Temporal trends and spatial clusters of high risk for maternal death due to COVID-19 pre and during COVID-19 vaccination in Brazil: a national population-based ecological study.

OBJECTIVE: This study comprehensively analyzed the temporal and spatial dynamics of COVID-19 cases and deaths within the obstetric population in Brazil, comparing the periods before and during mass COVID-19 vaccination. We explored the trends and geographical patterns of COVID-19 cases and maternal deaths over time. We also examined their correlation with the SARS-CoV-2 variant circulating and the social determinants of health. STUDY DESIGN: This is a nationwide population-based ecological study. METHODS: We obtained data on COVID-19 cases, deaths, socioeconomic status, and vulnerability information for Brazil's 5570 municipalities for both the pre-COVID-19 vaccination and COVID-19 vaccination periods. A Bayesian model was used to mitigate indicator fluctuations. The spatial correlation of maternal cases and fatalities with socioeconomic and vulnerability indicators was assessed using bivariate Moran. RESULTS: From March 2020 to June 2023, a total of 23,823 cases and 1991 maternal fatalities were recorded among pregnant and postpartum women. The temporal trends in maternal incidence and mortality rates fluctuated over the study period, largely influenced by widespread COVID-19 vaccination and the dominant SARS-CoV-2 variant. There was a significant reduction in maternal mortality due to COVID-19 following the introduction of vaccination. The geographical distribution of COVID-19 cases and maternal deaths exhibited marked heterogeneity in both periods, with distinct spatial clusters predominantly observed in the North, Northeast, and Central West regions. Municipalities with the highest Human Development Index reported the highest incidence rates, while those with the highest levels of social vulnerability exhibited elevated mortality and fatality rates. CONCLUSION: Despite the circulation of highly transmissible variants of concern, maternal mortality due to COVID-19 was significantly reduced following the mass vaccination. There was a heterogeneous distribution of cases and fatalities in both periods (before and during mass vaccination). Smaller municipalities and those grappling with social vulnerability issues experienced the highest rates of maternal mortality and fatalities.

Spatial clustering of low rates of COVID-19 vaccination among children and adolescents and their relationship with social determinants of health in Brazil: a nationwide population-based ecological study.

OBJECTIVE: This study aimed to investigate the spatial clusters of high and low COVID-19 vaccination rates among children and adolescents across Brazilian municipalities and their relationship to social determinants of health. STUDY DESIGN: This is a nationwide population-based ecological study. METHODS: We have obtained for each of the 5570 Brazilian municipalities data on the COVID-19 vaccination rate of children and adolescents by August 16, 2022, the Gini index, the social vulnerability index and the municipal human development index. A Bayesian empirical local model was used to identify fluctuations in the COVID-19 vaccination rates. Spatial clusters were identified using scan spatial statistic tests. The relationship among COVID-19 vaccination rates and social determinants of health was explored by using multiple linear regression models. RESULTS: Overall, 52.1% of children aged 5-11 years and 72.8% of adolescents aged 12-17 years have been fully vaccinated against COVID-19 in Brazil by mid-August 2022. There was spatial dependence on the smoothed rates for both children (I Moran 0.66; P < 0.001) and adolescent (I Moran 0.65; P < 0.001) groups. The lowest rates occurred in municipalities in the North and Northeast regions. Municipalities with a higher Gini Index, higher social vulnerability index and lower municipal human development index were more likely to have a lower COVID-19 vaccination rate for both children and adolescent groups. CONCLUSION: COVID-19 vaccination of children and adolescents was heterogeneously distributed, with spatial clusters of the lowest vaccination rates occurring mainly in municipalities with marked socio-economic disparities and social vulnerability, especially in the North and Northeast regions.

Socio-economic inequalities and COVID-19 incidence and mortality in Brazilian children: a nationwide register-based study.

