork, New Y ork, US c. Hospital de la Solidaridad, T arapo to Branch, T ar apoto, San Mar tin, P eru 06 Ar tículo Originales/ Original Ar ticles Suggested citation: Maco V , de Beaumont C, Robinson C, T erashima A , Marcos LA, Gotuzzo E. Prevalence of helminths and intestinal pr otozoa in the Amazon region of San Martin, Peru, using a multitec hnique approac h. Rev peru parasitol. 1 9(1): e06- e1 6. Acceso gratuito en línea a texto complet o. T odos los derechos r eser vados. Asociación de Parasitólogos del P erú. Copyright ® 20 1 1 R P P Resumen Abstract Key words: P alabras clave: Con el objetiv o de evaluar la carga de parásitos intestinales en el T o evaluate the prevalence of intestinal parasites in the noreste de la Amazonía P eruana, se condujo un estudio nor theast ern P eruvian Amazon, we conducted a cross-sectional coproparasitológico de cor te transversal entre individuos coprological study among individuals periodically exposed to periodicamente expuestos a antiparasit arios. Para un tamizaje antiparasitics. W e emplo yed strategic multi-tec hnique st ool estratégicos de las muestras coprológicas, utilizamos múltiples screening in 5 districts of San Mar tin: the direct smear, the técnicas en 5 distrit os de San Martín: examen directo, técnica Spontaneous Sedimentation in Tube tec hnique, the Kato-Katz de sedimentación espontánea en tubo, técnica de Kato-Katz, technique, the Lumbreras' modified Baermann technique, and técnica de Baermann modificada por Lumbreras, y tinción de the modified Ziehl-Neelsen stain. Among 246 par ticipants, the Ziehl-Neelsen modificada. De un t otal de 246 participantes, la mean age was 24.3 years (range 1 to 88). Fourteen species of edad media fue 24.3 años (rango de 1 a 88). En total se intestinal parasites were recov ered. Almost half (43.2%) of the encontraron 1 4 especies de parásitos intestinales. Alrededor de population carried at least one intestinal parasite. Mono or la mitad de la población (43,2 %) por tó al menos un parásito biparasitism occurred more frequently than polyparasitism. intestinal. El mono o biparasitismo fue más frecuente que el The highest prevalence of infection was caused by the non- poliparasitismo. La más alta prevalencia de inf ección fue pathogenic prot ozoan Entamoeba coli (20.7%), f ollowed by the causada por el protozoario no patógeno Entamoeba coli (20,7 pathogenic Giar dia lamblia (7 .7%), Blastocystis hominis (7 .7%), E. %), seguido por los patógenos Giardia lamblia (7 .7 %), h i s t o l y t i c a / di s p a r ( 1. 6 % ) , C y c l o s p o ra s p p. ( 0 . 4 %) a n d Blastocystis hominis (7,7 %), Entamoeba histolytica/dispar (1,6 %), Cr yptosporidium spp. (0.4%). Among the helminths, the most Cyclospor a spp. (0,4 %) y Cryptosporidium spp. (0,4 %). Entre los pre va len t w as As car is lu mbr ico ide s (5 .7% ), fol lowed by helmintos, el más prevalente fue Ascaris lumbricoides (5,7 %), Hymenolepis nana (4. 1%), Strongyloides stercor alis (3.7%), T richuris seguido por Hymenolepis nana (4, 1 %), Strongyloides stercor alis trichiur a (2.4%), and hookworms (2.0%). In the 1-1 0 age group, (3,7 %), T richuris trichiura (2,4%) y uncinarias (2,0 %). En el G. lamblia was statistically significantly more prevalent (15.2%, grupo de 1-1 0 años, la prevalencia de G. lamblia fue p=0.007). Males had a higher prevalence of Endolimax nana estadisticamente más prevalente (15.2%, p = 0,007). Los (8.7% vs. 1. 1%, p = 0.009). The non-pathogenic amoebas were hombres tuvieron una mayor prevalencia de Endolimax nana more prevalent than the pathogenic helminths which may (8,7 % vs. 1 , 1 %, p=0.009). Las amebas no patógenas fueron ref lect a partial success of targeted chemo therapy or the effect of más prevalentes que los helmintos patógenos lo cual ref lejaria p e ri o d i c s e l f -a n t i p a ra s i t i c t r e a t m e n t i n S a n M a r t í n . un éxito parcial del tratamiento antihelmíntico masivo y/o el P olyparasitism does not appear to be the rule in this Amazonian efecto del autotratamiento antiparasit ario que efectúan los area. The important prevalence of protozoan infection should pobladores en esta área de San Mar tin. El poliparasitismo no also be considered a target in the ef fort against intestinal parece ser común en esta área amazónica del P erú. Finalmente, parasites. la carga de infección protozoaria debería también considerarse un objetivo en el esfuerzo para el control de la parasitosis Intes tinal Diseases, Parasitic/epidemiology | intestinal. Helminthiasis | Pr otozoan Infections | San Martín | P eru. Parasitosis Intestinales/epidemiología | Helmintiasis | Infecciones por Prot ozoarios | San Martín | P erú. Revista P eruana de P arasitología V olumen 19, Número 1, Año 201 1 ISSN 2219-0848 (V ersión Electrónica) Artículo