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In the twenty-first century, neglected tropical diseases still remain a serious public health problem, especially in developing countries. Meeting several sustainable development objectives of the 2030 Agenda, by countries that are in this condition, will provide the population with another level of quality of life. In Brazil, this situation is far from being resolved, since its dimensions are continental, there is a lot of social inequity, lack of basic services, health, and education. In this context, the scenario of the last 10 years of six neglected tropical diseases that are classified as notifiable in Brazilian territory is presented. There are several public policies established by the Federal government containing actions, strategies, and programs to try to reduce the burden of these diseases, but there is a lack of political will for states and municipalities to comply with the established in order to achieve all objectives and goals. It is still necessary to have an active participation of the population so that the reduction process can be started for possible elimination.
Lutheran University of Brazil (ULBRA), Canoas, Brazil
Eliane Fraga Da Silveira
Lutheran University of Brazil (ULBRA), Canoas, Brazil
Letícia Thomasi Janhke Botton
Lutheran University of Brazil (ULBRA), Canoas, Brazil
Eduardo Périco*
University of Vale do Taquari (UNIVATES), Lajeado, Brazil
*Address all correspondence to: perico@univates.br
1. Introduction
Neglected tropical diseases (NTDs) form a group of diseases caused by infectious agents or parasites and are considered endemic, occurring mainly among low-income and marginalized populations in tropical and subtropical regions of the world, mainly in Africa, Asia, and Latin America. These diseases disable or lead to the death of millions of people and represent an important medical need that remains unmet [1]. There are 20 groups of NTDs, of which 14 occur in Brazil, which lead, along with three other African countries, to the global distribution of these diseases [2, 3].
Brazil is the largest country in South America and is located between the parallels of 5o 16′20” North and 33o 45′03” South and the meridians of 34o 47′30″ and 73o 59′32” West. It is the fifth largest country in the world in land area with an extension of 8,515,767.049 km2. The country is cut by the Equator and Tropic of Capricorn, with most of its territory located in the lowest latitudes of the globe, which gives it characteristics of a tropical country [4].
The Brazilian geographical extension and diversity allow for a wide variety of climates. The main climate zones in the country are: Equatorial climate (Amazon region); Tropical climate (most of Brazil, especially in the central and coastal regions); Semi-arid climate (predominantly northeast Brazil); Subtropical climate (south of the country).
Brazil is considered a country susceptible to climate change due to deforestation, forest fires, loss of biodiversity, air and water pollution, disorderly urbanization, and impacts on coastal communities due to rising sea levels. In addition, Brazil faces challenges regarding the implementation of policies to mitigate and adapt to climate change. The Amazon and the Cerrado play an important role in regulating the global climate and maintaining biodiversity [4]. Regarding the diversity of fauna and flora, it is one of the most biodiverse countries in the world, home to a wide variety of ecosystems and species. Considered one of the largest tropical forests on the planet, the Amazon Rainforest is known for its great biological diversity. In addition, the Brazilian territory has other biomes such as the Cerrado, the Atlantic Forest, the Caatinga, the Pantanal, and the Pampas region. However, deforestation, urbanization, unsustainable exploitation of natural resources, pollution, and climate change are conditions that have altered Brazilian biodiversity. The conservation of these ecosystems and species is an important concern to guarantee the sustainability, the environmental balance in the country and to help in adequate environmental conditions to prevent the transmissibility of diseases [4].
In Brazil, there is a concentration of neglected diseases, and the implementation of public policies has been carried out in order to promote protection to the citizens. In this context, fundamental, human, and social rights and their respective guarantees, protections, and individual and collective rights are contemplated in the Constitution of the Federal Republic of Brazil [5]. Among its fundamental principles is that of human dignity, which is an autonomous normative force, with a multidimensional character [6]. In a logical-juridical-social analysis, social rights must have a solid relationship between the resources used and the effective capacity to achieve efficient results. These rights are materially made available to the Brazilian population, based on public policies, which are instruments that are used to safeguard the principle of human dignity [7]. One of the public health problems in Brazil is NTDs. The expansion of cases of these injuries is linked to the precariousness of other rights, subjectively guaranteed by the FC, such as basic sanitation, access to drinking water, and health services in an integral and universal way [8].
