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1.
Rev Saude Publica ; 53: 89, 2019.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31644770

RESUMO

OBJECTIVE: Describe the clinical and epidemiological profile of confirmed cases of yellow fever whose patients were hospitalized in a general hospital for infectious diseases in the State of Rio de Janeiro, Brazil, from March 11, 2017 to June 15, 2018, during a recent outbreak and factors associated with death. METHODS: This is a retrospective observational study with analysis of secondary databases of local epidemiological surveillance system, and complementary data collection from epidemiological investigation records and clinical records. Study variables included demographic, epidemiological, clinical, and laboratory data. A descriptive statistical analysis and a bivariate and multivariate analysis by logistic regression were performed to analyze factors associated with death. RESULTS: Fifty-two patients diagnosed with yellow fever were hospitalized, 86.5% male patients, median age 49.5 years, 40.4% rural workers. The most frequent signs and symptoms were fever (90.4%), jaundice (86.5%), nausea and/or vomiting (69.2%), changes in renal excretion (53.8%), bleeding (50%), and abdominal pain (48.1%), with comorbidity in 38.5% of all cases. The lethality rate was 40.4%. Factors significantly associated with a higher chance of death in the bivariate analysis were: bleeding, changes in renal excretion, and maximum values of direct bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), urea, and creatinine. In the multivariate analysis by logistic regression, only changes in renal excretion and ALT remained significant predictors of higher chance of death. A threshold effect was also observed for AST. The cutoff points identified as high risk for death were ALT > 4,000 U/L and AST > 6,000 U/L. CONCLUSIONS: This study contributed to the knowledge on the profile of confirmed cases of high severity yellow fever. The main factors associated with death were changes in renal excretion and elevated serum transaminases, especially ALT. High lethality emphasizes the need for early diagnosis and treatment, and the importance of increasing vaccination coverage.


Assuntos
Surtos de Doenças/estatística & dados numéricos , Mortalidade Hospitalar , Febre Amarela/mortalidade , Adolescente , Adulto , Idoso , Alanina Transaminase/sangue , Aspartato Aminotransferases/sangue , Bilirrubina/sangue , Brasil/epidemiologia , Creatinina/sangue , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Valores de Referência , Estudos Retrospectivos , Fatores de Risco , Estatísticas não Paramétricas , Fatores de Tempo , Ureia/sangue , Febre Amarela/sangue , Adulto Jovem
2.
Stud Health Technol Inform ; 262: 101-104, 2019 Jul 04.
Artigo em Inglês | MEDLINE | ID: mdl-31349276

RESUMO

Tuberculosis (TB) represents a global challenge in terms of prevention, care and control. Decision support systems (DSS) can supply the necessary knowledge basis to underpin investigators, policy makers and health personnel actions and to provide crucial elements that can help reducing TB burden. Thus, the objectives of this work are to present the protocol to be followed for carrying out a scoping review to identify topics where DSSs are used, to define appropriate categories and to clarify main outcomes and research gaps. As part of the protocol, five electronic bibliographic databases will be searched for articles from 2006 to 2019 and two investigators will independently screen each work using the study inclusion criteria. Data extraction will be performed, and findings will be reported. The results will be used to provide a broad understanding of how DSSs for TB are being used.


Assuntos
Sistemas de Apoio a Decisões Clínicas , Tuberculose , Assistência à Saúde , Pessoal de Saúde , Humanos , Projetos de Pesquisa , Pesquisadores , Literatura de Revisão como Assunto , Tuberculose/terapia
3.
Stud Health Technol Inform ; 262: 264-267, 2019 Jul 04.
Artigo em Inglês | MEDLINE | ID: mdl-31349318

RESUMO

Data sharing, information exchange, knowledge acquisition and health intelligence are the basis of an efficient and effective evidence-based decision-making tool. A decentralized blockchain architecture is a flexible solution that can be adapted to institutional and managerial culture of organizations and services. Blockchain can play a fundamental role in enabling data sharing within a network and, to achieve that, this work defines the high-level resources necessary to apply this technology to Tuberculosis related issues. Thus, relying in open-source tools and in a collaborative development approach, we present a proposal of a blockchain based network, the TB Network, to underpin an initiative of sharing of Tuberculosis scientific, operational and epidemiologic data between several stakeholders across Brazilian cities.


