Improving accessibility to radiotherapy services in Cali, Colombia: cross-sectional equity analyses using open data and big data travel times from 2020.

In this study, we evaluated and forecasted the cumulative opportunities for residents to access radiotherapy services in Cali, Colombia, while accounting for traffic congestion, using a new people-centred methodology with an equity focus. Furthermore, we identified 1-2 optimal locations where new services would maximise accessibility. We utilised open data and publicly available big data. Cali is one of South America's cities most impacted by traffic congestion. METHODOLOGY: Using a people-centred approach, we tested a web-based digital platform developed through an iterative participatory design. The platform integrates open data, including the location of radiotherapy services, the disaggregated sociodemographic microdata for the population and places of residence, and big data for travel times from Google Distance Matrix API. We used genetic algorithms to identify optimal locations for new services. We predicted accessibility cumulative opportunities (ACO) for traffic ranging from peak congestion to free-flow conditions with hourly assessments for 6-12 July 2020 and 23-29 November 2020. The interactive digital platform is openly available. PRIMARY AND SECONDARY OUTCOMES: We present descriptive statistics and population distribution heatmaps based on 20-min accessibility cumulative opportunities (ACO) isochrones for car journeys. There is no set national or international standard for these travel time thresholds. Most key informants found the 20-min threshold reasonable. These isochrones connect the population-weighted centroid of the traffic analysis zone at the place of residence to the corresponding zone of the radiotherapy service with the shortest travel time under varying traffic conditions ranging from free-flow to peak-traffic congestion levels. Additionally, we conducted a time-series bivariate analysis to assess geographical accessibility based on economic stratum. We identify 1-2 optimal locations where new services would maximize the 20-min ACO during peak-traffic congestion. RESULTS: Traffic congestion significantly diminished accessibility to radiotherapy services, particularly affecting vulnerable populations. For instance, urban 20-min ACO by car dropped from 91% of Cali's urban population within a 20-min journey to the service during free-flow traffic to 31% during peak traffic for the week of 6-12 July 2020. Percentages represent the population within a 20-min journey by car from their residence to a radiotherapy service. Specific ethnic groups, individuals with lower educational attainment, and residents on the outskirts of Cali experienced disproportionate effects, with accessibility decreasing to 11% during peak traffic compared to 81% during free-flow traffic for low-income households. We predict that strategically adding sufficient services in 1-2 locations in eastern Cali would notably enhance accessibility and reduce inequities. The recommended locations for new services remained consistent in both of our measurements.These findings underscore the significance of prioritising equity and comprehensive care in healthcare accessibility. They also offer a practical approach to optimising service locations to mitigate disparities. Expanding this approach to encompass other transportation modes, services, and cities, or updating measurements, is feasible and affordable. The new approach and data are particularly relevant for planning authorities and urban development actors.

ESPAñOL: En este estudio, evaluamos y pronosticamos las oportunidades acumulativas para que los residentes accedan a los servicios de radioterapia en Cali, Colombia, teniendo en cuenta la congestión del tráfico, utilizando una nueva metodología centrada en las personas con un enfoque de equidad. Además, identificamos 1-2 ubicaciones óptimas donde los nuevos servicios maximizarían la accesibilidad. Utilizamos datos abiertos y macrodatos disponibles públicamente. Cali está entre las ciudades Sudamericanas más afectadas por la congestión del tráfico.Metodología: Usando un enfoque centrado en las personas, probamos una plataforma digital basada en la web desarrollada a través de un diseño participativo iterativo. La plataforma integra datos abiertos, incluyendo la ubicación de los servicios de radioterapia, los microdatos sociodemográficos desagregados de la población y los lugares de residencia, y los macrodatos de tiempos de viaje de la API de Google Distance Matrix. Usamos algoritmos genéticos para identificar ubicaciones óptimas para nuevos servicios. Pronosticamos oportunidades acumulativas de accesibilidad (ACO, por sus siglas en inglés) para el tráfico que va desde la congestión máxima hasta condiciones de flujo libre, con evaluaciones horarias hechas del 6 al 12 de julio de 2020 y del 23 al 29 de noviembre de 2020. La plataforma digital interactiva está públicamente disponible.Resultados Primarios y Secundarios: Presentamos estadísticas descriptivas y mapas de calor de la distribución de la población basados en isócronas de ACO de 20 minutos para viajes en coche. No existe un estándar nacional o internacional establecido para estos umbrales de tiempo de viaje. La mayoría de los informantes clave encontraron razonable el umbral de 20 minutos. Estas isócronas conectan el centroide poblacional ponderado de la zona de análisis de tráfico del lugar de residencia con la zona correspondiente del servicio de radioterapia con menor tiempo de viaje bajo condiciones variables de tráfico, que van desde el flujo libre hasta niveles de congestión de tráfico máximo. Además, realizamos un análisis bivariado de series temporales para evaluar la accesibilidad geográfica basada en el estrato económico. Identificamos 1-2 ubicaciones óptimas donde los nuevos servicios maximizarían el ACO de 20 minutos durante la congestión máxima del tráfico.Resultados: La congestión del tráfico redujo significativamente la accesibilidad a los servicios de radioterapia, afectando particularmente a las poblaciones vulnerables. Por ejemplo, el ACO urbano de 20 minutos en coche se redujo del 91% de la población urbana de Cali para viajes de hasta 20 minutos al servicio con flujo libre de tráfico, al 31% cuando hay congestión pico de tráfico durante la semana del 6 al 12 de julio de 2020. Los porcentajes representan la población con viajes de hasta 20 minutos en coche desde la residencia hasta el servicio de radioterapia. Grupos étnicos específicos, individuos con menor nivel educativo y residentes en las afueras de Cali experimentaron efectos desproporcionados, con la accesibilidad disminuyendo al 11% durante el tráfico máximo en comparación con el 81% durante el tráfico de flujo libre para hogares de bajos ingresos. Predecimos que agregar estratégicamente suficientes servicios en 1-2 ubicaciones en el este de Cali mejoraría notablemente la accesibilidad y reduciría las inequidades. Las ubicaciones recomendadas para los nuevos servicios se mantuvieron consistentes en nuestras dos mediciones.Estos hallazgos subrayan la importancia de priorizar la equidad y la atención integral en la accesibilidad a la atención médica. También ofrecen un enfoque práctico para optimizar las ubicaciones de los servicios para mitigar las disparidades. Es factible y accesible expandir este enfoque para abarcar otros modos de transporte, servicios y ciudades, o actualizar las mediciones. El nuevo enfoque y los datos son particularmente relevantes para las autoridades de planificación y los actores del desarrollo urbano.

