Motives and determinants for residence change after leprosy diagnosis, central Brazil.

OBJECTIVE: To determine the extent of population movement after diagnosis with leprosy and to describe the underlying motives and determinants for relocation. DESIGN: A cross-sectional study was conducted among those newly diagnosed with leprosy in 79 endemic municipalities in the state of Tocantins, central Brazil. Individuals were identified through the National Information System for Notifiable Diseases (SINAN) database and interviewed with structured questionnaires. RESULTS: In total, 224 (20.9%) out of 1070 individuals relocated after their diagnosis with leprosy. Respondents moved to another neighbourhood in the same municipality (n = 178, 79.5%), followed by another municipality in Tocantins state (n = 26, 11.6%) and in another state (n = 11, 4.9%). The primary motives and/or determinants for relocation were: home ownership (n = 55, 28.4%), familial reasons (n = 43, 19.2%), to seek better living conditions (n = 27, 13.9%), employment (n = 26, 11.6%), and better neighbourhood (n = 22, 9.8%). Other motives were related to better access to leprosy diagnosis/treatment (n = 11, 4.9%), owner-terminated rental (n = 5, 2.2%), personal finances/could not afford housing (n = 4, 1.8%). Perceived stigma due to leprosy was mentioned by one participant (0.5%). CONCLUSION: In Tocantins state, population movement is lower among individuals recently diagnosed with leprosy, as compared to the overall population. The primary motives for relocation after leprosy diagnosis were related to lifestyle changes. Stigma and treatment-related reasons did not appear to be common motives for population movement. These results may reflect policy changes instituted from the Brazilian Program of Leprosy Control to decentralise leprosy services and intensify health education campaigns within a broader concept of Information, Education and Communication.

High prevalence of intestinal infections and ectoparasites in dogs, Minas Gerais State (southeast Brazil).

In the present study, 155 dogs euthanized by the Zoonotic Disease Unit of Uberlândia in Minas Gerais State (Southeast Brazil) were autopsied. Ectoparasites were collected, and the intestinal content of dogs was systematically examined for the presence of helminthic parasites. In total, we isolated 5,155 metazoan parasites of eight species (three intestinal helminth species, five ectoparasite species). The cestode Dipylidium caninum was present in 57 dogs (36.8 %), the nematodes Ancylostoma caninum in 30 (19.4 %) and Toxocara canis in 24 (15.5 %), respectively. Among the ectoparasites, 139 (89.7 %) dogs were infested with Rhipicephalus sanguineus, 115 (74.2 %) with Ctenocephalides felis, 5 (3.2 %) with Tunga penetrans and one specimen (0.7 %) with Amblyomma cajennense, while myiasis was found in one dog (0.7 %). In logistic regression analysis, young age (adjusted odds ratio 5.74; 95 % confidence interval 1.18-27.85) and male sex (3.60; 1.24-10.40) were significantly associated with toxocariasis, and crossbreed dogs (8.20; 1.52-44.31), with dipylidiasis. Male (2.23; 1.12-4.43) and crossbreed dogs (5.17; 1.17-22.83) had also a significant higher number of concomitant parasitoses. Spatial distribution of dogs by neighbourhood identified high-risk areas. Our systematic study shows that dogs in Uberlândia carry a high number of parasites which may cause zoonotic diseases in humans; therefore, further specific evidence-based intervention measures are needed.

The epidemiology of scabies in an impoverished community in rural Brazil: presence and severity of disease are associated with poor living conditions and illiteracy.

BACKGROUND: We sought to study the epidemiology of scabies and to identify risk factors of severe disease in an impoverished rural community in northeast Brazil. METHODS: The study was designed as a repeated cross-sectional study based on two door-to-door surveys. One survey was carried out in the rainy season, the other in the dry season. The inhabitants of the community were examined for the presence of scabies and demographic, socioeconomic, and behavioral risk factors were assessed. Risk factors were analyzed using bivariate and multivariate regression analysis. RESULTS: The overall prevalence was 9.8% with no significant variation between seasons and the incidence was estimated to be 196/1000 person-years. The highest prevalence (18.2%) was observed in children younger than 4 years. Risk factors in the bivariate analysis were young age, presence of many children in the household, illiteracy, low family income, poor housing, sharing clothes and towels, and irregular use of shower. Age younger than 15 years, illiteracy, sharing of clothes, and living in the community for more than 6 months remained significant independent risk factors in multivariate regression analysis. LIMITATIONS: We used a clinical case definition; specificity and sensitivity were not verified. Men were underrepresented in the study population. CONCLUSIONS: In this impoverished community scabies is an important health problem characterized by continuous transmission throughout the year. The parasitic skin disease is embedded in a complex web of causation characterized by poor living conditions and a low level of education.

