Hyperendemic Area Research Articles

Heterogeneous zonal impacts of climate change on a wide hyperendemic area of human and animal fascioliasis assessed within a One Health action for prevention and control.

The Northern Bolivian Altiplano is the fascioliasis endemic area where the highest prevalences and intensities in humans have been recorded. In this hyperendemic area of human fascioliasis, the disease is caused only by Fasciola hepatica and transmitted by Galba truncatula, the sole lymnaeid species present in the area. When analysing the link between global warning and the recently reported geographical spread of lymnaeid populations to out-border localities, a marked heterogeneous climatic change was found throughout the endemic area. The aim of the present study is to analyse the physiographical heterogeneity of the fascioliasis hyperendemic area in the Northern Bolivian Altiplano, in order to assess its repercussions in the implementation of a One Health action. We applied multivariate linear mixed models to analyse the influence of a number of physiographical features on the long-term variation of climate and of the risk of transmission. Despite its apparent physiographic homogeneity, the findings of this study revealed markedly heterogeneous climate characteristics throughout the endemic area. This irregular pattern is influenced by physiographical features such as altitude, inner hills, closeness to Lake Titicaca, and El Niño-Southern Oscillation. This is the broadest study ever performed in a human fascioliasis endemic area about the influence of physiography on climate. It highlights the importance of considering physiographical features, an aspect usually not considered in studies dealing with the influences of climate and climate change on human and animal fascioliasis. Moreover, it shows that an endemic area may climatically evolve differently in its various inner zones and emphasizes the need for continuous monitoring to assess whether control measures should be modified accordingly.

Extracutaneous sporotrichosis.

SUMMARYSporotrichosis is a subacute-to-chronic infection endemic to tropical and subtropical regions. It usually involves subcutaneous tissue but can occasionally cause extracutaneous infections, especially in hyperendemic areas. Extracutaneous infections are classified based on the anatomic location of the lesion and the route of infection (primary or multifocal). The clinical forms are as follows: (i) pulmonary (primary or multifocal); (ii) osteoarticular (primary or multifocal); (iii) ocular (ocular adnexal lesions including eyelid lesions, conjunctivitis and dacryocystitis, and intraocular infections); (iv) central nervous system; and (v) mucosal (primary or disseminated). Multifocal clinical presentations are observed mainly in immunocompromised individuals. The diagnosis must be confirmed in the laboratory by mycological examination of the clinical samples. Itraconazole and amphotericin B are the most commonly used antifungal agents for treating pulmonary, osteoarticular, ocular, and mucosal forms. Treatment may include surgical excision of the initial lesions in pulmonary and osteoarticular forms. The treatment of neurological involvement is far from optimal and is associated with a high mortality rate despite long treatment periods.

Diagnosis of Mycobacterium leprae in a free-living animal hyperendemic area in Brazil

Diagnosis of Mycobacterium leprae in a free-living animal hyperendemic area in Brazil

Investigating the Efficacy of Vaccination Against Hepatitis B in Families of Infected Patients: in a Hyperendemic Area of Iran

Investigating the Efficacy of Vaccination Against Hepatitis B in Families of Infected Patients: in a Hyperendemic Area of Iran

Prevalence and Sociodemographic Risk Factors of Soil-Transmitted Helminths in Rural Communities Living in Endemic Foci of Onchocerciasis in Southern Gabon.

This prospective survey determined the prevalence and intensity of infections due to geohelminths and the associated risk factors in five onchocerciasis-endemic communities in Gabon between January and February 2020. Onchocerciasis endemicity was confirmed by Ov16 IgG testing. STHs were detected using the Kato-Katz techniques. Prevalence and parasite density were analyzed according to age, sex, and onchocerciasis endemicity. STHs were found in 64.8% of participants and were more common in hypoendemic (80.9%) and hyperendemic (63.9%) onchocerciasis communities (p < 0.01). Ascaris lumbricoides (65.5%), Trichuris trichiura (57.1%), and hookworms (17.3%) were prevalent in areas hypoendemic for onchocerciasis (p = 0.04). Male participants were more often infected by hookworms. Adults were more frequently infected by STHs (75.9%) than elders, who were the least infected (39.3%) (p < 0.01). Participants living in sporadic onchocerciasis areas frequently but not significantly harbored a moderate ascariasis load (6960.0 (1068.0-9492.0) eggs per gram) (p = 0.4). The highest parasite density was observed among participants aged 20-45 years (15,336.0 (3888.0-35,028.0)). A low T. trichiuria prevalence was found in all communities. STHs are highly prevalent in hypoendemic and hyperendemic areas and adults. An integrated combined approach of STH and onchocerciasis elimination through efficacious mass drug administration targeting all age groups should be considered.

