Prevalence of human leptospirosis in the Americas: a systematic review and meta-analysis / Prevalencia de la leptospirosis humana en las Américas: revisión sistemática y metanálisis / Prevalência da leptospirose humana nas Américas: revisão sistemática e metanálise

ABSTRACT Objective. To describe the prevalence of leptospirosis in the Americas. Methods. A systematic review and meta-analysis, in the period 1930 to 2017, performed on a search of six platforms: PubMed, Web of Science, Scopus, Lilacs, Embase, and Cochrane. Results. The search found 77 publications of which 53 (68%) were from the period 2000-2017. Of the 77, 62 studies were included in the analysis, from North America (11, 17%), Central America (9, 14%), and South America (42, 67%), and 22 studies were from urban areas. Leptospirosis prevalence in the 62 studies analyzed corresponded to 28% (95% CI [23, 32]). Countries with higher prevalence were United States of America (41%), Colombia (29%), and Brazil (21%). The most frequent serovars found were Icterohaemorrhagiae (43 of 77 publications, 55%), Canicola (35, 45%), Pomona (28, 36%), and Grippotyphosa (26, 33%). Conclusions. There is variability of Leptospira species and serovars with heterogenous distribution throughout the Americas, with high prevalence in some countries, highlighting the need for action to control the disease.

RESUMEN Objetivo. Describir la prevalencia de la leptospirosis en las Américas. Métodos. Revisión sistemática y metanálisis correspondientes al período 1930-2017, mediante una búsqueda en seis plataformas: PubMed, Web of Science, Scopus, Lilacs, Embase y Cochrane. Resultados. En la búsqueda se encontraron 77 publicaciones, de las que 53 (68%) eran del periodo 2000-2017. En el análisis se incluyeron 62 de los 77 estudios, correspondientes a América del Norte (11, 17%), Centroamérica (9, 14%) y América del Sur (42, 67%), y 22 estudios correspondientes a zonas urbanas. La prevalencia de la leptospirosis en los 62 estudios analizados fue del 28% (IC del 95% [23, 32]). Los países con mayor prevalencia fueron Estados Unidos de América (41%), Colombia (29%) y Brasil (21%). Las serovariedades más frecuentes fueron icterohaemorrhagiae (43 de 77 publicaciones, 55%), canicola (35, 45%), pomona (28, 36%) y grippotyphosa (26, 33%). Conclusiones. Se observa variabilidad de especies y serovariedades de Leptospira, con una distribución heterogénea en las Américas y una elevada prevalencia en algunos países, lo que pone de manifiesto la necesidad de adoptar medidas para controlar la enfermedad.

RESUMO Objetivo. Descrever a prevalência da leptospirose nas Américas. Métodos. Uma revisão sistemática e metanálise referente ao período de 1930 a 2017, realizada por meio de busca em seis plataformas: PubMed, Web of Science, Scopus, Lilacs, Embase e Cochrane. Resultados. A pesquisa encontrou 77 publicações, das quais 53 (68%) eram do período de 2000 a 2017. Dos 77 estudos, 62 foram incluídos na análise, da América do Norte (11, equivalente a 17%), América Central (9, equivalente a 14%) e América do Sul (42, equivalente a 67%), e 22 estudos foram realizados em áreas urbanas. A prevalência da leptospirose nos 62 estudos analisados correspondeu a 28% (IC 95% [23, 32]). Os países com maior prevalência foram os Estados Unidos da América (41%), a Colômbia (29%) e o Brasil (21%). Os sorovares mais frequentes encontrados foram Icterohaemorrhagiae (43 de 77 publicações, equivalente a 55%), Canicola (35, equivalente a 45%), Pomona (28, equivalente a 36%) e Grippotyphosa (26, equivalente a 33%). Conclusões. Há variabilidade nas espécies e sorovares de Leptospira, que têm distribuição heterogênea nas Américas e alta prevalência em alguns países, o que destaca a necessidade de ações para controlar a doença.