A simple approach improving the performance of urine reagent strips for rapid diagnosis of urinary schistosomiasis in Nigerian schoolchildren.

In Nigeria, schistosomiasis, caused predominantly by the species Schistosoma haematobium, is highly endemic in resource-poor communities. We performed a school-based survey in two rural communities in Osun State (Southwestern Nigeria) and assessed macrohaematuria, microhaematuria and proteinuria as indirect indicators for the presence of disease. Urine samples were inspected macroscopically for haematuria and screened for microhaematuria and proteinuria using urine reagent strips. The microscopic examination of schistosome eggs was used as the gold standard for diagnosis. In total, 447 schoolchildren were included in this study and had a 51% prevalence of urinary schistosomiasis. The sensitivity of microhaematuria (68%) and proteinuria (53%) for infection with S. haematobium was relatively low. In patients with a heavy infection (>or= 500 eggs/10 mL), the sensitivity of microhaematuria was high (95%). When the presence of macrohaematuria and the concomitant presence of microhaematuria and proteinuria were combined, it revealed a sensitivity of 63%, a specificity of 93% and a positive predictive value of 91%. Macrohaematuria also showed high specificity (96%) and a positive predictive value of 92%, while sensitivity was < 50%. These data show that combining urine reagent strip tests (presence of proteinuria and microhaematuria) and information on macrohaematuria increased the accuracy of the rapid diagnosis of urinary schistosomiasis in an endemic rural West African setting. This simple approach can be used to increase the quality of monitoring of schistosomiasis in schoolchildren.

A highly efficacious pediculicide based on dimeticone: randomized observer blinded comparative trial.

BACKGROUND: Infestation with the human head louse (Pediculus humanus capitis) occurs worldwide. Existing treatment options are limited, and reports of resistance to commonly used pediculicides have been increasing. In this trial we assessed the efficacy of a product containing a high (92%) concentration of the silicone oil dimeticone (identical in composition to NYDA(R)), as compared to a 1% permethrin lotion. METHODS: Randomized, controlled, observer blinded clinical trial. Participants were recruited from a poor urban neighbourhood in Brazil where pediculosis capitis was highly prevalent. To minimize reinfestation during the trial, participants (145 children aged 5-15 years with head lice infestations) were transferred to a holiday resort outside the endemic area for a period of 9 days. Two applications of dimeticone or 1% permethrin were done, seven days apart. Outcome measures were defined as cure (absence of vital head lice) after first application and before and after second applications, degree of itching, cosmetic acceptability, and clinical pathology. RESULTS: Overall cure rates were: day 2 - dimeticone 94.5% (95% CI: 86.6% - 98.5%) and permethrin 66.7% (95% CI: 54.6% - 77.3%; p < 0.0001); day 7 - dimeticone 64.4% (95% CI: 53.3% - 75.3%) and permethrin 59.7% (95% CI: 47.5% - 71.1%; p = 0.5); day 9 - dimeticone 97.2% (95% CI: 90.3% - 99.7%) and permethrin 67.6% (95% CI: 55.4%-78.2%); p < 0.0001). Itching was reduced similarly in both groups. Cosmetic acceptability was significantly better in the dimeticone group as compared to the permethrin group (p = 0.01). Two mild product-related incidents occurred in the dimeticone group. CONCLUSION: The dimeticone product is a safe and highly efficacious pediculicide. Due to its physical mode of action (interruption of the lice's oxygen supply of the central nervous system), development of resistance is unlikely. TRIAL REGISTRATION: Current Controlled Trials ISRCTN15117709.

