Automated detection of absence seizures using a wearable electroencephalographic device: a phase 3 validation study and feasibility of automated behavioral testing.

OBJECTIVE: Our primary goal was to measure the accuracy of fully automated absence seizure detection, using a wearable electroencephalographic (EEG) device. As a secondary goal, we also tested the feasibility of automated behavioral testing triggered by the automated detection. METHODS: We conducted a phase 3 clinical trial (NCT04615442), with a prospective, multicenter, blinded study design. The input was the one-channel EEG recorded with dry electrodes embedded into a wearable headband device connected to a smartphone. The seizure detection algorithm was developed using artificial intelligence (convolutional neural networks). During the study, the predefined algorithm, with predefined cutoff value, analyzed the EEG in real time. The gold standard was derived from expert evaluation of simultaneously recorded full-array video-EEGs. In addition, we evaluated the patients' responsiveness to the automated alarms on the smartphone, and we compared it with the behavioral changes observed in the clinical video-EEGs. RESULTS: We recorded 102 consecutive patients (57 female, median age = 10 years) on suspicion of absence seizures. We recorded 364 absence seizures in 39 patients. Device deficiency was 4.67%, with a total recording time of 309 h. Average sensitivity per patient was 78.83% (95% confidence interval [CI] = 69.56%-88.11%), and median sensitivity was 92.90% (interquartile range [IQR] = 66.7%-100%). The average false detection rate was .53/h (95% CI = .32-.74). Most patients (n = 66, 64.71%) did not have any false alarms. The median F1 score per patient was .823 (IQR = .57-1). For the total recording duration, F1 score was .74. We assessed the feasibility of automated behavioral testing in 36 seizures; it correctly documented nonresponsiveness in 30 absence seizures, and responsiveness in six electrographic seizures. SIGNIFICANCE: Automated detection of absence seizures with a wearable device will improve seizure quantification and will promote assessment of patients in their home environment. Linking automated seizure detection to automated behavioral testing will provide valuable information from wearable devices.

Spatial-temporal evolution of tuberculosis incidence rates in indigenous and non-indigenous people of Brazil, from 2011 to 2022.

OBJECTIVE: To describe the space-time evolution of TB incidence rates (TI) in indigenous and non-indigenous people, according to the Federative Units (UF) of Brazil, from 2011 to 2022. METHODS: Ecological, temporal, and spatial study on new tuberculosis cases in Brazil among indigenous and non-indigenous populations. Data from the Notifiable Diseases Information System (Sinan) were collected from 2011 to 2022 and stratified by Federal Unit, explored and statistically analyzed using R software version 4.2.3. RESULTS: The mean TI among indigenous populations in Brazil was 71.7 new cases per 100,000 inhabitants, while for non-indigenous populations it was 28.6/100,000 inhabitants. The regions of the country that presented the highest (mean) incidence among indigenous populations were: Central-West (102.8/100,000 inhabitants), Southeast (99.6/100,000 inhabitants), and North (79.9/100,000 inhabitants). For non-indigenous populations the highest incidence was in the North region (36.5/100,000 inhabitants), followed by the Southeast (31.3/100,000), and the Northeast (27,4/100,000 inhabitants). The analysis showed that the highest incidence of TB cases among indigenous populations occurred in the states of: SP, RO, RJ, MS, MT e PA. CONCLUSION: High incidence of the disease compared to the non-indigenous population show the need for a specific approach to address the health needs of these populations. Regional disparities in incidence indicate the need to address socioeconomic and infrastructure issues that affect the health of indigenous populations.

Registration with Primary Health Care and COVID-19 mortality: cohort of diabetics from five administrative health regions in the city of Rio de Janeiro, Brazil, 2020-2021. / Cadastro na Atenção Primária e mortalidade por COVID-19: coorte de diabéticos de cinco regiões administrativas de saúde do município do Rio de Janeiro, 2020­2021.

OBJECTIVE: The present study carried out an analysis of survival according to the status of registration with Primary Health Care (PHC) and of factors associated with death from COVID-19, in cases residing in Programmatic Area 3.1 (PA3.1) with a diagnosis of diabetes (in the notification form or in the electronic medical record), of the Municipality of Rio de Janeiro (RJ), Brazil, in 2020-2021. METHODS: A probabilistic linkage of databases was performed based on information on cases notified as COVID-19 and data from the electronic medical records of people living with diabetes. A survival analysis was carried out, using the Cox regression model stratified by age group and adjusted for confounding variables. RESULTS: Individuals registered with the PHC of PA3.1 had almost twice the risk of death from COVID-19 (adjusted hazard ratio [HRadj]=1.91) when compared to those unregistered. This association was stronger in individuals aged 18 to 59 years registered with the PHC (HRadj=2.82) than in individuals aged 60 years or over (HRadj=1.56). CONCLUSION: Surveillance strategies for identifying and adequately monitoring higher-risk groups, among individuals living with diabetes, within the scope of Primary Health Care, can contribute to reducing mortality from COVID-19.

OBJETIVO: O presente estudo realizou uma análise de sobrevivência segundo situação de cadastro na Atenção Primária à Saúde (APS) e de fatores associados ao óbito por COVID-19, nos casos residentes da Área Programática 3.1 (AP3.1) com diagnóstico de diabetes (na ficha de notificação ou no prontuário eletrônico) do município do Rio de Janeiro, em 2020­2021. MÉTODOS: Foi realizado relacionamento probabilístico de bases de dados com base nas informações dos casos notificados por COVID-19 e dos dados de prontuário eletrônico de pessoas que vivem com diabetes. Conduziu-se uma análise de sobrevivência, utilizando-se o modelo de regressão de Cox estratificado por faixa etária e ajustando-se por variáveis confundidoras. RESULTADOS: Verificou-se que indivíduos cadastrados na APS da AP3.1 possuíam risco quase duas vezes maior de óbito por COVID-19 (hazard ratio ajustada ­ HRaj=1,91) quando comparados aos não cadastrados na APS da AP3.1. Essa associação foi mais forte naqueles com 18 a 59 anos, cadastrados na APS (HRaj=2,82), do que nos de 60 anos ou mais (HRaj=1,56). CONCLUSÃO: Estratégias de vigilância para a identificação e acompanhamento adequado de grupos de maior risco de mortalidade, dentre indivíduos que vivem com DM, no âmbito da APS podem contribuir para a redução da mortalidade em decorrência da COVID-19.

The Potential of Films as Transmucosal Drug Delivery Systems.

