Causes of death in children with congenital Zika syndrome in Brazil, 2015 to 2018: A nationwide record linkage study.

BACKGROUND: Children with congenital Zika syndrome (CZS) have severe damage to the peripheral and central nervous system (CNS), greatly increasing the risk of death. However, there is no information on the sequence of the underlying, intermediate, immediate, and contributing causes of deaths among these children. The aims of this study are describe the sequence of events leading to death of children with CZS up to 36 months of age and their probability of dying from a given cause, 2015 to 2018. METHODS AND FINDINGS: In a population-based study, we linked administrative data on live births, deaths, and cases of children with CZS from the SINASC (Live Birth Information System), the SIM (Mortality Information System), and the RESP (Public Health Event Records), respectively. Confirmed and probable cases of CZS were those that met the criteria established by the Brazilian Ministry of Health. The information on causes of death was collected from death certificates (DCs) using the World Health Organization (WHO) DC template. We estimated proportional mortality (PM%) among children with CZS and among children with non-Zika CNS congenital anomalies (CA) by 36 months of age and proportional mortality ratio by cause (PMRc). A total of 403 children with confirmed and probable CZS who died up to 36 months of age were included in the study; 81.9% were younger than 12 months of age. Multiple congenital malformations not classified elsewhere, and septicemia unspecified, with 18 (PM = 4.5%) and 17 (PM = 4.2%) deaths, respectively, were the most attested underlying causes of death. Unspecified septicemia (29 deaths and PM = 11.2%) and newborn respiratory failure (40 deaths and PM = 12.1%) were, respectively, the predominant intermediate and immediate causes of death. Fetuses and newborns affected by the mother's infectious and parasitic diseases, unspecified cerebral palsy, and unspecified severe protein-caloric malnutrition were the underlying causes with the greatest probability of death in children with CZS (PMRc from 10.0 to 17.0) when compared to the group born with non-Zika CNS anomalies. Among the intermediate and immediate causes of death, pneumonitis due to food or vomiting and unspecified seizures (PMRc = 9.5, each) and unspecified bronchopneumonia (PMRc = 5.0) were notable. As contributing causes, fetus and newborn affected by the mother's infectious and parasitic diseases (PMRc = 7.3), unspecified cerebral palsy, and newborn seizures (PMRc = 4.5, each) were more likely to lead to death in children with CZS than in the comparison group. The main limitations of this study were the use of a secondary database without additional clinical information and potential misclassification of cases and controls. CONCLUSION: The sequence of causes and circumstances involved in the deaths of the children with CZS highlights the greater vulnerability of these children to infectious and respiratory conditions compared to children with abnormalities of the CNS not related to Zika.

Population-based surveillance for congenital zika virus syndrome: a latent class analysis of recorded cases from 2015-2018.

OBJECTIVE: This study aims to describe clinical findings and determine the medium-term survival of congenital zika syndrome (CZS) suspected cases. METHODS: A retrospective cohort study using routine register-based linked data. It included all suspected cases of CZS born in Brazil from January 1, 2015, to December 31, 2018, and followed up from birth until death, 36 months, or December 31, 2018, whichever came first. Latent class analysis was used to cluster unconfirmed cases into classes with similar combinations of anthropometry at birth, imaging findings, maternally reported rash, region, and year of birth. Kaplan-Meier curves were plotted, and Cox proportional hazards models were fitted to determine mortality up to 36 months. RESULTS: We followed 11,850 suspected cases of CZS, of which 28.3% were confirmed, 9.3% inconclusive and 62.4% unconfirmed. Confirmed cases had almost two times higher mortality when compared with unconfirmed cases. Among unconfirmed cases, we identified three distinct clusters with different mortality trajectories. The highest mortality risk was observed in those with abnormal imaging findings compatible with congenital infections (HR = 12.6; IC95%8.8-18.0) and other abnormalities (HR = 11.6; IC95%8.6-15.6) compared with those with normal imaging findings. The risk was high in those with severe microcephaly (HR = 8.2; IC95%6.4-10.6) and macrocephaly (HR = 6.6; IC95%4.5-9.7) compared with normal head size. CONCLUSION: Abnormal imaging and head circumference appear to be the main drivers of the increased mortality among suspected cases of CZS. We suggest identifying children who are more likely to die and have a greater need to optimise interventions and resource allocation regardless of the final diagnoses.

