Fifty Years of the National Rabies Control Program in Brazil under the One Health Perspective

In 1973, the National Rabies Program was created in Brazil through an agreement between the Ministry of Health and Agriculture. Since its beginning, it developed integrated action through access to free post-exposure prophylaxis (PEP) for people at risk, dog vaccination campaigns, a joint surveillance system, and awareness. This study aims to describe human rabies in Brazil under the One Health perspective in recent decades, including achievements in the control of dog-mediated cases and challenges in human cases transmitted by wild animals. This paper also explores possible drivers of human rabies in the Northeast Region with half of the cases. The first part of this study was descriptive, presenting data and examples by periods. Statistical analysis was performed in the last period (2010-2022) to explore possible drivers. Dog-mediated human cases decreased from 147 to 0, and dog cases decreased from 4500 to 7. A major challenge is now human cases transmitted by wild animals (bats, non-human primates, and wild canids). Most current human cases occur in municipalities with a tropical and subtropical moist broadleaf forest biome and a Gini index higher than 0.5. In the multivariable analysis, an association with temperature was estimated (OR = 1.739; CI95% = 1.181-2.744), and primary healthcare coverage (OR = 0.947; CI95% = 0.915-0.987) was identified as a protector. It is possible to significantly reduce the number of dog-mediated human rabies cases through the efforts presented. However, Brazil has wildlife variants of the rabies virus circulating. The association of human cases with higher temperatures in the Northeast is a concern with climate change. To reduce human cases transmitted by wild animals, it is important to continue distributing free PEP, especially in remote at-risk areas in the Amazon Region, and to increase awareness.

Leptospirosis Risk among Occupational Groups in Brazil, 2010-2015

Leptospirosis is a zoonotic disease that is primarily transmitted through close contact with contaminated environments or infected animals. Brazil has the highest number of reported cases of leptospirosis in the Americas (approximately 4,000 annual cases). The purpose of this study is to identify the occupational groups with a higher risk of leptospirosis in Brazil from 2010 through 2015 among suspected cases reported to the national surveillance system. Confirmed and unconfirmed cases of leptospirosis with laboratory diagnosis, 20,193 and 59,034 respectively, were classified into 12 occupational groups. Confirmed cases were predominantly male (79.4%), between 25 and 59 years of age (68.3%), white (53.4%), illiterate or with incomplete primary education (51.1%), and participating in agricultural work (19.9%). After controlling for age, sex, race, and area of residency, the multivariate analysis identified that between confirmed and unconfirmed cases of leptospirosis reported to the Brazilian national surveillance system, five occupational groups are at higher risk for leptospirosis: garbage and recycling collectors (odds ratio [OR] = 4.10; 95% CI = 3.36-4.99); agricultural, forestry, and fishery workers (OR = 1.65; 95% CI = 1.49-1.84); prisoners (OR = 1.56; 95% CI = 1.04-2.35); building workers (OR = 1.36; 95% CI = 1.22-1.51); cleaners and mining workers (OR = 1.25; 95% CI = 1.07-1.45). This is the first nationwide study to examine leptospirosis risk by occupational group in Brazil using national surveillance data. Our results suggest that among suspected cases there was an increased risk among occupational groups with low income and low educational levels.

Association between predator species richness and human hantavirus infection emergence in Brazil

Hantavirus infection is a rodent-borne disease (RBD) transmitted by urine or feces (as the natural reservoirs) with an annual estimated worldwide incidence of ~150,000 cases. Previous ecological studies suggested that higher species richness of rodents could decrease the risk of RBDs in humans, because the regulatory pressure of predators could reduce contact among rodents, and between humans and rodents. Using surveillance data, we investigated the association of predator species richness with hantavirus infection emergence in 5562 Brazilian inland municipalities between 2007 and 2017. Multivariable logistic regression models were used for the analyses. Diurnal and non-diurnal predator species were independent explanatory variables in the models. Rodent species richness and demographic, socioeconomic, and environmental factors were used as covariates. During the study period, 1084 cases were reported in 429 municipalities. The results showed a reverse-U-shaped association between diurnal predator species richness and hantavirus infection emergence (odds ratio [OR] 0.463, 0.688, and 0.553 for the first [lowest], third, and fourth [highest] quartiles, respectively, using the second quartile as a reference), while higher non-diurnal predator species richness tended to be associated with higher emergence risk (OR 0.134, 1.065, and 2.708 for the first, third, and fourth quartiles, respectively). The difference in these associations illustrates the complexity of the effects of predator species richness on human RBDs, which require further investigation in follow-up studies. The results showed a close link between environmental factors and public health, emphasizing that the One Health concept should be employed to understand the dynamics of RBDs.

Epidemiology of human leptospirosis in urban and rural areas of Brazil, 2000-2015

Background

Leptospirosis is one of the most widespread zoonosis in the world and Brazil has the highest number of cases in Latin America. Transmission occurs mainly through exposure to water and soil contaminated by the urine of infected animals. The goals of this study are to describe the geographic distribution, demographic characteristics and exposure factors of urban and rural cases of leptospirosis, and identify spatial clusters in urban and rural areas of Brazil.

Methods/results

A retrospective epidemiological study was carried out using 16 years (2000–2015) of surveillance data from the Brazilian Ministry of Health. Cases were described by age, sex and race, and exposure factors were characterized in urban and rural areas. A spatial autocorrelation analysis was conducted using local Moran’s I to identify urban and rural clusters of disease. On average 3,810 leptospirosis cases were reported annually with higher numbers in urban areas. National urban and rural incidence rates were the same (1.9 cases/100,000 population), however, regional differences were observed. Urban incidence rates were higher in the North and Northeast regions, while rural incidence rates were higher in the Southeast and South. The main exposure factor reported in urban and rural areas was exposure to places with signs of rodents, followed by flood in urban areas and agriculture and animal farming in rural areas. Clusters of leptospirosis were identified in densely populated urban areas of the North, Southeast and South regions, while rural clusters were concentrated in of the Southern region with large agriculture and animal farming practices.

Conclusions

This study highlights that leptospirosis is an important public health problem in both urban and rural areas of Brazil. The results provide decision-makers with detailed information about where disease incidence is high and can be used in the development of prevention and control strategies for priority areas and risk groups.

