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At least 19 recordsLinked to original sources
PubMed2006

Contemporary causes of skin and soft tissue infections in North America, Latin America, and Europe: report from the SENTRY Antimicrobial Surveillance Program (1998-2004).

The morbidity and cost for cure associated with skin and soft tissue infections (SSTIs) have recently become more complicated because of the increasing prevalence of multidrug-resistant pathogens associated with this healthcare problem. The SENTRY Antimicrobial Surveillance Program has been monitoring SSTI since 1997, and now presents data from 3 continents over a 7-year period (1998-2004). Isolates were tested by reference broth microdilution methods at a central laboratory using the Clinical and Laboratory Standards Institute (formerly the National Committee for Clinical Laboratory Standards) methods and interpretative criteria. The predominant pathogens included Staphylococcus aureus (ranked 1st in all geographic regions), Pseudomonas aeruginosa, Escherichia coli, and Enterococcus spp. A considerable variation in the methicillin (oxacillin)-resistant S. aureus rate was noted between countries and continents, with the overall rate highest in North America (35.9%) compared with Latin America (29.4%) and Europe (22.8%). Vancomycin-resistant Enterococcus spp. increased in Europe (4.1%) and North America (6.2%) during the period, but remained low and relatively unchanged in Latin America. Among the P. aeruginosa isolates tested, susceptibility to imipenem was much lower in Latin America (65.3%) compared with the other regions (80.7-88.7%), and resistance being associated with an increase in metallo-beta-lactamase-producing strains in Latin America and in some European countries. Multidrug-resistant strains of P. aeruginosa were also more of a concern in Latin America (24.7%) compared with Europe (10.8%) or North America (3.2%). Latin America also had the highest occurrence of extended-spectrum beta-lactamase-producing isolates among E. coli (15.1%) and Klebsiella spp. (48.0%) when compared with other regions. Continued surveillance of pathogen prevalence and antimicrobial resistance patterns should provide information that is important to improve empiric care particularly in the hospital environment.

Anti-Bacterial Agents↗
PubMed1995

Low-dose cyclosporine A improves severe disabling psoriasis in Latin America. Latin American Multicenter Study.

BACKGROUND: Severe forms of psoriasis have been treated successfully with cyclosporine A (cyA) in Europe and North America. The aim of the present investigation was to record and evaluate this drug treatment in Latin American patients with severe psoriasis in a multicenter controlled dose-efficacy study. PATIENTS AND METHODS: One hundred and fifty-two patients from 10 Latin American countries had on entry to the study a Psoriasis Area Severity Index (PASI) of 18 or more. Initial treatment was with cyA, 2.5 mg per kg per day for 6 weeks. At week 6, 27 patients with a baseline PASI score reduction of < 33% had the dose increased to 4 mg/kg/day. At week 12, 48 patients, who had not improved their baseline PASI scores by 66% or more, had their dose increased to 4 or 5 mg/kg/day, respectively. At the end of the study, 74 patients (56%) received cyA 2.5 mg/kg/day, 41 patients (31%) received 4 mg/kg/day, and 16 patients (12%) received 5 mg/kg/day. RESULTS: Cyclosporine A treatment was considered successful in 84.7% of the patients, who reduced their initial PASI score by 66% or more at the end of treatment at week 18. Adverse effects were seen in 29 patients (19%). Hypertension occurred in 27% and an increase of serum creatinine level above 30% of the initial value in 40% of patients. Among other side effects were gastrointestinal complaints (5.1%), hirsutism (4.3%), muscle pain (2.2%), joint pain (2.2%), respiratory infections (2.2%), headache (1.4%), and hemorrhagic gingivitis (0.7%). Twenty-one patients (13.8%) were withdrawn from the study for various reasons: adverse events in five cases (3.3%), noncompliance in five cases (3.3%), lack of efficacy in three cases (2%) and nonrelated diseases in two cases (1.3%). There were also six patients of a group that finished earlier than planned. A follow-up at 8 weeks after treatment was performed in 106 patients; in this phase 60 patients (56.5%) continued with their previous successful PASI reduction. Relapses (i.e., PASI increasing by more than 50% over baseline) were seen in 22.6% of cases. CONCLUSIONS: Cyclosporine A is an effective and well-tolerated treatment for severe psoriasis. An initial dose of 2.5 mg/kg/day is recommended. Most of the patients have a good response to this dose.

