COVID-19 death risk predictors in Brazil using survival tree analysis: a retrospective cohort from 2020 to 2022.

PURPOSE: This study analyses the survival of hospitalized patients with Severe Acute Respiratory Syndrome (SARS) due to COVID-19 and identifies the risk groups for death due to COVID-19 from the identification of potential interactions between its predictors. METHODS: This was a retrospective longitudinal study with data from 1,756,917 patients reported in the Influenza Epidemiological Surveillance Information System from 26 February 2020 to 31 December 2022. In this study, all adult and older (≥ 20 years) patients were hospitalized with SARS due to COVID-19, with death as the outcome. Survival tree analysis was used to identify potential interactions between the predictors. A model was built for each year of study. RESULTS: Hospital lethalitywas 33.2%. The worst survival curve was observed among those who underwent invasive mechanical ventilation and were aged 80 years or older in the three years of the pandemic. Black and brown race/color were predictors of deaths in the years 2020 and 2021 when there was greater demand from the health system due to the greater number of cases. CONCLUSION: By applying survival tree analysis we identified several numbers of homogeneous subgroups with different risks for mortality from COVID-19. These findings show the effects of wide inequalities of access by the population, requiring effective policies for the reduction and adequate management of the disease.

[COVID-19 mortality in metropolitan areas vs. other regions of Brazil, 2020 to 2021Mortalidad por COVID-19 en las regiones metropolitanas y en el interior de Brasil, 2020-2021]. / Mortalidade por covid-19 no interior e em regiões metropolitanas do Brasil, 2020 a 2021.

Objective: To compare hospital mortality rates (HMR) due to severe acute respiratory syndrome (SARS) associated with COVID-19 recorded in metropolitan areas and other regions (interior) of Brazil in 2020 and 2021. Method: This ecological study used public data available on OpenDataSUS. The information was accessed in May 2022. The following variables were considered: age, sex, hospitalization, presence of a risk factor, ICU stay, use of ventilatory support, and final classification in the individual registration form of SARS cases due to COVID-19. Cases and deaths were stratified into five age groups (0-19 years, 20-39 years, 40-59 years, 60-79 years, and ≥80 years) and by place of residence (metropolitan area or interior). The HMR had as numerator the absolute number of deaths by SARS associated with covid-19; and, as a denominator, the absolute number of cases of SARS due to covid-19 according to the year of occurrence, area of residence, age bracket, sex, hospitalization, presence of a risk factor, ICU admission, and use of ventilatory support. Results: There was a significant increase in HMR due to SARS associated with COVID-19 in 2021 in all age groups, except 0-19 years and ≥80 years, as well as among individuals admitted to an ICU and who used invasive ventilatory support, both in metropolitan areas as well as in the interior. Conclusions: There was a worsening of the epidemiological scenario in 2021 with an increase in HMR. However, no differences were identified between the metropolitan regions and the interior of the country.

Objetivo: Comparar las tasas de mortalidad hospitalaria por el síndrome respiratorio agudo grave relacionado con la COVID-19 registradas en las regiones metropolitanas y el interior de Brasil en el período 2020-2021. Método: Se realizó un estudio ecológico con datos públicos disponibles en el sistema OpenDataSUS. La información se consultó en mayo del 2022. Se tomaron en cuenta las siguientes variables: edad, sexo, hospitalización, presencia de factores de riesgo, ingreso en la unidad de cuidados intensivos, uso de apoyo ventilatorio y clasificación final en la hoja de registro individual de casos del síndrome respiratorio agudo grave por COVID-19. Los casos y las defunciones se estratificaron en cinco grupos etarios (0-19 años, 20-39 años, 40-59 años, 60-79 años y ≥80 años) y por ubicación del municipio de residencia (región metropolitana o interior). El numerador de la tasa de mortalidad hospitalaria fue el número absoluto de defunciones por el síndrome respiratorio agudo grave relacionado con la COVID-19, y el denominador, el número absoluto de casos del mismo síndrome relacionado con la COVID-19 según el año de aparición, la residencia en una región metropolitana o en el interior, el grupo etario, el sexo, la hospitalización, la presencia de factores de riesgo, el ingreso en la unidad de cuidados intensivos y el uso de apoyo ventilatorio. Resultados: Se comprobó un aumento significativo de la tasa de mortalidad hospitalaria por el síndrome respiratorio agudo grave relacionado con la COVID-19 en el 2021 en todos los grupos etarios, excepto en los grupos de 0-19 años y ≥80 años, así como entre las personas internadas en la unidad de cuidados intensivos que recibieron apoyo respiratorio invasivo, tanto en las regiones metropolitanas como en el interior. Conclusiones: La situación epidemiológica empeoró en el 2021 con el aumento de la tasa de mortalidad hospitalaria, pero no se observaron diferencias entre las regiones metropolitanas y el interior del país.