Pharmaceutical films are polymeric formulations used as a delivery platform for administration of small and macromolecular drugs for local or systemic action. They can be produced by using synthetic, semi-synthetic, or natural polymers through solvent casting, electrospinning, hot-melt extrusion, and 3D printing methods, and depending on the components and the manufacturing methods used, the films allow the modulation of drug release. Moreover, they have advantages that have drawn interest in the development and evaluation of film application on the buccal, nasal, vaginal, and ocular mucosa. This review aims to provide an overview of and critically discuss the use of films as transmucosal drug delivery systems. For this, aspects such as the composition of these formulations, the theories of mucoadhesion, and the methods of production were deeply considered, and an analysis of the main transmucosal pathways for which there are examples of developed films was conducted. All of this allowed us to point out the most relevant characteristics and opportunities that deserve to be taken into account in the use of films as transmucosal drug delivery systems.

Reference values for the tri-ponderal mass index and its association with cardiovascular risk factors in Brazilian adolescents aged 12 to 17 years.

OBJECTIVES: The aims of this study was to determine the cutoff values for tri-ponderal mass index (TMI) and investigate the association between overweight/obesity as classified by TMI and cardiometabolic risk factors in Brazilian adolescents aged 12 to 17 y. METHODS: This was a cross-sectional study comprising 37 815 adolescents (40 % boys; 12-17 y) enrolled in the Study of Cardiovascular Risks in Adolescents. TMI was calculated as weight divided by cubed height (kg/m3). Overweight (TMI-for-age ≥85th percentile to <95th percentile) and obesity (TMI-for-age ≥95th percentile) were determined for both sexes. Poisson regression model analyses were used to test associations. RESULTS: TMI was stable across the age span (12-17 y) in both sexes. Boys and girls classified by TMI as obese had higher prevalence ratios (PR) for hypertension (PR, 4.98; 95% confidence interval [CI], 3.26-7.61 for boys; PR, 6.88; 95% CI, 3.70-12.78 for girls), insulin resistance (PR, 19.72; 95% CI, 13.56-28.69 for boys; PR, 10.04; 95% CI, 7.47-13.50 for girls), hypercholesterolemia (PR,5.05; 95% CI, 3.68-6.94 for boys; PR, 1.44; 95% CI, 1.00-2.11 for girls), and hypertriacylglycerolemia (PR,7.36; 95% CI, 5.16-10.50 for boys; PR, 3.37; 95% CI, 2.52-4.51 for girls) when compared with normal weight counterparts. CONCLUSIONS: Obesity, as classified by TMI, was strongly associated with several cardiovascular risk factors. Our data showed that TMI was stable across the age span. Therefore, a fixed cutoff value to determine weight status in Brazilian adolescents seems appropriate.

Measles resurgence in Brazil: analysis of the 2019 epidemic in the state of São Paulo.

OBJECTIVE: To analyze the epidemiological profile of cases and the pattern of spatial diffusion of the largest measles epidemic in Brazil that occurred in the post-elimination period in the state of São Paulo. METHOD: A cross-sectional study based on confirmed measles cases in 2019. Bivariate analysis was performed for socioeconomic, clinical, and epidemiological variables, according to prior vaccination and hospitalization, combined with an analysis of spatial diffusion of cases using the Inverse Distance Weighting (IDW) method. RESULTS: Of the 15,598 confirmed cases, 2,039 were hospitalized and 17 progressed to death. The epidemic peak occurred in epidemiological week 33, after confirmation of the first case, in the epidemiological week 6. Most cases were male (52.1%), aged between 18 and 29 years (38.7%), identified as whites (70%). Young adults (39.7%) and children under five years (32.8%) were the most affected age groups. A higher proportion of previous vaccination was observed in whites as compared to Blacks, browns, yellows and indigenous people (p < 0.001), as well as in the most educated group compared to the other categories (p < 0.001). The risk of hospitalization was higher in children than in the older age group (RI = 2.19; 95%CI: 1.66-2.88), as well as in the unvaccinated than in the vaccinated (RI = 1.59; 95%CI: 1.45-1.75). The pattern of diffusion by contiguity combined with diffusion by relocation followed the urban hierarchy of the main cities' regions of influence. CONCLUSION: In addition to routine vaccination in children, the findings indicate the need for immunization campaigns for young adults. In addition, studies that seek to investigate the occurrence of clusters of vulnerable populations, prone to lower vaccination coverage, are essential to broaden the understanding of the dynamics of transmission and, thus, reorienting control strategies that ensure disease elimination.

[Identification of risk areas and factors associated with the 2019 measles epidemic in the State of São Paulo, Brazil]. / Identificação de áreas de risco e fatores associados à epidemia de sarampo de 2019 no Estado de São Paulo, Brasil.

This study aimed to analyze the occurrence of clusters and factors associated with the resurgence of measles cases from the largest epidemic of the post-elimination period in the State of São Paulo, Brazil, in 2019. Sociosanitary and care factors were analyzed by zero-inflated Poisson (ZIP) and ZIP models with structured and unstructured spatial effect. The SCAN statistic was used to analyze the occurrence of case clusters. Clusters of high-risk cases were identified in municipalities that make up the intermediate region of São Paulo. In the ZIP model, the following variables were observed as risk factors at the municipal level: household heads under 18 years old (adjusted RR =0 1.39; 95%CrI: 1.27-1.53), inequality in income distribution (adjusted RR = 36.67; 95%CrI: 26.36-51.15), unemployment in people over 18 years old (adjusted RR = 1.10; 95%CrI: 1.08-1.12), and non-existent street lighting (adjusted RR = 1.05; 95%CrI: 1.04-1.05). In the ZIP models with structured and unstructured spatial effect, the following variables were observed as risk factors: household heads under 18 years old (adjusted RR = 1.36; 95%CrI: 1.04-1.90) and inequality in income distribution (adjusted RR = 3.12; 95%CrI: 1.02-9.48). In both models, the coverage of health agents was presented as a protective factor. The findings reinforce the importance of intensifying measles surveillance actions articulated to the Family Health Strategy, especially in areas with greater social vulnerability, to ensure equitable and satisfactory vaccination coverage and reduce the risk of reemergence of the disease.

