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Zika virus in Brazil emergence and response
Carlos Magno C. B. Fortaleza, MD, PhD Department of Tropical Diseases
State University of São Paulo (UNESP)
São Paulo State Society for Epidemiology and Control of Healthcare-Associated Infections
A WEIRD COINCIDENCE…
Zika – is a member of the virus (…) genus Flavivirus.(…) Its name comes from the Zika Forest of Uganda, where the virus was first isolated in 1947.
(Wikipedia)
Zica – Brazilian slang, meaning “bad luck” or “big trouble”.
(Portuguese online dictionary)
Presenting the problem… • The greatest epidemics of Zika virus disease ever reported is going
on in Brazil.
• Neurological complications are increasingly described in this seemingly mild disease.
• WHO declared this event a Public Health Emergence of International Concern (February, 2016).
• Mass gatherings are expected in Brazil in the following months, including the Olympic Games.
• 52 countries and territories report Zika (31 in the Americas).
Maculo-papular rash, conjunctivitis, headache and low grade fever Neurological complications (!?)
Zika – a flavivirus Sexual transmission!?
Aedes spp.
Paixão ES et al. Am J Public Health 2016; 106: 606-12.
Clinical picture
Challenges for Diagnosis • Serological tests (IF and ELISA) show extensive
cross-reactivity with other flaviviruses, including Dengue and the Yellow Fever vaccine virus.
• Detection of viral RNA (RT-PCR): – Less than 5 days in blood – More than 7 days in urine
Phylogeografic analysis linked Brazilian strains to close Polynesian ancestors
Zanluca C et al. Mem Inst Oswaldo Cruz. 2015;110:569–72 Musso D. Emerging Infect Dis 2015; 21: 1887
Malone RW et al. PLoS Neglect Trop Dis 2016; 10: e0004530 Imperato PJ. J Community Health 2016 (ahead of print)
Zika Virus Worldwide Spread
1947 Uganda
1954 Nigeria 1960s Malasia
2007 Yap isl 2014 Fr.Polynesia
2015 Brazil
Upper Middle Income Country (World Bank) Estimated Population: 200 million people
Area: 8.5 million Km2 (3.3 million mi2)
Ocean Dry
frontier
Brazil Population Density (Kernel estimate)
Epicenter of Zika Epidemics
Climate ranging from humid equatorial to semi-arid
Lower Human Development Index (HDI)
Less access to basic satination
Northeastern Region
How did Zika virus reach Brazil?
World Soccer Cup, 2014? No affected country participated World Championship canoe race, 2014? Affected islands participating Tourism from Chile? Cases in Easter Islands in 2014.
Musso D. Emerging Infect Dis 2015; 21: 1887 Salvador FS, Fujita DM. Travel Med Infect Dis 2016; 1: 49-51
... into Brazil.
Estimated Zika virus infections in Brazil in year 2015
Difficulties: Lack of reliable serological tests, limited access to RT-PCR
Malone RW et al. PLoS Neglect Trop Dis 2016; 10: e0004530 Waggoner JJ, Pinsky BA. J Clin Microbiol 2016 (ahead of print)
... in Brazil ...
From Brazil...
Traveller’s returning from Brazil (September 2014 – August 2015) Total: 9.9 millions 65% to the Americas - USA, 2.7 millions - Argentina, 1.3 milions 27% to Europe - Italy, 419 thousands - Portugal, 411 thousands - France, 409 thousands
- 5% Asia USA, Argentina and Italy have more than 60% of their population living in receptive areas.
Bogoch II et al. Lancet 2016; 387 (online)
Microcephaly
de Oliveira W et al MMWR 2016; 65;242–247
> 3 SD > 20 SD Increase over baseline incidence
Cases in States with increases over 20 SD
Pernambuco
Paraíba
Bahia
2015
• Relevant temporal association in Brazil – 60%-70% of mothers reported rash during pregnancy
Miranda-Filho DB et al. Am J Public Health 2016; 106: 598-600
• Fetus autopsy and in vitro models of neurogenesis Mlakar J et al. N Engl J Med 2016;374:951-8
Tang H et al. Cell Stem Cell 2016 (ahead of print)
• Fetal abnormality in 12 out of 42 ZIKV (+) pregnant women
Brasil P et al. N Engl J Med 2016 (DOI: 10.1056/NEJMoa1602412)
• Relevant temporal association in Brazil – 60%-70% of mothers reported rash during pregnancy
Miranda-Filho DB et al. Am J Public Health 2016; 106: 598-600
• Fetus autopsy and in vitro models of neurogenesis Mlakar J et al. N Engl J Med 2016;374:951-8
Tang H et al. Cell Stem Cell 2016 (ahead of print)
• Fetal abnormality in 12 out of 42 ZIKV (+) pregnant women
Brasil P et al. N Engl J Med 2016 (DOI: 10.1056/NEJMoa1602412)
HOWEVER • Pre-epidemic rates probably underestimated
– USA and UK, 1-2 per 10,000 births / Brazil, 0.5 per 10,000 births Schuler-Facini L et al. MMWR 2016; 65: 59-62
• Conflicting definitions may have overestimated current rates Victora CG et al. Lancet 2016 (online)
Guillain-Barré Syndrome…
FRENCH POLYNESIA
Incidence: 0.24 case per 1,000 infections
Case-control (P<0.001):
GBS – 100% ZIKV (+) Controls – 56% ZIKV (+)
BAHIA STATE, BRAZIL
Incidence (preliminary): 1 case per 1,000 infections (?)
Paixão ES et al. Am J Public Health 2016; 106: 606-12
Cao-Lormeau et al. Lancet 2016 (online)
… plus myelitis, encephalitis, etc.
An agenda to fight Zika
1. To enlarge the basis of evidence on vulnerability. “Move from case reports to case-control” (*)
2. To develop a fast and reliable serological test. 3. To control infestation with Ae. aegypti, possibly with the use of
novel biotechnology.
4. To establish protocols of care, with emphasis on affected pregnant women and newborns.
5. To start the groundwork for a vaccine.
6. To reprogramme healthcare system.
Barreto ML et al. Lancet 2016; doi: 10.1016/S0140-6736(16)00545-6
(*) Musso D, Baud D. Lancet Infect Dis 2016; doi 10.1016/ S1473-3099(16)00096-7
Intensification of vector control
Extensive media campaing
Epidemiological office for mass gatherings and emergencies
Financial support for research in prevention and control
Sources: Brazil Ministry of Health / São Paulo State Health Department
In Conclusion • The Zika epidemics if a
worldwide concern. It is still a greater threat for pregnant women.
• Even though many Brazilian states report autochtonous cases, the disease is not equally spread.
• Brazil has started intense measures for fighting the spread of the disase.
ACKNOWLEDGEMENTS
APECIH Delegates (University of São Paulo) Sílvia Figueiredo Costa, Ícaro Boszczowski
Ministry of Health, Brazil
Cláudio Maierovich P. Henriques
São Paulo State Health Department Marcos Boulos, Alice Tiago
THANK YOU Email: [email protected]
Email: [email protected]