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Giuliano A.R.,H. Lee Moffitt Cancer Center and Research Institute | Palefsky J.M.,University of California at San Francisco | Goldstone S.,Mount Sinai School of Medicine | Moreira Jr. E.D.,Oswaldo Cruz Foundation | And 16 more authors.
New England Journal of Medicine | Year: 2011

Background: Infection with human papillomavirus (HPV) and diseases caused by HPV are common in boys and men. We report on the safety of a quadrivalent vaccine (active against HPV types 6, 11, 16, and 18) and on its efficacy in preventing the development of external genital lesions and anogenital HPV infection in boys and men. Methods: We enrolled 4065 healthy boys and men 16 to 26 years of age, from 18 countries in a randomized, placebo-controlled, double-blind trial. The primary efficacy objective was to show that the quadrivalent HPV vaccine reduced the incidence of external genital lesions related to HPV-6, 11, 16, or 18. Efficacy analyses were conducted in a per-protocol population, in which subjects received all three vaccinations and were negative for relevant HPV types at enrollment, and in an intention-to-treat population, in which subjects received vaccine or placebo, regardless of baseline HPV status. Results: In the intention-to-treat population, 36 external genital lesions were seen in the vaccine group as compared with 89 in the placebo group, for an observed efficacy of 60.2% (95% confidence interval [CI], 40.8 to 73.8); the efficacy was 65.5% (95% CI, 45.8 to 78.6) for lesions related to HPV-6, 11, 16, or 18. In the per-protocol population, efficacy against lesions related to HPV-6, 11, 16, or 18 was 90.4% (95% CI, 69.2 to 98.1). Efficacy with respect to persistent infection with HPV-6, 11, 16, or 18 and detection of related DNA at any time was 47.8% (95% CI, 36.0 to 57.6) and 27.1% (95% CI, 16.6 to 36.3), respectively, in the intention-to-treat population and 85.6% (97.5% CI, 73.4 to 92.9) and 44.7% (95% CI, 31.5 to 55.6) in the per-protocol population. Injection-site pain was significantly more frequent among subjects receiving quadrivalent HPV vaccine than among those receiving placebo (57% vs. 51%, P<0.001). Conclusions: Quadrivalent HPV vaccine prevents infection with HPV-6, 11, 16, and 18 and the development of related external genital lesions in males 16 to 26 years of age. (Funded by Merck and others; ClinicalTrials.gov number, NCT00090285.) Copyright © 2011 Massachusetts Medical Society. All rights reserved.


Lanata C.F.,Institute Investigacion Nutricional | Lanata C.F.,U.S. Navy | Lanata C.F.,Peruvian University of Applied Sciences | Olascoaga A.C.,Institute Investigacion Nutricional | And 2 more authors.
PLoS ONE | Year: 2013

Estimation of pathogen-specific causes of child diarrhea deaths is needed to guide vaccine development and other prevention strategies. We did a systematic review of articles published between 1990 and 2011 reporting at least one of 13 pathogens in children <5 years of age hospitalized with diarrhea. We included 2011 rotavirus data from the Rotavirus Surveillance Network coordinated by WHO. We excluded studies conducted during diarrhea outbreaks that did not discriminate between inpatient and outpatient cases, reporting nosocomial infections, those conducted in special populations, not done with adequate methods, and rotavirus studies in countries where the rotavirus vaccine was used. Age-adjusted median proportions for each pathogen were calculated and applied to 712 000 deaths due to diarrhea in children under 5 years for 2011, assuming that those observed among children hospitalized for diarrhea represent those causing child diarrhea deaths. 163 articles and WHO studies done in 31 countries were selected representing 286 inpatient studies. Studies seeking only one pathogen found higher proportions for some pathogens than studies seeking multiple pathogens (e.g. 39% rotavirus in 180 single-pathogen studies vs. 20% in 24 studies with 5-13 pathogens, p<0·0001). The percentage of episodes for which no pathogen could be identified was estimated to be 34%; the total of all age-adjusted percentages for pathogens and no-pathogen cases was 138%. Adjusting all proportions, including unknowns, to add to 100%, we estimated that rotavirus caused 197 000 [Uncertainty range (UR) 110 000-295 000], enteropathogenic E. coli 79 000 (UR 31 000-146 000), calicivirus 71 000 (UR 39 000-113 000), and enterotoxigenic E. coli 42 000 (UR 20 000-76 000) deaths. Rotavirus, calicivirus, enteropathogenic and enterotoxigenic E. coli cause more than half of all diarrheal deaths in children <5 years in the world.


