Elisabeth Carmen Duarte

Mortes evitáveis em menores de um ano, Brasil, 1997 a 2006: contribuições para a avaliação de desempenho do Sistema Único de Saúde

Infant deaths were classified as avoidable, non-avoidable, and resulting from ill-defined conditions, from 1997 to 2006, using the Brazilian List of Avoidable Causes of Mortality. Non-linear regression was used to calculate trends in cause-specific infant mortality rates. There was a significant decline in both avoidable deaths and deaths from ill-defined causes (p < 0.001). Avoidable deaths decreased by 37% overall. Mortality avoidable through adequate intrapartum care and adequate neonatal care decreased by 27.7% and 42.5%, respectively, while mortality avoidable through adequate prenatal care increased by 28.3%. In conclusion, health services contributed to the reduction in infant mortality. The decrease in ill-defined causes of death indicates expanded access to health services. The increase in access to intrapartum and neonatal care contributed to the reduction in infant deaths. The increase in mortality avoidable through adequate prenatal care indicates the need for improvement in prenatal care.

Diabetes in Bolivia

OBJECTIVE To measure the prevalence of diabetes mellitus (DM), hypertension, obesity, and related risk factors in major cities in Bolivia. METHODS A population-based survey was conducted in four Bolivian cities: La Paz, El Alto, Santa Cruz, and Cochabamba. The total sample size was chosen to be 2,948 persons. The overall response rate was 86%, with the rate varying somewhat among the four cities. DM was diagnosed through an oral glucose tolerance test (OGTT) 2 hours after an overload of 75 grams of glucose, using World Health Organization criteria. RESULTS The overall prevalence of DM in the four urban areas combined was 7.2% (95% confidence interval (CI): 6.2%-8.3%) and of impaired glucose tolerance (IGT) was 7.8%. A total of 73.1% (95% CI: 65.0%-81.0%) of those previously diagnosed with DM and 73.7% (95% CI: 61.0%-86.4%) of newly diagnosed cases were overweight, according to measurements of body mass index. Hypertension was found in 36.5% (95% CI: 27.6%-45.5%) of known diabetics and in 36.6% (95% CI: 23.0%-50.1%) of newly diagnosed cases, compared to only 15.9% (95% CI: 14.3%-17.5%) among people without DM. The disease was most common among older persons and those with little education. CONCLUSIONS Diabetes is a genuine public health problem in Bolivia. Further, the high prevalence of IGT that was found suggests that diabetes prevalence will increase in the near future in the country unless prevention strategies are implemented.

Causas de mortes evitáveis por ações efetivas dos serviços de saúde: uma revisão da literatura

Theoretical and empirical articles analyzing the Causes of Avoidable Mortality (CAM) due to healthcare published between 1975 and 2004 were reviewed. The purpose was to review the concepts and age limits for these analyses, as well as the uses and types of indicators and ratings for the CAM. Additionally, CAM listings for infant and perinatal mortality were reviewed. Many international articles were found, contrasting with a very small number of Brazilian articles. CAM may be conceptualized as being totally or partially preventable by the effective healthcare measures available (or accessible) at a given time and place. Consequently, these CAM lists must be reviewed, based on the knowledge and improvements in healthcare technology. Further developments should be deployed in support of adequate Brazilian listings, including the definition of CAM, with validation and details regarding the underlying assumptions in order to encourage discussions in greater depth. In conclusion, and despite some methodological difficulties, a process should be launched to define the Brazilian CAM listings through the actions of Brazils National Health System.

Nascimentos pré-termo no Brasil entre 1994 e 2005 conforme o Sistema de Informações sobre Nascidos Vivos (SINASC)

Monitoring preterm births is essential given their impact on infant morbidity and mortality and their economic and social costs. This article is based on data from the Information System on Live Births (SINASC), implemented in 1990 and expanded gradually to cover 90% of all births in the country. Preterm birth time trends are presented for Brazil, regions, and capitals from 1994 to 2005. At the national level, there was an increase in the preterm birth rate, accompanied by a reduction in the proportion of missing information on gestational age. The Southeast, South, and Central-West regions followed the national trend, while the preterm birth rate fell in the North and Northeast regions. We compared the findings from SINASC with those from population-based studies. The coverage and quality of SINASC has increased over time, but problems with the determination of gestational age still remain, leading to underestimation of preterm birth rates. Due to the importance of SINASC for monitoring, further efforts are needed to improve the systems accuracy.

