Interciencia ISSN: 0378-1844 [email protected] Asociación Interciencia Venezuela

Palhano-Silva, Cassius S.; Araújo, Adauto J. G.; Lourenço, Ana E. P.; Bastos, Otílio M. P.; Santos, Ricardo V.; Coimbra Jr., Carlos E. A. INTESTINAL PARASITIC INFECTION IN THE SURUÍ INDIANS, BRAZILIAN AMAZON Interciencia, vol. 34, núm. 4, abril, 2009, pp. 259-264 Asociación Interciencia Caracas, Venezuela

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How to cite Complete issue Scientific Information System More information about this article Network of Scientific Journals from Latin America, the Caribbean, Spain and Portugal Journal's homepage in redalyc.org Non-profit academic project, developed under the open access initiative Intestinal Parasitic Infection in the Suruí Indians, Brazilian Amazon

Cassius S. Palhano-Silva, Adauto J. G. Araújo, Ana E. P. Lourenço, Otílio M. P. Bastos, Ricardo V. Santos and Carlos E. A. Coimbra, Jr.

SUMMARY

This study reports the results of a cross-sectional survey carried tively. Based on ELISA, the prevalence of E. histolytica infection out in 2005 to investigate the epidemiology of intestinal parasit- was 3.2%. The overall prevalence of intestinal infec- ism among the Suruí Indians, Brazilian Amazon. A total of 519 tions depicted in this study was surprisingly low compared to what stool samples were examined by zinc-sulphate-flotation and for- is often reported for other indigenous populations in the Brazil- mol-ether-sedimentation. Entamoeba histolytica/E. dispar-positive ian Amazon. It is argued that the prevalence of helminths in the samples were further tested by ELISA. Thirty-six percent of the Suruí are associated with anthelminthic mass treatment schemes subjects were positive for one more helminth species; 70.7% har- undertaken by the Indian health service, in the absence of other bored at least one protozoan species. The most frequent helminth measures. The authors propose that a special program aimed at was (29.5%). were rare (hook- controlling intestinal parasitism in indigenous communities should worm= 3.3%; Strongyloides stercoralis= 0.2%). Capillaria sp. was step beyond the top-down distribution of medication, but rather be identified in 5.2% of the samples and one case of parasitism by designed in collaboration with the target population, encompass- Dipylidium caninum was detected. Prevalence of Giardia duode- ing education, better housing, alternative sewage disposal systems nalis and E. histolytica/E. dispar was 16.2% and 12.3%, respec- and safe water supply to all villagers.

Introduction As for intestinal protozoans, of population mobility and mission of intestinal parasites prevalence rates of Entamoe- the adoption of new housing at high levels of endemicity Intestinal parasites are im- ba histolytica/E. dispar and architecture have been point- in these populations (Law- portant causes of morbidity of Giardia duodenalis infec- ed out as major drawbacks rence et al., 1980; Coimbra among indigenous peoples tions are variable and may of such changes, directly im- and Mello, 1981; Chernela of Amazonia. Most studies affect nearly one fourth of plicated in the intensification and Thatcher, 1989; Coimbra carried out among differ- the population (Lawrence et of transmission of intesti- and Santos, 1991b; Fitton, ent ethnic groups stress a al., 1980; Coimbra and San- nal parasites (Schwaner and 2000; Gómez et al., 2004). high prevalence of intestinal tos, 1991a, b; Ferrari et al., Dixon, 1974; Kroeger et al., If these factors might inten- nematode infections (ascari- 1992; Kroeger et al., 1992; 1992). Against a background sify parasite transmission, asis, , hookworms, Santos et al., 1995; Gómez of inadequate and the implementation of basic and ), often et al., 2004; Rivero et al., insufficient safe water supply sanitation associated with the affecting over half the vil- 2007). associated with sedentariza- widespread use of antihelm- lage population, and mod- Recent changes experienced tion, environmental contami- inthic drugs, often cheap and erate prevalence of cestode by indigenous peoples from nation of indigenous villages readily available in the health infections (mainly hymenole- Amazonia might greatly in- with infective protozoan cysts services, might help to reduce piasis). Cases of fluence the epidemiology of as well as eggs and/or larvae prevalence. have been rarely reported intestinal parasites in these of helminths rapidly builds up The present study was car- (Coimbra and Mello, 1981). communities. The curtailment and sustains year-round trans- ried out in the context of a

KEYWORDS / Amazonia / Epidemiology / Helminth Control / Intestinal Helminths / Intestinal Protozoa / South American Indians / Received 07/26/2008. Modified: 03/16/2009. Accepted: 03/17/2009.