Mortality from Congenital Zika Syndrome - Nationwide Cohort Study in Brazil.

BACKGROUND: Prenatal exposure to Zika virus has potential teratogenic effects, with a wide spectrum of clinical presentation referred to as congenital Zika syndrome. Data on survival among children with congenital Zika syndrome are limited. METHODS: In this population-based cohort study, we used linked, routinely collected data in Brazil, from January 2015 through December 2018, to estimate mortality among live-born children with congenital Zika syndrome as compared with those without the syndrome. Kaplan-Meier curves and survival models were assessed with adjustment for confounding and with stratification according to gestational age, birth weight, and status of being small for gestational age. RESULTS: A total of 11,481,215 live-born children were followed to 36 months of age. The mortality rate was 52.6 deaths (95% confidence interval [CI], 47.6 to 58.0) per 1000 person-years among live-born children with congenital Zika syndrome, as compared with 5.6 deaths (95% CI, 5.6 to 5.7) per 1000 person-years among those without the syndrome. The mortality rate ratio among live-born children with congenital Zika syndrome, as compared with those without the syndrome, was 11.3 (95% CI, 10.2 to 12.4). Among infants born before 32 weeks of gestation or with a birth weight of less than 1500 g, the risks of death were similar regardless of congenital Zika syndrome status. Among infants born at term, those with congenital Zika syndrome were 14.3 times (95% CI, 12.4 to 16.4) as likely to die as those without the syndrome (mortality rate, 38.4 vs. 2.7 deaths per 1000 person-years). Among infants with a birth weight of 2500 g or greater, those with congenital Zika syndrome were 12.9 times (95% CI, 10.9 to 15.3) as likely to die as those without the syndrome (mortality rate, 32.6 vs. 2.5 deaths per 1000 person-years). The burden of congenital anomalies, diseases of the nervous system, and infectious diseases as recorded causes of deaths was higher among live-born children with congenital Zika syndrome than among those without the syndrome. CONCLUSIONS: The risk of death was higher among live-born children with congenital Zika syndrome than among those without the syndrome and persisted throughout the first 3 years of life. (Funded by the Ministry of Health of Brazil and others.).

Genomic characterization of silvergrass cryptic virus 1, a novel partitivirus infecting Miscanthus sinensis.

In the present study we report the identification of a novel partitivirus recovered from Miscanthus sinensis, for which the provisional name "silvergrass cryptic virus 1" (SgCV-1) is proposed. High-throughput sequencing (HTS) and rapid amplification of cDNA ends (RACE) allowed the assembly of the complete sequence of each double-stranded RNA genome segment of this novel virus. The largest dsRNA segment, dsRNA1 (1699 bp), was predicted to encode a viral RNA-dependent RNA polymerase protein (RdRp) with 478 aa, and dsRNA2 (1490 bp) and dsRNA3 (1508 bp) were predicted to encode putative capsid proteins (CPs) with 347 and 348 aa, respectively. SgCV-1 has the highest amino acid sequence identity (≤ 70.80% in RdPp and ≤ 34.5% in CPs) to members of the genus Deltapartitivirus, family Partitiviridae, especially to unclassified viruses related to members of this genus. Its genome segment and protein lengths are also within the range of those of deltapartitiviruses. Moreover, phylogenetic analysis based on RdRp amino acid sequences also showed clustering of this novel virus with the related unclassified deltapartitiviruses. An RT-PCR survey of 94 imported M. sinensis samples held in quarantine identified seven additional samples carrying SgCV-1. This new virus fulfils all ICTV criteria to be considered a new member of the genus Deltapartitivirus.

Classification algorithm for congenital Zika Syndrome: characterizations, diagnosis and validation.

