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Remote areas, such as the Amazon Forest, face unique geographical challenges of transportation-based access to health services. As transportation to healthcare in most of the Amazon Forest is only possible by rivers routes, any travel time and travel distance estimation is limited by the lack of data sources containing rivers as potential transportation routes. Therefore, we developed an approach to convert the geographical representation of roads and rivers in the Amazon into a combined, interoperable, and reusable dataset. To build the dataset, we processed and combined data from three data sources: OpenStreetMap, HydroSHEDS, and GloRiC. The resulting dataset can consider distance metrics using the combination of streets and rivers as a transportation route network for the Amazon Forest. The created dataset followed the guidelines and attributes defined by OpenStreetMap to leverage its reusability and interoperability possibilities. This new data source can be used by policymakers, health authorities, and researchers to perform time-to-care analysis in the International Amazon region. [ABSTRACT FROM AUTHOR]

In the Brazilian Amazon, long distances, low healthcare coverage, common use of ineffective or deleterious self-care practices, and resistance to seeking medical assistance have an impact on access to antivenom treatment. This study aimed to estimate snakebite underreporting, and analyze barriers that prevent victims from obtaining healthcare in communities located in 15 municipalities on the banks of the Solimões, Juruá and Purus Rivers, in the remote Western Brazilian Amazon. Information on the participants' demographics, previous snakebites, access to healthcare, time taken to reach medical assistance, use of self-care practices, and the reason for not accessing healthcare were collected through semi-structured interviews. In the case of deaths, information was collected by interviewing parents, relatives or acquaintances. A total of 172 participants who reported having suffered snakebites during their lifetime were interviewed. A total of 73 different treatment procedures was reported by 65.1% of the participants. Participants living in different river basins share few self-care procedures that use traditional medicine, and 91 (52.9%) participants reported that they had access to healthcare. Living in communities along the Juruá River [OR = 12.6 (95% CI = 3.2–49.7; p<0.001)] and the use of traditional medicine [OR = 11.6 (95% CI = 3.4–39.8; p<0.001)] were variables that were independently associated to the lack of access to healthcare. The main reasons for not accessing healthcare were the pprioritization of traditional treatments (70.4%), and the failure to recognize the situation as being potentially severe (50.6%). Four deaths from complications arising from the snakebite were reported, and three of these were from communities on the banks of the Juruá River. Only one of these received medical assistance. We found an unexpectedly high underreporting of snakebite cases and associated deaths. Snakebite victims utilized three main different healing systems: 1) self-care using miscellaneous techniques; 2) official medical healthcare generally combined with traditional practices; and 3) self-care using traditional practices combined with Western medicines. To mitigate snakebite burden in the Brazilian Amazon, an innovative intervention that would optimize timely delivery of care, including antivenom distribution among existing community healthcare centers, is needed. Author summary: Many patients bitten by snakes in the Brazilian Amazon do not seek medical care since they live great distinces from health facilities and often do not have the financial resources to travel in search of assistance. In this situation of vulnerability, a wide variety of traditional methods, without proven efficacy, and some known to be harmful, are used by individuals. As a result, many cases of snakebites that are not treated in the official health network are consequently not reported to the epidemiological surveillance system, thus generating underreporting. Knowing the proportion of underreported cases and their hostspots is very important for planning interventions that will improve the coverage of the healthcare network and the logistics of delivery of antivenoms. In a pioneering way in Brazil, this study was carried out to estimate snakebite underreporting and analyze obstacles that prevent victims from obtaining healthcare in the communities located in 15 municipalities on the banks of the Solimões, Juruá and Purus Rivers, in the remote Western Brazilian Amazon. Cases of deaths due to snakebites were also investigated. A total of 172 participants who reported having suffered snakebites during their lifetime were interviewed, as well as the circumstances of 4 deaths. Most patients recalled using some traditional medicine in the form of self-care to treat snakebite. In total, there were 73 different treatment procedures, which were quite different between the different regions studied. Almost half of the participants did not seek medical advice, claiming as reason for that the prioritization for traditional treatments and the non-regognition of the situation as potentially severe. In the Juruá River communities, this frequency was around 70%. The preference of traditional medicine was also associated with the lack of access to healthcare. We believe that this situation will only be mitigated if the antivenoms are made available closer to snakebite victims, i.e., in riverside and rural health units. [ABSTRACT FROM AUTHOR]

