Outbreak of aseptic meningitis and mumps after mass vaccination with MMR vaccine using the Leningrad-Zagreb mumps strain.

Data from routine surveillance during two mass immunisation campaigns (MIC) with Measles-mumps-rubella (MMR)vaccine using Leningrad-Zagreb mumps strain in two states in Brazil were analysed to estimate the risk of vaccine-related meningitis and mumps. Increase in the incidence of the two diseases was observed in both states, 3 weeks after the vaccination campaigns. The estimated number of doses applied per one case of vaccine-related meningitis ranged from 6199 (95% CI: 4854-8058) to 19,247 (95% CI: 12,648-29,513) depending on the diagnostic criteria used and state. It was 300 doses (95% CI: 286-317) for each case of mumps. The implications for vaccination policy are discussed.     

Outbreak of aseptic meningitis associated with mass vaccination with a urabe-containing measles-mumps-rubella vaccine: implications for immunization programs

A mass immunization campaign with a Urabe-containing measles-mumps-rubella vaccine was carried out in 1997 in the city of Salvador, northeastern Brazil, with a target population of children aged 1-11 years. There was an outbreak of aseptic meningitis following the mass campaign. Cases of aseptic meningitis were ascertained through data collected from the records of children admitted to the local referral hospital for infectious diseases between March and October of 1997, using previously defined eligibility criteria. Vaccination histories were obtained through home visits or telephone calls. Eighty-seven cases fulfilled the study criteria. Of those, 58 cases were diagnosed after the vaccination campaign. An elevated risk of aseptic meningitis was observed 3 weeks after Brazil's national vaccination day compared with the risk in the prevaccination period (relative risk = 14.3; 95% confidence interval: 7.9, 25.7). This result was confirmed by a case series analysis (relative risk = 30.4; 95% confidence interval: 11.5, 80.8). The estimated risk of aseptic meningitis was 1 in 14,000 doses. This study confirms a link between measles-mumps-rubella vaccination and aseptic meningitis. The authors discuss the implications of this for the organization and planning of mass immunization campaigns.     

Epidemiological aspects of suicide in Rio Grande do Sul, Brazil

OBJECTIVE: To describe epidemiological aspects of suicide mortality in a 10-year time series. METHODS: Suicide deaths reported in the state of Rio Grande do Sul (RS), Brazil, were put together as historical time series based on data from the Ministry of Health Mortality Reporting System for the period 1980 to 1999. Suicides were grouped according to the WHO criteria and analyzed using standard demographic variables. RESULTS: Suicide rates (proportional mortality and mortality rates) in RS during the study period were the highest in Brazil. The standardized rates grew from around 9 per 100,000 in the 1980s to 11 per 100,000 in 1999. This increase in mortality was attributed mainly to male mortality rates that grew from 14 per 100,000 to the current 20 per 100,000. The male:female ratio increased from 3 to 5. The highest ratios were seen among the elderly although this ratio has been increasing in young adults as well. Widows, widowers and farmers/fishers had the highest mortality rates. CONCLUSIONS: The study highlights suicide as a collective health problem in RS and shows aspects that could contribute to preventive action.     

Factors associated with cesarean sections among low-income women in Pelotas, Rio Grande do Sul, Brazil

The aim of this study was to investigate the association between patients' and prenatal care characteristics and cesarean section prevalence. A cross-sectional study including structural and process-of-care variables was conducted at primary health care facilities in Pelotas, Brazil. All health centers were selected and 712 mothers were interviewed. The observed cesarean rate was 30.0%. Adjusted analyses showed that cesareans were associated with maternal characteristics (short stature, few pregnancies, planned pregnancy, hospitalization, and high blood pressure). Among health services variables, the study detected a direct protective effect of time since graduation by the physician providing the prenatal care and compliance with Prenatal Care Program guidelines. Higher cesarean section rates were observed at university hospitals. To reduce the cesarean section rate, maternal education during pregnancy, early diagnosis, and proper management of hypertension and causes of hospitalization are possible strategies for approaching the problem in the primary health care sector.     

