BRAZIL'S EXPERIENCE WITH CONTROL OF INFECTIOUS DISEASES

Friday, 20th of May 2011 Print

Brazil is the yardstick by which other middle income countries can judge their performance in combatting infectious diseases. Infectious diseases, which used to account for half of all deaths in Brazil, now account for 5 percent of total mortality. Brazil has seen successes and, rarely, failures in its efforts to control infectious diseases.

One of a six part Lancet series on health in Brazil. Best read, with graphics, at

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60202-X/fulltext

  • Brazil is undergoing a rapid and sometimes unorganised urbanisation process. Cash transfer programmes for the neediest populations, the Unified Health System (SUS), and other social and environmental improvements (such as in sanitation and education) related to this rapid urbanisation are, and should continue to be, crucial for efforts to control infectious diseases.
  • Successful and moderately successful public health initiatives, such as those to control vaccine-preventable diseases, diarrhoea, respiratory infections, HIV/AIDS, and tuberculosis, have provided universal and free at the point of use vaccination, access to treatment, and primary health care. Such equitable policies must be supported and reinforced in the face of existing and renewed challenges, such as less than optimum adherence to treatment regimens and the emergence and transmission of drug-resistant pathogens.
  • The control of disease vectors in areas of rapid urbanisation and poor-quality housing cannot be achieved through health policies alone. Such efforts must be fully integrated into broad policies that incorporate the mobilisation of society, health and environmental education, improvements in habitation and sewerage, and attempts to avoid further deforestation.
  • Scientific research in Brazil has thrived in the past 10 years, with rapid and sustained growth in applied biomedical and epidemiological research on infectious disease prevention and management. Such academic achievements must be translated into deliverable products and policies so that they can be of benefit to the Brazilian population.

I

 

Successes and failures in the control of infectious diseases in Brazil: social and environmental context, policies, interventions, and research needs

Original Text

Prof Mauricio L Barreto MD a , M Gloria Teixeira MD a, Francisco I Bastos MD b, Ricardo AA Ximenes MD c, Rita B Barata MD d, Prof Laura C Rodrigues MD e

Summary

Despite pronounced reductions in the number of deaths due to infectious diseases over the past six decades, infectious diseases are still a public health problem in Brazil. In this report, we discuss the major successes and failures in the control of infectious diseases in Brazil, and identify research needs and policies to further improve control or interrupt transmission. Control of diseases such as cholera, Chagas disease, and those preventable by vaccination has been successful through efficient public policies and concerted efforts from different levels of government and civil society. For these diseases, policies dealt with key determinants (eg, the quality of water and basic sanitation, vector control), provided access to preventive resources (such as vaccines), and successfully integrated health policies with broader social policies. Diseases for which control has failed (such as dengue fever and visceral leishmaniasis) are vector-borne diseases with changing epidemiological profiles and major difficulties in treatment (in the case of dengue fever, no treatment is available). Diseases for which control has been partly successful have complex transmission patterns related to adverse environmental, social, economic, or unknown determinants; are sometimes transmitted by insect vectors that are difficult to control; and are mostly chronic diseases with long infectious periods that require lengthy periods of treatment.

This is the third in a Series of six papers on Health in Brazil

Introduction

Infectious diseases are still a public health problem in Brazil, despite the proportion of total deaths that are caused by infectious diseases decreasing from 50% to 5% in the past 80 years.1 Such reductions have been more pronounced for some infectious diseases than they have for others. Figure 1 shows the proportion of deaths from all causes between 1930 and 2007, and the proportion of deaths attributable to different infectious diseases between 1980 and 2008, from which time detailed data exists.4 A large proportion of deaths from infectious diseases in Brazil are due to respiratory infections, and respiratory infection deaths have become more common in adults than in children (figure 1). There have been some pronounced decreases in proportional mortality from specific diseases—ie, diarrhoeal diseases, vaccine-preventable diseases, and pneumonia in children. Deaths from HIV/AIDS have increased since the mid 1980s, dengue has emerged as a substantial cause of death, the number of deaths from tuberculosis and Chagas disease have remained stable, and the proportion of adult deaths due to respiratory infections is increasing (figure 1). The distribution of causes of death from infectious diseases has shifted towards one more commonly seen in high-income countries, especially in the predominance of pneumonia in the adult and elderly populations.4 In this report, we do not give a comprehensive review of trends for all infectious diseases in Brazil, but assess the relative successes of policies and interventions for selected diseases.

