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Gonçalves TDS, do Carmo CN, Marinho DS. Estimated annual costs of Chikungunya fever in the municipality of Rio de Janeiro, Brazil. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2024; 27:e240026. [PMID: 38896647 PMCID: PMC11182447 DOI: 10.1590/1980-549720240026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/19/2024] [Accepted: 03/06/2024] [Indexed: 06/21/2024] Open
Abstract
OBJECTIVE To estimate the cost of illness of Chikungunya in the municipality of Rio de Janeiro, Brazil, in 2019. METHODS The study is a partial economic evaluation carried out with secondary data with free and unrestricted access. Direct outpatient and indirect costs of the acute, post-acute, and chronic phases of Chikungunya fever were estimated, in addition to hospital costs. The estimate of direct costs was performed using the notified cases and the standard treatment flowchart in the state of Rio de Janeiro. The indirect ones consist of loss of productivity and disability, using the burden of disease indicator (Disability-adjusted life year - DALY). RESULTS The total number of reported cases was 38,830. Total costs were calculated at BRL 279,807,318, with 97% related to indirect costs. CONCLUSION The chronic phase and indirect costs were the most expensive. The inability and permanence of Chikungunya differentiate the disease and increase the costs of its treatment.
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Junior ADS, de Melo BO, Costa AKS, de Jesus Ferreira Costa D, Castro ÉJM, de Jesus Gomes Turri R, de Sousa Monteiro A, Zagmignan A, Bomfim MRQ, de Silva LCN. Molecular characterization of Chikungunya virus recovered from patients in the Maranhão state, Brazil. Mol Biol Rep 2024; 51:375. [PMID: 38427097 DOI: 10.1007/s11033-024-09252-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/12/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Chikungunya virus (CHIKV) is an arbovirus from the Togaviridae family which has four genotypes: West African (WA), East/Central/South African (ECSA) and Asian/Caribbean lineage (AL) and Indian Ocean Lineage (IOL). The ECSA genotype was first registered in Brazil in Feira de Santana and spread to all Brazilian regions. This study reports the characterization of CHIKV isolates recovered from sera samples of fifty patients from seventeen cities in Maranhão, a state from Brazilian northeast region and part of the Legal Amazon area. METHODS AND RESULTS Primers were developed to amplify the partial regions coding structural proteins (E1, E3, E2, 6 K, and Capsid C). The consensus sequences have 2871 bp, covering approximately 24% of the genome. The isolates were highly similar (> 99%) to the ECSA isolate from Feira de Santana (BHI3734/H804698), presenting 30 non-synonymous mutations in E1 (5.95%), 18 in E2 (4.46%), and 1 in E3 (3.03%), taking the BHI3734/H804698 isolate as standard. Although the mutations described have not previously been related to increased infectivity or transmissibility of CHIKV, in silico analysis showed changes in physicochemical characteristics, antigenicity, and B cell epitopes of E1 and E2. CONCLUSIONS These findings demonstrate the importance of molecular approaches for monitoring the viral adaptations undergone by CHIKV and its geographic distribution.
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Affiliation(s)
| | - Bruna Oliveira de Melo
- Laboratório de Microbiologia Aplicada, Universidade CEUMA, São Luís, MA, 65075-120, Brazil
| | | | | | | | | | | | - Adrielle Zagmignan
- Laboratório de Patogenicidade Microbiana, Universidade CEUMA, São Luís, MA, 65075-120, Brazil
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de Lima RC, Valente LMM, Familiar Macedo D, de-Oliveira-Pinto LM, dos Santos FB, Mazzei JL, Siani AC, Nunes PCG, de Azeredo EL. Antiviral and Virucidal Activities of Uncaria tomentosa (Cat's Claw) against the Chikungunya Virus. Viruses 2024; 16:369. [PMID: 38543735 PMCID: PMC10974475 DOI: 10.3390/v16030369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 05/23/2024] Open
Abstract
Uncaria tomentosa (UT) is a medicinal plant popularly known as cat's claw belonging to the Rubiaceae family that has been reported to display antiviral and anti-inflammatory activities. The chikungunya virus (CHIKV) outbreaks constitute a Brazilian public health concern. CHIKV infection develops an abrupt onset of fever, usually accompanied by a skin rash, besides incapacitating polyarthralgia. There is no vaccine available or treatment for CHIKV infection. The present study evaluates the hydroalcoholic extract of UT bark as a potential antiviral against CHIKV. The in vitro antiviral activity of the UT extract against the Brazilian CHIKV strain was assessed using quantitative reverse transcription polymerase chain reaction, flow cytometry, and plaque assay. Results obtained demonstrated that UT inhibits CHIKV infection in a dose-dependent manner. At the non-cytotoxic concentration of 100 µg/mL, UT exhibited antiviral activity above 90% as determined by plaque reduction assay, and it reduced the viral cytopathic effect. Similarly, a significant virucidal effect of 100 µg/mL UT was observed after 24 and 48 h post-infection. This is the first report on the antiviral activity of UT against CHIKV infection, and the data presented here suggests UT as a potential antiviral to treat CHIKV infection.