Early Growth and Neurologic Outcomes of Infants with Probable Congenital Zika Virus Syndrome.

We report the early growth and neurologic findings of 48 infants in Brazil diagnosed with probable congenital Zika virus syndrome and followed to age 1-8 months. Most of these infants had microcephaly (86.7%) and craniofacial disproportion (95.8%). The clinical pattern included poor head growth with increasingly negative z-scores, pyramidal/extrapyramidal symptoms, and epilepsy.

Spatial distribution of arboviruses and its association with a social development index and the waste disposal in São Luís, state of Maranhão, Brazil, 2015 to 2019.

OBJECTIVE: To detect spatial and spatiotemporal clusters of urban arboviruses and to investigate whether the social development index (SDI) and irregular waste disposal are related to the coefficient of urban arboviruses detection in São Luís, state of Maranhão, Brazil. METHODS: The confirmed cases of Dengue, Zika and Chikungunya in São Luís, from 2015 to 2019, were georeferenced to the census tract of residence. The Bayesian Conditional Autoregressive regression model was used to identify the association between SDI and irregular waste disposal sites and the coefficient of urban arboviruses detection. RESULTS: The spatial pattern of arboviruses pointed to the predominance of a low-incidence cluster, except 2016. For the years 2015, 2016, 2017, and 2019, an increase of one unit of waste disposal site increased the coefficient of arboviruses detection in 1.25, 1.09, 1.23, and 1.13 cases of arboviruses per 100 thousand inhabitants, respectively. The SDI was not associated with the coefficient of arboviruses detection. CONCLUSION: In São Luís, spatiotemporal risk clusters for the occurrence of arboviruses and a positive association between the coefficient of arbovirus detection and sites of irregular waste disposal were identified.

Individual and contextual factors associated with the survival of patients with severe acute respiratory syndrome by COVID-19 in Brazil.

OBJECTIVE: To analyze the influence of individual and contextual factors of the hospital and the municipality of care on the survival of patients with Severe Acute Respiratory Syndrome due to COVID-19. METHODS: Hospital cohort study with data from 159,948 adults and elderly with Severe Acute Respiratory Syndrome due to COVID-19 hospitalized from January 1 to December 31, 2022 and reported in the Influenza Epidemiological Surveillance Information System. The contextual variables were related to the structure, professionals and equipment of the hospital establishments and socioeconomic and health indicators of the municipalities. The outcome was hospital survival up to 90 days. Survival tree and Kaplan-Meier curves were used for survival analysis. RESULTS: Hospital lethality was 30.4%. Elderly patients who underwent invasive mechanical ventilation and were hospitalized in cities with low tax collection rates had lower survival rates compared to other groups identified in the survival tree (p<0.001). CONCLUSION: The study indicated the interaction of contextual factors with the individual ones, and it shows that hospital and municipal characteristics increase the risk of death, highlighting the attention to the organization, operation, and performance of the hospital network.

Spatial analysis of hospital-related mortality due to COVID-19 among children and adolescents in Brazil.

The objective was to perform a spatial analysis of the hospital mortality rate (HMR) due to severe acute respiratory syndrome (SARS) attributed to COVID-19 among children and adolescents in Brazil from 2020 to 2021. A cluster method was used to group federal units (FUs) based on HMR. In 2020, clusters with high HMRs were formed by north/northeast FUs. In 2021, there was a reduction in HMR. Clusters with higher rates remained in the N/NE region. Regional differences were observed in the HMR. The findings may reflect social inequalities and access to hospital care, especially in the under 1-year-old age group due to the severity of the disease in this group.

Deaths, crimes and violence not classified as a crime among children and adolescents in Maranhão, Brazil (2014 to 2020). / Óbitos, crimes e violências não tipificadas como crimes contra crianças e adolescentes no Maranhão, Brasil, 2014 a 2020.

This study compares temporal trends in violent deaths of children and adolescents and analyzes differences in incidents of violence classified and not classified as a crime. We analyzed data from the Mortality Information System and State of Maranhão Public Security Department for the period 2014 to 2020. Child and adolescent were defined as aged 0-11 and 12-17 years old, respectively. Types of violence were organized according to the groups, subgroups, and types of crimes set out in Brazil's penal code. A total of 1,326 deaths and 8,187 incidents of violence were reported, both of which were more frequent in adolescents. The most frequent types of violence in children and adolescentes, respectively, were: abduction of incapable persons (p < 0.001), abandonment of incapable persons (p = 0.045), rape of vulnerable persons (p = 0.003); homicides (p < 0.001), crimes against individual freedom (p = 0.004), crimes against sexual freedom (p < 0.001), psychological violence (p = 0.034). Domestic violence with bodily harm was more frequent in girls (p < 0.001), while severe bodily harm (p=0.002), homicide (p < 0.001), and harassment (p < 0.001) were more frequent in boys. The findings reveal differences over time in deaths and incidents of violence classified and not classified as crime among both children and adolescents.

