Date: Tue 23 Apr 2019 20:07 BRT
Source: G1, RBS TV report [in Portuguese, machine trans., edited]

Ten cases of toxoplasmosis in children were confirmed in Lagoa Vermelha, in the Northern Region of Rio Grande do Sul. Health officials investigate the focus of the contamination.

Nine of the diagnosed children studied until last year [2018] were from the Duque de Caxias school. Analyses of the water and food from the school have not revealed any problems.

Last month [March 2019], the management removed a sandbox from the patio, where the children played. "They inspected all possible sectors, investigated all possibilities, and all was ok, everything is within the standard of normality," says the director of the school, Lucelia Sguarizi. "We are most interested in finding out where the focus is. We do not want any students being contaminated anymore."

One of the children diagnosed with toxoplasmosis is the 5-year-old son of a nursing technician. "For the past 2 months he reported that he had a headache, not every day, but often he was very tired," the mother describes. "It is a disease that can infect a large number of people, and this creates concern and leads us to take effective measures to avoid the favourable conditions for proliferation of the disease," she says.

Last year [2018], Santa Maria, in the Central Region [of Brazil], reported an outbreak of the disease, whose origins are still under investigation. More than 900 cases were registered.

The main suspect of contamination was the water. The then Minister of Health, Gilberto Occhi, said in June 2018 that this was the origin of the outbreak. The statement sparked controversy. The mayor of Santa Maria, Jorge Pozzobon, denied this could be the source.

As early as March 2019, the Health Secretary of Santa Maria, Francisco Harrisson, reported that water has spread toxoplasmosis. The following month, after the declaration, the state government issued a statement stating that the case is still being investigated, so far without conclusion.
Communicated by:
Felippe Danyel Cardoso Martins
Universidade Estadual de Londrina
[Several outbreaks of toxoplasmosis (infection with _Toxoplasma gondii_] have been reported from Brazil (see ProMED reports below). Felines excrete oocysts in faeces which can remain viable in the environment, including fresh water, for months. Isolation of oocysts from water samples require special concentration techniques. A food source is another possibility as raw or undercooked meat containing _T. gondii_ tissue cysts is infective. - ProMED Mod.EP]

[HealthMap/ProMED-mail map of Rio Grande do Sul, Brazil:
Date: Wed, 10 Apr 2019 18:49:48 +0200

Rio de Janeiro, April 10, 2019 (AFP) - Residents of a hillside Rio de Janeiro favela risk finding hungry caimans at their front door after the city was hit hard by heavy flooding caused by torrential rain.   The cold-blooded creatures -- smaller relatives of alligators -- belong to
a resident of the Rolas favela in western Rio, and escaped on Tuesday when a wall holding them in burst when struck by a flash flood.

An animal control team has been mobilized to re-capture the reptiles, the Rio environmental services office told AFP.   How many were on the loose? Officials did not say.   The team faces a risky task: not only must they be wary of the aggressive animals, but they must navigate streets knee-deep in water or slick with mud, dodging uprooted trees and loose power lines like the one that electrocuted a man to death near where the caimans escaped from.   They also face more mundane dangers, such as being shot, knifed, mugged or kidnapped in the high-crime favela.

As of Wednesday the team had been unable to enter the favela "due to the strong presence of drug traffickers," city officials said.   "I saw the wall collapse and two people have already seen caimans at their front door," a local resident wrote on social media.   The unusually heavy rain, which began late Monday and continued into Tuesday, has killed at least 10 people, officials said.   The rain triggered flash flooding that turned some streets into raging rivers, uprooting trees and sweeping away vehicles.   Heavy runoff from neighbouring hills gushed through some apartment buildings and shops, leaving behind mud and debris.
Date: Sat 6 Apr 2019
Source: [in Portuguese, machine trans. edited]

In the Northern Region of Rio Grande do Sul, the death of cattle has worried producers. At least 50 animals have died this year [2019] on 15 properties with signs of rabies. [This appears to be a large outbreak and needs some serious support from the local and state governments. - ProMED Mod.TG]

In the town of Soledade, Adriano Borges Knopf lost 4 animals in less than 15 days. "We started to suspect it was not a normal thing. We noticed the animals lost their legs [weakness in legs] and did not get up any more," said the farmer.

