Dynamic transmission modeling of COVID-19 to support decision-making in Brazil: A scoping review in the pre-vaccine era.

Brazil was one of the countries most affected during the first year of the COVID-19 pandemic, in a pre-vaccine era, and mathematical and statistical models were used in decision-making and public policies to mitigate and suppress SARS-CoV-2 dispersion. In this article, we intend to overview the modeling for COVID-19 in Brazil, focusing on the first 18 months of the pandemic. We conducted a scoping review and searched for studies on infectious disease modeling methods in peer-reviewed journals and gray literature, published between January 01, 2020, and June 2, 2021, reporting real-world or scenario-based COVID-19 modeling for Brazil. We included 81 studies, most corresponding to published articles produced in Brazilian institutions. The models were dynamic and deterministic in the majority. The predominant model type was compartmental, but other models were also found. The main modeling objectives were to analyze epidemiological scenarios (testing interventions' effectiveness) and to project short and long-term predictions, while few articles performed economic impact analysis. Estimations of the R0 and transmission rates or projections regarding the course of the epidemic figured as major, especially at the beginning of the crisis. However, several other outputs were forecasted, such as the isolation/quarantine effect on transmission, hospital facilities required, secondary cases caused by infected children, and the economic effects of the pandemic. This study reveals numerous articles with shared objectives and similar methods and data sources. We observed a deficiency in addressing social inequities in the Brazilian context within the utilized models, which may also be expected in several low- and middle-income countries with significant social disparities. We conclude that the models were of great relevance in the pandemic scenario of COVID-19. Nevertheless, efforts could be better planned and executed with improved institutional organization, dialogue among research groups, increased interaction between modelers and epidemiologists, and establishment of a sustainable cooperation network.

Modeling the impact of child vaccination (5-11 y) on overall COVID-19 related hospitalizations and mortality in a context of omicron variant predominance and different vaccination coverage paces in Brazil.

Background: Developing countries have experienced significant COVID-19 disease burden. With the emergence of new variants, particularly omicron, the disease burden in children has increased. When the first COVID-19 vaccine was approved for use in children aged 5-11 years of age, very few countries recommended vaccination due to limited risk-benefit evidence for vaccination of this population. In Brazil, ranking second in the global COVID-19 death toll, the childhood COVID-19 disease burden increased significantly in early 2022. This prompted a risk-benefit assessment of the introduction and scaling-up of COVID-19 vaccination of children. Methods: To estimate the potential impact of vaccinating children aged 5-11 years with mRNA-based COVID-19 vaccine in the context of omicron dominance, we developed a discrete-time SEIR-like model stratified in age groups, considering a three-month time horizon. We considered three scenarios: No vaccination, slow, and maximum vaccination paces. In each scenario, we estimated the potential reduction in total COVID-19 cases, hospitalizations, deaths, hospitalization costs, and potential years of life lost, considering the absence of vaccination as the base-case scenario. Findings: We estimated that vaccinating at a maximum pace could prevent, between mid-January and April 2022, about 26,000 COVID-19 hospitalizations, and 4200 deaths in all age groups; of which 5400 hospitalizations and 410 deaths in children aged 5-11 years. Continuing vaccination at a slow/current pace would prevent 1450 deaths and 9700 COVID-19 hospitalizations in all age groups in this same time period; of which 180 deaths and 2390 hospitalizations in children only. Interpretation: Maximum vaccination of children results in a significant reduction of COVID-19 hospitalizations and deaths and should be enforced in developing countries with significant disease incidence in children. Funding: This manuscript was funded by the Brazilian Council for Scientific and Technology Development (CNPq - Process # 402834/2020-8).

Modelling the impact of school reopening and contact tracing strategies on Covid-19 dynamics in different epidemiologic settings in Brazil.

We simulate the impact of school reopening during the COVID-19 pandemic in three major urban centers in Brazil to identify the epidemiological indicators and the best timing for the return of in-school activities and the effect of contact tracing as a mitigation measure. Our goal is to offer guidelines for evidence-based policymaking. We implement an extended SEIR model stratified by age and considering contact networks in different settings - school, home, work, and community, in which the infection transmission rate is affected by various intervention measures. After fitting epidemiological and demographic data, we simulate scenarios with increasing school transmission due to school reopening, and also estimate the number of hospitalization and deaths averted by the implementation of contact tracing. Reopening schools results in a non-linear increase in reported COVID-19 cases and deaths, which is highly dependent on infection and disease incidence at the time of reopening. When contact tracing and quarantining are restricted to school and home settings, a large number of daily tests is required to produce significant effects in reducing the total number of hospitalizations and deaths. Policymakers should carefully consider the epidemiological context and timing regarding the implementation of school closure and return of in-person school activities. While contact tracing strategies prevent new infections within school environments, they alone are not sufficient to avoid significant impacts on community transmission.

Modelling optimal vaccination strategies against COVID-19 in a context of Gamma variant predominance in Brazil.

INTRODUCTION: Brazil experienced moments of collapse in its health system throughout 2021, driven by the emergence of variants of concern (VOC) combined with an inefficient initial vaccination strategy against Covid-19. OBJECTIVES: To support decision-makers in formulating COVID-19 immunization policy in the context of limited vaccine availability and evolving variants over time, we evaluate optimal strategies for Covid-19 vaccination in Brazil in 2021, when vaccination was rolled out during Gamma variant predominance. METHODS: Using a discrete-time epidemic model we estimate Covid-19 deaths averted, considering the currently Covid-19 vaccine products and doses available in Brazil; vaccine coverage by target population; and vaccine effectiveness estimates. We evaluated a 5-month time horizon, from early August to the end of December 2021. Optimal vaccination strategies compared the outcomes in terms of averted deaths when varying dose intervals from 8 to 12 weeks, and choosing the minimum coverage levels per age group required prior to expanding vaccination to younger target populations. We also estimated dose availability required over time to allow the implementation of optimal strategies. RESULTS: To maximize the number of averted deaths, vaccine coverage of at least 80 % should be reached in older age groups before starting vaccination into subsequent younger age groups. When evaluating varying dose intervals for AZD1222, reducing the dose interval from 12 to 8 weeks for the primary schedule would result in fewer COVID-19 deaths, but this can only be implemented if accompanied by an increase in vaccine supply of at least 50 % over the coming six-months in Brazil. CONCLUSION: Covid-19 immunization strategies should be tailored to local vaccine product availability and supply over time, circulating variants of concern, and vaccine coverage in target population groups. Modelling can provide valuable and timely evidence to support the implementation of vaccination strategies considering the local context, yet following international and regional technical evidence-based guidance.