PORTUGUêS: Neste estudo, avaliamos e previmos as oportunidades cumulativas para os residentes acessarem serviços de radioterapia em Cali, Colômbia, levando em consideração o congestionamento do tráfego, utilizando uma nova metodologia centrada nas pessoas com um foco na equidade. Além disso, identificamos 1-2 locais ideais onde os novos serviços poderiam maximizar a acessibilidade. Utilizamos dados abertos e big data disponíveis publicamente. Cali está entre as cidades sulamericanas mais afetadas pela congestionamento do tráfego.Metodologia: Usando uma abordagem centrada em pessoas, testamos uma plataforma digital baseada na web que foi desenvolvida através de um design participativo iterativo. A plataforma integra dados abertos, incluindo a localização dos serviços de radioterapia, microdados sociodemográficos desagregados por população e locais de residência, e big data da API Google Distance Matrix para os tempos de viagem. Utilizamos algoritmos genéticos para identificar locais ideais para novos serviços. Previmos oportunidades cumulativas de acessibilidade (ACO, por suas siglas em inglês) para o tráfego que varia desde o congestionamento máximo até condições de fluxo livre, com avaliações horárias de 6 a 12 de julho de 2020 e de 23 a 29 de novembro de 2020. A plataforma digital interativa está disponível publicamente.Resultados Primários e Secundários: Apresentamos estatísticas descritivas e mapas de calor da distribuição populacional baseados em isócronas de ACO de 20 minutos para viagens de carro. Não existe um padrão nacional ou internacional estabelecido para esses limites de tempo de viagem. A maioria dos entrevistados-chave considerou razoável o limite de 20 minutos. Essas isócronas conectam o centroide ponderado pela população da zona de análise de tráfego no local de residência e sua zona correspondente do serviço de radioterapia com o menor tempo de viagem sob condições variáveis de tráfego (que vão desde fluxo livre até níveis máximos de congestionamento do tráfego). Além disso, realizamos uma análise bivariada de séries temporais para avaliar a acessibilidade geográfica baseada na estratificação econômica. Identificamos 1-2 locais ideais onde os novos serviços maximizariam a ACO de 20 minutos durante o pico de congestionamento do tráfego.Resultados: O congestionamento do tráfego reduziu significativamente a acessibilidade aos serviços de radioterapia, afetando particularmente as populações vulneráveis. Por exemplo, a ACO urbana de 20 minutos de carro foi reduzida de 91% durante um fluxo livre de tráfego, para 31% durante picos de congestionamento de tráfego entre a semana de 6 a 12 de julho de 2020. As porcentagens representam a população com viagens de até 20 minutos de carro de sua residência até o serviço de radioterapia. Grupos étnicos específicos, indivíduos com menor nível educacional e residentes nos arredores de Cali experimentaram resultados desproporcionais, com a acessibilidade diminuindo para 11% durante o tráfego com congestionamento máximo em comparação com 81% durante o fluxo livre de tráfego para domicílios de baixa renda. Prevemos que adicionar estrategicamente serviços suficientes em 1-2 locais no leste de Cali melhoraria significativamente a acessibilidade e reduziria as desigualdades. Os locais recomendados para os novos serviços permaneceram consistentes em ambas medições. Esses resultados ressaltam a importância de priorizar a equidade e o atendimento integral na acessibilidade aos cuidados de saúde. Eles também oferecem uma abordagem prática para otimizar os locais dos serviços a fim de minimizar as desigualdades. A expansão dessa abordagem para abranger outros modos de transporte, serviços e cidades, ou a atualização das medições, é viável e acessível. A nova abordagem e os dados são particularmente relevantes para as autoridades de planejamento e os agentes do desenvolvimento urbano.