 

Figure 1 Full-size image (112K) Download to PowerPoint

Trends in the causes of death in Brazil

(A) All deaths between 1930—2007. (B) Deaths from infectious diseases, 1980—2008.2, 3

The relative contribution of different diseases to overall mortality in a country is associated with its gross domestic product (table 1). The past 60 years were a time of much change in Brazil. In the 1950s, 64% of the Brazilian population lived in rural areas. Vector-borne diseases and intestinal parasitic diseases with transmission cycles that require a stage of development in soil or water were common, and diarrhoea, respiratory infections, and measles caused most deaths in children younger than 5 years. Living conditions in both urban and rural areas were poor, with restricted access to health care (including vaccines), adequate housing, and water and sanitation, fostering the transmission of tuberculosis, poliomyelitis, measles, mumps, diphtheria, typhoid, and leptospirosis.1,6—9

Table 1Table image  

Mortality from different infectious diseases (in individuals without HIV) and gross domestic product in different countries, 2004

Key messages

  • Brazil is undergoing a rapid and sometimes unorganised urbanisation process. Cash transfer programmes for the neediest populations, the Unified Health System (SUS), and other social and environmental improvements (such as in sanitation and education) related to this rapid urbanisation are, and should continue to be, crucial for efforts to control infectious diseases.
  • Successful and moderately successful public health initiatives, such as those to control vaccine-preventable diseases, diarrhoea, respiratory infections, HIV/AIDS, and tuberculosis, have provided universal and free at the point of use vaccination, access to treatment, and primary health care. Such equitable policies must be supported and reinforced in the face of existing and renewed challenges, such as less than optimum adherence to treatment regimens and the emergence and transmission of drug-resistant pathogens.
  • The control of disease vectors in areas of rapid urbanisation and poor-quality housing cannot be achieved through health policies alone. Such efforts must be fully integrated into broad policies that incorporate the mobilisation of society, health and environmental education, improvements in habitation and sewerage, and attempts to avoid further deforestation.
  • Scientific research in Brazil has thrived in the past 10 years, with rapid and sustained growth in applied biomedical and epidemiological research on infectious disease prevention and management. Such academic achievements must be translated into deliverable products and policies so that they can be of benefit to the Brazilian population.

In 1953, with the creation of the Ministry of Health, a programme for rural diseases was established, which led to the systematic implementation of vector control measures.10 In the decades after industrialisation, which started in the late 1950s, many people migrated from rural areas to urban areas, amid much urbanisation, improvements in the country's infrastructure (ie, ports, energy generation, road networks), increased access to health care, and modernisation of the state, which increased its presence in different aspects of economic and social spheres (eg, industrial development, roads and communication, housing, water and sanitation, health, and science and technology). By 2000, only 19% of the population lived in rural areas—most of the burden of infectious diseases was borne by those living in urban areas. Between 1980 and 2007 the proportion of households with piped water supply increased from 52% to 84% (93% in urban areas) and the proportion with access to sewerage or a septic tank increased from 25% to 74%.11 These changes took place in a period of much social inequality—a common situation throughout much of Brazil's history—with a Gini coefficient of around 0·6, which, since only 2001, has begun to slowly decrease to 0·56.12

Such progress had some detrimental consequences. For example, much deforestation has taken place to enable agro-industrial activities, or the extraction of basic products and commodities, and increased population mobility has expanded areas of transmission for some endemic diseases (eg, yellow fever) and caused previously rural diseases to appear in urban areas (eg, visceral leishmaniasis and leprosy).13—16 The reintroduction of Aedes aegypti in 1976 resulted in successive dengue epidemics since 1986.17—19 The cholera pandemic in the 1990s and the rapid spread of the influenza A H1N1 virus in 2009 are examples of international infections that affected Brazil. Finally, changes in urban and rural environments were associated with emergence of new infectious diseases (eg, Brazilian haemorrhagic fever, hantaviruses).20—22 Diseases that were previously well controlled were reintroduced to Brazil (dengue17) or underwent epidemiological changes that compromised their effective control (visceral and cutaneous leishmaniases,13 hepatitis C23).24 Reductions in mortality from some diseases were not always accompanied by reduction in incidence; tuberculosis and HIV/AIDS are still a public health problem in many regions of the country, despite substantial decreases in mortality rates since the mid-1990s.25—27 A substantial proportion (13%) of resources allocated to health care are spent on infectious diseases.28

The health system: surveillance, prevention, and care

The Brazilian National System for Surveillance and Control of Diseases (SNVS) is a decentralised, hierarchical, integrated network that operates a horizontal and universal approach, as part of the Unified Health System (Sistema Único de Saúde, or SUS).29 All 27 states of Brazil have public health laboratories; there are 5 National Reference Laboratories and 51 Centres for Surveillance and Strategic Information (CIEVS).30 State Health Secretariats coordinate and assess state-level activities.31 Teams based in the municipalities investigate individual cases and outbreaks reported by the health service and implement relevant control measures. All reported cases (from public health services or from private health providers) are included in the notification database (SINAN), which is openly accessible on the internet. When necessary, CIEVS provide technical staff, material, and financial resources needed for clinical and epidemiological investigation and implementation of control measures. CIEVS are operational 24 h a day and 7 days a week, monitoring the information received and any relevant information, including information from the press and other media.

SNVS undertakes disease-specific surveillance and control programmes for vaccine-preventable diseases, dengue fever, malaria, HIV/AIDS, tuberculosis, leprosy, meningitis (panel 1; table 2), leishmaniasis, diarrhoea, leptospirosis, and other diseases. All drugs and immunobiological products used in such control programmes are given to individuals free of charge.

