Date: Mon, 10 Jun 2019 14:24:43 +0200

Lima, June 10, 2019 (AFP) - Peru has declared a health emergency in five regions, including Lima, after the deaths of at least four people linked to Guillain-Barre syndrome, an autoimmune disorder that attacks the nervous system.   Health Minister Zulema Tomas said Sunday that in addition to the deaths there were currently 206 cases of the disease.   "We have an outbreak, there has been a brusque increase" since June 5, Tomas said on state-run TV Peru, adding that health authorities were taking steps to control and contain the disease.

While the syndrome is not contagious, a 90-day health emergency was declared because the current cases "have unusual and atypical characteristics that require rapid or immediate initial treatment," Peru's Institute of Neurological Sciences said.   The precise cause of the disorder is unknown, but most cases develop after a person has been sick with diarrhoea or a respiratory infection.

The Centers for Disease Control and Prevention in the US says its research suggests that the syndrome is "strongly associated" with the Zika virus, a mosquito-borne illness.   The regions affected by GBS include three on the country's northern coast -- Piura, Lambayeque, La Libertad -- tourist destinations known for their archaeological sites and beaches.   Also included was the central region of Junin and Lima, which has nine million inhabitants.   Two deaths were reported in Piura, one in La Libertad and another in Junin.
Date: Tue, 4 Jun 2019 20:24:14 +0200

Lima, June 4, 2019 (AFP) - Peruvian police on Tuesday were searching for a British tourist who went missing last week in the forests of a national park in the centre of the country, officials said.   Mary Elizabeth Orchard disappeared on Friday after entering the Yanachaga-Chemillen national park with her sister and brother-in-law, local media reported.    Orchard got separated from the group, and her sister reported her disappearance, triggering a search by police, firefighters and park rangers.

Locals reported the missing tourist had slipped into a ravine in a remote and hilly area of the park.   Peruvian media reports said a helicopter had been deployed in the search, but had been hampered by dense cloud cover.   Yanachaga-Chemillen is a nature reserve of 122,000 hectares (300,000 acres) known for its cloud forests and diverse flora and fauna, some of which is under threat of extinction.
Date: Mon, 27 May 2019 05:16:24 +0200

Lima, May 27, 2019 (AFP) - A powerful 8.0-earthquake toppled houses, blocked roads and knocked out power in parts of Peru on Sunday, killing one person and injuring at least 26 others as the shockwave extended into neighbouring Ecuador.   The quake hit in a sparsely populated region of Peru's Amazon basin region but was felt over a wide area. In Lima and other cities, frightened residents rushed into the streets.   "There are many old houses that have collapsed after this strong earthquake," said Hugo Araujo, the mayor of Yurimaguas, a town near the epicentre.

Peru's civil defense coordinator Ricardo Seijas told RPP radio that a man was killed by falling debris in his house in Cajamarca.   Danilo Munoz, the 48-year-old victim, was asleep when the quake struck at 2:41 am (0741 GMT).   Seijas said 11 people were injured in Peru, and more than 50 houses were left uninhabitable.   Reports said 15 people had been hurt in Ecuador.

The quake blocked roads, damaged a bridge and knocked down houses, said Peru's President Martin Vizcarra, adding that it was the most powerful quake to hit the country in 12 years.   "It is an earthquake affecting the entire Peruvian jungle," he said.   "We are working on establishing an air bridge to transport people who have an emergency," he said.   The quake struck about 75 kilometers (45 miles) southeast of the town of Lagunas at a depth of at least 110 kilometres.   The US Geological Survey and Peruvian geophysicists said the quake registered 8.0 in magnitude. They said it lasted just over two minutes.

The mayor of Lagunas, Arri Pezo, said many residents who fled from their homes later stayed in the streets for fear of aftershocks.   "You could not walk at the time of the earthquake, things were falling," Pezo told RPP. Power was knocked out, making it difficult to assess the damage, he said.   One of the most dramatic moments captured on social media happened in Yurimaguas. Video from the police station shows the police chief shouting at his subordinates to quickly open the jail cells and get inmates outside.   "The earthquake is strong!" he is heard yelling. "Open the cells! Help with the detainees, get one each!"

