Inês Dourado

Internações por condições sensíveis à atenção primária: a construção da lista brasileira como ferramenta para medir o desempenho do sistema de saúde (Projeto ICSAP - Brasil)

Ambulatory care sensitive hospitalizations are a set of conditions for which access to effective primary care can reduce the likelihood of hospitalization. These hospitalizations have been used as an indicator of primary care performance in several countries and in three Brazilian states, but there is little consensus on which conditions should be included in this indicator. This paper presents a description of the steps undertaken to construct and validate a list for Brazil. The final list includes 20 groups of diagnostic conditions that represented 28.3% of a total of 2.8 million hospitalizations in the National Unified Health System in 2006. Gastroenteritis and complications, congestive heart failure, and asthma represented 44.1% of all ambulatory care sensitive hospitalizations. From 2000 to 2006, ambulatory care sensitive hospitalizations decreased by 15.8%, and this reduction was more significant than that observed in all other hospitalizations. The article concludes with potential applications and limitations of the proposed Brazilian list.

HTLV-I in the general population of Salvador, Brazil: a city with African ethnic and sociodemographic characteristics

The city of Salvador has the highest prevalence of HTLV-I among blood donors in Brazil. To study the prevalence of HTLV-I among the general population of Salvador, 30 “sentinel surveillance areas” were selected for the investigation of various infectious diseases, and 1385 individuals within these areas were surveyed according to a simple random sample procedure. ELISA was used to screen plasma samples for antibodies to HTLV-I, and the positive samples were tested by a confirmatory assay (Western blotting). The overall prevalence of HTLV-I was 1.76% (23/1385). Infection rates were 1.2% for males and 2.0% for females. Specific prevalence demonstrated an increasing linear trend with age. No one younger than 13 years of age was infected. Multivariate analysis estimated adjusted odds ratios for the association of HTLV-I with age of 9.7 (3.3; 30.4) for females and 12.3 (1.47; 103.1) for males. Less education and income might be associated with HTLV-I infection in females. Phylogenetic analysis of the long terminal repeat fragments showed that most of the samples belonged to the Latin American cluster of the Transcontinental subgroup (Cosmopolitan subtype). For the entire city of Salvador, it is estimated that ∼40,000 individuals are infected with HTLV-I. Our results suggest multiple post-Colombian introductions of African HTLV-Ia strains in Salvador.

Effect of BCG revaccination on incidence of tuberculosis in school-aged children in Brazil: the BCG-REVAC cluster-randomised trial.

BACKGROUND Many countries offer a second BCG vaccination to prevent tuberculosis, although there is little evidence of whether this confers additional protection. BCG vaccination is routine in Brazil but BCG revaccination procedures vary by state. We studied revaccination efficacy in two Brazilian cities with tuberculosis prevalence representative of Brazil. METHODS We did a cluster-randomised trial of the protection against tuberculosis from BCG revaccination in school-aged children who had had one BCG vaccination as infants. 767 schools in the cities of Salvador and Manaus, Brazil, participated; schools were the unit of randomisation. The study was open label with no placebo. Cases of tuberculosis were identified through record linkage to the Tuberculosis Control Programme. Revaccination status was masked during linkage and validation of cases. The incidence of tuberculosis was the primary outcome. Analysis was by intention to treat. FINDINGS 386 schools (176,846 children) were assigned BCG revaccination and 365 (171,293 children) no revaccination. 42,053 children in the vaccine group and 47,006 in the control group were absent from school on the day of the visit and were excluded. 31,163 and 27,146, respectively were also excluded because they had no BCG scar, two or more scars, or a doubtful scar on assessment. The crude incidence of tuberculosis in the intervention group was 29.3 per 100,000 person years and in the control group 30.2 per 100,000 person-years (crude-rate ratio 0.97; 95% CI 0.76-1.28). The efficacy of BCG revaccination was 9% (-16 to 29%). INTERPRETATION Revaccination given to children aged 7-14 years in this setting does not provide substantial additional protection and should not be recommended. Follow-up is ongoing and needed to assess the effect of other factors on revaccination efficacy: time since vaccination, age at vaccination, and high or low prevalence of environmental mycobacteria.

