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Objective: To perform a systematic review with meta-analysis to assess recent scientific evidence on the association between periodontitis and systemic parameters/conditions in individuals with chronic kidney disease (CKD)., Materials and Methods: The search for studies was performed in MedLine/PubMed, Scopus, Web of Science, and BIREME databases. Reference lists of selected articles were also searched. Studies with different epidemiological designs evaluating the influence of exposure to periodontitis on serum markers and mortality in individuals with CKD were eligible for inclusion. Three independent reviewers performed the article selection and data extraction. The assessment of methodological quality used the adapted Newcastle Ottawa Scale. Random effects meta-analysis was performed to calculate association measurements and 95% confidence intervals., Results: In total, 3053 records were identified in the database search, with only 25 studies meeting the eligibility criteria and, of these, 10 studies contributed data for meta-analysis. Using a random-effects model, periodontitis was associated with hypoalbuminemia (PR unadjusted  = 2.47; 95%CI:1.43-4.26), with high levels of C-reactive protein (PR unadjusted  = 1.35; 95%CI%:1.12-1.64), death from cardiovascular disease (RR unadjusted  = 2.29; 95%CI:1.67-3.15) and death from all causes (RR unadjusted  = 1.73; 95%CI:1.32-2.27)., Conclusions: The findings of this review validated a positive association between periodontitis and serum markers and mortality data in individuals with CKD., (© 2024 Wiley Periodicals LLC.)

Background: The risk of death due to tuberculosis (TB) in Brazil is high and strongly related to living conditions (LC). However, epidemiological studies investigating changes in LC and their impact on TB are lacking., Objectives: To evaluate the impact of LC on TB mortality in Brazil., Design and Setting: This ecological study, using panel data on spatial and temporal aggregates, was conducted in 1,614 municipalities between 2002 and 2015., Methods: Data were collected from the Mortality Information System and the Brazilian Institute of Geography and Statistics. The proxy variable used for LC was the Urban Health Index (UHI). Negative binomial regression models were used to estimate the effect of the UHI on TB mortality rate. Attributable risk (AR) was used as an impact measure., Results: From 2002 to 2015, TB mortality rate decreased by 23.5%, and LC improved. The continuous model analysis resulted in an RR = 0.89 (95%CI = 0.82-0.96), so the AR was -12.3%. The categorized model showed an effect of 0.92 (95%CI = 0.83-0.95) in municipalities with intermediate LC and of 0.83 (95%CI = 0.82-0.91) in those with low LC, representing an AR for TB mortality of -8.7% and -20.5%, respectively., Conclusions: Improved LC impacted TB mortality, even when adjusted for other determinants. This impact was greater in the strata of low-LC municipalities.

Background: Few studies have evaluated the effects of the Coronavirus disease 2019 (COVID-19) pandemic, caused by the SARS-CoV-2 virus, on maternal and perinatal health at a populational level. We investigated maternal and perinatal health indicators in Brazil, focusing on the effects of the COVID-19 pandemic, and SARS-CoV-2 vaccination campaign for pregnant women., Methods: Utilizing interrupted time series analysis (January 2013-December 2022), we examined Maternal Mortality Ratio, Perinatal Mortality Rate, Preterm Birth Rate, Cesarean Section Rate, and other five indicators. Interruptions occurred at the pandemic's onset (March 2020) and pregnant women's vaccination (July 2021). Results were expressed as percent changes on time series' level and slope., Findings: The COVID-19 onset led to immediate spikes in Maternal Mortality Ratio (33.37%) and Perinatal Mortality Rate (3.20%) (p < 0.05). From March 2020 to December 2022, Cesarean Section and Preterm Birth Rates exhibited upward trends, growing monthly at 0.13% and 0.23%, respectively (p < 0.05). Post start of SARS-CoV-2 vaccination (July 2021), Maternal Mortality Ratio (-34.10%) and Cesarean Section Rate (-1.87%) promptly declined (p < 0.05). Subsequently, we observed a monthly decrease of Maternal Mortality Ratio (-9.43%) and increase of Cesarean Section Rate (0.25%) (p < 0.05), while Perinatal Mortality Rate and Preterm Birth Rate showed a stationary pattern., Interpretation: The pandemic worsened all analyzed health indicators. Despite improvements in Maternal Mortality Ratio, following the SARS-CoV-2 vaccination campaign for pregnant women, the other indicators continued to sustain altered patterns from the pre-pandemic period., Funding: No funding., Competing Interests: All authors declare that they have no conflicts of interest., (© 2024 The Author(s).)

Background: Fetal loss is one of the most serious adverse outcomes of pregnancy. Since the onset of the COVID-19 pandemic, Brazil has recorded an unprecedented number of hospitalizations of pregnant women due to acute respiratory distress (ARD), thereby, we aimed to assess the risk of fetal deaths associated to ARD during pregnancy in Bahia state, Brazil, in the context of the COVID-19 pandemic., Methods: This is an observational population-based retrospective cohort study, developed with women at or after 20 weeks of pregnancy, residents in Bahia, Brazil. Women who had acute respiratory distress (ARD) in pregnancy during the COVID-19 pandemic (Jan 2020 to Jun 2021) were considered 'exposed'. Women who did not have ARD in pregnancy, and whose pregnancy occurred before the onset of the COVID-19 pandemic (Jan 2019 to Dec 2019) were considered 'non-exposed'. The main outcome was fetal death. We linked administrative data (under mandatory registration) on live births, fetal deaths, and acute respiratory syndrome, using a probabilistic linkage method, and analyzed them with multivariable logistic regression models., Results: 200,979 pregnant women participated in this study, 765 exposed and 200,214 unexposed. We found four times higher chance of fetal death in women with ARD during pregnancy, of all etiologies (adjusted odds ratio [aOR] 4.06 confidence interval [CI] 95% 2.66; 6.21), and due to SARS-CoV-2 (aOR 4.45 CI 95% 2.41; 8.20). The risk of fetal death increased more when ARD in pregnancy was accompanied by vaginal delivery (aOR 7.06 CI 95% 4.21; 11.83), or admission to Intensive Care Unit (aOR 8.79 CI 95% 4.96; 15.58), or use of invasive mechanical ventilation (aOR 21.22 CI 95% 9.93; 45.36)., Conclusion: Our findings can contribute to expanding the understanding of health professionals and managers about the harmful effects of SARS-CoV-2 on maternal-fetal health and alerts the need to prioritize pregnant women in preventive actions against SARS-CoV-2 and other respiratory viruses. It also suggests that pregnant women, infected with SARS-CoV-2, need to be monitored to prevent complications of ARD, including a careful assessment of the risks and benefits of early delivery to prevent fetal death., (© 2023. The Author(s).)

