Revisiting area risk classification of visceral leishmaniasis in Brazil.

BACKGROUND: Visceral leishmaniasis (VL) is a neglected tropical disease of public health relevance in Brazil. To prioritize disease control measures, the Secretaria de Vigilância em Saúde of Brazil's Ministry of Health (SVS/MH) uses retrospective human case counts from VL surveillance data to inform a municipality-based risk classification. In this study, we compared the underlying VL risk, using a spatiotemporal explicit Bayesian hierarchical model (BHM), with the risk classification currently in use by the Brazil's Ministry of Health. We aim to assess how well the current risk classes capture the underlying VL risk as modelled by the BHM. METHODS: Annual counts of human VL cases and the population at risk for all Brazil's 5564 municipalities between 2004 and 2014 were used to fit a relative risk BHM. We then computed the predicted counts and exceedence risk for each municipality and classified them into four categories to allow comparison with the four risk categories by the SVS/MH. RESULTS: Municipalities identified as high-risk by the model partially agreed with the current risk classification by the SVS/MH. Our results suggest that counts of VL cases may suffice as general indicators of the underlying risk, but can underestimate risks, especially in areas with intense transmission. CONCLUSION: According to our BHM the SVS/MH risk classification underestimated the risk in several municipalities with moderate to intense VL transmission. Newly identified high-risk areas should be further evaluated to identify potential risk factors and assess the needs for additional surveillance and mitigation efforts.

[Investigation of an outbreak of acute Chagas disease outside the Amazon Region, in Rio Grande do Norte State, Brazil, 2016]. / Investigação de surto de doença de Chagas aguda na região extra-amazônica, Rio Grande do Norte, Brasil, 2016.

The aim of this article was to confirm and describe an outbreak of acute Chagas disease involving oral transmission in the western region of Rio Grande do Norte State, Brazil. This was a descriptive case series study in which the data sources were medical records and interviews with suspected cases from September 16 to November 19, 2015. An entomological investigation was conducted in the probable sites of infection for acute Chagas disease cases. Eighteen cases of acute Chagas disease were confirmed in residents of four municipalities (counties) in Rio Grande do Norte State. The most frequently reported signs and symptoms were fever and weakness (n = 18), followed by myalgia (n = 17), prostration, loss of appetite, and edema of the lower limbs (n = 15). Median duration of fever was 20 days (range: 6 to 45 days). Fifteen cases were confirmed by the laboratory criterion and three by epidemiological link with consistent clinical characteristics. All confirmed cases reported having consumed sugar cane juice from the same mill. A total of 110 triatomines were captured on the plantation where the sugar cane had been crushed for juice. The insects were found in the peridomicile, in stacks of firewood and close to the sugar cane mill. The majority of the captured specimens were Triatoma brasiliensis and showed a natural infection rate of 63%. The Chagas disease outbreak was confirmed with oral transmission via ingestion of sugar cane juice contaminated with infected triatomines, as evidenced by the epidemiological link between the investigated cases and the entomological survey in the probable site where the infection occurred.

O objetivo do artigo foi confirmar e descrever um surto da doença de Chagas aguda por transmissão oral na mesorregião Oeste Potiguar, Rio Grande do Norte, Brasil. Trata-se de um estudo descritivo do tipo série de casos, tendo como fonte de dados os registros de atendimentos médicos e entrevistas com os casos suspeitos entre 16 de setembro e 19 de novembro de 2015. Realizou-se pesquisa entomológica nas prováveis localidades de infecção dos casos de doença de Chagas aguda. Foram confirmados 18 casos de doença de Chagas aguda em residentes de quatro municípios do Rio Grande do Norte. Os sinais e sintomas mais relatados foram febre e fraqueza (n = 18), seguidos de mialgia (n = 17), prostração, inapetência e edema de membros inferiores (n = 15). A mediana de duração da febre foi de 20 dias (intervalo: 6 a 45 dias). Quinze casos foram confirmados por critério laboratorial e três por vínculo epidemiológico com clínica compatível. Todos os casos confirmados relataram ter consumido caldo de cana da mesma procedência. Foram capturados 110 triatomíneos na fazenda onde ocorreu a moagem da cana consumida. Os insetos estavam no peridomicílio, em amontoados de lenha e próximos ao engenho. A maioria dos exemplares capturados era da espécie Triatoma brasiliensis, e apresentou um índice de infecção natural de 63%. Foi confirmado surto da doença de Chagas de transmissão oral por ingestão de caldo de cana contaminado por triatomíneo infectado, evidenciado pelo vínculo epidemiológico entre os casos investigados e a pesquisa entomológica no local provável de infecção.

