Ana Freitas Ribeiro

Incorporation of Real-Time PCR into Routine Public Health Surveillance of Culture Negative Bacterial Meningitis in São Paulo, Brazil

Real-time (RT)-PCR increases diagnostic yield for bacterial meningitis and is ideal for incorporation into routine surveillance in a developing country. We validated a multiplex RT-PCR assay for Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae in Brazil. Risk factors for being culture-negative, RT-PCR positive were determined. The sensitivity of RT-PCR in cerebrospinal fluid (CSF) was 100% (95% confidence limits, 96.0%–100%) for N. meningitidis, 97.8% (85.5%–99.9%) for S. pneumoniae, and 66.7% (9.4%–99.2%) for H. influenzae. Specificity ranged from 98.9% to 100%. Addition of RT-PCR to routine microbiologic methods increased the yield for detection of S. pneumoniae, N. meningitidis, and H. influenzae cases by 52%, 85%, and 20%, respectively. The main risk factor for being culture negative and RT-PCR positive was presence of antibiotic in CSF (odds ratio 12.2, 95% CI 5.9-25.0). RT-PCR using CSF was highly sensitive and specific and substantially added to measures of meningitis disease burden when incorporated into routine public health surveillance in Brazil.

American Visceral Leishmaniasis: Factors Associated with Lethality in the State of São Paulo, Brazil

Objectives. To identify factors associated with death in visceral leishmaniasis (VL) cases. Patients and Methodology. We evaluated prognostic factors for death from VL in São Paulo state, Brazil, from 1999 to 2005. A prognostic study nested in a clinical cohort was carried out by data analysis of 376 medical files. A comparison between VL fatal cases and survivors was performed for clinical, laboratory, and biological features. Association between variables and death was assessed by univariate analysis, and the multiple logistic regression model was used to determine adjusted odds ratio for death, controlling confounding factors. Results. Data analysis identified 53 fatal cases out of 376 patients, between 1999 and 2005 in São Paulo state. Lethality was 14.1% (53/376), being higher in patients older than fifty years. The main causes of death were sepsis, bleeding, liver failure, and cardiotoxicity due to treatment. Variables significantly associated with death were severe anemia, bleeding, heart failure, jaundice, diarrhea, fever for more than sixty days, age older than fifty years, and antibiotic use. Conclusion. Educational health measures are needed for the general population and continuing education programs for health professionals working in the affected areas with the purpose of identifying and treating early cases, thus preventing the disease evolution towards death.

Chagasic meningoencephalitis: case report of a recently included AIDS-defining illness in Brazil

Recently, reactivation of Chagas disease (meningoencephalitis and/or myocarditis) was included in the list of AIDS-defining illnesses in Brazil. We report a case of a 52-year-old patient with no history of previous disease who presented acute meningoencephalitis. Direct examination of blood and cerebrospinal fluid (CSF) showed Trypanosoma cruzi. CSF culture confirmed the diagnosis. Serological assays for T. cruzi and human immunodeficiency virus (HIV) were positive. Despite treatment with benznidazol and supportive measures, the patient died 24 hours after hospital admission. In endemic areas, reactivation of Chagas disease should always be considered in the differential diagnosis of meningoencephalitis among HIV-infected patients, and its presence is indicative of AIDS.

Effect of 10-valent pneumococcal conjugate vaccine on nasopharyngeal carriage of Streptococcus pneumoniae and Haemophilus influenzae among children in São Paulo, Brazil