Panel 1

Meningitis in Brazil

Of all types of meningitis, meningococcal meningitis has the most public-health importance because of its epidemic potential. There were several epidemics of meningococcal disease in the 20th century in Brazilian cities. In São Paulo, the largest metropolis in the country, there were four major epidemics, the largest of which was in the 1970s, when waves of serotypes A and C spread from peripheral urban areas to all social and demographic groups. To control this epidemic, the largest mass vaccination campaign with conjugated vaccines (serotypes A and C) was done—95% of the 11 million population of São Paulo city were vaccinated in 4 days. The epidemic was during the military dictatorship and lasted 7 years. During the first 5 years of the epidemic the government banned mention of the epidemic in the media and did not disclose the number of deaths or cases, fearing that links between the epidemic and accelerated economic growth could bring attention to the poor conditions in which the working population lived.32—34

Table 2Table image  

Meningitis incidence, fatality rate, and cause in Brazil, 2001—09

Control: successes and failures

Here we examine trends from 1980 to 2007 in selected infectious diseases of public health importance—grouped according to their control being either successful, partly successful, or a failure—and look for common factors in each group. We consider the control of diseases that were eliminated, are well controlled (less than one case per 100 000 population), or for which mortality has been reduced by at least 90% as successes. Control of diseases for which incidence or mortality rates have increased we consider as failures. The control of diseases that are defined by neither of the above two definitions are considered as partly successful.

Despite their importance, respiratory tract infections and health-care acquired infections were not selected for inclusion in this report. Respiratory infections in children are discussed elsewhere in this Series.35 In short, a pronounced decrease in child mortalities due to respiratory infections has been recorded in the past two decades—between 1991 and 2007, mortality decreased by about 80%—which was largely attributable to the increase in access to health care, including the Family Health Programme.36 In the elderly population, evidence exists that the incidence of fatal respiratory infections is also decreasing slowly, although becoming a larger proportion of all deaths. The universal availability of influenza vaccines since 1999 for this age group has substantially reduced the proportion of mortalities in this age group that are caused by respiratory infections.37, 38 Universal access to vaccination led to a decrease in the socioeconomic disparity in number of deaths due to respiratory infections.39 About a third of all hospital-acquired infections are pneumonia, making up a substantial proportion of the national burden of respiratory infections.40

Expansion of the Brazilian health system has led to an increase in the occurrence of health-care acquired infections.41 Although there has been a national programme of monitoring and control since 1983, available data are not sufficient for an adequate assessment of trends at a national level.42 However the little data available suggest that such infections are an important problem,43 which will probably increase as the access to the hospital system increases and the use of high-technology, and invasive interventions becomes more frequent.

Successful control

Vaccine-preventable diseases

The National Immunization Programme (Programa Nacional de Imunização; PNI) has been very successful, achieving one of the highest immunisation coverage rates worldwide, without the use of coercive strategies. All vaccines are given to individuals free at the point of use. Routine universal vaccination programmes include BCG; poliomyelitis, measles mumps, and rubella (MMR); diphtheria, pertussis, tetanus (DPT) plus Haemophilus influenzae type b (Hib); hepatitis B; yellow fever; rotavirus; 10-valent pneumococcal; and meningococcal C conjugate vaccines. These vaccines are provided in about 30 000 health units, and also in an additional 100 000 temporary vaccination points twice a year during national vaccination days. In 2007, the government spent R$710 million (US$373 million) on vaccines, most of which were produced in Brazil (panel 2). Vaccination against human papilloma virus is provided exclusively through private clinics, but recent public-private partnerships have increased its availability through substantial discounts offered to patients from both low-income and middle-income groups at outpatient units, with medical assistance by the charities in the Santa Casa da Misericórdia network.

Panel 2

Production of vaccines in Brazil

The domestic production of vaccines has increased substantially in the past 20 years. In 1992, roughly 60% of all vaccines used in the National Immunisation Programme were imported; by 2002, 70% were produced in Brazil.44 The largest national producers are the Butantan Institute and BioManguinhos, both public laboratories that produce only immunobiologicals. The Butantan Institute is affiliated to the State of São Paulo Health Secretariat and produces vaccines against hepatitis B; diphtheria, pertussis, and tetanus (DPT); diphtheria and tetanus; rabies; and seasonal influenza A. BioManguinhos is part of the Oswaldo Cruz Foundation (FIOCRUZ), is affiliated to the Brazilian Ministry of Health, and produces yellow fever, Haemophilus influenzae type b (Hib), polio, and tetravalent (DPT plus Hib) vaccines.