Perspectives on blastomycosis in Canada in the face of climate change.

Blastomycosis is a disease of potentially varied presentations caused by thermally dimorphic fungi that appear as mold at ambient temperatures and transform to yeast at body temperature. Inhalation of aerosolized fungal spores represents the primary mode of transmission. Exposure may follow outdoor activities that disturb soil, which is warm, moist, acidic and rich in organic debris, particularly within forested areas and in proximity to waterways. Blastomycosis is endemic to several parts of Canada, but is only reportable in Ontario and Manitoba, with Northwestern Ontario being considered a hyperendemic area with average annual incidence rates of over 25 cases per 100,000 population. Delays in diagnosis and treatment are frequently observed as the symptoms and imaging findings of blastomycosis may initially be mistaken for community-acquired pneumonia, tuberculosis or malignancy, which can result in interim disease progression and worsening clinical outcomes. Risks from fungal infections such as blastomycosis are likely to increase with climate change-associated shifts in temperature and rainfall, and this may contribute to the geographic expansion of cases, a phenomenon that appears to be already underway. Further research investigating the ecological niche of Blastomyces and its climate sensitivity could help facilitate better modelling of the potential impacts of climate change on risks to Canadians and inform more effective methods of exposure prevention. Early clinical recognition and treatment of blastomycosis remain the key to minimizing morbidity and mortality.

Global warming induced spread of the highest human fascioliasis hyperendemic area

BackgroundClimate change is driving the occurrence of several infectious diseases. Within a One Health action to complement the ongoing preventive chemotherapy initiative against human fascioliasis in the Northern Bolivian Altiplano hyperendemic area, field surveys showed a geographical expansion of its lymnaeid snail vector. To assess whether climate change underlies this spread of the infection risk area, an in-depth analysis of the long-term evolution of climatic factors relevant for Fasciola hepatica development was imperative.MethodsWe used monthly climatic data covering at least a 30-year period and applied two climatic risk indices, the water-budget-based system and the wet–day index, both of verified usefulness for forecasting fascioliasis transmission in this endemic area. To reveal the long-term trends of the climatic factors and forecast indices, we applied procedures of seasonal-trend decomposition based on locally weighed regression and trend analysis on the basis of linear models. To further demonstrate the changes detected, we depicted selected variables in the form of anomalies.ResultsThis study revealed a notorious climatic change affecting most of the hyperendemic area, with a strong impact on crucial aspects of the fascioliasis transmission. Trends in maximum and mean temperatures show significant increases throughout the endemic area, while trends in minimum temperatures are more variable. Precipitation annual trends are negative in most of the localities. Trends in climatic risk indices show negative trends at lower altitudes or when farther from the eastern Andean chain. However, monthly and yearly values of climatic risk indices indicate a permanent transmission feasibility in almost every location.ConclusionsWarmer temperatures have enabled lymnaeids to colonize formerly unsuitable higher altitudes, outside the endemicity area verified in the 1990s. Further, drier conditions might lead to an overexploitation of permanent water collections where lymnaeids inhabit, favoring fascioliasis transmission. Therefore, the present preventive chemotherapy by annual mass treatments is in need to widen the area of implementation. This study emphasizes the convenience for continuous monitoring of nearby zones for quick reaction and appropriate action modification.Graphical

Efficacy of Sustained-Release Formulation of Moxidectin (Guardian SR) in Preventing Heartworm Infection over 18 Months in Dogs Living in a Hyperendemic Area.

This study investigates the efficacy of a sustained-release (SR) moxidectin microsphere formulation in preventing canine heartworm infection over 18 months in Canary Hound dogs, a hunting breed common in the Canary Islands, which is a hyperendemic region. These dogs typically do not receive preventive treatments and act as reservoirs for the disease. This field study was conducted across 11 hunting kennels with 109 dogs living outdoors, none of whom were receiving heartworm prophylaxis, with Dirofilaria immitis prevalence ranging from 11.1% to 57.1% (average 36.7%). Among these, 20 clinically healthy, heartworm-negative dogs were randomly selected to receive a single subcutaneous injection of moxidectin SR (0.17 mg/kg body weight). Antigen and Knott's tests were performed at 6, 12, 18, and 24 months. All dogs completed the study without adverse reactions and remained heartworm-negative throughout. By the end of the study, kennel heartworm prevalence ranged from 14.3% to 46.7% (average 35.4%). A single subcutaneous dose of moxidectin SR at the recommended dosage may prevent patent heartworm infection in dogs for up to 18 months in hyperendemic regions. Further studies are required to confirm these findings. Extending the efficacy period of moxidectin could improve owner compliance, particularly among those with lower animal health awareness.

