Low levels of potentially toxic elements in workers are associated with self-reported health outcomes.

Occupational exposure to toxic elements can adversely affect health. The current study evaluated blood concentrations of potentially toxic elements (PTE) including As, Cd, Cr, Cu, Hg, Mn, Ni, Pb, Sb, Sn, and Zn in formal and informal workers. Additionally, the study investigated the associations between blood PTE concentrations and reported health outcomes in the study population. The exposed group included women engaged in informal jewelry welding within their homes in Limeira, São Paulo state, Brazil (n = 36) and men who worked at a steel company in Volta Redonda, Rio de Janeiro state, Brazil (n = 22). The control group comprised residents of the same neighborhoods as the workers but without occupational exposure to chemicals (n = 28 in Limeira; n = 27 in Volta Redonda). Triple Quadrupole Inductively Coupled Plasma Mass Spectrometry (TQ ICP-MS) was used to determine PTE concentrations in blood samples. Glycemia, insulin, and lipid profile tests were performed. All participants completed questionnaires on household risk and reported morbidity. The blood concentrations of Cd, As, and Pb, as well as glycemia, were higher in informal workers than in control subjects. No significant differences were observed between formal workers and control subjects. A robust Poisson regression model, adjusted for variables suggested by a Directed Acyclic Graph, disclosed associations of blood lead and arsenic concentrations with the prevalence of neurological manifestations in Limeira. Blood lead levels > 2.6 µg dL-1 were associated with 2.3 times the prevalence of self-reported neurological manifestations (95 % CI: 1.17-4.58; p = 0.02) than lower blood lead concentrations. Furthermore, a positive association between blood cadmium concentrations and glycemia was observed. Informal occupational exposure to these elements may indicate an increased risk of developing diseases. Monitoring exposure and implementing interventions to reduce PTE exposure in the work environment represent significant steps toward prevention.

Microclimate factors related to dengue virus burden clusters in two endemic towns of Mexico.

In dengue-endemic areas, transmission control is limited by the difficulty of achieving sufficient coverage and sustainability of interventions. To maximize the effectiveness of interventions, areas with higher transmission could be identified and prioritized. The aim was to identify burden clusters of Dengue virus (DENV) infection and evaluate their association with microclimatic factors in two endemic towns from southern Mexico. Information from a prospective population cohort study (2·5 years of follow-up) was used, microclimatic variables were calculated from satellite information, and a cross-sectional design was conducted to evaluate the relationship between the outcome and microclimatic variables in the five surveys. Spatial clustering was observed in specific geographic areas at different periods. Both, land surface temperature (aPR 0·945; IC95% 0·895-0·996) and soil humidity (aPR 3·018; IC95% 1·013-8·994), were independently associated with DENV burden clusters. These findings can help health authorities design focused dengue surveillance and control activities in dengue endemic areas.

Effectiveness of mass dengue vaccination with CYD-TDV (Dengvaxia®) in the state of Paraná, Brazil: integrating case-cohort and case-control designs.

Background: CYD-TDV (Dengvaxia®) was the first dengue vaccine approved, launched in Brazil in 2015 for individuals aged 9-44 years. We aimed to estimate the effectiveness of CYD-TDV in preventing symptomatic dengue cases during a campaign targeting individuals aged 15-27 years in selected municipalities in Paraná, Brazil. Additionally, we examined whether a history of dengue, as recorded by the surveillance system, modified the vaccine's effectiveness. Methods: We conducted a case-cohort analysis comparing the frequency of vaccination, with at least one dose of CYD-TDV, in individuals with dengue confirmed by RT-PCR, identified by the surveillance system during 2019 and 2020, with the vaccination coverage in the target population. Moreover, in a case-control design using weighted controls, we assessed the documented history of dengue as a modifier of the vaccine's effectiveness. We used a logistic random-effects regression model, with data clustered in municipalities and incorporating covariates such as the incidence of dengue before the campaign, age, and sex. We calculated vaccine effectiveness (VE) as (1-relative risk) x 100%. Findings: 1869 dengue cases were identified, which had a vaccination frequency significantly lower than the overall vaccination coverage in the target population (50.3% vs. 57.2%, respectively; overall VE: 21.3%; 95% confidence interval [CI]: 13.4%-28.4%). In individuals with a documented history of dengue, vaccination had a VE of 71% (95% CI: 58%-80%) in reducing the incidence of dengue. However, vaccination was not associated with a significant reduction in the overall dengue case risk in individuals without a documented history of dengue (VE: 12%; 95% CI: -21% to 36%). In this last stratum, vaccination was associated with reduced cases due to DENV-1 and DENV-4, but an excess of DENV-2 cases. Interpretation: Vaccination led to a significant reduction in reported dengue cases within the target population. The case-control design suggested that this reduction was primarily driven by the benefits observed in individuals with a documented history of dengue. In endemic regions with limited serological testing facilities, a previous history of dengue diagnosis recorded by epidemiological surveillance could be used to triage candidates for CYD-TDV vaccination. Funding: Research supported by Sanofi.