Congenital anomalies (CA) are a relevant problem for global public health, affecting about 3% to 6% of newborns worldwide. In Brazil, these are the second main cause of infant mortality. Thus, extensive studies are needed to demonstrate the impact of these anomalies on births and deaths. The present study describes the temporal trends of prevalence and infant mortality due to CA among live births in Brazil and regions, from 2001 to 2018, using the related data between the Live Birth Information System (SINASC, acronym in Portuguese) and the Mortality Information System (SIM, acronym in Portuguese). The prevalence and infant mortality due to CA has increased in Brazil and in most regions, especially in the Northeast and North. CAs in the musculoskeletal system were the most frequent at birth (29.8/10,000 live births), followed by those in the circulatory system (12.7/10,000 live births), which represented the primary cause of death in this group. The applied linkage technique made it possible to correct the national prevalence of CA by 17.9% during the analyzed period, after retrieving the anomalies reported in SIM, thereby proving to be a good tool to improve the quality of information on anomalies in Brazil.

Arbovirus can cause diseases with a broad spectrum from mild to severe and long-lasting symptoms, affecting humans worldwide and therefore considered a public health problem with global and diverse socio-economic impacts. Understanding how they spread within and across different regions is necessary to devise strategies to control and prevent new outbreaks. Complex network approaches have widespread use to get important insights on several phenomena, as the spread of these viruses within a given region. This work uses the motif-synchronization methodology to build time varying complex networks based on data of registered infections caused by Zika, chikungunya, and dengue virus from 2014 to 2020, in 417 cities of the state of Bahia, Brazil. The resulting network sets capture new information on the spread of the diseases that are related to the time delay in the synchronization of the time series among different municipalities. Thus the work adds new and important network-based insights to previous results based on dengue dataset in the period 2001-2016. The most frequent synchronization delay time between time series in different cities, which control the insertion of edges in the networks, ranges 7 to 14 days, a period that is compatible with the time of the individual-mosquito-individual transmission cycle of these diseases. As the used data covers the initial periods of the first Zika and chikungunya outbreaks, our analyses reveal an increasing monotonic dependence between distance among cities and the time delay for synchronization between the corresponding time series. The same behavior was not observed for dengue, first reported in the region back in 1986, either in the previously 2001-2016 based results or in the current work. These results show that, as the number of outbreaks accumulates, different strategies must be adopted to combat the dissemination of arbovirus infections., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Background: Children with congenital Zika syndrome (CZS) have severe damage to the peripheral and central nervous system (CNS), greatly increasing the risk of death. However, there is no information on the sequence of the underlying, intermediate, immediate, and contributing causes of deaths among these children. The aims of this study are describe the sequence of events leading to death of children with CZS up to 36 months of age and their probability of dying from a given cause, 2015 to 2018., Methods and Findings: In a population-based study, we linked administrative data on live births, deaths, and cases of children with CZS from the SINASC (Live Birth Information System), the SIM (Mortality Information System), and the RESP (Public Health Event Records), respectively. Confirmed and probable cases of CZS were those that met the criteria established by the Brazilian Ministry of Health. The information on causes of death was collected from death certificates (DCs) using the World Health Organization (WHO) DC template. We estimated proportional mortality (PM%) among children with CZS and among children with non-Zika CNS congenital anomalies (CA) by 36 months of age and proportional mortality ratio by cause (PMRc). A total of 403 children with confirmed and probable CZS who died up to 36 months of age were included in the study; 81.9% were younger than 12 months of age. Multiple congenital malformations not classified elsewhere, and septicemia unspecified, with 18 (PM = 4.5%) and 17 (PM = 4.2%) deaths, respectively, were the most attested underlying causes of death. Unspecified septicemia (29 deaths and PM = 11.2%) and newborn respiratory failure (40 deaths and PM = 12.1%) were, respectively, the predominant intermediate and immediate causes of death. Fetuses and newborns affected by the mother's infectious and parasitic diseases, unspecified cerebral palsy, and unspecified severe protein-caloric malnutrition were the underlying causes with the greatest probability of death in children with CZS (PMRc from 10.0 to 17.0) when compared to the group born with non-Zika CNS anomalies. Among the intermediate and immediate causes of death, pneumonitis due to food or vomiting and unspecified seizures (PMRc = 9.5, each) and unspecified bronchopneumonia (PMRc = 5.0) were notable. As contributing causes, fetus and newborn affected by the mother's infectious and parasitic diseases (PMRc = 7.3), unspecified cerebral palsy, and newborn seizures (PMRc = 4.5, each) were more likely to lead to death in children with CZS than in the comparison group. The main limitations of this study were the use of a secondary database without additional clinical information and potential misclassification of cases and controls., Conclusion: The sequence of causes and circumstances involved in the deaths of the children with CZS highlights the greater vulnerability of these children to infectious and respiratory conditions compared to children with abnormalities of the CNS not related to Zika., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Background: In addition to their direct pathogenic effects, arthropod-borne (arboviruses) have been hypothesized to indirectly contribute to hospitalizations and death through decompensation of pre-existing comorbidities. Using nationwide data routinely collected from 1 January 2014 to 31 December 2019 in Brazil, we investigated whether local increases in arbovirus notifications were associated with excess hospitalization., Methods: We estimated the relative risks for the association between municipality- and state-level increases in arboviral case notifications and age-standardized hospitalization rates (i.e., classified as direct or indirect based on ICD-10 codes) using Bayesian multilevel models with random effects accounting for temporal and geographic correlations. For municipality-level analyses, we excluded municipalities with <200 notifications of a given arbovirus and further adjusted the models for the local Gini Index, Human Development Index, and Family Healthcare Strategy (Estratégia de Saúde da Família) coverage. Models for dengue, Zika, and chikungunya were performed separately., Results: From 2014 to 2019, Brazil registered 7,566,330 confirmed dengue cases, 159,029 confirmed ZIKV cases, and 433,887 confirmed CHIKV cases. Dengue notifications have an endemic and seasonal pattern, with cases present in 5334 of the 5570 (95.8%) Brazilian municipalities and most (69.5%) registered between February and May. Chikungunya notifications followed a similar seasonal pattern to DENV but with a smaller incidence and were restricted to 4390 (78.8%) municipalities. ZIKV was only notified in 2581 (46.3%) municipalities. Increases in dengue and chikungunya notifications were associated with small increases in age-standardized arbovirus-related hospitalizations, but no consistent association was found with all-cause or other specific indirect causes of hospitalization. Zika was associated to increases in hospitalizations by neurological diseases., Conclusions: Although we found no clear association between increased incidence of the three arboviruses and excess risks of all-cause or indirect hospitalizations at the municipality- and state-levels, follow-up investigations at the individual-level are warranted to define any potential role of acute arbovirus infection in exacerbating risks of hospitalization from underlying conditions., Competing Interests: The authors have declared that no competing interests exist.