Adolescent↗
PubMed2006

Prevalence and antimicrobial susceptibility patterns among gastroenteritis-causing pathogens recovered in Europe and Latin America and Salmonella isolates recovered from bloodstream infections in North America and Latin America: report from the SENTRY Antimicrobial Surveillance Program (2003).

Gastroenteritis-causing pathogens are the second leading cause of morbidity and mortality worldwide. Complicating the clinical diarrhoea syndrome is the emergence of antimicrobial resistance among the responsible bacterial pathogens. The reported increases in fluoroquinolone resistance in Salmonella, Shigella and Campylobacter have been extremely worrisome considering the primary role of ciprofloxacin as a treatment. In this study, 1479 bacterial isolates from gastroenteritis infections were collected in Europe and Latin America, which included Salmonella spp. (834; 56%), Shigella spp. (311; 21%), Campylobacter spp. (182; 12%) and Aeromonas spp. (72; 5%). The fluoroquinolones displayed the greatest activity against these pathogens, with only three non-Campylobacter spp. strains being non-susceptible using current Clinical and Laboratory Standards Institute (CLSI) breakpoint criteria. Whilst ciprofloxacin resistance in European and Latin American Salmonella was only 0.2% and 0.0%, respectively, a total of 16.2% and 12.9% of isolates were resistant to nalidixic acid, indicating possible first-step gyrA mutations. Among confirmed extended-spectrum beta-lactamase-producing Salmonella strains, CTX-M genes were detected in 15 originating from Russia. Erythromycin and azithromycin were the most potent agents tested against Campylobacter spp. (values of minimum inhibitory concentration for 90% of the organisms, 0.5 mg/L and 0.12 mg/L, respectively), with erythromycin displaying the highest susceptibility (91.1%). Salmonella isolates from bloodstream infections displayed antibiograms that were nearly identical to strains causing gastroenteritis. Considering the role that antimicrobial therapy plays in the management of moderate to severe bacterial gastroenteritis, global surveillance and local/national public health programmes can provide critical data illuminating the dissemination of resistance and guidance for empirical therapy.

Aeromonas↗
PubMed2003

Organ transplants in Latin America.

Latin America has carried out kidney transplantation for 45 years. Twenty-four countries perform kidney transplantations, 14 perform heart transplantations, 12 perform liver transplantations, 9 perform pancreas transplantations, and, 2 perform small bowel transplantations. Seventeen countries have nephrology societies, 10 have transplantation societies, and 10 have national transplant organizations. The potential donor rate, 40 to 100 per million population per year (pmp/y), is similar to that observed in developed countries, but the rate of potential notified donors is 5 to 25 pmp/y, and the rate of effective donors is lower, 2 to 12 pmp/y. Approximately 77,000 transplantations were performed in the region until 2001, 70,000 kidney transplantations, 4000 liver transplantations, and 2500 heart transplantations. The annual number of kidney transplantations in Latin America increased from less than 3000 in 1991 to almost 7000 in 2001. Latin America, with only 8.5% of the world population, performed 12.7% of the kidney transplantations. Future strategies to improve the transplantation situation in Latin America include the following: obtain financial coverage for all the population, establish a National Transplant Organization and registries with transplantation results, and improve cadaveric and living donation to 10 pmp/y each.

Animals↗
PubMed2006

The cost of Latin American science Introduction for the second issue of CBP-Latin America.

Latin American researchers in science and engineering (S&E), including those in biology and biomedical sciences, are frequently exposed to unstable conditions of financial support, material and human resources, and a limited number of positions at public and private institutions. Such uncertainties impose continuous challenges for the scientific community which, in the best of cases, responds with careful planning and creativity, and in the worst scenario endures the migration of scientists to the USA or Europe. Still, the number of scientific publications from Latin American institutions in the last decade increased at a much faster rate than publications from the USA and Canada. A brief analysis per country of the gross domestic product (GDP) spent in research and development (R&D) and the S&E production reported by the Pascal bibliographic database suggests that the number and quality of S&E publications is directly proportional to the financial support for R&D. However, the investment in R&D in Latin America did not increase at the same rate (from 0.49 to 0.55% of GDP, from 1990 to 2003) at which S&E publications did in the same period (2.9-fold increase, from 1988 to 2001). In Latin America, the traditional financial support for scientific research continues to be from federal and state government funds, associated in some cases with institutional funds that are mostly directed towards administrative costs and infrastructure maintenance. The aim of this introduction is to briefly discuss the production cost of articles published in refereed S&E journals, including the cost of the scientific research behind them, and, at the same time, to increase the awareness of the high quality of scientific research in Latin American institutions despite the many challenges, especially financial constraints, faced by their scientists. The second issue of Comparative Biochemistry and Physiology dedicated to Latin America ("The Face of Latin American Comparative Biochemistry and Physiology") celebrates, by means of 26 manuscripts from five countries, the diversity and quality of biological science in the continent.

