[Spatial analysis of integrated health and environmental indicators for morbidity and mortality due to infant diarrhea in Brazil, 2010]

The Determinants of Infant Mortality in Brazil, 2010-2020: A Scoping Review

Despite the implementation of social and health policies that positively affected the health of the populations in Brazil, since 2009 the country has experienced a slower decline of infant mortality. After an economic and political crisis, Brazil witnessed increases in infant mortality that raised questions about what are the determinants of infant mortality after the implementation of such policies. We conducted a scoping review to identify and summarize those determinants with searches in three databases: LILACS, MEDLINE, and SCIELO. We included studies published between 2010 and 2020. We selected 23 papers: 83% associated infant mortality with public policies; 78% related infant mortality with the use of the health system and socioeconomic and living conditions; and 27% related to individual characteristics to infant mortality. Inequalities in the access to healthcare seem to have important implications in reducing infant mortality. Socioeconomic conditions and health-related factors such as income, education, fertility, housing, and the Bolsa Família. Program coverage was pointed out as the main determinants of infant mortality. Likewise, recent changes in infant mortality in Brazil are likely related to these factors. We also identified a gap in terms of studies on a possible association between employment and infant mortality.

Health capabilities and the determinants of infant mortality in Brazil, 2004-2015: an innovative methodological framework

BACKGROUND

Despite the implementation of a set of social and health policies, Brazil has experienced a slowdown in the decline of infant mortality, regional disparities and persistent high death levels, raising questions about the determinants of infant mortality after the implementation of these policies. The objective of this article is to propose a methodological approach aiming at identifying the determinants of infant mortality in Brazil after the implementation of those policies.

METHOD

A series of multilevel panel data with fixed effect nested within-clusters were conducted supported by the concept of health capabilities based on data from 26 Brazilian states between 2004 and 2015. The dependent variables were the neonatal, the infant and the under-five mortality rates. The independent variables were the employment rate, per capita income, Bolsa Família Program coverage, the fertility rate, educational attainment, the number of live births by prenatal visits, the number of health professionals per thousand inhabitants, and the access to water supply and sewage services. We also used different time lags of employment rate to identify the impact of employment on the infant mortality rates over time, and household income stratified by minimum wages to analyze their effects on these rates.

RESULTS

The results showed that in addition to variables associated with infant mortality in previous studies, such as Bolsa Família Program, per capita income and fertility rate, other factors affect child mortality. Educational attainment, quality of prenatal care and access to health professionals are also elements impacting infant deaths. The results also identified an association between employment rate and different infant mortality rates, with employment impacting neonatal mortality up to 3 years and that a family income below 2 minimum wages increases the odds of infant deaths.

CONCLUSION

The results proved that the methodology proposed allowed the use of variables based on aggregated data that could hardly be used by other methodologies.

Combination of conditional cash transfer program and environmental health interventions reduces child mortality: an ecological study of Brazilian municipalities

BACKGROUND

This study aims to assess the interactive effects of Brazilian public interventions, environmental health programs (access to water, sanitation and solid waste collection) and a Conditional Cash Transfer Program (PBF), on the mortality reduction due to diarrhea and malnutrition among children under 5 years old.

METHODS

The study design is ecological, with longitudinal analysis in a balanced panel. The period covered is 2006 to 2016, including 3467 municipalities from all regions of the country, which resulted in 38,137 observations. The generalized linear models were adjusted considering the Negative Binomial (NB) distribution for the number of deaths due to malnutrition and diarrhea, with fixed effects. NB models with and without zero-inflation were assessed. Subsequent interaction models were applied to assess the combined effects of the two public policies.

RESULTS

In relation to the decline of mortality rates due to diarrhea in the municipalities, positive effect modification were observed in the presence of: high coverage of the target population by the PBF and access to water, 0.54 (0.28-1.04) / 0.55 (0.29-1.04); high coverage by the total population by the PBF and access to water, 0.97 (0.95-1.00) and high coverage by the total population by the PBF and access to sanitation, 0.98 (0.97-1.00). Decline on diarrhea mortality was also observed in the joint presence of high coverage of solid waste collection and access to water, categories 1 (> 60% ≤85%): 0.98 (0.96-1.00), 0.98 (0.97-1, 00) and 2 (> 85% ≤ 100%): 0.97 (0.95-0.98), 0.97 (0.95-0.99). Negative effect modification were observed for mortality due to malnutrition in the presence of simultaneous high coverage of the total population by the PBF and access to sanitation categories 1 (≥ 20 < 50%): 1.0061 (0.9991-1.0132) and 2 (≥ 50 < 100%): 1.0073 (1.0002-1.0145) and high coverage of the total population by the PBF and solid waste collection, 1.0004 (1.0002-1.0005), resulting in malnutrition mortality rates increase.

