ABSTRACT Background: The school community was heavily impacted by the Covid-19 pandemic, especially with the long time of school closures. This study aimed to analyze the seroprevalence of SARS-CoV-2 antibodies and possible factors associated with seropositivity for COVID-19 in teachers and other school staff, and to estimate the fraction of asymptomatic individuals by sex and age group. Methods: We conducted a serological survey of SARS-CoV-2 infections. An analytical cross-sectional study was conducted in Fortaleza, Brazil. Teachers and other staff members from pre-schools to universities of higher education to were investigated. Results: A total of 1,901 professionals participated in the study, of which 1,021 were staff and 880 were teachers. The seroprevalence of SARS-CoV-2 was 8.0% (152/1901). In the seropositive group, 48.3% were asymptomatic. There was a predominance of women (68.4%); and, 47.1% of the participants were between 31 and 45 years old. There was an increase in prevalence with increasing age. An inverse relationship was found for education level: more professionals with less education tested positive for COVID-19. The presence of an infected person living in the same household was significantly associated with positive results for COVID-19 among the professionals. Conclusions: This is the first study to report the seroprevalence of IgG against SARS-CoV-2 in Brazilian educational staff after the first wave of the disease. In this study, the seroprevalence was much lower than that in the general population. During school reopening, a small fraction of school workers showed serologically detectable signs of SARS-CoV-2 exposure.

Abstract INTRODUCTION Chikungunya causes fever and severe and persistent joint pain. METHODS We reported a chikungunya outbreak that occurred in Ceará State, Brazil between 2016 and 2017 with emphasis on epidemiological characterization of cases, high number of deaths, mortality-associated factors, and spatial and temporal spread of the epidemic among municipalities. RESULTS: In November 2015, the first autochthonous cases of chikungunya were confirmed in Ceará, Brazil. In 2016-2017, 195,993 cases were reported, with an incidence of 2,186.5/100,000 inhabitants and 244 confirmed deaths. CONCLUSIONS: Rapid transmission and high mortality rate are serious problems, especially in regions with co-circulating arboviruses.

Resumo Objetivo: descrever a experiência e os resultados preliminares do Comitê de Investigação de Óbitos por Arboviroses no Ceará, Brasil, em 2017. Métodos: o Comitê investiga e discute todos os casos suspeitos de óbitos por arboviroses notificados pela vigilância epidemiológica. Resultados: foram notificados 443 óbitos suspeitos de arboviroses e 220 (49,7%) foram confirmados; destes, 88,2% por chikungunya e 11,8% por dengue; a mediana de idade dos óbitos por chikungunya foi mais elevada, quando comparada à da dengue (77 versus 56 anos), e o tempo de evolução até o óbito também foi mais prolongado, quando comparado ao da dengue (38 versus 12 dias); para o encerramento dos casos, a mediana foi de 54,5 dias; em 2017, o Ceará confirmou 80,4% dos óbitos por chikungunya no Brasil. Conclusão: a análise dos óbitos mostrou que o CHIKV foi o responsável pela maior parte dos óbitos por arboviroses no estado do Ceará, em 2017.

Abstract Objective: to describe the experience and preliminary results of the Arbovirus Death Investigation Committee in Ceará, Brazil, in 2017. Methods: the Committee investigates and discusses all suspected cases of arbovirus deaths reported by the epidemiological surveillance service. Results: a total of 443 suspected arbovirus deaths were reported, 220 (49.7%) of which were confirmed; of these, 88.2% were from chikungunya and 11.8% from dengue; the median age of chikungunya deaths was higher when compared to dengue (77 versus 56 years) and the time until death was also longer when compared to dengue (38 versus 12 days); median time for case closure was 54.5 days; in 2017, Ceará confirmed 80.4% of Brazilian chikungunya deaths. Conclusion: the investigation of deaths showed that CHIK viruses were responsible for the majority of arboviral deaths in the state of Ceará, in 2017.