Interactive monitoring dashboards for the COVID-19 pandemic in the world anticipating waves of the disease in Brazil with the use of open data.

OBJECTIVE: Describe the development, implementation, and utilization of dashboards for epidemiological analysis through open data research during the COVID-19 pandemic. METHODS: The dashboards were designed to analyze COVID-19 related public data from various sources, including official government data and social media, at world level. Data processing and cleaning techniques were used to join datasets. We calculated Spearman correlation coefficient between the COVID-like symptoms data of the University of Maryland and Facebook Health research, called COVID Trends and Impacts Survey (CTIS) and the official data of notified COVID-19 cases by the Brazilian Health Ministry. RESULTS: The dashboards were successful in predicting the onset of new waves of COVID-19 in Brazil. The data analysis revealed a correlation between the CTIS and the official number of cases the country. This article shows the potential of interactive dashboards as a decision-making tool in the context of public health emergencies, as it was used by the official communication of the Rio Grande do Sul state government. CONCLUSION: The use of dashboards for predicting the spread of COVID-19 in Brazil was a useful tool for decision-making. To anticipate waves of the disease gives time so that these decisions can be potentially more assertive. This drafts the need of more interdisciplinary actions of this nature, with visualization tools on epidemiologic research.

Interactive monitoring dashboards for the COVID-19 pandemic in the world anticipating waves of the disease in Brazil with the use of open data / Painéis de monitoramento interativos da pandemia de COVID-19 no mundo com o uso de dados abertos antecipando ondas da doença no Brasil

ABSTRACT Objective: Describe the development, implementation, and utilization of dashboards for epidemiological analysis through open data research during the COVID-19 pandemic. Methods: The dashboards were designed to analyze COVID-19 related public data from various sources, including official government data and social media, at world level. Data processing and cleaning techniques were used to join datasets. We calculated Spearman correlation coefficient between the COVID-like symptoms data of the University of Maryland and Facebook Health research, called COVID Trends and Impacts Survey (CTIS) and the official data of notified COVID-19 cases by the Brazilian Health Ministry. Results: The dashboards were successful in predicting the onset of new waves of COVID-19 in Brazil. The data analysis revealed a correlation between the CTIS and the official number of cases the country. This article shows the potential of interactive dashboards as a decision-making tool in the context of public health emergencies, as it was used by the official communication of the Rio Grande do Sul state government. Conclusion: The use of dashboards for predicting the spread of COVID-19 in Brazil was a useful tool for decision-making. To anticipate waves of the disease gives time so that these decisions can be potentially more assertive. This drafts the need of more interdisciplinary actions of this nature, with visualization tools on epidemiologic research.

RESUMO Objetivo: Descrever o desenvolvimento, a implementação e o uso de painéis para a análise epidemiológica de dados abertos durante a pandemia de COVID-19. Métodos: Os painéis foram criados para analisar dados públicos relacionados á COVID-19 de várias fontes, incluindo dados oficiais dos governos e de redes sociais, a nível global. Técnicas de processamento e limpeza foram utilizadas para aglutinar os bancos de dados. Calculamos o coeficiente de correlação de Spearman entre as curvas de sintomas gripais da pesquisa da Universidade de Maryland em conjunto com o Facebook, chamada COVID Trends and Impacts Survey (CTIS), e a curva de casos notificados pelo Ministério da Saúde no Brasil. Resultados: Os painéis obtiveram sucesso em antecipar a chegada de novas ondas de COVID-19 no Brasil. A análise do dado revelou a correlação entre a pesquisa CTIS e o número oficial de casos no país. O artigo destaca o potencial de painéis interativos como uma ferramenta de tomada de decisão no contexto de emergências de saúde pública, como, por exemplo, no uso destes para a comunicação oficial do governo do Rio Grande do Sul. Conclusão: O uso de painéis para prever o avanço da COVID-19 no Brasil foi uma ferramenta útil para a tomada de decisão. A antecipação de ondas da doença possibilita tempo oportuno para que essas decisões sejam potencialmente mais assertivas. Isso esboça a necessidade de mais ações interdisciplinares dessa natureza, com ferramentas de visualização nas pesquisas epidemiológicas.

