Vaccine uptake and associated factors in an irregular urban settlement in northeastern Brazil: a cross-sectional study.

BACKGROUND: Globally, childhood immunization saves the lives of 2-3 million children annually by protecting them against vaccine-preventable diseases. In 2017, 116.2 million children were vaccinated worldwide according to the World Health Organization. Nevertheless, figures suggest that 19.5 million children around the world fail to receive the benefits of complete immunization. METHODS: This cross-sectional study analyzed vaccine uptake and the factors associated with incomplete vaccination schedule in children of up to 36 months of age assisted by the family health strategy in an irregular settlement located in a state capital city in northeastern Brazil. This study was nested within a larger study entitled "Health, nutrition and healthcare services in an urban slum population in Recife, Pernambuco", conducted in 2015. A census included 309 children, with vaccination data obtained, exclusively, from their vaccination cards records. An ad hoc database was constructed with variables of interest. Absolute and relative values were calculated for the socioeconomic, demographic, obstetric and biological data. To identify possible factors associated with incomplete vaccination schedule, crude and multivariable Poisson regression analyses were performed, and conducted in accordance with the forward selection method with robust variance and the adjusted prevalence ratio was calculated with the 95% CI. Variables with p-values < 0.20 in the unadjusted stage were included in the multivariable analysis. The statistical significance of each variable was evaluated using the Wald test, with p-values < 0.05. RESULTS: Just half of the children (52,1%) was classified as complete vaccination schedule. In the final model, the factors associated with incomplete vaccination schedule were age 12-36 months and the mother who did not complete high school. CONCLUSION: The percentage of vaccine uptake found was far below the recommendation of the National Childhood Immunization Schedule and was associated with child's age and mother's education level. Based on these findings, the family healthcare teams may elaborate vaccination strategies aimed at reaching the coverage rates established by the national immunization program. Optimizing coverage will ultimately prevent the resurgence, at epidemic level, of infectious diseases that are already under control in this country.

[Anthropometric assessment of nutritional status in pregnancy: comparison of five diagnostic methods used in Latin AmericaClasificación antropométrica de las embarazadas: comparación de cinco métodos de diagnóstico utilizados en América Latina]. / Classificação antropométrica de gestantes: comparação entre cinco métodos diagnósticos utilizados na América Latina.

OBJECTIVE: To determine the agreement between five anthropometric methods used for nutritional assessment in pregnancy and to compare the distribution of nutritional status obtained with each method to that of the population of non-pregnant young women in Brazil. METHOD: This is a cross-sectional study with data from 1 108 pregnant women aged 19 to 35 years who received prenatal care from September 2011 to April 2012 in health services in the state of Pernambuco, Brazil. Nutritional status (underweight, appropriate weight, overweight/obesity) was determined using the criteria of Mardones and Rosso, Mardones et al., Atalah et al., Centro Latino Americano de Perinatologia (CLAP), and the Institute of Medicine (IOM-2009). Kappa agreement was estimated for the pairs of methods, and the chi-square goodness of fit test was performed to compare the frequency distribution of each nutritional category in each of the methods in comparison to the distribution in non-pregnant women classified according to body mass index (BMI, WHO cut-off points). RESULTS: Agreement between the methods was observed for overweight/obesity (kappa > 0.60), but not for underweight (kappa ≤ 0.60), particularly in the comparison of IOM-2009 (which relies on prepregnancy BMI) with other methods. The frequency distributions obtained with the five methods showed lower percentages of overweight/obesity and higher percentages of underweight as compared to the reference population of non-pregnant women (P < 0.001). CONCLUSION: The disparities observed in the present study may have resulted from the heterogeneity among the methods. This suggests that additional surveys are needed to establish population-specific anthropometric standards.

OBJETIVO: Verificar si hay concordancia entre cinco métodos antropométricos de clasificación nutricional de las embarazadas y comparar las clasificaciones obtenidas con la clasificación nutricional de la población brasileña de mujeres jóvenes no embarazadas. MÉTODO: Estudio transversal con datos de 1 108 embarazadas de 19 a 35 años atendidas desde septiembre del 2011 hasta abril del 2012 en servicios de atención prenatal en el estado de Pernambuco (Brasil). La clasificación nutricional (peso bajo, peso adecuado y sobrepeso u obesidad) se realizó de acuerdo con los criterios de Mardones y Rosso, de Mardones et al., de Atalah et al., del Centro Latinoamericano de Perinatología (CLAP) y del Instituto de Medicina del 2009 (IOM-2009). Se estimaron los coeficientes kappa de concordancia para los pares de métodos y la prueba del ji-cuadrado de la bondad del ajuste para comparar la distribución de frecuencias de cada categoría nutricional obtenida con cada método con la distribución en las mujeres que no están embarazadas clasificadas según el índice de masa corporal (IMC, puntos de corte de la OMS). RESULTADOS: Los métodos concordaron en lo que respecta al diagnóstico de sobrepeso y obesidad (kappa 0,60) y no concordaron en relación con el peso bajo (kappa ≤ 0,60), particularmente cuando se compararon las clasificaciones basadas en los criterios de la IOM-2009 (que utiliza el IMC pregestacional) con los demás. Las distribuciones de frecuencias muestrales obtenidas con los cinco métodos difirieron de la población de referencia de mujeres no embarazadas (P < 0,001), observándose porcentajes de sobrepeso y obesidad inferiores a la prevalencia nacional y porcentajes de peso bajo superiores a la prevalencia nacional. CONCLUSIÓN: Las disparidades observadas pueden atribuirse a la heterogeneidad de los métodos. Se justifica la realización de investigaciones para definir patrones antropométricos específicos para determinadas poblaciones.