Biological Science Disciplines↗
PubMedDate not supplied

Opportunities and challenges for clinical and cardiovascular research in Latin America.

Latin America in the past two decades has increasingly become a significant contributor of clinical research. The future capacity of clinical and specifically cardiovascular research has the potential to positively affect human health in the region and foster economic growth. However, the challenges of conducting clinical research in Latin America include a need for logistical support from local governments, continued commitment to education of physicians and ethics committees, and creation of oversight bodies to guarantee the highest quality of research. Bibliometric analyses were conducted to assess trends in clinical research. Latin American investigators demonstrated a tendency to publish clinical results in local and regional journals. The region offers many opportunities for clinical research including large treatment-naive patient populations and most importantly motivated investigators capable of producing high-quality results. Strategies to foster clinical research in Latin America must be based on development of a positive regulatory environment, leveraged protection of intellectual property, creation of alliances between private and public sectors with incentives for investment in science and technology, and finally focus on areas of clinical expertise such as cardiovascular disease, epidemiology, gastroenterology, and infectious diseases. Fostering the creation of research alliances across and between continents will help in establishing the supportive environment for dissemination of important ethical clinical research in the region.

Cardiovascular Diseases↗
PubMedDate not supplied

Randomized clinical trials in perinatology in Latin America.

Latin America needs means to obtain accurate figures about its health conditions in order to apply its resources to priority areas. In addition, health actions must be carefully evaluated to assess their impact, operation and costs. The randomized clinical trial (RCT) is the only design able to show the effectiveness of interventions of moderate effect. Also, it gives appropriate information about the expected effect of the interventions and implies an expediate implementation of interventions in the same places where the project has been performed. In a review of RCTs performed in Latin America on perinatal medicine it can be concluded that some of the focus of research is irrelevant to the region and there is not an orientation towards the cooperative solution of predominant problems in the area. It is imperative for researchers, in Latin America to initiate joint activities in order to assess which are the research priorities of the area, to focus their research on these priorities and to join their efforts in collaborative studies.

Health Services Needs and Demand↗
PubMed2003

[The organisation and future development of Veterinary Services in Latin America].

Latin America undoubtedly has comparative advantages in the fields of animal production, animal health and the production of food of animal origin. However, countries in Latin America must build on these strengths if the continent is to become more competitive and be able to deal with the complexities of world markets. To do this, Veterinary Services must define their objectives and establish quality standards on which to base their work. For this to occur, the State must create well-defined regulations, establish systems of audit and find ways of working which allow for a high degree of coordination and collaboration between the public and private sectors. This should be done within a framework of a quality assurance system, which allows for responsible accreditation and independent audit and evaluation. The author discusses the approaches of the different countries in the region to animal health, zoonosis, food safety, veterinary drugs control, animal welfare and export-import control. All programmes relating to these issues must be based on technical information gained through epidemiological surveillance, the network of diagnostic laboratories, quarantine systems, risk analysis, identification and traceability of animals and animal products, registration and control of veterinary drugs, and food safety research. In some countries these systems are already being developed. Maintaining good international relations and cooperating with neighbouring countries is always a challenge for official Veterinary Services and international organisations such as the OIE (World organisation for animal health) have a key role to play in facilitating these relationships.

Animal Husbandry↗
PubMed2002

Multiple species production systems: reversing underdevelopment and nonsustainability in Latin America.