A sample [from the animal necropsy, and the laboratory] report found Adrian's cattle had herbivore rabies, a disease caused by a virus transmitted by bats. [Cattle are herbivores, and consequently in some areas it is called herbivore rabies, but this virus could equally affect people, or dogs or horses. - ProMED Mod.TG]

Four other cattle belonging to the producer Luiz Carlos dos Santos also died because of the problem. "It's their milk we live on. We were even planning to improve this year [2019]," he lamented about the losses in production.

The challenge now is to control the transmission of the disease affecting these cattle. Most of the animals that died were attended by the veterinarian Bolivar Camargo, who is part of a cooperative in the region. "There are people who had 10 lactating cows and ended up losing 7, so their profitability ends, right?" he pointed out.

Last week, a bat was found near one of the affected properties. Technicians from the State Department of Agriculture are doing a survey to try to identify the source of these infections.  In addition to injury, producers are also concerned about the transmission of rabies to humans. The disease, however, is not transmitted by the consumption of milk or meat.  "They [the people] should be vaccinated if they have a very high risk, if they have suffered a bite from an animal, or had very intimate contact with an animal showing clinical signs of rabies," explained veterinarian Isadora Correa.

She added: "[The vaccine] is not available to the entire population, nor would it be the case, because the risk of transmission of herbivore rabies from a bovine to a human being is fairly low."
[Most likely, the bats responsible for transmitting the rabies virus are vampire bats. While these bats can and do move around, deforestation seems to upset them, causing them to move to areas where there previously has not been a problem.

Vampire bats are distributed in tropical areas of the western hemisphere from Argentina to Mexico and have been responsible for transmitting rabies virus, most frequently to cattle and equine animals, and, infrequently, to humans [by bite]. Of the 3 vampire bat species, _Desmodus rotundus_ is by far the most common rabies virus transmitter.

There are 2 options for rabies control in these situations:
vaccination of animals upon which the vampire bats feed, or reduction of the vampire bat populations, or perhaps a 3rd option would be a combination of the 2 approaches. Eliminating vampire bat hosts is the fastest and most effective approach when vampire bat-transmitted rabies appears in an area. In areas where repeated vampire bat-transmitted rabies occurs, control of these bats has been employed in some countries. Controlling vampire bats by eliminating their roosts is extremely difficult because these roosts can be hard to find. Effective vampire bat control has been accomplished by capturing bats in mist nets when they come to feed on livestock and applying anticoagulant jelly (warfarin and similar products), which they and their roost-mates ingest on grooming.

As animals can be vaccinated, it would prudent to do so immediately, as there is approximately 2 weeks from vaccination of the cattle until they are capable of mounting an immune response. In addition to vaccination, the suggestion of netting the bats and using anticoagulant jelly is perhaps equally as important. So, employing additional methods instead of only one method, would be the most prudent approach to a more rapid control of this disease from these bats.

The loss of these animals to these families is huge, and this is a large outbreak needing immediate containment. Perhaps the government could send out some vaccine and additional people to help vaccinate animals and to net and coat the bats with anticoagulant jelly. Coating the bats means handling the bats, minimally, and gloves should be worn. Likewise, any bite or scratch should receive immediate medical attention and post exposure prophylaxis rabies vaccine for the individual(s) affected.

