Human T-cell leukemia virus type 1 infection among Japanese immigrants and their descendants living in Southeast Brazil: A call for preventive and control responses.

Human T-cell leukemia virus type 1 (HTLV-1) has worldwide distribution and is considered endemic in southwestern Japan. HTLV-1 infection has been associated with adult T-cell leukemia/lymphoma (ATL) and HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) besides other diseases. This cross-sectional study aimed to investigate the prevalence, risk factors and molecular characterization of HTLV-1, among the world's largest population of Japanese immigrants and their descendants outside of Japan, in São Paulo, Southeast Brazil, as well as to analyze the phylogenetic relationship among isolates of HTLV-1. From July to December 2017, 2,139 individuals from five Japanese associations were interviewed and submitted to blood collection. All serum samples were first tested for the presence of anti-HTLV-1/2 antibodies by ELISA and then peripheral blood from individuals with positive serological results were analyzed for the presence of HTLV-1 5'LTR proviral DNA. Partial sequencing of the 5'LTR region of HTLV-1 proviral DNA was performed by Sanger. The prevalence of HTLV-1 infection was 5.1% (CI 95%: 4.2-6.0). In the multiple logistic regression model, HTLV-1 infection was associated with age ≥ 45 years, female sex, being first and second-generation Japanese immigrants, and having sexual partners with history of blood transfusion. The phylogenetic analysis revealed that all HTLV-1 were classified as Cosmopolitan (1a) subtype. Of them, 47.8% were classified as Transcontinental (A) subgroup and 52.2% as belonging to the Japanese (B) subgroup. Although most HTLV-1-infected patients were asymptomatic (97.3%), blurred vision was associated with HTLV-1 infection. The high prevalence of HTLV-1 infection found in this studied population and especially the intra- and interfamily HTLV-1 transmission presents an urgent call for preventive and control responses of this infection in Brazil.

The QualiRede intervention: improving the performance of care continuum in HIV, congenital syphilis, and hepatitis C in health regions.

INTRODUCTION: Care continuum models have supported recent strategies against sexually transmitted diseases, such as HIV and Hepatitis C (HCV). METHODS: HIV, HCV, and congenital syphilis care continuum models were developed, including all stages of care, from promotion/prevention to clinical control/cure. The models supported the intervention QualiRede, developed by a University-Brazilian National Health System (SUS) partnership focused on managers and other professionals from six priority health regions in São Paulo and Santa Catarina. Indicators were selected for each stage of the care continuum from the SUS information systems and from the Qualiaids and QualiAB facility's process evaluation questionnaires. The indicators acted as the technical basis of two workshops with professionals and managers in each region: the first one to identify problems and to create a Regional Technical Group; and the second one to design action plans for improving regional performance. RESULTS: The indicators are available at www.qualirede.org. The workshops took place in the regions of Alto Tietê, Baixada Santista, Grande ABC, and Registro (São Paulo) and of Foz do Rio Itajaí (Santa Catarina), which resulted in regional action plans in São Paulo, but not in Santa Catarina. A lack of awareness was observed regarding the new HIV and HCV protocols, as well as an incipient use of indicators in routine practices. CONCLUSION: Improving the performance of the care continuum requires appropriation of performance indicators and coordination of care flows at local, regional, and state levels of management.

IgG reactivity with 40-35 kDa soluble and membrane antigen of Strongyloides venezuelensis in immunocompromised patients.

Immunocompromised patients constitute a risk group for the development of severe clinical forms of human strongyloidiasis. The diagnosis of this infection is primarily performed by parasitological techniques, but with low sensitivity. Serological techniques appear as an alternative, especially with heterologous antigens use. The aim of this study was to perform the Western blot technique by using S. venezuelensis infective third stage larva (iL3) soluble (TS) and membrane (TM) saline antigens to reveal immunoreactive bands in immunocompromised patients with strongyloidiasis. Serum samples from 117 parasitologically well-characterized patients were divided into four groups: S. stercoralis positive and immunocompetent (S + IC); S. stercoralis positive and immunocompromised (S + IP); negative and immunocompetent (S-IC); negative and immunocompromised (S-IP). A 40-35 kDa band was recognized by 100% of patients in the S + IC group in both antigenic fractions, and by 62.5% and 50% in the S + IP group using the TS and TM fractions, respectively. A 29 kDa band was recognized by 86.3% and 72.7% (for TS and TM, respectively) of patients in the S + IC group, and only by 12.5% of patients in the S + IP group on the TM antigen. Regardless of the patients' immunological condition, the 40-35 kDa band from S. venezuelensis was detected more frequently and can be used as an important marker to the immunodiagnosis of human strongyloidiasis.

