Publications by authors named "Marcia C Castro"

114 Publications

COVID-19 and mental health of pregnant women in Ceará, Brazil.

Rev Saude Publica 2021 2;55:37. Epub 2021 Jun 2.

Universidade Federal do Ceará. Faculdade de Medicina. Departamento de Saúde Coletiva. Fortaleza, CE, Brasil.

Objective: To assess the perceptions of pregnant women about COVID-19 and the prevalence of common mental disorders during the implemented social distancing period.

Methods: This was an observational, cross-sectional study using digital media, of pregnant women exposed to social distancing due to the COVID-19 pandemic, in Fortaleza, Ceará, Northeastern Brazil. Common mental disorders were estimated using the modified Self-Report Questionnaire-20 (SRQ-20) scale, and the feelings towards COVID-19 were assessed using the Fear of COVID-19 scale through telephone calls made in May 2020. COX multivariate regression models were used to verify the associations.

Results: Of the 1,041 pregnant women, 45.7% (95%CI: 42.7-48.8) had common mental disorders (CMD). All items of the Fear of COVID-19 Scale showed a significant association with the prevalence of CMD (p < 0.001). A CMD risk gradient was observed, going from a prevalence ratio of 1.52 (95%CI: 1.13-2.04) in pregnant women with two positive items to 2.70 (95%CI: 2.08-3.51) for those with four positive items. Early gestational age and the lack of prenatal care were also associated with CMD.

Conclusions: The prevalence of common mental disorders in pregnant women was high during the period of social distancing and was aggravated by negative feelings towards COVID-19.
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http://dx.doi.org/10.11606/s1518-8787.2021055003225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8139842PMC
June 2021

Fine-scale variation in malaria prevalence across ecological regions in Madagascar: a cross-sectional study.

BMC Public Health 2021 05 29;21(1):1018. Epub 2021 May 29.

Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA, USA.

Background: Large-scale variation in ecological parameters across Madagascar is hypothesized to drive varying spatial patterns of malaria infection. However, to date, few studies of parasite prevalence with resolution at finer, sub-regional spatial scales are available. As a result, there is a poor understanding of how Madagascar's diverse local ecologies link with variation in the distribution of infections at the community and household level. Efforts to preserve Madagascar's ecological diversity often focus on improving livelihoods in rural communities near remaining forested areas but are limited by a lack of data on their infectious disease burden.

Methods: To investigate spatial variation in malaria prevalence at the sub-regional scale in Madagascar, we sampled 1476 households (7117 total individuals, all ages) from 31 rural communities divided among five ecologically distinct regions. The sampled regions range from tropical rainforest to semi-arid, spiny forest and include communities near protected areas including the Masoala, Makira, and Mikea forests. Malaria prevalence was estimated by rapid diagnostic test (RDT) cross-sectional surveys performed during malaria transmission seasons over 2013-2017.

Results: Indicative of localized hotspots, malaria prevalence varied more than 10-fold between nearby (< 50 km) communities in some cases. Prevalence was highest on average in the west coast region (Morombe district, average community prevalence 29.4%), situated near protected dry deciduous forest habitat. At the household level, communities in southeast Madagascar (Mananjary district) were observed with over 50% of households containing multiple infected individuals at the time of sampling. From simulations accounting for variation in household size and prevalence at the community level, we observed a significant excess of households with multiple infections in rural communities in southwest and southeast Madagascar, suggesting variation in risk within communities.

Conclusions: Our data suggest that the malaria infection burden experienced by rural communities in Madagascar varies greatly at smaller spatial scales (i.e., at the community and household level) and that the southeast and west coast ecological regions warrant further attention from disease control efforts. Conservation and development efforts in these regions may benefit from consideration of the high, and variable, malaria prevalences among communities in these areas.
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http://dx.doi.org/10.1186/s12889-021-11090-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8164762PMC
May 2021

Levels and trends in Chagas disease-related mortality in Brazil, 2000-2019.

Acta Trop 2021 May 7;220:105948. Epub 2021 May 7.

Institute of Studies in Public Health, Federal University of Rio de Janeiro, Avenida Horácio Macedo, S/N, Ilha do Fundão - Cidade Universitária, Rio de Janeiro 21941-598, Brazil; Department of Epidemiology, Social Medicine Institute, State University of Rio de Janeiro, Rua São Francisco Xavier 524, Maracanã, Rio de Janeiro 20550-013, Brazil.

Chagas disease remains an important public health problem with high morbidity and mortality in several Latin American countries. This nationwide population-based ecological study analyzes the epidemiological characteristics and time trends of Chagas disease-related mortality in Brazil, 2000-2019. We included all deaths reported in Brazil in which Chagas disease was mentioned in the death certificate either as an underlying or associated cause of death (multiple causes of death). Crude and age-adjusted mortality rates (per 100,000 inhabitants) were calculated and time trends analysis was performed using joinpoint regression models. In the study period, a total of 22,663,092 deaths were recorded in Brazil. Chagas disease was identified in 122,291 deaths (0.54%), 94.788 (77.5%) as an underlying cause and 27,503 (22.5%) as an associated cause. Average annual age-adjusted mortality rate was 3.22 deaths/100,000 inhabitants (95% confidence interval [CI]: 3.14-3.30). Chronic Chagas disease with cardiac involvement was the predominant clinical presentation mentioned. The highest mortality rates were observed in males, age group ≥80 years, black race/skin color, schooling 1-3 years of study, and residents in the Central-West region. Age-adjusted mortality rates showed a significant declining trend at the national level in the period (Average Annual Percent Change: -3.1%; 95% CI: -3.3; -3.0), with different local patterns and a more pronounced reduction in important endemic areas in the past. The findings show that, despite a consistent decline in mortality rates in Brazil over the study period, Chagas disease remains an important and neglected cause of death in the country, showing a marked regional variation that has social and health care implications. In addition to the control measures for disease transmission, it is necessary to guarantee access, coverage, and quality of health care to Chagas disease patients, seeking to prevent the occurrence of severe forms and deaths from the disease.
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http://dx.doi.org/10.1016/j.actatropica.2021.105948DOI Listing
May 2021

Interacting Epidemics in Amazonian Brazil: Prior Dengue Infection Associated with Increased COVID-19 Risk in a Population-Based Cohort Study.

