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Background: Dengue, Zika, and chikungunya, whose viruses are transmitted mainly by Aedes aegypti, significantly impact human health worldwide. Despite the recent development of promising vaccines against the dengue virus, controlling these arbovirus diseases still depends on mosquito surveillance and control. Nonetheless, several studies have shown that these measures are not sufficiently effective or ineffective. Identifying higher-risk areas in a municipality and directing control efforts towards them could improve it. One tool for this is the premise condition index (PCI); however, its measure requires visiting all buildings. We propose a novel approach capable of predicting the PCI based on facade street-level images, which we call PCINet. Methodology: Our study was conducted in Campinas, a one million-inhabitant city in São Paulo, Brazil. We surveyed 200 blocks, visited their buildings, and measured the three traditional PCI components (building and backyard conditions and shading), the facade conditions (taking pictures of them), and other characteristics. We trained a deep neural network with the pictures taken, creating a computational model that can predict buildings' conditions based on the view of their facades. We evaluated PCINet in a scenario emulating a real large-scale situation, where the model could be deployed to automatically monitor four regions of Campinas to identify risk areas. Principal findings: PCINet produced reasonable results in differentiating the facade condition into three levels, and it is a scalable strategy to triage large areas. The entire process can be automated through data collection from facade data sources and inferences through PCINet. The facade conditions correlated highly with the building and backyard conditions and reasonably well with shading and backyard conditions. The use of street-level images and PCINet could help to optimize Ae. aegypti surveillance and control, reducing the number of in-person visits necessary to identify buildings, blocks, and neighborhoods at higher risk from mosquito and arbovirus diseases. Author summary: The strategies to control Ae. aegypti require intensive work and considerable financial resources, are time-consuming, and are commonly affected by operational problems requiring urgent improvement. The PCI is a good tool for identifying higher-risk areas; however, its measure requires a high amount of human and material resources, and the aforementioned issues remain. In this paper, we propose a novel approach capable of predicting the PCI of buildings based on street-level images. This first work combines deep learning-based methods with street-level data to predict facade conditions. Considering the good results obtained with PCINet and the good correlations of facade conditions with PCI components, we could use this methodology to classify building conditions without visiting them physically. With this, we intend to overcome the high cost of identifying high-risk areas. Although we have a long road ahead, our results show that PCINet could help to optimize Ae. aegypti and arbovirus surveillance and control, reducing the number of in-person visits necessary to identify buildings or areas at risk. [ABSTRACT FROM AUTHOR]

Background: Outdoor air pollution is increasingly recognised as a key threat to population health globally, with particularly high risks for urban residents. In this study, we assessed the association between residential nitrogen dioxide (NO2) exposure and children's cognitive and behavioural development using data from São Paulo Brazil, one of the largest urban agglomerations in the world. Methods: We used data from the São Paulo Western Region Birth Cohort, a longitudinal cohort study aiming to examine determinants as well as long-term implications of early childhood development. Cross-sectional data from the 72-month follow-up was analysed. Data on NO2 concentration in the study area was collected at 80 locations in 2019, and land use regression modelling was used to estimate annual NO2 concentration at children's homes. Associations between predicted NO2 exposure and children's cognitive development as well as children's behavioural problems were estimated using linear regression models adjusted for an extensive set of confounders. All results were expressed per 10 μg/m3 increase in NO2. Results: 1143 children were included in the analysis. We found no association between NO2 and children's cognitive development (beta -0.05, 95% CI [-0.20; 0.10]) or behavioural problems (beta 0.02, 95% CI [-0.80; 0.12]). Conclusion: No association between child cognition or child behaviour and NO2 was found in this cross-sectional analysis. Further research will be necessary to understand the extent to which these null results reflect a true absence of association or other statistical, biological or adaptive factors not addressed in this paper. [ABSTRACT FROM AUTHOR]

When it comes to visceral leishmaniasis (VL) in Brazil, one of the main targets of public health policies of surveillance is the control of domestic canine reservoirs of Leishmania infantum. This paper aims to evaluate the effect of the dog population and household environment for the maintenance of natural foci in the transmission to human and animal hosts in an endemic city for VL, Bauru, in Brazil. We collected 6,578 blood samples of dogs living in 3,916 households from Nov.2019 to Mar.2020 and applied geospatial models to predict the disease risk based on the canine population. We used Kernel density estimation, cluster analysis, geostatistics, and Generalized Additive Models (GAM). To validate our models, we used cross-validation and created a receiver operating characteristic (ROC) curve. We found an overall canine VL (CVL) seroprevalence of 5.6% for the sampled dogs, while for the households, the positivity rate was 8.7%. Odds ratios (OR) for CVL increased progressively according to the number of canines for >2 dogs (OR 2.70); households that already had CVL in the past increased the chances for CVL currently (OR 2.73); and the cases of CVL increase the chances for human VL cases (OR 1.16). Our models were statistically significant and demonstrated a spatial association between canine and human disease cases, mainly in VL foci that remain endemic. Although the Kernel density ratio map had the best performance (AUC = 82), all the models showed high risk in the city's northwest area. Canine population dynamics must be considered in public policies, and geospatial methods may help target priority areas and planning VL surveillance in low and middle-income countries. [ABSTRACT FROM AUTHOR]

Tuberculosis (TB) in people living with HIV (PLHIV) is usually paucibacillary and the smear microscopy has limitations and may lead to high proportions of non-confirmed pulmonary tuberculosis (NC-PTB). Despite culture being the reference method, it usually takes 6 to 8 weeks to produce the results. This study aimed to analyze the effect of a rapid molecular test (Xpert) in the confirmatory rate of PTB among PLHIV, from 2010 to 2020, in São Paulo state, Brazil. This is an ecological study with time series analysis of the trend and the NC-PTB rates before and after Xpert implementation in 21 municipalities. The use of Xpert started and gradually increased after 2014, while the rate of NC-PTB in PLHIV decreased over this time, being more significant between late 2015 and mid-2017. The city of Ribeirão Preto stands out for having the highest percentage (75.0%) of Xpert testing among PLHIV and for showing two reductions in the NC-PTB rate. The cities with low Xpert coverage had a slower and smaller decrease in the NC-PTB rate. Despite being available since 2014, a significant proportion of PLHIV suspected of PTB in the state of São Paulo did not have an Xpert ordered by the doctors. The implementation of Xpert reduced the NC-PTB rates with growing effect as the coverage increased in the municipality. [ABSTRACT FROM AUTHOR]

The recently launched Brazilian “forest certificates” market is expected to reduce environmental compliance costs for landowners through an offset mechanism, after a long history of conservation laws based in command-and-control and strict rules. In this paper we assessed potential costs and evaluated the cost-effectiveness of the instrument when introducing to this market constraints that aim to address conservation objectives more specifically. Using the conservation planning software Marxan with Zones we simulated different scopes for the “forest certificates” market, and compared their cost-effectiveness with that of existing command-and-control (C&C), i.e. compliance to the Legal Reserve on own property, in the state of São Paulo. The simulations showed a clear potential of the constrained “forest certificates” market to improve conservation effectiveness and increase cost-effectiveness on allocation of Legal Reserves. Although the inclusion of an additional constraint of targeting the BIOTA Conservation Priority Areas doubled the cost (+95%) compared with a “free trade” scenario constrained only by biome, this option was still 50% less costly than the baseline scenario of compliance with Legal Reserve at the property. [ABSTRACT FROM AUTHOR]

The 2015–17 Zika virus (ZIKV) epidemic in the Americas subsided faster than expected and evolving population immunity was postulated to be the main reason. Herd immunization is suggested to occur around 60–70% seroprevalence, depending on demographic density and climate suitability. However, herd immunity was only documented for a few cities in South America, meaning a substantial portion of the population might still be vulnerable to a future Zika virus outbreak. The aim of our study was to determine the vulnerability of populations to ZIKV by comparing the environmental suitability of ZIKV transmission to the observed seroprevalence, based on published studies. Using a systematic search, we collected seroprevalence and geospatial data for 119 unique locations from 37 studies. Extracting the environmental suitability at each location and converting to a hypothetical expected seroprevalence, we were able to determine the discrepancy between observed and expected. This discrepancy is an indicator of vulnerability and divided into three categories: high risk, low risk, and very low risk. The vulnerability was used to evaluate the level of risk that each location still has for a ZIKV outbreak to occur. Of the 119 unique locations, 69 locations (58%) fell within the high risk category, 47 locations (39%) fell within the low risk category, and 3 locations (3%) fell within the very low risk category. The considerable heterogeneity between environmental suitability and seroprevalence potentially leaves a large population vulnerable to future infection. Vulnerability seems to be especially pronounced at the fringes of the environmental suitability for ZIKV (e.g. Sao Paulo, Brazil). The discrepancies between observed and expected seroprevalence raise the question: "why did the ZIKV epidemic stop with large populations unaffected?". This lack of understanding also highlights that future ZIKV outbreaks currently cannot be predicted with confidence. Author summary: After the ZIKV epidemic in the Americas, it remains unclear if and when a resurgence of the ZIKV could occur. We used publicly available data on environmental suitability of transmission as well as seroprevalence data to estimate future vulnerability to ZIKV outbreaks. Our results show a considerable discrepancy between the observed seroprevalence, from past exposure to the virus on one hand, and the environmental suitability, which raised the question why the epidemic subsided before reaching the expected herd immunization threshold in many locations. This lack of understanding also highlights that future ZIKV outbreaks currently cannot be predicted with confidence. Although we cannot provide an answer to the question why the epidemic subsided when it did, we present a better quantification and geospatial mapping of the potential vulnerability to future outbreaks, which will be crucial for decision makers to prepare for future outbreaks. [ABSTRACT FROM AUTHOR]