Objective: This study aims to describe clinical findings and determine the medium-term survival of congenital zika syndrome (CZS) suspected cases., Methods: A retrospective cohort study using routine register-based linked data. It included all suspected cases of CZS born in Brazil from January 1, 2015, to December 31, 2018, and followed up from birth until death, 36 months, or December 31, 2018, whichever came first. Latent class analysis was used to cluster unconfirmed cases into classes with similar combinations of anthropometry at birth, imaging findings, maternally reported rash, region, and year of birth. Kaplan-Meier curves were plotted, and Cox proportional hazards models were fitted to determine mortality up to 36 months., Results: We followed 11,850 suspected cases of CZS, of which 28.3% were confirmed, 9.3% inconclusive and 62.4% unconfirmed. Confirmed cases had almost two times higher mortality when compared with unconfirmed cases. Among unconfirmed cases, we identified three distinct clusters with different mortality trajectories. The highest mortality risk was observed in those with abnormal imaging findings compatible with congenital infections (HR = 12.6; IC95%8.8-18.0) and other abnormalities (HR = 11.6; IC95%8.6-15.6) compared with those with normal imaging findings. The risk was high in those with severe microcephaly (HR = 8.2; IC95%6.4-10.6) and macrocephaly (HR = 6.6; IC95%4.5-9.7) compared with normal head size., Conclusion: Abnormal imaging and head circumference appear to be the main drivers of the increased mortality among suspected cases of CZS. We suggest identifying children who are more likely to die and have a greater need to optimise interventions and resource allocation regardless of the final diagnoses., (© 2022. The Author(s).)

Background: Preterm birth (<37 weeks), low birth weight (LBW,<2500g), and small for gestational age (SGA,<10th centile of birth weight for gestational age and sex) are markers of newborn vulnerability with a high risk of mortality. We estimated the prevalence of phenotypes combining these three markers and quantified the mortality risk associated with them., Methods: Population-based cohort study using routine register-based linked data on all births and deaths in Brazil from January 1, 2011, to December 31, 2018. We estimated the prevalence of preterm, LBW, and SGA individually and for phenotypes combining these characteristics. The mortality risk associated with each phenotype: early neonatal, late neonatal, neonatal, post-neonatal, infant, 1-4 years, and under five years was quantified using mortality rates and hazard ratios (HRs) with 95% confidence interval (CI) were estimated using Cox proportional hazard models., Findings: 17,646,115 live births were included. Prevalence of preterm birth, LBW and SGA were 9.4%, 9.6% and 9.2%, respectively. Neonatal mortality risk was 16-fold (HR=15.9; 95% CI:15.7-16.1) higher for preterm compared to term, 3 times higher (HR=3.4; (95% CI:3.3-3.4) for SGA compared to adequate for gestational age (AGA), and >25 times higher for LBW (HR=25.8; (95% CI:25.5-26.1) compared to normal birth weight (NBW). 18% of all live births were included in one of the small vulnerable newborn phenotypes. Of those 8.2% were term-SGA (4.7%NBW, 3.5%LBW), 0.6% were term-AGA-LBW, 8.3% preterm-AGA (3.8%NBW, 4.5%LBW) and 1.0% preterm-SGA-LBW. Compared to term-AGA-NBW, the highest mortality risk was for preterm-LBW phenotypes (HR=36.2(95%CI 35.6-36.8) preterm-AGA-LBW, HR=62.0(95%CI 60.8-63.2) preterm-SGA-LBW). The increased mortality risk associated with vulnerable newborn phenotypes was highest in the first month of life, with attenuated but continued high risk in the post-neonatal period and 1-4 years of age., Interpretation: Our findings support the value of using more detailed phenotypes to identify those at highest risk. More granular data can inform care at the individual level, advance research, especially for prevention, and accelerate progress towards global targets such as the Sustainable Development Goals., Funding: Wellcome Trust., Competing Interests: We declare no competing interests. This research was funded in part by the Wellcome Trust. For the purpose of open access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission., (© 2021 The Author(s).)

Background: There is an increasing use of cesarean delivery (CD) based on preference rather than on medical indication. However, the extent to which nonmedically indicated CD benefits or harms child survival remains unclear. Our hypothesis was that in groups with a low indication for CD, this procedure would be associated with higher child mortality and in groups with a clear medical indication CD would be associated with improved child survival chances., Methods and Findings: We conducted a population-based cohort study in Brazil by linking routine data on live births between January 1, 2012 and December 31, 2018 and assessing mortality up to 5 years of age. Women with a live birth who contributed records during this period were classified into one of 10 Robson groups based on their pregnancy and delivery characteristics. We used propensity scores to match CD with vaginal deliveries (1:1) and prelabor CD with unscheduled CD (1:1) and estimated associations with child mortality using Cox regressions. A total of 17,838,115 live births were analyzed. After propensity score matching (PSM), we found that live births to women in groups with low expected frequencies of CD (Robson groups 1 to 4) had a higher death rate up to age 5 years if they were born via CD compared with vaginal deliveries (HR = 1.25, 95% CI: 1.22 to 1.28; p < 0.001). The relative rate was greatest in the neonatal period (HR = 1.39, 95% CI: 1.34 to 1.45; p < 0.001). There was no difference in mortality rate when comparing offspring born by a prelabor CD to those born by unscheduled CD. For the live births to women with a CD in a prior pregnancy (Robson group 5), the relative rates for child mortality were similar for those born by CD compared with vaginal deliveries (HR = 1.05, 95% CI: 1.00 to 1.10; p = 0.024). In contrast, for live births to women in groups with high expected rates of CD (Robson groups 6 to 10), the child mortality rate was lower for CD than for vaginal deliveries (HR = 0.90, 95% CI: 0.89 to 0.91; p < 0.001), particularly in the neonatal period (HR = 0.84, 95% CI: 0.83 to 0.85; p < 0.001). Our results should be interpreted with caution in clinical practice, since relevant clinical data on CD indication were not available., Conclusions: In this study, we observed that in Robson groups with low expected frequencies of CD, this procedure was associated with a 25% increase in child mortality. However, in groups with high expected frequencies of CD, the findings suggest that clinically indicated CD is associated with a reduction in child mortality., Competing Interests: NO authors have competing interests.

Background: Most studies on the effects of SARS-CoV-2 infection have been conducted with adults and non-pregnant women. Thus, its impacts on maternal health are not yet fully established. This study aimed to verify the relationship between the maternal mortality ratio and the incidence of COVID-19 in the State of Bahia, Brazil, 2020., Methods: This time-series study used publicly available information in Brazil, to obtain data on maternal deaths and live births in Bahia, State, from January 1, 2011, to December 31, 2020. The time trend of Maternal Mortality Ratio (MMR) was analysed through polynomial regression, of order 6. Expected MMR, monthly (Jan-Dec) and annual values for 2020, were predicted by the additive Holt-Winters exponential smoothing algorithm, with 95% confidence interval, based on the time series of the MMR from 2011 to 2019, and the accuracy of the forecasts for 2020 was assessed by checking the smoothing coefficients and the mean errors. According to the statistical forecast, the MMR values ​​recorded in the year 2020 were compared to those expected., Results: In 2020, the annual MMR in Bahia, Brazil, was 78.23/100,000 live births, 59.46% higher than the expected ratio (49.06 [95% CI 38.70-59.90]). The increase in maternal mortality ratio relative to expected values was observed throughout the 2020 months; however, only after May, when the COVID-19 epidemic rose sharply, it exceeded the upper limit of the 95% CI of the monthly prediction. Of the 144 registered maternal deaths in 2020, 19 (13.19%) had COVID-19 mentioned as the cause of death., Conclusions: Our study revealed the increase in maternal mortality, and its temporal relationship with the incidence of COVID-19, in Bahia, Brazil, in 2020. The COVID-19 pandemic may be directly and indirectly related to this increase, which needs to be investigated. An urgent public health action is needed to prevent and reduce maternal deaths during this pandemic, in Brazil.