Zika virus was responsible for the microcephaly epidemic in Brazil which began in October 2015 and brought great challenges to the scientific community and health professionals in terms of diagnosis and classification. Due to the difficulties in correctly identifying Zika cases, it is necessary to develop an automatic procedure to classify the probability of a CZS case from the clinical data. This work presents a machine learning algorithm capable of achieving this from structured and unstructured available data. The proposed algorithm reached 83% accuracy with textual information in medical records and image reports and 76% accuracy in classifying data without textual information. Therefore, the proposed algorithm has the potential to classify CZS cases in order to clarify the real effects of this epidemic, as well as to contribute to health surveillance in monitoring possible future epidemics.

Case Fatality Rate Related to Microcephaly Congenital Zika Syndrome and Associated Factors: A Nationwide Retrospective Study in Brazil †.

BACKGROUND: The clinical manifestations of microcephaly/congenital Zika syndrome (microcephaly/CZS) have harmful consequences on the child's health, increasing vulnerability to childhood morbidity and mortality. This study analyzes the case fatality rate and child-maternal characteristics of cases and deaths related to microcephaly/CZS in Brazil, 2015-2017. METHODS: Population-based study developed by linkage of three information systems. We estimate frequencies of cases, deaths, case fatality rate related to microcephaly/CZS according to child and maternal characteristics and causes of death. Multivariate logistic regression models were applied. RESULTS: The microcephaly/CZS case fatality rate was 10% (95% CI 9.2-10.7). Death related to microcephaly/CZS was associated to moderate (OR = 2.15; 95% CI 1.63-2.83), and very low birth weight (OR = 3.77; 95% CI 2.20-6.46); late preterm births (OR = 1.65; 95% CI 1.21-2.23), Apgar < 7 at 1st (OR = 5.98; 95% CI 4.46-8.02) and 5th minutes (OR = 4.13; 95% CI 2.78-6.13), among others. CONCLUSIONS: A high microcephaly/CZS case fatality rate and important factors associated with deaths related to this syndrome were observed. These results can alert health teams to these problems and increase awareness about the factors that may be associated with worse outcomes.

A recursive sub-typing screening surveillance system detects the appearance of the ZIKV African lineage in Brazil: Is there a risk of a new epidemic?

There is currently no system to track the emergence of Zika virus (ZIKV) subtypes. We developed a surveillance system able to retrieve sequence submissions and further classify distinct ZIKV genotypes in the world. This approach was able to detect a new occurrence of ZIKV from an African lineage in Brazil in 2019.

Interdependence between confirmed and discarded cases of dengue, chikungunya and Zika viruses in Brazil: A multivariate time-series analysis.

The co-circulation of different arboviruses in the same time and space poses a significant threat to public health given their rapid geographic dispersion and serious health, social, and economic impact. Therefore, it is crucial to have high quality of case registration to estimate the real impact of each arboviruses in the population. In this work, a Vector Autoregressive (VAR) model was developed to investigate the interrelationships between discarded and confirmed cases of dengue, chikungunya, and Zika in Brazil. We used data from the Brazilian National Notifiable Diseases Information System (SINAN) from 2010 to 2017. There were three peaks in the series of dengue notification in this period occurring in 2013, 2015 and in 2016. The series of reported cases of both Zika and chikungunya reached their peak in late 2015 and early 2016. The VAR model shows that the Zika series have a significant impact on the dengue series and vice versa, suggesting that several discarded and confirmed cases of dengue could actually have been cases of Zika. The model also suggests that the series of confirmed and discarded chikungunya cases are almost independent of the cases of Zika, however, affecting the series of dengue. In conclusion, co-circulation of arboviruses with similar symptoms could have lead to misdiagnosed diseases in the surveillance system. We argue that the routinely use of mathematical and statistical models in association with traditional symptom-surveillance could help to decrease such errors and to provide early indication of possible future outbreaks. These findings address the challenges regarding notification biases and shed new light on how to handle reported cases based only in clinical-epidemiological criteria when multiples arboviruses co-circulate in the same population.

Exotic Eucalyptus leaves are preferred over tougher native species but affect the growth and survival of shredders in an Atlantic Forest stream (Brazil).