Radiological Evaluation of Vascular Structures in Cats Infected with Immature Worms of Dirofilaria immitis.

This study aimed to assess thoracic radiographic abnormalities in cats infected with immature stages of Dirofilaria immitis to evaluate the utility of this diagnostic technique during early infection. A total of 123 cats from a hyperendemic area were classified into three groups: asymptomatic cats seronegative to anti-D.-immitis antibodies (Group A), seropositive asymptomatic cats (Group B), and seropositive cats with clinical signs that were at high risk of heartworm-associated respiratory disease (HARD) (Group C). Radiographic measurements and lung parenchymal abnormalities were analyzed and compared across the groups. Significant differences in several parameters, including CrPA/R4, and CdPA/R9 ratios, were observed between healthy and seropositive cats, suggesting early arterial damage even in the absence of adult worms. Other parameters that showed differences between healthy and infected cats were CVC/Ao and CVC/R4 ratios, but not the VHS. Group C exhibited a marked bronchointerstitial pattern, indicating severe parenchymal alterations associated with clinical signs. The study demonstrated that thoracic radiography can detect early vascular and parenchymal changes in feline D. immitis infections, providing valuable information for diagnosing HARD. However, it also highlights the limitations of radiographic techniques, as some seropositive cats displayed no significant abnormalities. The findings underscore the importance of combining radiography with clinical and serological assessments for a more accurate diagnosis of feline heartworm disease.

Asymptomatic carriage of Plasmodium falciparum in children living in a hyperendemic area occurs independently of IgG responses but is associated with a balanced inflammatory cytokine ratio

BackgroundAsymptomatic carriage of infected red blood cells (iRBCs) can be prevalent in communities regardless of transmission patterns and can occur with infection of different Plasmodium species. Clinical immunity dampens the inflammatory responses leading to disease symptoms in malaria. The aim of this study was to define the immunological correlates of asymptomatic carriage of Plasmodium falciparum in a highly exposed population.Methods142 asymptomatic Plasmodium-infected individuals greater than 2 years of age without fever (body temperature <37.5 ℃) were followed weekly for 10 weeks before being treated with artemisinin-based combination therapy (ACT). Plasma levels of 38 cytokines were measured at baseline by Luminex and the quantity and growth inhibitory activities of circulating parasite-reactive antibodies measured. The Plasmodium antigen tested included P. falciparum merozoite extract (ME) and schizont extract (SE), and the recombinant proteins erythrocyte binding antigen 175 (EBA-175) and merozoite surface protein 1 (MSP-119).ResultsMedian levels of IgG against P. falciparum EBA-175 and MSP-119 at baseline were significantly higher in those older than 20 years of age compared with the younger age group and appeared to correlate with better parasite control. Amongst all participants there were no discernible changes in IgG levels over time. Parasite density was higher in the younger age group and associated with IL-10, TNF and MCP-1 levels. A balanced IL-10:TNF ratio was associated with asymptomatic malaria regardless of age, and balanced ratios of IL-10/TNF and IL-10/IFN-γ were the only significant correlate of maintenance of asymptomatic malaria over the course of the study in individuals 20 years of age and younger.ConclusionThe above findings indicate that asymptomatic carriage of P. falciparum in children living in a hyperendemic area occurs independently of IgG but is associated with a balanced inflammatory cytokine ratio.

Non-Zoonotic Transmission of Sporotrichosis: A Translational Study of Forty-Three Cases in a Zoonotic Hyperendemic Area.

