Browsing by Author "Undurraga, Eduardo A. "

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    A dynamic modeling tool for estimating healthcare demand from the COVID19 epidemic and evaluating population-wide interventions
    (2020) Rainisch, Gabriel; Undurraga, Eduardo A.; Chowell, Gerardo
    Objectives: Public health officials need tools to assist in anticipating the healthcare resources required to confront the SARS-COV-2 pandemic. We constructed a modeling tool to aid active public health officials to estimate healthcare demand from the pandemic in their jurisdictions and to evaluate the potential impact of population-wide social-distancing interventions. Methods: The tool uses an SEIR compartmental model to project the pandemic’s local spread. Users input case counts, healthcare resources, and select intervention strategies to evaluate. Outputs include the number of infections and deaths with and without intervention, and the demand for hospital and critical care beds and ventilators relative to existing capacity. We illustrate the tool using data from three regions of Chile. Results: Our scenarios indicate a surge in COVID-19 patients could overwhelm Chilean hospitals by June, peaking in July or August at six to 50 times the current supply of beds and ventilators. A lockdown strategy or combination of case isolation, home quarantine, social distancing of individuals >70 years, and telework interventions may keep treatment demand below capacity. Conclusions: Aggressive interventions can avert substantial morbidity and mortality from COVID-19. Our tool permits rapid evaluation of locally-applicable policy scenarios and updating of results as new data become available.
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    A partisan pandemic: State government public health policies to combat COVID-19 in Brazil
    (BMJ Publishing Group, 2021) Touchton M.; Knaul F.M.; Arreola-Ornelas H.; Porteny T.; Méndez O.; Knaul F.M.; Edelson V.; Arreola-Ornelas H.; Méndez O.; Porteny T.; Sánchez M.; Faganello M.; Gygi B.; Hummel C.; Otero S.; Insua J.; Undurraga, Eduardo A.; Rosado J.A.
    © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.Introduction To present an analysis of the Brazilian health system and subnational (state) variation in response to the COVID-19 pandemic, based on 10 non-pharmaceutical interventions (NPIs). Materials and methods We collected daily information on implementation of 10 NPI designed to inform the public of health risks and promote distancing and mask use at the national level for eight countries across the Americas. We then analyse the adoption of the 10 policies across Brazil's 27 states over time, individually and using a composite index. We draw on this index to assess the timeliness and rigour of NPI implementation across the country, from the date of the first case, 26 February 2020. We also compile Google data on population mobility by state to describe changes in mobility throughout the COVID-19 pandemic. Results Brazil's national NPI response was the least stringent among countries analysed. In the absence of a unified federal response to the pandemic, Brazilian state policy implementation was neither homogenous nor synchronised. The median NPI was no stay-at-home order, a recommendation to wear masks in public space but not a requirement, a full school closure and partial restrictions on businesses, public transportation, intrastate travel, interstate travel and international travel. These restrictions were implemented 45 days after the first case in each state, on average. Rondônia implemented the earliest and most rigorous policies, with school closures, business closures, information campaigns and restrictions on movement 24 days after the first case; Mato Grosso do Sul had the fewest, least stringent restrictions on movement, business operations and no mask recommendation. Conclusions The study identifies wide variation in national-level NPI responses to the COVID-19 pandemic. Our focus on Brazil identifies subsequent variability in how and when states implemented NPI to contain COVID-19. States' NPIs and their scores on the composite policy index both align with the governors' political affiliations: opposition governors implemented earlier, more stringent sanitary measures than those supporting the Bolsonaro administration. A strong, unified national response to a pandemic is essential for keeping the population safe and disease-free, both at the outset of an outbreak and as communities begin to reopen. This national response should be aligned with state and municipal implementation of NPI, which we show is not the case in Brazil.
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    A review of the global emergence of multidrug-resistant Salmonella enterica subsp. enterica Serovar Infantis
    (ELSEVIER, 2023) Alvarez, Diana M.; Barron-Montenegro, Rocio; Conejeros, Jose; Rivera, Dacil; Undurraga, Eduardo A.; Moreno-Switt, Andrea I.
