Feeding characteristics and growth among children with prenatal exposure to Zika virus with and without microcephaly in the microcephaly epidemic research group pediatric cohort

OBJECTIVE

To describe the feeding characteristics and growth of children with prenatal exposure to Zika virus (ZIKV) from birth to 48 months.

DESIGN

Using data from the prospective Microcephaly Epidemic Research Group Pediatric Cohort (MERG-PC), children without microcephaly born to mothers with evidence of ZIKV infection during pregnancy (ZIKV-exposed children without microcephaly) and children with Zika-related microcephaly were compared using repeated cross-sectional analyses within the following age strata: birth; 1 to 12; 13 to 24; 25 to 36; and 37 to 48 months. The groups were compared in relation to prematurity, birth weight, breastfeeding, alternative feeding routes, dysphagia and anthropometric profiles based on the World Health Organization Anthro z-scores (weight-length/height, weight-age, length/height-age and BMI-age).

RESULTS

The first assessment included 248 children, 77 (31.05%) with microcephaly and 171 (68.95%) without microcephaly. The final assessment was performed on 86 children. Prematurity was 2.35 times higher and low birth weight was 3.49 times higher in children with microcephaly. The frequency of breastfeeding was high (> 80%) in both groups. On discharge from the maternity hospital, the frequency of children requiring alternative feeding route in both groups was less than 5%. After 12 months of age, children with microcephaly required alternative feeding route more often than children without microcephaly. In children with microcephaly, the z-score of all growth indicators was lower than in children without microcephaly.

CONCLUSIONS

Children with Zika-related microcephaly were more frequently premature and low birth weight and remained with nutritional parameters, i.e., weight-for-age, weight-for-length/height and length/height-for-age below those of the children without microcephaly.

Survival and mortality profile among people living with HIV in a cohort in the Northeastern region of Brazil

Conditions related to the acquired immune deficiency syndrome (AIDS) are still a significant cause of morbidity and mortality among people living with HIV (PLHIV). Longer survival in this population were reported to increase the risk of developing noncommunicable chronic diseases (NCDs). This study aimed to estimate the survival and causes of death according to age group and sex among PLHIV monitored at two referral centers in the Northeastern Brazil. This is a prospective, retrospective cohort with death records from 2007 to 2018, based on a database that registers causes of death using the International Classification of Disease (ICD-10), which were subsequently coded following the Coding Causes of Death in HIV (CoDe). A total of 2,359 PLHIV participated in the study, with 63.2% being men, with a follow-up period of 13.9 years. Annual mortality rate was 1.46 deaths per 100 PLHIV (95% CI: 1.33 - 1.60) with a frequency of 20.9%. Risk of death for men increased by 49% when compared to women, and the risk of death in PLHIV increased by 51% among those aged 50 years and over at the time of diagnosis. It was observed that 73.5% accounted for AIDS-related deaths, 6.9% for non-AIDS defining cancer, 6.3% for external causes, and 3.2% for cardiovascular diseases. Among the youngest, 97.2% presented an AIDS-related cause of death. Highest frequency of deaths from neoplasms was among women and from external causes among men. There is a need for health services to implement strategies ensuring greater adherence to treatment, especially among men and young people. Moreover, screening for chronic diseases and cancer is essential, including the establishment of easily accessible multidisciplinary care centers that can identify and address habits such as illicit drug use and alcoholism, which are associated with violent deaths.

Hematological Changes during Seven Days of Hospitalization in Patients with Acute Myocardial Infarction

BACKGROUND

Acute myocardial infarction is a major cause of mortality worldwide, and atherosclerotic plaque formation is the main pathophysiological mechanism, which results in chronic inflammation that induces erythrocyte maturation and may cause an increase in the red cell distribution width (RDW) index.

OBJECTIVE

Evaluate the role of the anisocytosis index in patients with acute myocardial infarction in both types of infarctions as a predictor of severity.

METHODS

Patients were included in the study according to the inclusion/exclusion criteria, following the hospital routine based on their clinical and laboratory history. Statistical analyzes were performed according to each variable. All conclusions were drawn considering the significance level of 5%.

RESULTS

During the follow-up period, in the 349 patients analyzed, the mortality rate was associated with the variables RDW (CV) and RDW (SD), in those patients who died, an increase was noted, as demonstrated in the multivariate model, for the effects of an acute ST elevation myocardial infarction and the RDW, adjusted for confounding factors (p-value = 0.03 and 0.04). In contrast, the total number of erythrocytes (p-value = 0.00) and hemoglobin (p-value = 0.03) showed a decrease during severe patients' hospitalization.

CONCLUSION

The anisocytosis index was a predictive factor of mortality and can be used as an indicator of worse prognosis in patients with acute myocardial infarction.

Interferon-gamma gene diplotype (AA-rs2069716 / AG-rs2069727) may play an important role during secondary outcomes of severe dengue in Brazilian patients

Dengue is a global and growing health threat, especially in Southeast Asia, West Pacific and South America. Infection by the dengue virus (DENV) results in dengue fever, which can evolve to severe forms. Cytokines, especially interferons, are involved in the immunopathogenesis of dengue fever, and so may influence the disease outcomes. The aim of this study was to investigate the association between severe forms of dengue and two single nucleotide polymorphisms (SNPs) in the interferon-gamma gene (IFNG): A256G (rs2069716) and A325G (rs2069727). We included 274 patients infected with DENV serotype 3: 119 cases of dengue without warning signs (DWoWS), and 155 with warning signs (DWWS) or severe dengue (SD). DNA was extracted, and genotyped with Illumina Genotyping Kit or real time PCR (TaqMan probes). We estimated the adjusted Odds Ratios (OR) by multivariate logistic regression models. When comparing with the ancestral AA/AA diplotype (A256G/A325G), we found a protective association of the AA/AG against DWWS/SD among patients with secondary dengue (OR 0.51; 95% IC 0.24-1.10, p = 0.085), adjusting for age and sex. The variant genotype at locus A325G of the IFNG, in combination with the ancestral genotype at locus A256G, can protect against severe clinical forms of secondary dengue in Brazilian DENV3-infected patients.

Impact of the COVID-19 pandemic on the mental health of frontline healthcare workers in a highly affected region in Brazil

BACKGROUND

The COVID-19 pandemic had a major impact on the mental health of healthcare workers (HCWs), especially in low and middle-income countries, which had to face additional political, social, and economic challenges. We thus aimed to assess the prevalence of mental health outcomes and the associated factors in HCWs treating COVID-19 patients in one of the most affected regions in Brazil.

METHODS

We used the Respondent-Driven Sampling method to assess the risks of COVID-19 infection and symptoms of mental disorders in nurses, nursing technicians, and physicians who worked on the frontline in the metropolitan region of Recife. 865 healthcare workers completed a survey regarding sociodemographic data, work-related risks, and symptoms of mental disorders - SRQ-20 for common mental disorders (CMD); AUDIT-C for problematic alcohol use; GAD-7 for anxiety; PHQ-9 for depression; PCL-5 for post-traumatic stress disorder (PTSD). Gile's successive sampling estimator was used to produce the weighted estimates by professional category. A Poisson regression model with robust variance was used to analyze factors associated with a positive screening for CMD. We will present the results of a cross-sectional analysis of the mental health outcomes after the first peak of COVID-19 - from August 2020 to February 2021.

RESULTS

The prevalence ratios for a positive screening for CMD were 34.9% (95% CI: 27.8-41.9) in nurses, 28.6% (95% CI: 21.3-36.0) in physicians, and 26.6% (95% CI: 16.8-36.5) in nursing technicians. Nurses presented a higher prevalence of depressive symptoms (23%). Positive screening for problematic alcohol use (10.5 to14.0%), anxiety (10.4 to 13.3%), and PTSD (3.3 to 4.4%) were similar between the professional categories. The main factors associated with CMD in nurses and physicians were related to an intrinsic susceptibility to mental illness, such as previous or family history of psychiatric disorder, and female sex. Among nurse technicians, work-related factors, such as accidents with biological material, presented the strongest association with CMD.

CONCLUSION

The mental health of HCWs fighting COVID-19 in Recife was severely affected. It is crucial that healthcare services provide adequate working conditions and psychological support, investing in programs to promote and protect HCWs mental health.

Heart rate variability as a predictor of mechanical ventilation weaning outcomes

BACKGROUND

Delays in the mechanical ventilation (MV) weaning process increase mortality. The spontaneous breathing test is the gold standard to assess weaning and extubation success, although it has approximately 85% accuracy. Studies have demonstrated a correlation between decreased heart rate variability (HRV) and weaning failure.

OBJECTIVES

To assess the usefulness of HRV as a predictor of MV weaning outcomes.

METHODS

Cross-sectional analytical study in adults of both sexes on MV in intensive care unit (ICU) stay. Patients were divided into weaning success and failure groups. Clinical data were collected, and HRV records were obtained with a heart rate monitor.

RESULTS

The study included 68 individuals - 91.1% in the weaning success group and 8.9% in the failure group. All HRV indices analyzed in both groups were lower than the reference values. No statistical difference was found in the mean RR interval (RRi), the standard deviation of the NN interval (SDNN), and the square root of the mean squared differences of successive NN intervals (RMSSD) between the groups. The weaning failure group had a significant increase in LF (41 vs. 69.4) and LF/HF ratio (0.685 vs. 2.6) and a significant decrease in HF (58.85 vs. 30.2).

