Dengue outlook for the World Cup in Brazil: an early warning model framework driven by real-time seasonal climate forecasts

BACKGROUND

With more than a million spectators expected to travel among 12 different cities in Brazil during the football World Cup, June 12-July 13, 2014, the risk of the mosquito-transmitted disease dengue fever is a concern. We addressed the potential for a dengue epidemic during the tournament, using a probabilistic forecast of dengue risk for the 553 microregions of Brazil, with risk level warnings for the 12 cities where matches will be played.

METHODS

We obtained real-time seasonal climate forecasts from several international sources (European Centre for Medium-Range Weather Forecasts [ECMWF], Met Office, Meteo-France and Centro de Previsão de Tempo e Estudos Climáticos [CPTEC]) and the observed dengue epidemiological situation in Brazil at the forecast issue date as provided by the Ministry of Health. Using this information we devised a spatiotemporal hierarchical Bayesian modelling framework that enabled dengue warnings to be made 3 months ahead. By assessing the past performance of the forecasting system using observed dengue incidence rates for June, 2000-2013, we identified optimum trigger alert thresholds for scenarios of medium-risk and high-risk of dengue.

FINDINGS

Our forecasts for June, 2014, showed that dengue risk was likely to be low in the host cities Brasília, Cuiabá, Curitiba, Porto Alegre, and São Paulo. The risk was medium in Rio de Janeiro, Belo Horizonte, Salvador, and Manaus. High-risk alerts were triggered for the northeastern cities of Recife (p(high)=19%), Fortaleza (p(high)=46%), and Natal (p(high)=48%). For these high-risk areas, particularly Natal, the forecasting system did well for previous years (in June, 2000-13).

INTERPRETATION

This timely dengue early warning permits the Ministry of Health and local authorities to implement appropriate, city-specific mitigation and control actions ahead of the World Cup.

FUNDING

European Commission's Seventh Framework Research Programme projects DENFREE, EUPORIAS, and SPECS; Conselho Nacional de Desenvolvimento Científico e Tecnológico and Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro.

[The experiment of participatory mapping in order to construct a cartographical alternative to the FHS]

Maps and mapping procedures are useful tools for systematic interpretation and evaluation and for reporting of results to management. Applied to the Family Health Strategy (FHS), these maps permit the demarcation of the territory and the establishment of links between the territory, its population and health services. In this paper the use of maps by the FHS in 17 municipalities in northern and northeastern Brazil is studied and the process of demarcation and digitization of areas with the participation of teams is described. The survey conducted using questionnaires and discussion workshops showed that difficulties still prevail in reconciling the map (drawing) produced at the local level with maps produced by other government sectors. In general, the maps used at local level employ their own references, which prevent the interplay of information with other cartographic documents and their full use as a tool for evaluation and management. The combination of participatory mapping tools, associated with Geographic Information Systems (GIS) applications proposed in this paper, represents an alternative to mapping the territory of operations of FHS teams, as well as a reflection on the concept of territory and operation by the FHS.

Conservation efforts and malaria in the Brazilian Amazon

We respond to Valle and Clark, who assert that "conservation efforts may increase malaria burden in the Brazilian Amazon," because the relationship between forest cover and malaria incidence was stronger than the effect of the deforestation rate. We contend that their conclusion is flawed because of limitations in their methodology that we discuss in detail. Most important are the exclusion of one-half the original data without a discussion of selection bias, the lack of model adjustment for either population growth or migration, and the crude classifications of land cover and protected areas that lead to aggregation bias. Of greater significance, we stress the need for caution in the interpretation of data that could have profound effects on regional land use decisions.

Desafios do desenvolvimento em Miracema (RJ): uma abordagem territorial sustentável de saúde e ambiente

O objetivo deste trabalho foi identificar e caracterizar um modelo de gestão do marketing como estratégia para promoção do município saudável e sustentável em Miracema (RJ). A estrutura da pesquisa deu-se, primeiro, pela coleta de dados primários, com a realização de entrevistas com gestores municipais para conhecer o Sistema de Gestão Municipal e construir mapas participativos para diagnóstico dos problemas e conflitos. Segundo, uma pesquisa de abordagem qualitativa, interpretando a percepção junto à população por meio de questionário estruturado da problemática no município. Na investigação de ferramentas e instrumentos para resposta à problemática no município de Miracema utilizou-se como referencial a matriz Pressão-Estado-Impacto-Resposta (PEIR). Com base no conhecimento produzido, elaborou-se a proposta de gestão do marketing no município baseada nos indicadores de resposta diagnosticados na esfera municipal. Miracema apresenta potencial para desenvolvimento nos setores primário e secundário. O agronegócio deve ser desenvolvido no modelo sustentável, em conformidade com políticas públicas capazes de promover a continuidade de investimentos. O mesmo aplica-se ao aproveitamento da matéria prima na indústria. Logo, o Zoneamento Econômico Ecológico do município contemplando o ambiente induz a ferramenta indispensável de sua viabilidade.

Vulnerabilidade e problemas de saúde em viagem: a visão do turista na cidade do Rio de Janeiro

Este artigo analisa como um grupo de turistas compreende a questão da saúde em viagem segundo aspectos de segurança, prevenção e busca de atendimento de saúde. Foram entrevistados turistas brasileiros visitando a cidade do Rio de Janeiro e cariocas saindo de viagem. Os depoimentos foram analisados segundo as dimensões de vulnerabilidade; informação; prevenção e assistência em saúde, das quais a vulnerabilidade emergiu como categoria de análise. O relato das trajetórias dos turistas permitiu identificar nós e percursos que poderiam ser utilizados pelo setor saúde para ações de prevenção e promoção. O meio de transporte condiciona o trajeto dos turistas e suas alternativas de atenção. A viagem em grupo e para locais conhecidos foram destacadas como fatores de proteção, o que reforça o papel da informação e de redes de apoio social como recursos utilizados pelos turistas na ausência de políticas específicas voltadas para estes grupos populacionais de grande mobilidade e vulnerabilidade.

