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Abstract Tuberculosis, in particular drug-resistant tuberculosis, is of global concern due to the high mortality and morbidity associated with it annually. The aim of this study was to determine the prevalence of and the risk factors for multidrug-resistant tuberculosis in Iran and its neighboring countries. Four databases (PubMed, BioMed Central, EMBASE, and Web of Science) were searched using key terms. Nineteen eligible articles were identified, of which 12 and seven were used for quantitative and qualitative analysis, respectively. The overall pooled estimate of the prevalence of multidrug-resistant tuberculosis, including both new and previously treated tuberculosis cases, in Iran, Iraq, Turkey and Pakistan was 16% (95% confidence interval [CI] 11-20). The patients with a previous tuberculosis treatment history (odds ratio [OR] = 6.45; 95% CI 5.12-7.79), those aged <45 years (OR = 1.57; 95% CI 1.12-2.03), and those who were males (OR = 1.83; 95% CI 1.19-2.48) had an increased pool risk of developing multidrug-resistant tuberculosis. The forest plot revealed that the pooled odds for the development of multidrug- resistant tuberculosis were 2.01 (95% CI 1.65-2.36). Poor adherence to treatment was one of the predictors of unsuccessful treatment outcomes. Multidrug-resistant tuberculosis is a great concern for public health programs in many countries globally, including those included in this review. The risk factors for the development of multidrug-resistant tuberculosis, specifically a previous tuberculosis treatment history, should be targeted through the implementation of specialized interventions.

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Abstract After more than one century since its discovery, Chagas disease is still extremely prevalent in 21 Latin American countries. Chagas disease is one of the most concerning public health problems in Latin America; the overall cost of CD treatment is approximately 7 billion United States dollars per year and it has a strong social impact on populations. Little progress has been made regarding the access to diagnosis and treatment at the primary health care level, calling into question the current policies to ensure the right to health and access to essential medications. In this article, diverse dimensions of access to treatment for Chagas disease are reviewed, illustrating the present state of benznidazole medication in relation to global production capacity, costs, and needs. The findings are based on an investigation requested by Médecins Sans Frontières Brazil through a consultancy in 2015, aiming to estimate the current costs of benznidazole production.

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Abstract INTRODUCTION: Transforming growth factor-beta 1 (TGFβ1) is a potent suppressive cytokine that contributes to chronic hepatitis B (CHB) infection. Disparities in TGFβ1 production among individuals have been attributed to TGFβ1 genetic polymorphisms. We examined whether three putative polymorphisms in TGFβ1[-509 C/T (rs1800469), +869 C/T (rs1800470), and +11929 C/T (rs1800472)]are associated with CHB infection in a South-Eastern Iranian population. METHODS: In total, 341 subjects were recruited, including 178 patients with CHB and 163 healthy individuals as controls. Genotyping of the three TGFβ1 SNPs was performed by tetra amplification refractory mutation system-PCR. RESULTS: TheTGFβ1 +869 TT vs.CC genotype in codominant (OR=0.445, p=0.012) and TT vs. TC+CC in the recessive (OR=0.439, p=0.003) model as well as the variant allele T vs. C(OR=0.714, p=0.038) were associated with lower CHB infection risk. However, the +11929 C/T polymorphism was associated with increased CHB risk, and the CT vs. CC genotype (OR=2.77, P=0.001) and T variant allele (OR=2.53, P=0.002) were risk factors for CHB. Furthermore, TTT (+869/-509/+11929) and CCC haplotypes were risk and protective factors for CHB, respectively. We found no significant association between viral DNA load and TGFβ1 genotype or hepatic enzyme levels (p >0.05). CONCLUSIONS: Results indicated that the TGFβ1+869TT genotype and T allele were protective factors, whereas the +11929 CT genotype and T allele were risk factors for CHB infection.

