Late entry into HIV care: estimated impact on AIDS mortality rates in Brazil, 2003-2006

Background

Worldwide, a high proportion of HIV-infected individuals enter into HIV care late. Here, our objective was to estimate the impact that late entry into HIV care has had on AIDS mortality rates in Brazil.

Methodology/Principal Findings

We analyzed data from information systems regarding HIV-infected adults who sought treatment at public health care facilities in Brazil from 2003 to 2006. We initially estimated the prevalence of late entry into HIV care, as well as the probability of death in the first 12 months, the percentage of the risk of death attributable to late entry, and the number of avoidable deaths. We subsequently adjusted the annual AIDS mortality rate by excluding such deaths. Of the 115,369 patients evaluated, 50,358 (43.6%) had entered HIV care late, and 18,002 died in the first 12 months, representing a 16.5% probability of death in the first 12 months (95% CI: 16.3–16.7). By comparing patients who entered HIV care late with those who gained timely access, we found that the risk ratio for death was 49.5 (95% CI: 45.1–54.2). The percentage of the risk of death attributable to late entry was 95.5%, translating to 17,189 potentially avoidable deaths. Averting those deaths would have lowered the 2003–2006 AIDS mortality rate by 39.5%. Including asymptomatic patients with CD4⁺ T cell counts >200 and ≤350 cells/mm³ in the group who entered HIV care late increased this proportion by 1.8%.

Conclusions/Significance

In Brazil, antiretroviral drugs reduced AIDS mortality by 43%. Timely entry would reduce that rate by a similar proportion, as well as resulting in a 45.2% increase in the effectiveness of the program for HIV care. The World Health Organization recommendation that asymptomatic patients with CD4⁺ T cell counts ≤350 cells/mm³ be treated would not have a significant impact on this scenario.     

Population based survival rates for childhood cancer in Britain, 1980-91.

OBJECTIVES--To investigate the survival of children with cancer diagnosed during 1980-91 in order to assess the impact of developments in medical care on a population basis. DESIGN--Retrospective cohort study. SETTING--Great Britain. SUBJECTS--14973 children with cancer diagnosed during 1980-91 and included in the population based National Registry of Childhood Tumours. MAIN OUTCOME MEASURES--Actuarial survival rates. RESULTS--For all cancers combined, two year survival increased from 66% to 76% between 1980-2 and 1989-91, and five year survival increased from 57% to 65% between 1980-2 and 1986-8. Significant increases in survival rates occurred among children with acute lymphoblastic leukaemia, acute nonlymphocytic leukaemia, retinoblastoma, osteosarcoma, Ewing''s sarcoma, rhabdomyosarcoma, and malignant gonadal germ cell tumours. No trend in survival was seen for children with Hodgkin''s disease, central nervous system tumours, neuroblastoma, or Wilms''s tumour. CONCLUSIONS--Nearly two thirds of children who have cancer diagnosed can now expect to survive at least 10 years.     

A review of prostate cancer incidence and mortality studies of farmers and non-farmers, 2002–2013

ObjectivesTo review the recent literature on the incidence and mortality of prostate cancer in farmers compared to non-farmers.MethodsSearches were conducted in seven electronic databases for observational studies published from 2002 to 2013. Studies were assessed against eligibility criteria and a narrative summary of findings presented.ResultsEighteen primary research articles were included in the review. Four of ten mortality studies and two of nine incidence studies reported statistically significant increases in prostate cancer risk in farmers. However, nearly half of all studies reported non-significant reductions in farmers’ risk. Additionally, one study reported significantly increased and decreased risk using different outcome measures. Results varied considerably by geographic region, study design and degree of control for confounders, affecting comparability and strength of findings.ConclusionsThe overall evidence for increased prostate cancer risk in farmers was weak.     

Epidemiology of mortality related to Chagas' disease in Brazil, 1999-2007

Background

Chagas'' disease is an important neglected public health problem in many Latin American countries, but population-based epidemiological data are scarce. Here we present a nationwide analysis on Chagas-associated mortality, and risk factors for death from this disease.

