Lluís Valerio

Las enfermedades tropicales en el mundo occidental

Las enfermedades tropicales son por definicion las endemi-cas de paises cuyo ecosistema permite la existencia de re-servorios y vectores que posibilitan el mantenimiento de ci-clos vitales –a veces muy complejos– de microorganismospatogenos. El paradigma de ello son las enfermedades pa-rasitarias. No obstante, a la sombra de la desigualdad exis-tente entre paises ricos y pobres, desde la segunda mitaddel siglo

High-Risk Travel Abroad Overtook Low-Risk Travel from 1999 to 2004: Characterization and Trends in 2,622 Spanish Travelers

BACKGROUND Travel medicine in Spain is provided by a few specialized centers that do not come under the auspices of the main health system. Some kind of reform is required to avoid common summer collapses and postponements of the service. In contrast to other European countries, neither the exact role nor the responsibilities of general practitioners and primary health care in travel medicine are clearly defined. METHODS An observational study was performed with retrospective data concerning 2,622 travelers from 1999 to 2004. Although the study was performed at a third-level travel medicine center, continuous contact with and support to general practitioners was maintained throughout the period. RESULTS International travel was a steadily increasing reality between 1999 and 2004 despite well-known tragic events involving world safety. The number of high-risk travels (53.4%) also increased and even overtook low-risk ones (46.6%). This trend was explained as the result of an increasing number of journeys to sub-Saharan Africa (14.9%) and those made by traveling immigrants (64.1% of those journeys), which represented a significantly higher proportion of high-risk travels compared with those made by autochthonous subjects (52.1%; p < .001). Moreover, traveling immigrants tend to consult more frequently in periods < 15 days prior to travel than do autochthonous travelers (p < .0001). A substantial number of highly vulnerable travelers, such as pregnant women, infants, elderly people, and immunosuppressed subjects, was found (1.8%). Low-risk travelers who could have been advised and vaccinated by general practitioners were 1,139 (43.4%). CONCLUSIONS Given the increasing number of travelers undertaking high-risk travels abroad, any kind of reinforcement of travel medicine provision in Spain should be considered essential. General practitioners could attend to a significant proportion of low-risk travelers.

Los inmigrantes viajeros

Objetivos Caracterizar a los inmigrantes viajeros y los desplazamientos internacionales que realizan. Identificar los viajes de riesgo que efectua dicha poblacion, asi como valorar las actividades preventivas internacionales quereciben en relacion con las aplicadas a viajeros autoctonos Diseno Estudio observacional retrospectivo Emplazamiento Unidad de Salud Internacional (USAI) de Santa Coloma de Gramenet (Barcelona). Ambito Sanitario del Barcelones Nord i Maresme. Division de Atencion Primaria. Institut Catala de la Salut Participantes Pacientes visitados desde junio de 1999 a junio de 2002 (n = 1.163) en la USAI. Se definieron dos grupos segun su procedencia: nacidos en la Union Europea (grupo autoctono; n0 = 1.019) o fuera de ella (grupo inmigrante; n1 = 144) Medidas principales Edad, pais de origen, tiempo de residencia en Espana, intervalo entre consulta/viaje, motivo del viaje, destino, duracion del viaje, tipo de viaje, estancia en zona rural o aislada, exposicion a paludismo, vacunaciones y quimioprofilaxis antipaludica prescritas y riesgo global del viaje Resultados Los inmigrantes residen en el extranjero durante mas tiempo que los autoctonos (media, 43,5 dias; intervalo de confianza [IC] del 95%, 37,9-49,1 y 15,8 dias; IC del 95%, 14,9-16,7, respectivamente; p Conclusiones Cabe considerar el colectivo inmigrante de nuestro ambito como un grupo de riesgo para la adquisicion e importacion de enfermedades tropicales durante sus desplazamientos internacionales. Conformanun a poblacion en la que se deberia priorizar la recepcion de medidas preventivas internacionales

Epidemiologic and biogeographic analysis of 542 VFR traveling children in Catalonia (Spain). A rising new population with specific needs.