CONCLUSIONS

HRV measure with spectral analysis can be a good predictor of MV weaning failure. Integrating this assessment tool in ICU to predict weaning outcomes could provide more precise prognoses and more adequate assistance quality.

Risk of adverse outcomes in offspring with RT-PCR confirmed prenatal Zika virus exposure: An individual participant data meta-analysis of 13 cohorts in the Zika Brazilian Cohorts Consortium

Background

Knowledge regarding the risks associated with Zika virus (ZIKV) infections in pregnancy has relied on individual studies with relatively small sample sizes and variable risk estimates of adverse outcomes, or on surveillance or routinely collected data. Using data from the Zika Brazilian Cohorts Consortium, this study aims, to estimate the risk of adverse outcomes among offspring of women with RT-PCR-confirmed ZIKV infection during pregnancy and to explore heterogeneity between studies.

Methods

We performed an individual participant data meta-analysis of the offspring of 1548 pregnant women from 13 studies, using one and two-stage meta-analyses to estimate the absolute risks.

Findings

Of the 1548 ZIKV-exposed pregnancies, the risk of miscarriage was 0.9%, while the risk of stillbirth was 0.3%. Among the pregnancies with liveborn children, the risk of prematurity was 10,5%, the risk of low birth weight was 7.7, and the risk of small for gestational age (SGA) was 16.2%. For other abnormalities, the absolute risks were: 2.6% for microcephaly at birth or first evaluation, 4.0% for microcephaly at any time during follow-up, 7.9% for neuroimaging abnormalities, 18.7% for functional neurological abnormalities, 4.0% for ophthalmic abnormalities, 6.4% for auditory abnormalities, 0.6% for arthrogryposis, and 1.5% for dysphagia. This risk was similar in all sites studied and in different socioeconomic conditions, indicating that there are not likely to be other factors modifying this association.

Interpretation

This study based on prospectively collected data generates the most robust evidence to date on the risks of congenital ZIKV infections over the early life course. Overall, approximately one-third of liveborn children with prenatal ZIKV exposure presented with at least one abnormality compatible with congenital infection, while the risk to present with at least two abnormalities in combination was less than 1.0%.

Profile of judicialization in access to antineoplastic drugs and their costs: a cross-sectional, descriptive study based on a set of all lawsuits filed between 2016 and 2018 in a state in the Northeast Region of Brazil

Background

The judicialization of the acquisition of medication for healthcare is not restricted to Brazil but can also be found in other Latin American countries, despite the existence of a universal health system in the case of Brazil, the Unified Health System (known as the SUS). Right-to-medicines litigation has existed ever since the emergence of a high demand for treatment of Acquired Immuno-deficiency Syndrome (AIDS) but the current focus is on cancer. Pharmaceutical Assistance (PA) is the area within the SUS that is responsible for ensuring access to medication and the aim of this article is thus to draw up a profile of litigation related to PA in one economically significant state in the Northeast Region of Brazil, in terms of the following characteristics of lawsuits: the plaintiff filing the lawsuit; medical and health information; the cost of acquiring the requested medications; and the proportion accounted for by spending on antineoplastic drugs.

Methods

A cross-sectional, descriptive study was conducted of lawsuits filed between 2016 and 2018 at the Litigation Center of the State of Pernambuco Department of Health.

Results

A total of 2,947 lawsuits containing at least one requested medication were analyzed. The majority of the plaintiffs were male (51.7%); 49.8% of the requests originated in the Unified Health System (SUS), and plaintiffs were primarily patients in the Metropolitan region of the State capital, Recife. The most frequent cancers involved were those classified by the ICD as C61, C71 and C50. The median general expense on medications for the actions was U$1,734.94. Considering antineoplastic drugs alone, the cost exceeded U$7,500 per lawsuit over the three years, given that the median unit price for antineoplastic drugs is approximately US$65 compared to US$4 for non-antineoplastic drugs.

Conclusion

The present study is of relevance to the field of public health and examines how a profile of such healthcare litigation can be used as a tool for managing and improving decision-making in times of economic austerity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14199-1.

HIV Pre-Exposure Prophylaxis (PrEP) in a Brazilian Clinical Setting: Adherence, Adverse Events, Sexual Behavior, and Sexually Transmitted Infections

Tenofovir/emtricitabine (TDF/FTC) has been used as pre-exposure prophylaxis (PrEP) in preventing HIV infection. PrEP is an effective prevention tool as demonstrated in clinical trials and studies in clinical practice and was incorporated into the Brazilian public health system in December 2017. The present study was a prospective cohort that included 219 PrEP users monitored over a 10 month follow-up period in a capital city in Northeastern Brazil. Data were collected from the PrEP users' electronic medical records platform made available by the Brazilian Health Ministry. During the observation period, there was good user retention to the prevention program (84%) and there was high adherence to medication (90%). Almost half the users (49%) presented an adverse event, although these were mild and transient, 30 days after starting prophylaxis. There was a significant reduction in creatinine clearance (p < .001), from 104.9 to 83.5 mL/min; however, there was no need for drug discontinuation. Throughout the cohort, there was no significant change in the number of sexual partners, but the use of condoms during sexual intercourse decreased (p < .001). There was a non-significant increase in the incidence of syphilis (p = .08), and there was a 50% decrease in reporting signs and symptoms of sexually transmitted infections. No cases of HIV infection were observed. PrEP proved to be an effective tool in HIV prevention, presenting few complications of adverse events.

Risk of SARS-CoV-2 infection among front-line healthcare workers in Northeast Brazil: a respondent-driven sampling approach

OBJECTIVES

We assessed the prevalence of SARS-CoV-2 infection, personal protective equipment (PPE) shortages and occurrence of biological accidents among front-line healthcare workers (HCW).

DESIGN, SETTING AND PARTICIPANTS

Using respondent-driven sampling, the study recruited distinct categories of HCW attending suspected or confirmed patients with COVID-19 from May 2020 to February 2021, in the Recife metropolitan area, Northeast Brazil.

OUTCOME MEASURES

The criterion to assess SARS-CoV-2 infection among HCW was a positive self-reported PCR test.

RESULTS

We analysed 1525 HCW: 527 physicians, 471 registered nurses, 263 nursing assistants and 264 physical therapists. Women predominated in all categories (81.1%; 95% CI: 77.8% to 84.1%). Nurses were older with more comorbidities (hypertension and overweight/obesity) than the other staff. The overall prevalence of SARS-CoV-2 infection was 61.8% (95% CI: 55.7% to 67.5%) after adjustment for the cluster random effect, weighted by network, and the reference population size. Risk factors for a positive RT-PCR test were being a nursing assistant (OR adjusted: 2.56; 95% CI: 1.42 to 4.61), not always using all recommended PPE while assisting patients with COVID-19 (OR adj: 2.15; 95% CI: 1.02 to 4.53) and reporting a splash of biological fluid/respiratory secretion in the eyes (OR adj: 3.37; 95% CI: 1.10 to 10.34).

CONCLUSIONS

This study shows the high frequency of SARS-CoV2 infection among HCW presumably due to workplace exposures. In our setting, nursing assistant comprised the most vulnerable category. Our findings highlight the need for improving healthcare facility environments, specific training and supervision to cope with public health emergencies.

Co-circulation of Chikungunya Virus during the 2015-2017 Zika Virus Outbreak in Pernambuco, Brazil: An Analysis of the Microcephaly Epidemic Research Group Pregnancy Cohort

Co-circulation of arthropod-borne viruses, particularly those with shared mosquito vectors like Zika (ZIKV) and Chikungunya (CHIKV), is increasingly reported. An accurate differential diagnosis between ZIKV and CHIKV is of high clinical importance, especially in the context of pregnancy, but remains challenging due to limitations in the availability of specialized laboratory testing facilities. Using data collected from the prospective pregnancy cohort study of the Microcephaly Epidemic Research Group, which followed up pregnant persons with rash during the peak and decline of the 2015-2017 ZIKV epidemic in Recife, Pernambuco, Brazil, this study aims to describe the geographic and temporal distribution of ZIKV and CHIKV infections and to investigate the extent to which ZIKV and CHIKV infections may be clinically differentiable. Between December 2015 and June 2017, we observed evidence of co-circulation with laboratory confirmation of 213 ZIKV mono-infections, 55 CHIKV mono-infections, and 58 sequential ZIKV/CHIKV infections (i.e., cases with evidence of acute ZIKV infection with concomitant serological evidence of recent CHIKV infection). In logistic regressions with adjustment for maternal age, ZIKV mono-infected cases had lower odds than CHIKV mono-infected cases of presenting with arthralgia (aOR, 99% CI: 0.33, 0.15-0.74), arthritis (0.35, 0.14-0.85), fatigue (0.40, 0.17-0.96), and headache (0.44, 0.19-1.90). However, sequential ZIKV/CHIKV infections complicated discrimination, as they did not significantly differ in clinical presentation from CHIKV mono-infections. These findings suggest clinical symptoms alone may be insufficient for differentiating between ZIKV and CHIKV infections during pregnancy and therefore laboratory diagnostics continue to be a valuable tool for tailoring care in the event of arboviral co-circulation.

