The outbreak of new coronavirus disease 2019 (COVID-19) reported for the first time in Wuhan, China in late December 2019 have rapidly spread to other countries and it was declared on January 30, ...2020 as a public health emergency of international concern (PHEIC) by the World Health Organization. Before the first COVID-19 cases were reported in Brazil, several measures have been implemented including the adjustment of legal framework to carry out isolation and quarantine. As the cases increased significantly, new measures, mainly to reduce mortality and severe cases, have also been implemented. Rapid and robust preparedness actions have been undertaken in Brazil while first cases have not yet been identified in Latin-American. The outcome of this early preparation should be analyzed in future studies.
In Brazil malaria is most frequent in the Amazon region, mainly in the Amazonas state, where it is found the most proportion of indigenous people of the whole country. It is remarkable publications ...about malaria in the Amazon, although information on malaria in indigenous populations is still poorly explored.
Identify factors associated with malaria in indigenous populations.
Cross-sectional study of positive cases of malaria in the state of Amazonas, Brazil, from 2007 to 2016. Secondary data were obtained from the Epidemiological Surveillance Information System for Malaria and from the Mortality Information System, both from Brazil. To tackle with race missing data, cases with no race fulfilled were classified according to the probable location where infection occurred. This way, was imputed indigenous race for those which the probable infection location was indigenous village (aldeia). Variables tested with race were: sex, age, schooling, microscope surveillance slide type, parasitic infection species, parasitemia level, and timeliness of treatment. Multivariate logistic regression was used.
A total of 1,055,852 cases of malaria were notified in the state of Amazonas. Among the factors that associate malaria and indigenous peoples, the most significant were sex, children and high levels of parasitemia. The magnitude of Plasmodium vivax infection is higher than Plasmodium falciparum, although this parasite was more frequent in indigenous than other races. In regards to mortality, 109 deaths were registered, most of them related to P. vivax.
The findings underscore the importance of look at indigenous people differently of other races. The associated factors highlight a profile of cases severity, because of highest parasitemia, many cases of P. falciparum although high frequency of P. vivax, and children. Furthermore, the mortality in indigenous, specially in older people is worrying.
Access to antivenoms is not guarranteed for vulnerable populations that inhabit remote areas in the Amazon. The study of therapeutic itineraries (TI) for treatment of snakebites would support ...strategies to provide timely access to users. A TI is the set of processes by which individuals adhere to certain forms of treatment, and includes the path traveled in the search for healthcare, and practices to solve their health problems. This study aims to describe TIs of snakebite patients in the Brazilian Amazon. This study was carried out at the Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, in Manaus, state of Amazonas, Brazil. The itinerary from the moment of the bite to the patient's admission to the reference unit was analyzed. Sample size was defined by saturation. After an exploratory survey to collect epidemiological variables, in-depth interviews were conducted following a semi-structured guide. Patients originated from rural areas of 11 different municipalities, including ones located >500 kilometers from Manaus. A great fragmentation was observed in the itineraries, marked by several changes of means of transport along the route. Four themes emerged from the analysis: exposure to snakebite during day-to-day activities, use of traditional therapeutic practices, and personal perception of the severity, as well as the route taken and its contingencies. Access to healthcare requires considerable effort on the part of snakebite patients. Major barriers were identified, such as the low number of hospitals that offer antivenom treatment, poor access to healthcare due to long distances and geographic barriers, low acceptability of healthcare offered in countryside, lack of use of personal protective equipment, common use of ineffective or deleterious self-care practices, late recognition of serious clinical signs and resistance to seeking medical assistance. Health education, promotion of immediate transport to health centers and decentralization of antivenom from reference hospitals to community healthcare centers in the Brazilian Amazon are more effective strategies that would to maximize access to antivenom treatment.
