Brazil's unified health system: the first 30 years and prospects for the future

Food intake markers in Sisvan: temporal trends in coverage and integration with e-SUS APS, Brazil 2015-2019

The aim of the present study was to estimate the population coverage of recording food intake markers in Brazil's Food and Nutrition Surveillance System (Sisvan) and mean annual percent change (APC) in coverage according to the system used for data entry (e-SUS APS and Sisvan Web). We conducted an ecological time series study of the period 2015-2019. The data were stratified into region and age group. APC in coverage was calculated using Prais-Winsten regression and the correlation between APC and HDI, GDP per capita and primary healthcare coverage was assessed using Spearman's correlation coefficient. Population coverage of recording food intake markers at national level was 0.92% in 2019. Mean APC in coverage throughout the period was 45.63%. The region and age group with the highest coverage rate were the Northeast (4.08%; APC=45.76%, p<0.01) and children aged 2-4 years (3.03%; APC=34.62%, p<0.01), respectively. There was an upward trend in data entry using e-SUS APS, to the detriment of Sisvan Web. There was a positive correlation between APC in coverage using e-SUS APS and HDI and GDP per capita in some age groups. Population coverage of recording Sisvan food intake markers remains low across the country. The e-SUS APS has the potential to be an important strategy for expanding food and nutrition surveillance.

Effective primary care attenuates the association between frailty and hospital admission in old age: the ELSI-Brazil

BACKGROUND

Frailty is a multidimensional syndrome leading to a higher hospitalization. However, few studies explicitly analyze whether measures of effective primary care modify the relationship between frailty and hospital admission.

METHODS

This cross-sectional study included data from the second wave of the Brazilian Longitudinal Study of Aging (ELSI-Brazil), a representative community-based study with older adults aged 50 years and over, conducted in 2019-2021. Self-reported hospital admission in the past 12 months was the outcome. Frailty included the 5 phenotypic criteria: weight loss, exhaustion, low physical activity, weakness, and slowness. The effective primary care index included 12 attributes indicators, continuously. Statistical analyzes comprised logistic regression.

RESULTS

Among the 7,436 study participants, frailty (odds ratio [OR] 2.17; 95% confidence intervals [95% CI] 1.31-3.62) and effective primary care index (OR 1.10; 95% CI 1.03-1.16) were positively associated with higher hospitalization. Interaction revealed that while effective primary care was positively associated with hospitalization, this association was different among frail older adults (OR 0.80; 95% CI 0.65-0.99). After stratification by frailty status, positive association with hospitalization remained only among prefrail and nonfrail individuals. The predicted probability of hospitalization tended to decrease along with higher primary care index values among frail older adults and became similar to prefrail/nonfrail at the highest end of the scale.

CONCLUSIONS

Effective primary care decreases the likelihood of hospital admission among frail older adults. Interventions for delaying frailty should be initiated in primary care along with policies to strengthen primary care's organizational and provider/team-level attributes.

The atlas of variation in healthcare Brazil: remarkable findings from a middle-income country

BACKGROUND

Brazil's Universal Health System is the world's largest and covers every citizen without out-of-pocket costs. Nonetheless, healthcare inequities across regions have never been systematically evaluated.

METHODS

We used government databases to compare healthcare resource utilization, outcomes, expenditure, and years of life lost between 2016 and 2019. The maps used patients' residences as reference and adjusted for age and private health insurance coverage.

RESULTS

The Atlas shows that for several comparisons, there were no procedures in some regions, including primary coronary angioplasty, thrombolysis for stroke, bariatric surgery, and kidney transplant. Colonoscopy varied 1481.2-fold, asthma hospitalizations varied 257.5-fold, and mammograms varied 133.9-fold. Cesarean births ranged from 19.5% to 84.0%, and myocardial infarction and stroke case-fatalities were 1.1% to 33.7% and 5.0% to 39.0%, respectively. Higher private health insurance coverage in each region was associated with increased resource utilization in the public system in most comparisons.

CONCLUSION

These findings demonstrate that the SUS does not fulfill the Brazilian constitutional rights due to underutilization, overutilization, and access disparities. The Atlas outlines multiple opportunities to generate value in the SUS.

Persistent inequalities in health care services utilisation in Brazil (1998-2019)

BACKGROUND

One of the primary objectives of the Brazilian health care system is to improve the health and well-being of all citizens. Since the establishment of the Unified Health System/Sistema Único de Saúde (SUS) in 1988, Brazil has made strides towards reducing inequalities in health care services utilisation. However, there are currently no comprehensive and up-to-date studies focused on inequalities in both curative and preventive health care services utilisation.

METHODS

We evaluated data from the National Household Sample Survey and the Brazilian National Health Survey, which are two nationally representative studies that include findings from 1998, 2003, and 2008 and 2013 and 2019, respectively. We calculated Erreygers-corrected Concentration Indices (CInds) to evaluate the magnitude of socioeconomic-related inequalities associated with five indicators of health care services utilisation, including physician visits, hospital admissions, surgical procedures, Pap smears, and mammograms. The main factors associated with these inequalities were identified via a decomposition analysis of the calculated CInds.

RESULTS

While the results of our analysis revealed persistent inequalities in health care services utilisation that favour the wealthy, we found that the overall magnitude of these inequalities decreased over time. The largest inequalities were observed in the utilisation of preventive care services (Pap smears and mammograms) and services available in the poorest regions of the country. Except for admissions for labour and delivery, our findings revealed that wealthier individuals were more likely to utilise hospital services; this represents a change from findings reported in previous years. Private health insurance coverage and individual socioeconomic status are significantly associated with inequalities in health care services utilisation throughout Brazil.

CONCLUSIONS

Collectively, our findings suggest that we must continue to monitor potential inequalities in health care service utilisation to determine whether Brazilian policy objectives focused on improved health outcomes for all will ultimately be achieved.

Sobrevida na hemodiálise no Brasil de acordo com a fonte pagadora do tratamento: Sistema Único de Saúde versus convênio privado

Resumo Introdução: O Brasil possui o maior sistema público e universal de saúde do mundo, mas pouco se sabe sobre os desfechos dos pacientes em hemodiálise (HD) no país de acordo com a fonte de financiamento do tratamento. Objetivo: Comparar o perfil e a sobrevida dos pacientes que têm o tratamento de HD custeado pelo Sistema Único de Saúde (SUS) com aqueles com convênio privado. Métodos: Análise retrospectiva dos adultos incidentes em HD entre 2012 e 2017 em 21 centros de diálise no Brasil que atendiam tanto pelo SUS quanto por convênios privados. Os participantes, independentemente da fonte pagadora, receberam tratamento dialítico semelhante. Os dados foram censurados com 60 meses de acompanhamento ou ao final de 2019. Resultados: Foram incluídos 4945 pacientes, sendo 59,7% financiados pelo SUS. Os pacientes financiados pelo SUS, em comparação aos que tinham convênio privado, eram mais jovens (58 vs 60 anos; p < 0,0001) e com menor prevalência de diabetes (35,8% vs 40,9%; p < 0,0001). As taxas de sobrevida, em 60 meses nesses grupos foram de 51,1% e 52,1%, respectivamente (p = 0,85). Na análise da razão de risco proporcional de subdistribuição pelo modelo de Fine-Gray, incluindo ajuste para desfechos concorrentes, foi encontrado um aumento significativo na razão de risco para morte (1,22 [intervalo de confiança de 95% 1,04 a 1,43]) nos pacientes com tratamento custeado pelo SUS. Conclusões: Pacientes em HD com tratamento custeado pelo SUS têm um risco ajustado de morte mais elevado do que aqueles com convênio privado, apesar do tratamento dialítico semelhante. Fatores não relacionados diretamente à terapia dialítica poderiam justificar esta diferença.

Serological and vaccine evaluation for hepatitis B among Community Health Workers

OBJECTIVE

to identify the vaccination and serological status against hepatitis B among community health workers; to vaccinate against hepatitis B virus and to evaluate the immune response of susceptible workers.

METHOD

phase I, cross-sectional and descriptive study, among community health workers in a capital city of the Midwest region, through a self-administered questionnaire, checking of vaccination cards, and blood collection for testing of serological markers for hepatitis B. Phase II, cohort study carried out in vaccinated non-immune workers identified in phase I. They received one dose of vaccine (challenge dose) and serological testing.

