Elisabeth França

Desigualdade social e mortalidade precoce por doenças cardiovasculares no Brasil

OBJETIVO: Investigar associacao entre alguns indicadores de nivel socioeconomico e mortalidade de adultos por doencas cardiovasculares no Brasil. METODOS: Foram analisados os obitos de adultos (35 a 64 anos), ocorridos entre 1999 a 2001, por doencas cardiovasculares, e pelos subgrupos das doencas isquemicas do coracao e doencas cerebrovasculares-hipertensivas, obtidos no Sistema de Informacao sobre Mortalidade. Foram selecionados para analise 98 municipios brasileiros, com melhor qualidade de informacao. Para analisar a associacao entre indicadores socioeconomicos e a mortalidade por doencas cardiovasculares, foi utilizada a regressao linear simples e multipla. RESULTADOS: Na analise univariada, verificou-se associacao negativa para a mortalidade por doencas cardiovasculares e o subgrupo das cerebrovasculares-hipertensivas com renda e escolaridade, e associacao direta com taxa de pobreza e condicoes precarias de moradia. Quanto as doencas isquemicas, houve associacao inversa com taxa de pobreza e escolaridade, e direta com condicoes precarias de moradia. A escolaridade, apos ajuste pelo modelo de regressao linear multipla, permaneceu associada a mortalidade pela doenca investigada e seus subgrupos. A cada ponto percentual de aumento na proporcao de adultos com alta escolaridade, a taxa de mortalidade por doencas cardiovasculares diminui em 3,25 por 100.000 habitantes. CONCLUSOES: A analise da mortalidade dos municipios mostrou que a associacao entre doencas cardiovasculares e fatores socioeconomicos e inversa, destacando-se a escolaridade. E provavel que melhor escolaridade possibilite melhores condicoes de vida e, consequentemente, impacto positivo na mortalidade precoce.

Evaluation of cause-of-death statistics for Brazil, 2002–2004

BACKGROUND Mortality statistics systems with reliable cause-of-death data constitute a major resource for effective health planning; however, many developing countries lack such information systems. Brazil has a long history of registering deaths, and a critical assessment of the quality of current cause-of-death statistics in its five different regions is crucial to identify strengths and weaknesses in the data, and present options for improvement. METHODS Quality of cause-of-death data from 2002 to 2004 was evaluated using an assessment framework based on four main attributes: generalizability, reliability, validity and policy relevance. A set of nine criteria: coverage, completeness, consistency of cause patterns with general mortality levels, consistency of cause specific mortality proportions over time, content validity, proportion of ill-defined causes and non-specific codes, incorrect or improbable age or sex patterns, timeliness, and geographical disaggregation were used to assess the four attributes of data quality. RESULTS Completeness of death registration varies from 72 to 80% in the northeast regions, compared with 85-90% in the Southeast and Centre-West regions, and 94-97% in the wealthier South region. The proportion of ill-defined deaths is an important problem in reported causes of death from almost all regions. Lack of adequate evidence limits the assessment of content validity of registered causes of death. Coverage, consistency of causes with general level of mortality, consistency over time, age and sex patterns, timeliness and usability of statistics for subnational purposes were judged to be reasonable and increase confidence in using the statistics. CONCLUSIONS There is considerable heterogeneity in the quality of cause-of-death statistics across Brazilian regions, especially for criteria such as completeness and ill-defined causes. These factors can influence generalizability and validity of reported causes of death, and must be considered in the interpretation and use of data for secondary descriptive analyses such as burden of disease estimation at regional level, with suitable adjustments to account for bias. The differences identified in this study could be a useful guide for defining measures and investments needed to improve data quality in Brazil.

Association between socioeconomic factors and infant deaths due to diarrhea, pneumonia, and malnutrition in a metropolitan area of Southeast Brazil: a case-control study

A population-based case-control study was carried out to identify determinant factors for post-neonatal infant deaths due to diarrhea, pneumonia, and malnutrition in Greater Metropolitan Belo Horizonte, Southeast Brazil. From May 1, 1991, to April 30, 1992, 511 post-neonatal deaths due to diarrhea, pneumonia, and malnutrition were selected after investigation of medical records to validate cause of death. Of this total, 396 deaths were compared to a neighborhood control group, matched for age. The study was carried out in a low-income area with a high proportion of families living in shantytowns. The article discusses the methodology and selected socioeconomic factors. Logistic regression analysis indicated that number of household appliances, mothers and fathers education, and mothers marital and work status were significantly associated with risk of infant death, i.e., they were determinants of infant deaths due to avoidable causes.