O objetivo foi analisar a ocorrência de clusters e fatores associados ao ressurgimento de casos de sarampo da maior epidemia do período pós-eliminação, ocorrida no Estado de São Paulo, Brasil, em 2019. Fatores sociossanitários e assistenciais foram analisados por modelos de Poisson inflacionado de zero (ZIP) e ZIP com efeito espacial estruturado e não estruturado. A estatística de varredura SCAN foi usada para analisar a ocorrência de clusters de casos. Foram identificados clusters de casos de alto risco em municípios que compõem a região intermediária de São Paulo. No modelo ZIP, foram observadas como fatores de risco no nível municipal as variáveis chefes de domicílio menores de 18 anos (RR ajustado = 1,39; ICr95%: 1,27-1,53), desigualdade na distribuição de renda (RR ajustado = 36,67; ICr95%: 26,36-51,15), desocupação em maiores de 18 anos (RR ajustado = 1,10; ICr95%: 1,08-1,12) e iluminação pública inexistente (RR ajustado = 1,05; ICr95%: 1,04-1,05). Nos modelos ZIP com efeito espacial estruturado e não estruturado, foram identificados como fatores de risco os indicadores chefes de domicílio menores de 18 anos (RR ajustado = 1,36; ICr95%: 1,04-1,90) e desigualdade na distribuição dos rendimentos do trabalho (RR ajustado = 3,12; ICr95%: 1,02-9,48). Em ambos os modelos, a cobertura de agentes de saúde se apresentou como fator de proteção. Os achados reforçam a importância de intensificar as ações de vigilância de sarampo articuladas à Estratégia Saúde da Família, especialmente em áreas de maior vulnerabilidade social, para garantir coberturas vacinais equânimes e satisfatórias e reduzir o risco de reemergência da doença.

El objetivo de este estudio fue analizar la ocurrencia de clusters y sus factores asociados al resurgimiento de los casos de sarampión teniendo por base la mayor epidemia del período poserradicación que tuvo lugar en el Estado de São Paulo, Brasil, en 2019. Los factores sociosanitarios y asistenciales se analizaron mediante modelos de Poisson zero inflated (ZIP) y ZIP con efecto espacial estructurado y no estructurado. La estadística de exploración SCAN se utilizó para analizar la ocurrencia de clusters de casos. Se identificaron clusters de casos de alto riesgo en municipios que componen la Región Intermedia de São Paulo. En el modelo ZIP se observaron como factores de riesgo a nivel municipal las variables jefes de hogar menores de 18 años (RR ajustado = 1,39; ICr95%: 1,27-1,53), desigualdad en la distribución de renta (RR ajustado = 36,67; ICr95%: 26,36-51,15), desempleo en mayores de 18 años (RR ajustado = 1,10; ICr95%: 1,08-1,12) y alumbrado público inexistente (RR ajustado = 1,05; ICr95%: 1,04-1,05). En los modelos ZIP con efecto espacial estructurado y no estructurado, se identificaron como factores de riesgo los indicadores jefe de hogar menor de 18 años (RR ajustado = 1,36; ICr95%: 1,04-1,90) y la desigualdad en la distribución de los ingresos de trabajo (RR ajustado = 3,12; ICr95%: 1,02- 9,48). En ambos modelos, la cobertura de los agentes de salud fue un factor protector. Los hallazgos evidencian la importancia de intensificar las acciones de vigilancia del sarampión vinculadas a la Estrategia de Salud Familiar, especialmente en las zonas de mayor vulnerabilidad social, para garantizar una cobertura de la vacunación de manera equitativa y satisfactoria, además de reducir el riesgo de reemergencia de la enfermedad.

[Unsafe abortions in the State of Rio de Janeiro, Brazil: magnitude and time trend from 2008 to 2017]. / Aborto inseguro no Estado do Rio de Janeiro, Brasil: magnitude e evolução de 2008 a 2017.

Data on unsafe abortions are scarce, and estimates based on hospitalizations have pointed to a decline in recent years. The study aimed to analyze the time trend in unsafe abortions in the State of Rio de Janeiro, Brazil, from 2008 to 2017. We used secondary data on hospitalizations in the Brazilian Unified National Health System (SUS) due to complications of abortion in childbearing-age women (CAW) 15 to 44 years of age. We applied indirect estimation with a correction factor based on national and state data. We calculated the unsafe abortion rate per CAW (UAR-CAW), ratio of unsafe abortions per live births (RUA-LB), according to age bracket. We also calculated new indicators: spontaneous abortion rate (SAR) and unspecified abortion rate (USAR) per CAW; ratio of spontaneous abortions (RSA) and ratio of unspecified abortions (RUSA) per live births, independently of age. Time trend was calculated by Joinpoint regression, calculating the annual percent change (APC) and 95% confidence intervals (95%CI). The women that most induced abortions were 20 to 24 years of age, with UAR of 8 per 1,000. Pregnancies that ended in unsafe abortion were most frequent in the 40-44-year bracket: UAR of 16 to 20 per 100 live births. Adolescents showed a reduction in UAR from 2015 to 2017 (APC = -10; 95%CI: -18.2; -1.1), while there was an increase in women 40-44 years of age from 2008 to 2017 (APC = 2.2; 95%CI 0.5 to 4.0). The other age brackets and the indicator UAR-LB showed stability. SAR (APC = -3.5; 95%CI: -5.9; -1.0), and RSA (APC = -3.8; 95%CI: -6.3; -1.2) decreased, while USAR (APC = 6.6; 95%CI: 1.7; 11.8) and RUSA (APC = 6.4; 95%CI: 1.6; 11.3) increased during the period. The magnitude and time trend of unsafe abortions in the State of Rio de Janeiro differed according to age bracket and ICD-10 code.

Dados sobre aborto inseguro são escassos e estimativas baseadas em internações apontaram decréscimo nos últimos anos. O objetivo foi analisar a evolução temporal de aborto inseguro no Estado do Rio de Janeiro, Brasil, de 2008 a 2017. Utilizamos dados secundários de internações hospitalares no Sistema Único de Saúde (SUS) por complicações de aborto, para mulheres em idade fértil de 15-44 anos. Aplicamos estimativa indireta com fator de correção baseado em dados nacionais e do estado. Calculamos: taxa de abortos inseguros por mulheres em idade fértil (TAI-MIF), razão de abortos inseguros por nascidos vivos (RAI-NV), segundo faixa etária. Adicionalmente, calculamos novos indicadores: taxa de aborto espontâneo (TAE) e não especificado (TANE) por mulheres em idade fértil; razão de aborto espontâneo (RAE) e não especificado (RANE) por nascidos vivos, independentemente da idade. A tendência temporal foi por regressão Joinpoint, calculando a mudança percentual anual (MPA) e intervalo de 95% de confiança (IC95%). As mulheres que mais induziram aborto têm de 20-24 anos: TAI de 8 por mil. Gestações terminaram em aborto inseguro mais frequentemente na faixa de 40-44 anos: RAI entre 16 e 20 por 100 nascidos vivos. As adolescentes tiveram redução da TAI entre 2015 e 2017 (MPA = -10; IC95%: -18,2; -1,1), e houve aumento para aquelas de 40-44 anos, entre 2008 e 2017(MPA = 2,2; IC95%: 0,5; 4,0). Para outras faixas e para o indicador RAI-NV houve estabilidade. A TAE (MPA = -3,5; IC95%: -5,9; -1,0), e a RAE (MPA = -3,8; IC95%: -6,3; -1,2) reduziram enquanto a TANE (MPA = 6,6; IC95%: 1,7; 11,8) e a RANE (MPA = 6,4; IC95%: 1,6; 11,3) aumentaram no período. O aborto inseguro no Estado do Rio de Janeiro mostrou magnitude e evolução temporal diferenciadas segundo faixas etárias e código da CID-10.