We evaluated the effect of leaves of native and exotic tree species on the feeding activity and performance of the larvae of Triplectides gracilis, a typical caddisfly shredder in Atlantic Forest streams. Leaves of four native species that differ in chemistry and toughness (Hoffmannia dusenii, Miconia chartacea, Myrcia lineata and Styrax pohlii) and the exotic Eucalyptus globulus were used to determine food preferences and rates of consumption, production of fine particulate organic matter (FPOM), growth and survival of shredders. We hypothesized that the consumption rates of leaves of Eucalyptus and their effects on the growth and survival of shredders could be predicted by leaf chemistry and toughness. The larvae preferred to feed on soft leaves (H. dusenii and M. chartacea) independently of the content of nutrients (N and P) and secondary compounds (total phenolics). When such leaves were absent, they preferred E. globulus and did not consume the tough leaves (M. lineata and S. pohlii). In monodietary experiments, leaf consumption and FPOM production differed among the studied leaves, and the values observed for the E. globulus treatments were intermediate between the soft and tough leaves. The larvae that fed on H. dusenii and M. chartacea grew constantly over five weeks, while those that fed on E. globulus lost biomass. Larval survival was higher on leaves of H. dusenii, M. chartacea and S. pohlii than on E. globulus and M. lineata leaves. Although E. globulus was preferred over tougher leaves, long-term consumption of leaves of the exotic species may affect the abundance of T. gracilis in the studied stream. Additionally, our results suggest that leaf toughness can be a determining factor for the behavior of shredders where low-quality leaves are abundant, as in several tropical streams.

Inhibition of HMG-CoA reductase activity and cholesterol permeation through Caco-2 cells by caffeoylquinic acids from Vernonia condensata leaves

ABSTRACT The aim of this study was to provide scientific knowledge to support the use of Vernonia condensata Baker, Asteraceae, beverages for their alleged hypocholesterolemic properties by testing their action as HMG-CoA reductase inhibitors and their capacity to lower dietary cholesterol permeation. Chlorogenic acid, and other caffeoylquinic acids derivatives were identified as the main components of these beverages by LC–MS/MS. No changes in the composition were notice after the in vitro gastrointestinal digestion and no toxicity against Caco-2 and HepG2 cell lines was detected. Cholesterol permeation through Caco-2 monolayers was reduced in 37% in the presence of these herbal teas, and the caffeoylquinic acids permeated the monolayers in 30–40% of their initial amount in 6 h. HMG-CoA reductase activity was reduced with these beverages, showing an IC50 of 217 µg ml−1. It was concluded that caffeoylquinic acids, the major components, justified 98% of the enzyme inhibition measured.

Antispasmodic effect of Ocimum selloi essential oil on the guinea-pig ileum.

Ocimum selloi is an herbal species popularly used in Brazil as antispasmodic. Herein, we report the antispasmodic effect of O. selloi essential oil (OS) in segments of guinea-pig ileum. OS did not reduce the tonus of the ileum. In contrast, OS reduced the contraction induced by carbachol (100 µM), BaCl2 (0.03 M) and low- and high-K(+) concentrations (25 and 60 mM, respectively). OS shifted the concentration-response curve for calcium to the right in a parallel manner. GC/MS analysis showed that OS consists mostly of methyl chavicol (97.57%). These results suggest that OS antispasmodic effect is mediated through calcium channel blockade. In addition, OS effect and mode of action could be accounted for methyl chavicol.

Rupture of glandular trichomes in Ocimum gratissimum leaves influences the content of essential oil during the drying method

Medicinal and aromatic plants are commonly sold dried; however, it is necessary to understand the effects different drying methods have on these materials, to ensure their efficiency and quality. Ocimum gratissimum L., Lamiaceae, is an aromatic plant whose essential oil is stored in glandular trichomes. This study aimed to confirm the effects of different drying temperatures and methods of O. gratissimum leaves on trichome integrity and essential oil content. Leaves dried in a forced ventilation oven at 60ºC display damaged trichomes and a reduction in the essential oil content. The different drying methods (oven, dehumidification and air drying) were not identified to elicit changes in the essential oil content or damage to trichomes. All of the drying methods showed a reduction in fungal contamination in a logarithmic cycle.

