Zika in Rio de Janeiro: Assessment of basic reproduction number and comparison with dengue outbreaks.

Zika virus infection was declared a public health emergency of international concern in February 2016 in response to the outbreak in Brazil and its suspected link with congenital anomalies. In this study, we use notification data and disease natural history parameters to estimate the basic reproduction number (R 0) of Zika in Rio de Janeiro, Brazil. We also obtain estimates of R 0 of dengue from time series of dengue cases in the outbreaks registered in 2002 and 2012 in the city, when DENV-3 and DENV-4 serotypes, respectively, had just emerged. Our estimates of the basic reproduction number for Zika in Rio de Janeiro based on surveillance notifications (R 0 = 2·33, 95% CI: 1·97-2·97) were higher than those obtained for dengue in the city (year 2002: R 0 = 1·70 [1·50-2·02]; year 2012: R 0 = 1·25 [1·18-1·36]). Given the role of Aedes aegypti as vector of both the Zika and dengue viruses, we also derive R 0 of Zika as a function of both dengue reproduction number and entomological and epidemiological parameters for dengue and Zika. Using the dengue outbreaks from previous years allowed us to estimate the potential R 0 of Zika. Our estimates were closely in agreement with our first Zika's R 0 estimation from notification data. Hence, these results validate deriving the potential risk of Zika transmission in areas with recurring dengue outbreaks. Whether transmission routes other than vector-based can sustain a Zika epidemic still deserves attention, but our results suggest that the Zika outbreak in Rio de Janeiro emerged due to population susceptibility and ubiquitous presence of Ae. aegypti.

Cost-effectiveness of tuberculosis screening and isoniazid treatment in the TB/HIV in Rio (THRio) Study.

OBJECTIVE: To estimate the incremental cost-effectiveness of tuberculosis (TB) screening and isoniazid preventive therapy (IPT) among human immunodeficiency virus (HIV) infected adults in Rio de Janeiro, Brazil. DESIGN: We used decision analysis, populated by data from a cluster-randomized trial, to project the costs (in 2010 USD) and effectiveness (in disability-adjusted life years [DALYs] averted) of training health care workers to implement the tuberculin skin test (TST), followed by IPT for TST-positive patients with no evidence of active TB. This intervention was compared to a baseline of usual care. We used time horizons of 1 year for the intervention and 20 years for disease outcomes, with all future DALYs and medical costs discounted at 3% per year. RESULTS: Providing this intervention to 100 people would avert 1.14 discounted DALYs (1.57 undiscounted DALYs). The median estimated incremental cost-effectiveness ratio was $2273 (IQR $1779-$3135) per DALY averted, less than Brazil's 2010 per capita gross domestic product (GDP) of $11,700. Results were most sensitive to the cost of providing the training. CONCLUSION: Training health care workers to screen HIV-infected adults with TST and provide IPT to those with latent tuberculous infection can be considered cost-effective relative to the Brazilian GDP per capita.

Tuberculosis control in a socially vulnerable area: a community intervention beyond DOT in a Brazilian favela.

OBJECTIVES: To evaluate the population-based impact of a comprehensive intervention to strengthen tuberculosis (TB) control in Rocinha, the largest urban slum in Rio de Janeiro, Brazil. DESIGN: In July 2003, 40 lay persons were hired and trained as community health workers to supervise treatment, implement educational activities and establish a supportive social network for anti-tuberculosis treatment. Between July 2005 and June 2008, a door-to-door active case finding campaign was conducted. Data were obtained from the Brazilian National Reporting System, which collects information from the TB notification form for every reported case. RESULTS: Between January 2001 and December 2008, 2623 TB cases were reported, 852 before and 1771 after the start of the program. Following the intervention, treatment success rates increased (67.6% vs. 83.2%, P < 0.001) and default rates dropped (17.8% vs. 5.5%, P < 0.001). Compared to the pre-intervention period, the TB case rate declined by an average of 39 cases per 100,000 population per 6 months (P = 0.003) in the post-intervention period, although this may have been due to secular trends already in place at the start of the intervention. Case rates declined from 591/100,000 in 2001 to 496/100,000 in 2008. CONCLUSION: With proper planning and effective community involvement, a successful intervention can lead to high cure rates and may contribute to a decrease in TB notification rates.

A nova tecnologia Genexpert e seu impacto na organização de novos serviços, captação de casos e controle da tuberculose droga resistente - Betina Durovni

 

Palestra proferida por Betina Durovni, superintendente da Secretaria Municipal de Saúde do Rio de Janeiro (SMS-RJ), durante a sessão científica do Centro de Estudos da Escola Nacional de Saúde Pública, realizada no Auditório do Salão Internacional da Escola (ENSP/Fiocruz) no dia 27 de fevereiro de 2013. A atividade foi coordenada por Gisele O’Dwyer e Jesus Pais Ramos, coordenadores de Ensino e Pesquisa do Centro de Saúde Escola Germano Sinval Faria/ENSP e do Centro de Referência Professor Hélio Fraga (CRPHF). O mediador da sessão foi o chefe do CRPHF, Miguel Aiub Hijjar. 

