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Background: Large-scale variation in ecological parameters across Madagascar is hypothesized to drive varying spatial patterns of malaria infection. However, to date, few studies of parasite prevalence with resolution at finer, sub-regional spatial scales are available. As a result, there is a poor understanding of how Madagascar's diverse local ecologies link with variation in the distribution of infections at the community and household level. Efforts to preserve Madagascar's ecological diversity often focus on improving livelihoods in rural communities near remaining forested areas but are limited by a lack of data on their infectious disease burden.Methods: To investigate spatial variation in malaria prevalence at the sub-regional scale in Madagascar, we sampled 1476 households (7117 total individuals, all ages) from 31 rural communities divided among five ecologically distinct regions. The sampled regions range from tropical rainforest to semi-arid, spiny forest and include communities near protected areas including the Masoala, Makira, and Mikea forests. Malaria prevalence was estimated by rapid diagnostic test (RDT) cross-sectional surveys performed during malaria transmission seasons over 2013-2017.Results: Indicative of localized hotspots, malaria prevalence varied more than 10-fold between nearby (< 50 km) communities in some cases. Prevalence was highest on average in the west coast region (Morombe district, average community prevalence 29.4%), situated near protected dry deciduous forest habitat. At the household level, communities in southeast Madagascar (Mananjary district) were observed with over 50% of households containing multiple infected individuals at the time of sampling. From simulations accounting for variation in household size and prevalence at the community level, we observed a significant excess of households with multiple infections in rural communities in southwest and southeast Madagascar, suggesting variation in risk within communities.Conclusions: Our data suggest that the malaria infection burden experienced by rural communities in Madagascar varies greatly at smaller spatial scales (i.e., at the community and household level) and that the southeast and west coast ecological regions warrant further attention from disease control efforts. Conservation and development efforts in these regions may benefit from consideration of the high, and variable, malaria prevalences among communities in these areas. [ABSTRACT FROM AUTHOR]

Background: After being eliminated during the 1950s, dengue reemerged in Brazil in the 1980s. Since then, incidence of the disease has increased, as serotypes move within and between cities. The co-circulation of multiple serotypes contributes to cycles of epidemic and interepidemic years, and a seasonal pattern of transmission is observed annually. Little is known regarding possible differences in the epidemiology of dengue under epidemic and interepidemic scenarios. This study addresses this gap and aims to assess the epidemiological characteristics and determinants of epidemic and interepidemic dengue transmission, utilizing data from the 5th largest city in Brazil (Fortaleza), at fine spatial and temporal scales. Methods/Principal findings: Longitudinal models of monthly rates of confirmed dengue cases were used to estimate the differential contribution of contextual factors to dengue transmission in Fortaleza between 2011 and 2015. Models were stratified by annual climatological schedules and periods of interepidemic and epidemic transmission, controlling for social, economic, structural, entomological, and environmental factors. Results revealed distinct seasonal patterns between interepidemic and epidemic years, with persistent transmission after June in interepidemic years. Dengue was strongly associated with violence across strata, and with poverty and irregular garbage collection during periods of low transmission, but not with other indicators of public service provision or structural deprivation. Scrapyards and sites associated with tire storage were linked to incidence differentially between seasons, with the strongest associations during transitional precipitation periods. Hierarchical clustering analysis suggests that the dengue burden concentrates in the southern periphery of the city, particularly during periods of minimal transmission. Conclusions/Significance: Our findings have direct programmatic implications. Vector control operations must be sustained after June even in non-epidemic years. More specifically, scrapyards and sites associated with tires (strongly associated with incidence during periods of minimal transmission), require sustained entomological surveillance, particularly during interepidemic intervals and in the urban periphery. Intersectoral collaborations that address urban violence are critical for facilitating the regular activities of vector control agents. [ABSTRACT FROM AUTHOR]