Original Maco, et al. Prevalence of heminths protozoa in the Amazon region San Martin, Peru. 07 Rev peru parasitol 2011; 19 (1) Acceso gratuito en línea a texto completo. Introduction Material and methods not inferior to KK for the diagnosis of STH and was significantly advantageous for the detection he prevalence of intestinal parasites in of Strongyloides spp. lar vae and intestina l (9-1 0) res ourc e-l imi ted cou ntr ies in L a ti n protozoa. America, suc h as P eru, is o ver whelming. T By emplo ying a strategic multi-techniq ue stool P ov erty, limited sewage disposal and sanit ar y screening approach, we conducted a cross- conditions along with a lack of systematic sectional study to evaluate the prevalence of screening sur veillance of the population at risk enteric parasites in the nor theastern P eruvian have pla ced so il-t rans mitte d helm inthi asi s ra i nfo re s t a mo n g a p op u la ti on re gu la rl y (STH ) within the spectr um of intestin al exposed to antiparasitic therapy. Individuals in parasitism as a priority in the list of neglected (1-2) t h i s a r e a a r e a d m i n i s t e r e d t a r g e t e d tropical dis eases (NTDs) w orldwide . In ch e mot he ra py (a nt ih el mi nt hi c s dr ug s a re addition, the heter ogeneous geograph y of P eru s u p p l i e d b y t h e N a t i o n a l P r o g r a m o f (coast, highlands, and rainforest) interferes with Deparasit ation/Deworming (NPD) at regular the ability of field researc hers and health care i n t e r v a l s i r r e s p e c t i v e o f t h e i n d i v i d u a l pro viders to reac h rural communities, conduct infectious statu s) or are self-treated. field studies and recommend strategies for the control of intestinal parasites that af fect the poorest communities across the countr y. The majority of the local coprological sur veys, Study ar ea and population characteris tics essential tools for assessing the success of W e con ducte d a pop ulat ion- based , cross - prev entive chemo therapy (PC) and mass drug sectional parasitological study in 5 districts of 2 a d m i n i s t r a t i o n ( M D A ) i n P e r u , a s adjacent provinces (San Mar tín and Lamas) in r e c o m m e n d e d b y t h e Wo r l d H e a l t h ( 3 ) the Department of San Mar tin, located in the O r g a n i z a t i o n ( W H O ) , s h o w s e v e r a l northeastern rainfor est of P eru (Figure 1) limitations. In particular , these sur veys hav e betw een No vember and December 20 1 0. In recruited a limited number of individuals, lack 2009, the Depar tment of San Martín reported a re l i a b l e an d c o s t- e f fe c t i ve c o n c e n t r a t i o n po ver ty ratio of 44. 1%, higher than the national techniq ues and special permanent stains for mean (34.8%). Appro ximately , 22.2% of its helminths and protozoa, and have a limited population's drinking water supply comes from number of stools evaluated per individual. For rivers, irrigation ditches, and springs, and 8.5% instance, the Lumbreras' modified Baermann of the dwellings in the region lack sewage techniq ue (BT), highly reliable for the diagnosis disposal. of Strongyloides stercor alis (S. stercoralis) and Balantidium coli (B. coli) infection, has not been systematically applied in all field studies in The city of T arapoto (06°3 1'S, 07 6°23'W), the (4-6) P eru despite its high yield, reproducibility , capital of San Martín pro vince, is the second (7) most populated district of the department, with and low cost. a total population (tp) of 1 7 6,384. T arapoto is Furthermore, the K ato-Katz (KK) techniq ue, 333 m above sea lev el and has an annual mean t h e st a n d a r d WH O - r e c o m m e n d e d s to o l temperatur e of 26 °C (78.8 °F). Four peripheral techniq ue for the diagnosis and evaluation of areas around T arapoto w ere randomly selected. the presence of schistosomiasis and soil- The ov erall study area included 4 districts in (8 ) tr a ns mi t t ed he l mi nt hs (S T H) , i s r are l y San Mar tin pro vince: T arapoto (tp = 68,295), e m p l oy e d n a t i o n w i d e . H o w e ve r, s e v e r a l Puerto Azul (tp=1,252), Morales (tp=23,56 1), preliminar y results have sho wn that our routine and Juan Guerra (tp=3,22 4) and 1 in Lamas parasitological techniq ue, the Spont aneous province: T abalosos (tp=1 2,645). Sedimentation in T ube T echniq ue (SSTT) was Field work and coprological techniq ues S S T T , a h i g h l y e f f i c a c i o u s q u a l i t a t i v e concentration technique used at our Institute; One day prior to enrollment, the physician-in- 3) the KK techniq ue; 4) BT ; and 5) the modified charge at each health care facility was contacted Z ie hl -Ne e ls en st a in (m ZN ) fo r i n te st in a l and informed of the aims of the study . All coccidian