An exploration of the protective effect of rodent species richness on the geographical expansion of Lassa fever in West Africa

BACKGROUND

Lassa fever (LF) is one of the most devastating rodent-borne diseases in West Africa, causing thousands of deaths annually. The geographical expansion of LF is also a concern; cases were recently identified in Ghana and Benin. Previous ecological studies have suggested that high natural-host biodiversity reduces the likelihood of spillover transmission of rodent-borne diseases, by suppressing the activities of reservoir species. However, the association of biodiversity with the geographical expansion of LF has not been the subject of epidemiological studies.

METHODOLOGY/PRINCIPAL FINDINGS

We conducted a spatial analysis based on sociodemographic, geographical, and ecological data, and found that higher rodent species richness was significantly associated with a lower risk of LF emergence in West Africa from 2008 to 2017 (Odds Ratio = 0.852, 95% Credible Interval = 0.745-0.971).

CONCLUSIONS/SIGNIFICANCE

The results reinforce the importance of the 'One Health' approach by demonstrating that a high level of biodiversity could benefit human health.

Protective effect of predator species richness on human hantavirus infection incidence

Are predators of rodents beneficial for public health? This question focuses on whether predators regulate the spillover transmission of rodent-borne diseases. No clear answer has emerged because of the complex linkages across multiple trophic levels and the lack of accessible data. Although previous empirical findings have suggested ecological mechanisms, such as resource partitioning, which implies protective effects from predator species richness, epidemiological evidence is needed to bolster these arguments. Thus, we investigated the association between predator species richness and incidence of rodent-borne haemorrhagic fever with renal syndrome in the human population using district-level longitudinal data of 13 years for South Korea. With the exception of districts with low species richness, we found a significant negative association between the incidence of haemorrhagic fever with renal syndrome and the species richness of both avian and mammalian predators; the trends for both predator types were similar. Thus, biodiversity conservation may benefit public health.

A systematic literature review of leptospirosis outbreaks worldwide, 1970-2012

Objective.

This review describes the geographic and temporal distribution of, detection methods for, and other epidemiological features of published leptospirosis outbreaks, with the aim of informing efforts to standardize outbreak-reporting practices.

Methods.

We conducted a systematic review of leptospirosis outbreaks reported in the scientific literature and ProMED during 1970–2012. Predefined criteria were used to identify and classify outbreaks and a standard form was used to extract information.

Results.

During 1970–2012, we identified 318 outbreaks (average: 7 outbreaks/year; range: 1–19). Most outbreaks were reported in the Latin America and the Caribbean region (36%), followed by Southern Asia (13%), and North America (11%). Most outbreaks were located in tropical and subtropical ecoregions (55%). Quality classification showed that there was clear description of laboratory-confirmed cases in 40% of outbreaks. Among those, the average outbreak size was 82 cases overall (range: 2–2 259) but reached 253 cases in tropical/subtropical ecoregions. Common risk factors included outdoor work activities (25%), exposure to floodwaters (23%), and recreational exposure to water (22%). Epidemiologic investigation was conducted in 80% of outbreaks, mainly as case interviews. Case fatality was 5% overall (range: 0%–60%).

Conclusions.

Outbreak reporting increased over the study period with outbreaks covering tropical and non-tropical regions. Outbreaks varied by size, setting, and risk factors; however, data reviewed often had limited information regarding diagnosis and epidemiology. Guidelines are recommended to develop standardized procedures for diagnostic and epidemiological investigations during an outbreak and for reporting.

A road map for leptospirosis research and health policies based on country needs in Latin America

This report summarizes the presentations, discussions and the recommendations coming from the Oswaldo Cruz Institute/FIOCRUZ International Workshop for Leptospirosis Research Based on Country Needs and the 5th Global Leptospirosis Environmental Action Network meeting, which was held in the city of Rio de Janeiro, Brazil, 10-12 November 2015. The event focused on health policy and worked to develop a road map as a consensus document to help guide decision-making by policymakers, funding bodies, and health care professionals. The direction that leptospirosis research should take in the coming years was emphasized, taking into account the needs of countries of Latin America, as well as experiences from other world regions, as provided by international experts. The operational concepts of "One Health" and translational research underlaid the discussions and the resulting recommendations. Despite the wide geographic distribution of leptospirosis and its impact in terms of incidence, morbidity, and mortality, leptospirosis is not yet considered a "tool-ready" disease for global initiatives. Surveillance programs need new tools and strategies for early detection, prevention, and follow-up. The major recommendations developed at the Rio meeting cover both health policy and research. The health policy recommendations should be taken into account by decisionmakers, government officials, and the Pan American Health Organization. The priorities for research, technological development, and innovation should be considered by research institutions, universities, and stakeholders.

Geographic patterns and environmental factors associated with human yellow fever presence in the Americas

Background

In the Americas, yellow fever virus transmission is a latent threat due to the proximity between urban and wild environments. Although yellow fever has nearly vanished from North and Central America, there are still 13 countries in the Americas considered endemic by the World Health Organization. Human cases usually occur as a result of the exposure to sylvatic yellow fever in tropical forested environments; but urban outbreaks reported during the last decade demonstrate that the risk in this environment still exists. The objective of this study was to identify spatial patterns and the relationship between key geographic and environmental factors with the distribution of yellow fever human cases in the Americas.

Methodology/Principal findings

An ecological study was carried out to analyze yellow fever human cases reported to the Pan American Health Organization from 2000 to 2014, aggregated by second administrative level subdivisions (counties). Presence of yellow fever by county was used as the outcome variable and eight geo-environmental factors were used as independent variables. Spatial analysis was performed to identify and examine natural settings per county. Subsequently, a multivariable logistic regression model was built. During the study period, 1,164 cases were reported in eight out of the 13 endemic countries. Nearly 83.8% of these cases were concentrated in three countries: Peru (37.4%), Brazil (28.1%) and Colombia (18.4%); and distributed in 57 states/provinces, specifically in 286 counties (3.4% of total counties). Yellow fever presence was significantly associated with altitude, rain, diversity of non-human primate hosts and temperature. A positive spatial autocorrelation revealed a clustered geographic pattern in 138/286 yellow fever positive counties (48.3%).

