Arnaldo Prata-Barbosa

Microcephaly Case Fatality Rate Associated with Zika Virus Infection in Brazil: Current Estimates

Considering the currently confirmed cases of microcephaly and related deaths associated with Zika virus in Brazil, the estimated case fatality rate (CFR) is 8.3% [95%CI:7.2-9.6]. However, a third of the reported cases remains under investigation. If the confirmation rates of cases and deaths are the same in the future, the estimated CFR will be as high as 10.5% (95%CI:9.5-11.7).Considering the currently confirmed cases of microcephaly and related deaths associated with Zika virus in Brazil, the estimated case fatality rate is 8.3% (95% confidence interval: 7.2–9.6). However, a third of the reported cases remain under investigation. If the confirmation rates of cases and deaths are the same in the future, the estimated case fatality rate will be as high as 10.5% (95% confidence interval: 9.5–11.7).

Trends of the microcephaly and Zika virus outbreak in Brazil, January–July 2016

In the last two months, there have been indications that the Zika virus epidemic is on the decline in Brazil. We reviewed the surveillance data published by the Brazilian Ministry of Health to assess trends of microcephaly and neurological abnormalities suggestive of congenital infection, as well as Zika virus disease in Brazil as a whole and its various regions. From November 2015 to July 2016, 8301 cases of microcephaly were reported in Brazil, mainly in the Northeast region. The number of newly reported cases is declining throughout the country, except in the Southeast region. The numbers of cases that remain under investigation still represent 37.7% of all reported cases in early July. Meanwhile, from January to June, 2016, 165,241 cases of Zika virus disease were reported in Brazil. The state of Rio de Janeiro (Southeast) experienced the third highest incidence, lagging behind only the states of Bahia (Northeast) and Mato Grosso (Midwest). In early June, the number of new Zika virus cases showed a marked decline in all of the regions, except the North. Although the Zika epidemic seems to be diminishing, continued monitoring and surveillance of reported microcephaly and neurological abnormality cases is essential, and investigation efforts need to be vastly improved, as some states still reported high incidences of Zika disease in the first half of 2016.

A review of selected Arboviruses during pregnancy.

Arboviruses are emerging infectious diseases with the ability to expand geographically and rapidly affect large populations.The recent epidemic caused by the Zika virus in the Americas and congenital Zika syndrome associated with maternal infection has called out attention to the importance of studying arboviruses during pregnancy.This is a review on selected arboviruses infections during gestation, including Zika, Chikungunya, Dengue and Yellow Fever viruses. Issues such as historical overview, pathogenesis, transmission, clinical conditions, diagnosis, treatment and prevention are addressed.

Validity of triage systems for paediatric emergency care: a systematic review

Aim To present a systematic review on the validity of triage systems for paediatric emergency care. Methods Search in MEDLINE, Cochrane Library, Latin American and Caribbean Health Sciences Literature (LILACS), Scientific Electronic Library Online (SciELO), Nursing Database Index (BDENF) and Spanish Health Sciences Bibliographic Index (IBECS) for articles in English, French, Portuguese or Spanish with no time limit. Validity studies of five-level triage systems for patients 0–18 years old were included. Two reviewers performed data extraction and quality assessment as recommended by PRISMA statement. Results We found 25 studies on seven triage systems: Manchester Triage System (MTS); paediatric version of Canadian Triage and Acuity Scale (PedCTAS) and its adaptation for Taiwan (paediatric version of the Taiwan Triage and Acuity System); Emergency Severity Index version 4 (ESI v.4); Soterion Rapid Triage System and South African Triage Scale and its adaptation for Bostwana (Princess Marina Triage Scale). Only studies on the MTS used a reference standard for urgency, while all systems were evaluated using a proxy outcome for urgency such as admission. Over half of all studies were low quality. The MTS, PedCTAS and ESI v.4 presented the largest number of moderate and high quality studies. The three tools performed better in their countries or near them, showing a consistent association with hospitalisation and resource utilisation. Studies of all three tools found that patients at the lowest urgency levels were hospitalised, reflecting undertriage. Conclusions There is some evidence to corroborate the validity of the MTS, PedCTAS and ESI v.4 for paediatric emergency care in their own countries or near them. Efforts to improve the sensitivity and to minimise the undertriage rates should continue. Cross-cultural adaptation is necessary when adopting these triage systems in other countries.

