Resumen El objetivo de esta investigación fue describir el estado actual de la leishmaniosis en Costa Rica, profundizar en las diferentes manifestaciones clínicas y en las especies identificadas a la fecha causantes de la enfermedad, para recomendar tratamientos de acuerdo con estas, así como describir su comportamiento epidemiológico con el propósito de recomendar estrategias de prevención y control en los grupos identificados. Como fuentes de información se utilizaron la base de datos del Registro Colectivo del Ministerio de Salud de Costa Rica, de 2011 a 2016 y las estimaciones de población del Instituto Nacional de Estadísticas y Censos. La incidencia promedio de leishmaniosis en el trienio 2005-07 fue de 35,5 casos por 100 000 y pasó a 30,5 en el trienio 2014-16. Los grupos más afectados fueron los menores de 15 años con: 44,42 casos por cien mil. En San Ramón, Guatuso, Turrialba y Talamanca las tasas de incidencia superan la tasa de incidencia promedio.

Abstract The purpose of the present research was to describe the different species of Leishmania sp. in Costa Rica so as to recommend specific treatment; also, we wish to describe the epidemiological behavior of the different species in order to suggest prevention and control strategies. Our sources were Collective Registry Data of the Ministry of Health estimates (2011 to 2016) and population data from the National Institute of Statistics and the Census. The average incidence rate from 2005 through 2007 was 35.5 cases per 100,000; the rate went down to 30.5 during the years 2011 through 2016. The most affected age group were those younger than 15 years with a rate of 44.42 per 100,000. Since 2005, the areas in which incidence rates are higher than the average national incidence rate are: San Ramón, Guatuso, Turrialba and Talamanca. Management must be carried out according to: the identified species of the parasite and also according to the experience of experts in Costa Rica. Prevention must be directed to the identified risk groups.

En Costa Rica se tamiza para la enfermedad de Chagas el 100 % de la donación sanguínea. Durante el cuatrienio de 2008-2011 se tamizó un total de 251 919 donantes de sangre. Materiales y Métodos: En ese período, el Laboratorio de Chagas del Centro Nacional de Referencia en Parasitología de INCIENSA, recibió 3 630 muestras de suero para confirmación diagnóstica. En cada suero, se realizaron tres pruebas serológicas de diferente fuente de antígeno (ELISA Recombinante, ELISA Lisado e Inmunofluorescencia Indirecta). Además, se investigó la concordancia entre los resultados del tamizaje con los del CNRP. Resultados: La mayoría de los donantes positivos por la enfermedad de Chagas estaba en los rangos de edad de 41-50 años (28,7 %). Para el análisis de concordancia se consideraron solamente 3 166 muestras, en 92,7 % de las muestras recibidas había concordancia con los resultados del CNRP. De 3 630 muestras recibidas, 4,6 % estaban positivas para la enfermedad de Chagas (prevalencia en bancosdesangrede0,07%).Del total de casos confirmados la mayoría provenían de las provincias de Heredia y San José. Discusión: El valor relativamente bajo observado en el VPP (82,0 %) está relacionado con la baja prevalencia de la enfermedad en el país. El origen de la mayoría de pacientes provenientes de San José y Heredia coincide con la presencia de zonas de riesgo para la transmisión de la enfermedad. La baja prevalencia de la enfermedad de Chagas en Costa Rica, es concordante con estudios previos realizados.

In Costa Rica, screening is performed for Chagas disease in 100 % of blood donations. During the 2008-2011 period a total of 251 919 blood donors were screened. Materials and Methods: In this period, the Chagas Laboratory of the Centro Nacional de Referencia en Parasitología of INCIENSA received 3 630 serum samples for diagnostic confirmation. In each serum, three serological tests were performed with different sources of antigen (recombinant ELISA, lysate ELISA and indirect immunofluorescence). Furthermore we investigated the agreement between the results of the screening with those of CNRP. Results: The majority of positive donors for Chagas disease were in the age range of 41-50 years (28,7 %). For the concordance analysis only 3 166 samples were considered, 92,7 % of the specimens received were consistent with the results of CNRP. Of 3 630 samples received, 4,6 % were positive for Chagas disease (prevalence in blood banks of 0,07 %). Most confirmed cases came from the provinces of San José and Heredia. Discussion: The relatively low value observed in the PPV (82,0 %) is related to the low prevalence of the disease in the country. Origin of most patients from the provinces of San José and Heredia agree with the presence of risk areas for transmission of the disease. The low prevalence of Chagas disease in Costa Rica is concordant with previous studies.