Cassius S. Palhano-Silva. M.D., ences, Fundação de Amparo a fessor and Director, Centro Carlos E. A. Coimbra Jr. B.Sc. Universidade Federal do Estado Pesquisa do Estado do Rio de de Ciências Médicas, UFF, in Biology, Universidade de do Rio de Janeiro (UNIRIO), Janeiro, Brazil. Brazil. Brasília, Brazil. Ph.D. in Med- Brazil. M.Sc. in Public Health, Ana E. P. Lourenço. Nutrition- Ricardo V. Santos. B.Sc. in Bi- ical Anthropology, Indiana Escola Nacional de Saúde ist, Universidade Federal Flu- ology, Universidade de Brasí- University, USA. Professor, Pública (ENSP), Brazil. Re- miniense (UFF), Brazil. M.Sc. lia, Brazil. Ph.D. in Biological ENSP, Brazil. Address: Escola searcher, ENSP, Rio de Janeiro, in Public Health and doctoral Anthropology, Indiana Univer- Nacional de Saúde Pública, Brazil. student, ENSP, Rio de Janeiro, sity USA. Professor, ENSP, FI- FIOCRUZ, Rua Leopoldo Bu- Adauto J. G. Araújo. M.D., Brazil. OCRUZ and UNIRIO, Brazil. lhões 1480, Rio de Janeiro, UNIRIO, Brazil. D.Sc. in Otílio M. P. Bastos. M.D., UFF, RJ 21041-210, Brazil. e-mail: Public Health, ENSP, Brazil. Brazil. D.Sc. in Parasitology, [email protected] Professor, ENSP and Director Fundação Instituto Oswaldo of Medical and Health Sci- Cruz (FIOCRUZ), Brazil. Pro-

APR 2009, VOL. 34 Nº 4 0378-1844/09/04/259-06 $ 3.00/0 259 PARASITOSIS Intestinal En LOS INDIOS Suruí, AMAZONIA BRASILERA Cassius S. Palhano-Silva, Adauto J. G. Araújo, Ana E. P. Lourenço, Otílio M. P. Bastos, Ricardo V. Santos y Carlos E. A. Coimbra, Jr. RESUMEN

Se reportan los resultados de un estudio transversal llevado a 16,2% y 12,3%, respectivamente. Según ELISA la prevalencia de cabo en 2005 sobre la epidemiología del parasitismo intestinal infección por E. histolytica fue 3,2%. La prevalencia de infección en indios Suruí de la amazonia brasilera. Un total de 519 mues- por nematodos fue sorpresivamente baja en comparación con re- tras de heces fueron examinadas por flotación en sulfato de zinc portes frecuentes en otras poblaciones indígenas de la amazonia y sedimentación en etil-éter. Muestras positivas para Entamoeba brasilera. Se argumenta que los cambios en la prevalencia de hel- histolytica/E. dispar fueron testeadas por ELISA. Una o más es- mintiasis en los Suruí se asocian a tratamientos masivos con anti- pecies de helmintos estuvieron presentes en 36% de los sujetos y helmínticos llevados a cabo por el servicio de salud de indígenas, 70,7% presentaron al menos una especie de protozoario. El hel- en ausencia de otras medidas. Se propone que un programa espe- minto más frecuente fue Hymenolepis nana (29,5%). Los nemato- cial orientado a controlar el parasitismo intestinal en poblaciones dos fueron escasos (anquilostomo= 3,3%; Strongyloides stercora- indígenas debe desligarse de la distribución de medicación, sino lis= 0.2%). Se identificó Capillaria sp. en 5,2% de las muestras y ser diseñado en colaboración con los habitantes locales, abarcando se detectó un caso de parasitismo por Dipylidium caninum. Las educación, mejores viviendas y sistemas de drenaje y disposición prevalencias de Giardia duodenalis y E. histolytica/E. dispar fueron de residuos, y suministro de agua segura a todos los pobladores.