Over the past two decades, zoonotic sporotrichosis transmitted by naturally infected cats has become hyperendemic in Rio de Janeiro, Brazil. Sporothrix brasiliensis is the main agent involved. However, there are other forms of transmission of sporotrichosis. The aim of this study was to evaluate and associate the epidemiological, clinical and therapeutic data and the susceptibility of Sporothrix spp. to antifungal drugs in 43 non-zoonotic sporotrichosis cases. Forty-three clinical strains of Sporothrix were identified by partial sequencing of the calmodulin gene. An antifungal susceptibility test of amphotericin B, terbinafine, itraconazole, posaconazole and isavuconazole was performed according to the broth microdilution method. Most patients were male (55.8%). Regarding the source of infection, 21 patients (48.8%) reported trauma involving plants and/or contact with soil. Sporothrix brasiliensis was the predominant species (n = 39), followed by S. globosa (n = 3) and S. schenckii (n = 1). Sporothrix brasiliensis was associated with all the sources of infection, reinforcing previous data showing the presence of this species in environmental sources, as well as with all the clinical forms, including severe cases. One clinical strain of Sporothrix brasiliensis was classified as a non-wild-type strain for amphotericin B and another for itraconazole. S. schenckii was classified as non-WT for all the antifungals tested. In this context, it is important to emphasize that non-zoonotic sporotrichosis still occurs in the state of Rio de Janeiro, with S. brasiliensis as the main etiological agent, primarily associated with infections acquired after traumatic inoculation with plants and/or soil contact, followed by S. globosa and S. schenckii. In addition, non-WT strains were found, indicating the need to monitor the antifungal susceptibility profile of these species. It is crucial to investigate other natural sources of S. brasiliensis to better understand this fungal pathogen and its environment and host cycle.

The impact of immune recovery and treatment duration on disseminated histoplasmosis consolidation therapy in AIDS patients

IntroductionThe present study investigated the impact of immune recovery and the duration of antifungal adherence in the consolidation phase of disseminated histoplasmosis (DH) in acquired immune deficiency syndrome (AIDS) patients living in a hyperendemic area in northeastern Brazil. Material and MethodsSixty-nine patients with DH/AIDS, admitted to the São José Hospital between 2010 and 2015, who continued histoplasmosis consolidation therapy at the outpatient clinic were studied. The follow-up duration was at least 24 months. ResultsSixty-eight patients used itraconazole 200–400 mg/day or amphotericin B deoxycholate weekly during the consolidation phase, and six patients relapsed during follow-up. The overall median duration of consolidation antifungal use was 250 days [IQR 101 - 372]. Antifungal withdrawal by medical decision occurred in 41 patients (70.7 %) after a median of 293 days [IQR 128 - 372] of use; 16 patients discontinued by their own decision, with a median of 106 days [IQR 37 - 244] of therapy; three patients had no information available, and nine continued on AF therapy. The median CD4+ T-cell count in the group without relapse was 248 cells/µL [IQR 115–355] within 6 months after admission; conversely, in the relapse group, the median cell count remained below 100 cells/µL. Irregular adherence to highly active antiretroviral therapy (HAART) was the leading risk factor associated with relapse and death (p< 0.01). DiscussionThe regular use of HAART, combined with immune recovery, proved to be highly effective in preventing relapses in DH/AIDS patients, suggesting that long-term antifungal therapy may not be necessary.

Modelling onchocerciasis-associated epilepsy and the impact of ivermectin treatment on its prevalence and incidence

Retrospective cohort studies in Cameroon found an association between Onchocerca volvulus microfilarial load in childhood (measured in 1991–1993) and risk of developing epilepsy later in life (measured in 2017). We parameterised and integrated this relationship (across children aged 3–15 years) into the previously published, stochastic transmission model, EPIONCHO-IBM, for Simulium damnosum sensu lato-transmitted onchocerciasis. We simulated 19 years (1998–2017) of annual ivermectin mass drug administration (MDA) reflecting coverage in the study area, and modelled epilepsy prevalence and incidence. Scenario-based simulations of 25 years of (annual and biannual) MDA in hyper- and holoendemic settings, with 65% and 80% therapeutic coverage, were also conducted. EPIONCHO-IBM predicted 7.6% epilepsy prevalence (compared to 8.2% in the Cameroon study) and incidence of 317 cases/100,000 person-years (compared to 350). In hyperendemic areas, 25 years of biannual MDA (80% coverage) eliminated onchocerciasis-associated epilepsy (OAE) and protected untreated under-fives from its development. Strengthening onchocerciasis programmes, implementing alternative strategies, and evaluating treatment for under-fives and school-age children are crucial to prevent OAE in highly-endemic settings.

Change in the Distribution Pattern of Dirofilaria immitis in Gran Canaria (Hyperendemic Island) between 1994 and 2020.

