Mortality and case fatality due to visceral leishmaniasis in Brazil: a nationwide analysis of epidemiology, trends and spatial patterns.
BACKGROUND
Visceral leishmaniasis (VL) is a significant public health problem in Brazil and several regions of the world. This study investigated the magnitude, temporal trends and spatial distribution of mortality related to VL in Brazil.


METHODS
We performed a study based on secondary data obtained from the Brazilian Mortality Information System. We included all deaths in Brazil from 2000 to 2011, in which VL was recorded as cause of death. We present epidemiological characteristics, trend analysis of mortality and case fatality rates by joinpoint regression models, and spatial analysis using municipalities as geographical units of analysis.


RESULTS
In the study period, 12,491,280 deaths were recorded in Brazil. VL was mentioned in 3,322 (0.03%) deaths. Average annual age-adjusted mortality rate was 0.15 deaths per 100,000 inhabitants and case fatality rate 8.1%. Highest mortality rates were observed in males (0.19 deaths/100,000 inhabitants), <1 year-olds (1.03 deaths/100,000 inhabitants) and residents in Northeast region (0.30 deaths/100,000 inhabitants). Highest case fatality rates were observed in males (8.8%), ≥ 70 year-olds (43.8%) and residents in South region (17.7%). Mortality and case fatality rates showed a significant increase in Brazil over the period, with different patterns between regions: increasing mortality rates in the North (Annual Percent Change--APC: 9.4%; 95% confidence interval--CI: 5.3 to 13.6), and Southeast (APC: 8.1%; 95% CI: 2.6 to 13.9); and increasing case fatality rates in the Northeast (APC: 4.0%; 95% CI: 0.8 to 7.4). Spatial analysis identified a major cluster of high mortality encompassing a wide geographic range in North and Northeast Brazil.


CONCLUSIONS
Despite ongoing control strategies, mortality related to VL in Brazil is increasing. Mortality and case fatality vary considerably between regions, and surveillance and control measures should be prioritized in high-risk clusters. Early diagnosis and treatment are fundamental strategies for reducing case fatality of VL in Brazil.
Department of Community Health, School of Medicine, Federal University of Ceará, Fortaleza, Brazil.
Francisco Rogerlândio
FR
Martins-Melo
Department of Community Health, School of Medicine, Federal University of Ceará, Fortaleza, Brazil.
Mauricélia da Silveira
Mda S
Lima
Department of Community Health, School of Medicine, Federal University of Ceará, Fortaleza, Brazil.
Alberto Novaes
AN
Ramos
Department of Community Health, School of Medicine, Federal University of Ceará, Fortaleza, Brazil.
Carlos Henrique
CH
Alencar
Department of Community Health, School of Medicine, Federal University of Ceará, Fortaleza, Brazil; Anton Breinl Centre for Public Health and Tropical Medicine, School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Australia.
Jorg
J
Heukelbach
D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001938:Brazil / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D005260:Female; D006306:Health Surveys; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007898:Leishmaniasis, Visceral / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D011634:Public Health; D012737:Sex Factors; D062206:Spatial Analysis; D055815:Young Adult