Clin Infect Dis 2021 May 6. Epub 2021 May 6.

Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil.

Background: Immunity after dengue virus (DENV) infection has been suggested to cross-protect from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and mortality.

Methods: We tested whether serologically proven prior DENV infection diagnosed in September-October 2019, before the coronavirus 2019 (COVID-19) pandemic, reduced the risk of SARS-CoV-2 infection and clinically apparent COVID-19 over the next 13 months in a population-based cohort in Amazonian Brazil. Mixed-effects multiple logistic regression analysis was used to identify predictors of infection and disease, adjusting for potential individual and household-level confounders. Virus genomes from 14 local SARS-CoV-2 isolates were obtained using whole-genome sequencing.

Results: Anti-DENV IgG was found in 37.0% of 1,285 cohort participants (95% confidence interval [CI], 34.3% to 39.7%) in 2019, with 10.4 (95% CI, 6.7 to 15.5) seroconversion events per 100 person-years during the follow-up. In 2020, 35.2% of the participants (95% CI, 32.6% to 37.8%) had anti-SARS-CoV-2 IgG and 57.1% of the 448 SARS-CoV-2 seropositives (95% CI, 52.4% to 61.8%) reported clinical manifestations at the time of infection. Participants aged >60 y were twice more likely to have symptomatic COVID-19 than under-five children. Locally circulating SARS-CoV-2 isolates were assigned to the B.1.1.33 lineage. Contrary to the cross-protection hypothesis, prior DENV infection was associated with twice the risk of clinically apparent COVID-19 upon SARS-CoV-2 infection, with P values between 0.025 and 0.039 after adjustment for identified confounders.

Conclusion: Higher risk of clinically apparent COVID-19 among individuals with prior dengue has important public health implications for communities sequentially exposed to DENV and SARS-CoV-2 epidemics.
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http://dx.doi.org/10.1093/cid/ciab410DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8135953PMC
May 2021

Characteristics, outcomes and risk factors for mortality of 522 167 patients hospitalised with COVID-19 in Brazil: a retrospective cohort study.

BMJ Open 2021 05 4;11(5):e049089. Epub 2021 May 4.

Secretariat of Health Surveillance, Brazilian Ministry of Health, Brasilia, Brazil.

Objective: To provide a comprehensive description of demographic, clinical and radiographic characteristics; treatment and case outcomes; and risk factors associated with in-hospital death of patients hospitalised with COVID-19 in Brazil.

Design: Retrospective cohort study of hospitalised patients diagnosed with COVID-19.

Setting: Data from all hospitals across Brazil.

Participants: 522 167 hospitalised patients in Brazil by 14 December 2020 with severe acute respiratory illness, and a confirmed diagnosis for COVID-19.

Primary And Secondary Outcome Measures: Prevalence of symptoms and comorbidities was compared by clinical outcomes and intensive care unit (ICU) admission status. Survival was assessed using Kaplan Meier survival estimates. Risk factors associated with in-hospital death were evaluated with multivariable Cox proportional hazards regression.

Results: Of the 522 167 patients included in this study, 56.7% were discharged, 0.002% died of other causes, 30.7% died of causes associated with COVID-19 and 10.2% remained hospitalised. The median age of patients was 61 years (IQR, 47-73), and of non-survivors 71 years (IQR, 60-80); 292 570 patients (56.0%) were men. At least one comorbidity was present in 64.5% of patients and in 76.8% of non-survivors. From illness onset, the median times to hospital and ICU admission were 6 days (IQR, 3-9) and 7 days (IQR, 3-10), respectively; 15 days (IQR, 9-24) to death and 15 days (IQR, 11-20) to hospital discharge. Risk factors for in-hospital death included old age, Black/Brown ethnoracial self-classification, ICU admission, being male, living in the North and Northeast regions and various comorbidities. Age had the highest HRs of 5.51 (95% CI: 4.91 to 6.18) for patients≥80, compared with those ≤20.

Conclusions: Characteristics of patients and risk factors for in-hospital mortality highlight inequities of COVID-19 outcomes in Brazil. As the pandemic continues to unfold, targeted policies that address those inequities are needed to mitigate the unequal burden of COVID-19.
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http://dx.doi.org/10.1136/bmjopen-2021-049089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8098282PMC
May 2021

Effect of socioeconomic inequalities and vulnerabilities on health-system preparedness and response to COVID-19 in Brazil: a comprehensive analysis.

Lancet Glob Health 2021 06 12;9(6):e782-e792. Epub 2021 Apr 12.

Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA.

Background: COVID-19 spread rapidly in Brazil despite the country's well established health and social protection systems. Understanding the relationships between health-system preparedness, responses to COVID-19, and the pattern of spread of the epidemic is particularly important in a country marked by wide inequalities in socioeconomic characteristics (eg, housing and employment status) and other health risks (age structure and burden of chronic disease).

