Maternal and congenital syphilis attributable to ethnoracial inequalities: a national record-linkage longitudinal study of 15 million births in Brazil.

BACKGROUND: This study estimated ethnoracial inequalities in maternal and congenital syphilis in Brazil, understanding race as a relational category product of a sociopolitical construct that functions as an essential tool of racism and its manifestations. METHODS: We linked routinely collected data from Jan 1, 2012 to Dec 31, 2017 to conduct a population-based study in Brazil. We estimated the attributable fraction of race (skin colour) for the entire population and specific subgroups compared with White women using adjusted logistic regression. We also obtained the attributable fraction of the intersection between two social markers (race and education) and compared it with White women with more than 12 years of education as the baseline. FINDINGS: Of 15 810 488 birth records, 144 564 women had maternal syphilis and 79 580 had congenital syphilis. If all women had the same baseline risk as White women, 35% (95% CI 34·89-36·10) of all maternal syphilis and 41% (40·49-42·09) of all congenital syphilis would have been prevented. Compared with other ethnoracial categories, these percentages were higher among Parda/Brown women (46% [45·74-47·20] of maternal syphilis and 52% [51·09-52·93] of congenital syphilis would have been prevented) and Black women (61% [60·25-61·75] of maternal syphilis and 67% [65·87-67·60] of congenital syphilis would have been prevented). If all ethnoracial groups had the same risk as White women with more than 12 years of education, 87% of all maternal syphilis and 89% of all congenital syphilis would have been prevented. INTERPRETATION: Only through effective control of maternal syphilis among populations at higher risk (eg, Black and Parda/Brown women with lower educational levels) can WHO's global health initiative to eliminate mother-to-child transmission of syphilis be made feasible. Recognising that racism and other intersecting forms of oppression affect the lives of minoritised groups and advocating for actions through the lens of intersectionality is imperative for attaining and guaranteeing health equity. Achieving health equality needs to be addressed to achieve syphilis control. Given the scale and complexity of the problem (which is unlikely to be unique to Brazil), structural issues and social markers of oppression, such as race and education, must be considered to prevent maternal and congenital syphilis and improve maternal and child outcomes globally. FUNDING: Wellcome Trust, CNPq-Brazil. TRANSLATION: For the Portuguese translation of the abstract see Supplementary Materials section.

Estimating the real burden of gestational syphilis in Brazil, 2007-2018: a Bayesian modeling study.

Background: Although several studies have estimated gestational syphilis (GS) incidence in several countries, underreporting correction is rarely considered. This study aimed to estimate the level of under-registration and correct the GS incidence rates in the 557 Brazilian microregions. Methods: Brazilian GS notifications between 2007 and 2018 were obtained from the SINAN-Syphilis system. A cluster analysis was performed to group microregions according to the quality of GS notification. A Bayesian hierarchical Poisson regression model was applied to estimate the reporting probabilities among the clusters and to correct the associated incidence rates. Findings: We estimate that 45,196 (90%-HPD: 13,299; 79,310) GS cases were underreported in Brazil from 2007 to 2018, representing a coverage of 87.12% (90%-HPD: 79.40%; 95.83%) of registered cases, where HPD stands for the Bayesian highest posterior density credible interval. Underreporting levels differ across the country, with microregions in North and Northeast regions presenting the highest percentage of missed cases. After underreporting correction, Brazil's estimated GS incidence rate increased from 8.74 to 10.02 per 1000 live births in the same period. Interpretation: Our findings highlight disparities in the registration level and incidence rate of GS in Brazil, reflecting regional heterogeneity in the quality of syphilis surveillance, access to prenatal care, and childbirth assistance services. This study provides robust evidence to enhance national surveillance systems, guide specific policies for GS detection disease control, and potentially mitigate the harmful consequences of mother-to-child transmission. The methodology might be applied in other regions to correct disease underreporting. Funding: National Council for Scientific and Technological Development; The Bill Melinda Gates Foundation and Wellcome Trust.

