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Komatsu N, Iwanaga M, Hasegawa Y, Miura S, Fuchi N, Moriuchi H, Yanagihara K, Miura K. Frequency of HTLV-1 seroconversion between pregnancies in Nagasaki, Japan, 2011–2018. Front Microbiol 2022; 13:1036955. [DOI: 10.3389/fmicb.2022.1036955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/20/2022] [Indexed: 11/16/2022] Open
Abstract
BackgroundHuman T-cell leukemia virus type-1 (HTLV-1) is transmitted vertically from an infected mother to her child via breastfeeding during infancy or horizontally via sexual contact. However, little information is available on the HTLV-1 seroconversion rate in pregnant mothers and the impact of new HTLV-1 infection on mothers and babies during the perinatal period.MethodsFrom the database of a prefecture-wide antenatal adult T-cell leukemia prevention program in Nagasaki, Japan, we extracted data on 57,323 pregnant women who were screened for anti-HTLV-1 antibody during 2011–2018. Data on the 16,863 subjects whose HTLV-1 proviral load (PVL) was measured more than twice were included in our analyses.ResultsIn total, 133 (0.79%) pregnant women were HTLV-1-positive during their first pregnancy and nine (0.05%) seroconverted before or during subsequent pregnancies (between pregnancies). The median PVL (per 100 peripheral blood mononuclear cells) was significantly lower in the seroconverted mothers (0.10%) than in the initially seropositive mothers (0.15%). A repeated measures correlation analysis for the individual PVLs of the HTLV-1-positive pregnant women showed that PVL increased with parity number (rrm = 0.25) with no perinatal problems.ConclusionThe HTLV-1 seroconversion rate between pregnancies was 0.05%, and their HTLV-1 PVL increased annually but no perinatal problems were noted.
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Barr RS, Drysdale SB, Boullier M, Lyall H, Cook L, Collins GP, Kelly DF, Phelan L, Taylor GP. A Review of the Prevention of Mother-to-Child Transmission of Human T-Cell Lymphotrophic Virus Type 1 (HTLV-1) With a Proposed Management Algorithm. Front Med (Lausanne) 2022; 9:941647. [PMID: 35872787 PMCID: PMC9304803 DOI: 10.3389/fmed.2022.941647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/10/2022] [Indexed: 01/06/2023] Open
Abstract
Human T cell lymphotropic virus type 1 (HTLV-1) is a human retrovirus that is endemic in a number of regions across the world. There are an estimated 5–10 million people infected worldwide. Japan is currently the only country with a national antenatal screening programme in place. HTLV-1 is primarily transmitted sexually in adulthood, however it can be transmitted from mother-to-child perinatally. This can occur transplacentally, during the birth process or via breastmilk. If HTLV-1 is transmitted perinatally then the lifetime risk of adult T cell leukemia/lymphoma rises from 5 to 20%, therefore prevention of mother-to-child transmission of HTLV-1 is a public health priority. There are reliable immunological and molecular tests available for HTLV-1 diagnosis during pregnancy and screening should be considered on a country by country basis. Further research on best management is needed particularly for pregnancies in women with high HTLV-1 viral load. A first step would be to establish an international registry of cases and to monitor outcomes for neonates and mothers. We have summarized key risk factors for mother-to-child transmission of HTLV-1 and subsequently propose a pragmatic guideline for management of mothers and infants in pregnancy and the perinatal period to reduce the risk of transmission. This is clinically relevant in order to reduce mother-to-child transmission of HTLV-1 and it's complications.
