Toxoplasmosis outbreak in São Paulo, Brazil: Epidemiology and visual outcome.

PURPOSE: To describe a 2019 acute toxoplasmosis outbreak in the city of São Paulo, Brazil, and to evaluate the laboratory serological profile for toxoplasmosis for three consecutive years. The ophthalmological manifestations of the patients involved in the outbreak were also studied. METHODS: A cross-sectional descriptive study of a toxoplasmosis outbreak in São Paulo, Brazil, between February and May 2019. Epidemiological data were described, as were the observed ocular manifestations. As part of this study the number of patients with positive IgM toxoplasmosis serology was obtained from a large laboratory network (DASA) for three consecutive years, including the year of the outbreak (2018, 2019, 2020). RESULTS: Eighty-three individuals were identified in the outbreak and two clusters were studied. The clinical picture of at least 77% of the patients, the epidemiological analysis, and the short incubation period (5-8 days) suggested contamination by oocysts. Serological laboratory data analysis revealed an increase of positive toxoplasmosis IgM in 2019 of 73% compared to the previous year. Ophthalmological examination revealed that at least 4.8% of the patients developed toxoplasmic retinochoroiditis, none of whom had been treated during the acute systemic disease. CONCLUSION: Our findings indicate vegetable contamination as the possible source of this outbreak, a high prevalence of toxoplasmosis in São Paulo during the outbreak period, and a drop in the number of tests during the COVID-19 pandemic. Retinochoroiditis was observed in at least 4.8% of the cases. We confirm the need to implement effective means for the prevention, diagnosis, and treatment of the disease. This may involve raising awareness among the population of the importance of vegetable hygiene, and improved quality control of food and water.

Toxoplasmosis outbreak in São Paulo, Brazil: Epidemiology and visual outcome

ABSTRACT Purpose: To describe a 2019 acute toxoplasmosis outbreak in the city of São Paulo, Brazil, and to evaluate the laboratory serological profile for toxoplasmosis for three consecutive years. The ophthalmological manifestations of the patients involved in the outbreak were also studied. Methods: A cross-sectional descriptive study of a toxoplasmosis outbreak in São Paulo, Brazil, between February and May 2019. Epidemiological data were described, as were the observed ocular manifestations. As part of this study the number of patients with positive IgM toxoplasmosis serology was obtained from a large laboratory network (DASA) for three consecutive years, including the year of the outbreak (2018, 2019, 2020). Results: Eighty-three individuals were identified in the outbreak and two clusters were studied. The clinical picture of at least 77% of the patients, the epidemiological analysis, and the short incubation period (5-8 days) suggested contamination by oocysts. Serological laboratory data analysis revealed an increase of positive toxoplasmosis IgM in 2019 of 73% compared to the previous year. Ophthalmological examination revealed that at least 4.8% of the patients developed toxoplasmic retinochoroiditis, none of whom had been treated during the acute systemic disease. Conclusion: Our findings indicate vegetable contamination as the possible source of this outbreak, a high prevalence of toxoplasmosis in São Paulo during the outbreak period, and a drop in the number of tests during the COVID-19 pandemic. Retinochoroiditis was observed in at least 4.8% of the cases. We confirm the need to implement effective means for the prevention, diagnosis, and treatment of the disease. This may involve raising awareness among the population of the importance of vegetable hygiene, and improved quality control of food and water.

Surveillance system for Healthcare-associated endophthalmitis at state level in a middle-income country: preliminary results / Sistema de vigilância epidemiológica para endoftalmites em nível estadual em um país de renda média: resultados preliminares

ABSTRACT Purpose: To describe the implementation pro cess and the preliminary results of a surveillance system for healthcare-associated endophthalmitis. Methods: This is a case study of the implementation of a surveillance system for healthcare-associated endophthalmitis. The system for healthcare-associated endophthalmitis is a structured system that enables surveillance of cases of healthcare-associated endophthalmitis after intraocular procedures, developed and coordinated by the Division of Hospital Infection at the State Health Department, São Paulo, Brazil. The implementation process included a pilot phase, followed by a scaling-up phase. Data were reported monthly to the Division of Hospital Infection by participating healthcare facilities that performed intraocular procedures in the state of São Paulo, Brazil, from September 2017 to December 2019. Results: Among the 1,483 eligible healthcare facilities, 175 engaged in the study (participation rate of 11.8%), reporting 222,728 intraocular procedures performed, of which 164,207 were cataract surgery and 58,521 were intravitreal injections. The overall incidence rate of endophthalmitis was reported to be 0.05% (n=105; 80 cases after cataract surgery and 25 cases after intravitreal injections). The incidence rates for healthcare facilities ranged from 0.02% to 4.55%. Most cases were caused by gram-positive bacteria, mainly Staphylococcus spp. In 36 (46.2%) of the cases, there was no bacterial growth; no sample was collected in 28 (26.7%) cases. This system for healthcare-associated endophthalmitis enabled the identification of an outbreak of four cases of endophthalmitis after intravitreal injections. Conclusion: The system for healthcare-associated endophthalmitis proved to be operationally viable and efficient for monitoring cases of endophthalmitis at the state level.

