High occurrence of HIV-positive siblings due to repeated mother-to-child transmission in Brazil.

Pregnancies in women without knowledge of their HIV-positive status increase the risk of mother-to-child transmission, and of disease progression. This study aimed to characterize the frequency of multiple pregnancies and of HIV-positive children in the family, during HAART era. We analyzed data of a national multicenter cohort study among Brazilian children with AIDS diagnosed between 1999 and 2002. In total, 945 children and their 928 mothers were included. Five hundred and ninety (64.6%) women had a history of multiple pregnancies, and 49.5% attended prenatal care (mean: 3.5 consultations; SD 3.6). In 483 child cases, HIV status of the sibling was known; 130 (26.9%) of these were infected with HIV. In 38.5% of cases, the child with AIDS included in the cohort study was the first case in the family. Despite the overall positive results of the Brazilian control policy of HIV/AIDS, our study shows that HIV infection in pregnant women was often undetected and that consequently there was a high frequency of repeated HIV-infected children. There is a need to improve comprehensive prenatal and postnatal care of Brazilian women. HIV-affected families are most vulnerable and should be targeted by specific control programs, preventing additional HIV infections in other children.

Household-wide ivermectin treatment for head lice in an impoverished community: randomized observer-blinded controlled trial.

OBJECTIVE: To generate evidence on the effectiveness of household-wide treatment for preventing the transmission of pediculosis capitis (head lice) in resource-poor communities. METHODS: We studied 132 children without head lice who lived in a slum in north-eastern Brazil. We randomized the households of the study participants into an intervention and a control group and prospectively calculated the incidence of infestation with head lice among the children in each group. In the intervention group, all of the children's family members who lived in the household were treated with ivermectin; in the control group, no family member was treated. We used the chi(2) test with continuity correction or Fisher's exact test to compare proportions. We performed survival analysis using Kaplan-Meier estimates with log rank testing and the Mann-Whitney U test to analyse the length of lice-free periods among sentinel children, and we used Cox regression to analyse survival data on a multivariate level. We also carried out a subgroup analysis based on gender. FINDINGS: Children in the intervention group remained free from infestation with head lice significantly longer than children in the control group. The median infestation-free period in the intervention group was 24 days (interquartile range, IQR: 11-45), as compared to 14 days (IQR: 11-25) in the control group (P = 0.01). Household-wide treatment with ivermectin proved significantly more effective among boys than among girls (P = 0.005). After treatment with ivermectin, the estimated number of annual episodes of head lice infestation was reduced from 19 to 14 in girls and from 15 to 5 in boys. Female sex and extreme poverty were independent risk factors associated with a shortened disease-free period. CONCLUSION: In an impoverished community, girls and the poorest of the poor are the population groups that are most vulnerable for head lice infestation. To decrease the number of head lice episodes per unit of time, control measures should include the treatment of all household contacts. Mass treatment with ivermectin may reduce the incidence of head lice infestation and associated morbidity in resource-poor communities.

[Ecoparasitoses and public health in Brazil: challenges for control]. / Ectoparasitoses e saúde pública no Brasil: desafios para controle.

Parasitic skin diseases such as scabies, pediculosis, tungiasis, and cutaneous larva migrans are hyperendemic in the numerous poor communities in Brazil and are commonly associated with considerable morbidity. However, programs to control ectoparasites are non-existent in the country's public health system. Due to neglect of these diseases by the population itself and health care professionals, the diseases' highly contagious characteristics, and lack of effective treatment and/or presence of animal reservoirs together with a complex life cycle, effective control of ectoparasites is an enormous public health challenge. This article discusses potential measures to control parasitic skin diseases in affected communities, based on mass treatment, health education, and (when applicable) eradication of animal reservoirs.

Efficacy of chemical and botanical over-the-counter pediculicides available in Brazil, and off-label treatments, against head lice ex vivo.

