Arboviroses Chikungunya - Dengue - Febre Amarela - Zika 2016

1. Alexandre Naime Barbosa MD, PhD
Professor Doutor - Infectologia
Auxílio Didático 6º Ano Med
UNESP - Faculdade de Medicina
Nov/2016- Botucatu - SP - Brasil

2. The following material is part of the educational project produced by
Prof. Dr. Alexandre Naime Barbosa
Objectives
1. Education: Training for Students & Health Professionals
2. Community: Provide and Translate Scientific Information to the Population;
3. Scientific: Encourage the Scientific Discussion and Share Teaching Materials.
Authorship and Assignment
1. Content: The following data are referenced in respect to the original author;
2. Use: It is allowed to use the material, if the source is mentioned;
3. Contact: Talk to Dr. Barbosa and keep in touch with his project in:

3. 1. Arbovirus: Overview
2. Yellow Fever
3. Dengue
4. Chikungunya
5. Zika
6. Conclusions

5. So what is the world's deadliest animal?

6. Maybe a smaller animal…

7. Arbovirus: Arthropod Borne viruses
WHO definition: viruses that are
maintained in nature principally, or to an
important extent, through biological
transmission between susceptible
vertebrate host by hematophagous
arthropods; viruses multiply in tissues of
arthropods, and are passed on to new
vertebrates by bites of arthropods after a
period of extrinsic incubation period.

8. Cycle Type 1: Man-Arthropod-Man

9. Cycle Type 2: Animal-Arthropod-Man

10. Family Members
Bunyaviridae La Crosse, Oropouche, Rift Valley, Sandfly, Crimean-Congo
Flaviviridae
Yellow Fever, Dengue, Zika, Japanese Encephalitis,
Saint Louis Encephalitis, West Nile, Kyasanur Forest, Omsk
Togaviridae
Chikungunya, O’nyong-nyong, Ross River, Equine Encephalitis
(East, West, Venezuelan), Sindbis

11. CDC - 2015

13. Family: Flaviviridae; Genus: Flavivirus
Distribution: restricted to Africa & Central and South America.

14. Family: Flaviviridae; Genus: Flavivirus
Distribution: restricted to Africa & Central and South America.

15. Brazil: Endemic vs Transition vs Free Areas

16. Brazil: Endemic vs Transition vs Free Areas

17. São Paulo State: Endemic vs Transition vs Free Areas

18. Botucatu 2009 Epidemic

19. Brazil: YF in 2012-13

20. Transmission:

21. Symptoms
The majority of persons infected with yellow
fever virus have no illness or only mild
illness.
In persons who develop symptoms, the
incubation period (time from infection until
illness) is typically 3–6 days.
The initial symptoms include sudden onset
of fever, chills, severe headache, back pain,
general body aches, nausea, and vomiting,
fatigue, and weakness. Most persons
improve after the initial presentation.

22. Symptoms
After a brief remission of hours to a day,
roughly 15% of cases progress to develop a
more severe form of the disease. The severe
form is characterized by high fever, jaundice,
bleeding, and eventually shock and failure of
multiple organs. Rate of Death: 50%

23. Pathogenesis

24. Diagnosis
Virus isolation
– From the blood or post-mortem liver tissue
Rapid diagnostic test:
– Detection viral genome by PCR in blood o tissues
– Not widely available
Detection IgM antibodies (ELISA)
– Simple sample provides a presumptive
diagnosis. Confirmation is made by a rise
between paired acute and convalescent samples
or a fall between early and late convalescent
samples.
– Cross-reactions with other flaviviruses
complicate the diagnosis particularity in Africa
(multiple flaviviruses cocirculate).

25. Treatment
No specific treatments have been
found to benefit patients with yellow
fever. Whenever possible, yellow
fever patients should be hospitalized
for supportive care and close
observation.
Treatment is symptomatic. Rest,
fluids, and use of pain relievers and
medication to reduce fever may
relieve symptoms of aching and
fever.