Perinatal deaths and childbirth healthcare evaluation in maternity hospitals of the Brazilian Unified Health System in Belo Horizonte, Minas Gerais, Brazil, 1999

This paper analyzes the association between perinatal mortality and factors related to hospital care during labor, considering that healthcare assessment is needed in order to reduce perinatal mortality. A population-based case-control study was conducted with 118 perinatal deaths (cases) and 492 births (controls) that took place in maternity hospitals of the Brazilian Unified Health System (SUS) in Belo Horizonte, Minas Gerais, Brazil. Male sex, prematurity, diseases during pregnancy, low birth weight, newborn diseases, lack of prenatal care, lack of partograph use during labor, and less than one fetus assessment per hour during labor were significantly associated with perinatal deaths. In the multiple regression analysis, lack of partograph use during labor and type of hospital were associated with perinatal deaths. These results indicate inadequate quality of care in maternity hospitals and show that health services structure and health care process are related to perinatal mortality due to preventable causes.

Qualidade dos dados da vigilância epidemiológica da dengue em Belo Horizonte, MG

OBJECTIVE To evaluate the quality of data from the Brazilian information system for mandatory reporting diseases, for the detection of cases notified as suspected dengue fever and hospitalized in the public and private hospitals associated to the Public Health System. METHODS The study was carried out in Belo Horizonte, Southeastern Brazil, during the years of 1996 to June 2002. The criterion of evaluation used were those recommended by the Guidelines for Evaluating Public Health Surveillance Systems. As a reference standard, medical charts recorded in the Unified System hospitalized discharge database system were revised and validated. A total of 266 (90%) of 294 medical charts were selected; 230 (86.5%) filled the suspect dengue fever criterion. To verify possible association between underreporting and selected variables, was used the odds ratio, with 95% of confidence interval in a logistic regression model. The sensitivity was defined as the proportion of hospitalized dengue cases registered in both systems. Predictive value positive was calculated as the proportion of confirmed cases and those recorded in the reporting system. RESULTS Underreporting of suspected dengue fever was of 37% cases during 1997 to 2002, it was five times higher during the first three years (OR=5.93; 95% CI: 2.50-14.04) and eight times higher for patients hospitalized in private hospitals than in the public ones (OR=8.42; 95% CI: 2.26-31.27). Underreport was also associated to cases with no haemorrhagic episodes (OR=2.81; 95% CI: 1.28-6.15) and without dengue-specific laboratory exams in medical charts (OR=4.07; 95% CI:1.00-16.52). Sensitivity was 63% and predictive value positive was 43%. CONCLUSIONS Cases recorded in the reporting system were those more severe and did not represent the total of cases hospitalized in Unified Health System, thus the case fatality rate may be overestimated. The results indicate the necessity of changes in the evaluated surveillance model and in the implementation of the qualification of the health professionals, mainly those working in the private hospitals associated to Unified Health System.

Avoidable perinatal deaths in Belo Horizonte, Minas Gerais, Brazil, 1999

The perinatal mortality rate is still high in Belo Horizonte. This study investigated all 826 perinatal deaths taking place in 1999, focusing on the possibility of their prevention, using the Wigglesworth classification. The perinatal mortality rate was 20.2 per one thousand births, and the risk of perinatal death was 20 times higher in children with low birthweight. Some 24.6% of the children weighed more than 2,500g, and the main cause of death in this group was asphyxia during labor. The antepartum cause of death contributed to 30% of all deaths, and 25% of these children weighed more than 2,500g. Some deaths occurred out of hospital, and in some cases the mother arrived at hospital in end-stage labor. About 40% of all perinatal deaths or 60% of all early neonatal deaths could have been prevented, suggesting flaws in prenatal, intrapartum, and neonatal care at both the clinical and health-care organizational levels. To intervene in this situation, progress is needed in improving quality of care and ensuring accountability in the specific health services and the health care system as a whole.

Infestação pelo Aedes aegypti e ocorrência da dengue em Belo Horizonte, Minas Gerais

OBJETIVO: Analisar a associacao entre a proporcao de imoveis prediais positivos para larvas de Aedes aegypti, por meio do indice de infestacao predial, e a taxa de incidencia da dengue. METODOS: Foram selecionados casos autoctones de dengue e valores de infestacao predial verificados nas areas de abrangencia dos distritos sanitarios de Belo Horizonte, MG, no periodo de outubro de 1997 a maio de 2001. Apos grupamento dos valores de infestacao predial segundo sua distribuicao em quartis, as medias das taxas de incidencias da dengue (referentes ao mes subsequente a realizacao dos levantamentos de infestacao predial) foram comparadas pelo teste ANOVA. RESULTADOS: Observou-se uma correlacao fraca, porem estatisticamente significativa, entre a taxa de incidencia mensal da doenca e os valores de infestacao predial para os distritos sanitarios (r=0,21; p=0,02) e areas de abrangencia (r=0,14; p=0,00) no periodo analisado. Apos grupamento dos valores de infestacao predial em quartis, as areas de abrangencia com infestacao predial entre 0,46% e 1,32% (2o quartil) apresentaram, em relacao as areas com infestacao predial, menor ou igual a 0,45% (1o quartil), taxa de incidencia mensal media da doenca duas vezes maior. Para as areas com infestacao predial entre 1,33% e 2,76% (3o quartil) e maior ou igual a 2,77%, as taxas de incidencias mensais medias foram, respectivamente, cinco e sete vezes maiores em relacao as areas com 0,45% ou menos. CONCLUSOES: Apesar das conhecidas limitacoes do indice de infestacao predial para estimar a infestacao vetorial e predizer a ocorrencia de epidemias de dengue, os resultados indicam que maiores indices se associaram a maior risco de transmissao da doenca nos distritos sanitarios e areas de abrangencia de Belo Horizonte.

