Julia Moreira Pescarini

Background and Aims: Despite the high burden of cardiovascular disease (CVD) in Latin America and the Caribbean (LAC), risk prediction models adapted for use in LAC populations remain limited. The aim of this study was to recalibrate the Systematic COronary Risk Evaluation 2 (SCORE2) risk models for estimating 10-year CVD risk in individuals without prior CVD or diabetes mellitus in LAC, resulting in the SCORE2 Latin America and the Caribbean (SCORE2-LAC) models. Methods: Sex-specific, competing risk-adjusted SCORE2 models were recalibrated to contemporary CVD incidence across four risk regions, defined by country-level age- and sex-standardized CVD mortality rates, using region-specific risk factor distributions. Cardiovascular disease incidence was estimated from CVD mortality data and ratios of the total first-to-fatal CVD events, derived from 40 237 152 individuals (1 261 329 CVD events). External validation included 132 512 individuals without prior CVD or diabetes from 11 cohorts across seven countries (3938 CVD events). Discrimination was assessed using Harrell’s C-index. Results: In the external validation datasets, the pooled C-index of SCORE2-LAC was .740 [95% confidence interval (CI) .716–.763], with cohort-specific C-indices ranging from .674 (95% CI .588–.761) to .789 (95% CI .747–.831). Estimated CVD risk varied several-fold across the four LAC risk regions. For a 50-year-old non-smoker with a systolic blood pressure of 140 mmHg, total cholesterol of 213 mg/dL (5.5 mmol/L), and HDL cholesterol of 50 mg/dL (1.3 mmol/L), the predicted risk ranged from 3% in low-risk countries to 10% in very-high-risk countries for women, and from 4% to 10% for men. Conclusions: The SCORE2-LAC models provide region-specific contemporary estimates of 10-year CVD risk in apparently healthy individuals, enabling identification of individuals at high CVD risk across LAC.

To develop and apply composite indices to assess immediate losses caused by hydrological disasters in Brazil between 2000 and 2023, with a focus on human losses and damages to health infrastructure. Data were obtained from the Integrated Disaster Information System, which consolidates national records of hydrological disasters. Seven indicators were selected for the Human Loss Index and four for the Health Infrastructure Loss Index. Indicators were normalized using Min-Max procedures and weighted through a combined Analytic Hierarchy Process and entropy method. The General Severity Index was calculated as the arithmetic mean of Human Loss Index and Health Infrastructure Loss Index, stratified into four levels of severity. Spatial and temporal analyses were conducted to identify critical regions and municipalities. The findings reveal significant heterogeneity in disaster impacts across time and space. Human losses exhibited greater variability than health infrastructure losses, with notable peaks in 2006, 2011, 2015, and 2019. Infrastructure damages were less frequent but highly disruptive, especially in 2012, 2019, and 2023. Municipalities in the Amazon region, particularly Japurá and Atalaia do Norte, registered the highest combined indices, reflecting compounded vulnerabilities from geographic isolation, fragile infrastructure, and socioeconomic inequalities. High General Severity Index scores were concentrated in the North, while human losses were more widely distributed, including along the densely populated southeastern coast. Results confirm that small and socioeconomically vulnerable municipalities are disproportionately affected, with limited institutional capacity to respond. Hydrological disasters in Brazil are strongly mediated by social inequalities, deficient urban planning, and weak preventive policies. Human and infrastructure losses disproportionately affect vulnerable populations, particularly in the North, where access to health services is precarious. The findings emphasize the need for territorially integrated strategies that combine climate adaptation, poverty reduction, and investments in resilient public health infrastructure.

Introduction The continuous cash benefit (Benefício de Prestação Continuada, BPC) is Brazil’s main non-contributory social pension. It guarantees a monthly income equivalent to one minimum wage to individuals aged ≥65 years and to people with disabilities living in poverty, but evidence on its health effects remains limited. This protocol describes the design and methods for evaluating the effects of BPC on hospitalisations and mortality among older adults and their household members. Methods and analysis This natural experiment study uses linked administrative records from the 100 Million Brazilian Cohort (2001–2021), BPC payments (2016–2021), mortality (2001–2020) and hospitalisation data (2008–2018). Eligibility for elders is defined by age (≥65 years) and monthly family per capita income (<¼ of the minimum wage or up to 1/2 the minimum wage for specified groups). We defined as treated individuals who initiate BPC receipt from 2016 onwards. Untreated individuals are income or age-eligible or near-eligible adults who do not receive the benefit. The study population comprised people who were registered at any time in the cohort but were still alive on 1 January 2016. We triangulate two approaches. First, we will employ fuzzy regression discontinuity design using age and income eligibility thresholds to estimate local average treatment effects for different bandwidths. To assess the continuity assumption, we will analyse individuals aged 60 years or older to test outcome smoothness, while eligibility remains defined at age 65. Second, we will employ survival models with inverse probability of treatment weighting to estimate effects under conditional exchangeability assumptions. Outcomes include all-cause and cause-specific mortality and hospitalisations among older adults and their co-inhabitants. Analyses account for household clustering using cluster-robust SEs. Sensitivity analyses will assess robustness to data quality, municipal characteristics and potential overlap with Bolsa Família receipt. Ethics and dissemination This study was approved by the Brazilian National Research Ethics Commission (CONEP) (approval number: 85981225.6.0000.0040), in accordance with the Brazilian National Health Council Resolution No. 466/2012. Findings will be disseminated through peer-reviewed publications, conference presentations, and policy briefs targeting stakeholders in social protection and health in Brazil. Results will also be shared with relevant governmental and non-governmental actors to support evidence-informed decision-making.