El objetivo de este artículo fue confirmar y describir un brote de la enfermedad de Chagas aguda por transmisión oral en la mesorregión oeste de Rio Grande do Norte, Brasil. Se trata de un estudio descriptivo del tipo serie de casos, contando como fuente de datos los registros de atención médica y entrevistas en los casos sospechosos entre el 16 de septiembre y el 19 de noviembre de 2015. Se realizó una investigación entomológica en las probables localidades de infección de los casos de enfermedad de Chagas aguda. Fueron confirmados 18 casos de enfermedad de Chagas aguda en residentes de cuatro municipios de Rio Grande do Norte. Los signos y síntomas más informados fueron fiebre y debilidad (n = 18), seguidos de mialgia (n = 17), postración, inapetencia y edema de miembros inferiores (n = 15). La media de duración de la fiebre fue de 20 días (intervalo: 6 a 45 días). Quince casos fueron confirmados por criterio de laboratorio y tres por vínculo epidemiológico con clínica compatible. Todos los casos confirmados informaron haber consumido caldo de caña de la misma procedencia. Fueron capturados 110 triatominos en la hacienda donde se produjo la molienda de la caña consumida. Los insectos estaban en el peridomicilio, en montones de leña y cerca del ingenio azucarero. La mayoría de los ejemplares capturados era de la especie Triatoma brasiliensis, y presentó un índice de infección natural de un 63%. Se confirmó un brote de la enfermedad de Chagas de transmisión oral por ingestión de caldo de caña contaminado por triatomino infectado, evidenciado por el vínculo epidemiológico entre los casos investigados y la investigación entomológica en el lugar probable de infección.

Investigação de surto de doença de Chagas aguda na região extra-amazônica, Rio Grande do Norte, Brasil, 2016 / Investigation of an outbreak of acute Chagas disease outside the Amazon Region, in Rio Grande do Norte State, Brazil, 2016 / Investigación del brote de la enfermedad de Chagas aguda en la región extra-amazónica, Rio Grande do Norte, Brasil, 2016

Resumo: O objetivo do artigo foi confirmar e descrever um surto da doença de Chagas aguda por transmissão oral na mesorregião Oeste Potiguar, Rio Grande do Norte, Brasil. Trata-se de um estudo descritivo do tipo série de casos, tendo como fonte de dados os registros de atendimentos médicos e entrevistas com os casos suspeitos entre 16 de setembro e 19 de novembro de 2015. Realizou-se pesquisa entomológica nas prováveis localidades de infecção dos casos de doença de Chagas aguda. Foram confirmados 18 casos de doença de Chagas aguda em residentes de quatro municípios do Rio Grande do Norte. Os sinais e sintomas mais relatados foram febre e fraqueza (n = 18), seguidos de mialgia (n = 17), prostração, inapetência e edema de membros inferiores (n = 15). A mediana de duração da febre foi de 20 dias (intervalo: 6 a 45 dias). Quinze casos foram confirmados por critério laboratorial e três por vínculo epidemiológico com clínica compatível. Todos os casos confirmados relataram ter consumido caldo de cana da mesma procedência. Foram capturados 110 triatomíneos na fazenda onde ocorreu a moagem da cana consumida. Os insetos estavam no peridomicílio, em amontoados de lenha e próximos ao engenho. A maioria dos exemplares capturados era da espécie Triatoma brasiliensis, e apresentou um índice de infecção natural de 63%. Foi confirmado surto da doença de Chagas de transmissão oral por ingestão de caldo de cana contaminado por triatomíneo infectado, evidenciado pelo vínculo epidemiológico entre os casos investigados e a pesquisa entomológica no local provável de infecção.

Abstract: The aim of this article was to confirm and describe an outbreak of acute Chagas disease involving oral transmission in the western region of Rio Grande do Norte State, Brazil. This was a descriptive case series study in which the data sources were medical records and interviews with suspected cases from September 16 to November 19, 2015. An entomological investigation was conducted in the probable sites of infection for acute Chagas disease cases. Eighteen cases of acute Chagas disease were confirmed in residents of four municipalities (counties) in Rio Grande do Norte State. The most frequently reported signs and symptoms were fever and weakness (n = 18), followed by myalgia (n = 17), prostration, loss of appetite, and edema of the lower limbs (n = 15). Median duration of fever was 20 days (range: 6 to 45 days). Fifteen cases were confirmed by the laboratory criterion and three by epidemiological link with consistent clinical characteristics. All confirmed cases reported having consumed sugar cane juice from the same mill. A total of 110 triatomines were captured on the plantation where the sugar cane had been crushed for juice. The insects were found in the peridomicile, in stacks of firewood and close to the sugar cane mill. The majority of the captured specimens were Triatoma brasiliensis and showed a natural infection rate of 63%. The Chagas disease outbreak was confirmed with oral transmission via ingestion of sugar cane juice contaminated with infected triatomines, as evidenced by the epidemiological link between the investigated cases and the entomological survey in the probable site where the infection occurred.