Could the erythrocyte indices or serum ferritin predict the therapeutic response to a trial with oral iron during pregnancy? Results from the Accuracy study for Maternal Anaemia diagnosis (AMA).

BACKGROUND: Treatment of maternal iron-deficiency anaemia can reduce risks of prematurity and low birth weight; hence a reliable diagnosis of maternal iron needs is critical. However, erythrocyte indices and serum ferritin have shown a weak correlation with iron status during pregnancy. This study verified the accuracy of those tests to predict the responsiveness to a therapeutic test with oral iron as reference standard for iron deficiency in pregnant women. METHODS: A prospective diagnostic study phase 3 was conducted in a single prenatal care center in Northeast Brazil. Between August 2011 and October 2012 a consecutive sampling included 187 women in their 2(nd)-3(rd) trimesters of low-risk pregnancy and having anaemia (haemoglobin <11.0 g/dL). Until December 2012, 139 women completed a trial with daily pills of ferrous sulfate (40 mg of iron), during 23 to 125 days. Haemoglobin (Hb), other erythrocyte indices and ferritin (index-tests) were assessed pre-treatment by automated analyzers. Hb was performed also post-treatment to assess the therapeutic response by its post-pretreatment differences. We estimated sensitivity (Se), specificity (Sp), predictive values (PV), likelihood ratios (LR), diagnostic Odds Ratio (OR), area under Receiver Operating Characteristic curve (AUC), accuracy ratio and agreement coefficient of the index-tests against an increase of at least 0.55 Hb Z-score (reference standard test). We calculated the Z-scores according to the reference population from Centers for Disease Control and Prevention. RESULTS: Hb had a mean increase of 0.24 Z-score after 30 iron pills (p 0.013). All index-tests demonstrated PV- above 70 %, PV+ around 40 %, LR around 1.0, and AUC of 0.5 to 0.6. Hb and haematocrit had Se of 50 % (95 % CI 40 to 70); and Sp of 59 % (95 % CI 43 to 74) and 47 % (95 % CI 38 to 57), respectively. Ferritin, Mean Corpuscular Volume, Mean Corpuscular Haemoglobin, Mean Corpuscular Haemoglobin Concentration and Red blood cell Distribution Width had Se below 40 % with Sp above 70 %. CONCLUSIONS: Erythrocyte indices and ferritin could not predict the iron needs of anemic pregnant women. Increases of Hb Z-scores after a short treatment with oral iron may be a reliable therapeutic test. TRIAL REGISTRATION: World Health Organization International Clinical Trials Registry Platform U1111-1123-2605; Brazilian Registry of Clinical Trials RBR-237wbg , registered 28 July 2011.

Diagnostic accuracy of hemoglobin for iron deficiency in pregnancy: disclosing results of a cited clinical trial.

OBJECTIVE: To analyze the accuracy of hemoglobin (Hb) concentrations as a diagnostic indicator of iron deficiency in pregnant women and to measure the efficacy of oral iron therapy using Hb z-scores rather than Hb absolute values. METHODS: The sensitivity and specificity of Hb < 11.0 g/dL, and its receiver operating characteristic (ROC) curve, in the diagnosis of iron deficiency (serum ferritin (SF) < 12.0 ng/mL) were determined in 318 women in their second trimester of pregnancy who had been screened for a clinical trial conducted in 2001 in Northeast Brazil. A secondary analysis of iron therapy efficacy was carried out using data from the trial's three different treatments (60 mg of oral iron once per week (n = 46), twice per week (n = 50), and once per day (n = 44)). The mean differences between post- and pre-treatment Hb absolute values (g/dL) and z-scores (standard deviation (SD)) were calculated for the three treatment groups for study participants with and without iron deficiency. RESULTS: Hb sensitivity, specificity, and area under the ROC curve were 60.7%, 44.3%, and 0.54 respectively. Women without iron deficiency showed improvements in Hb absolute values (as in the clinical trial's overall results) but did not have improved Hb z-scores (with scores of - 0.6 SD (95% confidence interval (CI): - 0.99, - 0.28); - 0.2 SD (95% CI: - 0.47, 0.08); and - 0.1 SD (95% CI: - 0.33, 0.18) for weekly, twice-per-week, and daily iron treatment schemes respectively). In contrast, iron-deficient women treated with the intermittent schemes had reductions in both Hb absolute values and Hb z-scores, respectively: weekly = - 0.42 g/dL (95% CI: - 0.72, - 0.12) and - 1.4 SD (95% CI: - 1.74, - 0.99); twice per week = - 0.14 g/dL (95% CI: - 0.46, 0.17) and - 1.1 SD (95% CI: - 1.44, - 0.75). CONCLUSIONS: These analyses revealed that Hb concentrations were not an accurate indicator of either iron needs or iron-therapy response in pregnant women.

