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da Silva FFB, Moura TDA, Siqueira-Silva T, Gutiérrez JM, Martinez PA. Predicting the drivers of Bothrops snakebite incidence across Brazil: A Spatial Analysis. Toxicon 2024; 250:108107. [PMID: 39343148 DOI: 10.1016/j.toxicon.2024.108107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Revised: 09/13/2024] [Accepted: 09/20/2024] [Indexed: 10/01/2024]
Abstract
Snakebite envenoming poses a significant public health challenge on a global basis, affecting millions of people annually and leading to complications that may result in fatalities. Brazil stands as one of the countries most impacted by snakebite envenoming, with snakes of the Bothrops genus being responsible for most bites. The current study aimed to identify the determinants of Bothrops snakebite incidence across different regions of Brazil. An ecological study was conducted using municipality-aggregated data, with snakebite incidence as the dependent variable. The study period comprised the years 2015-2021. We constructed Species Distribution Models (SDMs) for Bothrops species, and information was collected on precipitation, runoff, maximum and minimum temperatures, native forest, historical forest loss, agriculture, and pasture in each Brazilian municipality. These data were employed to assess the association between snakebite incidence and biotic, climatic, and landscape factors. The data were analyzed using Generalized Least Squares (GLS) regression. The SDMs demonstrated good performance. The average annual snakebite incidence during the study period ranged from zero to 428.89 per 100,000 inhabitants, depending on the municipality. Higher incidence rates were concentrated primarily in municipalities in the northern region of the country. In this study, we found that nationwide, areas with extensive native forests and those that have historically experienced significant loss of forest cover exhibited higher snakebite incidence rates. Additionally, areas with higher temperatures and precipitation levels, as well as greater climatic suitability for the species B. jararaca, showed significantly higher snakebite incidence rates in the South and Southeast of Brazil, respectively. These associations may be linked to increased snake abundance and active behavior, as well as to engagement in activities favoring human-snake contact in these areas. The findings of this study can contribute to the improvement of prevention and control strategies for this public health issue in Brazil.
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Affiliation(s)
| | | | | | - José María Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
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2
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Clare RH, Dawson CA, Westhorpe A, Albulescu LO, Woodley CM, Mosallam N, Chong DJW, Kool J, Berry NG, O’Neill PM, Casewell NR. Snakebite drug discovery: high-throughput screening to identify novel snake venom metalloproteinase toxin inhibitors. Front Pharmacol 2024; 14:1328950. [PMID: 38273820 PMCID: PMC10808794 DOI: 10.3389/fphar.2023.1328950] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 12/21/2023] [Indexed: 01/27/2024] Open
Abstract
Snakebite envenoming results in ∼100,000 deaths per year, with close to four times as many victims left with life-long sequelae. Current antivenom therapies have several limitations including high cost, variable cross-snake species efficacy and a requirement for intravenous administration in a clinical setting. Next-generation snakebite therapies are being widely investigated with the aim to improve cost, efficacy, and safety. In recent years several small molecule drugs have shown considerable promise for snakebite indication, with oral bioavailability particularly promising for community delivery rapidly after a snakebite. However, only two such drugs have entered clinical development for snakebite. To offset the risk of attrition during clinical trials and to better explore the chemical space for small molecule venom toxin inhibitors, here we describe the first high throughput drug screen against snake venom metalloproteinases (SVMPs)-a pathogenic toxin family responsible for causing haemorrhage and coagulopathy. Following validation of a 384-well fluorescent enzymatic assay, we screened a repurposed drug library of 3,547 compounds against five geographically distinct and toxin variable snake venoms. Our drug screen resulted in the identification of 14 compounds with pan-species inhibitory activity. Following secondary potency testing, four SVMP inhibitors were identified with nanomolar EC50s comparable to the previously identified matrix metalloproteinase inhibitor marimastat and superior to the metal chelator dimercaprol, doubling the current global portfolio of SVMP inhibitors. Following analysis of their chemical structure and ADME properties, two hit-to-lead compounds were identified. These clear starting points for the initiation of medicinal chemistry campaigns provide the basis for the first ever designer snakebite specific small molecules.