O presente estudo compara tendências temporais de óbitos por violências contra crianças e adolescentes e analisa diferenças em ocorrências tipificadas ou não como crimes. Foram analisados dados do Sistema de Informação sobre Mortalidade e da Secretaria de Segurança Pública do Estado do Maranhão, Brasil, de 2014-2020. Crianças e adolescentes foram definidos respectivamente como pessoas com 0-11 e 12-17 anos. Tipos de violências foram organizados segundo grupos, subgrupos e tipos penais do Código Penal Brasileiro. Foram contabilizados 1.326 óbitos e 8.187 ocorrências, mais frequentes na adolescência. Subtração de incapazes (p < 0,001), abandono de incapaz (p = 0,045) e estupro de vulnerável (p = 0,003) predominaram na infância. Homicídios (p < 0,001), crimes contra a liberdade individual (p = 0,004), crimes contra a liberdade sexual (p < 0,001) e violência psicológica (p = 0,034) foram mais frequentes na adolescência. Violência doméstica com lesão corporal predominou no sexo feminino (p < 0,001). Lesões corporais graves (p = 0,002), homicídios (p < 0,001) e constrangimento ilegal (p < 0,001) vitimizaram mais adolescentes do sexo masculino. Houve diferenças temporais em óbitos e ocorrências de violências contra crianças e adolescentes, assim como em características de violências tipificadas ou não como crimes.

Clinical-epidemiological characteristics and survival of cases of severe acute respiratory syndrome (SARS) due to COVID-19, according to the COVID-19 vaccination schedule in Brazil, 2021-2022: a prospective study.

OBJECTIVE: To analyze the clinical and sociodemographic characteristics and survival of individuals with severe acute respiratory syndrome due to COVID-19 according to the COVID-19 vaccination schedule, Brazil, 2021-2022. METHODS: This was a cohort study based on data from the Influenza Epidemiological Surveillance Information System; the Kaplan-Meier and Survival Tree methods were used to analyze survival. RESULTS: Among the 559,866 hospitalized cases, a higher proportion of vaccinated individuals was found among female (15.0%), elderly people aged ≥ 80 (34.5%), people from the Southeast region (15.7%), those who did not undergo respiratory support (21.2%) and those who did progress to death (15.2%); the survival curve showed that risk of death for unvaccinated individuals was higher in all age groups (p-value < 0.001); elderly people aged ≥ 80, who did not undergo mechanical ventilation and who had a booster dose had lower risk when compared to their peers who had two doses or were unvaccinated (hazard ratio = 0.64; 95%CI 0.62;0.67). CONCLUSION: Lowest risk of death was found in vaccinated individuals, especially those who had two doses or a booster dose as well. MAIN RESULTS: Prevalence was found to be high among unvaccinated individuals. Risk of death was lower among those vaccinated with a booster dose, compared to those not vaccinated, in all age groups analyzed. IMPLICATIONS FOR SERVICES: The number of hospitalizations of unvaccinated individuals with severe acute respiratory syndrome was high, which increases the demand for health services to care for these individuals. PERSPECTIVES: It is necessary to promote widespread vaccination of the entire population of Brazil, in addition to the regular provision of booster doses for the different population groups.

Comparison of beriberi cases in indigenous and non-indigenous people, Brazil, 2013 to 2018. / Comparação dos casos de beribéri entre indígenas e não indígenas, Brasil, 2013 a 2018.

Beriberi is the clinical manifestation of severe and prolonged thiamine (vitamin B1) deficiency. It is a neglected disease that affects low-income populations facing food and nutrition insecurity. The aim of this study was to compare cases of beriberi among indigenous and non-indigenous people in Brazil. We conducted a cross-sectional study using data on cases of beriberi during the period July 2013-September 2018 derived from beriberi notification forms available on the FormSUS platform. Cases in indigenous and non-indigenous patients were compared using the chi-squared test or Fisher's exact test, adopting a significance level of 0.05. A total of 414 cases of beriberi were reported in the country during the study period, 210 of which (50.7%) were among indigenous people. Alcohol consumption was reported by 58.1% of the indigenous patients and 71.6% of the non-indigenous patients (p = 0.004); 71.0% of the indigenous patients reported that they consumed caxiri, a traditional alcoholic drink. Daily physical exertion was reported by 76.1% of the indigenous patients and 40.2% of the non-indigenous patients (p < 0.001). It is concluded that beriberi disproportionately affects indigenous people and is associated with alcohol consumption and physical exertion.