INFECÇÃO por PARASITOSES INTESTINAIS ENTRE OS ÍNDIOS SURUÍ, AMAZÔNIA BRASILEIRA Cassius S. Palhano-Silva, Adauto J. G. Araújo, Ana E. P. Lourenço, Otílio M. P. Bastos, Ricardo V. Santos e Carlos E. A. Coimbra, Jr. RESUMO

Este trabalho apresenta os resultados de um estudo seccional tivamente. Baseada no teste ELISA, a prevalência de infecção por conduzido em 2005 que visou investigar o perfil epidemiológico E. histolytica foi de 3,2%. A prevalência total de infecção intestinal das parasitoses intestinais entre os índios Suruí, localizados em por nematódeos demonstrada neste estudo foi surpreendentemente Rondôna, Amazônia brasileira. Um total de 519 amostras fecais baixa se comparada ao que tem sido geralmente reportado para foi examinado pelas técnicas de flutuação com sulfato de zinco e outras populações indígenas da Amazônia brasileira. Argumenta-se sedimentação com formol-éter. Amostras positivas para Entamoe- que a baixa prevalência de helmintos entre os Suruí está em larga ba histolytica/E. díspar foram posteriormente testadas pelo método medida associada a esquemas de tratamento em massa com anti- ELISA. Trinta e seis por cento dos indivíduos encontravam-se posi- helmínticos dispensados pelo serviço de saúde indígena. Os auto- tivos para pelo menos uma espécie de helminto; 70,7% abrigavam res propõem que um programa especial destinado ao controle de pelo menos uma espécie de protozoário. O helminto mais freqüente parasitoses intestinais em comunidades indígenas deve ir além da foi Hymenolepis nana (29,5%). Nematódeos foram raros (ancilosto- distribuição de medicamentos. Preferencialmente, deve ser planeja- mídeos= 3,3%; Strongyloides stercoralis= 0,2%). Capillaria sp. foi do em colaboração com a população alvo, considerando aspectos identificado em 5,2% das amostras e um caso de parasitismo por educacionais e visando a melhoria nas moradias e no sistema de Dipylidium caninum foi observado. As prevalências de Giardia duo- esgoto e de fornecimento de água. denalis e E. histolytica/E. dispar foram de 16,2% e 12,3%, respec-

rapidly changing Indian so- include the implementation of Population and Methods annual temperature is 24- ciety of southwestern Brazil- basic sanitation in the villag- 26ºC; lower temperatures are ian Amazonia that is highly es and primary health care. Fieldwork and setting recorded during the short dry exposed to Western medical As far as we are aware, the season (June-August) when services, the Suruí. The study present study is the first of Fieldwork was carried out average temperature ranges was designed to examine the its kind carried out in an in- between February and March between 20-22ºC (Nimer, prevalence of intestinal para- digenous Amazonian society, 2005 among the Suruí peo- 1979). sitism taking into consider- as it provides a diachronic ple of the Sete de Setem- At the time of fieldwork ation two important pieces of perspective in the interpreta- bro Indian reserve, on the the Suruí totaled 993 indi- information: a) according to tion of parasitological results border between the states of viduals (nearly 51% of the previous assessments of in- by comparing the present-day Rondônia and Mato Grosso, population was <15 years old) testinal parasitism carried out situation among the Suruí southwestern Brazilian Ama- distributed over 11 villages. in the Suruí, the prevalence with a previous survey. The zon (~60-61ºW and 10-12ºS). Nine villages, including the of major parasitic helminths study also aims at contribut- The landscape is dominated two largest ones, were sur- and protozoa was very high ing to the understanding of by inter-fluvial tropical rain veyed by the research team, (Coimbra and Mello, 1981; the epidemiology of intestinal forest and is crisscrossed by accounting for nearly 80% of Coimbra and Santos, 1991a); parasitism in indigenous pop- small to medium-size rivers. the total population. and b) in recent years the ulations in Amazonia in or- Annual rainfall in the state Physical examinations were population has been receiving der to assist in the design of of Rondônia presents a north- carried out by one of the au- systematic health care by the more effective and culturally- south gradient that varies thors (Palhano-Silva) at a Brazilian government, which sensitive control measures. from 2500 to 1750mm. Mean field clinic that was estab-

