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1.
S Afr Med J ; 110(7): 671-677, 2020 Jul 07.
Artigo em Inglês | MEDLINE | ID: mdl-32880346

RESUMO

BACKGROUND: Despite substantial progress in reducing pregnancy-related preventable morbidity and mortality, these remain unacceptably high in developing countries. In 2016, the World Health Organization (WHO) revised recommendations for antenatal care (ANC) from a 4-visit model to a minimum of 8 ANC contacts to reduce perinatal mortality further and improve women's experience of care. The guidelines also recommend that the first ANC visit (ANC-1) should occur during the first trimester. OBJECTIVES: To describe the uptake of routine ANC and its associated factors in South Africa (SA) prior to the 2016 WHO recommendations, when the country recommended 4 ANC visits, to bring to light potential challenges in achieving the current recommendations. METHODS: Secondary data analyses were performed from 3 facility-based, cross-sectional national surveys, conducted to measure 6-week mother-to-child transmission of HIV and coverage of related interventions in SA. These surveys recruited mother-infant pairs attending selected public primary healthcare facilities for their infants' 6-week immunisation in 2010, 2011 -2012 and 2012 -2013. Quantitative questionnaires were used to gather sociodemographic and antenatal-to-peripartum information from Road to Health cards and maternal recall. The inclusion criteria for this secondary assessment were at least 1 ANC visit, the primary outcome being uptake of ≥4 ANC visits. A multivariable logistic regression model was used to: (i) identify maternal factors associated with ANC visits; and (ii) establish whether receiving selected ANC activities was associated with frequency or timing of ANC-1. RESULTS: Of the 9 470, 9 646 and 8 763 women who attended at least 1 ANC visit, only 47.5% (95% confidence interval (CI) 45.4 -49.6), 55.6% (95% CI 53.2 -58.0) and 56.7% (95% CI 54.3 -59.1) adhered to ≥4 ANC visits, while 36.0% (95% CI 34.5 -37.5), 43.5% (95% CI 42.0 -45.1) and 50.8% (95% CI 49.3 -52.2) attended ANC-1 early (before 20 weeks' gestation) in 2010, 2011 -2012 and 2012 -2013, respectively. Multiparity and lower socioeconomic status were significantly associated with non-adherence to the 4-visit ANC recommendation, while a later survey year, higher education, being married, >19 years old, HIV-positive, planned pregnancy and knowing how HIV is transmitted vertically were strongly related to ≥4 ANC visits. The number of women who received selected ANC activities increased significantly with survey year and ≥4 ANC visits, but was not associated with timing of ANC-1. CONCLUSIONS: Despite increases in the uptake of ≥4 ANC visits and early ANC-1 rates between 2010 and 2013, these practices remain suboptimal. Adhering to ≥4 ANC visits improved coverage of selected ANC activities, implying that strengthening efforts to increase the uptake of ANC from at least 4 to 8, could improve overall outcomes.


Assuntos
Infecções por HIV/epidemiologia , Cuidado Pré-Natal/estatística & dados numéricos , Adulto , Fatores Etários , Estudos Transversais , Escolaridade , Serviços de Planejamento Familiar/estatística & dados numéricos , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Estado Civil , Paridade , Cooperação do Paciente , Gravidez , Classe Social , África do Sul/epidemiologia
2.
JAMA Netw Open ; 3(9): e2019686, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32876685

RESUMO

Importance: The coronavirus disease 2019 (COVID-19) pandemic and the policies to contain it have been a near ubiquitous exposure in the US with unknown effects on depression symptoms. Objective: To estimate the prevalence of and risk factors associated with depression symptoms among US adults during vs before the COVID-19 pandemic. Design, Setting, and Participants: This nationally representative survey study used 2 population-based surveys of US adults aged 18 or older. During COVID-19, estimates were derived from the COVID-19 and Life Stressors Impact on Mental Health and Well-being study, conducted from March 31, 2020, to April 13, 2020. Before COVID-19 estimates were derived from the National Health and Nutrition Examination Survey, conducted from 2017 to 2018. Data were analyzed from April 15 to 20, 2020. Exposures: The COVID-19 pandemic and outcomes associated with the measures to mitigate it. Main Outcomes and Measures: Depression symptoms, defined using the Patient Health Questionnaire-9 cutoff of 10 or higher. Categories of depression symptoms were defined as none (score, 0-4), mild (score, 5-9), moderate (score, 10-14), moderately severe (score, 15-19), and severe (score, ≥20). Results: A total of 1470 participants completed the COVID-19 and Life Stressors Impact on Mental Health and Well-being survey (completion rate, 64.3%), and after removing those with missing data, the final during-COVID-19 sample included 1441 participants (619 participants [43.0%] aged 18-39 years; 723 [50.2%] men; 933 [64.7%] non-Hispanic White). The pre-COVID-19 sample included 5065 participants (1704 participants [37.8%] aged 18-39 years; 2588 [51.4%] women; 1790 [62.9%] non-Hispanic White). Depression symptom prevalence was higher in every category during COVID-19 compared with before (mild: 24.6% [95% CI, 21.8%-27.7%] vs 16.2% [95% CI, 15.1%-17.4%]; moderate: 14.8% [95% CI, 12.6%-17.4%] vs 5.7% [95% CI, 4.8%-6.9%]; moderately severe: 7.9% [95% CI, 6.3%-9.8%] vs 2.1% [95% CI, 1.6%-2.8%]; severe: 5.1% [95% CI, 3.8%-6.9%] vs 0.7% [95% CI, 0.5%-0.9%]). Higher risk of depression symptoms during COVID-19 was associated with having lower income (odds ratio, 2.37 [95% CI, 1.26-4.43]), having less than $5000 in savings (odds ratio, 1.52 [95% CI, 1.02-2.26]), and exposure to more stressors (odds ratio, 3.05 [95% CI, 1.95-4.77]). Conclusions and Relevance: These findings suggest that prevalence of depression symptoms in the US was more than 3-fold higher during COVID-19 compared with before the COVID-19 pandemic. Individuals with lower social resources, lower economic resources, and greater exposure to stressors (eg, job loss) reported a greater burden of depression symptoms. Post-COVID-19 plans should account for the probable increase in mental illness to come, particularly among at-risk populations.


