Malaria In Brazil Research Articles

Field evaluation of the BG-Malaria trap for monitoring malaria vectors in rural Tanzanian villages.

BG-Malaria (BGM) trap is a simple adaptation of the widely-used BG-Sentinel trap (BGS). It is proven to be highly effective for trapping the Brazilian malaria vector, Anopheles darlingi, in field conditions, and the African vector, Anopheles arabiensis, under controlled semi-field environments, but has not been field-tested in Africa. Here, we validated the BGM for field sampling of malaria vectors in south-eastern Tanzania. Using a series of Latin-Square experiments conducted nightly (6pm-7am) in rural villages, we compared mosquito catches between BGM, BGS and human landing catches (HLC). We also compared BGMs baited with different attractants (Ifakara-blend, Mbita-blend, BG-Lure and CO2). Lastly, we tested BGMs baited with Ifakara-blend from three odour-dispensing methods (BG-Cartridge, BG-Sachet and Nylon strips). One-tenth of the field-collected female Anopheles gambiae s.l. and Anopheles funestus were dissected to assess parity. BGM captured more An. gambiae s.l. than BGS (p < 0.001), but HLC caught more than either trap (p < 0.001). However, BGM captured more An. funestus than HLC. Proportions of parous An. gambiae s.l. and An. funestus consistently exceeded 50%, with no significant difference between methods. While the dominant species caught by HLC was An. gambiae s.l. (56.0%), followed by Culex spp. (33.1%) and Mansonia spp. (6.0%), the BGM caught mostly Culex (81.6%), followed by An. gambiae s.l. (10.6%) and Mansonia (5.8%). The attractant-baited BGMs were all significantly superior to un-baited controls (p < 0.001), although no difference was found between the specific attractants. The BG-Sachet was the most efficient dispenser for capturing An. gambiae s.l. (14.5(2.75–42.50) mosquitoes/trap/night), followed by BG-Cartridge (7.5(1.75–26.25)). The BGM caught more mosquitoes than BGS in field-settings, but sampled similar species diversity and physiological states as BGS. The physiological states of malaria vectors caught in BGM and BGS were similar to those naturally attempting to bite humans (HLC). The BGM was most efficient when baited with Ifakara blend, dispensed from BG-Sachet. We conclude that though BGM traps have potential for field-sampling of host-seeking African malaria vectors with representative physiological states, both BGM and BGS predominantly caught more culicines than Anopheles, compared to HLC, which caught mostly An. gambiae s.l.

ERRATUM: "Malaria in Brazil: what happens outside the Amazonian endemic region".

[This corrects the article doi: 10.1590/0074-0276140228].

Aspidosperma pyrifolium Mart: neuroprotective, antioxidant and anti-inflammatory effects in a Parkinson's disease model in rats.

Aspidosperma species are used for several diseases, especially for malaria in Brazil. Although the genus is object of pharmacological studies, almost none are found on Aspidosperma pyrifolium. We investigate neuroprotective, antioxidant and anti-inflammatory properties of the APSE-Aq fraction (benzoic acid glycosylated derivative) on Parkinson's disease model. Male Wistar rats were subjected to a 6-hydroxydopamine injection into the right striatum and treated or not with APSE-Aq (100 or 200 mg/kg, p.o.). The sham-operated group was injected with saline. Two weeks later, animals were subjected to behavioural, neurochemical and immunohistochemical evaluation. The data were analysed by ANOVA and Tukey test. The APSE-Aq-treated group shows a partial recovery of behavioural changes as compared with the untreated-6-hydroxydopamine group. A partial recovery was also observed in nitrite contents and lipid peroxidation. APSE-Aq treatments significantly reversed decreases in striatal dopamine and metabolites in the untreated 6-hydroxydopamine group. Immunostainings for markers as tyrosine hydroxylase and dopamine transporter decreased in the untreated 6-hydroxydopamine group and values recovered after APSE-Aq treatments. Similar data were seen for TNF-alpha. APSE-Aq presents neuroprotective, antioxidant and anti-inflammatory activities. Considering that APSE-Aq is chemically related to salicylic acid, it may act on similar targets.

