Cristiane Wanderley Cardoso

Outbreak of Exanthematous Illness Associated with Zika, Chikungunya, and Dengue Viruses, Salvador, Brazil

To the Editor: Zika virus (ZIKV) has been recognized as an emerging mosquito-borne flavivirus since outbreaks were reported from Yap Island in 2007 (1), French Polynesia in 2013 (2), and Cook Island and New Caledonia in 2014 (3). It has joined dengue virus (DENV) and chikungunya virus (CHIKV) as global public health threats (4). ZIKV infection typically causes a self-limited dengue-like illness characterized by exanthema, low-grade fever, conjunctivitis, and arthralgia, and an increase in rates of Guillain-Barre syndrome have been observed during ZIKV outbreaks (5). In Brazil, clusters of cases of acute exanthematous illness have been reported from various regions since late 2014, and in April 2015, ZIKV was identified as the etiologic agent (6). In May 2015, the Brazilian Ministry of Health recognized circulation of ZIKV in Brazil. We report epidemiologic findings for an ongoing outbreak of acute exanthematous illness in the population of Salvador, the third largest city in Brazil. The Salvador Epidemiologic Surveillance Office (ESO) was first alerted to cases of an acute exanthematous illness early in 2015. Reporting of cases increased during March, and in April the ESO established 10 public emergency health centers in Salvador as sentinel units for systematic surveillance of patients with acute exanthematous illness of unknown cause. The units searched retrospectively for suspected cases by review of medical charts of patients treated since February 15, continued with prospective case detection, and submitted weekly reports of identified cases to the ESO. During February 15−June 25, a total of 14,835 cases of an indeterminate acute exanthematous illness were reported from the 12 sanitary districts in Salvador. The overall attack rate was 5.5 cases/1,000 persons (4.6 cases/1,000 men and 6.3 cases/1,000 women, 8.2 cases/1,000 children 40 years of age). The epidemic curve peaked in the first week of May, which was 1 week after molecular diagnosis of ZIKV in 8 patients residing ≈50 km from Salvador and during a period of intense media coverage of the outbreak (Figure) (6). Reporting of suspected dengue cases in Salvador did not vary substantially from that in other years and was >5 times lower: 2,630 cases, of which 165/366 (45.1%) were positive for dengue IgM, 20/590 (3.4%) positive for dengue virus nonstructural protein 1, and 1/11 (9.1%) positive for dengue virus by reverse transcription PCR (Figure). During the same period, 58 cases of suspected chikungunya were reported and 24 patients with suspected Guillain-Barre syndrome were hospitalized. Figure Reported cases of indeterminate acute exanthematous illness and suspected dengue fever in Salvador, Brazil, by date of medical care, February 15−June 25, 2015. Letters indicate specific events. A) February 15: systematic reporting of cases of ... The median age of case-patients was 26 years (interquartile range 11–39 years), but all age groups were affected, which is a pattern typical of spread of new microorganisms (or subtypes) in a susceptible population. Median duration of symptoms at time of medical attention was 1 day (interquartile range 0–3 days). All patients had exanthema and most (12,711/14,093 [90.2%]) had pruritus. Fever (4,841/13,786, 35.1%), arthralgia (278/1,048 [26.5%]), headache (3,446/13,503 [25.6%]), and myalgia (223/1,033 [21.6%]) were less common. Serum samples from some patients were examined for rubella IgM (2/200, 1.0% positive), rubella IgG (15/18, 83.3% positive), measles IgM (0/11, 0% positive), dengue nonstructural protein 1 (3/185, 1.6% positive), dengue IgM (17/80, 21.3% positive), parvovirus B19 IgM (0/1, 0% positive), and parvovirus B19 IgG (1/1, 100% positive). Reverse transcription PCR was performed on 58 serum samples stored at −20°C and confirmed ZIKV in 3 (5.2%) samples, CHIKV in 3 (5.2%) samples, DENV type 3 in 1 (1.7%) sample, and DENV type 4 in 1 (1.7%) sample. Identification of ZIKV, CHIKV and DENV as etiologic agents of acute exanthematous illness suggests that these 3 Aedes spp. mosquito−transmitted viruses were co-circulating in Salvador and highlights the challenge in clinically differentiating these infections during outbreaks. Although we were not able to determine the specific incidence of each virus, the low frequency of fever and arthralgia, which are indicators of dengue and chikungunya, point to ZIKV as the probable cause of several of the reported cases. Furthermore, laboratory-confirmed cases of infection with ZIKV were simultaneously identified in other cities within metropolitan Salvador (6,7) and in other states in Brazil (8). Low diagnosis of ZIKV infection is likely because viremia levels among infected patients appear to be low (9). The spread of ZIKV represents an additional challenge for public health systems, particularly because of the risk for concurrent transmission of DENV and CHIKV by the same vectors, Ae. aegypti and Ae. albopictus mosquitoes, which are abundant throughout tropical and subtropical regions. To date, the largest outbreak of chikungunya in Brazil occurred in 2014 in Feira de Santana, Bahia, ≈100 km from Salvador, where dengue is also prevalent (10). This report illustrates the potential for explosive simultaneous outbreaks of ZIKV, CHIKV, and DENV in the Western Hemisphere and the increasing public health effects of Aedes spp. mosquitoes as vectors. The apparent increase in reports of Guillain-Barre syndrome during the outbreak deserves further investigation to elucidate whether this syndrome is associated with ZIKV infection. Public health authorities in Brazil and neighboring countries should plan accordingly.