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Affiliation(s)
- Raquel Curtinhas de Lima
- Laboratório das Interações Vírus Hospedeiros, Instituto Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil; (R.C.d.L.); (D.F.M.); (L.M.d.-O.-P.); (F.B.d.S.); (P.C.G.N.)
| | - Ligia Maria Marino Valente
- Instituto de Química, Universidade Federal do Rio de Janeiro, Av. Athos da Silveira Ramos, 149, Rio de Janeiro 21941-909, Brazil;
| | - Débora Familiar Macedo
- Laboratório das Interações Vírus Hospedeiros, Instituto Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil; (R.C.d.L.); (D.F.M.); (L.M.d.-O.-P.); (F.B.d.S.); (P.C.G.N.)
| | - Luzia Maria de-Oliveira-Pinto
- Laboratório das Interações Vírus Hospedeiros, Instituto Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil; (R.C.d.L.); (D.F.M.); (L.M.d.-O.-P.); (F.B.d.S.); (P.C.G.N.)
| | - Flavia Barreto dos Santos
- Laboratório das Interações Vírus Hospedeiros, Instituto Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil; (R.C.d.L.); (D.F.M.); (L.M.d.-O.-P.); (F.B.d.S.); (P.C.G.N.)
| | - José Luiz Mazzei
- Laboratório de Tecnologia para Biodiversidade em Saúde, Instituto de Tecnologia de Fármacos, Fundação Oswaldo Cruz, Rio de Janeiro 21041-250, Brazil; (J.L.M.); (A.C.S.)
| | - Antonio Carlos Siani
- Laboratório de Tecnologia para Biodiversidade em Saúde, Instituto de Tecnologia de Fármacos, Fundação Oswaldo Cruz, Rio de Janeiro 21041-250, Brazil; (J.L.M.); (A.C.S.)
| | - Priscila Conrado Guerra Nunes
- Laboratório das Interações Vírus Hospedeiros, Instituto Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil; (R.C.d.L.); (D.F.M.); (L.M.d.-O.-P.); (F.B.d.S.); (P.C.G.N.)
| | - Elzinandes Leal de Azeredo
- Laboratório das Interações Vírus Hospedeiros, Instituto Oswaldo Cruz, Rio de Janeiro 21040-900, Brazil; (R.C.d.L.); (D.F.M.); (L.M.d.-O.-P.); (F.B.d.S.); (P.C.G.N.)
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Ahmed S, Sultana S, Kundu S, Alam SS, Hossan T, Islam MA. Global Prevalence of Zika and Chikungunya Coinfection: A Systematic Review and Meta-Analysis. Diseases 2024; 12:31. [PMID: 38391778 PMCID: PMC10888207 DOI: 10.3390/diseases12020031] [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: 11/16/2023] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024] Open
Abstract
Zika virus (ZIKV) and chikungunya virus (CHIKV) are arthropod-borne viruses with significant pathogenicity, posing a substantial health and economic burden on a global scale. Moreover, ZIKV-CHIKV coinfection imposes additional therapeutic challenges as there is no specific treatment for ZIKV or CHIKV infection. While a growing number of studies have documented the ZIKV-CHIKV coinfection, there is currently a lack of conclusive reports on this coinfection. Therefore, we performed a systematic review and meta-analysis to determine the true statistics of ZIKV-CHIKV coinfection in the global human population. Relevant studies were searched for in PubMed, Scopus, and Google Scholar without limitation in terms of language or publication date. A total of 33 studies containing 41,460 participants were included in this meta-analysis. The study protocol was registered with PROSPERO under the registration number CRD42020176409. The pooled prevalence and confidence intervals of ZIKV-CHIKV coinfection were computed using a random-effects model. The study estimated a combined global prevalence rate of 1.0% [95% CI: 0.7-1.2] for the occurrence of ZIKV-CHIKV coinfection. The region of North America (Mexico, Haiti, and Nicaragua) and the country of Haiti demonstrated maximum prevalence rates of 2.8% [95% CI: 1.5-4.1] and 3.5% [95% CI: 0.2-6.8], respectively. Moreover, the prevalence of coinfection was found to be higher in the paediatric group (2.1% [95% CI: 0.0-4.2]) in comparison with the adult group (0.7% [95% CI: 0.2-1.1]). These findings suggest that the occurrence of ZIKV-CHIKV coinfection varies geographically and by age group. The results of this meta-analysis will guide future investigations seeking to understand the underlying reasons for these variations and the causes of coinfection and to develop targeted prevention and control strategies.
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Affiliation(s)
- Saleh Ahmed
- Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Shabiha Sultana
- Department of Cellular Biology and Anatomy, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Shoumik Kundu
- Department of Chemistry and Biochemistry, Texas Tech University, 2500 Broadway St., Lubbock, TX 79409, USA
| | - Sayeda Sadia Alam
- Department of Biochemistry and Molecular Biology, Jahangirnagar University, Savar, Dhaka 1342, Bangladesh
| | - Tareq Hossan
- Department of Biochemistry and Molecular Biology, Jahangirnagar University, Savar, Dhaka 1342, Bangladesh
- Department of Internal Medicine, Division of Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Md Asiful Islam
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
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Genomic Epidemiology Reveals the Circulation of the Chikungunya Virus East/Central/South African Lineage in Tocantins State, North Brazil. Viruses 2022; 14:v14102311. [PMID: 36298867 PMCID: PMC9611869 DOI: 10.3390/v14102311] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022] Open
Abstract
The chikungunya virus (CHIKV) is a mosquito-borne virus of the family Togaviridae transmitted to humans by Aedes spp. mosquitoes. In Brazil, imported cases have been reported since June 2014 through two independent introductions, one caused by Asian Lineage in Oiapoque, Amapá state, North Region, and another caused by East/Central/South African (ECSA) in Feira de Santana, Bahia state, Northeast Region. Moreover, there is still limited information about the genomic epidemiology of the CHIKV from surveillance studies. The Tocantins state, located in Northern Brazil, reported an increase in the number of CHIKV cases at the end of 2021 and the beginning of 2022. Thus, to better understand the dispersion dynamics of this viral pathogen in the state, we generated 27 near-complete CHIKV genome sequences from four cities, obtained from clinical samples. Our results showed that the newly CHIKV genomes from Tocantins belonged to the ECSA lineage. Phylogenetic reconstruction revealed that Tocantins' strains formed a single well-supported clade, which appear to be closely related to isolates from the Rio Grande do Norte state (Northeast Brazil) and the Rio de Janeiro state (Southeast Brazil), that experienced an explosive ECSA epidemic between 2016-2019. Mutation analyses showed eleven frequent non-synonymous mutations in the structural and non-structural proteins, indicating the autochthonous transmission of the CHIKV in the state. None of the genomes recovered within the Tocantins samples carry the A226V mutation in the E1 protein associated with increased transmission in A. albopictus. The study presented here highlights the importance of continued genomic surveillance to provide information not only on recording mutations along the viral genome but as a molecular surveillance tool to trace virus spread within the country, to predict events of likely occurrence of new infections, and, as such, contribute to an improved public health service.
