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Entry routes for zika virus in Brazil after 2014 World Cup: New Possibilities

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LETTER TO THE EDITOR
Entry routes for Zika virus in Brazil after
2014 world cup: New possibilities
KEYWORDS
Zika virus;
Brazil;
Travelers;
World cup
Dear Editor,
In the beginning of 2015, several cases of Dengue and Chi-
kungunya virus infections were reported in Brazil [1].
Dengue epidemics are located in the states of Sa
˜o Paulo
(637,029 confirmed cases), Minas Gerais (166,360 confirmed
cases), Goia
´s (121,501 confirmed cases), Pernambuco
(68,510 confirmed cases), Ceara
´(59,074 confirmed cases),
Rio de Janeiro (49,480 confirmed cases), Parana
´(46,694
confirmed cases), Bahia (42,476 confirmed cases), Rio
Grande do Norte (21,194 confirmed cases), Mato Grosso do
Sul (18,663 confirmed cases), Paraı
´
ba (18,018 confirmed
cases), Espı
´
rito Santo (16,477 confirmed cases), Alagoas
(13,846 confirmed cases) e Mato Grosso (13,700 confirmed
cases). For Chikungunya virus infection, the state of Bahia
appears as first in number of confirmed cases (7820), fol-
lowed by Amapa
´(1070) and Federal District (194).
Zika virus infections presented clinical pictures very
similar to dengue, and the number of cases reported offi-
cially are low, provided by problems in detection as it oc-
curs in a dengue virus area and co -infection of these
viruses is not uncommon [2]. The strongest hypothesis of
the introduction of Zika virus in Brazil has bought by African
travelers during the 2014 World Cup has virus transmission
by asymptomatic patients, aside to significant increase of
132% in international tourists flow (June/2014 compared to
June/2013) to the country.
But the circulating virus in Brazil was identified as Asian
genotype through phylogenetic analyzes of the envelope
region in the two cases from the state of Bahia, the area
with highest number of confirmed cases [3], and due to Zika
genotype found, alternative routes for new external
entrance must be studied, allowing better comprehension
of the virus circulation in the country.
We checked the numbers of travelers received in Brazil
(Table 1) from endemic regions of Zika Virus (Africa, Asia,
Pacific Islands and Chile eFig. 1) looking for those pre-
senting a greater potential for carrying the Asian Zika virus
strain. We found higher numbers of Asians tourists in this
period as compared to few Africans by several states, as
well as, the proximity of the country to Chile, which in the
period surrounding the 2014 World Cup presented
confirmed case of Zika virus from Easter Island, whose
phylogeny was detected as Asian strain [4]. Domestic
stream is another plausible possibility because the host
cities of the games were located in several states, requiring
the movement of foreign and domestic travelers between
these locations (Sa
˜o Paulo eSP, Rio de Janeiro eRJ, Sal-
vador eBA Christmas eRN, Cuiaba eMT, Belo Horizonte e
MG, Fortaleza eCE, Recife ePE, Manaus eAM, Brası
´lia e
DF, Porto Alegre eRS and Curitiba ePR).
The development of new studies becomes necessary to
provide more control and supervision of borders due to
exponential increase of foreign travelers to the country.
The actual scenario of Zika Virus outbreak in Brazil and the
detection of its entry route and spread in the country
suggest new measures of public health for travelers espe-
cially by the proximity of Olympic Games that will be host
in Rio de Janeiro in 2016.
Conflict of interest
The authors declare that they have no conflicts of interest.
+MODEL
Please cite this article in press as: Salvador FS, Fujita DM, Entry routes for Zika virus in Brazil after 2014 world cup: New possibilities,
Travel Medicine and Infectious Disease (2015), http://dx.doi.org/10.1016/j.tmaid.2015.10.004
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevierhealth.com/journals/tmid
Travel Medicine and Infectious Disease (2015) xx,1e3
http://dx.doi.org/10.1016/j.tmaid.2015.10.004
1477-8939/ª2015 Elsevier Ltd. All rights reserved.
Table 1 Inbound tourism in Brazil from endemic areas.