A systematic literature review of leptospirosis outbreaks worldwide, 1970-2012 / Revisión sistemática de los brotes de leptospirosis en el mundo, 1970-2012

ABSTRACT Objective. This review describes the geographic and temporal distribution of, detection methods for, and other epidemiological features of published leptospirosis outbreaks, with the aim of informing efforts to standardize outbreak-reporting practices. Methods. We conducted a systematic review of leptospirosis outbreaks reported in the scientific literature and ProMED during 1970-2012. Predefined criteria were used to identify and classify outbreaks and a standard form was used to extract information. Results. During 1970-2012, we identified 318 outbreaks (average: 7 outbreaks/year; range: 1-19). Most outbreaks were reported in the Latin America and the Caribbean region (36%), followed by Southern Asia (13%), and North America (11%). Most outbreaks were located in tropical and subtropical ecoregions (55%). Quality classification showed that there was clear description of laboratory-confirmed cases in 40% of outbreaks. Among those, the average outbreak size was 82 cases overall (range: 2-2 259) but reached 253 cases in tropical/subtropical ecoregions. Common risk factors included outdoor work activities (25%), exposure to floodwaters (23%), and recreational exposure to water (22%). Epidemiologic investigation was conducted in 80% of outbreaks, mainly as case interviews. Case fatality was 5% overall (range: 0%-60%). Conclusions. Outbreak reporting increased over the study period with outbreaks covering tropical and non-tropical regions. Outbreaks varied by size, setting, and risk factors; however, data reviewed often had limited information regarding diagnosis and epidemiology. Guidelines are recommended to develop standardized procedures for diagnostic and epidemiological investigations during an outbreak and for reporting.(AU)

RESUMEN Objetivo. Describir la distribución geográfica y temporal, los métodos de detección y otras características epidemiológicas de los brotes de leptospirosis publicados con el fin de fundamentar los esfuerzos tendientes a estandarizar las prácticas empleadas en la notificación de brotes. Métodos. Se llevó a cabo una revisión sistemática de los brotes de leptospirosis notificados en la bibliografía científica y en ProMED entre 1970 y 2012. Se utilizaron criterios predefinidos para identificar y clasificar los brotes y se empleó un formulario estándar para extraer la información. Resultados. Entre 1970 y 2012 se identificaron 318 brotes (promedio: 7 brotes/año; rango: 1-19), la mayoría de ellos en América Latina y el Caribe (36%), región seguida por Asia meridional (13%) y América del Norte (11%). La mayoría de los brotes se localizaron en ecorregiones tropicales y subtropicales (55%). La clasificación cualitativa reveló que en el 40% de los brotes había una clara descripción de los casos confirmados por laboratorio. Entre ellos, el tamaño promedio del brote fue de 82 casos (rango: 2-2259 casos) pero alcanzó los 253 casos en ecorregiones tropicales o subtropicales. Entre los factores de riesgo frecuentes figuraban las actividades laborales al aire libre (25%), la exposición a agua proveniente de inundaciones (23%) y la exposición a agua con fines recreativos (22%). En el 80% de los brotes se realizaron investigaciones epidemiológicas, principalmente entrevistas de casos. La mortalidad específica de los casos fue del 5% (rango: 0%-60%). Conclusiones. La notificación de brotes aumentó durante el período de estudio, y los brotes abarcaron regiones tropicales y no tropicales. Los brotes fueron diferentes en cuanto a su tamaño, el entorno y los factores de riesgo; sin embargo, los datos examinados con frecuencia incluían una información limitada respecto del diagnóstico y la epidemiología. Se recomiendan directrices para elaborar procedimientos estandarizados para las investigaciones diagnósticas y epidemiológicas durante un brote y para su notificación.(AU)

Osteomielitis por Mycobacterium tuberculosis / Mycobacterium tuberculosis osteomyelitis

Resumen Introducción: en Uruguay se ha notificado un aumento en el número de casos de tuberculosis en niños con formas pulmonares y extrapulmonares. La infección osteoarticular representa 10%-15% de las formas extrapulmonares. Objetivo: alertar sobre una etiología poco habitual de osteomielitis cuya forma de presentación genera dificultades diagnósticas. Caso clínico: niña de 18 meses, previamente sana. Consulta por edema e impotencia funcional de tobillo derecho de tres meses de evolución, en apirexia. La radiografía muestra múltiples imágenes geódicas en el sector distal de la diáfisis con secuestro en peroné derecho. Se realiza punción ósea obteniéndose líquido serohemático. El cultivo de dicha muestra y el hemocultivo fueron negativos. Luego de recibir clindamicina 21 días más gentamicina 10 días por via intravenosa y dos limpiezas quirúrgicas, se otorga alta con cefuroxime acetil vía oral. El cultivo de la muestra ósea desarrolló Mycobacterium tuberculosis. Se inició tratamiento con isoniacida, rifampicina y piracinamida. No fue identificado el caso índice. Discusión: la presentación clínica de la tuberculosis ósea es generalmente insidiosa lo que generando dificultades y retraso en el diagnóstico. Sólo la biopsia permite confirmar el diagnóstico. La situación epidemiológica actual obliga a descartar posible etiología tuberculosa ante un proceso inflamatorio osteoarticular de evolución tórpida. El tratamiento oportuno y adecuado requiere alto índice de sospecha y realización sistemática de punción ósea y/o articular.

