Hearing of neonates without risk indicators for hearing loss and use of antimalarial drugs during pregnancy: a historical cohort study in the Northern Region of Brazil / Audição de neonatos sem indicadores de risco para perda auditiva e utilização de antimaláricos na gestação: um estudo de coorte histórica na Região Norte

Abstract Introduction: Studies have demonstrated the ototoxic effects of antimalarial drugs in individuals who receive these drugs, but little is known regarding the toxicity of these drugs in the newborn auditory system when administered to the mother receive the drug during pregnancy. Objective: To verify the incidence of hearing loss in neonates who have no other associated risk indicators, born to mothers treated for malaria during pregnancy. Methods: A retrospective, quantitative cohort study was developed at Hospital de Base Dr. Ary Pinheiro and Clínica Limiar, both located in the municipality of Porto Velho (Rondônia). The sample consisted of 527 newborns divided into two groups: exposed to antimalarials drugs during pregnancy group (n = 32) and non-exposed group (n = 495). Data collection took place from September 2014 to December 2015, through an interview with the mothers and/or guardians of the newborn, through the newborns' and the mothers' records, and the neonatal hearing screening database of the above-mentioned institutions. Results: All the neonates in the exposed group, assessed through the recording of transient otoacoustic emissions associated with the automated brainstem auditory evoked potential test, underwent neonatal hearing screening in the first examination. Among the newborns in the non-exposed group, 30 showed failure and were retested. Of these, one continued to fail and was referred for diagnosis, in whom the results showed to be within the normal range. Among the neonates of the exposed group, infection with Plasmodium vivax was the most frequent, and was similarly distributed among the gestational trimesters, and chloroquine was the most commonly used antimalarial drug treatment more often given during the third trimester; these findings did not show any influence on the audiological findings of the studied neonates. Conclusion: The present study did not identify any cases of hearing loss in neonates born to mothers who used antimalarial drugs during gestation.

Resumo Introdução: Estudos comprovam os efeitos ototóxicos dos antimaláricos em pessoas que fazem uso destes medicamentos, porém pouco se sabe sobre a toxicidade destes fármacos no sistema auditivo de neonatos quando ingeridos pelas mães no período gestacional. Objetivo: Verificar a incidência de perda auditiva em neonatos de mães tratadas para malária durante a gestação sem outros indicadores de risco associados. Método: Estudo quantitativo, de coorte retrospectivo, desenvolvido no Hospital de Base Dr. Ary Pinheiro e na Clínica Limiar, ambos em Porto Velho (Rondônia). Compuseram a amostra 527 recém-nascidos divididos em dois grupos: grupo exposto (n = 32) e grupo não exposto (n = 495). A coleta de dados ocorreu de setembro de 2014 a dezembro de 2015, através de entrevista com as genitoras e/ou responsáveis pelo recém-nascido, investigação nos prontuários dos neonatos e das genitoras e no banco de dados da triagem auditiva neonatal das instituições supracitadas. Resultados: Todos os neonatos do grupo exposto, avaliados através do registro das emissões otoacústicas transientes associado a realização do potencial evocado auditivo de tronco encefálico automático passaram na triagem auditiva neonatal no primeiro exame. Já, entre os recém-nascidos do grupo não exposto, 30 apresentaram falha e foram retestados. Destes, um continuou falhando e foi encaminhado para diagnóstico, no qual foram evidenciados resultados dentro da normalidade. Nos neonatos do grupo exposto, a infecção pelo Plasmodium vivax foi a mais frequente, mostrando distribuição semelhante entre os trimestres gestacionais, sendo a cloroquina o antimalárico mais utilizado e o tratamento medicamentoso realizado mais frequentemente no terceiro trimestre, porém tais achados não mostraram influência sobre os achados audiológicos dos neonatos estudados. Conclusão: O presente estudo não identificou casos de perda auditiva nos neonatos de mães que utilizaram antimaláricos na gestação.

Proposta de classificação dos diferentes tipos de estudos epidemiológicos descritivos / Propuesta de clasificación de los diferentes tipos de estudios epidemiológicos descriptivos / Proposal for classifying the different types of descriptive epidemiological studies

A categoria dos estudos epidemiológicos descritivos é tema relevante, uma vez que existem inconsistências na literatura quanto a sua nomenclatura e classificação. Foram revistos livros de textos acadêmicos de epidemiologia, 19 estrangeiros e seis nacionais, sendo o critério principal tê-los disponíveis para revisão detalhada dos capítulos de epidemiologia descritiva e tipos de estudo. Em 11 livros, os autores dão prioridade aos estudos analíticos. Doze textos estrangeiros e dois brasileiros incluem estudos descritivos, apesar de a maioria não explicitar uma categoria específica com esse nome. Propõe-se uma classificação com base nas respostas a questões norteadoras de pesquisa, incluindo os seguintes tipos de estudos: relato de caso, série de casos, coorte clínica, estudo de prevalência, estudo de incidência (coorte) e estudo ecológico descritivo. Discutem-se as potencialidades do seu uso, a implementação de novos métodos de análise e sua relevância na vigilância à saúde.

