Acesso e direito à saúde para migrantes bolivianos em uma metrópole brasileira / Access and right to health for Bolivian migrants in a Brazilian metropolis

Resumo Este artigo analisa as condições de acesso do imigrante boliviano ao sistema de saúde brasileiro e a percepção do direito à saúde. É um estudo transversal de metodologia quantitativa e qualitativa, realizado de 2013 a 2015. Foi elaborado um questionário com perguntas fechadas respondidas por 633 bolivianos, e em relação ao acesso à saúde por 472 indivíduos bolivianos maiores de 18 anos. A abordagem qualitativa foi feita por meio da análise de conteúdo de entrevistas semiestruturadas com 55 sujeitos (bolivianos, profissionais de saúde, representantes de Secretarias de Saúde, Consulado da Bolívia, Defensoria Pública da União, Ministério Público Federal e Organizações Não Governamentais). Os bolivianos conhecem o Sistema Único de Saúde (SUS) e utilizam com frequência a Atenção Primária à Saúde (APS). Todavia, barreiras de acesso são descritas, como falta de documentação, condições de trabalho, procedimentos de média e/ou alta complexidades, dificuldades para entenderem o que é dito assim como para serem compreendidos, entre outras. Sobressai-se a obtenção do Cartão Nacional de Saúde (CNS) como porta de entrada para o acesso à saúde, desempenhando papel de integração social. O reconhecimento da Saúde como direito social destaca-se entre os entrevistados, apontado como valor humano e solidário. A garantia desse reconhecimento fica ameaçada quando não se apoia na consolidação de políticas sociais que visem o fortalecimento da proteção social universal.

Abstract This paper analyzes the health care accessibility conditions afforded to Bolivian immigrants in the Brazilian health system and their perception of the right to health. This was a cross-sectional, quantitative and qualitative study carried out from 2013 to 2015. Data were collected by a questionnaire with closed questions answered by 633 Bolivian individuals; questions regarding access to health were answered by 472 immigrants over 18 years old. Semi-structured interviews conducted with 55 subjects (Bolivians, health professionals, representatives of Health Departments, Consulate of Bolivia, Public Defender's Office, Federal Public Prosecutor's Office and Non-Governmental Organizations) underwent content analysis. Most Bolivian immigrants know the Brazilian National Health System (SUS) and often use Primary Health Care; however, they described structural and systemic barriers to health accessibility, such as lack of documentation, working conditions, medium and high complexity procedures, language barriers, among others. The National Health Card (CNS) is an important gateway to access health care, playing a role of social integration. Interviewees recognize health as a social right, pointing it out as a human and solidary value. Ensuring this recognition, when not based on the consolidation of social policies aimed at strengthening universal social protection, is threatened.

Awareness of Chagas disease and socioeconomic characteristics of Bolivian immigrants living in Sao Paulo, Brazil.

In this study which is part of a research project on Chagas disease (CD) among Bolivian immigrants in Sao Paulo, we describe socioeconomic characteristics, knowledge of CD and implications for acess to health care. We applied a structured questionnaire to a sample of 472 Bolivian adults (> 18 years) living in Sao Paulo and enrolled at the Barra Funda School Health Center. Participants' median age was 28.5 years, 75.0% were from the Bolivian department of La Paz, and >90% worked in the garment industry. Respondents had lived in Sao Paulo for a median of 5.8 years. Only 169 (35.8%) were familiar with CD, while roughly half (50.4%) had lived in natural materials houses in Bolivia, 225 (47.7%) indicated familiarity with the vector, 23.9% had seen the vector in their homes in Bolivia, and 6.4% reported having been bitten by a triatomine bug. Factors associated with awareness of CD were analyzed by chi square tests, and those with p values <0.25 were included in a multivariable logistic regression model. In the multivariable logistic regression analysis, having a relative with CD (OR=4.3, 95% CI=1.5-12.0), having lived in a house with mud or wood walls (OR=0.4, 95% CI=0.2-0.8), and having heard of the triatomine bug, or vinchuca, (OR=10.0, 95% CI=5.1-19.5) were significantly associated with awareness of CD. This study shows a low familiarity with CD among Bolivian migrants living in Sao Paulo, Brazil. Raising awareness of the disease through specific communication strategies should be an essential component of public health programs to reduce the burden of CD in this and other vulnerable populations.