Ecker L.,Institute Investigacion Nutricional | Ochoa T.J.,Cayetano Heredia Peruvian University | Ochoa T.J.,University of Houston | Vargas M.,Fundacio Clinic per A la Recerca Biomedica | And 2 more authors.
Pediatrics | Year: 2013

OBJECTIVE: To determine factors that affect caregivers' decisions about antibiotic use in children in settings where antibiotics are available without prescription. METHODS: In a house-to-house survey, 1200 caregivers in 3 periurban districts of Lima, Peru, were asked about antibiotic use in young children. RESULTS: In this sample, 87.2% of children aged ,5 years had received an antibiotic drug in their lives; 70.3% had received antibiotics before 1 year of age, and 98.8% of those had been prescribed by a physician. Given hypothetical cases of common cold and nondysenteric diarrhea, caregivers would seek medical advice in 76.4% and 87.1%, respectively, and 84.6% of caregivers said they respected medical decisions even if an antibiotic was not prescribed. Caregivers with high school-level education accepted 80% more medical decisions of not using an antibiotic and used fewer pharmacist-recommended antibiotics. For each additional year of life, the risk of self-medicated antibiotic use and the use of pharmacistrecommended antibiotics increased in 30%. (OR: 1.3, 95% CI: 1.1-1.4, P = .001 and OR: 1.3, 95% CI: 1.2-1.5, P < .001, respectively). Caregivers respected a medical decision of not prescribing an antibiotic 5 times more when physicians had explained the reason for their advice (OR: 5.0, 95% CI: 3.2-7.8, P < .001). CONCLUSIONS: Prescribed antibiotic use in these young children is common. Even if they are available without prescription, caregivers usually comply with medical advice and follow physicians' recommendations when antibiotics are not prescribed. Improving physician prescribing habits could reduce irrational antibiotic use, decreasing future caregiver-driven misuse.


Crookston B.T.,Brigham Young University | Schott W.,University of Pennsylvania | Cueto S.,Grupo de Analisis para el Desarrollo | Dearden K.A.,Boston University | And 6 more authors.
American Journal of Clinical Nutrition | Year: 2013

Background: Early life growth failure and resulting cognitive deficits are often assumed to be very difficult to reverse after infancy. Objective: We used data from Young Lives, which is an observational cohort of 8062 children in Ethiopia, India, Peru, and Vietnam, to determine whether changes in growth after infancy are associated with schooling and cognitive achievement at age 8 y. Design: We represented the growth by height-for-age z score at 1 y [HAZ(1)] and height-for-age z score at 8 y that was not predicted by the HAZ(1). We also characterized growth as recovered (stunted at age 1 y and not at age 8 y), faltered (not stunted at age 1 y and stunted at age 8 y), persistently stunted (stunted at ages 1 and 8 y), or never stunted (not stunted at ages 1 and 8 y). Outcome measures were assessed at age 8 y. Results: The HAZ(1) was inversely associated with overage for grade and positively associated with mathematics achievement, reading comprehension, and receptive vocabulary. Unpredicted growth from 1 to 8 y of age was also inversely associated with overage for grade (OR range across countries: 0.80-0.84) and positively associated with mathematics achievement (effect-size range: 0.05-0.10), reading comprehension (0.02-0.10), and receptive vocabulary (0.04-0.08). Children who recovered in linear growth had better outcomes than did children who were persistently stunted but were not generally different from children who experienced growth faltering. Conclusions: Improvements in child growth after early faltering might have significant benefits on schooling and cognitive achievement. Hence, although early interventions remain critical, interventions to improve the nutrition of preprimary and early primary school-age children also merit consideration. Am J Clin Nutr 2013;98:1555-63. © 2013 American Society for Nutrition.


Finkelstein J.L.,Cornell University | O'Brien K.O.,Cornell University | Abrams S.A.,Baylor College of Medicine | Zavaleta N.,Institute Investigacion Nutricional
American Journal of Clinical Nutrition | Year: 2013

Background: Effects of prenatal iron supplementation on maternal postpartum iron status and early infant iron homeostasis remain largely unknown. Objective: We examined iron absorption and growth in exclusively breastfed infants in relation to fetal iron exposure and iron status during early infancy. Design: Longitudinal, paired iron-absorption (<58


Obesity is a worldwide pandemic and children are a vulnerable group. In America, it was estimated that in 2010, 15.2% of 18 year-old children could suffer from this. Obesity in children and teenagers has a negative impact on health and on the load of diseases at this stage of life, and later on in adulthood, having a negative impact on the economy of a country due to the rise of risks of chronic diseases, health expenses and indirect costs as a result of the disease. Peru is going through an epidemiological transition, with unsolved malnutrition problems and high child obesity rates (10% of children under five), thus being one of the countries with a higher increase of child obesity in recent years in Latin America. Childhood and adolescence are considered critical periods because eating habits and physical activity start at this point; and because most obese children and teenagers will maintain those habits until they reach adulthood. For this reason, it is essential to seek strategies and interventions that prevent overweight and obesity among children and teenagers in order to improve the health conditions of a country.