BACKGROUND: There is a lack of reliable data on the efficacy of over-the-counter (OTC) pediculicides in Brazil. METHODS: We performed ex vivo assays of eight marketed pediculicides: 1% permethrin (Kwell, Clean Hair, Keltrina, Nedax), 0.02% deltamethrin (Deltacid, Pediderm), and two "natural" products (Piolho e Lêndea, Pilogenio). We also tested 5% permethrin (Keltrina Plus), traditional home remedies and an ivermectin-based product used in veterinary medicine. Head lice (49-52 per group) were immersed in the compound for 3 min and washed after 20 min to simulate the typical in vivo treatment protocol. Lice were examined for activity up to 24 h using stringent criteria for survival. RESULTS: Of the permethrin containing products, highest mortality was observed with Kwell and Clean Hair (97.9 and 90.2% after 4 h). Keltrina, Nedax, Keltrina Plus, and the two deltamethrin-based products showed only a low efficacy of <60% after 4 h. With exception of pure coconut oil (80% mortality after 4 h), home remedies showed a very low efficacy, and both marketed products killed few lice. The ivermectin-based product caused a mortality of 100% after 4 h. CONCLUSIONS: Most Brazilian OTC products did not show a satisfactory efficacy against head lice. Resistance may be present. Ivermectin and coconut oil are promising compounds for topical treatment. Laboratory-based tests should be used to assess resistance patterns and to identify formulations of the active ingredient that increase the efficacy. Standardized testing should be performed before a product is licensed for head lice treatment.

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.

Risk factors for sexually transmitted infections in women in rural Northeast Brazil.

BACKGROUND: Sexually transmitted infections (STIs) are highly prevalent in northeast Brazil, but factors associated with the presence of an STI have rarely been studied systematically. METHODOLOGY: We performed a population-based study to assess factors associated with STIs in women of reproductive age (12 to 49 years) in a rural setting in northeast Brazil. A total of 734 women were eligible; 592 (80.7%) had initiated sexual life and were included. Women were examined for the presence of an STI. Socio-economic variables, sexual history, and behaviour were assessed through a structured questionnaire. Laboratory testing included: polymerase chain reaction for human papillomavirus (HPV); ligase chain reaction for Chlamydia trachomatis and Neisseria gonorrhoeae; VDRL and FTA-ABS for Treponema pallidum; analysis of wet mounts, gram stain and Pap smears for Trichomonas vaginalis; and ELISA for HIV. RESULTS: At least one STI was present in 112 (19.6%) of the women. In logistic regression analysis, a previous visit to a Pap smear clinic was protective against an STI (OR=0.26; IC 95%: 0.12-0.57). The following variables were independently associated with STIs: > or =3 partners in life (2.35; 1.32-4.17); first pregnancy < 16 years of age (2.28; 1.09-4.78); not knowing if partner had another partner (3.56; 1.09-11.62). CONCLUSIONS: The protective and risk factors identified can guide the implementation of gender- and age-specific control programs in rural northeast Brazil. Offering a simple preventive measure (Pap smear collection), usually done by a nurse in this setting, may be a useful opportunity for diagnosis and treatment of curable STIs, without considerable additional costs.

Sexually transmitted infections, bacterial vaginosis, and candidiasis in women of reproductive age in rural Northeast Brazil: a population-based study.

Population-based data on sexually transmitted infections (STI), bacterial vaginosis (BV), and candidiasis reflect the epidemiological situation more accurately than studies performed in specific populations, but such data are scarce. To determine the prevalence of STI, BV, and candidiasis among women of reproductive age from a resource-poor community in Northeast Brazil, a population-based cross sectional study was undertaken. All women from seven hamlets and the centre of Pacoti municipality in the state of Ceará, aged 12 to 49 years, were invited to participate. The women were asked about socio-demographic characteristics and genital symptoms, and thereafter examined gynaecologically. Laboratory testing included polymerase chain reaction (PCR) for human papillomavirus (HPV), ligase chain reaction (LCR) for Chlamydia trachomatis and Neisseria gonorrhoeae, ELISA for human immunodeficiency virus (HIV), venereal disease research laboratory (VDRL) and fluorescent treponema antibody absorption test (FTA-ABS) for syphilis, and analysis of wet mounts, gram stains and Pap smears for trichomoniasis, candidiasis, and BV. Only women who had initiated sexual life were included in the analysis (n = 592). The prevalences of STI were: HPV 11.7% (95% confidence interval: 9.3-14.7), chlamydia 4.5% (3.0-6.6), trichomoniasis 4.1% (2.7-6.1), gonorrhoea 1.2% (0.5-2.6), syphilis 0.2% (0.0-1.1), and HIV 0%. The prevalence of BV and candidiasis was 20% (16.9-23.6) and 12.5% (10.0-15.5), respectively. The most common gynaecological complaint was lower abdominal pain. STI are common in women in rural Brazil and represent an important health threat in view of the HIV pandemic.

