Morbidity trend and space-time clusters of COVID-19 occurrence in children and adolescents

Abstract Objective: To analyze the morbidity trend and space-time distribution clusters of confirmed COVID-19 cases in children and adolescents. Method: An ecological study of COVID-19 cases confirmed in the Information System from 2020 to 2022 in the age group from 0 to 19 years old, residents in Mato Grosso municipalities, Brazilian Midwest region. A trend analysis of the monthly morbidity rate of cases/100,000 inhabitants was used, following Prais-Winsten's regression. A space-time distribution of the Bayesian incidence rate per 100,000 inhabitants was performed, in addition to a space-time scan to identify high-risk clusters. Results: Of all 79,592 COVID-19 cases studied, 51.6% were in females and 44.21% in people aged 15-19 years old. The mean monthly rate was 265.87 cases per 100,000 inhabitants, with a stationary trend in the period analyzed (Monthly Percentage Variation [MPV]) = 12.15; CI95%[MPV]: -0.73;26.70). The morbidity rate due to COVID-19 was higher in the female gender (283.14/ 100,000 inhabitants) and in the age group from 15 to 19 years old (485.90/100,000 inhabitants). An increasing trend was observed with a greater monthly time variation of 14.42% (CI95%[MPV]: 1.28;29.28)] among those aged from 10 to 14 years old. The primary cluster, which was also the one with the highest Relative Risk (RR = 5,16, p-value = 0.001), included 19 municipalities located in the North health macro-region. Conclusion: The findings indicated a monthly stationary trend in the study population, an increase in the age group from 10 to 14 years old, and areas at a higher risk for the disease in the North health macro-region of the state.

Factors associated with suicidal ideation during the COVID-19 pandemic in a population in the Brazilian Legal Amazon / Fatores associados a ideação suicida durante a pandemia da COVID-19 em população da Amazônia Legal Brasileira

Abstract This article aims to analyze the factors associated with suicidal ideation in the COVID-19 pandemic. A cross-sectional home-based survey, with three-stage cluster sampling, was conducted with 4,203 adults from ten municipalities in the Mato Grosso, Brazil. The data collection was carried households to assessment of sociodemographic characteristics, substance use and behavior in the pandemic. The Level 1 Symptom Cross Scale was used to identify suicidal ideation and aspects of mental health (somatic symptoms, sleep disturbances, dissociation, depression, anger, mania, anxiety, thoughts, substance use and memory). Chemiluminescence was used to detect IgG anti-SARS-CoV-2 antibodies. The prevalence of suicidal ideation was 19.2%, and the associated with increased consumption of alcohol (RP=1.16), smoking (RP=1.30), COVID-19 symptoms (RP=1.03), having one's life affected (RP=1.04), mental illness (RP=1.09) somatic symptoms (RP=1.15), sleep disturbance (RP=1.30), dissociation (RP=1.24), depression (RP=1.24), anger (RP=1.11), anxiety (RP=1.26), substance use (RP=1.19), drug prescription use (RP=1.18) and memory (RP=1.87). Highlights the high prevalence of suicidal ideation related to COVID-19 symptoms, changes in behavior post-pandemic and mental health factors.

Resumo O objetivo deste artigo é analisar fatores associados a ideação suicida durante a pandemia da COVID-19. Inquérito de base populacional conduzido com 4.203 adultos de dez municípios mato-grossenses, Brasil. A coleta de dados foi realizada no domicílio, com avaliação de características sociodemográficas, uso de substâncias e comportamentos durante a pandemia. A Escala Transversal de Sintomas de Nível 1 do DSM-5 foi utilizada na identificação dos aspectos da saúde mental (sintomas somáticos, distúrbios do sono, dissociação, depressão, raiva, mania, ansiedade, pensamentos, uso de substâncias e memória) e utilizou-se quimioluminescência para detecção de anticorpos IgG anti-SARS-CoV-2. A prevalência de ideação suicida foi de 19,2%, e associou-se ao aumento do consumo de álcool (RP=1,16) e tabagismo (RP=1,30), sintomas de COVID-19 (RP=1,03), ter a vida muito afetada (RP=1,04), doença mental (RP=1,09), sintomas somáticos (RP=1,15), distúrbio do sono (RP=1,30), dissociação (RP=1,24), depressão (RP=1,24), raiva (RP=1,11), ansiedade (RP=1,26), uso de substâncias (RP=1,19), uso de medicamentos (RP=1,18) e memória (RP=1,87). Destacou-se a alta prevalência de ideação suicida e sua associação à sintomas de COVID-19, mudanças de comportamento pós-pandemia e fatores de saúde mental.

Factors associated with suicidal ideation during the COVID-19 pandemic in a population in the Brazilian Legal Amazon.

This article aims to analyze the factors associated with suicidal ideation in the COVID-19 pandemic. A cross-sectional home-based survey, with three-stage cluster sampling, was conducted with 4,203 adults from ten municipalities in the Mato Grosso, Brazil. The data collection was carried households to assessment of sociodemographic characteristics, substance use and behavior in the pandemic. The Level 1 Symptom Cross Scale was used to identify suicidal ideation and aspects of mental health (somatic symptoms, sleep disturbances, dissociation, depression, anger, mania, anxiety, thoughts, substance use and memory). Chemiluminescence was used to detect IgG anti-SARS-CoV-2 antibodies. The prevalence of suicidal ideation was 19.2%, and the associated with increased consumption of alcohol (RP=1.16), smoking (RP=1.30), COVID-19 symptoms (RP=1.03), having one's life affected (RP=1.04), mental illness (RP=1.09) somatic symptoms (RP=1.15), sleep disturbance (RP=1.30), dissociation (RP=1.24), depression (RP=1.24), anger (RP=1.11), anxiety (RP=1.26), substance use (RP=1.19), drug prescription use (RP=1.18) and memory (RP=1.87). Highlights the high prevalence of suicidal ideation related to COVID-19 symptoms, changes in behavior post-pandemic and mental health factors.