26. Prevention
Vaccine:
- Types: Inactivated mouse brain or Live attenuated
- Mandatory for people that live at endemic area and
travelers
Others
- Use insect repellent
- Wear proper clothing to reduce mosquito bites
- Be aware of peak mosquito hours

28. Family: Flaviviridae; Genus: Flavivirus, 4 Serotypes (1,2,3,4)
Distribution: all tropical and some subtropical areas
- WHO: 2.5 billion people, two fifths
of the world's population, at risk from
dengue and estimates that there may
be 50 million cases of dengue
infection worldwide every year. The
disease is endemic in more than 100
countries

29. Brazil: 2014 - 2015 Epidemic

30. Brazil: 2014 - 2015 Epidemic

31. Transmission: 1 patterns (Cycle)
1. Person to person transmission by Aedes
A. aegypti (America) and A. albopictus (Asia)

32. Classic Dengue (Break bone Fever)
- Incubation: 3-10 days;
- Chills, high fever, intense headache, myalgia,
arthralgia, retro-orbital pain, colic pain and
abdominal tenderness. Fever biphasic (saddle
type).
- Maculopapular rashes develop on chest, trunk.

33. Dengue Hemorrhagic Fever (DHF) &
Dengue Shock Syndrome (DSS)
C/F-High fever, hemorrhagic phenomena
including bleeding from the eyes, nose, mouth,
ear, into the gut, and oozing of blood from skin
pores, thrombocytopenia, and
hemoconcentration
Vascular leak syndrome - blood leaks through
the skin and into spaces around the lungs and
abdomen. This fluid loss and severe bleeding can
cause blood pressure to fall; then Dengue Shock
Syndrome (DSS) sets in, which has a high
mortality rate.

34. Pathogenesis

35. Diagnosis
- Isolation of virus from blood
- Serology:
-Antibody detection IgM
-Antigen detection- NS1 ag
- RT-PCR

36. Treatment
No antiviral therapy available
Symptomatic management in majority of cases
Suitable fluid replacement

37. Prevention

39. Family: Togaviridae; Genus Alphavirus
Distribution:

40. Brazil: 2014 Epidemic

41. Brazil: 2014 Epidemic

42. Transmission: 2 patterns (Cycles)
1. Person to person transmission by Aedes sp.
2. Monkey-monkey by arboreal mosq. A. aegypti (America) and
A. albopictus (Asia)

43. Symptoms
- Fever
- Severe arthritis
- Chills, headache, photophobia
- Nausea, abdominal pain
- Rashes and petechias

44. Clinical Findings

45. Diagnosis
- Isolation of virus from blood
- Serology: Antibody detection IgM/IgG
- RT-PCR

46. Treatment and Prevention
No antiviral therapy available
Symptomatic management in majority of cases
No available vaccine

48. Family: Flaviviridae; Genus: Flavivirus
Distribution:

49. 14

50. - 1940 - 50: First evidences of human infections (Zika = Forest in Uganda)

51. - 1940 - 50: First evidencies of human infection (East Africa)
- 2007: Big epidemic in Yap Island and Micronesia (80% of total population)
- 2013: French Polynesia (neurologic complications, and others)
- 2015: Brazil and South America (Microcephaly)

52. Beginning of 2015:
- 21 cases of “Dengue-Like”: 8 RT-PCR ZKV Positives (Natal - RN)

53. First Identifield Cases:
- April 2015: Camaçari (BA)
- May 2015: Natal (RN)
- May 2015: Sumaré (SP)
Route Theory
- Va’a (Canoe) World Sprint Championships (RJ, Ago/2014)
- Ocean Pacific Countries: French Polynesia, New Caledonia, Cook Island, Easter Island
- Zika circulation starts in 2014
- Brazil Zika virus is close to Polynesia virus

56. Brasil, Ministério da Saúde - 2016
Dados Oficiais do Surto 2015-16 (23/02/2016)
Confirmados 583
Óbitos 120
Zika Identificado 67
Casos Suspeitos 4.107
Descartados 950

