Original article

Rev Peru Med Exp Public Health

EPIDEMIOLOGY OF THE GUILLAIN-BARRÉ SYNDROME

IN PERU

César V. Munayco1,a,b, Mirtha G. Soto Cabezas1,a, Mary F. Reyes1,a,c, Johans A. Arica Gutiérrez1,a,d, Omar
Napanga Saldaña2,a,e

ABSTRACT
Objective. To describe the epidemiological behavior of Guillain-Barré syndrome (GBS) in Peru. Materials and Methods.
Descriptive study of secondary data on the Ministry of Health (MINSA) hospital discharges during the period 2012-2017;
EsSalud and SuSalud hospital discharges between 2015 and 2017; and national mortality data between 2014-2016. The
identification of GBS in the databases was carried out using the International Classification of Diseases, 10th version, by
means of code G610. Incidence, fatality rate, and mortality were estimated by age, sex, and department group. Results.
A total of 955 cases of GBS were identified in the database of MINSA hospital discharges between 2012 and 2017, with a
higher frequency in men, within the 20 to 59-year old population. The national incidence of GBS per 100,000 inhabitants
was 0.62 (2015), 0.92 (2016), and 0.91 (2017), being higher in older adults and in men. The overall case fatality rate
was 3.5%, and was highest in those over 60. The average length of hospitalization was 16 ± 22 days. In addition, Lima
is the department that accounted for more than 40% of all GBS cases; and Cusco, Lima, Callao, Lambayeque, and
Arequipa had the highest incidence. Conclusions. This study provides relevant information to better understand the
epidemiological behavior of GBS in Peru, and thus ensure adequate patient care nationally.

Keywords: Guillain-Barré syndrome; epidemiology; Peru (source: MeSH NLM).

EPIDEMIOLOGÍA DEL SÍNDROME DE GUILLAIN-BARRÉ EN PERÚ

RESUMEN
Objetivos. Describir el comportamiento epidemiológico del síndrome de Guillain-Barré (SGB) en el Perú. Materiales y
métodos. Estudio descriptivo de datos secundarios sobre egresos hospitalarios del Ministerio de Salud (MINSA)
durante el periodo 2012 - 2017, egresos hospitalarios de EsSalud y de SuSalud entre 2015 y 2017, y datos nacionales
de mortalidad entre 2014-2016. La identificación del SGB en las bases de datos se realizó utilizando la Clasificación
Internacional de Enfermedades, 10ª versión, mediante el código G610. Se estimó la incidencia, tasa de letalidad y
mortalidad por grupos de edad, sexo y departamento. Resultados. En la base de datos de egresos hospitalarios del
MINSA se identificaron un total de 955 casos de SBG entre 2012 y 2017, con una mayor frecuencia en hombres y en la
población de 20 a 59 años. La incidencia nacional de SGB por cada 100 mil habitantes fue de 0,62 (2015), 0,92 (2016)
y 0,91 (2017), siendo más alta en adultos mayores y en hombres. La tasa de letalidad global fue de 3,5%, y fue más
alta en los mayores de 60 años. El promedio del tiempo de hospitalización fue de 16 ± 22 días.. Además, Lima es el
departamento que concentró más del 40% de casos de SGB y Cusco, Lima, Callao, Lambayeque y Arequipa tuvieron
la mayor incidencia. Conclusiones. Este estudio proporciona información relevante para entender mejor el
comportamiento epidemiológico del SGB en el Perú, y así poder garantizar una atención adecuada de los pacientes a
nivel nacional.
Palabras clave: Síndrome de Guillain-Barré; Epidemiología; Perú (fuente: DeCS BIREME).