Assuntos
Segurança Computacional , Tuberculose , Brasil , Confidencialidade , Humanos , Disseminação de Informação
4.
BMC Infect Dis ; 19(1): 93, 2019 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-30691448

RESUMO

BACKGROUND: Tuberculosis is a major challenge to health in the developing world. Triage prior to diagnostic testing could potentially reduce the volume of tests and costs associated with using the more accurate, but costly, Xpert MTB/RIF assay. An effective methodology to predict the impact of introducing triage prior to tuberculosis diagnostic testing could be useful in helping to guide policy. METHODS: The development and use of operational modelling to project the impact on case detection and health system costs of alternative triage approaches for tuberculosis, with or without X-ray, based on data from Porto Alegre City, Brazil. RESULTS: Most of the triage approaches modelled without X-ray were predicted to provide no significant benefit. One approach based on an artificial neural network applied to patient and symptom characteristics was projected to increase case detection (82% vs. 75%) compared to microscopy, and reduce costs compared to Xpert without triage. In addition, use of X-ray before diagnostic testing for HIV-negative patients could maintain diagnostic yield of using Xpert without triage, and reduce costs. CONCLUSION: A model for the impact assessment of alternative triage approaches has been tested. The results from using the approach demonstrate its usefulness in informing policy in a typical high burden setting for tuberculosis.


Assuntos
Técnicas de Apoio para a Decisão , Radiografia Torácica , Triagem/métodos , Tuberculose/diagnóstico , Algoritmos , Brasil/epidemiologia , Análise Custo-Benefício , Humanos , Programas de Rastreamento/economia , Programas de Rastreamento/métodos , Técnicas Microbiológicas/economia , Técnicas Microbiológicas/métodos , Modelos Organizacionais , Mycobacterium tuberculosis/isolamento & purificação , Radiografia Torácica/economia , Sensibilidade e Especificidade , Escarro/microbiologia , Triagem/economia , Triagem/organização & administração , Tuberculose/economia , Tuberculose/epidemiologia , Tuberculose Pulmonar/diagnóstico , Tuberculose Pulmonar/epidemiologia , Raios X
5.
Rev. saúde pública (Online) ; 53: 89, jan. 2019. tab, graf
Artigo em Inglês | LILACS-Express | ID: biblio-1043328

RESUMO

ABSTRACT OBJECTIVE Describe the clinical and epidemiological profile of confirmed cases of yellow fever whose patients were hospitalized in a general hospital for infectious diseases in the State of Rio de Janeiro, Brazil, from March 11, 2017 to June 15, 2018, during a recent outbreak and factors associated with death. METHODS This is a retrospective observational study with analysis of secondary databases of local epidemiological surveillance system, and complementary data collection from epidemiological investigation records and clinical records. Study variables included demographic, epidemiological, clinical, and laboratory data. A descriptive statistical analysis and a bivariate and multivariate analysis by logistic regression were performed to analyze factors associated with death. RESULTS Fifty-two patients diagnosed with yellow fever were hospitalized, 86.5% male patients, median age 49.5 years, 40.4% rural workers. The most frequent signs and symptoms were fever (90.4%), jaundice (86.5%), nausea and/or vomiting (69.2%), changes in renal excretion (53.8%), bleeding (50%), and abdominal pain (48.1%), with comorbidity in 38.5% of all cases. The lethality rate was 40.4%. Factors significantly associated with a higher chance of death in the bivariate analysis were: bleeding, changes in renal excretion, and maximum values of direct bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), urea, and creatinine. In the multivariate analysis by logistic regression, only changes in renal excretion and ALT remained significant predictors of higher chance of death. A threshold effect was also observed for AST. The cutoff points identified as high risk for death were ALT > 4,000 U/L and AST > 6,000 U/L. CONCLUSIONS This study contributed to the knowledge on the profile of confirmed cases of high severity yellow fever. The main factors associated with death were changes in renal excretion and elevated serum transaminases, especially ALT. High lethality emphasizes the need for early diagnosis and treatment, and the importance of increasing vaccination coverage.