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Affiliation(s)
- Rachael S. Barr
- Department of Paediatrics, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
- *Correspondence: Rachael S. Barr
| | - Simon B. Drysdale
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St. George's, University of London, London, United Kingdom
- Oxford Vaccine Group and NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Mary Boullier
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St. George's, University of London, London, United Kingdom
| | - Hermione Lyall
- Department of Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Lucy Cook
- National Centre for Human Retrovirology, Imperial College Healthcare NHS Trust, London, United Kingdom
- Section of Virology, Department of Infectious Disease, Imperial College London, London, United Kingdom
| | - Graham P. Collins
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Dominic F. Kelly
- Oxford Vaccine Group and NIHR Oxford Biomedical Research Centre, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Level 2, Children's Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Lorna Phelan
- Department of Obstetrics and Gynaecology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Graham P. Taylor
- Section of Virology, Department of Infectious Disease, Imperial College London, London, United Kingdom
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Rosadas C, Menezes MLB, Galvão-Castro B, Assone T, Miranda AE, Aragón MG, Caterino-de-Araujo A, Taylor GP, Ishak R. Blocking HTLV-1/2 silent transmission in Brazil: Current public health policies and proposal for additional strategies. PLoS Negl Trop Dis 2021; 15:e0009717. [PMID: 34555019 PMCID: PMC8460035 DOI: 10.1371/journal.pntd.0009717] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Human T-cell lymphotropic viruses 1 and 2 (HTLV-1/2) are relatively common in Brazil but remain silent and neglected infections. HTLV-1 is associated with a range of diseases with high morbidity and mortality. There is no curative treatment for this lifelong infection, so measures to prevent transmission are essential. This narrative review discusses HTLV-1/2 transmission routes and measures to prevent its continuous dissemination. The public health policies that are currently implemented in Brazil to avoid HTLV-1/2 transmission are addressed, and further strategies are proposed.
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Affiliation(s)
- Carolina Rosadas
- Section of Virology, Department of Infectious Disease, Imperial College London, London, United Kingdom
| | - Maria Luiza B. Menezes
- Departamento Materno-Infantil, Faculdade de Ciências Médicas, Universidade de Pernambuco, Pernambuco, Brazil
| | - Bernardo Galvão-Castro
- Centro Integrativo e Muldisciplinar de Atendimento ao Portador de HTLV (CHTLV), Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
| | - Tatiane Assone
- Faculdade de Medicina, Instituto de Medicina Tropical de São Paulo, Universidade de São Paulo, São Paulo, Brazil
| | - Angélica E. Miranda
- Programa de Pós-Graduação em Doenças Infecciosas, Universidade Federal do Espírito Santo, Espírito Santo, Brazil
| | - Mayra G. Aragón
- Programa de Pós-Graduação em Doenças Infecciosas, Universidade Federal do Espírito Santo, Espírito Santo, Brazil
| | | | - Graham P. Taylor
- Section of Virology, Department of Infectious Disease, Imperial College London, London, United Kingdom
| | - Ricardo Ishak
- Laboratório de Virologia, Instituto de Ciências Biológicas, Universidade Federal do Pará, Pará, Brazil
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Itabashi K, Miyazawa T. Mother-to-Child Transmission of Human T-Cell Leukemia Virus Type 1: Mechanisms and Nutritional Strategies for Prevention. Cancers (Basel) 2021; 13:cancers13164100. [PMID: 34439253 PMCID: PMC8394315 DOI: 10.3390/cancers13164100] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 07/29/2021] [Accepted: 08/13/2021] [Indexed: 12/17/2022] Open
Abstract
Approximately 95% of mother-to-child transmission (MTCT) of human T-cell leukemia virus type-1 (HTLV-1) is derived from prolonged breastfeeding, which is a major cause of adult T-cell leukemia (ATL). Exclusive formula feeding (ExFF) is therefore generally used to prevent MTCT. A recent cohort study revealed that 55% of pregnant carriers chose short-term breastfeeding for ≤3 months in Japan. Our meta-analysis showed that there was no significant increase in the risk of MTCT when breastfeeding was carried out for ≤3 months compared with ExFF (pooled relative risk (RR), 0.72; 95% confidence interval (CI), 0.30-1.77), but there was an almost threefold increase in risk when breastfeeding was carried out for up to 6 months (pooled RR, 2.91; 95% CI, 1.69-5.03). Thus, short-term breastfeeding for ≤3 months may be useful in preventing MTCT. Breastmilk is the best nutritional source for infants, and any approach to minimizing MTCT by avoiding or limiting breastfeeding must be balanced against the impact on the child's health and mother-child bonding. To minimize the need for nutritional interventions, it is necessary to identify factors that predispose children born to carrier mothers to MTCT and thereby predict MTCT development with a high degree of accuracy.