La categoría de estudios epidemiológicos descriptivos es relevante para los servicios de atención de salud ya que existen inconsistencias en la literatura con relación a su nomenclatura y clasificación. Se revisaron libros de texto académicos de epidemiología con ejemplares disponibles para revisión detallada de capítulos de epidemiología descriptiva y tipos de estudio: 19 extranjeros y 6 brasileños. En 11 libros, los autores no consideran ningún estudio que no sea analítico. Doce textos extranjeros y dos brasileños abarcan estudios descriptivos, aunque la mayoría no reconozca esa categoría explícitamente. Se propone una clasificación basada en las respuestas a preguntas orientadoras de la investigación incluyendo los siguientes tipos de estudios: relato de caso, serie de casos y cohorte clínica; cuatro de ámbito poblacional/comunitario: estudio de prevalencia, estudio de incidencia (cohorte), estudio descriptivo ecológico. Se discuten las potencialidades del uso, la implementación de nuevos métodos de análisis y su relevancia en la vigilancia epidemiológica.

Descriptive epidemiological studies are of relevance, given that there are inconsistencies in the literature with regard to their nomenclature and classification. We reviewed 19 international and six national academic textbooks on epidemiology, where the main criterion was to have them available in order to undertake an in-depth review of chapters on descriptive epidemiology and study types. In 11 books, the authors prioritize analytical studies. Twelve foreign texts and two from Brazil include descriptive studies, although the majority did not specifically refer to a category with this name. We propose a classification based on the answers to research questions, including the following types of study: case report, case series, clinical cohort, prevalence study, incidence study (cohort) and descriptive ecological study. We discuss potential uses, implementation of novel data analysis methods and their relevance in health surveillance.

Entry of dengue virus serotypes and their geographic distribution in Brazilian federative units: a systematic review / Entrada e distribuição geográfica dos sorotipos do vírus da dengue nas unidades federativas brasileiras: uma revisão sistemática

Objective: To describe the entry of Dengue virus (DENV) serotypes in Brazil and its federative units. Methods: A systematic review of studies published between 1980 and 2018 in databases and in the gray literature was performed using descriptors related to the years of entry of the DENV serotypes. Additionally, experts and official sources of information (Brazilian Ministry of Health) were consulted. Results: From 100 publications selected for the systematic review, 26 addressed the entry of DENV serotypes in the North region of the country, 33 in the Northeast, 24 in the Southeast, 14 in the Central-West, and five in the South. DENV-1 and DENV-4 were introduced in the North region in 1981. DENV-2 was introduced in the Southeast in 1990. DENV-3 was introduced in the North in 1999. Conclusion: The rapid expansion of dengue throughout the Brazilian territory was verified from the second half of the 1980s, with the gradual entry of the four serotypes, which resulted in the emergence of epidemics of arbovirus, which are currently verified in the country. Considering the epidemiology of the disease, more information should be disseminated and published in the wide-ranging scientific literature for a better understanding of the spread and circulation of DENV serotypes.

RESUMO: Objetivo: Descreveu-se a entrada de sorotipos do vírus da Dengue (DENV) no Brasil e em suas unidades federativas. Métodos: Realizou-se uma revisão sistemática de estudos publicados entre 1980 e 2018 em bancos de dados e na literatura cinzenta, utilizando-se descritores relacionados aos anos de entrada dos sorotipos do DENV. Além disso, consultou-se especialistas e fontes oficiais de informação (Ministério da Saúde do Brasil). Resultados: Das 100 publicações selecionadas para a revisão sistemática, 26 abordaram a entrada de sorotipos de DENV na região Norte do país, 33 no Nordeste, 24 no Sudeste, 14 no Centro-Oeste e cinco no Sul. O DENV-1 e o DENV-4 foram introduzidos na região Norte em 1981. O DENV-2 foi introduzido no Sudeste em 1990. O DENV-3 foi introduzido no Norte em 1999. Conclusão: A rápida expansão da dengue por todo o território brasileiro foi verificada a partir da segunda metade dos anos de 1980, com a entrada gradativa dos quatro sorotipos, o que resultou no surgimento de epidemias da arbovirose, que são atualmente verificadas no país. Considerando a epidemiologia da doença, mais informações devem ser divulgadas e publicadas na literatura científica de amplo alcance, para melhor entendimento da propagação e circulação dos sorotipos de DENV.

Leprosy in children under 15 years of age in a municipality in northeastern Brazil: evolutionary aspects from 2003 to 2015

Abstract INTRODUCTION The Integrated Program of Leprosy Control was initiated in 2003 in the municipality of Buriticupu, Maranhão, Brazil, an area considered hyperendemic for leprosy. Here, we present the evolution of the indicators of leprosy within the established period in children aged <15 years. METHODS: This is a descriptive study based on an active search for cases and spontaneous healthcare demand for leprosy, with an evolutionary analysis of the detection coefficient of new cases. We considered individuals aged <15 years diagnosed with leprosy from January 2003 to December 2015. To evaluate the factors associated with clinical and operational forms, Chi-square, Fisher's exact, or Fisher-Freeman-Halton tests were performed. RESULTS A total of 61 new cases were detected (6.9% of the total leprosy cases diagnosed in the municipality during the study period), and the majority was found in males (62.3%). The most frequent operational classification was paucibacillary (67.2%), and this association increased with age. The tuberculoid clinical form was the most prevalent in both sexes and in the age range of 10 to <15 years. There was a reduction in the detection coefficient from 21.84/100,000 inhabitants in 2003 to 2.79/100,000 in 2015. CONCLUSIONS Despite the progress in the control of leprosy, this historical series shows that it is necessary to strengthen educational measures and implement control actions, so that the disease ceases to be a public health problem in the population aged <15 years.