Introduction: The promotion of physical activity has been recognized as an important component in the management and prevention of multimorbidity, a condition that is increasing prevalent worldwide, including in Brazil. However, there is a scarcity of studies exploring the disparity in physical activity levels between individuals with and without multimorbidity. Therefore, the study aimed to estimate the prevalence of multimorbidity and physical activity among older adults, as well as analyze the relationship of a sufficient level of physical activity and multimorbidity, while considering sociodemographic characteristics of residents in São Paulo, Brazil. Materials and methods: Data from 1.019 participants aged 60 years or older (59.7% female; mean age 69.7±7.7) were collected from the Health Survey (ISA-Capital, 2015) conducted in the city of São Paulo, Brazil. We defined multimorbidity as the presence of two or more chronic conditions, and for physical activity, classified a sufficient level (≥150 min/week). Prevalence Ratios (PR) with 95% Confidence Intervals (95%CI) were estimated using univariate and multivariate Poisson regression to examine the relationship between multimorbidity and sufficient level of physical activity. Results: 67.7% of the participants lived with multimorbidity, while 30.1% had achieved a sufficient level of physical activity. There was a higher prevalence of sufficient level of physical activity among older adults with two (PR = 1.38; 95%CI 1.02–1.88) and four (PR = 1.37; 95%CI 1.00–1.87) chronic conditions. Older adults with multimorbidity who were 70 years or older (PR = 1.77; 95%IC 1.13–2.77), female (PR = 1.65; 95%CI 1.16–2.36), without a partner (PR = 1.43; 95%IC 1.03–1.99), and had a per capita income of 1 to 2.5 (PR = 1.83; 95%IC 1.00–3.33) were more likely to achieve a sufficient level of physical activity compared to their peers without multimorbidity. Conclusions: The study highlights sociodemographic disparities in the sufficient level of physical activity among multimorbidity, suggesting the importance of considering these factors when planning public policies aimed at promoting physical activity. [ABSTRACT FROM AUTHOR]

The aging process and the rising prevalence of Chronic Noncommunicable Diseases (NCDs) contribute to the decline in kidney function among elderly individuals. The aim of this research was to assess prevalence and incidence of decreased glomerular filtration rate (GFR) (GFR <60mL/min/1.73m2) over six-year period in elderly residents of São Paulo. This study relied on data from 2010 and 2016 waves of the cohort SABE Study ‐ Health, Wellbeing, and Aging, with a probabilistic and representative sample of elderly individuals residing in São Paulo. GFR was calculated using the 2021 Chronic Kidney Disease Epidemiology Collaboration creatinine (CKD-EPI) equation. Categorical variables were analyzed using chi-square test with Rao-Scott correction, and weighted means and standard errors were calculated for continuous variables. Logistic and linear regression models were constructed to analyse the data. Statistical analyses accounted for sample weights to ensure population representativeness. The prevalence of decreased GFR in 2010 was 17.3%, with mean GFR of 75.6 mL/min/1.73m2 (SE = 0.5). The incidence of decreased GFR between 2010 and 2016 was 14.9%, equivalent to an annual incidence of 2.5%. This incidence was associated with older age, hypertension, self-perceived fair/poor/very poor health, and greater number of comorbidities associated. Over the study period, 68.1% of the elderly participants experienced deterioration in GFR, with an average decline of 1 mL/min/1.73m2 each year. Renal function decline often occurs without noticeable symptoms, and the high prevalence of comorbidities contributes to the worsening of GFR. Therefore, monitoring renal function in the elderly is crucial for effectively managing the health of this population. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is a major risk factor for stroke. To enable improvements to AF diagnosis and follow-up care, understanding current patient pathways and barriers to optimal care are essential. We investigated the patient care pathways and their drivers, and the impact of the COVID-19 pandemic on patient pathways in a middle-income country setting, Brazil. Methods: This mixed-methods study in São Paulo, included adults (≥18y) with AF from 13 primary/secondary healthcare facilities. Surveys using baseline, follow-up (administered ≥two months after baseline) and COVID-19 questionnaires (quantitative), and three focus group discussions (FGDs) were conducted. Minimum sample size for the quantitative component was 236 and we aimed to reach saturation with at least three FGDs for the qualitative component. Descriptive statistics were used for quantitative data and a content analysis was used for qualitative data to identify themes related to AF diagnosis and follow-up care. Results: 267 participants completed the baseline questionnaire: 25% were diagnosed in primary care, 65% in an emergency or inpatient department. At follow-up (n = 259), 31% visited more than one facility for AF care, and 7% had no follow-up. Intervals between international normalised ratio (INR) tests were increased during the pandemic, and the number of healthcare visits and availability of medication were reduced. Seventeen patients participated in three FGDs and revealed that AF diagnosis often occurred following a medical emergency and patients often delay care-seeking due to misconceptions about AF symptoms. Long waiting times, doctor/patient interactions and health system factors, such as doctor availability and the referral system, influence where participants visited for follow-up care. Conclusions: Lack of public awareness and underdeveloped primary healthcare lead to delayed diagnosis, which impacts clinical outcomes and excess patient and healthcare system costs. Health system, care-provider, and pandemic factors disrupt timely and effective continuity of care. [ABSTRACT FROM AUTHOR]

Background: The short tenure of primary care physicians undermines the continuity of care, compromising health outcomes in low-, middle and in high-income countries. The purpose of this study was to investigate the contextual and individual factors associated with the tenure of physician in Primary Health Care (PHC) services. We consider individual-level sociodemographic variables such as education and work-related variables, as well as the characteristics of employers and services. Methods: This study is a retrospective cohort study of 2,335 physicians in 284 Primary Health Care Units across the São Paulo, Brazil, public health care system from 2016 to 2020. A multivariate hierarchical model was selected, and an adjusted Cox regression with multilevel analysis was employed. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was used to report the findings from the study. Results: The average physician tenure was 14.54 ± 12.89 months, and the median was 10.94 months. Differences between Primary Health Care Units accounted for 10.83% of the variance observed in the outcome, while the employing organizations were responsible for only 2.30%. The physician characteristics associated with higher tenure in PHC were age at hire, i.e., being between 30 and 60 years old, [HR: 0.84, 95% CI: (0.75–0.95)] and professional experience over five years [HR: 0.76, 95% CI: (0.59–0.96)]. Specialties not related to PHC practices were associated with a short tenure [HR: 1.25, 95% CI: (1.02–1.54)]. Conclusion: Differences between Primary Health Care Units and in the individual characteristics, such as specializations and experience, are related to the low tenure of professionals, but such characteristics can be changed through investments in PHC infrastructure and changes in work conditions, policies, training, and human resource policies. Finding a remedy for the short tenure of physicians is essential for guaranteeing a robust PHC system that can contribute to universal, resilient, and proactive health care. [ABSTRACT FROM AUTHOR]

This study is a concordance analysis comparing answers to two external assessment tools for Primary Health Care (PHC) facilities that use two different data collection methodologies: (a) external assessment through structured interviews and direct observation of facilities conducted by the National Program for Improvement of Access and Quality of Primary Care (AE-PMAQ-AB), and (b) a computerized web-based self-administered questionnaire for Assessment of the Quality of Primary Health Care Services (QualiAB). The two surveys were answered by 1,898 facilities located in 437 municipalities in the state of São Paulo, Brazil, between 2017 and 2018. Both surveys aimed to assess the management and organization of PHC facilities. A total of 158 equivalent questions were identified. The answers were grouped by thematic similarity into nine domains: Territory characteristics; Local management and external support; Structure; Health promotion, disease prevention, and therapeutic procedures; Attention to unscheduled patients; Women's health; Children's health; Attention to chronic conditions; and Oral health. The results show a high level of concordance between the answers, with 81% of the 158 compared questions showing concordance higher than 0.700. We showed that the information obtained by the web-based survey QualiAB was comparable to that of the structured interview-based AE-PMAQ-AB, which is considered the gold standard. This is important because web-based surveys are more practical and convenient, and do not require trained interviewers. Online assessment surveys can allow immediate access to answers, reports and guidelines for each evaluated facility, as provided by the QualiAB system. In this way, the answers to this type of survey can be directly employed by users, allowing the assessment to fulfill all phases of an assessment process. [ABSTRACT FROM AUTHOR]

Introduction: Solid organ transplant (SOT) recipients are at increased risk of Human Papillomavirus (HPV) persistent infection and disease. This study aimed to evaluate HPV seroprevalence, cervical HPV prevalence, genotype distribution, and frequency of HPV-related cervical lesions in SOT recipients in comparison to immunocompetent women. Methods: Cross-sectional study including SOT and immunocompetent women aged 18 to 45 years who denied previous HPV-related lesions. Cervical samples were screened for HPV-DNA by a polymerase chain reaction (PCR)-based DNA microarray system (PapilloCheck®) and squamous intraepithelial lesions (SIL) by liquid-based cytology. A multiplexed pseudovirion-based serology assay (PsV-Luminex) was used to measure HPV serum antibodies. Results: 125 SOT and 132 immunocompetent women were enrolled. Cervical samples were collected from 113 SOT and 127 immunocompetent women who had initiated sexual activity. HPV-DNA prevalence was higher in SOT than in immunocompetent women (29.6% vs. 20.2%, p = 0.112), but this difference was not statistically significant. High-risk (HR)-HPV was significantly more frequent in SOT than in immunocompetent women (19.4% vs. 7.9%, p = 0.014). Simultaneous infection with ≥2 HR-HPV types was found in 3.1% of SOT and 0.9% of immunocompetent women. HPV seropositivity for at least one HPV type was high in both groups: 63.8% of 105 SOT and 69.7% of 119 immunocompetent women (p = 0.524). Low-grade (LSIL) and high-grade SIL (HSIL) were significantly more frequent in SOT (9.7% and 5.3%, respectively) than in immunocompetent women (1.6% and 0.8%, respectively) (p = 0.001). Conclusions: These results may reflect the increased risk of HPV persistent infection and disease progression in SOT women due to chronic immunosuppression. [ABSTRACT FROM AUTHOR]

