Causes of death in children with congenital Zika syndrome in Brazil, 2015 to 2018: A nationwide record linkage study.

BACKGROUND: Children with congenital Zika syndrome (CZS) have severe damage to the peripheral and central nervous system (CNS), greatly increasing the risk of death. However, there is no information on the sequence of the underlying, intermediate, immediate, and contributing causes of deaths among these children. The aims of this study are describe the sequence of events leading to death of children with CZS up to 36 months of age and their probability of dying from a given cause, 2015 to 2018. METHODS AND FINDINGS: In a population-based study, we linked administrative data on live births, deaths, and cases of children with CZS from the SINASC (Live Birth Information System), the SIM (Mortality Information System), and the RESP (Public Health Event Records), respectively. Confirmed and probable cases of CZS were those that met the criteria established by the Brazilian Ministry of Health. The information on causes of death was collected from death certificates (DCs) using the World Health Organization (WHO) DC template. We estimated proportional mortality (PM%) among children with CZS and among children with non-Zika CNS congenital anomalies (CA) by 36 months of age and proportional mortality ratio by cause (PMRc). A total of 403 children with confirmed and probable CZS who died up to 36 months of age were included in the study; 81.9% were younger than 12 months of age. Multiple congenital malformations not classified elsewhere, and septicemia unspecified, with 18 (PM = 4.5%) and 17 (PM = 4.2%) deaths, respectively, were the most attested underlying causes of death. Unspecified septicemia (29 deaths and PM = 11.2%) and newborn respiratory failure (40 deaths and PM = 12.1%) were, respectively, the predominant intermediate and immediate causes of death. Fetuses and newborns affected by the mother's infectious and parasitic diseases, unspecified cerebral palsy, and unspecified severe protein-caloric malnutrition were the underlying causes with the greatest probability of death in children with CZS (PMRc from 10.0 to 17.0) when compared to the group born with non-Zika CNS anomalies. Among the intermediate and immediate causes of death, pneumonitis due to food or vomiting and unspecified seizures (PMRc = 9.5, each) and unspecified bronchopneumonia (PMRc = 5.0) were notable. As contributing causes, fetus and newborn affected by the mother's infectious and parasitic diseases (PMRc = 7.3), unspecified cerebral palsy, and newborn seizures (PMRc = 4.5, each) were more likely to lead to death in children with CZS than in the comparison group. The main limitations of this study were the use of a secondary database without additional clinical information and potential misclassification of cases and controls. CONCLUSION: The sequence of causes and circumstances involved in the deaths of the children with CZS highlights the greater vulnerability of these children to infectious and respiratory conditions compared to children with abnormalities of the CNS not related to Zika.

Previous BCG vaccination is associated with less severe clinical progression of COVID-19.

BACKGROUND: BCG vaccination, originally used to prevent tuberculosis, is known to "train" the immune system to improve defence against viral respiratory infections. We investigated whether a previous BCG vaccination is associated with less severe clinical progression of COVID-19 METHODS: A case-control study comparing the proportion with a BCG vaccine scar (indicating previous vaccination) in cases and controls presenting with COVID-19 to health units in Brazil. Cases were subjects with severe COVID-19 (O2 saturation < 90%, severe respiratory effort, severe pneumonia, severe acute respiratory syndrome, sepsis, and septic shock). Controls had COVID-19 not meeting the definition of "severe" above. Unconditional regression was used to estimate vaccine protection against clinical progression to severe disease, with strict control for age, comorbidity, sex, educational level, race/colour, and municipality. Internal matching and conditional regression were used for sensitivity analysis. RESULTS: BCG was associated with high protection against COVID-19 clinical progression, over 87% (95% CI 74-93%) in subjects aged 60 or less and 35% (95% CI - 44-71%) in older subjects. CONCLUSIONS: This protection may be relevant for public health in settings where COVID-19 vaccine coverage is still low and may have implications for research to identify vaccine candidates for COVID-19 that are broadly protective against mortality from future variants. Further research into the immunomodulatory effects of BCG may inform COVID-19 therapeutic research.

Physical disabilities caused by leprosy in 100 million cohort in Brazil.

