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ABSTRACT Sexually transmitted infections (STIs) represent a global health problem with variable prevalence depending on the geographical region and the type of population. Human papillomavirus (HPV) encompasses widespread virus types related to cervical carcinogenesis. The present study investigated the molecular prevalence of HPV and seven other important STIs in asymptomatic women working or studying at a Brazilian university. A secondary aim was to assess cytological abnormalities associated with HPV and other STIs coinfections. We recruited 210 women from a Brazilian university. HPV was detected using a single-round polymerase chain reaction (sPCR) followed by a viral genotyping by restriction fragment length polymorphism (RFLP-PCR). The presence of seven STIs: Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, Trichomonas vaginalis, Mycoplasma genitalium, herpes simplex virus (HSV)-1 and HSV-2 was detected by multiplex PCR (M-PCR). Furthermore, cytological findings and epidemiological characteristics were evaluated.The mean age of the participants was 27.1 years old. HPV prevalence was 33.8%, and HPV16 was the most frequently detected papillomavirus genotype. Moreover, multiple HPV infections were common (42.2%). We detected at least one STI agent in 11.4% of the tested women, most frequently C. trachomatis (6.7%). Among HPV-positive women, 14.1% were coinfected with other STI agents. Cytological abnormalities were observed in 9.5% of smears, and HPV-DNA, high-risk HPV (HR-HPV), HPV16 and HPV multiple infections were associated with abnormal cytological findings. There was a high prevalence of HPV, and C. trachomatis was the most prevalent STI agent, with low rates of cytological abnormalities. These findings highlight the need of timely STI diagnosis in young asymptomatic women and of a public policy design for STI prevention.

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ABSTRACT American Tegumentary Leishmaniasis (ATL) is endemic in the municipality of Montes Claros, Minas Gerais State. The use of geotechnology such as spatial statistics and remote sensing has contributed to a better understanding of the eco-epidemiology of diseases, and consequently a better definition of control strategies. This study aimed to analyze the spatial distribution of probable sites of cases of ATL infection (2007-2011) in the municipality of Montes Claros and to identify related socio-environmental factors. Data on ATL cases notification were obtained from the Municipal Health Department of Montes Claros. The annual incidence of ATL in the municipality was calculated and the probable sites of infection were georeferenced. Crude Rate and the Local Empirical Bayesian Rate were calculated with census sectors considered as the unit of analysis. The Normalized Difference Vegetation Index (NDVI) was calculated from LANDSAT 5 TM images. The spatial association between the crude rate of ATL and the NDVI of the census tracts was evaluated using the Local Bivariate of Moran I. The socio-environmental aspects of household structures were assessed based on a structured questionnaire. The incidence of ATL in the evaluated period ranged from 6.2 to 16.6 cases/100,000 inhabitants. The highest rates of ATL occurrence were found in the census sectors located in the rural area and in the peripheral census sectors in the city. Through the Empirical Bayes Smoothed Rate map, it was found that in the peripheral areas of the city, the rates of ATL occurrence were lower than in the rural area and their values decreased as they approach the city center. Local Bivariate of Moran I showed a positive correlation between NDVI and crude ATL rates, with significant high-high clusters observed in the rural area and in the census sectors in the Western peripheral area of the city that have experienced an urban expansion concomitant to the period investigated. In most homes of people affected by the disease, there were domestic animals and organic matter in the peridomicile. In addition, a high percentage of individuals affected by ATL reported the presence of rodents circulating near their homes. In conclusion, it is possible that the disorderly expansion process in the city of Montes Claros favored the establishment of the ATL periurban and urban transmission cycle. These regions deserve special attention from health surveillance to combat this zoonosis.

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ABSTRACT Syphilis, an infectious disease considered a global public health concern, can cause stillbirths and neonatal deaths. This highlights the importance of continuous surveillance studies among women of reproductive age. A cross-sectional study was carried out to analyze the prevalence and risk factors associated with Treponema pallidum infection in women assisted by primary health care units in Dourados, a city located in Mato Grosso do Sul State, Brazil, which borders Paraguay. A questionnaire was applied to a population-based sample, blood samples were collected for syphilis testing and multivariable analyses were performed to screen associations with T. pallidum infection. The prevalence of T. pallidum infection was 6.04%. Bivariate analysis showed that women referring multiple sexual partners (c2: 6.97 [p=0.014]), income less 2 minimal wages (c2: 15.93 [p=0.003]), who did not have high school (c2: 12.64 [p=0.005]), and reporting history of STIs (c2: 7.30 [p=0.018]) are more likely to have syphilis. In the multivariate analysis, a highest prevalence ratio was observed in women with income less than 2 minimal wages (PR: 0.96 [95% CI: 0.85 - 0.97]), and who did not have high school (PR: 0.94 [95% CI: 0.90 - 0.98]). In addition, 80% of the women reported irregular use of condoms and 63.89% declared having sexual intercourses with multiple partners, which creates more opportunities for the transmission of the infection. These results highlight the need for healthcare systems to implement initiatives to monitor syphilis screening and the commitment of patients and their sexual partners to the treatment in order to achieve a decrease of new cases.

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ABSTRACT Respiratory syncytial virus (RSV) is the main cause of lower respiratory disease in infants and children under five years of age. As there is no specific treatment for RSV infections, prophylaxis with the specific monoclonal antibody palivizumab (PVZ) has been widely recommended for high-risk cases during the RSV season. The present study aimed to evaluate the effectiveness of a public prophylaxis program with palivizumab on the incidence of hospitalizations for lower respiratory tract infections and RSV in children at high risk for severe RSV infections. A retrospective cohort study was carried out with preterm children or children under two years of age with chronic lung disease or hemodynamically significant congenital heart disease; the children were selected on the basis of their exposure status, which was defined as the prophylactic use of palivizumab during the RSV season. Children were enrolled retrospectively in two hospitals located in Southern Brazil, from May 2009 to August 2016. In a sample of 129 children, 69 (53.5%) received palivizumab and adherence to three or more doses was observed in 78%; 60 (46.5%) children did not receive palivizumab. PVZ prophylaxis was independently associated with a 66% reduction in hospitalizations for any cause (26/69 - 37.7%) in the PVZ group and 34/60 (56.7%) in the control group). A 52% reduction in hospitalizations due to lower respiratory tract infection was observed in the PVZ group (15/69 -21.7%) and 25/60 (41.7%) in the control group. These findings suggest that, for the group of studied patients, the adoption of an RSV prophylaxis scheme reached the same effectiveness as those described in previous clinical trials.

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ABSTRACT The efficacy of direct-acting antivirals (DAAs) in the treatment of chronic hepatitis C (CHC) in liver transplant recipients is poorly understood, and several factors, including immunosuppression, drug interactions, elevated viraemia, and intolerance to ribavirin (RBV), can reduce cure rates. We conducted a real-life study on liver transplant recipients with CHC treated with a combination of sofosbuvir (SOF) and daclatasvir (DCV) or simeprevir (SIM), with or without RBV, followed-up for 12 to 24 weeks. The treatment effectiveness was assessed by determining the sustained virological response (SVR) rates at 12 or 24 weeks after the treatment cessation. Eighty-four patients were evaluated, with a mean age of 63.4 ± 7.4 years, HCV genotype 1 being the most prevalent (63.1%). Nineteen patients (22.7%) had mild fibrosis (METAVIR < F2) and 41 (48.8%) significant fibrosis (METAVIR ≥ F2). The average time between liver transplantation and the start of treatment was 4 years (2.1-6.6 years). The SOF + DCV regimen was used in 58 patients (69%). RBV in combination with DAAs was used in seven patients (8.3%). SVR was achieved in 82 patients (97.6%), and few relevant adverse events could be attributed to DAA therapy, including a patient who stopped treatment due to a headache. There was a significant reduction in ALT, AST, GGT and FA levels, or the APRI index after 4 weeks of treatment, which remained until 12/24 weeks post-treatment. DAA treatment of CHC in liver-transplanted patients achieved a high SVR rate and resulted in the normalization of serum levels of liver enzymes.

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ABSTRACT Chagas disease (CD) is caused by the protozoan Trypanosoma cruzi and it is mainly acquired through the vector route, however, blood transfusion and congenital transmission are implicated in the spread of the illness worldwide. The congenital route can occur at any stage of pregnancy and its frequency varies. In the Federal District, in Brazil, the frequency of T. cruzi infection in pregnant women and their offspring has not been updated. Thus, the aim of this study was to estimate the prevalence of T. cruzi infection in pregnant women and the rate of congenital transmission in the Federal District. A cross-sectional study was conducted to estimate the seroprevalence of T. cruzi from 2014 to 2016 in the population of pregnant women attended by the public health service throughout the Federal District and a descriptive cohort for the evaluation of congenital transmission. During the study, prenatal data of 98,895 women were consulted and pregnant women registered in 2016, presenting with positive T. cruzi serology, were part of the descriptive cohort. The estimated prevalence of T. cruzi infection in the three years was 0.19% and the congenital transmission rate was 1/40 (2.5%). Our results have shown that, although the main routes of transmission of CD have been interrupted, there is still a risk of congenital transmission in the Federal District. This present study highlights the need for the continuous implementation of a screening program for pregnant women and timely treatment of infected newborns and children.

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ABSTRACT Human toxocariasis consists of chronic tissue parasitosis that is difficult to treat and control. This study aimed to evaluate the action of the probiotic Lactobacillus acidophilus ATCC 4356 on larvae of Toxocara canis and the effect of IFN-γ cytokine on parasite-host in vivo (1.109 CFU) and in vitro (1.106, 1.107, 1.108, 1.109 CFU) interactions. Four groups of six BALB/c mice were formed: G1 - L. acidophilus supplementation and T. canis infection; G2 - T. canis infection; G3 - L. acidophilus supplementation; and G4 - PBS administration. Mice were intragastrically suplemented with probiotics for 15 days before inoculation and 48 h after inoculation with 100 T. canis eggs. The inoculation of T. canis was also perfomed intragastrically. The recovery of larvae took place through digestion of liver and lung tissues; the evaluation of IFN-γ gene transcription in leukocytes was performed by qPCR. The in vitro test consisted of incubating the probiotic with T. canis larvae. The supplementation of probiotics produced a reduction of 57.7% (p = 0.025) in the intensity of infection of T. canis larvae in mice, whereas in the in vitro test, there was no larvicidal effect. In addition, a decrease in the IFN-γ gene transcription was observed in both, T. canis-infected and uninfected mice, regardless of whether or not they received supplementation. The probiotic L. acidophilus ATCC 4356 reduced T. canis infection intensity in mice, however, the probiotic did not have a direct effect on larvae, demonstrating the need of interaction with the host for the beneficial effect of the probiotic to occur. Yet, the proinflammatory cytokine IFN-γ did not apparently contributed to the observed beneficial effect of probiotics.

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ABSTRACT Visceral leishmaniasis (VL) is a neglected tropical disease caused by the Leishmania infantum parasite. The protozoan is able to infect several domestic and wild mammals. Since the first report on Leishmania spp. infection in horses in South America, leishmaniasis in equids has been highlighted in Brazil. A molecular epidemiological survey was carried out to verify the occurrence of Leishmania spp. DNA in horses and donkeys, in leishmaniases endemic areas in Sao Paulo State, Brazil. To this end, blood samples were obtained from 107 horses and 36 donkeys and subjected to DNA extraction followed by PCR targeting the ITS-1 region. Among the horses and donkeys, 1.87% (2/107) and 8.33% (3/36) were positive by PCR, respectively. The DNA sequencing of the ITS-1 amplification products confirmed L. infantum DNA in these animals. Our results suggest that horses and donkeys from non-VL and VL endemic areas of São Paulo State may be infected by the parasite.

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ABSTRACT Nasal carriage of Staphylococcus aureus by healthcare workers is of great clinical importance as it facilitates the contamination of medical devices and cross-transmission. However, studies regarding the epidemiology and dissemination of S. aureus and Methicillin-resistant S. aureus (MRSA) within the Primary Health Care in Brazil are scarce. The current study aimed to detect and characterize S. aureus and MRSA strains from the nasal cavities of 63 healthcare working in primary health care units in order to determine the prevalence of S. aureus and MRSA, biofilm formation and resistance profile of these isolates. PCR reactions were performed for detecting mecA, icaA and icaD genes. The phenotypic antimicrobial susceptibility was assessed by the disk diffusion method and biofilm formation by the Congo Red Agar (CRA) method. The MRSA isolates were typed for the Staphylococcal Cassette Chromosome mec (SCCmec). The prevalence of nasal carriage of S. aureus was 74.6%, of which 72.3% were MRSA carrying SCCmec type I (24.4%), III (34.1%), IV (36.6%). Two (4.9%) isolates presented a non-typeable cassette by the performed technique. The antimicrobial susceptibility evaluation evidenced penicillin resistance in 66.1% of S. aureus, erythromycin resistance in 49.2%, while 37.3% were resistant to oxacillin, 28.8% to cefoxitin, 5.1% to levofloxacin and 5.1% to clindamycin. All isolates were biofilm producers and 96.6% of the strains contained the ica biofilm-forming genes (icaA and/or icaD). We have demonstrated a high prevalence of S. aureus and MRSA carriage among health care working in Primary Health Care units, the presence of SCCmec types I, III and IV, in addition to their high ability to form biofilm, factors that possibly contribute to the dissemination and persistence of these pathogens within the primary care services. These observations highlight the importance of broadening the perspective of Health Care-Associated Infections prevention, including all health care levels, which are currently little explored. In addition, the dynamics and resistance mechanisms of S. aureus transmission still need to be further clarified to enable the implementation of more effective prevention measures.

