Comprehensive approach to HIV/AIDS testing and linkage to treatment among men who have sex with men in Curitiba, Brazil.

INTRODUCTION: The Curitiba (Brazil)-based Project, A Hora é Agora (AHA), evaluated a comprehensive HIV control strategy among men who have sex with men (MSM) aimed at expanding access to HIV rapid testing and linking HIV-positive MSM to health services and treatment. AHA's approach included rapid HIV Testing Services (HTC) in one mobile testing unit (MTU); a local, gay-led, non-governmental organization (NGO); an existing government-run health facility (COA); and Internet-based HIV self-testing. The objectives of the paper were to compare a) number of MSM tested in each strategy, its positivity and linkage; b) social, demographic and behavioral characteristics of MSM accessing the different HTC and linkage services; and c) the costs of the individual strategies to diagnose and link MSM to services. METHODS: We used data for 2,681 MSM tested at COA, MTU and NGO from March 2015 to March 2017. This is a cross sectional comparison of the demographics and behavioral factors (age group, race/ethnicity, education, sexually transmitted diseases, knowledge of AHA services and previous HIV test). Absolute frequencies, percentage distributions and confidence intervals for the percentages were used, as well as unilateral statistical tests. RESULTS AND DISCUSSION: AHA performed 2,681 HIV tests among MSM across three in-person strategies: MTU, NGO, and COA; and distributed 4,752 HIV oral fluid tests through the self-testing platform. MTU, NGO and COA reported 365 (13.6%) HIV positive diagnoses among MSM, including 28 users with previous HIV diagnosis or on antiretroviral treatment for HIV. Of these, 89% of MSM were eligible for linkage-to-care services. Linkage support was accepted by 86% of positive MSM, of which 66.7% were linked to services in less than 90 days. The MTU resulted in the lowest cost per MSM tested ($137 per test), followed by self-testing ($247). CONCLUSIONS: AHA offered MSM access to HTC through innovative strategies operating in alternative sites and schedules. It presented the Curitiba HIV/AIDS community the opportunity to monitor HIV-positive MSM from diagnosis to treatment uptake. Self-testing emerged as a feasible strategy to increase MSM access to HIV-testing through virtual tools and anonymous test kit delivery and pick-up. Cost per test findings in both the MTU and self-testing support expansion to other regions with similar epidemiological contexts.

Adapting the Ages and Stages Questionnaire to Identify and Quantify Development Among Children With Evidence of Zika Infection.

This article describes novel methods of applying the Ages and Stages Questionnaire-3rd edition (ASQ-3) to assess and quantify developmental delay among children following the 2015-2016 Zika virus outbreak in Brazil. Many of the children with Zika virus infection were expected to have severe developmental delay. However, administering the ASQ-3 to caregivers of these children according to standard protocol would have screened for the overall presence of delay but not the severity of delay. We adopted an amended protocol for administration of the ASQ-3 to quantify the developmental functioning of children severely affected by Zika virus infection in this investigation. Protocols for administering the ASQ-3 among this population were drafted in consultation with developmental measurement experts and are presented here. Specific developmental estimates are discussed, including developmental age equivalents, developmental quotients, and developmental quotient z scores. The calculations of these estimates are presented with examples in the context of the 2015-2016 Zika virus outbreak and associated microcephaly among prenatally infected children from 2 states in northeastern Brazil. Potential applications of these methods for estimating developmental ability among similar pediatric populations are discussed.

Early Growth Parameters as Predictors of Developmental Delay Among Children Conceived During the 2015-2016 Zika Virus Outbreak in Northeastern Brazil.

BACKGROUND: Identifying infants with congenital infection for early intervention will likely be challenging in future Zika virus outbreaks. We investigated indicators of risk for developmental delay among children born with and without obvious manifestations of congenital Zika virus infection. METHODS: We evaluated 120 children conceived during the 2015-2016 Zika virus outbreak in Paraíba, Brazil. We analyzed data from children at birth; ages 1-7 months and approximately 24 months, using medical records (i.e., anthropometric measurements diagnoses), medical evaluation (i.e., Zika/other laboratory tests, dysmorphic features), and parent report (seizures, developmental delay). We used a Bayesian modeling approach to identify predictors of developmental delay. RESULTS: Head circumference (HC) and length at birth and rates of growth for HC and length at follow-up were consistent across domains of developmental delay; (e.g., for every 1 cm per month decrease in HC growth rate; there was a corresponding decrease in the gross motor z-score). Modeling results indicated that HC and length at birth, and follow-up HC and length rates of growth, were predictive of developmental delay. CONCLUSION: These findings suggest that accurate measurement and frequent monitoring of HC and length, especially in the first few months of life, may be useful for identifying children possibly congenitally exposed to Zika virus who could benefit from early intervention services.