inf ections. For all techniq ues, we individuals aged 1 year or older were invited to u s e d f i l t e r e d b o t t l e d w a t e r t o a v o i d participate in local community campaigns that cont amination with an y non-specific free-living are regularly conducted by the health care nematode. Given that this area is not known to facility . Wide-mouthed plastic containers f or be endemic for F asciola hepatica or P aragonimus stool sample collection were distributed to all spp., trematodes that are notably prevalent in voluntar y par ticipants. One fresh morning (1 1) cert ain communities of the P eruvian Andes, s t o o l s a m p l e w a s c o l l e c t e d f r o m e a c h the Rapid Sediment ation T echniq ue described individual. The age, sex, and district for each (12) by Lumbreras was not performed. The sample wer e recorded on data sheets. All the Graham tec hnique f or Enterobius vermicularis participants receiv ed oral antiparasitics within and the agar plate culture for Strongyloides spp. the last 6 months as part of the NPD. and other lar vae were not used in the study . All samples w ere transported to the Section of Our multi-technique screening strategy was P arasitology of the Hospit al de la Solidaridad in applied to accurately detect a greater number of T arapoto and processed on the day of sampling intestinal parasites. A detailed report on the (av erage time from eac h district by motorcy cle ~ com parison and efficacies of the copr ological 45 min). Five coprological techniq ues were techniques used here is presented separately . performed and r ead under light microscopy (40 and 1 00 X magnification) b y 1 of 3 experienced Ethical considerations technicians in parasitology: 1) direct wet mount The study was appro ved by a designated review (D W) with normal saline and Lugol's iodine; 2) board (DRB) of the Hospitales de la Solidaridad Revista P eruana de P arasitología V olumen 19, Número 1, Año 201 1 ISSN 2219-0848 (V ersión Electrónica) 08 Rev peru parasitol 2011; 19 (1) Acceso gratuito en línea a texto completo. Figure 1. Location of study areas. Map of South America (A) and P eru (B) showing the geographical location of the 5 districts ( . ) and provinces in the depar tment of San Mar tin, P eruvian Amazon. San Martin is a province of the depar tment of the same name. Artículo Original Maco, et al. Prevalence of heminths protozoa in the Amazon region San Martin, Peru. LIMA 09 Rev peru parasitol 2011; 19 (1) Acceso gratuito en línea a texto completo. based in Lima, P eru. Since the collection of Statistical analyses stool samples presented no or minimal risk to Data were double enter ed and analyzed with the participants and involv ed no pr ocedures for Statistical P ackage for Social Sciences (SPSS), which written consent is usually r equired, the version 1 8.0 (SPSS Inc. Chicago IL) for DRB waived the requirement for a written descriptive and inf erential statistics. Scale and consent form. In each district's health care categorical variables were t abulated. A P earson facility , villagers wer e congregated by the local chi-sq uare was emplo yed to test the nominal ph ysician-in-charge and wer e informed about variables. A statistical significance of was the purpose, procedures, benefits and risks of used. The pr evalence values are presented with the study . A pre-appr ov ed inf ormation sheet a confidence inter val of 95%. The results are with det ails of study was r ead aloud to the presented as the mean ± stan dar d deviation public by one of the in ves tigators (VM) and (SD) for continuous variables and as number quest ions regarding the study were answer ed (n) or percentage (%) f or categorical variables. accordingly by the team. All individuals aged 1 The statistical significance of the association year or older were invited to par ticipate. In an between intes tinal parasite infection, sex and implemented room inside the health care age range was assessed with a P earson chi-sq uare facility , verbal consent was obt ained before test. registration of sociodemographic data and collection of stool samples in presence of the technical per sonnel. All parents pro vided consent on behalf of all minor par ticipants (any participant younger than 1 8 years old). The P opulation sample name, affiliation, occupation, and cont act inf ormation of the field inves tigators (VM, A to tal of 246 individuals from 5 districts CDB and CR) were placed on a wooden board par ticipated in the study . Of these individuals, outside the sample collection area at each 1 15 (46.7%) were males (mean age 20.7), and village, and remained visible to the public 13 1 (53.3%) were females (mean age 2 7 .4). The du ri ng t he du ra ti on o f t he s t ud y. Th e mean age of the population