title: Malaria in Brazil: what happens outside the Amazonian endemic region.
abstract: Brazil, a country of continental proportions, presents three profiles of malaria transmission. The first and most important numerically, occurs inside the Amazon. The Amazon accounts for approximately 60% of the nation's territory and approximately 13% of the Brazilian population. This region hosts 99.5% of the nation's malaria cases, which are predominantly caused by Plasmodium vivax (i.e., 82% of cases in 2013). The second involves imported malaria, which corresponds to malaria cases acquired outside the region where the individuals live or the diagnosis was made. These cases are imported from endemic regions of Brazil (i.e., the Amazon) or from other countries in South and Central America, Africa and Asia. Imported malaria comprised 89% of the cases found outside the area of active transmission in Brazil in 2013. These cases highlight an important question with respect to both therapeutic and epidemiological issues because patients, especially those with falciparum malaria, arriving in a region where the health professionals may not have experience with the clinical manifestations of malaria and its diagnosis could suffer dramatic consequences associated with a potential delay in treatment. Additionally, because the Anopheles vectors exist in most of the country, even a single case of malaria, if not diagnosed and treated immediately, may result in introduced cases, causing outbreaks and even introducing or reintroducing the disease to a non-endemic, receptive region. Cases introduced outside the Amazon usually occur in areas in which malaria was formerly endemic and are transmitted by competent vectors belonging to the subgenus Nyssorhynchus (i.e., Anopheles darlingi, Anopheles aquasalis and species of the Albitarsis complex). The third type of transmission accounts for only 0.05% of all cases and is caused by autochthonous malaria in the Atlantic Forest, located primarily along the southeastern Atlantic Coast. They are caused by parasites that seem to be (or to be very close to) P. vivax and, in a less extent, by Plasmodium malariae and it is transmitted by the bromeliad mosquito Anopheles (Kerteszia) cruzii. This paper deals mainly with the two profiles of malaria found outside the Amazon: the imported and ensuing introduced cases and the autochthonous cases. We also provide an update regarding the situation in Brazil and the Brazilian endemic Amazon.
authors.affiliation: Centro de Pesquisa, Diagnóstico e Treinamento em Malária, Reference Laboratory for Malaria in the Extra-Amazonian Region for the Brazilian Ministry of Health, Instituto Oswaldo Cruz-Fiocruz, Rio de Janeiro, RJ, Brasil.
authors.forename: Anielle
authors.initials: A
authors.lastname: de Pina-Costa
authors.affiliation: Centro de Pesquisa, Diagnóstico e Treinamento em Malária, Reference Laboratory for Malaria in the Extra-Amazonian Region for the Brazilian Ministry of Health, Instituto Oswaldo Cruz-Fiocruz, Rio de Janeiro, RJ, Brasil.
authors.forename: Patrícia
authors.initials: P
authors.lastname: Brasil
authors.affiliation: Núcleo de Estudos em Malária, Superintendência de Controle de Endemias, Secretaria de Saúde do Estado de São Paulo, São Paulo, SP, Brasil.
authors.forename: Sílvia Maria
authors.initials: SM
authors.lastname: Di Santi
authors.affiliation: Programa Nacional de Controle da Malária, Secretaria de Vigilância em Saúde, Ministério da Saúde, Brasilia, DF, Brasil.
authors.forename: Mariana Pereira
authors.initials: MP
authors.lastname: de Araujo
authors.affiliation: Laboratório de Doenças Parasitárias, Instituto Oswaldo Cruz-Fiocruz, Rio de Janeiro, RJ, Brasil.
authors.forename: Martha Cecilia
authors.initials: MC
authors.lastname: Suárez-Mutis
authors.affiliation: Programa Nacional de Controle da Malária, Secretaria de Vigilância em Saúde, Ministério da Saúde, Brasilia, DF, Brasil.
authors.forename: Ana Carolina Faria e Silva
authors.initials: AC
authors.lastname: Santelli
authors.affiliation: Laboratório de Imunoparasitologia, Instituto Oswaldo Cruz-Fiocruz, Rio de Janeiro, RJ, Brasil.
authors.forename: Joseli
authors.initials: J
authors.lastname: Oliveira-Ferreira
authors.affiliation: Centro de Pesquisa, Diagnóstico e Treinamento em Malária, Reference Laboratory for Malaria in the Extra-Amazonian Region for the Brazilian Ministry of Health, Instituto Oswaldo Cruz-Fiocruz, Rio de Janeiro, RJ, Brasil.
authors.forename: Ricardo
authors.initials: R
authors.lastname: Lourenço-de-Oliveira
authors.affiliation: Centro de Pesquisa, Diagnóstico e Treinamento em Malária, Reference Laboratory for Malaria in the Extra-Amazonian Region for the Brazilian Ministry of Health, Instituto Oswaldo Cruz-Fiocruz, Rio de Janeiro, RJ, Brasil.
authors.forename: Cláudio Tadeu
authors.initials: CT
authors.lastname: Daniel-Ribeiro
mesh_terms: D000818:Animals; D000852:Anopheles / Q000145:classification*; D001938:Brazil / Q000453:epidemiology; D019353:Endemic Diseases; D062306:Geography, Medical; D006801:Humans; D007303:Insect Vectors / Q000145:classification*; D016778:Malaria, Falciparum / Q000453:epidemiology* / Q000635:transmission; D016780:Malaria, Vivax / Q000453:epidemiology* / Q000635:transmission; D014195:Travel