RESUMO OBJETIVO Descrever o perfil clínico-epidemiológico dos casos confirmados de febre amarela internados em hospital geral de referência para doenças infecciosas no estado do Rio de Janeiro, Brasil, de 11 de março de 2017 a 15 de junho de 2018, durante recente surto e fatores associados ao óbito. MÉTODOS Estudo observacional retrospectivo, com análise de bases de dados secundários da vigilância epidemiológica local e coleta complementar de dados nas fichas de investigação epidemiológica e prontuários clínicos. As variáveis analisadas incluíram dados demográficos, epidemiológicos, clínicos e laboratoriais. Foi conduzida análise estatística descritiva bivariada e múltipla por regressão logística para estudo de fatores associados ao óbito. RESULTADOS Foram internados 52 casos confirmados, 86,5% deles homens, com mediana de idade de 49,5 anos e 40,4% trabalhadores rurais. Os sinais e sintomas mais frequentes foram: febre (90,4%), icterícia (86,5%), náuseas e/ou vômitos (69,2%), alterações de excreção renal (53,8%), hemorragias (50%) e dor abdominal (48,1%), com comorbidade em 38,5% dos casos. A letalidade foi de 40,4%. Os fatores associados significativamente à maior chance de óbito na análise bivariada foram: hemorragia, alterações de excreção renal e valores máximos de bilirrubina direta, aspartato aminotransferase (AST), alanina aminotransferase (ALT), ureia e creatinina. Na análise múltipla por regressão logística, apenas alterações de excreção renal e ALT permaneceram como preditores significativos de maior chance de óbito. Observou-se ainda efeito limítrofe para AST. Os pontos de corte identificados como de alto risco para óbito foram ALT > 4.000 U/L e AST > 6.000 U/L. CONCLUSÕES O estudo contribuiu para o conhecimento do perfil de casos confirmados de febre amarela com gravidade alta. Os principais fatores associados ao óbito foram a alteração da excreção renal e a elevação sérica de transaminases, sobretudo a ALT. A letalidade elevada reforça a necessidade de diagnóstico e tratamento precoces, e a importância do incremento da cobertura vacinal.

6.
Tuberculosis (Edinb) ; 111: 94-101, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-30029922

RESUMO

Tuberculosis (TB) remains a significant public health challenge, motivated by the diversity of healthcare epidemiological settings, as other factors. Cost-effective screening has substantial importance for TB control, demanding new diagnostic tools. This paper proposes a decision support tool (DST) for screening pulmonary TB (PTB) patients at a secondary clinic. The DST is composed of an adaptive resonance model (iART) for risk group identification (low, medium and high) and a multilayer perceptron (MLP) neural network for classifying patients as active or inactive PTB. Our tool attains an overall sensitivity (SE) and specificity (SP) of 92% (95% CI; 79-97) and 58% (95% CI; 47-68), respectively. SE values for smear-positive and smear-negative patients are 96% (95% CI; 80-99) and 82% (95% CI; 52-95), as well as higher than 83% (95% CI; 43-97) in low and high-risk cases. Even in scenarios with prevalence up to 20%, negative predictive values superior to 95% are obtained. The proposed DST provides a quick and low-cost pretest for presumptive PTB patients, which is useful to guide confirmatory testing and patient management, especially in settings with limited resources in low and middle-incoming countries.


Assuntos
Técnicas Bacteriológicas , Sistemas de Apoio a Decisões Clínicas , Técnicas de Apoio para a Decisão , Pulmão/microbiologia , Programas de Rastreamento/métodos , Mycobacterium tuberculosis/isolamento & purificação , Tuberculose Pulmonar/diagnóstico , Adulto , Brasil/epidemiologia , Bases de Dados Factuais , Diagnóstico por Computador , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prevalência , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Escarro/microbiologia , Tuberculose Pulmonar/epidemiologia , Tuberculose Pulmonar/microbiologia , Adulto Jovem
7.
Rev Soc Bras Med Trop ; 51(1): 2-6, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29513837

RESUMO

This article reviews tuberculosis control actions performed over the last decade, at a global level. The perspectives for the fulfillment of the goals of the new Global Tuberculosis Elimination Plan are described, where the insertion of social protection (Pillar 2) and research (Pillar 3) will play an innovative and strategic role, especially in high-burden countries, like Brazil.