CLARIPED: a new tool for risk classification in pediatric emergencies

Abstract Objective: To present a new pediatric risk classification tool, CLARIPED, and describe its development steps. Methods: Development steps: (i) first round of discussion among experts, first prototype; (ii) pre-test of reliability, 36 hypothetical cases; (iii) second round of discussion to perform adjustments; (iv) team training; (v) pre-test with patients in real time; (vi) third round of discussion to perform new adjustments; (vii) final pre-test of validity (20% of medical treatments in five days). Results: CLARIPED features five urgency categories: Red (Emergency), Orange (very urgent), Yellow (urgent), Green (little urgent) and Blue (not urgent). The first classification step includes the measurement of four vital signs (VIPE score); the second step consists in the urgency discrimination assessment. Each step results in assigning a color, selecting the most urgent one for the final classification. Each color corresponds to a maximum waiting time for medical care and referral to the most appropriate physical area for the patients clinical condition. The interobserver agreement was substantial (kappa=0.79) and the final pre-test, with 82 medical treatments, showed good correlation between the proportion of patients in each urgency category and the number of used resources (p<0.001). Conclusions: CLARIPED is an objective and easy-to-use tool for simple risk classification, of which pre-tests suggest good reliability and validity. Larger-scale studies on its validity and reliability in different health contexts are ongoing and can contribute to the implementation of a nationwide pediatric risk classification system.

Prevalence of microcephaly in eight south-eastern and midwestern Brazilian neonatal intensive care units: 2011-2015

Objective To describe the prevalence of microcephaly in infants admitted to the neonatal intensive care units (NICUs) in eight private hospitals in south-eastern and midwestern Brazil, from 2011 to 2015. Design Observational, cross-sectional study in a cohort of neonates. Setting Eight private NICUs situated in the cities of Rio de Janeiro (RJ), São Paulo (SP) and Federal District of Brasilia (FDB). Patients Neonates up to 7 days of age and >23 weeks of gestational age. Main outcome measures Primary outcomes were the annual prevalence of microcephaly and severe microcephaly, both overall and in subgroups according to gestational age, type of microcephaly (proportional or disproportional) and the NICUs location in RJ, SP or FDB. Results In this cohort of 8275 neonates admitted to eight private NICUs, the overall prevalence of microcephaly was 5.6% (95% CI 5.1% to 6.1%) and severe microcephaly, 1.5% (95% CI 1.2% to 1.7%). There was no annual variation in these overall estimates (p=0.48 and p=0.99, respectively), nor in the studied subgroups. Microcephaly prevalence was higher in extremely premature and term newborns (7.7% and 7.2%; p<0.001, respectively). Disproportional microcephaly was much more common than proportional microcephaly (prevalence 5.0% vs 0.6%; p<0.001). Conclusions The prevalence of microcephaly showed little variation from 2011 to 2015 in these south-eastern and midwestern Brazilian NICUs, suggesting that the impact of the Zika epidemic in neonates that occurred mainly in the north-eastern region in 2015 did not yet affect the infants of those regions during the studied period. These prevalence results can serve as a reference for comparisons with any future Zika outbreaks in the same or similar populations from these regions.

Patterns of C-reactive protein ratio response to antibiotics in pediatric sepsis: A prospective cohort study