Methods: From several publicly available sources in Brazil, we obtained data on health risk factors for severe COVID-19 (proportion of the population with chronic disease and proportion aged ≥60 years), socioeconomic vulnerability (proportions of the population with housing vulnerability or without formal work), health-system capacity (numbers of intensive care unit beds and physicians), coverage of health and social assistance, deaths from COVID-19, and state-level responses of government in terms of physical distancing policies. We also obtained data on the proportion of the population staying at home, based on locational data, as a measure of physical distancing adherence. We developed a socioeconomic vulnerability index (SVI) based on household characteristics and the Human Development Index. Data were analysed at the state and municipal levels. Descriptive statistics and correlations between state-level indicators were used to characterise the relationship between the availability of health-care resources and socioeconomic characteristics and the spread of the epidemic and the response of governments and populations in terms of new investments, legislation, and physical distancing. We used linear regressions on a municipality-by-month dataset from February to October, 2020, to characterise the dynamics of COVID-19 deaths and response to the epidemic across municipalities.

Findings: The initial spread of COVID-19 was mostly affected by patterns of socioeconomic vulnerability as measured by the SVI rather than population age structure and prevalence of health risk factors. The states with a high (greater than median) SVI were able to expand hospital capacity, to enact stringent COVID-19-related legislation, and to increase physical distancing adherence in the population, although not sufficiently to prevent higher COVID-19 mortality during the initial phase of the epidemic compared with states with a low SVI. Death rates accelerated until June, 2020, particularly in municipalities with the highest socioeconomic vulnerability. Throughout the following months, however, differences in policy response converged in municipalities with lower and higher SVIs, while physical distancing remained relatively higher and death rates became relatively lower in the municipalities with the highest SVIs compared with those with lower SVIs.

Interpretation: In Brazil, existing socioeconomic inequalities, rather than age, health status, and other risk factors for COVID-19, have affected the course of the epidemic, with a disproportionate adverse burden on states and municipalities with high socioeconomic vulnerability. Local government responses and population behaviour in the states and municipalities with higher socioeconomic vulnerability have helped to contain the effects of the epidemic. Targeted policies and actions are needed to protect those with the greatest socioeconomic vulnerability. This experience could be relevant in other low-income and middle-income countries where socioeconomic vulnerability varies greatly.

Funding: None.

Translation: For the Portuguese translation of the abstract see Supplementary Materials section.
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http://dx.doi.org/10.1016/S2214-109X(21)00081-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8041360PMC
June 2021

Spatiotemporal pattern of COVID-19 spread in Brazil.

Science 2021 05 14;372(6544):821-826. Epub 2021 Apr 14.

Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA.

Brazil has been severely hit by COVID-19, with rapid spatial spread of both cases and deaths. We used daily data on reported cases and deaths to understand, measure, and compare the spatiotemporal pattern of the spread across municipalities. Indicators of clustering, trajectories, speed, and intensity of the movement of COVID-19 to interior areas, combined with indices of policy measures, show that although no single narrative explains the diversity in the spread, an overall failure of implementing prompt, coordinated, and equitable responses in a context of stark local inequalities fueled disease spread. This resulted in high and unequal infection and mortality burdens. With a current surge in cases and deaths and several variants of concern in circulation, failure to mitigate the spread could further aggravate the burden.
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http://dx.doi.org/10.1126/science.abh1558DOI Listing
May 2021

Prioritizing COVID-19 vaccination by age.

Proc Natl Acad Sci U S A 2021 04;118(15)

Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610

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http://dx.doi.org/10.1073/pnas.2103700118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8053997PMC
April 2021

Cross-border malaria in Northern Brazil.

Malar J 2021 Mar 6;20(1):135. Epub 2021 Mar 6.

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Building 1, Room 1002A, Boston, MA, 02115, USA.

Background: Cross-border malaria is a major barrier to elimination efforts. Along the Venezuela-Brazil-Guyana border, intense human mobility fueled primarily by a humanitarian crisis and illegal gold mining activities has increased the occurrence of cross-border cases in Brazil. Roraima, a Brazilian state situated between Venezuela and Guyana, bears the greatest burden. This study analyses the current cross-border malaria epidemiology in Northern Brazil between the years 2007 and 2018.

Methods: De-identified data on reported malaria cases in Brazil were obtained from the Malaria Epidemiological Surveillance Information System for the years 2007 to 2018. Pearson's Chi-Square test of differences was utilized to assess differences between characteristics of cross-border cases originating from Venezuela and Guyana, and between border and transnational cases. A logistic regression model was used to predict imported status of cases.

Results: Cross-border cases from Venezuela and Guyana made up the majority of border and transnational cases since 2012, and Roraima remained the largest receiving state for cross-border cases over this period. There were significant differences in the profiles of border and transnational cases originating from Venezuela and Guyana, including type of movement and nationality of patients. Logistic regression results demonstrated Venezuelan and Guyanese nationals, Brazilian miners, males, and individuals of working age had heightened odds of being an imported case. Furthermore, Venezuelan citizens had heightened odds of seeking care in municipalities adjacent Venezuela, rather than transnational municipalities.

Conclusions: Cross-border malaria contributes to the malaria burden at the Venezuela-Guyana-Brazil border. The identification of distinct profiles of case importation provides evidence on the need to strengthen surveillance at border areas, and to deploy tailored strategies that recognize different mobility routes, such as the movement of refuge-seeking individuals and of Brazilians working in mining.
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http://dx.doi.org/10.1186/s12936-021-03668-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7937307PMC
March 2021

Bayesian evidence synthesis to estimate subnational TB incidence: An application in Brazil.

Epidemics 2021 Jun 20;35:100443. Epub 2021 Feb 20.

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston MA, 02115 United States.

Background: Evidence on local disease burden and the completeness of case detection represent important information for TB control programs. We present a new method for estimating subnational TB incidence and the fraction of individuals with incident TB who are diagnosed and treated in Brazil.

Methods: We compiled data on TB notifications and TB-related mortality in Brazil and specified an analytic model approximating incidence as the number of individuals exiting untreated active disease (sum of treatment initiation, death before treatment, and self-cure). We employed a Bayesian inference approach to synthesize data and adjust for known sources of bias. We estimated TB incidence and the fraction of cases treated, for each Brazilian state and the Federal District over 2008-2017.