In March 2010, Brazil introduced the 10-valent pneumococcal conjugate vaccine (PCV10) in the routine infant immunization program using a 4-dose schedule and catch-up for children <23months. We investigated PCV10 effect on nasopharyngeal carriage with vaccine-type Streptococcus pneumoniae (Spn) and non-typeable Haemophilus influenzae (NTHi) among children in São Paulo city. Cross-sectional surveys were conducted in 2010 (baseline) and 2013 (post-PCV10). Healthy PCV-naïve children aged 12-23months were recruited from primary health centers during immunization campaigns. Nasopharyngeal swabs were collected and tested for Hi; for Spn, all baseline and a stratified random sample of 400 post-PCV10 swabs were tested. We compared vaccine-type Spn and NTHi carriage prevalence pre-/post-PCV10, and used logistic regression to estimate PCV10 effectiveness (1-adjusted odds ratio×100%). Overall 501 children were included in the baseline and 1167 in the post-PCV10 survey (including 400 tested for Spn). Spn was detected in 40.3% of children at baseline and 48.8% post-PCV10; PCV10 serotypes were found in 19.8% and 1.8% respectively, representing a decline of 90.9% (p<0.0001). Carriage of vaccine-related serotypes increased (10.8-21.0%, p<0.0001), driven primarily by a rise in serotype 6C (1.8-11.2%, p<0.0001); carriage of serotypes 6A and 19A did not significantly change. PCV10 effectiveness (4 doses) against vaccine-type carriage was 97.3% (95% confidence interval 88.7-99.3). NTHi prevalence increased from 26.0% (130/501) to 43.6% (509/1167, p<0.0001); PCV10 vaccination seemed significantly associated with NTHi carriage, even after adjusting for other known risk factors. Carriage with PCV10 serotypes among toddlers declined dramatically following PCV10 introduction in São Paulo, Brazil. No protection of PCV10 against NTHi was observed. Our findings contribute to a growing body of evidence of PCV10 impact on vaccine-type carriage and highlight the importance of PCV10 as a tool to reduce the burden of pneumococcal disease in Brazil and globally.

Carriage Rate and Effects of Vaccination after Outbreaks of Serogroup C Meningococcal Disease, Brazil, 2010

Polysaccharide vaccine did not affect carriage nor interrupt transmission of an epidemic strain.

Travelers as sentinels for chikungunya fever, Brazil.