Purpose: Evaluate sequential C‐reactive protein (CRP) measurements and patterns of CRP‐ratio response to antibiotic therapy during first 7 days in Pediatric Intensive Care Unit (PICU) of septic children. Methods: Prospective, cohort study of children (1 month‐12 years) admitted at 3 PICUs, with diagnosis of sepsis with <72 h course. CRP‐ratio was calculated in relation to D0_CRP value. Children were classified according to an individual pattern of CRP‐ratio response: fast – CRP_D4 of therapy was <0.4 of D0_CRP; slow – continuous but slow decrease of CRP; non – CRP remained ≥0.8 of D0_CRP; biphasic – initial CRP decrease to levels <0.8 of D0_CRP followed by secondary rise ≥0.8. Results: 103 septic children (age‐median: 2 yrs; 54% male) were prospectively included (infection focus: 65% respiratory, 12.5% central nervous system). Overall PICU mortality was 11.7%. 102 children could be classified according to a predefined CRP‐ratio response pattern. Time‐dependent analysis of CRP‐ratio and CRP course of the different patterns were significantly different. Besides, PICU mortality rate was significantly different according CRP‐ratio response patterns: fast response 4.5%; slow response 5.8%; non‐response 29.4%; biphasic response 42.8%. Conclusions: In pediatric sepsis, CRP‐ratio serial evaluation was useful in early identification of patients with poor outcome. HighlightsSequential evaluation of CRP and CRP‐ratio was useful in the early identification of pediatric septic critically ill patients with poor outcome.CRP‐ratio patterns of response to antibiotics during the first week of therapy are useful for the recognition of individual clinical evolution.Persistently elevated CRP‐ratio is associated with worse outcomes. A thorough evaluation to identify a cause for such evolution is granted.In time‐dependent analysis of PELOD score we found a significant decrease in survivors compared to non‐survivors.CRP is widely available, reliable and inexpensive inflammatory biomarker. This justifies its implementation in low‐resource settings.

Co-infection with Zika and Chikungunya viruses associated with fetal death—A case report

We describe a case of fetal death associated with a recent infection by Chikungunya virus (CHIKV) in a Brazilian pregnant woman (positive RT-PCR in blood and placenta). Zika virus (ZIKV) infection during pregnancy was also identified, based on a positive RT-PCR in a fetal kidney specimen. The maternal infection caused by the ZIKV was asymptomatic and the CHIKV infection had a classical clinical presentation. The fetus had no apparent anomalies, but her weight was between the 3rd and 10th percentile for the gestational age. This is the second case report of congenital arboviral co-infection and the first followed by antepartum fetal death.

Viral detection profile in children with severe acute respiratory infection

Abstract Objectives The role of viral co-detection in children with severe acute respiratory infection is not clear. We described the viral detection profile and its association with clinical characteristics in children admitted to the Pediatric Intensive Care Unit (PICU) during the 2009 influenza A(H1N1) pandemic. Method Longitudinal observational retrospective study, with patients aged 0–18 years, admitted to 11 PICUs in Rio de Janeiro, with suspected H1N1 infection, from June to November, 2009. The results of respiratory samples which were sent to the Laboratory of Fiocruz/RJ and clinical data extracted from specific forms were analyzed. Results Of 71 samples, 38% tested positive for H1N1 virus. Of the 63 samples tested for other viruses, 58 were positive: influenza H1N1 (43.1% of positive samples), rhinovirus/enterovirus (41.4%), respiratory syncytial vírus (12.1%), human metapneumovirus (12.1%), adenovirus (6.9%), and bocavirus (3.5%). Viral codetection occured in 22.4% of the cases. H1N1-positive patients were of a higher median age, had higher frequency of fever, cough and tachypnea, and decreased leukometry when compared to H1N1-negative patients. There was no difference in relation to severity outcomes (number of organic dysfunctions, use of mechanical ventilation or amines, hospital/PICU length of stay or death). Comparing the groups with mono-detection and co-dection of any virus, no difference was found regarding the association with any clinical variable. Conclusions Other viruses can be implicated in SARI in children. The role of viral codetection has not yet been completely elucidated.

Congenital Zika infection: neurology can occur without microcephaly

The fetal repercussions of Zika virus (ZIKV) infection during pregnancy is of interest for maternal and child health.1 Studies on the psychomotor and neurodevelopment of children exposed in utero to arboviruses, especially non-microcephalic children, are lacking. At a maternity university hospital in Brazil, we started following the development of children, without microcephaly, born to mothers infected with ZIKV during pregnancy, searching for early warning signs of abnormalities. A normal head circumference for term newborns was defined, according to the 2016 WHO recommendation, as higher than 31.9 cm for boys and higher than 31.5 cm for girls.2 We used the Alberta Infant Motor Scale for the evaluation of motor development, and the Denver II test for tracking development in personal/social, fine motor/adaptive, language …