Conclusions/Significance

A clustered geographic pattern of yellow fever was identified mostly along the Andes eastern foothills. This risk map could support health policies in endemic countries. Geo-environmental factors associated with presence of yellow fever could help predict and adjust the limits of other risk areas of epidemiological concern.

Yellow fever (YF) is a zoonotic disease caused by yellow fever virus (YFV), which is transmitted to humans through the bite of an infected mosquito. Sylvatic and urban cycles have been present in different periods, but currently most cases result from human exposure to jungle or forested environments. The World Health Organization considers 13 countries endemic for YFV in the Americas. The objective of this study was to identify spatial patterns and the relationship between key geographic and environmental factors with the distribution of YF human cases in the Americas. Cases of YF from 2000 to 2014 aggregated by county and eight geo-environmental factors were studied via spatial and statistical analysis. A total of 1,164 cases were reported in this time period, with the majority of them located in Peru, Brazil and Colombia. Yellow fever presence was associated with rain, altitude, diversity of non-human primate hosts and temperature. A large clustered geographic pattern of YF cases was identified along the Andes eastern foothills. Although YF cases can be seen as rare events, the results of this study demonstrate that YF human cases in the Americas are geographically concentrated and are not happening at random, even within areas known to be at risk. Determining the geo-environmental factors related to YFV is essential to delineate risk areas and to consequently improve resource allocation and prevent human cases.

Leptospirosis in Latin America: exploring the first set of regional data

OBJECTIVES

To demonstrate the importance of country surveillance systems for leptospirosis and their use for preliminary epidemiological analysis, as well as to generate research questions for future, morecomprehensive studies on the disease.

METHODS

In 2015, for the first time, the Pan American Health Organization (PAHO) included human cases of leptospirosis in its Regional Core Health Data Initiative, an open-access database that collects annual health indicators from the countries and territories of the Americas. This new information was used to analyze leptospirosis cases by country and sex and to calculate cumulative incidence rates. Maps were used to help present the results. To supplement that general review of leptospirosis in the Americas, more detailed descriptions of the epidemiological situation and the surveillance programs of four selected countries (Brazil, Colombia, Cuba, and Honduras) were provided.

RESULTS

In this first year of PAHO requesting leptospirosis data, of the 49 countries and territories in the Americas, 38 of them (77.6%) reported information. Among those 38, 28 of them (73.7%) reported the presence of human cases; the majority of instances of zero cases were in Caribbean territories. From those 28, a total of 10 702 human cases were recorded. The largest numbers of cases in Latin America were in Brazil (40.2%), Peru (23.6%), Colombia (8.8%), and Ecuador (7.2%). The cumulative incidence rate for Latin America was estimated to be 2.0 per 100 000 population. On average, 65.1% of cases were males.

CONCLUSIONS

This study demonstrates that many countries in Latin America are making efforts to establish strong surveillance systems and programs for leptospirosis. The study also shows the importance of having leptospirosis surveillance systems as well as how the information generated can be used for evidence-based decision-making on leptospirosis.

The Use of Chemoprophylaxis after Floods to Reduce the Occurrence and Impact of Leptospirosis Outbreaks

Record-breaking and devastating rainfall events have occurred in the past decade. Rain and floods are considered the main risk factors for leptospirosis and several outbreaks have been reported following extreme weather events. In such situations, one possible intervention to prevent leptospirosis cases in high-risk groups is the use of chemoprophylaxis. However, not enough evidence of its effect is available. The objectives of this study were to review the literature on the current practices of chemoprophylaxis for leptospirosis and to explore, using a mathematical model, how various chemoprophylaxis scenarios may affect the progression of a leptospirosis outbreak. Twenty-six peer-reviewed publications were selected (10 quantitative studies, two systematic reviews and 14 articles of other types). Oral doxycycline was the most used antibiotic for chemoprophylaxis of leptospirosis. Post-exposure prophylaxis was assessed in four studies following a natural disaster. Although evidence of the effectiveness of post-exposure prophylaxis is inconsistent, the direction of association supported a protective effect for morbidity and mortality. The theoretical model showed how the assumed benefit of chemoprophylaxis was influenced by the time and rate of administration. Future models should consider the heterogeneity of affected communities, improved estimates of the effect of chemoprophylaxis on leptospirosis infection and disease, as well as potential detrimental impacts. Additional research is critical to provide clear evidence-based recommendations for leptospirosis control during an outbreak. The results of this study suggest that chemoprophylaxis may provide some protection in reducing the number of leptospirosis cases after a high-risk exposure; however, the effective benefit may depend on a variety of factors such as the timing and coverage of prophylaxis. The information summarized can be used to support decision-making during a high-risk event.

A road map for leptospirosis research and health policies based on country needs in Latin America

This report summarizes the presentations, discussions and the recommendations coming from the Oswaldo Cruz Institute/FIOCRUZ International Workshop for Leptospirosis Research Based on Country Needs and the 5th Global Leptospirosis Environmental Action Network meeting, which was held in the city of Rio de Janeiro, Brazil, 10–12 November 2015. The event focused on health policy and worked to develop a road map as a consensus document to help guide decision-making by policymakers, funding bodies, and health care professionals. The direction that leptospirosis research should take in the coming years was emphasized, taking into account the needs of countries of Latin America, as well as experiences from other world regions, as provided by international experts. The operational concepts of “One Health” and translational research underlaid the discussions and the resulting recommendations. Despite the wide geographic distribution of leptospirosis and its impact in terms of incidence, morbidity, and mortality, leptospirosis is not yet considered a “tool-ready” disease for global initiatives. Surveillance programs need new tools and strategies for early detection, prevention, and follow-up. The major recommendations developed at the Rio meeting cover both health policy and research. The health policy recommendations should be taken into account by decisionmakers, government officials, and the Pan American Health Organization. The priorities for research, technological development, and innovation should be considered by research institutions, universities, and stakeholders.

Effective secondary fracture prevention: implementation of a global benchmarking of clinical quality using the IOF Capture the Fracture® Best Practice Framework tool

Fracture Liaison Services are the best model to prevent secondary fractures. The International Osteoporosis Foundation developed a Best Practice Framework to provide a quality benchmark. After a year of implementation, we confirmed that a single framework with set criteria is able to benchmark services across healthcare systems worldwide.