Resumen Objetivo: describir la experiencia y los resultados preliminares del Comité de Investigación de Óbitos por Arbovirus desarrollada en Ceará, Brasil, en 2017. Métodos: el comité discute los casos sospechosos de muertes por arbovirus notificados por la vigilancia epidemiológica. Resultados: se notificaron 443 óbitos sospechosos y 220 (49,7%) fueron confirmados; de estos, 88,2% por chikungunya y 11,8% por dengue; el promedio de edad de los fallecimientos por chikungunya fue más elevado (77 versus 56 años) y el tiempo de evolución hasta el óbito más prolongado, en comparación con el dengue (38 versus 12 días); para el cierre de los casos el promedio fue de 54,5 días; en 2017, Ceará confirmó 80,4% de las muertes por chikungunya en Brasil. Conclusión: El análisis de muertes mostró que CHIKV fue responsable de la mayoría de las muertes por arbovirus en el estado de Ceará, en 2017.

Resumo Objetivo: descrever a experiência e os resultados preliminares do Comitê de Investigação de Óbitos por Arboviroses no Ceará, Brasil, em 2017. Métodos: o Comitê investiga e discute todos os casos suspeitos de óbitos por arboviroses notificados pela vigilância epidemiológica. Resultados: foram notificados 443 óbitos suspeitos de arboviroses e 220 (49,7%) foram confirmados; destes, 88,2% por chikungunya e 11,8% por dengue; a mediana de idade dos óbitos por chikungunya foi mais elevada, quando comparada à da dengue (77 versus 56 anos), e o tempo de evolução até o óbito também foi mais prolongado, quando comparado ao da dengue (38 versus 12 dias); para o encerramento dos casos, a mediana foi de 54,5 dias; em 2017, o Ceará confirmou 80,4% dos óbitos por chikungunya no Brasil. Conclusão: a análise dos óbitos mostrou que o CHIKV foi o responsável pela maior parte dos óbitos por arboviroses no estado do Ceará, em 2017.

Abstract Objective: to describe the experience and preliminary results of the Arbovirus Death Investigation Committee in Ceará, Brazil, in 2017. Methods: the Committee investigates and discusses all suspected cases of arbovirus deaths reported by the epidemiological surveillance service. Results: a total of 443 suspected arbovirus deaths were reported, 220 (49.7%) of which were confirmed; of these, 88.2% were from chikungunya and 11.8% from dengue; the median age of chikungunya deaths was higher when compared to dengue (77 versus 56 years) and the time until death was also longer when compared to dengue (38 versus 12 days); median time for case closure was 54.5 days; in 2017, Ceará confirmed 80.4% of Brazilian chikungunya deaths. Conclusion: the investigation of deaths showed that CHIK viruses were responsible for the majority of arboviral deaths in the state of Ceará, in 2017.

Resumen Objetivo: describir la experiencia y los resultados preliminares del Comité de Investigación de Óbitos por Arbovirus desarrollada en Ceará, Brasil, en 2017. Métodos: el comité discute los casos sospechosos de muertes por arbovirus notificados por la vigilancia epidemiológica. Resultados: se notificaron 443 óbitos sospechosos y 220 (49,7%) fueron confirmados; de estos, 88,2% por chikungunya y 11,8% por dengue; el promedio de edad de los fallecimientos por chikungunya fue más elevado (77 versus 56 años) y el tiempo de evolución hasta el óbito más prolongado, en comparación con el dengue (38 versus 12 días); para el cierre de los casos el promedio fue de 54,5 días; en 2017, Ceará confirmó 80,4% de las muertes por chikungunya en Brasil. Conclusión: El análisis de muertes mostró que CHIKV fue responsable de la mayoría de las muertes por arbovirus en el estado de Ceará, en 2017.

