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      COVID-19: challenges for a new epoch

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      Revista da Sociedade Brasileira de Medicina Tropical

      Sociedade Brasileira de Medicina Tropical - SBMT

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          Abstract

          Dear Editor: The term “pan-epidemic Anthropocene” was proposed by Lucey et al. to refer to multifocal large infectious disease epidemics related to anthropogenic forces that have impacted and transformed the Earth System 1 . Smallpox was restricted to the Old World for thousands of years but became the first “pan-epidemic Anthropocene” when Europeans brought it to the Americas in the 16th century. The arrival of Europeans in America was considered as the first globalization event where the two civilizations met on unequal terms after 12,000 years of separation. Smallpox emerged in January 1519 and spread rapidly to the mainland of Central America. Native Americans had no immunity to the infections brought in by the Europeans. Smallpox, influenza, measles, typhus, pneumonia, scarlet fever, malaria, and yellow fever emerged subsequently and affected millions. Approximately 90% of the estimated 50-80 million Native American population died of these diseases, which suggests approximately 10% of mankind died during 1493-1650. This event initiated the globalization and homogenization of the world’s species and diseases 2 . In the 20th century, epidemics and pandemics continued to kill millions of people. The first pandemic of the 21st century was reported as influenza A (H1N1) in 2009-2010 that resulted in 100,000-400,000 deaths in the first year; however, for the first time, a vaccine was developed, produced, and distributed worldwide during the first year 3 . Globalization, the exchange of species, materials, energy, and culture, as well as urbanization and the increase in the world’s population and the global flow of people, had a clear, and probably irreversible, impact on the environment and the equilibrium of the Earth System that led to the proposal of a new geological Epoch, called Anthropocene 4 . The term “Anthropocene” was proposed by Crutzen and Stoermer in 2000, to emphasize the central role of mankind in geology and ecology 5 . The increasing impact of human actions on the environment was substantial, global, and long-lasting 2 . There is an increasing consensus on the formal recognition of Anthropocene as a geological Epoch, functionally and stratigraphically distinct from the Holocene 6 . New anthropogenic materials such as plastics, concrete, aluminum, and synthetic fibers; modification of sedimentary process; wastes from nuclear weapons testing; increase in atmospheric methane and CO2 concentrations; changes in carbon, nitrogen, and phosphorus cycles; climate and biotic changes are clear Earth System trends that confirm the transformations to be driven by human residents. Globalization, urbanization, transportation, increase in economic activities, and the flux of people, live species, and manufactured products are clear socioeconomic trends that characterize this new epoch, commonly referred to as “Human Epoch.” All these factors, in addition to political destabilization and civil and international wars, led to poverty, increase in maternal and child death, and spread of diseases. Hotez 7 reported that these changes have promoted the emergence of catastrophic neglected tropical diseases (NTDs), first being dengue fever in the 1980s in the American continent, chikungunya and Zika virus infections in Latin-American and Caribbean regions, and malaria in the Amazonian region of South America. NTDs along with other infections such as leishmaniasis, schistosomiasis, and Middle East Respiratory Syndrome (MERS) coronavirus infection, measles, and polio spread in the Middle East and North Africa. During 2014-2015, the Western African Ebola virus epidemic decimated numerous families and caused a socioeconomic disruption in Guinea, Liberia, and Sierra Leone. The outbreak of COVID-19 provides strong evidence that urbanization and globalization have changed the way people live in communities, and advances in transport and communications have led to a rapid spread of diseases, through both domestic and international transportation modes such as buses, trains, boats, and flights. Increased density of people in residences, public transportation, work environments, shopping centers, and cultural, political, sport, and religious events have increased