Assessment of the foot-and-mouth disease surveillance system in Brazil.

In 2021, the 88th General Session of the World Assembly of National Delegates to the World Organisation for Animal Health (OIE) recognized the estates of Acre, Paraná, the Rio Grande do Sul, and Rondônia as being free of foot-and-mouth disease (FMD) without vaccination. The certification was also extended to some cities in Amazonas and Mato Grosso. The new national strategic plan for 2026, which focuses on creating and maintaining sustainable conditions to expand FMD-free zones without vaccination, imposes new challenges and requires continuous evaluation of the FMD surveillance system. The objective of this research was to evaluate the FMD surveillance system in Brazil using quantitative models through Bayesian network approaches. The research was conducted using the Continental Surveillance and Information System (SivCont) database for Official Veterinary Services in Brazil, which refers to notified vesicular syndromes. The data on states, reported diseases, source of notification, disease confirmation, and timeliness (TL in days) of the delay by owners in notifying (TL.1) after a suspected case of the disease, and the response of Brazilian Veterinary Services after being notified (TL.2), were analysed. The collected data were analysed using Bayesian networks. It was observed that diseases with symptoms identical to FMD are the most notified events. TL.1 was long (mean of 18.96, CI: 18.33-19.59), and a low number of notifications was observed throughout the study period, which increases the chances of disseminating FMD in the population. Meanwhile, TL.2 suggests appropriate effectiveness of the Veterinary Services responding to suspected cases of FMD with interventions in less than 24 h (mean of 1, CI: 0.68-1.31). This study evaluated the performance of Brazilian Veterinary Services facing the report of vesicular diseases in the period 2004-2018. The results can help the states improve the surveillance system and the transition to the vaccination stop. Furthermore, the analytical method presented in the paper could serve as a model for other countries to evaluate the effectiveness of FMD surveillance systems.

Outcomes of critically ill patients with acute kidney injury in COVID-19 infection: an observational study.

BACKGROUND: Early reports indicate that AKI is common during COVID-19 infection. Different mortality rates of AKI due to SARS-CoV-2 have been reported, based on the degree of organic dysfunction and varying from public to private hospitals. However, there is a lack of data about AKI among critically ill patients with COVID-19. METHODS: We conducted a multicenter cohort study of 424 critically ill adults with severe acute respiratory syndrome (SARS) and AKI, both associated with SARS-CoV-2, admitted to six public ICUs in Brazil. We used multivariable logistic regression to identify risk factors for AKI severity and in-hospital mortality. RESULTS: The average age was 66.42 ± 13.79 years, 90.3% were on mechanical ventilation (MV), 76.6% were at KDIGO stage 3, and 79% underwent hemodialysis. The overall mortality was 90.1%. We found a higher frequency of dialysis (82.7% versus 45.2%), MV (95% versus 47.6%), vasopressors (81.2% versus 35.7%) (p < 0.001) and severe AKI (79.3% versus 52.4%; p = 0.002) in nonsurvivors. MV, vasopressors, dialysis, sepsis-associated AKI, and death (p < 0.001) were more frequent in KDIGO 3. Logistic regression for death demonstrated an association with MV (OR = 8.44; CI 3.43-20.74) and vasopressors (OR = 2.93; CI 1.28-6.71; p < 0.001). Severe AKI and dialysis need were not independent risk factors for death. MV (OR = 2.60; CI 1.23-5.45) and vasopressors (OR = 1.95; CI 1.12-3.99) were also independent risk factors for KDIGO 3 (p < 0.001). CONCLUSION: Critically ill patients with SARS and AKI due to COVID-19 had high mortality in this cohort. Mortality was largely determined by the need for mechanical ventilation and vasopressors rather than AKI severity.

Participatory Surveillance Based on Crowdsourcing During the Rio 2016 Olympic Games Using the Guardians of Health Platform: Descriptive Study.