To the Editor: The reemergence of chikungunya virus (CHIKV) infection recently has been reported in travelers after they returned from affected areas (1–6). In the Americas, local transmission has not been identified, although imported cases have been reported in travelers returning from Reunion Island to Martinique, French Guiana, and Guadeloupe (7). In the United States, CHIKV infections have also been reported in travelers who returned from disease-endemic areas (8). Climate changes in recent decades have affected the dynamics of infectious disease transmission, increasing the incidence, prevalence, and number of outbreaks of mosquito-borne diseases, such as dengue fever. Both CHIKV and dengue virus are transmitted by Aedes spp. mosquitoes. Ae. aegypti mosquitoes are the most common mosquito involved in dengue transmission, and Ae. albopictus mosquitoes have been described as efficient vectors of CHIKV. Recent global expansion of Ae. albopictus mosquitoes has been associated with the introduction and dissemination of CHIKV in new areas (9). More than 4,000 cities in Brazil are infested with Ae. aegypti mosquitoes, which predominates in urban areas, and such areas have a high incidence of dengue fever and annual outbreaks of this disease. Ae. albopictus mosquitoes have been identified in Brazil, where they are more frequently found in rural areas (10). The confirmed chikungunya fever cases described here illustrate the risk for introduction and sustained transmission of the disease in Brazil. In August 2010, a 55-year-old man returned to Brazil from Indonesia, where he had spent 15 days. Seven days after his arrival in Indonesia, a fever (temperature 38.5–39.0°C) developed that lasted for 3 days, along with a facial rash that spread to his neck, trunk, legs, and ankles, followed by desquamation. During the trip, he experienced disabling pain and swelling in the ankles, accompanied by weight loss (5 kg). Four other travelers in his group experienced fever, arthralgia, and malaise. Upon his return to Brazil, the man immediately sought medical attention, and his symptoms were treated with intravenous fluids, parenteral corticosteroids, and nonsteroidal antiinflammatory drugs for 2 weeks. Despite improvement, the arthralgia recurred in the wrists and metacarpal bones. He was referred to the Travel Medicine Outpatient Clinic of the University of Sao Paulo School of Medicine Hospital das Clinicas. Laboratory tests showed elevated levels of aspartate transaminase (117 U/L), alanine transaminase (179 U/L), and C-reactive protein (27.8 mg/L). Test results for Plasmodium spp., dengue virus, cytomegalovirus, and Toxoplasma spp. were all negative. Fifty-three days after onset symptom, anti-CHIKV IgM and IgG antibodies were detected by ELISA. By day 60, his IgG titer had risen from 3,200 to 6,400, where it remained 11 months after onset of symptoms. In October 2010, a 25-year-old woman returned to Brazil from Rajasthan, India, where she had spent 30 days working with a humanitarian aid group. During her return, fever (38.0–39.0°C) and malaise developed. She sought medical attention in the emergency department of the Emilio Ribas Institute of Infectious Diseases, reporting fever, headache, myalgia, fatigue, general malaise, and paresthesia of the hands, as well as severe ankle and foot pain with gait impairment. Physical examination showed dehydration, conjunctival injection, and fever (temperature 38.0°C), as well as skin redness and a faint rash on the trunk. She also had swollen ankles. The fever (temperature 37.8°C) persisted, and she had pain in her ankles and left knee, which made it difficult for her to walk, accompanied by desquamation of palms and soles (Figure). Laboratory tests detected leukopenia and thrombocytopenia. Test results for Plasmodium spp. and dengue virus were negative, and blood culture results were negative as well. By using ELISA, anti-CHIKV IgM antibodies were detected 10 days after onset of symptoms, and anti-CHIKV IgG antibodies (titer 25,600) were detected 8 months later. Figure Clinical features exhibited by patient with chikungunya, Brazil 2010. A) Desquamation of palms after maculopapular rash, 33 days after symptom onset. B) Desquamation of soles after maculopapular rash, 33 days after symptom onset. Both patients were diagnosed after the viremic period; no virus could be isolated or genotyped. Nevertheless, health authorities were alerted and appropriate control measures were taken. Travelers can serve as sentinels for the introduction of viruses into previously non–disease-endemic areas. Several reports have been made of travelers carrying CHIKV to and from many regions of the world (2,4–6). Recent identification of the expansion of infested areas by Ae. aegypti and Ae. albopictus mosquitoes, population susceptibility for the virus, and the constant journeying of travelers from affected areas are relevant indications of the risk for introduction and sustained transmission of CHIKV in Brazil. Health care professionals and public health authorities should be aware of the epidemiologic and clinical aspects of CHIKV infection and diagnoses to adopt prompt control measures to avoid CHIKV transmission in Brazil. Healthcare facilities and epidemiologic surveillance teams have jointly implemented CHIKV prevention and control measures. To date, no autochthonous transmission of CHIKV has been reported in Brazil.

Risk Factors for Death from Influenza A(H1N1)pdm09, State of São Paulo, Brazil, 2009

This case-control study aimed to assess the risk factors for death from influenza A(H1N1)pdm09 in patients with laboratory confirmation, who had severe acute respiratory illness-SARI and were hospitalized between June 28th and August 29th 2009, in the metropolitan regions of São Paulo and Campinas, Brazil. Medical charts of all the 193 patients who died (cases) and the 386 randomly selected patients who recovered (controls) were investigated in 177 hospitals. Household interviews were conducted with those who had survived and the closest relative of those who had died. 73.6% of cases and 38.1% of controls were at risk of developing influenza-related complications. The 18-to-59-year age group (OR = 2.31, 95%CI: 1.31–4.10 (reference up to 18 years of age)), presence of risk conditions for severity of influenza (OR = 1.99, 95%CI: 1.11–3.57, if one or OR = 6.05, 95%CI: 2.76–13.28, if more than one), obesity (OR = 2.73, 95%CI: 1.28–5.83), immunosuppression (OR = 3.43, 95%CI: 1.28–9.19), and search for previous care associated with the hospitalization (OR = 3.35, 95%CI: 1.75–6.40) were risk factors for death. Antiviral treatment performed within 72 hours of the onset of symptoms (OR = 0.17, 95%CI: 0.08–0.37, if within 48hours, and OR = 0.30, 95%CI: 0.11–0.81, if between 48 and 72 hours) was protective against death. The identification of high-risk patients and early treatment are important factors for reducing morbi-mortality from influenza.