Is chemical exposure present in informal work associated with Sars-CoV-2 infection?

ABSTRACT OBJECTIVE To compare the incidence of covid-19 symptoms between informal home-based workers and a control group and to assess the association of these cases with blood elements concentrations and other relevant risk factors for Sars-Cov-2 infection. METHODS Welders chemically exposed to potentially toxic elements (PTEs) (n = 26) and control participants (n = 25) answered questionnaires on adherence to social distancing and signs and symptoms of the disease for five months during the covid-19 pandemic. After follow-up, covid-19 serology tests were performed on a subsample of 12 chemically exposed workers and 20 control participants. Before the pandemic, PTE concentrations in blood (As, Mn, Ni, Cd, Hg, Sb, Sn, Cu, Zn, and Pb) were measured by ICP-MS. RESULTS The chemically exposed group had higher lead and cadmium levels in blood (p < 0.01). The control group presented lower adherence to social distancing (p = 0.016). Although not significant, welders had a 74% greater chance of having at least one covid-19 symptom compared with control participants, but their adherence to social distancing decreased this chance by 20%. The use of taxis for transportation was a risk factor significantly associated with covid-19 symptoms. CONCLUSION The lower adherence to social distancing among the control group greatly influences the development of covid-19. The literature lacks data linking exposure to PTEs and Sars-Cov-2 infection and/or severity. In this study, despite chemical exposure, working from home may have protected welders against covid-19, considering that they maintained greater social distancing than control participants.

Evaluation of the initial response in clinical trials efforts for COVID-19 in Brazil / Avaliação da resposta inicial de desenvolvimento de ensaios clínicos para COVID-19 no Brasil

Objective: To describe the methodological characteristics and good research practices of the intervention studies for COVID-19 developed in Brazil in the first months of the pandemic. Method: A review in the CONEP-COVID bulletin (05/28/2020) and the International Clinical Trials Registry Platform, ClinicalTrials.gov, ReBEC was conducted to identify drug-type, biological therapy or vaccine intervention studies registered in Brazil. The studies were evaluated for methodological characteristics and power for different magnitudes of effect. Results: 62 studies were included, 55 identified on the CONEP website and seven on a registration database. Several interventions are being tested: chloroquine/hydroxychloroquine, azithromycin, plasma convalescent, tocilizumab, sarilumab, eculizumab, vaccine, corticoids, anticoagulants, n-acetylcysteine, nitazoxanide, ivermectin, lopinavir/ritonavir, etc. By May 2020, 22 research protocols were published in a protocol registry database, 82% were randomized clinical trials and 59% had adequate control group. However, 59% were not masked and only 24% included patients with positive test with diagnostic accuracy. Most of the studies would have power >80% just to identify large effect sizes. In a prospective follow-up, until July 21st/2020, 60% of the studies available at CONEP were not registered in the ICTRP/ReBEC/ClinicalTrials platforms. Conclusion: The interventions evaluated during the Brazilian research response reflect international initiatives, but with a different distribution, a larger proportion of studies asseessed hydroxychloroquine/chloroquine. Limitations in methodological design and sample planning represent challenges that could affect the research outreach.

Objetivo: Descrever as características metodológicas e de boas práticas em pesquisa dos estudos de intervenção para COVID-19 desenvolvidos no Brasil nos primeiros meses da pandemia. Método: Revisamos o boletim da CONEP-COVID (28/05/2020) e as bases International Clinical Trials Registry Platform, ClinicalTrials.gov e ReBEC para identificar estudos registrados no Brasil, avaliando intervenções de tipo medicamento, terapia biológica ou vacinas. Descrevemos as características metodológicas e calculamos o poder para diferentes magnitudes de efeito. Resultados: Foram incluídos 62 estudos, 55 identificados no site da CONEP e mais sete nas bases de registro. As intervenções medicamentosas mais frequentemente testadas nesses estudos foram: cloroquina/hidroxicloroquina, azitromicina, plasma convalescente, tocilizumabe, sarilumabe, eculizumabe, vacina, corticoides, anticoagulantes, n-acetilcisteína, nitazoxanida, ivermectina e lopinavir/ritonavir. De 22 protocolos, publicados até maio de 2020 nas bases de registro, 18 (82%) eram ensaios clínicos randomizados e 13 (59%) tinham grupo controle adequado. Entretanto, nove (41%) eram mascarados e somente cinco (24%) incluía pacientes diagnosticados com teste de laboratório específico (e.g. RT-PCR). A maioria desses trabalhos teria poder >80% apenas para identificar grandes tamanhos de efeito. Em seguimento prospectivo, observamos que 60% dos estudos, disponíveis na CONEP até maio de 2020, não estava em nenhuma das plataformas de registro (ICTRP/ReBEC/ClinicalTrials) até o dia 21/07/2020.Conclusão: As intervenções avaliadas durante a resposta brasileira em pesquisa refletem iniciativas internacionais, porém com uma distribuição diferente, tendo um número elevado de estudos avaliando hidroxicloroquina/ cloroquina. Limitações no delineamento metodológico e planejamento amostral representam desafios que poderiam afetar o alcance dos trabalhos.

