Post-therapeutic cure criterion in chronic Chagas disease using Trypanosoma cruzi chimeric proteins.

Chagas disease (CD) is a neglected disease caused by Trypanosoma cruzi Chagas, 1909. Causative treatment can be achieved with two drugs: benznidazole or Nifurtimox. There are some gaps that hinder progress in eradicating the disease. There is no test that can efficiently assess cure control after treatment. Currently, the decline in anti-T. cruzi antibody titres is assessed with conventional serological tests, which can take years. However, the search for new markers of cure must continue to fill this gap. The present study aimed to evaluate the decline in serological titres using chimeric proteins after treatment with benznidazole in chronic patients diagnosed with CD. It was a prospective cross-sectional cohort study between 2000 and 2004 of T. cruzi-positive participants from the Añatuya region (Argentina) treated with benznidazole. Serum samples from ten patients were collected before treatment (day zero) and after the end of treatment (2, 3, 6, 12, 24 and 36 months). For the detection of anti-T. cruzi antibodies, an indirect ELISA was performed using two chimeric recombinant proteins (IBMP-8.1 and IBMP-8.4) as antigens. The changes in reactivity index within the groups before and after treatment were evaluated using the Friedman test. All participants experienced a decrease in serological titres after treatment with benznidazole, especially IBMP-8.1. However, due to the small number of samples and the short follow-up period, it is premature to conclude that this molecule serves as a criterion for sustained cure. Further studies are needed to validate tests based on these or other biomarkers to demonstrate parasitological cure.

Análise dos feminicídios no estado de Pernambuco: violência de gênero e invisibilidade / Analysis of femicides in the state of Pernambuco: gender-based violence and invisibility / Análisis de los feminicidios en el estado de Pernambuco: violencia de género e invisibilidad

O feminicídio é um fenômeno decorrente da herança patriarcal machista e de estruturas sociais historicamente permeadas por relações desiguais de gênero. O objetivo desta dissertação, que é um estudo ecológico, foi analisar os aspectos epidemiológicos dos feminicídios registrados em Pernambuco, entre 2016 e 2019. Como proxy dos eventos de feminicídio, foi admitido como referência o registro de homicídios e de mortes por causas indeterminadas de mulheres no Sistema de Informações sobre Mortalidade. Foram estabelecidas etapas de buscas com o linkage probabilístico em bases de dados da saúde e, de forma complementar, de revisões manuais em plataforma do Tribunal de Justiça de Pernambuco (TJPE) e mídias noticiosas online. Realizou-se a descrição dos dados mediante a distribuição de frequências, medidas de tendência central e dispersão. Para analisar o padrão espacial das taxas de feminicídio, foram utilizados o método bayesiano empírico local e o índice de autocorrelação de Moran. Aplicou-se a regressão logística hierarquizada para verificar a associação entre o feminicídio e a violência interpessoal e estimar a razão de chances (Odds Ratio) com intervalos de confiança de 95% (IC95%). Assim, foram localizados 490 feminicídios, o que correspondeu a uma taxa de 2,5 por 100.000 mulheres. A maior proporção de feminicídios foi identificada pela busca manual em mídias noticiosas online e na base processual do TJPE (n = 247; 50,41%). As características principais das vítimas são: idade entre 20 e 39 anos (n = 286; 58,37%); raça/cor negra (n = 400; 81,63%); sem companheiro(a) (n = 407; 83,06%); e escolaridade superior a oito anos de estudo (n = 303; 61,84%). A autocorrelação espacial do evento foi confirmada pelo índice global de Moran das taxas suavizadas (I = 0,3; p = 0,001); a autocorrelação local reforça a interiorização do evento ao apontar área crítica (Q1) formada por municípios localizados na macrorregião do Vale do São Francisco e Araripe. No nível de determinação distal, identificou-se que as seguintes variáveis elevam as chances de ocorrência do feminicídio: residir em município de pequeno porte (OR = 2,10); indisponibilidade de delegacias especializadas no atendimento à mulher (OR = 1,11); e ausência de encaminhamentos para rede assistencial e protetiva na oportunidade de agressão anterior (OR = 1,32). Nos determinantes intermediários, destacou-se que, quanto maior é a intensidade do meio de ação empregado na prática da violência, maior é a chance do desfecho fatal, ressaltando-se o uso de objeto perfurocortante (OR = 3,93) e arma de fogo (OR = 11,14). E, acerca dos determinantes proximais, as vítimas inseridas na faixa etária entre 10 e 19 anos apresentaram menor chance quanto à ocorrência de feminicídio (OR = 0,51). A caracterização da população de estudo pode proporcionar a ampliação dos conhecimentos sobre violência estrutural contra as mulheres, aspectos da notificação e da rede assistencial e protetiva. A análise espacial identificou a interiorização do evento e áreas de transição em Pernambuco, as quais requerem priorização de intervenções. E a modelagem evidenciou que as mulheres estão expostas a múltiplos fatores de risco para a ocorrência de feminicídio, de forma que a discussão, de modo particularizado a todos os níveis de determinação, faz-se ainda mais necessária.