Atualização da lista de causas de mortes evitáveis por intervenções do Sistema Único de Saúde do Brasil

Endereço para correspondência: Ministério da Saúde, Secretaria de Vigilância em Saúde, Coordenação-Geral de Doenças e Agravos Não Transmissíveis, Esplanada dos Ministérios, Bloco G, Edifício-sede, 1 Andar, Sala 142, Brasília-DF. CEP: 10058-900 E-mail: deborah.malta@saude.gov.br; cgdant@saude.gov.br Deborah Carvalho Malta Secretaria de Vigilância em Saúde, Ministério da Saúde, Brasília-DF, Brasil Universidade Federal de Minas Gerais, Belo Horizonte-MG, Brasil

Factors associated with deaths among pulmonary tuberculosis patients: a case–control study with secondary data

Background: Tuberculosis remains an important public health problem in Brazil where over 100 000 new cases and 6000 deaths are reported every year. Current drug efficacy and wide availability should have curbed this toll. The goal was to study the factors associated with death in incident cases of pulmonary tuberculosis (PT) during treatment. Methods: This is a case–control study including all new cases of PT reported between 2000 and 2004; cases were patients who died of any cause and controls were those cured after initial PT treatment. Data analyses included unconditional multiple hierarchical logistic regression. Results: A total of 313 502 new cases of tuberculosis were reported between 2000 and 2004; 224 355 (71.6%) were cured after initial treatment and 20 721 (6.6%) died during the surveillance follow-up. Over 82% of all cases were diagnosed with PT. After controlling for significant variables, the factors associated with a higher risk of death included gender (males: odds ratio (OR) 1.4; 95% confidence interval (CI) 1.33 to 1.47), age (<5 years of age: OR 1.90; 95% CI 1.51 to 2.38; 30–59 years: OR 2.78; 95% CI 2.61 to 2.97; over 60 years: OR 10.92; 95% CI 10.09 to 11.81), positive HIV serology (OR 10.59; 95% CI 9.76 to 11.48), alcoholism (OR 1.49; 95% CI 1.36 to 1.65), mental disorder (OR 1.80; 95% CI 1.43 to 2.27) and presence of additional lung pathology on chest x ray (OR 2.22; 95% CI 1.83 to 2.70). Protective variables included education (highest level: OR 0.67; 95% CI 0.63 to 0.70). Conclusions: Preventive interventions should target the most vulnerable patients, in particular the very young and the elderly, those infected with HIV and those presenting with a mental disorder or additional lung pathology.

Mortalidade de motociclistas em acidentes de transporte no Distrito Federal, 1996 a 2007

OBJETIVO: Descrever caracteristicas sociodemograficas e analisar a tendencia temporal da mortalidade de motociclistas traumatizados em acidentes de transporte. METODOS: Estudo de series temporais com dados de 580 obitos de motociclistas do Distrito Federal, de 1996 a 2007, obtidos do Sistema de Informacoes sobre Mortalidade. Foram calculadas as taxas de mortalidade especificas segundo idade e sexo, as taxas padronizadas (metodo direto) e a razao de obitos por frota (motocicletas). A media movel centralizada da taxa padronizada de mortalidade de homens foi calculada para o periodo de tres anos e um modelo de regressao linear foi construido para estudar a evolucao temporal da mortalidade. Para calcular o incremento anual da taxa de mortalidade padronizada utilizou-se o metodo joinpoint (ponto de inflexao). RESULTADOS: A maior parte dos motociclistas mortos era do sexo masculino, (94,3%), pardo (71,0%) e tinha entre 20 e 39 anos (73,8%). A taxa padronizada de mortalidade de motociclistas (homens) residentes foi de 1,9 para 7,2 obitos/100 mil homens entre 1996 e 2007. Entre 1998 e 2007, a razao de obitos por frota passou de 2,0 obitos/10 mil motocicletas para 10,0 obitos/10 mil motocicletas entre os homens. Estimou-se incremento anual de 0,48 obito/100 mil homens (IC95% 0,31;0,65; p < 0,001). O incremento percentual anual da taxa padronizada de mortalidade para o sexo masculino foi de 36,2% no periodo 1998-2007 (IC 95% 21,2%;53,2%; p < 0,05). CONCLUSOES: A taxa de mortalidade de motociclistas decorrente de acidentes de transporte aumentou expressivamente. Esse aumento e explicado apenas em parte pelo aumento da frota de motocicletas. Caracteristicas individuais dos condutores, bem como as condicoes locais do trafego, necessitam ser investigadas para o planejamento de politicas preventivas.OBJECTIVE To describe sociodemographic characteristics and analyze temporal trends in the mortality of motorcyclists injured in traffic accidents. METHODS This was a time-series study with data from 580 motorcyclist deaths in the Brazilian Federal District from 1996 to 2007. The data were obtained from the Mortality Information System. Mortality rates specific for age and sex, the standardized rates (direct method), and the ratio of deaths per fleet (motorcycles) were calculated. The centralized moving average of the standardized mortality rate for men was calculated for a three-year period, and a linear regression model was constructed to study the evolution of mortality. The joinpoint method (inflection point) was used to calculate the annual increase in the standardized mortality rate. RESULTS Most of the motorcyclists killed were male (94.3%), mixed skin color (71.0%), and between the ages of 20 and 39 years (73.8%). The standardized mortality rate for resident motorcyclists (men) was 1.9 to 7.2 deaths/100,000 men between 1996 and 2007. Between 1998 and 2007, the ratio of deaths per fleet increased from 2.0 deaths/10,000 motorcyclists to 10.0 deaths/10,000 motorcyclists among men. There was an estimated annual increase of 0.48 deaths/100,000 men (95%CI 0.31, 0.65; p <0.001). The percent increase of the annual standardized mortality rate for males was 36.2% in the period from 1998-2007 (95%CI 21.2%, 53.2%; p <0.05). CONCLUSIONS The mortality rate resulting from motorcycle road accidents has increased dramatically. This increase is partially explained by the increase of the fleet of motorcycles. Individual characteristics of drivers, as well as local traffic conditions, need to be investigated for the planning of preventive policies.

