Uncovering the impact of COVID-19 on the place of death of cancer patients in South America.

The COVID-19 pandemic has significantly impacted healthcare systems worldwide, especially on the management of chronic diseases such as cancer. This study explores the effects of COVID-19 on cancer mortality trends in Brazil, Chile, and Peru. The monthly age-standardized mortality rates in different places of death (hospital/clinic or home) were estimated using vital statistics and death certificate databases. An interrupted time series analysis was performed for each country, using the date of lockdown implementation as the intervention point. Overall cancer mortality rates reduced after the implementation of pandemic restrictions, with a significant decrease in Brazil. In total, 75.3%, 55.4%, and 45.7% of deaths in Brazil, Peru, and Chile, respectively, occurred in hospitals. After lockdowns were implemented, at-home deaths increased in all countries, and in-hospital deaths correspondingly decreased only in Chile. Our results suggest that COVID-19 has significantly affected rates of cancer mortality and place of death in Latin America.

Reevaluating the protective effect of smoking on preeclampsia risk through the lens of bias.

Preeclampsia is a hypertensive disorder that is usually diagnosed after 20 weeks' gestation. Despite the deleterious effect of smoking on cardiovascular disease, it has been frequently reported that smoking has a protective effect on preeclampsia risk and biological explanations have been proposed. However, in this manuscript, we present multiple sources of bias that could explain this association. First, key concepts in epidemiology are reviewed: confounder, collider, and mediator. Then, we describe how eligibility criteria, losses of women potentially at risk, misclassification, or performing incorrect adjustments can create bias. We provide examples to show that strategies to control for confounders may fail when they are applied to variables that are not confounders. Finally, we outline potential approaches to manage this controversial effect. We conclude that there is probably no single epidemiological explanation for this counterintuitive association.

Structural determinants explain caries differences among preschool children in Chile's Metropolitan Region.

OBJECTIVE: To estimate the association between Social Determinants of Health (structural and intermediate) and caries indicators in Chile's Metropolitan Region preschool children. METHODS: A multilevel cross-sectional study of Social Determinants of Health (SDH) and caries in children aged 1 to 6 years in Chile's Metropolitan Region was conducted in 2014-2015, with three levels: district, school and child. Caries were assessed by the dmft-index and the prevalence of untreated caries. The structural determinants analyzed were Community Human Development Index (CHDI), urban/rural location, school type, caregiver's education and family income. Poisson multilevel regression models were fit. RESULTS: The sample size was 2,275 children from 40 schools in 13 districts. While the highest CHDI district had an untreated caries prevalence of 17.1% (12.3-22.7%), in the most disadvantaged district it was 53.9% (95% CI 46.0-61.6%). As family income increased, the probability of untreated caries prevalence decreased (PR = 0.9 95% CI 0.8-1.0). Rural districts had an average dmft-index of 7.3 (95% CI 7.2-7.4), while in urban districts, it was 4.4 (95% CI 4.3-4.5). Higher probabilities of untreated caries prevalence (PR = 3.0 95% CI 2.3-3.9) were observed in rural children. Greater probabilities of untreated caries prevalence (PR = 1.3 95% CI 1.1-1.6) and prevalence of caries experience (PR = 1.3 95% CI 1.1-1.5) were observed in children whose caregivers had a secondary educational level. CONCLUSIONS: A strong association was observed between the social determinants of health, specifically the structural ones, and the caries indicators studied in children of the Metropolitan Region of Chile. There were notable differences in caries between districts according to social advantage. Rurality and caregiver's education were the most consistent predictors.

A Causal Mediation Analysis for Investigating the Effect of a Randomized Cash-Transfer Program in Nicaragua.