Time Lags between Exanthematous Illness Attributed to Zika Virus, Guillain-Barré Syndrome, and Microcephaly, Salvador, Brazil.

There is strong evidence of a temporal relationship between virus infection in pregnant women and birth outcome.

Impact of vaccination during an epidemic of serogroup C meningococcal disease in Salvador, Brazil

To combat rising incidence of serogroup C meningococcal disease in the city of Salvador, Brazil, the Bahia state immunization program initiated routine childhood immunization with meningococcal C conjugate vaccine (MenC) in February 2010, followed by mass MenC vaccination of city residents 10-24 years of age from May through August 2010. We analyzed trends in incidence of reported cases of meningococcal disease and serogroup distribution among meningococcal isolates identified in hospital-based surveillance in Salvador from January 2000 to December 2011 and estimated vaccine effectiveness using the screening method. Annual incidence of serogroup C meningococcal disease increased from 0.1 cases per 100,000 population during 2000-2006 to 2.3 in 2009 and 4.1 in 2010, before falling to 2.0 per 100,000 in 2011. Estimated coverage of mass vaccination reached 80%, 67% and 41% among 10-14, 15-19 and 20-24 year olds, respectively. Incidence in 2011 was significantly lower than average rates in 2008-2009 among children <5 years, but reductions among 10-24 year olds were not significant. Among 10-24 year olds, a single dose of MenC vaccine was 100% effective (95% confidence interval, 79-100%) against serogroup C meningococcal disease. Low coverage in the population targeted for mass vaccination may have limited impact on ongoing transmission of serogroup C meningococcal disease despite high vaccine effectiveness.

Unrecognized Emergence of Chikungunya Virus during a Zika Virus Outbreak in Salvador, Brazil

Background Chikungunya virus (CHIKV) entered Brazil in 2014, causing a large outbreak in Feira de Santana, state of Bahia. Although cases have been recorded in Salvador, the capital of Bahia, located ~100 km of Feira de Santana, CHIKV transmission has not been perceived to occur epidemically, largely contrasting with the Zika virus (ZIKV) outbreak and ensuing complications reaching the city in 2015. Methodology/Principal Findings This study aimed to determine the intensity of CHIKV transmission in Salvador between November 2014 and April 2016. Results of all the CHIKV laboratory tests performed in the public sector were obtained and the frequency of positivity was analyzed by epidemiological week. Of the 2,736 tests analyzed, 456 (16.7%) were positive. An increasing in the positivity rate was observed, starting in January/2015, and peaking at 68% in August, shortly after the exanthematous illness outbreak attributed to ZIKV. Conclusions/Significance Public health authorities and health professionals did not immediately detect the increase in CHIKV cases, likely because all the attention was directed to the ZIKV outbreak and ensuing complications. It is important that regions in the world that harbor arbovirus vectors and did not experience intense ZIKV and CHIKV transmission be prepared for the potential co-emergence of these two viruses.