Assessment of the implementation of a nurse-initiated pain management protocol in the emergency department.

OBJECTIVES: to assess the implementation of a nurse-initiated pain management protocol for patients triaged as semi-urgent, and its impact in pain intensity, in the Emergency Department. METHODS: a prospective cohort study for adult patients with pain who had been triaged as semi-urgent and admitted to the hospital's Emergency Department. Patients who received the intervention (pain-management protocol with analgesic administration) were compared to those who were managed using the conventional approach (physician evaluation prior to analgesic administration). RESULTS: of the 185 patients included, 55 (30%) received the intervention, and 130 (70%) were managed conventionally. Patients in the intervention group were more likely to have taken pain medication in the 4 hours prior to admission, and reported higher levels of pain at admission and more significant reductions in pain level. CONCLUSIONS: despite low protocol adherence, the intervention resulted in higher reported pain relief.

Assessment of the implementation of a nurse-initiated pain management protocol in the emergency department / Avaliação da implementação de um protocolo de manejo da dor iniciado por enfermeiros no departamento de emergências / Evaluación de la implementación de un protocolo de manejo del dolor iniciado por enfermeros en el servicio de urgencias

ABSTRACT Objectives: to assess the implementation of a nurse-initiated pain management protocol for patients triaged as semi-urgent, and its impact in pain intensity, in the Emergency Department. Methods: a prospective cohort study for adult patients with pain who had been triaged as semi-urgent and admitted to the hospital's Emergency Department. Patients who received the intervention (pain-management protocol with analgesic administration) were compared to those who were managed using the conventional approach (physician evaluation prior to analgesic administration). Results: of the 185 patients included, 55 (30%) received the intervention, and 130 (70%) were managed conventionally. Patients in the intervention group were more likely to have taken pain medication in the 4 hours prior to admission, and reported higher levels of pain at admission and more significant reductions in pain level. Conclusions: despite low protocol adherence, the intervention resulted in higher reported pain relief.

RESUMO Objetivos: avaliar a implementação de um protocolo de manejo da dor iniciado por enfermeiros para pacientes triados como semi-urgentes, e seu impacto na intensidade da dor, no Departamento de Emergências. Métodos: um estudo prospectivo de coorte com pacientes adultos com dor triados como semi-urgente e admitidos no Departamento de Emergências do hospital. Os pacientes que receberam a intervenção (protocolo de manejo da dor com administração de analgésico) foram comparados aos que foram manejados com uso da abordagem convencional (avaliação médica antes da administração de analgésico). Resultados: do total de 185 pacientes incluídos, 55 (30%) receberam a intervenção, e 130 (70%) foram manejados convencionalmente. Os pacientes do grupo de intervenção apresentaram maior probabilidade de tomar medicação para dor nas 4 horas anteriores à internação, e relataram maiores níveis de dor na internação e reduções mais significativas no nível de dor. Conclusões: apesar da baixa adesão ao protocolo, a intervenção resultou em relatos de maior alívio da dor.

RESUMEN Objetivos: evaluar la implementación de un protocolo de manejo del dolor iniciado por enfermeros para pacientes clasificados como semi-urgentes, y su impacto en la intensidad del dolor, en el Servicio de Urgencias. Métodos: un estudio prospectivo de cohorte con pacientes adultos con dolor que habían sido clasificados cono semi-urgente y admitidos en el Servicio de Urgencias del hospital. Los pacientes que recibieron la intervención (protocolo de manejo del dolor con administración de analgésico) fueron comparados con aquellos que fueron manejados teniendo en cuenta el enfoque convencional (evaluación médica antes de la administración de analgésico). Resultados: del total de 185 pacientes incluidos, 55 (30%) recibieron la intervención, y 130 (70%) se gestionaron convencionalmente. Los pacientes del grupo de intervención eran más propensos a haber tomado analgésicos en las 4 horas previas al ingreso, y reportaron mayores niveles de dolor al momento de admisión y una reducción más significativa en el nivel de dolor. Conclusiones: a pesar de la baja adherencia al protocolo, la intervención resultó en un mayor alivio del dolor reportado.

Assessment of the implementation of a nurse-initiated pain management protocol in the emergency department / Avaliação da implementação de um protocolo de manejo da dor iniciado por enfermeiros no departamento de emergências / Evaluación de la implementación de un protocolo de manejo del dolor iniciado por enfermeros en el servicio de urgencias

ABSTRACT Objectives: to assess the implementation of a nurse-initiated pain management protocol for patients triaged as semi-urgent, and its impact in pain intensity, in the Emergency Department. Methods: a prospective cohort study for adult patients with pain who had been triaged as semi-urgent and admitted to the hospital's Emergency Department. Patients who received the intervention (pain-management protocol with analgesic administration) were compared to those who were managed using the conventional approach (physician evaluation prior to analgesic administration). Results: of the 185 patients included, 55 (30%) received the intervention, and 130 (70%) were managed conventionally. Patients in the intervention group were more likely to have taken pain medication in the 4 hours prior to admission, and reported higher levels of pain at admission and more significant reductions in pain level. Conclusions: despite low protocol adherence, the intervention resulted in higher reported pain relief.