    Salmonella enterica serovar Infantis is an emergent foodborne and zoonotic Salmonella serovar with critical implications for global health. In recent years, the prevalence of S. Infantis infections has increased in the United States, Europe, and Latin America, due to contaminated chicken and other foods. An essential trait of S. Infantis is its resistance to multiple antibiotics, including the critically important third-generation cephalosporins and quinolones, undermining effective medical treatment, particularly in low-resource settings. We describe the emergence of multidrug-resistant (MDR) S. Infantis, focusing on humans, animals, the environment, and food. We conducted a systematic review (1979-2021), selected 183 studies, and analyzed the origin, source, antimicrobial resistance, and presence of a conjugative plasmid of emerging S. Infantis (pESI) in reported isolates. S. Infantis has been detected worldwide, with a substantial increase since 2011. We found the highest number of isolations in the Americas (42.9 %), Europe (29.8 %), Western Pacific (17.2 %), Eastern Mediterranean (6.6 %), Africa (3.4 %), and South-East Asia (0.1 %). S. Infantis showed MDR patterns and numerous resistant genes in all sources. The primary source of MDR S. Infantis is broiler and their meat; however, this emerging pathogen is also present in other reservoirs such as food, wildlife, and the environment. Clinical cases of MDR S. Infantis have been reported in children and adults. The global emergence of S. Infantis is related to a plasmid (pESI) with antibiotic and arsenic- and mercury-resistance genes. Additionally, a new megaplasmid (pESI-like), carrying blaCTX-M-65 and antibiotic-resistant genes reported in an ancestral version, was detected in the broiler, human, and chicken meat isolates. Strains harboring pESI-like were primarily observed in the Americas and Europe. MDR S. Infantis has spread globally, potentially becoming a major public health threat, particularly in low- and middle-income countries.
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    Análisis epidemiológico de la leptospirosis humana en Colombia, 2015-2020
    (2023) Parra Barrera, Eliana Liseth; Torres Hidalgo, Marisa; Undurraga, Eduardo A.; Pontificia Universidad Católica de Chile. Escuela de Medicina
    Antecedentes: Colombia es un país endémico de la leptospirosis. La notificación de los casos sospechosos es obligatoria y se realiza al Sistema Nacional de Vigilancia. La confirmación diagnóstica de los casos se realiza en el Laboratorio Nacional de Referencia. El presente estudio planteó el desarrollo de dos objetivos generales, como sigue: Objetivo 1: Determinar la distribución de los casos de leptospirosis humana con confirmación diagnóstica por el Laboratorio Nacional de Referencia en Colombia entre los años 2015 a 2020. Objetivo 2: Analizar los factores clínicos y epidemiológicos de los casos de leptospirosis humana confirmados respecto a su asociación con la forma grave o letal de la enfermedad. Metodología: Para el desarrollo del primer objetivo general se planteó un diseño descriptivo retrospectivo de los casos confirmados al Laboratorio Nacional de Referencia. En el desarrollo del segundo objetivo general, se realizó un análisis de regresión de casos de leptospirosis con confirmación diagnóstica y reporte clínico para la identificación de los factores de riesgo asociados con el desenlace de leptospirosis grave y mortalidad. Resultados: En los seis años analizados se notificaron al laboratorio Nacional de Referencia 3.535 casos, 880 (24,9%). La incidencia general de casos confirmados fue de 1,9 por 100.000 habitantes, afectando más a hombres (82,1%) que a mujeres (17,8%). Un total de 54 (6,1%) muertes fueron confirmadas como leptospirosis. Los serovares más frecuentes fueron Australis (21,1%), Autumnalis (6,9%), Wolfii (6,3%), Ballum (5,8%), Tarasovi (5,7%), Bratislava (5,5%) y Hebdomadis (4,4%). El serovar Bratislava se asoció significativamente en los casos con mortalidad (p = 0,007). Los casos de leptospirosis grave fueron clasificados según las manifestaciones clínicas como falla renal (29,9%), hepática (27,4%) y multiorgánica (24,4%), shock séptico (24,4%), síndrome de Weil (18,4%), hemorragia pulmonar (18,4%) y meningitis (2,5%). Observándose casos que requirieron el ingreso a UCI (30,3%) y que fueron fatales (8,5%). Las variables asociadas a la leptospirosis grave fueron dificultad respiratoria (OR: 4,57 IC: 1,17-17,80, p<0,028), lesión renal (OR: 15,7 IC:2,40-103,29, p=0,004), taquicardia (OR: 5,93 IC:1,04-33,53, p<0,044) y erupción cutánea (OR:8,14 IC:2,61-25,42, p<0,001). El desenlace de admisión en la UCI se asoció a trombocitopenia (OR: 6,81 IC:1,89-24,4, p<0,003), dificultad respiratoria (OR:10,48 IC:3,12-35,13, <0,001), lesión renal (OR: 32,2 IC: 4,5-119,01, <0,001), taquicardia (OR: 4,29 IC:11,15-15,95, p=0,030) y erupción cutánea (OR: 7,78 IC:2,09 -29,00, p=0,002). La mortalidad fue asociada la edad avanzada (>60 años) (OR: 6,12 IC:1,40-26,76, p=0,016), ictericia (OR: 11,96 IC: 1,35-108,82, p=0,028) y meningitis (OR: 14,30 IC: 1,15-177,64, p=0,038). Conclusión: El estudio evidenció la persistencia de la transmisión de la leptospirosis en hombres, con casos en todos los grupos de edad analizados. Los datos presentaron una distribución heterogénea entre las regiones del país. La dificultad respiratoria y la erupción cutánea se asociaron tanto a la enfermedad grave como a la admisión a la UCI, y la ictericia se asoció con la mortalidad.