Parasites of importance for human health in Nigerian dogs: high prevalence and limited knowledge of pet owners.

BACKGROUND: Dogs are the most common pet animals worldwide. They may harbour a wide range of parasites with zoonotic potential, thus causing a health risk to humans. In Nigeria, epidemiological knowledge on these parasites is limited. METHODS: In a community-based study, we examined 396 dogs in urban and rural areas of Ilorin (Kwara State, Central Nigeria) for ectoparasites and intestinal helminths. In addition, a questionnaire regarding knowledge and practices was applied to pet owners. RESULTS: Nine ectoparasite species belonging to four taxa and six intestinal helminth species were identified: fleas (Ctenocephalides canis, Pulex irritans, Tunga penetrans), mites (Demodex canis, Otodectes sp., Sarcoptes scabiei var. canis), ticks (Rhipicephalus sanguineus, Ixodes sp.), and lice (Trichodectes canis); and Toxocara canis, Ancylostoma sp., Trichuris vulpis, Dipylidium caninum, Taenidae and Strongyloides sp. Overall prevalence of ectoparasites was 60.4% and of intestinal helminths 68.4%. The occurrence of C. canis, R. sanguineus, T. canis, Ancylostoma sp. and T. vulpis was most common (prevalence 14.4% to 41.7%). Prevalence patterns in helminths were age-dependent, with T. canis showing a decreasing prevalence with age of host, and a reverse trend in other parasite species. Knowledge regarding zoonoses was very limited and the diseases not considered a major health problem. Treatment with antiparasitic drugs was more frequent in urban areas. CONCLUSION: Parasites of importance for human health were highly prevalent in Nigerian dogs. Interventions should include health education provided to dog owners and the establishment of a program focusing on zoonotic diseases.

Pigs are the most important animal reservoir for Tunga penetrans (jigger flea) in rural Nigeria.

We examined the domestic animals and rodents in a community in rural Nigeria. Of the 133 animals examined, 29 (21.8%) were infested, the highest prevalence of infestation and highest parasite load was found in the pigs (prevalence 54.8%, median = nine embedded parasites), followed by dogs (45.5%; median = 4), Rattus rattus (29.4%; median = 2) and Mus minutoides (15.4%; median = 1.5). Of all the tungiasis lesions identified 83% were found in pigs. Our data confirm that tungiasis is a zoonotic disease, and that pigs are its most important animal reservoir in this endemic community.

[Tungiasis: a neglected disease causing severe morbidity in a shantytown in Fortaleza, State of Ceará]. / Tungíase: doença negligenciada causando patologia grave em uma favela de Fortaleza, Ceará.

The parasitic skin disease tungiasis, caused by the jigger flea Tunga penetrans, is endemic in low-income communities in Brazil. In this study, inhabitants of a shantytown in Fortaleza, northeastern Brazil, who had an elevated parasite load, were identified. The number of lesions, localization, staging and associated diseases were recorded. The 142 individuals identified were living in extremely precarious housing conditions. A total of 3,445 lesions located on the feet were counted (median = 17 lesions; maximum = 98 lesions). Almost without exception, the individuals had nail deformation and edema, and more than 70% presented with pain and fissures. There was nail loss in 46%; deformation of the digits in 25%; abscesses in 42%; and complaints of walking difficulty in 59%. Our data show that tungiasis in this low-income urban community typical of northeastern Brazil was associated with severe morbidity. Tungiasis needs to be recognized as a public health problem in this study area and other similar endemic areas.

Survey of visitors to a National Park in the savannah region of northeast Brazil: practices, incidents and hazardous situations.

