Specificities and challenges of public health policies in the Brazilian Amazon

Study of machine learning techniques for outcome assessment of leptospirosis patients

Leptospirosis is a global disease that impacts people worldwide, particularly in humid and tropical regions, and is associated with significant socio-economic deficiencies. Its symptoms are often confused with other syndromes, which can compromise clinical diagnosis and the failure to carry out specific laboratory tests. In this respect, this paper presents a study of three algorithms (Decision Tree, Random Forest and Adaboost) for predicting the outcome (cure or death) of individuals with leptospirosis. Using the records contained in the government National System of Aggressions and Notification (SINAN, in portuguese) from 2007 to 2017, for the state of Pará, Brazil, where the temporal attributes of health care, symptoms (headache, vomiting, jaundice, calf pain) and clinical evolution (renal failure and respiratory changes) were used. In the performance evaluation of the selected models, it was observed that the Random Forest exhibited an accuracy of 90.81% for the training dataset, considering the attributes of experiment 8, and the Decision Tree presented an accuracy of 74.29 for the validation database. So, this result considers the best attributes pointed out by experiment 10: time first symptoms medical attention, time first symptoms ELISA sample collection, medical attention hospital admission time, headache, calf pain, vomiting, jaundice, renal insufficiency, and respiratory alterations. The contribution of this article is the confirmation that artificial intelligence, using the Decision Tree model algorithm, depicting the best choice as the final model to be used in future data for the prediction of human leptospirosis cases, helping in the diagnosis and course of the disease, aiming to avoid the evolution to death.

Effect of long COVID-19 syndrome on health-related quality of life: a cross-sectional study

Purpose

This study aimed to assess the association of anxiety, headache, and insomnia on the QoL of patients with long COVID-19.

Methods

We conducted a cross-sectional survey between August 2020 and March 2023. A total of 200 participants were eligible, 53 were excluded and 147 patients with long COVID were included. QoL was evaluated across eight domains using the 36-Item Short Form Health Survey (SF-36). Standardized protocols including the Beck Anxiety Inventory (BAI) (n = 103), Pittsburgh Sleep Quality Index (PSQI) (n = 73), and Migraine Disability Assessment (MIDAS) (n = 67) were also used.

Results

Participants with sleep disorders had significantly lower Vitality (p < 0.001). Participants with anxiety disorders had significantly lower Vitality (p = 0.001), poorer Mental Health (p = 0.008), and more severe Bodily Pain (p = 0.008). Participants with headache had significantly lower Vitality (p = 0.032), poorer Mental Health (p = 0.036), and poorer Physical Functioning (p = 0.016). Participants with both headache and anxiety had significantly lower Vitality (p = 0.005) and Mental Health (p = 0.043) domain scores. Correlation analysis revealed that higher scores for anxiety, sleep disorder, and headache were independently correlated with poorer QoL across various domains. The presence of sleep disorder was associated with a fourfold increase in risk of experiencing diminished Vitality (odds ratio [OR]4.47; 95% CI 1.01-19.69; p = 0.048).

Conclusion

Participants with anxiety, sleep, and headache disorders tended to have a worse QoL. The Vitality and Mental Health domains were the most adversely affected in patients with long COVID. Sleep disorders were associated with a fourfold increase in the risk of poor Vitality.

Heat waves and mortality in the Brazilian Amazon: Effect modification by heat wave characteristics, population subgroup, and cause of death

BACKGROUND

The Brazilian Amazon faces overlapping socio-environmental, sanitary, and climate challenges, and is a hotspot of concern due to projected increases in temperature and in the frequency of heat waves. Understanding the effects of extreme events on health is a central issue for developing climate policies focused on the population's health.

OBJECTIVES

We investigated the effects of heat waves on mortality in the Brazilian Amazon, examining effect modification according to various heat wave definitions, population subgroups, and causes of death.

METHODS

We included all 32 Amazonian municipalities with more than 100,000 inhabitants. The study period was from 2000 to 2018. We obtained mortality data from the Information Technology Department of the Brazilian Public Healthcare System, and meteorological data were derived from the ERA5-Land reanalysis dataset. Heat waves were defined according to their intensity (90th; 92.5th; 95th; 97.5th and 99th temperature percentiles) and duration (≥2, ≥3, and ≥4 days). In each city, we used a time-stratified case-crossover study to estimate the effects of each heat wave definition on mortality, according to population subgroup and cause of death. The lagged effects of heat waves were estimated using conditional Poisson regression combined with distributed lag non-linear models. Models were adjusted for specific humidity and public holidays. Risk ratios were pooled for the Brazilian Amazon using a univariate random-effects meta-analysis.