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Abstract INTRODUCTION: Meteorological influences along with the lack of basic sanitation has contributed to disease outbreaks, resulting in large socio-economic losses, especially in terms of dengue. This study aimed to evaluate the meteorological influences on the monthly incidence of dengue in Arapiraca-AL, Brazil during 2008-2015. METHODS: We used generalized linear models constructed via logistic regression to assess the association between the monthly incidence of dengue (MID) of and 8 meteorological variables [rainfall (R), air temperature (AT), dew point temperature (DPT), relative humidity (RH), pressure surface, wind speed (WS), wind direction (WD), and gust], based on data obtained from DATASUS and meteorological station databases, respectively. The dengue-1 model included R, AT, DPT, and RH and the dengue-2 model included AT, DPT, RH, WS, and WD. A MID >100 (classified as moderate incidence) indicated an abnormal month. RESULTS: Based on the dengue-1 model, variables with the highest odds ratio included R-lag1, DPT-lag1, and AT-lag1 with a 10.1, 18.3, and 26.7 times greater probability of a moderate MID, respectively. Based on the dengue-2 model, variables with the highest odds ratio were AT-lag1 and RH-lag0 indicating an 8.9 and 18.1 times greater probability of a moderate MID, respectively. CONCLUSIONS: AT, DPT, R, RH and WS influenced the occurrence of a moderate MID.

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Abstract INTRODUCTION: Pseudomonas aeruginosa is one of the most common nosocomial pathogens. The emergence of extended spectrum β-lactamases (ESBLs) has been increasingly reported as a major clinical concern worldwide. The main aim of the present study was to determine the distribution of bla OXA, bla PER-1, bla VEB-1, and bla GES-1 genes among ESBL-producing P. aeruginosa isolated from two distinct provinces in Iran. METHODS: In this study, a total of 75 (27.5%) ESBL-producing isolates were identified from 273 P. aeruginosa isolates collected from patients in Qazvin and Tehran. Phenotypic detection of ESBLs and antimicrobial susceptibility testing were performed according to the Clinical and Laboratory Standards Institute guidelines. PCR and sequencing were employed to detect bla OXA-1, bla OXA, bla GES-1, bla PER-1, and bla VEB-1 genes. Isolate genetic relationships were evaluated by repetitive extragenic palindromic sequence-based PCR (REP-PCR). RESULTS: In total, 59 (78.7%) of the ESBL-producing isolates showed multidrug resistance. The highest rates of susceptibility were observed against colistin (75 isolates, 100%) and polymyxin B (75, 100%) followed by amikacin (44, 58.7%), and piperacillin-tazobactam (40, 53.3%). The bla OXA-1 (37.3%) gene was the most common of the genes investigated, followed by bla OXA-4 (32%), bla GES-1 (16%), and bla VEB-1 (13.3%). REP-PCR identified three different genotypes: types A (89.3%), B (6.7%), and C (4%). CONCLUSIONS: We found a significant presence of bla OXA-1, bla OXA-4, bla GES-1, and bla VEB-1 genes among P. aeruginosa isolates, highlighting the need for suitable infection control strategies to effectively treat patients and prevent the further distribution of these resistant organisms.

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Abstract INTRODUCTION: Infections caused by β-lactamase-producing gram-negative bacteria, such as Klebsiella pneumoniae, are increasing globally with high morbidity and mortality. The aim of the current study was to determine antimicrobial susceptibility patterns and the prevalence of antibiotic resistance genes (β-lactamase and integron genes) using multiplex PCR. METHODS One-hundred K. pneumoniae isolates were collected from different clinical samples. Antibiotic susceptibility testing was performed with thirteen different antibiotics. Multiplex-PCR was used to detect β-lactamase (bla TEM, bla CTX-M, bla SHV, bla VEB, bla PER, bla GES, bla VIM, bla IMP, bla OXA, and bla KPC) and integron genes (int I, int II, and int III). RESULTS: The highest and lowest rate of resistance was exhibited against amikacin (93%) and imipenem (8%), respectively. The frequency of β-lactamase-positive K. pneumoniae was 37%, and the prevalence of the bla TEM, bla CTX-M, bla SHV, bla VEB, bla PER, bla GES, bla VIM, bla IMP, bla OXA, and bla KPC genes was 38%, 24%, 19%, 12%, 6%, 11%, 33%, 0%, 28%, and 23%, respectively. Of the 100 isolates, eight (8%) were positive for class I integrons; however, class II and III integrons were not detected in any of the strains. CONCLUSIONS: These results indicate co-carriage of a number of β-lactamase genes and antibiotic resistance integrons on the same plasmids harboring multi-drug resistance genes. It seems that these properties help to decrease treatment complications due to resistant bacterial infections by rapid detection, infection-control programs and prevention of transmission of drug resistance.