BACKGROUND: Leprosy continues to be an important cause of physical disability in endemic countries such as Brazil. Knowledge of determinants of these events may lead to better control measures and targeted interventions to mitigate its impact on affected individuals. This study investigated such factors among the most vulnerable portion of the Brazilian population. METHODS: A large cohort was built from secondary data originated from a national registry of applicants to social benefit programs, covering the period 2001-2015, including over 114 million individuals. Data were linked to the leprosy notification system utilizing data from 2007 until 2014. Descriptive and bivariate analyses lead to a multivariate analysis using a multinomial logistic regression model with cluster-robust standard errors. Associations were reported as Odds Ratios with their respective 95% confidence intervals. RESULTS: Among the original cohort members 21,565 new leprosy cases were identified between 2007 and 2014. Most of the cases (63.1%) had grade zero disability. Grades 1 and 2 represented 21 and 6%, respectively. Factors associated with increasing odds of grades 1 and 2 disability were age over 15 years old (ORs 2.39 and 1.95, respectively), less schooling (with a clear dose response effect) and being a multibacillary patient (ORs 3.5 and 8.22). Protective factors for both grades were being female (ORs 0.81 and 0.61) and living in a high incidence municipality (ORs 0.85 and 0.67). CONCLUSIONS: The findings suggest that the developing of physical disabilities remains a public health problem which increases the burden of leprosy, mainly for those with severe clinical features and worse socioeconomic conditions. Early diagnosis is paramount to decrease the incidence of leprosy-related disability and our study points to the need for strengthening control actions in non-endemic areas in Brazil, where cases may be missed when presented at early stages in disease. Both actions are needed, to benefit patients and to achieve the WHO goal in reducing physical disabilities among new cases of leprosy.

Monitoring the progress of health-related sustainable development goals (SDGs) in Brazilian states using the Global Burden of Disease indicators.

BACKGROUND: Measuring the Global Burden of Disease (GBD) has been the key to verifying the evolution of health indicators worldwide. We analyse subnational GBD data for Brazil in order to monitor the performance of the Brazilian states in the last 28 years on their progress towards meeting the health-related SDGs. METHODS: As part of the GBD study, we assessed the 41 health-related indicators from the SDGs in Brazil at the subnational level for all the 26 Brazilian states and the Federal District from 1990 to 2017. The GBD group has rescaled all worldwide indicators from 0 to 100, assuming that for each one of them, the worst value among all countries and overtime is 0, and the best is 100. They also estimate the overall health-related SDG index as a function of all previously estimated health indicators and the SDI index (Socio-Demographic Index) as a function of per capita income, average schooling in the population aged 15 years or over, and total fertility rate under the age of 25 (TFU25). RESULTS: From 1990 to 2017, most subnational health-related SDGs, the SDG and SDI indexes improved considerable in most Brazilian states. The observed differences in SDG indicators within Brazilian states, including HIV incidence and health worker density, increased over time. In 2017, health-related indicators that achieved good results globally included the prevalence of child wasting, NTD, household air pollution, conflict mortality, skilled birth attendance, use of modern contraceptive methods, vaccine coverage, and health worker density, but poor results were observed for child overweight and homicide rates. The high rates of overweight, alcohol consumption, and smoking prevalence found in the historically richest regions (i.e., the South and Southeast), contrast with the high rates of tuberculosis, maternal, neonatal, and under-5 mortality and WASH-related mortality found in the poorer regions (i.e., the North and Northeast). CONCLUSIONS: The majority of Brazil's health-related SDG indicators have substantially improved over the past 28 years. However, inequalities in health among the Brazilian states and regions remain noticeable negatively affecting the Brazilian population, which can contribute to Brazil not achieving the SDG 2030 targets.

Migration and tuberculosis transmission in a middle-income country: a cross-sectional study in a central area of São Paulo, Brazil.

BACKGROUND: Little is known about the impact of growing migration on the pattern of tuberculosis (TB) transmission in middle-income countries. We estimated TB recent transmission and its associated factors and investigated the presence of cross-transmission between South American migrants and Brazilians. METHODS: We studied a convenient sample of cases of people with pulmonary TB in a central area of São Paulo, Brazil, diagnosed between 2013 and 2014. Cases with similar restriction fragment length polymorphism (IS6110-RFLP) patterns of their Mycobacterium tuberculosis complex isolates were grouped in clusters (recent transmission). Clusters with both Brazilian and South American migrants were considered mixed (cross-transmission). Risk factors for recent transmission were studied using logistic regression. RESULTS: Isolates from 347 cases were included, 76.7% from Brazilians and 23.3% from South American migrants. Fifty clusters were identified, which included 43% South American migrants and 60.2% Brazilians (odds ratio = 0.50, 95% confidence interval = 0.30-0.83). Twelve cross-transmission clusters were identified, involving 24.6% of all clustered cases and 13.8% of all genotyped cases, with migrants accounting for either an equal part or fewer cases in 11/12 mixed clusters. CONCLUSIONS: Our results suggest that TB disease following recent transmission is more common among Brazilians, especially among those belonging to high-risk groups, such as drug users. Cross-transmission between migrants and Brazilians was present, but we found limited contributions from migrants to Brazilians in central areas of São Paulo and vice versa.

Migration to middle-income countries and tuberculosis-global policies for global economies.