Los datos sobre aborto inseguro son escasos y las estimativas basadas en internamientos aportaron un descenso durante los últimos anos. El objetivo fue analizar la evolución temporal de aborto inseguro en el Estado de Río de Janeiro, Brasil, de 2008 a 2017. Utilizamos datos secundarios de internamientos hospitalarios en el Sistema Único de Salud (SUS) por complicaciones de aborto, en mujeres en edad fértil de 15 a 44 años. Aplicamos una estimativa indirecta con factor de corrección, basado en datos nacionales y del estado. Calculamos: tasa de abortos inseguros por mujeres en edad fértil (TAI-MIF), razón de abortos inseguros por nacidos vivos (RAI-NV), según franja de edad. Asimismo, calculamos nuevos indicadores: tasa de aborto espontáneo (TAE) y no especificado (TANE) por mujeres en edad fértil; razón de aborto espontáneo (RAE) y no especificado (RANE) por nacidos vivos, independientemente de la edad. La tendencia temporal fue por regresión Joinpoint, calculando el cambio de porcentaje anual (MP) e intervalo de 95% de confianza (IC95%). Las mujeres que más indujeron el aborto tienen de 20 a 24 años: TAI de 8 por mil. Las gestaciones terminaron en aborto inseguro más frecuentemente en la franja de 40-44 años: RAI entre 16 y 20 por 100 nacidos vivos. Las adolescentes tuvieron una reducción de la TAI entre 2015 y 2017 (MPA = -10; IC95%: -18,2; -1,1), y hubo aumento para aquellas de 40-44 años, entre 2008 y 2017 (MPA = 2,2; IC95%: 0,5; 4,0). Para otras franjas y para el indicador RAI-NV hubo estabilidad. La TAE (MPA = -3,5; IC95%: -5,9; -1,0), y la RAE (MPA = -3,8; IC95%: -6,3; -1,2) se redujeron mientras la TANE (MPA = 6,6; IC95%: 1,7; 11,8) y la RANE (MPA = 6,4; IC95%: 1,6; 11,3) aumentaron durante el período. El aborto inseguro en el Estado de Río de Janeiro mostró magnitud y evolución temporal diferenciadas, según franjas etarias y código de la CIE-10.

Mercury Exposure in Munduruku Indigenous Communities from Brazilian Amazon: Methodological Background and an Overview of the Principal Results.

The Amazonian indigenous peoples depend on natural resources to live, but human activities' growing impacts threaten their health and livelihoods. Our objectives were to present the principal results of an integrated and multidisciplinary analysis of the health parameters and assess the mercury (Hg) exposure levels in indigenous populations in the Brazilian Amazon. We carried out a cross-sectional study based on a census of three Munduruku indigenous villages (Sawré Muybu, Poxo Muybu, and Sawré Aboy), located in the Sawré Muybu Indigenous Land, between 29 October and 9 November 2019. The investigation included: (i) sociodemographic characterization of the participants; (ii) health assessment; (iii) genetic polymorphism analysis; (iv) hair mercury determination; and (v) fish mercury determination. We used the logistic regression model with conditional Prevalence Ratio (PR), with the respective 95% confidence intervals (CI95%) to explore factors associated with mercury exposure levels ≥6.0 µg/g. A total of 200 participants were interviewed. Mercury levels (197 hair samples) ranged from 1.4 to 23.9 µg/g, with significant differences between the villages (Kruskal-Wallis test: 19.9; p-value < 0.001). On average, the general prevalence of Hg exposure ≥ 6.0 µg/g was 57.9%. For participants ≥12 years old, the Hg exposure ≥6.0 µg/g showed associated with no regular income (PR: 1.3; CI95%: 1.0-1.8), high blood pressure (PR: 1.6; CI95%: 1.3-2.1) and was more prominent in Sawré Aboy village (PR: 1.8; CI95%: 1.3-2.3). For women of childbearing age, the Hg exposure ≥6.0 µg/g was associated with high blood pressure (PR: 1.9; CI95%: 1.2-2.3), with pregnancy (PR: 1.5; CI95%: 1.0-2.1) and was more prominent among residents in Poxo Muybu (PR: 1.9; CI95%: 1.0-3.4) and Sawré Aboy (PR: 2.5; CI95%: 1.4-4.4) villages. Our findings suggest that chronic mercury exposure causes harmful effects to the studied indigenous communities, especially considering vulnerable groups of the population, such as women of childbearing age. Lastly, we propose to stop the illegal mining in these areas and develop a risk management plan that aims to ensure the health, livelihoods, and human rights of the indigenous people from Amazon Basin.

Women who have undergone abortion in the city of Rio de Janeiro, Brazil: application of a Bayesian hierarchical model. / Mulheres que fizeram aborto no Município do Rio de Janeiro, Brasil: aplicação de um modelo hierárquico bayesiano.

Estimates of number of women who have undergone induced abortion in jurisdictions with restrictive abortion laws are still scarce in the scientific literature, and the disparate estimates from currently used methods call for the application of innovative estimation techniques such as new indirect methods. This need is especially acute in more densely populated areas, such as Brazil's state capitals, given the magnitude of unsafe abortions and the resulting risks and harms. The article aims to estimate the number of women who had induced abortions in the city of Rio de Janeiro in 2011, based on a Bayesian hierarchical model. The model was applied to data from a household survey that supported the use of the network scale-up method in the city of Rio de Janeiro, a Bayesian hierarchical model using indirect information based on the contact networks of randomly selected participants from the general population. Among the 1,758,145 women 15-49 years of age living in the city of Rio de Janeiro, 13,025 women (95%CrI: 10,635; 15,748) had induced abortions in 2011, resulting in a mean cumulative incidence of 7.41 (95%CrI: 6.05; 8.96) for every 1,000 women 15-49 years of age. The model's self-validation process identified patterns of underestimation in stigmatized subpopulations with low social visibility, such as women who have undergone induced abortion. Induced abortion is a common practice among women in the city of Rio de Janeiro. New indirect estimation methods can contribute to more precise measurement of this event, considering the context of illegality, and thereby contribute to appropriate health policies.

