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The recent licensure of two different serogroup B recombinant protein meningococcal vaccines in Brazil emphasizes the importance of a better knowledge of the real burden of serogroup B meningococcal (MenB) disease to establish evidence-based vaccination policies. We performed an observational, descriptive study, from 2001 to 2015, analyzing the incidence and case fatality rates (CFR) of MenB disease in Brazil, according to age group and region. In the absence of any vaccine use targeting MenB disease, a significant decline of 90% in the overall incidence rates of MenB disease was observed (from 0.55 cases/100,000 habitants in 2001 to 0.05 in 2015), with declines found in all age groups during the study period. The highest incidence rates were consistently observed in infants and children 1–4 year of age, whereas adults ≥ 60 years experienced the highest CFR (33.9%). The proportion of cases with serogroup identified increased from 37.1% in 2001 to 51.5% in 2015. Despite an improvement in recent years, the quality of diagnosis is highly heterogeneous in the diverse regions, presenting important deficiencies that still prevent the possibility of a robust and reliable analysis of the burden of the meningococcal disease in Brazil. Based on the findings of this study and taking in account the unlikely indirect effect associated with the use of the new recombinant serogroup B protein vaccines, infants < 1 year is the age group to be prioritized when considering the implementation of routine immunization programmes with MenB vaccines.

Background: The Brazilian state of Parana conducted a mass vaccination campaign against dengue with the tetravalent attenuated vaccine CYD-TDV. The campaign targeted thirty endemic municipalities. The objective of this study was to assess the effectiveness of CYD-TDV in preventing symptomatic virologically confirmed dengue cases according to specific age groups in five of the municipalities. Methods: A case-control study was carried out in the five most populous municipalities targeted by the vaccination, with a vaccine uptake of 25%. Symptomatic dengue cases were identified by the municipal health departments. The age groups targeted were 15–18 and 19–27 in four municipalities and 9–14 and 28–44 in one municipality. All cases were confirmed by real time reverse transcription quantitative polymerase chain reaction (RT-qPCR). For each case, two controls were selected: a neighborhood control and a workplace or school/college control, matched by age group. A conditional logistic regression model was used to determine the odds ratio for vaccination and the vaccine effectiveness. Findings: Study participants included 618 RT-qPCR-confirmed dengue cases and 1,236 matched controls (with a non-reactive dengue IgM serologic test). Vaccine effectiveness against dengue due to any serotype was 11·1% (95% CI: –19·0%; 33·6%). Effectiveness against DENV-1 was 33·3% (95% CI: -5·0%; 57·6%) and against DENV-2 was -56·7% (95% CI: -142·2%; -5·0%). No DENV-3 were detected. The vaccine was significantly effective in the prevention of DENV-4 cases (VE = 93·3%; 95% CI: 47·7%; 99·2%). Interpretation: CYD-TDV was effective in the prevention of symptomatic cases due to DENV-4, but not due to any serotype. The low dengue sero-prevalence in the target population could possibly be related to these results. Funding: This study was supported through a grant to the Sabin Vaccine Institute from Sanofi-Pasteur. Sanofi-Pasteur had no role in the study design, protocol development, data collection, analysis, or publication of results. Declaration of Interest: EJA Luna and JC Moraes have received consultancy fees and travel sponsorship from Sanofi-Pasteur. D Garrett, F. Crosewski, I Riediger, F Fantinato and K Ribeiro declare no conflict of interest. Ethical Approval: The Santa Casa de Sao Paulo Research Ethics Committee (Resolution no. 1817892, on November 11, 2016) and Pan American Health Organization Ethics Review Committee – PAHOERC (Resolution PAHO 2016-11-0056) approved the study protocol.

Neisseria lactamica is a nonpathogenic commensal bacterium that is potentially associated with the development of natural immunity against N. meningitidis. However, the genetic variation present in natural populations of N. lactamica has not been fully investigated. To better understand its epidemiology and genetic variation, we studied N. lactamica carriage in 1200 students aged 11-19 years old in Salvador, Brazil. The carriage prevalence was 4.5% (54/1200), with no statistical difference among sex and age, although we observed a trend towards higher carriage prevalence among 11-year-old individuals. Whole genome sequence analysis revealed a high genetic diversity among the isolates, with the presence of 32 different STs, 28 (87.5%) of which were new. A total of 21/50 (42%) isolates belonged to three different clonal complexes. While none of the isolates contained nadA or fHpb alleles, we detected 21 FetA variants, 20 NhbA variants and two variants of PorB. The data provide detailed information on circulating N. lactamica isolates in adolescents in Brazil and are complementary to studies in other countries.