RESULTS

a total of 109 workers participated in the study. Most had vaccination record (97; 89.0%) and vaccination completeness (75; 77.3%), while the isolated anti-HBs (Antibodies against hepatitis B virus) marker was detected in 78 (71.6%) workers. The prevalence of hepatitis B virus exposure was 8.2%. Of the ten non-immune vaccinated workers, after challenge dose, one remained susceptible.

CONCLUSION

although most workers are vaccinated and show immunological response to hepatitis B, susceptibility after challenge dose was identified. Therefore, it is necessary to have a surveillance program of the vaccination situation and serological status for this virus, to promote these workers' safety.

Chronic hemodialysis patients with COVID-19 cared for by the public health system have higher mortality than those treated in private facilities: analysis of the Brazilian dialysis registry

PURPOSE

Brazil is the third country globally in dialysis patients. Little is known about the impact of the type of health insurance on the outcome of these patients after COVID-19.

METHODS

We analyzed comorbidities, sociodemographic factors, and dialysis-related parameters from a retrospective cohort study of 1866 Brazilian chronic hemodialysis patients with COVID-19 from Feb 2020-July 2021. We evaluated the influence of health insurance (private vs. public) on the intensive care unit admission and 90 day fatality risk.

RESULTS

From 1866 hemodialysis patients, 455 (24%) were admitted to the intensive care unit, and 350 (19%) died. The mean age was 57.5 years, 88% had public health insurance. Crude case-fatality rate was not different between groups (private vs. public risk ratio 1.11; 95% CI 0.82-1.52, p = 0.498). In fully adjusted multivariate models, patients with private health insurance did not have a higher chance to be admitted to an intensive care unit (odds ratio 0.97; 95% CI 0.63-1.50, p = 0.888), but they presented a lower death risk (hazard ratio 0.56; 95% CI 0.37-0.85, p = 0.006).

CONCLUSION

The type of health insurance did not influence the access of hemodialysis patients with COVID-19 to an intensive care unit, but patients with private health insurance had a lower mortality risk.

Pela reconquista das altas coberturas vacinais

O declínio global das coberturas vacinais levou a Organização Mundial da Saúde (OMS), em 2019, a definir a hesitação vacinal como uma das dez maiores ameaças mundiais à saúde pública. No Brasil, a queda da cobertura vacinal teve início em 2012, acentuando-se a partir de 2016, e sendo agravada pela pandemia de COVID-19. O alerta da baixa cobertura vacinal vem acompanhado pela reintrodução de doenças imunopreveníveis como o sarampo. O retorno de doenças até então eliminadas, como a poliomielite, pode agravar a crise sanitária ainda em curso. Mesmo sendo reconhecido como um dos mais efetivos programas de imunizações do mundo e dos esforços permanentes, o Programa Nacional de Imunizações enfrenta um cenário extremamente adverso no que tange às coberturas vacinais. Este artigo descreve o Projeto pela Reconquista das Altas Coberturas Vacinais (PRCV) e a estratégia de trabalhar na ponta do sistema, executada nos territórios, que vem sendo implementada desde 2021 e já começa a apresentar resultados promissores. O PRCV foi organizado em três eixos temáticos com atuação compartilhada e ações específicas, a saber: vacinação; sistemas de informação; comunicação e educação. Os resultados já alcançados permitem afirmar que é possível conseguir a reversão das baixas coberturas vacinais, a partir da articulação de ações estruturais e interinstitucionais, com o fortalecimento das políticas públicas e desenvolvimento de medidas de curto, médio e longo prazos. Os fatores mais potentes do PRCV são sua abordagem junto aos profissionais da ponta, o pacto social pela vacinação, e a estruturação de redes locais de apoio às imunizações.

Repensar a Saúde Coletiva e o papel das Ciências Sociais e Humanas em Saúde

Este ensaio analisa conflitos e potencialidades das Ciências Sociais e Humanas em Saúde (CSHS) no campo da Saúde Coletiva e os desafios de atuar em uma área interdisciplinar. Inicialmente, apresentamos algumas particularidades das CSHS, dialogando com tensões internas. Em seguida, as metodologias qualitativas e seus usos nas pesquisas em Saúde Coletiva são problematizadas, mantendo um diálogo com as demais áreas. Por fim, apresentamos uma reflexão sobre as perspectivas futuras das CSHS e possíveis caminhos teórico-metodológicos que aprofundariam a transversalidade da área. Repensar as relações entre as áreas provoca uma reflexão sobre uma possível e oportuna reconfiguração da própria Saúde Coletiva. Os desafios nos colocam a necessidade de repensar a noção de CSHS; e de indagar sobre a linguagem que estamos construindo e sobre o que podemos fazer.

Emergency department use and Artificial Intelligence in Pelotas: design and baseline results

OBJETIVO

To describe the initial baseline results of a population-based study, as well as a protocol in order to evaluate the performance of different machine learning algorithms with the objective of predicting the demand for urgent and emergency services in a representative sample of adults from the urban area of Pelotas, Southern Brazil.

METHODS

The study is entitled "Emergency department use and Artificial Intelligence in PELOTAS (RS) (EAI PELOTAS)" (https://wp.ufpel.edu.br/eaipelotas/). Between September and December 2021, a baseline was carried out with participants. A follow-up was planned to be conducted after 12 months in order to assess the use of urgent and emergency services in the last year. Afterwards, machine learning algorithms will be tested to predict the use of urgent and emergency services over one year.

RESULTS

In total, 5,722 participants answered the survey, mostly females (66.8%), with an average age of 50.3 years. The mean number of household people was 2.6. Most of the sample has white skin color and incomplete elementary school or less. Around 30% of the sample has obesity, 14% diabetes, and 39% hypertension.

CONCLUSION

The present paper presented a protocol describing the steps that were and will be taken to produce a model capable of predicting the demand for urgent and emergency services in one year among residents of Pelotas, in Rio Grande do Sul state.

Distribution of COVID-19 cases and health resources in Brazil’s Amazon region: a spatial analysis

Abstract Spatial analysis can help measure the spatial accessibility of health services with a view to improving the allocation of health care resources. The objective of this study was to analyze the spatial distribution of COVID-19 detection rates and health care resources in Brazil’s Amazon region. We conducted an ecological study using data on COVID-19 cases and the availability of health care resources in 772 municipalities during two waves of the pandemic. Local and global Bayesian estimation were used to construct choropleth maps. Moran’s I was calculated to detect the presence of spatial dependence and Moran maps were used to identify disease clusters. In both periods, Moran’s I values indicate the presence of positive spatial autocorrelation in distributions and spatial dependence between municipalities, with only a slight difference between the two estimators. The findings also reveal that case rates were highest in the states of Amapá, Amazonas, and Roraima. The data suggest that health care resources were inefficiently allocated, with higher concentrations of ventilators and ICU beds being found in state capitals.

Preparedness of the Brazilian health-care system to provide access to a disease-modifying Alzheimer's disease treatment

BACKGROUND

While the majority of patients with Alzheimer's disease resides in low and middle-income countries, little is known of their preparedness for emerging disease-modifying treatments. We analyze the preparedness of Brazil, one of the most populous middle-income countries, from a capacity and institutional preparedness perspective.

METHODS

Desk research and 12 interviews for background and capacity data. Markov model to estimate wait times for access to treatment.

FINDINGS

Brazil has no national dementia strategy or established pathway for evaluation of cognitive concerns, and dementia is typically diagnosed late if at all. While members of private health plans have ready access to elective specialty care, wait times in the public sector are long. Assuming potentially treatment-eligible patients are referred from primary to specialty care based on a brief cognitive exam and a blood test for the Alzheimer's pathology, available capacity will not be sufficient to match the projected demand. The biggest obstacle is availability of dementia specialist visits, and the effect of population growth and ageing means that the wait list for specialist appointment will continue to grow from around 400,000 in 2022 to over 2.2 million in 2040. We do not project substantial wait times for confirmatory biomarker testing and treatment delivery but note that this is a consequence of patients waiting for their specialist appointments. These queues will result in estimated persistent wait times for treatment of around two years on average with substantial differences between the public and private sectors, as capacity growth is insufficient to keep up with increasing demand.