Feminicide results from the sexist patriarchal heritage and social structures historically permeated by unequal gender relations. This ecological study analyzes the epidemiological aspects of feminicides recorded in Pernambuco between 2016 and 2019. Records of homicides and undetermined causes of death of women available in the Mortality Information System were the proxy for feminicide events and accepted as reference. Search steps were established with probabilistic linkage in health databases, as well as manual reviews on the Pernambuco Court of Justice (TJPE) platform and online news media as a complement. Data were described by the distribution of frequencies, measures of central tendency and dispersion. Local empirical Bayesian method and Moran's autocorrelation index were used in the spatial pattern analysis of femicide rates. Hierarchical logistic regression was applied to verify the association between femicide and interpersonal violence and to estimate the Odds Ratio with 95% confidence intervals (95%CI). Search returned a total of 490 feminicides, corresponding to a rate of 2.5 per 100,000 women. The highest proportion of feminicides was identified by manual search in online news media and in the TJPE database (n = 247; 50.41%). Most victims were aged between 20 and 39 years (n = 286; 58.37%), black (n = 400; 81.63%), had no partner (n = 407; 83.06%) and with over eight years of schooling (n = 303; 61.84%). Spatial autocorrelation of the event was confirmed by the Global Moran Index of smoothed rates (I = 0.3; p = 0.001). Local autocorrelation reinforces the interiorization of the phenomenon by pointing to a critical area (Q1) formed by municipalities located in the Vale do São Francisco and Araripe macroregion. At the distal level, the following variables increase the chances of feminicide: living in a small city (OR = 2.10); unavailability of specialized police stations (OR = 1.11); and absence of referrals to the care and protection network in the event of a previous aggression (OR = 1.32). Regarding intermediate determinants, the greater the violence inflicted the greater the chance of a fatal outcome, emphasizing the use of sharp objects (OR = 3.93) and firearms (OR = 11.14). Regarding proximal determinants, victims in the age group 10-19 years old were less likely to be a victim of femicide (OR = 0.51). Characterizing the study population can further knowledge about structural violence against women, and aspects of the notification and the care and protection network. Spatial analysis pointed to the interiorization of the phenomenon and transition areas in Pernambuco, requiring prioritization of interventions. The modeling showed that women are exposed to multiple risk factors for feminicide and further discussions at all levels of determination are necessary.

El feminicidio es un fenómeno derivado de la herencia patriarcal machista y de estructuras sociales históricamente permeadas por relaciones desiguales de género. Este estudio de tipo ecológico tuvo por objetivo analizar los aspectos epidemiológicos de los feminicidios registrados en Pernambuco, en el período entre 2016 y 2019. Como proxy de los eventos de feminicidio, se utilizó como referencia el registro de homicidios y de causas indeterminadas de muertes de mujeres en el Sistema de Informaciones sobre Mortalidad. Se establecieron etapas de búsquedas con vinculación probabilística en las bases de datos de salud y, de forma complementaria, búsquedas manuales en la plataforma del Tribunal de Justicia de Pernambuco (TJPE) y medios en línea. Para describir los datos se utilizaron la distribución de frecuencias, medidas de tendencia central y dispersión. Para analizar el padrón espacial de las tasas de feminicidio se emplearon el método bayesiano empírico local y el índice de autocorrelación de Moran. Se aplicó la regresión logística jerarquizada para constatar la asociación entre el feminicidio y la violencia interpersonal, y estimar la razón de posibilidades (Odds Ratio) con intervalos de confianza del 95% (IC95%). Los resultados apuntaron a 490 feminicidios, lo que correspondió a una tasa de 2,5 por 100.000 mujeres. La mayor proporción de feminicidios se identificó mediante la búsqueda manual en prensa en línea y en la base procesal del TJPE (n = 247; 50,41%). Las principales características de las víctimas fueron edad entre 20 y 39 años (n = 286; 58,37%), raza/color negro (n = 400; 81,63%), sin compañero(a) (n = 407; 83,06%) y nivel de estudios superior a ocho años de estudio (n = 303; 61,84%). La autocorrelación espacial del evento se confirmó mediante el índice de Moran global de las tasas suavizadas (I = 0,3, p = 0,001); la autocorrelación local refuerza la interiorización del evento al señalar área crítica (Q1) formada por municipios situados en la macrorregión del Valle de São Francisco y Araripe. En el nivel de determinación distal se identificó que las siguientes variables aumentan las posibilidades de feminicidio: residir en municipio de pequeño tamaño, (OR = 2,10); indisponibilidad de comisarías especializadas en la atención a la mujer (OR = 1,1); y ausencia de remisiones a la red asistencial y protectora en la ocasión de agresión anterior (OR = 1,32). En los determinantes intermediarios, se destacó que cuanto mayor es la intensidad del medio de acción empleado en la práctica de la violencia, mayor es la posibilidad de desenlace fatal, destacándose el empleo de objeto cortopunzante (OR = 3,93) y arma de fuego (OR = 11,14). En cuanto a los determinantes proximales, las víctimas comprendidas en el tramo de edad comprendido entre los 10 y los 19 años presentaron menos posibilidad de incidencia de feminicidio (OR = 0,51). La caracterización de la población de estudio puede proporcionar la ampliación de los conocimientos sobre violencia estructural contra la mujer, aspectos de la notificación y de la red asistencial protectora. El análisis espacial identificó la interiorización del evento y áreas de transición en Pernambuco, las cuales requieren priorización de las intervenciones. Y el modelaje reveló que las mujeres están expuestas a múltiples factores de riesgo para la incidencia de feminicidio y el debate, de modo particularizado de todos los niveles de determinación, se hace todavía más necesario.

[Burning of sugarcane biomass and hospitalizations of children and older adults for respiratory problems in Pernambuco State, Brazil]. / Queima de biomassa da cana-de-açúcar e hospitalizações de crianças e idosos por agravos respiratórios em Pernambuco, Brasil.

This study aimed to analyze the relationship between hospitalizations for respiratory problems and the regular burning of sugarcane in Pernambuco State, Brazil. This is an ecological time series study corresponding to the period from 2008 to 2018. The rates of hospitalizations for respiratory diseases in children aged under 5 years and in adults older than 60 years in sugarcane-producing and non-producing municipalities were compared using nonparametric Mann-Whitney statistical analysis. Together, we observed the monthly distribution of the hot spots occurrences in the case and control municipalities and applied Pearson's correlation to analyze the association between both variables. For both age groups, hospitalization rates are higher in sugarcane-producing municipalities, with a statistically significant difference p < 0.005. The rate of hospitalization in older adults is 28% higher in the case municipalities, and is even higher in children aged under 5 years whose ratio of the medians is 40%. However, the seasonal behavior of hospitalizations for respiratory diseases differs from that observed in the monthly distribution of hot spots, without statistically significant correlation. These findings suggest a possible association with chronic exposure to particulates emitted by biomass burning, compromising the health of vulnerable groups, and endorse the need to replace fires in the monoculture of sugarcane and to structure public policies to protect human and environmental health.