Modelagem das covariáveis preditivas para falência do enxerto renal até seis meses do transplante

Introdução: Transplante renal (TR) é a terapia renal substitutiva (TRS) de escolha para pacientes com doença renal crônica (DRC). Entretanto, nem todo TR é bem-sucedido e alguns pacientes persistem em TRS. Objetivo: Modelar uma regressão logística com covariáveis de risco pré e pós-TR preditora da disfunção secundária do aloenxerto com necessidade de TRS ou alcance ao estágio V da DRC até os primeiros seis meses pós-TR. Métodos: Coorte com receptores transplantados realizado em hospital no Nordeste brasileiro. Analisou-se registros médicos dos TR realizados entre 2011-2018. Receptores com dados insuficientes ou que abandonaram seguimento foram excluídos. Foram analisadas covariáveis: demográficas; infecciosas; comorbidades pré e pós-TR; painel de reatividade; incompatibilidades de HLA; episódios de rejeições agudas mediadas por células-T ou por anticorpos; exames laboratoriais seis meses pós-TR. Resultados: Receptores idosos (OR:1,41; IC95%:1,01-1,99), tempo entre início da TRS e TR (∆T-TRS&TR)>10 anos (OR:3,54; IC95%:1,27-9,87), diabetes mellitus (DM) pré-TR (OR:3,35; IC95%:1,51-7,46), pielonefrite (OR:2,45; IC95%:1,24-4,84), nefropatia por poliomavírus (OR:4,99; IC95%:1,87-13,3), RAMA (OR:4,82; IC95%:1,35-17,2), proteinúria de 24h (Pt24h) ≥300mg/24h (OR:5,05; IC95%:2,00-12,7) e cálcio sérico (Ca)<8,5mg/dL (OR:4,72; IC95%:2,00-11,1) foram identificadas como covariáveis de maior risco para os desfechos analisados até seis meses pós-TR. O modelo multivariado apresentou acurácia de 88,1% e fator de inflação da variância médio de 1,81. Conclusão: Receptores idosos, ∆T-TRS&TR>10anos, DM pré-TR e agressões até seis meses pós-TR (pielonefrite, nefropatia por poliomavírus, RAMA, Pt24h≥300mg/24h e Ca<8,5mg/dL), apresentam alto poder preditivo para disfunção secundária do aloenxerto com necessidade de TRS ou alcance ao estágio V da DRC até os primeiros seis meses pós-TR.

Neighbourhood-level income and Zika virus infection during pregnancy in Recife, Pernambuco, Brazil: an ecological perspective, 2015-2017

Zika virus (ZIKV) infections during pregnancy can lead to adverse neurodevelopmental and clinical outcomes in congenitally infected offspring. As the city of Recife in Pernambuco State, Brazil—the epicentre of the Brazilian microcephaly epidemic—has considerable disparities in living conditions, this study used an ecological approach to investigate the association between income at the neighbourhood level and the risk of ZIKV infections in pregnant individuals between December 2015 and April 2017. The spatial distribution of pregnant individuals with ZIKV infection was plotted on a map of Recife stratified into four categories based on mean monthly income of household heads. Additionally, a Poisson regression model with robust variance was fitted to compare proportions of ZIKV infections among pregnant individuals in relation to the mean monthly income of household heads, based on the 2010 census data, across 94 neighbourhoods in Recife. The results provide evidence that the risk of ZIKV infection to pregnant individuals was higher among those residing in lower-income neighbourhoods: relative to neighbourhoods that had a mean monthly income of ≥5 times minimum wage, neighbourhoods with <1 and 1 to <2 times minimum wage had more than four times the risk (incidence rate ratio, 95% CI 4.08, 1.88 to 8.85 and 4.30, 2.00 to 9.20, respectively). This study provides evidence of a strong association between neighbourhood-level income and ZIKV infection risks in the pregnant population of Recife. In settings prone to arboviral outbreaks, locally targeted interventions to improve living conditions, sanitation, and mosquito control should be a key focus of governmental interventions to reduce risks associated with ZIKV infections during pregnancy.

Zika Brazilian Cohorts (ZBC) Consortium: Protocol for an Individual Participant Data Meta-Analysis of Congenital Zika Syndrome after Maternal Exposure during Pregnancy

Despite great advances in our knowledge of the consequences of Zika virus to human health, many questions remain unanswered, and results are often inconsistent. The small sample size of individual studies has limited inference about the spectrum of congenital Zika manifestations and the prognosis of affected children. The Brazilian Zika Cohorts Consortium addresses these limitations by bringing together and harmonizing epidemiological data from a series of prospective cohort studies of pregnant women with rash and of children with microcephaly and/or other manifestations of congenital Zika. The objective is to estimate the absolute risk of congenital Zika manifestations and to characterize the full spectrum and natural history of the manifestations of congenital Zika in children with and without microcephaly. This protocol describes the assembly of the Consortium and protocol for the Individual Participant Data Meta-analyses (IPD Meta-analyses). The findings will address knowledge gaps and inform public policies related to Zika virus. The large harmonized dataset and joint analyses will facilitate more precise estimates of the absolute risk of congenital Zika manifestations among Zika virus-infected pregnancies and more complete descriptions of its full spectrum, including rare manifestations. It will enable sensitivity analyses using different definitions of exposure and outcomes, and the investigation of the sources of heterogeneity between studies and regions.

Prevalence of trachoma in Pernambuco State, Brazil (2014-2015)

To estimate the prevalence of cases of trachoma in the population at social risk aged 1-9 years in Pernambuco State and its mesoregions. This was a cross-sectional study in which secondary data from the National Household Survey on Trachoma (2014-2015) were analyzed. The study covered 96 census tracts distributed across the mesoregions of Pernambuco State (Metropolitan Region of Recife, Zona da Mata, Agreste, Sertao do Sao Francisco and Sertao Pernambucano). The study included all homes with children aged 1-9 years, and all of them were examined for trachoma, using the WHO criteria. Among the total of 7,423 children aged 1-9 years who participated in this survey, 446 presented with active trachoma. Thus, the prevalence of trachoma in Pernambuco State, in children between 1-9 years old was 6.65%, and it was higher among children aged 5-9 years (7.12%) and among girls (7.23%). This result was seen in the majority of the mesoregions studied, except in the Zona da Mata and Sertao do Sao Francisco, where there were higher prevalences in the age group of 1-4 years (5.55%) and among boys (5.90%). A tendency towards a higher prevalence between 1 and 6 years of age was observed. The follicular trachoma continues to be an important public health problem in Pernambuco State. It particularly affects poor people, including those living in urban areas of the State.

The Microcephaly Epidemic Research Group Paediatric Cohort (MERG-PC): A Cohort Profile

This cohort profile aims to describe the ongoing follow-up of children in the Microcephaly Epidemic Research Group Paediatric Cohort (MERG–PC). The profile details the context and aims of the study, study population, methodology including assessments, and key results and publications to date. The children that make up MERG–PC were born in Recife or within 120 km of the city, in Pernambuco/Brazil, the epicentre of the microcephaly epidemic. MERG–PC includes children from four groups recruited at different stages of the ZIKV microcephaly epidemic in Pernambuco, i.e., the Outpatient Group (OG/n = 195), the Microcephaly Case–Control Study (MCCS/n = 80), the MERG Pregnant Women Cohort (MERG-PWC/n = 336), and the Control Group (CG/n = 100). We developed a comprehensive array of clinical, laboratory, and imaging assessments that were undertaken by a ‘task force’ of clinical specialists in a single day at 3, 6, 12, 18 months of age, and annually from 24 months. Children from MCCS and CG had their baseline assessment at birth and children from the other groups, at the first evaluation by the task force. The baseline cohort includes 711 children born between February 2015 and February 2019. Children’s characteristics at baseline, excluding CG, were as follows: 32.6% (184/565) had microcephaly, 47% (263/559) had at least one physical abnormality, 29.5% (160/543) had at least one neurological abnormality, and 46.2% (257/556) had at least one ophthalmological abnormality. This ongoing cohort has contributed to the understanding of the congenital Zika syndrome (CZS) spectrum. The cohort has provided descriptions of paediatric neurodevelopment and early epilepsy, including EEG patterns and treatment response, and information on the frequency and characteristics of oropharyngeal dysphagia; cryptorchidism and its surgical findings; endocrine dysfunction; and adenoid hypertrophy in children with Zika-related microcephaly. The study protocols and questionnaires were shared across Brazilian states to enable harmonization across the different studies investigating microcephaly and CZS, providing the opportunity for the Zika Brazilian Cohorts Consortium to be formed, uniting all the ZIKV clinical cohorts in Brazil.

Endocrine Dysfunction in Children with Zika-Related Microcephaly Who Were Born during the 2015 Epidemic in the State of Pernambuco, Brazil

Congenital viral infections and the occurrence of septo-optic dysplasia, which is a combination of optic nerve hypoplasia, abnormal formation of structures along the midline of the brain, and pituitary hypofunction, support the biological plausibility of endocrine dysfunction in Zika-related microcephaly. In this case series we ascertained the presence and describe endocrine dysfunction in 30 children with severe Zika-related microcephaly from the MERG Pediatric Cohort, referred for endocrinological evaluation between February and August 2019. Of the 30 children, 97% had severe microcephaly. The average age at the endocrinological consultation was 41 months and 53% were female. The most frequently observed endocrine dysfunctions comprised short stature, hypothyroidism, obesity and variants early puberty. These dysfunctions occurred alone 57% or in combination 43%. We found optic nerve hypoplasia (6/21) and corpus callosum hypoplasia (20/21). Seizure crises were reported in 86% of the children. The most common-and clinically important-endocrine dysfunctions were pubertal dysfunctions, thyroid disease, growth impairment, and obesity. These dysfunctions require careful monitoring and signal the need for endocrinological evaluation in children with Zika-related microcephaly, in order to make early diagnoses and implement appropriate treatment when necessary.

