Maternal health surveillance panel: a tool for expanding epidemiological surveillance of women's health and its determinants.

OBJECTIVE: To present the methodology used in the development of two products for maternal health surveillance and its determinants and discuss their possible uses. METHODS: Based on a theoretical model of the determinants of maternal death and databases of Brazilian health information systems, two free products were developed: an interactive panel "surveillance of maternal health" and an educational material "Aparecida: a story about the vulnerability of Brazilian women to maternal death", both available on the website of the Brazilian Obstetric Observatory. RESULTS: More than 30 indicators were calculated for the period 2012-2020, containing information on socioeconomic conditions and access to health services, reproductive planning, prenatal care, delivery care, conditions of birth and maternal mortality and morbidity. The indicators related to severe maternal morbidity in public hospitalizations stand out, calculated for the first time for the country. The panel allows analysis by municipality or aggregated by health region, state, macro-region and country; historical series analysis; and comparisons across locations and with benchmarks. Information quality data are presented and discussed in an integrated manner with the indicators. In the educational material, visualizations with national and international data are presented, aiming to help in the understanding of the determinants of maternal death and facilitate the interpretation of the indicators. CONCLUSION: It is expected that the two products have the potential to expand epidemiological surveillance of maternal health and its determinants, contributing to the formulation of health policies and actions that promote women's health and reduce maternal mortality.

Maternal health surveillance panel: a tool for expanding epidemiological surveillance of women's health and its determinants / Painel de vigilância da saúde materna: uma ferramenta para ampliação da vigilância epidemiológica da saúde das mulheres e seus determinantes

ABSTRACT Objective: To present the methodology used in the development of two products for maternal health surveillance and its determinants and discuss their possible uses. Methods: Based on a theoretical model of the determinants of maternal death and databases of Brazilian health information systems, two free products were developed: an interactive panel "surveillance of maternal health" and an educational material "Aparecida: a story about the vulnerability of Brazilian women to maternal death", both available on the website of the Brazilian Obstetric Observatory. Results: More than 30 indicators were calculated for the period 2012-2020, containing information on socioeconomic conditions and access to health services, reproductive planning, prenatal care, delivery care, conditions of birth and maternal mortality and morbidity. The indicators related to severe maternal morbidity in public hospitalizations stand out, calculated for the first time for the country. The panel allows analysis by municipality or aggregated by health region, state, macro-region and country; historical series analysis; and comparisons across locations and with benchmarks. Information quality data are presented and discussed in an integrated manner with the indicators. In the educational material, visualizations with national and international data are presented, aiming to help in the understanding of the determinants of maternal death and facilitate the interpretation of the indicators. Conclusion: It is expected that the two products have the potential to expand epidemiological surveillance of maternal health and its determinants, contributing to the formulation of health policies and actions that promote women's health and reduce maternal mortality.

RESUME Objetivo: Apresentar a metodologia utilizada no desenvolvimento de dois produtos para a vigilância da saúde materna e seus determinantes e discutir as suas possíveis utilizações. Métodos: A partir de modelo teórico dos determinantes do óbito materno e bases de dados dos sistemas de informação em saúde brasileiros, foram desenvolvidos dois produtos gratuitos: um painel interativo denominado "Vigilância da saúde materna" e um material educativo chamado "Aparecida: uma história sobre a vulnerabilidade da mulher brasileira à morte materna", ambos disponíveis no site do Observatório Obstétrico Brasileiro. Resultados: Foram calculados mais de 30 indicadores para o período 2012-2020, contendo informações sobre condições socioeconômicas e de acesso a serviços de saúde, planejamento reprodutivo, assistência pré-natal, assistência ao parto, condições de nascimento e mortalidade e morbidade materna. Destacam-se os indicadores relacionados à morbidade materna grave em internações públicas, calculados pela primeira vez para o país. O painel permite análises por município ou agregadas por região de saúde, unidade da federação, macrorregião e país; análises de série histórica; e comparações entre localidades e com padrões de referência. Dados de qualidade da informação são apresentados e discutidos de forma integrada aos indicadores. No material educativo, visualizações com dados nacionais e internacionais são apresentadas, visando auxiliar na compreensão dos determinantes do óbito materno e facilitar a interpretação dos indicadores. Conclusão: Espera-se que os produtos tenham o potencial de ampliar a vigilância epidemiológica da saúde materna e seus determinantes, contribuindo para a formulação de políticas e ações de saúde que promovam a saúde das mulheres e reduzam a mortalidade materna.

Racial inequalities in mental healthcare use and mortality: a cross-sectional analysis of 1.2 million low-income individuals in Rio de Janeiro, Brazil 2010-2016.