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ABSTRACT Dengue virus, the etiological agent of dengue fever (DF) occurs in four genetically distinct serotypes (DENV1-4), being transmitted by female Aedes mosquitoes. DF incidence is increasing in Brazil, following vector dispersal, proliferation and DENV serotypes introduction, co-circulation and substitution. Medium- and small-sized cities in Sao Paulo State, such as Marilia (Midwest region), have been affected by huge epidemics. To understand the evolution of DENV epidemics in medium-sized cities, in this study a historical data on DENV incidence (2000-2015) in Marilia, was evaluated. Previous studies disclosed regional and specific DF outcomes associated with 2007 outbreak in that city, when co-circulating DENV1 and DENV3 presented different hematological profiles. In this study, characteristics of 2007 DENV epidemics were compared to the epidemiological, hematological and demographic outlines of the major outbreak of DENV1 in Marilia in 2015. DENV1 genetic diversity was assessed through capsid and pre-membrane junction encoding gene (CprM) sequencing. The results revealed circulation of DENV1 serotype from 2007 to 2015, with epidemics occurring every three-years until 2013 and then, increasing yearly. There were significant differences in hematological profiles of DENV1 patients between 2015 and 2007. CprM showed DENV1 genetic variability in 2015, contrasting with the unique sequence pattern in 2007. These results reinforce the regional and temporal characteristics of DENV epidemics that need local public health research to improve care for people and to limit the spread of new serotypes/genotypes to uninfected areas.

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ABSTRACT The emergence and spread of extensively drug-resistant tuberculosis (XDR-TB) is a serious threat to global health. Therefore, its rapid diagnosis is crucial. The present study aimed to characterize mutations conferring resistance to second line drugs (SLDs) within multidrug Mycobacterium tuberculosis (MDR-MTB) isolates and to estimate the occurrence of XDR-TB in Casablanca, Morocco. A panel of 200 MDR-TB isolates was collected at the Pasteur Institute between 2015-2018. Samples were subjected to drug susceptibility testing to Ofloxacin (OFX), Kanamycin (KAN) and Amikacin (AMK). The mutational status of gyrA, gyrB, rrs, tlyA and eis was assessed by sequencing these target genes. Drug susceptibility testing for SLDs showed that among the 200 MDR strains, 20% were resistant to OFX, 2.5% to KAN and 1.5% to AMK. Overall, 14.5% of MDR strains harbored mutations in gyrA, gyrB, rrs and tlyA genes. From the 40 OFXR isolates, 67.5% had mutations in QRDR of gyrA and gyrB genes, the most frequent one being Ala90Val in gyrA gene. Of note, none of the isolates harbored simultaneously mutations in gyrA and gyrB genes. In eight out of the 200 MDR-TB isolates resistant either to KAN or AMK, only 25% had A1401G or Lys89Glu change in rrs and tlyA genes respectively. This study is very informative and provides data on the alarming rate of fluoroquinolone resistance which warrants the need to implement appropriate drug regimens to prevent the emergence and spread of more severe forms of Mycobacterium tuberculosis drug resistance.

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ABSTRACT We analyzed the clinical features and risk factors of candidemia due to C. parapsilosis (n=104) in the intensive care unit of a tertiary hospital over six years. This was a monocentric, retrospective study of candidemia, conducted from January 2013 to March 2019. Epidemiological characteristics, clinical features, invasive procedures, laboratory data and outcomes of 267 patients with candidemia were analyzed to determine risk factors of candidemia due to C. parapsilosis. Sixty-three cases of C. albicans and 204 cases of non-C. albicans Candida (NCAC) species were included, the latter was composed of 104 cases of C. parapsilosis and 100 cases of non-C. albicans species (46 cases of C. tropicalis, 22 cases of C. glabrata, 23 cases of C. guilliermondii, 5 cases of C. krusei and 4 cases of C. lusitaniae), suggesting that C. parapsilosis was the predominant Candida species isolated from cases of candidemia. A binary multivariate logistic regression analysis showed that APACHE II scores, central venous catheterization and the use of broad-spectrum antibiotics were closely related to C. parapsilosis candidemia, with OR values of 1.159, 3.913 and 2.217, respectively. In conclusion, we found that C. parapsilosis was the main pathogen among the NCAC candidemia in the ICU patients. APACHE II scores, central venous catheterization and the use of broad-spectrum antibiotics were independent risk factors for the occurrence of C. parapsilosis candidemia, which may provide data to support the early introduction of anti-fungal therapy.

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ABSTRACT COVID-19 is an infectious disease caused by the recently discovered coronavirus SARS-Cov-2. The disease became pandemic affecting many countries globally, including Brazil. Considering the expansion process and particularities during the initial stages of the epidemic, we aimed to analyze the spatial and spatiotemporal patterns of COVID-19 occurrence and to identify priority risk areas in Minas Gerais State, Southeast Brazil. An ecological study was performed considering all data from human cases of COVID-19 confirmed from the epidemiological week (EW) 11 (March 08, 2020) to EW 26 (June 27, 2020). Crude and smoothed incidence rates were used to analyze the distribution of disease patterns based on global and local indicators of spatial association and space-time risk assessment. Positive spatial autocorrelation and spatial dependence were found. Our results suggest that the metropolitan region of the State capital Belo Horizonte (MRBH) and Vale do Rio Doce mesoregions, as major epidemic foci in the beginning of the expansion process, have had important influence on the dispersion of SARS-CoV-2 in Minas Gerais State. Triangulo Mineiro/Alto Paranaiba region presented the highest risk of infection. In addition, six statistically significant spatiotemporal clusters were identified in the State, three at high risk and three at low risk. Our findings contribute to a greater understanding of the space-time disease dynamic and discuss strategies for identification of priority areas for COVID-19 surveillance and control.

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ABSTRACT A few studies have carried out the taxonomic and molecular characterization of sylvatic mosquito species in Latin America, where some species have been incriminated as vectors for arboviruses and parasites transmission. The present study reports the molecular characterization of mosquito species in the Sierra Nevada de Santa Marta, a natural ecosystem in the Northern coast of Colombia. Manual capture methods were used to collect mosquitoes, and the specimens were identified via classical taxonomy. The COI marker was used for species confirmation, and phylogenetic analysis was performed using the neighbor-joining method, with the Kimura-2-Parameters model. Aedes serratus , Psorophora ferox , Johnbelkinia ulopus , Sabethes chloropterus , Sabethes cyaneus , Wyeomyia aporonoma , Wyeomyia pseudopecten , Wyeomyia ulocoma and Wyeomyia luteoventralis were identified. We assessed the genetic variability of mosquitoes in this area and phylogenetic reconstructions allowed the identification at the species level. Classical and molecular taxonomy demonstrated to be useful and complementary when morphological characteristics are not well preserved, or the taxonomic group is not represented in public molecular databases.

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ABSTRACT Tuberculosis is a worldwide public health problem, which, even with available treatment, continues to cause deaths worldwide. One of the obstacles to control the disease is the multifactorial difficulty of patients to adhere to treatment, in addition to the difficulty of health workers in circumventing barriers to implement strategies such as the directly observed treatment (DOT). The aim of this study is to analyze the performance and challenges faced by health workers in the use of DOT in tuberculosis. This is a descriptive, quali-quantitative study using data from interviews with primary-care professionals working in nine municipalities of Parana State, Brazil. The professionals answered a questionnaire containing four closed questions about DOT and an open question related to their professional opinion about the strategy. Quantitative data were entered into a spreadsheet and statistically propagated. Qualitative data were treated from the transcription of statements, subsequently submitted to content analysis. Of the 387 professionals interviewed, at least 58.9% had some knowledge about DOT. Among the main challenges faced by the professionals are: lack of user commitment to treatment (48.3%), users' difficulty in attending the basic health clinics (BHC) (31.4%), professionals' difficulty to reach the place where patients are treated (8.8 %), insufficient staff / lack of human resources (4.1%) and use of illicit drugs by patients (3.9%). Blaming the user and the lack of resources are the main highlights, in addition to issues such as the professionals' lack of access and knowledge that are highlighted by the difficulty of patients to adhere to the treatment of tuberculosis according to the participants' statements. The issues were raised by health workers manifestations involving adherence to treatment according to the DOT in the studied health region. It is possible, in this context, to observe the need for improvement in the knowledge of professionals with regard to the DOT, the importance of their bond with patients and families and the recognition of the part of responsibility that belongs to the health team on guaranteeing treatment.

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ABSTRACT Sepsis is the organ dysfunction resulting from an infection associated with an unregulated host inflammatory response, which generates high mortality rates in Brazil. The aim of this stydy was to analyze the trend of early, late and post-neonatal mortality rates due to sepsis in Brazilian regions, from 2009 to 2018. This is an ecological study of time series. The trend of infant mortality from sepsis was analyzed using the International Classification of Diseases (ICD10) according to the place of residence (North, Northeast, Southeast, South and Midwest). Death Certificate data were collected from the Mortality Information System database. The temporal trend was analyzed using the Prais-Winsten estimate, interpreted as increasing, decreasing or stable, through the dependent variable (logarithm of mortality rates) and interdependent variables (years of the historical series). The Stata 14.0 statistical software was used. There were 39,867 infant deaths due to sepsis (78.67% for unspecified bacterial sepsis of the neonate ). Most of the children were male, had mixed ethnicity (black and white) , were born preterm with low birth weight and most mothers were 20-34 years old. There were decreasing trends in mortality rates from 2009 to 2018: early neonatal, in the Southeast (-3.57%), North (-3.33%) and South (-2.91%); late neonatal, in the South (-4.12%), Southeast (-4.53%), North (-4.55%) and Midwest (-6.21%); and post-neonatal, in the Northeast (-1.84%), North (-3.62%), Southeast (-3.83%) and Midwest (-5.81%). The Northeast showed a stable trend in early and late neonatal mortality rates. It was concluded that most regions showed a decreasing trend in mortality rates from sepsis in all age components, despite regional differences.

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ABSTRACT Despite the widespread use of chlorhexidine (CHX) to prevent infection, data regarding the in vitro action of CHX against methicillin-resistant Staphylococcus aureus (MRSA) are limited. Clinical isolates from Hospital das Clinicas, Sao Paulo, Brazil, identified during 2002/2003 and 2012/2013 were studied to describe the susceptibility to CHX and mupirocin, molecular characteristics, and virulence profile of MRSA. Susceptibility test to Mupirocin was performed by the disk diffusion method and to CHX by the agar dilution technique. PCR for virulence genes, mecA gene and Staphylococcal Cassette Chromosome mec (SCCmec) types were investigated as well. Mupirocin- and CHX-resistant isolates were sequenced using the IlluminaTM plataform. Two hundred and sixteen MRSA clinical isolates were evaluated: 154 from infected and 62 from colonized patients. Resistance to mupirocin was observed in four isolates assigned as SCCmec type III and STs (ST05; ST239 and ST105) carrying mupA and blaZ, two of them co-harboring the ileS gene. Only one isolate assigned as SCCmec type III was resistant to CHX (MIC of 8.0 μg.mL-1) and harbored the qacA gene. Resistance to chlorhexidine and mupirocin were found in isolates carrying qacA and mupA in our hospital. Since these genes are plasmid-mediated, this finding draws attention to the potential spread of resistance to mupirocin in our hospital.

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ABSTRACT Currently, the Milwaukee protocol presents healing results in human beings affected by the rabies virus. However, there are many points to clarify on the action of drugs and the immune mechanism involved in the evolution of the disease. One of the drugs used is biopterin, which is an important cofactor for nitric oxide, important for preventing vasospasm. Thus, we describe the effect of biopterin on some inflammatory factors in a rabies virus infection developed in an animal model. The immunological mediators studied in animals infected with rabies virus submitted to doses of sapropterin were Anti-RABV, IL-6, IL-2, IL-17a, INF-gamma and Anti-iNOS. It is suggested that the medication in the context of a RABV infection already installed, had the effect of modulating the inflammatory mechanisms mainly linked to the permeability of the blood-brain barrier and the migration of cytotoxic cells.

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ABSTRACT To estimate the prevalence of cases of trachoma in the population at social risk aged 1-9 years in Pernambuco State and its mesoregions. This was a cross-sectional study in which secondary data from the National Household Survey on Trachoma (2014-2015) were analyzed. The study covered 96 census tracts distributed across the mesoregions of Pernambuco State (Metropolitan Region of Recife, Zona da Mata, Agreste, Sertao do Sao Francisco and Sertao Pernambucano). The study included all homes with children aged 1-9 years, and all of them were examined for trachoma, using the WHO criteria. Among the total of 7,423 children aged 1-9 years who participated in this survey, 446 presented with active trachoma. Thus, the prevalence of trachoma in Pernambuco State, in children between 1-9 years old was 6.65%, and it was higher among children aged 5-9 years (7.12%) and among girls (7.23%). This result was seen in the majority of the mesoregions studied, except in the Zona da Mata and Sertao do Sao Francisco, where there were higher prevalences in the age group of 1-4 years (5.55%) and among boys (5.90%). A tendency towards a higher prevalence between 1 and 6 years of age was observed. The follicular trachoma continues to be an important public health problem in Pernambuco State. It particularly affects poor people, including those living in urban areas of the State.

