Mônica Cardoso Façanha

Intestinal permeability and malabsorption of rifampin and isoniazid in active pulmonary tuberculosis

Low antimycobacterial drug concentrations have been observed in tuberculosis (TB) patients under treatment. The lactulose/mannitol urinary excretion test (L/M), normally used to measure intestinal permeability, may be useful to assess drug absorption. The objective of this research was to study intestinal absorptive function and bioavailability of rifampin and isoniazid in TB patients. A cross sectional study was done with 41 patients and 28 healthy controls, using the L/M test. The bioavailabilities of rifampin (R) and isoniazid (H) were evaluated in 18 patients receiving full doses. Urinary excretion of mannitol and lactulose, measured by HPLC, was significantly lower in TB patients. The serum concentrations of the drugs were below the expected range for R (8-24 mcg/mL) or H (3-6 mcg/mL) in 16/18 patients. Analyzing the drugs individually, 12/18 patients had low serum concentrations of R, 13/18 for H and 8/18 for both drugs. We suggest that there is a decrease in the functional absorptive area of the intestine in TB patients, which would explain the reduced serum concentrations of antituberculosis drugs. There is a need for new approaches to improve drug bioavailability in TB patients.

Selective surveillance for nosocomial infections in a Brazilian hospital.

OBJECTIVE To devise a system for surveying the frequency of nosocomial infections in a tertiary care hospital in a developing country. DESIGN Prospective selective surveillance by nurses of the charts of patients at high risk for nosocomial infections, as identified by a form completed by resident physicians. The sensitivity, specificity, and predictive value of this method of selective surveillance were compared with those for total prospective chart review by two infectious disease specialists. SETTING A university hospital in northeastern Brazil. PATIENTS All patients hospitalized for more than 72 hours with an identified risk factor for nosocomial infection. RESULTS The ratio of nosocomial infections to 100 discharges was 13.4 and the incidence density was 11.2/1,000 patient days. The surveillance method demonstrated a sensitivity of 74% and a specificity of 99.7%. Positive predictive value was 93%, negative predictive value was 99%, and overall accuracy was 98%. CONCLUSIONS This method of selective surveillance for nosocomial infections based on risk factors identified by physicians demonstrated excellent predictive value and overall accuracy and may be of use to other hospitals that lack a nursing care plan book such as the Kardex. The relative frequency of nosocomial infections significantly exceeded the rates reported from hospitals in developed countries.

Tuberculose: subnotificação de casos que evoluíram para o óbito em Fortaleza-CE

O Plano Nacional de Controle da Tuberculose tem como meta diagnosticar pelo menos 92% dos casos esperados, e tratar com sucesso no minimo 85% deles. O acompanhamento dessas metas depende da informacao dos casos diagnosticados e de sua evolucao. O objetivo deste estudo e verificar se existe subnotificacao de casos de tuberculose que evoluiram para o obito. Este e um estudo descritivo de dados secundarios em que foi feita busca no Sistema de Informacao de Agravos de Notificacao (Sinan) dos obitos ocorridos entre 1999 e 2003, que tiveram tuberculose como uma das causas multiplas e estavam registrados no Sistema de Informacao em Mortalidade (SIM), tendo como variaveis de referencia o nome, data do nascimento e nome da mae. Dos obitos registrados, 610 tiveram tuberculose como uma das causas associadas, 204 (33,4%) deles notificados no Sinan. Em 438 (71,8%), a tuberculose foi causa basica. A media de notificacoes entre 1999 e 2002 foi de 37%, reduzindo-se para 19,3% em 2003 (p=0,03). Em cinco hospitais ocorreram 324 (53,1%) dos obitos e tiveram origem 114 (55,9%) notificacoes. O Sinan registrou 153 evolucoes para o obito. O acrescimo da notificacao dos 406 casos de tuberculose que evoluiram para o obito acarretara incremento de 5,9% no total de casos notificados no periodo e de 265,4% nas evolucoes para o obito. Os casos graves de tuberculose encontram-se subnotificados, sendo o SIM uma importante fonte de resgate desses casos, que pode ser utilizada de forma rotineira e preferencialmente informatizada.