Interdisciplinary approach at the primary healthcare level for Bolivian immigrants with Chagas disease in the city of São Paulo.

BACKGROUND/METHODS: In a pioneering cross-sectional study among Bolivian immigrants in the city of São Paulo, Brazil, the epidemiological profile, clinical manifestations and morbidity of Chagas disease were described. The feasibility of the management of Chagas disease at primary healthcare clinics using a biomedical and psychosocial interdisciplinary approach was also tested. Previously, a Trypanosoma cruzi (T. cruzi) infection rate of 4.4% among 633 immigrants was reported. The samples were screened using two commercial enzyme-linked immunoassay (ELISA) tests generated with epimastigote antigens, and those with discrepant or seropositive results were analyzed by confirmatory tests: indirect immunofluorescence (IFI), TESA-blot and a commercial recombinant ELISA. PCR and blood cultures were performed in seropositive patients. RESULTS: The majority of the 28 seropositive patients were women, of whom 88.89% were of child-bearing age. The predominant clinical forms of Chagas disease were the indeterminate and atypical cardiac forms. Less than 50% received the recommended antiparasitic treatment of benznidazole. An interdisciplinary team was centered on primary healthcare physicians who applied guidelines for the management of patients. Infectologists, cardiologists, pediatricians and other specialists acted as reference professionals. Confirmatory serology and molecular biology tests, as well as echocardiography, Holter and other tests, were performed for the assessment of affected organs in secondary healthcare centers. The published high performance of two commercial ELISA tests was not confirmed. CONCLUSION: An interdisciplinary approach including antiparasitic treatment is feasible at the primary healthcare level for the management of Chagas disease in Bolivian immigrants. The itinerant feature of immigration was associated with a lack of adherence to antiparasitic treatment and was considered a main challenge for the clinical management of this population. This approach is recommended for management of the infected population in endemic and nonendemic areas, although different strategies are needed depending on the severity of the disease and the structure of the healthcare system.

Impact of insecticide resistance on the field control of Aedes aegypti in the State of São Paulo.

INTRODUCTION: The need to control dengue transmission by means of insecticides has led to the development of resistance to most of the products used worldwide against mosquitoes. In the State of São Paulo, the Superintendência de Controle de Endemias (SUCEN) has annually monitored the susceptibility of Aedes aegypti to insecticides since 1996; since 1999, surveys were conducted in collaboration with the National Network of Laboratories (MoReNAa Network) and were coordinated by the Ministry of Health. In this study, in addition to the biological characterization of insecticide resistance in the laboratory, the impact of resistance on field control was evaluated for vector populations that showed resistance in laboratory assays. METHODS: Field efficacy tests with larvicides and adulticides were performed over a 13-year period, using World Health Organization protocols. RESULTS: Data from the field tests showed a reduction in the residual effect of temephos on populations with a resistance ratio of 3. For adults, field control was less effective in populations characterized as resistant in laboratory qualitative assays, and this was confirmed using qualitative assays and field evaluation. CONCLUSIONS: Our results indicated that management of resistance development needs to be adopted when insect populations show reduced susceptibility. The use of insecticides is a self-limiting tool that needs to be applied cautiously, and dengue control requires more sustainable strategies.

Impact of insecticide resistance on the field control of Aedes aegypti in the State of São Paulo

Introduction The need to control dengue transmission by means of insecticides has led to the development of resistance to most of the products used worldwide against mosquitoes. In the State of São Paulo, the Superintendência de Controle de Endemias (SUCEN) has annually monitored the susceptibility of Aedes aegypti to insecticides since 1996; since 1999, surveys were conducted in collaboration with the National Network of Laboratories (MoReNAa Network) and were coordinated by the Ministry of Health. In this study, in addition to the biological characterization of insecticide resistance in the laboratory, the impact of resistance on field control was evaluated for vector populations that showed resistance in laboratory assays. Methods Field efficacy tests with larvicides and adulticides were performed over a 13-year period, using World Health Organization protocols. Results Data from the field tests showed a reduction in the residual effect of temephos on populations with a resistance ratio of 3. For adults, field control was less effective in populations characterized as resistant in laboratory qualitative assays, and this was confirmed using qualitative assays and field evaluation. Conclusions Our results indicated that management of resistance development needs to be adopted when insect populations show reduced susceptibility. The use of insecticides is a self-limiting tool that needs to be applied cautiously, and dengue control requires more sustainable strategies. .

