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Candidemia has been considered a persistent public health problem with great impact on hospital costs and high mortality. We aimed to evaluate the epidemiology and prognostic factors of candidemia in a tertiary hospital in Northeast Brazil from January 2011 to December 2016. Demographic and clinical data of patients were retrospectively obtained from medical records and antifungal susceptibility profiling was performed using the broth microdilution method. A total of 68 episodes of candidemia were evaluated. We found an average incidence of 2.23 episodes /1000 admissions and a 30-day mortality rate of 55.9%. The most prevalent species were Candida albicans (35.3%), Candida tropicalis (27.4%), Candida parapsilosis (21.6%) and Candida glabrata (11.8%). Higher mortality rates were observed in cases of candidemia due to C. albicans (61.1%) and C. glabrata (100%), especially when compared to C. parapsilosis (27.3%). Univariate analysis revealed some variables which significantly increased the probability of death: older age (P = 0.022; odds ratio [OR] = 1.041), severe sepsis (P < 0.001; OR = 8.571), septic shock (P = 0.035; OR = 3.792), hypotension (P = 0.003; OR = 9.120), neutrophilia (P = 0.046; OR = 3.080), thrombocytopenia (P = 0.002; OR = 6.800), mechanical ventilation (P = 0.009; OR = 8.167) and greater number of surgeries (P = 0.037; OR = 1.920). Multivariate analysis showed that older age (P = 0.040; OR = 1.055), severe sepsis (P = 0.009; OR = 9.872) and hypotension (P = 0.031; OR = 21.042) were independently associated with worse prognosis. There was no resistance to amphotericin B, micafungin or itraconazole and a low rate of resistance to fluconazole (5.1%). However, 20.5% of the Candida isolates were susceptible dose-dependent (SDD) to fluconazole and 7.7% to itraconazole. In conclusion, our results could assist in the adoption of strategies to stratify patients at higher risk for developing candidemia and worse prognosis, in addition to improve antifungal management. [ABSTRACT FROM AUTHOR]

Nematode diseases have a worldwide importance for several economic agricultural crops, such as soybean. Frequently, new or secondary pathogens arise as emergent diseases due to the intensified use of agricultural lands, causing extensive yield losses. Helicotylenchus dihystera (Hd) and Scutellonema brachyurus (Sb) appear as potential pathogens for soybean in Brazil, since their spread and population densities have been increased on soybean growing areas. Aiming to evaluate the quantitative distribution of Hd and Sb in soybean fields in South Brazil, a survey was conducted during the growing seasons of 2014–2015 and 2015–2016 in which 1,088 soil samples and 1,043 root samples were analyzed. Besides, two greenhouse experiments were conducted to evaluate the pathogenicity of both nematodes to soybean plants, in comparison with P. brachyurus (Pb), a known pathogen of the crop. The survey demonstrated that Pb, Hd and Sb are widely distributed in the States of Paraná, Santa Catarina and Mato Grosso do Sul. Besides, we proved that Hd and Sb multiply and cause root lesions in soybean cv. Potência, since they were found inside roots, and can be considered as potential pathogens for soybean plants. [ABSTRACT FROM AUTHOR]

Background: Cryptococcosis is a neglected and predominantly opportunistic mycosis that, in Brazil, poses an important public health problem, due to its late diagnosis and high lethality. Methods: The present study analysed cryptococcosis mortality in Brazil from January 2000 to December 2012, based on secondary data (Mortality Information System/SIM-DATASUS and IBGE). Results: Out of 5,755 recorded deaths in which cryptococcosis was mentioned as one of the morbid states that contributed to death, two distinct groups emerged: 1,121 (19.5%) registered cryptococcosis as the basic cause of death, and 4,634 (80.5%) registered cryptococcosis associated with risk factors, mainly AIDS (75%), followed by other host risks (5.5%). The mortality rate by cryptococcosis as the basic cause was 6.19/million inhabitants, whereas the mortality rate by cryptococcosis as an associated cause was 25.19/million inhabitants. Meningitis was the predominant clinical form (80%), males were the more affected (69%), and 39.5 years old was the mean age. The highest mortality rate due to cryptococcosis as basic cause occurred in the state of Mato Grosso (10.96/million inhabitants). Mortality rates due to cryptococcosis as associated cause were highest in the states of Santa Catarina (70.41/million inhabitants) and Rio Grande do Sul (64.40/million inhabitants), both in the South Region. Southeast, Northeast and South showed significant time trends in mortality rates. Conclusions: This study is relevant because it shows the magnitude of cryptococcosis mortality linked to AIDS and removes the invisibility of a particular non-AIDS-related disease, accounting for almost 20% of all cryptococcosis deaths. It can also contribute to control and surveillance programs, beyond highlighting the urgent prioritization of early diagnosis and proper treatment to reduce the unacceptable mortality rate of this neglected mycosis in Brazil. [ABSTRACT FROM AUTHOR]

Mangroves play an essential ecological role in the maintenance of the coastal zone and are extremely important for the socioeconomics of coastal communities. However, mangrove ecosystems are impacted by a range of anthropogenic pressures, and the loss of this habitat can be attributed primarily to the human occupation of the coastal zone. In the present study, we analyzed the spatial patterns of land use in the mangrove of the Brazilian Amazon coast, and evaluated the anthropogenic drivers of this impact, using a remote sensing approach. We mapped the road network using RapidEye images, and human settlements using global data. The results of these analyses indicate that the Brazilian Amazon coast has a low population density and low rates of anthropogenic impact in most of the coastal microregions investigated, factors that contribute to the maintenance and conservation of the region’s mangrove. The study also revealed that the paved road network is one of the principal drivers of land use in the mangrove, whereas other factors, such as population density, urban centers, and the number of settlements are much less important. While the region has 2024 km of paved highways, unpaved roads (17,496 km) facilitate access to the mangrove, with approximately 90% of anthropogenic impact being recorded within a 3 km radius of these roads. While the network of paved highways is relatively reduced in extension, preventive measures are urgently required to impede any major shift in the current scenario, caused by the expansion of major development programs. The results of the study indicate that biophysical, economic, and political factors may also contribute to the reduction, stability, and development of one of the world’s largest areas of mangrove forest. [ABSTRACT FROM AUTHOR]

