Impacto e adesão à fortificação caseira com múltiplos micronutrientes em pó (MNP) na anemia e deficiência de micronutrientes em crianças de Rio Branco - Acre, Amazônia Ocidental Brasileira / Impact and adherence to the home fortification with multiple micronutrients in powder (MNP) on anemia and micronutrient deficiencies in children living in Rio Branco Acre, Western Brazilian Amazon

Introdução: A anemia afeta 273 milhões (43 por cento) de crianças pré-escolares em todo o mundo e constitui-se uma prioridade mundial dado seu risco para morbidade infantil, prejuízo no desenvolvimento e repercussões na vida adulta. A fortificação caseira (FC) com múltiplos micronutrientes em pó (MNP) consiste em uma das estratégias mais promissoras para reduzir anemia e deficiência de micronutrientes em crianças de 6 a 23 meses. Contudo, a baixa adesão tem sido uma barreira para o seu sucesso. Poucos são os estudos que têm avaliado os fatores que influenciam a adesão ao uso dos MNP a fim de melhorar a efetividade de sua implementação. Objetivo: Avaliar o impacto da FC com MNP na anemia e deficiência de micronutrientes em crianças do município de Rio Branco, Acre, bem como a aceitação delas e os fatores associados à adesão dos cuidadores à intervenção. Métodos: Esta investigação integra o Estudo Nacional de Fortificação caseira da Alimentação Complementar (ENFAC), estudo multicêntrico realizado nos anos de 2012 e 2013 em quatro cidades brasileiras (Rio Branco, Olinda, Goiânia e Porto Alegre), cujo delineamento foi do tipo ensaio clínico pragmático controlado em Unidades Básicas de Saúde (UBSs). Para a presente análise, foram considerados dados da cidade de Rio Branco Acre. No início do estudo, 150 crianças de 11 a 14 meses de idade foram recrutadas para composição do grupo controle (GC), na rotina de puericultura. Simultaneamente, e nas mesmas UBSs, 126 crianças de 6 a 8 meses de idade compuseram o grupo intervenção (GI) para receber FC com MNP adicionado diariamente na alimentação complementar (AC). A efetividade dos MNP foi avaliada comparando-se os grupos após 4-6 meses do início da intervenção, com os participantes do GI estando com a mesma idade do GC (11 a 14 meses). Os desfechos de interesse foram prevalências de anemia, DF, DVA, e outros micronutrientes; indicadores bioquímicos de inflamação e morbidades bem como o impacto do uso da fortificação nesses indicadores nutricionais e os fatores que influenciaram a adesão ao uso do sachê com MNP. Utilizaram-se teste de qui-quadrado de Pearson, teste de t Student ou de Mann-Whitney U e modelos de regressão de Poisson. Resultados: Os fatores associados à prevalência de anemia e o risco para esse desfecho foram: mãe ter mais de um filho [razão de prevalência (RP) (IC 95 por cento): 2,11 (1,06; 4,19)], ausência de TV a cabo ou internet no domicílio (como marcador de riqueza) [4,57 (1,13; 18,47)] e presença de desnutrição (escore Z do índice altura/idade prevalência de anemia nas crianças estudadas. A respeito da DF, entre crianças cujas mães possuíam maior escolaridade a deficiência foi 17 por cento menor comparadas àquelas com menor escolaridade. A ITARPAF representou risco 26 por cento maior de DF em relação aos que tiveram a AC introduzida oportunamente. A DVA também foi associada à maior DF [1,37 (1,17; 1,61)]. Após a fortificação com MNP, as crianças do GI mostraram um risco menor de DF (72,4 por cento versus 25,2 por cento), DVA (18,4 por cento vs 4,7 por cento), de insuficiência de vitamina E (73,4 por cento vs 33,6 por cento), de infecção (Proteína C-reativa>5 mg/l: 21 por cento vs 9,5 por cento; Alfaglicoproteína >1g/l: 41 por cento vs 26,7 por cento), tosse (68,8 por cento vs 37,5 por cento) e chiado no peito (46,1 por cento vs 8,9 por cento), quando comparadas com as crianças do GC. Embora a aceitabilidade ao sachê tenha sido considerada boa ou excelente por 65,5 por cento dos cuidadores, a adesão completa à estratégia (60 sachês em 2-3 meses) foi de apenas 29 por cento das crianças estudadas. Os fatores relacionados à baixa adesão ao uso do sachê com MNP foram: hospitalização da criança no ano anterior à pesquisa [RP (IC 95 por cento): 1,68 (1,14; 2,45)], ter mãe adolescente [1,48 (1,01; 2,18)] e introdução precoce de fórmula infantil [1,92 (1,13; 3,29)]; já as crianças que iniciaram a AC com fruta tiveram melhor adesão ao consumo do sachê [0,56 (0,34; 0,93)]. Conclusão: Em uma área com marcantes iniquidades sociais de acesso a bens e serviços e de alta carga de morbidade, nossos achados ratificam o papel das deficiências de micronutrientes e infecção no risco para anemia, DF e DVA. O aconselhamento nutricional permanente quanto às práticas alimentares saudáveis na infância deve ser integrado à estratégia do MNP a fim de reduzir DF, DVA e de outros micronutrientes, assim como algumas morbidades. A incorporação da fortificação com múltiplos micronutrientes em pó deve considerar uma atenção redobrada às mães adolescentes no serviço de atenção primária à saúde nesta região da Amazônia

