Cristina de Albuquerque Possas

Social ecosystem health: confronting the complexity and emergence of infectious diseases

The emergence and re-emergence of infectious diseases and their rapid dissemination worldwide are challenging national health systems, particularly in developing countries affected by extreme poverty and environmental degradation. The expectations that new vaccines and drugs and global surveillance would help reverse these trends have been frustrated thus far by the complexity of the epidemiological transition, despite promising prospects for the near future in biomolecular research and genetic engineering. This impasse raises crucial issues concerning conceptual frameworks supporting priority-setting, risk anticipation, and the transfer of science and technologys results to society. This article discusses these issues and the limitations of social and economic sciences on the one hand and ecology on the other as the main theoretical references of the health sciences in confronting the complexity of these issues on their own. The tension between these historically dissociated paradigms is discussed and a transdisciplinary approach is proposed, that of social ecosystem health, incorporating these distinct perspectives into a comprehensive framework.

Aeromonas spp. e Plesiomonas shigelloides isoladas a partir de mexilhões (Perna perna) in natura e pré-cozidos no Rio de Janeiro, RJ

O ecossistema aquatico e o habitat de mexilhoes (Perna perna), animais filtradores que refletem a qualidade ambiental atraves de analise microbiologica de sua carne. No presente trabalho avaliou-se a presenca de patogenos emergentes (Aeromonas hydrophila e Plesiomonas shigelloides), em mexilhoes in natura e pre-cozidos coletados por pescadores da Estacao Experimental de Cultivo de Mexilhoes situada em Jurujuba, Niteroi, Rio de Janeiro. Foram analisadas 86 amostras de mexilhoes (43 in natura e 43 pre-cozidos) as quais foram submetidas a enriquecimento em Agua Peptonada Alcalina (APA) acrescida de 1 e 3% de Cloreto de Sodio (NaCl) e em solucao Salina de Butterfield, incubadas a 37oC por 24 horas. Em seguida, foram semeadas em Agar Seletivo para Pseudomonas-Aeromonas (GSP), Agar Tiossulfato Citrato Bile Sacarose (TCBS) e Agar Inositol Bile Verde Brilhante (IBB). A analise geral dos resultados permitiu a identificacao de Areomonas spp e Plesiomonas shigelloides em 86% das amostras de mexilhoes in natura e pre-cozidas avaliadas. A posterior caracterizacao bioquimica permitiu a identificacao das especies Aeromonas media (37,10%), A. hydrophila (15,50%), A. caviae (14,80%), A. veronii biogrupo veronii (11,60%), Aeromonas sp. (7,36%), A. sobria (4,20%), A. trota (4,20%), A. schubertii (1,31%), A. jandaei (1,31%), A. veronii biogrupo sobria (0,52%) e Plesiomonas shigelloides (2,10%). A relevância epidemiologica desses microrganismos em casos de gastrenterite humana, apos consumo de mexilhoes crus ou parcialmente cozidos, revela a importância de alertar as autoridades de Saude Publica no Brasil, sobre a presenca desses patogenos na cadeia alimentar e seus riscos para a saude humana.

Zika puzzle in Brazil: peculiar conditions of viral introduction and dissemination - A Review

This article discusses the peculiar conditions that favoured the unexpected introduction of Zika virus into the poorest northeastern region of Brazil in 2015, its speed of transmission to other Brazilian states, other Latin American countries and other regions, and the severity of related neurological disorders in newborns and adults. Contrasting with evidence that Zika had so far caused only mild cases in humans in the last six decades, the epidemiological scenario of this outbreak in Brazil indicates dramatic health effects: in 2015, an increase of 20-fold in notified cases of microcephaly and/or central nervous system (CNS) alterations suggestive of Zika congenital infection, followed by an exponential increase in 2016, with 2366 cumulative cases confirmed in the country by the end of December 2016. A significant increase in Guillain-Barré syndrome in adults has also been reported. Factors involved in viral dissemination, neural pathogenesis and routes of transmission in Brazil are examined, such as the role of social and environmental factors and the controversies involved in the hypothesis of antibody-dependent enhancement, to explain the incidence of congenital Zika syndrome in Brazil. Responses to the Zika outbreak and the development of new products are also discussed.This article discusses the peculiar conditions that favoured the unexpected introduction of Zika virus into the poorest northeastern region of Brazil in 2015, its speed of transmission to other Brazilian states, other Latin American countries and other regions, and the severity of related neurological disorders in newborns and adults. Contrasting with evidence that Zika had so far caused only mild cases in humans in the last six decades, the epidemiological scenario of this outbreak in Brazil indicates dramatic health effects: in 2015, an increase of 20-fold in notified cases of microcephaly and/or central nervous system (CNS) alterations suggestive of Zika congenital infection, followed by an exponential increase in 2016, with 2366 cumulative cases confirmed in the country by the end of December 2016. A significant increase in Guillain-Barré syndrome in adults has also been reported. Factors involved in viral dissemination, neural pathogenesis and routes of transmission in Brazil are examined, such as the role of social and environmental factors and the controversies involved in the hypothesis of antibody-dependent enhancement, to explain the incidence of congenital Zika syndrome in Brazil. Responses to the Zika outbreak and the development of new products are also discussed.