FRANçAIS: Dans cette étude, nous avons évalué et prévu les opportunités cumulées pour les résidents d'accéder aux services de radiothérapie à Cali, en Colombie, tout en tenant compte de la congestion du trafic en utilisant une nouvelle méthodologie centrée sur les personnes avec axée sur l'équité. De plus, nous avons identifié 1 à 2 emplacements optimaux où de nouveaux services maximiseraient l'accessibilité. Nous avons utilisé des données ouvertes et des macrodonnées tenues à disposition du public. Cali est l'une des villes d'Amérique du Sud les plus touchées par la congestion du trafic.Méthodologie: En utilisant une approche centrée sur les personnes, nous avons testé une plateforme numérique basée sur le web développée à travers une conception participative itérative. La plateforme intègre des données ouvertes, y compris la localisation des services de radiothérapie, les microdonnées sociodémographiques désagrégées de la population et les lieux de résidence, ainsi que les mégadonnées des temps de trajet de l'API Google Distance Matrix. Nous avons utilisé des algorithmes génétiques pour identifier les emplacements optimaux pour de nouveaux services. Nous avons prévu les opportunités cumulatives d'accessibilité (ACO, désignant l'acronyme en anglais) pour le trafic allant de la congestion maximale aux conditions de flux libre, avec des évaluations horaires du 6 au 12 juillet 2020 et du 23 au 29 novembre 2020. La plateforme numérique interactive est disponible publiquement.Résultats Primaires et Secondaires: Nous présentons des statistiques descriptives et des cartes thermiques de la distribution de la population basées sur des ACO de 20 minutes pour les trajets en voiture. Il n'existe pas de norme nationale ou internationale établie pour ces seuils de temps de trajet. La majorité des informateurs clés ont trouvé le seuil de 20 minutes raisonnable. Ces isochrones relient le centroïde pondéré par la population de la zone d'analyse du trafic au lieu de résidence à la zone correspondante du service de radiothérapie avec le temps de trajet le plus court sous des conditions de trafic variables allant du flux libre aux niveaux de congestion de trafic maximum. De plus, nous avons réalisé une analyse bivariée des séries chronologiques pour évaluer l'accessibilité géographique en fonction de la stratification économique. Nous avons identifié 1 à 2 emplacements optimaux où de nouveaux services maximiseraient l'ACO de 20 minutes pendant la congestion maximale du trafic.Résultats: La congestion du trafic a considérablement réduit l'accessibilité aux services de radiothérapie, affectant particulièrement les populations vulnérables. Par exemple, l'ACO urbain de 20 minutes en voiture est passé de 91 % de la population urbaine de Cali pour des trajets de jusqu'à 20 minutes vers le service avec un flux de trafic libre à 31 % lors des pics de congestion de trafic pendant la semaine du 6 au 12 juillet 2020. Les pourcentages représentent la population avec des trajets de jusqu'à 20 minutes en voiture depuis la résidence jusqu'au service de radiothérapie. Des groupes ethniques spécifiques, des individus ayant un niveau d'éducation inférieur et des résidents des périphéries de Cali ont subi des effets disproportionnés, avec une accessibilité diminuant à 11 % pendant le trafic maximal par rapport à 81 % pendant le flux de trafic libre pour les ménages à faible revenu. Ajouter suffisamment de services à 1-2 emplacements stratégiques dans l'est de Cali a le potential d'améliorer considérablement l'accessibilité et réduirait les inégalités. Les emplacements recommandés pour les nouveaux services sont restés cohérents dans nos deux mesures. Ces conclusions soulignent l'importance de prioriser l'équité et une prise en charge globale dans le cadre de l'accessibilité aux soins de santé. Elles offrent également une approche pratique pour optimiser les emplacements des services afin de réduire les disparités. Il est faisable et abordable d'étendre cette approche pour inclure d'autres modes de transport, services et villes, ou pour mettre à jour les mesures. La nouvelle approche et les données sont particulièrement pertinentes pour les autorités de planification et les acteurs du développement urbain.

Health care accessibility and mobility in breast cancer: a Latin American perspective.

BACKGROUND: Latin America (LATAM) encompasses a vast region with diverse populations. Despite publicly funded health care systems providing universal coverage, significant socioeconomic and ethno-racial disparities persist in health care access across the region. Breast cancer (BC) incidence and mortality rates in Brazil are comparable to those in other LATAM countries, supporting the relevance of Brazilian data, with Brazil's health care policies and expenditures often serving as models for neighboring countries. We evaluated the impact of mobility on oncological outcomes in LATAM by analyzing studies of patients with BC reporting commuting routes or travel distances to receive treatment or diagnosis. METHODS: We searched MEDLINE (PubMed), Embase, Cochrane CENTRAL, LILACS, and Google Scholar databases. Studies eligible for inclusion were randomized controlled trials and observational studies of patients with BC published in English, Portuguese, or Spanish and conducted in LATAM. The primary outcome was the impact of mobility or travel distance on oncological outcomes. Secondary outcomes included factors related to mobility barriers and access to health services. For studies meeting eligibility, relevant data were extracted using standardized forms. Risk of bias was assessed using the Newcastle-Ottawa Scale. Quantitative and qualitative evidence synthesis focused on estimating travel distances based on available data. Heterogeneity across distance traveled or travel time was addressed by converting reported travel time to kilometers traveled and estimating distances for unspecified locations. RESULTS: Of 1142 records identified, 14 were included (12 from Brazil, 1 from Mexico, and 1 from Argentina). Meta-analysis revealed an average travel distance of 77.8 km (95% CI, 49.1-106.48) to access BC-related diagnostic or therapeutic resources. Nonetheless, this average fails to precisely encapsulate the distinct characteristics of each region, where notable variations persist in travel distance, ranging from 88 km in the South to 448 km in the North. CONCLUSION: The influence of mobility and travel distance on access to BC care is multifaceted and should consider the complex interplay of geographic barriers, sociodemographic factors, health system issues, and policy-related challenges. Further research is needed to comprehensively understand the variables impacting access to health services, particularly in LATAM countries, where the challenges women face during treatment remain understudied. TRIAL REGISTRATION: CRD42023446936.