RESULTS

The pooled relative risks (RR) for mortality from total non-external causes varied between 1.03 (95% CI: 1.01-1.06), for the less stringent heat wave definition, and 1.18 (95% CI: 1.04-1.33) for the more stringent definition. The mortality risk rose as the heat wave intensity increased, although the increase from 2 to 3, and 3-4 days was small. Although not statistically different, our results suggest a higher mortality risk for the elderly, this was also higher for women than men, and for cardiovascular causes than for non-external or respiratory ones.

CONCLUSIONS

Heat waves were associated with a higher risk of mortality from non-external causes and cardiovascular diseases. Heat wave intensity played a more important role than duration in determining this risk. Suggestive evidence indicated that the elderly and women were more vulnerable to the effects of heat waves on mortality.

[Care accessibility and availability for hypertensive patients in primary health care in a remote rural municipality in the state of Amazonas, Brazil, 2019]

This single-case study aimed to evaluate access the geographic accessibility and availability of primary health care (PHC) in a remote rural municipality in Amazonas Stater, Brazil, to control systemic arterial hypertension. A thematic analysis was conducted to interpret the content of 11 semi-structured interviews with municipal managers, PHC professionals, and hypertensive healthcare users. Geographical accessibility is associated with river mobility, transportation availability, users' financial travelling condition, and the presence of services near riverine communities, whereas availability to diagnose and monitor hypertensive patients depend on the presence of healthcare providers, medications, and equipment and the integration of PHC with the local health care network. Although access to health is more complex than our research goals, the evaluated dimensions show weaknesses which are exacerbated by a context marked by socio-spatial disparities and absent public policies, compromising the guarantee of individuals' right to health.

Hunger and its associated factors in the western Brazilian Amazon: a population-based study

BACKGROUND

Hunger affects millions of people worldwide. In the current pandemic scenario of coronavirus Brazil has experienced an epidemic peak of hunger, amplifying existing prepandemic vulnerabilities, mainly in the North Region of the country. The aim of the present study was to investigate the prevalence of food insecurity and its associated factors in homes with children under 5 years of age in an urban area of a municipality of the western Brazilian Amazon.

METHODS

A household survey was conducted with a probabilistic sample of 557 children and their families. Food insecurity (FI) was determined using the Brazilian Food Insecurity Scale. Associations between variables were analyzed based on the prevalence ratio (PR) and respective 95% confidence intervals (CI) calculated through multiple Poisson regression analysis. Variables with a P value < 0.05 after adjustments were considered significantly associated with the outcome.

RESULTS

A prevalence of 76.5% (CI 1.36-2.67) food insecurity was found among the families in the study; 42.9% had moderate (CI 1.31-2.83) and severe (CI 1.10-1.83) food insecurity. Moderate and severe FI was associated with low family income (P = 0.00), participation in governmental income transfer programs (P = 0.01), and heads of household with less than 7 years of schooling (P = 0.02). Moreover, substantial frequencies of height deficit and being overweight were found among the children.

CONCLUSIONS

The high prevalence of hunger and food insecurity and its associated factors reflects the context of geographic isolation and social exclusion in which these families live, suggesting that a substantial portion of the population under 5 years of age had experienced episodes of hunger in the 90 days prior to the survey. The prevalence of height deficit and being overweight among the children reveals a scenario of epidemiological/nutritional polarization, requiring the formulation of specific public policies for this population.

Primary Health Care sustainability in rural remote territories at the fluvial Amazon: organization, strategies, and challenges

The article analyzes singularities of the Primary Health Care (PHC) organization in rural remote municipalities (RRM) in the Amazon under the influence of rivers and discusses challenges for comprehensive care in the Unified Health System (SUS). This is a qualitative and quantitative study of multiple cases in seven RRM through the analysis of interviews with managers, visits to services and secondary data. The RRM of the fluvial Amazon are small, with a sparse, dispersed population living in conditions of social vulnerability. Long distances, rivers and transport irregularities interfere with access to PHC services. The Family Health Strategy is implemented in the municipal system, however areas without assistance coverage, unavailability of PHC services and adaptations to the Strategy imposed by the characteristics of the context remain. The challenges are related to the financing, provision and fixation of the workforce and barriers of geographic access compromise the PHC response capacity in SUS. PHC sustainability requires strategic measures, resources and actions from multiple sectors and public agents; national support policies with feasibility for local execution, so that PHC services are established and make sense in such unique spaces.