DISCUSSION

Our findings suggest that Brazil is ill-prepared to provide timely access to an Alzheimer's treatment with predicted wait times of about two years, largely because of a limited number of dementia specialists.

The governance of antimicrobial resistance in Brazil: Challenges for developing and implementing a one health agenda

This article explores stakeholders' perceptions of the challenges for developing a One Health agenda to tackle antimicrobial resistance (AMR) in Brazil, including the development and implementation of the Brazilian National Action Plan (BR-NAP). The data originate from 27 interviews conducted with human, environmental, and animal health stakeholders, including academics, managers, and policymakers involved in developing the BR-NAP. Through thematic analysis, we identified three interconnected themes: governance, the health system, and technical and scientific challenges. The findings draw particular attention to failures in the agenda-setting process, revealed by interviewees strongly emphasising that AMR is not considered a policy priority in Brazil. The lack of political will and awareness of the clinical, social, and economic impacts of AMR are considered the main impediments to the agenda's progress. The joint work across disciplines and ministries must be reinforced through policymaker engagement and better environmental sector integration. The agenda must include sustainable governance structures less affected by political winds. Policies should be designed jointly with state and local governments to create strategies to engage communities and improve their translation into effective implementation.

The Impact of Conditional Cash Transfers on Poverty, Inequality, and Employment During COVID-19: A Case Study from Brazil

The policy responses to the COVID-19 pandemic varied widely between countries. Understanding how effective these responses were is important to improve preparedness for future crises. This paper investigates how one of largest scale conditional cash transfer COVID relief policies in the world-the Brazilian Emergency Aid (EA)-impacted poverty, inequality, and the labor market amidst the public health crisis. We use fixed-effects estimators to analyze the impact of the EA on labor force participation, unemployment, poverty, and income at the household level. We find that inequality, measured by per capita household income, reduced to a historical low and was accompanied by substantial poverty declines-even as compared to pre-pandemic levels. Furthermore, our results suggest that the policy has effectively targeted those in most need-temporarily reducing historical racial inequalities-while not incentivizing reductions in labor force participation. Absent the policy, adverse shocks would have been significant and are likely to occur once the transfer is interrupted. We also observe that the policy was not enough to curb the spread of the virus, suggesting that cash transfers alone are insufficient to protect citizens.

Distribution of COVID-19 cases and health resources in Brazil's Amazon region: a spatial analysis

Spatial analysis can help measure the spatial accessibility of health services with a view to improving the allocation of health care resources. The objective of this study was to analyze the spatial distribution of COVID-19 detection rates and health care resources in Brazil's Amazon region. We conducted an ecological study using data on COVID-19 cases and the availability of health care resources in 772 municipalities during two waves of the pandemic. Local and global Bayesian estimation were used to construct choropleth maps. Moran's I was calculated to detect the presence of spatial dependence and Moran maps were used to identify disease clusters. In both periods, Moran's I values indicate the presence of positive spatial autocorrelation in distributions and spatial dependence between municipalities, with only a slight difference between the two estimators. The findings also reveal that case rates were highest in the states of Amapá, Amazonas, and Roraima. The data suggest that health care resources were inefficiently allocated, with higher concentrations of ventilators and ICU beds being found in state capitals.

Professional Factors Associated with Case Resolution without Referrals of Orofacial Pain Cases to Secondary Dental Care by Telehealth in Brazil: A Cross-Sectional Study in 2019 and 2020

This study aimed to identify professional factors associated with case resolution without a referral of orofacial pain to secondary health care by Brazilian Primary Health Care (PHC) practitioners who demanded asynchronous teleconsulting, stratified by year, in 2019 and 2020 (the COVID-19 Pandemic burst). A cross-sectional study employed secondary databases from asynchronous teleconsulting Telehealth Brazil Networks from January 2019 to December 2020. The outcome was the dichotomous variable "If referral to secondary care was avoided." As covariates: sex, healthcare professions, and category of orofacial pain doubts. A negative binomial regression model estimated each covariate's unadjusted and adjusted PR (95%CI) and p values, stratified for 2019 and 2020. There was a difference in descriptive factors associated with case resolution without a referral from 2019 to 2020. Females prevailed in both years, and the total demand decreased to a third from 2019 to 2020. The rate of resoluteness decreased by 19.1%. In 2019, nurses (PR = 0.69 CI 95% 0.57-0.83) and other professionals (PR = 0.84 CI 95% 0.73-0.97) showed less frequency of case resolution without a referral than did general dentists. In 2020, oral-cavity-related doubts (PR = 1.18 CI 95% 1.06-1.32) and temporomandibular disorders (PR = 1.33 95% 1.15-1.54) surpassed other causes of orofacial pain in case resolution without a referral, and female professionals avoided referrals more frequently than men (PR = 1.24 CI 95% 1.21-1.38). In conclusion, in 2019, oral cavity doubts and the PHC profession influenced the case resolution. Female professionals and oral cavity doubts scored the higher case resolution without a referral for the service in 2020.

Comparison of the healthcare system of Chile and Brazil: strengths, inefficiencies, and expenditures

BACKGROUND

Governments in Latin America are constantly facing the problem of managing scarce resources to satisfy alternative needs, such as housing, education, food, and healthcare security. Those needs, combined with increasing crime levels, require financial resources to be solved.

OBJECTIVE

The objective of this review was to characterizar the health system and health expenditure of a large country (Brazil) and a small country (Chile) and identify some of the challenges these two countries face in improving the health services of their population.

METHODS

A literature review was conducted by searching journals, databases, and other electronic resources to identify articles and research publications describing health systems in Brazil and Chile.

RESULTS

The review showed that the economic restriction and the economic cycle have an impact on the funding of the public health system. This result was true for the Brazilian health system after 2016, despite the change to a unique health system one decade earlier. In the case of Chile, there are different positions about which one is the best health system: a dual public and private or just public one. As a result, a referendum on September 4, 2022, of a new constitution, which incorporated a unique health system, was rejected. At the same time, the Government ended the copayment in the public health system in September 2022, excluding illnesses referred to the private sector. Another issue detected was the fragility of the public and private sector coverage due to the lack of funding.

CONCLUSIONS

The health care system in Chile and Brazil has improved in the last decades. However, the public healthcare systems still need additional funding and efficiency improvement to respond to the growing health requirements needed from the population.

Radical prostatectomies for treatment of prostate cancer: trends in a ten-year period in public health services in the city of São Paulo, Brazil

OBJECTIVE

To analyze the characteristics of public health services related to radical prostatectomy, according to hospital volume of surgeries and stratified as academic and non-academic centers.

METHODS

An ecological study was conducted using a database available in TabNet platform of the Unified Health System Department of Informatics. Number of surgeries, length of hospital stay, length of stay in intensive care unit, in-hospital mortality rate, and cost of hospitalization were evaluated. The hospitals were divided into three subgroups according to surgery volume (tercile), and results were compared. The same comparisons were made among academic and non-academic centers. We considered academic centers those providing Urology residency program.

RESULTS

A total of 11,259 radical prostatectomies were performed in the city of São Paulo between 2008 and 2018. We observed a significant trend of increase in radical prostatectomies for treating prostate cancer over the years (p=0.007). The length of stay in intensive care unit, and number of deaths were not statistically different among centers with diverse surgery volume, nor between academic and non-academic centers. However, length of hospital stay was significantly shorter in academic centers (p=0.043), while cost of hospitalization was significantly higher in high-volume center compared to low- (p<0.001) and intermediate-volume centers (p<0.001).

CONCLUSION

Length of hospital stay for radical prostatectomies performed in public services in the city of São Paulo was shorter in academic centers, whereas hospitals with a high volume of surgeries showed greater cost of hospitalization.