AM
2013
AM
2014
BA
2013
BA
2014
CE
2013
CE
2014
DF
2013
DF
2014
MS
2013
MS
2014
MG
2013
MG
2014
PA
2013
PA
2014
PR
2013
PR
2014
PE
2013
PE
2014
RN
2013
RN
2014
RS
2013
RS
2014
RJ
2013
RJ
2014
SC
2013
SC
2014
SP
2013
SP
2014
Africa
a
JAN 3 2 13 13 79 68 17 6 3 1 10 7 3 3 18 30 8 10 0 0 29 13 355 412 5 5 1.227 915
FEB 3 1 24 17 36 42 13 30 2 4 6 7 0 0 28 35 1 6 3 2 9 1 393 556 16 3 1.033 1.173
MAR 1 2 20 12 49 21 39 37 1 0 1 1 0 0 17 30 13 6 1 0 25 2 458 558 14 5 1.247 1.002
APR 1 0 13 42 43 34 47 64 6 1 7 3 0 0 22 29 5 20 0 0 12 4 329 343 3 2 1.292 1.473
MAY 3 1 71 18 93 39 160 24 0 0 10 9 0 0 30 7 29 9 0 0 33 11 298 521 1 0 1.768 1.596
JUN 0 0 15 181 76 102 34 316 0 0 17 2770 0 0 23 62 23 18 1 790 37 0 348 2638 0 0 1.568 7.646
Asia
b
JAN 22 23 14 13 7 6 23 13 14 8 2 6 1 0 236 258 21 6 5 6 35 22 882 1182 20 10 3057 2143
FEB 23 20 29 18 51 5 31 27 4 3 6 10 3 3 876 387 8 14 1 0 6 14 1900 1826 59 9 3836 3222
MAR 39 37 17 33 1 1 24 25 17 7 23 9 8 2 383 686 13 22 3 0 25 22 1720 1998 26 0 4460 2888
APR 94 26 15 15 11 4 26 107 7 3 2 7 2 0 406 442 12 23 1 0 52 12 1784 1653 24 0 4150 4654
MAY 66 30 25 14 5 4 35 71 10 7 21 7 2 4 340 470 20 32 0 0 20 21 1793 2374 35 0 4317 4695
JUN 28 112 13 129 9 29 27 269 1 4 26 80 7 0 257 444 43 54 0 0 35 253 1288 6549 6 1 4175 12,048
Chile
JAN 9 1 18 7 0 0 4 18 37 99 1 2 6 9 3191 4595 3 6 0 0 1756 327 7782 10,952 6132 5486 12,584 8067
FEB 1 0 16 1 3 2 8 6 79 76 3 49 5 3 2618 2890 5 6 0 0 527 245 11,498 13,865 9364 7140 20,384 16,874
MAR 5 1 11 4 6 0 17 14 21 23 4 4 0 0 716 412 15 2 0 0 250 152 9200 4264 98 89 11,849 5938
APR 1 2 4 78 3 0 8 27 9 33 67 5 2 2 493 375 6 0 0 0 1446 333 5485 4723 11 120 8336 8178
MAY 1 2 6 73 3 3 13 11 10 50 3 10 0 0 395 431 10 1 1 0 1572 589 5657 5294 7 7 9202 8289
JUN 1 18 1 1676 1 2 14 133 21 1195 13 547 2 2 469 4622 6 11 0 0 1145 25,628 4451 17,617 6 136 7551 24,599
AFRICA ASIA CHILE BY AIR
AFRICA
BY AIR
ASIA
BY AIR
CHILE
BY SEA
AFRICA
BY SEA
ASIA
BY SEA
CHILE
BY LAND
AFRICA
BY LAND
ASIA
BY LAND
CHILE
BY RIVER
AFRICA
BY RIVER
ASIA
BY RIVER
CHILE
2013 27,957 76,166 268,203 27,341 70,991 236,530 92 845 907 502 4296 30,706 22 34 60
2014 42,131 101,585 336,950 41,613 96,504 278,113 55 212 812 424 4778 57,995 39 91 30
***AM eAmazonas, BA eBahia, CE eCeara
´,DFeDistrito Federal, MS eMato Grosso do Sul, MG eMinas Gerais, PA ePara
´,PReParana
´,PEePernambuco, RN eRio Grande do Norte, RS e
Rio Grande do Sul, RJ eRio de Janeiro, SC eSanta Catarina e SP eSa
˜o Paulo.
a
AFRICA (Not Included: South Africa, Angola, Cabo Verde and Nigeria).
b
ASIA (Not Included: China, Japan, Israel and Korea).
