Article

Infectious Diseases, Social, Economic and Political Crises, Anthropogenic Disasters and Beyond: Venezuela 2019 – Implications for Public Health and Travel Medicine

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Infectious Diseases, Social, Economic and Political Crises, Anthropogenic Disasters and Beyond: Venezuela 2019 – Implications for Public Health and Travel Medicine

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Abstract

During the last months, there has been a significant increase in the evidence showing the catastrophic health situation in Venezuela. There are multiple epidemics, increase in emerging and reemerging infectious, tropical and parasitic diseases as consequences of the social, economic and political crises, which would be considered today an anthropogenic disaster. Venezuela is facing in 2019, the worse sanitary conditions, with multiple implications for public health and travel medicine. So far, from a global perspective, this situation will be an impediment for the achievement of sustainable development goals (SDG) in 2030. In this multiauthor review, there is a comprehensive analysis of the situation for infectious diseases, non-communicable diseases, their impact in the Americas region, given the migration crisis as well as the relative status of the SDG 2030. This discussion can provide input for prioritizing emerging health problems and establish a future agenda.

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... No one could have ever imagined that such a resource-rich country like Venezuela could fall in such a short time frame into one of the most complex humanitarian crisis ever witnessed in the western hemisphere [1,2]. The unexpected and rapid progress of a combined social, economic and political turmoil has driven one of the wealthiest economies of South America into a humanitarian mayhem, ruled by an unprecedented healthcare crisis and the largest forced exodus ever recorded in Latin American history [3,4]. ...
... In particular, 2019 has observed a more rapid increase in fleeing migrants, posing a significant challenge for bordering countries, such as Colombia [5][6][7], Brazil [8], as well as Guyana and other South American and Caribbean nations [9,10], for which accurate demographic records still remain largely unavailable. As the surge of Venezuelan migrants continues, so does the risk of spillover not only of infectious diseases, but also of non-communicable diseases [1] and the financial burden inflicted to neighboring countries and their economies throughout the region. ...
... Many migrants are pregnant and lactating women who are running away due to limited or no access to nutritional supplements [12], as well as to standard quality pre-and post-natal care. Also, children and adolescents, are particularly vulnerable of being forcibly recruited by paramilitary armed groups or other criminal elements near the border or along the route [1,11] favoring the ongoing epidemic of violence that has swept across border regions of Colombia and Venezuela. ...
Article
No one could have ever imagined that such a resource-rich country like Venezuela could fall in such a short time frame into one of the most complex humanitarian crisis ever witnessed in the western hemisphere [1,2]. The unexpected and rapid progress of a combined social, economic and political turmoil has driven one of the wealthiest economies of South America into a humanitarian mayhem, ruled by an unprecedented healthcare crisis and the largest forced exodus ever recorded in Latin American history [3,4]. As has been extensively reported over the last months, the growing flow of migrants and refugees continues to increase on a daily basis, with an estimated four million displaced Venezuelans over the past two years. In particular, 2019 has observed a more rapid increase in fleeing migrants, posing a significant challenge for bordering countries, such as Colombia [[5], [6], [7]], Brazil [8], as well as Guyana and other South American and Caribbean nations [9,10], for which accurate demographic records still remain largely unavailable. As the surge of Venezuelan migrants continues, so does the risk of spillover not only of infectious diseases, but also of non-communicable diseases [1] and the financial burden inflicted to neighboring countries and their economies throughout the region. As proposed by several international non-government organizations (NGO), there is an urgent and unmet need to complete the implementation of a plan to define priorities and set up a regional response strategy, as recently suggested by the Regional Refugee and Migrant Response Plan for Refugees and Migrants from Venezuela, from the Office of the United Nations High Commissioner for Refugees (UNHCR) and the International Organization for Migration (IOM) [11]. This initiative has clearly identified and outlined four areas of intervention: direct emergency assistance, legal and personal protection, socio-economic and cultural integration, and strengthening the capacity of host governments [11]. Regarding the direct emergency assistance area, overall healthcare issues, food security, and nutrition, as well as emergency shelters and refugee facilities are topics of main concern. Current migrant populations from Venezuela lack appropriate healthcare conditions with severe limitations in accessing medical assistance and essential drugs to treat chronic conditions. This situation places Venezuelan refugees at greater risk of suffering systemic complications or developing more serious medical conditions when arriving to host countries [11]. In addition, the lack of, and the need for, free access to reproductive health, family planning, and mental health services are important areas to consider. Many migrants are pregnant and lactating women who are running away due to limited or no access to nutritional supplements [12], as well as to standard quality pre- and post-natal care. Also, children and adolescents, are particularly vulnerable of being forcibly recruited by paramilitary armed groups or other criminal elements near the border or along the route [1,11] favoring the ongoing epidemic of violence that has swept across border regions of Colombia and Venezuela. Addressing the logistical and economic challenges associated with all the above-mentioned issues is a complex task [13], but at the same time should be a priority in the agenda of all neighboring countries governments, particularly Colombia and Brazil, who currently receive the largest share of Venezuelan migrants. The implementation of such response programs may lead to costs that have been estimated close to the amount of US$ 737,611,378 [11]. To date, agencies such as USAID have already announced (April 10, 2019) the release of humanitarian funding to mitigate the Venezuela migration crisis and its impact in Latin America. However, and despite the approval of US$ $213,304,315 [14], there is still a massive funding gap that remains to be filled. Fears are that as time goes by and the crisis deepens, more resources will be required, and the financial gap will broaden. As already mentioned, border areas are particularly susceptible to spillover and amplification of ongoing epidemics. The Venezuelan exodus has been an example of such phenomena, in a similar fashion to what has happened recently in other conflict-hit areas of the world such as Syria [15]. Today, as has been extensively reported, the Venezuelan border is a hotspot for the increase, transmission and reemergence of multiple infectious diseases, especially vaccine-preventable diseases [3,16], vector-borne diseases [[2], [3], [4],7,[17], [18], [19]], zoonoses [[20], [21], [22]], sexually transmitted infections [2,5,6], respiratory tract infections, water-borne and food-borne diseases (FBD) [1], which have exhibited a consistent ever increasing trend [3]. In the case of Colombia, dengue, mumps, acute flaccid paralysis, FBD, HIV/AIDS, leishmaniasis, tuberculosis, pertussis, varicella, and even bacterial meningitis are clearly on the rise in bordering states such as Norte de Santander [1]. Particularly in these areas, the risk of epidemics with its significant morbidity and mortality toll is a significant cause of concern. An important question with no foreseeable answer at the moment is whether such epidemics will remain confined to the refugee population or will continue to spill over onto other local resident populations. This highlights the need for enhanced surveillance, strategies for improved prevention and control, disposing of accurate disease case definition as well as field sampling and laboratory tests for prompt diagnosis, as well as early individual and collective interventions, including education, drugs, quarantine, and vaccines, among others [11]. Although the World Health Organization (WHO) has acknowledged the usefulness of a robust worldwide surveillance system for infectious diseases, an optimal and well-established geo-referenced dataset is still required in Venezuela in order to reach a better understanding of the epidemiological landscape of infectious diseases in the country, and the possible consequences linked to massive migration [23]. The Venezuelan crisis is unique and should be addressed in its appropriate context. Despite its similarities, by no means should the Venezuelan context be compared to other comparable scenarios like those ongoing in the Middle East and Europe. For example, there is a clear difference between Syrian migrants to European countries [15], where the risk of malaria or arbovirus autochthonous transmission is very low or even null. On the contrary, tropical countries such as Brazil and Colombia are still endemic for malaria and arboviral diseases [24], given their socio-economic, geographic and environmental conditions which favor vectorial transmission (Anopheles and Aedes, mainly). In fact, the Mayaro virus (MAYV) is emerging as a new threat [22,25,26]. In this setting, the arrival of imported cases from Venezuela and the reestablishment of local endemism could severely impact Colombia's administratively fragile public health system [27], posing an additional burden on its budget, and thus, leading to overloaded services and a potential collapse on healthcare across border areas. A similar situation would be seen in the northern areas of Brazil, where social and economic conditions are far from optimal [28]. Furthermore, 19 cases of measles were registered in Ecuador during 2018, and 11 of the cases were Venezuelans; while in Colombia, 26 confirmed cases of measles have been reported, 17 were imported from Venezuela [1,2,8,16]. A high level of suspicion, but more importantly an accurate knowledge about Venezuela's ongoing syndemics [3] and complex epidemiological scenery is crucial when addressing and diagnosing imported infectious diseases cases in neighboring countries. Border ar-eas with Venezuela, are particularly in the ‘Eye of the Storm’ for allowing the entry and spread of infectious diseases, and in which weakened surveillance systems along with delayed reporting can lead to a regional crisis. Moreover, the Venezuelan diaspora has extended beyond its immediate neighbors (Brazil, Colombia), establishing migration routes that include Ecuador, Peru, Chile, Argentina, Uruguay, Paraguay, Panama and the Caribbean amongst others, also posing a risk for the spread of disease to these nations [1]. North America and Europe, despite their robust public health systems as well as their stringent infection control practices for prevention and cross-border risk contention, are also at risk for the introduction of agents with prolonged or insidious incubation periods [29]. Such is the case of Chagas disease, visceral leishmaniasis and other endemic tropical diseases [1,4,16,20,30]. Public health and travel medicine practitioners should be aware of this situation and promote research, diagnosis, and identification of travel routes and health-status profiling of migrants in order to deliver appropriate individual and collective healthcare and attention policies aimed at mitigating the impact of migration to bordering countries [3,4,7,12]. The international community should advocate for the timely installation of a united front based on cooperation between local and global public health organizations as the most effective tool for curtailing the ongoing risk of spillover to the region and beyond. This storm will have a long-lasting impact on the epidemiology of infectious diseases in countries bordering Venezuela and South America.