Biases arising from linked administrative data for epidemiological research: a conceptual framework from registration to analyses

Linked administrative data offer a rich source of information that can be harnessed to describe patterns of disease, understand their causes and evaluate interventions. However, administrative data are primarily collected for operational reasons such as recording vital events for legal purposes, and planning, provision and monitoring of services. The processes involved in generating and linking administrative datasets may generate sources of bias that are often not adequately considered by researchers. We provide a framework describing these biases, drawing on our experiences of using the 100 Million Brazilian Cohort (100MCohort) which contains records of more than 131 million people whose families applied for social assistance between 2001 and 2018. Datasets for epidemiological research were derived by linking the 100MCohort to health-related databases such as the Mortality Information System and the Hospital Information System. Using the framework, we demonstrate how selection and misclassification biases may be introduced in three different stages: registering and recording of people's life events and use of services, linkage across administrative databases, and cleaning and coding of variables from derived datasets. Finally, we suggest eight recommendations which may reduce biases when analysing data from administrative sources.

Interprofissionalidade, formação e trabalho colaborativo no contexto da saúde da família: pesquisa-ação

RESUMO Objetivou-se construir Práticas Colaborativas Interprofissionais (PCI) e avaliá-las sob a perspectiva de docentes e discentes de cursos da área da saúde de uma Instituição de Ensino Superior (IES) federal e de uma equipe de Saúde da Família (eSF). Realizou-se pesquisa-ação, com abordagem qualitativa, em um território de uma eSF de uma capital do Nordeste, visando à construção de PCI em prol da saúde da criança. Esta envolveu 15 participantes: profissionais da eSF; docentes e discentes dos cursos de enfermagem, odontologia e nutrição de uma IES. Efetuaram-se três etapas: diagnóstico sobre educação interprofissional e PCI a partir de entrevistas; planejamento e realização de ações de saúde da criança; avaliação mediante grupo focal. As entrevistas e o grupo focal foram gravados, transcritos, e interpretados pela análise temática. A intervenção favoreceu reencontro entre os sujeitos, troca de experiência e aprendizado coletivo, e reconhecimento de papéis, constituindo-se em espaço dialógico e participativo de produção de saberes e fazeres. A ação só foi possível pela intencionalidade envolvida em seu planejamento, e o desenvolvimento das ações foi permeado de escuta e criação em torno da saúde da criança nesse território. A interação proporcionou a ressignificação da produção de cuidado interprofissional centrado nas crianças e suas famílias.

The impact of the COVID-19 pandemic in the frontline health workforce: Perceptions of vulnerability of Brazil's community health workers

The COVID-19 pandemic has resulted in calls for an increased integration of community health workers (CHWs) into the health system response. Historically, CHWs can play an important role in ensuring the sustainability of health policy implementation - by addressing social determinants of health and maintaining care for ongoing health problems. Their frontline work, with close contact to populations, places CHWs in a position of increased vulnerability to becoming infected and to being the target of abuse and violence. These vulnerabilities compound underlying problems faced by CHWs, who often come from poor backgrounds, are insufficiently paid and receive inadequate training. Speaking to a scarcity of studies on how CHWs are impacted by the pandemic, this paper conducts a systematic study of CHWs in Brazil. Based on quantitative and qualitative data collected during June and July 2020, it considers perceptions and experiences of CHWs, comparing them with other health professionals. We study the extent to which the pandemic added to existing vulnerabilities and created new problems and imbalances in the work of CHWs. We conclude that COVID-19 led to a deterioration of the working conditions of CHWs, of their relations with other health professionals, and of their ability to carry out their essential work in the public health system.

Socioeconomic and racial/ethnic inequalities in depression prevalence and the treatment gap in Brazil: A decomposition analysis

Depression is a major global health burden and there are stark socioeconomic inequalities in both the prevalence of depression and access to treatment for depression. In Brazil, racial/ethnic inequalities are of particular concern, but the factors contributing to these inequalities remain mostly unknown. This paper firstly explores determinants of depression and the treatment gap (i.e., untreated afflicted individuals) in Brazil and identifies if socio-economic and health system factors explain changes over time. Secondly, it analyses income and racial/ethnic inequalities in depression and the treatment gap and identifies factors explaining inequalities through decomposition methods. Data from two waves (2013 and 2019) of a representative household-based survey are used. In 2019, 10.8% of adults were depressed, but over 70% of depressed adults did not receive care. Black or brown/mixed Brazilians were more likely to have untreated depression, and region of residence was the most important determinant of these racial/ethnic inequalities. Notably, 44.6% of the difference in the treatment gap between white individuals and black and brown/mixed individuals was not explained by differences in observables, which could potentially be due to discrimination or difficulties in accessing treatment due to other non-observable characteristics. Employment, age, exposure to violence and physical activity are the main contributing factors to income inequalities in depression. These results suggest that policies aimed at improving the levels of exposure of lower-income individuals to risk factors may positively impact mental health and mental health inequalities, while addressing inequalities in service provision and resourcing for mental health and tackling barriers to access stemming from discrimination are essential to bridge the treatment gap equitably.

Impact of COVID-19 on the prescription of contraceptives in a city in São Paulo

OBJECTIVE

In the beginning of the pandemic, measures, such as social distancing, lockdown strategies, and restrictions on mobility, as well as the fear of transiting through health facilities, raised concerns about the impact of COVID-19 on women's ability to continue using contraceptives.

METHODS

This is a retrospective cohort study, which evaluated reports of medication distribution spreadsheets in Bauru - SP, from January 2019 to June 2021.

RESULTS

Our study showed that the municipal dispensation of contraceptives in the SUS was markedly impacted by the COVID-19 pandemic, suffering reductions that can impact on an increase in unplanned pregnancy rates. It is possible to note a significant decrease in the distribution of combined oral contraceptives (44.18%), combined injectable contraceptives (47.58% reduction), and medroxyprogesterone acetate (13.98%). This fact may be associated with the reduction in offers of face-to-face consultations in gynecology, due to the social isolation necessary at the time of the pandemic.

CONCLUSION

Ensuring access to contraceptives during health emergencies should be a public health policy priority. Thus, it is essential to draw up strategic plans to encourage full access to reproductive planning services even in times of health emergency, so that the occurrence of unplanned pregnancies can be adequately prevented.

Risk areas for the occurrence of leprosy in border countries of South America - Brazil and Argentina

OBJECTIVE

The aim was to analyze the spatial association and relative risk (RR) of leprosy cases diagnosed in southern Brazil and in the Argentinean province of Misiones during 2010 to 2016.

METHODS

This ecological-type epidemiological study analyzed data from the Health Ministries of both countries. The analysis included frequency measures, spatial autocorrelation, RR cluster analysis and map construction.

RESULTS

A hyperendemic occurrence was identified in all study regions, in the state of Paraná 71.2% of the municipalities were hyperendemic and in Misiones, Argentina 41.2%. The GI* statistical analysis showed clusters of high incidence rates in the state of Paraná and low-risk clusters in much of the state of Rio Grande do Sul, both in Brazil. The analysis indicated an area with RR equal to 3.87 - (p < .0001) when considering the entire territory and an RR of 2.80 - (p < .0001) excluding the state of Paraná, with the number of departments of Misiones, Argentina included in the risk clusters increasing significantly.

CONCLUSIONS

The findings indicate a high probability of similar illness in adjacent areas, according to their relative position in space, as the occurrence of the disease is influenced by neighboring clusters.

Challenges to the provision of specialized care in remote rural municipalities in Brazil

This case study analyses the challenges to providing specialized care in Brazilian remote rural municipalities (RRM). Interviews were conducted with managers from two Brazilian states (Piauí and Bahia). We identified that the distance between municipalities is a limiting factor for access and that significant care gaps contribute to different organizational arrangements for providing and accessing specialized care. Physicians in all the RRMs offer specialized care by direct disbursement to users or sale of procedures to managers periodically, compromising municipal and household budgets. Health regions do not meet the demand for specialized care and exacerbate the need for extensive travel. RRM managers face additional challenges for the provision of specialized care regarding the financing, implementation of cooperative arrangements, and the provision of care articulated in networks to achieve comprehensive care, seeking solutions to the locoregional specificities.

Towards Safe Patient Identification Practices: the Development of a Conceptual Framework from the Findings of a Ph.D. Project

Patient identification errors are considered the root cause of other patient safety incidents. Despite the development, recommendation, and application of several initiatives to reduce and prevent misidentification in hospital settings, errors continue to occur. They directly impact the quality of care provided, resulting in delays in care, added costs, unnecessary injuries, misdiagnosis or wrong treatment, and other serious and irreversible types of harm and death. Furthermore, the certainty of the evidence of the effectiveness of interventions to reduce patient identification errors is considered very low.