[Regional inequalities in access to hospital birth in the state of Rio de Janeiro, Brazil: travel networks, distance, and time (2010-2019)]. / Desigualdades regionais no acesso ao parto hospitalar no Estado do Rio de Janeiro, Brasil: redes de deslocamento, distância e tempo (2010-2019).

Difficult access to birth care services is associated with infant and neonatal mortality and maternal morbidity and mortality. In this study, data from the Brazilian Unified National Health System (SUS) were used to map the evolution of geographic accessibility to hospital birth of usual risk in the state of Rio de Janeiro, Brazil, corresponding to 418,243 admissions in 2010-2011 and 2018-2019. Travel flows, distances traveled, and intermunicipal travel time between the pregnant women's municipality and hospital location were estimated. An increase from 15.9% to 21.5% was observed in the number of pregnant women who needed to travel. The distance traveled increased from 24.6 to 26km, and the travel time from 76.4 to 96.1 minutes, with high variation between Health Regions (HR). Pregnant women living in HR Central-South traveled more frequently (37.4-48.9%), and those living in the HRs Baía da Ilha Grande and Northwest traveled the largest distances (90.9-132.1km) and took more time to get to the hospital in 2018-2019 (96-137 minutes). The identification of municipalities that received pregnant women from many other municipalities and municipalities that treated a higher number of pregnant women (hubs and attraction poles, respectively) reflected the unavailability and disparities in access to services. Regional inequalities and reduced accessibility highlight the need to adapt supply to demand and review the distribution of birth care services in the state of Rio de Janeiro. This study contributes to research and planning on access to maternal and child health services and can be used as a reference study for other states in the country.

A dificuldade de acesso aos serviços de atenção ao parto está associada à mortalidade infantil e neonatal e à morbimortalidade materna. Neste estudo, dados do Sistema Único de Saúde (SUS) foram utilizados para mapear a evolução da acessibilidade geográfica ao parto hospitalar de risco habitual no Estado do Rio de Janeiro, Brasil, correspondentes a 418.243 internações nos biênios 2010-2011 e 2018-2019. Foram estimados os fluxos de deslocamento, as distâncias percorridas e o tempo de deslocamento intermunicipal entre o município de residência e de internação das gestantes. Houve um crescimento de 15,9% para 21,5% na proporção de gestantes que precisaram se deslocar. A distância percorrida aumentou de 24,6 para 26km, e o tempo de deslocamento de 76,4 para 96,1 minutos, com grande variação entre as Regiões de Saúde (RS). As gestantes residentes na RS Centro Sul se deslocaram mais frequentemente (37,4-48,9%), e as residentes nas RS Baía da Ilha Grande e Noroeste percorreram as maiores distâncias (90,9-132,1km) e levaram mais tempo para chegar ao hospital no último biênio (96-137 minutos). A identificação dos municípios que receberam gestantes de muitos outros municípios e daqueles que atenderam maior volume de gestantes (núcleos e polos de atração, respectivamente) refletiu a indisponibilidade e as disparidades no acesso aos serviços. As desigualdades regionais e a redução da acessibilidade alertam para a necessidade de adequar a oferta à demanda e de revisar a distribuição dos serviços de atenção ao parto no Rio de Janeiro. O estudo contribui para as pesquisas e o planejamento sobre o acesso a serviços de saúde materno-infantil, além de servir como referência para outros estados do país.

La dificultad para acceder a los servicios de atención al parto está asociada con la mortalidad infantil y neonatal, y con la morbimortalidad materna. En este estudio, se utilizaron datos del Sistema Único de Salud (SUS) para mapear la evolución de la accesibilidad geográfica al parto hospitalario de riesgo habitual en el estado de Río de Janeiro, Brasil, correspondiente a 418.243 hospitalizaciones en los bienios 2010-2011 y 2018-2019. Se estimaron los flujos de desplazamiento, las distancias recorridas y el tiempo de desplazamiento intermunicipal entre el municipio de residencia y la hospitalización de las mujeres embarazadas. Hubo un aumento del 15,9% al 21,5% en la proporción de mujeres embarazadas que necesitaron desplazarse. La distancia recorrida aumentó de 24,6 a 26km y el tiempo de desplazamiento de 76,4 a 96,1 minutos, con gran variación entre las Regiones de Salud (RS). Las mujeres embarazadas residentes en la RS Centro Sul se desplazaron con mayor frecuencia (37,4-48,9%), y las residentes en las RS Baía da Ilha Grande y Noroeste recorrieron las mayores distancias (90,9-132,1km) y tardaron más en llegar al hospital en el últimos bienio (96-137 minutos). La identificación de los municipios que recibieron mujeres embarazadas de muchos otros municipios y de aquellos que atendieron a un mayor volumen de mujeres embarazadas (núcleos y polos de atracción, respectivamente) reflejó la indisponibilidad y las disparidades en el acceso a los servicios. Las desigualdades regionales y la reducida accesibilidad alertan sobre la necesidad de adaptar la oferta a la demanda, y de revisar la distribución de los servicios de atención al parto en el estado de Rio de Janeiro. El estudio contribuye a las investigaciones y a la planificación sobre el acceso a los servicios de salud materno-infantil, y puede servir como referencia para otros estados del país.