BACKGROUND Imported diseases recorded in the European Union (EU) increasingly involve traveling immigrants returning from visits to their relatives and friends (VFR). Children of these immigrant families can represent a population of extreme vulnerability. METHODS A randomized cross-sectional study of 698 traveling children under the age of 15 was performed. VFR traveling children and non-VFR (or tourist) children groups were compared. RESULTS A total of 698 individuals were analyzed: 354 males (50.7%) and 344 females (49.3%), with a median age (interquartile range) of 4 (2-9) years. Of these, 578 (82.8%) had been born in the EU with 542 (77.7%) being considered as VFR, whereas 156 (22.3%) were considered tourists. VFR children were younger (4.7 vs 8.2 yr; p < 0.001), they had more frequently been born in the EU (62.8% vs 20.1%; p < 0.01) and were more frequently lodged in private homes (76.6% vs 3.2%: p < 0.001) and rural areas (23.2% vs 1.6%; p < 0.001). Furthermore, VFR remained abroad longer (51.6 vs 16.6 d; p < 0.001), the visit/travel time interval was shorter (21.8 vs 32.2 d; p < 0.001) than tourists, and consultation was within 10 days prior to the departure (26.4% vs 2.7%; p < 0.001). The risk factor most differentiating VFR children from tourists was accommodation in a rural setting [odds ratio(OR) = 5.26;95%CI = 2.704-10.262;p < 0.001]. CONCLUSIONS VFR traveling children showed a greater risk of exposure to infectious diseases compared with tourists. Immigrant families may represent a target group to prioritize international preventive activities.

Arboviral infections diagnosed in a European area colonized by Aedes albopictus (2009–2013, Catalonia, Spain)

BACKGROUND The invasive mosquito Aedes albopictus, with proven vectorial ability to transmit European autochthonous cycles of dengue and chikungunya virus, has currently colonized every coastal department of Eastern Spain. The main objective of the study was to define the epidemiological and clinical characteristics as well as the trends of these two arboviral diseases in a European area heavily colonized by Ae. albopictus. METHOD A voluntarily-based, prospective and multicenter surveillance study was performed in all medical units of the North Metropolitan area of Barcelona (406,000 inhabitants, Catalonia; Spain) with diagnostic capability from 2009 to 2013. Since any possible increase in arboviral cases could be justified by changes in traveling behaviors along the study period (especially longer trips) the trend showed by these two arboviral diseases was compared with that displayed by malaria cases during the same period. RESULTS 38 out of 52 (73.1%) suspected cases could be serologically confirmed (IgM+): dengue 34/38 (89.5%) and chikungunya 4/38 (11.5%). No autochthonous cases were identified. The overall incidence of both arboviruses was 0.19 cases/10,000 inhabitants-year (95% CI: 0.07-0.3); dengue = 0.17 cases/10,000 inhabitants-year (95% CI: 0.05-0.3), and chikungunya = 0.02 cases/10,000 inhabitants-year (95% CI: 0.001-0.03). The Incidence Relative Risk of arboviral disease between 2009 and 2013 shown a significant trend (IRR = 1.27. IC 95%: 1.01-1.59; p = 0.043) when compared with that displayed by malaria (IRR = 1.04. IC 95%: 0.924-1.192). If no unexpected circumstances concur, the arboviral disease incidence tax would equal that of malaria about 2021-2022. CONCLUSIONS The incidence of dengue and chikungunya is steadily increasing in the North Metropolitan area of Barcelona, a region densely colonized by Ae. albopictus, at the entire expense of imported cases (especially Visiting Friends and Relatives travelers). To date, no secondary autochthonous cases have been identified and, thus, they have not taken part in this rise.

