High Levels of NfL, GFAP, TAU, and UCH-L1 as Potential Predictor Biomarkers of Severity and Lethality in Acute COVID-19

Few studies showed that neurofilament light chain (NfL), glial fibrillary acidic protein (GFAP), total tubulin-associated unit (TAU), and ubiquitin carboxy-terminal hydrolase-L1 (UCH-L1) may be related to neurological manifestations and severity during and after SARS-CoV-2 infection. The objective of this work was to investigate the relationship among nervous system biomarkers (NfL, TAU, GFAP, and UCH-L1), biochemical parameters, and viral loads with heterogeneous outcomes in a cohort of severe COVID-19 patients admitted in Intensive Care Unit (ICU) of a university hospital. For that, 108 subjects were recruited within the first 5 days at ICU. In parallel, 16 mild COVID-19 patients were enrolled. Severe COVID-19 group was divided between "deceased" and "survivor." All subjects were positive for SARS-CoV-2 detection. NfL, total TAU, GFAP, and UCH-L1 quantification in plasma was performed using SIMOA SR-X platform. Of 108 severe patients, 36 (33.33%) presented neurological manifestation and 41 (37.96%) died. All four biomarkers - GFAP, NfL, TAU, and UCH-L1 - were significantly higher among deceased patients in comparison to survivors (p < 0.05). Analyzing biochemical biomarkers, higher Peak Serum Ferritin, D-Dimer Peak, Gamma-glutamyltransferase, and C-Reactive Protein levels were related to death (p < 0.0001). In multivariate analysis, GFAP, NfL, TAU, UCH-L1, and Peak Serum Ferritin levels were correlated to death. Regarding SARS-CoV-2 viral load, no statistical difference was observed for any group. Thus, Ferritin, NFL, GFAP, TAU, and UCH-L1 are early biomarkers of severity and lethality of SARS-COV-2 infection and may be important tools for therapeutic decision-making in the acute phase of disease.

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

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.

Clinical Profile and Risk Factors for Severe COVID-19 in Hospitalized Patients from Rio de Janeiro, Brazil: Comparison between the First and Second Pandemic Waves

Since COVID-19 was declared a pandemic, Brazil has become one of the countries most affected by this disease. A year into the pandemic, a second wave of COVID-19 emerged, with a rapid spread of a new SARS-CoV-2 lineage of concern. Several vaccines have been granted emergency-use authorization, leading to a decrease in mortality and severe cases in many countries. However, the emergence of SARS-CoV-2 variants raises the alert for potential new waves of transmission and an increase in pathogenicity. We compared the demographic and clinical data of critically ill patients infected with COVID-19 hospitalized in Rio de Janeiro during the first and second waves between July 2020 and October 2021. In total, 106 participants were included in this study; among them, 88% had at least one comorbidity, and 37% developed severe disease. Disease severity was associated with older age, pre-existing neurological comorbidities, higher viral load, and dyspnea. Laboratory biomarkers related to white blood cells, coagulation, cellular injury, inflammation, renal, and liver injuries were significantly associated with severe COVID-19. During the second wave of the pandemic, the necessity of invasive respiratory support was higher, and more individuals with COVID-19 developed acute hepatitis, suggesting that the progression of the second wave resulted in an increase in severe cases. These results can contribute to understanding the behavior of the COVID-19 pandemic in Brazil and may be helpful in predicting disease severity, which is a pivotal for guiding clinical care, improving patient outcomes, and defining public policies.

The effect of BCG vaccination on infection and antibody levels against SARS-CoV-2-The results of ProBCG: a multicenter randomized clinical trial in Brazil

OBJECTIVES

Evatuate if Bacillus Calmette-Guérin (BCG) vaccine could be used as a tool against SARS-CoV-2 based on the concept of trained immunity.

METHODS

A multicenter, double-blinded, randomized clinical trial recruited health care workers (HCWs) in Brazil. The incidence rates of COVID-19, clinical manifestations, absenteeism, and adverse events among HCWs receiving BCG vaccine (Moreau or Moscow strains) or placebo were compared. BCG vaccine-mediated immune response before and after implementing specific vaccines for COVID-19 (CoronaVac or COVISHIELD) was analyzed. Cox proportional hazard and linear mixed effect modeling were used.

RESULTS

A total of 264 volunteers were included for analysis (BCG = 134 and placebo = 130). The placebo group presented a COVID-19 cumulative incidence of 0.75% vs 0.52% of BCG. The Moreau strain also presented a higher incidence rate (1.60% × 0.22%). BCG did not show a protective hazard ratio against COVID-19. In addition, the log (immunoglobulin G) level against SARS-CoV-2 presented a higher increase in the BCG group, whether or not participants had COVID-19, but also without statistical significance.

CONCLUSION

Our results suggest that BCG has a tendency of protection against SARS-CoV-2 and higher immunoglobulin G levels than placebo. The clinical trial was registered at https://clinicaltrials.gov/ (NCT04659941).

Overlap between dengue, Zika and chikungunya hotspots in the city of Rio de Janeiro

Background

Arboviruses represent a threat to global public health. In the Americas, the dengue fever is endemic. This situation worsens with the introduction of emerging, Zika fever and chikungunya fever, causing epidemics in several countries within the last decade. Hotspot analysis contributes to understanding the spatial and temporal dynamics in the context of co-circulation of these three arboviral diseases, which have the same vector: Aedes aegypti.

Objective

To analyze the spatial distribution and agreement between the hotspots of the historical series of reported dengue cases from 2000 to 2014 and the Zika, chikungunya and dengue cases hotspots from 2015 to 2019 in the city of Rio de Janeiro.

Methods

To identify hotspots, Gi* statistics were calculated for the annual incidence rates of reported cases of dengue, Zika, and chikungunya by neighborhood. Kendall’s W statistic was used to analyze the agreement between diseases hotspots.

Results

There was no agreement between the hotspots of the dengue fever historical series (2000–2014) and those of the emerging Zika fever and chikungunya fever (2015–2019). However, there was agreement between hotspots of the three arboviral diseases between 2015 and 2019.

Conclusion

The results of this study show the existence of persistent hotspots that need to be prioritized in public policies for the prevention and control of these diseases. The techniques used with data from epidemiological surveillance services can help in better understanding of the dynamics of these diseases wherever they circulate in the world.

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.

Impacts of a delayed and slow-paced vaccination on cases and deaths during the COVID-19 pandemic: a modelling study

In Brazil, vaccination has always cut across party political and ideological lines, which has delayed its start and brought the whole process into disrepute. Such divergences put the immunization of the population in the background and create additional hurdles beyond the pandemic, mistrust and scepticism over vaccines. We conduct a mathematical modelling study to analyse the impacts of late vaccination along with slowly increasing coverage, as well as how harmful it would be if part of the population refused to get vaccinated or missed the second dose. We analyse data from confirmed cases, deaths and vaccination in the state of Rio de Janeiro in the period between 10 March 2020 and 27 October 2021. We estimate that if the start of vaccination had been 30 days earlier, combined with efforts to drive vaccination rates up, about 31 657 deaths could have been avoided. In addition, the slow pace of vaccination and the low demand for the second dose could cause a resurgence of cases as early as 2022. Even when reaching the expected vaccination coverage for the first dose, it is still challenging to increase adherence to the second dose and maintain a high vaccination rate to avoid new outbreaks.

Identificação de áreas de risco e fatores associados à epidemia de sarampo de 2019 no 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.

Spatial analysis of tuberculosis cure in primary care in Rio de Janeiro, Brazil

Background

Tuberculosis (TB) presents a high burden of disease and is considered a global emergency by the World Health Organization (WHO), as the leading cause of death from infectious disease in adults. TB incidence is related directly to access to health services and socioeconomic determinants and inequality. Providing primary care settings can lead to improved access, shorter waiting times for patients, and enhanced TB case detection. The article aims to identify the spatial and temporal risk areas for TB and the relationship between TB cure and primary healthcare coverage from 2012 to 2014 in Rio de Janeiro, Brazil.

