Les épidémies humaines sont un problème important de santé publique dans le monde. La modélisation mathématique fait partie de la panoplie des instruments pour les combattre. La thèse "Optimisation et contrôle viable de modèles épidémiologiques de dengue" se penche sur le cas de la dengue, une maladie endémique en Colombie. Le document de thèse est organisé en deux grandes parties, une partie I plus théorique et une partie II plus appliquée. Dans la partie I théorique, la dynamique de propagation d’une maladie infectieuse transmise par vecteur (comme la dengue, par moustiques) est représentée par des systèmes d'équations différentielles, reliant populations d'individus et de vecteurs. Nous considérons le modèle épidémique de Ross-Macdonald et le modèle endémique SIR SI. Après l'analyse quantitative de ces modèles, ce travail de thèse comporte deux contributions théoriques originales. L’étude du comportement transitoire traite du contrôle d'un épisode épidémique dans sa phase aiguë, avant son éventuelle extinction asymptotique. Nous cherchons, en jouant sur la variable de contrôle qu'est la mortalité du vecteur, à maintenir la proportion d'humains infectés (état) sous un seuil donné pour tous les temps (contrainte de viabilité). Par définition, le noyau de viabilité est l'ensemble des états initiaux pour lesquels il existe au moins une trajectoire de contrôles qui permette de satisfaire la contrainte de viabilité. Notre principale contribution est une description complète du noyau. Nous discutons de possibles contrôles viables, dont l'application garantit la satisfaction de la contrainte. Ensuite, nous analysons deux problèmes de contrôle optimal. L’un est la gestion d'un épisode épidémique à une échelle de temps courte. L’autre traite d'une maladie infectieuse endémique à une échelle plus longue où sont prises en complètes naissances et les morts des populations (humains et vecteurs).Nous déterminons les conditions nécessaires d'existence d'une solution optimale en utilisant le principe du maximum de Pontryagin. Nous abordons aussi l'analyse du cas de ressources limitées dans le temps. Dans la partie II, nous appliquons les approches de la partie I théorique à la gestion d'épisodes de dengue dans la ville de Santiago de Cali. Nous estimons les paramètres des modèles par moindres carrés, avec les données fournies par le Programme de vigilance épidémiologique du Secrétariat municipal de santé. Nous calculons numériquement le noyau de viabilité ajusté aux données observées durant les épisodes épidémiques de 2010 et 2013.Pour ce qui est du contrôle optimal, nous utilisons l'algorithme traditionnel de balayage avant et arrière, et comparons plusieurs alternatives pour le contrôle chimique du moustique. La meilleure stratégie est une combinaison d'aspersion d'un insecticide de faible létalité et d'implémentation de mesures de protection qui réduisent modérément le taux de piqûre du moustique. Enfin, nous abordons le problème de contrôle dynamique de la dengue sous incertitude. Nous développons un modèle de type Ross-Macdonald en temps discret avec incertitudes. Le noyau robuste de viabilité est l'ensemble des états initiaux tels qu'il existe au moins une stratégie d'aspersion d’insecticide qui garantisse que le nombre de personnes infectées se maintienne au-dessous d'un seuil, pour tous les temps, et ce quelles que soient les incertitudes. Sous des hypothèses appropriées sur l'ensemble des scénarios d'incertitudes(correspondant à l'indépendance temporelle), une équation de programmation dynamique permet de calculer numériquement des noyaux. Après avoir choisi trois ensembles d'incertitudes emboîtés, un déterministe (sans incertitude), un moyen et un grand, nous pouvons mesurer l'incidence des incertitudes sur la taille du noyau, notamment sur sa réduction par rapport au cas déterministe (sans incertitude) / Human epidemics are an important problem of public health in the world. Mathematical modelling is part of the instruments to fight them. The thesis «Optimization and viable control of epidemiological models of dengue» deals with the case of the dengue, an endemic disease in Colombia. The document is organized in two parts, a more theoretical Part I, and a Part II centered on applications. In Part I, the dynamics of propagation of an infectious vector-borne disease (such as dengue, transmitted by mosquitoes) is represented by systems of differential equations, connecting populations of individuals and vectors. We consider the epidemic model of Ross-Macdonald, and an endemic model of SIR-SI type. After the stability analysis of these dynamical models, this work brings forward two original theoretical contributions. The study of the transitory behavior deals with the control of an epidemic episode in its acute phase, before its possible asymptotic extinction. We look, by playing on the variable of control that is the mortality of the vector, to maintain human infected proportion (state) under a given threshold for all times (viability constraint). By definition, the viability kernel is the set of all initial states for which there is at least a trajectory of controls which allows to satisfy the viability constraint. Our main contribution is a complete description of the kernel. We discuss possible viable controls, whose application guarantees the satisfaction of the constraint. Then, we analyze two problems of optimal control. First problem is concerned with handling of an epidemic outbreak over a short timescale. Second one deals with an endemic infectious disease over a longer scale, where births and deaths within both populations (human and vector) are taken into account. We determine the necessary conditions of existence