Toxoplasmosis: Outbreak in Santa Maria, RS, Brazil, should be confirmed as the world’s largest

Publicação: 13 de August de 2018

Registry of confirmed cases of the disease in Santa Maria exceeds those occurred in Paraná, in 2002, considered, in figures, the biggest outbreak of toxoplasmosis in the world

Last Update Report of Investigation of an outbreak of Toxoplasmosis points 647 confirmed cases and 515 patients under investigation

A new bulletin  released on August 10 raised the confirmed cases of toxoplasmosis in Santa Maria to 647, but the trend is that this number increases, as there are still 515 in research.

The records entered to date should confirm the city as the largest outbreak of the disease in the world, overtaking Santa Isabel do Ivaí, Paraná, occurred in 2001/2002, which was considered the largest outbreak in the world, having water as the source of contamination. At that time, 600 patients were reported to have symptoms and 450 were diagnosed with acute toxoplasmosis. An article about this epidemic from 2002 was published in the journal Ciência & Saúde Coletiva entitled “Sociopolitical Aspects of the Toxoplasmosis Epidemic in Santa Isabel do Ivaí (PR). Ophthalmologist Cláudio Silveira, who heads the Toxoplasmosis Reference Center in Erechim (RS), confirms that the outbreak of Santa Maria will be confirmed to be the largest in the world. Asked about the delay in discovering the source, the doctor says that it was expected, since it is necessary to perform an assessment of the epidemiological situation, but he admits that the most important thing, in Santa Maria, is to know what contaminated the water. “We still must investigate possible animals near the springs or reservoirs”, he stresses.

Considered one of the foremost experts in toxoplasmosis in the world, Dr. Silveira makes another important alert. “Almost 20% of those infected with toxoplasmosis in Santa Maria may have sight problems.” The infectious disease doctor Lessandra Michelim, from the Brazilian Society of Infectious Diseases (SBI), remembers that toxoplasmosis is extremely common. In the South, it is estimated that six out of ten people have already contracted the disease at some point in life.

Santa Maria can be a national reference in disease treatment protocol

Although outbreaks of toxoplasmosis have been recorded in the last decades throughout Brazil, until now the Country did not have a specific protocol for the treatment of patients with toxoplasmosis. “Currently, the Ministry of health is developing the Clinical Protocol and Therapeutic Guidelines (PCDT) for the disease,” the board affirmed in a notice. The forecast is that it be terminated still in August.

Secretary of Health of Santa Maria, Liliane Mello Duarte, said that the city will not be reference in the treatment, but could become a reference in the creation of protocols. The outbreak registered in the city, made health authorities send numerous demands to the Senate, such as the expansion of the serology test to include testing for Toxoplasmosis and the implementation of a guideline for monthly examination of Toxoplasmosis in prenatal follow-up. “We want the experience from Santa Maria to serve as an encouragement to the country’s entire population, especially to pregnant women,” she said.

From professionals’ research instruments based on Santa Maria’s reality, a local protocol was firmed, and a paradigm shift was consolidated in four fronts:

– The submission of serological examinations for toxoplasmosis (IGG and IGM) in pregnant women will become monthly instead of quarterly;

– Ophthalmologic referral regardless of injury;

– Absolute prevention measures until the identification of the contamination source;

-Recommendation that women with or without the disease to avoid becoming pregnant for the next six months.

However, the effectiveness of actions must come with time. The numbers of cases disclosed through weekly bulletins are still rising, and sequelae of the disease or reinfection cases may arise over the years.

The disease and the vaccine

Toxoplasmosis, a disease that came to light in the recent months as a result of the outbreak in the city of Santa Maria, leaving more than 1,000 people suspected of the disease, is an infection caused by the Protozoan Toxoplasma gondii. These Protozoan lives and reproduces in the body of cats, producing oocysts that are eliminated in their droppings, ready to infect other animals that come into contact with these wastes.

According to Claudio Silveira there are no vaccines for humans, all we have so far are initial studies. The expert is categorical in stating that one cannot expect a vaccine in the short or medium term. “What we have is a prevention of recurrence of ocular toxoplasmosis lesions developed by us, in Erechim in 1998 through a study published in the American Journal of Ophthalmology” he adds. This study was considered by The Cochrane Library, of Sweden, as the most important work on toxoplasmosis treatment in the last 50 years. It is able to create a 75% protection level.

