Food handlers: an important reservoir of protozoans and helminth parasites of public health importance / Manipuladores de alimentos: um importante reservatório de protozoários e helmintos parasitas de importância para a saúde pública

Food handlers plays a primary role in the transmission of pathogenically important protozoans and helminth parasites. This study was aimed to evaluate the prevalence of intestinal pathogenic protozoans and helminth parasites among food handlers in and around University of Malakand, Lower Dir, Pakistan. Stool samples were collected from 642 food handlers (all of male) in a cross-sectional study from January to November, 2017. Wet Mount Techniques and concentration methods by using salt and formol–ether solutions. Three hundred and eighty four cases (59.8%) were found infected with one more parasites. Most of the individuals were found infected with helminth (47.6%) as compared to intestinal protozoans (0.93%). Seventy two cases (11.2%) of the cases presented mixed infection with both intestinal protozoan and helminth parasites. The order of prevalence for intestinal helminth was Ancylostoma duodenale (n = 258, 40.1%), followed by Taeniasa ginata (n=96, 14.9%) Ascaris lumbricoides (n = 54, 8.40%) and Trichuris trichura (n=30, 4.60%). For intestinal protozoa, Entamoeba histolytica/dispar (n = 36, 5.64%) was the only protozoan detected. Mono-parasitism was higher than poly-parasitism. Family size income and education level were the factors significantly (P<0.05) associated in the parasites prevalence. Current research showed that IPIs are primarily the foodborne pathogens still an important public health problem in Pakistan. Effective control programs on parasitic diseases transfer and their associated factors are recommended.

Os manipuladores de alimentos desempenham um papel fundamental na transmissão de protozoários e helmintos parasitas patogenicamente importantes. Este estudo teve como objetivo avaliar a prevalência de protozoários patogênicos intestinais e helmintos parasitas entre manipuladores de alimentos na Universidade de Malakand, Lower Dir, Paquistão. Amostras de fezes foram coletadas de 642 manipuladores de alimentos (todos do sexo masculino) em um estudo transversal de janeiro a novembro de 2017. Técnicas de montagem úmida e métodos de concentração usando soluções de sal e formol-éter. Trezentos e oitenta e quatro casos (59,8%) foram encontrados infectados com mais um parasita. A maioria dos indivíduos foi encontrada infectada por helmintos (47,6%) em comparação com protozoários intestinais (0,93%). Setenta e dois casos (11,2%) dos casos apresentavam infecção mista com protozoários intestinais e helmintos parasitas. A ordem de prevalência de helmintos intestinais foi Ancylostoma duodenale (n = 258, 40,1%), seguido por Taeniasa ginata (n = 96, 14,9%) Ascaris lumbricoides (n = 54, 8,40%) e Trichuris trichura (n = 30, 4,60 %). Para protozoários intestinais, Entamoeba histolytica / dispar (n = 36, 5,64%) foi o único protozoário detectado. Monoparasitismo foi maior do que poliparasitismo. A renda familiar e o nível de escolaridade foram os fatores significativamente (P <0,05) associados na prevalência de parasitos. A pesquisa atual mostrou que os IPIs são principalmente os patógenos de origem alimentar, ainda um importante problema de saúde pública no Paquistão. Programas eficazes de controle da transferência de doenças parasitárias e seus fatores associados são recomendados.

Hippocampal Atrophy/Sclerosis Is Associated with Old, Calcified Parenchymal Brain Neurocysticercosis, But Not with More Recent, Viable Infections.

Magnetic resonance images from 197 patients with calcified neurocysticercosis (NCC), 38 with viable NCC and 197 NCC-free healthy rural villagers were evaluated to compare the frequency of hippocampal atrophy/sclerosis (HAS) across these populations. Scheltens' medial temporal atrophy scale was used for hippocampal rating. The median age of the 432 study participants was 46 years (interquartile range, 29-62 years), and 58% were women. Hippocampal atrophy/sclerosis was disclosed in 26.9% patients with calcified NCC, compared with 7.9% in patients with viable NCC and 8.1% in healthy rural villagers. After adjusting for age, gender, and history of epilepsy, hippocampal atrophy/sclerosis was more frequent in patients with calcified NCC than in those with viable cysts (RR, 3.60; 95% CI, 1.18- 0.99; P = 0.025) and healthy rural villagers (RR, 3.43; 95% CI, 1.94-6.06; P < 0.001), suggesting that hippocampal damage develops late in the course of this parasitic disease.