OBJECTIVES: This study aimed to estimate the incidence and mortality rates of coronavirus disease 2019 (COVID-19) in Brazilian children and to analyze its relationship with socio-economic inequalities in a state-level analysis. STUDY DESIGN: This is a nationwide register-based study. METHODS: To estimate the incidence and mortality rates of COVID-19 in Brazilian children aged 0-19 years, we extracted data of confirmed cases and deaths from the de-identified microdata catalog and official bulletins of the 27 Brazilian states' health department websites until September 3, 2020. Social and economic inequalities were evaluated using the Social Vulnerability Index and Gini coefficient, respectively. The relationship between COVID-19 rates in Brazilian children and socio-economic vulnerability at the state level was analyzed using Spearman's rank correlation. RESULTS: Of the 3,998,055 individuals with COVID-19 included in our database, 335,279 (8.4%) were children aged 0-19 years. Eight hundred deaths in children were registered, which accounts for about 0.7% of the deaths related to COVID-19 in the country. There were important differences in the incidence and mortality rates among Brazilian regions, and a correlation between mortality rates and social (ρ = 0.519; P-value = 0.007; effect magnitude: moderate) and economic (ρ = 0.615; P-value < 0.001; effect magnitude: strong) inequalities was found in a state-level analysis. CONCLUSIONS: This population-based study showed important regional differences in COVID-19 estimates for children in Brazil and a relationship between mortality rates and socio-economic inequalities. The knowledge of sociogeographic differences in the estimates of COVID-19 is crucial to planning societal strategies and local decision-making to mitigate the effects of disease in the pediatric population.

Prevalence of human papillomavirus types associated with cervical lesions in Sergipe state, Northeastern Brazil: high frequency of a possibly carcinogenic type.

Persistent infection with high-risk human papillomavirus (HPV) is the main cause of cervical cancer and the prevalence of HPV types varies depending on the geographic region. Therefore, this study assessed the prevalence of HPV types in women with cervical lesions from Sergipe state, Northeastern Brazil. A cross-sectional study was conducted in women with cervical lesions from March to December 2014. These lesions were investigated by PCR and HPV types were identified by DNA sequencing. 432 patients were included, of which 337 patients tested positive for HPV. Eighteen different HPV types were detected, and high-risk HPV types were detected in 69.2%. HPV 16 (63.4%) was the most prevalent HPV type found, followed by HPV 66 (4.6%), HPV 18 (1.6%) and HPV 45 (1.4%). These results highlight the importance of the high prevalence of HPV 66, which is a possibly carcinogenic virus type not covered by the available vaccines. The prevalence of HPV 16 was high in the studied population, reaffirming the importance of young vaccination. However, the high prevalence of HPV 66 found in this study shows the importance of monitoring the diversity of HPV types in different populations and geographic regions to better understand the impacts of current HPV vaccines.

Bone mineral density, growth, pubertal development and other parameters in Brazilian children and young adults with sickle cell anaemia.

OBJECTIVES: To evaluate the occurrence of low bone mineral density (BMD) and its relationship with clinical and laboratorial characteristics in children and young adults with sickle cell anaemia living in Northeast-Brazil, and to assess the role of radiography in diagnosing low BMD. METHODS: Bone mineral density of lumbar spine was measured by dual energy X-ray absorptiometry (DXA) in 27 patients with Sickle cell anaemia (SCA) aged 7-28 years. Clinical history, calcium and calorie intake, laboratory measurements, anthropometrics and pubertal development were assessed, and X-rays were obtained. Z-scores and T-scores for weight, height, Body Mass Index (BMI) and BMD were calculated using age and gender matched reference data. RESULTS: Mean lumbar spine BMD Z-scores and T-scores were -1.81 SD in boys and -0.80 SD in girls. BMD Z-scores were below -2 SD in 33.3% of girls and in 46.7% of boys. Low BMD (<-2 SD) occurred significantly more in patients with low height-for-age (P = 0.02), low weight-for-age (P = 0.001) and low BMI-for-age (P = 0.006). No significant relationships were found between BMD and other clinical and laboratory parameters. Radiography had a sensitivity of 75% and a specificity of 36% to detect low BMD, and was considered not useful in this context. CONCLUSIONS: Patients with low height and/or low weight-for-age seem to be at high risk for developing low BMD.

Juvenile xanthogranuloma as a differential diagnosis for sellar and suprasellar lesions in child: Case report and review of literature.