Intestinal protozoa in returning travellers: a GeoSentinel analysis from 2007 to 2019.

BACKGROUND: Prolonged diarrhoea is common amongst returning travellers and is often caused by intestinal protozoa. However, the epidemiology of travel-associated illness caused by protozoal pathogens is not well described. METHODS: We analysed records of returning international travellers with illness caused by Giardia duodenalis, Cryptosporidium spp., Cyclospora cayetanensis or Cystoisospora belli, reported to the GeoSentinel Network during January 2007-December 2019. We excluded records of travellers migrating, with an unascertainable exposure country, or from GeoSentinel sites that were not located in high-income countries. RESULTS: There were 2517 cases, 82.3% giardiasis (n = 2072), 11.4% cryptosporidiosis (n = 287), 6.0% cyclosporiasis (n = 150) and 0.3% cystoisosporiasis (n = 8). Overall, most travellers were tourists (64.4%) on long trips (median durations: 18-30 days). Cryptosporidiosis more frequently affected people < 18 years (13.9%) and cyclosporiasis affected people ≥ 40 years (59.4%). Giardiasis was most frequently acquired in South Central Asia (45.8%) and sub-Saharan Africa (22.6%), cryptosporidiosis in sub-Saharan Africa (24.7%) and South-Central Asia (19.5%), cyclosporiasis in South East Asia (31.3%) and Central America (27.3%), and cystoisosporiasis in sub-Saharan Africa (62.5%). Cyclosporiasis cases were reported from countries of uncertain endemicity (e.g. Cambodia) or in countries with no previous evidence of this parasite (e.g. French Guiana). The time from symptom onset to presentation at a GeoSentinel site was the longest amongst travellers with giardiasis (median: 30 days). Over 14% of travellers with cryptosporidiosis were hospitalized. CONCLUSIONS: This analysis provides new insights into the epidemiology and clinical significance of four intestinal protozoa that can cause morbidity in international travellers. These data might help optimize pretravel advice and post-travel management of patients with travel-associated prolonged gastrointestinal illnesses. This analysis reinforces the importance of international travel-related surveillance to identify sentinel cases and areas where protozoal infections might be undetected or underreported.

North to south gradient and local waves of influenza in Chile.

Influenza seasonality is caused by complex interactions between environmental factors, viral mutations, population crowding, and human travel. To date, no studies have estimated the seasonality and latitudinal patterns of seasonal influenza in Chile. We obtained influenza-like illness (ILI) surveillance data from 29 Chilean public health networks to evaluate seasonality using wavelet analysis. We assessed the relationship between the start, peak, and latitude of the ILI epidemics using linear and piecewise regression. To estimate the presence of incoming and outgoing traveling waves (timing vs distance) between networks and to assess the association with population size, we used linear and logistic regression. We found a north to south gradient of influenza and traveling waves that were present in the central, densely populated region of Chile. Our findings suggest that larger populations in central Chile drive seasonal influenza epidemics.

Assessing the impact of human mobility to predict regional excess death in Ecuador.

COVID-19 outbreaks have had high mortality in low- and middle-income countries such as Ecuador. Human mobility is an important factor influencing the spread of diseases possibly leading to a high burden of disease at the country level. Drastic control measures, such as complete lockdown, are effective epidemic controls, yet in practice one hopes that a partial shutdown would suffice. It is an open problem to determine how much mobility can be allowed while controlling an outbreak. In this paper, we use statistical models to relate human mobility to the excess death in Ecuador while controlling for demographic factors. The mobility index provided by GRANDATA, based on mobile phone users, represents the change of number of out-of-home events with respect to a benchmark date (March 2nd, 2020). The study confirms the global trend that more men are dying than expected compared to women, and that people under 30 show less deaths than expected, particularly individuals younger than 20 with a death rate reduction between 22 and 27%. The weekly median mobility time series shows a sharp decrease in human mobility immediately after a national lockdown was declared on March 17, 2020 and a progressive increase towards the pre-lockdown level within two months. Relating median mobility to excess deaths shows a lag in its effect: first, a decrease in mobility in the previous two to three weeks decreases excess death and, more novel, we found an increase of mobility variability four weeks prior increases the number of excess deaths.

Maternal Infection and Adverse Pregnancy Outcomes among Pregnant Travellers: Results of the International Zika Virus in Pregnancy Registry.

In this multicentre cohort study, we evaluated the risks of maternal ZIKV infections and adverse pregnancy outcomes among exposed travellers compared to women living in areas with ZIKV circulation (residents). The risk of maternal infection was lower among travellers compared to residents: 25.0% (n = 36/144) versus 42.9% (n = 309/721); aRR 0.6; 95% CI 0.5-0.8. Risk factors associated with maternal infection among travellers were travelling during the epidemic period (i.e., June 2015 to December 2016) (aOR 29.4; 95% CI 3.7-228.1), travelling to the Caribbean Islands (aOR 3.2; 95% CI 1.2-8.7) and stay duration >2 weeks (aOR 8.7; 95% CI 1.1-71.5). Adverse pregnancy outcomes were observed in 8.3% (n = 3/36) of infected travellers and 12.7% (n = 39/309) of infected residents. Overall, the risk of maternal infections is lower among travellers compared to residents and related to the presence of ongoing outbreaks and stay duration, with stays <2 weeks associated with minimal risk in the absence of ongoing outbreaks.