NTDs are diseases that receive little attention from the government and have less incentives in terms of research and investment in health, production of new drugs, training of professionals for early and correct diagnosis, adequate socio-environmental infrastructure, health education, and monitoring and vector control [1]. However, the signatory countries of the 2030 Agenda are committed to achieving the sustainable development goals, elaborated interdependently, and aimed at stimulating actions that meet human needs, access to rights, and basic services [9]. The reduction of epidemics caused by NTDs is among the goals of meeting the Sustainable Development Goals, whose disease prevention, expansion, and consolidation of vaccine coverage and access to correct treatment are priorities [10].
The control of NTDs involves actions aimed at involving public authorities, the local population, health professionals, and operational technicians who participate in the monitoring and reporting of diseases. This is necessary to obtain intersectoral work with broad engagement with the challenge of prevention and control and intervention in specific scenarios [10]. These efforts are essential for a strategic and coordinated response by developing countries to deal with the growing burden and threat of these diseases, especially in times of epidemic outbreaks. A common approach to the elimination of NTDs becomes paramount, as there are tools and technologies that make it feasible. It is necessary to promote integration and synergy between priority public health programs and primary health care centered on the local and regional community and on the health provisions offered to all [10].
Among the main NTDs are malaria, dengue, Chagas disease, leishmaniasis, and schistosomiasis, whose transmission patterns are influenced by socioeconomic, demographic, and environmental factors. These diseases impede economic development due to their direct and indirect costs, such as loss of productivity, for example. Unplanned urbanization, increased movement of people, environmental changes, and biological challenges, such as insecticide-resistant vectors, increase the risk of transmission, and allow the population to be exposed to emergency risk [11].
Health systems must be prepared to detect and respond to epidemiological changes in these diseases quickly and efficiently. This response requires not only the availability of effective and evidence-based control interventions but also health professionals and staff trained for this demand [11]. Most of these can be avoided based on a properly implemented control and prevention that optimizes programs and interventions aligned with the local and regional context, monitoring system, and population participation.
Brazil does not have specific legislation establishing a public policy whose main objective is the elimination and/or reduction of NTDs, but there are specific infra-constitutional laws that address them. Several strategies have been adopted and among the main public policies are:
Neglected Tropical Diseases Control Program: prioritizes the prevention and control of diseases such as Chagas disease, leishmaniasis, schistosomiasis, among others. It involves diagnosis, treatment, epidemiological surveillance, training of health professionals, and social mobilization.
Distribution of medicines: guarantee of free access to medicines for the treatment of NTDs distributed in health units.
Research and development: investment in scientific research for the development of new tests for diagnosis, drugs, and prevention.
Strengthening epidemiological surveillance: monitoring the occurrence and geographic distribution of NTDs in order to identify cases, investigate outbreaks, and implement control measures.
Despite the efforts of the Brazilian government, there are still challenges to be faced. The lack of adequate infrastructure in some regions, the difficulty of accessing remote areas, socioeconomic inequality, and lack of awareness among the population are obstacles to the effective control of NTDs. Continuous work is needed, involving integrated actions between different sectors of society, to reduce the incidence and improve the quality of life of the affected populations.
From an ecological, descriptive, and retrospective analysis, having NTD notifications as a universe, from 2012 to 2022, it was possible to establish the spatial and temporal scenario of six neglected tropical diseases (dengue, visceral leishmaniasis, malaria, schistosomiasis, Chagas disease, and leprosy) that affect the Brazilian population. For this, we used data obtained from the Unified Health System, DATASUS, in the public domain. (https://datasus.saude.gov.br/acesso-a-informacao/doencas-e-agravos-de-notificacao-de-2007-em-diante-sinan/). This system uses the files of the Notifiable Diseases Information System (SINAN) as a source, which enables the global and integrated analysis of information related to priority diseases in Brazil. Data from the local base is transferred between the different levels of management of the system, being distributed to the coordinators of each condition.
NTD incidence rates were calculated by sex and region, using the equation: number of notifications for NTDs divided by the total population size of the region ×100,000. Population data are in line with the 2022 census [12]. The maps were prepared in QGIS software, version 3.28.2 using the cartographic base of the Brazilian territory (state boundaries) provided by IBGE. After elaboration, they were edited in CorelDraw for better finishing. (https://www.ibge.gov.br/geociencias/organizacao-do-territorio/malhas-territoriais/15774-malhas.html).