Prevalencia de diabetes mellitus en inmigrantes indostánicos jóvenes en Santa Coloma de Gramenet, España

Fundamento y objetivo Hay un acuerdo general en considerar que la poblacion de origen indostanico, sobre todo los inmigrantes de paises occidentales, tiene un riesgo especialmente elevado a desarrollar diabetes mellitus tipo 2 (DM2). Para explicarlo se han defendido argumentos basados en el impacto de los cambios debidos a la inmigracion, especialmente el atribuible a la adopcion de una dieta occidental (hipotesis ambiental) o debidos a la presencia de resistencia tisular a la insulina (hipotesis genetica). El objetivo principal del estudio es valorar la prevalencia de DM2 en tres poblaciones de inmigrantes: indostanicos, inmigrantes no indostanicos y autoctonos. Poblacion y metodo Estudio transversal y multicentrico realizado en 3 centros de atencion primaria de Santa Coloma de Gramenet (Barcelona, Espana). Se estudiaron tres poblaciones nacidas entre 1948 y 1973 segun su origen: indostanico, no indostanico y autoctono. Se analizo la prevalencia de DM2 y la relacion de variables sociodemograficas y de comorbilidad entre los pacientes diabeticos. Resultados Se estudio a 2.690 individuos de los que un 4,6% tenia DM2. La prevalencia de DM2 fue superior en el grupo de indostanicos (20,9%, intervalo de confianza [IC] del 95%, 12,1-29,1) en relacion con el grupo de autoctonos (3,6%, IC del 95%, 2,9-4,3; p Conclusiones Se observa una mayor prevalencia de DM2 en poblacion inmigrante joven en relacion con la poblacion autoctona. La prevalencia de DM2 en inmigrantes indostanicos es la mas alta de las registradas en la Union Europea y superior a la de los inmigrantes no indostanicos, despues son necesarios subsiguientes estudios que comparen ambas poblaciones.

Exantema hemorrágico por virus dengue inducido por ácido acetil-salicílico

El dengue, enfermedad infecciosa virica propia de los climas tropicales, se considera una patologia reemergente que ha dado lugar a graves epidemias en la ultima decada. En la expansion del virus y de su mosquito vector se barajan factores relacionados con la alteracion humana del medio, con la rapidez en el transito de mercancias y personas y debidos al cambio climatico. Como reflejo de ello, se asiste a un aumento de casos importados que, al ser una enfermedad con periodo de incubacion corto (7-10 dias), afecta especialmente a turistas procedentes de areas endemicas. El reconocimiento de los antecedentes personales de viajes, de los sintomas-guia de la enfermedad y de las potenciales complicaciones (dengue hemorragico) deben ser incluidos en una anamnesis para el estudio de fiebre de origen desconocido o de exantema febril. Se presenta el caso de una paciente cuya clinica de dengue clasico se agravo por el autotratamiento con acido acetil-salicilico.

Chagas Cardiomyopathy: Usefulness of EKG and Echocardiogram in a Non-Endemic Country.

Background Chagas disease (CD) is a major cause of cardiomyopathy in Latin America, and migration movements have now spread the disease worldwide. However, data regarding Chagas cardiomyopathy (CC) and the usefulness of echocardiography in non endemic countries are still scarce. Methods and results We selected 485 patients in the chronic phase of CD from two Spanish settings. Data from physical examination, electrocardiogram (EKG), x-ray, and two dimensional transthoracic echocardiogram were recorded. Trypanosoma cruzi DNA was assessed by PCR in peripheral blood. Patients were stratified according to the Kuschnir classification and a combination of echocardiogram and electrocardiogram findings. Patients mainly came from Bolivia (459; 94.6%). One hundred and forty three patients (31.5%) had at least one electrocardiogram abnormality. Twenty seven patients (5.3%) had an abnormal echocardiography. Patients with abnormal echocardiography were older (47 (IQR 38–57) years vs 41 (IQR 38–57) years); p = 0.019) and there was a greater proportion of males (66.7% vs 29.7%); p<0.001). Among echocardiographic variables, diastolic dysfunction was associated with poor cardiac status. In the multivariate analysis, abnormal EKG and gender were associated with abnormal echocardiography. Echocardiography may be spared for males under 30 and females under 45 years old with normal EKG as the likelihood of having an abnormal echocardiography is minimal. Association between T. cruzi DNA in the peripheral blood and cardiac involvement was not observed. Conclusion CC rates in the studied population are low. Age and sex are important determinants for the development of CC, and with the EKG should guide echocardiogram performance.