CONCLUSION

Implementation of environmental health services and the coverage expansion by the PBF may enhance the prevention of early deaths in children under 5 years old due to diarrhea, a poverty related disease.

Combined effects of conditional cash transfer program and environmental health interventions on diarrhea and malnutrition morbidity in children less than five years of age in Brazil, 2006-2016

INTRODUCTION

Governmental measures aiming at social protection, with components of disease control, have potential positive impacts in the nutritional and health outcomes of the beneficiaries. The concomitant presence of these measures with environmental sanitation interventions may increase their positive effect. The context of simultaneous improvement of social protection and environmental sanitation is found in Brazil since 2007 and an assessment of the combined effects of both programs has not been performed so far.

OBJECTIVE

To evaluate whether interaction effects between improvement of access to water, sanitation and solid waste collection with the Bolsa Família Program [PBF] were related to better responses in the reduction of morbidity due to diarrhea and malnutrition in children less than five years of age, acknowledging the positive results of these improved conditions and the PBF separately in coping with these diseases.

METHODS

Descriptive and inferential analyses were performed through Generalized Linear Models of the Negative Binomial type of fixed effects, with and without addition of zeros. Interaction models were inserted in order to evaluate the outcomes when the two public policies of interest in the current study were present simultaneously in the municipalities.

RESULTS

Interaction with negative effect when a concomitantly high municipal coverage of the Bolsa Família Program and adequate access to sanitation and solid waste collection were present. In contrast, regardless of municipal coverage by the PBF, the simultaneous presence of water and sanitation (0.028% / 0.019%); water and solid waste collection (0.033% / 0.014%); sanitation and solid waste collection (0.018% / 0.021%), all resulted in a positive effect, with a decrease in the average morbidity rates for both diseases.

CONCLUSION

Investments aimed at universalizing water, sanitation and solid waste collection services should be priorities, aiming at reducing the incidence of morbidity due to malnutrition and diarrhea and preventing deaths from these poverty-related diseases.

Control and prevention of infectious diseases from a One Health perspective

The ongoing COVID-19 pandemic has caught the attention of the global community and rekindled the debate about our ability to prevent and manage outbreaks, epidemics, and pandemics. Many alternatives are suggested to address these urgent issues. Some of them are quite interesting, but with little practical application in the short or medium term. To realistically control infectious diseases, human, animal, and environmental factors need to be considered together, based on the One Health perspective. In this article, we highlight the most effective initiatives for the control and prevention of infectious diseases: vaccination; environmental sanitation; vector control; social programs that encourage a reduction in the population growth; control of urbanization; safe sex stimulation; testing; treatment of sexually and vertically transmitted infections; promotion of personal hygiene practices; food safety and proper nutrition; reduction of the human contact with wildlife and livestock; reduction of social inequalities; infectious disease surveillance; and biodiversity preservation. Subsequently, this article highlights the impacts of human genetics on susceptibility to infections and disease progression, using the SARS-CoV-2 infection as a study model. Finally, actions focused on mitigation of outbreaks and epidemics and the importance of conservation of ecosystems and translational ecology as public health strategies are also discussed.

FEEDING PRACTICES IN THE FIRST YEAR OF LIFE: CHALLENGES TO FOOD AND NUTRITION POLICIES

OBJECTIVE

To evaluate the feeding practices for infants under one year of age, according to food and nutrition policies.

METHODS

This is a descriptive cross-sectional study based on secondary data from the Chamada Neonatal project (research on prenatal, childbirth, and infant care) in the state of Rio Grande do Norte. The sample analyzed comprised 837 mother/child (under one year of age) pairs. We found a prevalence of data on exclusive breastfeeding (EBF) in the first hour of life - partial and total -, as well as on food consumed by children 24 hours prior to the interview. We estimated the probability of consumption according to the child's age in days using the probit analysis.