Background: Anemia affects 273 million (43 per cent) of preschoolers around the world and is a global priority given its risk for child morbidity, developmental impairment and repercussions in adult life. Home fortification (HF) with multiple micronutrients powder (MNP) consists in one of the most promising strategies to reduce micronutrient deficiency and anemia in children aged 6-23 months. However, the poor compliance has been a barrier to its success. Few studies have evaluated the factors that influence MNP adherence in order to improve the effectiveness of its implementation. Objective: To assess the impact of home fortification with MNP on anemia and deficiency of micronutrients in children as well as the acceptance of them and the factors associated to the caregivers adherence to the intervention. Methods: This research is part of the Estudo Nacional de Fortificação caseira da Alimentação Complementar (ENFAC), a multicentre pragmatic controlled clinical trial carried out in the years of 2012 and 2013 in Basic Health Units (BHUs) from four Brazilian cities (Rio Branco, Olinda, Goiânia e Porto Alegre). For the present analysis, data from the city of Rio Branco - Acre were considered. In the beginning of the study, 150 children aged 11 to 14 months were recruited for composition of control group (CG), in childcare routine. Simultaneously, and in the same BHUs, 126 children aged 6 to 8 months comprised the intervention group (GI) to receive HF with MNP added daily in the complementary feeding (CF). The effectiveness of MNP was evaluated by comparing the groups after 4-6 months of the beginning of the intervention, with the GI participants being of the same age as the CG (11 to 14 months). Outcomes of interest were prevalence of anemia, ID, VAD, and other micronutrients; biochemical indicators of inflammation and morbidities as well as the impact of the use of fortification on these nutritional indicators and the factors that influenced adherence to the sachet use with MNP. Pearsons 2 test, Students t test or the MannWhitney U test and Poisson regression models were used in the analysis. Results: The main factors that influenced the prevalence of anemia and the risk of this outcome were: the mother having more than one child [prevalence ratio (CI 95 per cent): 2.11 (1.06; 4.19)], living in households without access to cable TV or internet (as a marker of wealth) [4.57 (1.13; 18.47)] and presence of stunting (Z-scores for length/height for- age < -2) [2.28 (1.28; 4.09)]. Late introduction of iron-rich foods or which promote its absorption [1.92 (1.10; 3.37)], presence of inflammation/infection [2.21 (1.38; 3.54)] and vitamin A [1.85 (1.05; 3.28)] and vitamin B12 deficiencies [1.90 (1.05; 3.46)] were also related with > risk of anemia in the study children. Regarding ID, among children whose mothers had a higher level of schooling a 17 per cent lower risk was observed when compared to those with lower schooling. The late introduction of iron-rich foods represented a 26 per cent higher risk of ID in relation to those who had the CF introduced timely. The VAD was also associated with highest ID risk [1.37 (1.17; 1.61)]. The IG children after home fortification with MNP showed a lower risk of ID (72.4 per cent versus 25.2 per cent), VAD (18.4 per cent vs 4.7 per cent), of vitamin E insufficiency (73,4 per cent vs 33,6 per cent), of infection (C-reactive protein>5 mg/l: 21 per cent vs 9.5 per cent; 1-acid glycoprotein>1g/l: 41 per cent vs 26.7 per cent), cough (68.8 per cent vs 37.5 per cent) and wheezing (46.1 per cent vs 8.9 per cent), when compared with the CG children. Although the overall acceptability of the MNP sachet was considered good or excellent by 65.5 per cent of caregivers, the complete adherence to the strategy (60 sachets in 2-3 months) was reached in only 29 per cent of the study children. The main factors related to the low adherence to the use of the MNP sachet were: hospitalization of the child in the year prior to the survey [prevalence ratio (CI 95 per cent): 1.68 (1.14, 2.45)], having teenage mother [1.48 (1.01; 2.18)] and early introduction of infant formula [1.92 (1.13; 3.29)]; children who started timely the CF with fruits had better adherence to the sachet consumption [0.56 (0.34, 0.93)]. Conclusion: In an area with marked social inequities in access to goods and services and with high burden of morbidity, our findings confirm the role of micronutrient deficiencies and infection status in the risk for anemia, ID and VAD. The continuous nutritional counseling to promote healthy eating practices in childhood should be integrated to the MNP strategy for reducing ID, VAD and other micronutrient deficiencies, as well as some morbidities. The implementation of MNP fortification should consider an increased attention to adolescent mothers in the primary health care services in this Amazonian region

Child undernutrition in one of the cities with greater nutritional risk in Brazil: population-based study in the Western Brazilian Amazon. / Desnutrição infantil em um dos municípios de maior risco nutricional do Brasil: estudo de base populacional na Amazônia Ocidental Brasileira.

OBJECTIVE:: To estimate the prevalence of child undernutrition and associated factors in a municipality with high nutritional risk in Brazil. METHODS:: This cross-sectional, population-based study was conducted with a sample of 478 children aged under 5 years in the city of Jordão, Acre, Brazil. The following indicators were calculated: weight for age (W/A), height for age (H/A), and weight for height (W/H), using the growth curves of the WHO as reference, which adopts a cutoff of -2 z scores for identification of malnourished children. Adjusted prevalence ratios (PRs) were obtained using multiple Poisson regression models with robust error estimate (p < 0.05). RESULTS:: A high prevalence of stunting (35.8%) was observed. Children with indigenous ancestry living in rural areas showed the highest prevalence of malnutrition (59.4%). After controlling for age, gender, and indigenous ancestry, the factors associated with stunting risk were: living in rural area (PR = 1.6; 95%CI 1.2 - 2.1); lower tertile of household wealth index (PR = 1.6; 95%CI 1.1 - 2.3); living in houses made of walking palm (PR = 1.6; 95%CI 1.1 - 2.4); maternal height less than or equal to 146.4 cm (PR = 3.1; 95%CI 1.9 - 5.0); and history of introduction of cow's milk before 30 days of age (PR = 1.4; 95%CI 1.0 - 1.8). Children with updated vaccination cards were inversely associated with stunting risk (PR = 0.7; 95%CI 0.5 - 0.9). CONCLUSION:: Child undernutrition remains a serious public health problem in the Amazon, indicating additional difficulties in facing the problem in this region of the country.