Objective: To determine Shock Index (SI) reference values in the first two hours of the postpartum period after objectively measuring postpartum bleeding. Materials and methods: A complementary analysis using data from a prospective cohort study at Women’s Hospital of the University of Campinas, Brazil, between 1 February 2015 and 31 March 2016. It included women giving birth vaginally unless they had one of these conditions: gestational age below 34 weeks, hypertension, hypo- or hyperthyroidism without treatment, any cardiac disease, infections with fever or sepsis, history of coagulopathy or delivery by C-section. Blood loss was measured by adding the blood volume collected in the drape placed under the women’s buttocks and the weight of gauzes and compresses used (excluding the dry weight). Vital signs were measured every 5–15 min after delivery. Exploratory data analysis was performed to assess the mean, standard deviation, median, and percentiles (5th, 10th, 25th, 50th, 75th, 90th, 95th). To identify variation among the periods after delivery, the mean SI and heart rate (HR) values observed for the following intervals were used in the analysis: 0–20 min, 21–40 min, 41–60 min, 61–90 min and 91–120 min. Results: One hundred eighty-six women were included. The mean age ± SD was 24.9 ± 6.1 years and the mean gestational age at birth was 39.2 ± 1.8 weeks. At the puerperal period, the mean SI values ranged from 0.68 ± 0.14 to 0.74 ± 0.15. The percentile distribution ranged from 0.46 (5th percentile) to 1.05 (95th percentile). The mean HR values ranged from 80.8 ± 12.7 bpm to 92.3 ± 14.4 bpm. The percentile distribution ranged from 62.0 bpm (5th percentile) to 117 bpm (95th percentile). Conclusion: Reference ranges were established for SI and HR values which showed small variations throughout the postpartum period. [ABSTRACT FROM AUTHOR]

Background: The implementation of antiretroviral (ARV) therapy caused a significant decrease in HIV-associated mortality worldwide. Nevertheless, mortality is still high among people living with HIV/AIDS and tuberculosis (TB). ARV-naïve HIV patients coinfected with tuberculosis (TB) have more options to treat both diseases concomitantly. Nevertheless, some TB-HIV patients undertaking ARVs (ARV-experienced) are already failing the first line efavirenz-based regimen and seem to display different response to second line ARV therapy and exhibit other predictors of mortality. Methods: We performed a retrospective cohort study including 273 patients diagnosed with TB-HIV and treated at a referral center in Rio de Janeiro, Brazil, between 2008 and 2016. Multivariate analysis and Cox regression models were used to evaluate the effectiveness of ARV therapy regimens (viral load [VL] <80 copies from the 4th to 10th months after TB therapy introduction) and to identify predictors of early mortality (100 days after TB therapy initiation) considering ARV-naïve and ARV-experienced patients adjusting for sociodemographic, clinical and therapeutic covariates. Findings: Survival analysis included 273 patients, out of whom 154 (56.4%) were ARV-naïve and 119 (43.6%) were ARV-experienced. Seven deaths occurred within 6 months of anti-TB treatment, 4 in ARV-naïve and 3 in ARV-experienced patients. Multivariate analysis revealed that in ARV-naïve patients, the chance of death was substantially higher in patients who developed immune reconstitution inflammatory syndrome during the study follow up (HR = 40.6, p<0.01). For ARV-experienced patients, similar analyses failed to identify factors significantly associated with mortality. Variables independently associated with treatment failure for the ARV-naïve group were previous TB (adjusted OR [aOR] = 6.1 p = 0.03) and alcohol abuse (aOR = 3.7 p = 0.01). For ARV-experienced patients, a ritonavir boosted. Protease Inhibitor-based regimen resulted in a 2.6 times higher risk of treatment failure compared to the use of efavirenz based ARV regimens (p = 0.03) and High baseline HIV VL (p = 0.03) were predictors of treatment failure. Conclusions: Risk factors for mortality and ARV failure were different for ARV-naïve and ARV-experienced patients. The latter patient group should be targeted for trials with less toxic and rifampicin-compatible drugs to improve TB-HIV treatment outcomes and prevent death. [ABSTRACT FROM AUTHOR]

Primary health care has been recognized as a critical strategy for improving population health in developing countries. This paper investigates the effect of primary care physicians on the infant mortality rate in Brazil using a dynamic panel data approach. This method accounts for the endogeneity problem and the persistence of infant mortality over time. The empirical analysis uses an eight-year panel of municipalities between 2005 and 2012. The results indicate that primary care physician supply contributed to the decline of infant mortality in Brazil. An increase of one primary care physician per 10,000 population was associated with 7.08 fewer infant deaths per 10,000 live births. This suggests that, in addition to other determinants, primary care physicians can play an important role in accounting for the reduction of infant mortality rates. [ABSTRACT FROM AUTHOR]

Background: Linking routinely-collected data provides an opportunity to measure the effects of exposures that occur before birth on maternal, fetal and infant outcomes. High quality linkage is a prerequisite for producing reliable results, and there are specific challenges in mother-baby linkage. Using population-based administrative databases from Brazil, this study aimed to estimate the accuracy of linkage between maternal deaths and birth outcomes and dengue notifications, and to identify potential sources of bias when assessing the risk of maternal death due to dengue in pregnancy. Methods: We identified women with dengue during pregnancy in a previously linked dataset of dengue notifications in women who had experienced a live birth or stillbirth during 2007–2012. We then linked this dataset with maternal death records probabilistically using maternal name, age and municipality. We estimated the accuracy of the linkage, and examined the characteristics of false-matches and missed-matches to identify any sources of bias. Results: Of the 10,259 maternal deaths recorded in 2007–2012, 6717 were linked: 5444 to a live birth record, 1306 to a stillbirth record, and 33 to both a live and stillbirth record. After identifying 2620 missed-matches and 124 false-matches, our estimated sensitivity was 72%, specificity was 88%, and positive predictive value was 98%. Linkage errors were associated with maternal education and self-identified race; women with more than 7 years of education or who self-declared as Caucasian were more likely to link. Dengue status was not associated with linkage error. Conclusion: Despite not having unique identifiers to link mothers and birth outcomes, we demonstrated a high standard of linkage, with sensitivity and specificity values comparable to previous literature. Although there were no differences in the characteristics of dengue cases missed or included in our linked dataset, linkage error occurred disproportionally by some social-demographic characteristics, which should be taken into account in future analyses. [ABSTRACT FROM AUTHOR]