INTRODUCTION

Despite evidence for the clinical effectiveness of secondary fracture prevention, translation in the real-world setting remains disappointing. Where implemented, a wide variety of service models are used to deliver effective secondary fracture prevention. To support use of effective models of care across the globe, the International Osteoporosis Foundation's Capture the Fracture® programme developed a Best Practice Framework (BPF) tool of criteria and standards to provide a quality benchmark. We now report findings after the first 12 months of implementation.

METHODS

A questionnaire for the BPF was created and made available to institutions on the Capture the Fracture website. Responses from institutions were used to assign gold, silver, bronze or black (insufficient) level of achievements mapped across five domains. Through an interactive process with the institution, a final score was determined and published on the Capture the Fracture website Fracture Liaison Service (FLS) map.

RESULTS

Sixty hospitals across six continents submitted their questionnaires. The hospitals served populations from 20,000 to 15 million and were a mix of private and publicly funded. Each FLS managed 146 to 6200 fragility fracture patients per year with a total of 55,160 patients across all sites. Overall, 27 hospitals scored gold, 23 silver and 10 bronze. The pathway for the hip fracture patients had the highest proportion of gold grading while vertebral fracture the lowest.

CONCLUSION

In the first 12 months, we have successfully tested the BPF tool in a range of health settings across the globe. Initial findings confirm a significant heterogeneity in service provision and highlight the importance of a global approach to ensure high quality secondary fracture prevention services.

Leptospirosis in Rio Grande do Sul, Brazil: An Ecosystem Approach in the Animal-Human Interface

BACKGROUND

Leptospirosis is an epidemic-prone neglected disease that affects humans and animals, mostly in vulnerable populations. The One Health approach is a recommended strategy to identify drivers of the disease and plan for its prevention and control. In that context, the aim of this study was to analyze the distribution of human cases of leptospirosis in the State of Rio Grande do Sul, Brazil, and to explore possible drivers. Additionally, it sought to provide further evidence to support interventions and to identify hypotheses for new research at the human-animal-ecosystem interface.

METHODOLOGY AND FINDINGS

The risk for human infection was described in relation to environmental, socioeconomic, and livestock variables. This ecological study used aggregated data by municipality (all 496). Data were extracted from secondary, publicly available sources. Thematic maps were constructed and univariate analysis performed for all variables. Negative binomial regression was used for multivariable statistical analysis of leptospirosis cases. An annual average of 428 human cases of leptospirosis was reported in the state from 2008 to 2012. The cumulative incidence in rural populations was eight times higher than in urban populations. Variables significantly associated with leptospirosis cases in the final model were: Parana/Paraiba ecoregion (RR: 2.25; CI95%: 2.03-2.49); Neossolo Litolítico soil (RR: 1.93; CI95%: 1.26-2.96); and, to a lesser extent, the production of tobacco (RR: 1.10; CI95%: 1.09-1.11) and rice (RR: 1.003; CI95%: 1.002-1.04).

CONCLUSION

Urban cases were concentrated in the capital and rural cases in a specific ecoregion. The major drivers identified in this study were related to environmental and production processes that are permanent features of the state. This study contributes to the basic knowledge on leptospirosis distribution and drivers in the state and encourages a comprehensive approach to address the disease in the animal-human-ecosystem interface.

Where does human plague still persist in Latin America?

BACKGROUND

Plague is an epidemic-prone disease with a potential impact on public health, international trade, and tourism. It may emerge and re-emerge after decades of epidemiological silence. Today, in Latin America, human cases and foci are present in Bolivia, Brazil, Ecuador, and Peru.

AIMS

The objective of this study is to identify where cases of human plague still persist in Latin America and map areas that may be at risk for emergence or re-emergence. This analysis will provide evidence-based information for countries to prioritize areas for intervention.

METHODS

Evidence of the presence of plague was demonstrated using existing official information from WHO, PAHO, and Ministries of Health. A geo-referenced database was created to map the historical presence of plague by country between the first registered case in 1899 and 2012. Areas where plague still persists were mapped at the second level of the political/administrative divisions (counties). Selected demographic, socioeconomic, and environmental variables were described.

RESULTS

Plague was found to be present for one or more years in 14 out of 25 countries in Latin America (1899-2012). Foci persisted in six countries, two of which have no report of current cases. There is evidence that human cases of plague still persist in 18 counties. Demographic and poverty patterns were observed in 11/18 counties. Four types of biomes are most commonly found. 12/18 have an average altitude higher than 1,300 meters above sea level.

DISCUSSION

Even though human plague cases are very localized, the risk is present, and unexpected outbreaks could occur. Countries need to make the final push to eliminate plague as a public health problem for the Americas. A further disaggregated risk evaluation is recommended, including identification of foci and possible interactions among areas where plague could emerge or re-emerge. A closer geographical approach and environmental characterization are suggested.

Chromosomal characteristics of a Brazilian whip spider (Amblypygi) and evolutionary relationships with other arachnid orders

We analyzed mitotic and meiotic cells of a Brazilian amblypygid, Heterophrynus longicornis, using conventional and molecular cytogenetic techniques (Giemsa staining, C-banding, Ag-NOR, and FISH with rDNA probe). This is the first study that focuses solely on amblypygid chromosomes; it was undertaken to add data on cytogenetic knowledge of this group and contribute to the understanding of chromosome evolution in the Arachnida. We found 2n = 66 for male and female individuals, monocentric chromosomes, and absence of morphologically differentiated sex chromosomes. C-banding showed heterochromatin in the pericentromeric region of most chromosomes. Mitotic and meiotic nuclei submitted to silver impregnation and FISH revealed, respectively, Ag-NORs and ribosomal genes in the terminal region of two chromosome pairs. Most chromosome features that we observed in H. longicornis are shared with species of other arachnid orders; however, the absence of morphologically differentiated sex chromosomes in amblypygid contrasts with the remarkable variety of sex chromosome systems recorded for the Araneae. Consequently, we conclude that analysis of species of the Tetrapulmonata clade is useful for understanding the trends of sex chromosome evolution in this arachnid group.