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Affiliation(s)
- Rachel H. Clare
- Department of Tropical Disease Biology, Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Department of Tropical Disease Biology, Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Charlotte A. Dawson
- Department of Tropical Disease Biology, Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Department of Tropical Disease Biology, Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Adam Westhorpe
- Department of Tropical Disease Biology, Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Department of Tropical Disease Biology, Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Laura-Oana Albulescu
- Department of Tropical Disease Biology, Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Department of Tropical Disease Biology, Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Nada Mosallam
- Department of Chemistry, University of Liverpool, Liverpool, United Kingdom
| | - Daniel J. W. Chong
- Department of Chemistry, University of Liverpool, Liverpool, United Kingdom
| | - Jeroen Kool
- Division of BioAnalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Science, Amsterdam Institute of Molecular and Life Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Neil G. Berry
- Department of Chemistry, University of Liverpool, Liverpool, United Kingdom
| | - Paul M. O’Neill
- Department of Chemistry, University of Liverpool, Liverpool, United Kingdom
| | - Nicholas R. Casewell
- Department of Tropical Disease Biology, Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Department of Tropical Disease Biology, Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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3
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Jati SR, dos Anjos Martins TA, Rocha AM, Melo-dos-Santos G, de Oliveira IS, Ferreira IG, de Farias AS, Filardi ETM, Cerni FA, Sartim MA, de Almeida Gonçalves Sachett J, Monteiro WM, Pucca MB. The State-of-the-Art of the Humoral Memory Response to Snakebites: Insights from the Yanomami Population. Toxins (Basel) 2023; 15:638. [PMID: 37999502 PMCID: PMC10675402 DOI: 10.3390/toxins15110638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 10/26/2023] [Accepted: 10/30/2023] [Indexed: 11/25/2023] Open
Abstract
Snakebite envenomation (SBE)-induced immunity refers to individuals who have been previously bitten by a snake and developed a protective immune response against subsequent envenomations. The notion stems from observations of individuals, including in the indigenous population, who present only mild signs and symptoms after surviving multiple SBEs. Indeed, these observations have engendered scientific interest and prompted inquiries into the potential development of a protective immunity from exposure to snake toxins. This review explores the evidence of a protective immune response developing following SBE. Studies suggest that natural exposure to snake toxins can trigger protection from the severity of SBEs, mediated by specific antibodies. However, the evaluation of the immune memory response in SBE patients remains challenging. Further research is needed to elucidate the immune response dynamics and identify potential targets for therapeutic interventions. Furthermore, the estimation of the effect of previous exposures on SBE epidemiology in hyperendemic areas, such as in the indigenous villages of the Amazon region (e.g., the Yanomami population) is a matter of debate.
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Affiliation(s)
- Sewbert Rodrigues Jati
- Graduate Program in Tropical Medicine (PPGMT), State University of Amazonas, Manaus 69850-000, Brazil; (S.R.J.); (T.A.d.A.M.); (A.M.R.); (A.S.d.F.); (F.A.C.); (M.A.S.); (J.d.A.G.S.); (W.M.M.)
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus 69850-000, Brazil
- Department of Education and Sports of Roraima, Boa Vista 69301-130, Brazil
| | - Thais Andréa dos Anjos Martins
- Graduate Program in Tropical Medicine (PPGMT), State University of Amazonas, Manaus 69850-000, Brazil; (S.R.J.); (T.A.d.A.M.); (A.M.R.); (A.S.d.F.); (F.A.C.); (M.A.S.); (J.d.A.G.S.); (W.M.M.)