The SINAN and IBGE databases, which are in the public domain, do not allow the identification of individuals. In this context, this study is based on Resolution No. 510/2016 of the National Health Council (CONEP), which establishes the non-mandatory analysis of ethics in studies that use secondary data and that are publicly available and do not provide information that identifies individuals (http://conselho.saude.gov.br/resolucoes/2016/reso510.pdf).
Brazil is the largest country in Latin America, with a population of around 214 million inhabitants and a density of 23.86 inhabitants/km2, in a territorial area of 8,510,417.771 km2 [12] (https://cidades.ibge.gov.br/brasil/panorama). The country borders nine countries in South America: Uruguay, Argentina, Paraguay, Bolivia, Peru, Colombia, Venezuela, Guyana, and Suriname, in addition to the French Overseas Department of Guyana. Politically and administratively, Brazil is divided into 26 states and a Federal District. The Federation is made up of five macro-regions (North, Northeast, Southeast, South and Midwest) and 558 micro-regions containing 5570 municipalities with different environmental and cultural characteristics (Figure 1).
Figure 1.
Brazil is geographically divided into five macro-regions. Center-West (DF: Distrito Federal, GO: Goiás, MT: Mato Grosso and MS: Mato Grosso do Sul); North (AC: Acre, AM: Amazonas, AP: Amapá´, RO: Rondônia and RR: Roraima); Northeast (AL: Alagoas, BA: Bahia, CE: Ceara´, MA: Maranhão, PB: Paraíba, PE: Pernambuco, PI: Piauí, RN: Rio Grande do Norte and SE: Sergipe); South (PR: Paraná, RS: Rio Grande do Sul and SC: Santa Catarina); Southeast (ES: Espírito Santo, MG: Minas Gerais, RJ: Rio de Janeiro and SP: São Paulo).
3. Space-time analysis of the main NTDs in Brazilian territory
According to data obtained from SINAN, between 2012 and 2020, a total of 10,455,616 individuals with an NTD were reported in the Brazilian territory. Among the diseases analyzed, dengue and leprosy had the highest number of reported cases (Table 1).
Macroregions
Malaria
Visceral leishmaniasis
Schistosomiasis
Dengue
Chagas disease
Leprosy
Total
North
0
5981
613
404,666
2681
87,258
501,199
Northeast
1273
19,416
11,349
2,018,979
100
192,054
2,243,171
Southeast
3228
6481
39,127
5,498,518
12
68,001
5,615,367
South
899
122
524
933,383
4
15,998
950,930
Center-West
1052
2854
632
1,984,431
12
89,351
2,078,332
Total
6452
34,854
52,245
9,906,594
2809
452,662
10,455,616
Table 1.
Number of people infected with neglected diseases by region in Brazil, between 2012 and 2022. (Source: SINAN, 2023).
Considering the NTDs among the regions of Brazil, dengue was the most notified in all regions of the country. The percentage of infected ranged from 80.7% in the North region to 98.1% in the South region. Chagas disease had the highest occurrence in the North region, although the frequency in the other regions was below 0.004%. Leprosy (17.4%) and visceral leishmaniasis (1.2%) were more frequent in the Northeast region. Malaria had a low frequency in all regions, and the absence of cases in the North is an indication of underreporting. Schistosomiasis was more prevalent in the Southeast (0.70%) and Northeast (0.51%) regions. The concentration of NTDs was higher in the Southeast region, with 53.7% of notifications, due to dengue notifications (5,498,518 cases) (Figure 2).
Figure 2.
Percentage of NTDs between regions of Brazil in the period from 2012 to 2022.
The profile of those affected, when considering the gender of the individuals, made it possible to identify that men are more prevalent in all NTDs, with the exception of dengue (Figure 3).
Figure 3.
Percentage of those infected notified by NTD group and sex, in the period 2012 and 2022, in Brazil.
From the calculated incidence rates for NTDs, by sex, in the different regions, it was observed that malaria affected men more (0.3–1.0/100,000 inhabitants.) in the Midwest region when compared to other regions. Visceral leishmaniasis had a higher incidence rate in men in all regions, but the Northeast (4.4/100,000 inhabitants.) and North (3.7/100,000 inhabitants) regions had the highest rates. Schistosomiasis occurred mainly in the Northeast and Southeast regions, with a higher incidence in males. Dengue is the disease with the highest incidence in all regions of the country, with greater prominence in the Midwest region with a rate of 1238.7/100,000 inhabitants in women. Females had higher incidence rates in all regions. Chagas disease had the highest number of records in the Midwest region, with a predominant incidence in males. Leprosy had the highest incidence rates in males in the Midwest and North regions (Figure 4).
