Fellowship Site: Brazil

The site in Salvador is a center for tropical disease research in Brazil that has made major contributions to the understanding of the natural history of endemic diseases such as leishmaniasis, leptospirosis, schistosomiasis and Chagas' disease. The principal research institutions are the the School of Medicine at the Federal University of Bahía (UFBa) and the Oswaldo Cruz Foundation/Brazilian Ministry of Health (Fiocruz). Both institutions share graduate programs in medical sciences, immunology and experimental pathology and have had a long-term research partnership such as the current NIAID sponsored Tropical Medicine Research Center (TMRC).

FICRS Scholars are encouraged to participate in seminars and journal clubs and to avail themselves of opportunities to learn about endemic tropical diseases at the university hospital and field sites as time permits. Scholars typically have ample opportunity to participate in inpatient rounds, immunology, medicine and disease-specific grand rounds, as well as outpatient clinics for rheumatic heart disease, Chagas' disease, HTLV-1 and leprosy, among other illnesses. They are also encouraged to participate in clinical and teaching activities at the city's infectious disease hospital, Couto Maia. Scholars typically have the opportunities to present their data at national and international conferences throughout the year and to engage in dialogue regarding other ongoing projects in the laboratories.

Weill Cornell Medical College, under the direction of Warren Johnson, Jr., M.D., has had an ongoing training program with UFBa and Fiocruz since 1964. This has provided long-term research and clinical opportunities to more than 150 U.S. medical students, residents and fellows.

Field and hospital-based opportunities in Salvador include work with Dr. Edgar Carvalho's group on ongoing studies of the immunopathogenesis, clinical manifestations, and management of American tegumentary leishmaniasis. The leishmania projects are based at a field site located in the village of Corte de Pedra, an endemic area 280 kilometers from Salvador. Other ongoing projects in Dr. Carvalho's group at UFBa relate to the clinical manifestations and immunopathogenesis of HTLV-I infection. Recent FICRS Scholars have conducted clinical epidemiological investigations of early cutaneous leishmaniasis and the effect of helminthic co-infection on the response of cutaneous leishmaniasis to standard treatment. The latter project led to a randomized clinical trial of immediate versus deferred treatment of helminthes in patients with cutaneous leishmaniasis. Dr. Carvalho also supervises an HTLV-1 Clinic that follows more than 500 HTLV-1 infected individuals. Epidemiologic, immunologic and clinical studies have been conducted with the aim of correlating immunologic responses with disease expression in HTLV-1 infection and to describe the natural history of HTLV-1 infection in Brazil. Dr. Marshall Glesby (domestic PI), a clinical investigator based at Weill Cornell in New York, has helped the recent FICRS Scholars with the design and analysis of these projects.

At Fiocruz, Dr. Albert Ko's group offers training opportunities on infectious diseases that have emerged due to rapid urbanization and urban poverty. Ongoing projects focus on applying translational research approaches to identify public health interventions in urban slum or favela settings. These studies include cohort investigations on the natural history of urban leptospirosis and pneumococcal disease, the development of rapid diagnostic tests and vaccines for leptospirosis, and the application of molecular epidemiology to study the transmission of bacterial meningitis and acute respiratory infections. The primary field site is a favela community within Salvador where a large cohort has been established to study urban infectious diseases. A recent FICRS Scholar conducted an epidemiological study of hypertension in this setting. Furthermore, clinical and research training is offered at the state infectious disease hospital where population-based surveillance for endemic infectious diseases is being conducted.

The major strengths of the Salvador site for training U.S. students are:

• the longstanding collaboration between the U.S. and Brazilian institutions aimed at training and research in tropical diseases;
• the spectrum of clinical and field opportunities for training which include natural history studies on disease transmission, outbreak investigations and clinical trials;
• established community-based field sites for the study of tegumentary leishmaniasis, leptospirosis, acute respiratory infections, and HTLV-I infection; several of these field sites in Salvador have been the home of ongoing research for more than 30 years;
• the School of Medicine at UFBa, the first medical school founded in Brazil in 1829, and its network of teaching hospitals;
• the complementary and synergistic interaction between the the federal university system (UFBa) and the Brazilian Ministry of Health (Fiocruz), which has created a critical mass of expertise and laboratory infrastructure for public health and biomedical research in Salvador; and,
• the long history of NIH and Brazilian-supported research projects at the site, which currently includes the Tropical Medicine Research Center program (NIAID), two active and one pending R01-funded projects (NIAID, FIC), a recently completed and a pending R03-funded project (NIAID). Research capacity at the site has been strengthened by Fogarty training grants: Tropical Infectious Diseases Training Grant [PI: Edgar Carvalho] and Emerging Infectious Diseases and Urbanization [PI: Albert Ko]). Notably, the site has been the recipient of continuous NIH funding since 1979;

The NIH-funded clinical research includes the following projects:

1. Pathogenesis of Leishmaniasis: Host, Parasite and Vector
2. Natural History of Urban Leptospirosis
3. Immunological Response, Viral Factors and Helminth Infections in Disease Expression of HTLV-1
4. Transmission of drug-resistant Streptococcus pneumoniae in Brazil
5. The Polymorphism and Biology of Leishmania braziliensis Infection