Mediation analysis can be applied to data from randomized trials of health and social interventions to draw causal inference concerning their mechanisms. We used data from a cluster-randomized trial in Nicaragua, fielded between 2000 and 2002, to investigate whether the impact of providing access to a conditional cash-transfer program on child nutritional outcomes was mediated by child health check-ups and household dietary diversity. In a sample of 443 children 6-35 months old, we estimated the controlled direct (CDE) effect of random assignment on measured height-for-age z scores had we intervened so that all children received a health check-up and had the same level of household dietary diversity, using inverse-probability weighted marginal structural models to account for mediator-outcome confounding. Sensitivity analyses corrected the CDE for potential nondifferential error in the measurement of dietary diversity. Treatment assignment increased height-for-age z score by 0.37 (95% CI: 0.05, 0.69) standard deviations. The CDE was 0.20 (95% CI: -0.17, 0.57) standard deviations, suggesting nearly one-half of the program's impact on child nutrition would be eliminated had we intervened on these factors, although estimates were relatively imprecise. This study provides an illustration of how causal mediation analysis can be applied to examine the mechanisms of multifaceted interventions.

Uncovering the impact of COVID-19 on the place of death of cancer patients in South America / Descobrindo o impacto da COVID-19 no local de morte de pacientes com câncer na América do Sul / Descubriendo el impacto de la COVID-19 en el local del fallecimiento de pacientes con cáncer en América del Sur

Abstract: The COVID-19 pandemic has significantly impacted healthcare systems worldwide, especially on the management of chronic diseases such as cancer. This study explores the effects of COVID-19 on cancer mortality trends in Brazil, Chile, and Peru. The monthly age-standardized mortality rates in different places of death (hospital/clinic or home) were estimated using vital statistics and death certificate databases. An interrupted time series analysis was performed for each country, using the date of lockdown implementation as the intervention point. Overall cancer mortality rates reduced after the implementation of pandemic restrictions, with a significant decrease in Brazil. In total, 75.3%, 55.4%, and 45.7% of deaths in Brazil, Peru, and Chile, respectively, occurred in hospitals. After lockdowns were implemented, at-home deaths increased in all countries, and in-hospital deaths correspondingly decreased only in Chile. Our results suggest that COVID-19 has significantly affected rates of cancer mortality and place of death in Latin America.

Resumo: A pandemia de COVID-19 impactou significativamente os sistemas de saúde ao redor do mundo, especialmente no manejo de doenças crônicas, como o câncer. Este estudo explora os efeitos da COVID-19 nas tendências de mortalidade por câncer no Brasil, Chile e Peru. As taxas de mortalidade mensais padronizadas por idade em diferentes locais de morte (hospital/clínica ou domicílio) foram estimadas usando estatísticas vitais e bancos de dados de atestados de óbito. Uma análise de série temporal interrompida foi realizada para cada país, tendo como ponto de intervenção a data de implementação do lockdown. As taxas gerais de mortalidade por câncer reduziram após a implementação das restrições, com uma queda significativa no Brasil. No total, 75,3%, 55,4% e 45,7% dos óbitos no Brasil, Peru e Chile, respectivamente, ocorreram em hospitais. Depois da implementação dos lockdowns, as mortes em domicílio aumentaram em todos os países, e as mortes hospitalares diminuíram de forma correspondente apenas no Chile. Nossos resultados sugerem que a COVID-19 afetou significativamente as taxas de mortalidade por câncer e o local de morte na América Latina.

Resumen: La pandemia de COVID-19 impactó significativamente los sistemas de salud de todo el mundo, sobre todo en el manejo de enfermedades crónicas, como el cáncer. Este estudio explora los efectos de la COVID-19 en las tendencias de mortalidad por cáncer en Brasil, Chile y Perú. Las tasas de mortalidad mensuales estandarizadas por edad en diferentes locales de fallecimiento (hospital/clínica o domicilio) se estimaron utilizando estadísticas vitales y base de datos de certificados de defunción. Se realizó un análisis de serie temporal interrumpida para cada país, teniendo como punto de intervención la fecha de implementación del lockdown. Las tasas generales de mortalidad por cáncer redujeron tras la implementación de las restricciones, con una disminución significativa en Brasil. En total, el 75,3% de los óbitos ocurrieron en hospitales en Brasil, el 55,4% en Perú y el 45,7% en Chile. Tras la implementación del lockdown, las muertes domiciliarias aumentaron en todos los países, y las muertes hospitalarias solo redujeron de forma correspondiente en Chile. Nuestros resultados sugieren que la COVID-19 afectó significativamente las tasas de mortalidad por cáncer y el local del fallecimiento en América Latina.