The effects of social determinants of health on acquired immune deficiency syndrome in a low-income population of Brazil: a retrospective cohort study of 28.3 million individuals.

Background: Social determinants of health (SDH) include factors such as income, education, and race, that could significantly affect the human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS). Studies on the effects of SDH on HIV/AIDS are limited, and do not yet provide a systematic understanding of how the various SDH act on important indicators of HIV/AIDS progression. We aimed to evaluate the effects of SDH on AIDS morbidity and mortality. Methods: A retrospective cohort of 28.3 million individuals was evaluated over a 9-year period (from 2007 to 2015). Multivariable Poisson regression, with a hierarchical approach, was used to estimate the effects of SDH-at the individual and familial level-on AIDS incidence, mortality, and case-fatality rates. Findings: A total of 28,318,532 individuals, representing the low-income Brazilian population, were assessed, who had a mean age of 36.18 (SD: 16.96) years, 52.69% (14,920,049) were female, 57.52% (15,360,569) were pardos, 34.13% (9,113,222) were white/Asian, 7.77% (2,075,977) were black, and 0.58% (154,146) were indigenous. Specific socioeconomic, household, and geographic factors were significantly associated with AIDS-related outcomes. Less wealth was strongly associated with a higher AIDS incidence (rate ratios-RR: 1.55; 95% confidence interval-CI: 1.43-1.68) and mortality (RR: 1.99; 95% CI: 1.70-2.34). Lower educational attainment was also greatly associated with higher AIDS incidence (RR: 1.46; 95% CI: 1.26-1.68), mortality (RR: 2.76; 95% CI: 1.99-3.82) and case-fatality rates (RR: 2.30; 95% CI: 1.31-4.01). Being black was associated with a higher AIDS incidence (RR: 1.53; 95% CI: 1.45-1.61), mortality (RR: 1.69; 95% CI: 1.57-1.83) and case-fatality rates (RR: 1.16; 95% CI: 1.03-1.32). Overall, also considering the other SDH, individuals experiencing greater levels of socioeconomic deprivation were, by far, more likely to acquire AIDS, and to die from it. Interpretation: In the population studied, SDH related to poverty and social vulnerability are strongly associated with a higher burden of HIV/AIDS, most notably less wealth, illiteracy, and being black. In the absence of relevant social protection policies, the current worldwide increase in poverty and inequalities-due to the consequences of the COVID-19 pandemic, and the effects of war in the Ukraine-could reverse progress made in the fight against HIV/AIDS in low- and middle-income countries (LMIC). Funding: National Institute of Allergy and Infectious Diseases (NAIDS), National Institutes of Health (NIH), US Grant Number: 1R01AI152938.

Time trends and social inequalities in infant and young child feeding practices: national estimates from Brazil's Food and Nutrition Surveillance System, 2008-2019.

OBJECTIVE: To describe the time trends and socio-economic inequalities in infant and young child feeding practices in accordance with the Brazilian deprivation index (BDI). DESIGN: This time-series study analysed the prevalence of multiple breast-feeding and complementary feeding indicators based on data from the Brazilian Food and Nutrition Surveillance System, 2008-2019. Prais-Winsten regression models were used to analyse time trends. Annual percent change (APC) and 95 % CI were calculated. SETTING: Primary health care services, Brazil. PARTICIPANTS: Totally, 911 735 Brazilian children under 2 years old. RESULTS: Breast-feeding and complementary feeding practices differed between the extreme BDI quintiles. Overall, the results were more favourable in the municipalities with less deprivation (Q1). Improvements in some complementary feeding indicators were observed over time and evidenced such disparities: minimum dietary diversity (Q1: Δ 47·8-52·2 %, APC + 1·44, P = 0·006), minimum acceptable diet (Q1: Δ 34·5-40·5 %, APC + 5·17, P = 0·004) and consumption of meat and/or eggs (Q1: Δ 59·7-80·3 %, APC + 6·26, P < 0·001; and Q5: Δ 65·7-70·7 %, APC + 2·20, P = 0·041). Stable trends in exclusive breast-feeding and decreasing trends in the consumption of sweetened drinks and ultra-processed foods were also observed regardless the level of the deprivation. CONCLUSIONS: Improvements in some complementary food indicators were observed over time. However, the improvements were not equally distributed among the BDI quintiles, with children from the municipalities with less deprivation benefiting the most.

