Health in Brazil 6 Health conditions and health-policy innovations in Brazil: the way forward

Brazil is a large complex country that is undergoing rapid economic, social, and environmental change In this Series of six articles, we have reported important improvements in health status and life expectancy, which can be ascribed largely to progress in social determinants of health and to implementation of a comprehensive national health system with strong social participation. Many challenges remain, however. Socioeconomic and regional disparities are still unacceptably large, reflecting the fact that much progress is still needed to improve basic living conditions for a large proportion of the population. New health problems arise as a result of urbanisation and social and environmental change, and some old health issues remain unabated. Administration of a complex, decentralised public-health system, in which a large share of services is contracted out to the private sector, together with many private insurance providers, inevitably causes conflict and contradiction. The challenge is ultimately political, and we conclude with a call for action that requires continuous engagement by Brazilian society as a whole in securing the right to health for all Brazilian people.

Barriers to interventions aimed at promoting the health of health care workers in Brazil

Objective. To search the literature for circumstances that impede injury and disease prevention and other activities intended to improve the health of the health care worker. Methods. The SciELO database was searched for articles published in 1967-2008. This was supplemented by a PubMed search for the period 1950-2008. The following key words were used to identify articles in English, Portuguese, and Spanish: work, health personnel, occupational, risks, diseases, ergonomics, work ability, quality of life, organization, accidents, work conditions, intervention, and administration. Articles on injury and disease prevention and occupational health in a health care setting in Latin America were selected, along with articles focused on health promotion in the health sector. Results. The following shortcomings were identified: activities lacked a sound theoretical foundation and were not integrated with the health services management; a failure to evaluate the effectiveness of the activity; health surveillance focused solely on a specific disease or injury; management not committed to the proposed activity; miscommunication; inability of workers to participate, or control the work environment; and, programs or efforts that were limited to changing the workers` behaviors. Conclusions. The literature shows that all the barriers identified by this study affect both the health care workers` health as well as their productivity.

Emergence of Klebsiella pneumoniae carrying the novel extended-spectrum beta-lactamase gene variants bla(SHV-40), bla(TEM-116) and the class 1 integron-associated bla(GES-7) in Brazil

A clinical Klebsiella pneumoniae isolate carrying the extended-spectrum beta-lactamase gene variants bla(SHV-40), bla(TEM-116) and bla(GES-7) was recovered. Cefoxitin and ceftazidime activity was most affected by the presence of these genes and an additional resistance to trimethoprim-sulphamethoxazole was observed. The bla(GES-7) gene was found to be inserted into a class 1 integron. These results show the emergence of novel bla(TEM) and bla(SHV) genes in Brazil. Moreover, the presence of class 1 integrons suggests a great potential for dissemination of bla(GES) genes into diverse nosocomial pathogens. Indeed, the bla(GES-7) gene was originally discovered in Enterobacter cloacae in Greece and, to our knowledge, has not been reported elsewhere.

Brazilian sugar cane bagasse ashes from the cogeneration industry as active pozzolans for cement manufacture

For proper management of wastes and their possible recycling as raw materials, complete characterization of the materials is necessary to evaluate the main scientific aspects and potential applications. The current paper presents a detailed scientific study of different Brazilian sugar cane bagasse ashes from the cogeneration industry as alternative cementing materials (active addition) for cement manufacture. The results show that the ashes from the industrial process (filter and bottom ones) present different chemical and mineralogical compositions and pozzolanic properties as well. As a consequence of its nature, the kinetic rate constant (K) states that the pozzolanic activity is null for the bottom ash and very low for the filter ash with respect to a sugar cane bagasse ash obtained in the laboratory under controlled burning conditions (reference). The scarce pozzolanic activity showed by ashes could be related to a possible contamination of bagasse wastes (with soils) before their use as alternative combustibles. For this reason, an optimization process for these wastes is advisable, if the ashes are to be used as pozzolans. (C) 2011 Elsevier Ltd. All rights reserved.

A study of the chemical and physical properties of cashew nut shell ash for use in cement materials.

