Fellowship Site: Salvador, Brazil

The sites in Salvador are centers for tropical disease research in Brazil that have 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 Oswaldo Cruz Foundation/Brazilian Ministry of Health (Fiocruz) and the School of Medicine at the Federal University of Bahía (UFBa). 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).

Weill Medical College of Cornell University, under the direction of Warren Johnson, Jr. (domestic PI), has had an on-going training program with Fiocruz and UFBa 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 Fogarty 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, a clinical investigator based at Weill Cornell in New York, has helped the recent Fogarty 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 Fogarty 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 40 years;
• the School of Medicine at UFBa, the first medical school founded in Brazil, and its network of teaching hospitals;
• the complementary and synergistic interaction between the Brazilian Ministry of Health (Fiocruz) and the federal university system (UFBa) which has created a critical mass of expertise and laboratory infrastructure for public health and biomedical research in Salvador; and,
• the history of Brazilian and NIH-supported research projects at the site which currently includes the Centers of Excellence in Research program (Brazilian National Research Council), TMRC program (NIAID), a longstanding four-time ICIDR program, two R01 projects (NIAID), and two International Training and Research in Emerging Infectious Diseases (ITREID) programs of Cornell, Berkeley and U.Va.

The NIH-funded clinical research includes the following projects:

1. Emerging Infectious Diseases and Urbanization
2. Lab-based Field Epidemiology Training in Emerging Infectious Diseases
3. Pathogenesis of Leishmaniasis: Host, Parasite and Vector
4. Natural History of Urban Leptospirosis
5. Immunological Response and Disease Expression in HTLV-1
6. Transmission of drug-resistant Streptococcus pneumoniae in Brazil
7. Rapid serodiagnostic test for leptospirosis

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. 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. The Oswaldo Cruz Foundation is a 30-minute ride from the apartment by local bus. The School of Medicine, Federal University of Bahía is a 20-minute walk from the apartment. The approximate cost for room and board is $350/month.

Immunizations Needed for this Site:
See the U.S. Centers for Disease Control Web site and The Yellow Book: Health Information for international Travel.

The NIH/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 immunizations).

Safety and Danger Issues:
See the U.S. State Department Web site for information.

Language Requirements Other Than English:
A working knowledge of Portuguese is useful but not essential for most clinical research activities. 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.