Características de Vibrio parahaemolyticus isolados de mexilhões (Perna perna) comercializados em Niterói, Rio de Janeiro

The marine ecosystem is the natural habitat of bacteria like Vibrio parahaemolyticus, an important pathogen that cause human gastroenteritis associated with seafood consumption. In the present investigation, the presence of V. parahaemolyticus in 86 in natural and precooked mussel samples was evaluated. Vibrio parahaemolyticus was isolated from 11.6% of the in natural and precooked mussels. All strains tested were urease-positive and 28.5% were Kanagawa-positive, which suggests that they have pathogenic potential for humans. There was predominance of the O10:K52 serotype and the emerging O3:K6 strain was identified. These results show the epidemiological relevance of V. parahaemolyticus in cases of human gastroenteritis following mussel consumption without adequately cooking them (100 degrees C/15 min). Moreover, it is important to alert the Brazilian Sanitary Surveillance authorities regarding their presence in the food chain and their public health risks.

Zika: what we do and do not know based on the experiences of Brazil

OBJECTIVES: Zika virus, which was first discovered in 1947, has become a global threat to human health as it is rapidly spreading through Latin America, the Caribbean, the US and Asia, after causing a large outbreak in the Northeast region of Brazil in 2015. There is ample evidence to support that Zika virus is associated with neurological complications such as microcephaly. The review aims to provide an overview on the complex issues involved in the emergence of Zika virus’s neurological disorders and to discuss possible explanations of Zika virus introduction and dissemination in Brazil. We also suggest national and global strategies to adequately respond to the Zika virus emergence. METHODS: We provide an analytical evaluation of the main issues related to the Zika outbreak in Brazil, based on available scientific literature, including government documents, and on epidemiological information from national surveillance databases. RESULTS: The studies on the clinical manifestations of the Zika virus infection coupled with the epidemiological surveillance information in Brazil have provided significant evidence that the Zika virus is associated with neurological disorders such as microcephaly and Guillain-Barré syndrome. Based on phylogenetic and molecular analysis, the hypothesis regarding the introduction of Zika virus in the country is that it took place following international events in 2013 and 2014, when many foreign visitors could have brought Zika virus into Brazil. The immunologically naïve status of populations in the Americas, previous infection with dengue virus, and the increased activity of Aedes aegypti might be the contributing factors for such an outbreak in Brazil. The Zika virus emergence emphasized the importance of cross-disciplinary perspective. Besides the scientific-based vector control strategies, it is important to understand the nature of the evolutionary processes involved in the viral evolution in complex ecosystems and to have social and anthropological knowledge on the conditions related to the spread of the disease in order to properly respond to the spread of the Zika virus. CONCLUSIONS: The experiences of Brazil have demonstrated the significance of multi-disciplinary approach in response to new and resurgent arboviral diseases and provided important lessons that could be applied to other developing countries.

Urgent call for action: avoiding spread and re-urbanisation of yellow fever in Brazil.