Juvenile xanthogranuloma (JXG) is a rare type of non-Langerhans cell histiocytosis. Its systemic form affects 4% of patients. Lesions in the Central Nervous System (CNS) occur in 2% of systemic cases. Sellar JXG should be one of the differential diagnoses for sellar lesions in young. This is a 15-year-old patient with non-specific headache, progressive visual loss and magnetic resonance imaging showing sellar lesion with suprasellar extension. The patient underwent microsurgery by pterional craniotomy with partial resection of the tumor. Pathology evidenced JXG. It progressively evolved with impairment of neuroendocrine functions, new lesions in different CNS locations and death two years after diagnosis. Sellar JXG without cutaneous manifestations is rare. There are no specific findings of the disease. Diagnosis requires additional tests, being defined by pathological analysis. Total resection presents a greater potential control comparing to partial resection. Even so, some patients may have progressive disease with poor clinical outcome.

Ocular manifestations of sickle cell disease.

Sickle cell disease (SCD) is the most common genetic disease worldwide. The increase in life expectancy of SCD patients in recent years has led to the emergence of more complications of the disease, e.g. ocular, which in the past were uncommon. This review describes current knowledge of the ocular manifestations of patients with SCD. SCD can affect virtually every vascular bed in the eye and can cause blindness in the advanced stages. The most significant ocular changes are those which occur in the fundus, which can be grouped into proliferative sickle retinopathy, and non-proliferative retinal changes based on the presence of vascular proliferation. This distinction is important because the formation of new vessels is the single most important precursor of potentially blinding complications. Although various systemic complications of SCD are known to be more common in patients with the Hb SS genotype, visual impairment secondary to proliferative sickle retinopathy is more common in patients with the Hb SC genotype. There is also an increase with age in the incidence and prevalence rates of all ocular complications of SCD. It is therefore recommended that all patients with SCD undergo periodic ophthalmological screening from the age of 10 years.

Occupational injuries in children and adolescents in emergency services of Aracaju, Brazil.

BACKGROUND: The incidence of occupational injuries among children and adolescents is not well known in Brazil. This study aims to identify occurrences and characteristics of occupational injuries in children and adolescents at the two major public emergency hospitals in Aracaju, Brazil. METHODS: In a cross sectional study, all children and adolescents (5-17 years) attending the services because of accidents of external cause in October-November 2006 and May-June 2007 were evaluated. The patients and their responsibles were interviewed to obtain information about the injury, family and patient characteristics and relation to work in the last 7 days. Data were analysed in number and percentages using descriptive statistics and chi-squared and Fisher's exact tests. RESULTS: There were 917 patients with injuries of external cause in the period studied. Seventy-one (8%) had worked in the last 7 days and in 40 (4%) the injury was related to work, with 2 (0.21%) deaths. Occupational injuries occurred more frequently in boys (95%); in the 14- to 17-year-old age group (77%); in agricultural (46%) and commercial activities (18%); to help with family budget (54%); without any safety training (73.5%) and not using personal protective equipment (94%). Main mechanisms of injuries were transportation incidents (42.5%) and contact with tools and equipment (27.5%). Injuries were mostly fractures (37.5%) and lacerations (22.5%). Upper extremities were injured in 49% of cases and the lower extremities in 26.5%. Comparison between the two groups (accident related or not related to labour) shows that there were significant differences for gender, age group, the main mechanism of injury and the part of the body injured, but not for the nature of injury. CONCLUSION: Working children and adolescents have been injured during their occupational activities and work-related injuries represent 4% of injuries of external causes in the emergency departments of Aracaju with 5% lethality.

Anemia and intestinal parasitic infections in primary school students in Aracaju, Sergipe, Brazil.