RESUMO Objetivo: Descrever o processo de implementação e os resultados preliminares de um sistema de vigilância epidemiológica para endoftalmites associada à assistência à saúde. Métodos: Trata-se de um estudo de caso de implementação de um sistema de vigilância epidemiológica para endoftalmites. O sistema de vigilância epidemiológica para endoftalmites é um sistema estruturado que possibilita a vigilância de casos de endoftalmite associados à assistência à saúde após procedimentos oftalmológicos invasivos, desenvolvido e coordenado pela Divisão de Infecção Hospitalar da Secretaria de Estado da Saúde, São Paulo, Brasil. O processo de implementação incluiu uma fase piloto, seguida pela fase de expansão. Os dados foram enviados mensalmente à Divisão de Infecção Hospitalar pelos estabelecimentos de saúde participantes que realizaram procedimentos oftalmológicos no estado de São Paulo, Brasil no período de setembro de 2017 a dezembro de 2019. Resultados: Entre os 1.483 estabelecimentos de saúde elegíveis, 175 participaram do estudo (taxa de adesão de 11,8%), relatando 222.728 procedimentos oftalmológicos realizados, sendo 164.207 cirurgias de catarata e 58.521 injeções intravítreas. A taxa de incidência global de endoftalmite relatada foi de 0,05% (n=105; 80 casos após cirurgia de catarata e 25 casos após injeção intravítrea). As taxas de incidência entre os estabelecimentos de saúde variaram de 0,02% a 4,55%. A maioria dos casos foi causada por bactérias gram-positivas, principalmente Staphylococcus spp. Em 36 (46,2%) casos não houve crescimento bacteriano; nenhuma amostra foi coletada em 28 (26,7%) casos. O sistema de vigilância epidemiológica para endoftalmites possibilitou a identificação de um surto de quatro casos de endoftalmite após injeção intravítrea. Conclusão: O sistema de vigilância epidemiológica para endoftalmites mostrou-se operacionalmente viável e eficiente para o monitoramento de casos de endoftalmite em nível estadual.

Impact of COVID-19 on healthcare-associated infections: Antimicrobial consumption does not follow antimicrobial resistance.

BACKGROUND: This study aimed to analyze the Healthcare-Associated Infections (HAI) rates and antimicrobial consumption in Intensive Care Units (ICU) in São Paulo city during the COVID-19 pandemic and compare them with the pre-pandemic period. METHODS: This cohort included all hospitals that reported HAI rates (Central-Line-Associated Bloodstream Infection ‒ CLABSI and Ventilator-Associated Pneumonia ‒ VAP), the proportion of microorganisms that caused CLABSI, the proportion of resistant microorganisms, and antimicrobial consumption from January 2017 ‒ December 2020. Hospitals were stratified by the number of beds, Central Venous Catheter (CVC) utilization rate, Mechanical-Ventilation (MV) utilization rate, and type of funding. Statistical analyses were based on time-series plots and regression models. RESULTS: 220 ICUs were included. The authors observed an abrupt increase in CLABSI rates after the pandemic onset. High CLABSI rates during the pandemic were associated with hospital size, funding (public and non-profit private), and low CVC use (≤ 50%). An increase in VAP rates was associated with public hospitals, and high MV use (> 35%). The susceptibility profile of microorganisms did not differ from that of the pre-pandemic period. polymyxin, glycopeptides, and antifungal use increased, especially in COVID-19 ICUs. CONCLUSIONS: HAI increased during COVID-19. The microorganisms' susceptibility profile did not change with the pandemic, but the authors observed a disproportionate increase in large-spectrum antimicrobial drug use.

Seroprevalence of SARS-CoV-2 antibodies in schoolchildren in the city of São Paulo, 2020.