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Abstract INTRODUCTION: Methicillin resistant Staphylococcus hominis (MRSHo) has been recognized as an important human pathogen, particularly in immunocompromised patients. METHODS: A total of 19 S. hominis isolates were collected from children at the Children’s Medical Centre, Tehran, Iran, from March 2012 to February 2013. MRSHo susceptibility against 13 antimicrobial and 3 antiseptic agents was determined using disk diffusion (DAD) and minimum inhibitory concentration (MIC), respectively. All isolates were subjected to polymerase chain reaction (PCR) assay for 15 distinct resistance genes, staphylococcal cassette chromosome mec (SCCmec), and arginine catabolic mobile elements (ACMEs). Biofilm production of the isolates was determined using a colorimetric microtiter plate assay. RESULTS: Of the 19 isolates, 16 were resistant to oxacillin and harbored mecA. High resistance was also observed against trimethoprim/sulfamethoxazole (81.2%). All MRSHo isolates were susceptible to the three disinfectants tested (Septicidine-PC, Septi turbo, and Sayacept-HP). In total, 15 (78.9%) isolates produced biofilms. Three isolates had SCCmec types (V and VIII), 13 were untypable (UT), and 5 had ACME type II. CONCLUSIONS: The results indicate that MRSHo with high antibiotic resistance and unknown SCCmec might become a serious problem in the future for the treatment of patients such as children.

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Abstract INTRODUCTION Benznidazole (BNZ) is a drug available for the etiological treatment of Chagas disease. However, this drug is toxic and has a limited effectiveness on the chronic phase of this disease, often leading to poor treatment adherence. METHODS: This is a descriptive and exploratory study conducted at the Pharmaceutical Care Service for Chagas disease patients of the Federal University of Ceará. Drug-related problems (DRPs) and pharmaceutical interventions (PIs) were classified according to the Second Consensus of Granada. RESULTS: The average age of patients with Chagas disease was 62 years, with the majority residing in the Ceará countryside (86.7%), and having low education levels (63.3% with elementary school education). Regarding family income, most patients belonged to a household that earned ≤1-2 times the minimum wage per month. Approximately 73% of these patients complied with the BNZ treatment, and nearly 7% underwent therapy interruption after medical evaluation. A total of 189 DRPs were identified, of which 51.9% (n=98) were classified as potential, and 48.1% (n=91) as actual. The most frequent DRPs were related to safety (qualitative safety; n=70; 37%), necessity (non-adherence; n=52; 27.5%), and effectiveness (qualitative effectiveness/non-optimal drug selection; n=45; 23.8%). Among the 216 PIs conducted, the majority were related to patient education (n=168; 77.8%) and pharmacological strategy (n=42; 19.4%). CONCLUSIONS: This study indicates the need for pharmacotherapeutic monitoring in patients with Chagas because of the high number of therapeutic interventions, DRPs (approximately 3 DRPs/patient), BNZ adherence, and polypharmacy.

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Abstract INTRODUCTION: Enriched environments normally increase behavioral repertoires and diminish the expression of abnormal behaviors and stress-related physiological problems in animals. Although it has been shown that experimental animals infected with microorganisms can modify their behaviors and physiology, few studies have evaluated how environmental enrichment affects these parameters. This study aimed to evaluate the effects of environmental enrichment on the behavior and physiology of confined mice infected with Trypanosoma cruzi. METHODS: The behaviors of 20 T. cruzi-infected mice and 20 non-infected mice were recorded during three treatments: baseline, enrichment, and post-enrichment. Behavioral data were collected using scan sampling with instantaneous recording of behavior every 30s, totaling 360h. Plasma TNF, CCL2, and IL-10 levels and parasitemia were also evaluated in infected enriched/non-enriched mice. Behavioral data were evaluated by Friedman’s test and physiological data by one-way ANOVA and area under the curve (AUC) analysis. RESULTS: Results showed that environmental enrichment significantly increased exploratory behaviors and diminished inactivity. The use of environmental enrichment did not diminish circulating levels of TNF and IL-10 but diminished circulating levels of CCL2 and parasitemia. CONCLUSIONS: Positive behavioral and physiological effects of environmental enrichment were observed in mice living in enriched cages. Thus, environmental enrichment improved the welfare of these animals.