Malignant catarrhal fever: An emerging yet neglected disease in captive sika deer (Cervus nippon) herds in China.

Malignant catarrhal fever (MCF) is a fatal lymphoproliferative disease that represents a serious problem in the deer-rearing industry. To better understand an MCF-like disease that has emerged in northern China since 2015, we investigated ten cases by documenting clinical and epidemiological data and analysing causative agents and histopathological changes. In addition, a retrospective screen for Macavirus DNA and a questionnaire-based survey were conducted. Epizootic MCF in Chinese sika deer herds has emerged with a low morbidity of 3.8% (95% CI: 2.5%-5.1%) and a high mortality of 93.2% (95% CI: 86.6%-99.9%). The disease course varied from 3 to 12 days. Aetiologically, OvHV-2 was predominant in the MCFV, accounting for most MCF cases (21/23). In contrast, only two CpHV-2 isolates were phylogenetically closely related to CpHV-2. Diarrhoea and nasal discharges were the most frequent manifestations, although clinical signs varied in some cases. Pathologically typical lesions of haemorrhage, necrosis and lymphoid cell infiltration were readily observed in a variety of organs. Vasculitis caused by vascular and perivascular lymphoid cell infiltration was common. The retrospective survey suggested a low positive rate (3/275) of MCFV DNA in peripheral blood lymphocytes (PBL). The questionnaire-based survey suggested the disease was neglected by local veterinarians, who did not acknowledge the risk of co-rearing deer with reservoir species. Collectively, the emerging epizootic MCF in Chinese sika deer herds remains neglected, emphasizing the urgency of initiating full-field diagnoses and control strategies.

Multiple food-borne trematodiases with profound systemic involvement: a case report and literature review.

BACKGROUND: Food-borne trematodiases are an important group of neglected global diseases. Affected patients in regions with low prevalence usually experience delayed diagnosis, especially when presenting with atypical clinical symptoms. Here, we presented a rare case of a Chinese patient infected with three food-borne trematodiases. CASE PRESENTATION: A 42-year-old man presented with diarrhea, lower extremity edema, and symptoms of cardiac dysfunction. He had a history of intermittent consumption of raw freshwater fishes for 6-7 years. Upon evaluation, he had eosinophilia, anemia, intrahepatic bile duct dilatation and a growing space-occupying lesion in the left atrium. The patient underwent a cardiac surgery which revealed an endocardial hematoma due to mechanical injuries. Imaging investigations also revealed intracranial and pulmonary lesions. A total of three trematodiases were diagnosed based upon microscopic stool examination, from which eggs of Clonorchis sinensis, Heterophyidae and Echinostomatidae were identified. Deposition of Clonorchis sinensis eggs was also observed from ileocecal squash slides. The patient was successfully treated with three cycles of praziquantel. CONCLUSIONS: Food-borne trematodiases may present with systemic involvement. Patients with dietary history of high risk or atypical ingestions should be evaluated for parasitic infection, even in non-endemic areas.

Could SUVmax be an auxiliary parameter in the clinical management of pulmonary hydatid disease?

OBJECTIVE: The aim of this study was to investigate the role of 18F-fluorodeoxyglucose positron emission tomography/computerized tomography (FDG-PET/CT) in the diagnosis and treatment of pulmonary hydatid disease and also compare the morphological characteristics of the lesions with SUVmax values and identify complicated disease. METHODS: Thirty-six patients with a diagnosis of pulmonary hydatid disease who underwent 18F-FDG PET/CT imaging were included in this retrospective study. The size of the lesions, morphological characteristics, accompanying parenchymal and pleural findings, SUVmax and HUmean values and FDG uptake in mediastinal lymph nodes were noted. The relationship between morphologic properties, SUVmax of the lesions and lymphatic FDG uptake was analysed. RESULTS: A total of 99 lesions of 36 patients were classified as solid (7.1%), cystic (53.5%), semisolid (20.2%) and cavitary (19.2%). Thirty-two of the lesions were encapsulated, 38 of the lesions had border irregularity. Accompanying consolidation was present in 10 cases, bronchial obstruction in 9, pleural thickening in 28 and effusion in 3. There was positive correlation between lesions HUmean and SUVmax values (r = 0.285). SUVmax values were significantly higher in lesions with irregular borders, solid or semisolid type and presence of consolidation, bronchial obstruction and pleural thickening. Also more lymphatic FDG uptake was detected in this group. CONCLUSION: Higher SUVmax values may be a useful parameter in the diagnosis of complicated pulmonary hydatid disease. FDG-PET may provide guidance for determining the priority of lesion for surgery in cases with multiple lesions and may be helpful to evaluate the response to medical treatment.