Background: Brazil faced a yellow fever(YF) outbreak in 2016–2018 and vaccination was considered for autoimmune rheumatic disease patients(ARD) with low immunosuppression due to YF high mortality. Objective: This study aimed to evaluate, prospectively for the first time, the short-term immunogenicity of the fractional YF vaccine(YFV) immunization in ARD patients with low immunossupression. Objective: Methodology and principal findings: A total of 318 participants(159 ARD and 159 age- and sex-matched healthy controls) were vaccinated with the fractional-dose(one fifth) of 17DD-YFV. All subjects were evaluated at entry(D0), D5, D10, and D30 post-vaccination for clinical/laboratory and disease activity parameters for ARD patients. Post-vaccination seroconversion rate(83.7%vs.96.6%, p = 0.0006) and geometric mean titers(GMT) of neutralizing antibodies[1143.7 (95%CI 1012.3–1292.2) vs.731 (95%CI 593.6–900.2), p<0.001] were significantly lower in ARD compared to controls. A lower positivity rate of viremia was also identified for ARD patients compared to controls at D5 (53%vs.70%, p = 0.005) and the levels persisted in D10 for patients and reduced for controls(51%vs.19%, p = 0.0001). The viremia was the only variable associated with seroconvertion. No serious adverse events were reported. ARD disease activity parameters remained stable at D30(p>0.05). Objective: Conclusion: Fractional-dose 17DD-YF vaccine in ARD patients resulted in a high rate of seroconversion rate(>80%) but lower than controls, with a longer but less intense viremia. This vaccine was immunogenic, safe and did not induce flares in ARD under low immunosuppression and may be indicated in YF outbreak situations and for patients who live or travel to endemic areas. Trial registration: This clinical trial was registered with Clinicaltrials.gov (#NCT03430388). Author summary: Yellow fever is a viral hemorragic fever with high mortality rate and the vaccine is a remarkably successful way of preventing it. As a live attenuated virus vaccine, it isnot recommended for rheumatic and other immunossupressed patients in general. However, in an outbreak scenario, the risk of dying of the disease can be higher than the risk of a vaccine serious adverse event. In 2018, the fractional-dose yellow fever vaccine was offered to the hospital employees and to the rheumatic patients without or with low immunossupression therapy in Hospital das Clinicas of University of São Paulo, during the yellow fever outbreak in São Paulo, Brazil. In order to optimize the yellow fever vaccine (YFV) supply, the fractional-dose (corresponding to one fifth) was adopted in the public vaccine campaign. This is the first study evaluating the primary vaccination with fractional-dose YFV in autoimmune rheumatic diseases(ARD) patients (n = 159) under low immunosuppression. Most vaccinated participants were able to produce enough neutralizing antibodies to be protected against yellow fever (seroconversion rate of 84% versus 96% in healthy controls). Neither activity of the rheumatic disease or serious adverse event was identified during the 30 days of followup after the vaccination. [ABSTRACT FROM AUTHOR]

A second wave of COVID-19 has demonstrated how challenging it will be to achieve sustained control of the disease, even with vaccination underway in many countries. Therefore, it remains relevant to keep improving our understanding of the distribution of COVID-19, especially of asymptomatic individuals, among different populations, and particularly in vulnerable regions. Hence, this population-based serosurvey had the objective of estimating the prevalence of individuals 18 years of age or older infected by SARS-CoV-2, and the proportion of asymptomatic individuals, among a vulnerable population living in an urban setting. This was a cross-sectional single-stage cluster sampling serosurvey conducted between September and December of 2019, in a vulnerable region of the city of São Paulo, Brazil. Families covered by three public primary healthcare units represented the selected clusters. After study inclusion, participants were asked about signs and symptoms related to COVID-19, and had collected 10 mL of blood for serology testing. A total of 272 individuals from 185 families were included in the study, out of the 400 eligible individuals for inclusion, resulting in a non-response rate of 32%. The post stratified prevalence of individuals infected by SARS-CoV-2 was 45.2% (95% CI: 39.4–51.0%), with a proportion of asymptomatic cases of 30.2% (95% CI: 23.3–38.0%). This population-based serosurvey identified a greater prevalence of infected individuals by SARS-CoV-2 compared to data from the beginning of the pandemic, and from a recent citywide serosurvey, with a similar proportion of asymptomatic individuals. It demonstrated the value of primary healthcare services for disease surveillance activities, and the importance of more focused serosurveys, especially in vulnerable locations, and the need to evaluate new surveillance strategies to take into account asymptomatic cases. [ABSTRACT FROM AUTHOR]

Coronavirus disease 2019 (CoViD-19), with the fatality rate in elder (60 years old or more) being much higher than young (60 years old or less) patients, was declared a pandemic by the World Health Organization on March 11, 2020. A mathematical model considering young and elder subpopulations under different fatality rates was formulated based on the natural history of CoViD-19 to study the transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The model considered susceptible, exposed, asymptomatic, pre-symptomatic, mild CoViD-19, severe CoViD-19, and recovered compartments, besides compartments of isolated individuals and those who were caught by test. This model was applied to study the epidemiological scenario resulting from the adoption of quarantine (isolation or lockdown) in many countries to control the rapid propagation of CoViD-19. We chose as examples the isolation adopted in São Paulo State (Brazil) in the early phase but not at the beginning of the epidemic, and the lockdown implemented in Spain when the number of severe CoViD-19 cases was increasing rapidly. Based on the data collected from São Paulo State and Spain, the model parameters were evaluated, and we obtained a higher estimation for the basic reproduction number R0 (9.24 for São Paulo State, and 8 for Spain) compared to the currently accepted estimation of R0 around 2 using the SEIR (susceptible, exposed, infectious, and recovered compartments) model. In comparison with the lockdown in Spain, the relatively early adoption of the isolation in São Paulo State resulted in enlarging the period of the first wave of the epidemic and delaying its peak. The model allowed to explain the flattening of the epidemic curves by quarantine when associated with the protective measures (face mask, washing hands with alcohol and gel, and social distancing) adopted by the population. The description of the epidemic under quarantine and protections can be a background to foreseen the epidemiological scenarios from the release strategies, which can help guide public health policies by decision-makers. [ABSTRACT FROM AUTHOR]

Visceral leishmaniasis (VL) is one of the most prevalent parasitic diseases worldwide. In 2019, 97% of the total numbers of cases in Latin America were reported in Brazil. In São Paulo state, currently 17.6% of infected individuals live in the western region. To study this neglected disease on a regional scale, we describe the spread of VL in 45 municipalities of the Regional Network for Health Assistance11(RNHA11). Environmental, human VL (HVL), and canine VL (CVL) cases, Human Development Index, and Lutzomyia longipalpis databases were obtained from public agencies. Global Moran's I index and local indicators of spatial association (LISA) statistics were used to identify spatial autocorrelation and to generate maps for the identification of VL clusters. On a local scale, we determined the spread of VL in the city of Teodoro Sampaio, part of the Pontal of Paranapanema. In Teodoro Sampaio, monthly peri-domicile sand fly collection; ELISA, IFAT and Rapid Test serological CVL; and ELISA HVL serum surveys were carried out. In RNHA11 from 2000 to 2018, Lu. longipalpis was found in 77.8%, CVL in 69%, and HVL in 42.2% of the 45 municipalities, and 537 individuals were notified with HVL. Dispersion occurred from the epicenter in the north to Teodoro Sampaio, in the south, where Lu. longipalpis and CVL were found in 2010, HVL in 2018, and critical hotspots of CVL were found in the periphery. Moran's Global Index showed a weak but statistically significant spatial autocorrelation related to cases of CVL (I = 0.2572), and 11 municipalities were identified as priority areas for implementing surveillance and control actions. In RNHA11, a complex array of socioeconomic and environmental factors may be fueling the epidemic and sustaining endemic transmission of VL, adding to the study of a neglected disease in a region of São Paulo, Brazil. Author summary: Visceral leishmaniasis (VL) is considered the second most important disease caused by a protozoan worldwide. Currently, 97% of the cases in Latin America are in Brazil. In São Paulo state, since 1997, the disease has been found in an increasing number of municipalities, mainly in the western region. The reasons why VL is spreading in a crescent shape in this region is not well understood, however, socioeconomic and environmental risk factors that increase vulnerability to the disease may be involved. From 2000 to 2018, vectors of Lutzomyia longipalpis were found in 77.8%, canine VL in 69%, and human VL in 44.4% of the 45 municipalities of the western region. Dispersion occurred from the epicenter in the north and followed central and radial highways, reaching Teodoro Sampaio in the south. Among the 45 municipalities, 11 were identified as priority areas for implementing surveillance and control actions. Considered the last frontier and one of the poorest regions of São Paulo, our findings are relevant for planning interventions aimed at reducing the cases of VL in the region. [ABSTRACT FROM AUTHOR]