Actions by the Pan American Health Organization, who have a prominent role in the control of vaccine-preventable diseases in South America, have contributed much to the success in control of such diseases in Brazil.45, 46 Between 1980 and 2007, the number of deaths from tetanus decreased by 81% and deaths from pertussis decreased by 95%—no deaths were registered from diphtheria, poliomyelitis, or measles in 2007.47, 48 Poliomyelitis was eliminated in Brazil in 1990 (although a few cases of vaccine-related poliomyelitis have been reported since).47 Measles transmission was interrupted in the past decade; sporadic cases, however, been reported from cases imported from Europe and Asia.48 As in many places with high vaccine coverage, the incidence of and mortality from meningitis caused by H influenzae type b in children younger than 5 years substantially decreased after the introduction of the Hib vaccine to the routine schedule in 1999.49, 50 Although, in general, vaccine coverage in Brazil is very high, it is not uniform across socioeconomic levels, with lowest coverage in the highest and lowest socioeconomic groups (figure 2).

 

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National Programme of Immunization coverage, by socioeconomic group, 2007—08

Data are for coverage of children aged 18 months in state capital cities and federal district in Brazil.51

Diarrhoea and cholera

Mortality from diarrhoea decreased substantially in the 1980s with the generalised use of oral rehydration therapy. In addition to use of oral rehydration therapy, increased access to health services52 and especially to primary health care36 contributed to this reduction in mortality. In children younger than 1 year, diarrhoea-related mortality decreased from 11·7 deaths per 1000 livebirths in 1980, to 1·5 deaths per 1000 livebirths in 2005, a reduction of about 95%.53 Incidence of diarrhoea also decreased during this period,54, 55 as a result of the pronounced increase in provision of treated, piped drinking water and, to a lesser extent, of hygienic sewage disposal.54—56 Such improvements in sanitation have caused a shift in the predominant causes of diarrhoea, from bacteria spread by faecal-oral transmission (eg, Salmonella spp and Shigella spp) to viruses spread by person-to-person transmission (mainly rotaviruses, but also adenovirus and norovirus).57—59 In 2006, after successful efficacy trials, vaccination against rotavirus was introduced to the routine schedule.60

After an epidemic in mid-19th century, no new cases of cholera were recorded in South America until the end of the 20th century in Peru,61 and was detected in the Brazilian Amazon region, close to the Peru border, in 1991.62 The disease spread quickly through cities in the north and northeast regions, leading to an epidemic that peaked in 1993, with only 60 000 reported cases (39·8 cases per 100 000 population) and 1·1% case fatality rate;63 the last case of cholera in Brazil was reported in 2005.64

Chagas disease

The chronic form of Chagas disease presents with myocardiopathy, mega-oesophagus, or megacolon. The myocardiopathy is very severe with a high case fatality rate of 80% within 5 years of diagnosis, mostly in men aged 30—40 years. Chagas disease is caused by the protozoan parasite Trypanosoma cruzi, and the main insect vector in Brazil is Triatoma infestans, a haemophagic bug that lives mostly indoors. Infective forms of T cruzi are transmitted to human beings via the vector's faeces, entering through an individual's skin (at the point of a bite) or through mucosal membranes. Alternative routes of transmission are blood transfusions, mother-to-child transmission, and, very rarely, contaminated fresh foods. Until the 1970s, T cruzi transmission was intense in two-thirds of Brazil (18 states). At the end of the 1970s, an estimated 5 million people were infected with T cruzi,65 although only 2% of infections progress to the severe, chronic form of Chagas disease.66 An intensive vector control programme in Brazil, done in conjunction with other South American countries, eliminated the main vector of the disease and has thus interrupted vector-borne transmission since 2006.67 Transmission through blood transfusions was also interrupted through mandatory screening procedures.68 The seroprevalence of T cruzi infection in children younger than 5 years is presently 0·00005%, presumably a result of mother-to-child transmission before control measures were implemented.68, 69 The national programme for Chagas disease control is one of the clearest successes of Brazil's public health system. However, because of Chagas disease's long latency period, 3·5 million individuals in Brazil still have the chronic form of the disease, meaning that diagnosis and care of such individuals is a continuing burden on health services.70 Even so, mortality due to chronic Chagas disease (mostly due to myocardiopathy) is decreasing, and most deaths are among people older than 60 years.71, 72

Partly successful control

HIV/AIDS

The incidence of HIV-related illnesses has been stable in the past 5 years, with about 33 000 new cases registered every year.73 An estimated 600 000 people have HIV infection in Brazil, and the mean national seroprevalence is less than 0·6%.74 These estimates have been stable since 2000,74 and accord with population-based studies of the general population.75, 76 Although incidence of AIDS-related illnesses has decreased substantially in large urban areas, low-level transmission still occurs in municipalities of small and medium size,77 suggesting that resources for diagnosis and treatment in such municipalities are not sufficient and need to be increased.78, 79

A continuing challenge is to decrease, or at least prevent the increase, of transmission in vulnerable populations, such as men who have sex with men, injecting and non-injecting drug users, and commercial sex workers.80 Rates of HIV infection and other sexually transmitted infections are high in populations of men who have sex with men.80 The prevalence of HIV infection in injecting drug users has decreased substantially—from about 25% to 8%,81 presumably a result of prevention programmes implemented nationally since the mid-1990s (eg, syringe-exchange programmes, targeted condom distribution, and referral to treatment centres), and because many drug users have switched to non-injecting drugs, particularly crack cocaine.82, 83

