Artigos

Conteúdo (article):

AÇÕES EDUCATIVAS DE ENFRENTAMENTO AO AEDES AEGYPTI – REVISÃO INTEGRATIVA
EDUCATION-BASED AEDES AEGYPTI CONTROL ACTIONS – AN INTEGRATIVE REVIEW
Ítala Keane Rodrigues Dias - Universidade Regional do Cariri (URCA), e-mail: itala_keany@hotmail.com , ORCID: 0000-0003-3027-825X

Rosa Maria Grangeiro Martins, Universidade Regional do Cariri (URCA), e-mail: rosamaria13gm@gmail.com, ORCID: 0000-0002-2516-0719

Cicera Luciana da Silva Sobreira, Universidade Regional do Cariri (URCA), e-mail: luciana.sob3@hotmail.com, ORCID: 0000-0003-2380-9606

Rhavena Maria Gomes Sousa Rocha, Universidade Regional do Cariri (URCA), e-mail: rhavena_mgsr@hotmail.com, ORCID: 0000-0001-6341-4735

Maria do Socorro Vieira Lopes, Universidade Regional do Cariri (URCA), e-mail: socorrovieira@hotmail.com, ORCID: 0000-0003-1335-5487

RESUMO
Objetivou sintetizar os estudos, publicados na literatura cientifica, que abordem estratégias de enfrentamento às arboviroses mediante ações educativas. Os dados foram coletados nas bases de dados: LILACS, BDENF e MEDLINE utilizando os descritores “Educação em Saúde” e “Aedes” empregando o operador booleano “AND”. Foram encontrados 242 estudos, dos quais após aplicação dos critérios de inclusão e exclusão, 14 foram incluídos na revisão. Os dados foram analisados utilizando a abordagem qualitativa. Foram identificadas quatro categorias: ações de enfrentamento vetorial mediante capacitação da comunidade; mobilização social em torno do combate às arboviroses; combate vetorial a partir de ações educativas associadas ao uso de controle biológico; ações integradas de enfrentamento às arboviroses. Infere-se que a educação em saúde é um elemento indispensável para o enfrentamento às arboviroses que deverá ser implementada de forma conjunta e articuladas às demais estratégia de combate vetorial.
Palavras-Chave: Controle de Vetores, Aedes, Vigilância em Saúde Pública, Prevenção & Controle, Educação em Saúde.

ABSTRACT
The aim of this study was to provide a synthesis of published studies investigating education-based arbovirus control strategies. The data were collected from the LILACS, BDENF and MEDLINE databases using the descriptors "Health Education" and "Aedes", together with the Boolean operator "AND". The searches retrieved 242 studies, 14 of which were included in the review after applying the inclusion and exclusion criteria. The data were analyzed using a qualitative approach, resulting in the identification of four categories: vector control actions based on community capacity building; social mobilization for arbovirus control; education-based vector control combined with biological control; and integrated arbovirus control actions. The findings show that health education is an essential element of arbovirus control and should be implemented in conjunction with other vector control strategies.
Key words: Vector Control, Aedes, Public Health Surveillance, Prevention & Control, Health Education.