Rare case of neglected large sacral Chordoma in a young female treated by wide En bloc resection and Sacrectomy.

BACKGROUND: Sacral chordoma is a locally aggressive malignant tumour originating from ectopic notochordal cells. The natural history of sacral chordoma is a slow growing tumour arising at the midline of the lower sacrum that can invade the sacrum and progressively increase in size expanding cranially and anteriorly. Metastasis is very rare even when the tumour is large. Sacral chordoma affects males more than females and is more commonly found in middle age and elderly patients. CASE PRESENTATION: A 25 years old female had neglected an extremely large midline sacral mass for 2 years. On presentation to hospital, she had been bed bound for the past 2 years. The sacral mass was so large that it prevented her from lying down supine and sitting on the wheelchair comfortably. Clinical examination showed a 40 cm × 30 cm × 20 cm hard mass over the sacrum that involved both buttocks and the gluteal fold. Neurological exam of bilateral lower limb was normal. Computed Tomography Scan of the Pelvis showed a large destructive sacrococcygeal mass measuring 43 cm × 38 cm × 27 cm with extension into the presacral space resulting in anterior displacement of the rectum, urinary bladder and uterus; and posterior extension into the dorsal soft tissue with involvement of the gluteus, piriformis, and left erector spinae muscles. Biopsy taken confirmed Chordoma. This patient was managed by a multidisciplinary team in an Oncology referral centre. The patient had undergone Wide En Bloc Resection and Sacrectomy, a complex surgery that was associated with complications namely bleeding, surgical site infection and neurogenic bowel and bladder. Six months post operatively the patient was able to lie supine and sit on wheelchair comfortably. She required extensive rehabilitation to help her ambulate in future. CONCLUSION: This is a rare case of neglected sacral chordoma in a young female treated with Wide En Bloc Resection and Sacrectomy associated with complications of this complex surgery. Nevertheless, surgery is still worthwhile to improve the quality of life and to prevent complications secondary to prolonged immobilization. A multidisciplinary approach is ideal and team members need to be prepared to address the complications once they arise.

Histological assessment of granulomas in natural and experimental Schistosoma mansoni infections using whole slide imaging.

The pathology of schistosomiasis mansoni, a neglected tropical disease of great clinical and socioeconomic importance, results from the parasite eggs that become trapped in host tissues, particularly in the liver and intestines. Continuous antigenic stimulation from these eggs leads to recruitment of inflammatory cells to the sites of infection with formation of periovular granulomas. These complex structures have variable size and composition and are the most striking histopathological feature of schistosomiasis mansoni. However, evaluation of granulomas by conventional microscopy methods is time-consuming and limited, especially in large-scale studies. Here, we used high resolution Whole Slide Imaging (WSI), which allows fast scanning of entire histological slides, and multiple morphometric evaluations, to assess the granulomatous response elicited in target organs (liver, small and large intestines) of two models of schistosomiasis mansoni. One of the advantages of WSI, also termed virtual microscopy, is that it generates images that simultaneously offer high resolution and a wide field of observation. By using a model of natural (Nectomys squamipes, a wild reservoir captured from endemic areas in Brazil) and experimental (Swiss mouse) infection with Schistosoma mansoni, we provided the first detailed WSI characterization of granulomas and other pathological aspects. WSI and quantitative analyses enabled a fast and reliable assessment of the number, evolutional types, frequency and areas of granulomas and inflammatory infiltrates and revealed that target organs are differentially impacted by inflammatory responses in the natural and experimental infections. Remarkably, high-resolution analysis of individual eosinophils, key cells elicited by this helminthic infection, showed a great difference in eosinophil numbers between the two infections. Moreover, features such as the intestinal egg path and confluent granulomas were uncovered. Thus, WSI may be a suitable tool for detailed and precise histological analysis of granulomas and other pathological aspects for clinical and research studies of schistosomiasis.

