Use of insect repellent as personal protection among women of childbearing age in an arbovirus endemic area in Northeastern Brazil.

OBJECTIVE: To analyze the factors associated with the individual use of insect repellent by women of childbearing age living in area endemic for arboviruses in Fortaleza, Brazil. METHODS: This is a cohort study carried out between 2018 and 2019 with women aged between 15 and 39 years in Fortaleza, state of Ceará, Brazil. A total of 1,173 women users of one of the four selected primary health care units participated in the study. The outcome was divided into: continued use, discontinued use, and nonuse of insect repellent. Crude and adjusted multinominal logistic regression analysis was carried out guided by a hierarchical model, with presentation of the respective odds ratio (OR) and 95% confidence intervals (95%CI). The independent variables include: socioeconomic and demographic data, environmental and sanitary characteristics, knowledge of the insect repellent, and behavioral and pregnancy-related aspects. RESULTS: Only 28% of the participants reported using insect repellent during the two waves of the cohort. Women with higher education (OR=2.55; 95%CI 1.44-4.51); who are employed (OR=1.51; 95%CI 1.12-2.03); who received guidance from healthcare professionals (OR=1.74; 95%CI 1.28-2.36) and the media (OR=1.43; 95%CI 1.01-2.02); who intensified precautions against mosquitoes during the epidemic (OR=3.64; 95%CI 2.29-5.78); and who were pregnant between 2016 and 2019 (OR=2.80; 95%CI 1.83-4.30) had increased odds for continued use of insect repellent. CONCLUSION: The use of insect repellent among women of childbearing age was associated with a higher level of education, employment, guidance on insect repellent provided by healthcare professionals and the media, behavioral changes to protect against mosquitoes during the Zika virus epidemic, and pregnancy when occurring as of the beginning of the epidemic period.

Positivity of dengue, chikungunya, and Zika infections in women in Northeast Brazil post-Zika epidemic.

The state of Ceará, in the Northeast Region of Brazil, presents the simultaneous circulation of Zika (ZIKV), dengue (DENV) and chikungunya (CHIKV) viruses. In 2017 there were a high number of cases of these three arboviruses, especially CHIKV. Here, we detected the presence of arboviruses ZIKV, DENV and CHIKV and their coinfections in women in endemic regions of the city of Fortaleza, Ceará in a post-Zika epidemic year. Sociodemographic and environmental characteristics associated with arbovirus positivity were also analyzed. Women (n = 1289) between 15 and 39 years old were included. RT-qPCR was performed for virus detection and IgM antibody positivity was also analyzed. One hundred and six (8.3%) participants were positive for one or more arboviruses. Monoinfections (76; 5.9%) were distributed between 22 (1.7%) for ZIKV, 39 (3.1%) for DENV and 15 (1.2%) for CHIKV. Co-infections were detected in 30 (2.3%) of the positive participants and one case with triple infection was found. IgM positivity was found in 2.4% of ZIKV RT-qPCR, 9.6% of DENV and 16.3% of CHIKV. RT-qPCR positivity for arboviruses was associated with low socioeconomic class and presence of a water box sealing in the household. A higher positivity to the three viruses occurred in the month with the lowest wind velocity, which was also preceded by the highest peak of rain and humidity. We identified the simultaneous circulation and co-infection of ZIKV, DENV and CHIKV in Fortaleza in a post-Zika epidemic year. We also highlight the need for continuous epidemiological surveillance combined with molecular diagnostic tools.

Epidemiological Aspects and High Magnitude of Human Visceral Leishmaniasis in Ceará, Northeast of Brazil, 2007-2021.

BACKGROUND: Human visceral leishmaniasis HVL is endemic to 75 countries. The state of Ceará, the Northeast region of Brazil, is of great sanitary importance for the transmission of HVL, and it stands out as an area of interest for epidemiological aspects and control strategies. This study aimed to characterize HVL in relation to epidemiological aspects, composite incidence, and mortality rates in the state of Ceará, Brazil, from 2007 to 2021. METHODS: This ecological study used temporal and spatial cuts of HVL data from the notifiable diseases information system. Epidemiological indicators such as incidence, mortality, and composite indices of incidence and mortality were calculated according to the Ministry of Health standardization. RESULTS: There were 6,775 confirmed cases, with high incidence coefficients in 2009 6.96 cases/100,000 inhabitants and 2011 9.83 cases/100,000 inhabitants, and the highest mortality rate in 2011 6.96 deaths/100,000 inhabitants. The composite index of incidence and mortality identified municipalities in the Northern, Northwestern, and Southern regions of Ceará as having the highest risk of HVL. CONCLUSIONS: HVL remained endemic throughout the study period, with epidemiological indicators and risk of transmission expressing high magnitude, mainly in the Northeast, Northwest, and South regions of Ceará.