In 2010, introduction of the meningococcal C conjugate vaccine in Brazil for children2 years provided an immediate reduction in the incidence rates of disease among the age groups targeted for the vaccine, but no early impact was observed in unvaccinated age groups. Knowledge about meningococcal carriage is crucial for improving our understanding of the disease epidemiology and for designing effective vaccination programs. Taking in account the very limited published data currently available describing meningococcal carriage in Brazil, we performed a study to evaluate the prevalence of Neisseria meningitidis carriage among adolescent students.A cross-sectional study was conducted in 2012 to assess the prevalence of meningococcal carriage among a representative sample of 1208 students 11-19 years of age in Campinas, Brazil. Genotypic and phenotypic characterization of isolated carriage strains and the effect of potential risk factors for carriage were also analyzed.The overall carriage prevalence was 9.9% (95% confidence interval, 8.3-11.8%), with dominance of serogroup C (1.32%), followed by serogroups B (0.99%), E (0.74%), Y (0.49%) and W (0.25%). A lower level of education of the parents was independently associated with a higher risk of carriage. A high diversity of genotypes was found among carriage strains.The evidence gathered during this study provides estimates of carriage prevalence in Brazilian adolescents, showing an unusually high dominance of serogroup C. These results have important implications in future strategies to optimize the impact of the current meningococcal C vaccination program in Brazil.

Characterization of meningococci isolated from the pharynx is essential towards understanding the dynamics of meningococcal carriage and disease. Meningococcal isolates, collected from adolescents resident in Salvador, Brazil during 2014, were characterized by multilocus sequence typing, genotyping or whole-genome sequencing. Most were nongroupable (61.0%), followed by genogroups B (11.9%) and Y (8.5%). We identified 34 different sequence types (STs), eight were new STs, distributed among 14 clonal complexes (cc), cc1136 represented 20.3% of the nongroupable isolates. The porA and fetA genotypes included P1.18,25-37 (11.9%), P1.18-1,3 (10.2%); F5-5 (23.7%), F4-66 (16.9%) and F1-7 (13.6%). The porB class 3 protein and the fHbp subfamily A (variants 2 and 3) genotypes were found in 93.0 and 71.0% of the isolates, respectively. NHBA was present in all isolates, and while most lacked NadA (94.9%), we detected the hyperinvasive lineages B:P1.19,15:F5-1:ST-639 (cc32); C:P1.22,14-6:F3-9:ST-3780 (cc103) and W:P1.5,2:F1-1:ST-11 (cc11). This is the first report on the genetic diversity and vaccine antigen prevalence among N. meningitidis carriage isolates in the Northeast of Brazil. This study highlights the need for ongoing characterization of meningococcal isolates following the introduction of vaccines and for determining public health intervention strategies.

Proponer y poner a prueba un modelo para analizar el nivel de riesgo de reintroducción y transmisión del virus del sarampión que existe en los municipios durante el período posterior a la eliminación en la Región de las Américas.Se realizó un estudio ecológico y analítico empleando datos sobre la epidemia de sarampión que afectó al noreste del Brasil del 2013 al 2015. Las variables para el análisis se seleccionaron después de efectuar un amplio examen de las publicaciones científicas sobre el riesgo de importación de casos de sarampión. Se llevó a cabo un análisis con una sola variable considerando la presencia o ausencia de los casos de sarampión confirmados en 184 municipios del estado de Ceará (Brasil) para evaluar la asociación entre la variable dependiente y 23 variables independientes, que se agruparon en cuatro categorías: 1) características de los municipios; 2) indicadores de calidad de los programas de vacunación y la vigilancia epidemiológica; 3) estructura de organización de la respuesta de salud pública, y 4) indicadores del impacto seleccionados. Se consideró significativo un valor deEl modelo tenía una sensibilidad de 95% en el caso de la concordancia entre los municipios clasificados dentro de las categorías de “riesgo alto” y “riesgo muy alto” y los que tuvieron una epidemia entre el 2013 y el 2015 en Ceará. De los 38 municipios que tuvieron una epidemia, 76% (29/38) se clasificaron dentro de las categorías de “riesgo alto” y “riesgo muy alto”; 146 municipios no notificaron casos (Dado el riesgo inminente de reintroducción de la circulación del sarampión durante el período posterior a la eliminación en la Región de las Américas, este modelo puede ser útil para reconocer las zonas en las que existe un mayor riesgo de reintroducción y transmisión continua del sarampión. El conocimiento de las zonas vulnerables podría desembocar en actividades de vigilancia y seguimiento apropiadas para evitar la transmisión sostenida.Elaborar e testar um modelo para analisar o risco de reintrodução e transmissão do vírus do sarampo ao nível municipal no período pós-eliminação nas Américas.Um estudo analítico-ecológico foi realizado com base nos dados da epidemia de sarampo ocorrida em 2013–2015 no nordeste do Brasil. As variáveis para análise foram selecionadas após extensa revisão da literatura científica sobre o risco de importação de casos de sarampo. Uma análise univariada considerando a presença ou a ausência de casos confirmados de sarampo em 184 municípios no Estado do Ceará foi conduzida para avaliar a associação entre a variável dependente e 23 variáveis independentes divididas em quatro grupos: 1) características dos municípios, 2) indicadores de qualidade dos programas de vacinação e da vigilância epidemiológica, 3) estrutura organizacional para resposta em saúde pública e 4) indicadores de impacto selecionados. Um nível de significância de 5% foi definido. Todas as variáveis comA sensibilidade do modelo foi de 95% para concordância entre os municípios categorizados como “risco alto” e “risco muito alto” e os que registraram a ocorrência de epidemia entre 2013 e 2015 no Ceará. Dos 38 municípios onde ocorreu uma epidemia, 76% (29/38) apresentaram “risco alto” e “risco muito alto” de reintrodução e transmissão do vírus do sarampo e 146 municípios não notificaram casos (Diante do risco iminente de reintrodução da circulação do vírus do sarampo no período pós-eliminação nas Américas, este modelo pode servir para identificar as áreas de maior risco de reintrodução e transmissão contínua do vírus do sarampo. Conhecer as áreas vulneráveis incentiva a adoção de procedimentos adequados de vigilância e monitoramento a fim de prevenir a transmissão sustentada.