of an optimal solution by using the maximum principle of Pontryagin. We also tackle the case of resources limited over the time span. In part II, we apply the theoretical approaches of part I to the management of episodes of dengue in the city of Santiago of Cali. We estimate the parameters of the models by least squares, with the data supplied by the Program of epidemiological vigilance of the Municipal Secretariat of Public Health. We calculate numerically the viability kernel, fitted to the data observed during the epidemic episodes of 2010 and 2013.As for optimal control, we use the traditional forward-backward sweep algorithm, and compare several alternatives for the chemical control of the mosquito. The best strategy is a combination of spraying of an insecticide of low lethality, together with implementation of protective measures, which moderately reduce the biting rate of the mosquitos. Finally, we tackle the problem of dynamic control of the dengue under uncertainty. We develop a Ross-Macdonald model at discrete time with uncertainties. The robust viability kernel is the set of all initial states such as there is at least a strategy of insecticide spraying which guarantees that the number of infected people remains below a threshold, for all times, and whatever the uncertainties. Under proper assumptions on the set of scenarios of uncertainties (corresponding to temporal independence), an equation of dynamic programming allows to numerically calculate kernels. Having chosen three nested subsets of uncertainties a deterministic one (without uncertainty), a medium one and a large one we can measure the incidence of the uncertainties on the size of the kernel, in particular on its reduction with respect to the deterministic case (without uncertainty)

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by Chan Chuek Kee. / Thesis (Ph.D.)--Chinese University of Hong Kong, 1992. / Includes bibliographical references (leaves 165-201). / Abstract --- p.i / Table of Content --- p.iv / List of Abbreviations --- p.viii / List of Tables --- p.x / List of Figures --- p.xii / Acknowledgement --- p.xiii / Chapter Chapter 1. --- Introduction / Chapter 1.1. --- Discovery and historical events --- p.1 / Chapter 1.2. --- General characteristics of rotavirus --- p.3 / Chapter 1.2.1. --- Virus morphology --- p.3 / Chapter 1.2.2. --- Physicochemical properties --- p.3 / Chapter 1.2.3. --- Virus stability and inactivation --- p.4 / Chapter 1.2.4. --- Genome structure --- p.4 / Chapter 1.2.5. --- Rotavirus proteins --- p.5 / Chapter 1.2.6. --- Morphogenesis --- p.8 / Chapter 1.3. --- Characteristics of rotavirus infection --- p.9 / Chapter 1.3.1. --- Morbidity and mortality --- p.9 / Chapter 1.3.2. --- Clinical features --- p.11 / Chapter 1.3.3. --- Pathogenesis --- p.13 / Chapter 1.3.4. --- Seasonal variation of rotavirus infection --- p.13 / Chapter 1.3.5. --- Nosocomial rotavirus infection --- p.14 / Chapter 1.3.6. --- Route of transmission --- p.14 / Chapter 1.4. --- Classification and epidemiology of rotaviruses --- p.15 / Chapter 1.4.1. --- Rotavirus groups --- p.15 / Chapter 1.4.2. --- Rotavirus subgroups --- p.16 / Chapter 1.4.3. --- Rotavirus serotypes --- p.17 / Chapter 1.4.4. --- Rotavirus electropherotypes --- p.20 / Chapter 1.4.5. --- "Relationship between subgroup, serotype and electropherotype" --- p.23 / Chapter 1.4.6. --- Mechanisms contributing to strain variations --- p.24 / Chapter 1.5. --- Detection of rotavirus --- p.28 / Chapter 1.5.1. --- Electron microscopy (EM) --- p.28 / Chapter 1.5.2. --- Virus isolation --- p.29 / Chapter 1.5.3. --- Serological methods --- p.30 / Chapter 1.5.4. --- RNA analysis --- p.30 / Chapter 1.5.5. --- Nucleic acid hybridization --- p.31 / Chapter 1.6. --- Prevention and control of rotavirus infection --- p.32 / Chapter 1.6.1. --- Host resistance --- p.32 / Chapter 1.6.2. --- Vaccine development --- p.33 / Chapter 1.6.3. --- Passive immunization --- p.35 / Chapter 1.7. --- Objectives of this study --- p.36 / Chapter Chapter 2. --- Materials and methods / Chapter 2.1. --- Materials --- p.38 / Chapter 2.1.1. --- Reagents for tissue culture work --- p.38 / Chapter 2.1.2. --- Reagents for electropherotyping --- p.39 / Chapter 2.1.3. --- Reagents for ELISA --- p.42 / Chapter 2.1.4. --- Reagents for hybridization assay --- p.43 / Chapter 2.2. --- Methods / Chapter 2.2.1. --- Collection of specimens --- p.46 / Chapter 2.2.2. --- Rotavirus strains --- p.46 / Chapter 2.2.3. --- Monoclonal antibodies --- p.48 / Chapter 2.2.4. --- Detection of rotavirus antigen by ELISA --- p.49 / Chapter 2.2.5. --- Rotavirus electropherotyping --- p.50 / Chapter 2.2.6. --- Serotyping of rotavirus by fluorescent foci neutralization --- p.52 / Chapter 2.2.7. --- Serotyping of rotavirus by oligo- nucleotide probes hybridization --- p.55 / Chapter 2.2.8. --- Rotavirus serotyping by ELISA --- p.59 / Chapter 2.2.9. --- Rotavirus subgrouping by ELISA --- p.61 / Chapter Chapter 3. --- Results / Chapter 3.1. --- Age and sex distribution of the study population --- p.63 / Chapter 3.2. --- Detection of rotavirus by ELISA --- p.63 / Chapter 3.3. --- Seasonal distribution of rotavirus infections --- p.67 / Chapter 3.4. --- Genetic diversity of human rotaviruses --- p.74 / Chapter 3.5. --- Subgroup determination by ELISA --- p.99 / Chapter 3.6. --- Rotavirus serotypes by fluorescent foci neutralization (FFN) --- p.102 / Chapter 3.7. --- Rotavirus serotypes by ELISA --- p.107 / Chapter 3.8. --- Rotavirus serotypes as determined by oligonucleotide probes --- p.110 / Chapter 3.8.1. --- Dot hybridization --- p.110 / Chapter 3.8.2. --- Northern blots of electrophoresed RNAs --- p.118 / Chapter 3.9. --- Temporal