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Scabies is a neglected tropical disease and has been highlighted as a target for control. Sarcoptic mange affects animals, but mange is also considered a zoonosis. We present rapid assessment data on scabies and sarcoptic mange collected from key informants via a web-based questionnaire in Ceará State (1265 data entries). A total of 181/184 (98.3%) municipalities reported the occurrence of human scabies; 149 (80.9%) current occurrence; 168 (91.3%) severe cases; and 113 (61.4%) severe cases currently. Sarcoptic mange was reported from 149/184 (80.9%) municipalities, and severe mange from 128 (69.9%), most commonly in dogs (117 municipalities), cats (79), pigs (17), cattle (15), horses (15), and goats (2). Respondents from 171 (92.9%) municipalities observed seasonality of occurrence. Scabies and sarcoptic mange are important public health issues in a northeast Brazilian state. The wide distribution of severe cases requires an integrated One Health approach effectively and sustainably to reduce the disease burden., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: To analyse the temporal trends and spatiotemporal distribution of leprosy relapse in Brazil from 2001 to 2021., Methods: An ecological study with a temporal trend approach and space-time analysis of leprosy relapse in Brazil was carried out with data from the Notifiable Diseases Information System., Results: A total of 31 334 patients who experienced leprosy relapse were identified. The number of recurrent cases tended to increase throughout the study period, and this increase was significant among females and in almost all age groups, except for those <15, 50-59 and ≥70 y. Several clusters of high- and low-risk patients were identified across all regions with a heterogeneous distribution., Conclusions: The burden of relapse showed an increasing trend in some groups and was distributed in all regions., (© The Author(s) 2024. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Data on the temporal and spatial evolution of SARS-CoV-2 and local control measures and their effects on morbidity and mortality patterns in rural Brazil are scarce. We analyzed the data from case notification systems, epidemiological investigation reports, and municipal decrees in Itapajé, a small municipality in Ceará State in northeast Brazil. For spatial and spatio-temporal analyses, cases and deaths were mapped. There were a total of 3020 cases of COVID-19, recorded between April 2020 and December 2021; 135 (4.5%) died. The cumulative incidence and mortality rates were 5650.3 cases and 252.6 deaths per 100,000 people, respectively. The index case of SARS-CoV-2 in Itapajé was diagnosed in March 2020. The first peak of cases and deaths occurred in May 2020. The second wave peaked in May 2021, with the highest number of deaths in March 2021. According to the spatial analysis, the highest density of cases and deaths occurred in the central urban areas. In these areas, there were also the clusters of highest risk according to the spatio-temporal analyses. The municipal government issued 69 decrees on restriction measures, surveillance, and the maintenance of social isolation as a response to the pandemic. The spread of the SARS-CoV-2 pandemic in Itapajé mirrored the dynamics in large metropolitan regions, going from central neighborhoods of low socio-economic status to the wealthier peripheries.

Background: Systematic data on the occurrence of tungiasis are scarce., Methods: We analyzed data on tungiasis in humans and animals from all municipalities of Ceará State, Northeast Brazil, using a rapid assessment questionnaire., Results: Among the 184 municipalities, 181 (98.3%) reported tungiasis in the past (before 2021) or currently, 120 (65.2%) reported current occurrence, 155 (84.2%) reported severe cases in the past or currently, 47 (25.5 %) reported severe cases currently, and 132 (71.7%) reported tungiasis in animals., Conclusions: Tungiasis is a significant public health concern in Ceará. A One Health approach is required to reduce the disease burden in humans and animals.

This study evaluated the insecticidal activity of crude extracts from Enterolobium contortisiliquum (Vell.) seeds on eggs and larvae of A. aegypti, and also verified the phytochemical profile and the presence of lectins in the extract. The 0.15 M NaCl saline solution was used as the extracting substance. For tests with eggs and larvae, the crude extract was used in its raw form (RCE) and boiled at 100º C for 5 min (BCE). Concentrations of 4.68; 9.37; 18.75; 28.13; 37.13 and 46.89 mg/mL, with distilled water as a negative control. Assays were performed in triplicate. The results were subjected to analysis of variance, Tukey's test and Log-Probit analysis to determine LC50 and LC90. BCE showed better results on eggs than RCE, managing to prevent the hatching of larvae in 81.66% ± 10.40 of treated eggs, at a concentration of 46.89 mg/mL. The LC50 and LC90 were set at 35.95 and 52.67 mg/mL, respectively. In tests with larvae, concentrations of 46.89 and 37.13 mg/mL, for RCE and BCE, caused 100% mortality in 24 hours of exposure. Larval mortality at the other concentrations increased with exposure time extending to 48 h. RCE, at 48 h exposure is the most promising extract on larvae (E = 72.77%, LC90 = 10.86 mg/mL). In RCE, the presence of lectins and secondary metabolites: flavonoids, xanthones and phenols, were detected. The results demonstrate the potential of E. contortisiliquum seed extracts with ovicidal and larvicidal action on A. aegypti.

Objectives: To analyse the flow of cases of visceral leishmaniasis (VL) in the state of Ceará, Brazil, between 2007 and 2021., Methods: An ecological study was conducted using a spatial approach of newly confirmed cases of VL recorded in the Notifiable Diseases Information System. We identified individuals whose municipality of diagnosis differed from that of their residence. Flow maps, constructed using Tabwin 32 and ArcMap 9.2, allowed for the identification of the volume of traffic between the municipality of residence and that of initial care., Results: There were 6775 confirmed VL cases. As a flow indicator, 178 counties had at least one resident diagnosed in another municipality in Ceará, with 2491 VL cases and an average trip of 79 km. The largest hub for receiving cases for diagnosis was the capital Fortaleza (1478 patients from 129 other municipalities), followed by Sobral, located in the northwestern region of Ceará (599 from 55 municipalities), and Barbalha, in the southern region (171 from 29 municipalities). In this southern region, 25 municipalities moved 55 people for treatment to Juazeiro do Norte and 11 municipalities moved 39 patients to Crato. A total of 255 patients with VL from 11 municipalities in other Brazilian states, mainly from the Northeast and North, were observed and notified in health services in Ceará., Conclusions: The major centres of VL diagnosis outside residence were in the cities of Fortaleza, Sobral, Barbalha, Juazeiro do Norte and Crato. There was also an outflow of cases from other municipalities located in the northeastern and northern regions of Brazil. The flows were more intense during the first triennium of the analysis and milder from 2019 to 2021. Understanding the diagnostic flow of VL helps in decision making and the development of public policies to improve the lives of the population., (© 2023 John Wiley & Sons Ltd.)

Background: Human rabies outbreak transmitted by bats continues to be a relevant public health problem not only in the Amazon region. The disease has affected one of the areas with the greatest poverty in southeastern Brazil, a region inhabited by the Maxakali indigenous people., Case Presentation: We describe four cases of rabies among indigenous children that occurred in the indigenous village of Pradinho, municipality of Bertópolis, Minas Gerais, Brazil. Cases were notified between April and May 2022, all of whom died on average eight days after the first symptoms. All cases were observed in rural residents under 12 years of age. The probable form of exposure was through bat bites. The predominant symptoms were prostration, fever, dyspnea, sialorrhea, tachycardia, and altered level of consciousness. Half of the cases underwent late and/or incomplete post-exposure rabies prophylaxis, however, the other half underwent pre-exposure rabies prophylaxis, with only one case completing the scheme and another undergoing the adapted Milwaukee Protocol (Recife Protocol). All cases ended in death., Conclusions: This was the first rabies outbreak among indigenous people in Brazil. Among the manifested clinical forms in the series, there was a disease atypical presentation in at least one case. We suggest active surveillance and an intercultural educational campaign to prevent new cases., (© 2023. National Institute of Parasitic Diseases.)

