[Show abstract][Hide abstract] ABSTRACT: The study of non-atopic asthma/wheeze in children separately from atopic asthma is relatively recent. Studies have focused on single risk factors and had inconsistent findings.
Emerging Themes in Epidemiology 01/2014; 11:5. · 2.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A large number of human diseases are related to poor access to water and sewer systems, inadequate solid waste management and deficient storm water drainage. The goal of this study was to formulate environmental sanitation indicators and classify sanitation conditions in specific sewer basins and their respective neighborhoods. The database used contains information on the following sanitation components in these areas: water supply, sewer systems, urban drainage, road pavement, building typology and public cleaning. Data was analyzed using cluster analysis. The key variable of each component was identified, and eight sewer basins and twenty-three neighborhoods were classified into the following categories: good, regular, and poor. The use of environmental sanitation indicators allows decision makers to identify critical areas and define priorities for improving environmental sanitation conditions.
Cadernos de saúde pública / Ministério da Saúde, Fundação Oswaldo Cruz, Escola Nacional de Saúde Pública 06/2013; 29(6):1173-85. · 0.83 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This paper discusses the role of qualitative approaches in epidemiological studies, beginning with a general discussion of epidemiological and anthropological methods. It focuses on a case study of the health impact of an environmental intervention carried out in Salvador, Bahia State, Brazil. Most of the precedent studies fields, based on primary date, use to devote little attention to the methodological and theorethical questions attached to long-term studies. Four specific aspects of this experience are highlighted: (a) drawing up epidemiological study; (b) construction of an observational instrument to measure hygiene habits; (c) an ethnographic study that was carried out before the epidemiological study; (d) observation of the effects of health intervention on health inequalities. Finally, the report details how the findings of qualitative and quantitative studies might be synthesized. It provides a critical overview of follow-up strategies, illustrated with proper examples whenever possible.
Cadernos de saúde pública / Ministério da Saúde, Fundação Oswaldo Cruz, Escola Nacional de Saúde Pública 03/2013; 29(3):461-74. · 0.83 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A case-control study, aimed at identifying factors associated with rotavirus diarrhoea cases presenting to health facilities, was conducted in children from low-income and middle-low-income families in Brazil. Cases were 390 children with diarrhoea and rotavirus in stools; controls were 1674 children without diarrhoea presenting to the same facilities. Data were collected by questionnaire and observations during home visits. Explanatory variables were grouped according to a conceptual model of causation. The ORs by non-conditional logistic regression and population-attributable fractions were calculated. Socioeconomic factors contributed a third of cases, followed by contact with diarrhoea cases and by not being breast fed. In cases aged <1 year, not being breast fed was the main determinant, followed by socioeconomic factors, and crowding and contact outside the home; in older children, socioeconomic factors followed by contact inside and outside the home were the main determinants. Environmental and sanitation variables were not associated with diarrhoea in the final model, and socioeconomic factors were only partly mediated by proximal variables. Transmission of rotavirus appears to be mostly by person-to-person contact, and shows marked social differentials not explained by the biological factors studied. The rotavirus vaccine is unlikely to protect against the full range of circulating genotypes of rotavirus, and understanding rotavirus epidemiology remains essential to the development of control policies.
Transactions of the Royal Society of Tropical Medicine and Hygiene 05/2012; 106(7):445-51. · 1.82 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study investigated individual and contextual factors associated with the duration of diarrhoeal episodes in 693 young children living in a large Brazilian city who were followed-up for at least 3 months. The outcome is analysed as a continuous variable, by means of a hierarchical conceptual model organizing the factors in meaningful blocks. A total of 2397 episodes were recorded (median duration 2 days, interquartile range 1-3 days). Low percentage of households connected to the sewerage system in the neighbourhood, low family purchasing power, high agglomeration, mother aged <19 years, low zinc content in child's diet, and episode severity were significantly associated with longer duration (0·26-0·69 days more). Purchasing power effect was largely mediated by environmental conditions, characteristics of the child, and hygienic behaviour. Environmental conditions acted as a possible effect modifier, enhancing the effect on duration of diarrhoea of the child not having being vaccinated against measles or breastfed for >6 months.