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ABSTRACT Chagas cardiomyopathy (ChCM) is a severe consequence of Trypanosoma cruzi infection and has a range of electrocardiographic (ECG) and echocardiographic (ECHO) manifestations. There is a need for a standard and parsimonious research cardiac end point that does not rely on expert panel adjudication, and it is not intended to change the ChCM definition. We use data from the REDS-II cohort to propose a simplified cardiac endpoint. A total of 499 T. cruzi-seropositive blood donors were included. All participants underwent a 12-lead ECG, echocardiogram and clinical examination, and those with abnormal findings were reviewed by a panel of cardiologists who classified cases as having Chagas cardiomyopathy or not. We created an exhaustive set of ECG and ECHO finding combinations and compared these with the panel’s classification. We selected the simplest combination that most accurately reproduced the panel’s results. Individual ECG and ECHO variables had low sensitivity for panel-defined cardiomyopathy. The best performing combination was right bundle branch block and/or ECHO evidence of left ventricular hypocontractility. This combination had 98% specificity and 85% sensitivity for panel-defined ChCM. It was not possible to improve the overall accuracy by addition of any other ECG or ECHO variable. Substituting right bundle branch block for the more inclusive finding of QRS interval > 120 ms produced similar results. The combination of prolonged QRS interval and/or left ventricular hypocontractility closely reproduced the REDS-II expert panel classification of Chagas ChCM. In conclusion, the simple and reproducible research endpoint proposed here captures most of the spectrum of cardiac abnormalities in Chagas disease.

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ABSTRACT Blastocystis sp. is an enteric protist commonly found in human fecal samples. In Brazil, few studies have been developed, but none of them has explored the presence of Blastocystis in patients with diabetes mellitus. We evaluated the occurrence and molecular identification of Blastocystis sp. among patients with diabetes mellitus in the Midwest region, Goias State, Brazil. Genomic DNA was obtained from 175 fecal samples (99 from the diabetic group and 76 from the control group). PCR was performed using pan-Blastocystis primers from the SSU-rDNA gene. Microscopic examination revealed positivity of 12.1% and 7.9% for Blastocystis in diabetics and in controls, respectively. Amplification of Blastocystis DNA was observed in 34.4% (34 of 99) and 30.3% (23 of 76) from the diabetic and control groups, respectively. Phylogenetic analyses and BLAST searches revealed six subtypes among Blastocystis isolates in the diabetic group, represented by ST1 (38.2%), ST2 (11.8%), ST3 (35.3%), ST6 (2.9%), ST7 (2.9%) and ST8 (8.8%). In the control group, ST1 (21.8%), ST2 (21.8%), ST3 (43.5%), ST6 (4.4%) and ST8 (8.7%) were identified. This study is the first report regarding the occurrence and subtypes distribution of Blastocystis in patients with diabetes mellitus in Brazil. The results reinforce the potential risk of Blastocystis infection in patients with diabetes, in addition, it contributes to the understanding of the genetic diversity of this enigmatic organism.

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ABSTRACT HIV-infected patients are at high risk for developing critical diseases, including opportunistic infections (OI), with consequent admission in intensive care units (ICU). Renal disfunctions are risk factors for death in HIV/AIDS patients, and survival rates in patients undergoing hemodialysis are smaller than the ones observed in the general population. In this context, this study aimed to investigate death-related factors in HIV/AIDS patients in an intensive care setting. This is a retrospective cross-sectional study performed through the analysis of medical records from 271 HIV/AIDS-diagnosed patients hospitalized in an intensive care unit of an infectious disease hospital, in Fortaleza, Ceara State, Brazil. Patients were divided into two groups: those who underwent dialysis during hospitalization and those who did not. Clinical and demographic parameters that could be associated with death were evaluated. Results indicated a prevalence of death of 19.1% (CI 95%: 14.8-24.3). The median age of patients was 47 years, with a male predominance (71.3%). The main causes of admission were pulmonary tuberculosis (16.9%), followed by neurotoxoplasmosis (14.9%). In the bivariate analysis, for those that did not undergo dialysis, age, fever, dyspnea, oliguria, disorientation, kidney injury, use of lamivudine and efavirenz, length of hospitalization, CD4 count, WBC count, platelet count, urea, sodium and LDH levels were the associated variables. In those who needed dialysis, the use of stavudine, abacavir and ritonavir, and the length of hospitalization were associated factors. Renal toxicity by the antiretroviral agents and length of hospitalization increased the risk of death among HIV patients under dialysis.

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ABSTRACT Hepatitis A virus (HAV) infection has been considered one of the leading causes of acute hepatitis. The aim of the present study was to estimate the prevalence of HAV among children and adolescents in a population-based study in the capitals of the States of the North, Southeast and South of Brazil and identify predictive factors for the infection. A multi-stage sampling was used to select subjects aged between 5-9 and 10-19 years. Individual and household levels aside from the level of variables in the areas were collected. The outcome was the total IgG antibodies to HAV levels detected using a commercial Enzyme Immuno Assay (EIA). The associations between HAV and the independent variables were assessed using the odds ratio. A multilevel analysis was performed by GLLAMM using the Stata software. The prevalence of HAV infection in the 5-9 and 10-19 age groups was 28.7% and 67.5%, respectively for the North, 20.6% and 37.7%, for the Southeast and 18.9% and 34.5% for the South Region. The prevalence of HAV increased according to age in all sites. Variables related to education at the individual level (North and South), family and area level (South and Southeast) and family income level (Southeast and South) were independently associated with HAV infection. This emphasizes the need for individualized strategies to prevent the infection.

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ABSTRACT To date, blood banks apply routine diagnosis to a specific spectrum of transfusion-transmitted viruses. Even though this measure is considered highly efficient to control their transmission, the threat imposed by emerging viruses is increasing globally, which can impact transfusion safety, especially in the light of the accelerated viral discovery by novel sequencing technologies. One of the most important groups of patients, who may indicate the presence of emerging viruses in the field of blood transfusion, is the group of individuals who receive multiple transfusions due to hereditary hemoglobinopathies. It is possible that they harbor unknown or unsuspected parenterally-transmitted viruses. In order to elucidate this, nucleic acids from 30 patients with beta-thalassemia were analyzed by Illumina next-generation sequencing and bioinformatics analysis. Three major viral families: Anelloviridae, Flaviviridae and Hepadnaviridae were identified. Among them, anelloviruses were the most representative, being detected with high number of reads in all tested samples. Human Pegivirus 1 (HPgV-1, or GBV-C), Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) were also identified. HBV and HCV detection was expected due to the high seroprevalence in patients with beta thalassemia. Our results do not confirm the presence of emerging or unsuspected viruses threatening the transfusion safety at present, but can be used to actively search for viruses that threaten blood transfusion safety. We believe that the application of viral metagenomics in multiple-transfused patients is highly useful to monitor possible viral transfusion threats and for the annotation of their virome composition.

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ABSTRACT Leprosy may present kidney and endothelial abnormalities, being a risk factor for complications. However, the involvement of renal and vascular endothelia has been poorly investigated. We aimed to investigate if the levels of systemic endothelial biomarkers are associated with kidney abnormalities and the clinical forms of leprosy. This is a cross-sectional study with leprosy patients enrolled in January 2017 to December 2018, before the initiation of the multidrug therapy. Leprosy-associated clinical and epidemiological data were collected. Two groups were investigated: Paucibacillary (PB) and Multibacillary (MB) infections, for the comparisons. Serum and urine samples were obtained for laboratory analysis. In serum samples, were evaluated the endothelial biomarkers VCAM-1 and ICAM-1. In total, 101 leprosy patients were included, the mean age was 48±١٥ years and 71 (70%) were male. The multibacillary form occurred in 81 cases (80%), among which 22 had the Virchowian form. Serum creatinine was more elevated in the MB group than in PB patients. In addition, VCAM-1 was elevated in the MB group and was correlated with the bacteriological index (rho = 0.372, p <0.01), the duration of disease symptoms (rho = 0.234, p = 0.04), and the number of skin lesions (rho = 0.468, p <0.001). Moreover, in MB patients who presented albuminuria >15 mg/g of creatinine, VCAM-1 showed a significant correlation with increased albuminuria and improved the correlation with the number of skin lesions (rho= 0.563, p=0.010). In conclusion, higher systemic VCAM-1 levels were associated with the multibacillary clinical form of leprosy and with increased albuminuria. Prospective studies are necessary to establish a cause-effect and evaluate the preventive role of these biomarkers to improve the clinical care.

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ABSTRACT COVID-19 pandemic has changed the way we live our lives for the foreseen future. To date, there have been over 113 million reported cases and 2.5 million deaths worldwide. Many studies investigated the factors affecting the number of daily cases such as weather conditions, lockdown duration and other factors. In this study, we propose a COVID-19 analytical formula for factors contributing to the number of the new coronavirus daily cases. We have also calculated values of relative weights of those factors. We focus on the first wave data that are publically available. Seven countries were considered including the UK, Italy, Spain, Canada, South Korea, Germany and France. We considered the following factors: temperature, humidity, government expenditure, lockdown hours and the number of daily tests for COVID-19 performed. The weights were calculated based on the hypothesis that a high correlation between recorded data of a given pair of countries implies a high correlation of the pair’s COVID-19 proposed analytical formula. The factors are calculated using the brute-force technique. Our results showed that in five out of the seven countries; temperature, humidity, and lockdown duration were the most dominant with values of 26%, 32% and 38%, respectively. In other countries, however, humidity, government expenditure and the daily performed tests for COVID-19 were the most effective factors, with relative values of 35%, 26%, and 28%.

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ABSTRACT Chagas disease (CD) has been considered endemic in the South of Rio Grande do Sul (RS) State, Brazil. This study aimed at evaluating the occurrence of Trypanosoma cruzi vectors based on the main species captured in Southern Rio Grande do Sul State from 2008 to 2019. The study area comprised counties that belong to the 3rd Regional Health Coordination (RHC) and to the 7th RHC, whose headquarters are in Pelotas and Bage, respectively. The study was based on secondary data provided by the partnership between the Federal University of Pelotas, Rio Grande do Sul State (UFPel-RS) and the State Health Surveillance Center in RS (SCHS-RS). One thousand and four hundred triatomines were captured in the area supervised by the 3rd RHC, mainly in Cangucu (37.7%), Piratini (22.4%) and Pinheiro Machado (15.1%), while, in the area supervised by the 7th RHC, the largest number of triatomines was captured in Lavras do Sul (64.15%). In both areas, Triatoma rubrovaria (90.6%) and Panstrongylus tupynambai (7.4%) were the most common species. Most were captured inside households but T. cruzi-positive insects were not found in the period under study. The results of this study show that, in Southern Rio Grande do Sul State, there is still a high rate of triatomine household invasion and dispersal, mainly by T. rubrovaria. Thus, the entomological surveillance should be maintained with the participation of the population and further studies should be deepened in the area.

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ABSTRACT In December 2019, several cases of pneumonia of unknown origin were reported in the city of Wuhan, province of Hubei, China. The pathogen was named as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease was named coronavirus disease 2019 (COVID-19). Acute phase reactans (APRs) are critical in the early diagnosis, treatment, and for monitoring the progression of COVID-19. Seventy two patients were included in the study and infections confirmed by real-time reverse transcription polymerase chain reaction. Clinical parameters, the level of APFs and D-dimer were assessed and results were retrived from the patients’ medical records. Chest computed tomography (CT) findings were described for each patient and they were divided into two groups, with or without COVID-19 pneumonia. The correlation between APRs and CT findings and the patients’ prognosis were evaluated. Twenty eight (38.8%) of the 72 patients were female and 44 (61.2%) were male. The most common symptom was cough (43%) and the most common associated chronic disease was hypertension (12.5%). Thirty (41.6%) patients had completely normal chest CT, while 42 (58.4%) patients had typical findings in terms of COVID-19 pneumonia. C reactive protein (CRP), lactate dehydrogenase (LDH), erythrocyte sedimentation rate (ESR), ferritin, procalcitonin and D-Dimer levels were statistically significantly higher in patients with pneumonia than in those without pneumonia and these parameters were also statistically significantly higher in patients with severe illness. In conclusion, CRP, LDH, ESR, ferritin, and D-Dimer were associated with severe COVID-19 pneumonia. These biomarkers can be used to evaluate the prognosis to predict the clinical course of disease, allowing a proper management and treatment of the patients.