Precarização do trabalho odontológico na saúde suplementar: uma análise bioética / Precarisation of dentistry in private healthcare: bioethical analysis

Resumo O presente trabalho evidenciou o processo de trabalho do cirurgião-dentista (CD) no setor de saúde suplementar a partir da visão do profissional, sob a luz da Bioética de Intervenção. Foi realizado um estudo observacional-seccional do tipo inquérito circunscrito à região do Distrito Federal. Os dados foram coletados por meio de 108 questionários respondidos por CDs credenciados à duas modalidades de operadora: autogestão e odontologia de grupo, com a finalidade de conhecer a percepção e o grau de satisfação profissional diante do mercado de trabalho odontológico. A insatisfação maior por parte dos profissionais foi relacionada à remuneração dos trabalhos odontológicos pelas operadoras. Para a operadora de autogestão 1, 38,1% dos profissionais responderam que a remuneração era satisfatória, enquanto para a de autogestão 2 e odontologia de grupo, houve 100% de insatisfação. Outro dado encontrado foi que a operadora de odontologia de grupo restringiu os tratamentos selecionados aos pacientes de forma expressiva. Conclui-se que existe a perda de autonomia profissional, desvalorização dos ressarcimentos e precarização do trabalho odontológico na saúde suplementar, demonstrando conflitos éticos nessa relação de trabalho.

Abstract The present study highlighted the labour process of the dental surgeon (DS) in the private healthcare sector from the healthcare professional's perspective based on intervention bioethics. An observational, cross-sectional survey study was performed within the Federal District (Distrito Federal) region. Data were collected from 108 questionnaires completed by DSs affiliated with two types of private health insurers, self-insurance and group insurance, to assess job perception and the degree of job satisfaction in the dentistry market. The main source of dissatisfaction for healthcare professionals was related to the pay for dental procedures by insurers. For self-insurer 1, 38.1% healthcare professionals replied that the pay was satisfactory, whereas in self-insurance 2 and in the group insurance, 100% of healthcare professionals were dissatisfied. Another finding was that the group insurer considerably restricted elective treatments. In conclusion, loss of professional autonomy, depreciation of insurance claims and precarisation of dentistry occurs in the private healthcare sector, thus demonstrating the ethical conflicts in this relationship.

Factors associated with leprosy in a municipality of the Pre-Amazon region, state of Maranhão, Brazil

Abstract INTRODUCTION: The Integrated Program of Leprosy Control was initiated in the municipality of Buriticupu, Maranhão, Brazil, an area considered hyperendemic for leprosy in 2003. It aims at assessing the clinical and epidemiological characteristics of the disease to reduce the detection rate of new cases until 2015. Here, we present the evolution of the indicators of leprosy within the period from 2003 to 2015. METHODS: We conducted a descriptive analytical study based on the active search for and voluntary referral of cases of leprosy. The detection rate of new cases was analyzed over time. We included individuals diagnosed with leprosy between January 2003 and December 2015. The association between categorical variables was assessed using the chi-square test of independence, considering a level of significance of 5%. When the association was significant, the detection rate (with a confidence interval of 95%) was calculated. RESULTS: Overall, 879 new leprosy cases were detected; the majority of the affected individuals were men (65.9%). Multibacillary leprosy was the most common type of the disease, according to the operational classification (55.5%); it showed the strongest association with an age ≥60 years. We also detected an association between the male sex and both, lepromatous and multibacillary leprosy. The detection rate reduced from 211.09/100,000 population in 2003 to 50.26/100,000 population in 2015. CONCLUSIONS: We found an improvement in leprosy control, with a reduction in the detection rate and the absolute number of cases. Strengthening of disease control measures should be prioritized to eliminate leprosy as a public health concern in this municipality.

Yellow fever outbreak in Brazil: the puzzle of rapid viral spread and challenges for immunisation

We discuss the complex eco-social factors involved in the puzzle of the unexpected rapid viral spread in the ongoing Brazilian yellow fever (YF) outbreak, which has increased the reurbanisation risk of a disease without urban cases in Brazil since 1942. Indeed, this rapid spatial viral dissemination to the Southeast and South regions, now circulating in the Atlantic Forest fragments close to peri-urban areas of the main Brazilian megalopolises (São Paulo and Rio de Janeiro) has led to an exponential increase in the number of yellow fever cases. In less than 18 months, 1,833 confirmed cases and 578 deaths were recorded most of them reported in the Southeast region (99,9%). Large epizooties in monkeys and other non-human primates (NHPs) were communicated in the country with 732 YF virus (YFV) laboratory confirmed events only in the 2017/2018 monitoring period. We also discuss the peculiarities and similarities of the current outbreak when compared with previous great epidemics, examining several hypotheses to explain the recent unexpected acceleration of epizootic waves in the sylvatic cycle of the YFV together with the role of human, NHPs and mosquito mobility with respect to viral spread. We conclude that the most feasible hypothesis to explain this rapidity would be related to human behavior combined with ecological changes that promoted a significant increase in mosquito and NHP densities and their contacts with humans. We emphasize the urgent need for an adequate response to this outbreak such as extending immunisation coverage to the whole Brazilian population and developing novel strategies for immunisation of NHPs confined in selected reserve areas and zoos. Finally, we stress the urgent need to improve the quality of response in order to prevent future outbreaks and a catastrophic reurbanisation of the disease in Brazil and other South American countries. Continuous monitoring of YFV receptivity and vulnerability conditions with effective control of the urban vector Aedes aegypti and significant investments in YF vaccine production capacity and research and development for reduction of adverse effects are of the highest priority.

