scholarly journals Prevalence and genotype distribution of cervical human papilomavirus infection in the pre-vaccination era: a population-based study in the Canary Islands

BMJ Open ◽  
2020 ◽  
Vol 10 (9) ◽  
pp. e037402 ◽  
Author(s):  
Miguel Andujar ◽  
Esther Roura ◽  
Alejandra Torres ◽  
Begoña Vega ◽  
Marta Pavcovich ◽  
...  
Keyword(s):  
Canary Islands ◽  
Age Groups ◽  
Hpv Infection ◽  
Adult Women ◽  
Genotype Distribution ◽  
Cervical Lesions ◽  
Female Population ◽  
Factors Associated ◽  
Increased Risk ◽  
Hpv Types

ObjectiveNational Spanish studies show that prevalence of cervical human papillomavirus (HPV) infection in the female population is increasingly frequent, with an overall estimate of 14% in women aged 18–65 years. The objective of this study is to know the prevalence and distribution of HPV types in the female population of the Canary Islands prior to the introduction of HPV vaccines and to investigate the associated clinical and sociodemographic factors.MethodsBased on the Primary Health Care database, a sample of adult women (aged 18–65 years) of Gran Canaria (GC) and Tenerife (TF) stratified into nine age groups was carried out between 2002 and 2007. Women were contacted by postal letter and telephone call and were visited in their primary care centre. A clinical-epidemiological survey was completed and cervical samples were taken for cytological study and HPV detection. HPV prevalence and its 95% CI were estimated, and multivariate analyses were performed using logistic regression to identify factors associated with the infection.Results6010 women participated in the study, 3847 from GC and 2163 from TF. The overall prevalence of HPV infection was 13.6% (CI 12.8%–14.5%) and 11.1% (CI 10.3%–11.9%) for high-risk types. The most frequent HPV type was 16 followed by types 51, 53, 31, 42 and 59. HPV types included in the nonavalent vaccine were detected in 54.1% of infected women. Factors associated with an increased risk of infection were: young ages (18–29 years), the number of sexual partners throughout life, not being married, being a smoker, and having had previous cervical lesions or genital warts.ConclusionsIt is confirmed that prevalence of HPV infection in the female population of the Canary Islands is high, but similar to that of Spain, HPV 16 being the most frequent genotype. The determinants of infection are consistent with those of other populations.

scholarly journals Distribution and Prevalence of High-Risk Human Papillomavirus Genotypes in Cervical Specimens

2020 ◽  
Vol 25 (3) ◽  
pp. 325-331
Author(s):  
Erkan Özmen ◽  
Ülkü Altoparlak ◽  
Muhammet Hamidullah Uyanık ◽  
Abdulkadir Gülen
Keyword(s):  
Cervical Cancer ◽  
Human Papillomavirus ◽  
Age Groups ◽  
Hpv Infection ◽  
High Rate ◽  
Genotype Distribution ◽  
Hpv Dna ◽  
Hpv Test ◽  
Significant Difference ◽  
Hpv Types

Introduction: Human papillomavirus (HPV) is frequently a sexually transmitted virus and can cause cervical cancer in women. Cervical cancer is the second most common type of cancer among the developing countries. In this study, cervical HPV DNA positivity and genotype distributions were investigated in female patients living in our region and the results were compared with different studies. Materials and Methods: Between 1 July, 2017 and 1 March, 2019, 433 cervical swabs were sent to Ataturk University, Medical Faculty Hospital, Medical Microbiology Laboratory due to suspicion of HPV. Swab samples were evaluated for HPV virus using molecular (Polymerase Chain Reaction-PCR) methods. For this purpose, Xpert HPV Test (Cepheid, Inc, Sunnyvale, CA) was used to identify HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68 t in a single sample. Results: Mean age of the patients ranged from 20 to 69 years, with a mean of 39.8 years (± 10.0). Positivity was detected in 62 of the 433 patients. Mean age of the positive patients was 40.2 years (± 11.3). When the positive patients were examined in terms of HPV types, the presence of HPV 16 was observed with a rate of 25.6%, while the HPV 18/45 types were found to be 9.0% in total. When patients were evaluated according to age groups, HPV DNA positivity was highest in the 25-34 age group with 38.7%. In our statistical study, there was no significant difference in HPV DNA positivity rate between the ages of 35 and under 35 years. Conclusion: This study demonstrates the prevalence and viral genotype distribution of HPV infection in women in Erzurum region. HPV type 16 is seen with a high rate in our region.