Social school contacts of multibacillary leprosy cases in children living in the hyperendemic region of the Midwest of Brazil

Abstract Objective: To analyze the prevalence of Mycobacterium leprae detection and the associated factors among social contacts in the school environment of multibacillary cases living in a hyperendemic municipality of the state of Mato Grosso. Methods: Cross-sectional study with 236 social contacts of multibacillary leprosy from public schools and residents in Cuiabá (Mato Grosso) in 2018. The sources of information were interviews and nasal swab tests for molecular analysis by polymerase chain reaction - PCR. For the prevalence ratio estimates, crude and adjusted analyses were performed using robust Poisson regression and their respective confidence intervals (95% CI). The ArcGIS 9.1 software was used for the geographic distribution analyses. Results: The prevalence of detection of M. leprae in social contacts was 14%. A total of 63.6% of the schools surveyed had 5.1% to 50% of the social contacts of leprosy with positive PCR. The analysis of the geographic distribution in the neighborhoods showed a high prevalence of infection, being higher than 50% in some localities. The highest proportion of positive results occurred in the northern region of the city and from a precarious socioeconomic class. Conclusion: The results showed a high prevalence of detection of M. leprae among social contacts in areas with poor socioeconomic conditions. In these regions, there is a greater risk of

[Prevalence of SARS-CoV-2 antibodies in the State of Mato Grosso, Brazil: a population-based survey]. / Prevalência de anticorpos contra SARS-CoV-2 em Mato Grosso, Brasil: pesquisa de base populacional.

Seroprevalence data provide relevant information on the development and progression of the COVID-19 pandemic. The study aimed to estimate the prevalence of SARS-CoV-2 antibodies in Mato Grosso State, Brazil, and its distribution according to sociodemographic and economic characteristics. This population-based serological survey was conducted in September-October 2020 in individuals 18 years or older in ten municipalities (counties) in the state of Mato Grosso. Interviews and collection of biological samples were conducted in the households, and determination of IgG antibodies to SARS-CoV-2 was performed with chemiluminescence. A total of 4,306 individuals were evaluated, and COVID-19 prevalence was estimated at 12.5% (95%CI: 10.5; 14.7), ranging from 7.4% to 24.3% between municipalities. No significant differences were found in prevalence of infection according to race/color, schooling, or family income, but lower prevalence was seen in individuals with a pensioner living in the same household, who did not receive emergency financial aid, and whose family income had not decreased after social distancing measures during the epidemic. Estimated prevalence of SARS-CoV-2 antibodies in this population-based survey is essential to measure the magnitude of the disease and will back measures to confront and control the pandemic.

Dados de soroprevalência oferecem informações relevantes relacionadas ao desenvolvimento e progressão de pandemia da COVID-19. Estimar a prevalência de anticorpos anti-SARS-CoV-2 em Mato Grosso, Brasil e sua distribuição segundo características sociodemográficas e econômicas. Inquérito soroepidemiológico de base populacional conduzido entre setembro e outubro de 2020, com indivíduos de 18 anos ou mais de idade, em dez municípios do Estado de Mato Grosso. As entrevistas e coleta de material biológico foram realizadas em domicílio, e a determinação de anticorpos IgG contra o SARS-CoV-2 foi feita por meio da quimioluminescência. Foram 4.306 indivíduos avaliados, e a prevalência de COVID-19 foi estimada em 12,5% (IC95%: 10,5; 14,7), variando de 7,4% a 24,3% entre os municípios. Não foram verificadas diferenças na prevalência da infecção segundo raça/cor da pele, escolaridade ou renda familiar, entretanto verificou-se menor prevalência entre indivíduos que residiam com algum morador que recebia aposentadoria, que não receberam auxílio financeiro emergencial e que a renda familiar não diminuiu após as medidas de distanciamento social para enfrentamento da epidemia. A prevalência de anticorpos contra SARS-CoV-2 estimada nesta pesquisa de base populacional é essencial para conhecer a magnitude da doença no estado e subsidiará ações de combate e controle da pandemia.

Los datos de seroprevalencia proporcionan información relevante relacionada con el desarrollo y la progresión de la pandemia del COVID-19. El objetivo fue estimar la prevalencia de anticuerpos anti-SARS-CoV-2 en Mato Grosso, Brasil, y su distribución según las características sociodemográficas y económicas. Encuesta seroepidemiológica de base poblacional, realizada entre septiembre y octubre de 2020 con individuos de los 18 años o más en diez municipios del estado de Mato Grosso. Las entrevistas y la recolección de material biológico se realizaron en el domicilio de los participantes, y para la determinación de anticuerpos IgG contra el SARS-CoV-2 se utilizó la quimioluminiscencia. Se evaluaron a 4.306 individuos, y la prevalencia del COVID-19 se estimó en un 12,5% (IC95%: 10,5; 14,7), que van del 7,4% al 24,3% entre los municipios. No se encontraron diferencias en la prevalencia de infección según la raza/color de la piel, la educación o los ingresos familiares; sin embargo, se encontró una menor prevalencia entre los individuos que vivían con un residente que recibía una pensión, que no recibía ayuda económica de emergencia y que los ingresos familiares no disminuyeron tras las medidas de distanciamiento social para hacer frente a la pandemia. La prevalencia de anticuerpos contra el SARS-CoV-2 estimada en esta investigación de base poblacional es imprescindible para conocer la magnitud de la enfermedad en el estado y subvencionar las acciones de enfrentamiento y control de la pandemia.

Prevalência de anticorpos contra SARS-CoV-2 em Mato Grosso, Brasil: pesquisa de base populacional / Prevalence of SARS-CoV-2 antibodies in the State of Mato Grosso, Brazil: a population-based survey / Prevalencia de anticuerpos contra el SARS-CoV-2 en Mato Grosso, Brasil: encuesta de base poblacional

Dados de soroprevalência oferecem informações relevantes relacionadas ao desenvolvimento e progressão de pandemia da COVID-19. Estimar a prevalência de anticorpos anti-SARS-CoV-2 em Mato Grosso, Brasil e sua distribuição segundo características sociodemográficas e econômicas. Inquérito soroepidemiológico de base populacional conduzido entre setembro e outubro de 2020, com indivíduos de 18 anos ou mais de idade, em dez municípios do Estado de Mato Grosso. As entrevistas e coleta de material biológico foram realizadas em domicílio, e a determinação de anticorpos IgG contra o SARS-CoV-2 foi feita por meio da quimioluminescência. Foram 4.306 indivíduos avaliados, e a prevalência de COVID-19 foi estimada em 12,5% (IC95%: 10,5; 14,7), variando de 7,4% a 24,3% entre os municípios. Não foram verificadas diferenças na prevalência da infecção segundo raça/cor da pele, escolaridade ou renda familiar, entretanto verificou-se menor prevalência entre indivíduos que residiam com algum morador que recebia aposentadoria, que não receberam auxílio financeiro emergencial e que a renda familiar não diminuiu após as medidas de distanciamento social para enfrentamento da epidemia. A prevalência de anticorpos contra SARS-CoV-2 estimada nesta pesquisa de base populacional é essencial para conhecer a magnitude da doença no estado e subsidiará ações de combate e controle da pandemia.