Yellow fever (YF), a haemorrhagic viral disease with a high fatality rate, is considered one of the greatest scourges of mankind. Historically, devastating epidemics of this disease have been reported since the seventeenth century in Africa, the Americas, and Europe (WHO 2017). The control of urban YF in Rio de Janeiro in the beginning of the last century is recognised as one of the most successful public health initiatives in the world. Oswaldo Cruz’s successful campaigns with a strong and enforceable fight against the domestic mosquito vector Aedes aegypti dramatically dropped the number of urban YF cases in the city. The measures were applied with success across the country. The elimination of urban transmission in Brazil and all over the Americas was achieved in the early 1940’s with a combination of vaccine campaigns and Ae. aegypti eradication (Franco 1969). However, the ineradicable zoonotic sylvatic transmission cycle maintained between Haemagogus and Sabethes mosquitoes and nonhuman primates (NHPs) has annually caused infections and death in humans. Importantly, YF virus (YFV) epizootics have cyclically been reported every 7-14 years in Brazil, with marked special expansion in the past decades. The last two epidemics in Brazil spanned more than one year: from 1998 to 2003, and again in 2008 and 2009, despite vaccine campaigns (Vasconcelos 2010, Jentes et al. 2011, MS/SVS 2017). The recent sylvatic YF outbreak in Brazil has been the most severe in the last seven decades and became an epidemic. As of 31 May, 2017, a total of 3240 cases have been reported in Brazil: 792 confirmed, 1929 dismissed, and 519 remain under investigation, including 435 deaths (274 confirmed, 124 discarded, and 37 under investigation). The case fatality rate (CFR) among confirmed cases is 34.5% (MS/SVS 2017). For NHPs, 3850 epizootics were reported (642 confirmed, 96 dismissed, and 1448 under investigation). The rapid spread of YF cases in Brazil has led to a major concern: infections were no longer reported just in the jungle and remote inland rural areas, but sylvatic transmission also occurred in the surroundings of the most densely populated cities in the states of São Paulo (SP), Minas Gerais (MG), Espírito Santo (ES), Bahia (BA), and Rio de Janeiro (RJ) (MS/SVS 2017). It started in MG late in 2016. Despite being an area where routine immunisation is recommended and there is good vaccination coverage in the young population, the epidemic reached and hit with severity the rural area of north-eastern MG, due to poor vaccine coverage among adults. The rapid spread to the coastal state of ES, an area where YF vaccine was not routinely recommended, led to a severe epidemic with 260 confirmed cases and 85 deaths. Subsequently, the virus also spread to RJ, which also had no previous recommendation for routine YF vaccination. Fortunately, some of the areas at higher risk in RJ had already been partially vaccinated at this time. Nevertheless, 17 confirmed cases and seven deaths were recorded in the state from March to June 2017 (MS/SVS 2017). The YFV circulating in Brazil since 2008 belongs to the South American Genotype I, lineage 1E (Cardoso et al. 2010, Souza et al. 2010). The whole genome of YFV causing the 2017 outbreak in ES was sequenced and phylogenetic analysis revealed that it clusters in the 1E sub-clade along with recent Brazilian and Venezuelan strains (Mir et al. 2017). However, it was discovered that this virus strain displays seven new mutations, and their role in host infectivity and virus replication and spreading is still under investigation (Bonaldo et al. 2017). The unique amino acid signatures carried by the 2017 YFV occur in non-structural proteins, one being a change in the capsid protein and the other in components of the viral replicase complex, the NS3 (two changes), and the NS5 (five changes) proteins; no change was detected in the envelop protein. Although the amino acid changes may affect the viral fitness, they would not potentially impact the efficacy of the available vaccines (Bonaldo et al. 2017). A complex combination of ecological, social, and behavioural factors may help to explain the severity and efficient spread of the YFV in Southeast Brazil, particularly its dissemination to the Atlantic coast. Among them, ecological issues included changing environmental and climate conditions favouring a high density of competent sylvatic and urban vectors and primary amplifier vertebrate hosts (NHPs); the uncontrolled occupation of forest areas by human populations; and the large number of susceptible NHP and nonvaccinated people in peri-urban areas in close contact with forests, mainly the adult human populations from rural areas in north-eastern MG affected by the recent YFV outbreak as well as in vast coastal receptive zones (Vasconcelos 2010, Couto-Lima et al. 2017). In these zones, lack of access of populations to sanitation and garbage collection in urban areas, favouring Aedes proliferation, is contributing to an increase in the potential for re-urbanisation of YF in Brazil. YF epidemics are not acceptable and are an ethical issue. Brazil is the largest producer of the YF vaccine, which is provided free of charge. Vaccination was not recommended universally in Brazil due to the serious adverse events associated with it, 0.42 cases/100,000 administered doses in Brazil, similar to those found in Africa. In the United States, Europe, and Australia, reported rates of serious adverse events are about ten times higher. The reasons for such large differences are not clear, but intensity and quality of surveillance are crucial (Staples et al. 2008, Martins et al. 2010, 2014, MS 2014). Now the risk of transmission has increased, and the risk-benefit balance favours universal vaccination. This action is urgent, taking advantage of the temporary relief in YFV transmission in most of Brazil caused by the reduced rainfall and lower mean temperatures recorded during the dry season (July-October). These environmental conditions reduce the availability of mosquito larval sites, larval developmental time, mosquito adult longevity, and viral replication. YFV epizootics and human cases will potentially re-emerge in the following rainy season. The last two epidemics in Brazil spanned more than one year: from 1998 to 2003, and again in 2008 and 2009, despite vaccine campaigns (Vasconcelos 2010, Jentes et al. 2011, MS/SVS 2017).