The aim of this study was to carry out phytochemical prospecting and evaluate the larvicidal activity of Himatanthus drasticus latex extracts against Aedes aegypti. The extracts were obtained by maceration from 5 g of latex powder concentrated separately in 100 mL of methanol, ethyl acetate, and hexane solvents. The concentrations of 100, 200, 300, 400, and 500 ppm of each extract were tested in triplicate with a solution of pyriproxyfen as the positive control and distilled water and dimethylsulfoxide as the negative control. The phytochemical prospection of the methanolic extract showed the presence of phenolic compounds, such as anthocyanins, anthocyanidins, catechins, chalcones, aurones, leucoanthocyanidins, and condensed tannins. The insecticidal bioactivity was most significant for the methanolic extract. The methanolic extract lethal concentrations (LC) of 50 and 90% were 190.76 and 464.74 ppm, respectively. After 48 hours of exposure, the extracts using methanol, ethyl acetate, and hexane at their highest concentrations (500 ppm) caused larval mortality of 100, 73.33, and 66.67%, respectively. These extracts also promoted changes in the external morphology of the larvae, such as damage to the anal papillae, darkening of the body, and reduction in the number of bristles. The methanolic extract showed greater expressivity for morphological changes. The latex of H. drasticus has larvicidal activity against third-stade larvae of A. aegypti and it is more significant when obtained through maceration in methanol. The methanolic extract of H. drasticus latex contains phenolic compounds with insecticidal activity against A. aegypti larvae.

Objective: We evaluated the impact of direct and indirect medical costs incurred through chikungunya infections in patients treated in Fortaleza, Brazil., Methods: Cross-sectional study about the cost of illness. The valuation method of medical costs was based on the micro-costing approach (bottom-up). The study was carried out in a large general hospital of the private health network. The study population consisted of patients treated as suspected cases of chikungunya and hospital professionals who applied for sick leave due to chikungunya., Results: In 2017, there were 2683 patients treated at this hospital who incurred an estimated cost of $383,514.40. From this amount, $174,322.91 (45.5%) were expended on emergency care, $194,700.59 (50.8%) on hospitalisations. 123 hospital professionals were infected with chikungunya and sick leave duration ranged between 1 and 19 days. Health professionals generated 746 days of absence and an amount of $14,490.90 due to absenteeism from work related to chikungunya. 31 symptoms were reported, especially arthralgia (91.1%) and fever (79.4%). There was a predominance of females (58.8%) and the age group of 20-39 years (42.1%)., Conclusion: The average cost of admissions was over $2400. Considering the epidemic potential of chikungunya, our data indicate the huge economic burden of this disease to healthcare units in the presence of epidemics. Economic factors, added to the loss of life and the consequences of chronic chikungunya, make this disease a real scourge for countries with fewer material resources., (© 2022 John Wiley & Sons Ltd.)

Human Visceral Leishmaniasis (HVL) presents a subacute clinical evolution with systemic involvement, which can result in high case fatality, especially among untreated individuals or those with low socioeconomic status. This study aimed to identify epidemiological and clinical factors associated with HVL case fatality in the Ceara State, from 2007 to 2018. This is an analytical cross-sectional study. The bivariate analysis was performed by Stata 15.1 using Pearson's Chi-square or Fisher's exact test; and Poisson regression for age-controlled multivariate analysis. From 2007 to 2018, there were 4,863 new confirmed cases and 343 deaths from HVL (case fatality rate=7.05%). The risk factors associated with case fatalities were: age group (RR=8.69; 95%CI:3.56-21.20); black population (RR=2.21; 95%CI:1.45-3.35); jaundice symptoms (RR=1.72; 95%CI:1.38-2.14); edema (RR=2.62; 95%CI:2.10-3.26) and hemorrhagic phenomena (RR=1.63; 95%CI:1.26-2.10); and no prescription drug intake (RR=4.03; 95%CI:2.98-5.46). Treatment with pentavalent antimonial was a protective factor (RR=0.35; 95%CI:0.27-0.45). The number of deaths increased among the elderly, illiterate, urban residents, and black skin color individuals. The drugs pentavalent antimonial and amphotericin B showed an association with death, but were not considered causal factors. Treatment failure led to a high risk of death. In multivariate analysis, the risk factors for fatal cases were age group, black skin, symptoms of jaundice, edema and hemorrhagic phenomena; and failure to take the prescription drugs. Treatment with pentavalent antimonial was shown to be a protective factor. Knowing the factors associated with the fatality of VL-HIV cases may help to improve public policies, in order to refine the epidemiological surveillance program and, consequently, prevent deaths related to the disease in Ceara.

Background: Human visceral leishmaniasis HVL is endemic to 75 countries. The state of Ceará, the Northeast region of Brazil, is of great sanitary importance for the transmission of HVL, and it stands out as an area of interest for epidemiological aspects and control strategies. This study aimed to characterize HVL in relation to epidemiological aspects, composite incidence, and mortality rates in the state of Ceará, Brazil, from 2007 to 2021., Methods: This ecological study used temporal and spatial cuts of HVL data from the notifiable diseases information system. Epidemiological indicators such as incidence, mortality, and composite indices of incidence and mortality were calculated according to the Ministry of Health standardization., Results: There were 6,775 confirmed cases, with high incidence coefficients in 2009 6.96 cases/100,000 inhabitants and 2011 9.83 cases/100,000 inhabitants, and the highest mortality rate in 2011 6.96 deaths/100,000 inhabitants. The composite index of incidence and mortality identified municipalities in the Northern, Northwestern, and Southern regions of Ceará as having the highest risk of HVL., Conclusions: HVL remained endemic throughout the study period, with epidemiological indicators and risk of transmission expressing high magnitude, mainly in the Northeast, Northwest, and South regions of Ceará.

Background: The school community was heavily impacted by the Covid-19 pandemic, especially with the long time of school closures. This study aimed to analyze the seroprevalence of SARS-CoV-2 antibodies and possible factors associated with seropositivity for COVID-19 in teachers and other school staff, and to estimate the fraction of asymptomatic individuals by sex and age group., Methods: We conducted a serological survey of SARS-CoV-2 infections. An analytical cross-sectional study was conducted in Fortaleza, Brazil. Teachers and other staff members from pre-schools to universities of higher education to were investigated., Results: A total of 1,901 professionals participated in the study, of which 1,021 were staff and 880 were teachers. The seroprevalence of SARS-CoV-2 was 8.0% (152/1901). In the seropositive group, 48.3% were asymptomatic. There was a predominance of women (68.4%); and, 47.1% of the participants were between 31 and 45 years old. There was an increase in prevalence with increasing age. An inverse relationship was found for education level: more professionals with less education tested positive for COVID-19. The presence of an infected person living in the same household was significantly associated with positive results for COVID-19 among the professionals., Conclusions: This is the first study to report the seroprevalence of IgG against SARS-CoV-2 in Brazilian educational staff after the first wave of the disease. In this study, the seroprevalence was much lower than that in the general population. During school reopening, a small fraction of school workers showed serologically detectable signs of SARS-CoV-2 exposure.