Seroprevalence data provide relevant information on the development and progression of the COVID-19 pandemic. The study aimed to estimate the prevalence of SARS-CoV-2 antibodies in Mato Grosso State, Brazil, and its distribution according to sociodemographic and economic characteristics. This population-based serological survey was conducted in September-October 2020 in individuals 18 years or older in ten municipalities (counties) in the state of Mato Grosso. Interviews and collection of biological samples were conducted in the households, and determination of IgG antibodies to SARS-CoV-2 was performed with chemiluminescence. A total of 4,306 individuals were evaluated, and COVID-19 prevalence was estimated at 12.5% (95%CI: 10.5; 14.7), ranging from 7.4% to 24.3% between municipalities. No significant differences were found in prevalence of infection according to race/color, schooling, or family income, but lower prevalence was seen in individuals with a pensioner living in the same household, who did not receive emergency financial aid, and whose family income had not decreased after social distancing measures during the epidemic. Estimated prevalence of SARS-CoV-2 antibodies in this population-based survey is essential to measure the magnitude of the disease and will back measures to confront and control the pandemic.

Los datos de seroprevalencia proporcionan información relevante relacionada con el desarrollo y la progresión de la pandemia del COVID-19. El objetivo fue estimar la prevalencia de anticuerpos anti-SARS-CoV-2 en Mato Grosso, Brasil, y su distribución según las características sociodemográficas y económicas. Encuesta seroepidemiológica de base poblacional, realizada entre septiembre y octubre de 2020 con individuos de los 18 años o más en diez municipios del estado de Mato Grosso. Las entrevistas y la recolección de material biológico se realizaron en el domicilio de los participantes, y para la determinación de anticuerpos IgG contra el SARS-CoV-2 se utilizó la quimioluminiscencia. Se evaluaron a 4.306 individuos, y la prevalencia del COVID-19 se estimó en un 12,5% (IC95%: 10,5; 14,7), que van del 7,4% al 24,3% entre los municipios. No se encontraron diferencias en la prevalencia de infección según la raza/color de la piel, la educación o los ingresos familiares; sin embargo, se encontró una menor prevalencia entre los individuos que vivían con un residente que recibía una pensión, que no recibía ayuda económica de emergencia y que los ingresos familiares no disminuyeron tras las medidas de distanciamiento social para hacer frente a la pandemia. La prevalencia de anticuerpos contra el SARS-CoV-2 estimada en esta investigación de base poblacional es imprescindible para conocer la magnitud de la enfermedad en el estado y subvencionar las acciones de enfrentamiento y control de la pandemia.

Syphilis in pregnant women and congenital syphilis: spatial pattern and relationship with social determinants of health in Mato Grosso.

INTRODUCTION: The increasing incidence of syphilis among pregnant women (PS) and congenital syphilis (CS) has negatively affected maternal-child health in Brazil. The spatial approach to diseases with social indicators improves knowledge of health situations. Herein, we aimed to evaluate the spatiotemporal distribution of incidences, identify the priority areas for infection control actions, and analyze the relationship of PS and CS clusters with social determinants of health in Mato Grosso. METHODS: This is an ecological study with data from different health information systems. After data procedure linkage, we analyzed the Bayesian incidences of triennial infections during specific periods. We performed SATSCAN screenings to identify spatiotemporal clusters. Further, we verified the differences between the clusters and indicators using Pearson's chi-square test. RESULTS: The variations in PS incidence were 0.9-20.5/1,000 live births (LB), 0.6-46.3/1,000 LB, and 2.1-23.2/1,000 LB in the first, second, and last triennium, respectively; for CS, the variations were 0-7.1/1,000 LB, 0-7.5/1,000 LB, and 0.3-10.8/1,000 LB in the first, second, and last triennium, respectively. Three clusters each were identified for PS (RR=2.02; RR=0.30; RR=21.45, p<0.0001) and CS (RR=3.55; RR=0.10; RR=0.26, p<0.0001). The high-risk clusters overlapped in time-space; CS incidence was associated with municipalities with a higher proportion of LB mothers of race/non-white color and with poor sanitary conditions, lower proportion of pregnant teenagers, and under 8 years of schooling. CONCLUSIONS: The increase in the spatiotemporal evolution of PS and CS incidences and the extension of areas with persistent infections indicate the need for monitoring, especially of priority areas in the state.

[Analysis of spatial patterns and characterization of suicides in Brazil from 1990 to 2015]. / Análise dos padrões espaciais e caracterização dos suicídios no Brasil entre 1990 e 2015.

This study aimed to analyze the spatial pattern in mortality rates from suicide in Brazil from 1990 to 2015. A spatial analysis was performed for the mortality rates from suicide in municipalities (counties) in three-year periods using Bayesian inference and clusters according to risk of death adjusted by sex and age bracket. The mortality rate from suicide increased from 3.5 deaths in 1990 to 5.3 deaths/100,000 inhabitants in 2015, when there was one death from suicide every 64 minutes. There was a predominance of suicide deaths in males in all the periods, while the variables age and race/color showed some changes. High suicide mortality rates among youth and indigenous people were seen in the most recent three-year period. We observed a loss of areas without suicide reporting, a reduction in areas with low suicide mortality rates, as opposed to an increase in areas with medium rates in all the regions of Brazil. The high rates, previously concentrated in the South of Brazil, had expanded to other regions of the country. Very high rates emerged in southern Mato Grosso do Sul state. Clusters with higher likelihood in all the periods were observed in the South. Suicide mortality rates increased, with changes in the spatial during the 25-year period. Despite the initial concentration of high suicide mortality rates in the South, the deaths spread to other regions of the country with different magnitudes. There was a reduction in suicide deaths among the elderly in the South and an increase in the Northeast, and an increase in deaths in adults and black Brazilians in the Central and among youth and indigenous persons in northwestern Amazonas state.