distribution of rotavirus serotypes --- p.124 / Chapter 3.10. --- "Association between serotype, subgroups and electropherotypes" --- p.128 / Chapter 3.11. --- Unusual rotavirus strains --- p.135 / Chapter 3.12. --- Nosocomial rotavirus infection --- p.135 / Chapter Chapter 4. --- Discussion / Chapter 4.1. --- Seasonal variation of rotavirus infection --- p.141 / Chapter 4.2. --- Molecular epidemiology of rotavirus infection --- p.143 / Chapter 4.3. --- Subgrouping of human rotavirus strains --- p.146 / Chapter 4.4. --- Serotyping rotaviruses by ELISA --- p.147 / Chapter 4.5. --- Serotyping rotaviruses by oligonucleotide probe hybridization --- p.150 / Chapter 4.6 --- Advantage and disadvantage of different methods for serotyping of rotaviruses --- p.152 / Chapter 4.7. --- Distribution of rotavirus serotypes --- p.153 / Chapter 4.8. --- Association between rotavirus serotype and electropherotype --- p.156 / Chapter 4.9. --- Nosocomial rotavirus infection --- p.158 / Chapter 4.10. --- Unusual rotavirus strains --- p.159 / Chapter 4.11. --- Concluding remark --- p.162 / Chapter 4.12. --- Future studies --- p.164 / References --- p.165

Background: Mental ill-health among adolescents is one of the most increasing public health problems in Sweden. Particularly girls suffer from mental and psychosomatic symptoms. The National Board of Health and Welfare recommend the DISA method as a preventive measure. Problem: Investigations has been done of the DISA method, but further investigations needs to be done. Aim: The aim of the study was partly to investigate how participants in DISA groups in two counties understand the method and its eventual effect and partly how their mood change, to contribute with knowledge to the development of the DISA method. Methods: A questionnaire and the self-report CES-D scale were collected from a population of 154 participants. A statistical analysis with Paired-Samples T Test carried out to examine if the difference between the sum of points of the group from the first and the last completing of the self-report CES-D scale was statistical guaranteed. Results: The participants were most satisfied with the group size and the rules. They were less satisfied with the mood diary and the homework. They wanted to talk less about negative thoughts and wanted it to be voluntary to participate in a DISA group. The participants got better insight and understanding of mental health and mental ill health. It is statistical significant that the average sum of points of the participants got lower the last time they completed the self-report CES-D scale compared to the first time. Conclusion: There are many indicators who points out that DISA is a well functioning depression preventive method.

A prevalência da tuberculose está diretamente relacionada às condições sociais e, por isso, deve constituir-se como questão prioritária na Saúde Coletiva. Tendo em vista que a tuberculose tem estado presente no cenário epidemiológico do Município de Curitiba-PR, o presente estudo teve como objetivo identificar aspectos que caracterizam a vulnerabilidade tuberculose com a finalidade de propor medidas apropriadas de intervenção. Conduzido sob o marco teórico da vulnerabilidade integraram o estudo 26 sujeitos matriculados em unidades básicas de saúde do Distrito Sanitário de Santa Felicidade. Estes, foram entrevistados após consentimento esclarecido. Os dados foram coletados no período de julho a agosto de 2005. Identificou-se que os sujeitos apresentavam características relevantes em termos de vulnerabilidade, principalmente no que se refere ao trabalho e à vida, particularmente quanto à inserção no trabalho, as condições financeiras decorrentes e aglomeração nas moradias. Verificou-se, ainda, que apresentavam dificuldades na obtenção de medicamentos para o tratamento da tuberculose, assim como no que diz respeito à distância entre o domicilio e o serviço de saúde, o que pode comprometer a adesão ao tratamento. Além disso, os conhecimentos acerca da tuberculose revelaram-se inadequados, assim como a ausência de informação recebida, identificando-se concepções equivocadas em relação à doença. Os resultados apontam a necessidade de envidar esforços para o controle da enfermidade, destacando-se questões que se referem ao grau e à qualidade de informação, além de melhorar as condições de vida da população. / Tuberculosis prevalence is proportionally related to social conditions, that is why, it must be assumed as a priority in Public Health. Keeping in mind that tuberculosis has been present in the epidemiologicl setting of Curitiba City/ Parana State – Brazil, this study objectified to identify aspects that feature tuberculosis vulnerability in order to design appropriate intervention measures. Under the theoretical landmark of vulnerability, 26 subjects - registered in primary care health units of Santa Felicidade Sanitary District – participated in the study. They were interviewed after informed consent. Data were gathered from July to August/ 2005. Relevant vulnerability features were pointed out in the subjects mainly concerning their work and lifestyle, particularly in terms of job insertion, correlated financial conditions and crowded homes. It was still evidenced that they found difficulties in getting the drugs to treat tuberculosis and the distance from their homes to the health unit, hampering treatment completion. Besides, it was verified inadequate knowledge in relation to the disease, lack of information and consequent misconceptions in relation to the disease. The results pointed out the need for disease control, issues on degree and information quality, besides the improvement of population’s living conditions.