Rabies transmitted by sylvatic populations has become an increasing concern in Brazil. A total of 113 participants with a history of contact with sylvatic populations were interviewed in 27 municipalities of Ceará State in northeast Brazil. Questionnaires included questions on knowledge, attitudes and practices (KAP) regarding sylvatic rabies. Most of the respondents (92%) knew about rabies and confirmed at least one species that transmitted the disease (79.6%). Of these respondents, 69% mentioned monkeys, and 67.2% mentioned dogs. However, 16% of the respondents listed an incorrect species. In general, knowledge on the symptoms and signs and on prevention measures was weak. The majority raised pets (93.8%), most commonly dogs and cats, and, of all the pets, 85.7% were claimed to be vaccinated against rabies. A total of 67.3% reported the appearance of free-living wild animals around their houses, mostly marmosets and wild canids; 18.3% reported that sylvatic populations had attacked animals or humans. Seventy-three percent had raised or still were raising wild animals as pets, mostly capuchin monkeys (79.5%) and marmosets (24.1%). This is the first KAP study on sylvatic rabies in Brazil. The data indicate important knowledge gaps and risk behavior within a high-risk population. There is a need for strengthening and improving sylvatic rabies surveillance and control, combined with the intensification of education and information campaigns.

This study aimed to identify the seroprevalence of chikungunya and its associated factors in the city of Quixadá, Ceará, Brazil. We also aimed to identify the spatial distribution patterns of positive cases. A cross-sectional survey was conducted with a questionnaire about clinical symptoms, socioeconomic and demographic factors, and a 10 ml blood sample was collected and analysed by ELISA. For the bivariate analysis, we use the chi-square test, a prevalence ratio and its 95% confidence interval. A robust Poisson hierarchical regression was used to adjust for confounders. The Kernel density was performed for the spatial analysis. A total of 409 samples were analysed; of them, 70.7% were seropositive for previous exposure to chikungunya virus (CHIKV). High seropositivity for CHIKV was higher in female participants (75.5%; PR = 1.23; 95% CI: 1.06-1.43), those aged 31 years or more (74.3%; PR = 1.62; 95% CI: 1.04-2.52), and those with elementary education level (75.0%; PR = 1.30; 95% CI: 1.06-1.60). There were also high seroprevalence in those with less than a minimum wage per month (89.5%; PR = 1.59; 95% CI: 1.11-2.30), housewives (87.5%; PR = 1.64; 95% CI: 1.24-2.18) and unemployed (80.0%; PR = 1.50; 95% CI: 1.10-2.06). After adjusting for age, morning stiffness was the only chikungunya symptom that remained associated (PR = 1.20; 95% CI: 1.06-1.37; p < .001). There was an area of high density of cases in the downtown and two areas of medium density in nearby regions. Otherwise, the higher seroprevalence rates were in the peripherical neighbourhoods. There is a hyperendemicity of CHIKV in Quixadá, and most cases are spatially contiguous. The main associated clinical sign is morning stiffness, but other factors such as low income and spending a longer time at home were significantly associated with higher seroprevalence., (© 2021 Wiley-VCH GmbH.)

Visceral leishmaniasis (VL) is considered as an important tropical disease because it rapidly spreads across a wide geographical area. This study aimed to analyse the temporal and spatial patterns of incidence, mortality and case fatality rates due to human VL in Ceará, Brazil, from 2007 to 2018. This is an ecological study involving time series and spatial analyses, and data were obtained from human VL notifications. Temporal trend analysis was carried out using the Joinpoint Regression Program. SaTScan 9.6 was used for conducting spatial analyses, and ArcMap 9.2 was used for building maps. There were 6,066 incident cases and 516 deaths due to human VL. There was an increasing trend in the incidence rate from 2007 to 2014 (annual per cent change [APC] = 3.8; 95% confidence interval [CI]:0.5 to 7.3; p = .031). Mortality (APC = -0.3; 95%CI: -2.5 to 1.9; p = .765) and VL case fatality rates (APC = -3.0; 95%CI: -4.3 to -1,7; p = .188) showed non-significant decline. The incidence rates were higher in the northwest and south regions of the state, with 11 high incidence rate clusters from 2007 to 2010, seven clusters in 44 municipalities from 2011 to 2014, and six clusters in 49 municipalities from 2015 to 2018. During 2007-2010, only one significant mortality rate cluster was identified in the southern region (relative risk [RR] = 7.6); during 2011-2014, two clusters in the northwest region were identified (RR=3.9 and RR=4.6). In the last period, a cluster of 11 municipalities in the southern region was identified (RR = 4.2). Mortality rate clusters were identified in the centre-south (2007-2010), northwest and south (both from 2011 to 2018). VL has a heterogeneous distribution, with maintenance of clusters with high incidence and mortality rates, as well as case fatality rates in municipalities in the northwest and south regions. These clusters present areas with the greatest risk of transmission of human VL., (© 2021 Wiley-VCH GmbH.)

CD44 and CD133 have been considered as cancer stem cell (CSC) markers. Stem cell markers are rarely described in healthy stomach tissues. However, the clinicopathological and prognostic value of CD44 and CD133 in gastric cancer remains controversial. This study investigated the expression of CD44 and CD133 in gastric cancer and non-neoplastic gastric mucosa. We used samples of primary gastric adenocarcinomas (n = 69), metastatic lymph nodes (n = 30), intestinal metaplasia (n = 17), and histologically normal gastric tissues of surgical margins (n = 54). The expression of CD44 and CD133 were studied in samples by immunohistochemistry. Fisher's exact test and a logistic regression model were used in this study. CD44 expression was observed in 12% of samples with intestinal metaplasia, 20% with lymph node metastases, 22% with normal mucosa, to 30% of samples with primary tumors. Most of these positive tumors showed immunostaining in less than 4% of cancerous cells, mainly in the diffuse type. CD133 expression was observed in 7% (intestinal metaplasia) to 46% (normal mucosa). In the positive cases of cancer (24%), in most of them, less than 3% of cells were marked. CD44 and CD133 expression in the histologically normal gastric mucosa was restricted to the deeper regions of the gastric crypts at the level where stem cells and progenitor cells are usually found. CD44 and CD133 expression occurs in few gastric cancer cells, mainly in diffuse carcinomas, and are expressed in histologically normal gastric mucosae. None of the markers are specific for cancer and are also present in intestinal metaplasia and the normal mucosa., (Copyright © 2021 Elsevier GmbH. All rights reserved.)