Assuntos
Tuberculose/prevenção & controle , Brasil/epidemiologia , Saúde Global , Humanos , Incidência , Tuberculose/epidemiologia , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia
8.
Lancet Respir Med ; 6(4): 265-275, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29595509

RESUMO

BACKGROUND: Isoniazid-resistant, rifampicin-susceptible (INH-R) tuberculosis is the most common form of drug resistance, and is associated with failure, relapse, and acquired rifampicin resistance if treated with first-line anti-tuberculosis drugs. The aim of the study was to compare success, mortality, and acquired rifampicin resistance in patients with INH-R pulmonary tuberculosis given different durations of rifampicin, ethambutol, and pyrazinamide (REZ); a fluoroquinolone plus 6 months or more of REZ; and streptomycin plus a core regimen of REZ. METHODS: Studies with regimens and outcomes known for individual patients with INH-R tuberculosis were eligible, irrespective of the number of patients if randomised trials, or with at least 20 participants if a cohort study. Studies were identified from two relevant systematic reviews, an updated search of one of the systematic reviews (for papers published between April 1, 2015, and Feb 10, 2016), and personal communications. Individual patient data were obtained from authors of eligible studies. The individual patient data meta-analysis was performed with propensity score matched logistic regression to estimate adjusted odds ratios (aOR) and risk differences of treatment success (cure or treatment completion), death during treatment, and acquired rifampicin resistance. Outcomes were measured across different treatment regimens to assess the effects of: different durations of REZ (≤6 months vs >6 months); addition of a fluoroquinolone to REZ (fluoroquinolone plus 6 months or more of REZ vs 6 months or more of REZ); and addition of streptomycin to REZ (streptomycin plus 6 months of rifampicin and ethambutol and 1-3 months of pyrazinamide vs 6 months or more of REZ). The overall quality of the evidence was assessed using GRADE methodology. FINDINGS: Individual patient data were requested for 57 cohort studies and 17 randomised trials including 8089 patients with INH-R tuberculosis. We received 33 datasets with 6424 patients, of which 3923 patients in 23 studies received regimens related to the study objectives. Compared with a daily regimen of 6 months of (H)REZ (REZ with or without isoniazid), extending the duration to 8-9 months had similar outcomes; as such, 6 months or more of (H)REZ was used for subsequent comparisons. Addition of a fluoroquinolone to 6 months or more of (H)REZ was associated with significantly greater treatment success (aOR 2·8, 95% CI 1·1-7·3), but no significant effect on mortality (aOR 0·7, 0·4-1·1) or acquired rifampicin resistance (aOR 0·1, 0·0-1·2). Compared with 6 months or more of (H)REZ, the standardised retreatment regimen (2 months of streptomycin, 3 months of pyrazinamide, and 8 months of isoniazid, rifampicin, and ethambutol) was associated with significantly worse treatment success (aOR 0·4, 0·2-0·7). The quality of the evidence was very low for all outcomes and treatment regimens assessed, owing to the observational nature of most of the data, the diverse settings, and the imprecision of estimates. INTERPRETATION: In patients with INH-R tuberculosis, compared with treatment with at least 6 months of daily REZ, addition of a fluoroquinolone was associated with better treatment success, whereas addition of streptomycin was associated with less treatment success; however, the quality of the evidence was very low. These results support the conduct of randomised trials to identify the optimum regimen for this important and common form of drug-resistant tuberculosis. FUNDING: World Health Organization and Canadian Institutes of Health Research.