Este estudo buscou analisar a relação entre as hospitalizações por agravos respiratórios e a queima regular da cana-de-açúcar em Pernambuco, Brasil. Trata-se de um estudo ecológico de série temporal correspondente ao período de 2008 a 2018. Foram comparadas as taxas de hospitalizações por agravos respiratórios em crianças menores de 5 anos e em idosos maiores de 60 anos em municípios produtores e não produtores de cana-de-açúcar, por meio da análise estatística não paramétrica de Mann-Whitney. Conjuntamente, foi observada a distribuição mensal das ocorrências de focos de calor nos municípios casos e controles e aplicada a correlação de Pearson para analisar a associação entre ambas as variáveis. Foi verificado que, para ambos os grupos etários, as taxas de hospitalizações são maiores nos municípios produtores de cana-de-açúcar, com diferença estatística significativa p < 0,005. A taxa de internação hospitalar em idosos é 28% mais elevada nos municípios casos, sendo ainda maior em crianças menores de 5 anos, cuja razão das medianas é 40%. No entanto, foi identificado que o comportamento sazonal das hospitalizações por agravos respiratórios diverge do observado na distribuição mensal dos focos de calor, não havendo correlação estatística significativa. Esses achados sugerem possível associação com a exposição crônica aos particulados emitidos pela queima de biomassa, comprometendo a saúde de grupos vulneráveis, e endossam a necessidade de substituição das queimadas no monocultivo da cana-de-açúcar, bem como a estruturação de políticas públicas de proteção à saúde humana e ambiental.

Este estudio buscó analizar la relación entre las hospitalizaciones por enfermedades respiratorias y la quema regular de caña de azúcar en Pernambuco, Brasil. Se trata de un estudio ecológico de serie temporal correspondiente al período entre 2008 y 2018. Las tasas de hospitalizaciones por enfermedades respiratorias en niños menores de 5 años y en ancianos mayores de 60 años en municipios productores de caña de azúcar y en los municipios no productores de azúcar se compararon mediante el análisis estadístico no paramétrico de Mann-Whitney. Se observó en conjunto la distribución mensual de las ocurrencias de puntos calientes en los casos y controles de los municipios, y se aplicó la correlación de Pearson para analizar la asociación entre ambas variables. Se encontró que, para ambos grupos de edad, las tasas de hospitalización fueron más altas en los municipios productores de caña de azúcar, con una diferencia estadísticamente significativa p < 0,005. La tasa de hospitalización de los ancianos fue un 28% mayor en los municipios casos, y aún mayor que la de los niños menores de 5 años cuya relación de las medianas fue del 40%. Sin embargo, se identificó que el comportamiento estacional de las hospitalizaciones por enfermedades respiratorias difiere de lo observado en la distribución mensual de puntos calientes, sin correlación estadística significativa. Estos hallazgos evidencian una posible asociación con la exposición crónica a partículas emitidas por la quema de biomasa, lo que afecta la salud de los grupos vulnerables, además apuntan a la necesidad de implementar medidas contra los incendios en el monocultivo de la caña de azúcar y políticas públicas para proteger la salud humana y el medioambiente.

The impact of implementing the 10-valent pneumococcal conjugate vaccine on hospitalizations for pneumonia among children.

Pneumonia is a major cause of morbidity and mortality in children, with pneumococcus as the main etiologic agent. In Brazil, the 10-valent pneumococcal conjugate vaccine (PCV-10) was introduced into the childhood immunization schedule in 2010. The aim of this study was to assess the impact caused by implementing PCV-10 on the hospitalizations of children with pneumonia, between 2005 and 2015, in the state of Pernambuco, Brazil. An ecological time series study and a forecasting analysis were conducted. A comparison was made between the hospitalizations of children aged between seven months and four years due to pneumonia in the Brazilian Unified Health System, in the 5 years before (2005-2009) and after (2011-2015) implementation of PCV-10. Descriptive analysis included absolute and relative values, means and rates of hospitalization. The chi-square test was used to compare the annual incidence of hospitalizations and the t-Student test to compare the five-year mean values. For the temporal modeling of hospitalizations, an autoregressive integrated moving average was used, adjusted with seasonal-SARIMA (Box-Jenkins methodology), with a prediction of the monthly number of hospitalizations for 2011-2015. The predicted and observed values for 2011-2015 were then compared. The number of hospitalizations after implementing PCV-10 was reduced by 24.5 %. The monthly average of hospitalizations dropped from 681 (2005-2009) to 514 (2011-2015). The hospitalization rate dropped from 56.1 per thousand live births in the five-year period prior to PCV-10 to 43.4 in the following five-year period (a 22.7% reduction). Comparing the values predicted by the SARIMA model for a scenario without PCV-10 in the second five-year period, with those reported after implementing PCV-10, the estimated number of prevented hospitalizations was 8,682 in the five years following the introduction of the vaccine. In conclusion, in the five years following implementation of PCV-10, hospitalizations of children with pneumonia in Pernambuco decrease by 22%.

Impact of the COVID-19 pandemic on the mental health of frontline healthcare workers in a highly affected region in Brazil.