Polysaccharide vaccine did not affect carriage nor interrupt transmission of an epidemic strain., During 2010, outbreaks of serogroup C meningococcal (MenC) disease occurred in 2 oil refineries in São Paulo State, Brazil, leading to mass vaccination of employees at 1 refinery with a meningococcal polysaccharide A/C vaccine. A cross-sectional study was conducted to assess the prevalence of meningococci carriage among workers at both refineries and to investigate the effect of vaccination on and the risk factors for pharyngeal carriage of meningococci. Among the vaccinated and nonvaccinated workers, rates of overall meningococci carriage (21.4% and 21.6%, respectively) and of MenC carriage (6.3% and 4.9%, respectively) were similar. However, a MenC strain belonging to the sequence type103 complex predominated and was responsible for the increased incidence of meningococcal disease in Brazil. A low education level was associated with higher risk of meningococci carriage. Polysaccharide vaccination did not affect carriage or interrupt transmission of the epidemic strain. These findings will help inform future vaccination strategies.

Introduction In March, 2006, oral rotavirus vaccine was added to Brazil's infant immunization schedule with recommended upper age limits for initiating (by age 14 weeks) and completing (by age 24 weeks) the two-dose series to minimize age-specific risk of intussusception following rotavirus vaccination. Several years after introduction, estimated coverage with rotavirus vaccine (83%) was lower compared to coverage for other recommended childhood immunizations (≥94%). Methods We analyzed data from Brazil's national immunization program on uptake of oral rotavirus vaccine by geographic region and compared administrative coverage estimates for first and second doses of oral rotavirus vaccine (Rota1 and Rota2) with first and second doses of diphtheria-tetanus-pertussis-Haemophilus influenzae type b vaccine (DTP-Hib1 and DTP-Hib2). For 27 Brazilian cities, we compared differences between estimated rotavirus and DTP-Hib coverage in 2010 with delayed receipt of DTP-Hib vaccine among a cohort of children surveyed before rotavirus introduction. Results In 2010, infant vaccination coverage was 99.0% for DTP-Hib1 versus 95.2% for Rota1 (3.8% difference), and 98.4% for DTP-Hib2 versus 83.0% for Rota2 (15.4% difference), with substantial regional variation. Differences between DTP-Hib and rotavirus vaccination coverage in Brazilian cities correlated with delay in DTP-Hib vaccination among children surveyed. Age restrictions for initiating and completing the rotavirus vaccination series likely contributed to lower coverage with rotavirus vaccine in Brazil. Conclusion To maximize benefits of rotavirus vaccination, strategies are needed to improve timeliness of routine immunizations; monitoring rotavirus vaccine uptake and intussusception risk is needed to guide further recommendations for rotavirus vaccination.

Neisseria meningitidis is a commensal bacterium of the human nasopharynx. In rare cases, it penetrates the mucosa, entering the blood stream and causing various forms of disease. Meningococcal conjugate vaccines can prevent invasive disease not only by direct effect in vaccinated individuals but also by herd protection, preventing acquisition of carriage, which interrupts transmission and leads to protection of unvaccinated persons. In 2010 in Salvador, Brazil, an outbreak of group C meningococcal disease led to a mass meningococcal serogroup C conjugate vaccination drive, targeting those

BACKGROUND Meningococcal C conjugate (MenC) vaccine was introduced as part of the Brazilian National Immunisation Program in 2010 for children < 1 year of age. OBJECTIVES The study objective was to evaluate the impact of this vaccination strategy. METHODS An observational, mixed ecological and analytical study was conducted, based on time series panel data from surveillance records (2001-2013). FINDINGS A total of 37,538 of meningococcal disease cases were recorded during the study period. Of these, 19,997 were attributed to serogroup C. A decrease in meningococcal disease serogroup C (MDC) incidence among children aged < 1 year [65.2%; 95% confidence interval (CI): 20.5-84.7%] and 1-4 years (46.9%; 95%CI: 14.6-79.1%) were found in the three years following vaccination introduction. Vaccination impact on the reduction of MDC incidence varied from 83.7% (95%CI: 51.1-100.0%) in the Midwest region to 56.7% (95%CI: 37.4-76.0%) in the Northeast region. MAIN CONCLUSIONS Vaccination against MDC in Brazil had a positive impact on the population of children aged < 1 year, across all regions, and on the 1-4 year-old cohort. Nevertheless, in our view there is scope for improving the vaccination strategy adopted in Brazil.

