title: Spatial and temporal epidemiology of malaria in extra-Amazonian regions of Brazil.
abstract: BACKGROUND
  Mosquitoes, Plasmodium parasites, and humans live in sympatry in some extra-Amazonian regions of Brazil. Recent migrations of people from Amazonia and other countries to extra-Amazonian regions have led to many malaria outbreaks. Lack of relevant expertise among health professionals in non-endemic areas can lead to a neglect of the disease, which can be dangerous given its high fatality rate. Therefore, understanding the spatial and temporal epidemiology of malaria is essential for developing strategies for disease control and elimination. This study aimed to characterize imported (IMP) and autochthonous/introduced (AU/IN) cases in the extra-Amazonian regions and identify risk areas and groups.
  
  
  METHODS
  Epidemiological data collected between 2007 and 2014 were obtained from the Notifiable Diseases Information System of the Ministry of Health (SINAN) and from the Department of the Unified Health System (DATASUS). High malaria risk areas were determined using the Local Indicator of Spatial Association. IMP and AU/IN malaria incidence rates were corrected by Local Empirical Bayesian rates.
  
  
  RESULTS
  A total of 6092 malaria cases (IMP: 5416, 88.9 %; AU/IN: 676, 11.1 %) was recorded in the extra-Amazonian regions in 2007-2014. The highest numbers of IMP and AU/IN cases were registered in 2007 (n = 862) and 2010 (n = 149), respectively. IMP cases were more frequent than AU/IN cases in all states except for Espírito Santo. Piauí, Espírito Santo, and Paraná states had high incidences of AU/IN malaria. The majority of infections were by Plasmodium falciparum in northeast and southeast regions, while Plasmodium vivax was the predominant species in the south and mid-west showed cases of dual infection. AU/IN malaria cases were concentrated in the coastal region of Brazil, which contains the Atlantic Forest and hosts the Anopheles transmitters. Several malaria clusters were also associated with the Brazilian Pantanal biome and regions bordering the Amazonian biome.
  
  
  CONCLUSIONS
  Malaria is widespread outside the Amazonian region of Brazil, including in more urbanized and industrialized states. This fact is concerning because these highly populated areas retain favourable conditions for spreading of the parasites and vectors. Control measures for both IMP and AU/IN malaria are essential in these high-risk areas.
authors.affiliation: Instituto Butantan, Avenida Vital Brasil, 1500, São Paulo, CEP 05509-300, Brazil. camilalorenz@usp.br.|Biologia da Relação Patógeno-Hospedeiro-Instituto de Ciências Biomédicas-USP, São Paulo, Brazil. camilalorenz@usp.br.
authors.forename: Camila
authors.initials: C
authors.lastname: Lorenz
authors.affiliation: Instituto Butantan, Avenida Vital Brasil, 1500, São Paulo, CEP 05509-300, Brazil. fv.fonseca@usp.br.|Biologia da Relação Patógeno-Hospedeiro-Instituto de Ciências Biomédicas-USP, São Paulo, Brazil. fv.fonseca@usp.br.
authors.forename: Flávia
authors.initials: F
authors.lastname: Virginio
authors.affiliation: Departamento de Epidemiologia, Faculdade de Saúde Pública, Universidade de São Paulo, Av Dr Arnaldo, 715, São Paulo, CEP 05509-300, Brazil. brenosaguiar@usp.br.
authors.forename: Breno S
authors.initials: BS
authors.lastname: Aguiar
authors.affiliation: Instituto Butantan, Avenida Vital Brasil, 1500, São Paulo, CEP 05509-300, Brazil. lincoln.suesdek@butantan.gov.br.|Biologia da Relação Patógeno-Hospedeiro-Instituto de Ciências Biomédicas-USP, São Paulo, Brazil. lincoln.suesdek@butantan.gov.br.|Instituto de Medicina Tropical, Avenida Dr Enéas Carvalho de Aguiar, 470, São Paulo, CEP 05403-000, Brazil. lincoln.suesdek@butantan.gov.br.
authors.forename: Lincoln
authors.initials: L
authors.lastname: Suesdek
authors.affiliation: Departamento de Epidemiologia, Faculdade de Saúde Pública, Universidade de São Paulo, Av Dr Arnaldo, 715, São Paulo, CEP 05509-300, Brazil. franciscochiara@usp.br.
authors.forename: Francisco
authors.initials: F
authors.lastname: Chiaravalloti-Neto
mesh_terms: D000818:Animals; D000852:Anopheles / Q000254:growth & development; D001938:Brazil / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D016778:Malaria, Falciparum / Q000453:epidemiology*; D016780:Malaria, Vivax / Q000453:epidemiology*; D062211:Spatio-Temporal Analysis; D019371:Topography, Medical