Findings: For 2017, TB incidence was estimated as 41.5 (95 % interval: 40.7, 42.5) per 100 000 nationally, and ranged from 11.7-88.3 per 100 000 across states. The fraction of cases treated was estimated as 91.9 % (89.6 %, 93.7 %) nationally and ranged 86.0 %-94.8 % across states, with an estimated 6.9 (5.3, 9.2) thousand cases going untreated in 2017. Over 2008-2017, incidence declined at an average annual rate of 1.4 % (1.1 %, 1.9 %) nationally, and -1.1%-4.2 % across states. Over this period there was a 0.5 % (0.2 %, 0.9 %) average annual increase in the fraction of incident TB cases treated.

Interpretation: Time-series estimates of TB burden and the fraction of cases treated can be derived from routinely-collected data and used to understand variation in TB outcomes and trends.
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http://dx.doi.org/10.1016/j.epidem.2021.100443DOI Listing
June 2021

Trends in Untreated Tuberculosis in Large Municipalities, Brazil, 2008-2017.

Emerg Infect Dis 2021 Mar;27(3):957-960

We adapted a mathematical modeling approach to estimate tuberculosis (TB) incidence and fraction treated for 101 municipalities of Brazil during 2008-2017. We found the average TB incidence rate decreased annually (0.95%), and fraction treated increased (0.30%). We estimated that 9% of persons with TB did not receive treatment in 2017.
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http://dx.doi.org/10.3201/eid2703.204094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920690PMC
March 2021

Resurgence of COVID-19 in Manaus, Brazil, despite high seroprevalence.

Lancet 2021 02 27;397(10273):452-455. Epub 2021 Jan 27.

Departamento de Molestias Infecciosas e Parasitarias and Instituto de Medicina Tropical da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP 05403-000, Brazil; MRC Centre for Global Infectious Disease Analysis, J-IDEA, Imperial College London, London, UK; Department of Zoology, University of Oxford, Oxford, UK.

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http://dx.doi.org/10.1016/S0140-6736(21)00183-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7906746PMC
February 2021

Assessing the performance of beneficiary targeting in Brazil's More Doctors Programme.

Health Policy Plan 2021 Mar;36(2):149-161

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA.

Many countries employ strategies that rest on the use of an explicitly defined set of criteria to identify underserved communities. Yet, we know relatively little about the performance of community-level targeting in large-scale health programmes. To address this gap, we examine the performance of community targeting in the More Doctors Programme (MDP). Our analysis covers all 5570 municipalities in the period between 2013 and 2017 using publicly available data. We first calculate the rate at which vulnerable municipalities enrolled in the MDP. Next, we consider two types of mistargeting: (1) proportion of vulnerable municipalities that did not have any MDP physicians (i.e. under-coverage municipalities) and (2) proportion of MDP enrolees that did not fit the vulnerability criteria (i.e. non-target municipalities). We found that almost 70% of vulnerable municipalities received at least one MDP physician between 2013 and 2017; whereas non-target municipalities constituted 33% of beneficiaries. Targeting performance improved over time. Non-target municipalities had the highest levels of socioeconomic development and greater physician availability. The poverty rate among under-coverage municipalities was almost six times that in non-target municipalities. Under-coverage municipalities had the lowest primary care physician availability. They were also smaller and more sparsely populated. We also found small differences in the political party alignments of mayors and the President between under-coverage and non-target municipalities. Our results suggest that using community-level targeting approaches in large-scale health programmes is a complex process. Programmes using these approaches may face substantial challenges in beneficiary targeting. Our results highlight that policymakers who consider using these approaches should carefully study various municipal characteristics that may influence the implementation process, including the level of socioeconomic development, health supply factors, population characteristics and political party alignments.
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http://dx.doi.org/10.1093/heapol/czaa137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7996646PMC
March 2021

Prenatal care and preterm birth in the Western Brazilian Amazon: A population-based study.

Glob Public Health 2021 Jan 10:1-12. Epub 2021 Jan 10.

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

Brazil is among the top ten countries in preterm delivery worldwide. This study assesses the factors associated with preterm birth in the Western Brazilian Amazon. A population-based cross-sectional study was held between July 2015 to June 2016 in Cruzeiro do Sul, Brazilian Amazon. A total of 1525 births were included in this analysis. Preterm birth was defined as births at gestational age < 37 weeks. A stepwise multiple logistic regression was used to identify factors associated with preterm delivery. The prevalence rate of preterm birth was 7.9% ( = 120; 95% CI: 6.5-9.3). After adjusting for confounding factors, a positive association with preterm birth was observed for pregnant women who completed less than six antenatal care visits (OR: 2.93; 95% CI: 1.89-4.56), who had a birth interval of < 18 months (OR: 2.65; 95% CI: 1.04-6.75), and who experienced bleeding (OR: 2.17; 95% CI: 1.39-3.38) and hypertension during pregnancy (OR: 1.74; 95% CI: 1.07-2.82). Factors associated with preterm birth in the Western Brazilian Amazon were mostly related to the aspects of health care provided to women, and thus could be prevented. Proper, timely, and regular antenatal care visits can help reduce adverse outcomes, such as hypertension and bleeding.
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http://dx.doi.org/10.1080/17441692.2020.1865429DOI Listing
January 2021

Impact of Brazil's More Doctors Program on hospitalizations for primary care sensitive cardiovascular conditions.

SSM Popul Health 2020 Dec 18;12:100695. Epub 2020 Nov 18.

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA.