Because Brazil operates the largest programme of free-of-charge, highly active antiretroviral therapy in the world, the emergence of resistance to many antiviral drugs was predicted.84 However, rates of infection with resistant strains have been consistently low, with a slow increase in resistance to first-line traditional drugs that is no higher than that seen in the USA or Europe.84

Free and universal access to antiretroviral treatment represents a formidable achievement by the health system in Brazil. However, the undeniable gains have been challenged by the slow but progressive increase of resistance and side-effects associated with most drugs, especially those associated with the long-term consequences of their continued use, such as metabolic (eg, insulin resistance and dyslipidaemias) and cardiovascular disorders.85 Brazil has tackled this challenge with a well structured treatment programme, and a diverse portfolio of drugs, providing locally produced first-line generic drugs at low cost, second-line drugs produced through compulsory licences (eg, efavirenz), and drugs under patent protection bought at discount prices from other countries. Costs of antiretroviral treatment have increased in the past 5 years, before which time the progressive introduction of locally produced generic drugs caused prices to decrease (figure 3).87

 

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Health spending by the Brazilian Government

*Estimated costs, based on preliminary data.86

HIV control efforts in Brazil include prevention of mother-to-child transmission (with provision of testing and prophylaxis in prenatal care) and treatment of children and adolescents with HIV/AIDS. The incidence of vertically transmitted infections has decreased over the past decade, but prenatal care is sometimes substandard and the introduction of prophylaxis can be delayed in some underserved neighbourhoods.88 Such drawbacks are partly compensated for by the country-wide use of rapid HIV-diagnostic tests for pregnant women in peripartum who are unaware of their serostatus.89 Substantial improvements have been made in survival and quality-of-life in children with HIV/AIDS.90

HIV/AIDS has been the subject of many campaigns that emphasise the need to practise safe sex and to seek prompt treatment. Such measures have had an effect on both incidence and mortality, which have decreased substantially over the past 15 years. Because mortality from and transmission of HIV/AIDS still occurs, we have categorised HIV/AIDS control efforts in Brazil as partly successful. However, such efforts have been as effective in Brazil as they have been in most developed countries.

Hepatitis A and B

In the past two decades there has been evidence of reduced transmission of hepatitis A and B,91—93 although this reduction has not been apparent in surveillance data.94 However, data from repeated seroprevalence surveys and from death registration show a decrease in both prevalence and mortality.91, 65, 96 A national survey of seroprevalence of viral hepatitis is being done in the 26 state capital cities and in the federal district (Brasilia), and will produce an accurate map of the prevalence of these infections by the end of 2011. Early findings from this survey in a large area of the country, including the northeast region, the centre-west region, and Brasilia,92 show an overall seroprevalence of hepatitis A in children aged 5—9 years of 41·4%, which is considered medium endemicity. Earlier surveys in the same areas noted high endemicity.97 Because hepatitis A vaccine is given to high-risk groups and not to healthy children, the decrease in prevalence rates among children was not the result of vaccination programmes, but rather of improvements in water supply and sanitation, and in hygiene and living conditions in general.

For hepatitis B, data for the same three regions show a seroprevalence of HBsAg of less than 1%,93 an improvement from earlier findings.98 Vaccination against hepatitis B has been part of the national basic vaccination schedule and given free at the point of use since 1989 in the western Amazon (the region with the highest prevalence of hepatitis B),99, 100 and rolled out in 2001 to the whole country as a routine schedule for children and adolescents. In the northeast and the centre-west regions, and in the Federal District (Brasilia city), the national hepatitis survey showed that 30% of people aged 10—19 years received at least one dose of the vaccine.93 A national vaccination survey had shown that for those younger than 1 year, coverage is 86·7%.101 To further reduce transmission and mortality, a policy was implemented in 2001 that defined the standard treatment regimens for chronic infection, with all drugs given free of charge.102

Leprosy

Leprosy is detected in every state of Brazil, but the highest detection rates are in the Amazon region and in a few urban centres in the northeast region; more than 50% of cases are reported in areas where 17·5% of the country's population lives.103 In 2006, the annual new-case detection rates per 100 000 population were 70·1 in the north region, 61·8 in the centre-west region, and 32·2 in the northeast region. Because the incubation period of leprosy is long, the geographical pattern of occurrence is related to historical transmission levels and other epidemiological determinants (eg, migration patterns), which are poorly understood.104