OBJECTIVE: To estimate seroprevalence of SARS-CoV-2 antibodies in schoolchildren aged 4 to 14 years living in the city of São Paulo, according to clinical, demographic, epidemiological, and social variables, during the school closure period as a measure against covid-19 spread. METHODS: A serological survey was made in September 2020 with a random sample stratified by school system (municipal public, state public and private) type. A venous blood sample was collected using the Wondfo SARS-CoV-2 Antibody Test (lateral flow method) for detection of total SARS-CoV-2 virus antibodies. Semi-structured questionnaires were applied to collect clinical, demographic, social, and epidemiological data. RESULTS: Seroprevalence of SARS-CoV-2 antibodies in schoolchildren was of 16.6% (95%CI 15.4-17.8). The study found higher seroprevalence in the municipal (18.5%; 95%CI 16.6-20.6) and state (16.2%; 95%CI 14.4-18.2) public school systems compared to the private school system (11.7; 95%CI 10.0-13.7), among black and brown students (18.4%; 95%CI 16.8-20.2) and in the most vulnerable social stratum (18.5 %;95%CI 16.9-20.2). Lower seroprevalence was identified in schoolchildren who reported following the recommended protective measures against covid-19. CONCLUSION: Seroprevalence of SARS-CoV-2 antibodies is found mainly in the most socially vulnerable schoolchildren. This study can contribute to support public policies that reinforce the importance of suspending face-to-face classes and developing strategies aimed at protective measures and monitoring of the serological status of those who have not yet been included in the vaccination schedule.

Seroprevalence of SARS-CoV-2 antibodies in schoolchildren in the city of São Paulo, 2020 / Soroprevalência de anticorpos do vírus SARS-CoV-2 em escolares no município de São Paulo, 2020

ABSTRACT OBJECTIVE To estimate seroprevalence of SARS-CoV-2 antibodies in schoolchildren aged 4 to 14 years living in the city of São Paulo, according to clinical, demographic, epidemiological, and social variables, during the school closure period as a measure against covid-19 spread. METHODS A serological survey was made in September 2020 with a random sample stratified by school system (municipal public, state public and private) type. A venous blood sample was collected using the Wondfo SARS-CoV-2 Antibody Test (lateral flow method) for detection of total SARS-CoV-2 virus antibodies. Semi-structured questionnaires were applied to collect clinical, demographic, social, and epidemiological data. RESULTS Seroprevalence of SARS-CoV-2 antibodies in schoolchildren was of 16.6% (95%CI 15.4-17.8). The study found higher seroprevalence in the municipal (18.5%; 95%CI 16.6-20.6) and state (16.2%; 95%CI 14.4-18.2) public school systems compared to the private school system (11.7; 95%CI 10.0-13.7), among black and brown students (18.4%; 95%CI 16.8-20.2) and in the most vulnerable social stratum (18.5 %;95%CI 16.9-20.2). Lower seroprevalence was identified in schoolchildren who reported following the recommended protective measures against covid-19. CONCLUSION Seroprevalence of SARS-CoV-2 antibodies is found mainly in the most socially vulnerable schoolchildren. This study can contribute to support public policies that reinforce the importance of suspending face-to-face classes and developing strategies aimed at protective measures and monitoring of the serological status of those who have not yet been included in the vaccination schedule.

RESUMO OBJETIVO Estimar a soroprevalência de anticorpos do vírus SARS-CoV-2 em escolares de quatro a 14 anos de idade residentes no município de São Paulo, segundo variáveis clínicas, demográficas, epidemiológicas e sociais, durante o período de fechamento das escolas como medida de controle da covid-19. MÉTODOS Realizou-se um inquérito sorológico em setembro de 2020 com amostra aleatória estratificada por tipo de rede de ensino (pública municipal, pública estadual e privada). Foi coletada amostra de sangue venoso utilizando-se o teste de imunoensaio de fluxo lateral da fabricante Wondfo para detecção de anticorpos totais contra o vírus SARS-CoV-2. Aplicaram-se questionários semiestruturados para o levantamento de dados clínicos, demográficos, sociais e epidemiológicos. RESULTADOS A soroprevalência de anticorpos do vírus SARS-CoV-2 em escolares foi de 16,6% (IC95% 15,4-17,8). O estudo encontrou soroprevalências mais elevadas na rede pública municipal (18,5%; IC95% 16,6-20,6) e estadual (16,2%; IC95% 14,4-18,2) em relação à rede privada (11,7; IC95% 10,0-13,7) e entre escolares da raça/cor preta e parda (18,4%; IC95% 16,8-20,2) e no estrato social mais vulnerável (18,5%; IC95% 16,9-20,2). A pesquisa identificou menores soroprevalências nos escolares que relataram seguir as medidas recomendadas de proteção contra a covid-19. CONCLUSÃO A soroprevalência de anticorpos contra o vírus SARS-CoV-2 atinge principalmente os escolares socialmente mais vulneráveis. Este estudo pode contribuir para embasar políticas públicas que reforcem a importância da suspensão das aulas presenciais e da necessidade de estratégias de medidas de proteção e acompanhamento do status sorológico daqueles que ainda não foram contemplados no calendário vacinal.