Light affects Varronia curassavica essential oil yield by increasing trichomes frequency

Light can act on essential oil yield directly on synthesis of secondary metabolites, or indirectly on plant growth. Varronia curassavica Jacq., Boraginaceae, is a native medicinal species from Brazil known as “erva-baleeira”, with anti-inflammatory activity related to its essential oil. Despite pharmacological evidences of this species and its economic importance for herbal medicine production, little is known about the effect of light on growth and essential oil production. This study aimed to analyze the influence of different irradiances on growth, frequency of trichomes, essential oil yield and composition of V. curassavica. The irradiance affected plant growth, but no significant alteration on leaf biomass was detected. The increase in essential oil content under higher irradiance reflected on essential oil yield, and is associated with higher frequency of glandular, globular trichomes. The essential oil composition, rich in caryophyllene derivatives was affected by irradiance, but α-humulene, the constituent of pharmaceutical interest, remained unchanged.

Light intensity on growth, leaf micromorphology and essential oil production of Ocimum gratissimum

Light conditions can promote the growth and development of plants and contribute to increase the essential oil production of commercially cultivated medicinal and aromatic species. In view of the great importance of Ocimum gratissimum L., Lamiaceae, as an aromatic plant, the objective of this work was to determine the effect of light intensities (approximately 4, 7, 11 and 20 mol m-2 d-1) on growth, foliar micromorphology, essential oil content, yield and chemical composition of O. gratissimum. Biomass production of different organs, root:shoot ratio and leaf mass per area were found to linearly increase with increased light availability, whereas stem dry matter fraction, number of leaves, leaf area and plant height have increased up to 10 mol m-2 d-1 and decreased from this value. The tector trichomes density increased with increased light availability, but there was no effect of light treatments on the glandular trichomes density and essential oil content. Regardless of the light level, the major component of the essential oil was eugenol. The essential oil yield per plant increased linearly with light intensity as a direct effect of increased leaf biomass under similar conditions.

Lippia alba morphotypes cidreira and melissa exhibit significant differences in leaf characteristics and essential oil profile

Lippia alba (Mill.) N.E. Br. ex Britton & P. Wilson, Verbenaceae, is widely used in traditional Brazilian medicine for the treatment of abdominal distress. The species exhibits considerable chemical and morphological diversity, and various chemotypes have been characterized. A comparative study of L. alba, has been carried out of the morphoanatomical characteristics of the leaves and the profiles of the essential oils of the morphotypes cidreira and melissa grown in the Medicinal Plant Garden of the Universidade Estadual de Santa Cruz, Ilhéus, Bahia, Brazil. The mean plant height of cidreira was 1.80 m and the stems and branches were fairly erect, while melissa plants were smaller (1.60 m) and presented prostrate stems and branches. Although the leaf of the morphotypes look were similar, the mean values of length, width and area of the leaves of cidreira (respectively, 7.42 cm, 3.32 cm and 17.31 cm²) differed significantly from those of melissa (4.68 cm, 2.35 cm and 7.32 cm2). The morphotypes presented amphistomatic leaves with uniseriate epidermis on both surfaces. The mesophyll was dorsiventral, but in cidreira the palisade parenchyma was biseriate while in melissa it was uniseriate. Simple tector and capitate glandular trichomes were present on the adaxial and abaxial surfaces of the leaf blades of both morphotypes. Six distinct types of glandular trichomes could be distinguished: types I and II were present in both morphotypes, while type III was detected only in cidreira, and types IV to VI were present only in melissa. The two morphotypes also differed with respect to the composition of the essential oil, cidreira produced oil composed mainly of citral, while the oil from melissa was rich in citral, limonene and carvone.

Analgesic and antidiarrheal properties of Ocimum selloi essential oil in mice.

Ocimum selloi essential oil (2, 20, and 200 mg/kg; p.o.) reduced, in a dose-dependent way, the abdominal contraction induced by acetic acid (0.6%; i.p.) and the diarrhea episodes induced by castor oil in mice. At the higher dose (200 mg/kg; p.o.), the essential oil significantly reduced intestinal transit (P<0.05) in the charcoal meal test. The main component detected in O. selloi essential oil was methyl chavicol (98%; GC and GC/MS).These effects seems to support the use of O. selloi against diarrhea, intestinal spasm and visceral pain.