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.
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.
Snake envenomation is a major public health problem in Brazil. Systemic complications that may arise from snakebites are mainly related to coagulopathy. The Lee-White clotting time (LWCT) is a simple ...and inexpensive test and available even in remote health facilities. However, the diagnostic value of such test needs to be evaluated to accurately diagnose coagulopathy in the clinical practice. This study aimed to assess the reliability of the LWCT performed in hospital routine to diagnose venom-induced coagulopathy. We studied 186 patients admitted at the Tropical Medicine Foundation Dr. Heitor Vieira Dourado in Manaus, Amazonas, Brazil, with
envenomation diagnosis. At admission, blood samples were collected for performing LWCT and the concentration of fibrinogen. Sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios, diagnostic odds ratio, and accuracy were calculated with 95% confidence intervals. From the total, 85.5% had hypofibrinogenemia. The sensitivity of the LWCT to the diagnosis of hypofibrinogenemia was 78.0% and the specificity 40.7%. The accuracy of the test was 72.6%, and patients with a prolonged LWCT had 2.4 higher odds of developing hypofibrinogenemia. In addition, the LWCT was also compared with venom antigen levels and systemic hemorrhage. The LWCT showed moderate sensitivity to detect consumption coagulopathy and constitutes a valuable tool for the diagnosis of
snake envenomation and indication of antivenom therapy.
Abstract
Background
Relapses in vivax malaria have posed great challenges for malaria control, and they also account for a great proportion of reported cases. Knowing the real effectiveness of a ...7-day primaquine (PQ) scheme is crucial in order to evaluate not only the cost-effectiveness of implementing new anti-hypnozoite drugs, but also how health education strategies can guarantee better compliance and be reinforced. This study aimed to evaluate the effect of daily treatment with chloroquine and PQ supervised by health workers
versus
prescription without supervision.
Methods
The outcome was the passive detection of new positive thick blood smears up to 180 days, based on the official data records from the National Malaria Control Programme. The recurrences seen in the real life were, therefore, used as a surrogate for true relapses.
Results
Patients under supervised treatment had a lower risk of recurrence up to day 180 when compared to the unsupervised treatment (17.9%
vs.
36.1%;
p
= 0.027).
Conclusions
The lack of supervision in the non-supervised group (which followed standard of care in the real life) enabled proper comparison, as consent itself would have lead to greater compliance in this group. Future studies should scale such an analysis to different settings in the Brazilian Amazon.
As quantitative glucose 6-phosphate dehydrogenase deficiency (G6PDd) screening tools are evaluated in operational studies, questions remain as to whether they are cost-effective. Here, a ...cost-effectiveness analysis (CEA) was performed to estimate the Incremental Cost-effectiveness Ratio (ICER) of the introduction of quantitative screening test to detect G6PDd among P. vivax carriers in two municipalities in the Brazilian Amazon.
This cost-effectiveness analysis evaluated the use of the Standard G6PD quantitative screening test in vivax malaria treatment units in two municipalities of the Brazilian Amazon. Using the perspective of the Brazilian public health system, the analysis was performed for the outcome 'PQ-associated hospitalization avoided', based on a decision tree model. The results indicated that the G6PDd screening strategy compared with the routine strategy was highly cost-effective, with an ICER of US$495 per additional hospitalization avoided, which represented less than 8% of one Brazilian gross domestic product per capita (US$6,822). The uncertainties evaluated in the sensitivity analysis did not significantly affect the ICER identified in the base-case.
This cost-effectiveness analysis showed the quantitative G6PD testing was effective in avoiding PQ-associated hospitalizations. The incorporation of G6PD screening is of paramount importance towards P. vivax malaria elimination in the Amazon to promote the safe use of primaquine and tafenoquine.
Abstract
Background
Although considerable success in reducing the incidence of malaria has been achieved in Brazil in recent years, an increase in the proportion of cases caused by the ...harder-to-eliminate
Plasmodium vivax
parasite can be noted. Recurrences in
P. vivax
malaria cases are due to new mosquito-bite infections, drug resistance or especially from relapses arising from hypnozoites. As such, new innovative surveillance strategies are needed. The aim of this study was to develop an infographic visualization tool to improve individual-level malaria surveillance focused on malaria elimination in the Brazilian Amazon.