2 Letter to the Editor
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Please cite this article in press as: Salvador FS, Fujita DM, Entry routes for Zika virus in Brazil after 2014 world cup: New possibilities,
Travel Medicine and Infectious Disease (2015), http://dx.doi.org/10.1016/j.tmaid.2015.10.004
Acknowledgments
The authors wish to acknowledge the critical review of
Prof. Heitor Franco de Andrade Jr, besides to the assistance
from Instituto de Medicina Tropical de Sa
˜o Paulo eUSP, LIM
e49/LIM e52 eHCFMUSP and CAPES.
References
[1] Ministe
´rio da Sau
´de, Secretaria de Vigila
ˆncia em Sau
´de. Mon-
itoramento dos casos de dengue e febre de chikungunya ate
´a
Semana Epidemiolo
´gica 30, 2015. Bol Epidemiolo
´gico 2015;
46(24). Avaliable from, http://portalsaude.saude.gov.br/
images/pdf/2015/setembro/03/2015-029-SE-30.pdf.
[2] Dupont-Rouzeyrol M, O’Connor O, Calvez E, Daure
`s M, John M,
Grangeon JP, et al. Co-infection with zika and dengue viruses in
2 patients, New Caledonia, 2014. Emerg Infect Dis 2015 Feb;
21(2):381e2. http://dx.doi.org/10.3201/eid2102.141553.
[3] Zanluca C, de Melo VC, Mosimann AL, dos Santos GI, dos
Santos CN, Luz K. First report of autochthonous transmission of
Zika virus in Brazil. Mem Inst Oswaldo Cruz 2015 Jun;110(4):
569e72. http://dx.doi.org/10.1590/0074-02760150192 [Epub
2015 Jun 9].
[4] PAHO. Epidemiological Alert: zika virus infection. May 7, 2015.
Available from, http://www.paho.org/hq/index.php?option=
com_docman&taskZdoc_download&ItemidZ&gidZ30075&la
ngZpt.
Felipe Scassi Salvador
Dennis Minoru Fujita*
Instituto de Medicina Tropical de Sa
˜o Paulo, USP, Sa
˜o
Paulo, Brazil
*Corresponding author. Av. Dr. Ene
´as Carvalho de Aguiar,
470 e1oandar, CEP: 05403-000, Sa
˜o Paulo, Brazil.
Tel.: þ55 1130617004.
E-mail address: dmfujita@usp.br (D.M. Fujita)
7 October 2015
Figure 1 CDC eCountries that have past or current evidence of Zika virus transmission (as of May 2015) ehttp://www.cdc.gov/
zika/geo/index.html.
Letter to the Editor 3
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Please cite this article in press as: Salvador FS, Fujita DM, Entry routes for Zika virus in Brazil after 2014 world cup: New possibilities,
Travel Medicine and Infectious Disease (2015), http://dx.doi.org/10.1016/j.tmaid.2015.10.004
... 3,4 The risk of importation of ZIKV to Pakistan from viraemic travellers is tangible. 2,5,6 The Aedes mosquitoes are in abundance in Pakistan although no human cases of ZIKV infection have been reported so far. 7 Many repeated outbreaks of Aedes-borne diseases such as Dengue and Chikungunya, however have been reported from Pakista, 8 especially in Punjab, where number of reported dengue cases accounted for 74% of total cases in Pakistan in the period of [2006][2007][2008][2009][2010][2011]7 Punjab is the most populated province with about 40% of population living in urban areas. ...
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In this Health Policy we examine the association between the financing structure of health systems and universal health coverage. Latin American health systems encompass a wide range of financial sources, which translate into different solidarity-based schemes that combine contributory (payroll taxes) and non-contributory (general taxes) sources of financing. To move towards universal health coverage, solidarity-based schemes must heavily rely on countries' capacity to increase public expenditure in health. Improvement of solidarity-based schemes will need the expansion of mandatory universal insurance systems and strengthening of the public sector including increased fiscal expenditure. These actions demand a new model to integrate different sources of health-sector financing, including general tax revenue, social security contributions, and private expenditure. The extent of integration achieved among these sources will be the main determinant of solidarity and universal health coverage. The basic challenges for improvement of universal health coverage are not only to spend more on health, but also to reduce the proportion of out-of-pocket spending, which will need increased fiscal resources.