The development of an early warning system for climate-sensitive disease risk with a focus on dengue epidemics in Southeast Brazil

Previous studies demonstrate statistically significant associations between disease and climate variations, highlighting the potential for developing climate-based epidemic early warning systems. However, limitations include failure to allow for non-climatic confounding factors, limited geographical/temporal resolution, or lack of evaluation of predictive validity. Here, we consider such issues for dengue in Southeast Brazil using a spatio-temporal generalised linear mixed model with parameters estimated in a Bayesian framework, allowing posterior predictive distributions to be derived in time and space. This paper builds upon a preliminary study by Lowe et al. but uses extended, more recent data and a refined model formulation, which, amongst other adjustments, incorporates past dengue risk to improve model predictions. For the first time, a thorough evaluation and validation of model performance is conducted using out-of-sample predictions and demonstrates considerable improvement over a model that mirrors current surveillance practice. Using the model, we can issue probabilistic dengue early warnings for pre-defined 'alert' thresholds. With the use of the criterion 'greater than a 50% chance of exceeding 300 cases per 100,000 inhabitants', there would have been successful epidemic alerts issued for 81% of the 54 regions that experienced epidemic dengue incidence rates in February-April 2008, with a corresponding false alarm rate of 25%. We propose a novel visualisation technique to map ternary probabilistic forecasts of dengue risk. This technique allows decision makers to identify areas where the model predicts with certainty a particular dengue risk category, to effectively target limited resources to those districts most at risk for a given season.

[Production of transmission foci for cutaneous leishmaniasis: the case of Pau da Fome, Rio de Janeiro, Brazil]

This study analyzes the characteristics of one of the main foci for cutaneous leishmaniasis transmission in the city of Rio de Janeiro, Brazil, examining its territorial configuration and the relations with spatial organization processes. An analytical model was applied to the process of occupation and organization of urban space on a local scale, considering the new functions acquired by the spatial elements expressed by different work relations, land use, and land value. The study employed geoprocessing techniques and classification of images obtained by remote sensing, localization of households, and cases of cutaneous leishmaniasis, associated with qualitative data on the historical process of land occupation and use. The analysis detected areas with distinct conditions of vulnerability and showed that changes in these conditions allowed production of the epidemic in a given time period and its subsequent reduction. The study contributes to monitoring of the disease at the local level and application of effective measures for cutaneous leishmaniasis surveillance and control.

[Tourism and health: methodological approaches and courses of action]

OBJECTIVE

To identify relationships between tourism and health as well as the methods employed in studies about this topic.

METHODS

The PubMed and SciELO databases were searched in March of 2008 using the following strategy: traveler or traveller or tourism or tourist AND risk or hazard or vulnerability AND health or surveillance. The following were excluded: articles on animal health, conceptual and review articles, articles about non-tourist travel, and articles written in languages other than Portuguese, English, Italian, and Spanish. Of 153 articles identified, 112 were excluded, and 41 articles were examined.

RESULTS

The number of articles on tourism and health increased from one in the 1970s to 34 in the 2000s. Most studies were carried out in Europe, followed by the Americas, and most covered insect-borne diseases, respiratory diseases transmitted from person to person, and gastrointestinal diseases. Mail, telephone, or face-to-face questionnaires were generally used for data collection. In terms of location, 21 studies were performed at the place of departure, 17 at the destination, and in 3 this information was not specified. Four studies were carried out before the trip, 9 during the trip, 24 after the trip, and 3 did not specify this information. Most studies focus on the tourist as a likely victim of health problems, unprepared to face situations of exposure during the trip.

CONCLUSIONS

The need to implement health care policies aimed at the tourist population is evident, with emphasis on infectious diseases and emergency actions to detect outbreaks involving tourists. A tourist-specific surveillance and notification system is also necessary, together with measures to prepare health care institutions to meet the individual demands of this population.

Highways and outposts: economic development and health threats in the central Brazilian Amazon region

Background

Economic development is often evoked as a driving force that has the capacity to improve the social and health conditions of remote areas. However, development projects produce uneven impacts on local communities, according to their different positions within society. This study examines the spatial distribution of three major health threats in the Brazilian Amazon region that may undergo changes through highway construction. Homicide mortality, AIDS incidence and malaria prevalence rates were calculated for 70 municipalities located within the areas of influence of the Cuiabá-Santarém highway (BR-163), i.e. in the western part of the state of Pará state and the northern part of Mato Grosso.

Results

The municipalities were characterized using social and economic indicators such as gross domestic product (GDP), urban and indigenous populations, and recent migration. The municipalities' connections to the region's main transportation routes (BR-163 and Trans-Amazonian highways, along with the Amazon and Tapajós rivers) were identified by tagging the municipalities that have boundaries crossing these routes, using GIS overlay operations. Multiple regression was used to identify the major driving forces and constraints relating to the distribution of health threats. The main explanatory variables for higher malaria prevalence were: proximity to the Trans-Amazonian highway, high proportion of indigenous population and low proportion of migrants. High homicide rates were associated with high proportions of migrants, while connection to the Amazon River played a protective role. AIDS incidence was higher in municipalities with recent increases in GDP and high proportions of urban population.

Conclusions

Highways induce social and environmental changes and play different roles in spreading and maintaining diseases and health threats. The most remote areas are still protected against violence but are vulnerable to malaria. Rapid economic and demographic growth increases the risk of AIDS transmission and violence. Highways connect secluded localities and may threaten local populations. This region has been undergoing rapid localized development booms, thus creating outposts of rapid and temporary migration, which may introduce health risks to remote areas.