Mortality inequalities measured by socioeconomic indicators in Brazil: a scoping review.

OBJECTIVE: Summarize the literature on the relationship between composite socioeconomic indicators and mortality in different geographical areas of Brazil. METHODS: This scoping review included articles published between January 1, 2000, and August 31, 2020, retrieved by means of a bibliographic search carried out in the Medline, Scopus, Web of Science, and Lilacs databases. Studies reporting on the association between composite socioeconomic indicators and all-cause, or specific cause of death in any age group in different geographical areas were selected. The review summarized the measures constructed, their associations with the outcomes, and potential study limitations. RESULTS: Of the 77 full texts that met the inclusion criteria, the study reviewed 24. The area level of composite socioeconomic indicators analyzed comprised municipalities (n = 6), districts (n = 5), census tracts (n = 4), state (n = 2), country (n = 2), and other areas (n = 5). Six studies used composite socioeconomic indicators such as the Human Development Index, Gross Domestic Product, and the Gini Index; the remaining 18 papers created their own socioeconomic measures based on sociodemographic and health indicators. Socioeconomic status was inversely associated with higher rates of all-cause mortality, external cause mortality, suicide, homicide, fetal and infant mortality, respiratory and circulatory diseases, stroke, infectious and parasitic diseases, malnutrition, gastroenteritis, and oropharyngeal cancer. Higher mortality rates due to colorectal cancer, leukemia, a general group of neoplasms, traffic accident, and suicide, in turn, were observed in less deprived areas and/or those with more significant socioeconomic development. Underreporting of death and differences in mortality coverage in Brazilian areas were cited as the main limitation. CONCLUSIONS: Studies analyzed mortality inequalities in different geographical areas by means of composite socioeconomic indicators, showing that the association directions vary according to the mortality outcome. But studies on all-cause mortality and at the census tract level remain scarce. The results may guide the development of new composite socioeconomic indicators for use in mortality inequality analysis.

Differentials in death count records by databases in Brazil in 2010.

OBJECTIVE: To compare the death counts from three sources of information on mortality available in Brazil in 2010, the Mortality Information System (SIM - Sistema de Informações sobre Mortalidade ), Civil Registration Statistic System (RC - Sistema de Estatísticas de Resgistro Civil ), and the 2010 Demographic Census at various geographical levels, and to confirm the association between municipal socioeconomic characteristics and the source which showed the highest death count. METHODS: This is a descriptive and comparative study of raw data on deaths in the SIM, RC and 2010 Census databases, the latter held in Brazilian states and municipalities between August 2009 and July 2010. The percentage of municipalities was confirmed by the database showing the highest death count. The association between the source of the highest death count and socioeconomic indicators - the Índice de Privação Brasileiro (IBP - Brazilian Deprivation Index) and Índice de Desenvolvimento Humano Municipal (IHDM - Municipal Human Development Index) - was performed by bivariate choropleth and Moran Local Index of Spatial Association (LISA) cluster maps. RESULTS: Confirmed that the SIM is the database with the highest number of deaths counted for all Brazilian macroregions, except the North, in which the highest coverage was from the 2010 Census. Based on the indicators proposed, in general, the Census showed a higher coverage of deaths than the SIM and the RC in the most deprived (highest IBP values) and less developed municipalities (lowest IDHM values) in the country. CONCLUSION: The results highlight regional inequalities in how the databases chosen for this study cover death records, and the importance of maintaining the issue of mortality on the basic census questionnaire.