Ponga las arbovirosis en su esquema diagnóstico

En agosto de 2015 un hombre de 60 años fue diagnosticado e fiebre chikungunya en Alicante. En su momento representó el rimer caso de transmisión autóctona del virus por picaduras de edes albopictus (el conocido mosquito tigre). Después de un proeso de identificación redundante y confuso, persisten dudas sobre l diagnóstico definitivo, pero, en todo caso, ello no debía haber onstituido ninguna sorpresa epidemiológica mayor y, hasta cierto unto, lo extraño había sido la ausencia de casos autóctonos hasta a fecha1. En el mapa europeo de incidencia de casos la península bérica aparecía extrañamente como una isla en blanco. En efecto, era inevitable; la vertiente mediterránea de España cumula una notable colección de factores favorecedores a la transisión de los arbovirus: millones de personas no inmunes, amplio erritorio colonizado por un mosquito-vector compatible (aunue afortunadamente no es el vector más eficiente), existencia e casos autóctonos en el sur de Francia y un alto tránsito de ersonas, inmigrantes y turistas, que se desplazan a zonas endéicas (Sudeste Asiático y África Oriental) y epidémicas (Centro y udamérica)2. Y todo ello, además, bajo la amenaza de un cambio limático que tiende a borrar los límites entre los climas templado subtropical3,4. Bien, ¿pero se trata de un caso puntual?, ¿de una nécdota? Veamos cuál es la situación presente de las arbovirosis, sí como un asomo de lo que nos depara el futuro. Llamamos arbovirus a cualquier virus en cuyo ciclo vital interenga un vector artrópodo. Dichos artrópodos pueden ser insectos mosquitos) o arácnidos (garrapatas), pero, con mucho, son los osquitos del género Aedes los de mayor relevancia epidemioógica. En la Unión Europea han sido probadamente capaces de ransmitir virus de las familias Togaviridae (chikungunya y Sindis), Flaviviridae (dengue, Nilo Occidental, Usutu) y Bunyaviridae Toscana, Batai y Tahyna)5,6. Disponen de una amplia gama de ecanismos de supervivencia, como, por ejemplo, la infección ectorial transgeneracional (mosquitos vectores que transmiten

Imported cases of Chikungunya in Barcelona in relation to the current American outbreak

BACKGROUND The Chikungunya virus (CKIKV) is currently present in America. Travel between America and Europe is particularly intense and one of the main vectors of CHIKV, Aedes albopictus, is well established in the Mediterranean basin. We describe a series of imported cases that could originate a European outbreak. METHODS We retrospectively studied cases of CHIKV originating in America and diagnosed in the last year in three Tropical Medicine Units of Barcelona of the International Health Program of the Catalan Health Institute (PROSICS). Clinical, microbiological and epidemiological data were analyzed. RESULTS Forty-two CHIKV cases who had returned from 11 American countries were included. Fever was the most common symptom at onset (96.1%). Three months after symptom onset 50% continued with arthralgias, 35.3% fatigue and 11.8% arthritis. Three patients were viremic at the time of diagnosis by RT-PCR, and the remaining were diagnosed by serology (CHIKV IgM or IgG). Five (11.9%) patients had positive IgM for both dengue virus and CHIKV. CONCLUSIONS The origin of the cases was diverse, the most frequent being initially the Dominican Republic, followed later by Venezuela and Colombia. Symptoms were not severe but persisted, accompanied by unremitting positive IgM. Diagnosis was mainly based on serology and RT-PCR, with the performance of the rapid immunochromatographic test being low. Phylogenetic studies showed that two viremic cases were caused by a strain of Asian lineage with a lower adaptability to Aedes albopictus. Co-infection with the dengue virus was common, but the clinical course was not affected by coinfection. Non-steroidal anti-inflammatory drugs were administered to 71.4% and steroids to 21.4%. The number of imported cases of CHIKV in Spain is rising due to introduction of this virus in America, and this could lead to an autochthonous outbreak if Public Health measures are not taken.