Resumo Objetivo: descrever os aspectos entomológicos e epidemiológicos das epidemias de dengue ocorridas em Fortaleza, Ceará, Brasil, de 2001 a 2012. Métodos: estudo descritivo com dados dos Sistemas de Informação de Agravos de Notificação (Sinan), de Informações Hospitalares (SIH), do Programa de Febre Amarela e Dengue (2001-2009), do Programa Nacional de Controle da Dengue (2010-2012) e Levantamento Rápido do Índice de Infestação de Aedes aegypti, referentes aos anos quando a incidência da doença superou o percentil 75%. Resultados: De 2001 a 2012 foram notificados 194.446 casos suspeitos de dengue. Os anos epidêmicos foram: 2001, 2006, 2008, 2011 e 2012. Houve aumento progressivo da incidência (587,0/100 mil hab. [2001] e 1.561,1/100 mil hab [2012]), com cocirculação de até três sorotipos e elevada infestação vetorial, principalmente em depósitos para armazenar água. Conclusão: após longo período de circulação do vírus em Fortaleza, a dengue permanece como importante problema de saúde, com casos graves e alta letalidade.

Abstract Objective: to characterize the entomological and epidemiological aspects of dengue epidemics occurred in Fortaleza, Ceará, Brazil, from 2001 to 2012. Methods: descriptive study with data from the Information System for Notifiable Diseases (Sinan), Information System of Hospitalizations due to Yellow Fever and Dengue (2001-2009), National Program for Dengue Control (2010-2012), and Rapid Survey of Aedes aegypti Infestation Index, referring to the years in which the incidence of dengue was above 75%. Results: from 2001 to 2012, 194,446 cases of suspected dengue were notified; the epidemic years were 2001, 2006, 2008, 2011 and 2012; there was a progressive increase in the incidence of the disease (587.0/100 thousand inhabitants in 2001 and 1,561.1/100 inhabitants in 2012); there was co-circulation of up to three serotypes and high vector infestation, especially in water tanks. Conclusion: after a long period of virus circulation in Fortaleza, dengue remains as an important health issue, with severe cases and high fatality rate.

Resumen Objetivo: caracterizar los aspectos entomoepidemiológicos de epidemias de dengue ocurridas en Fortaleza, Ceará, Brasil, entre 2001 y 2012. Métodos: estudio descriptivo con datos del Sistema de Información de Agravios de Notificación (Sinan), de Hospitalizaciones, del Sistema de Información de Fiebre Amarilla y Dengue (2001-2009), SisPNCD (2010-2012) y del Levantamiento Rápido del Índice de Infestación de Aedes aegypti, referentes a los años cuando la incidencia de dengue fue superior al percentil 75%. Resultados: en 2001-2012, se notificaron 194.446 casos sospechosos de dengue; los años epidémicos fueron 2001, 2006, 2008, 2011 y 2012; hubo un aumento progresivo de incidencia de dengue (587,0/100 mil hab. en 2001 y 1.561,1/100 hab. en 2012), con co-circulación de hasta tres serotipos y elevada infestación vectorial, principalmente en depósitos utilizados para almacenar agua. Conclusión: tras un largo período de circulación del virus en Fortaleza, el dengue permanece como un importante problema de salud, con casos más graves y alta letalidad.

Resumo Objetivo: descrever os aspectos entomológicos e epidemiológicos das epidemias de dengue ocorridas em Fortaleza, Ceará, Brasil, de 2001 a 2012. Métodos: estudo descritivo com dados dos Sistemas de Informação de Agravos de Notificação (Sinan), de Informações Hospitalares (SIH), do Programa de Febre Amarela e Dengue (2001-2009), do Programa Nacional de Controle da Dengue (2010-2012) e Levantamento Rápido do Índice de Infestação de Aedes aegypti, referentes aos anos quando a incidência da doença superou o percentil 75%. Resultados: De 2001 a 2012 foram notificados 194.446 casos suspeitos de dengue. Os anos epidêmicos foram: 2001, 2006, 2008, 2011 e 2012. Houve aumento progressivo da incidência (587,0/100 mil hab. [2001] e 1.561,1/100 mil hab [2012]), com cocirculação de até três sorotipos e elevada infestação vetorial, principalmente em depósitos para armazenar água. Conclusão: após longo período de circulação do vírus em Fortaleza, a dengue permanece como importante problema de saúde, com casos graves e alta letalidade.