Accuracy of erythrogram and serum ferritin for the maternal anemia diagnosis (AMA): a phase 3 diagnostic study on prediction of the therapeutic responsiveness to oral iron in pregnancy.

BACKGROUND: Pregnancy anemia remains as a public health problem, since the official reports in the 70's. To guide the treatment of iron-deficiency anemia in pregnancy, the haemoglobin concentration is the most used test in spite of its low accuracy, and serum ferritin is the most reliable test, although its cutoff point remains an issue. METHODS/DESIGN: The aim of this protocol is to verify the accuracy of erythrocyte indices and serum ferritin (studied tests) for the diagnosis of functional iron-deficiency in pregnancy using the iron-therapy responsiveness as the gold-standard. This is an ongoing phase III accuracy study initiated in August 2011 and to be concluded in April 2013. The subjects are anemic pregnant women (haemoglobin concentration < 11.0 g/dL) attended at a low-risk prenatal care center in the Northeast of Brazil. The sample size (n 278) was calculated to estimate sensitivity of 90% and 80% of specificity with relative error of 10% and power of 95%. This study has a prospective design with a before-after intervention of 80 mg of daily oral iron during 90 days and will be analyzed as a delayed-type cross-sectional study. Women at the second trimester of pregnancy are being evaluated with clinical and laboratorial examinations at the enrollment and monthly. The 'responsiveness to therapeutic test with oral iron' (gold-standard) was defined to an increase of at least 0.55 Z-score in haemoglobin after 4 weeks of treatment and a total dose of 1200 mg of iron. At the study conclusion, sensitivities, specificities, predictive values, likelihood ratios and areas under the ROC (Receiver Operating Characteristic) curves of serum ferritin and erythrocyte indices (red blood cell count, haematocrit, haemoglobin concentration, mean corpuscular volume, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration, red blood cell distribution width, reticulocyte count) will be tested. The compliance and adverse effects are considered confounding variables, since they are the main obstacles for the iron-therapy responsiveness. DISCUSSION: This study protocol shows a new approach on iron-deficiency anemia in pregnancy from a functional point of view that could bring some insights about the diagnostic misclassifications arising from the dynamic physiologic changes during the gestational cycle. TRIAL REGISTRATION: WHO International Clinical Trials Registry Platform U1111-1123-2605.

[Development and application of a new index for assessment of prenatal care]. / Desenvolvimento e aplicação de um novo índice para avaliação do pré-natal.

OBJECTIVE: To develop and apply a new instrument to evaluate prenatal care based on the guidelines of the Brazilian Humanization Program for Prenatal Care and Birth, including quantitative and qualitative elements distributed according to the evaluation triad of structure, process, and outcomes. METHODS: An analytic, descriptive, quantitative cross-sectional study was carried out with 238 women receiving care in 44 primary care services in the city of João Pessoa, Northeast Brazil, between November 2010 and December 2011. Physicians and nurses involved in prenatal care were also interviewed. The instrument developed by the investigators contains 23 questions relating to structure, process and outcomes of pre-natal care. Based on the information collected, pre-natal care was classified according to an IPR/Pre-Natal index (Índice IPR/Pré-Natal, where I stands for infrastructure, P for work process and R for results). A value of 1 is attributed to each question if it complies with the criteria established for quality, or 2 if it does not comply. The percent of adequate answers in relation to the 23 total questions is used to classify prenatal care as: upper adequate (100% adequate answers); adequate (>75%); intermediate (51 to 74%); and inadequate (<50%). The classification categories for the Pre-Natal/IPR index were compared to those of the Kessner and Adequacy of Prenatal Care Utilization (APNCU) indices. RESULTS: Questions relating to the work process contributed significantly to the classification of prenatal care as intermediate according to the IPR/Pre-Natal. IPR/Pre-Natal classification categories were consistent to detect prematurity, insufficient weight at birth and absence of exclusive breastfeeding. CONCLUSIONS: The IPR/Pre-Natal index effectively incorporated quantitative and qualitative elements for the assessment of pre-natal care.

Temporal evolution of anemia in children aged six to 59 months in the state of Pernambuco, Brazil, 1997 to 2016. / Evolução temporal da anemia em crianças de seis a 59 meses no estado de Pernambuco, Brasil, 1997 a 2016.