Methods

A cross-sectional study was conducted in Rio de Janeiro, Brazil. All cases of TB reported to the Information System on Diseases of Notification (SINAN) from 2012 to 2014 were included. Socioeconomic variables from the 2010 Brazilian national census were also added. Socioeconomic variables were selected from multivariate analysis using principal factors analysis. Spatial association was verified with generalized additive model (GAM). It was possible to identify areas at higher risk of failure to cure TB.

Results

TB rates showed strong positive spatial autocorrelation. TB cure rate varied according to schooling (individuals with complete secondary schooling had higher cure rates than illiterate individuals; OR 1.72, 95% CI 1.30–2.29), alcohol consumption (OR 0.47, 95% CI 0.35–0.64), contact investigation (OR 2.00, 95% CI 1.56–2.57), positive HIV serology (OR 0.31, 95% CI 0.23–0.42), and census tracts with higher elderly rates (OR 9.39, 95% CI 1.03–85.26). Individuals who had been covered by primary healthcare (PHC) for 35 to 41 months had 1.64 higher odds of cure, compared to those with no PHC coverage (95% CI 1.07–2.51).

Conclusion

A comprehensive risk map was developed, allowing public health interventions. Spatial analysis allowed identifying areas with lower odds of TB cure in the city of Rio de Janeiro. TB cure was associated statistically with time of coverage by primary healthcare. TB cure rate also varied according to sociodemographic factors like schooling, alcohol abuse, and population density.

This methodology can be generalized to other areas and/or other public health problems.

Highlights

We studied standardized municipal TB cure rates in an area of social inequality in Brazil.

TB rates showed strong positive spatial autocorrelation.

Higher rates were associated with population density and socioeconomic conditions. Illiterate individuals were less likely to achieve TB cure.

TB cure was less likely in individuals with HIV and alcohol abuse.

TB cure was greater in areas with high primary healthcare coverage.

[Aedes aegypti larval indices and dengue incidence: an ecological study in the state of Rio de Janeiro, Brazil]

The simultaneous circulation of dengue, Zika, and chikungunya poses major challenges for Brazil. Due to climate changes and other associated factors, more than two billion people in the world may be exposed to these arbovirus infections, according to the World Health Organization. The principal strategy for Aedes aegypti control programs is based on the Infestation Index Rapid Survey for Ae. aegypti (LIRAa), a sample survey in which the Building Infestation Index (BII) is used to prioritize areas for intervention. This study analyzed the performance of LIRAa in terms of its sensitivity for predicting dengue epidemics in municipalities in the state of Rio de Janeiro in epidemic years. Incidence rates per municipality for the years 2011, 2012, 2013, 2015, and 2016, plus the BII in October of the previous years. Scatterplots were created, aimed at an exploratory analysis and graphic visualizations of the relationship between the above-mentioned variables, as well as analyses of the Spearman correlation between the BII and the Breteau Index for each year, aimed at estimating the quality of the LIRAa. Comparative analysis of the values for the BII and the respective incidence rates in the period only indicated significant correlation between these variables in 2011/2012 (rs = 0.479; p < 0.01). There was also a correlation between BII and Breteau Index. It is urgent to rethink the parameters established by the LIRAa methodology and invest in alternative methodologies in entomological and epidemiological surveillance that reliably measure transmission risk in the territory and thus design more effective strategies to control these arbovirus infections.

Fatores associados ao óbito em casos confirmados de COVID-19 no estado do Rio de Janeiro

BACKGROUND

COVID-19 can occur asymptomatically, as influenza-like illness, or as more severe forms, which characterize severe acute respiratory syndrome (SARS). Its mortality rate is higher in individuals over 80 years of age and in people with comorbidities, so these constitute the risk group for severe forms of the disease. We analyzed the factors associated with death in confirmed cases of COVID-19 in the state of Rio de Janeiro. This cross-sectional study evaluated the association between individual demographic, clinical, and epidemiological variables and the outcome (death) using data from the Unified Health System information systems.

METHODS

We used the extreme boosting gradient (XGBoost) model to analyze the data, which uses decision trees weighted by the estimation difficulty. To evaluate the relevance of each independent variable, we used the SHapley Additive exPlanations (SHAP) metric. From the probabilities generated by the XGBoost model, we transformed the data to the logarithm of odds to estimate the odds ratio for each independent variable.

RESULTS

This study showed that older individuals of black race/skin color with heart disease or diabetes who had dyspnea or fever were more likely to die.

CONCLUSIONS

The early identification of patients who may progress to a more severe form of the disease can help improve the clinical management of patients with COVID-19 and is thus essential to reduce the lethality of the disease.

Association between socio-environmental factors, coverage by family health teams, and rainfall in the spatial distribution of Zika virus infection in the city of Rio de Janeiro, Brazil, in 2015 and 2016

BACKGROUND

Zika virus (ZIKV) infection caused outbreak in Brazil, in 2015 and 2016. Disorganized urban growth, facilitates the concentration of numerous susceptible and infected individuals. It is useful to understand the mechanisms that can favor the increase in ZIKV incidence, such as areas with wide socioeconomic and environmental diversity. Therefore, the study analyzed the spatial distribution of ZIKV in the city of Rio de Janeiro, Brazil, in 2015 and 2016, and associations between the incidence per 1000 inhabitants and socio-environmental factors.

METHODS

The census tracts were used as the analytical units reported ZIKV cases among the city's inhabitants. Local Empirical Bayesian method was used to control the incidence rates' instability effect. The spatial autocorrelation was verified with Moran's Index and local indicators of spatial association (LISA). Spearman correlation matrix was used to indicate possible collinearity. The Ordinary Least Squares (OLS), Spatial Lag Model (SAR), and Spatial Error Model (CAR) were used to analyze the relationship between ZIKV and socio-environmental factors.

RESULTS

The SAR model exhibited the best parameters: R2 = 0.44, Log-likelihood = - 7482, Akaike Information Criterion (AIC) = 14,980. In this model, mean income between 1 and 2 minimum wages was possible risk factors for Zika occurrence in the localities. Household conditions related to adequate water supply and the existence of public sewage disposal were associated with lower ZIKV cumulative incidence, suggesting possible protective factors against the occurrence of ZIKV in the localities. The presence of the Family Health Strategy in the census tracts was positively associated with the ZIKV cumulative incidence. However, the results show that mean income less than 1 minimum wage were negatively associated with higher ZIKV cumulative incidence.

CONCLUSION

The results demonstrate the importance of socio-environmental variables in the dynamics of ZIKV transmission and the relevance for the development of control strategies.

Spatial analysis of COVID-19 incidence and the sociodemographic context in Brazil

BACKGROUND

Identified in December 2019 in the city of Wuhan, China, the outbreak of COVID-19 spread throughout the world and its impacts affect different populations differently, where countries with high levels of social and economic inequality such as Brazil gain prominence, for understanding of the vulnerability factors associated with the disease. Given this scenario, in the absence of a vaccine or safe and effective antiviral treatment for COVID-19, nonpharmacological measures are essential for prevention and control of the disease. However, many of these measures are not feasible for millions of individuals who live in territories with increased social vulnerability. The study aims to analyze the spatial distribution of COVID-19 incidence in Brazil's municipalities (counties) and investigate its association with sociodemographic determinants to better understand the social context and the epidemic's spread in the country.

METHODS

This is an analytical ecological study using data from various sources. The study period was February 25 to September 26, 2020. Data analysis used global regression models: ordinary least squares (OLS), spatial autoregressive model (SAR), and conditional autoregressive model (CAR) and the local regression model called multiscale geographically weighted regression (MGWR).