Brazil has the highest biodiversity of native stingless bees in the world. However, Brazilian regulations are based on protocols standardized by the Organization for Economic Cooperation and Development (OECD), which uses Apis mellifera as a model organism. The safety of the use of an exotic species as a substitute for a native species is a problem that concerns members of the academy and the government agencies responsible for studies of this nature in the neotropical regions where there are occurrences of stingless bee species. Regarding the exposure of larvae to pesticides, several indicators suggest that the same rearing method for A. mellifera cannot be applied to stingless bees, mainly because of their different feeding systems. Thus, it is necessary to establish an in vitro rearing method for native social bees. We developed a larval rearing method for the stingless bee species Melipona scutellaris and evaluated parameters such as the defecation rate, pupation, emergence, mortality and morphometry of the newly emerged workers. The control was represented by the morphometry of individuals that emerged from natural combs (in vivo). In addition, we determined the average lethal concentration (LC50) of the insecticide dimethoate, the standard active ingredient used for the validation of toxicity tests. Procedures conducted prior to the in vitro bioassays allowed us to obtain the actual dimensions of the rearing cells for making acrylic plates for use in establishing how much each larva consumes during its development, that is, determining how much larval food should be placed in every artificial cell. Tests performed with M. scutellaris indicated an average of 80.2% emergence of individuals relative to the larvae, 92.61% relative to the pupae and a mean of 7.42% larval mortality. The mean of the intertegular distance, head width and wing asymmetry parameters were not significantly different between individuals from the in vitro and in vivo rearing methods. The LC50 value determined was 27.48 ng dimethoate / μL diet. The method described for M. scutellaris showed development rates above OECD standards, which requires at least 75% emergence, and produced newly emerged workers with similar dimensions to those produced under natural conditions; thus these results enable their use as a rearing protocol for this species (or genus) and, consequently, their use in toxicity tests. The results produced with M. scutellaris are the first steps for a proposed toxicity test protocol for stingless bee larvae that can be standardized and included as a protocol in the OECD. [ABSTRACT FROM AUTHOR]

Background: Stroke is the third major cause of death in the world and the second in Brazil. The purpose of this work was to assess the stroke-related hospitalization, in-hospital mortality, and case fatality rates under the Brazilian Unified Health System (SUS) from 2009 to 2016. Methods: We evaluated the hospital admissions for stroke and their associated outcomes using data from the Hospital Information available at the Informatics Department of SUS. We selected hospitalization registries according to stroke diagnosis codes from the International Statistical Classification of Diseases and Related Health Problems (ICD-10). We identified the association of age and sex with patient death through multiple logistic regression and calculated the rates of hospitalization, mortality and case-fatality per 100,000 inhabitants using age-adjustment methodology. Results: We analyzed 1,113,599 stroke hospitalizations. From 2009 to 2016, the number of admissions increased from 131,122 to 146,950 and the absolute number of in-hospital deaths increased from 28,731 to 31,937. Younger age and male sex were significantly associated with patient survival. Our results showed that the annual age-adjusted hospitalization and in-hospital mortality rates decreased by 11.8% and 12.6%, respectively, but the case fatality rate increased for patients older than 70 years. Conclusions: Although the age-adjusted hospitalization and in-hospital mortality rates declined, the total number of hospitalization and deaths have increased. It is expected a continuous increase over the next years of stroke admissions with the rapid aging of the Brazilian population. Efforts should be renewed targeting risk factors, access to hospital and rehabilitation in particular for the elderly population. [ABSTRACT FROM AUTHOR]

Background: Chagas disease (CD) is a neglected chronic parasitic infection and a public health problem that is preventable, and has serious complications. In this study, the effects of age, period and birth cohort (APC Effects) on the evolution of the mortality of that disease in Brazil, from 1980–2014, according to sex and geographic region of the country, were analyzed. Mortality forecasts from the years 2015 to 2034 were estimated. Methods: This is an ecological cross-sectional study in which death records and population data were extracted from the DATASUS (Department of Information Technology of the National Health System) website, in age groups from 20–24 years of age to 80 years and over, from 1980 to 2014. The rates were standardized according to age and sex distributions using the direct method. The APC models were estimated using the Bayesian approach, and the INLA (Integrated Nested Laplace Approximations) method was used for parameter inference. Super dispersion of the data was considered, and we included unstructured random terms in the models. Results: During the analyzed period, there were 178,823 deaths in Brazil (3.85 annual deaths per 100,000 inhabitants). It was found that temporal effects on CD mortality varied by sex and region. In general, there was an increase in mortality rates up to 30 years of age, and the mortality rates were higher between 50 and 64 years of age. On average, men died five years younger than women. Mortality rates were highest in the Central West and Southeast regions. The Central West, Southeast and Southern regions had a reduction over time in the rate of CD deaths between 2000 and 2014. The mortality rate in the Northeast was not statistically different in any period analyzed, while the North had tendency to increase; however, a significant risk increase was only observed between 1995 and 1999. The rate of mortality was high in older birth cohorts. The overall prediction for the next two decades showed a progressive decline in CD mortality, which will be highest among the young. The expected average reduction was 76.1% compared to the last observed period (2010–2014) and the last predicted (2030–2034) period. The average reduction ranged from 86% in the 20–24 age group to 50% in the 80 and over age group. Conclusions: In the present study, a higher death rate was observed for ages above 30 years, especially 50 to 64 years, and in the older birth cohorts. We believe these results can be related to period effects of vector control actions and preventive and care measures by the health system of Brazil, in addition to demographic changes in the period. The differences among the regions reflect socioeconomic inequities and access to the healthcare systems in the Brazilian population. [ABSTRACT FROM AUTHOR]