Acute lower respiratory illness in under-five children in Rio Grande, Rio Grande do Sul State, Brazil: prevalence and risk factors

This study aimed to determine the prevalence of acute lower respiratory illness and to identify associated factors among children less than five years of age in the city of Rio Grande, southern Brazil. Using a cross-sectional survey, a standardized household questionnaire was applied to mothers or guardians. Information was collected on household conditions, socioeconomic status, and parental smoking. Prenatal care attendance, nutritional status, breastfeeding pattern, and use of health services for the children were also investigated. Data analysis was based on prevalence ratios and logistic regression, using a conceptual framework. Among 771 children studied, 23.9% presented acute lower respiratory illness. The main risk factors were previous episodes of acute lower respiratory infection or wheezing, crowding, maternal schooling less than five years, monthly family income less than US$ 200, four or more people per room, asthma in family members, and maternal smoking. Mothers 30 years or older were identified as a protective factor. These results can help define specific measures to reduce morbidity and mortality due to acute lower respiratory illness in this setting.     

The Pelotas birth cohort study, Rio Grande do Sul, Brazil, 1982-2001

Given the growing recognition of the importance of the life course approach for the determination of chronic diseases, birth cohort studies are becoming increasingly important. This paper describes the methods used in the 1982 Pelotas (Brazil) birth cohort study, one of the largest and longest studies of this type in developing countries. All 5,914 hospital births occurring in Pelotas in 1982 (over 99% of all deliveries) were studied prospectively. The main stages of the study took place in 1983, 1984, 1986, 1995, 1997, 2000, and 2001. More than two thousand variables are available for each subject who participated in all stages of the study. Recent phases of the study included the examination of 2,250 males when presenting for the army recruitment exam in 2000, the study of a 27% sample of men and women in 2001 through household visits, and the study of over 400 children born to the cohort women. Follow-up rates in the recent stages of the cohort were 78.9% for the army examination and 69.0% for the household visits. Ethnographic and oral health studies were conducted in sub-samples. Some recent results on blood pressure, adolescent pregnancy, and asthma are presented as examples of utilization of the data. Suggestions on lessons learned for other cohort studies are proposed.     

Pap test coverage in the city of Pelotas,Rio Grande do Sul,Brazil

In Brazil, the effectiveness of preventive public heath programs and actions is rarely evaluated. A cross-sectional study was thus performed in a population-based sample focused on several health characteristics of adults living in Pelotas, Rio Grande do Sul, Brazil. The study aimed to measure temporal trends in coverage of Pap smear testing in the city. The authors studied the factors associated with failure of women to submit to a Pap smear. An updated Pap smear was defined as one performed in the previous 3 years. The sample consisted of 1,122 women ages 20 to 69 years, 72.2% of whom had an updated Pap smear, 16.6% of whom were behind schedule for testing, and 11.2% of whom had never had a Pap smear. Risk factors for never having a test were low socioeconomic status and old age. Logistic regression showed an independent effect of social class, low family income, age, skin color, marital status, and no medical appointment in the previous year. However, the effect of chronic diseases disappeared in logistic regression. The authors compare the results of the study conducted in 1992 with the present. Pap smear coverage increased from 65.0% to 72.2% (1992 to 1999/2000) in the city, yet such figures had still not ensured the effectiveness of the program for uterine cervical cancer prevention.     

Clinical and laboratory features of aseptic meningitis associated with measles-mumps-rubella vaccine]

OBJECTIVE: To describe epidemiological, clinical, and cerebrospinal fluid (CSF) findings in cases of aseptic meningitis associated with measles-mumps-rubella vaccination following a mass immunization campaign in the Brazilian state of Bahia in August 1997 promoted by the country's Ministry of Health, and to compare these cases to the cases of aseptic meningitis not associated with the vaccine that occurred in the same year. METHODS: Between March 1997 and October 1997, all individuals between 1 and 12 years of age admitted to the Couto Maia Hospital (the Bahia reference hospital for infectious illnesses) with a clinical and laboratory diagnosis of aseptic meningitis were prospectively followed. The study population was divided into two groups: one with individuals who had received the vaccine, and one with individuals who had not received the vaccine. Demographic, clinical, and laboratory information was collected on both groups. RESULTS: In September, following the vaccination campaign, 74 cases of aseptic meningitis were registered at the Couto Maia Hospital, versus the monthly average of 7.5 cases. We observed a greater frequency of nuchal rigidity and increased CSF cellularity among children whose meningitis was associated with the vaccine. However, encephalitic involvement was more frequent in the group of children with non-vaccinal meningitis. CONCLUSIONS: Although the course of post-vaccinal meningitis is more benign than that of other forms of the disease, its treatment generates costs related to ancillary exams and hospitalizations. Mass vaccination campaigns should employ less reactogenic vaccine strains.     