Prevalence of nutritional deficiencies and morbidity by infectious diseases in children 0-5 years of age in Iñapari in the Peruvian Amazon

Introduction: Iñapari is a town located in Peru, on the border of Brazil, between the Amazonian states of Acre and Amazonas. The local Peruvian children under five years of age present moderate anemia while the percentage of chronic child malnutrition is a major public health problem in the country as a whole. Goals: The purpose of this study was to identify the prevalence of major childhood morbidities caused by anemia, malnutrition, intestinal parasites, toxocariasis, and hepatitis A, and identify connections with the socioeconomic and environmental conditions found in Iñapari. Methods: Interviews with questionnaires; anthropometric measurements, collection of feces and venous blood samples. Results: A 20% prevalence of anemia and 8.5% prevalence of chronic malnutrition (height for age deficiency) was found. A pathogenic intestinal parasite was noted in 24.5% of the samples, where Giardia intestinalis (14.7%) was the most frequent. The seroprevalence of toxocariasis was 33.8% and hepatitis A was 21.2%. Conclusion: There is a connection between the results found and the poor living and sanitary conditions of the population. The low income noted is also linked to the malnutrition and anemia detected

Desnutrição infantil em um dos municípios de maior risco nutricional do Brasil: estudo de base populacional na Amazônia Ocidental Brasileira / Child undernutrition in one of the cities with greater nutritional risk in Brazil: population-based study in the Western Brazilian Amazon

RESUMO: Objetivo: Estimar a prevalência de desnutrição infantil e fatores associados em um município de elevado risco nutricional do Brasil. Métodos: Estudo transversal de base populacional com amostra de 478 crianças menores de 5 anos do município de Jordão, Acre. Foram calculados os indicadores peso para idade (P/I), altura para idade (A/I) e peso para altura (P/A) utilizando como referências as curvas de crescimento da Organização Mundial da Saúde de 2006, que adota ponto de corte -2 escores z para identificação dos desnutridos. Razões de prevalência (RP) ajustadas foram obtidas por modelos múltiplos de regressão de Poisson com estimativa de erro robusta (p < 0,05). Resultados: Observou-se elevada prevalência de déficit de A/I (35,8%). Crianças com ascendência indígena residentes na área rural do município apresentaram as maiores prevalências de desnutrição (59,4%). Após ajuste para sexo, idade e ascendência indígena, os fatores positivamente associados ao déficit de crescimento foram: residir na área rural (RP = 1,6; IC95% 1,2 - 2,1); menor terço do índice de riqueza domiciliar (RP = 1,6; IC95% 1,1 - 2,3); morar em casa de paxiúba (RP = 1,6; IC95% 1,1 - 2,4); altura materna inferior ou igual a 146,4 cm (RP = 3,1; IC95% 1,9 - 5,0) e introdução de leite de vaca antes de 30 dias de idade (RP = 1,4; IC95% 1,0 - 1,8). Apresentar cartão de vacina em dia foi inversamente associado ao déficit de crescimento (RP = 0,7; IC95% 0,5 - 0,9). Conclusão: A desnutrição infantil permanece um grave problema de saúde pública no interior da Amazônia, indicando dificuldades adicionais para o enfrentamento do problema nessa região do país.

ABSTRACT: Objective: To estimate the prevalence of child undernutrition and associated factors in a municipality with high nutritional risk in Brazil. Methods: This cross-sectional, population-based study was conducted with a sample of 478 children aged under 5 years in the city of Jordão, Acre, Brazil. The following indicators were calculated: weight for age (W/A), height for age (H/A), and weight for height (W/H), using the growth curves of the WHO as reference, which adopts a cutoff of -2 z scores for identification of malnourished children. Adjusted prevalence ratios (PRs) were obtained using multiple Poisson regression models with robust error estimate (p < 0.05). Results: A high prevalence of stunting (35.8%) was observed. Children with indigenous ancestry living in rural areas showed the highest prevalence of malnutrition (59.4%). After controlling for age, gender, and indigenous ancestry, the factors associated with stunting risk were: living in rural area (PR = 1.6; 95%CI 1.2 - 2.1); lower tertile of household wealth index (PR = 1.6; 95%CI 1.1 - 2.3); living in houses made of walking palm (PR = 1.6; 95%CI 1.1 - 2.4); maternal height less than or equal to 146.4 cm (PR = 3.1; 95%CI 1.9 - 5.0); and history of introduction of cow's milk before 30 days of age (PR = 1.4; 95%CI 1.0 - 1.8). Children with updated vaccination cards were inversely associated with stunting risk (PR = 0.7; 95%CI 0.5 - 0.9). Conclusion: Child undernutrition remains a serious public health problem in the Amazon, indicating additional difficulties in facing the problem in this region of the country.

Stunting in children under five years old is still a health problem in the Western Brazilian Amazon: a population-based study in Assis Brasil, Acre, Brazil.

Despite the process of nutritional transition in Brazil, in some places, such as the Amazon region, stunting is still an important public health problem. We identified the prevalence and factors associated with stunting in children under five years old residing in the urban area of Assis Brasil. A survey was conducted in which a questionnaire on socioeconomic, maternal and children's conditions was applied, and height or length was measured. The children with height for age index below -2 Z-scores were considered stunted, according to the criteria by the World Health Organization. Four hundred and twenty-eight children were evaluated. Of these, 62 were stunted. Factors associated with stunting, according to adjusted models, were: the presence of open sewer, the wealth index for households, the receipt of governmental financial aid and the mother's height, age and education. Therefore, it was observed that family and the mother's characteristics as well as environmental and socioeconomic factors were closely related to the occurrence of stunting in the population studied, and such nutritional disturbance is still a health problem in the Brazilian Amazon.