RESUMO Objetivos: avaliar a implementação de um protocolo de manejo da dor iniciado por enfermeiros para pacientes triados como semi-urgentes, e seu impacto na intensidade da dor, no Departamento de Emergências. Métodos: um estudo prospectivo de coorte com pacientes adultos com dor triados como semi-urgente e admitidos no Departamento de Emergências do hospital. Os pacientes que receberam a intervenção (protocolo de manejo da dor com administração de analgésico) foram comparados aos que foram manejados com uso da abordagem convencional (avaliação médica antes da administração de analgésico). Resultados: do total de 185 pacientes incluídos, 55 (30%) receberam a intervenção, e 130 (70%) foram manejados convencionalmente. Os pacientes do grupo de intervenção apresentaram maior probabilidade de tomar medicação para dor nas 4 horas anteriores à internação, e relataram maiores níveis de dor na internação e reduções mais significativas no nível de dor. Conclusões: apesar da baixa adesão ao protocolo, a intervenção resultou em relatos de maior alívio da dor.

RESUMEN Objetivos: evaluar la implementación de un protocolo de manejo del dolor iniciado por enfermeros para pacientes clasificados como semi-urgentes, y su impacto en la intensidad del dolor, en el Servicio de Urgencias. Métodos: un estudio prospectivo de cohorte con pacientes adultos con dolor que habían sido clasificados cono semi-urgente y admitidos en el Servicio de Urgencias del hospital. Los pacientes que recibieron la intervención (protocolo de manejo del dolor con administración de analgésico) fueron comparados con aquellos que fueron manejados teniendo en cuenta el enfoque convencional (evaluación médica antes de la administración de analgésico). Resultados: del total de 185 pacientes incluidos, 55 (30%) recibieron la intervención, y 130 (70%) se gestionaron convencionalmente. Los pacientes del grupo de intervención eran más propensos a haber tomado analgésicos en las 4 horas previas al ingreso, y reportaron mayores niveles de dolor al momento de admisión y una reducción más significativa en el nivel de dolor. Conclusiones: a pesar de la baja adherencia al protocolo, la intervención resultó en un mayor alivio del dolor reportado.

Social distancing measures in the fight against COVID-19 in Brazil: description and epidemiological analysis by state. / Medidas de distanciamento social para o enfrentamento da COVID-19 no Brasil: caracterização e análise epidemiológica por estado.

Social distancing measures have been widely adopted to mitigate the COVID-19 pandemic. However, little is known about the timing of measures' implementation, scope, and duration in relation to their impact. The study aimed to describe the social distancing measures implemented by Brazil's states and the Federal District, including the types of measures and the timing of their implementation. This is a descriptive study of the measures' type, chronological and epidemiological timing of the implementation, and scope. The survey of measures used searches in official websites of the government departments and each state's Government Register. The official number of COVID-19 cases and deaths were obtained from an official a data platform. We considered the following categories of social distancing measures: suspension of events, school closure, quarantine of risk groups, economic lockdown (partial or full), restrictions on transportation, and quarantine of the population. The implementation's timing considered both the chronological date and the epidemiological timing, based on the time since the 10th case or 1st death from COVID-19 in each state. All the states implemented distancing measures, mostly during the latter half of March 2020. Economic lockdown was implemented early, prior to the 10th case by 67% of the states and prior to the 1st death from COVID-19 by 89% of the states. Early social distancing measures were widely implemented in Brazil, before or in the initial phase of the exponential growth curve of COVID-19 cases and deaths in the great majority of states.

Medidas de distanciamento social vêm sendo amplamente adotadas para mitigar a pandemia da COVID-19. No entanto, pouco se sabe quanto ao seu impacto no momento da implementação, abrangência e duração da vigência das medidas. O objetivo deste estudo foi caracterizar as medidas de distanciamento social implementadas pelas Unidades da Federação (UF) brasileiras, incluindo o tipo de medida e o momento de sua adoção. Trata-se de um estudo descritivo com caracterização do tipo, momento cronológico e epidemiológico da implementação e abrangência das medidas. O levantamento das medidas foi realizado por meio de buscas em sites oficiais das Secretarias de Governo e no Diário Oficial de cada UF. Os números de casos e óbitos por COVID-19 foram obtidos de uma plataforma de informações oficiais. Consideramos as seguintes categorias de medidas de distanciamento social: suspensão de eventos, suspensão de aulas, quarentena para grupos de risco, paralisação econômica (parcial ou plena), restrição de transporte e quarentena para a população. O momento de implementação considerou a data cronológica e também o momento epidemiológico, levando em conta o tempo após o décimo caso ou primeiro óbito por COVID-19 em cada UF. Todas as UF implementaram medidas de distanciamento, em sua maioria durante a segunda quinzena de março de 2020. Paralisação econômica foi implementada precocemente, anterior ao décimo caso por 67% e anterior ao primeiro óbito por COVID-19 por 89% das UF. As medidas de distanciamento social foram amplamente implementadas no Brasil, de maneira precoce, antes ou na fase inicial da curva de crescimento exponencial de casos e óbitos por COVID-19 na grande maioria das UF.

Medidas de distanciamiento social están siendo ampliamente adoptadas para mitigar la pandemia de la COVID-19. No obstante, poco se sabe en cuanto al momento de implementación, alcance y duración de la vigencia de las medidas en su impacto. El objetivo de este estudio fue caracterizar las medidas de distanciamiento social, implementadas por las Unidades de la Federación (UF) brasileñas, incluyendo el tipo de medida y el momento de su implementación. Se trata de un estudio descriptivo con caracterización del tipo, momento cronológico y epidemiológico de la implementación y alcance de las medidas. La obtención de las medidas se realizó a través de búsquedas en sitios oficiales de las Secretarías de Gobierno y Boletín Oficial de cada UF. Los números de casos y óbitos por COVID-19 se obtuvieron de una plataforma de información oficial. Consideramos las siguientes categorías de medidas de distanciamiento social: suspensión de eventos, suspensión de clases, cuarentena para grupos de riesgo, paralización económica (parcial o plena), restricción de transporte y cuarentena para la población. El momento de implementación consideró la fecha cronológica y también el momento epidemiológico, considerando el tiempo tras el 10º caso o 1er óbito por COVID-19 en cada UF. Todas las UF implementaron medidas de distanciamiento, en su mayoría durante la segunda quincena de marzo de 2020. Se implementó la paralización económica precozmente, anterior al 10º caso por 67% y anterior al 1er óbito por COVID-19 por 89% de las UF. Las medidas de distanciamiento social fueron ampliamente implementadas en Brasil, de manera precoz, antes o en la fase inicial de la curva de crecimiento exponencial de casos y óbitos por COVID-19 en la gran mayoría de las UF.

