Date: Fri 31 May 2019
Source: G1 [in Portuguese, trans. ProMED Corr.SB, abridged, edited]

The epidemiology department of the Santarem public health network in western Para is investigating a case of suspected human rabies in a patient who arrived in the city on Thursday night [30 May 2019) from Ruropolis, in Para state.

The patient, a boy only 9 years old, who came from Ruropolis with a referral to TOD (treatment out of domicile) is hospitalized at the Municipal Hospital Dr Alberto Tolentino Sotelo (HMS/Santarem Municipal Hospital). Due to the suspicion of human rabies, the child was placed in an isolation room, where he is receiving medication and going through collection of material for [laboratory] examination.

Through a notice, the Municipal Hospital reported that the epidemiology team at HMS, led by 2 infectious diseases experts, is monitoring the case. Among possible diseases, human rabies is suspected.

Blood, and saliva tests are in the process of being collected and will be sent to the authorized laboratory in Belem. The results should arrive the next week [week of 3 Jun 2019].

Also according to the notice, the clinical picture of the patient is serious. He is intubated in the unit's isolation room.
[As my ProMED-Port colleague RNA commented this account lacks any information on how this boy might have been exposed and when, when did his symptoms start, and whether he is receiving the appropriate post-exposure immune serum and vaccine. Treatment of human rabies cases once symptoms have started is difficult and rarely successful though latterly, with better knowledge, there have been successes.

HealthMap/ProMED-mail map of Brazil:

Ruropolis is a municipality in the state of Para in the northern region of Brazil. The municipality contains part of the Trairao National Forest, in which logging is permitted subject to a management plan. It also holds part of the Tapajos National Forest, a 549,067 hectares (1 356 770 acres) sustainable use conservation unit created in 1974 (<>). This amount of woodland raises the possibility that this boy, if he has rabies, was infected by a bat. Bat rabies is common in Brazil. Of course it could have been from a rabid dog. - ProMED Mod.MHJ]

[More information on the results of testing and epidemiologic information such as route of transmission and location of exposure would be greatly appreciated. - ProMED Mod.MPP]
Date: Fri 24 May 2019
Source: Virologica Sinica [edited]

[Concern about yellow fever (YF) vaccine availability has been increasing following the large outbreak in Angola and the Democratic Republic of the Congo and more recently in Brazil. Because YF vaccine supplies were not adequate to provide full 0.5 ml doses during those outbreaks, a 1/5th fractional dose was used. The abridged report below reviews the situation and proposes measures to be taken. - ProMED Mod.TY]

Daniel R Lucey, Kristen R Kent. Boosting global yellow fever vaccine supply for epidemic preparedness: 3 actions for China and the USA. Virol Sin. (2019). <>

In 2016, 2 unprecedented events occurred regarding yellow fever flavivirus infection and vaccine. 1st, in China, 11 persons were diagnosed with yellow fever virus after being infected while working in Angola and returning to China in March-April 2016 (WHO 2016a; Wang et al, 2016; Chen et al, 2016). No transmission within China occurred (Chen and Lu 2016). These were the 1st persons anywhere in Asia known to have laboratory-documented yellow fever infection. 2nd, a global shortage of yellow fever vaccine resulted in the 1st-ever use of a fractional (1/5th) normal dose of yellow fever vaccine anywhere in the world when it was given to 7.5 million people in Kinshasa, Democratic Republic of the Congo (DRC) in August 2016 (Monath et al. 2016; WHO 2016b).
These 2 events catalyzed multiple reports about the potential risk and implications of yellow fever epidemics occurring for the 1st-time ever in China or anywhere else in Asia where the _Aedes aegypti_ vector for yellow fever and dengue exists - for example, India, Pakistan, Thailand, Indonesia and beyond (Wasserman et al, 2016: Baumgaertner 2016; The Economist 2016; Schlagenhauf and Chen 2017; Wilder-Smith and Leong 2017; Lucey and Donaldson 2017; Brey et al, 2018; Shearer et al, 2018; Musso et al, 2018; Wilder-Smith and Massad 2018; Brent et al, 2018). Moreover, this fractional dosing of vaccine in Kinshasa in 2016 signified that if additional outbreaks occurred soon after anywhere in the world - for example, Africa, Latin America or Asia, then shortages of full-dose vaccine would likely occur as well.