Frequency of multiple neonatal malformations in Pelotas, Rio Grande do Sul, Brazil, and associated socio-demographic factors

This study aimed to estimate the frequency and to correlate the possible causal agents and monitor the occurrence of multiple neonatal malformations in Pelotas, Rio Grande do Sul, Brazil. The study included all births from 1990 to 2002 in the local maternity hospitals with birth weight > 500 g. Each newborn presenting a malformation (case) was assigned a live matched neonate (control) without any malformation and of the same sex. A database was established by filling out the ECLAMC-MONITOR forms, 1982 edition, tabulated with SPSS. Statistical analysis used Student t and chi2. During the study period, 71,500 children were born, of whom 0.11% presented multiple malformations. Significant results were found for birth weight, twin births, parents' ethnic background, paternal age, and number of previous abortions and stillbirths. In Pelotas, the proportion of newborns with malformations during the study period was 1.37%. Of these, 8.1% presented multiple malformations, predominantly in females and in births occurring during the winter.     

Risk factors for orthotopic liver transplantation failure in Rio Grande do Sul, Brazil

Risk factors for failure of liver transplantation from cadaveric donors were investigated in this retrospective study using data from medical records of patients in Rio Grande do Sul, Brazil, who were submitted to liver transplantation for the first time from January 1999 to July 2003 and were over 15 years of age at the time of surgery. Some 13% of failures occurred in the first month, 11% from 2 to 12 months, and 5% after 12 months; 88% of failures resulted in death and 12% in retransplantation. In the multivariate models, rate ratios for failure were higher for total family income less than 10 times the minimum wage, recipient's age > 45 years, non-whites, high clinical risk, and donor's age > or = 56 years. Female gender showed an effect in the unadjusted model only. Special attention to patients at increased risk, with income support for those with low family income, and early diagnosis of the need for transplantation may improve the success of liver transplantation.     

Adult obesity in Pelotas, Rio Grande do Sul, Brazil, and the association with socioeconomic status

The objectives of this study were to: (1) describe obesity prevalence in a Brazilian city; (2) test the association between obesity and socio-demographic variables; and (3) compare results with a survey in the same city in 1994. A cross-sectional population-based study was carried out in a random sample of 1,968 20-69-year-olds residing in the urban area of Pelotas, Rio Grande do Sul State. Obesity was defined as Body Mass Index (BMI) > 30 kg/m(2). Age and sex-adjusted obesity prevalence was 19.4%. Schooling was not associated with obesity in men. Obesity prevalence was higher in middle-income men. Women with more schooling had lower obesity rates. There was a non-statistically significant reduction in obesity rates compared to a similar study from 1994.     

Risks of convulsion and aseptic meningitis following measles-mumps-rubella vaccination in the United Kingdom

Measles-mumps-rubella (MMR) vaccines containing the Urabe strain of mumps were withdrawn in the United Kingdom in 1992 following demonstration of an increased risk of aseptic meningitis 15-35 days after vaccination. Following introduction of a replacement MMR vaccine (Priorix; GlaxoSmithKline, London, United Kingdom) in 1998, active surveillance of aseptic meningitis and convulsion was established to evaluate the risk associated with the new vaccine. No laboratory-confirmed cases of mumps meningitis were detected among children aged 12-23 months after administration of 1.6 million doses of Priorix (upper 95% confidence limit of risk: 1:437,000) in England and Wales. The upper 95% confidence limit excluded the risk found for mumps meningitis with Urabe vaccines (1:143,000 doses). No cases of aseptic meningitis were detected among children aged 12-23 months, who had received over 99,000 doses of Priorix (upper 95% confidence limit of risk: 1:27,000), in a regional database of hospital-admitted cases. This compares with an observed risk of 1:12,400 for Urabe vaccines. An elevated relative incidence of convulsion was found in the 6- to 11-day period after receipt of Priorix (relative incidence = 6.26, 95% confidence interval: 3.85, 10.18)-consistent with the known effects of the measles component of MMR vaccine-but not in the 15- to 35-day period (relative incidence = 1.48, 95% confidence interval: 0.88, 2.50) as occurred with Urabe-containing vaccines. This study demonstrates the power of active postmarketing surveillance to identify or exclude events too rare to be detected in prelicensure trials.     