Introdução: A Doença Cerebrovascular é uma das principais causas de morte no mundo, inclusive no Brasil, além de ser a primeira causa de internação hospitalar no Sistema Único de Saúde brasileiro. Objetivo: avaliar os desfechos epidemiológicos da doença cerebrovascular em adultos jovens residentes no município de São Paulo, assim como avaliar os fatores associados à falta de assistência hospitalar nos óbitos ocasionados pelo acidente cerebrovascular no estado de São Paulo. Método: foram utilizados dados oficiais de mortalidade e hospitalização por DCV provenientes do Sistema de Informações sobre Mortalidade e Sistema de Informações Hospitalares do Sistema Único de Saúde, respectivamente. As séries temporais foram padronizadas pelo método direto, segundo sexo, idade e tipos da doença. Para a mortalidade, utilizouse dois intervalos de tempo de 10 anos consecutivos (1996-2005 e 2006-2015). Foi utilizado o modelo de regressão de Prais-Winsten, obtendo o Annual Percent Change (APC). Para analisar a associação entre os óbitos por doença cerebrovascular sem assistência hospitalar e as variáveis explicativas utilizou-se regressão de Poisson. Resultados: Ocorreram 13.129 óbitos e 17.972 hospitalizações em adultos jovens residentes na cidade de São Paulo. Quando analisadas conjuntamente, a mortalidade por doença cerebrovascular apresentou tendência decrescente (APC -4,94% entre 1996-2005 e APC -3,17% entre 2006-2017). Mulheres tiveram redução da mortalidade por DCV durante todo o período (1996-2005; APC: -4,29% e 2006-2015; APC: -4,57%), enquanto homens apresentaram redução da mortalidade por DCV somente na primeira década do estudo (1996-2005; APC= -5,71%). A tendência de hospitalização foi estacionária, sem diferenças segundo sexo e faixa etária. A morbimortalidade por DCV no mês mais frio do ano (junho) foi 11,5% mais elevada, em média durante o período 1996-2015 e 2008-2017, em comparação com o período mais quente, no mês de dezembro (p<0,05). Também foram registrados 127.319 óbitos por Doença Cerebrovascular no estado de São Paulo nos períodos de 1996-1998 e 2013-2015. Destes, 19.362 (15,2%) não tiveram assistência hospitalar. No período mais recente (2013-2015) a proporção da falta de assistência hospitalar foi maior para indivíduos de cor da pele amarela (RR=1,48; IC95%, 1,25 : 1,77), enquanto pessoas de cor preta (RR=0,85; IC95%, 0,76 : 0,95), casadas (RR=0,70; IC95%, 0,64 : 0,75), residentes no município de São Paulo (RR=0,92; IC95%: 0,86 - 0,98) e acometidos pela Doença Cerebrovascular hemorrágica (RR=0,47; IC95%, 0,43 : 0,51) tiveram menor proporção de falta de atendimento hospitalar na análise multivariada. Conclusão: a tendência da mortalidade por Doença Cerebrovascular em adultos jovens declinou durante 1996- 2015, com variação segundo sexo, idade e tipos da DCV, enquanto a incidência de hospitalização permaneceu estacionária durante 2008-2017. Além disso, verificamos variação sazonal significante, com maior morbimortalidade por doença cerebrovascular em adultos jovens na cidade de São Paulo, no período mais frio do ano. Em relação aos fatores associados aos óbitos por Doença Cerebrovascular sem assistência hospitalar, identificamos que as mesmas condições continuaram restringindo ou favorecendo a falta de assistência hospitalar nesses óbitos durante os dois períodos de tempo. / Introduction: Cerebrovascular disease (CVD) is one of the leading causes of death worldwide, including in Brazil. Besides being the first cause of hospitalization in the Brazilian Unified Health System. Objective: to evaluate the epidemiological outcomes of cerebrovascular disease in young adults living in the city of São Paulo, as well as to evaluate the factors associated with the lack of hospital care in the deaths caused by stroke in the state of São Paulo. Method: Official data on mortality and hospitalization for CVD from the Mortality Information System and Hospital Information System of the National Health System were used, respectively. Time series were standardized by the direct method, according to sex, age and types of disease. For mortality, two time intervals of 10 consecutive years (1996-2005 and 2006-2015) were used. The Prais- Winsten regression model was used, obtaining Annual Percent Change (APC). Poisson regression was used to analyze the association between deaths due to cerebrovascular disease without hospital care and the explanatory variables. Results: There were 13,129 deaths and 17,972 hospitalizations among young adults living in the city of São Paulo. When analyzed together, stroke mortality presented a decreasing trend (APC -4.94% between 1996-2005 and APC -3.17% between 2006-2017). Women had a reduction in CVD mortality during the whole period (1996-2005, APC: -4.29% and 2006-2015, APC: -4.57%), while men had a reduction in CVD mortality only in the first decade of the study (1996-2005; APC = -5.71%). The trend of hospitalization was stationary, with no differences according to gender and age group. CVD morbidity and mortality in the coldest month of the year (June) was 11.5% higher, on average during the period 1996- 2015 and 2008-2017, compared to the warmer period in December (p<0.05). There were also 127,319 deaths due to stroke in the State of São Paulo during 1996-1998 to 2013- 2015. Of these, 19,362 (15.2%) did not have hospital care. In the most recent period (2013-2015), the proportion of hospital attendance was higher for yellow-skinned individuals (RR = 1.48, 95% CI, 1.25: 1.77), whereas black people ( RR = 0.85, 95% CI 0.76 : 0.95), married (RR = 0.70, 95% CI, 0.64: 0.75), living in the