O objetivo deste estudo foi analisar o padrão espacial das taxas de mortalidade por suicídio no Brasil entre 1990 e 2015. Realizou-se análise espacial das taxas de mortalidade por suicídio dos municípios, em triênios, por meio de inferência bayesiana e análise de clusters, segundo risco de óbito ajustado por sexo e faixa etária. A taxa de mortalidade por suicídio aumentou de 3,5 óbitos em 1990 para 5,3 óbitos/100 mil habitantes em 2015 quando, a cada 64 minutos, uma morte foi registrada. Houve predominância de óbitos masculinos em todos os períodos, e as variáveis idade e raça/cor apresentaram alterações. Alta taxa de mortalidade entre jovens e indígenas foi observada no último triênio. Observamos perda de áreas sem notificação, bem como redução de áreas com taxas baixas de mortalidade em oposição ao aumento de áreas com taxas médias em todas as regiões. As taxas altas, que se concentravam no Sul, se dispersaram para outras regiões. Taxas muito altas surgiram no sul de Mato Grosso do Sul. Clusters de maior verossimilhança em todos os períodos são observados no Sul. As taxas de mortalidade por suicídio aumentaram, com alteração no padrão espacial no período estudado. Apesar da concentração inicial das altas taxas de mortalidade no Sul, houve dispersão dos óbitos para as demais regiões com diferentes magnitudes. Por um lado, houve redução dos óbitos entre idosos no Sul; por outro lado, houve aumento de óbitos no Nordeste, de adultos e pessoas negras no Centro-oeste e entre jovens e indígenas no noroeste do Amazonas.

El objetivo de este estudio fue analizar el patrón espacial de la tasa de mortalidad por suicidio en Brasil entre 1990 y 2015. Se realizó un análisis espacial de las tasas de mortalidad por suicidio en municipios durante trienios, mediante inferencia bayesiana y análisis de clústeres, según el riesgo de fallecimiento, ajustado por sexo y franja de edad. La tasa de mortalidad por suicidio aumentó de 3,5 óbitos en 1990 a 5,3 óbitos/100 mil habitantes en 2015, cuando cada 64 minutos se registró una muerte. Hubo predominancia de fallecimientos masculinos en todos los períodos, mientras que las variables edad y raza/color presentaron alteraciones. Una alta tasa de mortalidad entre jóvenes e indígenas se observó en el último trienio. Observamos pérdida de áreas sin notificación, reducción de áreas con tasas bajas de mortalidad, frente al aumento de áreas con tasas medias en todas las regiones. Las tasas altas, que se concentraban en el Sur, se dispersaron hacia otras regiones. Aparecieron tasas muy altas en el sur de Mato Grosso do Sul. Los clústeres con mayor verosimilitud durante todos los períodos se observan en el Sur. Las tasas de mortalidad por suicidio aumentaron, con alteración en el patrón espacial durante el período estudiado. A pesar de la concentración inicial de las altas tasas de mortalidad en el Sur, hubo una dispersión de los fallecimientos hacia las demás regiones con diferentes magnitudes. Hubo una reducción de los óbitos entre ancianos en el Sur y un aumento en el Nordeste, así como un aumento de óbitos de adultos y personas negras en el Centro-oeste, y entre jóvenes e indígenas en el noroeste del Amazonas.

Análise dos padrões espaciais e caracterização dos suicídios no Brasil entre 1990 e 2015 / Analysis of spatial patterns and characterization of suicides in Brazil from 1990 to 2015 / Análisis de los patrones espaciales y caracterización de los suicidios en Brasil entre 1990 y 2015

Resumo: O objetivo deste estudo foi analisar o padrão espacial das taxas de mortalidade por suicídio no Brasil entre 1990 e 2015. Realizou-se análise espacial das taxas de mortalidade por suicídio dos municípios, em triênios, por meio de inferência bayesiana e análise de clusters, segundo risco de óbito ajustado por sexo e faixa etária. A taxa de mortalidade por suicídio aumentou de 3,5 óbitos em 1990 para 5,3 óbitos/100 mil habitantes em 2015 quando, a cada 64 minutos, uma morte foi registrada. Houve predominância de óbitos masculinos em todos os períodos, e as variáveis idade e raça/cor apresentaram alterações. Alta taxa de mortalidade entre jovens e indígenas foi observada no último triênio. Observamos perda de áreas sem notificação, bem como redução de áreas com taxas baixas de mortalidade em oposição ao aumento de áreas com taxas médias em todas as regiões. As taxas altas, que se concentravam no Sul, se dispersaram para outras regiões. Taxas muito altas surgiram no sul de Mato Grosso do Sul. Clusters de maior verossimilhança em todos os períodos são observados no Sul. As taxas de mortalidade por suicídio aumentaram, com alteração no padrão espacial no período estudado. Apesar da concentração inicial das altas taxas de mortalidade no Sul, houve dispersão dos óbitos para as demais regiões com diferentes magnitudes. Por um lado, houve redução dos óbitos entre idosos no Sul; por outro lado, houve aumento de óbitos no Nordeste, de adultos e pessoas negras no Centro-oeste e entre jovens e indígenas no noroeste do Amazonas.

Abstract: This study aimed to analyze the spatial pattern in mortality rates from suicide in Brazil from 1990 to 2015. A spatial analysis was performed for the mortality rates from suicide in municipalities (counties) in three-year periods using Bayesian inference and clusters according to risk of death adjusted by sex and age bracket. The mortality rate from suicide increased from 3.5 deaths in 1990 to 5.3 deaths/100,000 inhabitants in 2015, when there was one death from suicide every 64 minutes. There was a predominance of suicide deaths in males in all the periods, while the variables age and race/color showed some changes. High suicide mortality rates among youth and indigenous people were seen in the most recent three-year period. We observed a loss of areas without suicide reporting, a reduction in areas with low suicide mortality rates, as opposed to an increase in areas with medium rates in all the regions of Brazil. The high rates, previously concentrated in the South of Brazil, had expanded to other regions of the country. Very high rates emerged in southern Mato Grosso do Sul state. Clusters with higher likelihood in all the periods were observed in the South. Suicide mortality rates increased, with changes in the spatial during the 25-year period. Despite the initial concentration of high suicide mortality rates in the South, the deaths spread to other regions of the country with different magnitudes. There was a reduction in suicide deaths among the elderly in the South and an increase in the Northeast, and an increase in deaths in adults and black Brazilians in the Central and among youth and indigenous persons in northwestern Amazonas state.

