Doutorado em Saúde Coletiva

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    Gestão de risco na segurança do paciente na atenção primária à saúde em um município da região central do Espírito Santo
    (Universidade Federal do Espírito Santo, 2024-11-18) Sirtoli, Fernanda Cordeiro; Lima, Eliane de Fátima Almeida; https://orcid.org/0000-0001-5128-3715; http://lattes.cnpq.br/4640538188376728; Primo, Cândida Caniçali; https://orcid.org/0000-0001-5141-2898; http://lattes.cnpq.br/4739920753105018; https://orcid.org/0000-0002-3601-3394; Sarti, Thiago Dias; Barcelos, Mara Rejane Barroso; Nunes, Elisabete Maria Garcia Teles; Figueiredo, Karla Crozeta
    Introdução: A segurança do paciente é um eixo essencial da qualidade do serviço de assistência à saúde e o desenvolvimento de estratégias e práticas seguras na atenção primária à saúde deve ser entendida como uma prioridade na gestão dos riscos. A gestão de riscos trata-se de um um processo para conhecer os riscos aos quais há exposição e, então, avançar para a tomada de decisão sobre o que fazer com relação a eles. Objetivo geral: Desenvolver ferramentas para a gestão de riscos na Atenção Primária à Saúde de um município da Região Central do Espírito Santo. Objetivos específicos: Conhecer a situação de gestão de riscos; definir as prioridades e ferramentas para a gestão de riscos; construir as ferramentas para a gestão de riscos; elaborar uma página eletrônica sobre Segurança do Paciente vinculada ao site institucional do município para divulgação das ferramentas construídas para a gestão de riscos na segurança do paciente. Método: Foi realizada uma Pesquisa-Ação, de abordagem qualitativa. A pesquisa foi desenvolvida no município de Aracruz. A população do estudo foi constituída por um Grupo de Planejamento, com profissionais que atuam na Vigilância Sanitária e Atenção Primária à Saúde, que foram indicados pela Secretaria Municipal de Saúde. O grupo era formado por 46 participantes. Houve uma perda de 10 participantes no segmento da pesquisa, o que equivale a 21,73% dos participantes. Para a análise dos dados foi utilizada a técnica de análise de conteúdo de Bardin (2011). Resultados: Foi realizado o diagnóstico situacional sobre a gestão de riscos na Atenção Primária à Saúde, que apontou que o município não possuia a gestão de riscos implantada de maneira sistemática e efetiva. O grupo definiu as prioridades para a gestão de risco na segurança do paciente no contexto das Unidades Básicas de Saúde, e após isso se seu o processo de construção de tecnologias gerenciais como ferramentas para gestão de riscos: conjunto de protocolos de segurança do paciente na Atenção Primária à Saúde; material instrucional sobre segurança do paciente para profissionais de saúde; formulário eletrônico para gestão interna de notificações de incidentes relacionadas a segurança do paciente e página eletrônica sobre a gestão de riscos assistenciais vinculada ao site institucional do município para fortalecer e consolidar a gestão de riscos assistenciais na Atenção Primária à Saúde. Considerações Finais: Além do alcance dos objetivos desta pesquisa, ressalta-se que ocorreram algumas mudanças no município, como a criação e nomeação oficial do Núcleo de Segurança do Paciente. Estima-se que a pesquisa iniciou um processo de mudança de cultura no município em estudo referente à Segurança do Paciente. Para a assistência multiprofissional na Atenção Primária à Saúde, os resultados deste estudo oferecem uma linha direcional para que o cuidado seguro seja oferecido aos usuários do serviço, além de fortalecer a prática dos profissionais com padronização das ações baseadas nos princípios de segurança do paciente. Para o campo da Saúde Coletiva, essa pesquisa apresenta contribuição para os movimentos de promoção da saúde e políticas públicas saudáveis.