1 Working Group on Epidemiological Research and Evaluation of Health Interventions. National Center for Epidemiology, Prevention
and Control of Diseases. Lima Peru.
2 Directorate of Health Intelligence. National Center for Epidemiology, Prevention and Control of Diseases. Lima Peru.
a Medical surgeon; b Doctor in Public Health; c Master in Epidemiology; d master's degree in Applied Geographic Information
Systems; e Specialist in Field Epidemiology.
Received: 06/12/2018 Approved: 01/16/2019 Online: 03/20/2019

Cite as: Munayco CV, Soto MG, Reyes MF, Arica JA, Napanga O. Epidemiology of Guillain-Barré syndrome in Peru. Rev Peru Med
Exp Public Health. 2019; 36 (1): 10-6. doi: 10.17843 / rpmesp.2019.361.3729
INTRODUCTION
Guillain-Barré syndrome (GBS) is a group of
neuropathies characterized by progressive motor
weakness, decrease and absence of deep reflexes
(1). It is an autoimmune disease and triggered in two
thirds of cases, by a preceding infection, most often
respiratory or gastrointestinal infections (2).
SGB incidence has been estimated in countries such
as the United States and Europe. In a study
published by Amer et al. (3), it was estimated that the
annual incidence of GBS between 2000 and 2004
was between 1.65 to 1.79 per 100 000 inhabitants. In
addition, a meta-analysis estimated that the
incidence rate of GBS for all age groups studied was
0.62 to 2.66 per 100,000 population-year, and that
the incidence increased in ages over 80 years. (4)
In Peru, information on the epidemiology of GBS is
limited. Thus, a series of cases published by Ballón-
Manrique et al., Indicates that cases of GBS occur
mainly in adults between 20 and 60 years of age,
with the same frequency between men and women,
and that the axonal subtype is the most frequent. (5).
Suarez et al., Studied an outbreak of acute flaccid
paralysis in adults related to echovirus, in the
department of Ancash. In this outbreak, 16 cases of
acute flaccid paralysis were identified, the majority of
whom were men with an average age of 41 years
and a history of respiratory infection (6). In addition,
the case-fatality rate in this outbreak was 8.3%.
Currently, there is no information on the
epidemiological behavior of this syndrome, nor has it
been estimated its incidence, lethality or mortality
rate in Peru. Also, in May 2018, an epidemiological
alert was issued for a significant number of new
cases of GBS in the department of La Libertad (more
than 20 cases), and notifications were received from
other departments (7). Therefore, the objective of this
study was to describe the epidemiological behavior
of GBS in Peru, using the databases of various
institutions. In addition, the number of SGB hospital
discharges nationwide was estimated for 2018.
MATERIALS AND METHODS
A descriptive study of secondary data on hospital
discharges of the Ministry of Health (MINSA) during
the 2012 and 2017 period, hospital discharges of the
Social Security (EsSalud) and the National
Superintendence of Health (SuSalud) between 2015
and 2017, and of the Civil Registry or Registration
System of Vital Facts between 2014-2016 of the
MINSA (mortality database).
The hospital database of the MINSA collects data on
the epicrisis contained in the History
KEY MESSAGES
Motivation to carry out the study. The increase in cases of
Guillain-Barré syndrome during May 2018 generated the
need for epidemiological information on this health
problem. Unfortunately, information on this pathology is
limited in the country. An analysis was made of all the
sources that had data on this syndrome.
Main findings. GBS was more frequent in men and the most
affected age group was 20 to 59 years old. The global case-
fatality rate was 3.5% and was highest in those over 60
years of age. The average number of days of hospitalization
was 16 ± 22 days.
Implications. This study contributes to the epidemiological
knowledge of Guillain-Barré syndrome in Peru.
The patient's clinic, in some hospitals that have the SIS-
GalenPlus platform, use it as a data source for hospital
discharges (8,9). These data are sent by hospitals and health
centers with hospitalization services. The database contains
information on age, sex, usual residence of the patient, dates
of admission and discharge (hospital stay) and condition of
discharge.
The data of the SGB hospital discharges of the Armed and
Police Forces and private health establishments were
obtained from the SuSalud report, since they do not use the
hospital discharge system of the Ministry of Health. The
hospital discharges of the SGB cases of EsSalud were
obtained from the Hospital Management System, which is a
system that records the data of all outpatients and
hospitalized in EsSalud.
The database of the Civil Registry or vital registration
system collects data on death certificates that are filled out
by health personnel at the national level (10). This
database was used to calculate the SGB mortality rate.