FINDINGS

The higher the GINI index, the higher the incidence of the disease at the municipal level. Likewise, the higher the nurse ratio per 1,000 inhabitants in the municipalities, the higher the COVID-19 incidence. Meanwhile, the proportional mortality ratio was inversely associated with incidence of the disease.

DISCUSSION

Social inequality increased the risk of COVID-19 in the municipalities. Better social development of the municipalities was associated with lower risk of the disease. Greater access to health services improved the diagnosis and notification of the disease and was associated with more cases in the municipalities. Despite universal susceptibility to COVID-19, populations with increased social vulnerability were more exposed to risk of the illness.

Fetal, neonatal, and infant outcomes associated with maternal Zika virus infection during pregnancy: A systematic review and meta-analysis

The occurrence of fetal and neonatal disorders in pregnant women with Zika virus infection in the literature is not consistent. This study aims to estimate the prevalence rate of these disorders in fetuses/neonates of pregnant women with confirmed or probable infection by Zika virus. A systematic review with meta-analysis was conducted in November 2020. Cohort studies that contained primary data on the prevalence of unfavorable outcomes in fetuses or neonates of women with confirmed or probable Zika virus infection during pregnancy were included. A total of 21 cohort studies were included, with a total of 35,568 pregnant women. The meta-analysis showed that central nervous system abnormalities had the highest prevalence ratio of 0.06 (95% CI 0.03-0.09). Intracranial calcifications had a prevalence ratio of 0.01 (95% CI 0.01-0.02), and ventriculomegaly 0.01 (95% CI 0.01-0.02). The prevalence ratio of microcephaly was 0.03 (95% CI 0.02-0.05), fetal loss (miscarriage and stillbirth) was 0.04 (95% CI 0.02-0.06), Small for Gestational Age was 0.04 (95% CI 0.00-0,09), Low Birth Weight was 0.05 (95% CI 0.03-0.08) and Prematurity was 0.07 (95% CI 0.04-0.10). The positivity in RT-PCR for ZIKV performed in neonates born to infected mothers during pregnancy was 0.25 (95% CI 0.06-0.44). We also performed the meta-analysis of meta-analysis for microcephaly with the prevalence ratios from other two previously systematic reviews: 0.03 (95% CI 0.00-0.25). Our results contribute to measuring the impact of Zika virus infection during pregnancy on children's health. The continuous knowledge of this magnitude is essential for the implementation development of health initiatives and programs, in addition to promoting disease prevention, especially in the development of a vaccine for Zika virus. PROSPERO protocol registration: http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42019125543.

Microcefalia e alterações do sistema nervoso central relacionadas à infecção congênita pelo vírus Zika e outras etiologias infecciosas no estado do Rio de Janeiro: estudo transversal, 2015 a 2017

Objetivo.

Descrever o perfil clínico-epidemiológico dos casos confirmados de microcefalia e/ou alterações do sistema nervoso central (SNC) relacionadas a infecção congênita pelo vírus Zika e outras etiologias infecciosas no estado do Rio de Janeiro no período de novembro de 2015 a julho de 2017.

Métodos.

Realizou-se um estudo transversal de 298 casos (conforme definição do Ministério da Saúde) notificados à Secretaria de Estado de Saúde do Rio de Janeiro no período estudado. Analisaram-se variáveis demográficas, epidemiológicas, clínicas, radiológicas e laboratoriais, com análise estatística descritiva bivariada e múltipla por regressão logística para estudo de fatores associados ao óbito.

Resultados.

A idade mediana das mães foi 24 anos; 30,9% relataram febre, e 64,8%, exantema à gestação. A mediana do perímetro cefálico ao nascer foi 29 cm e a do peso foi 2 635 g. O diagnóstico etiológico foi de Zika congênita em 46,0%; de sífilis, toxoplasmose, rubéola, citomegalovírus e vírus herpes simplex (STORCH) em 13,8%, com predomínio da sífilis; e de agente infeccioso não definido em 40,3%. Alterações do SNC diferentes de microcefalia foram descritas em 88,3%, predominando calcificações cerebrais, ventriculomegalia e atrofia cerebral. A letalidade total foi 7,0%, sendo 19,0% nos casos de Zika confirmada laboratorialmente e 22,2% nos de toxoplasmose. Na análise múltipla, o peso ao nascer foi o principal preditor de óbito.

Conclusões.

Apesar da epidemia de Zika, 13,8% dos casos foram por STORCH. A letalidade e a elevada ocorrência de malformações neurológicas além da microcefalia mostram a gravidade da infecção, com impacto nas famílias e no sistema de saúde.

Modelagem espacial da hanseníase no estado da Bahia, Brasil, (2001-2015) e determinantes sociais da saúde

Resumo O trabalho analisa a distribuição espacial da hanseníase na Bahia e os determinantes sociais relacionados. Estudo ecológico com dados de hanseníase do período 2001-2015. Três indicadores epidemiológicos foram selecionados: coeficiente de detecção na população geral e em menores de 15 anos e a taxa de casos novos com grau II de incapacidade. Os indicadores foram suavizados pelo Modelo Bayesiano Empírico Local e aplicou-se estatística de Moran Global e Local. As variáveis independentes foram selecionadas a partir do Censo IBGE-2010. Regressões multivariadas foram empregadas, seguidas de regressão espacial. Observou-se distribuição heterogênea no estado, com concentração no eixo norte-oeste e região sul. Para o coeficiente de detecção geral, cinco variáveis compuseram o modelo: densidade demográfica, proporção da população urbana, renda per capita, proporção de extremamente pobres e domicílios com mais de três pessoas por dormitório. A proporção de analfabetismo compôs o modelo final para a taxa de grau II de incapacidade física. Não foram identificados determinantes da ocorrência da doença em menores de 15 anos. A modelagem utilizada contribuiu para demonstrar a heterogeneidade espacial e os determinantes sociais da doença na Bahia, colocando em evidência a complexidade do problema.

Seroprevalence of anti-SARS-CoV-2 among blood donors in Rio de Janeiro, Brazil

OBJECTIVE To estimate the seroprevalence of antibodies to SARS-CoV-2 among blood donors in the state of Rio de Janeiro, Brazil. METHODS Data were collected on 2,857 blood donors from April 14 to 27, 2020. This study reports crude prevalence of antibodies to SARS-CoV-2, population weighted prevalence for the state, and prevalence adjusted for test sensitivity and specificity. Logistic regression models were used to establish the correlates of SARS-CoV-2 prevalence. For the analysis, we considered collection period and site, sociodemographic characteristics, and place of residence. RESULTS The proportion of positive tests for SARS-Cov-2, without any adjustment, was 4.0% (95%CI 3.3-4.7%), and the weighted prevalence was 3.8% (95%CI 3.1-4.5%). We found lower estimates after adjusting for test sensitivity and specificity: 3.6% (95%CI 2.7-4.4%) for the non-weighted prevalence, and 3.3% (95%CI 2.6-4.1%) for the weighted prevalence. Collection period was the variable most significantly associated with crude prevalence: the later the period, the higher the prevalence. Regarding sociodemographic characteristics, the younger the blood donor, the higher the prevalence, and the lower the education level, the higher the odds of testing positive for SARS-Cov-2 antibody. We found similar results for weighted prevalence. CONCLUSIONS Our findings comply with some basic premises: the increasing trend over time, as the epidemic curve in the state is still on the rise; and the higher prevalence among both the youngest, for moving around more than older age groups, and the less educated, for encountering more difficulties in following social distancing recommendations. Despite the study limitations, we may infer that Rio de Janeiro is far from reaching the required levels of herd immunity against SARS-CoV-2.