INTRODUCTION: Mental health inequalities across racial and ethnic groups are large and unjust in many countries, yet these inequalities remain under-researched, particularly in low-income and middle-income countries such as Brazil. This study investigates racial and socioeconomic inequalities in primary healthcare usage, hospitalisation and mortality for mental health disorders in Rio de Janeiro, Brazil. METHODS: A cohort of 1.2 million low-income adults from Rio de Janeiro, Brazil with linked socioeconomic, demographic, healthcare use and mortality records was cross-sectionally analysed. Poisson regression models were used to investigate associations between self-defined race/colour and primary healthcare (PHC) usage, hospitalisation and mortality due to mental disorders, adjusting for socioeconomic factors. Interactions between race/colour and socioeconomic characteristics (sex, education level, income) explored if black and pardo (mixed race) individuals faced compounded risk of adverse mental health outcomes. RESULTS: There were 272 532 PHC consultations, 10 970 hospitalisations and 259 deaths due to mental disorders between 2010 and 2016. After adjusting for a wide range of socioeconomic factors, the lowest PHC usage rates were observed in black (adjusted rate ratio (ARR): 0.64; 95% CI 0.60 to 0.68; compared with white) and pardo individuals (ARR: 0.87; 95% CI 0.83 to 0.92). Black individuals were more likely to die from mental disorders (ARR: 1.68; 95% CI 1.19 to 2.37; compared with white), as were those with lower educational attainment and household income. In interaction models, being black or pardo conferred additional disadvantage across mental health outcomes. The highest educated black (ARR: 0.56; 95% CI 0.47 to 0.66) and pardo (ARR: 0.75; 95% CI 0.66 to 0.87) individuals had lower rates of PHC usage for mental disorders compared with the least educated white individuals. Black individuals were 3.7 times (ARR: 3.67; 95% CI 1.29 to 10.42) more likely to die from mental disorders compared with white individuals with the same education level. CONCLUSION: In low-income individuals in Rio de Janeiro, racial/colour inequalities in mental health outcomes were large and not fully explainable by socioeconomic status. Black and pardo Brazilians were consistently negatively affected, with lower PHC usage and worse mental health outcomes.

Delays in treatment initiation and conclusion in women with stage IA to IIIB cervical cancer: A survival study in a hospital-based cohort from a developing country.

AIM: To evaluate the effect of delays in stage IA to IIIB cervical cancer treatment initiation and conclusion on hospital-based survival among Brazilian women. METHODS: A retrospective follow-up study was conducted in a stage IA to IIIB cervical cancer cohort treated from 2012 and 2014 and followed until December 31, 2017 in Rio de Janeiro. Delay in treatment initiation definition was defined based on the Brazilian law of 60 days for treatment initiation after diagnosis. Delay in treatment conclusion was defined based on the literature and sample distributions: < 120/121-200/> 200 days. The endpoint was death(from all causes or cervical cancer). Death causes and dates were obtained by a record linkage procedure between the hospital cancer registry and the Mortality Information System. Global 36-month survival and HRs were estimated by the KaplanMeier method and proportional Cox regression models, respectively. RESULTS: From 865 patients, 269(31.1%) died over the median follow-up time of 27 months. Delay on treatment initiation(>60-days) was 92.8%, while the delay in treatment conclusion(>120 days) was 87.5%. Overall survival was 61.3% (<60-days:62.6%; 61-90 days:63.5%). Among stage IIB-IIIB, women treated < 60-days presented 40.1% survival, while 61-90-days had 52.5%, and > 90-days had 53.3%. Delays in treatment conclusion significantly reduced survival[72.2%(<120-days) to 60.7%(>200-days)]. Multivariate analysis showed that delays in treatment initiation did not affect 36-month death risk. Compared to women concluding treatment in < 120-days, those taking 121-200-days or > 200-days showed increases in death risk of 89%(95%CI:1.10-3.24) and 111%(95%CI:1.31-3.39), respectively, regardless of age, stage, treatment protocol, and time to treatment initiation. CONCLUSION: Delays in cervical cancer treatment conclusion (but not treatment initiation) affected 36-month survival and death risk among Brazilians.

Associations between primary healthcare and infant health outcomes: a cohort analysis of low-income mothers in Rio de Janeiro, Brazil.