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus 69850-000, Brazil
| | - Anderson Maciel Rocha
- Graduate Program in Tropical Medicine (PPGMT), State University of Amazonas, Manaus 69850-000, Brazil; (S.R.J.); (T.A.d.A.M.); (A.M.R.); (A.S.d.F.); (F.A.C.); (M.A.S.); (J.d.A.G.S.); (W.M.M.)
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus 69850-000, Brazil
| | - Guilherme Melo-dos-Santos
- Graduate Program in Bioscience and Biotechnology Applied to Pharmacy, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Campus Araraquara, São Paulo 19060-900, Brazil; (G.M.-d.-S.); (E.T.M.F.)
| | - Isadora Sousa de Oliveira
- Department of BioMolecular Sciences, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto 19040-903, Brazil; (I.S.d.O.); (I.G.F.)
- Department of Biotechnology and Biomedicine, Technical University of Denmark, 2800 Kongens Lyngby, Denmark
| | - Isabela Gobbo Ferreira
- Department of BioMolecular Sciences, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto 19040-903, Brazil; (I.S.d.O.); (I.G.F.)
| | - Altair Seabra de Farias
- Graduate Program in Tropical Medicine (PPGMT), State University of Amazonas, Manaus 69850-000, Brazil; (S.R.J.); (T.A.d.A.M.); (A.M.R.); (A.S.d.F.); (F.A.C.); (M.A.S.); (J.d.A.G.S.); (W.M.M.)
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus 69850-000, Brazil
| | - Eloise T. M. Filardi
- Graduate Program in Bioscience and Biotechnology Applied to Pharmacy, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Campus Araraquara, São Paulo 19060-900, Brazil; (G.M.-d.-S.); (E.T.M.F.)
| | - Felipe Augusto Cerni
- Graduate Program in Tropical Medicine (PPGMT), State University of Amazonas, Manaus 69850-000, Brazil; (S.R.J.); (T.A.d.A.M.); (A.M.R.); (A.S.d.F.); (F.A.C.); (M.A.S.); (J.d.A.G.S.); (W.M.M.)
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus 69850-000, Brazil
| | - Marco Aurélio Sartim
- Graduate Program in Tropical Medicine (PPGMT), State University of Amazonas, Manaus 69850-000, Brazil; (S.R.J.); (T.A.d.A.M.); (A.M.R.); (A.S.d.F.); (F.A.C.); (M.A.S.); (J.d.A.G.S.); (W.M.M.)
- Pro-Rectory of Research and Graduate Studies, Nilton Lins University, Manaus 69850-000, Brazil
| | - Jacqueline de Almeida Gonçalves Sachett
- Graduate Program in Tropical Medicine (PPGMT), State University of Amazonas, Manaus 69850-000, Brazil; (S.R.J.); (T.A.d.A.M.); (A.M.R.); (A.S.d.F.); (F.A.C.); (M.A.S.); (J.d.A.G.S.); (W.M.M.)
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus 69850-000, Brazil
| | - Wuelton Marcelo Monteiro
- Graduate Program in Tropical Medicine (PPGMT), State University of Amazonas, Manaus 69850-000, Brazil; (S.R.J.); (T.A.d.A.M.); (A.M.R.); (A.S.d.F.); (F.A.C.); (M.A.S.); (J.d.A.G.S.); (W.M.M.)
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus 69850-000, Brazil
| | - Manuela Berto Pucca
- Graduate Program in Tropical Medicine (PPGMT), State University of Amazonas, Manaus 69850-000, Brazil; (S.R.J.); (T.A.d.A.M.); (A.M.R.); (A.S.d.F.); (F.A.C.); (M.A.S.); (J.d.A.G.S.); (W.M.M.)
- Graduate Program in Bioscience and Biotechnology Applied to Pharmacy, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Campus Araraquara, São Paulo 19060-900, Brazil; (G.M.-d.-S.); (E.T.M.F.)