Assuntos
Infecções por Coronavirus/epidemiologia , Depressão/epidemiologia , Renda/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Estresse Psicológico/epidemiologia , Adolescente , Adulto , Betacoronavirus , Depressão/psicologia , Escolaridade , Feminino , Humanos , Masculino , Estado Civil/estatística & dados numéricos , Pessoa de Meia-Idade , Pandemias , Questionário de Saúde do Paciente , Prevalência , Fatores de Risco , Índice de Gravidade de Doença , Estresse Psicológico/psicologia , Estados Unidos/epidemiologia , Adulto Jovem
3.
Work ; 66(4): 767-775, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32925138

RESUMO

BACKGROUND: Prevention is the best way to manage a pandemic like COVID-19. The World Health Organization has issued public advice to create awareness by providing people knowledge to prevent/protect them from COVID-19. Hence, the present study was planned to assess knowledge of prevention and its practical use amongst samples from the Saudi Arabian population. It can be used to bring awareness among the masses not only in expanding their knowledge about COVID-19 but also on how to enforce a practicing behavior in relation to the prevention of COVID-19. The study is among the pioneer studies on the issue related to knowledge and practice of the prevention of COVID-19 among Saudis and foreign nationals residing in Saudi Arabia. OBJECTIVE: The prime objective of this study is to examine the existence of knowledge among the Saudi and non-Saudi nationals about COVID-19 and its impact on their behavior to practice the protocols to prevent the disastrous infection of COVID-19. This study has also examined how the residents in Saudi Arabia react to the methods and protection measures adopted by the government for their dominions to eradicate the spread of COVID-19. METHODS: The study used a survey-based methodology and data was collected from Saudi nationals as well as expatriates living and working in five different regions of Saudi Arabia. Non-probability snowball sampling was used to reach and select the population of the current study. A self-designed, structured, and validated questionnaire was electronically distributed among the respondents. SPSS version 21 was used to analyze the data of the current study. RESULTS: Out of the 443 respondents, 356 respondents (84%) knew they had to wash their hands for 20 seconds and did this as well, 303 respondents (75%) knew that sneezing or coughing into the arm/elbow can prevent the spread of COVID-19 and were doing this as well, 357 respondents (82%) knew that COVID-19 can be transferred by shaking hands and avoided this, 333 respondents (79%) knew that they had to maintain a safe distance of at least one meter and kept this distance, 315 respondents (76%) knew that touching one's face can transfer the virus and avoid this, and 414 respondents (95%) knew that staying at home can decrease the chances of getting infected. The relationship between different regions and most of the knowledge-based and practice-based questions was significant (p < 0.05). CONCLUSION: Results reveal that there is a significant relationship between knowledge and practice, but the strength of association is weak. It was found that knowledge and practice of COVID-19 was followed differently in the five regions of Saudi Arabia and the level of education of the respondents influenced their choice of practice to protect themselves from the effects of COVID-19. The study has contributed in the body of literature by examining the inter-relationship between knowledge and practice and their use in prevention of COVID-19 among the Saudi population.


Assuntos
Betacoronavirus/patogenicidade , Infecções por Coronavirus/prevenção & controle , Conhecimentos, Atitudes e Prática em Saúde , Controle de Infecções/normas , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Adolescente , Adulto , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/transmissão , Infecções por Coronavirus/virologia , Estudos Transversais , Escolaridade , Feminino , Higiene das Mãos/normas , Higiene das Mãos/estatística & dados numéricos , Humanos , Controle de Infecções/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/epidemiologia , Pneumonia Viral/transmissão , Pneumonia Viral/virologia , Arábia Saudita/epidemiologia , Distância Social , Inquéritos e Questionários/estatística & dados numéricos , Adulto Jovem
4.
PLoS One ; 15(9): e0237307, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32915825

RESUMO

OBJECTIVE: To estimate the prevalence of multimorbidity and investigate the socioeconomic factors that are associated with multimorbidity among persons 70 years and older in Trinidad and Tobago. DESIGN AND METHODS: The data were obtained from a nationally representative comprehensive cross-sectional survey conducted in 2014 among elderly persons in the targeted age group. The prevalence of multimorbidity among the elderly population was estimated. A logit model was utilized to determine the socioeconomic characteristics that are associated with multimorbidity in the elderly. RESULTS: The results of the study show that multimorbidity in the elderly population is strongly associated with age, ethnicity, lower education, smoking history, no physical activity and being female. An interesting finding is that elderly persons in the richest quintile are in general, more prone to multimorbidity. CONCLUSION: The findings suggest that interventions to reduce multimorbidity among the elderly population must encourage greater levels of physical activity, provide education on the risk factors of multimorbidity, and discourage smoking.


Assuntos
Escolaridade , Renda/estatística & dados numéricos , Expectativa de Vida , Idoso , Idoso de 80 Anos ou mais , Feminino , Estilo de Vida Saudável , Humanos , Masculino , Morbidade , Fatores Sexuais , Fumar/epidemiologia , Trinidad e Tobago
5.
PLoS One ; 15(9): e0236487, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32956409

RESUMO

Studies have found that education differences in women's body weight increase until middle adulthood. The explanatory mechanisms behind this increase are not well-understood. This study examined the role of education differences in the prevalence of motherhood as a risk factor for weight gain and in vulnerability to its effects on weight gain. We used longitudinal data from the German Socio-economic Panel Study. Our sample included 2,668 women aged between 17 and 45 and observed at least twice between 2002 and 2016 (n = 13,899 panel observations). We used OLS regression models to estimate initial education differences in body weight and fixed-effects panel regression models to estimate education differences in body-weight trajectories. Motherhood was associated with increasing body weight, and the effects of motherhood on weight gain varied by education. Motherhood partially accounted for the increase of education differences during reproductive age. Until the age of 30, differences in the prevalence of motherhood accounted for about 20% of the bodyweight gap between lower and higher educated women. From age 35 until 45, differential vulnerability to the effects of motherhood on body weight explained about 15% of the education gap in body weight.