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    Analysis of Extreme Rainfall and Natural Disasters Events Using Satellite Precipitation Products in Different Regions of Brazil
    (MDPI, 2022) Palharini R.; Undurraga, Eduardo A.; Vila D.; Rodrigues D.; Mattos E.
    © 2022 by the authors.The number of natural disasters triggered by extreme events is increasing worldwide and significantly impacts modern society. Extreme rainfall is one of the most important factors contributing to these events. A better understanding of the physical process that causes extreme rainfall can allow rapid responses from decision-makers to lessen the impact of natural disasters on the local population. Satellite monitoring is widely used for this purpose and is essential for regions where terrestrial observations are limited or non-existent. The primary purpose of this study is to describe the performance of satellite products for extreme rainfall events that caused natural disasters in various climate regimes in Brazil and discuss the contribution of mesoscale convective systems (MCS) to these events. We defined regions based on the climatological rainfall distribution. Cases with rain values above the 99th percentile during 2012–2016 were considered statistically extreme. Our analysis is based on three datasets, with precipitation from (i) rain gauge stations, (ii) different satellite-based estimates, and (iii) mesoscale convective tracking data. The methodology was based on identifying extreme rainfall events, analyzing the performance of satellite precipitation estimates and, finally, quantifying the influence of convective systems on extreme rain. Although all regions of Brazil may be affected by natural disasters caused by extreme rains, the results suggest that the impacts caused in each region are different in magnitude. Convective systems explained over 90% of extreme rains in the case analyzed in Brazil’s south and about 60% to 90% of extreme rains in the case analyzed in the Northeast. In general, satellite products have identified rain events; however, in the southern region of Brazil, products have tended to overestimate rainfall, while other regions have tended to underestimate extreme rain values. The methods used in satellite precipitation estimation products have limitations to accurately identifying specific extreme rain events.
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    Andes network-studying early psychosis in Latin America
    (2019) Crossley, Nicolás; Guinjoan, S.; Rivera, G.; Jackowski, A.; Gadelha, A.; Elkis, H.; Louza, M.; Gama, C.; Evans-Lacko, S.; Castaneda, C.P.; Undurraga, Eduardo A.; Cordoba, R.; Bressan, R.
    Background Our knowledge about schizophrenia is largely based on studies in developed countries such as the United States, Western Europe or Japan. Their findings have pointed to several risk factors or modulators of response which unfortunately are more prevalent and stronger in low and middle-income countries. These include exposure to violence and trauma, poor perinatal care, or limited (and potentially late) access to healthcare. In this context, there is a pressing need to raise information from these countries about psychosis. We here present to the SIRS community the Latin American Consortium ANDES whose main aim is to study early psychosis within the Latin American context. Methods This is a descriptive study characterizing the groups and the cohorts of patients included that are part of the ANDES network. Results 15 different groups from 6 different countries from Latin America are part of the network, including Argentina, Bolivia, Brazil, Chile, Colombia and Mexico. The network includes several early intervention clinical services, such as those in São Paulo and Santiago, who receive jointly around 5 new cases of first episode a week. ANDES also integrates three groups studying ultra-high-risk subjects (2 in São Paulo, 1 in Mexico). All groups have already acquired data from studies on first episode patients whose characteristics will be presented. Available data includes clinical and sociodemographic information from more than 1,000 patients, cognitive assessments using MATRICS from more than 500 patients, and 600 MRI T1 scans, DTI and resting-state fMRI (350 patients and 250 controls). Discussion ANDES is a unique opportunity to study psychosis in deprived settings which are frequently less represented in research publications. The inequality present in Latin America provides opportunities to study the effect of exposures to an adverse environment within this population.