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ABSTRACT The gold standard for the laboratory diagnosis of COVID-19 is the reverse transcription quantitative real-time polymerase chain reaction (RT-qPCR) assay, which searches for SARS-CoV-2 target genes in nasopharyngeal/oropharyngeal (NP/OP) samples, and its performance depends on the quantity and quality of the RNA input. This study compared the performance and cost-effectiveness of three different kits/reagents for RNA extraction used in COVID-19 diagnosis in Sao Paulo, Brazil. A total of 300 NP/OP samples belonging to suspected cases of COVID-19 stored in a biorepository were randomly selected, and RNA was extracted using (i) automated extraction (Loccus, Extracta Kit FAST), (ii) manual extraction (BioGene Kit, Bioclin, Quibasa), and (iii) quick extraction methods (Lucigen, Quick DNA Extract Kit). Next, the samples were tested using RT-qPCR for SARS-CoV-2 with the Allplex 2019-nCoV modified assay and the Charité-Berlin protocol. All assays/kits were used according to the manufacturer’s instructions. For the Allplex kit, the sensitivity in detecting SARS-CoV-2 with previously extracted RNA by different procedures was 100.0% for Loccus, 100.0% for BioGene and 91.9% for Quick. Using the Charité-Berlin protocol, the sensitivities were 81.4% for Loccus, 81.2% for BioGene and 60.7% for Quick. The least sensitive target gene and the gene most affected by RNA extraction procedures was the RNA-dependent RNA polymerase gene (Charité-Berlin protocol). No false-positive SARS-CoV-2 results were detected using RNA obtained from any of the different protocols. In conclusion, Loccus and BioGene RNA extractions were efficient for RT-qPCR assays, and although the BioGene procedure is less expensive, Loccus is the best choice because it allows the rapid handling of hundreds or thousands of samples, a desirable feature during pandemics. Although less sensitive, the Quick extraction is useful during outbreaks coupled with the Allplex amplification kit for SARS-CoV-2 diagnosis (κ = 0.925).

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ABSTRACT Many infants are nurtured with milk supplied by human banks, whose bacteriological and physical-chemical profiles are a major issue. We investigated the bacteriological and physical-chemical characteristics, as well as genotypic and phenotypic and profiles of Staphylococcus species isolated from 240 samples of breast milk from a bank in a teaching hospital. Dornic acidity of milk revealed that 95.4% (229/240) had acceptable limits (< 8.0 oD). Caloric intake showed a wide variation in cream content (4%), fat (4%) and energy values (559.81 Kcal/L). Staphylococcus (105/186 or 56.5%) and Enterobacter (25/186 or 13.4%) were the most prevalent genera, although other microorganisms were identified, including Klebsiella pneumoniae and Pseudomonas aeruginosa. Amoxicillin/clavulanic acid (125/157 or 79.6%), vancomycin (115/157 or 73.2%), and cephalexin (112/157 or 71.3%) were the most effective antimicrobials. High resistance rates of isolates were found to penicillin G (141/157 or 89.8%), ampicillin (135/157 or 86%), and oxacillin (118/157 or 75.2%). Multidrug resistance to ≥ 3 antimicrobials occurred in 66.2% (123/186) of the isolates. Residues of microbial multiplication inhibitory substances were found in 85% (204/240) of samples. Among the coagulase-positive-CPS and negative-CoNS staphylococci, the mecA gene was detected in 53.3% (8/15) and 75% (30/40), respectively. Genes sea, seb and sec were detected in 20% (3/15) of CPS, while tsst-1 was detected in 13.34% (2/15). In addition, 13.3% (2/15) of S. aureus were toxin-producers. Genes sea, seb and sec were detected in 90% (36/40), 5% (2/40) and 15% (6/40) CoNS, respectively. Enterotoxin production was identified in 5% (2/40) of CoNS. The identification of multidrug-resistant bacteria, staphylococci species toxin-producers harboring methicillin-resistance genes, and residues of microbial multiplication inhibitory substances reinforce the need for a continuous vigilance of milk quality offered to infant consumption by human banks.

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ABSTRACT Cryptococcal infection is a frequent cause of mortality in Brazilian HIV-infected patients. The present study aimed to evaluate the cost-effectiveness and budgetary impact of four cryptococcosis screening strategies in HIV-infected patients with CD4+ ≤ 200 cells/mm3, in Brazil. A Monte Carlo microsimulation was used to compare the following diagnostic tests: a systematic serum cryptococcal antigen (CRAG) screening with latex agglutination (CRAG-LA), a lateral flow immunochromatographic test (CRAG-LFA), India ink staining and no intervention. The rationale was that of the Unified Health System (SUS), and the time horizon was of one year for the intervention and of five years for the budgetary impact analysis (BIA). The effectiveness outcomes were years of life and years of life adjusted for quality (QALY). The cost-effectiveness analysis showed that the two cryptococcal antigen tests were cost-effective, presenting with superior results in comparison with India ink and no screening. CRAG-LFA, compared to CRAG-LA, has an incremental cost of US$0.25 and an incremental cost-effectiveness ratio of US$73.36 (considering the US dollar equal to 5 reais, the Brazilian current money). The probabilistic sensitivity analysis between CRAG-LFA and CRAG-LA, despite showing a high agreement between the two tests, indicated the superiority of CRAG-LFA. The BIA estimated that the incorporation of CRAG-LFA would have an additional cost of approximately U$S 10.4 million dollars in five years. These findings suggest that, for the group of studied patients, the adoption of CRAG-LFA and CRAG-LA are cost-effective, while the India ink test and no intervention are less effective strategies. The BIA showed that using the CRAG-LFA test for people living with HIV (PLHIV) with CD4+ ≤ 200 cells/mm3 could reduce costs for the Brazilian Unified Health System (SUS).

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ABSTRACT This molecular epidemiological study was designed to determine the antimalarial drug resistance pattern, and the genetic diversity of malaria isolates collected from a war-altered Federally Administered Tribal Area (FATA), in Pakistan. Clinical isolates were collected from Bajaur, Mohmand, Khyber, Orakzai and Kurram agencies of FATA region between May 2017 and May 2018, and they underwent DNA extraction and amplification. The investigation of gene polymorphisms in drug resistance genes (dhfr, dhps, crt, and mdr1) of Plasmodium falciparum and Plasmodium vivax was carried out by pyrosequencing and Sanger sequencing, respectively. Out of 679 PCR-confirmed malaria samples, 523 (77%) were P. vivax, 121 (18%) P. falciparum, and 35 (5%) had mixed-species infections. All P. falciparum isolates had pfdhfr double mutants (C59R+S108N), while pfdhfr/pfdhps triple mutants (C59R+S108N+A437G) were detected in 11.5% of the samples. About 97.4% of P. falciparum isolates contained pfcrt K76T mutation, while pfmdr1 N86Y and Y184F mutations were present in 18.2% and 10.2% of the samples. P. vivax pvdhfr S58R mutation was present in 24.9% of isolates and the S117N mutation in 36.2%, while no mutation in the pvdhps gene was found. Pvmdr1 F1076L mutation was found in nearly all samples, as it was observed in 98.9% of isolates. No significant anti-folate and chloroquine resistance was observed in P. vivax; however, mutations associated with antifolate-resistance were found, and the chloroquine-resistant gene has been observed in 100% of P. falciparum isolates. Chloroquine and sulphadoxine-pyrimethamine resistance were found to be high in P. falciparum and low in P. vivax. Chloroquine could still be used for P. vivax infection but need to be tested in vivo, whereas a replacement of the artemisinin combination therapy for P. falciparum appears to be justified.

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ABSTRACT The majority of malaria cases in South America occur in rural areas of the Amazon region. Although these areas have a significant impact on malaria cases, few entomological studies have been carried out there. This study aimed to describe entomological parameters in settlements in Rondonia State, Brazil. Collections of anopheles were carried out using the Protected Human Attraction Technique (PHAT). The risk and the potential for malaria transmission were assessed using the human biting rate (HBR), the sporozoite rate (SR) and the entomological inoculation rate (EIR). The results confirmed that Nyssorhynchus darlingi is the predominant species in the two studied locations. Although settlement in the two study sites has occurred at different times, the species richness found was low, showing that environmental changes caused by anthropological actions have probably favor the adaptation of Ny. darlingi species. From the total of 615 anopheline mosquitoes assessed, seven (1.1%) were positive for Plasmodium sp. infections. The EIR revealed that Ny. darlingi contributes to malaria transmission in both locations, as it was responsible for 0.05 infectious bites in humans at night in the old settlement and 0.02 in the recent occupation. In the two study sites, the biting occurred more frequently at dusk. Nyssorhynchus darlingi was prevalent in areas of recent colonization but, even when present in a low density, this species could maintain the transmission of malaria in the older settlement. The entomological information obtained in this study is important and may aid the selection of vector control actions in these locations.

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ABSTRACT Chagas disease (CD) has been changing from an endemic Latino-American disease to a condition found outside endemic regions, due to migratory movements. Although often subclinical, its acute phase can be lethal. This study aimed to assess survival during the acute phase of CD and its relationship with ventricular function in an experimental model. To this end, 30 Syrian hamsters were inoculated with Trypanosoma cruzi (IG) and other 15 animals received saline solution (CG). Groups were monitored daily and submitted to echocardiography in two moments: before the challenge and 15 days post-infection. Left ventricular ejection fraction (LVEF) and global longitudinal myocardial strain (GLS) of the LV were measured. The IG was divided into groups of animals with and without clinical signs of disease. ANOVA for mixed models was used to compare ventricular function parameters. Survival analysis was studied using Kaplan-Meier curves and the log-rank test. The follow-up lasted 60 days. LVEF in IG was reduced through time (53.80 to 43.55%) compared to CG (57.86 to 59.73%) (p=0.002). There was also a reduction of GLS (−18.97% to −12.44%) in the IG compared to CG (p=0.012). Twelve animals from IG died compared to one animal from CG. Eleven out of the 12 animals from the IG group died before presenting with clinical signs of infection. Survival was reduced in the IG compared to CG over time (p=0.02). The reduced survival during the acute phase of this experimental model of Chagas disease was related to the significant reduction of LV function. The mortality rate in the IG was higher in the group presenting with clinical signs of infection.

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ABSTRACT This study presents 25 cases of recurrent respiratory papillomatosis (RRP) that occurred in Sao Luis, Maranhao State, Northeast region, Brazil, between January 2007 and December 2018. Sociodemographic and clinical profile of patients as well as human papillomavirus (HPV) infection status were evaluated. Clinical and histopathological data were collected from the patients’ medical records. For the HPV infection analysis, DNA was extracted and subjected to amplification by a nested polymerase chain reaction. Viral genotyping was performed by automated sequencing. The median age of patients was 12.40 ± 12.6. years, and the juvenile form of the disease (68%) was the predominant form of disease. Female participants were predominant (60%), and they were from cities located in the interior of the State (60%). The most common clinical manifestation was dysphonia; recurrence was observed in most cases (56%), and tracheostomy was necessary in seven patients (26.9%). When comparing the RRP forms, patients in the juvenile-RRP group had higher recurrence rates and need of tracheostomy than those in the adult-RRP group. The viral genotyping analysis revealed that 47.8% of patients had low-risk HPVs, whereas 13.1% had high-risk HPVs, and in 39.1% of patients the viral genotype was not obtained. HPV-6 was the most prevalent type and Juvenile-RRP was more prevalent in our population. HPV was present at a high rate, and HPV-6 was the predominant genotype. This study serves as the basis for further studies to be conducted in the Brazilian population. Our findings aid the better understanding of RRP, possibly suggesting some prognostic factors associated with the disease aggressiveness.

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ABSTRACT Infections caused by arboviruses that have mostly impacted the Brazilian morbidity and mortality are caused by the same vector, Aedes aegypti. Preventive actions related to the vector are the most effective strategies in the prevention and control of these diseases. This study aimed to associate the knowledge on the vector that transmits dengue, Zika and chikungunya with the sociodemographic and behavioral preventive practices towards Aedes aegypti in the municipality of Tangara da Serra, Mato Grosso State, in the Brazilian Legal Amazon. A probabilistic urban population sampling was obtained by clusters: census sectors and households. The sample size calculation considered 10% of loss and a 1.5 design effect. This is a cross-sectional research carried out through a household survey in February and March 2018. There were 583 participants. The study variables were knowledge on the vector, sociodemographic characteristics and preventive practices related to the vector. The statistical analysis was based on a bivariate analysis and Poisson multiple regressions. Inadequate or insufficient knowledge on the vector Aedes aegypti remained associated with education in the categories illiterate (p<0.001) and 8 years of study or less (p<0.001), in addition to not adopting practices of capping and cleaning the water tank (p=0.002) and not using insecticides at home (p=0.007). It is concluded that there is a need for health communication actions that consider characteristics the population, especially the level of education and previous knowledge on the vector, allowing a dialogical approach and enabling the community participation in preventive practices and control of the vector Aedes aegypti .

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ABSTRACT Even when treated adequately, pulmonary tuberculosis can lead to pulmonary sequelae. Patients treated for PTB between 2012 and 2016 answered a standardized questionnaire and underwent chest radiography and spirometry, measurement of absolute pulmonary volume, Diffusing Capacity for Carbon Monoxide (DLCO) and the 6-min walk test (6MWT) on two occasions: within the first year after the end of treatment (follow-up 1), and one and two years after follow-up 1 (follow-up 2). A total of 55 patients they underwent spirometry, 23 (41.82%) had obstructive ventilatory disorder (OVD) and eight (14.5%) had moderate OVD. In total, 29 patients underwent pulmonary function tests (PFTs) and 24 patients underwent the 6MWT on two occasions. The functional changes after PTB treatment appear not to have varied between one and two years of follow-up. There was a correlation between low FEV1 and low DLCO (p<0.001); low DLCO and low 6MWT (p<0.001) and radiographic abnormalities and low FEV1 (p=0.033). The most frequently observed change in spirometry was found in patients with OVD.