Estimativas de mulheres que fizeram aborto provocado em localidades cujas leis são restritivas ainda são escassas na literatura científica, e a não coincidência de estimativas oriundas dos métodos hoje em uso clama pela aplicação de métodos inovadores, como novos métodos indiretos. Tal necessidade é especialmente aguda nas áreas mais densamente povoadas, como as capitais brasileiras, dada a magnitude do fenômeno e os danos e riscos daí decorrentes. O artigo objetiva estimar o número de mulheres que fez aborto provocado no Município do Rio de Janeiro, Brasil, em 2011, por meio de um modelo hierárquico bayesiano. Ele foi aplicado aos dados de um inquérito domiciliar que subsidiou a utilização do método network scale-up, no Município do Rio de Janeiro, um modelo hierárquico bayesiano utilizando as informações indiretas baseadas na rede de contatos dos participantes selecionados de forma aleatória da população. Das 1.758.145 mulheres de 15-49 anos residentes no Município do Rio de Janeiro (13.025; ICr95%: 10.635; 15.748) mulheres fizeram aborto provocado em 2011, resultando numa incidência acumulada média de 7,41 (ICr95%: 6,05; 8,96) para cada 1.000 mulheres de 15-49 anos. O estudo de autovalidação do modelo permitiu identificar padrões de subestimação em subpopulações estigmatizadas com baixa visibilidade social, como mulheres fizeram aborto provocado. O abortamento provocado é uma prática recorrente entre as mulheres no Município do Rio de Janeiro. Novos métodos de estimação indireta podem contribuir para a apreensão mais precisa do evento, considerando o contexto de ilegalidade, e contribuir para formulação de políticas de saúde.

Las estimaciones de mujeres que tuvieron un aborto provocado en localidades cuyas leyes son restrictivas todavía son escasas en la literatura científica, y la no coincidencia de las estimaciones procedentes de los métodos hoy en uso reclama urgentemente la aplicación de métodos innovadores, como los nuevos métodos indirectos. Tal necesidad es especialmente acuciante en las áreas más densamente pobladas, como las capitales brasileñas, dada la magnitud del fenómeno y los daños y riesgos derivados de allí. El artículo tiene como objetivo estimar el número de mujeres que realizaron un aborto provocado en el Municipio de Río de Janeiro, Brasil, en 2011, a partir de un modelo jerárquico bayesiano. Este se aplicó a los datos de una encuesta domiciliaria que fomentó la utilización del método network scale-up, en el Municipio de Río de Janeiro, un modelo jerárquico bayesiano utilizando información indirecta, basada en la red de contactos de los participantes seleccionados de forma aleatoria en la población. De las 1.758.145 mujeres de 15-49 años, residentes en el Municipio de Río de Janeiro, 13.025 (ICr95%: 10.635; 15.748) mujeres tuvieron un aborto provocado en 2011, resultando en una incidencia acumulada media de 7,41 (ICr95%: 6,05; 8,96) para cada 1.000 mujeres de 15-49 años. El estudio de autovalidación del modelo permitió identificar patrones de subestimación en subpoblaciones estigmatizadas con baja visibilidad social, como las mujeres que tuvieron un aborto provocado. El aborto provocado es una práctica recurrente entre mujeres en el municipio de Río de Janeiro. Nuevos métodos de estimación indirecta pueden contribuir a la aprehensión más precisa de este evento, considerando el contexto de ilegalidad, y contribuir a la formulación de políticas de salud.

Predictive Ability of Seven Anthropometric Indices for Cardiovascular Risk Markers and Metabolic Syndrome in Adolescents.

PURPOSE: The aim of the study was to evaluate the reliability of 7 anthropometric indices in predicting cardiovascular risk markers (CRMs) and metabolic syndrome (MetS) in Brazilian adolescents. METHODS: A cross-sectional study conducted with 1,069 participants of the Cardiovascular Risk in Adolescents Study aged 12-17 years. Receiver operating characteristics curves were plotted, and area under curve (AUC) was calculated for body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHR), conicity index (CoI), body shape index (BSI), adjusted BSI for adolescents (adjusted BSI), and body roundness index (BRI). RESULTS: In girls, reliability of BMI, WC, WHR, and BRI was sufficient (≥.6 AUC <.7) only to predict high blood pressure. Among boys, reliability of BMI, WC, WHR, BRI, and adjusted BSI ranged from good to sufficient (≥6 AUC <.8) to predict insulin resistance and high blood pressure, but poor to sufficient (≥.5 AUC <.7) for high total cholesterol, triglycerides, and low-density lipoprotein. For both sexes, CoI and BSI presented AUC ≤.5 for all CRM. A majority of the anthropometric indices showed AUC ≥.9 for MetS. CONCLUSION: Reliability of CoI, BSI, adjusted BSI, and BRI is not superior to BMI, WC, and WHR in predicting CRM and MetS. All the anthropometric indices had excellent predictive capacity for MetS, but limited accuracy for CRM. Among the evaluated indices, we recommend the use of cutoff point WHR ≥.55 to screening MetS in girls and boys because of its easy to measure and interpretation.

Factors associated with death in patients with tuberculosis in Brazil: Competing risks analysis.

OBJECTIVES: This study aimed to analyze the factors associated with likely TB deaths, likely TB-related deaths and deaths from other causes. Understanding the factors associated with mortality could help the strategy to End TB, especially the goal of reducing TB deaths by 95% between 2015 and 2035. METHODS: A retrospective, population-based cohort study of the causes of death was performed using a competing risk model in patients receiving treatment for TB. Patients had started TB treatment in Brazil 2008-2013 with any death certificates dated in the same period. We used three categories of deaths, according to ICD-10 codes: i) probable TB deaths; ii) TB-related deaths; iii) deaths from other causes. RESULTS: In this cohort, 39,997 individuals (14.1%) died, out of a total of 283,508 individuals. Of these, 8,936 were probable TB deaths (22.4%) and 3,365 TB-related deaths (8.4%), illustrating high mortality rates. 27,696 deaths (69.2%) were from other causes. From our analysis, factors strongly associated with probable TB deaths were male gender (sHR = 1.33, 95% CI: 1.26-1.40), age over 60 years (sHR = 9.29, 95% CI: 8.15-10.60), illiterate schooling (sHR = 2.33, 95% CI: 2.09-2.59), black (sHR = 1.33, 95% CI: 1.26-1.40) and brown (sHR = 13, 95% CI: 1.07-1.19) color/race, from the Southern region (sHR = 1.19, 95% CI: 1.10-1.28), clinical mixed forms (sHR = 1.91, 95% CI: 1.73-2.11) and alcoholism (sHR = 1.90, 95% CI: 1.81-2.00). Also, HIV positive serology was strongly associated with probable TB deaths (sHR = 62.78; 95% CI: 55.01-71.63). CONCLUSIONS: In conclusion, specific strategies for active surveillance and early case detection can reduce mortality among patients with tuberculosis, leading to more timely detection and treatment.