After the introduction of multidrug therapy, which is given free-of-charge to patients with leprosy by the SUS, the prevalence of leprosy in Brazil decreased substantially—from 180 cases per 100 000 population in 1988 to 26 cases per 100 000 population in 2008 (figure 4), with much reduction in disabilities associated with leprosy.106 However, during this period incidence rates changed little, with a case-detection rate in individuals younger than 15 years staying at about 7 cases per 100 000 population every year. This finding suggests that although efforts to control leprosy by identification and treatment of cases reduced disease prevalence, this strategy had little effect on reducing transmission. Identification of new ways to control leprosy (ie, interrupting transmission) are necessary, as is keeping leprosy as a world priority on the public health and research agenda to avoid waning of interest and financial support for research, prevention, and care.107, 108

 

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Prevalence and detection rate of Leprosy in Brazil105

Tuberculosis

During the 1980s, the incidence of tuberculosis was high, largely because of the high prevalence of HIV infection in the population. However, with the rollout of antiretroviral therapy programmes, tuberculosis incidence decreased from 51·4 cases per 100 000 person-years in 1990 to 38·2 cases per 100 000 person-years in 2007 (a 26% reduction)—mortality also decreased during this period, from 3·6 deaths per 100 000 person-years to 1·4 deaths per 100 000 person-years (a 32% reduction).109 However, pronounced regional differences in incidence of and mortality from tuberculosis exist, with larger incidences in states with higher prevalences of HIV infection, such as Rio de Janeiro, and in states with restricted access to health services, such as those in the Amazon region.110, 111 Pronounced socioeconomic differences in incidence and mortality also exist within urban areas.112 Although there are clear guidelines for tuberculosis diagnosis and treatment,113 delays from onset of symptoms to diagnosis and treatment still vary between and within regions, and reorganisation of the health-care system has not yet resulted in uniformly early diagnosis of tuberculosis.114

Completion of treatment is essential for tuberculosis control and is carefully monitored and reported in the SINAN database. 63% of patients are cured with complete treatment, but 8% of patients stop treatment before completion.109 These estimates, although improving, do not meet the Ministry of Health's targets of 85% and 5%, respectively, and are lower than needed to interrupt transmission.109

Because prevention of acquired resistance depends on early case finding and effective treatment, standardised treatment and the supply of drugs at no cost to the patient are crucial to avoid the development of resistance. In Brazil, multi-drug resistance seems to be largely associated with retreatment, probably because of irregular treatment schedules or patients' abandonment of treatment.115, 116 Of all individuals with tuberculosis in Brazil, an estimated 6·0% are infected with strains resistant to isoniazid and 1·4% are infected with strains resistant to both isoniazid and rifampicin.116—118 The prevalence of such resistant strains might decrease with a decision made in 2009 to change the first-line treatment regimen, introducing ethambutol as a fourth drug during the first 2 months of treatment and the use of one pill containing the four drugs.117 Extensive data for the prevalence of extensively drug-resistant tuberculosis are not available, but cases have been reported.119

The proportion of health services that offer directly supervised treatment increased from 7% in 2000 to 81% in 2006,120 although these seem to be reaching no more than a quarter of patients in treatment.121 Brazil has a very successful Family Health Programme, and there are plans to include tuberculosis monitoring in its activities, therefore extending the coverage of supervised treatment.

In the 1990s, 30% of individuals with HIV also had tuberculosis—this proportion decreased to 10% after the introduction of highly active antiretroviral therapy.110 Among tuberculosis patients attending health services for treatment, the proportion of individuals also infected with HIV is roughly 20%, but only half of patients with tuberculosis are routinely tested for HIV.122 The Ministry of Health now recommends the use of rapid diagnostic tests for HIV for all patients with tuberculosis in the first 2 weeks of treatment.123

Treatment of latent tuberculosis infection with isoniazid in adolescents and adults in Brazil is recommended.124 Treatment criteria are well defined, varying according to age and comorbidities that increase the risk for developing active tuberculosis (ie, HIV infection, diabetes, use of corticosteroids, etc). Assessment of the extent to which this recommendation is being implemented and its effect on tuberculosis control, treatment completion rates, and the occurrence of adverse events is not yet possible because it was implemented in only 2009, but either the Ministry of Health or other research teams will assess it in the future.124

Brazil has a prison population of about 400 000 individuals (227 prisoners per 100 000 population).125 The prevalence of active tuberculosis among prisoners in different studies has ranged from 2·5%126 to 8·6%,127 and a prevalence of 2·7% was recorded among inmates entering prisons from police remand centres.126, 128 Further studies are needed to assess the role of prisons in tuberculosis transmission and development of drug resistance in Brazil.