Considerações bioéticas sobre o processo de trabalho do cirurgião dentista na saúde suplementar / Bioethical considerations about the working process of the dentists in the supplementary health care system

INTRODUÇÃO: Conhecer o funcionamento do setor de saúde suplementar na área da odontologia. OBJETIVOS: Avaliar a percepção do cirurgião-dentista, o grau de satisfação, sua autonomia e a vulnerabilidade em relação a seu processo de trabalho em uma análise bioética, bem como sua relação com operadoras de odontologia suplementar no atendimento aos beneficiários dos planos de saúde em duas modalidades: Autogestão e Odontologia de Grupo. MATERIAL E MÉTODO: Trata-se de uma pesquisa do tipo inquérito, cujos dados foram coletados por meio de 108 questionários respondidos por cirurgiões-dentistas em Brasília-DF. Os profissionais foram selecionados ao acaso e foram entrevistados entre os meses de setembro de 2009 e maio de 2010. RESULTADOS: A inserção e consolidação no mercado de trabalho estão insatisfatórias para o cirurgião-dentista (87,1%), bem como o grau de satisfação pelo ressarcimento financeiro da odontologia como prática de trabalho, pois 57,4% dos profissionais responderam que a odontologia como prática de trabalho não atende suas necessidades financeiras. O profissional apresenta vulnerabilidade frente a algumas operadoras que credenciam seus serviços pela injusta remuneração e pela perda da de cisão ético-tecnológica. CONCLUSÕES: O profissional ainda tem certa autonomia para decidir o plano de tratamento, mas encontra-se vulnerável diante do mercado da odontologia suplementar. A reflexão dessas questões à luz da bioética permite redimensionar novas discussões na busca de soluções éticas e políticas que espelhem em dignidade ao profissional e benefícios à população coberta pela assistência suplementar.

INTRODUCTION: The purpose of this study was to analyze the function of the supplementary oral health care system. AIM: The aim of this study was to evaluate the dentist’s perception, job satisfaction, work autonomy and vulnerability about working in the supplemental health system, in the light of bioethical considerations. In addition the study analyzed the relationship between dentists, supplemental dental providers and dental care plans beneficiaries in two modes: self-management and dental group. MATERIAL AND METHOD: This is a survey research and the data were collected through questionnaires answered by 108 dentists in Brasilia-DF, Brazil. The professionals were selected randomly and were interviewed between the months of September 2009 and May 2010. RESULTS: The results showed the labor market integration and consolidation are unsatisfactory for the dental surgeon (87.1%), as well as the degree of satisfaction with the financial compensation of dentistry and practical work, as 57.4% of professionals said that dentistry does not meet your financial needs. Professional showed vulnerability to some operators by unfair compensation and the loss of ethical and technological decision. CONCLUSIONS: Research shows that professional still has some autonomy to decide the treatment of patient, but is vulnerable on the supplemental dental market. The reflection of these issues in the light of bioethics allows pursue further discussions in the search for ethical and policy solutions that reflect dignity and professional benefits to the population covered by the additional assistance.

Características epidemiológicas da febre amarela no Brasil, 2000-2012 / Características epidemiológicas de la fiebre amarilla en Brasil en el período 2000-2012 / Epidemiological characteristics of yellow fever in Brazil, 2000-2012

OBJETIVO: o estudo visa descrever as características epidemiológicas da febre amarela no Brasil no período de 2000 a 2012. MÉTODOS: estudo epidemiológico, ecológico, descritivo, utilizando informações dos bancos de dados do Ministério da Saúde. RESULTADOS: foram confirmados 326 casos de febre amarela no país nesse período, com 156 óbitos e taxa de letalidade média de 47,8%; o grupo de adultos jovens do sexo masculino foi o mais acometido; nas epizootias, foi identificado um total de 2.856 primatas não humanos notificados com suspeita de febre amarela, 31,1% deles confirmados laboratorialmente; no período estudado, foi identificada expansão da área de transmissão silvestre da doença para regiões densamente povoadas, como Sul, Sudeste e Centro-Oeste. CONCLUSÃO: persiste o risco de transmissão urbana da febre amarela, pois a incidência silvestre da doença tem se expandido para regiões onde existe alta infestação do Aedes aegypti, mosquito transmissor do ciclo urbano da doença.

OBJETIVO: el estudio tiene como objetivo describir las características epidemiológicas de la fiebre amarilla en Brasil entre 2000 y 2012. MÉTODOS: estudio epidemiológico descriptivo, ecológico, utilizando información de bases de datos del Ministerio de Salud. RESULTADOS: se confirmaron 326 casos de fiebre amarilla en el país en este periodo, con un total de 156 muertes y una tasa de letalidad de 47,8%; el grupo de adultos jóvenes del sexo masculino fue el más afectado; se identificó un total de 2.856 primates notificados sospechosos de fiebre amarilla, de los cuales 31,1% fueron confirmados laboratoriálmente; en el período estudiado, identificamos una expansión del área de transmisión silvestre de la enfermedad a zonas densamente pobladas como el Sur, Sudeste y Centro-Oeste. CONCLUSIÓN: persiste el riesgo de transmisión de fiebre amarilla, ya que la incidencia de la enfermedad se ha extendido a regiones donde hay una alta infestación de Aedes aegypti, el mosquito transmisor del ciclo urbano de la enfermedad.