the possibilities of virus transmission in the metros. Social inequalities lead to higher risks, particularly in middle- and low-income countries that generally have weaker health systems and a limited capacity to handle a rapid surge in cases. Poverty contributes to disseminating epidemics and pandemics, while simultaneously helping to perpetuate poverty through their longstanding negative effects. As no specific drugs or vaccines are available, the mitigation of the exponential spread of COVID-19 relies on community mitigation strategies 8 . There is a crescent consensus that social isolation to prevent the virus spread is the correct strategy from not only the human rights point of view but also the economic point of view. It seems clear that the collapse of the health care systems and millions of deaths would decimate countries financially, and as a society, thus saving human lives must be the governments’ first priority. Although the pandemic is a global phenomenon and the consequence of urbanization, transport, and interchange of people, live species, and manufactured products, its impact is greatly shaped by decisions taken by the individual governments. Many governments responded swiftly while others, after an initial slow response, acknowledged their error and adopted the World Health Organization’s (WHO) recommendations. Unfortunately for all, some are still ignoring WHO’s recommendations on avoiding mass gatherings. Recently, Croda et al. 9 reported on the progression of COVID-19 cases in Brazil and previous experiences with other health emergencies that constituted an important legacy in dealing with epidemics and demonstrated Brazil’s scientific capacity. They also discussed the initially implemented measures to reduce the virus spread and mortality. Despite the exceptional efforts by the state governors and city mayors, the response of the country’s President contributes to the growing uncertainty among the population about the health risks and economic impacts of the pandemic 10 . In uncertain times, positive leadership navigates through a crisis; leaders are required to make the right decisions based on science and to craft a good narrative to clarify the problems and unite the population to manage the situation. Global problems require global solutions and everybody’s efforts. In addition to all the negative impacts, the pandemic has opened new opportunities, displayed examples of solidarity in the local communities, and allowed sharing of resources, information, and expertise from countries further ahead in the pandemic or with better results and knowledge in controlling the spread. The scientific communities worldwide have joined hands and many universities have organized groups of researchers and students to help in the pandemic relief efforts in every possible manner. The pandemic is a strong reminder that to be prepared for the future, a fundamental change in our mindset, commitments, and values is necessary. It is necessary to create a change in our current way of living and a concentrated effort to establish conditions for humanity to manage itself in the Anthropocene, the “Age of Humans.” British economist Kate Raworth, from Oxford University, has rightly mentioned that humanity’s 21st-century challenge is to meet the needs of all within the means of the Planet 11 . Her model, known as “Doughnut Economics”, has recently been adopted to guide Amsterdam out of the economic impact left by the coronavirus pandemic 12 . Environmental repair, renewable energy, more investments in science, public health, and education are needed to reduce inequalities, climate changes, and the human impact on Earth’s equilibrium, else, humanity will never be prepared enough to confront the devastating challenges of a pandemic. Humans have the opportunity of saving their own lives and the life of all species in the Earth System through advanced technology and science. Preparedness is crucial to reduce the health, economic, and social impacts of a future epidemic, it is also the only way to avoid the spread of other diseases. Pandemics are not aleatory events but are the consequence of human interactions with the environment and could be avoided or reduced through science and investments in health, education and transportation and improved through better conditions of living. This is an opportunity for the global community to take advantage of the spirit of cooperation, embrace diversity and arrive at a necessary common global agreement to manage the future of Earth collectively.