Vargas S.,Agrarian National University | Penny M.E.,Institute Investigacion Nutricional
Public Health Nutrition | Year: 2010

Objective To adapt a scale to measure perceptions on food insecurity and hunger among households in urban and rural communities in Peru.Design Qualitative and quantitative methodology including consultation with regional experts, key informant interviews and focus groups. A field survey trial was conducted in urban and rural communities using an adapted version of the US Department of Agriculture (USDA) Food Insecurity and Hunger Module (FIHM).Setting Five communities in three regions in Peru - Lima (coast), Ayacucho (Andean highlands) and San Martn (Amazon basin).Subjects The qualitative component included forty intentionally selected people (fourteen key informants and twenty-six focus group participants). For the quantitative component 300 households that complied with selection criteria (poor or non-poor with at least one child below 12 years of age) were surveyed.Results Qualitative research showed that concern about food availability and access was common among the three regions but its main cause varied across them. Participation in food aid programmes was a strategy to face constraints in food access. Mothers perceptions on the importance of balanced meals varied across households from different regions. Quantitative results showed robust findings for the reliability of the adapted FIHMs fifteen-item scale (r > 0863). In addition, descriptive results confirmed parallelism of item responses in the scale for variables such as farm ownership, family size and use of Communal Kitchens.Conclusions This mixed-method study allowed us to adapt the USDA module to assess food insecurity in Peru. © 2009 The Authors.


Black M.M.,University of Maryland Baltimore County | Creed-Kanashiro H.M.,Institute Investigacion Nutricional
Revista Peruana de Medicina Experimental y Salud Publica | Year: 2012

Interventions to prevent malnutrition or overweight in children focus on the diet, and give little attention to the behaviors of their caretakers. In their first two years of life, children adopt practices that are embedded in their environment and the behaviors of their caretakers, thus turning into nutrition patterns that will persist during their lifetimes. Therefore, children and caretakers establish a relationship in which they recognize, construe and respond to verbal and non verbal communication signs. Feeding a child by adopting a "responsive" behavior in which caretakers provide guidance and structure, and respond to children's signs of hunger and satiety promotes self-regulation and children's awareness of healthy nutrition. In this article, we give recommendations to include responsive nutrition and model healthy eating behaviors in nutritional interventions.


Penny M.E.,Institute Investigacion Nutricional
Annals of Nutrition and Metabolism | Year: 2013

Zinc is necessary for physiological processes including defense against infections. Zinc deficiency is responsible for 4% of global child morbidity and mortality. Zinc supplements given for 10-14 days together with low-osmolarity oral rehydration solution (Lo-ORS) are recommended for the treatment of childhood diarrhea. In children aged ≥6 months, daily zinc supplements reduce the duration of acute diarrhea episodes by 12 h and persistent diarrhea by 17 h. Zinc supplements could reduce diarrhea mortality in children aged 12-59 months by an estimated 23%; they are very safe but are associated with an increase in vomiting especially with the first dose. Heterogeneity between the results of trials is not understood but may be related to dose and the etiology of the diarrhea infection. Integration of zinc and Lo-ORS into national programs is underway but slowly, procurement problems are being overcome and the greatest challenge is changing health provider and caregiver attitudes to diarrhea management. Fewer trials have been conducted of zinc adjunct therapy in severe respiratory tract infections and there is as yet insufficient evidence to recommend addition of zinc to antibiotic therapy. Daily zinc supplements for all children >12 months of age in zinc deficient populations are estimated to reduce diarrhea incidence by 11-23%. The greatest impact is in reducing multiple episodes of diarrhea. The effect on duration of diarrheal episodes is less clear, but there may be up to 9% reduction. Zinc is also efficacious in reducing dysentery and persistent diarrhea. Zinc supplements may also prevent pneumonia by about 19%, but heterogeneity across studies has not yet been explained. When analyses are restricted to better quality studies using CHERG (Child Health Epidemiology Reference Group) methodology, zinc supplements are estimated to reduce diarrheal deaths by 13% and pneumonia deaths by 20%. National-level programs to combat childhood zinc deficiency should be accelerated. Copyright © 2013 S. Karger AG, Basel.


Bentley M.E.,University of North Carolina at Chapel Hill | Wasser H.M.,University of North Carolina at Chapel Hill | Creed-Kanashiro H.M.,Institute Investigacion Nutricional
Journal of Nutrition | Year: 2011

Growth faltering and nutritional deficiencies continue to be highly prevalent in infants and young children (IYC) living in low- and middle-income (LAMI) countries. There is increasing recognition that feeding behaviors and styles, particularly responsive feeding (RF), could influence acceptance of food and dietary intake and thus the growth of IYC. This paper presents the evolution of RF research and the strength of the evidence for RF on child undernutrition in LAMI countries. Multiple approaches were used to identify studies, including keyword searches in many databases, hand searches of retrieved articles, and consultation with experts in the field. Articles were included if they contained a RF exposure and child undernutrition outcome. In total, we identified 21 studies: 15 on child growth, 4 on dietary intake, 3 on disease, and 8 on eating behaviors. Most studies were conducted among children <36 mo of age and were published in the last 10 y. Cross-study comparisons were difficult due to multiple definitions of RF. One-half of the studies were observational with cross-sectional designs and few interventions were designed to isolate the effect of RF on child undernutrition. Overall, few studies have demonstrated a positive association between RF and child undernutrition, although there is promising evidence that positive caregiver verbalizations during feeding increase child acceptance of food. Recommendations for future research include consensus on the definition and measurement of RF, longitudinal studies that begin early in infancy, and randomized controlled trials that isolate the effect of RF on child undernutrition. © 2011 American Society for Nutrition.

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