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Abstract INTRODUCTION: Molecular techniques have been shown to be alternative methods for the accurate detection of infectious and parasitic diseases, such as the leishmaniases. The present study describes the optimization and evaluation of a duplex real-time quantitative PCR (qPCR) protocol developed for the simultaneous detection of Leishmania infantum DNA and sample quality control. METHODS: After preliminary tests with the newly designed TaqMan® probes for the two targets ( L. infantum and glyceraldehyde 3-phosphate dehydrogenase (G3PD) gene), the duplex qPCR protocol was optimized. For the evaluation of the standardized protocol, human blood samples were tested (n=68) and the results were compared to those obtained by reference diagnostic techniques. Statistical analyses included percentage agreement and the Kappa ( k ) coefficient. RESULTS: The detection limit of L. infantum DNA reached 2x10 2 fg (corresponding to ~1 parasite) per µL of blood (ε: 93.9%). The percentage agreement obtained between the duplex VL qPCR and the reference techniques was individually obtained as follows: molecular: 88.3% ( k =0.666; 95% CI 0.437-0.894, good), and serological: 81.7% ( k =0.411; 95% CI 0.125-0.697, moderate). Between the reference techniques, the percentage agreement was 86.7% ( k =0.586; 95% CI 0.332-0.840, moderate). CONCLUSIONS: The new duplex VL qPCR protocol indicated good potential for the accurate, fast, and reliable detection of L. infantum DNA, when applied as a complement to the classical diagnostic tools already available, especially in health or research reference centers.

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Abstract INTRODUCTION: The Kato-Katz technique is the standard diagnostic test for Schistosoma mansoni infection in rural areas. However, the utility of this method is severely limited by the day-to-day variability in host egg excretion in the stool. In high-transmission areas, the point-of-care circulating cathodic antigen (POC-CCA) urine assay has proven to be a reliable test. However, investigations of the reliability of the POC-CCA assay in low-transmission regions are under way. This study aimed to evaluate the sensitivity and specificity of the POC-CCA assay and the morbidity of schistosomiasis in a low-endemic area in Brazil. METHODS: Pains City is a low-transmission zone for schistosomiasis. A total of 300 subjects aged 7-76 years were randomly selected for the POC-CCA cassette test. For S. mansoni diagnosis, three stool samples on six slides were compared with one urine sample for each subject. The sensitivity and specificity in the absence of a gold standard were calculated using latent class analysis. Clinical examinations and abdominal ultrasounds were performed in 181 volunteers to evaluate morbidity associated with schistosomiasis. RESULTS: The sensitivity and specificity of the Kato-Katz technique were 25.6% and 94.6%, respectively. By contrast, the sensitivity and specificity of the POC-CCA assay were 68.1% and 72.8%, respectively. Hepatosplenic schistosomiasis was diagnosed in two patients (1.1%). CONCLUSIONS: Overall, the POC-CCA urine assay proved to be a useful test for diagnosing S. mansoni in a low-endemic area in Brazil. Severe clinical forms of schistosomiasis can be present even in such low-endemic areas.

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Abstract INTRODUCTION: The coral snake Micrurus surinamensis, which is widely distributed throughout Amazonia, has a neurotoxic venom. It is important to characterize the biological and molecular properties of this venom in order to develop effective antitoxins. METHODS: Toxins from the venom of M. surinamensis were analyzed by two-dimensional polyacrylamide gel electrophoresis and their neurotoxic effects in vivo were evaluated. RESULTS AND CONCLUSIONS: Most proteins in the venom had masses < 14kDa, low phospholipase A2 activity, and no proteolytic activity. The toxins inhibited the coagulation cascade. The venom had neurotoxic effects in mice, with a median lethal dose upon intravenous administration of 700 µg/kg. Immunogenic studies revealed abundant cross-reactivity of antielapidic serum with 14kDa toxins and limited cross-reactivity with toxins < 10kDa. These results indicate that antielapidic serum against M. surinamensis venom has weak potency (0.35mg/ml) in mice.