Progress towards eliminating canine rabies: policies and perspectives from Latin America and the Caribbean

Human rabies transmitted by dogs is considered a neglected disease that can be eliminated in Latin America and the Caribbean (LAC) by 2015. The aim of this paper is to discuss canine rabies policies and projections for LAC regarding current strategies for achieving this target and to critically review the political, economic and geographical factors related to the successful elimination of this deadly disease in the context of the difficulties and challenges of the region. The strong political and technical commitment to control rabies in LAC in the 1980s, started with the regional programme coordinated by the Pan American Health Organization. National and subnational programmes involve a range of strategies including mass canine vaccination with more than 51 million doses of canine vaccine produced annually, pre- and post-exposure prophylaxis, improvements in disease diagnosis and intensive surveillance. Rabies incidence in LAC has dramatically declined over the last few decades, with laboratory confirmed dog rabies cases decreasing from approximately 25 000 in 1980 to less than 300 in 2010. Dog-transmitted human rabies cases also decreased from 350 to less than 10 during the same period. Several countries have been declared free of human cases of dog-transmitted rabies, and from the 35 countries in the Americas, there is now only notification of human rabies transmitted by dogs in seven countries (Bolivia, Peru, Honduras, Haiti, Dominican Republic, Guatemala and some states in north and northeast Brazil). Here, we emphasize the importance of the political commitment in the final progression towards disease elimination. The availability of strategies for rabies control, the experience of most countries in the region and the historical ties of solidarity between countries with the support of the scientific community are evidence to affirm that the elimination of dog-transmitted rabies can be achieved in the short term. The final efforts to confront the remaining obstacles, like achieving and sustaining high vaccination coverage in communities that are most impoverished or in remote locations, are faced by countries that struggle to allocate sufficient financial and human resources for rabies control. Continent-wide cooperation is therefore required in the final efforts to secure the free status of remaining countries in the Americas, which is key to the regional elimination of human rabies transmitted by dogs.

Leptospirosis outbreaks in Nicaragua: identifying critical areas and exploring drivers for evidence-based planning

Leptospirosis is an epidemic-prone zoonotic disease that occurs worldwide. In Central America, leptospirosis outbreaks have been reported in almost all countries; Nicaragua in particular has faced several outbreaks. The objective of this study was to stratify the risk and identify "critical areas" for leptospirosis outbreaks in Nicaragua, and to perform an exploratory analysis of potential "drivers". This ecological study includes the entire country (153 municipalities). Cases from 2004 to 2010 were obtained from the country's health information system, demographic and socioeconomic variables from its Census, and environmental data from external sources. Criteria for risk stratification of leptospirosis were defined. Nicaragua reported 1,980 cases of leptospirosis during this period, with the highest percentage of cases (26.36%) in León, followed by Chinandega (15.35%). Among the 153 municipalities, 48 were considered critical areas, 85 were endemic and 20 silent. Using spatial and statistical analysis, the variable presenting the most evident pattern of association with critical areas defined by top quintile of incidence rate is the percentage of municipal surface occupied by the soil combination of cambisol (over pyroclastic and lava bedrock) and andosol (over a volcanic ashes foundation). Precipitation and percentage of rural population are also associated with critical areas. This methodology and findings could be used for Nicaragua's Leptospirosis Intersectoral Plan, and to identify possible risk areas in other countries with similar drivers.

Natural disasters and communicable diseases in the Americas: contribution of veterinary public health

The consequences of natural disasters on the people living in the Americas are often amplified by socio-economic conditions. This risk may be increased by climate-related changes. The public health consequences of natural disasters include fatalities as well as an increased risk of communicable diseases. Many of these diseases are zoonotic and foodborne diseases. The aim of this article is to provide an overview of the importance of natural disasters for the Americas and to emphasise the contribution of veterinary public health (VPH) to the management of zoonotic and foodborne disease risks. An analysis was conducted of natural disasters that occurred in the Americas between 2004 and 2008. Five cases studies illustrating the contributions of VPH in situations of disaster are presented. The data shows that natural disasters, particularly storms and floods, can create very important public health problems. Central America and the Caribbean, particularly Haiti, presented a higher risk than the other areas of the Americas. Two priority areas of technical cooperation are recommended for this region, namely: reducing the risk of leptospirosis and other vector-borne disease outbreaks related to floods and hurricanes and improving food safety. The contribution of different disciplines and sectors in disaster preparedness and response is of paramount importance to minimise morbidity and mortality.

Importance of animal/human health interface in potential Public Health Emergencies of International Concern in the Americas

This study analyzed the importance of zoonoses and communicable diseases common to man and animals as potential Public Health Emergencies of International Concern to build an evidence base for future efforts to reduce risk of infection at the animal/human health interface. The events recorded in the World Health Organization (WHO) Event Management System (EMS) database for the Americas during the 18 months since the implementation of the 2005 revised version of WHO's International Health Regulations (15 June 2007-31 December 2008) were the main source for this analysis. Of the 110 events recorded by the EMS for the Americas during the study period, 86 were classified as communicable diseases-77 (70.0%) "within the animal/human health interface," 9 (8.2%) "not common to man and animals," 16 (14.5%) "syndromes with unknown etiologies," and 8 (7.3%) "product-related/ other." Of the 77 events within the animal/human health interface, 48 were "substantiated" (the presence of hazard was confirmed and/or human cases occurred clearly in excess of normal expectancy). These results confirm previous research and underscore the importance of the animal/human health interface as well as inter-sectoral collaboration.

Elimination of neglected diseases in latin america and the Caribbean: a mapping of selected diseases

In Latin America and the Caribbean, around 195 million people live in poverty, a situation that increases the burden of some infectious diseases. Neglected diseases, in particular, are often restricted to poor, marginalized sections of the population. Tools exist to combat these diseases, making it imperative to work towards their elimination. In 2009, the Pan American Health Organization (PAHO) received a mandate to support the countries in the Region in eliminating neglected diseases and other poverty-related infections. The objective of this study is to analyze the presence of selected diseases using geo-processing techniques. Five diseases with information available at the first sub-national level (states) were mapped, showing the presence of the disease ("hotspots") and overlap of diseases ("major hotspots"). In the 45 countries/territories (approximately 570 states) of the Region, there is: lymphatic filariasis in four countries (29 states), onchocerciasis in six countries (25 states), schistosomiasis in four countries (39 states), trachoma in three countries (29 states), and human rabies transmitted by dogs in ten countries (20 states). Of the 108 states with one or more of the selected diseases, 36 states present the diseases in overlapping areas ("major hotspots"). Additional information about soil-transmitted helminths was included. The analysis suggests a majority of the selected diseases are not widespread and can be considered part of an unfinished agenda with elimination as a goal. Integrated plans and a comprehensive approach, ensuring access to existing diagnostic and treatment methods, and establishing a multi-sectoral agenda that addresses social determinants, including access to adequate water and sanitation, are required. Future studies can include additional diseases, socio-economic and environmental variables.