Epidemiological and clinical factors associated with lethality from Human Visceral Leishmaniasis in Northeastern Brazil, 2007 to 2018.

Human Visceral Leishmaniasis (HVL) presents a subacute clinical evolution with systemic involvement, which can result in high case fatality, especially among untreated individuals or those with low socioeconomic status. This study aimed to identify epidemiological and clinical factors associated with HVL case fatality in the Ceara State, from 2007 to 2018. This is an analytical cross-sectional study. The bivariate analysis was performed by Stata 15.1 using Pearson's Chi-square or Fisher's exact test; and Poisson regression for age-controlled multivariate analysis. From 2007 to 2018, there were 4,863 new confirmed cases and 343 deaths from HVL (case fatality rate=7.05%). The risk factors associated with case fatalities were: age group (RR=8.69; 95%CI:3.56-21.20); black population (RR=2.21; 95%CI:1.45-3.35); jaundice symptoms (RR=1.72; 95%CI:1.38-2.14); edema (RR=2.62; 95%CI:2.10-3.26) and hemorrhagic phenomena (RR=1.63; 95%CI:1.26-2.10); and no prescription drug intake (RR=4.03; 95%CI:2.98-5.46). Treatment with pentavalent antimonial was a protective factor (RR=0.35; 95%CI:0.27-0.45). The number of deaths increased among the elderly, illiterate, urban residents, and black skin color individuals. The drugs pentavalent antimonial and amphotericin B showed an association with death, but were not considered causal factors. Treatment failure led to a high risk of death. In multivariate analysis, the risk factors for fatal cases were age group, black skin, symptoms of jaundice, edema and hemorrhagic phenomena; and failure to take the prescription drugs. Treatment with pentavalent antimonial was shown to be a protective factor. Knowing the factors associated with the fatality of VL-HIV cases may help to improve public policies, in order to refine the epidemiological surveillance program and, consequently, prevent deaths related to the disease in Ceara.

Dengue in northeastern Brazil: a spatial and temporal perspective.

INTRODUCTION: The state of Ceará (Brazilian Northeast) has a high incidence of dengue. Therefore, we aimed to characterize the temporal patterns and spatial distribution of dengue cases in Ceará during 2001-2019. METHODS: A spatiotemporal ecological study was performed with secondary data. Time-trend analysis was performed using a segmented log-linear regression model to estimate the average annual percentage change (AAPC) and the annual percentage change (APC) in incidence of dengue. We also performed spatiotemporal analysis to identify the place, time, and relative risk (RR) of dengue clusters. RESULTS: There were 539,653 dengue cases. The AAPC reduced over time (-9.5%; 95% confidance interval [CI]: -18.3; -0.3). Three trends were identified-2001-2004: APC=-20.9% (95% CI: -65.1 to 44.8), 2005-2015: APC=7.9% (95% CI: -6.0 to 98.9), and 2016-2019: APC=-48.8% (95% CI: -83.0 to -6.1). During 2001-2007, 10 significant clusters were identified (RR=3.57-14.38: n=4 and RR=0.05-0.39: n=6). During 2008-2013, there was 1 cluster in the western region (RR= 3.40) and four other clusters (RR=0.02-0.15). The last period presented 5 high-RR clusters (RR=2.95-9.24). The low-RR clusters were located in the central-north, central-south, south, and northwest regions. However, the central-west region remained a high-RR cluster region throughout the study period. CONCLUSIONS: Dengue showed a decreasing incidence. During the epidemic years, the southern, eastern, and western regions presented high-risk clusters. Introduction of a new dengue serotype in a low-RR area can cause explosive outbreaks due to population susceptibility.

Human visceral leishmaniasis: epidemiological, temporal and spacial aspects in Northeast Brazil, 2003-2017.

Visceral leishmaniasis is a highly lethal zoonosis transmitted by a sandfly. It is caused by a Leishmania protozoan parasite and dogs are the main reservoir. Ceara State is endemic to visceral leishmaniasis and it is considered a high risk transmission area. Temporal and spatial epidemiological studies have been used as tools to analyze the distribution and frequency of human visceral leishmaniasis (HVL). This study aimed to characterize HVL in its epidemiological andtemporal aspects in Ceara State, from 2003 to 2017, as this is a neglected disease and a public health problem. This is an ecological study carried out with HVL confirmed cases in Ceara, using three blocks of years (2003 to 2007, 2008 to 2012 and 2013 to 2017). The disease presented an endemic behavior, affecting mainly male residents in the urban area, especially children under five and young adults between 30 and 49 years old. HVL is recorded in all the municipalities, for more than 10 years, with a growing trend and territorial expansion to the Central and Eastern regions of the State. The results of this study indicated the increase in the incidence and lethality, as well as the expansion of leishmaniasis in Ceara State.