OBJECTIVE: this study aims to describe the epidemiological characteristics of yellow fever in Brazil in the period 2000-2012. METHODS: this is a descriptive ecological epidemiological study, using information from Ministry of Health databases. RESULTS: 326 cases of yellow fever were confirmed in Brazil during this period, with 156 deaths and an average case fatality rate of 47.8%; the young male adult age group was the most affected; in epizootic terms, 2,856 suspected cases of yellow fever in non-human primates were reported and 31.1% of these were confirmed by laboratory tests; during the study period the area in which sylvatic transmission of the disease occurs was found to have expanded to densely population regions, such as South, Southeast and Midwest Brazil. CONCLUSION: the risk of urban yellow fever transmission persists, as sylvatic incidence of the disease has expanded to regions with high Aedes aegypti infestation, this being the mosquito responsible for urban transmission of the disease.

Avaliação da completude e da oportunidade das notificações de malária na Amazônia Brasileira, 2003-2012 / Evaluación de la integridad y reporte oportuno de las notificaciones de malaria en la Amazonia brasileña en el período de 2003 a 2012 / Evaluation of the completeness and timeliness of malaria reporting in the Brazilian Amazon, 2003-2012

OBJETIVO: avaliar a completude e oportunidade das notificações, do diagnóstico e do tratamento da malária na Amazônia Legal Brasileira. MÉTODOS: estudo descritivo, com dados de 23 campos das fichas de notificação registradas no Sistema de Informação de Vigilância Epidemiológica da Malária (Sivep-Malária) no período de 2003 a 2012. RESULTADOS: em 86,0% dos campos da ficha de notificação, a completude foi boa (≥90,0% de preenchimento); nas Secretarias Municipais de Saúde, 40,6% das notificações tiveram registro oportuno (0-7 dias após a notificação), e no Ministério da Saúde, 75,6% (0-30 dias após a notificação); o diagnóstico e o tratamento oportunos ocorreram em 44,6% e 45,4% dos pacientes, respectivamente. CONCLUSÃO: a maioria das notificações apresentou boa completude; a oportunidade no registro das notificações ficou aquém dos padrões internacionais; e a oportunidade no diagnóstico e no tratamento revelou-se abaixo das recomendações do Ministério da Saúde.

OBJETIVO: evaluar la integridad de los datos y reporte oportuno de las notificaciones, de diagnóstico y tratamiento de malaria en la Amazonía brasileña. MÉTODOS: estudio descriptivo, con datos de 23 ítems de las fichas de notificación registradas en el Sistema de Información de Malaria (Sivep-Malária), en el periodo 2003-2012. RESULTADOS: el 86,0% de los ítems de la ficha de notificación fueron completados adecuadamente (≥90,0% completado); en las secretarias municipales de salud, 40,6% de las notificaciones tuvieron registro oportuno (0-7 días después de la notificación) y en el Ministerio de Salud, 75,6% (0-30 días después de la notificación); el diagnóstico y tratamiento oportunos ocurrieron en 44,6% y 45,4% de los pacientes, respectivamente. CONCLUSIÓN: la mayoría de las notificaciones mostró una buena integridad; la tasa de registro oportuno de las notificaciones fue inferior a los estándares internacionales y el diagnóstico y tratamiento oportuno fue inferior a lorecomendado por el Ministerio de Salud.

OBJECTIVE: to evaluate the completeness and timeliness of malaria case reporting, diagnosis and treatment in the Brazilian Amazon. METHODS: this is a descriptive study using data from 23 fields of notification forms recorded on the Malaria Epidemiological Surveillance Information System (Sivep-Malaria) between 2003 and 2012. RESULTS: data completeness was good in 86,0% of fields (≥90,0% filled in); there was timely recording of 40,6% of notifications at the Municipal Health Departments (0-7 days following notification) and 75,6% at the Ministry of Health (0-30 days following notification); timely diagnosis and timely treatment occurred in 44,6% and 45,4% of patients, respectively. CONCLUSION: most notification forms had good completeness; timeliness in recording notifications was below international standards; timeliness of diagnosis and treatment was below the Ministry of Health recommendations.

Ten years of a hantavirus disease emergency in the Federal District, Brazil

Abstract: INTRODUCTION: Hantavirus diseases are emerging human diseases caused by Hantavirus spp. of the Bunnyaviridae family. Hantavirus pulmonary syndrome (HPS) has been detected in the Federal District (DF) of Brazil since 2004. Among the 27 Brazilian Federal Units, DF has the highest fatality rate. More than 10 years have already passed since then, with confirmation of cases caused by the Araraquara and Paranoa species. The reservoir is Necromys lasiurus. METHODS: Local surveillance data of the confirmed cases were analyzed, including age, sex, month and year of occurrence, clinical symptoms, syndromes and outcomes, and probable transmission place (PTP). The cases were mainly confirmed by IgM detection with a capture enzyme immunoassay. The cases were classified as autochthonous if PTPs were in the DF area. RESULTS: From 2004 to 2013, in the DF, 126 cases of hantavirus were confirmed, and the cumulative incidence was 5.0 per 100,000 inhabitants. The occurrence of cases was predominantly from April to August. At least 75% of the cases were autochthonous. Acute respiratory failure was reported in 47.5% of cases, and the fatality rate was 40%. CONCLUSIONS: In the DF, the cumulative incidence of HPS was one of the highest worldwide. A seasonal pattern of hantavirus disease in the dry season is clear. There was a high frequency of severe clinical signals and symptoms as well as a high fatality rate. For the near future, visitors and inhabitants of DF rural areas, particularly male adults, should receive continuous education about hantavirus transmission and prevention.