Influenza B Outbreak on a Cruise Ship off the São Paulo Coast, Brazil

BACKGROUND In February 2012, crew and passengers of a cruise ship sailing off the coast of São Paulo, Brazil, were hospitalized for acute respiratory illness (ARI). A field investigation was performed to identify the disease involved and factors associated. METHODS Information on passengers and crew with ARI was obtained from the medical records of hospitalized individuals. Active case finding was performed onboard the ship. ARI was defined as the presence of one nonspecific symptom (fever, chills, myalgia, arthralgia, headache, or malaise) and one respiratory symptom (cough, nasal congestion, sore throat, or dyspnea). A case-control study was conducted among the crew. The cases were crew members with symptoms of influenza-like illness (ILI) (fever and one of the following symptoms: cough, sore throat, and dyspnea) in February 2012. The controls were asymptomatic crew members. RESULTS The study identified 104 ARI cases: 54 (51.9%) crew members and 50 (49.1%) passengers. Among 11 ARI hospitalized cases, 6 had influenza B virus isolated in nasopharyngeal swab. One mortality among these patients was caused by postinfluenza Staphylococcus aureus pneumonia. The crew members housed in the two lower decks and those belonging to the 18- to 32-year-old age group were more likely to develop ILI [odds ratio (OR) = 2.39, 95% confidence interval (CI) 1.09-5.25 and OR = 3.72, CI 1.25-11.16, respectively]. CONCLUSIONS In February 2012, an influenza B outbreak occurred onboard a cruise ship. Among crew members, ILI was associated with lower cabin location and younger age group. This was the first influenza outbreak detected by Brazilian public health authorities in a vessel cruising in South American waters.