Impact of meningococcal C conjugate vaccination four years after introduction of routine childhood immunization in Brazil

BACKGROUND Routine infant immunization with meningococcal C conjugate (MCC) vaccination started in Brazil in November 2010, scheduled at three and five months plus a booster at 12-15months of age. No catch-up was implemented. We assessed the impact of vaccination on meningococcal C disease (MenC) four years after vaccination start in the National Immunization Program. METHODS We performed an ecological quasi-experimental design from 2008 to 2014 using a deterministic linkage between the National Notification and the National Reference Laboratory databases for meningitis. We conducted an interrupted time-series analysis considering Brazil except for Salvador municipality, because an epidemic of serogroup C disease occurred in this city, which prompted a mass vaccination campaign with catch-up for adolescents in 2010. Observed MenC rates in the post-vaccination period were compared to expected rates calculated from the pre-vaccination years. Results for Salvador were presented as descriptive data. An additional time-series analysis was performed for the state of São Paulo. RESULTS A total of 18,136 MenC cases were analyzed. The highest incidence rates were observed for infants aged <12months and no second incident peak was observed for adolescents. For Brazil, MenC rates were reduced by 67.2% (95%CI 43.0-91.4%) for infants <12months of age, 92.0% (77.3-106.8%) for the age-group 12-23months, and 64.6% (24.6-104.5%) for children aged 2-4years. For children 5-9years old, MenC rates reduced 19.2% (9.5-28.9%). Overall, 955 MenC cases were averted in Brazil in individuals aged <40years after MCC vaccination. Results from São Paulo State, mirror the patterns seen in Brazil. CONCLUSION After four years of infants and toddlers vaccination start, MenC invasive disease reduced in the target population. This investigation provide a robust baseline to ascertain how much the upcoming catch-up dose in 12-13years of age will accelerate the decrease in MenC incidence rates among youths in Brazil.

Epizootic Outbreak of Yellow Fever Virus and Risk for Human Disease in Salvador, Brazil.

Background: Yellow fever virus (YFV) is an RNA virus maintained in an enzootic, sylvatic cycle involving nonhuman primates (NHPs) and sylvatic mosquito vectors primarily of the genus Haemagogus and Sabethes. Transmission occasionally spills over to humans entering forested regions. In the Americas, urban transmission of YFV to humans has not occurred since the mid-1900s because of vaccination and near-elimination of the anthropophilic Aedes aegypti, the urban vector (1). However, concerns about reemergence of urban YFV have recently increased because of the reappearance and rapid spread of A aegypti in the urban environment. Furthermore, immunization coverage for YFV is insufficient because vaccination is generally indicated only for higher-risk populations, such as those living in or travelling to areas with sylvatic transmission. Objective: To investigate the 2017 epizootic outbreak of YFV and the risk for human disease in Salvador, Brazil. Methods and Findings: Since November 2016, deaths of NHPs due to YFV in Brazil have been reported in the state of So Paulo. Beginning in December 2016, human cases were also reported in the states of So Paulo and Minas Gerais. By the end of May 2017, the YFV outbreak in humans had spread to 9 Brazilian states, with more than 130 municipalities reporting confirmed cases (Appendix Figure 1), all deemed of sylvatic origin (rather than via urban A aegypti transmission). Of 3240 suspected reported human cases, 792 were laboratory-confirmed. Among all reported patients, 435 died and 274 of these had laboratory-confirmed infection with YFV (casefatality ratio for laboratory-confirmed cases, 34.6%) (2). Appendix Figure 1. Brazilian states where human cases of YFV were reported between December 2016 and May 2017, according to laboratory confirmation status. YFV = yellow fever virus. Reports of deaths of NHPs due to YFV also simultaneously increased. By the end of May 2017, a total of 3850 NHPs was suspected to have died of YFV infection, 642 of which were confirmed from 12 states (2). Since the beginning of the outbreak, the Brazilian Ministry of Health has distributed more than 25 million YFV vaccine doses to persons in areas with confirmed human or NHP cases, likely reducing incidence (2). On 14 January 2017, deaths of NHPs suspected of having YFV were first reported in Salvador, the fourth largest Brazilian city, which had not been considered a risk area for transmission (Appendix Figure 1). The number of NHPs found dead throughout the city rapidly increased, and by 24 August, 205 NHPs of the genus Callithrix suspected of having infection with YFV had been collected (Appendix Figure 2). Reverse transcriptase polymerase chain reaction testing for the virus was done on tissue samples of 21 dead animals at the Oswaldo Cruz Foundation in Rio de Janeiro; samples from 13 animals (61.9%) tested positive. Animals suspected of being infected were found throughout Salvador, with a cluster (3 of the 13 YFV-positive animals) around a city park, a 0.66-km2 recreational area of residual Atlantic forest with trees less than 10 m high (Figure). Appendix Figure 2. Temporal distribution of NHPs collected in Salvador, Brazil, by epidemiologic week in 2017. NHP = nonhuman primate. Figure. Spatial distribution of locations of NHP collections according to YFV status and of sites of mosquito collections in Salvador, Brazil. Distribution of 7 of the 8 YFV-negative NHPs, all 13 of the YFV-positive NHPs, and 173 of the 184 NHPs that were not tested is shown. NHP = nonhuman primate; YFV = yellow fever virus. To investigate potential vectors involved in YFV transmission among NHPs in Salvador, we initiated ground-level mosquito collections within and around the city park and the naval base, another preserved Atlantic forest area where dead, YFV-positive NHPs were found. During 10 days of fieldwork in 26 sites between 10 April and 7 June 2017, a total of 435 adult mosquitoes (307 females) was captured using human landing catches (Table). Most females captured were Wyeomyia species and A albopictus. Although we did not capture Haemagogus or Sabethes species, Haemagogus mosquitoes were identified in Salvador in January 2017 in a suburban, forested area. Pools of captured female mosquitoes from each species were tested for YFV by reverse transcriptase polymerase chain reaction (primers CAG and YF7) (3) and cell culture (C6/36, A albopictus), and none was positive. Table. Number of Mosquitos Collected at Ground Level in Salvador, Brazil* Discussion: To date, urban Aedes mosquitoes have not been associated with YFV transmission to humans in Brazil. However, cases of YFV in NHPs in densely urbanized areas pose a considerable risk for resurgence of A aegyptimediated YFV transmission to humans. Salvador has long been an epicenter of dengue transmission and more recently of Zika (4) and chikungunya (5) viruses, all with A aegypti as the main vector. In addition, A albopictus, which is susceptible to YFV infection in laboratory settings, is commonly found here, particularly in peridomestic and green areas. Although never implicated in natural YFV transmission, this species was only introduced into the Americas in the 1980s. Continuous entomologic and veterinary surveillance of mosquitoes and NHP deaths, accompanied by laboratory testing for YFV, is the cornerstone of assessing the risk that this virus will establish an urban transmission cycle. In parallel, scaling up YFV vaccination coverage is critical to prevent additional human cases of this disease.