Latin America (LA) is suffering the environmental consequences of worldwide increased productivity and agricultural expansion as well as strong economic restrictions. To survive, LA landowners must turn to higher income products and/or increase productivity. Alternatives are few. But while intensification relies on unaffordable and nonsustainable subsidies, diversification is solely dependent on improved management of available resources. Diversified, multiple-species production systems (MSPS) add wildlife use to traditional production systems, promoting economic and ecological stability. We present examples of MSPS in Latin America. Although results are technically encouraging, their future sustainability is threatened by: i) local subvaluation of wildlife and ii) restricted international markets.

Agriculture↗
PubMed2000

Bloodstream infections due to Candida species: SENTRY antimicrobial surveillance program in North America and Latin America, 1997-1998.

An international program of surveillance of bloodstream infections (BSI) in the United States, Canada, and Latin America detected 306 episodes of candidemia in 34 medical centers (22 in the United States, 6 in Canada, and 6 in Latin America) in 1997 and 328 episodes in 34 medical centers (22 in the United States, 5 in Canada, and 7 in Latin America) in 1998. Of the 634 BSI, 54.3% were due to Candida albicans, 16.4% were due to C. glabrata, 14.9% were due to C. parapsilosis, 8.2% were due to C. tropicalis, 1.6% were due to C. krusei, and 4.6% were due to other Candida spp. The percentage of BSI due to C. albicans decreased very slightly in the United States between 1997 and 1998 (56.2 to 54.4%; P = 0.68) and increased in both Canada (52.6 to 70.1%; P = 0.05) and Latin America (40.5 to 44. 6%; P = 0.67). C. glabrata was the second most common species observed overall, and the percentage of BSI due to C. glabrata increased in all three geographic areas between 1997 and 1998. C. parapsilosis was the third most prevalent BSI isolate in both Canada and Latin America, accounting for 7.0 and 18.5% of BSI, respectively. Resistance to fluconazole (MIC, >/=64 microgram/ml) and itraconazole (MIC, >/=1.0 microgram/ml) was observed infrequently in both 1997 (2.3 and 8.5%, respectively) and 1998 (1.5 and 7.6%, respectively). Among the different species of Candida, resistance to fluconazole and itraconazole was observed in C. glabrata and C. krusei, whereas isolates of C. albicans, C. parapsilosis, and C. tropicalis were all highly susceptible to both fluconazole (98.9 to 100% susceptible) and itraconazole (96.4 to 100% susceptible). Isolates from Canada and Latin America were generally more susceptible to both triazoles than U.S. isolates were. Continued surveillance appears necessary to detect these important changes.

Antifungal Agents↗
PubMed2002

Tobacco industry success in preventing regulation of secondhand smoke in Latin America: the "Latin Project".

OBJECTIVE: To examine the tobacco industry's strategy to avoid regulations on secondhand smoke exposure in Latin America. METHODS: Systematic search of tobacco industry documents available through the internet. All available materials, including confidential reports regarding research, lobbying, and internal memoranda exchanged between the tobacco industry representatives, tobacco industry lawyers, and key players in Latin America. RESULTS: In Latin America, Philip Morris International and British American Tobacco, working through the law firm Covington & Burling, developed a network of well placed physicians and scientists through their "Latin Project" to generate scientific arguments minimising secondhand smoke as a health hazard, produce low estimates of exposure, and to lobby against smoke-free workplaces and public places. The tobacco industry's role was not disclosed. CONCLUSIONS: The strategies used by the industry have been successful in hindering development of public health programmes on secondhand smoke. Latin American health professionals need to be aware of this industry involvement and must take steps to counter it to halt the tobacco epidemic in Latin America.

Consultants↗
PubMed1998

Telemedicine in Latin America.

Latin America, stretching 6,000 miles from Mexico to Tierro del Fuego, is comprised of twenty countries totaling nearly 1/2 billion people. There are wide variations in median income levels, medical access, telecommunications infrastructures, and levels of rurality. The great variety of settings precludes any simple approach to telemedicine deployment.

Computer Communication Networks↗
PubMed2005

End-stage renal disease prevention strategies in Latin America.