This paper reports on the development of a conceptual framework for safe practices in the area of patient identification. The proposed conceptual framework was developed based on presuppositions regarding learning health systems and the available evidence from the published systematic reviews of the effectiveness of interventions in reducing patient identification errors in hospital settings. The core circle of the framework represents the partnership between managers, healthcare professionals, patients, and families working toward integrative and collaborative efforts for safe patient identification practices. The inner dimension states the recommendations for practice sustained by applying technological resources and educational strategies to raise awareness of the importance of accurate patient identification and interdisciplinarity, which works as an axis that supports integrated and collective work between healthcare professionals aiming for safe care. The outer dimension represents recommendations for teaching and research to develop effective patient identification practices that can enhance patient safety and the quality of care provided in hospital settings.

This framework provides a valuable method for engaging interdisciplinary teams to improve the safety of patient identification systems.

Impact of the COVID-19 Pandemic on Solid Organ Transplant and Rejection Episodes in Brazil's Unified Healthcare System

BACKGROUND

Brazil has the world's largest public organ transplant program, which was severely affected by the COVID-19 pandemic. The primary aim of the study was to evaluate differences in solid organ transplants and rejection episodes during the COVID-19 pandemic compared to the five years before the pandemic in the country.

METHODS

A seven-year database was built by downloading data from the DATASUS server. The pandemic period was defined as March 2020 to December 2021. The pre-pandemic period was from January 2015 to March 2020.

RESULTS

During the pandemic, the number of solid organ transplants decreased by 19.3% in 2020 and 22.6% in 2021 compared to 2019. We found a decrease for each evaluated organ, which was more pronounced for lung, pancreas, and kidney transplants. The seasonal plot of rejection data indicated a high rejection rate between 2018 and 2021. There was also an 18% (IRR 1.18 (95% CI 1.01 to 1.37), p = 0.04) increase in the rejection rate during the COVID-19 pandemic.

CONCLUSIONS

The total number of organ transplants performed in 2021 represents a setback of six years. Transplant procedures were concentrated in the Southeast region of the country, and a higher proportion of rejections occurred during the pandemic. Together, these findings could have an impact on transplant procedures and outcomes in Brazil.

Influence of Population Size, the Human Development Index and the Gross Domestic Product on Mortality by COVID-19 in the Southeast Region of Brazil

We evaluated the influence of population size (POP), HDI (Human Development Index) and GDP (gross domestic product) on the COVID-19 pandemic in the Southeast region of Brazil, between February 2020 and May 2021.

METHODS

Cases, deaths, incidence coefficient, mortality rate and lethality rate were compared among states. The cities were divided into strata according to POP, GDP, and HDI. Data were compared by Welch's ANOVA, nonlinear polynomial regression, and Spearman's correlation test (rS).

RESULTS

The highest incidence coefficient (p < 0.0001) and mortality rate (p < 0.05) were observed in the states of Espírito Santo and Rio de Janeiro, respectively. Until the 45th week, the higher the POP, the higher the mortality rate (p < 0.01), with no differences in the remaining period (p > 0.05). There was a strong positive correlation between POP size and the number of cases (rS = 0.92, p < 0.0001) and deaths (rS = 0.88, p < 0.0001). The incidence coefficient and mortality rate were lower (p < 0.0001) for low GDP cities. Both coefficients were higher in high- and very high HDI cities (p < 0.0001). The lethality rate was higher in the state of Rio de Janeiro (p < 0.0001), in large cities (p < 0.0001), in cities with medium GDP (p < 0.0001), and in those with high HDI (p < 0.05).

CONCLUSIONS

Both incidence and mortality were affected by time, with minimal influence of POP, GDP and HDI.

Prevalence of not receiving a home visit by Community Health Agents in Brazil and associated factors

Abstract This article aimed to identify the prevalence of not receiving a home visit by a community health agent (CHA) and the factors associated with it. This was a cross-sectional study, conducted with 38,865 health teams and 140,444 users in the entire country, who participated in the external evaluation of the Program of Access and Quality Improvement in Primary Health (PMAQ-AB, in Portuguese) in 2017/2018. The association between not receiving a home visit by a CHA and the characteristics of the towns, teams, and individuals were estimated by the prevalence ratio (PR) with 95% confidence intervals. The prevalence of not receiving a home visit by a CHA was 18.6% and the main causes were: CHA did not visit the home, lack of knowledge of the existence of CHAs in the neighborhood or unit, and no one present at the home when the CHA visited. The probability of receiving a home visit was higher in poorer regions like the Northeast Region of the country; in towns with a smaller population; among older age users with a lower income, users with chronic health conditions, or users who have someone with a physical disability at home. The results showed that there is a need to increase the coverage of CHA visits in the country, considering that their home visits improve equity in health care.

Prevalência do não recebimento de visita domiciliar pelo Agente Comunitário de Saúde no Brasil e fatores associados

Resumo O objetivo do artigo é identificar a prevalência de não recebimento de visita domiciliar por Agente Comunitário de Saúde (ACS) e os fatores associados. Trata-se de um estudo transversal realizado com 38.865 equipes e 140.444 usuários em todo o território nacional, que participaram da avaliação externa do Programa de Melhoria do Acesso e da Qualidade da Atenção Básica em 2017/2018. A associação de não recebimento de visita domiciliar por ACS e características dos municípios, equipes e indivíduos foi estimada pela razão de prevalência e intervalos de confiança de 95%. A prevalência de não recebimento de visita domiciliar pelo ACS foi de 18,6% e os principais motivos foram: ACS não realiza visita na casa, desconhecimento da existência de ACS no bairro ou unidade, e não tem ninguém em casa para atendê-lo. A probabilidade de receber visita domiciliar foi maior em regiões mais pobres como o Nordeste, em municípios com menor porte populacional, entre usuários com maior idade e menor renda, com condições crônicas de saúde ou que possuem alguém com dificuldade de locomoção no domicílio. Os resultados evidenciam a necessidade de aumento da cobertura de ACS no país, considerando que sua visita domiciliar promove equidade em saúde.

Perspectives on a psychiatric outpatient service for immigrants and refugees in São Paulo, Brazil over a 15-year period

BACKGROUND

Immigrants and refugees have specific mental health needs. Studies of immigrant/refugee psychiatric patients in Latin America are scarce.

AIMS

Present the profile of patients from an outpatient psychiatric service in Sao Paulo (Brazil) to better inform mental health service planning for immigrants and refugees in the Global South.

METHODS

Exploratory study to characterize the sociodemographic and mental health profile of refugees and immigrants attending outpatient psychiatric service from 2003 to 2018. Chi-square tests and logistic regressions were used to examine the association of demographic variables, exposure to violence, and immigrant status with psychiatric diagnosis. Cluster analysis was used to identify subgroups within the sample.

RESULTS

A total of 162 immigrants and refugees referred to the service obtained treatment. Of these patients, 57.4% were men, 59.8% were refugees/asylum seekers, 51.9% were Black, 48.8% were single, 64.2% had 10 years of education, and 57.4% were unemployed; the mean age of the sample was 35.9. Half of the sample (52.5%) was exposed to violence. The most common diagnosis was depression (54.2%), followed by PTSD (16.6%). Approximately 34% of the participants sought psychiatric care within 6 months of arrival. Logistic regressions showed that men had lower odds of presenting with depression (OR = 0.34). Patients with PTSD were more likely to be refugees (OR = 3.9) and not have a university degree (OR = 3.1).In the cluster analysis, a cluster of patients with PTSD included almost all Black refugee men exposed to violence. Most patients diagnosed with psychotic disorders were also Black refugee men.

CONCLUSION

Immigrants and refugees represent a vulnerable group. The majority of the sample was Black, refugee men, who were also more likely to present with PTSD. Future studies are needed to better understand issues in treatment adherence in relation to socioeconomic characteristics.