Functional Outcomes among a Cohort of Children in Northeastern Brazil Meeting Criteria for Follow-Up of Congenital Zika Virus Infection.

Following the large outbreak of Zika virus in the Western Hemisphere, many infants have been born with congenital Zika virus infection. It is important to describe the functional outcomes seen with congenital infections to allow for their recognition and appropriate interventions. We evaluated 120 children conceived during the 2015-2016 Zika virus outbreak in Paraíba, Brazil, who were approximately 24 months old, to assess functional outcomes. All children met either anthropometric criteria or laboratory criteria suggestive of possible congenital Zika virus infection. We collected results of previous medical evaluations, interviewed parents, and performed physical examinations and functional assessments, for example, the Hammersmith Infant Neurological Examination (HINE). We compared patterns of neurologic outcomes and developmental delay at age 24 months by whether children met anthropometric or laboratory criteria, or both. Among children meeting both criteria, 60% (26/43) were multiply affected (had severe motor impairment, severe developmental delay, and suboptimal HINE scores), compared with 5% (3/57) meeting only laboratory criteria and none (0/20) meeting only anthropometric criteria. Of the remaining 91 children, 49% (45) had developmental delay, with more severe delay seen in children meeting both criteria. Although children meeting physical and laboratory criteria for potential congenital Zika virus infection were more severely affected, we did identify several children with notable adverse neurologic outcomes and developmental delay with no physical findings but potential laboratory evidence of Zika virus infection. Given this, all children who were potentially exposed in utero to Zika virus should be monitored in early childhood for deficits to allow for early intervention.

Health and Development at Age 19-24 Months of 19 Children Who Were Born with Microcephaly and Laboratory Evidence of Congenital Zika Virus Infection During the 2015 Zika Virus Outbreak - Brazil, 2017.

In November 2015, the Brazilian Ministry of Health (MOH) declared the Zika virus outbreak a public health emergency after an increase in microcephaly cases was reported in the northeast region of the country (1). During 2015-2016, 15 states in Brazil with laboratory-confirmed Zika virus transmission reported an increase in birth prevalence of microcephaly (2.8 cases per 10,000 live births), significantly exceeding prevalence in four states without confirmed transmission (0.6 per 10,000) (2). Although children with microcephaly and laboratory evidence of Zika virus infection have been described in early infancy (3), their subsequent health and development have not been well characterized, constraining planning for the care and support of these children and their families. The Brazilian MOH, the State Health Secretariat of Paraíba, and CDC collaborated on a follow-up investigation of the health and development of children in northeastern Brazil who were reported to national surveillance with microcephaly at birth. Nineteen children with microcephaly at birth and laboratory evidence of Zika virus infection were assessed through clinical evaluations, caregiver interviews, and review of medical records. At follow-up (ages 19-24 months), most of these children had severe motor impairment, seizure disorders, hearing and vision abnormalities, and sleep difficulties. Children with microcephaly and laboratory evidence of Zika virus infection have severe functional limitations and will require specialized care from clinicians and caregivers as they age.

Evaluation of the completeness and timeliness of malaria reporting in the Brazilian Amazon, 2003-2012. / Avaliação da completude e da oportunidade das notificações de malária na Amazônia Brasileira, 2003-2012.

OBJECTIVE: to evaluate the completeness and timeliness of malaria case reporting, diagnosis and treatment in the Brazilian Amazon. METHODS: this is a descriptive study using data from 23 fields of notification forms recorded on the Malaria Epidemiological Surveillance Information System (Sivep-Malaria) between 2003 and 2012. RESULTS: data completeness was good in 86.0% of fields (≥90.0% filled in); there was timely recording of 40.6% of notifications at the Municipal Health Departments (0-7 days following notification) and 75.6% at the Ministry of Health (0-30 days following notification); timely diagnosis and timely treatment occurred in 44.6% and 45.4% of patients, respectively. CONCLUSION: most notification forms had good completeness; timeliness in recording notifications was below international standards; timeliness of diagnosis and treatment was below the Ministry of Health recommendations.