57. - Família: Flaviviridae
- Gênero: Flavivirus
- Vírus RNA
- Arbovírus
- Duas linhagens
- Africana
- Asiática
CDC - 2016

58. Importância Epidemiológica: Transmissão Vetorial
- Aedes aegypti, Aedes africanus e outros Aedes
- Culex???

59. Transmission: 2 patterns (Cycles)
1. Person to person transmission by Aedes sp.
2. Monkey-monkey by arboreal mosq.
Aedes aegypti
Aedes africanus,
Aedes apicoargenteus
Aedes furcifer
Aedes luteocephalus
Aedes vitattus

60. Outras Vias de Menor Importância Epidemiológica
- Transplacentária e Perinatal
- Transfusional
- Sexual
- Saliva e Urina (???)
- Leite Materno (??????)

61. - Período de Incubação (Mosquitos): 10 dias
- Reservatórios de Importância: Humanos e Pequenos Primatas
- Infecção em Humanos:
Células Dendríticas
Linfonodos
Corrente Sanguínea
- Sintomas Clínicos: Leves a Moderados (Febre, Rash Cutâneo e Conjuntivite)
- Associação Possível e Provável com Malformações Fetais e Sde. de Guillain-Barré
- Associação Causal e Dano Neurológico Direto (e outros): em estudo e análise

62. - Microcefalia pode ocorrer, mas não se limita a esse achado (Z-TORCH)
- Podem ocorrer medidas normais de PC, mas com graves malformações de SNC
- Necrose tecidual => Redução massa cerebral => Microcefalia
- Lisencefalia, hidrocefalia, calcificações multifocais corticais e subcorticais
- Perda do tecido cortical, e presença de necrose e inflamação
- Lesões oftalmológicas: mácula e peri-mácula; nervo óptico
- Artrogripose: endurecimento da musculatura e as articulações
- Taxa de Transmissão Transplacentária: 2-5% (???)
- ZKV no feto: permanência e reativação por um longo período
- Momento de maior risco na gestação (???)

63. 18/Nov/2015

64. 10/Fev/2016

65. 13/04/2016

68. Pacientes com quadro de exantema máculo-papular e DOIS dos seguintes sintomas:
- febre (<38,5º C) ou
- hiperemia conjuntival sem secreção ou
- prurido ou
- artralgia ou
- edema periarticular
Outros Achados: mialgia, cefaleia, edema de membros inferiores, dor retrorbital,
anorexia, vômitos, diarreia ou dor abdominal.
Manifestações neurológicas:
- Síndrome de Guillain Barré, ADEM: 4 a 20 dias após o início dos sintomas

69. Symptoms
About 1 in 5 people infected with Zika virus
become ill.
The most common symptoms of Zika are fever,
rash, joint pain, or red eyes. Other symptoms
include muscle pain, headache, pain behind
the eyes, and vomiting.
The illness is usually mild with symptoms
lasting for several days to a week.
Severe disease requiring hospitalization is
uncommon.
Deaths due to Zika are very rare.

70. Matsuda EM - 2016

71. Brasil, Ministério da Saúde - 2016

72. Treatment and Prevention
No antiviral therapy available
Symptomatic management in majority of cases
No available vaccine

74. Não há vacina
Eliminação dos criadouros dos mosquitos
Evitar locais com presença do mosquito, uso de telas
Repelentes
- < 6 meses: sem indicação
- 6 meses - 2 anos: IR3535
- 2 anos a 12 anos: DEET 10% (no máximo, aplicar 3x/dia) ou Icaridina;
> 12 anos ou gestantes: DEET > 10% ou Icaridina
Uso de inseticidas
Uso de cobertura de áreas expostas com roupa
Atualização de carteira vacinal

77. Comparison of Symptoms (Chikungunya, Dengue anda Zika)

81. Obrigado pela Atenção!
SAE de Infectologia HC UNESP Botucatu Faculdade de Medicina UNESP