BACKGROUND: With the evolution of digital media, areas such as public health are adding new platforms to complement traditional systems of epidemiological surveillance. Participatory surveillance and digital epidemiology have become innovative tools for the construction of epidemiological landscapes with citizens' participation, improving traditional sources of information. Strategies such as these promote the timely detection of warning signs for outbreaks and epidemics in the region. OBJECTIVE: This study aims to describe the participatory surveillance platform Guardians of Health, which was used in a project conducted during the 2016 Olympic and Paralympic Games in Rio de Janeiro, Brazil, and officially used by the Brazilian Ministry of Health for the monitoring of outbreaks and epidemics. METHODS: This is a descriptive study carried out using secondary data from Guardians of Health available in a public digital repository. Based on syndromic signals, the information subsidy for decision making by policy makers and health managers becomes more dynamic and assertive. This type of information source can be used as an early route to understand the epidemiological scenario. RESULTS: The main result of this research was demonstrating the use of the participatory surveillance platform as an additional source of information for the epidemiological surveillance performed in Brazil during a mass gathering. The platform Guardians of Health had 7848 users who generated 12,746 reports about their health status. Among these reports, the following were identified: 161 users with diarrheal syndrome, 68 users with respiratory syndrome, and 145 users with rash syndrome. CONCLUSIONS: It is hoped that epidemiological surveillance professionals, researchers, managers, and workers become aware of, and allow themselves to use, new tools that improve information management for decision making and knowledge production. This way, we may follow the path for a more intelligent, efficient, and pragmatic disease control system.

Timeliness of vesicular disease notification system in Brazilian foot-and-mouth disease surveillance programme.

Animal health surveillance programmes should be reliable and informative to ensure their effective implementation. As such, the regular assessment of those aiming to demonstrate the absence of disease, as well as the ability to detect outbreaks on time, is of vital importance. Several criteria make it possible to assess the performance of surveillance systems, including timeliness, which represents the speed between steps in a surveillance system. Therefore, the objective of this study was to evaluate the variability in the timeliness, within and between states, of the surveillance programme of the Brazilian Veterinary Services (BVS) for foot-and-mouth disease (FMD), for the notification of vesicular disease. A total of 14 years (2004-2017) of data relating to vesicular syndromes from the Brazilian Continental Information and Surveillance System (SivCont) were included. A categorical variable was created with four classes to group the notified vesicular processes in the SivCont, according to two criteria, the similarity of the symptoms of the diseases reported with FMD and aetiology (viral, bacterial, fungal and non-infectious). The three timeliness values (TL-1, TL-2 and TL-3) related to different portions of the FMD surveillance system were analysed as a response in a generalized linear model in which the states of Brazil were the explanatory variables. The analyses were performed separately for each notification class (FMD, vesicular stomatitis, similar symptoms and similar non-infectious symptoms) and included comparisons within and between states. The study results provide an understanding and evaluation of the timeliness of the Brazilian FMD surveillance system, thereby providing a base of knowledge from which involved agents and decision-makers can evaluate BVS and reinforce surveillance measures in the states with poorer timeliness than permitted.

Saúde na Copa: The World's First Application of Participatory Surveillance for a Mass Gathering at FIFA World Cup 2014, Brazil.

BACKGROUND: The 2005 International Health Regulations (IHRs) established parameters for event assessments and notifications that may constitute public health emergencies of international concern. These requirements and parameters opened up space for the use of nonofficial mechanisms (such as websites, blogs, and social networks) and technological improvements of communication that can streamline the detection, monitoring, and response to health problems, and thus reduce damage caused by these problems. Specifically, the revised IHR created space for participatory surveillance to function, in addition to the traditional surveillance mechanisms of detection, monitoring, and response. Participatory surveillance is based on crowdsourcing methods that collect information from society and then return the collective knowledge gained from that information back to society. The spread of digital social networks and wiki-style knowledge platforms has created a very favorable environment for this model of production and social control of information. OBJECTIVE: The aim of this study was to describe the use of a participatory surveillance app, Healthy Cup, for the early detection of acute disease outbreaks during the Fédération Internationale de Football Association (FIFA) World Cup 2014. Our focus was on three specific syndromes (respiratory, diarrheal, and rash) related to six diseases that were considered important in a mass gathering context (influenza, measles, rubella, cholera, acute diarrhea, and dengue fever). METHODS: From May 12 to July 13, 2014, users from anywhere in the world were able to download the Healthy Cup app and record their health condition, reporting whether they were good, very good, ill, or very ill. For users that reported being ill or very ill, a screen with a list of 10 symptoms was displayed. Participatory surveillance allows for the real-time identification of aggregates of symptoms that indicate possible cases of infectious diseases. RESULTS: From May 12 through July 13, 2014, there were 9434 downloads of the Healthy Cup app and 7155 (75.84%) registered users. Among the registered users, 4706 (4706/7155, 65.77%) were active users who posted a total of 47,879 times during the study period. The maximum number of users that signed up in one day occurred on May 30, 2014, the day that the app was officially launched by the Minister of Health during a press conference. During this event, the Minister of Health announced the special government program Health in the World Cup on national television media. On that date, 3633 logins were recorded, which accounted for more than half of all sign-ups across the entire duration of the study (50.78%, 3633/7155). CONCLUSIONS: Participatory surveillance through community engagement is an innovative way to conduct epidemiological surveillance. Compared to traditional epidemiological surveillance, advantages include lower costs of data acquisition, timeliness of information collected and shared, platform scalability, and capacity for integration between the population being served and public health services.