The first hundred days of COVID-19 in Pernambuco State, Brazil: epidemiology in historical context

The timeline of the COVID-19 pandemic began on December 31, 2019, in China, with SARS-CoV-2 identified as the etiological agent. This article aims to describe the COVID-19 epidemic's spatial and temporal dynamics in the first hundred days in the State of Pernambuco, Brazil. We present the evolution in cases and deaths according to epidemiological weeks. We analyzed the series of accumulated daily confirmed COVID-19 cases, with projections for the subsequent 15 days, using the JoinPoint app. This software allows identifying turning points, testing their statistical significance. We also analyze the trend in the spread of COVID-19 to the interior of the state, considering the percent distribution of cases in the state capital, Recife, municipalities in Greater Metropolitan Recife, and the state's interior, by sets of three weeks, constructing thematic maps. The first hundred days of the COVID-19 epidemic resulted in 52,213 cases and 4,235 deaths from March 12, or epidemiological week 11, until June 20, 2020 (epidemiological week 25). The peak in the epidemic curve occurred in epidemiological week 21 (May 23), followed by deceleration in the number of cases. We initially detected the spread of cases from the city center to the periphery of the state capital and Metropolitan Area, followed by rapid spread to the state's interior. There was a decrease in the mean daily growth starting in April, but with an average threshold of more than 6,000 weekly cases of COVID-19. At the end of the period, the state's case series indicates the persistence of SARS-CoV-2 circulation and community transmission. Finally, paraphrasing Gabriel Garcia Marques in One Hundred Years of Solitude, we ask whether we are facing "a pause in the storm or a sign of redoubled rain".

Zika virus infection in pregnancy: a protocol for the joint analysis of the prospective cohort studies of the ZIKAlliance, ZikaPLAN and ZIKAction consortia

INTRODUCTION

Zika virus (ZIKV) infection in pregnancy has been associated with microcephaly and severe neurological damage to the fetus. Our aim is to document the risks of adverse pregnancy and birth outcomes and the prevalence of laboratory markers of congenital infection in deliveries to women experiencing ZIKV infection during pregnancy, using data from European Commission-funded prospective cohort studies in 20 centres in 11 countries across Latin America and the Caribbean.

METHODS AND ANALYSIS

We will carry out a centre-by-centre analysis of the risks of adverse pregnancy and birth outcomes, comparing women with confirmed and suspected ZIKV infection in pregnancy to those with no evidence of infection in pregnancy. We will document the proportion of deliveries in which laboratory markers of congenital infection were present. Finally, we will investigate the associations of trimester of maternal infection in pregnancy, presence or absence of maternal symptoms of acute ZIKV infection and previous flavivirus infections with adverse outcomes and with markers of congenital infection. Centre-specific estimates will be pooled using a two-stage approach.

ETHICS AND DISSEMINATION

Ethical approval was obtained at each centre. Findings will be presented at international conferences and published in peer-reviewed open access journals and discussed with local public health officials and representatives of the national Ministries of Health, Pan American Health Organization and WHO involved with ZIKV prevention and control activities.

Incidence and spatial distribution of cases of dengue, from 2010 to 2019: an ecological study

BACKGROUND

Dengue is an arbovirus that has caused serious problem in Brazil, putting the public health system under severe stress. Understanding its incidence and spatial distribution is essential for disease control and prevention.

OBJECTIVE

To perform an analysis on dengue incidence and spatial distribution in a medium-sized, cool-climate and high-altitude city.

DESIGN AND SETTING

Ecological study carried out in a public institution in the city of Garanhuns, Pernambuco, Brazil.

METHODS

Secondary data provided by specific agencies in each area were used for spatial analysis and elaboration of kernel maps, incidence calculations, correlations and percentages of dengue occurrence. The Geocentric Reference System for the Americas (Sistema de Referência Geocêntrico para as Américas, SIRGAS), 2000, was the software of choice.

RESULTS

The incidence rates were calculated per 100,000 inhabitants. Between 2010 and 2019, there were 6,504 cases and the incidence was 474.92. From 2010 to 2014, the incidence was 161.46 for a total of 1,069 cases. The highest incidence occurred in the period from 2015 to 2019: out of a total of 5,435 cases, the incidence was 748.65, representing an increase of 485.97%. Population density and the interaction between two climatic factors, i.e. atypical temperature above 31 °C and relative humidity above 31.4%, contributed to the peak incidence of dengue, although these variables were not statistically significant (P > 0.05).

CONCLUSION

The dengue incidence levels and spatial distribution reflected virus and vector adjustment to the local climate. However, there was no correlation between climatic factors and occurrences of dengue in this city.

Torcular dural sinus malformations: a grading system proposal

BACKGROUND

Torcular dural sinus malformations (tDSMs) are congenital complex vascular anomalies often referred as a single unit. Nevertheless, they possess distinct anatomical features, clinical diversity, and markedly different outcomes.

OBJECTIVE

On the basis of our institutional experience and analysis of published data, we propose a grading system.

METHODS

We have identified 44 papers to which we added our four institutional cases for a total of 126 patients. Eight predictor variables were studied. In order to assess their individual impact on mortality and possible correlations, a logistic regression model was constructed through a stepwise forward process.

RESULTS

Overall mortality was 22.1%. Mortality was higher in tDSM patients diagnosed postnatally, 40.7% versus a 15.6% in prenatally found cases (p = 0.007). We divided the patients into four grades. Grade I comprised patients with no feeder evidence and possessed the best outcomes (mortality of 7.55%). Mortality rose for grades II and III defined respectively by scarce and multiple feeders. Brain damage was the defining feature of grade IV. A mortality of 75% could be observed within this grade. Grade IV was further divided into grades IVa (antenatal) and IVb (postnatal cases). Furthermore, our logistic regression model found that brain damage (OR 11.3, p < 0.001, 95% CI 2.97-42.91) and patent feeders (OR 4, p = 0.03, 95% CI 1.15-13.86) were major determinants of poor outcome (area under ROC curve of 81.44%).

CONCLUSION

The grading system (tDSM-GS) streamlines classification into four different grades facilitating both diagnosis, clinical decision-making, and proper prognostication.

Pediatric neurodevelopment by prenatal Zika virus exposure: a cross-sectional study of the Microcephaly Epidemic Research Group Cohort

Background

The implications of congenital Zika Virus (ZIKV) infections for pediatric neurodevelopment and behavior remain inadequately studied. The aim of this study is to investigate patterns of neurodevelopment and behavior in groups of children with differening severities of ZIKV-related microcephaly and children with prenatal ZIKV exposure in the absence of microcephaly.

Methods

We conducted a cross-sectional study, nested in a cohort, of 274 children (aged 10–45 months) who were born during the peak and decline of the microcephaly epidemic in Northeast Brazil. Participants were evaluated between February 2017 and August 2019 at two tertiary care hospitals in Recife, Pernambuco, Brazil. We analyzed the children in four groups assigned based on clinical and laboratory criteria: Group 1 had severe microcephaly; Group 2 had moderate microcephaly; Group 3 had prenatal ZIKVexposure confirmed by maternal RT-PCR testing but no microcephaly; and Group 4 was a neurotypical control group. Groups were evaluated clinically for neurological abnormalities and compared using the Survey of Wellbeing of Young Children (SWYC), a neurodevelopment and behavior screening instrument validated for use in Brazil. Children with severe delays underwent further evaluation with an adapted version of the SWYC.

Results

Based on the SWYC screening, we observed differences between the groups for developmental milestones but not behavior. Among the 114 children with severe microcephaly of whom 98.2% presented with neurological abnormalities, 99.1% were ‘at risk of development delay’ according to the SWYC instrument. Among the 20 children with moderate microcephaly of whom 60% presented with neurological abnormalities, 65% were ‘at risk of development delay’. For children without microcephaly, the percentages found to be ‘at risk of developmental delay’ were markedly lower and did not differ by prenatal ZIKV exposure status: Group 3 (N = 94), 13.8%; Group 4 (N = 46), 21.7%.

Conclusions

Among children with prenatal ZIKV exposure, we found a gradient of risk of development delay according to head circumference. Children with severe microcephaly were at highest risk for delays, while normocephalic ZIKV-exposed children had similar risks to unexposed control children. We propose that ZIKV-exposed children should undergo first-line screening for neurodevelopment and behavior using the SWYC instrument. Early assessment and follow-up will enable at-risk children to be referred to a more comprehensive developmental evaluation and to multidisciplinary care management.