A historical perspective on malaria control in Brazil

Malaria has always been an important public health problem in Brazil. The early history of Brazilian malaria and its control was powered by colonisation by Europeans and the forced relocation of Africans as slaves. Internal migration brought malaria to many regions in Brazil where, given suitableAnopheles mosquito vectors, it thrived. Almost from the start, officials recognised the problem malaria presented to economic development, but early control efforts were hampered by still developing public health control and ignorance of the underlying biology and ecology of malaria. Multiple regional and national malaria control efforts have been attempted with varying success. At present, the Amazon Basin accounts for 99% of Brazil’s reported malaria cases with regional increases in incidence often associated with large scale public works or migration. Here, we provide an exhaustive summary of primary literature in English, Spanish and Portuguese regarding Brazilian malaria control. Our goal was not to interpret the history of Brazilian malaria control from a particular political or theoretical perspective, but rather to provide a straightforward, chronological narrative of the events that have transpired in Brazil over the past 200 years and identify common themes.

The changing distribution of malaria in the Brazilian Amazon, 2003-2004 and 2008-2009

Introduction More than half of the malaria cases reported in the Americas are from the Brazilian Amazon region. While malaria is considered endemic in this region, its geographical distribution is extremely heterogeneous. Therefore, it is important to investigate the distribution of malaria and to determine regions whereby action might be necessary. Methods Changes in malaria indicators in all municipalities of the Brazilian Amazon between 2003-2004 and 2008-2009 were studied. The malaria indicators included the absolute number of malaria cases and deaths, the bi-annual parasite incidence (BPI), BPI ratios and differences, a Lorenz curve and Gini coefficients. Results During the study period, mortality from malaria remained low (0.02% deaths/case), the percent of municipalities that became malaria-free increased from 15.6% to 31.7%, and the Gini coefficient increased from 82% to 87%. In 2003, 10% of the municipalities with the highest BPI accumulated 67% of all malaria cases, compared with 2009, when 10% of the municipalities (with the highest BPI) had 80% of the malaria cases. Conclusions This study described an overall decrease in malaria transmission in the Brazilian Amazon region. As expected, an increased heterogeneity of malaria indicators was found, which reinforces the notion that a single ...

Spatial dependence of malaria epidemics in municipalities of the Brazilian Amazon / Dependência espacial das epidemias de malária em municípios da Amazônia Brasileira

Introduction: In 2010, there were 305 (37.8%) municipalities with malaria epidemics in the Brazilian Amazon. The epidemics spread can be explained by the spatial distribution pattern. Objective: To analyze the spatial dependence, autocorrelation, of the malaria epidemics in the municipalities of this region. Methods: An automated algorithm was used for the detection of epidemic municipalities in 2003, 2007 and 2010. Spatial dependence was analyzed by applying the global and local Moran index on the epidemic months proportion variable. The epidemic municipalities clusters were identified using the TerraView software. Results: The global Moran index values were 0.4 in 2003; 0.6 in 2007; and 0.5 in 2010 (p = 0.01), confirming the spatial dependence among the epidemic municipalities. Box Map and Moran Map identified inter-municipal, interstate and borders clusters with spatial autocorrelation (p < 0.05). There were 10 epidemic municipalities clusters in 2003; 9 in 2007 and 8 in 2010. Discussion: The epidemic municipalities clusters may be linked to the health facilities difficulties on acting together. The structural limitations of the health services can be overcome by territorial integration to support planning and control activities, strengthening the interventions. Conclusion: The routine analysis of the epidemic municipalities clusters with spatial and temporal persistence may provide a new indicator of planning and integrated control prioritization, contributing to malaria epidemics reducing in inter-municipal, interstate and borders areas. .

Introdução: Em 2010, foram observados 305 (37,8%) municípios com epidemias de malária na Amazônia brasileira. A propagação dos eventos epidêmicos pode ser explicada pelo padrão da distribuição espacial. Objetivo: Analisar a dependência espacial, autocorrelação, das epidemias de malária nos municípios dessa região. Métodos: Foi utilizado algoritmo automatizado para detecção dos municípios epidêmicos nos anos de 2003, 2007 e 2010. A dependência espacial foi analisada por meio da variável proporção de meses epidêmicos, aplicando-se os índices de Moran global e local. Foram identificados os agrupamentos de municípios epidêmicos com o programa TerraView. Resultados: Os valores do índice global de Moran foram 0,4 em 2003; 0,6 em 2007; e 0,5 em 2010 (p = 0,01), confirmando a existência de dependência espacial entre os municípios epidêmicos. O Box Map e o Moran Map identificaram agrupamentos intermunicipais, interestaduais e fronteiriços com autocorrelação espacial estaticamente significante, sendo 10 clusters em 2003; 9 em 2007; e 8 em 2010 (p < 0,05). Discussão: Agrupamentos de municípios epidêmicos podem estar vinculados às dificuldades dos serviços de saúde em atuar articuladamente. Limitações estruturais podem ser superadas buscando a integração territorial para sustentação do planejamento e ações de controle, potencializando as intervenções no contexto espacial abrangente. Conclusão: A análise rotineira da autocorrelação espacial entre municípios epidêmicos, identificando os agrupamentos com persistência espaço-temporal, poderá fornecer novo indicador de grande utilidade para o planejamento e priorização ...