Hydro-meteorological and geological disasters can pose serious harm to community health, such as an increased risk of infectious diseases and related mortality. We conducted a scoping review to compile the available literature on the effects of hydro-meteorological and geological disasters on routine immunisation and vaccine-preventable disease (VPD) outbreaks among children and adolescents under 18 years. We searched Medline, Embase, Global Health, Scopus, and Web of Science for original studies and systematic reviews on the topic published by the 21st of October 2024. We included studies that quantitatively analysed the effect of any of the thirty Emergency Events Database (EM-DAT) recognised hydro-meteorological and geological disasters (or those fitting EM-DAT criteria) on a comprehensive list of World Health Organization (WHO)-recommended vaccines and the 23 diseases against which they prevent. We included 26 studies, of which 19 concerned with vaccine-preventable disease outbreaks and seven focused on routine immunisation disruption.. Our review indicates that floods, cyclones, droughts, extreme temperatures, tsunamis, and earthquakes may result in vaccine-preventable disease outbreaks and routine immunisation disruption, and identified young children and refugees as at-risk populations. Flooding was reported to be associated with water-borne and vector-borne vaccine-preventable disease outbreaks such as malaria. Poor water, sanitation and hygiene (WASH) were further recognised as facilitating conditions for vaccine-preventable disease outbreaks after disasters. The vaccination studies reported reduction in routine immunisation rates in the months following a disaster, considering infrastructural damage to health facilities and vaccine storage issues as common causes. Finally, there was significant knowledge gap on the effects of specific disasters (e.g., wildfires and volcanic eruptions) and diseases (e.g., influenza, yellow fever, malaria, and dengue).In conclusion, our review reinforce the need for better policies to ensure vaccine equity, resilient health system and safe WASH to prevent vaccine-preventable disease (VPD) outbreaks following hydro-meteorological and geological disasters.

Background: Achieving universal social protection (SP) coverage for people affected by tuberculosis (TB) is increasingly recognised as an essential component of its response, as well as other diseases of poverty. Realising this goal requires to clearly understand the SP needs of people affected by TB and to identify means to maximise their access to existing or new SP benefits in an efficient, effective, and sustainable manner. Main body: To address these questions, between 2022 and 2023, the WHO Western Pacific Regional office conducted the first SP baseline assessment for people affected by TB in Mongolia, Lao People’s Democratic Republic, the Philippines, Cambodia, and Viet Nam. This exercise encompassed a desk review of SP programmes operating in these countries, followed by an expert consultation to discuss barriers and entry points to expand SP coverage among people affected by TB. Overall evidence gathered from publicly available reports and publications suggests that existing SP programmes in these countries are insufficiently accessible and inadequate to meet the needs of people affected by TB. Most countries provide TB-specific benefits only to people with multidrug-resistant TB, leaving most people with TB unserved. The most reported barriers to access to SP included lack of awareness, stigma, poverty, as well as programmes’ fragmentation, and administrative and financial constraints. Identified solutions included raising awareness about SP, extending TB-specific SP benefits to all people with TB in need, advocating for a better inclusion of people with TB into existing governmental programmes, and strengthening the referral system across the health and SP sectors. Conclusions: By identifying concrete policy entry points and actionable solutions, this SP baseline assessment provided a foundation for these five countries to embed social protection more systematically into their national TB responses. Ideally, this effort should now be replicated in all high TB-burden countries willing to achieve universal SP coverage among people affected by TB. The lessons that emerged from this baseline assessment are consistent with the recommended actions and principles underlying the Western Pacific Regional Framework for Reaching the Unreached and are thus transferrable to other diseases of poverty.