Primary Spinal Intramedullary Neurocysticercosis: A Report of 3 Cases.

We describe a series of 3 cases of the rare intramedullary form of primary spinal neurocysticercosis. The cases were seen in varied age groups and showed different profiles at presentation. All the cases were thoroughly evaluated clinically and radiologically. Serologic tests were not conducted. In all cases, magnetic resonance imaging showed a large intramedullary lesion in the thoracic spinal cord consisting of a cystic lesion with a well-defined intramural nodule. One case was managed with steroids and cysticidal therapy, a second case was managed with steroids and surgery (2 emergency procedures), while the third case was managed without any medical or surgical intervention, as the patient was unwilling for either. All cases showed good neurologic recovery. In the second case where surgery was done, histologic examination of the resected specimen demonstrated the cysticercal parasite surrounded by mixed inflammatory infiltrate. As there were no intracranial lesions in all 3 cases, the final diagnosis was primary isolated intramedullary neurocysticercosis. Primary isolated intramedullary-neurocysticercosis remains a rare condition afflicting the spinal cord. It forms a small subset of cysticercal infestation of the neuraxis. Such evidence is rare, and only anecdotal reports are available. Our case series captures the wide spectrum of presentations, as well as the management options, and highlights the varied ways in which these cases were managed.

Lepromatous leprosy simulating rheumatoid arthritis - Report of a neglected disease

Abstract Brazil has the second largest number of leprosy cases in the world; nevertheless, late diagnosis is common. We report the case of a male patient with pain and numbness in both hands and feet for six years with positive rheumatoid factor and anticardiolipin under rheumatoid arthritis treatment for five years. Examination revealed diffuse cutaneous infiltration and leonine facies, characteristic features of lepromatous leprosy. Autoantibodies such as rheumatoid factor and anticardiolipin are markers of rheumatic autoimmune diseases, but their presence is also described in leprosy. We report the present case in order to alert health professionals to remember leprosy, even in areas where the disease is considered eliminated as a public health problem, avoiding misinterpretations of serologic findings and misdiagnosis.

The causal relationship between neurocysticercosis infection and the development of epilepsy - a systematic review.

BACKGROUND: Neurocysticercosis (NCC) is a parasitic infection of the human central nervous system, the most common form of which involves infection of the brain parenchyma with the larval form of the Taenia solium tapeworm. A causal relationship between such an NCC infection and the development of epilepsy in infected individuals is acknowledged, in part supported by high levels of comorbidity in endemic countries worldwide. METHODS: This study undertook a systematic review and critical analysis of the NCC-epilepsy relationship with the primary objective of quantifying the risk of developing epilepsy following NCC infection. A secondary aim was to analyse the proportions of NCC-associated epilepsy within different populations. Significant emphasis was placed on the importance of neuroimaging (CT or MRI) availability and use of clear guidelines for epilepsy diagnosis, in order to avoid overestimations of prevalence rates of either condition; a limitation identified in several previous studies. RESULTS: A common odds ratio of 2.76 was identified from meta-analysis of case-control studies, indicating that an individual infected with NCC has almost a three times higher risk of developing epilepsy than an uninfected individual. Furthermore, meta-analysis of studies identified a common proportion of 31.54% of epilepsy cases associated with NCC infection which suggests that amongst epileptic populations in at risk countries, approximately one-third may be associated with NCC infection. CONCLUSION: A significant finding was the lack of good clinical data to enable accurate determination of a causal relationship. Even studies that were included had noticeable limitations, including a general lack of consistency in diagnostics, and lack of accurate epidemiological data. This review highlights a need for consistency in research in this field. In the absence of reliable estimates of its global burden, NCC will remain of low priority in the eyes of funding agencies - a truly neglected disease.

Promoting awareness of neonatal menstruation.