Judicialisation, right to health and justice at Rio de Janeiro's 'Health Dispute Resolution Chamber': Users' conceptions

The responses to the judicialisation are based on legal discourses and local practices that impact on access to health and justice. How citizens understand rights is key to holding government accountable. On a human right in health approach and emphasising the right to health and access to justice, this article explores these links through in-depth interviews of claimants at the Rio de Janeiro State Department, whose assist vulnerable groups. To the interviewees, the right to health was a remote, legal fiction, and entitlement and application were liable be treated 'flexibly'; judicialisation was a last resort to meet urgent demands and the impossibility of 'consuming' by their own means; the lawsuits as 'slow', 'painful' and unreliable in ensuring rights; access to health involved sacrifices and the need to fight for their rights. They understood was intimately bound up with the vulnerabilities, obstacles and service denial they had encountered previously. The bureaucratic, technological and technocratic dimensions of health care were incomprehensible and created barriers to access and conflicts. The findings suggested ineffective government responses to the main health problems of vulnerable populations and call for urgent efforts to address equitable and emancipatory implementation of health and justice policies.

Negotiating human rights narratives in Global Mental Health: Autism and ADHD controversies in Brazil

Promoting evidence-based treatments and the human rights of people living with mental illness are the two pillars of Global Mental Health (GMH). Critics counter that human rights narratives must also include social justice frameworks. We draw on the cases of autism and ADHD in Brazil to discuss the role of human rights in mental health in the context of GMH. A human rights perspective involves citizenship rights for individuals living with mental distress and provides a framework to problematise the logic of GMH centred on individual rights and rights to treatment. We begin with an overview on human rights discussions in GMH and examine the introduction of human rights discourses in the Brazilian psychiatric reform. We then explore how autism and ADHD became priorities of GMH interventions as well as the constitution of two styles of activism and mobilisation of human rights around these conditions. One follows the universal public health logic and promotes health as a social right. The other follows the logic of parents' associations that redefined those conditions as forms of disability to advocate for specialised services and interventions. Finally, we discuss these forms of human rights mobilisation and their implications for Brazilian mental health and GMH.

Liquidity constraints, cash transfers and the demand for health care in the Covid-19 pandemic

This paper proposes the hypothesis that liquidity constraints may delay or even prevent sick individuals from seeking medical help. If this is the case, a cash transfer can directly increase the demand for medical care. We evaluated this hypothesis empirically in the context of the implementation of Emergency Aid (EA), a large-scale cash transfer program in Brazil, during the Covid-19 pandemic. We used the program's implementation calendar along with a Regression Discontinuity in Time to assess the causal effects of EA on the search for the health system. Consistent with our hypothesis, we estimate that the transfer immediately decreased the time to search for the health system by 14% and increased COVID-19 hospitalizations by 0.015%.

Patterns of pregnancy loss among women living with and without HIV in Brazil, 2008-2018

BACKGROUND

Pregnancy loss is poorly understood, but infection may be a risk factor. Few studies have evaluated pregnancy loss among women living with HIV in the era of potent combination antiretroviral therapy.

OBJECTIVE

We hypothesize that maternal HIV and syphilis infection lead to increased risk of pregnancy loss, including both miscarriage and stillbirth. This study aimed to assess trends and possible predictors of spontaneous miscarriage and stillbirth among women living with HIV in a cohort of nearly 56,000 deliveries at a major referral institution in a city with the highest prevalence of HIV in Brazil.

STUDY DESIGN

Data from hospital records for women delivering from January 1, 2008 to December 31, 2018 were reviewed. Rates of stillbirth, miscarriage, and any pregnancy loss were compared using the Pearson chi-square test. Predictors of pregnancy loss were evaluated by robust univariate log-linear Poisson regression using a generalized estimating equations approach.

RESULTS

A total of 55,844 pregnancies were included in the analysis, with 54,308 pregnancies from 43,502 women without HIV and 1536 pregnancies from 1186 women living with HIV (seroprevalence of maternal HIV: 2.7%). Overall, 1130 stillbirths (2.0%) and 6558 miscarriages (11.7%) occurred. Any pregnancy loss was similar in both groups (13.8% in women without and 14.1% in women with HIV; P=.733). Stillbirth was higher among women living with HIV (3.4%) than among women without HIV (2.0%; P<.001), but there was no difference in overall miscarriage rates (10.7% in women with vs. 11.8% in women without HIV; P=.188). Women living with HIV had higher miscarriage rates between 12 and 20 weeks than women without HIV (34.8% vs 23.7%; P=.001), likely because of syphilis coinfection. Stillbirth rates were higher for women living with HIV from 2008 to 2014; however, a steady plateau was reached from 2014 to 2018, mirroring stillbirth rates in women without HIV. Maternal HIV infection did not increase the risk of miscarriage (relative risk, 0.90; 95% confidence interval, 0.77-1.05) or any pregnancy loss (relative risk, 1.00; 95% confidence interval, 0.88-1.15), but was associated with stillbirth (relative risk, 1.65; 95% confidence interval, 1.23-2.21). Maternal syphilis was associated with any pregnancy loss (relative risk, 1.24; 95% confidence interval, 1.11-1.38) and stillbirth (relative risk, 3.39; 95% confidence interval, 2.77-4.14), but not miscarriage (relative risk, 0.91; 95% confidence interval, 0.80-1.04).

CONCLUSION

In the era of combination antiretroviral therapy, there was no difference in miscarriage rates between women with and without HIV. HIV was associated with stillbirth risk but improved over time. Maternal syphilis was significantly associated with any pregnancy loss and stillbirth in all women. Syphilis is likely the main driver of pregnancy loss in women living with HIV in Brazil.

Population-based analysis of the epidemiology of the surgical correction of hyperhidrosis in 1,216 patients over 11 years: a cross-sectional study

BACKGROUND

Endoscopic thoracic sympathectomy is the definitive surgical treatment for hyperhidrosis and a nationwide study has suggested that cultural and socioeconomic factors play a role in the numbers of operations performed. Thus, there is a need to evaluate local data in order to understand the local epidemiology and trends in hyperhidrosis treatment.

OBJECTIVE

To study the epidemiology of sympathectomy for treating hyperhidrosis in São Paulo, the largest city in Brazil.

DESIGN AND SETTING

Population-based retrospective cross-sectional study.

METHODS

Data on sympathectomies for treating hyperhidrosis between 2008 and 2018 were assessed from the database of the Municipal Health Department of São Paulo, Brazil.

RESULTS

65.29% of the patients were female, 66.2% were aged between 20 and 39 years and 37.59% had registered with addresses outside São Paulo. 1,216 procedures were performed in the city of São Paulo from 2008 to 2018, and 78.45% of them were in only two public hospitals. The number of procedures significantly declined over the years (P = 0.001). 71.63% of the procedures were associated with 2-3 days of hospital stay, only 78 intensive care unit days were billed and we did not observe any intra-hospital death.

CONCLUSION

The profile of patients operated on in São Paulo (young women) is similar to that described in other populations. Sympathectomy is a very safe procedure, with no mortality in our series. There was a decreasing trend in the number of surgeries over the years.

Hospital characteristics associated with COVID-19 mortality: data from the multicenter cohort Brazilian Registry

The COVID-19 pandemic caused unprecedented pressure over health care systems worldwide. Hospital-level data that may influence the prognosis in COVID-19 patients still needs to be better investigated. Therefore, this study analyzed regional socioeconomic, hospital, and intensive care units (ICU) characteristics associated with in-hospital mortality in COVID-19 patients admitted to Brazilian institutions. This multicenter retrospective cohort study is part of the Brazilian COVID-19 Registry. We enrolled patients ≥ 18 years old with laboratory-confirmed COVID-19 admitted to the participating hospitals from March to September 2020. Patients' data were obtained through hospital records. Hospitals' data were collected through forms filled in loco and through open national databases. Generalized linear mixed models with logit link function were used for pooling mortality and to assess the association between hospital characteristics and mortality estimates. We built two models, one tested general hospital characteristics while the other tested ICU characteristics. All analyses were adjusted for the proportion of high-risk patients at admission. Thirty-one hospitals were included. The mean number of beds was 320.4 ± 186.6. These hospitals had eligible 6556 COVID-19 admissions during the study period. Estimated in-hospital mortality ranged from 9.0 to 48.0%. The first model included all 31 hospitals and showed that a private source of funding (β = - 0.37; 95% CI - 0.71 to - 0.04; p = 0.029) and location in areas with a high gross domestic product (GDP) per capita (β = - 0.40; 95% CI - 0.72 to - 0.08; p = 0.014) were independently associated with a lower mortality. The second model included 23 hospitals and showed that hospitals with an ICU work shift composed of more than 50% of intensivists (β = - 0.59; 95% CI - 0.98 to - 0.20; p = 0.003) had lower mortality while hospitals with a higher proportion of less experienced medical professionals had higher mortality (β = 0.40; 95% CI 0.11-0.68; p = 0.006). The impact of those association increased according to the proportion of high-risk patients at admission. In-hospital mortality varied significantly among Brazilian hospitals. Private-funded hospitals and those located in municipalities with a high GDP had a lower mortality. When analyzing ICU-specific characteristics, hospitals with more experienced ICU teams had a reduced mortality.