... Indigenous groups living in these areas are at a higher risk of acquiring this parasitic infection resulting in high rates of disability and premature mortality [2,8,9]. Progressive urbanization of rural communities with increasing populations, expanding deforestation, agriculture, and livestock has led to reduced mammalian biodiversity as a food source for triatomine vectors [3,[17][18][19][20]. Increasing subsistence hunting practices are also leading to substantial loss of biodiversity in these forests [17][18][19][20][21]. ...
... Progressive urbanization of rural communities with increasing populations, expanding deforestation, agriculture, and livestock has led to reduced mammalian biodiversity as a food source for triatomine vectors [3,[17][18][19][20]. Increasing subsistence hunting practices are also leading to substantial loss of biodiversity in these forests [17][18][19][20][21]. In turn, triatomines enter human dwellings attracted by light [4]. ...
... There is a need for increased conservation efforts to reduce deforestation in Latin America [11,40]. This is not an easy task given the prevailing social inequities, collapse of indigenous economies, structural racism, forced displacements of populations, food insecurity, and limited access to education, health, and social services; all factors which predispose unsanitary food practices [17,18,20,21]. ...
Article
Over the past two decades, several countries in Latin American, particularly Brazil, Venezuela, and Colombia, have experienced multiple outbreaks of oral Chagas disease. Transmission occurs secondary to contamination of food or beverages by triatomine (kissing bug) feces containing infective Trypanosoma cruzi metacyclic trypomastigotes. Orally transmitted infections are acute and potentially fatal. Oral Chagas transmission carries important clinical implications from management to public health policies compared to vector-borne transmission. This review aims to discuss the contemporary situation of orally acquired Chagas disease, and its eco-epidemiology, pathogenesis, and clinical management. We also propose preventive public health interventions to reduce the burden of disease and provide important perspectives for travel medicine. Travel health advisors need to counsel intending travellers to South America on avoidance of “deadly feasts” - risky beverages such as fruit juices including guava juice, bacaba, babaçu and palm wine (vino de palma), açai pulp, sugar cane juice and foodstuffs such as wild animal meats that may be contaminated with T. cruzi.
... Esto llevó a que el país dejara de ser líder en el control de las enfermedades transmitidas por vectores para convertirse en la nación con la mayor tasa de morbilidad en la Región de las Américas. 4 Las enfermedades prevenibles mediante vacunación, como el sarampión, la difteria, la parotiditis, la tos ferina y la hepatitis A, muestran un panorama similar, con una alta cobertura de vacunación en Colombia y brotes sostenidos por muchos años en Venezuela en la última década. 5 Asimismo, el riesgo y el surgimiento de casos importados de estas enfermedades en Brasil, Colombia, Ecuador, Panamá y otros países de América Latina y de otras regiones, también aumentaron debido a la migración masiva de venezolanos en la región. ...
... Además, Venezuela sufre de largas y profundas crisis políticas y económicas que han contribuido a reducir la movilidad interna debido a la escasez de combustible y electricidad, así como a un elevado porcentaje de pobreza. 4,7 Las diferencias en los viajes internacionales y en la movilidad de la población posiblemente favorecieron la rápida propagación de la COVID-19 en Colombia y una propagación más lenta en Venezuela. Es importante señalar los beneficios paradójicos de la crisis de las aerolíneas y las dificultades económicas en Venezuela. ...
... Tropical diseases have reemerged in Venezuela as a consequence of an unprecedented humanitarian crisis [1,2], coinciding with a complex growing migration crisis from Venezuela to other Latin American countries. Although malaria, HIV, tuberculosis, and more recently yellow fever [1][2][3][4], have been highlighted through publications, and alerts by PAHO; other infections such as Venezuelan Hemorrhagic Fever (VHF) [5], continue to be overlooked. ...
... Tropical diseases have reemerged in Venezuela as a consequence of an unprecedented humanitarian crisis [1,2], coinciding with a complex growing migration crisis from Venezuela to other Latin American countries. Although malaria, HIV, tuberculosis, and more recently yellow fever [1][2][3][4], have been highlighted through publications, and alerts by PAHO; other infections such as Venezuelan Hemorrhagic Fever (VHF) [5], continue to be overlooked. We discuss the current epidemiological situation of this Mammarenavirus and its potential implications in view of the current migratory situation. ...
Article
Full-text available
Venezuelan Hemorrhagic Fever is an endemic zoonosis exhibiting a high lethality. Discovered decades ago, it is still causing seasonal hemorrhagic fever outbreaks. With the ongoing migration crisis, transmission and spreading to other countries in Latin America, remains a latent threat that should be monitored, particularly in light of recent cases.
... The epidemics beginning in 2017, have included so far, 18,465 cases in the region (10,448 from Brazil, and 6729 from Venezuela, the country of origin of the South American region as demonstrated by phylogenetics of the D8 lineage MVi/HuluLangat.MYS/26.11) [7][8][9][10]. Travelers to Peru during the Pan American Games should be vaccinated against measles (can be recommended for individuals aged 6 months and older) using the mumps, measles and rubella (MMR) vaccine. ...
... With the games, a significant number of travelers to Peru, excluding those born before 1965, will pose a risk for introduction of the virus [5]. Measles outbreaks in the past have demonstrated that unvaccinated persons place themselves and their communities at risk for measles and that high vaccination coverage is essential to prevent the spread of measles during air travel and after importation [5,[7][8][9][10]. ...
Article
The next Pan American Games will be held in Peru in the period July-August 2019. Around 6680 participants from 41 countries are expected to take part in the event. There will be a total of 62 sport disciplines. This event poses specific challenges, given its size and the diversity of attendees. Such gatherings also have potential for the transmission of imported or endemic communicable diseases, including measles in view of the global outbreak situation, but also tropical endemic diseases. In anticipation of increased travel, a panel of experts from the Latin American Society for Travel Medicine (SLAMVI) developed the current recommendations taking into consideration the epidemiology and risks of the main communicable diseases at potential destinations in Peru, recommended immunizations and other preventives measures. These recommendations can be used as a basis for advice for travelers and travel medicine practitioners. Mosquito-borne infections also pose a challenge. Although Lima is malaria free, travelers visiting Peruvian high-risk areas for malaria should be assessed regarding the need for chemoprophylaxis. Advice on the correct timing and use of repellents and other personal protection measures is key to preventing vector-borne infections. Other important recommendations for travelers should focus on preventing water-and food-borne diseases including travelers' diarrhea. This paper addresses pre-travel, preventive strategies to reduce the risk of acquiring communicable diseases during the Pan American Games and also reviews the spectrum of endemic infections in Lima and Peru to facilitate the recognition and management of infectious diseases in travelers returning to their countries of origin.
