BackgroundIn 2015, Brazil was faced with the cocirculation of three arboviruses of major public health importance. The emergence of Zika virus (ZIKV) presents new challenges to both clinicians and public health authorities. Overlapping clinical features between diseases caused by ZIKV, Dengue (DENV) and Chikungunya (CHIKV) and the lack of validated serological assays for ZIKV make accurate diagnosis difficult.Methodology / Principal FindingsThe outpatient service for acute febrile illnesses in Fiocruz initiated a syndromic clinical observational study in 2007 to capture unusual presentations of DENV infections. In January 2015, an increase of cases with exanthematic disease was observed. Trained physicians evaluated the patients using a detailed case report form that included clinical assessment and laboratory investigations. The laboratory diagnostic algorithm included assays for detection of ZIKV, CHIKV and DENV. 364 suspected cases of Zika virus disease were identified based on clinical criteria between January and July 2015. Of these, 262 (71.9%) were tested and 119 (45.4%) were confirmed by the detection of ZIKV RNA. All of the samples with sequence information available clustered within the Asian genotype.Conclusions / SignificanceThis is the first report of a ZIKV outbreak in the state of Rio de Janeiro, based on a large number of suspected (n = 364) and laboratory confirmed cases (n = 119). We were able to demonstrate that ZIKV was circulating in Rio de Janeiro as early as January 2015. The peak of the outbreak was documented in May/June 2015. More than half of the patients reported headache, arthralgia, myalgia, non-purulent conjunctivitis, and lower back pain, consistent with the case definition of suspected ZIKV disease issued by the Pan American Health Organization (PAHO). However, fever, when present, was low-intensity and short-termed. In our opinion, pruritus, the second most common clinical sign presented by the confirmed cases, should be added to the PAHO case definition, while fever could be given less emphasis. The emergence of ZIKV as a new pathogen for Brazil in 2015 underscores the need for clinical vigilance and strong epidemiological and laboratory surveillance.

The first confirmed case of Zika virus infection in the Americas was reported in Northeast Brazil in May 2015, although phylogenetic studies indicate virus introduction as early as 2013. Zika rapidly spread across Brazil and to more than 50 other countries and territories on the American continent. The Aedes aegypti mosquito is thought to be the principal vector responsible for the widespread transmission of the virus. However, sexual transmission has also been reported. The explosively emerging epidemic has had diverse impacts on population health, coinciding with cases of Guillain–Barré Syndrome and an unexpected epidemic of newborns with microcephaly and other neurological impairments. This led to Brazil declaring a national public health emergency in November 2015, followed by a similar decision by the World Health Organization three months later. While dengue virus serotypes took several decades to spread across Brazil, the Zika virus epidemic diffused within months, extending beyond the area of permanent dengue transmission, which is bound by a climatic barrier in the south and low population density areas in the north. This rapid spread was probably due to a combination of factors, including a massive susceptible population, climatic conditions conducive for the mosquito vector, alternative non-vector transmission, and a highly mobile population. The epidemic has since subsided, but many unanswered questions remain. In this article, we provide an overview of the discovery of Zika virus in Brazil, including its emergence and spread, epidemiological surveillance, vector and non-vector transmission routes, clinical complications, and socio-economic impacts. We discuss gaps in the knowledge and the challenges ahead to anticipate, prevent, and control emerging and re-emerging epidemics of arboviruses in Brazil and worldwide.

A new approach to dengue vector surveillance based on permanent egg-collection using a modified ovitrap and

SignificanceForecasts routinely provide critical information for dangerous weather events but not yet for epidemics. Researchers develop computational models that can be used for infectious disease forecasting, but forecasts have not been broadly compared or tested. We collaboratively compared forecasts from 16 teams for 8 y of dengue epidemics in Peru and Puerto Rico. The comparison highlighted components that forecasts did well (e.g., situational awareness late in the season) and those that need more work (e.g., early season forecasts). It also identified key facets to improve forecasts, including using multiple model ensemble approaches to improve overall forecast skill. Future infectious disease forecasting work can build on these findings and this framework to improve the skill and utility of forecasts.

O livro Análise de Sobrevida ganha nova edição. Agora, porém, ele se chama Análise de Sobrevivência, termo mais utilizado em Portugal, onde o livro vem sendo bastante adotado. Nesta segunda edição, todos os capítulos foram reescritos e alguns foram desdobrados em dois, com atualizações e incorporação de novos temas. Embora tenha uma linguagem acessível, não se trata de uma obra somente introdutória: ela inclui desenvolvimentos bastante recentes, como modelos para tratamento de eventos múltiplos e modelos de efeitos aleatórios. A análise de sobrevivência consiste em técnicas estatísticas empregadas para estudar o tempo até a ocorrência de algum evento de saúde, que pode ser o óbito ou a cura, por exemplo. Esse conjunto de técnicas permite verificar de que forma uma variável – por exemplo, a adesão ao tratamento – influencia o tempo até a falha terapêutica de uma droga. Baseados em problemas e pesquisas reais, os exercícios de modelagem de dados de sobrevivência encontrados no livro utilizam o pacote estatístico R, um software livre

