Alberto Novaes Ramos

Control of mother-to-child transmission of infectious diseases in Brazil: progress in HIV/AIDS and failure in congenital syphilis

In Brazil, syphilis and HIV infection are considered serious public health problems. However, in practice, epidemiological surveillance, prevention measures, and prenatal care seem to be more effective in the control of mother-to-child transmission of the HIV than in the control of transmission of the Treponema pallidum. Here we discuss the differences in surveillance, prenatal care, and care of the newborn. Important differences were identified. It is concluded that there is an urgent need to establish prevention of mother-to-child transmission of syphilis as a public health priority, using an integrated approach including womens health, childrens health, primary health care, and STD/AIDS programs on all governmental levels. These issues also need to be discussed with all stakeholders involved. Important aspects related to the problem are the training of public health professionals, as well as the participation of the community. The elimination of congenital syphilis does not require expensive drugs, and diagnostic tools, but a long-term sustainable approach.

II Consenso Brasileiro em Doença de Chagas, 2015

Chagas disease is a neglected chronic condition that presents high morbidity and mortality burden, with considerable psychological, social, and economic impact. The disease represents a significant public health issue in Brazil, with different regional patterns. This document presents the evidence that resulted in the Brazilian Consensus on Chagas Disease. The objective was to review and standardize strategies for diagnosis, treatment, prevention, and control of Chagas disease in the country, based on the available scientific evidence. The consensus is based on collaboration and contribution of renowned Brazilian experts with vast knowledge and experience on various aspects of the disease. It is the result of close collaboration between the Brazilian Society of Tropical Medicine and the Ministry of Health. This document shall strengthen the development of integrated control measures against Chagas disease in the country, focusing on epidemiology, management, comprehensive care (including families and communities), communication, information, education, and research.

2 nd Brazilian Consensus on Chagas Disease, 2015

Chagas disease is a neglected chronic condition with a high burden of morbidity and mortality. It has considerable psychological, social, and economic impacts. The disease represents a significant public health issue in Brazil, with different regional patterns. This document presents the evidence that resulted in the Brazilian Consensus on Chagas Disease. The objective was to review and standardize strategies for diagnosis, treatment, prevention, and control of Chagas disease in the country, based on the available scientific evidence. The consensus is based on the articulation and strategic contribution of renowned Brazilian experts with knowledge and experience on various aspects of the disease. It is the result of a close collaboration between the Brazilian Society of Tropical Medicine and the Ministry of Health. It is hoped that this document will strengthen the development of integrated actions against Chagas disease in the country, focusing on epidemiology, management, comprehensive care (including families and communities), communication, information, education, and research .

Prevalence of Chagas disease in Brazil: a systematic review and meta-analysis.

Chagas disease is a major public health problem in Brazil and Latin America. During the last years, it has become an emerging problem in North America and Europe due to increasing international migration. Here we describe the prevalence of Chagas disease in Brazil through a systematic review. We searched national and international electronic databases, grey literature and reference lists of selected articles for population-based studies on Chagas disease prevalence in Brazil, performed from 1980 until September 2012. Forty-two articles with relevant prevalence data were identified from a total of 4985 references. Prevalence ranged from 0% to 25.1%. Most surveys were performed in the Northeast region, especially in the state of Piauí. We observed a high degree of heterogeneity in most pooled estimates (I(2)>75%; p<0.001). The pooled estimate of Chagas disease prevalence across studies for the entire period was 4.2% (95% CI: 3.1-5.7), ranging from 4.4% (95% CI: 2.3-8.3) in the 1980s to 2.4% (95% CI: 1.5-3.8) after 2000. Females (4.2%; 95% CI: 2.6-6.8), >60 year-olds (17.7%; 95% CI: 11.4-26.5), Northeast (5.0%; 95% CI: 3.1-8.1) and Southeast (5.0%; CI: 2.4-9.9) regions and mixed (urban/rural) areas (6.4%; 95% CI: 4.2-9.4) had the highest pooled prevalence. About 4.6 million (95% CI: 2.9-7.2 million) of people are estimated to be infected with Trypanosoma cruzi. The small number of studies and small-scale samples of the general population in some areas limit interpretation, and findings of this review do not necessarily reflect the situation of the entire country. Systematic population-based studies at regional and national level are recommended to provide more accurate estimates and better define the epidemiology and risk areas of Chagas disease in Brazil.