1. Brass DA. Rabies in bats: natural history and public health implications. Ridgefield CN: Livia Press, 1994. 335 pp.
2. Greenhall AM: Feeding behavior. In: AM Greenhall and U Schmidt, editors. Natural history of vampire bats. Boca Raton, FL: CRC Press, 1988. 111:31. - Mod.TG

HealthMap/ProMED map available at:
Rio Grande do Sul, Brazil: <>]
Friday 5th April 2019

Brazil is currently in the seasonal period for yellow fever, which occurs between December and May. The expansion of the historical area of YF transmission to areas previously considered risk-free led to two prior waves of transmission one during the 2016-2017 seasonal period, with 778 human cases, including 262 deaths, and another during the 2017-2018 seasonal period, with 1,376 human cases, including 483 deaths.  Human cases reported so far during the current 2018-2019 period, (July 2018 to March 2019) in in São Paolo State, as well as the confirmation of a human case and epizootics due to yellow fever in the states  of Paraná, and Santa Catarina mark the beginning of what could be a third wave and a progression of the outbreak towards the Southeast and South regions of the country.

From December 2018 through March 2019, 75 confirmed human cases, including 17 deaths, have been reported in the states of São Paulo (62 cases), Paraná (12 cases), and Santa Catarina (1 case). Among these confirmed cases, 88% are male, the median age is 43 years, and 71% are rural workers. Between 1 July 2018 and 18 March 2019, 33 confirmed epizootics were reported, in five federal entities: São Paulo (20), Rio de Janeiro (8), Minas Gerais (1), Mato Grosso (2), and Parana (2). In the last 4 weeks epizootics have been confirmed in São Paulo and Parana states.

Given the gradual geographical expansion of the epizootic wave that Brazil has faced during the last two seasonal periods, the country has had to adjust its immunization policies for yellow fever. The number of areas with recommended vaccination has increased from 3,526 municipalities in 2010 to 4,469 municipalities in 2018.

In line with the World Health Organization guidelines, Brazil has adopted a single dose vaccination scheme for yellow fever since April 2017. The use of fractional doses to respond to outbreaks and the risk of urbanization of yellow fever, especially in large cities, was also adopted. This strategy was implemented in 77 municipalities with the greatest risk for yellow fever in the states of São Paulo (54 municipalities), Rio de Janeiro (15 municipalities), and Bahía (8 municipalities). As of epidemiological week (EW) 39 of 2018 (23-29 September), preliminary results of the mass vaccination campaign against yellow fever indicate that 13.2 million people were vaccinated. With respect to the accumulated doses and doses administered during the campaign, a total of 13.3 million people in São Paulo, 6.5 million people in Rio de Janeiro, and 1.85 million in Bahía states were vaccinated, which represent vaccination coverage of 53.62%, 55.60% and 55.03%, respectively.

WHO risk assessment

Further transmission is expected in the coming months based on seasonal patterns. Recent human cases of YF during the current seasonal cycle have been reported in São Paulo, Paraná, and Santa Catarina states in Southeast Brazil.

The preliminary results of the vaccination coverages in municipalities from Paraná, Rio Grande do Sul, São Paulo, and Santa Catarina states suggests a high proportion of persons remaining at-risk and the necessity to intensify risk communications among high-risk groups.

The geographical distribution of human cases and epizootics from the current and previous two seasonal cycles suggests southward movement of the virus, which presents further risk to the states of Paraná, Rio Grande do Sul, and Santa Catarina. Furthermore, these areas have ecosystems favourable for yellow fever transmission and borders with other countries such as Argentina, Paraguay, and Uruguay.

During the previous season cycle, human yellow fever cases were reported among travellers, though to date, most imported cases have been reported in countries where the vector are absent (or absent during winter). These reports illustrate the importance of maintaining high levels of awareness, especially for international travellers from areas with favourable ecosystems for yellow fever transmission.