Schistosomiasis

The only schistosome species in Brazil is Schistosoma mansoni. In 1997, about six million people were infected.129 Different sources of data show a decrease in schistosomiasis occurrence and severity: from 1995 to 2006, the number of hospital admissions for complications of schistosomiasis per 100 000 population per year decreased from 21 to 4 (a reduction of 80%) and deaths per 100 000 population per year decreased from 0·38 to 0·27 (a reduction of 29%).130 Prevalence estimates from stool examinations in repeated surveys in large areas showed a decrease in positive detection rates from 8·4% in 1995 to 5·5% in 2006.130—132

Transmission requires specific freshwater snails as intermediate hosts and occurs mainly in the northeast region, in rural and poor peri-urban areas. The schistosomiasis control programme started in 1975 in Brazil, it was vertical and based on mass treatment. In 1993 the programme was decentralised to states, then to municipalities, and was eventually integrated into primary health care in 2007—10. Much of the reduction in schistosomiasis prevalence is attributable to improvements in access to clean water and sanitation, which has meant that individuals now have less contact with fresh water bodies; mass treatment is likely to have reduced severity of disease and could have contributed to decreased transmission.133, 134 A remaining challenge is to integrate specific control measures with more general measures (eg, expansion of the sewerage network) and to basic health care.131

Malaria

Malaria is a public health problem in Brazil, with roughly 300 000 new cases registered every year. Although still substantial, this incidence is much lower than it was in the 1940s and 1950s, when about 5 million new cases were registered every year.135—137 After implementation of the malaria eradication programme in the early 1960s, the yearly number of cases decreased rapidly, to a low in 1969, when 52 469 cases were reported in the Amazon region (figure 5),139 only to increase again as a result of a chaotic and rapid settlement process in the Amazon.135Plasmodium vivax accounts for more than 80% of cases and Plasmodium falciparum accounts for less than 20% of cases, unlike in 1960—88 when the prevalences of both species were much the same.140 The case-fatality rate for malaria—which has been less than 1% since 1960—decreased substantially in the past 10 years, possibly because of improved access to diagnosis and treatment, which are given free of charge. Standardised treatment protocols kept levels of drug resistance low, and much work has been done to develop new drugs (eg, artemisinin combination therapies).140

 

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Trends in the prevalence of malaria in the Amazon region, Brazil (1960—2008)138

99% (315 809 cases) of all malaria cases are reported in the legal Amazon area, where geographical, economic, and social factors facilitate transmission and limit the use of standard control measures. Malaria incidence is lower in rubber extraction areas, and higher in areas that were colonised in the past 10 years and open-air mining areas. Peri-urban areas also have high incidence, largely because of migration from failed agricultural settlements in malarious areas.135—137 Malaria transmission occurs in 67% of legal Amazon's municipalities; 49% have low endemicity (an annual parasite incidence [API] <10), 10% have moderate endemicity (an API of 10—50) and 8% have intense transmission (an API >50; figure 6).

 

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Malaria transmission in Brazil, 2008

High risk=annual parasite incidence (API) greater than 50 cases per 100 population.138 Medium risk=API between 10 and 50 cases per 100 population. Low risk=API less than 10 cases per 100 population.

Failures

Dengue fever

Dengue fever is a major public health problem in Brazil. Since 1986, incidence has increased with successive epidemics (figure 7),17, 18 and an increasing proportion of patients are presenting with severe disease (0·06% of patients in the 1990s rising to 0·38% in 2002—08).17 Three serotypes (DENV1—3) circulate throughout the country; DENV4 was isolated in the north region of Brazil in 2010.141 Three in four Brazilian municipalities are densely populated with A aegypti mosquitoes, the main vector of dengue fever.17 Between 2000 and 2009, 3·5 million cases of dengue fever were reported, 12 625 of which were dengue hemorrhagic fever, with 845 reported deaths.142 The annual incidence between 1986 and 2009 varied between 40 cases per 100 000 population and 400 cases per 100 000 population, with incidence peaking in 2008 and remaining stable since—a high proportion of severe cases are in children.17 The causes and mechanisms involved in progression from dengue fever to dengue hemorrhagic fever are not completely understood.18,143—145

 

Figure 7 Full-size image (84K) Download to PowerPoint

Incidence of dengue fever and number of municipalities with high a high density of Aedes aegypti mosquitoes, 1985—201017

Prospects for future control are not encouraging. Reduction in density of A aegypti, the most targetable link in the transmission chain, remains a challenge. Even with more than half a billion US dollars (about R$900 million) dollars invested by the government every year in vector control, vector densities low enough to effectively limit or reduce the spread of dengue fever have not been achieved in a sustained manner.146, 147 Such difficulties in controlling A aegypti populations also exist in other countries, such as Singapore, where A aegypti control is very efficient but dengue epidemics still occur.148 No safe vaccine is available and there is little prospect for one in the near future. During epidemics, public health efforts in Brazil are directed towards increasing awareness of symptoms to improve early presentation to health services and to enable early diagnosis and treatment of severe forms.

