Reports from the frontline: health workers describe COVID-19 risks and fears in five cities in Brazil.

BACKGROUND: Health providers are under unprecedented pressures to perform in the COVID-19 health crisis and under unprecedented risks. We initiated a large mixed-method survey of health professionals in five large metropolitan areas in Brazil to document the risks and needs of health professionals. To initiate the study, we conducted formative research. METHODS: We conducted 77 open-ended semi-structured interviews online in a convenience sample of physicians, nurses, nurse technicians, and physiotherapists in Belem, Fortaleza, Porto Alegre, Recife, and São Paulo, Brazil. Design, data collection, and analysis were informed by Rapid Ethnographic Analysis (REA). RESULTS: Responses are organized into three themes that emerged in the interviews: the lack of preparation - both locally and nationally-for the pandemic and its effects on staffing and training; the overlap of personal, family, and professional risk and consequences; and inadequately addressed anxiety and suffering among health staff. CONCLUSIONS: Our respondents were unprepared for the epidemic, especially the institutional sequelae and psychological cost. These consequences were exacerbated by both lack of leadership and sweeping changes undercutting the Brazilian health system noted by almost all participants.

Survival and risk factors for mortality in pediatric patients with acute myeloid leukemia in a single reference center in low-middle-income country.

Despite advances in therapy and care for children with acute myeloid leukemia (AML), survival rates for children in low- and middle-income countries (LMICs) remain poor. We studied risk factors for mortality and survival in children with AML in a LMIC to develop strategies to improve survival for AML children in these countries. This retrospective cohort (2000-2014) analyzed newly diagnosed AML patients (age < 19 years) at a reference center in Brazil. Demographic and clinical variables were reviewed by AML subtype: acute promyelocytic leukemia (APL), AML with Down syndrome (AML-DS), and other AML subtypes. Cumulative hazard risk for early death (ED) until 6 weeks of treatment and risk factors for mortality were determined by the multivariate Cox hazard models. Survival was assessed for each AML subtypes. A total of 220 patients were diagnosed: APL 50 (22.7%), AML-DS 16 (7.3%), and other AML subtypes 154 (70.0%). The cumulative hazard function values for ED for all patients with AML were 12.5% (95% CI 8.5-18.4%); for each AML patients subtypes: APL, 21.7% (95% CI 11.7-40.5%); AML-DS, 6.2% (95% CI 0.9-44.4%); and other AML subtypes, 10.2% (95% CI 6.2-17.0%). White blood cell count (cutoff 10 × 109/L for APL and 100 × 109/L for other AML subtypes) and Afro-descendance were significant risk factors for mortality in APL and other AML subtypes, respectively. Overall survival for patients with APL, AML-DS, and other AML subtypes was 66.8%, 62.5%, and 38.0%, respectively. APL patients had the highest incidence of ED and those with other subtypes had increased relapse risk. We also observed high rates of death in complete remission mainly due to infection. Better risk classification and identification of risk factors for infection may improve the survival of these patients.

Factors associated with mother-to-child transmission of the human immunodeficiency virus in Pernambuco, Brazil, 2000-2009.

OBJECTIVE: To identify risk factors associated with mother-to-child transmission of HIV in the Brazilian state of Pernambuco. METHODS: Retrospective cohort study with 1200 HIV-exposed children born in Pernambuco, registered up to the age of 2 months in a public programme to prevent vertical transmission. Univariate and multivariate logistic regression analyses were conducted for maternal and peripartum characteristics and prophylactic interventions, to identify risk factors for mother-to-child transmission of HIV. RESULTS: The transmission rate was 9.16% (95% CI: 7.4-10.9). The following risk factors were independently associated with transmission: non-use of antiretroviral during pregnancy (OR: 7.8; 95% CI: 4.1-15); vaginal delivery (OR: 2.02; 95% CI: 1.2-3.4); prematurity (OR: 2.5; 95% CI: 1.3-4.7); and breastfeeding (OR: 2.6; 95% CI: 1.4-4.6). CONCLUSIONS: This mother-to-child transmission rate is unacceptably high, as prophylactic interventions such as antiretroviral therapy and infant feeding formula are free of charge. Absence of antiretroviral therapy during pregnancy was the main risk factor. Therefore, early identification of exposed mothers and initiating prophylactic interventions are the main challenges for controlling transmission.

Is it better to be rich in a poor area or poor in a rich area? A multilevel analysis of a case-control study of social determinants of tuberculosis.

BACKGROUND: Tuberculosis is known to have socio-economic determinants at individual and at area levels, but it is not known whether they are independent, whether they interact and their relative contributions to the burden of tuberculosis. METHODS: A case-control study was conducted in Recife, Brazil, to investigate individual and area social determinants of tuberculosis, to explore the relationship between determinants at the two levels and to calculate their relative contribution to the burden of tuberculosis. It included 1452 cases of tuberculosis diagnosed by the tuberculosis services and 5808 controls selected at random from questionnaires completed for the demographic census. Exhaustive information on social factors was collected from cases, using the questionnaire used in the census. Socio-economic information for areas was downloaded from the census. Multilevel logistic regression investigated individual and area effects. RESULTS: There was a marked and independent influence of social variables on the risk of tuberculosis, both at individual and area levels. At individual level, being aged >or=20, being male, being illiterate, not working in the previous 7 days and possessing few goods, all increased the risk of tuberculosis. At area level, living in an area with many illiterate people and where few households own a computer also increased this risk; individual and area levels did not appear to interact. Twice as many cases were attributable to social variables at individual level than at area level. CONCLUSIONS: Although individual characteristics are the main contributor to the risk of tuberculosis, contextual characteristics make a substantial independent contribution.

Smoking increases the risk of relapse after successful tuberculosis treatment.

BACKGROUND: Recent tobacco smoking has been identified as a risk factor for developing tuberculosis, and two studies which have investigated its association with relapse of tuberculosis after completion of treatment had conflicting results (and did not control for confounding). The objective of this study was to investigate risk factors for tuberculosis relapse, with emphasis on smoking. METHODS: A cohort of newly diagnosed TB cases was followed up from their discharge after completion of treatment (in 2001-2003) until October 2006 and relapses of tuberculosis ascertained during that period. A case of relapse was defined as a patient who started a second treatment during the follow up. RESULTS: Smoking (OR 2.53, 95% CI 1.23-5.21) and living in an area where the family health program was not implemented (OR 3.61, 95% CI 1.46-8.93) were found to be independently associated with relapse of tuberculosis. CONCLUSIONS: Our results establish that smoking is associated with relapse of tuberculosis even after adjustment for the socioeconomic variables. Smoking cessation support should be incorporated in the strategies to improve effectiveness of Tuberculosis Control Programs.