Stunting in children under five years old is still a health problem in the Western Brazilian Amazon: a population-based study in Assis Brasil, Acre, Brazil / Nanismo em crianças menores de cinco anos de idade ainda é um problema de saúde na Amazônia Ocidental Brasileira: um estudo de base populacional em Assis Brasil, Acre, Brasil

Abstract Despite the process of nutritional transition in Brazil, in some places, such as the Amazon region, stunting is still an important public health problem. We identified the prevalence and factors associated with stunting in children under five years old residing in the urban area of Assis Brasil. A survey was conducted in which a questionnaire on socioeconomic, maternal and children’s conditions was applied, and height or length was measured. The children with height for age index below -2 Z-scores were considered stunted, according to the criteria by the World Health Organization. Four hundred and twenty-eight children were evaluated. Of these, 62 were stunted. Factors associated with stunting, according to adjusted models, were: the presence of open sewer, the wealth index for households, the receipt of governmental financial aid and the mother’s height, age and education. Therefore, it was observed that family and the mother’s characteristics as well as environmental and socioeconomic factors were closely related to the occurrence of stunting in the population studied, and such nutritional disturbance is still a health problem in the Brazilian Amazon.

Resumo Apesar do processo de transição nutricional no Brasil, em alguns lugares, como a região amazônica, o nanismo ainda é um importante problema de saúde pública. Identificou-se a prevalência e fatores associados ao déficit de crescimento em crianças menores de cinco anos de idade residentes na área urbana de Assis Brasil. Um inquérito foi realizado utilizando instrumento semiestruturado sobre características socioeconômicas, maternas e das crianças, e foram aferidas medidas antropométricas. As crianças com índice de estatura para idade inferior a -2 escores-Z foram consideradas com déficit de crescimento, de acordo com os critérios da Organização Mundial da Saúde. Quatrocentos e vinte e oito crianças foram avaliadas. Destas, 62 apresentaram déficit de crescimento. Os fatores associados à baixa estatura, de acordo com modelos ajustados, foram: presença de esgoto a céu aberto, índice de riqueza para as famílias, recebimento de ajuda financeira governamental, altura materna, idade e escolaridade maternas. Portanto, observou-se que as características familiares e da mãe, bem como fatores ambientais e socioeconômicos estavam intimamente relacionados com a ocorrência de déficit de crescimento na população estudada, e que a desnutrição ainda é um problema de saúde na Amazônia brasileira.

Anemia and micronutrient deficiencies in infants attending at Primary Health Care in Rio Branco, Acre, Brazil.

The present study investigated the factors associated with anemia and micronutrient deficiencies in a cross-sectional analysis conducted with 150 children aged 11 to 14 months attending at basic health centers in Rio Branco, Acre. Venous blood samples were obtained to assess the occurrence of anemia and deficiencies of iron (ID), vitamin A (VAD), and B12 (VB12D). Multiple Poisson regression models were used to identify factors associated with anemia. Anemia, ID, VAD and B12D were observed in 23%, 76%, 18% and 20% of children, respectively. The factors associated with anemia were: do not be only child, living in households without access to cable TV or internet, stunting, late introduction of the complementary feeding (more than 240 days), VAD, VB12D, and current evidence of infection (plasma CRP > 5 mg/L). There was a lower prevalence of anemia among children with birth weight > 3,500 g. Overall, 82% of the study children had at least one of the micronutrient deficiencies (ID, VAD and VB12D). Actions with emphasis on timely and healthy feeding practices, better management of morbidities and supplementation with other micronutrients should be focused on the improvement of child care services at primary health care in this county.

Anemia e deficiência de micronutrientes em lactentes atendidos em unidades básicas de saúde em Rio Branco, Acre, Brasil / Anemia and micronutrient deficiencies in infants attending at Primary Health Care in Rio Branco, Acre, Brazil

Resumo O presente estudo investigou os fatores associados à anemia e deficiência de micronutrientes em análise transversal conduzida com 150 crianças de 11 a 14 meses atendidas em unidades básicas de saúde em Rio Branco, Acre. Amostras de sangue venoso foram obtidas para avaliar a ocorrência de anemia, deficiência de ferro (DF) e de vitaminas A (DVA) e B12 (DVB12). Modelos múltiplos de regressão de Poisson foram utilizados para identificar fatores associados à anemia. Anemia, DF, DVA e DVB12 foram observadas em 23%, 76%, 18% e 20% das crianças, respectivamente. Os fatores associados à anemia foram: não ser filho único, residir em domicílio sem acesso a TV a cabo ou internet, déficit de estatura para idade (E/I), introdução tardia da alimentação complementar superior a 240 dias, DVA, DVB12, e evidência de infecção vigente (proteína C reativa plasmática > 5 mg/L). Houve menor ocorrência de anemia entre crianças com peso ao nascer > 3.500g. Do total de crianças, 82% apresentaram pelo menos uma das deficiências de micronutrientes (DF, DVA, DVB12). Ações com ênfase em práticas alimentares saudáveis oportunas, melhor manejo de morbidades e suplementação com outros micronutrientes devem ser priorizadas no aprimoramento do serviço de puericultura da atenção básica à saúde deste município.

Abstract The present study investigated the factors associated with anemia and micronutrient deficiencies in a cross-sectional analysis conducted with 150 children aged 11 to 14 months attending at basic health centers in Rio Branco, Acre. Venous blood samples were obtained to assess the occurrence of anemia and deficiencies of iron (ID), vitamin A (VAD), and B12 (VB12D). Multiple Poisson regression models were used to identify factors associated with anemia. Anemia, ID, VAD and B12D were observed in 23%, 76%, 18% and 20% of children, respectively. The factors associated with anemia were: do not be only child, living in households without access to cable TV or internet, stunting, late introduction of the complementary feeding (more than 240 days), VAD, VB12D, and current evidence of infection (plasma CRP > 5 mg/L). There was a lower prevalence of anemia among children with birth weight > 3,500 g. Overall, 82% of the study children had at least one of the micronutrient deficiencies (ID, VAD and VB12D). Actions with emphasis on timely and healthy feeding practices, better management of morbidities and supplementation with other micronutrients should be focused on the improvement of child care services at primary health care in this county.