Background: The study presents estimates for the burden of visceral leishmaniasis (VL) and cutaneous and mucocutaneous leishmaniasis (CML) in Brazil and its 27 federated units using data from the Global Burden of Disease Study (GBD) 2016. Methodology: We report the incidence, years of life lost (YLL), years lived with disability (YLD), and disability-adjusted life years (DALY) for leishmaniasis in Brazil from 1990 to 2016. The metrics are presented as age-standardized rates per 100,000 inhabitants with their respective uncertainty intervals (95%UI) and relative percentages of change. Principal findings: The age-standardized incidence rate of leishmaniasis decreased 48.5% from 1990 (71.0, 95%UI 24.3–150.7) to 2016 (36.5, 95%UI 24.7–50.9), whereas the age-standardized DALY increased 83.6% over the studied period from 12.2 (95%UI 7.9–18.8) to 22.4 (95%UI 13.3–36.2). The age-standardized incidence rate and YLL for VL increased by 52.9% and 108% from 1990 to 2016, respectively. Considering CML, the age-standardized incidence rate and YLD decreased by 51% and 31.8% respectively for the same period. For VL, similar profiles for male and female were observed, with YLL and DALY increasing over time; with males presenting slightly higher values. The highest YLL rates were among "under 1-year old" children, which increased 131.2% from 1990 to 2016. Regarding CML, the highest values of YLD and DALY were verified among males, and YLD values showed a similar profile, with rates increasing with age. The VL burden increased in some states in the Northeast and Southeast regions and decreased for CML in some Northern states. Conclusion: The increase of VL burden over the study period might be associated with the difficulties in controlling the disease spread. Information regarding the weight of VL and CML, including the death and disability tolls that they cause, highlights the impact of these neglected diseases on public health and the importance of effective prevention and treatment. [ABSTRACT FROM AUTHOR]

Family Health Strategy, the primary health care program in Brazil, has been scaled up throughout the country, but its expansion has been heterogeneous across municipalities. We investigate if there are unique municipal characteristics that can explain the timing of uptake and the pattern of expansion of the Family Health Strategy from years 1998 to 2012. We categorized municipalities in six groups based on the relative speed of the Family Health Strategy uptake and the pattern of Family Health Strategy coverage expansion. We assembled data for 11 indicators for years 2000 and 2010, for 5,507 municipalities, and assessed differences in indicators across the six groups, which we mapped to examine spatial heterogeneities. Important factors differentiating early and late adopters of the Family Health Strategy were supply of doctors and population density. Sustained coverage expansion was related mainly to population size, marginal benefits of the program and doctors’ supply. The uptake was widespread nationwide with no distinct patterns among regions, but highly heterogeneous at the state and municipal level. The Brazilian experience of expanding primary health care offers three lessons in relation to factors influencing diffusion of primary health care. First, the funding mechanism is critical for program implementation, and must be accompanied by ways to support the supply of primary care physicians in low density areas. Second, in more developed and bigger areas the main challenge is lack of incentives to pursue universal coverage, especially due to the availability of private insurance. Third, population size is a crucial element to guarantee coverage sustainability over time. [ABSTRACT FROM AUTHOR]

Background: Since 2015, a major economic crisis in Brazil has led to increasing poverty and the implementation of long-term fiscal austerity measures that will substantially reduce expenditure on social welfare programmes as a percentage of the country's GDP over the next 20 years. The Bolsa Família Programme (BFP)-one of the largest conditional cash transfer programmes in the world-and the nationwide primary healthcare strategy (Estratégia Saúde da Família [ESF]) are affected by fiscal austerity, despite being among the policy interventions with the strongest estimated impact on child mortality in the country. We investigated how reduced coverage of the BFP and ESF-compared to an alternative scenario where the level of social protection under these programmes is maintained-may affect the under-five mortality rate (U5MR) and socioeconomic inequalities in child health in the country until 2030, the end date of the Sustainable Development Goals.Methods and Findings: We developed and validated a microsimulation model, creating a synthetic cohort of all 5,507 Brazilian municipalities for the period 2017-2030. This model was based on the longitudinal dataset and effect estimates from a previously published study that evaluated the effects of poverty, the BFP, and the ESF on child health. We forecast the economic crisis and the effect of reductions in BFP and ESF coverage due to current fiscal austerity on the U5MR, and compared this scenario with a scenario where these programmes maintain the levels of social protection by increasing or decreasing with the size of Brazil's vulnerable populations (policy response scenarios). We used fixed effects multivariate regression models including BFP and ESF coverage and accounting for secular trends, demographic and socioeconomic changes, and programme duration effects. With the maintenance of the levels of social protection provided by the BFP and ESF, in the most likely economic crisis scenario the U5MR is expected to be 8.57% (95% CI: 6.88%-10.24%) lower in 2030 than under fiscal austerity-a cumulative 19,732 (95% CI: 10,207-29,285) averted under-five deaths between 2017 and 2030. U5MRs from diarrhoea, malnutrition, and lower respiratory tract infections are projected to be 39.3% (95% CI: 36.9%-41.8%), 35.8% (95% CI: 31.5%-39.9%), and 8.5% (95% CI: 4.1%-12.0%) lower, respectively, in 2030 under the maintenance of BFP and ESF coverage, with 123,549 fewer under-five hospitalisations from all causes over the study period. Reduced coverage of the BFP and ESF will also disproportionately affect U5MR in the most vulnerable areas, with the U5MR in the poorest quintile of municipalities expected to be 11.0% (95% CI: 8.0%-13.8%) lower in 2030 under the maintenance of BFP and ESF levels of social protection than under fiscal austerity, compared to no difference in the richest quintile. Declines in health inequalities over the last decade will also stop under a fiscal austerity scenario: the U5MR concentration index is expected to remain stable over the period 2017-2030, compared to a 13.3% (95% CI: 5.6%-21.8%) reduction under the maintenance of BFP and ESF levels of protection. Limitations of our analysis are the ecological nature of the study, uncertainty around future macroeconomic scenarios, and potential changes in other factors affecting child health. A wide range of sensitivity analyses were conducted to minimise these limitations.Conclusions: The implementation of fiscal austerity measures in Brazil can be responsible for substantively higher childhood morbidity and mortality than expected under maintenance of social protection-threatening attainment of Sustainable Development Goals for child health and reducing inequality. [ABSTRACT FROM AUTHOR]