Increasing Representation of Epidemiologists From Around the World in the Society for Epidemiologic Research: The Case of Mexico.

Mexico has a population of 129 million and is considered one of the most unequal countries in the world, suffering from widespread health disparities. There is a pressing need to strengthen epidemiologic capacity in Mexico, to help solve the complex health problems the country faces and to reduce health inequities. However, the representation of Mexican epidemiologists in the largest epidemiologic society in North America is low, despite the short distance to the United States. In this commentary, we discuss the barriers to higher representation of Mexican epidemiologists within the Society for Epidemiologic Research (SER), including language barriers, costs, and regional necessities. We also discuss opportunities to expand Mexican SER representation and collaboration. Overall, we hope that this is a call towards expanding SER global participation and starting a conversation on a common agenda for epidemiologic research.

A joint spatial marked point process model for dengue and severe dengue in Medellin, Colombia.

The spatial distribution of surveillance-reported dengue cases and severity are usually analyzed separately, assuming independence between the spatial distribution of non-severe and severe cases. Given the availability of data for the individual geo-location of surveillance-notified dengue cases, we conducted a spatial analysis to model non-severe and severe dengue simultaneously, using a hierarchical Bayesian model. We fit a joint model to the spatial pattern formed by dengue cases as well as to the severity status of the cases. Results showed that age and socioeconomic status were associated with dengue presence, and there was evidence of clustering for overall cases but not for severity. Our findings inform decision making to address the preparedness or implementation of dengue control strategies at the local level.

Decomposition of socioeconomic inequalities in arboviral diseases in Brazil and Colombia (2007-2017).

BACKGROUND: We used surveillance data from Brazil and Colombia during 2007-2017 to assess the presence of socioeconomic inequalities on dengue, chikungunya and Zika at the neighborhood level in two Latin American cities. METHODS: To quantify the inequality, we estimated and decomposed the relative concentration index of inequality (RCI) accounting for the spatiotemporal distribution of the diseases. RESULTS: There were 281 426 arboviral cases notified in Fortaleza, Brazil, and 40 889 in Medellin, Colombia. The RCI indicated greater concentration of dengue cases among people living in low socioeconomic settings in both sites. The RCIs for chikungunya in Fortaleza covered the line of equality during their introduction in 2014, while the RCIs for Zika and chikungunya in Medellin indicated the presence of a small inequality. The RCI decomposition showed that year of notification and age were the main contributors to this inequality. In Medellin, the RCI decomposition showed that age and access to waste management accounted for 75.5%, 72.2% and 54.5% of the overall inequality towards the poor for dengue, chikungunya and Zika, respectively. CONCLUSIONS: Our study presents estimates of the socioeconomic inequality of arboviruses and its decomposition in two Latin American cities. We corroborate the concentration of arboviral diseases in low socioeconomic neighborhoods and identify that year of occurrence, age, presence of healthcare facilities and waste management are key determinants of the heterogenous distribution of endemic arboviruses across the socioeconomic spectrum.

Effects of 2019's social protests on emergency health services utilization and case severity in Santiago, Chile: a time-series analysis.

Background: On October 18th, 2019, protestors gathered across Chile to call for social equity, resulting in widespread civil unrest and violent confrontation with the police. In this study, we quantify the effects of the 2019 Chilean protests on emergency health services utilization and inpatient admission in Santiago. Methods: We used weekly emergency department (ED) admissions (2015-2019) from three large public hospitals near the focal point of protests in Santiago. The exposure period was from October 18th to December 31st, 2019. The outcomes were the number of weekly consultations and hospitalizations by trauma and respiratory causes and the proportion of hospitalizations among consultants per 1,000. We implemented Bayesian structural time series models to calculate the absolute and relative effects and 95% credible intervals (CrI). Findings: During the first ten weeks of protests ED consultations declined on average by 14% for trauma (95%CrI: -40·2%, 11·5%) and 30% for respiratory causes (95%CrI: -89·4%, 30·2%), 7% for respiratory hospitalizations (95%CrI: -43·6%, 30·8%); however, none of these three results were statistically distinguishable from the null. Trauma hospitalizations, on the other hand, increased by 15% (95%CrI: 4·0%, 26·4%), and the proportion of hospitalizations per consultations increased by 40% for trauma (95%CrI: 13·1%, 68·0%) and 59% for respiratory causes (95%CrI: 29·4%, 87·9%). Interpretation: The 2019 Chilean protests affected the use of emergency health services by increasing the trauma hospitalizations and the case hospitalization ratio per 1,000 consultations for trauma and respiratory causes. Crowd-control protocols must be reviewed to prevent the negative effects of civil unrest.