Experiencia y percepción del riesgo asociados a conocimientos, actitudes y prácticas sobre dengue en Riohacha, Colombia / Experience and perception of risk associated with knowledge, attitudes and practices regarding dengue in Riohacha, Colombia

Resumen Para el control del dengue es esencial el reconocimiento de los determinantes de los conocimientos, actitudes y prácticas (CAP), los cuales podrían estar condicionados por las experiencias y percepciones de la población a riesgo. El propósito de este artículo es estimar la asociación entre la percepción del riesgo y la experiencia de dengue con los CAP sobre dengue, en una población endémica de Colombia. Estudio analítico de corte transversal y muestreo probabilístico, polietápico por conglomerados. Como medidas de asociación se estimaron las razones de prevalencia ajustadas (RPa) usando modelos de regresión. Se entrevistaron 206 familias. El 7% saben que la enfermedad del dengue es causada por un virus y menos del 40% reconocen otros síntomas diferentes a la fiebre. El 31% practica la eliminación de criaderos y el 58% fumiga como estrategias de control. El 73% percibe el riesgo de dengue. Se estimó una asociación significativa de la percepción del riesgo de dengue con el conocimiento sobre el vector (RPa = 3,32 IC95% 1,06-10,36). Además, el antecedente de diagnóstico de dengue se asoció con la actitud frente a su control (RPa = 1,61 IC95% 1,09-2,37). La percepción del riesgo y la experiencia con dengue podrían ser determinantes de los CAP en relación a esta enfermedad.

Abstract Recognition of the determinants of knowledge, attitudes and practices (KAP), which could be conditioned by the experiences and perceptions of the population at risk, is essential for the control of dengue. The scope of this article is to estimate the relationship between the risk perception and dengue diagnosis experiences with KAPs on dengue in an endemic Colombian population. A cross-sectional study with multi-stage random sampling was conducted. Adjusted prevalence ratios (aPR) were estimated using regression models as measures of association. Of the 206 families interviewed, 7% know dengue is caused by a virus and less than 40% recognize other symptoms besides fever. As control strategies, 31% eliminate hatchery sites and 58% use fumigation, though 73% perceive the risk of dengue. The association was identified between the perception of the risk of dengue and knowledge about the vector (aPR = 3.32 CI95% 1.06-10.36), and the experience of diagnosis of dengue with the attitude towards dengue control (aPR = 1.61 CI95% 1.09-2.37). Risk perception and experience with dengue could become determinants of KAPs in relation to this disease.

Translating transmissibility measures into recommendations for coronavirus prevention

ABSTRACT The rapid increase in clinical cases of the new coronavirus disease, COVID-19, suggests high transmissibility. However, the estimates of the basic reproductive number reported in the literature vary widely. Considering this, we drew the function of contact-rate reduction required to control the transmission from both detectable and undetectable sources. Based on this, we offer a set of recommendations for symptomatic and asymptomatic populations during the current pandemic. Understanding the dynamics of transmission is essential to support government decisions and improve the community's adherence to preventive measures.

Factors associated with diarrheal disease in the rural Caribbean region of Colombia / Factores asociados con enfermedad diarreica en área rural del Caribe colombiano