BLOOD SUPPLEMENTATION WITH VITAMINS INCREASES THE FERTILITY OF Anopheles darlingi (DIPTERA: CULICIDAE)

Anopheles darlingi is one of the main vectors of human malaria in Brazil. Female mosquitoes use blood from vertebrates to produce their eggs and larvae. Blood composition, including vitamins, may alter fecundity and fertility, impacting mass production in the laboratory. Thus, the objective of this work was to evaluate the effect of blood supplementation with vitamins on the reproductive parameters of An. darlingi. Mosquito females were collected in a rural area of Porto Velho, and a blood meal was given in the field, adding different amounts of multivitamins in concentrations between 1 and 0.01%. The number of engorged mosquitoes and, subsequently, other variables such as survival up to oviposition, proportion of mosquitoes laying eggs, number of eggs and larvae produced were recorded. Engorgement, survival, and proportion of females laying eggs, as well as egg production, except in females supplemented with 1% of the multivitamin, were not altered by supplementation. However, the number of larvae produced increased significantly (about 20%) in females supplemented with 0.01% compared to control (no vitamins added). The present results suggest that general supplementation by vitamins increases the fertility of An. darlingi.

Anophelines species and the receptivity and vulnerability to malaria transmission in the Pantanal wetlands, Central Brazil.

BACKGROUNDStudies on malaria vectors in the Pantanal biome, Central Brazil, were conducted more than half a century ago.OBJECTIVESTo update anopheline records and assess receptivity and vulnerability to malaria transmission.METHODSFive-day anopheline collections were conducted bimonthly in Salobra, Mato Grosso do Sul state, for one year. Indoors, mosquitoes were collected from their resting places, while in open fields, they were captured using protected human-baited and horse-baited traps near the house and at the Miranda River margin, respectively. Hourly biting activity outdoors was also assessed. Secondary data were collected on the arrival of tourists, economic projects, and malaria cases.FINDINGSA total of 24,894 anophelines belonging to 13 species were caught. The main Brazilian malaria vector Anopheles darlingi was the predominant species, followed by An. triannulatus s.l. Hourly variation in anopheline biting showed three main peaks occurring at sunset, around midnight, and at sunrise, the first and last being the most prominent. The highest density of all species was recorded near the river margin and during the transition period between the rainy and early dry seasons. This coincides with the time of main influx of outsider workers and tourists, whose activities mostly occur in the open fields and frequently start before sunrise and last until sunset. Some of these individuals originate from neighbouring malaria-endemic countries and states, and are likely responsible for the recorded imported and introduced malaria cases.MAIN CONCLUSIONPantanal is a malaria-prone area in Brazil. Surveillance and anopheline control measures must be applied to avoid malaria re-emergence in the region.

Efficacy and safety of artemisinin-based combination therapy and chloroquine with concomitant primaquine to treat Plasmodium vivax malaria in Brazil: an open label randomized clinical trial

BackgroundThere is general international agreement that the importance of vivax malaria has been neglected, and there is a need for new treatment approaches in an effort to progress towards control and elimination in Latin America. This open label randomized clinical trial evaluated the efficacy and safety of three treatment regimens using either one of two fixed dose artemisinin-based combinations or chloroquine in combination with a short course of primaquine (7–9 days: total dose 3–4.2 mg/kg) in Brazil. The primary objective was establishing whether cure rates above 90% could be achieved in each arm.ResultsA total of 264 patients were followed up to day 63. The cure rate of all three treatment arms was greater than 90% at 28 and 42 days. Cure rates were below 90% in all three treatment groups at day 63, although the 95% confidence interval included 90% for all three treatments. Most of the adverse events were mild in all treatment arms. Only one of the three serious adverse events was related to the treatment and significant drops in haemoglobin were rare.ConclusionThis study demonstrated the efficacy and safety of all three regimens that were tested with 42-day cure rates that meet World Health Organization criteria. The efficacy and safety of artemisinin-based combination therapy regimens in this population offers the opportunity to treat all species of malaria with the same regimen, simplifying protocols for malaria control programmes and potentially contributing to elimination of both vivax and falciparum malaria.Trial registration RBR-79s56s

Semi-field assessment of the BG-Malaria trap for monitoring the African malaria vector, Anopheles arabiensis.