Avaliação da mortalidade associada ao status tireoidiano em uma coorte de pessoas idosas eutireoidianas de ambulatório de geriatria em hospital universitário / Assessment of mortality associated with thyroid status in a cohort of euthyroid older adults from a geriatric outpatient clinic at a university hospital

Resumo Objetivo Avaliar associações entre a média da tireotropina (TSH) e tiroxina livre (T4L) mantida durante follow-up, e mortalidade em pacientes idosos eutireoidianos definidos de acordo com a faixa de referência específica para a idade (FR-e) do TSH. Método Coorte retrospectiva tipo análise de sobrevivência incluindo pacientes idosos eutireoidianos acompanhados no ambulatório de hospital universitário entre 2010 e 2013. Todos os participantes haviam sido avaliados quanto ao risco de incapacidade funcional como critério para admissão nesse ambulatório. As médias dos valores de TSH e T4L foram calculadas através das dosagens obtidas no período de acompanhamento. Cada FR-e de TSH foi dividida em quatro partes iguais, considerando níveis mais baixos como variável de exposição (≤1,75 mUI/L para <80 e ≤2,0 mUI/L para ≥80 anos). Os níveis de T4L foram dicotomizados em duas categorias (< e ≥1,37 ng/dL). O desfecho foi o tempo até a morte. A regressão de risco proporcional de Cox foi empregada para estimar a hazard ratio (HR) e o intervalo de confiança (IC) de 95% Resultados 285 participantes (73% mulheres, idade média =80,4 anos) seguidos pela mediana de 5,7 anos (IQR =3,7-6,4; máximo =7), sendo que 114 faleceram. Após o modelo final ajustado, a mortalidade esteve associada ao TSH no limite inferior (HR=1,7; IC=1,1-2,7; p=0,016) e ao T4L mais elevado. (HR=2,0; IC=1,0-3,8; p=0,052). Conclusão Níveis médios de T4L mais altos e de TSH mais baixos foram associados ao risco de morte em coorte de idosos eutireoidianos usando FR-e de TSH.

Abstract Objective To assess the associations between the mean thyrotropin (TSH) and mean free thyroxine (FT4), detected during follow-up, and mortality in a group of older euthyroid patients according to age-specific reference range (as-RR) for TSH. Method Retrospective survival analysis cohort including euthyroid elderly patients who were being monitored at the outpatient clinic of a university hospital from 2010 to 2013. All participants had been assessed for the risk of functional disability as a criterion for admission to this outpatient clinic. Mean TSH and FT4 values were calculated using hormone dosages obtained during the follow-up period. Each as-RR for TSH was divided into four equal parts, considering the lower levels as the main exposure variable (≤1.75 mlU/L for <80, and ≤2.0 mlU/L for ≥80 years). FT4 levels were explored according to two categories (< e ≥1.37 ng/dL). The outcome was time to death. We used Cox proportional hazard regression to estimate the hazard ratio (HR) and 95% confidence interval (CI). Results 285 participants (73% females, mean age =80.4 years) followed by a median of 5.7 years (IQR =3.7-6.4; maximum =7), of which 114 died. After the adjusted final model, mortality was associated with the lowest mean TSH (HR=1.7; CI=1.1-2.7; p=0.016) and with the upper mean of FT4 (HR=2.0; CI=1.0-3.8; p=0.052). Conclusions Higher FT4 and lower TSH mean levels were associated with risk of death in a cohort of euthyroid older adults using an as-RR of TSH.

Oral and nasal vaccination: current prospects, challenges, and impact of nanotechnology-based delivery systems

Abstract Currently, mucosal vaccine administration has stood out as an easier and non-invasive application method. It can also be used to induce local and systemic immune responses. In the COVID-19 pandemic context, nasal and oral vaccines have been developed based on different technological platforms. This review addressed relevant aspects of mucosal vaccine administration, with emphasis on oral and nasal vaccinations, in addition to the importance of using nanotechnology-based delivery systems to enable these strategies.

Prevalência dos Fatores de Risco e de Proteção para o Câncer entre Trabalhadores de Saúde durante a Pandemia de Covid-19 / Prevalence of Risk and Protective Factors for Cancer among Health Workers during the COVID-19 / Pandemic Prevalencia de Factores de Riesgo y Protección para el Cáncer en los Trabajadores de la Salud durante la Pandemia de la Covid-19

Introdução: A covid-19 e seus impactos são preocupantes. Os profissionais de saúde são fundamentais para controlar a disseminação da doença e o funcionamento dos serviços. Objetivo: Analisar os fatores de risco e de proteção para o câncer entre os trabalhadores de uma unidade de saúde durante a pandemia de covid-19. Método: Estudo transversal com aplicação de questionário em 138 trabalhadores de saúde envolvendo o perfil dos participantes e a prevalência de tabagismo, prática de exercícios físicos, consumo de bebidas alcoólicas, sucos artificiais/refrigerantes, verduras/legumes e frutas. Os dados foram apresentados por meio de estatística descritiva. Resultados: A prevalência de tabagismo foi de 4,3% entre os 138 entrevistados. O consumo de bebidas alcoólicas e de sucos artificiais/refrigerantes correspondeu a 46% e 53%, respectivamente, com maior frequência do consumo na faixa etária de até 40 anos (p=0,005). A prevalência do consumo de verduras/legumes foi de 99,3% e de frutas foi de 94%. Cerca de 66% dos trabalhadores realizavam exercícios físicos pelo menos um dia por semana. Durante a pandemia de covid-19, observou-se menor prática de exercícios físicos entre os trabalhadores de saúde entrevistados. Conclusão: O monitoramento dos fatores de risco e de proteção para o câncer é determinante para estilos de vida saudáveis. A melhora da qualidade de vida dos trabalhadores de saúde é fundamental para a prestação qualificada de serviços, sobretudo no Sistema Único de Saúde (SUS)

Introduction: COVID-19 and its impacts are worrying. Health workers are essential to control the spread of the disease and services functioning. Objective: To analyze the risk and protective factors for cancer among health workers at a health unit during the COVID-19 pandemic. Method: Cross-sectional study with the application of a questionnaire in 138 health workers involving the profile of the participants and the prevalence of smoking, physical activity, use of alcoholic beverages, artificial juices/soft drinks, greens/vegetables and fruits. Data were presented through descriptive statistics. Results: The prevalence of smoking was 4.3% among the 138 respondents. The use of alcoholic beverages and artificial juices/soft drinks corresponded to 46% and 53%, respectively, with a higher intake frequency in the age-range of younger than 40 years old (p=0.005). The prevalence of intake of greens/vegetables was 99.3% and 94% for fruits. Nearly 66% of the workers performed physical activities at least once a week. During the COVID-19 pandemic, the frequency of physical activities by the workers interviewed declined. Conclusion: Monitoring risk and protective factors for cancer is crucial for healthy lifestyles. Improving the quality of life of health workers is fundamental to offer quality services, especially by the National Health System (SUS)