Summary Introduction: in Uruguay, an increase in the number of cases of TB with pulmonary and extra-pulmonary involvement in children has been reported. Osteoarticular infections represent 10%-15% of extra-pulmonary involvement. Objective: to warn about an uncommon etiology of osteomyelitis whose presentation results in diagnostic difficulties. Clinical case: 18 month-old girl, previously healthy. Consultation was due to edema and right ankle functional insuficiency with three-month evolution, under apyrexia. X-ray imaging revealed multiple geodesic images in the distal portion of diaphysis, as well as a small sequestrum in right fibula. Through a bone puncture, serohematic fluid was extracted. Culture and hemoculture were negative. Treatment consisted of 21 days of intravenous clindamycin and 10 days of gentamicin. Two surgical debridements were performed. Progressive recovery followed. The child was discharged under cefuroxime axetil oral suspension and later a bone culture showed positive results for Mycobacterium TB. Treatment with isoniazid, rifampin and pyrazinamide was started. Index case could not be identified. Discussion: clinical presentation of bone tuberculosis is generally insidious. This explains difficulties and delays in diagnosis. It is remarkable that only biopsy allows the confirmation of diagnosis. The present epimediologic condition forces us to rule out possible TB etiology in the presence of an inflammatory osteoarticular process of lethargic evolution. Timely and accurate treatment requires a high degree of suspicion, as well as the performance of systematic bone and/or joint puncture.

Rat infestation associated with environmental deficiencies in an urban slum community with high risk of leptospirosis transmission / Infestação por roedores associada a fatores ambientais numa comunidade carente com alto risco de transmissão da leptospirose / Infestación por roedores asociada a factores ambientales en una comunidad sin recursos con alto riesgo de transmisión de la leptospirosis

Abstract: We analyzed environmental factors that provide food, water and harborage to rodents and the risk of household rodent infestation in a slum community with a high risk of leptospirosis transmission. Detailed environmental surveys were performed in 221 households. Multivariate regression models evaluated the association between rodent infestation and socioeconomic status and environmental attributes obtained from Geographical Information System surveys. The general household infestation rate was 45.9%. Rattus norvegicus signs were the most prevalent, present in 74% of the infested households. The risk for rodent infestation was associated with environmental factors supporting harborage for rats, such as dilapidated fences/walls (OR: 8.95; 95%CI: 2.42-33.12) and households built on an earthen slope (OR: 4.68; 95%CI: 2.23-9.81). An increase of 1 meter from the nearest sewer was associated with a 3% (95%CI: 1%-5%) decrease in the risk of rodent infestation. A lack of sanitation where poor people live provides factors for rat infestation and could the target of educational interventions.

Resumo: O estudo analisou fatores ambientais que facilitam a presença de alimento, água e abrigo para roedores e risco de infestação por roedores numa comunidade com alto risco de transmissão da leptospirose. Foram realizados inquéritos ambientais detalhados em 221 domicílios. Modelos de regressão multivariada avaliaram a associação entre infestação por roedores e nível socioeconômico e atributos ambientais obtidos através de inquéritos com Sistemas de Informação Geográfica. O estudo mostrou uma taxa global de 45,9% de infestação domiciliar. Sinais de Rattus norvegicus eram os mais prevalentes, presentes em 74% dos domicílios infestados. O risco de infestação por roedores esteve associado a fatores ambientais que forneciam abrigo aos ratos, tais como cercas e muros dilapidados (OR: 8,95; IC95%: 2,42-33,12) e domicílios construídos diretamente sobre encostas (OR: 4,68; IC95%: 2,23-9,81). Cada incremento de um metro de distância a partir do esgoto mais próximo esteve associado a uma diminuição de 3% (IC95%: 1%-5%) no risco de infestação por roedores. A falta de saneamento básico nos locais de moradia das famílias pobres facilita a infestação por ratos e é alvo prioritário para intervenções educativas.