The Malaria System MicroApp: A New, Mobile Device-Based Tool for Malaria Diagnosis.

BACKGROUND: Malaria is a public health problem that affects remote areas worldwide. Climate change has contributed to the problem by allowing for the survival of Anopheles in previously uninhabited areas. As such, several groups have made developing news systems for the automated diagnosis of malaria a priority. OBJECTIVE: The objective of this study was to develop a new, automated, mobile device-based diagnostic system for malaria. The system uses Giemsa-stained peripheral blood samples combined with light microscopy to identify the Plasmodium falciparum species in the ring stage of development. METHODS: The system uses image processing and artificial intelligence techniques as well as a known face detection algorithm to identify Plasmodium parasites. The algorithm is based on integral image and haar-like features concepts, and makes use of weak classifiers with adaptive boosting learning. The search scope of the learning algorithm is reduced in the preprocessing step by removing the background around blood cells. RESULTS: As a proof of concept experiment, the tool was used on 555 malaria-positive and 777 malaria-negative previously-made slides. The accuracy of the system was, on average, 91%, meaning that for every 100 parasite-infected samples, 91 were identified correctly. CONCLUSIONS: Accessibility barriers of low-resource countries can be addressed with low-cost diagnostic tools. Our system, developed for mobile devices (mobile phones and tablets), addresses this by enabling access to health centers in remote communities, and importantly, not depending on extensive malaria expertise or expensive diagnostic detection equipment.

Using mobile technology to conduct epidemiological investigations.

INTRODUCTION: The aim of this study was to report the experience of an epidemiological field survey for which data were collected and analyzed using tablets. METHODS: The devices used Epi Info 7 (Android version), which has been modeled a database with variables of the traditional form. RESULTS: Twenty-one households were randomly selected in the study area; 75 residents were registered and completed household interviews with socioeconomic and environmental risk variables. CONCLUSIONS: This new technology is a valuable tool for collecting and analyzing data from the field, with advantageous benefits to epidemiological surveys.

The schisto track: a system for gathering and monitoring epidemiological surveys by connecting geographical information systems in real time.

BACKGROUND: Using the Android platform as a notification instrument for diseases and disorders forms a new alternative for computerization of epidemiological studies. OBJECTIVE: The objective of our study was to construct a tool for gathering epidemiological data on schistosomiasis using the Android platform. METHODS: The developed application (app), named the Schisto Track, is a tool for data capture and analysis that was designed to meet the needs of a traditional epidemiological survey. An initial version of the app was finished and tested in both real situations and simulations for epidemiological surveys. RESULTS: The app proved to be a tool capable of automation of activities, with data organization and standardization, easy data recovery (to enable interfacing with other systems), and totally modular architecture. CONCLUSIONS: The proposed Schisto Track is in line with worldwide trends toward use of smartphones with the Android platform for modeling epidemiological scenarios.

Epidemiologia da esquistossomose no litoral de Pernambuco / Epidemiology of schistosomiasis in coastal areas of Pernambuco State, Brazil

