Jornadas de arbovirosis: dengue, chikungunya y Zika. Preparación y respuesta de los países del Cono Sur. Buenos Aires, Argentina, 4-5 noviembre 2015.

1. “Introduction of Zika in Brazil:
A personal perspective
Maurício Lacerda Nogueira, MD, PhD
Associate Professor
Department of Microbiology and Infectious Diseases
Faculdade de Medicina de São José do Rio Preto
Senior Visiting Scientist
Virology Section
Fundação de Medicina Tropical – Doutor Heitor Vieira Dourado
Manaus
International Faculty
Center for Tropical Diseases
University of Texas Medical Branch
Galveston, TX, USA
mnogueira@famerp.br

2. ArbovirusesArboviruses
• Over 210 species were isolated in Brazil
– 36 causes human diseases in sporadic, endemic or epidemic forms
– Mostly were identified in the 60´s and 70´s
Togaviridae - Alphavirus
Flaviviridae –Flavivirus
 Bunyaviridae –Orthobunyavirus
VASCONCELOS, 2005; FIGUEIREDO, 2007

3. The Brazilian Flaviviruses
• 14 were known in Brazil:
– Dengue 1 to 4
– SLEV, WNV
– YF
– Bussuquara, Cacipacoré, Iguape, Ilheus, Rocio
– Zika
Nhumirim (?)
Cause: Hemorrhagic diseases (DEN and YF) and/or encephalitis
(Rocio and SLEV)
Bussuquara, Cacipacoré, Iguape, Ilheus - ?????
VASCONCELOS, 2005; FIGUEIREDO, 2007

4. ▪ São José do Rio Preto
Size: 432 km² (20°49'12" S 49°22'44" O)
Estimated population: 442.548 hab. (2015)
Weather: Tropical Humid
Annual medium temperature: 23.6 °C
Annual average rainfall: 1400 mm
IDHM: 0,797
→ Hyperendemic for DENV
IBGE, 2010.

5. ▪ Dengue cases in SJRP since 2006
Years Official data:
Divisão de Zoonoses, CVE and SINAN
2014 15381
2013 33772
2012 773
2011 3834
2010 36133
2009 2097
2008 621
2007 9346
2006 24108
DENV-1/4
DENV-4
DENV-1
DENV-2
DENV-3

6. DENV by serotype during 2006 to 2014 in
SJRP

7. Yellow Fever

8. Yellow Fever in Sao Paulo and
Brazil
• 1990 to 2007 – only 2cases in SP
– “2008 - Mendonça (NHP) and Human Cases in
Ribeirao Preto and Sao Carlos Region
• 2009 – Outbreak in Botucatu (over 20 human
cases)
• After 2010 – Increase # cases and distribution
– Rio Grande do Sul
• 2015 - NHP cases in Brasilia

9. YF Vaccine Coverage 2012

10. Different Viruses – Same
symptoms: The SLEV –Dengue co-
circulation in SP

11. SLEV in SP
• Several isolations in 1967 to 1969
– Rodents, sentinels and birds
• Itapetininga, Casa Grande e Guaratuba
• Isolated in 1993 - Pereira Barreto
• Anopheles
• Isolated in Araçatuba
– Culex
– 5% ab prevalence in the region (no dengue at the time)
• High level of circulation between 2005-2006(IAL)

14. SLEV in Ribeirão Preto, 2009
Felipe Gonçalves M. Maia,
Juliana Helena Chavez,
Benedito Antonio L. Fonseca,
Luiz Tadeu M. Figueiredo

15. The clinical epidemiological
diagnosis in a outbreak – our
experience in sjrp

16. Amostra (soro)
Extração de RNA
Duplex-RT-PCR
Primers gênero-específicos para
Alphavirus e Flavivirus
Multiplex-Nested-PCR
Primers espécie-específicos para MAYV,
VEEV, WEEV, EEEV
Nested-PCR
Primer espécie-específico SLEV
Nested-PCR
Primer espécie-específico para
DENV-4, ROCV, ILHV, WNV, BSQV
Multiplex-Nested-PCR
Primers espécie-específicos para DENV 1-
3, YFV
RT-PCR
Primers gênero-específico para
Orthobunyavirus
Nested-PCR
Primer espécie-específico para
OROV
Sample Processing
Eletroforese em gel de agarose
+ -
Bronzoni et al, 2004 e 2005

17. Analyzed samples that were considered dengue only by clinicalAnalyzed samples that were considered dengue only by clinical
and epidemiological criteriaand epidemiological criteria
São José do Rio PretoSão José do Rio Preto
413 samples 325 +
• 320 (77,5%) DENV-3
• 3 (0,7%) DENV-2
• 6 (1,4%) SLEV
 Co infection
• 1 DENV-2 e DENV-3
300 pb
600 pb
M C+ C+
DENV-2 DENV-3
600 pb
200 pb
M C+ C+
SLEV DENV-3 C-
• 3 DENV-3 e SLEV
Terzian et al, 2010 – Vector Borne and Zoonotic Diseases

18. West nile in brazil – another piece
to the flavivirus puzzle

20. RT-PCR and Viral Isolation negative
PRNT90 with High titer to WNV and low to SLEV
Other sorological tests + for WNV

21. RocioRocio
 neurotropic and associate to oubreak
 birds - Aedes sp. and Psorophora sp.
1973 to 1977: outbreak in Vale do Ribeira -1000 cases and 10% fatality rate
Ab in population
Some unpublished reports
Lopes, 1978; Lopes, 1979; Iversson, 1989; Iversson, 1992; Straatmann, Santos-Torres et al., 1997; Travassos Da Rosa, 1997; Figueiredo, 2000; Figueiredo, 2007
Flavivirus
BussuquaraBussuquara
Just 1 human case
Iguape andIguape and
CacipacoréCacipacoré ?