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ABSTRACT Trachoma is a keratoconjunctivitis caused by Chlamydia trachomatis, considered an important leading cause of preventable blindness in the world. This study aimed at verifying if flies can be the vectors for trachoma in our municipality. Flies were assessed in the households of children diagnosed with inflammatory trachoma at the municipality of Botucatu, Sao Paulo State, Brazil. Fly traps were placed in the backyard of the houses during 24 h, in each of the four weather seasons, over a period of one year. The collected dipterans were taxonomically classified and the presence of Chlamydia trachomatis in the flies was evidenced by using the Polymerase Chain Reaction (PCR). During the studied period, 2,188 flies were collected, mainly during the summer and the spring. The most common identified fly was Musca domestica. All fly samples were negative for Chlamydia trachomatis but several other different bacteria were identified in these flies. The authors concluded that flies are probably not the vectors for trachoma in the studied area. Further studies should be conducted to evaluate other possible factors responsible for the maintenance of the disease in our environment.

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ABSTRACT Chagas disease (CD) is still a neglected disease. Infected individuals are diagnosed late, being treated in worse clinical conditions. Thus, this study aimed to analyze the prevalence and the factors associated with new confirmed cases of CD identified by serological screening in an endemic region of Minas Gerais State, Brazil. This is an analytical cross-sectional study with data from a project of the Research Center in Tropical Medicine of Sao Paulo- Minas Gerais (SaMi-Trop) conducted in two municipalities. Data collection included a questionnaire with closed questions, a venous blood collection and an ELISA serological test for CD. A total of 2,038 individuals with no previous diagnosis of CD participated in the study. The result of the serological test for CD was adopted as the dependent variable. The independent variables addressed personal issues, health conditions and lifetime housing. A descriptive analysis of individual variables was performed. Subsequently, a bivariate analysis was performed using the Pearson’s chi-square test. Households sheltering individuals positive for CD were georeferenced, and the analysis of spatial distribution was performed using the quartic function to estimate the density of the nucleus. Among the participants, 188 (9.2 %) were positive for CD. The profile of participants with CD was associated with place of residence, age, relative/family member with CD and living conditions. It is noteworthy that there are still patients with CD who are unaware of their diagnosis in both, rural and urban areas.

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ABSTRACT Blood transfusion is still an irreplaceable therapeutic modality, widely applied to medical care. Clinical interviews and laboratory testing for transfusion-transmitted infections (TTI) are routinely performed to prevent TTI among the recipients. However, there is still a residual risk of TTI, and some blood banks have adopted the confidential unit exclusion (CUE) as an additional safety strategy. In this study, we investigated the demographic characteristics and laboratory results of the screening of TTI among blood donors who opted for the CUE, compared to blood donors who did not opt for the CUE. In this study, we included 32,261 blood donations collected in a single blood bank in Sao Paulo, Brazil. A very small proportion of donors (0.25%) opted for the CUE. They were mainly single males and were more likely to have HBV, syphilis, and other positive results in the combined screening for TTI, in comparison with those who did not opt for the CUE. This difference was statistically significant in both the univariable and the multivariable analysis adjusted for age, gender , marital status and years of schooling. Our findings highlight that CUE may be a useful tool to improve the safety for blood recipients, but its efficiency is context-dependent.

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ABSTRACT Dengue fever is re-emerging worldwide, however the reasons of this new emergence are not fully understood. Our goal was to report the incidence of dengue in one of the most populous States of Brazil, and to assess the high-risk areas using a spatial and spatio-temporal annual models including geoclimatic, demographic and socioeconomic characteristics. An ecological study with both, a spatial and a temporal component was carried out in Sao Paulo State, Southeastern Brazil, between January 1st, 2007 and December 31st, 2019. Crude and Bayesian empirical rates of dengue cases following by Standardized Incidence Ratios (SIR) were calculated considering the municipalities as the analytical units and using the Integrated Nested Laplace Approximation in a Bayesian context. A total of 2,027,142 cases of dengue were reported during the studied period. The spatial model allocated the municipalities in four groups according to the SIR values: (I) SIR<0.8; (II) SIR 0.8<1.2; (III) SIR 1.2<2.0 and SIR>2.0 identified the municipalities with higher risk for dengue outbreaks. “Hot spots” are shown in the thematic maps. Significant correlations between SIR and two climate variables, two demographic variables and one socioeconomical variable were found. No significant correlations were found in the spatio-temporal model. The incidence of dengue exhibited an inconstant and unpredictable variation every year. The highest rates of dengue are concentrated in geographical clusters with lower surface pressure, rainfall and altitude, but also in municipalities with higher degree of urbanization and better socioeconomic conditions. Nevertheless, annual consolidated variations in climatic features do not influence in the epidemic yearly pattern of dengue in southeastern Brazil.

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ABSTRACT Pseudomonas aeruginosa is one of the most common bacterium with a broad spectrum of human-associated infections. It is intrinsically resistant to many antimicrobial drugs, making carbapenems crucial in clinical management. The emergence and dissemination of carbapenemases among P. aeruginosa clinical isolates is a serious public health concern as it limits the options for the treatment of bacterial infections. Here, we described the molecular and epidemiological characteristics of 28 carbapenem-resistant P. aeruginosa strains isolated from patients hospitalized in an intensive care unit (ICU). The antimicrobial susceptibility of carbapenem-resistant P. aeruginosa strains was determined by broth microdilution. The presence of resistance genes was evaluated by PCR and DNA sequencing. Additionally, alterations in genes encoding P. aeruginosa outer membrane proteins were analyzed by PCR as well as SDS-PAGE. Clinical characteristics of the patients and the economic impact of hospitalization on the public health system were evaluated. PCR amplification showed that the blaKPC-2 and blaTEM genes were identified in three isolates (11%) and blaSHV gene in two isolates (7%). Outer membrane profiles obtained by SDS–PAGE indicated that the OprD porin was either absent or was produced at very low levels. A PCR assay using oprD-specific primers failed to show the presence of mutations in this gene. P. aeruginosa strains were isolated from 28 patients, among whom 43% (12/28) had sepsis, 31% (9/28) had respiratory failure, and 31% (9/28) had systemic arterial hypertension. A high mortality rate (39%) was observed in these patients, with an average duration of hospitalization of 34.6 days and a median cost of 3.275 dollars per patient. The production of carbapenemase was not the main mechanism of resistance in these strains. All carbapenem-resistant P. aeruginosa were isolated from patients hospitalized in the ICU. Besides the high mortality rate, many patients remained hospitalized for several days, resulting in a high cost of hospitalization for the public health system. Therefore, the evolution of this resistance and its dissemination should be actively monitored among critically ill patients to improve their health conditions.

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ABSTRACT The SaMi-Trop project is a cohort study conducted in 21 municipalities of endemic areas of Chagas disease, including 1,959 patients with chronic Chagas cardiomyopathy. In this article we updated the results of the project, adding information from the second cohort visit. Trypanosoma cruzi-seropositive patients were enrolled from the primary care Telehealth service in Minas Gerais State, Brazil. The eligibility criterium for the second visit was the participation in the baseline evaluation. Of 1,959 participants at the baseline assessment, 1,585 (79.9%) returned after two years for the second evaluation. The mortality rate was 6.7%, but varied from 0.9% to 18.2% when it was stratified by certain clinical characteristics. A lower age-adjusted NT-Pro-BNP level (less than 300) and a prior benznidazole treatment were associated with lower mortality. There was an improvement in most quality of life domain scores. Participants have also reported fewer signs and symptoms and greater use of medication. The second follow-up visit will be complete in Oct 2021.

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ABSTRACT PrEP users are under high risk for bacterial sexually transmitted infections (STI), including those caused by Treponema pallidum (Tp), Chlamydia trachomatis (Ct) and Neisseria gonorrhoeae (Ng). Ct and Ng screening at multiple anatomic sites may improve the diagnostic sensitivity among high-risk populations. We analyzed the prevalence and incidence of Ct, Ng, and Tp and investigated predictors of bacterial STI occurrence between January 2018 and November 2019 in a retrospective cohort of PrEP users in Sao Paulo, Brazil. We describe the frequency and percentage of Ct/Ng per anatomical site and calculate the percentage of missed diagnosis if molecular testing were applied only in symptomatic patients, or only in urine samples. Patients underwent syphilis testing every 3-4 months and Ct/Ng testing every 6 months. We included 413 PrEP users with a median age of 31 years. At baseline, 25% had a positive treponemal test and 7% had active syphilis; Ct and Ng were more frequently detected in the oropharynx and anus (6.4-6.9%) than in urine samples (0.7-2.6%). Twelve months after the onset of PrEP, the incidence of Tp, Ct and Ng was, respectively, 13.4%, 11.4% and 8.9%. During follow-up, 23 out of 33 Ct/Ng cases (69%, 95% CI 51-84) would have been missed if oropharynx and anus samples had not been tested. In addition, if only symptomatic cases had been tested, 30 out of 33 Ct/Ng cases (90%, 95% CI 75-98) would have been missed. Participants with incident STI had a higher baseline number of sexual partners and a longer follow-up. Our study reinforces that active and frequent screening for STI is a powerful strategy to improve the diagnostic sensitivity.

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ABSTRACT Surveillance strategies to detect colonization are an important tool to prevent and control the spread of microorganisms in hematopoietic stem cell transplant (HSCT) units. The aim of this study was to evaluate routine surveillance cultures for screening colonization and infection by carbapenem-resistant Enterobacteriaceae (CRE), carbapenem-resistant Pseudomonas aeruginosa (CRPa), and vancomycin-resistant enterococci (VRE). Surveillance cultures were collected (1,323 samples) from 200 patients admitted to an HSCT unit over one year; swabs were taken on admission and then weekly. We compared the positivity of cultures for each site, agent, clinical and epidemiological data according to the colonization status. Infection due to multidrug-resistant organisms (MDROs) occurred in 52 (21.5%) patients, 45 (86.5%) due to blood stream infection; 12 (23%) patients had a positive surveillance culture before the infection. Cultures of 554 (41.8%) samples were performed for CRPa, 413 (31.2%) for VRE and 356 (27%) for CRE. Of these, 179 (13.5%) were positive. Colonization by any MDRO, CRE or CRPa was associated with increased risk of infection (P < 0.05), but not with death. Previous colonization by an MDRO was a significant risk for infection by these pathogens, specially by CRE. Overall, rectal swabs had the highest positivity rate compared with other sites, oropharynx swabs were an option for CRPa, and fecal cultures showed low positivity. Although the impact of the strategy on the mortality of patients undergoing HSCT is not clear, routine VRE surveillance should be questioned with regard to patients undergoing auto-HSCT due to the additional cost and little impact on survival rates.

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ABSTRACT In Brazil, few studies on the molecular aspects of hepatitis B virus (HBV) infection have been conducted in the interior regions of Sao Paulo State. This study aimed to identify HBV genotypes and evaluate strains with resistance mutations for nucleoside analogues in the Administrative Region (AR) of the municipality of Sao Jose do Rio Preto. We performed nested PCRs of 127 samples from the Health Care Services of the AR to amplify, sequence and analyze fragments of the HBV DNA, in order to identify genotypes and resistance mutations. The HBV S/Pol regions of 126 samples were successfully amplified and sequenced. Five different genotypes were found, and the main ones were A, D and F; a greater number of samples contained the subgenotypes A1 (n = 51; 40.5%), D3 (n = 36; 28.6%), A2 (n = 14; 11.1%) and F2a (n = 9; 7.1%). Resistance mutations (rtM204V/I/S) associated or not with compensatory mutations (rtL180M, rtV173L) were identified in 13.9% (5/36) of patients undergoing viral treatment and 1.1% (1/90) of naïve patients. The diversity of genotypes/subgenotypes found is probably due to the intense migration occurring in the region. These data can complement epidemiological and clinical surveillance, and can be used for a more effective management of chronic HBV patients.

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ABSTRACT Snake envenoming is a neglected tropical disease that affects more than 2.7 million people worldwide. The treatment is based on the administration of antivenom composed of heterologous immunoglobulins, species-specific therapy involving the possibility of adverse reactions due to activation of the immune system. Considering the scarcity of prospective studies evaluating the safety of snake antivenoms, this study aimed to describe and characterize adverse events after antivenom infusion in an observational, prospective, single-centre investigation conducted in a referral centre in Brazil. A total of 47 victims of snake envenoming were included in the study, who were mostly men (75%), with ages ranging from 2 to 83 years. Twenty-two participants (47%) presented manifestations compatible with infusion-related reactions (IRRs) during or up to two hours after F(ab’)2 heterologous immunoglobulin infusion. The most common clinical manifestation related to the infusion was a diffuse cutaneous rash (82%), followed by respiratory manifestations (46%) and facial swelling (23%). In four cases (9%), IRR were considered serious adverse events (SAE), characterized by haemodynamic instability, airway obstruction or hypoxia. Only one patient developed symptoms compatible with serum sickness. Although almost half of the patients treated with antivenom sera experienced IRRs, the SAE rate was 9%; in all cases, the adverse reaction was reversible by using supportive treatment, and there were no deaths. The results have shown that there is much to improve in the antivenom production process to obtain a more purified and specific product. Even so, a timely antivenom serum administration managed by well-trained health teams is safe and prevents complications after snake-related accidents.