Background: Sepsis is considered a major worldwide health burden, with high mortality and associated costs. Health indicators are essential to define strategies to improve the treatment of diseases, and the epidemiology information of sepsis in developing countries is scarce. Thus, the aim of this work is to assess trends in the incidence, lethality, costs, and other indicators of sepsis for Brazilian Unified Health System (SUS—Sistema Único de Saúde) hospitalizations for the period from January 2006 to December 2015. Materials and methods: We conducted this study using data from the SUS hospital information system. We selected registries of SUS hospitalizations of patients diagnosed with sepsis (total of 724,458 cases from 4,271 public and private Brazilian hospitals). Results: From 2006 to 2015, the annual sepsis incidence increased 50.5% from 31.5/100,000 to 47.4/100,000 persons. The mean hospital length of stay (LOS) was 9.0 days. A total of 29.1% of the hospitalizations had admission to the intensive care unit (ICU) with a mean ICU LOS of 8.0 days. The mean cost per hospitalization was US$624.0 and for hospitalizations requiring intensive care was U$1,708.1. The overall sepsis lethality rate was 46.3%, and for hospitalizations with admission to the ICU, it was 64.5%. During the study period, the lethality rate for children/teenagers decreased 40.1%, but for all other age groups it increased 11.4%. The sepsis lethality rate in public hospitals (55.5%) was higher than private hospitals (37.0%) (p < 0.001). The mean hospitalization LOS for public hospitals (10.3 days) was higher than private hospitals (7.6 days) (p < 0.001). Conclusions: The incidence and lethality rate of sepsis increased in SUS hospitalizations during the study period. The SUS’s low reimbursement to hospitals for treating sepsis may be one of the reasons for the high lethality rate. [ABSTRACT FROM AUTHOR]

We project forward total Zika virus disease (ZVD) under varying hazards of infection and consider how the age distribution of disease burden varies between these scenarios. Pathogens with age structured disease outcomes, such as rubella and Zika virus, require that management decisions consider their impact not only on total disease incidence but also on distribution of disease burden within a population. Some situations exhibit a “paradox of control” in which reductions of overall transmission decrease the total incidence but increase the incidence of severe disease. This happens because of corresponding increases in the average age of infection. Beginning with the current population structure and demographic rates of Brazil, we project forward total ZVD burden as measured by cases occurring in pregnant women and document the scenarios under which a paradox of control for ZVD management emerges. We conclude that while a paradox of control can occur for ZVD, the higher total costs from increasing the average age of infection will only be realized after several decades and vanish under conservative discounting of future costs. This indicates that managers faced with an emerging pathogen are justified to prioritize current disease incidence over potential increases in severe disease outcomes in the endemic state. [ABSTRACT FROM AUTHOR]

The main objective of the study was to analyze the effect of age, period and birth cohort on esophageal cancer mortality in Brazil and its geographic regions, per sex. An ecological study is presented herein, which evaluated the deaths by esophageal cancer and the distribution, per geographic region. Poisson Regression was utilized to calculate the effects of age, period and birth cohort, and projections were made with the statistical software R, using the age-period-cohort model. Projection of data covered the period 2015–2029. Regarding the geographic regions of Brazil, a decrease was verified, throughout time, for the mortality rates of the South and Southeast regions, for men and women. For the North, Northeast and Midwest regions, an increase was evidenced in mortality rates, mainly for men, after the 2000's. Regarding the projections, a progressive increase of mortality rates was verified for the Northeast and North regions. Divergences evidenced for observed and projected esophageal cancer mortality rates revealed inequalities among the geographic regions of Brazil. [ABSTRACT FROM AUTHOR]

Introduction: The aims of this study were to estimate all-cause and cause-specific mortality and years of life lost, investigated by disability-adjusted life-years (DALYs), due to colorectal cancer attributable to physical inactivity in Brazil and in the states; to analyze the temporal trend of these estimates over 25 years (1990–2015) compared with global estimates and according to the socioeconomic status of states of Brazil. Methods: Databases from the Global Burden of Disease Study (GBD) for Brazil, Brazilian states and global information were used. It was estimated the total number and the age-standardized rates of deaths and DALYs for colorectal cancer attributable to physical inactivity in the years 1990 and 2015. We used the Socioeconomic Development Index (SDI). Results: Physical inactivity was responsible for a substantial number of deaths (1990: 1,302; 2015: 119,351) and DALYs (1990: 31,121; 2015: 87,116) due to colorectal cancer in Brazil. From 1990 to 2015, the mortality and DALYs due to colorectal cancer attributable to physical inactivity increased in Brazil (0.6% and 0.6%, respectively) and decreased around the world (-0.8% and -1.1%, respectively). The Brazilian states with better socioeconomic indicators had higher rates of mortality and morbidity by colorectal cancer due to physical inactivity (p<0.01). Physical inactivity was responsible for deaths and DALYs due to colorectal cancer in Brazil. Conclusions: Over 25 years, the Brazilian population showed more worrisome results than around the world. Actions to combat physical inactivity and greater cancer screening and treatment are urgent in the Brazilian states. [ABSTRACT FROM AUTHOR]