Child Health in the Peruvian Amazon: Prevalence and Factors Associated with Referred Morbidity and Health Care Access in the City of Iñapari.

Introduction. Children under 5 years of age are more susceptible to developing morbidities such as diarrhea, respiratory infections, anemia, and malnutrition. The objective of the study is to evaluate the prevalence of reported morbidities in this age group in the city of Iñapari (Peru) and the access to health services in this municipality. Methods. Data collection using interviews that assessed socioeconomic and demographic conditions, child morbidity, and access to health services was performed in 2011. Statistical analysis was performed using SPSS 13.0. Results. Regarding morbidities that occurred during lifetime, 39.8% reported previous anemia and intestinal parasite infection. About 53.7% of the children reported any type of morbidities in the last 15 days before interview, being most frequent respiratory symptoms (38.9%), diarrhea (23,4%), and fever (23,1%). Only 63.1% of those reporting recent morbidities sought health care. These morbidities were associated with precarious sanitation and lack of infrastructure, the presence of other comorbidities, and poor access to health services. Conclusion. The main referred morbidities in Amazonian Peruvian children were diarrhea, respiratory symptoms, anemia, and vomiting. Incentives and improvements in the health and sanitation conditions would be important measures to improve the quality of life of the Amazonian child population.

Socioeconomic inequities and hepatitis A virus infection in Western Brazilian Amazonian children: spatial distribution and associated factors.

BACKGROUND: Hepatitis A is still a neglected health problem in the world. The most affected areas are the ones with disadvantaged socioeconomic conditions. In Brazil, seroprevalence studies showed that 64.7 % of the general population has antibodies against HAV (hepatitis A virus), and the Amazon region has the highest seroprevalence in the country. METHODS: In the present study the seroprevalence of total HAV antibodies in children between 1 and 5 years old residing in the urban area of Assis Brasil, Acre was measured and spatial distribution of several socioeconomic inequities was evaluated. RESULTS: In the year of 2011, seroprevalence rate was 16.66 %. Factors associated with having a positive serology identified by multivariate analysis were being of indigenous ethnicity [adjusted Odds Ratio (aOR) = 3.27, CI 1.45-7.28], usage of water from the public system (aOR = 8.18, CI 1.07-62.53), living in a house not located in a street (aOR = 3.48, CI 1.54-7.87), and child age over 4 years old (aOR = 2.43, CI 1.23-4.79). The distribution of seropositive children was clustered in the eastern part of the city, where several socioeconomic inequities (lack of flushed toilets, lack of piped water inside the household and susceptibility of the household to flooding during rain, low maternal education, having wood or ground floor at home, and not owning a house, lack of piped water at home, and type of drinking water) also clustered. CONCLUSIONS: The findings highlight that sanitation and water treatment still need improvement in the Brazilian Amazon, and that socioeconomic development is warranted in order to decrease this and other infectious diseases.

Seroprevalence and seroconversion of dengue and implications for clinical diagnosis in amazonian children.

This study aimed to evaluate the prevalence of serum IgG dengue in children in an Amazonian population, to assess the seroconversion rate in 12 months, and to estimate how many seropositive children had a prior clinical diagnosis of dengue. We conducted a population-based study between 2010 and 2011, with children aged 6 months to 12 years that were living in the urban area of a small town in the Brazilian Amazon. The prevalence of IgG antibodies against dengue antigens was determined by indirect ELISA technique, and seronegative children were reexamined after 12 months to determine seroconversion rates. Results showed seroprevalence of IgG antibodies against dengue type of 2.9%, with no significant association between age, race, and sex. In seropositive children, only 8.4% had received a clinical diagnosis of dengue, and the ratio of clinically diagnosed cases and subclinical cases was 1 : 11. The seroconversion rate between 2010 and 2011 was 1.4% (CI 3.8% to 35.1%). The seroprevalence of dengue in this pediatric population was low, and the vast majority of cases were not clinically detected, suggesting a difficulty in making the clinical diagnosis in children and a high frequency of asymptomatic infections.

Socioeconomic inequalities are still a barrier to full child vaccine coverage in the Brazilian Amazon: a cross-sectional study in Assis Brasil, Acre, Brazil.

INTRODUCTION: Vaccines are very important to reduce morbidity and mortality by preventable infectious diseases, especially during childhood. Optimal coverage is not always achieved, for several reasons. Here we assessed vaccine coverage for the first 12 months of age in children between 12 and 59 months old, residing in the urban area of a small Amazonian city, and factors associated with incomplete vaccination. METHODS: A census was performed in the urban area of Assis Brasil, in the Brazilian Amazon, in January 2010, with mothers of 282 children aged 12 to 59 months old, using structured interviews and data from vaccination cards. Mixed logistic regression was used to determine factors associated with incomplete vaccination schemes. RESULTS: Only 82.6% of all children had a completed the basic vaccine scheme for the first year of life. Vaccine coverage ranged from 52.7% coverage (oral rotavirus vaccine) to 99.7% coverage (for Bacille Calmette-Guérin). The major deficiencies occurred in doses administered after the first six months of life. Incomplete vaccination was associated with not having enough income to buy a house (aOR = 2.12, 95% CI 1.06-4.21), low maternal schooling (aOR = 2.60, 95% CI 1.28 - 5.29) , and time of residence of the child in the urban area of the city (aOR = 0.73, 95% CI 0.55 - 0.95). CONCLUSIONS: This study showed that vaccine coverage in the first twelve months of life in Assis Brasil is similar to other areas in the Amazon and it is below the coverage postulated by the Brazilian Ministry of Health. Low vaccine coverage was associated with socioeconomic inequities that still prevail in the Brazilian Amazon. Short and long-term strategies must be taken to update child vaccines and increase vaccine coverage in the Amazon.