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University, Araraquara 19060-900, Brazil
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4
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Pucca MB, Wen HF, Moura-da-Silva AM, Monteiro WM. Snakebite Clinics and Pathogenesis: From Preclinical to Resource Mapping Studies. Toxins (Basel) 2023; 15:626. [PMID: 37999489 PMCID: PMC10675680 DOI: 10.3390/toxins15110626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 10/22/2023] [Indexed: 11/25/2023] Open
Abstract
Amidst the global healthcare landscape, the menace of snakebite envenoming (SBE) has persisted, silently afflicting millions and annually claiming tens of thousands of lives [...].
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Affiliation(s)
- Manuela B. Pucca
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University, Araraquara 14800-903, Brazil
| | - Hui F. Wen
- Butantan Institute, São Paulo 05503-900, Brazil; (H.F.W.); (A.M.M.-d.-S.)
| | | | - Wuelton M. Monteiro
- Department of Medicine and Nursing, School of Health Sciences, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus 69040-000, Brazil
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus 69040-000, Brazil
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5
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Galan LEB, Silva VS, Silva VS, Monte RC, Jati SR, Oliveira IS, Cerni FA, Monteiro WM, Sachett J, Dantas DSM, Carbonell RCC, Pucca MB. Acute mesenteric ischemia following lancehead snakebite: an unusual case report in the Northernmost Brazilian Amazon. Front Med (Lausanne) 2023; 10:1197446. [PMID: 37425310 PMCID: PMC10323676 DOI: 10.3389/fmed.2023.1197446] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/05/2023] [Indexed: 07/11/2023] Open
Abstract
Snakebites have a great impact in the Brazilian Amazon, being the lancehead Bothrops atrox the species responsible for most accidents, disabilities, and deaths. This study shows a case report of an indigenous patient from the Yanomami ethnicity, male, 33 years-old, envenomed by a B. atrox snake. Envenoming caused by B. atrox are characterized by local manifestations (e.g., pain and edema) and systemic manifestations, mainly coagulation disorders. The indigenous victim was admitted in the main hospital of Roraima and evolved with an unusual complication, an ischemia and necrosis of the proximal ileum, requiring segmental enterectomy with posterior side-to-side anastomosis. The victim was discharge after 27 days of hospitalization with no complaints. Snakebite envenomations may evolve with life-threatening complications, which can be treated by the antivenom following access to a healthcare unit, often late in indigenous population. This clinical case shows the need of strategies that aim improvement in the access to the healthcare by indigenous people, as well as demonstrates an unusual complication that may result from lancehead snakebites. The article also discusses the decentralization of snakebites clinical management to indigenous community healthcare centers to mitigate complications.
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Affiliation(s)
- Luis E. B. Galan
- Medical School, Federal University of Roraima, Boa Vista, Roraima, Brazil
| | | | | | - Rommel C. Monte
- Medical School, Federal University of Roraima, Boa Vista, Roraima, Brazil
| | - Sewbert R. Jati
- Post Graduate Program in Tropical Medicine (PPGMT) of the State University of Amazonas, Manaus, Amazonas, Brazil
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| | - Isadora S. Oliveira
- Department of BioMolecular Sciences, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Felipe A. Cerni
- Post Graduate Program in Tropical Medicine (PPGMT) of the State University of Amazonas, Manaus, Amazonas, Brazil
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| | - Wuelton M. Monteiro
- Post Graduate Program in Tropical Medicine (PPGMT) of the State University of Amazonas, Manaus, Amazonas, Brazil
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| | - Jacqueline Sachett
- Post Graduate Program in Tropical Medicine (PPGMT) of the State University of Amazonas, Manaus, Amazonas, Brazil
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil
| | - Domingos S. M. Dantas
- Programa Doutoral de Bioética da Faculdade de Medicina do Porto, Cidade do Porto, Portugal
