Clinical Profile and Risk Factors for Severe COVID-19 in Hospitalized Patients from Rio de Janeiro, Brazil: Comparison between the First and Second Pandemic Waves.

Since COVID-19 was declared a pandemic, Brazil has become one of the countries most affected by this disease. A year into the pandemic, a second wave of COVID-19 emerged, with a rapid spread of a new SARS-CoV-2 lineage of concern. Several vaccines have been granted emergency-use authorization, leading to a decrease in mortality and severe cases in many countries. However, the emergence of SARS-CoV-2 variants raises the alert for potential new waves of transmission and an increase in pathogenicity. We compared the demographic and clinical data of critically ill patients infected with COVID-19 hospitalized in Rio de Janeiro during the first and second waves between July 2020 and October 2021. In total, 106 participants were included in this study; among them, 88% had at least one comorbidity, and 37% developed severe disease. Disease severity was associated with older age, pre-existing neurological comorbidities, higher viral load, and dyspnea. Laboratory biomarkers related to white blood cells, coagulation, cellular injury, inflammation, renal, and liver injuries were significantly associated with severe COVID-19. During the second wave of the pandemic, the necessity of invasive respiratory support was higher, and more individuals with COVID-19 developed acute hepatitis, suggesting that the progression of the second wave resulted in an increase in severe cases. These results can contribute to understanding the behavior of the COVID-19 pandemic in Brazil and may be helpful in predicting disease severity, which is a pivotal for guiding clinical care, improving patient outcomes, and defining public policies.

Beyond arboviruses: A multicenter study to evaluate differential diagnosis of rash diseases and acute febrile illness cases in Rio de Janeiro, Brazil.

INTRODUCTION: A wide variety of viruses can cause rash diseases (RDs) or acute febrile illness (AFIs) in children, adolescents and adults; however, approximately 19% of RD cases and 40% of AFI cases remain without a defined etiology. Parvovirus B19 (B19V) and herpesvirus infection can also cause RD and/or AFI, and in some risk groups, these infections can become persistent (or latent) and may require hospital treatment. Since these infections do not have mandatory reporting, they can be hidden by other diseases, such as those caused by arboviruses (e.g., dengue virus). In this context, the aim of this study was to pursue the differential laboratory diagnoses of B19V and herpesvirus infections in patients with RD and AFI, without a defined etiology, seen in hospitals and/or reference centers for infectious diseases in Rio de Janeiro. METHODS: A total of 114 participants were enrolled in the study, including 54 children and 60 adults. B19V infection was assessed by real-time PCR (qPCR) and ELISA (anti-B19V IgM and IgG). EBV was assessed through qPCR, and betaherpesviruses (HCMV, HHV-6 and HHV-7) were assessed through multiplex qPCR. Sociodemographic and clinical data were obtained from the medical record data of these participants. RESULTS: The median age of children with RD was 2 years (interquartile range (IQR): 5), and 55.6% were male. Among adults with AFI, the median age was 38 years (IQR: 21), and 56.7% were female. Regarding RD patients, viral prevalence (and load) were 5.5%(104IU/mL), 3.4%(104IU/mL), 5.5%(104IU/mL) and 11.1%(105IU/mL) for B19V, EBV, HCMV and HHV-6 infection, respectively, and in AFI patients they were 6.6%(105IU/mL), 1.6%(103IU/mL), 3.3%(104IU/mL) for B19V, HCMV and HHV-6, respectively. HHV-7 was not detected in RD or AFI patients. CONCLUSION: These results suggest the importance of including B19V and herpesviruses in the differential laboratory diagnoses for patients with RD and AFI, not only for epidemiological purposes but also for the proper management of the patient.

Evaluation of Molecular Test for the Discrimination of "Naked" DNA from Infectious Parvovirus B19 Particles in Serum and Bone Marrow Samples.