A study of the chemical and physical properties of cashew nut shell ash for use in cement materials. Ash occupies a prominent place among agro-industrial wastes, as it is derived from energy generation processes. Several types of ash have pozzolanic reactivity, and might be used as replacement material for cement, resulting in less energy waste and lower cost. This work aimed to investigate the physical and chemical properties of the cashew nut shell ash (CNSA), by performing the following measurement tests: chemical analysis, bulk density, specific mass, leaching and solubilization process, X-ray diffraction (XrD), specific surface area (BET) and pozzolanicity analysis with cement and lime. The results indicate a low reactivity of CNSA and the presence of heavy metals, alkalis and phenol.

Induced seismicity in the Castarthao reservoir, NE Brazil - Preliminary results

The Castanhao reservoir was built in the state of Ceara, a dry region in Northeastern Brazil, to regulate the flow of the Jaguaribe River, for irrigation, and for power generation. It is an earth-filled dam, 60 m high, with a water capacity of 4.5 x 10(9) m(3). The seismicity in the area has been monitored since 1998, with a few interruptions, using one analog or one digital station and, during a few periods, a three-station network. The first earthquakes likely to be induced events were detected in 2003, when the water level was about 20 in high. In early 2004 a very heavy rainfall season quickly filled the reservoir. Shortly after, an increase in the seismic activity occurred and many micro-earthquakes were recorded. We suggest that this activity resulted from an increase in pore pressure due to undrained response. Therefore, we may classify this cluster of microearthquakes as ""initial seismicity."" We deployed a network with four analog stations in the area, following this activity, to determine the epicentral zone. At least three epicentral areas under the reservoir were detected. The spatio-temporal analysis of the available data revealed that the seismicity occurs in clusters and that these were activated at different periods. We identified four sets of faults (N-S-, E-W-, NW-SE-, and NE-SW-oriented), some of which moved in shallow crustal levels and as recently as the Quaternary (1.8 Ma). Under the present-day stress regime, the last two sets moved as strike-slip structures. We suggest a possible correlation between dormant faults and the observed induced seismicity. (c) 2008 Elsevier B.V. All rights reserved.

The occurrence of Laurencia marilzae (Ceramiales, Rhodophyta) in Brazil based on morphological and molecular data

Laurencia marilzae is recorded for the first time from the western Atlantic Ocean; it was found in Laje de Santos Marine State Park, Sao Paulo, southeastern Brazil. The specimens were collected in the rocky subtidal zone from 7 to 15 m depth. The most distinctive characteristic of this species is the presence of corps en cerise in all cells of the thallus, including cortex, medulla, and trichoblasts. The phylogenetic position of the species was inferred by analysis of the chloroplast-encoded rbcL gene sequences from 43 taxa, using two other rhodomelacean taxa and two members of the Ceramiaceae as outgroups. Within the Laurencia assemblage, L. marilzae from Brazil and from the Canary Islands ( type locality) formed a distinctive lineage sister to all other Laurencia species analyzed. Male plants are described for the first time. This study expands the geographical distribution of L. marilzae to the western Atlantic Ocean.

Phylogenetic relationships in Kumanoa (Batrachospermales, Rhodophyta) species in Brazil with the proposal of Kumanoa amazonensis sp nov.

This Study evaluated the species-level taxonomy and phylogenetic relationship among Kumanoa species from Brazil with other regions of the world based on the plastid-encoded RUBISCO large Subunit gene (rhcL). Partial rbcL sequences were obtained for 11 Kulnanoa specimens. Eight species are recognised from Brazil on the basis of molecular and morphological data: seven previously described (K abilii, K ambignia, K. breviarticulata, K. cipoensis, K. equisetoidea, K. globospora and K procarpa) and a new species here proposed (K. amazonensis sp. nov. Necchi & Vis). The new species has reduced and dense whorls but differs from the two closest related species in lacking secondary fascicles. Previously proposed infrageneric categories were not supported by the molecular data. Species described and endemic (K. breviarticulata, K. cipoensis, K equiseloidea and K. procarpa) to Brazil are not grouped together but are variously related to other species from North America, Europe and Australasia. With the species recognised in this study using molecular and morphological data and those previously distinguished by morphology, 13 species of Kumanoa are Currently documented from Brazil.