Methodology/Principal Findings

We analyzed all death certificates of individuals who died between 1999 and 2007 in Brazil, based on the nationwide Mortality Information System (a total of 243 data sets with about 9 million entries). Chagas'' disease was mentioned in 53,930 (0.6%) of death certificates, with 44,537 (82.6%) as an underlying cause and 9,387 (17.4%) as an associated cause of death. Acute Chagas'' disease was responsible for 2.8% of deaths. The mean standardized mortality rate was 3.36/100.000 inhabitants/year. Nationwide standardized mortality rates reduced gradually, from 3.78 (1999) to 2.78 (2007) deaths/year per 100,000 inhabitants (−26.4%). Standardized mortality rates were highest in the Central-West region, ranging from 15.23 in 1999 to 9.46 in 2007 (−37.9%), with a significant negative linear trend (p = 0.001; R² = 82%). Proportional mortality considering multiple causes of death was 0.60%. The Central-West showed highest proportional mortality among regions (2.17%), with a significant linear negative trend, from 2.28% to 1.90% (−19.5%; p = 0.001; R² = 84%). There was a significant increase in the Northeast of 38.5% (p = 0.006; R² = 82%). Bivariable analysis on risk factors for death from Chagas'' disease showed highest relative risks (RR) in older age groups (RR: 10.03; 95% CI: 9.40–10.70; p<0.001) and those residing in the Central-West region (RR: 15.01; 95% CI: 3.90–16.22; p<0.001). In logistic regression analysis, age ≥30 years (adjusted OR: 10.81; 95% CI: 10.03–10.65; p<0.001) and residence in one of the three high risk states Minas Gerais, Goiás or the Federal District (adjusted OR: 5.12; 95% CI: 5.03–5.22, p<0.001) maintained important independent risk factors for death by Chagas'' disease.

Conclusions/Significance

This is the first nationwide population-based study on Chagas mortality in Brazil, considering multiple causes of death. Despite the decline of mortality associated with Chagas'' disease in Brazil, the disease remains a serious public health problem with marked regional differences.     

Epidemiological aspects of hepatitis C virus infection among renal transplant recipients in Central Brazil

An investigation was conducted involving 255 renal transplant recipients in the state of Goiás, Central Brazil, to determine the prevalence of hepatitis C virus (HCV), its risk factors, the genotypes involved, and the level of alanine aminotransferase (ALT) present in the patients. All serum samples were tested for anti-HCV antibodies and HCV RNA. Forty-one patients were anti-HCV and/or HCV RNA positive, resulting in an overall HCV infection prevalence of 16.1% (95% CI: 11.9-21.3). A multivariate analysis of risk factors showed that a history of blood transfusions without anti-HCV screening, the length of time spent on hemodialysis, and renal transplantation before 1994 are all associated with HCV positivity. In HCV-positive patients, only 12.2% had ALT levels above normal. Twenty-eight samples were genotyped as genotype 1, subtypes 1a (62.5%) and 1b (31.3%), and two samples (6.2%) were genotype 3, subtype 3a. These data show a high prevalence of HCV infection and low ALT levels in the studied population. The risk factor analysis findings emphasize the importance of public health strategies such as anti-HCV screening of candidate blood and organ donors, in addition to the stricter adoption of hemodialysis-specific infection control measures. The present study also demonstrates that HCV genotype 1 (subtype 1a) is predominant in this population.     

Epidemiological study on removable denture deliveries in different districts of Croatia, 1996-2001 and 2002

Aim of this study was to determine the prevalence of removable denture (complete and partial) deliveries through Croatian Public Health Service (covered by insurance) in different districts of Croatia and to compare the two periods: 1996 to 2001 and 2002. Number of dentures delivered was obtained from Croatian Institute for Health Insurance for the district of Zagreb, Rijeka, Split and Karlovac. Information of the population living in the same districts was obtained from the National Institute for Statistics. The percentage of fully edentulous inhabitants varied from more than 13% to more than 20%, dependent on the district, while the percentage of partial edentulism reconstructed with removable partial dentures varied from more than 13% to more than 30%. The highest percentage (average for living population) of complete and removable partial dentures was delivered in Zagreb in the both observed periods. In all districts, the number of complete denture wearers increased in 2002, except in Split. The percentage of removable partial denture deliveries increased significantly in all examined districts. Partial and complete denture deliveries increased in higher percentage in population younger than 70 years than in older population. The percentage of metal framework removable partial dentures increased significantly in all districts. The prevalence of removable denture deliveries increased, especially in patients younger than 70 years. This was attributed not only to the consequences of the 1991-1995 war, the migrations from rural to urban areas, decrease of economic status, but also to the new rules of the Croatian Insurance System.     

Population based study of rates of multiple pregnancies in Denmark, 1980-94.