Assuntos
Antibióticos Antituberculose/administração & dosagem , Etambutol/administração & dosagem , Fluoroquinolonas/administração & dosagem , Pirazinamida/administração & dosagem , Rifampina/administração & dosagem , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Estudos de Coortes , Esquema de Medicação , Quimioterapia Combinada , Humanos , Estudos Observacionais como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Literatura de Revisão como Assunto , Estreptomicina/administração & dosagem , Tuberculose Resistente a Múltiplos Medicamentos/mortalidade
9.
Rev. Soc. Bras. Med. Trop ; 51(1): 2-6, Jan.-Feb. 2018.
Artigo em Inglês | LILACS-Express | ID: biblio-897047

RESUMO

Abstract This article reviews tuberculosis control actions performed over the last decade, at a global level. The perspectives for the fulfillment of the goals of the new Global Tuberculosis Elimination Plan are described, where the insertion of social protection (Pillar 2) and research (Pillar 3) will play an innovative and strategic role, especially in high-burden countries, like Brazil.

10.
Front Immunol ; 9: 3147, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30687336

RESUMO

Background: Pulmonary tuberculosis (PTB) can lead to lung tissue damage (LTD) and compromise the pulmonary capacity of TB patients that evolve to severe PTB. The molecular mechanisms involved in LTD during anti-tuberculous treatment (ATT) remain poorly understood. Methods and findings: We evaluated the role of neutrophil extracellular trap (NET) and the occurrence of LTD through chest radiographic images, the microbial load in sputum, and inflammatory serum profile (IL-12p40/p70, IL-8, IL-17A, IL-23, VEGF-A, MMP-1, and -8, galectin-3, citrunillated histone H3-cit-H3, alpha-1-antitrypsin-α1AT, C-reactive protein-CRP and albumin) in a cohort of 82 PTB patients before and after 60 days of ATT. Using univariate analysis, LTD was associated with neutrophilia and increase of several inflammatory proteins involved in the neutrophil-mediated response, being cit-H3 the more related to the event. In the multivariate analysis, neutrophilia and cit-H3 appear as directly related to LTD. The analysis of the ROC curve at day 60 presented AUC of 0.97 (95.0% CI 0.95-1). Interestingly, at day 0 of ATT, these biomarkers demonstrated fine relation with LTD showing an AUC 0.92 (95.0% CI 0.86-0.99). Despite of that, the same molecules have no impact in culture conversion during ATT. Conclusions: Our data revealed that NETs may play a key role in the pathway responsible for non-specific inflammation and tissue destruction in PTB. High level of cit-H3 and low level of α1AT was observed in the serum of severe TB patients, suggesting a breakdown in the intrinsic control of NET-driven tissue damage. These data show a new insight to knowledge TB immunopathogenesis, the role of neutrophil and NET pathway. Likewise, we identified possible biomarkers to screening of PTB patients eligible to adjuvants therapies, as anti-inflammatories and alpha-1-antitrypsin.


Assuntos
Armadilhas Extracelulares/imunologia , Armadilhas Extracelulares/metabolismo , Infiltração de Neutrófilos , Tuberculose Pulmonar/etiologia , Tuberculose Pulmonar/metabolismo , alfa 1-Antitripsina/metabolismo , Adulto , Biomarcadores , Estudos de Coortes , Comorbidade , Citocinas/metabolismo , Feminino , Humanos , Mediadores da Inflamação/metabolismo , Masculino , Metaloproteases/metabolismo , Pessoa de Meia-Idade , Neutrófilos/imunologia , Neutrófilos/metabolismo , Neutrófilos/patologia , Radiografia Torácica , Índice de Gravidade de Doença , Trombocitose/sangue , Tuberculose Pulmonar/diagnóstico por imagem , Tuberculose Pulmonar/patologia , Adulto Jovem
11.
Int J Infect Dis ; 49: 33-9, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27235086