... O estado de Roraima, por exemplo, cotidianamente é impactado pela migração desenfreada advinda da crise humanitária a qual enfrenta a República Bolivariana da Venezuela. O que se observa é o aumento de migrantes venezuelanos no estado, fato responsável em intensificar as demandas por trabalho, saúde, alimento, moradia e segurança [5][6][7] . ...
Article
Objetivo: Analisar a situação laboral no plano da informalidade vivenciada por migrantes venezuelanos e descrever as mudanças físicas globais ocasionadas pelo processo de trabalho informal autopercebidas em migrantes venezuelanos. Metodologia: Trata-se de um estudo quantitativo, transversal, descritivo e não randomizado, com base em dados primários, coletados por meio de entrevista com entrevistador bilíngue. Resultados: Foram entrevistados 76 migrantes, e os resultados indicaram uma precária situação laboral, onde 58% trabalham de segunda-feira a domingo, deixando evidente a não existência de dias de folga. Quanto ao turno, 49% relataram trabalhar dois turnos diários, enquanto 34% trabalham em turno integral com média de 8,36h de trabalho diário. Observou-se o predomínio das funções laborais no cargo de vendedor ambulante. E entre as alterações físicas autopercebidas 33% relataram apresentar eritema ocular, 4% estão com a audição diminuída, 33% dos participantes alegaram ter sofrido queimadura solar, e 43% mencionaram sentir dores em mais de uma das regiões corporais. Conclusão: Essa pesquisa aponta para a precária condição social, econômica e laboral da população venezuelana na cidade de Boa Vista-RR, com riscos ao agravamento da condição de saúde autodeclarada.
... Multiple social and economic issues are ongoing and will impact the situation, including the massive exodus from Venezuela to many countries in the region. This human migration is associated with other infectious diseases, such as malaria or measles [8]. ...
Article
Over the past weeks the spread of the Coronavirus Disease 2019 (COVID-19), caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) [1], has been steady in Asia and other regions in the world. Latin America was an exception until February 25, 2020, when the Brazilian Ministry of Health, confirmed the first case. This first case was a Brazilian man, 61 years-old, who traveled from February 9 to 20, 2020, to Lombardy, northern Italy, where a significant outbreak is ongoing. He arrived home on February 21, 2020, and was attended at the Hospital Albert Einstein in São Paulo, Brazil. At this institution, an initial real-time RT-PCR was positive for SARS-CoV-2 and then confirmed by the National Reference Laboratory at the Instituto Adolfo Lutz using the real-time RT-PCR protocol developed by the Institute of Virology at Charité in Berlin, Germany [2]. The established protocol also included now, as part of the Sao Paulo State Health Secretary, to include metagenomics and immunohistochemistry with PCR, as part of the response plan to COVID-19 outbreak in the city [3]. The patient presented with fever, dry cough, sore throat, and coryza. So far, as of February 27, the patient is well, with mild signs. He received standard precautionary care, and in the meantime, he is isolated at home [4]. Local health authorities are carrying out the identification and tracing of contacts at home, at the hospital, and on the flight. For now, other cases are under investigation in São Paulo, and other cities in Latin America. In addition to the Sao Paulo State Health Secretary, the Brazilian Society for Infectious Diseases have developed technical recommendations [4].
... such as tuberculosis, HIV, and malaria, are under reasonable control.Malaria, in particular, has significantly decreased during the past decade.3 Conversely, in Venezuela, all of these diseases are rising, especially malaria, which is shifting the country from being the former leader in vector-borne disease control to the nation with the highest morbidity in the Americas.4 Vaccine-preventable illnesses, such as measles, diphtheria, mumps, pertussis, and hepatitis A, show a similar picture, Colombia was a country with high international air traffic.Alternatively in Venezuela, even before the pandemic, there were significant decreases in the number of international flights, as many airlines left the country and discontinued regular flights to the capital Caracas and other cities. not accurate, similar to gaps in data collection of multiple other notifiable communicable diseases that were not publicly available. ...
Article
Full-text available
Over the past two years the world and its different regions, including Latin America, have been suffering from the enormous burden and impact of the COVID-19 pandemic, which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Colombia and Venezuela have been greatly affected.1,2 Despite sharing historical and cultural roots and similarities, each nation has entirely different sanitary conditions, especially regarding infectious, tropical, and reemerging illnesses, including vaccine-preventable diseases. Such differences have increased especially during the last two decades.
... Cette dynamique résultait d'une part de la dispersion des mouffettes juvéniles et de leur rencontre en automne avec les ratons-laveurs (animaux réservoirs de la rage), et d'autre part du début de leur activité de reproduction au printemps (Gremillion- Smith et Woolf 1988 ;Guerra et al. 2003). Au Gabon, la survenue des épidémies du virus Ebola est expliquée par la fin de la saison des pluies et le début de la saison sèche, ce qui coïnciderait avec la fructification des arbres et l'agrégation de différentes espèces de mammifères autour de ces ressources (Pinzon et al. 2004 Ashraf et al. 2017 ;Hassell et al. 2017 ;Suárez et al. 2018 Pour mieux comprendre les systèmes complexes que sont les cycles de transmissions des maladies infectieuses, il est possible de hiérarchiser leur étude en différents niveaux biologiques qui interagissent les uns avec les autres ( Figure 3). ...
Thesis
Les cycles de transmission des maladies zoonotiques et les facteurs qui les influencent sont difficiles à déterminer, particulièrement lorsqu’ils sont dus à des agents pathogènes généralistes dépendant de plusieurs espèces hôtes et vectrices pour être transmis. De plus, perturbations anthropiques et changements climatiques exercent de fortes pressions sur les systèmes hôtes-pathogène-vecteurs pouvant modifier les cycles de transmission. Une approche globale à différentes échelles spatiales est alors nécessaire pour caractériser et quantifier l’importance relative de ses facteurs. Cette approche a été utilisée pour étudier l’écologie du cycle de transmission de la leishmaniose cutanée (LC) en Guyane, une maladie vectorielle sylvatique avec de multiples hôtes et vecteurs. Ce cycle, soumis à des pressions anthropiques grandissantes, a vu sa dynamique se modifier, ce qui a entrainé une augmentation du risque de transmission aux populations humaines. Dans cette thèse, nous avons étudié l’influence des facteurs environnementaux, climatiques et anthropiques, à l’échelle globale du biome amazonien et régionale de la Guyane sur la distribution des cas humains de LC, en utilisant des modèles de niches écologiques. Puis, grâce à l’utilisation du séquençage à haut débit et d’outils probabilistes, nous avons observé la réponse des communautés de vecteurs à une échelle régionale dans des sites forestiers soumis à différents degrés de perturbation. Enfin, nous avons contribué à l’amélioration de la gamme d’outils disponibles pour l’identification des phlébotomes en utilisant le MALDI-TOF MS. Cette thèse a permis d’améliorer les connaissances générales du cycle de la LC en Guyane.
... In the last few years, Venezuela has been the epicentre for multiple concurrent epidemics (syndemics) [1] of emerging and reemerging infectious and tropical diseases. These events have severe implications for public health control efforts in Latin American and other regions due to the latent threat of case importation [1,2]. At the top of the list, the resurgence of vector-borne diseases (VBD) [3,4], such as malaria and dengue pose substantial challenges for the region [5]. ...
... Most of this, not saying probably all, is due to human actions (12)(13)(14). We have the fault. ...