Universal Health Coverage (UHC) is one of the United Nations Sustainable Development Goals (SDGs). Achieving UHC will require strong health systems to promote and deliver equitable and integrated healthcare services through primary healthcare (PHC). In Brazil, the Family Health Strategy (FHS) delivers PHC through the public health system. Created in 1994, the FHS covered almost 123 million individuals (63% of the Brazilian population) by 2015. The FHS has been associated with many health improvements, but gaps in coverage still remain. This article examines factors associated with the implementation and expansion of the FHS across 5419 Brazilian municipalities from 1998 to 2012. The proportion of the municipal population covered by the FHS over time was assessed using a longitudinal multilevel model for change that accounted for variables covering eight domains: economic development, healthcare supply, healthcare needs/access, availability of other sources of healthcare, political context, geographical isolation, regional characteristics and population size. Data were obtained from multiple publicly available sources. During the 15-year study period, national coverage of the FHS increased from 4.4% to 54%, with 58% of the municipalities having population coverage of 95% or more, and municipalities that had not adopted the programme decreased from 86.4% to 4.9%. The increase in FHS uptake and coverage was not homogenous across municipalities, and was positively associated with small population size, low population density, low coverage of private health insurance, low level of economic development, alignment of the political party of the Mayor and the state Governor, and availability of healthcare supply. Efforts to expand the FHS coverage will need to focus on increasing the availability of health personnel, devising financial incentives for municipalities to uptake/expand the FHS and devising new policies that encompass both private and public sectors. [ABSTRACT FROM AUTHOR]

Background: Tuberculosis (TB) remains a public health problem, despite recent achievements in reducing incidence and mortality rates. In Brazil, these achievements were above the worldwide average, but marked by large regional heterogeneities. In Fortaleza (5th largest city in Brazil), the tuberculosis cure rate has been declining and treatment abandonment has been increasing in the past decade, despite a reduction in incidence and an increase in directly observed therapy (DOT). These trends put efforts to eliminate tuberculosis at risk. We therefore sought to determine social and programmatic determinants of tuberculosis incidence and treatment abandonment in Fortaleza.Methods: We analyzed sociodemographic and clinical data for all new tuberculosis cases notified in the Notifiable Diseases Information System (SINAN) from Fortaleza between 2007 and 2014. We calculated incidence rates for 117 neighborhoods in Fortaleza, assessed their spatial clustering, and used spatial regression models to quantify associations between neighborhood-level covariates and incidence rates. We used hierarchical logistic regression models to evaluate how individual- and neighborhood-level covariates predicted tuberculosis treatment abandonment.Results: There were 12,338 new cases reported during the study period. Case rates across neighborhoods were significantly positively clustered in two low-income areas close to the city center. In an adjusted model, tuberculosis rates were significantly higher in neighborhoods with lower literacy, higher sewerage access and homicide rates, and a greater proportion of self-reported black residents. Treatment was abandoned in 1901 cases (15.4%), a rate that rose by 71% between 2007 and 2014. Abandonment was significantly associated with many individual sociodemographic and clinical factors. Notably, being recommended for DOT was protective for those who completed DOT, but associated with abandonment for those who did not.Conclusion: Low socioeconomic status areas have higher tuberculosis rates, and low socioeconomic individuals have higher risk of treatment abandonment, in Fortaleza. Treatment abandonment rates are growing despite the advent of universal DOT recommendations in Brazil. Proactive social policies, and active contact tracing to find missed cases, may help reduce the tuberculosis burden in this setting. [ABSTRACT FROM AUTHOR]