Health services utilization in the Brazilian Amazon: panel of two cross-sectional studies

OBJECTIVE

To investigate the use of health services among adults living in Manaus, Amazonas.

METHODS

This was a panel of two cross-sectional studies conducted in Manaus in 2015 and 2019. Individuals aged ≥ 18 years were selected by probabilistic sampling and interviewed at home. The study outcomes were doctor visits and hospitalizations in the previous 12 months, and unmet surgical needs. Variations between 2015 and 2019 were tested using chi-squared goodness-of-fit test. Poisson regression with robust variance was employed to calculate the prevalence ratios (PR) of the outcomes with 95% confidence intervals (95%CI).

RESULTS

The surveys included 5,800 participants in total. Visits to the doctor decreased from 2015 (78.7%) to 2019 (76.3%; p < 0.001), hospital admissions increased from 2015 (7.9%) to 2019 (11.5%; p < 0.001), and unmet surgical needs decreased in the period (15.9% to 12.1%; p < 0.001). These variations were particularly observed in vulnerable individuals – sicker; poorer; non-whites; and those belonging to lower social classes, with less access to education, formal jobs, and health insurance (p < 0.05). Doctor visits were higher in people with fair health status (PR = 1.09; 95%CI 1.06–1.12), health insurance (PR = 1.13; 95%CI 1.09–1.17), and chronic diseases (p < 0.001) but lower in men (PR = 0.87; 95%CI 0.84–0.90) and informal workers (PR = 0.89; 95%CI 0.84–0.94). Hospitalizations were higher in people with worse health statuses (p < 0.001), without partners (PR = 1.27; 95%CI 1.05–1.53), and with multimorbidity (PR = 1.68; 95%CI 1.33–2.12) but lower in men (PR = 0.55; 95%CI 0.44–0.68), older adults (p < 0.001), informal workers (PR = 0.67; 95%CI 0.51–0.89), and unemployed (PR = 0.72; 95%CI 0.53–0.97). Unmet surgical needs were higher in older adults (p < 0.001), middle-class people (PR = 1.24; 95%CI 1.01–1.55), worse health statuses (p < 0.001), and chronic diseases (p < 0.001) but lower in men (PR = 0.76; 95%CI 0.65–0.86).

CONCLUSIONS

From 2015 to 2019, less people visited the doctor, more were admitted to hospitals, and less were in need of surgery or aware of that need, potentially indicating poorer access to health services.

Challenges of Rabies Surveillance in the Eastern Amazon: The Need of a One Health Approach to Predict Rabies Spillover

Brazil has been promoting essential improvements in health indicators by implementing free-access health programs, which successfully reduced the prevalence of neglected zoonosis in urban areas, such as rabies. Despite constant efforts from the authorities to monitor and control the disease, sylvatic rabies is a current issue in Amazon's communities. The inequalities among Amazon areas challenge the expansion of high-tech services and limit the implementation of active laboratory surveillance to effectively avoid outbreaks in human and non-human hosts, which also reproduces a panorama of vulnerability in risk communities. Because rabies is a preventable disease, the prevalence in the particular context of the Amazon area highlights the failure of surveillance strategies to predict spillovers and indicates the need to adapt the public policies to a “One Health” approach. Therefore, this work assesses the distribution of free care resources and facilities among Pará's regions in the oriental Amazon; and discusses the challenges of implanting One Health in the particular context of the territory. We indicate a much-needed strengthening of the sylvatic and urban surveillance networks to achieve the “Zero by 30” goal, which is inextricable from multilateral efforts to combat the progressive biome's degradation.