Variation in Non-external and External Causes of Death in Peru in Relation to the COVID-19 Lockdown.

Introduction: Lockdowns are designed to slow COVID-19 transmission, but they may have unanticipated relationships with other aspects of public health. Assessing the overall pattern in population health as a country implements and relaxes a lockdown is relevant, as these patterns may not necessarily be symmetric. We aimed to estimate the changing trends in cause-specific mortality in relation to the 2020 COVID-19 related lockdowns in Peru. Methods: Based on data from the Peruvian National Death Information System (SINADEF), we calculated death rates per 10 million population to assess the trends in mortality rates for non-external and external causes of death (suicides, traffic accidents, and homicides). We compared these trends to 2018-2019, before, during, and after the lockdown, stratified by sex, and adjusted by Peruvian macro-region (Lima & Callao (capital region), Coast, Highland, and Jungle). Results: Non-external deaths presented a distinctive pattern among macro-regions, with an early surge in the Jungle and a later increase in the Highland. External deaths dropped during the lockdown, however, suicides and homicides returned to previous levels in the post-lockdown period. Deaths due to traffic accidents dropped during the lockdown and returned to pre-pandemic levels by December 2020. Conclusions: We found a sudden drop in external causes of death, with suicides and homicides returning to previous levels after the lifting of the lockdown. Non-external deaths showed a differential pattern by macro-region. A close monitoring of these trends could help identify early spikes among these causes of death and take action to prevent a further increase in mortality indirectly affected by the pandemic.

Dengue, Severity Paradox, and Socioeconomic Distribution Among Afro-Colombians.

BACKGROUND: The clinical presentation of dengue ranges from self-limited mild illness to severe forms, including death. African ancestry is often described as protective against dengue severity. However, in the Latin American context, African ancestry has been associated with increased mortality. This "severity paradox" has been hypothesized as resulting from confounding or heterogeneity by socioeconomic status (SES). However, few systematic analyses have been conducted to investigate the presence and nature of the disparity paradox. METHODS: We fit Bayesian hierarchical spatiotemporal models using individual-level surveillance data from Cali, Colombia (2012-2017), to assess the overall morbidity and severity burden of notified dengue. We fitted overall and ethnic-specific models to assess the presence of heterogeneity by SES across and within ethnic groups (Afro-Colombian vs. non-Afro-Colombians), conducting sensitivity analyses to account for potential underreporting. RESULTS: Our study included 65,402 dengue cases and 13,732 (21%) hospitalizations. Overall notified dengue incidence rates did not vary across ethnic groups. Severity risk was higher among Afro-Colombians (risk ratio [RR] = 1.16; 95% Credible Interval [95% CrI] = 1.08, 1.24) but after accounting for underreporting by ethnicity this association was nearly null (RR = 1.02; 95% CrI = 0.97, 1.07). Subsidized health insurance and low-SES were associated with increased overall dengue rates and severity. CONCLUSION: The paradoxically increased severity among Afro-Colombians can be attributed to differential health-seeking behaviors and reporting among Afro-Colombians. Such differential reporting can be understood as a type of intersectionality between SES, insurance scheme, and ethnicity that requires a quantitative assessment in future studies.

Spatiotemporal distribution and socioeconomic disparities of dengue, chikungunya and Zika in two Latin American cities from 2007 to 2017.