Survival analysis in non-congenital neurological disorders related to dengue, chikungunya and Zika virus infections in Northeast Brazil

The Northeast of Brazil has experienced a triple epidemic, with the simultaneous circulation of dengue virus (DENV), chikungunya virus (CHIKV) and Zika virus (ZIKV), which may have contributed to the observed increase across this region of atypical forms of disease and deaths. In view of this fact, non-congenital neurological disorders related to arboviruses were compared with other etiologies, mortality and survival rates of patients admitted to referral neurology hospitals in Pernambuco State, Northeast Brazil, from 2015 to 2018. Blood and cerebrospinal fluid samples were collected and tested using molecular and serological assays. The arbovirus-exposed groups were compared with respect to epidemiological, clinical and neurologic characteristics by using the Pearson’s chi-square test. For the survival analysis, the Kaplan-Meier and Hazard Ratio (HR) tests were used, with a 95% confidence interval (CI). Encephalitis and encephalomyelitis were more frequent in arboviruses, while myelitis predominated in the neurological disorders of other etiologies. Guillain-Barré Syndrome (GBS) was similarly distributed amongst the groups. Exposure to one of the arboviruses caused a six-fold increase in the risk of death (HR: 6.37; CI: 2.91 - 13.9). Amongst the arbovirus-exposed groups, infection (DENV/CHIKV) increased nine times the risk of death (HR: 9.07; CI: 3.67 - 22.4). The survival curve indicates that have been exposed to some arbovirus decreased the likelihood of survival compared to those with other etiologies (Log-Rank: p<0.001). Within this scenario, neurologic manifestations of DENV, CHIKV and ZIKV have the potential to increase mortality and decrease survival, and concomitant infection (DENV/CHIKV) is an aggravating factor in reducing the likelihood of survival when compared to monoinfections.

Comparison of Oropharyngeal Dysphagia in Brazilian Children with Prenatal Exposure to Zika Virus, With and Without Microcephaly

Severe brain damage associated with Zika-related microcephaly (ZRM) have been reported to result in oropharyngeal dysphagia (OPD); however, it is unknown if OPD presents in children with prenatal Zika virus (ZIKV) exposure but only mild or undetectable abnormalities. The aims of this study were: to compare the frequency and characteristics of OPD in children with ZRM and in children without microcephaly born to mothers who tested polymerase chain reaction positive (PCR+) for ZIKV during pregnancy; and to investigate the concordance of caregiver reports of OPD with the diagnosis from the clinical swallowing assessment (CSA). Between Mar/2017 and May/2018, we evaluated 116 children (n = 58 with microcephaly, n = 58 children without microcephaly born to ZIKV PCR + mothers) participating in the Microcephaly Epidemic Research Group (MERG) cohort of children born during the 2015–2016 ZIKV epidemic in Pernambuco, Brazil. To assess OPD we used: a CSA; a clinical assessment of the stomatognathic system; and a questionnaire administered to caregivers. The frequency of OPD was markedly higher in children with ZRM (79.3%) than in the exposed but normocephalic group (8.6%). The children with microcephaly also presented more frequently with anatomic and functional abnormalities in the stomatognathic system. There was a high degree of agreement between the caregiver reports of OPD and the CSA (κ = 0.92). In conclusion, our findings confirm that OPD is a feature of Congenital Zika Syndrome that primarily occurs in children with microcephaly and provide support for policies in which children are referred for rehabilitation with an OPD diagnosis based on caregiver report.

The frequency and clinical presentation of Zika virus coinfections: a systematic review

BACKGROUND

There is limited knowledge on the influence of concurrent coinfections on the clinical presentation of Zika virus (ZIKV) disease.

METHODS

To better understand the types, frequencies and clinical manifestations of ZIKV coinfections, we did a systematic review of four databases (PubMed, Embase, Web of Science, LILACS) without restrictions for studies on ZIKV coinfections confirmed by nucleic acid (quantitative real-time-PCR) testing of ZIKV and coinfecting pathogens. The review aimed to identify cohort, cross-sectional, case series and case report studies that described frequencies and/or clinical signs and symptoms of ZIKV coinfections. Conference abstracts, reviews, commentaries and studies with imprecise pathogen diagnoses and/or no clinical evaluations were excluded.

RESULTS

The search identified 34 articles from 10 countries, comprising 2 cohort, 10 cross-sectional, 8 case series and 14 case report studies. Coinfections were most frequently reported to have occurred with other arthropod-borne viruses (arboviruses); out of the 213 coinfections described, ZIKV infections co-occurred with chikungunya in 115 cases, with dengue in 68 cases and with both viruses in 19 cases. Other coinfecting agents included human immunodeficiency, Epstein-Barr, human herpes and Mayaro viruses, Leptospira spp, Toxoplasma gondii and Schistosoma mansoni. ZIKV-coinfected cases primarily presented with mild clinical features, typical of ZIKV monoinfection; however, 9% of cases in cohort and cross-sectional studies were reported to experience complications.

CONCLUSION

Based on the evidence collated in this review, coinfections do not appear to strongly influence the clinical manifestations of uncomplicated ZIKV infections. Further research is needed to confirm whether risk of severe complications is altered when ZIKV infection co-occurs with other infections.

PROSPERO REGISTRATION NUMBER

CRD42018111023.

ZikaPLAN: addressing the knowledge gaps and working towards a research preparedness network in the Americas

Zika Preparedness Latin American Network (ZikaPLAN) is a research consortium funded by the European Commission to address the research gaps in combating Zika and to establish a sustainable network with research capacity building in the Americas. Here we present a report on ZikaPLAN`s mid-term achievements since its initiation in October 2016 to June 2019, illustrating the research objectives of the 15 work packages ranging from virology, diagnostics, entomology and vector control, modelling to clinical cohort studies in pregnant women and neonates, as well as studies on the neurological complications of Zika infections in adolescents and adults. For example, the Neuroviruses Emerging in the Americas Study (NEAS) has set up more than 10 clinical sites in Colombia. Through the Butantan Phase 3 dengue vaccine trial, we have access to samples of 17,000 subjects in 14 different geographic locations in Brazil. To address the lack of access to clinical samples for diagnostic evaluation, ZikaPLAN set up a network of quality sites with access to well-characterized clinical specimens and capacity for independent evaluations. The International Committee for Congenital Anomaly Surveillance Tools was formed with global representation from regional networks conducting birth defects surveillance. We have collated a comprehensive inventory of resources and tools for birth defects surveillance, and developed an App for low resource regions facilitating the coding and description of all major externally visible congenital anomalies including congenital Zika syndrome. Research Capacity Network (REDe) is a shared and open resource centre where researchers and health workers can access tools, resources and support, enabling better and more research in the region. Addressing the gap in research capacity in LMICs is pivotal in ensuring broad-based systems to be prepared for the next outbreak. Our shared and open research space through REDe will be used to maximize the transfer of research into practice by summarizing the research output and by hosting the tools, resources, guidance and recommendations generated by these studies. Leveraging on the research from this consortium, we are working towards a research preparedness network.

Knowledge, attitudes and practices of community health agents regarding pulmonary tuberculosis in a capital city in northeastern Brazil

This article analyses the knowledge, attitudes and practices of community health agents (CHAs) regarding tuberculosis in Recife, a municipality with a high incidence of tuberculosis and high treatment dropout rates in Brazil. The cross-sectional study was conducted with a representative sample of CHAs and a standardized questionnaire. The frequencies of the variables related to knowledge, attitudes and practices were described, and the association between satisfactory knowledge and appropriate practices of CHAs was analysed. Of the 401 eligible CHAs, 385 (96.0%) were interviewed. The majority were women (87.5%) aged ≥ 40 years (66.0%) and had been on the job for more than nine years (74.5%). A large percentage (61.7%) had satisfactory knowledge about tuberculosis, and this knowledge (75.8%) was associated with appropriate practices (p = 0.008). Regarding attitudes, 97.1% of CHAs were believed to be at risk of contracting tuberculosis, and 53.2% attributed this risk to their job. The results suggest the need for investment in training actions that may help improve tuberculosis indicators in the municipality.

Quality of life may be a more valuable prognostic factor than depression in older hemodialysis patients

PURPOSE

Depression and impairment of quality of life (QoL) reduce the survival of individual on hemodialysis (HD). However, few studies evaluated the impact of these conditions on the survival of older patients undergoing HD.

METHODS

A retrospective cohort study was performed including patients aged ≥ 60 years on HD in Recife, Brazil, assessed in 2013 and monitored until 2017. Depression was evaluated with the Mini-International Neuropsychiatric Interview and QoL with the Control, Autonomy, Self-realization, and Pleasure Questionnaire (CASP-16). Survival differences according to the depression and QoL status were measured by Kaplan-Meier analysis and Cox regression. Death Certificates were analyzed to assess the cause of death.

RESULTS

A total of 171 patients were included (mean age 68.7 ± 6.9 years). The mean follow-up time was 3 years (maximum 4.5 years) and there were 98 deaths (57.3% of the sample). In a multivariate model that included depression and QoL, only QoL impairment was associated with a higher risk of death (HR 1.62, p = 0.035). Among CASP domains, only "Control" was associated with survival (HR 0.90, p = 0.014). Depression was unrelated to the cause of death, but there was a trend for death by endocrine diseases if QoL was impaired (p = 0.057).

CONCLUSION

QoL impairment is a key predictor of prognosis in older patients on HD and may be more important than depression. It is important that teams dealing with this population include in protocols an assessment of QoL, in order to offer a range of care according to the needs of these patients.

Factors associated to modification of first-line antiretroviral therapy due to adverse events in people living with HIV/AIDS

Antiretroviral therapy (ART) has modified the outcome of patients with HIV infection, providing virological control and reducing mortality. However, there are several reasons as to why patients may discontinue their antiretroviral therapy, with adverse events being one of the main reasons reported in the literature. This is a case-control nested in a cohort of people living with HIV/AIDS, conducted to identify the incidence of ART modification due to adverse events and the associated factors, in two referral services in Recife, Brazil, between 2011 and 2014. Of the modifications occurred in the first year of ART, 25.7% were driven by adverse events. The median time elapsed between initiating ART and the first modification due to adverse events was 70.5 days (95% CI: 26-161 days). The main adverse events were dermatological, neuropsychiatric and gastrointestinal. Dermatological events were the earliest to appear after initiating ART. Efavirenz was the most prescribed and most modified drug during the study period. The group of participants who used zidovudine, lamivudine, and efavirenz had a 2-fold greater chance (adjusted OR: 2.16 95% CI: 1.28-3.65) of switching ART due to adverse events when compared to the group that used tenofovir with lamivudine and efavirenz.