6. Prevalence, genotype diversity and determinants of anal HPV infection in high-risk men attending a sexually transmitted infection clinic in Puerto Rico

Sexual Health ◽  
2013 ◽  
Vol 10 (6) ◽  
pp. 572
Author(s):  
Vivian Colón-López ◽  
Ana Patricia Ortiz ◽  
Lizbeth Del Toro-Mejías ◽  
Michael Craig Clatts ◽  
Joel M. Palefsky
Keyword(s):  
Logistic Regression ◽  
Puerto Rico ◽  
High Risk ◽  
Multivariate Logistic Regression Analysis ◽  
Hpv Infection ◽  
Bivariate Analysis ◽  
Heterosexual Men ◽  
Genotype Distribution ◽  
Factors Associated ◽  
Hpv Types

Background Recent studies in Puerto Rico (PR) have reported an increasing incidence of anal cancer in Puerto Rican men. The objective of this study was to determine the prevalence, genotype distribution and risk factors associated with anal HPV infection among heterosexual men and men who have sex with men (MSM) attending an STI clinic in PR. Methods: We conducted a cross-sectional study of men 18 years and older. A comprehensive survey was administered that included a demographic and behavioural assessment. Logistic regression was performed to determine factors associated with any, high-risk (HR), low-risk (LR) and multiple anal HPV infection. Results: The mean age of the study sample was 38.0 ± 13.5 and 37.7 ± 13.0 years for MSM and heterosexual men, respectively. A third (29.8%) of the study sample reported being MSM. Significant differences were observed in the prevalence of any anal HPV infection for MSM (84.5%) as compared with heterosexual men (45.7%; P < 0.001). Although MSM showed a higher prevalence of both HR and LR HPV types, no significant differences were observed in the bivariate analysis. Overall, HR anal HPV infection was found in 58.5% of the participants. The most common HR types were 53, 58, 68, 51 and 31. Multiple HPV types in the anal canal were found in 50.0% of the sample. Multivariate logistic regression analysis showed that being a MSM was associated with any anal HPV infection (OR = 6.2; 95% CI 1.5, 25.7). Conclusions: Anal HPV is common among sexually active men attending this STI clinic, with a higher likelihood of any anal HPV infection among MSM.

Age differences in mortality in patients undergoing surgery for infective endocarditis

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
L Ostergaard ◽  
M.H Smerup ◽  
K Iversen ◽  
A.D Jensen ◽  
A Dahl ◽  
...  
Keyword(s):  
Infective Endocarditis ◽  
Aortic Valve ◽  
Hospital Mortality ◽  
Hazard Analysis ◽  
Age Groups ◽  
Prosthetic Heart Valve ◽  
Valve Surgery ◽  
Aortic Valve Surgery ◽  
Factors Associated ◽  
Increased Risk

Abstract Background Infective endocarditis (IE) is associated with high mortality. Surgery may improve survival, but the intercept between benefit and harm is hard to balance and may be closely related to age. Purpose To examine the in-hospital and 90-day mortality in patients undergoing surgery for IE and to identify differences between age groups and type of valvular intervention. Methods By crosslinking nationwide Danish registries we identified patients with first-time IE undergoing surgical treatment in the period from 2000 to 2017. The study population was grouped in patients &lt;60 years, 60–75 years, and ≥75 years of age. High-risk subgroups by age and surgical valve intervention (mitral vs aortic vs mitral+aortic) during IE admission were examined. Kaplan Meier estimates was used to identify 90-day mortality by age groups and multivariable adjusted Cox proportional hazard analysis was used to examine factors associated with 90-day mortality. Results We included 1,767 patients with IE undergoing surgery, 735 patients &lt;60 years (24.1% female), 766 patients 60–75 years (25.8% female), and 266 patients &gt;75 years (36.1% female). The proportion of patients with IE undergoing surgery was 35.3%, 26.9%, and 9.1% for patients &lt;60 years, 60–75 years, and &gt;75 years, respectively. For patients with IE undergoing surgery, the in-hospital mortality was 6.4%, 13.6%, and 20.3% for patients &lt;60 years, 60–75 years, and ≥75 years of age, respectively and mortality at 90 days were 7.5%, 13.9%, and 22.3%, respectively. Factors associated with an increased risk 90-day mortality were: mitral valve surgery and a combination of mitral and aortic valve surgery as compared with isolated aortic valve surgery, patients 60–75 years and &gt;75 years as compared with patients aged &lt;60 years, prosthetic heart valve prior to IE admission, and diabetes, Figure. Patients &gt;75 years undergoing a combination of mitral and aortic valve surgery had an in-hospital mortality of 36.3%. Conclusion In patients undergoing surgery for IE, a stepwise increase in 90-day mortality was seen for age groups, highest among patients &gt;75 years with a 90-day mortality of more than 20%. Patients undergoing mitral and combined mitral and aortic valve surgery as compared to isolated aortic valve surgery were associated with a higher mortality. These findings may be of importance for the management strategy of patients with IE. Mortality risk Funding Acknowledgement Type of funding source: None