Impact of COVID-19 on healthcare-associated infections: Antimicrobial consumption does not follow antimicrobial resistance

Abstract Background This study aimed to analyze the Healthcare-Associated Infections (HAI) rates and antimicrobial consumption in Intensive Care Units (ICU) in São Paulo city during the COVID-19 pandemic and compare them with the pre-pandemic period. Methods This cohort included all hospitals that reported HAI rates (Central-Line-Associated Bloodstream Infection ‒ CLABSI and Ventilator-Associated Pneumonia ‒ VAP), the proportion of microorganisms that caused CLABSI, the proportion of resistant microorganisms, and antimicrobial consumption from January 2017 ‒ December 2020. Hospitals were stratified by the number of beds, Central Venous Catheter (CVC) utilization rate, Mechanical-Ventilation (MV) utilization rate, and type of funding. Statistical analyses were based on time-series plots and regression models. Results 220 ICUs were included. The authors observed an abrupt increase in CLABSI rates after the pandemic onset. High CLABSI rates during the pandemic were associated with hospital size, funding (public and non-profit private), and low CVC use (≤ 50%). An increase in VAP rates was associated with public hospitals, and high MV use (> 35%). The susceptibility profile of microorganisms did not differ from that of the pre-pandemic period. polymyxin, glycopeptides, and antifungal use increased, especially in COVID-19 ICUs. Conclusions HAI increased during COVID-19. The microorganisms' susceptibility profile did not change with the pandemic, but the authors observed a disproportionate increase in large-spectrum antimicrobial drug use.

Surveillance system for Healthcare-associated endophthalmitis at state level in a middle-income country: preliminary results.

PURPOSE: To describe the implementation pro cess and the preliminary results of a surveillance system for healthcare-associated endophthalmitis. METHODS: This is a case study of the implementation of a surveillance system for healthcare-associated endophthalmitis. The system for healthcare-associated endophthalmitis is a structured system that enables surveillance of cases of healthcare-associated endophthalmitis after intraocular procedures, developed and coordinated by the Division of Hospital Infection at the State Health Department, São Paulo, Brazil. The implementation process included a pilot phase, followed by a scaling-up phase. Data were reported monthly to the Division of Hospital Infection by participating healthcare facilities that performed intraocular procedures in the state of São Paulo, Brazil, from September 2017 to December 2019. RESULTS: Among the 1,483 eligible healthcare facilities, 175 engaged in the study (participation rate of 11.8%), reporting 222,728 intraocular procedures performed, of which 164,207 were cataract surgery and 58,521 were intravitreal injections. The overall incidence rate of endophthalmitis was reported to be 0.05% (n=105; 80 cases after cataract surgery and 25 cases after intravitreal injections). The incidence rates for healthcare facilities ranged from 0.02% to 4.55%. Most cases were caused by gram-positive bacteria, mainly Staphylococcus spp. In 36 (46.2%) of the cases, there was no bacterial growth; no sample was collected in 28 (26.7%) cases. This system for healthcare-associated endophthalmitis enabled the identification of an outbreak of four cases of endophthalmitis after intravitreal injections. CONCLUSION: The system for healthcare-associated endophthalmitis proved to be operationally viable and efficient for monitoring cases of endophthalmitis at the state level.

Clonal spread of ArmA- and OXA-23-coproducing Acinetobacter baumannii International Clone 2 in Brazil during the first wave of the COVID-19 pandemic.