In Brazil, the SARS-CoV-2 vaccination program has so far prioritized people over 75 years of age. By the end of March 2021, in Ceará State, a total of 313,328 elderly people had received at least one dose of vaccine (45% Oxford-AstraZeneca/Fiocruz and 55% CoronaVac-Sinovac/Butantan), and 159,970 had received two doses (83% CoronaVac-Sinovac/Butantan and 17% Oxford-AstraZeneca/Fiocruz). After a single dose, there was already a significant reduction in COVID 19-related deaths (protection ratio: 19.31 (95% CI: 18.20-20.48), attributable protection ratio: 94.8%); higher protection ratios were observed after the application of two doses of the vaccine (132.67; 95% CI: 109.88-160.18), with an attributable protection ratio of 99.2%. SARS-CoV-2 vaccines are highly effective in reducing the number of COVID-19-related deaths in over 75-year-olds in Brazil, one of the hardest hit countries by the current pandemic.

Objective: To describe cases of human rabies in Ceará State, Brazil between 1970 and 2019., Methods: This was a descriptive study using secondary data from the Ceará State Department of Health and the state reference hospital., Results: Of 171 cases, 75.7% occurred in males, 60.0% in <19-year-olds, and 56.0% in urban areas. Rabies was transmitted by dogs in 74.0% of cases, marmosets in 16.7% and bats in 7.3%. Between 1970 and 1978, there was an increase of cases (using the Joinpoint Regression Program, annual percentage change [APC] = 13.7 - 95%CI 4.6;41.5), while between 1978 and 2019 there was a decrease (APC = -6.7 - 95%CI -8.8;-5.9). There was a reduction in transmission by dogs (71 cases, last case in 2010) and an increase by sylvatic animals (5 cases since 2005)., Conclusion: This study demonstrates changes in rabies transmission dynamics during the period studied, with a reduction in transmission by dogs and an increase of transmission by sylvatic animals.

Introduction: This study analyzed the magnitude and temporal trends of leprosy relapse in Ceará in 2001-2018., Methods: Descriptive cross-sectional and ecological-time trend studies were performed., Results: We diagnosed 1,777 leprosy relapse cases. Higher prevalence of relapse was observed in men, illiterates, mixed race, multibacillary leprosy, lepromatous leprosy, and persons with visible disabilities. The proportion of relapse increased throughout the study period., Conclusions: Leprosy relapse is prevalent in certain groups.

Introduction: The state of Ceará (Brazilian Northeast) has a high incidence of dengue. Therefore, we aimed to characterize the temporal patterns and spatial distribution of dengue cases in Ceará during 2001-2019., Methods: A spatiotemporal ecological study was performed with secondary data. Time-trend analysis was performed using a segmented log-linear regression model to estimate the average annual percentage change (AAPC) and the annual percentage change (APC) in incidence of dengue. We also performed spatiotemporal analysis to identify the place, time, and relative risk (RR) of dengue clusters., Results: There were 539,653 dengue cases. The AAPC reduced over time (-9.5%; 95% confidance interval [CI]: -18.3; -0.3). Three trends were identified-2001-2004: APC=-20.9% (95% CI: -65.1 to 44.8), 2005-2015: APC=7.9% (95% CI: -6.0 to 98.9), and 2016-2019: APC=-48.8% (95% CI: -83.0 to -6.1). During 2001-2007, 10 significant clusters were identified (RR=3.57-14.38: n=4 and RR=0.05-0.39: n=6). During 2008-2013, there was 1 cluster in the western region (RR= 3.40) and four other clusters (RR=0.02-0.15). The last period presented 5 high-RR clusters (RR=2.95-9.24). The low-RR clusters were located in the central-north, central-south, south, and northwest regions. However, the central-west region remained a high-RR cluster region throughout the study period., Conclusions: Dengue showed a decreasing incidence. During the epidemic years, the southern, eastern, and western regions presented high-risk clusters. Introduction of a new dengue serotype in a low-RR area can cause explosive outbreaks due to population susceptibility.

Objective: To analyze the temporal trend and describe the spatial distribution of Visceral Leishmaniasis (VL) in Fortaleza from 2007 to 2017., Methods: This was an ecological study using segmented temporal regression and thematic mapping., Results: Between 2007-2017, 1,660 new cases and 97 deaths were confirmed. The overall incidence rate showed a rising trend (Annual Percent Change - APC=8.7% - 95%CI -3.3;34.1), while the mortality rate (APC=-25.9 - 95%CI -48.5;-10.6) and lethality (APC=-33.0 - 95%CI -53.7;-17.6) showed a falling trend. From 2010-2015 the incidence rate fell (APC=-15.8 - 95%CI -25.1;-4.0), but mortality (APC=18.7 - 95%CI 9.4;50.6) and lethality (APC=40.1 - 95%CI 22.5;72.0) had an upward trend. In 2015-2017, incidence (APC=-24.6 - 95%CI -36.2;-10.3), and mortality (APC=-44.6 - 95%CI -58.8;-17,6) fell, while lethality remained stable (APC=-13.5 - 95%CI -38.7;3.8). High incidence neighborhoods were clustered in the western region of the city, however, mortality and lethality did not present defined spatial patterns., Conclusion: VL is endemic in Fortaleza, although there was a reduction in the last three years studied.

Background: The State of Ceará, in Northeastern Brazil, suffers from a triple burden of arboviruses (dengue, Zika and chikungunya). We measured the seroprevalence of chikungunya, dengue and Zika and its associated factors in the population of Juazeiro do Norte, Southern Ceará State, Brazil., Methods: A cross-sectional study of analytical and spatial analysis was performed to estimate the seroprevalence of dengue, Zika and chikungunya, in the year 2018. Participants were tested for IgM and IgG against these three viruses. Those with IgM and/or IgG positive tests results were considered positive. Poisson regression was used to analyze the factors associated with positive cases, in the same way that the spatial analysis of positive cases was performed to verify whether the cases were grouped., Results: Of the 404 participants, 25.0% (103/404) were positive for CHIKV, 92.0% (373/404) for flavivirus (dengue or Zika) and of these, 37.9% (153/404) samples were classified as probable dengue infection. Of those who reported having had an arbovirus in the past, positive CHIKV cases had 58.7% arthralgia (PR = 4.31; 95% CI: 2.06-9.03; p = 0.000) mainly in the hands, ankles and feet. Age over 60 years had a positive association with cases of flavivirus (PR = 1.29; 95% CI: 1.09-1.54; p = 0.000). Fever, muscle pain, joint pain and skin rash were the most reported symptoms (46.1, 41.0, 38.3 and 28.41%, respectively). The positive cases of chikungunya and dengue or Zika were grouped in space and the city center was most affected area., Conclusions: Four years after the introduction of CHIKV, where DENV has been in circulation for over 30 years, 1/4 of the population has already been exposed, showing the extent of the epidemic. The measured prevalence was much higher than that reported by local epidemiological surveillance.

Objective: To analyze the spatial pattern of AIDS mortality and social factors associated with its occurrence., Methods: An ecological study that considered 955 AIDS deaths of residents in Piauí, reported in the Mortality Information System (MIS) from 2007 to 2015. Non-spatial and spatial regression models were used to identify social determinants of AIDS mortality, with a significance of 5%., Results: The predictors of AIDS mortality were illiteracy rate in males (p = 0.020), proportion of households with water supply (p = 0.015), percentage of people in households with inadequate walls (p = 0.022), percentage of people in households vulnerable to poverty and in whom no one has completed primary education (p = 0.000) and percentage of people in households vulnerable to poverty and dependent on the elderly (p = 0.009)., Conclusion: Social indicators related to education, job and income generation and housing were associated with AIDS mortality.