Ethnoracial inequalities and child mortality in Brazil: a nationwide longitudinal study of 19 million newborn babies.

BACKGROUND: Racism is a social determinant of health inequities. In Brazil, racial injustices lead to poor outcomes in maternal and child health for Black and Indigenous populations, including greater risks of pregnancy-related complications; decreased access to antenatal, delivery, and postnatal care; and higher childhood mortality rates. In this study, we aimed to estimate inequalities in childhood mortality rates by maternal race and skin colour in a cohort of more than 19 million newborns in Brazil. METHODS: We did a nationwide population-based, retrospective cohort study using linked data on all births and deaths in Brazil between Jan 1, 2012, and Dec 31, 2018. The data consisted of livebirths followed up to age 5 years, death, or Dec 31, 2018. Data for livebirths were extracted from the National Information System for livebirths, SINASC, and for deaths from the Mortality Information System, SIM. The final sample consisted of complete data for all cases regarding maternal race and skin colour, and no inconsistencies were present between date of birth and death after linkage. We fitted Cox proportional hazard regression models to calculate the crude and adjusted hazard ratios (HRs) and 95% CIs for the association between maternal race and skin colour and all-cause and cause-specific younger than age 5 mortality rates, by age subgroups. We calculated the trend of HRs (and 95% CI) by time of observation (calendar year) to indicate trends in inequalities. FINDINGS: From the 20 526 714 livebirths registered in SINASC between Jan 1, 2012, and Dec 31, 2018, 238 436 were linked to death records identified from SIM. After linkage, 1 010 871 records were excluded due to missing data on maternal race or skin colour or inconsistent date of death. 19 515 843 livebirths were classified by mother's race, of which 224 213 died. Compared with children of White mothers, mortality risk for children younger than age 5 years was higher among children of Indigenous (HR 1·98 [95% CI 1·92-2·06]), Black (HR 1·39 [1·36-1·41]), and Brown or Mixed race (HR 1·19 [1·18-1·20]) mothers. The highest hazard ratios were observed during the post-neonatal period (Indigenous, HR 2·78 [95% CI 2·64-2·95], Black, HR 1·54 [1·48-1·59]), and Brown or Mixed race, HR 1·25 [1·23-1·27]) and between the ages of 1 year and 4 years (Indigenous, HR 3·82 [95% CI 3·52-4·15]), Black, HR 1·51 [1·42-1·60], and Brown or Mixed race, HR 1·30 [1·26-1·35]). Children of Indigenous (HR 16·39 [95% CI 12·88-20·85]), Black (HR 2·34 [1·78-3·06]), and Brown or Mixed race mothers (HR 2·05 [1·71-2·45]) had a higher risk of death from malnutrition than did children of White mothers. Similar patterns were observed for death from diarrhoea (Indigenous, HR 14·28 [95% CI 12·25-16·65]; Black, HR 1·72 [1·44-2·05]; and Brown or Mixed race mothers, HR 1·78 [1·61-1·98]) and influenza and pneumonia (Indigenous, HR 6·49 [95% CI 5·78-7·27]; Black, HR 1·78 [1·62-1·96]; and Brown or Mixed race mothers, HR 1·60 [1·51-1·69]). INTERPRETATION: Substantial ethnoracial inequalities were observed in child mortality in Brazil, especially among the Indigenous and Black populations. These findings demonstrate the importance of regular racial inequality assessments and monitoring. We suggest implementing policies to promote ethnoracial equity to reduce the impact of racism on child health. FUNDING: MCTI/CNPq/MS/SCTIE/Decit/Bill & Melinda Gates Foundation's Grandes Desafios Brasil, Desenvolvimento Saudável para Todas as Crianças, and Wellcome Trust core support grant awarded to CIDACS-Center for Data and Knowledge Integration for Health.