BACKGROUND: Wilderness travellers to remote National Parks of Brazil may be particularly at risk of tropical diseases and injury. The aim of this study was to describe injury and illness, potentially hazardous situations, accidents and other incidents experienced by travellers to a remote National Park in Brazil. METHOD: The study was done in the National Park, "Serra da Capivara", in Piauí State northeast Brazil. Key informants were interviewed using semi-structured interviews, and a self-administered questionnaire was used for visitors. Questions included information on health problems and risk behaviour in the park, as well as pre-travel health advice. RESULTS: In total, 14 tour guides, 7 hotel managers and 17 health professionals were interviewed, as key informants. Eighty visitors returned the completed questionnaires (60 Brazilian, 20 foreigners). The key informants reported different risk behaviour of groups and individuals travellers, and incidents most commonly mentioned were minor injuries, insect bites/bee stings and allergic reactions. Seventy percent of the Brazilian and 55% of the foreign visitors had obtained pre-travel health advice, but only 5% of Brazilians and 15% of foreign visitors has obtained this advice from a physician. The most common source of information was other people who already had visited the park and travel books. Of the Brazilians, 13.3% reported some health incident during their stay, most commonly bee bites and headache. Two foreign travellers reported three incidents (insect bites/bee stings, diarrhoea and sunburn). Most commonly reported hazardous situations perceived by the tourists were possible accidents caused by falling from a stairway or falling stones, poisonous animals and insect bites/bee stings. CONCLUSIONS: Surveys conducted at remote tourist destinations are a feasible approach to report vulnerable situations, practices and incidents of visitors to a National Park. We have shown that most travellers are not adequately prepared and many experienced vulnerable situations during their visit to the National Park. It is important that visitors to National Parks in Brazil are encouraged to obtain travel health advice. The most common and potentially serious incident (bee stings) is rarely addressed in pre-travel health advice. Travel health advisers should ensure that they have access to locally relevant information for travellers, so that appropriate preventive measures can be instituted.

Prevalence and clinical aspects of tungiasis in south-west Nigerian schoolchildren.

Tungiasis is highly prevalent in resource-poor communities in sub-Saharan Africa, but studies among schoolchildren are scanty. We assessed prevalence, parasite load and clinical aspects of tungiasis in schoolchildren in south-western Nigeria. A total of 545 schoolchildren was examined. Of these, 133 (24.4%; 95% CI, 20.9-28.2%) were infested with Tunga penetrans Boys showed a higher prevalence than girls (31% versus 18%, P < 0.0001); in those infested, the median number of lesions was two, with no gender difference (2 boys, interquartile range, 1-4; 2 girls; interquartile range, 1-4; P = 0.34). The maximum number of 44 lesions was found in a 14-year-old boy. Desquamation was present in 90.2%, followed by erythema (54.9%) and oedema (43.6%); 54.9% showed any chronic pathology and more one-third nail deformations. Our study indicates that tungiasis is an important health problem in rural Nigerian schoolchildren. Sustainable interventions are required to control the disease in this and similar communities.

History of deep vein thrombosis is a discriminator for concomitant atrial fibrillation in pulmonary embolism.

BACKGROUND: Pulmonary embolism (PE) is the consequence of deep vein thrombosis (DVT) in 70% of all cases. Although, PE and DVT are commonly related to risk factors of Virchow's triad, both entities are linked to cardiovascular risk factors, but risk factors seem differently important in both entities. OBJECTIVES: We aimed to investigate clinical profile and outcome of patients with PE history stratified by concomitant DVT. PATIENTS/METHODS: Data from the observational multi-center thrombEVAL-study were analyzed. RESULTS: The sample (N=2,318) comprised 295 PE patients, of whom 69.2% (N=204) had DVT. Individuals without DVT were older and had higher prevalence of concomitant atrial fibrillation (AF), chronic lung diseases, coronary artery disease, heart failure and hypertension. Multivariable regression revealed an independent association of AF (Odds Ratio (OR) 3.17, 95% CI 1.63-6.18, P<0.001) and coronary artery disease (OR 2.31, 95% CI 1.15-4.66, P=0.019) with PE without DVT. There was higher frequency of permanent AF in individuals without DVT, whereas paroxysmal AF was more prevalent in individuals with DVT. All AF subtypes were independently associated with PE without DVT with increasing ORs from paroxysmal to permanent AF. PE patients with and without DVT did not differ in survival (P=0.32) and cost-relevant clinical outcome (P=0.26) during follow-up. AF in PE patients was associated with cost-relevant clinical outcome (Hazard Ratio (HR) 1.78, 95% CI 1.03-3.09, P=0.040), but no significant difference in survival (HR 0.93, 95% CI 0.35-2.50, P=0.88) was observed. CONCLUSIONS: History of DVT is a significant discriminator for clinical profile of PE patients. Individuals without DVT had more often cardiac and pulmonary disease with strongest association with AF. Data advocate a potential link between AF and PE. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov, Unique identifier NCT01809015.