OBJECTIVE: To analyze the temporal evolution of anemia in children aged six to 59 months in Pernambuco, based on population surveys from 1997, 2006, and 2016 and the factors associated with the situation in 2016. METHODS: The field studies took place in the participants' households, in the Recife Metropolitan Area, as well as in the urban and rural inland. The trend study of anemia in children used data from the State Health and Nutrition Survey (Pesquisa Estadual de Saúde e Nutrição - PESN) II (40.9%) and III (32.8%). Data from PESN IV were collected using questionnaires administered to families to verify socioeconomic and individual conditions, as well as anthropometric - weight and height - and biochemical - hemoglobin - records. We adopted the test for trend in proportion for the time trend study and Poisson regression for hypothesis tests for the associated factors. Statistically significance was set at a p-value<0.05. RESULTS: In 2016, the prevalence of anemia was 24.2%, indicating a significant reduction in disease incidence. In children aged 6-23 months, this number decreased from PENS II and III to PENS IV - 63 and 55.6 to 37.7% (p<0.001), respectively. In 2016, the statistically significant variables for anemia in children were maternal hemoglobin, child's age, current or recent case of diarrhea, and weight-for-age index. CONCLUSION: Between 1997 and 2016, anemia rates decreased, showing an epidemiological trend that can contribute to continuously improve the health of children under five years of age in Pernambuco.

OBJETIVO: Analisar a evolução temporal da anemia em crianças de seis a 59 meses em Pernambuco, com base nos inquéritos populacionais de 1997, 2006 e 2016 e os fatores associados à situação em 2016. MÉTODOS: Os estudos de campo ocorreram nos domicílios dos participantes, na Região Metropolitana do Recife, interior urbano e rural. No estudo de tendência da anemia em crianças, utilizaram-se dados da II (40,9%) e III PESNs (Pesquisa Estadual de Saúde e Nutrição) (32,8%). Os dados da IV PESN foram coletados por formulários com famílias para verificação das condições socioeconomicas e individuais, bem como registros antropométricos, peso e altura, e bioquímicos, hemoblobina. Para o estudo de tendência temporal, utilizou-se o teste de tendência de proporção; e para os fatores associados a regressão de Poisson para testes de hipóteses. Estatisticamente considerou-se significante o valor p<0,05. RESULTADOS: A prevalência de anemia, em 2016, foi de 24,2%, expressando uma diminuição significativa na ocorrência da doença. Nas crianças de 6­23 m., houve redução da II e III para IV PESN de 63 e 55,6 para 37,7% (p<0,001), respectivamente. Em 2016, as variáveis com significância estatística para a anemia em crianças foram a hemoglobina materna, a idade da criança, a ocorrência atual ou recente de diarreia e o índice P/I. CONCLUSÃO: Entre 1997 e 2016, houve redução da anemia, demostrando uma tendência epidemiológica que pode contribuir para melhoria contínua da saúde das crianças abaixo de cinco anos em Pernambuco.

Temporal trends and anaemia-associated factors in 6- to 59-month-old children in Northeast Brazil.

OBJECTIVE: To analyse the trends and factors associated with anaemia in 6- to 59-month-old children in Northeast Brazil. DESIGN: Cross-sectional study assessed information from the second and third Pernambuco State Health and Nutrition Surveys carried out in 1997 and 2006. A multiple regression analysis was performed from a conceptual model addressing biological and socio-economic factors, housing and sanitation conditions, maternal factors, health care and nutrition, consumption, morbidity and nutritional status. Poisson's regression with robust variance was used. SETTING: Pernambuco, Brazil. SUBJECTS: A total of 777 and 993 children, respectively, in the second and third Pernambuco State Health and Nutrition Surveys. RESULTS: The prevalence of anaemia (Hb < 11 g/dl) decreased by 19·3 % (40·9 % down to 33·0 %) between surveys. Maternal education level (less than 8 years in school), households ranked in the lowest environmental index tertile and children between 6 and 23 months of age were the variables common to the final models in the surveys of 1997 and 2006. Elements like living in rural areas, household income less than two minimum official wages and low birth weight were still present in the final model of the 1997 survey. Households ranked in the lowest economic index tertile were associated with anaemia in the model of the 2006 survey. CONCLUSIONS: The study results are quite encouraging from the perspective of reducing the prevalence of anaemia. Maternal education level, environmental conditions and child age were determinant factors in both surveys, and economic factors were determinant in 2006.

Anemia in pregnant women according to two different assessment criteria (WHO versus CDC).

OBJECTIVE: To determine the prevalence of anemia among pregnant women and the associated factors and perinatal outcomes according to two different diagnostic criteria: the WHO criterion and the US Center for Disease Control and Prevention (CDC) criterion. METHODS: Cohort study, operationalized through a database. The sample comprised 781 pregnant women who had laboratory data regarding hemoglobin levels during the second trimester of pregnancy. Anemia was diagnosed when hemoglobin was less than 11 g/dl according to WHO and less than 10.5 g/dl according to CDC. Factors possibly associated with anemia were identified by adjusting Poisson univariate and multivariate regression models. To analyze the association between perinatal outcomes and anemia, the χ2 test and Fisher exact test were performed. RESULTS: The prevalence of anemia was 22.9% according to WHO and 10.9% according to CDC. A significantly higher risk of low birth weight was found in children of women with anemia, regardless of the diagnostic criteria used, while a greater risk of having a small-for-gestational-age newborn was seen only when the CDC criterion were applied. CONCLUSION: Anemia during pregnancy remains an important public health issue, but its magnitude may be overestimated by overly sensitive assessment criteria.

