Ricardo Almendra

Geospatial distribution of intestinal parasitic infections in Rio de Janeiro (Brazil) and its association with social determinants

Background Intestinal parasitic infections remain among the most common infectious diseases worldwide. This study aimed to estimate their prevalence and provide a detailed analysis of geographical distribution of intestinal parasites in the metropolitan region of Rio de Janeiro, considering demographic, socio-economic, and epidemiological contextual factors. Methods/Principal findings The cross-section survey was conducted among individuals attending the Evandro Chagas National Institute of Infectious Diseases (FIOCRUZ, RJ) during the period from April 2012 to February 2015. Stool samples were collected and processed by sedimentation, flotation, Kato-Katz, Baermann-Moraes and Graham methods, iron haematoxylin staining and safranin staining. Of the 3245 individuals analysed, 569 (17.5%) were infected with at least one parasite. The most common protozoa were Endolimax nana (28.8%), Entamoeba coli (14.8%), Complex Entamoeba histolytica/Entamoeba dispar (13.5%), Blastocystis hominis (12.7%), and Giardia lamblia (8.1%). Strongyloides stercoralis (4.3%), Schistosoma mansoni (3.3%), Ascaris lumbricoides (1.6%), and hookworms (1.5%) were the most frequent helminths. There was a high frequency of contamination by protozoa (87%), and multiple infections were observed in 141 participants (24.8%). A positive association between age (young children) and gender (male) with intestinal parasites was observed. Geospatial distribution of the detected intestinal parasitic infections was not random or homogeneous, but was influenced by socioeconomic conditions (through the material deprivation index (MDI)). Participants classified in the highest levels of deprivation had higher risk of having intestinal parasites. Conclusions/Significance This study provides the first epidemiological information on the prevalence and distribution of intestinal parasitic infections in the Rio de Janeiro metropolitan area. Intestinal parasites, especially protozoa, are highly prevalent, indicating that parasitic infections are still a serious public health problem. MDI showed that intestinal parasites were strongly associated with the socioeconomic status of the population, thus making it possible to identify social vulnerable areas.

Evidence of social deprivation on the spatial patterns of excess winter mortality

ObjectivesThe aims of this study are to identify the patterns of excess winter mortality (due to diseases of the circulatory system) and to analyse the association between the excess winter deaths (EWD) and socio-economic deprivation in Portugal.MethodsThe number of EWD in 2002–2011 was estimated by comparing the number of deaths in winter months with the average number in non-winter months. The EWD ratio of each municipality was calculated by following the indirect standardization method and then compared with two deprivation indexes (socio-material and housing deprivation index) through ecological regression models.ResultsThis study found that: (1) the EWD ratio showed considerable asymmetry in its geography; (2) there are significant positive associations between the EWD ratio and both deprivation indexes; and (3) at the higher level of deprivation, housing conditions have a stronger association with EWD than socio-material conditions.ConclusionsThe significant association between two deprivation dimensions (socio-material and housing deprivation) and EWDs suggests that EWD geographical pattern is influenced by deprivation.

The influence of the winter North Atlantic Oscillation index on hospital admissions through diseases of the circulatory system in Lisbon, Portugal

The aim of this paper is to analyze the relationship between North Atlantic Oscillation (NAO), meteorological variables, air pollutants, and hospital admissions due to diseases of circulatory systems in Lisbon (Portugal) during winter months (2003–2012). This paper is one of the few studies analyzing the impact of NAO on health through its influence on thermal stress and air pollution and is the first to be conducted in Lisbon. This study uses meteorological data (synthetized into a thermal comfort index), air pollutant metrics, and the NAO index (all clustered in 10-day cycles to overcome daily variability of the NAO index). The relationship between morbidity, thermal comfort index, NAO index, and air pollutants was explored through several linear models adjusted to seasonality through a periodic function. The possible indirect effect between the NAO index and hospital admissions was tested, assuming that NAO (independent variable) is affecting hospital admissions (outcome variable) through thermal discomfort and/or pollution levels (tested as individual mediators). This test was conducted through causal mediation analysis and adjusted for seasonal variation. The results from this study suggest a possible indirect relationship between NAO index and hospital admissions. Although NAO is not significantly associated with hospital admissions, it is significantly associated with CO, PM2.5, NO, and SO2 levels, which in turn increase the probability of hospitalization. The discomfort index (built with temperature and relative humidity) is significantly associated with hospital admissions, but its variability is not explained by the NAO index. This study highlights the impacts of the atmospheric circulation patterns on health. Furthermore, understanding the influence of the atmospheric circulation patterns can support the improvement of the existing contingency plans.