Introduction. Carbapenem-resistant Acinetobacter baumannii (CRAB) is the primary pathogen causing hospital-acquired infections. The spread of CRAB is mainly driven by the dissemination of resistant clones, and in Latin America, International Clones IC-1 (also known as clonal complex CC1), IC-4 (CC15) and IC-5 (CC79) are the most prevalent.Gap Statement. There are no documented outbreaks of CRAB International Clone 2 (IC-2) reported in Brazil.Aim. To describe a large outbreak of CRAB caused by the uncommon IC-2 in a Brazilian COVID-19 hospital.Methodology. From May 2020 to May 2021, 224 patients infected or colonized with CRAB were identified in a single hospital; 92 % of them were also infected with SARS-CoV-2. From these patients, 137 isolates were recovered and subjected to antimicrobial susceptibility testing, PCR analysis and molecular typing. Whole-genome sequencing and downstream analysis were carried out on a representative isolate (the first available isolate).Results. In 76 % of the patients, a single OXA-23-producing CRAB IC-2 was identified. All the isolates were susceptible to polymyxin B, but highly resistant (>95 %) to aminoglycosides, fluoroquinolones and beta-lactams. Genomic analysis revealed that the representative isolate also carried the 16S rRNA Methylase ArmA, which was detected for the first time in this species in Brazil.Conclusion. We report the rapid spread of an emerging CRAB clone responsible for causing a large outbreak in a hospital in Brazil, a country with predominance of other CRAB clones. Continuous and prospective surveillance is warranted to evaluate the impact of this clone in Brazilian hospital settings.

Nosocomial outbreaks: A review of governmental reporting systems.

OBJECTIVE: Identifying and describing components of existent governmental reporting systems of NO aiming at informing the design of the implementation of NO reporting systems in countries where they were not fully established. DESIGN: A systematic search was carried out on PubMed, Embase, and the Latin American and Caribbean Health Sciences Literature database. We included studies published from January 2007 to June 2019 describing NO governmental reporting systems. Additionally, we included studies from the list of references in the identified papers, to gather more information about NO reporting systems. We also reviewed documents published in the governmental health department's Web sites, such as outbreak management guidelines and surveillance protocols, provided they were cited in the papers. RESULTS: NO reporting systems were reported in France (Alsace Region), Germany, Norway, United Kingdom, United States (New York State; New York City), Australia (Victoria State), Sweden (Skane Region), Ireland, Scotland (Lothian Region), and Canada (Winnipeg; Ontario). These systems vary according to the type of targeted NO event, such as gastroenteritis, influenza-like illness, invasive group A streptococcal disease or all-health care-acquired infection NO. Germany, Norway, New York City, New York State, Ireland, Winnipeg, and Ontario have established a mandatory reporting for NO. CONCLUSIONS: There is high variability among countries regarding governmental NO reporting systems. This may hinder opportune inter- and intracountries communication concerning NO of potential international public health relevance.

Statewide evaluation of infection control measures for preventing coronavirus disease 2019 in hemodialysis facilities.

OBJECTIVE: This study aimed to evaluate the occurrence of coronavirus disease 2019 (COVID-19) in hemodialysis facilities and the occurrence of and risk factors for clustering of COVID-19 cases. METHODS: We conducted a cross-sectional online survey between March and July 2020, in all dialysis facilities in São Paulo state, using Google Forms. The online questionnaire contained questions addressing specific components of infection prevention and control practices and the number of cases during the COVID-19 pandemic. RESULTS: A total of 1,093 (5%) COVID-19 cases were reported among 20,984 patients; approximately 56% of the facilities had ≥1 cluster. Most facilities implemented various measures (such as allocation of dedicated COVID-19 areas/shifts, symptom screening, environmental disinfection, and maintenance of adequate ventilation) to prevent the transmission of severe acute respiratory syndrome coronavirus 2. Clustering of COVID-19 cases was suspected in only 7% of dialysis facilities. The only variable associated with this event was the performance of aerosol-generating procedures (odds ratio: 4.74; 95% confidence interval: 1.75-12.86). CONCLUSION: Attention should be paid to avoiding the performance of aerosol-generating procedures in dialysis facilities and monitoring the clustering of cases.

Prevalence evolution of SARS-CoV-2 infection in the city of São Paulo, 2020-2021.