The QualiRede intervention: improving the performance of care continuum in HIV, congenital syphilis, and hepatitis C in health regions / A intervenção QualiRede: melhoria do desempenho do contínuo do cuidado em HIV, sífilis congênita e hepatite C em regiões de saúde

ABSTRACT Introduction: Care continuum models have supported recent strategies against sexually transmitted diseases, such as HIV and Hepatitis C (HCV). Methods: HIV, HCV, and congenital syphilis care continuum models were developed, including all stages of care, from promotion/prevention to clinical control/cure. The models supported the intervention QualiRede, developed by a University-Brazilian National Health System (SUS) partnership focused on managers and other professionals from six priority health regions in São Paulo and Santa Catarina. Indicators were selected for each stage of the care continuum from the SUS information systems and from the Qualiaids and QualiAB facility's process evaluation questionnaires. The indicators acted as the technical basis of two workshops with professionals and managers in each region: the first one to identify problems and to create a Regional Technical Group; and the second one to design action plans for improving regional performance. Results: The indicators are available at www.qualirede.org. The workshops took place in the regions of Alto Tietê, Baixada Santista, Grande ABC, and Registro (São Paulo) and of Foz do Rio Itajaí (Santa Catarina), which resulted in regional action plans in São Paulo, but not in Santa Catarina. A lack of awareness was observed regarding the new HIV and HCV protocols, as well as an incipient use of indicators in routine practices. Conclusion: Improving the performance of the care continuum requires appropriation of performance indicators and coordination of care flows at local, regional, and state levels of management.

RESUMO Introdução: Modelos de cuidado contínuo baseiam recentes estratégias em HIV, infecções sexualmente transmissíveis e hepatite C (HCV). Métodos: Desenvolveram-se modelos de contínuo do cuidado em HIV, HCV e sífilis congênita incluindo todas as etapas da atenção, desde a promoção e a prevenção até o controle clínico/cura. O modelo baseou a intervenção QualiRede, desenvolvida em parceria entre universidade e Sistema Único de Saúde (SUS), direcionada a gestores e demais profissionais de 6 regiões de saúde prioritárias em São Paulo e Santa Catarina. Selecionaram-se indicadores para cada etapa do contínuo do cuidado, provenientes dos sistemas de informação do SUS e dos questionários de avaliação de processo Qualiaids e QualiAB. Os indicadores formaram a base técnica de duas oficinas com profissionais e gestores de cada região: a primeira para identificar problemas e formar um Grupo Técnico Regional; e a segunda para construir planos de ação e metas a fim de melhorar o desempenho regional. Resultados: Os indicadores estão disponíveis no website www.qualirede.org. As oficinas ocorreram em quatro regiões de São Paulo (Alto Tietê, Baixada Santista, Grande ABC e Registro) e uma região de Santa Catarina (Foz do Rio Itajaí), resultando em planos regionais em São Paulo, mas não em Santa Catarina. Observou-se domínio limitado dos novos protocolos para HIV e HCV e uso incipiente de indicadores na rotina dos serviços. Conclusão: Melhorar o desempenho do contínuo do cuidado exige apropriação dos indicadores de desempenho e coordenação integrada dos fluxos de atenção em todos os níveis de gestão.

DIAGNOSIS OF Strongyloides stercoralis INFECTION IN IMMUNOCOMPROMISED PATIENTS BY SEROLOGICAL AND MOLECULAR METHODS.