Mortality inequalities measured by socioeconomic indicators in Brazil: a scoping review

ABSTRACT OBJECTIVE Summarize the literature on the relationship between composite socioeconomic indicators and mortality in different geographical areas of Brazil. METHODS This scoping review included articles published between January 1, 2000, and August 31, 2020, retrieved by means of a bibliographic search carried out in the Medline, Scopus, Web of Science, and Lilacs databases. Studies reporting on the association between composite socioeconomic indicators and all-cause, or specific cause of death in any age group in different geographical areas were selected. The review summarized the measures constructed, their associations with the outcomes, and potential study limitations. RESULTS Of the 77 full texts that met the inclusion criteria, the study reviewed 24. The area level of composite socioeconomic indicators analyzed comprised municipalities (n = 6), districts (n = 5), census tracts (n = 4), state (n = 2), country (n = 2), and other areas (n = 5). Six studies used composite socioeconomic indicators such as the Human Development Index, Gross Domestic Product, and the Gini Index; the remaining 18 papers created their own socioeconomic measures based on sociodemographic and health indicators. Socioeconomic status was inversely associated with higher rates of all-cause mortality, external cause mortality, suicide, homicide, fetal and infant mortality, respiratory and circulatory diseases, stroke, infectious and parasitic diseases, malnutrition, gastroenteritis, and oropharyngeal cancer. Higher mortality rates due to colorectal cancer, leukemia, a general group of neoplasms, traffic accident, and suicide, in turn, were observed in less deprived areas and/or those with more significant socioeconomic development. Underreporting of death and differences in mortality coverage in Brazilian areas were cited as the main limitation. CONCLUSIONS Studies analyzed mortality inequalities in different geographical areas by means of composite socioeconomic indicators, showing that the association directions vary according to the mortality outcome. But studies on all-cause mortality and at the census tract level remain scarce. The results may guide the development of new composite socioeconomic indicators for use in mortality inequality analysis.

Differentials in death count records by databases in Brazil in 2010

ABSTRACT OBJECTIVE To compare the death counts from three sources of information on mortality available in Brazil in 2010, the Mortality Information System (SIM - Sistema de Informações sobre Mortalidade ), Civil Registration Statistic System (RC - Sistema de Estatísticas de Resgistro Civil ), and the 2010 Demographic Census at various geographical levels, and to confirm the association between municipal socioeconomic characteristics and the source which showed the highest death count. METHODS This is a descriptive and comparative study of raw data on deaths in the SIM, RC and 2010 Census databases, the latter held in Brazilian states and municipalities between August 2009 and July 2010. The percentage of municipalities was confirmed by the database showing the highest death count. The association between the source of the highest death count and socioeconomic indicators - the Índice de Privação Brasileiro (IBP - Brazilian Deprivation Index) and Índice de Desenvolvimento Humano Municipal (IHDM - Municipal Human Development Index) - was performed by bivariate choropleth and Moran Local Index of Spatial Association (LISA) cluster maps. RESULTS Confirmed that the SIM is the database with the highest number of deaths counted for all Brazilian macroregions, except the North, in which the highest coverage was from the 2010 Census. Based on the indicators proposed, in general, the Census showed a higher coverage of deaths than the SIM and the RC in the most deprived (highest IBP values) and less developed municipalities (lowest IDHM values) in the country. CONCLUSION The results highlight regional inequalities in how the databases chosen for this study cover death records, and the importance of maintaining the issue of mortality on the basic census questionnaire.

Time trends and social inequalities in child malnutrition: nationwide estimates from Brazil's food and nutrition surveillance system, 2009-2017.

