Diabetes increases the risk of recent-transmission tuberculosis in household contacts in São Paulo, Brazil.

SETTING: A cohort of household contacts of tuberculosis (TB) index cases from four public health clinics in São Paulo, Brazil. OBJECTIVE: To measure the association between diabetes mellitus (DM) among household contacts and recent-transmission TB (RT TB). DESIGN: Index TB cases (n = 263) identified from 2001 to 2002 in São Paulo, whose household contacts (n = 1383) were monitored for active TB until December 2010. RESULTS: From 2001 to 2010, there were 29 cases of RT TB among household contacts (cumulative incidence 2.1%, 95%CI 1.4-2.9). DM in household contacts was associated with RT TB (OR 3.96, 95%CI 1.33-11.79) even after adjustment for human immunodeficiency virus (HIV) status, smoking and alcohol use (adjusted OR [aOR] 3.21, 95%CI 1.01-10.19). HIV infection was also associated with RT TB (OR 6.40, 95%CI 1.40-29.40; aOR 4.81, 95%CI 0.96-24.18). Household contact DM was not associated with non-RT TB (OR 1.27, 95%CI 0.30-5.40). The time to diagnosis of TB was shorter in household contacts with and without DM (P = 0.035) and in household contacts with and without HIV (P = 0.0002). CONCLUSION: Household contact DM was associated with an increased risk of RT TB in a cohort in Brazil, lending support to the active screening of household contacts with DM for TB in Brazil.

Post-polio syndrome: epidemiologic and prognostic aspects in Brazil.

OBJECTIVES: To describe the clinical and epidemiological aspects of post-polio syndrome (PPS) and identify predictors of its severity. MATERIALS AND METHODS: 132 patients with PPS were selected at the Neuromuscular Disease Outpatient Clinic of the Federal University of São Paulo. Descriptive analysis was carried out and predictors of PPS severe forms were investigated using an unconditional logistic regression. RESULTS: The average age at onset was 39.4 years. The most common symptoms were fatigue (87.1%), muscle pain (82.4%) and joint pain (72.0%); 50.4% of the cases were severe. The following were associated with PPS severity: a < or =4-year period of neurological recovery (OR 2.8), permanent damage in two limbs (OR 3.6) and residence at the time of acute polio in a city with more advanced medical assistance (OR 2.5). CONCLUSIONS: Health professionals should carefully evaluate polio survivors for PPS and be aware of the implications of muscle overuse in the neurological recovery period.

A population-based study of drug resistance and transmission of tuberculosis in an urban community.

SETTING: A low-income neighborhood of Sao Paulo, Brazil. OBJECTIVE: To determine the incidence, risk factors and transmission patterns of multidrug-resistant tuberculosis (MDR-TB). DESIGN: Prospective longitudinal study of patients with pulmonary TB (PTB). METHODS: Sputum culture-confirmed patients with PTB were recruited between March 2000 and May 2002. Bivariate and multivariate logistic regression analyses were performed to identify factors associated with MDR-TB. Mycobacterium tuberculosis isolates were tested for drug susceptibility and typed by IS6110-RFLP analysis. RESULTS: Of 420 patients, respectively 71% and 27% were new and previously treated; 15.5% of the patients' M. tuberculosis isolates were resistant to at least one drug; of these, 11% and 27% were found among new and previously treated cases, respectively. Respectively 1% and 16.7% of the new and previously treated cases were MDR-TB. RFLP analysis showed that new transmission of MDR strains was uncommon. By multivariate logistic regression analysis, previous TB and hospitalization in the 24 months before TB diagnosis were identified as independent predictors of MDR-TB. CONCLUSIONS: The results showed an intermediate level of MDR-TB incidence in a neighborhood of Sao Paulo and identified predictors that can be targeted for intervention by national and local TB control programs.

The impact of AIDS, immigration and housing overcrowding on tuberculosis deaths in São Paulo, Brazil, 1994-1998.