Background: Expanding primary healthcare to urban poor populations is a priority in many low-and middle-income countries and is essential to achieve universal health coverage (UHC). Between 2008 and 2016 the city of Rio de Janeiro undertook an ambitious programme to rapidly expand primary care to low-income areas through the family health strategy (FHS). Infant health impacts of this roll out are unknown. This study examines associations between maternal FHS utilisation and birth outcomes, neonatal and infant mortality. Methods: A cohort of 75,339 live births (January 2009-December 2014) to low-income mothers in Rio de Janeiro was linked to primary care, birth, hospital and death records. The relationship between maternal FHS use and infant health outcomes was assessed through logistic regression with inverse probability treatment weighting and regression adjustment. Socioeconomic inequalities in the associations between FHS use and outcomes were explored through interactions. Primary outcomes were neonatal and infant death. Thirteen secondary outcomes were also examined to explore other important health outcomes and potential mechanisms. Results: A total of 9002 (12.0%) infants were born to mothers in the cohort who used FHS services either before pregnancy or in the first two trimesters. There was a total of 527 neonatal and 893 infant deaths. Maternal FHS usage during the first two trimesters was associated with substantial reductions in neonatal [adjusted odds ratio (aOR): 0.527, 95% confidence interval (95% CI): 0.345; 0.806] and infant mortality (aOR: 0.672, 95% CI: 0.48; 0.924). Infants born to lower-income mothers and those without formal employment had larger reductions in neonatal and infant mortality associated with FHS use. Maternal FHS in the first two trimesters use was also associated with more antenatal care consultations and a lower risk of low birth weight and preterm birth. Interpretation: Expanding primary care to low-income populations in Rio de Janeiro was associated with improved infant health and health equity benefits. Funding: DFID/MRC/Wellcome Trust/ESRC.

Contextualizing and optimizing novel strategies to improve the latent TB continuum of care: Insights from people living with HIV and health care providers in Brazil.

Tuberculosis (TB) causes 1 in 3 deaths among people living with HIV (PLHIV). Diagnosing and treating latent tuberculosis infection (LTBI) is critical to reducing TB incidence and mortality. Blood-based screening tests (e.g., QuantiFERON-TB Gold Plus (QFT+)) and shorter-course TB preventive therapy (TPT) regimens such as 3HP (3 months weekly isoniazid-rifapentine) hold significant promise to improve TB outcomes. We qualitatively explored barriers and solutions to optimizing QFT+ and 3HP among PLHIV in three cities in Brazil. We conducted 110 in-depth interviews with PLHIV, health care providers (HCP) and key informants (KI). Content analysis was conducted including the use of case summaries and comparison of themes across populations and contexts. LTBI screening and treatment practices were dependent on HCP's perceptions of whether they were critical to improving TB outcomes. Many HCP lacked a strong understanding of LTBI and perceived the current TPT regimen as complicated. HCP reported that LTBI screening and treatment were constrained by clinic staffing challenges. While PLHIV generally expressed willingness to consider any test or treatment that doctors recommended, they indicated HCP rarely discussed LTBI and TPT. TB testing and treatment requests were constrained by structural factors including financial and food insecurity, difficulties leaving work for appointments, stigma and family responsibilities. QFT+ and 3HP were viewed by all participants as tools that could significantly improve the LTBI cascade by avoiding complexities of TB skin tests and longer LTBI treatment courses. QFT+ and 3HP were perceived to have challenges, including the potential to increase workload on over-burdened health systems if not implemented alongside improved supply chains, staffing, and training, and follow-up initiatives. Multi-level interventions that increase understanding of the importance of LTBI and TPT among HCP, improve patient-provider communication, and streamline clinic-level operations related to QFT+ and 3HP are needed to optimize their impact among PLHIV and reduce TB mortality.

Excess mortality from all causes during the COVID-19 pandemic in the city of Rio de Janeiro, Brazil.

OBJECTIVE: To evaluate excess mortality in the city of Rio de Janeiro, Brazil, due to the COVID-19 pandemic (March 2020 to January 2022). METHODS: Ecological study using secondary data from the Brazilian Mortality Information System, having the city of Rio de Janeiro as the unit of analysis. Excess mortality was estimated by the difference between the mean number of all expected deaths and the mean number of observed deaths, considering the 2015-2019 period. The quantile regression method was adjusted. The total value of cases above that expected by the historical series was estimated. Among all deaths, cases of COVID-19 and Influenza as underlying causes of death were selected. The ratio between excess mortality and deaths due to COVID-19 was calculated. RESULTS: We identified an excess of 31,920 deaths by the mean (increase of 26.8%). The regression pointed to 31,363 excess deaths. We found 33,401 deaths from COVID-19 and 176 deaths from Influenza. The ratio between the verified excess mortality and deaths due to COVID-19 was 0.96 by the mean and 0.95 by the regression. CONCLUSION: The study pointed to large excess deaths during the COVID-19 pandemic in the city of Rio de Janeiro distributed in waves, including the period of the Influenza outbreak.