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Faustino R, Carvalho FR, Medeiros T, Familiar-Macedo D, Vianna RADO, Leite PEC, Pereira IR, Cardoso CAA, De Azeredo EL, Silva AA. Pro-Inflammatory Profile of Children Exposed to Maternal Chikungunya Virus Infection during the Intrauterine Period: A One-Year Follow-Up Study. Viruses 2022; 14:v14091881. [PMID: 36146688 PMCID: PMC9501274 DOI: 10.3390/v14091881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Chikungunya virus (CHIKV) vertical transmission occurs due to maternal viremia in the prepartum. Clinical presentation in neonates can be varied; however, the consequences of intrauterine exposure on the immune response are unclear. Thus, we aimed to analyze inflammatory alterations in children exposed to maternal CHIKV infection. This is a cross-sectional study that included children exposed to maternal CHIKV infection (confirmed by RT-qPCR and/or IgM). Circulant immune mediators were analyzed by a multiplex assay. RESULTS: We included 33 children, with a mean age of 3 ± 2.9 months-old, and 19 (57.6%) were male. Only one child presented neurological alterations. CHIKV-exposed infants showed elevated levels of MIP-1α, MIP-1β, and CCL-2 (p < 0.05). Pro-inflammatory cytokines such as TNFα, IL-6, and IL-7 (p < 0.0001) were also increased. In addition, lower levels of PDGF-BB and GM-CSF were observed in the same group (p < 0.0001). Principal component (PC) analysis highlighted a distinction in the inflammatory profile between groups, where PC explained 56.6% of the alterations. Our findings suggest that maternal exposure to CHIKV can affect the circulating levels of pro-inflammatory cytokines during the infants’ first year of life. The long-term clinical consequences of these findings should be investigated.
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Affiliation(s)
- Renan Faustino
- Multiuser Laboratory for Research Support in Nephrology and Medical Sciences (LAMAP), Hospital Universitario Antonio Pedro, Faculty of Medicine, Universidade Federal Fluminense, Niteroi 24033-900, Brazil
| | - Fabiana Rabe Carvalho
- Multiuser Laboratory for Research Support in Nephrology and Medical Sciences (LAMAP), Hospital Universitario Antonio Pedro, Faculty of Medicine, Universidade Federal Fluminense, Niteroi 24033-900, Brazil
| | - Thalia Medeiros
- Multiuser Laboratory for Research Support in Nephrology and Medical Sciences (LAMAP), Hospital Universitario Antonio Pedro, Faculty of Medicine, Universidade Federal Fluminense, Niteroi 24033-900, Brazil
- Department of Pathology, Faculty of Medicine, Universidade Federal Fluminense, Niterói 24033-900, Brazil
| | - Débora Familiar-Macedo
- Viral Immunology Laboratory, Oswaldo Cruz Institute, Fundação Oswaldo Cruz, Rio de Janeiro 21040-360, Brazil
| | - Renata Artimos de Oliveira Vianna
- Multiuser Laboratory for Research Support in Nephrology and Medical Sciences (LAMAP), Hospital Universitario Antonio Pedro, Faculty of Medicine, Universidade Federal Fluminense, Niteroi 24033-900, Brazil
| | | | - Isabela Resende Pereira
- Department of Pathology, Faculty of Medicine, Universidade Federal Fluminense, Niterói 24033-900, Brazil
| | - Claudete Aparecida Araújo Cardoso
- Multiuser Laboratory for Research Support in Nephrology and Medical Sciences (LAMAP), Hospital Universitario Antonio Pedro, Faculty of Medicine, Universidade Federal Fluminense, Niteroi 24033-900, Brazil
- Department of Maternal and Child, Faculty of Medicine, Universidade Federal Fluminense, Niterói 24033-900, Brazil
| | - Elzinandes Leal De Azeredo
- Viral Immunology Laboratory, Oswaldo Cruz Institute, Fundação Oswaldo Cruz, Rio de Janeiro 21040-360, Brazil
- Correspondence: (E.L.D.A.); (A.A.S.); Tel.: +55-(21)-3674-7285 (A.A.S.)
| | - Andrea Alice Silva
- Multiuser Laboratory for Research Support in Nephrology and Medical Sciences (LAMAP), Hospital Universitario Antonio Pedro, Faculty of Medicine, Universidade Federal Fluminense, Niteroi 24033-900, Brazil
- Department of Pathology, Faculty of Medicine, Universidade Federal Fluminense, Niterói 24033-900, Brazil
- Correspondence: (E.L.D.A.); (A.A.S.); Tel.: +55-(21)-3674-7285 (A.A.S.)