Summary Objectives In emerging countries, pneumonia is a leading cause of hospitalization and death, particularly among the youngest and oldest. This retrospective study aimed to quantify the incidence of hospitalization due to all-cause pneumonia (HDTP) and in-hospital case fatality rates (CFRs) in all age groups, in five administrative regions of Brazil. Methods The International Classification of Diseases Tenth Revision coding for pneumonia (J12–J18) and an interactive web-based database of individuals covered by the Unified Health System in Brazil who were hospitalized from 2003 to 2007, were used to identify cases. In-hospital CFRs were the percentage of hospitalized cases that died. Results The overall HDTP incidence per 100 000 people of all ages decreased from 451 in 2003 to 388 in 2007. When categorized by age group, the HDTP incidence was lowest for those aged 5–49 years, and highest in children aged ≤4 years and adults aged ≥50 years. The in-hospital CFR increased from 2.89% in 2003 to 4.02% in 2007. Regional differences in HDTP incidence rates and in-hospital CFR were observed from 2003 to 2007. Conclusions As expected, the highest HDTP rates were observed in the very young and the elderly. Regional differences in hospitalization incidence rates and in-hospital CFRs were observed.

Household contacts are important sources of Bordetella pertussis in infants. A total of 353 household contacts of 97 index cases were evaluated for pertussis by culture and polymerase chain reaction. Twenty eight contacts were positive (8.0%). The presence of symptoms did not influence the rate of diagnosed bacteriologic pertussis in communicants. We conclude that contacts with an index case can be positive for B. pertussis independently of the presence of symptoms.

Background: Brazil implemented routine immunization with the human rotavirus vaccine, Rotarix, in 2006 and vaccination coverage reached 81% in 2008 in Sao Paulo. Our aim was to assess the impact of immunization on the incidence of severe rotavirus acute gastroenteritis (AGE). Methods: We performed a 5-year (2004-2008) prospective surveillance at a sentinel hospital in Sao Paulo, with routine testing for rotavirus in all children less than 5 years of age hospitalized with AGE. Genotypes of positive samples were determined by reverse transcription polymerase chain reaction. Results: During the study, 655 children hospitalized with AGE were enrolled; of whom 169 (25.8%) were positive for rotavirus. In the post-vaccine period, a 59% reduction in the number of hospitalizations of rotavirus AGE and a 42.2% (95% confidence interval [CI], 18.6%-59.0%; P = 0.001) reduction in the proportion of rotavirus-positive results among children younger than 5 years were observed, with the greatest decline among infants (69.2%; 95% CI, 24.7%-87.4%; P = 0.004). Furthermore, the number of all-cause hospitalizations for AGE was reduced by 29% among children aged

OBJECTIVE: To compare the costs and benefits of pneumococcal conjugate vaccination compared with no vaccination from the perspectives of the health care system and society. METHODS: Using data from established sources, we estimated the incidence and mortality due to invasive pneumococcal disease, pneumonia, and acute otitis media (AOM) for a hypothetical birth cohort of children from birth to 5 years. RESULTS: A universal pneumococcal conjugate vaccination program was estimated capable of annually avoiding 1 047 cases of invasive disease, 58 226 cases of pneumonia, and 209 862 cases of AOM. When herd immunity effects were considered, the program prevented 1.3 million cases of pneumococcal disease and over 7 000 pneumococcal deaths. At a vaccination cost of R$ 51.12 (US$ 26.35) per dose, vaccination would cost annually R$ 4 289 (US$ 2,211) per disability-adjusted life years averted. This does not take into account herd immunity effects. CONCLUSIONS: At the current vaccine price, conjugate vaccination could be a cost-effective investment compared to other options to control childhood diseases. Further analysis is required to determine whether vaccination at the current price is affordable to Brazil.OBJETIVO: Comparar los costos y los beneficios de la aplicación de la vacuna conjugada antineumocócica en comparación con la no vacunación, desde las perspectivas del sistema de salud y la sociedad. MÉTODOS: A partir de fuentes reconocidas, se estimaron la incidencia y la mortalidad por enfermedad neumocócica invasora, neumonía y otitis media aguda (OMA) para una cohorte hipotética de niños desde su nacimiento hasta los 5 años. RESULTADOS: Se estimó que un programa de vacunación universal con una vacuna conjugada antineumocócica sería capaz de evitar anualmente 1 047 casos de la enfermedad invasora, 58 226 casos de neumonía y 209 862 casos de OMA. Si se considera el efecto de la inmunidad de grupo, el programa evitaría 1,3 millones de casos de enfermedad y más de 7 000 muertes por infección neumocócica. A R$ 51,12 (US$ 26,35) por dosis, la vacunación costaría anualmente R$ 4 286 (US$ 2,211) por cada año de vida ajustado por discapacidad evitado, sin tomar en cuenta el efecto de la inmunidad de grupo. CONCLUSIONES: En comparación con otras opciones de control de estas enfermedades infantiles y con los precios actuales de la vacuna conjugada, la vacunación antineumocócica podría ser una inversión efectiva en función del costo. Se requieren más estudios para determinar si la vacunación es costeable para Brasil a los precios actuales.