Improved understanding of multimorbidity (MM) treatment adherence in primary health care (PHC) in Brazil is needed to achieve better healthcare and service outcomes. This study explored experiences of healthcare providers (HCP) and primary care patients (PCP) with mental-physical MM treatment adherence. Adults PCP with mental-physical MM and their primary care and community mental health care providers were recruited through maximum variation sampling from nine cities in São Paulo State, Southeast of Brazil. Experiences across quality domains of the Primary Care Assessment Tool-Brazil were explored through semi-structured in-depth interviews with 19 PCP and 62 HCP, conducted between April 2016 and April 2017. Through thematic conent analysis ten meta-themes concerning treatment adherence were developed: 1) variability and accessibility of treatment options available through PHC; 2) importance of coming to terms with a disease for treatment initation; 3) importance of person-centred communication for treatment initiation and maintenance; 4) information sources about received medication; 5) monitoring medication adherence; 6) taking medication unsafely; 7) perceived reasons for medication non-adherence; 8) most challenging health behavior change goals; 9) main motives for initiation or maintenance of treatment; 10) methods deployed to improve treatment adherence. Our analysis has advanced the understanding of complexity inherent to treatment adherence in mental-physical MM and revealed opportunities for improvement and specific solutions to effect adherence in Brazil. Our findings can inform research efforts to transform MM care through optimization. [ABSTRACT FROM AUTHOR]

This study aimed to analyze the discourses of patients who were diagnosed with multidrug-resistant tuberculosis, the perception of why they acquired this health condition and barriers to seeking care in a priority city in Brazil during the COVID-19 pandemic. This was an exploratory qualitative study, which used the theoretical-methodological framework of the Discourse Analysis of French matrix, guided by the Consolidated Criteria for Reporting Qualitative Research. The study was conducted in Ribeirão Preto, São Paulo, Brazil. Seven participants were interviewed who were undergoing treatment at the time of the interview. The analysis of the participants' discourses allowed the emergence of four discursive blocks: (1) impact of the social determinants in the development of multidrug-resistant tuberculosis, (2) barriers to seeking care and difficulties accessing health services, (3) perceptions of the side effects and their impact on multidrug-resistant tuberculosis treatment, and (4) tuberculosis and COVID-19: a necessary dialogue. Through discursive formations, these revealed the determinants of multidrug-resistant tuberculosis. Considering the complexity involved in the dynamics of multidrug-resistant tuberculosis, advancing in terms of equity in health, that is, in reducing unjust differences, is a challenge for public policies, especially at the current moment in Brazil, which is of accentuated economic, political and social crisis. The importance of psychosocial stressors and the lack of social support should also be highlighted as intermediary determinants of health. The study has also shown the situation of COVID-19, which consists of an important barrier for patients seeking care. Many patients reported fear, insecurity and worry with regard to returning to medical appointments, which might contribute to the worsening of tuberculosis in the scenario under study. [ABSTRACT FROM AUTHOR]

Background: Studies have shown an association between depression and frailty, even though the literature has not reached a consensus regarding how these syndromes interact. Although prospective cohort studies on this topic are still scarce, they could contribute to understanding this relationship. We aimed to observe whether depressive symptoms are risk factors for the onset of frailty among older adults living in São Paulo, Brazil. Methods: Prospective cohort study using the "Health, Well-being and Aging" (SABE) Study databases of 2006 and 2010. The sample was representative of the community-dwelling older adults living in São Paulo, and it is composed of non-frail men and women aged 60 years and older without cognitive decline. We calculated the frailty incidence rate between older adults with and without depressive symptoms and calculated the incidence rate ratio. Multiple analysis was carried out through Poisson regression with robust variance estimation. Results: The initial sample (n = 1,109) presented a mean age of 72 years (from 60 to 96) and 61.1% were women. The final sample was composed of 830 individuals, and the mean follow-up time in the study was 3.8 years. After adjusting the model, depressive symptoms did not predict the onset of frailty at follow-up. Conclusion: Depressive symptoms were not shown to be a risk factor for frailty among older adults living in São Paulo in this study. [ABSTRACT FROM AUTHOR]

We analyze the trade-offs between health and the economy during the period of social distancing in São Paulo, the state hardest hit by the COVID-19 pandemic in Brazil. We use longitudinal data with municipal-level information and check the robustness of our estimates to several sources of bias, including spatial dependence, reverse causality, and time-variant omitted variables. We use exogenous climate shocks as instruments for social distancing since people are more likely to stay home in wetter and colder periods. Our findings suggest that the health benefits of social distancing differ by levels of municipal development and may have vanished if the COVID-19 spread was not controlled in neighboring municipalities. In turn, we did not find evidence that municipalities with tougher social distancing performed worse economically. Our results also highlight that estimates that do not account for endogeneity may largely underestimate the benefits of social distancing on reducing the spread of COVID-19. [ABSTRACT FROM AUTHOR]

Objective: To compare maternal complications and describe neonatal outcomes in women with severe preeclampsia at ≤ 26+0 weeks in two countries with different management policies: expectant management (Brazil) versus termination of pregnancy (France). Methods: We conducted a retrospective comparative study by reviewing the medical records of women with severe preeclampsia at ≤ 26+0 weeks, from January 2010 to June 2018, in two centers: Hospital das Clínicas da Faculdade de Medicina, in Sao Paulo, Brazil (where medical abortion is forbidden in this indication) and Hôpital Antoine-Béclère, Clamart, France (where medical termination is accepted). We collected information on maternal characteristics, laboratory tests, maternal complications and fetal and newborn characteristics. We used Student's t-test and the Mann-Whitney U nonparametric test to compare quantitative variables, and Chi-square test or Fisher's exact test to evaluate the associations between the qualitative variables. Results: There was no between-group difference in maternal complications during hospitalization (p = 0.846). In Brazil, the rate of cesarean section was 66.7%, and 20% of patients had vertical incision. The rate of spontaneous fetal death was 35.6% and among the live-born infants 26.6% were discharged from hospital. In France, one patient had a cesarean section with vertical incision. Conclusion: When comparing termination of pregnancy to expectant management in severe preeclampsia before 26 weeks, maternal complications were equivalent but maternal reproductive future might have been compromised in 20% of cases due to a higher risk of uterine rupture in subsequent pregnancies for patients having classic cesarean (vertical incision). 26.6% of children survived the neonatal period when pregnancy was pursued, however we lack information on their long-term follow-up. [ABSTRACT FROM AUTHOR]

Canine obesity is associated with genetic, environmental, and behavioural factors, with the latter including both the behaviour of the dog and the owner. Knowledge about owner perception of canine obesity and its treatment can inform the development of new strategies to help prevent and manage this disease. Therefore, the aim of this study was to evaluate the opinions of dog owners regarding canine obesity and weight management. Dog owners residing in the city of Sao Paulo (Brazil) completed a questionnaire, either at home or in the waiting rooms of 3 veterinary hospitals. Owners determined their dog's body condition score (BCS), and this was compared with BCS determined by a veterinarian. Questionnaire findings from dogs that were in overweight (BCS 6-7/9) or obese (BCS (8-9/9) condition were compared with those in ideal weight (4-5/9) using chi-square tests and odds ratios. A total of 926 dogs were included, of which 480 (52%), 317 (34%) and 129 (14%) were in ideal, overweight and obese condition, respectively. Many owners under-estimated their dog's weight status, with the proportion increasing as the dog's weight status increased (ideal 60/480, 13%; overweight 174/317, 55%; obese 88/129, 68%; P<0.001). Although most owners (890/926, 96%) believed that canine obesity could pose health risks, the proportion that disagreed increased as weight status increased (ideal 12/480, 2%; overweight 14/317, 4%; 10/129, 8%; P = 0.006). Finally, although most owners (880/926, 95%) stated that they would let their dog undergo weight management, only a minority (182/926; 20%) believed that a trained professional was needed, and they had various misperceptions including potential cost and what the strategies that would be effective. Based on the findings of this study, it would be advisable for veterinarians to spend time addressing these misperceptions, in the hope of both improving awareness of obesity and the outcomes of weight management. [ABSTRACT FROM AUTHOR]

Brazil detected community transmission of COVID-19 on March 13, 2020. In this study we identified which areas in the country were the most vulnerable for COVID-19, both in terms of the risk of arrival of cases, the risk of sustained transmission and their social vulnerability. Probabilistic models were used to calculate the probability of COVID-19 spread from São Paulo and Rio de Janeiro, the initial hotspots, using mobility data from the pre-epidemic period, while multivariate cluster analysis of socio-economic indices was done to identify areas with similar social vulnerability. The results consist of a series of maps of effective distance, outbreak probability, hospital capacity and social vulnerability. They show areas in the North and Northeast with high risk of COVID-19 outbreak that are also highly socially vulnerable. Later, these areas would be found the most severely affected. The maps produced were sent to health authorities to aid in their efforts to prioritize actions such as resource allocation to mitigate the effects of the pandemic. In the discussion, we address how predictions compared to the observed dynamics of the disease. [ABSTRACT FROM AUTHOR]

Objectives: The objectives of this study were to describe a novel statewide registry for cardiac surgery in Brazil (REPLICCAR), to compare a regional risk model (SPScore) with EuroSCORE II and STS, and to understand where quality improvement and safety initiatives can be implemented. Methods: A total of 11 sites in the state of São Paulo, Brazil, formed an online registry platform to capture information on risk factors and outcomes after cardiac surgery procedures for all consecutive patients. EuroSCORE II and STS values were calculated for each patient. An SPScore model was designed and compared with EuroSCORE II and STS to predict 30-day outcomes: death, reoperation, readmission, and any morbidity. Results: A total of 5222 patients were enrolled in this study between November 2013 and December 2017. The observed 30-day mortality rate was 7.6%. Most patients were older, overweight, and classified as New York Heart Association (NYHA) functional class III; 14.5% of the patient population had a positive diagnosis of rheumatic heart disease, 10.9% had insulin-dependent diabetes, and 19 individuals had a positive diagnosis of Chagas disease. When evaluating the prediction performance, we found that SPScore outperformed EuroSCORE II and STS in the prediction of mortality (0.90 vs. 0.76 and 0.77), reoperation (0.84 vs. 0.60 and 0.56), readmission (0.84 vs. 0.55 and 0.51), and any morbidity (0.80 vs. 0.65 and 0.64), respectively (p<0.001). Conclusions: The REPLICCAR registry might stimulate the creation of other cardiac surgery registries in developing countries, ultimately improving the regional quality of care provided to patients. [ABSTRACT FROM AUTHOR]