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de Oliveira Ribeiro G, Gill DE, do Socorro Foro Ramos E, Villanova F, Soares D’Athaide Ribeiro E, Monteiro FJC, Morais VS, Rego MODS, Araújo ELL, Pandey RP, Raj VS, Deng X, Delwart E, da Costa AC, Leal É. Chikungunya Virus Asian Lineage Infection in the Amazon Region Is Maintained by Asiatic and Caribbean-Introduced Variants. Viruses 2022; 14:v14071445. [PMID: 35891427 PMCID: PMC9319912 DOI: 10.3390/v14071445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/22/2022] [Accepted: 06/25/2022] [Indexed: 02/04/2023] Open
Abstract
The simultaneous transmission of two lineages of the chikungunya virus (CHIKV) was discovered after the pathogen’s initial arrival in Brazil. In Oiapoque (Amapá state, north Brazil), the Asian lineage (CHIKV-Asian) was discovered, while in Bahia state, the East-Central-South-African lineage (CHIKV-ECSA) was discovered (northeast Brazil). Since then, the CHIKV-Asian lineage has been restricted to the Amazon region (mostly in the state of Amapá), whereas the ECSA lineage has expanded across the country. Despite the fact that the Asian lineage was already present in the Amazon region, the ECSA lineage brought from the northeast caused a large outbreak in the Amazonian state of Roraima (north Brazil) in 2017. Here, CHIKV spread in the Amazon region was studied by a Zika–Dengue–Chikungunya PCR assay in 824 serum samples collected between 2013 and 2016 from individuals with symptoms of viral infection in the Amapá state. We found 11 samples positive for CHIKV-Asian, and, from these samples, we were able to retrieve 10 full-length viral genomes. A comprehensive phylogenetic study revealed that nine CHIKV sequences came from a local transmission cluster related to Caribbean strains, whereas one sequence was related to sequences from the Philippines. These findings imply that CHIKV spread in different ways in Roraima and Amapá, despite the fact that both states had similar climatic circumstances and mosquito vector frequencies.
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Affiliation(s)
- Geovani de Oliveira Ribeiro
- Laboratório de Diversidade Viral, Instituto de Ciências Biológicas, Universidade Federal do Pará, Belem 66075-000, Brazil; (G.d.O.R.); (E.d.S.F.R.); (F.V.)
| | - Danielle Elise Gill
- Instituto de Medicina Tropical da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil; (D.E.G.); (V.S.M.); (A.C.d.C.)
| | - Endrya do Socorro Foro Ramos
- Laboratório de Diversidade Viral, Instituto de Ciências Biológicas, Universidade Federal do Pará, Belem 66075-000, Brazil; (G.d.O.R.); (E.d.S.F.R.); (F.V.)
| | - Fabiola Villanova
- Laboratório de Diversidade Viral, Instituto de Ciências Biológicas, Universidade Federal do Pará, Belem 66075-000, Brazil; (G.d.O.R.); (E.d.S.F.R.); (F.V.)
| | - Edcelha Soares D’Athaide Ribeiro
- Public Health Laboratory of Amapa-LACEN/AP, Health Surveillance Superintendence of Amapa, Macapa 68905-230, Brazil; (E.S.D.R.); (F.J.C.M.); (M.O.d.S.R.)
| | - Fred Julio Costa Monteiro
- Public Health Laboratory of Amapa-LACEN/AP, Health Surveillance Superintendence of Amapa, Macapa 68905-230, Brazil; (E.S.D.R.); (F.J.C.M.); (M.O.d.S.R.)
| | - Vanessa S. Morais
- Instituto de Medicina Tropical da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil; (D.E.G.); (V.S.M.); (A.C.d.C.)
| | - Marlisson Octavio da S. Rego
- Public Health Laboratory of Amapa-LACEN/AP, Health Surveillance Superintendence of Amapa, Macapa 68905-230, Brazil; (E.S.D.R.); (F.J.C.M.); (M.O.d.S.R.)
| | - Emerson Luiz Lima Araújo
- General Coordination of Public Health, Laboratories of the Strategic Articulation, Department of the Health Surveillance Secretariat of the Ministry of Health (CGLAB/DAEVS/SVS-MS), Brasília 70719-040, Brazil;
| | - Ramendra Pati Pandey
- Centre for Drug Design Discovery and Development (C4D), SRM University, Delhi-NCR, Rajiv Gandhi Education City, Sonepat 131029, Haryana, India; (R.P.P.); (V.S.R.); (E.D.)
| | - V. Samuel Raj
- Centre for Drug Design Discovery and Development (C4D), SRM University, Delhi-NCR, Rajiv Gandhi Education City, Sonepat 131029, Haryana, India; (R.P.P.); (V.S.R.); (E.D.)
| | - Xutao Deng
- Vitalant Research Institute, 270 Masonic Avenue, San Francisco, CA 94118, USA;
- Department Laboratory Medicine, University of California San Francisco, San Francisco, CA 94118, USA
| | - Eric Delwart
- Centre for Drug Design Discovery and Development (C4D), SRM University, Delhi-NCR, Rajiv Gandhi Education City, Sonepat 131029, Haryana, India; (R.P.P.); (V.S.R.); (E.D.)