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Abstract INTRODUCTION Freshwater stingray envenomations are an important cause of morbidity in riverine populations living in various regions of Brazil. The sequelae include temporary or permanent disability. This study aimed to identify sociodemographic, clinical, and therapeutic aspects related to stingray injuries in such populations. METHODS This cross-sectional study was conducted in the Extractive Reserve of Tapajos-Arapiuns, located in the municipalities of Santarém and Aveiro (Pará State). A convenience sample comprising 300 local adults was used to obtain data by means of a questionnaire/ interview. RESULTS Overall, 19 (6.3%) participants reported having sustained a stingray injury in the 12 months prior to the study. All 19 were injured either while fishing (n=13 [68.4%]) or engaging in other riverine activities. Most injuries [n=14 (73.7%)] occurred from September through November, and most injured respondents [n=15 (78.9%)] reported seeing stingrays at beaches. Severe pain and the appearance of ulcers in the later stages of envenomation were described by 18 (94.7%) and 12 (63.2%) participants, respectively. CONCLUSIONS Freshwater stingray injuries, which should be considered occupational injuries, are common in the study area, especially in places like beaches or in the lakes that form during the dry season, when stingrays are routinely observed. A significant proportion of respondents was unaware of the correct first aid measures and had insufficient resources to treat the complications of these injuries in the locality where they reside. Interactive activities involving local residents - such as lectures and the distribution of simple pamphlets providing information about stingray injuries - are needed.

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Abstract INTRODUCTION: The incidence of dengue has increased throughout the 2000s with a consequent global increase in atypical clinical forms. METHODS: This study reports a series of cases of neurological dengue out of 498 confirmed cases of laboratory dengue in Goiânia, Brazil. Cases were confirmed based on viral RNA detection via polymerase chain reaction or IgM antibody capture. RESULTS: Neurological symptoms occurred in 5.6% of cases, including paresthesia (3.8%), encephalitis (2%), encephalopathy (1%), seizure (0.8%), meningoencephalitis (0.4%), and paresis (0.4%). DENV-3 was the predominant circulating serotype (93%). CONCLUSIONS: We reported dengue cases with neurological manifestations in endemic area.

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Abstract INTRODUCTION: This cross-sectional study analyzed the spatial distribution of hepatitis B or C virus (HBV/HBC) and schistosomiasis coinfection. METHODS: Serum samples were collected from patients with Schistosoma mansoni infection. These were tested for serological markers of HBV/HCV infection. The spatial distribution of coinfection was analyzed using intensity kernel estimation. RESULTS: Overall, 9.4% of individuals had contact with HBV and 1.7% of samples tested positive for anti-HCV antibodies. We identified clusters of risk located in the central region. CONCLUSIONS: Spatial analysis allowed visualization of high-risk areas, leading to a definition of priority areas to be targeted for intensification of control interventions.

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Abstract INTRODUCTION: The muscoid fly Dermatobia hominis causes cutaneous myiases in mammals. Females of this species use a vector to carry their eggs to the host. This note describes Anopheles konderi acting as phoretic vector for D. hominis. METHODS: A female A. konderi carrying D. hominis was collected using light traps in Oriximiná, Pará, Brazil. The A. konderi specimen was identified at morphological and molecular levels. RESULTS: Eight eggs of D. hominis were observed on the Anopheles konderi female. CONCLUSIONS: Anopheles konderi, only the third Anopheles species recorded as a phoretic vector, may be a potential vector of D. hominis.

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Abstract INTRODUCTION: This study analyzed blackfly awareness and perceptions of health education practices for blackfly control among vulnerable populations in Brazil. METHODS: An exploratory descriptive quantitative research analysis was performed to investigate and analyze the awareness of and potential participation in blackfly control measures by vulnerable populations. RESULTS: Countryside resident participants (n = 24/38; 63.2% of the total sample) reported that blackflies were an obstacle to the performance of their work activities. CONCLUSIONS: Blackflies are a public health problem, and actions for blackfly control have been carried out without social participation or educational health practices that involve proper community knowledge.