A expansão da esquistossomose para o litoral de Pernambuco vem sendo registrada desde 1992 coma detecção de casos agudos da doença em indivíduos de classe média/alta. Para diagnosticar estenovo cenário de transmissão da endemia em localidades turísticas na orla marítima do estado é defundamental importância o conhecimento prévio da distribuição georreferenciada das espécies demoluscos vetores, por meio de mapas que apontem sua exata localização, assim como é necessárioespacializar as situações de risco biológico e as condições ambientais insalubres. Nos períodos de 15a 18 de setembro de 2008 e 10 a 13 de setembro de 2013 foram realizadas caravanas expedicionárias,por epidemiologistas e parasitologistas por 11 municípios do litoral do estado, percorrendo todasas coleções de água doce distantes até 2 km da beira-mar. Os dados foram georreferenciados paraposterior condução de análises espaciais. Para identificação da positividade dos exemplares deBiomphalaria glabrata, foi utilizada a técnica de exposição à luz. Os espécimes de B. stramineaque permaneceram negativos até o 15º dia foram submetidos à técnica de diagnóstico molecular(PCR-single tube). Nas coletas de 2008 foram capturados 3.392 caramujos B. glabrata e 725 B.straminea, cujas taxas de infecção variaram entre 0,9 por cento a 22,2 por cento. Em 2013, foram coletados 948B. glabrata e 504 B. straminea e somente foram encontrados caramujos eliminando cercarias nalocalidade Porto de Galinhas com taxa de infectividade de 81,4 por cento, permanecendo como localidadede maior risco para transmissão da esquistossomose.

The expansion of schistosomiasis to the coast of Pernambuco has been registered since 1992 withthe detection of acute cases of the disease in individuals of middle/upper class. To diagnose thisnew scenario of transmission of schistosomiasis in tourist areas on the waterfront of the state,knowledge of georeferenced species distribution of vector snails through maps that show theirexact location seems essential, as it is necessary to localize situations with biohazard and unhealthyenvironmental conditions. From 15 to 18 September 2008 and 10 to 13 September 2013, expeditionswere conducted by groups of epidemiologists and parasitologists for 11 coastal municipalities ofthe state, checking all the collections of fresh water up to 2 km away from the seaside. Data weregeoreferenced for a later conduction of spatial analysis. For positive identification of Biomphalariaglabrata, the technique of light exposure was used. Specimens of B. straminea that remainednegative until the 15th day underwent the technique of molecular diagnosis (PCR-single tube). Inthe 2008 expedition, 3,392 B. glabrata snails and 725 B. straminea snails were captured, whose infection rates ranged from 0.9 percent to 22.2 percent. In the 2013 expedition, 948 B. glabrata and 504 B. straminea snails were collected and only in Porto de Galinhas city were B. glabrata snails found releasing S. mansoni cercariae, with an infectivity rate of 81.4 percent, confirming that in this locality the risk of schistosomiasis transmission is still present.

Schistosomiasis transmission and environmental change: a spatio-temporal analysis in Porto de Galinhas, Pernambuco--Brazil.

BACKGROUND: In Brazil, schistosomiasis mansoni infection is an endemic disease that mainly affects the country's rural populations who carry out domestic and social activities in rivers and water accumulations that provide shelter for the snails of the disease. The process of rural migration to urban centers and the disorderly occupation of natural environments by these populations from endemic areas have favored expansion of schistosomiasis to locations that had been considered to be disease-free. Based on environmental changes that have occurred in consequent to an occupation and urbanization process in the locality of Porto de Galinhas, the present study sought to identify the relationship between those chances, measure by remote-sensing techniques, and establish a new endemic area for schistosomiasis on the coast of Pernambuco State--Brazil. METHODS: To gather prevalence data, two parasitological census surveys were conducted (2000 and 2010) using the Kato-Katz technique. Two malacological surveys were also conducted in the same years in order to define the density and infection rate of the intermediate host. Based on these data, spatial analyses were done, resulting in maps of the risk of disease transmission. To ascertain the environmental changes that have occurred at the locality, images from the QuickBird satellite were analyzed, thus resulting in land use maps. RESULTS: Over this 10-year period, the foci of schistosomiasis became more concentrated in the Salinas district. This area was considered to be at the greatest risk of schistosomiasis transmission and had the highest prevalence rates over this period. The study illustrated that this was the area most affected by the environmental changes resulting from the disorderly urbanization process, which gave rise to unsanitary environments that favored the establishment and maintenance of foci of schistosomiasis transmission, thereby consolidating the process of expansion and endemization of this parasitosis.

Spatial pattern, water use and risk levels associated with the transmission of schistosomiasis on the north coast of Pernambuco, Brazil.

