Eliseu Alves Waldman

Incorporation of Real-Time PCR into Routine Public Health Surveillance of Culture Negative Bacterial Meningitis in São Paulo, Brazil

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

Tuberculosis in the twentieth century: time-series mortality in São Paulo, Brazil, 1900-97

The objective of this study was to characterize tuberculosis mortality trends in the Municipality of São Paulo, Brazil, from 1900 to 1997. Standardized tuberculosis mortality rates and proportional mortality ratios were calculated and stratified by gender and age group based on data provided by government agencies. These measures were submitted to time-series analysis. We verified distinct trends: high mortality and a stationary trend from 1900 to 1945, a heavy reduction in mortality (7.41% per year) from 1945 to 1985, and a resumption of increased mortality (4.08% per year) from 1985 to 1995. In 1996 and 1997 we observed a drop in tuberculosis mortality rates, which may be indicating a new downward trend for the disease. The period from 1945 to 1985 witnessed a real reduction in tuberculosis, brought about by social improvements, the introduction of therapeutic resources, and expansion of health services. Recrudescence of tuberculosis mortality from 1985 to 1995 may reflect the increasing prevalence of Mycobacterium and HIV co-infection, besides loss of quality in specific health programs.

Características da tuberculose pulmonar em área hiperendêmica: município de Santos (SP)

OBJECTIVE To characterize the profile of patients with pulmonary tuberculosis (PTB) in the city of Santos, Brazil, according to biological, environmental and institutional factors. METHODS Descriptive study, using the TB surveillance database, including patients with PTB, aged 15 years or older, residing in the city of Santos and whose treatment was initiated between 2000 and 2004. RESULTS We identified 2,176 cases, of which 481 presented a history of TB. Of those 481 patients, 29.3% were cured, and 70.7% abandoned treatment. In 61.6% of the cases, the diagnosis was confirmed by sputum smear microscopy, whereas it was confirmed based on clinical and radiological criteria in 33.8%; 69.0% were male; and 69.5% were between 20 and 49 years of age. There were 732 hospitalizations, and the mean length of hospital stay was 32 days (first hospitalization). The prevalence of alcoholism, diabetes and TB/HIV coinfection was, respectively, 11.7%, 8.2% and 16.2%. The prevalence of TB/HIV coinfection decreased from 20.7% to 12.9% during the study period. The treatment outcome was cure, abandonment, death from TB and death attributed to TB/HIV coinfection in 71.0%, 12.1%, 3.9% and 2.5%, respectively. The directly observed treatment, short-course (DOTS) was adopted in 63.4% of cases, and there were no significant differences between DOTS and the conventional treatment approach in terms of outcomes (p > 0.05). The mean annual incidence of PTB was 127.9/100,000 population (range: 72.8-272.92/100,000 population, varying by region). The mean annual mortality rate for PTB was 6.9/100,000 population. CONCLUSIONS In areas hyperendemic for TB, DOTS should be prioritized for groups at greater risk of treatment abandonment or death, and the investigation of TB contacts should be intensified.

Inquéritos populacionais: aspectos metodológicos, operacionais e éticos

Eliseu Alves Waldman H. Maria Dutilh Novaes Maria de Fatima Militao de Albuquerque Maria do Rosario Dias de Oliveira Latorre Manoel Carlos Sampaio de Almeida Ribeiro Mauricio Vasconcellos Ricardo Arraes de Alencar Ximenes Rita Barradas Barata Tânia Giacomo do Lago Zilda Pereira da Silva 1 Universidade de Sao Paulo, Faculdade de Saude Publica 2 Faculdade de Medicina da Universidade de Sao Paulo 3 Universidade Federal de Pernambuco, Centro de Ciencias da Saude, Departamento de Medicina Clinica 4 Universidade de Sao Paulo, Faculdade de Saude Publica, Departamento de Epidemiologia 5 Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo, Departamento de Medicina Social 6 Instituto Brasileiro de Geografia e Estatistica IBGE 7 Universidade Federal de Pernambuco, Centro de Ciencias da Saude, Departamento de Medicina Tropical 8 Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo, Departamento de Medicina Social 9 Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo, Departamento de Medicina Social 10 Fundacao Sistema Estadual de Analise de Dados SEADE

Trends and spatial distribution of deaths of children aged 12-60 months in São Paulo, Brazil, 1980-98