We conducted a multi-stage household cluster survey to calculate hepatitis B vaccine coverage among children 18–30 months of age in 27 Brazilian cities. Hepatitis B vaccine is administered at birth, 1 month and 6 months of age by Brazil's national immunization program. Among 17,749 children surveyed, 40.2% received a birth dose within one day of birth, 94.8% received at least one dose of hepatitis B vaccine, and 86.7% completed the three-dose series by 12 months of age. Increased coverage with the birth dose and administration of hepatitis B in combination with diphtheria–tetanus–pertussis– Haemophilus influenzae type b antigens could improve protection against hepatitis B.

Despite almost universal use of measles vaccines in recent decades, epidemics of the disease continue to occur. Understanding the role of primary vaccine failure (failure to seroconvert after vaccination) and secondary vaccine failures (waning immunity after seroconversion) in measles epidemics is important for the evaluation of measles control programs in developing countries. After a measles epidemic in São Paulo, Brazil, 159 cases previously confirmed by detection of specific immunoglobulin M (IgM) antibodies were tested for IgG avidity, and a secondary immune response, defined by an IgG avidity index of at least 30%, was established in 30 of 159 (18.9%) patients. Among the 159 patients, 107 (67.3%) had not been vaccinated and 52 (32.7%) had received one or more doses of measles vaccine. Of the 107 unvaccinated patients, 104 (97.2%) showed a primary immune response, defined as an IgG avidity index of less than 30%. Among the 52 patients with documented vaccination, 25 (48.1%) showed a primary immune response and 27 (51.9%) showed a secondary immune response, thereby constituting a secondary vaccine failure. Primary vaccine failure was observed in 13 of 13 patients vaccinated prior to 1 year of age and in 43.5 and 12.5%, respectively, of patients receiving one or two doses after their first birthdays. These results provide evidence that measurement of IgG avidity can be used to distinguish between primary and secondary vaccine failures in vaccinated patients with measles; the method can also be a useful tool for the evaluation of measles control programs.

During a resurgence of measles in Sao Paulo, Brazil, in 1997, >40,000 cases (peak incidence rate of 246/ 100,000 inhabitants) and 42 measles-related deaths were reported. Reverse transcriptase-polymerase chain reaction and nucleotide sequencing were used to analyze specimens from patients who had typical clinical measles infection during this outbreak and from six patients who had had measles in 1995 and 1996. Although wild-type measles viruses (genotypes D5 and D6) were present in Sao Paulo before this resurgence, we detected only D6 viruses. The genotype D6 viruses isolated during this outbreak had identical sequences to genotype D6 viruses isolated in other parts of Brazil and South America in 1997 and 1998, suggesting that a single chain of transmission was responsible. We also identified genotype A viruses in two vaccine-associated cases from 1995 and 1996. Our findings extend the knowledge of the circulation patterns of measles virus in South America, contributing to measles control efforts in the Americas.