Tendências da epidemia de Aids no Brasil após a terapia anti-retroviral

OBJETIVO: A terapia anti-retroviral disponivel no Brasil a partir de 1996, modificou o curso da epidemia de Aids, alterando sua evolucao e tendencias. Nesse sentido, o estudo teve por objetivo avaliar a epidemia da Aids no Brasil, nos seus aspectos epidemiologicos. METODOS: Estudo realizado a partir de bases de dados do Ministerio da Saude que caracterizavam a evolucao temporal da Aids nas macrorregioes brasileiras, de 1990 a 2003. Foram utilizados modelos de regressao exponencial, ajustados a serie temporal de 1990 a 1996 e estimados valores esperados para toda a serie. RESULTADOS: O percentual de internacoes nao se modificou no tempo, mas ocorreu diminuicao de hospitalizacoes entre os usuarios de terapia anti-retrovial. Houve um incremento de 2,7 vezes no numero de individuos em uso da terapia, de 1997 a 2003. Incidencia e mortalidade apresentaram crescimentos uniformes ate 1995, em todas as regioes. A partir de 1996, verificou-se uma reducao progressiva da mortalidade, embora a incidencia continue crescendo. Em todas as regioes, exceto a Norte, as incidencias esperadas foram maiores do que as observadas nos ultimos anos, embora as diferencas somente tenham atingido niveis de significância estatistica nas regioes Sudeste e Centro-Oeste. CONCLUSOES: As mudancas observadas no perfil de morbi-mortalidade da epidemia de Aids no Brasil poderiam ser explicadas pelo amplo acesso a terapia anti-retroviral. Tal fato representou um impacto importante sobre a mortalidade por HIV/Aids, porem, outros fatores devem ser considerados, como idade da epidemia, medidas de prevencao, conhecimento sobre HIV/Aids e anos de escolaridade.

Major Expansion Of Primary Care In Brazil Linked To Decline In Unnecessary Hospitalization

In 1994 Brazil launched what has since become the worlds largest community-based primary health care program. Under the Family Health Program, teams consisting of at least one physician, one nurse, a medical assistant, and four to six trained community health agents deliver most of their services at community-based clinics. They also make regular home visits and conduct neighborhood health promotion activities. This study finds that during 1999-2007, hospitalizations in Brazil for ambulatory care-sensitive chronic diseases, including cardiovascular disease, stroke, and asthma, fell at a rate that was statistically significant and almost twice the rate of decline in hospitalizations for all other causes. In municipalities with high Family Health Program enrollment, chronic disease hospitalization rates were 13 percent lower than in municipalities with low enrollment, when other factors were held constant. These results suggest that the Family Health Program has improved health system performance in Brazil by reducing the number of potentially avoidable hospitalizations.

Human T-cell lymphotropic virus type 1 infection among pregnant women in northeastern Brazil.

Summary: An evaluation of human T‐cell lymphotropic virus type 1 (HTLV‐1) infection among 6754 pregnant women in Salvador, Bahia, Brazil using enzyme‐linked immunosorbent assay, Western blot analysis, and polymerase chain reaction assay found a rate of infection of 0.84% (57 of 6754 women). Epidemiologic and obstetric data on the HTLV‐1‐positive pregnant women were analyzed and compared with data on a control group of HTLV‐1‐negative pregnant women. The mean age of the HTLV‐1‐positive women was 26.2 years. All were seronegative for HIV and syphilis, and only 2 reported a past history of sexually transmitted infection and more than 10 sexual partners. Of the HTLV‐1‐positive women, 88.5% were breast‐fed, 4% were bottle fed, and 7.5% did not know. Six women had received blood transfusions, and only 1 reported intravenous drug use. Fifty‐two HTLV‐1‐positive women could be followed: 45 had full‐term deliveries, 5 had premature deliveries, and 2 had abortions. Our results indicate that (1) the frequency of HTLV‐1 infection among pregnant women is relatively high in Salvador, Bahia, Brazil; (2) maternal infection was probably acquired more frequently through breast‐feeding, but the sexual route was cer tainly the second most important means of transmission; (3) HTLV‐1‐positive women had a history of eczema‐like infections in childhood more frequently than the control group; (4) HTLV‐1 infection did not interfere in the course of pregnancy; and (5) no associated congenital infections were observed in the HTLV‐1‐positive women.