Objective: To analyze association between social position and access to health services., Methods: This was a cross-sectional study carried out in primary health care centers in Salvador, Bahia, Brazil, where a project for improving accessibility was implemented. Pearson's chi-square test and logistic regression were used., Results: 467 users took part in the study, 75.6% had not finished high school; 78.7% had <2 minimum wages; 51.8% had intermediate/qualified occupations. Low income was associated with starting to queue at the health care center the night before or before 8 a.m. (odds ratio = 2.09 - 95%CI 1.13;3.87) and spending more time scheduling an appointment (odds ratio = 2.13 - 95%CI 1.05;4.31). Having an elementary occupation was associated with face-to-face appointment scheduling (odds ratio = 1.68 - 95%CI 1.14;2.45). Education and social trajectory showed no significant association with use of health services., Conclusion: Social inequalities in access to health services remained after the intervention to improve accessibility.

Background: Chikungunya is an arbovirus, transmitted by Aedes mosquitoes, which emerged in the Americas in 2013 and spread rapidly to almost every country on this continent. In Brazil, where the first cases were detected in 2014, it currently has reached all regions of this country and more than 900,000 cases were reported. The clinical spectrum of chikungunya ranges from an acute self-limiting form to disabling chronic forms. The purpose of this study was to estimate the seroprevalence of chikungunya infection in a large Brazilian city and investigate the association between viral circulation and living condition., Methodology/principal Findings: We conducted a population-based ecological study in selected Sentinel Areas (SA) through household interviews and a serologic survey in 2016/2017. The sample was of 1,981 individuals randomly selected. The CHIKV seroprevalence was 22.1% (17.1 IgG, 2.3 IgM, and 1.4 IgG and IgM) and varied between SA from 2.0% to 70.5%. The seroprevalence was significantly lower in SA with high living conditions compared to SA with low living condition. There was a positive association between CHIKV seroprevalence and population density (r = 0.2389; p = 0.02033)., Conclusions/significance: The seroprevalence in this city was 2.6 times lower than the 57% observed in a study conducted in the epicentre of the CHIKV epidemic of this same urban centre. So, the herd immunity in this general population, after four years of circulation of this agent is relatively low. It indicates that CHIKV transmission may persist in that city, either in endemic form or in the form of a new epidemic, because the vector infestation is persistent. Besides, the significantly lower seroprevalences in SA of higher Living Condition suggest that beyond the surveillance of the disease, vector control and specific actions of basic sanitation, the reduction of the incidence of this infection also depends on the improvement of the general living conditions of the population., Competing Interests: The authors have declared that no competing interests exist.

Zika virus was responsible for the microcephaly epidemic in Brazil which began in October 2015 and brought great challenges to the scientific community and health professionals in terms of diagnosis and classification. Due to the difficulties in correctly identifying Zika cases, it is necessary to develop an automatic procedure to classify the probability of a CZS case from the clinical data. This work presents a machine learning algorithm capable of achieving this from structured and unstructured available data. The proposed algorithm reached 83% accuracy with textual information in medical records and image reports and 76% accuracy in classifying data without textual information. Therefore, the proposed algorithm has the potential to classify CZS cases in order to clarify the real effects of this epidemic, as well as to contribute to health surveillance in monitoring possible future epidemics.

Objective: To identify socioeconomic and health care determinants of spatial variation in adolescent pregnancy in Brazil in 2014., Methods: This was a spatial ecological study having municipalities as units of analysis. Spatial linear regression was used to verify association between the fertility rate in 15-19 year-old women and socioeconomic and health variables., Results: The adolescent fertility rate was negatively associated with higher Family Health Strategy coverage (β = -0.011 - 95%CI -0.017;-0.005), an adequate number of prenatal consultations (β = -0.122 - 95%CI -0.132;-0.224) and low average family income per capita (β = -0.104 - 95%CI -0.105;-0.103). Association was positive in relation to the Gini index (β = 7.031 - 95%CI 4.793;9.269), low income (β = 0.127 - 95%CI 0.108;0.145), higher household density (β = 6.292 - 95%CI 5.062;7.522) and less schooling (β = 0.260 - 95%CI 0.224;0.295)., Conclusion: Reduced access to primary care and lower income are associated with higher adolescent fertility rates. Poorer socioeconomic and health care indicators are associated with higher adolescent fertility rates.

Zika virus (ZIKV) became a worldwide public health emergency after its introduction in the Americas. Brazil was implicated as central in the ZIKV dispersion, however, a better understanding of the pathways the virus took to arrive in Brazil and the dispersion within the country is needed. An updated genome dataset was assembled with publicly available data. Bayesian phylogeography methods were applied to reconstruct the spatiotemporal history of ZIKV in the Americas and with more detail inside Brazil. Our analyses reconstructed the Brazilian state of Pernambuco as the likely point of introduction of ZIKV in Brazil, possibly during the 2013 Confederations Cup. Pernambuco played an important role in spreading the virus to other Brazilian states. Our results also underscore the long cryptic circulation of ZIKV in all analyzed locations in Brazil. Conclusions: This study brings new insights about the early moments of ZIKV in the Americas, especially regarding the Brazil-Haiti cluster at the base of the American clade and describing for the first time migration patterns within Brazil.

Background: An association between periodontitis and cardiovascular disease is now well documented; however, the effect of periodontitis severity levels on this outcome, specifically on acute myocardial infarction (AMI), remains unexplored. This study investigated the association between levels of periodontitis severity (exposure) and AMI (outcome)., Methods: This case-control study, matched by sex and age, was conducted with 621 participants, with 207 individuals treated in the emergency department of Santa Izabel and Ana Nery Hospitals in Salvador, Bahia, Brazil, diagnosed with a first AMI event, and compared to 414 individuals without a diagnosis of AMI. Levels of periodontitis severity followed two criteria: (1) Center for Disease Prevention and Control and American Academy of Periodontology; (2) Gomes-Filho et al. (2018) using criteria that also evaluated bleeding upon probing. Conditional logistic regression analysis was performed and odds ratios (ORs) and their 95% confidence intervals (CIs) were obtained., Results: The adjusted association measurements showed a positive association between both severe (OR adjusted ranged from 2.21 to 3.92; 95% CI ranged from 1.03 to 10.05) and moderate periodontitis (OR adjusted ranged from 1.96 to 2.51; 95% CI ranged from 1.02 to 6.19), and AMI, for both periodontitis diagnostic criteria. It demonstrated that among those with moderate and severe periodontitis, the chance of having AMI was approximately two to four times greater than among those without periodontitis., Conclusion: The findings demonstrate that there is an association between the severity of the periodontal condition and AMI, suggesting a possible relationship among the levels of periodontitis severity and the cardiovascular condition., (© 2020 American Academy of Periodontology.)