Detection of aflatoxin B1 adducts in Mexican women with cervical lesions

2021 ◽  
pp. 1-12
Author(s):  
L. Díaz de León-Martínez ◽  
C.M. López-Mendoza ◽  
Y. Terán-Figueroa ◽  
R. Flores-Ramírez ◽  
F. Díaz-Barriga ◽  
...  
Keyword(s):  
Human Papillomavirus ◽  
Dna Adducts ◽  
Hpv Infection ◽  
Mexican Women ◽  
Cervical Lesions ◽  
Increased Risk ◽  
Secondary Objective ◽  
E6 And E7 ◽  
Aflatoxin B ◽  
Potent Carcinogen

Cervical cancer (CC) is one of the most serious threats to the lives of women; co-factors in addition to oncogenic human papillomavirus (HPV) infection may be important in causing CC. Women in Mexico are exposed to dietary aflatoxin B1, a potent carcinogen, which may act as a co-factor, in inducing progression to CC. Scarce studies are addressing environmental risks associated with the development of CC, thus the study aimed to establish a relationship between the presence of AFB1 and the detection of human papillomavirus in the genome of Mexican women. Forty samples from cervical tissue of women infected with HPV were obtained; positive results regarding the HPV type (16 and/or 18) were found in 92.5% women and the presence of AFB1-DNA adducts were detected in 77.5% of the same positive HPV samples. Detection of AFB1-DNA adducts and genomic concentrations were correlated with the detection of two oncogenic types of HPV 16 and 18. AFB1-DNA positivity and higher genomic concentrations of AFB1-DNA adducts were correlated with an increased risk of oncogenic detection of HPV in cervical samples from women in Mexico. As a secondary objective, a hypothetical interaction of the adducts with the NRF2 pathway has been proposed, therefore activation of p62 and in turn E6 and E7 (HPV proteins) would inhibit the formation of autophagosomes, which would result in a presence or recurrence of CC.

scholarly journals Pulmonary tuberculosis among men over forty

1959 ◽  
Vol 57 (4) ◽  
pp. 367-385 ◽  
Author(s):  
Cecily M. Tinker
Keyword(s):  
Royal College ◽  
Age Groups ◽  
The Elderly ◽  
Older Age ◽  
Personal Hygiene ◽  
Tuberculous Infection ◽  
Elderly Men ◽  
Female Population ◽  
Heavy Smoking ◽  
Increased Risk