BACKGROUND: The COVID-19 pandemic had a major impact on the mental health of healthcare workers (HCWs), especially in low and middle-income countries, which had to face additional political, social, and economic challenges. We thus aimed to assess the prevalence of mental health outcomes and the associated factors in HCWs treating COVID-19 patients in one of the most affected regions in Brazil. METHODS: We used the Respondent-Driven Sampling method to assess the risks of COVID-19 infection and symptoms of mental disorders in nurses, nursing technicians, and physicians who worked on the frontline in the metropolitan region of Recife. 865 healthcare workers completed a survey regarding sociodemographic data, work-related risks, and symptoms of mental disorders - SRQ-20 for common mental disorders (CMD); AUDIT-C for problematic alcohol use; GAD-7 for anxiety; PHQ-9 for depression; PCL-5 for post-traumatic stress disorder (PTSD). Gile's successive sampling estimator was used to produce the weighted estimates by professional category. A Poisson regression model with robust variance was used to analyze factors associated with a positive screening for CMD. We will present the results of a cross-sectional analysis of the mental health outcomes after the first peak of COVID-19 - from August 2020 to February 2021. RESULTS: The prevalence ratios for a positive screening for CMD were 34.9% (95% CI: 27.8-41.9) in nurses, 28.6% (95% CI: 21.3-36.0) in physicians, and 26.6% (95% CI: 16.8-36.5) in nursing technicians. Nurses presented a higher prevalence of depressive symptoms (23%). Positive screening for problematic alcohol use (10.5 to14.0%), anxiety (10.4 to 13.3%), and PTSD (3.3 to 4.4%) were similar between the professional categories. The main factors associated with CMD in nurses and physicians were related to an intrinsic susceptibility to mental illness, such as previous or family history of psychiatric disorder, and female sex. Among nurse technicians, work-related factors, such as accidents with biological material, presented the strongest association with CMD. CONCLUSION: The mental health of HCWs fighting COVID-19 in Recife was severely affected. It is crucial that healthcare services provide adequate working conditions and psychological support, investing in programs to promote and protect HCWs mental health.

Risk of adverse outcomes in offspring with RT-PCR confirmed prenatal Zika virus exposure: An individual participant data meta-analysis of 13 cohorts in the Zika Brazilian Cohorts Consortium.

Background: Knowledge regarding the risks associated with Zika virus (ZIKV) infections in pregnancy has relied on individual studies with relatively small sample sizes and variable risk estimates of adverse outcomes, or on surveillance or routinely collected data. Using data from the Zika Brazilian Cohorts Consortium, this study aims, to estimate the risk of adverse outcomes among offspring of women with RT-PCR-confirmed ZIKV infection during pregnancy and to explore heterogeneity between studies. Methods: We performed an individual participant data meta-analysis of the offspring of 1548 pregnant women from 13 studies, using one and two-stage meta-analyses to estimate the absolute risks. Findings: Of the 1548 ZIKV-exposed pregnancies, the risk of miscarriage was 0.9%, while the risk of stillbirth was 0.3%. Among the pregnancies with liveborn children, the risk of prematurity was 10,5%, the risk of low birth weight was 7.7, and the risk of small for gestational age (SGA) was 16.2%. For other abnormalities, the absolute risks were: 2.6% for microcephaly at birth or first evaluation, 4.0% for microcephaly at any time during follow-up, 7.9% for neuroimaging abnormalities, 18.7% for functional neurological abnormalities, 4.0% for ophthalmic abnormalities, 6.4% for auditory abnormalities, 0.6% for arthrogryposis, and 1.5% for dysphagia. This risk was similar in all sites studied and in different socioeconomic conditions, indicating that there are not likely to be other factors modifying this association. Interpretation: This study based on prospectively collected data generates the most robust evidence to date on the risks of congenital ZIKV infections over the early life course. Overall, approximately one-third of liveborn children with prenatal ZIKV exposure presented with at least one abnormality compatible with congenital infection, while the risk to present with at least two abnormalities in combination was less than 1.0%.

Queima de biomassa da cana-de-açúcar e hospitalizações de crianças e idosos por agravos respiratórios em Pernambuco, Brasil / Burning of sugarcane biomass and hospitalizations of children and older adults for respiratory problems in Pernambuco State, Brazil / Quema de biomasa de caña de azúcar y hospitalizaciones de niños y ancianos por enfermedades respiratorias en Pernambuco, Brasil

Resumo: Este estudo buscou analisar a relação entre as hospitalizações por agravos respiratórios e a queima regular da cana-de-açúcar em Pernambuco, Brasil. Trata-se de um estudo ecológico de série temporal correspondente ao período de 2008 a 2018. Foram comparadas as taxas de hospitalizações por agravos respiratórios em crianças menores de 5 anos e em idosos maiores de 60 anos em municípios produtores e não produtores de cana-de-açúcar, por meio da análise estatística não paramétrica de Mann-Whitney. Conjuntamente, foi observada a distribuição mensal das ocorrências de focos de calor nos municípios casos e controles e aplicada a correlação de Pearson para analisar a associação entre ambas as variáveis. Foi verificado que, para ambos os grupos etários, as taxas de hospitalizações são maiores nos municípios produtores de cana-de-açúcar, com diferença estatística significativa p < 0,005. A taxa de internação hospitalar em idosos é 28% mais elevada nos municípios casos, sendo ainda maior em crianças menores de 5 anos, cuja razão das medianas é 40%. No entanto, foi identificado que o comportamento sazonal das hospitalizações por agravos respiratórios diverge do observado na distribuição mensal dos focos de calor, não havendo correlação estatística significativa. Esses achados sugerem possível associação com a exposição crônica aos particulados emitidos pela queima de biomassa, comprometendo a saúde de grupos vulneráveis, e endossam a necessidade de substituição das queimadas no monocultivo da cana-de-açúcar, bem como a estruturação de políticas públicas de proteção à saúde humana e ambiental.

Abstract: This study aimed to analyze the relationship between hospitalizations for respiratory problems and the regular burning of sugarcane in Pernambuco State, Brazil. This is an ecological time series study corresponding to the period from 2008 to 2018. The rates of hospitalizations for respiratory diseases in children aged under 5 years and in adults older than 60 years in sugarcane-producing and non-producing municipalities were compared using nonparametric Mann-Whitney statistical analysis. Together, we observed the monthly distribution of the hot spots occurrences in the case and control municipalities and applied Pearson's correlation to analyze the association between both variables. For both age groups, hospitalization rates are higher in sugarcane-producing municipalities, with a statistically significant difference p < 0.005. The rate of hospitalization in older adults is 28% higher in the case municipalities, and is even higher in children aged under 5 years whose ratio of the medians is 40%. However, the seasonal behavior of hospitalizations for respiratory diseases differs from that observed in the monthly distribution of hot spots, without statistically significant correlation. These findings suggest a possible association with chronic exposure to particulates emitted by biomass burning, compromising the health of vulnerable groups, and endorse the need to replace fires in the monoculture of sugarcane and to structure public policies to protect human and environmental health.