Medidas de distanciamento social para o enfrentamento da COVID-19 no Brasil: caracterização e análise epidemiológica por estado / Medidas de distanciamiento social para el combate a la COVID-19 en Brasil: caracterización y análisis epidemiológico por estado / Social distancing measures in the fight against COVID-19 in Brazil: description and epidemiological analysis by state

Medidas de distanciamento social vêm sendo amplamente adotadas para mitigar a pandemia da COVID-19. No entanto, pouco se sabe quanto ao seu impacto no momento da implementação, abrangência e duração da vigência das medidas. O objetivo deste estudo foi caracterizar as medidas de distanciamento social implementadas pelas Unidades da Federação (UF) brasileiras, incluindo o tipo de medida e o momento de sua adoção. Trata-se de um estudo descritivo com caracterização do tipo, momento cronológico e epidemiológico da implementação e abrangência das medidas. O levantamento das medidas foi realizado por meio de buscas em sites oficiais das Secretarias de Governo e no Diário Oficial de cada UF. Os números de casos e óbitos por COVID-19 foram obtidos de uma plataforma de informações oficiais. Consideramos as seguintes categorias de medidas de distanciamento social: suspensão de eventos, suspensão de aulas, quarentena para grupos de risco, paralisação econômica (parcial ou plena), restrição de transporte e quarentena para a população. O momento de implementação considerou a data cronológica e também o momento epidemiológico, levando em conta o tempo após o décimo caso ou primeiro óbito por COVID-19 em cada UF. Todas as UF implementaram medidas de distanciamento, em sua maioria durante a segunda quinzena de março de 2020. Paralisação econômica foi implementada precocemente, anterior ao décimo caso por 67% e anterior ao primeiro óbito por COVID-19 por 89% das UF. As medidas de distanciamento social foram amplamente implementadas no Brasil, de maneira precoce, antes ou na fase inicial da curva de crescimento exponencial de casos e óbitos por COVID-19 na grande maioria das UF.

Medidas de distanciamiento social están siendo ampliamente adoptadas para mitigar la pandemia de la COVID-19. No obstante, poco se sabe en cuanto al momento de implementación, alcance y duración de la vigencia de las medidas en su impacto. El objetivo de este estudio fue caracterizar las medidas de distanciamiento social, implementadas por las Unidades de la Federación (UF) brasileñas, incluyendo el tipo de medida y el momento de su implementación. Se trata de un estudio descriptivo con caracterización del tipo, momento cronológico y epidemiológico de la implementación y alcance de las medidas. La obtención de las medidas se realizó a través de búsquedas en sitios oficiales de las Secretarías de Gobierno y Boletín Oficial de cada UF. Los números de casos y óbitos por COVID-19 se obtuvieron de una plataforma de información oficial. Consideramos las siguientes categorías de medidas de distanciamiento social: suspensión de eventos, suspensión de clases, cuarentena para grupos de riesgo, paralización económica (parcial o plena), restricción de transporte y cuarentena para la población. El momento de implementación consideró la fecha cronológica y también el momento epidemiológico, considerando el tiempo tras el 10º caso o 1er óbito por COVID-19 en cada UF. Todas las UF implementaron medidas de distanciamiento, en su mayoría durante la segunda quincena de marzo de 2020. Se implementó la paralización económica precozmente, anterior al 10º caso por 67% y anterior al 1er óbito por COVID-19 por 89% de las UF. Las medidas de distanciamiento social fueron ampliamente implementadas en Brasil, de manera precoz, antes o en la fase inicial de la curva de crecimiento exponencial de casos y óbitos por COVID-19 en la gran mayoría de las UF.

Social distancing measures have been widely adopted to mitigate the COVID-19 pandemic. However, little is known about the timing of measures' implementation, scope, and duration in relation to their impact. The study aimed to describe the social distancing measures implemented by Brazil's states and the Federal District, including the types of measures and the timing of their implementation. This is a descriptive study of the measures' type, chronological and epidemiological timing of the implementation, and scope. The survey of measures used searches in official websites of the government departments and each state's Government Register. The official number of COVID-19 cases and deaths were obtained from an official a data platform. We considered the following categories of social distancing measures: suspension of events, school closure, quarantine of risk groups, economic lockdown (partial or full), restrictions on transportation, and quarantine of the population. The implementation's timing considered both the chronological date and the epidemiological timing, based on the time since the 10th case or 1st death from COVID-19 in each state. All the states implemented distancing measures, mostly during the latter half of March 2020. Economic lockdown was implemented early, prior to the 10th case by 67% of the states and prior to the 1st death from COVID-19 by 89% of the states. Early social distancing measures were widely implemented in Brazil, before or in the initial phase of the exponential growth curve of COVID-19 cases and deaths in the great majority of states.

Economic burden of diabetes in Brazil in 2014.