Latin America (LA), defined here as the countries in the Western hemisphere located south of the United States, is a region with a total population of nearly 520,000,000 that increases 1.5% annually and has a human development index of 0.77. The countries that form this region present extreme contrasts. These contrasts are first and foremost within the countries themselves, because extremes of wealth and poverty are present in their social and economic fabric. In addition, in LA a vast variety of government modalities and political systems are represented. Therefore, in order for prevention strategies to be effective, they need to be tailored to the specific characteristics and idiosyncrasies of individual nations. This article will address the following aspects: first, a broad outline of the basic health statistics in LA, with focus on treatment of end-stage renal disease and its derived economic burden. Data from LA countries will be contrasted with 95% confidence interval of corresponding data from 10 industrialized countries (Canada, France, Germany, Italy, Japan, United Kingdom, United States, Spain, Sweden, and Switzerland). Second, we will discuss the prevalence of some risk factors for end-stage renal disease in the nations of the region. For this reason, we will focus on data that provide reliable information. Finally, we will consider general guidelines for the implementation of prevention strategies that may have common applicability in LA countries.

Diabetes Complications↗
PubMed2005

Analysis of Salmonella spp. with resistance to extended-spectrum cephalosporins and fluoroquinolones isolated in North America and Latin America: report from the SENTRY Antimicrobial Surveillance Program (1997-2004).

Emerging antimicrobial-resistant Salmonella spp. requires increased efforts to appropriately test susceptibility. The SENTRY Antimicrobial Surveillance Program monitored Salmonella spp. and detected nalidixic acid-resistant strains with elevated fluoroquinolone minimum inhibitory concentration (MIC) results and strains with extended-spectrum beta-lactamase (ESBL) "phenotypes" over the last 8 years. A total of 786 stool and bloodstream isolates from North American and Latin American medical centers (2001-2003) were tested by reference broth microdilution methods. Genetic analysis was used to further characterize the resistance mechanisms. Twenty-one sites forwarded 89 (11.3%) nalidixic acid-resistant (MIC, > or =32 microg/mL) strains. Nineteen of these isolates were studied to determine mutations in the quinolone resistance-determining region (QRDR). Among the nalidixic acid-resistant Salmonella spp. isolates, fluoroquinolone MIC values were also elevated (8- to 32-fold) compared with "wild-type" strains. Ciprofloxacin and gatifloxacin (MIC(90), 0.5 microg/mL) were more potent than levofloxacin and garenoxacin (1 microg/mL) against nalidixic acid-resistant strains. Single gyrA mutations were responsible for elevated fluoroquinolone MIC values and included D87Y (5), S83F (7), D87N (5), and S83Y (2). During 2001, 9 sites contributed 11 (2.9%) strains that met ESBL screening criteria (> or =2 microg/mL) for aztreonam or ceftazidime or ceftriaxone. ESBL confirmation was evaluated by Etest (AB BIODISK, Solna, Sweden) ESBL strips and the enzymes were characterized by polymerase chain reaction and gene sequencing. The ESBL phenotype isolates had the following MIC patterns: ceftazidime (> or =16 microg/mL), aztreonam (4 to >16 microg/mL), and ceftriaxone (8-32 microg/mL). All strains were susceptible to cefepime, carbapenems, gentamicin, and fluoroquinolones. No strains were inhibited by clavulanic acid consistent with all isolates producing the identified CMY-2, AmpC-like enzyme. Fluoroquinolones may be compromised among isolates with QRDR mutations detected using nalidixic acid as a screening agent. Salmonella spp. with ESBL phenotypes were likely to harbor CMY-2 (not an ESBL) and remain susceptible to cefepime, carbapenems, and fluoroquinolones, which can be used for serious invasive Salmonella spp. infections. Compared with the stool culture isolates, the blood culture isolates had higher QRDR mutations, but remained susceptible to the fluoroquinolones. The blood culture isolates were more susceptible to penicillins (ampicillin and ticarcillin) and not significantly different for ceftriaxone or trimethoprim/sulfamethoxazole susceptibility patterns. No QRDR trends over time were detected in North America, but increased resistance was observed in Latin America.

Anti-Bacterial Agents↗
PubMed1999

In vitro activities of BMS-207147 against over 600 contemporary clinical bloodstream isolates of Candida species from the SENTRY Antimicrobial Surveillance Program in North America and Latin America.

We compared the in vitro activity of BMS-207147, an investigational triazole, with those of itraconazole and fluconazole against 613 clinical bloodstream isolates of Candida spp. collected from SENTRY participating hospitals during 1997 and 1998. Overall, BMS-207147 was the most active azole against all Candida spp. While both BMS-207147 and itraconazole displayed a stepwise decrease in activity against isolates for which the fluconazole MICs were elevated, BMS-207147 had two- to fourfold greater activity than itraconazole both against Candida spp. that were dose-dependently fluconazole susceptible and against those that were fluconazole resistant.