Excess weight among women in a low-income urban community: socioeconomic, demographic and reproductive factors. / Excesso de peso em mulheres de uma comunidade urbana de baixa renda: fatores socioeconômicos, demográficos e reprodutivos.

The aim of the present study was to investigate the prevalence of excess weight and associated factors in women of reproductive age living in a low-income community. A cross-sectional study was conducted with a sample of 663 women 15 to 49 years of age residing in the neighborhood of Coelhos in the city of Recife, Brazil. Body mass index (BMI)-for-age was used to classify the nutritional status of the adolescents (15 to 19 years of age), adopting Z-score of ≥+1 for the definition of overweight. For the adults, BMI≥25.0 kg/m² was considered indicative of overweight. Socioeconomic, demographic and reproductive variables were analyzed as possible factors associated with overweight. The prevalence of excess weight was found in two thirds of the sample. The results of the Poisson multiple regression analysis showed a significantly higher prevalence of excess weight with the advance in age, among those with a younger menarche age, those who had three or more pregnancies, those living with their partner and those self-declared black or white. Multiparity was the only factor associated with excess weight that could be modified, which underscores the importance of prenatal and family planning services to its prevention and control.

O objetivo do estudo foi avaliar a prevalência de excesso de peso e fatores associados nas mulheres em idade reprodutiva, residentes em uma comunidade de baixa renda. Estudo transversal cuja amostra consistiu em 663 mulheres, na faixa etária de 15 a 49 anos, domiciliadas na comunidade dos Coelhos, Recife-PE. O IMC para idade foi utilizado para classificar o estado nutricional de mulheres entre 15 e 19 anos, considerando ≥+1 escore Z para definir excesso de peso. Nas mulheres com idade superior a 19 anos, considerou-se o IMC≥25,0 kg/m². Variáveis socioeconômicas, demográficas e reprodutivas foram analisadas como possíveis fatores associados ao excesso de peso. A prevalência do excesso de peso foi observada em dois terços das mulheres estudadas. Os resultados da análise de regressão múltipla de Poisson mostraram uma prevalência significantemente maior do excesso de peso em mulheres com o avançar da idade cronológica, com menor idade da menarca, que tiveram três ou mais gestações, que coabitavam com o companheiro e se autodenominaram com cor preta ou cor branca. A multiparidade foi o único fator associado ao excesso de peso passível de modificação, o que reforça a necessidade de destacar a importância dos serviços de pré-natal e planejamento familiar na sua prevenção e controle.

Prevalence, Trends and Conditions for the DTP3 Vaccine: A 25-Year Historical Perspective.

BACKGROUND: The aim was to verify the prevalence of vaccination coverage, tendency and factors of the third dose of the vaccine against diphtheria, tetanus and pertussis-DTP3 in surveys over the period of 25 years in a state of the Northeast of Brazil. METHODS: Cross-sectional and temporal series, utilizing ad hoc database, were extracted from the Health and Nutrition State Research 1991, 1997, 2006 and 2015/2016. Children from 12 to 23 months of age with proof in the vaccination card were included. The vaccination coverage (outcome) of each year was calculated, the tendency throughout the period was analyzed and the associations through Pearson chi-squared were tested. The results of the first and last survey were compared with a significance level of 5%. The reasons of the crude prevalence and confidence intervals of 95% were estimated. RESULTS: The vaccination coverage in 1991, 1997, 2006 and 2015/2016 was 77.6%, 82.7%, 89.7% and 72.9%, respectively, with an increasing tendency from 1991 to 2006 (p<0.001) and decreasing between 2006 and 2015/2016 (p<0.001). Factors in 1991: low socioeconomic conditions; lack of access to health service and pre-natal care, nutritional deficit and diarrhea in children (p<0.005). In 2015/2016, low socioeconomic conditions and diarrhea persisted and a larger family size, black, negative self-perception of happiness, both from the mother (p<0.05), were identified. CONCLUSION: The factors of the recent decrease of vaccination coverage are complex, multifactorial, dependent of context and even on subjective aspects of the maternal perception. Its identification contributed to the understanding of inadequate vaccination at the state level.

Overweight and obesity and associated factors in adults in a poor urban area of Northeastern Brazil. / Sobrepeso, obesidade e fatores associados aos adultos em uma área urbana carente do Nordeste Brasileiro.

INTRODUCTION: The changes that occurred in the health/disease process, especially in the field of nutrition, corroborate the replacement of nutritional deficiencies with the pandemic emergency of overweight (overweight/obesity). OBJECTIVE: To analyze the prevalence and factors associated with overweight in adults living in a poor urban area in Recife, Northeast Brazil. METHODS: This is a cross-sectional study with a sample of 644 adults aged 20-59 years. Possible associations of overweight with demographic, socioeconomic, behavioral and morbidity factors were analyzed through Poisson Regression, considering as statistically significant those with p < 0.05. RESULTS: The prevalence of overweight was 70.3%, being lower in the age range of 20-29 years, greater in the range of 30-39 years and stabilizing in the others. In the final multivariate model, it was observed that the age group, economic class, diabetes mellitus and high blood pressure were directly associated with overweight, while bean consumption showed an inverse association. The high prevalence of overweight found indicates that poor communities are already included in the nutritional transition process that is in course in country. CONCLUSION: The significant result of overweight found at this poor urban area imposes the need to include this problem as a public health priority in these communities.