WHO created the 1st-ever "Global strategy for eliminating yellow fever epidemics (EYE) 2017-2026" program in September 2016 (WHO 2016d). This program estimated that 1.38 billion doses of yellow fever vaccine would be required to eliminate yellow fever epidemics from endemic areas in sub-Saharan Africa and in Latin America and the Caribbean (WHO 2016d). This projected 1.38 billion doses of vaccine did not include any doses for Asia, a continent with no prior yellow fever transmission or vaccination campaigns, and, therefore, immunologically-susceptible to yellow fever epidemics.

Of concern, in Brazil throughout 2018 and into 2019, a YF vaccine shortage required use of the fractional (1/5th) dose involving at least 21 million persons (PAHO 2018, 2019). Due to their national vaccine shortage, Brazil was no longer able to export YF vaccine, as they had done for use in Angola and DRC in 2016. Of note, only the Brazilian vaccine has been used for fractional dosing. Thus, vaccine being used outside of Brazil - for example, sub-Saharan Africa, in 2018 was full-dose vaccine.

Actions to boost YF vaccine supply by China and the USA:

We advocate for 3 actions to be taken by the USA and China to help boost global supply of YF vaccine and increase epidemic preparedness and response. 1st, both nations would work with the WHO to have their YF vaccines prequalified. Thus, their vaccines could be used outside their own borders as part of the international stockpile of YF vaccine as traditionally administrated by the WHO, UNICEF and other members of the multi-partner International Coordinating Group (ICG). 2nd, production of this vaccine would be sharply scaled up by both countries. These vaccines could be made available nationally, regionally, and globally through the ICG - for example, to help stop and prevent epidemics anywhere in the world. 3rd, clinical studies would be coordinated with the WHO to assess the efficacy and safety of fractional dosing using 1/5th normal dose and, if needed, even a 1/10th dose.
[Readers interested in the YF vaccine situation are encouraged to read the full report available at the above URL. Unfortunately, it is available only through subscription or purchase. - ProMED Mod.TY]
Date: Fri 17 May 2019
Source: The Rio Times [edited]

A new threat to public health haunts the state of Rio de Janeiro: Scientists at the Federal University of Rio de Janeiro (UFRJ) have discovered that a virus with symptoms similar to those of the chikungunya virus [infection] may precipitate an epidemic in the Southeast.

Both have similar characteristics, such as disabling intense joint pains that last for months. There is no vaccine or any specific treatment.

Laboratory tests have shown that the Mayaro virus can be transmitted by both the _Aedes_ mosquito and the common mosquito (_Culex_). According to Amilcar Tanuri, coordinator of the Laboratory of Molecular Virology at UFRJ, where the study was carried out, this increases the risk of an epidemic.

Mistaken for chikungunya [virus], Mayaro [virus] has been present in Rio since 2016. Additionally, the gravity of the discovery lies in the fact that the cases are autochthonous, meaning the victims were infected here, rather than in other locations. To date, 3 cases are known, all from Niteroi.
[Mayaro virus (MAYV) has been found to cause human disease in other areas in Brazil. This is the 1st report of Mayaro virus infection in Rio de Janeiro state that ProMED-mail has posted. The 1st report of Mayaro virus cases was in 1955, in an outbreak in Para state, Brazil. In 2011, thousands of cases of Mayaro fever were reported an outbreak occurred in Manaus, Amazonas, Brazil.

As ProMED Mod.JT noted in an early ProMED-mail post, MAYV, of the _Alphavirus_ genus, Togaviridae family, is endemic in tropical areas of South America (Trinidad, Suriname, French Guyana, Brazil, Peru, Bolivia and Venezuela). The transmission cycle is very similar to yellow fever virus, utilizing primates as reservoirs and _Haemagogus_ mosquitoes as vectors.

MAYV has been associated with a variety of mosquitoes that are possible vectors that can transmit it humans. MAYV has been isolated from _Aedes aegypti_ and _Culex quinquefasciatus_ captured in the field in Brazil. _Anopheles_ mosquitoes have been implicated as important virus vectors (see references below).

Brustolin M, Pujhari S, Henderson CA, Rasgon JL. _Anopheles_ mosquitoes may drive invasion and transmission of Mayaro virus across geographically diverse regions. PLoS Negl Trop Dis 2018;12(11):e0006895. <> Serra OP, Cardoso BF, Ribeiro AL, et al. Mayaro virus and dengue virus 1 and 4 natural infection in culicids from Cuiaba, state of Mato Grosso, Brazil. Mem Inst Oswaldo Cruz 2016;111(1):20-9.  <>

Several public health experts have expressed concern that MAYV could become a significant problem in the tropical Americas. - ProMED Mod.TY]

[HealthMap/ProMED-mail maps:
Brazil: <>
Rio de Janeiro State, Brazil: <>]
Date: 6 May 2019
Source: [in Portuguese, machine trans. edited]

Santa Catarina has recorded its 1st case of human rabies in 38 years.