Epidemiology and Infection 05/2011; 140(4):689-96. · 2.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Sanitation affects health, especially that of young children. Residents of Salvador, in Northeast Brazil, have had a high prevalence of intestinal parasites. A citywide sanitation intervention started in 1996 aimed to raise the level of sewer coverage from 26% to 80% of households.
We evaluated the impact of this intervention on the prevalence of Ascaris lumbricoides, Trichuris trichuria, and Giardia duodenalis infections in preschool children.
The evaluation was composed of two cross-sectional studies (1998 and 2003-2004), each of a sample of 681 and 976 children 1-4 years of age, respectively. Children were sampled from 24 sentinel areas chosen to represent the range of environmental conditions in the study site. Data were collected using an individual/household questionnaire, and an environmental survey was conducted in each area before and after the intervention to assess basic household and neighborhood sanitation conditions. Stool samples were examined for the presence of intestinal parasites. The effect of the intervention was estimated by hierarchical modeling, fitting a sequence of multivariate regression models.
The prevalence ofA. lumbricoides infection was reduced from 24.4% to 12.0%, T. trichuria from 18.0% to 5.0%, and G. duodenalis from 14.1% to 5.3%. Most of this reduction appeared to be explained by the increased coverage in each neighborhood by the sewage system constructed during the intervention. The key explanatory variable was thus an ecological measure of exposure and not household-based, suggesting that the parasite transmission prevented by the program was mainly in the public (vs. the domestic) domain.
This study, using advanced statistical modeling to control for individual and ecological potential confounders, demonstrates the impact on intestinal parasites of sanitation improvements implemented at the scale of a large population.
Environmental Health Perspectives 11/2010; 118(11):1637-42. · 7.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Instruments for field diagnosis of eczema are increasingly used, and it is essential to understand specific limitations to make best use of their strengths. Our objective was to assess the validity of ISAAC and UK Working Party criteria for field diagnosis of eczema in children.
We performed a cohort study in urban Brazil. Parents/guardians of 1,419 children answered ISAAC phase II questionnaire. Children were examined for skin lesions (UKWP protocol). Two dermatologists examined most cases of eczema (according to ISAAC or UKWP), and a sample without eczema.
Agreement between repeat questionnaires on the filter question was poor (kappa = 0.4). Agreement between the 2 dermatologists was fair (kappa = 0.6). False positive reports included scabies in 39% of ISAAC cases and 33% of UKWP cases. Sensitivity and PPV were low (ISAAC: 37.1% and 16.1%; UKWP: 28.6% and 23.8%). Specificity and NPV were high (ISAAC: 90.0% and 96.6%; UKWP: 95.3% and 96.2%). One-year prevalence of eczema was 11.3% (ISAAC), 5.9% (UKWP) and 4.9% (adjusted dermatologist diagnosis). Point prevalence of scabies (alone or not) was 43%, 33% and 18%, in eczemas according to ISAAC, to UKWP and to dermatologists. The reasons why children with eczema were not identified by ISAAC or UKWP were wrongly denying dry skin, itchy rash or personal history of atopic diseases. A limitation is that questionnaire was already validated in Brazil, but not field tested in this specific setting.
Studies using UKWP or ISAAC criteria should include a validation arm, to contribute to the understanding of potential limitations of their use in different contexts and to explore solutions. We list specific recommendations.
[Show abstract][Hide abstract] ABSTRACT: Background: The causation of asthma is poorly understood. Risk factors for atopic and non-atopic asthma may be different. This study aimed to analyze the associations between markers of poverty, dirt and infections and wheezing in atopic and non-atopic children.
