Brazil's large-scale, successful HIV/AIDS treatment programme is considered by many to be a model for other developing countries aiming to improve access to AIDS treatment. Far less is known about Brazil's important role in changing global norms related to international pharmaceutical policy, particularly international human rights, health and trade policies governing access to essential medicines. Prompted by Brazil's interest in preserving its national AIDS treatment policies during World Trade Organisation trade disputes with the USA, these efforts to change global essential medicines norms have had important implications for other countries, particularly those scaling up AIDS treatment. This paper analyses Brazil's contributions to global essential medicines policy and explains the relevance of Brazil's contributions to global health policy today.

BackgroundVisceral leishmaniasis is an emerging zoonosis and its geographic distribution is restricted to tropical and temperate regions. Most of the individuals infected in Latin America are in Brazil. Despite the control measures that have been adopted, the disease is spreading throughout new regions of the country. Domestic dogs are involved in the transmission cycle and are considered to be the main epidemiologic reservoir of Leishmania infantum (syn. L. chagasi). Our aim was to determine the prevalence of canine leishmaniasis (CL) and Ehrlichiosis infection in Presidente Prudente as well as the spatial dispersion of the disease in the western region of São Paulo state.MethodsDogs underwent clinical examination and symptoms related to CL were recorded. Anti-Leishmania antibodies were detected using ELISA, rK39-immunocromatographic tests (DPP), and an indirect fluorescent antibody test (IFAT). Anti-E. canis antibodies were detected by IFAT. A follow-up was conducted in dogs that were positive in the ELISA at the baseline study. Data on the spatial distribution of L. longipalpis and CL in São Paulo state were obtained from Brazilian public health agencies.ResultsSerum samples from 4547 dogs were analyzed. The seroprevalence of CL was 11.2 % by ELISA and 4.5 % by IFAT. In the follow-up, seroprevalence was 32.9 % by ELISA, 15.3 % by IFAT, 11.8 % by DPP test, and 66.5 % for E. canis. There was a significant positive association between Leishmania and E. canis infection (P < 0.0001). In the follow-up, clinical examinations revealed symptoms compatible with CL in 33.5 % of the dogs. L. longipalpis was found in 24 and CL in 15 counties of the Presidente Prudente mesoregion. The dispersion route followed the west frontier of São Paulo state toward Paraná state.ConclusionsLow CL and high ehrlichiosis prevalence rates were found in Presidente Prudente city. This emerging focus of CL is moving through the western region of São Paulo state toward the border of Paraná state. Integrated actions to fight the vector, parasites, infected dogs, and humans are needed to monitor the disease and implement strategies for epidemiologic control.

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Malaria in Bhutan has fallen significantly over the last decade. As Bhutan attempts to eliminate malaria in 2022, this study aimed to characterize the space–time clustering of malaria from 2010 to 2019. Malaria data were obtained from the Bhutan Vector-Borne Disease Control Program data repository. Spatial and space–time cluster analyses of Plasmodium falciparum and Plasmodium vivax cases were conducted at the sub-district level from 2010 to 2019 using Kulldorff’s space–time scan statistic. A total of 768 confirmed malaria cases, including 454 (59%) P. vivax cases, were reported in Bhutan during the study period. Significant temporal clusters of cases caused by both species were identified between April and September. The most likely spatial clusters were detected in the central part of Bhutan throughout the study period. The most likely space–time cluster was in Sarpang District and neighboring districts between January 2010 to June 2012 for cases of infection with both species. The most likely cluster for P. falciparum infection had a radius of 50.4 km and included 26 sub-districts with a relative risk (RR) of 32.7. The most likely cluster for P. vivax infection had a radius of 33.6 km with 11 sub-districts and RR of 27.7. Three secondary space–time clusters were detected in other parts of Bhutan. Spatial and space–time cluster analysis identified high-risk areas and periods for both P. vivax and P. falciparum malaria. Both malaria types showed significant spatial and spatiotemporal variations. Operational research to understand the drivers of residual transmission in hotspot sub-districts will help to overcome the final challenges of malaria elimination in Bhutan.

Visceral leishmaniasis (VL) is a neglected tropical disease transmitted by Lutzomyia longipalpis, a sand fly widely distributed in Brazil. Despite efforts to strengthen national control programs reduction in incidence and geographical distribution of VL in Brazil has not yet been successful; VL is in fact expanding its range in newly urbanized areas. Ecological niche models (ENM) for use in surveillance and response systems may enable more effective operational VL control by mapping risk areas and elucidation of eco-epidemiologic risk factors. ENMs for VL and Lu. longipalpis were generated using monthly WorldClim 2.0 data (30-year climate normal, 1-km spatial resolution) and monthly soil moisture active passive (SMAP) satellite L4 soil moisture data. SMAP L4 Global 3-hourly 9-km EASE-Grid Surface and Root Zone Soil Moisture Geophysical Data V004 were obtained for the first image of day 1 and day 15 (0:00-3:00 hour) of each month. ENM were developed using MaxEnt software to generate risk maps based on an algorithm for maximum entropy. The jack-knife procedure was used to identify the contribution of each variable to model performance. The three most meaningful components were used to generate ENM distribution maps by ArcGIS 10.6. Similar patterns of VL and vector distribution were observed using SMAP as compared to WorldClim 2.0 models based on temperature and precipitation data or water budget. Results indicate that direct Earth-observing satellite measurement of soil moisture by SMAP can be used in lieu of models calculated from classical temperature and precipitation climate station data to assess VL risk.