Rationale and design of three observational, prospective cohort studies including biobanking to evaluate and improve diagnostics, management strategies and risk stratification in venous thromboembolism: the VTEval Project.

INTRODUCTION: Venous thromboembolism (VTE) with its two manifestations deep vein thrombosis (DVT) and pulmonary embolism (PE) is a major public health problem. The VTEval Project aims to investigate numerous research questions on diagnosis, clinical management, treatment and prognosis of VTE, which have remained uncertain to date. METHODS AND ANALYSIS: The VTEval Project consists of three observational, prospective cohort studies on VTE comprising cohorts of individuals with a clinical suspicion of acute PE (with or without DVT), with a clinical suspicion of acute DVT (without symptomatic PE) and with an incidental diagnosis of VTE (PE or DVT). The VTEval Project expects to enrol a total of approximately 2000 individuals with subsequent active and passive follow-up investigations over a time period of 5 years per participant. Time points for active follow-up investigations are at months 3, 6, 12, 24 and 36 after diagnosis (depending on the disease cohort); passive follow-up investigations via registry offices and the cancer registry are performed 48 and 60 months after diagnosis for all participants. Primary short-term outcome is defined by overall mortality (PE-related death and all other causes of death), primary long-term outcome by symptomatic VTE (PE-related death, recurrence of non-fatal PE or DVT). The VTEval Project includes three 'all-comer' studies and involves the standardised acquisition of high-quality data, covering the systematic assessment of VTE including symptoms, risk profile, psychosocial, environmental and lifestyle factors as well as clinical and subclinical disease, and it builds up a large state-of-the-art biorepository containing various materials from serial blood samplings. ETHICS AND DISSEMINATION: The VTEval Project has been approved by the local data safety commissioner and the responsible ethics committee (reference no. 837.320.12 (8421-F)). Trial results will be published in peer-reviewed journals and presented at national and international scientific meetings. TRIAL REGISTRATION NUMBER: NCT02156401.

Migration among individuals with leprosy: a population-based study in central Brazil.

This study investigates social and clinical factors associated with migration among individuals affected by leprosy. A cross-sectional study was conducted among those newly diagnosed with leprosy (2006-2008), in 79 endemic municipalities in the state of Tocantins, Brazil (N = 1,074). In total, 76.2% were born in a municipality different from their current residence. In the five years before diagnosis 16.7% migrated, and 3.6% migrated after leprosy diagnosis. Findings reflect aspects associated with historical rural-urban population movement in Brazil. Indicators of poverty were prominent among before-diagnosis migrants but not after-diagnosis migrants. Migration after diagnosis was associated with prior migration. The association of multibacillary leprosy with migration indicates healthcare access may be an obstacle to early diagnosis among before-diagnosis migrants, which may also be related to the high mobility of this group.

Interruption and defaulting of multidrug therapy against leprosy: population-based study in Brazil's Savannah Region.