Resumen: Este estudio buscó analizar la relación entre las hospitalizaciones por enfermedades respiratorias y la quema regular de caña de azúcar en Pernambuco, Brasil. Se trata de un estudio ecológico de serie temporal correspondiente al período entre 2008 y 2018. Las tasas de hospitalizaciones por enfermedades respiratorias en niños menores de 5 años y en ancianos mayores de 60 años en municipios productores de caña de azúcar y en los municipios no productores de azúcar se compararon mediante el análisis estadístico no paramétrico de Mann-Whitney. Se observó en conjunto la distribución mensual de las ocurrencias de puntos calientes en los casos y controles de los municipios, y se aplicó la correlación de Pearson para analizar la asociación entre ambas variables. Se encontró que, para ambos grupos de edad, las tasas de hospitalización fueron más altas en los municipios productores de caña de azúcar, con una diferencia estadísticamente significativa p < 0,005. La tasa de hospitalización de los ancianos fue un 28% mayor en los municipios casos, y aún mayor que la de los niños menores de 5 años cuya relación de las medianas fue del 40%. Sin embargo, se identificó que el comportamiento estacional de las hospitalizaciones por enfermedades respiratorias difiere de lo observado en la distribución mensual de puntos calientes, sin correlación estadística significativa. Estos hallazgos evidencian una posible asociación con la exposición crónica a partículas emitidas por la quema de biomasa, lo que afecta la salud de los grupos vulnerables, además apuntan a la necesidad de implementar medidas contra los incendios en el monocultivo de la caña de azúcar y políticas públicas para proteger la salud humana y el medioambiente.

Spatiotemporal distribution analysis of syphilis in Brazil: Cases of congenital and syphilis in pregnant women from 2001-2017.

In Brazil, the notification of congenital (CS) and syphilis in pregnant women (SiP) is compulsory. Notification data provided by the Ministry of Health in combination with the mapping of vulnerable geographic areas is essential to forecasting possible outbreaks and more effectively combating infection through monitoring. We aim to evaluate the spatiotemporal distribution and epidemiological aspects of reported cases of CS and SiP in Brazil. A retrospective ecological study was carried out using secondary surveillance data obtained from the Brazilian National Notifiable Diseases Information System (SINAN) database, considering all reported cases of CS and SiP between 2001 to 2017. Epidemiological characteristics and time trends were analyzed using joinpoint regression models and spatial distribution, considering microregions or states/macroregions as units of analysis. A total of 188,630 (359/100,000 birth lives) CS and 235,895 of SiP (6.3/100,000 inhabitants) were reported during the period studied. In general, the epidemiologic profile of Brazil indicates most reported CS cases occurred in "mixed-race" newborns who were diagnosed within seven days of birth and whose mothers had received prenatal care, but the epidemiologic profile varies by Brazilian macroregion. Regarding SiP, most cases were among women who self-reported 'mixed-race', were aged 20-39 years, had up to eight years of formal education and were diagnosed with primary or latent syphilis. Approximately 549 (98.4%) and 558 (100%) microregions reported at least one case of CS and SiP, respectively. From 2012 to 2016, CS cases increased significantly in almost all Brazilian states, most notably in the South, Southeast, and Central-West macroregions, from 2001-2017 and the relative risk (RR) of SiP increased around 400% (RR: 1,00 to 445,50). Considering the epidemiological scenario of the infection in Brazil, it is necessary to enhance preventive, control and eradication measures.

Systematic Review of Survival Analysis in Leprosy Studies-Including the Following Outcomes: Relapse, Impairment of Nerve Function, Reactions and Physical Disability.

Leprosy is a public health problem in South American, African and Oceanian countries. National programs need to be evaluated, and the survival analysis model can aid in the construction of new indicators. The aim of this study was to assess the period of time until the outcomes of interest for patients with or exposed to leprosy by means of survival analysis surveys. This review researched articles using the databases of PubMed, Science Direct, Scopus, Scielo and BVS published in English and Portuguese. Twenty-eight articles from Brazil, India, Bangladesh, the Philippines and Indonesia were included. The Kaplan-Meier method, which derives the log-rank test, and Cox's proportional hazards regression, which obtains the hazard ratio, were applied. The mean follow-up until the following outcomes were: (I) leprosy (2.3 years) in the population who were exposed to it, (II) relapse (5.9 years), (III) clinical manifestations before, during and after treatment-nerve function impairment (5.2 years), leprosy reactions (4.9 years) and physical disability (8.3 years) in the population of patients with leprosy. Therefore, the use of survival analysis will enable the evaluation of national leprosy programs and assist in the decision-making process to face public health problems.

Characteristics of children of the Microcephaly Epidemic Research Group Pediatric Cohort who developed postnatal microcephaly.

The number of studies published on postnatal microcephaly in children with Congenital Zika Syndrome is small, clinical presentations vary and aspects of the evolution of these children remain unclarified. The present case series examined clinical characteristics and assessed the growth velocity of the head circumference, weight and height Z-scores in 23 children who developed postnatal microcephaly during follow-up in the Microcephaly Epidemic Research Group Pediatric Cohort. To estimate the change in the head circumference, weight and height Z-scores over time and compare the mean difference between sexes, we used multilevel mixed-effects linear regressions with child-specific random effects. Among these children, 60.9% (n = 14/23) presented with craniofacial disproportion, 60.9% (n = 14/23) with strabismus, 47.8% (n = 11/23) with early onset seizures, 47.8% (n = 11/23) with dysphagia and 43.5% (n = 10/23) with arthrogryposis. Of the 82.7% (n = 19/23) children who underwent neuroimaging, 78.9% (n = 15/19) presented with alterations in the central nervous system. Monthly growth velocity, expressed in Z-scores, of the head circumference was - 0.098 (95% CI % - 0.117 to - 0.080), of weight was: - 0.010 (95%-CI - 0.033 to 0.014) and of height was: - 0.023 (95%-CI - 0.046 to 0.0001). Postnatal microcephaly occurred mainly in children who had already presented with signs of severe brain damage at birth; there was variability in weight and height development, with no set pattern.