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Affiliation(s)
- Kazuo Itabashi
- Aiseikai Memorial Ibaraki Welfare Medical Center, 1872-1 Motoyoshida-cho, Mito-City 310-0836, Japan
- Department of Pediatrics, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan;
- Correspondence: ; Tel.: +81-29-353-7171; Fax: +81-29-353-6112
| | - Tokuo Miyazawa
- Department of Pediatrics, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan;
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Anti-HTLV-1/2 IgG Antibodies in the Breastmilk of Seropositive Mothers. Microorganisms 2021; 9:microorganisms9071413. [PMID: 34209130 PMCID: PMC8304728 DOI: 10.3390/microorganisms9071413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/17/2021] [Accepted: 06/26/2021] [Indexed: 11/29/2022] Open
Abstract
Background: HTLV-1/2 mother-to-child transmission (MTCT) is an important route for the maintenance of HTLV-1/2 within populations and disproportionally contributes to the burden of HTLV-1-associated diseases. Avoidance of breastfeeding is the safest recommendation to prevent MTCT. Due to the benefits of breastfeeding, alternative methods that would allow seropositive mothers to breastfeed their babies are needed. There is limited knowledge about HTLV-1/2 infection and breastmilk. Methods: Paired blood and milk samples collected from HTLV-1/2 seropositive mothers were tested for HTLV-1 proviral load (PVL) quantification and for the detection of anti-HTLV-1/2 IgG. Results: All breastmilk samples had detectable anti-HTLV-1/2 IgG. HTLV-1/2 proviral DNA was detected in all samples except for one. HTLV-1 PVL and IgG binding ratio (BR) was similar in milk and plasma. However, antibody titer was significantly higher in blood (Median (95%CI): Milk:128 (32–512); Plasma:131,584 (16,000–131,584), p < 0.05). There was a strong correlation between HTLV-1 PVL, anti-HTLV-1/2 IgG BR, and titer when comparing milk and blood. PVL did not correlate with antibody BR nor titer in blood or milk. Conclusions: Anti-HTLV-1/2 IgG are present in milk in the same proportion as blood but in lower quantity. PVL in milk correlates with blood.
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Caterino-de-Araujo A, Barbosa-Stancioli EF, Alonso JB, Aragón MG, Galvão-Castro B, Ishak R, Rosadas C. Laboratory diagnosis of human T-lymphotropic virus in Brazil: assays, flowcharts, challenges, and perspectives. Rev Soc Bras Med Trop 2021; 54:e01752021. [PMID: 34105630 PMCID: PMC8186893 DOI: 10.1590/0037-8682-0175-2021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/26/2021] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION We present a data analysis and review of recent studies regarding the laboratory diagnosis of human T-lymphotropic virus 1 and 2 (HTLV-1/2) infections in Brazil. METHODS Target populations, available diagnostic serological assays (screening and complementary tests), molecular assays (in-house), causes of false-positive and false-negative results, and flowcharts were analyzed. RESULTS A table presents the target populations, two diagnostic flowcharts (depending on laboratory infrastructure and study population), and recent research that may improve how HTLV-1/2 is diagnosed in Brazil. CONCLUSIONS Our results support the implementation of public policies to reduce HTLV-1/2 transmission and its associated diseases.
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Affiliation(s)
- Adele Caterino-de-Araujo
- Instituto Adolfo Lutz, Centro de Imunologia, Laboratório de Pesquisa em HTLV, São Paulo, SP, Brasil
| | - Edel Figueiredo Barbosa-Stancioli
- Universidade Federal de Minas Gerais, Instituto de Ciências Biológicas, Laboratório de Virologia Básica e Aplicada, Belo Horizonte, MG, Brasil
| | - José Boullosa Alonso
- Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis, Brasília, DF, Brasil
| | - Mayra Gonçalves Aragón
- Universidade Federal do Espírito Santo, Programa de Pós-Graduação em Doenças Infecciosas, Vitória, ES, Brasil
| | - Bernardo Galvão-Castro
- Escola Bahiana de Medicina e Saúde Pública, Centro Integrativo e Muldisciplinar de Atendimento ao Portador de HTLV, Salvador, BA, Brasil
| | - Ricardo Ishak
- Universidade Federal do Pará, Instituto de Ciências Biológicas, Laboratório de Virologia, Belém, PA, Brasil
| | - Carolina Rosadas
- Imperial College Healthcare NHS Trust, St. Mary’s Hospital, National Centre for Human Retrovirology, London, United Kingdom
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Rosadas C, Brites C, Arakaki-Sanchez D, Casseb J, Ishak R. Brazilian Protocol for Sexually Transmitted Infections 2020: human T-cell lymphotropic virus (HTLV) infection. Rev Soc Bras Med Trop 2021; 54:e2020605. [PMID: 34008723 PMCID: PMC8210483 DOI: 10.1590/0037-8682-605-2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/10/2021] [Indexed: 12/26/2022] Open
Abstract
This article addresses the Human T-lymphotropic virus (HTLV). This subject comprises the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health. HTLV-1/2 infection is a public health problem globally, and Brazil has the largest number of individuals living with the virus. HTLV-1 causes several clinical manifestations of neoplasm (adult T-cell leukemia/lymphoma) and inflammatory nature, such as HTLV-1-associated myelopathy and other manifestations such as uveitis, arthritis, and infective dermatitis. These pathologies have high morbidity and mortality and negatively impact the quality of life of infected individuals. This review includes relevant information for health authorities professionals regarding viral transmission, diagnosis, treatment, and monitoring of individuals living with HTLV-1 and 2 in Brazil. HTLV-1/2 transmission can occur through blood transfusion and derivatives, injectable drug use, organ transplantation, unprotected sexual intercourse, and vertical transmission.