1. A review of the few studies so far made on the high mortality from tuberculosis among elderly men, and a consideration of the available statistics, indicate that urbanization is one of the principal factors responsible.2. In the present inquiry, which was confined to London, 445 newly diagnosed cases of tuberculosis in men over 40, together with the same number of paired controls, were studied by means of a questionnaire and of personal interview.3. It was found that the tuberculous patients differed significantly from the controls in the following characteristics; Scots, Irish, Welsh, or foreign nationality; single, widower or divorced; resident in common lodging houses or hostels; inadequate or special diet; history of gastrectomy; a winter cough; shortness of breath; insufficient sleep; and heavy drinking and smoking. On the other hand, overtime or night work, diabetes, rheumatoid arthritis, asthma, and mental illness were distributed fairly evenly in the two groups.4. Unfortunately no group of elderly women exists in this country living under the same sort of conditions as the elderly men studied here, so that it was impossible to determine how far the various factors considered were responsible for the high rate of late adult male tuberculosis. A study, however, of a population of established civil servants living under ordinary conditions revealed little difference between the observed rates of tuberculosis and those expected on the basis of national notification figures for men and women in the older age groups.5. It appears that a low standard of personal hygiene, associated especially with heavy smoking and drinking and residence in loading houses, predispose to the development of tuberculosis in the elderly male. Part of the evil effect of living in common lodging houses in particular may be due to the increased risk of exposure to tuberculous infection that it entails.6. It is tentatively concluded that the casual workers of an urbanized community are one of the principal reservoirs of tuberculous infection in large towns, and since there is no numerically comparable female population, this group, and its immediate male contacts, account in large measure for the difference between the male and female tuberculosis rates in the older age groups.This work was initiated during the tenure of a Prophit Scholarship of the Royal College of Physicians, and completed with the aid of a grant from the Medical Research Council.I am indebted to members of the Prophit Committee of the Royal College of Physicians for their support and encouragement, and most particularly to Dr G. S. Wilson, Director of the Public Health Laboratory Service, under whose guidance the work was carried out. Figures relating to the incidence of tuberculosis in the Civil Service are published by kind permission of Dr W. E. Chiesman, Treasury Medical Adviser, and Dr M. C. W. Long, Dr J. W. Parks, and Dr H. Stannus Stannus, whose departmental records were used to compute the figures.I am greatly indebted to the consultants and staff of the seventeen chest clinics who co-operated in the investigation, for their interest and help in tracing patients, and to the medical superintendents of numerous sanatoria and chest hospitals, and to the surgeons who permitted me to interview patients under their care as controls.I should like also to acknowledge the assistance received from the medical officers of health of the metropolitan boroughs who kept me informed of notifications from lodging houses in their areas, and supplied information about the accommodation.

The Role of Early Colposcopy in the Management of Females with First Episode Anogenital Warts

1994 ◽  
Vol 5 (5) ◽  
pp. 343-345 ◽  
Author(s):  
K A Ward ◽  
J R Houston ◽  
B E Lowry ◽  
R D Maw ◽  
W W Dinsmore
Keyword(s):  
Intraepithelial Neoplasia ◽  
Hpv Infection ◽  
Cervical Cytology ◽  
First Episode ◽  
Low Grade ◽  
High Grade ◽  
Anogenital Warts ◽  
Cervical Smear ◽  
Cervical Lesions ◽  
Increased Risk

212 females attending a genitourinary medicine (GUM) clinic with first episode anogenital warts were screened by cervical cytology and colposcopy/histology for the presence of cervical epithelial abnormalities in keeping with infection by the human papillomavirus (HPV infection) and/or cervical intraepithelial neoplasia (CIN). The prevalence of cervical epithelial abnormalities detected by cervical cytology alone was 32%, rising to 56% after colposcopic examination. However, the majority of cervical lesions detected by colposcopy alone were of low grade (HPV infection and/or CIN I). Histologically confirmed high grade cervical lesions (CIN II or CIN III) were detected more frequently in those females in whom cervical cytological examination indicated dyskaryosis in keeping with any grade of CIN, compared to females without dyskaryotic changes on cervical smear ( P<0.05, chi-squared test with Yates' correction). Early colposcopy is indicated for females with anogenital warts in the presence of a cervical smear showing dyskaryosis in keeping with any grade of CIN, because of the statistically significant increased risk of detecting a potentially progressive high grade cervical lesion. In females without dyskaryotic changes on cervical smear, the value of early colposcopy is uncertain and warrants larger more long-term trials.