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    Uso de aprendizado de máquina em análise preditiva na interrupção do tratamento da tuberculose em pessoas que vivem com HIV
    (Universidade Federal do Espírito Santo, 2025-01-30) Soares, Karllian Kerlen Simonelli; Hisatugu, Wilian Hiroshi; https://orcid.org/0000-0001-8333-0539; http://lattes.cnpq.br/6597878238749014; Prado, Thiago Nascimento do; https://orcid.org/0000-0001-8132-6288; http://lattes.cnpq.br/6388559394015871; https://orcid.org/0000-0002-2296-1190; Sanabria, Gladys Mercedes Estigarribia; Negri, Leticya dos Santos Almeida; Rissino, Silvia das Dores; Possuelo, Lia Gonçalves
    Objective: To build a prediction model for interruption of tuberculosis treatment in people living with HIV. Methods: This is a cross-sectional study developed in three stages: first, the analysis of the quality of SINAN data using the Centers for Disease Control and Prevention (CDC) Guide, from 2016 to 2018, with five methodological stages that included quality analysis, standardization of records, duplication analysis, data completeness through linkage with the SINAN-HIV database, and data anonymization. In the second stage, in addition to the methodological process of preparing the database and descriptive data analysis, the STATA statistical package, version 16 (StataCorp LP, College Station, TX, USA) was used to perform descriptive analyses with identification of relative and absolute values, and tables were generated for data analysis. The third stage consists of building the predictive model through machine learning using Multilayer Perceptron (MLP) and Restricted Boltzmann Machines (RBM) artificial neural network algorithms and Random Forest and CatBoost decision trees of TB-HIV co-infection, from 2016 to 2021, in Brazil, implemented in Python version 3.10.3; with validation through accuracy, sensitivity, specificity, true positive values and true negative values. The study obtained ethical approval under opinion no. 4022892 on 05/12/2020. Results: In the first stage, the study showed that 89% of the mandatory variables and 91% of the essential variables presented satisfactory completeness. In the case of TB-HIV co-infection, 73% of the variables were completed, but essential variables related to monitoring of TB treatment presented unsatisfactory completeness. In the second stage, of a total of 4,428 cases, 325 cases were of TB-HIV co-infection, 322 cases were located in the SINAN-TB database and three cases were located after linkage with the SINAN-HIV database that presented a record of a negative result for the HIV diagnostic test in the SINAN-TB database. The vulnerability profile of coinfection was observed in men (71%), young (20 to 39 years) (52%), mixed race (59%), with up to 8 years of education (25%), alcoholics (29%) and smokers (37%) and who used drugs (26%), with 65% adherence to antiretroviral therapy and only 44% with a cure outcome and 20% interrupted treatment; approximately 61% did not undergo directly observed treatment and only 6.9% of cases reported receiving assistance from the government's income transfer program. In the third stage, a total of 12,556 cases of TB-HIV coinfection in Brazil were analyzed, and the Multilayer Perceptron neural network algorithms were sensitive in identifying potential cases of treatment interruption, and were validated by an accuracy of 0.73, sensitivity of 0.75, and specificity of 0.62; Positive Predictive Value (PPV) of 0.91 and Negative Predictive Value (NPV) of 0.31. Conclusion: Training and capacity building to improve data collection, integration and analysis are essential to promote data quality. As well as social support, in order to enable access to health services and timely treatment for the most vulnerable. And finally, the implementation of new technologies, which optimize the breaking of the chain of TB transmission in people living with HIV, favoring actions aimed at screening, treatment and monitoring of cases. To strengthen care networks and promote equity in access to health services.
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    Qualidade da alimentação, potencial inflamatório da dieta e resistência à insulina e diabetes mellitus no ELSA-Brasil
    (Universidade Federal do Espírito Santo, 2025-03-14) Aprelini, Carla Moronari de Oliveira; Molina, Maria del Carmen Bisi; https://orcid.org/0000-0002-8614-988X; http://lattes.cnpq.br/9238370951122705; Guandalini, Valdete Regina; Faria, Carolina Perim de; Luft, Vivian Cristine; Pereira, Marlus Henrique Queiroz