Vulnerabilidade social e risco ambiental: uma abordagem metodológica para avaliação de injustiça ambiental

O objetivo deste artigo é avaliar a vulnerabilidade sócio-ambiental por meio da seleção e análise de indicadores sócio-econômicos, demográficos e de infra-estrutura no entorno do Distrito Industrial Fazenda Botafogo, no Município do Rio de Janeiro, Brasil, utilizado neste trabalho como estudo de caso. Buscou-se verificar nesse espaço se existe alguma correlação entre grupos socialmente vulneráveis e risco ambiental, conformando um quadro de injustiça ambiental. O estudo caracteriza-se por ser uma análise quantitativa e espacial pautado na utilização de um Sistema de Informações Geográficas (SIG). As análises evidenciam uma forte correlação entre vulnerabilidade social e risco ambiental, tendo por referência a proximidade das indústrias na região escolhida. Os indicadores mostram que, na região analisada, as populações com as piores condições sócio-econômicas tendem a se localizar mais próximas às fontes industriais de riscos ambientais. De modo inverso, também foi verificado que os grupos populacionais com melhores condições sócio-econômicas tendem a se localizar mais distantes de tais espaços.

Surveillance of mother-to-child HIV transmission: socioeconomic and health care coverage indicators

OBJECTIVE: To identify clustering areas of infants exposed to HIV during pregnancy and their association with indicators of primary care coverage and socioeconomic condition. METHODS: Ecological study where the unit of analysis was primary care coverage areas in the city of Porto Alegre, Southern Brazil, in 2003. Geographical Information System and spatial analysis tools were used to describe indicators of primary care coverage areas and socioeconomic condition, and estimate the prevalence of liveborn infants exposed to HIV during pregnancy and delivery. Data was obtained from Brazilian national databases. The association between different indicators was assessed using Spearman's nonparametric test. RESULTS: There was found an association between HIV infection and high birth rates (r=0.22, p<0.01) and lack of prenatal care (r=0.15, p<0.05). The highest HIV infection rates were seen in areas with poor socioeconomic conditions and difficult access to health services (r=0.28, p<0.01). The association found between higher rate of prenatal care among HIV-infected women and adequate immunization coverage (r=0.35, p<0.01) indicates that early detection of HIV infection is effective in those areas with better primary care services. CONCLUSIONS: Urban poverty is a strong determinant of mother-to-child HIV transmission but this trend can be fought with health surveillance at the primary care level.

Spatial point analysis based on dengue surveys at household level in central Brazil

Background

Dengue virus (DENV) affects nonimunne human populations in tropical and subtropical regions. In the Americas, dengue has drastically increased in the last two decades and Brazil is considered one of the most affected countries. The high frequency of asymptomatic infection makes difficult to estimate prevalence of infection using registered cases and to locate high risk intra-urban area at population level. The goal of this spatial point analysis was to identify potential high-risk intra-urban areas of dengue, using data collected at household level from surveys.

Methods

Two household surveys took place in the city of Goiania (~1.1 million population), Central Brazil in the year 2001 and 2002. First survey screened 1,586 asymptomatic individuals older than 5 years of age. Second survey 2,906 asymptomatic volunteers, same age-groups, were selected by multistage sampling (census tracts; blocks; households) using available digital maps. Sera from participants were tested by dengue virus-specific IgM/IgG by EIA. A Generalized Additive Model (GAM) was used to detect the spatial varying risk over the region. Initially without any fixed covariates, to depict the overall risk map, followed by a model including the main covariates and the year, where the resulting maps show the risk associated with living place, controlled for the individual risk factors. This method has the advantage to generate smoothed risk factors maps, adjusted by socio-demographic covariates.

Results

The prevalence of antibody against dengue infection was 37.3% (95%CI [35.5–39.1]) in the year 2002; 7.8% increase in one-year interval. The spatial variation in risk of dengue infection significantly changed when comparing 2001 with 2002, (ORadjusted = 1.35; p < 0.001), while controlling for potential confounders using GAM model. Also increasing age and low education levels were associated with dengue infection.

Conclusion

This study showed spatial heterogeneity in the risk areas of dengue when using a spatial multivariate approach in a short time interval. Data from household surveys pointed out that low prevalence areas in 2001 surveys shifted to high-risk area in consecutive year. This mapping of dengue risks should give insights for control interventions in urban areas.

An overview of mercury contamination research in the Amazon basin with an emphasis on Brazil

This article provides an overview of research on mercury contamination in the Amazon Basin and its evolution from 1990 to 2005. The assessment was based on an extensive and systematic review using bibliographic databases available online and a review of projects by research groups. Brazilian research groups were identified using the database of the Brazilian National Research Council (CNPq). A geographic information system was used to determine the location of the studies. Different aspects of mercury contamination were evaluated (environmental studies, impacts on human health, technological improvements). For 1990-2005, a total of 455 publications were identified. The main advances and remaining gaps in relation to environmental issues and human health were identified and discussed. Although the scientific output varied considerably over the period, there was a general increase in the total number of publications per year from the early 1990s (fewer than 20) until 2005 (more than 30), considering the articles published in indexed journals.

A interiorização da epidemia de HIV/AIDS e o fluxo intermunicipal de internação hospitalar na Zona da Mata, Minas Gerais, Brasil: uma análise espacial

O objetivo deste artigo foi analisar o processo de interiorização da epidemia de AIDS e investigar o acesso aos serviços em HIV/AIDS, entre 1988-2002, na Zona da Mata, Minas Gerais, Brasil. Realizou-se estudo ecológico, com abordagem têmporo-espacial. Construiu-se um fluxo de internação hospitalar, tendo como referência pacientes maiores de 15 anos, internados pelo Sistema Único de Saúde, nos anos de 1996 e 2004, residentes nos municípios da região. Foram registrados 2.469 casos de AIDS em maiores de 15 anos no período; as taxas médias de incidência e mortalidade foram calculadas e reestimadas pelo estimador bayesiano empírico local para representar de maneira mais clara os municípios com maior concentração de casos e de óbitos. Verificou-se a interiorização da epidemia. Juiz de Fora é o município com maior número de casos e provável centro difusor da AIDS na região. A assistência hospitalar dos casos de AIDS da Zona da Mata está concentrada nesse município. Destaca-se necessidade de investigações adicionais sobre causas da não-participação de hospitais de referência em outros municípios da região na gerência e prestação de cuidados aos pacientes que vivem com HIV/AIDS.