Dirofilariosis is a zoonotic disease that mainly affects dogs and cats, with a high risk to public health. The island of Gran Canaria (Spain) has been shown to be a hyperendemic area of infection and, therefore, a model for studying the evolution of the disease. The objective of this study was to track the prevalence and distribution of heartworm in dogs, cats, and residents of Gran Canaria from 1994 to 2020, using published and unpublished data. Blood samples from 5841 dogs, 1203 cats, and 1604 humans were collected in the years analyzed, considering geographical and isoclimatic factors. In 1994, a prevalence of Dirofilaria immitis of 67.02% in dogs was reported, while in 2020 it was 15.81%. In cats, the seroprevalence in 2010 was 33.03%, compared to 17.20% in 2020. The incidence of D. immitis in humans in 2008 was 18.66%, while in 2020 it was 8.27%. For all study groups, temperate cold zone (TC) and temperate mild zone (TM) climates had the highest prevalence. Throughout these 20 years, the prevalence of heartworm disease has decreased. Despite this, it continues to be a hyperendemic island. This study highlights the importance of using the "One Health" perspective and the risks of contagion of the disease.

Verification of the reactivity of immunoglobulins in dried blood spots collected for onchocerciasis sero-surveillance by an Escherichia coli ELISA

The World Health Organization guidelines for verification of onchocerciasis elimination include demonstrating that the prevalence of exposure to the parasite in individuals born since transmission was interrupted needs to be less than 0.1%. The guidelines recommend using seropositivity to an Onchocerca volvulus specific antigen (Ov16) for this purpose. Ov16 seropositivity has most often been assessed using the Ov16 ELISA assay. Currently, the Ov16 ELISA assay includes internal positive and negative controls to monitor for proper assay performance but does not control for the quality of the dried blood spots (DBS) being tested. Previous studies have reported a high prevalence of antibodies recognizing Escherichia coli in children. Through the development of an ELISA assay to detect antibodies recognizing E. coli, a common commensal in humans, DBS may be prescreened for quality assurance prior to testing for Ov16. Results demonstrated antibodies to E. coli were detected in 100% of randomly selected serum samples collected from O. volvulus infected individuals residing in an onchocerciasis hyperendemic area. Furthermore, when DBS were improperly stored, the E. coli antibodies were found to decay over a period of one week, while remaining unchanged over the same period in properly stored samples. Similarly, E. coli antibodies were detected in 100% of a batch of field collected properly stored DBS, while being present only in 5% of a batch of improperly stored spots. This study demonstrates the value of E. coli ELISA for DBS quality control testing and validation of proper storage of collections of DBS for the Ov16 ELISA.

Outbreak of Feline Sporotrichosis with Zoonotic Potential in the Seventh Health District of Maceió-AL.

Sporotrichosis is a mycosis with zoonotic potential caused by species of Sporothrix. Once thought rare in northeastern Brazil, the disease has recently been spreading, leading to an emergency health issue. In this paper, we describe an outbreak of feline sporotrichosis in the Seventh Health District of Maceió-AL. We collected samples from 23 domiciled and non-domiciled felines without regard for age, breed, sex, and neutering state. Skin samples were analyzed cytologically under a light microscope and seeded onto Sabouraud dextrose agar at 25 °C for from 15 to 30 days. Fifteen of the twenty-three cats with suspected skin lesions were positive for Sporothrix spp. on either cytological or microbiological evaluation. Most of the infected cats were male, young adults, non-neutered, with free access to external areas, and living in environments with poor sanitation, a high population density, and an accumulation of garbage and organic matter. Three owners were bitten or scratched by infected cats and subsequently developed suspicious cutaneous lesions suggestive of sporotrichosis. The epidemiological features of feline sporotrichosis in the outbreaks of Maceió seemed to share similarities with the data obtained from outbreaks in current hyperendemic areas. Identifying geographical sites of infection and providing compulsory notification of the disease is essential for avoiding an epidemic in Alagoas.

Histoplasmosis in non-immunosuppressed patients from an endemic area in Northeastern Brazil.