Yellow fever: profile of cases and factors associated with death in a hospital in the State of Rio de Janeiro, 2017-2018

OBJECTIVE

Describe the clinical and epidemiological profile of confirmed cases of yellow fever whose patients were hospitalized in a general hospital for infectious diseases in the State of Rio de Janeiro, Brazil, from March 11, 2017 to June 15, 2018, during a recent outbreak and factors associated with death.

METHODS

This is a retrospective observational study with analysis of secondary databases of local epidemiological surveillance system, and complementary data collection from epidemiological investigation records and clinical records. Study variables included demographic, epidemiological, clinical, and laboratory data. A descriptive statistical analysis and a bivariate and multivariate analysis by logistic regression were performed to analyze factors associated with death.

RESULTS

Fifty-two patients diagnosed with yellow fever were hospitalized, 86.5% male patients, median age 49.5 years, 40.4% rural workers. The most frequent signs and symptoms were fever (90.4%), jaundice (86.5%), nausea and/or vomiting (69.2%), changes in renal excretion (53.8%), bleeding (50%), and abdominal pain (48.1%), with comorbidity in 38.5% of all cases. The lethality rate was 40.4%. Factors significantly associated with a higher chance of death in the bivariate analysis were: bleeding, changes in renal excretion, and maximum values of direct bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), urea, and creatinine. In the multivariate analysis by logistic regression, only changes in renal excretion and ALT remained significant predictors of higher chance of death. A threshold effect was also observed for AST. The cutoff points identified as high risk for death were ALT > 4,000 U/L and AST > 6,000 U/L.

CONCLUSIONS

This study contributed to the knowledge on the profile of confirmed cases of high severity yellow fever. The main factors associated with death were changes in renal excretion and elevated serum transaminases, especially ALT. High lethality emphasizes the need for early diagnosis and treatment, and the importance of increasing vaccination coverage.

Efficacy, immunogenicity and safety of a recombinant tetravalent dengue vaccine (CYD-TDV) in children aged 2-17 years: systematic review and meta-analysis

BACKGROUND

Randomised controlled trials have evaluated the recombinant tetravalent dengue vaccine (CYD-TDV). However, individual results may have little power to identify differences among the populations studied.

OBJECTIVE

To evaluate efficacy, immunogenicity and safety of CYD-TDV in the prevention of dengue in children aged 2-17 years.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE (from 1950 to 5 December 2018), EMBASE (from 1947 to 5 December 2018) and Cochrane (from 1993 to 5 December 2018).

ELIGIBILITY CRITERIA OF STUDIES

Randomised trials comparing efficacy, immunogenicity and safety of CYD-TDV with placebo or other vaccines for preventing dengue cases in children aged 2-17 years.

OUTCOME MEASURES

Efficacy, immunogenicity and safety of CYD-TDV.

STUDY APPRAISAL AND METHODS

Calculations were made of relative risk (RR) and mean difference (MD) for dichotomous and continuous outcomes, respectively. All estimates were calculated considering a 95% CI estimate. A p<0.05 was considered statistically significant.

RESULTS

Nine studies involving 34 248 participants were included. The overall efficacy of CYD-TDV was 60% (RR 0.40 (0.30 to 0.54)). Serotype-specific efficacy of the vaccine was 51% for dengue virus type-1 (DENV-1) (RR 0.49 (0.39 to 0.63)); 34% for DENV-2 (RR 0.66 (0.50 to 0.86)); 75% for DENV-3 (RR 0.25 (0.18 to 0.35)) and 77% for DENV-4 (RR 0.23 (0.15 to 0.34)). Overall immunogenicity (MD) of CYD-TDV was 225.13 (190.34 to 259.93). Serotype-specific immunogenicity was: DENV-1: 176.59 (123.36 to 229.83); DENV-2: 294.21 (181.98 to 406.45); DENV-3: 258.78 (146.72 to 370.84) and DENV-4: 189.35 (141.11 to 237.59). The most common adverse events were headache and pain at the injection site.

LIMITATIONS

The main limitation of this study was unclear or incomplete data.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

CYD-TDV is considered safe and able to partially protect children and adolescents against four serotypes of DENV for a 1-year period. Despite this, research should prioritise improvements in vaccine efficacy, thus proving higher long-term protection against all virus serotypes.

PROSPERO REGISTRATION NUMBER

CRD42016043628.

Three decades of hospital epidemiology and the challenge of integrating Health Surveillance: reflections from a case study

This study proposes a reflection on the uses and future prospects of hospital-based health surveillance based on the account of a pioneering experience in hospital epidemiology, the epidemiology service at the Hospital Federal dos Servidores do Estado - HFSE, which served as the basis for the creation of epidemiologic surveillance units in municipal and state hospitals in Rio de Janeiro, Brazil. The epidemiology service has combined epidemiological surveillance, continuing education, in-service training, research, and health service evaluation since 1986. The service is part of the national epidemiological surveillance network and was responsible for the notification of 55,747 cases between 1986 and 2016, most of which were the result of active search. The integration of various levels of health surveillance and health care makes classical control activities more agile and provides instruments for measuring. The important role played by the service in human resources training is evident in the training of 1,835 medical interns and 78 residents up to 2016. In addition, this experience has served as the basis for the implantation of several other hospital epidemiological surveillance units. Current challenges include the promotion of effective communication and coordination among the other health surveillance committees.

Classification of containers with Aedes aegypti pupae using a Neural Networks model

Introduction

This paper discusses the presence of Aedes aegypti pupae in different types of containers considering: volume, pH of the container, among other variables.

Methods

A nonlinear method for selection was applied, based on Mutual Information, by placing in order of importance the most appropriate variables for identifying containers with and without Aedes aegypti pupae. Such variables were used for input into a Neural Network in layers for classification.

Results

Among the experiments carried out, the best result obtained used the first eight variables selected by order of importance. The percentage of hits for containers which had no Aedes aegypti pupae was 73.3%, and 80.9% for those which did have Aedes aegypti pupae in the containers. This Neural Network method, a model with the capacity to emulate non-linear data, got better results in comparison with the discriminant power of the Logistic Regression model. Thus, the outcomes of using the Neural Networks method achieved better separability in classifying the containers with pupae and those with no pupae.

Conclusion

This type of analysis will aid in the efforts to design an efficient program to control Aedes aegypti that can concentrate principally on containers which present the greatest productivity.

The authors discuss a nonlinear method, based on Mutual Information, for selection of the presence of Aedes aegypti pupae in different breeding sites. The authors compare this method with the logistic regression model. In this study, using the Neural Network model, the variables that better discriminate the containers with Aedes aegypti pupae from the containers without pupae were size—the larger the container volume the greater the proportion of containers positive for pupae–, the presence of another type of pupa other than Aedes aegypti and the location of the container outside the home. The Neural Network method, a model with the capacity to emulate non-linear data, got better results in comparison with the discriminant power of the Logistic Regression model. Thus, the outcomes of the Neural Networks method achieved better separability in classifying the containers with pupae and those with no pupae. This type of analysis will aid in the efforts to design an efficient program to control Aedes aegypti that can concentrate principally on containers which present the greatest productivity.

