Spatiotemporal Analysis of the Population Risk of Congenital Microcephaly in Pernambuco State, Brazil.

Since an outbreak in Brazil, which started in 2015, Zika has been recognized as an important cause of microcephaly. The highest burden of this outbreak was in northeast Brazil, including the state of Pernambuco. The prevalence of congenital microcephaly in Pernambuco state was estimated from the RESP (Registro de Eventos em Saúde Pública) surveillance system, from August 2015 to August 2016 inclusive. The denominators were estimated at the municipality level from official demographic data. Microcephaly was defined as a neonatal head circumference below the 3rd percentile of the Intergrowth standards. Smoothed maps of the prevalence of microcephaly were obtained from a Bayesian model which was conditional autoregressive (CAR) in space, and first order autoregressive in time. A total of 742 cases were identified. Additionally, high and early occurrences were identified in the Recife Metropolitan Region, on the coast, and in a north-south band about 300 km inland. Over a substantial part of the state, the overall prevalence, aggregating over the study period, was above 0.5%. The reasons for the high occurrence in the inland area remain unclear

o caso da Vigilância em Saúde de Pernambuco, Brasil

O desempenho dos sistemas e políticas de saúde estão intimamente relacionados à capacidade de alcançar objetivos e metas, dentro de um contexto de claras prioridades de governança. Nesta perspetiva, a Gestão do Desempenho (GD), qual seja um conjunto de elementos e procedimentos que ajustam taticamente ações delineadas para garantir o alcance de resultados, parece cumprir esse propósito. O objetivo desse estudo foi avaliar a Política de M&A da Secretaria Executiva de Vigilância em Saúde de Pernambuco (SEVS), com base nesse modelo. Foi realizada uma avaliação normativa, utilizando-se uma abordagem descritivo-qualitativa partindo-se do desenho do modelo lógico da GD e de critérios pré-estabelecidos. Foram entrevistados 10 informantes-chave e analisados documentos. A Política de M&A da SEVS é convergente com o modelo de Gestão do Desempenho, a partir dos componentes propostos na análise: liderança do desempenho, estrutura gerencial e produção de informação e conhecimento. O M&A são elementos chave nesse processo, porém é preciso diferenciá-los e buscar estratégias que os perenizem. Mais amiúde, o Monitoramento do Desempenho da Gestão da Vigilância em Saúde revela-se o impulsionador da sustentabilidade da Política. A avaliação precisa assumir uma agenda mais permanente na SEVS, como parte do desempenho que se persegue. The performance of systems and health policies is closely related to their capacity of reaching objectives and goals within a context of clear governance priorities. In this perspective, Performance Management (GD), which is a set of elements and procedures that tactically adjust actions outlined to ensure the achievement of results, seems to fulfill this purpose. The objective of this study was to evaluate the Monitoring and Evaluation Policy used by the Executive Secretariat for Health Surveillance of Pernambuco (SEVS), based of this model. A normative evaluation was carried out, using a qualitative descriptive approach starting with the design of the PM logical model and pre-established criteria. For this study, we interviewed 10 key informants and documents were analyzed. The SEVS M & E Policy is convergent with the Performance Management model, based on the components proposed in the analysis: performance leadership, management structure and production of information and knowledge.The M & E are key elements in this process, but it is necessary to differentiate them and seek strategies that will keep them alive. More often than not, monitoring the performance of Health Surveillance Management is the driving force behind the sustainability of the Policy. The evaluation needs to take on a more permanent agenda at SEVS, as part of the performance that is pursued.publishersversionpublishe

Microcephaly in Pernambuco State, Brazil: epidemiological characteristics and evaluation of the diagnostic accuracy of cutoff points for reporting suspected cases.

The increase in the number of reported cases of microcephaly in Pernambuco State, and Northeast Brazil, characterized an epidemic that led the Brazilian Ministry of Health to declare a national public health emergency. The Brazilian Ministry of Health initially defined suspected cases as newborns with gestational age (GA) ≥ 37 weeks and head circumference (HC) ≤ 33cm, but in December 2015 this cutoff was lowered to 32cm. The current study aimed to estimate the accuracy, sensitivity, and specificity of different cutoff points for HC, using ROC curves, with the Fenton and Intergrowth (2014) curves as the gold standard. The study described cases reported in Pernambuco from August 8 to November 28, 2015, according to sex and GA categories. The Fenton and Intergrowth methods provide HC growth curves according to GA and sex, and microcephaly is defined as a newborn with HC below the 3rd percentile in these distributions. Of the 684 reported cases, 599 were term or post-term neonates. For these, the analyses with ROC curves show that according to the Fenton criterion the cutoff point with the largest area under the ROC curve, with sensitivity greater than specificity, is 32cm for both sexes. Using the Intergrowth method and following the same criteria, the cutoff points are 32cm and 31.5cm for males and females, respectively. The cutoff point identified by the Fenton method (32cm) coincided with the Brazilian Ministry of Health recommendation. Adopting Intergrowth as the standard, the choice would be 32cm for males and 31.5cm for females. The study identified the need to conduct critical and on-going analyses to evaluate cutoff points, including other characteristics for microcephaly case definition