Resumen: El estudio analizó factores ambientales que facilitan la presencia de alimento, agua y abrigo para roedores y el riesgo de infestación por roedores en una comunidad sin recursos con alto riesgo de transmisión de la leptospirosis. Se realizaron encuestas ambientales detalladas en 221 domicilios. Los modelos de regresión multivariada evaluaron la asociación entre infestación por roedores, nivel socioeconómico y características ambientales, obtenidos a través de encuestas con Sistemas de Información Geográfica. El estudio mostró una tasa global de un 45,9% de infestación domiciliaria. Los indicios de Rattus norvegicus eran los más prevalentes, presentes en un 74% de los domicilios infestados. El riesgo de infestación por roedores estuvo asociado a factores ambientales que proporcionaban abrigo a las ratas, tales como cercas y muros derruidos (OR: 8,95; IC95%: 2,42-33,12) y domicilios construidos directamente sobre pendientes (OR: 4,68; IC95%: 2,23-9,81). Cada incremento de un metro de distancia, a partir del alcantarillado más próximo, estuvo asociado a una disminución de un 3% (IC95%: 1%-5%) en el riesgo de infestación por roedores. La falta de saneamiento básico en las viviendas de las familias pobres facilita la infestación por ratas y es el objetivo prioritario para intervenciones educativas.

Heterogenic colonization patterns by Leptospira interrogans in Rattus norvegicus from urban slums

Abstract We evaluated the renal colonization by Leptospira interrogans in Rattus norvegicus (rats), as it is the major natural reservoir of urban leptospirosis. We caught 72 R. norvegicus, out of which 32 were found to be positive for L. interrogans by immunofluorescence assay. From these rats, we selected 17 and divided them into six groups based on the mass-age/sex. We performed the immunohistochemistry test against L. interrogans in the kidney sections of the rats and systematically counted the colonized tubules (CTs) in 20 fields. The proportion of positive fields varied from 5% to 95%. The number of CTs in 20 fields varied from 0.5 to 85.5. These differences were not related to age or sex of the animals. The characterization of leptospiral colonization patterns in the natural reservoirs is important to better understand the host-pathogen interactions in leptospirosis.

Surveillance for leptospirosis in the Americas, 1996-2005: a review of data from ministries of health / Vigilancia de la leptospirosis en la Región de las Américas, de 1996 al 2005: análisis de los datos de los ministerios de salud

Objective. To characterize current leptospirosis reporting practices in the Americas.Methods. Information was collected from the official websites of national ministries ofhealth from the Americas region and two international organizations; personal communications;and three international morbidity databases. For all sources other than the morbiditydatabases, the review was limited to official reports citing clinically suspected and laboratoryconfirmed leptospirosis cases or deaths during the period 1996–2005.Results. A total of 73 out of 1 644 reports met the selection criteria and were included inthe analysis. Published leptospirosis data were available from half of the countries/sovereignterritories (24 out of 48), and 18 of them had mandatory notification policies for leptospirosis.The sum of the median number of leptospirosis cases notified annually by the 24 countries/territories was 4 713.5, but just three countries (Brazil, Costa Rica, and Cuba) accounted for83.1% (3 920 cases) of the notifications. Eight (16.7%) countries reported deaths due to leptospirosis.The sum of the median number of deaths reported annually for the eight countrieswas 380, but 349 (91.8%) were reported by Brazil.Conclusions. Notification practices in the Americas for leptospirosis are limited. Therefore,the numbers of cases and deaths reported are not representative for the region. The lack ofleptospirosis data for many countries/territories may reflect weaknesses in certain aspects ofnational surveillance systems, including mandatory reporting policies, clinical laboratory infrastructurefor performing case confirmation, and capacity to collect reported cases. Improvedsurveillance of leptospirosis cases and deaths in the Americas is needed to allow monitoring ofregional epidemiological patterns and to estimate the burden of this important disease.

Actinomicose primária em extremidade: apresentaçäo de um caso e revisäo de literatura

A actinomicos primária em extremidade é rara. É descrito um caso clínico, com quatro anos de evoluçäo, de acometimento de pé esquerdo. O estudo radiológico levantou as hipóteses de osteomielite e osteossarcoma. A confirmaçäo de actinomicose foi feita pelo estudo anatomopatológico. A terapia efetiva foi estabelecida com penicilina associada a sulfonamidas. As lesöes regrediram no período aproximado de seis meses