city of São Paulo (RR = 0.92 ; 95% CI: 0.86-0.98) and hemorrhagic cerebrovascular disease (RR = 0.47, 95% CI, 0.43: 0.51) had a lower proportion of lack of hospital care in the multivariate analysis. Conclusion: The trend of mortality due to stroke in young adults declined during 1996- 2015, with variation according to gender, age and types of CVD, while the incidence of hospitalization remained stationary during 2008-2017. In addition, we verified a significant seasonal variation, with higher morbidity and mortality due to cerebrovascular disease in young adults in the city of São Paulo, during the coldest period of the year. Regarding the factors associated with deaths due to Cerebrovascular Disease without hospital care, we identified that the same conditions continued to restrict or favor the lack of hospital care in these deaths during the two time periods.

O diagnóstico da asma baseia-se na anamnese e no exame clínico, mas provas de função pulmonar e avaliação da alergia contribuem para o diagnóstico. A espirometria é o exame complementar mais utilizado em pacientes asmáticos, por ser útil para o diagnóstico, por ser o exame mais disponível no sistema de saúde, para classificação da gravidade e para o monitoramento terapêutico. A medida da reatividade brônquica é um exame mais demorado, tem maior risco, maior custo e é menos disponível. No entanto, é superior por representar melhor a fisiopatologia da asma. Este projeto tem o objetivo de determinar o valor da espirometria na investigação de asma em estudos epidemiológicos (tendo como referência a medida de reatividade brônquica). Foram analisados os dados de 1922 indivíduos que constituíram uma coorte de nascidos em hospitais de Ribeirão Preto em 1978 e 1979. Estes indivíduos preencheram questionários, incluindo o questionário da European Community Respiratory Health Survey; foram submetidos à espirometria e ao teste de broncoprovocação com metacolina, que mede a reatividade brônquica. Para análise dos dados, a asma foi definida pela associação de teste de broncoprovocação positivo com pelo menos um dos sintomas: sibilância, aperto no peito, dispneia, dispneia noturna. A prevalência de volume expiratório forçado no primeiro segundo menor que oitenta por cento (VEF1 < 80%) do previsto (espirometria alterada ou VEF1 reduzido) foi de 10,9%, a prevalência de hiperreatividade brônquica foi de 22,2% e a prevalência de asma foi de 10,4% na amostra de 1922 indivíduos. A espirometria teve sensibilidade de 38% para detectar asma no sexo masculino e de 16% no sexo feminino com especificidades de 94% e 90%, respectivamente. Na análise univariada, houve associação entre espirometria alterada e diagnóstico de asma apenas no sexo masculino com razão de prevalência (RP) de 5,31 com intervalo de confiança de 95% de 3,60-7,83. No sexo feminino, a RP foi de 1,34 (0,87-2,07). Na análise multivariada, a associação entre espirometria alterada e o diagnóstico de asma foi evidenciada em homens pela RP de 4,20 (2,71-6,71), mas não foi evidenciada em mulheres: 1,24 (0,79-1,93). O índice Kappa entre VEF1 reduzido e asma foi de 0,13 (0,08 - 0,19). Portanto, empregando-se o teste de broncoprovocação com sintomas para definir asma, a espirometria demonstra limitações, como baixa sensibilidade, fraca concordância e diferenças na capacidade de detectar asma entre homens e mulheres. / The diagnosis of asthma is based on history and clinical examination, but pulmonary function tests and allergy evaluation contribute to diagnosis. Spirometry is the most used complementary test in patients with asthma because it is useful and the most available in medical routine to classify the severity and therapeutic monitoring. Measurement of bronchial reactivity is more time consuming, has a higher risk, higher cost and lower availability. However, it is thought to be superior because it represents the pathophysiology of asthma. This project aims to determine the value of spirometry for asthma screening in epidemiological studies (as compared with bronchial reactivity measurement). Data from 1922 individuals who comprised a cohort of children born in hospitals in Ribeirão Preto in 1978 and 1979 were analyzed. These individuals completed questionnaires, including the questionnaire of the European Community Respiratory Health Survey; underwent spirometry and methacholine challenge test, which measures the bronchial reactivity. For data analysis, asthma was defined by the association of bronchial hyper reactivity with corresponding symptoms: wheezing, tightness in the chest, dyspnea and nocturnal dyspnea. The prevalence of reduced forced expiratory volume in one second (FEV1), i.e. less than 80% of predicted, was 10.9%; the prevalence of bronchial hyper reactivity was 22.2%; and, the prevalence of asthma was 10.4% in this sample of 1922 individuals. Spirometry had a sensitivity of 38% to detect asthma in males and 16% in females with specificities of 94% and 90%, respectively. According to univariate analysis, there was an association between spirometry and asthma diagnosis in males, with prevalence ratio (PR) of 5.31 and 95% confidence interval of 3.60 to 7.83, but there was not association in females, PR was 1.34 (0.87 to 2.07). These results were confirmed by multivariate analysis with PR of 4.20 (2.71 to 6.71) in men and 1.24 (0.79 to 1.93) in women. Kappa agreement between reduced FEV1 and asthma was 0.13 (0.08 - 0.19). Therefore, by using positive methacholine challenge test with symptoms to define asthma, spirometry shows limits, as low sensitivity, poor concordance and differences between genders.