Rabies transmitted by vampire bats to humans: an emerging zoonotic disease in Latin America?

Human rabies transmitted by vampire bats reached new heights in Latin America in 2005. A total of 55 human cases were reported in several outbreaks, 41 of them in the Amazon region of Brazil. Peru and Brazil had the highest number of reported cases from 1975 to 2006. In Peru, outbreaks involving more than 20 cases of bat-transmitted human rabies were reported during the 1980s and 1990s. During this period, a smaller number of cases were reported from outbreaks in Brazil. A comparison of data from field studies conducted in Brazil in 2005 with those from the previous decade suggests similar bat-bite situations at the local level. The objective of this study was to review the epidemiological situation and, on the basis of this information, discuss possible factors associated with the outbreaks. Prevention and control measures already recommended for dealing with this problem are also reviewed, and some further suggestions are provided.

Current status of human rabies transmitted by dogs in Latin America

Latin American countries made the political decision to eliminate human rabies transmitted by dogs by the year 2005. The purpose of the current study is to evaluate to what extent this goal has been reached. The epidemiological situation and control measures were analyzed and broken down within the countries by georeferencing. The 27 human cases reported in 2003 occurred in some 0.2% of the second-level geopolitical units (municipalities or counties) in the region, suggesting that the disease is a local problem. Several areas within the countries reported no more transmission of rabies in dogs. Nearly 1 million people potentially exposed to rabies received treatment. On average, 34,383 inhabitants per health post receive anti-rabies treatment (range: 4,300-148,043). Nearly 42 million dogs are vaccinated annually. Surveillance is considered fair according to the epidemiological criteria adopted by the study. Samples sent for rabies testing represent 0.05% of the estimated canine population (range: 0.001 to 0.2%). The countries are quite close to achieving the goal.

Oral misoprostol vs. intravenous oxytocin in reducing blood loss after emergency cesarean delivery

OBJECTIVE

To compare the effectiveness of oral misoprostol and intravenous oxytocin in reducing blood loss in women undergoing indicated or elective cesarean delivery (CD) under spinal anesthesia.

METHODS

In this prospective, double-blind pilot study, 56 parturients who received 5 IU of intravenous oxytocin after cord clamping were randomized to further receive either misoprostol orally and a placebo infusion intravenously or placebo orally and an oxytocin infusion intravenously.

RESULTS

After adjustment was made for the sonographically estimated amniotic fluid volume, there was no statistical difference in blood loss between the 2 groups (mean+/-S.D., 1083+/-920 mL in the oxytocin group vs. 970+/-560 mL in the misoprostol group; P=.59).

CONCLUSION

Oxytocin followed by oral misoprostol is as effective as an oxytocin injection followed by an oxytocin infusion in reducing postoperative blood loss after CD, and the protocol may be a safe, valuable, and cost-effective alternative to oxytocin alone. Visual estimation of intraoperative blood loss undervalues the effective value of misoprostol use by 30%.

Impact of spinal anaesthesia on peri-operative lung volumes in obese and morbidly obese female patients*

Although obesity predisposes to postoperative pulmonary complications, data on the relationship between body mass index (BMI) and peri-operative respiratory performance are limited. We prospectively studied the impact of spinal anaesthesia, obesity and vaginal surgery on lung volumes measured by spirometry in 28 patients with BMI 30-40 kg.m(-2) and in 13 patients with BMI > or = 40 kg.m(-2). Vital capacity, forced vital capacity, forced expiratory volume in 1 s, mid-expiratory and peak expiratory flows were measured during the pre-operative visit (baseline), after effective spinal anaesthesia with premedication, and after the operation at 20 min, 1 h, 2 h, and 3 h (after mobilisation). Spinal anaesthesia and premedication were associated with a significant decrease in spirometric parameters. Spinal anaesthesia and premedication were associated with a significant decrease in spirometric parameters; mean (SD) vital capacities were - 19% (6.4) in patients with BMI 30-40 kg.m(-2) and - 33% (9.0) in patients with BMI > 40 kg.m(-2). The decrease of lung volumes remained constant for 2 h, whereas 3 h after the operation and after mobilisation, spirometric parameters significantly improved in all patients. This study showed that both spinal anaesthesia and obesity significantly impaired peri-operative respiratory function.

Ropivacaine versus bupivacaine 0.125% with fentanyl 1 microg/ml for epidural labour analgesia: is daily practice more important than pharmaceutical choice?

Ropivacaine might be superior to bupivcaine for epidural labour analgesia because it appears to induce less lower extremity motor blockade. The clinical relevance of this difference is not yet clear.

METHODS

In a double-blind randomised trial bupivacaine and ropivacaine each at 0.125% with 1 microg/ml fentanyl were compared for epidural labour analgesia. This study was performed in two university hospitals.

RESULTS

Sixty-three nulliparous women with singleton pregnancies at term were included. There were no differences between bupivacaine and ropivacaine as far as motor blockade, analgesic outcome, mode of delivery and neonatal outcome are concerned. However, the clinical management of epidural analgesia differed significantly between the two institutions involved. Parturients of one institution had their epidural catheter placed earlier, needed less top-up medication, and had more successful mobilisations, when compared to the other institution.

CONCLUSIONS

Institutional clinical practice can be significantly different. Pharmacological differences between bupivacaine and ropivacaine at 0.125% with 1 microg/ml fentanyl seem to be less important than differences between institutions in terms of clinical practice.