Se presenta la evolución clínica y serológica de una paciente de once años de edad con Enfermedad de Chagas y afectación miocárdica con enfermedad del nodo sinusal. Se discuten los hallazgos cardiológicos, entomológicos, microbiológicos y antropológicos hechos por un equipo interdisciplinario.

We present herein the clinical and serological evolution of a child aged eleven years old with Chagas disease and myocardial compromise with sinus node disease. Cardiological, entomological, microbiological an anthropological issues of this case are discussed.

In light of the Central American Initiative for the control of Chagas disease, efforts were made on the part of Costa Rican and Nicaraguan teams, working separately, to determine the present status of Rhodnius pallescens in areas close to the common border of the two countries, where the insect has appeared within the last few years. The opportunity was also used to establish whether R. prolixus, a vector present in some areas of Nicaragua, has been introduced in recent years into Costa Rica with Nicaraguan immigrants. It became evident that wild adults of R. pallescens are common visitors to houses in different towns of a wide area characterized as a humid, warm lowland, on both sides of the frontier. Up to the present, this bug has been able to colonize a small proportion of human dwellings only on the Nicaraguan side. There was strong evidence that the visitation of the adult bug to houses is related to the attraction of this species to electric lights. There were no indications of the presence of R. prolixus either in Nicaragua or in Costa Rica in this area of the Caribbean basin. Triatoma dimidiata, a widespread domestic species in both countries, was totally absent in the explored areas of Costa Rica but occasionally occurs on the Nicaraguan side. Serological surveys in children of both areas showed that transmission of Chagas disease takes place in a rather small degree in Costa Rica and more commonly in Nicaragua, indicating that R. pallescens could be a potential threat as a vector in this particular region.

Triatoma dimidiata has been found in several cities and towns of those countries where the insect is a domestic or peridomestic pest. In Central America, urban infestations occur in the capitals of at least five countries. During 2001 and 2002 a survey was carried out in the county of San Rafael, Heredia province, located 15 km northwest of San José, capital of Costa Rica, in order to determine the degree of infestation by T. dimidiata in an entire city block. Six peridomestic colonies of the insect were detected in the backyards of eight households. The ecotopes occupied by the insects consisted of store rooms with old objects, wood piles or firewood, and chicken coops. A total of 1917 insects were found in the six foci, during two sampling periods, and a mean infection rate by Trypanosoma cruzi of 28.4% was found in 1718 insects examined. The largest colony found in one of the households yielded 872 insects that were thriving mainly at the expenses of two dogs. Opossums and adult insects were common visitors of the houses and it became evident that this marsupial is closely related to the peridomestic cycle of the Chagas disease agent. Lack of colonization of the insect inside the human dwellings is explained by the type of construction and good sanitary conditions of the houses, in contrast to the situation in most peridomiciliary areas. Stomach blood samples from the insects showed that the main hosts were, in order of decreasing frequency: rodents, dogs, fowl, humans, opossums, and cats. The fact that no indication of infection with Chagas disease could be detected in the human occupants of the infested houses, vis a vis the high infection rate in dogs, is discussed.