BACKGROUND: Low adherence to multidrug therapy against leprosy (MDT) is still an important obstacle of disease control, and may lead to remaining sources of infection, incomplete cure, irreversible complications, and multidrug resistance. METHODOLOGY/PRINCIPAL FINDING: We performed a population-based study in 78 municipalities in Tocantins State, central Brazil, and applied structured questionnaires on leprosy-affected individuals. We used two outcomes for assessment of risk factors: defaulting (not presenting to health care center for supervised treatment for >12 months); and interruption of MDT. In total, 28/936 (3.0%) patients defaulted, and 147/806 (18.2%) interrupted MDT. Defaulting was significantly associated with: low number of rooms per household (OR = 3.43; 0.98-9.69; p = 0.03); moving to another residence after diagnosis (OR = 2.90; 0.95-5.28; p = 0.04); and low family income (OR = 2.42; 1.02-5.63: p = 0.04). Interruption of treatment was associated with: low number of rooms per household (OR = 1.95; 0.98-3.70; p = 0.04); difficulty in swallowing MDT drugs (OR = 1.66; 1.03-2.63; p = 0.02); temporal non-availability of MDT at the health center (OR = 1.67; 1.11-2.46; p = 0.01); and moving to another residence (OR = 1.58; 95% confidence interval: 1.03-2.40; p = 0.03). Logistic regression identified temporal non-availability of MDT as an independent risk factor for treatment interruption (adjusted OR = 1.56; 1.05-2.33; p = 0.03), and residence size as a protective factor (adjusted OR = 0.89 per additional number of rooms; 0.80-0.99; p = 0.03). Residence size was also independently associated with defaulting (adjusted OR = 0.67; 0.52-0.88; p = 0.003). CONCLUSIONS: Defaulting and interruption of MDT are associated with some poverty-related variables such as family income, household size, and migration. Intermittent problems of drug supply need to be resolved, mainly on the municipality level. MDT producers should consider oral drug formulations that may be more easily accepted by patients. Thus, an integrated approach is needed for further improving control, focusing on vulnerable population groups and the local health system.

Control of tungiasis through intermittent application of a plant-based repellent: an intervention study in a resource-poor community in Brazil.

BACKGROUND: Tungiasis, an ectoparasitosis caused by the female sand flea Tunga penetrans, is an important health problem in many impoverished communities in the tropics. Sand flea disease is associated with a broad spectrum of clinical pathology and severe sequels are frequent. Treatment options are limited. METHODOLOGY/PRINCIPAL FINDINGS: We assessed the effectiveness of the intermittent application of the plant-based repellent Zanzarin to reduce infestation intensity and tungiasis-associated morbidity in a resource-poor community in Brazil, characterized by a very high attack rate. The study population was randomized into three cohorts. Initially, during a period of four weeks, the repellent was applied twice daily to the feet of all cohort members. This reduced the number of embedded sandfleas to 0 in 98% of the participants. Thereafter members of cohort A applied the repellent every second week twice daily for one week, members of cohort B every fourth week for one week, and members of cohort C served as controls. Infestation intensity and tungiasis-associated morbidity were monitored during five months. The intermittent application of Zanzarin for one week every second week significantly reduced infestation intensity from a median 4 lesions (IQR 1-9) during the whole transmission season. In contrast, in cohort B (application of the repellent every fourth week) the infestation intensity remained twice as high (median 8 lesions, IQR 9-16; p = 0.0035), and in the control cohort C 3.5 times as high (median 14 lesions; IQR 7-26; p = 0.004 during the transmission season). Tungiasis-related acute pathology remained very low in cohort A (median severity score 2; IQR 1-4) as compared to cohort B (median severity score 5; IQR 3-7; p<0.001), and control cohort C (median severity score 6.5; IQR 4-8; p<0.001). CONCLUSIONS/SIGNIFICANCE: Our study shows that in a setting with intense transmission, tungiasis-associated morbidity can be minimized through the intermittent application of a plant-based repellent.

Prevalence and risk factors of toxoplasmosis among pregnant women in Fortaleza, Northeastern Brazil.

We determined the seroprevalence of Toxoplasma gondii and associated risk factors among 963 pregnant women attending an obstetric hospital in Fortaleza, Brazil. Seroprevalences of IgG and IgM against T. gondii were 68.6% (95% confidence interval [CI] = 65.6-71.6%) and 0.5% (95% CI = 0.06-1.0%), respectively. Seroprevalence of IgG was high in women less than 25 years of age (91.7%) and in low-income women (odds Ratio [OR] = 1.40, 95% CI = 1.02-1.90). Multivariate regression analysis showed that consumption of homemade water ice (adjusted OR = 1.49, 95% CI = 1.09-2.04), vegetables washed with untreated water (adjusted OR = 1.43, 95% CI = 1.05-1.94), consumption of chicken (adjusted OR = 1.49, 95% CI = 1.12-2.0), and dog ownership (adjusted OR= 1.46, 95% CI = 1.07-1.98) were factors associated with IgG seropositivity. Young women in northeastern Brazil living under poor socioeconomic conditions are at highest risk for acquiring infection with T. gondii. Oocyst contamination of water and soil must be addressed in future prevention strategies.