Trends in maternal-infant transmission of AIDS after antiretroviral therapy in Brazil

OBJECTIVE The increase in the number of AIDS cases among women has led to an increase in the maternal-infant transmission of human acquired immunodeficiency virus. Measures for the control of this type of transmission were implemented in Brazil in 1996. The aim of the present study was to analyze time trends in maternal-infant transmission of AIDS among Brazilian children. METHODS The present study included children born in Brazil between 1990 and 2001. We used the database of notified AIDS cases in children 13 years of age or younger between 1990 and 2004. Exponential regression models adjusted to the time series provided the annual variation rates and observed and expected values for the period. RESULTS We found a significant increasing trend for cases born prior to the year in which anti retroviral therapy was introduced, with an increase rate of about 12% (t<0.003) per year. Rates from different states ranged from 5.9% to 31%. The analysis of expected and observed cases for each of the countrys five Regions showed a reduction in the number of cases among children born from 1997 onwards, with a progressive year-to-year reduction. The number of notified cases among children born in 2001 was less than 10% the number of expected cases. CONCLUSIONS The results obtained suggest a favorable response to the implementation of policies for the prevention of maternal-infant HIV transmission in Brazil, as observed in other parts of the world.

Outbreak of aseptic meningitis and mumps after mass vaccination with MMR vaccine using the Leningrad-Zagreb mumps strain

Data from routine surveillance during two mass immunisation campaigns (MIC) with Measles-mumps-rubella (MMR)vaccine using Leningrad-Zagreb mumps strain in two states in Brazil were analysed to estimate the risk of vaccine-related meningitis and mumps. Increase in the incidence of the two diseases was observed in both states, 3 weeks after the vaccination campaigns. The estimated number of doses applied per one case of vaccine-related meningitis ranged from 6199 (95% CI: 4854-8058) to 19,247 (95% CI: 12,648-29,513) depending on the diagnostic criteria used and state. It was 300 doses (95% CI: 286-317) for each case of mumps. The implications for vaccination policy are discussed.

Lower prevalence of reported asthma in adolescents with symptoms of rhinitis that received neonatal BCG

Background:  BCG is a vaccine used against tuberculosis and leprosy and is an immunostimulant that primes TH1 lymphocytes to produce cytokines that antagonize atopy both in animal models and in man. Considering that atopy is the main risk factor for asthma, one can hypothesize that vaccination inducing TH1 responses, such as BCG, can be protective against asthma.

Trends in primary health care-sensitive conditions in Brazil: the role of the Family Health Program (Project ICSAP-Brazil)

BackgroundThis study describes trends in hospital admission rates for primary healthcare-sensitive conditions (PHCSC) in Brazil. ObjectivesTo evaluate the impact of increased primary healthcare availability through the implementation of the Family Health Program (FHP) on PHCSC admissions rates at the national, regional, and state-levels between 1999 and 2007. Research DesignAn ecologic panel data study was used and a fixed effects multivariate negative binomial model was used to estimate the association of PHCSC admission rate and FHP controlling for other relevant covariates. ResultsIt was shown that, at the national level, PHCSC hospital admissions declined by 24%—over 2.5 times more rapidly than the decline in hospitalizations for all other (non-PHCSC) conditions. Greater reductions in the PHCSC admission rates when compared with the non-PHCSC admission rates were also observed when the data were divided by regions and states. Regression models showed that at the state level the greater the FHP coverage, the less was the PHCSC hospital admissions even when controlling for confounding variables. ConclusionsThe results of this study have important implications for the healthcare model in countries that base their national health systems on primary healthcare. This is the first study to evaluate the association between FHP coverage and PHCSC admissions rates in all the Brazilian states over a long and relevant period for the consolidation of FHP in the country.