INTRODUCTION
The climate in Brazil, combined with factors such as the size of the country, vegetation, and poor housing conditions and basic sanitation contribute to the occurrence of epidemics of arboviruses transmitted by the mosquito Aedes aegypti1. Although with some diseases transmitted by arboviruses the patient recovers completely after the acute phase, there are cases in which symptoms can last for weeks or months, leading to the development of bleeding or neurological complications, some of which are irreversible2,3. The persistence of arboviruses such as dengue and the prominence of outbreaks of emerging diseases like chikungunya and Zika reveal the country’s social and political weaknesses and need for effective vector control strategies1. The fact that the World Health Organization (WHO) issued a warning in 2016 declaring the Zika virus (ZIKV) a public health concern after associating the virus with cases of microcephaly illustrates the magnitude of the arbovirus problem, which besides overburdening health services, perpetuates the cycle of poverty in the country4,5.
Larvicides and insecticides have been widely employed in the absence of vaccines and specific treatment, especially during endemic periods, without achieving vector control6,7. These chemical substances result in the development of insecticide resistance and contribute to an increase in the magnitude of future epidemics7. These substances have an initially high cost until they reduce mosquito numbers; however, vector numbers increase as resistance evolves6,7,8.
Other strategies, such as infecting Aedes aegypti with Wolbachia bacteria, have also been applied and assessed. Infection triggers changes in the mosquito’s immune system that are capable of interrupting the chain of infection in diseases such as dengue 9.
In 2002, the Brazilian government created the National Dengue Control Program (PNCD, acronym in Portuguese), which proposed changes in the control of arboviruses, emphasizing the importance of social mobilization and public adherence, and encouraging people to take responsibility for managing potential breeding sites. The PNCD was a milestone in arbovirus control in Brazil10.
Health education has assumed a prominent position in control interventions, being viewed as an essential prevention strategy. Education enables the construction of the foundations of a sustainable society, driving cultural and social changes that facilitate social and environmental improvements that are necessary to strengthen individual and collective care for the environment, which in turn is essential for eliminating the risk of mosquito breeding8,11.
An integrative review conducted in 2013 investigating health education strategies for arbovirus control used in Brazil found that only a small number of publications associate the fight against these diseases with health education. The study identified the need to change education strategies, making it clear that traditional forms of education have not been enough to motivate the population to implement effective vector control measures12.
In view of government investment in policies to mobilize public support for the fight against arboviruses and gaps in research in Brazil on control strategies using education actions, this study was designed around the following guiding questions: What education-based arbovirus control strategies have been implemented worldwide and published in the scientific literature? What were the results reported in the respective studies?
The answers to these questions provide a theoretical framework that can support the planning of education-based vector-borne disease response programs and policies aimed at reducing the spread of the main diseases transmitted by the mosquito Aedes aegypti. The aim of this study was therefore to provide a synthesis of published studies investigating education-based arbovirus control strategies.
METHOD
We conducted an integrative literature review, which is a method that enables the collection, critical analysis and synthesis of available evidence on a topic of interest, where the final product is the current state of knowledge on that topic. To this end, we followed the following six stages: 1) identification of the research question; 2) literature search; 3) study categorization; 4) analysis of the studies included in the review; 5) results interpretation; and 6) presentation of the review13.
The literature search was guided by the following research questions: What education-based arbovirus control strategies have been implemented worldwide and published in the scientific literature? What were the results reported in the respective studies?
A search of the following databases was performed in 2016: Latin American and Caribbean Health Sciences Literature (LILACS), Nursing Database (BDENF), and Medical Literature Analysis and Retrieval System Online (MEDLINE). The Portuguese terms “Educação em Saúde” (“Health Education”) and “Aedes” from the Health Sciences Descriptors (DeCS) were cross referenced using the Boolean operator “AND”.
The following filters were applied in all searches: full text availability; studies published between 2010 and 2016. The first filter was applied due to lack of research funding to purchase non-free articles and the second was applied assuming that studies published during this period would provide an up-to-date picture of the knowledge on the topic of interest. We included articles written in Portuguese, English and Spanish.
We excluded letters to the editor and editorials, due to limitations in their scientific rigor, duplicate articles, and studies that were not consistent with the review’s aim, as shown in Figure 1 (“Eligibility”).
Figure 1

The searches retrieved 242 results. After applying the above filters, the titles, abstracts and full versions of the articles were read to verify whether they met the review inclusion and exclusion criteria, resulting in 59 studies (Figure 1).
The full versions of the 59 articles were then read to identify content and those publications that did not meet the review’s objectives were excluded, resulting in a final sample of 14 studies (Figure 1).
The data from the included articles were entered into a Microsoft Excel worksheet and organized into the following categories: authors, article title, journal, year of publication, country, study period, language, type of study, participants, mosquito control interventions, findings, and conclusions.
The data were analyzed using a qualitative approach involving the detailed reading of the articles to identify thematic categories. A total of four categories were identified. To facilitate the understanding of the findings, the data were summarized and compiled in boxes.