O beribéri é a manifestação clínica da deficiência grave e prolongada de tiamina (vitamina B1). Doença negligenciada que acomete a população de baixa renda, em situação de insegurança alimentar e nutricional. O objetivo do estudo foi comparar casos de beribéri em indígenas com casos em não indígenas no Brasil. Trata-se de estudo transversal de casos notificados de beribéri no período de 2013 a 2018, no formulário do SUS (FormSUS) do Ministério da Saúde. Foram comparados os casos em indígenas e em não indígenas pelo teste qui-quadrado ou teste exato de Fisher com nível de significância de p < 0,05. No período estudado foram notificados no país 414 casos de beribéri, sendo 210 (50,7%) indígenas. Referiram consumo de bebidas alcoólicas 58,1% dos indígenas e 71,6% dos não-indígenas (p = 0,004); adicionalmente, 71,0% dos indígenas consumiam caxiri (bebida alcoólica tradicional fermentada). Relataram fazer esforço físico diário 76,1% dos indígenas e 40,2% dos não-indígenas (p <0 ,001). Conclui-se que o beribéri no país acomete mais indígenas e está relacionado ao consumo de álcool e ao esforço físico.

COVID-19 severe acute respiratory syndrome in Brazilian newborns in 2020-2021.

OBJECTIVE: To describe the clinical characteristics of cases of COVID-19 severe acute respiratory syndrome (SARS) in Brazilian newborns (NBs) in 2020 and 2021, recorded in the Influenza Epidemiological Surveillance Information System (Sistema de Informação da Vigilância Epidemiológica da Gripe - SIVEP-Gripe). METHODS: The variables analyzed were gender, race/skin color, hospitalization, intensive care unit (ICU) admission, use of ventilatory support, signs and symptoms (fever, cough, O2 saturation<95%, dyspnea, respiratory distress, diarrhea, and vomiting), progress (death or cure), risk factors/comorbidities. Categorical variables were expressed as absolute and relative frequencies. RESULTS: We found 1,649 records of COVID-19 SARS in NBs, with a predominance of multiracial babies in both years. The most frequent symptoms in 2020 and 2021 were, respectively: respiratory distress (67.0 and 69.7%), fever (46.3 and 46.2%), and cough (37.0 and 46.3%). In 2020, 30.5% of patients received invasive ventilatory support; in 2021, this number was 41.6%. In addition, more than 55% of cases required ICU admission, and over 16% died. CONCLUSION: We emphasize the high proportion of cases that required intensive care and progressed to death.

Spatial Analysis of Notified Zika Virus Congenital Syndrome, Maranhão, 2015 to 2018. / Análise espacial da taxa de detecção de casos suspeitos de síndrome congênita pelo vírus Zika, Maranhão, 2015 a 2018.

OBJECTIVE: To identify spatial patterns in cases of changes in growth and development related to Zika virus infection and other infectious etiologies (denominated Zika virus congenital syndrome in this study) reported in Maranhão from 2015 to 2018 and their relation with socioeconomic and demographic variables. METHODS: Ecological study of notified Zika virus congenital syndrome cases in the 217 cities of Maranhão, Brasil. Spatial autocorrelation was calculated using GeoDa 1.14 software and the local and global (I) Moran's index in univariate and bivariate analyses on Zika virus congenital syndrome incidence rate with Municipal Human Development Index (MHDI), population density, Gini coefficient and the cities' time of administrative political emancipation. Local Moran's Index was calculated to identify clusters with significant spatial autocorrelation. RESULTS: Spatial autocorrelation was checked in univariate analysis of the incidence rate of Zika virus congenital syndrome (I=0,494; p=0,001) and positive correlation in bivariate analysis of the incidence rate with Municipal Human Development Index (I=0,252; p=0,001), population density (I=0,338; p=0,001) and the cities' time of administrative political emancipation (I=0,134; p=0,001). The correlation between incidence rate with Gini coefficient was not significant (I= -0,033; p=0,131). Five high-incidence clusters were found in distinct areas of the state. CONCLUSIONS: Cities with higher MHDI, higher population density and more years of administrative political emancipation had more cases of Zika virus congenital syndrome notified.

OBJETIVO: Identificar padrões espaciais em casos de lactentes com alterações de crescimento e desenvolvimento relacionadas à infecção pelo vírus Zika e outras etiologias infecciosas (neste trabalho denominado de síndrome congênita pelo vírus Zika), notificados no Maranhão de 2015 a 2018 e sua relação com variáveis socioeconômicas e demográficas. MÉTODOS: Estudo ecológico de casos suspeitos notificados de síndrome congênita pelo vírus Zika nos 217 municípios do Maranhão, Brasil. Calculou-se a autocorrelação espacial pelos índices de Moran local e global (I) univariado e bivariado da taxa de detecção de casos suspeitos de síndrome congênita pelo vírus Zika com índice de desenvolvimento humano municipal, densidade demográfica, índice de Gini e tempo de emancipação político-administrativa dos municípios. O índice de Moran local foi calculado para localizar clusters com autocorrelação espacial significativa. RESULTADOS: Houve autocorrelação espacial na análise univariada da taxa municipal de detecção de casos suspeitos de síndrome congênita pelo vírus Zika (I=0,494; p=0,001) e, na análise bivariada, correlação positiva da taxa de detecção de casos suspeitos com índice de desenvolvimento humano municipal (I=0,252; p=0,001), densidade demográfica (I=0,338; p=0,001) e tempo de emancipação dos municípios (I=0,134; p=0,001). Não houve correlação significativa da taxa de detecção de casos suspeitos com o índice de Gini (I= -0,033; p=0,131). Cinco clusters de alta detecção de casos suspeitos foram encontrados em áreas distintas do estado. CONCLUSÕES: Os municípios com maior índice de desenvolvimento humano municipal, maior densidade demográfica e mais tempo de emancipação político-administrativa tiveram mais casos suspeitos notificados de síndrome congênita pelo vírus Zika.