[Estimate of HIV prevalence in pregnant women by means of spatial analysis in Southern Brazil]

Spatial analysis techniques were used to estimate the interurban differential HIV prevalence among pregnant women in the city of Porto Alegre, Southern Brazil. The estimates were produced through the spatial smoothing of residence pinpoints with live newborns and HIV infected pregnant women for the year of 2003. The overlay of high prevalence areas in city slums was identified. This finding confirms the intensification of AIDS epidemic among poor urban populations, and indicates areas where basic care and educational strategies should be reinforced.

Surveillance and monitoring of disease outbreaks in rural areas: systematisation of low cost geographic information system techniques

The authors describe three recent experiences of epidemiological surveys of zoonotic diseases in Brazil. The role of spatial data acquisition and analysis has been reinforced, considering the intrinsic complexity of environmental and social factors affecting transmission. Health surveillance in Brazil is undergoing a decentralisation process, in accordance with which different responsibilities are attributed to each health institution, from federal level to county health secretaries, including local non-governmental organisations. The availability of data, as well as the skilled use of spatial analysis tools, contributed in this process, allowing rapid and low cost assessments of environmental risks.

Hepatite A no Município do Rio de Janeiro, Brasil: padrão epidemiológico e associação das variáveis sócio-ambientais. Vinculando dados do SINAN aos do Censo Demográfico

Objetivamos discutir a vinculação do Sistema de Informações de Agravos de Notificação (SINAN) e do Censo Demográfico para conhecer o contexto sócio-ambiental da hepatite A, analisando a contribuição das variáveis ambientais e sócio-demográficas para ocorrência de casos notificados e confirmados da infecção. Também, com base nas informações individuais sobre os casos de hepatite A notificados e confirmados, obtidos no SINAN, discutimos o padrão de endemicidade no Município do Rio de Janeiro, Brasil. No estudo agregado, a unidade de análise foi o setor censitário e as informações do Censo 2000, associadas à localização dos 1.553 casos notificados e confirmados de hepatite A ocorridos na cidade entre 1999-2001. Observou-se um padrão epidemiológico entre alta e média endemicidades, indicando situação menos favorável do que a observada nos estudos soro-epidemiológicos. A média rank do número de domicílios com condições sócio-ambientais desfavoráveis foi maior nos setores censitários de sobre-risco para hepatite A (dois ou mais casos) com significância estatística pelo teste de Mann-Whitney. As variáveis sócio-demográficas mostraram ter maior influência do que as ambientais na ocorrência de casos: maior percentual de pobreza e de menores de cinco anos apresentou as maiores diferenças de médias rank.

Ecological analysis of the distribution and socio-spatial context of homicides in Porto Alegre, Brazil

Over the last decade, the number of homicides in Porto Alegre has increased to the point where external causes are now the main group of causes of death in the 5-34-year age group. Preventing these deaths depends fundamentally on identifying factors related to excess violence in population groups. The overall aim of this study is to analyse the spatial distribution of homicide victims by place of residence in Porto Alegre, the capital of the southernmost Brazilian State of Rio Grande do Sul, in 1996, in order to identify and understand the socio-spatial context. Demographic and socioeconomic indicators based on the 1991 census and 1996 population count were used to build a multivariate classification characterizing the 1851 census tracts. Homicides occurring in 1996 were located using the municipality's Geographic Information System. Four socioeconomic groups were identified, mainly differentiated by housing indicators. Small areas on the urban periphery in which slums (favelas) are concentrated presented higher homicide rates. Homicide rates were lower in the two groups with higher income and educational level. The second step was to classify the census tracts according to the homicide indicator. In this case, areas were differentiated by the number of household inhabitants per room, income, schooling, and median age. We conclude that the multivariate socioeconomic classification presents a limited capacity to identify populations exposed to homicides, suggesting that socioeconomic conditions themselves do not determine violent behaviour. On the other hand, the spatial methods allowed us to identify small areas where deaths are concentrated and whose populations should receive special attention in planning measures to prevent violent deaths.

[Environmental surveillance in health in Brazil's Unified Health System]

The incorporation of environmental surveillance in the field of public health policies is a relatively recent demand in Brazil. One of the major challenges in environmental health surveillance is defining its object and the specificity of its practice. The expanded concept of exposure, treated as a set of complex relations between a society and the environment, and not as a personal attribute, is central to the definition of indicators and should guide the practice of environmental surveillance in the health sector. Among the difficulties encountered in applying this concept within the Brazilian Health System, is the need to restructure health surveillance activities and to form multidisciplinary teams capable of dialoguing with other sectors. Furthermore, information systems capable of aiding in health situation analysis and decision making must be constructed. Taking this into consideration, a review of the object and concepts of environmental health surveillance was undertaken and the challenges with respect to its implementation in the Brazilian Health System were identified.