RESULTS
The 14 studies included in the integrative review are all scientific articles published in journals. Most of the articles were written in English (N = 9, 64.2%), followed by Spanish (N = 3, 21.4%) and Portuguese (N = 2, 14.2%). Most of the studies adopted an experimental research design (N=9, 64.2%), followed by quasi-experimental (N=3, 28.5%) and an experience report (N=1, 7.1%). The studies were conducted in different continents, predominantly Latin America. The country with the largest number of studies was Brazil (N=3).
The content analysis identified four thematic categories. The first was “Vector control actions based on community capacity building”, consisting of six studies shown in Box 1. The education interventions in these studies were implemented in schools and households. The target audiences were teachers, adults, children, students, community leaders, school janitors and other professionals. The main methods used were capacity building involving the use of leaflets, conferences, workshops, slides, websites and talks.
The second category was “Social mobilization for arbovirus control”, consisting of six studies shown in Box 2. The studies in this category focused on Education interventions involving community mobilization. Actions were developed in neighborhoods, communities and with groups. In addition to the distribution of educational material, the interventions included clean-up campaigns involving litter-picking, group clean-ups, school competitions and collection of recyclable material.
The third category was “Education-based vector control combined with biological control”, consisting of just one study using natural predators in conjunction with education actions (Box 3).
The fourth category, “Integrated arbovirus control actions”, consisted of one study of interventions involving education actions integrated with the implementation of public policies.
Box 1
Box 2
Box 3
Box 4

The interventions that achieved satisfactory results were those that employed multiple arbovirus response strategies focusing on community mobilization, active methods and the involvement of local authorities.