Temporal variation in prevalence, awareness and control of hypertension in urban and rural areas in Northeast Brazil between 2006 and 2016.

To assess the evolution in prevalence, awareness and control of hypertension for over 10 years in Pernambuco State, Northeast Brazil, two cross-sectional studies were conducted based on random samples of households in urban and rural areas, in 2006 and 2015/2016, involving adults aged 20 years or older. Hypertension was defined as systolic blood pressure of at least 140mmHg or diastolic blood pressure of at least 90mmHg as well as the reported use of antihypertensive medication. A logistic regression analysis was conducted to estimate the influence of the social, behavioral and anthropometric determinants on hypertension. Although social and behavioral factors improved in this 10-year period, overweight and abdominal obesity increased. Approximately one third of the adult population of Pernambuco had hypertension in 2006 and this prevalence was maintained in 2015/2016. In rural areas, awareness concerning hypertension rose from 44.8% in 2006 to 67.3% in 2015/2016, and control from 5.3% to 27.1%, so that awareness and control were similar in urban and rural areas in 2015/2016. After an adjustment for potential confounding factors, the likelihood of having hypertension more than doubled among men (OR = 2.03; p < 0.001), middle (OR = 4.41; p < 0.001) and old-age subjects (OR = 14.44; p < 0.001), and those who had abdominal obesity (OR = 2.04; p < 0.001) in urban areas and among middle-aged (OR = 2.56; p < 0.001), less educated individuals (OR = 2.21; p = 0.006) and those who were overweight (OR = 2.23; p < 0.001) in rural areas. Despite the favorable evolution in the management of hypertension in Pernambuco, public health measures focused in vulnerable populations are still required, mainly in rural areas, to improve primary prevention and decrease the disease rate.

Decline in hospital mortality rate after the use of the World Health Organization protocol for management of severe malnutrition.

We studied the implementation of the World Health Organization protocol for the treatment of malnourished children at the largest maternal and infant hospital in the northeast of Brazil. The implementation of the protocol resulted in a reduction in the mortality rate from 38.0% to 16.2%.

Vitamin A and Pregnancy: A Narrative Review.

Vitamin A is a crucial micronutrient for pregnant women and their fetuses. In addition to being essential for morphological and functional development and for ocular integrity, vitamin A exerts systemic effects on several fetal organs and on the fetal skeleton. Vitamin A requirements during pregnancy are therefore greater. Vitamin A deficiency (VAD) remains the leading cause of preventable blindness in the world. VAD in pregnant women is a public health issue in most developing countries. In contrast, in some developed countries, excessive vitamin A intake during pregnancy can be a concern since, when in excess, this micronutrient may exert teratogenic effects in the first 60 days following conception. Routine prenatal vitamin A supplementation for the prevention of maternal and infant morbidity and mortality is not recommended; however, in regions where VAD is a public health issue, vitamin A supplementation is recommended to prevent night blindness. Given the importance of this topic and the lack of a complete, up-to-date review on vitamin A and pregnancy, an extensive review of the literature was conducted to identify conflicting or incomplete data on the topic as well as any gaps in existing data.

[Chronic noncommunicable diseases and associated factors among adults in an impoverished urban area of the Brazilian northeast]. / Doenças crônicas não transmissíveis e fatores associados em adultos numa área urbana de pobreza do nordeste brasileiro.

The scope of this study is to analyze the prevalence and factors associated with Chronic Noncommunicable Diseases (CNCD) in adults living in an impoverished urban area located in Recife in the Brazilian northeast. It is a cross-sectional study with a sample of 631 adults of 20 to 59 years of age. The possible associations of CNCD with demographic, socioeconomic, behavioral and health-related factors were analyzed using Poisson Regression, considering a p value of < 0.05 as being statistically significant. The prevalence of CNCD was 56.7%; highest among males (60.8%); adults aged 50-59 years (80.5%); lower economic class (57.7%); and lower level of schooling (62%). The problem was also associated with individuals with BMI ≥ 25 kg/m2 (34.2%) as well as individuals who reported poor health status (76.4%). In the multivariate hierarchical model, the statistically significant variables were: schooling, BMI, health perception, gender and age bracket. A high prevalence of at least one CNCD was observed, as well as a statistically significant association between CNCD and the following variables: schooling, BMI, health perception, gender and age bracket. These results suggest the need to intensify health promotion actions in poor communities, aiming at enhanced control of health in general.