Abstract Objective: to characterize the entomological and epidemiological aspects of dengue epidemics occurred in Fortaleza, Ceará, Brazil, from 2001 to 2012. Methods: descriptive study with data from the Information System for Notifiable Diseases (Sinan), Information System of Hospitalizations due to Yellow Fever and Dengue (2001-2009), National Program for Dengue Control (2010-2012), and Rapid Survey of Aedes aegypti Infestation Index, referring to the years in which the incidence of dengue was above 75%. Results: from 2001 to 2012, 194,446 cases of suspected dengue were notified; the epidemic years were 2001, 2006, 2008, 2011 and 2012; there was a progressive increase in the incidence of the disease (587.0/100 thousand inhabitants in 2001 and 1,561.1/100 inhabitants in 2012); there was co-circulation of up to three serotypes and high vector infestation, especially in water tanks. Conclusion: after a long period of virus circulation in Fortaleza, dengue remains as an important health issue, with severe cases and high fatality rate.

Resumen Objetivo: caracterizar los aspectos entomoepidemiológicos de epidemias de dengue ocurridas en Fortaleza, Ceará, Brasil, entre 2001 y 2012. Métodos: estudio descriptivo con datos del Sistema de Información de Agravios de Notificación (Sinan), de Hospitalizaciones, del Sistema de Información de Fiebre Amarilla y Dengue (2001-2009), SisPNCD (2010-2012) y del Levantamiento Rápido del Índice de Infestación de Aedes aegypti, referentes a los años cuando la incidencia de dengue fue superior al percentil 75%. Resultados: en 2001-2012, se notificaron 194.446 casos sospechosos de dengue; los años epidémicos fueron 2001, 2006, 2008, 2011 y 2012; hubo un aumento progresivo de incidencia de dengue (587,0/100 mil hab. en 2001 y 1.561,1/100 hab. en 2012), con co-circulación de hasta tres serotipos y elevada infestación vectorial, principalmente en depósitos utilizados para almacenar agua. Conclusión: tras un largo período de circulación del virus en Fortaleza, el dengue permanece como un importante problema de salud, con casos más graves y alta letalidad.

BACKGROUND The first dengue cases in Brazil with laboratory confirmation occurred in the northern region of the country, with the isolation of two serotypes, dengue virus 1 (DENV-1) and DENV-4. In Ceará, the introduction of DENV-4 was reported during a DENV-1 epidemic in 2011, with only two isolations. OBJECTIVES The aim of this study was to characterise the first DENV-4 epidemic in the state of Ceará, Brazil. METHODS The study population was composed of patients with suspected dengue that were reported to health care units from January to December 2012. The laboratory confirmation of infection was made by viral isolation, reverse transcription polymerase chain reaction (RT-PCR), AgNS1, immunohistochemistry and IgM enzyme-linked immunosorbent assay (ELISA). MAIN CONCLUSIONS In the study year, 72,211 suspected dengue cases were reported and 51,865 of these cases (71.8%) were confirmed to be positive. Co-circulation of three serotypes, DENV-1, DENV-3 and DENV-4, was detected with a predominance of DENV-4 (95.3%). Most cases were not severe, but there were 44 fatal outcomes. DENV-4 Genotype II was identified for the first time in Ceará.

Abstract We report on four patients with fatal influenza A(H1N1)pdm09 and dengue virus coinfections. Clinical, necropsy and histopathologic findings presented in all cases were characteristic of influenza-dengue coinfections, and all were laboratory-confirmed for both infections. The possibility of influenza and dengue coinfection should be considered in locations where these two viruses’ epidemic periods coincide to avoid fatal outcomes. Dengue is a mosquito-borne viral infection caused by one of the four dengue viruses (DENV-1 to 4). Each of these viruses is capable of causing nonspecific febrile illnesses, classic dengue fever and dengue haemorrhagic fever (Gubler 1998). As a result, dengue is often difficult to diagnose clinically, especially because peak dengue season often coincides with that of other common febrile illnesses in tropical regions (Chacon et al. 2015). In April 2009, a new virus, influenza A/H1N1/pandemic (FluA/H1N1/09pdm), caused a severe outbreak in Mexico. The virus quickly spread throughout the world, and in June 2009, the World Health Organization declared a pandemic (WHO 2010). In Brazil, the first laboratory confirmed case of FluA/H1N1/09pdm was in July 2009 (Pires Neto et al. 2013). The state of Ceará, in Northeast Brazil, is a dengue endemic area. In this state, the virus influenza A(H1N1)pdm09 has circulated since 2009, and through the first half of 2012, 11 deaths caused by the virus were confirmed (Pires Neto et al. 2013). The influenza and dengue seasons in Ceará overlap, which led to diagnostic difficulties. We report four cases of laboratory-confirmed coinfection of deadly influenza A(H1N1)pdm09 with DENV, which occurred during the dengue and influenza season in 2012 and 2013 in Ceará.

