Melissa Mascheretti

Human herpesvirus-8 infection and oral shedding in Amerindian and non-amerindian populations in the Brazilian Amazon region

BACKGROUND Human herpesvirus type 8 (HHV-8) is hyperendemic in Amerindian populations, but its modes of transmission are unknown. METHODS Antibodies against either HHV-8 lytic antigen or HHV-8 latency-associated nuclear antigen (LANA) were detected, by immunofluorescence assays, in 339 Amerindians and 181 non-Amerindians from the Brazilian Amazon. Serological markers of oro-fecal (hepatitis A), parenteral (hepatitis B and C), and sexual (herpes simplex virus type 2 and syphilis) transmission were measured by specific ELISAs. Salivary HHV-8 DNA was detected by use of a nested polymerase chain reaction assay and was sequenced. RESULTS Antibodies against either lytic antigen or LANA were detected in 79.1% of Amerindians and in 6.1% of non-Amerindians (adjusted seroprevalence ratio [SR], 12.63 [95% confidence interval {CI}, 7.1-22.4]; P<.0001). HHV-8 seroprevalence increased with age among Amerindians (P(Trend) < .001) and already had high prevalence in childhood but was not sex specific in either population. The 2 populations did not differ in seroprevalence of oro-fecal or parenteral markers, but seroprevalence of markers of sexual transmission was lower among Amerindians. HHV-8 DNA in saliva was detected in 47 (23.7%) of 198 HHV-8 seropositive Amerindians. Detection of HHV-8 DNA decreased with age (P(Trend) < .04) and was more common in men (SR, 2.14 [95% CI, 1.3-3.5]; P=.003). A total of 36 (76.6%) of the 47 saliva HHV-8 DNA samples were sequenced, and all clustered as subtype E. CONCLUSION The data support the hypothesis of early acquisition and horizontal transmission, via saliva, of HHV-8 subtype E in Amerindian populations.

Immunohistochemistry and polymerase chain reaction on paraffin-embedded material improve the diagnosis of cutaneous leishmaniasis in the Amazon region

Background  Recently, there has been an increase in the incidence of cutaneous leishmaniasis (CL), which represents an important health problem. This increase may be related to the epidemiologic expansion of the infective agent and the increase in tourism in tropical areas. The difficulty in clinical diagnosis, mainly in areas in which CL is not the first consideration of local physicians, has intensified efforts to describe diagnostic tests, which should be specific, sensitive, and practical. Amongst the new tests described are those including nucleic acid amplification (polymerase chain reaction, PCR) and immunohistochemistry (IHC).

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.

Intervention to increase influenza vaccination rates among healthcare workers in a tertiary teaching hospital in Brazil

Teaching Hospital in Brazil • Author(s): Marta H. Lopes , MD, PhD; Ana M. C. Sartori , MD, PhD; Melissa Mascheretti , MD; Tania S. S. Chaves , MD, MSc; Rosa M. M. Andreoli , RN; Mariusa Basso , RN, MSc; Antonio A. Barone , MD, PhD Source: Infection Control and Hospital Epidemiology, Vol. 29, No. 3 (March 2008), pp. 285-286 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/528700 . Accessed: 22/05/2014 13:02

Occurrence of early adverse events after vaccination against influenza at a brazilian reference center

INTRODUCTION Since 1999, the Ministry of Health in Brazil has conducted campaigns of vaccination against influenza targeted towards the elderly, chronically-diseased people and health care workers. The vaccine against influenza is associated with adverse events of minor importance. OBJECTIVE To investigate the early adverse events related to the vaccine against influenza. CASUISTICS AND METHODS One hundred and ninety seven elderly individuals and health care workers vaccinated against influenza were included. An inquiry regarding adverse events related to the vaccine was applied seven days after the vaccination. RESULTS Local adverse events were reported by 32.5% and systemic effects by 26.4% of the vaccinated subjects. Pain in the region of the injection, headache, myalgia, malaise, and coryza were more frequent in the workers than in the elderly (p<0.05). There was no statistically significant difference in the occurrence of fever. CONCLUSIONS The belief of part of the population that credits frequent and uncomfortable adverse events to the vaccine was not confirmed. The subjective adverse events were more frequent in the health care workers, which can influence, in a negative way, the disclosure of the benefits of this vaccine due to their role as opinion makers.

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.

Seroprevalence of Kaposi Sarcoma&#8211;associated Herpesvirus and Other Serologic Markers in the Brazilian Amazon.

To determine the presence of Kaposi sarcoma–associated herpesvirus (KSHV) and other serologic markers, we tested serum specimens of 339 Amerindians, 181 rural non-Amerindians, and 1,133 urban blood donors (13 Amerindians) in the Brazilian Amazon. High KSHV seroprevalence in children and inverse association with herpes simplex virus type 2 indicates predominant nonsexual transmission among Amerindians.

Febre amarela silvestre: reemergência de transmissão no estado de São Paulo, Brasil, 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.

Leishmania (Viannia) braziliensis identification by PCR in the state of Para, Brazil

The incidence of cutaneous leishmaniasis (CL) is increasing and there is limited surveillance of Leishmania species throughout the world. We identified the species associated with CL in a region of Amazonia, an area recognized for its Leishmania species variability. Clinical findings were analyzed and correlated with the species identified in 93 patients. PCR assays were based on small subunit ribosomal DNA (SSU-rDNA) and G6PD, and were performed in a laboratory located 3,500km away. Leishmania (V.) braziliensis was identified in 53 patients (57%). The other 40 patients (43%) carried a different species (including six cases of L. (L.) amazonensis). Molecular methods can be employed, using special media, to allow transport to distant laboratories. L. (V.) braziliensis is the most common species in the area of Para. The location of ulcers can suggest CL species.

First report of an accident with the speckled forest pit viper (Bothriopsis taeniata) in Brazil

The first reported case of an accident with Bothriopsis taeniata in Brazil is described. The victim, a 43-year-old man, was bitten just above his right heel and presented a clinical condition compatible with mild Bothrops poisoning: local edema with hemorrhage at the bite site and pain, although without coagulopathy.