Low levels of parvovirus B19 (B19V) DNA can be detected in the circulation and in different tissue of immunocompetent individuals for months or years, which has been linked to inflammatory diseases such as cardiomyopathy, rheumatoid arthritis, hepatitis, and vasculitis. However, the detection of B19V DNA does not necessarily imply that infectious virions are present. This study aimed to evaluate the method based on the Benzonase® treatment for differentiation between the infectious virions from "naked" DNA in serum and bone marrow (BM) samples to be useful for the B19V routine diagnosis. In addition, we estimated the period of viremia and DNAemia in the sera and bone marrow of nonhuman primates experimentally infected with B19V. Serum samples from ten patients and from four cynomolgus monkeys experimentally infected with B19V followed up for 60 days were used. Most of the human serum samples became negative after pretreatment; however, only decreased viral DNA loads were observed in four patients, indicating that these samples still contained the infectious virus. Reduced B19V DNA levels were observed in animals since 7th dpi. At approximately 45th dpi, B19V DNA levels were below 105 IU/mL after Benzonase® pretreatment, which was not a consequence of active B19V replication. The test based on Benzonase® pretreatment enabled the discrimination of "naked DNA" from B19V DNA encapsidated in virions. Therefore, this test can be used to clarify the role of B19V as an etiological agent associated with atypical clinical manifestations.

Low prevalence of hepatitis B and C virus markers among children and adolescents.

This study aimed to determine the prevalence of HBV and HCV among children and adolescents attending schools and daycare centres in Rio de Janeiro State, located in southern Brazil. Serum samples from 1,217 individuals aged 0 to 18 years were collected from 1999 to 2012 and tested for HBsAg, total anti-HBc, anti-HBs, and anti-HCV by ELISA. Reactive HBsAg and anti-HBc samples were tested for HBV DNA. Reactive anti-HCV samples were tested for HCV RNA and genotyped by RFLP. HBsAg was detected in 1.8% of individuals, and total anti-HBc was detected among 3.6% of individuals. Anti-HBs reactivity was found among 25.3% (322/1,217) of the individuals and increased from 6.28% in the years 1999-2000 to 76.2% in the years 2001-2012 (P < 0.0001). HBV DNA was detected in 18 of 51 individuals who presented with HBsAg or isolated anti-HBc, and nine were considered occult hepatitis B cases. Three individuals were anti-HCV- and HCV RNA-positive: two of them were infected with genotype 1, and the other was infected with genotype 3. Low levels of HBV and HCV markers were observed in children and adolescents. HBV immunity increased during the period of study, indicating that childhood universal HBV vaccination has been effective for controlling HBV infection in Brazil.

Detection of replication-defective hepatitis A virus based on the correlation between real-time polymerase chain reaction and ELISA in situ results.

ELISA in situ can be used to titrate hepatitis A virus (HAV) particles and real-time polymerase chain reaction (RT-PCR) has been shown to be a fast method to quantify the HAV genome. Precise quantification of viral concentration is necessary to distinguish between infectious and non-infectious particles. The purpose of this study was to compare cell culture and RT-PCR quantification results and determine whether HAV genome quantification can be correlated with infectivity. For this purpose, three stocks of undiluted, five-fold diluted and 10-fold diluted HAV were prepared to inoculate cells in a 96-well plate. Monolayers were then incubated for seven, 10 and 14 days and the correlation between the ELISA in situ and RT-PCR results was evaluated. At 10 days post-incubation, the highest viral load was observed in all stocks of HAV via RT-PCR (10(5) copies/mL) (p = 0.0002), while ELISA revealed the highest quantity of particles after 14 days (optical density = 0.24, p < 0.001). At seven days post-infection, there was a significant statistical correlation between the results of the two methods, indicating equivalents titres of particles and HAV genome during this period of infection. The results reported here indicate that the duration of growth of HAV in cell culture must be taken into account to correlate genome quantification with infectivity.