Seasonal mortality patterns and regional contrasts in Portugal

Abstract The main aim of this study is to identify the geographical seasonal mortality patterns in Portugal and, for the first time, to assess the relationship between seasonal and overall mortality. Monthly data from the Portuguese mortality database (2000-2009) by major cause of death were analysed and standardized to 30 days with adjustments for leap years. The chi-square goodness-of-fit test was used to compare the observed monthly deaths with deaths that could be expected if mortality were randomly distributed throughout the year. The seasonal burden was measured using the excess winter deaths (EWD) rate and the seasonal impact of winter on mortality was assessed through the EWD Index. The regions were clustered according to the overall mortality rate and the seasonal impact: 1-low seasonality and high values of overall mortality; 2-high seasonality and high values of overall mortality; 3-low values of seasonality and low overall mortality; 4-high seasonality and low overall mortality. Significant seasonal mortality increases were found in all causes of death. There were 86,000 EWDs, mostly through circulatory and respiratory diseases. 73% of the population lives in regions with high winter vulnerability to respiratory mortality and 60% in regions with high winter vulnerability to circulatory mortality. This study reinforces the idea that vulnerability to cold weather may play an important role in the public health in Portugal. This knowledge may be used to construct a set of regulations or policies designed to implement better health planning procedures and more effective warning systems.

SEASONAL MORTALITY PATTERNS DUE TO DISEASES OF THE CIRCULATORY SYSTEM IN PORTUGAL

Exposure to cold weather has negative consequences on human health. Studies have been showing that the seasonality of mortality has an evident peak during winter months in European countries. However, the highest increases in mortality are registered in countries with mild winters. According to several studies winter deaths seem to be associated with low socioeconomic conditions. The main aims of this study are to identify the trends of mortality due to diseases of the circulatory system and excess winter deaths in Portugal and to assess the geographical pattern of seasonal mortality. In the 20 years under analyses, mortality due to diseases of the circulatory system increased 38% during winter months when compared to the non-winter period. Important regional disparities were found, the Excess Winter Death index ranged from 21% to 48%, the central regions tend to have better results. Our results indicate that although circulatory mortality is significantly decreasing in Portugal, the vulnerability to seasonal cold weather remains as an important public health issue. These findings suggest that the exposure to cold weather is an important determinant of cardiovascular diseases that is still neglected in Portugal.

The socio-spatial context as a risk factor for hospitalization due to mental illness in the metropolitan areas of Portugal

Abstract This study’s aims are: (i) identifying spatial patterns for the risk of hospitalization due to mental illness and for the potential risk resulting from contextual factors with influence on mental health; and (ii) analyzing the spatial association between risk of hospitalization due to mental illness and potential risk resulting from contextual factors in the metropolitan areas of Lisbon and Porto, Portugal. A cross-sectional ecological study was conducted by applying statistical methods for assessing spatial dependency and heterogeneity. Results reveal a spatial association between risk of hospitalization due to mental illness and potential risk resulting from contextual factors with a statistical relevance of moderate intensity. 20% of the population under study lives in areas with a simultaneously high potential risk resulting from contextual factors and risk of hospitalization due to mental illness. Porto Metropolitan Area show the highest percentage of population living in parishes with a significantly high risk of hospitalization due to mental health, which puts forward the need for interventions on territory-adjusted contextual factors influencing mental health.This studys aims are: (i) identifying spatial patterns for the risk of hospitalization due to mental illness and for the potential risk resulting from contextual factors with influence on mental health; and (ii) analyzing the spatial association between risk of hospitalization due to mental illness and potential risk resulting from contextual factors in the metropolitan areas of Lisbon and Porto, Portugal. A cross-sectional ecological study was conducted by applying statistical methods for assessing spatial dependency and heterogeneity. Results reveal a spatial association between risk of hospitalization due to mental illness and potential risk resulting from contextual factors with a statistical relevance of moderate intensity. 20% of the population under study lives in areas with a simultaneously high potential risk resulting from contextual factors and risk of hospitalization due to mental illness. Porto Metropolitan Area show the highest percentage of population living in parishes with a significantly high risk of hospitalization due to mental health, which puts forward the need for interventions on territory-adjusted contextual factors influencing mental health.

Short-term impacts of air temperature on hospitalizations for mental disorders in Lisbon

BACKGROUND Individuals with mental disorders are often susceptible to the effects of extreme ambient temperatures. The aim of this study is to assess the short-term impacts of daily mean temperature on hospitalizations for mental disorders in the Lisbon Metropolitan Area, Portugal. METHODS To assess the short-term impacts of daily mean temperature on hospitalizations for mental disorders (2008-2014), a quasi-Poisson generalized additive model combined with a distributed lag non-linear model was applied. The model was adjusted for day of the week, air pollution, relative humidity, time and seasonality. RESULTS The number of hospital admissions for mental disorder during the study period was 30,139. Hospital admissions increase significantly with high temperatures on day of exposure, at lag 0-1 and at lag 0-2. Women are more vulnerable than men, and there was no difference between the age groups studied. CONCLUSIONS The exposure to high temperatures should be considered a significant risk factor for mental disorders; therefore, patient management services may need to be strengthened when extreme high temperature alerts are given.