 

Apresentou o Estudo-piloto de implementação do GeneXpert para o diagnóstico da tuberculose pulmonar em dois municípios no Brasil, realizado no Rio de Janeiro e em Manaus. Segundo Betina, a inovação no tratamento da TB é fundamental para diminuir o número de casos. O objetivo do estudo foi estimar, em condições de rotina de unidades públicas de saúde de dois municípios do Brasil, o impacto da implementação do teste Xpert na detecção de casos de TB pulmonar e na detecção de tuberculose multirresistente.

Arquivos disponíveis para leitura:

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O Centro de Estudos da ENSP (Ceensp) é um importante espaço de atualização científica, com a troca permanente de experiências e conhecimentos entre pesquisadores de instituições do Brasil e de vários países, que vêm a Escola para debates com pesquisadores, alunos e demais interessados em contribuir com os diversos temas da saúde pública.
O objetivo é apresentar e consolidar reflexões para a realidade de saúde púública e para o sistema de ciência e tecnologia. O Ceensp é um componente estratégico para a formação dos alunos, destinado a circulação de idéias e de diálogo com os diversos setores da saúde pública.

Quality of life among people treated for tuberculosis and human immunodeficiency virus in Rio de Janeiro, Brazil.

We measured quality of life (QOL) among individuals receiving treatment for human immunodeficiency virus (HIV; n = 45), active tuberculosis (TB; n = 44) and both TB and HIV (n = 9) in Rio de Janeiro, Brazil. Active treated TB was associated with lower physical health (absolute decrease of 0.95 standard deviation in summary score), but not mental health, among people being treated for HIV. Visual analogue scale scores were similar across all three populations, and corresponded closely to standard disability weights used in the literature. Among patients receiving treatment, those with HIV, active TB and both conditions together appear to have similar QOL.

Controlled trial of active tuberculosis case finding in a Brazilian favela.

SETTING: A large, impoverished squatters' settlement (favela), Rio de Janeiro, Brazil. OBJECTIVE: To assess the community impact of active case finding for tuberculosis (TB) compared to an enhanced case-finding strategy. DESIGN: A pair-matched, cluster-randomized trial comparing household symptom screening and spot sputum collection (Arm 1) vs. distribution of an educational pamphlet (Arm 2) was performed in a large Brazilian favela. We compared TB case-notification rates, time from symptom onset to treatment start and treatment completion proportions between arms. Fourteen neighborhoods (estimated population 58,587) were pair-matched by prior TB case rates and randomly allocated to one of two interventions. TB was diagnosed using acid-fast bacilli smears. New TB cases were interviewed and clinic records were reviewed. RESULTS: A total of 193 TB cases were identified in the 14 study neighborhoods (incidence proportion 329 per 100,000 population). The case identification rate in Arm 1 was 934/100,000 person-years (py) vs. 604/100,000 py in Arm 2 (RR 1.55, 95%CI 1.10-1.99). No significant differences were found in time from cough onset to treatment start or proportion completing treatment. CONCLUSIONS: A door-to-door case-finding campaign was more effective (while ongoing) at detecting prevalent cases and influencing people to come for care than leafleting, but no differences were seen in time to treatment start or treatment completion.

Community-randomized trial of enhanced DOTS for tuberculosis control in Rio de Janeiro, Brazil.

SETTING: Central Rio de Janeiro, Brazil. OBJECTIVE: To compare the impact of routine DOTS vs. enhanced DOTS (DOTS-Ampliado or DOTS-A) on tuberculosis (TB) incidence. DESIGN: Cluster-randomized trial in eight urban neighborhoods pair-matched by TB incidence and randomly assigned to receive either the DOTS-A or DOTS strategy. DOTS-A added intensive screening of household contacts of active TB cases and provision of treatment to secondary cases and preventive therapy to contacts with latent TB infection (LTBI) to the standard DOTS strategy. The primary endpoint was the TB incidence rates in communities after 5 years of intervention. RESULTS: From November 2000 to December 2004, respectively 339 and 311 pulmonary TB cases were enrolled and 1003 and 960 household were identified in DOTS and DOTS-A communities. Among contacts from DOTS-A communities, 26 (4%) had active TB diagnosed and treated, 429 (61.3%) had LTBI detected and 258 (60.1%) started preventive therapy. TB incidence increased by 5% in DOTS communities and decreased by 10% in DOTS-A communities, for a difference of 15% after 5 years (P = 0.04). CONCLUSION: DOTS-A was associated with a modest reduction in TB incidence and may be an important strategy for reducing the burden of TB.

Tuberculosis as primary cause of death among AIDS cases in Rio de Janeiro, Brazil.