Neonatal uterine bleeding (NUB) has been carefully studied in the past through case reports, small series, clinical cohort studies, pathology investigations of fetal and neonatal. Following a historical recount, this review summarizes biological mechanisms conditioning NUB, starting from the persistence till birth of an 'ontogenetic progesterone resistance' (OPR), causing decreased responsiveness of target tissues to bioavailable progesterone. Several pregnancy-related conditions, such as preeclampsia, fetal growth restriction, prematurity, post-maturity and even Rhesus or ABO incompatibility, influence the occurrence of NUB. It seems therefore that the phenomenon is precipitated by chronic fetal distress. When present, OPR may persists until telarche; as a consequence, if pregnancy occurs in early teenage, the disorder known as "defective deep placentation" may ensue, increasing the risk of obstetrical syndromes. In the presence of NUB, retrograde shedding into the peritoneal cavity of endometrial stem/progenitor and niche cells may occur. There, given the right environment, these cells can survive and become activated at the time of telarche, causing the specific phenotype of early-onset endometriosis. In conclusion, neonatal menstruation is a fetal distress indicator and can alter the incidence of a variety of pathological conditions later in life. For this reason, it should be carefully recorded and the parents informed.

IFN-gamma role in granuloma formation in experimental subcutaneous cysticercosis.

Cysticercosis is an infection caused by the metacestode larval stage of Taenia parasites in tissues and elicits a host-parasite reaction in which the immune response may be decisive in the disease development. The aim of this study was to evaluate the role of IFNγ (IFN-gamma) in the experimental model of subcutaneous infection with Taenia crassiceps (T. crassiceps) cysticerci using IFNγ knockout mice. Male C57BL/6 and C57BL/6 KO IFNγ mice 8-12 weeks of age were inoculated with T. crassiceps cysticerci into the subcutaneous tissue of the dorsum. At 7 and 30 (acute phase), 60 and 90 (chronic phase) days post infection, animals from each group had their blood and the subcutaneous tissues collected for serologic and pathological studies. IFNγ and IL-4 were dosed and the histopathological analysis was performed. In the presence of IFNγ there was the establishment of a mixed Th1/Th2 systemic immune profile. This profile also locally induced the granuloma formation which was constituted by cells that played important roles in the parasitary destruction and that were likely associated to the Th1 axis of mixed immune response. On the other hand, the absence of IFNγ appears to favor the parasitary growth which may be related to the development of a systemic Th2 immune response. This profile influenced the granuloma formation with immunoregulatory properties and appears to be important in the collagen synthesis.

Dientamoeba fragilis, One of the Neglected Intestinal Protozoa.

Dientamoeba fragilis is a single-celled protozoan, closely related to the trichomonads. Reported worldwide as causing human gastrointestinal symptoms, D. fragilis is very common and is second only to Blastocystis spp. Dientamoebiasis equals or exceeds the incidence of giardiasis. This minireview includes diagnostic options, clinical relevance, therapy, an animal model, the confirmed cyst stage, and sequencing data. The development of a rodent model, fulfilling Koch's postulates, and the confirmation of a cyst stage have clarified transmission routes, including fecal-oral transmission. The prevalence of D. fragilis varies between 0% to over 82%; results depend on the geographic location, group studied, and diagnostic methods used.

Cystic Echinococcosis.

Echinococcosis is one of the 17 neglected tropical diseases (NTDs) recognized by the World Health Organization. The two major species of medical importance are Echinococcus granulosus and Echinococcus multilocularis. E. granulosus affects over 1 million people and is responsible for over $3 billion in expenses every year. In this minireview, we discuss aspects of the epidemiology, clinical manifestations, and diagnosis of cystic echinococcosis or cystic hydatid disease caused by E. granulosus.

Old and new challenges in Chagas disease.

Chagas disease, caused by the parasite Trypanosoma cruzi, is a neglected disease, which can lead to cardiomyopathy, arrhythmias, megaviscera, and more rarely, polyneuropathy in up to 30-40% of patients around 20 to 30 years after acute infection. Although it is endemic in the Americas, global population movements mean that it can be located wherever migrants from endemic areas settle. The disease was first described 100 years ago and still challenges clinicians worldwide, since diagnostic, therapeutic, and prognostic methods remain insufficient. Furthermore, factors such as HIV co-infection, immunosuppressive drugs, transplantation, and neoplastic disease can alter the natural course of the infection. We present the case of a Bolivian woman with chronic T cruzi infection diagnosed at our clinic in Madrid, Spain, who subsequently developed non-Hodgkin lymphoma. Our report illustrates the challenges of an increasingly common infection seen in non-endemic countries, and highlights both daily management dilemmas and associated difficulties that arise.

Filarial hydrocele: a neglected condition of a neglected tropical disease.