Understand the outbreak investigation and actions so far

The first investigations started in early April, when the infectious diseases doctors in town noticed an increase of patients with common symptoms, such as fever, muscle and joint pain, as well as headaches, what characterized, until then, a feverish syndrome. Since then, a research work was started, between the Municipality and the State, in a first moment. On the day of April 19th, it was confirmed that it was an outbreak of toxoplasmosis. At the time, an active search was made with symptomatic patients and, by then, out of the 59 registered cases, according to analyses of the Central Public Health Laboratory of Rio Grande do Sul (Lacen), 14 were confirmed.

From the observation of the outbreak, a joint work for research between the municipality, the State and the Federal Government begun, in order to find the origin of the contamination. Technicians – from different sectors, such as food, water and environment – from Santa Maria Surveillance Supervision, from the State Health surveillance Center (CEVS) and the Ministry of Health worked at first in the application of a questionnaire with symptomatic patients, besides those who were not confirmed.

The investigations were based on the results obtained by these questionnaires, which were applied by the teams of the State and the municipality, in addition to those carried out by technicians from the training program in Epidemiology Applied to Single System Health Services (EpiSUS). According to this line of investigation, and the way the questionnaires were presented, among other things, information about consumer habits, supervision on supermarkets, food depots, butchers and producers of vegetables was intensified. Meat and fresh produce inspection, surveys on vegetable and irrigation water storage and collection were performed by teams from the municipality’s Food and Water Surveillance in Health ($th CRS) and CEVS.

Water samples from household reservoirs, from hydroponic process and from the Water Treatment Station of Companhia Riograndense de Saneamento (Corsan) were collected and passed through analysis. Products of animal origin and fruits or vegetables were also collected at different points and were analyzed.

Upon completion of the application step of the questionnaires, in field research, the EpiSUS team went on to a second stage, which was the detailed analysis of the information. After crossing data, on June 26th, the Ministry of Health team returned to the municipality, where the analysis performed until then were explained. According to the professionals, the research of the outbreak origin is still in course and there isn’t so far an exact confirmation of the source of contamination. However, the technicians explained that, after a preliminary analysis, there are two possibilities for the origin of the outbreak: water or vegetables.

During the presentation of the possible causes, the National Secretary of health surveillance, Iresh Okumoto, who represented the Ministry of health at the time, pointed out that there was a retrospective study of all information collected in Santa Maria, and besides having considered the cases of Toxoplasmosis outbreak recorded in Brazil and abroad. Still according to him, the data are able to point a direction, but they still cannot give certainty of this possibility of contamination having happened by water or by vegetables.

Since an exact cause has not been found, the prevention recommendations remain put, as only drinking filtered or boiled water and properly cleaning food before consumption. According to Dr. Eunice Chaplin, a retired professor of Protozoology and Bacteriology at the Federal University of Rio Grande do Sul (UFRGS): Rest leaves in 1 liter of water added with 1 tablespoon of baking soda and detergent drops for 15 minutes; remove leaves and put it in one liter of water added with 2 tablespoons of vinegar for 15 minutes; remove the leaves and rinse with cold, previously boiled, water.

Still intending to prevent new toxoplasmosis cases in the municipality, representatives of health organs from Santa Maria, State and Federal Government are working, since July 17th, in assessing the city’s water supply network. Technicians from the National Programme of Drinking Water Quality Surveillance (Vigiagua), from the Ministry of Health, besides professionals from the municipality and the State, perform surveys in different parts of the city, in order to analyze the system. The objective is to find points of possible risk in water sources and in the reservoir network, in addition to always seeking to enhance the water supply service to the population. Corsan also works on tank cleaning (which is done annually). The measure must also be adopted by the community, in water tanks and cisterns.

Tests – To confirm the cases of the disease, initially, all tests were held at the Central Public Health Laboratory of Rio Grande do Sul (Lacen). Furtherly, the State has enabled the accreditation of laboratories in Santa Maria to carry out tests that could make the rebuttal of toxoplasmosis. Sera from patients are tested for antibodies IgM, IgG avidity test and to Toxoplasmosis avidity. Still, other tests were performed, as explained earlier, regarding the investigation of the outbreak, which consisted in the analysis of water, mud and food, in search of the source of infection.