SETTING: Data from the mortality database, Rio de Janeiro City (RJC) Health Department, Rio de Janeiro, Brazil. OBJECTIVES: To determine the role played by tuberculosis (TB) in Brazil's human immunodeficiency virus (HIV) positive population, we investigated the frequency of TB as the primary cause of death among HIV-positive subjects in RJC. DESIGN: Information about acquired immune-deficiency syndrome (AIDS) deaths from 1996 to 2005 in individuals aged >12 years was obtained from the Mortality Information System (SIM), and the cause of death was classified according to the International Classification of Diseases (ICD-10), through primary causes coded in Chapter I--B20 to B24 (HIV disease). RESULTS: There were 8601 AIDS-related deaths in RJC between 1996 and 2005. TB was the primary cause of death in 9.0% of all AIDS-related deaths, while Pneumocystis carinii pneumonia (PCP) accounted for 4.7%. TB cases erroneously classified under other infectious diseases may have contributed to an underestimation of the number of TB deaths among HIV-positive patients. CONCLUSION: Our study showed that TB is the leading cause of AIDS-related deaths and is responsible for twice as many deaths as PCP, in a scenario of free access to antiretrovirals. The potential benefits of TB preventive treatment and of the availability of highly active antiretroviral treatment could not be established by this analysis.

Community DOT for tuberculosis in a Brazilian favela: comparison with a clinic model.

SETTING: Rio de Janeiro City, Brazil. OBJECTIVE: To compare community-based directly observed treatment (DOT) for tuberculosis (TB), using community health workers (CHWs), with clinic-based DOT. DESIGN: In a longitudinal study in a cohort of TB patients in a region of Rio de Janeiro city, we evaluated treatment modalities and outcomes in 1811 patients diagnosed with TB between 1 January 2003 and 30 December 2004. Patients were offered DOT when they presented to out-patient clinics for an initial diagnosis. DOT was provided in the clinic or in the community, using CHWs, for patients living in a large favela. Outcomes of treatment were assessed using treatment registry databases. RESULTS: Of the 1811 TB patients, 1215 (67%) were treated under DOT; among these, 726 (60%) received clinic-based treatment and 489 (40%) community-based treatment. Patients offered community-based treatment were more likely to accept DOT (99%) than those offered clinic-based treatment (60%, P<0.001). Treatment success rates for new smear-positive and retreatment TB cases were significantly higher among those treated with community-based DOT compared to clinic-based DOT. CONCLUSION: We conclude that using CHWs to deliver DOT in the community may improve TB treatment outcomes in selected areas such as urban slums.

Occupational exposures to bloodborne pathogens among healthcare workers in Rio de Janeiro, Brazil.

Healthcare workers (HCWs) frequently face the risk of occupational infection from bloodborne pathogens following exposure to blood and body fluids. This study describes the results of a surveillance system of occupational exposure to bloodborne pathogens among HCWs in Rio de Janeiro, Brazil, during an eight-year period. A total of 15 035 exposures reported from 537 health units were reviewed. Six circumstances comprised nearly 70% of the reported exposures: recapping needles (14%), performing surgical procedures or handling surgical equipment (14%), handling trash (13%), during disposal into sharps containers (13%), performing percutaneous venepuncture (10%) and during blood drawing (5%). Easily preventable exposures, such as incidents related to recapping needles, handling trash, and sharps left in an inappropriate place, represented 30% of the exposures reported. Post-exposure prophylaxis (PEP) for human immunodeficiency virus (HIV) was initiated for 46% of exposed HCWs. Although Brazilian guidelines indicate that PEP is usually not recommended for exposures with insignificant or very low risk of HIV infection, PEP was prescribed to a large proportion of exposed HCWs under these circumstances. The prevention of occupational exposure to bloodborne pathogens among HCWs and their safety must be considered as a public health issue. Although infection-preventative measures such as antiretroviral drugs and rapid tests are available, this study shows that there are still a high number of easily preventable exposures. The implementation of more effective prevention strategies is urgently required in this country.

Improvements in treatment success rates with directly observed therapy in Rio de Janeiro City.

SETTING: Rio de Janeiro City, Brazil. OBJECTIVE: To evaluate the effect of directly observed therapy (DOT) on treatment success, by comparing the treatment success rates between patients treated under DOT with those who received self-administered therapy (SAT). DESIGN: A longitudinal study in a cohort of tuberculosis (TB) patients. Of 9929 new pulmonary TB cases, 1190 (12%) were treated under DOT and 8739 (88%) under SAT. All patients received a three-drug regimen consisting of rifampicin (RMP), isoniazid (INH) and pyrazinamide for 2 months followed by 4 months of RMP and INH. RESULTS: Patients under DOT were more likely to convert to sputum-negative at the end of the second month than those treated under SAT (86.3% vs. 61.9%, P < 0.001). DOT alone was significantly associated with successful treatment (OR 1.6, 95%CI 1.37-1.86, P < 0.001), even when controlled by sex, age and positive smear or culture at enrollment (OR 1.56, 95%CI 1.33-1.82, P < 0.001). CONCLUSION: This pilot DOTS implementation phase showed that DOT is highly effective and feasible in a large urban centre of a developing country.