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Introduction We hypothesize that high altitudes could have an adverse effect on neonatal health outcomes, especially among at-risk neonates. The current study aims to assess the association between higher altitudes on survival time among at-risk neonates. Methods Retrospective survival analysis. Setting: Ecuadorian neonates who died at ≤28 days of life. Patients: We analyzed the nationwide dataset of neonatal deaths from the Surveillance System of Neonatal Mortality of the Ministry of Public Health of Ecuador, registered from 126 public and private health care facilities, between January 2014 to September 2017. Main outcome measures: We retrospectively reviewed 3016 patients. We performed a survival analysis by setting the survival time in days as the primary outcome and fixed and mixed-effects Cox proportional hazards models to estimate hazard ratios (HR) for each altitude stratum of each one of the health care facilities in which those neonates were attended, adjusting by individual variables (i.e., birth weight, gestational age at birth, Apgar scale at 5 minutes, and comorbidities); and contextual variables (i.e., administrative planning areas, type of health care facility, and level of care). Results Altitudes of health care facilities ranging from 80 to <2500 m, 2500 to <2750m, and ≥2750 m were associated respectively with 20% (95% CI: 1% to 44%), 32% (95% CI:<1% to 79%) and 37% (95% CI: 8% to 75%) increased HR; compared with altitudes at <80 m. Conclusion Higher altitudes are independently associated with shorter survival time, as measured by days among at-risk neonates. Altitude should be considered when assessing the risk of having negative health outcomes during neonatal period.

ObjectiveTo assess the association between 5-minutes Apgar score and neonatal survival among at-risk neonates.DesignRetrospective survival analysis.SettingEcuadorian neonates who died at ≤28 days of life.PatientsWe analyzed the nationwide neonatal deaths registered by the Ministry of Public Health of Ecuador between January 2014 to September 2017.Main outcome measuresWe performed a survival analysis and estimated adjusted hazard ratios (HR) per each 5-minutes Apgar score stratum, by Cox proportional hazards models.ResultsWe included in the study 2893 neonates, 1380 (48%) were female and had a median (P25 to P75) gestational age at birth of 31 (27 to 36) weeks. On univariate analyses, the median survival time in days of life was significantly longer per each increase in the 5-minutes Apgar score, as follows: 0.2 days for ≤4 points, 2 days for 5 points, 2.9 days for 6 points, 3.1 days for 7 points, 3.8 days for 8 points, 4.4 days for 9 points, and 5.5 days for 10 points. On multivariate analyses, and after adjusting for individual and contextual variables, and considering an Apgar score of 9 to 10 points as the reference, the HR was 32% (95% CI: 27% to 37%) higher per each decrease in the Apgar score category of two-to-three points (p-value for trend <0.01).ConclusionsThere is a strong direct association between Apgar score at 5 minutes and neonatal survival in neonates considered at-risk. This association is independent of gestational age and other neonatal determinants of neonatal mortality.

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IntroductionThere is evidence that demonstrates lower incidence rates of cardiometabolic factors at the highlands. There are no studies which correlate the altitude with formally calculated cardiovascular risk by a meter-by-meter approach. Under the hypothesis that cardiovascular risk is inversely associated with altitude, this study was aimed to assess such association.Materials and methodsCross sectional study using data from the Ecuadorian National Health Survey of 2012. We analyzed available information of adults of ≥ 40 to 60 years old who have sociodemographic, anthropometric, cardiovascular risk factors, and laboratory biomarkers that were included in the survey. We assessed the independent association between altitude of the housing in which survey participants lived at, on a meter-by-meter approach, and cardiovascular health risk at ten years, formally calculated by Framingham equations.ResultsLinear regression model showed that participants had 0.0005 % less probability of developing cardiovascular disease at 10 years per each increase in a meter in the altitude that participants live at (p<0.001), adjusted for sex, age, ethnicity, educational level, availability of social security, immigrants in family, area, income quintile, overcrowding (≥ 7 inhabitants in the house), any alcohol consumption, history of hypertension, body mass index, hematocrit, and triglycerides.ConclusionFrom a public health perspective, altitude at which individuals live is an important health determinant of cardiovascular risk. Specifically, per each increase of 1000 m in the altitude that people live at, there is a reduction of almost half a percentual point in the cardiovascular risk at 10 years.