was 2 4.3 (range 1 to ph ysicians and laborator y technicians of the 88): 8 (3.3%) from Puer to Azul, 38 (15.4%) Hospital de la Solidaridad in T arapoto attended from Morales, 25 (1 0.2%) from Juan Guerra, an oral presentation of the study results, and 1 1 6 (4 7 .2%) from T arapoto, and 59 (2 4.0%) awarene ss was rai sed of th e bene fits of from T abalosos. performing a comple te coproparasitological Occurrence and distribution of parasites screening instead of D W only. A customized summar y with the results of the prevalence at a A total of 1 4 dif f erent species of intestinal district level and a personalized report for each parasites were recov ered from our sample individual were provided to the local physician population: 4 soil-transmitted nematodes, 1 at the end of the study . cestode, and 9 intestinal pro tozoa, most of them (8/1 4) considered pathogenic. Directed antiparasitic treatment at standard dosages (or weight-based) was given free of Almost half (43.2%) of the population carried charge to all individuals who carried pathogenic at least one intestinal parasite. Individuals with organisms. The medi cations, administered mon opar asit ism were ob ser ved in 24.4% under the super vision of the ph ysician in charge (60/246), biparasitism in 1 4.6% (36/246), of the health car e facility , included albendazole, t r i p a r a s i t i s m i n 2 . 4 % ( 6 / 2 4 6 ) a n d m e b e n d a z o l e , m e t r o n i d a z o l e , i ve r m e c t i n te traparasitism in 0.8% (2/2 46) (Figure 2). and/or praziquantel. Results Revista P eruana de P arasitología V olumen 19, Número 1, Año 201 1 ISSN 2219-0848 (V ersión Electrónica) Artículo Original Maco, et al. Prevalence of heminths protozoa in the Amazon region San Martin, Peru. Revista P eruana de P arasitología V olumen 19, Número 1, Año 201 1 ISSN 2219-0848 (V ersión Electrónica) 1 0 Rev peru parasitol 2011; 19 (1) Acceso gratuito en línea a texto completo. Figure 2. Frequency of mono and polyparasitism. Prevalence of intestinal parasites in 5 Amazonian districts of the depar tment of San Martín, P eru, using 5 copr ological tec hniques (n=2 46). Globally , the highest pr evalence of infection The distribution of the prevalence of all was caused by the non-pathogenic amoeba parasites by district is shown in T able 1. Entamoeba coli (E. coli) (20.7%, 95% confidence inter val (CI) = 15.4-26.8), follo wed by the The distribution of intestinal parasites by sex pathogenic protozoa Giardia lamblia (G. lamblia) and age group is summarized in T able 2. The (7 .7%, 95% CI = 4.5-1 1 .4), Blastocys tis hominis distribution of all parasites was homogenous in (B. hominis) (7 .7%, 95% CI = 4.5-1 1 .0), and all age groups except in the 1-1 0 group, wher e G. lamblia was more prevalent (1 5.2%, X2=13.95, Entamoeba histolytica/dispar (E. histolytica/dispar) (1 .6%, 95% CI = 0.4-3.3). In contrast, the non- p=0.007). Although the dif f erence was not pathogenic protozoa Endolimax nana (En. nana) statistically significant, H. nana was more (4.9%, 95% CI = 2. 1-7 .7), P ent atrichomonas spp. prevalent at earlier ages (7 . 1% in the age gr oup (2.4%, 95% CI = 0.8-4.8), and Chilomastix >1-1 0). The 1 1-20 and 3 1-40 age groups did not mesnili (C. mesnili) (0.8%, 95% CI = 0.0-2.0) carr y an y nematodes or cestodes. The dat a on wer e less frequently obser ved. T wo individuals sex show ed that males had a higher prevalence with coccidia, one with Cyclospor a spp. (0.4%, of En. nana than females (8.7% vs. 1. 1%, 95% CI = 0.0-1 .2) in T arapoto and the other X2=6.78, p=0.009). There were no dif f erences with Cr yptosporidium spp. (0.4%, 95% CI = 0.0- by sex in the prevalences of the other parasites. 1 .2) in T abalosos were detected by mZN. Among the helminths, the most prevalent The prevalence of intestinal parasites in the area n e m a t o d e w a s A s c a r i s l u m b r i c o i d e s ( A . is high (43.2%), but this value is lower than lumbricoides) (5.7%, 95% CI = 2.8-8.8), f ollow ed those f ound in previous local studies. In 1 99 1 , a by S. stercor alis (3.7, 95% CI = 1 .6-6. 1), T richuris stool examination study using the Faust, Willis trichiur a ( T . tric hiura ) (2.4%, 95% CI = 0.8-4.4), f l o t a t i o n - c o n c e n t r a t i o n a n d G r a h a m and hookworms (2.0%, 95% CI 0.4-4.0). techniq ues in a shantyto wn of T arapoto (n=1 1 0) Among the cestodes, Hymenolepis nana (H. rev ealed 99. 1 8% of intestinal parasites, with A . (13) nana) was the only found (4. 1%, 95% CI = 1 .6- lumbricoides the most pr evalent (68. 1 8%). 