OBJECTIVE To characterize patients of primary health care services according to demographic and socioeconomic aspects, habits and lifestyle, health condition, and demand for health services and medicines. METHODS This study is part of the Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos – Serviços (PNAUM – National Survey on Access, Use and Promotion of Rational Use of Medicines – Services), a cross-sectional study carried out between 2014 and 2015. Interviews were conducted with patients over the age of 17 years, with a standardized questionnaire, in primary health care services of a representative sample of cities, stratified by regions of Brazil. The analysis was performed for complex samples and weighted according to the population size of each region. RESULTS A total of 8,676 patients were interviewed, being 75.8% women, most of them aged from 18 to 39 years; 24.2% men, most of them aged from 40 to 59 years; 53.7% with elementary school; 50.5% reported to be of mixed race ethnicity, 39.7%, white, and 7.8%, black. Half of patients were classified as class C and 24.8% received the Bolsa Familia benefit. Only 9.8% had health insurance, with higher proportion in the South and lower in the North and Midwest. The proportion of men who consumed alcohol was higher than among women, as well as smokers. The self-assessment of health showed that 57% believed it to be very good or good, with lower proportion in the Northeast. The prevalence of chronic diseases/conditions, such as hypertension (38.6%), dyslipidemia (22.7%), arthritis/rheumatism (19.4%), depression (18.5%), diabetes (13.6%), and others are higher in these patients them among the general population. Medicines were predominantly sought in the health care service or in pharmacies of the Brazilian Unified Health System. CONCLUSIONS It was possible to characterize the profile of patients of Primary Health Care, but the originality of the research and its national scope hinders the comparison of results with official data or other articles. RESUMO OBJETIVO Caracterizar os usuários dos serviços de atenção primária à Saúde segundo aspectos demográficos, socioeconômicos, hábitos e estilo de vida, condições de saúde referidas e demanda aos serviços de saúde e medicamentos. MÉTODOS Foram utilizados dados da Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos – Serviços, um estudo transversal, exploratório, de natureza avaliativa, realizado entre 2014 e 2015. As entrevistas foram realizadas com usuários maiores de 17 anos, com questionário padronizado, em serviços de atenção primária de amostra representativa de municípios, estratificada pelas regiões do Brasil. A análise realizada foi para amostras complexas e ponderada de acordo com o tamanho da população de cada região. RESULTADOS No total foram entrevistados 8.676 usuários, sendo 75,8% mulheres, a maioria de 18 a 39 anos de idade; 24,2% homens, e entre estes, a maioria de 40 a 59 anos; 53,7% com ensino fundamental; 50,5% se autodeclararam pardo, 39,7% branco e 7,8% preto. Metade dos usuários foi classificada como classe C e 24,8% recebia bolsa-família. Apenas 9,8% possuía plano de saúde, com maior proporção no Sul e menor no Norte e no Centro-Oeste. A proporção de homens que consumia bebida alcóolica foi maior que entre mulheres, assim como os fumantes. A autoavaliação de saúde mostrou que 57% acreditavam ser muito boa ou boa, com menor proporção no Nordeste. As prevalências de doenças/condições crônicas como hipertensão (38,6%), dislipidemia (22,7%), artrites/reumatismo (19,4%), depressão (18,5%), diabetes (13,6%) e outras são maiores nesses usuários que na população geral. Os medicamentos eram predominantemente procurados no próprio serviço ou em farmácias do Sistema Único de Saúde. CONCLUSÕES Foi possível caracterizar o perfil dos usuários da Atenção Básica, mas o ineditismo da pesquisa e sua abrangência nacional dificulta a comparação dos resultados com dados oficiais ou de outros artigos.

The objective of this research was to analyze the relationship between socioeconomic statistics and homicide mortality rates in the city of São Paulo between 1988 and 1994. City districts were grouped into five geographic areas. A socioeconomic indicator (ISE) was constructed with census information combining average income of the family head, illiteracy rate for the population over 5 yr of age, average number of rooms and number of persons per household. The higher the score, the better the socioeconomic situation (possible values: 4 to 384). Deaths from homicide were grouped by residential areas, and the rates for these areas were calculated. The association between homicide rates and the socioeconomic situation was analyzed with Spearman correlation coefficients. Average ISE scores varied from 291 in the Central area (homicide rate = 27.96 deaths per 100000) to 119.9 in the East area (homicide rate = 40.38). The Spearman coefficient between ISEs and homicide rates was -0.98 (p0.05). Due to the heterogeneity inside the areas, the median ISE is a better indicator of the socioeconomic conditions yielding an rs = -1.0. Almost half the population resides in areas with the highest risk of homicide mortality (East and South). Taking the Central area as a reference, we found risks of 1.36 in the Western, 1.37 in the Northern, 1.44 in the Eastern and 2.67 in the Southern areas.

The aim of the present study was to identify the rubella virus (RV) and enterovirus (EV) genotypes detected during the Epidemiological Surveillance on Exanthematic Febrile Diseases (VIGIFEX) study and to perform phylogenetic analysis. Ten RV- and four EV-positive oropharyngeal samples isolated from cell culture were subjected to RT-PCR and sequencing. Genotype 1G and echovirus 9 (E-9) was identified in RV- and EV-positive samples, respectively. The RV 1G genotype has been persisting in Brazil since 2000-2001. No evidence of E-9 being involved in exanthematic illness in Brazil has been reported previously. Differential laboratory diagnosis is essential for management of rash and fever disease.

BackgroundSince 1988, Brazil's Unified Health System has sought to provide universal and equal access to immunisations. Inequalities in immunisation may be examined by contrasting vaccination coverage among children in the highest versus the lowest socioeconomic strata. The authors examined coverage with routine infant immunisations from a survey of Brazilian children according to socioeconomic stratum of residence census tract.MethodsThe authors conducted a household cluster survey in census tracts systematically selected from five socioeconomic strata, according to average household income and head of household education, in 26 Brazilian capitals and the federal district. The authors calculated coverage with recommended vaccinations among children until 18 months of age, according to socioeconomic quintile of residence census tract, and examined factors associated with incomplete vaccination.ResultsAmong 17 295 children with immunisation cards, 14 538 (82.6%) had received all recommended vaccinations by 18 months of age. Among children residing in census tracts in the highest socioeconomic stratum, 77.2% were completely immunised by 18 months of age versus 81.2%–86.2% of children residing in the four census tract quintiles with lower socioeconomic indicators (pConclusionsEvidence from Brazilian capitals shows success in achieving high immunisation coverage among poorer children. Strategies are needed to reach children in wealthier areas.