Colonization of palm trees by Rhodnius neglectus and household and invasion in an urban area, Araçatuba, São Paulo State, Brazil.

The objective of this study is to report on the colonization of palm trees by Rhodnius neglectus, its invasion in an urban area, in Araçatuba - São Paulo, and the control and surveillance measures that have been put in place. Domiciliary triatomine searches occurred in apartments upon the inhabitants' notification. The collected insects were identified and examined for natural infection and food sources with a precipitin test. To search the palm trees, tarps were used to cover the floor, and a "Munck" truck equipped with a tree-pruning device was utilized. Chemical control was performed with the utilization of a manual compression. In 2009, 81 specimens of Rhodnius neglectus were collected from the domiciles by the population. The precipitin test revealed a presence of human blood in 2.7% of the samples. Entomological studies were carried out in these domiciles and in those located within a radius of 200 meters. The search performed in the palm trees resulted in the capture of 882 specimens of triatomines, negative for tripanosomatids. Mechanical and chemical controls were carried out. New searches conducted in the palm trees in the same year resulted in the capture of six specimens. The mechanical and chemical controls of the palm trees, together with the population's work, proved to be effective, therefore preventing these insects' colonization of the city's domiciles.

COLONIZATION OF PALM TREES BY Rhodnius neglectus AND HOUSEHOLD AND INVASION IN AN URBAN AREA, ARAÇATUBA, SÃO PAULO STATE, BRAZIL / Colonização de palmeiras por Rhodnius neglectus e invasão domiciliar em área urbana, Araçatuba, São Paulo, Brasil

The objective of this study is to report on the colonization of palm trees by Rhodnius neglectus, its invasion in an urban area, in Araçatuba - São Paulo, and the control and surveillance measures that have been put in place. Domiciliary triatomine searches occurred in apartments upon the inhabitants' notification. The collected insects were identified and examined for natural infection and food sources with a precipitin test. To search the palm trees, tarps were used to cover the floor, and a “Munck” truck equipped with a tree-pruning device was utilized. Chemical control was performed with the utilization of a manual compression. In 2009, 81 specimens of Rhodnius neglectus were collected from the domiciles by the population. The precipitin test revealed a presence of human blood in 2.7% of the samples. Entomological studies were carried out in these domiciles and in those located within a radius of 200 meters. The search performed in the palm trees resulted in the capture of 882 specimens of triatomines, negative for tripanosomatids. Mechanical and chemical controls were carried out. New searches conducted in the palm trees in the same year resulted in the capture of six specimens. The mechanical and chemical controls of the palm trees, together with the population's work, proved to be effective, therefore preventing these insects' colonization of the city's domiciles.

O objetivo deste trabalho é relatar a colonização de palmeiras por Rhodnius neglectus, sua invasão em área urbana, na cidade de Araçatuba - São Paulo, o controle e as medidas de vigilância instituídas. As pesquisas de triatomíneos nos domicílios ocorreram nos apartamentos quando da notificação pelo morador. Os insetos coletados foram identificados, examinados quanto à infecção natural e teste de precipitina. Na pesquisa das palmeiras foram utilizados lonas para forração do chão e caminhão Munck equipado com moto poda. O controle químico foi realizado com a utilização de compressor manual. No ano de 2009, foram coletados pela população 81 exemplares de Rhodnius neglectus em domicílios. O teste de precipitina acusou presença de sangue humano em 2,7% das amostras. Pesquisas entomológicas foram realizadas nestas edificações e naquelas situadas em um raio de 200 metros onde ocorreram as invasões. A pesquisa realizada nas palmeiras resultou na captura de 882 exemplares de triatomíneos, negativos para tripanosomatídeos. Foi realizado controle mecânico e químico. Novas pesquisas realizadas nas palmeiras avaliadas no mesmo ano resultaram na coleta de seis exemplares. Os controles mecânicos e químicos das palmeiras aliado ao trabalho de participação popular mostraram-se factíveis impedindo a colonização destes insetos nos domicílios da cidade.

Magnitude and trend of American Tegumentary Leishmaniasis in the State of São Paulo, Brazil, 1975 to 2008.