Resumen: El objetivo de este estudio fue analizar el patrón espacial de la tasa de mortalidad por suicidio en Brasil entre 1990 y 2015. Se realizó un análisis espacial de las tasas de mortalidad por suicidio en municipios durante trienios, mediante inferencia bayesiana y análisis de clústeres, según el riesgo de fallecimiento, ajustado por sexo y franja de edad. La tasa de mortalidad por suicidio aumentó de 3,5 óbitos en 1990 a 5,3 óbitos/100 mil habitantes en 2015, cuando cada 64 minutos se registró una muerte. Hubo predominancia de fallecimientos masculinos en todos los períodos, mientras que las variables edad y raza/color presentaron alteraciones. Una alta tasa de mortalidad entre jóvenes e indígenas se observó en el último trienio. Observamos pérdida de áreas sin notificación, reducción de áreas con tasas bajas de mortalidad, frente al aumento de áreas con tasas medias en todas las regiones. Las tasas altas, que se concentraban en el Sur, se dispersaron hacia otras regiones. Aparecieron tasas muy altas en el sur de Mato Grosso do Sul. Los clústeres con mayor verosimilitud durante todos los períodos se observan en el Sur. Las tasas de mortalidad por suicidio aumentaron, con alteración en el patrón espacial durante el período estudiado. A pesar de la concentración inicial de las altas tasas de mortalidad en el Sur, hubo una dispersión de los fallecimientos hacia las demás regiones con diferentes magnitudes. Hubo una reducción de los óbitos entre ancianos en el Sur y un aumento en el Nordeste, así como un aumento de óbitos de adultos y personas negras en el Centro-oeste, y entre jóvenes e indígenas en el noroeste del Amazonas.

Syphilis in pregnant women and congenital syphilis: spatial pattern and relationship with social determinants of health in Mato Grosso

Abstract INTRODUCTION: The increasing incidence of syphilis among pregnant women (PS) and congenital syphilis (CS) has negatively affected maternal-child health in Brazil. The spatial approach to diseases with social indicators improves knowledge of health situations. Herein, we aimed to evaluate the spatiotemporal distribution of incidences, identify the priority areas for infection control actions, and analyze the relationship of PS and CS clusters with social determinants of health in Mato Grosso. METHODS: This is an ecological study with data from different health information systems. After data procedure linkage, we analyzed the Bayesian incidences of triennial infections during specific periods. We performed SATSCAN screenings to identify spatiotemporal clusters. Further, we verified the differences between the clusters and indicators using Pearson's chi-square test. RESULTS: The variations in PS incidence were 0.9-20.5/1,000 live births (LB), 0.6-46.3/1,000 LB, and 2.1-23.2/1,000 LB in the first, second, and last triennium, respectively; for CS, the variations were 0-7.1/1,000 LB, 0-7.5/1,000 LB, and 0.3-10.8/1,000 LB in the first, second, and last triennium, respectively. Three clusters each were identified for PS (RR=2.02; RR=0.30; RR=21.45, p<0.0001) and CS (RR=3.55; RR=0.10; RR=0.26, p<0.0001). The high-risk clusters overlapped in time-space; CS incidence was associated with municipalities with a higher proportion of LB mothers of race/non-white color and with poor sanitary conditions, lower proportion of pregnant teenagers, and under 8 years of schooling. CONCLUSIONS: The increase in the spatiotemporal evolution of PS and CS incidences and the extension of areas with persistent infections indicate the need for monitoring, especially of priority areas in the state.

Space-time scan for identification of risk areas for hospitalization of children due to asthma in Mato Grosso, Brazil. / Varredura espaço-temporal para identificação de áreas de risco para hospitalização de crianças por asma em Mato Grosso.

INTRODUCTION: Asthma is the result of a complex interaction between genetic, environmental and socioeconomic factors. It represents a serious global public health problem. The goal of this study was to identify geographic areas for priority actions in order to control of asthma in children. METHOD: Ecological study that space-time statistic Scan was used. Non-elective, short-stay (type 1) paid authorizations of hospitalizations were selected according to hospitalizations year and children place of residence. RESULTS: In the two periods of the study, the high risk primary cluster was located in the region of Barra do Bugres (relative risk = 8.17, in the first period, and 10.37, in the second). The number of high-risk clusters increased from 8, in the period 2001-2004, to 9, in 2005-2012; while low-risk clusters decreased from 6, in the initial period, to 4, in the latest. The priority geographic areas for attention and intervention for children with asthma are the region around Barra do Bugres, which remained in the two periods with high risk primary clusters and the southwest border of the State that presented increase of the risk. Furthermore, there was an increase of 87% in the number of high risk counties and a reduction of 28% of the counties of protection. CONCLUSION: In conclusion, the surroundings areas of Barra do Bugres and Porto Estrela and the east and northeast border of the state are priority for health care, once there was an increased risk of hospitalization of children due to asthma.

INTRODUÇÃO: A asma resulta de complexa interação entre fatores genéticos, ambientais e socioeconômicos e representa um importante problema de saúde pública mundial. O objetivo deste trabalho foi identificar áreas prioritárias para ações de controle de asma em crianças. MÉTODO: Estudo ecológico no qual foi utilizada a varredura espaço-temporal. Selecionaram-se as autorizações de internação hospitalar pagas, não eletivas, de curta permanência (tipo 1), segundo o ano de ocorrência e o local de residência. Os períodos de análise compreendem os anos de 2001-2004 e 2005-2012. RESULTADOS: O cluster primário de alto risco esteve localizado na região do entorno de Barra do Bugres nos dois períodos de estudo (risco relativo = 8,17, no primeiro período, e 10,37, no segundo). O número de clusters de alto risco aumentou de 8, no período 2001-2004, para 9, entre 2005-2012; enquanto os clusters de baixo risco diminuíram de 6, no período inicial, para 4, no último. As áreas prioritárias para atenção e intervenção às crianças com asma são a região do entorno de Barra do Bugres, que se manteve nos dois períodos com clusters primários de alto risco, e a borda leste e nordeste do estado, que apresentou aumento do risco. Além disso, houve aumento de 87% do número de municípios de alto risco e diminuição em 28% dos municípios de proteção. CONCLUSÃO: Conclui-se que as áreas prioritárias para a atenção à saúde, nas quais aumentou o risco de internação por asma em crianças, são o entorno de Barra do Bugres e Porto Estrela e a borda leste e nordeste do estado.