BACKGROUND: International migration to middle-income countries is increasing and its health consequences, in particular increasing transmission rates of tuberculosis (TB), deserve consideration. Migration and TB are a matter of concern in high-income countries and targeted screening of migrants for active and latent TB infection is a main strategy to manage risk and minimize transmission. In this paper, we discuss some aspects of TB control and migration in the context of middle-income countries, together with the prospect of responding with equitable and comprehensive policies. MAIN BODY: TB rates in middle-income countries remain disproportionally high among the poorest and most vulnerable groups in large cities where most migrant populations are concentrated. Policies that tackle migrant TB in high-income countries may be inadequate for middle-income countries because of their different socio-economic and cultural scenarios. Strategies to control TB in these settings must take into account the characteristics of middle-income countries and the complexity of TB as a disease of poverty. Intersectoral policies of social protection such as cash-transfer programs help reducing poverty and improving health in vulnerable populations. We address the development of new approaches to improve well-established strategies including contact tracing and active and latent TB screening as an 'add on' to the existing health care guidelines of conditional cash transfer programs. In addition, we discuss how it might improve health and welfare among both poor migrants and locally-born populations. Authorities from middle-income countries should recognise that migrants are a vulnerable social group and promote cooperation efforts between sending and receiving countries for mitigation of poverty and prevention of disease in this group. CONCLUSIONS: Middle-income countries have long sent migrants overseas. However, the influx of large migrant populations into their societies is relatively new and a growing phenomenon and it is time to set comprehensive goals to improve health among these communities. Conditional cash transfer policies with TB screening and strengthening of DOTS are some strategies that deserve attention. Reduction of social and health inequality among migrants should be incorporated into concerted actions to meet TB control targets.

Performance evaluation of tuberculosis control in Brazilian municipalities.

OBJECTIVE: To evaluate the performance of tuberculosis control in Brazilian municipalities. METHODS: This is an ecological study on Brazilian municipalities that notified at least four new cases of tuberculosis, with a minimum of one new case of pulmonary tuberculosis between 2015 and 2018. The municipalities were stratified according to the population in < 50 thousand, 50-100 thousand, 100-300 thousand, and > 300 thousand inhabitants, and the k-means method was used to group them within each population range according to the performance of six indicators of the disease. RESULTS: A total of 2,845 Brazilian municipalities were included, comprising 98.5% (208,007/211,174) of new tuberculosis cases in the period. For each population range, three groups (A, B, and C) of municipalities were identified according to the performance of the indicators: A, the most satisfactory; B, the intermediates; and C, the least satisfactory. Municipalities in group A with < 100 thousand inhabitants presented results above the targets for laboratory confirmation (≥ 72%), abandonment (≤ 5%), and cure (≥ 90%), and comprised 2% of new cases of the disease. Conversely, municipalities of groups B and C presented at least five indicators with results below the targets - HIV testing (< 100%), contact investigation (< 90%), directly observed therapy (< 90%), abandonment (> 5%), and cure (< 90%) -, and corresponded to 66.7% of new cases of tuberculosis. In group C of municipalities with > 300 thousand inhabitants, which included 19 of the 27 capitals and 43.1% of new cases of tuberculosis, the lowest percentages of contact investigation (mean = 56.4%) and directly observed therapy (mean = 15.4%) were verified, in addition to high abandonment (mean = 13.9%) and low coverage of primary health care (mean = 66.0%). CONCLUSIONS: Most new cases of tuberculosis occurred in municipalities with unsatisfactory performance for disease control. Expanding the coverage of primary health care in these places can reduce abandonment and increase the contact investigation and directly observed therapy.

Cloth masks in public places: an essential intervention to prevent COVID-19 in Brazil. / Máscaras de tecido em locais públicos: intervenção essencial na prevenção da COVID-19 no Brasil.

There is increasing evidence that the use of masks is an indispensable protective measure against COVID-19, given the high transmissibility of the new coronavirus through the respiratory system, including by asymptomatic individuals. The use of cloth masks in public places has been established as a protective measure to be adopted alongside social distancing and hand hygiene. This narrative review aims to systematize the scientific evidence that informs the widespread use of cloth masks as a preventive measure against COVID-19 and to describe the evolution of positions contrary to or in favor of its use outside the home, in view of the advance of the new coronavirus pandemic globally. The scientific articles, technical notes, governmental decrees and other documents analyzed indicate that widespread use of masks has the potential to reduce the spread of the new coronavirus. We recommend that the Brazilian government adopt strategies to increase the supply of reusable cloth masks to the public, especially to vulnerable populations and to support studies on the impact of this measure to control the pandemic in the country. Finally, it is imperative to ensure that use of masks does not exacerbate stigmatization of racial groups that already face prejudice.