6.9). Discussion Artículo Original Maco, et al. Prevalence of heminths protozoa in the Amazon region San Martin, Peru. 1 1 Rev peru parasitol 2011; 19 (1) Acceso gratuito en línea a texto completo. Revista P eruana de P arasitología T able 1 . Prevalences of intestinal parasites among individuals from 5 districts in San Mar tín, P eru. Int e s ti n al paras ite D istric t T o ta l n =24 6 Pu er t o Azul n = 8 M oral es n =38 J u a n Gue rra n =25 T ar a po to n = 118 T ab alo s o s n =59 n Pre v a lenc e ( 9 5 % C I ) n % n % n % n % n % Ne mat odes A sc aris l umb ricoid e s 1 4 5 .7 ( 2 . 8 - 8.8 ) 1 12 .5 1 2 .6 0 0 2 1.7 10 1 6.9 T ric huris t rich iu ra 6 2 .4 ( 0 .8 -4.4 ) 2 25. 0 0 0 0 0 0 0 4 6.8 Ho o k w o rm s a 5 2 .0 ( 0 .4 -4.0 ) 2 2 5 2 5 .3 0 0 0 0 1 1.7 St rong y loi d e s s terc oralis 9 3 .7 ( 1 . 6 - 6.1 ) 1 12 .5 4 1 0.5 1 4.0 0 0 3 5.1 Ce s t o de s Hyme nolep is nana 1 0 4 .1 ( 1 . 6 - 6.9 ) 2 25 1 2 .6 0 0 2 1 .7 5 8.5 Pro t o zo a Pa th og e n ic Gia rd ia l amb lia 1 9 7.7 (4. 5-1 1 .4 ) 0 0 4 1 0.5 0 0 9 7 .8 6 1 0.2 En t amoe b a histol y t i ca/ d ispa r b 4 1 .6 (0.4 -3.3 ) 0 0 3 7 .9 0 0 1 0 .9 0 0 B las toc ys tis hom ini s c 1 9 7.7 (4. 5-1 1 .0 ) 1 1 2 .5 5 1 3.2 0 0 8 6 .9 5 8.5 Cr y pt osp oridiu m s p p. 1 0 .4 ( 0.0 - 1.2 ) 0 0 0 0 0 0 0 0 1 1.7 Cy c los pora sp p. 1 0. 4 ( 0 .0 -1.2 ) 0 0 0 0 0 0 1 0.9 0 0 No n - pa th og eni c En t amoe b a coli 5 1 20. 7 (1 5.4 - 2 6. 8) 2 2 5 7 1 8.4 4 1 6.0 2 1 1 8 .1 17 2 8 .8 En d oli max na na 1 2 4 .9 ( 2 . 1 - 7.7 ) 2 25 1 2 .6 1 4.0 5 4 .3 3 5.1 Chi l o m asti x me snili 2 0. 8 ( 0 .0 -2.0 ) 0 0 1 2.6 0 0 0 0 1 1 .7 P e ntatric homo na s spp . 6 2 .4 (0.8 -4.8 ) 1 1 2 .5 1 2.6 0 0 2 1.7 2 3.4 a Ancylostoma duodenale/Necator americanus b Intestinal amebas morphologically indistinguishable c P athogenicity probably related t o intensity of infection and the host immune status Artículo Original Maco, et al. Prevalence of heminths protozoa in the Amazon region San Martin, Peru. Betw een 200 1 and 2002, a prevalence study was almost 50%, with a broad diversity of (1 4) u s i n g DW , t h e T e l e m a n s e d i m e n t a t i o n genera. This broad diversity has been techniq ue, and the Kiny oun stain conducted in obser ved throughout all stool studies in all (13-1 8) ad jac ent i ndi gen ou s com mun iti es i n th e geographic regions in P eru, with ver y high (1 9-20) pro vince of Bagua, Amazonas (~ 250 km indices seen in the earliest studies . In 1 965, northwest of T arapoto) (n= 1 049) also rev ealed the global prevalence of intes tinal parasites in higher prevalences and diversity of intestinal childr en living in a mining center located at parasites, as high as 5 7 .8% f or E. coli and 28.9% 4600 m of altitude was 94.53%, one-third of (5) (20) f or A . lumbricoides. More recently , in 20 1 0, a them (33.5%) carr ying 3 parasites. The smaller study (n= 66) using D W and Harada- envir onmental conditions are adequate for the Mori culture in 2 communities in the pr ovince development of inf ectiv e forms of STH and of Y urimaguas, Amazonas (~125 km nor theast p r o to z o a . C l e a r l y, t h e u s e o f m u l t i p l e of T arapoto) showed an overall intestinal concentration tec hniques is of substantial value (6 ) pa r as it is m p re v a le nc e o f 7 5. 7% . T he to ensure the accuracy of the data. It is prevalence found by our study was lo wer than important to note the value of the D W for t ha t fo un d in s i m i l a r e c os y st e m s. T hi s di a gn o s in g m o bi l e f l a g el l at e s a nd ot h er difference ma y ref lect the ef f ect of t arge ted amoebas. In par ticular , all the cases of the chemo therapy in the area. nonpathogenic protozoa P ent atrichomonas spp. (6/2 46) found in the study w ere diagnosed only Th e overa ll pre val en c e of a ny i nte stin al with D W . parasites, based on 5 coprological techniq ues, V olumen 19, Número 1, Año 201 1 ISSN 2219-0848 (V ersión Electrónica) Revista P eruana de P arasitología 12 Rev peru parasitol 2011; 19 (1) Acceso gratuito en línea a texto completo. T able 2. Distribution of intestinal parasites by age and sex group a ea n h qu e P rso C i s ar b ig fic ce 05 S ni an p 0. c n st a o a N to m ica s A cylo om du den le/ eca r a er nu d nt in a b m ph lo a in st gu a I est al me as or o gyc lly di in ish ble e at ge ci pr a r te to e te it f ec n nd e os m un st s P ho ni ty ob bly ela d th in ns y o inf tio a th h t i m e atu Artículo Original Maco, et al. Prevalence of heminths protozoa in the Amazon region San Martin, Peru. P ar as ite s Sex A ge ran g e ( ye ars) M al e F e mal e X 2 a p va lue b > 1 to 10 (N = 99) 11 to 2 0 (N =3 2) 21 to 3 0 (N =3 0) 31 to 40 (N =2 8) > 40 (N =5 7) X 2 p va lu e Ne m a t od es As ca ri s lu m br ico id es 6 .1 ( 7) 5.3 (7 ) 0 .0 63 0.8 02 8 .1 ( 8) 0 (0 ) 6. 7 (2 ) 0 (0 ) 7.0 (4 ) 4. 914 0.2 96 Tr ich u ris t r ich iu ra 2 .6 ( 3) 2.3 (3 ) 0 .0 26 0.8 72 3 .0 ( 3) 0 (0 ) 0 (0 ) 0 (0 ) 5.3 (3 ) 4. 