Quality of the environment and associated factors: a pediatric study in Pelotas, Rio Grande do Sul, Brazil

This study aims to describe and identify factors associated with environmental quality and characteristics of children exposed to environmental risk factors in Pelotas, Rio Grande do Sul, Brazil. This was a prospective, population-based study, including 630 children from the 1993 birth cohort. During the year 1998, environmental quality and other information were assessed using the Home Observation for the Measurement of the Environment. Data were submitted to univariate analysis. The association between the variables and the outcome was evaluated through prevalence ratios, 95% confidence intervals, and chi-square. Logistic regression was performed according to a hierarchical model. Some 97 children (15%) were living in negative environments. Eight risk factors were associated with environmental quality: low monthly family income, low maternal schooling, male gender, households with more than 7 members, 4 or more siblings, tobacco use during gestation, children sleeping in their parents' bed at age 4 years, and mothers with psychiatric disorders.     

Spatial risk distribution: modeling infant mortality in Porto Alegre, Rio Grande do Sul State, Brazil]

Estimation and mapping of risk profiles are the main concerns of epidemiology. This paper analyzes spatial distribution of infant mortality cases as compared to live-born controls from Porto Alegre, Rio Grande do Sul. The modeling framework adopted in this research work is a spatial point process. Under this structure, a risk measure which continuously varies over the study region is defined and estimated using generalized additive model methods. This approach has the advantage of allowing for risk factors that are simple and easy to interpret. The procedure also allows the construction of tolerance contours which help identify areas of significantly high/low risk and an overall test for the null hypothesis of constant risk over the region. Application of this method to infant mortality data showed a highly significant spatial variation in risk for neonatal mortality data and non-significant results for post-neonatal mortality data.     

Evaluation of knowledge on prenatal care and pregnancy risk among women living in a peripheral area of Rio Grande, Rio Grande do Sul State, Brazil

The aim of this study was to assess knowledge on prenatal care and pregnancy risk among women in poor neighborhoods in the city of Rio Grande, Rio Grande do Sul State, Brazil. Data were collected using a cross-sectional design. A standard questionnaire was applied to all pregnant women from poor neighborhoods. Trained interviewers visited these women at home, covering demographic, socioeconomic, and reproductive data and knowledge concerning prenatal care and pregnancy risk factors. A total of 367 pregnant women were interviewed using non-random sampling. Except for urine tests and HIV testing, spontaneously reported as necessary, other procedures were reported by no more than 30% of the women. Digital vaginal examination, clinical breast examination, and Pap smear were reported by a maximum of 7% of the women. Only two-thirds felt that vaginal bleeding and abdominal pain were serious signs during gestation. Other signs and symptoms were reported by a maximum of one-third of the women. In conclusion, knowledge of prenatal tests and situations indicating serious risk fell far short of the desired levels. Improving this level of information in pregnant women could help reduce maternal and child morbidity and mortality.     

Regional health systems management: a case study in Rio Grande do Sul, Brazil

This article analyzes the management system in a health district in the State of Rio Grande do Sul, Brazil, through qualitative analysis, using a case study as the methodology and macro-organization theory as the analytical framework. For the current management system in the 6th Health Region, a clear mission statement and wide acceptance by health workers are facilitating factors for the current organizational practices within the health system. Nevertheless, the way health coordinators are currently prioritizing their time has diverted necessary resources from critical problems towards more remedial issues. The 6th Health Region has encouraged social control (or public oversight) in order to improve accountability. However, there is room for improvement in quality assurance management, since there were no well-defined goals, objectives, or accountability. Decentralized consultancy provided to the municipalities and the funding model itself have both promoted decentralization and autonomy, although the strategy requires better regional integration and greater commitment in managerial practices.