Detection of replication-defective hepatitis A virus based on the correlation between real-time polymerase chain reaction and ELISA in situ results

ELISA in situ can be used to titrate hepatitis A virus (HAV) particles and real-time polymerase chain reaction (RT-PCR) has been shown to be a fast method to quantify the HAV genome. Precise quantification of viral concentration is necessary to distinguish between infectious and non-infectious particles. The purpose of this study was to compare cell culture and RT-PCR quantification results and determine whether HAV genome quantification can be correlated with infectivity. For this purpose, three stocks of undiluted, five-fold diluted and 10-fold diluted HAV were prepared to inoculate cells in a 96-well plate. Monolayers were then incubated for seven, 10 and 14 days and the correlation between the ELISA in situ and RT-PCR results was evaluated. At 10 days post-incubation, the highest viral load was observed in all stocks of HAV via RT-PCR (10(5) copies/mL) (p = 0.0002), while ELISA revealed the highest quantity of particles after 14 days (optical density = 0.24, p < 0.001). At seven days post-infection, there was a significant statistical correlation between the results of the two methods, indicating equivalents titres of particles and HAV genome during this period of infection. The results reported here indicate that the duration of growth of HAV in cell culture must be taken into account to correlate genome quantification with infectivity.

Could oral fluid be used to evaluate anti-hepatitis A virus status in individuals living in difficult-to-access areas?

A strategy adopted by different countries to reduce the number of new cases of hepatitis A is the vaccination. However, the mosaic of the epidemiological profile in developing countries has hampered the establishment of a unified nationwide vaccination program. To determinate national vaccination policies, the results of epidemiological studies need to be carefully considered. For this monitoring, the use of oral fluid is very important due to the painless and non invasive collection characteristics. There are few studies investigating which oral fluid collection device is optimal to detect low antibody levels and its use in selecting individuals for vaccination. So, the present study aimed to evaluate different oral fluid collection devices to detect humoral immune response against hepatitis A virus and its application in epidemiological studies. Therefore, 90 matched serum and oral fluid samples were collected from volunteers with different immune status, under ideal conditions of collection (optimization panel); and 224 matched samples in difficult-to-access areas (epidemiological study). Serum was collected by venipuncture and the oral fluid was obtained using three commercial devices: Salivette(®), OraSure(®) and ChemBio(®). Serum and oral fluid were submitted to a commercial immunoblot to detect total anti-HAV antibodies. The optimization panel demonstrated that ChemBio(®) device had the best performance (100% agreement), followed by OraSure(®) (95.4%) and Salivette(®) (90.8%). The optimal collection device (ChemBio(®)), tested in a difficult-to-access area and evaluated under precarious conditions of collection, showed similar prevalence of total anti-HAV between serum and oral fluid, 80.8% and 79%, respectively. A follow-up was performed to evaluate the stability of oral fluid and it was observed that 210 days after the collection it was possible to detect anti-HAV antibodies. Oral fluid can be used to detect low levels of specific-antibody, being important to select age groups to be vaccinated. Therewith, the choice of proper collection device is essential to evaluate HAV antibodies in the epidemiological scenario.

Declining prevalence of hepatitis A virus antibodies among children from low socioeconomic groups reinforces the need for the implementation of hepatitis A vaccination in Brazil.

Age-related seroprevalence studies that have been conducted in Brazil have indicated a transition from a high to a medium endemicity of hepatitis A virus (HAV) infection in the population. However, most of these studies have focused on urban populations that experience lower incidence rates of HAV infection. In the current study, the prevalence of anti-HAV antibodies was investigated in children with a low socioeconomic status (SES) that live on the periphery of three capital cities in Brazil. A total of 1,162 dried blood spot samples were collected from individuals whose ages ranged from one-18 years and tested for anti-HAV antibodies. A large number of children under five years old (74.1-90%) were identified to be susceptible to HAV infection. The anti-HAV antibody prevalence reached ≥ 50% among those that were 10-14 years of age or older. The anti-HAV prevalence rates observed were characteristics of regions with intermediate level of hepatitis A endemicity. These data indicated that a large proportion of children with a low SES that live at the periphery of urban cities might be at risk of contracting an HAV infection. The hepatitis A vaccine that is currently offered in Brazil is only available for high-risk groups or at private clinics and is unaffordable for individuals with a lower SES. The results from this study suggest that the hepatitis A vaccine should be included in the Brazilian National Program for Immunisation.