Introdução: A prevalência de nascimento pré-termo vem aumentando nos últimos anos e é atualmente um problema de saúde pública mundial, sendo responsável por significante mortalidade neonatal e morbidades infantil e na vida adulta. As causas são multifatoriais e estão relacionadas às dimensões socioeconômica, psicossocial e biológica que se interrelacionam e se sobrepõem. Os fatores de risco diferem entre as populações e grupos étnicos, no entanto, ainda não estão claros quais e como os determinantes etiológicos estão envolvidos. As estratégias de cuidado pré-natal desenvolvidas tem sido insuficientes para a prevenção. Objetivo: estudar os fatores de risco para o nascimento pré-termo em crianças nascidas de partos hospitalares de mães residentes no município de Campina Grande/PB, Brasil. Métodos: O desenho foi um caso-controle de base populacional, que foi realizado no período de junho de 2008 a maio de 2009. Os casos foram nascidos com menos de 37 semanas gestacionais e os controles os nascidos com 37 semanas ou mais. A idade gestacional foi definida em semanas utilizando-se critérios de seleção baseados na acurácia da estimativa. Foram realizadas entrevistas com as mães e coleta de registros hospitalares. Foram selecionados 341 casos e 424 controles. A análise foi baseada em modelo de regressão múltipla hierarquizada. Resultados: os fatores de risco para nascimento pré-termo foram: filho anterior pré-termo (OR=2,32; IC 95%: 1,25-4,29), assistência pré-natal inadequada (categoria II três ou mais prérequisitos negativos) (OR=2,15; IC 95%: 1,40-3,27), ganho ponderal materno insuficiente (OR=2,33; IC 95%: 1,45-3,75), dano físico materno durante a gestação (OR=2,10; IC 95%: 1,22-3,60), hipertensão arterial na gestação com eclâmpsia (OR=17,08; IC 95%: 3,67-79,43) e sem eclâmpsia (OR=6,42; IC 95%: 3,50-11,76), internação durante a gestação (OR=5,64; IC 95%: 3,47-9,15), alteração do volume amniótico (OR=2,28; IC 95%: 1,32-3,95); sangramento vaginal (OR=1,54; IC 95%: 1,01-2,34) e gestação múltipla (OR=22,65; IC 95%: 6,22-82,46). Segundo o mesmo modelo, a renda familiar per capita menor que um salário mínimo foi fator protetor (OR=0,63; IC 95%: 0,39-0,99). Conclusão: Os fatores de risco foram semelhantes ao observado em outros estudos nacionais e internacionais, a não ser para o resultado da variável do nível socioeconômico. A elevada prevalência da pobreza e baixa escolaridade, maior que em estudos realizados na Região Sul, tanto nos casos como nos controles, pode ter contribuído para esse resultado. Estudos adicionais são necessários para o aprofundamento do conhecimento sobre a complexidade das cadeias causais no parto pré-termo, em diferentes contextos e a diferenciação pelos subtipos, espontâneo e indicado / Introduction: The prevalence of preterm birth has increased in recent years and it is currently a worldwide public health problem, being responsible for significant neonatal mortality and morbidity in childhood and adulthood. The causes are multifactorial and related to socioeconomic, psychosocial and biological factors that interrelate and overlap. Risk factors differ between ethnic groups and populations, however, it is not yet clear which are and how the etiological determinants are involved. Strategies for prenatal care have been developed enough for prevention. Objective: To study the risk factors for preterm birth in newborn of hospital deliveries by mothers, residents in the city of Campina Grande/PB, Brazil. Methods: The study design was a case-control population-based, which was conducted from June 2008 to May 2009. Cases were born at less than 37 weeks of gestation and controls, at 37 weeks or more. Gestational age in weeks was defined using selection criteria based on the accuracy of the estimate. Interviews were conducted with mothers and collection of hospital records. It was selected 341 cases and 424 controls. The analysis was based a logistic multiple regression model, based on a hierarchized conceptual modelling approach. Results: The risk factors for preterm birth were: previous preterm birth (OR=2,32; 95%CI: 1,25-4,29), inadequate prenatal care (category II three or more negative prerequisites) (OR=2,15; 95%CI: 1,40- 3,27), inadequate maternal weight gain (OR=2,33; 95%CI: 1,45-3,75), physical damage to the mother during pregnancy (OR=2,10; 95%CI: 1,22-3,60), hypertension pressure (OR=17,08; 95%CI: 3,67-79,43), hospitalization during pregnancy (OR=5,64; 95%CI: 3,47-9,15), amniotic fluid volume changes (OR=2,28; 95%CI: 1,32-3,95), vaginal bleeding (OR=1,54; 95%CI: 1,01-2,34) and multiple gestation (OR=22,65; 95%CI: 6,22-82,46). According to the model, the per capita income less than the minimum wage was a protective factor (OR=0,63; 95%CI: 0,39-0,99). Conclusion: The risk factors were similar to those observed in other national and international studies, except for the result of varying socioeconomic level. The high prevalence of poverty and low educational level, higher than in studies in the South in both outcomes, may have contributed to this result. Further studies are needed on the complexity of causal chains in preterm delivery in different contexts and differentiation by subtypes, spontaneous and indicated