Acumulam-se evidências de que o uso de máscaras é uma medida indispensável de proteção à COVID-19, devido ao alto poder de transmissão do novo coronavírus por via respiratória, inclusive por indivíduos assintomáticos. Por sua vez, o uso das máscaras de tecido em locais públicos tem se consolidado como medida adicional de proteção às medidas de distanciamento social e higienização das mãos. Objetivou-se sistematizar as evidências científicas que justificam o amplo uso de máscaras de tecido como prevenção à COVID-19 e descrever a evolução dos posicionamentos contrários ou favoráveis ao seu uso em ambientes extradomiciliares, diante do avanço da pandemia do novo coronavírus pelo mundo. A triagem de artigos e documentos oficiais do Brasil e de outros países indica que o uso de máscaras em locais públicos tornou-se uma intervenção essencial graças ao potencial de reduzir a velocidade de propagação do novo coronavírus. Recomenda-se que o poder público adote estratégias para aumentar a oferta deste produto e fomente estudos para avaliação do impacto da medida no controle da pandemia no Brasil. É imperativo assegurar disponibilidade de máscaras a grupos socioeconomicamente desfavorecidos e garantir que determinados grupos raciais não sejam estigmatizados diante do uso de máscaras em ambientes extradomiciliares.

The effect of laboratory testing on COVID-19 monitoring indicators: an analysis of the 50 countries with the highest number of cases. / O efeito da testagem laboratorial nos indicadores de acompanhamento da COVID-19: uma análise dos 50 países com maior número de casos.

OBJECTIVE: To analyse how testing the population influences the health indicators used to monitor the COVID-19 pandemic in the 50 countries with the highest number of diagnosed cases. METHODS: This was an ecological study using secondary data retrieved on 8/19/2020. Cumulative incidence, mortality rate, case-fatality rate, and proportion of positive tests were calculated. The data were described and presented graphically, with their respective Spearman Correlation Coefficients. RESULTS: The testing rate varied enormously between countries. Cumulative incidence and the proportion of positive tests were correlated with the number of tests, while the mortality rate and case-fatality rate showed low correlation with this indicator. CONCLUSION: Most countries do not test enough to ensure adequate monitoring of the pandemic, and this is reflected in the quality of the indicators. Expanding the number of tests is essential, but it needs to be accompanied by other measures, such as isolation of diagnosed cases and contact tracing.

Epidemiological characteristics and temporal trends of new leprosy cases in Brazil: 2006 to 2017.

Our study aims to describe trends in new case detection rate (NCDR) of leprosy in Brazil from 2006 to 2017 overall and in subgroups, and to analyze the evolution of clinical and treatment characteristics of patients, with emphasis on cases diagnosed with grade 2 physical disabilities. We conducted a descriptive study to analyze new cases of leprosy registered in the Brazilian Information System for Notificable Diseases (SINAN), from 2006-2017. We calculated the leprosy NCDR per 100,000 inhabitants (overall and for individuals aged < 15 and ≥ 15 years) by sex, age, race/ethnicity, urban/rural areas, and Brazilian regions, and estimated the trends using the Mann-Kendall non-parametric test. We analyzed the distributions of cases according to relevant clinical characteristics over time. In Brazil, there was a sharp decrease in the overall NCDR from 23.4/100,000 in 2006 to 10.3/100,000 in 2017; among children < 15 years, from 6.94 to 3.20/100,000. The decline was consistent in all Brazilian regions and race/ethnicity categories. By 2017, 70.2% of the cases were multibacillary, 30.5% had grade 1 (G1D) or 2 (G2D) physical disabilities at diagnosis and 42.8% were not evaluated at treatment completion/discharge; cases with G2D at diagnosis were mostly detected in urban areas (80%) and 5% of cases died during the treatment (leprosy or other causes). Although the frequency of leprosy NCDR decreased in Brazil from 2006 to 2017 across all evaluated population groups, the large number of cases with multibacillary leprosy, physical disabilities or without adequate evaluation, and among children suggest the need to reinforce timely diagnosis and treatment to control leprosy in Brazil.

Methods to evaluate COVID-19 vaccine effectiveness, with an emphasis on quasi-experimental approaches. / Métodos para avaliação da efetividade de vacinas para COVID-19 com ênfase em abordagens quase-experimentais.

The evaluation of vaccine effectiveness is conducted with real-world data. They are essential to monitor the performance of vaccination programmes over time, and in the context of the emergence of new variants. Until now, the effectiveness of COVID-19 vaccines has been assessed based on classic methods, such as cohort and test-negative case-control studies, which may often not allow for adequate control of inherent biases in the assignment of vaccination campaigns. The aim of this review was to discuss the study designs available to evaluate vaccine effectiveness, highlighting quasi-experimental studies, which seek to mimic randomized trials, by introducing an exogenous component to allocate to treatment, in addition to the advantages, limitations, and applicability in the context of Brazilian data. The use of quasi-experimental approaches, such as interrupted time series, difference-in-differences, propensity scores, instrumental variables, and regression discontinuity design, are relevant due to the possibility of providing more accurate estimates of COVID-19 vaccine effectiveness. This is especially important in scenarios such as the Brazilian, which characterized by the use of various vaccines, with the respective numbers and intervals between doses, applied to different age groups, and introduced at different times during the pandemic.