Declining prevalence of hepatitis A virus antibodies among children from low socioeconomic groups reinforces the need for the implementation of hepatitis A vaccination in Brazil

Age-related seroprevalence studies that have been conducted in Brazil have indicated a transition from a high to a medium endemicity of hepatitis A virus (HAV) infection in the population. However, most of these studies have focused on urban populations that experience lower incidence rates of HAV infection. In the current study, the prevalence of anti-HAV antibodies was investigated in children with a low socioeconomic status (SES) that live on the periphery of three capital cities in Brazil. A total of 1,162 dried blood spot samples were collected from individuals whose ages ranged from one-18 years and tested for anti-HAV antibodies. A large number of children under five years old (74.1-90%) were identified to be susceptible to HAV infection. The anti-HAV antibody prevalence reached ≥ 50% among those that were 10-14 years of age or older. The anti-HAV prevalence rates observed were characteristics of regions with intermediate level of hepatitis A endemicity. These data indicated that a large proportion of children with a low SES that live at the periphery of urban cities might be at risk of contracting an HAV infection. The hepatitis A vaccine that is currently offered in Brazil is only available for high-risk groups or at private clinics and is unaffordable for individuals with a lower SES. The results from this study suggest that the hepatitis A vaccine should be included in the Brazilian National Program for Immunisation.

Exposure to multiple subgenotypes of hepatitis A virus during an outbreak using matched serum and saliva specimens.

Matched serum and saliva samples were collected simultaneously from 124 subjects exposed during a hepatitis A virus (HAV) outbreak at a daycare center in Rio de Janeiro, Brazil. All samples were tested for IgM and total anti-HAV antibodies by enzyme immunoassay (EIA). HAV was detected by nested PCR in serum, saliva, and water samples employing primers for the VP1/2A region of the viral RNA; all positive products were then sequenced. The viral load of the matched samples was determined by real-time PCR using the TaqMan system. HAV-RNA was identified by nested PCR in 37.7% of the saliva samples, 29% of the serum samples, and one drinking water sample. The mean HAV viral load was similar in the serum and saliva specimens (10(3) copies/ml). HAV genotypes IA and IB were detected in both specimen types, and the water sample isolate was classified as genotype IB, indicating the existence of more than one source of infection at the daycare center. In six infected patients, a different HAV subgenotype was found in their serum than in their saliva, and this unusual pattern of mixed HAV infection was investigated further by molecular cloning followed by nucleotide sequencing. All clones derived from the saliva samples belonged to subgenotype IB and shared 96.5-100% identity. However, clones derived from their corresponding serum sample belonged to subgenotype IA and shared 90.5-100% identity. This study showed the important role that non-invasive saliva samples can play in the molecular epidemiological analysis of a hepatitis A outbreak.

Importance of the cutoff ratio for detecting antibodies against hepatitis A virus in oral fluids by enzyme immunoassay.

Multiple studies have examined the use of oral fluids in modified serum-based assays aiming to replace serum in antibody detection for hepatitis A. However, the reliable detection of HAV immunity in oral fluid requires an extremely sensitive assay; most immunoassays designed for serum antibody determination lack sufficient sensitivity for this purpose. Consequently, an "in-house" competitive enzyme immunoassay (EIA) designed specifically for use with oral samples collected using a ChemBio(®) device was developed to detect total anti-HAV antibodies (IgG and IgM). This system was compared to an in-house competitive EIA and a commercial EIA considered to be the "gold standard" using corresponding serum samples (n=225) to determine the accuracy of the assay and to evaluate the importance of the cutoff ratio for the detection of anti-HAV antibodies in oral fluids. When the median serum cutoff and the optimal oral fluid cutoff (ROC analysis) obtained from the in-house competitive EIA were compared, the oral fluid cutoff was found to be 28.8% higher than the serum cutoff. When different oral fluid cutoff values were compared, a reduction of about 17% was shown to be essential to increase test accuracy. At an oral fluid cutoff value of 0.351, sensitivity and specificity were higher, reaching 91.7% and 86.2% (p<0.001, AUROC=0.915), respectively. The convenience, accuracy and non-invasive nature of the developed method make it a useful alternative to serum-based assays for discriminating between HAV-immune and non-immune individuals.