Spatial analysis of Tuberculosis in Rio de Janeiro in the period from 2005 to 2008 and associated socioeconomic factors using micro data and global spatial regression models

The present study analyses the spatial pattern of tuberculosis (TB) from 2005 to 2008 by identifying relevant socioeconomic variables for the occurrence of the disease through spatial statistical models. This ecological study was performed in Rio de Janeiro using new cases. The census sector was used as the unit of analysis. Incidence rates were calculated, and the Local Empirical Bayesian method was used. The spatial autocorrelation was verified with Moran's Index and local indicators of spatial association (LISA). Using Spearman's test, variables with significant correlation at 5% were used in the models. In the classic multivariate regression model, the variables that fitted better to the model were proportion of head of family with an income between 1 and 2 minimum wages, proportion of illiterate people, proportion of households with people living alone and mean income of the head of family. These variables were inserted in the Spatial Lag and Spatial Error models, and the results were compared. The former exhibited the best parameters: R2 = 0.3215, Log-Likelihood = -9228, Akaike Information Criterion (AIC) = 18,468 and Schwarz Bayesian Criterion (SBC) = 18,512. The statistical methods were effective in the identification of spatial patterns and in the definition of determinants of the disease providing a view of the heterogeneity in space, allowing actions aimed more at specific populations.

Cure rates for tuberculosis in the municipality of Rio de Janeiro, Brazil, in 2012 compared with coverage by, and time of establishment of, Family Health units, and socio-economic and demographic factors

Tuberculosis (TB) has high prevalence and is considered a world emergency by the World Health Organization (WHO), being the greatest cause of death from infectious diseases in adults. It is directly associated with access to health services and socio-economic factors. A reform of Primary Care in the municipality of Rio de Janeiro began in 2010, with coverage increasing from 7% in that year to 48.2% in 2014. This article compares the proportion of cures of TB, coverage by the Family Health Strategy (FHS), how long it has been in place, and socio-economic and demographic factors in the municipality of Rio, based on new cases notified in the year 2012. An association was found between cure of TB and the variable gender, being 40% greater in females - odds ratio 1.4 (CI95% 1.21-1.62); and with residence in favelas - OR 0.86 (CI95% 0.73-1.02), but there was no association with coverage of the FHS (OR 1.06; CI95% 0.92-1.22), nor with the time for which the teams had been in place. FHS coverage in the municipality of Rio was put in place as priority in areas of greater vulnerability; at the time of this study, more than 91% of the teams had been in place for less than five years before the date of diagnosis. These factors probably contributed to it not being possible to detect better results in the cure of tuberculosis in areas covered by the FHS in the year 2012.

Analysis of the spatial distribution of dengue cases in the city of Rio de Janeiro, 2011 and 2012

OBJECTIVE

Analyze the spatial distribution of classical dengue and severe dengue cases in the city of Rio de Janeiro.

METHODS

Exploratory study, considering cases of classical dengue and severe dengue with laboratory confirmation of the infection in the city of Rio de Janeiro during the years 2011/2012. The georeferencing technique was applied for the cases notified in the Notification Increase Information System in the period of 2011 and 2012. For this process, the fields "street" and "number" were used. The ArcGis10 program's Geocoding tool's automatic process was performed. The spatial analysis was done through the kernel density estimator.

RESULTS

Kernel density pointed out hotspots for classic dengue that did not coincide geographically with severe dengue and were in or near favelas. The kernel ratio did not show a notable change in the spatial distribution pattern observed in the kernel density analysis. The georeferencing process showed a loss of 41% of classic dengue registries and 17% of severe dengue registries due to the address in the Notification Increase Information System form.

CONCLUSIONS

The hotspots near the favelas suggest that the social vulnerability of these localities can be an influencing factor for the occurrence of this aggravation since there is a deficiency of the supply and access to essential goods and services for the population. To reduce this vulnerability, interventions must be related to macroeconomic policies.

OBJETIVO

Analisar a distribuição espacial dos casos de dengue clássico e dengue grave no município do Rio de Janeiro.

MÉTODOS

Estudo exploratório, considerando casos de dengue clássico e de dengue grave com comprovação laboratorial da infecção, ocorridos no município do Rio de Janeiro nos anos de 2011/2012. Foi aplicada a técnica de georreferenciamento dos casos notificados no Sistema de Informação de Agravos de Notificação, no período de 2011 e 2012. Para esse processo, utilizaram-se os campos "logradouro" e "número". Foi realizado o processo automático da ferramenta Geocoding do programa ArcGis10. A análise espacial foi feita a partir do estimador de densidade Kernel.

RESULTADOS

A densidade de Kernel apontou áreas quentes para dengue clássico não coincidente geograficamente a dengue grave, estando localizadas dentro ou próximas de favelas. O cálculo da razão de Kernel não apresentou modificação significativa no padrão de distribuição espacial observados na análise da densidade de Kernel. O processo de georreferenciamento mostrou perda de 41% dos registros de dengue clássico e 17% de dengue grave devido ao endereçamento da ficha do Sistema de Informação de Agravos de Notificação.

CONCLUSÕES

As áreas quentes próximas às favelas sugerem que a vulnerabilidade social existente nessas localidades pode ser um fator de influência para a ocorrência desse agravo, uma vez que há deficiência da oferta e acesso a bens e serviços essenciais para a população. Para diminuir essa vulnerabilidade, as intervenções devem estar relacionadas a políticas macroeconômicas.

Spatial distribution and socioeconomic context of tuberculosis in Rio de Janeiro, Brazil

OBJECTIVE

To analyze the spatial distribution of risk for tuberculosis and its socioeconomic determinants in the city of Rio de Janeiro, Brazil.

METHODS

An ecological study on the association between the mean incidence rate of tuberculosis from 2004 to 2006 and socioeconomic indicators of the Censo Demográfico (Demographic Census) of 2000. The unit of analysis was the home district registered in the Sistema de Informação de Agravos de Notificação (Notifiable Diseases Information System) of Rio de Janeiro, Southeastern Brazil. The rates were standardized by sex and age group, and smoothed by the empirical Bayes method. Spatial autocorrelation was evaluated by Moran’s I. Multiple linear regression models were studied and the appropriateness of incorporating the spatial component in modeling was evaluated.

RESULTS

We observed a higher risk of the disease in some neighborhoods of the port and north regions, as well as a high incidence in the slums of Rocinha and Vidigal, in the south region, and Cidade de Deus, in the west. The final model identified a positive association for the variables: percentage of permanent private households in which the head of the house earns three to five minimum wages; percentage of individual residents in the neighborhood; and percentage of people living in homes with more than two people per bedroom.

CONCLUSIONS

The spatial analysis identified areas of risk of tuberculosis incidence in the neighborhoods of the city of Rio de Janeiro and also found spatial dependence for the incidence of tuberculosis and some socioeconomic variables. However, the inclusion of the space component in the final model was not required during the modeling process.

[A Bayesian model to investigate excess mortality during the dengue epidemic in Greater Metropolitan Rio de Janeiro, Brazil, in 2007-2008]

The aim of this study was to investigate excess mortality from dengue in Greater Metropolitan Rio de Janeiro, Brazil, during an epidemic in 2007-2008. A Poisson dynamic model was tested to predict the number of deaths during these epidemic years. Inference was conducted with a Bayesian approach. Excess mortality was detected in March 2008 in children < 15 years. In addition, the highest number of reported dengue cases in Rio de Janeiro was in March and April 2008. Since the increase in mortality should be preceded by an increase in morbidity, one can hypothesize that there was excess mortality from dengue in children during the epidemic in Greater Metropolitan Rio de Janeiro in March 2008.

Avaliação do dado sobre endereço no Sistema de Informação de Agravos de Notificação utilizando georreferenciamento em nível local de casos de tuberculose por dois métodos no município do Rio de Janeiro

O presente trabalho objetivou avaliar a qualidade dos dados referentes ao endereço dos casos notificados de tuberculose (TB) ao Sistema de Informação de Agravos de Notificação (SINAN), de 2005 a 2008, no município do Rio de Janeiro. Criou-se um indicador a partir da razão entre a taxa de incidência da TB calculada a partir do bairro de moradia declarado pelo paciente e a taxa de incidência do bairro obtida após o georreferenciamento do endereço do mesmo indivíduo, com o intuito de medir possíveis impactos que inconsistências no endereço podem causar nos cálculos de indicadores da doença por bairro. Foram utilizadas duas técnicas de georreferenciamento de dados a partir do endereço de residência. Foi realizada uma correção no campo endereço que modificou 27% dos registros. Houve uma diferença no resultado do georreferenciamento entre os dois métodos de 64 e 69%. Com o processo manual, chegou-se a 89% de localização. A partir do indicador criado, nota-se que apenas 28% dos bairros apresentaram um valor entre 0,85 e 1,15, considerado como razoável. O processo de localização pode ser mais rápido e eficaz após maior conscientização e treinamento dos profissionais responsáveis e utilização de algum cadastro oficial de logradouros. As diferenças apresentadas no indicador I podem auxiliar na tomada de decisões mais acertadas.