OBJECTIVE: In Brazil, national estimates of childhood malnutrition have not been updated since 2006. The use of health information systems is an important complementary data source for analysing time trends on health and nutrition. This study aimed to examine temporal trends and socio-demographic inequalities in the prevalence of malnutrition in children attending primary health care services between 2009 and 2017. DESIGN: Time trends study based on data from Brazil's Food and Nutrition Surveillance System. Malnutrition prevalence (stunting, wasting, overweight and double burden) was annually estimated by socio-demographic variables. Prais-Winsten regression models were used to analyse time trends. Annual percent change (APC) and 95 % CI were calculated. SETTING: Primary health care services, Brazil. PARTICIPANTS: Children under 5 years old. RESULTS: In total, 15,239,753 children were included. An increase in the prevalence of overweight (APC = 3·4 %; P = 0·015) and a decline in the prevalence of wasting (-6·2 %; P = 0·002) were observed. The prevalence of stunting (-3·2 %, P = 0·359) and double burden (-1·4 %, P = 0·630) had discrete and non-significant reductions. Despite the significant reduction in the prevalence of undernutrition among children in the most vulnerable subgroups (black, conditional cash transfer's recipients and residents of poorest and less developed areas), high prevalence of stunting and wasting persist alongside a disproportionate increase in the prevalence of overweight in these groups. CONCLUSIONS: The observed pattern in stunting (high and persistent prevalence) and increase in overweight elucidate setbacks in advances already observed in previous periods and stresses the need for social and political strategies to address multiple forms of malnutrition.

Conditional cash transfer program and child mortality: A cross-sectional analysis nested within the 100 Million Brazilian Cohort.

BACKGROUND: Brazil has made great progress in reducing child mortality over the past decades, and a parcel of this achievement has been credited to the Bolsa Família program (BFP). We examined the association between being a BFP beneficiary and child mortality (1-4 years of age), also examining how this association differs by maternal race/skin color, gestational age at birth (term versus preterm), municipality income level, and index of quality of BFP management. METHODS AND FINDINGS: This is a cross-sectional analysis nested within the 100 Million Brazilian Cohort, a population-based cohort primarily built from Brazil's Unified Registry for Social Programs (Cadastro Único). We analyzed data from 6,309,366 children under 5 years of age whose families enrolled between 2006 and 2015. Through deterministic linkage with the BFP payroll datasets, and similarity linkage with the Brazilian Mortality Information System, 4,858,253 children were identified as beneficiaries (77%) and 1,451,113 (23%) were not. Our analysis consisted of a combination of kernel matching and weighted logistic regressions. After kernel matching, 5,308,989 (84.1%) children were included in the final weighted logistic analysis, with 4,107,920 (77.4%) of those being beneficiaries and 1,201,069 (22.6%) not, with a total of 14,897 linked deaths. Overall, BFP participation was associated with a reduction in child mortality (weighted odds ratio [OR] = 0.83; 95% CI: 0.79 to 0.88; p < 0.001). This association was stronger for preterm children (weighted OR = 0.78; 95% CI: 0.68 to 0.90; p < 0.001), children of Black mothers (weighted OR = 0.74; 95% CI: 0.57 to 0.97; p < 0.001), children living in municipalities in the lowest income quintile (first quintile of municipal income: weighted OR = 0.72; 95% CI: 0.62 to 0.82; p < 0.001), and municipalities with better index of BFP management (5th quintile of the Decentralized Management Index: weighted OR = 0.76; 95% CI: 0.66 to 0.88; p < 0.001). The main limitation of our methodology is that our propensity score approach does not account for possible unmeasured confounders. Furthermore, sensitivity analysis showed that loss of nameless death records before linkage may have resulted in overestimation of the associations between BFP participation and mortality, with loss of statistical significance in municipalities with greater losses of data and change in the direction of the association in municipalities with no losses. CONCLUSIONS: In this study, we observed a significant association between BFP participation and child mortality in children aged 1-4 years and found that this association was stronger for children living in municipalities in the lowest quintile of wealth, in municipalities with better index of program management, and also in preterm children and children of Black mothers. These findings reinforce the evidence that programs like BFP, already proven effective in poverty reduction, have a great potential to improve child health and survival. Subgroup analysis revealed heterogeneous results, useful for policy improvement and better targeting of BFP.