The objective of this paper was to describe the distribution of tuberculosis (TB) mortality by area in the municipality of São Paulo, Brazil, from 1994 to 1998, and to evaluate its statistical association with several population characteristics. We surveyed TB deaths grouped by residential area, at the district level, and we calculated the rates for these areas standardized by gender and age groups. We applied simultaneous autoregressive--SAR regression analysis (autocorrelated errors model) in order to fit a "stepwise" model correlating TB deaths with the variables of interest. Significant associations were found between TB mortality rates and AIDS mortality rates, overcrowding at the household level, social development (expressed by a socioeconomic index), and rates of foreign immigration and immigration from other Brazilian States. Regression analysis allowed us to estimate the frequency of TB deaths virtually attributable to co-infection with HIV at 22.37% (95% confidence interval: 12.15-41.17%). TB death rates and utilization of public health services were not statistically associated, suggesting a reduced effectiveness of programs directed at control of the disease. The correlation between TB death rates and deprivation, measured by the socioeconomic index, indicates higher mortality in underprivileged areas. The significance of the association between housing overcrowding and TB deaths, in contrast to the absence of association with district-level overcrowding, indicates that prolonged contact is needed for disease transmission. Although the influx of foreigners and national migrants to the city diminished after the 1980s, immigration rates have been significantly correlated with TB mortality, suggesting greater vulnerability of these population segments to the disease.

Tuberculosis in the twentieth century: time-series mortality in São Paulo, Brazil, 1900-97.

The objective of this study was to characterize tuberculosis mortality trends in the Municipality of São Paulo, Brazil, from 1900 to 1997. Standardized tuberculosis mortality rates and proportional mortality ratios were calculated and stratified by gender and age group based on data provided by government agencies. These measures were submitted to time-series analysis. We verified distinct trends: high mortality and a stationary trend from 1900 to 1945, a heavy reduction in mortality (7.41% per year) from 1945 to 1985, and a resumption of increased mortality (4.08% per year) from 1985 to 1995. In 1996 and 1997 we observed a drop in tuberculosis mortality rates, which may be indicating a new downward trend for the disease. The period from 1945 to 1985 witnessed a real reduction in tuberculosis, brought about by social improvements, the introduction of therapeutic resources, and expansion of health services. Recrudescence of tuberculosis mortality from 1985 to 1995 may reflect the increasing prevalence of Mycobacterium and HIV co-infection, besides loss of quality in specific health programs.

Enterovirus 71 infection and acute neurological disease among children in Brazil (1988-1990).

Surveillance for Enterovirus 71 (EV-71) infection in children up to 15 years of age was carried out in Brazil, from 1988 to 1990. Patients with acute neurological diseases (AND) such as flaccid paralysis, Bell's palsy, acute cerebellar ataxia and Guillain-Barré syndrome were included in the study. EV-71 infection was detected in 24 of 426 children (5.6%) with AND. EV-71 infection was confirmed only by virus isolation in 13 children, by virus isolation and seroconversion in 4, and by seroconversion alone in 7. EV-71 was also isolated from 15 of the 427 household contacts (3.5%) of 165 AND patients. There was some evidence of high infectivity of EV-71: household clusters were detected in the case of 7 of 24 children (29.1%) infected with EV-71 and manifesting AND; EV-71 was isolated from 11/40 household contacts (27.5%) of the infected patients but from only 4/387 household contacts (1.0%) of children in whom it was not possible to demonstrate EV-71 infection. Seven of the 24 children infected with EV-71 exhibited residual motor deficiency when examined 6 months after the disease onset. The relevance of these results for the Plan for Global Eradication of Wild Poliovirus is discussed, as well as the need to increase knowledge about the behaviour of this virus and its possible association with AND.

[Gastroenteritis and acute respiratory infections among children up to 5 years old in an area of Southeastern Brazil, 1986-1987, II--Diarrhea]. / Gastroenterites e infecções respiratórias agudas em crianças menores de 5 anos, em área da região Sudeste do Brasil, 1986-1987. II--Diarréias.