The identification of GBS in the databases studied was done
using code G610 of the International Classification of
Diseases, 10th version (ICD-10). It should be noted that no
validation of the diagnostics of these databases has been
carried out.
A descriptive analysis of the characteristics of the patients
with GBS was carried out through tables of relative and
absolute frequencies for the categorical variables (sex,
condition of discharge), and mean and standard deviation for
numerical variables (age, hospital stay). In addition, the
incidence rate was calculated by age, sex and by
department, and the case-fatality rate by age. The mortality
rate was estimated by age and sex for the years 2014, 2015
and 2016. For the calculation of the rates
used the population estimated by the National The departments that registered the highest number of
Institute of Statistics and Informatics (INEI) available hospital discharges (2015-2017) by SGB were: Lima,
at https: // www.inei.gob.pe/estadisticas/indice- Arequipa, Cusco, La Libertad and Lambayeque (Table
tematic/poblation-and- livingplace /. Finally, maps 3). The department of Lima concentrated more than 40%
were designed to show the geographical distribution of GBS cases in the years studied. On the other hand,
of GBS cases by department and for years. the departments with the highest incidence were: Cusco,
Lima, Callao, Lambayeque and Arequipa.
In order to have a baseline for 2018, monthly hospital
discharges for the whole country were estimated Characteristics of N=955 Percentage
using monthly data between 2015 and 2017, through patients with GBS
the space-state model (11), for which the "stlf" Age groups (years)
command of the "forecast" package in R. This "stlf Medium (RI) 40 (19- -
command" is an acronym for the "Seasonal and Trend 56)
decomposition using Loess" method, which is a 0-9 134 14,0
robust method for decomposing time series that uses 10-19 112 11,8
the Loess method to estimate non- linear (12). This 20-59 531 55,6
method allowed adjusting the data to the space-state 60 or more 178 18,6
model or latent variables and estimating the cases for Sex
2018. Male 579 60,6
Female 376 39,4
Regarding the ethical aspects, in order to guarantee
the confidentiality of the information, the databases Hospitalization time
were obtained, omitting the names and identifying (days)
data of the persons, in addition to the institutional Medium (RI) 11 (6- -
authorization for the dissemination of the data. 19)
<15 614 64,3
15 a 29 225 23,6
RESULTS
In the database of hospital discharges of the MINSA, 30 a 60 83 8,7
a total of 955 cases of SBG cases were identified > 60 33 3,5
between 2012 and 2017.
Exit condition
high 922 96,5
50% of GBS cases were under 38 years old. The Passed away 33 3,5
highest percentage of cases was reported in the Lethality rate by age
group of 20 to 59 years and 60.6% of cases were group (years)
men. The median time of hospitalization was 11 days, 0-9 1/134 0,7
while 64% of GBS cases had an incidence time of
less than 15 days. Hospitalization time varied with 10-19 3/112 2,7
age: in those under 20 years, half of the cases had a 20-59 14/531 2,6
hospitalization time of ten days, in the group of 20 to
59 years it was 11 days and in those over 60 years >60 15/178 8,4
was 13 days. The case-fatality rate for all ages was
3.5%, but in those over 60 years, it was the highest SGB: Guillain-Barré syndrome; RI: interquartile range (p25 and p75)
Data sources: Hospital Expenditure Base of the Ministry of Health.
(8.4%) (Table 1).
Figure 1A shows the trend of hospital discharges per
Table 1. General characteristics of hospital
GBS and the spatial distribution by departments for the
discharges of Guillain-Barré syndrome cases of health
years 2015, 2016 and 2017 (Figure 1B-D). SBG's
establishments of the Ministry of Health, Peru 2012-
outflows trend is stable over time, with some peaks
2017.
during the first months of the year during the 2015 and
2017 periods. In addition, on average 22 hospital
Table 2 shows the number of cases and the number discharges per month of GBS were registered
of SGB deaths, in addition to the incidence and nationwide. Figure 1A, shows the hospital discharges
mortality rates, by age group and sex. During the estimated by month for 2018, based on what was
years 2015, 2016 and 2017, there were 214, 291 and reported during the three previous years.
290 SGB hospital discharges, respectively. The
national incidence per 100 thousand inhabitants for
The department of Lima always presented the highest
these same years was 0.62, 0.92 and 0.91,
number of cases in the three years studied (Figure 1BD).
respectively. According to age groups, those over 60
In 2017, in addition to Lima, the departments of La
years had the highest incidence, and the incidence
Libertad, Cusco, Arequipa and the Callao region
was higher in men compared to women, in all the
presented more than 15 cases per year (Figure 1D).
years studied.