Background: Little is known about physical development of children with Congenital Zika Syndrome (CZS). This study aims to evaluate the anthropometric characteristics of children with CZS up to 12 months., Methods: This is a cross-sectional study developed with 46 children with CZS living in Bahia. We used the Public Health Events Register, Live Births Information System and Childcare Records of Primary Health Care Services. Descriptive analysis was performed by distributing absolute and relative frequencies and median and interquartile range. The Weight/Age (W/A), Length/Age (L/A), Weight/Length (W/L) and Head Circumference/Age (HC/A) indexes were calculated for each month and expressed in z-score values, and the results were evaluated individually and by group average. Values between ≥ - 2 and ≤ 2 standard deviations were used as reference. T-Student and Spearman's Correlation Tests were applied to verify the existence of any relationship between maternal and children's variables with the anthropometric indexes weight/age and height/age at birth and at 3, 6 and 12 months of age., Results: The studied children had high proportions of low birth weight (23.9%), dysphagia (56.8%) and seizures (53.5%). The mean z-score for the HC/A index at birth was - 3.20 and remained below - 3 z-scores throughout the assessed period. The analysis of the indices equivalent to every single child's anthropometric measurement showed a deficit in 20.4% of the W/A, 39.1% of the L/A, 9.2% of the W/L and 85.7% of the HC/A measurements. Distribution of the mean values of these anthropometric indices revealed a risk of delayed stature growth (L/A < -1 z-score). There was a statistically significant association between L/A at 12 months and dysphagia (p = 0.0148) and a positive correlation between breastfeeding time and W/A. No statistically significant correlation was found between any other tested variables., Conclusions: We observed a deficit in the HC/A index, which is a common feature in CZS, but also a high proportion of W/A and L/A deficit. The average group z-score highlighted the risk of delay in stature growth for age, which calls attention to the need for health interventions, as this condition exposes them to a higher risk of morbidity and mortality.

Objective: This study estimated the association between stress and periodontitis., Materials and Methods: A cross-sectional study was conducted with a sample of 621 individuals. Information about individuals was obtained through a questionnaire. Stress was evaluated using the Perceived Stress Scale. The diagnosis of periodontitis was based on a complete periodontal examination including clinical attachment level, probing depth, and bleeding on probing. Prevalence ratios (PR), crude and adjusted, and their respective 95% confidence intervals (95%CI) were estimated by Poisson regression analysis., Results: In the final sample, 48.47% (301) of the individuals were classified as having stress, of which, 23.92% (72) had the diagnosis of periodontitis. Association measurements between stress and probing depth ≥ 4 mm (PR adjusted  = 1.28, 95%CI [1.04 to 1.58]), stress and clinical attachment level ≥ 5 mm (PR adjusted  = 1.15, 95%CI [1.01 to 1.31]), and stress and periodontitis (PR adjusted  = 1.36, 95%CI [1.01 to 1.83]) showed that the frequency of these outcomes among those exposed to stress was 15-36% higher than those without the condition of stress, after adjustment for age, sex, schooling level, current smoking habit, pulmonary disease, and body mass index., Conclusions: The findings showed positive association between exposure to stress and the presence of periodontitis, reaffirming the need to prevent and control stress., Clinical Relevance: Although there are limitations in this study, the results showed that an association exists between stress and periodontitis, signaling the necessity of a multidisciplinary attention when considering the psychological status in the management of oral and general health conditions of the individual.

Objectives: This research evaluated the association between exposure to common mental disorder (CMD) and the presence of periodontitis., Background: Common mental disorder is characterized by the presence of irritation, fatigue, insomnia, forgetfulness, decreased ability to concentrate, anxiety, and depression. It has been associated with several diseases; however, there are few studies that have associated it with periodontitis., Methods: This cross-sectional study was carried out with 621 individuals. Data collection involved the application of a general questionnaire and the self-reporting questionnaire for diagnosis of CMD. The diagnosis of periodontitis involved a full mouth periodontal examination using: clinical attachment level, probing depth, and bleeding on probing. Prevalence ratios and 95% confidence intervals between CMD (exposure) and periodontitis (outcome) were obtained., Results: In the final sample, 38.16% (237) of the individuals were classified with CMD. Among these, 28.27% (67) had periodontitis. Association measurements showed that the occurrence of periodontitis among those exposed to CMD is approximately 50% higher than in those without this mental condition, with statistical significance, after adjustment for age, sex, family income, current smoking habit, alcohol beverage consumption, and cardiovascular disease (PR adjusted  = 1.54, 95% CI: [1.13 to 2.10])., Conclusions: The findings showed a positive association between exposure to CMD and periodontitis, revealing the importance of broadening public actions targeting mental health, which seems to be related to oral health, mainly due to the high frequency of the diseases in the studied sample., (© 2019 John Wiley & Sons A/S . Published by John Wiley & Sons Ltd.)

The co-circulation of different arboviruses in the same time and space poses a significant threat to public health given their rapid geographic dispersion and serious health, social, and economic impact. Therefore, it is crucial to have high quality of case registration to estimate the real impact of each arboviruses in the population. In this work, a Vector Autoregressive (VAR) model was developed to investigate the interrelationships between discarded and confirmed cases of dengue, chikungunya, and Zika in Brazil. We used data from the Brazilian National Notifiable Diseases Information System (SINAN) from 2010 to 2017. There were three peaks in the series of dengue notification in this period occurring in 2013, 2015 and in 2016. The series of reported cases of both Zika and chikungunya reached their peak in late 2015 and early 2016. The VAR model shows that the Zika series have a significant impact on the dengue series and vice versa, suggesting that several discarded and confirmed cases of dengue could actually have been cases of Zika. The model also suggests that the series of confirmed and discarded chikungunya cases are almost independent of the cases of Zika, however, affecting the series of dengue. In conclusion, co-circulation of arboviruses with similar symptoms could have lead to misdiagnosed diseases in the surveillance system. We argue that the routinely use of mathematical and statistical models in association with traditional symptom-surveillance could help to decrease such errors and to provide early indication of possible future outbreaks. These findings address the challenges regarding notification biases and shed new light on how to handle reported cases based only in clinical-epidemiological criteria when multiples arboviruses co-circulate in the same population., Competing Interests: The authors have declared that no competing interests exist.