Prevalence and Genotype distribution of Human Papillomavirus Infection in Different Anatomical Sites among Men Who Have Sex with Men (MSM): A Systematic Review and Meta-Analysis

2020 ◽  
Author(s):  
Mohammad Farahmand ◽  
Seyed Hamidreza Monavari ◽  
Ahmad Tavakoli
Keyword(s):  
Systematic Review ◽  
Human Papillomavirus ◽  
High Risk ◽  
Sexual Behaviors ◽  
Meta Analysis ◽  
Hpv Infection ◽  
Genotype Distribution ◽  
Increased Risk ◽  
Pertinent Data ◽  
Sex With Men

Abstract Background: Homosexual men or men who have sex with men (MSM) are at increased risk of human papillomavirus (HPV) infection because of their high-risk sexual behaviors. In this large study, a meta-analytic approach was used to systematically analyze the literature to elucidate the prevalence and genotype distribution of anal, penile, oral, and urethral HPV infection among MSM in the world.Methods: To carry out this systematic review, five electronic databases were searched for relevant studies published from January 2012 through to November 2019, and pertinent data were collected from the eligible articles. The pooled HPV prevalences were calculated for each anatomical region using random-effect model weighted by the inverse variance method. Subgroup analyses were performed to identify the probable sources of heterogeneity. The meta-analysis was performed using the “Metaprop” function in the R package Meta.Results: The overall pooled prevalence of anal, penile, oral, and urethral HPV infection among MSM were 78.11 % (95% CI: 75.50%-80.52%), 36.26% (95% CI: 29.13%–44.05%), 17.33% (95% CI: 13.65%–21.75%), and 15.40% (95% CI: 7.86%–27.97%), respectively. Stratified analyses showed that the prevalences of HPV were significantly higher in HIV-positive than HIV-negative MSM. The most frequent HPV high-risk type detected in the anus, penis, and oral cavity was HPV-16 (20.32%, 4.96%, and 3.16%, respectively). Conclusion: HPV infection is on the dramatic rise in MSM because of high-risk sexual behaviors, strongly suggesting the increased risk of developing HPV-related diseases and malignancies in this population. Among different sexual orientations, male homosexuality is associated with the highest risk of acquiring sexually transmitted infections.

scholarly journals Knowledge of human papillomavirus and Pap test among Brazilian university students

2019 ◽  
Vol 65 (5) ◽  
pp. 625-632 ◽  
Author(s):  
Aimée Denzeler Baptista ◽  
Carolina Xavier Simão ◽  
Vitoria Carvalho Guimarães dos Santos ◽  
Juliana Gil Melgaço ◽  
Silvia Maria Baeta Cavalcanti ◽  
...  
Keyword(s):  
Cervical Cancer ◽  
Human Papillomavirus ◽  
University Students ◽  
Pap Test ◽  
Hpv Infection ◽  
Health Science ◽  
Cancer Information ◽  
Papanicolaou Test ◽  
Factors Associated ◽  
Increased Risk

SUMMARY OBJECTIVE: Human papillomavirus (HPV) is the most prevalent sexually transmitted virus in the world and is associated with an increased risk of cervical cancer. The most effective approach to cervical cancer control continues to be screening through the preventive Papanicolaou test (Pap test). This study analyzes the knowledge of university students of health science programs as well as undergraduate courses in other areas of knowledge on important questions regarding HPV. METHOD: Four hundred and seventy-three university students completed a questionnaire assessing their overall knowledge regarding HPV infection, cervical cancer, and the Pap test. A descriptive analysis is presented, and multivariate analysis using logistic regression identified factors associated with HPV/cervical cancer information. RESULTS: Knowledge was higher for simple HPV-related and Pap test questions but was lower for HPV interrelations with genital warts and cervical cancer. Being from the health science fields and having high income were factors associated with greater knowledge. Only the minority of the participants recognized all the situations that increased the risk of virus infection presented in the questionnaire. CONCLUSIONS: These findings highlight the need for educational campaigns regarding HPV infection, its potential as a cervical cancer agent and the forms of prevention available.

scholarly journals Human papillomavirus and abnormal cervical lesions among HIV-infected women in HIV-discordant couples from Kenya

2020 ◽  
Vol 96 (6) ◽  
pp. 457-463 ◽  
Author(s):  
Brandon L Guthrie ◽  
Anne F Rositch ◽  
Joy Alison Cooper ◽  
Carey Farquhar ◽  
Rose Bosire ◽  
...  
Keyword(s):  
Human Papillomavirus ◽  
Hpv Infection ◽  
Cervical Neoplasia ◽  
Cervical Cytology ◽  
High Grade ◽  
Cervical Lesions ◽  
Hpv Prevalence ◽  
High Grade Lesion ◽  
Hpv Types ◽  
Hpv Screening