A avalição da efetividade de vacinas é feita com dados do mundo real e é essencial para monitorar o desempenho dos programas de vacinação ao longo do tempo bem como frente a novas variantes. Até o momento, a avaliação da efetividade das vacinas para COVID-19 tem sido baseada em métodos clássicos como estudos de coorte e caso controle teste-negativo, que muitas vezes podem não permitir o adequado controle dos vieses intrínsecos da alocação das campanhas de vacinação. O objetivo dessa revisão foi discutir os desenhos de estudo disponíveis para avaliação de efetividade das vacinas, enfatizando os estudos quase-experimentais, que buscam mimetizar os estudos aleatorizados ao introduzir um componente exógeno para atribuição ao tratamento, bem como suas vantagens, limitações e aplicabilidade no contexto dos dados brasileiros. O emprego de métodos quase-experimentais, incluindo as séries temporais interrompidas, o método de diferença em diferenças, escore de propensão, variáveis instrumentais e regressão descontínua, são relevantes pela possibilidade de gerar estimativas mais acuradas da efetividade de vacinas para COVID-19 em cenários como o brasileiro, que se caracteriza pelo uso de várias vacinas, com respectivos número e intervalos entre doses, aplicadas em diferentes faixas etárias e em diferentes momentos da pandemia.

Correction: Geographic and socioeconomic factors associated with leprosy treatment default: An analysis from the 100 Million Brazilian Cohort.

[This corrects the article DOI: 10.1371/journal.pntd.0007714.].

The global scientific research response to the public health emergency of Zika virus infection.

BACKGROUND: Science studies have been a field of research for different knowledge areas, and they have been successfully used to analyse the construction of scientific knowledge, practice and dissemination. In this study, we aimed to verify how the Zika epidemic has moulded the scientific articles published worldwide by analysing international collaborations and the knowledge landscape through time, as well as research topics and country involvement. METHODOLOGY: We searched the Web of Science (WoS), Scopus and PubMed for studies published up to 31st December 2018 on Zika using the search terms "zika", "zkv" or "zikv". We analysed the scientific production regarding which countries have published the most, on which topics, as well as country level collaboration. We performed a scientometric analysis of research on Zika focusing on knowledge mapping and the scientific research path over time and space. FINDINGS: We found two well defined research areas divided into three subtopics accounting for six clusters. With regard to country analysis, the USA and Brazil were the countries with the highest numbers of publications on Zika. China entered as a new player focusing on specific research areas. When we took into consideration the epidemics and reported cases, Brazil and France were the leading research countries on related topics. As for international collaboration, the USA followed by England and France stand out as the main hubs. The research areas most published included public health-related topics from 2015 until the very beginning of 2016, followed by an increase in topics related to the clinical aspects of the disease in 2016 and the emergence of laboratory research in 2017/2018. CONCLUSIONS: Mapping the response to Zika, a public health emergency, demonstrated a clear pattern of the participation of countries in the scientific advances. The pattern of knowledge production found in this study represented varying country perspectives, research capacity and interests based first on their level of exposure to the epidemic and second on their financial positions regarding science.

Incidence of and Factors Associated With Leprosy Among Household Contacts of Patients With Leprosy in Brazil.

Importance: Despite progress toward reducing global incidence, leprosy control remains a challenge in low- and middle-income countries. Objective: To estimate new case detection rates of leprosy among household contacts of patients with previously diagnosed leprosy and to investigate its associated risk factors. Design, Setting, and Participants: This population-based cohort study included families registered in the 100 Million Brazilian Cohort linked with nationwide registries of leprosy; data were collected from January 1, 2007, through December 31, 2014. Household contacts of patients with a previous diagnosis of leprosy from each household unit were followed up from the time of detection of the primary case to the time of detection of a subsequent case or until December 31, 2014. Data analysis was performed from May to December 2018. Exposures: Clinical characteristics of the primary case and sociodemographic factors of the household contact. Main Outcomes and Measures: Incidence of leprosy, estimated as the new case detection rate of leprosy per 100 000 household contacts at risk (person-years at risk). The association between occurrence of a subsequent leprosy case and the exposure risk factors was assessed using multilevel mixed-effects logistic regressions allowing for state- and household-specific random effects. Results: Among 42 725 household contacts (22 449 [52.5%] female; mean [SD] age, 22.4 [18.5] years) of 17 876 patients detected with leprosy, the new case detection rate of leprosy was 636.3 (95% CI, 594.4-681.1) per 100 000 person-years at risk overall and 521.9 (95% CI, 466.3-584.1) per 100 000 person-years at risk among children younger than 15 years. Household contacts of patients with multibacillary leprosy had higher odds of developing leprosy (adjusted odds ratio [OR], 1.48; 95% CI, 1.17-1.88), and the odds increased among contacts aged 50 years or older (adjusted OR, 3.11; 95% CI, 2.03-4.76). Leprosy detection was negatively associated with illiterate or preschool educational level (adjusted OR, 0.59; 95% CI, 0.38-0.92). For children, the odds were increased among boys (adjusted OR, 1.70; 95% CI, 1.20-2.42). Conclusions and Relevance: The findings in this Brazilian population-based cohort study suggest that the household contacts of patients with leprosy may have increased risk of leprosy, especially in households with existing multibacillary cases and older contacts. Public health interventions, such as contact screening, that specifically target this population appear to be needed.