Efficacy of Chloroquine and Primaquine for the Treatment of Uncomplicated Plasmodium vivax Malaria in Cruzeiro do Sul, Brazil.

We evaluated the efficacy of chloroquine and primaquine on uncomplicated Plasmodium vivax malaria in Cruzeiro do Sul, Brazil, in 2014. Patients ≥ 5 years of age with either fever or history of fever, and laboratory-confirmed P. vivax monoinfection received chloroquine (total dose = 25 mg/kg) and primaquine (total dose = 3.5 mg/kg), and were followed up for 168 days (24 weeks). We used microsatellite genotyping to differentiate recurrent infections caused by heterologous parasites from those caused by homologous ones. No new P. vivax episode occurred by Day 28 among 119 enrolled patients, leading to Day 28, with adequate clinical and parasitological response (ACPR) of 100% (95% confidence interval [CI] = 96.7-100%). Twenty-eight P. vivax episodes occurred by Day 168, with uncorrected ACPR of 69.9% (95% CI = 59.5-79.0%). Fifteen of these episodes were caused by either homologous haplotypes or haplotypes that could not be determined. Excluding the 13 recurrent episodes caused by heterologous parasites, Day 168 microsatellite-corrected ACPR was estimated at 81.2% (95% CI = 71.0-89.1%). Chloroquine and primaquine remain efficacious to treat acute uncomplicated P. vivax infection, but moderate recurrence rates were observed within 24 weeks of follow-up.

Avaliação da completude e da oportunidade das notificações de malária na Amazônia Brasileira, 2003-2012 / Evaluación de la integridad y reporte oportuno de las notificaciones de malaria en la Amazonia brasileña en el período de 2003 a 2012 / Evaluation of the completeness and timeliness of malaria reporting in the Brazilian Amazon, 2003-2012

OBJETIVO: avaliar a completude e oportunidade das notificações, do diagnóstico e do tratamento da malária na Amazônia Legal Brasileira. MÉTODOS: estudo descritivo, com dados de 23 campos das fichas de notificação registradas no Sistema de Informação de Vigilância Epidemiológica da Malária (Sivep-Malária) no período de 2003 a 2012. RESULTADOS: em 86,0% dos campos da ficha de notificação, a completude foi boa (≥90,0% de preenchimento); nas Secretarias Municipais de Saúde, 40,6% das notificações tiveram registro oportuno (0-7 dias após a notificação), e no Ministério da Saúde, 75,6% (0-30 dias após a notificação); o diagnóstico e o tratamento oportunos ocorreram em 44,6% e 45,4% dos pacientes, respectivamente. CONCLUSÃO: a maioria das notificações apresentou boa completude; a oportunidade no registro das notificações ficou aquém dos padrões internacionais; e a oportunidade no diagnóstico e no tratamento revelou-se abaixo das recomendações do Ministério da Saúde.

OBJETIVO: evaluar la integridad de los datos y reporte oportuno de las notificaciones, de diagnóstico y tratamiento de malaria en la Amazonía brasileña. MÉTODOS: estudio descriptivo, con datos de 23 ítems de las fichas de notificación registradas en el Sistema de Información de Malaria (Sivep-Malária), en el periodo 2003-2012. RESULTADOS: el 86,0% de los ítems de la ficha de notificación fueron completados adecuadamente (≥90,0% completado); en las secretarias municipales de salud, 40,6% de las notificaciones tuvieron registro oportuno (0-7 días después de la notificación) y en el Ministerio de Salud, 75,6% (0-30 días después de la notificación); el diagnóstico y tratamiento oportunos ocurrieron en 44,6% y 45,4% de los pacientes, respectivamente. CONCLUSIÓN: la mayoría de las notificaciones mostró una buena integridad; la tasa de registro oportuno de las notificaciones fue inferior a los estándares internacionales y el diagnóstico y tratamiento oportuno fue inferior a lorecomendado por el Ministerio de Salud.