ABSTRACT OBJECTIVE: To analyze factors associated with diarrheal disease in the rural Caribbean region of Colombia. METHOD: A cross-sectional study conducted in the rural area of the Cesar Department, Colombia, between November 2017 and June 2018. Self-reported cases of diarrheal disease were surveyed, and water samples from 42 households were collected and analyzed. Descriptive statistics were employed in the analysis of socioeconomic status, environmental and sanitary conditions, and we evaluated their association with the diarrheal disease using the Poisson regression models. Each model was adjusted with variables suggested by specific directed acyclic graphs. RESULTS: Poor water supply conditions, hygiene and basic sanitation were reported in the study area. All water samples were classified either as high risk for health problems or unfit for human consumption. The diarrheal disease had a prevalence of 7.5% across all ages and of 23.5% in children under five years old. The variables rainy season (PR = 0.24; 95%CI 0.07-0.85), children under five years old (PR = 4.05; 95%CI 1.70-9.68), water from deep wells (PR = 16.90; 95%CI 2.45-116.67), water from artificial ponds (PR = 11.47; 95%CI 1.27-103.29), toilets availability (PRA = 0.23; 95%CI 0.06-0.96), and swine presence (PR = 0.20; 95%CI 0.05-0.74) were significantly associated with the occurrence of diarrheal disease. CONCLUSION: Water supply, hygiene and basic sanitation conditions have been associated with the diarrheal disease, affecting almost a quarter of the population under five years old. There is an urge for the design of effective policies that improve environmental and sanitation conditions in rural areas.

RESUMEN OBJETIVO: Analizar factores asociados con enfermedad diarreica en área rural del Caribe colombiano. MÉTODO: Estudio transversal en área rural dispersa del departamento del Cesar, Colombia, entre noviembre de 2017 y junio de 2018. Se indagó sobre morbilidad auto-reportada de enfermedad diarreica y se recolectaron y analizaron muestras de agua en 42 domicilios. Fue realizado un análisis descriptivo de condiciones socioeconómicas, ambientales y sanitarias y evaluamos su asociación con enfermedad diarreica mediante modelo robusto de regresión de Poisson. Cada modelo fue ajustado con variables sugeridas por diagramas causales específicos. RESULTADOS: Se evidenciaron condiciones precarias de abastecimiento de agua, higiene y saneamiento básico en la zona de estudio. Todas las muestras de agua se clasificaron entre los niveles de riesgo alto e inviable sanitariamente. La prevalencia de enfermedad diarreica fue 7,5% en todas las edades y 23,5% en niños menores de cinco años. Las variables estación lluviosa (RP = 0,24; IC95% 0,07-0,85), niños menores de cinco años (RP = 4,05; IC95% 1,70-9,68), abastecimiento de agua desde pozo profundo (RP = 16,90; IC95% 2,45-116,67), abastecimiento de agua desde estanco (RP = 11,47; IC95% 1,27-103,29), tenencia de baño (RPA = 0,23; IC95% 0,06-0,96) y presencia de cerdos (RP = 0,20; IC95% 0,05-0,74) mostraron asociaciones estadísticamente significativas con la ocurrencia de enfermedad diarreica. CONCLUSIÓN: Condiciones de abastecimiento de agua, higiene y saneamiento básico estuvieron asociadas con la ocurrencia de enfermedad diarreica, afectando alrededor de un cuarto de la población menor de cinco años. Urge un diseño efectivo de políticas que contribuyan al mejoramiento de condiciones ambientales y saneamiento en áreas rurales.

Variabilidade climática e internações por doenças diarreicas infecciosas em um município da Amazônia Ocidental brasileira / Climate variability and hospitalizations due to infectious diarrheal diseases in a municipality of the Western Brazilian Amazon Region

Resumo A morbimortalidade por doenças diarreicas infecciosas ainda representa um grave problema de saúde no Brasil e está altamente relacionada a fatores como condições climáticas, ambientais e de vida da população. O objetivo deste estudo foi analisar a associação das taxas de internações por doenças diarreicas infecciosas na população do município de Rio Branco/AC com a precipitação, o nível do rio, a umidade e a temperatura, entre os anos de 2000 e 2013. Os dados foram extraídos do Sistema de Informações Hospitalares do SUS, do Instituto Nacional de Meteorologia e da Agência Nacional das Águas. Foram ajustados modelos múltiplos de regressão de Poisson e binomial negativa. Os resultados mostram que existe uma associação positiva entre as internações por doenças diarreicas infecciosas e o nível do Rio Acre (RT:1,07; IC95%:1,04 a 1,1); houve um decréscimo de 14% nestas taxas de internações entre os anos de 2000 e 2013 (RT:0,86; IC95%:0,85 a 0,87); o grupo mais vulnerável pertence à faixa etária de menores de 1 ano de vida. Este estudo mostrou a vulnerabilidade de uma cidade na Amazônia quanto à variabilidade climática e a respectiva influência epidemiológica na incidência de internações por doenças diarreicas infecciosas.