Periosteum is a fibrous sheath, coating the external bone, except in the articular surfaces, tendon insertions and sesamoid bone surface¹. It changes its aspects and characteristics with aging, becoming progressively less elastic and more firm. It is composed of two different layers: outer fibrous (firm, collagen-filled) and inner proliferative (cambium, containing osteoprogenitor cells) ² . Four vascular systems are responsible for the blood supply of the periosteum: the intrinsic periosteal system, located between fibrous and proliferative layer; the periosteocortical, the main nutritional arteries of the periosteum; the musculoperiosteal, responsible for the callus formation after fractures; the fascioperiosteal, specifically for each bone.³ It is crucial to bone formation and resorption, reacting to insults in the cortical bone, such as tumors, infections, traumas, medications and arthritic diseases. The aggressiveness of the reaction can be suggested by its radiological aspect and appearance 4 . The periosteum in children is looser compared to adults, resulting in earlier and more exuberant reactions. All these aspects will be detailed, so the essential information all radiologists need to know will be discussed., Competing Interests: No conflict of interest exists., (© 2020 Published by Elsevier Ltd.)

The intensification of dog, cat and livestock vaccination campaigns significantly reduced rabies cases in humans and domestic animals in Ceará State, Brazil. However, sylvatic animals-bats (order Chiroptera), wild canids, raccoons and non-human primates- remain as reservoirs for the virus. Our hypothesis is that surveillance and monitoring of rabies virus in bats, especially passive surveillance, is of fundamental importance, besides the implementation of health education and strengthening of surveillance actions in humans exposed to aggressions. Thus, we assessed the occurrence of rabies virus in animals focusing on bats, before and after launching of the Sylvatic Rabies Surveillance Program in 2010. Surveillance data from the 184 municipalities of Ceará State were analysed, collected during the periods 2003-2010 (active surveillance) and 2011-2016 (passive surveillance), respectively. A total of 13,543 mammalian samples were received for rabies diagnosis from 2003 to 2016. Of these, 10,960 were from dogs or cats (80.9%), 1,180 from bats (8.7%), 806 from other sylvatic animals (foxes, marmosets, raccoons; 6.0%) and 597 from herbivores (cattle, goats, sheep, equines, pigs; 4.4%). A total of 588 (4.3%) samples were positive for rabies. About 8.4% (99/1,180) of the bat samples were infected with rabies virus, 92 (92.9%) of these were from non-haematophagous bat species and 7 (7.1%) from haematophagous species. The number of bat samples received and infection rates increased considerably, after a shift from active surveillance (9/355 [2.5%] samples positive), to passive surveillance (90/825 [10.9%] samples positive). Surveillance of rabies virus in bats is fundamental for human and domestic animal health in Ceará State. Bats have to be considered as targets in surveillance and control programmes. Virus lineages should be characterized to increase knowledge on transmission dynamics of sylvatic rabies virus to domestic animals and the human population, and to provide additional evidence for planning and implementation of improved control measures., (© 2019 Blackwell Verlag GmbH.)

Visceral leishmaniasis is a highly lethal zoonosis transmitted by a sandfly. It is caused by a Leishmania protozoan parasite and dogs are the main reservoir. Ceara State is endemic to visceral leishmaniasis and it is considered a high risk transmission area. Temporal and spatial epidemiological studies have been used as tools to analyze the distribution and frequency of human visceral leishmaniasis (HVL). This study aimed to characterize HVL in its epidemiological andtemporal aspects in Ceara State, from 2003 to 2017, as this is a neglected disease and a public health problem. This is an ecological study carried out with HVL confirmed cases in Ceara, using three blocks of years (2003 to 2007, 2008 to 2012 and 2013 to 2017). The disease presented an endemic behavior, affecting mainly male residents in the urban area, especially children under five and young adults between 30 and 49 years old. HVL is recorded in all the municipalities, for more than 10 years, with a growing trend and territorial expansion to the Central and Eastern regions of the State. The results of this study indicated the increase in the incidence and lethality, as well as the expansion of leishmaniasis in Ceara State.

Introduction: This study investigated the spatial distribution of inappropriate post-exposure human rabies procedures in Ceará, Brazil, between 2007 and 2015., Methods: The ecological study population was based on the records of post-exposure human rabies procedures from the Notification Disease Information System. We analyzed the data using the Moran Index (I) and the Moran Local Index., Results: There were 222,036 (95.8%) records with inappropriate post-exposure human rabies procedures. There was heterogeneity in their spatial distribution, with two significant clusters in the northeast and northwest regions., Conclusions: These findings help elaborate differentiated strategies to reduce unnecessary post-exposure human rabies procedures.

Introduction: Chikungunya causes fever and severe and persistent joint pain., Methods: We reported a chikungunya outbreak that occurred in Ceará State, Brazil between 2016 and 2017 with emphasis on epidemiological characterization of cases, high number of deaths, mortality-associated factors, and spatial and temporal spread of the epidemic among municipalities., Results: In November 2015, the first autochthonous cases of chikungunya were confirmed in Ceará, Brazil. In 2016-2017, 195,993 cases were reported, with an incidence of 2,186.5/100,000 inhabitants and 244 confirmed deaths., Conclusions: Rapid transmission and high mortality rate are serious problems, especially in regions with co-circulating arboviruses.

The study aimed to characterize food insecurity, nutritional status, and eating habits of people affected by leprosy. This is a descriptive cross-sectional study based on a census population. We evaluated 276 cases, reported in the Notifiable Diseases Information System, between 2001 and 2014, in the municipalities of Vitória da Conquista and Tremedal, in the state of Bahia. Food insecurity was estimated according to the Brazilian Food Insecurity Scale. We collected weight and height measurements, meal frequency, and household, socioeconomic, psychosocial and clinical variables. The prevalence of food insecurity was 41.0% among the study population - 28.3% mild, 8.0% moderate and 4.7% severe. Overweight/obesity was estimated in 60.1% of the study participants, and excessive salt intake was reported by 8.6%. Beans and red meat were the most regularly consumed foods; there was low consumption of milk, raw and cooked vegetables, and fruits. This population presented high food insecurity prevalence, inadequate eating habits and nutritional status, reflecting nutritional vulnerability. The insertion of nutritional assistance in the leprosy control programmes is recommended, to improve health care.