Assuntos
Trajetória do Peso do Corpo , Escolaridade , Ganho de Peso , Adolescente , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , Mães , Parto , Adulto Jovem
6.
Pediatrics ; 146(4)2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32943535

RESUMO

Potential long-lasting adverse effects of child maltreatment have been widely reported, although little is known about the distinctive long-term impact of differing types of maltreatment. Our objective for this special article is to integrate findings from the Mater-University of Queensland Study of Pregnancy, a longitudinal prenatal cohort study spanning 2 decades. We compare and contrast the associations of specific types of maltreatment with long-term cognitive, psychological, addiction, sexual health, and physical health outcomes assessed in up to 5200 offspring at 14 and/or 21 years of age. Overall, psychological maltreatment (emotional abuse and/or neglect) was associated with the greatest number of adverse outcomes in almost all areas of assessment. Sexual abuse was associated with early sexual debut and youth pregnancy, attention problems, posttraumatic stress disorder symptoms, and depression, although associations were not specific for sexual abuse. Physical abuse was associated with externalizing behavior problems, delinquency, and drug abuse. Neglect, but not emotional abuse, was associated with having multiple sexual partners, cannabis abuse and/or dependence, and experiencing visual hallucinations. Emotional abuse, but not neglect, revealed increased odds for psychosis, injecting-drug use, experiencing harassment later in life, pregnancy miscarriage, and reporting asthma symptoms. Significant cognitive delays and educational failure were seen for both abuse and neglect during adolescence and adulthood. In conclusion, child maltreatment, particularly emotional abuse and neglect, is associated with a wide range of long-term adverse health and developmental outcomes. A renewed focus on prevention and early intervention strategies, especially related to psychological maltreatment, will be required to address these challenges in the future.


Assuntos
Maus-Tratos Infantis/psicologia , Maus-Tratos Infantis/estatística & dados numéricos , Adolescente , Comportamento do Adolescente , Asma/epidemiologia , Transtornos de Deficit da Atenção e do Comportamento Disruptivo/epidemiologia , Austrália/epidemiologia , Estatura , Criança , Cognição , Estudos de Coortes , Gorduras na Dieta/administração & dosagem , Escolaridade , Feminino , Humanos , Inteligência , Estudos Longitudinais , Transtornos Mentais/epidemiologia , Gravidez , Gravidez na Adolescência/estatística & dados numéricos , Qualidade de Vida , Comportamento Sexual , Transtornos do Sono-Vigília/epidemiologia , Evasão Escolar/estatística & dados numéricos , Desemprego/estatística & dados numéricos , Adulto Jovem
7.
Nutrients ; 12(9)2020 Sep 02.
Artigo em Inglês | MEDLINE | ID: mdl-32887422

RESUMO

The COVID-19 pandemic has exacerbated economic vulnerabilities and disrupted the Australian food supply, with potential implications for food insecurity. This study aims to describe the prevalence and socio-demographic associations of food insecurity in Tasmania, Australia, during the COVID-19 pandemic. A cross-sectional survey (deployed late May to early June 2020) incorporated the U.S. Household Food Security Survey Module: Six-Item Short Form, and fifteen demographic and COVID-related income questions. Survey data (n = 1170) were analyzed using univariate and multivariate binary logistic regression. The prevalence of food insecurity was 26%. The adjusted odds of food insecurity were higher among respondents with a disability, from a rural area, and living with dependents. Increasing age, a university education, and income above $80,000/year were protective against food insecurity. Food insecurity more than doubled with a loss of household income above 25% (Adjusted Odds Ratio (AOR): 2.02; 95% CI: 1.11, 3.71; p = 0.022), and the odds further increased with loss of income above 75% (AOR: 7.14; 95% CI: 2.01, 24.83; p = 0.002). Our results suggest that the prevalence of food insecurity may have increased during the COVID-19 pandemic, particularly among economically vulnerable households and people who lost income. Policies that support disadvantaged households and ensure adequate employment opportunities are important to support Australians throughout and post the COVID-19 pandemic.


Assuntos
Infecções por Coronavirus/epidemiologia , Abastecimento de Alimentos/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Adulto , Fatores Etários , Idoso , Infecções por Coronavirus/complicações , Infecções por Coronavirus/economia , Estudos Transversais , Demografia , Pessoas com Deficiência , Escolaridade , Emprego , Família , Feminino , Abastecimento de Alimentos/economia , Humanos , Renda , Masculino , Pessoa de Meia-Idade , Pandemias/economia , Pneumonia Viral/complicações , Pneumonia Viral/economia , Prevalência , Fatores de Risco , População Rural , Fatores Sexuais , Fatores Socioeconômicos , Tasmânia/epidemiologia , Adulto Jovem
8.
Pediatrics ; 146(4)2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32900877

RESUMO

BACKGROUND: Children born preterm are at high risk for autism spectrum disorder (ASD). However, there is still a lack of appropriate developmental markers. In this study, we aim to examine whether early mental performance trajectory is related to ASD outcome in the preterm population. METHODS: The population-based cohort included 414 very preterm survivors born between 2008 and 2014. After excluding children with severe neurosensory impairment, 319 children with available records of developmental quotients before age 2 years were enrolled. The trajectory of mental performance evaluated by using the Bayley Scales of Infant Development across 6, 12, and 24 months of age was analyzed with group-based trajectory modeling. At 5 years of age, the ASD diagnosis was established by using the Autism Diagnostic Observation Schedule and the Autism Diagnostic Interview-Revised. RESULTS: There were 29 children with ASD and 290 children without ASD. The mental performances from age 6 to 24 months could be classified into 3 trajectory patterns: low declining, high declining, and high stable, which corresponded to ASD prevalence at age 5 years of 35%, 9%, and 3%, respectively. ASD odds was 15 times higher in the low-declining group than in the high-stable group (odds ratio 15; 95% confidence interval 3.8-59; P < .001). Through the analysis of multinomial logistic regression, we found that male infants with longer exposure to oxygen therapy whose mothers had lower maternal education levels tended to follow the low-declining trajectory. CONCLUSIONS: The early-life mental trajectory patterns, by using the Bayley Scales of Infant Development, may lead to identification of vulnerable children born preterm for early ASD diagnosis and targeted intervention.