OBJECTIVE: To assess the presence, pattern and magnitude of socioeconomic inequalities on dengue, chikungunya and Zika in Latin America, accounting for their spatiotemporal distribution. METHODS: Using longitudinal surveillance data (reported arboviruses) from Fortaleza, Brazil and Medellin, Colombia (2007-2017), we fit Bayesian hierarchical models with structured random effects to estimate: (i) spatiotemporally adjusted incidence rates; (ii) Relative Concentration Index and Absolute Concentration Index of inequality; (iii) temporal trends in RCIs; and (iv) socioeconomic-specific estimates of disease distribution. The spatial analysis was conducted at the neighbourhood level (urban settings). The socioeconomic measures were the median monthly household income (MMHI) for Brazil and the Socio-Economic Strata index (SES) in Colombia. RESULTS: There were 281 426 notified arboviral cases in Fortaleza and 40 887 in Medellin. We observed greater concentration of dengue among residents of low socioeconomic neighbourhoods in both cities: Relative Concentration Index = -0.12 (95% CI = -0.13, -0.10) in Fortaleza and Relative Concentration Index = -0.04 (95% CI = -0.05, -0.03) in Medellin. The magnitude of inequalities varied over time across sites and was larger during outbreaks. We identified a non-monotonic association between disease rates and socioeconomic measures, especially for chikungunya, that changed over time. The Relative Concentration Index and Absolute Concentration Index showed few if any inequalities for Zika. The socioeconomic-specific model showed increased disease rates at MMHI below US$400 in Brazil and at SES-index below level four, in Colombia. CONCLUSIONS: We provide robust quantitative estimates of socioeconomic inequalities in arboviruses for two Latin American cities. Our findings could inform policymaking by identifying spatial hotspots for arboviruses and targeting strategies to decrease disparities at the local level.

Impact of COVID-19 lockdown policy on homicide, suicide, and motor vehicle deaths in Peru.

Although lockdown measures to stop COVID-19 have direct effects on disease transmission, their impact on violent and accidental deaths remains unknown. Our study aims to assess the early impact of COVID-19 lockdown on violent and accidental deaths in Peru. Based on data from the Peruvian National Death Information System, an interrupted time series analysis was performed to assess the immediate impact and change in the trend of COVID-19 lockdown on external causes of death including homicide, suicide, and traffic accidents. The analysis was stratified by sex and the time unit was every 15 days. All forms of deaths examined presented a sudden drop after the lockdown. The biggest drop was in deaths related to traffic accidents, with a reduction of 12.22 deaths per million men per month (95% CI: -14.45, -9.98) and 3.55 deaths per million women per month (95% CI:-4.81, -2.30). Homicide and suicide presented similar level drop in women, while the homicide reduction was 2.5 the size of the suicide reduction in men. The slope in homicide in men during the lock-down period increased by 6.66 deaths per million men per year (95% CI:3.18, 10.15). External deaths presented a sudden drop after the lockdown was implemented and an increase in homicide in men was observed. Falls in mobility have a natural impact on traffic accidents, however, the patterns for suicide and homicide are less intuitive and reveal important characteristics of these events, although we expect all of these changes to be transient.

A pragmatic stepped-wedge cluster randomized trial to evaluate the effectiveness and cost-effectiveness of active case finding for household contacts within a routine tuberculosis program, San Juan de Lurigancho, Lima, Peru.

BACKGROUND: Active case finding (ACF) in household contacts of tuberculosis (TB) patients is now recommended for National TB Programs (NTP) in low- and middle-income countries. However, evidence supporting these recommendations remains limited. This study evaluates the effectiveness and cost-effectiveness of ACF for household contacts of TB cases in a large TB endemic district of Lima, Peru. METHODS: A pragmatic stepped-wedge cluster randomized controlled trial was conducted in 34 health centers of San Juan de Lurigancho district. Centers were stratified by TB rate and randomly allocated to initiate ACF in groups of eight or nine centers at four-month intervals. In the intervention arm, NTP providers visited households of index patients to screen contacts for active TB. The control arm was routine passive case finding (PCF) of symptomatic TB cases. The primary outcomes were the crude and adjusted active TB case rates among household contacts. Program costs were directly measured, and the cost-effectiveness of the ACF intervention was determined. FINDINGS: 3222 index TB cases and 12,566 household contacts were included in the study. ACF identified more household contact TB cases than PCF, 199.29/10,000 contacts/year vs. 132.13 (incidence rate ratio of 1.51 (95% CI 1.21-1.88)). ACF was associated with an incremental cost-effectiveness ratio of US $16,400 per disability-adjusted life year averted and not cost-effective assuming a willingness-to-pay threshold for Peru of US $6360. CONCLUSION: ACF of TB case household contacts detected significantly more secondary TB cases than PCF alone, but was not cost-effective in this setting. In threshold analyses, ACF becomes cost-effective if associated with case detection rates 2.5 times higher than existing PCF programs.