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    Antibiotic Consumption During the Coronavirus Disease 2019 Pandemic and Emergence of Carbapenemase-Producing Klebsiella pneumoniae Lineages Among Inpatients in a Chilean Hospital: A Time-Series Study and Phylogenomic Analysis
    (2023) Allel, Kasim; Peters, Anne; Conejeros, Jose; Martinez, Jose R. W.; Spencer-Sandino, Maria; Riquelme-Neira, Roberto; Rivas, Lina; Rojas, Pamela; Orellana Chea, Cristian; Garcia, Patricia; Araos, Rafael; McGovern, Olivia; Patel, Twisha S.; Arias, Cesar A.; Lessa, Fernanda C.; Undurraga, Eduardo A.; Munita, Jose M.
    The increased usage of carbapenems and broad-spectrum & beta;-lactams during the COVID-19 pandemic was associated with a higher prevalence of carbapenemase-producing Klebsiella pneumoniae in a public hospital in Chile. We observed emergence and spread of bla(NDM) ST45 during the pandemic.
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    Benchmarking the Covid-19 pandemic across countries and states in the USA under heterogeneous testing
    (2020) Asahi Kodama, Kenzo Javier; Undurraga, Eduardo A.; Wagner, Rodrigo; CEDEUS (Chile)
    Public health officials need to make urgent decisions to reduce the potential impact of the CoVID-19 pandemic. Benchmarking based on the increase in total cases or case fatality rates is one way of comparing performance across countries or territories (such as states in the USA), and could inform policy decisions about COVID-19 mitigation strategies. But comparing cases and fatality across territories is challenging due to heterogeneity in testing and health systems. We show two complementary ways of benchmarking across countries or US states. First, we used multivariate regressions to estimate the test-elasticity-of-COVID-19-case-incidence. We found a 10% increase in testing yielded ~9% (95% CI:4.2–3.4%; p<0.001) increase in reported cases across countries, and ~2% (95%CI:0.1-3.4%; p=0.03) increase across US states during the week ending April 10th, 2020. We found comparable negative elasticities for fatality rates (across countries: β =-0.77, 95%CI:-1.40– -0.14; p=0.02; US states: β=-0.15, 95%CI:-0.30-0.01; p=0.06). Our results were robust to various model specifications. Second, we decomposed the growth in cases into test growth and positive test ratio (PTR) growth to intuitively visualize the components of case growth. We hope these results can help support evidence-based decisions by public health officials as more consistent data hopefully becomes available.
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    Birth seasons and heights among girls and boys below 12 years of age: lasting effects and catch-up growth among native Amazonians in Bolivia
    (2018) Brabec, Marek; Behrman, Jere R.; Emmett, Susan D.; Gibson, Edward; Kidd, Celeste; Leonard, William; Penny, Mary E.; Piantadosi, Steven T.; Sharma, Abhishek; Tanner, Susan; Undurraga, Eduardo A.; Godoy, Ricardo A.
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    Bridging gaps to universal palliative care access in Chile: serious health-related suffering and the cost of expanding the package of care services
    (2023) Perez-Cruz, Pedro E.; Undurraga, Eduardo A.; Arreola-Ornelas, Hector; Corsi, Oscar; Kwete, Xiao-Xiao Jiang; Krakauer, Eric L.; Rosa, William E.; Knaul, Felicia M.