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ABSTRACT Leprosy is an infectious and contagious disease affecting skin and nerves. The number of cases in individuals under 15 years old is one of the parameters used in Brazil as an indicator of endemic permanence of the disease and its continuous transmission. Rio Grande do Sul State, in Southern Brazil, is low-endemic to leprosy. However, the disease remains a public health problem. This is a retrospective, observational and analytical study of a historical series of new cases of leprosy in children under 15 years old diagnosed in the period from 2000 to 2019, in all health units in Rio Grande do Sul State. Seventy-seven new cases were notified. The male gender was predominant in 53.2% of the cases (n=41). The average age was 10.4 years (standard deviation of 2.9), with predominance of the age group between 10 and 15 incomplete years old. The most frequent operational classification was multibacillary, in 62.3% of cases (n=48), and the most common clinical form was borderline, in 38.9% of cases (n=28). The predominant disability degree in the sample was grade zero, in 80.0% of the cases (n=60), but in 4.0% (n=3) the grade assessed was 2. In 54.0% of cases (n=27), bacilloscopy was performed, with positive results in 36.0% (n=9) of the exams. Multibacillary cases, with physical disability and/or positive bacilloscopy, draws attention that that the diagnosis is frequently not made in early stages.

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ABSTRACT Lutzomyia longipalpis is the natural vector of Leishmania (Leishmania) infantum, but it is also permissive for several Leishmania species that are related to cutaneous leishmaniasis (CL). Maranhao State (Northeast of Brazil) is endemic for CL and has the highest number of cases of diffuse cutaneous leishmaniasis (DCL) in the country. It is a rare disease associated with a defective immune response mainly caused by L. (L.) amazonensis. Additionally, the number of immunosuppressed patients infected with the etiologic agents of CL has increased, including regions in which the main vectors of CL are rare. Therefore, we investigated whether Lu. longipalpis is able to transmit L. (L.) amazonensis to uninfected and immunosuppressed mice, resulting in CL. For that, 291 sand flies took an initial blood meal in mice infected with L. (L.) amazonensis. Of these, 17 underwent a second feeding on uninfected and immunosuppressed mice (of which 58.8% were also positive for Leishmania according to data on the dissection of the intestine). After 27 days of infection, these mice exhibited leishmaniotic lesions. The occurrence of parasites on the animal’s skin was confirmed by limiting dilution and immunohistopathological analyses. Parasite DNA was also detected in paw lesions and inguinal lymph nodes. DNA sequencing confirmed the Leishmania species in insects and mice. The results confirmed the ability of Lu. longipalpis to become infected and experimentally transmit L. (L.) amazonensis to immunosuppressed rodents, resulting in leishmaniotic lesions. Our data open perspectives for the potential role of Lu. longipalpis in the epidemiology of urban cutaneous leishmaniasis, especially in immunosuppressed patients.

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ABSTRACT The methicillin resistant Staphylococcus aureus (MRSA) is recognized by its ability to acquire and transferring resistance genes through interspecies conjugative plasmids. However, transference of plasmids from Gram-positive cocci to Gram-negative bacilli is not well characterized. In this report, we describe the transfer of a conjugative plasmid carrying qacA from MRSA to Escherichia coli C600. We performed a conjugation experiment using a chlorhexidine resistant MRSA isolate (ST-105/SCCmec type III) carrying the gene qacA and qacC as the donor and a chlorhexidine susceptible E. coli C600 isolate as the receptor. Transconjugants were selected using MacConkey agar plates containing chlorhexidine in concentrations ranging from 0.25 to 16 g.L-1. To genotypically confirm the transfer of the resistance gene, the transconjugants were screened by Polymerase Chain Reaction (PCR) and submitted to Sanger’s sequencing. MRSA isolates successfully transferred the chlorhexidine resistance gene (qacA) to the recipient E. coli strain C600. The E. coli transconjugant exhibited an important reduction of chlorhexidine susceptibility, with MICs increasing from ≤ 0.25 to ≥ 16 g.L-1 after conjugation. The qacA gene was detected by PCR as well as in the Sanger’s sequencing analysis of DNA from transconjugant plasmids. To the best of our knowledge, this is the first report of the plasmid p_8N_qac(MN687830.1) carrying qacA and its transfer by conjugation from a MRSA to an E. coli. These findings increase concerns on the emergence of resistance dissemination across the genus and emphasizes the importance of continuous antiseptic stewardship.

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ABSTRACT Malaria represents a serious public health problem, presenting with high rates of incidence, morbidity and mortality in tropical and subtropical regions of the world. According to the World Health Organization, in 2018 there were 228 million cases and 405 thousand deaths caused by this disease in the world, affecting mainly children and pregnant women in Africa. Despite the programs carried out to control this disease, drug resistance and invertebrate vector resistance to insecticides have generated difficulties. An efficient vaccine against malaria would be a strategy with a high impact on the eradication and control of this disease. Researches aimed at developing vaccines have focused on antigens of high importance for the survival of the parasite such as the Circumsporozoite Surface Protein, involved in the pre-erythrocytic cycle during parasites invasion in hepatocytes. Currently, RTS’S is the most promising vaccine for malaria and was constructed using CSP; its performance was evaluated using two types of adjuvants: AS01 and AS02. The purpose of this review was to provide a bibliographic survey of historical researches that led to the development of RTS’S and its performance analysis over the decade. The search for new adjuvants to be associated with this antigen seems to be a way to obtain higher percentages of protection for a future malaria vaccine.

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ABSTRACT Currently, there are no biomarkers for Chikungunya fever (CHIK) in clinical practice that can accurately predict the severity or chronification of the disease. The aim of this study is to evaluate the existing literature on biomarkers related to the severity and chronification of CHIK. In this sense, a systematic review was conducted based on the PRISMA Statement guideline. Articles that described the association of biomarkers with the evolution of the disease (severity or chronification), published until August 20th 2019 were considered eligible. The search was carried out in the PubMed, Scopus, Virtual Health Library (VHL) and Science Direct databases. After searching the databases, 17 articles were added to the review, and after analyzing the articles, several biomarkers were associated with severity, such as increased levels of IL-6, IP-10, IL-1b, MIG, MCP-1, and reduced levels of RANTES and IL-8 or chronification, such as increased levels of IL-6, TNF-α, MCP-1, IL-12, INF-α, IL-13, INF-γ, GM-CSF, CRP, IL-1a, IL-15, Factor VII, IP-10, IL-10, IL-4, IL-1RA, IL-8, MIP-1α, MIP-1β, ferritin, MIG, ESR, NO, malondialdehyde, and reduced levels of RANTES, ferritin, eotaxin, HGF, IL-27, IL-17A, IL-29, TGF-β, IL-10, and thiols. IL-6, CRP and TNF-α were included in the meta-analysis to assess the relationship with chronification, although they did not reach statistical significance. It was concluded that several biomarkers showed a relationship with severity and chronification of CHIK; the search for these biomarkers can reveal prognostic factors and important therapeutic targets for the treatment of the disease.

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ABSTRACT The aim of this systematic review was to determine the causal role of Erysipelatoclostridium ramosum in specific invasive infections in humans, and to assess the clinical outcome of antibiotic therapy used to treat them. Several electronic databases were systematically searched for clinical trials, observational studies or individual cases on patients of any age and gender with a systemic inflammatory response syndrome (SIRS) due to E. ramosum isolated from body fluids or tissues in which it is not normally present. Only reports identifying E. ramosum as the only microorganism isolated from a patient with SIRS were included. This systematic review included 15 studies reporting 19 individual cases in which E. ramosum caused invasive infections in various tissues, mainly in immunocompromised patients. E. ramosum was most often isolated by blood cultures and identified by specific biochemical tests. Severe infections caused by E. ramosum were in most cases effectively treated with antibiotics, except in two patients, one of whom died. More than one isolate of E. ramosum exhibited 100% susceptibility to metronidazole, amoxicillin/clavulanate and piperacillin/tazobactam. On the other hand, individual resistance of this bacterium to penicillin, ciprofloxacin, clindamycin, imipenem and ertapenem was reported. This systematic review confirmed the clinical relevance of E. ramosum as a cause of a number of severe infections mainly in immunocompromised inpatients. Metronidazole and meropenem appear to be the antibiotics of choice that should be used in combination or as monotherapy to treat E. ramosum infections, depending on the type and severity of the infection.

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ABSTRACT The human T cell lymphotropic virus type 1 (HTLV-1) is the first human retrovirus discovered. Since then, it has spread worldwide and is mainly associated with adult T cell leukemia/lymphoma (ATLL) and HTLV1-associated myelopathy (HAM). Its relationship, however, with other types of cancer is controversial. We describe the case of a patient presenting with small cells lung epidermoid carcinoma who had recently developed HAM, and a review of the literature related to these conditions. This is the first case of this type of lung cancer, the same of the first description in the literature, associated with HAM outside Japan.

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ABSTRACT Neglected tropical diseases (NTDs) are those affecting vulnerable people and causing additional social and economic burden. The aim of this study was to carry out a general overview of the health economic assessments involving the diagnosis and treatment of six NTDs: cutaneous leishmaniasis (CL), Chagas disease, cysticercosis, filariasis, schistosomiasis and visceral leishmaniasis (VL). The literature search was based on two of the main medical literature databases (Medline and SciELO) and identified 46 studies. Twenty-six studies (57%) addressed therapeutic strategies, while other 20 (43%) assessed diagnostic or both diagnostic and therapeutic approaches. The studies were published between 1994 and 2021, and 57% of them (26/46) were carried out in four countries. Cost-effectiveness analyses were conducted in 59% (27/46) of the studies. Economic studies of NTDs have timidly increased in recent years. Despite the improvement of analytical methods, completeness and accuracy of information, there are few new technologies applied to NTDs and public health systems. In addition, economic studies for NTDs are concentrated in a few countries. Thus, this review points out the need for investment in research, development and training of human resources dedicated to the economic analysis in health, especially on NTDs, as a strategy to reduce inequalities by optimizing the use of health resources.

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ABSTRACT Chagas disease (CD) is a neglected tropical highly morbid disease that can have a negative impact on the quality of life (QoL). The purpose of this study was to conduct an integrative review to analyze the QoL of patients with CD in the chronic phase of the disease, as well as the instruments used and the effect of different interventions. The review was carried out based on the criteria and recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guideline (PRISMA) using the PubMed, Scopus, Web of Science and Science Direct databases. An analysis of the reference list of the included articles was also carried out. Publications in all languages have been included. Two independent reviewers selected the eligible articles and extracted the data. A total of 1,479 articles were identified, and after applying the inclusion criteria 18 articles were included. Four different instruments were used to assess QoL and the most used was the Minnesota Living with Heart Failure Questionnaire (MLWHFQ) [33.3% (n = 6)]. Investigations involving intervention showed a positive impact on the patients’ QoL, and the Environment domain had the lowest score. Heterogeneity of instruments and lack of methodology standardization for assessing QoL was observed. QoL proved to be an important indicator for the planning and monitoring of patients with CD, however it is suggested that the instruments for its assessment should be the ones recommended by the validation studies. This process will allow the comparison of data between investigations.

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ABSTRACT The aim of this study was to establish an evidence-based guideline for the antibiotic treatment of Corynebacterium striatum infections. Several electronic databases were systematically searched for clinical trials, observational studies or individual cases on patients of any age and gender with systemic inflammatory response syndrome, harboring C. striatum isolated from body fluids or tissues in which it is not normally present. C. striatum had to be identified as the only causative agent of the invasive infection, and its isolation from blood, body fluids or tissues had to be confirmed by one of the more advanced diagnostic methods (biochemical methods, mass spectrometry and/or gene sequencing). This systematic review included 42 studies that analyzed 85 individual cases with various invasive infections caused by C. striatum. More than one isolate of C. striatum exhibited 100% susceptibility to vancomycin, linezolid, teicoplanin, piperacillin-tazobactam, amoxicillin-clavulanate and cefuroxime. On the other hand, some strains of this bacterium showed a high degree of resistance to fluoroquinolones, to the majority majority of β-lactams, aminoglycosides, macrolides, lincosamides and cotrimoxazole. Despite the antibiotic treatment, fatal outcomes were reported in almost 20% of the patients included in this study. Gene sequencing methods should be the gold standard for the identification of C. striatum, while MALDI-TOF and the Vitek system can be used as alternative methods. Vancomycin should be used as the antibiotic of choice for the treatment of C. striatum infections, in monotherapy or in combination with piperacillin-tazobactam. Alternatively, linezolid, teicoplanin or daptomycin may be used in severe infections, while amoxicillin-clavulanate may be used to treat mild infections caused by C. striatum.