Characteristics associated with drug resistant epilepsy in children up to 36 months old with Congenital Zika Syndrome.

OBJECTIVES: To verify characteristics associated with drug resistant epilepsy in children up to 36 months of age with Congenital Zika Syndrome (CZS). METHODS: This is a prospective cohort study with children aged up to 36 months diagnosed with CZS. Obstetric, demographic, phenotype and other clinical signs, cranial tomography, growth and motor development of the children were collected. RESULTS: Of a total of 109 children diagnosed with CZS, 100 (91.7%) had epilepsy and 68 (68%) with drug resistant seizures. The types of seizures associated with drug resistant epilepsy were focal seizures from the occipital lobe, generalized tonic and generalized tonic-clonic seizures. There was an association between drug resistant epilepsy and microcephaly at birth, severe microcephaly at birth, excess nuchal skin, ventriculomegaly, reduced brain parenchyma volume, and hypoplasia or malformation of the cerebellum. Difficulty sleeping, irritability, continuous crying, dysphagia and gross motor function were clinical signs associated with drug resistant epilepsy, as were the presence of ocular abnormalities, low head circumference in the first year of life and low weight in the first six months. CONCLUSIONS: The prevalence of drug resistant epilepsy in children up to 36 months with CZS was 62.4% and was associated with the severity of the child's neurological damage, with emphasis on the reduction of brain parenchyma volume and damage to the cerebellum.

In- and Out-of-Hospital Deaths by Acute Myocardial Infarction in Brazilian State Capitals. / Óbitos Intra e Extra-Hospitalares por Infarto Agudo do Miocárdio nas Capitais Brasileiras.

BACKGROUND: Acute myocardial infarction (AMI) is the main cause of death in Brazil and the world. Approximately half of these deaths occur outside the hospital. OBJECTIVES: To analyze the distribution, temporal evolution, and sociodemographic characteristics (SDC) of in- and out-of-hospital deaths by AMI in Brazilian state capitals and their relationship with municipal development indicators (MDI). METHODS: This is an ecological study of the number of deaths due to AMI reported annually by the 27 Brazilian state capitals from 2007 to 2016; these were divided into 2 groups: in-hospital (H) and out-of-hospital (OH). We evaluated the temporal evolution of mortality rates in each group and differences in SDC. Negative binomial regression models were used to compare the temporal evolution of the number of deaths in each group with the following variables: residing in the South/Southeast regions (S/SE), municipal human development index (MHDI), Gini coefficient, and expected years of schooling (EYS). We considered p-values<0.05 as statisticallysignificant. RESULTS: The OH mortality rate increased with time for all state capitals. All studied SDC were different between groups (p<0.001). In the OH group, most deaths were of men and patients aged 80 years or older and not married. S/SE increased the incidence of OH deaths (incidence rate ratio [IRR]=2.84; 95% confidence interval [CI]=1.67-4.85), while higher EYS reduced it (IRR=0.86; 95% CI=0.77-0.97). In the H group, higher MHDI reduced the incidence of deaths (IRR=0.44; 95% CI=0.33-0.58), while higher EYS increased it (IRR=1.09; 95% CI=1.03-1.15). CONCLUSIONS: In- and out-of-hospital deaths due to AMI in Brazilian state capitals were influenced by MDI, presented sociodemographic differences and a progressive increase in out-of-hospital occurrences.