At the national level, using the records of the vital

events system between 2014 and 2016, a total of 69
deaths were estimated per GBS, with estimated
mortality rates of 0.03, 0.11 and 0.08 per 100
thousand inhabitants, and the mortality rate was
higher in those older than 60 years (Table 2).
Table 2. Cases, incidence and mortality of Guillain-Barré syndrome by age and sex groups, Peru 2014-2017

Population Number of cases Incidence per 100 Number of deceased Mortality per 100
characteristics thousand inhabitants thousand inhabitants
2015 2016 2017 2015 2016 2017 2014 2015 2016 2014 2015 2016
Age groups (years)
0 to 9 16 30 27 0,28 0,52 0,47 0 0 3 0,00 0,00 0,05
10 to 19 30 29 30 0,52 0,50 0,52 0 0 5 0,00 0,00 0,09
20 to 59 99 171 162 0,60 1,02 0,95 3 25 5 0,02 0,15 0,03
60 more 69 61 71 2,29 1,96 2,20 6 9 13 0,20 0,30 0,42
Sex
Male 137 186 172 0,88 1,18 1,08 9 11 16 0,06 0,07 0,10
Female 77 105 118 0,50 0,67 0,74 0 23 10 0,00 0,15 0,06
National total 214 291 290 0,69 0,92 0,91 9 34 26 0,03 0,11 0,08
Data sources: Hospital outpatient base of the Ministry of Health; Report of the Hospital Management System of EsSalud;
Database of SuSalud data records; Systems of registration of vital events (mortality). The population estimated by the
National Institute of Statistics and Information was used to calculate the rates.

Table 3. Number of hospital discharges and incidence of Guillain-Barré syndrome by department, Peru 2015-2017

Department Number of hospital discharges per SGB Incidence per 100 thousand inhabitants

2015 2016 2017 2015 2016 2017

Amazon 0 1 0 0,00 0,24 0,00
Ancash 8 9 11 0,70 0,78 0,95
Apurímac 2 2 0 0,44 0,43 0,00
Arequipa 13 14 20 1,01 1,08 1,52
Ayacucho 2 3 4 0,29 0,43 0,57
Cajamarca 9 9 11 0,59 0,59 0,72
Callao 6 16 16 0,59 1,56 1,54
Cusco 15 14 20 1,14 1,06 1,50
Huancavelica 3 3 1 0,61 0,60 0,20
Huánuco 3 7 3 0,35 0,81 0,34
Ica 4 7 6 0,51 0,88 0,75
Junín 5 13 9 0,37 0,96 0,66
The freedom 15 15 19 0,81 0,80 1,00
Lambayeque 12 14 13 0,95 1,10 1,02
Lima 95 142 127 0,97 1,42 1,25
Loreto 5 5 2 0,48 0,48 0,19
Mother of God 1 0 2 0,73 0,00 1,39
Moquegua 0 0 1 0,00 0,00 0,54
Pasco 2 1 4 0,66 0,33 1,30
Piura 4 3 4 0,22 0,16 0,21
Puno 1 3 3 0,07 0,21 0,21
San Martin 4 7 8 0,48 0,82 0,93
Tacna 3 0 5 0,88 0,00 1,43
Tumbes 2 1 0 0,84 0,42 0,00
Ucayali 0 2 1 0,00 0,40 0,20
National total 214 291 290 0,69 0,92 0,91

SGB: Guillain-Barré syndrome.