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Abstract INTRODUCTION: Leptospirosis is an important health concern in Brazil. Currently, information on the epidemiology of the disease in the rural areas of the country is lacking. METHODS: Serological and molecular techniques were used to characterize a clinical isolate of Leptospira. RESULTS: The strain CLEP 00060, isolated from a 59-year-old man in a rural area of Rio Grande do Sul state, Brazil, was identified as belonging to L. kirschneri serogroup Pomona serovar Mozdok. CONCLUSIONS: This study contributes to the local epidemiological knowledge of leptospirosis, prevention of the disease by vaccines, and improvements in its diagnosis.

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Abstract INTRODUCTION The epidemiology of Rickettsia and Ehrlichia species infection is underestimated in Mato Grosso State. METHODS: Serum samples obtained during a Dengue outbreak in 2011-2012 were tested via indirect immunofluorescence and/or ELISA. RESULTS: Samples from 19/506 (3.8%) patients presented antibodies for at least one of three Rickettsia species; 2/506 (0.4%) samples reacted against Ehrlichia canis. Most afflicted patients are residents of cities from the south-central region of the state, where these diseases have been reported in animals. CONCLUSIONS: These results show serological evidence of human exposure to Rickettsia and Ehrlichia species in Mato Grosso State.

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Abstract INTRODUCTION: We evaluated the effects of a cardiac rehabilitation program on quality of life. METHODS This secondary analysis of a single-arm study included 12 patients with Chagas heart failure. The cardiac rehabilitation program comprised exercise training and nutritional and pharmaceutical counseling. Quality of life was assessed using the SF-36 questionnaire. RESULTS: The program promoted improved physical functioning (β= +5.7; p=0.003), role-physical (β= +1.9; p=0.03), and bodily pain (β= +3.5; p=0.02) scores. Moreover, the summary physical health score (β= +1.4; p=0.001) improved. CONCLUSION: The cardiac rehabilitation program significantly improved the physical quality of life of patients with Chagas heart failure.

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Abstract INTRODUCTION: This study compares the clinical and epidemiological features of patients with TB, with and without DM. METHODS New cases of active pulmonary TB that occurred in Salvador, Bahia, Brazil between 2008 and 2010 were included. DM was diagnosed by based on diagnostic criteria established by the American Diabetes Association. RESULT S: Of the 323 cases of TB, 44 (13.6%) were diabetic . Patients with TB and DM were older (44.7%), with a high level of education (34.%); had slow wound healing (23.4%) and fatigue (61.7%). CONCLUSIONS Clinical symptoms differed between patients with TB, with and without DM.

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Abstract Chikungunya, an alphavirus infection presenting with fever, rash, and polyarthritis, is most often an acute febrile illness. Neurologic complications of chikungunya infection have been reported. Here we report the clinical and neuroimaging data of 2 patients with chikungunya-associated encephalitis during the recent Brazilian epidemic.

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Abstract The symptoms of chikungunya virus (CHIKV) infection include fever, headache, muscle aches, skin rash, and polyarthralgia, characterized by intense pain, edema, and temporary functional impairment. This is the first report of encephalitis caused by CHIKV infection associated with an atypical presentation of syndrome of inappropriate antidiuretic hormone secretion, evolving to cognitive impairment and apraxia of speech.

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Abstract Acquired hepatocerebral degeneration is a neurological syndrome with typical clinical (extrapyramidal and neuropsychiatric) symptoms and brain magnetic resonance imaging findings (high T1 signal in the globus pallidus). It occurs mainly in patients with advanced liver disease, such as in patients co-infected with hepatitis B virus (HBV) and hepatitis delta virus (HDV). However, there are no reports relating HBV/HDV coinfection and acquired hepatocerebral degeneration. This report presents the case of a 49-year-old woman with characteristics of acquired hepatocerebral degeneration and liver cirrhosis due to HBV/HDV coinfection, and presents the main theories of the physiopathology of this condition.

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Abstract Herein, four cases of scorpion stings caused by Tityus apiacas recorded from the municipality of Apuí, in the southern region of the Brazilian Amazon, are described. Patients showed systemic clinical manifestations, described as unusual, involuntary, and generalized tingling and numbness, reported by patients as an electric shock sensation, lasting up to 24 hours after the sting. All patients described local pain and sensation, along with other clinical symptoms including local edema and erythema. Systemic manifestations were not life threatening. Antivenom therapy was administered to all patients, who were discharged without complaints.