- Power cuts in Ecuador -
The shockwave of Sunday's tremor also extended to neighboring Ecuador, where power cuts were reported in parts of its Amazon basin region.    Peruvian media said the tremor was also felt in parts of Colombia and Venezuela.   Peru lies on the so-called Ring of Fire -- an arc of fault lines that circles the Pacific Basin and is prone to frequent earthquakes and volcanic eruptions.

The South American country records about 200 earthquakes a year, most of them going unnoticed by the public.   In February, a quake measuring 7.5 with its epicenter in Ecuador rattled the coast and Amazon region of northern Peru.   It left nine people injured and caused damage in Ecuador, but Peru was unscathed.
Date: Sat, 11 May 2019 03:17:40 +0200

Lima, May 11, 2019 (AFP) - Peru announced on Friday a two-week restriction to three important areas at Machu Picchu to prevent greater degradation to the iconic Inca citadel.   From May 15-28, access to the Temple of the Sun, Temple of the Condor and Intihuatana Stone will be strictly controlled at the UNESCO World Heritage Site, the government said.   "These measures are necessary to conserve Machu Picchu, given the evidence of deterioration" on stone surfaces caused by visitors to the three areas, the culture ministry said.

Almost 6,000 visitors a day are permitted onto the 15th century site in two waves.   The new plan will give tourists just three hours to visit the three emblematic areas.   Authorities will evaluate the impact of the measures before applying new permanent rules from June 1.

Machu Picchu, which means "old mountain" in the Quechua language indigenous to the area, is at the top of a lush mountain and was built during the reign of the Inca emperor Pachacuti (1438-1471).   It lies around 100 kilometres (60 miles) from the Andean city of Cusco, the old Inca capital in south-eastern Peru.   It was rediscovered in 1911 by the American explorer Hiram Bingham. UNESCO declared it a World Heritage Site in 1983.
Date: Wed 1 May 2019
Source: PAHO Epidemiological Alert [edited]

Given the recent detection of Mayaro fever cases through laboratory surveillance in areas where cases had not previously been reported, the Pan American Health Organization / World Health Organization (PAHO/WHO) encourages member states to implement and maintain capacity to detect this disease, including laboratory diagnostic capacity and raising awareness among healthcare workers.

Mayaro fever
Mayaro fever is a zoonosis caused by an arbovirus of the _Alphavirus_ genus, Togavirus family. Transmission by _Haemagogus_ mosquitoes has been documented. Human cases are associated with recent exposures to humid forest environments inhabited by these vectors (7).

In the 1st days, the disease presents as a nonspecific clinical picture similar to other arboviruses: fever, headache, myalgia, retro-ocular pain, chills, severe arthralgia, dizziness, nausea, photophobia, anorexia, often incapacitating joint edema, rash (mainly on the chest, legs, back, arms, and, less frequently, in the face), abdominal pain, leukopenia, and thrombocytopenia. In some cases, mild hemorrhagic disease symptoms have been described (5, 8-13).

The incubation period is relatively short, ranging between one and 12 days (4,7). The disease is self-limiting, with a duration from 3-5 days, with persistence of arthralgia that can remain for weeks or months (9,11,12,14); a fatal case with encephalopathy has been documented (13).

Situation summary in the Americas
Mayaro virus (MAYV) was isolated for the1st time in Trinidad and Tobago in 1954. However, a retrospective study showed evidence of infection by MAYV in sera collected during the construction of channels in Panama and Colombia between 1904 and 1914 (1,2). Since then, cases have been reported in Central America and South America, particularly in the regions around the Amazon basin.

Following the cases identified in Trinidad and Tobago, Mayaro fever cases were reported in Brazil (1955), Colombia (1958-1960), Bolivia (1959), Suriname (1964), Peru (1965), the USA (cases imported from Peru and Bolivia, 1997), Ecuador (1997), French Guiana (1998), Venezuela (2000), Mexico (2001), Panama (2010), and Haiti (2015) (3,4).