Excess mortality from all causes during the COVID-19 pandemic in the city of Rio de Janeiro, Brazil / Excesso de mortalidade por todas as causas na pandemia de COVID-19 no município do Rio de Janeiro (RJ)

ABSTRACT Objective: To evaluate excess mortality in the city of Rio de Janeiro, Brazil, due to the COVID-19 pandemic (March 2020 to January 2022). Methods: Ecological study using secondary data from the Brazilian Mortality Information System, having the city of Rio de Janeiro as the unit of analysis. Excess mortality was estimated by the difference between the mean number of all expected deaths and the mean number of observed deaths, considering the 2015-2019 period. The quantile regression method was adjusted. The total value of cases above that expected by the historical series was estimated. Among all deaths, cases of COVID-19 and Influenza as underlying causes of death were selected. The ratio between excess mortality and deaths due to COVID-19 was calculated. Results: We identified an excess of 31,920 deaths by the mean (increase of 26.8%). The regression pointed to 31,363 excess deaths. We found 33,401 deaths from COVID-19 and 176 deaths from Influenza. The ratio between the verified excess mortality and deaths due to COVID-19 was 0.96 by the mean and 0.95 by the regression. Conclusion: The study pointed to large excess deaths during the COVID-19 pandemic in the city of Rio de Janeiro distributed in waves, including the period of the Influenza outbreak.

RESUMO Objetivo: Analisar o excesso de óbitos no município do Rio de Janeiro (MRJ), RJ, durante a pandemia de COVID-19 (março de 2020 a janeiro de 2022). Métodos: Foi realizado um estudo ecológico com dados secundários do Sistema de Informação sobre Mortalidade cuja unidade de análise foi o MRJ. O excesso de mortalidade foi calculado pela diferença entre a média de óbitos esperados e a média dos óbitos observados levando-se em conta o período de 2015 a 2019. Foi ajustado um método de regressão quantílica. Calculou-se o valor total dos casos acima do esperado pela série histórica. Foram selecionados os óbitos por causa básica COVID-19 e Influenza. Também foi calculada a razão entre o excesso de óbitos e os óbitos atribuídos à COVID-19. Resultados: Foi identificado excesso de 31.920 óbitos pela média (26,8% de incremento). Pela regressão quantílica, encontrou-se excesso de 31.363 óbitos. Ocorreram 33.401 óbitos por COVID-19 e 176 por Influenza. A razão entre o excesso de óbitos encontrado e os óbitos atribuídos à COVID-19 foi de 0,96 pela média e 0,95 pela regressão quantílica. Conclusão: O estudo apontou grande excesso de óbitos durante a pandemia de COVID-19 no MRJ, distribuído em ondas, incluindo-se o período do surto de Influenza.

Estimating the effect of the wMel release programme on the incidence of dengue and chikungunya in Rio de Janeiro, Brazil: a spatiotemporal modelling study.

BACKGROUND: Introgression of genetic material from species of the insect bacteria Wolbachia into populations of Aedes aegypti mosquitoes has been shown in randomised and non-randomised trials to reduce the incidence of dengue; however, evidence for the real-world effectiveness of large-scale deployments of Wolbachia-infected mosquitoes for arboviral disease control in endemic settings is still scarce. A large Wolbachia (wMel strain) release programme was implemented in 2017 in Rio de Janeiro, Brazil. We aimed to assess the effect of this programme on the incidence of dengue and chikungunya in the city. METHODS: 67 million wMel-infected mosquitoes were released across 28 489 locations over an area of 86·8 km2 in Rio de Janeiro between Aug 29, 2017 and Dec 27, 2019. Following releases, mosquitoes were trapped and the presence of wMel was recorded. In this spatiotemporal modelling study, we assessed the effect of the release programme on the incidence of dengue and chikungunya. We used spatiotemporally explicit mathematical models applied to geocoded dengue cases (N=283 270) from 2010 to 2019 and chikungunya cases (N=57 705) from 2016 to 2019. FINDINGS: On average, 32% of mosquitoes collected from the release zones between 1 month and 29 months after the initial release tested positive for wMel. Reduced wMel introgression occurred in locations and seasonal periods in which cases of dengue and chikungunya were historically high, with a decrease to 25% of mosquitoes testing positive for wMel during months in which disease incidence was at its highest. Despite incomplete introgression, we found that the releases were associated with a 38% (95% CI 32-44) reduction in the incidence of dengue and a 10% (4-16) reduction in the incidence of chikungunya. INTERPRETATION: Stable establishment of wMel in the geographically diverse, urban setting of Rio de Janeiro seems to be more complicated than has been observed elsewhere. However, even intermediate levels of wMel seem to reduce the incidence of disease caused by two arboviruses. These findings will help to guide future release programmes. FUNDING: Bill & Melinda Gates Foundation and the European Research Council.

[COVID-19 emergency operations center: experience of the Rio de Janeiro municipality, BrazilCentro de operaciones de emergencia en respuesta a la COVID-19: la experiencia del municipio de Rio de Janeiro]. / Centro de operações de emergência na COVID-19: a experiência do município do Rio de Janeiro.