RESULTS

Among the interviewed mothers, 64.8% (95%CI 62.4-70.8) declared breastfeeding in the first hour of life, and 60% (95%CI 56.41-63.07) of the children were still breastfed at the end of their first year of life. The median duration of EBF was 63 days (95%CI 60-67). Water or tea, dairy products, fruits, and vegetables were introduced early, with medians lower than 180 days. The probit analysis revealed that the consumption of breast milk tended to decrease and food intake to increase as the child gets older, with exponential growth in the "unhealthy food" group.

CONCLUSIONS

Although most children were breastfed up to one year of life, few did so exclusively. Foods were introduced early, with increased consumption of unhealthy ones, resulting in inadequate dietary quality according to recommendations from food and nutrition public policies.

Fatores de risco para ocorrência de diarreia em crianças residentes na Ilha de Guaratiba (RJ)

RESUMO Este artigo visou analisar a ocorrência de diarreia aguda em crianças menores de 5 anos assistidas pela Estratégia Saúde da Família de Ilha de Guaratiba, e as condições habitacionais e de saneamento da localidade. Foi realizado um estudo epidemiológico transversal. A análise das variáveis foi feita por meio de regressão logística simples e múltipla. As variáveis que apresentaram associação com a diarreia foram: (a) criança de idade <2,5 anos; frequentar creche/escola e renda familiar <um salário mínimo; (b) presença de filtro de água e tratamento domiciliar da água; (c) presença de inundações, esgoto a céu aberto, transbordamento de fossa e lixo a céu aberto. No modelo de regressão logística, foram considerados dois cenários epidemiológicos, com e sem inundações. No primeiro cenário, as variáveis que mantiveram associação estatisticamente significante com o desfecho foram: tratamento domiciliar da água, esgoto a céu aberto e presença de inundações. No segundo cenário, encontrou-se evidência de associação também da variável frequência a creche/escola. Portanto, este artigo ressalta a importância de políticas públicas, programas e ações com vistas à ampliação do saneamento básico, ao planejamento de ações de saúde pública e à garantia do acesso à educação infantil.

[Basic sanitation and inequalities in color/race in urban households with under-five children, with a focus on the indigenous population]

This study aimed to analyze the presence of basic sanitation services in households with children under five years of age located in urban areas of Brazil, with a focus on indigenous children. This cross-sectional study was based on data from the 2010 Population Census. We calculated the rates of households with running water (public system), sewage disposal (public system or septic tanks), and garbage collection (directly or via public dumpsters). Multiple logistic regression (MLR) models were used to estimate associations between color/race and presence of sanitation services, based on odds ratios (OR). The study considered Brazil's urban metropolitan areas and stratified the results by major geographic region. Significance was set at 5%. The lowest frequencies were for sewage disposal, and all the rates were lower for indigenous people. MLR analyses included 29 comparisons (48.3%) in which households with indigenous children (compared to other color/race categories) were at a disadvantage, especially in the South of Brazil, where all comparisons were negative for indigenous households. Similar results appeared in metropolitan areas. The results thus suggest inequalities basic sanitation services based on color/race, where indigenous people are generally at a disadvantage, especially in the South of Brazil. Given the relationship between sanitation and health, as already demonstrated in the literature, these results can partly explain the low health levels in indigenous children in Brazil.

Socio-environmental factors and diarrheal diseases in under five-year old children in the state of Tocantins, Brazil

BACKGROUND

Diarrhea is a waterborne disease that affects children, especially those under 5 years of age. The objective of this study was to identify the spatial patterns of distribution of diarrheal disease in under 5-year-old children in the State of Tocantins, Brazil, from 2008 to 2013.

METHODS

Geoprocessing tools were used to carry out an epidemiological study, to prepare thematic maps in the TerraView 4.2.2 software based on secondary data. General indicators of the disease, presence of spatial dependence through the Global Moran's Index (I) and the Spatial Association Index (LISA) were described.