Household Survey of Trachoma among Children Living in Pernambuco, Brazil

This study analyzed the association between individual and household factors and the incidence of trachoma among a population aged between 1 and 9 years in the state of Pernambuco. This was a population-based household study conducted using a population-based sample of residents from 96 census sectors of the 1778 sectors considered to be at social risk in the state. The estimated odds ratio of the univariate analysis presented a confidence interval of 95%. Weights and clusters were adjusted through the Generalized Linear and Latent Mixed Model (GLLAM) method. Trachoma cases were the dependent variable in the multivariate analysis. The independent variables were selected through the stepwise forward method, with an input criterion of 20% (p < 0.20) and an output criterion of 10% (p < 0.10). The prevalence was 6.65%. Trachoma was associated with a female sex, age of 5–9 years, either the absence of use or infrequent use of soap to wash the hands and face, the presence of nasal secretion, a lack of piped water from a public supply system, a greater number of rooms used for sleeping, a greater number of people living in the same household, and a family income of up to one minimum monthly wage. The prevalence of follicular trachoma in Pernambuco was higher than what is recommended by the World Health Organization (WHO).

Zika virus infection in pregnancy: Establishing a case definition for clinical research on pregnant women with rash in an active transmission setting

Defining cases of Zika virus (ZIKV) infection is a critical challenge for epidemiological research. Due to ZIKV’s overlapping clinical features and potential immunologic cross-reactivity with other flaviviruses and the current lack of an optimal ZIKV-specific diagnostic assay, varying approaches for identifying ZIKV infections have been employed to date. This paper presents the laboratory results and diagnostic criteria developed by the Microcephaly Epidemic Research Group for defining cases of maternal ZIKV infection in a cohort of pregnant women with rash (N = 694) recruited during the declining 2015–2017 epidemic in northeast Brazil. For this investigation, we tested maternal sera for ZIKV by quantitative reverse transcription polymerase chain reaction (qRT-PCR), Immunoglobulin (Ig) M and IgG3 enzyme-linked immunosorbent assays (ELISAs), and Plaque Reduction Neutralization Test (PRNT₅₀). Overall, 23.8% of participants tested positive by qRT-PCR during pregnancy (range of detection: 0–72 days after rash onset). However, the inter-assay concordance was lower than expected. Among women with qRT-PCR-confirmed ZIKV and further testing, only 10.1% had positive IgM tests within 90 days of rash, and only 48.5% had ZIKV-specific PRNT₅₀ titers ≥20 within 1 year of rash. Given the complexity of these data, we convened a panel of experts to propose an algorithm for identifying ZIKV infections in pregnancy based on all available lines of evidence. When the diagnostic algorithm was applied to the cohort, 26.9% of participants were classified as having robust evidence of a ZIKV infection during pregnancy, 4.0% as having moderate evidence, 13.3% as having limited evidence of a ZIKV infection but with uncertain timing, and 19.5% as having evidence of an unspecified flavivirus infection before or during pregnancy. Our findings suggest that integrating longitudinal data from nucleic acid and serologic testing may enhance diagnostic sensitivity and underscore the need for an on-going dialogue regarding the optimization of strategies for defining cases of ZIKV in research.

On February 1, 2016, the World Health Organization declared a Public Health Emergency of International Concern following a “cluster of microcephaly cases and other neurological disorders in Brazil” and highlighted the “urgent need” for coordinated international efforts to investigate the relationship between maternal Zika virus (ZIKV) infections and microcephaly. Due to the lack of a standard algorithm, resultant epidemiological investigations have utilized different strategies for defining cases of ZIKV infections in pregnancy. Here, we report the experience of the Microcephaly Epidemic Research Group in Pernambuco, Brazil, in evaluating 694 pregnant women presenting with rash (i.e., a common sign of ZIKV infection) during the 2015–2017 Latin American outbreak. Integrating time-sensitive data from both nucleic acid amplification testing and serologic assays, a panel of experts developed an evidence-graded set of criteria for identifying cases of maternal infection. When applied to the cohort, nearly one-third of the participants were categorized as having robust or moderate evidence of being infected with ZIKV in pregnancy. The classifications described in this investigation will enable scientists to investigate maternal ZIKV infection and estimate the absolute and relative risks of adverse pregnancy outcomes. The results also underscore the importance of on-going efforts to develop robust diagnostic assays for ZIKV.

Non Electrocardiographic alterations in exercise testing in asymptomatic women. Associations with cardiovascular risk factors

OBJECTIVES

To estimate the prevalence of exercise testing alterations in middle-aged women without symptoms of heart disease and to verify the associations of functional capacity and heart rate behavior during and after exercise with cardiovascular risk factors.

METHODS

A cross-sectional study was conducted with 509 asymptomatic women aged between 46 and 65 years who underwent clinical evaluations and exercise testing (Bruce protocol). The heart rate behavior was evaluated by the maximal predicted heart rate achieved, chronotropic index and recovery heart rate.

RESULTS

The mean age was 56.4±4.8 years, and 13.4% of the patients had a Framingham risk score above 10%. In the exercise treadmill testing, 58.0% presented one or more of the following alterations (listed in order of ascending prevalence): symptoms (angina, dyspnea, and dizziness), ST-segment depression, arrhythmia, reduction in recovery heart rate of ≤12 bpm at 1 minute, altered maximal predicted heart rate achieved, abnormal blood pressure, functional capacity deficiency, and altered chronotropic index. In the multivariate analysis, the following associations (odds ratio) were observed for these alterations: chronotropic index was associated with obesity (2.08) and smoking (4.47); maximal predicted heart rate achieved was associated with smoking (6.45); reduction in the recovery heart rate at 1 minute was associated with age (1.09) and obesity (2.78); functional capacity was associated with age (0.92), an overweight status (2.29) and obesity (6.51).

CONCLUSIONS

More than half of middle-aged women without cardiovascular symptoms present alterations in one or more exercise testing parameters. Alterations in the functional capacity or heart rate behavior, as verified by exercise testing, are associated with age, smoking, an overweight status and obesity.

HIV and Headache: A Cross-Sectional Study

INTRODUCTION

The head and neck are the second most common locations for pain among HIV-positive individuals. Most studies were conducted among HIV patients at an advanced stage of the disease.

METHODS

This was a cross-sectional study. Patients with HIV and CD4+ T lymphocyte counts >500 were included. Semi-structured interview, the Headache Impact Test (HIT-6), and the Hospital Anxiety and Depression Scale were used.

RESULTS

Of the 119 cases included, 63% were men. The mean age was 35.5 ± 10.4 years. Among the patients, 103 (87%) had headaches, 53 (45%) had migraines, 50 (42%) had tension-type headaches, and 53 (45%) had substantial and severe impact of headaches. Eleven patients had headaches that started after they had been diagnosed with HIV. These patients had more migraines (72% vs 43%; P < 0.05), greater intensity (8 ± 2 vs 6 ± 2; P < 0.01), and impact (HIT-6: 60 ± 11 vs 51 ± 12; P = 0.02) of headaches compared to others HIV patients. There were no correlations between CD4 counts and the intensity, frequency, or impact of headaches.

CONCLUSIONS

HIV-positive patients had a high frequency of headaches, which had a great impact on patients' lives. The pattern most often found was migraine. There was no correlation between CD4 counts and the severity of headaches.

Survival of people living with HIV who defaulted from tuberculosis treatment in a cohort, Recife, Brazil

Background

Tuberculosis is a serious public health problem worldwide. It is the leading cause of death amongst people living with HIV, and default from tuberculosis (TB) treatment in people living with HIV increases the probability of death. The aim of this study was to estimate the survival probability of people living with HIV who default treatment for TB compared to those who complete the treatment.

Methods

This was a longitudinal cohort study of people living with HIV, from June 2007 to December 2013 with two components: a retrospective (for those who started tuberculosis treatment before 2013 for whom failure (death) or censoring occurred before 2013), and prospective (those who started tuberculosis treatment at any time between 2007 and June 2013 and for whom death or censoring occurred after the beginning of 2013), at two referral hospitals for people living with HIV (Correia Picanço Hospital - HCP and at Hospital Universitário Oswaldo Cruz – HUOC), in Recife/PE. A total of 317 patients who initiated TB treatment were studied. Default from TB treatment was defined as any patient who failed to attend their pre-booked return appointment at the health center for more than 30 consecutive days, in accordance with Brazilian Ministry of Health recommendations.

Results

From a cohort of 2372 people living with HIV we analyzed 317 patients who had initiated TB treatment. The incidence of death was 5.6 deaths per 100 persons per year (CI 95% 4.5 to 7.08). Independent factors associated with death: default from TB treatment 3.65 HR (95% CI 2.28 to 5.83); CD4 < 200 cells/mm³ 2.39 HR (95% CI 1.44 to 3.96); extrapulmonary tuberculosis 1.56 HR (95% CI 0.93 to 2.63); smoking 2.28 HR (95% CI 1.33 to 3.89); alcohol light 0.13 HR (95% CI 0.03 to 0.56).