Strongyloidiasis is a potentially serious infection in immunocompromised patients. Thus, the availability of sensitive and specific diagnostic methods is desirable, especially in the context of immunosuppressed patients in whom the diagnosis and treatment of strongyloidiasis is of utmost importance. In this study, serological and molecular tools were used to diagnose Strongyloides stercoralis infections in immunosuppressed patients. Serum and stool samples were obtained from 52 patients. Stool samples were first analyzed by Lutz, Rugai, and Agar plate culture methods, and then by a quantitative real time polymerase chain reaction (qPCR). Serum samples were evaluated by an enzyme-linked immunosorbent assay (ELISA) using a soluble (AS) or a membrane fractions antigen (AM) obtained from alkaline solutions of the filariform larvae of Strongyloides venezuelensis. Of the 52 immunosuppressed patients, three (5.8%) were positive for S. stercoralis by parasitological methods, compared to two patients (3.8%) and one patient (1.9%) who were detected by ELISA using the AS and the AM antigens, respectively. S. stercoralis DNA was amplified in seven (13.5%) stool samples by qPCR. These results suggest the utility of qPCR as an alternative diagnostic tool for the diagnosis of S. stercoralis infection in immunocompromised patients, considering the possible severity of this helminthiasis in this group of patients.

Ser Irmão de uma Pessoa Surda: Relatos da Infância à Fase Adulta / Being the Sibling of a Deaf Person: Reports from Childhood to Adulthood

RESUMO: o objetivo do presente estudo foi analisar a experiência de irmãos de pessoas surdas acerca de sua história de vida e das implicações da deficiência nos relacionamentos fraternos. Tratou-se de um estudo exploratório, de abordagem qualitativa, que contou com a participação de cinco irmãos de pessoas surdas com idade entre 31 a 44 anos. Para a coleta de dados foram utilizados os seguintes instrumentos: questionário de identificação e roteiro de entrevista em profundidade. Os dados obtidos foram analisados a partir do modelo de produções de sentido das práticas discursivas. Os principais resultados apontaram que a dificuldade de comunicação entre os participantes e seus irmãos surdos repercutiu em questões nos relacionamentos desde a infância até a fase adulta. Considera-se que as questões inerentes à deficiência trouxeram consequências a todos os membros da família, em especial nos quesitos relacionamentos e comunicação e que disponibilizar atenção especializada aos pais e irmãos destas pessoas auxiliaria no manejo das situações vinculadas à deficiência e fortalecimento dos vínculos familiares.

ABSTRACT: The aim of this study was to analyze the experience of deaf persons' siblings about their life stories and the implications of the disability in fraternal relationships. This was an exploratory study of qualitative approach, which included the participation of five siblings of deaf persons aged 31-44 years. The following instruments for data collection were used: identification questionnaire and in-depth interview guide. Data were analyzed from Social Representation Analysis. The main results showed that the difficulty in communicating with their deaf siblings reflected in difficulties in relationships that persisted from childhood to adulthood. It is considered that the issues relating to the disability brought repercussions to all family members, especially in the communication and relationship categories and that providing specialized care to the parents and siblings of deaf persons would help in coping with situations related to the disability and in strengthening family ties.

Cotidiano e estresse de avós de crianças com deficiência e de avós de crianças com desenvolvimento típico / Daily life and stress of grandmothers of children with disabilities and of grandmothers of children with typical development

O aumento da expectativa de vida e a diminuição da natalidade tem feito com que por um período de tempo mais longo as gerações possam interagir e se relacionar. Contudo, os efeitos dessa mudança contemporânea ainda tem sido alvo de poucos estudos. O objetivo do presente estudo foi identificar a experiência de avos de crianças com deficiência intelectual e de crianças com desenvolvimento típico acerca do cotidiano e das praticas de apoio exercidas no contexto familiar e sobre a percepção do estresse dentre as participantes do estudo. O estudo qualitativo e comparativo contou com a participação de doze avos de crianças com deficiência intelectual ou de crianças com desenvolvimento típico. As avós foram separadas por dois grupos e responderam a uma entrevista semiestruturada e a um instrumento de avaliação de estresse. Os resultados apontaram que as avós são importante fonte de ajuda as famílias, conferindo diferentes tipos de auxilio. Alem disso, de acordo com o relato das avós, estas se encontram estressadas independentemente da condição do neto, se com deficiência ou não. Reforça-se a necessidade de estudos futuros que possam ampliar a compreensão acerca do cotidiano de avos, mensurar o estresse e identificar as fontes de apoio social recebidas.