BACKGROUND: Diabetes and its complications produce significant clinical, economic and social impact. The knowledge of the costs of diabetes generates subsidies to maintain the financial sustainability of public health and social security systems, guiding research and health care priorities. AIMS: The aim of this study was to estimate the economic burden of diabetes in Brazilian adults in 2014, considering the perspectives of the public health care system and the society. METHODS: A prevalence-based approach was used to estimate the annual health resource utilization and costs attributable to diabetes and related conditions. The healthcare system perspective considered direct medical costs related to outpatient and hospitalization costs. The societal perspective considered non-medical (transportation and dietary products) and indirect costs (productivity loss, disability, and premature retirement). Outpatient costs included medicines, health professional visits, exams, home glucose monitoring, ophthalmic procedures, and costs related to end stage renal disease. The costs of hospitalization attributed to diabetes related conditions were estimated using attributable risk methodology. Costs were estimated in Brazilian currency, and then converted to international dollars (2014). RESULTS: Based on a national self-reported prevalence of 6.2%, the total cost of diabetes in 2014 was Int$ 15.67 billion, including Int$ 6.89 billion in direct medical costs (44%), Int$ 3.69 billion in non-medical costs (23.6%) and Int$ 5.07 billion in indirect costs (32.4%). Outpatient costs summed Int$ 6.62 billion and the costs of 314,334 hospitalizations attributed to diabetes and related conditions was Int$ 264.9 million. Most hospitalizations were due to cardiovascular diseases (47.9%), followed by diabetes itself (18%), and renal diseases (13.6%). Diet and transportation costs were estimated at Int$ 3.2 billion and Int$ 462.3 million, respectively. CONCLUSIONS: Our results showed a substantial economic burden of diabetes in Brazil, and most likely are underrated as they are based on an underestimated prevalence of diabetes. Healthcare policies aiming at diabetes prevention and control are urgently sought.

Effectiveness of rapid response teams in reducing intrahospital cardiac arrests and deaths: a systematic review and meta-analysis. / Efetividade do uso de times de resposta rápida para reduzir a ocorrência de parada cardíaca e mortalidade hospitalar: uma revisão sistemática e metanálise.

OBJECTIVE: To evaluate the effectiveness of rapid response teams using early identification of clinical deterioration in reducing the occurrence of in-hospital mortality and cardiorespiratory arrest. DATA SOURCES: The MEDLINE, LILACS, Cochrane Library, Center for Reviews and Dissemination databases were searched. STUDY SELECTION: We included studies that evaluated the effectiveness of rapid response teams in adult hospital units, published in English, Portuguese, or Spanish, from 2000 to 2016; systematic reviews, clinical trials, cohort studies, and prepost ecological studies were eligible for inclusion. The quality of studies was independently assessed by two researchers using the Newcastle-Ottawa, modified Jadad, and Assessment of Multiple Systematic Reviews scales. DATA EXTRACTIONS: The results were synthesized and tabulated. When risk measures were reported by the authors of the included studies, we estimated effectiveness as 1-RR or 1-OR. In pre-post studies, we estimated effectiveness as the percent decrease in rates following the intervention. RESULTS: Overall, 278 studies were identified, 256 of which were excluded after abstract evaluation, and two of which were excluded after full text evaluation. In the meta-analysis of the studies reporting mortality data, we calculated a risk ratio of 0.85 (95%CI 0.76 - 0.94); and for studies reporting cardiac arrest data the estimated risk ratio was 0.65 (95%CI 0.49 - 0.87). Evidence was assessed as low quality due to the high heterogeneity and risk of bias in primary studies. CONCLUSION: We conclude that rapid response teams may reduce in-hospital mortality and cardiac arrests, although the quality of evidence for both outcomes is low.

OBJETIVO: Avaliar a efetividade de times de resposta rápida com uso de identificação precoce de deterioração clínica, na redução das ocorrências de parada cardiorrespiratória e morte no hospital. FONTES DE DADOS: Realizaram-se buscas nas bases de dados MEDLINE, LILACS, Cochrane Library e Center for Reviews and Dissemination. SELEÇÃO DE ESTUDOS: Incluímos trabalhos que avaliaram a efetividade de times de resposta rápida em unidades hospitalares de pacientes adultos, publicados em inglês, português ou espanhol, no período entre 2000 e 2016. Consideraram-se elegíveis revisões sistemáticas, ensaios clínicos, estudos de coorte e ecológicos pré-pós. A qualidade dos trabalhos foi avaliada de forma independente por dois dos pesquisadores com utilização das escalas Newcastle-Ottawa e Jadad modificada, e da ferramenta Assessment of Multiple Systematic Reviews. EXTRAÇÃO DOS DADOS: Os resultados foram resumidos e tabulados. Quando os autores dos estudos incluídos relataram medidas de risco, estimamos a efetividade como 1-RR ou 1-OR. Nos estudos pré-pós, estimamos a efetividade como a diminuição porcentual nas taxas após a intervenção. RESULTADOS: Identificou-se um total de 278 trabalhos, dos quais 256 foram excluídos após avaliação do resumo, e dois outros após avaliação do texto completo. Na metanálise dos estudos que relataram dados de mortalidade, calculamos uma proporção de risco de 0,85 (IC95% 0,76 - 0,94); para os trabalhos que relataram dados de parada cardíaca, o cálculo da proporção de risco foi de 0,65 (IC95% 0,49 - 0,87). A evidência foi de baixa qualidade em razão da heterogeneidade e do risco de viés nos ensaios primários. CONCLUSÃO: Os times de resposta rápida podem reduzir a incidência de morte e parada cardíaca no hospital, embora a qualidade da evidência seja baixa para ambos os desfechos.