Background: Gastric cancer (GC) is an important cause of morbidity and mortality worldwide. However, population-based data on GC mortality dynamics in low and middle income countries are scarce., Methods: We analyzed GC mortality in Brazil based on all GC-related deaths registered 2000-2015., Results: A total of 17,374,134 deaths were recorded, with GC identified in 214,808 (1.24%) cases-203,941 (94.9%) as underlying cause, and 10,867 (5.1%) as associated cause of death. Adjusted rates for age and sex was 6.85 deaths/100,000 inhabitants [95% confidence interval (CI) 6.73-6.97]. The highest mortality rates were found in males [10.00; rate ratio (RR) 1.85; 95% CI 1.78-1.91; p < 0.0001] and patients ≥ 45 years of age (24.98; RR 3.79; 95% CI 3.55-4.05; p < 0.0001). The South (7.56; RR 1.62; 95% CI 1.50-1.76; p < 0.0001) and Southeast (7.36; RR 1.59; 95% CI 1.48-1.71; p < 0.0001) regions had the highest regional rates. Spatial and spatiotemporal high-risk mortality areas in 2004-2007 were located mainly in the South, Southeast, and Central-West regions. After 2008, the Northeast region became a high-risk area, especially Ceará State., Conclusion: GC remains a significant public health problem with high mortality burden and unequal distribution in Brazilian states. The new patterns in poorer regions and the high risk in some specific populations show a clear process of epidemiological transition over time. There is a need to strengthen nationwide epidemiological monitoring, surveillance, prevention, and control for GC in the country.

Objective: to analyze the prevalence of inadequate human anti-rabies post-exposure prophylaxis in patients attacked by animals in the state of Ceará, Brazil, 2007-2015., Methods: this was a study of the prevalence of inadequate prophylaxis procedures, using data on reported cases of accidents involving animals potentially capable of transmitting rabies registered on the Notifiable Diseases Information System (SINAN) from January 2007 to December 2015., Results: of the 231,694 reported cases, 95.8% were found to have inadequate procedures, especially in young people aged under 19 (37.6%), with no difference between the sexes (p=0.04); higher prevalence rate of inadequate procedures occurred with regard to exposure to bites (PR=1.03 - 95%CI 1.02;1.03), multiple injuries (PR=1.07 - 95%CI 1.06;1.07), accidents involving dead/missing animals (RP=1.05 - 95%CI 1.05;1.06), and vaccine treatments (RP=1.03 - 95%CI 1.02;1.03)., Conclusion: high prevalence of inadequate procedures indicates the need for a better epidemiological evaluation of cases and compliance with the Human Rabies Prophylaxis Technical Standards, in order to ensure adequate anti-rabies prophylaxis procedures.

The detection of leprosy cases is distributed unequally in Brazil, with high-risk clusters mainly in the North and Northeast regions. Knowledge on epidemiology and spatiotemporal patterns of leprosy occurrence and late diagnosis in these areas is critical to improve control measures. We performed a study including all leprosy cases notified in the 417 municipalities of Bahia state, from 2001 to 2014. New case detection (overall and pediatric <15 years) and grade 2 disability (G2D) rates were calculated and stratified according to socio-demographic variables. Spatial analyses were performed to detect high-risk areas for occurrence and late diagnosis. A total of 40,060 new leprosy cases was reported in the period (mean = 2861 cases/year), 3296 (8.2%) in <15-year-olds, and 1921 (4.8%) with G2D. The new case detection rate was 20.41 cases/100,000 inhabitants (95% CI: 19.68⁻21.17). A higher risk was identified in older age groups (RR = 8.45, 95% CI: 7.08⁻10.09) and in residents living in the state capital (RR = 5.30, 95% CI: 4.13⁻6.79), in medium-sized cities (RR = 2.80; 95% CI: 2.50⁻3.13), and in the west (RR = 6.56, 95% CI: 5.13⁻8.39) and far south regions of the state (RR = 6.56, 95% CI: 5.13⁻8.39). A higher risk of G2D was associated with male gender (RR = 2.43, 95% CI: 2.20⁻2.67), older age (RR = 44.08, 95% CI: 33.21⁻58.51), Afro-Brazilian ethnicity (RR = 1.59; 95% CI: 1.37⁻1.85), living in medium-sized cities (RR = 2.60; 95% CI: 2.27⁻2.96) and residency in the north (RR = 5.02; 95% CI: 3.74⁻6.73) and far south (RR = 7.46; 95% CI: 5.58⁻9.98) regions. Heterogeneous space⁻time patterns of leprosy distribution were identified, indicating high endemicity, recent transmission, and late diagnosis. This heterogeneous distribution of the disease was observed throughout the study period. Leprosy remains a relevant public health problem in Bahia state. The disease has a focal distribution. We reinforce the importance of integrating surveillance, prevention and control actions in regions of higher risk of leprosy detection and late diagnosis, and in the most vulnerable populations.

The aim of this study was to analyze operational indicators and time trends in leprosy control from a gender perspective in Bahia State, Brazil, from 2001 to 2014. This was a time series study based on epidemiological data on leprosy from the Brazilian National System of Diseases of Notification, using joinpoint Poisson and polynomial regression. Of the 40,054 new cases of leprosy, 47.1% of the recorded contacts were not examined, with a significant upward trend, especially in women (average annual percentage change - AAPC = 5.6; 95%CI: 3.5; 7.7) when compared to men (AAPC = 3.0; 95%CI: 0.5; 5.6). The proportion of cure in the 2003-2014 cohort was 85%, with a downward trend, especially in men (AAPC = -0.5; 95%CI: -0.9; 0.0), compared to women (AAPC = -0.4; 95%CI: -0.7; -0.1). Treatment dropout rate was 5.5%, with a more significant downward trend in women (AAPC = -4.9; 95%CI: -8.7; -1.1) than in men (AAPC = -2.7; 95%CI: -4.4; -1.0). Relapse was recorded in 3.8% of all the entries during the same period; women showed a significant downward trend (AAPC = -2.2; 95%CI: -3.3; -1.0) and men a significant upward trend (AAPC = 4.9; 95%CI: 2.9; 6.8). Polynomial regression analysis was consistent with joinpoint regression. Leprosy in Bahia State shows operational indicators with significant magnitude and time trends, especially in the male population. Health services' insufficient performance in conducting contact surveillance and longitudinal care reveal various dimensions of vulnerability.

OBJECTIVE To analyze, stratifield by gender, trends of the new case leprosy detection rates in the general population and in children; of grade 2 disability, and of proportion of multibacillary cases, in the state of Bahia, Brazil from 2001 to 2014. METHODS A time series study based on leprosy data from the National Information System for Notifiable Diseases. The time trend analysis included Poisson regression models by infection points (Joinpoint) stratified by gender. RESULTS There was a total of 40,054 new leprosy cases with a downward trend of the overall detection rate (Average Annual Percent Change [AAPC = -0.4, 95%CI -2.8-1.9] and a non-significant increase in children under 15 years (AAPC = 0.2, 95%CI -3.9-4.5). The proportion of grade 2 disability among new cases increased significantly (AAPC = 4.0, 95%CI 1.3-6.8), as well as the proportion of multibacillary cases (AAPC = 2.2, 95%CI 0.1-4.3). Stratification by gender showed a downward trend of detection rates in females and no significant change in males; in females, there was a more pronounced upward trend of the proportion of multibacillary and grade 2 disability cases. CONCLUSIONS Leprosy is still highly endemic in the state of Bahia, with active transmission, late diagnosis, and a probable hidden endemic. There are different gender patterns, indicating the importance of early diagnosis and prompt treatment, specifically in males without neglecting the situation among females.