Resumen: El objetivo de este artículo fue confirmar y describir un brote de la enfermedad de Chagas aguda por transmisión oral en la mesorregión oeste de Rio Grande do Norte, Brasil. Se trata de un estudio descriptivo del tipo serie de casos, contando como fuente de datos los registros de atención médica y entrevistas en los casos sospechosos entre el 16 de septiembre y el 19 de noviembre de 2015. Se realizó una investigación entomológica en las probables localidades de infección de los casos de enfermedad de Chagas aguda. Fueron confirmados 18 casos de enfermedad de Chagas aguda en residentes de cuatro municipios de Rio Grande do Norte. Los signos y síntomas más informados fueron fiebre y debilidad (n = 18), seguidos de mialgia (n = 17), postración, inapetencia y edema de miembros inferiores (n = 15). La media de duración de la fiebre fue de 20 días (intervalo: 6 a 45 días). Quince casos fueron confirmados por criterio de laboratorio y tres por vínculo epidemiológico con clínica compatible. Todos los casos confirmados informaron haber consumido caldo de caña de la misma procedencia. Fueron capturados 110 triatominos en la hacienda donde se produjo la molienda de la caña consumida. Los insectos estaban en el peridomicilio, en montones de leña y cerca del ingenio azucarero. La mayoría de los ejemplares capturados era de la especie Triatoma brasiliensis, y presentó un índice de infección natural de un 63%. Se confirmó un brote de la enfermedad de Chagas de transmisión oral por ingestión de caldo de caña contaminado por triatomino infectado, evidenciado por el vínculo epidemiológico entre los casos investigados y la investigación entomológica en el lugar probable de infección.

[Estimating demand for anti-Chagas drugs: a contribution for access in Latin America]. / Estimación de la demanda de medicamentos antichagásicos: una contribución para el acceso en América Latina.

OBJECTIVE: Describe a tool to estimate demand for benznidazole and nifurtimox to treat Chagas disease, and report on its implementation in a group of Latin American countries. METHODS: The project was carried out in the following stages: 1) development of a tool to estimate demand, and definition of the evaluation and decision variables to estimate demand 2) data collection via a questionnaire completed by representatives of control programs, complemented with data from the literature; 3) presentation of the tool, followed by validation, and adaptation by representatives of the control programs in order to plan drug procurement for 2012 and 2013; and 4) further analysis of the obtained data, especially regarding benznidazole, and comparison of country estimates. RESULTS: Fourteen endemic countries of Latin America took part in the third stage, and a consolidated estimate was made. The number of estimated treatments, based on the number of tablets per treatment established in the regimen of reference was: 867 in the group under 1 year of age; 2 042 835 in the group from 1 to 15 years old; 2 028 in the group from 15 to 20 years old; and 10 248 in adults over 20. This means that it is possible to provide benznidazole to less than 1% of people for whom treatment is indicated. CONCLUSIONS: The development and systematic use of demand management tools can play a key role in helping to provide access to the anti-Chagas drugs. There is a significant gap between the projected demand for drugs and current estimates of prevalence rates.

Corrigendum: The contemporary distribution of Trypanosoma cruzi infection in humans, alternative hosts and vectors.

This corrects the article DOI: 10.1038/sdata.2017.50.

The contemporary distribution of Trypanosoma cruzi infection in humans, alternative hosts and vectors.

Chagas is a potentially fatal chronic disease affecting large numbers of people across the Americas and exported throughout the world through human population movement. It is caused by the Trypanosoma cruzi parasite, which is transmitted by triatomine vectors to humans and a wide range of alternative host species. The database described here was compiled to allow the risk of vectorial transmission to humans to be mapped using geospatial models. The database collates all available records, published since 2003, for prevalence and occurrence of infection in humans, vectors and alternative hosts, and links each record to a defined time and location. A total of 16,802 records of infection have been extracted from the published literature and unpublished sources. The resulting database can be used to improve our understanding of the geographic variation in vector infection prevalence and to estimate the risk of vectorial transmission of T. cruzi to humans.

2 nd Brazilian Consensus on Chagas Disease, 2015.