Selective mass treatment with ivermectin to control intestinal helminthiases and parasitic skin diseases in a severely affected population.

OBJECTIVE: To assess the short-term and long-term impact of selective mass treatment with ivermectin on the prevalence of intestinal helminthiases and parasitic skin diseases in an economically depressed community in north-east Brazil. METHODS: An intervention was carried out in a traditional fishing village in north-east Brazil where the population of 605 is heavily affected by ectoparasites and enteroparasites. The prevalence of intestinal helminths was determined by serial stool examination and the prevalence of parasitic skin diseases by clinical inspection. A total of 525 people out of a target population of 576 were treated at baseline. The majority of these were treated with ivermectin (200 microg/kg with a second dose given after 10 days). If ivermectin was contraindicated, participants were treated with albendazole or mebendazole for intestinal helminths or with topical deltamethrin for ectoparasites. Follow-up examinations were performed at 1 month and 9 months after treatment. FINDINGS: Prevalence rates of intestinal helminthiases before treatment and at 1 month and 9 months after mass treatment were: hookworm disease 28.5%, 16.4% and 7.7%; ascariasis 17.1%, 0.4% and 7.2%; trichuriasis 16.5%, 3.4% and 9.4%; strongyloidiasis 11.0%, 0.6% and 0.7%; and hymenolepiasis 0.6%; 0.4% and 0.5%, respectively. Prevalence rates of parasitic skin diseases before treatment and 1 month and 9 months after mass treatment were: active pediculosis 16.1%, 1.0% and 10.3%; scabies 3.8%, 1.0% and 1.5%; cutaneous larva migrans 0.7%, 0% and 0%; tungiasis 51.3%, 52.1% and 31.2%, respectively. Adverse events occurred in 9.4% of treatments. They were all of mild to moderate severity and were transient. CONCLUSION: Mass treatment with ivermectin was an effective and safe means of reducing the prevalence of most of the parasitic diseases prevalent in a poor community in north-east Brazil. The effects of treatment lasted for a prolonged period of time.

Efficacy of ivermectin in a patient population concomitantly infected with intestinal helminths and ectoparasites.

Ivermectin (CAS 70288-86-7) is a potent antiparasitic drug. However, studies have not been published evaluating the efficacy of ivermectin in a patient population concomitantly infected with intestinal helminths and ectoparasites. Here the results of an open trial on the efficacy of ivermectin in a heavily poly-parasitized population in northeast Brazil are presented. Two hundred and fifty-one patients were enrolled. Two doses of ivermectin (200 microg/kg) were given at an interval of 10 days. The cure rates for intestinal helminthiases were: 100% for strongyloidiasis and enterobiasis, 99% for ascariasis, 84% for trichuriasis, 68% for hookworm disease, and 50% for hymenolepiasis. Cure rates for ectoparasitoses were: 100% for cutaneous larva migrans, 99% for pediculosis, 88% for scabies and 64% for tungiasis. The results show that two doses of ivermectin are highly efficacious for most intestinal helminths and ectoparasites simultaneously present in an impoverished population. The drug seems to be particularly useful when polyparasitism is expected to occur or when public health measures aim to reduce both intestinal helminthiases and parasitic skin diseases by mass chemotherapy.

Grandes represas e seu impacto em saúde pública: ii. Efeitos a jusante / Impact of large dams on public health: ii. Dowstream effects