The present report describes the implementation of an emergency operations center to coordinate the response to the COVID-19 pandemic in the municipality of Rio de Janeiro, Brazil. Following the public health emergency management framework proposed by the World Health Organization (WHO), this temporary center (COE COVID-19 RIO) started operating in January 2021. The report is organized along five themes: legal framework; structure, planning, and procedures; institutional articulation; health information for decision-making; and risk communication. Major advances obtained with the initiative include improvements in governance for the management of COVID-19, increase in the synergy among sectors and institutions, improved information sharing in relation to COVID-19 prevention and control measures, innovation in epidemiologic analyses, and gains in transparency and decision-making opportunities. In conclusion, even if conceived at an advanced stage of the pandemic in the municipality of Rio de Janeiro, the COE COVID-19 RIO has played a relevant role in shaping the city's responses to the pandemic. Also, despite its temporary character, the experience will leave a lasting legacy for the management of future public health emergencies in the municipality of Rio de Janeiro.

En el presente artículo se describe la experiencia al establecerse un centro de operaciones de emergencia (COE) para coordinar la respuesta a la pandemia de COVID-19 en el municipio de Rio de Janeiro (Brasil). Siguiendo el modelo de gestión de emergencias de salud pública promovido por la Organización Mundial de la Salud (OMS), este centro temporal se activó en enero del 2021. El informe se estructuró con base en cinco ejes temáticos: marco legal; estructura, planes y procedimientos; articulaciones institucionales; información en materia de salud para sustentar las decisiones; y comunicación sobre riesgos. Entre los principales avances relacionados con esta iniciativa cabe destacar los adelantos en cuanto a la gobernanza para organizar la forma de enfrentar la COVID-19, el aumento de la sinergia entre los sectores y las instituciones correspondientes, un mayor intercambio de información sobre las medidas de prevención y control de la enfermedad, innovación en los análisis epidemiológicos, mayor transparencia en la toma de decisiones y decisiones tomadas de manera más oportuna. Se llegó a la conclusión de que este COE, a pesar de que había sido establecido en una fase avanzada de la pandemia en la ciudad, tuvo un papel importante en la estructuración de la respuesta. Sin embargo, a pesar de su carácter temporal, la experiencia demostró ser un importante legado para enfrentar futuras emergencias de salud pública en el municipio de Rio de Janeiro.

Contribution of primary care expansion to Sustainable Development Goal 3 for health: a microsimulation of the 15 largest cities in Brazil.

OBJECTIVES: As middle-income countries strive to achieve the Sustainable Development Goals (SDGs), it remains unclear to what degree expanding primary care coverage can help achieve those goals and reduce within-country inequalities in mortality. Our objective was to estimate the potential impact of primary care expansion on cause-specific mortality in the 15 largest Brazilian cities. DESIGN: Microsimulation model. SETTING: 15 largest cities by population size in Brazil. PARTICIPANTS: Simulated populations. INTERVENTIONS: We performed survival analysis to estimate HRs of death by cause and by demographic group, from a national administrative database linked to the Estratégia de Saúde da Família (Family Health Strategy, FHS) electronic health and death records among 1.2 million residents of Rio de Janeiro (2010-2016). We incorporated the HRs into a microsimulation to estimate the impact of changing primary care coverage in the 15 largest cities by population size in Brazil. PRIMARY AND SECONDARY OUTCOME MEASURES: Crude and age-standardised mortality by cause, infant mortality and under-5 mortality. RESULTS: Increased FHS coverage would be expected to reduce inequalities in mortality among cities (from 2.8 to 2.4 deaths per 1000 between the highest-mortality and lowest-mortality city, given a 40 percentage point increase in coverage), between welfare recipients and non-recipients (from 1.3 to 1.0 deaths per 1,000), and among race/ethnic groups (between Black and White Brazilians from 1.0 to 0.8 deaths per 1,000). Even a 40 percentage point increase in coverage, however, would be insufficient to reach SDG targets alone, as it would be expected to reduce premature mortality from non-communicable diseases by 20% (vs the target of 33%), and communicable diseases by 15% (vs 100%). CONCLUSIONS: FHS primary care coverage may be critically beneficial to reducing within-country health inequalities, but reaching SDG targets will likely require coordination between primary care and other sectors.

Expansion of primary healthcare and emergency hospital admissions among the urban poor in Rio de Janeiro Brazil: A cohort analysis.

Background: Robust evidence on the relationship between primary care and emergency admissions is lacking in low- and middle-income countries. This study evaluates how the phased roll out of the family health strategy (FHS) to the urban poor in Rio de Janeiro Brazil affected emergency hospital admissions and readmissions from ambulatory-care sensitives conditions (ACSCs). Methods: A cohort of 1.2 million adults in Rio de Janeiro city were followed for five years (Jan 2012 to Dec 2016). The association between FHS use and the likelihood of emergency hospital admissions and 30-day readmissions were evaluated using multi-level Poisson regression models with inverse probability treatment weighting and regression adjustment (IPTW-RA) for socioeconomic and household characteristics. Inequalities in associations were examined across groups of causes and by key socioeconomic groups. Results: Records from 2,551,934 primary care consultations and 15,627 admissions were analysed. In IPTW-RA analyses, each additional FHS consultation was associated with a 3% lower rate of ACSC admission (RR: 0.97; 95%CI: 0.95, 0.98), a 63% lower rate of 30-day readmissions from any non-birth cause (RR: 0.37; 95%CI: 0.30, 0.46), and an 57% lower rate of 30-day readmissions from ACSCs (RR: 0.43; 95%CI: 0.33, 0.55). Individuals who were older, had the lowest educational attainment, were unemployed, and had higher incomes had larger reductions in ACSC admissions associated with FHS use. Interpretation: Investment in primary care is important for reducing emergency hospital admissions and their associated costs in LMICs. Funding: DFID/MRC/Wellcome Trust/ESRC.