The Office of Epidemiological Surveillance of Santa Catarina (DIVE/SC), linked to the Superintendence of Health Surveillance (SUV) of the State Health Department (SES/SC), reports that laboratory diagnosis was confirmed by the Laboratory Institute Pasteur as rabies for the death of a 58-year-old woman living in a rural area of the municipality of Gravatal, last Saturday (4 May 2019).

The samples were sent to Sao Paulo by the Central Laboratory of Public Health (LACEN/SC). Santa Catarina had not registered cases of rabies in humans since 1981, when a patient from Ponte Serrada was a victim of the disease. The last cases of rabies in dogs and cats were recorded in 2006, in the municipalities of Xanxere (1 dog and 1 cat), Itajai (1 dog), and in 2016, in Jabora (1 dog).

DIVE/SC technicians were present on Mon 6 May 2019 in the municipality of Tubarao meeting with the Regional Health Management, the Municipal Health Department of Gravatal and Capivari de Baixo, CIDASC (Integrated Company for Agricultural Development of Santa Catarina) and UNISUL for the development of actions, according to the protocol of the Ministry of Health, considering Santa Catarina is a controlled area for animal rabies in the urban cycle. The actions involve home-to-house vaccinations of dogs and cats within a 5-mile radius from the patient's home as well as active search for sick and dead animals and population orientation. "In addition, if a person is attacked by a dog or any other animal, it is very important to seek health services even if the injury is not serious, as there may be a need to take the vaccine against rabies," says John Fuck, manager of Zoonoses of Dive/SC.

Vaccination of all dogs and cats is the most effective form of protection against the disease. The vaccination is expected to begin on Thu 9 May 2019. The population of Gravatal and Capivari de Baixo can search for more detailed information about the action directly at the Municipal Health Department. DIVE/SC has already requested 10,000 doses of rabies vaccine for the vaccination scheme.

According to the veterinarian of DIVE/SC, Alexandra Schlickmann Pereira, the population should be attentive to the strange behavior of their pets. "Any change in behavior such as restlessness, increased aggression, limb paralysis and photophobia (sensitivity to light) should be observed and reported to the Municipal Health Department," he warns.

Rabies is a transmissible disease affecting mammals such as dogs, cats, oxen, horses, monkeys, bats and humans when the saliva of the infected animal comes into contact with the skin or mucosal membranes such as eyes, by biting, scratching or licking of the animal. The virus attacks the central nervous system, leading to death after a short time of incubation. Rabies has no established cure (there are only 3 known cases of cure in the world, one in Brazil), and the only way to prevent it is through the vaccine.  [Byline: Amanda Mariano, Bruna Matos, Patricia Pozzo]
[As the article points out, survival is extremely rare once a person shows symptoms after being bitten by a rabid animal, even with treatment.

Rabies post-exposure vaccinations
For people who have never been vaccinated against rabies previously, post-exposure anti-rabies vaccination should always include administration of both passive antibody and vaccine.

The combination of human rabies immune globulin (HRIG) and vaccine is recommended for both bite and non-bite exposures, regardless of the interval between exposure and initiation of treatment.

People who have been previously vaccinated or are receiving pre-exposure vaccination for rabies should receive only vaccine.

Adverse reactions to rabies vaccine and immune globulin are not common. Newer vaccines in use today cause fewer adverse reactions than previously available vaccines. Mild local reactions to the rabies vaccine, such as pain, redness, swelling, or itching at the injection site, have been reported. Rarely, symptoms such as headache, nausea, abdominal pain, muscle aches, and dizziness have been reported. Local pain and low-grade fever may follow injection of rabies immune globulin.

The vaccine should be given at recommended intervals for best results. Talk with your doctor or state or local public health officials if you will not be able to have shots at the recommended interval. Rabies prevention is a serious matter and changes should not be made in the schedule of doses.

People cannot transmit rabies to other people unless they themselves are sick with rabies. The prophylaxis you are receiving will protect you from developing rabies, and therefore you cannot expose other people to rabies. You should continue to participate in your normal activities.

There is no recognized value in administering rabies immune globulin greater than 7 days after initiating a vaccine course, since vaccine-induced antibodies begin to appear within one week.

Portions of this comment were extracted from
<>. - ProMED Mod.TG]

[HealthMap/ProMED map available at:
Santa Catarina, Brazil: <>]
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:
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