A painful journey to antivenom: The therapeutic itinerary of snakebite patients in the Brazilian Amazon (The QUALISnake Study)

Access to antivenoms is not guarranteed for vulnerable populations that inhabit remote areas in the Amazon. The study of therapeutic itineraries (TI) for treatment of snakebites would support strategies to provide timely access to users. A TI is the set of processes by which individuals adhere to certain forms of treatment, and includes the path traveled in the search for healthcare, and practices to solve their health problems. This study aims to describe TIs of snakebite patients in the Brazilian Amazon. This study was carried out at the Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, in Manaus, state of Amazonas, Brazil. The itinerary from the moment of the bite to the patient's admission to the reference unit was analyzed. Sample size was defined by saturation. After an exploratory survey to collect epidemiological variables, in-depth interviews were conducted following a semi-structured guide. Patients originated from rural areas of 11 different municipalities, including ones located >500 kilometers from Manaus. A great fragmentation was observed in the itineraries, marked by several changes of means of transport along the route. Four themes emerged from the analysis: exposure to snakebite during day-to-day activities, use of traditional therapeutic practices, and personal perception of the severity, as well as the route taken and its contingencies. Access to healthcare requires considerable effort on the part of snakebite patients. Major barriers were identified, such as the low number of hospitals that offer antivenom treatment, poor access to healthcare due to long distances and geographic barriers, low acceptability of healthcare offered in countryside, lack of use of personal protective equipment, common use of ineffective or deleterious self-care practices, late recognition of serious clinical signs and resistance to seeking medical assistance. Health education, promotion of immediate transport to health centers and decentralization of antivenom from reference hospitals to community healthcare centers in the Brazilian Amazon are more effective strategies that would to maximize access to antivenom treatment.

Organização da Atenção Primária à Saúde em um município rural remoto do norte do Brasil

RESUMO O objetivo do artigo foi caracterizar a organização da Atenção Primária à Saúde (APS) e suas interfaces com os demais serviços da rede assistencial em um Município Rural Remoto (MRR). Foi realizado estudo de caso único em Assis Brasil (AC), por meio de entrevistas com usuários, gestores e profissionais de saúde. Os resultados indicaram distribuição desigual de estabelecimentos de saúde com áreas descobertas; dificuldades de acesso por condições climáticas; barreiras econômicas para custeio de transporte; promoção de ações itinerantes na zona rural; descontinuidade e insuficiência de medicamentos; dificuldades para a fixação de profissionais; escassez de recursos tecnológicos; falta de acesso à internet; necessidade de adaptação cultural; concentração de serviços especializados do SUS na capital. Foram identificados esforços da gestão local para manutenção da Estratégia Saúde da Família (ESF) e adequação dos processos de trabalho para atendimento ao grande fluxo de demanda espontânea, estrangeiros e população indígena. Argumenta-se que o MRR e suas populações somam vulnerabilidades econômicas, sociais e de acesso aos serviços de saúde, parcialmente atendidas pelas políticas nacionais, e que o ente municipal, sem o suficiente apoio e aporte de recursos estadual e federal, mantém arranjos possíveis para a provisão de APS, nem sempre afeitos aos princípios abrangentes da ESF.

Barriers to access and organization of primary health care services for rural riverside populations in the Amazon

BACKGROUND

The ways of life in the Amazon are diverse and not widely known. In addition, social inequities, large geographic distances and inadequate health care network noticeably limit access to health services in rural areas. Over the last decades, Brazilian health authorities have implemented fluvial mobile units (FMU) as an alternative to increase access and healthcare coverage. The aim of the study was to identify the strategies of access and utilization of primary health care (PHC) services by assessing the strengths and limitations of the healthcare model offered by the FMU to reduce barriers to services and ensure the right to healthcare.

METHODS

Qualitative and ethnographic research involving participant observation and semi-structured interviews. Data collection consisted of interviews with users and health professionals and the observation of service organization and healthcare delivered by the FMU, in addition to the therapeutic itineraries that determine demand, access and interaction of users with healthcare services.

RESULTS

Primary care is offered by the monthly locomotion of the FMU that serves approximately 20 rural riverside communities. The effectiveness of the actions of the FMU proved to be adequate for conditions such as antenatal care for low-risk pregnancy, which require periodic consultations. However, conditions that require continued attention are not adequately met through the organization of care established in the FMU. The underutilization of the workforce of community health workers and disarrangement between their tasks and those of the rest of the multi-professional team are some of the reasons pointed out, making the healthcare continuity unfeasible within the intervals between the trips of the FMU. From the users' perspective, although the presence of the FMU provides healthcare coverage, the financial burden generated by the pursuit for services persists, since the dispersed housing pattern requires the locomotion of users to reach the mobile unit services as well as for specialized care in the urban centers.

CONCLUSIONS

The implementation of the FMU represents an advance in terms of accessibility to PHC. However, the organization of their activity uncritically replicates the routines adopted in the daily routine of health services located in urban spaces, proving to be inadequate for providing healthcare strategies capable of mitigating social and health inequalities faced by the users.