To date, yellow fever transmission by Aedes aegypti has not been documented. More recently, an investigation conducted by the Evandro Chagas Institute reported by the Brazil Ministry of Health revealed the detection of yellow fever virus in Aedes albopictusmosquitoes captured in rural areas of 2 municipalities in Minas Gerais (Ituêta and Alvarenga) in 2017. The significance of this finding requires further investigation. The last documented outbreak of urban yellow fever in Brazil was recorded in 1942. The sylvatic yellow fever virus is transmitted to monkeys by forest dwelling mosquitoes such as Haemagogus and Sabethes spp. Humans who are exposed to these mosquitoes can become infected if they are not vaccinated. In entomological studies conducted during the 2016-2017 outbreak in some of the affected states, isolated Haemagogus mosquitoes were found to be positive for yellow fever, indicating predominantly sylvatic transmission.

WHO continues to monitor the epidemiological situation and review the risk assessment based on the latest available information. Currently, based on available information, WHO assesses the overall risk as High at the national level, Moderate at the regional level, and Low at the global level.

WHO advice

On 25 January 2019, PAHO/WHO alerted Member States about the beginning of the seasonal period for yellow fever and therefore, the highest risk of transmission to unvaccinated humans. Thus, PAHO/WHO advises Member States with areas at-risk for yellow fever to continue efforts to immunize the at-risk populations and to take the necessary actions to keep travelers informed and vaccinated prior to traveling to areas where yellow fever vaccination is recommended.

WHO recommends vaccination of international travelers above 9 months of age going to Brazil. The updated areas at-risk for yellow fever transmission and the related recommendations for vaccination of international travelers were updated by WHO on 3 May 2018; the map of revised areas at risk and yellow fever vaccination recommendations is available on the WHO ITH website:

Yellow fever can easily be prevented through immunization, provided that vaccination is administered at least 10 days before travel. A single dose of yellow fever vaccine is sufficient to confer sustained immunity and life-long protection against yellow fever disease: a booster dose of the vaccine is not needed and cannot be required of international travelers as a condition of entry. The vaccine has been used for many decades and is safe and affordable.


·         Information on the YF situation in Brazil and other countries in the Americas is published regularly on the PAHO/WHO website. Available at:
·         Information on the yellow fever situation in Brazil is available on the Brazil Ministry of Health website. Available at
·         Information on the yellow fever situation in Sao Paulo State. Available at:
·         Information on the yellow fever situation in Paraná State. Available at:
·         Information on the yellow fever situation in Santa Catarina State. Available at:

Further Information:

The WHO Risk Assessment is as follows:
Serious Public Health impact: Yes

Yellow fever (YF) is an acute viral disease transmitted by mosquitoes infected with the yellow fever virus with a high case-fatality rate among patients presenting with the toxic phase of the disease.  In 2018 Brazil launched mass YF vaccination campaigns and preliminary results of the campaigns indicate 64.2% of vaccination coverage in São Paulo, 55.6% in Rio de Janeiro and 51.7%, in Bahia states [1]. Suboptimal vaccine coverage implies that herd immunity is not reached and that a high proportion of persons remain at-risk.

Unusual or unexpected: Yes

Human cases of yellow fever during the current seasonal cycle have been reported in the states of São Paulo, Paraná and Santa Catarina in Southeast Brazil, with probable sites of infection in municipalities which had no confirmed epizootics or human cases due to yellow fever in the previous 2 seasonal cycles. In the state of Paraná there had been no reported human cases since 2015 and in the state of Santa Catarina none since 1966.

International disease spread: Yes
The geographical distribution of human cases and epizootics from the current and previous two seasonal cycles suggest southward movement of the virus where there are ecosystems favorable for yellow fever transmission and an area bordering other countries (Argentina, Paraguay, and Uruguay). However, so far, no YF human cases have been reported outside Brazil, in link with the current outbreak.
Interference with international travel or trade: No 
WHO does not recommend any restrictions on travel and/or trade for Brazil based on available information on this event.
Actions requested: For information only, please circulate to all relevant staff
Additional documents included: None
Further sources of information:
·         PAHO/WHO yellow fever fact sheet:   
·         WHO yellow fever Health Topics:   
·         WHO list of countries with vaccination requirements and recommendations for international travelers:
·         WHO yellow fever risk mapping and recommended vaccination for travelers:
·         WHO International Travel and Health website: strategy for yellow fever epidemic preparedness and response:
Date: Sun 30 Mar 2019
Source: Tribuna do Norte [in Portuguese trans. ProMED Mod.TY, edited]