The increase in life expectancy and declining birth rates have meant that for a longer period of time generations can interact and relate. However, the effects of this contemporary change has yet been the subject of few studies. The purpose of this study was to identify the experience of grandmothers of children with intellectual disabilities and of children with typical development, about the daily life and support practices carried out in the family context and the perception of stress among the study participants. The qualitative and comparative study had the participation of twelve grandmothers of children with intellectual disabilities or children with typical development. The grandmothers were separated into two groups and answered a semi-structured interview and a stress assessment instrument. The results indicated that grandmothers are an important source of help to families, providing different types of assistance. In addition, according to the report of the grandmothers, they are stressed regardless of the grandchild condition if disabled or not. The need for future studies is reinforced to expand the understanding of the daily lives of grandmothers, measuring stress and identify the sources of social support received.

Immunofluorescence assay for diagnosis of strongyloidiasis in immunocompromised patients.

BACKGROUND: Strongyloides stercoralis is a parasite that causes human strongyloidiasis. The disease ranges from asymptomatic to severe forms, which are often fatal in immunocompromised individuals. Laboratory diagnosis is challenging owing to limitations in the use of conventional parasitological techniques. The present study aimed to evaluate the indirect immunofluorescence assay (IFA) using infective larvae of S. venezuelensis as an antigen for the immunodiagnosis of human strongyloidiasis in immunocompromised patients. METHODS: Serum and stool samples from 200 immunocompromised patients (HIV-positive, HTLV-1-positive, and renal, liver, and/or bone marrow transplantation candidates) were used. Stool samples were examined using three parasitological methods: Lutz, Rugai, and culture agar plate. IFA was performed using sections of infective larvae of S. venezuelensis as antigens, and showed 95.4% sensitivity and 95.8% and specificity. RESULTS: Among the 200 patients, 17 (8.5%) were positive for S. stercoralis by at least one parasitological method, and 43 (21.5%) were positive by IFA. CONCLUSIONS: IFA can be used as a screening method for the detection of S. stercoralis in immunocompromised patients.

Apoio intergeracional em famílias com crianças com deficiência / Intergenerational support for families of children with disabilities / Apoyo intergeneracional en las familias con niños con discapacidades

As distintas formas de comportamento entre as gerações influenciam a qualidade das relações familiares, as quais permitem que o indivíduo se construa, desenvolva-se e se realize como um ser social. Neste artigo, objetivou-se identificar a experiência de avós e de mães de famílias de crianças com deficiência intelectual, acerca do cotidiano, das práticas de apoio e da intergeracionalidade. O estudo exploratório de abordagem qualitativa contou com a participação de seis mães e seis avós de crianças/adolescentes com deficiência intelectual. Para a coleta de dados, foram utilizados roteiros de entrevistas semiestruturadas. Os principais resultados apontaram que as práticas de apoio exercidas no contexto familiar integram o cotidiano das avós e representam importante fonte de apoio às mães e aos netos. Além disso, o estudo apontou a importância dos relacionamentos intergeracionais, tendo em vista os benefícios por eles produzidos para ambas as gerações envolvidas. Considerando-se a heterogeneidade das famílias brasileiras, aponta-se ainda para a necessidade de estudos intergeracionais que focalizem a opinião de diferentes gerações em localidades e contextos distintos.

The different forms of behavior among generations influence the quality of family relationships, which allow the individual to build, to develop and to achieve himself as a social being. This study aimed to identify the experience of the grandmothers and the mothers of families of children with intellectual disabilities, regarding their everyday life, the support and the intergenerationality practices. The exploratory study of qualitative approach had the participation of six mothers and grandmothers of six children / adolescents with intellectual disabilities. Semi-structured interviews scripts were used to collect the data. The main results showed that support practices exercised within the family are part of the grandparents' daily lives and represent an important source of support for mothers and their grandchildren. In addition, the study pointed out the importance of the intergenerational relationships in view of the benefits produced by the same for both the generations involved. Considering the heterogeneity of Brazilian families, yet it is pointed out to the need for further intergenerational studies that focus on the opinion of different generations in different locations and contexts.

The different forms of behavior among generations influence the quality of family relationships, which allow the individual to build, to develop and to achieve himself as a social being. This study aimed to identify the experience of the grandmothers and the mothers of families of children with intellectual disabilities, regarding their everyday life, the support and the intergenerationality practices. The exploratory study of qualitative approach had the participation of six mothers and grandmothers of six children / adolescents with intellectual disabilities. Semi-structured interviews scripts were used to collect the data. The main results showed that support practices exercised within the family are part of the grandparents' daily lives and represent an important source of support for mothers and their grandchildren. In addition, the study pointed out the importance of the intergenerational relationships in view of the benefits produced by the same for both the generations involved. Considering the heterogeneity of Brazilian families, yet it is pointed out to the need for further intergenerational studies that focus on the opinion of different generations in different locations and contexts.