306 0.3 66 H ook wo rm s c 2 .6 ( 3) 1.5 (2 ) 0 .3 60 0.5 48 1 .0 ( 1) 0 (0 ) 3. 3 (1 ) 0 (0 ) 5.3 (3 ) 5. 007 0.2 87 S tro ngy l oide s s t er cor a l is 4 .3 ( 5) 3.1 (4 ) 0 .2 91 0.5 90 2 .0 ( 2) 0 (0 ) 6. 7 (2 ) 0 (0 ) 8.8 (5 ) 8. 031 0.0 90 Ce st od e s Hy me no lep is nana 3 .5 ( 4) 4.6 (6 ) 0 .1 91 0.6 62 7 .1 ( 7) 0 (0 ) 3. 3 (1 ) 0 (0 ) 3.5 (2 ) 4. 922 0.2 95 P r otoz o a P ath o ge nic G ia rdia la m blia 9.6 (1 1) 6.1 (8 ) 1 .0 28 0.3 11 15 .2 ( 15 ) 3.1 (1 ) 0 (0 ) 0 (0 ) 5.3 (3 ) 13 .952 0 .0 07 * E n ta m oeba h isto lyt ica /d is pa r d 1 .7 ( 2) 1.5 (2 ) 0 .0 17 0.8 95 0 ( 0) 3. 1 (1 ) 0 (0 ) 3.6 (1 ) 3. 5 (2 ) 4. 50 7 0. 3 42 B l ast o cyst is ho min is e 1 0. 4 ( 12 ) 5.3 (7 ) 2 .227 0.1 36 9 .1 ( 9) 9. 4 (3 ) 3.3 (1 ) 3. 6 (1 ) 7.7 (5 ) 1. 959 0. 7 53 C ry pt os por id ium s pp . 0 .0 ( 0) 0.8 (1 ) 0 .8 81 0.3 48 0 ( 0) 0 (0 ) 0 (0 ) 0 (0 ) 1. 8 (1 ) 7. 229 0.1 24 C yc l o s p or a s p p. 0 .0 ( 0) 0. 8 (1 ) 0 .881 0. 3 48 0 ( 0 ) 0 (0 ) 3. 3 (1 ) 0 (0 ) 0 (0 ) 7. 22 9 0. 1 24 No n -p at ho g en i c E nt a mo e ba co li 2 3. 8 ( 18 ) 27 .2 ( 33) 3 .3 91 0.0 66 19 .2 ( 19 ) 1 2.5 (4 ) 1 6.7 (5 ) 3 9.3 (11 ) 21 .1 (1 2) 7. 633 0.1 06 E n dol im ax n a n a 8.7 (1 0) 1.5 (2 ) 6 .7 83 0 .00 9 * 7 .1 ( 7) 6.3 (2 ) 3.3 (1 ) 0 (0 ) 3.5 (2 ) 2. 976 0.5 62 C hil om a s t ix m esn il i 0 .9 ( 1) 0.8 (1 ) 0 .0 09 0.9 26 2 .0 ( 2) 0 (0 ) 0 (0 ) 0 (0 ) 0 (0 ) 2. 99 4 0. 5 59 P en t atr ich o mo na s s pp . 3 .5 ( 4) 1. 5 (2 ) 0 .980 0. 3 32 4 .0 ( 4) 3. 1 (1 ) 0 (0 ) 0 (0 ) 1.8 (1 ) 2. 692 0.6 11 Although polyparasitism is the rule in tropical transmi ssion and po or sa nitat ion in the (2 1) p o p u l a t i o n b e c a u s e o t h e r c o - p a t h o ge n i c and subtropical countries, this does not seem parasites are transmitted in the same way (f ecal- to be the case in this Amazonian area of P eru, (23) where mono- (24.2%) or biparasitism (1 4.6%) oral route). Other factors, including the lack occurred more frequently than tri- (2.4%), or of sewage disposal obser ved in 8.5% of the tetraparasitism (0.8%). - dwellings in the region and the common practice of defecation in open areas, play an These estimates should be viewed with caution important role in the transmission of amoebas because our study was based on only one stool a n d h e l m i n t h s . S e v e r a l a u t h o r s h a v e specimen per individual. Despite our multi- highlighted the possibility of the transmission techniq ue approac h, our results may not of protozoa and helminths via street vendors. necessarily ref lect the actual prevalence of Of 23 sam ples of ceviche (raw fish marinated in parasites. How ever , our results are similar to the green lime juice) from street-f ood vendors in f i n d i n g s o f p r e v i o u s s t u d i e s i n w h i c h mar ke ts on the nor thern coast of P eru, 1 7 .4% m o n o p a r a s i t i s m ( 24 . 4 % ) o c c u r r ed m o r e (24) wer e cont aminated with En. nana . This freq uently than bi (1 4.6%), tri (2.4%) or pa tter n of t r ans mis sio n is e v ide ntl y not (4, 6, 13, 22) tetraparasitism (0.8 1%). uncommon in other par ts of Latin America, (25) (26) (2 7) The highest percentage of infection was caused such as Bolivia , V enezuela , and Brazil , by non-pathogenic amoebas, par ticularly E. coli and it may partially explain the high rate of (20.7% globally), which was higher in the rural infection with amoebas in our population. district of T abalosos (28.8%). The relevance of Not sur prisingly , G. lamblia was the most the non-pathogenic protozoa is that they ser ve common pathogenic protozoan.It has shown a as a surrogate marker of the ef f ectiveness of f ecal wide distribution in most coprological studies V olumen 19, Número 1, Año 201 1 ISSN 2219-0848 (V ersión Electrónica) 13 Rev peru parasitol 2011; 19 (1) Acceso gratuito en línea a texto completo. (1 7, 28, 29) traditional medicine, regional herbs and other from all geographic regions of P eru since remedies for the treatment of diverse parasites the earliest studies conducted in Lima in the among the population. A non-controlled trial mid-1 900s. Our results are in agreement with a to evaluate the ef ficacy of American wormseed systematic review b y Alarcon et al. for the period ( Chenopodium ambrioisoides ), locally known as from 1 943 through 1 990. This review included paico, in 2 rural communities of T arapoto 1 40 P eruvia n public ations ad dressing the s h o w e d a m o d e r a t e e f f e c t a g a i n s t A . prevalence of giardiasis and repr esented all (4) (29) lumbricoides , but these results are quest ionable geographic regions and departments of P eru. due to inadequate f ollow-up. In addition, we This review found a national prevalence of G. may hav e missed cer tain cases by collecting only lamblia infection of 15.3% among a