Background: In most emergency situations or severe illness, patients are unable to consent for clinical trial enrollment. In such circumstances, the decision about whether to participate in a scientific study or not is made by a legally designated representative. Objective: To address the willingness of patients admitted to the intensive care unit (ICU) to be enrolled in a scientific study as volunteers, and to assess the agreement between patients' and their legal representatives' opinion concerning enrollment in a scientific study. Methods: This survey was conducted in two hospitals in São Paulo, Brazil. Patients (≥18 years) with preserved cognitive functions accompanied by a surrogate admitted to the ICU were eligible for this study. A survey containing 28 questions for patients and 8 questions for surrogates was applied within the first 48h from ICU admission. The survey for patients comprised three sections: demographic characteristics, opinion about participation in clinical research and knowledge about the importance of research. The survey for legal representatives contained two sections: demographic characteristics and assessment of legal representatives' opinion in authorizing patients to be enrolled in research. Results: Between January 2017 and May 2018, 208 pairs of ICU patients and their respective legal representatives answered the survey. Out of 208 ICU patients answering the survey, 73.6% (153/208) were willing to be enrolled in the study as volunteers. Of those patients, 65.1% (97/149) would continue participating in a research even if their legal representative did not support their enrollment. Agreement between patients' and surrogates' opinion concerning participation was poor [Kappa = 0.11 (IC95% -0.02 to 0.25)]. If a consent for study participation had been obtained, 69.1% (103/149) of patients would continue participating in the study until its conclusion, and 23.5% (35/149) would allow researchers to use data collected to date, but would withdraw from the study on that occasion. Conclusion: The majority of patients admitted to the ICU were willing to be enrolled in a scientific study as volunteers, also after a deferred informed consent procedure has been used. Nevertheless, contradictory opinions between patients and their and their legal representatives' concerning enrollment in a scientific study were often observed. [ABSTRACT FROM AUTHOR]

Background: Protease inhibitors (PI) are especially important in salvage therapy. Previous treatment failure with a PI containing regimen may elicit resistance mutations, reducing PI susceptibility and limiting treatment options. The aim of this study was to describe major PI mutations among patients exposed to at least one PI to evaluate predictors of mutation emergence and the impact of subtypes on resistance. Methodology: Partial HIV-1 pol sequences (Sanger Sequencing) from patients exposed to PI with virological failure were genotyped from January 2014 to December 2017. Drug resistance mutations (DRM), antiretroviral susceptibility (GSS) and subtypes, along clinical and laboratory parameters, were evaluated using logistic regression to access the predictors of mutation emergence. Results: In 27.5% (466/1696) of the cases at least one major PI mutations was identified, most commonly M46 (14.7%), V82 (13.8%) and I54 (13.3%). Mutations to NRTI and NNRTI were observed in 69.6% and 59.9%, respectively, of the 1696 sequences. Full activity to darunavir was predicted in 88% (1496/1696), but was only 57% among those with at least one PI-DRM. Subtype C sequences had less major PI-DRMs (10%, 9/87) compared to B (28%, 338/1216) or F (35%, 58/168) (p <0.001) but adjusted analysis suggested that this association is not independent from a shorter treatment time and fewer regimens (OR 0.59, Confidence Interval 95: 0.2–2.5, p = 0.48). Subtype F, together with NRTI mutations and longer time on treatment was associated to presence of PI-DRM, to a lower darunavir GSS and to mutations at codon I50. Conclusions: Among patients with PI-DRM, full activity to darunavir was compromised in almost half of the cases and efforts to detect failure at earlier time are warranted, particularly for HIV-1 subtype F that showed association to the emergence of resistance, with potential impact in protease inhibitors sequencing. Furthermore, NRTI mutations may serve as an indicative of sufficient adherence to allow PI-DRM emergence. [ABSTRACT FROM AUTHOR]

Direct road mortality and the barrier effect of roads are typically identified as one of the greatest threats to wildlife. In addition, collisions with large mammals are also a threat to human safety and represent an economic cost to society. We documented and explored the effects of animal-vehicle crashes on human safety in São Paulo State, Brazil. We estimated the costs of these crashes to society, and we summarized the legal perspectives. On average, the Military Highway Police of São Paulo reported 2,611 animal-vehicle crashes per year (3.3% of total crashes), and 18.5% of these resulted in human injuries or fatalities. The total annual cost to society was estimated at R$ 56,550,642 (US $ 25,144,794). The average cost for an animal-vehicle crash, regardless of whether human injuries and fatalities occurred, was R$ 21,656 (US $ 9,629). The Brazilian legal system overwhelmingly (91.7% of the cases) holds the road administrator liable for animal-vehicle collisions, both with wild and domestic species. On average, road administrators spent R$ 2,463,380 (US $ 1,005,051) per year compensating victims. The logical conclusion is that the Brazilian legal system expects road administrators to keep animals, both wild and domestic species, off the road. We suggest an improved coordination between the laws that relate to animal-vehicle collisions and human safety, and the process for environmental licenses that focusses on reducing collisions with wildlife and providing habitat connectivity. In addition, we suggest better management practices, raising awareness and social change with regard to abandoned domesticated animals including horses, cattle, and dogs. This should ultimately result in a road system with improved human safety, reduced unnatural mortality for both domestic and wild animal species, safe crossing opportunities for wildlife, and reduced monetary costs to society. [ABSTRACT FROM AUTHOR]

Introduction: Guidelines for the treatment of psychoses recommend antipsychotic monotherapy. However, the rate of antipsychotic polytherapy has increased over the last decade, reaching up to 60% in some settings. Studies evaluating the costs and impact of antipsychotic polytherapy in the health system are scarce. Objective: To estimate the costs of antipsychotic polytherapy and its impact on public health costs in a sample of subjects with psychotic disorders living in residential facilities in the city of Sao Paulo, Brazil. Method: A cross-sectional study that used a bottom-up approach for collecting costs data in a public health provider´s perspective. Subjects with psychosis living in 20 fully-staffed residential facilities in the city of Sao Paulo were assessed for clinical and psychosocial profile, severity of symptoms, quality of life, use of health services and pharmacological treatment. The impact of polytherapy on total direct costs was evaluated. Results: 147 subjects were included, 134 used antipsychotics regularly and 38% were in use of antipsychotic polytherapy. There were no significant differences in clinical and psychosocial characteristics between polytherapy and monotherapy groups. Four variables explained 30% of direct costs: the number of antipsychotics, location of the residential facility, time living in the facility and use of olanzapine. The costs of antipsychotics corresponded to 94.4% of the total psychotropic costs and to 49.5% of all health services use when excluding accommodation costs. Olanzapine costs corresponded to 51% of all psychotropic costs. Conclusion: Antipsychotic polytherapy is a huge economic burden to public health service, despite the lack of evidence supporting this practice. Great variations on antipsychotic costs explicit the need of establishing protocols for rational antipsychotic prescriptions and consequently optimising resource allocation. Cost-effectiveness studies are necessary to estimate the best value for money among antipsychotics, especially in low and middle income countries. [ABSTRACT FROM AUTHOR]

Background: American visceral leishmaniasis (AVL) is an emerging disease in the state of São Paulo, Brazil. Its geographical expansion and the increase in the number of human cases has been linked to dispersion of Lutzomyia longipalpis into urban areas. To produce more accurate risk maps we investigated the geographic distribution and routes of expansion of the disease as well as chemotype populations of the vector. Methodology/Principal Findings: A database, containing the annual records of municipalities which had notified human and canine AVL cases as well as the presence of the vector, was compiled. The chemotypes of L. longipalpis populations from municipalities in different regions of São Paulo State were determined by Coupled Gas Chromatography – Mass Spectrometry. From 1997 to June 2014, L. longipalpis has been reported in 166 municipalities, 148 of them in the Western region. A total of 106 municipalities were identified with transmission and 99 were located in the Western region, where all 2,204 autochthonous human cases occurred. Both the vector and the occurrence of human cases have expanded in a South-easterly direction, from the Western to central region, and from there, a further expansion to the North and the South. The (S)-9-methylgermacrene-B population of L. longipalpis is widely distributed in the Western region and the cembrene-1 population is restricted to the Eastern region. Conclusion/Significance: The maps in the present study show that there are two distinct epidemiological patterns of AVL in São Paulo State and that the expansion of human and canine AVL cases through the Western region has followed the same dispersion route of only one of the two species of the L. longipalpis complex, (S)-9-methylgermacrene-B. Entomological vigilance based on the routes of dispersion and identification of the chemotype population could be used to identify at-risk areas and consequently define the priorities for control measures. Author Summary: Information on the geographical distribution, dispersal mechanisms and dispersion route of insect-borne diseases can help to identify ongoing transmission areas, new risk areas and guide surveillance and control activities. Lutzomyia longipalpis, the principal vector of American visceral leishmaniasis disease in the Americas, is a group of closely related species that can be separated according to the type of pheromone produced by male individuals. It is still unclear how many members there are in this complex, how they are related and if some are more important vectors than others. In the present study, we show that the expansion of human visceral leishmaniasis in the state of São Paulo, Brazil, has followed the same dispersion route of only one of the two related species of L. longipalpis found in the state. The maps that we produced in the present study will allow us to determine risk areas for the occurrence of human visceral leishmaniasis, and reinforces our hypothesis that within São Paulo state these chemotype populations could have different biological capacities to act as a vector. [ABSTRACT FROM AUTHOR]