Efetividade do uso de times de resposta rápida para reduzir a ocorrência de parada cardíaca e mortalidade hospitalar: uma revisão sistemática e metanálise / Effectiveness of rapid response teams in reducing intrahospital cardiac arrests and deaths: a systematic review and meta-analysis

RESUMO Objetivo: Avaliar a efetividade de times de resposta rápida com uso de identificação precoce de deterioração clínica, na redução das ocorrências de parada cardiorrespiratória e morte no hospital. Fontes de dados: Realizaram-se buscas nas bases de dados MEDLINE, LILACS, Cochrane Library e Center for Reviews and Dissemination. Seleção de estudos: Incluímos trabalhos que avaliaram a efetividade de times de resposta rápida em unidades hospitalares de pacientes adultos, publicados em inglês, português ou espanhol, no período entre 2000 e 2016. Consideraram-se elegíveis revisões sistemáticas, ensaios clínicos, estudos de coorte e ecológicos pré-pós. A qualidade dos trabalhos foi avaliada de forma independente por dois dos pesquisadores com utilização das escalas Newcastle-Ottawa e Jadad modificada, e da ferramenta Assessment of Multiple Systematic Reviews. Extração dos dados: Os resultados foram resumidos e tabulados. Quando os autores dos estudos incluídos relataram medidas de risco, estimamos a efetividade como 1-RR ou 1-OR. Nos estudos pré-pós, estimamos a efetividade como a diminuição porcentual nas taxas após a intervenção. Resultados: Identificou-se um total de 278 trabalhos, dos quais 256 foram excluídos após avaliação do resumo, e dois outros após avaliação do texto completo. Na metanálise dos estudos que relataram dados de mortalidade, calculamos uma proporção de risco de 0,85 (IC95% 0,76 - 0,94); para os trabalhos que relataram dados de parada cardíaca, o cálculo da proporção de risco foi de 0,65 (IC95% 0,49 - 0,87). A evidência foi de baixa qualidade em razão da heterogeneidade e do risco de viés nos ensaios primários. Conclusão: Os times de resposta rápida podem reduzir a incidência de morte e parada cardíaca no hospital, embora a qualidade da evidência seja baixa para ambos os desfechos.

ABSTRACT Objective: To evaluate the effectiveness of rapid response teams using early identification of clinical deterioration in reducing the occurrence of in-hospital mortality and cardiorespiratory arrest. Data sources: The MEDLINE, LILACS, Cochrane Library, Center for Reviews and Dissemination databases were searched. Study selection: We included studies that evaluated the effectiveness of rapid response teams in adult hospital units, published in English, Portuguese, or Spanish, from 2000 to 2016; systematic reviews, clinical trials, cohort studies, and prepost ecological studies were eligible for inclusion. The quality of studies was independently assessed by two researchers using the Newcastle-Ottawa, modified Jadad, and Assessment of Multiple Systematic Reviews scales. Data extractions: The results were synthesized and tabulated. When risk measures were reported by the authors of the included studies, we estimated effectiveness as 1-RR or 1-OR. In pre-post studies, we estimated effectiveness as the percent decrease in rates following the intervention. Results: Overall, 278 studies were identified, 256 of which were excluded after abstract evaluation, and two of which were excluded after full text evaluation. In the meta-analysis of the studies reporting mortality data, we calculated a risk ratio of 0.85 (95%CI 0.76 - 0.94); and for studies reporting cardiac arrest data the estimated risk ratio was 0.65 (95%CI 0.49 - 0.87). Evidence was assessed as low quality due to the high heterogeneity and risk of bias in primary studies. Conclusion: We conclude that rapid response teams may reduce in-hospital mortality and cardiac arrests, although the quality of evidence for both outcomes is low.

Single-dose varicella vaccine effectiveness in Brazil: A case-control study.

BACKGROUND: Varicella vaccine was introduced into the Brazilian Immunization Program in October 2013, as a single-dose schedule administered at 15 months of age. Its effectiveness had not yet been assessed in the country. METHODS: A matched case-control study was carried out in São Paulo and Goiânia (Southeast and Midwest regions, respectively), Brazil. Suspected cases, were identified through a prospective surveillance established in the study sites. All cases had specimens from skin lesion collected for molecular laboratory testing. Cases were confirmed by either clinical or PCR of skin lesions and classified as mild, moderate, and severe disease. Two neighborhood controls were selected for each case. Cases and controls were aged 15-32 months and interviewed at home. Evidence of prior vaccination was obtained from vaccination cards. Univariate and multivariate logistic regression models were used, and odds ratio and its respective 95% confidence intervals were estimated. Vaccine effectiveness was estimated by comparing de odds of having received varicella vaccine among cases and controls. RESULTS: A total of 168 cases and 301 controls were enrolled. Moderate and severe illness, was found in 33.3% and 9.9% of the cases. Effectiveness of a single dose varicella vaccine was 86% (95%CI 72-92%) against disease of any severity and 93% (95%CI 82-97%) against moderate and severe disease. Out of 168 cases, 81.8% had positive PCR results for wild-type strains, and 22.0% were breakthrough varicella cases. Breakthrough cases were milder compared to non-breakthrough cases (p < .001). CONCLUSIONS: Effectiveness of single dose varicella vaccine in Brazil is comparable to that in other countries where breakthrough varicella cases have also been found to occur. The goal of the varicella vaccination program, along with disease burden and affordability should be taken into consideration when considering the adoption of a second dose of varicella vaccine into national immunization programs.

Impact assessment of an automated drug-dispensing system in a tertiary hospital.

OBJECTIVE: To evaluate the costs and patient safety of a pilot implementation of an automated dispensing cabinet in a critical care unit of a private tertiary hospital in São Paulo/Brazil. METHODS: This study considered pre- (January-August 2013) and post- (October 2013-October 2014) intervention periods. We considered the time and cost of personnel, number of adverse events, audit adjustments to patient bills, and urgent requests and returns of medications to the central pharmacy. Costs were evaluated based on a 5-year analytical horizon and are reported in Brazilian Reals (R$) and US dollars (USD). RESULTS: The observed decrease in the mean number of events reported with regard to the automated drug-dispensing system between pre- and post-implementation periods was not significant. Importantly, the numbers are small, which limits the power of the mean comparative analysis between the two periods. A reduction in work time was observed among the nurses and administrative assistants, whereas pharmacist assistants showed an increased work load that resulted in an overall 6.5 hours of work saved/day and a reduction of R$ 33,598 (USD 14,444) during the first year. The initial investment (R$ 206,065; USD 88,592) would have been paid off in 5 years considering only personnel savings. Other findings included significant reductions of audit adjustments to patient hospital bills and urgent requests and returns of medications to the central pharmacy. CONCLUSIONS: Evidence of the positive impact of this technology on personnel time and costs and on other outcomes of interest is important for decision making by health managers.