Odour-baited technologies are increasingly considered for effective monitoring of mosquito populations and for the evaluation of vector control interventions. The BG-Malaria trap (BGM), which is an upside-down variant of the widely used BG-Sentinel trap (BGS), has been demonstrated to be effective to sample the Brazilian malaria vector, Anopheles darlingi. We evaluated the BGM as an improved method for sampling the African malaria vectors, Anopheles arabiensis. Experiments were conducted inside a large semi-field cage to compare trapping efficiencies of BGM and BGS traps, both baited with the synthetic attractant, Ifakara blend, supplemented with CO2. We then compared BGMs baited with either of four synthetic mosquito lures, Ifakara blend, Mbita blend, BG-lure or CO2, and an unbaited BGM. Lastly, we compared BGMs baited with the Ifakara blend dispensed via either nylon strips, BG cartridges (attractant-infused microcapsules encased in cylindrical plastic cartridge) or BG sachets (attractant-infused microcapsules encased in plastic sachets). All tests were conducted between 6P.M. and 7A.M., with 200–600 laboratory-reared An. arabiensis released nightly in the test chamber. The median number of An. arabiensis caught by the BGM per night was 83, IQR:(73.5–97.75), demonstrating clear superiority over BGS (median catch = 32.5 (25.25–37.5)). Compared to unbaited controls, BGMs baited with Mbita blend caught most mosquitoes (45 (29.5–70.25)), followed by BGMs baited with CO2 (42.5 (27.5–64)), Ifakara blend (31 (9.25–41.25)) and BG lure (16 (4–22)). BGM caught 51 (29.5–72.25) mosquitoes/night, when the attractants were dispensed using BG-Cartridges, compared to BG-Sachet (29.5 (24.75–40.5)), and nylon strips (27 (19.25–38.25)), in all cases being significantly superior to unbaited controls (p < 000.1). The findings demonstrate potential of the BGM as a sampling tool for African malaria vectors over the standard BGS trap. Its efficacy can be optimized by selecting appropriate odour baits and odour-dispensing systems.

Pharmacotherapy follow-up: Role in active malaria surveillance in a travel medicine centre outside the transmission area in Brazil.

Malaria is a potentially severe disease, widespread in tropical and subtropical areas. Apart from parasite drug resistance, which receives the largest share of attention, several factors directly influence the response to antimalarial treatment such as incorrect doses, adverse drug events, lack of adherence to treatment, drug quality and drug-drug interactions. Pharmacotherapy follow-up can be used to monitor and improve the effectiveness of treatment, prevent drug-related problems and ensure patient safety. The aim of this study was to describe the results of the implementation of pharmacotherapy follow-up of patients with malaria seen at a reference centre for malaria diagnosis and treatment (CPD-Mal) located in the city of Rio de Janeiro, an area without malaria transmission. A descriptive study was conducted from January 2009 to September 2013 at the Instituto Nacional de Infectologia Evandro Chagas (INI) of the Fundação Oswaldo Cruz (Fiocruz). All malaria patients enrolled in the study were treated according to the Brazilian Malaria Therapy Guidelines. Data collected during pharmacotherapy follow-up were recorded in a standardized form. The variables included were age, gender, comorbidities, antimalarials and concomitant medications used, adverse drug reactions (ADR), clinical and parasitological cure times, and treatment outcomes classified as success, recurrence (recrudescence or relapse); and lost to follow-up. The ADR were classified by severity (DAIDS-NIH), organ system affected (WHO-ART) and likelihood to be caused by drugs (Naranjo scale). One hundred thirteen cases of malaria were included. Patients were aged between 13 and 66years and the majority of them (75.2%) were male. Ninety-four ADR were observed, most classified as mild (85.1%), related to disorders of the gastrointestinal system (63.8%), such as nausea and vomiting, and assessed as "possibly" caused by the antimalarial drugs (91.5%). The majority of clinical (90.9%) and parasitological (87.1%) cure occurred less than 72hours after treatment initiation. Pharmacotherapy follow-up of malaria treatment by surveillance activities is therefore important regarding information about treatment outcomes as well as patient safety, resulting in better patient care and reducing the chance of relapses. The results underscore its use as a tool for monitoring adherence and drug resistance outside an endemic area. Pharmacotherapy follow-up should be considered a useful malaria surveillance tool that can be developed by reference centres for comprehensive health care assistance and monitoring of therapeutic resistance.