Prevalence and associated factors to anaemia in children

Objetivos: Analisar a prevalência e os fatores associados à anemia em crianças de Rio Branco, Acre. Métodos: Participaram do estudo 610 crianças de 6 a 59 meses. Foi aplicado um questionário com questões sobre as características da mãe, práticas alimentares e morbidades pregressas. O diagnóstico de anemia baseou-se no valor de hemoglobina de 110 g/l. Na análise dos fatores associados foi utilizada a regressão de Poisson múltipla, com entrada das variáveis em blocos hierarquizados. Resultados: A prevalência de anemia foi de 51,8 por cento. Os fatores associados à anemia foram: idade abaixo de 24 meses: (razão de prevalência [RP]: 1,51; intervalo de confiança em 95 por cento [IC95 por cento]: 1,17-1,95); anos de estudo da mãe entre 5-8 anos (RP: 1,34; IC95 por cento: 1,13-1,58) e igual ou inferior a 4 anos (RP: 1,32; IC95 por cento: 1,05-1,65); situação de anemia da mãe (RP: 1,28; IC95 por cento:1,08-1,51); freqüência de consumo em menos de uma vez por semana de carnes (RP: 1,35; IC95 por cento:1,03-1,77) e frutas (RP: 1,28; IC95 por cento: 1,09-1,52). Conclusões: A prevalência de anemia em crianças de Rio Branco é um problema grave em saúde pública. Destaca-se a necessidade do fortalecimentode políticas em atenção à saúde da família e ao aconselhamento sobre as práticas alimentares voltadas a mãe.(AU)

OBJECTIVES: to analyse the prevalence and factors associated with anaemia in children from Rio Branco, Acre. METHODS: the study included 610 children between 6 and 59 months old. A questionnaire was issued with questions on characteristics of the mother, feeding practices and antecedent morbidity. The anaemia diagnosis was based on haemoglobin levels at 110 g/l. Multiple Poisson regression was used to analyse the associated factors with variables entered into hierarchical blocks. RESULTS: the anaemia prevalence was 51.8%. The factors associated with anaemia were the following: age below 24 months (prevalence ratio [PR]: 1.51 and 95% confidence interval [95% CI]: 1.17 to 1.95); years of formal education for the mother between 5-8 years (PR: 1.34 and 95% CI: 1.13 to 1.58) and less than or equal to 4 years (PR: 1.32 and 95% CI: 1.05 to 1.65); anaemia in the mother (PR: 1.28 and 95% CI: 1.08 to 1.51); and consumption frequency less than once a week for meats (PR: 1.35 and 95% CI: 1.03 to 1.77) and fruits (PR: 1.28 and 95% CI: 1.09 to 1.52). CONCLUSIONS: the prevalence of anaemia among children in Rio Branco is a serious public health problem. The results highlight the need to strengthen policies on family health care and provide mothers with counselling on feeding practices.(AU)

Prevalence and associated factors to anaemia in children / Anemia em crianças de Rio Branco, AC: prevalência e fatores associados

OBJECTIVES: to analyse the prevalence and factors associated with anaemia in children from Rio Branco, Acre. METHODS: the study included 610 children between 6 and 59 months old. A questionnaire was issued with questions on characteristics of the mother, feeding practices and antecedent morbidity. The anaemia diagnosis was based on haemoglobin levels at 110 g/l. Multiple Poisson regression was used to analyse the associated factors with variables entered into hierarchical blocks. RESULTS: the anaemia prevalence was 51.8 percent. The factors associated with anaemia were the following: age below 24 months (prevalence ratio [PR]: 1.51 and 95 percent confidence interval [95 percent CI]: 1.17 to 1.95); years of formal education for the mother between 5-8 years (PR: 1.34 and 95 percent CI: 1.13 to 1.58) and less than or equal to 4 years (PR: 1.32 and 95 percent CI: 1.05 to 1.65); anaemia in the mother (PR: 1.28 and 95 percent CI: 1.08 to 1.51); and consumption frequency less than once a week for meats (PR: 1.35 and 95 percent CI: 1.03 to 1.77) and fruits (PR: 1.28 and 95 percent CI: 1.09 to 1.52). CONCLUSIONS: the prevalence of anaemia among children in Rio Branco is a serious public health problem. The results highlight the need to strengthen policies on family health care and provide mothers with counselling on feeding practices.(AU)

OBJETIVOS: Analisar a prevalência e os fatores associados à anemia em crianças de Rio Branco, Acre. MÉTODO: Participaram do estudo 610 crianças de 6 a 59 meses. Foi aplicado um questionário com questões sobre as características da mãe, práticas alimentares e morbidades preessas. O diagnóstico de anemia baseou-se no valor de hemoglobina de 110 g/l. Na análise dos fatores associados foi utilizada a reessão de Poisson múltipla, com entrada das variáveis em blocos hierarquizados. RESULTADOS: A prevalência de anemia foi de 51,8 por cento. Os fatores associados &aave; anemia foram: idade abaixo de 24 meses: (razão de prevalência [RP]: 1,51; intervalo de confiança em 95 por cento [IC95 por cento]: 1,17-1,95); anos de estudo da mãe entre 5-8 anos (RP: 1,34; IC95 por cento: 1,13-1,58) e igual ou inferior a 4 anos (RP: 1,32; IC95 por cento: 1,05-1,65); situação de anemia da mãe (RP: 1,28; IC95 por cento: 1,08-1,51); freqüência de consumo em menos de uma vez por semana de carnes (RP: 1,35; IC95 por cento: 1,03-1,77) e frutas (RP: 1,28; IC95 por cento: 1,09-1,52). CONCLUSÕES: A prevalência de anemia em crianças de Rio Branco é um problema ave em saúde pública. Destaca-se a necessidade do fortalecimento de políticas em atenção &aave; saúde da família e ao aconselhamento sobre as práticas alimentares voltadas a mãe (AU)