Mortality and case fatality due to visceral leishmaniasis in Brazil: a nationwide analysis of epidemiology, trends and spatial patterns.

Background Visceral leishmaniasis (VL) is a significant public health problem in Brazil and several regions of the world. This study investigated the magnitude, temporal trends and spatial distribution of mortality related to VL in Brazil. Methods We performed a study based on secondary data obtained from the Brazilian Mortality Information System. We included all deaths in Brazil from 2000 to 2011, in which VL was recorded as cause of death. We present epidemiological characteristics, trend analysis of mortality and case fatality rates by joinpoint regression models, and spatial analysis using municipalities as geographical units of analysis. Results In the study period, 12,491,280 deaths were recorded in Brazil. VL was mentioned in 3,322 (0.03%) deaths. Average annual age-adjusted mortality rate was 0.15 deaths per 100,000 inhabitants and case fatality rate 8.1%. Highest mortality rates were observed in males (0.19 deaths/100,000 inhabitants), <1 year-olds (1.03 deaths/100,000 inhabitants) and residents in Northeast region (0.30 deaths/100,000 inhabitants). Highest case fatality rates were observed in males (8.8%), ≥70 year-olds (43.8%) and residents in South region (17.7%). Mortality and case fatality rates showed a significant increase in Brazil over the period, with different patterns between regions: increasing mortality rates in the North (Annual Percent Change – APC: 9.4%; 95% confidence interval – CI: 5.3 to 13.6), and Southeast (APC: 8.1%; 95% CI: 2.6 to 13.9); and increasing case fatality rates in the Northeast (APC: 4.0%; 95% CI: 0.8 to 7.4). Spatial analysis identified a major cluster of high mortality encompassing a wide geographic range in North and Northeast Brazil. Conclusions Despite ongoing control strategies, mortality related to VL in Brazil is increasing. Mortality and case fatality vary considerably between regions, and surveillance and control measures should be prioritized in high-risk clusters. Early diagnosis and treatment are fundamental strategies for reducing case fatality of VL in Brazil.

AIDS by mother-to-child transmission: Survival analysis of cases followed from 1983 to 2002 in different regions of Brazil.

Antiretroviral therapy contributes to decreasing morbidity and mortality, and ultimately to increasing survival. In Brazil, there are regional differences in HIV epidemiology regarding pregnant women and children with HIV/AIDS. This study evaluates survival time after AIDS diagnosis in 914 children infected by mother-to-child transmission, reported between 1983 and 1998 and followed until 2002, in Brazils five regions. Time between birth and HIV diagnosis decreased over the years, mainly in the South and Southeast Regions. There was a significant improvement in survival; more than 75% of cases were still living four years after diagnosis in the 1997-1998 group. This Brazilian study demonstrates that even with regional inequalities in health care infrastructure it is possible for a developing country to establish an effective system of universal and free access to antiretroviral therapy that produces a significant increase in survival for children with AIDS.

Clusters of leprosy transmission and of late diagnosis in a highly endemic area in Brazil: focus on different spatial analysis approaches

Objective  The Brazilian National Hansen’s Disease Control Program recently identified clusters with high disease transmission. Herein, we present different spatial analytical approaches to define highly vulnerable areas in one of these clusters.

[Intestinal parasite infections in a semiarid area of Northeast Brazil: preliminary findings differ from expected prevalence rates].