RESULTS

There were 3,015 cases of under 5-year-old children hospitalized for diarrhea, with an average annual rate (AAR) of 4.10/1,000 inhabitants (inhab.). Among the main characteristics were: increasing rates in under 1-year-old children (6.16 to 9.66/1,000 inhabitants); children aged 1 to 4 full years (63%); males (55%); 8 deaths of under one-year-old children (75%); county of Araguaína (67%); incidence in the county of Nazaré (63.97/1,000 inhab.); prevalence and incidence in the Araguaína microregion (45%, AAR 9.38/1,000 inhab.). The presence of a cluster with spatial autocorrelation was found in the Araguaína microregion, which was statistically significant (I = 0.11, p-value < 0.03), with priority of intervention (Moran Map).

CONCLUSIONS

There was an increase in the number of hospitalizations for diarrhea in under 5-year-old children in the state of Tocantins. The spatial analysis identified clusters of priority areas for measures of maintenance and control of diarrheal diseases.

Condições de saneamento e desigualdades de cor/raça no Brasil urbano: uma análise com foco na população indígena com base no Censo Demográfico de 2010

RESUMO: Objetivo: Os objetivos deste estudo foram analisar e descrever a presença da infraestrutura de saneamento básico nas áreas urbanas do Brasil, contrastando os perfis dos domicílios indígenas com os de não indígenas. Métodos: Trata-se de um estudo transversal com base nos microdados do Censo 2010. As análises foram baseadas em estatísticas descritivas (prevalências) e na construção de modelos de regressão logística múltipla (ajustados por covariáveis socioeconômicas e demográficas). Estimaram-se as razões de chance para a associação entre as variáveis explicativas (covariáveis) e de desfecho (abastecimento de água, esgotamento sanitário, coleta de lixo e saneamento adequado). O nível de significância estatística estabelecido foi de 5%. Resultados: Entre os serviços analisados, o esgotamento sanitário mostrou-se o mais precário. Em relação à cor ou raça, os domicílios com responsáveis indígenas apresentaram as menores frequências de presença de infraestrutura sanitária no Brasil Urbano. Os resultados das regressões ajustadas mostraram que, em geral, os domicílios indígenas se encontram em desvantagem quando comparados aos de outras categorias de cor ou raça, especialmente quanto à presença do serviço de coleta de lixo. Essas desigualdades foram de maior magnitude nas regiões Sul e Centro-Oeste. Conclusão: As análises deste estudo não somente confirmam o perfil de precárias condições de infraestrutura de saneamento básico dos domicílios indígenas em área urbana, como também evidenciam a persistência de iniquidades associadas à cor ou raça no país.

Use of oral rehydration therapy in the treatment of childhood diarrhoea in Douala, Cameroon

INTRODUCTION

The use of oral rehydration solutions in our context remains limited. This study was conducted to analyze the rate of this use in Douala, Cameroon and thereby determine the factors associated with it.

METHOD

A cross-sectional survey was administered to parents of children aged five years and younger during a six-month study period. The studied variables focused on the socio-demographic data of the population, data on diarrhoea and its severity, data on oral rehydration salts (ORS), and data related to other interventions for diarrhoea. The chi-square test was used to qualify associations between variables, with the significance level being set at 5%.

RESULTS

Overall, 672 people agreed to participate in the study. Among them, 418 (62.2%) correctly defined diarrhoea. When their children develop diarrhoea, the majority of the parents (348, 51.8%) reported seeking hospital assistance before any intervention, while 225 parents (33.5%) preferred the use of ORS first. Four hundred seventy-five parents (70.7%) had heard of ORS and among them 313 (65.9%) had actually given ORS to their children as treatment during these children's most recent episodes of diarrhoea. Of the parents who had given their children ORS, 217 (69.3%) knew how to prepare it, and 122 (39.0%) knew how to administer it. One hundred thirty-five parents (20.1%) had administered metronidazole to treat their children's diarrhoea. The age of the children, the parents' level of education, and the number of children in the household significantly influenced the use or non-use of ORS (respectively, p < 0.001, p = 0.003 and p < 0.0001). Rehydration was correctly identified by 234 parents (34.8%) as the purpose of administering ORS.

CONCLUSION

The knowledge and the use of ORS in diarrhoea by the study sample was insufficient. The role of ORS was poorly known. Awareness campaigns can be carried out in order to improve the use of this effective intervention for diarrhoea.