total of one stool sample per individual (due to the 30 7,7 44 individuals studied. In our population, intermittent excr etion of parasite eggs in the G. lamblia was statistically significantly more stools or the insensitivity of the method to light prevalent at younger ages (15.2%, X2=13.95, infections). p=0.00 7). All studies of age series have found presc hool- and school-aged children to be the Another import ant nematode in the ar ea was S. most af f ected, with prevalences of up to stercor alis , with a r elatively high prevalence of (29) 33.4%, because of high rates of fecal-oral 3.7%. W e have previously reported differ ent contamination in this par ticular group. prevalences of strongyloidiasis in comparable Amazonian areas, from as high as 45% in In o ur st ud y , E n. n ana w as st a tist ic al ly (15) soldiers in Iquitos (Lore to) to 2.85% in a significantly more prevalent in males than in (30) females (8.7% vs. 1 .5%, X2=6.78, p=0.009), rural population in Sandia (Puno). Although whe reas t he rem ain der o f the i ntest ina l we used BT for all of the samples, it is probable parasites wer e evenly distributed with regar d to that the actual prevalence is higher because sex. This result is in contrast to the findings of a sequential stools must be examined due to the (3 1) study that show ed no sex dif f erence in the intermittent excr etion of lar vae in the stools. (23) prevalence of infection by this protozoan. If Moreov er , stool cultures (agar plate) for S . we co ns ide r th e ra te o f no n- pat ho g en ic stercor alis, although cumbersome, have a higher pro tozoal infection as a surrogate mar ker of detection rate and can be useful if the parasite envir onment al contamination, the effective load is low . How ever , caution should be used to infectious inoculum in males ma y be lower differentiate Strongyloides spp. lar vae fr om those compar ed with that of the rest of the pro tozoa, of hookworms. In contrast, other authors have although the number of stools samples in our reported prevalences of strongyloidiasis of study is limited. 1 8.5% in 1,0 15 childr en of pre-school age from (32) Junín and 20% in 1 , 1 1 3 individuals from A . lu m b r i c o i d e s , th e most p reval ent S TH (33) Puerto Maldonado , even with one or serial worldwide, was the predominant nematode in D W . Interes tingly , S. stercoralis is also present in our study . As in the case of G. lamblia , a wide coastal areas of P eru, with 1 . 1% reported in a distribution was found f or A . lumbricoides . The (34) shantytown of Lima . It is probable that this relativ ely low prevalence of this intestinal finding is related to population migration from nematode in the study area ma y repr esent the the Amazon region to coastal regions. effect of t arge ted chemotherapy or the efficacy of self-administered antihelminthics in the Af ter A . lum bricoides , the most preval ent po p ula tio n. Th e us e o f se l f-a dmi nist ered parasite and the only cestode in our study was a n t i h e l m i n t h i c s b y t h e p o p u l a t i o n i s H. nana (3.7%). This parasite was found at a ackno wledged by local ph ysicians in the 5 lower prevalence than that found in previous districts. Another factor that could have studies of the same area (20.9 1% in T arapoto). inf luenced our results is the popular use of Other areas of the Amazon with similar Revista P eruana de P arasitología Artículo Original Maco, et al. Prevalence of heminths protozoa in the Amazon region San Martin, Peru. V olumen 19, Número 1, Año 201 1 ISSN 2219-0848 (V ersión Electrónica) 1 4 Rev peru parasitol 2011; 19 (1) Acceso gratuito en línea a texto completo. prevalences are Puerto Maldonado, with 4.3%, e f fe ct o f p e ri o d i c se l f -t re a t me n t b y t h e (32) (5) population. This high frequency of pro tozoa and Bagua, with 9. 1%. It is probable that also clearly shows that fecal-oral transmission the prevalence of this cestodiasis is less af f ected occurs. In addition, the import ance of multi- by PC because no ef f ective cestocidal is of f ered techniq ue stool analyses in local field studies by the NPD. Hymenolepiasis is a parasitosis (35) should be strongly emphasized. In the future, with similar prevalences in all regions of P eru, these analyses should include at least one although a higher prevalence of H. nana has concentration techniq ue. The prevalence of been reported recently in the coastal area. In prot oz oa ns i n th is a rea s ho ul d al so b e Lima, up to 2 4. 