The aim of this study was to analyze the magnitude and trend of American Tegumentary Leishmaniasis (ATL) in the State of São Paulo from 1975 to 2008. An ecological study that classified municipalities according to the magnitude of transmission was performed. From 1975 to 1985, 1,281 cases of ATL were registered in 45 municipalities, rising to 258 municipalities and 4,093 cases from 1986 to 1995; and reaching 385 municipalities and 7,604 cases from 1996 to 2008. Lutzomyia intermedia s.l. was collected in most of the entomological surveys. In the classification of municipalities according to magnitude, 67.5% were observed to have a "small magnitude," 19.2% "moderate magnitude" and 13.3% "high magnitude." The highest incidences of ATL have been restricted to underserved areas close to the Atlantic forest. There was an increase in the number of municipalities with small occurrence of cases and expansion in the area of risk.

Magnitude e tendência da Leishmaniose Tegumentar Americana no Estado de São Paulo, Brasil, 1975 a 2008 / Magnitude and trend of American Tegumentary Leishmaniasis in the State of São Paulo, Brazil, 1975 to 2008

O objetivo deste estudo foi analisar a magnitude e tendência da Leishmaniose Tegumentar Americana (LTA) no Estado de São Paulo entre 1975 e 2008. Foi conduzido um estudo ecológico que categorizou os municípios segundo a magnitude da transmissão. No período de 1975 a 1985, 45 municípios foram responsáveis pelo registro de 1.281 casos de LTA, passando a 258 municípios e 4.093 casos entre 1986 e 1995, e a 385 municípios e 7.604 casos entre 1996 a 2008. O vetor Lutzomyia intermedia s.l. foi coletado na maioria das pesquisas entomológicas. Na classificação dos municípios segundo a magnitude pode-se verificar que 67,5% possuíam "pequena magnitude", 19,2% "média magnitude" e 13,3% "grande magnitude". As maiores incidências de LTA permanecem restritas a algumas áreas carentes e próximas à Mata Atlântica. Houve aumento no número de municípios com pequena ocorrência de casos e ampliação da área de risco.

The aim of this study was to analyze the magnitude and trend of American Tegumentary Leishmaniasis (ATL) in the State of São Paulo from 1975 to 2008. An ecological study that classified municipalities according to the magnitude of transmission was performed. From 1975 to 1985, 1,281 cases of ATL were registered in 45 municipalities, rising to 258 municipalities and 4,093 cases from 1986 to 1995; and reaching 385 municipalities and 7,604 cases from 1996 to 2008. Lutzomyia intermedia s.l. was collected in most of the entomological surveys. In the classification of municipalities according to magnitude, 67.5% were observed to have a "small magnitude," 19.2% "moderate magnitude" and 13.3% "high magnitude." The highest incidences of ATL have been restricted to underserved areas close to the Atlantic fo-rest. There was an increase in the number of municipalities with small occurrence of cases and expansion in the area of risk.

Indicadores de infestação larvária e influência do porte populacional na transmissão de dengue no estado de São Paulo, Brasil: um estudo ecológico no período de 2007-2008 / Larval infestation indicators and influence of population size on dengue transmission in the State of São Paulo, Brazil: an ecological study in the periodo 2007-2008

Objetivo: descrever indicadores de infestação larvária e analisar a associação entre ocorrência de dengue, porte populacional e distância entre municípios no estado de São Paulo. Métodos: estudo ecológico utilizando indicadores larvários, segundo tipo de imóvel, e regressão logística. Foram utilizados dados dos sistemas da Superintendência de Controle de Endemias (Sucen) e do Centro de Vigilância Epidemiológica (CVE) dos anos 2007 e 2008. Resultados: o Índice de Infestação Predial e a positividadede Pontos Estratégicos e Imóveis Especiais apresentaram valores maiores em municípios com dengue. Nos municípios contidos num raio de 50km dos municípios-pólo, a chance de ocorrência de dengue foi o dobro dos municípios mais distantes. Naqueles com população maior que 50.000 habitantes, a chance de ocorrência de dengue foi cinco vezes aquela em municípios menores. Conclusão: é evidenciada a importância da adoção de estratégias de controle baseadas nos indicadores entomológicos, sobretudo nos municípios de grande porte.