FUNDAMENTO: O infarto agudo do miocárdio (IAM) é a principal causa de óbito no Brasil e no mundo. Aproximadamente metade dos óbitos ocorrem fora do ambiente hospitalar. OBJETIVOS: Analisar a distribuição, a evolução temporal e as características sociodemográficas (CSD) dos óbitos intra e extra-hospitalares por IAM nas capitais brasileiras e a sua relação com indicadores municipais de desenvolvimento (IMD). MÉTODOS: Estudo ecológico com contagem anual dos óbitos por IAM nas 27 capitais brasileiras de 2007 a 2016, os quais foram divididos em dois grupos, intra-hospitalar (H) e extra-hospitalar (EH). Avaliou-se a evolução temporal das taxas de mortalidade em cada grupo e as diferenças das CSD. Modelos de regressão binominal negativa compararam temporalmente a contagem de óbitos em cada grupo com as seguintes variáveis: residir nas regiões Sul e Sudeste (S/SE), índice de desenvolvimento humano municipal (IDHM), índice de Gini e expectativa de anos de estudo (EAE). Considerou-se estatisticamente valores significativos de p < 0,05. RESULTADOS: A taxa de mortalidade EH para o conjunto das capitais aumentou ao longo do tempo. Todas as CSD pesquisadas foram difententes entre os grupos (p < 0,001). No grupo EH prevaleceram os óbitos em homens, em pacientes ≥ 80 anos e em solteiros. O S/SE elevou a incidência de óbitos extra-hospitalares (IRR = 2,84; IC 95% = 1,67-4,85), enquanto o maior EAE registrou queda (IRR = 0,86; IC 95% = 0,77-0,97). Para o grupo H, o maior IDHM reduziu a incidência de óbitos (IRR = 0,44; IC 95% = 0,33-0,58), enquanto o maior EAE apresentou crescimento (IRR = 1,09; IC 95% = 1,03-1,15). CONCLUSÃO: Os óbitos intra e extra-hospitalares por IAM nas capitais apresentam diferenças sociodemográficas, incidência influenciada por IMD e progressivo aumento da ocorrência extra-hospitalar.

Autoregressive spatial modeling of possible cases of dengue, chikungunya, and Zika in the capital of Northeastern Brazil.

INTRODUCTION: Dengue, chikungunya, and Zika are a growing global health problem. This study analyzed the spatial distribution of dengue, chikungunya, and Zika cases in São Luís, Maranhão, from 2015 to 2016 and investigated the association between socio-environmental and economic factors and hotspots for mosquito proliferation. METHODS: This was a socio-ecological study using data from the National Information System of Notifiable Diseases. The spatial units of analysis were census tracts. The incidence rates of the combined cases of the three diseases were calculated and smoothed using empirical local Bayes estimates. The spatial autocorrelation of the smoothed incidence rate was measured using Local Moran's I and Global Moran's I. Multiple linear regression and spatial autoregressive models were fitted using the log of the smoothed disease incidence rate as the dependent variable and socio-environmental factors, demographics, and mosquito hotspots as independent variables. RESULTS: The findings showed a significant spatial autocorrelation of the smoothed incidence rate. The model that best fit the data was the spatial lag model, revealing a positive association between disease incidence and the proportion of households with surrounding garbage accumulation. CONCLUSIONS: The distribution of dengue, chikungunya, and Zika cases showed a significant spatial pattern, in which the high-risk areas for the three diseases were explained by the variable "garbage accumulated in the surrounding environment," demonstrating the need for an intersectoral approach for vector control and prevention that goes beyond health actions.

Excess deaths from all causes and by COVID-19 in Brazil in 2020.

OBJECTIVE: To estimate the 2020 all-cause and COVID-19 excess mortality according to sex, age, race/color, and state, and to compare mortality rates by selected causes with that of the five previous years in Brazil. METHODS: Data from the Mortality Information System were used. Expected deaths for 2020 were estimated from 2015 to 2019 data using a negative binomial log-linear model. RESULTS: Excess deaths in Brazil in 2020 amounted to 13.7%, and the ratio of excess deaths to COVID-19 deaths was 0.90. Reductions in deaths from cardiovascular diseases (CVD), respiratory diseases, and external causes, and an increase in ill-defined causes were all noted. Excess deaths were also found to be heterogeneous, being higher in the Northern, Center-Western, and Northeastern states. In some states, the number of COVID-19 deaths was lower than that of excess deaths, whereas the opposite occurred in others. Moreover, excess deaths were higher in men aged 20 to 59, and in black, yellow, or indigenous individuals. Meanwhile, excess mortality was lower in women, in individuals aged 80 years or older, and in whites. Additionally, deaths among those aged 0 to 19 were 7.2% lower than expected, with reduction in mortality from respiratory diseases and external causes. There was also a drop in mortality due to external causes in men and in those aged 20 to 39 years. Moreover, reductions in deaths from CVD and neoplasms were noted in some states and groups. CONCLUSION: There is evidence of underreporting of COVID-19 deaths and of the possible impact of restrictive measures in the reduction of deaths from external causes and respiratory diseases. The impacts of COVID-19 on mortality were heterogeneous among the states and groups, revealing that regional, demographic, socioeconomic, and racial differences expose individuals in distinct ways to the risk of death from both COVID-19 and other causes.

Beriberi in Brazil: A Disease That Affects Indigenous People.