Vigilância em saúde e território utilizado: possibilidades teóricas e metodológicas

Nos diagnósticos de condições de vida e de situação de saúde, os elementos constitutivos da reprodução da vida social nos diversos lugares são listados e tratados como conteúdos desarticulados do território. O reconhecimento da dinâmica social, hábitos e costumes é de grande importância para a determinação de vulnerabilidades para a saúde humana, originadas nas interações de grupos sociais em determinados espaços geográficos. O uso pleno do território como estratégia de análise sobre condições de saúde e intervenção nestas pressupõe a identificação de objetos geográficos, sua utilização pela população e sua importância para os fluxos das pessoas e materiais. Para isso, é necessário o desenvolvimento de metodologias para o reconhecimento, em campo e mediante dados secundários, de objetos e suas formas, que são condições da ação e meios de existência do agir humano. Neste trabalho, é apresentada uma aproximação para a incorporação de conceitos da geografia humana nas práticas de saúde, à luz de dois autores principais: Milton Santos ("constituição do território") e Anthony Giddens ("constituição da sociedade").

[Identification of places with potential transmission of dengue fever in Porto Alegre using Geographical Information Systems]

The social-environmental conditions that promote the continuity of Aedes aegypti in urban areas and its capacity for dengue transmission have yet to be determined. The aim of this work was to locate dengue cases and vector presence, then to identify social-environmental factors that characterize these sites, through Geographical Information Systems (GIS), with a view to developing a dengue fever prevention model. The vector was mainly located in south and east areas of the city, with a broad dispersion, while most of the cases were located in the central region of the city. The sectors with cases present characteristics of high income. Otherwise, sectors with vector present a predominance of houses and good sanitation infrastructure. The difference between cases and vector spatial patterns ensured for 2002 an absence of dengue transmission in the city.

Geoprocessamento dos dados da saúde: o tratamento dos endereços

Este trabalho faz uma análise da situação atual das informações de endereços nos Sistemas de Informações em Saúde (SIS) em alguns municípios, visando a sua utilização em Sistemas de Informações Geográficas (SIG), para a análise e avaliação de riscos dos eventos de saúde pública em grandes cidades, com localização destes eventos em áreas intra-urbanas. Utiliza como base de dados uma amostra dos cadastros do Sistema de Informações de Agravos de Notificação (SINAN) e tem como objetivo propor alternativas para aproveitamento de grandes volumes de dados já existentes. Nas amostras trabalhadas, cerca de metade dos endereços foi localizada automaticamente e aproximadamente 19%, em uma busca manual. As principais perdas ocorreram por falta de completitude ou de consistência nos dados de endereço.

Ecologia da paisagem da hantavirose no Estado do Rio Grande do Sul

Esse trabalho tem como objetivo estudar a ecologia da paisagem das hantaviroses no Rio Grande do Sul através do mapeamento da ocorrência de casos e sua sobreposição a mapas de vegetação e relevo. A maior parte dos casos ocorre na primavera em regiões serranas com vegetação secundária e atividade agrícola.

Distribuição espacial da leptospirose no Rio Grande do Sul, Brasil: recuperando a ecologia dos estudos ecológicos

A leptospirose apresenta no Estado do Rio Grande do Sul uma grande diversidade de situações de exposição, reservatórios, agentes etiológicos e quadros clínicos. O principal objetivo desse trabalho é identificar áreas de maior risco e possíveis componentes ecológicos da transmissão da leptospirose por meio da agregação de dados epidemiológicos em unidades espaciais que representem a diversidade sócio-ambiental do Estado. Os 1.274 casos confirmados de leptospirose ocorridos em 2001 foram georreferenciados por município de residência. Os mapas de municípios foram sobrepostos aos de caracterização de uso do solo, relevo e bacias hidrográficas. Com as operações de SIG, foram calculadas as taxas de incidência para cada categoria e sua significância estatística. As maiores taxas de incidência foram verificadas em áreas sedimentares litorâneas, de baixa altitude e uso do solo predominantemente agrícola. Nessas áreas, a maior parte dos casos está associada à lavoura irrigada. Os resultados sugerem a existência de características ecológicas favoráveis à transmissão da leptospirose em locais de proliferação de roedores sinantrópicos e de produção agrícola intensiva. São discutidos os efeitos da agregação de dados em unidades ambientais na análise de dados epidemiológicos e estratégias de controle da endemia no Estado.

[Distribution of AIDS cases in women in Rio de Janeiro, Brazil, 1982-1997: a spatial analysis]

The AIDS epidemic has spread and reached various population groups differently. The epidemic's dynamics have also differed according to the characteristics of different areas within cities, related to the principal modes of spread. This study analyzes the AIDS epidemic in women in the city of Rio de Janeiro using the space referential. The epidemic is on the rise among women, particularly in the Northern and Western Zones of the city. In this group it constitutes a "sub-epidemic", to the extent that it displays different characteristics in terms of clinical presentation, access to health services, and knowledge of risks. There was a high proportion of unknown transmission category among the women, thus revealing ignorance of their own risk situation. In addition, the high proportion of unknown level of schooling emphasizes the implications of the investigative system on quality of data recorded for women.

[Spatial clusters detection of violent deaths in Porto Alegre, Rio Grande do Sul, Brazil, 1996]

Violence is of major importance in the health profile of Brazilian metropolitan areas and should be treated as a public health problem. Spatial analysis methods can be highly useful for the surveillance and prevention of violence. This paper analyzes the spatial distribution of victims' place of residence in relation to the main causes of violent death in Porto Alegre (1996) in order to identify vulnerable areas. For motor vehicle accidents, homicides, and suicide, the victim's place of residence was pinpointed using the municipal Geographic Information System. The point patterns of health events and population density were analyzed using a Kernel smoother, visually compared. Some areas with higher concentration of events are similar to population distribution but differ from each other in the remaining high concentration areas, thus indicating specific micro-areas at risk. Areas of higher homicide risk are mainly located on the periphery of the more urbanized area, with worse socioeconomic conditions. Motor vehicle accidents are concentrated in areas that are simultaneously commercial and residential and are traversed by streets with heavy traffic. Suicide deaths are more evenly distributed over the territory. Identification of risk areas provides meaningful information for developing preventive and health promotion measures focusing on the events for which health policies may play a central role.