260 APR 2009, VOL. 34 Nº 4 lished in every village. No service in Cacoal for treat- was no refusal for physical ans was 70.7%. While the specific sampling technique ment. A single dose of examination (individuals who most affected age group by was used. An attempt was 400mg of was were not assessed were absent E. histolytica/E. dispar was made to examine all will- prescribed against nematode from the village during our that of adults >40 years old ing individuals of both sexes, infections, a single dose visit). Abdominal complaints (19.7%), for G. duodena- independent of age. At the of 5-10mg/Kg (such as pain, , nau- lis children 5-9 years were time of examination, a plas- against cestodes, and Met- sea and/or epigastralgia) were the most affected (28.8%). tic container marked with ronidazole 500-750mg three the most common symptoms, Helminths were detected in an identification number and times a day against proto- referred by 90% of the sub- 36.0% of the samples ex- the name of the person was zoan infections by G. duode- jects. Respiratory symptoms amined. Overall prevalence handed out along with in- nalis and/or E. histolytica/E. (mostly dry cough) and ar- of hymenolepiasis (i.e., H. structions about how to col- dispar infections, following thralgia were also common nana and/or H. diminuta) lect a stool sample. Samples standard dosages. complaints. No associations was 30.1%, with the highest returned next morning were This study is part of a between symptoms and in- prevalence observed in chil- split into two subsamples: broader project about the testinal parasitism were ob- dren 5-9 years old (51.0%). one was preserved with 5% health of Suruí Indians, served. The only nematodes detected formalin for examination by whose major focus is the Approximately 98% of Su- were hookworms (3.3%) and light microscopy and the oth- epidemiology of tuberculosis, ruí houses have walls made S. stercoralis (0.2%). It is er frozen at -20°C for ELISA but which also includes the of wood boards or bricks worth mentioning the absence testing. A household survey general health and nutritional (mixed constructions were of and aimed at characterizing Suruí assessment of the population observed). Cemented floors , often housing conditions and sani- (Basta et al., 2006; Orella- are present in 95.4% of the reported in previous surveys tation was also carried out. na et al., 2006). Guidelines houses. Roofs are often made of the kind. On the other Data collected included house for research in humans de- with simple zinc corrugated hand, the finding of two hel- structure (type of walls, roof, termined by the Brazilian sheets (77.0%); roofing tiles minth species not typically and floor), availability of san- National Committee on Re- were observed in 20.8% of reported in surveys carried itary facilities and sources of search Ethics (CONEP) of the houses. All households out in Amazonia should be drinking water. the Ministry of Health were referred the village well as highlighted. Twenty-eight followed. A research permit their major source of water subjects of various ages and Laboratory analyses was also obtained from the for domestic use. These wells both sexes presented Capil- National Indian Foundation were excavated by the In- laria sp. eggs in the stools Stool specimens were ex- (FUNAI). A consent form dian health service and usu- and the sample from one amined by zinc sulphate flo- was signed by the leaders ally have an electric pump adult woman was positive to tation and formol-ether sedi- of the surveyed villages. All in order to distribute water Dipylidium caninum. Consid- mentation techniques. One field procedures were under- to one or more public faucet ering the rarity of this find- slide was prepared from each taken in the company of a taps scattered throughout the ing, a new stool sample was stool sample processed by local Suruí health agent in- village. As for sewage dis- collected from this person each technique. Slides were dicated by the community, posal, collective pit latrines two months later and again independently examined by who helped explain the objec- installed by the Indian health proved positive to D. cani- two of the authors (Palhano- tives of the research plan and service are the rule and can num. No association between Silva and Bastos). The pres- acted as an interpreter when be seen in the back of almost prevalence of protozoan and/ ence of parasites was con- necessary. every house (93.8%) in all or helminth infection was firmed when eggs, cysts and/ villages. These are shallow discernible. Parasitism by or larvae were observed with Statistical analyses holes covered with a wooden more than one species of any of the two techniques. platform that has an opening helminth and/or protozoa In order to estimate E. Prevalence ratios were in the middle, encircled by was detected in 46.2% of the histolytica infection, sam- used to assess differences a rudimentary wall made of samples. ples kept in the freezer were in proportions between age wood boards painted white. For the three most frequent defrosted at room tempera- groups and sexes for the most Very few houses (6.0%) have parasite species found (Hyme- ture and used in a mono- prevalent helminths and pro- private indoor privies with a nolepis spp., G. duodenalis clonal ELISA essay for E. tozoans. P values <0.05 were flushing system. and E. histolytica/E. dispar), histolytica adhesin (Entam- considered statistically sig- A total of 519 stool sam- ratios of prevalence of in- oeba histolytica II -TechLab nificant and 95% confidence ples were processed, repre- fection between adults and Inc., Blacksburg, VA, USA). intervals were constructed senting 66.0% of the sub- children were constructed ELISA was performed only around estimates. All statis- jects who underwent physical (the ratio’s numerator indi- on those samples that tested tics were performed using examinations. Losses were cates the proportion of a giv- positive for E. histolytica/E. SPSS version 11 (SPSS Inc., determined by insufficient en infection in adults, while dispar under the micro- Chicago, IL, USA). stools turned in or by the the denominator indicates its scope. person’s inability to collect relative weight in children). Results any specimen within the Prevalence ratios for hyme- Management of patients and time-span given. nolepiasis and giardiasis were, ethics A total of 786 Suruí indi- Table I summarizes the respectively, 0.48 (95% confi- viduals of all ages and both findings for protozoa and dence interval: 0.34-0.68) Subjects diagnosed with sexes (79.2% of the total helminths by sex and age and 0.31 (95% confidence intestinal parasites were re- population in the visited vil- groups. The overall preva- interval: 0.18-0.54), indicating ferred to the Indian health lages) were examined. There lence of intestinal protozo- that children <10 years old