Towards a better integration of social sciences in arbovirus research and decision-making: an experience from scientific collaboration between Cuban and Quebec institutions.

In 2017, the Institute of Tropical Medicine Pedro Kourí, University of Montreal Public Health Research Institute, and McGill University joined efforts to provide scenarios for scientific exchange and knowledge dissemination about the social science contribution on arboviral research. This commentary describes the scientific collaboration between Cuban and Canadian (Quebec) institutions, illustrating the need and opportunities to facilitate research and effective decision-making processes for arboviral prevention and control, going beyond traditional biomedical aspects. We organized a set of scientific activities within three international events conducted in Cuba between 2017 and 2018. Given the collaborating institutions' expertise and the knowledge gaps in arboviral research, we selected three main thematic areas: social determinants and equity, community-based interventions and use of evidence for decision-making. The partnership shows that interdisciplinary collaboration and the use and integration of quantitative and qualitative methods from the social sciences is essential to face the current challenges in arbovirus research.

The impact of anti-tobacco legislation on birth weight in Peru.

Background: Tobacco exposure remains a significant issue for public health, especially for pregnant women. It increases the risk for premature labor, low birth weight and small for gestational age (SGA), among other effects. To reduce these risks, many countries have enacted public policies to curb tobacco exposure. Peru enacted anti-tobacco laws that forbid smoking in public places, require prevention text and images in products and publicity, along with restriction of sales to adults. We evaluated the effect of the implementation of this law on newborn outcomes: birth weight, prematurity and SGA. Methods: This was a quasi-experimental study that utilized data from the Peruvian Live Birth Registry. Children born to mothers from urban areas were the intervention group, while children born to mothers from rural areas were considered the control group. Only singletons with information on birth weight and gestational age, born to mothers aged 12 to 49 years were included in the study. In addition, newborns with birth weights greater than + 4 standard deviations (SD) or less than - 4 SD from the gestational age-specific mean were excluded. To measure the effect of legislation on birth weight we performed a difference in differences analysis. Results: A total of 2,029,975 births were included in the analysis. After adjusting for characteristics of the mother and the child, and contextual variables, the anti-tobacco law in Peru reduced the incidence of prematurity by 30 cases per 10,000 live births (95% CI: 19 to 42). Conclusions: The reform had negligible effects on overall birth weights and on the incidence of SGA. This modest result suggests the need for a more aggressive fight against tobacco, prohibiting all types of advertising and promotion of tobacco products, among others measures.

Health profile differences between recipients and non-recipients of the Brazilian Income Transfer Program in a low-income population.

We investigated the relationship between living in a household that receives the Brazilian Income Transfer Program (Bolsa Família, in Portuguese - BF), a Brazilian conditional cash transfer program, and aspects of health and whether these relationships are heterogeneous across the 27 Brazilian states. According to data from the 2013 Brazilian National Health Survey, 18% of households participated in BF. Among households with household per capita income below BRL 500, many aspects of health differed between people living in BF and non-BF houses. For example, BF households were less likely to have medical coverage but more likely to have visited the doctor in the last 12 months as well as being more likely to smoke and less likely to do exercise. They ate nearly one less serving of fruits and vegetables a week but were less likely to substitute junk food for a meal. They reported worse self-rated health but did not differ importantly on reporting illnesses. Moderate amounts of heterogeneity in the difference in health characteristics were found for some variables. For instance, medical coverage had an I2 value of 40.7% and the difference in coverage between BF and non-BF households ranged from -0.09 to -0.03. Some illnesses differed qualitatively across states such as high cholesterol, asthma and arthritis. This paper is the first to outline the health profile of people living in households receiving payments from a cash transfer program. It is also the first to find geographic heterogeneity in the relationship between a cash transfer program and health variables. These results suggest the possibility that the effect of cash transfer programs may differ based on the population on which it is implemented.