Methodology for construction of a panel of indicators for monitoring and evaluation of unified health system (SUS) management

Este estudo teve como objetivo desenvolver uma metodologia de construção de um Painel de Monitoramento e Avaliação da Gestão do Sistema Único de Saúde (SUS). O processo participativo utilizado e a sistematização realizada permitiram identificar uma estratégia efetiva para a construção de instrumentos de gestão em parceria entre pesquisadores, instituições acadêmicas e gestores do SUS. A sistematização final do Painel selecionou indicadores da gestão do SUS em termos de Demandas, Insumos, Processos, Produtos e Resultados de forma a disponibilizar um instrumento simples, ágil e útil para a avaliação em qualquer instância de gestão e mais transparente e de mais fácil comunicação com todos os interessados na tomada de decisão. Tomar a gestão do SUS como objeto destes processos e práticas em seus aspectos normativos possibilitou o diálogo entre teorias sistêmicas e aquelas que consideram a centralidade do ator social no processo de tomada de decisão.This study sought to develop methodology for the construction of a Panel for the Monitoring and Evaluation of Management of the Unified Health System (SUS). The participative process used in addition to the systematization conducted made it possible to identify an effective strategy for building management tools in partnership with researchers, academic institutions and managers of the SUS. The final systematization of the Panel selected indicators for the management of the SUS in terms of Demand, Inputs, Processes, Outputs and Outcomes in order to provide a simple, versatile and useful tool for evaluation at any level of management and more transparent and easier communication with all stakeholders in decision-making. Taking the management of the SUS as the scope of these processes and practices in all normative aspects enabled dialog between systemic theories and those which consider the centrality of the social actor in the decision-making process

Neighbourhood-level income and Zika virus infection during pregnancy in Recife, Pernambuco, Brazil: an ecological perspective, 2015-2017.

Zika virus (ZIKV) infections during pregnancy can lead to adverse neurodevelopmental and clinical outcomes in congenitally infected offspring. As the city of Recife in Pernambuco State, Brazil-the epicentre of the Brazilian microcephaly epidemic-has considerable disparities in living conditions, this study used an ecological approach to investigate the association between income at the neighbourhood level and the risk of ZIKV infections in pregnant individuals between December 2015 and April 2017. The spatial distribution of pregnant individuals with ZIKV infection was plotted on a map of Recife stratified into four categories based on mean monthly income of household heads. Additionally, a Poisson regression model with robust variance was fitted to compare proportions of ZIKV infections among pregnant individuals in relation to the mean monthly income of household heads, based on the 2010 census data, across 94 neighbourhoods in Recife. The results provide evidence that the risk of ZIKV infection to pregnant individuals was higher among those residing in lower-income neighbourhoods: relative to neighbourhoods that had a mean monthly income of ≥5 times minimum wage, neighbourhoods with <1 and 1 to <2 times minimum wage had more than four times the risk (incidence rate ratio, 95% CI 4.08, 1.88 to 8.85 and 4.30, 2.00 to 9.20, respectively). This study provides evidence of a strong association between neighbourhood-level income and ZIKV infection risks in the pregnant population of Recife. In settings prone to arboviral outbreaks, locally targeted interventions to improve living conditions, sanitation, and mosquito control should be a key focus of governmental interventions to reduce risks associated with ZIKV infections during pregnancy

Microcephaly epidemic related to the Zika virus and living conditions in Recife, Northeast Brazil.

BACKGROUND: Starting in August 2015, there was an increase in the number of cases of neonatal microcephaly in Northeast Brazil. These findings were identified as being an epidemic of microcephaly related to Zika virus (ZIKV) infection. The present study aims to analyse the spatial distribution of microcephaly cases in Recife (2015-2016), which is in Northeast Brazil, and its association with the living conditions in this city. METHODS: This was an ecological study that used data from reported cases of microcephaly from the State Health Department of Pernambuco (August 2015 to July 2016). The basic spatial unit of analysis was the 94 districts of Recife. The case definition of microcephaly was: neonates with a head circumference of less than the cut-off point of -2 standard deviations below the mean value from the established Fenton growth curve. As an indicator of the living conditions of the 94 districts, the percentage of heads of households with an income of less than twice the minimum wage was calculated. The districts were classified into four homogeneous strata using the K-means clustering algorithm. We plotted the locations of each microcephaly case over a layer of living conditions. RESULTS: During the study period, 347 microcephaly cases were reported, of which 142 (40.9%) fulfilled the definition of a microcephaly case. Stratification of the 94 districts resulted in the identification of four strata. The highest stratum in relation to the living conditions presented the lowest prevalence rate of microcephaly, and the overall difference between this rate and the rates of the other strata was statistically significant. The results of the Kruskal-Wallis test demonstrated that there was a strong association between a higher prevalence of microcephaly and poor living conditions. After the first 6 months of the study period, there were no microcephaly cases recorded within the population living in the richest socio-economic strata. CONCLUSION: This study showed that those residing in areas with precarious living conditions had a higher prevalence of microcephaly compared with populations with better living conditions

