Analyzing a national health surveillance strategy to reduce mother-to-child transmission of syphilis: the case of Brazilian investigation committees

Objectives: This study aimed to analyze the relevance of investigation committees in eliminating mother-to-child transmission of syphilis in Brazil. Methods: Questionnaires and interviews were conducted with health managers of 25 Brazilian Federative Units and Brazil’s Federal District. Data were analyzed using Bardin’s content analysis technique and subsequently compared with the global prescriptions for syphilis response of the Pan American Health Organization, World Health Organization, and recent research publications examining the course of syphilis in Brazil, in Brazilian regions, and globally. Results: While the investigation committees drew on the successful experience of those in reducing maternal mortality, which helped the country achieve the Millennium Development Goals, they are not demonstrated to be sufficient for preventing mother-to-child transmission of syphilis. The committees’ systematic and bureaucratic agenda has not been efficient in managing avoidable factors for syphilis, nor do they operate in the scope of the integration of surveillance and care actions, as recommended by the health policy. Conclusion: The committees’ model needs to be reviewed in the context of Brazil’s National Health System. The research process should be rescaled in order to remain a cornerstone for the induction of health policy that integrates surveillance and healthcare across Brazilian Federative Units. The advancement toward an automated case management model becomes relevant for the country to meet global commitments to eliminate congenital syphilis transmission and achieve the goals outlined in the 2030 Agenda.info:eu-repo/semantics/publishedVersio

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p<0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status