Cross-border malaria in Northern Brazil.

BACKGROUND: Cross-border malaria is a major barrier to elimination efforts. Along the Venezuela-Brazil-Guyana border, intense human mobility fueled primarily by a humanitarian crisis and illegal gold mining activities has increased the occurrence of cross-border cases in Brazil. Roraima, a Brazilian state situated between Venezuela and Guyana, bears the greatest burden. This study analyses the current cross-border malaria epidemiology in Northern Brazil between the years 2007 and 2018. METHODS: De-identified data on reported malaria cases in Brazil were obtained from the Malaria Epidemiological Surveillance Information System for the years 2007 to 2018. Pearson's Chi-Square test of differences was utilized to assess differences between characteristics of cross-border cases originating from Venezuela and Guyana, and between border and transnational cases. A logistic regression model was used to predict imported status of cases. RESULTS: Cross-border cases from Venezuela and Guyana made up the majority of border and transnational cases since 2012, and Roraima remained the largest receiving state for cross-border cases over this period. There were significant differences in the profiles of border and transnational cases originating from Venezuela and Guyana, including type of movement and nationality of patients. Logistic regression results demonstrated Venezuelan and Guyanese nationals, Brazilian miners, males, and individuals of working age had heightened odds of being an imported case. Furthermore, Venezuelan citizens had heightened odds of seeking care in municipalities adjacent Venezuela, rather than transnational municipalities. CONCLUSIONS: Cross-border malaria contributes to the malaria burden at the Venezuela-Guyana-Brazil border. The identification of distinct profiles of case importation provides evidence on the need to strengthen surveillance at border areas, and to deploy tailored strategies that recognize different mobility routes, such as the movement of refuge-seeking individuals and of Brazilians working in mining.

Imported SARS-CoV-2 Variant P.1 in Traveler Returning from Brazil to Italy.

We report an imported case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant P.1 detected in an asymptomatic traveler who arrived in Italy on an indirect flight from Brazil. This case shows the risk for introduction of SARS-CoV-2 variants from indirect flights and the need for continued SARS-CoV-2 surveillance.

International Experience of US Pediatricians and Level of Comfort Caring for Immigrant Children and Children Traveling Internationally.

OBJECTIVE: To determine whether international experience is associated with greater comfort in providing care to US children who are immigrants, refugees, and traveling internationally. STUDY DESIGN: Following enrollment into the 2018 American Board of Pediatrics Maintenance of Certification program, general pediatricians and subspecialists received a voluntary, online survey with questions about their experience and self-reported comfort caring for immigrant, refugee, and internationally traveling children and previous international experiences. Using multivariable logistic regression, we examined how previous international experiences, and other personal characteristics, were associated with self-reported comfort. RESULTS: A total of 5461 eligible participants completed the survey; 76.3%, (n = 4168) reported caring for immigrant children, 35.8% (n = 1957) cared for refugee children, and 79.8% (n = 4358) cared for children traveling internationally. High levels of comfort caring for immigrant children were reported by 68.5% (n = 3739), for refugee children by 50.1% (n = 2738), and for children traveling internationally by 72.7% (n = 3968). One-third of respondents (34.1%, n = 1866) reported past international experiences. In multivariable analysis, respondents with previous international experience and of Hispanic origin were significantly more likely to report high levels of comfort caring for all 3 populations. CONCLUSIONS: The majority of pediatricians report caring for children in the US who are immigrants, refugees, and traveling internationally, and previous international experience was associated with greater comfort with care. Training programs and professional organizations should consider ways to encourage a more diverse workforce and to support all pediatricians in achieving the skills and confidence required to care for children in our highly mobilized society.

Access to Lung Transplantation in the United States: The Potential Impact of Access to a High-volume Center.

BACKGROUND: Health disparities plague our healthcare system. Utilizing a novel approach, we sought to assess the effects of geographic disparities on access to lung transplantation (LT) in the United States. METHODS: A total of 13 743 LT adult recipients in the United Network for Organ Sharing Database were identified between May 2005 and December 2014 with a zip code status. Geographic access was defined by global spherical distance from patient zip code centroid to transplant center. Measures analyzed included the association among socioeconomic status (SES), distance to a transplant center, and center switching behavior. RESULTS: Median distance traveled was 62.9 miles. There was an inverse relationship between Diez Roux SES and median distance traveled (90 versus 80.1 versus 60.5 versus 30, P < 0.001). There was no association found between 5-y survival and distance traveled (P = 0.099). However, traveling >158.7 miles was associated with worse survival (hazard ration 1.1; 95% confidence interval, 1.0-1.2; P = 0.005). Over 80% of patients exhibiting center switching were transplanted at a high-volume center than their home institution. Those more likely to switch to a high-volume center were those with an associates/bachelor (P < 0.005) or graduate-level degree (P < 0.05). Recipients with high-volume home institutions had the lowest probability of switching to an alternative center (odds ratio, 0.009; P < 0.001). There was no difference in survival when comparing those transplanted at their home institution versus those who sought transplantation at an alternative institution (55.3% versus 55.0%, P = 0.41). CONCLUSIONS: Although there was no association among SES, distance traveled, and survival, access to LT services varies among populations in the United States.

Human myiasis in Ecuador.