Irmãos mais velhos de crianças comdefi ciência e de crianças com desenvolvimento típico: cotidiano e Relacionamentos fraternos / Older Siblings of children with disabilities and children with typical development: daily life and fraternal relationships

Estudos nacionais e internacionais têm discorrido acerca das implicações, provenientes do nascimento de um segundo filho na família, ao desenvolvimento infantil do primogênito. O objetivo do presente estudo foi identificar a experiência de irmãos de crianças com deficiência intelectual e de irmãos de crianças com desenvolvimento típico, acerca do cotidiano e das práticas de apoio exercidas no contexto familiar. De abordagem qualitativa e comparativa, o estudo exploratório contou com a participação de 12 adolescentes, irmãos mais velhos de crianças com deficiência e de crianças com desenvolvimento típico. Para coleta de dados foramutilizadas entrevistas semiestruturadas, as quais foram analisadas à luz da técnica do Discurso do Sujeito Coletivo. Os principais resultados apontam que os irmãos de ambos os grupos familiares representam importante fonte de ajuda às famílias. Além disso,os irmãos de ambos os grupos relataram positivamente acerca do relacionamento estabelecido com a criança mais nova. Novos estudos nessa direção se fazem necessários para que se possa ampliar a compreensão do tema e disponibilizar maiores fontes de suporte aos irmãos de crianças com deficiência ou mesmo aosirmãos mais velhos de crianças com desenvolvimento típico.

National and international studies have discoursed about the implications, coming from the birth of a second child on the eldest child development. The aim of this study was to identify the experience of siblings of children with intellectual disabilities and siblings of children with typical development, about the daily life and support practices exercised within the family. With a qualitative and comparative approach, the exploratory study had the participation of 12 adolescents, older siblings of children with disabilities and children with typical development. For data collection semi-structured interviews were used, which were analyzed in the light of the technical Collective Subject Discourse.The main results show that siblings of both family groups are an important source of aid to the families. Furthermore, the brethren of both groups reported positively about the relationship established with the younger child. New studies in this direction are needed so that we can broaden the understanding of the topicand provide major sources of support for siblings of children with disabilities or even older siblings of children with typical development.

Relacionamento intergeracional, práticas de apoio e cotidiano de famílias de crianças com necessidades especiais / Intergenerational relationships, support practices and daily life of families of children with special needs

O estudo exploratório, de abordagem qualitativa, objetivou investigar o relacionamento intergeracional e as práticas de apoio presentes no cotidiano de famílias de crianças com necessidades especiais. Participaram do estudo cinco mães, avós e irmãos mais velhos de crianças com deficiência, que responderam a roteiros de entrevistas semiestruturadas. As entrevistas foram analisadas qualitativamente por meio da técnica do Discurso do Sujeito Coletivo. Verificou-se que as avós apresentam-se como importante fonte de apoio à família ao dedicarem, inclusive, atenção e cuidado ao irmão da criança com necessidades especiais. O estudo revela um relacionamento intergeracional positivo entre avós e netos. Destaca-se a necessidade de direcionar maior atenção especializada a esses membros da família e para a continuidade de investigação sobre o tema.

This exploratory study based on a qualitative approach aimed to investigate intergenerational relationships and support practices in the daily lives of families of children with special needs. Study participants were five mothers, grandmothers and older siblings of children with disabilities, who answered a semi-structured interview guide. The interviews were analyzed qualitatively using the Collective Subject Discourse technique. It was found that grandmothers have been an important source of support for the family, because they are also concerned about devoting attention and care to the siblings of the child with disabilities. The study reveals a positive intergenerational relationship between grandmothers and grandchildren. The study highlights the need for directing more specialized attention to these family members and points out the need for further research on the subject.

Pseudo-outbreak of Clostridium difficile associated diarrhea (CDAD) in a tertiary-care hospital.