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Affiliation(s)
- Carolina Rosadas
- Imperial College London, Department of Infectious Disease, London, United Kingdom
| | - Carlos Brites
- Universidade Federal da Bahia, Faculdade de Medicina, Salvador, BA, Brasil
| | | | - Jorge Casseb
- Universidade de São Paulo, Faculdade de Medicina, São Paulo, SP, Brasil
| | - Ricardo Ishak
- Universidade Federal do Pará, Instituto de Ciências Biológicas, Belém, PA, Brasil
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Rosadas C, Brites C, Arakaki-Sánchez D, Casseb J, Ishak R. [Brazilian Protocol for Sexually Transmitted Infections 2020: human T cell lymphotropic virus (HTLV) infection]. ACTA ACUST UNITED AC 2021; 30:e2020605. [PMID: 33729406 DOI: 10.1590/s1679-497420200006000015.esp1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/07/2020] [Indexed: 11/22/2022]
Abstract
This manuscript is related to the chapter about human T-cell lymphotropic virus (HTLV) that is part of the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Health Ministry. HTLV-1/2 infection is a worldwide public health problem and Brazil has the largest number of individuals living with the virus. HTLV-1 causes a variety of clinical manifestations of a neoplastic nature, such as adult leukemia/T-cell lymphoma, and also of an inflammatory nature, such as HTLV-1-associated myelopathy, as well as other manifestations such as uveitis, arthritis and infective dermatitis. These pathologies have high morbidity and mortality and negatively impact the quality of life of infected individuals. This review includes relevant information for health service managers and workers regarding virus transmission modes, diagnosis, treatment and monitoring of individuals living with HTLV-1 and 2 in Brazil.
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Affiliation(s)
- Carolina Rosadas
- Imperial College London, Department of Infectious Disease, Londres, Reino Unido
| | - Carlos Brites
- Universidade Federal da Bahia, Faculdade de Medicina, Salvador, BA, Brasil
| | | | - Jorge Casseb
- Universidade de São Paulo, Faculdade de Medicina, São Paulo, SP, Brasil
| | - Ricardo Ishak
- Universidade Federal do Pará, Instituto de Ciências Biológicas, Belém, PA, Brasil
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Motedayen Aval L, Boullier M, Lyall H, Collins GP, Ayto R, Kelly DF, Tedder RS, Drysdale SB, Taylor GP, Cook LB. Adult T cell leukaemia/lymphoma (ATL) in pregnancy: A UK case series. EJHAEM 2021; 2:131-135. [PMID: 35846087 PMCID: PMC9175930 DOI: 10.1002/jha2.142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 01/17/2023]
Abstract
Introduction Chronic infection with human T-cell lymphotropic virus type-1 (HTLV-1) may result in aggressive adult T-cell leukaemia/lymphoma (ATL) in 4-6% carriers. The majority of this risk arises in carriers infected during infancy, and so each infant has ∼25% lifetime risk. Other risk factors include a family history of ATL. Antenatal HTLV-1 screening is not undertaken in the UK. Methods Here we describe four cases of ATL diagnosed during pregnancy and describe strategies to minimise HTLV-1 transmission to neonates. Results/conclusion These cases highlight undiagnosed HTLV-1 in pregnancy which allows ongoing mother to child vertical transmission and risk of future ATL. We recommend the UK National Screening Committee incorporate HTLV-1 serology into antenatal screening.