Respiratory Research 01/2010; 11(1). · 3.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In the city of Salvador, a large urban centre in Northeast Brazil, a city-wide sanitation intervention started in 1997, aimed at improving the sewerage coverage of households from 26% to 80%. Our aim was to study the impact of the intervention on the prevalence and incidence of geohelminths in the school-aged population.
THE STUDY COMPRISED TWO COMPARABLE COHORTS: the first assembled in 1997, before the intervention, and the second assembled in 2003, after the intervention. Both were sampled from 24 sentinel areas chosen to represent the different environmental conditions throughout the city. Copro-parasitological examinations were carried out on every individual from both cohorts, at baseline and nine months later. Demographic, socio-economic, and environmental data were collected using semi-structured questionnaires and environmental surveys. A hierarchical modelling approach fitting a sequence of Poisson multivariate linear models was undertaken to test the effect of the intervention variables on the prevalence and incidence rate ratios.
729 and 890 children aged 7-14 years (mean = 10.4 y, SD = 0.05 y) were analysed over the first and the second cohorts, respectively. The adjusted reductions of the prevalence and incidence rates at the second in relation to the first cohort were 27% and 34%, 25% and 32%, 33% and 26%, and 82% and 42% for geohelminths overall, Ascaris lumbricoides, Trichuris trichiura, and hookworm, respectively. Hierarchical modelling showed that a major part of each of these reductions was explained by the intervention.
Our results show that a city-wide sanitation program may reduce significantly the prevalence and incidence of geohelminths.
[Show abstract][Hide abstract] ABSTRACT: Acute gastroenteritis caused by viruses is one of the leading causes of infantile morbidity. The aim of the present study was to investigate the presence of human caliciviruses of the genera norovirus and sapovirus in children up to 3 years of age with acute gastroenteritis from low-income communities in the city of Salvador, Brazil. This study is an extension of previous work carried out to establish the profile of the most prevalent enteric pathogens present in these communities. In this report, 139 fecal samples, collected from July 2001 to January 2002 were analyzed by RT-PCR and 13 (9%) were positive for human caliciviruses. By sequencing, seven isolates were characterized as norovirus genogroup GII and one as sapovirus genotype GII/1. Sequencing of the previously detected group-A rotaviruses and human astroviruses was also performed and revealed the circulation of rotavirus group A genotypes G1P and G9P, and human astrovirus genotypes 6, 7, and 8. No mixed infection was observed. Community-based studies provide geographically representative information on disease burden. However, there are only a few reports in developing countries concerning the genotypes of the most important gastroenteric viruses detected in such communities. The present findings demonstrate the wide diversity of genotypes of the most important viruses responsible for acute gastroenteritis circulating in low-income communities.
Brazilian journal of medical and biological research = Revista brasileira de pesquisas medicas e biologicas / Sociedade Brasileira de Biofisica ... [et al.] 06/2009; 42(5):438-44. · 1.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Poor socioeconomic status (SES) increases diarrhoea risk, mostly mediated by lack of sanitation, poor infrastructure and living conditions. The effectiveness of a city-wide sanitation intervention on diarrhoea in a large urban centre in Northeast Brazil has recently been demonstrated. This article aims to explore how this intervention altered the magnitude of relative and attributable risks of diarrhoea determinants and the pathways by which those factors affect diarrhoea risk.
We investigated determinants of prevalence of diarrhoea in two cohort studies conducted before and after the intervention. Each study enrolled pre-school children followed up for 8 months. For both cohorts, we calculated relative, attributable and mediated risks of diarrhoea determinants by a hierarchical effect decomposition strategy.
The intervention reduced diarrhoea and also changed attributable and relative risks of diarrhoea determinants by altering the pathways of mediation. Before the intervention SES was a major distal diarrhoea determinant (attributable risk: 24%) with 90% of risk mediated by other factors, mostly by lack of sanitation and poor infrastructure (53%). After the intervention, only 13% of risk was attributed to SES, with only 42% mediated by other factors (18% by lack of sanitation and poor infrastructure).