Article
Full-text available
Over the last decades, zoonoses have increased in number and magnitude (1, 2). For a long time, the aetiology of infections transmitted between animals and humans has been diverse, including multiple organisms such as bacteria, viruses, parasites, fungi, and even prions (3-6). The turnover of recent events has led to multiple pathogens jump from animals and humans and cause infection, disease and even death (7, 8). Many of them previously did not affect humans (9). Then, the spillover is a genuine threatening concern that is also associated with emerging epidemics and pandemics, such as those recently affecting globally, as occurred with Swine A H1N1 Influenza in 2009 or the current Coronavirus Disease 2019 (COVID-19), that has led to the most significant social disruption in over the last century, only compared with the 1918 H1N1 Influenza pandemic (5, 10, 11). COVID-19 has affected more than 182 million people globally, causing almost four million deaths (June 30, 2021). Most of this, not saying probably all, is due to human actions (12-14). We have the fault. These events are linked to disordered human development and their consequences, as the anthropogenic impacts on the environment, led to climate change (15). We are responsible for this situation. As it was wisely stated by a fictional character of the Netflix's series Dark (16) the Stranger: "In the end, we will all get just what we deserve", and as another character in that acclaimed series said: "Things only change when we change them. But you have to do it" (Mikkel Nielsen). That means we need to change the course of the events actively. Unbalanced and vulnerable social and environmental issues that are prone, or multiple risk factors, eventually led to emerging and re-emerging zoonoses. As occur with many tropical diseases, and global public health threats, the determinants are especially social and environmental (17-19). Zoonoses are indeed socio-environmental diseases (20). Among zoonoses, many of them, such as Ebola, rabies, multiple viral haemorrhagic fevers, have a high case fatality rate (5, 17-19). How to avoid this in the near future? How to arrest a Dark future? A future where multiple scenarios or realities may become the worst nightmares of microbe hunters, physicians, veterinarians, and other infectious diseases. Maybe is not too late, but education on these topics, substantial investment in research, enhanced human-animal-environment interfaces surveillance with a One Health approach, as well as better diagnostic approaches (multiplex) and therapeutics and vaccines, are urgently needed to avoid a near-apocalyptic future (20-24). "There are moments when we must understand that the decisions we make influence more than just our own fate" (Claudia Tiedemann character)(16). We need to make the right decisions right now, on all levels, locally, nationally, regionally and globally. A multidisciplinary approach must prevail in all the public policies that should address the concerns of zoonotic diseases, known and unknown. There are no reasons to consider that we will not witness more spillovers and new zoonoses in the future. Recently, with alpha and delta coronaviruses, new potential zoonoses, in addition to COVID-19, have been reported from canine and swine species in humans, respectively, in Malaysia and Haiti, in reports published in 2021, but corresponding with samples of patients in 2017-2018 and 2014-2015, respectively. Then, research on coronavirus beyond COVID-19 is needed not only in those countries but globally (25, 26). With COVID-19, not only animal to human transmission occur, but the opposite. Studies have shown that even in Latin America, especially domestic cats may become infected from humans with COVID-19 (27). Human-to-cat transmission of the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) occurred during the COVID-19 pandemic in multiple countries and continents (28, 29). Other domestic animals, such as dogs, are also affected (30, 31). In other settings, such as farms, minks have become among the most frequently infected animals, and the COVID-19 pandemic has led to devastating animal and economic losses, especially in Europe (31). Wildlife, domestic animals and pets are susceptible and suffering from these spillovers from humans to animals during the COVID-19 pandemic (33, 34). At the same time, interactions between pathogens have also led to coinfections, including those with COVID-19, such as dengue and less considered viral pathogens, such as Lassa (35, 36). With viruses previously considered more anthroponotic, such as dengue, growing evidence indicates multiple animals may serve as reservoirs, implying potential zoonotic cycles in some ecological sites (37). "But it ain’t the end of the world" (George Segal and Blu Mankuma song played in the Roland Emmerich’s film 2012, 38), yet, nevertheless we need to work on this in multiple ways and improve our world, reset the suitable balance between human, animal and environmental health, and make the development ecologically-friendly and sustainable as ideally desired.
... Over the last 5 years, Venezuela has become a significant problem in terms of malaria for the regional health authorities. The highest number of cases and the highest incidence rate are now in Venezuela, above Brazil, Mexico, Colombia, and other countries that are reducing and controlling this disease [27,28]. Human immunodeficiency virus (HIV) [29,30], tuberculosis, antimicrobial resistance, and health care-associated infections caused by Candida auris have been other infectious diseases causing concern [31,32], some of them also in relation to the forced migration from Venezuela, but the common and regular problems of the countries in the region. ...
Chapter
Over the year 2020, the Coronavirus Disease 2019 (COVID-19) impact, caused by the Severe Respiratory Syndrome Coronavirus 2, has been highly significant in the world. As expected, resource-constrained areas of the world, as is the case of Latin America, have been more affected given their previous epidemiological context, health care systems, and socioeconomic conditions. In this chapter the main epidemiological features of the COVID-19 during the first year of the pandemic in this region are revised.
... O estado de Roraima, por exemplo, cotidianamente é impactado pela migração desenfreada advinda da crise humanitária a qual enfrenta a República Bolivariana da Venezuela. O que se observa é o aumento de migrantes venezuelanos no estado, fato responsável em intensificar as demandas por trabalho, saúde, alimento, moradia e segurança [5][6][7] . ...
Article
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Objetivo: Analisar a situação laboral no plano da informalidade vivenciada por migrantes venezuelanos e descrever as mudanças físicas globais ocasionadas pelo processo de trabalho informal autopercebidas em migrantes venezuelanos. Metodologia: Trata-se de um estudo quantitativo, transversal, descritivo, não randomizado, com base em dados primários.coletados por meio de entrevista bilíngue. Resultados: Foram entrevistados 76 migrantes, e os resultados indicaram uma precária situação laboral, onde 58% trabalham de segunda-feira a domingo, deixando evidente a não existência de dias de folga. Quanto ao turno, 49% relataram trabalhar dois turnos diários, enquanto 34% trabalham em turno integral com média de 8,36h de trabalho diário. Observou-se o predomínio das funções laborais no cargo de vendedor ambulante. E entre as alterações físicas autopercebidas 33% relataram apresentar eritema ocular, 4% estão com a audição diminuída, 33% dos participantes alegaram ter sofrido queimadura solar, e 43% mencionaram sentir dores em mais de uma das regiões corporais. Conclusão: Essa pesquisa aponta para a precária condição social, econômica e laboral da população venezuelana na cidade de Boa Vista-RR, com riscos ao agravamento da condição de saúde autodeclarada.
... There are some triatomines whose involvement in oral outbreaks is suspected due to sporadic domicile intrusion: Panstrongylus geniculatus, Rhodnius pallescens, R. pictipes, R. colombiensis and R. prolixus in Colombia (Ramírez et al., 2013a;Soto et al., 2014;Hernández et al., 2016a) P. geniculatus in Venezuela (Carrasco et al., 2005) and Triatoma sordida, P. megistus, T. maculata, R. pictipes and T. brasiliensis in Brazil (Shikanai-Yasuda and Carvalho, 2012; Labello- Barbosa et al., 2019). These triatomines can reach human dwellings attracted by artificial light (Coura, 2015) and their domiciliation is attributed to progressive urbanization due to deforestation (habitat loss), extensive agriculture and monocrops that reduce the reservoirs biodiversity forcing the triatomines to move towards dwellings to find food sources thus generating new epidemiological scenarios (Coura and Viñas, 2010;Bonilla-Aldana et al., 2019;Suárez et al., 2018). The majority of oral outbreaks are reported in dry and warm season, because is more likely to find a higher number of triatomines, thus increasing the risk of transmission (Zeledón et al., 2001;Botto-Mahan et al., 2005;Santana et al., 2011;Carrasco et al., 2014;Cantillo-Barraza et al., 2014;Péneau et al., 2016;Di Iorio and Gürtler, 2017). ...
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Chagas disease is a neglected tropical disease transmitted by the protozoan Trypanosoma cruzi that lately has been highlighted because several outbreaks attributed to oral transmission of the parasite have occurred. These outbreaks are characterized by high mortality rates and massive infections that cannot be related to other types of transmission such as the vectorial route. Oral transmission of Chagas disease has been reported in Brazil, Colombia, Venezuela, Bolivia, Ecuador, Argentina and French Guiana, most of them are massive oral outbreaks caused by the ingestion of beverages and food contaminated with triatomine feces or parasites’ reservoirs secretions and considered since 2012 as a foodborne disease. In this review, we present the current status and all available data regarding oral transmission of Chagas disease, highlighting its relevance as a veterinary and medical foodborne zoonosis.