Objective: The objective of this study was to investigate an association between obesity (exposure) and periodontitis (outcome) in pregnant women., Background: This association was investigated and only five studies were identified as showing a positive association. However, some of these studies had limitations such as reduced sample sizes, inadequate exposure criteria and outcome measures, which question the internal validity of these investigations., Methods: A cross-sectional study was carried out with a sample of 644 pregnant women of the public health service of the municipality of Santo Antônio de Jesus, Bahia, Brazil. Data were obtained by collecting of socioeconomic-demographic information, health behavior, health conditions, and reproductive history through an interview. Obesity was evaluated using body mass index adjusted for gestational age and expected weight gain. The diagnosis of periodontitis followed two criteria: (a) Center for Disease Prevention and Control and American Academy of Periodontology (CDC/AAP); (b) Gomes-Filho et al (2018) using criterion that also evaluated bleeding upon probing; Prevalence ratios and respective 95% confidence intervals were obtained by Poisson regression analysis., Results: In accordance with the outcome diagnostic criterion, the frequency of periodontitis was 17.24% (Gomes-Filho et al) and 66.92% (CDC/AAP). The participants were classified as low weight (19.72%), adequate weight (42.39%), overweight (24.84%), and obesity (13.04%), based on the exposure diagnostic criterion. The low weight and overweight groups were excluded from the data analysis, giving a final sample of 357 pregnant women. The association between obesity in pregnant women and periodontitis was not statistically significant, after adjusting for confounders such as age, schooling level, alcoholic beverage consumption, alimentary and nutritional orientation, urinary infection, and dental flossing., Conclusions: The findings showed a high frequency of periodontitis, obesity, and overweight in the studied population but no association between obesity and periodontitis in pregnant women was found., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objective: to describe the epidemiological profile of congenital syphilis (CS) in Tocantins, from 2007 to 2015., Methods: this was a cross-sectional descriptive study conducted with data from the Notifiable Health Conditions Information System (SINAN) and the Live Birth Information System (SINASC)., Results: 1,029 CS cases were reported; mean CS incidence was 4.6/1,000 Live Births (LB), increasing from 3.1/1,000 LB in 2007 to 9.8/1,000 LB in 2015 (increase of 216.1%); municipalities located in the central and northern regions of the state had the highest rates; the majority of mothers of newborn babies were 15-24 years old, had elementary school education, started prenatal care in the third trimester of pregnancy, and received inadequate prenatal care., Conclusion: high occurrence of congenital syphilis in Tocantins requires immediate intensification of CS surveillance and improved prenatal care quality, especially in municipalities with higher incidence.

Objective To describe the occurrence of Zika virus disease and its complications in the state of Tocantins and in its capital, the city of Palmas. Methods This was a descriptive study using data from health information systems. Results Incidence of reported Zika virus disease cases in 2015 and 2016 was 295.2/100,000 inhabitants and 411.1/100,000 inhab. in the general population, and 5.9/1,000 and 27.8/1,000 live births, respectively. Higher risks occurred in women, the 20-39 year age group, municipalities in the central and northwestern regions of the state and in hotter months (February and March). Incidence of Zika-related microcephaly during pregnancy was 0.06/1,000 live births. One case of Guillain-Barré Syndrome resulting from Zika virus infection was confirmed. Conclusion Zika virus disease hit Tocantins intensely, although its adverse outcomes were less frequent than in other states.

This study aimed to assess the impact of the Zika epidemic on the registration of birth defects in Brazil. We used an interrupted time series analysis design to identify changes in the trends in the registration of congenital anomalies. We obtained monthly data from Brazilian Live Birth Information System and used two outcome definitions: 1) rate of congenital malformation of the brain and eye (likely to be affected by Zika and its complications) 2) rate of congenital malformation not related to the brain or eye unlikely to be causally affected by Zika. The period between maternal infection with Zika and diagnosis of congenital abnormality attributable to the infection is around six months. We therefore used September 2015 as the interruption point in the time series, six months following March 2015 when cases of Zika started to increase. For the purposes of this analysis, we considered the period from January 2010 to September 2015 to be "pre-Zika event," and the period from just after September 2015 to December 2017 to be "post-Zika event." We found that immediately after the interruption point, there was a great increase in the notification rate of congenital anomalies of 14.9/10,000 live births in the brain and eye group and of 5.2/10,000 live births in the group not related with brain or eye malformations. This increase in reporting was in all regions of the country (except in the South) and especially in the Northeast. In the period "post-Zika event", unlike the brain and eye group which showed a monthly decrease, the group without brain or eye malformations showed a slow but significant increase (relative to the pre-Zika trend) of 0.2/10,000 live births. These findings suggest an overall improvement in the registration of birth malformations, including malformations that were not attributed to Zika, during and after the Zika epidemic., Competing Interests: The authors have declared that no competing interests exist.

Objective: The clinical manifestations of Congenital Zika Syndrome (CZS) are not fully known, for example its effect on birth weight. This study estimated the prevalence of low birth weight (LBW) among children with CZS, and identified associated factors., Methods: Cross-sectional study involving 393 children with CZS living in Bahia, Brazil, in 2015-2017. Official Information Systems were the data sources. We calculated LBW prevalence and applied Logistic Regression to assess associated factors., Results: Prevalence of LBW among children with CZS was 37.2%. Excluding pre-term births the proportion was 29.9%. This prevalence was 81.0% and 28.0% among children born pre-term and term/post term, respectively. There was a higher proportion (53.2%) in female children, and in those delivered by cesarean section (51.4%). Most mothers were single/separated (62.1%) and had a low level of schooling (70.0%). In the model adjusted for type of delivery, preterm births presented a 10.8 times greater chance of presenting LBW than term/post-term ones. However, the Confidence Interval was very wide. Adjusting for gestation duration, children born by cesarean section had a 1.63 higher probability of presenting LBW than those born by vaginal delivery (OR=1,63; CI 95% 1.01, 2.63)., Conclusions: The prevalence of LBW among children with CZS was very elevated, both preterm and term/post-term live births. This can contribute to increasing their risk for morbimortality. The association of LBW with prematurity and cesarean deliveries is known, but in children with CZS, it has not been clarified whether or not this is related to pathological conditions caused by fetal infection by the Zika virus., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

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., Competing Interests: The authors have declared that no competing interests exist.

Objective: to evaluate the time trend of proportional mortality due to ill-defined causes, in Tocantins and Palmas, Brazil, 1998-2014., Methods: this was a time trend study using data from the Mortality Information System (SIM) and the Death Verification Service (SVO); we evaluated the time trend of this type of this mortality using Joinpoint Regression., Results: between 1998 and 2014, proportional mortality from ill-defined causes fell 88.5% in Tocantins and 88.1% in Palmas; the trend test indicated statistically significant inflection points in 1998-2004 (-4.14; p=0.001) for Tocantins and in 1998-2000 (-7.92; p<0.005) for Palmas; a certain degree of stability was observed with effect from 2004., Conclusion: there was a significant decline in proportional mortality due to ill-defined causes in Tocantins; however, it is still necessary to intensify actions aimed at improving the quality of information on mortality in some municipalities.