Does immunity after Zika virus infection cross-protect against dengue?

Brazilian National Council for Scientific and Technological Development (grant 550160/2010-8 to MGR, grants 400830/2013-2 and 440891/2016-7

Clinical and laboratory evidence of Haff disease – case series from an outbreak in Salvador, Brazil, December 2016 to April 2017

We describe a series of 15 Haff disease cases from an outbreak in Salvador, Brazil, starting early December 2016. Eleven cases were grouped in four family clusters of two to four individuals, four were isolated cases. All but one patient consumed cooked fish; 11 within 24h before symptoms onset. Cases consumed ‘Olho de Boi’ (Seriola spp.) and ’Badejo’ (Mycteroperca spp.). A total of 67 cases were detected, the last case was reported on 5 April 2017.

Can Zika virus antibodies cross-protect against dengue virus? – Authors' reply

Fil: Ribeiro, Guilherme S.. Fundacion Oswaldo Cruz; Brasil. Universidade Federal da Bahia; Brasil

Dissemination of the ST-103 clonal complex serogroup C meningococci in Salvador, Brazil

Invasive meningococcal disease (IMD) is a major public health problem worldwide. An epidemic of serogroup C (NmC) IMD occurred in 2010 in the city of Salvador. In this study, we describe the antigenic and genetic characterization of meningococcal isolates collected from meningitis cases in Salvador from 2001 to 2012. Pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) were performed for the analysis of IMD isolates. A total of 733 cases were identified, and the serogroup was determined for 391 (53.0%) of these. Most cases were caused by NmC (53%) or B (47%). The most prevalent strains were B:4,7:P1.19,15 (32.9%; 129/391) and C:23:P1.14-6 (28.6%; 112/391). Based on PFGE/MLST analysis, 71.3% (77/108 PFGE-tested isolates) clustered as two clones of sequence type ST-3779 and ST-3780, both belonging to the ST-103 clonal complex. ST-3779 has been detected in Salvador since 1996 and together with ST-3780 became predominant after 2005. There was a predominance of C:23:P1.14-6, ST-3779/3780 in Salvador during the period of 2007-2012, establishing a major clonal lineage, which remained in the community for a long time; this has serious implications for public health, particularly in terms of prevention and control strategies of IMD.