Figure 4.
Incidence rate of neglected tropical diseases (NTD) in the regions of Brazil, between 2012 and 2022.
Among the forms of transmission of the diseases studied, four have vector transmission (dengue, visceral leishmaniasis, malaria, and Chagas disease) (Figure 5). Dengue was the NTD with the highest percentage in all regions, and transmission occurs through the bite of females of the Aedes aegypti species, popularly known as the dengue mosquito or black stilt. This vector is from the Culicidae family, with a wide distribution in the country and anthropophilic habits (depending on the human presence in the place to establish itself). The A. aegypti species is well adapted to urban areas, mainly in human homes [13]. Leprosy had the second highest prevalence among NTDs, and is a disease transmitted by continuous contact with infected people [14]. Schistosomiasis is a disease that is directly related to risk areas that have unfavorable sanitary conditions. The infective larvae are in bodies of water contaminated with human feces from carriers of Schistosoma mansoni which causes water belly or human schistosomiasis [15].
Figure 5.
Neglected tropical diseases (NTD), mode of transmission, and percentage of notifications in Brazil, between 2012 and 2022.
Brazil has specific federal public policies established for the control of NTDs and implemented in states and municipalities. These policies aim to prevent the transmission of disease, reduce the incidence of cases, and improve the quality of life of the population. It is important to emphasize that the strategies (Figure 6) used by the Brazilian government may vary according to the region and the epidemiological situation of each location [16, 17].
Figure 6.
Government actions for six NTDs in Brazilian territory.
The surveillance system is responsible for monitoring the occurrence of cases throughout the country, identifying areas of risk, prevalence, incidence, outbreaks, and adopting preventive and control actions. This involves data collection, analysis, and sharing of relevant information to guide strategies to combat these diseases [18]. The Notifiable Diseases Information System (SINAN) is a platform of the federal government for the dissemination of notified data in the national territory [16].
The government promotes health awareness and education campaigns, aiming to inform the population about the risks, prophylactic measures, prevention, and recognition of signs and symptoms. These campaigns are carried out through the media (radio, television, and internet), in addition to the distribution of educational materials and other social mobilization actions encouraging active participation in environmental care and the adoption of appropriate hygienic practices [19].
Vector control is one of the main strategies adopted. Actions include the elimination of breeding sites, larvicide and insecticide spraying actions, use of mosquito nets impregnated with insecticide, residential screens, and health education [11, 16].
The training of health professionals, both in the public and private networks, is an important strategy for early diagnosis and adequate treatment of cases. This includes training physicians, nurses, and other professionals in the field on clinical management protocols for these diseases [20].
The Brazilian Ministry of Health has implemented screening programs in blood banks, public agencies, and other strategic locations, with the aim of identifying infected individuals [21], performing early diagnosis, and offering adequate and free treatment [2]. Access to treatment is one of the main concerns of public policies.
Environmental management aims to reduce the number of sites conducive to the development of vectors/hosts. In addition, improving basic sanitation conditions is an important strategy for controlling NTDs. This reduces the exposure of the population to the risk of contamination [19].
Comprehensive care for patients with these diseases is necessary. This includes regular clinical follow-up, psychosocial support, rehabilitation, and disability prevention, as well as actions to promote social inclusion. In addition, the Ministry of Health provides medication free of charge, with the aim of reducing the progression of diseases and improving the quality of life of patients [20, 22].
Within the strategies designed for the monitoring and prevention of NTDs, the Federal Government has established some national programs:
National Dengue Control Program (Programa Nacional de Controle da Dengue - PNCD): prioritizes the reduction of infestation by Aedes aegypti; incidence and lethality due to dengue hemorrhagic fever. For this, it emphasizes some essential aspects such as: the elaboration of permanent programs; the development of information and mobilization campaigns; strengthening epidemiological and entomological surveillance; improving the quality of vector combat field work; the integration of dengue control actions in primary care, with the mobilization of the Community Health Agents Program (Pacs) and the Family Health Program (PSF) Programa Saúde da Família; the use of legal instruments that facilitate the work of public authorities; multisectoral action and the development of more effective instruments for monitoring and supervising the actions developed by the Ministry of Health, states, and municipalities [23].