    Background The Lancet Commission on Palliative Care (PC) and Pain Relief quantified the burden of serious health-related suffering (SHS), proposing an Essential Package of PC (EPPC) to narrow the global PC divide. We applied the EPPC framework to analyze PC access in Chile, identify gaps in coverage, and provide recommendations to improve PC access. Methods Total SHS and population in need of PC was estimated using official 2019 government data. We differ-entiated between cancer and non-cancer related SHS given guaranteed Chilean PC coverage for cancer. We calculated differences between the Chilean PC package and the Lancet Commission EPPC to estimate the cost of expanding to achieve national coverage of palliative care. Findings In 2019, nearly 105,000 decedent and non-decedent Chileans experienced SHS with a lower-bound estimate of 12.1 million days and an upper-bound estimate of 42.4 million days of SHS. Each individual experienced between 116 and 520 days of SHS per year. People living with a cancer diagnosis had PC access with financial protection, accounting for almost 42% of patients in need. People with non-cancer diagnoses-about 61 thousand patients- lacked PC coverage. Expanding coverage of the EPPC for all patients in need would cost just above $123 million USD, equivalent to 0.47% of Chilean National Health Expenditure. Interpretation Achieving universal PC access is urgent and feasible for Chile, classified as a high-income country. Expanding PC services and coverage to the EPPC standard are affordable and critical health system responses to ensuring financial protection for patients with SHS. In Chile, this requires closing large gaps in PC coverage pertaining to patients with non-cancer conditions and treatment of symptoms that go beyond pain. Our research provides an empirical approach for applying the Lancet Commission SHS framework to estimate the cost of achieving national universal PC access anchored in a package of health care services. Funding This research was partially funded by the Chilean Government through the Fondo Nacional de Ciencia y Tecnologia (Fondecyt Regular) grant number 1201721, the U.S. Cancer Pain Relief Committee grant AWD-003806 awarded to the University of Miami and by the University of Miami Institute for Advanced Study of the Americas. We acknowledge NIH/NCI award P30CA008748. Copyright & COPY; 2023 The Authors. Published by Elsevier Ltd.
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    Case fatality risk by age from COVID-19 in a high testing setting in Latin America: Chile, March-May, 2020
    (2020) Undurraga, Eduardo A. ; Chowell, Gerardo ; Mizumoto, Kenji
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    Catch-up growth and growth deficits : Nine-year annual panel child growth for native Amazonians in Bolivia
    (2016) Leonard, W.; Behrman, J.; Godoy, R.; Zhang, R.; Undurraga, Eduardo A.; Zeng, W.; Reyes García, V.; Tanner, S.
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    Centre-based care is a significant predictor of lower body mass index in early childhood: Longitudinal evidence from Chile
    (2020) Allel, Kasim; Narea Biscupovich, Marigen Soledad; Undurraga, Eduardo A.
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    Challenges and Potential of Remote Sensing for Assessing Salmonella Risk in Water Sources: Evidence from Chile
    (MDPI, 2025) Palharini, Rayana Santos Araujo; González Reyes, Makarena Sofía; Ferreira Monteiro, Felipe; Mendoza Villavicencio, Lourdes Milagros; Adell, Aiko D.; Toro, Magaly; Moreno Switt, Andrea Isabel; Undurraga, Eduardo A.
    Waterborne illnesses, including those caused by Salmonella, are an increasing public health challenge, particularly in developing countries. Potential sources of salmonellosis include fruits and vegetables irrigated/treated with surface water, leading to human infections. Salmonella causes millions of gastroenteritis cases annually, but early detection through routine water quality surveillance is time-consuming, requires specialized equipment, and faces limitations, such as coverage gaps, delayed data, and poor accessibility. Climate change-driven extreme events such as floods and droughts further exacerbate variability in water quality. In this context, remote sensing offers an efficient and cost-effective alternative for environmental monitoring. This study evaluated the potential of Sentinel-2 satellite imagery to predict Salmonella occurrence in the Maipo and Mapocho river basins (Chile) by integrating spectral, microbiological, climatic, and land use variables. A total of 1851 water samples collected between 2019 and 2023, including 704 positive samples for Salmonella, were used to develop a predictive model. Predicting Salmonella in surface waters using remote sensing is challenging for several reasons. Satellite sensors capture environmental proxies (e.g., vegetation cover, surface moisture, and turbidity) but not pathogens. Our goal was to identify proxies that reliably correlate with Salmonella. Twelve spectral indices (e.g., NDVI, NDWI, and MNDWI) were used as predictors to develop a predictive model for the presence of the pathogen, which achieved 59.2% accuracy. By spatially interpolating the occurrences, it was possible to identify areas with the greatest potential for Salmonella presence. NDWI and AWEI were most strongly correlated with Salmonella presence in high-humidity areas, and spatial interpolation identified the higher-risk zones. These findings reveal the challenges of using remote sensing to identify environmental conditions conducive to the presence of pathogens in surface waters. This study highlights the methodological challenges that must be addressed to make satellite-based surveillance an accessible and effective public health tool. By integrating satellite data with environmental and microbiological analyses, this approach can potentially strengthen low-cost, proactive environmental monitoring for public health decision-making in the context of climate change.