OBJECTIVE To describe trends in the mortality of children aged 12-60 months and to perform spatial data analysis of its distribution at the inner city district level in São Paulo from 1980 to 1998. METHODS Official mortality data were analysed in relation to the underlying causes of death. The population of children aged 12-60 months, disaggregated by sex and age, was estimated for each year. Educational levels, income, employment status, and other socioeconomic indices were also assessed. Statistical Package for Social Sciences software was used for the statistical processing of time series. The Cochrane-Orcutt procedure of generalized least squares regression analysis was used to estimate the regression parameters with control of first-order autocorrelation. Spatial data analysis employed the discrimination of death rates and socioeconomic indices at the inner city district level. For classifying area-level death rates the method of K-means cluster analysis was used. Spatial correlation between variables was analysed by the simultaneous autoregressive regression method. FINDINGS There was a steady decline in death rates during the 1980s at an average rate of 3.08% per year, followed by a levelling off. Infectious diseases remained the major cause of mortality, accounting for 43.1% of deaths during the last three years of the study. Injuries accounted for 16.5% of deaths. Mortality rates at the area level clearly demonstrated inequity in the citys health profile: there was an increasing difference between the rich and the underprivileged social strata in this respect. CONCLUSION The overall mortality rate among children aged 12-60 months dropped by almost 30% during the study period. Most of the decline happened during the 1980s. Many people still live in a state of deprivation in underserved areas. Time-series and spatial data analysis provided indications of potential value in the planning of social policies promoting well-being, through the identification of factors affecting child survival and the regions with the worst health profiles, to which programmes and resources should be preferentially directed.

Surveillance for adverse events after DTwP/Hib vaccination in Brazil: sensitivity and factors associated with reporting.

We estimated the sensitivity, i.e., the proportion of all cases of adverse events following immunization (AEFIs) reported to the Brazilian passive surveillance for adverse events following immunization (PSAEFI) with the diphtheria-tetanus-whole-cell pertussis-Haemophilus influenzae type b (DTwP/Hib) vaccine, as well as investigating factors associated with AEFIs reporting. During 2003-2004, 8303 AEFIs associated with DTwP-Hib were reported; hypotonic-hyporesponsive episodes (HHEs), fever and convulsions being the most common. Cure without sequel was achieved in 98.4% of the cases. The mean sensitivity of the PSAEFI was 22.3% and 31.6%, respectively, for HHE and convulsions, varying widely among states. Reporting rates correlated positively with the Human Development Index and coverage of adequate prenatal care, correlating negatively with infant mortality rates. Quality of life indicators and the degree of organization of health services are associated with greater PSAEFI sensitivity. In addition to consistently describing the principal AEFIs, PSAEFI showed the DTwP/Hib vaccine to be safe and allayed public fears related to its use.

Emergence and Disappearance of a Virulent Clone of Haemophilus influenzae Biogroup aegyptius, Cause of Brazilian Purpuric Fever

SUMMARY In 1984, children presented to the emergency department of a hospital in the small town of Promissão, São Paulo State, Brazil, with an acute febrile illness that rapidly progressed to death. Local clinicians and public health officials recognized that these children had an unusual illness, which led to outbreak investigations conducted by Brazilian health officials in collaboration with the U.S. Centers for Disease Control and Prevention. The studies that followed are an excellent example of the coordinated and parallel studies that are used to investigate outbreaks of a new disease, which became known as Brazilian purpuric fever (BPF). In the first outbreak investigation, a case-control study confirmed an association between BPF and antecedent conjunctivitis but the etiology of the disease could not be determined. In a subsequent outbreak, children with BPF were found to have bacteremia caused by Haemophilus influenzae biogroup aegyptius (H. aegyptius), an organism previously known mainly to cause self-limited purulent conjunctivitis. Molecular characterization of blood and other isolates demonstrated the clonal nature of the H. aegyptius strains that caused BPF, which were genetically distant from the diverse strains that cause only conjunctivitis. This led to an intense effort to identify the factors causing the unusual invasiveness of the BPF clone, which has yet to definitively identify the virulence factor or factors involved. After a series of outbreaks and sporadic cases through 1993, no additional cases of BPF have been reported.