Plasmodium vivax malaria elimination: should innovative ideas from the past be revisited?

In the 1950s, the strategy of adding chloroquine to food salt as a prophylaxis against malaria was considered to be a successful tool. However, with the development of Plasmodium resistance in the Brazilian Amazon, this control strategy was abandoned. More than 50 years later, asexual stage resistance can be avoided by screening for antimalarial drugs that have a selective action against gametocytes, thus old prophylactic measures can be revisited. The efficacy of the old methods should be tested as complementary tools for the elimination of malaria.

Algoritmo para monitoramento da incidência da malária na Amazônia brasileira, 2003 a 2010 / An algorithm to monitor the incidence of malaria in the Brazilian Amazon, 2003 to 2010

OBJETIVO: Avaliar um algoritmo para detecção da variação da incidência da malária nos municípios da Amazônia brasileira. MÉTODOS: Avaliou-se um sistema de monitoramento automatizado, baseado em um algoritmo desenvolvido anteriormente pelos autores. O algoritmo utiliza o diagrama de controle por quartis para classificação dos municípios em quatro grupos, conforme a variação da incidência da malária: grupo 1 (redução da incidência)-aqueles com incidência abaixo dos valores esperados; grupo 2 (incidência esperada)-aqueles com incidência dentro dos valores esperados; grupo 3 (epidemia)-aqueles com incidência acima dos valores esperados; grupo 4 (caso esporádico)-aqueles com apenas um caso durante o ano. O período de análise foi de 2003 a 2010. Foram estudados todos os municípios existentes nos nove estados que compõem a Amazônia brasileira (805 municípios em 2003 e 807 a partir de 2004). RESULTADOS: Com base nessa metodologia, os municípios da região foram assim classificados: grupo 1, 152 municípios (18,8% da região) em 2003 e 109 (13,5%) em 2010; grupo 2, 206 (25,6%) em 2003 e 331 (41,0%) em 2010; grupo 3, 391 (48,6%) em 2003 e 308 (38,2%) em 2010; e grupo 4, 56 (7,0%) em 2003 e 59 (7,3%) em 2010. CONCLUSÕES: O algoritmo possibilitou verificar que, na Amazônia brasileira, o número de municípios com epidemias de malária em 2010 diminuiu em relação a 2003, enquanto o número de municípios com incidência esperada aumentou. No mesmo período, houve pouca variação no número de municípios com redução da incidência e daqueles com casos esporádicos.

OBJECTIVE: To evaluate an algorithm developed for detecting variations in the incidence of malaria in the Brazilian Amazon. METHODS: An evaluation was conducted of an automated monitoring system based on an algorithm that had been previously developed by the authors. The algorithm employs quartile diagrams to classify municipalities according to variations in the incidence of malaria: group 1 (reduced incidence)-municipalities with below the expected incidence rates; group 2 (expected incidence)- within the expected incidence rates; group 3 (epidemics)-higher than the expected incidence rates; and group 4 (sporadic case)-a single case during a year. The period from 2003 to 2010 was analyzed. All the municipalities in the nine states that make up the Brazilian Amazon were studied (805 municipalities in 2003 and 807 starting in 2004). RESULTS: Based on this method, Amazonian municipalities were classified as follows: group 1, 152 (18.8%) municipalities in 2003 and 109 (13.5%) in 2010; group 2, 206 (25.6%) municipalities in 2003 and 331 (41.0%) in 2010; group 3, 391 (48.6%) municipalities in 2003 and 308 (38.2%) in 2010; and group 4, 56 (7.0%) municipalities in 2003 and 59 (7.3%) in 2010. CONCLUSIONS: The use of the algorithm revealed that in 2010, the number of Amazonian municipalities in group 3 (epidemics) decreased when compared to 2003, while the number of municipalities in group 2 (expected incidence) increased. In the same period, there was no significant variation in the number of municipalities in group 1 (reduced incidence) and in group 4 (sporadic case).

Risk factors for prolonged hospital stay after isolated coronary artery bypass grafting / Fatores de risco para tempo de internação prolongada após revascularização isolada do miocárdio

INTRODUCTION: Characteristics of the patient and the coronary artery bypass grafting may predispose individuals to prolonged hospitalization, increasing costs and morbidity and mortality. OBJECTIVE: The objective of this study was to evaluate individual and perioperative risk factors of prolonged hospitalization in intensive care units and wards. METHODS: We conducted a case-control study of 104 patients undergoing isolated coronary artery bypass grafting with cardiopulmonary bypass. Patients hospitalized >3 days in the intensive care unit or >7 days in the ward were considered for the study. The association between variables was estimated by the chi-square test, odds ratio and logistic regression; P <0.05 was considered statistically significant. RESULTS: Hospital stay >3 days in the intensive care unit occurred for 22.1% of patients and >7 days in the ward for 27.9%. Among preoperative factors, diabetes (OR=3.17) and smoking (OR=4.07) were predictors of prolonged intensive care unit stay. Combining the pre-, intra-and postoperative variables, only mechanical ventilation for more than 24 hours (OR=6.10) was predictive of intensive care unit outcome. For the ward outcome, the preoperative predictor was left ventricular ejection fraction <50% (OR=3.04). Combining pre- and intraoperative factors, diabetes (OR=2.81), and including postoperative factors, presence of infection (OR=4.54) were predictors of prolonged hospitalization in the ward. CONCLUSION: Diabetes and smoking were predictors of intensive care unit outcome, and ejection fraction <50% of ward outcome. For the set of perioperative factors, prolonged hospitalization after isolated coronary artery bypass grafting was associated with mechanical ventilation >24 hours for the intensive care unit and presence of infection for the ward.