... Multiple social and economic issues are ongoing and will impact the situation, including the massive exodus from Venezuela to many countries in the region. This human migration is associated with other infectious diseases, such as malaria or measles [8]. ...
Preprint
Over the past weeks the spread of the Coronavirus Disease 2019 (COVID-19), caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) [1], has been steady in Asia and other regions in the world. Latin America was an exception until February 25, 2020, when the Brazilian Ministry of Health, confirmed the first case. This first case was a Brazilian man, 61 years-old, who traveled from February 9 to 20, 2020, to Lombardy, northern Italy, where a significant outbreak is ongoing. He arrived home on February 21, 2020, and was attended at the Hospital Albert Einstein in São Paulo, Brazil. At this institution, an initial real-time RT-PCR was positive for SARS-CoV-2 and then confirmed by the National Reference Laboratory at the Instituto Adolfo Lutz using the real-time RT-PCR protocol developed by the Institute of Virology at Charité in Berlin, Germany [2]. The established protocol also included now, as part of the Sao Paulo State Health Secretary, to include metagenomics and immunohistochemistry with PCR, as part of the response plan to COVID-19 outbreak in the city [3]. The patient presented with fever, dry cough, sore throat, and coryza. So far, as of February 27, the patient is well, with mild signs. He received standard precautionary care, and in the meantime, he is isolated at home [4]. Local health authorities are carrying out the identification and tracing of contacts at home, at the hospital, and on the flight. For now, other cases are under investigation in São Paulo, and other cities in Latin America. In addition to the Sao Paulo State Health Secretary, the Brazilian Society for Infectious Diseases have developed technical recommendations [4]. This is the first case of COVID-19 in the South American region with a population of over 640 million people [5] who have also experienced significant outbreaks of infections which were declared Public Health Emergencies of International Concern (PHIC), by the World Health Organization (WHO). So it was with Zika in 2016. The Zika outbreak also began in Brazil [6]. In the current scenario, the spread of COVID-19 to other neighboring countries is expected and is probably inevitable in the light of the arrival of suspected cases from Italy, China, and other significantly affected countries. São Paulo is the most populated city in South America, with more than 23 million people and high flight connectivity in the region (Figure 1). Its main airport, the São Paulo-Guarulhos International Airport, is the largest in Brazil, with non-stop passenger flights scheduled to 103 destinations in 30 countries, and 52 domestic flights, connecting not only with major cities in Latin America but also with direct flights to North America, Europe, Africa and the Middle East (Dubai). There are also buses that offer a service to and from the metropolitan centers of Paraguay, Argentina, Uruguay and Bolivia. Brazil also connects with the countries of Chile, Argentina and Bolivia through some rail connections. The main seaport of Brazil is in Rio de Janeiro, where many international cruises also arrive. Thus, over the course of the next few days, a significant expansion in the region would be possible.
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Malaria has been a major parasitic disease affecting humankind over centuries, with a disproportionate impact among populations, regions of the world and living conditions [1, 2, 3, 4, 5]. Caused by five well-accepted species, Plasmodium falciparum, P. vivax, P. malariae, P. ovale, and P. knowlesi [6] malaria remains a global public health threat due to multiple reasons [7, 8] including biological, social and climatic factors [3, 9, 10, 11, 12, 13] influencing the distribution of Anopheles vectors, especially A. darlingi in the Americas [14, 15]. There is an ongoing debate regarding the potential role of Plasmodium cynomolgi as the sixth etiological species of human malaria [16, 17]. The etiological diagnosis and the epidemiological and clinical management of malaria remains a major challenge in many settings, populations, and during specific clinical scenarios including cases of severe malaria in travelers [18, 19, 20].
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The first case of the new coronavirus (2019 nCoV) or COVID19, was registered in December 2019 in the province of Hubei, China; on March 11, 2020, it was declared by the WHO as a pandemic and until April 22, 2020, approximately 2.5 million cases and more than 180 thousand deaths have been registered in the world (Jhon Hopkins University, 2020). Objective: to describe the COVID19 morbidity and mortality statistics in Venezuela until April 22, 2020. Method: quantitative approach, exploratory type and nonexperimental, documentary and crosssectional design. This descriptive review compiles, analyzes, synthesizes and discusses the published information on the morbidity and mortality casuistry of COVID19 in Venezuela. The information consulted comes from WHO, PAHO, Johns Hopkins University and other official sources. Results and Discussion: In Venezuela, an average of 7.27 cases per day have been registered in 40 days of social isolation, an incidence rate of 1.05 cases / 100,000 inhabitants, with the group of 30 to 39 years being most affected (1, 15 cases / 100,000 inhabitants), 0.04 deaths / 100,000 inhabitants, case fatality rate of 3.4%, 40.9% of recovered, 6.3 PCR tests / 100,000 inhabitants. Conclusions: Low morbidity and mortality rates and very little application of PCR tests were found in Venezuela until April 22, 2020. Recommendations: Carry out studies in all areas regarding COVID19 in Venezuela; increase the number of specific diagnostic tests in real time and with kits approved by international and national entities.
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Revista GICOS, Volumen 5, Número especial 1
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After the first 20 months of the Coronavirus Disease 2019 (COVID-19) pandemic, caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), many lessons have been learnt in Colombia, Latin America and the world from many points of view.1 When the COVID-19 arrived to Colombia,2 and other countries in the region,3 many other infectious diseases concerned affected us, including previous epidemics of chikungunya,4,5 Zika,6,7 and most recently of dengue,8 as well as, the impact of certain vaccine-preventable diseases, such as measles, particularly linked to the forced migration from Venezuela, and the persistent threat of malaria and other vector-borne diseases, HIV and tuberculosis, among many other.9-11 Even more, in Colombia, as well as in other countries of Latin America, a envisioned challenge in pediatrics is to recover the appropriate vaccination coverage for other diseases different to COVID-19, that have decreased during the pandemic.12 Such situation may impose a risk for reemergence of certain vaccine-preventable diseases. During the pandemic, a drop in vaccination coverage was observed in the child population, one of the great challenges in the immediate future is to increase this coverage to avoid the appearance of outbreaks of preventable diseases such as measles, rubella, and chicken pox. Fortunately, as consequence of the public health measures took for COVID-19, a decrease on the incidence of many respiratory tract infections has been observed. Other pathogens that are transmitted by contact and drops, such as respiratory syncytial virus, influenza, adenovirus, pneumococcus, causing acute respiratory infection, have decreased. Then, the challenge is to maintain surveillance and establish prevention strategies for these agents, since it is very likely that they would increase in the post-pandemic era and will put pressure on the health system together with COVID-19.13
Preprint
No one could have ever imagined that such a resource-rich country like Venezuela could fall in such a short time frame into one of the most complex humanitarian crisis ever witnessed in the western hemisphere [1, 2]. The unexpected and rapid progress of a combined social, economic and political turmoil has driven one of the wealthiest economies of South America into a humanitarian mayhem, ruled by an unprecedented healthcare crisis and the largest forced exodus ever recorded in Latin American history [3, 4]. As has been extensively reported over the last months, the growing flow of migrants and refugees continues to increase on a daily basis, with an estimated four million displaced Venezuelans over the past two years. In particular, 2019 has observed a more rapid increase in fleeing migrants, posing a significant challenge for bordering countries, such as Colombia [5-7], Brazil [8], as well as Guyana and other South American and Caribbean nations [9, 10], for which accurate demographic records still remain largely unavailable.
