LECTURE 7 Malaria Epidemiology in Brazil

2. Epidemiological structure

3. Historical antecedents 1898 Ross - Avian malaria is transmitted by mosquitoes 1899 Grassi, Bastianelli e Bignani � Human malaria is transmitted by mosquitoes Vector control actions: Small engineering works to reduce the anopheline breeding sites Petroleum or kerosene to kill the larvae

4. Historical antecedents Gorgas and the Panama Canal Control of breeding places Protection of windows and doors Quinine as prophylactic Oswaldo Cruz and the Madeira Mamor� railway Quinine as prophylactic: compulsory use Protection of windows and doors Restriction on exposure: people confined in rooms at the maximum day exposure time

5. Historical antecedents 1922 � Use of Paris Green as larvicide 1927 Carlos Chagas (Nations League Commission) Chrysanthemum (piretro) burn to kill the adults mosquitoes World War II: Residual action from DDT New synthetic drugs such as chloroquine

6. Epidemiological situation in Brazil 1913 Rockefeller Commission in S�o Paulo Diagnoses rural centers to malaria and ancylostomosis 1914 Malaria notification begins 1916 Orientation on rustic house construction 1928 Adolpho Lutz Alerts to the possibility that African mosquitoes can be introduced in the northeast region with the intensification of travel between Brazil (Natal) and Senegal (Dacar)

7. 1930 Shannon identified A.gambiae focus in Natal Epidemic with 10,000 cases controlled by vector (larvae) control interventions 1938 Vale do Jaguaribe (CE) Epidemic with 110,000 cases First effort to eradicate anopheles by Fred Soper Combat breeding locations Domestic insecticide use (�Flit�) Epidemiological situation in Brazil

8. Eradication Campaign 1959 to 1963 S�o Paulo State Incidence: 5.4 times reduction in five years 1965-1979 Brazil 40 million living in risk areas 110,000 cases in 1967 (attack phase) 50,000 cases in 1970

10. Control Models Environmental-ecologic model (1930-1950) Complexity Specific local characteristics Limited application of technical instruments Purpose: keep the work force active Campaign-based technical model (1950-1970) Standardization and massification Slide and vector binome Purpose: zero case

11. Focal and preventive model: (1970-1990) Focus on individual Actions concentrated in risk areas Epidemiological surveillance Purpose � Mortality and morbidity reduction Control of epidemics Control Models

12. 1980�s Transmission concentrated in Amazon (97.5% of cases) Seringais � low population density, enduring settlements and slow mobility ? low incidence Feeding grounds ? the same Building company settlement � Control of entrance of people, vector control, rapid treatment and diagnosis ? controlled transmission Close settlement of miners and prospectors � the same Open settlement of miners and prospectors � high exposition, multiple breeding sites, asymptomatic carriers, difficult control activities ? high incidence New areas of colonization � favorable conditions to transmission plus susceptible persons ? very high incidence, usually epidemic Old colonization � better house conditions, domestic animals and agricultures ? low incidence

13. 1980�s Amazon region: �Raids� � the same as the new colonization areas Peri-urban � population migratory flux are continuous, sanitation conditions are bad ? high incidence Indigenous settlements - variable conditions, depends on the mayor or minor contact with other populations Extra-Amazon region Receptive states: Vectorial density Infection sources circulation Epidemiological surveillance structure Exemples Garimpo do Cumaru exported 8,683 cases to 381 cities in 11 states. Ariquemes rural settlements exported 1,134 cases to 204 cities in 10 states

14. Control activities 1970�s � incidence increases x 3 1980-1985 � incidence increase x 2.4 1986: 80% of cases concentrated in MT, PA and RO Impact operation � �zoning� All febrile cases and other family members treated All parasitized individuals treated Mefloquine introduction for P.falciparum malaria treatment

15. 1990�s Malaria transmitted in only 80 cities About 450,000 to 500,000 cases per year WHO Ministerial Conference 1992 in Amsterdam totally changed control strategies

16. WHO Ministerial Conference 1992 Mass strategies were abandoned and were replaced by risk strategies Disease management: case diagnosis and treatment assigned to primary care facilities Disease prevention: measures of individual protection, chemoprophylaxis, and domiciliary vector control Prevention and control of epidemics: traditional epidemiologic surveillance activities Consequences: Reduction of the financial support of malaria control Reduction in vectorial control activities Reduction in active case search activities Epidemiological situation aggravated all over the world

18. PCMAM - Amazon Basin Malaria Control Program Objetive: Incidence reduction Promote the institutional development of SUCAM Straiten the malaria control Malaria control within the indigenous population Results: Organization of local health care facilities Human resources training Strategic research Mortality reduction from 7.0 to 1.8 per 1,000 inhabitants between 1988 and 1996 Prevent the occurrence of 1.9 million new cases and 236,000 deaths

19. PCIN � National Integrated Control Program Objetive: Diagnosis and treatment of all cases Opportunely prevent and detect all epidemics Use selective vector control strategies Strengthen epidemiologic surveillance Periodic evaluation of epidemiologic situation Crisis at the FUNASA prevents the success of this plan

20. Incidence of Malaria in Amazon 1989-1999

21. Present Risk Areas

28. Seasonal Distribution

29. API in Amazon Region2005 -2006

30. Proportional age distribution

31. Treatment

32. PROGRAM OF INTENSIFICATION OF MALARIA CONTROL EFFORTS Control efforts were transferred to municipalities Political commitment by the President, governors and mayors Social costs taken into consideration Inter-sectoral activities Regular and constant funding Monitoring program by means of periodic evaluations

33. PIACM Results (2000-2002) Incidence reduction of 32% Reduction in hospitalization Fewer cases of P.vivax infection, proportionally Fatality reduction

35. National malaria control program Objetive: Avoid malaria mortality Reduction in severity of cases Reduction in incidence of Malaria Elimination of urban malaria Sustain transmission interruption in non- endemic areas

36. National malaria control program Goals: 20% reduction in deaths per year 20% reduction in number of malaria hospitalizations per year 20% reduction in the API per year Urban malaria elimination by 2006 Avoid the autochthonous cases in areas where transmission was interrupted by surveillance activities

37. Epidemiologic characteristic Legal Amazon concentrates 99% of malaria cases 76 high risk cities and 111 of median risk High API (10 times more than observed in 1970) 500,000 to 600,000 cases per year Low fatality rate and low hospitalization rate Median to high % of P.falciparum Occurrence of urban epidemics

38. Bibliography Tauil, PL, Deane L, Sabroza PC. Ribeiro C. A mal�ria no Brasil. Cadernos de Sa�de P�blica 1985, 1(1):71-111 Barata RB. Mal�ria no Brasil: panorama epidemiol�gico na �ltima d�cada. Cadernos de Sa�de P�blica 1995, 11(1):128-136 Barata RB. Mal�ria e seu controle. Editora HUCITEC 1998. Loiola CCP, Silva CJM, Tauil,PL. Controle da mal�ria no Brasil: 1965-2001. Revista Panamericana de Salud P�blica 2002, 11(4):235-244 Silva Junior JB. A mal�ria no Brasil. SVS / MS, 2005.