Varredura espaço-temporal para identificação de áreas de risco para hospitalização de crianças por asma em Mato Grosso / Space-time scan for identification of risk areas for hospitalization of children due to asthma in Mato Grosso, Brazil

RESUMO: Introdução: A asma resulta de complexa interação entre fatores genéticos, ambientais e socioeconômicos e representa um importante problema de saúde pública mundial. O objetivo deste trabalho foi identificar áreas prioritárias para ações de controle de asma em crianças. Método: Estudo ecológico no qual foi utilizada a varredura espaço-temporal. Selecionaram-se as autorizações de internação hospitalar pagas, não eletivas, de curta permanência (tipo 1), segundo o ano de ocorrência e o local de residência. Os períodos de análise compreendem os anos de 2001-2004 e 2005-2012. Resultados: O cluster primário de alto risco esteve localizado na região do entorno de Barra do Bugres nos dois períodos de estudo (risco relativo = 8,17, no primeiro período, e 10,37, no segundo). O número de clusters de alto risco aumentou de 8, no período 2001-2004, para 9, entre 2005-2012; enquanto os clusters de baixo risco diminuíram de 6, no período inicial, para 4, no último. As áreas prioritárias para atenção e intervenção às crianças com asma são a região do entorno de Barra do Bugres, que se manteve nos dois períodos com clusters primários de alto risco, e a borda leste e nordeste do estado, que apresentou aumento do risco. Além disso, houve aumento de 87% do número de municípios de alto risco e diminuição em 28% dos municípios de proteção. Conclusão: Conclui-se que as áreas prioritárias para a atenção à saúde, nas quais aumentou o risco de internação por asma em crianças, são o entorno de Barra do Bugres e Porto Estrela e a borda leste e nordeste do estado.

ABSTRACT: Introduction: Asthma is the result of a complex interaction between genetic, environmental and socioeconomic factors. It represents a serious global public health problem. The goal of this study was to identify geographic areas for priority actions in order to control of asthma in children. Method: Ecological study that space-time statistic Scan was used. Non-elective, short-stay (type 1) paid authorizations of hospitalizations were selected according to hospitalizations year and children place of residence. Results: In the two periods of the study, the high risk primary cluster was located in the region of Barra do Bugres (relative risk = 8.17, in the first period, and 10.37, in the second). The number of high-risk clusters increased from 8, in the period 2001-2004, to 9, in 2005-2012; while low-risk clusters decreased from 6, in the initial period, to 4, in the latest. The priority geographic areas for attention and intervention for children with asthma are the region around Barra do Bugres, which remained in the two periods with high risk primary clusters and the southwest border of the State that presented increase of the risk. Furthermore, there was an increase of 87% in the number of high risk counties and a reduction of 28% of the counties of protection. Conclusion: In conclusion, the surroundings areas of Barra do Bugres and Porto Estrela and the east and northeast border of the state are priority for health care, once there was an increased risk of hospitalization of children due to asthma.

Socioeconomic factors and risk for hospitalisation due to asthma in children in the municipalities of Mato Grosso State, Brazil.

This ecological study used data accumulated between 2001 and 2012 hospital admissions of children under five years of age with asthma in 141 municipalities in the Mato Grosso. Hospital data were extracted from the SIH/SUS system, and hospitalisation rates were estimated using the Bayesian inference method. SaTScan software was used for the calculation of the relative risk (RR). Differences in socioeconomic characteristics among municipalities with high and low hospitalization rates were evaluated by nonparametric Wilcoxon-Mann-Whitney test. This test indicates that municipalities with better socioeconomic characteristics have lower hospitalization rates. The analysis of the linear models in the two study periods indicated that the decreasing trend in the number of admissions was 3-fold higher in the 2005-2012 period compared with the 2001-2004 period. In addition, a decrease of 76% in the hospitalisation incidence rate was observed during the 12-year study period; this decrease was more evident from 2005 onward. The municipalities identified as having increased risk of hospitalisation of children with asthma were located in areas subjected to intense burning practices and with low municipal development indices.

Socioeconomic factors and risk for hospitalisation due to asthma in children in the municipalities of Mato Grosso State, Brazil / Fatores socioeconômicos e risco para a hospitalização por asmaem crianças em municípios de Mato Grosso, Brasil

Abstract This ecological study used data accumulated between 2001 and 2012 hospital admissions of children under five years of age with asthma in 141 municipalities in the Mato Grosso. Hospital data were extracted from the SIH/SUS system, and hospitalisation rates were estimated using the Bayesian inference method. SaTScan software was used for the calculation of the relative risk (RR). Differences in socioeconomic characteristics among municipalities with high and low hospitalization rates were evaluated by nonparametric Wilcoxon-Mann-Whitney test. This test indicates that municipalities with better socioeconomic characteristics have lower hospitalization rates. The analysis of the linear models in the two study periods indicated that the decreasing trend in the number of admissions was 3-fold higher in the 2005-2012 period compared with the 2001-2004 period. In addition, a decrease of 76% in the hospitalisation incidence rate was observed during the 12-year study period; this decrease was more evident from 2005 onward. The municipalities identified as having increased risk of hospitalisation of children with asthma were located in areas subjected to intense burning practices and with low municipal development indices.

Resumo Trata-se de um estudo ecológico com dados de hospitalizações de crianças menores de cinco anos de idade com asma, entre 2001 a 2012, nos 141 municípios do estado de Mato Grosso, com o objetivo de analisar a distribuição e o risco de hospitalização por esse problema em crianças no estado de Mato Grosso. Os dados hospitalares foram extraídos do SIH/SUS e as taxas de internação foram estimadas por meio do método de inferência bayesiana. Para realização do cálculo do risco relativo (RR) utilizou-se a técnica de varredura espacial, com o software SatScan. Diferenças de características socioeconômicas entre municípios com altas e com baixas taxas de hospitalização foram avaliadas pelo teste não paramétrico de Wilcoxon-Mann-Whitney. Avaliou-se que municípios com características socioeconômicas melhores têm menores taxas de hospitalização. Além disso, foi verificada uma redução de 76% ao longo de doze anos, mais evidenciada a partir de 2005. Os municípios identificados com maior risco de hospitalização de crianças por asma localizam-se em áreas com intensa atividade de queimadas e baixo índice de desenvolvimento municipal.

Aspects on the ecology of phlebotomine sand flies and natural infection by Leishmania hertigi in the Southeastern Amazon Basin of Brazil.