Impacto da vacinação de maiores de 60 anos para influenza sobre as internações e óbitos por doenças respiratórias e circulatórias em Fortaleza - CE - Brasil

OBJECTIVE: The objective of this study was to evaluate the impact of influenza vaccination on hospital admissions and deaths from respiratory and circulatory diseases in the city of Fortaleza, located in the state of Ceara, Brazil. METHODS: Brazilian Health Ministry data regarding deaths from respiratory and circulatory diseases occurring between 1995 and 2001, as well as hospital admissions related to such diseases between 1995 among 2003, in both cases limited to residents of Fortaleza above the age of 60 years, were analyzed. RESULTS: There were 29,867 admissions for respiratory disease. Between 1995 and 1998, the mean number of annual admissions was 3067.3 (standard deviation, 365.8). Between 1999 and 2003, the average was 3519 (standard deviation, 195.6). When adjusted for the increase in population, the difference between the two periods was less than significant. From 1998 to 1999, there was no significant reduction in the number of admissions from circulatory disease (p > 0.641). Nor was there a significant reduction from 1998 to 2000 (p 0.72), although there were significant reductions in 2000 (p < 0.002) and 2001 (p < 0.0014). There was a significant reduction in the number of deaths and in overall mortality rates during 1999, 2000 and 2001 in relation to 1998 (p < 0.05), with no difference between 2000 and 2001. The monthly distribution of admissions was not altered as a result of the vaccinations. CONCLUSION: Our data show that vaccination of the elderly did not achieve the desired results. This suggests that seasonality studies are needed in order to identify the ideal time of year for such vaccinations.

Health team training and active community surveillance: strategies for the detection of TB cases

OBJECTIVE To evaluate the impact that Family Health Program (FHP) team training and active surveillance have on the detection of TB cases in a low-income community in the city of Fortaleza, Brazil. METHODS The study was performed in an area with approximately 25,000 inhabitants, served by a health care center with five FHP teams, in the city of Fortaleza, Brazil. Although all of the teams were trained, active surveillance was carried out only in one of the areas (area 5). We compared the number of TB cases detected in each of the five areas prior to and after the intervention. We also compared the number of TB cases detected in area 5 to the number of those detected in the other areas, as well as to the citywide number of reported TB cases in Fortaleza, within the same period. RESULTS The number of TB cases detected in the area studied increased from 1 in 2002 to 22 in 2004 (p < 0.05). There was no significant difference between the number of TB cases in area 5 and that observed for each of the other four areas (p > 0.05). There was a significant increase in the number of TB cases detected in the area studied when compared to the city as a whole (p < 0.05). CONCLUSIONS Training and sensitization of FHP professionals were effective in promoting an increase in the number of TB cases detected in a low-income community.

Acute diarrhea treated by health care services in Fortaleza, Ceará State, Brazil, from 1996 to 2001

Diarrhea is still an important cause of morbidity and mortality among children under five years old. It is not mandatory to report diarrheal diseases, and the statistics are not accurate. The objective of this study was to describe follow-up of acute diarrhea in Fortaleza, the capital of Ceará State, Brazil. From 1994 to 2001, cases of acute diarrhea were reported by 100 health care units using a standardized form, keyed-in and analyzed by month, age group, treatment plan, place of treatment, and place of residence. There were 489,069 cases reported, with an annual average of 81,511. February and March had the highest monthly rates. Incidence in infants (< 1 year) was 538.8, three times that of children from 1 to 4 years and 13 times the rate in the 5-to-9-year bracket. All areas in the city reported cases of diarrhea. Diarrhea shows a persistently high incidence, mainly among infants, and merits attention as a major public health problem.

Evolução da mortalidade por tuberculose em Fortaleza (CE), entre 1980 e 2001

OBJECTIVE To evaluate the evolution of tuberculosis-related mortality, as well as gender-related and age-related tendencies, in the city of Fortaleza, Brazil. METHODS A descriptive study, based on secondary data, was conducted. All deaths from tuberculosis occurring among residents of Fortaleza in the 1980-2001 period and reported to the Ministry of Health via the Mortality Database were included. The evolution of tuberculosis-related mortality was compared with that of overall mortality and with that of mortality from all infectious diseases. The tendencies of the coefficients of overall mortality and of tuberculosis-related mortality, adjusted and unadjusted for age and gender, were calculated for the study period. RESULTS The coefficients of overall mortality and of tuberculosis-related mortality presented decreasing tendencies. The coefficient of tuberculosis-related mortality presented a decreasing tendency in individuals = 19 years of age (y = -0.0906x + 2.5133), from 20 to 59 years of age (y = -0.414x + 12.29) and 60 years of age (y = -1.2494x + 40.289), as well as in males (y = -0.3175x + 10.971) and females (y = -0.1933x + 6.8051). CONCLUSION Despite displaying a decreasing tendency, the coefficient of tuberculosis-related mortality remains high.