Comparison of perioperative spirometric data following spinal or general anaesthesia in normal-weight and overweight gynaecological patients

BACKGROUND

There is limited data comparing the impact of spinal anaesthesia (SA) and general anaesthesia (GA) on perioperative lung function. Here we assessed the differences of these two anaesthetic techniques on perioperative lung volumes in normal-weight (BMI < 25) and overweight (BMI 25-30) patients using spirometry.

METHODS

We prospectively studied 84 consenting patients having operations in the vaginal region receiving either GA (n = 41) or SA (n = 43). Both groups (GA and SA) were further divided into two subgroups each (normal-weight vs. overweight). We measured vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), midexpiratory (MEF25-75) and peak expiratory flow rates (PEFR) at the preoperative assessment (baseline), after premedication, after effective SA, and 20 min, 1 h, 2 h and 3 h after the operation (last measurement after patient mobilization).

RESULTS

Premedication was associated with a small but significant decrease in lung volumes in direct correlation with BMI (-5%). Spinal anaesthesia resulted in a significant reduction in lung volumes in overweight as opposed to normal-weight patients. Postoperatively, lung volumes were significantly more reduced following GA than SA as indicated by differences in mean VC (SD) of -12 (6)% vs. -6 (5)% 20 min after the end of the operation in the normal-weight and -18 (5)% vs. -10 (5)% in the overweight patients. There was a significant impact of BMI on postoperative respiratory function, which was significantly more important in the GA group than in the SA group, and recovery of lung volumes was more rapid in the normal-weight patients than in the overweight patients, particularly in the SA group.

CONCLUSION

In gynaecological patients undergoing vaginal surgery, the impact of anaesthesia on postoperative lung function as assessed by spirometry was significantly less after SA than GA, particularly in overweight patients.

Overview of rabies in the Americas

Between 1993 and 2002, the number of human and canine rabies cases in the Americas Region fell by approximately 80%. There were 39 human cases in 2002, 63% of them transmitted by dogs. Furthermore, human rabies transmitted by wildlife, mostly by bats is a risk to inhabitants in many countries in the Region. The objective of this study is to describe this epidemiological situation based in the information received from the countries of the Americas Region in Regional Rabies Surveillance System in the Americas (SIRVERA) administrated by the Pan American Health Organization. This sharp reduction is attributable mainly to the control measures implemented by the countries of the Region, such as the mass vaccination of dogs and prophylactic treatment for people who have been exposed.

Effect of obesity and thoracic epidural analgesia on perioperative spirometry

BACKGROUND

Lung volumes in obese patients are reduced significantly in the postoperative period. As the effect of different analgesic regimes on perioperative spirometric tests in obese patients has not yet been studied, we investigated the effect of thoracic epidural analgesia and conventional opioid-based analgesia on perioperative lung volumes measured by spirometry.

METHODS

Eighty-four patients having midline laparotomy for gynaecological procedures successfully completed the study. Premedication, anaesthesia and analgesia were standardized. The patients were given a free choice between epidural analgesia (EDA) (n=42) or opioids (n=42) for postoperative analgesia. We performed spirometry to measure vital capacity (VC), forced vital capacity, peak expiratory flow, mid-expiratory flow and forced expiratory volume in 1 s at preoperative assessment, 30-60 min after premedication and 20 min, 1 h, 3 h and 6 h after extubation.

RESULTS

Baseline values were all within the normal range. All perioperative spirometric values decreased significantly with increasing body mass index (BMI). The greatest reduction in VC occurred directly after extubation, but was less in the EDA group than in the opioid group: mean of -23(sd 8)% versus -30(12)% (P<0.001). In obese patients (BMI>30) the difference in VC was significantly more pronounced than in patients of normal weight (BMI<25): -45(10)% versus -33(4)% (P<0.001). Recovery of spirometric values was significantly quicker in patients receiving EDA, particularly in obese patients.

CONCLUSION

We conclude that EDA should be considered in obese patients undergoing midline laparotomy to improve postoperative spirometry.

Impact of spinal anaesthesia and obesity on maternal respiratory function during elective Caesarean section*

Spinal anaesthesia for Caesarean section has gained widespread acceptance. We assessed the impact of spinal anaesthesia and body mass index (BMI) on spirometric performance. In this prospective study, we consecutively assessed 71 consenting parturients receiving spinal anaesthesia with hyperbaric bupivacaine and fentanyl for elective Caesarean section. We performed spirometry during the antepartum visit (baseline), immediately after spinal anaesthesia, 10-20 min, 1 h, 2 h after the operation, and after mobilisation (3 h). Baseline values were within normal ranges. There was a significant decrease in all spirometric parameters after effective spinal anaesthesia that persisted throughout the study period. The decrease in respiratory function was significantly greater in obese (BMI > 30 kg x m(-2)) than in normal-weight parturients (BMI < 25 kg x m(-2)), e.g. median (IQR) vital capacity directly after spinal anaesthesia; -24 (-16 to -31)% vs. -11 (-6 to -16)%, p < 0.001 and recovery was significantly slower. We conclude that both spinal anaesthesia and obesity significantly impair respiratory function in parturients.

The effect of epidural analgesia in labour on maternal respiratory function

Lumbar epidural analgesia during labour has gained widespread acceptance. The impact of epidural analgesia based on mixtures of low-dose local anaesthetic solutions and lipophilic opioids on most clinically relevant obstetric outcomes is minimal. Since the pregnant state per se is associated with important alterations in respiration, we assessed whether a subtle degree of motor blockade brought about by epidural analgesia might compromise respiratory function as assessed by spirometry. Sixty consenting parturients receiving epidural analgesia were consecutively included in this prospective study. We performed spirometry during the antepartum visit and in labour after effective epidural analgesia was established; at both assessments the women were pain-free. Values were within normal ranges but increased significantly after effective epidural analgesia; median (IQR [range]) increase for vital capacity 7.4 (3.0-13 [-12-27])% (p < 0.001); forced vital capacity 4.4 (1.7-9.8 [-13-26])% (p < 0.001); forced expiratory volume in 1 s 5.5 (1.7-8.6 [-14-28])% (p < 0.001); and peak expiratory flow rate 2.3 (-1.6-5.8 [-18-16])% (p = 0.01)). We conclude that epidural analgesia for labour significantly improved respiratory function.