Represas vêm sendo construídas há milhares de anos, e, atualmente, quase metade dos rios do mundo possui pelo menos uma grande represa. Os efeitos das grandes represas na saúde de populações a montante são comuns na literatura. Entretanto, o papel das represas na saúde pública de comunidades a jusante continua sendo negligenciado. Para contribuir nessa discussão, apresenta-se uma revisão da literatura a respeito dos efeitos das grandes represas na saúde pública de populações a jusante. Foram pesquisados os bancos de dados Medline, Lilacs, Repidisca, ISI Web of Science, WHOLIS, Banco de Teses da CAPES, Scielo, PAHO database, DESASTRES, World Commission on Dams database, Google, Science Direct, Wiley Interscience, MEDCARIB, além de páginas específicas na internet. São apresentados e discutidos a redução da biodiversidade aquática, a diminuição das áreas de desova de peixes e o declínio dos serviços ambientais prestados pelas planícies aluviais, brejos, ecossistemas fluviais, estuarinos e marinhos adjacentes. Conclui-se que a construção de represas está diretamente relacionada com o status nutricional das populações ribeirinhas a jusante, como conseqüência de mudanças na pesca e na agricultura. As condições precárias de saúde dessas comunidades, vulneráveis ou suscetíveis, por diversos motivos contextuais e históricos, terão grandes chances de se ampliar. É inquestionável que represas possam trazer inúmeros benefícios, entretanto, o risco para a saúde das populações vivendo a jusante também precisa ser identificado e prevenido.

Sexually transmitted infections, bacterial vaginosis, and candidiasis in women of reproductive age in rural Northeast Brazil: a population-based study

Population-based data on sexually transmitted infections (STI), bacterial vaginosis (BV), and candidiasis reflect the epidemiological situation more accurately than studies performed in specific populations, but such data are scarce. To determine the prevalence of STI, BV, and candidiasis among women of reproductive age from a resource-poor community in Northeast Brazil, a population-based cross sectional study was undertaken. All women from seven hamlets and the centre of Pacoti municipality in the state of Ceará, aged 12 to 49 years, were invited to participate. The women were asked about socio-demographic characteristics and genital symptoms, and thereafter examined gynaecologically. Laboratory testing included polymerase chain reaction (PCR) for human papillomavirus (HPV), ligase chain reaction (LCR) for Chlamydia trachomatis and Neisseria gonorrhoeae, ELISA for human immunodeficiency virus (HIV), venereal disease research laboratory (VDRL) and fluorescent treponema antibody absorption test (FTA-ABS) for syphilis, and analysis of wet mounts, gram stains and Pap smears for trichomoniasis, candidiasis, and BV. Only women who had initiated sexual life were included in the analysis (n = 592). The prevalences of STI were: HPV 11.7 percent (95 percent confidence interval: 9.3-14.7), chlamydia 4.5 percent (3.0-6.6), trichomoniasis 4.1 percent (2.7-6.1), gonorrhoea 1.2 percent (0.5-2.6), syphilis 0.2 percent (0.0-1.1), and HIV 0 percent. The prevalence of BV and candidiasis was 20 percent (16.9-23.6) and 12.5 percent (10.0-15.5), respectively. The most common gynaecological complaint was lower abdominal pain. STI are common in women in rural Brazil and represent an important health threat in view of the HIV pandemic.

Ectoparasitoses e saúde pública no Brasil: desafios para controle / Ecoparasitoses and public health in Brazil: challenges for control

Doenças ectoparasitárias como a escabiose, a pediculose, a tungíase e a larva migrans cutânea säo hiperendêmicas em inúmeras comunidades carentes no Brasil, e näo raramente associadas à severidade considerável. Entretanto, programas que priorizem o controle de ectoparasitas näo existem em nível de saúde pública no país. Como conseqüência da alta contagiosidade, de manejo inadequado, de negligência tanto da populaçäo como dos profissionais de saúde e/ou da presença de reservatórios animais, além de ciclos de vida complexos, o controle efetivo das ectoparasitoses é um desafio para a saúde pública. Aqui discutimos possíveis medidas de intervençäo para o controle de doenças ectoparasitárias em comunidades afetadas, baseadas em tratamento em massa, educaçäo em saúde e, caso se aplique, na erradicaçäo dos reservatórios animais

Ectoparasitoses e saúde pública no Brasil: desafios para controle / Ecoparasitoses and public health in Brazil: challenges for control