Evolução da mortalidade infantil por causas evitáveis, Belo Horizonte, 1984-1998

OBJETIVO: Analisar a evolucao da mortalidade infantil em regiao urbana com enfoque para o grupamento de causas evitaveis no periodo neonatal e pos-neonatal. METODOS: O numero de obitos ocorridos na regiao metropolitana de Belo Horizonte, MG, foi obtido do Sistema de Informacoes em Mortalidade do Ministerio da Saude (SIM-MS) e o numero de nascidos vivos foi estimado a partir das estatisticas do registro civil da Fundacao Instituto Brasileiro de Geografia e Estatistica (IBGE), com correcao dos registros atrasados de nascimentos. Utilizou-se modelo de regressao linear simples para estimar a tendencia temporal das taxas de mortalidade infantil e seus componentes. A significância estatistica da inclinacao das curvas de regressao foi considerada para o nivel p<0,05. RESULTADOS: Foi observado decrescimo da taxa de mortalidade infantil de 48,5 para 22,1 por mil nascidos vivos em toda a regiao. Entretanto, a queda mais acentuada foi observada nos ultimos quatro anos da serie. O componente pos-neonatal foi o principal responsavel pelo declinio tanto na capital como nos demais municipios que compoem a regiao metropolitana de Belo Horizonte. CONCLUSOES: Embora tenha sido observada para a regiao uma queda significativa da mortalidade infantil e particularmente da mortalidade pos-neonatal, esta ultima ainda se apresenta elevada em relacao aos paises desenvolvidos. As afeccoes perinatais e o grupamento diarreia-pneumonia-desnutricao representam importante potencial de reducao. Discute-se o papel dos servicos de saude na evitabilidade de tais obitos.

Uso da autópsia verbal na investigação de óbitos com causa mal definida em Minas Gerais, Brasil

Ill-defined causes of death can be related to problems in access to health services or poor quality of medical care and are indicators of data quality in the Mortality Information System (MIS). A sample of municipalities (counties) was selected from the Northeastern Macro-Region of Minas Gerais State, Brazil, with the aim of investigating deaths from ill-defined causes and deaths not reported to the Mortality Information System in 2007, using the verbal autopsy technique. The method allowed identifying 87% of the causes of investigated deaths, of which 17% (n = 37) were due to violent causes. At the end of the study, of the 779 investigated deaths, 9.5% (n = 74) were due to external causes found outside the MIS. The distribution of causes was similar when comparing deaths reported (versus not reported) to the MIS for natural causes, but different when external causes were included. The article concludes that the verbal autopsy method can be a valuable tool for improving the MIS, allowing the identification of causes of death and improving data completeness.

Subnotificação de nascidos vivos: procedimentos de mensuração a partir do Sistema de Informação Hospitalar

OBJETIVO: Avaliar a subnotificacao de registros de nascidos vivos em sistemas de informacao em saude. METODOS: Foram utilizados dados secundarios do Sistema de Informacao Hospitalar (SIH) e Sistema de Informacao sobre Nascidos Vivos (Sinasc) em municipios de Minas Gerais, 2001. A analise foi feita por meio de dois procedimentos: a comparacao do numero de nascidos vivos por municipio de residencia e a tecnica de relacionamento probabilistico de dados individuais. Em ambos os casos, consideraram-se como indicadores de subnotificacao as proporcoes de nascidos vivos informadas ao SIH e nao obtidas no Sinasc. Os municipios foram posteriormente agregados em quatro faixas de tamanho populacional. RESULTADOS: O relacionamento probabilistico identificou maior proporcao de nascidos vivos subnotificados no Sinasc, relativamente a comparacao do numero de nascidos vivos nos municipios. As variacoes das diferencas entre os percentuais de subnotificacao por procedimentos foram: 9,4% nos municipios com populacao menor que 5.000 habitantes; 9,1% nos municipios com populacao entre 5.000 e 9.999 e 8,0% nos municipios com populacao entre 10.000 e 49.999 e com mais de 50.000 habitantes. CONCLUSOES: A magnitude de acrescimos revelou-se sensivel ao procedimento adotado. O relacionamento probabilistico incrementou certeza no pareamento e possibilitou identificacao de maior proporcao de casos nao registrados no Sinasc, inclusive em grandes municipios. O SIH apresentou-se como importante indicador de subnotificacao de nascidos vivos.