OBJECTIVE: To study trends in multiple pregnancies not explained by changes in maternal age and parity patterns. DESIGN: Trends in population based figures for multiple pregnancies in Denmark studied from complete national records on parity history and vital status. POPULATION: 497,979 Danish women and 803,019 pregnancies, 1980-94. MAIN OUTCOME MEASURES: National rates of multiple pregnancies, infant mortality, and stillbirths controlled for maternal age and parity. Special emphasis on primiparous women > or = 30 years of age, who are most likely to undergo fertility treatment. RESULTS: The national incidence of multiple pregnancies increased 1.7-fold during 1980-94, the increase primarily in 1989-94 and almost exclusively in primiparous women aged > or = 30 years, for whom the adjusted population based twinning rate increased 2.7-fold and the triplet rate 9.1-fold. During 1989-94, the adjusted yearly increase in multiple pregnancies for these women was 19% (95% confidence interval 16% to 21%) and in dizygotic twin pregnancies 25% (21% to 28%). The proportion of multiple births among infant deaths in primiparous women > or = 30 years increased from 11.5% to 26.9% during the study period. The total infant mortality, however, did not increase for these women because of a simultaneous significant decrease in infant mortality among singletons. CONCLUSIONS: A relatively small group of women has drastically changed the overall national rates of multiple pregnancies. The introduction of new treatments to enhance fertility has probably caused these changes and has also affected the otherwise decreasing trend in infant mortality. Consequently, the resources, both economical and otherwise, associated with these treatments go well beyond those invested in specific fertility enhancing treatments.     

Increasing pre-term and low-birth-weight rates over time and their impact on infant mortality in south-east Brazil

This study investigates the possible effects of pre-term births and low birth weight on infant mortality rates (IMRs) over a 15-year period in Ribeir?o Preto, Brazil, based on surveys carried out in 1978/79 and 1994. The 1978/79 survey included 6750 births over a 12-month period and the 1994 survey 2846 births over a 4-month period. Infant deaths were retrieved monthly from the city register. Infant mortality rate decreased from 36.6 to 16.9 deaths per 1000 over 15 years. The decrease in IMR was larger in the 2500-2999 g group than in any other group. The observed falls in IMR were attributable to decreases in birth-weight-specific mortality rates. Likewise, there was a general decrease in IMR in mild, moderate and severe pre-term births. The incidence rate ratio of infant mortality between surveys was 0.46 (95% CI 0.34-0.63); it increased to 0.57 (95% CI 0.35-0.75) when adjusted for birth weight and other factors in the model and rose to 0.69 (95% CI 0.49-0.97) when adjusted for length of gestation and other variables. The increase in pre-term births and low birth weight may have had, at most, a marginal effect on the IMR. Progress in the care of newborns may have decreased the mortality risk, but even mild pre-term birth still has an impact on infant mortality. There is room for further improvement in IMR by tackling the high rates of pre-term birth.     

A simple method for calculating mosquito mortality rates, correcting for seasonal variations in recruitment

Abstract A simple age‐structured exponential growth model is presented for the analysis of the population dynamics of mosquitoes (Diptera: Culicidae). In this model, the proportion of parous mosquitoes R depends on the birth rate β, and the length of the first gonotrophic cycle g, but not on the mortality rate. If the age structure is fairly constant, R= exp(– βg). Extensions of the model correcting for feeding patterns are given. A simple method is applied to an example of Anopheles gambiae Giles biting density and parity ratio in Côte d'Ivoire (fortnightly sampled longitudinal data set), for calculation of the seasonally fluctuating mortality rate, correcting for effects of recruitment. The seasonal variations in birth rate and mortality rate are discussed in relation to variations in density and rainfall.     

Income Inequality,Economic Growth and Stroke Mortality in Brazil: Longitudinal and Regional Analysis 2002-2009

Background and Purpose

Stroke accounts for more than 10% of all deaths globally and most of it occurs in low- and middle-income countries (LMIC). Income inequality and gross domestic product (GDP) per capita has been associated to stroke mortality in developed countries. In LMIC, GDP per capita is considered to be a more relevant health determinant than income inequality. This study aims to investigate if income inequality is associated to stroke mortality in Brazil at large, but also on regional and state levels, and whether GDP per capita modulates the impact of this association.

Methods

Stroke mortality rates, Gini index and GDP per capita data were pooled for the 2002 to 2009 period from public available databases. Random effects models were fitted, controlling for GDP per capita and other covariates.

Results

Income inequality was independently associated to stroke mortality rates, even after controlling for GDP per capita and other covariates. GDP per capita reduced only partially the impact of income inequality on stroke mortality. A decrease in 10 points in the Gini index was associated with 18% decrease in the stroke mortality rate in Brazil.

Conclusions

Income inequality was independently associated to stroke mortality in Brazil.     