APR 2009, VOL. 34 Nº 4 261 Table I Prevalence rates of intestinal protozoa and helminths in the Suruí Indians, by sex and age groups, Brazilian Amazon (2005) Age n Eh/Ed Ec En Ib Gd Bc Bh Hkw Hn Hd Ss Cap Dc (years) Male 42 3 (7.1) 19 (45.2) 1 (2.4) - 9 (21.4) - 4 (9.5) 1 (2.4) 14 (33.3) 3 (7.1) - 1 (2.4) - 0-4 Female 52 2 (3.8) 17 (32.7) 8 (15.4) - 11 (21.2) - 3 (5.8) 2 (3.8) 11 (21.2) 3 (5.8) 1 (1.9) 1 (1.9) - Both 94 5 (5.3) 36 (38.3) 9 (9.6) - 20 (21.3) - 7 (7.4) 3 (3.2) 25 (26.6) 6 (6.4) 1 (1.1) 2 (2.1) - Male 64 8 (12.5) 42 (65.6) 15 (23.4) 1 (1.6) 16 (25.0) 1 (1.6) 7 (10.9) 3 (4.7) 36 (56.3) 6 (9.4) - 2 (3.1) - 5-9 Female 40 5 (12.5) 23 (57.5) 8 (20.0) 1 (2.5) 14 (35.0) - 4 (10.0) 2 (5.0) 17 (42.5) - - 1 (2.5) - Both 104 13 (12.5) 65 (62.5) 23 (22.1) 2 (1.9) 30 (28.8) 1 (1.0) 11 (10.6) 5 (4.8) 53 (51.0) 6 (5.8) - 3 (2.9) - Male 49 3 (6.1) 20 (40.8) 10 (20.4) 1 (2.0) 8 (16.3) - 4 (8.2) 1 (2.0) 14 (28.6) 2 (4.1) - 4 (8.2) - 10-19 Female 84 12 (14.3) 45 (53.6) 17 (20.2) 2 (2.4) 12 (14.3) - 3 (3.6) 3 (3.6) 27 (32.1) 1 (1.2) - 1 (1.2) - Both 133 15 (11.3) 65 (48.9) 27 (20.3) 3 (2.3) 20 (15.0) - 7 (5.3) 4 (3.0) 41 (30.8) 3 (2.3) - 5 (3.8) - Male 55 10 (18.2) 25 (45.5) 7 (12.7) 2 (3.6) 3 (5.5) - 7 (12.7) 4 (7.3) 9 (16.4) 3 (5.5) - 5 (9.1) - 20-40 Female 67 8 (11.9) 38 (56.7) 8 (11.9) - 7 (10.4) - 3 (4.5) - 14 (20.9) 2 (3.0) - 4 (6.0) 1 (1.5) Both 122 18 (14.8) 63 (51.6) 15 (12.3) 2 (1.6) 10 (8.2) - 10 (8.2) 4 (3.3) 23 (18.9) 5 (4.1) - 9 (7.4) 1 (0.8) Male 31 7 (22.6) 18 (58.1) 6 (19.4) 1 (3.2) 2 (6.5) - 2 (6.5) 1 (3.2) 7 (22.6) - - 3 (9.7) - >40 Female 35 6 (17.1) 20 (57.1) 9 (25.7) 2 (5.7) 2 (5.7) - 3 (8.6) - 4 (11.4) - - 5 (14.3) - Both 66 13 (19.7) 38 (57.6) 15 (22.7) 3 (4.5) 4 (6.1) - 5 (7.6) 1 (1.5) 11 (16.7) - - 8 (12.1) - Male 241 31 (12.9) 124 (51.5) 39 (16.2) 5 (2.1) 38 (15.8) 1 (0.4) 24 (10.0) 10 (4.1) 80 (33.2) 14 (5.8) - 15 (6.2) - Total Female 278 33 (11.9) 143 (51.4) 50 (18.0) 5 (1.8) 46 (16.5) - 16 (5.8) 7 (2.5) 73 (26.3) 6 (2.2) 1 (0.4) 12 (4.3) 1 (0.4) Both 519 64 (12.3) 267 (51.4) 89 (17.1) 10 (1.9) 84 (16.2) 1 (0.2) 40 (7.7) 17 (3.3) 153 (29.5) 20 (3.9) 1 (0.2) 27 (5.2) 1 (0.2) Eh/Ed: Entamoeba histolytica/ dispar, Ec: Entamoeba coli, En: Endolimax nana, Ib: Iodamoeba butschlii, Gd: Giardia duodenalis, Bc: Balantidium coli, Bh: Blastocystis hominis, Hkw: Hookworms, Hn: Hymenolepis nana, Hd: , Ss: Strongyloides stercoralis, Cap: Capillaria sp., Dc: Dipylidium caninum. constitute the most affected parasites observed in 2005 Discussion 1987 and 2005, the present age group for these parasitic with previous data collected and Conclusions study revealed a much higher diseases. The infection preva- in 1987 for Suruí children prevalence of hymenolepia- lence ratio for amoebiasis was <10 years old (Coimbra and The overall prevalence of sis. 1.83 (95% confidence inter- Santos, 1991a) that was ana- intestinal nematode infec- It is well established that val: 1.06-3.17), which shows lyzed by the same technique tions depicted in this study environmental contamination that this infection is almost and whose sample comprised was