Brazil currently contributes 42 % of all malaria cases reported in the Latin America and the Caribbean, a region where major progress towards malaria elimination has been achieved in recent years. In 2014, malaria burden in Brazil (143,910 microscopically confirmed cases and 41 malaria-related deaths) has reached its lowest levels in 35 years, Plasmodium falciparum is highly focal, and the geographic boundary of transmission has considerably shrunk. Transmission in Brazil remains entrenched in the Amazon Basin, which accounts for 99.5 % of the country's malaria burden. This paper reviews major lessons learned from past and current malaria control policies in Brazil. A comprehensive discussion of the scientific and logistic challenges that may impact malaria elimination efforts in the country is presented in light of the launching of the Plan for Elimination of Malaria in Brazil in November 2015. Challenges for malaria elimination addressed include the high prevalence of symptomless and submicroscopic infections, emerging anti-malarial drug resistance in P. falciparum and Plasmodium vivax and the lack of safe anti-relapse drugs, the largely neglected burden of malaria in pregnancy, the need for better vector control strategies where Anopheles mosquitoes present a highly variable biting behaviour, human movement, the need for effective surveillance and tools to identify foci of infection in areas with low transmission, and the effects of environmental changes and climatic variability in transmission. Control actions launched in Brazil and results to come are likely to influence control programs in other countries in the Americas. [ABSTRACT FROM AUTHOR]

Objectives: In this study we evaluate the relationship between early stage of breast cancer diagnosis and geographic access to mammography in New York State. Methods: We utilized indicators of spatial autocorrelation to assess if significant clusters of early stage breast cancer diagnosis and mammogram facilities occurred across NY counties over the years 2007-11. We used spatial autoregressive models to evaluate the importance of density and proximity of facilities in early stage cancer, controlling for several demographic and socioeconomic factors. Results: Among 62 counties, the density of mammogram facilities varied from 0.2 to 2 sites/10,000 women, while distance to a facility from population centroid ranged between 0.44 to 38.58 miles. Four significant spatial clusters of high percentages of early stage breast cancer diagnosis were identified. The spatial autoregressive model indicated that the only statistically significant variable relating to higher percent of early stage at diagnosis was higher education (p=0.005). Conclusion: Using the county as the spatial unit of analysis, higher education was more significant than spatial access to mammography on the percent of early stage breast cancer diagnosis. [ABSTRACT FROM AUTHOR]

Abstract: We investigated the spatial distribution, and social and economic correlates, of tuberculosis in Brazil between 2002 and 2009 using municipality-level age/sex-standardized tuberculosis notification data. Rates were very strongly spatially autocorrelated, being notably high in urban areas on the eastern seaboard and in the west of the country. Non-spatial ecological regression analyses found higher rates associated with urbanicity, population density, poor economic conditions, household crowding, non-white population and worse health and healthcare indicators. These associations remained in spatial conditional autoregressive models, although the effect of poverty appeared partially confounded by urbanicity, race and spatial autocorrelation, and partially mediated by household crowding. Our analysis highlights both the multiple relationships between socioeconomic factors and tuberculosis in Brazil, and the importance of accounting for spatial factors in analysing socioeconomic determinants of tuberculosis. [Copyright &y& Elsevier]

Background: The use of larval source management is not prioritized by contemporary malaria control programs in sub-Saharan Africa despite historical success. Larviciding, in particular, could be effective in urban areas where transmission is focal and accessibility to Anopheles breeding habitats is generally easier than in rural settings. The objective of this study is to assess the effectiveness of a community-based microbial larviciding intervention to reduce the prevalence of malaria infection in Dar es Salaam, United Republic of Tanzania. Methods and Findings: Larviciding was implemented in 3 out of 15 targeted wards of Dar es Salaam in 2006 after two years of baseline data collection. This intervention was subsequently scaled up to 9 wards a year later, and to all 15 targeted wards in 2008. Continuous randomized cluster sampling of malaria prevalence and socio-demographic characteristics was carried out during 6 survey rounds (2004–2008), which included both cross-sectional and longitudinal data (N = 64,537). Bayesian random effects logistic regression models were used to quantify the effect of the intervention on malaria prevalence at the individual level. Effect size estimates suggest a significant protective effect of the larviciding intervention. After adjustment for confounders, the odds of individuals living in areas treated with larviciding being infected with malaria were 21% lower (Odds Ratio = 0.79; 95% Credible Intervals: 0.66–0.93) than those who lived in areas not treated. The larviciding intervention was most effective during dry seasons and had synergistic effects with other protective measures such as use of insecticide-treated bed nets and house proofing (i.e., complete ceiling or window screens). Conclusion: A large-scale community-based larviciding intervention significantly reduced the prevalence of malaria infection in urban Dar es Salaam. [ABSTRACT FROM AUTHOR]