Differently from immunocompromised patients, very little information is available in the literature regarding the clinical presentation, epidemiology, and outcomes of histoplasmosis in non-immunosuppressed individuals living in endemic areas. This retrospective case series study was carried out by reviewing the medical records of non-immunocompromised patients with histoplasmosis, residents in a hyperendemic area in northeastern Brazil, between 2011 and 2022. Thirty HIV-negative patients were identified with histoplasmosis, and 19 cases met the inclusion criteria: three had acute, five subacute and one chronic pulmonary forms; two with mediastinal picture and eight had disseminated disease (two with severe symptoms). The median age of our sample was 32.7 years old [interquartile range: 24-45]. Most of the patients were male (male-to-female ratio=15:4) and resided in the state capital (n=9). The majority had a previous history of exposure to well-known risk factors for Histoplasma infection. Pulmonary nodules were observed in all subacute form, two patients (acute and subacute forms) were initially treated empirically for pulmonary tuberculosis; one death was registered in the subacute form. The chronic pulmonary form of histoplasmosis was diagnosed in one patient only after the symptoms persisted despite specific treatment. The primary clinical manifestations of the moderate form of DH were enlarged lymph nodes, with histopathology being the main diagnostic method. The cases were detected as isolated occurrences and not as an outbreak, suggesting that exposure to Histoplasma can be more widespread than presumed. Despite the self-limiting nature of the disease, death can occur even in previously heathy patients.

Seroprevalence of Arboviruses in a Malaria Hyperendemic Area in Southern Mali.

Diagnostics for febrile illnesses other than malaria are not readily available in rural sub-Saharan Africa. This study assessed exposure to three mosquito-borne arboviruses-dengue virus (DENV), Zika virus (ZIKV), and chikungunya virus (CHIKV)-in southern Mali. Seroprevalence for DENV, CHIKV, and ZIKV was analyzed by detection of IgG antibodies and determined to be 77.2%, 31.2%, and 25.8%, respectively. Among study participants, 11.3% were IgG-positive for all three arboviruses. DENV had the highest seroprevalence rate at all sites; the highest seroprevalence of CHIKV and ZIKV was observed in Bamba. The seroprevalence for all three arboviruses increased with age, and the highest seroprevalence was observed among adults older than 50 years. The prevalence of Plasmodium spp. in the cohort was analyzed by microscopy and determined to be 44.5% (N = 600) with Plasmodium falciparum representing 95.1% of all infections. This study demonstrates the co-circulation of arboviruses in a region hyperendemic for malaria and highlights the needs for arbovirus diagnostics in rural sub-Saharan Africa.

Tick-Borne Relapsing Fever Infection from a Bunker, a Case Report on a "One Health" Approach.

Background: Tick-borne relapsing fever (TBRF) caused by Borrelia persica is an endemic disease in Israel and highly prevalent in military personnel. Prevention among the Israel Defense Force soldiers is based on increased awareness mainly in hyperendemic areas and selective postexposure prophylaxis with doxycycline. In this study, we report the presence of a suspected outbreak of TBRF in four soldiers who spent 30 h inside a deserted bunker. Materials and Methods: Clinical data on TBRF suspected cases were retrieved from clinical records, soft ticks were collected using carbon dioxide (CO2) traps and their DNA was extracted and analysed by PCR and nucleotide sequencing. Environmental conditions such as relative humidity, air temperature, wind speed, and type of soil, as well as presence or absence of animal traces inside the bunkers were documented. Results: TBRF-like clinical symptoms in the patients included: tick bite scars, fever (37.5-39.2°C), rash, tachycardia, hypotension, myalgia, cough, headache, cervical lymphadenopathy and nausea. Microscopic search for B. persica in blood smears was performed in three patients and was negative. Out of the 255 Ornithodoros tholozani ticks collected from the bunker, 198 were analyzed and 2 (1%) were infected with B. persica. To determine if tick infestation in military bunkers is a common phenomenon, we surveyed nine additional military bunkers located in four different geographical areas for the presence of soft ticks. Only one additional bunker was infested with two O. tholozani ticks, both negative for B. persica. Presence of earth that probably helped sustain a relatively big tick population was observed on the floor in the highly infested bunker. Environmental treatment with lambda-cyhalothrin at 9.7% was performed and showed efficacy with no ticks recovered in the infested bunker 124 days after intervention. Conclusion: This study shows that military bunkers may harbor soft ticks infected with B. persica and entrance into bunkers should be considered as a risk for acquiring this infection like entrance into natural caves and archeological ruins.

Correction: Investigating risk factors for under-five mortality in an HIV hyper-endemic area of rural South Africa, from 2000–2014

Correction: Investigating risk factors for under-five mortality in an HIV hyper-endemic area of rural South Africa, from 2000–2014