surprisingly low com- with infective parasite forms twice more frequent among 95% of the population in this pared to the 40-60% often (e.g., eggs, larvae, cysts) is adults than children. age group. There have been reported for other indigenous critical to the epidemiology A total of 64 E. histo­ly­ti­ sharp decreases in prevalence populations in the Brazil- of intestinal parasitism. For ca/E. dispar positive samples for most nematode species; ian Amazon (Chernela and this reason, housing and sani- under microscopy underwent frequencies dropping from Thatcher, 1989; Confalonieri tation play a key role in con- ELISA, 17 of which tested >60% to <5% for A. lum- et al., 1989; Salzano, 1990; trol strategies. Educational positive for E. histolytica. bricoides and hookworms. Coimbra and Santos, 1991b; interventions to promote bet- Therefore, based on ELISA Substantial decreases were Santos et al., 1995). Previous ter hygiene (e.g., food prepa- results, the prevalence of also observed in the preva- surveys carried out in the ration, clean water storage, E. histolytica infection in lence of S. stercoralis and Suruí (Coimbra and Mello, housekeeping) and periodic the population assessed was T. trichiura. Notwithstand- 1981; Coimbra and Santos, de-worming aimed at target 3.2%. These include individu- ing, while infection frequen- 1991a) revealed a completely populations (e.g., children) als of both sexes (53% males) cies dropped for all nematode different picture, more simi- are considered important sup- and all age groups. species, cestode (Hymenolepis lar to what most authors have plementary measures (Okun, Table II compares the spp.) prevalence increased found in other indigenous 1988; Albonico et al., 1999; prevalence of major intestinal from 19.4 to 39.4%. communities in Amazonia, Scolari et al., 2000; Asaolu i.e., high prevalence of infec- and Ofoezie, 2003; Urbani tion by A. lumbricoides, T. and Albonico, 2003; Sur et Table II trichiura and hookworms, al., 2005). Comparison of intestinal parasites with over 50% of the popu- Health services provided prevalence among Suruí children lation harboring at least one to indigenous peoples in Bra- under 10 years of age, 1987 and 2005 helminth species. These early zil have gone through major Year of Sample Eh/ Ed Gd Hn Hkw Ss Al Tt Ev surveys carried out among changes in the last decade. A survey size the Suruí also showed high new system, integrated with infection rates by S. sterc- the national unified health 1987 124 21.8 46.8 19.4 76.6 41.1 64.5 27.4 15.3 oralis (30%), the highest so system (known as SUS) was 2005 198 9.1 25.2 39.4 4.0 0.5 0.0 0.0 0.0 far reported for an indigenous initiated in 1999 (Garnelo et Eh/Ed: Entamoeba histolytica/E. dispar, Gd: Giardia duodenalis, Hkw: group in Amazonia. Interest- al., 2003). Primary care is to Hookworms, Hn: Hymenolepis nana, Ss: Strongyloides stercoralis, Al: As- ingly, when comparing data be dispensed at the village caris lumbricoides, Tt: Trichuris trichiura, Ev: Enterobius vermicularis. for children below age 10 in level by Indian health agents.