Schistosomiasis Control Program (Programa de Controle da Esquistossomose - PCE): it was proposed with the aim of eliminating schistosomiasis as a public health problem. It provides morbidity control using early diagnosis, classification of risk areas, and treatment strategies for those affected in endemic areas. It also carries out health education activities and mobilization of communities at risk. In the environment, it performs the mapping of water collections, control of snails, and interventions in outbreaks of transmission with chemical control when indicated. They propose an interface and articulation with environmental agencies responsible for domestic and environmental sanitary conditions. In addition, it seeks to observe the scenario in endemic and non-endemic areas through the notifications of cases in SINAN [22].
National Leprosy Control Program (Programa Nacional de Controle da Hanseníase - PNCH): It aims to reduce the incidence of the disease, diagnose early, and provide adequate treatment. The program promotes epidemiological surveillance actions, training of health professionals, health education, multidisciplinary treatment, and social reintegration of patients [24].
National Leishmaniasis Surveillance and Control Program (Programa Nacional de Vigilância e Controle da Leishmaniose - PNVCL): It aims to control the transmission of leishmaniasis and reduce its morbidity and mortality. The program encourages epidemiological surveillance actions, early diagnosis, adequate treatment, vector control, and health education and canine vaccination actions in endemic areas [25].
National Malaria Control Program (Programa Nacional de Controle da Malária - PNCM): It aims to reduce morbidity and mortality caused by the disease, based on actions such as diagnosis, treatment, epidemiological surveillance, training of health professionals, and prevention actions [26].
NTDs affect the poorest and most disadvantaged people in tropical and subtropical regions of the world. The injuries can cause suffering and permanent disability of men, women, and children, resulting in generations condemned to illness and misery [27]. The scenario is challenging and requires an irrevocable commitment from countries to control NTDs and improve quality of life.
In Latin America, Brazil is the leader in the number of cases of Chagas disease, leishmaniasis, leprosy, dengue, and schistosomiasis, which is why they are classified as priorities by the Ministry of Health. The epidemiological picture shows the vulnerability of epidemic occurrences, the risk of increasing deaths and lethality [17].
In relation to priority health problems in Brazil:
Dengue: It is the most prevalent urban arbovirus in the Americas, and is an acute febrile viral disease, with seasonal, systemic, and dynamic characteristics, presenting a broad clinical spectrum, ranging from asymptomatic to severe cases. It occurs in environments with climatic and environmental conditions favorable to the development and proliferation of vectors (Aedes aegypti). Common characteristics of tropical and subtropical countries present local risk variations influenced by precipitation, temperature, and unplanned urbanization [23, 28]. This disease has epidemiological patterns, hyperendemicity of several serotypes of the virus, in addition to affecting the health of the population and the economies of countries that are unable to minimize or eliminate the disease. With this scenario, it has been observed that the burden on health services and their cost to countries has increased. The maintenance of the disease causes outpatient and hospital expenses, in addition to surveillance activities, vector control and population mobilization. The incidence of dengue has increased a lot all over the world, but the real number of cases of the disease is underreported and many are misclassified. Thus, the global burden of the disease remains uncertain [28]. Furthermore, early detection and access to adequate health services reduce mortality rates to below 1% [28].
The great challenge of the epidemiological scenario of dengue in Brazil, characterized by the simultaneous circulation of the four virus serotypes, is the work of assistance and surveillance. Urban arboviruses are similar in that they share several clinical signs. This has made it difficult for health professionals to adopt appropriate clinical management, which can progress to severe forms and eventual death [17].
Chagas disease: It is also known as American trypanosomiasis. It is a parasitic disease caused by the protist Trypanosoma cruzi, which is transmitted by an insect vector (kissing bug), blood transfusion, organ transplantation, consumption of contaminated food, or during pregnancy [29]. It is part of the NTD group, endemic in Latin America and has a high prevalence and morbidity and mortality burden, thus maintaining a critical cycle of vulnerability and representing one of the four major causes of death from infectious and parasitic diseases [30]. In 2020, chronic Chagas disease was defined as a nationally notifiable disease [31]. In this context, the need for an adequate social response is evident, based on the efforts of public authorities and health networks (Health Care Network – RAS Rede de Atenção à Saúde and the Unified Health System – Sistema Único de Saúde SUS) [32], in addition to the community participation in environmental care.