Zika is a viral disease transmitted mainly by mosquitoes of the genus Aedes. In recent years, it has expanded geographically, changing from an endemic mosquito-borne disease across equatorial Asia and Africa, to an epidemic disease causing large outbreaks in several areas of the world. With the recent Zika virus (ZIKV) outbreaks in the Americas, the disease has become a focus of attention of public health agencies and of the international research community, especially due to an association with neurological disorders in adults and to the severe neurological and ophthalmological abnormalities found in fetuses and newborns of mothers exposed to ZIKV during pregnancy. A large number of studies have been published in the last 3 years, revealing the structure of the virus, how it is transmitted and how it affects human cells. Many different animal models have been developed, which recapitulate several features of ZIKV disease and its neurological consequences. Moreover, several vaccine candidates are now in active preclinical development, and three of them have already entered phase I clinical trials. Likewise, many different compounds targeting viral and cellular components are being tested in in vitro and in experimental animal models. This review aims to discuss the current state of this rapidly growing literature from a multidisciplinary perspective, as well as to present an overview of the public health response to Zika and of the perspectives for the prevention and treatment of this disease.

Objective: To identify the socioeconomic, demographic, operational, and health service-related factors associated with the occurrence of leprosy in a hyperendemic State in North Brazil., Methods: This is an ecological study based on secondary data from the Sistema de Informações de Agravos de Notificação in municipalities of the State of Tocantins from 2001 to 2012. Units of analysis were the 139 municipalities of the State. Negative binomial log linear regression models were used to estimate incidence rate ratios., Results: In bivariate analysis, the incidence rate ratios were significantly higher for municipalities with higher income ratio of the poorest 20.0% (1.47; 95%CI 1.19-1.81) and better Municipal Human Development Index (1.53; 95%CI 1.14-2.06). In multivariate analysis, the incidence rate ratios were significantly higher in municipalities with higher proportion of immigrants (1.31; 95%CI 1.11-1.55) and higher proportion of households with waste collection (1.37; 95%CI 1.11-1.69). There was a significant reduction in the incidence rate ratio with increased coverage of the Bolsa Família Program (0.98; 95%CI 0.96-0.99)., Conclusions: Control programs need to focus on activities in municipalities of greater social vulnerability with intersectoral investment for the improvement of the living conditions of the population., Objetivo: Identificar fatores socioeconômicos, demográficos, operacionais e de serviços de saúde associados à ocorrência da hanseníase em um estado hiperendêmico do norte do Brasil., Métodos: Estudo ecológico com dados secundários do Sistema de Informações de Agravos de Notificação em municípios do estado do Tocantins de 2001 a 2012. As unidades de análise foram os 139 municípios do estado. Modelos de regressão log linear binomial negativa foram utilizados para estimar as razões de taxas de incidência., Resultados: Na análise bivariada, a razão de taxa de incidência foi significativamente maior para os municípios com maior razão de renda dos 20,0% mais pobres (1,47; IC95% 1,19-1,81) e melhor Índice de Desenvolvimento Humano Municipal (1,53; IC95% 1,14-2,06). Na múltipla, a razão de taxa de incidência foi significativamente superior em municípios com maior concentração de imigrantes (1,31; IC95% 1,11-1,55) e proporção de domicílios com coleta de lixo (1,37; IC95% 1,11-1,69). Houve redução significativa da razão de taxa de incidência com o aumento da cobertura do programa bolsa família (0,98; IC95% 0,96-0,99)., Conclusões: Os programas de controle precisam focar as atividades em municípios de maior vulnerabilidade social com investimentos intersetoriais para a melhoria das condições de vida da população.

Soil-transmitted helminth (STH) infections are widely distributed in tropical and subtropical areas, including Brazil. We performed a nationwide population-based study including all deaths in Brazil from 2000 to 2011, in which STHs (ascariasis, trichuriasis and/or hookworm infection) were mentioned on death certificates, either as underlying or as associated causes of death. Epidemiological characteristics, time trends and spatial analysis of STH-related mortality were analysed. STHs was identified on 853/12 491 280 death certificates: 827 (97·0%) deaths related to ascariasis, 25 (2·9%) to hookworm infections, and 1 (0·1%) to trichuriasis. The average annual age-adjusted mortality rate was 0·34/1 000 000 inhabitants (95% confidence interval: 0·27-0·44). Females, children <10 years of age, indigenous ethnic groups and residents in the Northeast region had highest STH-related mortality rates. Nationwide mortality decreased significantly over time (annual percent change: -5·7%; 95% CI: -6·9 to -4·4), with regional differences. We identified spatial high-risk clusters for STH-related mortality mainly in the North, Northeast and South regions. Diseases of the digestive system and infectious/parasitic diseases were the most commonly associated causes of death mentioned in the STH-related deaths. Despite decreasing mortality in Brazil, a considerable number of deaths is caused by STHs, with ascariasis responsible for the vast majority. There were marked regional differences, affecting mainly children and vulnerable populations.

Neurocysticercosis (NCC) is an important cause of severe neurological disease mainly in low- and middle-income countries, but data on NCC mortality from endemic areas are scarce. Here we analysed the epidemiological patterns of NCC-related mortality in Brazil. We included all deaths recorded in Brazil between 2000 and 2011, in which NCC was mentioned on death certificates, either as underlying or as associated cause of death. NCC was identified in 1829/12,491,280 deaths (0.015%), 1130 (61.8%) as underlying cause, and 699 (38.2%) as associated cause. Overall age-adjusted mortality rate for the period was 0.97 deaths/1,000,000 inhabitants (95% confidence interval [CI]: 0.83-1.12). The highest NCC-related mortality rates were found in males, elderly, white race/colour and residents in endemic states/regions. Age-adjusted mortality rates at national level decreased significantly over time (annual percent change [APC]: -4.7; 95% CI: -6.0 to -3.3), with a decrease in the Southeast, South and Central-West regions, and a non-significant increasing trend in the North and Northeast regions. We identified spatial and spatiotemporal high-risk mortality clusters located mainly in NCC-endemic areas. Conditions related to the nervous system were the most commonly associated causes of death when NCC was mentioned as an underlying cause, and HIV/AIDS was the main underlying cause when NCC was an associated cause. NCC is a neglected and preventable cause of severe neurologic disease and death with high public health impact in Brazil. There is a clear need to strengthen nationwide epidemiological surveillance and control for the taeniasis/cysticercosis complex., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Co-infection of tuberculosis (TB)-HIV/AIDS is a persistent public health problem in Brazil. This study describes epidemiological patterns and time trends of mortality related to TB-HIV/AIDS co-infection. Based on mortality data from 2000-2011 (almost 12.5 million deaths), 19,815 deaths related to co-infection were analyzed. The average age-adjusted mortality rate was 0.97 deaths/100,000 inhabitants. The highest mortality rates were found among males, those in economically productive age groups, black race/color and residents of the South region. There was a significant reduction in the mortality coefficient at the national level (annual average percent change: -1.7%; 95%CI: -2.4; -1.0), with different patterns among regions: increases in the North, Northeast and Central regions, a reduction in the Southeast and a stabilization in the South. The strategic integration of TB-HIV/AIDS control programmes is fundamental to reduce the burden of mortality related to co-infection in Brazil.