PODOCARPUS SP.PL. REFUGIA IN BRAZIL`S ATLANTIC FOREST: ANALYSING THE PAST TO IMPROVE FUTURE PROTECTION

The Atlantic rainforest has the second highest biodiversity in Brazil. It has been shrinking rapidly in area as a result of intensive deforestation, and only 7% of the original cover now remains, as isolated patches or in ecological reserves. In order to obtain new information on the distribution of the Atlantic rainforest during the Quaternary, we examined herbarium data to locate relevant populations and extracted DNA from fresh leaves from 26 populations. The present-day distribution of endemic Podocarpus populations shows that they are widely dispersed across eastern Brazil, and that the expansion of Podocarpus recorded in single Amazonian pollen records may have originated from either western or eastern populations. Genetic analysis enabled us to determine the boundaries of their regional expansion: northern and central populations of P. sellowii appeared between 5 degrees and 15 degrees S some 16,000 years ago; populations of P lambertii or sellowii have appeared between 15 degrees and 23 degrees S at different times since the last glaciation at least; and P lambertii appeared between 23 degrees and 30 degrees S during the recent expansion of Araucaria forests. The combination of botanical, pollen, and molecular analyses proved to be a rapid means of inferring distribution boundaries for sparse populations and their regional evolution within tropical ecosystems. Today the rainforest refugia we identified have become hotspots that are crucial to the survival of the Atlantic forest under unfavourable climatic conditions and, as such, offer the only possible opportunity for this type of forest to expand in the event of future climate change.

Chemical Communication in the Gregarious Psocid Cerastipsocus sivorii (Psocoptera: Psocidae)

The objectives of this study were: (1) to test the existence of an aggregation pheromone in the gregarious psocid Cerastipsocus sivorii; (2) to compare the attractiveness of odors from different aggregations; (3) to test whether nymphs are able to chemically recognize damage-released alarm signals. In a choice experiment conducted in the laboratory, we showed that psocids are able to detect chemical cues from groups of conspecifics. Laboratory experiments also showed that nymphs are capable of chemically recognizing the aggregations where they came from. Finally, in a field experiment, most aggregations dispersed when exposed to the body fluids of a crushed conspecific, but no aggregations dispersed upon exposure to a crushed termite. The implications of these results for the evolution of sociality in psocopterans are discussed.

How does a riverine setting affect the lifestyle of shellmound builders in Brazil?

The contact of inland and coastal prehistoric groups in Brazil is believed to have been restricted to regions with no geographical barrier, as is the case in the Ribeira de Iguape valley. The inland osteological collection from the riverine shellmound Moraes (5800-4500 BP) represents a unique opportunity to test this assumption for this region. Despite cultural similarities between riverine and coastal shellmounds, important ecological and site distribution differences are expected to impact on lifestyle. The purpose of this study is thus to document and interpret health and lifestyle indicators in Moraes in comparison to coastal shellmound groups. Specifically we test if the rare evidence of fish and mollusc remains in the riverine shellmound led to (a) higher caries rates and (b) lower auditory exostosis frequency and (c) if the small size of the riverine shellmound translates into reduced demographic density and thus rarity of communicable infectious diseases. Of the three hypotheses, (a) was confirmed, (b) was rejected and (c) was partly rejected. Bioanthropological similarities between Moraes and coastal shellmounds include auditory exostoses with equally high frequencies; significantly more frequent osteoarthritis in upper than in lower limbs; cranial and dental morphological affinities and low frequencies of violent trauma. However, there are also important differences: Moraes subsisted on a much broader protein diet and consumed more cariogenic food, but showed a stature even shorter than coastal groups. Thus, despite the contact also suggested by treponematoses in both site types, there was enough time for the people at the riverine site to adapt to local conditions. (c) 2008 Elsevier GmbH. All rights reserved.