Antifungal Agents↗
PubMedDate not supplied

Opportunistic infections in pediatric HIV infection: a study of 74 autopsy cases from Latin America. The Latin American AIDS Pathology Study Group.

The present report describes opportunistic infections found at 74 autopsies of pediatric HIV/AIDS patients performed at several hospitals in Latin American countries. Fungal infections were the most common (53 cases), Candida sp. (39.18%) and Pneumocystis carinii (20.27%) being the most frequently recognized. Other fungal diseases included histoplasmosis, aspergillosis, and cryptococcosis. Viral infections were present in 31 cases, 38.7% being due to cytomegalovirus. Other viruses recognized included herpes simplex and adenovirus. Additional opportunistic infections were due to Mycobacterium avium-intracellulare, toxoplasmosis, and tuberculosis. Nonspecific bacterial bronchopneumonia was present in 11 cases. Cytomegalovirus and P. carinii coinfection was the most common association found. In this series patients died at a younger age (72% at or younger than 1 year old) and there was a slightly higher number of cases of histoplasmosis and brain toxoplasmosis than in other previously published series of infants and children.

AIDS-Related Opportunistic Infections↗
PubMed2005

Asthma control in Latin America: the Asthma Insights and Reality in Latin America (AIRLA) survey.

OBJECTIVES: The aims of this survey were (1) to assess the quality of asthma treatment and control in Latin America, (2) to determine how closely asthma management guidelines are being followed, and (3) to assess perception, knowledge and attitudes related to asthma in Latin America. METHODS: We surveyed a household sample of 2,184 adults or parents of children with asthma in 2003 in 11 countries in Latin America. Respondents were asked about healthcare utilization, symptom severity, activity limitations and medication use. RESULTS: Daytime asthma symptoms were reported by 56% of the respondents, and 51% reported being awakened by their asthma at night. More than half of those surveyed had been hospitalized, attended a hospital emergency service or made unscheduled emergency visits to other healthcare facilities for asthma during the previous year. Patient perception of asthma control did not match symptom severity, even in patients with severe persistent asthma, 44.7% of whom regarded their disease as being well or completely controlled. Only 2.4% (2.3% adults and 2.6% children) met all criteria for asthma control. Although 37% reported treatment with prescription medications, only 6% were using inhaled corticosteroids. Most adults (79%) and children (68%) in this survey reported that asthma symptoms limited their activities. Absence from school and work was reported by 58% of the children and 31% of adults, respectively. CONCLUSIONS: Asthma control in Latin America falls short of goals in international guidelines, and in many aspects asthma care and control in Latin America suffer from the same shortcomings as in other areas of the world.

Adolescent↗
PubMed2005

Incidence of aplastic anemia and agranulocytosis in Latin America--the LATIN study.

CONTEXT AND OBJECTIVE: Aplastic anemia and agranulocytosis are rare but life-threatening disorders, often caused by drugs and other environmental exposures. Reported incidence of these diseases seems to vary between different geographic regions, and few data on their incidence are available for Latin American countries. The aim of this work is to determine the incidence of agranulocytosis and aplastic anemia in Brazil. DESIGN AND SETTING: Incidence study. Seven centers took part in the pilot phase, so as to represent all Brazilian regions. METHODS: Each center conducted an active search for new cases in a defined region by means of regular contacts with all hematologists, main clinical laboratories and clinicians in hospitals of the region. RESULTS: 74 patients with aplastic anemia and 16 with agranulocytosis were identified. Patients with agranulocytosis had a median age of 31 years (interquartile range, IQR: 12.5-48.2); 32.2% were male and 81.2% were white. The median age of aplastic anemia patients was 21 years (IQR 15.0-35.2); 62.2% were male, 50.0% were white and 39.2% mulatto. The incidence of agranulocytosis was estimated to be 0.5 cases per million individuals per year, ranging from 0.0 to 1.1 cases per million per year between regions. The incidence of aplastic anemia was 2.7 cases per million per year, ranging from 1.1 to 7.1 cases per million per year between regions. CONCLUSIONS: Aplastic anemia and agranulocytosis are rare diseases in Brazil. However, there is considerable variability in their incidences between different regions.

Adult↗