Objective: to describe larval indicators and analyze the association of occurrence of dengue and population size and distance between municipalities in the State of São Paulo, Brazil. Methods: ecological study utilizing larval indicators according to property type and logistic regression. The data was obtained from the systems of Endemics Control Bureau and Center of Epidemiological Vigilance in 2007 and 2008. Results: household Index Infestation andpositivity of Strategic Points and Special Property were higher in municipalities with dengue. The chance of occurrence of dengue in municipalities less than 50km away from the major municipalities was twice as likely. The municipalities with populations greater than 50.000 inhabitants hadfive times more chance of dengue occurrence compared to the small municipalities. Conclusion: this study emphasizes the importance of adopting control strategies based on entomological indicators, especially in big municipalities.

[Control Program of Chagas disease in São Paulo, Brazil: the control and surveillance of vector transmission]. / Programa de Controle da Doença de Chagas no estado de São Paulo, Brasil: o controle e a vigilância da transmissão vetorial.

The control of the vectors of Chagas' disease in the State of Sao Paulo are discussed, mainly those activities that led to the elimination of Triatoma infestans. Secondary factors that helped the control such as rural exodus are also analyzed. The article shows that since 1965 the control became a campaign with different phases due to the epidemiological situation, the acquired knowledge and the entomological surveillance. After 25 years of work, the elimination of all the focus of Triatoma infestans was finally reached and the campaign was ended. However, due to the possibility of reintroduction of the vector in rural areas by passive transportation besides the presence of secondary vectors (Triatoma sordida and Panstrongylus megistus) in several localities, the vector control activities were not interrupted and the surveillance is continuous.

[Chagas disease Control Program in the State of São Paulo, Brazil: seroepidemiological aspects of homogeneous geographic microregions]. / Programa de Controle da Doença de Chagas no Estado de São Paulo: aspectos soroepidemiológicos em microrregiões geográficas homogêneas.

Between the years 1976 and 1980, the American trypanosomiasis was searched for among residents in two geographic microregions of the State of São Paulo: Campos de Itapetininga, in the region of Sorocaba, and Encosta Ocidental da Mantiqueira Paulista, in the region of Campinas. Both areas have in the past been colonized by Triatoma infestans. Campos de Itapetininga remained, until the beginning of the 1970s as a stronghold of this species in the State of São Paulo. Panstrongylus megistus has currently colonized in these areas, now classified as having serological titer profiles characteristic of low endemicity. Transmission of Chagas disease was interrupted earlier in the Encosta Ocidental. Intense exposure to the vector in Campos de Itapetininga can explain the seroreactivity frequencies observed in people born before 1956, aged more than 20 years. Among the residents in this region born between 1972 and 1977, a low positivity rate remains, which might also include cases of congenital transmission. The mean age of seroreagents resident in the Encosta indicates that they must have been born in the 1930s; positivity levels here vary in different municipalities according to their growth in capital goods. After 1984 new criteria were adopted for the use of serology in the Program for the Control of Chagas disease, the detection of seroreagents has not been statistically associated to notification of the occurrence of domestic triatomines in these regions.

[Chagas disease Control Program in the State of São Paulo, Brazil: serological and entomological aspects of primary school-children surveys]. / Programa de Controle da Doença de Chagas no Estado de São Paulo: aspectos sorológicos e entomológicos de inquéritos entre escolares de ensino fundamental.

Two serological surveys were carried out to evaluate the effectiveness of measures put into effect in the State of São Paulo (Brazil) to control Chagas disease vectors. The first one, during the period from 1968 to 1970; the complement fixation reaction was performed on serum samples from school-children resident in all municipalities of the State of São Paulo, with the exception of the Greater São Paulo. The second one, annually, from 1973 to 1983, involving school-children resident in municipalities with high trypanosomiasis prevalence values; the indirect immuno-fluorescence test was performed on filter paper total blood eluates. Data on the occurrence of triatomines and their infection with Trypanosoma cruzi in each municipality formed the basis of insight into the epidemiological situation associated with the school-children's dates of birth. Most positive serological results, as well as the highest proportion of autochthonous cases associated with Triatoma infestans were observed in the region of Sorocaba until the early 1970s, while the proportions of both autochthonous and imported cases were kept in equilibrium elsewhere. It has been inferred that as recently as 1974, vectorial transmission of Chagas disease could still be observed in the State of São Paulo. We emphasize that, even rather lacking in coverage, no seropositive cases have been observed in people inhabiting the regions included in the Control Program for the State of São Paulo and now aged less than 15 years.