Data sources: MINSA hospital outpatient basis; Report of the Hospital Management System of EsSalud; Database of
SuSalud data records.
The population estimated by the National Institute of Statistics and Information was used to calculate the rates.
Figure 1. A. Estimation of hospital discharge for Guillain-Barré syndrome cases in 2018. B. Spatial distribution of cases of
Guillain-Barré syndrome in 2015. C. Spatial distribution of cases of Guillain-Barré syndrome. Barré 2016. D. Spatial
distribution of cases of Guillain-Barré syndrome in 2017.
DISCUSSION
The present study shows that GBS was more
frequent in men than in women, and the most
affected age group was 20 to 59 years old. Likewise,
the global case-fatality rate was 3.5%, which was
higher in those over 60 years of age. On the other
hand, the highest incidence rate occurred in those
over 60 and in men. Lima is the department that
concentrates more than 40% of GBS cases. The
departments with the highest incidence were: Cusco,
Lima, Callao, Lambayeque and Arequipa.
The few studies conducted in our country indicate
that GBS cases are more frequent in men and that
the average age varies between 32 and 44 years
(14.5). Studies conducted in other countries (15-17),
found results similar to those reported in Peru. In the
study by Olivé et al., Carried out in children under 15
years of age, GBS was more frequent in men with a
male ratio / Figure 1. A. Estimation of hospital
discharges from cases of Guillain-Barré syndrome.
2018. B. Spatial distribution of cases of Guillain-
Barré syndrome in 2015. C. Spatial distribution of
cases of Guillain-Barré syndrome in 2016. D. Spatial
distribution of cases of Guillain-Barré syndrome in
2017. woman of 1,36. In another study by Mao et al.
(15), the average age was 31 years, and the percentage
of men and women was similar. Similar findings were
found in our study, where GBS was more frequent in
men and the average age of the cases by GBS was 38 ±
22 years.
Apaza et al. (14) found that the time of hospitalization of
SBG cases varies according to the electrophysiological
type, for example, acute inflammatory demyelinating
polyneuropathy and Miller-Fisher syndrome had an
average hospitalization time of 21 days, whereas the
hospitalization time of acute motor axonal neuropathy
was 16 days. Unfortunately, in this study it was not
possible to identify the physiological types of GBS
because in the revised databases that variable is not
included, but it was estimated that the average
hospitalization time was 16 ± 22 days and that, the older,
the older it was hospitalization time, this is how those
over 60 had a higher average time (20 ± 24 days).
According to the study by Olivé et al. (17) performed
in Latin America in patients younger than 15 years,
the case-fatality rate by SGB was 7%. In the study by
Mao et al. (15) conducted in all age groups, a case-
fatality rate of 6% was found. According to the
findings of this study, a lower global lethality of 3.5%
was found. In addition, the lethality in children under
ten years of age (0.7%) was much lower than that
reported by Olivé et al. (17) It is important to highlight
that, in our study, the case-fatality rate in those over
60 years of age was 8.4%. These differences in
case-fatality rates could be explained by the type of
GBS included in each study, as shown by the study
by Mao et al., Where it is observed that there are
important differences in lethality according to the type
of GBS (15 ). In this study it was not possible to
differentiate the type of GBS, because that data was
not available in the revised database.
The incidence of GBS varies according to the age
groups and the country. In Finland the incidence of
SBG in children under 15 years of age was 0.38 per
100 000 inhabitants (18), in Curacao the incidence
was 2.53 per 100 000 inhabitants (19). In the United
States, the adjusted incidence ranged from 1.65 to
1.79 per 100,000 population (20). In our study, the
global incidence fluctuated between 0.69 to 0.91 in
the three years studied. In addition, the incidence of
GBS was higher in men than in women and in those
older than 60 years. This increase in the incidence in