Migration among individuals with leprosy: a population-based study in Central Brazil / Migração entre pessoas com hanseníase: estudo de base populacional no Centro-Oeste do Brasil / La migración entre personas con lepra: un estudio basado en la población en el centro de Brasil

This study investigates social and clinical factors associated with migration among individuals affected by leprosy. A cross-sectional study was conducted among those newly diagnosed with leprosy (2006-2008), in 79 endemic municipalities in the state of Tocantins, Brazil (N = 1,074). In total, 76.2% were born in a municipality different from their current residence. In the five years before diagnosis 16.7% migrated, and 3.6% migrated after leprosy diagnosis. Findings reflect aspects associated with historical rural-urban population movement in Brazil. Indicators of poverty were prominent among before-diagnosis migrants but not after-diagnosis migrants. Migration after diagnosis was associated with prior migration. The association of multibacillary leprosy with migration indicates healthcare access may be an obstacle to early diagnosis among before-diagnosis migrants, which may also be related to the high mobility of this group.

Este estudo investiga fatores sociais e clínicos associados à migração entre pessoas afetadas pela hanseníase. Estudo transversal entre recém- diagnosticados com hanseníase (2006-2008), em 79 municípios endêmicos do Estado de Tocantins, Brasil (N = 1.074). No total, 76,2% nasceram em município diferente de sua residência atual. Nos cinco anos antes do diagnóstico, 16,7% migraram, e 3,6% migraram após o diagnóstico da hanseníase. Resultados refletem aspectos associados com o movimento histórico da população rural-urbana no Brasil. Indicadores de pobreza foram proeminentes antes do diagnóstico de migrantes. A migração após o diagnóstico foi associada com migração anterior. A associação da forma multibacilar com migração indica que o acesso à saúde pode ser um obstáculo para o diagnóstico precoce de migrantes, o que pode também estar relacionado com a elevada mobilidade desse grupo.

Este estudio investiga los factores sociales y clínicos asociados con la migración entre las personas afectadas por lepra. Un estudio transversal se llevó a cabo entre las personas recién diagnosticadas con lepra (2006-2008), en 79 municipios endémicos en el estado de Tocantins, Brasil (N = 1,074). En total, el 76,2% nacieron en otro municipio diferente a su residencia actual. En los cinco años antes del diagnóstico el 16,7% emigró, y el 3,6% migró después del diagnóstico de lepra. Los resultados reflejan aspectos relacionados con el movimiento histórico de la población rural-urbana en Brasil. Los indicadores de pobreza fueron sobresalientes entre el grupo de migrantes antes del diagnóstico. La migración tras el diagnóstico se asoció a una migración anterior. La asociación de lepra multibacilar con migración indica que el acceso a la atención médica puede ser un obstáculo para el diagnóstico temprano en el grupo de migrantes antes de la migración.

Risk factors for tungiasis in Nigeria: identification of targets for effective intervention.

BACKGROUND: The parasitic skin disease tungiasis (caused by the flea Tunga penetrans) affects resource-poor communities in Latin America, the Caribbean and sub-Saharan Africa. Prevalences in endemic areas are high, and severe pathology occurs commonly. However, risk factors for infestation have never been assessed in Africa. METHODS AND FINDINGS: A cross-sectional study was conducted in Erekiti, a rural community in Lagos State (Nigeria), where tungiasis is endemic. Individuals were examined clinically for the presence of tungiasis, and a questionnaire was applied. Data from 643 individuals (86.6% of the target population) were analyzed; 252 (42.5%) were infested with T. penetrans. In the multivariate logistic regression analysis, presence of pigs on the compounds (adjusted odds ratio = 17.98; 95% confidence interval: 5.55-58.23), sand or clay floor inside houses (9.33; 5.06-17.19), and having the common resting place outside the house (7.14; 4.0-14.29) were the most important risk factors identified. The regular use of closed footwear (0.34; 0.18-0.62) and the use of insecticides indoors (0.2; 0.05-0.83) were protective against infestation. The population attributable fractions associated with tungiasis were: sand or clay floor inside the house (73.7%), resting usually outside the house (65.5%), no regular use of closed footwear (51.1%), and pigs on the compound (37.9%). CONCLUSION: The presence of tungiasis in Erekiti is determined to an important extent by a limited number of modifiable variables. Effective and sustainable intervention measures addressing these factors need to be implemented in this and other West African communities with high disease burden.