Yellow fever: reemerging in the state of Sao Paulo, Brazil, 2009

OBJECTIVE To describe the investigation of a sylvatic yellow fever outbreak in the state of Sao Paulo and the main control measures undertaken. METHODS This is a descriptive study of a sylvatic yellow fever outbreak in the Southwestern region of the state from February to April 2009. Suspected and confirmed cases in humans and in non-human primates were evaluated. Entomological investigation in sylvatic environment involved capture at ground level and in the tree canopy to identify species and detect natural infections. Control measures were performed in urban areas to control Aedes aegypti . Vaccination was directed at residents living in areas with confirmed viral circulation and also at nearby cities according to national recommendation. RESULTS Twenty-eight human cases were confirmed (39.3% case fatality rate) in rural areas of Sarutaiá, Piraju, Tejupá, Avaré and Buri. The deaths of 56 non-human primates were also reported, 91.4% were Allouatta sp. Epizootics was confirmed in two non-human primates in the cities of Itapetininga and Buri. A total of 1,782 mosquitoes were collected, including Haemagogus leucocelaenus , Hg. janthinomys/capricornii , and Sabethes chloropterus, Sa. purpureus and Sa. undosus . Yellow fever virus was isolated from a group of Hg. Leucocelaenus from Buri. Vaccination was carried out in 49 cities, with a total of 1,018,705 doses. Nine serious post-vaccination adverse events were reported. CONCLUSIONS The cases occurred between February and April 2009 in areas with no recorded yellow fever virus circulation in over 60 years. The outbreak region occurred outside the original recommended vaccination area with a high percentage of susceptible population. The fast adoption of control measures interrupted the human transmission within a month and the confirmation of viral circulation in humans, monkeys and mosquitoes. The results allowed the identification of new areas of viral circulation but further studies are required to clarify the dynamics of the spread of this disease.OBJETIVO Describir la investigacion de brote de fiebre amarilla silvestre y las principales medidas de control realizadas en el estado de Sao Paulo. METODOS Estudio descriptivo del brote de fiebre amarilla silvestre en la region suroeste del Estado, entre febrero y abril de 2009. Se evaluaron casos sospechosos y confirmados en humanos y primates no humanos. La investigacion entomologica, en ambiente silvestre, involucro capturo en suelo y copa de arboles para identificacion de las especies y deteccion de infeccion natural. Se realizaron acciones de control de Aedes aegypti en areas urbanas. La vacunacion fue direccionada a residentes de los municipios con confirmacion de circulacion viral y en los municipios contiguos, siguiendo recomendacion nacional. RESULTADOS Se confirmaron 28 casos en humanos (letalidad 39,3%) en areas rurales de Sarutaia, Piraju, Tejupa, Avare y Buri. Se notificaron 56 muertes de primates no humanos, 91,4% del genero Allouatta sp. La epizootia fue confirmada laboratorialmente en dos primates no humanos siendo uno de Buri y el otro de Itapetininga. Se colectaron 1.782 mosquitos, entre ellos Haemagogus leucocelaenus, Hg. janthinomys/capricornii, y Sabethes chloropterus, Sa. purpureus y Sa. undosus. El virus de la fiebre amarilla fue aislado de un lote de Hg. leucocelaenus procedente de Buri. La vacunacion fue realizada en 49 municipios, con 1.018.705 dosis aplicadas y el registro de nueve eventos adversos graves post-vacunacion. CONCLUSIONES Los casos humanos ocurrieron entre febrero a abril de 2009 en areas sin registro de circulacion del virus de la fiebre amarilla por mas de 60 anos. La region se encontraba fuera del area de recomendacion de vacunacion, con alto porcentaje de poblacion susceptible. La adopcion oportuna de medidas de control permitio la interrupcion de la transmision humana en un mes, asi como, la confirmacion de la circulacion viral en humanos, primates no humanos y mosquitos. Los aislamientos facilitaron la identificacion de las areas de circulacion viral, pero nuevos estudios son importantes con el objeto de aclarar la dinamica de transmision de la enfermedad.

Serodiagnosis as Adjunct Assay for Pertussis Infection in São Paulo, Brazil

ABSTRACT Pertussis remains an important public health problem in many countries despite extensive immunization. Cultures and real-time PCR (RT-PCR) assays are the recommended pertussis diagnostic tests, but they lack sensitivity at the later stage of the disease. This study introduces the IgG anti-pertussis toxin enzyme-linked immunosorbent assay (PT ELISA) in our routine diagnosis to improve disease burden estimation. Serum samples and nasopharyngeal swabs (n = 503) were collected at the same time from patients presenting with cough illness suspected of being pertussis and tested by the PT ELISA and culture and/or RT-PCR, respectively. Patients were separated into three age groups: group 1, <1 year (n = 260; mean age, 3 months), group 2, 1 to 6 years (n = 81; mean age, 3 years), and group 3, ≥7 years (n = 162; mean age, 26 years). The times (means) from cough onset to specimen collection were 16, 24, and 26 days, respectively. In group 1, 83 (82.2%) of 101 positive cases were positive for pertussis by culture/RT-PCR, while 40 (39.6%) tested positive by PT ELISA. In group 2, 6 (19.4%) of 31 positive cases were culture/RT-PCR positive, and 29 (93.6%) were seropositive. In group 3, 13 (13.8%) of 94 positive cases were positive by culture/RT-PCR and 91 (96.8%) were positive by serology. Culture/RT-PCR detected more cases of pertussis in infants (P < 0.0001), whereas the PT ELISA detected more cases in adolescents and adults (P < 0.0001). The timing between cough onset and specimen collection or recent vaccination may have partially affected our results. Serology is a suitable, cost-effective, and complementary pertussis diagnostic tool, especially among older children, adolescents, and adults during the later disease phase.