Dengue fever is a major public health problem worldwide, caused by any of four virus (DENV-1, DENV-2, DENV-3 and DENV-4; Flaviviridae: Flavivirus), transmitted by Aedes aegypti mosquito. Reducing the levels of infestation by A. aegypti is one of the few current strategies to control dengue fever. Entomological indicators are used by dengue national control program to measure the infestation of A. aegypti, but little is known about predictive power of these indicators to measure dengue risk. In this spatial case-control study, we analyzed the spatial distribution of the risk of dengue and the influence of entomological indicators of A. aegypti in its egg, larva-pupa and adult stages occurring in a mid-size city in the state of São Paulo. The dengue cases were those confirmed by the city's epidemiological surveillance system and the controls were obtained through random selection of points within the perimeter of the inhabited area. The values of the entomological indicators were extrapolated for the entire study area through the geostatistical ordinary kriging technique. For each case and control, the respective indicator values were obtained, according with its geographical coordinates and analyzed by using a generalized additive model. Dengue incidence demonstrated a seasonal behavior, as well as the entomological indicators of all mosquito's evolutionary stages. The infestation did not present a significant variation in intensity and was not a limiting or determining factor of the occurrence of cases in the municipality. The risk maps of the disease from crude and adjusted generalized additive models did not present differences, suggesting that areas with the highest values of entomological indicators were not associated with the incidence of dengue. The inclusion of other variables in the generalized additive models may reveal the modulatory effect for the risk of the disease, which is not found in this study. Author Summary: Dengue is a disease caused by a virus which has four serotypes DENV-1, DENV-2, DENV-3 and DENV-4. In Americas, A. aegypti is acknowledged as the only dengue vector in America. Currently the only strategy to prevent dengue is controlling A. aegypti mosquitoes. The generalized additive model was used to understand the relationship of the indicators of the presence of eggs, larvae-pupae and adult stages of A. aegypti with the occurrence of dengue cases in a medium sized city of São Paulo state, Brazil. Dengue incidence as well as the entomological indicators in all stages of the mosquito showed a seasonal behavior. The infestation level was not a limiting or a determinant factor of the occurrence of cases in the municipality. Risk maps of the disease, from the crude and adjusted by generalized additive models, showed no differences, suggesting that the entomological indicators did not influence the incidence of dengue in the city. The inclusion of other variables in the generalized additive model could reveal the modulating effect on the disease risk, not found in this study. [ABSTRACT FROM AUTHOR]

Current control methodologies have not prevented the spread of visceral leishmaniasis (VL) across Brazil. Here, we describe the development of a new tool for controlling the sand fly vector of the disease: a long-lasting lure, which releases a synthetic male sex pheromone, attractive to both sexes of Lutzomyia longipalpis. This device could be used to improve the effectiveness of residual insecticide spraying as a means of sand fly control, attracting L. longipalpis to insecticide-treated animal houses, where they could be killed in potentially large numbers over a number of weeks. Different lure designs releasing the synthetic pheromone (±)-9-methylgermacrene-B (CAS 183158-38-5) were field-tested in Araçatuba, São Paulo (SP). Experiments compared numbers of sand flies caught overnight in experimental chicken sheds with pheromone lures, to numbers caught in control sheds without pheromone. Prototype lures, designed to last one night, were first used to confirm the attractiveness of the pheromone in SP, and shown to attract significantly more flies to test sheds than controls. Longer-lasting lures were tested when new, and at fortnightly intervals. Lures loaded with 1 mg of pheromone did not attract sand flies for more than two weeks. However, lures loaded with 10 mg of pheromone, with a releasing surface of 15 cm2 or 7.5 cm2, attracted female L. longipalpis for up to ten weeks, and males for up to twelve weeks. Approximately five times more sand flies were caught with 7.5 cm2 10 mg lures when first used than occurred naturally in non-experimental chicken resting sites. These results demonstrate that these lures are suitably long-lasting and attractive for use in sand fly control programmes in SP. To our knowledge, this is the first sex pheromone-based technology targeting an insect vector of a neglected human disease. Further studies should explore the general applicability of this approach for combating other insect-borne diseases. Author Summary: Visceral leishmaniasis is a neglected disease of increasing worldwide importance. In Brazil, the protozoan parasites which cause visceral leishmaniasis are transmitted through blood-feeding of the female sand fly Lutzomyia longipalpis. As no human vaccine is available against VL, new tools for targeting sand flies are urgently needed to reduce transmission. Here, we develop and test a new tool for controlling L. longipalpis: a long-lasting lure, which releases a synthetic sex pheromone that attracts both male and female L. longipalpis. Through a series of field experiments conducted in São Paulo state, we show that these lures can attract female L. longipalpis for up to 10 weeks from first use, and males for up to 12 weeks. This technology could be applied by disease control agencies to attract sand flies away from feeding on people and their animals, and towards insecticide treated surfaces where they can be killed. To our knowledge, this is the first example of a feasible insect sex pheromone technology that could be applied as part of a programme designed to protect against a human disease. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence of psychiatric disorders in the prison population in the State of São Paulo, Brazil. Methods: Through stratified random sampling, 1.192 men and 617 women prisoners were evaluated for the presence of psychiatric disorders by the Composite International Diagnostic Interview, 2.1 version, according to definitions and criteria of International Classification of Diseases (ICD-10). The prevalence estimates of mental disorders and their respective 95% confidence intervals were calculated and adjusted for sample design through complex sample analysis. Results: Lifetime and 12-month prevalence rates differed between genders. Lifetime and 12-month prevalence of any mental disorder was, respectively, 68.9% and 39.2% among women, and 56.1% and 22.1% among men. Lifetime and 12-month prevalence of anxious-phobic disorders was, respectively, 50% and 27.7% among women and 35.3% and 13.6% among men, of affective disorders was 40% and 21% among women and 20.8% and 9.9% among men, and of drug-related disorders was 25.2% and 1.6% among women and 26.5% and 1.3% among men. For severe mental disorders (psychotic, bipolar disorders, and severe depression), the lifetime and 12-month prevalence rates were, respectively, 25.8% and 14.7% among women, and 12.3% and 6.3% among men. Conclusions: This is the first large-scale epidemiological study performed with the prison population in Brazil, revealed high rates of psychiatric disorders among men and women. Many similarities, as well as some differences, were found between our results and those of studies conducted in other countries. The differences observed are more likely due to the peculiarities of the prison systems in each country than to the diagnostic criteria adopted in the studies. This fact reinforces the importance of conducting such studies as part of planning and development of appropriate policies for the particular mental health needs of specific prison populations. [ABSTRACT FROM AUTHOR]

Background: The scarcity of information on the immature stages of sand flies and their preferred breeding sites has resulted in the focus of vectorial control on the adult stage using residual insecticide house-spraying. This strategy, along with the treatment of human cases and the euthanasia of infected dogs, has proven inefficient and visceral leishmaniasis continues to expand in Brazil. Identifying the breeding sites of sand flies is essential to the understanding of the vector's population dynamic and could be used to develop novel control strategies. Methodology/Principal finding: In the present study, an intensive search for the breeding sites of Lutzomyia longipalpis was conducted in urban and peri-urban areas of two municipalities, Promissão and Dracena, which are endemic for visceral leishmaniasis in São Paulo State, Brazil. During an exploratory period, a total of 962 soil emergence traps were used to investigate possible peridomiciliary breeding site microhabitats such as: leaf litter under tree, chicken sheds, other animal sheds and uncovered debris. A total of 160 sand flies were collected and 148 (92.5%) were L. longipalpis. In Promissão the proportion of chicken sheds positive was significantly higher than in leaf litter under trees. Chicken shed microhabitats presented the highest density of L. longipalpis in both municipalities: 17.29 and 5.71 individuals per square meter sampled in Promissão and Dracena respectively. A contagious spatial distribution pattern of L. longipalpis was identified in the emergence traps located in the chicken sheds. Conclusion: The results indicate that chicken sheds are the preferential breeding site for L. longipalpis in the present study areas. Thus, control measures targeting the immature stages in chicken sheds could have a great effect on reducing the number of adult flies and consequently the transmission rate of Leishmania (Leishmania) infantum chagasi. Author Summary: Sand flies are the vectors of a number of pathogens that infect man, especially cutaneous and visceral leishmaniasis. The control of sand flies through residual house-spraying insecticide has proven inefficient in preventing the spread of these diseases in several areas of the globe. Sand flies have a life cycle including eggs, larvae and pupae that are found in the ground, and winged adults. We developed a soil emergence trap that allowed us to identify chicken sheds as the preferred breeding sites for L. longipalpis that is the vector of visceral leishmaniasis in urban areas of municipalities in South-eastern region of Brazil. This finding opens up the possibility of controlling the immature stages which could complement the usual control strategies that focus on the adult fly. [ABSTRACT FROM AUTHOR]