The intervention reduced diarrhoea risk by reducing direct exposure to unfavourable sanitation conditions. At the same time it altered the effect and mediation pathways of most distal diarrhoea determinants, especially SES. This finding corroborates the importance of public sanitation measures in reducing the impact of poverty on diarrhoea. It also underlines the value of studying the impact of public health interventions to improve our understanding of health determinants.
International Journal of Epidemiology 08/2008; 37(4):831-40. · 6.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to estimate the association between Giardia duodenalis infection and anthropometric deficits, as measured by weight-for-age and height-for-age. This cross-sectional study included 629 children from 12 to 48 months of age, selected from 30 geographic areas in the city of Salvador, Bahia State, Brazil. Poisson regression and linear regression were used for the multivariate statistical analyses. G. duodenalis was diagnosed in 13.5% of the children. The children's breastfeeding duration and living conditions (garbage collection and paved streets or sidewalks) modified the effect of G. duodenalis infection on anthropometric status. Among infected children, there were statistically significant associations between weight deficit and shorter breastfeeding (PR=2.22; 95%CI: 1.56-3.14) and inadequate paving of streets and sidewalks (PR=2.00; 95%CI: 1.37-2.92), while height deficit was associated with deficient public garbage collection (PR=2.21; 95%CI: 1.31-2.51). In the linear regression, the association with the anthropometric indicators remained positive and statistically significant. The child's unhealthy living environment aggravated the negative effect of G. duodenalis infection on anthropometric status, and breastfeeding was a protective factor in the outcome.
Cadernos de Saúde Pública 08/2008; 24(7):1527-35. · 0.83 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To identify factors associated with diarrhoea occurrence in children in a city in a middle-income country, with high access to water and sanitation.
A case-control study in the city of Salvador, north-eastern Brazil was conducted from November 2002 to August 2004. The study population consisted of children presenting at a health facility. A total of 1688 cases of diarrhoea and 1676 controls were selected. Data collection was by a questionnaire and structured observation during home visits. The explanatory variables were grouped according to a conceptual model defined previously. Analysis was done using a hierarchical approach, to provide a more dynamic view of the transmission characteristics of childhood diarrhoea. Non-conditional logistic regression was used, and odds ratio and population-attributable fractions were estimated.
Socioeconomic factors contributed most to determining diarrhoea occurrence, followed by interpersonal contact, while factors related to food preparation, the environment and water and sanitation made a smaller contribution.
The findings indicate that the transmission of diarrhoea is influenced by factors from all hierarchical levels, with interpersonal transmission playing a relatively higher role than previously thought. This is compatible with a predominance of viruses and other agents spread by interpersonal routes including Shigella, Giardia and Cryptosporidium. Diarrhoea control strategies in similar settings (middle-income countries in which a large proportion of the population has access to water and sanitation) must give greater emphasis to policies geared towards reducing person-to-person transmission for the prevention of diarrhoea.
International Journal of Epidemiology 06/2008; 37(4):805-15. · 6.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is evidence that poverty, health and nutrition affect children's cognitive development. This study aimed to examine the relative contributions of both proximal and distal risk factors on child cognitive development, by breaking down the possible causal pathways through which poverty affects cognition.
This cohort study collected data on family socioeconomic status, household and neighbourhood environmental conditions, child health and nutritional status, psychosocial stimulation and nursery school attendance. The effect of these on Wechsler Pre-School and Primary Scale of Intelligence scores at five years of age was investigated using a multivariable hierarchical analysis, guided by the proposed conceptual framework.
Unfavourable socioeconomic conditions, poorly educated mother, absent father, poor sanitary conditions at home and in the neighbourhood and low birth weight were negatively associated with cognitive performance at five years of age, while strong positive associations were found with high levels of domestic stimulation and nursery school attendance.