We report on intestinal parasite infection prevalence in a population sample from Sao Raimundo Nonato, Southeast Piaui State, Brazil, aimed at comparison with previous studies on Trichuris trichiura and Ascaris lumbricoides infection. A total of 265 stool specimens were collected and examined by spontaneous sedimentation. Approximately 57% of specimens were infected with at least one parasite species. Entamoeba coli (35.8%), Endolimax nana (13.6%), Hymenolepis nana (9.4%), and hookworm (9.4%) were the most frequently observed parasites. Two cases of roundworm infection were detected, probably acquired outside the region. T. trichiura eggs were not found. Interestingly, neither A. lumbricoides nor T. trichiura has been found in local prehistoric human coprolites. Nevertheless, hookworm infection has been present in the region for at least 7,000 years.We report on intestinal parasite infection prevalence in a population sample from S o Raimundo Nonato, Southeast Piau State, Brazil, aimed at comparison with previous studies on Trichuris trichiura and Ascaris lumbricoides infection. A total of 265 stool specimens were collected and examined by spontaneous sedimentation. Approximately 57% of specimens were infected with at least one parasite species. Entamoeba coli (35.8%), Endolimax nana (13.6%), Hymenolepis nana (9.4%), and hookworm (9.4%) were the most frequently observed parasites. Two cases of roundworm infection were detected, probably acquired outside the region. T. trichiura eggs were not found. Interestingly, neither A. lumbricoides nor T. trichiura has been found in local prehistoric human coprolites. Nevertheless, hookworm infection has been present in the region for at least 7,000 years.

Eliminating vertical transmission of HIV in Sao Paulo Brazil: progress and challenges.

Background:HIV infection in children is an important public health problem in the world, mainly in poorer countries. If all recommendations are followed, the elimination of HIV vertical transmission is a concrete possibility. This study aims to estimate vertical transmission rates of HIV in São Paulo State, Brazil, based on pregnant women diagnosed and reported in 2006, identifying potentially associated factors. Methods:This study involves a retrospective cross-sectional analysis of information systems and records of infected pregnant women and children exposed to HIV. The rate of vertical transmission was estimated and variables associated with the antenatal, delivery, and postnatal periods were analyzed by the chi-square test, and Fisher exact test was used for variables with an expected frequency <5. The relative risks were calculated with 95% confidence intervals. Results:The rate of vertical transmission in São Paulo state was 2.7% (95% confidence interval: 1.86 to 3.94) in 2006, decreasing 83.1% in comparison with 1988-1993. The main associated variables were lack of prenatal visits or <6 visits, no antiretroviral prophylaxis during labor or neonatal use for <6 weeks, and maternal breastfeeding. Conclusions:There is a decreasing trend of HIV vertical transmission in São Paulo with levels approaching elimination, which seems to be associated with antiretroviral policy and interruption of breastfeeding. Although there are serious operational issues, conditions exist to respond effectively. São Paulo state demonstrates that it is possible to achieve advanced levels of control for this mode of HIV transmission.

Hanseníase no município de Fortaleza, CE, Brasil: aspectos epidemiológicos e operacionais em menores de 15 anos (1995-2006)

This is a sectional study that aims to analyze the occurrence of Hansens disease cases in 15 year-old minors in the Municipality of Fortaleza and notified in SINAN. The epidemiological indicators in this population show hiperendemicity. In operational terms is observed the maintenance of the service concentration in some reference units, in spite of some progress. Late diagnosis, a high degree of incapacity in the diagnosis and low degree of evaluation of contacts registered reveal the fragility of the actions of control. This study emphasizes the possibility of error diagnostic front to the characteristics of the infection in this population. The occurrence of cases of leprosy in this population represents an epidemiologic indicator of great importance and its analysis extends the discussion on operational problems in the network of health services.Estudio transversal con el objetivo de analizar las ocurrencias de los casos de lepra en menores de 15 anos de edad sitiados en la ciudad de Fortaleza y enterados en el SINAN. Los indicadores epidemicos en esta poblacion se presentaron hiperendemicos. En la operacinalizacion, se observa el mantenimiento de la concentracion de atencion en algunas unidades recomendables, a pesar de algunos avances. Diagnosticos muy tardes, gran grado de incapacidad en el diagnostico y bajo grado de evaluacion de contactos registrados, muestran la fragilidad de las acciones de control. Se resalta asi la posibilidad de error de diagnostico delante de las caracteristicas de la infeccion en esta poblacion. La ocurrencia de casos de lepra en esta poblacion representa un indicador epidemico de gran importancia y su analisis amplia la discusion sobre los problemas operacionales en la red de servicios publicos.