The objective of this study was to describe a pseudo-outbreak of C. difficile in a hospital, following a change in the method used to detect the toxin. In February 2002, there were two cases of CDAD and in March 7 occurred, coinciding with a change of the test (from detection of toxin A to toxin A/B). An outbreak was suspected. Active surveillance and education of staff were started. A CDAD case was defined as a patient with acute onset of diarrhea (> or = three episodes of liquid stools) and a positive stool test. They were classified as hospital or community-acquired. Stool samples were also collected for C. difficile culture and isolates were typed using AP-PCR. From March 2002 through December 2003 there were 138 cases of CDAD: 70% were hospital-acquired and among the 30% with CDAD present on admission, most (81%) came directly from the community (50% had no history of hospitalization). Fifty-two percent of hospital-acquired CDAD and 94% of cases on admission had already used antibiotics. The incidence of CDAD in hospitalized patients during surveillance was 3.3 per 1000 patient-admissions. The incidence of CDAD present on admission was 6.1/1000 patients. Sixteen isolates were typed and presented 13 different profiles. In conclusion, the CDAD increase in our study occurred due to change in diagnostic methods and not due to an outbreak, as suspected initially. The incidence in hospitalized patients was much lower than in reported outbreaks. There were 13 molecular types suggesting that an outbreak did not occur. CDAD was largely community-acquired.

Pseudo-outbreak of Clostridium difficile associated diarrhea (CDAD) in a tertiary-care hospital / Pseudo-surto de diarréia associada a Clostridium difficile (DACD) em hospital terciário

The objective of this study was to describe a pseudo-outbreak of C. difficile in a hospital, following a change in the method used to detect the toxin. In February 2002, there were two cases of CDAD and in March 7 occurred, coinciding with a change of the test (from detection of toxin A to toxin A/B). An outbreak was suspected. Active surveillance and education of staff were started. A CDAD case was defined as a patient with acute onset of diarrhea (³ three episodes of liquid stools) and a positive stool test. They were classified as hospital or community-acquired. Stool samples were also collected for C. difficile culture and isolates were typed using AP-PCR. From March 2002 through December 2003 there were 138 cases of CDAD: 70 percent were hospital-acquired and among the 30 percent with CDAD present on admission, most (81 percent) came directly from the community (50 percent had no history of hospitalization). Fifty-two percent of hospital-acquired CDAD and 94 percent of cases on admission had already used antibiotics. The incidence of CDAD in hospitalized patients during surveillance was 3.3 per 1000 patient-admissions. The incidence of CDAD present on admission was 6.1/1000 patients. Sixteen isolates were typed and presented 13 different profiles. In conclusion, the CDAD increase in our study occurred due to change in diagnostic methods and not due to an outbreak, as suspected initially. The incidence in hospitalized patients was much lower than in reported outbreaks. There were 13 molecular types suggesting that an outbreak did not occur. CDAD was largely community-acquired.

O objetivo deste estudo foi descrever um pseudo-surto de C. difficile em um hospital após a troca do método de detecção de toxina. Em fevereiro de 2002 houve dois casos de DACD e em março ocorreram sete casos, que coincidiram com a mudança de teste (que detectava apenas toxina A e passou a detectar toxinas A e B). Foi suspeitado que houvesse um surto e vigilância ativa e reforço educacional para os profissionais de saúde foi implantado. Um caso de DACD foi definido como um paciente com início abrupto de diarréia (> 3 episódios de fezes líquidas) e um teste positivo. Os casos foram classificados como de aquisição comunitária ou hospitalar. Foram colhidas fezes para cultura para C. difficile e os isolados foram tipados por AP-PCR. De março de 2002 a dezembro de 2003 houve 138 casos de DACD: 70 por cento foram hospitalares e, entre os 30 por cento de casos comunitários, a maioria (81 por cento) foi de pacientes provenientes diretamente da comunidade (50 por cento não tinham histórico de internação). Cinquenta e dois por cento dos casos de DCAD hospitalar e 94 por cento de casos na admissão haviam utilizado antimicrobianos. A incidência de DCAD em pacientes internados foi de 3,3/100 pacientes e na admissão foi 6,1/1000 pacientes. Dezesseis isolados foram tipados e apresentaram 13 perfis diferentes. Em conclusão, o aumento de DACD no nosso estudo ocorreu por uma mudança de método diagnóstico e não devido a um surto como foi suspeitado inicialmente. A incidência em pacientes internados foi muito inferior ao que já foi relatado em surtos. Houve 13 perfis moleculares sugerindo que não ocorreu um surto. DACD foi, em grande parte, de aquisição comunitária.