Julio Castro

Large Urban Outbreak of Orally Acquired Acute Chagas Disease at a School in Caracas, Venezuela

BACKGROUND Trypanosoma cruzi oral transmission is possible through food contamination by vectors feces. Little is known about the epidemiology and clinical features of microepidemics of orally acquired acute Chagas disease (CD). METHODS A case-control, cohort-nested, epidemiological study was conducted during an outbreak of acute CD that affected a school community. Structured interviews were designed to identify symptoms and sources of infection. Electrocardiograms were obtained for all patients. Specific serum antibodies were assessed by immunoenzimatic and indirect hemagglutination tests. In some cases, parasitemia was tested directly or by culture, animal inoculation, and/or a polymerase chain reaction technique. RESULTS Infection was confirmed in 103 of 1000 exposed individuals. Of those infected, 75% were symptomatic, 20.3% required hospitalization, 59% showed ECG abnormalities, parasitemia was documented in 44, and 1 child died. Clinical features differed from those seen in vectorial transmission. The infection rate was significantly higher among younger children. An epidemiological investigation incriminated contaminated fresh guava juice as the sole source of infection. CONCLUSIONS This outbreak was unique, because it affected a large, urban, predominantly young, middle-class, otherwise healthy population and resulted in an unprecedented public health emergency. Rapid diagnosis and treatment avoided higher lethality. Food-borne transmission of T. cruzi may occur more often than is currently recognized.

The health and economic impact of dengue in Latin America

In the last two decades, all countries in the tropical regions of Latin America have experienced marked increases in the incidence of both classic dengue and dengue hemorrhagic fever. Major risk factors for the occurrence of dengue in the region, as well as some regional peculiarities in its clinical expression, such as the extensive involvement of older age groups, have been defined. While little information exists on the economic impact of dengue in the region in terms of disease burden, the estimated loss associated with the disease is on the same order of magnitude as tuberculosis, sexually transmitted diseases (excluding HIV/AIDS), Chagas disease, leishmaniasis, or intestinal helminths. Therefore, similar priority should be given in the allocation of resources for dengue research and control. Data on cost-efficacy and cost-benefit analysis of dengue control programs in Latin America are scarce; however, the cost per DALY averted by control programs during endemic periods appears low, as compared to other mosquito-borne diseases like yellow fever, leishmaniasis, or malaria. Additionally, the cost-benefit ratio of the control programs has proven to be positive.

Chikungunya fever: Atypical and lethal cases in the Western hemisphere: A Venezuelan experience

A large epidemic of Chikungunya fever currently affects the Caribbean, Central and South America. Despite a high number of reported cases, little is known on the occurrence of severe clinical complications. We describe four Venezuelan patients with a severe and/or lethal course who exhibit unusual manifestations of the disease. Case 1 describes a 75 year-old man with rapid onset of septic shock and multi-organ failure. Cases 2 and 3 describe two patients with rapid aggressive clinical course who developed shock, severe purpuric lesions and a distinct area large of necrosis in the nasal region. Case 4 depicts a splenectomized woman with shock, generalized purpuric lesions, bullous dermatosis and acronecrosis of an upper limb. Chikungunya fever in the Western hemisphere may also associate with atypical and severe manifestations. Some patients experience a life-threatening, aggressive clinical course, with rapid deterioration and death due to multisystem failure.

Prevalence of antiretroviral drug resistance among treatment-naive and treated HIV-infected patients in Venezuela

An in-house, low-cost method was developed to determine the genotypic resistance of immunodeficiency virus type 1 (HIV-1) isolates. All 179 Venezuelan isolates analysed belonged to subtype B. Primary drug resistance mutations were found in 11% of 63 treatment-naïve patients. The prevalence of resistance in isolates from 116 HIV-positive patients under antiretroviral treatment was 47% to protease inhibitors, 65% to nucleoside inhibitors and 38% to non-nucleoside inhibitors, respectively. Around 50% of patients in the study harboured viruses with highly reduced susceptibility to the three classical types of drugs after only five years from their initial diagnoses.

Nasal Skin Necrosis: An Unexpected New Finding in Severe Chikungunya Fever

Three adult Venezuelan patients with virologically confirmed Chikungunya fever, who developed extensive acute nasal skin necrosis early in the course of a life-threatening illness characterized by shock and multiple organ dysfunction syndrome, are discussed. One patient survived and fully recovered. Nasal necrosis has not previously been associated with the disease.

Google dengue trends: An indicator of epidemic behavior. The Venezuelan Case

INTRODUCTION Dengue Fever is a neglected increasing public health thread. Developing countries are facing surveillance system problems like delay and data loss. Lately, the access and the availability of health-related information on the internet have changed what people seek on the web. In 2004 Google developed Google Dengue Trends (GDT) based on the number of search terms related with the disease in a determined time and place. The goal of this review is to evaluate the accuracy of GDT in comparison with traditional surveillance systems in Venezuela. METHODS Weekly epidemic data from GDT, Official Reported Cases (ORC) and Expected Cases (EC) according the Ministry of Health (MH) was obtained Monthly and yearly correlation between GDT and ORC from 2004 until 2014 was obtained. Linear regressions taking the reported cases as dependent variable were calculated. RESULTS The overall Pearson correlation between GDT and ORC was r=0.87 (p <0.001), while between ORC and EC according the Ministry of Health (MH) was r=0.33 (p<0.001). After clustering data in epidemic and non-epidemic weeks in comparison with GDT correlation were r=0.86 (p<0.001) and r=0.65 (p <0.001) respectively. Important interannual variation of the epidemic was observed. The model shows a high accuracy in comparison with the EC, particularly when the incidence of the disease is higher. CONCLUSIONS This early warning tool can be used as an indicator for other communicable diseases in order to apply effective and timely public health measures especially in the setting of weak surveillance systems.

Long-term comparative pharmacovigilance of orally transmitted Chagas disease: first report

ABSTRACT Background: Two old drugs are the only choice against Trypanosoma cruzi and little is known about their secondary effects in the acute stage of oral-transmitted Chagas disease (ChD). Methods: A cross-sectional analytical surveillance study was conducted in a sizable cohort of patients seen during the largest acute foodborne ChD microepidemic registered so far. Individuals were treated with benznidazole (BNZ) or nifurtimox (NFX). ‘Common Terminology Criteria for Adverse Events’ was assessed to categorize side effects according to severity. Results: Out of 176 treatments applied, 79% had one or more adverse effects, which predominated in adults (97.8%) as compared to children (75.5%). Risk of side effects with NFX was significantly higher than BNZ. Four adults and a child treated with NFX had severe side effects (pulmonary infarction, facial paralysis, neutropenia, blurred vision, bone marrow hypoplasia) warranting hospitalization, and drug suspension. Adverse effects frequently reported with NFX were abdominal pain, hyporexia, weight loss, headache, nausea and lymphocytosis, whereas skin rash, neurosensory effects, hyporexia, fatigue, pyrosis, abdominal pain and eosinophilia were observed with BNZ. Conclusions: Frequency and severity of side effects during treatment of acute oral infection by T. cruzi demand direct supervision and close follow-up, even in those asymptomatic, to prevent life-threatening situations.