Sporothrix schenckii, previously assumed to be the sole agent of human and animal sporotrichosis, is in fact a species complex. Recently recognized taxa include S. brasiliensis, S. globosa, S. mexicana, and S. luriei, in addition to S. schenckii sensu stricto. Over the last decades, large epidemics of sporotrichosis occurred in Brazil due to zoonotic transmission, and cats were pointed out as key susceptible hosts. In order to understand the eco-epidemiology of feline sporotrichosis and its role in human sporotrichosis a survey was conducted among symptomatic cats. Prevalence and phylogenetic relationships among feline Sporothrix species were investigated by reconstructing their phylogenetic origin using the calmodulin (CAL) and the translation elongation factor-1 alpha (EF1α) loci in strains originated from Rio de Janeiro (RJ, n = 15), Rio Grande do Sul (RS, n = 10), Paraná (PR, n = 4), São Paulo (SP, n = 3) and Minas Gerais (MG, n = 1). Our results showed that S. brasiliensis is highly prevalent among cats (96.9%) with sporotrichosis, while S. schenckii was identified only once. The genotype of Sporothrix from cats was found identical to S. brasiliensis from human sources confirming that the disease is transmitted by cats. Sporothrix brasiliensis presented low genetic diversity compared to its sister taxon S. schenckii. No evidence of recombination in S. brasiliensis was found by split decomposition or PHI-test analysis, suggesting that S. brasiliensis is a clonal species. Strains recovered in states SP, MG and PR share the genotype of the RJ outbreak, different from the RS clone. The occurrence of separate genotypes among strains indicated that the Brazilian S. brasiliensis epidemic has at least two distinct sources. We suggest that cats represent a major host and the main source of cat and human S. brasiliensis infections in Brazil. Author Summary: Sporotrichosis is a subcutaneous mycosis acquired by traumatic inoculation of soil and plant material contaminated with infectious propagules of the pathogen. The transmission of the disease by cats to other animals and humans occurs by biting or scratching, promoting direct inoculation of yeast cells into host tissue. This may represent an alternative and a successful transmission of the fungus. In order to understand the impact of felines on the epidemiology of sporotrichosis, we evaluated the phenotypic and genotypic features of isolates obtained from animals and humans living in outbreak areas. Although sporotrichosis is caused by a complex of species, in this study we observed that S. brasiliensis is the prevalent etiological agent of feline sporotrichosis, having been recovered from 96.9% of the samples. Moreover, this approach allowed us to recognize that isolates from RJ, SP, PR and MG states are genetically similar among them but different from feline isolates recovered from the RS epidemic. Our study brings new insights into the eco-epidemiology of sporotrichosis in Brazil, clarifying the distribution and prevalence of S. brasiliensis in feline outbreaks. Knowledge about the source and distribution of the etiological agent between outbreak areas may help to establish public strategies for the containment of the epidemic of sporotrichosis in Brazil. [ABSTRACT FROM AUTHOR]

Background: Severe dengue virus (DENV) disease is associated with extensive immune activation, characterized by a cytokine storm. Previously, elevated lipopolysaccharide (LPS) levels in dengue were found to correlate with clinical disease severity. In the present cross-sectional study we identified markers of microbial translocation and immune activation, which are associated with severe manifestations of DENV infection. Methods: Serum samples from DENV-infected patients were collected during the outbreak in 2010 in the State of São Paulo, Brazil. Levels of LPS, lipopolysaccharide binding protein (LBP), soluble CD14 (sCD14) and IgM and IgG endotoxin core antibodies were determined by ELISA. Thirty cytokines were quantified using a multiplex luminex system. Patients were classified according to the 2009 WHO classification and the occurrence of plasma leakage/shock and hemorrhage. Moreover, a (non-supervised) cluster analysis based on the expression of the quantified cytokines was applied to identify groups of patients with similar cytokine profiles. Markers of microbial translocation were linked to groups with similar clinical disease severity and clusters with similar cytokine profiles. Results: Cluster analysis indicated that LPS levels were significantly increased in patients with a profound pro-inflammatory cytokine profile. LBP and sCD14 showed significantly increased levels in patients with severe disease in the clinical classification and in patients with severe inflammation in the cluster analysis. With both the clinical classification and the cluster analysis, levels of IL-6, IL-8, sIL-2R, MCP-1, RANTES, HGF, G-CSF and EGF were associated with severe disease. Conclusions: The present study provides evidence that both microbial translocation and extensive immune activation occur during severe DENV infection and may play an important role in the pathogenesis. Author Summary: The pathogenesis of severe dengue virus (DENV) infection is still not fully understood. It is hypothesized that it is caused by a cytokine storm as is described in severe sepsis. In the sepsis field, the potent immunostimulator lipopolysaccharide (LPS) is proposed to play an important role in the development of a cytokine storm. In a previous study we have found elevated levels of LPS in children with severe DENV infection. In this study we have investigated if we could confirm that microbial translocation occurs in DENV-infected patients. Moreover, we have determined the levels of thirty cytokines to get more insight in the cytokine storm during DENV infections and we have investigated whether microbial translocation is associated with immune activation. The patients in this cohort were classified according to their clinical presentation. Furthermore, a cluster analysis based on the expression of the determined cytokines was applied to identify patients with similar cytokine profiles. With these two techniques, we identified cytokines that may contribute significantly to the cytokine storm, and we could relate elevated levels of LPS to patients with a pro-inflammatory cytokine profile. [ABSTRACT FROM AUTHOR]

Background: Blood donor screening leads to large numbers of new diagnoses of Trypanosoma cruzi infection, with most donors in the asymptomatic chronic indeterminate form. Information on electrocardiogram (ECG) findings in infected blood donors is lacking and may help in counseling and recognizing those with more severe disease. Objectives: To assess the frequency of ECG abnormalities in T.cruzi seropositive relative to seronegative blood donors, and to recognize ECG abnormalities associated with left ventricular dysfunction. Methods: The study retrospectively enrolled 499 seropositive blood donors in São Paulo and Montes Claros, Brazil, and 483 seronegative control donors matched by site, gender, age, and year of blood donation. All subjects underwent a health clinical evaluation, ECG, and echocardiogram (Echo). ECG and Echo were reviewed blindly by centralized reading centers. Left ventricular (LV) dysfunction was defined as LV ejection fraction (EF),0.50%. Results: Right bundle branch block and left anterior fascicular block, isolated or in association, were more frequently found in seropositive cases (p,0.0001). Both QRS and QTc duration were associated with LVEF values (correlation coefficients 20.159,p,0.0003, and 20.142,p = 0.002) and showed a moderate accuracy in the detection of reduced LVEF (area under the ROC curve: 0.778 and 0.790, both p,0.0001). Several ECG abnormalities were more commonly found in seropositive donors with depressed LVEF, including rhythm disorders (frequent supraventricular ectopic beats, atrial fibrillation or flutter and pacemaker), intraventricular blocks (right bundle branch block and left anterior fascicular block) and ischemic abnormalities (possible old myocardial infarction and major and minor ST abnormalities). ECG was sensitive (92%) for recognition of seropositive donors with depressed LVEF and had a high negative predictive value (99%) for ruling out LV dysfunction. Conclusions: ECG abnormalities are more frequent in seropositive than in seronegative blood donors. Several ECG abnormalities may help the recognition of seropositive cases with reduced LVEF who warrant careful follow-up and treatment. [ABSTRACT FROM AUTHOR]

Yellow fever (YF) is endemic in much of Brazil, where cases of the disease are reported every year. Since 2008, outbreaks of the disease have occurred in regions of the country where no reports had been registered for decades, which has obligated public health authorities to redefine risk areas for the disease. The aim of the present study was to propose a methodology of environmental risk analysis for defining priority municipalities for YF vaccination, using as example, the State of São Paulo, Brazil. The municipalities were divided into two groups (affected and unaffected by YF) and compared based on environmental parameters related to the disease's eco-epidemiology. Bivariate analysis was used to identify statistically significant associations between the variables and virus circulation. Multiple correspondence analysis (MCA) was used to evaluate the relationship among the variables and their contribution to the dynamics of YF in Sao Paulo. The MCA generated a factor that was able to differentiate between affected and unaffected municipalities and was used to determine risk levels. This methodology can be replicated in other regions, standardized, and adapted to each context. Author Summary: Yellow fever (YF) is an infectious disease, transmitted by mosquitoes, and very common in North and Middle East region of Brazil, where cases of the disease are reported every year. Since 2008, outbreaks of the disease have occurred in regions of the country where no reports had been registered for decades, which has obligated public health authorities to redefine risk areas for the disease. The aim of the present study was to propose a methodology of environmental risk analysis for defining priority municipalities for YF vaccination. The municipalities were divided into two groups (affected and unaffected by YF) and compared based on environmental parameters related to the disease's epidemiology. Statistical analysis was used to identify associations between the variables and virus circulation, as well as, to evaluate the relationship among the variables and their contribution to the dynamics of YF. The MCA generated a factor that was able to differentiate between affected and unaffected municipalities and was used to determine risk levels. This methodology can be replicated in other regions, standardized, and adapted to each context. [ABSTRACT FROM AUTHOR]