- Vitalant Research Institute, 270 Masonic Avenue, San Francisco, CA 94118, USA;
| | - Antonio Charlys da Costa
- Instituto de Medicina Tropical da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil; (D.E.G.); (V.S.M.); (A.C.d.C.)
| | - Élcio Leal
- Laboratório de Diversidade Viral, Instituto de Ciências Biológicas, Universidade Federal do Pará, Belem 66075-000, Brazil; (G.d.O.R.); (E.d.S.F.R.); (F.V.)
- Correspondence:
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Increased Indoleamine 2,3-Dioxygenase 1 (IDO-1) Activity and Inflammatory Responses during Chikungunya Virus Infection. Pathogens 2022; 11:pathogens11040444. [PMID: 35456119 PMCID: PMC9028473 DOI: 10.3390/pathogens11040444] [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: 02/07/2022] [Revised: 03/24/2022] [Accepted: 03/29/2022] [Indexed: 12/13/2022] Open
Abstract
Chikungunya virus (CHIKV) infection causes intense cytokine/chemokine inflammatory responses and debilitating joint pain. Indoleamine2,3–dioxygenase 1 (IDO-1) is an enzyme that initiates the tryptophan degradation that is important in initial host innate immune defense against infectious pathogens. Besides that, IDO-1 activation acts as a regulatory mechanism to prevent overactive host immune responses. In this study, we evaluated IDO-1 activity and cytokine/chemokine patterns in CHIKV patients. Higher IDO-1 (Kyn/Trp ratio) activation was observed during the early acute phase of CHIKV infection and declined in the chronic phase. Importantly, increased concentrations of Tumor Necrosis Factor-α (TNF-α), Interleukin-6 (IL-6), Interferon γ (IFN-γ), C-C motif chemokine ligand 2/Monocyte Chemoattractant Protein-1 (CCL2/MCP-1) and C-X-C motif chemokine ligand 10/Interferon Protein-10 (CXCL10/IP-10) were found in the acute phase of infection, while C-C motif chemokine ligand 4/Macrophage Inflammatory Protein 1 β (CCL4/MIP-1β) was found at increased concentrations in the chronic phase. Likewise, CHIKV patients with arthritis had significantly higher concentrations of CCL4/MIP-1β compared to patients without arthritis. Taken together, these data demonstrated increased IDO-1 activity, possibly exerting both antiviral effects and regulating exacerbated inflammatory responses. CCL4/MIP-1β may have an important role in the persistent inflammation and arthritic symptoms following chikungunya infection.
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Was It Chikungunya? Laboratorial and Clinical Investigations of Cases Occurred during a Triple Arboviruses’ Outbreak in Rio de Janeiro, Brazil. Pathogens 2022; 11:pathogens11020245. [PMID: 35215188 PMCID: PMC8879879 DOI: 10.3390/pathogens11020245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/04/2022] [Accepted: 02/09/2022] [Indexed: 02/04/2023] Open
Abstract
The co-circulation of chikungunya virus (CHIKV), dengue virus (DENV) and Zika virus (ZIKV) in Rio de Janeiro (RJ), Brazil, caused a challenging triple epidemic, as they share similar clinical signs and symptoms and geographical distribution. Here, we aimed to investigate the clinical and laboratorial aspects of chikungunya suspected cases assisted in RJ during the 2018 outbreak, focusing on the differential diagnosis with dengue and zika. All suspected cases were submitted to molecular and/or serological differential diagnostic approaches to arboviruses. A total of 242 cases suspected of arbovirus infection were investigated and 73.6% (178/242) were molecular and/or serologically confirmed as chikungunya. In RT-qPCR confirmed cases, cycle threshold (Ct) values ranged from 15.46 to 35.13, with acute cases presenting lower values. Chikungunya cases were mainly in females (64%) and the most frequently affected age group was adults between 46 to 59 years old (27%). Polyarthralgia affected 89% of patients, especially in hands and feet. No dengue virus (DENV) and Zika virus (ZIKV) infections were confirmed by molecular diagnosis, but 9.5% (23/242) had serological evidence of DENV exposure by the detection of specific anti-DENV IgM or NS1, and 42.7% (76/178) of chikungunya positive cases also presented recent DENV exposure reflected by a positive anti-DENV IgM or NS1 result. A significantly higher frequency of arthritis (p = 0.023) and limb edema (p < 0.001) was found on patients with CHIKV monoinfection compared to dengue patients and patients exposed to both viruses. Lastly, phylogenetic analysis showed that the chikungunya cases were caused by the ECSA genotype. Despite the triple arboviruses’ epidemic in the state of RJ, most patients with fever and arthralgia investigated here were diagnosed as chikungunya cases, and the incidence of CHIKV/DENV co-detection was higher than that reported in other studies.