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Affiliation(s)
| | - Mary Boullier
- Department of PaediatricsSt George's University Hospitals NHS Foundation TrustLondonUK
| | - Hermione Lyall
- Department of Paediatric Infectious DiseasesImperial College Healthcare NHS TrustLondonUK
| | - Graham P. Collins
- Department of HaematologyOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Robert Ayto
- Department of HaematologyPortsmouth Hospitals NHS TrustHampshireUK
| | - Dominic F. Kelly
- Oxford Vaccine GroupDepartment of PaediatricsUniversity of OxfordOxfordUK
- NIHR Oxford Biomedical Research CentreOxfordUK
| | | | - Simon B. Drysdale
- Department of PaediatricsSt George's University Hospitals NHS Foundation TrustLondonUK
- Oxford Vaccine GroupDepartment of PaediatricsUniversity of OxfordOxfordUK
| | - Graham P. Taylor
- Section of Virology, Imperial CollegeLondonUK
- National Centre for Human RetrovirologyImperial College Healthcare NHS TrustLondonUK
| | - Lucy B. Cook
- Section of Virology, Imperial CollegeLondonUK
- Centre for HaematologyImperial College Healthcare NHS TrustLondonUK
- National Centre for Human RetrovirologyImperial College Healthcare NHS TrustLondonUK
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da Silva RX, Campos KR, Caterino-de-Araujo A. Pooling of sera for human T-cell lymphotropic virus (HTLV) screening in a time of increasing health care expenditure and limited resources. Rev Inst Med Trop Sao Paulo 2020; 62:e27. [PMID: 32401960 PMCID: PMC7232958 DOI: 10.1590/s1678-9946202062027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/14/2020] [Indexed: 12/15/2022] Open
Abstract
Identifying the true prevalence of human T-cell lymphotropic virus, mostly type 1 (HTLV-1), and the number of patients with HTLV-1-associated diseases, in addition to introducing HTLV-1/2 serology during the prenatal of pregnant women and in individuals infected with other viruses that share transmission routes with HTLV-1, are actions that could help to recognize the importance of this virus by WHO and national health organizations, and to control its transmission/dissemination. As Brazil is endemic to HTLV and there is an increase in health care expenditure, but resources are limited, any strategy that could reduce the cost of HTLV screening is needed and welcomed. This study aimed to determine whether the strategy of pooling sera for HTLV antibody determination is feasible and reduces the costs. Two enzyme immunoassays (EIA Murex HTLV-I+II, Diasorin, UK, and Gold ELISA HTLV-1+2, REM Ind. Com. Ltda., SP, Brazil), and serum samples that resulted in different levels of HTLV-1/2 antibodies by EIA and of which a volume allowed assay validation were employed for analysis. The diagnostic sensitivity and specificity and Cohen's Kappa value, as well as the accuracy and precision were analyzed. After validating the five-sample pool using the EIA Murex (Cohen's Kappa = 1.0), the technique was employed for individual cost comparison in 2,625 serum samples from populations at risk of HTLV infections (HBV, HCV, and HIV-infected individuals). The results from individual and pooled samples confirmed the diagnostic sensitivity (100%) and specificity (100%) of the pooling and a cost minimization varying from 60.7% to 73.6%. In conclusion, the results of this study suggest the use of pooling sera in sero-epidemiological surveillance studies and possibly in prenatal care screening programs in Brazil.
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Affiliation(s)
- Rafael Xavier da Silva
- Secretaria de Estado da Saúde de São Paulo, Coordenadoria de Controle de Doença, Instituto Adolfo Lutz, Centro de Imunologia, São Paulo, São Paulo, Brazil
| | - Karoline Rodrigues Campos
- Secretaria de Estado da Saúde de São Paulo, Coordenadoria de Controle de Doença, Instituto Adolfo Lutz, Centro de Imunologia, São Paulo, São Paulo, Brazil
| | - Adele Caterino-de-Araujo
- Secretaria de Estado da Saúde de São Paulo, Coordenadoria de Controle de Doença, Instituto Adolfo Lutz, Centro de Imunologia, São Paulo, São Paulo, Brazil
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