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          COVID-19 in Brazil: advantages of a socialized unified health system and preparation to contain cases

          Abstract The outbreak of new coronavirus disease 2019 (COVID-19) reported for the first time in Wuhan, China in late December 2019 have rapidly spread to other countries and it was declared on January 30, 2020 as a public health emergency of international concern (PHEIC) by the World Health Organization. Before the first COVID-19 cases were reported in Brazil, several measures have been implemented including the adjustment of legal framework to carry out isolation and quarantine. As the cases increased significantly, new measures, mainly to reduce mortality and severe cases, have also been implemented. Rapid and robust preparedness actions have been undertaken in Brazil while first cases have not yet been identified in Latin-American. The outcome of this early preparation should be analyzed in future studies.
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            The “Anthropocene”

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              Neglected Tropical Diseases in the Anthropocene: The Cases of Zika, Ebola, and Other Infections

               Peter Hotez (2016)
              While we advance through a geological epoch that increasingly reflects human intervention on a massive scale, we might expect to see the continued expansion of epidemic neglected tropical diseases, as we have recently seen for Zika and Ebola virus infections. Emerging evidence indicates that the Holocene, our most recent geological epoch that began at the end of the last ice age almost 12,000 years ago, has undergone some fundamental changes because of human activity. Since the origins of agriculture and deforestation and later accelerating with the industrial revolution, followed by rapid 20th century population growth extending into the nuclear age, our planet has undergone a fundamental and seemingly irreversible geological shift [1]. According to many (but not all) prominent Earth scientists, humans have profoundly altered the planet, thereby ushering in a new and so-called Anthropocene epoch (Fig 1). 10.1371/journal.pntd.0004648.g001 Fig 1 Geological epochs over the last 5 million years. In a January 2016 article in Science, Colin Waters from the British Geological Survey and his colleagues provide important geochemical evidence to support designating the end of the Holocene as the Anthropocene [1]. It includes data showing increasing lead levels after World War II, altered soil nitrogen and phosphorous levels because of increased fertilizer use, and the appearance of newly created radionuclides, beginning with the atomic bomb tests in the New Mexico desert at Los Alamos [1]. Alongside these human-induced geochemical signatures are elevated carbon dioxide and methane levels and sharp increases in average global temperatures [1]. Levels of concrete and plastic have also dramatically increased in recent years, while in parallel, there has been massive loss of animal and plant species [2]. Species extinctions have reached unprecedented levels [1,3]. In this late Anthropocene epoch, we have seen significant increases in the incidence or prevalence rates of several neglected tropical diseases (NTDs), due partly or mostly to human-induced changes to our planet. This is especially true for NTDs transmitted by invertebrate vectors, including mosquitoes, kissing bugs, and snails, as well as highly lethal zoonotic virus infections from bats and other mammals. For example, in the Americas, dengue fever reemerged in the 1980s, while chikungunya and Zika virus infections have aggressively spread across the Latin American and Caribbean region. Venezuela in particular has seen dramatic increases in malaria and most of its neglected tropical diseases (NTDs), including Chagas disease, schistosomiasis, and Zika virus infection, for which unprecedented urban foci are also occurring [4]. Across the Atlantic Ocean, Southern Europe has of late seen the emergence or reemergence of malaria in Greece, West Nile virus infection and chikungunya in Italy and Spain, dengue in Portugal, and schistosomiasis on the French island of Corsica [5]. The Middle East and North Africa (MENA) region is now considered one of the worst-affected global hotspots for NTDs and other emerging infections such as leishmaniasis, schistosomiasis, and MERS coronavirus infection; measles and polio have also returned [6]. Ebola caused thousands of deaths and overwhelmed the health systems of Guinea, Liberia, and Sierra Leone in West Africa in 2014–2015 [7], while East Africa and the Sahel are considered among the most important regions for kala-azar and multiple other NTDs [8]. Schistosomiasis continues to increase throughout Africa, where it is now a major cofactor in its AIDS epidemic [9]. Southeast Asia has seen the rise of Nipah and Hendra virus from bats, in addition to drug resistant malaria, enterovirus 71, melioidosis, and foodborne trematodiases transmitted by snails [10]. Several human activities that characterize the Anthropocene account for the increases in NTDs. It is instructive to see how some of these factors illustrated in Fig 2 helped to facilitate the emergence of two of the most devastating NTDs in 2014 and 2015—Ebola and Zika virus infections, respectively, as well as other high-disease-burden NTDs such as the cutaneous and visceral forms of leishmaniasis and schistosomiasis. 