We conducted a scoping review to investigate planned (intentional) and unplanned (not intentional) effects of social protection on socioeconomic determinants of health (SDH) and health inequalities among children, adolescents, elders and people with disabilities, and their caregivers. We reviewed seven programs in (i) Brazil ( Programa Bolsa Familia (BFP) and Beneficio de Prestacao Continuada (BPC)), and (ii) Ecuador ( Bono de Desarrolo Humano (BDH) , Bono 1000 días , Pensión Mis Mejores Años/Pensión para Adultos Mayores , Pensión Toda una Vida/Pensión para personas con discapacidad and Bono Joaquín Gallegos Lara) . We searched PubMed, EMBASE, LILACS, Scopus, Econlit, PsycINFO, Global Health, Global Index Medicus and grey literature for studies evaluating program implementation and effects on health outcomes or SDH from 1990 to 2023. We extracted data from 114 studies (84 on BFP, 17 on BDH and 13 on BPC). No studies were identified for the remaining programs. In Brazil, we found substantial evidence of BFP planned effects on children’s health and some SDH but little evidence on its unplanned effects in adults and caregivers. Evidence effects of BPC on health outcomes were scarce, with only one study in elders and none among people with disabilities. In Ecuador, we found evidence only for BDH, with some studies on planned health effects and few on SDH and its unplanned effects. Very few studies used longitudinal data, quasi-experimental designs, or comparison groups of eligible non-recipients. Finally, we found large variations coverage and implementation of programs. In summary, our review highlights the lack of evidence on the overall impacts of social protection in Ecuador, particularly those targeting older adults and people with disabilities. In Brazil, further research is needed on unplanned health effects of the BFP and on the impacts of social protection targeting elders and people with disabilities.

O ensaio discute as relações entre regulação migratória e assistência social, no tocante aos migrantes internacionais com deficiência. Nos apoiamos em documentos normativos nacionais e internacionais que mencionam imigração e deficiência, investigando os sentidos de proteção social que deles emergem. Enfatizamos o caráter eugênico e capacitista das normativas brasileiras de longa duração, aspecto que conjuga com desafios atuais, como: pouca repercussão das orientações humanitárias sobre a gestão migratória brasileira; invisibilidade informacional e política dessa população; e limitações estruturantes da política socioassistencial, cuja atuação com imigrantes com deficiência ainda demanda maiores reflexões e mobilização dos mecanismos de justiça para efetivação, ampliação e universalização.

Background: Residential segregation is considered a social determinant of health, but there is limited evidence of its impact on tuberculosis (TB). We investigated the associations between municipality-level income and racial segregation and TB treatment outcomes in Brazil. Methods: We studied nationwide registries of new TB cases between 1 January 2010 and 31 December 2019. TB treatment was dichotomised as unfavourable (ie, loss to follow-up, modification of treatment regimen, treatment failure and death) and favourable (ie, cured/treatment completion). We assessed individuals' municipality-level income and racial segregation (ie, dispersion of household heads earning ≤half versus those earning >half minimum wage; and of household heads identifying as black or brown/mixed race (Pardo/a) versus white). Logistic regression adjusted for sociodemographic and clinical variables was used to estimate the OR of experiencing an unfavourable treatment outcome associated with segregation overall and by self-identified race/ethnicity. Results: Individuals living in highly economically and racially segregated municipalities (fifth versus first quintiles) were more likely to have an unfavourable TB treatment outcome (income segregation: adjusted OR 1.34 (95% CI 1.31 to 1.37); racial segregation: 1.13 (0.94 to 1.36)). Living in municipalities of higher income segregation (third, fourth and fifth quintiles) was associated with higher unfavourable TB treatment outcomes in all self-identified racial groups (fifth quintile: white 1.25 (0.96 to 1.64); black 1.42 (1.15 to 1.74); brown/mixed 1.37 (1.20 to 1.56); Asian=1.30 (1.00 to 1.69) and Indigenous 1.37 (1.00 to 1.87)). Conclusions: Living in highly income and racially segregated environments is associated with unfavourable TB treatment outcomes for all self-identified races in Brazil. TB programmes should account for segregation as a barrier to TB treatment completion.

Background: This paper focuses on the impacts of climate change on vulnerable ecosystems and its implications for the health and well-being of populations. It specifically examines the Semi-arid region of Brazil, where the introduction of a social climate adaptation tool, cisterns, has brought about significant positive changes. Cisterns, a low-cost climate adaptation technology, can be replicated globally, reducing the negative health impacts of frequent droughts, especially for vulnerable groups in remote rural areas. Objective: We analyze the impact of the “One Million Cisterns Program” (P1MC) on health by synthesizing the literature and modeling its interactions with climatic and environmental factors with the DPSEEA framework. Methods: Our case study employs a multidisciplinary approach, focusing on two key objectives: (i) synthesizing the literature on the implementation of the P1MC and its association with health outcomes; and (ii) developing a conceptual framework to model the relationship between climatic and environmental factors, adaptive ecosystems, and health outcomes. The Driving Force–Pressure–State–Exposure–Effect–Action (DPSEEA) framework evaluates the structural connections between climate change and human health. Findings: The study found a significant gap in the literature concerning the relationship between P1MC and health outcomes. Cisterns target the pressure/state linkages related to contextual factors and health effects, addressing the root causes of drought-related health issues. This framework also provides a foundation for collaboration among health, environmental, and policy sectors to address shared challenges, such as water security and health outcomes. Conclusion: We offer a multidisciplinary analytical framework that can be used to explore various perspectives – environmental, social, and health-related – with experts and stakeholders to develop and improve adaptive social technology strategies for living in the emergence of climate change. This framework also facilitates the implementation of qualitative and quantitative well-being and health assessments.