Dengue 4 in Ceará, Brazil: characterisation of epidemiological and laboratorial aspects and causes of death during the first epidemic in the state.

BACKGROUND The first dengue cases in Brazil with laboratory confirmation occurred in the northern region of the country, with the isolation of two serotypes, dengue virus 1 (DENV-1) and DENV-4. In Ceará, the introduction of DENV-4 was reported during a DENV-1 epidemic in 2011, with only two isolations. OBJECTIVES The aim of this study was to characterise the first DENV-4 epidemic in the state of Ceará, Brazil. METHODS The study population was composed of patients with suspected dengue that were reported to health care units from January to December 2012. The laboratory confirmation of infection was made by viral isolation, reverse transcription polymerase chain reaction (RT-PCR), AgNS1, immunohistochemistry and IgM enzyme-linked immunosorbent assay (ELISA). MAIN CONCLUSIONS In the study year, 72,211 suspected dengue cases were reported and 51,865 of these cases (71.8%) were confirmed to be positive. Co-circulation of three serotypes, DENV-1, DENV-3 and DENV-4, was detected with a predominance of DENV-4 (95.3%). Most cases were not severe, but there were 44 fatal outcomes. DENV-4 Genotype II was identified for the first time in Ceará.

Coinfection with influenza A(H1N1)pdm09 and dengue virus in fatal cases.

We report on four patients with fatal influenza A(H1N1)pdm09 and dengue virus coinfections. Clinical, necropsy and histopathologic findings presented in all cases were characteristic of influenza-dengue coinfections, and all were laboratory-confirmed for both infections. The possibility of influenza and dengue coinfection should be considered in locations where these two viruses' epidemic periods coincide to avoid fatal outcomes. Dengue is a mosquito-borne viral infection caused by one of the four dengue viruses (DENV-1 to 4). Each of these viruses is capable of causing nonspecific febrile illnesses, classic dengue fever and dengue haemorrhagic fever (Gubler 1998). As a result, dengue is often difficult to diagnose clinically, especially because peak dengue season often coincides with that of other common febrile illnesses in tropical regions (Chacon et al. 2015). In April 2009, a new virus, influenza A/H1N1/pandemic (FluA/H1N1/09pdm), caused a severe outbreak in Mexico. The virus quickly spread throughout the world, and in June 2009, the World Health Organization declared a pandemic (WHO 2010). In Brazil, the first laboratory confirmed case of FluA/H1N1/09pdm was in July 2009 (Pires Neto et al. 2013). The state of Ceará, in Northeast Brazil, is a dengue endemic area. In this state, the virus influenza A(H1N1)pdm09 has circulated since 2009, and through the first half of 2012, 11 deaths caused by the virus were confirmed (Pires Neto et al. 2013). The influenza and dengue seasons in Ceará overlap, which led to diagnostic difficulties. We report four cases of laboratory-confirmed coinfection of deadly influenza A(H1N1)pdm09 with DENV, which occurred during the dengue and influenza season in 2012 and 2013 in Ceará.

Seroepidemiological survey on chikungunya in endemic zones for arboviruses in Brazil, 2019.

This study aimed to identify the seroprevalence of chikungunya and its associated factors in the city of Quixadá, Ceará, Brazil. We also aimed to identify the spatial distribution patterns of positive cases. A cross-sectional survey was conducted with a questionnaire about clinical symptoms, socioeconomic and demographic factors, and a 10 ml blood sample was collected and analysed by ELISA. For the bivariate analysis, we use the chi-square test, a prevalence ratio and its 95% confidence interval. A robust Poisson hierarchical regression was used to adjust for confounders. The Kernel density was performed for the spatial analysis. A total of 409 samples were analysed; of them, 70.7% were seropositive for previous exposure to chikungunya virus (CHIKV). High seropositivity for CHIKV was higher in female participants (75.5%; PR = 1.23; 95% CI: 1.06-1.43), those aged 31 years or more (74.3%; PR = 1.62; 95% CI: 1.04-2.52), and those with elementary education level (75.0%; PR = 1.30; 95% CI: 1.06-1.60). There were also high seroprevalence in those with less than a minimum wage per month (89.5%; PR = 1.59; 95% CI: 1.11-2.30), housewives (87.5%; PR = 1.64; 95% CI: 1.24-2.18) and unemployed (80.0%; PR = 1.50; 95% CI: 1.10-2.06). After adjusting for age, morning stiffness was the only chikungunya symptom that remained associated (PR = 1.20; 95% CI: 1.06-1.37; p < .001). There was an area of high density of cases in the downtown and two areas of medium density in nearby regions. Otherwise, the higher seroprevalence rates were in the peripherical neighbourhoods. There is a hyperendemicity of CHIKV in Quixadá, and most cases are spatially contiguous. The main associated clinical sign is morning stiffness, but other factors such as low income and spending a longer time at home were significantly associated with higher seroprevalence.