Introducción: La covid-19 y sus impactos son preocupantes. Los profesionales de la salud son esenciales para controlar la propagación de la enfermedad y el funcionamiento de los servicios. Objetivo: Analizar los factores de riesgo y protección para el cáncer en los trabajadores de salud en una unidad de salud durante la pandemia de la covid-19. Método: Estudio transversal con la aplicación de un cuestionario a 138 trabajadores de la salud que involucró el perfil de los participantes y la prevalencia de tabaquismo, ejercicio físico, consumo de bebidas alcohólicas, jugos artificiales/bebidas gaseosas, verduras/legumbres y frutas. Los datos fueron presentados usando estadística descriptiva. Resultados: La prevalencia de tabaquismo fue del 4,3% entre los 138 encuestados. El consumo de bebidas alcohólicas y jugos artificiales/bebidas gaseosas correspondió al 46% y 53%, respectivamente, encontrándose una mayor frecuencia de consumo en el grupo etario de menores de 40 años (p=0,005). La prevalencia del consumo de verduras/ legumbres fue del 99,3% y de frutas del 94%. Alrededor del 66% de los trabajadores realizaban ejercicio físico por lo menos un día a la semana. Durante la pandemia de la covid-19, fue observada una menor práctica de ejercicios físicos entre los trabajadores de la salud entrevistados. Conclusión: El monitoreo de los factores de riesgo y protección para el cáncer es crucial para los estilos de vida saludables. Mejorar la calidad de vida de los trabajadores de la salud es fundamental para la prestación calificada de los servicios, especialmente en el Sistema Único de Salud (SUS)

Spatial-temporal evolution of tuberculosis incidence rates in indigenous and non-indigenous people of Brazil, from 2011 to 2022 / Evolução espaço-temporal da incidência de tuberculose em indígenas e não indígenas no Brasil, no período de 2011 a 2022

ABSTRACT Objective: To describe the space-time evolution of TB incidence rates (TI) in indigenous and non-indigenous people, according to the Federative Units (UF) of Brazil, from 2011 to 2022. Methods: Ecological, temporal, and spatial study on new tuberculosis cases in Brazil among indigenous and non-indigenous populations. Data from the Notifiable Diseases Information System (Sinan) were collected from 2011 to 2022 and stratified by Federal Unit, explored and statistically analyzed using R software version 4.2.3. Results: The mean TI among indigenous populations in Brazil was 71.7 new cases per 100,000 inhabitants, while for non-indigenous populations it was 28.6/100,000 inhabitants. The regions of the country that presented the highest (mean) incidence among indigenous populations were: Central-West (102.8/100,000 inhabitants), Southeast (99.6/100,000 inhabitants), and North (79.9/100,000 inhabitants). For non-indigenous populations the highest incidence was in the North region (36.5/100,000 inhabitants), followed by the Southeast (31.3/100,000), and the Northeast (27,4/100,000 inhabitants). The analysis showed that the highest incidence of TB cases among indigenous populations occurred in the states of: SP, RO, RJ, MS, MT e PA. Conclusion: High incidence of the disease compared to the non-indigenous population show the need for a specific approach to address the health needs of these populations. Regional disparities in incidence indicate the need to address socioeconomic and infrastructure issues that affect the health of indigenous populations.

RESUMO Objetivo: Descrever a evolução espaço-temporal das taxas de incidência (TIs) de tuberculose (TB) em indígenas e não indígenas, segundo as unidades federativas do Brasil, no período de 2011 a 2022. Métodos: Estudo ecológico, temporal e espacial sobre os casos novos de tuberculose no Brasil em indígenas e não indígenas. Dados provenientes do Sistema de Informação de Agravos de Notificação (SINAN) foram coletados de 2011 a 2022 e estratificados por UF, analisados exploratória e estatisticamente por meio do software R 4.2.3. Resultados: A TI média entre indígenas no Brasil foi 71,7 casos novos para cada 100 mil habitantes, enquanto para não indígenas foi de 28,6/100 mil habitantes. As regiões do país que apresentaram as maiores incidências (médias) para indígenas foram: Centro-Oeste (102,8/100 mil hab.), Sudeste (99,6/100 mil hab.) e Norte (79,9/100 mil hab.), e para não indígenas foram: Norte (36,5/100 mil hab.), Sudeste (31,3/100 mil hab.) e Nordeste (27,4/100 mil hab.). A análise mostrou que a maior incidência de casos de TB nas populações indígenas ocorreu nos estados de São Paulo, Rondônia, Rio de Janeiro, Mato Grosso do Sul, Mato Grosso e Pará. Conclusão: Altas incidências da doença em comparação com a população não indígena mostraram a necessidade de abordagem específica para atender às necessidades de saúde dessas populações. As disparidades regionais nas incidências indicaram a necessidade de abordar questões socioeconômicas e de infraestrutura que afetam a saúde desses povos.

Cadastro na Atenção Primária e mortalidade por COVID-19: coorte de diabéticos de cinco regiões administrativas de saúde do município do Rio de Janeiro, 2020-2021 / Registration with Primary Health Care and COVID-19 mortality: cohort of diabetics from five administrative health regions in the city of Rio de Janeiro, Brazil, 2020-2021

RESUMO Objetivo: O presente estudo realizou uma análise de sobrevivência segundo situação de cadastro na Atenção Primária à Saúde (APS) e de fatores associados ao óbito por COVID-19, nos casos residentes da Área Programática 3.1 (AP3.1) com diagnóstico de diabetes (na ficha de notificação ou no prontuário eletrônico) do município do Rio de Janeiro, em 2020-2021. Métodos: Foi realizado relacionamento probabilístico de bases de dados com base nas informações dos casos notificados por COVID-19 e dos dados de prontuário eletrônico de pessoas que vivem com diabetes. Conduziu-se uma análise de sobrevivência, utilizando-se o modelo de regressão de Cox estratificado por faixa etária e ajustando-se por variáveis confundidoras. Resultados: Verificou-se que indivíduos cadastrados na APS da AP3.1 possuíam risco quase duas vezes maior de óbito por COVID-19 (hazard ratio ajustada — HRaj=1,91) quando comparados aos não cadastrados na APS da AP3.1. Essa associação foi mais forte naqueles com 18 a 59 anos, cadastrados na APS (HRaj=2,82), do que nos de 60 anos ou mais (HRaj=1,56). Conclusão: Estratégias de vigilância para a identificação e acompanhamento adequado de grupos de maior risco de mortalidade, dentre indivíduos que vivem com DM, no âmbito da APS podem contribuir para a redução da mortalidade em decorrência da COVID-19.