INTRODUCTION: The decrease morbi-mortality gastroenteritis in is related to the factor responsible largely for the fall in infant mortality and mortality from communicable diseases in developing countries. Nevertheless, diarrhea is still a considerable public health problem in these countries, especially among children under 5 years old. OBJECTIVES: To describe some aspects of the of gastroenteritis epidemiology among children up to 5 years old, resident in areas of S. Paulo county. MATERIAL AND METHOD: A probabilistic sample of children up to 5 years old was studied (n = 468). The epidemiological survey was undertaken in five areas S. Paulo county (Brazil) from March 1986 to May 1987. Data were obtained through household interviews once a month over a year. RESULTS: During the follow-up 139 diarrhea episodes were registered, with a mean duration of 5.5 days. Twenty percent of the diarrhea events were followed by at least one other case in the household. The incidence of gastroenteritis was 2.78 episodes per 100 children/month. The highest incidence affected the children of up to 2 years of age. In 46.1% of the gastroenteritis episodes medical assistance was not sought, the children were treated by their mothers or not at all: 51.8% of the diarrhea events were attended to by the primary health care service, and only 2.1% were attended to by a hospital. No child died as a consequence of diarrhea. Of the therapeutical interventions used the most frequent were oral rehydration (25.2%) and oral rehydration with antibiotics (11.5%). Various socio-economic and personal background factors such as living conditions, water supply, sewarage, coverage; family income per capita and prior history of frequent gastroenteritis were associated with a higher incidence of gastroenteritis. DISCUSSION: The results seen to reflect the tendency of morbi-mortality by gastroenteritis to decrease in S. Paulo county during the 1980's when hospital treatment of diarrhea presented a considerable reduction. This tendency must be observed closely, because it will influence the changes to be mode in the kind of demand for medical care.

[Gastroenteritis and acute respiratory infections among children under 5 years old in an area of southeastern Brazil, 1986-1987. I--Acute respiratory infections]. / Gastroenterites e infecções respiratórias agudas em crianças menores de 5 anos em área da região sudeste do Brasil, 1986-1987. I--Infecções respiratórias agudas.

A probabilistic sample of children up to 5 years old was studied (n = 468). The epidemiological survey was carried out in five areas in the municipality of S. Paulo (Brazil), from March 1986 to May 1987. Data were obtained through household interviews once a month during one year. Some of the most relevant socioeconomic characteristics of the children's families are: low family income "per capita"; 29.3% of the parents were migrants with a mean period of residence in S. Paulo city of 18.6 years; 40% of the families had access exclusively to public or philanthropic health care services. Among the children included in the research, 87.3% were eutrophic, 94% were fully vaccinated, 90.6% had never been hospitalized as a consequence of acute respiratory infections (ARI). During the follow up of 1 year, 554 episodes of ARI with mean of 6.8 days of duration were identified. The incidence of ARI was 11.8 episodes per 100 children/month. The most vulnerable age group consisted of children up to one year of age. Thirty six percent of the ARI events were followed by at least one other case in the household. The index case in 53% of these cases were children up to 6 years old. Around 52.6% of the episodes did not require a medical assistance, 46.7% were assisted in ambulatory, 4 cases (0.7%) have had hospital treatment and only one died. The most frequent therapeutical conduct regarding children submitted to medical care assistance was the prescription of antibiotics and expectorants. Some factors related to social economic status and personal background such as living conditions and history of previous respiratory diseases were associated with higher incidence of ARI.

Human enterovirus infection in stray dogs. Some aspects of interest to public health.