Children's cognitive development in urban contexts in developing countries could be substantially increased by interventions promoting early psychosocial stimulation and preschool experience, together with efforts to prevent low birth weight and promote adequate nutritional status.
BMC Public Health 02/2008; 8:202. · 2.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A city-wide sanitation intervention was started in Salvador, Brazil, in 1997 to improve sewerage coverage from 26% of households to 80%. Our aim was to investigate the epidemiological effect of this city-wide sanitation programme on diarrhoea morbidity in children less than 3 years of age.
The investigation was composed of two longitudinal studies done in 1997-98 before the intervention (the sanitation programme) and in 2003-04 after the intervention had been completed. Each study consisted of a cohort of children (841 in the preintervention study and 1007 in the postintervention study; age 0-36 months at baseline) who were followed up for a maximum of 8 months. Children were sampled from 24 sentinel areas that were randomly chosen to represent the range of environmental conditions in the study site. At the start of each study an individual or household questionnaire was applied by trained fieldworkers; an environmental survey was done in each area before and after introduction of the sanitation programme to assess basic neighbourhood and household sanitation conditions. Daily diarrhoea data were obtained during home visits twice per week. The effect of the intervention was estimated by a hierarchical modelling approach fitting a sequence of multivariate regression models.
Diarrhoea prevalence fell by 21% (95% CI 18-25%)-from 9.2 (9.0-9.5) days per child-year before the intervention to 7.3 (7.0-7.5) days per child-year afterwards. After adjustment for baseline sewerage coverage and potential confounding variables, we estimated an overall prevalence reduction of 22% (19-26%).
Our results show that urban sanitation is a highly effective health measure that can no longer be ignored, and they provide a timely support for the launch of 2008 as the International Year of Sanitation.
The Lancet 12/2007; 370(9599):1622-8. · 39.06 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Several longitudinal studies have investigated factors associated with childhood diarrhea in developing countries. However, most studies have neglected important dynamic features of the longitudinal design and hierarchical interrelationships among the potential risk factors.
We conducted a longitudinal study of 902 children, age 0 to 36 months at baseline, in a large urban center in northeastern Brazil. Diarrhea data were collected by following children from October 2000 until January 2002 with biweekly home visits. We used a dynamic time-to-event analysis to account for several longitudinal features. We applied an effect-decomposition strategy to quantify direct and indirect effects of risk factors grouped in different blocks.
Child's age and an autoregressive effect of past diarrhea episodes explained some of the decline of diarrhea incidence observed throughout the study (from more than 14 episodes to 2 episodes per child-year), a phenomenon already observed but not explained in other longitudinal diarrhea studies. We identified the following major diarrhea determinants: low socioeconomic status, poor sanitation conditions, presence of intestinal parasites, and absence of prenatal examination. The effect of socioeconomic status was mediated mostly by living and sanitation conditions.
Our study shows important advantages of applying a dynamic analysis approach to longitudinal observational studies of diarrhea or other acute diseases and highlights the complex interrelationships of diarrhea determinants. Our results confirm the importance of sanitation as a major determinant of child health in urban settings of developing countries.
[Show abstract][Hide abstract] ABSTRACT: Community-based monitoring was conducted in order to investigate the occurrence of diarrhea in 'sentinel areas' of Salvador, Brazil, and to establish a preliminary profile of the most common pathogens present in children's diarrhea by screening stool samples. This report describes the results obtained from twice weekly home visits to identify and follow diarrhea episodes and testing of carer-requested stool sample collection over a 6-month period. Participants were selected from a large longitudinal study in 21 areas representing the city's poorer socioeconomic and sanitary conditions. Fecal samples were examined for the presence of pathogenic bacteria, viruses and protozoa. The mean incidence of diarrhea was 4.97 episodes per child-year, and longitudinal prevalence was 13.6 days per child-year (3.7%). Pathogens were found in 44% of the fecal samples examined. Bacteria were the most frequently encountered pathogens (isolated in 22% of samples), followed by protozoa (19.5%) and viruses (16%). Viral and bacterial pathogens were associated with episodes of severe diarrhea, while viral and protozoan pathogens were associated with longer episodes. The study demonstrated the importance of a public health monitoring system based on 'sentinel areas'.
