Fernando Gracia

Outbreak of Hantavirus Pulmonary Syndrome, Los Santos, Panama, 1999-2000

The first identified outbreak of hantavirus pulmonary syndrome in Central America is described.

Prevalence and Incidence of Multiple Sclerosis in Panama (2000–2005)

Background: The first cases of multiple sclerosis (MS) in Panama were notified in the 1980s and it was considered a low-risk region for this disease. Between 2000 and 2005, a prevalence study was conducted to characterize MS in Panama. Methods: An instrument was developed to gather information from clinical files and interviews with previous informed consent. The diagnosis was confirmed by neurologists applying the Poser and McDonald criteria as per the inclusion period. Results: 178 patients from the public and private health sectors were captured between 1970 and 2005. The prevalence rate was 5.24/100,000 inhabitants, and the incidence was between 0.28 and 0.61/100,000 inhabitants. The disease was predominant among women, the mean age ± SD being 34.76 ± 10.909 years (1st crisis), and the average number of crises was 2.88. The most common clinical findings were motor, optic neuritis, sensitive and cerebellous. 52.4% presented monosymptomatic manifestations, 71.6% were clinically defined according to Poser’s criteria and 55.6% had MS according to McDonald’s criteria. 77.8% had their debut with the relapsing-remitting type and presented an Expanded Disability Status Scale score of 2.7 after the first crisis. Conclusion: MS is in Panama a neurological pathology with a low prevalence and the results of this investigation improved early treatment and diagnosis of this disease.

Serosurvey of Wild Rodents for Hantaviruses in Panama, 2000–2002

Five hundred fifty-six samples representing 24 species of small mammals (two species of marsupials and 22 rodents) were collected in Panama between February 2000 and July 2002. The samples were examined for antibodies to hantaviruses by means of enzyme-linked immunosorbent assay or immunoblot assays. The serologic results indicated that several rodent species might act as hantaviral reservoirs in Panama: Costa Rican pygmy rice rat (Oligoryzomys fulvescens costaricensis), four positive of 72 tested (5.6%); Cherries cane rat (Zygodontomys brevicauda cherriei), five of 108 (4.6%); Mexican deer mouse (Peromyscus mexicanus), one of 22 (5%); Mexican harvest mouse (Reithrodontomys mexicanus), one of seven (14%); Chiriquí harvest mouse (Reithrodontomys creper), one of two (50%); and Sumichrasts harvest mouse (Reithrodontomys sumichrasti), three of four (75%). Hantavirus infection in Peromyscus mexicanus and the three species of Reithrodontomys was caused by Rio Segundo hantavirus, a species of virus not previously reported from Panama. At least three hantaviruses, therefore, are known to infect populations of wild rodents in the country. However, given the total number of animals tested, the role of these rodent species in the epidemiology and epizootiology of hantavirus infections remains unclear.

Incidence Rate for Hantavirus Infections without Pulmonary Syndrome, Panama

During 2001–2007, to determine incidence of all hantavirus infections, including those without pulmonary syndrome, in western Panama, we conducted 11 communitywide surveys. Among 1,129 persons, antibody prevalence was 16.5%–60.4%. Repeat surveys of 476 found that patients who seroconverted outnumbered patients with hantavirus pulmonary syndrome by 14 to 1.

Risk Factors for Human T Cell Lymphotropic Virus Type II Infection among the Guaymi Indians of Panama

To examine risk factors for human T cell lymphotropic virus type II (HTLV-II) infection, a case-control study was conducted among the Guaymi Indians of Panama. In females, HTLV-II seropositivity was associated with early sexual intercourse (</=13 vs. >15 years; odds ratio [OR], 2.50; 95% confidence interval [CI], 1.11-6.14) and number of lifetime sex partners. One partner increased risk of seropositivity by 30% (OR, 1.30; CI, 1.05-1.64), and risk increased with number of partners. Similar risk was associated with number of long-term sexual relationships. Among males, intercourse with prostitutes was associated with HTLV-II seropositivity (OR, 1.68; CI, 1.04-2.72). These data support a role for sexual transmission in HTLV-II infection. Association of seropositivity with primary residence in a traditional village (OR, 3.75; CI, 1.02-15.38) and lack of formal education (0 vs. >6 years [OR, 3.89; CI, 1.67-9.82]) observed in males may reflect differences in sexual practices associated with acculturation.