OBJECTIVE: To estimate the evolution of the prevalence of SARS-CoV-2 virus infection among residents aged 18 years or over in the municipality of São Paulo. METHODS: This is a population-based household survey conducted every 15 days, between June and September 2020, and January and February 2021. In total, the study comprised 11 phases. The presence of antibodies against SARS-CoV-2 was identified in venous blood using a lateral flow test, Wondfo Biotech. In the last phase, the researchers combined it with an immunoenzymatic test, Euroimmun. The participants also answered a semi-structured questionnaire on sociodemographic and economic factors, and on social distancing measures. Prevalence estimates and the 95% confidence interval were estimated according to regions, Human Development Index, sex, age group, ethnicity, education, income, and variables associated with risk or prevention of infection. To compare the frequencies among the categories of each variable, the chi-square test with Rao-Scott correction was used, considering a significance level of 5%. RESULTS: In total, 23,397 individuals were interviewed and had their samples collected. The estimated prevalence of antibodies against SARS-CoV-2 ranged from 9.7% (95%CI: 7.9-11.8%) to 25.0% (95%CI: 21.7-28.7). The prevalence of individuals with antibodies against the virus was higher among black and brown people, people with lower schooling and income, and among residents of regions with lower Human Development Index. The lowest prevalences were associated with recommended measures of disease protection. The proportion of asymptomatic infection was 45.1%. CONCLUSION: The estimated prevalence of the infection was lower than the cumulative incidence variation, except for the last phase of the study. The differences in prevalence estimates observed among subpopulations showed social inequality as a risk of infection. The lower prevalence observed among those who could follow prevention measures reinforce the need to maintain social distancing measures as a way to prevent SARS-CoV-2 infection.

Current Status of Antimicrobial Stewardship Programs in São Paulo Hospitals.

OBJECTIVES: Antimicrobial stewardship programs (ASPs) comprise coordinated interventions designed to improve antimicrobial use. Understanding the current structure of ASP hospitals will support interventions for the improvement of these programs. This study aimed to describe the status of ASPs in hospitals in São Paulo, Brazil. METHODS: A cross-sectional survey was conducted on the ASPs of hospitals in the state of São Paulo from March to July 2018. Through interviews by telephone or e-mail, we queried which components of the Infectious Diseases Society of America/Society for Healthcare Epidemiology of America and Centers for Disease Control and Prevention guidelines were implemented. RESULTS: The response rate was 30% (28/93 hospitals), and 26 hospitals (85%) reported having a formal ASP. The most frequently implemented strategies were antimicrobial surgical prophylaxis guidelines (100%), empiric sepsis guidelines (93%), and the presence of ASP team members during bedside rounds (96%). The least commonly implemented strategies included prior authorization for all antimicrobials (11%), pharmacokinetic monitoring, and an adjustment program for patients on IV aminoglycosides (3%). Regarding the metrics of the ASP, the most common indicator was the rate of antimicrobial resistance (77%). Eighteen hospitals evaluated antimicrobial consumption using defined daily dose, and only 29% evaluated the days of therapy; 61% of hospitals reported their results to the hospital administration and 39% to the prescribers. CONCLUSIONS: Most hospitals have a formal and active ASP, but with timely actions. We observed inconsistencies between what program leaders understand as the main objective of ASP and the metrics used to evaluate it. Part of the effort for the next few years should be to improve program evaluation metrics and to provide feedback to physicians and hospital leadership.

The Molecular Characterization of Hepatitis A Virus Strains Circulating during Hepatitis A Outbreaks in São Paulo, Brazil, from September 2017 to May 2019.

Outbreaks of hepatitis A may occur in countries of medium and high socioeconomic levels in which the population generally exhibits an increased susceptibility in young adults to this infection if they are not vaccinated against the hepatitis A virus (HAV). In Europe, an outbreak involved approximately 22 European countries with 4475 cases reported from 2016 to 2018; most of them were men who have sex with men (MSM). This outbreak expanded to North and South America, including Brazil, particularly in São Paulo city with 1547 reported cases from 2016 to 2019. In the present study, we characterized the HAV strains involved in the acute hepatitis A cases identified in the reference centers of São Paulo city during this outbreak. A total of 51 cases with positive anti-HAV IgM were included, 80.4% male, 68.6% of them between 20 and 40 years old and 41.7% MSM. HAV RNA was detected in 92% (47/51) of the cases. Subgenotype IA of HAV was identified and most of the strains were closely related to that isolated in outbreaks that occurred in different European countries in 2016. These results showed the epidemiological relation between these outbreaks and reinforce the need to implement vaccination against hepatitis A for the adult population, particularly for a population with a high-risk behavior.