Field work is not limited to animal collection; it also includes studies of behavioral patterns such as diet, reproduction, and activities to establish phylogeny patterns for identifying risk ...factors of the envenomings. Acknowledgments To all participants of the workshop, from the Instituto Butantan (São Paulo, SP), Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (Manaus, AM), Fundação de Vigilância em Saúde (Manaus, AM), Universidade Federal do Amazonas (Manaus, AM), Instituto Nacional de Pesquisas da Amazônia (Manaus, AM), Secretaria de Estado da Saúde de Rondônia (Porto Velho, RO), Hospital Cemetron (Porto Velho, RO), Secretaria de Estado da Saúde do Acre (Rio Branco, AC), Universidade Federal do Acre (Cruzeiro do Sul, AC), Secretaria de Estado da Saúde de Roraima (Boa Vista, RR), Universidade Estadual de Roraima (Boa Vista, RR), Secretaria de Estado da Saúde do Pará (Belém, PA), Hospital Universitário João de Barros Barreto (Belém, PA), Universidade Federal do Pará (Belém, PA), Faculdades Integradas do Tapajós (Santarém, PA), Universidade Estadual do Pará (Santarém, PA), Secretaria de Estado da Saúde do Amapá (Macapá, AP), Secretaria de Estado da Saúde do Tocantins (Palmas, TO), Universidade Federal do Tocantins (Palmas, TO), Secretaria de Estado da Saúde do Mato Grosso (Cuiabá, MT), Secretaria de Estado da Saúde do Mato Grosso (Cuiabá, MT), Secretaria de Vigilância em Saúde do Ministério da Saúde (Brasília, DF), Secretaria Especial de Saúde Indígena do Ministério da Saúde (Brasília, DF), Fundação Ezequiel Dias (Belo Horizonte, MG) and Instituto Vital Brazil (Niterói, RJ).
The 20-minute whole blood clotting test (20WBCT) has been used to detect coagulopathy following snakebite for almost 50 years. A systematic review and meta-analysis of the 20WBCT was conducted to ...evaluate the accuracy of the 20WBCT to detect coagulopathy, indicative of systemic envenoming.
Databases were searched from inception up to 09/12/2020 to identify studies that compared the 20WBCT and INR/fibrinogen on five or more subjects. Data was extracted from full-text articles by two reviewers using a predetermined form. Authors of 29 studies that lacked sufficient details in the manuscript were contacted and included if data meeting the inclusion criteria were provided. Included studies were evaluated for bias using a tailored QUADAS-2 checklist. The study protocol was prospectively registered on PROSPERO database (CRD42020168953). The searches identified 3,599 studies, 15 met the inclusion criteria and 12 were included in the meta-analysis. Data was reported from 6 countries and included a total of 2,270 patients. The aggregate weighted sensitivity of the 20WBCT at detecting INR >1.4 was 0.84 (CI 0.61 to 0.94), the specificity was 0.91 (0.76 to 0.97) and the SROC AUC was 0.94 (CI 0.91 to 0.96). The aggregate weighted sensitivity of the 20WBCT at detecting fibrinogen <100 mg/dL was 0.72 (CI 0.58 to 0.83), the specificity was 0.94 (CI 0.88 to 0.98) and the SROC AUC was 0.93 (0.91 to 0.95). Both analyses that used INR and fibrinogen as the reference test displayed considerable heterogeneity.
In the absence of laboratory clotting assays, the 20WBCT remains a highly specific and fairly sensitive bedside test at detecting coagulopathy following snakebite. However, clinicians should be aware of the importance of operator training, standardized equipment and the lower sensitivity of the 20WBCT at detecting mild coagulopathy and resolution of coagulopathy following antivenom.
In tropical areas, a major concern regarding snakebites treatment effectiveness relates to the failure in liquid antivenom (AV) distribution due to the lack of an adequate cold chain in remote areas. ...To minimize this problem, freeze-drying has been suggested to improve AV stability.