Objetiva-se analisar a prevalência e os fatores associados às Doenças Crônicas não Transmissíveis (DCNT), em adultos residentes numa área urbana de pobreza situada em Recife, Nordeste do Brasil. Trata-se de um estudo transversal, com amostra de 631 adultos de 20 a 59 anos. Analisaram-se possíveis associações das DCNT com fatores demográficos, socioeconômicos, comportamentais e relativos à saúde, por meio de Regressão de Poisson, considerando-se como estatisticamente significantes aqueles com valor de p < 0,05. A prevalência de DCNT foi de 56,7%, sendo maior no sexo masculino (60,8%), entre os adultos com 50-59 anos (80,5%), de menor classe econômica (57,7%) e menor nível de instrução (62%). O problema também predominou entre aqueles com IMC ≥ 25Kg/m2 (34,2%) e que referiram estado de saúde ruim (76,4%). No modelo multivariado hierarquizado, as variáveis estatisticamente significantes foram: escolaridade, IMC, percepção da própria saúde, sexo e faixa etária. Observou-se, neste estudo, uma elevada prevalência de pelo menos uma DCNT, bem como, associação estatisticamente significante entre DCNT e as variáveis: escolaridade, IMC, percepção da própria saúde, sexo e faixa etária. Estes resultados sugerem a necessidade de se intensificar as ações de promoção à saúde, em comunidades carentes, com vistas ao seu melhor controle.

Nutritional status of exclusive breastfed infants in the state of Pernambuco. / Estado nutricional de crianças em amamentação exclusiva prolongada no Estado de Pernambuco.

INTRODUCTION: Exclusive breastfeeding (BF), after the sixth month of life, as a single food source is not recommended. It is believed that it is not possible to supply the caloric needs of protein, iron and vitamin without adequate food supplementation. OBJECTIVE: To comparethe nutritional statusof children withexclusive breastfeeding(BF)for more than 6monthsversuschildren with otherbreastfeeding practices. METHOD: Cross-sectionalexploratory studywith685children(39BF >6months and646with otherbreastfeeding practices).Situations ofanthropometricdeficit were considered by values< -2 in Z score, anemia evaluated by hemoglobin < 11 g/dL,and deficient/lowlevels ofvitamin A by serumretinol < 1.05 µmol/L. RESULTS: There were nocases ofdeficitin the anthropometric ratios of weight/height, weight/age andbody mass index(BMI)among childrenBF > 6months,while the comparison group was approximately 0.5%. In theheight/ageratio,the deficitwasaround 2.6% in both groups.Inthe weight/height ratioand BMI,the resultsranged from28.7 to 31.9% foroverweight in group comparisson. TheaverageHb, serumretinol, weightand heightwere similarbetween thegroups. DISCUSSION: The low prevalence (≤ 0.6%) of protein energy malnutrition in both groups represents a surprising finding, below the values found in reference to normal international reference, WHO standard. CONCLUSION: Children who maintained BF after six months exhibited equivalent nutritional status to those of children with other breastfeeding practices.

INTRODUÇÃO: O aleitamento materno exclusivo (AME), após o sexto mês de vida, como fonte alimentar única não é recomendado. Acredita-se que não é possível suprir às necessidades calórico proteicas, de ferro e vitaminas sem a devida complementação alimentar. OBJETIVO: Comparar a situação nutricional de crianças com AME por mais de seis mesesversuscrianças com outras práticas de amamentação. MÉTODO: Estudo transversal/exploratório com685 crianças (39 em AME > 6meses e 646com outras práticas de amamentação). Situações de déficit antropométrico foram consideradas por valores < - 2 no escore Z, anemia avaliada por hemoglobina (Hb) < 11 g/dL e níveis deficientes/baixos de vitamina A por retinol sérico < 1,05 µmol/L. RESULTADOS: Nãoocorreram déficitsnas relações de peso/altura, peso/idade e índice de massa corporal (IMC) no grupo de crianças em AME > 6meses, enquanto no grupo de comparação esse índice foi de aproximadamente 0,5%. O déficit na relação altura/idade foi de aproximadamente 2,6% nos dois grupos. Na relação peso/altura e no IMC, os resultados variaram de 28,7 a 31,9% para excesso de peso no grupo de comparação. As médias de Hb, retinol sérico, peso e altura foram similares nos grupos. DISCUSSÃO: A baixa prevalência (≤ 0,6%) de desnutrição energético proteica (DEP) nos dois grupos representa um achado, surpreendentemente, abaixo dos valores encontrados em população de referência de normalidade internacional, padrão da Organização Mundial da Saúde (OMS). CONCLUSÃO: As crianças que se mantiveram em AME após seis meses apresentaram situação nutricional equivalente àquelas com outras práticas de amamentação.

[Monitoring of infant growth by health services in Pernambuco State, Brazil]. / Acompanhamento do crescimento em crianças menores de um ano: situação nos serviços de saúde em Pernambuco, Brasil.

A situational diagnosis was performed on infant growth monitoring in Greater Metropolitan Recife and in the interior of the State of Pernambuco, Brazil, using the database from the Survey on Maternal and Child Health in the State of Pernambuco, 1998, which included 816 infants (< 1 year of age) and 120 health units. Epi Info version 6.04 was used for the analysis. In the health services infrastructure, 15.8% of the health units lacked infant scales and the Child's Health Card, and 75.4% lacked the guidelines for monitoring growth and development. Of these variables, the first two showed a difference between the two study areas. As for process evaluation, 81.2% of the mothers had the Child's Health Card, 53.1% of the children had been weighed, and only 21% had been measured. Mothers had received insufficient orientation. These variables also showed differences between the two study areas. Care for children with nutritional risk received little attention in the two areas, although there was a difference between the interior and Metropolitan Recife. In conclusion, monitoring of infant growth has not been effectively consolidated in the State of Pernambuco.