Risk of SARS-CoV-2 infection among front-line healthcare workers in Northeast Brazil: a respondent-driven sampling approach.

OBJECTIVES: We assessed the prevalence of SARS-CoV-2 infection, personal protective equipment (PPE) shortages and occurrence of biological accidents among front-line healthcare workers (HCW). DESIGN, SETTING AND PARTICIPANTS: Using respondent-driven sampling, the study recruited distinct categories of HCW attending suspected or confirmed patients with COVID-19 from May 2020 to February 2021, in the Recife metropolitan area, Northeast Brazil. OUTCOME MEASURES: The criterion to assess SARS-CoV-2 infection among HCW was a positive self-reported PCR test. RESULTS: We analysed 1525 HCW: 527 physicians, 471 registered nurses, 263 nursing assistants and 264 physical therapists. Women predominated in all categories (81.1%; 95% CI: 77.8% to 84.1%). Nurses were older with more comorbidities (hypertension and overweight/obesity) than the other staff. The overall prevalence of SARS-CoV-2 infection was 61.8% (95% CI: 55.7% to 67.5%) after adjustment for the cluster random effect, weighted by network, and the reference population size. Risk factors for a positive RT-PCR test were being a nursing assistant (OR adjusted: 2.56; 95% CI: 1.42 to 4.61), not always using all recommended PPE while assisting patients with COVID-19 (OR adj: 2.15; 95% CI: 1.02 to 4.53) and reporting a splash of biological fluid/respiratory secretion in the eyes (OR adj: 3.37; 95% CI: 1.10 to 10.34). CONCLUSIONS: This study shows the high frequency of SARS-CoV2 infection among HCW presumably due to workplace exposures. In our setting, nursing assistant comprised the most vulnerable category. Our findings highlight the need for improving healthcare facility environments, specific training and supervision to cope with public health emergencies.

Co-circulation of Chikungunya Virus during the 2015-2017 Zika Virus Outbreak in Pernambuco, Brazil: An Analysis of the Microcephaly Epidemic Research Group Pregnancy Cohort.

Co-circulation of arthropod-borne viruses, particularly those with shared mosquito vectors like Zika (ZIKV) and Chikungunya (CHIKV), is increasingly reported. An accurate differential diagnosis between ZIKV and CHIKV is of high clinical importance, especially in the context of pregnancy, but remains challenging due to limitations in the availability of specialized laboratory testing facilities. Using data collected from the prospective pregnancy cohort study of the Microcephaly Epidemic Research Group, which followed up pregnant persons with rash during the peak and decline of the 2015-2017 ZIKV epidemic in Recife, Pernambuco, Brazil, this study aims to describe the geographic and temporal distribution of ZIKV and CHIKV infections and to investigate the extent to which ZIKV and CHIKV infections may be clinically differentiable. Between December 2015 and June 2017, we observed evidence of co-circulation with laboratory confirmation of 213 ZIKV mono-infections, 55 CHIKV mono-infections, and 58 sequential ZIKV/CHIKV infections (i.e., cases with evidence of acute ZIKV infection with concomitant serological evidence of recent CHIKV infection). In logistic regressions with adjustment for maternal age, ZIKV mono-infected cases had lower odds than CHIKV mono-infected cases of presenting with arthralgia (aOR, 99% CI: 0.33, 0.15-0.74), arthritis (0.35, 0.14-0.85), fatigue (0.40, 0.17-0.96), and headache (0.44, 0.19-1.90). However, sequential ZIKV/CHIKV infections complicated discrimination, as they did not significantly differ in clinical presentation from CHIKV mono-infections. These findings suggest clinical symptoms alone may be insufficient for differentiating between ZIKV and CHIKV infections during pregnancy and therefore laboratory diagnostics continue to be a valuable tool for tailoring care in the event of arboviral co-circulation.

Neighbourhood-level income and Zika virus infection during pregnancy in Recife, Pernambuco, Brazil: an ecological perspective, 2015-2017.

Zika virus (ZIKV) infections during pregnancy can lead to adverse neurodevelopmental and clinical outcomes in congenitally infected offspring. As the city of Recife in Pernambuco State, Brazil-the epicentre of the Brazilian microcephaly epidemic-has considerable disparities in living conditions, this study used an ecological approach to investigate the association between income at the neighbourhood level and the risk of ZIKV infections in pregnant individuals between December 2015 and April 2017. The spatial distribution of pregnant individuals with ZIKV infection was plotted on a map of Recife stratified into four categories based on mean monthly income of household heads. Additionally, a Poisson regression model with robust variance was fitted to compare proportions of ZIKV infections among pregnant individuals in relation to the mean monthly income of household heads, based on the 2010 census data, across 94 neighbourhoods in Recife. The results provide evidence that the risk of ZIKV infection to pregnant individuals was higher among those residing in lower-income neighbourhoods: relative to neighbourhoods that had a mean monthly income of ≥5 times minimum wage, neighbourhoods with <1 and 1 to <2 times minimum wage had more than four times the risk (incidence rate ratio, 95% CI 4.08, 1.88 to 8.85 and 4.30, 2.00 to 9.20, respectively). This study provides evidence of a strong association between neighbourhood-level income and ZIKV infection risks in the pregnant population of Recife. In settings prone to arboviral outbreaks, locally targeted interventions to improve living conditions, sanitation, and mosquito control should be a key focus of governmental interventions to reduce risks associated with ZIKV infections during pregnancy.

A new insight into the definition of microcephaly in Zika congenital syndrome era.