Centro de operações de emergência na COVID-19: a experiência do município do Rio de Janeiro / COVID-19 emergency operations center: experience of the Rio de Janeiro municipality, Brazil / Centro de operaciones de emergencia en respuesta a la COVID-19: la experiencia del municipio de Rio de Janeiro

RESUMO O presente artigo descreve a experiência de implantação de um centro de operações de emergência (COE) para coordenação da resposta à pandemia de COVID-19 no município do Rio de Janeiro, Brasil. Seguindo o modelo de gestão de emergências em saúde pública preconizado pela Organização Mundial da Saúde (OMS), este centro de caráter temporário (COE COVID-19 RIO) foi ativado em janeiro de 2021. O relato foi estruturado com base em cinco eixos temáticos: arcabouço legal; estrutura, planos e procedimentos; articulações institucionais; informações em saúde para apoio decisório; e comunicação de risco. Entre os avanços importantes relacionados ao estabelecimento desta iniciativa, destacaram-se ganhos em governança para a organização do enfrentamento à COVID-19, aumento da sinergia entre setores e instituições, maior compartilhamento de informações em relação às medidas de prevenção e controle da doença, inovação nas análises epidemiológicas e ganhos na transparência e oportunidade na tomada de decisões. Concluiu-se que, mesmo sendo concebido em estágio avançado da pandemia na cidade, o COE COVID-19 RIO teve papel relevante na estruturação da resposta. Ainda, apesar do caráter temporário do COE, a experiência mostrou-se como importante legado para a condução de futuras emergências em saúde pública no município do Rio de Janeiro.

ABSTRACT The present report describes the implementation of an emergency operations center to coordinate the response to the COVID-19 pandemic in the municipality of Rio de Janeiro, Brazil. Following the public health emergency management framework proposed by the World Health Organization (WHO), this temporary center (COE COVID-19 RIO) started operating in January 2021. The report is organized along five themes: legal framework; structure, planning, and procedures; institutional articulation; health information for decision-making; and risk communication. Major advances obtained with the initiative include improvements in governance for the management of COVID-19, increase in the synergy among sectors and institutions, improved information sharing in relation to COVID-19 prevention and control measures, innovation in epidemiologic analyses, and gains in transparency and decision-making opportunities. In conclusion, even if conceived at an advanced stage of the pandemic in the municipality of Rio de Janeiro, the COE COVID-19 RIO has played a relevant role in shaping the city's responses to the pandemic. Also, despite its temporary character, the experience will leave a lasting legacy for the management of future public health emergencies in the municipality of Rio de Janeiro.

RESUMEN En el presente artículo se describe la experiencia al establecerse un centro de operaciones de emergencia (COE) para coordinar la respuesta a la pandemia de COVID-19 en el municipio de Rio de Janeiro (Brasil). Siguiendo el modelo de gestión de emergencias de salud pública promovido por la Organización Mundial de la Salud (OMS), este centro temporal se activó en enero del 2021. El informe se estructuró con base en cinco ejes temáticos: marco legal; estructura, planes y procedimientos; articulaciones institucionales; información en materia de salud para sustentar las decisiones; y comunicación sobre riesgos. Entre los principales avances relacionados con esta iniciativa cabe destacar los adelantos en cuanto a la gobernanza para organizar la forma de enfrentar la COVID-19, el aumento de la sinergia entre los sectores y las instituciones correspondientes, un mayor intercambio de información sobre las medidas de prevención y control de la enfermedad, innovación en los análisis epidemiológicos, mayor transparencia en la toma de decisiones y decisiones tomadas de manera más oportuna. Se llegó a la conclusión de que este COE, a pesar de que había sido establecido en una fase avanzada de la pandemia en la ciudad, tuvo un papel importante en la estructuración de la respuesta. Sin embargo, a pesar de su carácter temporal, la experiencia demostró ser un importante legado para enfrentar futuras emergencias de salud pública en el municipio de Rio de Janeiro.

Biomonitoring of Exposure to Metals in a Population Residing in an Industrial Area in Brazil: A Feasibility Study.