The prevention of Chagas disease is closely related to the form of transmission. The control of the disease must be through the elimination of the vector and quick access to health services for infected people. Vector control has been the most effective method of preventing and controlling the disease in Latin America and has a lower cost when compared to the amount spent on medical care for patients with cardiac, digestive, neurological, or mixed forms of the disease [33]. The determinants and conditions that contribute to the transmission of trypanosomatid are uncontrolled human migration, unplanned urbanization with population concentration and socio-environmental and economic vulnerability. These conditions generate inequalities that, for infected populations, result in greater risk [34]. Consequently, there is low quality in the Primary Health Care (PHC) services provided, difficulty in diagnosing, not guaranteeing the integration of patient care, and failures in preventive interventions. In this context, there is a probability of an increase in the development of severe forms of the disease. The lack of knowledge of health professionals and managers and the population about the risk conditions and identification of new cases, late diagnosis, and inopportune treatment help in the disease chronicity which causes significant sequelae, which may progress to death [33]. Knowing how to recognize the weaknesses of the Brazilian health system is necessary for greater control of the disease and the identification of epidemiological scenarios. This knowledge is essential for the effective success of effective and efficient management, surveillance, control, and health care strategies and actions [35]. The territorialization of both information and professional performance can be allies in improving public health. The demarcation of areas of activity in the Health Units, in addition to the integration of actions and practices of integral reception of the care for the carrier of Chagas disease, is necessary [34].
Schistosomiasis: It is an endemic parasitosis caused by Schistosoma mansoni that occurs in Brazilian territory with an important health impact on the affected populations in Brazil and worldwide. The conditions that contribute to the occurrence of the injury are places without sanitation or with inadequate basic sanitation, socioeconomic conditions, occupation, leisure, education, and population exposure to risk. The prevalence of parasitosis is also linked to the growth of urban centers, which leads to the establishment of human settlements in peripheral areas, lacking minimal sanitary infrastructure. This scenario creates conditions for the maintenance and transmission of the injury [36, 37]. The complex transmission mechanism of schistosomiasis, together with the different conditions for the cycle to occur, means that the control of the disease requires preventive actions such as: early diagnosis and adequate treatment; monitoring of environmental conditions favorable to transmission, the establishment of adequate basic sanitation and health education [36]. In this context, it is up to the municipalities and especially to the managers of both the Unified Health System and the other government sectors involved in environmental intervention and education actions to articulate themselves so that there is an effective and efficient control of schistosomiasis, in addition to carrying out, in an organized and regular manner, the active search for carriers and promoting timely treatment, in order to maintain low prevalence and reduce severe forms [37]. This work is necessary to contain the geographic expansion of schistosomiasis and the advance of the silent infection [36].
Leprosy: It is an infectious disease caused by the bacteria Mycobacterium leprae (Hansen’s bacillus) and transmitted by close and frequent contact with untreated infected people [38]. The disease can cause progressive and permanent sequelae, such as deformities and mutilations, reduced limb mobility and even blindness, when not treated at the onset of signs and symptoms [39].
In the Americas, Brazil has the highest burden of leprosy and the second highest in the world, being a public health problem. It is a treatable disease, which is curable, and early diagnosis and treatment are essential to avoid complications and reduce the chances of the affected person having a disability, and prevent transmission. Leprosy treatment is free [38].
The disease is associated with stigma, especially when deformities are present. This situation has a negative impact on access to diagnosis, on the outcome of treatment and care, in addition to violating civil, political, and social rights. Ending discrimination, stigma, and prejudice is essential for eliminating leprosy [38, 39, 40]. In order to minimize this problem, the Principles and Guidelines for the elimination of discrimination against people affected by leprosy and their families were established worldwide. These principles and guidelines make national governments responsible for eliminating discrimination related to it. Most endemic countries have made efforts to integrate leprosy care services into their health services [38, 40]. An important legislative and social landmark of leprosy was Ordinance No. 165/95, which established the Leprosy Control Policy prohibiting the terms “leprosy”, “leper” and derivatives [41]. The National Strategy for Combating Leprosy 2019–2022 seeks to guide services at all levels, considering the complexity of cases, in compliance with the principles of the Unified Health System, strengthening actions related to leprosy with the aim of promoting the promotion of health [33, 42]. To enhance these actions and strategies, the month of January was designated as the month of alert for leprosy and the color purple was defined. Brazil became the first country in the world to offer inputs in the public network for the detection of the disease, from the distribution of rapid tests to support the diagnosis of leprosy in the SUS [43].