Methods
Action Research methodology was employed to deal with the complex malaria surveillance problem in the Amazon region. Iterative cycles were used, totalling four cycles with a formal validation of an operational version of the Malaria Trigram tool at the end of the process. Further probabilistic data linkage was carried out so that information on the same patients could be linked, allowing for follow-up analysis since the official system was not planned in such way that includes this purpose.
Results
An infographic user interface was developed for the Malaria Trigram that incorporates all the visual and descriptive power of the Trigram concept. It is a multidimensional and interactive historical representation of malaria cases per patient over time and provides visual input to decision-makers on recurrences of malaria.
Conclusions
The Malaria Trigram is aimed to help public health professionals and policy makers to recognise and analyse different types of patterns in malaria events, including recurrences and reinfections, based on the current Brazilian health surveillance system, the SIVEP-Malária system, with no additional primary data collection or change in the current process. By using the Malaria Trigram, it is possible to plan and coordinate interventions for malaria elimination that are integrated with other parallel actions in the Brazilian Amazon region, such as vector control management, effective drug and vaccine deployment strategies.
There is no specific antiviral therapy recommended for coronavirus disease 2019 (COVID-19). In vitro studies indicate that the antiviral effect of chloroquine diphosphate (CQ) requires a high ...concentration of the drug.
To evaluate the safety and efficacy of 2 CQ dosages in patients with severe COVID-19.
This parallel, double-masked, randomized, phase IIb clinical trial with 81 adult patients who were hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was conducted from March 23 to April 5, 2020, at a tertiary care facility in Manaus, Brazilian Amazon.
Patients were allocated to receive high-dosage CQ (ie, 600 mg CQ twice daily for 10 days) or low-dosage CQ (ie, 450 mg twice daily on day 1 and once daily for 4 days).
Primary outcome was reduction in lethality by at least 50% in the high-dosage group compared with the low-dosage group. Data presented here refer primarily to safety and lethality outcomes during treatment on day 13. Secondary end points included participant clinical status, laboratory examinations, and electrocardiogram results. Outcomes will be presented to day 28. Viral respiratory secretion RNA detection was performed on days 0 and 4.
Out of a predefined sample size of 440 patients, 81 were enrolled (41 50.6% to high-dosage group and 40 49.4% to low-dosage group). Enrolled patients had a mean (SD) age of 51.1 (13.9) years, and most (60 75.3%) were men. Older age (mean SD age, 54.7 13.7 years vs 47.4 13.3 years) and more heart disease (5 of 28 17.9% vs 0) were seen in the high-dose group. Viral RNA was detected in 31 of 40 (77.5%) and 31 of 41 (75.6%) patients in the low-dosage and high-dosage groups, respectively. Lethality until day 13 was 39.0% in the high-dosage group (16 of 41) and 15.0% in the low-dosage group (6 of 40). The high-dosage group presented more instance of QTc interval greater than 500 milliseconds (7 of 37 18.9%) compared with the low-dosage group (4 of 36 11.1%). Respiratory secretion at day 4 was negative in only 6 of 27 patients (22.2%).
The preliminary findings of this study suggest that the higher CQ dosage should not be recommended for critically ill patients with COVID-19 because of its potential safety hazards, especially when taken concurrently with azithromycin and oseltamivir. These findings cannot be extrapolated to patients with nonsevere COVID-19.
ClinicalTrials.gov Identifier: NCT04323527.
Snakebites were included by the World Health Organization in their list of neglected diseases. In Latin America, most snakebites are caused by species of the Viperidae family, notably by the genus ...Bothrops. Bothrops atrox accounts for 90% of the cases of envenoming in the Brazilian Amazon. In this report, we present a series of three cases of snakebites that evolved with hemorrhagic stroke due to delays in the access to antivenom in the Brazilian Amazon, being fundamental for diagnosis to validate the clinical suspicion and make decisions that would improve the treatment and prognosis of the patients.
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.
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