Challenges for malaria elimination in Brazil.

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

Aspidosperma species as sources of anti-malarials: uleine is the major anti-malarial indole alkaloid from Aspidosperma parvifolium (Apocynaceae).

BackgroundSeveral species of the genus Aspidosperma (Apocynaceae) are used for the treatment of human malaria in Brazil and other meso- and South American countries.MethodsEthanol extract from Aspidosperma parvifolium trunk bark was submitted to acid–base extractions leading to alkaloid and neutral fractions. The alkaloid fraction was chromatographed over a silica gel column. Ethanol extract, fractions and uleine were analysed by HPLC–DAD, UPLC-ESI–MS/MS and HPLC-ESI-MicroTOF-MS. The anti-malarial activity was assayed against resistant and sensitive chloroquine Plasmodium falciparum strains by microscopic, [3H]-hypoxanthine incorporation and HRPII techniques. Cytotoxicity (CC50) was evaluated against Vero and HepG2 cell lines by the MTT technique; selectivity indexes (SI = CC50/IC50) were calculated.ResultsThe major peak in the HPLC–DAD chromatograms of the ethanol extract, alkaloid and neutral fractions suggested the presence of uleine that was isolated from the alkaloid fraction by column chromatography and was characterized by spectroscopic methods. A total of 15 alkaloids, besides uleine, were identified in the alkaloid fraction by UPLC-DAD-ESI–MS/MS and HPLC-ESI-MicroTOF-MS. The ethanol extract from Aspidosperma parvifolium and the neutral fraction were moderately active against P. falciparum strains. The alkaloid fraction and uleine disclosed high anti-malarial activity against chloroquine-resistant P. falciparum strain (IC50 < 1 µg/mL). The ethanol extract, neutral fraction and uleine showed low cytotoxicity against Vero and HepG2 cell lines (CC50 > 300 µg/mL). The alkaloid fraction showed moderate cytotoxicity to HepG2 cell line (CC50 = 74.4 µg/mL). High SI values (>10) were determined for all samples.ConclusionEthanol extract from Aspidosperma parvifolium trunk bark afforded uleine that is the major constituent of the alkaloid fraction and disclosed a good in vitro anti-malarial activity. Moreover, 15 other indole alkaloids have been identified along with uleine.

A historical perspective on malaria control in Brazil.

Malaria has always been an important public health problem in Brazil. The early history of Brazilian malaria and its control was powered by colonisation by Europeans and the forced relocation of Africans as slaves. Internal migration brought malaria to many regions in Brazil where, given suitableAnopheles mosquito vectors, it thrived. Almost from the start, officials recognised the problem malaria presented to economic development, but early control efforts were hampered by still developing public health control and ignorance of the underlying biology and ecology of malaria. Multiple regional and national malaria control efforts have been attempted with varying success. At present, the Amazon Basin accounts for 99% of Brazil’s reported malaria cases with regional increases in incidence often associated with large scale public works or migration. Here, we provide an exhaustive summary of primary literature in English, Spanish and Portuguese regarding Brazilian malaria control. Our goal was not to interpret the history of Brazilian malaria control from a particular political or theoretical perspective, but rather to provide a straightforward, chronological narrative of the events that have transpired in Brazil over the past 200 years and identify common themes.

