LECTURE #9 Pre-departure Lecture: Araçatuba and Jequitinhonha

1. Collaborative Course on Infectious Diseases January 2008 LECTURE #9 Pre-departure Lecture: Araçatuba and Jequitinhonha Jessé Alves and Tania Chaves jesse.alves@fleury.com.br tania.chaves@uol.com.br Harvard School of Public Health Faculdade de Ciências Médicas da Santa Casa de São Paulo Brazil Studies Program, DRCLAS, Harvard University

2. Objectives • Assess the most prevalent health risks based on local epidemiology • Provide information about health and disease prevention based on travel medicine practices

3. Basic travel medicine evaluation • Who • Health history, previous immunization, allergy • Where • Detailed information about itinerary, accommodation • When • Amount of time prior to departure, season, duration of trip • Why • Reasons for travel (vacation, work, study)

4. Vaccines • Required • Yellow fever • Routine • Updating missed doses and boosters • Recommended • Variable according to the trip and previous medical history (Hepatitis A, Typhoid fever, MMR, Rabies and Hepatitis B)

5. Other pre-travel recommendations • Protection against vector-borne diseases • Repellents • Risk from food and water (drinking and recreational activities) • How to eat and drink safely • Boiling, chemical disinfection, filters • Possible infections related to wading or swimming.

9. Southeast • Largest regional population (72,412,411)* • Most industrialized • São Paulo state is leader in health, social and educational development • Contrasts between different states and regions * 2000 census

11. Yellow fever shot. Why? • High morbidity and mortality • Recent changes in epidemiology • Epizootic transmission outside endemic area • Both Araçatuba and Jequitinhonha inside transition zone of transmission • Allow for the possibility of additional, unplanned travel

12. Yellow Fever Epidemiological status in Brazil, 2001 Endemic area 12 states Population:29,327,171 Transition area 7 states Population: 17,892,237 YF-Free area 8 states Population: 117,896,554 Source: FUNASA; adapted from Vasconcelos and cols., 2001

13. Human Yellow Fever areas Minas Gerais 2001 / 2002 / 2003 Primate occurrence - 2002 Serro Sabinópolis Santa Vitória Alvorada de Minas Pitangui Leandro-Ferreira Municipalities with cases of FA 2001/2003 Municipalities with cases of FA 2001/2003 and epizootic transmission Municipalities with cases of FA 2001/2003 Itaúna Municipalities with cases of FA 2001/2003 and epizootic transmission Divinópolis Municipalities with cases of FA 2001/2003 Source: FUNASA Area of epizootic transmission and yellow fever

14. Municipality of Jequitinhonha

15. Yellow fever - Brazil, 1990 - 2007* Endemic area Transition area Safe area Potencial risk area * Initial data Source: SVS/MS

16. Araçatuba region

17. Yellow Fever – epizootic transmission and human Cases, Brazil 1999 - 2006 Source: SVS/MS

19. Leishmaniasis • Transmitted by insects • Cutaneous and visceral diseases • Most cases reported in the North • Predominantly rural transmission • Urban cases in the Southeast and Northeast

20. Cases of cutaneous leishmaniasis 2003 - 2004 Source: SVS/DESP

21. Cutaneous leishmaniasis in Minas Gerais, 2006

22. Cutaneous leishmaniasis in Minas Gerais, 2002 to 2006

24. Wild reservoir Rattus rattus Nectomys squamipes Bolomys lasiurus

31. Visceral leishmaniasis in Minas Gerais, 2001 to 2006

32. Visceral Leishmaniasis Deadliness of visceral leishmaniasis in Brazil, 1994 to 2004 Source: SVS/MS

33. Schistosomiasis • Aquired through contact with fresh water • Still prevalent in Minas Gerais, Bahia and other NE states • Cause of acute and chronic disease and complications like portal hypertension syndrome

34. Endemic Areas of Schistosomiasis in Minas Gerais Concentrated Areas of Schistosomiasis in Minas Gerais Source: SVS/DVE/SES/MG

35. Deaths caused by Schistosomiasis in Minas Gerais, 1996 to 2004 Source: DATASUS/MS

36. Hospital admittances due to Schistosomiasis, 1994 to 2005 Source: DATASUS/MS

37. Fresh water exposure Women in Jequitinhonha river

38. Chagas disease • Vector-borne disease • High prevalence in Bahia, Minas Gerais, São Paulo, Goiás • Presently, low incidence among children and young adults • Changes in the epidemiology (food borne transmission)

39. Year # Municipalities Sample Size Positive Samples % Prevalence Chagas disease sero-prevalence among students in Minas Gerais Source: CCZ/DVE/SE/SES-MG

40. State Municipality Cases Deaths Death rate Transmission Transmitted by Acute Chagas disease, food acquired, 2007

43. Snakes, spiders, etc. • Accidents are rare among travelers • Most cases are reported in farm land • Pay attention while walking in the country

44. # accidents % Snake bites, by type

48. Coefficient of annual occurance of snake incidents per 100,000 inhabitants, by region of Minas Gerais State, 2001 to 2005 Source: CCZ/DVE/SE/SES-MG

49. Per 100,000 inhabitants * Partial data subject to change Coefficient of annual occurance of poisonous animal incidents per 100,000 inhabitants, Minas Gerais state, 1986 to 2004* Source: CCZ/DVE/SE/SES-MG

50. Incidence of snake bites in São Paulo state Source: CVE