Sustained Virologic Suppression Reduces HIV-1 DNA Proviral Levels and HIV Antibodies in Perinatally HIV-Infected Children Followed from Birth

The extent to which perinatally HIV-infected children, following cART initiation, develop a low proviral reservoir burden over time, as measured by HIV DNA droplet-digital polymerase chain reaction (ddPCR) and the effect on HIV antibody is not well characterized. We measured proviral HIV DNA and plasma RNA virus load (VL) in 37 perinatally HIV-infected children at 6 months of age who initiated stable cART. At 6-11 years of age, HIV proviral DNA, HIV VL (RNA), and HIV antibody by Western Blot (WB) were assessed. CART was initiated before 6 months of age in 13 children and after 6 months in 24. At school age, the HIV DNA levels did not differ by the timing of cART, and the HIV DNA levels were lower in children with negative/indeterminate WB (p = 0.0256). Children with undetectable HIV RNA VL > 50% of the time since cART initiation had lower median DNA VL than children with undetectable VL < 50% of the time (p = 0.07). Long-term viral suppression in perinatally HIV-infected children is associated with a decrease in HIV antibodies and reduced HIV reservoirs.

Direct and indirect costs attributed to alcohol consumption in Brazil, 2010 to 2018

INTRODUCTION

Alcohol consumption is the main risk factor for death and disability in the world population between 15 to 49 years old, is related to more than 200 causes of death, and has an important economic impact on the health and social security systems. In 2016, three million deaths were attributable to alcohol worldwide and 131.4 million DALYs. In Brazil, alcohol consumption per inhabitant was 7.8 liters in 2016; and the prevalence of abusive consumption was 17.1% in 2019.

OBJECTIVE

Estimate the costs attributable of alcohol consumption in the Brazilian population 18 years-old and over, in the period 2010 to 2018.

METHODS

This is a prevalence-based cost-of-illness study, with a top-down and retrospective approach, including direct costs (hospital and outpatient) and indirect costs (absenteeism from work) related to alcohol consumption. A list of diseases and conditions for which alcohol is a risk factor was used, and the Population Attributable Risk (PAR) was calculated to estimate what portion of the cost of these diseases is attributable to alcohol consumption. Prevalence was calculated by sex and level of alcohol consumption, based on data from the 2019 National Health Survey. Relative risk data were identified by disease/injury and level of daily consumption obtained from the Global Burden Disease study in 2017. The cost data used are from the Brazilian Unified Health System and social security system. All costs were adjusted for inflation for the period and converted to purchasing power parity.

RESULTS

Prevalence data revealed that 73.6% of the Brazilian population reported not consuming alcoholic beverages, which included 62.9% of men and 83.0% of women. The lowest values for the PAR were found at the consumption range of 60 grams per day. Although the 12 grams per day consumption category is the least in terms of the quantity of alcohol consumed, it is one of the main ones in terms of PAR, given the higher prevalence of consumption. The total cost attributable to alcohol between 2010 and 2018 was Int$ 1,487,417,115.43, of which Int$ 737,834,696.89 was for hospital expenses, Int$ 416,052,029.75 for outpatient care, and Int$ 333,530,388.79 due to absenteeism from work.

CONCLUSION

Few comprehensive studies of alcohol-related costs have been developed, which suggests a knowledge gap in Brazil and worldwide and indicates the need for more research in this area. Understanding the economic impact of alcohol consumption is essential to help measure this public health problem in all its aspects and encourage implementation of public policies.

Sustainable development goals and ending ECC as a public health crisis

Early Childhood Caries (ECC) remains a global issue despite numerous advancements in research and interventional approaches. Nearly, 530 million children suffer from untreated dental caries of primary teeth. The consequences of such untreated dental caries not only limit the child's chewing and eating abilities but also, significantly impact the child's overall growth. Research has demonstrated that ECC is associated with nearly 123 risk factors. ECC has also been associated with local pain, infections, abscesses, and sleep pattern. Furthermore, it can affect the child's emotional status and decrease their ability to learn or perform their usual activities. In high-income countries, dental care continues to endorse a "current treatment-based approach" that involves high-technology, interventionist, and specialized approaches. While such approaches provide immediate benefit at an individual level, it fails to intercept the underlying causes of the disease at large. In low-income and middle-income countries (LMICs), the "current treatment approach" often remains limited, unaffordable, and unsuitable for the majority of the population. Rather, dentistry needs to focus on "sustainable goals" and integrate dental care with the mainstream healthcare system and primary care services. Dental care systems should promote "early first dental visits," when the child is 1 year of age or when the first tooth arrives. The serious shortages of appropriately trained oral healthcare personnel in certain regions of the world, lack of appropriate technologies and isolation of oral health services from the health system, and limited adoption of prevention and oral health promotion can pose as critical barriers. The oral health care systems must focus on three major keystones to combat the burden of ECC-1. Essential oral health services are integrated into healthcare in every country ensuring the availability of appropriate healthcare accessible and available globally, 2. Integrating oral and general healthcare to effectively prevent and manage oral disease and improve oral health, 3. Collaborating with a wide range of health workers to deliver sustainable oral health care tailored to cater to the oral health care needs of local communities.

Space-Time Clustering and Socioeconomic Factors Associated with Mortality from Diarrhea in Alagoas, Northeastern Brazil: A 20-Year Population-Based Study

Acute diarrhea is the second leading cause of death among children in developing countries and is strongly related with the socioeconomic conditions of the population. In Brazil, data show a drop in the diarrhea mortality rate. Nevertheless, the northeastern region still has the most deaths. Considering this, we analyze high-risk areas for diarrhea- and gastroenteritis-related deaths, and their association with social determinants of health (SDH) in the state with one of the worst human development indicators in Brazil (Alagoas) between 2000 and 2019. We applied temporal, spatial, and space−time risk modelling. We used a log-linear regression model to assess temporal trends and the local empirical Bayesian estimator, the global and local Moran indices for spatial analysis. Spearman’s correlation was used to correlate mortality rates with SDH. A total of 3472 diarrhea-related deaths were reported during this period in Alagoas. We observed a decreasing time trend of deaths in the state (9.41/100,000 in 2000 to 2.21 in 2019; APC = −6.7; p-value < 0.001), especially in children under one year of age. However, there was stability among adults and the elderly. We identified two high-risk spatiotemporal clusters of mortality in inland municipalities. Lastly, mortality rates correlated significantly with 90% of SDH. Taken together, these findings indicate that diarrhea diseases remain a serious public health concern in Alagoas, mainly in the poorest and inland municipalities. Thereby, it is urgently necessary to invest in measures to control and prevent cases, and improve the living conditions of the poorest populations and those with the highest social vulnerability index.

The National Health Policy for people with disabilities in Brazil: an analysis of the content, context and the performance of social actors

The purpose of this article is to analyse the circumstances in which the National Health Policy for Persons with Disabilities (PNSPCD) came into place in 2002 and the factors supporting or impeding its implementation from 2002 to 2018. The analysis was based on the Comprehensive Policy Analysis Model proposed by Walt and Gilson and focussed on understanding the context, process, content and actors involved in the formulation and implementation of the Policy. Data were obtained from two sources: document analysis of the key relevant documents and seven key informant interviews. Content analysis was undertaken using the Condensation of Meanings technique. The research demonstrates that the development and implementation of PNSPCD is marked by advances and retreats, determined, above all, by national and international macro-political decisions. The policy was formulated during Fernando Henrique's governments, under pressure from social movements and the international agenda and constituted a breakthrough for the rights of persons with disabilities. However, progress on implementation only took place under subsequent centre-left governments with the establishment of a care network for people with disabilities and a defined specific budget. These developments resulted from the mobilization of social movements, the ratification of the United Nations Convention on the rights of people with disabilities and the adherence of these governments to the human rights agenda. The coming to power of ultra-right governments triggered fiscal austerity, a setback in the implementation of the care network and a weakening in the content of various social policies related to the care of people with disabilities. During this era, the political approach changed, with the attempt to evade the role of the State, and the perspective of guaranteeing social rights. Undoubtedly, the neoliberal offensive on social policies, especially the Unified Health System, is the main obstacle to the effective implementation of the PNPCD in Brazil.