We review epidemiological and clinical data on human myiasis from Ecuador, based on data from the Ministry of Public Health (MPH) and a review of the available literature for clinical cases. The larvae of four flies, Dermatobia hominis, Cochliomyia hominivorax, Sarcophaga haemorrhoidalis, and Lucilia eximia, were identified as the causative agents in 39 reported clinical cases. The obligate D. hominis, causing furuncular lesions, caused 17 (43.5%) cases distributed along the tropical Pacific coast and the Amazon regions. The facultative C. hominivorax was identified in 15 (38%) clinical cases, infesting wound and cavitary lesions including orbital, nasal, aural and vaginal, and occurred in both subtropical and Andean regions. C. hominivorax was also identified in a nosocomial hospital-acquired wound. Single infestations were reported for S. haemorrhoidalis and L. eximia. Of the 39 clinical cases, 8 (21%) occurred in tourists. Ivermectin, when it became available, was used to treat furuncular, wound, and cavitary lesions successfully. MPH data for 2013-2015 registered 2,187 cases of which 54% were reported in men; 46% occurred in the tropical Pacific coast, 30% in the temperate Andes, 24% in the tropical Amazon, and 0.2% in the Galapagos Islands. The highest annual incidence was reported in the Amazon (23 cases/100,000 population), followed by Coast (5.1/100,000) and Andes (4.7/100,000). Human myiasis is a neglected and understudied ectoparasitic infestation, being endemic in both temperate and tropical regions of Ecuador. Improved education and awareness among populations living in, visitors to, and health personnel working in high-risk regions, is required for improved epidemiological surveillance, prevention, and correct diagnosis and treatment.

Exposure to unsafe mobility: Traveling in the cargo area of pickup trucks in three Mexican cities.

Objective: To estimate the prevalence of pickup trucks transporting people in the cargo area and to identify factors associated to this behavior in three Mexican cities.Methods: Eight rounds of roadside observations of randomly selected pickup trucks were conducted from August 2012 to November 2014 in three Mexican cities: Guadalajara-Zapopan, León and Cuernavaca.Results: Overall, 4.03% of the 4,611 pickup trucks observed were transporting people in the cargo area (95% CI: 3.48 - 4.64%). This implies that a total of 427 passengers were traveling unsafely in the cargo area of pickup trucks; of all them 22.01% were children and 82.20% were male. Prevalence of exposure to this risky behavior was higher in León (5.77%, 95% CI: 4.73 - 6.97%) than in Cuernavaca (3.73%, 95% CI: 2.49 - 5.35%) and Guadalajara-Zapopan (2.70%, 95% CI: 2.05 - 3.48%). According to this data, exposure to this risk factor has decreased in time. Male drivers, not using seatbelt correctly carried passengers in the cargo area more frequently.Conclusions: Results support the importance of improving and enforcing current legislation and evaluating strategies directed to prevent exposure to this risky behavior with the potential of contributing to lowering the high burden that road traffic injuries imposed in Mexican public health.

Impacting Health through Cross-Border Pharmaceutical Purchases.

Annually, retirees known as Winter Texans travel to spend the winter along the Texas/Mexico border and while there, many purchase medicine in Mexico. However, strategies that are used when purchasing Mexican medicine and the health implications of doing so have not been adequately explored. The results of the study we report illustrate that Winter Texans are knowledgeable about their healthcare and act more as choice-making consumers than patients seeking care. Furthermore, the use of Mexican medication did not increase rates of adverse drug events or decrease health-related quality of life scores.

Addressing travelers' perception of risk in pre-travel care: Reports from a travel clinic in Rio de Janeiro, Brazil.

INTRODUCTION: Travel medicine is aimed at promoting health risk reduction. However, travelers' perception of risk is subjective and may influence implementation of recommendations. This study reports on travelers' perception of risk, pre-travel characteristics, and recommended interventions. METHODS: This is a descriptive cross-sectional study. RESULTS: This study included 111 individuals. Most travelers (74%) perceived their risk as low. Significant differences in travel-related risk perception between practitioners and travelers were observed (Gwet's agreement coefficient [AC1] 0.23; standard error 0.10; 95% confidence interval 0.02-0.44). CONCLUSIONS: Future studies should investigate the relationship between travelers' perception of risk and implementation of recommendations.

Temporal availability of public health care in developing countries of the Caribbean: An improved two-step floating catchment area method for estimating spatial accessibility to health care.

Due to restrictions on personnel availability, the service capacity at a health facility may vary day to day based on an established schedule. This temporal variability influences a user's choice set, modifying their possible choices. As a result, the spatial accessibility of public health care may be constantly reshaped rather than being a relatively static experience as commonly represented in place-based spatial accessibility literature. Building on the latest advances in the two-step floating catchment method, this study presents further advancements through the inclusion of health facility schedules to better represent health care availability in the assessment of accessibility. The results show that the proposed method reveals communities with relatively poor accessibility that are hidden with many existing methods. By exposing the available care within time windows, a more accurate picture of the services available to be accessed is revealed. The findings suggest that improvement in the number of doctor hours at health facilities may reduce the disparities found in accessibility scores for communities. Further, in public health care systems similarly structured, the spatial configuration of facilities with doctors can be considered at the administrative level to ensure adequate levels of access across the jurisdiction.