DISCUSSION
The articles were mostly written in English, reflecting the hegemony of this language. The fact that we found studies undertaken in different countries demonstrates that countries from different continents are seeking to improve and develop alternative strategies that contribute to the prevention of health problems caused by arboviruses.
The number of studies conducted in Brazil is explained by the environmental and structural factors in the country that contribute to the persistence of health problems caused by Aedes, thus demanding a greater focus on research in this area1. However, despite the predominance of studies in Brazil, the number of publications may be considered relatively small, given that these diseases are endemic in the country. Our findings are consistent with a previous integrative review on the use of education actions to control arboviruses, which found only five publications in Brazil12.
Category 1 included studies that used education strategies designed to increase public knowledge of arboviruses with the aim of sensitizing participants to interventions that are capable of managing mosquito-breeding habitats, making them vector-free.
The effectiveness of the strategies used in this category depends on community engagement in key aspects of disease prevention, such as mosquito management and identifying and eliminating mosquito breeding sites. It is essential to address the impact of the vector on communities and suggest simple control measures to raise public awareness of the importance of adhering to response strategies18.
Box 1 shows that the interventions in which the main education strategy was the distribution of educational brochures did not obtain significantly different results when compared to non-intervention areas. Strategies that rely solely on education materials are too passive in motivating the public to implement effective arbovirus prevention measures. Traditional passive means of education, long considered the gold standard for mosquito control, are not sufficient to motivate the public to eliminate mosquito breeding sites16.
A previous integrative review also showed that many education actions take the form of talks given by qualified professionals, resulting in vertical and unattractive education. These strategies have several limitations that need to be addressed to ensure good quality health education. Factors related to lack of public participation include public resistance to campaigns and the trivialization of the problem, where diseases are seen as part of everyday life rather than a public health problem12.
A study showed that repeated measures analysis of variance showed significant differences between sites where there was active education and those where passive education was adopted, demonstrating that the former approach is capable of reducing mosquito sources and improving community behavior25.
With regard to the characteristics of education materials, it was possible to observe that materials with color variations were more effective in conveying the message than black and white material, with the latter showing similar results to interventions that did not provide materials. Education materials should therefore use appropriate language and layout and design to make them as attractive as possible and easy to understand16.
In addition to homes, schools and other public spaces were chosen as settings for education interventions. This finding demonstrates that there have been major advances in vector control actions, with strategies no longer limiting their scope to households, as observed in previous years19. Expanding the scope of actions to include a range of different public spaces is warranted by the fact that these spaces are also common mosquito habitats25.
A large number of studies included in the review used schools as intervention sites, which are regarded as suitable settings for community-based programs. School-based campaigns are also generally low cost and provide promising results. Through such programs, it is possible to increase the knowledge of school children and improve attitudes and mosquito management practices, strengthening their capacity to promote changes in attitudes towards tackling the diseases transmitted by the mosquito19, 21. The variation in the age, sex, level of education and occupation of study participants demonstrates the importance an overall population approach and how each population group, according to their particular characteristics, is responsible for combatting and reducing the diseases transmitted by Aedes in different contexts, schools, streets, homes and workplaces.
Endemic disease control agents are a priority group among professionals who require continuous training. These agents work directly with vector control and are a direct point of communication with the community, meaning that it is important that they receive continuous training, update their knowledge and improve practices. Factors such as having spent a long time in the profession and lack of work incentives mean that managers should provide periodic refresher training18.
The analysis of the studies included in category 2 show that vector control strategies have been gradually implemented in a coordinated manner. In addition to capacity building, they include activities involving community participation in the form of group clean-ups and collection of recyclable material. These activities promote the active participation of the community, making it part of vector control efforts. This approach is consistent with the measures proposed by the PNCD10.
Public participation helps to break the authoritarianism of health care and health surveillance services, reinforcing the need to reflect on public participation in health actions and the incorporation of activities aimed at promoting community participation in the control of endemic diseases into government guidelines24. According to some researchers, the strategies that are effective in improving knowledge and practices and empowering the community for the prevention and control of vector-borne diseases are those that involve social mobilization17.
Our findings also point to the need to train other professionals responsible for maintaining public spaces (school janitors, general cervices assistants, etc.). The provision of training for these professionals is essential, as they generally demonstrate a high level of confidence in their work and have a low level of education, which can negatively affect mosquito control19.
Communities with a historically strong organizational culture have greater capacity to cope with this type of problem. On the other hand, poor leadership influences community dynamics, hampering efforts to resolve collective problems. It was possible to observe that arbovirus control strategies in neighborhoods in which people demonstrated initiative, public participation, commitment and leadership were successful23.
The study included in Category 3 highlights the importance of education actions even when interventions use biological control methods, such as those involving fish species. Biological control using larvae predators in water storage tanks is another alternative adopted by many public managers. However, studies show that biological control without education strategies is not sufficient to reduce larvae27,28.
The use of fish in water tanks as a control strategy is fairly common in Brazil. Fish species used include Betta splendens, Trichogaster trichopterus, Xiphophorus maculatus and Poecilia reticulata. Although all species are effective in eliminating mosquito larvae, when placed in environments that have both larvae and a higher quantity of substrates that the fish also feed on, the fish eat the substrates rather than the larvae29.
According to the studies, isolated, irregular and vertical larva control programs without any community involvement tend to be unsuccessful22. When using natural predators, it is essential to instruct the community on proper water storage practices and alternative fish feed in the absence of larvae27,28.
Category 4 consisted of an intervention that integrates multiple arbovirus control strategies. Although the education strategies demonstrated great potential, on their own they would be insufficient to prevent this public health problem, with other factors such as the provision of quality public health, infrastructure, security and leisure services playing an essential role28. Studies show that, when used on their own, interventions such as health education, biological control and insecticides are not effective, highlighting that the combination of multiple strategies and the involvement of local authorities is essential29.
The provision of essential services in all communities should be a priority for public managers. This requires investment to revitalize neighborhoods, improve basic sanitation and build roads, sidewalks and parks, the provision of adequate security and waste collection services, improved housing, and the use of different mediums to inform the public about the importance of keeping the environment free from health risks30.
There is an urgent need for a paradigm shift, moving from a top-down approach to a horizontal one, and the incorporation and strengthening of epidemiological and entomological surveillance28. Arboviruses need to be understood as everyone’s problem, whose solution lies in uniting states, services, professionals and the population. Responsibilities should therefore be shared and government and civil society should work together to create solutions. The seasonal nature of campaigns should be replaced by permanent education that values popular knowledge and promotes interventions tailored to local realities and culture, and the education process should be horizontal12.
Although the “war against the mosquito” is a pressing need, it should not conceal the fact that the list of enemies of health is a lot longer. The immediate suspension of cuts in social spending is urgently needed, together with the prioritization of investment in basic sanitation and strengthening of the country\'s public health care system, the Sistema Único de Saúde (SUS) or Unified Health System. Only an efficient health system can ensure the continuity of health care. Furthermore, there is an urgent need to create a scientific agenda that includes major investment in research to better assess the efficacy and cost-effectiveness of interventions implemented in different setttings30.