Background. Few population-based studies of infectious etiologies of fever-rash illnesses have been conducted. This study reports on enhanced febrile-rash illness surveillance in Campinas, Brazil, a setting of low measles and rubella virus transmission. Methods. Cases of febrile-rash illnesses in individuals aged ,40 years that occurred during the period 1 May 2003–30 May 2004 were reported. Blood samples were collected for laboratory diagnostic confirmation, which included testing for adenovirus, dengue virus, Epstein-Barr virus (EBV), enterovirus, human herpes virus 6 (HHV6), measles virus, parvovirus-B19, Rickettsia rickettsii, rubella virus, and group A streptococci (GAS) infections. Notification rates were compared with the prestudy period. Results. A total of 1248 cases were notified, of which 519 (42%) had laboratory diagnosis. Of these, HHV-6 (312 cases), EBV (66 cases), parvovirus (30 cases), rubella virus (30 cases), and GAS (30 cases) were the most frequent causes of infection. Only 10 rubella cases met the rubella clinical case definition currently in use. Notification rates were higher during the study than in the prestudy period (181 vs 52.3 cases per 100,000 population aged ,40 years). Conclusions. Stimulating a passive surveillance system enhanced its sensitivity and resulted in additional rubella cases detected. In settings with rubella elimination goals, rubella testing may be considered for all cases of febrile-rash illness, regardless of suspected clinical diagnosis.

To evaluate the immunogenicity and safety of a novel hepatitis B vaccine, after increasing antigen concentration to 25 mug, in comparison to the reference vaccine.Single-blinded randomized trial comparing VrHB-IB (Instituto Butantan) and the reference vaccine (Engerix B(R), Glaxo Smith Kline). Volunteers aged 31 to 40 years were randomized to either experimental (n=216) or control (n=203) groups, and were given three doses of vaccine. The first dose was administered upon recruitment, and the second and third doses 30 and 180 days later, respectively, between 2004 and 2005. Blood samples were collected for analysis before randomization and after the second and third doses. Active search for adverse effects was perforned in the first five days after vaccination. Differences were evaluated using chi-square and Fisher's exact tests, with a 5% significance level.No severe adverse effects were observed. Seroprotection was confirmed in 98.6% (213/216) of volunteers in the experimental group and 95.6% (194/203) of those in the control group. Geometric mean titers were 12,557 and 11,673, respectively.The Brazilian vaccine was considered to be equivalent to the reference vaccine and its use is recommended for adults.

To analyze the efficacy and safety of a recombinant Hepatitis B vaccine in newborns.The study was carried out in a general hospital in the city of Guarulhos, Southeastern Brazil, between 2002 and 2005. The recombinant Hepatitis B vaccine from Instituto Butantan (VrHB-IB) was tested in two clinical trials. In both trials, newborns were randomly allocated to the experimental or control (reference vaccine) groups. Newborns were given three doses of vaccine, one up to 24 hours after birth and the other two 30 and 180 days later. In the first trial, 538 newborns completed the immunization protocol, and 486 in the second. Vaccines were considered equivalent when seroprotection difference was below 5%.Seroprotection in the first trial (anti-HBsor = 10mUI/ml) was 92.5% (247/267) in the experimental group, compared to 98.5% (267/271) in the control (p = 0.001). With this result, VrHB-IB did not fulfill the pre-established criterion for equivalence. After increasing the concentration of antigen in the vaccine to 25 microg, seroprotection reached 100% in the experimental group and 99.2% in the control. No severe adverse effects were recorded.The reformulated VrHB-IB is considered equivalent to the reference vaccine, and its use is recommended in newborns.

The present article rescues initially the forms, content and operational projection of the epidemiological surveillance as indispensable tool for the knowledge field and public health practices. After that, we verify that the health surveillance model establishes an enlargement of this operational concept of surveillance by integrating the collectives and individuals practices in different health necessities dimensions, which includes beyond of the risks and damages control also the eco-socials determinants. In the sequence, we search to dimension the distinct levels of actuation of this sanitary practice articulated to the interventions of promotion, protection and recovery under a located and integrated logic of the unique system of Brazilian health. Finally, we argue that all the conceptual-operational model framework of public health surveillance itself constitutes as a politics and sanitary base for the consolidation of the health promotion paradigm in the collective health field.