The Genetics of Alzheimer`s Disease in Brazil: 10 Years of Analysis in a Unique Population

Alzheimer`s Disease (AD) is the most common type of dementia among the elderly, with devastating consequences for the patient, their relatives, and caregivers. More than 300 genetic polymorphisms have been involved with AD, demonstrating that this condition is polygenic and with a complex pattern of inheritance. This paper aims to report and compare the results of AD genetics studies in case-control and familial analysis performed in Brazil since our first publication, 10 years ago. They include the following genes/markers: Apolipoprotein E (APOE), 5-hidroxytryptamine transporter length polymorphic region (5-HTTLPR), brain-derived neurotrophin factor (BDNF), monoamine oxidase A (MAO-A), and two simple-sequence tandem repeat polymorphisms (DXS1047 and D10S1423). Previously unpublished data of the interleukin-1 alpha (IL-1 alpha) and interleukin-1 beta (IL-1 beta) genes are reported here briefly. Results from others Brazilian studies with AD patients are also reported at this short review. Four local families studied with various markers at the chromosome 21, 19, 14, and 1 are briefly reported for the first time. The importance of studying DNA samples from Brazil is highlighted because of the uniqueness of its population, which presents both intense ethnical miscegenation, mainly at the east coast, but also clusters with high inbreeding rates in rural areas at the countryside. We discuss the current stage of extending these studies using high-throughput methods of large-scale genotyping, such as single nucleotide polymorphism microarrays, associated with bioinformatics tools that allow the analysis of such extensive number of genetics variables, with different levels of penetrance. There is still a long way between the huge amount of data gathered so far and the actual application toward the full understanding of AD, but the final goal is to develop precise tools for diagnosis and prognosis, creating new strategies for better treatments based on genetic profile.

The genus Prosphaerosyllis (Polychaeta: Syllidae: Exogoninae) in Brazil, with description of a new species

In studies carried out off the north-eastern and south-eastern coast of Brazil, three species of Prosphaerosyllis were found: P. isabellae, which was already recorded for Brazilian waters; P. xarifae, a newly recorded species for the area; and P. brachycephala sp. nov., a new to science species. Prosphaerosyllis brachycephala sp. nov., is characterized by having swollen anterior part of the body, prostomium retractable within the peristomium and anterior segments, short antennae, short peristomial and dorsal cirri, and falcigers with short, unidentate blades throughout. All these species are herein described and compared to the most similar congeners.

Molecular characterization of human erythrovirus B19 strains obtained from patients with several clinical presentations in the Amazon region of Brazil

Background: Human erythrovirus B 19, endemic in the Amazon region since 1990, is associated with a wide spectrum of clinical presentations. Objectives: To assess the prevalence of erythrovirus B 19 infection and the relative frequency of erythrovirus B 19 genotypes in patients in the Amazon region with various clinical presentations. Study design: A total of 487 clinical samples obtained from patients with symptoms suggestive of erythrovirus infection were tested using specific IgM and IgG antibody assays (ELISA) and PCR for viral DNA detection. Partial VP1 and VP2 regions were sequenced and genotyped by phylogenetic reconstruction. Results: B 19 DNA was detected in 117 (24%) of 487 samples. Of these, 106 (91%) isolates were genotype I and II (9%) were genotype 3. No genotype 2 was found. Genotype I had three clusters (A1, A2 and 13) and all genotype 3 sequences were subtype 3b. All patients with hernatological disorders within cluster B of genotype I were infected by the sarne B 19 lineage, suggesting that this lineage of B 19 may have been transmitted via transfusion of blood products. Conclusion: We reported two genotypes, I and 3b, with three genotype I clusters co-circulating in the Amazon region during the past 10 years. (C) 2008 Elsevier B.V. All rights reserved.

The Challenges of Antimicrobial Resistance in Brazil

Brazil is a country with continental proportions with high geographic and economic diversity. Despite its medical centers of excellence, antimicrobial resistance poses a major therapeutic challenge. Rates of methicillin-resistant Staphylococcus aureus are up to 60% and are related to an endemic Brazilian clone. Local resistance to vancomycin in Enterococci was first related to Enterococcus faecalis, which differs from European and American epidemiology. Also, local Klebsiella pneumoniae and Escherichia coli isolates producing extended-spectrum beta-lactamases have a much higher prevalence (40%-50% and 10%-18%, respectively). Carbapenem resistance among the enterobacteriaceae group is becoming a major problem, and K. pneumoniae carbapenemase isolates have been reported in different states. Among nonfermenters, carbapenem resistance is strongly related to SPM-1 (Pseudomonasaeruginosa) and OXA-23 (Acinetobacter baumannii complex) enzymes, and a colistin-only susceptible phenotype has also emerged in these isolates, which is worrisome. Local actions without loosing the global resistance perspective will demand multidisciplinary actions, new policies, and political engagement.