Anemia is estimated to affect half the school-age children and adolescents in developing countries. The main causes are parasitic infections, malaria, and low iron intake. This study aimed to describe the prevalence of anemia, parasitic infections, and nutritional status of children attending public primary schools in Aracaju, Northeast Brazil. Of 360 students, 26.7% were anemic, and prevalence was higher in children under 8 and over 15 years of age. Overall prevalence of intestinal parasites was 42%, with Ascaris lumbricoides (28.7%), Trichuris trichiura (15.6%), and hookworm (1. 7%) most frequently found. There was an association between parasitic infections and poor sanitary conditions, but there was no association between anemia and presence of intestinal parasites. Height-for-age Z scores were lower than the NCHS standard, and prevalence of stunting was 5.4%. Although intestinal parasites were not associated with anemia, children with parasites had lower nutritional indices (weight- and height-for-age Z scores) than those without parasites.

[Incidence and risk factors for diarrhoea and acute respiratory infections in urban communities of Pernambuco, Brazil]. / Incidência e fatores de risco de diarréia e infecções respiratórias agudas em comunidades urbanas de Pernambuco, Brasil.

Magnitude and distribution of Diarrhoea and Acute Respiratory Infections (ARI) in children were studied within a larger broader research that focused on health education. Two household surveys were conducted in a sample of families with at least one child under five years of Recife and Olinda in April-May 1992 and 1994. The total number of children studied was 5,436. The estimated adjusted annual incidence rate (AAIR) of diarrhoea was 2.7 episodes per child. The two-week incidence rate of diarrhoea was 10.2% for both years. Risk factors associated with higher incidence of diarrhoea were age (under two years), lack of sanitation facilities, and absence of electrical appliances in the household. Estimated AAIR of ARI was 9. 5 episodes per child. The two-week incidence rate of ARI was 41.0% in 1992 and 32.6% in 1994. Majority of ARIs affected the upper respiratory tract (75.9%). The only factor consistently associated with a higher risk of ARI was age (under three years). Study results indicate that both pathologies are still an important health problem for children under five in Pernambuco. In particular, in the case of diarrhoea the need for improving the access to basic services, such as water supply and sewage system is urgently needed.

SHV-27, a novel cefotaxime-hydrolysing beta-lactamase, identified in Klebsiella pneumoniae isolates from a Brazilian hospital.

From a collection of cefotaxime-resistant Klebsiella pneumoniae isolated from neonatal blood culture specimens in a maternity hospital in Aracaju, Brazil, two isolates (strains KPBRZ-842 and -843, indistinguishable by pulsed-field gel electrophoresis) were found to produce beta-lactamases with isoelectric points (pI) of 5.4 and 8.2, respectively. Using a gel overlay method, cefotaxime hydrolysis was shown to be associated with the pI 8.2 protein. Nucleotide sequencing of the gene encoding the pI 8.2 beta-lactamase revealed a bla(SHV-ESBL)-type gene differing from the gene encoding SHV-1 by three silent point mutations, and a fourth that resulted in an amino acid substitution, aspartate for glycine, at position 156. This novel SHV-type extended-spectrum beta-lactamase is designated SHV-27.

Capture-recapture to estimate the number of street children in a city in Brazil.

BACKGROUND: Street children are an increasing problem in Latin America. It is however difficult to estimate the number of children in the street as this is a highly mobile population. AIMS: To estimate the number of street children in Aracaju, northeast Brazil, and describe the characteristics of this population. METHODS: Three independent lists of street children were constructed from a non-governmental organisation and cross-sectional surveys. The number of street children was estimated using the capture-recapture method. The characteristics of the children were recorded during the surveys. RESULTS: The estimated number of street children was 1456. The estimated number of street children before these surveys was 526, although non-official estimates suggested that there was a much larger population. Most street children are male, maintain contact with their families, and are attending school. Children contribute to the family budget a weekly average of R21.2 dollars (4.25 pounds sterling, 6.0 euros, US7.5 dollars) for boys and R17.7 dollars(3.55 pounds sterling, 5.0 euros, US6.3 dollars) for girls. CONCLUSION: Street children of Aracaju have similar characteristics to street children from other cities in Brazil. The capture-recapture method could be a useful method to estimate the size of this highly mobile population. The major advantage of the method is its reproducibility, which makes it more acceptable than estimates from interested parties.

Immunogenicity of Haemophilus influenzae-diphtheria CRM197 protein conjugate vaccine (HbOC) in Libyan infants.