Initially this article revises some of the conceptual and operational elements on evaluative research by gathering knowledge and action fields on public health practices. Such concepts are taken according to a wider conception of quality. Then, the article intends to arrange a theoretical model design considering the proposition for implementation of health surveillance actionsAn image-objective definition of organization and integration of health polices and practices based on hierarchic and local logic also take place. Finally, becomings and challenges around the theory in the health evaluation field turn to be the aim of our reflection in order to enable the production of knowledge and approaches to construct logic models which reveals the complexity of interventionist objects as well as its transforming nature of social practices.

This study analyzes the epidemiological behavior of meningococcal disease in the city of São Paulo, Brazil, over the course of the 20th century. Applying data from patient records, death certificates, and epidemiological surveillance, the authors describe trends in the disease throughout the century, seasonal variations, and incidence distribution by area, age, and gender. The temporal trends show constant incidence during endemic periods, interrupted by epidemic events. Four epidemic events during the last century occurred in circumstances of serious social disturbances and were caused by serogroups A (the first two), A and C, and B and C, respectively. Seasonal variations involved aggravation during autumn and winter throughout the entire century. Geographic distribution followed the displacement of the poor population in the urban territory. Age and gender distribution remained unaltered during all the endemic periods, showing an increased risk associated with younger age. The epidemic periods (except for the last) showed major alterations in age and gender distribution, with an increased risk among young people and youth adults and occurrence in all age brackets.

Rubella is a viral infection which causes a mild disease. Teratogenic effects do however occur in 20-50% of children born to women during the first trimester of pregnancy. The goal of rubella vaccination should therefore be to prevent the adverse effects of congenital rubella syndrome caused by intrauterine rubella infection. A major vaccination strategy against measles-mumps-rubella was introduced in 1992 in the state of Sao Paulo Brazil based upon mathematical models and comprised of a pulse vaccination covering all children aged 1-10 years followed by the inclusion of the vaccine in the routine calendar at 15 months of age. This paper reports the evaluation of the efficacy of this mixed vaccination strategy. A rubella seroprevalence survey was conducted on 4953 children aged 1-15 years immediately and one year after the campaign showing the average rubella seroprevalence to have increased from 0.40 to 0.97 over the period. There was a commensurately dramatic drop in the reported number of congenital rubella syndrome cases.

A controlled trial was performed with the purpose of investigating which factors could be considered of significant risk for the development of basal cell carcinoma. A total of 259 cases of basal cell carcinoma diagnosed from July 1991 to July 1992 were compared with 518 controls matched for age and sex. All subjects in both groups were white. Protocol data were submitted to statistical analysis by the chi-square test and by multiple conditional logistic regression analysis and the following conclusions were reached: 1) light skin color (types I and II of the Fitzpatrick classification), odds ratio of 2.8; outdoor work under constant sunlight, odds ratio of 5.0; the presence of actinic lesions due to exposure to the sun, odds ratio of 4.9, are risk factors perse. 2) Type III skin in the Fitzpatrick classification only represents a risk factor when the patient reports a history of intense sunburns, but not in the absence of such a history. 3) Sunburns per se do not represent a risk factor althorig the point made in item 2 of these conclusions is valid. 4) Other suspected risk factors whose significance was not confirmed by multiple conditioned logistic regression analysis were: residence in rural areas, light eyes and blond hair color, extent of the awareness of the "sun x skin cancer" relationship, familial occurrence of skin cancer, excessive exposure to the sun, and freckles appearing in childhood.Realizou-se estudo controlado para investigar quais os fatores de risco, para o desenvolvimento do carcinoma basocelular, são significantes. Foram utilizados 259 casos de carcinoma basocelular (diagnosticados entre julho de 1991 e julho de 1992) e 518 controles, pareados segundo sexo e idade. Submetidos os dados constantes do protocolo à análise estatística (Qui-quadrado e Regressão Logística Múltipla Condicional), foi possível obter as seguintes conclusões na população estudada: 1 - Representam fatores de risco, por si só: - as peles claras de tipo l e II de Fitzpatrick; - a atividade profissional desenvolvida sob exposição constante à luz solar (atividade agropecuária); - a presença de alterações cutâneas decorrentes da exposição crônica à radiação solar. 2 - A pele do tipo III, na classificação de Fitzpatrick, representa fator de risco somente quando há história anterior de queimaduras solares intensas; já em ausência destas queimaduras anteriores, a pele do tipo III passa para o grupo de não-risco. 3 - Os fatores de risco assinalados puderam ser incluídos na equação logarítimica que expressa o Modelo Logístico de Probabilidade de Doença: 1,6041.x1 + 1,5938.x2 + 1,0208.x3 onde x1 é a atividade agropecuária, x2 são as alterações actínicas de pele e x3 o tipo de pele. 4 - Queimaduras solares não representam fator de risco, embora seja válida a ressalva feita no item 2, destas conclusões. 5 - Os outros fatores suspeitos de risco e não confirmados pela Análise de Regressão Logística Múltipla Condicional foram: residência em área rural, olhos e cabelos claros, nível de informação sobre a relação sol X câncer de pele, história familiar de câncer de pele, exposição solar intensa e aparecimento de efélides na infância.