Globally, cardiovascular diseases are the leading cause of disease burden and death. Timely and appropriate provision of primary care may lead to sizeable reductions in hospitalizations for a range of chronic and acute health conditions. In this paper, we study the impact of Brazil's More Doctors Program (MDP) on hospitalizations due to cerebrovascular disease and hypertension. We exploit the geographic variation in the uptake of the MPD and combine coarsened exact matching and difference-in-difference methods to construct valid counterfactual estimates. We use data from the Hospital Information System in Unified Health System, the MDP administrative records, the Brazilian Regulatory Agency, the Ministry of Health, and the Brazilian Institute of Geography and Statistics, covering the years from 2009 to 2017. Our analysis resulted in estimated coefficients of -1.47 (95%CI: -4.04,1.10) for hospitalizations for cerebrovascular disease and -1.20 (95%CI: -5.50,3.11) for hypertension, suggesting an inverse relationship between the MDP and hospitalizations. For cerebrovascular disease, the estimated MDP coefficient was -0.50 (95%CI: -2.94,1.95) in the year of program introduction, -5.21 (95%CI: -9.43,-0.99) and -8.21 (95%CI: -13.68,-2.75) in its third and fourth year of implementation, respectively. Our results further suggest that the beneficial impact of MDP on hospitalizations due to cerebrovascular disease became discernable in urban municipalities starting from the fourth year of implementation. We found no evidence that the MDP led to reductions in hospitalizations due to hypertension. Our results highlight that increased investment in resources devoted to primary care led to improvements in hospitalizations for selected cardiovascular conditions. However, it took time for the beneficial effects of the MDP to become discernable and the Program did not guarantee declines in hospitalizations for all cardiovascular conditions, suggesting that further improvements may be needed to enhance the beneficial impact of the MDP on the level and distribution of population health in Brazil.
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http://dx.doi.org/10.1016/j.ssmph.2020.100695DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7725939PMC
December 2020

Predicting Aedes aegypti infestation using landscape and thermal features.

Sci Rep 2020 12 10;10(1):21688. Epub 2020 Dec 10.

Department of Epidemiology, School of Public Health - University of Sao Paulo, Av. Dr. Arnaldo, São Paulo, SP, 715, Brazil.

Identifying Aedes aegypti breeding hotspots in urban areas is crucial for the design of effective vector control strategies. Remote sensing techniques offer valuable tools for mapping habitat suitability. In this study, we evaluated the association between urban landscape, thermal features, and mosquito infestations. Entomological surveys were conducted between 2016 and 2019 in Vila Toninho, a neighborhood of São José do Rio Preto, São Paulo, Brazil, in which the numbers of adult female Ae. aegypti were recorded monthly and grouped by season for three years. We used data from 2016 to 2018 to build the model and data from summer of 2019 to validate it. WorldView-3 satellite images were used to extract land cover classes, and land surface temperature data were obtained using the Landsat-8 Thermal Infrared Sensor (TIRS). A multilevel negative binomial model was fitted to the data, which showed that the winter season has the greatest influence on decreases in mosquito abundance. Green areas and pavements were negatively associated, and a higher cover of asbestos roofs and exposed soil was positively associated with the presence of adult females. These features are related to socio-economic factors but also provide favorable breeding conditions for mosquitos. The application of remote sensing technologies has significant potential for optimizing vector control strategies, future mosquito suppression, and outbreak prediction.
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http://dx.doi.org/10.1038/s41598-020-78755-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7729962PMC
December 2020

Three-quarters attack rate of SARS-CoV-2 in the Brazilian Amazon during a largely unmitigated epidemic.

Science 2021 01 8;371(6526):288-292. Epub 2020 Dec 8.

Department of Zoology, University of Oxford, Oxford, UK.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread rapidly in Manaus, the capital of Amazonas state in northern Brazil. The attack rate there is an estimate of the final size of the largely unmitigated epidemic that occurred in Manaus. We use a convenience sample of blood donors to show that by June 2020, 1 month after the epidemic peak in Manaus, 44% of the population had detectable immunoglobulin G (IgG) antibodies. Correcting for cases without a detectable antibody response and for antibody waning, we estimate a 66% attack rate in June, rising to 76% in October. This is higher than in São Paulo, in southeastern Brazil, where the estimated attack rate in October was 29%. These results confirm that when poorly controlled, COVID-19 can infect a large proportion of the population, causing high mortality.
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http://dx.doi.org/10.1126/science.abe9728DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857406PMC
January 2021

Emerging arboviruses in the urbanized Amazon rainforest.

BMJ 2020 11 13;371:m4385. Epub 2020 Nov 13.

Department of Ecology and Evolution, University of Chicago, Chicago, Illinois, USA

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http://dx.doi.org/10.1136/bmj.m4385DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7664915PMC
November 2020

Spatiotemporal transmission dynamics of co-circulating dengue, Zika, and chikungunya viruses in Fortaleza, Brazil: 2011-2017.

PLoS Negl Trop Dis 2020 10 26;14(10):e0008760. Epub 2020 Oct 26.

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America.

The mosquito-borne viruses dengue (DENV), Zika (ZIKV), and chikungunya (CHIKV), now co-endemic in the Americas, pose growing threats to health worldwide. However, it remains unclear whether there exist interactions between these viruses that could shape their epidemiology. This study advances knowledge by assessing the transmission dynamics of co-circulating DENV, ZIKV, and CHIKV in the city of Fortaleza, Brazil. Spatiotemporal transmission dynamics of DENV, ZIKV, and CHIKV were analyzed using georeferenced data on over 210,000 reported cases from 2011 to 2017 in Fortaleza, Brazil. Local spatial clustering tests and space-time scan statistics were used to compare transmission dynamics across all years. The transmission of co-circulating viruses in 2016 and 2017 was evaluated at fine spatial and temporal scales using a measure of spatiotemporal dependence, the τ-statistic. Results revealed differences in the diffusion of CHIKV compared to previous DENV epidemics and spatially distinct transmission of DENV/ZIKV and CHIKV during the period of their co-circulation. Significant spatial clustering of viruses of the same type was observed within 14-day time intervals at distances of up to 6.8 km (p<0.05). These results suggest that arbovirus risk is not uniformly distributed within cities during co-circulation. Findings may guide outbreak preparedness and response efforts by highlighting the clustered nature of transmission of co-circulating arboviruses at the neighborhood level. The potential for competitive interactions between the arboviruses should be further investigated.
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http://dx.doi.org/10.1371/journal.pntd.0008760DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7644107PMC
October 2020

Geospatial evaluation of trade-offs between equity in physical access to healthcare and health systems efficiency.