Pandemic influenza A (H1N1) 2009: epidemiological analysis of cases in a tropical/semi-arid region of Brazil

INTRODUCTION The year 2009 marked the beginning of a pandemic caused by a new variant of influenza A (H1N1). After spreading through North America, the pandemic influenza virus (H1N1) 2009 spread rapidly throughout the world. The aim of this study was to describe the clinical and epidemiological characteristics of cases of pandemic influenza in a tropical/semi-arid region of Brazil. METHODS A retrospective study analyzed all suspected cases of pandemic influenza (H1N1) 2009 reported in the Ceará State through the National Information System for Notifiable Diseases during the pandemic period between 28 April, 2009 and November 25, 2010. RESULTS A total of 616 suspected cases were notified, 58 (9.4%) in the containment phase and 558 (90.6%) in the mitigation phase. Most cases were of affected young people resident in the City of Fortaleza, the largest urban center in the State of Ceará. The most frequent symptoms presented by the cases with confirmed infection were fever, cough, myalgia, arthralgia, and nasal congestion. Mortality rate was 0.0009/1,000 inhabitants and lethality was 5.6%. Deaths were observed only in the mitigation phase. Mortality rates were similar for both sexes but were higher in the age group under 5 years. CONCLUSIONS The study suggests that the influenza A (H1N1) pandemic in this tropical/semi-arid region had a lower magnitude when compared to states in the Southern and Southeastern regions of Brazil.

Fatores associados à tuberculose pulmonar em pacientes que procuraram serviços de saúde de referência para tuberculose

OBJECTIVE The identification of behavioral and clinical factors that are associated with pulmonary tuberculosis might improve the detection and treatment of the disease, thereby reducing its duration and transmission. Our objective was to identify sociodemographic, clinical, and behavioral factors that are associated with the diagnosis of pulmonary tuberculosis. METHODS This was a cross-sectional study conducted between April of 2008 and March of 2009 at three health care clinics in the city of Fortaleza, Brazil. We selected 233 patients older than 14 years of age who spontaneously sought medical attention and presented with cough for > 2 weeks. Sociodemographic, clinical, and behavioral data were collected. Sputum smear microscopy for AFB and mycobacterial culture were also carried out, as were tuberculin skin tests and chest X-rays. The patients were divided into two groups (with and without pulmonary tuberculosis). The categorical variables were compared by the chi-square test, followed by logistic regression analysis when the variables were considered significant. RESULTS The prevalence of pulmonary tuberculosis was 41.2%. The unadjusted OR showed that the following variables were statistically significant risk factors for pulmonary tuberculosis: fever (OR = 2.39; 95% CI, 1.34-4.30), anorexia (OR = 3.69; 95% CI, 2.03-6.75), and weight loss (OR = 3.37; 95% CI, 1.76-6.62). In the multivariate analysis, only weight loss (OR = 3.31; 95% CI, 1.78-6.14) was significantly associated with pulmonary tuberculosis. CONCLUSIONS In areas with a high prevalence of tuberculosis, weight loss could be used as an indicator of pulmonary tuberculosis in patients with chronic cough for > 2 weeks.

Occupational and nosocomial transmission of varicella

We examined varicella transmission in a hospital specialized in cancer treatment. A cases series study was made of a case of intra-hospital transmission of varicella, based on a revision of the records of patients who had been admitted during the time the index case was in the same service. Records of interviews of employees were also reviewed. During the period that the index case was in the intensive care unit, 34 patients were admitted and 35 employees worked there. Two employees and a patient developed the illness, due to transmission directly or indirectly from the index case. Although this is a service in which most of the patients are adults who have cancer, attention needs to be directed towards diagnosis and to procedures to reduce the transmission of this illness, both to healthcare professionals, and to other patients. A standard schedule for varicella prevention already exists; however, this case reinforces the need for specific vaccination of at-risk professionals.