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ABSTRACT Round pneumonia is an unusual radiological manifestation of a bacterial lung infection. We present the case of an elderly male patient who arrived at the emergency room with a productive cough and exertional dyspnea. His chest x-ray and CT showed a round opacity and air bronchograms in the right upper lobe. Taken together, the patient’s symptoms and images strongly suggest a pulmonary infection. Empirical antibiotic therapy with ceftriaxone and clarithromycin was started. The sputum culture was positive for Enterobacter hormaechei and the bacterium was sensitive to levofloxacin; therefore, the antibiotic therapy was changed. Despite the treatment, the patient progressed to respiratory failure and septic shock, dying six days after admission. Although round pneumonia is uncommon, it is a potentially curable disease and clinicians should always consider it in their differential diagnosis.

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ABSTRACT Osteomyelits due to concurrent multi-drug resistance organisms is difficult to treat for any surgeon and infectious disease physician. An eleven-year-old boy presenting with an open fracture of the left radius and ulna after a fall in a stagnant wet field. Despite prophylactic antibiotics and surgical intervention, the open wound was infected, and Chromobacterium violaceum as well as Klebsiella pneumoniae were isolated. He was treated with six weeks of parenteral cefepime and amikacin and was discharged upon clinical improvement. Unfortunately, chronic osteomyelitis set in with persistent sinus drainage. He then underwent a second procedure for debridement of the wound and Burkholderia pseudomallei was isolated. Parenteral antibiotic therapy was initiated progressing with a marked improvement. However, the long course of antibiotics had exhausted the patient and his family, leading to a premature interruption of the parenteral antibiotic. Despite the suboptimal antibiotic course, there were no signs of relapsed osteomyelitis during subsequent review. The timely surgical intervention with appropriate sampling for subsequent microorganism isolation guided the suitability of the treatment line.

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ABSTRACT Congenital cytomegalovirus infection causes lethal diseases with neurological, visual, auditory and systemic injuries, including the hemophagocytic syndrome. Hemophagocytic lymphohistiocytosis (HLH) can be caused by primary hereditary immunological defects, as well as several infectious triggering factors, such as viruses, bacteria and fungus, among them the cytomegalovirus (CMV). Here we present the case report of a male newborn male, delivered by cesarean at term (gestation age of 39 weeks), weighing 3,250 g, with suffusion skin lesions spread throughout the body, anemia, generalized edema, hepatosplenomegaly, thrombocytopenia associated with grunts and difficulty breathing, treated with ganciclovir after receiving the diagnosis of congenital CMV infection. After a few days of hospitalization, the patient presented with high fever, persistent hepatosplenomegaly and pancytopenia, in addition to elevated ferritin and triglycerides, receiving the diagnosis of HLH treated with immunosuppressive therapy, corticosteroids and intravenous human immunoglobulin. The present case report highlights the importance for health professionals to carry out the investigation of congenital diseases, especially in developing countries, as well as their complications, such as HLH.

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ABSTRACT We report a rare case of an infective endocarditis by Aerococcus spp in a bioprosthetic aortic valve following a prostate biopsy, in an asymptomatic adult with no additional risk factor for prostate cancer, excepting for age. The diagnosis was based on the presence of vegetations on the bioprosthesis seen on the echocardiogram, positive blood cultures and fever, and a favorable clinical outcome following the treatment with ceftriaxone and gentamicin.

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ABSTRACT Human immunodeficiency virus (HIV)-associated neurocognitive disorders are the main cause of cognitive decline and dementia in people living with HIV (PLHIV). However, extensive workup should be done in patients with rapidly progressive dementia (RPD) and HIV, especially when secondary infection in the central nervous system (CNS) is ruled out. Sporadic Creutzfeldt-Jakob disease (sCJD) is the main cause of RPD in non-HIV patients. It is a fatal neurodegenerative condition caused by prions that mainly affects elderly patients. Our objective is to describe two cases of PLHIV presenting with controlled infections and sCJD, and to review the literature. Our patients were younger than expected for sCJD and one of them had a longer disease course. As aging is expected to occur earlier in PLHIV, sCJD must be excluded in younger PLHIV presenting with RPD and without CNS infection.

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ABSTRACT Reinfection by the severe acute respiratory syndrome coronavirus type 2 (SARS-COV-2) has been reported in many countries, suggesting that the virus may continue to circulate among humans despite the possibility of local herd immunity due to massive previous infections. The emergence of variants of concern (VOC) that are more transmissible than the previous circulating ones has raised particular concerns on the vaccines effectiveness and reinfection rates. The P.1 lineage was first identified in December 2020 in Manaus city and is now globally spread. We report the first case of reinfection of SARS-CoV-2 caused by the P.1 variant outside of Manaus. The potential of these new variants to escape naturally and vaccine- induced immunity highlights the need for a global vigilance.

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ABSTRACT This study aims to report the diagnostic course and treatment of a fast-growing mycobacteria infection after cesarean delivery. We report the case of a 37-year-old woman admitted to the Infectious Diseases’ Clinic of the Hospital das Clinicas da Universidade Federal de Pernambuco, Pernambuco State, Brazil, four months after a cesarean section, presenting with healing difficulties and located pain outside the surgical site. The first diagnosis was a probable rejection of the sutures that were not absorbed, but based on the clinical signs, reported history, complementary laboratory tests and no response to treatment with the conventional antibiotic therapy (cephalosporins/quinolones) prescribed, the ultimate diagnosis was a mycobacteriosis caused by Micobacterium fortuitum. Since fast-growing mycobacteria do not easily penetrate host tissues, they is mainly related to post-trauma or post-surgical procedures. It is extremely important to call attention to these occurrences in the gynecological-obsthetric field. Treatment for mycobacteriosis is often complicated because of the side effects of antibiotics, especially the ototoxicity of amikacin.

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ABSTRACT Acute generalised exanthematous pustulosis (AGEP) is an unusual cutaneous reaction, most often related with a hypersensitivity reaction to commonly used drugs. It is characterized by an abrupt onset of a pustular rash within hours or days after drug exposure and usually resolves spontaneously within 1-2 weeks after drug discontinuation. Some cases associated with systemic involvement and shock have been reported. We present the case of a severe AGEP, manifesting in association with systemic involvement and haemodynamic instability resulting in shock and multiorgan dysfunction in an adult female patient diagnosed with COVID-19 infection. There were no identifiable associated drugs, and the patient was not initiated on antimalarial drugs. Our patient improved rapidly, both hemodynamically and dermatologically with no directed therapy.

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ABSTRACT Taenia solium is the most common parasitic infection of the central nervous system and it can cause parenchymal or extra-parenchymal lesions. Subarachnoid cysticercosis is a type of extra-parenchymal infection in which the prevalence is not known and racemose NC with cerebellar involvement has been rarely reported. The diagnosis is challenging because of its similarity to other infectious diseases or to subarachnoid involvement of systemic malignancies. Treatment usually requires cysticide drugs, however, there are no randomized studies concerning the anti-parasitic treatment in subarachnoid NC. We present a case of racemose NC in the cerebellar hemisphere to draw attention to this pathology, endemic in many parts of the world; and highlight all the current gaps in our understanding of this entity.

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ABSTRACT This study describes difficulties in the monitoring of a child born during an oral outbreak of Chagas disease, in which there are several indications that the transmission occurred through the congenital route: 1. the mother was in the third trimester of pregnancy when she was infected; 2. She presented high parasitemia at the time of delivery; 3. In both, the mother and her daughter, T. cruzi was classified as DTU TcIV. The parasites were not found in the blood at birth and the infection was detected only three months later in an asymptomatic infant. As the mother and her child live in a highly endemic area, vector transmission could not be excluded during this period.

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ABSTRACT From February 26, 2020 to March 11, 2021, coronavirus disease 2019 (COVID-19) pandemic resulted in 11,439,558 cases and 277,102 deaths in Brazil. Among them, 2,195,130 cases and 63,965 deaths occurred in Sao Paulo State, Southeast Brazil. The recent emergence and rise of new variants of SARS-CoV-2 is of concern because of their higher transmissibility and possible association with more severe disease. Cases of SARS-CoV-2 reinfections have been described since December 2020 in Brazil. This report describes two cases of COVID-19 reinfection, that occurred five and six months after the first infection, during the second wave of the pandemic in Sao Paulo State. Both patients presented mild symptoms in the two COVID-19 episodes and different lineages of SARS-CoV-2 were identified: B.1.1.33 and B.1.1.28 lineages in case 1 and B1.1.128 and P. 2 lineages in case 2.

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ABSTRACT Hiccups are involuntary, spasmodic contractions of the diaphragm and intercostal muscles and can be classified as acute (< 48 h), persistent (48 h to a month) or intractable (> 1 month). A previously healthy 29-year-old man sought the Emergency Department with flu-like symptoms and a two-day history of persistent hiccups. His physical examination was otherwise unremarkable and vital signs were within normal limits. An unenhanced computed tomography scan of the chest showed small focal ground-glass opacities scattered throughout 25% of the lungs. A COVID-19 test was positive. Chlorpromazine was prescribed for the hiccups with improvement over 10 h. The patient was discharged home on the same day without hiccups and no other complications.

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ABSTRACT Syphilis is a chronic bacterial sexually transmitted infectious disease caused by Treponema pallidum. Different age groups are affected by heterogeneous clinical forms of the disease. We report a case of atypical secondary syphilis in an elderly patient with diffuse annular erythematous lesions on the chest, back, upper and lower limbs diagnosed by histopathological, immunohistochemical and serological tests.

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ABSTRACT Salmonella is Gram-negative bacilli that cause a foodborne infections. When the disease occurs in patients living with HIV (PLWHA), salmonellosis is an AIDS defining illness. Here we describe the case of a 26-year-old HIV-infected female patient who was hospitalized for pain in the right upper quadrant of the abdomen, and whose explorations revealed a liver abscess due to salmonella enterica enterica that progressed well after needle aspiration and antibiotic treatment.

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ABSTRACT Acute pancreatitis (AP) is an inflammatory disease associated with abdominal pain and elevated serum pancreatic enzymes. The most common etiologies are gallstones and alcoholism. Drug-induced AP is quite rare, lacks a solid understanding and has been occasionally reported. The diagnosis requires a great suspicion and a careful exclusion of other causes. We present a case of a 37-year-old man, previously diagnosed with leprosy that developed acute pancreatitis after starting the multibacillary polychemotherapy (PCT/MB). After a month of treatment and the discontinuation of the PCT/MB, the therapy was restarted and a new episode of AP occurred. Three months after this last episode, the PCT/MB was reintroduced, changing one of the medications and the patient had no recurrence of AP or other reactions. Therefore, it is important to take into account that there is a risk of acute pancreatitis in patients on multidrug therapy (MDT) for leprosy.

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ABSTRACT Cytomegalovirus (CMV) is a member of the Herpesviridae family, including viruses that are well-known agents of keratitis, anterior uveitis, scleritis and retinitis. CMV is usually associated with ocular diseases in immunosuppressed individuals, with a notable exception of hypertensive anterior uveitis with distinctive clinical features in immunocompetent patients. This syndrome was characterized in the last two decades in Europe and Southeast Asia, and then documented in the rest of world. Definitive diagnosis in these cases is usually made by Polymerase Chain Reaction (PCR) of the anterior chamber fluid. We report three immunocompetent Brazilian adults with history of multiple glaucomatocyclitic crises and presenting with chronic hypertensive anterior uveitis invariably with mild anterior chamber inflammation and characteristic scarce nummular keratic precipitates. CMV DNA was successfully amplified and detected in the aqueous humor of all patients. Corneal endothelial counts were significantly reduced in the involved eyes, with one patient developing bullous keratopathy. All patients were then treated with topical ganciclovir gel and corticosteroids, with subsequent control of the intraocular inflammation. CMV may represent an overlooked / underestimated etiology of hypertensive anterior uveitis that may progressively lead to endothelial dysfunction, culminating in bullous keratopathy. Management of patients is challenging, with the potential use of topical antivirals to decrease the number of relapses, and corticosteroids to control anterior uveitis / endotheliitis and to protect the corneal endothelium.

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ABSTRACT Extensive drug-resistant tuberculosis (XDR-TB) is highly life threatening and its diagnosis is usually difficult and time-consuming. Here we present the first two cases of XDR and pre-XDR-TB diagnosed in 2018 on the Thailand-Myanmar border, more specifically in Tak province. Rapid detection of XDR-TB was performed by loop-mediated isothermal amplification (LAMP), Xpert MTB/RIF, and line probe assays. Mutation analyses targeting rpoB, katG, inhA, gyrA and rrs genes showed an association with drug-resistant phenotypes, except for rifampicin resistance. Spoligotyping revealed uncommon Beijing and T2 genotypes and the analysis of M. tuberculosis interspersed repetitive unit-variable number tandem repeat (MIRU-VNTR) showed the presence of more polymorphisms. This report highlights the importance of the early detection of drug-resistant tuberculosis by molecular tests followed by phenotyping assays. Based on the up-to-date definition of XDR- and pre-XDR-TB, the susceptibility testing for bedaquiline and linezolid is required and the two reported cases may correspond to putative XDR-TB.