Prevalence evolution of SARS-CoV-2 infection in the city of São Paulo, 2020-2021

ABSTRACT OBJECTIVE To estimate the evolution of the prevalence of SARS-CoV-2 virus infection among residents aged 18 years or over in the municipality of São Paulo. METHODS This is a population-based household survey conducted every 15 days, between June and September 2020, and January and February 2021. In total, the study comprised 11 phases. The presence of antibodies against SARS-CoV-2 was identified in venous blood using a lateral flow test, Wondfo Biotech. In the last phase, the researchers combined it with an immunoenzymatic test, Euroimmun. The participants also answered a semi-structured questionnaire on sociodemographic and economic factors, and on social distancing measures. Prevalence estimates and the 95% confidence interval were estimated according to regions, Human Development Index, sex, age group, ethnicity, education, income, and variables associated with risk or prevention of infection. To compare the frequencies among the categories of each variable, the chi-square test with Rao-Scott correction was used, considering a significance level of 5%. RESULTS In total, 23,397 individuals were interviewed and had their samples collected. The estimated prevalence of antibodies against SARS-CoV-2 ranged from 9.7% (95%CI: 7.9-11.8%) to 25.0% (95%CI: 21.7-28.7). The prevalence of individuals with antibodies against the virus was higher among black and brown people, people with lower schooling and income, and among residents of regions with lower Human Development Index. The lowest prevalences were associated with recommended measures of disease protection. The proportion of asymptomatic infection was 45.1%. CONCLUSION The estimated prevalence of the infection was lower than the cumulative incidence variation, except for the last phase of the study. The differences in prevalence estimates observed among subpopulations showed social inequality as a risk of infection. The lower prevalence observed among those who could follow prevention measures reinforce the need to maintain social distancing measures as a way to prevent SARS-CoV-2 infection.

Statewide evaluation of infection control measures for preventing coronavirus disease 2019 in hemodialysis facilities

OBJECTIVE: This study aimed to evaluate the occurrence of coronavirus disease 2019 (COVID-19) in hemodialysis facilities and the occurrence of and risk factors for clustering of COVID-19 cases. METHODS: We conducted a cross-sectional online survey between March and July 2020, in all dialysis facilities in São Paulo state, using Google Forms. The online questionnaire contained questions addressing specific components of infection prevention and control practices and the number of cases during the COVID-19 pandemic. RESULTS: A total of 1,093 (5%) COVID-19 cases were reported among 20,984 patients; approximately 56% of the facilities had ≥1 cluster. Most facilities implemented various measures (such as allocation of dedicated COVID-19 areas/shifts, symptom screening, environmental disinfection, and maintenance of adequate ventilation) to prevent the transmission of severe acute respiratory syndrome coronavirus 2. Clustering of COVID-19 cases was suspected in only 7% of dialysis facilities. The only variable associated with this event was the performance of aerosol-generating procedures (odds ratio: 4.74; 95% confidence interval: 1.75-12.86). CONCLUSION: Attention should be paid to avoiding the performance of aerosol-generating procedures in dialysis facilities and monitoring the clustering of cases.

Current status of antimicrobial stewardship programs in São Paulo Hospitals

OBJECTIVES: Antimicrobial stewardship programs (ASPs) comprise coordinated interventions designed to improve antimicrobial use. Understanding the current structure of ASP hospitals will support interventions for the improvement of these programs. This study aimed to describe the status of ASPs in hospitals in São Paulo, Brazil. METHODS: A cross-sectional survey was conducted on the ASPs of hospitals in the state of São Paulo from March to July 2018. Through interviews by telephone or e-mail, we queried which components of the Infectious Diseases Society of America/Society for Healthcare Epidemiology of America and Centers for Disease Control and Prevention guidelines were implemented. RESULTS: The response rate was 30% (28/93 hospitals), and 26 hospitals (85%) reported having a formal ASP. The most frequently implemented strategies were antimicrobial surgical prophylaxis guidelines (100%), empiric sepsis guidelines (93%), and the presence of ASP team members during bedside rounds (96%). The least commonly implemented strategies included prior authorization for all antimicrobials (11%), pharmacokinetic monitoring, and an adjustment program for patients on IV aminoglycosides (3%). Regarding the metrics of the ASP, the most common indicator was the rate of antimicrobial resistance (77%). Eighteen hospitals evaluated antimicrobial consumption using defined daily dose, and only 29% evaluated the days of therapy; 61% of hospitals reported their results to the hospital administration and 39% to the prescribers. CONCLUSIONS: Most hospitals have a formal and active ASP, but with timely actions. We observed inconsistencies between what program leaders understand as the main objective of ASP and the metrics used to evaluate it. Part of the effort for the next few years should be to improve program evaluation metrics and to provide feedback to physicians and hospital leadership.