BMJ Glob Health 2020 10;5(10)

Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.

Introduction: Decisions regarding the geographical placement of healthcare services require consideration of trade-offs between equity and efficiency, but few empirical assessments are available. We applied a novel geospatial framework to study these trade-offs in four African countries.

Methods: Geolocation data on population density (a surrogate for efficiency), health centres and cancer referral centres in Kenya, Malawi, Tanzania and Rwanda were obtained from online databases. Travel time to the closest facility (a surrogate for equity) was estimated with 1 km resolution using the Access Mod 5 least cost distance algorithm. We studied associations between district-level average population density and travel time to closest facility for each country using Pearson's correlation, and spatial autocorrelation using the Global Moran's I statistic. Geographical clusters of districts with inefficient resource allocation were identified using the bivariate local indicator of spatial autocorrelation.

Results: Population density was inversely associated with travel time for all countries and levels of the health system (Pearson's correlation range, health centres: -0.89 to -0.71; cancer referral centres: -0.92 to -0.43), favouring efficiency. For health centres, negative spatial autocorrelation (geographical clustering of dissimilar values of population density and travel time) was weaker in Rwanda (-0.310) and Tanzania (-0.292), countries with explicit policies supporting equitable access to rural healthcare, relative to Kenya (-0.579) and Malawi (-0.543). Stronger spatial autocorrelation was observed for cancer referral centres (Rwanda: -0.341; Tanzania: -0.259; Kenya: -0.595; Malawi: -0.666). Significant geographical clusters of sparsely populated districts with long travel times to care were identified across countries.

Conclusion: Negative spatial correlations suggested that the geographical distribution of health services favoured efficiency over equity, but spatial autocorrelation measures revealed more equitable geographical distribution of facilities in certain countries. These findings suggest that even when prioritising efficiency, thoughtful decisions regarding geographical allocation could increase equitable physical access to services.
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http://dx.doi.org/10.1136/bmjgh-2020-003493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7580044PMC
October 2020

Open-Source 3D Printable GPS Tracker to Characterize the Role of Human Population Movement on Malaria Epidemiology in River Networks: A Proof-of-Concept Study in the Peruvian Amazon.

Front Public Health 2020 24;8:526468. Epub 2020 Sep 24.

Instituto de Medicinal Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru.

Human movement affects malaria epidemiology at multiple geographical levels; however, few studies measure the role of human movement in the Amazon Region due to the challenging conditions and cost of movement tracking technologies. We developed an open-source low-cost 3D printable GPS-tracker and used this technology in a cohort study to characterize the role of human population movement in malaria epidemiology in a rural riverine village in the Peruvian Amazon. In this pilot study of 20 participants (mean age = 40 years old), 45,980 GPS coordinates were recorded over 1 month. Characteristic movement patterns were observed relative to the infection status and occupation of the participants. Applying two analytical animal movement ecology methods, utilization distributions (UDs) and integrated step selection functions (iSSF), we showed contrasting environmental selection and space use patterns according to infection status. These data suggested an important role of human movement in the epidemiology of malaria in the Peruvian Amazon due to high connectivity between villages of the same riverine network, suggesting limitations of current community-based control strategies. We additionally demonstrate the utility of this low-cost technology with movement ecology analysis to characterize human movement in resource-poor environments.
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http://dx.doi.org/10.3389/fpubh.2020.526468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7542225PMC
May 2021

Spatial-temporal trends in forced migrant mortality, 2014-2018.

BMJ Glob Health 2020 10;5(10)

Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA.

Introduction: The identification of spatial-temporal clusters of forced migrant mortality is urgently needed to inform preventative policies and humanitarian response. As a first step towards understanding the geography of forced migrant mortality, this study investigates spatial-temporal patterns in death at a global scale.

Methods: We used information on the location and dates of forced migrant deaths reported in the International Organization for Migration's from 2014 to 2018. Kulldorff's spatial-temporal and seasonal scans were used to detect spatial-temporal and temporal heterogeneity in mortality.

Results: A total of 16 314 deaths were reported during the study period. A preponderance of deaths occurred at sea each year (range 26%-54% across 5 years). Twelve spatial-temporal clusters of forced migrant mortality were detected by maximum likelihood testing. Annually, the period of August-October was associated with a 40-percentage-point increase in the risk of mortality, relative to other time periods.

Conclusions: Death during forced migration occurs close to national borders and during periods of intense conflict. This evidence may inform the design of policies and targeting of interventions to prevent forced migration-related deaths.
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http://dx.doi.org/10.1136/bmjgh-2020-002885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549474PMC
October 2020

Crowding and the shape of COVID-19 epidemics.

Nat Med 2020 12 5;26(12):1829-1834. Epub 2020 Oct 5.

Department of Zoology, University of Oxford, Oxford, UK.