Social distancing measures to control the COVID-19 pandemic: potential impacts and challenges in Brazil. / Medidas de distanciamento social no controle da pandemia de COVID-19: potenciais impactos e desafios no Brasil.

The COVID-19 pandemic has challenged researchers and policy makers to identify public safety measures forpreventing the collapse of healthcare systems and reducingdeaths. This narrative review summarizes the available evidence on the impact of social distancing measures on the epidemic and discusses the implementation of these measures in Brazil. Articles on the effect of social distancing on COVID-19 were selected from the PubMed, medRXiv and bioRvix databases. Federal and state legislation was analyzed to summarize the strategies implemented in Brazil. Social distancing measures adopted by the population appear effective, particularly when implemented in conjunction with the isolation of cases and quarantining of contacts. Therefore, social distancing measures, and social protection policies to guarantee the sustainability of these measures, should be implemented. To control COVID-19 in Brazil, it is also crucial that epidemiological monitoring is strengthened at all three levels of the Brazilian National Health System (SUS). This includes evaluating and usingsupplementary indicators to monitor the progression of the pandemic and the effect of the control measures, increasing testing capacity, and making disaggregated notificationsand testing resultstransparentand broadly available.

A pandemia de COVID-19 tem desafiado pesquisadores e gestores a encontrar medidas de saúde pública que evitem o colapso dos sistemas de saúde e reduzam os óbitos. Esta revisão narrativa buscou sistematizar as evidências sobre o impacto das medidas de distanciamento social na epidemia de COVID-19 e discutir sua implementação no Brasil. Foram triados artigos sobre o efeito do distanciamento social na COVID-19 no PubMed, medRXiv e bioRvix, e analisados atos do poder público nos níveis federal e estadual para sumarizar as estratégias implementadas no Brasil. Os achados sugerem que o distanciamento social adotado por população é efetivo, especialmente quando combinado ao isolamento de casos e à quarentena dos contatos. Recomenda-se a implementação de medidas de distanciamento social e de políticas de proteção social para garantir a sustentabilidade dessas medidas. Para o controle da COVID-19 no Brasil, é imprescindível que essas medidas estejam aliadas ao fortalecimento do sistema de vigilância nos três níveis do SUS, que inclui a avaliação e uso de indicadores adicionais para monitorar a evolução da pandemia e o efeito das medidas de controle, a ampliação da capacidade de testagem, e divulgação ampla e transparente das notificações e de testagem desagregadas.

Austerity policies in Brazil may affect violence related outcomes.

Economic crisis is often managed with austerity policies. These measures seem to burden the population disproportionately, with the poorer being more affected. This paper aims to investigate health outcomes performance after the recent Brazilian crisis and gauge whether that pattern also emerged. Public domain data from 2010 to 2017 was used, and it was found that suicide and homicide rates increased after 2014, while mortality by road traffic injuries decreased at the same time. Furthermore, these trends were exacerbated in the North and Northeast regions and in the municipalities with the poorest quintiles of Human Development Index (HDI). The austerity policies followed by the Brazilian economic crisis may have influenced the mortality trends due to external causes, with a possible stronger impact in the North and Northeast regions and among less developed municipalities.

Socioeconomic determinants of leprosy new case detection in the 100 Million Brazilian Cohort: a population-based linkage study.