Diarrheal diseases and hospitalization of children under five years of age according to population-based surveys in the State of Pernambuco, Brazil, in the years 1997 and 2006. / Doenças diarreicas e hospitalizações em menores de cinco anos no estado de Pernambuco, Brasil, nos anos de 1997 e 2006.

The scope of this paper was to assess the temporal and geographical trends of diarrhea and its implications on the demands of hospitalizations of children under five years of age in the state of Pernambuco in 1997 and 2006. Databases of two population-based surveys were assessed with probabilistic samples of 2078 children (1997) and 1650 children (2006) evaluated in 18 municipalities of Pernambuco, including the Metropolitan Region of Recife, Urban Interior and Rural Interior. Prevalence was considered to involve the occurrence of cases on the day or in the two weeks prior to the interview and as admissions, service cases with minimal hospital stay of 24 hours in the period, covering up to one year before the interview. The prevalence of diarrhea in Pernambuco had a statistically non-significant decline (19.8% to 18.1%; p = 0.192). However, a statistically-significant reduction was observed (16.9% to 10.5%; p = 0.003) in the Metropolitan Region of Recife. The number of admissions increased by more than double (2.7% to 5.5% in the State and from 1.6% to 3.8% within the Metropolitan Region of Recife), in contrast with national trends. Therefore, diarrhea in the State appears as the main component of the demands of pediatric hospitalizations during the period under scrutiny.

O objetivo deste estudo foi avaliar as tendências temporais e geográficas das diarreias e suas implicações nas demandas de hospitalizações de crianças menores de cinco anos no Estado de Pernambuco, nos anos 1997 e 2006. Foram usados os bancos de dados de dois inquéritos de base populacional, com amostras probabilísticas de 2078 crianças, em 1997, e 1650 crianças, em 2006, avaliadas em 18 municípios de Pernambuco, incluindo a Região Metropolitana do Recife, Interior Urbano e Interior Rural. Considerou-se como prevalência a ocorrência de casos no dia ou nas duas semanas anteriores à entrevista e como internações o atendimento de casos com internação mínima de 24 horas, cobrindo o retrospecto de 12 meses. A prevalência das diarreias em Pernambuco teve um declínio estatisticamente não significante (19,8% para 18,1%; p = 0,192); contudo, na Região Metropolitana do Recife, foi observada uma redução estatisticamente significante (16,9% para 10,5%; p = 0,003). As internações aumentaram em mais de duas vezes (2,7% para 5,5%, no estado, e de 1,6% para 3,8%, na RMR), contrapondo-se, assim, às tendências nacionais. Portanto, as diarreias no Estado passaram a figurar como o principal componente das demandas de hospitalizações pediátricas no período analisado.

Factors associated with diarrhea in children under five years old in the state of Pernambuco, according to surveys conducted in 1997 and 2006.

OBJECTIVE Describe and compare variations of the factors associated with the prevalence of diarrhea in children under five years old in the state of Pernambuco. METHODS We used the databases of two population-based surveys from the years 1997 and 2006, with 2,078 and 1,650 children, respectively, evaluated in 18 municipalities of Pernambuco (Metropolitan Region of Recife, urban and rural interior). The variables, allocated at hierarchical levels, were analyzed using prevalence and Poisson regression ratios. RESULTS Only four variables were independently associated and were included in the final hierarchical model: geographical area, number of people per room, maternal age and the age of the child. In 1997: urban interior = 1.33 (95%CI 1.06-1.66), rural interior = 1.22 (95%CI 0.97-1.53) and in 2006: urban interior = 1.87 (95%CI 1.31-2.66), rural interior = 2.07 (95%CI 1.50-2.85); number of persons per room (1997): 1 to less than 2 = 1.29 (95%CI 0.98-1.68), two or more = 1.47 (95%CI 1.11-1.95) and in 2006: 1 to less than 2 = 0.86 (95%CI 0.68-1.09), two or more = 1.29 (95%CI 0.94-1.75); maternal age (1997): 10 to 19 years = 1.48 (95%CI 1.05-2.08), 20 to 24 years = 1.23 (95%CI 0.94-1.60), 25 to 34 years = 1.01 (95%CI 0.78-1.30) and in 2006: 10 to 19 years old = 1.70 (95%CI 1.08-2.66), 20 to 24 years old = 1.64 (95%CI 1.16-2.32), 25 to 34 years = 1.20 (95%CI 0.89-1.62); and age of the child (1997): 0-11 months = 1.57 (95%CI 1.27-1.94), 12-23 months = 1.73 (95%CI 1.41-2.12) and in 2006: 0-11 months = 1.04 (95%CI 0.76-1.41), 12-23 months = 1.77 (95%CI 1.41-2.23). CONCLUSIONS There was a great variability of the conditioners of diarrhea in children between the two periods analyzed. At the public policy level, despite changes in terms of people, time sequences, and geographic spaces, diarrhea remains on an important scale in the ranking of government power.