[AIDS epidemic dynamics in the municipality of Rio de Janeiro, Brazil, 1988-1996: Spatial-temporal statistic modeling]

This study uses a spatial-temporal model to analyze the spatial spread of the AIDS epidemic (adult cases) in the municipality of Rio de Janeiro, Brazil, during three periods: 1988-1990, 1991-1993, and 1994-1996. City districts were used as the geographic units of analysis. A spatial analysis was also performed for pediatric AIDS cases due to vertical HIV transmission, according to period of birth, 1985-90 and 1991-96. For total adult AIDS cases, the initial period was characterized by a polygonal cluster located around the harbor area, which expanded from west to east. Among homosexual cases, in situ growth predominated, and a decrease in the intensity of the diffusion process was observed from the second to the final period. Among heterosexual cases, the epidemic displayed a relevant geographic spread, mainly from 1988-1990 to 1991-1993. Among female cases in the final time period, a cluster of high incidence rates was found towards the northwest, including very poor areas. Among pediatric cases in 1991-1996, a significant correlation was found between AIDS incidence rates and poverty levels in the respective municipal districts. The results suggest that a more complete understanding of AIDS spatial-temporal dynamics can make a major contribution to preventive measures.

The place behind the case: leptospirosis risks and associated environmental conditions in a flood-related outbreak in Rio de Janeiro

The environmental context in which a leptospirosis outbreak took place during the summer of 1996 in the Rio de Janeiro Western Region was examined by using spatial analysis of leptospirosis cases merged with socio-demographic data using Geographic Information System (GIS). Risk areas were mapped based on flood and solid waste accumulation information for the region. Incidence rates were calculated for each area by the division of number of cases per total population in the specific areas. Higher rates were observed for census tracts inside the flood risk area and in the vicinities of waste accumulation sites. These findings are in agreement with the expected risk of leptospirosis, evidencing the role of environmental and collective factors in the determination of the disease.

Unsupported valvuloplasty in children with congenital mitral valve anomalies. Late clinical results

OBJECTIVE

To analyze late clinical evolution after surgical treatment of children, with reparative and reconstructive techniques without annular support.

METHODS

We evaluated 21 patients operated upon between 1975 and 1998. Age 4.67+/-3.44 years; 47.6% girls; mitral insufficiency 57.1% (12 cases), stenosis 28.6% (6 cases), and double lesion 14.3% (3 cases). The perfusion 43.10+/-9.50 min, and ischemia time were 29.40+/-10.50 min. The average clinical follow-up in mitral insufficiency was 41.52+/-53.61 months. In the stenosis group (4 patients) was 46.39+/-32.02 months, and in the double lesion group (3 patients), 39.41+/-37.5 months. The echocardiographic follow-up was in mitral insufficiency 37.17+/-39.51 months, stenosis 42.61+/-30.59 months, and in the double lesion 39.41+/-37.51 months.

RESULTS

Operative mortality was 9.5% (2 cases). No late deaths occurred. In the group with mitral insufficiency, 10 (83.3%) patients were asymptomatic (p=0.04). The majority with mild reflux (p=0.002). In the follow-up of the stenosis group, all were in functional class I (NYHA); and the mean transvalve gradient varied between 8 and 12 mmHg, average of 10.7 mmHg. In the double lesion group, 1 patient was reoperated at 43 months. No endocarditis or thromboembolism were reported.

CONCLUSION

Mitral stenosis repair has worse late results, related to the valve abnormalities and associated lesions. The correction of mitral insufficiency without annular support showed good long-term results.

[Organization and quality of health care for Kaingáng Indians in Rio Grande do Sul, Brazil]

This study assesses the health care provided to Kaingáng Indians in Rio Grande do Sul, Brazil. Deaths preventable by primary health care among the Indians and occurring from 1985 to 1995 were compared to the same rates for the State of Rio Grande do Sul as a whole. Secondary data on health care services were supplemented by field interviews with indigenous leaders and with employees from participating institutions. A Geographic Information System (GIS) was used to correlate distribution of deaths and access to health services. The Kaingáng settlements are connected by paved roads to counties with at least a public health clinic or even a small hospital in some cases. Secondary referrals are treated in Palmeiras das Missões and Frederico Westphallen and tertiary care is provided in Passo Fundo. What distinguishes the Indian settlements from the rest of the State are the high rates of deaths preventable by primary health care and those related to ill-defined conditions, malnutrition, tuberculosis, and cancer of the uterine cervix.

Human immunodeficiency virus/acquired immunodeficiency syndrome and tropical diseases: a Brazilian perspective

The paper summarizes recent findings on the epidemiology and pathogenesis of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/Aids), highlighting the role of co-infections with major tropical diseases. Such co-infections have been studied in the Brazilian context since the beginning of the Aids epidemic and are expected to be more frequent and relevant as the Aids epidemic in Brazil proceeds towards smaller municipalities and the countryside, where tropical diseases are endemic. Unlike opportunistic diseases that affect basically the immunocompromised host, most tropical diseases, as well as tuberculosis, are pathogenic on their own, and can affect subjects with mild or no immunosuppression. In the era of highly active anti-retroviral therapies (HAART), opportunistic diseases seem to be on decrease in Brazil, where such medicines are fully available. Benefiting from HAART in terms of restoration of the immune function, putative milder clinical courses are expected in the future for most co-infections, including tropical diseases. On the other hand, from an ecological perspective, the progressive geographic diffusion of Aids makes tropical diseases and tuberculosis a renewed challenge for Brazilian researchers and practitioners dealing with HIV/Aids in the coming years.