The medical and veterinary importance of sand flies (Diptera: Psychodidae) follow as a result of some species ability to transmit the zoonotic protozoa of the genus Leishmania. Of all municipalities in the state of Mato Grosso, Sinop ranks first in reported cases of American Cutaneous Leishmaniasis (ACL). Sinop urban zone encompasses three permanent forest preservation areas (APPs) that provide refuge for insects and other vertebrate hosts. We assessed ecological parameters and investigated the natural infection by Leishmania spp. of the phlebotomine fauna from four ecotypes with different levels of urbanization in the urban area of Sinop. A total of 62,745 sand flies were collected, of which 52.34% female. Out of 37 species in this study, nine were found to be constant. Sand flies frequency and diversity were highest in APPs (96.85%; 33 species). Lutzomyia dasypodogeton was the most frequent species and exhibited the greatest abundance (SISA=0.977). The neighborhoods around APPs and completely urbanized neighborhoods presented noteworthy ecological similarity. Moreover, eight vector sand fly species with medicalwere identified, and one L. antunesi sample pool was found to be naturally infected with Le. hertigi. We observed a high frequency and diversity of sand flies, including some species that are known to be major vectors of ACL. Further studies are needed on the natural rates of infection in humans, domestic animals, and sylvatic hosts to better comprehend the leishmaniases dynamics.

Risk factors in cardiovascular disease mortality associated with high exposure to vehicular traffic. / Fatores de risco para mortalidade por doenças cardiovasculares associados à alta exposição ao tráfego veicular.

OBJECTIVE: To identify areas and risk factors in cardiovascular disease (CD) mortality associated with air pollution from high exposure to vehicular traffic. METHODS: Cross-sectional study of CD mortality in 2,617 individuals aged 45-85 years living in the urban area of Cuiabá and Várzea Grande, Mato Grosso State, Brazil, between 2009 and 2011. We used the residential proximity of up to 150 meters to a roadway of great vehicle flow as a proxy of high exposure to air pollution from vehicular traffic. The association between age, gender, income, and traffic intensity with vehicular traffic exposure was assessed through the multiple logistic regression. We conducted stratified analyses to observe the influence of seasons and groups of causes. We used Bernoulli's spatial model of probability to identify high-risk clusters. RESULTS: Risk factors for CD mortality associated with high exposure to vehicular traffic were: living in census tracts with very unequal income (OR = 1.78; 95%CI 1.36 - 2.33), heavy traffic (OR = 1.20; 95%CI 1.01 - 1.43), and female gender (OR = 1.18; 95%CI 1.01 - 1.38). The CD mortality risk increases about 10% during the dry season period. We identified nine areas of risk. CONCLUSION: High exposure to traffic is associated with CD mortality in Cuiabá and Várzea Grande. Income inequality, traffic intensity, and female gender presented as the main determiners for this exposure. The dry season period enhances the effects of traffic exposure.

OBJETIVO: Identificar áreas e fatores de risco para a mortalidade causada por doenças cardiovasculares (DC) associados à poluição do ar proveniente da alta exposição ao tráfego. MÉTODOS: Estudo transversal da mortalidade por DC em 2.617 indivíduos de 45 a 85 anos residentes na zona urbana de Cuiabá e Várzea Grande, Mato Grosso, entre 2009 e 2011. Utilizou-se a proximidade residencial de até 150 metros de uma via de grande fluxo de veículos como proxy da alta exposição à poluição atmosférica proveniente do tráfego. A associação entre idade, sexo, renda e intensidade do trânsito com a exposição ao tráfego foi avaliada por meio de regressão logística múltipla. Foram realizadas análises estratificadas para observar a influência das estações do ano e dos grupos de causas. Utilizou-se modelo espacial de probabilidade de Bernoulli para identificação de áreas de risco. RESULTADOS: Os principais fatores de risco para mortalidade por DC associados à alta exposição ao tráfego foram: residir em setores censitários com renda muito desigual (OR = 1,78; IC95% 1,36 - 2,33), trânsito intenso (OR = 1,20; IC95% 1,01 - 1,43) e sexo feminino (OR = 1,18; IC95% 1,01 - 1,38). O risco de mortalidade por DC aumenta cerca de 10% no período de seca. Foram identificadas nove áreas de risco. CONCLUSÃO: A alta exposição ao tráfego está associada à mortalidade por DC em Cuiabá e Várzea Grande. A desigualdade de renda, a intensidade do trânsito e o sexo feminino apresentaram-se como os principais determinantes dessa exposição, além da estação seca potencializá-la.

Fatores de risco para mortalidade por doenças cardiovasculares associados à alta exposição ao tráfego veicular / Risk factors in cardiovascular disease mortality associated with high exposure to vehicular traffic

RESUMO: Objetivo: Identificar áreas e fatores de risco para a mortalidade causada por doenças cardiovasculares (DC) associados à poluição do ar proveniente da alta exposição ao tráfego. Métodos: Estudo transversal da mortalidade por DC em 2.617 indivíduos de 45 a 85 anos residentes na zona urbana de Cuiabá e Várzea Grande, Mato Grosso, entre 2009 e 2011. Utilizou-se a proximidade residencial de até 150 metros de uma via de grande fluxo de veículos como proxy da alta exposição à poluição atmosférica proveniente do tráfego. A associação entre idade, sexo, renda e intensidade do trânsito com a exposição ao tráfego foi avaliada por meio de regressão logística múltipla. Foram realizadas análises estratificadas para observar a influência das estações do ano e dos grupos de causas. Utilizou-se modelo espacial de probabilidade de Bernoulli para identificação de áreas de risco. Resultados: Os principais fatores de risco para mortalidade por DC associados à alta exposição ao tráfego foram: residir em setores censitários com renda muito desigual (OR = 1,78; IC95% 1,36 - 2,33), trânsito intenso (OR = 1,20; IC95% 1,01 - 1,43) e sexo feminino (OR = 1,18; IC95% 1,01 - 1,38). O risco de mortalidade por DC aumenta cerca de 10% no período de seca. Foram identificadas nove áreas de risco. Conclusão: A alta exposição ao tráfego está associada à mortalidade por DC em Cuiabá e Várzea Grande. A desigualdade de renda, a intensidade do trânsito e o sexo feminino apresentaram-se como os principais determinantes dessa exposição, além da estação seca potencializá-la.