Leishmaniasis: It is an infectious disease caused by parasites of the genus Leishmania, transmitted by the bite of sandflies, also known as sandflies or birigui. There are three main forms of leishmaniasis: visceral, cutaneous, and mucocutaneous [25]. This condition continues to be an important health problem in four eco-epidemiological regions of the world: Americas, East Africa, North Africa, West and Southeast Asia. It is among the top 10 NTDs, being endemic in 99 countries and its occurrence is directly related to poverty, social, environmental, and climatic factors, which directly influence its epidemiology [44].
In the Americas, leishmaniasis is zoonoses with notification of 85% of cases in three countries (Brazil, Colombia, and Peru). There is a situation that makes clinical and therapeutic management difficult and becomes more costly, which is Leishmania-HIV co-infection, already registered in 42 countries [44].
In Brazil, visceral leishmaniasis, also called kala-azar, is the most common (68%) and severe form of the disease and can be fatal if not properly treated. It is endemic in the North, Northeast, and Midwest regions [25, 44], but with cases registered in other parts of the nation. The profile change in the manifestation of visceral leishmaniasis was evidenced in all regions of the country by the predominance of its occurrence in urban areas [45].
Exposed persons should take measures to reduce contact with the vector and avoid exposure to areas with a high incidence of the disease [25, 46]. Euthanasia of the reservoir is not advised, as the dog is not responsible for transmitting the disease [45, 47]. Contributing to this, the Ministry of Health established, as a control tool for canine visceral leishmaniasis in the most affected municipalities, the distribution of collars impregnated with insecticide. In some regions of the country, testing on dogs has been adopted as another way to maintain monitoring [48]. In addition, health authorities must implement surveillance actions and, when necessary, carry out public health interventions, considering the standardized risk stratification for leishmaniasis. Early diagnosis is essential to establish adequate treatment, prevent disease progression, relieve signs and symptoms, reduce mortality, and improve patients’ quality of life [44].
It is important to emphasize that the control of leishmaniasis is complex due to the wide geographic distribution of the disease in a country with continental extensions. In addition, community participation and the integration of different sectors, such as health, environment, and agriculture, are essential for the success of public policies to control this disease [25]. In this context, Brazil performs risk stratification of municipalities with transmission based on the classification used by the Pan American Health Organization (PAHO). This stratification aims to direct and prioritize the planning, execution, and evaluation of municipal surveillance, prevention, and control actions in defined territories. The municipalities are stratified according to the transmission intensity (low, medium, high, intense, and very intense) [46].
Malaria: It is an infectious disease transmitted by the bite of the genus Anopheles mosquito infected with the Plasmodium parasite and presents a risk of death but can be prevented and cured. Plasmodium vivax and P. falciparum are the most common parasite species found in Brazil. P. vivax is the most prevalent and usually causes a milder form of the disease, while P. falciparum is responsible for the most severe and potentially fatal form of malaria [49, 50].
There is a risk of malaria in 18 countries, but the WHO certified Paraguay, Argentina, and El Salvador as malaria-free regions in 2018, 2019, and 2021, respectively [50]. In Brazil, malaria is considered a public health problem, although its impact has decreased significantly in recent decades. Its distribution is uneven, with a higher incidence in the Amazon region. The states of the Legal Amazon, such as Amazonas, Pará, Rondônia, and Acre, have the highest rates of cases. However, other states, such as Maranhão, Mato Grosso, and Tocantins, also register cases of the disease [49].
Malaria prevention involves several environmental strategies, early diagnosis, and adequate treatment of cases [51]. Over the years, Brazil created services, departments, and institutes that developed plans, actions, programs, and measures to interrupt the transmission of malaria [52]. As in 2000, when the Brazilian government established strategies to combat malaria such as creating: the Plan for Intensifying Malaria Control in the Legal Amazon, the Health Surveillance Secretariat and the National Malaria Control Program, the Epidemiological Surveillance Information System (Sivep-Malaria), the participation in the Global Fund Project, the Plan to Eliminate Falciparum Malaria and the observance of the Sustainable Development Goals. Actions include: broad coverage of free diagnoses and treatments; online computerized system; partnerships in various sectors and malaria research network. There are still challenges such as ensuring access of patients with this disease to the primary care, early diagnosis, and timely and adequate treatment in remote areas, updating professionals, special attention to indigenous and mining areas, and environmental surveillance aimed at elimination of the vector [52].