Confiabilidade dos dados de uma população de muito baixo peso ao nascer no Sistema de Informações sobre Nascidos Vivos 2005-2006

O objetivo do presente estudo foi avaliar a completitude e a concordância entre informações do Sistema de Informação sobre Nascidos Vivos (SINASC) e registros hospitalares em uma situação de elevado risco neonatal. Foi realizado o relacionamento probabilístico entre dados de uma Unidade de Cuidados Intensivos Neonatal pública e do SINASC (2005-2006), o que tornou possível analisar os dados de 170 nascidos vivos, com muito baixo peso ao nascer (500g - 1.499g) presentes em ambas as bases. As variáveis analisadas foram: idade materna, número de consultas de pré-natal, tipo de parto, sexo, peso ao nascer, Apgar 1º e 5º minutos e idade gestacional. A completitude no SINASC variou de 91,8% (Apgar 1º minuto) a 100% (sexo, parto e idade materna). Para avaliação da concordância foram utilizados o coeficiente kappa para variáveis dicotômicas, o coeficiente kappa ponderado para variáveis ordinais, e o coeficiente de correlação intraclasse (ICC) e a abordagem gráfica de Bland-Altman para variáveis contínuas. A concordância foi considerada boa a excelente para Apgar 1º minuto (kappa = 0,98), tipo de parto (kappa = 0,96), idade materna (ICC 0,95), Apgar 5º minuto (kappa = 0,93), sexo (kappa = 0,92) e consultas de pré-natal (kappa = 0,76); mas apenas razoável para idade gestacional (kappa = 0,50) e peso ao nascer (ICC = 0,57). Embora o peso ao nascer possa ser mais susceptível a erros de registro em uma população de risco neonatal elevado, a elevada confiabilidade observada na maioria das variáveis analisadas corrobora a importância do SINASC como fonte de informações para estudos de epidemiologia perinatal, mesmo para situações de elevado risco neonatal.

[Estimated parameters in linkage between mortality and hospitalization databases according to quality of records on underlying cause of death]

The purpose of the study was to compare the linkage parameter estimates between hospitalization and mortality databases, calculated separately for the subsets of deaths from ill-defined causes and deaths from known causes. The databases for deaths from known causes and ill-defined causes were linked to a hospital admissions database. Parameters were estimated using two strategies: (1) first name, last name, and day, month, and year of birth, (2) full name and date of birth. In the first strategy, the estimates for the first and last name were at least 97% in both sets. However, the items day, month, and year of birth produced low values in both sets. In the second strategy there was an important difference between the two groups, with much lower values for full name and especially for date of birth in the group of deaths from ill-defined causes. Our results emphasize the need for pilot studies to evaluate possible internal heterogeneity of databases during the planning stage of linkage projects.

Identification of risk areas for visceral leishmaniasis in Teresina, Piaui State, Brazil

This study used spatial analysis to identify areas at greatest risk of visceral leishmaniasis (VL) in the urban area of Teresina, Brazil during 2001-2006. The results from kernel ratios showed that peripheral census tracts were the most heavily affected. Local spatial analysis showed that in the beginning of the study period local clusters of high incidence of VL were mostly located in the southern and northeastern parts of the city, but in subsequent years those clusters also appeared in the northern region of the city, suggesting that the pattern of VL is not static, and the disease may occasionally spread to other areas of the municipality. We also observed a spatial correlation between VL rates and all socioeconomic and demographic indicators evaluated (P < 0.01). The concentration of interventions in high-risk areas could be an effective strategy to control the disease in the urban setting.

[Urban space and mortality from ischemic heart disease in the elderly in Rio de Janeiro]

BACKGROUND

Cardiovascular diseases are the leading cause of death in Brazil, especially among the elderly. In the city of Rio de Janeiro (RJC), ischemic heart disease (IHD) is the predominant cause of mortality. Studies show an association between the process of urbanization, socioeconomic conditions and changes in lifestyle with the occurrence of IHD.

OBJECTIVE

To describe the geographical distribution of the IHD mortality rates in the elderly of RJC in 2000 and its correlation with socioeconomic variables.

METHODS

This was an ecological study with a spatial analysis of the distribution of the IHD mortality rates in the elderly residing in RJC in 2000, standardized by gender and age, and its correlation with socioeconomic variables from the demographic census.

RESULTS

There were no strong correlations between the socioeconomic variables and IHD mortality in the elderly in the districts. Some correlations, albeit weak, showed an association between higher socioeconomic status and higher mortality. After correcting the IHD mortality rate by adding ill-defined causes (IDC) of death, an association between low socioeconomic status and higher mortality from IHD was observed. The study showed spatial dependence for socioeconomic variables, but not for mortality from IHD.

CONCLUSION

The spatial dependence observed in economic variables shows that the urban space in MRJ, although heterogeneous, has a certain amount of discrimination in the districts. Some correlations between IHD and socioeconomic variables were opposite to those found in the literature, and this may be partly related to the proportion of IDC, or to the exclusive profile of this age group.

Spatial analysis of dengue and the socioeconomic context of the city of Rio de Janeiro (Southeastern Brazil)

OBJECTIVE

To analyze the dengue epidemic in relation to the socioeconomic context according to geographical areas.

METHODS

An ecological study was conducted in the municipality of Rio de Janeiro (Southeastern Brazil), in areas delimited as neighborhoods, based on information about notified dengue cases concerning residents in the municipality. The average incidence rate of dengue was calculated between the epidemiological weeks: 48th of 2001 and 20th of 2002. The occurrence of dengue was correlated with socioeconomic variables through Pearsons' correlation coefficient. Moran's global and local indexes were used to assess the spatial auto-correlation between dengue and the variables that significantly correlated with the disease. The multiple linear regression model and the conditional auto-regression spatial model were used to analyze the relationship between dengue and socioeconomic context.

RESULTS

The neighborhoods located in the west zone of the municipality presented high rates of average dengue incidence. The variables presenting significant correlation were: percentage of households connected with the general sanitary network, households with washing machines, and population density per urban area. Moran's spatial auto-correlation index revealed spatial dependence between dengue and the selected variables. The utilized models indicated percentage of households connected with the general sanitary network as the sole variable significantly associated with the disease. The residual figures in both models revealed significant spatial auto-correlation, with a positive Moran Index (p<0.001) for linear regression model, and a negative one (p=0.005) for the conditional auto-regression one.

CONCLUSIONS

Problems related to basic sanitation contribute decisively to increase the risk of the disease.

[Socio-demographic factors and the dengue fever epidemic in 2002 in the State of Rio de Janeiro, Brazil]

This study analyzed the dengue fever epidemic in 2002 and the socio-demographic context of the State of Rio de Janeiro, Brazil, using spatial analysis and statistical modeling. The incidence rate was calculated for resident dengue cases in the State in 2002. The study analyzed associations between incidence and socio-demographic variables and spatial autocorrelation using the Moran Global Index, which showed spatial dependence for both the outcome and the independent variables. A multivariate linear regression model was used. The variables' proportion of urban population, percentage of the population with running water, and percentage of coverage by the Family Health Program (FHP) explained 30.2% of the total variance in the epidemic's incidence rate. The model's residuals did not show spatial autocorrelation. The associations were in the expected direction, and the findings are corroborated by other studies that showed higher dengue incidence in areas characterized by growing urbanization and deficient running water and water supply, while highlighting the FHP as an important facilitator of vector control strategies.