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Rufalco-Moutinho P, de Noronha LAG, de Souza Cardoso Quintão T, Nobre TF, Cardoso APS, Cilião-Alves DC, Bellocchio Júnior MA, von Glehn MDP, Haddad R, Romero GAS, de Araújo WN. Evidence of co-circulation of multiple arboviruses transmitted by Aedes species based on laboratory syndromic surveillance at a health unit in a slum of the Federal District, Brazil. Parasit Vectors 2021; 14:610. [PMID: 34924014 PMCID: PMC8684590 DOI: 10.1186/s13071-021-05110-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/25/2021] [Indexed: 11/29/2022] Open
Abstract
Background Vector-borne diseases, especially arboviruses transmitted by Aedes sp. mosquitos, should be a health policy priority in Brazil. Despite this urgency, there are significant limitations in the traditional surveillance system, mainly in vulnerable areas. This study aimed to investigate the circulation of dengue (DENV), Zika (ZIKV), and chikungunya viruses (CHIKV) by laboratory syndromic surveillance (LSS) in a slum area of the Federal District of Brazil, comparing the results with traditional surveillance data. Methods LSS for acute febrile and/or exanthematous symptoms was developed at a health unit of Cidade Estrutural, in order to identify the circulation of arboviruses transmitted by Aedes sp. mosquitos. Between June 2019 and March 2020, 131 valid participants were identified and sera tested by reverse transcription polymerase chain reaction (RT-PCR) for DENV (by serotype), ZIKV, and CHIKV acute infection and by immunoglobulin M enzyme-inked immunosorbent assay (ELISA-IgM) for DENV and CHIKV 15–21 days after symptom onset, when the participant reported no respiratory signs (cough and/or coryza). The results obtained were compared with traditional surveillance data for the study area and period. Results At least three DENV-1 (2.3%), four DENV-2 (3%), and one CHIKV (0.7%) cases were confirmed in the laboratory, showing evidence of hyperendemicity even though LSS had not reached the historic peak dengue fever months in the Federal District (April–May). When the results obtained here were compared with traditional surveillance, a significant discrepancy was observed, including underreporting of CHIKV infection. Conclusions In addition to the risks posed to the study population, the area investigated with its respective socio-environmental profile may be a potential site for spread of the virus, given the cosmopolitan presence of Aedes sp. and human mobility in the Federal District. It is also suggested that traditional epidemiological surveillance may be reporting acute viral infections other than DENV as dengue fever, while underreporting other arboviruses transmitted by Aedes sp. mosquitos in the Federal District. Graphical Abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s13071-021-05110-9.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Rodrigo Haddad
- Center of Tropical Medicine, University of Brasília, Federal District, Brazil.,Ceilândia Faculty, University of Brasília, Federal District, Brazil
| | | | - Wildo Navegantes de Araújo
- Center of Tropical Medicine, University of Brasília, Federal District, Brazil.,Ceilândia Faculty, University of Brasília, Federal District, Brazil
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11
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Rocha DCP, Souza TMA, Nunes PCG, Mohana-Borges R, Paes MV, Guimarães GMC, Arcila JCS, Paiva IA, Azeredo ELD, Damasco PV, de Souza LJ, Dos Santos FB, Allonso D. Increased circulating levels of High Mobility Group Box 1 (HMGB1) in acute-phase Chikungunya virus infection: Potential disease biomarker. J Clin Virol 2021; 146:105054. [PMID: 34920373 DOI: 10.1016/j.jcv.2021.105054] [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: 04/13/2021] [Revised: 11/01/2021] [Accepted: 12/08/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Chikungunya virus (CHIKV) causes a febrile syndrome with intense and debilitating arthralgia that can persist for several months or years after complete virus clearance. As there is no specific antiviral treatment or vaccine against CHIKV, identification of serological markers that help clinical management of CHIKV patients is urgent. The High Mobility Group Box 1 (HMGB1) protein is secreted to extracellular milieu and triggers an intense inflammatory process by inducing the overexpression of pro-inflammatory cytokines. HMGB1 plays an important role in several virus diseases as well as in rheumatoid arthritis. OBJECTIVES This study focus on the investigation of HMGB1 serum levels in a sera panel from CHIKV-infected patients in an attempt to assess its potential as a biomarker for chikungunya clinical management. STUDY DESIGN Eighty CHIKV-positive samples and 32 samples from healthy donors were subjected to a quantitative HMGB1 ELISA assay to assess the HMGB1 circulating levels. RESULTS HMGB1 levels were significantly higher in CHIKV-positive samples (516.12 ng/mL, SEM ± 48.83 ng/mL) compared to negative control (31.20 ng/mL, SEM ± 3.24 ng/mL, p < 0.0001). Circulating levels of HMGB1 persisted elevated during the whole acute-phase of disease and correlated with virus titer (p < 0.05). CONCLUSIONS The present study is the first to describe increased serum levels of HMGB1 in CHIKV infection and its positive correlation with virus titer, suggesting its potential use as a biomarker for diagnosis and treatment of chikungunya fever.
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Affiliation(s)
- Daniele C P Rocha
- Departamento de Biotecnologia Farmacêutica, Faculdade de Farmácia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ 21941-902, Brazil; Laboratório de Biotecnologia e Bioengenharia Estrutural, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ 21941-590, Brazil
| | - Thiara Manuelle Alves Souza
- Laboratório de Imunologia Viral, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, RJ 21040-900, Brazil
| | - Priscila Conrado Guerra Nunes
- Laboratório de Biomedicina do Cérebro, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, RJ 20231-092, Brazil; Superintendência de Informações Estratégicas de Vigilância em Saúde (SIEVS/RJ), Secretaria de Saúde, Governo do Estado do Rio de Janeiro, Rio de Janeiro, RJ 20031-142, Brazil
| | - Ronaldo Mohana-Borges
- Laboratório de Biotecnologia e Bioengenharia Estrutural, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ 21941-590, Brazil
| | - Marciano V Paes
- Laboratório Interdisciplinar de Pesquisas Médicas, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz/FIOCRUZ, Rio de Janeiro, RJ 21040-900, Brazil
| | - Gabriel M C Guimarães
- Laboratório de Imunologia Viral, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, RJ 21040-900, Brazil
| | - Juan C S Arcila
- Laboratório de Imunologia Viral, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, RJ 21040-900, Brazil
| | - Iury Amâncio Paiva
- Laboratório de Imunologia Viral, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, RJ 21040-900, Brazil
| | - Elzinandes Leal de Azeredo
- Laboratório de Imunologia Viral, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, RJ 21040-900, Brazil
| | - Paulo Vieira Damasco
- Hospital Universitário Gaffrée Guinle, Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Rio de Janeiro, RJ 20270-004, Brazil; Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ 20551-030, Brazil
| | - Luiz José de Souza
- Hospital dos Plantadores de Cana, Campos dos Goytacazes, RJ 28025-496, Brazil
| | - Flavia B Dos Santos
- Laboratório de Imunologia Viral, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, RJ 21040-900, Brazil
| | - Diego Allonso
- Departamento de Biotecnologia Farmacêutica, Faculdade de Farmácia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ 21941-902, Brazil.