Prevalence and associated factors to anaemia in children

Objetivos: Analisar a prevalência e os fatores associados à anemia em crianças de Rio Branco, Acre. Métodos: Participaram do estudo 610 crianças de 6 a 59 meses. Foi aplicado um questionário com questões sobre as características da mãe, práticas alimentares e morbidades pregressas. O diagnóstico de anemia baseou-se no valor de hemoglobina de 110 g/l. Na análise dos fatores associados foi utilizada a regressão de Poisson múltipla, com entrada das variáveis em blocos hierarquizados. Resultados: A prevalência de anemia foi de 51,8 por cento. Os fatores associados à anemia foram: idade abaixo de 24 meses: (razão de prevalência [RP]: 1,51; intervalo de confiança em 95 por cento [IC95 por cento]: 1,17-1,95); anos de estudo da mãe entre 5-8 anos (RP: 1,34; IC95 por cento: 1,13-1,58) e igual ou inferior a 4 anos (RP: 1,32; IC95 por cento: 1,05-1,65); situação de anemia da mãe (RP: 1,28; IC95 por cento:1,08-1,51); freqüência de consumo em menos de uma vez por semana de carnes (RP: 1,35; IC95 por cento:1,03-1,77) e frutas (RP: 1,28; IC95 por cento: 1,09-1,52). Conclusões: A prevalência de anemia em crianças de Rio Branco é um problema grave em saúde pública. Destaca-se a necessidade do fortalecimentode políticas em atenção à saúde da família e ao aconselhamento sobre as práticas alimentares voltadas a mãe.

OBJECTIVES: to analyse the prevalence and factors associated with anaemia in children from Rio Branco, Acre. METHODS: the study included 610 children between 6 and 59 months old. A questionnaire was issued with questions on characteristics of the mother, feeding practices and antecedent morbidity. The anaemia diagnosis was based on haemoglobin levels at 110 g/l. Multiple Poisson regression was used to analyse the associated factors with variables entered into hierarchical blocks. RESULTS: the anaemia prevalence was 51.8%. The factors associated with anaemia were the following: age below 24 months (prevalence ratio [PR]: 1.51 and 95% confidence interval [95% CI]: 1.17 to 1.95); years of formal education for the mother between 5-8 years (PR: 1.34 and 95% CI: 1.13 to 1.58) and less than or equal to 4 years (PR: 1.32 and 95% CI: 1.05 to 1.65); anaemia in the mother (PR: 1.28 and 95% CI: 1.08 to 1.51); and consumption frequency less than once a week for meats (PR: 1.35 and 95% CI: 1.03 to 1.77) and fruits (PR: 1.28 and 95% CI: 1.09 to 1.52). CONCLUSIONS: the prevalence of anaemia among children in Rio Branco is a serious public health problem. The results highlight the need to strengthen policies on family health care and provide mothers with counselling on feeding practices.

[Anemia in children 6 to 59 months of age and associated factors in Jordão, Acre State, Brazil]. / Anemia em crianças de 6 a 59 meses e fatores associados no Município de Jordão, Estado do Acre, Brasil.

This study investigated anemia prevalence and associated factors using a cross-sectional approach with 429 children 6 to 59 months of age in Jordão, Acre State, Brazil. Multiple Poisson regression in hierarchical models was used in the analysis. Overall anemia prevalence was 57.3% (95%CI: 52.5%-2.1%). Age under 24 months [prevalence ratio - PR (95%CI): 1.40 (1.09-1.74)], living in rural areas [PR: 1.23 (1.04-1.44)], households with 5-14 children [PR: 1.23 (1.04-1.44)], stunting [PR: 1.19 (1.01-1.39)], maternal anemia [PR: 1.18 (1.00-1.39)], and smoking during pregnancy [PR: 1.29 (1.09-1.53)] were associated with increased risk of anemia. Children of working mothers were at lower risk of anemia [PR: 0.78 (0.64-0.94)]. Anemia prevalence in childhood was found to be a serious public health problem in this municipality. Multi-sector prevention strategies should be implemented, addressing poverty and maternal-infant healthcare.

Anemia em crianças de 6 a 59 meses e fatores associados no Município de Jordão, Estado do Acre, Brasil / Anemia in children 6 to 59 months of age and associated factors in Jordão, Acre State, Brazil

Examinou-se a prevalência e fatores associados à anemia em estudo transversal com 429 crianças de 6 a 59 meses do Município de Jordão, Estado do Acre, Brasil. Modelos múltiplos de regressão de Poisson foram utilizados com seleção hierárquica das variáveis independentes. A anemia foi altamente prevalente (57,3 por cento; IC95 por cento: 52,5 por cento-62,1 por cento). Ter idade entre 6 e 23,9 meses [razão de prevalência - RP (IC95 por cento): 1,40 (1,09-1,74)], morar na área rural [RP: 1,23 (1,04-1,44)], morar em domicílio com 5 a 14 crianças [RP: 1,23 (1,04-1,44)], ter mãe que fumou na gravidez [RP: 1,29 (1,09-1,53)], mãe anêmica [RP: 1,18 (1,00-1,39)] e apresentar déficit de altura para idade [RP: 1,19 (1,01-1,39)] foram fatores associados ao risco de anemia, e ter mãe que trabalha fora [RP: 0,78 (0,64-0,94)] foi fator de proteção. A anemia é um grave problema de saúde pública nesse município. Estratégias multissetoriais de combate à pobreza, aumento da cobertura e qualidade de serviços de assistência à saúde materno-infantil devem ser implementados.