FINAL CONSIDERATIONS
The findings show that health education is an essential element of arbovirus control and should be implemented in conjunction with other vector control strategies. Education actions for combating Aedes aegypti contribute to improving knowledge and changing community behavior, sensitizing the public to the need to manage mosquito habitats.
The following positive results were associated with the use of education strategies: reduction of mosquito habitats; elimination of breeding sites; decrease in vector infestation levels; and improved vector control knowledge, attitudes and practices, contributing to the empowerment of communities.
Education interventions focusing on diseases transmitted by Aedes aegypti are key actions that should be implemented continuously in a participatory manner and using active methods. These methods have been shown to provide satisfactory results from a health promotion perspective, unlike vertical teaching appraoches, which are limited in their ability to motivate the community to control vectors.
Based on the results of this integrative review, it is recommended that pubic managers and civil society representatives engage in frequent dialogue with all segments of the community to identify the main factors influencing vector control, considering that each community has its own specific characteristics. These actors should define priorities for ensuring that environments are free of vector-borne diseases, including social mobilization, investment in health, security, leisure, infrastructure and, above all, basic sanitation.

REFERENCES

1. Lopes N, Linhares REC, Nozawa C. Características gerais e epidemiologia dos arbovírus emergentes no Brasil. Rev Pan-Amaz Saude 2014; 5(3):55-64.
2. Lima-Camara TN. Arboviroses emergentes e novos desafios para a saúde pública no Brasil. Rev Saúde Pública 2016;50:36.
3. Boeuf P, Drummer HE, Richards JS, Scoullar MJL, Beeson JG. The global threat of Zika virus to pregnancy: epidemiology, clinical perspectives, mechanisms, and impact. BMC Medicine 2016; 14:112.
4. Fauci AS, Morens DM. Zika Virus in the Americas — Yet Another Arbovirus Threat. N engl j med 2016; 374:601-604.
5. Carvalho NS, Carvalho BF, Dóris B, Biscaia ES, Fugaça CA, Noronha L. Zika virus and pregnancy: An overview. Am J Reprod Immunol 2017; 77:e12616.
6. Al-Muhandis N, Hunter PR. The Value of Educational Messages Embedded in a Community-Based Approach to Combat Dengue Fever: A Systematic Review and Meta Regression Analysis. PLoS Negl Trop Dis. 2011; 5:e1278.
7. Luz PM, Vanni T, Medlock J, Paltiel AD, Galvani AP. Dengue vector control strategies
in an urban setting: an economic modelling assessment. Lancet 2011; 377(9778):1673-1680.
8. Seley CM, González LJ, Tornese ML, Marchesi Olid LS, Martínez FN, Rossi ML, Troncoso A. Dengue and dengue haemorrhagic fever: its history and resurgence as a global public health problem: progress and challenges. Prensa Med Argent 2009;96(7):395-406.
9. Batista G, Thomé RCA, Pastore DH, Arruda EF, Dias CM, Yang HM. Modelagem do Aedes aegypti utilizando a bacteria Wolbachia como agente de controle. Blumenau-SC. XLIX Simpósio Brasileiro de Pesquisa Operacional 2017; 27-30 de Ago.
10. Ministério da Saúde (BR). Fundação Nacional de Saúde. Dengue: aspectos epidemiológicos, diagnóstico e tratamento. Brasília: Fundação Nacional de Saúde, 2002.
11. Ioosa S, Mallet HP, Goffart IL, Gauthier V, Cardoso T, Herida M. Current Zika virus epidemiology and recent epidemics. Médecine et maladies infectieuses 2014; 44:302-307.
12. Silva VB, Mallmann DG, Vasconcelos EMR. Estratégias de combate à dengue através da educação em saúde: uma revisão integrativa. Saúde (Santa Maria). 2015; 41(2):27-34.
13. Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm 2008;17(4):758-764.
14. Galvão TF, Pansani TSA, Harrad D. Principais itens para relatar Revisões sistemáticas e Meta-análises: A recomendação PRISMA. Epidemiol. Serv. Saúde 2015; 24(2):335-342.