| | | | - Manuela B. Pucca
- Post Graduate Program in Tropical Medicine (PPGMT) of the State University of Amazonas, Manaus, Amazonas, Brazil
- Department of Clinical Analysis, School of Pharmaceutical Sciences, São Paulo State University, Araraquara, São Paulo, Brazil
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6
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de Farias AS, Cristino JS, da Costa Arévalo M, Carneiro Junior A, Gomes Filho MR, Ambrosio SA, Nickenig Vissoci J, Wen FH, Azevedo Machado V, Sachett J, Monteiro W. Children Growing Up with Severe Disabilities as a Result of Snakebite Envenomations in Indigenous Villages of the Brazilian Amazon: Three Cases and Narratives. Toxins (Basel) 2023; 15:352. [PMID: 37368653 PMCID: PMC10305629 DOI: 10.3390/toxins15060352] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 06/29/2023] Open
Abstract
Snakebites are a major public health problem in the Brazilian Amazon and may lead to local complications and physical deficiencies. Access to antivenom treatment is poorer in indigenous populations compared to other populations. In this study, we report three cases of long-term severe disabilities as a result of Bothrops atrox snakebites in indigenous children, according to the narratives of the parents. The three cases evolved to compartment syndrome, secondary bacterial infection and extensive necrosis. The cases are associated with delayed antivenom treatment due to very fragmented therapeutic itineraries, which are marked by several changes in means of transport along the route. The loss of autonomy at such an early stage of life due to a disability caused by a snakebite, as observed in this study, may deprive children of sensory and social experiences and of learning their future roles in the community. In common to all cases, there was precarious access to rehabilitation services, which are generally centralized in the state capital, and which leads to a prolonged hospitalization of patients with severe snakebite, and distances them from their territory and family and community ties. Prospective studies should be conducted in the Amazon that estimate the burden of disabilities from snakebites in order to formulate public policies for the treatment and rehabilitation of patients through culturally tailored interventions.
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Affiliation(s)
- Altair Seabra de Farias
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus 69065-001, Brazil; (A.S.d.F.); (J.S.C.); (V.A.M.); (J.S.)
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus 69040-000, Brazil
| | - Joseir Saturnino Cristino
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus 69065-001, Brazil; (A.S.d.F.); (J.S.C.); (V.A.M.); (J.S.)
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus 69040-000, Brazil
| | - Macio da Costa Arévalo
- Distrito Sanitário Especial Indígena Alto Rio Solimões, Secretaria Especial de Saúde Indígena, Tabatinga 69640-000, Brazil; (M.d.C.A.); (M.R.G.F.)
| | - Alceonir Carneiro Junior
- Distrito Sanitário Especial Indígena Manaus, Secretaria Especial de Saúde Indígena, Manaus 69050-010, Brazil;
| | - Manoel Rodrigues Gomes Filho
- Distrito Sanitário Especial Indígena Alto Rio Solimões, Secretaria Especial de Saúde Indígena, Tabatinga 69640-000, Brazil; (M.d.C.A.); (M.R.G.F.)
| | | | - João Nickenig Vissoci
- Department of Emergency Medicine, Duke University School of Medicine, Durham, NC 27710, USA;
- Duke Global Health Institute, Duke University, Durham, NC 27708, USA
| | - Fan Hui Wen
- Instituto Butantan, São Paulo 05503-900, Brazil;
| | - Vinícius Azevedo Machado
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus 69065-001, Brazil; (A.S.d.F.); (J.S.C.); (V.A.M.); (J.S.)
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus 69040-000, Brazil
| | - Jacqueline Sachett
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus 69065-001, Brazil; (A.S.d.F.); (J.S.C.); (V.A.M.); (J.S.)
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus 69040-000, Brazil
- Diretoria de Ensino e Pesquisa, Fundação Alfredo da Matta, Manaus 69065-130, Brazil
| | - Wuelton Monteiro
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus 69065-001, Brazil; (A.S.d.F.); (J.S.C.); (V.A.M.); (J.S.)
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus 69040-000, Brazil
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