Increased detection of rabies virus in bats in Ceará State (Northeast Brazil) after implementation of a passive surveillance programme.

The intensification of dog, cat and livestock vaccination campaigns significantly reduced rabies cases in humans and domestic animals in Ceará State, Brazil. However, sylvatic animals-bats (order Chiroptera), wild canids, raccoons and non-human primates- remain as reservoirs for the virus. Our hypothesis is that surveillance and monitoring of rabies virus in bats, especially passive surveillance, is of fundamental importance, besides the implementation of health education and strengthening of surveillance actions in humans exposed to aggressions. Thus, we assessed the occurrence of rabies virus in animals focusing on bats, before and after launching of the Sylvatic Rabies Surveillance Program in 2010. Surveillance data from the 184 municipalities of Ceará State were analysed, collected during the periods 2003-2010 (active surveillance) and 2011-2016 (passive surveillance), respectively. A total of 13,543 mammalian samples were received for rabies diagnosis from 2003 to 2016. Of these, 10,960 were from dogs or cats (80.9%), 1,180 from bats (8.7%), 806 from other sylvatic animals (foxes, marmosets, raccoons; 6.0%) and 597 from herbivores (cattle, goats, sheep, equines, pigs; 4.4%). A total of 588 (4.3%) samples were positive for rabies. About 8.4% (99/1,180) of the bat samples were infected with rabies virus, 92 (92.9%) of these were from non-haematophagous bat species and 7 (7.1%) from haematophagous species. The number of bat samples received and infection rates increased considerably, after a shift from active surveillance (9/355 [2.5%] samples positive), to passive surveillance (90/825 [10.9%] samples positive). Surveillance of rabies virus in bats is fundamental for human and domestic animal health in Ceará State. Bats have to be considered as targets in surveillance and control programmes. Virus lineages should be characterized to increase knowledge on transmission dynamics of sylvatic rabies virus to domestic animals and the human population, and to provide additional evidence for planning and implementation of improved control measures.

Post-exposure human rabies prophylaxis: spatial patterns of inadequate procedures in Ceará - Brazil, 2007 to 2015.

INTRODUCTION: This study investigated the spatial distribution of inappropriate post-exposure human rabies procedures in Ceará, Brazil, between 2007 and 2015. METHODS: The ecological study population was based on the records of post-exposure human rabies procedures from the Notification Disease Information System. We analyzed the data using the Moran Index (I) and the Moran Local Index. RESULTS: There were 222,036 (95.8%) records with inappropriate post-exposure human rabies procedures. There was heterogeneity in their spatial distribution, with two significant clusters in the northeast and northwest regions. CONCLUSIONS: These findings help elaborate differentiated strategies to reduce unnecessary post-exposure human rabies procedures.

Use of insect repellent as personal protection among women of childbearing age in an arbovirus endemic area in Northeastern Brazil / Uso de repelente como medida de proteção pessoal por mulheres em idade fértil residentes em áreas endêmicas para arboviroses no Nordeste do Brasil

ABSTRACT Objective: To analyze the factors associated with the individual use of insect repellent by women of childbearing age living in area endemic for arboviruses in Fortaleza, Brazil. Methods: This is a cohort study carried out between 2018 and 2019 with women aged between 15 and 39 years in Fortaleza, state of Ceará, Brazil. A total of 1,173 women users of one of the four selected primary health care units participated in the study. The outcome was divided into: continued use, discontinued use, and nonuse of insect repellent. Crude and adjusted multinominal logistic regression analysis was carried out guided by a hierarchical model, with presentation of the respective odds ratio (OR) and 95% confidence intervals (95%CI). The independent variables include: socioeconomic and demographic data, environmental and sanitary characteristics, knowledge of the insect repellent, and behavioral and pregnancy-related aspects. Results: Only 28% of the participants reported using insect repellent during the two waves of the cohort. Women with higher education (OR=2.55; 95%CI 1.44-4.51); who are employed (OR=1.51; 95%CI 1.12-2.03); who received guidance from healthcare professionals (OR=1.74; 95%CI 1.28-2.36) and the media (OR=1.43; 95%CI 1.01-2.02); who intensified precautions against mosquitoes during the epidemic (OR=3.64; 95%CI 2.29-5.78); and who were pregnant between 2016 and 2019 (OR=2.80; 95%CI 1.83-4.30) had increased odds for continued use of insect repellent. Conclusion: The use of insect repellent among women of childbearing age was associated with a higher level of education, employment, guidance on insect repellent provided by healthcare professionals and the media, behavioral changes to protect against mosquitoes during the Zika virus epidemic, and pregnancy when occurring as of the beginning of the epidemic period.