Abstract Morbimortality due to infectious diarrheal diseases still is a serious health issue in Brazil and is highly related to factors such as weather, environment, and people's life conditions. This study aimed to analyze the relationship between hospitalization rates due to infectious diarrheal diseases among the population of the municipality of Rio Branco (AC), Brazil and precipitation, river level, humidity and temperature between 2000 and 2013. Data were retrieved from the Hospital Information System of the SUS (Unified Health System), the National Institute of Meteorology and the National Water Agency. Multiple Poisson and negative binomial regression models were adjusted. Results showed that there is a positive association between hospitalization due to infectious diarrheal diseases and the level of the Acre river (RR: 1.07; CI 95%: 1.04 to 1.1); these hospitalization rates fell 14% between 2000 and 2013 (RR: 0.86; CI 95%: 0.85 to 0.87). The most vulnerable group was the age group of less than 1 year of age. This study showed the vulnerability of an Amazonian city to climate variability and its respective epidemiological influence on the incidence of hospitalizations due to infectious diarrheal diseases.

Climatic variables associated with dengue incidence in a city of the Western Brazilian Amazon region

Abstract INTRODUCTION: This study aimed to examine the impact of climate variability on the incidence of dengue fever in the city of Rio Branco, Brazil. METHODS: The association between the monthly incidence of dengue fever and climate variables such as precipitation, temperature, humidity, and the Acre River level was evaluated, using generalized autoregressive moving average models with negative binomial distribution. Multiple no-lag, 1-month lag, and 2-month lag models were tested. RESULTS: The no-lag model showed that the incidence of dengue fever was associated with the monthly averages of the Acre River level (incidence rate ratio [IRR]: 1.09; 95% confidence interval [CI]: 1.02-1.17), compensated temperature (IRR: 1.54; 95% CI: 1.22-1.95), and maximum temperature (IRR: 0.68; 95% CI: 0.58-0.81). The 1-month lag model showed that the incidence of dengue fever was predicted by the monthly averages of total precipitation (IRR: 1.21; 95% CI: 1.06-1.39), minimum temperature (IRR: 1.54; 95% CI: 1.24-1.91), compensated relative humidity (IRR: 0.90; 95% CI: 0.82-0.99), and maximum temperature (IRR: 0.76; 95% CI: 0.59-0.97). The 2-month lag model showed that the incidence of dengue fever was predicted by the number of days with precipitation (IRR: 1.03; 95% CI: 1.00-1.06) and maximum temperature (IRR: 1.23; 95% CI: 1.05-1.44). CONCLUSIONS: Considering the impact of global climate change on the region, these findings can help to predict trends in dengue fever incidence.

Cadastro Nacional de Estabelecimentos de Saúde como ferramenta de análise da descentralização do atendimento da tuberculose para a atenção básica / Brazilian National Registry of Healthcare Establishments as a tool for the analysis of decentralization of tuberculosis treatment to basic care services / Registro Nacional de Establecimientos de Salud como herramienta de análisis de la descentralización de la atención a la tuberculosis en la atención básica

Resumo: Os objetivos deste artigo foram validar um método de classificação dos serviços de saúde (atenção básica vs. outros níveis) e descrever a descentralização do atendimento da tuberculose (TB) para a atenção básica no Brasil no período de 2002 a 2016. Os serviços de saúde que notificaram e acompanharam pessoas com TB foram classificados como "atenção básica" ou "outros níveis", considerando-se o tipo de estabelecimento registrado no Cadastro Nacional de Estabelecimentos de Saúde (CNES). Foi estimada a concordância entre essa classificação e uma realizada em 2013 pelos programas estaduais e municipais de TB. Posteriormente, utilizando-se o CNES, calculou-se o percentual de pessoas com TB atendidas na atenção básica no período de 2002 a 2016. A concordância foi de 94,4% e o índice kappa global foi 0,86. Houve um incremento relativo de 31,2% do atendimento de TB na atenção básica (50,9% em 2002 para 66,8% em 2016). Todas as regiões apresentaram aumento desse percentual, exceto a Região Sul. A classificação baseada no CNES permitiu analisar a evolução da descentralização do atendimento da TB para a atenção básica no Brasil.

Abstract: This study aimed to validate a method for classification of healthcare services in Brazil (basic care vs. other levels) and describe the decentralization of tuberculosis (TB) care to basic services (2002 to 2016). The healthcare services that reported and followed TB cases were classified as either "basic care" or "other levels" based on the type of establishment registered in the Brazilian National Registry of Healthcare Establishments (CNES, in Portuguese). The study estimated the agreement between this classification with a previous classification performed in 2013 by Brazil's state and local tuberculosis programs. Using the CNES registry, the authors then calculated the percentage of TB patients treated in basic care from 2002 to 2016. Agreement was 94.4%, and overall kappa index was 0.86. There was a relative increment of 31.2% in TB care provided by basic services (from 50.9% in 2002 to 66.8% in 2016). All regions of Brazil showed an increase in this percentage, except the South. The classification based on the CNES registry allowed analyzing the trend in decentralization of TB treatment to basic healthcare services in Brazil.