Conhecimento dos profissionais de saúde sobre a situação da tungíase em uma área endêmica no município de Uberlândia, Minas Gerais, Brasil, 2010 / Tungiasis-related knowledge of health professionals from an endemic area of Uberlândia, Minas Gerais, Brazil, 2010

Objetivo: descrever o conhecimento dos profissionais de saúde sobre a tungíase em área endêmica. Métodos: estudo transversal, mediante aplicação de questionário estruturado a profissionais de Saúde Pública de seis bairros no município de Uberlândia, estado de Minas Gerais, Brasil, em 2010. Resultados: participaram do estudo 78 profissionais de saúde, dos quais 38 observaram alta prevalência de tungíase em humanos; para 61 deles, a ocorrência da tungíase tem variação sazonal, de julho a setembro; casos graves foram corretamente associados a infecções secundárias (20/78) ou superinfestação (11/78); a maioria das questões teve considerável proporção de respostas ‘Não sabe’ (Mín-Máx: 8/78-52/78), especialmente aquelas relacionadas à epidemiologia da doença. Conclusão: a tungíase é negligenciada na atenção primária e o conhecimento dos profissionais de saúde sobre a doença, mesmo lotados em área endêmica, é insuficiente.

Objective: to describe tungiasis-related knowledge of health professionals in an endemic area. Methods: a cross-sectional study, using structured questionnaire applied to 78 public health professionals of six districts in the municipality of Uberlândia, state of Minas Gerais, Brazil, in 2010. Results: the study included 78 health professionals, from which 38 reported their observation of high prevalence of tungiasis in humans; for 61 of them, tungiasis occurrence has seasonal variation, from July to September; severe cases were correctly associated with secondary infections (20/78) or superinfestation (11/78); most of the questions had considerable proportion of answers 'Do not know' (Min-Max: 8/78-52/78), especially those related to the epidemiology of the disease. Conclusion: tungiasis is neglected by primary health care and the knowledge of health professionals about the disease, even in endemic areas were they work, is insufficient.

A simple approach improving the performance of urine reagent strips for rapid diagnosis of urinary schistosomiasis in Nigerian schoolchildren

In Nigeria, schistosomiasis, caused predominantly by the species Schistosoma haematobium, is highly endemic in resource-poor communities. We performed a school-based survey in two rural communities in Osun State (Southwestern Nigeria) and assessed macrohaematuria, microhaematuria and proteinuria as indirect indicators for the presence of disease. Urine samples were inspected macroscopically for haematuria and screened for microhaematuria and proteinuria using urine reagent strips. The microscopic examination of schistosome eggs was used as the gold standard for diagnosis. In total, 447 schoolchildren were included in this study and had a 51 percent prevalence of urinary schistosomiasis. The sensitivity of microhaematuria (68 percent) and proteinuria (53 percent) for infection with S. haematobium was relatively low. In patients with a heavy infection (>500 eggs/10 mL), the sensitivity of microhaematuria was high (95 percent). When the presence of macrohaematuria and the concomitant presence of microhaematuria and proteinuria were combined, it revealed a sensitivity of 63 percent, a specificity of 93 percent and a positive predictive value of 91 percent. Macrohaematuria also showed high specificity (96 percent) and a positive predictive value of 92 percent, while sensitivity was < 50 percent. These data show that combining urine reagent strip tests (presence of proteinuria and microhaematuria) and information on macrohaematuria increased the accuracy of the rapid diagnosis of urinary schistosomiasis in an endemic rural West African setting. This simple approach can be used to increase the quality of monitoring of schistosomiasis in schoolchildren.