BACKGROUND: Industries are sources of environmental pollutants. However, there are few human biomonitoring (HBM) studies in the vicinity of industrial areas. Thus, we evaluate the feasibility of conducting an HBM study to assess exposure to metals in an industrial area in Rio de Janeiro, Brazil. METHODOLOGY: A cross-sectional survey was conducted near a steel factory. Adults (exposed = 775; controls = 775) were randomly selected and sex-matched. Subjects were interviewed using a questionnaire and a 24 h dietary recall. Blood samples were collected to analyze metal concentrations, blood count, biochemical parameters, and thyroid hormones. The feasibility of the survey was assessed following guidelines. The descriptive analysis was performed for the first 250 participants (pilot study). RESULTS: Adjustments were made to the survey execution, including age-matching, fieldwork team, questionnaire, blood collection, and research awareness. The complete questionnaire was answered by ≥97% of participants; metals were measured in ≥98% and clinical parameters in ≥89%, except thyroid hormones (13-44%). The average age and family income were of 50 years and USD 575/month, respectively. The participants had equal distribution among sexes: 50% had a medium education level, and 59% were nonwhite. CONCLUSION: This preliminary HBM study demonstrates feasibility for the total population, with results indicating representativeness of the target population.

Brief Report: Yield of Repeat Tuberculin Skin Testing for People Living With HIV in Brazil.

OBJECTIVES: In Brazil, annual tuberculin skin tests (TSTs) are recommended for people living with HIV (PLWH) with CD4 >350, with tuberculosis preventive therapy provided on test conversion. We aimed to determine the yield of repeat TSTs for PLWH. DESIGN: Secondary analysis of the stepped-wedge, cluster-randomized THRio trial for isoniazid preventive therapy (IPT) to prevent tuberculosis (TB). METHODS: We analyzed data from newly registered PLWH with negative baseline TST results. We calculated the number of TST conversions after 1 and/or 2 years among patients eligible for follow-up TSTs, the proportion of converters initiating IPT, and incidence of TB/death. RESULTS: Among 1770 PLWH with a negative baseline TST, 679 (38%) were female and median age was 36 years (IQR 29-43). Eighty-six (5%) developed TB or died within 1 year. Among 1684 eligible for a follow-up 1-year TST, 582 (35%) were tested and 53 (9%) were positive. Forty-nine converters (92%) started IPT. Of 529 patients with a negative 1-year TST, 7 (1%) developed TB or died over the following year. Of 522 patients eligible for a 2-year TST, 158 (30%) were tested and 13 (8%) were positive. Ten converters (77%) started IPT. Of 1102 patients who did not receive a 1-year TST, 33 (3%) developed TB or died. Of the 1069 patients eligible for a 2-year TST, 259 (24%) were tested and 34 (13%) were positive. Thirty converters (88%) started IPT. CONCLUSIONS: In this cohort of PLWH in Brazil, TST conversion was high among those retested, but only 48% received a follow-up TST within 2 years.

Racial and socioeconomic disparities in multimorbidity and associated healthcare utilisation and outcomes in Brazil: a cross-sectional analysis of three million individuals.

BACKGROUND: Evidence is limited on racial/ethnic group disparities in multimorbidity and associated health outcomes in low- and middle-income countries hampering effective policies and clinical interventions to address health inequalities. METHODS: This study assessed race/ethnic and socioeconomic disparities in the prevalence of multimorbidity and associated healthcare utilisation, costs and death in Rio de Janeiro, Brazil. A cross-sectional analysis was carried out of 3,027,335 individuals registered with primary healthcare (PHC) services. Records included linked data to hospitalisation, mortality, and welfare-claimant (Bolsa Família) records between 1 Jan 2012 and 31 Dec 2016. Logistic and Poisson regression models were carried out to assess the likelihood of multimorbidity (two or more diagnoses out of 53 chronic conditions), PHC use, hospital admissions and mortality from any cause. Interactions were used to assess disparities. RESULTS: In total 13,509,633 healthcare visits were analysed identifying 389,829 multimorbid individuals (13%). In adjusted regression models, multimorbidity was associated with lower education (Adjusted Odds Ratio (AOR): 1.26; 95%CI: 1.23,1.29; compared to higher education), Bolsa Família receipt (AOR: 1.14; 95%CI: 1.13,1.15; compared to non-recipients); and black race/ethnicity (AOR: 1.05; 95%CI: 1.03,1.06; compared to white). Multimorbidity was associated with more hospitalisations (Adjusted Rate Ratio (ARR): 2.75; 95%CI: 2.69,2.81), more PHC visits (ARR: 3.46; 95%CI: 3.44,3.47), and higher likelihood of death (AOR: 1.33; 95%CI: 1.29,1.36). These associations were greater for multimorbid individuals with lower educational attainment (five year probability of death 1.67% (95%CI: 1.61,1.74%) compared to 1.13% (95%CI: 1.02,1.23%) for higher education), individuals of black race/ethnicity (1.48% (95%CI: 1.41,1.55%) compared to 1.35% (95%CI: 1.31,1.40%) for white) and individuals in receipt of welfare (1.89% (95%CI: 1.77,2.00%) compared to 1.35% (95%CI: 1.31,1.38%) for non-recipients). CONCLUSIONS: The prevalence of multimorbidity and associated hospital admissions and mortality are greater in individuals with black race/ethnicity and other deprived socioeconomic groups in Rio de Janeiro. Interventions to better prevent and manage multimorbidity and underlying disparities in low- and middle-income country settings are needed.