Abstract: INTRODUCTION: The dengue classification proposed by the World Health Organization (WHO) in 2009 is considered more sensitive than the classification proposed by the WHO in 1997. However, no study has assessed the ability of the WHO 2009 classification to identify dengue deaths among autopsied individuals suspected of having dengue. In the present study, we evaluated the ability of the WHO 2009 classification to identify dengue deaths among autopsied individuals suspected of having dengue in Northeast Brazil, where the disease is endemic. METHODS: This retrospective study included 121 autopsied individuals suspected of having dengue in Northeast Brazil during the epidemics of 2011 and 2012. All the autopsied individuals included in this study were confirmed to have dengue based on the findings of laboratory examinations. RESULTS: The median age of the autopsied individuals was 34 years (range, 1 month to 93 years), and 54.5% of the individuals were males. According to the WHO 1997 classification, 9.1% (11/121) of the cases were classified as dengue hemorrhagic fever (DHF) and 3.3% (4/121) as dengue shock syndrome. The remaining 87.6% (106/121) of the cases were classified as dengue with complications. According to the 2009 classification, 100% (121/121) of the cases were classified as severe dengue. The absence of plasma leakage (58.5%) and platelet counts <100,000/mm3 (47.2%) were the most frequent reasons for the inability to classify cases as DHF. CONCLUSIONS: The WHO 2009 classification is more sensitive than the WHO 1997 classification for identifying dengue deaths among autopsied individuals suspected of having dengue.

Estudo de caso fatal de coinfecção de melioidose e dengue grave em um motorista de 28 anos, residente no município de Pacoti, nordeste do Brasil. O paciente apresentou inicialmente sintomas respiratórios com evolução por 48 dias. Foi internado em três diferentes unidades de saúde com suspeitas de pneumonia, leishmaniose visceral, tuberculose e sepse fúngica. Após o óbito, a cultura de líquido ascítico identificou a bactéria Burkholderia pseudomallei. O vírus da dengue tipo 1 foi detectado por PCR no líquor do paciente. Esta descrição reforça a necessidade de considerar a melioidose entre os diagnósticos diferenciais de infecções comunitárias onde as duas doenças são endêmicas.

This report focuses on a fatality involving severe dengue fever and melioidosis in a 28-year-old truck driver residing in Pacoti in northeastern Brazil. He exhibited long-term respiratory symptoms (48 days) and went through a wide-ranging clinical investigation at three hospitals, after initial clinical diagnoses of pneumonia, visceral leishmaniasis, tuberculosis, and fungal sepsis. After death, Burkholderia pseudomallei was isolated in a culture of ascitic fluid. Dengue virus type 1 was detected by polymerase chain reaction in cerebrospinal fluid (CSF); this infection was the cause of death. This description reinforces the need to consider melioidosis among the reported differential diagnoses of community-acquired infections where both melioidosis and dengue fever are endemic.

Dengue outbreaks have occurred in several regions in Brazil and cocirculating dengue virus type 1 (DENV-1), DENV-2, and DENV-3 have been frequently observed. Dual infection by DENV-2 and DENV-3 was identified by type-specific indirect immunofluorescence assay and confirmed by reverse transcription polymerase chain reaction in a patient in Ceará with a mild disease. This is the first documented case of simultaneous infection with DENV-2 and DENV-3 in Brazil. Sequencing confirmed DENV-2 and DENV-3 (South-East/American) genotype III and (SriLanka/India), genotype III respectively.