Infectious disease physicians in the state health network of the Rio Grande do Sul Federal University UFRN) did not confirm that the disease, having symptoms similar to chikungunya [virus infection], observed this past week in 140 residents of 2 neighborhoods of Tirol and Petropolis in Natal [state] is in fact chikungunya. Blood tests done on Sat 23 Mar 2019 on samples from 6 individuals detected the presence of that virus, but the specialist physicians do not discard other hypotheses. Occurrence of this number of cases in less than one month is considered an outbreak.

Investigations were done on 73 cases in order to identify whether there is a mutation of that virus or a new virus in circulation in Natal. "The fact of a confirmation of chikungunya [virus infection] in some of the cases does not close the case [outbreak]," stated Kleber Luz, an infectious disease physician at the Federal University of Rio Grande do Norte.

In a meeting of infectious disease physicians convened for studies in order to identify the virus [responsible for the cases], 4 hypotheses were presented:
- 1st that this could be an arbovirus called "Ross River" that is present in Australia,
- 2nd an arbovirus call Barmah Forest, also in Australia,
- 3rd Mayaro virus present in other states of Brazil since 2016,
- Last, it could be a modification [mutant] of chikungunya [virus] caused by the circulation of another virus [another type of chikungunya virus? - ProMED Mod.TY]
All are transmitted by the _Aedes aegypti_ mosquito [not correct. See comment below. - ProMED Mod.TY].

The profile of the ill individuals:
The majority are women with a median age of 58 years. No children were identified with the disease. The majority are residents and workers in the Tirol neighborhood, a locality in which the numbers of _Aedes aegypti_ mosquitoes increased according to the municipal surveillance team. The most frequent symptoms are pain in the joints, fever and rash.

It is the unusual nature of the symptoms that impede the diagnosis as chikungunya [virus infection], Zika [virus infection] or dengue. For example: the majority of the patients examined present with arthralgia, sores in the mouth and fever, which are common in chikungunya cases, but also have a rash which is common in Zika cases, but with strong itching; a symptom that the new patients have is itching, but not to the point of troubling them as in Zika [virus infections].

The symptoms of the new cases are less intense than the known diseases and appear more rapidly. Most of the patients feel pain in the soles of their feet on the 1st day [of illness]; when this pain happens in known chikungunya cases, generally it appears during the 2nd week.

"A patient told me, 'Doctor, when I decelerate (step on the clutch) of the car, it hurts a lot.' This pain of the soles of the feet only appears at the end of [chikungunya] disease," said Kleber.

This difference does not mean that this could be a new virus. During the meeting, the infectious disease physician Andre Prudente called attention to the "spectrum" of symptoms that arboviruses produce. "The big problems with arbovirus diseases is that the spectrum of symptoms is very wide. Some patients have intense pain, and others do not. And this can be with the same disease [virus]," he explained.

"Some symptoms seem to be a milder chikungunya," a caveat offered by infectious disease physician Kleber Luz. He accredits this to the hypothesis of a modified virus but will not discard the others [hypotheses] until the end of the investigation. "That is to say, laboratory tests, and until then, we will continue to work with all the hypotheses. I believe that it is chikungunya, but not only that."

The specialists discussed the progress of the studies.

Hypotheses raised up to now:
- A modified chikungunya or other virus is circulating or present in the people.
This hypothesis takes into consideration that the chikungunya virus could have had a modification from another [chikungunya] virus in circulation. This could explain why patients had chikungunya [virus] present in their blood but with symptoms different from the disease.