The coronavirus disease 2019 (COVID-19) pandemic is straining public health systems worldwide, and major non-pharmaceutical interventions have been implemented to slow its spread. During the initial phase of the outbreak, dissemination of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was primarily determined by human mobility from Wuhan, China. Yet empirical evidence on the effect of key geographic factors on local epidemic transmission is lacking. In this study, we analyzed highly resolved spatial variables in cities, together with case count data, to investigate the role of climate, urbanization and variation in interventions. We show that the degree to which cases of COVID-19 are compressed into a short period of time (peakedness of the epidemic) is strongly shaped by population aggregation and heterogeneity, such that epidemics in crowded cities are more spread over time, and crowded cities have larger total attack rates than less populated cities. Observed differences in the peakedness of epidemics are consistent with a meta-population model of COVID-19 that explicitly accounts for spatial hierarchies. We paired our estimates with globally comprehensive data on human mobility and predict that crowded cities worldwide could experience more prolonged epidemics.
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http://dx.doi.org/10.1038/s41591-020-1104-0DOI Listing
December 2020

Variation in Anopheles distribution and predictors of malaria infection risk across regions of Madagascar.

Malar J 2020 Sep 29;19(1):348. Epub 2020 Sep 29.

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Building 2, Room 329, Boston, MA, 02115, USA.

Background: Deforestation and land use change is widespread in Madagascar, altering local ecosystems and creating opportunities for disease vectors, such as the Anopheles mosquito, to proliferate and more easily reach vulnerable, rural populations. Knowledge of risk factors associated with malaria infections is growing globally, but these associations remain understudied across Madagascar's diverse ecosystems experiencing rapid environmental change. This study aims to uncover socioeconomic, demographic, and ecological risk factors for malaria infection across regions through analysis of a large, cross-sectional dataset.

Methods: The objectives were to assess (1) the ecological correlates of malaria vector breeding through larval surveys, and (2) the socioeconomic, demographic, and ecological risk factors for malaria infection in four ecologically distinct regions of rural Madagascar. Risk factors were determined using multilevel models for the four regions included in the study.

Results: The presence of aquatic agriculture (both within and surrounding communities) is the strongest predictive factor of habitats containing Anopheles larvae across all regions. Ecological and socioeconomic risk factors for malaria infection vary dramatically across study regions and range in their complexity.

Conclusions: Risk factors for malaria transmission differ dramatically across regions of Madagascar. These results may help stratifying current malaria control efforts in Madagascar beyond the scope of existing interventions.
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http://dx.doi.org/10.1186/s12936-020-03423-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526177PMC
September 2020

The effects of changes in distance to nearest health facility on under-5 mortality and health care utilization in rural Malawi, 1980-1998.

BMC Health Serv Res 2020 Sep 24;20(1):899. Epub 2020 Sep 24.

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 655 Huntington Ave, Boston, MA, 02115, USA.

Background: Despite important progress, the burden of under-5 mortality remains unacceptably high, with an estimated 5.3 million deaths in 2018. Lack of access to health care is a major risk factor for under-5 mortality, and distance to health care facilities has been shown to be associated with less access to care in multiple contexts, but few such studies have used a counterfactual approach to produce causal estimates.

Methods: We combined retrospective reports on 18,714 births between 1980 and 1998 from the 2000 Malawi Demographic and Health Survey with a 1998 health facility census that includes the date of construction for each facility, including 335 maternity or maternity/dispensary facilities built in rural areas between 1980 and 1998. We estimated associations between distance to nearest health facility and (i) under-5 mortality, using Cox proportional hazards models, and (ii) maternal health care utilization (antenatal visits prior to delivery, place of delivery, receiving skilled assistance during delivery, and receiving a check-up following delivery), using linear probability models. We also estimated the causal effect of reducing the distance to nearest facility on those outcomes, using a two-way fixed effects approach.

Findings: We found that greater distance was associated with higher mortality (hazard ratio 1.007 for one additional kilometer [95%CI 1.001 to 1.014]) and lower health care utilization (for one additional kilometer: 1.2 percentage point (pp) increase in homebirth [95%CI 0.8 to 1.5]; 0.8 pp. decrease in at least three antenatal visits [95% CI - 1.4 to - 0.2]; 1.2 pp. decrease in skilled assistance during delivery [95%CI - 1.6 to - 0.8]). However, we found no effects of a decrease in distance to the nearest health facility on the hazard of death before age 5 years, nor on antenatal visits prior to delivery, place of delivery, or receiving skilled assistance during delivery. We also found that reductions in distance decrease the probability that a woman receives a check-up following delivery (2.4 pp. decrease for a 1 km decrease [95%CI 0.004 to 0.044]).

Conclusion: Reducing under-5 mortality and increasing utilization of care in rural Malawi and similar settings may require more than the construction of new health infrastructure. Importantly, the effects estimated here likely depend on the quality of health care, the availability of transportation, the demand for health services, and the underlying causes of mortality, among other factors.
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http://dx.doi.org/10.1186/s12913-020-05738-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7517642PMC
September 2020

Gridded population survey sampling: a systematic scoping review of the field and strategic research agenda.

Int J Health Geogr 2020 09 9;19(1):34. Epub 2020 Sep 9.

Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA.

Introduction: In low- and middle-income countries (LMICs), household survey data are a main source of information for planning, evaluation, and decision-making. Standard surveys are based on censuses, however, for many LMICs it has been more than 10 years since their last census and they face high urban growth rates. Over the last decade, survey designers have begun to use modelled gridded population estimates as sample frames. We summarize the state of the emerging field of gridded population survey sampling, focussing on LMICs.

Methods: We performed a systematic scoping review in Scopus of specific gridded population datasets and "population" or "household" "survey" reports, and solicited additional published and unpublished sources from colleagues.

Results: We identified 43 national and sub-national gridded population-based household surveys implemented across 29 LMICs. Gridded population surveys used automated and manual approaches to derive clusters from WorldPop and LandScan gridded population estimates. After sampling, some survey teams interviewed all households in each cluster or segment, and others sampled households from larger clusters. Tools to select gridded population survey clusters include the GridSample R package, Geo-sampling tool, and GridSample.org. In the field, gridded population surveys generally relied on geographically accurate maps based on satellite imagery or OpenStreetMap, and a tablet or GPS technology for navigation.