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Little is known about travel insurance claims made by travelers returning from abroad. This study was designed to investigate travel insurance claims made by travelers from Australia, particularly examining demographic factors, type of travel insurance coverage, nature and duration of travel, when treatment was sought during travel or when the problem arose, use of emergency assistance, nature of claim, and claim outcome, including cost. A random sample of approximately one in five claims reported during the period 1996 to 1998 to a major Australian travel insurance company were examined. A total of 855 claims were examined, of which 42.6% (356/836) were made by male travelers and 57.1% (477/836) were made by female travelers. The majority of claimants were in the 55 years and over age groups (445/836, 53.2%). Medical and dental conditions accounted for 66.6% of claims (569/854), with the remainder associated with loss, theft, and damage (285/854, 33.4%). The most common medical conditions were respiratory (110/539, 20.4%), musculoskeletal (90/539, 16.7%), gastrointestinal (75/539, 13.9%), ear, nose, and throat (67/539, 12.4%), and dental conditions (39/539, 7.2%). Only one case of venous thrombosis was reported, secondary to a lower limb infection. Use of the travel insurance company's emergency telephone service was reported in 17.1% of claims (146/853). Almost two-thirds (559/853, 65.5%) of claims were fully accepted. Those who claimed medical treatment, assault, and theft were significantly more likely to have their claims accepted compared to those claiming dental conditions, cancellation, curtailment, loss and damage (chi2 = 127.78, df = 40, p <.00001). The majority of medical and dental conditions did not require further medical investigations (427/569, 75.0%). The mean cost of claim refunds was Australian dollars (AUD)991.31 (standard deviation [SD] 6 AUD5400.76) for males and AUD508.90 (SD 6 AUD1446.10) for females. Claims for assault, cancellation, and curtailment were significantly more expensive than other types of claims (Kruskal-Wallis one way analysis of variance [ANOVA]; chi2 = 106.87, df = 8, p <.00001). Claims for treatment of gastrointestinal, cerebrovascular, cardiovascular, musculoskeletal conditions, and pyrexias of unknown origin were significantly more expensive than other medical and dental claims (Kruskal-Wallis one way ANOVA; x2 = 61.68, df = 15, p <.00001). This explorative study highlights the importance of travelers taking out appropriate travel insurance. Claims for medical and dental conditions represent the majority of travel insurance claims made by Australian travelers returning from abroad, although travel insurance also covers against such contingencies as loss, theft, and cancellation. The most common medical conditions claimed were respiratory, musculoskeletal, and gastrointestinal disorders. Travelers should be advised to take out appropriate travel insurance before departure overseas and to take care with preexisting medical and dental conditions, which may not be able to be claimed against travel insurance.
Available from: 164 http
  • Allianz Global
Allianz Global Assistance. 2012 Annual Report. 2013. [cited 2013 Dec. 16] Available from: 164 http://www.mondial-assistance.com.br/institucional/images/Annual Report 2012.pdf
Monitoramento dos casos de dengue e febre de chikungunya até a Semana Epidemiológica 30 Avaliable from
  • Ministério Da Saúde
  • Secretaria De Vigilância Em Saúde
Ministério da Saúde, Secretaria de Vigilância em Saúde. Monitoramento dos casos de dengue e febre de chikungunya até a Semana Epidemiológica 30, 2015. Bol Epidemiológico 2015; 46(24). Avaliable from, http://portalsaude.saude.gov.br/ images/pdf/2015/setembro/03/2015-029-SE-30.pdf.
Epidemiological Alert: zika virus infection Available from
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PAHO. Epidemiological Alert: zika virus infection. May 7, 2015. Available from, http://www.paho.org/hq/index.php?option= com_docman&taskZdoc_download&ItemidZ&gidZ30075&la ngZpt.
Secretaria de Vigilância em Saúde. Monitoramento dos casos de dengue e febre de chikungunya até a Semana Epidemiológica 30
  • Saúde Ministério Da
Ministério da Saúde, Secretaria de Vigilância em Saúde. Monitoramento dos casos de dengue e febre de chikungunya até a Semana Epidemiológica 30, 2015. Bol Epidemiológico 2015;
Alert: zika virus infection
  • Paho
PAHO. Epidemiological Alert: zika virus infection. May 7, 2015. Available from, http://www.paho.org/hq/index.php?option= com_docman&taskZdoc_download&ItemidZ&gidZ30075&la ngZpt.