ABSTRACT Objective: The present study carried out an analysis of survival according to the status of registration with Primary Health Care (PHC) and of factors associated with death from COVID-19, in cases residing in Programmatic Area 3.1 (PA3.1) with a diagnosis of diabetes (in the notification form or in the electronic medical record), of the Municipality of Rio de Janeiro (RJ), Brazil, in 2020-2021. Methods: A probabilistic linkage of databases was performed based on information on cases notified as COVID-19 and data from the electronic medical records of people living with diabetes. A survival analysis was carried out, using the Cox regression model stratified by age group and adjusted for confounding variables. Results: Individuals registered with the PHC of PA3.1 had almost twice the risk of death from COVID-19 (adjusted hazard ratio [HRadj]=1.91) when compared to those unregistered. This association was stronger in individuals aged 18 to 59 years registered with the PHC (HRadj=2.82) than in individuals aged 60 years or over (HRadj=1.56). Conclusion: Surveillance strategies for identifying and adequately monitoring higher-risk groups, among individuals living with diabetes, within the scope of Primary Health Care, can contribute to reducing mortality from COVID-19.

Identificação de áreas de risco e fatores associados à epidemia de sarampo de 2019 no Estado de São Paulo, Brasil / Identification of risk areas and factors associated with the 2019 measles epidemic in the State of São Paulo, Brazil / Identificación de áreas de riesgo y factores asociados a la epidemia de sarampión de 2019 en el Estado de São Paulo, Brasil

O objetivo foi analisar a ocorrência de clusters e fatores associados ao ressurgimento de casos de sarampo da maior epidemia do período pós-eliminação, ocorrida no Estado de São Paulo, Brasil, em 2019. Fatores sociossanitários e assistenciais foram analisados por modelos de Poisson inflacionado de zero (ZIP) e ZIP com efeito espacial estruturado e não estruturado. A estatística de varredura SCAN foi usada para analisar a ocorrência de clusters de casos. Foram identificados clusters de casos de alto risco em municípios que compõem a região intermediária de São Paulo. No modelo ZIP, foram observadas como fatores de risco no nível municipal as variáveis chefes de domicílio menores de 18 anos (RR ajustado = 1,39; ICr95%: 1,27-1,53), desigualdade na distribuição de renda (RR ajustado = 36,67; ICr95%: 26,36-51,15), desocupação em maiores de 18 anos (RR ajustado = 1,10; ICr95%: 1,08-1,12) e iluminação pública inexistente (RR ajustado = 1,05; ICr95%: 1,04-1,05). Nos modelos ZIP com efeito espacial estruturado e não estruturado, foram identificados como fatores de risco os indicadores chefes de domicílio menores de 18 anos (RR ajustado = 1,36; ICr95%: 1,04-1,90) e desigualdade na distribuição dos rendimentos do trabalho (RR ajustado = 3,12; ICr95%: 1,02-9,48). Em ambos os modelos, a cobertura de agentes de saúde se apresentou como fator de proteção. Os achados reforçam a importância de intensificar as ações de vigilância de sarampo articuladas à Estratégia Saúde da Família, especialmente em áreas de maior vulnerabilidade social, para garantir coberturas vacinais equânimes e satisfatórias e reduzir o risco de reemergência da doença.

This study aimed to analyze the occurrence of clusters and factors associated with the resurgence of measles cases from the largest epidemic of the post-elimination period in the State of São Paulo, Brazil, in 2019. Sociosanitary and care factors were analyzed by zero-inflated Poisson (ZIP) and ZIP models with structured and unstructured spatial effect. The SCAN statistic was used to analyze the occurrence of case clusters. Clusters of high-risk cases were identified in municipalities that make up the intermediate region of São Paulo. In the ZIP model, the following variables were observed as risk factors at the municipal level: household heads under 18 years old (adjusted RR =0 1.39; 95%CrI: 1.27-1.53), inequality in income distribution (adjusted RR = 36.67; 95%CrI: 26.36-51.15), unemployment in people over 18 years old (adjusted RR = 1.10; 95%CrI: 1.08-1.12), and non-existent street lighting (adjusted RR = 1.05; 95%CrI: 1.04-1.05). In the ZIP models with structured and unstructured spatial effect, the following variables were observed as risk factors: household heads under 18 years old (adjusted RR = 1.36; 95%CrI: 1.04-1.90) and inequality in income distribution (adjusted RR = 3.12; 95%CrI: 1.02-9.48). In both models, the coverage of health agents was presented as a protective factor. The findings reinforce the importance of intensifying measles surveillance actions articulated to the Family Health Strategy, especially in areas with greater social vulnerability, to ensure equitable and satisfactory vaccination coverage and reduce the risk of reemergence of the disease.

El objetivo de este estudio fue analizar la ocurrencia de clusters y sus factores asociados al resurgimiento de los casos de sarampión teniendo por base la mayor epidemia del período poserradicación que tuvo lugar en el Estado de São Paulo, Brasil, en 2019. Los factores sociosanitarios y asistenciales se analizaron mediante modelos de Poisson zero inflated (ZIP) y ZIP con efecto espacial estructurado y no estructurado. La estadística de exploración SCAN se utilizó para analizar la ocurrencia de clusters de casos. Se identificaron clusters de casos de alto riesgo en municipios que componen la Región Intermedia de São Paulo. En el modelo ZIP se observaron como factores de riesgo a nivel municipal las variables jefes de hogar menores de 18 años (RR ajustado = 1,39; ICr95%: 1,27-1,53), desigualdad en la distribución de renta (RR ajustado = 36,67; ICr95%: 26,36-51,15), desempleo en mayores de 18 años (RR ajustado = 1,10; ICr95%: 1,08-1,12) y alumbrado público inexistente (RR ajustado = 1,05; ICr95%: 1,04-1,05). En los modelos ZIP con efecto espacial estructurado y no estructurado, se identificaron como factores de riesgo los indicadores jefe de hogar menor de 18 años (RR ajustado = 1,36; ICr95%: 1,04-1,90) y la desigualdad en la distribución de los ingresos de trabajo (RR ajustado = 3,12; ICr95%: 1,02- 9,48). En ambos modelos, la cobertura de los agentes de salud fue un factor protector. Los hallazgos evidencian la importancia de intensificar las acciones de vigilancia del sarampión vinculadas a la Estrategia de Salud Familiar, especialmente en las zonas de mayor vulnerabilidad social, para garantizar una cobertura de la vacunación de manera equitativa y satisfactoria, además de reducir el riesgo de reemergencia de la enfermedad.