Assuntos
Transtorno do Espectro Autista , Desenvolvimento Infantil , Lactente Extremamente Prematuro , Fatores Etários , Transtorno do Espectro Autista/classificação , Transtorno do Espectro Autista/diagnóstico , Transtorno do Espectro Autista/epidemiologia , Transtorno do Espectro Autista/fisiopatologia , Pré-Escolar , Intervalos de Confiança , Diagnóstico Precoce , Escolaridade , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Razão de Chances , Oxigênio/uso terapêutico , Prevalência , Fatores Sexuais
9.
Pediatrics ; 146(4)2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32973120

RESUMO

BACKGROUND: Low socioeconomic status (SES) has emerged as an important risk factor for higher short-term mortality and neurodevelopmental outcomes in children with hypoplastic left heart syndrome and related anomalies; yet little is known about how SES affects these outcomes over the long-term. METHODS: We linked data from the Single Ventricle Reconstruction trial to US Census Bureau data to analyze the relationship of neighborhood SES tertiles with mortality and transplantation, neurodevelopment, quality of life, and functional status at 5 and 6 years post-Norwood procedure (N = 525). Cox proportional hazards regression and linear regression were used to assess the association of SES with mortality and neurodevelopmental outcomes, respectively. RESULTS: Patients in the lowest SES tertile were more likely to be racial minorities, older at stage 2 and Fontan procedures, and to have more complications and fewer cardiac catheterizations over follow-up (all P < .05) compared with patients in higher SES tertiles. Unadjusted mortality was highest for patients in the lowest SES tertile and lowest in the highest tertile (41% vs 29%, respectively; log-rank P = .027). Adjustment for patient birth and Norwood factors attenuated these differences slightly (P = .055). Patients in the lowest SES tertile reported lower functional status and lower fine motor, problem-solving, adaptive behavior, and communication skills at 6 years (all P < .05). These differences persisted after adjustment for baseline and post-Norwood factors. Quality of life did not differ by SES. CONCLUSIONS: Among patients with hypoplastic left heart syndrome, those with low SES have worse neurodevelopmental and functional status outcomes at 6 years. These differences were not explained by other patient or clinical characteristics.


Assuntos
Técnica de Fontan/métodos , Síndrome do Coração Esquerdo Hipoplásico/cirurgia , Classe Social , Cateterismo Cardíaco/estatística & dados numéricos , Criança , Desenvolvimento Infantil , Pré-Escolar , Deficiências do Desenvolvimento/epidemiologia , Escolaridade , Feminino , Técnica de Fontan/mortalidade , Técnica de Fontan/estatística & dados numéricos , Transplante de Coração/estatística & dados numéricos , Humanos , Síndrome do Coração Esquerdo Hipoplásico/complicações , Síndrome do Coração Esquerdo Hipoplásico/etnologia , Síndrome do Coração Esquerdo Hipoplásico/mortalidade , Renda , Recém-Nascido , Masculino , Ocupações , Complicações Pós-Operatórias/epidemiologia , Modelos de Riscos Proporcionais , Qualidade de Vida , Características de Residência , Resultado do Tratamento , Coração Univentricular/mortalidade , Coração Univentricular/cirurgia
10.
J Pregnancy ; 2020: 7019676, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32953177

RESUMO

Background: Ethiopia still suffers high levels of neonatal and maternal mortality, so the maternity continuum of care is a continuous framework for the delivery of maternal care from pregnancy to the postnatal period. Skilled care during pregnancy, childbirth, and the postpartum period is an important intervention in reducing maternal and neonatal morbidity and mortality. But in Ethiopia, there are limited studies on the completion of the maternity continuum of care, so this study will help to suggest interventions in order to reduce the dropout of the maternity continuum of care. Objective: To assess the completion of the maternity continuum of care and factors associated with it among mothers who gave birth in the last one year in Enemay District, Northwest Ethiopia. Method and Materials. A community-based cross-sectional study was conducted from February 25 to March 10, 2019, on 651 women who gave birth in the last one year. The data were collected by a face-to-face interview through pretested and structured questionnaires. Binary logistic regression was used to identify predictors of the completion of the maternity continuum of care. Variables with a P value < 0.05 in multivariable analysis were declared as statistically significant associated factors. Results: This study revealed that about 45% (95% CI: 40.9%, 48.8%) of respondents completed the continuum of care. Women with secondary education (AOR = 6, 95% CI: 2.26, 16.6), women whose occupation is farming (AOR = 0.18, 95%, CI: 0.1, 0.32), women who have autonomy in health care decision (AOR = 4, 95% CI: 2.26, 7.2), women who have exposure to media (AOR = 1.97, 95% CI: 1.2, 3.27), women with wanted pregnancies (AOR = 3.33, 95% CI: 1.87, 5.9), para five and above women (AOR = 2.85, 95% CI: 1.28, 6.3), and women whose husbands are employed (AOR = 4.97, 95% CI: 1.16, 21.2) were significantly associated with the completion of the maternity continuum of care. Conclusions and Recommendation. This study showed that less than half of the participants had achieved the continuum of care and education level, and both respondents and their husband's occupation, parity, autonomy in health care decision, exposure to the mass media, and wantedness of pregnancy were associated with the completion of the maternity continuum of care; therefore, working on enhancing the capacity of women's autonomy in health care and decision-making and preventing unintended pregnancy helps to improve the completion of the maternity continuum of care.