Implementation of an Integrated Lung Cancer Prevention and Screening Program Using a Mobile Computed Tomography (CT) Unit in Brazil

INTRODUCTION

Lung cancer is the deadliest cancer worldwide and in Brazil. Despite strong evidence, lung cancer screening by low-dose computed tomography (LDCT) in high-risk individuals is far from a reality in many countries, particularly in Brazil. Brazil has a universal public health system marked with important inequalities. One affordable strategy to increase the coverage of resources is to use mobile units.

OBJECTIVES

To describe the implementation and results of an innovative lung cancer prevention program that integrates tobacco cessation and lung cancer screening using a mobile CT unit.

METHODOLOGY

From May 2019 to Dec 2020, health professionals from 18 public primary health care units in Barretos, Brazil, were trained to offer smoking cessation counseling and treatment. Eligible high-risk participants of this program were also invited to perform lung cancer screening in a mobile LDCT unit that was specially conceived to be dispatched to the community. A detailed epidemiological questionnaire was administered to the LDCT participants.

RESULTS

Among the 233 screened participants, the majority were women (54.9%), and the average age was 62 years old. A total of 52.8% of participants showed high or very high nicotine dependence. After 1 year, 27.8% of participants who were involved in smoking cessation groups had quit smoking. The first LDCT round revealed that the majority of participants (83.7%) exhibited lung-Rads 1 or 2; 7.3% exhibited lung-Rads 3; 7.7% exhibited lung-Rads 4a; and 3% exhibited lung-Rads 4b or 4x. The three participants with lung-Rads 4b were further confirmed, and their surgery led to the diagnosis of early-stage cancer (1 case of adenocarcinoma and two cases of squamous cell carcinoma), leading to a cancer diagnosis rate of 12.8/1000.

CONCLUSION

Our results indicate promising outcomes for an onsite integrative program enrolling high-risk individuals in a middle-income country. Evidence barriers and challenges remain to be overcome.

Primary healthcare protects vulnerable populations from inequity in COVID-19 vaccination: An ecological analysis of nationwide data from Brazil

Background

There is limited information on the inequity of access to vaccination in low-and-middle-income countries during the COVID-19 pandemic. Here, we described the progression of the Brazilian immunisation program for COVID-19, and the association of socioeconomic development with vaccination rates, considering the potential protective effect of primary health care coverage.

Methods

We performed an ecological analysis of COVID-19 immunisation data from the Brazilian National Immunization Program from January 17 to August 31, 2021. We analysed the dynamics of vaccine coverage in the adult population of 5,570 Brazilian municipalities. We estimated the association of human development index (HDI) levels (low, medium, and high) with age-sex standardised first dose coverage using a multivariable negative binomial regression model. We evaluated the interaction between the HDI and primary health care coverage. Finally, we compared the adjusted monthly progression of vaccination rates, hospital admission and in-hospital death rates among HDI levels.

Findings

From January 17 to August 31, 2021, 202,427,355 COVID-19 vaccine doses were administered in Brazil. By the end of the period, 64·2% of adults had first and 31·4% second doses, with more than 90% of those aged ≥60 years with primary scheme completed. Four distinct vaccine platforms were used in the country, ChAdOx1-S/nCoV-19, Sinovac-CoronaVac, BNT162b2, Ad26.COV2.S, composing 44·8%, 33·2%, 19·6%, and 2·4% of total doses, respectively. First dose coverage differed between municipalities with high, medium, and low HDI (Median [interquartile range] 72 [66, 79], 68 [61, 75] and 63 [55, 70] doses per 100 people, respectively). Municipalities with low (Rate Ratio [RR, 95% confidence interval]: 0·87 [0·85-0·88]) and medium (RR [95% CI]: 0·94 [0·93-0·95]) development were independently associated with lower vaccination rates compared to those with high HDI. Primary health care coverage modified the association of HDI and vaccination rate, improving vaccination rates in those municipalities of low HDI and high primary health care coverage. Low HDI municipalities presented a delayed decrease in adjusted in-hospital death rates by first dose coverage compared to high HDI locations.

Interpretation

In Brazil, socioeconomic disparities negatively impacted the first dose vaccination rate. However, the primary health care mitigated these disparities, suggesting that the primary health care coverage guarantees more equitable access to vaccines in vulnerable locations.

Funding

This work is part of the Grand Challenges ICODA pilot initiative, delivered by Health Data Research UK and funded by the Bill & Melinda Gates Foundation and the Minderoo Foundation. This study was supported by the National Council for Scientific and Technological Development (CNPq), the Coordination for the Improvement of Higher Education Personnel (CAPES) - Finance Code 001, Carlos Chagas Filho Foundation for Research Support of the State of Rio de Janeiro (FAPERJ) and the Pontifical Catholic University of Rio de Janeiro.

Geographic Distribution and Time Trends of Colorectal Cancer in Brazil from 2005 to 2018

BACKGROUND

Colorectal cancer (CRC) is the third most common malignancy and the second leading cause of cancer-related death in the world. The aim of this study was to investigate the geographic distribution and time trends of CRC in Brazil.

METHODS

Data were retrospectively retrieved from January 2005 to December 2018 from the Brazilian Public Health System. The incidence and lethality rates of CRC per 100,000 inhabitants in each municipality were estimated from hospitalizations and in-hospital deaths and were classified by age, sex, and demographic features.

RESULTS

During the study period, the mean incidence of CRC estimated from hospitalizations and adjusted to available hospital beds more than tripled from 14.6 to 51.4 per 100,000 inhabitants (352%). Increases in CRC incidence were detected in all age ranges, particularly among people aged 50-69 years (266%). Incidence rates increased in all 5 macroregions, with a clear South to North gradient. The greatest changes in incidence and lethality rates were registered in small-sized municipalities. CRC lethality estimated from in-hospital deaths decreased similarly in both sexes, from 12 to 8% for males and females, from 2005 to 2018. The decline in lethality rates was seen in all age ranges, mainly in people aged 50 to 69 years (- 38%).

CONCLUSIONS

CRC incidence is increasing, predominantly above fifty years of age, and also in areas previously considered as having low incidence, but the increase is not paralleled by lethality rates. This suggests recent improvements in CRC screening programs and treatment, but also supports the spread of environmental risk factors throughout the country.

Study of Health in Primary Care of the Amazonas Population: Protocol for an Observational Study on Diabetes Management in Brazil

BACKGROUND

Changes in the profiles of patients have significant impacts on the health care system. Diabetes mellitus type 2 (T2DM) prevention and management should be studied in different contexts.

OBJECTIVE

The Study of Health in Primary Care for the Amazonas Population (SAPPA) primarily aims to describe T2DM prevention and management actions offered by primary health care settings in Brazil and whether the care delivered is consistent with the chronic care model (CCM). Second, the study aims to examine the impact of T2DM management actions on health and lifestyle, and third, to understand how sociodemographic characteristics, health, and subjective outcomes impact diabetes management.

METHODS

As part of this observational study, managers and health professionals complete a questionnaire containing information about T2DM prevention and management actions and CCM dimensions. During in-home visits, patients are asked about their health, lifestyle, sociodemographics, diabetes care, and subjective variables.

RESULTS

A total of 34 managers, 1560 professional health workers, and 955 patients will be recruited. The data collection will be completed in October 2022.

CONCLUSIONS

The SAPPA is an observational study that intends to understand the T2DM management process in primary health care, including planning, execution, reach, and impact on patient motivation and adherence.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/37572.