Coronary artery bypass grafting in Canada: hospital mortality rates, 1992-1995

BACKGROUND: Rates of in-hospital death after coronary artery bypass grafting (CABG) have been studied in many regions of Canada as possible indicators of hospital-specific quality of care. This nationwide study examined observed and risk-adjusted death rates for 23 Canadian hospitals performing CABG. METHODS: Hospital discharge data were obtained from the Canadian Institute for Health Information and were used to identify all CABG procedures performed in Canadian hospitals in fiscal years 1992/93 through 1995/96. Cases from Quebec hospitals were not studied because hospitals in that province do not report to the institute. Observed death rates were evaluated, and a logistic regression model was used to calculate a risk-adjusted death rate for each hospital for the 4-year period studied. Changes over time in hospital-specific death rates were also examined. RESULTS: A total of 50,357 CABG cases were studied, with an overall death rate of 3.6%. Interhospital comparisons showed that average severity of illness varied considerably across hospitals. Despite risk adjustment accounting for this variable severity, there was considerable variation in adjusted death rates across the 23 hospitals, from 1.95% to 5.76% (p < 0.001 for difference across hospitals). For some hospitals, death rates decreased between 1992/93 and 1995/96, whereas for others the rates were stable or increased. INTERPRETATION: Risk-adjusted rates of in-hospital death after CABG vary widely across Canadian hospitals. There may be differences in quality of care across hospitals, and focused quality-improvement initiatives may be necessary in some institutions.     

Epidemiological analysis of testicular malignant neoplasm incidence and mortality in Poland 1963-1986

Epidemiological analysis of both morbidity and mortality rates for testicular cancer in Poland between 1963 and 1986 was carried out. A particular attention was drawn to the period between 1981 and 1986, when a program of combined chemotherapy and surgery was introduced in Poland. The study aimed at analysing an effect of this combined treatment on mortality rate for testicular cancer. Between 1963 and 1986, a constant increase in morbidity for the testicular cancer was noted. Mortality rate increased between 1963 and 1983. This trend was inhibited between 1984 and 1986. "Splitting" of the morbidity and mortality curves was observed between 1984 and 1986. A decrease in mortality rate was noted at the constant morbidity for testicular tumors. It was particularly clear in younger age groups (15-39 years), as well as older age groups (60-64 years and over 75 years). A decrease in mortality rate for testicular tumors within 1984-1986 may be attributed to the introduction of combined treatment in Poland.     

Epidemiological and molecular study of Ehrlichia canis in dogs in Bahia, Brazil

The objective of the present article was an epidemiological and molecular study of Ehrlichia canis in dogs of Ilhéus and Itabuna in Bahia, as well as an evaluation of associated risk factors. Blood samples were collected from 153 dogs and DNA was extracted and analyzed by the nested-polymerase chain reaction, using one pair of primers to detect Ehrlichia bacteria and another pair to detect the presence of E. canis. Of the 153 animals, 12 (7.8%) were polymerase chain reaction-positive for E. canis, indicating the presence of the parasite in dogs of the Ilhéus-Itabuna microregion. The associated risk factors were exposure to tick-infested habitats and the fact that the dogs lived in the countryside.     

Birth spacing and infant mortality in Brazil

The effects of birth spacing on neonatal and post-neonatal mortality in Brazil were found to be very consistent with models based on data from other South American countries. The model for neonatal mortality simplified to three significant variables, whereas the model for post-neonatal mortality included four significant interactions.     

Racial differences in infant mortality attributable to birth defects in the United States, 1989-2002

BACKGROUND: The objective is to study racial differences in infant mortality attributable to birth defects (IMBD) in the United States. METHODS: We analyzed 1989-1991 and 1995-2002 linked birth/death files for trends and racial differences in IMBD by selected categories of birth defects for infants of non-Hispanic white, non-Hispanic black, and Hispanic mothers. RESULTS: In 1989-2002, the IMBD rates declined. However, the decline in postneonatal mortality attributable to birth defects (PMBD) rate was significantly slower than that of overall postneonatal mortality. The adjusted rate ratio for non-Hispanic black and Hispanic versus non-Hispanic white for neonatal mortality attributable to birth defects (NMBD) remained unchanged from 1989-1991 through 2000-2002. For PMBD, it increased from 0.97 (95% confidence interval [CI], 0.90-1.13) in 1989-1991 to 1.12 (95% CI, 1.04-1.21) in 2001-2002 and from 1.08 (95% CI, 1.00-1.16) to 1.18 (95% CI, 1.10-1.27) for non-Hispanic black and Hispanic, respectively. Infant mortality due to cardiovascular and central nervous system defects were the main contributors to the increased racial disparities in PMBD rates. CONCLUSIONS: The disparity in PMBD between infants of non-Hispanic black and Hispanic mothers and infants of non-Hispanic white mothers increased significantly from 1989-1991 to 2000-2002. Further studies are needed to assess the extent to which delays in care or lack of access to care for infants with birth defects might be contributing to the disparity in IMBD.