Urban Malaria: Understanding its Epidemiology, Ecology, and Transmission Across Seven Diverse ICEMR Network Sites.

A major public health question is whether urbanization will transform malaria from a rural to an urban disease. However, differences about definitions of urban settings, urban malaria, and whether malaria control should differ between rural and urban areas complicate both the analysis of available data and the development of intervention strategies. This report examines the approach of the International Centers of Excellence for Malaria Research (ICEMR) to urban malaria in Brazil, Colombia, India (Chennai and Goa), Malawi, Senegal, and Uganda. Its major theme is the need to determine whether cases diagnosed in urban areas were imported from surrounding rural areas or resulted from transmission within the urban area. If infections are being acquired within urban areas, malaria control measures must be targeted within those urban areas to be effective. Conversely, if malaria cases are being imported from rural areas, control measures must be directed at vectors, breeding sites, and infected humans in those rural areas. Similar interventions must be directed differently if infections were acquired within urban areas. The hypothesis underlying the ICEMR approach to urban malaria is that optimal control of urban malaria depends on accurate epidemiologic and entomologic information about transmission.

Natural Plasmodium infection in neotropical primates in the island of São Luís, state of Maranhão, Brazil.

The states that make up the Legal Amazon Region, which include the state of Maranhão, account for 99% of registered cases of human malaria in Brazil. It is also believed that transmission of malaria from nonhuman primates (NHP) to humans occurs in this region, because of current reports of seroepidemiological results from samples from humans and NHP coexisting in the same areas. This study aimed to make morphological, serological and molecular diagnoses of Plasmodium spp. in neotropical primates on the island of São Luís, state of Maranhão, Brazil. The diagnostic techniques used were optical microscopy, the polymerase chain reaction (PCR) and the indirect immunofluorescence assay (IFA). From June 2009 to April 2010, 70 NHP were sampled: 50 at the Wild Animal Screening Center (CETAS), located in the municipality of São Luís and 20 free-living individuals that were caught in a private reserve located in the municipality of São Jose de Ribamar, state of Maranhão. Under an optical microscope, 140 slides (two from each animal) were evaluated and five animals (7.1%) were found to be positive. IFA did not detect anti-Plasmodium spp. From PCR on the 70 animals sampled, amplified Plasmodium spp. products were observed in 13 samples, of which eight (61.5%) were from free-living animals and five (38.5%) were from animals at CETAS.

The Juscelino Kubitschek government and the Brazilian Malaria Control and Eradication Working Group: collaboration and conflicts in Brazilian and international health agenda, 1958-1961.

Malaria, a disease which was under control in the beginning of Juscelino Kubitschek government, became the most important endemic disease in 1958, when Brazil made a commitment with the World Health Organization to convert its control programs into eradication programs. For this purpose a Malaria Control and Eradication Group was set up under the leadership of the malaria specialist Mário Pinotti. Malaria would become an important bargaining chip in the context of the development policies of Kubitschek. This article focuses on path of the Malaria Control and Eradication Working Group in Brazil, in its varying relationships with the arguments and guidelines established at international level.

Large-scale drivers of malaria and priority areas for prevention and control in the Brazilian Amazon region using a novel multi-pathogen geospatial model.