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Background In 2012, the first dengue virus outbreak was reported on the Portuguese island of Madeira with 1080 confirmed cases. Dengue virus of serotype 1 (DENV-1), probably imported from Venezuela, caused this outbreak with autochthonous transmission by invasive Aedes aegypti mosquitoes. Results We investigated the seroprevalence among the population on Madeira Island four years after the outbreak. Study participants (n = 358), representative of the island population regarding their age and gender, were enrolled in 2012 in a cross-sectional study. Dengue antibodies were detected with an in-house enzyme-linked immunosorbent assay (ELISA) using the dimer of domain III (ED3) of the DENV-1 envelope protein as well as commercial Panbio indirect and capture IgG ELISAs. Positive ELISA results were validated with a neutralization test. The overall seroprevalence was found to be 7.8% (28/358) with the in-house ELISA, whereas the commercial DENV indirect ELISA detected IgG antibodies in 8.9% of the individuals (32/358). The results of the foci reduction neutralization test confirmed DENV-1 imported from South America as the causative agent of the 2012 epidemic. Additionally, we found a higher seroprevalence in study participants with an age above 60 years old and probable secondary DENV infected individuals indicating unreported dengue circulation before or after 2012 on Madeira Island. Conclusions This study revealed that the number of infections might have been much higher than estimated from only confirmed cases in 2012/2013. These mainly DENV-1 immune individuals are not protected from a secondary DENV infection and the majority of the population of Madeira Island is still naïve for DENV. Surveillance of mosquitoes and arboviruses should be continued on Madeira Island as well as in other European areas where invasive vector mosquitoes are present.
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Background: Drug resistance is a challenge for the global control of tuberculosis. We examined mortality in patients with tuberculosis from high-burden countries, according to concordance or discordance of results from drug susceptibility testing done locally and in a reference laboratory. Methods: This multicentre cohort study was done in Côte d'Ivoire, Democratic Republic of the Congo, Kenya, Nigeria, South Africa, Peru, and Thailand. We collected Mycobacterium tuberculosis isolates and clinical data from adult patients aged 16 years or older. Patients were stratified by HIV status and tuberculosis drug resistance. Molecular or phenotypic drug susceptibility testing was done locally and at the Swiss National Center for Mycobacteria, Zurich, Switzerland. We examined mortality during treatment according to drug susceptibility test results and treatment adequacy in multivariable logistic regression models adjusting for sex, age, sputum microscopy, and HIV status. Findings: We obtained M tuberculosis isolates from 871 patients diagnosed between 2013 and 2016. After exclusion of 237 patients, 634 patients with tuberculosis were included in this analysis; the median age was 33·2 years (IQR 26·9-42·5), 239 (38%) were women, 272 (43%) were HIV-positive, and 69 (11%) patients died. Based on the reference laboratory drug susceptibility test, 394 (62%) strains were pan-susceptible, 45 (7%) monoresistant, 163 (26%) multidrug-resistant (MDR), and 30 (5%) had pre-extensively or extensively drug resistant (pre-XDR or XDR) tuberculosis. Results of reference and local laboratories were concordant for 513 (81%) of 634 patients and discordant for 121 (19%) of 634. Overall, sensitivity to detect any resistance was 90·8% (95% CI 86·5-94·2) and specificity 84·3% (80·3-87·7). Mortality ranged from 6% (20 of 336) in patients with pan-susceptible tuberculosis treated according to WHO guidelines to 57% (eight of 14) in patients with resistant strains who were under-treated. In logistic regression models, compared with concordant drug susceptibility test results, the adjusted odds ratio of death was 7·33 (95% CI 2·70-19·95) for patients with discordant results potentially leading to under-treatment. Interpretation: Inaccurate drug susceptibility testing by comparison with a reference standard leads to under-treatment of drug-resistant tuberculosis and increased mortality. Rapid molecular drug susceptibility test of first-line and second-line drugs at diagnosis is required to improve outcomes in patients with MDR tuberculosis and pre-XDR or XDR tuberculosis. Funding: National Institutes of Allergy and Infectious Diseases, Swiss National Science Foundation, Swiss National Center for Mycobacteria.
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Venezuela’s tumbling economy and authoritarian rule have precipitated an unprecedented humanitarian crisis. Hyperinflation rates now exceed 45,000%, and Venezuela’s health system is in free fall. The country is experiencing a massive exodus of biomedical scientists and qualified healthcare professionals. Reemergence of arthropod-borne and vaccine-preventable diseases has sparked serious epidemics that also affect neighboring countries. In this article, we discuss the ongoing epidemics of measles and diphtheria in Venezuela and their disproportionate impact on indigenous populations. We also discuss the potential for reemergence of poliomyelitis and conclude that action to halt the spread of vaccine-preventable diseases within Venezuela is a matter of urgency for the country and the region. We further provide specific recommendations for addressing this crisis.
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Mass migration from Venezuela has increased malaria resurgence risk across South America. During 2018, migrants from Venezuela constituted 96% of imported malaria cases along the Ecuador–Peru border. Plasmodium vivax predominated (96%). Autochthonous malaria cases emerged in areas previously malaria-free. Heightened malaria control and a response to this humanitarian crisis are imperative.
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Background: Between the 1950s and 2000, Venezuela showed one of the most substantial improvements in infant mortality rates in Latin America. However, the recent economic crisis alongside an increase in infectious and parasitic diseases might be reversing previous patterns. Because no official updated mortality statistics have been published since 2013, the effect of these recent events has been difficult to assess accurately. We therefore aimed to estimate infant mortality rate trends and report the effect of the crisis. Methods: We estimated infant mortality rates using direct methods (ie, death counts from Venezuelan Ministry of Health via yearbooks and notifiable diseases bulletins, and birth records published by the UN Economic Commission for Latin America and the Caribbean and the Venezuelan National Institute of Statistics) and indirect methods (using census data and a Living Conditions Survey ENCOVI 2016). We shaped yearly estimations using a semiparametric regression model, specifically a P-Spline model with a cubic thin plate base. The primary objective was to estimate infant mortality rate trends from 1985 to 2016. Findings: Around 2009, the long-term decline in infant mortality rate stopped, and a new pattern of increase was observed. The infant mortality rate reached 21·1 deaths per 1000 livebirths (90% CI -17·8 to 24·3) in 2016, almost 1·4 times the rate of 2008 (15·0, -14·0 to 16·1). This increase represents a huge setback on previous achievements in reducing infant mortality. Interpretation: Our conservative estimation indicates that Venezuela is in the throes of a humanitarian crisis. The increase in infant mortality rate in 2016 compared with 2008 takes the country back to the level observed at the end of the 1990s, wiping out 18 years of expected progress, and leaves the Venezuelan Government far from achieving the target of nine deaths per 1000 livebirths stated in the UN Millennium Development Goals. Funding: None.
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Author summary Zika virus (ZIKV) is an emerging flaviviral infection that causes significant clinical disease. It is estimated that approximately one half of the world’s population is at risk for ZIKV infection. There are only a limited number of studies describing the human immune response to ZIKV infection. Carlin et al. combined conventional and genomic approaches to longitudinally analyze the innate and adaptive immune responses to acute ZIKV infection and its resolution in a person who was infected while traveling in Venezuela during the 2016 ZIKV epidemic year. Genome-wide sequencing in individual cell types revealed that although many populations respond to interferon stimulation, only specific cell populations within peripheral blood mononuclear cells upregulate important inflammatory cytokine gene expression. Additionally, analysis of open chromatin using ATAC-seq suggests that chromatin remodeling at sites containing cell-type specific transcription factor binding motifs may help us understand changes in gene expression. Consistent with previous reports, this individual with prior exposure to dengue virus (DENV), rapidly developed neutralizing anti-ZIKV responses that were cross-reactive with multiple DENV serotypes. Collectively this study combines traditional and genomic approaches to characterize the cell-type specific development of an in vivo human immune response to acute ZIKV infection.
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This article seeks to explore the relationship between populism, 21st-century socialism, and the emergence of what has been referred to as an ‘estado delincuente’ (criminal state), in the case of Venezuela. That is, a state structure permeated with transnational organized crime mafias in the executive and the judiciary, in the financial system, the prosecutor’s office, the police, the armed forces, the prison system, state-owned companies, governorships, and city councils, among other state institutions. First, I review conceptual aspects of populism to understand how this served as the basis for creating the postulates of 21st-century socialism, which promoted the institutional destruction of Venezuelan democracy and created the conditions for the unbridled dissemination of state corruption. Second, emblematic cases of white-collar and blood crimes, nepotism and other corrupt activities are discussed to provide an idea of the magnitude of the issues that permeate the state apparatus. To conclude, I provide a critical summary of the consequences of this way of doing politics in contemporary Venezuela.