Programa de Controle da Doença de Chagas no estado de São Paulo, Brasil: o controle e a vigilância da transmissão vetorial / Control Program of Chagas disease in São Paulo, Brazil: the control and surveillance of vector transmission

Discute-se o controle dos transmissores da doença de Chagas, no Estado de São Paulo, e as atividades que levaram à eliminação do Triatoma infestans. São destacados os fatores coadjuvantes as ações de controle, particularmente o êxodo rural. A partir de 1965, o combate tomou a forma de uma verdadeira campanha, com fases distintas em função das alterações epidemiológicas, experiência adquirida e pressão dos custos. Após 25 anos de trabalho a campanha foi considerada encerrada, com a eliminação dos focos da espécie do planalto paulista. Porém, em função da possibilidade da reintrodução de Triatoma iinfestans(transporte passivo) e da presença, em diversas localidades, de exemplares de espécies vetoras semidomiciliares (Triatoma sordida e Panstrogylus megistus) as atividades de controle não foram interrompidas. Em consequência, continuam em andamento as ações de vigilância entomológica.

The control of the vectors of Chagas' disease in the State of Sao Paulo are discussed, mainly those activities that led to the elimination of Triatoma infestans. Secondary factors that helped the control such as rural exodus are also analyzed. The article shows that since 1965 the control became a campaign with different phases due to the epidemiological situation, the acquired knowledge and the entomological surveillance. After 25 years of work, the elimination of all the focus of Triatoma infestans was finally reached and the campaign was ended. However, due to the possibility of reintroduction of the vector in rural areas by passive transportation besides the presence of secondary vectors (Triatoma sordida and Panstrongylus megistus) in several localities, the vector control activities were not interrupted and the surveillance is continuous.

Programa de Controle da Doença de Chagas no Estado de São Paulo: aspectos soroepidemiológicos em microrregiões geográficas homogêneas / Chagas disease Control Program in the State of São Paulo, Brazil Seroepidemiological aspects of homogeneous geographic microregions

A infecção chagásica foi averiguada entre moradores de duas microrregiões geográficas homogêneas do Estado de São Paulo, entre os anos de 1976 a 1980. Campos de Itapetininga, na região de Sorocaba e Encosta Ocidental da Mantiqueira Paulista, na região de Campinas, foram áreas de colonização de Triatoma infestans, no passado, tendo permanecido, na primeira, até o início da década de 70, como reduto da espécie no estado. Atualmente as duas áreas são colonizadas por triatomíneos da espécie Panstrongylus megistus. Perfis de títulos sorológicos caracterizaram ambas as microrregiões como áreas de baixa endemicidade; a interrupção da transmissão foi mais precoce na Encosta, com diferença de 17 anos, em média. Em Campos de Itapetininga, a intensa exposição ao vetor é traduzida pela sororreatividade observada nas idades superiores a 20 anos, correspondentes aos nascidos antes de 1956. Dentre os nascidos entre 1972 e 1977, nessa área, permanece uma baixa positividade, podendo, também, associar-se à transmissão congênita. Na Encosta, a média de idade dos sororreagentes corresponde a nascimentos na década de 1930; os níveis de positividade variaram nos municípios que a compõe segundo o desenvolvimento de capital. Após 1984, com a adoção de novos critérios para o uso da sorologia no Programa de Controle, o encontro de sororreagente não tem sido associado estatisticamente a moradores notificantes de domicílios com presença de triatomíneos.

Between the years 1976 and 1980, the American trypanosomiasis was searched for among residents in two geographic microregions of the State of São Paulo: Campos de Itapetininga, in the region of Sorocaba, and Encosta Ocidental da Mantiqueira Paulista, in the region of Campinas. Both areas have in the past been colonized by Triatoma infestans. Campos de Itapetininga remained, until the beginning of the 1970s as a stronghold of this species in the State of São Paulo. Panstrongylus megistus has currently colonized in these areas, now classified as having serological titer profiles characteristic of low endemicity. Transmission of Chagas disease was interrupted earlier in the Encosta Ocidental. Intense exposure to the vector in Campos de Itapetininga can explain the seroreactivity frequencies observed in people born before 1956, aged more than 20 years. Among the residents in this region born between 1972 and 1977, a low positivity rate remains, which might also include cases of congenital transmission. The mean age of seroreagents resident in the Encosta indicates that they must have been born in the 1930s; positivity levels here vary in different municipalities according to their growth in capital goods. After 1984 new criteria were adopted for the use of serology in the Program for the Control of Chagas disease, the detection of seroreagents has not been statistically associated to notification of the occurrence of domestic triatomines in these regions.