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Background: In Latin America, where Plasmodium vivax malaria is more prevalent, it is known that this species plays an important role in the sustainability of transmission, and can have an impact on morbidity in terms of anaemia, nutritional status, and cognitive development in children. Methods: The present study aimed to assess the impact of malaria infection on cognition of children in a peri-urban community in the Brazilian Amazon with moderate endemicity by applying Home Inventory and WPPSI-IV. A non-concurrent cohort study was designed and the cognitive, haematological, and nutritional profiles of the children were assessed. Children with documented malaria history were identified from official reported data. Results: A total of 219 children aged between 2 and 7 years were enrolled. Although 205 (95%) children had normal birth weight, 177 (81%) were malnourished, and 35 (16%) had anaemia. Among the 100 (46%) children who experienced at least one episode of malaria, 89 (89%) children demonstrated low level of cognitive development. The findings showed that Plasmodium vivax malaria was an independent risk factor for low cognitive development. Conclusions: In addition to the known economic impact of malaria in the Amazon region, the study highlights the deleterious effects P. vivax malaria has on the socio-cultural development of the population. [ABSTRACT FROM AUTHOR]

Background: In tropical areas, a major concern regarding snakebites treatment effectiveness relates to the failure in liquid antivenom (AV) distribution due to the lack of an adequate cold chain in remote areas. To minimize this problem, freeze-drying has been suggested to improve AV stability. Methods and findings: This study compares the safety and efficacy of a freeze-dried trivalent antivenom (FDTAV) and the standard liquid AV provided by the Brazilian Ministry of Health (SLAV) to treat Bothrops, Lachesis and Crotalus snakebites. This was a prospective, randomized, open, phase IIb trial, carried out from June 2005 to May 2008 in the Brazilian Amazon. Primary efficacy endpoints were the suppression of clinical manifestations and return of hemostasis and renal function markers to normal ranges within the first 24 hours of follow-up. Primary safety endpoint was the presence of early adverse reactions (EAR) in the first 24 hours after treatment. FDTAV thermal stability was determined by estimating AV potency over one year at 56°C. Of the patients recruited, 65 and 51 were assigned to FDTAV and SLAV groups, respectively. Only mild EARs were reported, and they were not different between groups. There were no differences in fibrinogen (p = 0.911) and clotting time (p = 0.982) recovery between FDTAV and SLAV treated groups for Bothrops snakebites. For Lachesis and Crotalus snakebites, coagulation parameters and creatine phosphokinase presented normal values 24 hours after AV therapy for both antivenoms. Conclusions/Significance: Since promising results were observed for efficacy, safety and thermal stability, our results indicate that FDTAV is suitable for a larger phase III trial. Trial registration: ISRCTNregistry: ISRCTN12845255; DOI: (). [ABSTRACT FROM AUTHOR]

Introduction: The common lancehead snakes (Bothrops atrox) are responsible for up to 90% of snakebites in the Amazon, especially in remote areas. The prevalence of microhematuria is similar to that of coagulopathy in B. atrox envenomation in the Amazon. Thus, this study aimed to assess the reliability of microhematuria as an inexpensive and simple alternative to detect snake-induced consumption coagulopathy. Methods: We analyzed samples from patients with confirmed B. atrox envenomation in terms of plasma fibrinogen and microhematuria (>3 red blood cells per high power field) in order to access the reliability of microhematuria to detect snakebite-induced coagulopathy, within 12 hours from admission. Results: A total of 186 patients were recruited. From the total, 85.5% of patients had hypofibrinogenemia and only about 50% (n = 94) had a microscopic examination of urine within 12 hours where microhematuria was present in 39 (41.5%). Diagnostic performance showed 38.6% sensitivity and 36.4% specificity (cutpoint 200 mg/dL). No clear association was seen between microhematuria and hypofibrinogenemia (r: −0.10; p:.34). Conclusion: In this study, microhematuria presented poor diagnostic performance to detect coagulopathy. Further studies are necessary to screen inexpensive and simple alternative diagnostic tools. [ABSTRACT FROM AUTHOR]