    Insulin resistance (IR) is considered an independent predictor of diabetes mellitus (DM), which is currently a global emergency. Its determinants are complex and include, among other factors, behavioral ones. Chronic subclinical inflammation participates in the pathogenesis of IR and DM through different mechanisms, and there is evidence that diet interferes with these processes. Therefore, this thesis aims to propose a new diet quality index and analyze the association between the inflammatory potential of the diet and the occurrence of IR and DM. The analyses were conducted using data from three waves of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil): baseline (2008-2010), second follow-up (2017-2019), and the Covid wave (2020-2021), and are presented in three articles. Socioeconomic information and lifestyle habits were collected through structured questionnaires, and standardized clinical and physical examinations. The first article developed and validated Food Quality Score (FQS) using a qualitative Food Frequency Questionnaire. Pearson correlation, Principal Component Analysis, and Cronbach's alpha were used to test validity and reliability. Women and older individuals who engaged in more physical activity and had higher income levels exhibited higher FQS, in contrast to those who reported higher alcohol consumption and smoking. Cronbach's alpha coefficient was 0.47. The DQS demonstrated satisfactory validity and reliability and was associated with socioeconomic and lifestyle variables. The second article examined the relationship between the Inflammatory Food Index (IFI) and socioeconomic conditions and lifestyle habits. Multiple Correspondence Analysis and Multinomial Logistic Regression were used, with p < 0.05 considered statistically significant. Groups with more anti- or proinflammatory dietary patterns were expressed in a bidimensional graph. Low-income individuals, smokers, males, sedentary individuals, those diagnosed with obesity and those under 60 years of age were more likely to have a pro-inflammatory diet. The third article evaluated the prospective association between the inflammatory potential of the diet, estimated by the IFI, and the risk of IR and DM. Adjusted Cox regression models were used, considering a bilateral p-value of < 0.05. Incident cases of IR and DM were identified in 19.6% and 10.1% of participants, respectively. Being in the highest quintiles (greater dietary inflammatory potential) at the beginning of the study increased the risk of IR and DM in both sexes. Individuals who maintained a high score across the analyzed periods had a 1.5-fold increased risk for IR (95% CI 1.2-1.9; and 1.2-1.8, for men and women, respectively). These results contribute to a better understanding of the life and health aspects that impact dietary patterns and, consequently, the development of chronic diseases, enabling the improvement of dietary prescriptions focused on the prevention and treatment of IR and DM. Furthermore, the developed IFI allows for the analysis and comparison of the diet across other waves of ELSA-Brasil, contributing to the investigation of associations between eating habits, social determinants, and health outcomes within the context of nutritional epidemiology
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    Consumo de sal e sua relação com a pressão arterial em populações indígenas
    (Universidade Federal do Espírito Santo, 2024-03-10) Porto, Aline Silva; Mill, José Geraldo ; https://orcid.org/0000-0002-0987-368X; http://lattes.cnpq.br/2497419234600362; https://orcid.org/0000-0002-4780-3228; http://lattes.cnpq.br/0733677667808693; Alvim, Rafael de Oliveira; https://orcid.org/0000-0003-3150-4239; http://lattes.cnpq.br/3204117077254917; Zaniqueli, Divanei dos Anjos ; https://orcid.org/0000-0002-6146-1658; http://lattes.cnpq.br/1478607888567973; Miotto, Maria Helena Monteiro de Barros ; https://orcid.org/0000-0002-3227-7608; http://lattes.cnpq.br/4289442514763843
    Introduction: Diets high in sodium/salt can increase blood pressure. However, the pressure increase per gram of dietary salt shows significant differences among populations. Objective: To determine the consumption of salt, sodium, and potassium and their relationship with blood pressure in the indigenous population living in the villages of Aracruz, Espírito Santo. Methods: The doctoral project was structured in the format of three original papers and a literature review. Data collection in the indigenous population was conducted in two phases: the first in 2003 and the most recent in 2020-2022. Data from the general population of Vitória, studied in the MONICA-OMS/Vitória Project in 1999-2000, served as a comparison parameter. The studies were approved by the Ethics Research Committee of the Health Sciences Center at UFES. Results: The first manuscript is an integrative literature review on salt consumption in different populations. The second manuscript compares the impact of salt consumption in the urban population of Vitória and the indigenous people of Aracruz, with salt consumption estimated from the sodium excretion in 12-hour urine samples collected at night in both surveys. Only individuals not using antihypertensive medications were included in the analysis. The estimated salt consumption was high in both populations, higher among the indigenous (12.8 ± 5.7 g/day vs. 11.8 ± 5.9 g/day; p<0.01). Data from two collected