10.1371/journal.pntd.0004648.g002 Fig 2 The major forces arising out of the Anthropocene now promoting the emergence of catastrophic neglected tropical diseases (NTDs). Poverty and Blue Marble Health As has been said very frequently in our editorials, poverty is front and center. NTDs are most common in the setting of poverty [11,12], while simultaneously helping to perpetuate poverty through their long-standing negative effects on maternal and child health and human productivity and labor [13,14]. Ebola has so far emerged almost exclusively in impoverished nations such as the Democratic Republic of Congo or Guinea, Liberia, and Sierra Leone, while Zika is disproportionately affecting impoverished areas such as Brazil’s poorest northeastern provinces. In the case of Zika or other vector-borne NTDs such as leishmaniasis and Chagas disease, poverty equates to poor quality housing, in addition to uncollected garbage and standing water in poor neighborhoods that allow certain insects to breed nearby. For these reasons, we might expect poor countries such as Haiti or Jamaica to suffer greatly from the advance of Zika in the Caribbean region. Yet another feature of Zika, leishmaniasis, Chagas disease, and other NTDs are their propensity to strike the poorest people who live in the wealthier group of 20 countries, such as Brazil or Mexico. The concept of “blue marble health” has been invoked to describe the surprising disease burden of NTDs among the poor living in these countries [15]. Today, most of the world’s NTDs paradoxically occur in the world’s largest economies, but mostly among the disenfranchised poor in those nations [15]. Political Destabilization, Conflict, and Post-conflict Next to poverty, these forces may account for the largest risk factor for NTDs [6,16,17]. The long-standing atrocities and civil and international conflicts decimated the health systems of Guinea, Liberia, and Sierra Leone, thereby allowing Ebola and Lassa fever to flourish [7,17], while these same forces facilitated the rapid spread and lethality of human African trypanosomiasis and kala-azar in Africa [8,18]. Conflict and post-conflict settings are central to the massive epidemic of cutaneous leishmaniasis in the Middle East [6]. While Zika has so far not been linked to these factors, the political destabilization in Venezuela could become a contributory factor. Deforestation In Asia, deforestation may have increased human and bat contact to promote Nipah and Hendra viruses and SARS [10]. Deforestation is also an important factor promoting the expansion of vector borne NTDs, including leishmaniasis [19]. Deforestation has been noted to have some possible links with the emergence of Ebola [20]. For instance, the Guinea forest region where Ebola emerged in 2014 has been severely and adversely affected by clear-cut logging [7]. Dams Bodies of fresh water arising from large-scale hydroelectric projects can help aquatic snails to proliferate, including those that transmit schistosomiasis in Africa and foodborne trematodiases in Asia. Dams and newly formed reservoirs of fresh water also create mosquito breeding sites for arbovirus infections and malaria and also facilitate waterborne intestinal infections [21]. In China, on the other hand, the Three Gorges Dam on the Yangtze River has assisted flood control and so far has not been shown to promote the emergence of Schistosoma japonicum infection [22]. Urbanization and Human Migrations The large-scale movement of human populations into cities can create crowded conditions, which together with destruction of the environment favor arthropod vectors [23], including the Aedes aegypti mosquito that transmits Zika, dengue, chikungunya, and yellow fever. Accelerated urbanization that outpaces sanitation and sewage control infrastructures is also a key factor in the endemicity of leptospirosis and enteric NTDs [24,25]. Overall, human migrations of immunologically naïve populations to endemic regions have accounted for rapid spread of infections, as well as the converse—infected populations introducing new diseases. The 2014 Brazilian FIFA World Cup soccer games may have been a factor in bringing Asian populations with Zika into areas where Aedes aegypti is found, although this hypothesis has since been dismissed [26]. However, the annual Hajj, the Muslim pilgrimage to Mecca that brings millions of people to Saudi Arabia, has also been postulated as having helped introduce dengue [27,28], as it could Zika virus infection in 2016 or 2017. The Hajj has also had a role in the emergence of meningococcal disease and other acute respiratory infections [29,30]. Climate Change and El Niño Events Major climate change events in the Anthropocene include increased temperatures and altered rainfall patterns that expand arthropod vector habitats and ranges. Such factors could be responsible for accelerating the geographic expansions of arbovirus infections [31,32], leishmaniasis [33], and Chagas disease [34], but this concept requires further exploration. In addition, we are just beginning to understand the role of El Niño events in promoting these and other NTDs [35,36]. The fact that Zika virus expanded dramatically in an El Niño year is also of interest, but as yet, there are no proven links. Many of the factors highlighted above were either manufactured or shaped by human activity. The dramatic expansions in the number of cases of arbovirus infections caused by dengue, chikungunya, and now Zika in recent years, together with a recent explosive Ebola outbreak in 2014–2015, give us pause to evaluate human influence on the biosphere and to recognize that beyond globalization, the Anthropocene could become a dominant theme for spreading NTDs or creating catastrophic human epidemics in the years to come.
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                Author and article information

                Journal
                Rev Soc Bras Med Trop
                Rev. Soc. Bras. Med. Trop
                rsbmt
                Revista da Sociedade Brasileira de Medicina Tropical
                Sociedade Brasileira de Medicina Tropical - SBMT
                0037-8682
                1678-9849
                01 June 2020
                2020
                : 53
                Affiliations
                [1 ] Universidade Federal do Rio de Janeiro, Instituto de Química, Rio de Janeiro, RJ, Brasil.
                [2 ] Universidade Veiga de Almeida, Rio de Janeiro, RJ, Brasil.
                Author notes
                Corresponding author: Prof. Graciela Arbilla. e-mail: gracielaiq@ 123456gmail.com

                Authors’ contribution: All authors contributed towards the conceptualization, drafting, critical review, and finalization of the manuscript.

                Conflict of Interest: The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this manuscript.

                Article
                00913
                10.1590/0037-8682-0270-2020
                7269525
                32491108

                This is an open-access article distributed under the terms of the Creative Commons Attribution License

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