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    Changes in adult well-being and economic inequalities: An exploratory observational longitudinal study (2002-2010) of micro-level trends among Tsimane', a small-scale rural society of Indigenous People in the Bolivian Amazon
    (2024) Godoy, Ricardo; Bauchet, Jonathan; Behrman, Jere R.; Huanca, Tomas; Leonard, William R.; Reyes-Garcia, Victoria; Rosinger, Asher; Tanner, Susan; Undurraga, Eduardo A.; Zycherman, Ariela
    Knowing what happens over time to the lifeways of people in contemporary small-scale non-industrial societies of the rural Global South matters because it helps assess changes in the quality of life of underrepresented groups. It has been hard to answer the question because longitudinal information is rarely collected in such settings. A longitudinal dataset of nine years (2002-2010) from a horticultural-foraging society of Indigenous People in the Bolivian Amazon (Tsimane') is used for an exploratory analysis of micro-level trends in indicators of well-being and economic inequalities. We selected 13 Tsimane' villages (from - 100) that varied in proximity to town and surveyed all households in each village. - 240 households were followed yearly to estimate trends of 21 outcomes (e.g., income, sociality, macronutrients). For each economic outcome, annual and all-years-combined Gini coefficients were estimated for the entire sample across the 13 villages. We show a rise in total asset wealth, a change in asset composition (less traditional wealth, more commercial wealth), higher monetary value of foods eaten, and better-perceived health, but a decline in caloric and protein consumption and no marked gender differences in objective or hedonic measures of well-being. Economic inequalities were non-trivial and showed no marked trend but varied between years; asset inequality varied less than income inequality. We document the value of longitudinal, locally grounded indexes of well-being to obtain a granular view of micro-level changes in well-being and the possible use of inequality in the consumption of calories and macronutrients as a valid proxy for income inequality in rural areas of the Global South with tenuous links to the market economy.
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    Child stunting is associated with weaker human capital among native Amazonians
    (2018) Undurraga, Eduardo A.; Behrman, Jere R.; Emmett, Susan D.; Kidd, Celeste; Leonard, William R.; Piantadosi, Steven T.; Reyes-Garcia, Victoria; Sharma, Abhishek; Zhang, Rebecca; Godoy, Ricardo A.
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    Childhood adversity increases risk of psychotic experiences in patients with substance use disorder
    (ELSEVIER IRELAND LTD, 2022) Borquez-Infante, Ignacio; Vasquez, Javiera; Dupre, Sofia; Undurraga, Eduardo A.; Crossley, Nicolas A.; Undurraga, Juan
    Introduction: Adverse childhood experiences (ACEs) increase the risk of psychotic experiences (PE), but little is known about heterogeneities of this association in different developmental stages, dimensions, or whether they are affected by substance use disorder (SUD). This study examines the association between different types of ACEs at various developmental stages and lifetime PE in patients with SUD in Chile.Methods: We included 399 consenting adults in outpatient or residential SUD treatment programs. Sociodemo-graphic data and information about PE and ACEs were obtained by trained clinical psychologists.Results: Patients reporting PE experienced more ACEs compared to patients without PE (4.2 versus 3.4). They also experienced more complex adversities (41.8% versus 25.1%), had more psychiatric comorbidities (85% versus 70.4%), and reported using more substances (mean 4.5 versus 3.9). Adjusted association between ACEs and PE showed the highest OR for arrests (1.88), sexual abuse (1.81), alcohol abuse by parents (1.48), school exclusion (1.39), foster or residential care (18.3).Conclusion: Early exposure to ACEs is a risk factor for later PE among patients with SUD. Type of ACE and the period when they occurred is important, suggesting the existence of critical periods where the individual is more susceptible to adverse environmental stimuli.
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    Clinical, laboratory, and demographic determinants of hospitalization due to dengue in 7613 patients : a retrospective study based on hierarchical models
    (2018) Santos da Silva, Natal; Undurraga, Eduardo A.; da Silva Ferreira, Elis Regina; Estofolete, Cássia Fernanda; Lacerda Nogueira, Maurício
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    Commentary: Challenges to Achieve Conceptual Clarity in the Definition of Pandemics
    (CAMBRIDGE UNIV PRESS, 2020) Undurraga, Eduardo A.