Additional projects funded by the Brazilian National Research Council include:

1. Use of Miltefosine in Tegumentary Leishmaniasis
2. Immunologic Response and Tissue Damage in L. braziliensis Infection
3. Influence of HTLV-1 in the Immune Response and Clinical Course of Tuberculosis
4. Immunological Response and Pathology in HTLV-1 Infection

Possible additional research: Pulmonary
Additional research conducted at the site may include the following project:

Title: Severe Pulmonary Haemorrhage Syndrome Associated with Leptospirosis

Description of the problem:
Hemorrhagic fever is an important pulmonary disease in regions where leptospirosis, melioidosis, dengue and hantavirus are endemic. This disease is associated with high case fatality (>50%) and impart the highest burden among neglected populations within developing countries. Leptospirosis, a spirochaetal zoonotic disease, has become an urban health problem as slum settlements have grown worldwide. In this setting, leptospirosis-associated severe pulmonary hemorrhage syndrome (SPHS) has replaced Weil's disease, the classic severe clinical form, as the cause of death due to leptospirosis. In Salvador, Brazil, active surveillance has identified a significant increase in cases since 2003. Despite ICU monitoring and aggressive supportive care for pulmonary bleeding and acute lung injury, case fatality among SPHS patients is >70%. The reasons for the sudden emergence of SPHS in slum communities remain not well understood.

On-going research and training opportunities:
As part of its response to this public health problem, the Salvador site has focused on
1) Developing and validating predictive scores which would enable early detection and triage of SPHS patients during hospitalization
2) Implementing case-control studies in slum communities to identify risk factors for acquiring SPHS
3) Conducting translational research studies which use molecular typing and virulence assays in experimental animal models to evaluate whether a virulent clone of Leptospira was responsible for the emergence of SPHS.

Housing Availability:
The Brazil program, through Cornell, has a furnished three-bedroom apartment to house visiting medical students and scientists engaged in research projects at the site. High speed internet access, a wireless network, and housekeeping services are provided. The apartment is used to house medical and graduate students from the U.S. and from other regions of Brazil. U.S. students benefit from this interaction since Brazilian students are colleagues in the same research projects and aid U.S. students in learning Portuguese and integrating into the laboratory and field teams as well as study site communities. Scholars may travel readily by bus or taxi to the UFBa (10 min) and Fiocruz (20 min). In addition, the Scholar has the option to walk to UFBa (30 min). The approximate cost for room and board is 400 US$ /month (R$650/month) which is low rent for the neighborhood where it is situated. Scholars are welcome to arrange alternate housing if they desire and will be provided with assistance in securing such housing. They are able to stay at the Cornell apartment until they find other housing. A private furnished 1 room apartment is generally 800-1000 US$ per month. Food costs are similar to those in the US, approximately 200 US$/month. Daily bus fare is 3 US$, and a cab ride to the hospital is 8 US$.

Health Issues and Immunizations Needed for this Site:
All Scholars are encouraged to complete hepatitis A and B, yellow fever, typhoid, and quadrivalent meningococcal vaccinations before arrival. Wise food, water, and personal choices avoid most health issues in Salvador, and bottled or filtered water is readily available. Use of insect repellent is also recommended as dengue is prevalent in the region. No long-term prophylaxis (e.g. for malaria) is necessary for Salvador.

There are many high quality private sector hospitals located in the city that provide equivalent medical care to U.S. health care institutions. Both UFBa and Fiocruz provide standard post-exposure prophylaxis for accidents that may occur during clinical and research-related activities, such as needle-stick injuries or contact with pathogens, such as Leptospira (doxycycline prophylaxis) and Neisseria meningitidis (rifampin prophylaxis).

See the Centers for Disease Control and Prevention Web site and The Yellow Book: CDC Health Information for International Travel for additional information.

The FICRS program mandates that all Scholars see a physician prior to their assignment abroad. The site will require a formal letter from your physician stating that you have received the necessary immunizations prior to the start of your fellowship (yellow fever vaccine, quadrivalent meningococcal capsular vaccine, and typhoid and hepatitis A & B immunizations).

Safety and Danger Issues:
Like most large cities, crime, including violent crime, is an issue in Salvador. Fellows are given extensive advice in how to minimize the risk of being a crime victim. Although it is very unlikely that scholars would need to be evacuated from Brazil due to civil strife, any such evacuation would be coordinated with the U.S. embassy/consulate and administrative staff at Cornell. Weill Cornell Medical College subscribes to International SOS, a 24/7 medical, security, and travel assistance program that will be made available to ICRS Scholars at no cost.

See the U.S. State Department Web site for additional information.

Language Requirements Other Than English:
Some fluency in Portuguese is necessary for most daily and clinical activities at this site. All scholars are offered 1-2 weeks of intensive language training on arrival and find this to be sufficient when accompanied by continued personal study.. An intensive 1-2 month language program can be arranged, which should facilitate both the personal and professional experience of the Scholar.

What is it like to live in Brazil?
In the view of the program staff, the city of Salvador, Bahía, is arguably the most beautiful city in Brazil and the "heart and soul" of the country.