Assuntos
Assistência à Saúde , Serviços de Saúde Materna/estatística & dados numéricos , Mães , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adulto , Estudos Transversais , Tomada de Decisões , Escolaridade , Etiópia/epidemiologia , Feminino , Humanos , Meios de Comunicação de Massa , Autonomia Pessoal , Gravidez , Gravidez não Planejada , Inquéritos e Questionários , Fatores de Tempo , Adulto Jovem
11.
J Pregnancy ; 2020: 8395142, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32953178

RESUMO

Background: Episiotomy is the most common obstetric procedure, performed when the clinical circumstances place the patient at a high risk of high-degree laceration. However, episiotomy should be done with judicious indication to lower perineal laceration with fewer complications. Despite its adverse effects, the magnitude of episiotomy is increasing due to different factors. Therefore, this study is aimed at determining the recent magnitude of episiotomy and at identifying associated factors among women who gave delivery in Arba Minch General Hospital, Southern Ethiopia. Methods: An institution-based cross-sectional study was conducted from December 15, 2018, to January 30, 2019. A systematic random sampling technique was used to select study participants. A semistructured questionnaire was used to collect data. This was supplemented with a review of the labor and delivery records. Binary and multivariable logistic regression analyses were performed to identify factors associated with the magnitude of episiotomy. P value ≤ 0.05 was used to determine the level of statistically significant variables. Results: The magnitude of episiotomy was found to be 272 (68.0%) with 95%CI = 64.0-72.5. Women who attended secondary education [AOR = 10.24, 95%CI = 2.81-37.34], women who attended college and above [AOR = 4.61, 95%CI = 1.27-16.71], birth weight ≥ 3000 g [AOR = 4.84, 95%CI = 2.66-8.82], primipara [AOR = 4.13, 95%CI = 2.40-7.12], being housewife occupants [AOR = 3.43, 95%CI = 1.20-9.98], married women [AOR = 2.86, 95%CI = 1.40-5.84], and body mass index < 25 kg/m2 [AOR = 2.85, 95%CI = 1.50-5.44] were independent variables found to have significant association with episiotomy. Conclusion: The magnitude of episiotomy was 68.0% which is higher than the recommended practice by WHO (10%). The study participants' occupational status, marital status, educational status, parity, birth weight, and BMI were significantly associated with the magnitude of episiotomy in the study area. Therefore, to reduce the rate of episiotomy, it is better to have periodic training for birth attendants regarding the indication of episiotomy.


Assuntos
Episiotomia/estatística & dados numéricos , Hospitais Gerais/estatística & dados numéricos , Trabalho de Parto , Lacerações/prevenção & controle , Mães/estatística & dados numéricos , Adolescente , Adulto , Peso ao Nascer , Índice de Massa Corporal , Estudos Transversais , Escolaridade , Episiotomia/efeitos adversos , Etiópia/epidemiologia , Feminino , Humanos , Ocupações , Paridade , Gravidez , Risco , Cônjuges , Inquéritos e Questionários , Adulto Jovem
12.
BMC Public Health ; 20(1): 1362, 2020 Sep 05.
Artigo em Inglês | MEDLINE | ID: mdl-32891120

RESUMO

BACKGROUND: An estimate of 2-3 million children under 5 die in the world annually due to vaccine-preventable disease. In Ethiopia, incomplete immunization accounts for nearly 16% of under-five mortality, and there is spatial variation for vaccination of children in Ethiopia. Spatial variation of vaccination can create hotspot of under vaccination and delay control and elimination of vaccine preventable disease. Thus, this study aims to assess the spatial distribution of incomplete immunization among children in Ethiopia from the three consecutive Ethiopia demographic and health survey data. METHOD: A cross-sectional study was employed from Ethiopia demographic and health survey (2005, 2011and 2016) data. In total, 7901mothers who have children aged (12-35) months were included in this study. ArcGIS 10.5 Software was used for global and local statistics analysis and mapping. In addition, a Bernoulli model was used to analyze the purely spatial cluster detection of incomplete immunization. GWR version 4 Software was used to model spatial relationships. RESULT: The proportion of incomplete immunization was 74.6% in 2005, 71.4% in 2011, and 55.1% in 2016. The spatial distribution of incomplete immunization was clustered in all the study periods (2005, 2011, and 2016) with global Moran's I of 0.3629, 1.0700, and 0.8796 respectively. Getis-Ord analysis pointed out high-risk regions for incomplete immunization: In 2005, hot spot (high risk) regions were detected in Kefa, Gamogofa, KembataTemibaro, and Hadya zones of SNNPR region, Jimma zone of Oromiya region. Similarly, Kefa, Gamogofa, Kembatatemibaro, Dawuro, and Hadya zones of SNNPR region; Jimma and West Arsi zones of Oromiya region were hot spot regions. In 2016, Afder, Gode, Korahe, Warder Zones of Somali region were hot spot regions. Geographically weighted regression identified different significant variables; being not educated and poor wealth index were the two common for incomplete immunization in different parts of the country in all the three surveys. CONCLUSION: Incomplete immunization was reduced overtime across the study periods. The spatial distribution of incomplete immunization was clustered and High-risk areas were identified in all the study periods. Predictors of incomplete immunization were identified in the three consecutive surveys.


Assuntos
Vacinação/estatística & dados numéricos , Adulto , Pré-Escolar , Estudos Transversais , Demografia , Escolaridade , Etiópia , Feminino , Inquéritos Epidemiológicos , Humanos , Lactente , Masculino , Fatores de Risco , Classe Social , Análise Espacial , Regressão Espacial , Inquéritos e Questionários , Cobertura Vacinal
13.
PLoS One ; 15(9): e0238293, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32881873