This study aimed to compare the anthropometric measurements and body proportionalities of neonates born before the Zika virus epidemic with those born during this period. We compared 958 neonates born during the pre-Zika epidemic with 264 neonates born during the epidemic period. The newborns had their head circumference, weight, and length classified according to the Fenton & Kim growth chart. We considered disproportionate those individuals that presented microcephaly and adequate weight or length for sex and gestational age, and those whose head circumferences were lower than the ratio ((length / 2) + 9.5) - 2.5cm. We estimated the frequencies of Zika positivity and brain imaging findings among neonates with microcephaly born during the epidemic period, concerning the anthropometric and body proportionality parameters. Low weight and proportionate microcephaly were similar among newborns from both periods. However, the frequencies of newborns with microcephaly with a very low length and disproportionate microcephaly were higher among the neonates of the epidemic period with brain abnormalities and positive for Zika virus. We conclude that, at birth, the disproportion between head circumference and length can be an indicator of the severity of microcephaly caused by congenital Zika.

Zika virus infection and microcephaly: spatial analysis and socio-environmental determinants in a region of high Aedes aegypti infestation in the Central-West Region of Brazil.

BACKGROUND: More than 5 years after the Zika virus (ZIKV) epidemic, Zika infection remains a major concern in regions with high Aedes infestation. The objectives of this study were (i) to identify clusters of ZIKV infection and microcephaly, and/or central nervous system (CNS) alterations associated with congenital infection during the epidemic peak in 2016 and subsequently, in 2017 and 2018; (ii) to measure the non-spatial correlation between ZIKV infection and microcephaly and/or CNS alterations associated with congenital infection; and (iii) to analyse the sociodemographic/economic, health, and environmental determinants associated with the incidence of ZIKV in a region of high infestation by Aedes aegypti in the Central-West Region of Brazil. METHODS: This ecological study analysed 246 municipalities in the state of Goiás (6.9 million inhabitants). The data were obtained from the Information System for Notifiable Diseases (ZIKV cases) and the Public Health Event Registry (microcephaly and/or CNS alterations associated with congenital infection). Incidence rates and prevalence of ZIKA infection were smoothed by an empirical Bayesian estimator (LEbayes), producing the local empirical Bayesian rate (LEBR). In the spatial analysis, ZIKV infection and microcephaly cases were georeferenced by the municipality of residence for 2016 and grouped for 2017 and 2018. Global Moran's I and the Hot Spot Analysis tool (Getis-Ord Gi* statistics) were used to analyse the spatial autocorrelation and clusters of ZIKV infection and microcephaly, respectively. A generalised linear model from the Poisson family was used to assess the association between ecological determinants and the smoothing incidence rate of ZIKV infection. RESULTS: A total of 9892 cases of acute ZIKV infection and 121 cases of microcephaly were confirmed. The mean LEBR of the ZIKV infection in the 246 municipalities was 22.3 cases/100,000 inhabitants in 2016, and 10.3 cases/100,000 inhabitants in 2017 and 2018. The LEBR of the prevalence rate of microcephaly and/or CNS alterations associated with congenital infection was 7 cases/10,000 live births in 2016 and 2 cases/10,000 live births during 2017-2018. Hotspots of ZIKV infection and microcephaly cases were identified in the capital and neighbouring municipalities in 2016, with new clusters in the following years. In a multiple regression Poisson analysis, ZIKV infection was associated with higher population density, the incidence of dengue, Aedes larvae infestation index, and average rainfall. The important determinant of ZIKV infection incidence reduction was the increase in households attended by endemic disease control agents. CONCLUSIONS: Our analyses were able to capture, in a more granular way, aspects that make it possible to inform public managers of the sentinel areas identified in the post-epidemic hotspots.

COVID-19 in northeast Brazil: first year of the pandemic and uncertainties to come.

OBJECTIVE: To analyze the epidemic of COVID-19 in northeastern Brazil, one of the regions most affected by the virus. METHODS: The official data for COVID-19, from March 2020 to March 2021 in the states of the Northeast Region (NE), were used. The analysis of capital cities and states for accumulated weekly cases and confirmed deaths was made using the JoinPoint Trend Analysis application. RESULTS: In one year, the Northeast region reported 22.9% of the cases and 21.5% of the deaths in the country due to COVID-19. At the beginning of the pandemic, all states showed a growing number of cases, first in the capitals and then in the interior. Following this wave, decreases are observed in all states and their capitals, but with many still reporting a large number of cases. In the middle of the 2nd semester of 2020 the number of cases begins to increase again simultaneously in states and their capitals-some at explosive speed-especially in late 2020 and early 2021. A similar pattern is observed in deaths, which exceed or approach the peak seen in the first wave. In the first wave, all capitals and northeastern states adopted intense isolation measures. Fortaleza, Recife and Teresina reached the highest isolation index of all capitals, close to 0.60. This index decreases, with a slight growth trend until the end of December. With the exception of Fortaleza and Salvador, the other capitals fell to less than 0.40. CONCLUSION: The Brazilian NE and the country are in increasingly complicated health, social and economic situations. It is necessary to speed up vaccinations and maintain non-pharmacological measures: face masks, social distancing measures and hygiene care, in addition to policies to protect workers who have lost their incomes and to subsidize small business owners.

The Microcephaly Epidemic Research Group Paediatric Cohort (MERG-PC): A Cohort Profile.

This cohort profile aims to describe the ongoing follow-up of children in the Microcephaly Epidemic Research Group Paediatric Cohort (MERG-PC). The profile details the context and aims of the study, study population, methodology including assessments, and key results and publications to date. The children that make up MERG-PC were born in Recife or within 120 km of the city, in Pernambuco/Brazil, the epicentre of the microcephaly epidemic. MERG-PC includes children from four groups recruited at different stages of the ZIKV microcephaly epidemic in Pernambuco, i.e., the Outpatient Group (OG/n = 195), the Microcephaly Case-Control Study (MCCS/n = 80), the MERG Pregnant Women Cohort (MERG-PWC/n = 336), and the Control Group (CG/n = 100). We developed a comprehensive array of clinical, laboratory, and imaging assessments that were undertaken by a 'task force' of clinical specialists in a single day at 3, 6, 12, 18 months of age, and annually from 24 months. Children from MCCS and CG had their baseline assessment at birth and children from the other groups, at the first evaluation by the task force. The baseline cohort includes 711 children born between February 2015 and February 2019. Children's characteristics at baseline, excluding CG, were as follows: 32.6% (184/565) had microcephaly, 47% (263/559) had at least one physical abnormality, 29.5% (160/543) had at least one neurological abnormality, and 46.2% (257/556) had at least one ophthalmological abnormality. This ongoing cohort has contributed to the understanding of the congenital Zika syndrome (CZS) spectrum. The cohort has provided descriptions of paediatric neurodevelopment and early epilepsy, including EEG patterns and treatment response, and information on the frequency and characteristics of oropharyngeal dysphagia; cryptorchidism and its surgical findings; endocrine dysfunction; and adenoid hypertrophy in children with Zika-related microcephaly. The study protocols and questionnaires were shared across Brazilian states to enable harmonization across the different studies investigating microcephaly and CZS, providing the opportunity for the Zika Brazilian Cohorts Consortium to be formed, uniting all the ZIKV clinical cohorts in Brazil.