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

Fortalecimento da vigilância em saúde no Brasil: Rede de Monitoramento da Resistência dos Triatomíneos aos Inseticidas / Strengthening of health surveillance in Brazil: Monitoring network of the insecticide resistance in Triatominae

Em 2010 foi criada no Brasil, pelo Ministério da Saúde e pelo Laboratório de Referência em Triatomíneos e Epidemiologia da Doença de Chagas da Fundação Oswaldo Cruz a "Rede de Monitoramento da Resistência de Triatomíneos aos Inseticidas" com vistas a: 1) caracterizar e monitorar a suscetibilidade/resistência das populações triatomínicas brasileiras aos inseticidas, 2) desenvolver métodos destinados ao diagnóstico da resistência dos triatomíneos aos inseticidas e 3) contribuir na avaliação e melhoria das atividades desenvolvidas junto ao controle químico dos triatomíneos. A implantação desta iniciativa, que possui hoje reconhecimento internacional junto a Organização Mundial de Saúde, está apresentada neste trabalho de forma detalhada.

[Brazilian Consensus on Chagas Disease, 2015]. / II Consenso Brasileiro em Doença de Chagas, 2015.

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

II Consenso Brasileiro em Doença de Chagas, 2015 / Brazilian Consensus on Chagas Disease, 2015

A doença de Chagas é uma condição crônica negligenciada com elevada carga de morbimortalidade e impacto dos pontos de vista psicológico, social e econômico. Representa um importante problema de saúde pública no Brasil, com diferentes cenários regionais. Este documento traduz a sistematização das evidências que compõe o Consenso Brasileiro de Doença de Chagas. O objetivo foi sistematizar estratégias de diagnóstico, tratamento, prevenção e controle da doença de Chagas no país, de modo a refletir as evidências científicas disponíveis. Sua construção fundamentou-se na articulação e contribuição estratégica de especialistas brasileiros com conhecimento, experiência e atualização sobre diferentes aspectos da doença. Representa o resultado da estreita colaboração entre a Sociedade Brasileira de Medicina Tropical e o Ministério da Saúde. Espera-se com este documento fortalecer o desenvolvimento de ações integradas para enfrentamento da doença no país com foco em epidemiologia, gestão, atenção integral (incluindo famílias e comunidades), comunicação, informação, educação e pesquisas.

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

2 nd Brazilian consensus on Chagas Disease, 2015

Chagas disease is a neglected chronic condition with ahigh burden of morbidity and mortality. It has considerable psychological, social, and economic impacts. The disease represents a significant public health issue in Brazil, with different regional patterns. This document presents the evidence that resulted in the Brazilian Consensus on Chagas Disease. The objective was to review and standardize strategies for diagnosis, treatment, prevention, and controlof Chagas disease in the country, based on the available scientific evidence. The consensus is based on the articulation and strategic contribution of renowned Brazilian experts with knowledge and experience on various aspects of the disease. It is the result of a close collaboration between the Brazilian Society of Tropical Medicine and the Ministry of Health...

Assessing the vulnerability of Brazilian municipalities to the vectorial transmission of Trypanosoma cruzi using multi-criteria decision analysis.

Despite the dramatic reduction in Trypanosoma cruzi vectorial transmission in Brazil, acute cases of Chagas disease (CD) continue to be recorded. The identification of areas with greater vulnerability to the occurrence of vector-borne CD is essential to prevention, control, and surveillance activities. In the current study, data on the occurrence of domiciliated triatomines in Brazil (non-Amazonian regions) between 2007 and 2011 were analyzed. Municipalities' vulnerability was assessed based on socioeconomic, demographic, entomological, and environmental indicators using multi-criteria decision analysis (MCDA). Overall, 2275 municipalities were positive for at least one of the six triatomine species analyzed (Panstrongylus megistus, Triatoma infestans, Triatoma brasiliensis, Triatoma pseudomaculata, Triatoma rubrovaria, and Triatoma sordida). The municipalities that were most vulnerable to vector-borne CD were mainly in the northeast region and exhibited a higher occurrence of domiciliated triatomines, lower socioeconomic levels, and more extensive anthropized areas. Most of the 39 new vector-borne CD cases confirmed between 2001 and 2012 in non-Amazonian regions occurred within the more vulnerable municipalities. Thus, MCDA can help to identify the states and municipalities that are most vulnerable to the transmission of T. cruzi by domiciliated triatomines, which is critical for directing adequate surveillance, prevention, and control activities. The methodological approach and results presented here can be used to enhance CD surveillance in Brazil.