Addressing travelers' perception of risk in pre-travel care: Reports from a travel clinic in Rio de Janeiro, Brazil

Abstract INTRODUCTION: Travel medicine is aimed at promoting health risk reduction. However, travelers' perception of risk is subjective and may influence implementation of recommendations. This study reports on travelers' perception of risk, pre-travel characteristics, and recommended interventions. METHODS: This is a descriptive cross-sectional study. RESULTS: This study included 111 individuals. Most travelers (74%) perceived their risk as low. Significant differences in travel-related risk perception between practitioners and travelers were observed (Gwet's agreement coefficient [AC1] 0.23; standard error 0.10; 95% confidence interval 0.02-0.44). CONCLUSIONS: Future studies should investigate the relationship between travelers' perception of risk and implementation of recommendations.

Infectious disease implications of large-scale migration of Venezuelan nationals.

Background: The ongoing economic and political crisis in Venezuela has resulted in a collapse of the healthcare system and the re-emergence of previously controlled or eliminated infectious diseases. There has also been an exodus of Venezuelan international migrants in response to the crisis. We sought to describe the infectious disease risks faced by Venezuelan nationals and assess the international mobility patterns of the migrant population. Methods: We synthesized data on recent infectious disease events in Venezuela and among international migrants from Venezuela, as well as on current country of residence among the migrant population. We used passenger-level itinerary data from the International Air Transport Association to evaluate trends in outbound air travel from Venezuela over time. We used two parameter-free mobility models, the radiation and impedance models, to estimate the expected population flows from Venezuelan cities to other major Latin American and Caribbean cities. Results: Outbreaks of measles, diphtheria and malaria have been reported across Venezuela and other diseases, such as HIV and tuberculosis, are resurgent. Changes in migration in response to the crisis are apparent, with an increase in Venezuelan nationals living abroad, despite an overall decline in the number of outbound air passengers. The two models predicted different mobility patterns, but both highlighted the importance of Colombian cities as destinations for migrants and also showed that some migrants are expected to travel large distances. Despite the large distances that migrants may travel internationally, outbreaks associated with Venezuelan migrants have occurred primarily in countries proximate to Venezuela. Conclusions: Understanding where international migrants are relocating is critical, given the association between human mobility and the spread of infectious diseases. In data-limited situations, simple models can be useful for providing insights into population mobility and may help identify areas likely to receive a large number of migrants.

Brucellosis in Adults and Children: A 10-Year Case Series at Two Large Academic Hospitals in Houston, Texas.

OBJECTIVES: Brucellosis is one of the most common zoonoses worldwide. Most cases in the United States occur among travelers or immigrants from endemic regions, mostly Central America. In this study, we aimed at describing and comparing the epidemiology and clinical presentation of brucellosis in pediatric and adult patients at two large tertiary care centers in Houston, Texas. METHODS: We identified patients diagnosed as having brucellosis between January 2000 and December 2009 by searching electronic medical records and reviewing microbiology records for positive cultures. Cases were defined as those with a positive blood culture for Brucella sp, a serum agglutination titer ≥1:80 (or both positive blood culture and serum agglutination titer ≥1:80), along with an epidemiologic risk factor and clinical presentation that is consistent with brucellosis. RESULTS: Six adult and 12 pediatric cases were identified; 13 of 18 (72%) cases were immigrants, mostly from Central America. The median ages for adult and pediatric patients were 53 and 3 years old, respectively. Ingestion of unpasteurized milk products was frequently reported. Common clinical features included fever (83%), arthralgias or arthritis (67%), and hepatosplenomegaly (61%). Positive blood cultures were more frequently reported among children than adults (83% vs 33%, P = 0.03). The most common laboratory finding was mildly elevated transaminases. Three adults (50%) but no children developed thrombocytopenia (P = 0.02). Relapsed infection was a frequent occurrence. CONCLUSIONS: In the southern United States, brucellosis is an important consideration in the differential diagnosis of immigrants presenting with undifferentiated fever and joint complaints. A careful history often reveals an epidemiologic risk factor such as ingestion of unpasteurized dairy products.

Imported leishmaniasis in Sweden 1993-2016.

In Sweden, leishmaniasis is an imported disease and its epidemiology and incidence were not known until now. We conducted a retrospective, nationwide, epidemiological study from 1993 to 2016. Probable cases were patients with leishmaniasis diagnoses reported to the Swedish Patient registry, collecting data on admitted patients in Swedish healthcare since 1993 and out-patient visits since 2001. Confirmed cases were those with a laboratory test positive for leishmaniasis during 1993-2016. 299 probable cases and 182 confirmed cases were identified. Annual incidence ranged from 0.023 to 0.35 per 100 000 with a rapid increase in the last 4 years. Of 182 laboratory-verified cases, 96 were diagnosed from 2013 to 2016, and in this group, almost half of the patients were children under 18 years. Patients presented in different healthcare settings in all regions of Sweden. Cutaneous leishmaniasis was the most common clinical manifestation and the majority of infections were acquired in Asia including the Middle East, specifically Syria and Afghanistan. Leishmania tropica was responsible for the majority of cases (42%). A combination of laboratory methods increased the sensitivity of diagnosis among confirmed cases. In 2016, one-tenth of the Swedish population were born in Leishmania-endemic countries and many Swedes travel to these countries for work or vacation. Swedish residents who have spent time in Leishmania-endemic areas, could be at risk of developing disease some time during their lives. Increased awareness and knowledge are needed for correct diagnosis and management of leishmaniasis in Sweden.