Conclusion

The probability of death in people living with HIV who default TB treatment is approximately four times greater when compared to those who do not default from treatment.

Factors associated with glycemic control in people with diabetes at the Family Health Strategy in Pernambuco

Abstract OBJECTIVE Identifying factors associated with glycemic control in people with type 2 Diabetes Mellitus (DM) registered in the Family Health Strategy (FHS) in Pernambuco, Brazil. METHOD Associations between glycemic control (glycosylated hemoglobin A lower or equal to 7%) presented by people with DM and variables related to sociodemographic conditions, lifestyle, characteristics of diabetes, treatment and follow-up of patients by health services were investigated by multiple regression. RESULTS More than 65% of the participants presented inadequate glycemic control, especially those with lower age, longer illness duration, more annual contacts with FHS and complex therapeutic regimen. People with DM without referrals to specialists presented greater glycemic control. Associations with education level and obesity did not remain significant in the multivariate model. CONCLUSION The evolution of diabetes hinders adequate control, however, attention to younger people with DM and referrals to specialists are factors that can improve glycemic control.

Validating a scoring system for the diagnosis of smear-negative pulmonary tuberculosis in HIV-infected adults

Background

The challenge of diagnosing smear-negative pulmonary TB (tuberculosis) in people living with HIV justifies the use of instruments other than the smear test for diagnosing the disease. Considering the clinical-radiological similarities of TB amongst HIV-infected adults and children, the proposal of this study was to assess the accuracy of a scoring system used to diagnose smear-negative pulmonary TB in children and adolescents, in HIV-infected adults suspected of having smear-negative pulmonary TB.

Methods

A Phase III validation study aiming to assess the diagnostic accuracy of a scoring system for diagnosing smear-negative pulmonary TB in HIV-infected adults. The study assessed sensitivity, specificity, positive and negative likelihood ratios, and positive and negative predictive values of the scoring system. Three versions of the scoring system were tested.

Results

From a cohort of 2,382 (HIV-infected adults), 1276 were investigated and 128 were diagnosed with pulmonary TB. Variables associated with the diagnosis of TB were: coughing, weight loss, fever, malnutrition, chest X-ray, and positive tuberculin test. The best diagnostic performance occurred with the scoring system with new scores, with sensitivity = 81.2% (95%-CI 74.5% –88%), specificity = 78% (75.6% –80.4%), PPV = 29.2% (24.5% –33.9%) and NPV = 97.4% (96.4% –98.4%), LR+ = 3.7 (3.4–4.0) and LR− = 0.24 (0.2–0.4).

Conclusion

The proposed scoring system (with new scores) presented a good capacity for discriminating patients who did not have pulmonary TB, in the studied population. Further studies are necessary in order to validate it, thus permitting the assessment of its use in diagnosing smear-negative pulmonary TB in HIV-infected adults.

Factors related to changes in CD4+ T-cell counts over time in patients living with HIV/AIDS: a multilevel analysis

Background

The measurement of CD4+ T-cell (CD4) counts is a strong predictor of progression to AIDS and a means of monitoring antiviral therapy (ART). The success or failure of controlling virus levels in untreated patients or those taking ART may be associated with treatment adherence, habits, correlated infections unrelated to HIV, cancer, immunosuppressive drugs; as well as socio-economic and psychosocial aspects and access to healthcare. The aim of the present study was to identify, using a multilevel model, the factors related to the variations of CD4 counts over time, in patients living with HIV.

Methodology

A cohort study was conducted with patients living with HIV, selected from July 2007 to December 2010. Patients were monitored from records of their first CD4 count after being diagnosed with HIV. A multilevel model with 3 levels of aggregation was applied to analyze the associations of predictor variables and the behavior of CD4 over time.

Principal Findings

A total of 1870 patients were enrolled. The mean number of CD4 at the beginning of the cohort was 393.1 cells/mm³, and there was a mean increase of 1.529 cells/mm³ per month. Patient's age, smoking, use of illicit drugs, hospital treatment, changing doctors and the use of ART, were factors that affected the kinetics of the CD4 count during the follow-up period.

Conclusion/Significance

The results of this study indicated increased levels of CD4 over time in a cohort of patients living with HIV/AIDS and identified factors that may influence this increase and are liable to intervention.

Concordance between expected and observed bacilloscopy results of clinical forms of leprosy: a 6-year retrospective study in Recife, State of Pernambuco, Brazil

INTRODUCTION

Operational classification of leprosy based on the number of skin lesions was conceived to screen patients presenting severe forms of the disease to enable their reception of a more intense multidrug regimen without having to undergo lymph smear testing. We evaluated the concordance between operational classification and bacilloscopy to define multibacillary and paucibacillary leprosy.

METHODS

We selected 1,213 records of individuals with leprosy, who were untreated (new cases) and admitted to a dermatology clinic in Recife, Brazil, from 2000 to 2005, and who underwent bacteriological examination at diagnosis for ratification of the operational classification.

RESULTS

Compared to bacilloscopy, operational classification demonstrated 88.6% sensitivity, 76.9% specificity, a positive predictive value of 61.8%, and a negative predictive value of 94.1%, with 80% accuracy and a moderate kappa index. Among the bacilloscopy-negative cases, 23% had more than 5 skin lesions. Additionally, 11% of the bacilloscopy-positive cases had up to 5 lesions, which would have led to multibacillary cases being treated as paucibacillary leprosy if the operational classification had not been confirmed by bacilloscopy.

CONCLUSIONS

Operational classification has limitations that are more obvious in borderline cases, suggesting that in these cases, lymph smear testing is advisable to enable the selection of true multibacillary cases for more intense treatment, thereby contributing to minimization of resistant strain selection and possible relapse.

Risk factors for subclinical atherosclerosis in HIV-infected patients under and over 40 years: a case-control study

Background

Cardiovascular diseases (CVD) are a major cause of death in people with AIDS. Factors contributing to atherosclerosis include traditional risk factors, antiretrovirals and inflammatory factors related to HIV infection. This study set out to compare risk factors associated with subclinical atherosclerosis in individuals under and over 40 years of age.

Methods

Case–control study with 697 HIV/AIDS individuals without HAART or who remain on their first antiretroviral regimen. Of the total, 351 individuals under 40 years and 346 over 40 years were analyzed separately. Subclinical atherosclerosis was assessed by carotid intima-media thickness, using B-mode ultrasound. Multivariate logistic regression was performed to find predictors of subclinical atherosclerosis in the entire group. Subsequent analysis excluded patients with major risk factors for CVD. Magnitudes of associations were expressed by odds ratio (OR) statistical significance, using a 95% confidence interval and p-value <0.05.

Results

In the <40 years group subclinical atherosclerosis was associated with male gender (OR: 2.77, 95% CI: 1.43–5.34), nonwhite race (OR: 3.01, 95% CI: 1.23-6.53), obesity (OR: 5.13, 95% CI: 1.79–14.7) and metabolic syndrome (OR: 3.30, 95% CI: 1.44–7.58). In the group ≥40 years predictors of subclinical atherosclerosis were overweight and obesity (OR = 2.53, 95% CI, 0.85–7.54), current CD4 ≥350 cells/mL (OR: 2.81, 95% CI: 1.22–6.47) and NNRTI use ≥ 5 years (OR: 2.65, 95% CI: 1.10-6.37) or PI use >5 years (OR: 1.81, 95% CI: 0.38-8.59). In the multivariate model excluding patients with major risk factors for CVD, age, male sex and nonwhite race were associated with subclinical atherosclerosis in the <40 y group, while in the ≥40 y group, age, HIV viral load >10,000 copies and the use of NNRTI (OR: 7.60, 95% CI: 1.61-35.8) or PI ≥5 years (OR: 3.62, 95% CI: 0.48-26.8) were associated with subclinical atherosclerosis.

Conclusions

In young people the fight against obesity and metabolic syndrome is the main aim in the prevention of CVD. In individuals aged ≥40 y, the prevention of obesity is also of great importance. Moreover, the effects of uncontrolled viremia and the prolonged use of HAART appear to be more harmful in the older group.

Incidence and risk factors for tuberculosis in people living with HIV: cohort from HIV referral health centers in Recife, Brazil

OBJECTIVE

To identify the incidence of and risk factors for tuberculosis in people living with HIV (PLHIV).

DESIGN

Observational, prospective cohort study.

METHODS

A total of 2069 HIV-infected patients was observed between July 2007 and December 2010. The Kaplan-Meier method was used to estimate the probability of survival free of tuberculosis, and Cox regression analysis to identify risk factors associated with the development of tuberculosis.

RESULTS

Survival free of tuberculosis (TB) was 91%. The incidence rate of tuberculosis was 2.8 per 100 persons/years. Incidence of tuberculosis was higher when subjects had CD4 cell count <200 cells/mm(3); were not on antiretroviral therapy; in those who had, a body mass index <18.5 kg/m(2), anemia (or were not tested for it), were illiterate or referred previous tuberculosis treatment at entry into the cohort. Those not treated for latent TB infection had a much higher risk (HR = 7.9) of tuberculosis than those with a negative tuberculin skin test (TST). Having a TST≥5 mm but not being treated for latent TB infection increased the risk of incident tuberculosis even in those with a history of previous tuberculosis.

CONCLUSIONS

Preventive actions to reduce the risk of TB in people living with HIV should include an appropriate HAART and treatment for latent TB infection in those with TST≥5 mm. The actions towards enabling rigorous implementation of treatment of latent TB infection and targeting of PLHIV drug users both at the individual and in public health level can reduce substantially the incidence of TB in PLHIV.