Total antibiotic use in a state-wide area and resistance patterns in Brazilian hospitals: an ecologic study

ABSTRACT Introduction: Use of antibiotic and bacterial resistance is the result of a complex interaction not completely understood. Objectives: To evaluate the impact of entire antimicrobial use (community plus hospitals) on the incidence of bloodstream infections in intensive care units adjusted by socioeconomic factors, quality of healthcare, and access to the healthcare system. Design: Ecologic study using a hierarchical spatial model. Setting: Data obtained from 309 hospitals located in the state of São Paulo, Brazil from 2008 to 2011. Participants: Intensive care units located at participant hospitals. Outcome: Hospital acquired bloodstream infection caused by MDRO in ICU patients was our primary outcome and data were retrieved from São Paulo Health State Department. Socioeconomic and healthcare indexes data were obtained from IBGE (Brazilian Foundation in charge of national decennial census) and SEADE (São Paulo Planning and Development Department). Information on antimicrobial sales were obtained from IMS Brazil. We divided antibiotics into four different groups (1-4). Results: We observed a direct association between the use of group 1 of antibiotics and the incidences of bloodstream infections caused by MRSA (1.12; 1.04-1.20), and CR-Acinetobacter sp. (1.19; 1.10-1.29). Groups 2 and 4 were directly associated to VRE (1.72; 1.13-2.39 and 2.22; 1.62-2.98, respectively). Group 2 was inversely associated to MRSA (0.87; 0.78-0.96) and CR-Acinetobacter sp. (0.79; 0.62-0.97). Group 3 was inversely associated to Pseudomonas aeruginosa (0.69; 0.45-0.98), MRSA (0.85; 0.72-0.97) and VRE (0.48; 0.21-0.84). No association was observed for third generation cephalosporin-resistant Klebsiella pneumoniae and Escherichia coli. Conclusions: The association between entire antibiotic use and resistance in ICU was poor and not consistent for all combinations of antimicrobial groups and pathogens even after adjusted by socioeconomic indexes. Selective pressure exerted at the community level seemed not to affect the incidences of MDRO infection observed in intensive care setting.

Total antibiotic use in a state-wide area and resistance patterns in Brazilian hospitals: an ecologic study.

INTRODUCTION: Use of antibiotic and bacterial resistance is the result of a complex interaction not completely understood. OBJECTIVES: To evaluate the impact of entire antimicrobial use (community plus hospitals) on the incidence of bloodstream infections in intensive care units adjusted by socioeconomic factors, quality of healthcare, and access to the healthcare system. DESIGN: Ecologic study using a hierarchical spatial model. SETTING: Data obtained from 309 hospitals located in the state of São Paulo, Brazil from 2008 to 2011. PARTICIPANTS: Intensive care units located at participant hospitals. OUTCOME: Hospital acquired bloodstream infection caused by MDRO in ICU patients was our primary outcome and data were retrieved from São Paulo Health State Department. Socioeconomic and healthcare indexes data were obtained from IBGE (Brazilian Foundation in charge of national decennial census) and SEADE (São Paulo Planning and Development Department). Information on antimicrobial sales were obtained from IMS Brazil. We divided antibiotics into four different groups (1-4). RESULTS: We observed a direct association between the use of group 1 of antibiotics and the incidences of bloodstream infections caused by MRSA (1.12; 1.04-1.20), and CR-Acinetobacter sp. (1.19; 1.10-1.29). Groups 2 and 4 were directly associated to VRE (1.72; 1.13-2.39 and 2.22; 1.62-2.98, respectively). Group 2 was inversely associated to MRSA (0.87; 0.78-0.96) and CR-Acinetobacter sp. (0.79; 0.62-0.97). Group 3 was inversely associated to Pseudomonas aeruginosa (0.69; 0.45-0.98), MRSA (0.85; 0.72-0.97) and VRE (0.48; 0.21-0.84). No association was observed for third generation cephalosporin-resistant Klebsiella pneumoniae and Escherichia coli. CONCLUSIONS: The association between entire antibiotic use and resistance in ICU was poor and not consistent for all combinations of antimicrobial groups and pathogens even after adjusted by socioeconomic indexes. Selective pressure exerted at the community level seemed not to affect the incidences of MDRO infection observed in intensive care setting.