Resumen: Los objetivos de este artículo fueron validar un método de clasificación de los servicios de salud (atención básica vs. otros niveles) y describir la descentralización del cuidado de la tuberculosis (TB) hacia los servicios de atención básica en Brasil, durante el período de 2002 a 2016. Los servicios de salud que notificaron y efectuaron el seguimiento a personas con TB fueron clasificados como "atención básica" u "otros niveles", considerándose el tipo de establecimiento registrado en el Registro Nacional de Establecimientos de Salud (CNES). Se estimó la concordancia entre esta clasificación y una realizada en 2013 por los programas estatales y municipales de TB. Posteriormente, utilizando el CNES, se calculó el porcentaje de personas con TB atendidas en la atención básica durante el período de 2002 a 2016. La concordancia fue de 94,4% y el índice kappa global fue 0,86. Hubo un incremento relativo de un 31,2% del manejo de la TB en la atención básica (de un 50,9% en 2002 hasta un 66,8% en 2016). Todas las regiones presentaron un aumento de ese porcentaje, excepto la región Sur. La clasificación, basada en el CNES, permitió analizar la evolución de la descentralización del manejo de la TB hacia la atención básica en Brasil.

Offer of primary care services and detection of tuberculosis incidence in Brazil / Oferta de serviços pela atenção básica e detecção da incidência de tuberculose no Brasil

ABSTRACT OBJECTIVE To evaluate the association between the health services offered by primary care teams and the detection of new tuberculosis cases in Brazil. METHODS This was an ecological study covering all Brazilian municipalities that registered at least one new tuberculosis case (diagnosed between 2012 to 2014 and notified in the Information System of Notifiable Diseases) and with at least one primary care team evaluated by the second cycle of the National Program for Improving Access and Quality of Primary Care (PMAQ-AB). The variables of the PMAQ-AB were classified as proximal or distal, according to their relation with the tuberculosis diagnosis. Then, they were tested hierarchically in multiple models (adjusted by States) using negative binomial regression. RESULTS An increase of 10% in the primary health care coverage was associated with a decrease of 2.24% in the tuberculosis detection rate (95%CI -3.35- -1.11). Regarding the proximal variables in relation to diagnosis, in the multiple model, the detection of tuberculosis was associated with the proportion of teams that conduct contact investigation (increase in Incidence Rate Ratio [IRR] = 2.97%, 95%CI 2.41-3.53), carry out tuberculosis active case finding (increase in IRR = 2.17%, 95%CI 1.48-2.87), and request culture for mycobacteria (increase in IRR = 1.87%, 95%CI 0.98-2.76). CONCLUSIONS The variables related to the search actions were positively associated with the detection of new tuberculosis cases, which suggests a significant contribution to the strengthening of the sensitivity of the surveillance system. On the other hand, primary care coverage was inversely associated with the tuberculosis detection rate, which could represent the overall effect of the primary care on transmission control, probably from the identification and early treatment of cases.

RESUMO OBJETIVO Avaliar a associação entre os serviços de saúde ofertados por equipes de atenção básica e a detecção de casos novos de tuberculose no Brasil. MÉTODOS Estudo ecológico, abrangendo todos os municípios brasileiros que registraram pelo menos um caso novo de tuberculose (diagnosticado entre 2012 a 2014 e notificado no Sistema de Informação de Agravos de Notificação) e com pelo menos uma equipe de atenção básica avaliada pelo segundo ciclo do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB). As variáveis do PMAQ-AB foram classificadas como próximais ou distais, segundo a sua relação com o diagnóstico de tuberculose. Em seguida, foram testadas hierarquicamente em modelos múltiplos (ajustados por Unidade Federada), usando regressão binomial negativa. RESULTADOS Um incremento de 10% na cobertura da atenção básica esteve associado à redução de 2,24% na taxa de detecção de tuberculose (IC95% -3,35- -1,11). No que se refere às variáveis proximais ao diagnóstico, no modelo múltiplo, a detecção da tuberculose esteve associada à proporção de equipes que: realizam vigilância de contatos (incremento na Razão de Taxas de Incidência [RTI] = 2,97%; IC95% 2,41-3,53); fazem busca ativa de casos de tuberculose (incremento na RTI = 2,17%; IC95% 1,48-2,87); e, ofertam cultura para micobactérias (incremento na RTI = 1,87%; IC95% 0,98-2,76). CONCLUSÕES As variáveis relacionadas às ações de detecção estiveram positivamente associadas à detecção de casos novos de tuberculose, sugerindo uma contribuição significativa ao fortalecimento da sensibilidade do sistema de vigilância. Por outro lado, a cobertura da atenção básica esteve inversamente associada à taxa de detecção de tuberculose, o que poderia representar o efeito global da atenção básica sobre o controle da transmissão, provavelmente, através da identificação e tratamento precoce de casos.