Association between Zika virus infection and microcephaly in Brazil, January to May, 2016: preliminary report of a case-control study.

BACKGROUND: The microcephaly epidemic, which started in Brazil in 2015, was declared a Public Health Emergency of International Concern by WHO in 2016. We report the preliminary results of a case-control study investigating the association between microcephaly and Zika virus infection during pregnancy. METHODS: We did this case-control study in eight public hospitals in Recife, Brazil. Cases were neonates with microcephaly. Two controls (neonates without microcephaly), matched by expected date of delivery and area of residence, were selected for each case. Serum samples of cases and controls and cerebrospinal fluid samples of cases were tested for Zika virus-specific IgM and by quantitative RT-PCR. Laboratory-confirmed Zika virus infection during pregnancy was defined as detection of Zika virus-specific IgM or a positive RT-PCR result in neonates. Maternal serum samples were tested by plaque reduction neutralisation assay for Zika virus and dengue virus. We estimated crude odds ratios (ORs) and 95% CIs using a median unbiased estimator for binary data in an unconditional logistic regression model. We estimated ORs separately for cases with and without radiological evidence of brain abnormalities. FINDINGS: Between Jan 15, 2016, and May 2, 2016, we prospectively recruited 32 cases and 62 controls. 24 (80%) of 30 mothers of cases had Zika virus infection compared with 39 (64%) of 61 mothers of controls (p=0·12). 13 (41%) of 32 cases and none of 62 controls had laboratory-confirmed Zika virus infection; crude overall OR 55·5 (95% CI 8·6-∞); OR 113·3 (95% CI 14·5-∞) for seven cases with brain abnormalities; and OR 24·7 (95% CI 2·9-∞) for four cases without brain abnormalities. INTERPRETATION: Our data suggest that the microcephaly epidemic is a result of congenital Zika virus infection. We await further data from this ongoing study to assess other potential risk factors and to confirm the strength of association in a larger sample size. FUNDING: Brazilian Ministry of Health, Pan American Health Organization, and Enhancing Research Activity in Epidemic Situations

Co-circulation of Chikungunya Virus during the 2015-2017 Zika Virus Outbreak in Pernambuco, Brazil: An Analysis of the Microcephaly Epidemic Research Group Pregnancy Cohort.

Co-circulation of arthropod-borne viruses, particularly those with shared mosquito vectors like Zika (ZIKV) and Chikungunya (CHIKV), is increasingly reported. An accurate differential diagnosis between ZIKV and CHIKV is of high clinical importance, especially in the context of pregnancy, but remains challenging due to limitations in the availability of specialized laboratory testing facilities. Using data collected from the prospective pregnancy cohort study of the Microcephaly Epidemic Research Group, which followed up pregnant persons with rash during the peak and decline of the 2015-2017 ZIKV epidemic in Recife, Pernambuco, Brazil, this study aims to describe the geographic and temporal distribution of ZIKV and CHIKV infections and to investigate the extent to which ZIKV and CHIKV infections may be clinically differentiable. Between December 2015 and June 2017, we observed evidence of co-circulation with laboratory confirmation of 213 ZIKV mono-infections, 55 CHIKV mono-infections, and 58 sequential ZIKV/CHIKV infections (i.e., cases with evidence of acute ZIKV infection with concomitant serological evidence of recent CHIKV infection). In logistic regressions with adjustment for maternal age, ZIKV mono-infected cases had lower odds than CHIKV mono-infected cases of presenting with arthralgia (aOR, 99% CI: 0.33, 0.15-0.74), arthritis (0.35, 0.14-0.85), fatigue (0.40, 0.17-0.96), and headache (0.44, 0.19-1.90). However, sequential ZIKV/CHIKV infections complicated discrimination, as they did not significantly differ in clinical presentation from CHIKV mono-infections. These findings suggest clinical symptoms alone may be insufficient for differentiating between ZIKV and CHIKV infections during pregnancy and therefore laboratory diagnostics continue to be a valuable tool for tailoring care in the event of arboviral co-circulation