Estimativa de áreas de risco para hepatite A

Este estudo estimou áreas de risco de hepatite A e de variáveis associadas em região de Duque de Caxias, Rio de Janeiro, Brasil. Foi realizado um inquérito soroepidemiológico para hepatite A e domiciliar em 19 setores censitários. Destes, foram selecionados 11 setores contíguos com diferentes cotas altimétricas e todas as 1.298 crianças com idade menor que dez anos foram incluídas no estudo. Construiu-se semivariogramas para a hepatite A, não uso de filtro, número de pontos de água e tempo de encanamento de água. A estimativa espacial foi obtida por krigagem indicadora e ordinária. O ajuste dos modelos foi avaliado por meio de validação cruzada. Os quatro modelos ajustados de semivariogramas do desfecho e das três variáveis sócio-econômicas apresentaram um padrão isotrópico; mapas do risco estimado segundo a krigagem para hepatite A e para as variáveis sócio-econômicas foram construídos; a validação cruzada mostrou um bom ajuste. A utilização do método de estimativa espacial usando-se a krigagem possibilitou a detecção de áreas com maior probabilidade de ocorrência da hepatite A, independentemente da divisão político-administrativa dos setores censitários.

Evolução da contagem de células T CD4+ de portadores de AIDS em contextos socialmente desiguais

Este estudo analisou a evolução da contagem de células T CD4+ em portadores de AIDS do Município do Rio de Janeiro, submetidos a esquemas anti-retrovirais altamente ativos (HAART), no Centro Municipal de Saúde (CMS) da Maré, localizado em complexo de favelas e no de Copacabana, localizado em área de elites. Imediatamente, antes de HAART, a mediana de linfócitos T CD4+ foi 181células/mm³ na Maré e 182células/mm³ em Copacabana. Após 24 semanas de HAART, a mediana alcançou 302 e 315células/mm³ nos dois CMS, respectivamente. Após HAART, os portadores de AIDS da Maré tiveram 2,8 vezes mais chances de não apresentarem resposta imunológica do que casos de Copacabana (IC95%: 1,1-7,2). Residentes em favelas da Maré tiveram 3,7 mais chances de não apresentarem resposta imunológica do que não residentes em favelas de Copacabana (IC95%: 1,2-11,5). Homens da Maré tiveram 4,4 mais chances de não apresentarem resposta imunológica do que os de Copacabana (IC95%: 1,1-18,2). Resultados sugerem pior prognóstico e maior letalidade para portadores de AIDS residentes em favelas, independente do acesso a HAART.

Confiabilidade do diagnóstico final de dengue na epidemia 2001-2002 no Município do Rio de Janeiro, Brasil

Este estudo analisou a confiabilidade do diagnóstico final das 155.242 notificações de dengue da epidemia 2001-2002 no Município do Rio de Janeiro, fornecidas pela Secretaria Municipal de Saúde do Rio de Janeiro, por meio do Sistema de Informação de Agravos de Notificação (SINAN). O diagnóstico final possui como opções de preenchimento: dengue clássico, febre hemorrágica do dengue, descartado, inconclusivo e ignorado. Foi construída uma rotina em Epi Info para comparar o diagnóstico final digitado no SINAN com os critérios do Ministério da Saúde (MS), agrupando os casos como dengue clássico, dengue hemorrágico, descartado e inconclusivo (inclui ignorado). O diagnóstico final mostrou 52,4% dengue clássico, 0,6% dengue hemorrágico, 0,9% descartado e 46% de inconclusivo e ignorado, sendo que 78% de dengue clássico, 69% de dengue hemorrágico e 21,1% dos descartados preencheram os critérios do MS. A confiabilidade do diagnóstico final digitado foi em geral satisfatória (kappa = 0,681; IC95%: 0,685-0,677), porém baixa para os óbitos (kappa = 0,152; IC95%: 0,046-0,258). Considerando-se o volume da epidemia, o diagnóstico final de dengue clássico e dengue hemorrágico foi satisfatório, porém a alta proporção de casos ignorados e inconclusivos e a baixa qualidade da informação nos óbitos limitam o uso do SINAN nesse contexto.

Spatial ascariasis risk estimation using socioeconomic variables

Frequently, disease incidence is mapped as area data, for example, census tracts, districts or states. Spatial disease incidence can be highly heterogeneous inside these areas. Ascariasis is a highly prevalent disease, which is associated with poor sanitation and hygiene. Geostatistics was applied to model spatial distribution of Ascariasis risk and socioeconomic risk events in a poor community in Rio de Janeiro, Brazil. Data were gathered from a coproparasitologic and a domiciliary survey in 1550 children aged 1-9. Ascariasis risk and socioeconomic risk events were spatially estimated using Indicator Kriging. Cokriging models with a Linear Model of Coregionalization incorporating one socioeconomic variable were implemented. If a housewife attended school for less than four years, the non-use of a home water filter, a household density greater than one, and a household income lower than one Brazilian minimum wage increased the risk of Ascariasis. Cokriging improved spatial estimation of Ascariasis risk areas when compared to Indicator Kriging and detected more Ascariasis very-high risk areas than the GIS Overlay method.

AIH versus prontuário médico no estudo do risco de óbito hospitalar no infarto agudo do miocárdio no Município do Rio de Janeiro, Brasil

O objetivo deste estudo é avaliar o desempenho do Sistema de Informações Hospitalares (SIH) em relação ao prontuário médico na análise dos fatores associados à variação do risco de óbito hospitalar no infarto agudo do miocárdio. O estudo envolveu uma amostra aleatória, estratificada por hospital, de 391 prontuários médicos sorteados com base nos 1.936 formulários de Autorização de Internação Hospitalar (AIH) registrados com o diagnóstico principal de infarto agudo do miocárdio no Município do Rio de Janeiro, Brasil, em 1997. Para estudo dos fatores associados à variação do risco de óbito hospitalar foram usados modelos logísticos a partir do SIH e do prontuário, com construção de curvas ROC para comparar desempenho relativo entre eles. O diagnóstico foi confirmado em 91,7% dos casos; a letalidade foi 20,6%. O modelo desenvolvido a partir do prontuário apresentou o melhor ajuste por incluir variáveis de gravidade e processo não disponíveis no SIH (concordância = 90,1%). O modelo derivado do SIH teve um menor poder explicativo (concordância = 70,6%), mas a correção de erros de digitação e informação através do prontuário não modificou significativamente seu desempenho. A maior limitação do SIH foi o elevado sub-registro do diagnóstico secundário.

Usando redes neurais artificiais e regressão logística na predição da Hepatite A

Este trabalho desenvolve um sistema para predição da soroprevalência da Hepatite A. Para isto, são considerados os modelos de regressão de logística e redes neurais artificiais. O desempenho de tais modelos é medido através da taxa de classificação incorreta em uma amostra do município de Duque de Caxias, Rio de Janeiro, que possui elevada prevalência da doença. Resultados mostram que o modelo neural, aplicado sobre a informação relevante extraída do modelo de regressão logística, apresenta um bom desempenho, alcançando uma eficiência de classificação geral acima de 88%.