BACKGROUND: Although leprosy is recognised as a disease of poverty, there is little evidence on the specific socioeconomic factors associated with disease risk. To inform targeted strategies for disease elimination, we investigated socioeconomic markers of leprosy risk in Brazil. METHODS: Socioeconomic data from the 100 Million Brazilian Cohort were linked to the Brazilian national disease registry (Sistema de Informação de Agravos de Notificação) for leprosy from Jan 1, 2007, to Dec 31, 2014. Using Poisson regression, we assessed the association of socioeconomic factors with risk of incident leprosy in the full cohort and in children (aged 0-15 years), by leprosy subtype and region of residence. FINDINGS: In an analysis of 23 899 942 individuals including 18 518 patients with leprosy, increased levels of deprivation were associated with an increased risk of leprosy in Brazil. Directions of effect were consistent in children younger than 15 years and across disease subtypes. Individuals residing in regions with the highest poverty in the country (central-west, north, and northeast regions) had a risk of leprosy incidence five-to-eight times greater than did other individuals. Decreased levels of income and education and factors reflecting unfavourable living conditions were associated with an up to two-times increase in leprosy incidence (incidence rate ratio 1·46, 95% CI 1·32-1·62, for lowest vs highest quartile of income per capita; 2·09, 95% CI 1·62-2·72, for lowest vs highest level of education). INTERPRETATION: Within the poorest half of the Brazilian population, the most deprived individuals have the greatest risk of leprosy. Strategies focusing on early detection and treatment in the poorest populations could contribute substantially to global disease control. FUNDING: Medical Research Council, Wellcome Trust, Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Brazil), the Conselho Nacional das Fundações Estaduais de Amparo à Pesquisa, Economic and Social Research Council, Biotechnology and Biological Sciences Research Council, Conselho Nacional de Desenvolvimento Científico e Tecnológico, and Fundação de Apoio à Pesquisa do Distrito Federal.

Socioeconomic risk markers of leprosy in high-burden countries: A systematic review and meta-analysis.

Over 200,000 new cases of leprosy are detected each year, of which approximately 7% are associated with grade-2 disabilities (G2Ds). For achieving leprosy elimination, one of the main challenges will be targeting higher risk groups within endemic communities. Nevertheless, the socioeconomic risk markers of leprosy remain poorly understood. To address this gap we systematically reviewed MEDLINE/PubMed, Embase, LILACS and Web of Science for original articles investigating the social determinants of leprosy in countries with > 1000 cases/year in at least five years between 2006 and 2016. Cohort, case-control, cross-sectional, and ecological studies were eligible for inclusion; qualitative studies, case reports, and reviews were excluded. Out of 1,534 non-duplicate records, 96 full-text articles were reviewed, and 39 met inclusion criteria. 17 were included in random-effects meta-analyses for sex, occupation, food shortage, household contact, crowding, and lack of clean (i.e., treated) water. The majority of studies were conducted in Brazil, India, or Bangladesh while none were undertaken in low-income countries. Descriptive synthesis indicated that increased age, poor sanitary and socioeconomic conditions, lower level of education, and food-insecurity are risk markers for leprosy. Additionally, in pooled estimates, leprosy was associated with being male (RR = 1.33, 95% CI = 1.06-1.67), performing manual labor (RR = 2.15, 95% CI = 0.97-4.74), suffering from food shortage in the past (RR = 1.39, 95% CI = 1.05-1.85), being a household contact of a leprosy patient (RR = 3.40, 95% CI = 2.24-5.18), and living in a crowded household (≥5 per household) (RR = 1.38, 95% CI = 1.14-1.67). Lack of clean water did not appear to be a risk marker of leprosy (RR = 0.94, 95% CI = 0.65-1.35). Additionally, ecological studies provided evidence that lower inequality, better human development, increased healthcare coverage, and cash transfer programs are linked with lower leprosy risks. These findings point to a consistent relationship between leprosy and unfavorable economic circumstances and, thereby, underscore the pressing need of leprosy control policies to target socially vulnerable groups in high-burden countries.

Performance evaluation of tuberculosis control in Brazilian municipalities / Avaliação de desempenho do controle da tuberculose em municípios brasileiros

ABSTRACT OBJECTIVE To evaluate the performance of tuberculosis control in Brazilian municipalities. METHODS This is an ecological study on Brazilian municipalities that notified at least four new cases of tuberculosis, with a minimum of one new case of pulmonary tuberculosis between 2015 and 2018. The municipalities were stratified according to the population in < 50 thousand, 50-100 thousand, 100-300 thousand, and > 300 thousand inhabitants, and the k-means method was used to group them within each population range according to the performance of six indicators of the disease. RESULTS A total of 2,845 Brazilian municipalities were included, comprising 98.5% (208,007/211,174) of new tuberculosis cases in the period. For each population range, three groups (A, B, and C) of municipalities were identified according to the performance of the indicators: A, the most satisfactory; B, the intermediates; and C, the least satisfactory. Municipalities in group A with < 100 thousand inhabitants presented results above the targets for laboratory confirmation (≥ 72%), abandonment (≤ 5%), and cure (≥ 90%), and comprised 2% of new cases of the disease. Conversely, municipalities of groups B and C presented at least five indicators with results below the targets - HIV testing (< 100%), contact investigation (< 90%), directly observed therapy (< 90%), abandonment (> 5%), and cure (< 90%) -, and corresponded to 66.7% of new cases of tuberculosis. In group C of municipalities with > 300 thousand inhabitants, which included 19 of the 27 capitals and 43.1% of new cases of tuberculosis, the lowest percentages of contact investigation (mean = 56.4%) and directly observed therapy (mean = 15.4%) were verified, in addition to high abandonment (mean = 13.9%) and low coverage of primary health care (mean = 66.0%). CONCLUSIONS Most new cases of tuberculosis occurred in municipalities with unsatisfactory performance for disease control. Expanding the coverage of primary health care in these places can reduce abandonment and increase the contact investigation and directly observed therapy.