Success in tuberculosis control depends on the implementation of steps that reduce social inequities, allowing the diagnosis and effective treatment of the disease. Little is known about the conditions affecting antituberculosis treatment non-adherence in areas of great social and economic heterogeneity, such as the municipality of Rio de Janeiro. This study aimed to describe and identify the social determinants of antituberculosis treatment non-adherence in the municipality of Rio de Janeiro between 2008 and 2012. An ecological study was conducted with the districts of Rio de Janeiro as the units of analysis. Analyzes using Poisson regression models allowed us to identify the association between dropout from antituberculosis treatment and the human development index and social development index. The final model showed that economic conditions, infrastructure, and the tuberculosis control quality of surveillance were associated with treatment non-adherence. This study demonstrated that the scenarios of socio-environmental precariousness found in the districts of Rio de Janeiro were able to identify populations with an increased risk of default treatment from antituberculosis. [ABSTRACT FROM AUTHOR]

Background: Differential trends in mortality suggest that stillbirths may dominate neonatal mortality in the medium to long run. Brazil has made major efforts to improve data collection on health indicators at granular geographic levels, and provides an ideal environment to test this hypothesis. Our goals were to examine levels and trends in stillbirths and neonatal deaths and the extent to which the mortality burden caused by stillbirths dominates neonatal mortality at the municipality- and state-level. Methods: We used data from the Brazilian Ministry of Health’s repository on births, fetal, and neonatal deaths (2010–2014) to calculate stillbirth and neonatal mortality rates for São Paulo state’s 645 municipalities. Results: At the state level, 7.9 per 1000 pregnancies ended in stillbirth (fetal death >22 weeks gestation or fetal weight >500g), but this varied from 0.0 to 28.4 per 1000 across municipalities. 7.9 per 1000 live births also died within the first 28 days. 42% of municipalities had a higher stillbirth rate than neonatal mortality rate, and in 61% of areas with low neonatal mortality (<8.0 per 1000), stillbirth rates exceeded neonatal mortality rates. Conclusions: This analysis suggests large variability and inequality in mortality outcomes at the sub-national level. The results also imply that stillbirth mortality may exceed neonatal mortality in Brazil and similar settings in the next few decades, which suggests a need for a shift in policy. This work further underscores the importance of continued research into causes and prevention of stillbirth. [ABSTRACT FROM AUTHOR]

Dengue occurrence is partially influenced by the immune status of the population. Consequently, the introduction of a new Dengue virus serotype can trigger explosive epidemics in susceptible populations. The determination of clusters in this scenario can help to identify hotspots and understand the disease dispersion regardless of the influence of the population herd immunity. The present study evaluated the pattern and factors associated with dengue dispersion during the first epidemic related to Dengue virus serotype 4 in Vitória, Espírito Santo state, Brazil. Data on 18,861 dengue cases reported in Vitória from September 2012 to June 2013 were included in the study. The analysis of spatial variation in temporal trend was performed to detect clusters that were compared by their respective relative risk, house index, population density, and income in an ecological study. Overall, 11 clusters were detected. The time trend increase of dengue incidence in the overall study population was 636%. The five clusters that showed a lower time trend increase than the overall population presented a higher incidence in the beginning of the epidemic and, compared to the six clusters with higher time trend increase, they presented higher relative risk for their inhabitants to acquire dengue infection (P-value = 0.02) and a lower income (P-value <0.01). House index and population density did not differ between the clusters. Early increase of dengue incidence and higher relative risk for acquiring dengue infection were favored in low-income areas. Preventive actions and improvement of infrastructure in low-income areas should be prioritized in order to diminish the magnitude of dengue dispersion after the introduction of a new serotype. [ABSTRACT FROM AUTHOR]

Background: Improper antibiotic use is one of the main drivers of bacterial resistance to antibiotics, increasing infectious diseases morbidity and mortality and raising costs of healthcare. The level of antibiotic consumption has been shown to vary according to socioeconomic determinants (SED) such as income and access to education. In many Latin American countries, antibiotics could be easily purchased without a medical prescription in private pharmacies before enforcement of restrictions on over-the-counter (OTC) sales in recent years. Brazil issued a law abolishing OTC sales in October 2010. This study seeks to find SED of antibiotic consumption in the Brazilian state of São Paulo (SSP) and to estimate the impact of the 2010 law. Methods: Data on all oral antibiotic sales having occurred in the private sector in SSP from 2008 to 2012 were pooled into the 645 municipalities of SSP. Linear regression was performed to estimate consumption levels that would have occurred in 2011 and 2012 if no law regulating OTC sales had been issued in 2010. These values were compared to actual observed levels, estimating the effect of this law. Linear regression was performed to find association of antibiotic consumption levels and of a greater effect of the law with municipality level data on SED obtained from a nationwide census. Results: Oral antibiotic consumption in SSP rose from 8.44 defined daily doses per 1,000 inhabitants per day (DID) in 2008 to 9.95 in 2010, and fell to 8.06 DID in 2012. Determinants of a higher consumption were higher human development index, percentage of urban population, density of private health establishments, life expectancy and percentage of females; lower illiteracy levels and lower percentage of population between 5 and 15 years old. A higher percentage of females was associated with a stronger effect of the law. Conclusions: SSP had similar antibiotic consumption levels as the whole country of Brazil, and they were effectively reduced by the policy. [ABSTRACT FROM AUTHOR]