This study aimed to describe epidemiological aspects of schistosomiasis in Carne de Vaca, Goiana, on the coast of Pernambuco State, Brazil and analyze the spatial distribution of households' sanitary conditions and patterns of water contact. A parasitological survey was conducted between 2006 and 2007. An indicator was set to establish risk levels for schistosomiasis based on variables of water contact pattern, household characteristics and proximity to the foci of vector snails. The prevalence was 18.71 in men and 15.96 in women. The age groups most affected were 20-29 years among men and 10-19 among women. The most common parasite load was 1-99 eggs per gram of feces. The prevalence was 17.3 cases per 100 inhabitants and its spatial distribution was not homogeneous. The Bayesian analysis proved unsatisfactory. It is concluded that schistosomiasis is endemic in Carne de Vaca and the risk indicator, based on geoprocessing, proved to be satisfactory, highlighting areas where the problem is more acute.

Spatial pattern, water use and risk levels associated with the transmission of schistosomiasis on the north coast of Pernambuco, Brazil / Padrão espacial, uso da água e níveis de risco associados à transmissão da esquistossomose no litoral norte de Pernambuco, Brasil

This study aimed to describe epidemiological aspects of schistosomiasis in Carne de Vaca, Goiana, on the coast of Pernambuco State, Brazil and analyze the spatial distribution of households' sanitary conditions and patterns of water contact. A parasitological survey was conducted between 2006 and 2007. An indicator was set to establish risk levels for schistosomiasis based on variables of water contact pattern, household characteristics and proximity to the foci of vector snails. The prevalence was 18.71 in men and 15.96 in women. The age groups most affected were 20-29 years among men and 10-19 among women. The most common parasite load was 1-99 eggs per gram of feces. The prevalence was 17.3 cases per 100 inhabitants and its spatial distribution was not homogeneous. The Bayesian analysis proved unsatisfactory. It is concluded that schistosomiasis is endemic in Carne de Vaca and the risk indicator, based on geoprocessing, proved to be satisfactory, highlighting areas where the problem is more acute.

O estudo objetivou descrever aspectos epidemiológicos da esquistossomose em Carne de Vaca, litoral de Pernambuco, Brasil, e analisar a distribuição espacial das condições de esgotamento sanitário e padrão de contato com a água. Foi realizado um inquérito parasitológico entre 2006 e 2007, e criado indicador de risco para a esquistossomose com base em variáveis do padrão de água de contato, características do agregado familiar e da proximidade com focos de moluscos vetores. A prevalência em homens foi de 18,71, e 15,96 em mulheres. A faixa etária mais acometida em homens e mulheres foi de 20-29 e 10-19, respectivamente. A carga parasitária mais freqüente foi de 1-99 ovos por grama de fezes. A prevalência foi de 17,3 casos por 100 habitantes e sua distribuição espacial não foi homogênea. A estatística Bayesiana não se mostrou satisfatória. Conclui-se que a esquistossomose é endêmica em Carne de Vaca e que o indicador de risco com base em geoprocessamento revelou-se satisfatório, destacando as áreas onde o problema é mais relevante.

Aspectos ecológicos e levantamento malacológico para identificação de áreas de risco para transmissão da esquistossomose mansoni no litoral norte de Pernambuco, Brasil

It was carried out a malacological survey at Carne de Vaca beach, Goiana municipality, Pernambuco North coast, between November 2006 and October 2007 in order to know the malacological fauna of this town and verify the natural, slightly or more modified conditions of mollusks sites by using an habitat diversity protocol analysis. From 5,912 mollusks collected, they belong to seven species and four families, as follows: 5,209 Biomphalaria glabrata (Say, 1818) specimens, 113 of Drepanotrema lucidum (Pfeiffer, 1839), 55 of Drepanotrema cimex (Moricand, 1837), 13 of Drepanotrema anatinum (Pfeiffer, 1839), 222 of Melanoides tuberculatus (Muller, 1774), 263 of Pomacea sp. and 37 of Physa marmorata Guilding, 1828. Among B. glabrata collected, 44 specimens were positive for Schistosoma mansoni Sambon, 1907 cercariae and 91 specimens were positive for other trematode larvae. One Pomacea sp. specimen was positive for trematode larvae. These data, spatially georeferenced, will be used for determination of risk' sites for schistosomiasis transmission at Carne de Vaca beach and furthermore, they will be used for computational simulations to determine the expansion process of schistosomiasis in state of Pernambuco.