To investigate the possible role of domestic animals as reservoirs of human enteroviruses, we studied 212 stray dogs captured in different areas of the municipality of São Paulo. The captured animals were divided into 19 groups of 10 to 20 dogs each; faeces of 126 of the 212 dogs were processed for enterovirus isolation. The following viruses were isolated from 12 dogs; poliovirus type 1 (2 dogs), poliovirus type 3 (1 dog), echovirus type 7 (8 dogs) and echovirus type 15 (1 dog). Of the 12 infected animals, four had specific homotypic neutralizing antibody titres > or = 16. All 212 animals were tested for the presence of neutralizing antibodies to human enteroviruses. The frequency of neutralizing antibodies present in titres of > or = 16 was 10.3%, 3.8% and 4.3% for vaccinal prototypes of polioviruses 1, 2 and 3 respectively; 1.9%, 1.4% and 1.5% for wild prototypes of the same viruses, 11.3% for echovirus 7, and 2.4% for echovirus 15. The proportion of dogs with neutralizing antibodies varied with the virus studied. Some indication of the susceptibility of dogs to infection with human enteroviruses was demonstrated, and the importance of this fact for the Plan for Global Eradication of the Wild Poliovirus is discussed.

An exanthematic disease epidemic associated with coxsackievirus B3 infection in a day care center.

An epidemic of exanthematic illness in a day care center is described. Ten children aged 7 to 13 months were affected by the illness. The exanthem was characterized by nonconfluent macular or maculopapular lesions that appeared on the face, body and limbs. Fifty percent of the infected children had fever of up to 39 degrees C at the beginning of the disease. Coxsackievirus B3 (CB3) was isolated from the stool of one ill child. Paired serum samples were obtained from eight ill children and six of them presented seroconversion to CB3. Antibodies to CB3 were detected at titers higher than 16 in a single serum sample collected from the other two patients. Neutralizing antibodies to CB3 were detected in 71.0% of the contact children.

Preliminary characterization of a new virus isolated from the spinal fluid of patients with meningitis in São Paulo, Brazil.

A total of 138 patients with the age of 4 months to 57 years were attended in different hospitals of São Paulo State with aseptic meningitis. A probable new agent was isolated from the cerebrospinal fluid of 35 of 53 specimens examined. Replication of the agent with similar characteristics was detected by CPE produced in the MDCK cell line. Virus-like particles measuring about 40 nm in diameter were observed by negative staining electron microscopy. No hemagglutinating activity was detected at pH 7.2 by using either human, guinea pig, chicken and at pH ranged 6.0-7.2 with goose red blood cells. The agent was not pathogenic to newborn or adult mice. Virus infectivity as measured by CPE was sensitive to chloroform and not inhibited by BuDR, suggesting that agent is an enveloped virus with RNA genome.

[Enterovirus 70 in the metropolitan region of São Paulo, Brazil, from 1984 to 1987: infection aspects in endemic and epidemic periods]. / Enterovírus-70 na região metropolitana de São Paulo, Brasil, de 1984 a 1987: aspectos da infecção em períodos epidêmico e endêmico.

Results of investigation about Enterovirus-70 (EV-70) as an etiologic agent of epidemic of acute haemorrhagic conjunctivitis (AHC) and neurological disease in the metropolitan area of São Paulo city are presented. During the first three months of 1984, in an epidemic period of AHC, 3 groups with a total of 291 persons were studied. The group A included 90 individuals affected by AHC; the 99 persons belonging to group B did not acquire the AHC but referred familiar contact with the ill individuals; the group C included 102 persons who denied the AHC or any contact with the illness. Neutralization test in BHK-21 cell culture was used for measurement of antibodies in sera. For the detection of the presence of IgM, indirect immunofluorescence assay was utilized. The presence of IgM antibodies was observed in 56.7%, 33.3% and 20.6% of persons belonging to groups A, B and C, respectively. The 10-29 age group was the most affected in the group A. From april 1984, after the end of epidemic period of AHC, until December 1987, three sporadic cases of AHC and 10 cases with acute neurological disease associated with recent infection by EV-70 were observed. Nine of 10 persons with acute neurological symptoms had paralysis of cranial nerves, all of them recovering without sequelae. The circulation of EV-70 in the population during the endemic period was maintained by either asymptomatic, sporadic cases of AHC or neurological diseases.