Dengue is a mosquito-borne disease with major public health importance due to its growing incidence and geographical spread. There is a lack of knowledge on its contribution to maternal death. We conducted a population-based cohort study to investigate the association between symptomatic dengue during pregnancy and deaths in Brazil from 2007 to 2012. We did this by linking routine records of confirmed dengue cases to records of deaths of women who had a live birth. Using the Firth method, we estimated odds ratios for maternal deaths associated with dengue during pregnancy. Dengue increased the risk of maternal death by 3 times (95%CI,1.5-5.8) and dengue haemorrhagic fever increased the risk of maternal death by 450 times (95%CI,186.9-1088.4) when compared to mortality of pregnant women without dengue. The increase in risk occurred mostly during acute dengue 71.5 (95%CI,32.8-155.8), compared with no dengue cases. This study showed an increased risk of adverse outcomes in pregnant women with dengue. Therefore in areas where dengue is circulating, the health of pregnant women should be not only a public health priority, but health professionals attending pregnant women with dengue should more closely observe these patients to be able to intervene in a timely way and avoid deaths.

Background: Chikungunya is a mosquito-borne disease caused by an arthritogenic alphavirus, with four genotypes: East Central South African (ECSA), West African, ECSA-diverged or Indian Ocean Lineage (IOL) and Asian lineage. Overall, the disease is self-limited; however, in some patients, joint pain and other non-specific symptoms can last for months or years. This systematic review and meta-analysis aims to estimate the proportion of people that self-report chikungunya-related chronic non-specific symptoms., Methods: Medline, EMBASE, Global Health Library and Scopus were searched for articles published before March 2017. Case-control, cohort, cross-sectional, clinical trials studies and outcome-independent case series were eligible. It was estimated that the proportion of patients who did not recover, by virus genotype, and by the time between disease onset and assessment of chronic symptoms., Results: A total of 38 studies were included in the review and 34 in the meta-analysis. Of 6532 chikungunya patients, 3157 did not recover fully after 3 months. The overall no recovery rate associated with chikungunya was 43% (95% CI, 35-52%); Inter-genotype group heterogeneity was observed, the highest prevalence in the ECSA-diverged genotype: 50% (95% CI; 40-60%), followed by the Asian lineage genotype: 36% (95% CI; 20-52%). After 12 months follow-up, the overall no-recovery rate was 21% (95% CI; 19-22%)., Conclusion: The evidence suggests that the prevalence of chronic discomfort associated with chikungunya illness varies by virus lineage. The proportion of people that do not fully recovered after chikungunya was high and, therefore, health authorities must prepare to treat patients with symptoms of long-lasting chikungunya adequately addressing the physical, psychological and social needs.

This article presents the development of the epidemiological situation of some of the major communicable diseases (CD) in Brazil, with emphasis on the interventions by the SUS and other social policies. The data and information were collected from Datasus, epidemiological newsletters from the Brazilian Ministry of Health, and scientific articles on the issue. The universalization, decentralization and expansion of the surveillance, control and prevention of CD has produced an impact on the morbidity and mortality of these diseases, mainly those which are vaccine-preventable. The emergence and re-emergence of three arboviruses, for which there are no effective control instruments, interrupted the downward trend in the morbidity profile of CD in Brazil. Other social and economic programs, which are geared to the needier sectors of the Brazilian population, have also contributed to the improvement of the analyzed health indicators. However, the universalization of access to healthcare services, as well as improvements in the scope of the surveillance of diseases and health risks, has played a key role in improving the health and quality of life of the population, as well as contributing to the process of the democratization of Brazil.

This article analyses the process of construction of Health Surveillance in Brazil concerning the political, historical and organizational context of this component of the Unified Health System (UHS), by means of its historical view and presentation of the advances, limits, setbacks and perspectives. Throughout trajectory of Health Surveillance, its objects of study and intervention have been expanded, strengthening the integration among the different areas of surveillance, increasing its capacity for prediction and intervention. It evolved from surveillance of people, to surveillance of diseases and now to surveillance of health risks, promoting greater articulation of HS professionals with agents of endemics and Family Health Teams. The first National Health Surveillance Conference, in February 2018, provided opportunities for discussion and formulation of proposals aimed at strengthening HS, expanding its scope of actions with a view to achieving a comprehensive care model. Adequate and audacious alternatives are necessary so that there are no setbacks in the financing modalities in order to maintain and expand the advances achieved in the field of Health Surveillance in Brazil.

Chikungunya has had a substantial impact on public health because of the magnitude of its epidemics and its highly debilitating symptoms. We estimated the seroprevalence, proportion of symptomatic cases, and proportion of chronic form of disease after introduction of chikungunya virus (CHIKV) in 2 cities in Brazil. We conducted the population-based study through household interviews and serologic surveys during October-December 2015. In Feira de Santana, we conducted a serologic survey of 385 persons; 57.1% were CHIKV-positive. Among them, 32.7% reported symptoms, and 68.1% contracted chronic chikungunya disease. A similar survey in Riachão do Jacuípe included 446 persons; 45.7% were CHIKV-positive, 41.2% reported symptoms, and 75.0% contracted the chronic form. Our data confirm intense CHIKV transmission during the continuing epidemic. Chronic pain developed in a high proportion of patients. We recommend training health professionals in management of chronic pain, which will improve the quality of life of chikungunya-affected persons.

Objective: To evaluate the association between periodontitis and severe asthma, with participants in treatment for severe asthma, controlled by therapy., Methods: A case-control investigation was performed to compare 130 adults with severe asthma with 130 without asthma. Individuals with periodontitis were those with ≥4 teeth with ≥1 site with probing depth ≥4 mm, clinical attachment level ≥3 mm, and bleeding upon probing at the same site. Severe asthma diagnosis was based on Global Initiative for Asthma criteria., Results: Association between exposure to periodontitis and severe asthma was found: OR crude  = 2.98 (95% CI: 1.74-5.11). When confounders were considered, the association between exposure to periodontitis and severe asthma was maintained: OR adjusted  = 3.01-3.25. Individuals with periodontitis had about a threefold increased risk of severe asthma than those without periodontitis. Frequency of periodontitis in participants with severe asthma was greater than that of those without asthma (46.6% vs 22.3%, p ≤ .05)., Conclusions: Association between periodontitis and severe asthma was observed. Further investigation is required to determine the direction of this relationship. It may be causal, but it may also be a consequence of the immunopathological process that characterizes asthma, or else, consequence of the medication used for treatment., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. All rights reserved.)