This study investigated anemia prevalence and associated factors using a cross-sectional approach with 429 children 6 to 59 months of age in Jordão, Acre State, Brazil. Multiple Poisson regression in hierarchical models was used in the analysis. Overall anemia prevalence was 57.3 percent (95 percentCI: 52.5 percent-2.1 percent). Age under 24 months [prevalence ratio - PR (95 percentCI): 1.40 (1.09-1.74)], living in rural areas [PR: 1.23 (1.04-1.44)], households with 5-14 children [PR: 1.23 (1.04-1.44)], stunting [PR: 1.19 (1.01-1.39)], maternal anemia [PR: 1.18 (1.00-1.39)], and smoking during pregnancy [PR: 1.29 (1.09-1.53)] were associated with increased risk of anemia. Children of working mothers were at lower risk of anemia [PR: 0.78 (0.64-0.94)]. Anemia prevalence in childhood was found to be a serious public health problem in this municipality. Multi-sector prevention strategies should be implemented, addressing poverty and maternal-infant healthcare.

Perfil clínico-epidemiológico dos casos de hanseníase notificados no município de Assis Brasil, Acre, no período de 2003 a 2010 / Clinical and epidemiological profile of leprosy cases reported in Assis Brazil, Acre, in the period 2003 to 2010

A hanseníase é considerada um problema de saúde pública nos países em desenvolvimento. No período de 2001 a 2007, o Acre foi o 8o Estado com os maiores coeficientes de prevalência e incidência de hanseníase em todo o Brasil. Este é um estudo retrospectivo que utilizou os dados das fichas de notificação de casos de hanseníase do Sistema de Informação de Agravos de Notificação do município de Assis Brasil, Acre, entre 2003 e 2010. Os dados foram digitados e analisados no programa SPSS, sendo que médias e proporções foram comparadas com o Teste de Anova e o Teste do Qui-Quadrado. Foram notificados 25 casos novos, com coeficiente de detecção de 98,7/100.000 habitantes em 2010, sendo 56% casos índices e 44% contatos; oito (32%) casos de hanseníase paucibacilar e 17 (68%) de hanseníase multibacilar. Predominou a forma dimorfa (52%), seguido da forma tuberculóide (32%) e forma virchowiana (16%). A bacilos-copia foi negativa em 75% dos testes. Nove pacientes foram considerados curados no tempo preconizado, um paciente necessitou de maior tempo de tratamento, oito pacientes ainda estavam em tratamento e seis casos ti-veram evolução desconhecida. A alta frequência de ca-sos de hanseníase multibacilar reforça a ideia da demora no diagnóstico e da dificuldade em detectar formas mais leves da doença, contribuindo para manter a transmis-são, necessitando de maior ação do sistema de saúde.

Leprosy is a public health problem in the developing world. Between 2001 and 2007, Acre state presented the 8th highest incidence and prevalence coefficients in the whole country. This is a retrospective study that used the notification data from the local health system, between 2003 and 2010. Data was analyzed in SPSS; av-erages and proportions were compared using Anova and Chi-square test. There were 25 new cases notified, with a new case detection coefficient of 98,7/100.000 inhabitants in 2010, being 56% index cases, 44% con-tacts; eight (32%) paucibacillary cases and 17 (68%) multibacillary cases. The predominant clinical form was dimorphous (52%), followed by tuberculoid (32%) and virchow ́s forms (16%). The baciloscopy was negative in 75% of cases. Nine patients were considered cured in the allotted time, one patient needed longer treatment time, eight patients were still under treatment and six patients had unknown follow-up. The high frequency of multibacillary cases reinforces the idea that the diag-nosis is taking long to be performed and it is difficult to detect mild forms of the disease, contributing for main-taining the transmission, therefore a more effective ac-tion must be taken by the health system.

Anemia em crianças de 6 a 60 meses no interior da Amazônia, Jordão-Acre, Brasil / Anemia in children age between 6 and 60 months from the interior of Amazônia, Jordão - Acre, Brazil

Introdução: A anemia constitui o problema de maior magnitude no mundo, sendo as crianças menores de cinco anos um dos grupos populacionais de maior risco juntamente com mulheres grávidas. Como os demais problemas de saúde pública sua origem é multicausal. Como determinantes principais dessa deficiência destacam-se a dieta, no que diz respeito ao consumo e biodisponibilidade de ferro, e a idade da criança. No Brasil nos últimos anos, muitos estudos têm investigado a prevalência e fatores associados à anemia na infância em diferentes regiões. Contudo, são ainda escassos inquéritos de base populacional na região norte do país, especialmente na área rural e em municípios de difícil acesso. Objetivo: Verificar a prevalência de anemia segundo variáveis sócio-demográficas, ambientais, nutricionais e de morbidade em crianças de 6 a 60 meses no município do Jordão, Estado do Acre, Amazônia Brasileira. Métodos: estudo transversal de base populacional conduzido em 429 crianças de 6 a 60 meses no município de Jordão (área urbana, n=186; área rural=243 crianças). Foram coletadas informações sobre características demográficas, socioeconômicas, antropométricas de morbidade e condições de saúde. A determinação de hemoglobina sanguínea foi feita por punção digital com uso de hemoglobinômetro portátil Hemocue, adotando-se Hb < 11,0g/dL para diagnóstico de anemia. Para análise estatística utilizou-se o teste de qui-quadrado, adotando-se p < 0,05. Resultados: A prevalência geral de anemia foi de 57,3 por cento com maior ocorrência entre crianças de 6 meses a um ano (77,3 por cento). Com relação à distribuição por origem étnica, não houve diferença estatisticamente significante na prevalência de anemia em crianças cujos pais ou avós eram de etnia indígena quando comparada à prevalência nas demais (p=0,29). Houve maior prevalência de anemia entre crianças residentes na área rural (62,1 por cento) comparada à zona urbana (51,1 por cento), p=0,02. A ocorrência de anemia foi maior en...