Angina pectoris in patients with HIV/AIDS: prevalence and risk factors

INTRODUCTION

The incidence of ischemic heart disease is higher in patients with HIV/AIDS. However, the frequency of angina pectoris in these patients is still not known. Literature about this subject is still scarce.

OBJECTIVE

To evaluate the prevalence of angina pectoris and risk factors for coronary disease and to examine the association between traditional risk factors and HIV-related risk factors and angina pectoris.

METHOD

An epidemiological cross-sectional study, analyzed as case-control study, involving 584 patients with HIV/AIDS. Angina pectoris was identified by Rose questionnaire, classified as definite or possible. Information regarding risk factors was obtained through a questionnaire, biochemical laboratory tests, medical records and anthropometric measures taken during consultations at AIDS treatment clinics in Pernambuco, Brazil, from June 2007 to February 2008. To adjust the effect of each factor in relation to others, multiple logistic regression was used.

RESULTS

There was a preponderance of men (63.2%); mean ages were 39.8 years for men, 36.8 years for women. The prevalence of definite and possible angina were 11% and 9.4%, respectively, totaling 20.4%, with independent associations between angina and smoking (OR = 2.88; 95% CI: 1.69-4.90), obesity (OR = 1.62; 95% CI: 0.97-2.70), family history of heart attack (OR = 1.70; 95% CI: 1.00-2.88), low schooling (OR = 2.11; 95% CI: 1.24-3.59), and low monthly income (OR = 2.93; 95% CI: 1.18-7.22), even after adjustment for age.

CONCLUSION

This study suggests that angina pectoris is underdiagnosed, even in patients with medical monitoring, revealing lost opportunities in identification and prevention of cardiovascular morbidity.

Is arterial stiffness in HIV-infected individuals associated with HIV-related factors?

We investigated the association between pulse wave velocity (PWV) and HIV infection, antiretroviral treatment-related characteristics, viral load, immune status, and metabolic changes in a cross-sectional study nested in a cohort of HIV/AIDS patients who have been followed for metabolic and cardiovascular changes since 2007. The study included patients recruited from the cohort (N = 261) and a comparison group (N = 82) of uninfected individuals, all enrolled from April to November 2009. Aortic stiffness was estimated using the carotid-femoral PWV (Complior-Artech, Paris, France). The groups were similar with respect to age, metabolic syndrome, diabetes mellitus, Framingham score, and use of antihypertensive and hypolipidemic medications. Hypertension was more frequent among the controls. Individuals with HIV had higher triglyceride, glucose and HDL cholesterol levels. Among individuals with HIV/AIDS, those with a nadir CD4⁺ T-cell count <200 cells/mm³ had a higher PWV (P = 0.01). There was no statistically significant difference when subjects were stratified by gender. Heart rate, age, male gender, and blood pressure were independently correlated with PWV. Nadir CD4⁺ T-cell count did not remain in the final model. There was no significance difference in PWV between HIV-infected individuals and uninfected controls. PWV was correlated with age, gender, and blood pressure across the entire population and among those infected with HIV. We recommend cohort studies to further explore the association between inflammation related to HIV infection and/or immune reconstitution and antiretroviral use and PWV.

Validation of a case definition for leptospirosis diagnosis in patients with acute severe febrile disease admitted in reference hospitals at the State of Pernambuco, Brazil

INTRODUCTION: Leptospirosis is often mistaken for other acute febrile illnesses because of its nonspecific presentation. Bacteriologic, serologic, and molecular methods have several limitations for early diagnosis: technical complexity, low availability, low sensitivity in early disease, or high cost. This study aimed to validate a case definition, based on simple clinical and laboratory tests, that is intended for bedside diagnosis of leptospirosis among hospitalized patients. METHODS: Adult patients, admitted to two reference hospitals in Recife, Brazil, with a febrile illness of less than 21 days and with a clinical suspicion of leptospirosis, were included to test a case definition comprising ten clinical and laboratory criteria. Leptospirosis was confirmed or excluded by a composite reference standard (microscopic agglutination test, ELISA, and blood culture). Test properties were determined for each cutoff number of the criteria from the case definition. RESULTS: Ninety seven patients were included; 75 had confirmed leptospirosis and 22 did not. Mean number of criteria from the case definition that were fulfilled was 7.8±1.2 for confirmed leptospirosis and 5.9±1.5 for non-leptospirosis patients (p<0.0001). Best sensitivity (85.3%) and specificity (68.2%) combination was found with a cutoff of 7 or more criteria, reaching positive and negative predictive values of 90.1% and 57.7%, respectively; accuracy was 81.4%. CONCLUSIONS: The case definition, for a cutoff of at least 7 criteria, reached average sensitivity and specificity, but with a high positive predictive value. Its simplicity and low cost make it useful for rapid bedside leptospirosis diagnosis in Brazilian hospitalized patients with acute severe febrile disease.

Methodology of a nationwide cross-sectional survey of prevalence and epidemiological patterns of hepatitis A, B and C infection in Brazil

A population-based survey to provide information on the prevalence of hepatitis viral infection and the pattern of risk factors was carried out in the urban population of all Brazilian state capitals and the Federal District, between 2005 and 2009. This paper describes the design and methodology of the study which involved a population aged 5 to 19 for hepatitis A and 10 to 69 for hepatitis B and C. Interviews and blood samples were obtained through household visits. The sample was selected using stratified multi-stage cluster sampling and was drawn with equal probability from each domain of study (region and age-group). Nationwide, 19,280 households and ~31,000 residents were selected. The study is large enough to detect prevalence of viral infection around 0.1% and risk factor assessments within each region. The methodology seems to be a viable way of differentiating between distinct epidemiological patterns of hepatitis A, B and C. These data will be of value for the evaluation of vaccination policies and for the design of control program strategies.

Multilevel analysis of hepatitis A infection in children and adolescents: a household survey in the Northeast and Central-west regions of Brazil

Background The objectives were to estimate the prevalence of hepatitis A among children and adolescents from the Northeast and Midwest regions and the Federal District of Brazil and to identify individual-, household- and area-levels factors associated with hepatitis A infection.

Methods This population-based survey was conducted in 2004–2005 and covered individuals aged between 5 and 19 years. A stratified multistage cluster sampling technique with probability proportional to size was used to select 1937 individuals aged between 5 and 19 years living in the Federal capital and in the State capitals of 12 states in the study regions. The sample was stratified according to age (5–9 and 10- to 19-years-old) and capital within each region. Individual- and household-level data were collected by interview at the home of the individual. Variables related to the area were retrieved from census tract data. The outcome was total antibodies to hepatitis A virus detected using commercial EIA. The age distribution of the susceptible population was estimated using a simple catalytic model. The associations between HAV infection and independent variables were assessed using the odds ratio and corrected for the random design effect and sampling weight. Multilevel analysis was performed by GLLAMM using Stata 9.2.

Results The prevalence of hepatitis A infection in the 5–9 and 10–19 age-group was 41.5 and 57.4%, respectively for the Northeast, 32.3 and 56.0%, respectively for the Midwest and 33.8 and 65.1% for the Federal District. A trend for the prevalence of HAV infection to increase according to age was detected in all sites. By the age of 5, 31.5% of the children had already been infected with HAV in the Northeast region compared with 20.0% in the other sites. By the age of 19 years, seropositivity was ∼70% in all areas. The curves of susceptible populations differed from one area to another. Multilevel modeling showed that variables relating to different levels of education were associated with HAV infection in all sites.

Conclusion The study sites were classified as areas with intermediate endemicity area for hepatitis A infection. Differences in age trends of infection were detected among settings. This multilevel model allowed for quantification of contextual predictors of hepatitis A infection in urban areas.

Tendência de AIDS no grupo etário de 50 anos e mais no período anterior e posterior à introdução de medicamentos para disfunção erétil: Brasil, 1990 a 2003

Resumo Objetivo Descrever o comportamento da incidência de Aids no grupo etário de 50 anos e mais, no Brasil e suas macrorregiões, no período de 1990 a 2003, analisando o momento anterior e posterior à introdução dos medicamentos para disfunção erétil no país, em 1998. Procedimentos metodológicos Realizou-se estudo ecológico, através de análise espaço-temporal dos casos de Aids notificados. Modelos de regressão linear, ajustados à série temporal dos casos de Aids com data de diagnóstico de 1990 a 1997, forneceram as taxas de variação média anual, bem como os valores esperados, possibilitando, dessa forma, a comparação das taxas de incidência observadas e estimadas. Resultados Foram analisados 25.223 casos de Aids no grupo etário de 50 anos e mais, estando a grande maioria (84%) situados nas regiões Sudeste e Sul do país. Essas regiões também apresentaram as maiores taxas de variação média anual até o ano de 1997 (1,002 e 0,906, respectivamente), seguidas de Centro-Oeste (0,570), Norte (0,441) e Nordeste (0,254), apresentando o Brasil uma taxa de 0,588. Após 1998, a comparação das taxas acumuladas no período de 1998 a 2003 revelou tendências esperadas maiores do que as observadas em todas as regiões, exceto a Nordeste. Conclusão A tendência de crescimento da Aids na faixa etária de 50 anos e mais apresentou maiores taxas de crescimento no período entre 1990 e 1997, mantendo esse crescimento no período posterior à introdução dos medicamentos para disfunção erétil, só que em menor velocidade.