Dengue: 30 years of cases in an endemic area.

The present study aimed to review literature on studies of dengue cases conducted over 30 years in the state of Ceará.Between November 2015 and January 2016, articles published in Portuguese and English in 7 databases were searched using keywords and a Boolean operator. A total of 191 articles were identified in the databases; 133 were excluded according to the exclusion criteria, and 58 were included in the study.Of the 58 articles analyzed, 6 reported data from Brazil; including the Northeast region and the state of Ceará; 41 reported data for only the city of Fortaleza; 7 reported data for the state of Ceará; 4 reported data for cities in the interior of the state; and 3 included only children. The studies adopted different approaches and focused on different aspects of the disease. Study outcomes included the identification of serological, epidemiological, clinical, and laboratory characteristics; potential larvicides and biological predators of mosquitoes; potential antiviral agents; vector density characteristics; and educational dengue prevention and control strategies. Additionally, one vaccine trial was included.Although studies on dengue in the state of Ceará are scarce, they are encompassing, including several lines of research, and the number of studies and reports on dengue in the state of Ceará continues to increase.

Experience of the Arbovirus Death Investigation Committee in Ceará, Brazil, in 2017: advances and challenges. / Experiência do Comitê de Investigação de Óbitos por Arboviroses no Ceará em 2017: avanços e desafios.

OBJECTIVE: to describe the experience and preliminary results of the Arbovirus Death Investigation Committee in Ceará, Brazil, in 2017. METHODS: the Committee investigates and discusses all suspected cases of arbovirus deaths reported by the epidemiological surveillance service. RESULTS: a total of 443 suspected arbovirus deaths were reported, 220 (49.7%) of which were confirmed; of these, 88.2% were from chikungunya and 11.8% from dengue; the median age of chikungunya deaths was higher when compared to dengue (77 versus 56 years) and the time until death was also longer when compared to dengue (38 versus 12 days); median time for case closure was 54.5 days; in 2017, Ceará confirmed 80.4% of Brazilian chikungunya deaths. CONCLUSION: the investigation of deaths showed that CHIK viruses were responsible for the majority of arboviral deaths in the state of Ceará, in 2017.

DENV-1 Genotype V in Brazil: Spatiotemporal dispersion pattern reveals continuous co-circulation of distinct lineages until 2016.

In Brazil, DENV-1 introduced in the 80's, remained the prevalent serotype from 2012 to 2016. After its re-emergence in the country in 2009, the co-circulation of different viral lineages was identified, however, its transmission dynamics afterwards, was not fully characterized. In this study, we performed the continuous molecular surveillance after the reemergence period (2012 to 2016), covering the 30 years of circulation of DENV-1 in Brazil. Phylogenetic analysis allowed confirmation of the continued presence of genotype V, as well as three distinct co-circulating lineages. The molecular characterization of the E gene presented two new amino acid substitutions previously unidentified in the country. Phylogeographic analysis has shown that a large flow of migrations has occurred between Brazil and Argentina in the last 10 years.