[Covid-19 in the Northeast of Brazil: from lockdown to the relaxation of social distancing measures]. / Covid-19 no nordeste do Brasil: entre o lockdown e o relaxamento das medidas de distanciamento social.

Even in the period when the Covid-19 pandemic was on the rise in the Northeast of Brazil, the relaxation of social distancing measures was introduced. The scope of the study is to assess, in the light of the epidemiological-sanitary situation in the region, the suitability of relaxation of social distancing measures. Based on the WHO guidelines for relaxation of social distancing, operational indicators were created and analyzed for each guideline in the context of the Northeast. To analyze the behavior of the epidemic, according to selected indicators, Joinpoint trend analysis techniques, heat maps, rate ratios and time trends between capitals and the state interior were compared. The weekly growth peak of the epidemic occurred in May-July 2020 (epidemiological weeks 19 to 31). In most capitals, there was no simultaneous downward trend in the number of cases and deaths in the 14 days prior to flexibilization. In all states the number of tests performed was insufficient. In epidemiological week 24, the state percentages of ICU/Covid-19 bed occupancy were close to or above 70%. The epidemiological situation of the nine Northeastern state capitals analyzed here did not meet criteria and parameters recommended by the World Health Organization for the relaxation of social distancing measures.

Mesmo no período em que a pandemia de Covid-19 encontrava-se em crescimento no Nordeste do Brasil, iniciou-se a adoção de medidas de flexibilização do distanciamento social. O objetivo do estudo é o de avaliar a pertinência das propostas de flexibilização, tomando-se em conta a situação da pandemia em cada local e o momento em que foram adotadas. Tendo como referência as diretrizes da OMS, foram construídos e analisados indicadores operacionais para cada diretriz, no contexto da região Nordeste. Para análise do comportamento da epidemia, conforme indicadores selecionados, foram usadas técnicas de Joinpoint Trend Analysis, mapas de calor, razão de taxas e comparação da tendência temporal entre capitais e interior dos estados. O pico do crescimento semanal ocorreu em maio-julho/2020 (semanas epidemiológicas 19 a 31). Na maioria das capitais não se observou tendência decrescente simultânea do número de casos e óbitos nos 14 dias prévios à flexibilização. Em todos os estados o quantitativo de testes realizados foi insuficiente. Na semana epidemiológica 24 os percentuais estaduais de ocupação de leitos de UTI/Covid-19 foram próximos ou superiores 70%. A situação epidemiológica das nove capitais dos estados do Nordeste, no momento em que a decisão de flexibilização foi tomada, mostra que nenhuma delas atendia aos critérios e parâmetros recomendados pela OMS.

Covid-19 no nordeste do Brasil: entre o lockdown e o relaxamento das medidas de distanciamento social / Covid-19 in the Northeast of Brazil: from lockdown to the relaxation of social distancing measures

Resumo Mesmo no período em que a pandemia de Covid-19 encontrava-se em crescimento no Nordeste do Brasil, iniciou-se a adoção de medidas de flexibilização do distanciamento social. O objetivo do estudo é o de avaliar a pertinência das propostas de flexibilização, tomando-se em conta a situação da pandemia em cada local e o momento em que foram adotadas. Tendo como referência as diretrizes da OMS, foram construídos e analisados indicadores operacionais para cada diretriz, no contexto da região Nordeste. Para análise do comportamento da epidemia, conforme indicadores selecionados, foram usadas técnicas de Joinpoint Trend Analysis, mapas de calor, razão de taxas e comparação da tendência temporal entre capitais e interior dos estados. O pico do crescimento semanal ocorreu em maio-julho/2020 (semanas epidemiológicas 19 a 31). Na maioria das capitais não se observou tendência decrescente simultânea do número de casos e óbitos nos 14 dias prévios à flexibilização. Em todos os estados o quantitativo de testes realizados foi insuficiente. Na semana epidemiológica 24 os percentuais estaduais de ocupação de leitos de UTI/Covid-19 foram próximos ou superiores 70%. A situação epidemiológica das nove capitais dos estados do Nordeste, no momento em que a decisão de flexibilização foi tomada, mostra que nenhuma delas atendia aos critérios e parâmetros recomendados pela OMS.

Abstract Even in the period when the Covid-19 pandemic was on the rise in the Northeast of Brazil, the relaxation of social distancing measures was introduced. The scope of the study is to assess, in the light of the epidemiological-sanitary situation in the region, the suitability of relaxation of social distancing measures. Based on the WHO guidelines for relaxation of social distancing, operational indicators were created and analyzed for each guideline in the context of the Northeast. To analyze the behavior of the epidemic, according to selected indicators, Joinpoint trend analysis techniques, heat maps, rate ratios and time trends between capitals and the state interior were compared. The weekly growth peak of the epidemic occurred in May-July 2020 (epidemiological weeks 19 to 31). In most capitals, there was no simultaneous downward trend in the number of cases and deaths in the 14 days prior to flexibilization. In all states the number of tests performed was insufficient. In epidemiological week 24, the state percentages of ICU/Covid-19 bed occupancy were close to or above 70%. The epidemiological situation of the nine Northeastern state capitals analyzed here did not meet criteria and parameters recommended by the World Health Organization for the relaxation of social distancing measures.