Doenças ectoparasitárias como a escabiose, a pediculose, a tungíase e a larva migrans cutânea säo hiperendêmicas em inúmeras comunidades carentes no Brasil, e näo raramente associadas à severidade considerável. Entretanto, programas que priorizem o controle de ectoparasitas näo existem em nível de saúde pública no país. Como conseqüência da alta contagiosidade, de manejo inadequado, de negligência tanto da populaçäo como dos profissionais de saúde e/ou da presença de reservatórios animais, além de ciclos de vida complexos, o controle efetivo das ectoparasitoses é um desafio para a saúde pública. Aqui discutimos possíveis medidas de intervençäo para o controle de doenças ectoparasitárias em comunidades afetadas, baseadas em tratamento em massa, educaçäo em saúde e, caso se aplique, na erradicaçäo dos reservatórios animais (AU)

Grandes represas e seu impacto em saúde pública: ii. Efeitos a jusante / Impact of large dams on public health: ii. Dowstream effects

Represas vêm sendo construídas há milhares de anos, e, atualmente, quase metade dos rios do mundo possui pelo menos uma grande represa. Os efeitos das grandes represas na saúde de populações a montante são comuns na literatura. Entretanto, o papel das represas na saúde pública de comunidades a jusante continua sendo negligenciado. Para contribuir nessa discussão, apresenta-se uma revisão da literatura a respeito dos efeitos das grandes represas na saúde pública de populações a jusante. Foram pesquisados os bancos de dados Medline, Lilacs, Repidisca, ISI Web of Science, WHOLIS, Banco de Teses da CAPES, Scielo, PAHO database, DESASTRES, World Commission on Dams database, Google, Science Direct, Wiley Interscience, MEDCARIB, além de páginas específicas na internet. São apresentados e discutidos a redução da biodiversidade aquática, a diminuição das áreas de desova de peixes e o declínio dos serviços ambientais prestados pelas planícies aluviais, brejos, ecossistemas fluviais, estuarinos e marinhos adjacentes. Conclui-se que a construção de represas está diretamente relacionada com o status nutricional das populações ribeirinhas a jusante, como conseqüência de mudanças na pesca e na agricultura. As condições precárias de saúde dessas comunidades, vulneráveis ou suscetíveis, por diversos motivos contextuais e históricos, terão grandes chances de se ampliar. É inquestionável que represas possam trazer inúmeros benefícios, entretanto, o risco para a saúde das populações vivendo a jusante também precisa ser identificado e prevenido.(AU)

Mulheres com HIV/AIDS no estado do Ceará: comportamentos, vida reprodutiva e fatores associados à infecção / Women with HIV / AIDS in the state of Ceará: behavior, reproductive life and factors associated with infection

A epidemia de HIV/AIDS está se disseminando em direção a mulheres principalmente através da via heterossexual, onde questões de gênero detêm papel decisivo. O objetivo desse estudo foi descrever características sócio-econômicas, comportamentais e reprodutivas, e identificar fatores associados a infecção pelo HIV em mulheres com e sem o diagnóstico de AIDS. Realizamos um estudo caso-controle com pacientes atendidas em ambulatório de HIV/AIDS (casos) em hospital de referência em Fortaleza, Ceará, e mulheres HIV negativo frequentando outro serviço do mesmo hospital (controles), entre junho e agosto de 2004. Participaram do estudo 290 mulheres com AIDS, 83 mulheres HIV (sem AIDS) e 209 controles. Dentre as mulheres com parceiro fico, 79,3% (AIDS), 62,3% (HIV) e 20,6% (controles) utilizaram o preservativo na última relação sexual (p < 0,001 para AIDS ou HIV vs. controles). Dentre as 106 mulheres soropositivas com parceiro fixo HIV negativo ou de sorologia desconhecida, apenas 79 (75,2%) utilizaram o preservativo naquela ocasião. O motivo mais frequente para o não uso do preservativo foi "o parceiro não gosta" (53,8%), dentre as soropositivas, e "usa outro método contraceptivo", dentre os controles (30,7%). Mulheres HIV foram diagnosticadas mais frequentemente devido ao parceiro ter adoecido (36,6%), e mulheres com AIDS, por ter adoecido (45,7%). O modo de infecção principal foi a heterossexual (79,5%). Somente quatro mulheres soropositivas (1,1%) relataram ter usado droga injetável, porém, 20,6% (AIDS) e 17,8% (HIV) das mulheres relataram ter tido parceiros usuários de drogas injetáveis (UDI), em comparação com 4,0% dos controles (p < 0,001 para AIDS ou HIV vs. controles)...