Dengue: 30 years of cases in an endemic area

The present study aimed to review literature on studies of dengue cases conducted over 30 years in the state of Ceará. Between November 2015 and January 2016, articles published in Portuguese and English in 7 databases were searched using keywords and a Boolean operator. A total of 191 articles were identified in the databases; 133 were excluded according to the exclusion criteria, and 58 were included in the study. Of the 58 articles analyzed, 6 reported data from Brazil; including the Northeast region and the state of Ceará; 41 reported data for only the city of Fortaleza; 7 reported data for the state of Ceará; 4 reported data for cities in the interior of the state; and 3 included only children. The studies adopted different approaches and focused on different aspects of the disease. Study outcomes included the identification of serological, epidemiological, clinical, and laboratory characteristics; potential larvicides and biological predators of mosquitoes; potential antiviral agents; vector density characteristics; and educational dengue prevention and control strategies. Additionally, one vaccine trial was included. Although studies on dengue in the state of Ceará are scarce, they are encompassing, including several lines of research, and the number of studies and reports on dengue in the state of Ceará continues to increase.

Dengue 4 in Ceará, Brazil: characterisation of epidemiological and laboratorial aspects and causes of death during the first epidemic in the state

BACKGROUND The first dengue cases in Brazil with laboratory confirmation occurred in the northern region of the country, with the isolation of two serotypes, dengue virus 1 (DENV-1) and DENV-4. In Ceará, the introduction of DENV-4 was reported during a DENV-1 epidemic in 2011, with only two isolations. OBJECTIVES The aim of this study was to characterise the first DENV-4 epidemic in the state of Ceará, Brazil. METHODS The study population was composed of patients with suspected dengue that were reported to health care units from January to December 2012. The laboratory confirmation of infection was made by viral isolation, reverse transcription polymerase chain reaction (RT-PCR), AgNS1, immunohistochemistry and IgM enzyme-linked immunosorbent assay (ELISA). MAIN CONCLUSIONS In the study year, 72,211 suspected dengue cases were reported and 51,865 of these cases (71.8%) were confirmed to be positive. Co-circulation of three serotypes, DENV-1, DENV-3 and DENV-4, was detected with a predominance of DENV-4 (95.3%). Most cases were not severe, but there were 44 fatal outcomes. DENV-4 Genotype II was identified for the first time in Ceará.

Trinta anos de dengue no Ceará: história, contribuições para ciência e desafios no cenário atual com tripla circulação de arbovírus / Thirty years of dengue in Ceará: history, contributions to science and challenges in the current scenario with triple arbovirus circulation

Introdução: Embora os primeiros casos de dengue no estado do Ceará tenham ocorrido em 1986, há registros da presença do mosquito Aedes aegypti desde os anos de 1851/1852. Mesmo após 30 anos, a dengue permanece como um problema grave de saúde pública com epidemias cada vez mais frequentes. Objetivo: Resgatar, reunir e sintetizar a evidência científica produzida nos primeiros 30 anos de dengue no Ceará, contribuindo para melhorar sua compreensão e as intervenções de vigilância e controle. Métodos: Realizou-se uma revisão de literatura com busca de artigos (inglês, português e espanhol) nas bases de dados Pubmed, Scielo, Clinicalkey, Lilacs, Google Acadêmico e banco virtual de teses e dissertações da CAPES, além de livros. O período de 1986 a 2016 foi usado como limite de busca e a mesma foi realizada entre os meses de agosto a novembro de 2016. Utilizaram-se os descritores controlados: dengue, Ceará, Fortaleza e Aedes; com interposição do operador boleano "AND". Resultados: Foram identificadas 574 publicações potencialmente elegíveis, sendo 461 artigos e 113 dissertações ou teses. Foram retirados 272 artigos duplicados ou que não atenderam aos critérios de inclusão. Foram lidos 114 artigos publicados em 60 revistas diferentes, sendo 72,8% artigos completos, 75,2% em inglês, 42,2% experimentais e 81,5% com abordagem quantitativa. Foi publicado apenas um artigo na década de 1980, já na década seguinte foram sete, número que cresceu bastante nos anos 2000, com 38 artigos. No entanto, já há 69 artigos publicados apenas na primeira metade da década de 2010. No período, o Ceará confirmou quase um milhão de casos de dengue, com a circulação dos quatro sorotipos (DENV1 - 1986, DENV2 - 1994, DENV3 - 2002 e DENV4 - 2011) e registrou pelo menos 14 epidemias. A partir de 2015, o Ceará passou a apresentar um cenário diferenciado de tripla epidemia, com a cocirculação autóctone de dois outros arbovírus: Chikungunya e Zika. Conclusão: Nesse período de 30 anos (1986-2016), o Ceará vivenciou várias epidemias de dengue, e, de certa forma, isto vem impulsionando a busca por respostas para o controle desta doença. Há claramente um crescimento em número de artigos publicados a cada ano, revelando a pujança dos grupos locais, que contribuiu de forma importante para a produção científica em diversos fatores relacionados à compreensão da epidemiologia e controle da dengue. (AU)