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ABSTRACT This cross-sectional seroepidemiological survey presents the seroprevalence of SARS-CoV-2 in a population living in 15 Long-Term Care Facilities (LTCFs), after two intra-institutional outbreaks of COVID-19 in the city of Botucatu, Sao Paulo State, Brazil. Residents were invited to participate in the serological survey performed in June and July 2020. Sociodemographic and clinical characterization of the participants as well as the LTCF profile were recorded. Blood samples were collected, processed and serum samples were tested using the rapid One Step COVID-19 immunochromatography test to detect IgM and IgG anti-SARS-CoV-2. Among 209 residents, the median of age was 81 years old, 135 (64.6%) were female and 171 (81.8%) self-referred as being white. An overall seroprevalence of 11.5% (95% CI: 7.5% – 16.6%) was found. The highest seroprevalences of 100% and 76.9% were observed in LTCFs that had experienced COVID-19 outbreaks. Most residents with positive immunochromatography tests (70.8%) referred previous contact with a confirmed COVID-19 case. Although there was a relatively low seroprevalence of COVID-19 in the total number of elderly people, this population is highly vulnerable and LTCFs are environments at higher risk for COVID-19 dissemination. A well-established test for COVID-19 policies, the adequate characterization of the level of interaction between residents and the healthcare provider team and the level of complexity of care are crucial to monitor and control the transmission of SARS-CoV-2 in these institutions.

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ABSTRACT This observational retrospective study conducted during an yellow fever (YF) outbreak in Sao Paulo, Brazil, in 2017-2018, describes adverse events (AE) following YF vaccination of immunocompromised persons. Risks and benefits of vaccination were individually evaluated by physicians. AE were assessed by phone call or electronic mail, 14 to 90 days after vaccination. Three hundred and eighty one immunocompromised persons received a full-dose of YF vaccine. Their age ranged from 1.4 to 89.3 years (median 50.8 years); 53% were women; 178 (46.7%) had chronic kidney disease, 78 (20.5%) had immune-mediated inflammatory diseases; 94 (24.7%) were using or had recently used immunosuppressive/ immunomodulatory drugs. All of them denied previous YF vaccination. We were able to contact 341 (89.5%) vaccinees: 233 (68.3%) of them received the YF vaccine from BioManguinhos and 108 (31.7%) received the vaccine from Sanofi-Pasteur; 130 (38.1%) vaccinees received other vaccines (up to 4) simultaneously with the the YF vaccine, mostly hepatitis B (59 vaccinees), pneumococcal polysaccharide 23-valent (46), influenza (43) and diphtheria-tetanus (dT, 41). One hundred and eleven vaccinees (32.6%) reported at least one AE: 79 (23.2%) presented systemic AE, 44 (12.9%) had local AE and 12 had both, local and systemic AE. The most common AE was pain at the injection site (41 persons, 12%), myalgia (34; 10%), fever (25; 7.3%) and headache (16; 4.7%). There was no statistically significant difference on the AE frequency according to the vaccine producer. There were four severe AE: one hospitalization and three deaths, considered not related to the YF vaccine.

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ABSTRACT The plasmid-mediated colistin-resistance gene named mcr-1 has been recently described in different countries and it became a public health challenge. Of note, few studies have addressed the spread of Escherichia coli harboring the mcr-1 gene in both, community and hospital settings. A total of seven colistin-resistant E. coli carrying mcr-1, collected from 2016 to 2018, from community (n=4), healthcare-acquired infections (n=2) and colonization (n=1) were identified in three high complexity hospitals in Sao Paulo, Brazil. These colistin-resistant isolates were screened for mcr genes by PCR and all strains were submitted to Whole Genome Sequencing and the conjugation experiment. The seven strains belonged to seven distinct sequence types (ST744, ST131, ST69, ST48, ST354, ST57, ST10), and they differ regarding the resistance profiles. Transference of mcr-1 by conjugation to E. coli strain C600 was possible in five of the seven isolates. The mcr-1 gene was found in plasmid types IncX4 or IncI2. Three of the isolates have ESBL-encoding genes (blaCTX-M-2, n=2; blaCTX-M-8, n=1). We hereby report genetically distinct E. coli isolates, belonging to seven STs, harboring the mcr-1 gene, associated to community and healthcare-acquired infections, and colonization in patients from three hospitals in Sao Paulo. These findings point out for the potential spread of plasmid-mediated colistin-resistance mechanism in E. coli strains in Brazil.

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ABSTRACT In order to provide additional data on the prevalence and genetic diversity of Dientamoeba fragilis in human populations, we conducted a study in children from low-income communities in Sao Paulo State, Brazil. Fecal samples from daycare center attendees up to 6 years old (n=156) and staff members (n=18) were submitted to PCR and sequencing of D. fragilis as well as to microscopic examination for the presence of other intestinal parasites. All children assessed were asymptomatic and 10.3% (16/156) were positive for D. fragilis. No worker was found to be positive. An association between Dientamoeba and coinfection with other intestinal parasites was observed. Concerning the genetic diversity, 14 and only two isolates were genotype 1 and genotype 2, respectively. Our findings outline interesting aspects: (1) asymptomatic children as carriers of Dientamoeba in communities in which environmental conditions ensure parasite transmission and, (2) association between Dientamoeba infection in young children and coinfection with other enteric parasites, reinforcing its transmission via the fecal–oral route.

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ABSTRACT We examined whether the COVID-19 pandemic has affected the incidence of tuberculosis (TB) and influenza in Serbia, a Southeast European country with a low TB incidence rate and a mandatory BCG vaccination at birth. The first case of COVID-19 was registered on March 6, 2020. Despite the need for a sudden adaptation of the health care system, routines of mycobacterial laboratories have never stopped. In 2020, the number of newly diagnosed TB patients was significantly lower than expected (p = 0.04), but the number of patients with influenza increased when compared to 2019. Although many patients with influenza A H1N1 were observed before the beginning of the COVID-19 pandemic, the increment of cases could also be a consequence of cases of influenza with COVID-like symptoms detected thereafter. It may also be attributed to misclassification of clinical cases that were negative for SARS-CoV-2 and reported as influenza. Difficulties to seek medical attention because of the COVID-19 pandemic and possible underreporting are considered as reasons for the decline in the incidence rate of TB. On the other hand, individual and social measures to prevent the spread of SARS-CoV-2 such as wearing face masks, social distancing, lockdown, which were strictly applied to COVID-19 patients, health care staffs and most of the population, could have hindered TB infections more than the two viral diseases, which appear to be more contagious. The increased motivation of the population to protect their health during the COVID-19 pandemic provided an opportunity for their effective education. This is crucial in further combating TB as a preventable disease.

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ABSTRACT Latent tuberculosis infection (LTBI) is a condition that has no clinical signs and symptoms. LTBI patients are characterized by persistent immune responses to Mycobacterium tuberculosis, and approximately 5-10% of these infected individuals will develop active TB at some point in their lives. The antigen transporter associated with antigen processing (TAP1) is a protein involved in the transport of the antigen from the cytoplasm to the endoplasmic reticulum by means of the association with MHC class I molecules. It plays a fundamental role in the immune response, promoting the clearance of intracellular pathogens. Our pilot study aimed to determine the association between TAP1 gene 1177A>G (rs1057141) and 2090A>G (rs1135216) genetic polymorphisms with susceptibility to LTBI. In this case-control study, 153 individuals from shelters were analyzed (46 were LTBI-positive and 92 were controls). Genotyping of the rs11352216 (2090A>G) and rs1057141 (1177A>G) gene IDs was performed using the Applied Biosystems Step One Thermal Cycler Real-Time PCR allelic discrimination technology. The haplotypic analyses were performed with the Arlequin 3.5 program. Social assistance centers and shelters that serve vulnerable populations represent high-risk sites due to overcrowding and the impaired nutritional status of their residents. The G allele (OR=1.99, CI=1.109-3.587, p=0.021) and the GG genotype of rs11352216 (A>G) were associated with susceptibility to LTBI, according to the codominant genetic model (OR=8.32, CI=1.722-61.98, p=0.007). The rs1057141 (A>G) polymorphism was not associated with LTBI risk. The results suggest that carriers of the G allele of rs1135216 (A>G) are susceptible to LTBI.

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ABSTRACT Health education and training of primary health care (PHC) professionals are highly recommended to reduce the occurrence and lethality of visceral leishmaniasis (VL). This study assessed the impact of an educational intervention on the basic knowledge about visceral leishmaniasis (VL) among PHC professionals from the Brazilian municipality of Rondonopolis, an important endemic area for VL. Responses provided by physicians, nurses, nursing technicians and community health agents from 12 PHC facilities were recorded through the application of self-completed and semi-structured questionnaires before (n=92) and after (n=64) an in-person health training course covering various aspects of VL. Closed- and open-ended responses were compared by the chi-square test and analyses of word clouds, respectively. The proportion of professionals aware of the correct etiological agent (p<0.001) and transmission route (p<0.001) of VL increased post-intervention. In addition, they increased their ability to recognize fever (p<0.001), weakness (p<0.001), weight loss (p<0.001), pallor (p<0.001) and abdominal distention (p=0.013) as clinical manifestations of human VL, and weakness (p<0.001), alopecia (p<0.001) and weight loss (p=0.019) as signs of canine VL. Analyses of word clouds suggested that the participants became more aware of the role of dogs in VL transmission and the role of environmental management in the prevention of VL. In conclusion, the intervention positively impacted the baseline knowledge concerning VL among the professionals. This can support the planning of educational activities for the PHC team regarding early case detection, prevention and control of VL in endemic areas.

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ABSTRACT Multiple variants of the Severe Acute Respiratory Syndrome coronavirus 2 virus (SARS-CoV-2) have been constantly reported across the world. The B.1.1.28 lineage has been evolving in Brazil since February 2020 and originated the P.1 variant of concern (VOC), recently named as the Gamma variant by the newly WHO nomenclature proposal, and P.2 as a variant of interest (VOI). Here we describe an early case of P.1 primary infection in Southern Brazil in late November 2020, soon after the emergence of the variant in Manaus, Northern Brazil. The same male patient was reinfected by another B.1.1.28 variant, namely P.2, in March, 2021. The genomic analysis confirmed genetically significant differences between the two viruses recovered in both infections, the P.1 lineage in the first episode and P.2 in the reinfection. Due the very early detection of P.1, we have also investigated the circulation of P.1 in the same region by differential RT-qPCR, showing that this was an isolated case of P.1 at the time of detection, and this variant has disseminated and became prominent from late January to the end of March, 2021. SARS-CoV-2 recent reports of reinfection have raised critical questions on whether and how well a first infection protects against reinfection.

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ABSTRACT Mobile phones (MPs) have become an important work tool around the world including in hospitals. We evaluated whether SARS-CoV-2 can remain on the surface of MPs of first-line healthcare workers (HCW) and also the knowledge of HCWs about SARS-CoV-2 cross-transmission and conceptions on the virus survival on the MPs of HCWs. A cross-sectional study was conducted in the COVID-19 Intensive Care Unit of a teaching hospital. An educational campaign was carried out on cross-transmission of SARS-CoV-2, and its permanence in fomites, in addition to the proper use and disinfection of MPs. Herewith an electronic questionnaire was applied including queried conceptions about hand hygiene and care with MP before and after the pandemic. The MPs were swabbed with a nylon FLOQ Swab™, in an attempt to increase the recovery of SARS-CoV-2. All MP swab samples were subjected to SARS-CoV-2 RT-PCR; RT-PCR positive samples were subjected to viral culture in Vero cells (ATCC® CCL-81™). Fifty-one MPs were swabbed and a questionnaire on hand hygiene and the use and disinfection of MP was applied after an educational campaign. Most HCWs increased adherence to hand hygiene and MP disinfection during the pandemic. Fifty-one MP swabs were collected and two were positive by RT-PCR (4%), with Cycle threshold (Ct ) values of 34-36, however, the cultures of these samples were negative. Although most HCWs believed in the importance of cross-transmission and increased adherence to hand hygiene and disinfection of MP during the pandemic, SARS-CoV-2 RNA was detected in MPs. Our results suggest the need for a universal policy in infection control guidelines on how to care for electronic devices in hospital settings.

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ABSTRACT Twenty-seven children aged seven months to 5 years were inadvertently vaccinated with a COVID-19 vaccine, the CoronaVac (Sinovac, China), an inactivated SARS-CoV-2 vaccine, in two different cities of Sao Paulo State, Brazil. After the event, these children were monitored by local pediatricians and serum samples were collected at the first visit and 30 days after vaccination and tested for SARS-CoV-2 S1 serology with Ortho total IgG anti-S1 protein and Cpass, an ACE2 receptor binding domain inhibition assay. Only one child had a mild symptom after vaccination, with no other adverse events documented up to the 30 days follow-up. Of 27 children tested 3-9 days after vaccination, 5 (19%) had positive serology suggesting a previous natural SARS-CoV-2 infection, with all 19 tested on day 30 after vaccination and presenting with positive tests, with an increment of antibody titers in those initially positive. A low Cpass binding inhibition was observed in the first collection in 11 seronegative cases, with high titers among those anti-S1 positive. All children showed an important increase in antibody titers on day 30. The event allowed the documentation of a robust serological response to one dose of CoronaVac in this small population of young children, with no major adverse effects. Although it was an unfortunate accident, this event may contribute with future vaccine strategies in this age group. The data suggest that CoronaVac is safe and immunogenic for children.