Valve repair in children with congenital mitral lesions: late clinical results

Mitral valve repair may be performed without ring support with advantages related to results and complications. The objective of this study was to analyze the long-term clinical results following surgical repair and reconstruction without the use of rings in cases of congenital mitral lesions in children less than 12 years of age. Twenty-one patients who had undergone surgery during the period from 1975 to 1998 were evaluated. The mean age was 4.6 +/- 3.4 years. Females represented 47.6% of the total. Mitral regurgitation was present in 57.1% (12 patients), stenosis in 28.6% (6 patients), and the mixed lesion group represented 14.3% (3 patients). Perfusion time was 43.1 +/- 9.5 minutes and ischemic time 29.4 +/- 10.5 minutes. Follow-up time was 41.5 +/- 53.6 months for the regurgitation group, 46.3 +/- 32.0 months for the stenosis group, and 39.41 +/- 37.51 months for the mixed lesion group. Echocardiographical follow-up time was 37.17 +/- 39.51 months for the regurgitation group, 42.61 +/- 30.59 months for the stenosis group, and 39.41 +/- 37.51 months for the mixed lesion group. Operative mortality was 9.5% (two cases). There were no late deaths. In the regurgitation group, 10 patients (83.3%) were asymptomatic (p = 0.004). In the echocardiographical follow-up, most of the patients had minimal regurgitation. In the clinical follow-up of the stenosis group all patients were in functional class I (NYHA). The mean transvalvular gradient measured by echocardiography was from 8 to 12 mmHg with a mean gradient of 10.7 mmHg. In the mixed lesion group there was one reoperation at postoperative month 43. There were no cases of endocarditis or thromboembolism. Mitral valve repair in congenital lesions is associated with good late results. The majority of cases in the regurgitation group remain asymptomatic and do not require reoperation. Rings or annular support are not necessary in such cases. Satisfactory repair is more difficult to achieve in cases of mitral stenosis due to valvular abnormalities and the seriousness of the associated lesions.

Socio-environmental determinants of the leptospirosis outbreak of 1996 in western Rio de Janeiro: a geographical approach

The environmental and social context in which a leptospirosis outbreak took place during the summer of 1996 in the Rio de Janeiro Western Region was examined by using spatial analysis of leptospirosis cases merged with population and environmental data in a Geographical Information System (GIS). Important differences were observed between places where residences of leptospirosis cases are concentrated and other places in the region. Water supply coverage, solid waste collection, sewerage system coverage and flood risk area were the main determining variables from an initial list of ten. The influence of these unfavorable social and environmental factors is verified hundreds of meters distant from the leptospirosis case residences, demonstrating a necessity to broaden the area of health surveillance practices. The geocoding indicated that some cases did not report contact with flood water, even though they were geographically adjacent to cases who did report this contact. Cases may only report exposures they believe are related to the disease. Geocoding is a useful tool for evaluating such bias in the exposure recall.

Health conditions and residential concentration of poverty: a study in Rio de Janeiro, Brazil

STUDY OBJECTIVES

To establish the geographical relation of health conditions to socioeconomic status in the city of Rio de Janeiro, Brazil.

DESIGN

All reported deaths in the municipality of Rio de Janeiro, from 1987 to 1995, obtained from the Mortality Information System, were considered in the study. The 24 "administrative regions" that compose the city were used as the geographical units. A geographical information system (GIS) was used to link mortality data and population census data, and allowed the authors to establish the geographical pattern of the health indicators considered in this study: "infant mortality rate"; "standardised mortality rate"; "life expectancy" and "homicide rate". Information on location of low income communities (slums) was also provided by the GIS. A varimax rotation principal component analysis combined information on socioeconomic conditions and provided a two dimension basis to assess contextual variation.

MAIN RESULTS

The 24 administrative regions were aggregated into three different clusters, identified as relevant to reflect the socioeconomic variation. Almost all health indicator thematic maps showed the same socioeconomic stratification pattern. The worst health situation was found in the cluster composed of the harbour area and northern vicinity, precisely in the sector where the highest concentration of slum residents are present. This sector of the city exhibited an extremely high homicide rate and a seven year lower life expectancy than the remainder of the city. The sector that concentrates affluence, composed of the geographical units located along the coast, showed the best health situation. Intermediate health conditions were found in the west area, which also has poor living standards but low concentration of slums.

CONCLUSIONS

The findings suggest that social and organisation characteristics of low income communities may have a relevant role in understanding health variations. Local health and other social programmes specifically targeting these communities are recommended.

Co-infection with malaria and HIV in injecting drug users in Brazil: a new challenge to public health?

AIMS

To describe AIDS and malaria geography in Brazil, highlighting the role of injecting drug users (IDUs) in malaria outbreaks occurring in malaria-free regions, and the potential clinical and public health implications of malaria/HIV co-infection.

DESIGN

Review of the available literature and original analyses using geoprocessing and spatial analysis techniques.

FINDINGS

Both HIV/AIDS and malaria distribution are currently undergoing profound changes in Brazil, with mutual expansion to intersecting geographical regions and social networks. Very recent reports describe the first clinical case of AIDS in a remote Amazonian ethnic group, as well as malaria cases in Rio de Janeiro state (hitherto a malaria-free area for 20 years); in addition, two outbreaks of both infections occurred at the beginning of the 1990s in the most industrialized Brazilian state (São Paulo), due to the sharing of needles and syringes by drug users. Spatial data point to: (a) the expansion of HIV/AIDS towards malarigenic areas located in the centre-west and north of Brazil, along the main cocaine trafficking routes, with IDU networks apparently playing a core role; and (b) the possibility of new outbreaks of secondary malaria in urban settings where HIV/AIDS is still expanding, through the sharing of needles and syringes.

CONCLUSIONS

New outbreaks of cases of HIV and malaria are likely to occur among Brazilian IDUs, and might conceivably contribute to the development of treatment-resistant strains of malaria in this population. Health professionals should be alert to this possibility, which could also eventually occur in IDU networks in developed countries.