INTRODUÇÃO: Características do paciente e da cirurgia de revascularização do miocárdio podem predispor à internação prolongada, aumentando custos e a morbimortalidade. OBJETIVO: Avaliar fatores de risco individuais e transoperatórios para internação prolongada na unidade de terapia intensiva e na enfermaria. MÉTODOS: Realizou-se estudo de caso-controle com 104 pacientes submetidos à revascularização do miocárdio isolada sob circulação extracorpórea. Consideraram-se casos os pacientes com internação >3 para terapia intensiva ou >7 dias para enfermaria. A associação entre variáveis foi estimada pelo teste do qui-quadrado e pela razão de chances (odds ratio-OR) empregando-se a regressão logística, ao nível de P<0,05. RESULTADOS: A permanência >3 dias na terapia intensiva ocorreu em 22,1% dos pacientes e >7 dias na enfermaria em 27,9%. Entre os fatores pré-operatórios, o diabetes (OR=3,17) e o tabagismo (OR=4,07) foram os preditores para permanência prolongada na terapia intensiva. Combinando-se as variáveis pré-, intra- e pós-operatórias, somente a ventilação mecânica por mais que 24 horas (OR=6,10) foi preditora para o desfecho na terapia intensiva. Para o desfecho na enfermaria, o preditor pré-operatório foi a fração de ejeção ventricular esquerda <50% (OR=3,04). Combinando os fatores pré- e intraoperatórios, o diabetes (OR=2,81) e, somando-se os pós-operatórios, a presença de infecção (OR=4,54), foram os preditores para internação prolongada na enfermaria. CONCLUSÃO: Diabetes e tabagismo foram os preditores para o desfecho na terapia intensiva, e a fração de ejeção <50% para a enfermaria. Para o conjunto dos fatores transoperatórios, internação prolongada após revascularização do miocárdio isolada associou-se à ventilação mecânica >24 horas para terapia intensiva e à presença de infecção para a enfermaria.

Caracterização das epidemias de malária nos municípios da Amazônia Brasileira em 2010 / Characteristics of malaria epidemics in the municipalities of the Brazilian Amazon, 2010 / Caracterización de las epidemias de malaria en los municipios de la Amazonia brasileña en 2010

Malaria epidemics occur annually in various municipalities (counties) in the Brazilian Amazon. However, health services do not systematically adopt tools to detect and promptly control these events. This article aimed to characterize malaria epidemics in the Brazilian Amazon Region based on their duration, the Plasmodium species involved, and the population's degree of vulnerability. An automatic malaria incidence monitoring system based on quartiles was assessed for prompt identification of malaria epidemics. In 2010, epidemics were identified in 338 (41.9%) of the counties in the Brazilian Amazon. P. falciparum and P. vivax epidemics were detected, both singly and in combination. Epidemics lasted from 1 to 4 months in 58.3% of the counties, 5 to 8 months in 34.5%, and 9 to 12 months in 17.4%. Systematic monitoring of malaria incidence could contribute to early detection of epidemics and improve the effectiveness of control measures.

Epidemias de malária ocorrem anualmente nos municípios da Região Amazônica, Brasil, no entanto os serviços de saúde não adotam, de maneira sistemática, instrumentos para detecção e contenção oportunas desses eventos. O objetivo foi caracterizar as epidemias de malária na região segundo duração, espécie de Plasmodium e vulnerabilidade das populações. Foi avaliado um sistema de monitoramento automatizado da incidência da malária, com base no diagrama de controle segundo quartis, para identificar as epidemias da doença. Em 2010, ocorreram epidemias em 338 (41,9%) municípios da região. Houve epidemias por P. falciparum e por P. vivax, separadamente, e também por ambas as espécies. Epidemias com duração de um a quatro meses ocorreram em 58,3% dos municípios epidêmicos; de cinco a oito meses, em 24,3%; e de nove a 12 meses, em 17,4%. O monitoramento automatizado da variação da incidência da malária poderá contribuir para detecção precoce das epidemias e melhorar o seu controle oportuno.

Las epidemias de malaria ocurren anualmente en los municipios de la Región Amazónica, Brasil, no obstante, los servicios de salud no adoptan de manera sistemática instrumentos para la detección y contención oportuna de este tipo de eventos. El objetivo fue caracterizar las epidemias de malaria en la región según su duración, especie de Plasmodium y vulnerabilidad de las poblaciones. Se evalúo un sistema de supervisión automatizado de la incidencia de la malaria, en base al diagrama de control según cuartiles, con el fin de identificar las epidemias de la enfermedad. En 2010, se produjeron epidemias en 338 (41,9%) municipios de la región. Hubo epidemias por P. falciparum y por P. vivax, separadamente, y también por ambas especies. Hubo epidemias con una duración de uno a cuatro meses que se produjeron en un 58,3% de los municipios epidémicos; de cinco a ocho meses, en un 24,3%; y de nueve a 12 meses, en un 17,4%. La supervisión automatizada de la variación de la incidencia de la malaria podrá contribuir a la detección precoz de las epidemias y mejorar su control adecuado.