This study compares the safety and efficacy of a freeze-dried trivalent antivenom (FDTAV) and the standard liquid AV provided by the Brazilian Ministry of Health (SLAV) to treat Bothrops, Lachesis and Crotalus snakebites. This was a prospective, randomized, open, phase IIb trial, carried out from June 2005 to May 2008 in the Brazilian Amazon. Primary efficacy endpoints were the suppression of clinical manifestations and return of hemostasis and renal function markers to normal ranges within the first 24 hours of follow-up. Primary safety endpoint was the presence of early adverse reactions (EAR) in the first 24 hours after treatment. FDTAV thermal stability was determined by estimating AV potency over one year at 56°C. Of the patients recruited, 65 and 51 were assigned to FDTAV and SLAV groups, respectively. Only mild EARs were reported, and they were not different between groups. There were no differences in fibrinogen (p = 0.911) and clotting time (p = 0.982) recovery between FDTAV and SLAV treated groups for Bothrops snakebites. For Lachesis and Crotalus snakebites, coagulation parameters and creatine phosphokinase presented normal values 24 hours after AV therapy for both antivenoms.
Since promising results were observed for efficacy, safety and thermal stability, our results indicate that FDTAV is suitable for a larger phase III trial.
ISRCTNregistry: ISRCTN12845255; DOI: 10.1186/ISRCTN12845255 (http://www.isrctn.com/ISRCTN12845255).
Acute Kidney Injury (AKI) is the main systemic complication and cause of death in viperid envenomation. Although there are hypotheses for the development of AKI, the mechanisms involved are still not ...established. The aim of this study was to evaluate the clinical-laboratorial-epidemiological factors associated with AKI in victims of Bothrops sp envenomation. This is an observational study carried out at the Fundação de Medicina Tropical Dr. Heitor Vieira Dourado. AKI was defined according to the guidelines of the Acute Kidney Injury Network (AKIN). Among the 186 patients evaluated, AKI was observed in 24 (12.9%) after 48 hours of admission. Stage I was present in 17 (70.8%) patients, II in 3 (12.5%) and III in 4 (16.7%). Epidemiological characterization showed predominance of men, occurrence in rural areas, aged between 16-60 years, feet as the most affected anatomical region, and time to medical assistance less than 3 hours. Hypertension and diabetes were the comorbidities identified. Most of the accidents were classified as moderate, and clinical manifestations included severe pain, mild edema, local bleeding and headache. Laboratory results showed blood uncoagulability, hypofibrinogenemia, leukocytosis, increase of creatine kinase, and high lactate dehydrogenase levels. Multivariate analysis showed an association with high LDH levels AOR = 1.01 (95% CI = 1.01-1.01, p<0.002), local bleeding AOR = 0.13 (95%CI = 0.027-0.59, p<0.009), and the presence of comorbidities AOR = 60.96 (95%CI = 9.69-383.30; p<0.000). Herein, laboratory markers such as high LDH levels along with local bleeding and comorbidities may aid in the diagnosis of AKI.
A distinctive feature of Plasmodium vivax infections is the overall low parasite density in peripheral blood. Thus, identifying asymptomatic infected individuals in endemic communities requires ...diagnostic tests with high sensitivity. The detection limits of molecular diagnostic tests are primarily defined by the volume of blood analysed and by the copy number of the amplified molecular marker serving as the template for amplification. By using mitochondrial DNA as the multi-copy template, the detection limit can be improved more than tenfold, compared to standard 18S rRNA targets, thereby allowing detection of lower parasite densities. In a very low transmission area in Brazil, application of a mitochondrial DNA-based assay increased prevalence from 4.9 to 6.5%. The usefulness of molecular tests in malaria epidemiological studies is widely recognized, especially when precise prevalence rates are desired. Of concern, however, is the challenge of demonstrating test accuracy and quality control for samples with very low parasite densities. In this case, chance effects in template distribution around the detection limit constrain reproducibility. Rigorous assessment of false positive and false negative test results is, therefore, required to prevent over- or under-estimation of parasite prevalence in epidemiological studies or when monitoring interventions.