The immunogenicity of the HbOC, a Haemophilus influenzae type b conjugate vaccine, was evaluated in a randomized clinical trial of Arab children resident in Tripoli. The HbOC vaccine was given as part of a three-dose series at 2, 3 and 4 months of age together with hepatitis B, OPV and DPT to 90 children. Anti-H. influenzae antibody levels were compared with 81 infants receiving hepatitis B, OPV and DPT but not the HbOC vaccine. The immunogenicity and safety of HbOC was as high as that observed in industrialised countries. There were no major complications, and fever and temporary local discomfort were observed in fewer than approximately 2% of the infants. Infants receiving the HbOC vaccine had an increase in Hib antibodies with only one dose. Geometric mean anti-Hib antibody levels were 0.41, 1.36 and 2.91 mg/ml after one, two and three doses. After two doses, all children had antibody levels above 0.20 mg/ml and the lowest antibody concentration was 0.80 mg/ml. Antibody levels in our children are similar to those observed in Europe and the USA and it is thus likely that HbOC will provide good clinical protection in this population. As most of the children develop antibody titres above or near 1 mg/ml, it is likely that they are protected even with two doses of the vaccine. The anti-Hib antibody levels observed are similar to those in studies from Europe where hepatitis B vaccine is not routinely given.

Diarrhoea mortality in Aracaju, Brazil.

We report diarrhoea mortality rates in the city of Aracaju, Brazil from 1992 to 1994 when there were 318 deaths due to diarrhoea. Eighty-nine per cent of deaths occurred in infants: 53.1% were boys and 78.9% died in hospital. Diarrhoea mortality rates for children under 5 years of age were 2.63, 1.78 and 1.28 for 1992, 1993 and 1994, respectively. The district with the most slums and least sewerage services had the highest mortality rates (4.29, 2.53 and 1.87 for 1992, 1993 and 1994, respectively) and the district with most services and fewest slums had the lowest rates each year (0.79, 0.55 and 0.38). Malnutrition was associated with diarrhoea on 26.5% of death certificates. Mortality rates fell during the study period but still remained high in infants from poor areas of the city. Study of the geographical distribution of mortality allowed identification of priority areas for targeted interventions.

Childhood and adolescent growth of patients with sickle cell disease in Aracaju, Sergipe, north-east Brazil.

Sickle cell disease (SCD) is the most prevalent inherited monogenic pathology in South America. Although children with SCD have normal birthweight, weight deficit is often seen from early childhood. On the other hand, paradoxically, normal final height associated with delayed puberty has been reported from Brazil and Jamaica. This cross-sectional study describes the growth pattern by age and sex in 76 children and adolescents with SCD in Sergipe, north-east Brazil with a median age of 110 months. Median weights and heights for age were below the NCHS standards. The weight and height deficits were statistically significant for boys of all ages, except for 7-year-olds. Most girls have median weights and heights below the NCHS standards but this only becomes statistically significant at 15 years of age. Family channels were calculated from the parents' heights. The observed height was lower than the expected percentile value for the family in seven (41%) children, equal to expected family height in six (35%) and above expected family height in four (24%) of 17 teenagers. Our findings suggest that Brazilian children with SCD do not attain normal height and weight. It is therefore likely that, although maximum height and weight velocity occur significantly later than normal due to delayed puberty, the magnitude of this spurt is less than normal.

Echocardiographic characteristics of patients with sickle cell anaemia in Sergipe, Brazil.

This study describes the cardiac size and function of patients with sickle cell anaemia, in Segipe, Brazil, and its association to the clinical severity, duration of illness and haemoglobin levels. Heart measurements were obtained by echocardiography from 38 children and adolescents and compared to international reference values. Sickle cell patients had increased left atrial and ventricular dimensions in systole and an increased end diastolic septal and left ventricular free wall thickness. These findings correlated with age. There were no abnormalities in the ejection or shortening fractions. These results suggest early haemodynamic changes with progressive cardiac chamber dilation and diastolic dysfunction that become increasingly abnormal with growth.