Introduction: Of all syphilis-related pregnancy outcomes, fetal death is certainly the most common one, being directly related to the availability, accessibility and quality of prenatal care. The present study aimed to analyze the underreporting of fetal and infant deaths and other maternal factors associated with congenital syphilis (CS) death. Methods: This cross-sectional study integrated data of infants that were diagnosed and/or died of CS from the Sistema de Informação de Agravos de Notificação–Sinan (Notifiable Diseases Information System) and the Sistema de Informação de Mortalidade–SIM (Mortality Information System) in Fortaleza, Northeastern Brasil to identify unreported cases of congenital syphilis. We assessed data during the period from 2007 to 2013. Results: The underreporting of CS as a cause of fetal or infant death increased from 41 to 415 cases (90.1%) during 2007–2013. Exactly 3,209 cases of CS were identified in Sinan and 6,578 deaths in SIM. After database linkage, we identified 382 cases that were reported in the SIM and SINAN databases consisting of 309 fetal deaths and 73 infant deaths related to CS. From the children notified at Sinan that born alive, 3.0% (78/2,542) died; Out of these, 39 (50.0%) were early and 25 (32.1%) were late neonatal deaths. The proportion of death by CS increased from 0.62 to 5.8 from 2007 to 2013. At logistic regression, the variable that maintained statistical significance with fetal and infant death outcomes was the presence of CS signs and/or symptoms at birth (OR = 3.20; IC 95% 1.54–6.62; p = 0.002). Conclusions: Neonatal and Infant deaths following CS-associated live births are underreported in Northeastern Brazil. Data base linkage identified unreported fetal and neonatal deaths due to CS leading to an increased awareness of fetal/infant mortality due to this infection. [ABSTRACT FROM AUTHOR]

Background: In Brazil, the incidence of dengue greatly increased in the last two decades and there are several factors impeding the control of the disease. The present study focused on describing the space-time evolution of dengue in Brazil from 2001 to 2012 and analyzing the relationship of the reported cases with socio-demographic and environmental factors. Methods: The analytic units used in the preparation of thematic maps were municipalities. Statistical tests and multilevel regression models were used to evaluate the association between dengue incidence and the following factors: climate, diagnostic period, demographic density, percentage of people living in rural areas, Gross Domestic Product, Gini index, percentage of garbage collection and the rate of households with a sewage network. Results: The largest accumulation of dengue cases in Brazil was concentrated on the Atlantic coast and in the interior part of São Paulo State. The risk of dengue in subtropical and tropical climates was 1.20–11 times lower than that observed in semi-arid climates. In 2009–2010 and 2011–2012, the risks were ten and six times higher than in 2003–2004, respectively. Conclusion: Dengue is a common infection in the Brazilian population, with the largest accumulation of dengue cases concentrated on the Atlantic coast and in the interior area of São Paulo State. The high dengue rates observed in the Brazilian coastal region suggest that the cases imported from neighboring countries contribute to the spread of the disease in the country. Our results suggest that several socio-demographic and environmental factors resulted in the increase of dengue in the country over time. This is likely applicable to the occurrence of other arboviruses like Zika and chikungunya. To reverse the situation, Brazil must implement effective public policies that offer basic services such as garbage collection and sanitation networks as well as reduce vector populations. [ABSTRACT FROM AUTHOR]

Dengue is a major public health problem in tropical and subtropical areas worldwide. There is a lack of information on the risk factors for death due to severe dengue fever in developing countries, including Brazil where the state of Amazonas is located. This knowledge is important for decision making and the implementation of effective measures for patient care. This study aimed to identify factors associated with death among patients with severe dengue, in Amazonas from 2001 to 2013. We conducted a retrospective cohort study based on secondary data from the epidemiological surveillance of dengue provided by the Fundação de Vigilância em Saúde do Amazonas, FVS (Health Surveillance Foundation) of the Secretaria de Saúde do Amazonas, SUSAM (Health Secretariat of the State of Amazonas). Data on dengue cases were obtained from the SINAN (Notifiable Diseases Information System) and SIM (Mortality Information System) databases. We selected cases of severe dengue with laboratory confirmation, including dengue-related deaths of residents in the state of Amazonas from January 1, 2001, to December 31, 2013. The explanatory variables analyzed were sex, age, level of education, spontaneous hemorrhagic manifestations, plasma extravasation and platelet count. Patients who died due to severe dengue had more hematuria, gastrointestinal bleeding, and thrombocytopenia than the survivors. Considering the simultaneous effects of demographic and clinical characteristics with a multiple logistic regression model, it was observed that the factors associated with death were age >55 years (odds ratio [OR] 4.98), gastrointestinal bleeding (OR 10.26), hematuria (OR 5.07), and thrombocytopenia (OR 2.55). Gastrointestinal bleeding was the clinical sign most strongly associated with death, followed by hematuria and age >55 years. The study results showed that the best predictor of death from severe dengue is based on the characteristic of age >55 years, together with the clinical signs of gastrointestinal bleeding, hematuria, and low platelet count. [ABSTRACT FROM AUTHOR]

Visceral leishmaniasis (VL) is a zoonosis found worldwide. Its incidence has increased in Brazil in recent years, representing a serious public and animal health problem. The strategies applied in Brazil are questionable and are not sufficient to control the disease. Thus, we have compared the efficacy of some of the currently available strategies focused on dogs to prevent and control zoonotic VL in endemic areas by optimizing a mathematical model. The simulations showed that the elimination of seropositive dogs, the use of insecticide-impregnated dog collars, and the vaccination of dogs significantly contribute to reducing the prevalence of infection in both canines and humans. The use of insecticide-impregnated collars presented the highest level of efficacy mainly because it directly affected the force of infection and vector-dog contact. In addition, when used at a coverage rate of 90%, insecticide-impregnated collar was able to decrease the prevalence of seropositive dogs and humans to zero; moreover, because of the easy application and acceptance by the targeted population, these collars may be considered the most feasible for inclusion in public policies among the three simulated measures. Vaccination and euthanasia were efficacious, but the latter method is strongly criticized on ethical grounds, and both methods present difficulties for inclusion in public policies. When we compared the use of euthanasia and vaccination at coverages of 70 and 90%, respectively, the proportion of infected populations were similar. However, on evaluating the implications of both of these methods, particularly the negative aspects of culling dogs and the proportion of animals protected by vaccination, the latter measure appears to be the better option if the total cost is not significantly higher. The comparison of complications and advantages of different control strategies allows us to analyze the optimal measure and offer strategies to veterinary and public health authorities for making decisions to prevent and control zoonotic VL. Hence, improvements in both public and animal health can be achieved in regions with scenarios similar to that considered in the present study; such scenarios are characteristically found in some areas of Brazil and other countries. [ABSTRACT FROM AUTHOR]