ABSTRACT: Objective: To identify areas and risk factors in cardiovascular disease (CD) mortality associated with air pollution from high exposure to vehicular traffic. Methods: Cross-sectional study of CD mortality in 2,617 individuals aged 45-85 years living in the urban area of Cuiabá and Várzea Grande, Mato Grosso State, Brazil, between 2009 and 2011. We used the residential proximity of up to 150 meters to a roadway of great vehicle flow as a proxy of high exposure to air pollution from vehicular traffic. The association between age, gender, income, and traffic intensity with vehicular traffic exposure was assessed through the multiple logistic regression. We conducted stratified analyses to observe the influence of seasons and groups of causes. We used Bernoulli's spatial model of probability to identify high-risk clusters. Results: Risk factors for CD mortality associated with high exposure to vehicular traffic were: living in census tracts with very unequal income (OR = 1.78; 95%CI 1.36 - 2.33), heavy traffic (OR = 1.20; 95%CI 1.01 - 1.43), and female gender (OR = 1.18; 95%CI 1.01 - 1.38). The CD mortality risk increases about 10% during the dry season period. We identified nine areas of risk. Conclusion: High exposure to traffic is associated with CD mortality in Cuiabá and Várzea Grande. Income inequality, traffic intensity, and female gender presented as the main determiners for this exposure. The dry season period enhances the effects of traffic exposure.

Frequency and diversity of phlebotomine sand flies (Diptera: Psychodidae) in Sinop, State of Mato Grosso, Brazil.

INTRODUCTION:: Understanding the diversity of sand flies is important for the epidemiology and control of leishmaniasis. This study aimed to understand the frequency, diversity, and seasonality of medically important sand flies in the municipality of Sinop, State of Mato Grosso, Brazil. METHODS:: The study was conducted in an urban area, including four ecotypes with different levels of urbanization. The sand flies were collected using light traps for three nights per month, from May 2014 to April 2015. RESULTS:: A total of 62,745 sand flies was collected, 52.34% of which were female. The frequency and diversity of sand flies was the highest in areas of permanent preservation (APPs) (96.85%), and was lower in more urbanized areas. Lutzomyia dasypodogeton was the most frequent species in the APPs. Lutzomyia antunesi was the most frequent in neighborhoods with forest fragments and neighborhoods around APPs, and L. aragaoi was the most frequent in completely urbanized neighborhoods. A higher frequency and diversity of sand flies was observed in the rainy season (87.92%) than in the dry season (12.08%). Eight medically important species were captured, and Lutzomyia antunesi, which is associated with American cutaneous leishmaniasis and visceral leishmaniasis, was observed in all ecotypes throughout the year. CONCLUSIONS:: We observed a high frequency and diversity of sand flies in all urban areas, and some species collected were major vectors of leishmaniasis. These results support the need for further studies of the natural rates of infection of these insects and the circulation of the disease in hosts and vectors.

Frequency and diversity of phlebotomine sand flies (diptera: psychodidae) in sinop, state of Mato Grosso, Brazil

Abstract INTRODUCTION: Understanding the diversity of sand flies is important for the epidemiology and control of leishmaniasis. This study aimed to understand the frequency, diversity, and seasonality of medically important sand flies in the municipality of Sinop, State of Mato Grosso, Brazil. METHODS: The study was conducted in an urban area, including four ecotypes with different levels of urbanization. The sand flies were collected using light traps for three nights per month, from May 2014 to April 2015. RESULTS: A total of 62,745 sand flies was collected, 52.34% of which were female. The frequency and diversity of sand flies was the highest in areas of permanent preservation (APPs) (96.85%), and was lower in more urbanized areas. Lutzomyia dasypodogeton was the most frequent species in the APPs. Lutzomyia antunesi was the most frequent in neighborhoods with forest fragments and neighborhoods around APPs, and L. aragaoi was the most frequent in completely urbanized neighborhoods. A higher frequency and diversity of sand flies was observed in the rainy season (87.92%) than in the dry season (12.08%). Eight medically important species were captured, and Lutzomyia antunesi, which is associated with American cutaneous leishmaniasis and visceral leishmaniasis, was observed in all ecotypes throughout the year. CONCLUSIONS: We observed a high frequency and diversity of sand flies in all urban areas, and some species collected were major vectors of leishmaniasis. These results support the need for further studies of the natural rates of infection of these insects and the circulation of the disease in hosts and vectors.

Migração e hanseníase em Mato Grosso / Migration and Hansen's disease in Mato Grosso

Trabalhos de geografia médica sobre hanseníase discutem o papel da ocupação dos territórios como fundamento da permanência de focos leprógenos. No Brasil, os Estados que apresentam as mais altas taxas de detecção, historicamente, se localizam na região amazônica, o que evidencia uma desigual evolução regional da doença. Este trabalho analisa a evolução da hanseníase contextualizando os processos migratórios que ocorreram no Estado de Mato Grosso a partir da segunda metade do século XX. O crescimento econômico ocorrido no Estado nas décadas de 1970, 1980 e 1990 provocou taxas de crescimento populacional maiores que a média nacional. Os dados analisados permitem uma associação entre o crescimento e dispersão dos coeficientes de detecção da hanseníase com o processo de ocupação do território mato-grossense. Entretanto, a permanência da hanseníase em municípios da Baixada Cuiabana, assim como em outros municípios que sofreram perda de população, parece apontar a existência de contextos geográficos de diferentes vulnerabilidades à produção social da doença. A migração explicaria a instalação e evolução da hanseníase, entretanto consideramos que a manutenção da endemia pode estar associada a fatores contextuais relacionados com o ambiente.

Studies on medical geography about leprosy discuss the role of the detailed report of the occupation of the territories as a basis of the permanence of leprosy focus. In Brazil, the states that present the highest rates of detection historically are in the Amazon region, which shows an uneven regional evolution of the disease. This paper analyzes the evolution of leprosy contextualizing the migratory processes that occurred in the State of Mato Grosso since the second half of the 20th century. The economic dynamism that occurred in the State in the 1970s, 1980s and 1990s caused population growth rates higher than the national average. The data analyzed permitted an association between the evolution of leprosy and the process of occupation of the mato-grossense territory. However, the permanence of leprosy in the municipalities of the Baixada Cuiabana, as well as in other municipalities that lost population, seem to point to the existence of geographic contexts of different vulnerability to the social production of the disease in the tate. The migration would explain the appearance and evolution of leprosy. However, we consider that the maintenance of the endemic can be associated to contextual factors related to environment.