Bayesian Methods for Exposure Misclassification Adjustment in a Mediation Analysis: Hemoglobin and Malnutrition in the Association Between Ascaris and IQ.

BACKGROUND: Soil-transmitted helminth infections have been found to be associated with child development. The objective was to investigate hemoglobin levels and malnutrition as mediators of the association between Ascaris infection and intelligence quotient (IQ) scores in children. METHODS: We conducted a longitudinal cohort study in Iquitos, Peru, between September 2011 and July 2016. A total of 1760 children were recruited at 1 year of age and followed up annually to 5 years. We measured Ascaris infection and malnutrition at each study visit, and hemoglobin levels were measured as of age 3. The exposure was defined as the number of detected Ascaris infections between age 1 and 5. We measured IQ scores at age 5 and used Bayesian models to correct exposure misclassification. RESULTS: We included a sample of 781 children in the analysis. In results adjusted for Ascaris misclassification, mean hemoglobin levels mediated the association between Ascaris infection and IQ scores. The natural direct effects (not mediated by hemoglobin) (95% CrI) and natural indirect effects (mediated by hemoglobin) (95% CrI) were compared with no or one infection: -0.9 (-4.6, 2.8) and -4.3 (-6.9, -1.6) for the effect of two infections; -1.4 (-3.8, 1.0) and -1.2 (-2.0, -0.4) for three infections; and -0.4 (-3.2, 2.4) and -2.7 (-4.3, -1.0) for four or five infections. CONCLUSION: Our results are consistent with the hypothesis that hemoglobin levels mediate the association between Ascaris infection and IQ scores. Additional research investigating the effect of including iron supplements in STH control programs is warranted.

Health profile differences between recipients and non-recipients of the Brazilian Income Transfer Program in a low-income population / Diferenças no perfil de saúde entre beneficiários e não-beneficiários do programa Bolsa Família em uma população de baixa renda / Diferencias en el perfil de salud entre beneficiarios y no-beneficiarios del programa Bolsa Familia en una población con bajos ingresos

Abstract: We investigated the relationship between living in a household that receives the Brazilian Income Transfer Program (Bolsa Família, in Portuguese - BF), a Brazilian conditional cash transfer program, and aspects of health and whether these relationships are heterogeneous across the 27 Brazilian states. According to data from the 2013 Brazilian National Health Survey, 18% of households participated in BF. Among households with household per capita income below BRL 500, many aspects of health differed between people living in BF and non-BF houses. For example, BF households were less likely to have medical coverage but more likely to have visited the doctor in the last 12 months as well as being more likely to smoke and less likely to do exercise. They ate nearly one less serving of fruits and vegetables a week but were less likely to substitute junk food for a meal. They reported worse self-rated health but did not differ importantly on reporting illnesses. Moderate amounts of heterogeneity in the difference in health characteristics were found for some variables. For instance, medical coverage had an I2 value of 40.7% and the difference in coverage between BF and non-BF households ranged from -0.09 to -0.03. Some illnesses differed qualitatively across states such as high cholesterol, asthma and arthritis. This paper is the first to outline the health profile of people living in households receiving payments from a cash transfer program. It is also the first to find geographic heterogeneity in the relationship between a cash transfer program and health variables. These results suggest the possibility that the effect of cash transfer programs may differ based on the population on which it is implemented.