Therapeutic Armamentarium and Health System Coverage of Multiple Sclerosis in Latin America

fer significant support to the different groups of patients and their families and 60% have a multiple sclerosis center/clinic. Only half of the countries have their own formal guidelines to unify the therapeutic approach from a methodological standpoint. There are few collaborative studies, whether national or Epidemiological studies on multiple sclerosis in Latin America have been increasing over the last decade, promoted and encouraged by the Latin American Committee for Treatment and Research in Multiple Sclerosis (LACTRIMS) and societies or academic groups in each particular country. Although they present some methodological differences, recent publications and personal communications begin to provide a reasonable estimate of its frequency as well as some of its features. Prevalence seems to range between 0.75 and 30 per 100,000 inhabitants. The incidence is between 0.6 and 2.2 per 100,000 inhabitants, which in general terms can be regarded as a lowprevalence disease [1–6] . There is scarce information on treatment availability, coverage and therapeutic effectiveness, treatment guides, the existence of academic, patients’ and family associations, participation in clinical trials and national and international collaborative research projects or the disease burden. During a regional meeting on multiple sclerosis held in Cartagena, Colombia on May 20–21, 2011, and the Latin American Workshop on the Consensus for the Management of Multiple Sclerosis held in Quito, Ecuador on July 8–9, 2011, a voluntary survey was applied using a structural questionnaire (treatment availability and coverage; guides; academic, patients’ and family associations; clinical trials and research projects) to some participating neurologists involved in multiple sclerosis and LACTRIMS delegates, considered opinion leaders in multiple sclerosis in their respective countries in order to obtain the information. Twenty countries were included ( table 1 ). This data, although unofficial, gives an idea of the general situation of multiple sclerosis in Latin America. Analyses of the absolute and relative frequencies (percentages) were obtained. We concluded that significant advances have been made in the availability of drugs for treating acute crisis and the use of immunomodulators for relapsing/remitting multiple sclerosis; however, the population’s access to these treatments is below 35% in half of the countries. Among the countries that have the newest drugs available, only 4 have oral treatment with fingolimod and 11 with natalizumab. However, in more than 90% of the countries azathioprine, cyclophosphamide and mitoxantrone are available. On the other hand, all countries have founded associations that ofReceived: November 1, 2011 Accepted: February 10, 2012 Published online: April 27, 2012

Relation between human T-lymphotropic virus type I and neurologic diseases in Panama: 1985-1990.

Human T-cell lymphotropic virus type I (HTLV-I) is endemic in the Caribbean basin and in Japan. HTLV-II, a closely related virus, is endemic in several groups of native Americans, including Panamanian Guaymi. In Panama, a nationwide HTLV-I/II seroprevalence of 1-2% has been reported. We evaluated the frequency of HTLV-I/II infection in patients with neurologic diseases admitted to state tertiary hospitals in Panama City between 1985 and 1990. Nineteen of 322 patients with eligible diagnoses had antibodies to HTLV-I/II, 17 with HTLV-I and 2 with HTLV-II. HTLV-I was associated with spastic paraparesis (13 of 23, 56.5% versus 4 of 299, 1.3%, p < 0.001) and with cerebellar syndrome (2 of 13, 15.4%) and multiple sclerosis (2 of 54, 3.7%) (p < 0.05 for both diseases compared with subject with none of these diagnoses). The two HTLV-I infected patients with cerebellar syndrome later developed spastic paraparesis. HTLV-II infection was noted in one patient with cerebellar syndrome and one with amyotrophic lateral sclerosis. All patients with other diagnoses were seronegative. Among patients with spastic paraparesis, HTLV-I-infected patients were clinically indistinguishable from seronegative subjects. There is apparently an overlapping clinical spectrum of neurologic diseases associated with HTLV-I and HTLV-II infection.

Costs of multiple sclerosis in Panama from societal, patient perspectives and health-related quality of life

The purpose of this work is to estimate the costs associated with managing patients with MS in Panama and evaluating the impact of the disease on their health-related quality of life (HRQoL). Multicentric observational, retrospective, cross-sectional study. The costs were estimated from societal and patient perspectives and expressed in USD, 2015. The focus of the study is based on prevalence and on a “bottom-up” approach. To estimate the total cost per patient, annual reported use for each resource was multiplied by its unit cost. To evaluate HRQoL, patients completed the EQ-5D-3L questionnaire. 108 patients took part in the study. 82.41% were women with 44.78 (SD: 12.27) years. 61.11% presented mild (EDSS = 0–3.5), 25.93% moderate (EDSS = 3.5–6) and 12.96%, severe disability (EDSS≥6.5). The mean annual cost from the patient’s perspective was estimated at 777.99 USD (SD: 1,741.45) per patient. The mean cost from a societal perspective was estimated at 23,803.21 USD (SD: 13,331.83) per patient. Disease-modifying therapies (DMT) accounted for the main component of the cost. A deterioration in HRQoL was observed as the disease advances and as disability increases, with mobility and usual activities being the areas most affected by its progression. From both perspective, the cost per MS patient in Panama is high. In addition to the high economic impact, MS also exerts a negative impact on patient HRQoL, which increases as the disease advances.