Objective: To perform spatial distribution analysis of reported cases of Zika virus and congenital Zika syndrome (CZS) in the state of Espírito Santo, Brazil, by neighborhood, and relate the results to sociodemographic indicators and implications for the health process.Methods: An ecological study using data from the 2016 National Notifiable Diseases Surveillance System, epidemiological records, and information on neighborhoods of families confirmed with CZS from qualitative field research.Results: Sociodemographic indicators were analyzed in three distinct groups: general population with Zika virus, pregnant women with Zika virus, and cases of CZS visited. For the three groups, average literacy rates were 71.1%, 71.0%, and 68.3%; the average income per minimum wage was 1.4, 1.1, and 1.4; sanitary sewage coverage was 75.6%, 76.1%, and 71.4%; garbage coverage was 90.8%, 91.2%, and 89.2%; and water supply was 93.8%, 94.1% and 93.8%, respectively. Socioeconomic indicators showed no significant differences between groups, although they were above the national average. A nonsignificant variation of 68.3%-71.1% was seen in the average literacy level above 15 years of age.Conclusion: Socioeconomic and demographic indicators of cases of Zika virus infection and CZS may indicate that the outbreak had different impacts according to class, social group, or gender, reflecting the persistence and social geography of inequality in Brazil. [ABSTRACT FROM AUTHOR]

Background: In November, 2015, an epidemic of microcephaly was reported in Brazil, which was later attributed to congenital Zika virus infection. 7830 suspected cases had been reported to the Brazilian Ministry of Health by June 4, 2016, but little is known about their characteristics. We aimed to describe these newborn babies in terms of clinical findings, anthropometry, and survival.Methods: We reviewed all 1501 liveborn infants for whom investigation by medical teams at State level had been completed as of Feb 27, 2016, and classified suspected cases into five categories based on neuroimaging and laboratory results for Zika virus and other relevant infections. Definite cases had laboratory evidence of Zika virus infection; highly probable cases presented specific neuroimaging findings, and negative laboratory results for other congenital infections; moderately probable cases had specific imaging findings but other infections could not be ruled out; somewhat probable cases had imaging findings, but these were not reported in detail by the local teams; all other newborn babies were classified as discarded cases. Head circumference by gestational age was assessed with InterGrowth standards. First week mortality and history of rash were provided by the State medical teams.Findings: Between Nov 19, 2015, and Feb 27, 2015, investigations were completed for 1501 suspected cases reported to the Brazilian Ministry of Health, of whom 899 were discarded. Of the remainder 602 cases, 76 were definite, 54 highly probable, 181 moderately probable, and 291 somewhat probable of congenital Zika virus syndrome. Clinical, anthropometric, and survival differences were small among the four groups. Compared with these four groups, the 899 discarded cases had larger head circumferences (mean Z scores -1·54 vs -3·13, difference 1·58 [95% CI 1·45-1·72]); lower first-week mortality (14 per 1000 vs 51 per 1000; rate ratio 0·28 [95% CI 0·14-0·56]); and were less likely to have a history of rash during pregnancy (20·7% vs 61·4%, ratio 0·34 [95% CI 0·27-0·42]). Rashes in the third trimester of pregnancy were associated with brain abnormalities despite normal sized heads. One in five definite or probable cases presented head circumferences in the normal range (above -2 SD below the median of the InterGrowth standard) and for one third of definite and probable cases there was no history of a rash during pregnancy. The peak of the epidemic occurred in late November, 2015.Interpretation: Zika virus congenital syndrome is a new teratogenic disease. Because many definite or probable cases present normal head circumference values and their mothers do not report having a rash, screening criteria must be revised in order to detect all affected newborn babies.Funding: Brazilian Ministry of Health, Pan American Health Organization, and Wellcome Trust. [ABSTRACT FROM AUTHOR]