The reality of the epidemiological situation shows a decrease between 2019 and 2020 (7.8%). The territorial areas that need greater attention for the elimination of malaria are the North region, some foci in states in the Northeast and Midwest regions, in addition to micro foci in the Southeast and South regions. Thus, actions and strategies must be thought out in a sectoral way, in view of the incidence of transmission risk. It is important to emphasize that information about malaria in Brazil may vary over time, in addition to underreporting on SINAN/DATASUS and Sivep-Malaria (not in the public domain) [51].
NTDs must be a permanent public agenda in all countries affected by them. Its control is essential to improve the health and well-being of the most vulnerable populations, reduce health inequalities, and achieve the global goals of sustainable development. It is a matter of social justice and a global responsibility, as well as ensuring access to adequate healthcare. The justifications for establishing a permanent agenda are:
Public health impact: NTDs primarily affect the most vulnerable populations in low-income countries, resulting in high rates of morbidity and mortality. Control of these diseases is essential to reduce human suffering and improve the quality of life of those affected.
Cycle of poverty and inequality: NTDs have a negative impact on the health of affected communities, leading to lost productivity, inability to work, and increased health care costs. This can lead to a decrease in family income, limiting access to education, food, and other basic resources.
Barriers to Accessing Health Care: NTDs affect populations that are in areas where health services are limited. Controlling these diseases requires strengthening health systems, improving access to diagnostic services and adequate treatment. This contributes to the reduction of inequities in access to health care.
Potential for control and elimination: adequate control of NTDs in the country can contribute to global elimination, bringing benefits to regional and global public health.
Impact on sustainable development goals: NTD control is included in the goals of the SDGs linked to health promotion, poverty reduction, gender equality, and sustainable development.
Global warming and the Brazilian economic growth model characterized by the disorderly expansion of urban centers are some of the conditions for the maintenance of NTDs. These conditions, together with the low coverage of water supply and sanitary sewage infrastructure, added to the favorable climatic characteristics, establish a scenario that prevents, in the short term, the proposition of actions aimed at reducing the transmissibility and elimination of the diseases.
Brazil has an extensive territory with climatic variations, where the specificities of each region must be considered when proposing programs and action plans for NTDs, in order to prevent, reduce, monitor, and map these diseases in the country. For there to be a stagnation of this public health problem in the national territory, it is essential to have political will, and investments in basic infrastructure to improve the living conditions of communities in areas still deprived of these services. These actions must meet the demographic and cultural characteristics of the population and the peculiarities of each region.
The participative posture of the community, based on changing habits, practices, attitudes, and behaviors, together with the integration of government agencies, institutions and social organizations can promote strategies and actions for the prevention and adequate control of injuries, in each social context. It is worth emphasizing the government’s responsibility to delve deeper into the social, political, and economic determinants linked to the occurrence of endemic diseases and intervene appropriately in the control.
Brazil, in order to succeed in the individual and collective right to health, mainly regarding the reduction and prevention of NTDs, it is necessary to establish legislation that addresses them in a united way and groups by type of transmission to gather efforts and avoid waste of public investment by sectoring the illnesses. It is necessary to include NTDs in the Previne Brasil Program, which is financially stimulated by the Federal Government through the actions of municipalities regarding their performance in the Primary Health Care indicators. Monitoring the indicators means improving the quality of the service offered to the population and, in this context, the NTDs should be included in the same Program. It is worth noting the importance of efforts by states and municipalities in meeting these demands, as well as raising awareness and community participation.
Raising public awareness and strengthening public policies are essential for controlling and eliminating NTDs in Brazil. It is critical to keep policies up to date and adapted to changes in your epidemiology and emerging challenges.
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Written By
Nádia Teresinha Schröder, Eliane Fraga Da Silveira, Letícia Thomasi Janhke Botton and Eduardo Périco
Submitted: 20 July 2023Reviewed: 27 July 2023Published: 18 December 2023
Open access peer-reviewed chapter