262 APR 2009, VOL. 34 Nº 4 Multi-professional health clear-cut intervals between transmission (Asaolu and sion have not been effectively teams provide continuous mass treatments are estab- Ofoezie, 2003; Corrales et eliminated in the Suruí. Pro- supervision, and patients in lished. The long-term chal- al., 2006). As shown in this tozoa species well known for need of further assistance are lenge, however, remains, since study, most Suruí families their role in determining seri- referred to Indian health clin- as it has been exhaustively have access to pit-latrines. ous gastrointestinal ailments ics (Casa de Saúde do Índio) demonstrated, re-infection is These are usually installed were detected during the or general hospitals in the likely to take place rapidly. outdoors, at the back of the study, and the presence of E. nearest town. Another aspect Drug mass therapy may re- houses, and are intended for histolytica in the population that has been emphasized is duce morbidity in the short collective use. Through obser- was confirmed by ELISA. village sanitation, focusing on run but it does not ensure vation and informal conversa- Although more severe forms the construction of pit-latrines sustained control of intesti- tions with Suruí villagers, of amoebiasis and giardiasis and collective wells. nal parasitism (Machado et however, one finds that these are rare, both E. histolytica Despite its many limita- al., 1996; Idris et al., 2001; are not always used (as is and G. duodenalis can cause tions (e.g., lack of personnel WHO, 2001; Beltramino et revealed by the dense grasses acute and persistent diarrhea and uncertain budget), the al., 2003; Zani et al., 2004). that often encircle the little and may be implicated in current system has facilitated This can only be achieved by latrines), with the excuse of nutrient malabsorption, lead- the access of Indian patients significantly reducing both fe- insufficient privacy, bad smell ing to growth and develop- to health services. A greatly cal contamination of the envi- and the constant nuisance of ment retardation (Lima and increased investment of re- ronment and human exposure flies. Guerrant, 1992; Farthing, sources from higher levels to potentially contaminated This study also revealed 2002; Gendrel et al., 2003). of the system to the local sources. Moreover, indepen- some further unusual parasi- This constitutes an issue of levels has produced at least dently of its practicality and tological findings that deserve concern since protein-energy one immediate result: village minimal risks for human sub- comment. The presence of malnutrition affect one-fourth health posts are stocked with jects, the indiscriminate dis- Capillaria sp. eggs in stools of Suruí children <10 years an unprecedented diversity tribution of antihelmintics to has been reported in other old and the prevalence of of drugs. Among these are Indian villagers can produce studies carried out among anemia in this age group is the antihelminthics. During at least one unwanted effect indigenous peoples in the 80% (Orellana et al., 2006). fieldwork it was found that in the long run: the emer- Amazon (Coimbra and Mel- Although the precise diag- the Suruí had been under a gence of resistant helminth lo, 1981; Santos et al., 1985, nosis of protozoal parasites mass treatment regime for at strains (Geerts and Gryssels, 1995; Carme et al., 2002). by conventional microscopy least the previous 18 months. 2001; Albonico, 2003). This has been interpreted as presents difficulties, enzyme According to the head nurse The efficacy of such unsys- resulting from transit eggs immunoassays and molecular of the local Indian health tematic distribution of anti- probably due to the recent techniques are not readily clinic in the city of Cacoal, helmintics can also be chal- ingestion of lightly cooked available in laboratory routine to where Suruí patients are lenged on the basis of its lack game liver. Among the Suruí by the Brazilian public health referred, the following bi- of specificity. Although this game liver is considered a service. annual regime was being survey identified hymenole- delicacy. True parasitism by A