O Brasil é um país com extensa dimensão territorial e com acentuadas desigualdades socioeconômicas entre suas regiões, o que reflete diretamente no acesso à saúde, principalmente da população mais carente. O mesmo ocorre nos estados, como é o caso de Minas Gerais, com diversidade regional, com características sociais, econômicas e culturais variadas. Daí a importância de se promoverem estudos de cunho regional na tentativa de evidenciar as potencialidades e fragilidades que as regiões apresentam, para que, assim, as políticas públicas de saúde possam ser desenvolvidas com maior eficácia, possibilitando as autoridades sanitárias ações mais assertivas no combate a COVID-19. Em face a essa realidade, o presente artigo tem como objetivo apresentar uma reflexão sobre a situação epidemiológica da transmissão da covid-19 no norte de Minas Gerais, Brasil. Considerando que a pandemia de Covid-19 ainda não chegou definitivamente ao Norte de Minas, e que a relação leitos de UTI/população não é adequada, isso impõe ao Estado e às autoridades sanitárias da Região de Saúde tomar medidas urgentes para ampliar o número de leitos com respiradores para atender a demanda crescente que se espera, quando a região enfrentar o  pico da pandemia. Outra questão importante é que a hora de estabelecer medidas que imponham o isolamento social com mais rigor é agora, para achatar a curva de transmissão, antes que o número de casos da doença cresça e a situação fique fora de controle.

O Estado de Minas Gerais apresenta, diferentemente da maioria dos Estados brasileiros, um patamar de transmissão ainda baixo, porque suas principais cidades, Belo Horizontes, Uberlândia, Juiz de Fora, Contagem, Montes Claros não atingiram ainda o nível de transmissão da doença que pode colocar o Sistema de Saúde Pública em colapso, por falta de leitos de UTI, respiradores e equipamentos de proteção individual para os profissionais de saúde, como já se vê em Manaus, Belém, São Luiz, Fortaleza, Rio de Janeiro e São Paulo. O que se percebe é que, no início, a entrada do novo coronavírus no Estado seguiu o mesmo ocorrido nos demais Estados, desembarcando de avião na capital e nas cidades que tinham maior conectividade com a Europa, principalmente com a Itália, que era o epicentro da pandemia mundial nos meses de fevereiro e março de 2020. No início, a pandemia no Estado se manteve em níveis baixos porque as medidas de isolamento social foram suficientes para achatar a curva de transmissão. Mas, logo veio o crescimento da curva e o número de casos cresceu, porque o isolamento social foi enfraquecido pelos decretos municipais que flexibilizavam a quarentena e abria o comércio, mandando as pessoas para a rua. O momento agora é de apreensão, com o número de casos e óbitos por Covid-19 crescendo na capital e nas cidades médias polos regionais. No memento, o novo coronavírus está viajando de ônibus e de carro, das cidades polos regionais para as pequenas cidades do interior. A intensificação da transmissão nessas cidades pode ser catastrófica, porque nelas só tem a atenção básica à saúde, conforme diretrizes do SUS e elas se valem do sistema hospitalar de atenção secundária e terciária das cidades médias, que já estão chegando no limite de sua capacidade de leitos de UTI. Este trabalho tem por objetivo avaliar a situação epidemiológica e a Covid-19 no Estado de Minas Gerais, considerando a sua difusão pela rede urbana do Estado, a partir das cidades polos regionais.

When it comes to visceral leishmaniasis (VL) in Brazil, one of the main targets of public health policies of surveillance is the control of domestic canine reservoirs of Leishmania infantum. This paper aims to evaluate the effect of the dog population and household environment for the maintenance of natural foci in the transmission to human and animal hosts in an endemic city for VL, Bauru, in Brazil. We collected 6,578 blood samples of dogs living in 3,916 households from Nov.2019 to Mar.2020 and applied geospatial models to predict the disease risk based on the canine population. We used Kernel density estimation, cluster analysis, geostatistics, and Generalized Additive Models (GAM). To validate our models, we used cross-validation and created a receiver operating characteristic (ROC) curve. We found an overall canine VL (CVL) seroprevalence of 5.6% for the sampled dogs, while for the households, the positivity rate was 8.7%. Odds ratios (OR) for CVL increased progressively according to the number of canines for >2 dogs (OR 2.70); households that already had CVL in the past increased the chances for CVL currently (OR 2.73); and the cases of CVL increase the chances for human VL cases (OR 1.16). Our models were statistically significant and demonstrated a spatial association between canine and human disease cases, mainly in VL foci that remain endemic. Although the Kernel density ratio map had the best performance (AUC = 82), all the models showed high risk in the city’s northwest area. Canine population dynamics must be considered in public policies, and geospatial methods may help target priority areas and planning VL surveillance in low and middle-income countries.