Effect of obesity and site of surgery on perioperative lung volumes

BACKGROUND

Although obese patients are thought to be susceptible to postoperative pulmonary complications, there are only limited data on the relationship between obesity and lung volumes after surgery. We studied how surgery and obesity affect lung volumes measured by spirometry.

METHODS

We prospectively studied 161 patients having either breast surgery (Group A, n=80) or lower abdominal laparotomy (Group B, n=81). Premedication and general anaesthesia were standardized. Spirometry was measured with the patient supine, in a 30 degrees head-up position. We measured vital capacity (VC), forced vital capacity, peak expiratory flow and forced expiratory volume in 1 s at preoperative assessment (baseline), after premedication (before induction of anaesthesia) and 10-20 min, 1 h and 3 h after extubation.

RESULTS

Baseline spirometric values were all within the normal range. All perioperative values decreased significantly with increasing body mass index (BMI). The greatest reduction of mean VC (expressed as percentage of baseline values) occurred after extubation, and was more marked after laparotomy than after breast surgery (23 (SD 14)% vs 20 (14)%). Considering patients according to BMI (<25, 25-30, >30), VC decreased after surgery by 12 (7)%, 24 (8)% and 40 (10)%, respectively. VC recovered more rapidly in Group A.

CONCLUSION

Postoperative reduction in spirometric volumes was related to BMI. Obesity had more effect on VC than the site of surgery.

Dnase1l3 deficiency in lupus-prone MRL and NZB/W F1 mice

Loss of deoxyribonuclease I (Dnase1) function is associated with systemic lupus erythematosus (SLE) in humans and mice; however, no coding mutations in Dnase1 are found in polygenic murine models. Instead, both MRL-lpr strains and NZB/W F1 hybrids are homozygous for T89I missense in the macrophage-DNASE, desoxyribonuclease I-like 3 (Dnase1l3). By in vitro expression studies, this substitution decreases this enzyme's nuclease activity against free DNA by only approximately twofold; however, the mutation has a greater effect on the capacity of media conditioned with Dnase1l3 to confer a barrier to liposomal gene transfection to HeLa cells. The 89I substitution decreases the Dnase1l3 barrier function in vitro by eightfold (P < 0.01). In splenocytes and BM-derived macrophages of SLE mice, while cellular Dnase1l3 levels are induced relative to C57BL/6 (control) mice, levels of FD-nuclease activity are similar. Finally, media conditioned by MRL and NZB/W F1 macrophages, relative to control, contains a weak interferon-gamma (IFN-gamma) inducible Dnase1l3-associated barrier to transfection. This barrier function is hypothesized to reflect the inability of SLE mice to degrade membrane-enveloped DNA-associated antigens, such as apoptotic bodies, which are predicted to stimulate the characteristic autoimmunity of SLE. Our results for these two generally independent models strongly suggest that Dnase1l3 deficiency increases the susceptibility of these mice to polygenic SLE.

[Comments on models for studying human rabies outbreaks from bats]

This paper analyzes which of the possible public health models could contribute to an understanding of human rabies outbreaks transmitted by bats. First, we present a short review of the most common pertinent models. Second, we present an investigation of a human rabies outbreak transmitted by bats based on the socio-epidemiological model. The same outbreak is analyzed again using the complex system theory as a theoretical framework, as both a theoretical-practical exercise seeking an approximation to this theory and a model to study this problem.

Recurrent post-partum seizures after epidural blood patch

There are many causes for headaches after childbirth. Even though postdural puncture headache (PDPH) has to be considered in a woman with a history of difficult epidural anaesthesia, pre-eclampsia should always be excluded as an important differential diagnosis. We report a case with signs of late-onset pre-eclampsia where administration of an epidural blood patch (EBP) was associated with eclampsia. A hypothetical causal relationship between the EBP and seizures was discarded on the basis of evidence presented in this report.

[Methods for measuring inequalities in health]

Measuring health inequalities is indispensable for progress in improving the health situation in the Region of the Americas, where the analysis of average values is no longer sufficient. Analyzing health inequalities is a fundamental tool for action that seeks greater equity in health. There are various measurement methods, with differing levels of complexity, and choosing one rather than another depends on the objective of the study. The purpose of this article is to familiarize health professionals and decision-making institutions with methodological aspects of the measurement and simple analysis of health inequalities, utilizing basic data that are regularly reported by geopolitical unit. The calculation method and the advantages and disadvantages of the following indicators are presented: the rate ratio and the rate difference, the effect index, the population attributable risk, the index of dissimilarity, the slope index of inequality and the relative index of inequality, the Gini coefficient, and the concentration index. The methods presented are applicable to measuring various types of inequalities and at different levels of analysis.

[Analgesia during labour: from taboo to evidence-based medicine]

Peripartum care of parturients has contributed a great deal to the development of modern anaesthesia during the past 150 years. The introduction of general and regional anaesthesia provided new options of relieving pain during delivery and preventing suffering. However,provision of effective labor analgesia gave and still gives rise to controversy as to whether interfering with natural events such as delivery was justifiable on a religious,moral or ideological level. A new era of obstetric pain relief was initiated when a study design was devised to define the Minimum Local Analgesic Concentration (MLAC) needed for epidural analgesia. Using the MLAC model as a scientifically based pharmacodynamic measure of analgesia, empirically developed "recipes" can be compared and validated. The importance of this clinical model will be put into a pharmacological context including issues such as the up-down sequential allocation technique, dose-response curves and differential nerve blockade.

[Indices based on entropy for measuring social inequalities in health]

As described in the scientific literature, indices used to measure social inequalities in health have positive features, but they also have shortcomings, depending on how they are applied. The objective of this article is to put forward and to demonstrate, in both theoretical and practical terms, the advantages of measurements of inequality based on the notion of entropy, which is well known in physics and in information theory. The article defines and presents the main properties of indices based on the notions of entropy and redundancy. The application of the indices is illustrated with two fictitious data sets and also with real data derived from basic health indicators for the Americas, from the Pan American Health Organization. Indices based on the notion of entropy have properties that include: a) not varying with scale changes, b) being symmetrical, c) incorporating a socioeconomic dimension, and d) being easy to interpret thanks to the condition of equivalence between entropy and a system with two categories.