Although some studies suggest transmission in urban areas (5,6), outbreaks described in the last decade in the Americas were reported among residents of rural communities in the Amazon region of Brazil, Bolivia, Peru, and Venezuela. The majority of human cases occurred among persons who work or reside in tropical rainforests. For the documented outbreaks, the vector identified was the _Haemagogus_ mosquito found in rural and sylvatic habitats. The reservoir for MAYV is unknown, but some studies have reported virus isolation or high levels of antibodies in host vertebrates, such as nonhuman primates (8).

In 2015, one case of Mayaro fever was reported in Haiti. The case is an 8-year-old child from a rural area who was diagnosed with a coinfection of dengue and Mayaro (15).

In 2018, Peru reported 35 cases of Mayaro fever (16).

In 2019, 2 cases were confirmed in Peru in the provinces of Quispicanchis (Cusco region) and La Mar (Ayacucho region) (16).

Additionally, on 26 Apr 2019, Ecuador reported that of 34 samples that were negative for dengue, chikungunya, Zika, and leptospirosis, 5 were positive for Mayaro. The cases correspond to 4 different cantons: Guayaquil (2 cases), Portoviejo (1 case), Santo Domingo (1 case), and Babahoyo (1 case). These cantons are in the eastern part of the country, with a distance of up to 300 km [186 mi] between them. The detection occurred through laboratory surveillance of MAYV, which has been implemented in Ecuador since 2018.

Advice for national authorities
Given the broad distribution in the region of the mosquito implicated in transmission, and in light of the recent detection of cases in new geographic areas, PAHO/WHO encourages member states to implement actions for detecting cases and keeping healthcare professionals informed to therefore consider Mayaro fever as part of the differential diagnosis for other arboviruses such as chikungunya, dengue, and Zika.

Below is a summary of the main recommendations.

Considering the similar clinical presentation for Mayaro fever with that of other arboviruses, such as dengue, chikungunya, and Zika, surveillance for Mayaro fever could be integrated with existing arbovirus surveillance.

Surveillance should focus on:
- Detecting MAYV circulation in a timely manner
- Monitoring the geographical spread of MAYV once detected
- Contributing to the knowledge regarding the clinical characteristics of the disease
- Monitoring the circulating viral lineages

Laboratory diagnosis
The diagnosis of Mayaro fever is performed through virologic methods (i.e., detection of the viral genome or isolation of the virus) and/or serological methods (ELISA, PRNT). As with any other laboratory test, results need to be considered within the epidemiological and clinical context.

Laboratory testing for Mayaro fever should be considered as a differential diagnosis for chikungunya virus (CHIKV) and should be attempted after a sample from a suspected case is negative for CHIKV (notably if negative using polymerase chain reaction (PCR) during the acute phase of infection). Dengue and Zika should also be ruled out based on the clinical and epidemiological background.

Laboratory surveillance for Mayaro fever can also be performed by analyzing a proportion of samples from patients with clinically compatible presentations and who have tested negative for dengue, chikungunya, Zika, and other prevalent arboviruses.

Virological methods
The replication dynamics of MAYV are not well defined. In contrast to CHIKV, which has high and relatively long viremia, MAYV appears to have low levels of viremia lasting up to 5 days following the onset of symptom. Therefore, samples collected during this period should be analyzed using molecular methods or viral isolation.

- Molecular diagnostics: Viral RNA can be detected in serum samples up to 5 days following the onset of symptoms (viremic phase) by molecular methods such as conventional or real-time reverse transcription PCR (RT-PCR). A positive result by molecular testing (when using the appropriate controls and interpretation) confirms the diagnosis of MAYV infection.

Due to the low viremia of MAYV, high cut-off point (Ct) values can be observed with well-defined amplification curves in real time RT-PCR assays. Results should be carefully evaluated in the light of the clinical and epidemiological background.