Using the Robson classification to assess caesarean section rates in Brazil: an observational study of more than 24 million births from 2011 to 2017.

BACKGROUND: Applying the Robson classification to all births in Brazil, the objectives of our study were to estimate the rates of caesarean section delivery, assess the extent to which caesarean sections were clinically indicated, and identify variation across socioeconomic groups. METHODS: We conducted a population-based study using routine records of the Live Births Information System in Brazil from January 1, 2011, to December 31, 2017. We calculated the relative size of each Robson group; the caesarean section rate; and the contribution to the overall caesarean section rate. We categorised Brazilian municipalities using the Human Development Index to explore caesarean section rates further. We estimated the time trend in caesarean section rates. RESULTS: The rate of caesarean sections was higher in older and more educated women. Prelabour caesarean sections accounted for more than 54 % of all caesarean deliveries. Women with a previous caesarean section (Group 5) made up the largest group (21.7 %). Groups 6-9, for whom caesarean sections would be indicated in most cases, all had caesarean section rates above 82 %, as did Group 5. The caesarean section rates were higher in municipalities with a higher HDI. The general Brazilian caesarean section rate remained stable during the study period. CONCLUSIONS: Brazil is a country with one of the world's highest caesarean section rates. This nationwide population-based study provides the evidence needed to inform efforts to improve the provision of clinically indicated caesarean sections. Our results showed that caesarean section rates were lower among lower socioeconomic groups even when clinically indicated, suggesting sub-optimal access to surgical care.

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

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

The need for fast-track, high-quality and low-cost studies about the role of the BCG vaccine in the fight against COVID-19.

Bacillus Calmette-Guérin (BCG) vaccination is routine and near-universal in many low- and middle-income countries (LMIC). It has been suggested that BCG can have a protective effect on COVID-19 morbidity and mortality. This commentary discusses the limitations of the evidence around BCG and COVID-19. We argue that higher-quality evidence is necessary to understand the protective effect of the BCG vaccine from existing, secondary data, while we await results from clinical trials currently conducted in different settings.

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

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

Public Involvement & Engagement in health inequalities research on COVID-19 pandemic: a case study of CIDACS/FIOCRUZ BAHIA.

Introduction: Health inequalities in Brazil have deepened on Covid-19 pandemic, and the most vulnerable people were the more affected. A multidisciplinary team from Cidacs/Fiocruz Bahia developed a Social Disparities Index for Covid-19 (IDS-COVID-19) to support the evaluation of effects of health inequalities on the pandemic in Brazil. Public Involvement and Engagement were the pillars of this research because they allowed us to access first hand experiences about the social context in our country. Objectives: This paper aims to describe our Public Involvement and Engagement experience by analysing our challenges, strategies, activities, results, and lessons learned during the construction of IDS-COVID-19. Methods: The basis of the IDS-Covid-19 public engagement model was the participation of different social groups through methods and techniques that allow dialogue. Several activities and communication products supported the continuous interactions. Another guideline was the inclusion and the welcoming of participants from the beginning of the project to ensure that the participant's contributions could drive decision-making about the research. Results: Participants made several contributions to the research as a new layer of information to the Index, and improvements were made to the interactive panel. They also compromised to support the dissemination and use of the product. Eight representatives of community groups and 29 policymakers participated in our engagement activities during the project. More than 500 people were in our open webinars. In addition, more than 140 news items about IDS-Covid-19 were published in national and international media. Conclusions: We highlight as lessons learned the adaptation of some dissemination formats to the public, and the necessity of being flexible and accessible to participants. We strengthened the relationship with relevant stakeholders by exploring individual conversations by phone, WhatsApp, email, and interviews to produce a documentary that registered this whole experience. Cidacs/Fiocruz Bahia has also embedded public engagement and involvement in the study agenda.

Administrative Data Linkage in Brazil: Potentials for Health Technology Assessment.