RESUMO Objetivo: Analisar os fatores associados ao uso de repelente individual por mulheres em idade fértil residentes em área endêmicas para arboviroses em Fortaleza, Brasil. Métodos: Coorte realizada entre 2018 e 2019, com mulheres entre 15 e 39 anos, moradoras em Fortaleza, Ceará, Brasil. Participaram 1.173 mulheres, usuárias de quatro unidades primárias de saúde do município. O desfecho foi categorizado em: uso continuado, uso descontinuado e não uso de repelente. Realizada análise de regressão logística multinominal norteada por modelo hierárquico, com apresentação dos respectivos odds ratio (OR) e intervalos de confiança de 95% (IC95%). As variáveis independentes incluem: dados socioeconômicos e demográficos, características ambientais e sanitárias, conhecimento sobre o repelente e aspectos comportamentais e relacionados à gravidez. Resultados: Somente 28% das participantes referiram o uso de repelente durante as duas ondas da coorte. Mulheres com escolaridade superior (OR=2,55; IC95% 1,44-4,51); com emprego (OR=1,51; IC95% 1,12-2,03); que receberam orientações por profissionais da saúde (OR=1,74; IC95% 1,28-2,36) e pela mídia (OR=1,43; IC95% 1,01-2,02); que intensificaram os cuidados contra o mosquito na epidemia (OR=3,64; IC95% 2,29-5,78); estavam grávidas entre 2016 e 2019 (OR=2,80; IC95% 1,83-4,30) tiveram as chances aumentadas para uso continuado de repelente. Conclusões: O uso de repelente entre mulheres em idade fértil mostrou-se associado a um maior nível de escolaridade, ao emprego, às orientações sobre repelente fornecidas por profissionais de saúde e pela mídia, às mudanças comportamentais de cuidado contra o mosquito durante a epidemia da Zika e à gravidez quando ocorrida a partir do início do período epidêmico.

Epidemiological and clinical factors associated with lethality from Human Visceral Leishmaniasis in Northeastern Brazil, 2007 to 2018

ABSTRACT Human Visceral Leishmaniasis (HVL) presents a subacute clinical evolution with systemic involvement, which can result in high case fatality, especially among untreated individuals or those with low socioeconomic status. This study aimed to identify epidemiological and clinical factors associated with HVL case fatality in the Ceara State, from 2007 to 2018. This is an analytical cross-sectional study. The bivariate analysis was performed by Stata 15.1 using Pearson's Chi-square or Fisher's exact test; and Poisson regression for age-controlled multivariate analysis. From 2007 to 2018, there were 4,863 new confirmed cases and 343 deaths from HVL (case fatality rate=7.05%). The risk factors associated with case fatalities were: age group (RR=8.69; 95%CI:3.56-21.20); black population (RR=2.21; 95%CI:1.45-3.35); jaundice symptoms (RR=1.72; 95%CI:1.38-2.14); edema (RR=2.62; 95%CI:2.10-3.26) and hemorrhagic phenomena (RR=1.63; 95%CI:1.26-2.10); and no prescription drug intake (RR=4.03; 95%CI:2.98-5.46). Treatment with pentavalent antimonial was a protective factor (RR=0.35; 95%CI:0.27-0.45). The number of deaths increased among the elderly, illiterate, urban residents, and black skin color individuals. The drugs pentavalent antimonial and amphotericin B showed an association with death, but were not considered causal factors. Treatment failure led to a high risk of death. In multivariate analysis, the risk factors for fatal cases were age group, black skin, symptoms of jaundice, edema and hemorrhagic phenomena; and failure to take the prescription drugs. Treatment with pentavalent antimonial was shown to be a protective factor. Knowing the factors associated with the fatality of VL-HIV cases may help to improve public policies, in order to refine the epidemiological surveillance program and, consequently, prevent deaths related to the disease in Ceara.