O processo de mudanças climáticas e ambientais globais, que vem se agravando nas últimas décadas mas que foi divulgado mais amplamente pela mídia nos últimos dois anos, porta para a sociedade e setores de governo um desafio sobre as causas e o papel das alterações ambientais sobre as condições de saúde. Esse trabalho tem como objetivo avaliar cenários de mudanças climáticas e ambientais e suas incertezas para o Brasil. Além disso identifica recursos que podem ser utilizados para desenvolver uma rede de diagnóstico, modelagem, análise e intervenção sobre as repercussões dessas mudanças sobre as condições de saúde. Os principais grupos de doenças que podem ser afetados por essas mudanças são as doenças de veiculação hídrica, as transmitidas por vetores e as respiratórias. No entanto, os riscos associados às mudanças climáticas globais não podem ser avaliados em separado do contexto globalização, mudanças ambientais e precarização de sistemas de governo. Cabe ao setor saúde, não só prevenir esses riscos, mas atuar na redução de suas vulnerabilidades sociais.Palavras-chave: mudanças globais; vigilância ambiental em saúde; vigilância epidemiológica; modelos preditivos.

O objetivo foi identificar fatores associados às admissões hospitalares no Brasil, analisando se essa utilização é eqüitativa e identificando características associadas aos grandes usuários. A PNAD/1998 foi analisada, utilizando regressão logística e regressão logística multinomial, com pesos normalizados e técnicas estatísticas para correção do efeito de desenho. O modelo teórico utilizado foi o Comportamental de Andersen. No modelo ajustado por necessidade de saúde e fatores capacitantes, pessoas com menor renda apresentaram maior chance de se internar; o contrário ocorreu no modelo ajustado somente por necessidade de saúde. Todas as variáveis de necessidade mostraram-se menos relacionadas ao uso nas pessoas com duas internações, em comparação com aquelas com mais do que duas internações. Não houve associação entre variáveis sociais e ocorrência de duas internações, mas essa associação ocorreu para três ou mais internações. A redução das desigualdades sociais nos aspectos que "capacitam" ao uso de admissões hospitalares reduziria as desigualdades neste uso. Um sistema de saúde que ofereça um "serviço de uso regular", além de baixo ou nenhum pagamento no ato do consumo, seriam medidas de impacto positivo na eqüidade do consumo de serviços hospitalares no Brasil.

Background Temperature and rainfall patterns are known to influence seasonal patterns of dengue transmission. However, the effect of severe drought and extremely wet conditions on the timing and intensity of dengue epidemics is poorly understood. In this study, we aimed to quantify the non-linear and delayed effects of extreme hydrometeorological hazards on dengue risk by level of urbanisation in Brazil using a spatiotemporal model. MethodsWe combined distributed lag non-linear models with a spatiotemporal Bayesian hierarchical model framework to determine the exposure-lag-response association between the relative risk (RR) of dengue and a drought severity index. We fit the model to monthly dengue case data for the 558 microregions of Brazil between January, 2001, and January, 2019, accounting for unobserved confounding factors, spatial autocorrelation, seasonality, and interannual variability. We assessed the variation in RR by level of urbanisation through an interaction between the drought severity index and urbanisation. We also assessed the effect of hydrometeorological hazards on dengue risk in areas with a high frequency of water supply shortages. Findings The dataset included 12 895 293 dengue cases reported between 2001 and 2019 in Brazil. Overall, the risk of dengue increased between 0-3 months after extremely wet conditions (maximum RR at 1 month lag 1•56 [95% CI 1•41-1•73]) and 3-5 months after drought conditions (maximum RR at 4 months lag 1•43 [1•22-1•67]). Including a linear interaction between the drought severity index and level of urbanisation improved the model fit and showed the risk of dengue was higher in more rural areas than highly urbanised areas during extremely wet conditions (maximum RR 1•77 [1•32-2•37] at 0 months lag vs maximum RR 1•58 [1•39-1•81] at 2 months lag), but higher in highly urbanised areas than rural areas after extreme drought (maximum RR 1•60 [1•33-1•92] vs 1•15 [1•08-1•22], both at 4 months lag). We also found the dengue risk following extreme drought was higher in areas that had a higher frequency of water supply shortages.Interpretation Wet conditions and extreme drought can increase the risk of dengue with different delays. The risk associated with extremely wet conditions was higher in more rural areas and the risk associated with extreme drought was exacerbated in highly urbanised areas, which have water shortages and intermittent water supply during droughts. These findings have implications for targeting mosquito control activities in poorly serviced urban areas, not only during the wet and warm season, but also during drought periods.