Transactions of the Royal Society of Tropical Medicine and Hygiene 04/2006; 100(3):234-42. · 1.82 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report the frequency of the different diarrheagenic Escherichia coli (DEC) categories isolated from children with acute endemic diarrhea in Salvador, Bahia. The E. coli isolates were investigated by colony blot hybridization with the following genes probes: eae, EAF, bfpA, Stx1, Stx2, ST-Ih, ST-Ip, LT-I, LT-II, INV, and EAEC, as virulence markers to distinguish typical and atypical EPEC, EHEC/STEC, ETEC, EIEC, and EAEC. Seven of the eight categories of DEC were detected. The most frequently isolated was atypical EPEC (10.1%) followed by ETEC (7.5%), and EAEC (4.2%). EHEC, STEC, EIEC, and typical EPEC were each detected once. The strains of ETEC, EAEC, and atypical EPEC belonged to a wide variety of serotypes. The serotypes of the others categories were O26:H11 (EHEC), O21:H21 (STEC), O142:H34 (typical EPEC), and O:H55 (EIEC). We also present the clinical manifestations and other pathogenic species observed in children with DEC. This is the first report of EHEC and STEC in Salvador, and one of the first in Brazil.
Memórias do Instituto Oswaldo Cruz 08/2005; 100(4):359-63. · 1.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study sought to assess the effect of giardiasis on growth of young children. In Salvador, northeast Brazil, 597 children initially aged 6 to 45 months were followed for a year in 1998/9, measured anthropometrically thrice, every 6 months, and monitored for diarrhoea prevalence twice weekly. Stool samples were collected and examined during the second round of anthropometry, and infected children were treated 39 days later, on average (S.D. 20 days). For each 6-month interval, the gains in z-scores of infected and uninfected children were compared, after adjustment for potential confounding factors, including longitudinal prevalence of diarrhoea. No significant difference was found for the first interval but in the second, the gain in adjusted height-for-age z-score was 0.09 less in infected than uninfected children, equivalent to a difference in height gain of 0.5 cm. The shortfall in growth was greater in children who remained free of diarrhoea, and was significantly correlated with the proportion of the second interval during which the child had remained untreated. We conclude that Giardia can impede child growth even when asymptomatic, presumably through malabsorption. This finding challenges the view that young children found to have asymptomatic giardiasis in developing countries should not be treated.
[Show abstract][Hide abstract] ABSTRACT: This study examined the evolution and duration of diarrhoea episodes observed in a community setting, with regard to symptoms and carers' responses. The study group comprised 1156 children, aged 0-36 months, who were followed-up with twice-weekly home visits in 30 sampling areas in the city of Salvador, northeast Brazil. A total of 2403 diarrhoea episodes (mean duration: 2.9 days) were recorded. The number of soft/liquid motions per day (3.6) did not vary significantly with duration, but other symptoms were more commonly reported in the longer episodes. However, when the data were analysed by day of the episode, rather than the episode's overall duration, the reported frequency of fever and vomiting declined significantly with time. During the course of an episode, rehydration, medication and care-seeking also showed a decline in frequency after the first or second week. As episodes continue, less rehydration and medical care are provided by carers, whereas they ought to be maintained because of the continued purging and cumulative effect of the symptoms. Since most cases of diarrhoea are managed at home, it is important to understand how to encourage better management of the longer episodes, which cause an increasing proportion of mortality in some countries.
Transactions of the Royal Society of Tropical Medicine and Hygiene 07/2005; 99(6):407-16. · 1.82 Impact Factor