those over 60 years of age was also observed in
other studies (16,19,20). The death rate due to GBS
was estimated, and there was no study to compare.
The results of the study show a geographical
variability in the incidence of GBS, where the highest
rates occurred in Cusco, Lima, Callao, Lambayeque
and Arequipa. The departments of the highlands and
jungle presented incidences lower than the national
average. These differences can be explained by a
greater number of specialists and better
infrastructure of hospitals to make the diagnosis of
GBS.
Previous studies have proposed that GBS presents
seasonality, although it has not been demonstrated
that there is a significant increase in cases of GBS in
certain periods of the year (2). In some studies, a
greater number of cases have been reported during
winter (21,22), others in spring and summer (23). In
our study, no seasonality is observed, although the
number of cases is greater during the first months of
the year. In addition, there is not enough data
available to evaluate it.
Another important point of this study was to estimate
the hospital expenditures of the SGB so that the
National Center for Epidemiology, Prevention and
Control of Diseases (CDC Peru), have the cases
expected for 2018 and be able to compare them with
the cases observed in this year and thus define if you
are facing an increase above the expected of cases
of SGB (outbreak of GBS) in the northern part of the
country.
This study presents some limitations considering that the
data used come from secondary sources. Among these
limitations, we have the quality of the data and the sub-
registry of hospital discharges and mortality data. In
order to improve their quality, the data of all the
institutions were crossed, completing the missing data or
cases, or the inconsistent information. The
underreporting of hospital discharges could not be
determined, but it is estimated that it is reduced, due to
the use of epicrisis (no patient can be discharged without
epicrisis) and the SIS-GalenPlus platform. In addition,
those responsible for entering the information to the
hospital discharge system are the statistical offices of
the hospitals that guarantee the entry of these data. On
the other hand, it is known that the underreporting of
mortality of vital events is around 43.3% by 2015 (13),
and estimates of mortality rates included the
underreporting of deaths by SGB (10) . Another
limitation to take into account, is that the data obtained
correspond to different periods of time, which does not
allow to adequately compare the data over time, but
despite this we can have an idea of the temporary
evaluation of the SGB. Finally, it is important to highlight
that the offer of diagnosis and treatment may have
affected the distribution by departments, mainly in the
mountain and jungle areas of the country.
This study provides important epidemiological
information to better understand the behavior of GBS in
Peru through hospital discharges, for the planning of
both human resources and medical supplies, ensuring
an adequate response to GBS cases that arise Nacional
level. Added to this, it provides the baseline of cases of
GBS for this year and thus be able to identify any
variation above the expected, to ensure a rapid
response.
Acknowledgments: The authors thank the graduate
Yovanna Seclén for having shared the consolidated
information on hospital discharges from EsSalud. In
addition, to thank Mrs. María Berto and Dr. José Medina,
for preparing the consultations of the hospital discharge
and mortality databases. Finally, we want to thank the
National Health Superintendence (SuSalud) for sharing
their hospital discharge report.
Funding sources: self-financed.
Conflicts of interest: none to declare.
Disclaimer: All opinions expressed in this manuscript
are the responsibility of the authors and not the National
Center for Epidemiology, Prevention and Control of
Diseases.
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Correspondence: César Vladimir Munayco Escate
National Center for Epidemiology, Prevention and
Control of Diseases CDC Peru.
Address: Calle Saturno 117, Ate, Lima - Peru.
Phone: +51 982508166
Email: cmunayco@dge.gob.pe