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The following four key messages derive from the Lancet Countdown’s 2018 report: 1 Present day changes in heat waves, labour capacity, vector-borne disease, and food security provide early warning of the compounded and overwhelming impact on public health that are expected if temperatures continue to rise. Trends in climate change impacts, exposures, and vulnerabilities show an unacceptably high level of risk for the current and future health of populations across the world. 2 A lack of progress in reducing emissions and building adaptive capacity threatens both human lives and the viability of the national health systems they depend on, with the potential to disrupt core public health infrastructure and overwhelm health services. 3 Despite these delays, a number of sectors have seen the beginning of a low-carbon transition, and it is clear that the nature and scale of the response to climate change will be the determining factor in shaping the health of nations for centuries to come. 4 Ensuring a widespread understanding of climate change as a central public health issue will be crucial in delivering an accelerated response, with the health profession beginning to rise to this challenge.
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BACKGROUND The World Health Organization recommends drug-susceptibility testing of Mycobacterium tuberculosis complex for all patients with tuberculosis to guide treatment decisions and improve outcomes. Whether DNA sequencing can be used to accurately predict profiles of susceptibility to first-line antituberculosis drugs has not been clear. METHODS We obtained whole-genome sequences and associated phenotypes of resistance or susceptibility to the first-line antituberculosis drugs isoniazid, rifampin, ethambutol, and pyrazinamide for isolates from 16 countries across six continents. For each isolate, mutations associated with drug resistance and drug susceptibility were identified across nine genes, and individual phenotypes were predicted unless mutations of unknown association were also present. To identify how whole-genome sequencing might direct first-line drug therapy, complete susceptibility profiles were predicted. These profiles were predicted to be susceptible to all four drugs (i.e., pansusceptible) if they were predicted to be susceptible to isoniazid and to the other drugs or if they contained mutations of unknown association in genes that affect susceptibility to the other drugs. We simulated the way in which the negative predictive value changed with the prevalence of drug resistance. RESULTS A total of 10,209 isolates were analyzed. The largest proportion of phenotypes was predicted for rifampin (9660 [95.4%] of 10,130) and the smallest was predicted for ethambutol (8794 [89.8%] of 9794). Resistance to isoniazid, rifampin, ethambutol, and pyrazinamide was correctly predicted with 97.1%, 97.5%, 94.6%, and 91.3% sensitivity, respectively, and susceptibility to these drugs was correctly predicted with 99.0%, 98.8%, 93.6%, and 96.8% specificity. Of the 7516 isolates with complete phenotypic drug-susceptibility profiles, 5865 (78.0%) had complete genotypic predictions, among which 5250 profiles (89.5%) were correctly predicted. Among the 4037 phenotypic profiles that were predicted to be pansusceptible, 3952 (97.9%) were correctly predicted. CONCLUSIONS Genotypic predictions of the susceptibility of M. tuberculosis to first-line drugs were found to be correlated with phenotypic susceptibility to these drugs. (Funded by the Bill and Melinda Gates Foundation and others.)
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Background: Venezuela, the country with the largest oil reserves in the world, is facing the worst economic, social and political crisis in its history; which has notably affected the quality of life of the workforce and the entire population. Objectives: Identify and analyze the main social factors derived from the Venezuelan crisis, which are affecting the workers' health and working conditions. Methods: Document study. Several sources of information from the last twenty years were consulted, ranging from public statistics and reports, newspaper articles, and results of scientific research. The information gathered was carefully studied to ensure that only reliable sources were used to ultimately reach valid conclusions. Results: Both workers from the formal and informal sector and their families are struggling to fulfill their basic needs. Low salaries and soaring inflation have resulted in a dramatic reduction in the purchasing power of the people. General violence and high prices of basic goods are some of the major problems affecting workers both inside and outside of their working environment. Being a formal employee is no longer a guarantee for an acceptable quality of life. As a result, over 1.6 million Venezuelans have left their country since 2015 in a migration crisis never seen before in Latin America. Conclusion: Quality of life and wellbeing of most of the Venezuelan population has being deteriorated in the last 5 years and Occupational Safety and Health (OSH) is not a priority for enterprises in the middle of the economic emergency and general deterioration of daily life.Despite the relevance of this problem, research on the subject is very limited. Recent and pertinent data is needed to properly identify and measure the risks and negative consequences that workers and families are exposed caused by the ongoing crisis.
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Background: The ongoing economic and political crisis in Venezuela has resulted in a collapse of the healthcare system and the re-emergence of previously controlled or eliminated infectious diseases. There has also been an exodus of Venezuelan international migrants in response to the crisis. We sought to describe the infectious disease risks faced by Venezuelan nationals and assess the international mobility patterns of the migrant population. Methods: We synthesized data on recent infectious disease events in Venezuela and among international migrants from Venezuela, as well as on current country of residence among the migrant population. We used passenger-level itinerary data from the International Air Transport Association to evaluate trends in outbound air travel from Venezuela over time. We used two parameter-free mobility models, the radiation and impedance models, to estimate the expected population flows from Venezuelan cities to other major Latin American and Caribbean cities. Results: Outbreaks of measles, diphtheria and malaria have been reported across Venezuela and other diseases, such as HIV and tuberculosis, are resurgent. Changes in migration in response to the crisis are apparent, with an increase in Venezuelan nationals living abroad, despite an overall decline in the number of outbound air passengers. The two models predicted different mobility patterns, but both highlighted the importance of Colombian cities as destinations for migrants and also showed that some migrants are expected to travel large distances. Despite the large distances that migrants may travel internationally, outbreaks associated with Venezuelan migrants have occurred primarily in countries proximate to Venezuela. Conclusions: Understanding where international migrants are relocating is critical, given the association between human mobility and the spread of infectious diseases. In data-limited situations, simple models can be useful for providing insights into population mobility and may help identify areas likely to receive a large number of migrants.
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There have been recent trends of parents in Western countries refusing to vaccinate their children due to numerous reasons and perceived fears. While opposition to vaccines is as old as the vaccines themselves, there has been a recent surge in the opposition to vaccines in general, specifically against the MMR (measles, mumps, and rubella) vaccine, most notably since the rise in prominence of the notorious British ex-physician, Andrew Wakefield, and his works. This has caused multiple measles outbreaks in Western countries where the measles virus was previously considered eliminated. This paper evaluates and reviews the origins of the anti-vaccination movement, the reasons behind the recent strengthening of the movement, role of the internet in the spread of anti-vaccination ideas, and the repercussions in terms of public health and safety.
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Background: In many countries, regular monitoring of the emergence of resistance to anti-tuberculosis drugs is hampered by the limitations of phenotypic testing for drug susceptibility. We therefore evaluated the use of genetic sequencing for surveillance of drug resistance in tuberculosis. Methods: Population-level surveys were done in hospitals and clinics in seven countries (Azerbaijan, Bangladesh, Belarus, Pakistan, Philippines, South Africa, and Ukraine) to evaluate the use of genetic sequencing to estimate the resistance of Mycobacterium tuberculosis isolates to rifampicin, isoniazid, ofloxacin, moxifloxacin, pyrazinamide, kanamycin, amikacin, and capreomycin. For each drug, we assessed the accuracy of genetic sequencing by a comparison of the adjusted prevalence of resistance, measured by genetic sequencing, with the true prevalence of resistance, determined by phenotypic testing. Findings: Isolates were taken from 7094 patients with tuberculosis who were enrolled in the study between November, 2009, and May, 2014. In all tuberculosis cases, the overall pooled sensitivity values for predicting resistance by genetic sequencing were 91% (95% CI 87-94) for rpoB (rifampicin resistance), 86% (74-93) for katG, inhA, and fabG promoter combined (isoniazid resistance), 54% (39-68) for pncA (pyrazinamide resistance), 85% (77-91) for gyrA and gyrB combined (ofloxacin resistance), and 88% (81-92) for gyrA and gyrB combined (moxifloxacin resistance). For nearly all drugs and in most settings, there was a large overlap in the estimated prevalence of drug resistance by genetic sequencing and the estimated prevalence by phenotypic testing. Interpretation: Genetic sequencing can be a valuable tool for surveillance of drug resistance, providing new opportunities to monitor drug resistance in tuberculosis in resource-poor countries. Before its widespread adoption for surveillance purposes, there is a need to standardise DNA extraction methods, recording and reporting nomenclature, and data interpretation. Funding: Bill & Melinda Gates Foundation, United States Agency for International Development, Global Alliance for Tuberculosis Drug Development.