- Viral isolation: Viral isolation can be performed in cell culture (using Vero or C6/36 cells). Due to its complexity, this methodology is rarely used as a 1st-line diagnostic tool. However, as MAYV viremia may be very low, viral isolation might increase the viral concentration for subsequent detection by molecular assays.

Serological methods
IgM for both CHIKV and MAYV viruses can be detected as of day 6 following symptom onset, so samples collected after day 6 should be analyzed by serological methods. Serological techniques often have cross-reactions with other alphavirus infections. Therefore, the use of RT-PCR is preferred for MAYV detection and diagnosis.

- IgM detection: Anti-MAYV IgM antibodies can be detected by ELISA (mainly capture of IgM antibodies, MAC-ELISA) or any other immunoassay (e.g., indirect immunofluorescence). To date, there are no validated, commercially available serology kits for MAYV. Therefore, in-house protocols with purified antigens are used. Cross-reactivity of MAYV IgM assays with other alphaviruses has been described. Thus, in areas where other alphaviruses co-circulate (especially CHIKV), the probability of cross-reactivity is high. As with any IgM test, a positive result in a single sample is only presumptive of a recent infection. Laboratory confirmation requires demonstration of seroconversion in paired serum samples (acute and convalescent with at least one week apart) and no seroconversion to other relevant alphaviruses.

Clinical management
Symptomatic management with nonsteroidal anti-inflammatory drugs (NSAIDS), rest, hydration, and supportive treatment of possible complications is recommended, following the exclusion of more severe diseases such as malaria, dengue, or bacterial infections.

There is no specific antiviral treatment for Mayaro virus infection.

Prevention measures
Public health measures to minimize exposure of persons to mosquitoes are imperative to prevent the spread of the virus and, therefore, the disease.

Currently, the only preventive protective measure is to avoid exposure to MAYV vectors (_Haemagogus_ species mosquitoes), which is also the vector for yellow fever virus and is present in wild or rural habitats.

The community must be informed on the risk of transmission and ways to minimize the risk of exposure to vectors, whether in a rural area or within a home in peri-urban areas or those bordering rural areas.
[Some epidemiologists have suggested that MAYV could become epidemic in much the same way that chikungunya virus has. The question is: Can it be transmitted efficiently between humans by _Aedes aegypti_ in the tropics? As noted above, MAYV is transmitted in tropical forests of the Americas by _Haemagogus_ mosquitoes. MAYV was isolated from 2 pools of _Ae. aegypti_ adults reared from wild-collected eggs. Preliminary laboratory tests have shown that this mosquito, as well as _Ae. albopictus_, is susceptible to MAYV infection and can transmit it. One hopes that surveillance systems with laboratory support can include MAYV in their routine efforts as PAHO/WHO suggests.

Maia LMS, Bezerra MCF, Costa MCS, Souza EM, Oliveira MEB, Ribeiro ALM, Miyazaki RD, Slhessarenko RD: Natural vertical infection by dengue virus serotype 4, Zika virus and Mayaro virus in _Aedes (Stegomyia) aegypti_ and _Aedes (Stegomyia) albopictus_. Med Vet Entomol. 2019 Feb 18; doi: 10.1111/mve.12369.

Kantor AM, Lin J, Wang A, Thompson DC, Franz AWE: Infection Pattern of Mayaro Virus in _Aedes aegypti_ (Diptera: Culicidae) and Transmission Potential of the Virus in Mixed Infections with Chikungunya Virus. J Med Entomol. 2019 Apr 16; 56(3): 832-843. doi: 10.1093/jme/tjy241.

Wiggins K, Eastmond B, Alto BW: Transmission potential of Mayaro virus in Florida _Aedes aegypti_ and _Aedes albopictus_ mosquitoes. Med Vet Entomol. 2018; 32(4): 436-442. doi: 10.1111/mve.12322. Epub 2018 Jul 13.

The PAHO/WHO report also has several references. The report is accessible at the above URL. - ProMED Mod.TY]

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