Background: The relationship between malaria and undernutrition is controversial and complex. Synergistic associations between malnutrition and malaria morbidity and mortality have been suggested, as well as undernutrition being protective against infection, while other studies found no association. We sought to evaluate the relationship between the number of malaria episodes and nutritional statuses in a cohort of children below 15 years of age living in a rural community in the Brazilian Amazon. Methodology/Principal Findings: Following a baseline survey of clinical, malaria and nutritional assessment including anthropometry measurements and hemoglobin concentration, 202 children ranging from 1 month to 14 years of age were followed for one year through passive case detection for malaria episodes. After follow-up, all children were assessed again in order to detect changes in nutritional indicators associated with malaria infection. We also examined the risk of presenting malaria episodes during follow-up according to presence of stunting at baseline. Children who suffered malaria episodes during follow-up presented worse anthropometric parameters values during this period. The main change was a reduction of the linear growth velocity, associated with both the number of episodes and how close the last or only malaria episode and the second anthropometric assessment were. Changes were also observed for indices associated with chronic changes, such as weight-for-age and BMI-for-age, which conversely, were more frequently observed in children with the last or only episode occurring between 6 and 12 months preceding the second nutritional assessment survey. Children with inadequate height-for-age at baseline (Z-score < -2) presented lower risk of suffering malaria episodes during follow-up as assessed by both the log-rank test (p =0.057) and the multivariable Cox-proportional hazards regression (Hazard Ratio = 0.31, 95%CI [0.10; 0.99] p=0.049). Conclusions: Malaria was associated with impaired nutritional status amongst children in an endemic area of the Western Brazilian Amazon where P. vivax predominates. Our data all supports that the association presents differential effects for each age group, suggesting distinct pathophysiology pathways. We were also able to demonstrate that undernourishment at baseline was protective to malaria during follow-up. These findings support an intriguing interaction between these conditions in the rural Amazon and the need for a more integrative approach by health systems in endemic areas. [ABSTRACT FROM AUTHOR]

Background: Chagas disease is an emergent tropical disease in the Brazilian Amazon Region, with an increasing number of cases in recent decades. In this region, the sylvatic cycle of Trypanosoma cruzi transmission, which constitutes a reservoir of parasites that might be associated with specific molecular, epidemiological and clinical traits, has been little explored. The objective of this work is to genetically characterize stocks of T. cruzi from human cases, triatomines and reservoir mammals in the State of Amazonas, in the Western Brazilian Amazon. Methodology/Principal Findings: We analyzed 96 T. cruzi samples from four municipalities in distant locations of the State of Amazonas. Molecular characterization of isolated parasites from cultures in LIT medium or directly from vectors or whole human blood was performed by PCR of the non-transcribed spacer of the mini-exon and of the 24 S alfa ribosomal RNA gene, RFLP and sequencing of the mitochondrial cytochrome c oxidase subunit II (COII) gene, and by sequencing of the glucose-phosphate isomerase gene. The T. cruzi parasites from two outbreaks of acute disease were all typed as TcIV. One of the outbreaks was triggered by several haplotypes of the same DTU. TcIV also occurred in isolated cases and in Rhodnius robustus. Incongruence between mitochondrial and nuclear phylogenies is likely to be indicative of historical genetic exchange events resulting in mitochondrial introgression between TcIII and TcIV DTUs from Western Brazilian Amazon. TcI predominated among triatomines and was the unique DTU infecting marsupials. Conclusion/Significance: DTU TcIV, rarely associated with human Chagas disease in other areas of the Amazon basin, is the major strain responsible for the human infections in the Western Brazilian Amazon, occurring in outbreaks as single or mixed infections by different haplotypes. [ABSTRACT FROM AUTHOR]

Background: Brazil has considerably reduced the number of cases of malaria in recent years and aims to eradicate the disease completely, however, vivax malaria continues to be a major challenge for the health system. In this context, the key to building a successful elimination programme may lie in the knowledge and the perceptions of the health agents, the patients affected by the disease and the personnel responsible for malaria diagnosis, treatment and control at the local level. Methods: A qualitative study was undertaken in Manaus, capital of the state of Amazonas, Western Brazilian Amazon, using a sample of 33 patients who were being treated for malaria and 22 health agents who were working in malaria diagnosis, treatment and control at the local level. A semi-structured interview with a further thematic analysis was performed. Results: There are still many myths regarding malaria transmission and treatment that may hinder the sensitization of the population of this region in relation to the use of current control tools and elimination strategies, such as mass drug administration (MDA). Most health professionals reported that the abandonment of treatment for malaria by the patient is related to poor social conditions, the high incidence of alcoholism and the low level of schooling of the affected population. One negative perception, observed in both groups with regard to the use of insecticide-treated nets, is that they may cause skin irritations and allergies. Most patients and health professionals have described malaria as an impossible disease to eliminate because it is intrinsically associated with forest landscapes, and according to them, elimination would only be possible if there were a vaccine against malaria. Conclusion: In the Amazon, cultural perceptions about the etiology of this disease can influence the behaviour and practices that social groups adopt in relation to the different forms of living in a malaria-endemic context. Negative perceptions about malaria elimination can act as a barrier when trying to reach proper coverage for control strategies such as mosquito nets and MDA. [ABSTRACT FROM AUTHOR]