Ross River arbovirus, for its similarity of symptoms
Transmitted by _Aedes aegypti_, Ross River [virus] causes joint pains,rash, but unlike the symptoms identified in Natal, the rash appears just 10 days after illness. [In Australia, the recognized vectors for Ross River virus are _Aedes vigilax_, _Ae. camptorhynchus_, and _Culex. annulirostris_. _Aedes aegypti_ is not considered a significant vector. - ProMED Mod.TY]

Barmah Forest arbovirus is also present in Australia
Barmah Forest virus also causes similar symptoms, mainly a red rash. They are similar to those of Ross River [virus infections] but the symptoms last longer. Another similarity is that Barmah [Forest virus] is found in possums. According to some of the physicians present in the meeting, there are species of possums in Dunas Park near Tirol, a place most related to the cases. [The recognized vectors of Barmah Forest virus in Australia are: _Ochlerotatus vigilax_, _Culex annulirostris_, _Aedes (Oc.) camptorhynchus_, _Ae. normanensis_, and _Coquillettidia spp._. _Aedes notoscriptus_ is considered an additional potential vector (see ProMED-mail archive Barmah Forest virus - Australia: (TS) _Aedes aegypti_ is not considered a significant vector of this virus. - ProMED Mod.TY]

Mayaro arbovirus, present in Brazil but never identified in Ro Grande do Norte Cases of Mayaro, an arbovirus similar to those in Natal, are related to Goiania. The symptoms are similar and [the virus occurs] near cities with forests [as is the case with Goiania and wetlands; in Natal Dunas Park) which is a common factor.

[Mayaro virus was 1st isolated by Charles Anderson and his colleagues during the 1950s from humans with febrile illnesses in Trinidad. Mayaro virus has since been identified in the Amazon and other tropical regions (Trinidad, Suriname, French Guyana, Brazil, Peru, Bolivia, and Venezuela) and more recently in Haiti. In South America, it has been shown mostly to be transmitted by _Haemogogus_ mosquitoes. However, the urban mosquito _Aedes aegypti_ has now been also shown to be an experimental vector of the virus and was recovered from this mosquito captured in Mato Grosso state.

[There follows a summary of the observations, discussion and points covered in the above text. - ProMED Mod.TY]
[Occurrence of Ross River or Barma Forest viruses in Natal state, Brazil, is very unlikely. Mayaro virus is a much more likely possibility. The laboratory tests that were done identified chikungunya virus (CHIKV), but apparently, differences in the clinical picture caused the infectious-disease physicians to doubt that diagnosis or instead postulate a variant of that virus that causes milder disease. The type of test that was done that detected the virus (or RNA?) in the blood of affected patients is not specified. There is no mention of whether mosquitoes, especially _Aedes aegypti_, were collected in the area where the cases occurred and were tested for the presence of viruses. Until further laboratory tests are completed, the only laboratory-based evidence points to CHIKV infections. ProMED would appreciate receiving additional information as it becomes available. - ProMED Mod.TY]

[Regarding unidentified febrile disease in Rio Grande do Norte, 23 of 34 samples examined suggested CHIKV infection (there is no information about if the tests performed were serological and/or biomolecular tests). On 25 Mar [2019], it was informed by local public health authorities that there is the circulation of all DENV serotypes, ZIKAV, and CHIKV. The director of the Natal Health Surveillance Department said, "I do not consider that [the disease] is any mystery. We have 6 types of arboviruses circulating in the [Tirol] municipality: dengue types 1, 2, 3, and 4; Zika virus; and chikungunya [virus]." ([in Portuguese]).

Despite the lack of more qualified clinical, epidemiological, and laboratorial clues, it should be considered that the current circulating arboviruses are the most probable agent of this apparent cluster. - ProMED Mod.RNA]

[HealthMap/ProMED-mail map:
Brazil: <>]
More ...