Saliva como espécime clínico para o estudo da hepatite A: aplicações no diagnóstico, na epidemiologia molecular e na patogênese / Saliva as clinical specimen for the study of hepatitis A: usefulness for diagnosis, molecular epidemiology and pathogenesis

No Brasil, surtos de hepatite A em comunidades fechadas, principalmente em creches e escolas, constituem um importante problema para a saúde pública, que requerem investigação epidemiológica e rápida intervenção de controle, devido ao risco de propagação silenciosa para as comunidades próximas. Entretanto, a coleta de sangue é invasiva e dolorosa o que dificulta o acesso à população infantil para a realização do diagnóstico, muitas vezes inviabiliza o estudo epidemiológico quando este envolve um número grande de indivíduos. A coleta de amostras de saliva como uma alternativa, oferece potenciais vantagens, pois se trata de uma coleta não-invasiva, indolor e rápida. A fim de avaliar a utilização da saliva como espécime clínico para o diagnóstico e estudos epidemiológicos da hepatite A, estudos foram conduzidos a partir de amostras pareadas de saliva/soro de pacientes envolvidos em um surto de hepatite A. No primeiro estudo, otimizamos métodos para detecção de anticorpos anti-HAV e do HAV-RNA em amostras de saliva. Neste estudo, observamos sensibilidade e especificidade do teste de detecção de anti-HAV IgM na saliva de 96por cento e 98por cento, respectivamente. Após estabelecer os protocolos para detecção do HAV RNA, verificamos uma alta frequência de detecção de HAV RNA em amostras de saliva tanto de pacientes em fase aguda como em pacientes em período de janela iminológica (37,2por cento). O estudo da epidemiologia molecular conduzido durante o surto revelou co-circulação dos dubgenótipos IA e IB do HAV e a ocorrência de casos de co-infecção por subgenótipos diferentes do HAV entre as amostras pareadas de soro e saliva. Este resultado nos levou a investigação de uma possível replicação extra hepática do HAV em glândulas salivares, através de um estudo de infecção experimental em cinomolgos. Neste estudo constatamos a presença...

Detecção e caracterização molecular do vírus da hepatite A em amostras de saliva / Detection and molecular characterization of the hepatitis A virus in saliva samples

A infecção pelo vírus da hepatite A(HAV)é comum em creches e devido à característica de disseminação assintomática da doença entre crianças,pode gerar surtos principalmente em comunidades fechadas...Foram coletadas amostras pareadas de soro e saliva de 126 indivíduos envolvidos em um surto de hepatite A, ocorrido em outubro de 2004,em uma creche pública no Rio de Janeiro.Todas as amostras foram...da infecção.Para detecção do RNA do HAV em amostras de saliva foram avaliadas duas técnicas:RT-nested-PCR e PCR em tempo real.Em ambas as técnicas vários parâmetros foram avaliados:diferentes métodos de extração do RNA, eficiência de 2 transcriptases reversas e volumes variados de cDNA e Taq Pol.A técnica de RT-nested-PCR apresentou um limite mínimo de detecção de 6x10(ao cubo) cópias/mL,não foi observada a presença de inibidores e não houve relação entre a detecção do HAV na saliva e a presença de sangue nestas amostras.Foi observada uma predominância do RNA do HAV na saliva(50por cento)de pacientes agudos,em relação às amostras de soro(42por cento).Entre as amostras sem marcadores,3 foram positivas no soro e na saliva.A técnica de PCR em tempo real foi padronizada para detecção e quantificação do RNA viral nas amostras de saliva,apresentando sensibilidade de 140 cópias/mL e alta reprodutibilidade.Pela técnica de PCR em tempo real,o RNA do HAV foi detectado em 60por cento das amostras de saliva testadas,entre elas 32 eram anti-HAV IgM positivas e 17 anti-HAV IgM/total negativas.A carga viral média no soro foi de 2,8x10(ao cubo)cópias/mL,e na saliva foi de 1,7x10(ao cubo)cópias/mL,não houve diferença significativa entre estas médias,indicando que não houve associação entre a detecção do RNA do HAV em amostras de saliva e a carga viral no soro.As amostras de soro e de saliva HAV-RNA positivas foram seqüenciadas.As amostras seqüenciadas neste estudo foram todas classificadas como genótipo I.Entre as amostras de soro, 16 foram classificadas como subgenótipo IA e 7 como...