BACKGROUND: Beriberi is the clinical manifestation of thiamine deficiency. It is multicausal and typically associated with poverty and food insecurity among vulnerable populations, such as indigenous people. OBJECTIVE: The objective of this study was to carry out a spatial analysis of reported cases of beriberi among indigenous people in Brazil. METHODS: Cross-sectional study using time series data on suspected cases of beriberi reported to the Ministry of Health via the FormSUS between July 2013 and September 2018. Indigenous villages were georeferenced, and Kernel density estimation was used to identify patterns of the spatial distribution of beriberi cases. RESULTS: A total of 414 cases of beriberi were reported in the country of which 210 (50.7%) were indigenous people. All the cases in indigenous people occurred in states located in the Legal Amazon (Maranhão, Roraima, and Tocantins). Kernel density estimation showed high-density areas in Tocantins and Roraima. CONCLUSIONS: This is the first nationwide study of reported cases of beriberi. The findings can be used to guide actions that contribute to the monitoring and prevention of beriberi among indigenous people.

Congenital Zika syndrome: Growth, clinical, and motor development outcomes up to 36 months of age and differences according to microcephaly at birth.

BACKGROUND: Little is known regarding the developmental consequences of congenital Zika syndrome (CZS) without microcephaly at birth. Most previously published clinical series were descriptive and they had small sample sizes. STUDY DESIGN: We conducted a cohort study to compare the growth, clinical, and motor development outcomes for 110 children with CZS born with and without microcephaly up to their third birthday. Ninety-three had their head circumference (HC) at birth abstracted and they did not have hypertensive hydrocephalus at birth, where 61 were born with microcephaly and 32 without. RESULTS: The HC z-scores decreased steeply from birth to six months of age, i.e., from -3.77 to -6.39 among those with microcephaly at birth and from -1.03 to -3.84 among those without. Thus, at 6 months of age, the mean HC z-scores for children born without microcephaly were nearly the same as those for children born with microcephaly. Children born without microcephaly were less likely to have brain damage, ophthalmic abnormalities, and drug-resistant epilepsy, but the differences in many conditions were not statistically significant. CONCLUSIONS: Children born without microcephaly were only slightly less likely to present severe neurologic impairment and to develop postnatal-onset microcephaly, and some of the original differences between the groups tended to dissipate with age.

Bolsa Família program and incomplete childhood vaccination in two Brazilian cohorts.

OBJECTIVE: To estimate the effect of being a beneficiary of the Bolsa Família Program (BFP) in the vaccination of children aged 13 to 35 months. METHODS: Our study was based on all birth records of residents of Ribeirão Preto (SP) and probabilistic sampling with 1/3 of the births of residents of São Luís (MA), selecting low-income children, born in 2010, belonging to the cohorts Brazilian Ribeirão Preto and São Luís Birth Cohort Studies and eligible for the Bolsa Família program. The information of Cadastro Único (CadÚnico - Single Registry) was used to categorize the receipt of benefit from the BFP (yes or no). The final sample consisted of 532 children in Ribeirão Preto and 1,229 in São Luís. The outcome variable was a childhood vaccine regimen, constructed with BCG, tetravalent, triple viral, hepatitis B, poliomyelitis, rotavirus and yellow fever vaccines. The adjustment variables were: economic class, mother's schooling and mother's skin color. Children with monthly per capita family income of up to R$ 280.00 and/or economic class D/E were considered eligible for the benefit of the BFP. A theoretical model was constructed using a directed acyclic graph to estimate the effect of being a beneficiary of the BFP in the vaccination of low-income children. In the statistical analyses, weighing was used by the inverse of the probability of exposure and pairing by propensity score. RESULTS: Considering a monthly per capita family income of up to R$ 280.00, being a beneficiary of the BFP had no effect on the childhood vaccination schedule, according to weighing by the inverse of the probability of exposure (SL-coefficient: -0.01; 95%CI -0.07 to 0.04; p = 0.725 and RP-coefficient: 0.04; 95%CI -0.02 to 0.10; p = 0.244) and pairing by propensity score (SL-coefficient: -0.01; 95%CI -0.07 to 0.05; p = 0.744 and RP-coefficient: 0.04; 95%CI -0.02 to 0.10; p = 0.231). CONCLUSIONS: The receipt of the benefit of the BFP did not influence childhood vaccination, which is one of the conditionalities of the program. This may indicate that this conditionality is not being adequately monitored.