Delays in investigation and information mismatch – Inquired, the Santa Maria Mayor’s Office, by the press board, stressed that according to technical information, in many cities where the outbreak has been reported, the contamination focus was not found, since toxoplasmosis investigations are very complex. Since the main transmission takes place by contaminated water or food and considering the vast water supply network of Santa Maria (29 reservoirs, besides the artesian wells), and most of the food comes from other regions. Regarding the mismatch of information, the city stressed that as soon as the information of an outbreak arrived, the information was passed on to the press, in order to be strengthen, especially, the need to carry out preventive measures.

Neglect or carelessness/water treatment – Inquired, the Sanitation Company of Rio Grande do Sul (Corsan), clarified by notice that the treated water that is distributed to the population of Santa Maria reaches all requirements for drinking water as established by law (Annex XX of the Consolidation Ordinance No. 5/2017 from the Ministry of Health; and Ordinance nº 320/2014 of the State Department of Health), especially regarding its disinfection. In this sense, ensures that your quality is duly attested.

The company stated it adopts, accurately and carefully, established processes and procedures in the treatment of water, which results in an efficient barrier against the various types of water contamination and carrying out various tests and analyses during the treatment process, which, in a simple way, consists in steps of clarification (removal of impurities that give color and turbidity), disinfection (Elimination of pathogenic microorganisms) and of fluoridation (addition of fluorine to prevent tooth decay), through the water treatment plant (WTP) of Santa Maria. At the same time, there is also the systematic analytical control of the achieved results, which are carried out in their own laboratories (in Santa Maria, in ETA, and in Porto Alegre), in order to assess the completeness of the required parameters and acting corrective/preventively for the possible changes that arise in the process.

The note also says that they are permanently monitoring, and extends from fresh water capture, to the process of treatment, and follow up to the distribution network, reaching in the water inlet (measurement framework). In this way, systematically, samples are collected for analysis that includes all the parameters required by national legislation (Ministry of Health) and State (Health Department), both for raw water from the source of supply and treated water. In addition, all results of monitoring conducted by Corsan are constantly available to the regulatory agencies of the city and the State and feed the information system for monitoring the quality of water intended for human consumption (Sisagua), which is an instrument of the National Program of Surveillance of the Quality of Drinking Water (Vigiagua).

Finally, the Company reiterated its quality of water treatment and distribution services to the households, making sure that all care is taken regarding the annual cleaning and conservation of the internal reservoirs of private properties. “Corsan also keeps its position of assistance in studies and evaluations, providing clarifications and participating in actions aimed at elucidating this case of Santa Maria,” the document concludes.

Medications and care – Regarding the inventory and distribution of drugs to patients with toxoplasmosis and assistance to pregnant women and the type of medication, the City Hall reported that the medication is distributed by the 4th Regional Health Coordination ($th CRS), following orders by the Ministry of Health. However, to date, the Ministry of Health has not allocated any medication for the treatment of patients. The supply is being maintained by the city of Santa Maria and by the State Government.

Patients reagent for Toxoplasmosis serology are attended in Casa 13 de Maio. The ambulatory created in the site was restructured and expanded and, thus, all the references of the Basic Attention and the Emergencies and Urgencies will be sent, through the city’s Central of Regulation, to Casa 13 de Maio. On site, two infectious diseases doctors are attending. The attendances of Ophthalmology (since one of the main consequences of the disease are vision problems) are being directed to the ambulatory created at the Hospital Casa de Saúde.

Pregnant women and children are attended at the University Hospital. The pregnant women are referred to HUSM – AGAR – High Risk Pregnancy Outpatient Clinic; while the infants are directed to the HUSM Infectious-Pediatric Outpatient Clinic. For pregnant women, the medication is pyrimethamine + Sulfadiazine + Spiramycin + folinic acid, according to the gestational time at the time of diagnosis.

Check here the answer (in Portuguese) given by the Director of the State Center of Health Surveillance, Marilina Bercini.

To know more about the disease, what the characteristics, diagnosis, symptoms, available treatments, prophylaxis, see the links below:

https://drauziovarella.uol.com.br/doencas-e-sintomas/toxoplasmose-3/

https://www.cdc.gov/dpdx/toxoplasmosis/index.html