RESUMO

OBJECTIVES: Molecular tests show low sensitivity for smear-negative pulmonary tuberculosis (PTB). A screening and risk assessment system for smear-negative PTB using artificial neural networks (ANNs) based on patient signs and symptoms is proposed. METHODS: The prognostic and risk assessment models exploit a multilayer perceptron (MLP) and inspired adaptive resonance theory (iART) network. Model development considered data from 136 patients with suspected smear-negative PTB in a general hospital. RESULTS: MLP showed higher sensitivity (100%, 95% confidence interval (CI) 78-100%) than the other techniques, such as support vector machine (SVM) linear (86%; 95% CI 60-96%), multivariate logistic regression (MLR) (79%; 95% CI 53-93%), and classification and regression tree (CART) (71%; 95% CI 45-88%). MLR showed a slightly higher specificity (85%; 95% CI 59-96%) than MLP (80%; 95% CI 54-93%), SVM linear (75%, 95% CI 49-90%), and CART (65%; 95% CI 39-84%). In terms of the area under the receiver operating characteristic curve (AUC), the MLP model exhibited a higher value (0.918, 95% CI 0.824-1.000) than the SVM linear (0.796, 95% CI 0.651-0.970) and MLR (0.782, 95% CI 0.663-0.960) models. The significant signs and symptoms identified in risk groups are coherent with clinical practice. CONCLUSIONS: In settings with a high prevalence of smear-negative PTB, the system can be useful for screening and also to aid clinical practice in expediting complementary tests for higher risk patients.


Assuntos
Programas de Rastreamento/métodos , Tuberculose Pulmonar/diagnóstico , Adulto , Feminino , Humanos , Modelos Logísticos , Masculino , Programas de Rastreamento/instrumentação , Pessoa de Meia-Idade , Mycobacterium tuberculosis/isolamento & purificação , Mycobacterium tuberculosis/fisiologia , Curva ROC , Tuberculose Pulmonar/microbiologia
12.
Open Forum Infect Dis ; 3(4): ofw203, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28053996

RESUMO

Brazil has experienced a Zika virus (ZIKV) outbreak with increased incidence of congenital malformations and neurological manifestations. We describe a case of a 26-year-old Brazilian Caucasian man infected with ZIKV and diagnosed with encephalomyelitis. Brain and spinal cord images showed hyperintense lesions on T2 and fluid-attenuated inversion recovery (FLAIR), and levels of proinflammatory cytokines in the cerebrospinal fluid showed a remarkable increase of interleukin (IL)-6 and IL-8. The observed pattern suggests immune activation during the acute phase, along with the neurological impairment, with normalization in the recovery phase. This is the first longitudinal report of ZIKV infection causing encephalomyelitis with documented immune activation.

13.
14.
Cad. saúde colet., (Rio J.) ; 17(4)out.-dez. 2009.
Artigo em Português | LILACS-Express | ID: lil-621187

RESUMO

A doença de Chagas, desde sua descoberta em 1909, marca a história da ciência e da medicina no Brasil. Na descrição inicial do ciclo de transmissão, o Triatoma infestans e as casas de pau a pique formaram o cenário mais difundido desta doença. A possibilidade de outras formas de transmissão com expressão clínico-epidemiológica diversa foi eclipsada, apesar de epidemias de transmissão oral terem sido descritas desde 1968. A partir do referencial da epidemiologia histórica discutimos a doença de Chagas e as mudanças na visão desta doença num período em que o país inverte sua proporção de população urbana/rural; industrializa-se; insere o campo em um sistema de produção de baixa necessidade de mão de obra; e erradica o principal vetor. Apontamos o surgimento de novos cenários e a necessidade de estudos que explorem as condições de ocorrência da doença de Chagas de transmissão oral superando o binômio do desenvolvimento e do atraso no entendimento da complexidade da história desta doença.


Chagas disease has been a relevant chapter of the history of science and medicine in Brazil ever since its discovery in 1909. The initial descriptions of the transmission cycle with the Triatoma infestans in the wattle and daub houses make up for a powerful image of this disease, that resulted in other forms of transmission and clinical-epidemiological presentations being largely ignored even though reports of orally transmitted disease epidemics go back to 1968. We have studied Chagas disease from the point of view of historical epidemiology in the light of the changes observed in the 20th century with the inversion of the urban/rural population distribution; industrialization; lowering man-power usage in agriculture; and vector eradication. We discuss the occurrence of oral transmission pointing to the need to consider the complexity of the history of Chagas disease beyond the model of the development/underdevelopment binomium.

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