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Introduction Although the current Zika virus (ZIKV) epidemic is a major public health concern, most reports have focused on congenital ZIKV syndrome, its most devastating manifestation. Severe ocular complications associated with ZIKV infections and possible pathogenetic factors are rarely described. Here, we describe three Venezuelan patients who developed severe ocular manifestations following ZIKV infections. We also analyse their serological response to ZIKV and dengue virus (DENV). Case presentation One adult with bilateral optic neuritis, a child of 4 years of age with retrobulbar uveitis and a newborn with bilateral congenital glaucoma had a recent history of an acute exanthematous infection consistent with ZIKV infection. The results of ELISA tests indicated that all patients were seropositive for ZIKV and four DENV serotypes. Conclusion Patients with ZIKV infection can develop severe ocular complications. Anti-DENV antibodies from previous infections could play a role in the pathogenesis of these complications. Well-designed epidemiological studies are urgently needed to measure the risk of ZIKV ocular complications and confirm whether they are associated with the presence of anti-flaviviral antibodies.
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Background: In Colombia, the dengue virus (DENV) has been endemic for decades, and with the recent entry of the chikungunya virus (CHIKV) (2014) and the Zika virus (ZIKV) (2015), health systems are overloaded because the diagnosis of these three diseases is based on clinical symptoms, and the three diseases share a symptomatology of febrile syndrome. Thus, the objective of this study was to use molecular methods to identify their co-circulation as well as the prevalence of co-infections, in a cohort of patients at the Colombian-Venezuelan border. Methods: A total of 157 serum samples from patients with febrile syndrome consistent with DENV were collected after informed consent and processed for the identification of DENV (conventional PCR and real-time PCR), CHIKV (conventional PCR), and ZIKV (real-time PCR). DENV-positive samples were serotyped, and some of those positive for DENV and CHIKV were sequenced. Results: Eighty-two patients were positive for one or more viruses: 33 (21.02%) for DENV, 47 (29.94%) for CHIKV, and 29 (18.47%) for ZIKV. The mean age range of the infected population was statistically higher in the patients infected with ZIKV (29.72 years) than in those infected with DENV or CHIKV (21.09 years). Both co-circulation and co-infection of these three viruses was found. The prevalence of DENV/CHIKV, DENV/ZIKV, and CHIKV/ZIKV co-infection was 7.64%, 6.37%, and 5.10%, with attack rates of 14.90, 12.42, and 9.93 cases per 100,000 inhabitants, respectively. Furthermore, three patients were found to be co-infected with all three viruses (prevalence of 1.91%), with an attack rate of 4.96 cases per 100,000 inhabitants. Conclusion: Our results demonstrate the simultaneous co-circulation of DENV, CHIKV, ZIKV and their co-infections at the Colombian-Venezuelan border. Moreover, it is necessary to improve the differential diagnosis in patients with acute febrile syndrome and to study the possible consequences of this epidemiological overview of the clinical outcomes of these diseases in endemic regions.
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Background Community integration in dengue control requires assessments of knowledge, attitudes and practices (KAPs), which can vary widely according to demographic and educational factors. We aimed to describe and compare the KAPs according to level of education in municipalities in the Caribbean region of Colombia. Methods A survey was administered from October to December 2015, including families selected through probabilistic sampling in eleven municipalities. The analysis focused on the comparative description of the responses according to level of education. The KAP prevalence ratios (PR) according to education were estimated using Poisson regression (robust), including age and sex as adjustment variables. Results Out of 1057 participants, 1054 (99.7%) surveys were available for analysis, including 614 (58.3%) who had a high school level of education or higher and 440 (41.7%) who had a lower level of education (not high school graduates). The high school graduates showed a higher frequency of correct answers in relation to knowledge about dengue symptoms and transmission. On the other hand, graduates showed a higher probability of practices and attitudes that favor dengue control, including not storing water in containers (PR: 2.2; 95% Confidence Interval [CI]: 1.42–3.43), attend community meetings (PR: 1.33; 95% CI: 1.07–1.65), educate family members and neighbors in prevention measures (PR: 1.35; 95% CI: 1.15–1.59). Conclusions Level of education could be a key determinant of knowledge of the disease and its transmission, as well as attitudes and practices, especially those that involve the integration of community efforts for dengue control.
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Zika virus (ZIKV) is an emerging viral pathogen that continues to spread throughout different regions of the world. Herein we report a case that provides further evidence that ZIKV transmission can occur through breastfeeding by providing a detailed clinical, genomic, and virological case-based description. Keywords. Zika virus; Venezuela; asymptomatic; breast milk; breastfeeding transmission. Zika virus (ZIKV) continues to spread throughout tropical and subtropical regions of the world [1]. Transmission of ZIKV can occur through mosquito vectors, sexual contact, blood transfusion , or accidental laboratory exposure [2]. There is evidence that postnatal transmission between mother and child can occur during breastfeeding, delivery, or close contact between the mother and her newborn [1-7]. We present additional evidence supporting transmission of ZIKV through breastfeeding. In March 2016, a 32-year-old female patient from Barquisimeto, Venezuela presented with a 1-day history of malaise, arthralgia, conjunctival hyperemia, and pru-ritic maculopapular rash (Figure 1). At that time, she was exclusively breastfeeding her 5-month-old child, who was asymptomatic. Breast milk, plasma, and urine were collected from the mother 4 days later, as were plasma and urine from the child, who was asymptomatic. Specimens were collected, analyzed, and cryopreserved for shipment and virus isolation as detailed in the Supplementary Data. For virus detection and isolation, Vero E6 and LLC-MK2 cells were inoculated with aliquots of the mother's milk (whole, lipid, and aqueous fractions) and urine and child's plasma and urine specimens. Cytopathic effects (CPE) characteristic of ZIKV infection [8] (perinuclear vacuoles prior to cell death: Supplementary Figure 1) were observed 9 and 12 days postinoculation of the mother's and child's specimens, respectively. Virus-induced CPE were initially most plentiful and detected first in cells inoculated with the lipid fraction of breast milk. The cultures were screened for chikungunya virus (CHIKV), dengue viruses (DENVs) 1, 2, 3, and 4, and ZIKV genomic RNA by reverse-transcription polymerase chain reaction (RT-PCR). All cultures were negative for CHIKV and DENV1-4. The presence of ZIKV genomic RNA (vRNA) was confirmed in all cultures by RT-PCR. The mother's urine was positive for ZIKV vRNA by real-time RT-PCR (cycle threshold [Ct], 26.73; level of detection, Ct 36.8). The child's plasma and urine were positive for ZIKV by real-time RT-PCR, with Ct 35.57 and 35.36. Serologic analysis was performed using the Zika Virus ViraStripe IgG/IgM Test Kit (Viramed Planegg, Germany) revealing that the mother had immunoglobulin M (IgM) and borderline immunoglobulin G (IgG) antibodies against ZIKV, and no detectable antibodies against CHIKV. She also exhibited IgG against DENV, but no IgM against DENV. The mother was negative for parvovirus, cytomegalovirus, Epstein-Barr virus, varicella zoster virus, and herpes simplex virus types 1 and 2. ZIKV genomes were sequenced by extracting vRNA from viri-ons in the spent media of LLC-MK2 cells 14 days postinocu-lation with mother's milk (lipid-enriched fraction) and child's urine, and sequenced as described previously [8] and in the Supplementary Data. In the mother, arthralgias and malaise lasted 10 days, with the rash and conjunctival hyperemia resolving 4 days after the onset of symptoms. The child remained asymptomatic throughout the observation period. Full-genome sequencing of ZIKV isolated from breast milk and the child's urine (GenBank accession numbers KX702400 and KX893855) revealed 99% identity, with only 2 synonymous nucleotide substitutions at third codon positions between the 2 strains [9]. Both genomes were different from the genomic sequences of other ZIKV strains in the laboratory. Moreover, sequencing of the NS5 gene of the other isolates indicated that identical virus was in all specimens from both mother and child. Mock-infected cells did B R I E F R E P O R T
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