Vigilância para acidentes e violência: instrumento para estratégias de prevenção e controle

A rapida e expressiva elevacao da morbi-mortalidade por acidentes e violencia constituiu um dos pontos mais relevantes da transicao epidemiologica no Brasil, a partir dos anos 80. A complexidade do problema implica a aplicacao de medidas no âmbito de politicas sociais, elaboracao de legislacao especifica e desenvolvimento de instrumentos de intervencao voltados a prevencao, ao tratamento e a reabilitacao dos atingidos, o que pressupoe a identificacao de grupos e fatores de risco. O objetivo deste texto e discutir aspectos conceituais e operacionais da utilizacao da vigilância em eventos adversos a saude relacionados a acidentes e a violencia. Apresentados os conceitos, caracteristicas comuns e aspectos relativos a operacionalizacao dos sistemas de vigilância, independente do evento adverso a saude a que se destinam, foram discutidas algumas questoes especificas relativas a elaboracao de definicoes de caso, a identificacao de fontes de informacao e a coleta dos dados de interesse, buscando identificar diferencas da utilizacao da vigilância para acidentes e violencia se comparadas com a aplicacao deste instrumento para doencas infecciosas, salientando entre elas que, para a identificacao de fatores de risco, geralmente, se faz necessario complementar os resultados obtidos pela vigilância com pesquisas epidemiologicas.

Enterovirus 71 infection and acute neurological disease among children in Brazil (1988–1990)

Surveillance for Enterovirus 71 (EV-71) infection in children up to 15 years of age was carried out in Brazil, from 1988 to 1990. Patients with acute neurological diseases (AND) such as flaccid paralysis, Bells palsy, acute cerebellar ataxia and Guillain-Barré syndrome were included in the study. EV-71 infection was detected in 24 of 426 children (5.6%) with AND. EV-71 infection was confirmed only by virus isolation in 13 children, by virus isolation and seroconversion in 4, and by seroconversion alone in 7. EV-71 was also isolated from 15 of the 427 household contacts (3.5%) of 165 AND patients. There was some evidence of high infectivity of EV-71: household clusters were detected in the case of 7 of 24 children (29.1%) infected with EV-71 and manifesting AND; EV-71 was isolated from 11/40 household contacts (27.5%) of the infected patients but from only 4/387 household contacts (1.0%) of children in whom it was not possible to demonstrate EV-71 infection. Seven of the 24 children infected with EV-71 exhibited residual motor deficiency when examined 6 months after the disease onset. The relevance of these results for the Plan for Global Eradication of Wild Poliovirus is discussed, as well as the need to increase knowledge about the behaviour of this virus and its possible association with AND.

Prevalência de cárie não tratada na dentição decídua em áreas urbanas e rurais do Estado de São Paulo, Brasil

OBJETIVO: Descrever os diferenciais urbano-rurais da prevalencia de carie dentaria em criancas com denticao decidua no Estado de Sao Paulo e identificar fatores associados. METODOS: Participaram do estudo 24 744 criancas de 5 a 7 anos examinadas no Levantamento Epidemiologico de Saude Bucal do Estado de Sao Paulo. Utilizou-se a analise multinivel para verificar se havia associacao entre a prevalencia de carie nao tratada e as caracteristicas sociodemograficas das criancas examinadas ou os aspectos socioeconomicos das cidades participantes. RESULTADOS: Ser negro ou pardo (razao de chances, ou OR, ajustada = 1,27), estudar na area rural (OR ajustada = 1,88) e frequentar a escola publica (OR ajustada = 3,41) foram identificados como determinantes individuais de chance mais elevada de apresentar um ou mais dentes deciduos com carie nao tratada. Ser do sexo feminino (OR ajustada = 0,83) foi identificado como fator de protecao para essa condicao. Os coeficientes negativos obtidos para as variaveis independentes de segundo nivel indicaram que o perfil de saude bucal das cidades participantes se beneficiou de valores mais elevados de indice de desenvolvimento humano municipal (beta = -0,47) e da adicao de fluor a rede de aguas (beta = -0,32). CONCLUSOES: A prevalencia de carie nao tratada e influenciada por fatores sociodemograficos de ordem individual e contextual. O presente estudo apresenta informacoes epidemiologicas das areas rurais do Estado de Sao Paulo, oferecendo subsidios para o planejamento estrategico e normativo das acoes de saude bucal nos sistemas locais de saude, com o intuito de contribuir para a promocao de equidade em saude bucal.