Vigilância epidemiológica e avaliação da assistência às meningites

OBJETIVO: Analisar o perfil clínico-epidemiológico dos casos de meningite internados em hospital público e os fatores associados à evolução hospitalar. MÉTODOS: Foram analisados 694 casos confirmados, notificados e investigados pelo serviço de epidemiologia de um hospital público de 1986 a 2002. Os dados foram coletados do Sistema de Informação de Agravos de Notificação (Sinan), como parte da rotina local de vigilância epidemiológica. Foi realizada análise multivariada por regressão logística. RESULTADOS: Etiologias mais freqüentes: criptocócica (12,3%; letalidade =37,7%); meningocócica (8,7%; letalidade =13,3%); pneumocócica (7,2%; letalidade =46%); tuberculosa (6,1%; letalidade =40,5%); estafilocócica (5,2%; letalidade =38,9%), viral (5,5%; letalidade =7,9%); hemófilo (2,9%; letalidade =20%). 38,8% dos casos apresentavam etiologia não especificada (letalidade =36%) e 17,3% estavam associados à infecção pelo HIV. Observou-se meningite hospitalar em 27,1% e seqüelas em 9,2% dos casos com alta hospitalar. Variáveis associadas a uma maior chance de óbito: etiologia (referência viral) - tuberculose, criptococo, estafilococo, meningococo, não especificada, outros gram negativos, cândida e pneumococo; infecção pelo HIV; coma. A tríade febre, vômitos e rigidez de nuca associou-se a uma menor chance de óbito. CONCLUSÕES: A elevada proporção de etiologia não especificada e letalidade alta podem refletir problemas de processo de assistência e/ou seleção dos casos relacionada ao perfil do hospital. A vigilância epidemiológica operante no nível hospitalar foi capaz de retro-alimentar os serviços com indicadores da assistência, sendo pertinente o uso do Sinan neste nível.

[Clinical differences observed in patients with dengue caused by different serotypes in the epidemic of 2001/2002, occurred in Rio de Janeiro]

The authors evaluated clinical and epidemiological differences among the serotypes of dengue in Rio de Janeiro's 2001-2002 outbreak of the disease. Out of 362 cases that had viral isolation samples, notified by the Information System for Notification Diseases (SINAN), from January/2001 to June/2002, 62 were caused by serotype 1,62 by serotype 2 and 238 by serotype 3. In comparison with serotype 2, an individual infected by serotype 3 had a 6.07 times higher chance (OR = 6.07; CI: 1.10-43.97) of presenting shock and a 3.55 times higher chance (OR = 3.55; CI: 1.28-9.97) of developing exanthema. When compared to serotype 1, serotype 3 had a 3.06 times higher chance (OR = 3.06; CI: 0.99-9.66) of causing abdominal pain and a 3.61 times higher chance of exanthema (OR = 3.61; CI: 1.16-11.51). It was found that individuals infected by serotype 3 of the virus presented signs indicating a more severe disease.

A epidemia de dengue/dengue hemorrágico no município do Rio de Janeiro, 2001/2002

O objetivo deste estudo foi avaliar a ocorrência dos principais sinais e sintomas dos casos de dengue clássico e dengue hemorrágico na epidemia de 2001-2002 do município do Rio de Janeiro. Foram analisados os 155.242 casos notificados ao Sistema de Informações de Agravos de Notificação, desde janeiro/2001, até junho/2002; deste total, excluindo-se os ignorados, 81.327 casos foram classificados como dengue clássico e 958 como dengue hemorrágico, com um total de 54 óbitos. Avaliaram-se as variáveis referentes à sintomatologia da doença. Manifestações gerais como febre, cefaléia, prostração, mialgia, náuseas e dor retro-orbitária tiveram alta incidência tanto no dengue clássico como no dengue hemorrágico. Por outro lado, manifestações hemorrágicas e algumas de maior gravidade como choque, hemorragia digestiva, petéquias, epistaxe, dor abdominal e derrame pleural, estiveram significativamente associadas ao dengue hemorrágico. Além disso, a evolução do quadro clínico para o óbito foi 34,8 vezes maior no dengue hemorrágico que no dengue clássico (OR=34,8; IC 19,7-61,3).

Modelagem geoestatística da infecção por Ascaris lumbricoides

O estudo tem por objetivo modelar a distribuição espacial da ocorrência de ascaríase, utilizando mapas de risco mediante técnicas de geoprocessamento e análise geoestatística. Com base no banco de dados do PAISQUA, foram selecionados 19 setores censitários do Rio de Janeiro. Foram amostradas e georreferenciadas, no centróide de seu respectivo domicílio, 1.550 crianças com idade de 1 a 9 anos. Mapas de risco de Ascaris lumbricoides foram gerados usando krigagem indicadora. Com base na validação cruzada, os valores estimados foram comparados aos observados por intermédio da curva ROC. Um modelo de semivariograma isotrópico esférico com alcance de 30m e efeito pepita de 50% foi empregado na krigagem ordinária indicadora para a construção de um mapa de probabilidade de infecção por A. lumbricoides. A acurácia global, mensurada por meio da área sob a curva ROC, mostrou-se significativa. O uso da krigagem ordinária indicadora permitiu a modelagem de mapas de risco valendo-se da amostra de uma variável indicadora. O emprego das técnicas de análise estatística espacial mostrou-se adequado na predição da ocorrência do fenômeno, não ficando restrita a delimitações político-administrativas da região.

Análise espacial da soroprevalência da hepatite A em crianças de uma região carente de Duque de Caxias, RJ, Brasil

Os autores estimaram áreas de risco para hepatite A em quatro setores censitários de Duque de Caxias, Rio de Janeiro, área de intervenção ambiental do Programa de Despoluição da Baía de Guanabara, a partir de um inquérito de soroprevalência para hepatite A em crianças residentes nesta localidade. A amostra consistiu de 454 crianças com idade entre 1 e 9 anos, selecionadas através de amostra aleatória simples em cada grupo etário. Foram coletadas alíquotas de sangue para detecção de anticorpos totais para hepatite A pela técnica de ELISA. Entrevistas domiciliares foram realizadas para obtenção de informações sobre as condições físicas e sanitárias dos domicílios e peridomicílios, assim como as condições socioeconômicas das famílias. Com a utilização de técnicas geoestatísticas, foi possível definir áreas de risco para a ocorrência da hepatite A de forma mais precisa, não se restringindo apenas aos limites dos setores censitários da região de estudo.

Acute myocardial infarction: clinical and epidemiological profile and factors associated with in-hospital death in the municipality of Rio de Janeiro

OBJECTIVE

To study the factors associated with the risk of in-hospital death in acute myocardial infarction in the Brazilian public health system in Rio de Janeiro, Brazil.

METHODS

Sectional study of a sample with 391 randomly drawn medical records of the hospitalizations due to acute myocardial infarction recorded in the hospital information system in 1997.

RESULTS

The diagnosis was confirmed in 91.7% of the cases; 61.5% males; age = 60.2 +/- 2.4 years; delta time until hospitalization of 11 hours; 25.3% were diabetic; 58.1% were hypertensive; 82.6% were in Killip I class. In-hospital mortality was 20.6%. Thrombolysis was used in 19.5%; acetylsalicylic acid (ASA) 86.5%; beta-blockers 49%; angiotensin-converting enzyme (ACE) inhibitors 63.3%; calcium channel blockers 30.5%. Factors associated with increased death: age (61-80 years: OR=2.5; > 80 years: OR=9.6); Killip class (II: OR=1.9; III: OR=6; IV: OR=26.5); diabetes (OR=2.4); ventricular tachycardia (OR=8.5); ventricular fibrillation (OR=34); recurrent ischemia (OR=2.7). The use of ASA (OR=0.3), beta-blockers (OR=0.3), and ACE inhibitors (OR=0.4) was associated with a reduction in the chance of death.

CONCLUSION

General lethality was high and some interventions of confirmed efficacy were underutilizated. The logistic model showed the beneficial effect of beta-blockers, and ACE inhibitors on the risk of in-hospital death.