sustainable program for applied at the time: Al- piasis as the major helminth C. hepatica does not pass the control of intestinal par- bendazole 400mg single dose problem in the population, eggs in stools, and human asites in the Suruí should for adults and children ≥10 the drug regime prescribed intestinal parasitism by any consider alternative ways for years old, and Mebendazole by the Indian health service other species of Capillaria is environmental sanitation that 100mg twice daily during was clearly not adequate to unknown in South America take into account Suruí per- three days for children <10 eliminate cestodes (Amato- (Bhattacharya et al., 1999). ceptions about gastrointestinal years old. The regime was Neto et al., 1990; MeCraeken The finding of D. caninum disease, housing, personal repeated after one week. The et al., 1992; Horton, 2000; is rather unusual in surveys hygiene and environmental last de-worming campaign Juan et al., 2000). Over 30% carried out throughout Brazil health. Top-down approaches among the Suruí had been of the general population is and probably indicates close like those observed are un- carried out at all villages in infected with H. nana/H. human-dog contact (Marinho likely to produce long-lasting the semester previous to this diminuta and nearly 50% of and Neves, 1979). Suruí vil- results. A special consider- survey. the children <10 years old lages have countless free- ation should be given to chil- Unfortunately, it appears harbor the parasite. As noted roaming dogs, increasing the dren, since they tend to be that the ready availability by Mirdha and Samantray likelihood of human exposure more susceptible to gastroin- of unexpensive anti-parasitic (2002), the clinical and epi- to zoonotic helminths. testinal infection in general. drugs in Brazil, coupled with demiological importance of As already indicated, the For this reason, a sanitation the prevailing view among hymenolepiasis should not changing pattern in intestinal program should be designed health professionals that these be overlooked, especially in parasitic infections (especially in collaboration with the tar- are relatively safe and can be children, due to its implica- nematodes) among the Su- get population, encompassing administered with minimal tion in immunosuppression ruí is probably related to re- educational measures, better technical supervision, has led and flattered growth. cent interventions undertaken housing, an alternative sew- to the adoption of unsystem- Various authors have by the Indian health service age disposable system, and atic de-worming campaigns highlighted that it does not with a focus on mass che- safe water supply to all vil- by the Indian health service. necessarily follow that sim- motherapy. Notwithstanding, lagers. These measures will Usually, baseline surveys are ply increasing the number the high prevalence of intes- yield results far beyond the not conducted, which pre- of latrines in a community tinal protozoa infections in control of specific diseases or cludes the proper evaluation achieves a significant reduc- general clearly indicates that parasites, raising health stan- of the intervention, and no tion in the rate of parasite fecal-oral routes of transmis- dards more effectively.

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Osw. albendazole and praziquantel populations. In Swedlund AC, Cruz 76: 299-302. in the treatment of , Armelagos GJ (Eds.) Disease Rondônia, as well as the local Coimbra CEA, Santos RV (1991a) trichuriasis and hymenolepiasis in Populations in Transition: staff of the National Health Avaliação do estado nutricio- in children from Peru. Trans. Anthropological and Epide- Foundation (FUNASA) and nal num contexto de mudan- R. Soc. Trop. Med. Hyg. 96: miological Perspectives. Bergin the National Indian Founda- ça sócio-econômica: o grupo 193-196. and Garvey. New York, USA. tion (FUNAI) provided lo- indígena Suruí do estado de Kroeger A, Schulz S, Witte B, pp. 201-221. gistical support and advice. Rondônia, Brasil. Cad. Saúde Skewes-Ramm R, Etzler A Santos RV, Coimbra CEA, Ott Publ. 7: 538-562. 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