Climate variability and hospitalizations due to infectious diarrheal diseases in a municipality of the Western Brazilian Amazon Region / Variabilidade climática e internações por doenças diarreicas infecciosas em um município da Amazônia Ocidental brasileira

Abstract Morbimortality due to infectious diarrheal diseases still is a serious health issue in Brazil and is highly related to factors such as weather, environment, and people's life conditions. This study aimed to analyze the relationship between hospitalization rates due to infectious diarrheal diseases among the population of the municipality of Rio Branco (AC), Brazil and precipitation, river level, humidity and temperature between 2000 and 2013. Data were retrieved from the Hospital Information System of the SUS (Unified Health System), the National Institute of Meteorology and the National Water Agency. Multiple Poisson and negative binomial regression models were adjusted. Results showed that there is a positive association between hospitalization due to infectious diarrheal diseases and the level of the Acre river (RR: 1.07; CI 95%: 1.04 to 1.1); these hospitalization rates fell 14% between 2000 and 2013 (RR: 0.86; CI 95%: 0.85 to 0.87). The most vulnerable group was the age group of less than 1 year of age. This study showed the vulnerability of an Amazonian city to climate variability and its respective epidemiological influence on the incidence of hospitalizations due to infectious diarrheal diseases

A morbimortalidade por doenças diarreicas infecciosas ainda representa um grave problema de saúde no Brasil e está altamente relacionada a fatores como condições climáticas, ambientais e de vida da população. O objetivo deste estudo foi analisar a associação das taxas de internações por doenças diarreicas infecciosas na população do município de Rio Branco/AC com a precipitação, o nível do rio, a umidade e a temperatura, entre os anos de 2000 e 2013. Os dados foram extraídos do Sistema de Informações Hospitalares do SUS, do Instituto Nacional de Meteorologia e da Agência Nacional das Águas. Foram ajustados modelos múltiplos de regressão de Poisson e binomial negativa. Os resultados mostram que existe uma associação positiva entre as internações por doenças diarreicas infecciosas e o nível do Rio Acre (RT:1,07; IC95%:1,04 a 1,1); houve um decréscimo de 14% nestas taxas de internações entre os anos de 2000 e 2013 (RT:0,86; IC95%:0,85 a 0,87); o grupo mais vulnerável pertence à faixa etária de menores de 1 ano de vida. Este estudo mostrou a vulnerabilidade de uma cidade na Amazônia quanto à variabilidade climática e a respectiva influência epidemiológica na incidência de internações por doenças diarreicas infecciosas

Regresiones aplicadas al estudio de eventos discretos en epidemiología / Regressions applied to the study of discrete events in epidemiology

En este manuscrito se revisan algunos aspectos básicos de la utilización de regresiones en los estudios epidemiológicos, haciendo énfasis en aquellas aplicadas al estudio de eventos discretos. De esta manera se hace una introducción a los modelos lineales generalizados, cuya estructura es una extensión de una ecuación lineal para analizar desenlaces discretos. De este modo podemos estimar medidas de asociación como la razón de tasas usando la regresión de Poisson, o bien, el riesgo relativo (o la razón de prevalencias) usando la regresión log-binomial. En cada caso es esencial conocer la naturaleza de la variable dependiente, su distribución y reconocer las limitaciones de cada una de las herramientas de análisis.

Some basic aspects about using regressions in epidemiological studies are reviewed. Particularly, this manuscript focused on those applied to the study of discrete events. Generalized lineal models, such as Poisson and log-binomial, have a structure that is an extension of a lineal equation to analyze discrete outcomes. Thus, we can estimate association measures as the incidence rate ratio, using the Poisson regression, or the relative risk (or prevalence ratio), using log-binomial regression. In each case it is essential to know the nature of the dependent variable, as well as, its distribution and recognize the limitations of each analysis tool.