OBJECTIVE: to evaluate the completeness and timeliness of malaria case reporting, diagnosis and treatment in the Brazilian Amazon. METHODS: this is a descriptive study using data from 23 fields of notification forms recorded on the Malaria Epidemiological Surveillance Information System (Sivep-Malaria) between 2003 and 2012. RESULTS: data completeness was good in 86,0% of fields (≥90,0% filled in); there was timely recording of 40,6% of notifications at the Municipal Health Departments (0-7 days following notification) and 75,6% at the Ministry of Health (0-30 days following notification); timely diagnosis and timely treatment occurred in 44,6% and 45,4% of patients, respectively. CONCLUSION: most notification forms had good completeness; timeliness in recording notifications was below international standards; timeliness of diagnosis and treatment was below the Ministry of Health recommendations.

Situação epidemiológica da malária na região amazônica brasileira, 2003 a 2012

Objetivo. Descrever a situação epidemiológica da malária na região amazônica brasileira entre 2003 e 2012. Métodos. Este estudo ecológico retrospectivo utilizou dados do Sistema de Informação de Vigilância Epidemiológica e Notificação de Casos de Malária, Sistema de Internações Hospitalares e Sistema de Informações de Mortalidade. Determinaram-se o percentual de Plasmodium falciparum, o número de internações e óbitos e a letalidade por malária em cada ano. Para a infecção pelo P. falciparum, foi avaliada a distribuição dos casos por estado. Os dados de 2012 foram comparados aos de 2005, ano em que a região amazônica notificou um maior número de casos, e aos do ano anterior, 2011. Resultados. Em 2012, foram registrados 241 806 casos de malária, representando uma redução de 60,1% em relação a 2005 e de 9,1% em relação a 2011. Entre 2003 e 2005, houve um aumento de 48,3% no número de casos, com registro de 606 069 casos em 2005. Desde 2006, observa-se tendência à redução do número de casos, principalmente na transmissão do P. falciparum, com 155 169 casos notificados em 2005 e 35 385 casos em 2012 (redução de 77,2%). Entre 2005 e 2012, houve redução no número de internações (74,6%) e nos óbitos (54,4%) por malária. Conclusões. Apesar da redução no número de casos de malária no período analisado, o possível surgimento de parasitos resistentes às drogas e a menor frequência de casos de malária por P. falciparum indicam a necessidade de novas estratégias de vigilância, com utilização de ferramentas de diagnóstico mais sensíveis e manejo integrado de vetores, visando à ousada, mas não impossível, eliminação do P. falciparum.

Objective. To describe the epidemiological status of malaria in the Brazilian Amazon region between 2003 and 2012. Methods. The present retrospective ecological study employed data from the Brazilian Epidemiological Surveillance and Malaria Communication System (SIVEPMalária/SVS/MS), Hospital Admissions System (SIH/DATASUS/MS), and Mortality Information System (SIM). For each year, the percentage of Plasmodium falciparum cases, the number of admissions, and deaths and lethality due to malaria were determined. The distribution of P. falciparum cases in each state was also described. Data from 2012 were compared to data from 2005, when the Amazon region recorded a peak number of cases, and with data from 2011. Results. In 2012, 241 806 malaria cases were recorded in the region, a reduction of 60.1% vs. 2005 and of 9.1% vs. 2011. Between 2003 and 2005, there was an increase of 48.3% in the number of cases, with 606 069 recorded cases in 2005. Since 2006, a declining trend in number of cases has been observed, especially for P. falciparum, with 155 169 cases notified in 2005 vs. 35 385 in 2012 (reduction of 77.2%). Between 2005 and 2012, the number of malaria hospital admissions (74,6%) and deaths (54,4%) was also reduced. Conclusions. Despite a decline in the number of malaria cases, the possible emergence of drug-resistant parasites and the lower frequency of P. falciparum indicate the need to adopt new surveillance strategies, more sensitive tools, and integrated vector management to achive a bold, but not impossible, goal: the elimination of P. falciparum.

Situação epidemiológica da malária na região amazônica brasileira, 2003 a 2012 / Epidemiological situation of malaria in the brazilian amazon region, 2003 to 2012