Impact assessment of an automated drug-dispensing system in a tertiary hospital

OBJECTIVE: To evaluate the costs and patient safety of a pilot implementation of an automated dispensing cabinet in a critical care unit of a private tertiary hospital in São Paulo/Brazil. METHODS: This study considered pre- (January-August 2013) and post- (October 2013-October 2014) intervention periods. We considered the time and cost of personnel, number of adverse events, audit adjustments to patient bills, and urgent requests and returns of medications to the central pharmacy. Costs were evaluated based on a 5-year analytical horizon and are reported in Brazilian Reals (R$) and US dollars (USD). RESULTS: The observed decrease in the mean number of events reported with regard to the automated drug-dispensing system between pre- and post-implementation periods was not significant. Importantly, the numbers are small, which limits the power of the mean comparative analysis between the two periods. A reduction in work time was observed among the nurses and administrative assistants, whereas pharmacist assistants showed an increased work load that resulted in an overall 6.5 hours of work saved/day and a reduction of R$ 33,598 (USD 14,444) during the first year. The initial investment (R$ 206,065; USD 88,592) would have been paid off in 5 years considering only personnel savings. Other findings included significant reductions of audit adjustments to patient hospital bills and urgent requests and returns of medications to the central pharmacy. CONCLUSIONS: Evidence of the positive impact of this technology on personnel time and costs and on other outcomes of interest is important for decision making by health managers.

Hospitalization costs of severe bacterial pneumonia in children: comparative analysis considering different costing methods.

OBJECTIVE: To determine and compare hospitalization costs of bacterial community-acquired pneumonia cases via different costing methods under the Brazilian Public Unified Health System perspective. METHODS: Cost-of-illness study based on primary data collected from a sample of 59 children aged between 28 days and 35 months and hospitalized due to bacterial pneumonia. Direct medical and non-medical costs were considered and three costing methods employed: micro-costing based on medical record review, micro-costing based on therapeutic guidelines and gross-costing based on the Brazilian Public Unified Health System reimbursement rates. Costs estimates obtained via different methods were compared using the Friedman test. RESULTS: Cost estimates of inpatient cases of severe pneumonia amounted to R$ 780,70/$Int. 858.7 (medical record review), R$ 641,90/$Int. 706.90 (therapeutic guidelines) and R$ 594,80/$Int. 654.28 (Brazilian Public Unified Health System reimbursement rates). Costs estimated via micro-costing (medical record review or therapeutic guidelines) did not differ significantly (p=0.405), while estimates based on reimbursement rates were significantly lower compared to estimates based on therapeutic guidelines (p<0.001) or record review (p=0.006). CONCLUSION: Brazilian Public Unified Health System costs estimated via different costing methods differ significantly, with gross-costing yielding lower cost estimates. Given costs estimated by different micro-costing methods are similar and costing methods based on therapeutic guidelines are easier to apply and less expensive, this method may be a valuable alternative for estimation of hospitalization costs of bacterial community-acquired pneumonia in children. OBJETIVO: Determinar e comparar custos hospitalares no tratamento da pneumonia bacteriana adquirida na comunidade por diferentes metodologias de custeio, na perspectiva do Sistema Único de Saúde. MÉTODOS: Estudo de custo, com coleta de dados primários de uma amostra de 59 crianças com 28 dias a 35 meses de idade hospitalizadas por pneumonia bacteriana. Foram considerados custos diretos médicos e não médicos. Três metodologias de custeio foram utilizadas: microcusteio por revisão de prontuários, microcusteio considerando diretriz terapêutica e macrocusteio por ressarcimento do Sistema Único de Saúde. Os custos estimados pelas diferentes metodologias foram comparados utilizando o teste de Friedman. RESULTADOS: Os custos hospitalares de crianças com pneumonia grave foram R$ 780,70 ($Int. 858.7) por revisão de prontuários, R$ 641,90 ($Int. 706.90) por diretriz terapêutica e R$ 594,80 ($Int. 654.28) por ressarcimento do Sistema Único de Saúde, respectivamente. A utilização de metodologias de microcusteio (revisão de prontuários e diretriz) resultou em estimativas de custos equivalentes (p=0,405), enquanto o custo estimado por ressarcimento foi significativamente menor do que aqueles estimados por diretriz (p<0,001) e por revisão de prontuário (p=0,006), sendo, assim, significativamente diferentes. CONCLUSÃO: Na perspectiva do Sistema Único de Saúde, existe diferença significativa nos custos estimados quando se utilizam diferentes metodologias, sendo a estimativa por ressarcimento a que resulta em valores menores. Considerando que não há diferença nos valores de custos estimados por diferentes metodologias de microcusteio, a metodologia de custeio por diretriz, de mais fácil e rápida execução, é uma alternativa válida para estimativa de custos de hospitalização por pneumonias bacterianas em crianças.

Hospitalization costs of severe bacterial pneumonia in children: comparative analysis considering different costing methods / Custos hospitalares de pneumonia bacteriana grave em crianças: análise comparativa por diferentes métodos de custeio

ABSTRACT Objective To determine and compare hospitalization costs of bacterial community-acquired pneumonia cases via different costing methods under the Brazilian Public Unified Health System perspective. Methods Cost-of-illness study based on primary data collected from a sample of 59 children aged between 28 days and 35 months and hospitalized due to bacterial pneumonia. Direct medical and non-medical costs were considered and three costing methods employed: micro-costing based on medical record review, micro-costing based on therapeutic guidelines and gross-costing based on the Brazilian Public Unified Health System reimbursement rates. Costs estimates obtained via different methods were compared using the Friedman test. Results Cost estimates of inpatient cases of severe pneumonia amounted to R$ 780,70/$Int. 858.7 (medical record review), R$ 641,90/$Int. 706.90 (therapeutic guidelines) and R$ 594,80/$Int. 654.28 (Brazilian Public Unified Health System reimbursement rates). Costs estimated via micro-costing (medical record review or therapeutic guidelines) did not differ significantly (p=0.405), while estimates based on reimbursement rates were significantly lower compared to estimates based on therapeutic guidelines (p<0.001) or record review (p=0.006). Conclusion Brazilian Public Unified Health System costs estimated via different costing methods differ significantly, with gross-costing yielding lower cost estimates. Given costs estimated by different micro-costing methods are similar and costing methods based on therapeutic guidelines are easier to apply and less expensive, this method may be a valuable alternative for estimation of hospitalization costs of bacterial community-acquired pneumonia in children.