Aims: To investigate the hypothesis that the change from the female predominance of diabetes mellitus to a standard of equality or even male preponderance can already be observed in Brazilian mortality statistics. Methods: Data on deaths for which diabetes mellitus was listed as the underlying cause were obtained from the Brazilian Mortality Information System for the years 1980 to 2012. The mortality data were also analyzed according to the multiple causes of death approach from 2001 to 2012. The population data came from the Brazilian Institute of Geography and Statistics. The mortality rates were standardized to the world population. We used a log-linear joinpoint regression to evaluate trends in age-standardized mortality rates (ASMR). Results: From 1980 to 2012, we found a marked increment in the diabetes ASMR among Brazilian men and a less sharp increase in the rate among women, with the latter period (2003–2012) showing a slight decrease among women, though it was not statistically significant. Conclusions: The results of this study suggest that diabetes mellitus in Brazil has changed from a pattern of higher mortality among women compared to men to equality or even male predominance. [ABSTRACT FROM AUTHOR]

We described a comprehensive analysis of the molecular epidemiology of multidrug-resistant (MDR) P. aeruginosa. Molecular analysis included typing by Pulsed Field Gel Electrophoresis, identification of genes of interest through PCR-based assays and sequencing of target genes. Case-control study was conducted to better understand the prognostic of patients and the impact of inappropriate therapy in patients with bacteremia, as well as the risk factors of MDR infections. We observed a high rate of MDR isolates (40.7%), and 51.0% of them was independently associated with inappropriate antibiotic therapy. Bacteremia was detected in 66.9% of patients, and prolonged hospital stay was expressive in those resistant to fluoroquinolone. Plasmid-mediated quinolone resistance genes (PMQR), qnrS1 and aac(6’)Ib-cr, were detected in two different nosocomial isolates (5.3%), and the aac(6’)-Ib7 variant was detected at a high frequency (87.5%) in those negative to PMQR. The presence of mutations in gyrA and parC genes was observed in 100% and 85% of selected isolates, respectively. Isolates harboring PMQR genes or mutations in gyrA and parC were not closely related, except in those containing SPM (São Paulo metallo-β-lactamase) clone. In addition, there is no study published in Brazil to date reporting the presence of Pseudomonas aeruginosa isolates harboring both qnrS1 and aac(6’)Ib-cr genes, with alarming frequency of patients with inappropriate therapy. [ABSTRACT FROM AUTHOR]

Objective: This study analysed clinical and sociodemographic aspects and follow-up for notified cases of tuberculosis (TB) and explored inequalities in incidence rates and outcome by colour or race and the geographic macro-regions of Brazil. Methods: This paper reports the results of a population-based descriptive epidemiological study of all notified cases of TB in Brazil during the period from 01/01/2008 to 31/12/2011. We analysed sociodemographic and clinical variables according to colour or race (white, black, Asian, mixed, and indigenous) and geographic macro-regions of the country (North, Northeast, Central-West, South, and Southeast). Results: During the study period, the average incidence of TB in Brazil was 36.7 cases per 100,000 inhabitants, with the highest rates occurring in the North and Southeast regions. The analysis of TB notifications by colour or race revealed that the indigenous population presented the highest incidence rates in all macro-regions except the South, where higher rates were reported in black patients. ‘Cured’ was the most frequently reported treatment outcome for all skin colour categories. The highest cure rate occurred among the indigenous population (76.8%), while the lowest cure rate occurred among the black population (70.7%). Rates of treatment default were highest among blacks (10.5%) and lowest among the indigenous population (6.9%). However, the fatality rate was similar across race categories, varying between 2.8% and 3.8% for whites and the indigenous population, respectively. The lowest cure rates were observed when follow-up was inadequate (58.3%), and the highest was observed when the follow-up was classified as excellent (96.8%). Conclusions: This study revealed that—apart from the heterogeneous distribution of TB among the Brazilian macro-regions—ethnic-racial inequalities exist in terms of clinical-epidemiological characteristics and incidence rates as well as follow-up for cases undergoing treatment. The highest rates of TB occurred among the indigenous people. [ABSTRACT FROM AUTHOR]

The physical activity practice is highlighted as a strategy to health promotion and to avoid chronic diseases. In addition to individual factors, environmental characteristics in which people live, may offer opportunities or barriers in adopting healthy habits and this is related to the physical activity (PA) practice among individuals. The aim of this study is to investigate the associations between neighborhood environment and leisure-time physical activity in adults. This is a cross-sectional study, developed using the database of Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey (VIGITEL 2008/2010) of Belo Horizonte, Brazil. Individuals with the habit of practicing PA for at least 150 minutes of moderate-intensity PA or at least 75 minutes of vigorous-intensity PA throughout the week in leisure time were classified as active in leisure time. To characterize the built and social environment we used georeferenced data of public and private places for physical activity, population density, residential density, homicide rate and total income of the coverage area of the basic health units. The covered area of the basic health units was used as context unit. For data analysis, we used multilevel logistic regression. The study included 5779 adults, 58.77% female. There was variability of physical activity in leisure time between area covered by the basic health units (Median Odds ratio = 1.30). After adjusting for individual characteristics, the increase of density of private places for physical activity (Odds ratios—OR = 1.31; 95% confidence interval—95% CI: 1.15 to 1.48) and the smaller homicide rate (OR = 0.82; IC95%: 0.70 to 0.96) in the neighborhood increased physical activity in leisure time. The evidence of this study shows that neighborhood environment may influence the physical activity practice in leisure time and should be considered in future interventions and health promotion strategies. [ABSTRACT FROM AUTHOR]