Resumo: Os autores investigaram a relação entre pertencimento a uma família beneficiária do programa Bolsa Família (BF) e características de saúde, e se tais relações são heterogêneas, comparando os 26 estados e Distrito Federal, Brasil. De acordo como dados da Pesquisa Nacional de Saúde de 2013, 18% dos domicílios brasileiros participavam do BF. Entre as famílias com renda per capita abaixo de R$ 500,00, havia diferenças entre diversas características de saúde, comparando pessoas de famílias beneficiárias e não beneficiárias do BF. Por exemplo, pessoas de famílias matriculadas no BF mostraram menor probabilidade de ter cobertura médica, mas maior probabilidade de haverem consultado um médico nos últimos 12 meses, além de maior probabilidade de serem fumantes e menor probabilidade de serem fisicamente ativas. Consumiam quase uma porção a menos de frutas e verduras por semana, mas tinham menor probabilidade de substituir refeições com lanches. Apresentavam pior percepção da própria saúde, mas não mostravam diferenças importantes no relato de doenças. Houve uma heterogeneidade moderada nas características de saúde em relação a algumas variáveis. Por exemplo, a cobertura de saúde mostrou um valor de I2 de 40,7%, enquanto a diferença de cobertura entre famílias com e sem BF variou entre 0,09 e -0,03. Houve diferenças qualitativas entre estados em relação a algumas doenças, tais como hipercolesterolemia, asma e artrite. Este estudo foi o primeiro a definir o perfil de saúde de pessoas em famílias beneficiárias do BF. Também é o primeiro a encontrar uma heterogeneidade geográfica na relação entre o programa e variáveis de saúde. Os resultados sugerem que o efeito de um programa de renda mínima pode variar de acordo com a população na qual é implementado.

Resumen: Investigamos la relación entre vivir en un hogar que recibe ayudas del programa Bolsa Familia (BF), programa brasileño de transferencia monetaria condicionada, y aspectos de salud, además de estudiar si estas relaciones son heterogéneas entre los 27 estados brasileños. De acuerdo con los datos de 2013 en la Encuesta Nacional de Salud brasileña, un 18% de los hogares participaron en BF. Entre los hogares con unos ingresos per cápita por debajo de BRL 500, muchos aspectos de salud difirieron entre la gente que vivía en hogares con BF y sin BF. Por ejemplo, los hogares con BF fueron menos propensos a contar cobertura médica, pero era más probable que hubieran visitado al doctor en los últimos 12 meses, al igual que más probabilidad de fumar y menos propensos a hacer ejercicio. Comían frutas y verduras menos de casi una vez a la semana y eran menos propensos a sustituir la comida basura por una comida. Informaban de una peor salud autoevaluada, pero no difieren significativamente respecto a las enfermedades relatadas. Se encontraron algunas variables de heterogeneidad en cantidades moderadas, respecto a la diferencia en las características de salud. Por ejemplo, la cobertura médica tenía una cobertura con un valor I2 de 40,7% y la diferencia en la cobertura entre hogares con BF y no-BF oscilaba en un rango de -0.09 a -0.03. Algunas enfermedades se diferenciaban cualitativamente entre estados como el colesterol alto, asma y artritis. Este trabajo es el primero en resaltar el perfil de salud de la gente que vive en hogares que reciben pagos del programa brasileño de transferencia monetaria condicionada. Asimismo, es el primero en encontrar una heterogeneidad geográfica en la relación entre el programa brasileño de transferencia monetaria condicionada y variables de salud. Estos resultados sugieren la posibilidad de que el efecto del programa brasileño de transferencia monetaria condicionada puede ser diferente en función de la población en la que se implementa.

Burden of dengue among febrile patients at the time of chikungunya introduction in Piedecuesta, Colombia.

OBJECTIVE: To estimate the age-specific incidence of symptomatic dengue and chikungunya in Colombia. METHOD: A passive facility-based fever surveillance study was conducted among individuals with undifferentiated fever. Confirmatory diagnostics included serological and molecular tests in paired samples, and surveillance's underreporting was assessed using capture-recapture methods. RESULTS: Of 839 febrile participants 686 completed the study. There were 33.2% (295/839) dengue infections (51% primary infections), and 35.9% (191/532) of negative dengue cases there were chikungunya cases. On average, dengue cases were younger (median = 18 years) than chikungunya cases (median = 25 years). Thrombocytopaenia and abdominal pain were the main dengue predictors, while presence of rash was the main predictor for chikungunya diagnosis. Underreporting of dengue was 31%; the estimated expansion factors indicate an underreporting rate of dengue cases of threefold for all cases and of almost sixfold for inpatients. CONCLUSIONS: These findings highlight the ongoing coexistence of both arboviruses, a distinct clinical profile of each condition in the study area that could be used by clinicians to generate a differential diagnosis, and the presence of underreporting, mostly among hospitalised cases.