databases (between 1999-2004) were used to compare salt consumption (12-hour urinary excretion) and its relationship with blood pressure in two populations, one with a representative sample from Vitória (ES) (n = 1,279) and the indigenous population of Aracruz (ES) (n = 526). High salt consumption was found in both populations (12.8 ± 5.7 g/day vs. 11.8 ± 5.9 g/day; even higher in the indigenous population, P<0.01). The slope of systolic blood pressure in indigenous people in the multivariate analysis showed that the salt consumption, age, and BMI explained 27% and 21% of the systolic and diastolic BP variability in the indigenous group. However the strongest predictor of both systolic and diastolic BP was the body adiposity. The third manuscript used data from indigenous populations collected in 2022, which sought to reassess salt consumption (casual urine) and its relationship with blood pressure (n = 800). The average salt consumption was 10 g/day. The variability of systolic pressure after adjustment for age, BMI, and salt was 24%. The fourth manuscript aimed to identify the sodium and potassium consumption profile, totaling 1,048 indigenous participants, and found very high values for salt consumption (10 g/day) and very low values for potassium consumption (1.8 g/day). Additionally, unsatisfactory diet quality was found for the indigenous community (Na+/K+=3.8).Conclusion: Salt consumption is high in both populations and appears to be associated with blood pressure, particularly systolic pressure. The diet quality of the indigenous populations is poor and requires government public health policies focused on food and nutrition to reduce the development of cardiovascular diseases in this population
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    Imunogenicidade natural e induzida pelas vacinas contra a Covid-19 em uma coorte de trabalhadores da saúde
    (Universidade Federal do Espírito Santo, 2024-11-18) Gouvea, Maria da Penha Gomes; Valim, Valéria; https://orcid.org/0000-0002-0625-1308; Mill, Jose Geraldo; Pinto, Lauro Ferreira; Machado, Ketty Lysie Libardi Lira; Duarte, Djane Braz
    The clinical profile of COVID-19 has been linked to age, pre-existing comorbidities, viral load, immunological profile, and individual vaccination status. This study resulted from two consecutive projects. Objectives: In the first phase, monitoring of symptoms and antibody production in a cohort of unvaccinated healthcare professionals over six months. The aim of the second phase was to evaluate the immunogenicity and duration of humoral response of the CoronaVac and AstraZeneca (ChAdOx1) vaccines in a cohort of workers for 180 days after the primary schedule and 180 days after booster dose with ChAdOx1 or Pfizer/BioNTech (BNT 162b2), in homologous and heterologous schemes. Method: Observational longitudinal study. The first phase included healthcare workers diagnosed with COVID-19 confirmed by RT-PCR. The presence of anti-nucleocapsid IgG and IgM antibodies against SARS-CoV-2 was detected by chemiluminescent microparticle immunoassay (ARCHITECT i1000SR, Abbott Laboratories, IL, USA). IgG results > 1.4 AU/mL and IgM > 1.0 AU/mL were considered seroconverted (group A), and those with values below were non-seroconverted (group B). Serologic tests were conducted at 15, 30, 45, 60, 90, and 180 days after COVID-19 symptoms onset. The second phase included healthcare workers which were immunized with two doses of CoronaVac or ChAdOx1 followed by a booster dose with ChAdOx1 or BNT 162b2 (BNT). Subjects underwent 8-9 blood collections for IgG anti-spike antibody levels (IgG-S) measurement, immediately before the first dose, 28 days after the first dose, immediately before the second dose, 28 days and 180 days after the second dose (*), immediately before the third dose, 28, 90, and 180 after the booster dose (#). IgG antibody titers to the SARS-CoV-2 spike receptor binding domain (IgG-S) were determined using a chemiluminescent microparticle immunoassay (CMIA) (ARCHITECT i1000SR, SARS-CoV-2 IgG II Quant assay, Abbott Laboratories, Abbott Park, IL, USA). Results were expressed in arbitrary units per mL (AU/mL) and converted to Binding Antibody Units per mL (BAU/mL), as standardized by the World Health Organization (WHO). Results: The first phase included 73 healthcare workers with COVID-19. 