O diagnóstico da asma baseia-se na anamnese e no exame clínico, mas provas de função pulmonar e avaliação da alergia contribuem para o diagnóstico. A espirometria é o exame complementar mais utilizado em pacientes asmáticos, por ser útil para o diagnóstico, por ser o exame mais disponível no sistema de saúde, para classificação da gravidade e para o monitoramento terapêutico. A medida da reatividade brônquica é um exame mais demorado, tem maior risco, maior custo e é menos disponível. No entanto, é superior por representar melhor a fisiopatologia da asma. Este projeto tem o objetivo de determinar o valor da espirometria na investigação de asma em estudos epidemiológicos (tendo como referência a medida de reatividade brônquica). Foram analisados os dados de 1922 indivíduos que constituíram uma coorte de nascidos em hospitais de Ribeirão Preto em 1978 e 1979. Estes indivíduos preencheram questionários, incluindo o questionário da European Community Respiratory Health Survey; foram submetidos à espirometria e ao teste de broncoprovocação com metacolina, que mede a reatividade brônquica. Para análise dos dados, a asma foi definida pela associação de teste de broncoprovocação positivo com pelo menos um dos sintomas: sibilância, aperto no peito, dispneia, dispneia noturna. A prevalência de volume expiratório forçado no primeiro segundo menor que oitenta por cento (VEF1 < 80%) do previsto (espirometria alterada ou VEF1 reduzido) foi de 10,9%, a prevalência de hiperreatividade brônquica foi de 22,2% e a prevalência de asma foi de 10,4% na amostra de 1922 indivíduos. A espirometria teve sensibilidade de 38% para detectar asma no sexo masculino e de 16% no sexo feminino com especificidades de 94% e 90%, respectivamente. Na análise univariada, houve associação entre espirometria alterada e diagnóstico de asma apenas no sexo masculino com razão de prevalência (RP) de 5,31 com intervalo de confiança de 95% de 3,60-7,83. No sexo feminino, a RP foi de 1,34 (0,87-2,07). Na análise multivariada, a associação entre espirometria alterada e o diagnóstico de asma foi evidenciada em homens pela RP de 4,20 (2,71-6,71), mas não foi evidenciada em mulheres: 1,24 (0,79-1,93). O índice Kappa entre VEF1 reduzido e asma foi de 0,13 (0,08 - 0,19). Portanto, empregando-se o teste de broncoprovocação com sintomas para definir asma, a espirometria demonstra limitações, como baixa sensibilidade, fraca concordância e diferenças na capacidade de detectar asma entre homens e mulheres. / The diagnosis of asthma is based on history and clinical examination, but pulmonary function tests and allergy evaluation contribute to diagnosis. Spirometry is the most used complementary test in patients with asthma because it is useful and the most available in medical routine to classify the severity and therapeutic monitoring. Measurement of bronchial reactivity is more time consuming, has a higher risk, higher cost and lower availability. However, it is thought to be superior because it represents the pathophysiology of asthma. This project aims to determine the value of spirometry for asthma screening in epidemiological studies (as compared with bronchial reactivity measurement). Data from 1922 individuals who comprised a cohort of children born in hospitals in Ribeirão Preto in 1978 and 1979 were analyzed. These individuals completed questionnaires, including the questionnaire of the European Community Respiratory Health Survey; underwent spirometry and methacholine challenge test, which measures the bronchial reactivity. For data analysis, asthma was defined by the association of bronchial hyper reactivity with corresponding symptoms: wheezing, tightness in the chest, dyspnea and nocturnal dyspnea. The prevalence of reduced forced expiratory volume in one second (FEV1), i.e. less than 80% of predicted, was 10.9%; the prevalence of bronchial hyper reactivity was 22.2%; and, the prevalence of asthma was 10.4% in this sample of 1922 individuals. Spirometry had a sensitivity of 38% to detect asthma in males and 16% in females with specificities of 94% and 90%, respectively. According to univariate analysis, there was an association between spirometry and asthma diagnosis in males, with prevalence ratio (PR) of 5.31 and 95% confidence interval of 3.60 to 7.83, but there was not association in females, PR was 1.34 (0.87 to 2.07). These results were confirmed by multivariate analysis with PR of 4.20 (2.71 to 6.71) in men and 1.24 (0.79 to 1.93) in women. Kappa agreement between reduced FEV1 and asthma was 0.13 (0.08 - 0.19). Therefore, by using positive methacholine challenge test with symptoms to define asthma, spirometry shows limits, as low sensitivity, poor concordance and differences between genders.