Vibrio spp. isolados a partir de mexilhões (Perna perna) in natura e pré-cozidos de Estação Experimental de Cultivo, Rio de Janeiro, RJ, Brasil

The microbiology analysis of mussels reflects the aquatic environment quality because these animals retain various pathogens such as Vibrionaceae family microorganisms in their organism. In the present investigation, we evaluated the presence of Vibrio spp. in mussels (in natura and precooked) commercialized at an Experimental Station Mussel Culture in Jurujuba, Niteroi, Rio de Janeiro. A total of 86 samples were analyzed using the enrichment in Alkaline Peptone Water (APW) added to 1 and 3% of NaCl, isolated in Thiossulfate Citrate Bile Sucrose Agar (TCBS) and confirmed that there were suspect colonies by biochemical tests. The results showed the identification of 12 different Vibrio species whereby Vibrio alginolyticus, V. cholerae non-O1, V. parahaemolyticus, V. carchariae and V. vulnificus were the prevalent species. The epidemiological relevance of these pathogens associated with cases of human gastroenteritis after in natura or precooked mussels show the need to alert Sanitary Officials about their presence in the food chain and their risks to Public Health.

Vaccine research, development, and innovation in Brazil: A translational science perspective

This article examines the Brazilian innovation policy for vaccines and its impact on infectious diseases, with emphasis on advances in translational science. The results indicate significant progress, with a rapid increase over the past two decades in the number of vaccine research groups, indicating scientific excellence. Advances and gaps in technological development and in public-private partnership initiatives were also identified. We stress the crucial role of partnerships, technology transfer, and targeted policies that could accelerate Brazils participation in global vaccine research and development. We propose that new strategies should be urgently conceived to strengthen the links between the scientific and technological policies, the National Health System, and the National Immunizations Program in Brazil to provide access to low-cost vaccines to address major public health challenges. We also discuss the lessons learned from the Brazilian experience in the implementation of governmental policies on vaccine innovation that could be applicable to other developing countries.

Access to new technologies in multipatented vaccines: challenges for Brazil

Partnerships, technology transfer and targeted policies are needed to accelerate Brazils participation in global vaccine research and development.

Yellow fever outbreak in Brazil: the puzzle of rapid viral spread and challenges for immunisation

We discuss the complex eco-social factors involved in the puzzle of the unexpected rapid viral spread in the ongoing Brazilian yellow fever (YF) outbreak, which has increased the reurbanisation risk of a disease without urban cases in Brazil since 1942. Indeed, this rapid spatial viral dissemination to the Southeast and South regions, now circulating in the Atlantic Forest fragments close to peri-urban areas of the main Brazilian megalopolises (São Paulo and Rio de Janeiro) has led to an exponential increase in the number of yellow fever cases. In less than 18 months, 1,833 confirmed cases and 578 deaths were recorded most of them reported in the Southeast region (99,9%). Large epizooties in monkeys and other non-human primates (NHPs) were communicated in the country with 732 YF virus (YFV) laboratory confirmed events only in the 2017/2018 monitoring period. We also discuss the peculiarities and similarities of the current outbreak when compared with previous great epidemics, examining several hypotheses to explain the recent unexpected acceleration of epizootic waves in the sylvatic cycle of the YFV together with the role of human, NHPs and mosquito mobility with respect to viral spread. We conclude that the most feasible hypothesis to explain this rapidity would be related to human behavior combined with ecological changes that promoted a significant increase in mosquito and NHP densities and their contacts with humans. We emphasize the urgent need for an adequate response to this outbreak such as extending immunisation coverage to the whole Brazilian population and developing novel strategies for immunisation of NHPs confined in selected reserve areas and zoos. Finally, we stress the urgent need to improve the quality of response in order to prevent future outbreaks and a catastrophic reurbanisation of the disease in Brazil and other South American countries. Continuous monitoring of YFV receptivity and vulnerability conditions with effective control of the urban vector Aedes aegypti and significant investments in YF vaccine production capacity and research and development for reduction of adverse effects are of the highest priority.