Introduction: We report the behavioral changes in use of oviposition sites in Aedes aegypti in Fortaleza, Brazil., Methods: We evaluated the relationship between different types of breeding sites and changes in use from 2001 to 2012., Results: More than 40% of the infested breeding sites were used to store water. We observed a three-fold reduction in the infestation of water tanks (p = 0.038) and more than nine-fold in tires (p = 0.035). The proportion of infested plant pots increased six-fold (p < 0.001)., Conclusions: Infested breeding sites changed over time from domestic water tanks to small-volume breeding sites.

Introduction: Since the end of 2014, Zika virus (ZIKV) infection has been rapidly spreading in Brazil., Methodology: To analyze the possible association of yellow fever vaccine with a protective effect against ZIKV-related microcephaly, the following spatial analyses were performed, using Brazilian municipalities as units: i) yellow fever vaccination coverage in Brazilian municipalities in individuals aged 15-49; ii) reported cases of microcephaly by municipality; and iii) confirmed cases of microcephaly related to ZIKV, by municipality. SaTScan software was used to identify clusters of municipalities for high risk of microcephaly., Results: There were seven significant high risk clusters of confirmed microcephaly cases, with four of them located in the Northeast where yellow fever vaccination rates were the lowest. The clusters harbored only 2.9% of the total population of Brazil, but 15.2% of confirmed cases of microcephaly., Conclusion: We hypothesize that pregnant women in regions with high yellow fever vaccination coverage may pose their offspring to lower risk for development of microcephaly. There is an urgent need for systematic studies to confirm the possible link between low yellow fever vaccination coverage, Zika virus infection and microcephaly.

Background: Leprosy is an infectious chronic condition associated with potentially serious physical, social and psychological impacts., Objectives: To characterize the clinical and epidemiological profile of leprosy patients treated from 2007 to 2011 in the University Hospital of Ceará, Northeastern Brazil., Methods: This is a retrospective and descriptive study. The study population consisted of residents in the state of Ceará treated in a dermatology clinic between 2007-2011. Clinical and epidemiological data analyzed were obtained from medical records and from the database of national Information System for Notifiable Diseases., Results: 475 cases were analyzed, mostly women (51.8%), aged 45-59 years (35.0%) - mean of 45.2 years at diagnosis - with 6.3% of children under 15 , with low education (73.7%), white color (68.8%), residency in the city of Fortaleza (82.3%), and no defined work occupation (59.6%). At diagnosis, most patients were multibacillary (MB) (65.5%), had borderline clinical form (48.0%), and 22.7% had physical disability (8.0% with grade 2), predominantly in MB cases (p <0.001). We observe worsening of disability in 5.1% of cases post-MDT. The proportion of cases with reactional episodes was 42.7%, mainly during MDT (51.2%)., Conclusion: This is the first study conducted in this hospital context, revealing late diagnosis, high burden of disease, hidden endemicity, and high social vulnerability in the state of Ceará. This study reinforces the need to strengthen health care network for timely diagnosis and treatment, aiming at longitudinality of assistance.

We analysed nationwide trends and spatial distribution of NTD-related mortality in Brazil. We included all death certificates in Brazil from 2000 to 2011, in which NTDs were recorded as any causes of death. A total of 100,814/12,491,280 (0.81%) death certificates were identified, which mentioned at least one NTD. Age-adjusted NTD-related mortality rates showed a significant decrease over time (annual percent change [APC]: - 2.1%; 95% CI: - 2.8 to - 1.3), with decreasing mortality rates in the Southeast, South, and Central-West regions, stability in the Northeast region, and increase in the North region. We identified spatial and spatiotemporal high-risk clusters for NTD-related mortality in all regions, with a major cluster covering a wide geographic range in central Brazil. Despite nationwide decrease of NTD-related mortality in the observation period, regional differences remain, with increasing mortality trends especially in the socioeconomically disadvantaged regions of the country. The existence of clearly defined high-risk areas for NTD-related deaths reinforces the need for integrated prevention and control measures in areas with highest disease burden.

Introduction: The spatial distribution of disseminated histoplasmosis (DH) and acquired immunodeficiency syndrome (AIDS) co-infection in adult residents of Fortaleza, Ceará, Brazil was evaluated., Methods: Socio-demographic data for the DH/AIDS cases were obtained from a reference hospital, and socio-environmental indicators were obtained from an official Brazilian institute. Kernel analysis and local indicators of spatial autocorrelation (LISA) cluster maps were used to estimate the case density within the city., Results: DH/AIDS cases were concentrated in the Northwestern and Southwestern peripheral areas of the city, related with low human development indices, but different from AIDS cases distribution., Conclusion: Risk factors other than AIDS infection must affect histoplasmosis development in this area.

The objective of this study was to characterize epidemiological and temporal trends of leprosy in the city of Fortaleza, Ceará, Brazil, from 2001 to 2012. A total of 9,658 new cases were reported. Their temporal trend was analyzed by the jointpoint regression model. The overall detection rate showed a declining trend, with annual percent change (APC) of -4.0 and 95% confidence interval (95%CI) -5.6 - -2.3. The detection rate in children under 15 years of age (APC = -1.4; 95%CI -5.4 - 2.8) and the detection rate of disability grade 2 (APC = -0.8; 95%CI -4.5 - 3.1) were stable. The proportion of female patients was descending (APC = -1,5; 95%CI -2.3 - -0.8). The proportion of multibacillary cases from 2005 to 2012 (APC = 1.4; 95%CI 0.6 - 2.3) and among them, lepromatous cases from 2004 to 2012 (APC = 6.0; 95%CI 3.4 - 8.6) were increasing. There was stability in the proportion of cases with grade 1 (APC = 1.4; 95%CI -0.9 - 3.7) and grade 2 disability (APC = 3.7; 95%CI -0.1 - 7.8). Despite the trend towards a reduction in detection, the disease transmission persists in the city. The data also suggest late diagnosis.

Zika virus (ZIKV) infection is spreading rapidly within the Americas after originating from an outbreak in Brazil. We describe the current ZIKV infection epidemic in Brazil and the neurological symptoms arising. First cases of an acute exanthematic disease were reported in Brazil's Northeast region at the end of 2014. In March 2015, autochthonous ZIKV was determined to be the causative agent of the exanthematic disease. As cases of neurological syndromes in regions where ZIKV, dengue and/or Chikungunya viruses co-circulate were reported, ZIKV was also identified in the cerebrospinal fluid of patients with acute neurological syndromes and previous exanthematic disease. By the end of September 2015, an increasing number of infants with small head circumference or microcephaly were noted in Brazil's Northeast which was estimated to be 29 cases between August and October. ZIKV was identified in blood and tissue samples of a newborn and in mothers who had given birth to infants with microcephaly and ophthalmological anomalies. In 2015, there were an estimated 440,000 - 1,300,000 Zika cases in Brazil. There have been 4,783 suspected cases of microcephaly, most of them in the Northeast of Brazil associated with 76 deaths. The Ministry of Health is intensifying control measures against the mosquito Aedes aegypti and implemented intensive surveillance actions. Further studies are needed to confirm the suspected association between ZIKV infection and microcephaly; to identify antiviral, immunotherapy, or prophylactic vaccine; to introduce diagnostic ELISA testing. Clinical and epidemiological studies must be performed to describe viral dynamics and expansion of the outbreak.