Conclusions: For gridded population survey sampling to be adopted more widely, several strategic questions need answering regarding cell-level accuracy and uncertainty of gridded population estimates, the methods used to group/split cells into sample frame units, design effects of new sample designs, and feasibility of tools and methods to implement surveys across diverse settings.
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http://dx.doi.org/10.1186/s12942-020-00230-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7488014PMC
September 2020

Spatial analysis of COVID-19 clusters and contextual factors in New York City.

Spat Spatiotemporal Epidemiol 2020 08 21;34:100355. Epub 2020 Jun 21.

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston 02115, MA, USA. Electronic address:

Identifying areas with low access to testing and high case burden is necessary to understand risk and allocate resources in the COVID-19 pandemic. Using zip code level data for New York City, we analyzed testing rates, positivity rates, and proportion positive. A spatial scan statistic identified clusters of high and low testing rates, high positivity rates, and high proportion positive. Boxplots and Pearson correlations determined associations between outcomes, clusters, and contextual factors. Clusters with less testing and low proportion positive tests had higher income, education, and white population, whereas clusters with high testing rates and high proportion positive tests were disproportionately black and without health insurance. Correlations showed inverse associations of white race, education, and income with proportion positive tests, and positive associations with black race, Hispanic ethnicity, and poverty. We recommend testing and health care resources be directed to eastern Brooklyn, which has low testing and high proportion positives.
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http://dx.doi.org/10.1016/j.sste.2020.100355DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7306208PMC
August 2020

Effectiveness of insecticide-impregnated collars for the control of canine visceral leishmaniasis.

Prev Vet Med 2020 Sep 25;182:105104. Epub 2020 Jul 25.

Programa de Pós-graduação em Saúde Coletiva, Instituto de Estudos em Saúde Coletiva, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil; Lemann Visiting Scholar, David Rockefeller Center for Latin American Studies, Cambridge, Massachusetts, United States of America. Electronic address:

Visceral leishmaniasis is a neglected tropical disease widely distributed worldwide. In Brazil, the control measures adopted in the last decades have not been able to prevent the spread of the disease. This study aimed to evaluate the effectiveness of a population-based intervention using 4% deltamethrin-impregnated dog collars on the incidence of canine visceral leishmaniasis. A community intervention study was carried out in two areas of the city of Montes Claros, State of Minas Gerais, Brazil. In the control area, the preventive measures recommended by the Brazilian Program for Surveillance and Control of Visceral Leishmaniasis were implemented (culling of infected dogs and vector control with residual insecticides). In the intervention area, deltamethrin-impregnated collars were fit to domiciled dogs, in addition to the above mentioned preventive measures. At the beginning of the study, a census survey was carried out among domiciled dogs to detect the prevalence of L. infantum infection. Dogs found seronegative at recruitment were longitudinally followed-up to evaluate the incidence of infection. Monitoring of canine infection (control and intervention areas) and replacement of collars (intervention area) occurred through sequential surveys at 12, 18, and 24 months after the initial survey. At each survey, dogs were tested, and the owner answered a questionnaire about the general characteristics of the animal. Multilevel logistic regression models were used to test the effect of collars on the risk of canine infection, with households considered as aggregation units. Associations were expressed as odds ratios (OR) and respective 95% confidence intervals (95%CI). The prevalence of infection in the initial survey was 9.7% and 9.9% in the intervention and control areas, respectively (p = 0.732). Among a total of 20,477 dogs participating in the study, 9,770 were seronegative at recruitment. The cumulative incidence of infection was 4.1% in the intervention area and 7.9% in the control area (p < 0.001). In the multivariable analysis, the risk of infection was 52% lower in the intervention area as compared to the control area (OR = 0.48, 95%CI:0.39-0.59), after adjusting for the number of dogs in the house, period of recruitment, time of dog ownership, and age, sex, length of fur and breed. The use of 4% deltamethrin-impregnated dog collars was effective in reducing the incidence of canine leishmaniasis. Cost-effectiveness studies are recommended before the incorporation of collars in the arsenal of control measures of the Brazilian Program for Surveillance and Control of Visceral Leishmaniasis.
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http://dx.doi.org/10.1016/j.prevetmed.2020.105104DOI Listing
September 2020

Spatiotemporal pattern of COVID-19 and government response in South Korea (as of May 31, 2020).

Int J Infect Dis 2020 Sep 4;98:328-333. Epub 2020 Jul 4.

Harvard T.H. Chan School of Public Health, Department of Global Health and Population, 665 Huntington Avenue, Boston, MA 02115, USA. Electronic address:

Objectives: The aim of this study was to assess how coronavirus disease 2019 (COVID-19) clustered across districts in South Korea and to assess whether the pattern and duration of clusters changed following the country's containment strategy.

Methods: A spatiotemporal analysis of COVID-19 daily confirmed cases by 250 districts in South Korea from January 20 to May 31, 2020, obtained from the Korea Centers for Disease Control and Prevention and each provincial website, was conducted. The global Moran's I statistic was used for spatial autocorrelation analysis, and the retrospective space-time scan statistic was used to analyze spatiotemporal clusters of COVID-19.

Results: The geographical distribution showed strong spatial autocorrelation, with a global Moran's I coefficient of 0.784 (p=0.0001). Twelve statistically significant spatiotemporal clusters were identified by space-time scan statistic using a discrete Poisson model. The spatial pattern of clusters changed and the duration of clusters became shorter over time.

Conclusions: The results indicate that South Korea's containment strategy for COVID-19 was highly effective in both early detection and mitigation, with recent clusters being small in size and duration. Lessons from South Korea should spark a discussion on epidemic response.
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http://dx.doi.org/10.1016/j.ijid.2020.07.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7334954PMC
September 2020