OBJECTIVE: To identify differences in the level of coverage of and opportunity for vaccination among schoolchildren in three areas in Costa Rica with different characteristics: an urban area (with the highest level of socioeconomic development of the three areas), a rural area (with a medium level of socioeconomic development), and a border area (a rural area in northern Costa Rica, on the border with Nicaragua, with the lowest level of socioeconomic development and the highest proportion of foreign immigrants). METHODOLOGY: Following selection of schools by proportional probability, surveys were used with children chosen at random from the first and second grades of elementary schools in the three areas: urban (961 students), rural (544 students), and border (811 students). The data on the vaccines that had been administered were obtained from the children's vaccination cards. Differences among the three areas were evaluated: (1) in the coverage with BCG; with three doses of diphtheria-tetanus- pertussis vaccine (DTP3); with three doses of oral polio vaccine (OPV3); with the first dose of measles-mumps-rubella vaccine (MMR1); and with the second dose of MMR vaccine (MMR2) and (2) in the "opportunity" for the children having received DTP1 + OPV1 before 3 months of age, DTP3 + OPV3 before 7 months of age, and DTP4 + OPV4 + MMR1 before 24 months of age. RESULTS: Out of all the students who had been selected, 80% of them in the urban area had a vaccination card, 73% did in the rural area, and 72% did in the border area (P < 0.05). The coverage levels for BCG, DTP3, and OPV3 were each over 95% in both the urban area and the rural area; however, the coverage levels were significantly lower (P < 0.05) in the border area: BCG, 83%; OPV3, 88%; and DTP3, 88%. Coverage with MMR1 and MMR2 was similar in the three areas. The percentage of schoolchildren with two or more doses of measles vaccine was 98% in the urban area, 92% in the rural area, and 85% in the border area (P < 0.05). In terms of opportunity, 90% of the children had received DTP1 + OPV1 before 3 months of age in the urban area, 89% had in the rural area, and 80% had in the border area (P < 0.05). The percentage of application of the complete basic schedule (DTP4 + OPV4 + MMR1) before 24 months of age was 93% in the urban area, 95% in the rural area, and 84% in the border area (P < 0.05). CONCLUSIONS: The border area had lower coverage of and opportunity for the basic schedule of vaccines, except for MMR. Follow-up campaigns for measles eradication have increased the coverage of the initial and booster doses in all three areas, but the increase has been greatest in the urban area. A greater effort should be made to identify children with an incomplete schedule of vaccinations, with priority going to areas that have a high proportion of immigrants.

OBJETIVO: Identificar diferencias en el nivel de cobertura y en la oportunidad de la vacunación de escolares residentes en tres tipos de zonas de Costa Rica: urbana, rural y fronteriza (rural de la frontera norte del país). MÉTODOS: Mediante encuesta, previa selección de escuelas por probabilidad proporcional, se reunió al azar a alumnos de primero y segundo grados de enseñanza primaria de tres zonas: urbana (n = 961), rural (n = 544) y fronteriza (n = 811). Los datos de las vacunas aplicadas se obtuvieron del carné (cartilla) de vacunación. Se evaluaron las diferencias en la cobertura con BCG, DPT3, VOP3, SRP1 y SRP2 y en la oportunidad de la administración de DPT1 + VOP1 antes de los 3 meses, de DPT3 + VOP3 antes de los 7 meses y de DPT4 + VOP4 + SRP1 antes de los 24 meses de edad, entre las tres zonas. RESULTADOS: Del total de alumnos seleccionados, 80% presentaron carné de vacunación en la zona urbana, 73% en la rural y 72% en la fronteriza (P <0.05). Las coberturas con BCG, DPT3, VOP3 fueron >95% en las zonas urbana y rural, y se encontraron cifras significativamente menores (P <0,05) en la zona fronteriza: BCG, 83%, VOP3, 88% y DPT3, 88%. La cobertura con SRP1 y SRP2 fue similar en las tres zonas. El porcentaje de escolares con dos o más dosis de sarampión fue: 98% en la zona urbana, 92% en la rural y 85% en la fronteriza (P <0,05). Una proporción de 90% recibió DPT1 y VOP1 antes de los tres meses de edad en la zona urbana, 89% en la rural y 80% en la fronteriza (P <0,05). El porcentaje de aplicación del esquema básico completo (DPT4 + VOP4 + SRP1) antes de los 24 meses fue: 93% en la zona urbana, 95% en la rural y 84% (P <0,05) en la fronteriza. CONCLUSIONES: La zona fronteriza mostró menor cobertura y oportunidad en la aplicación de vacunas del esquema básico, con excepción de SRP. La realización de campañas de seguimiento para la erradicación del sarampión ha elevado las coberturas con la SRP1 y el refuerzo de sarampión en todas las zonas, pero el incremento ha sido mayor en la urbana. Debe hacerse un mayor esfuerzo por identificar a niños con esquemas incompletos, principalmente en zonas de alta migración.