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12
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Viral and Prion Infections Associated with Central Nervous System Syndromes in Brazil. Viruses 2021; 13:v13071370. [PMID: 34372576 PMCID: PMC8310075 DOI: 10.3390/v13071370] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/05/2021] [Accepted: 05/11/2021] [Indexed: 12/12/2022] Open
Abstract
Virus-induced infections of the central nervous system (CNS) are among the most serious problems in public health and can be associated with high rates of morbidity and mortality, mainly in low- and middle-income countries, where these manifestations have been neglected. Typically, herpes simplex virus 1 and 2, varicella-zoster, and enterovirus are responsible for a high number of cases in immunocompetent hosts, whereas other herpesviruses (for example, cytomegalovirus) are the most common in immunocompromised individuals. Arboviruses have also been associated with outbreaks with a high burden of neurological disorders, such as the Zika virus epidemic in Brazil. There is a current lack of understanding in Brazil about the most common viruses involved in CNS infections. In this review, we briefly summarize the most recent studies and findings associated with the CNS, in addition to epidemiological data that provide extensive information on the circulation and diversity of the most common neuro-invasive viruses in Brazil. We also highlight important aspects of the prion-associated diseases. This review provides readers with better knowledge of virus-associated CNS infections. A deeper understanding of these infections will support the improvement of the current surveillance strategies to allow the timely monitoring of the emergence/re-emergence of neurotropic viruses.
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13
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Freitas LP, Schmidt AM, Cossich W, Cruz OG, Carvalho MS. Spatio-temporal modelling of the first Chikungunya epidemic in an intra-urban setting: The role of socioeconomic status, environment and temperature. PLoS Negl Trop Dis 2021; 15:e0009537. [PMID: 34143771 PMCID: PMC8244893 DOI: 10.1371/journal.pntd.0009537] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 06/30/2021] [Accepted: 06/03/2021] [Indexed: 01/07/2023] Open
Abstract
Three key elements are the drivers of Aedes-borne disease: mosquito infestation, virus circulating, and susceptible human population. However, information on these aspects is not easily available in low- and middle-income countries. We analysed data on factors that influence one or more of those elements to study the first chikungunya epidemic in Rio de Janeiro city in 2016. Using spatio-temporal models, under the Bayesian framework, we estimated the association of those factors with chikungunya reported cases by neighbourhood and week. To estimate the minimum temperature effect in a non-linear fashion, we used a transfer function considering an instantaneous effect and propagation of a proportion of such effect to future times. The sociodevelopment index and the proportion of green areas (areas with agriculture, swamps and shoals, tree and shrub cover, and woody-grass cover) were included in the model with time-varying coefficients, allowing us to explore how their associations with the number of cases change throughout the epidemic. There were 13627 chikungunya cases in the study period. The sociodevelopment index presented the strongest association, inversely related to the risk of cases. Such association was more pronounced in the first weeks, indicating that socioeconomically vulnerable neighbourhoods were affected first and hardest by the epidemic. The proportion of green areas effect was null for most weeks. The temperature was directly associated with the risk of chikungunya for most neighbourhoods, with different decaying patterns. The temperature effect persisted longer where the epidemic was concentrated. In such locations, interventions should be designed to be continuous and to work in the long term. We observed that the role of the covariates changes over time. Therefore, time-varying coefficients should be widely incorporated when modelling Aedes-borne diseases. Our model contributed to the understanding of the spatio-temporal dynamics of an urban Aedes-borne disease introduction in a tropical metropolitan city.