Health technology assessment (HTA) is the systematic evaluation of the properties and impacts of health technologies and interventions. In this article, we presented a discussion of HTA and its evolution in Brazil, as well as a description of secondary data sources available in Brazil with potential applications to generate evidence for HTA and policy decisions. Furthermore, we highlighted record linkage, ongoing record linkage initiatives in Brazil, and the main linkage tools developed and/or used in Brazilian data. Finally, we discussed the challenges and opportunities of using secondary data for research in the Brazilian context. In conclusion, we emphasized the availability of high quality data and an open, modern attitude toward the use of data for research and policy. This is supported by a rigorous but enabling legal framework that will allow the conduct of large-scale observational studies to evaluate clinical, economical, and social impacts of health technologies and social policies.

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

BACKGROUND: Although leprosy is largely curable with multidrug therapy, incomplete treatment limits therapeutic effectiveness and is an important obstacle to disease control. To inform efforts to improve treatment completion rates, we aimed to identify the geographic and socioeconomic factors associated with leprosy treatment default in Brazil. METHODOLOGY/PRINCIPAL FINDINGS: Using individual participant data collected in the Brazilian national registries for social programs and notifiable diseases and linked as part of the 100 Million Brazilian Cohort, we evaluated the odds of treatment default among 20,063 leprosy cases diagnosed and followed up between 2007 and 2014. We investigated geographic and socioeconomic risk factors using a multivariate hierarchical analysis and carried out additional stratified analyses by leprosy subtype and geographic region. Over the duration of follow-up, 1,011 (5.0%) leprosy cases were observed to default from treatment. Treatment default was markedly increased among leprosy cases residing in the North (OR = 1.57; 95%CI 1.25-1.97) and Northeast (OR = 1.44; 95%CI 1.17-1.78) regions of Brazil. The odds of default were also higher among cases with black ethnicity (OR = 1.29; 95%CI 1.01-1.69), no income (OR = 1.41; 95%CI 1.07-1.86), familial income ≤ 0.25 times Brazilian minimum wage (OR = 1.42; 95%CI 1.13-1.77), informal home lighting/no electricity supply (OR = 1.53; 95%CI 1.28-1.82), and household density of > 1 individual per room (OR = 1.35; 95%CI 1.10-1.66). CONCLUSIONS: The findings of the study indicate that the frequency of leprosy treatment default varies regionally in Brazil and provide new evidence that adverse socioeconomic conditions may represent important barriers to leprosy treatment completion. These findings suggest that interventions to address socioeconomic deprivation, along with continued efforts to improve access to care, have the potential to improve leprosy treatment outcomes and disease control.

Area deprivation measures used in Brazil: a scoping review.

OBJECTIVE: To describe and assess currently used area-based measures of deprivation in Brazil for health research, to the purpose of informing the development of a future small area deprivation index. METHODS: We searched five electronic databases and seven websites of Brazilian research institutions and governmental agencies. Inclusion criteria were: studies proposing measures of deprivation for small areas (i.e., finer geography than country-level) in Brazil, published in English, Portuguese or Spanish. After data-extraction, results were tabulated according to the area level the deprivation measure was created for and to the dimensions of deprivation or poverty included in the measures. A narrative synthesis approach was used to summarize the measures available, highlighting their utility for public health research. RESULTS: A total of 7,199 records were retrieved, 126 full-text articles were assessed after inclusion criteria and a final list of 30 articles was selected. No small-area deprivation measures that have been applied to the whole of Brazil were found. Existing measures were mainly used to study infectious and parasitic diseases. Few studies used the measures to assess inequalities in mortality and no studies used the deprivation measure to evaluate the impact of social programs. CONCLUSIONS: No up-to-date small area-based deprivation measure in Brazil covers the whole country. There is a need to develop such an index for Brazil to measure and monitor inequalities in health and mortality, particularly to assess progress in Brazil against the Sustainable Development Goal targets for different health outcomes, showing progress by socioeconomic groups.