Epidemiological Aspects and High Magnitude of Human Visceral Leishmaniasis in Ceará, Northeast of Brazil, 2007-2021

ABSTRACT Background: Human visceral leishmaniasis HVL is endemic to 75 countries. The state of Ceará, the Northeast region of Brazil, is of great sanitary importance for the transmission of HVL, and it stands out as an area of interest for epidemiological aspects and control strategies. This study aimed to characterize HVL in relation to epidemiological aspects, composite incidence, and mortality rates in the state of Ceará, Brazil, from 2007 to 2021. Methods: This ecological study used temporal and spatial cuts of HVL data from the notifiable diseases information system. Epidemiological indicators such as incidence, mortality, and composite indices of incidence and mortality were calculated according to the Ministry of Health standardization. Results: There were 6,775 confirmed cases, with high incidence coefficients in 2009 6.96 cases/100,000 inhabitants and 2011 9.83 cases/100,000 inhabitants, and the highest mortality rate in 2011 6.96 deaths/100,000 inhabitants. The composite index of incidence and mortality identified municipalities in the Northern, Northwestern, and Southern regions of Ceará as having the highest risk of HVL. Conclusions: HVL remained endemic throughout the study period, with epidemiological indicators and risk of transmission expressing high magnitude, mainly in the Northeast, Northwest, and South regions of Ceará.

Spatial distribution of disseminated histoplasmosis and AIDS co-infection in an endemic area of Northeastern Brazil.

INTRODUCTION: The spatial distribution of disseminated histoplasmosis (DH) and acquired immunodeficiency syndrome (AIDS) co-infection in adult residents of Fortaleza, Ceará, Brazil was evaluated. METHODS: Socio-demographic data for the DH/AIDS cases were obtained from a reference hospital, and socio-environmental indicators were obtained from an official Brazilian institute. Kernel analysis and local indicators of spatial autocorrelation (LISA) cluster maps were used to estimate the case density within the city. RESULTS: DH/AIDS cases were concentrated in the Northwestern and Southwestern peripheral areas of the city, related with low human development indices, but different from AIDS cases distribution. CONCLUSION: Risk factors other than AIDS infection must affect histoplasmosis development in this area.

Dengue in northeastern Brazil: a spatial and temporal perspective

Abstract INTRODUCTION: The state of Ceará (Brazilian Northeast) has a high incidence of dengue. Therefore, we aimed to characterize the temporal patterns and spatial distribution of dengue cases in Ceará during 2001-2019. METHODS: A spatiotemporal ecological study was performed with secondary data. Time-trend analysis was performed using a segmented log-linear regression model to estimate the average annual percentage change (AAPC) and the annual percentage change (APC) in incidence of dengue. We also performed spatiotemporal analysis to identify the place, time, and relative risk (RR) of dengue clusters. RESULTS: There were 539,653 dengue cases. The AAPC reduced over time (-9.5%; 95% confidance interval [CI]: -18.3; -0.3). Three trends were identified-2001-2004: APC=-20.9% (95% CI: -65.1 to 44.8), 2005-2015: APC=7.9% (95% CI: -6.0 to 98.9), and 2016-2019: APC=-48.8% (95% CI: -83.0 to -6.1). During 2001-2007, 10 significant clusters were identified (RR=3.57-14.38: n=4 and RR=0.05-0.39: n=6). During 2008-2013, there was 1 cluster in the western region (RR= 3.40) and four other clusters (RR=0.02-0.15). The last period presented 5 high-RR clusters (RR=2.95-9.24). The low-RR clusters were located in the central-north, central-south, south, and northwest regions. However, the central-west region remained a high-RR cluster region throughout the study period. CONCLUSIONS: Dengue showed a decreasing incidence. During the epidemic years, the southern, eastern, and western regions presented high-risk clusters. Introduction of a new dengue serotype in a low-RR area can cause explosive outbreaks due to population susceptibility.

Post-exposure human rabies prophylaxis: spatial patterns of inadequate procedures in Ceará - Brazil, 2007 to 2015

Abstract INTRODUCTION: This study investigated the spatial distribution of inappropriate post-exposure human rabies procedures in Ceará, Brazil, between 2007 and 2015. METHODS: The ecological study population was based on the records of post-exposure human rabies procedures from the Notification Disease Information System. We analyzed the data using the Moran Index (I) and the Moran Local Index. RESULTS: There were 222,036 (95.8%) records with inappropriate post-exposure human rabies procedures. There was heterogeneity in their spatial distribution, with two significant clusters in the northeast and northwest regions. CONCLUSIONS: These findings help elaborate differentiated strategies to reduce unnecessary post-exposure human rabies procedures.