Introduction: Although the first cases of dengue in the state of Ceará occurred in 1986, there are records of the presence of the Aedes aegypti mosquito since the years 1851/1852. Even after 30 years, dengue remains a serious public health problem with frequent epidemics. Objective: To rescue, gather and synthesize scientific evidence in the first 30 years of dengue in Ceará, contributing to improve its understanding, surveillance and control interventions. Methods: An integrative review was carried out with the search of articles (English, Portuguese and Spanish) in the databases Pubmed, Scielo, Clinicalkey, Lilacs, Google Scholar and virtual bank of thesis and dissertations of CAPES, as well as books. The period from 1986 to 2016 was used as a search limit and it was carried out between August and November 2016. The following descriptors were used: dengue, Ceará, Fortaleza and Aedes; with interposition of the Boolean operator "AND". Results: 574 potentially eligible publications were identified, 461 articles and 113 dissertations or thesis. 272 duplicate articles were removed or did not meet the inclusion criteria. We have read 114 articles published in 60 different journals, 72.8% were full articles, 75.2% were in English, 42.2% were experimental and 81.5% were quantitative. Only one article was published in the 1980s, and in the next decade there were seven, this number grew up considerably in the 2000s with 38 articles. However, there are already 69 articles published only in the first half of the decade of 2010. In this period, Ceará confirmed almost 1 million cases of dengue with the circulation of the four serotypes (DENV1 - 1986, DENV2 - 1994, DENV3 - 2002 and DENV4 - 2011) and recorded at least 14 epidemics. From 2015 on, Ceará started to present a differentiated scenario of a triple epidemic, with the autochthonous co-circulation of two other arboviruses: chikungunya and Zika. Conclusion: In this period of 30 years (1986-2016), Ceará experienced. (AU)

Concurrent infection with dengue virus type-2 and DENV-3 in a patient from Ceará, Brazil.

Dengue outbreaks have occurred in several regions in Brazil and cocirculating dengue virus type 1 (DENV-1), DENV-2, and DENV-3 have been frequently observed. Dual infection by DENV-2 and DENV-3 was identified by type-specific indirect immunofluorescence assay and confirmed by reverse transcription polymerase chain reaction in a patient in Ceará with a mild disease. This is the first documented case of simultaneous infection with DENV-2 and DENV-3 in Brazil. Sequencing confirmed DENV-2 and DENV-3 (South-East/American) genotype III and (SriLanka/India), genotype III respectively.

Concurrent infection with dengue virus type-2 and DENV-3 in a patient from Ceará, Brazil

Dengue outbreaks have occurred in several regions in Brazil and cocirculating dengue virus type 1 (DENV-1), DENV-2, and DENV-3 have been frequently observed. Dual infection by DENV-2 and DENV-3 was identified by type-specific indirect immunofluorescence assay and confirmed by reverse transcription polymerase chain reaction in a patient in Ceará with a mild disease. This is the first documented case of simultaneous infection with DENV-2 and DENV-3 in Brazil. Sequencing confirmed DENV-2 and DENV-3 (South-East/American) genotype III and (SriLanka/India), genotype III respectively.