Filarial hydrocele is the most common chronic manifestation of lymphatic filariasis (LF) and poses a major public health burden to several filarial endemic countries. This review highlights the socio-economic impact of the disease, the role of the immune system in hydrocele development, current diagnostic approaches, and the control and management of filarial hydrocele. In the quest to facilitate the global effort to eliminate filarial hydrocele as a neglected tropical disease, a more comprehensive understanding of the mechanisms underlying the pathogenesis and development of the condition is important. In general, success has been achieved using annual treatment with ivermectin, but much remains to be done, particularly with late-stage infected individuals where surgery remains the only option. Studies have successfully demonstrated that inhibition of embryogenesis in adult female worms occurs after weeks of tetracycline treatment. Even more intriguing was the observation that the Wolbachia endosymbionts potently induce proinflammatory cytokines such as tumor necrosis factors (TNFs) and vascular endothelial growth factors (VEGFs), which are crucial for the development of filarial hydrocele. Furthermore, reports from human studies show that doxycycline treatment significantly ameliorates filarial hydrocele and markedly reverses early-stage filarial hydrocele. However, with the enormous challenges that face LF elimination such as global funding, logistics, civil wars, and drug resistance, a more relentless and collective approach from local governments as well as other stakeholders is needed to accelerate the fight against filarial hydrocele if the goal to eliminate it by 2020 is be to achieved.

Estudio de los conocimientos, actitudes y prácticas de la leishmaniasis: evidencias del olvido estatal en el Darién Colombiano / Study of knowledge, attitudes, and practices related to leishmaniasis: evidence of government neglect in the Colombian Darién / Estudo dos conhecimentos, atitudes e práticas da leishmaniose: evidências da negligência do Estado no Darién colombiano

La leishmaniasis cutánea americana (LCA) es considerada un problema de salud pública a nivel mundial, y su incidencia en Colombia es de 12 mil casos por año. Durante años se han implementado programas de control, que frecuentemente ignoran características sociales, económicas y demográficas de las regiones afectadas. Como parte de un estudio de tipo epidemiológico, en este artículo se presentarán los resultados de un estudio sobre los conocimientos, actitudes y prácticas (CAP) frente a la leishmaniasis, que tienen las poblaciones de las zonas rurales del municipio de Acandí, en el Darién Colombiano. Para el estudio se utilizaron herramientas cualitativas como la etnografía y cuantitativas, como las encuestas dirigidas. Los resultados ponen en manifiesto el desconocimiento de la población en aspectos fundamentales como el reconocimiento del vector. Además, existen diferencias en las CAP por género y por tipo de población, pero no por su distribución geográfica. Se evidenció el abandono estatal como factor determinante en la perpetuación de la enfermedad.

American cutaneous leishmaniasis (ACL) is considered a public health problem worldwide, and incidence in Colombia is 12,000 cases per year. Colombia has implemented control programs for years which have often overlooked the social, economic, and demographic characteristics of the regions where the disease occurs. As part of an epidemiological study, this article presents the results of a survey on knowledge, attitudes, and practices (KAP) related to leishmaniasis in rural populations in Acandí in the Colombian Darién. Qualitative and quantitative tools were used (ethnography and surveys, respectively). The results show scarce knowledge among the population on basic aspects such as recognition of the sand fly vector. There were also differences in KAP according to gender and type of population, rather than by geographic area. The study points to government neglect as a critical factor in the persistence of the disease.

A leishmaniose tegumentar americana (LTA) é considerada um problema de saúde pública em todo o mundo, e sua incidência na Colômbia é de 12 mil casos por ano. Os programas de controle implementados muitas vezes falham, provavelmente, por ignorarem as características sociais, econômicas e demográficas das regiões onde a doença ocorre. Como parte de um estudo de tipo ecoepidemiológico, neste artigo apresentamos os resultados de um estudo sobre os Conhecimentos, Atitudes e Práticas (CAP) sobre a leishmaniose em populações rurales do município de Acandí, na região do Darien colombiano. Para o estudo foram utilizados ferramentas qualitativas como a etnografia e quantitativas como levantamentos. Os resultados indicam que a população desconhece aspectos fundamentais da LTA, como por exemplo, o vetor. Além disso, existem diferenças nos CAP por sexo e tipo de população, mas não pela área geográfica. Desta forma, a nossa abordagem evidencia a negligência dos entes públicos de saúde, encabeçados pelo governo do estado. Esta negligencia é um fator determinante na perpetuação da doença.