22. Zika: a new flavivirus in brazil

33. GENETIC ANDGENETIC AND
GEOGRAPHICAL ANALYSIS OFGEOGRAPHICAL ANALYSIS OF
ZIKA VIRUS (ZIKV) ISOLATEDZIKA VIRUS (ZIKV) ISOLATED
FROM AN AUTOCHNOUSFROM AN AUTOCHNOUS
CASE IN SÃO PAULO STATE,CASE IN SÃO PAULO STATE,
BRAZIL, 2015BRAZIL, 2015
Presenting author: Mariana Sequetin CunhaPresenting author: Mariana Sequetin Cunha
Núcleo de Doenças de Transmissão Vetorial – Instituto Adolfo Lutz - SPNúcleo de Doenças de Transmissão Vetorial – Instituto Adolfo Lutz - SP

34. Blood donor, male, 52 years,Blood donor, male, 52 years,
from Sumaré (SP) with no travelfrom Sumaré (SP) with no travel
reportedreported
Blood donor, male, 52 years,Blood donor, male, 52 years,
from Sumaré (SP) with no travelfrom Sumaré (SP) with no travel
reportedreported
NDTV/IAL:
20/03

35. Receptor, male, 55 yearsReceptor, male, 55 years
NDTV: 27/03 NDTV: 17/04

36. ResultsResults
Blood Donor
This sample was
retrieved from
HC/UNICAMP and
was sent later to
NDTV
Receptor

37. Receptor SampleReceptor Sample
IFA Anti-flavivirus
Positive
RT-PCR/IFA Anti-DENV
Negative
RT-PCR
SLEV
RT-PCR
WNV
RT-PCR YFV
Zika Virus RT-PCR
Positive
(Lanciotti et al., 2008)
NSP5 sequenced
Applied Biosystems
377 DNA sequencer
NSP5 sequenced
Applied Biosystems
377 DNA sequencer

41. Dengue kills, so lets assume that all cases
are dengue and treat them like it until
prove otherwise. What about the $
impact?

42. CHIKV en Las Américas 42

43. 2 points before the end

44. 1 - Arboviruses surveillance in
Brazil (and SA?)
• Only data from official labs (IEC, IAL, etc..) are considered as
real
• Patients with encephalitis or hemorrhagic fever only get to
medical attention after the viremia is over (only serology for
diagnosis)
• Most if not all arbovirus suspected infections will be
considered dengue (or now Zika or CHIKV) in the initial
approach, and will be tested only for this (if tested at all)
• There will be a large number of cross reaction for dengue as
the population is mostly YF vaccinated and dengue exposed
• Brazil has a strong network of university based labs, that have
capacity and technology to do virus surveillance
• It HAS to be used (and funded)

45. 2 - Public Health X Individual care
• Brazil has a large number of health insurance
covered population
• They (and their doctors) don’t accept clinical-
epidemiological diagnosis
• There will be a pressure for private and university
labs to develop and use molecular tests for ZKV and
CHKV
– Lack of “controls” : eg: My lab (I will not have a
Zika control, until I isolate and sequence a Zika
virus as I did with CHKV….)
– Data will be not officially counted as cases

46. Flavivirus challenges in Brazil
• Co circulation of several viruses
• Lack of RT-PCR or viral isolation in large majority of
the cases
– No PCR in prodromal phases , except in
universities* or by chance in dengue surveillance -
*They do NOT exist officially
• Diagnosis made by either serology or clinical
epidemiological data
• Lack of confidence in flavivirus serology in a
population YF vaccinated and dengue primed
• Low levels of diagnosis of SLEV, WNV, Rocio, etc… -
Everything is DENGUE!!

47. Take home....
• DENGUE is not the only arbovirus causing diseases in
Brazil.
• Mayaro, SLEV and Oropouche are being detected in
Brazil.
• YFV is going to the south of brazil and to new areas.
• WNV, CPC, ILHV, etc…
• Introduction of ZIKA and CHKV
– The number of Zika cases are not known? They
probaly are in several thousand cases
• Surveillance is mandatory, but it has to be
decentralized and shared with university and private
labs

48. LPV-FAMERP
Maurício L Nogueira, MD, PhD
Roberta V M Bronzoni, DVM, PhD
Adriano Mondini, MSc, PhD
Eliane Fávaro, PhD
Alessandra Vidotto, PhD
Danila Vedovello, PhD
Joice Biseli, PhD
Carolina Pacca, PhD
Ana Carolina Terzian, DVM, PhD
Ana Theresa Morais, PhD
Danilo Vilas Boas Duarte, MSc
Ariele Gavioli, DVM, MSc
Daiane Machado
Faculdade de Saúde Pública - USP
Francisco Chiaravalloti Neto, PhD
ICB/USP
Paolo Zanotto, PhD
Marcelo Urbano Ferreira, MD, PhD
UFJF
Betania Drummond, PhD
FMRP – USP
Luiz Tadeu Moraes Figueiredo, MD, PhD
IBILCE-UNESP
Paula Rahal, PhD
UFPE
Ana Cristina Lima Leite, PhD
UQ - Australia
Alex Kromikh, PhD
CDC
Nick Komar, PhD
MSSM
Ana Sesma, PhD
MIT
Lee Gerkh, PhD
Irene Bosch, PhD
UTMB
Nikkos Vasilakis, PhD
Scott Weaver, PhD
Jonatham Auguste, PhD
UFMG
Erna Kroon, PhD
Alvaro Eiras, PhD
Mauro M Teixeira, MD, PhD

49. https://www.facebook.com/#!/groups/205746489469432/