BackgroundMost of the malaria burden in the Americas is concentrated in the Brazilian Amazon but a detailed spatial characterization of malaria risk has yet to be undertaken.MethodsUtilizing 2004-2008 malaria incidence data collected from six Brazilian Amazon states, large-scale spatial patterns of malaria risk were characterized with a novel Bayesian multi-pathogen geospatial model. Data included 2.4 million malaria cases spread across 3.6 million sq km. Remotely sensed variables (deforestation rate, forest cover, rainfall, dry season length, and proximity to large water bodies), socio-economic variables (rural population size, income, and literacy rate, mortality rate for children age under five, and migration patterns), and GIS variables (proximity to roads, hydro-electric dams and gold mining operations) were incorporated as covariates.ResultsBorrowing information across pathogens allowed for better spatial predictions of malaria caused by Plasmodium falciparum, as evidenced by a ten-fold cross-validation. Malaria incidence for both Plasmodium vivax and P. falciparum tended to be higher in areas with greater forest cover. Proximity to gold mining operations was another important risk factor, corroborated by a positive association between migration rates and malaria incidence. Finally, areas with a longer dry season and areas with higher average rural income tended to have higher malaria risk. Risk maps reveal striking spatial heterogeneity in malaria risk across the region, yet these mean disease risk surface maps can be misleading if uncertainty is ignored. By combining mean spatial predictions with their associated uncertainty, several sites were consistently classified as hotspots, suggesting their importance as priority areas for malaria prevention and control.ConclusionThis article provides several contributions. From a methodological perspective, the benefits of jointly modelling multiple pathogens for spatial predictions were illustrated. In addition, maps of mean disease risk were contrasted with that of statistically significant disease clusters, highlighting the critical importance of uncertainty in determining disease hotspots. From an epidemiological perspective, forest cover and proximity to gold mining operations were important large-scale drivers of disease risk in the region. Finally, the hotspot in Western Acre was identified as the area that should receive highest priority from the Brazilian national malaria prevention and control programme.Electronic supplementary materialThe online version of this article (doi:10.1186/1475-2875-13-443) contains supplementary material, which is available to authorized users.

The exponential-Poisson model for recurrent event data: an application to a set of data on malaria in Brazil.

In this paper, we introduce a new model for recurrent event data characterized by a baseline rate function fully parametric, which is based on the exponential-Poisson distribution. The model arises from a latent competing risk scenario, in the sense that there is no information about which cause was responsible for the event occurrence. Then, the time of each recurrence is given by the minimum lifetime value among all latent causes. The new model has a particular case, which is the classical homogeneous Poisson process. The properties of the proposed model are discussed, including its hazard rate function, survival function, and ordinary moments. The inferential procedure is based on the maximum likelihood approach. We consider an important issue of model selection between the proposed model and its particular case by the likelihood ratio test and score test. Goodness of fit of the recurrent event models is assessed using Cox-Snell residuals. A simulation study evaluates the performance of the estimation procedure in the presence of a small and moderate sample sizes. Applications on two real data sets are provided to illustrate the proposed methodology. One of them, first analyzed by our team of researchers, considers the data concerning the recurrence of malaria, which is an infectious disease caused by a protozoan parasite that infects red blood cells.

We need to talk more about transfusion-transmitted malaria in Plasmodium vivax endemic areas.

alaria is the most widespread and relevant parasitic disease orldwide; it is primarily transmitted by bites of Anopheles sp., ut can also be transmitted congenitally or through infected lood transfusions. The major species infecting humans are lasmodium falciparum and P. vivax. Even considering that oth species lead to severe disease, the first has been traitionally associated to more deaths, mostly in the African ontinent. No vaccine is available so far and the major control ools are based on early diagnosis and treatment, and vector ontrol. In Brazil, after the eradication campaign started in the 950s, malaria became restricted to the Amazon Region, which espite representing 50% of the national territory holds no ore than 10% of the population. After the 1990s, due to better ontrol of P. falciparum, P. vivax became the main species, and is esponsible for almost 85% of the reported cases, paralleling he decrease in the overall fatality rate, the most successful oal of the Brazilian Malaria Control Program.1 However, this arasite is able to develop dormant stages (hypnozoites) in he liver leading to frequent relapses, thereby confounding fficially reported data, since it is not possible to distinguish ew infections from relapse. With renewed interest in malaria

Cellular and humoral immune responses against the Plasmodium vivax MSP-119 malaria vaccine candidate in individuals living in a Brazilian endemic area in northeastern Amazon

Background Plasmodium vivax Merozoite Surface Protein-1 (MSP-1) is an antigen considered to be one of the leading malaria vaccine candidates. PvMSP-1 is immunogenic and evidences suggest that it is a target for protective immunity against asexual blood stages of malaria parasites. This study aims to evaluate the acquired cellular and antibody immune responses against PvMSP-1 in individuals exposed to malaria infections in a Brazilian malaria endemic area.