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Affiliation(s)
- Laís Picinini Freitas
- Programa de Pós-Graduação em Epidemiologia em Saúde Pública, Escola Nacional de Saúde Pública Sergio Arouca (ENSP), Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
- Programa de Computação Científica (PROCC), Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Alexandra M. Schmidt
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - William Cossich
- Department of Physics and Astronomy, University of Bologna, Bologna, Italy
| | - Oswaldo Gonçalves Cruz
- Programa de Computação Científica (PROCC), Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Marilia Sá Carvalho
- Programa de Computação Científica (PROCC), Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
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14
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Lima MDRQ, de Lima RC, de Azeredo EL, dos Santos FB. Analysis of a Routinely Used Commercial Anti-Chikungunya IgM ELISA Reveals Cross-Reactivities with Dengue in Brazil: A New Challenge for Differential Diagnosis? Diagnostics (Basel) 2021; 11:diagnostics11050819. [PMID: 33946597 PMCID: PMC8147240 DOI: 10.3390/diagnostics11050819] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/23/2021] [Accepted: 01/24/2021] [Indexed: 12/17/2022] Open
Abstract
In Brazil, chikungunya emerged in 2014, and by 2016, co-circulated with other arbovirosis, such as dengue and zika. ELISAs (Enzyme-Linked Immunosorbent Assays) are the most widely used approach for arboviruses diagnosis. However, some limitations include antibody cross reactivities when viruses belong to the same genus, and sensitivity variations in distinct epidemiological scenarios. As chikungunya virus (CHIKV) is an alphavirus, no serological cross reactivity with dengue virus (DENV) should be observed. Here, we evaluated a routinely used chikungunya commercial IgM (Immunoglobulin M) ELISA test (Anti-Chikungunya IgM ELISA, Euroimmun) to assess its performance in confirming chikungunya in a dengue endemic area. Samples (n = 340) representative of all four DENV serotypes, healthy individuals and controls were tested. The Anti-CHIKV IgM ELISA test had a sensitivity of 100% and a specificity of 25.3% due to the cross reactivities observed with dengue. In dengue acute cases, the chikungunya test showed an overall cross-reactivity of 31.6%, with a higher cross-reactivity with DENV-4. In dengue IgM positive cases, the assay showed a cross-reactivity of 46.7%. Serological diagnosis may be challenging and, despite the results observed here, more evaluations shall be performed. Because distinct arboviruses co-circulate in Brazil, reliable diagnostic tools are essential for disease surveillance and patient management.
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15
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Co-Circulation of Two Independent Clades and Persistence of CHIKV-ECSA Genotype during Epidemic Waves in Rio de Janeiro, Southeast Brazil. Pathogens 2020; 9:pathogens9120984. [PMID: 33255865 PMCID: PMC7759993 DOI: 10.3390/pathogens9120984] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/24/2020] [Accepted: 10/29/2020] [Indexed: 12/16/2022] Open
Abstract
The Chikungunya virus infection in Brazil has raised several concerns due to the rapid dissemination of the virus and its association with several clinical complications. Nevertheless, there is limited information about the genomic epidemiology of CHIKV circulating in Brazil from surveillance studies. Thus, to better understand its dispersion dynamics in Rio de Janeiro (RJ), one of the most affected states during the 2016–2019 epidemic waves, we generated 23 near-complete genomes of CHIKV isolates from two main cities located in the metropolitan mesoregion, obtained directly from clinical samples. Our phylogenetic reconstructions suggest the 2019-CHIKV-ECSA epidemic in RJ state was characterized by the co-circulation of multiple clade (clade A and B), highlighting that two independent introduction events of CHIKV-ECSA into RJ state have occurred between 2016–2019, both mediated from the northeastern region. Interestingly, we identified that the two-clade displaying eighteen characteristic amino acids changes among structural and non-structural proteins. Our findings reinforce that genomic data can provide information about virus genetic diversity and transmission dynamics, which might assist in the arbovirus epidemics establishing of an effective surveillance framework.
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16
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Ciccozzi M, Lai A, Zehender G, Borsetti A, Cella E, Ciotti M, Sagnelli E, Sagnelli C, Angeletti S. The phylogenetic approach for viral infectious disease evolution and epidemiology: An updating review. J Med Virol 2019; 91:1707-1724. [PMID: 31243773 DOI: 10.1002/jmv.25526] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/24/2019] [Indexed: 12/16/2022]
Abstract
In the last decade, the phylogenetic approach is recurrent in molecular evolutionary analysis. On 12 May, 2019, about 2 296 213 papers are found, but typing "phylogeny" or "epidemiology AND phylogeny" only 199 804 and 20 133 are retrieved, respectively. Molecular epidemiology in infectious diseases is widely used to define the source of infection as so as the ancestral relationships of individuals sampled from a population. Coalescent theory and phylogeographic analysis have had scientific application in several, recent pandemic events, and nosocomial outbreaks. Hepatitis viruses and immunodeficiency virus (human immunodeficiency virus) have been largely studied. Phylogenetic analysis has been recently applied on Polyomaviruses so as in the more recent outbreaks due to different arboviruses type as Zika and chikungunya viruses discovering the source of infection and the geographic spread. Data on sequences isolated by the microorganism are essential to apply the phylogenetic tools and research in the field of infectious disease phylodinamics is growing up. There is the need to apply molecular phylogenetic and evolutionary methods in areas out of infectious diseases, as translational genomics and personalized medicine. Lastly, the application of these tools in vaccine strategy so as in antibiotic and antiviral researchers are encouraged.
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Affiliation(s)
- Massimo Ciccozzi
- Unit of Medical Statistics and Molecular Epidemiology, University Campus Bio-Medico of Rome, Rome, Italy
| | - Alessia Lai
- Department of Biomedical and Clinical Sciences 'L. Sacco', University of Milan, Milan, Italy
| | - Gianguglielmo Zehender
- Department of Biomedical and Clinical Sciences 'L. Sacco', University of Milan, Milan, Italy
| | - Alessandra Borsetti
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, Roma, Italy
| | - Eleonora Cella
- Unit of Medical Statistics and Molecular Epidemiology, University Campus Bio-Medico of Rome, Rome, Italy
| | - Marco Ciotti
- Laboratory of Molecular Virology, Polyclinic Tor Vergata Foundation, Rome, Italy
| | - Evangelista Sagnelli
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Caterina Sagnelli
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Silvia Angeletti
- Unit of Clinical Laboratory Science, University Campus Bio-Medico of Rome, Rome, Italy
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