Indicators for evaluating European population health: a Delphi selection process

BackgroundIndicators are essential instruments for monitoring and evaluating population health. The selection of a multidimensional set of indicators should not only reflect the scientific evidence on health outcomes and health determinants, but also the views of health experts and stakeholders. The aim of this study is to describe the Delphi selection process designed to promote agreement on indicators considered relevant to evaluate population health at the European regional level.MethodsIndicators were selected in a Delphi survey conducted using a web-platform designed to implement and monitor participatory processes. It involved a panel of 51 experts and 30 stakeholders from different areas of knowledge and geographies. In three consecutive rounds the panel indicated their level of agreement or disagreement with indicator’s relevance for evaluating population health in Europe. Inferential statistics were applied to draw conclusions on observed level of agreement (Scott’s Pi interrater reliability coefficient) and opinion change (McNemar Chi-square test). Multivariate analysis of variance was conducted to check if the field of expertise influenced the panellist responses (Wilk’s Lambda test).ResultsThe panel participated extensively in the study (overall response rate: 80%). Eighty indicators reached group agreement for selection in the areas of: economic and social environment (12); demographic change (5); lifestyle and health behaviours (8); physical environment (6); built environment (12); healthcare services (11) and health outcomes (26). Higher convergence of group opinion towards agreement on the relevance of indicators was seen for lifestyle and health behaviours, healthcare services, and health outcomes. The panellists’ field of expertise influenced responses: statistically significant differences were found for economic and social environment (p < 0.05 in round 1 and 2), physical environment (p < 0.01 in round 1) and health outcomes (p < 0.01 in round 3).ConclusionsThe high levels of participation observed in this study, by involving experts and stakeholders and ascertaining their views, underpinned the added value of using a transparent Web-Delphi process to promote agreement on what indicators are relevant to appraise population health.

Mortality from Suicide in the Municipalities of Mainland Portugal: Spatio-Temporal Evolution between 1980 and 2015

INTRODUCTION Suicide is considered a public health priority. It is a complex phenomenon resulting from the interaction of several factors, which do not depend solely on individual conditions. This study analyzes the spatio-temporal evolution of suicide mortality between 1980 and 2015, identifying areas of high risk, and their variation, in the 278 municipalities of Continental Portugal. MATERIAL AND METHODS Based on the number of self-inflicted injuries and deaths from suicide and the resident population, the spatio-temporal evolution of the suicide mortality rate was assessed via: i) a Poisson joinpoint regression model, and ii) spatio-temporal clustering methods. RESULTS The suicide mortality rate evolution showed statistically significant increases over three periods (1980 - 1984; 1999 - 2002 and 2006 - 2015) and two statistically significant periods of decrease (1984 - 1995 and 1995 - 1999). The spatio-temporal analysis identified five clusters of high suicide risk (relative risk >1) and four clusters of low suicide risk (relative risk < 1). DISCUSSION The periods when suicide mortality increases seem to overlap with times of economic and financial instability. The geographical pattern of suicide risk has changed: presently, the suicide rates from the municipalities in the Center and North are showing more similarity with those seen in the South, thus increasing the ruralization of the phenomenon of suicide. CONCLUSION Between 1980 and 2015 the spacio-temporal pattern of mortality from suicide has been changing and is a phenomenon that is currently experiencing a growing trend (since 2006) and is of higher risk in rural areas.

Padrão geográfico e sazonal de internamentos por perturbações mentais

Res_por:A incidencia da doenca mental apresenta variacoes territoriais, entre paises e entre regioes do mesmo pais. Apesar disso, o conhecimento sobre a distribuicao geografica da doenca mental e ainda insuficiente. O objetivo deste trabalho e analisar o padrao espacial e sazonal da morbilidade hospitalar por perturbacoes mentais em Portugal Continental, entre 2008 e 2012. Com base na informacao proveniente da base de dados dos Grupos de Diagnosticos Homogeneos (GDH) fornecida pela Administracao Central do Sistema de Saude (ACSS), foram analisados os internamentos hospitalares cuja principal causa foi perturbacao mental (CID 9: 290-319) ou causa externa (principal) de suicidio e lesao auto-infligida (CID9: E95), agregando a informacao para as 28 NUT III do Continente. Foram calculadas taxas de internamento padronizadas, razoes padronizadas de internamento e testou-se a possivel existencia de aumentos sazonais estatisticamente significativos atraves do teste chi-square goodness of fit. Verificou-se que a morbilidade hospitalar por perturbacoes mentais e superior nas mulheres, principalmente nas classes etarias mais envelhecidas. Foram identificados importantes contrastes territoriais, destacando-se a regiao Centro pelos valores elevados. Contrariamente a maioria das causas de internamento, e de morte, as perturbacoes mentais sao superiores na primavera e verao e muito inferiores no inverno. A identificacao de territorios de risco proporciona importantes informacoes que devem ser incorporadas no desenvolvimento de politicas e estrategias que resultem em melhores resultados em saude.