Programa de Controle da Doença de Chagas no Estado de São Paulo: aspectos sorológicos e entomológicos de inquéritos entre escolares de ensino fundamental / Chagas disease Control Program in the State of São Paulo, Brazil: serological and entomological aspects of primary school-children surveys

Como parte de avaliação de medidas de controle de vetores, levadas a efeito no Estado de São Paulo, na década de 60, inquéritos sorológicos entre crianças escolares nascidas após sua aplicação foram realizados nos períodos abrangidos entre os anos 1968 e 1970, em todos os municípios do estado, à exceção dos da Grande São Paulo e, anualmente, de 1973 a 1983, em amostra selecionada a partir daqueles com as maiores soroprevalências para a infecção chagásica. No primeiro caso, a metodologia sorológica previu os exames à base da reação de fixação de complemento, em soros e, no segundo, a reação de imunofluorescência indireta, em eluatos de sangue total absorvido em papel-filtro. Presença de triatomíneos e sua condição de infecção por Trypanosoma cruzi, coligidas nos diversos municípios de acordo com o ano dos nascimentos dos escolares e da realização dos inquéritos, permitiram vislumbrar o quadro da infecção chagásica no Estado de São Paulo, naquelas épocas. A região de Sorocaba destacou-se das demais em termos sorológicos, sustentada pela presença do Triatoma infestans até o início da década de 70. Similarmente, a autoctonia dos casos foi aí observada de maneira preponderante, enquanto que em outras regiões do estado manteve-se um equilíbrio entre casos autóctones e importados. A análise dos dados revela que, ainda em 1974, a transmissão vetorial poderia registrar-se no estado. É importante destacar que, mesmo com falhas de cobertura, até o ano de 1997, não se observou mais sororreatividade para infecção chagásica nas idades inferiores a 15 anos, no Programa de Controle do Estado de São Paulo.

Two serological surveys were carried out to evaluate the effectiveness of measures put into effect in the State of São Paulo (Brazil) to control Chagas disease vectors. The first one, during the period from 1968 to 1970; the complement fixation reaction was performed on serum samples from school-children resident in all municipalities of the State of São Paulo, with the exception of the Greater São Paulo. The second one, annually, from 1973 to 1983, involving school-children resident in municipalities with high trypanosomiasis prevalence values; the indirect immuno-fluorescence test was performed on filter paper total blood eluates. Data on the occurrence of triatomines and their infection with Trypanosoma cruzi in each municipality formed the basis of insight into the epidemiological situation associated with the school-children's dates of birth. Most positive serological results, as well as the highest proportion of autochthonous cases associated with Triatoma infestans were observed in the region of Sorocaba until the early 1970s, while the proportions of both autochthonous and imported cases were kept in equilibrium elsewhere. It has been inferred that as recently as 1974, vectorial transmission of Chagas disease could still be observed in the State of São Paulo. We emphasize that, even rather lacking in coverage, no seropositive cases have been observed in people inhabiting the regions included in the Control Program for the State of São Paulo and now aged less than 15 years.

Doença de Chagas no estado de São Paulo: dos primórdios do controle vetorial à vigilância sustentável. / Chagas' disease in São Paulo state: from the beginning of vector control to sustainable surveillance.

São apresentados os resultados do controle dos transmissores da doença de Chagas no estado de São Paulo que levaram à eliminação do Triatoma infestans do solo paulista. São descritas as fases pelas quais passou o programa, destacando os fatores, somados às ações de controle, que contribuíram para o seu êxito. Finalmente, são descritas as ações de vigilância dos vetores vigentes no estado, desencadeadas a partir de notificações de insetos, originadas pela população, cujos resultados apontam continuidade e garantem sustentabilidade ao Programa.

We show in this article the results of Chagas? disease vector control program in São Paulo state, Brazil, which resulted in the eradication of Triatoma infestans from the state territory. We describe the various phases of the program, emphasizing the factors which complemented such control actions and contributed to their success. Then, we describe the vector surveillance actions in effect in this state, based on insect notification by the population, which show continuity and warrant the sustainability of the program.