1% of the population between 5 (36) considered a t arget in the national effort against and 1 9 years of age were infected, but this intestinal parasites in our population. geographic area (the Andean region) differs from T arapoto (rainfor est). For this reason, the finding should be considered uncer tain but Au t h o r s ' c o n t r i b u t i o n s : V M a n d C d B merits fur ther evaluation. designed the study protocol. VM, CdB and CR Our study has sev eral limitations. Only one coll ected th e so ciodem ogra ph ic dat a and stool sam ple per individual was assessed. Other super vised the sample processing. VM, CdB, techniq ues, such as the Graham tec hnique, agar A T , LM and EG analyzed the dat a results and plate, and trichrome stain for Microsporidia, par ticipating in draf ting and revising the wer e not included. Given the nature of the m a n u s c r i p t f o r a p p r o p r i a t e i n t e l l e c t u a l study , we did not dif f erentiate between E. content. All authors read and appro ved the histolytica and dispar , and we did not speciate the final manuscript. VM is guarantor of the paper . hookworms. In the P eruvian Amazon, several Ac knowledgments: W e would like to thank all authors hav e repor ted a predominance of the ph ysicians working in the districts of the Necator americanus (5 1.7%), mor phologically study area, the laborator y technicians of the recognized fir st in the P eruvian f orest in Iquitos (3 7) Hospital de la Solidaridad (T arapoto, San in 1 94 7, over Ancylostoma duodenale (5.5%) (38) Martin) where our laborator y was based. and mixed infections (15.8%). Funding: None. In summar y, the prevalence of intestinal parasites is of paramount import ance in this Compe ting interest: N one declar ed. area. The non-pathogenic amoebas wer e more Ethical approval: The study was appro ved by a prevalent than the pathogenic helminths. This designated review board of the Hospit ales de la result may ref lect a par tial success of t arge ted Solidaridad. 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T ar apot o. 32. Huapaya P , Chávez V , V alverde S, 1 99 1; 1 1(3):153-60. T rans R Soc T rop Med Hyg. R o s e M . 1 4. Concha R, Huiza A, Espinoza Y , P arasitosis intestinales en pobladores de dos localidades de Yu r i m a g u a s , A l t o A m a z o n a s , Detección de parásitos Loreto, P erú. intestinales en agua y alimentos de T rujillo, P erú. Difer encias de pr evalencia de A l t a p a r a s i t o s i s i n t e s t i n a l e n t r e l o s cont aminación por enteroparásitos hos pit ales M ilit ar y Regi onal de de hor talizas comercializadas en los I qu i to s , L o re t o- Per ú . mercados de la ciudad de La P az, Bolivia. Guidelines f or the evaluation of soil- t r a n m i t t e d h e l m i n t h i a s i s a n d Distribución de la enter oparasitosis Co nt amin aci ón en terop ara sit ari a schist osomiasis at community level. en el altiplano P eruano: estudio en 6 de lechugas expendidas en mercados c o m u n i d a d e s r u r a l e s d e l del estado Lara. V enezuela. depart amento de Puno, P erú. Prevalencia de enteroparasitosis en R e l a t i o n s h i p b e t w e e n Highly effective and inexpensive una comunidad altoandina de la in test ina l p ara sit ic infec ti on i n p a r a s i t o l o g i c a l t e c h n i q u e f o r P r o v i n c i a d e V í c t o r F a j a r d o , childr en and soil cont amination in diagnosis of intestinal parasites in A yacucho, P erú. an urban slum. developing countries: spontaneous sedimentation technique in tube Prevalencia de parasitosis intestinal en E L I S A a n d s p o n t a n e o u s escolares de una institución educativa sedimentation techniq ue for the de un distrito de la sierra peruana. d i a g n o s i s o f G i a r d i a l a m b l i a D i a g n o s i s o f s o i l - t r a n s m i t t e d in f ec t i o n i n st o o l s a m p l e s o f h el m i n th i a s is i n a n Am a z o ni c P eruvian childr en. community of Peru using multiple diagnostic tec hniques. P r e v a l e n c i a d e g i a r d i a s i s e n encuestas parasitologicas publicadas en la literatura peruana, Hiperendemicidad de Fasciolosis humana en el V alle del Mantaro, P erú: Factor es de riesgo de la infección por Fasciola hepatica. P a r a s i t o s i s i n t e s t i n a l e n poblaciones urbanas y rural en Sandia, Depart amento de Puno, P erú. P olyparasitism. Efectividad del trat amiento médico antiparasit ario en niños de P a t t e r n s o f d e t e c t i o n o f edad pre-escolar . Lima, Perú. St r o ng y l o i de s s t e r c o ra l i s i n s t oo l s p e c i m e n s : i m p l i c a t i o n s f o r diagnosis and clinical trials. Cyst production and t r a n s m i s s i o n o f E n t a m o e b a a n d P r e v a l e n c i a d e Endolimax. Revista P eruana de P arasitología Artículo Original Maco, et al. Prevalence of heminths protozoa in the Amazon region San Martin, Peru. V olumen 19, Número 1, Año 201 1 ISSN 2219-0848 (V ersión Electrónica)

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