Made available in DSpace on 2016-08-10T10:55:34Z (GMT). No. of bitstreams: 1 FABIO FERNANDES RODRIGUES.pdf: 954225 bytes, checksum: 5d064ea8e5f258f04a154e91365850bb (MD5) Previous issue date: 2007-06-11 / Toxoplasmosis is a zoonosis with universal distribution. The protozoan Toxoplasma gondii is responsible for the pathology, which infects fowls and mammals including men. The present study is an epidemiologic inquiry that has as objective to establish epidemiologic profile of toxoplasmosis in Anápolis County, delineating periodic incidences and the prevalence. The epidemiologic inquiry has as the aim acquires data which lead primary, secondary and tertiary prevention for toxoplasmosis more efficient and effective in Anápolis County and other cities. Results of serologic assays for antibodies anti-toxoplasma of immunoglobulins (Ig) M and G class, carried out by public laboratories of Anápolis were used. Results correlated with sex and laboratorial techniques during five years (2001 January to 2005 December) were used. Term of free and revealed consent was sign by six laboratories which participated of research. In all laboratories was analyzed 2399 exams, but 56 was considered missing cases, therefore, left 2343 exams. The data was submitted to descriptive statistic analysis, which showed absolute results and percentiles. In Anápolis County the acute toxoplasmosis prevalence was 11% in the group with antibodies antitoxoplasma IgM+ IgG- combination. Cases prevalence which has previous contact with Toxoplasma gondii followed by acquired immunity was 3% in the group with antibodies anti-toxoplasma IgM- IgG+ combination. Cases prevalence, with exclusion of acute toxoplasmosis diagnosis, without discard previous infection possibility, was 60% in the group with antibodies anti-toxoplasma IgM- IgG+ combination. Cases prevalence with exclusion of acute toxoplasmosis and previous infection possibility in the group IgM- IgG- was 25%. Indeterminate cases have a prevalence of 1%. In gender variable female corresponded to 93,42%. The laboratorial technique most used was immunefluorescence (IFI), representing 66,75% of all exams. In conclusion cases prevalence with exclusion of acute toxoplasmosis diagnosis, without discard previous infection possibility is in agreement with literature; global prevalence was undertook without consider ages; was impossible to know toxoplasmosis positivity in pregnancy; acute toxoplasmosis rate was 11%. / A toxoplasmose é uma zoonose de distribuição universal. O protozoário Toxoplasma Gondii, responsável pela patologia, infecta animais homeotérmicos incluindo o homem. O presente estudo trata-se de um inquérito epidemiológico que objetivou traçar o perfil epidemiológico da toxoplasmose no Município de Anápolis, estabelecendo incidências periódicas e a prevalência. O inquérito epidemiológico aplicado tem o objetivo de obter dados que permitirão maior eficácia e efetividade nas futuras medidas de prevenção primária, secundária e terciária a serem adotadas na cidade de Anápolis ou em outros municípios para a toxoplasmose. Foram utilizados os resultados dos testes sorológicos realizados pelos laboratórios da rede assistencial de saúde da cidade de Anápolis para a pesquisa de anticorpos anti-toxoplasma das classes de imunoglobulinas (Ig) M e G, correlacionados com as variáveis sexo e técnica laboratorial utilizada, em uma série histórica de 05 anos (janeiro de 2001 a dezembro de 2005). Assinaram o Termo de Consentimento Livre e Esclarecido e participaram da pesquisa seis (06) laboratórios, e foi contabilizado um total de 2399 exames analisados, sendo que 56 casos foram considerados faltosos (missing cases), utilizando-se, então, o resultado de 2343 exames. Para avaliação dos dados, os mesmos foram submetidos à análise estatística descritiva, apresentando valores absolutos em cada variável e seus respectivos percentuais. No Município de Anápolis a prevalência da toxoplasmose aguda no grupo resultante da combinação de anticorpos anti-toxoplasma IgM+ IgG-, foi de 11%. Constatou-se que a prevalência de casos em que houve contato prévio com o Toxoplasma gondii seguidos de uma imunidade adquirida foi de 3% para o grupo resultante da combinação de anticorpos anti-toxoplasma IgM+ IgG+. Averiguou-se que a prevalência de casos em que se exclui o diagnóstico de toxoplasmose aguda, sem descartar a possibilidade de infecções antigas foi de 60% para o grupo resultante da combinação de anticorpos anti-toxoplasma IgM- IgG +. A prevalência de casos em que se exclui o diagnóstico de toxoplasmose aguda e que também se descarta a possibilidade de infecções antigas, representada pelo grupo IgM-/IgG -, foi de 25%. Ressalta-se que a situação indeterminada teve uma prevalência de 1%. Com relação à variável sexo, predominou o feminino, correspondendo a 93,42% dos participantes e a técnica laboratorial mais utilizada foi a de Imunofluorescência (IFI), com 66,75%. Concluiu-se que a prevalência de casos em que se exclui o diagnóstico de toxoplasmose aguda, sem descartar a possibilidade de infecções antigas, está em concordância com a literatura; a prevalência global foi apontada sem se considerar as faixas etárias; não foi possível conhecer a positividade de toxiplasmose para gestação; a taxa de toxoplasmose aguda foi de 11%.