Effectiveness of Wolbachia-infected mosquito deployments in reducing the incidence of dengue and other Aedes-borne diseases in Niterói, Brazil: A quasi-experimental study.

BACKGROUND: The introduction of the bacterium Wolbachia (wMel strain) into Aedes aegypti mosquitoes reduces their capacity to transmit dengue and other arboviruses. Evidence of a reduction in dengue case incidence following field releases of wMel-infected Ae. aegypti has been reported previously from a cluster randomised controlled trial in Indonesia, and quasi-experimental studies in Indonesia and northern Australia. METHODOLOGY/PRINCIPAL FINDINGS: Following pilot releases in 2015-2016 and a period of intensive community engagement, deployments of adult wMel-infected Ae. aegypti mosquitoes were conducted in Niterói, Brazil during 2017-2019. Deployments were phased across four release zones, with a total area of 83 km2 and a residential population of approximately 373,000. A quasi-experimental design was used to evaluate the effectiveness of wMel deployments in reducing dengue, chikungunya and Zika incidence. An untreated control zone was pre-defined, which was comparable to the intervention area in historical dengue trends. The wMel intervention effect was estimated by controlled interrupted time series analysis of monthly dengue, chikungunya and Zika case notifications to the public health surveillance system before, during and after releases, from release zones and the control zone. Three years after commencement of releases, wMel introgression into local Ae. aegypti populations was heterogeneous throughout Niterói, reaching a high prevalence (>80%) in the earliest release zone, and more moderate levels (prevalence 40-70%) elsewhere. Despite this spatial heterogeneity in entomological outcomes, the wMel intervention was associated with a 69% reduction in dengue incidence (95% confidence interval 54%, 79%), a 56% reduction in chikungunya incidence (95%CI 16%, 77%) and a 37% reduction in Zika incidence (95%CI 1%, 60%), in the aggregate release area compared with the pre-defined control area. This significant intervention effect on dengue was replicated across all four release zones, and in three of four zones for chikungunya, though not in individual release zones for Zika. CONCLUSIONS/SIGNIFICANCE: We demonstrate that wMel Wolbachia can be successfully introgressed into Ae. aegypti populations in a large and complex urban setting, and that a significant public health benefit from reduced incidence of Aedes-borne disease accrues even where the prevalence of wMel in local mosquito populations is moderate and spatially heterogeneous. These findings are consistent with the results of randomised and non-randomised field trials in Indonesia and northern Australia, and are supportive of the Wolbachia biocontrol method as a multivalent intervention against dengue, chikungunya and Zika.

Record linkage under suboptimal conditions for data-intensive evaluation of primary care in Rio de Janeiro, Brazil.

BACKGROUND: Linking Brazilian databases demands the development of algorithms and processes to deal with various challenges including the large size of the databases, the low number and poor quality of personal identifiers available to be compared (national security number not mandatory), and some characteristics of Brazilian names that make the linkage process prone to errors. This study aims to describe and evaluate the quality of the processes used to create an individual-linked database for data-intensive research on the impacts on health indicators of the expansion of primary care in Rio de Janeiro City, Brazil. METHODS: We created an individual-level dataset linking social benefits recipients, primary health care, hospital admission and mortality data. The databases were pre-processed, and we adopted a multiple approach strategy combining deterministic and probabilistic record linkage techniques, and an extensive clerical review of the potential matches. Relying on manual review as the gold standard, we estimated the false match (false-positive) proportion of each approach (deterministic, probabilistic, clerical review) and the missed match proportion (false-negative) of the clerical review approach. To assess the sensitivity (recall) to identifying social benefits recipients' deaths, we used their vital status registered on the primary care database as the gold standard. RESULTS: In all linkage processes, the deterministic approach identified most of the matches. However, the proportion of matches identified in each approach varied. The false match proportion was around 1% or less in almost all approaches. The missed match proportion in the clerical review approach of all linkage processes were under 3%. We estimated a recall of 93.6% (95% CI 92.8-94.3) for the linkage between social benefits recipients and mortality data. CONCLUSION: The adoption of a linkage strategy combining pre-processing routines, deterministic, and probabilistic strategies, as well as an extensive clerical review approach minimized linkage errors in the context of suboptimal data quality.