Visceral leishmaniasis

In Brazil, incidence of visceral leishmaniasis, also known as kala-azar, is high, with an average of two cases per 100 000 population per year. The increase in incidence and the expansion of transmission areas are both causes for concern. Nearly 70% of all cases of visceral leishmaniasis in South America are in Brazil, where the geographical reach of the disease is substantial—between 1999 and 2008, more than a third of Brazilian municipalities have reported autochthonous cases.149, 150 The disease has severe manifestations and is sometimes lethal in children. The case-fatality rate of visceral leishmaniasis in Brazil has varied between 3·2% and 6·9% in the past 10 years.151

Visceral leishmaniasis is a disease caused by the protozoan parasite Leishmania chagasi and is transmitted by phlebotomine sandflies. The transmission cycle of L chagasi, formerly restricted to rural areas, has changed since the 1980s, spreading to urban areas. Small, medium-sized, and large cities have been affected, including state capitals such as Teresina (in the northeast region), Belo Horizonte (in the southeast region), and Campo Grande (in the centre-west region).149, 150 Rapid urban expansion has brought domestic dog populations into contact with zoonotic cycles in rural areas and, as a consequence, they have become a major reservoir for the disease in the urban environment.149, 150 Furthermore, the main vector, Lutzomiya longipalpis, has adapted well to the peri-domiciliary environment.

Visceral leishmaniasis control in Brazil has focused on vector control and elimination of animals that are reservoirs for the disease, but available strategies and technologies have so far had little effect.51, 152 Available treatment for the disease is lengthy, expensive, and must be taken under medical supervision because it is highly toxic, limiting access, especially in isolated rural areas.

Conclusion

A pressing need exists to develop new treatments and vaccines for those diseases which have proved difficult to control. In Brazil, biomedical and epidemiological research is thriving,153, 154 as is public health research into infectious diseases, with much collaboration with developing and developed countries.155—158

Several major bottlenecks in public health research exist: biomedical and public health research centres are concentrated in the southeast region of Brazil, which does not have the highest burden of disease; administrative procedures are lengthy for the importation of research equipment; private companies invest little into research; little research in Brazil generates international patents or translates into implementable interventions such as new medicines, vaccines, and diagnostic kits.159

Further research is needed in the following areas: biomedical research for the development of vaccines, better treatments, fast diagnostics, and innovative vector-control methods; population based research to assess new technologies before adoption in the health system and to investigate the social determinants of diseases such as leprosy and tuberculosis; health-service research to develop and assess new strategies to deliver efficient diagnostics and treatment for chronic infectious diseases (such as HIV, tuberculosis, leprosy, and visceral leishmaniasis) or outbreaks of severe acute disease such as dengue fever.

The substantial reorganisation of the Brazilian health system has had notable effects on the structure and functioning of initiatives to control infectious diseases. The previous vertical control structure has been replaced by horizontal actions at the municipality level. Even though successful actions have been implemented by local administrations (eg, vaccination programmes and schistosomiasis and dengue control measures), the provision of support and expertise from the federal government and state administrations is crucial. For instance, the series of dengue fever epidemics in Brazil's major urban centres has repeatedly challenged the health system to provide quality care to a growing number of severe cases, to be managed in specialised units staffed by well-trained professionals. Maintenance of such channels of communication and help will require preparedness studies and pilot projects to address emergent questions and renewed challenges.

Another key issue is the need to harmonise broad social and economic policies and specific demands and needs for the effective control of infectious diseases. Since 1970, access to clean water has increased substantially, and in the past 10 years access to sewage systems has become a priority of public policies. The full attainment of such goals will be key to the sustainable control of faecal transmitted diseases.

In the past 10 years, cash transfer programmes for the neediest populations in Brazil have helped reduce poverty and, albeit only marginally, reduce social and economic inequalities for the first time in Brazil's history.12 More substantial improvements in education and actions to reduce socioeconomic inequalities might improve the control of diseases such as tuberculosis and leprosy. However, despite improvements recorded in the past decade, living conditions in urban slums create an ideal environment to maintain the transmission of many infectious diseases.160 Initiatives such as the Programa de Aceleração do Crescimento (PAC) have been implemented to provide such underserved areas with proper sewage, running water, health centres, and schools. But much remains to be done and local infrastructure remains far from acceptable in many parts of Brazil. Challenges for the future include further reduction of individual and regional differentials in wealth, improvement of infrastructure and social services, and further expansion of programmes that support better prevention and care. Furthermore, the fast growth in medical research in Brazil must be sustained—efforts must go towards identification of new treatments (eg, for leishmaniasis), new vaccines (eg, for dengue), and more effective ways to deliver specific care.

Contributions

All authors contributed to the planning, review of data and evidences and writing of this manuscript. All authors read and approved the final version.

Conflicts of interest

We declare that we have no conflicts of interest.

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a Instituto de Saúde Coletiva, Federal University of Bahia, Salvador, Brazil

b Fundação Oswaldo Cruz, Rio de Janeiro, Brazil, and Brown University, Providence, RI, USA

c Federal University of Pernambuco, Recife, Brazil

d Faculty of Medical Sciences, Santa Casa de São Paulo, São Paulo, Brazil

e London School of Hygiene and Tropical Medicine, London, UK

Corespondence to: Prof Mauricio L Barreto, Instituto de Saúde Coletiva, Federal University of Bahia, Rua Basilio da Gama s/n, Canela, 40110-040 Salvador-Bahia, Brazil

 

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