RESUMO

BACKGROUND: Vasectomy is one of the most effective and permanent male contraceptive methods, and involves cutting and ligating the vas deferens to make the semen free of sperm during ejaculation. Although it is effective, simple, and safe, it is not well known and practiced in the majority of our community. This study assessed the intention to use vasectomy and its associated factors among married men in Debre Tabor Town, North West Ethiopia, 2019. METHODS: A community- based cross-sectional study was conducted among 402 married men from March 05 to April 15, 2019. A simple random sampling technique was employed to select the study participants. Data was collected by face to face interview using a structured and pre-tested questionnaire. Questions concerned socio-demographic and reproductive variables and views on vasectomy. The association between variables was analyzed using a bivariable and multivariable logistic regression model. RESULT: A total of 402 participants were included with a response rate of 98.75%. The mean participant age was 37.12(SD ± 6.553) years with the age range of 20-56 years. The prevalence of intention to use vasectomy was 19.6% with 95%CI (15.6%-23.4%). Multivariable logistic regression showed that age from 30-39 years (AOR = 3.2(95% CI: 1.19-8.86)), having more than three living children (AOR = 2.5(95% CI: 1.41-4.68)), good knowledge (AOR = 3.4(95%CI: 1.88-6.40)) and positive attitude (AOR = 4.8(95% CI: 2.61-8.80)) of married men were significantly associated with intention to use vasectomy. CONCLUSION AND RECOMMENDATION: Intention to use vasectomy was comparable with findings in four regions of Ethiopia (Amhara, Oromia, SNNP, and Tigray). Age, the number of living children, knowledge, and attitude were significantly associated with the intention to use vasectomy. Improving the level of knowledge and attitude towards vasectomy is an essential strategy to scale up the intention of men to use vasectomy.


Assuntos
Anticoncepção/psicologia , Vasectomia/psicologia , Adulto , Estudos Transversais , Escolaridade , Etiópia , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Inquéritos e Questionários , Adulto Jovem
14.
PLoS One ; 15(8): e0236775, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32756585

RESUMO

BACKGROUND: Options to increase the ease of testing for SARS-CoV-2 infection and immune response are needed. Self-collection of diagnostic specimens at home offers an avenue to allow people to test for SARS-CoV-2 infection or immune response without traveling to a clinic or laboratory. Before this study, survey respondents indicated willingness to self-collect specimens for COVID-related tests, but hypothetical willingness can differ from post-collection acceptability after participants collect specimens. METHODS: 153 US adults were enrolled in a study of the willingness and feasibility of patients to self-collect three diagnostic specimens (saliva, oropharyngeal swab (OPS) and dried blood spot (DBS) card) while observed by a clinician through a telehealth session. After the specimens were collected, 148 participants participated in a survey about the acceptability of the collection, packing and shipping process, and their confidence in the samples collected for COVID-related laboratory testing. RESULTS: A large majority of participants (>84%) reported that collecting, packing and shipping of saliva, OPS, and DBS specimens were acceptable. Nearly nine in 10 (87%) reported being confident or very confident that the specimens they collected were sufficient for laboratory analysis.There were no differences in acceptability for any specimen type, packing and shipping, or confidence in samples, by gender, age, race/ethnicity, or educational level. CONCLUSIONS: Self-collection of specimens for SARS-CoV-2 testing, and preparing and shipping specimens for analysis, were acceptable in a diverse group of US adults. Further refinement of materials and instructions to support self-collection of saliva, OPS and DBS specimens for COVID-related testing is needed.


Assuntos
Betacoronavirus/isolamento & purificação , Infecções por Coronavirus/diagnóstico , Orofaringe/virologia , Cooperação do Paciente , Pneumonia Viral/diagnóstico , Saliva/virologia , Manejo de Espécimes/métodos , Adulto , Betacoronavirus/genética , Infecções por Coronavirus/virologia , Teste em Amostras de Sangue Seco/métodos , Escolaridade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Cooperação do Paciente/etnologia , Pneumonia Viral/virologia , Autocuidado , Inquéritos e Questionários , Telemedicina
15.
Medicina (Kaunas) ; 56(8)2020 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-32823727

RESUMO

Background and objectives: Spreading of SARS-CoV-2 infection from China to countries with a higher prevalence of inflammatory bowel disease (IBD) has generated concern among gastroenterologists and patients. The aim of this survey is to evaluate knowledge about clinical importance of COVID-19, disease management, prevention measures, and anxiety level during pandemic among patients with IBD. Material and methods: From 15th March to 15th April 2020, a questionnaire survey was administered to 200 patients with IBD by email or phone application. The questionnaire consisted of five sections: (1) anthropometric, demographic and clinical characteristics, (2) knowledge about clinical importance of COVID-19, (3) IBD management, (4) prevention measures, (5) anxiety level during pandemic. Results: One hundred forty two questionnaires were completed. Ninety-seven patients (68.3%) were males with a mean age of 46 years (SD 13; range 17-76). Fifty-four individuals (38%) were affected by Crohn disease and 88 (62%) by Ulcerative Colitis. Most patients reported high knowledge about clinical importance of COVID-19 (80%), IBD management (72%), and prevention measures (97%). Sixty-two percent of them showed moderate-high level of anxiety. High education level was independently associated with high knowledge about clinical importance of COVID-19 (odds ratio [OR] 5, 95% confidence interval [CI] 1.49-16.6, p = 0.009) and older age (OR 1, 95%, CI 1.01-1.1, p = 0.01), while the receipt of e-format educational material with low knowledge about clinical importance of COVID-19 (OR 3, 95%, CI 1.08-9.3, p = 0.03). Displaying an active disease appeared to be independently associated with low knowledge of IBD management (OR 5.8, 95% CI 1.4-22.8, p = 0.01) and no variables other than an older age was independently associated with higher level of anxiety (OR 1.04, 95% CI 1.009-1.09, p = 0.01). Conclusions: High educational level and aging promote knowledge about clinical importance of COVID-19, while e-format educational material does not. Taken together with findings that an active disease status compromises knowledge of IBD management and the high level of anxiety related to increasing age, these data suggest the need of further supporting patient-oriented strategies in IBD during Covid-19 pandemic.