Tendência da mortalidade por tuberculose no Brasil, 1980 a 2004

OBJETIVO: Analisar o perfil atual e as tendencias da mortalidade por tuberculose no Brasil, de 1980 a 2004. METODOS: Estudo descritivo de tuberculose como causa basica ou associada de obito do Brasil. Foram utilizados dados secundarios do Sistema de Informacao sobre Mortalidade. RESULTADOS: Houve reducao inconstante do numero e da taxa de mortalidade por tuberculose ao longo do periodo estudado, de 5,8 em 1980 para 2,8 por 100 mil habitantes, em 2004. Foi observada reducao acentuada da mortalidade ate 1985, mais evidente nos estados do Rio de Janeiro e Sao Paulo. Houve tendencia de aumento da mortalidade por tuberculose em idades mais avancadas. Em 2004, foram notificados no Brasil 4.981 obitos por tuberculose como causa basica, valor que aumentaria para 50% se fossem incluidos os obitos por tuberculose como causa associada e por sequela de tuberculose como causa basica. Em 2004, as maiores taxas padronizadas foram dos estados de Pernambuco (5,4) e Rio de Janeiro (5,0), e das capitais Recife (7,7) e Belem (5,8). CONCLUSOES: Dada a conhecida associacao entre tuberculose e Aids, a influencia da epidemia de Aids reflete indiretamente nas tendencias de mortalidade de tuberculose.

Associação entre a produção anual de ouro em garimpos e incidência de malária em Mato Grosso - Brasil, 1985-1996

A secondary data analysis was performed using an ecological design to study the association between malaria incidence rates, the reported annual production of gold mining extraction and monetary investments for the control of malaria from 1985 to 1996 in Mato Grosso, Brazil. A positive and statistically significant (p<0.001) association between the amount of gold extracted and MIR was obtained in multivariate regression analysis, even after allowing for financial investments in malaria control activities. This finding contributes to an understanding of the decrease observed in malaria incidence in Mato Grosso during the last decade, in view of the significant decrease in gold mining within the region during this period.

Leprosy in Brazil and its association with characteristics of municipalities: ecological study, 2009-2011.

To analyse the ecological association between the demographic and socio‐economic characteristics of the Brazilian municipalities and average leprosy incidence rate in the period 2009–2011.OBJECTIVE To analyse the ecological association between the demographic and socio-economic characteristics of the Brazilian municipalities and average leprosy incidence rate in the period 2009-2011. METHODS An ecological study taking the Brazilian municipalities as its units of analysis. The local empirical Bayes estimation method was used to obtain smoothed incidence rates (SIR) for leprosy. The mean, median, first quartile (Q1) and third quartile (Q3) of the SIR were calculated per 100 000 inhabitants. Hierarchical log-linear negative binomial regression models were used to estimate the incidence rate ratios (IRR). RESULTS In the period 2009-2011, the average SIR of leprosy in Brazil was 20.2 per 100 000 inhabitants, and the median incidence rate among municipalities was 9.1 per 100 000 inhabitants. Significantly higher adjusted IRR were identified for large municipalities (IRR = 1.67) compared to small municipalities, as well as in municipalities with higher illiteracy rates (IRR = 2.15), more urbanised municipalities (IRR = 1.53), those with greater social inequality as per the Gini index (IRR = 1.26), high percentage of households with inadequate sanitation (IRR = 1.63), higher average number of people per room (IRR = 1.41), high proportions of Family Health Programme coverage (IRR = 1.29), high percentage of household contacts investigated (IRR = 2.30) and those with percentage of cases with grade 2 disability considered to be the medium (IRR = 1.26). CONCLUSIONS In this study, SIR was significantly associated with municipalities with low socio-economic status. Disease control activities need to be focused on these municipalities, and investments need to be made in improving the populations living conditions.