Malaria in Brazil: what happens outside the Amazonian endemic region.

Brazil, a country of continental proportions, presents three profiles of malaria transmission. The first and most important numerically, occurs inside the Amazon. The Amazon accounts for approximately 60% of the nation’s territory and approximately 13% of the Brazilian population. This region hosts 99.5% of the nation’s malaria cases, which are predominantly caused by Plasmodium vivax (i.e., 82% of cases in 2013). The second involves imported malaria, which corresponds to malaria cases acquired outside the region where the individuals live or the diagnosis was made. These cases are imported from endemic regions of Brazil (i.e., the Amazon) or from other countries in South and Central America, Africa and Asia. Imported malaria comprised 89% of the cases found outside the area of active transmission in Brazil in 2013. These cases highlight an important question with respect to both therapeutic and epidemiological issues because patients, especially those with falciparum malaria, arriving in a region where the health professionals may not have experience with the clinical manifestations of malaria and its diagnosis could suffer dramatic consequences associated with a potential delay in treatment. Additionally, because the Anopheles vectors exist in most of the country, even a single case of malaria, if not diagnosed and treated immediately, may result in introduced cases, causing outbreaks and even introducing or reintroducing the disease to a non-endemic, receptive region. Cases introduced outside the Amazon usually occur in areas in which malaria was formerly endemic and are transmitted by competent vectors belonging to the subgenus Nyssorhynchus (i.e., Anopheles darlingi, Anopheles aquasalis and species of the Albitarsis complex). The third type of transmission accounts for only 0.05% of all cases and is caused by autochthonous malaria in the Atlantic Forest, located primarily along the southeastern Atlantic Coast. They are caused by parasites that seem to be (or to be very close to) P. vivax and, in a less extent, by Plasmodium malariae and it is transmitted by the bromeliad mosquito Anopheles (Kerteszia) cruzii. This paper deals mainly with the two profiles of malaria found outside the Amazon: the imported and ensuing introduced cases and the autochthonous cases. We also provide an update regarding the situation in Brazil and the Brazilian endemic Amazon.

Imported malaria in a non-endemic area: the experience of the university of Campinas hospital in the Brazilian Southeast.

BackgroundAlthough malaria in Brazil almost exclusively occurs within the boundaries of the Amazon Region, some concerns are raised regarding imported malaria to non-endemic areas of the country, notably increased incidence of complications due to delayed diagnoses. However, although imported malaria in Brazil represents a major health problem, only a few studies have addressed this subject.MethodsA retrospective case series is presented in which 263 medical charts were analysed to investigate the clinical and epidemiological characterization of malaria cases that were diagnosed and treated at Hospital & Clinics, State University of Campinas between 1998 and 2011.ResultsAmongst all medical charts analysed, 224 patients had a parasitological confirmed diagnosis of malaria. Plasmodium vivax and Plasmodium falciparum were responsible for 67% and 30% of the infections, respectively. The majority of patients were male (83%) of a productive age (median, 37 years old). Importantly, severe complications did not differ significantly between P. vivax (14 cases, 9%) and P. falciparum (7 cases, 10%) infections.ConclusionsSevere malaria cases were frequent among imported cases in Brazil outside of the Amazon area. The findings reinforce the idea that P. vivax infections in Brazil are not benign, regardless the endemicity of the area studied. Moreover, as the hospital is located in a privileged site, it could be used for future studies of malaria relapses and primaquine resistance mechanisms. Finally, based on the volume of cases treated and the secondary complications, referral malaria services are needed in the non-endemic areas of Brazil for a rapid and efficient and treatment.