Assuntos
Infecções por Coronavirus/prevenção & controle , Conhecimentos, Atitudes e Prática em Saúde , Doenças Inflamatórias Intestinais/terapia , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Adolescente , Adulto , Idoso , Ansiedade , Betacoronavirus , Escolaridade , Feminino , Humanos , Controle de Infecções , Doenças Inflamatórias Intestinais/fisiopatologia , Itália , Masculino , Pessoa de Meia-Idade , Razão de Chances , Inquéritos e Questionários , Adulto Jovem
16.
PLoS One ; 15(8): e0236877, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32760136

RESUMO

OBJECTIVE: To identify current maternal and infant predictors of infant mortality, including maternal sociodemographic and economic status, maternal perinatal smoking and obesity, mode of delivery, and infant birthweight and gestational age. METHODS: This retrospective study analyzed data from the linked birth and infant death files (birth cohort) and live births from the Birth Statistical Master files (BSMF) in California compiled by the California Department of Public Health for 2007-2015. The birth cohort study comprised 4,503,197 singleton births including 19,301 infant deaths during the nine-year study period. A subpopulation to study fetal growth consisted of 4,448,300 birth cohort records including 13,891 infant deaths. RESULTS: The infant mortality rate (IMR) for singleton births decreased linearly (p <0.001) from 4.68 in 2007 to 3.90 (per 1,000 live births) in 2015. However, significant disparities in IMR were uncovered in different population groups depending upon maternal sociodemographic and economic characteristics and maternal characteristics during pregnancy. Children of African American women had almost twice the risk of infant mortality when compared with children of White women (AOR 2.12; 95% CI, 1.98-2.27; p<0.001). Infants of women with Bachelor's degrees or higher were 89% less likely to die (AOR 1.89; 95% CI, 1.76-2.04; p<0.001) when compared to infants of women with education less than high school. Infants of maternal smokers were 75% more likely to die (AOR 1.75; 95% CI, 1.58-1.93; p<0.001) than infants of nonsmokers. Infants of women who were overweight and obese during pregnancy accounted for 55% of IMR over all women in the study. More than half of the infant deaths were to children of women with lower socioeconomic status; infants of WIC participants were 59% more likely to die (AOR 1.59; 95% CI, 1.52-1.67; p<0.001) than infants of non-WIC participants. With respect to infant predictors, infants born with LBW or PTB were more than six times (AOR 6.29; 95% CI, 5.90-6.70; p<0.001) and almost four times (AOR 3.95; 95% CI, 3.73-4.19; p<0.001) more likely to die than infants who had normal births, respectively. SGA and LGA infants were more than two times (AOR 2.03; 95% CI, 1.92-2.15; p<0.001) and 41% (AOR 1.41; 95% CI, 1.32-1.52; p<0.001) more likely to die than AGA infants, respectively. CONCLUSIONS: While the overall IMR in California is declining, wide disparities in death rates persist in different groups, and these disparities are increasing. Our data indicate that maternal sociodemographic and economic factors, as well as maternal prepregnancy obesity and smoking during pregnancy, have a prominent effect on IMR though no causality can be inferred with the current data. These predictors are not typically addressed by direct medical care. Infant factors with a major effect on IMR are birthweight and gestational age-predictors that are addressed by active medical services. The highest value interventions to reduce IMR may be social and public health initiatives that mitigate disparities in sociodemographic, economic and behavioral risks for mothers.


Assuntos
Mortalidade Infantil , Mães , Adulto , Análise de Variância , California/epidemiologia , Estudos de Coortes , Grupos de Populações Continentais/estatística & dados numéricos , Escolaridade , Grupos Étnicos/estatística & dados numéricos , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Obesidade/epidemiologia , Saúde Pública/estatística & dados numéricos , Estudos Retrospectivos , Fumar/epidemiologia , Fatores Socioeconômicos , Adulto Jovem
17.
PLoS One ; 15(8): e0237107, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32745121

RESUMO

OBJECTIVE: In this study we aimed to estimate the effect of diabetes, educational level and income on the risk of mortality and cardiovascular events in primary care patients with hypertension. METHODS: We followed 62,557 individuals with hypertension diagnosed 2001-2008, in the Swedish Primary Care Cardiovascular Database. Study outcomes were death, myocardial infarction, and ischemic stroke, assessed using national registers until 2012. Cox regression models were used to estimate adjusted hazard ratios of outcomes according to diabetes status, educational level, and income. RESULTS: During follow-up, 13,231 individuals died, 9981 were diagnosed with diabetes, 4431 with myocardial infarction, and 4433 with ischemic stroke. Hazard ratios (95% confidence intervals) for diabetes versus no diabetes: mortality 1.57 (1.50-1.65), myocardial infarction 1.24 (1.14-1.34), and ischemic stroke 1.17 (1.07-1.27). Hazard ratios for diabetes and ≤9 years of school versus no diabetes and >12 years of school: mortality 1.56 (1.41-1.73), myocardial infarction 1.36 (1.17-1.59), and ischemic stroke 1.27 (1.08-1.50). Hazard ratios for diabetes and income in the lowest fifth group versus no diabetes and income in the highest fifth group: mortality 3.82 (3.36-4.34), myocardial infarction 2.00 (1.66-2.42), and ischemic stroke 1.91 (1.58-2.31). CONCLUSIONS: Diabetes combined with low income was associated with substantial excess risk of mortality, myocardial infarction and ischemic stroke among primary care patients with hypertension.


Assuntos
Diabetes Mellitus/epidemiologia , Cardiopatias/epidemiologia , Hipertensão/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Escolaridade , Feminino , Cardiopatias/mortalidade , Humanos , Hipertensão/mortalidade , Renda/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/mortalidade , Suécia
18.
PLoS One ; 15(8): e0235781, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32760096