ObjectiveHIV infection increases the risk of high-grade cervical neoplasia and invasive cervical carcinoma. The study addresses the limited data describing human papillomavirus (HPV) infection and cervical neoplasia among HIV-infected women in HIV-discordant relationships in sub-Saharan Africa, which is needed to inform screening strategies.MethodsA cross-sectional study of HIV-infected women with HIV-uninfected partners was conducted to determine the distribution of type-specific HPV infection and cervical cytology. This study was nested in a prospective cohort recruited between September 2007 and December 2009 in Nairobi, Kenya. Cervical cells for HPV DNA testing and conventional cervical cytology were collected. HPV types were detected and genotyped by Roche Linear Array PCR assay.ResultsAmong 283 women, the overall HPV prevalence was 62%, and 132 (47%) had ≥1 high-risk (HR)-HPV genotype. Of 268 women with cervical cytology results, 18 (7%) had high-grade cervical lesions or more severe by cytology, of whom 16 (89%) were HR-HPV-positive compared with 82 (41%) of 199 women with normal cytology (p<0.001). The most common HR-HPV types in women with a high-grade lesion or more severe by cytology were HPV-52 (44%), HPV-31 (22%), HPV-35 (22%), HPV-51 (22%) and HPV-58 (22%). HR-HPV genotypes HPV-16 or HPV-18 were found in 17% of women with high-grade lesions or more severe. HR-HPV screening applied in this population would detect 89% of those with a high-grade lesion or more severe, while 44% of women with normal or low-grade cytology would screen positive.ConclusionHR-HPV prevalence was high in this population of HIV-infected women with an uninfected partner. Choice of screening for all HR genotypes versus a subset of HR genotypes in these HIV-infected women will strongly affect the performance of an HPV screening strategy relative to cytological screening. Regional and subpopulation differences in HR-HPV genotype distributions could affect screening test performance.

scholarly journals Prevalence of and factors associated with self-reported high blood pressure in Brazilian adults

2017 ◽  
Vol 51 (suppl 1) ◽  
Author(s):  
Deborah Carvalho Malta ◽  
Regina Tomie Ivata Bernal ◽  
Silvânia Suely Caribé de Araújo Andrade ◽  
Marta Maria Alves da Silva ◽  
Gustavo Velasquez-Melendez
Keyword(s):  
Blood Pressure ◽  
High Blood Pressure ◽  
Skin Color ◽  
Adult Population ◽  
Age Groups ◽  
Federal District ◽  
Noncommunicable Diseases ◽  
Factors Associated ◽  
Brazilian State ◽  
Increased Risk

ABSTRACT OBJECTIVE To analyze factors associated with self-reported high blood pressure among adults in Brazilian state capitals. METHODS The study uses data from Sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (Vigitel – Surveillance System of Risk and Protection Factors of Noncommunicable Diseases by Telephone Survey) collected in 2013. Prevalence rates and their respective 95% confidence intervals by gender were estimated according to sociodemographic variables, lifestyle, reported noncommunicable diseases and self-rated health status. Multivariate logistic regression modeling was used to identify variables associated with self-reported high blood pressure with α < 0.05. RESULTS Prevalence of self-reported high blood pressure among adults living in Brazilian state capitals and the Federal District was 24.1%. The following variables were associated with self-reported high blood pressure: age group, taking 18-24 as reference (all age groups presented increased risk – from 25-34 years [OR = 2.6; 95%CI 2.0–3.4] up to 65 years or more [OR = 28.1; 95%CI 21.7–36.4]); low education level (9 to 11 years of study [OR = 0.8; 95%CI 0.7–0.9] and 12 years or more [OR = 0.6; 95%CI 0.6–0.7]); Black race or skin color (OR = 1.3; 95%CI 1.1–1.5); being a former smoker (OR = 1.2; 95%CI 1.1–1.3); obesity (OR = 2.7; 95%CI 2.4–3.0); diabetes (OR = 2.9; 95%CI 2.5–3.5%), and high cholesterol (OR = 1.9; 95%CI 1.8–2.2). CONCLUSIONS Approximately one quarter of the adult population living in Brazilian state capitals reported having high blood pressure. Information from Vigitel is useful to monitor high blood pressure and identity its associated factors, supporting public policies for health promotion, surveillance and care.

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