OBJETIVO: Descrever a situação epidemiológica da malária na região amazônica brasileira entre 2003 e 2012. MÉTODOS: Este estudo ecológico retrospectivo utilizou dados do Sistema de Informação de Vigilância Epidemiológica e Notificação de Casos de Malária, Sistema de Internações Hospitalares e Sistema de Informações de Mortalidade. Determinaram-se o percentual de Plasmodium falciparum,o número de internações e óbitos e a letalidade por malária em cada ano. Para a infecção pelo P. falciparum, foi avaliada a distribuição dos casos por estado. Os dados de 2012 foram comparados aos de 2005, ano em que a região amazônica notificou um maior número de casos, e aos do ano anterior, 2011. RESULTADOS: Em 2012, foram registrados 241806 casos de malária, representando uma redução de 60,1% em relação a 2005 e de 9,1% em relação a 2011. Entre 2003 e 2005, houve um aumento de 48,3% no número de casos, com registro de 606 069 casos em 2005. Desde 2006, observa-se tendência à redução do número de casos, principalmente na transmissão do P. falciparum, com 155 169 casos notificados em 2005 e 35 385 casos em 2012 (redução de 77,2%). Entre 2005 e 2012, houve redução no número de internações (74,6%) e nos óbitos (54,4%) por malária. CONCLUSÕES: Apesar da redução no número de casos de malária no período analisado, o possível surgimento de parasitos resistentes às drogas e a menor frequência de casos de malária por P. falciparum indicam a necessidade de novas estratégias de vigilância, com utilização de ferramentas de diagnóstico mais sensíveis e manejo integrado de vetores, visando à ousada, mas não impossível, eliminação do P. falciparum.

OBJECTIVE: To describe the epidemiological status of malaria in the Brazilian Amazon region between 2003 and 2012. METHODS: The present retrospective ecological study employed data from the Brazilian Epidemiological Surveillance and Malaria Communication System (SIVEP-Malária/SVS/MS), Hospital Admissions System (SIH/DATASUS/MS), and Mortality Information System (SIM). For each year, the percentage of Plasmodium falciparum cases, the number of admissions, and deaths and lethality due to malaria were determined. The distribution of P. falciparum cases in each state was also described. Data from 2012 were compared to data from 2005, when the Amazon region recorded a peak number of cases, and with data from 2011. RESULTS: In 2012, 241 806 malaria cases were recorded in the region, a reduction of 60.1% vs. 2005 and of 9.1% vs. 2011. Between 2003 and 2005, there was an increase of 48.3% in the number of cases, with 606 069 recorded cases in 2005. Since 2006, a declining trend in number of cases has been observed, especially for P. falciparum, with 155 169 cases notified in 2005 vs. 35 385 in 2012 (reduction of 77.2%). Between 2005 and 2012, the number of malaria hospital admissions (74,6%) and deaths (54,4%) was also reduced. CONCLUSIONS: Despite a decline in the number of malaria cases, the possible emergence of drug-resistant parasites and the lower frequency of P. falciparum indicate the need to adopt new surveillance strategies, more sensitive tools, and integrated vector management to achive a bold, but not impossible, goal: the elimination of P. falciparum.

[Epidemiological situation of malaria in the brazilian amazon region, 2003 to 2012]. / Situação epidemiológica da malária na região amazônica brasileira, 2003 a 2012.

OBJECTIVE: To describe the epidemiological status of malaria in the Brazilian Amazon region between 2003 and 2012. METHODS: The present retrospective ecological study employed data from the Brazilian Epidemiological Surveillance and Malaria Communication System (SIVEP-Malária/SVS/MS), Hospital Admissions System (SIH/DATASUS/MS), and Mortality Information System (SIM). For each year, the percentage of Plasmodium falciparum cases, the number of admissions, and deaths and lethality due to malaria were determined. The distribution of P. falciparum cases in each state was also described. Data from 2012 were compared to data from 2005, when the Amazon region recorded a peak number of cases, and with data from 2011. RESULTS: In 2012, 241 806 malaria cases were recorded in the region, a reduction of 60.1% vs. 2005 and of 9.1% vs. 2011. Between 2003 and 2005, there was an increase of 48.3% in the number of cases, with 606 069 recorded cases in 2005. Since 2006, a declining trend in number of cases has been observed, especially for P. falciparum, with 155 169 cases notified in 2005 vs. 35 385 in 2012 (reduction of 77.2%). Between 2005 and 2012, the number of malaria hospital admissions (74,6%) and deaths (54,4%) was also reduced. CONCLUSIONS: Despite a decline in the number of malaria cases, the possible emergence of drug-resistant parasites and the lower frequency of P. falciparum indicate the need to adopt new surveillance strategies, more sensitive tools, and integrated vector management to achive a bold, but not impossible, goal: the elimination of P. falciparum.

Malaria in Brazil: what happens outside the Amazonian endemic region.

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.

Malaria in Brazil: what happens outside the Amazonian endemic region

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.