RESUMO OBJETIVO Avaliar o desempenho no controle da tuberculose dos municípios brasileiros. MÉTODOS Estudo ecológico com municípios brasileiros que notificaram pelo menos quatro casos novos de tuberculose, com no mínimo um caso novo de tuberculose pulmonar entre 2015 e 2018. Os municípios foram estratificados de acordo com a população em < 50 mil, 50-100 mil, 100-300 mil e > 300 mil habitantes e foi utilizado o método k-médias para agrupá-los dentro de cada faixa populacional segundo desempenho de seis indicadores da doença. RESULTADOS Foram incluídos 2.845 municípios brasileiros abrangendo 98,5% (208.007/211.174) dos casos novos de tuberculose do período. Para cada faixa populacional identificou-se três grupos (A, B e C) de municípios segundo desempenho dos indicadores: A os mais satisfatórios, B os intermediários e C os menos satisfatórios. Municípios do grupo A com < 100 mil habitantes apresentaram resultados acima das metas para confirmação laboratorial (≥ 72%), abandono (≤ 5%) e cura (≥ 90%), e abrangeram 2% dos casos novos da doença. Por outro lado, os municípios dos grupos B e C apresentaram pelo menos cinco indicadores com resultados abaixo das metas - testagem HIV (< 100%), exame de contatos (< 90%), tratamento diretamente observado (< 90%), abandono (> 5%) e cura (< 90%) -, e corresponderam a 66,7% dos casos novos de tuberculose. Já no grupo C dos municípios com > 300 mil habitantes, que incluiu 19 das 27 capitais e 43,1% dos casos novos de tuberculose, encontrou-se os menores percentuais de exames de contatos (média = 56,4%) e tratamento diretamente observado (média = 15,4%), elevado abandono (média = 13,9%) e baixa cobertura da atenção básica (média = 66,0%). CONCLUSÕES Grande parte dos casos novos de tuberculose ocorreu em municípios com desempenho insatisfatório para o controle da doença, onde expandir a cobertura da atenção básica pode reduzir o abandono e elevar o exame de contatos e tratamento diretamente observado.

Máscaras de tecido em locais públicos: intervenção essencial na prevenção da COVID-19 no Brasil / Cloth masks in public places: an essential intervention to prevent COVID-19 in Brazil

Resumo Acumulam-se evidências de que o uso de máscaras é uma medida indispensável de proteção à COVID-19, devido ao alto poder de transmissão do novo coronavírus por via respiratória, inclusive por indivíduos assintomáticos. Por sua vez, o uso das máscaras de tecido em locais públicos tem se consolidado como medida adicional de proteção às medidas de distanciamento social e higienização das mãos. Objetivou-se sistematizar as evidências científicas que justificam o amplo uso de máscaras de tecido como prevenção à COVID-19 e descrever a evolução dos posicionamentos contrários ou favoráveis ao seu uso em ambientes extradomiciliares, diante do avanço da pandemia do novo coronavírus pelo mundo. A triagem de artigos e documentos oficiais do Brasil e de outros países indica que o uso de máscaras em locais públicos tornou-se uma intervenção essencial graças ao potencial de reduzir a velocidade de propagação do novo coronavírus. Recomenda-se que o poder público adote estratégias para aumentar a oferta deste produto e fomente estudos para avaliação do impacto da medida no controle da pandemia no Brasil. É imperativo assegurar disponibilidade de máscaras a grupos socioeconomicamente desfavorecidos e garantir que determinados grupos raciais não sejam estigmatizados diante do uso de máscaras em ambientes extradomiciliares.

Abstract There is increasing evidence that the use of masks is an indispensable protective measure against COVID-19, given the high transmissibility of the new coronavirus through the respiratory system, including by asymptomatic individuals. The use of cloth masks in public places has been established as a protective measure to be adopted alongside social distancing and hand hygiene. This narrative review aims to systematize the scientific evidence that informs the widespread use of cloth masks as a preventive measure against COVID-19 and to describe the evolution of positions contrary to or in favor of its use outside the home, in view of the advance of the new coronavirus pandemic globally. The scientific articles, technical notes, governmental decrees and other documents analyzed indicate that widespread use of masks has the potential to reduce the spread of the new coronavirus. We recommend that the Brazilian government adopt strategies to increase the supply of reusable cloth masks to the public, especially to vulnerable populations and to support studies on the impact of this measure to control the pandemic in the country. Finally, it is imperative to ensure that use of masks does not exacerbate stigmatization of racial groups that already face prejudice.