[Linkage of environmental and health data: health risk analysis of the Rio de Janeiro water supply by using geographical information systems]

Exposure assessment of population groups is based on linkage of environmental and health data. This relationship can be hard to establish due to spatial and temporal lags in data sets. Environmental data generally refer to scattered sampling points, while epidemiological data integrate periods of time within administrative territories. GIS can be used as a basis for organizing health-related and environmental data sets. We examined potential health risk in the Rio de Janeiro city water supply based on the overlay of information layers containing data on the presence and quality of water supply services. We used census tracts as the primary georeferenced data, since they contain information on how households are supplied, water supply pipes, sources, and reservoirs, and water quality according to the monitoring program. Population groups exposed to risks were located and quantified using spatial operations among these layers and adopting different risk criteria. The main problems related to water supply are located on the northern slope of the Tijuca Mountain Range (involving the absence or poor quality of water) and in the western area of the city of Rio, where the population relies on alternative water supply sources. The different origins, objectives, and structures of data have to be analyzed critically, and GIS can be used as a data validation tool as well as an instrument for detailed identification of inconsistencies.

A organização espacial condiciona as relações entre ambiente e saúde: o exemplo da exposição ao mercúrio em uma fábrica de lâmpadas fluorescentes

O espaço tem sido utilizado nas análises que relacionam o ambiente com a saúde, ora como simples plano geométrico para a disposição de dados epidemiológicos, ora como uma aproximação para a diferenciação de condições sociais, ou mesmo como uma circunstância de fatores espaciais que induzem risco. Neste trabalho são descritas as três principais abordagens espaciais em saúde e suas limitações. O uso do geoprocessamento na área de saúde tem sido facilitado pelo amplo acesso a bases de dados epidemiológicos e pela disponibilização de ferramentas cartográficas e estatísticas computadorizadas. O uso desta ferramenta pressupõe, no entanto, modelos de explicação do processo saúde/doença, que são baseados em variáveis espaciais como a distância, vizinhança, e o interrelacionamento com dados de caracterização do lugar. O exemplo de uma fábrica de lâmpadas fluorescentes permite compreender o espaço como mediador de relações sociais. A localização e atividade dos trabalhadores na fábrica condicionam os riscos a que estes estarão submetidos. Através da análise espacial de indicadores de emissão, contaminação e exposição ao mercúrio, foi possível identificar áreas e atividades de risco aos trabalhadores. Estes fatores, por sua vez, estão intrinsecamente ligados à organização interna e externa da produção.

[Social networks and diffusion of AIDS in Brazil]

The HIV/AIDS epidemic has been simplistically interpreted as a phenomenon restricted to risk groups that are socially and spatially circumscribed. However, epidemic trends in recent years have demonstrated the need to employ open diffusion models that emphasize social interaction as a means of spread of HIV. This study is a spatial analysis of the AIDS epidemic in Brazil, which sought to incorporate variables reflecting economic and demographic events into a system for processing geographically referenced health information. Findings indicate that metropolises and regional urban centers, mainly those in the Southeast, play an important role in the spread of the epidemic, not only because of their population density but also because they are centers of trade and social interaction. In smaller cities located in the state of São Paulo, a large number of AIDS cases among injecting drug users are concentrated, revealing the routes and centers of cocaine use.

[The social geography of AIDS in Brazil]

The first of a series of papers concerning the evaluation of the dynamics of the AIDS epidemic in Brazil employing techniques of geographical analysis, is here presented. Results of research undertaken in the US (especially in New York City) are compared with those of a recent investigation carried out in the city of S.Paulo, Brazil (Grangeiro, 1994). In both, geographical patterns of socio-demographic variables correlate with different patterns of the spread of the AIDS epidemic through the transmission groups. Recent trends of the AIDS epidemic in Brazil: the displacement toward medium sized cities and expansion frontiers, increasing report of AIDS cases among the poor and underprivileged, changes in the pattern of transmission with proportional augmentation of heterosexual transmission and IDUs as transmission groups, are described and analysed. The geographical distribution of the AIDS cases registered between 1987-1993 in Brazil throughout the Brazilian States is evaluated by means of worksheets, maps, and non-parametric statistics. Results show that Gravimetric Centers (obtained by the use of the calculus spatial means) of AIDS in Brazil are situated within a triangle the sides of which are formed lines joining the three main metropolitan areas of the wealthiest region of Brazil--the southeast, i.e. São Paulo, Rio de Janeiro and Belo Horizonte. These especially S. Paulo, function as points of attraction for these Gravimetric Centers (GCs) towards the south as compared with the GCs of the general population calculated ia accordance with data from the 1980 and 1991 censuses. It is possible to observe a displacement of the GCs toward the northwest over this period in accordance with the migration patterns of the Brazilian population in general, though with a dynamic of its own. These changes in the geographical, socio-demographic and transmission group patterns show the complex nature of the epidemic in Brazil and pose additional difficulties for the development of prevention strategies.

Cadmium and zinc source assessment in the Sepetiba Bay and basin region

Industrial and weathering inputs of Cd and Zn to the Sepetiba Bay and basin were assessed, based on production parameters obtained from local environment and industry authorities, and literature data. The results are compared with similar evaluations from other coastal regions and field data obtained in measuring Zn and Cd transport by rivers, direct run-off and atmospheric deposition in the region. Cadmium and zinc inputs to the bay increased by three orders of magnitude relative to pre-industrial fluxes and presently reach up to 1.6 and 180 tonnes per year for Cd and Zn, respectively, which represents a large input-to-area ratio, and explains the high concentration of these metals previously reported in the estuarine biota and sediments of Sepetiba Bay. Industrial activities, mainly metallurgical and chemical, comprise 94% and 84% of the total Cd and Zn inputs to the Bay. This figure identifies the point sources as being responsible for the environmental contamination and for regional poisoning risks.