4 subjects were separately evaluated due to reinfection. COVID-19 evolved mildly to moderately in all 69 subjects. Mean age was 40 (±10) years, 74% female, 78.3% with previous comorbidities, and 21.7% used at least one medication for chronic disease. Common initial symptoms were muscle pain (76.9%), headache (75.5%), anosmia (59.6%), ageusia (63.8%), rhinorrhea (58.4%), fever (52.2%), and cough (52.2%). After 30 days, persistent symptoms included anosmia (18.9%), asthenia (18.9%), adynamia (14.5%), muscle pain and ageusia (7.3%). IgG serology curve peaked on the 30th day with an average value of 3.25 AU/mL, and IgM peaked on the 15th day with an average value of 7.2 AU/mL, both showing progressive decline in subsequent serologies. Non-seroconversion for IgG or IgM was observed in 26% of participants (n=18). Among IgG seropositive individuals, 28.3% (n=15) maintained IgG reactivity for 180 days. The symptom Diarrhea had a 4-fold higher likelihood of IgM seropositivity, while sore throat and shortness of breath increased the likelihood by 6-fold for reactive IgG after 180 days. The 4 patients with recurrent infection belonged to the non-seropositive group. The mean period between infection and reinfection was 112 (± 65) days. The recurrence rate was 5.47%. Symptomatic period duration ranged from 3 to 22 days for the first infection and 5 to 19 days for the second infection. RT-PCR cycle threshold (Ct) data showed lower Ct values during COVID-19 recurrence in the four cases. All four participants became IgM and IgG seropositive during reinfection, with symptoms considered more severe in one participant requiring medical care and non-invasive respiratory support for 24 hours. In the second phase of this study, serological results from the first blood collection showed 42.8% IgG-S reactivity in the VAC group and 29.7% in the AZV group. In both groups, IgG-S levels increased [Geometric Mean Titers (95% CI)], with CoronaVac or ChAdOx1 [D28 = 12(10–15) vs. 71(57–88) and D28* = 115(96–137) vs. 488(407–586)]. Seroconversion rate at D28* was 100% in both groups. At D180, 88% of VAC participants remained reactive, and 100% in the AZV group. Sharp decline in titers averaged 3.73 times and 2.61 times in seronegative groups, and averaged 2.16 times and 1.66 times in seropositive, VAC and AZV groups, respectively. Six months after primary vaccination (D180), the geometric mean titer significantly decreased in VAC [30(24–39)] and AZV [186(155–226)]. Confirming this, PRNT neutralizing antibody test demonstrated higher geometric mean titers in the AZV group compared to VAC, regardless of serological status [237 (181–311) vs. 43 (34–55) seronegative and 748 (534–1,048) vs. 145 (111–189) seropositive], with high correlation (r = 0.93, p < 0.001). In the VAC seronegative group, soluble plasma mediators were increased at D28* compared to D28 and compared to AZV. The AZV seropositive group showed high levels of soluble plasma mediators at D28 and D28* compared to the VAC group. Levels of soluble immune mediators were reduced at D28 compared to D0 in both seronegative groups. At D28*, the CCL3, CCL2, IL-1B, IL-6, IFN-y, IL-5, VEGF, and PDGF set was increased, while the IL-12, IL-15, IL-17, IL-10, IL-13, FGF-basic, G-CSF, GM-CSF, and IL-2 set remained unchanged. Soluble mediators that differed between vaccine schemes were CCL11, CXCL8, CCL4, CCL5, CXCL10, TNF-a, IL-1Ra, IL-4, and IL-9, with the VAC seronegative group showing higher levels than AZV at D28*. On the booster day (D0#), all AZV group participants remained seropositive, while in the VAC group, seropositivity rate was 16% lower. Heterologous groups were formed: VAC/BNT, VAC/AZV, AZV/BNT, and 1 homologous group AZV/AZV. At D28#, heterologous groups showed stronger titers with VAC/AZV and VAC/BNT (45 times and 118 times, respectively) compared to AZV/BNT (29 times), while the homologous AZV/AZV scheme showed a slight increase (3.9 times). Heterologous schemes induced higher neutralizing antibody titers against the Wuhan ancestral lineage, Delta, and Omicron variants. Seropositivity rate for the Omicron variant was significantly lower in the homologous scheme (VAC/AZV = 93%; VAC/BNT = 100%; AZV/BNT = 100% vs. AZV/AZV = 64%). Following booster dose, antibody response in VAC or AZV groups showed exponential growth. VAC/BNT scheme induced titers as high as AZV/BNT and maintained them up to 180 days after the booster dose. Conclusion: IgM and IgG peak approximately 15/30 days after symptom onset. Natural infection with SARS CoV-2 does not provide similar protection in all individuals, and absence of specific antibodies may increase reinfection risk. Exacerbated symptoms in second infection may be associated with higher viral load. 28 days after the second dose, CoronaVac and AstraZeneca vaccines induced seroconversion in 100% of patients. CoronaVac induced lower titers and shorter duration of immunity compared to AstraZeneca. Higher activation of inflammatory response biomarkers was observed in the VAC group compared to the AZV group, possibly due to the multiplicity of antigens present in the inactivated virus vaccine. Heterologous booster with AstraZeneca or BNT 162b2 provided protection against the ancestral strain and Delta and Omicron variants, regardless of primary immunization scheme. Overall, kinetic analysis of IgGS reactivity reinforces the efficacy of the heterologous scheme in inducing antibody response to SARS-CoV-2. Additionally, the heterologous scheme produced higher geometric mean titers than the homologous regimen. Lower titers and faster decline of specific antibody levels suggest the need for a booster dose.