Spatial distribution of arboviruses and its association with a social development index and the waste disposal in São Luís, state of Maranhão, Brazil, 2015 to 2019 / Distribuição espacial de arboviroses e sua associação com um índice de desenvolvimento social e o descarte de lixo em São Luís, Maranhão, 2015 a 2019

ABSTRACT Objective: To detect spatial and spatiotemporal clusters of urban arboviruses and to investigate whether the social development index (SDI) and irregular waste disposal are related to the coefficient of urban arboviruses detection in São Luís, state of Maranhão, Brazil. Methods: The confirmed cases of Dengue, Zika and Chikungunya in São Luís, from 2015 to 2019, were georeferenced to the census tract of residence. The Bayesian Conditional Autoregressive regression model was used to identify the association between SDI and irregular waste disposal sites and the coefficient of urban arboviruses detection. Results: The spatial pattern of arboviruses pointed to the predominance of a low-incidence cluster, except 2016. For the years 2015, 2016, 2017, and 2019, an increase of one unit of waste disposal site increased the coefficient of arboviruses detection in 1.25, 1.09, 1.23, and 1.13 cases of arboviruses per 100 thousand inhabitants, respectively. The SDI was not associated with the coefficient of arboviruses detection. Conclusion: In São Luís, spatiotemporal risk clusters for the occurrence of arboviruses and a positive association between the coefficient of arbovirus detection and sites of irregular waste disposal were identified.

RESUMO Objetivo: Detectar aglomerados espaciais e espaço-temporais de arboviroses urbanas e investigar se o índice desenvolvimento social (IDS) e o descarte irregular de lixo estão relacionados ao coeficiente de detecção das arboviroses urbanas em São Luís, Maranhão. Métodos: Os casos confirmados de dengue, Zika e chikungunya em São Luís, no período de 2015 a 2019, foram georreferenciados para o setor censitário de residência. O modelo de regressão Autorregressivo Condicional Bayesiano foi utilizado para identificar a associação entre o coeficiente de detecção de arboviroses urbanas, IDS e pontos de descarte irregular de lixo. Resultados: O padrão espacial de arboviroses apontou para a predominância de cluster de baixo coeficiente de detecção, exceto em 2016. Para os anos de 2015, 2016, 2017 e 2019, o aumento de uma unidade de ponto de lixo aumenta o coeficiente de detecção de arboviroses em 1,25, 1,09, 1,23 e 1,13 casos de arboviroses por 100 mil habitantes, respectivamente. O IDS não foi associado ao coeficiente de detecção de arboviroses. Conclusão: Em São Luís foram identificados aglomerados espaço-temporais de risco para a ocorrência de arboviroses e a associação positiva entre o coeficiente de detecção de arboviroses e os pontos de descarte irregular de lixo.

Individual and contextual factors associated with the survival of patients with severe acute respiratory syndrome by COVID-19 in Brazil / Fatores individuais e contextuais associados à sobrevida de pacientes com síndrome respiratória aguda grave por COVID-19 no Brasil

ABSTRACT Objective: To analyze the influence of individual and contextual factors of the hospital and the municipality of care on the survival of patients with Severe Acute Respiratory Syndrome due to COVID-19. Methods: Hospital cohort study with data from 159,948 adults and elderly with Severe Acute Respiratory Syndrome due to COVID-19 hospitalized from January 1 to December 31, 2022 and reported in the Influenza Epidemiological Surveillance Information System. The contextual variables were related to the structure, professionals and equipment of the hospital establishments and socioeconomic and health indicators of the municipalities. The outcome was hospital survival up to 90 days. Survival tree and Kaplan-Meier curves were used for survival analysis. Results: Hospital lethality was 30.4%. Elderly patients who underwent invasive mechanical ventilation and were hospitalized in cities with low tax collection rates had lower survival rates compared to other groups identified in the survival tree (p<0.001). Conclusion: The study indicated the interaction of contextual factors with the individual ones, and it shows that hospital and municipal characteristics increase the risk of death, highlighting the attention to the organization, operation, and performance of the hospital network.

RESUMO Objetivo: Analisar a influência dos fatores individuais e contextuais do hospital e do município de assistência sobre a sobrevida de pacientes com Síndrome Respiratória Aguda Grave por COVID-19. Métodos: Estudo de coorte hospitalar com dados de 159.948 adultos e idosos com Síndrome Respiratória Aguda Grave por COVID-19 internados de 01 de janeiro a 31 de dezembro de 2022 e notificados no Sistema de Informação de Vigilância Epidemiológica da Influenza. As variáveis contextuais foram relacionadas à estrutura, aos profissionais e equipamentos dos estabelecimentos hospitalares e indicadores socioeconômicos e de saúde dos municípios. O desfecho foi a sobrevida hospitalar em até 90 dias. Árvore de sobrevida e curvas de Kaplan-Meier foram utilizados para analisar a sobrevida. Resultados: A letalidade hospitalar foi de 30,4%. Idosos submetidos à ventilação mecânica invasiva e internados em cidades com baixo percentual de arrecadação de impostos apresentaram menor sobrevida quando comparados aos demais grupos identificados na árvore de sobrevida (p<0,001). Conclusão: O estudo indicou a interação de fatores contextuais com os individuais, e evidencia que características hospitalares e dos municípios aumentam o risco de óbito, destacando a atenção à organização, ao funcionamento e desempenho da rede hospitalar.