Background: Maternal infections during pregnancy can increase the risk of fetal death. Dengue infection is common, but little is known about its role in fetal mortality. We aimed to investigate the association between symptomatic dengue infection during pregnancy and fetal death., Methods: We did a nested case-control study using obstetrician-collected data from the Brazilian livebirth information system (SINASC), the mortality information system (SIM), and the national reportable disease information system (SINAN). We identified all pregnancies ending in stillbirth and a random sample of livebirths between Jan 1, 2006, and Dec 31, 2012. We did linkage to determine which mothers were diagnosed with dengue infection during pregnancy. By use of stillbirths as cases and a sample of matched livebirths as a control, we calculated matched odds ratios (mORs) using conditional logistic regression adjusted for maternal age and education., Findings: 275 (0·2%) of 162 188 women who had stillbirths and 1507 (0·1%) of 1 586 105 women who had livebirths were diagnosed with dengue infection during pregnancy. Symptomatic dengue infection during pregnancy almost doubled the odds of fetal death (mOR 1·9, 95% CI 1·6-2·2). The increase in risk was similar when analyses were restricted to laboratory-confirmed cases of dengue infection (1·8, 1·4-2·4). Severe dengue infection increased the risk of fetal death by about five times (4·9, 2·3-10·2)., Interpretation: Symptomatic dengue infection during pregnancy is associated with an increased risk of fetal death. We recommend further epidemiological and biological studies of the association between dengue and poor birth outcomes to measure the burden of subclinical infections and elucidate pathological mechanisms., Funding: Brazilian National Council for Scientific and Technological Development, Horizon 2020., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: To identify the spatial distribution patterns and areas of higher risk of preventable perinatal mortality in the city of Salvador, State of Bahia, Brazil., Methods: We carried out a spatial aggregated study in 2007, considering the weighting areas (census tracts contiguous sets) of Salvador, of which the center and north present low life conditions. Data were obtained from national vital statistics systems and the 2010 Census. Addresses of live births and stillbirths were geocoded by weighting area. The spatial distribution of the perinatal mortality rate was analyzed from thematic maps. Spatial dependence was evaluated by the Global and Local Geary's and Moran's Indexes., Results: Crude and smoothed perinatal mortality rates were high in areas situated to the north, west, and in center of Salvador. The smoothed rates in weighting areas ranged from 4.9/1,000 to 22.3/1,000 births. Of all perinatal deaths, 92.1% could have been prevented. We identified spatial dependence for preventable perinatal mortality for care in pregnancy, with neighboring areas with high risk in the north of the city., Conclusions: The preventability potential of perinatal mortality was high in Salvador, in 2007. The spatial distribution pattern with higher rates in disadvantaged areas of the city suggests the existence of social inequalities in health. The characteristics of the process of urban development of Salvador, which has inadequate prenatal care, possibly influenced the magnitude and spatial distribution pattern of this mortality.

Background: Due to the increasing availability of individual-level information across different electronic datasets, record linkage has become an efficient and important research tool. High quality linkage is essential for producing robust results. The objective of this study was to describe the process of preparing and linking national Brazilian datasets, and to compare the accuracy of different linkage methods for assessing the risk of stillbirth due to dengue in pregnancy., Methods: We linked mothers and stillbirths in two routinely collected datasets from Brazil for 2009-2010: for dengue in pregnancy, notifications of infectious diseases (SINAN); for stillbirths, mortality (SIM). Since there was no unique identifier, we used probabilistic linkage based on maternal name, age and municipality. We compared two probabilistic approaches, each with two thresholds: 1) a bespoke linkage algorithm; 2) a standard linkage software widely used in Brazil (ReclinkIII), and used manual review to identify further links. Sensitivity and positive predictive value (PPV) were estimated using a subset of gold-standard data created through manual review. We examined the characteristics of false-matches and missed-matches to identify any sources of bias., Results: From records of 678,999 dengue cases and 62,373 stillbirths, the gold-standard linkage identified 191 cases. The bespoke linkage algorithm with a conservative threshold produced 131 links, with sensitivity = 64.4% (68 missed-matches) and PPV = 92.5% (8 false-matches). Manual review of uncertain links identified an additional 37 links, increasing sensitivity to 83.7%. The bespoke algorithm with a relaxed threshold identified 132 true matches (sensitivity = 69.1%), but introduced 61 false-matches (PPV = 68.4%). ReclinkIII produced lower sensitivity and PPV than the bespoke linkage algorithm. Linkage error was not associated with any recorded study variables., Conclusion: Despite a lack of unique identifiers for linking mothers and stillbirths, we demonstrate a high standard of linkage of large routine databases from a middle income country. Probabilistic linkage and manual review were essential for accurately identifying cases for a case-control study, but this approach may not be feasible for larger databases or for linkage of more common outcomes.

Background: Little is known about the possible adverse effects of dengue infection during pregnancy on fetal outcomes. In this systematic review and meta-analysis we aimed to estimate the increase in risk of four adverse fetal outcomes in women who had dengue infection during pregnancy., Methods: For this systematic review and meta-analysis, we searched Medline, Embase, Global Health Library, and Scopus for articles published before Aug 1, 2015. We included original studies that reported any fetal outcomes for pregnant women who had dengue infection during the gestational period. Case-control, cohort, and cross-sectional studies and unselected case series were eligible for inclusion. We excluded case reports, ecological studies, reviews, in-vitro studies, and studies without data for pregnancy outcomes. We independently screened titles and abstracts to select papers for inclusion and scored the quality of those included in meta-analyses. For each study, we recorded study design, year of publication, study location, period of study, and authors and we extracted data for population characteristics such as the number of pregnancies, dengue diagnostic information, and the frequency of outcomes. We investigated four adverse fetal outcomes: stillbirth, miscarriage, preterm birth, and low birthweight. We estimated the increase in risk of these adverse fetal outcomes by use of Mantel-Haenszel methods. We assessed heterogeneity of odds ratios (OR) with the I(2) statistic., Findings: We identified 278 non-duplicate records, of which 107 full-text articles were screened for eligibility. 16 studies were eligible for inclusion in the systematic review and eight were eligible for the meta-analyses, which included 6071 pregnant women, 292 of whom were exposed to dengue during pregnancy. For miscarriage, the OR was 3·51 (95% CI 1·15-10·77, I(2)=0·0%, p=0·765) for women with dengue infection during pregnancy compared with those without. We did not do a meta-analysis for stillbirth because this outcome was investigated in only one study with a comparison group; we calculated the crude relative risk to be 6·7 (95% CI 2·1-21·3) in women with symptomatic dengue compared with women without dengue. Preterm birth and low birthweight were the most common adverse pregnancy outcomes. The OR for the association with dengue was 1·71 (95% CI 1·06-2·76, I(2)=56·1%, p=0·058) for preterm birth and 1·41 (95% CI 0·90-2·21, I(2)=0·0%, p=0·543) for low birthweight., Interpretation: Evidence suggests that symptomatic dengue during pregnancy might be associated with fetal adverse outcomes. If confirmed, it would be important to monitor pregnancies during which dengue is diagnosed and to consider pregnant women in dengue control policies., Funding: National Council for Scientific and Technological Development (CNPq)., (Copyright © 2016 Elsevier Ltd. All rights reserved.)