RESUMO

BACKGROUND: An association between education and dementia is well-established but it is unclear whether education is associated with dementia after accounting for early life cognitive ability and whether there is a joint effect, such that the risk associated with one of the exposures depends on the value of the other. We examined separate and joint associations of adolescent cognitive ability and educational attainment with risk of dementia among Danish men born between 1939 and 1959. METHODS: Men (N = 477,421) from the Danish Conscription Database were followed for dementia from the age 60 for up to 17 years via patient and prescription registry linkages. Exposure measures included cognitive ability assessed at the conscript board examination around age 18 and highest educational level (low: 0-10 year, medium: 10-13 years, high: ≥13 years) at age 30 from registry records. Associations with dementia diagnosis were estimated in Cox proportional hazards models adjusted for birth year and age at conscript board examination. Interaction was assessed on the multiplicative scale by including a product term between the two exposure measures and on the additive scale by calculating relative excess risk due to interaction (RERI) between different levels of the exposure measures. RESULTS: Compared to men in the high education group hazard ratio [HR] for men in the medium and low group were 1.21 (95% confidence interval [CI]: 1.13, 1.30) and 1.34 (95% CI: 1.24, 1.45), respectively when not adjusting for cognitive ability. Additional adjustment for cognitive ability attenuated the magnitude of the associations, but they remained significant (education medium: HR = 1.10, 95% CI: 1.02, 1.19 and education low: HR = 1.12, 95% CI: 1.02, 1.22). A 10% higher cognitive ability score was associated with a 3.8% lower hazard of dementia (HR = 0.962; 95% CI: 0.957, 0.967), and the magnitude of the association only changed marginally after adjustment for education. Men in the low education group with relatively low cognitive ability were identified as a high-risk subgroup for dementia. The increased risk associated with exposure to both risk factors did, however, not significantly depart from the sum of risk experienced by men only exposed to one of the risk factors (estimates of RERI were not significantly different from 0) and no significant evidence of either additive or multiplicative interactions was found. CONCLUSIONS: In conclusion, the results suggest that education and cognitive ability protect against the risk of dementia independently of one another and that increases in educational attainment may at least partially offset dementia risk due to low cognitive ability.


Assuntos
Desenvolvimento do Adolescente/fisiologia , Cognição/fisiologia , Demência/epidemiologia , Escolaridade , Adolescente , Idoso , Demência/fisiopatologia , Dinamarca/epidemiologia , Seguimentos , Humanos , Testes de Inteligência , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Sistema de Registros/estatística & dados numéricos , Medição de Risco , Fatores de Risco
19.
BMJ ; 370: m2791, 2020 08 19.
Artigo em Inglês | MEDLINE | ID: mdl-32816747

RESUMO

OBJECTIVE: To identify risk factors (air pollution and family related) for the onset of asthma and persistent wheezing in children. DESIGN: Nationwide case-control study. SETTING: Denmark. PARTICIPANTS: All Danish children born from 1997 to 2014 and followed for asthma onset and persistent wheezing from age 1 year to 15 years. MAIN OUTCOME MEASURE: Onset of asthma and persistent wheezing. RESULTS: A higher incidence of asthma was found in children of parents with asthma (adjusted hazard ratio 2.29 (95% confidence interval 2.22 to 2.35) and mothers who smoked during pregnancy (1.20, 1.18 to 1.22), whereas a lower incidence was found in children of parents with high educational attainment (0.72, 0.69 to 0.75) and high incomes (0.85, 0.81 to 0.89). Exposure to particulate matter ≤2.5 µm (PM2.5) and ≤10 µm (PM10) and nitrate was associated with an increased risk of asthma and persistent wheezing, with hazard ratios per 5 µg/m3 increase in pollutant concentrations 1.05 (1.03 to 1.07) for PM2.5, 1.04 (1.02 to 1.06) for PM10, and 1.04 (1.03 to 1.04) for nitrogen dioxide. Only the positive association of PM2.5 with asthma and persistent wheezing remained robust across the different models and in sensitivity analyses. CONCLUSIONS: The findings of this study suggest that children exposed to higher levels of PM2.5 are more likely to develop asthma and persistent wheezing than children who are not exposed. Other risk factors associated with these outcomes were parental asthma, parental education, and maternal smoking during pregnancy.


Assuntos
Poluentes Atmosféricos/efeitos adversos , Asma/epidemiologia , Material Particulado/efeitos adversos , Sons Respiratórios , Adolescente , Estudos de Casos e Controles , Criança , Pré-Escolar , Dinamarca/epidemiologia , Escolaridade , Feminino , Humanos , Incidência , Lactente , Masculino , Nitratos/efeitos adversos , Dióxido de Nitrogênio/efeitos adversos , Fatores de Risco , Fumar/efeitos adversos
20.
Mult Scler ; 26(10): 1163-1171, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32772807

RESUMO

BACKGROUND: People with multiple sclerosis (MS) may be at higher risk for complications from the 2019 coronavirus (COVID-19) pandemic due to use of immunomodulatory disease modifying therapies (DMTs) and greater need for medical services. OBJECTIVES: To evaluate risk factors for COVID-19 susceptibility and describe the pandemic's impact on healthcare delivery. METHODS: Surveys sent to MS patients at Cleveland Clinic, Johns Hopkins, and Vall d'Hebron-Centre d'Esclerosi Múltiple de Catalunya in April and May 2020 collected information about comorbidities, DMTs, exposures, COVID-19 testing/outcomes, health behaviors, and disruptions to MS care. RESULTS: There were 3028/10,816 responders. Suspected or confirmed COVID-19 cases were more likely to have a known COVID-19 contact (odds ratio (OR): 4.38; 95% confidence interval (CI): 1.04, 18.54). In multivariable-adjusted models, people who were younger, had to work on site, had a lower education level, and resided in socioeconomically disadvantaged areas were less likely to follow social distancing guidelines. 4.4% reported changes to therapy plans, primarily delays in infusions, and 15.5% a disruption to rehabilitative services. CONCLUSION: Younger people with lower socioeconomic status required to work on site may be at higher exposure risk and are potential targets for educational intervention and work restrictions to limit exposure. Providers should be mindful of potential infusion delays and MS care disruption.


Assuntos
Infecções por Coronavirus/epidemiologia , Emprego , Fatores Imunológicos/uso terapêutico , Esclerose Múltipla/terapia , Terapia Ocupacional , Modalidades de Fisioterapia , Pneumonia Viral/epidemiologia , Classe Social , Adulto , Fatores Etários , Betacoronavirus , Comorbidade , Infecções por Coronavirus/prevenção & controle , Assistência à Saúde , Gerenciamento Clínico , Suscetibilidade a Doenças , Escolaridade , Feminino , Comportamentos Relacionados com a Saúde , Acesso aos Serviços de Saúde , Terapia por Infusões no Domicílio , Humanos , Hipertensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Obesidade/epidemiologia , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Fatores de Risco , Espanha/epidemiologia , Estados Unidos/epidemiologia
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