Realizou-se levantamento malacológico na praia de Carne de Vaca, município de Goiana, litoral norte de Pernambuco, entre novembro de 2006 e outubro de 2007, com o objetivo de conhecer a fauna malacológica dessa localidade e verificar as condições naturais, pouco ou bastante alteradas das áreas de estudo através da aplicação de um protocolo de avaliação de diversidade de hábitats. Foram coletados 5.912 moluscos, representados por sete espécies e quatro famílias, dos quais, 5.209 exemplares de Biomphalaria glabrata (Say, 1818), 113 de Drepanotrema lucidum (Pfeiffer, 1839), 55 de Drepanotrema cimex (Moricand, 1837), 13 de Drepanotrema anatinum (Pfeiffer, 1839), 222 de Melanoides tuberculatus (Muller, 1774), 263 de Pomacea sp. e 37 de Physa marmorata Guilding, 1828. Entre os exemplares de B. glabrata coletados, 44 mostraram-se positivos para Schistosoma mansoni Sambon, 1907 e 91 mostraram-se positivos para outras larvas de trematódeos. Um exemplar de Pomacea sp. mostrou-se positivo para larva de trematódeo. Os dados obtidos, georreferenciados espacialmente, serão utilizados para a determinação das áreas de risco para a transmissão da esquistossomose na praia de Carne de Vaca, além de simulações computacionais para estudos de previsibilidade e comportamento do processo de expansão da esquistossomose no estado de Pernambuco.

Aspectos ecológicos e levantamento malacológico para identificação de áreas de risco para transmissão da esquistossomose mansoni no litoral norte de Pernambuco, Brasil

It was carried out a malacological survey at Carne de Vaca beach, Goiana municipality, Pernambuco North coast, between November 2006 and October 2007 in order to know the malacological fauna of this town and verify the natural, slightly or more modified conditions of mollusks sites by using an habitat diversity protocol analysis. From 5,912 mollusks collected, they belong to seven species and four families, as follows: 5,209 Biomphalaria glabrata (Say, 1818) specimens, 113 of Drepanotrema lucidum (Pfeiffer, 1839), 55 of Drepanotrema cimex (Moricand, 1837), 13 of Drepanotrema anatinum (Pfeiffer, 1839), 222 of Melanoides tuberculatus (Muller, 1774), 263 of Pomacea sp. and 37 of Physa marmorata Guilding, 1828. Among B. glabrata collected, 44 specimens were positive for Schistosoma mansoni Sambon, 1907 cercariae and 91 specimens were positive for other trematode larvae. One Pomacea sp. specimen was positive for trematode larvae. These data, spatially georeferenced, will be used for determination of risk' sites for schistosomiasis transmission at Carne de Vaca beach and furthermore, they will be used for computational simulations to determine the expansion process of schistosomiasis in state of Pernambuco.

Realizou-se levantamento malacológico na praia de Carne de Vaca, município de Goiana, litoral norte de Pernambuco, entre novembro de 2006 e outubro de 2007, com o objetivo de conhecer a fauna malacológica dessa localidade e verificar as condições naturais, pouco ou bastante alteradas das áreas de estudo através da aplicação de um protocolo de avaliação de diversidade de hábitats. Foram coletados 5.912 moluscos, representados por sete espécies e quatro famílias, dos quais, 5.209 exemplares de Biomphalaria glabrata (Say, 1818), 113 de Drepanotrema lucidum (Pfeiffer, 1839), 55 de Drepanotrema cimex (Moricand, 1837), 13 de Drepanotrema anatinum (Pfeiffer, 1839), 222 de Melanoides tuberculatus (Muller, 1774), 263 de Pomacea sp. e 37 de Physa marmorata Guilding, 1828. Entre os exemplares de B. glabrata coletados, 44 mostraram-se positivos para Schistosoma mansoni Sambon, 1907 e 91 mostraram-se positivos para outras larvas de trematódeos. Um exemplar de Pomacea sp. mostrou-se positivo para larva de trematódeo. Os dados obtidos, georreferenciados espacialmente, serão utilizados para a determinação das áreas de risco para a transmissão da esquistossomose na praia de Carne de Vaca, além de simulações computacionais para estudos de previsibilidade e comportamento do processo de expansão da esquistossomose no estado de Pernambuco.