Introduction: Human T-cell lymphotropic virus type 1 (HTLV-1) infection is intractable and endemic in many countries. Although a few individuals have severe symptoms, most patients remain asymptomatic throughout their lives and their infections may be unknown to many health professionals. HTLV-1 can be considered a neglected public health problem and there are not many studies specifically on patients' needs and emotional experiences. Objective: To better understand how women and men living with HTLV-1 experience the disease and what issues exist in their healthcare processes. Methods: A qualitative study using participant observation and life story interview methods was conducted with 13 symptomatic and asymptomatic patients, at the outpatient clinic of the Emilio Ribas Infectious Diseases Institute, in Sao Paulo, Brazil. Results and Discussion: The interviewees stated that HTLV-1 is a largely unknown infection to society and health professionals. Counseling is rare, but when it occurs, focuses on the low probability of developing HTLV-1 related diseases without adequately addressing the risk of infection transmission or reproductive decisions. The diagnosis of HTLV-1 can remain a stigmatized secret as patients deny their situations. As a consequence, the disease remains invisible and there are potentially negative implications for patient self-care and the identification of infected relatives. This perception seems to be shared by some health professionals who do not appear to understand the importance of preventing new infections. Conclusions: Patients and medical staff referred that the main focus was the illness risk, but not the identification of infected relatives to prevent new infections. This biomedical model of care makes prevention difficult, contributes to the lack of care in public health for HTLV-1, and further perpetuates the infection among populations. Thus, HTLV-1 patients experience an "invisibility" of their complex demands and feel that their rights as citizens are ignored. Author Summary: Human T-cell lymphotropic virus type 1 (HTLV-1) infection is commonly confounded with Human Immunodeficiency Virus (HIV) infection and it is unknown to many health professionals. It is endemic in many countries and there is no effective treatment available. Although a few individuals have severe symptoms, most patients remain asymptomatic throughout their lives. Further, HTLV-1 is considered a neglected public health problem and limited studies cover specific patients' needs and emotional experiences. To better understand how women and men living with HTLV-1 experience the disease and what issues exist in their healthcare processes, we conducted a qualitative study of both symptomatic and asymptomatic patients at an outpatient clinic at the Emílio Ribas Infectious Diseases Institute in São Paulo, Brazil. We found that the main focus of health staff was on illness risk, but not identifying infected relatives and preventing new infections. This point of view, ultimately neglected patients' complex demands, and overshadows the prevention of new infections and contributes to the lack of care in public health for HTLV-1 infected subjects. Furthermore, this perpetuates the infection among these populations and the patients experience an "invisibility" of their specific needs, such as reproductive rights and feel that their rights as citizens are ignored. [ABSTRACT FROM AUTHOR]

Background: Genetic variability is a major feature of human immunodeficiency virus type 1 (HIV-1) and is considered the key factor frustrating efforts to halt the HIV epidemic. A proper understanding of HIV-1 genomic diversity is a fundamental prerequisite for proper epidemiology, genetic diagnosis, and successful drugs and vaccines design. Here, we report on the partial and near full-length genomic (NFLG) variability of HIV-1 isolates from a well-characterized cohort of recently infected patients in São Paul, Brazil. Methodology: HIV-1 proviral DNA was extracted from the peripheral blood mononuclear cells of 113 participants. The NFLG and partial fragments were determined by overlapping nested PCR and direct sequencing. The data were phylogenetically analyzed. Results: Of the 113 samples (90.3% male; median age 31 years; 79.6% homosexual men) studied, 77 (68.1%) NFLGs and 32 (29.3%) partial fragments were successfully subtyped. Of the successfully subtyped sequences, 88 (80.7%) were subtype B sequences, 12 (11%) BF1 recombinants, 3 (2.8%) subtype C sequences, 2 (1.8%) BC recombinants and subclade F1 each, 1 (0.9%) CRF02 AG, and 1 (0.9%) CRF31 BC. Primary drug resistance mutations were observed in 14/101 (13.9%) of samples, with 5.9% being resistant to protease inhibitors and nucleoside reverse transcriptase inhibitors (NRTI) and 4.9% resistant to non-NRTIs. Predictions of viral tropism were determined for 86 individuals. X4 or X4 dual or mixed-tropic viruses (X4/DM) were seen in 26 (30.2%) of subjects. The proportion of X4 viruses in homosexuals was detected in 19/69 (27.5%). Conclusions: Our results confirm the existence of various HIV-1 subtypes circulating in São Paulo, and indicate that subtype B account for the majority of infections. Antiretroviral (ARV) drug resistance is relatively common among recently infected patients. The proportion of X4 viruses in homosexuals was significantly higher than the proportion seen in other study populations. [ABSTRACT FROM AUTHOR]

Real-time (RT)-PCR increases diagnostic yield for bacterial meningitis and is ideal for incorporation into routine surveillance in a developing country. We validated a multiplex RT-PCR assay for Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae in Brazil. Risk factors for being culture-negative, RT-PCR positive were determined. The sensitivity of RT-PCR in cerebrospinal fluid (CSF) was 100% (95% confidence limits, 96.0%-100%) for N. meningitidis, 97.8% (85.5%-99.9%) for S. pneumoniae, and 66.7% (9.4%-99.2%) for H. influenzae. Specificity ranged from 98.9% to 100%. Addition of RT-PCR to routine microbiologic methods increased the yield for detection of S. pneumoniae, N. meningitidis, and H. influenzae cases by 52%, 85%, and 20%, respectively. The main risk factor for being culture negative and RT-PCR positive was presence of antibiotic in CSF (odds ratio 12.2, 95% CI 5.9-25.0). RT-PCR using CSF was highly sensitive and specific and substantially added to measures of meningitis disease burden when incorporated into routine public health surveillance in Brazil. [ABSTRACT FROM AUTHOR]

Hepatitis C virus (HCV) infects 170 million people worldwide, and is a major public health problem in Brazil, where over 1% of the population may be infected and where multiple viral genotypes co-circulate. Chronically infected individuals are both the source of transmission to others and are at risk for HCV-related diseases, such as liver cancer and cirrhosis. Before the adoption of anti-HCV control measures in blood banks, this virus was mainly transmitted via blood transfusion. Today, needle sharing among injecting drug users is the most common form of HCV transmission. Of particular importance is that HCV prevalence is growing in non-risk groups. Since there is no vaccine against HCV, it is important to determine the factors that control viral transmission in order to develop more efficient control measures. However, despite the health costs associated with HCV, the factors that determine the spread of virus at the epidemiological scale are often poorly understood. Here, we sequenced partial NS5b gene sequences sampled from blood samples collected from 591 patients in Säo Paulo state, Brazil. We show that different viral genotypes entered Säo Paulo at different times, grew at different rates, and are associated with different age groups and risk behaviors. In particular, subtype 1b is older and grew more slowly than subtypes 1a and 3a, and is associated with multiple age classes. In contrast, subtypes 1a and 3b are associated with younger people infected more recently, possibly with higher rates of sexual transmission. The transmission dynamics of HCV in Säo Paulo therefore vary by subtype and are determined by a combination of age, risk exposure and underlying social network. We conclude that social factors may play a key role in determining the rate and pattern of HCV spread, and should influence future intervention policies. [ABSTRACT FROM AUTHOR]

Since 1999 the World Health Organization issues annually an additional influenza vaccine composition recommendation. This initiative aimed to extend to the Southern Hemisphere (SH) the benefits-previously enjoyed only by the Northern Hemisphere (NH)-of a vaccine recommendation issued as close as possible to the moment just before the onset of the influenza epidemic season. A short time between the issue of the recommendation and vaccine delivery is needed to maximize the chances of correct matching between putative circulating strains and one of the three strains present in the vaccine composition. Here we compare the effectiveness of the SH influenza vaccination adopted in Brazil with hypothetical alternative scenarios defined by different timings of vaccine delivery and/or composition. Scores were based on the temporal overlap between vaccine-induced protection and circulating strains. Viral data were obtained between 1999 and 2007 from constant surveillance and strain characterization in two Brazilian cities: Belém, located at the Equatorial region, and São Paulo, at the limit between the tropical and subtropical regions. Our results show that, among currently feasible options, the best strategy for Brazil would be to adopt the NH composition and timing, as in such case protection would increase from 30% to 65% (p<.01) if past data can be used as a prediction of the future. The influenza season starts in Brazil (and in the equator virtually ends) well before the SH winter, making the current delivery of the SH vaccination in April too late to be effective. Since Brazil encompasses a large area of the Southern Hemisphere, our results point to the possibility of these conclusions being similarly valid for other tropical regions. [ABSTRACT FROM AUTHOR]

Background. Recent studies have sought to describe HIV infection and transmission characteristics around the world. Identification of early HIV-1 infection is essential to proper surveillance and description of regional transmission trends. In this study we compare people recently infected (RI) with HIV-1, as defined by Serologic Testing Algorithm for Recent HIV Seroconversion (STARHS), to those with chronic infection. Methodology/Principal Findings. Subjects were identified from 2002-2004 at four testing sites in São Paulo. Of 485 HIV-1-positive subjects, 57 (12%) were defined as RI. Of the participants, 165 (34.0%) were aware of their serostatus at the time of HIV-1 testing. This proportion was statistically larger (p<0.001) among the individuals without recent infection (n = 158, 95.8%) compared to 7 individuals (4.2%) with recently acquired HIV-1 infection. In the univariate analysis, RI was more frequent in <25 and >59 years-old age strata (p<0.001). The majority of study participants were male (78.4%), 25 to 45 years-old (65.8%), white (63.2%), single (61.7%), with family income of four or more times the minimum wage (41.0%), but with an equally distributed educational level. Of those individuals infected with HIV-1, the predominant route of infection was sexual contact (89.4%), with both hetero (47.5%) and homosexual (34.5%) exposure. Regarding sexual activity in these individuals, 43.9% reported possible HIV-1 exposure through a seropositive partner, and 49.4% reported multiple partners, with 47% having 2 to 10 partners and 37.4% 11 or more; 53.4% of infected individuals reported condom use sometimes; 34.2% reported non-injecting, recreational drug use and 23.6% were reactive for syphilis by VDRL. Subjects younger than 25 years of age were most vulnerable according to the multivariate analysis. Conclusions/Significance. In this study, we evaluated RI individuals and discovered that HIV-1 has been spreading among younger individuals in São Paulo and preventive approaches should, therefore, target this age stratum. [ABSTRACT FROM AUTHOR]