RESUMO Objetivo Determinar e comparar custos hospitalares no tratamento da pneumonia bacteriana adquirida na comunidade por diferentes metodologias de custeio, na perspectiva do Sistema Único de Saúde. Métodos Estudo de custo, com coleta de dados primários de uma amostra de 59 crianças com 28 dias a 35 meses de idade hospitalizadas por pneumonia bacteriana. Foram considerados custos diretos médicos e não médicos. Três metodologias de custeio foram utilizadas: microcusteio por revisão de prontuários, microcusteio considerando diretriz terapêutica e macrocusteio por ressarcimento do Sistema Único de Saúde. Os custos estimados pelas diferentes metodologias foram comparados utilizando o teste de Friedman. Resultados Os custos hospitalares de crianças com pneumonia grave foram R$ 780,70 ($Int. 858.7) por revisão de prontuários, R$ 641,90 ($Int. 706.90) por diretriz terapêutica e R$ 594,80 ($Int. 654.28) por ressarcimento do Sistema Único de Saúde, respectivamente. A utilização de metodologias de microcusteio (revisão de prontuários e diretriz) resultou em estimativas de custos equivalentes (p=0,405), enquanto o custo estimado por ressarcimento foi significativamente menor do que aqueles estimados por diretriz (p<0,001) e por revisão de prontuário (p=0,006), sendo, assim, significativamente diferentes. Conclusão Na perspectiva do Sistema Único de Saúde, existe diferença significativa nos custos estimados quando se utilizam diferentes metodologias, sendo a estimativa por ressarcimento a que resulta em valores menores. Considerando que não há diferença nos valores de custos estimados por diferentes metodologias de microcusteio, a metodologia de custeio por diretriz, de mais fácil e rápida execução, é uma alternativa válida para estimativa de custos de hospitalização por pneumonias bacterianas em crianças.

Costs of the Smoking Cessation Program in Brazil.

OBJECTIVE: To assess the costs of the Smoking Cessation Program in the Brazilian Unified Health System and estimate the cost of its full implementation in a Brazilian municipality. METHODS: The intensive behavioral therapy and treatment for smoking cessation includes consultations, cognitive-behavioral group therapy sessions, and use of medicines. The costs of care and management of the program were estimated using micro-costing methods. The full implementation of the program in the municipality of Goiania, Goias was set as its expansion to meet the demand of all smokers motivated to quit in the municipality that would seek care at Brazilian Unified Health System. We considered direct medical and non-medical costs: human resources, medicines, consumables, general expenses, transport, travels, events, and capital costs. We included costs of federal, state, and municipal levels. The perspective of the analysis was that from the Brazilian Unified Health System. Sensitivity analysis was performed by varying parameters concerning the amount of activities and resources used. Data sources included a sample of primary care health units, municipal and state secretariats of health, and the Brazilian Ministry of Health. The costs were estimated in Brazilian Real (R$) for the year of 2010. RESULTS: The cost of the program in Goiania was R$429,079, with 78.0% regarding behavioral therapy and treatment of smoking. The cost per patient was R$534, and, per quitter, R$1,435. The full implementation of the program in the municipality of Goiania would generate a cost of R$20.28 million to attend 35,323 smokers. CONCLUSIONS: The Smoking Cessation Program has good performance in terms of cost per patient that quit smoking. In view of the burden of smoking in Brazil, the treatment for smoking cessation must be considered as a priority in allocating health resources. OBJETIVO: Analisar os custos do Programa de Tratamento do Tabagismo no Sistema Único de Saúde e estimar o custo de sua implementação plena em um município brasileiro. MÉTODOS: A abordagem intensiva e tratamento do tabagismo engloba consultas, sessões de terapia cognitivo-comportamental em grupo e uso de medicamentos. Os custos do atendimento e gerenciamento do programa foram estimados utilizando a metodologia do microcusteio. A implementação plena do programa no município de Goiânia, Goiás, foi definida como sua expansão para suprir a demanda de todos os fumantes motivados a parar de fumar no município que seriam atendidos pelo Sistema Único de Saúde. Foram considerados custos médicos e não médicos diretos: recursos humanos, medicamentos, material de consumo, despesas gerais, transporte, viagens, eventos e custos de capital. Foram incluídos custos dos níveis federal, estadual e municipal de gestão. A perspectiva da análise foi a do Sistema Único de Saúde. Análise de sensibilidade foi realizada variando parâmetros referentes à quantidade de atividades e aos recursos utilizados. As fontes de dados incluíram uma amostra de unidades de saúde da Atenção Primária, secretarias de saúde municipal e estadual e Ministério da Saúde. Os custos foram estimados em reais (R$) para o ano de 2010. RESULTADOS: O custo do programa em Goiânia foi de R$429.079, sendo 78,0% referentes à abordagem e tratamento do tabagismo. O custo por paciente foi de R$534 e, por paciente que deixou de fumar, de R$1.435. A implementação plena do programa no município de Goiânia geraria custo de R$20,28 milhões, para atender 35.323 fumantes. CONCLUSÕES: O Programa de Tratamento do Tabagismo tem bom desempenho em termos de custo por paciente que deixa de fumar. Tendo em vista a carga do tabagismo no Brasil, o tratamento para cessação de fumar deve ser considerado prioritário ao se programar a alocação de recursos de saúde.