Objective
To analyse the temporal and spatial distribution as well as the environmental and socioeconomic factors associated with cutaneous leishmaniasis incidence in the state of Amazonas, Brazil ...from 2007 to 2015.
Methods
Spatial and temporal distribution was evaluated from sequential thematic maps of the mean incidence rates of the disease. A negative binomial regression analysis was performed to evaluate the association of the factors studied with the mean incidence rate of ACL.
Results
The average proportion of deforestation was negatively associated with the average incidence rate of cutaneous leishmaniasis in municipalities (β = −2.178; P = 0.019; 95%CI −3.996, −0.361), and the health system performance index (effectiveness) (β = −0.852; P = 0.008; 95%CI −1.481, −0.225). Conversely, the municipal human development index (MHDI) was a factor positively related to the average incidence among the municipalities (β = 7.728; P = 0.003; 95%CI 2.716, 12.738).
Conclusion
Our study shows the important impact of socioeconomic and environmental factors on ACL incidence in the Amazonas State.
Objectif
Analyser la distribution temporelle et spatiale ainsi que les facteurs environnementaux et socioéconomiques associés à l'incidence de la leishmaniose cutanée dans l'Etat de l'Amazonas, au Brésil, de 2007 à 2015.
Méthodes
La distribution spatiale et temporelle a été évaluée à partir de cartes thématiques séquentielles des taux d'incidence moyens de la maladie. Une analyse de régression binomiale négative a été réalisée pour évaluer l'association des facteurs étudiés avec le taux d'incidence moyen de la LCA.
Résultats
La proportion moyenne de déforestation était négativement associée au taux d'incidence moyen de la leishmaniose cutanée dans les municipalités (β = ‐2,178; p = 0,019; IC95%: ‐3,996 à ‐0,361) et à l'indice de performance du système de santé (efficacité) (β = ‐0,852; p = 0,008; IC95%: ‐1,481 à ‐0,225). Par contre, l'indice de développement humain municipal (IDHM) était un facteur positivement lié à l'incidence moyenne dans les municipalités (β = 7,728; p = 0,003; IC95%: 2,716 à 12,738).
Conclusion
Notre étude montre l'impact important des facteurs socioéconomiques et environnementaux sur l'incidence de la LCA dans l'Etat d'Amazonas.
In the Brazilian Amazon, the snake Bothrops atrox is the primary cause of snakebites. B. atrox (BaV) venom can cause systemic pathophysiological changes such as acute kidney injury (AKI), which leads ...to the production of chemokines and cytokines in response to the envenomation. These soluble immunological molecules act by modulating the inflammatory response; however, the mechanisms associated with the development of AKI are still poorly understood. Here, we characterize the profile of these soluble immunological molecules as possible predictive biomarkers of the development of AKI. The study involved 34 patients who had been victims of snakebites by Bothrops sp. These were categorized into two groups according to the development of AKI (AKI(-)/AKI(+)), using healthy donors as the control (HD). Peripheral blood samples were collected at three-time points: before antivenom administration (T0) and at 24 and 48 hours after antivenom (T1 and T2, respectively). The soluble immunological molecules (CXCL-8, CCL-5, CXCL-9, CCL-2, CXCL-10, IL-6, TNF, IL-2, IL-10, IFN-γ, IL-4, and IL-17A) were quantified using cytometric bead array. Our results demonstrated an increase in CXCL-9, CXCL-10, IL-6, IL-2, IL-10, and IL-17A molecules in the groups of patients who suffered Bothrops snakebites (AKI(-) and AKI(+)) before antivenom administration, when compared to HD. In the AKI(+) group, levels of CXCL-8 and CCL-2 molecules were elevated on admission and progressively decreased during the clinical evolution of patients after antivenom administration. In addition, in the signature analysis, these were produced exclusively by the group AKI(+) at T0. Thus, these chemokines may be related to the initiation and extension of AKI after envenomation by Bothrops and present themselves as two potential biomarkers of AKI at T0.
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