15. Bartlett-Healy K, Hamilton G, Healy S, Crepeau T, Unlu I, Farajollahi A. Fonseca D, Gaugler R, Clark GG, Strickman D. Source reduction behavior as an independent measurement of the impact of a public health education campaign in an integrated vector management program for the Asian tiger mosquito. Int. J. Environ. Res. Public Health 2011; 8:1358-1367.
16. Cáceres-Manrique FM, Angulo-Silva MP, Vesga-Gómez C. Eficacia de la movilización y la participación social para la apropiación o "empoderamiento" (sic.) (empowerment) de las medidas de control del dengue, Comuna Norte, Bucaramanga, 2008-2009. Biomédica 2010; 30:539-50.
17. Contreras NH, Oliva JN, Francisco NC, Valdés LS, Álvarez HH, Cantelar NC. Impacto de una intervención educativa en trabajadores de la campaña antivectorial. Revista Cubana de Medicina Tropical 2012; 64(3):304-314.
18. Hernández-Suárez CM, Mendoza-Cano O. Empirical evidence of the effect of school gathering on the dynamics of dengue epidemics. Glob Health Action 2016, 9:28026.
19. Silva PC, Martins AM, Schall VT. Cooperação entre agentes de endemias e escolas na identificação e controle da dengue. Rev Bras Promoc Saude 2013; 26(3):404-411.
20. Torres JL, Ordóñez JG, Vázquez-Martínez MG. Conocimientos, actitudes y prácticas sobre el dengue en las escuelas primarias de Tapachula, Chiapas, México. Rev Panam Salud Publica 2014; 35(3):214-218.
21. Arunachalam N, Tyagi BK, Samuel M, Krishnamoorthi R, Manavalan R, Tewari SC, Ashokkumar V, Kroeger A, Sommerfeld J, Petzold M. Community-based control of Aedes aegypti by adoption of eco-health methods in Chennai City, India. Pathogens and Global Health 2012; 106(8):488-496.
22. Caprara A, Lima JWO, Peixoto ACR, Motta CMV, Nobre JMS, Sommerfeld J, Kroeger A. Entomological impact and social participation in dengue control: a cluster randomized trial in Fortaleza, Brazil. Trans R Soc Trop Med Hyg 2015; 109:99-105.
23. Costa MMC, Barbosa MJP, Freitas VC, Albuquerque PC. Amigos do bairro contra dengue: a experiência do distrito sanitário da III secretaria de saúde do Recife, implantação de um projeto de participação popular em saúde. Rev APS 2012; 15(4):517-521.
24. Healy K, Hamilton G, Crepeau T, Healy S, Unlu I, Farajollahi A, Fonseca D Integrating the Public in Mosquito Management: Active Education by Community Peers Can Lead to Significant Reduction in Peridomestic Container Mosquito Habitats. PLoS One 2014; 9:e108504.
25. Kittayapong P, Thongyuan S, Olanratmanee P, Aumchareoun W, Koyadun S, Kittayapong R, Butraporn P. Application of eco-friendly tools and eco-biosocial strategies to control dengue vectors in urban and peri-urban settings in Thailand. Pathogens and Global Health 2012; 106(8):446-454.
26. Mitchell-Foster K, Ayala EB, Breilh J, Spiegel J, Wilches AA, Leon TO, Delgado JA. Integrating participatory community mobilization processes to improve dengue prevention: an eco-bio-social scaling up of local success in Machala, Ecuador. Trans R Soc Trop Med Hyg 2015; 109:126-133.
27. Ghosh SK, Chakaravarthy P, Panch SR, Krishnappa P, Tiwari S, Ojha VP, Manjushree R, Dash AP. Comparative efficacy of two poeciliid fish in indoor cement tanks against chikungunya vector Aedes aegypti in villages in Karnataka, India. BMC Public Health 2011; 11:599.
28. Nam VS, Yen NT, Duc HM, Tu TC, Thang VT, Le NH, San LH, Loan LL, Huong VTQ, Khanh LHK, Trang HTT, Lam LZY, Kutcher SC, Aaskov JG, Jeffery JAL, Ryan PA, Kay BH. Community-Based Control of Aedes aegypti By Using Mesocyclops in Southern Vietnam. Am. J. Trop. Med. Hyg 2012; 86(5):850-859.
29. Paiva CN, Lima JW, Camelo SS, Lima Cde F, Cavalcanti LP. Survival of larvivorous fish used for biological control of Aedes aegypti (Diptera: Culicidae) combined with different larvicides. Tropical Medicine & International Health. 2014; 19(9):1082-1086.
30. Possas, C. Zika: what we do and do not know based on the experiences of Brazil. epidemiology and Health. 2016; 38:e201602