Socio-economic vulnerability and deaths of despair in Brazilian counties

Over the past few years, there has been a progressive increase in premature deaths attributable to suicide, drug overdose, and alcohol-related liver disease that impact life expectancy. Regarding the relationship with contextual effects, the evidence is developing, especially in countries with a peripheral economy, as is the case of Brazil. We carried out an analysis aimed at estimating the relationship between socioeconomic insecurity and deaths due to despair in Brazilian cities. We used 5,570 counties' data to create clusters concerning socioeconomic development and then analyzed age-adjusted mortality rates (ASMR) from each of them and compared them using the ANOVA test. Cluster analysis generated two groups of Brazilian municipalities. DoD rates are consistently higher in the group that experiences more deprivation. However, considering differences between 2010 and 2019, the increase in rates was higher in the group with less deprivation experience (48.82 % vs. 39.53 %) We verified an existing gap between the clusters before the beginning of economic stagnation in 2010 The gap between those two groups decreased from 20.58 % (p < 0.001) in 2010 to 14.03 % in 2019 (p = 0.034). The conjuncture of economic crises creates mortality differentials in certain population groups. Also, significant inequalities explain how causes of death from despair affect different subpopulations. Our first approach assessed this assumption, and we could check those differentials at an ecological level. Public policies should focus on reducing the difference in mortality from despair between higher and lower socioeconomic strata.

Impact of sociodemographic factors on COVID-19 survival: a nationwide 2,000,000 in-patients' cohort in Brazil

OBJECTIVE

To estimate the impact of sociodemographic factors on survival from COVID-19 in Brazil.

METHODS

Longitudinal data from a retrospective cohort of 2,000,000 hospitalizations due to COVID-19 in Brazil between March 2020 and May 2022, enrolled in SIVEP-Gripe, were analyzed.

RESULTS

The adjusted Cox model showed a 7% higher probability of death for men. 9% and 13% for the brown population compared to white and 16% for those living in the rural region. Long-lived elderly has a 301% higher probability when compared to young people.

CONCLUSION

Sociodemographic factors interfere with survival from COVID-19 and should gain prominence in theoretical models and clinical aspects, and should be considered when formulating public policies, especially in countries with greater social inequality, such as Brazil.

Covid-19 Fiocruz Observatory - an analysis of the evolution of the pandemic from February 2020 to April 2022

The COVID-19 pandemic had a significant impact on the living and working conditions of the entire population of Brazil, having a different and more intense effect on groups considered to be vulnerable. The objective of this article is to present an overview of the evolution of the pandemic in the country according to the bulletins of the Covid-19 Fiocruz Observatory in the period between the declarations of the beginning and end of the Public Health Emergency of National Concern (ESPIN, in Portuguese), February 2020 to April 2022. Several of the indicators adopted in the 69 bulletins published for the analysis of the pandemic were used, such as cases and deaths due to SARIs and COVID-19, age groups, % of occupancy of ICU beds, and vaccination, among others. The evolution analysis was organized between years and phases of the pandemic, seeking to highlight what characterized each moment. The closing statement of ESPIN in Brazil coincides with the discussions on the transition from a pandemic to an endemic scenario, without this representing the elimination of the virus, infections, and disease, posing the challenges of advances in vaccination processes in Brazil and around the world, as well as living with scenarios that may require the adoption of temporary protection measures in epidemic periods and periods of greater risk for vulnerable groups.

Female Homicides in Brazil and Its Major Regions (1980-2019): An Analysis of Age, Period, and Cohort Effects

The objective was to analyze the temporal effects of age, period, and cohort on mortality from all female homicides, and from female homicides and by firearms, in Brazil from 1980 to 2019. Data were accessed from Brazilian health records. There was an increase in the risk of death in the 2000s in the North and Northeast regions and a decrease in the Southeast, South, and Midwest. Younger women had a higher risk of death than women born between 1950 and 1954. The findings may be correlated with the inefficiency of the Brazilian state in protecting female victims of violence.

Factors associated with time-to-treatment initiation of breast cancer

The present retrospective study investigated factors associated with time-to-treatment initiation of breast cancer of a cohort of 12,100 cases of health facilities qualified for high complexity in oncology within the scope of the Brazilian Public Health System (SUS) of Rio de Janeiro between 2013 and 2019. Multivariate logistic regression was used to estimate odds ratios and 95% confidence intervals. Of all cases, 82.1% were submitted to the first treatment >60 days. Patients without previous diagnosis history, higher education and in stages III and IV were less likely to have their first treatment >60 days, while treatment at a health facility outside the capital showed a higher probability. Patients with a previous diagnosis history, aged ≥50, non-white race/skin color and in stage I were more likely to be submitted to their first treatment >60 days, while subjects with higher education, treated in a health facility outside the capital and in stage IV showed a lower probability. To summarize, sociodemographic, clinical and health facility-related factors are associated with time-to-treatment initiation of breast cancer.

Telemedicine Support for Primary Care Providers versus Usual Care in Patients with Heart Failure: Protocol of a Pragmatic Cluster Randomised Trial within the Brazilian Heart Insufficiency with Telemedicine (BRAHIT) Study

Heart failure is a prevalent condition and a frequent cause of hospital readmissions and poor quality of life. Teleconsultation support from cardiologists to primary care physicians managing patients with heart failure may improve care, but the effect on patient-relevant outcomes is unclear. We aim to evaluate whether collaboration through a novel teleconsultation platform in the Brazilian Heart Insufficiency with Telemedicine (BRAHIT) project, tested on a previous feasibility study, can improve patient-relevant outcomes. We will conduct a parallel-group, two-arm, cluster-randomised superiority trial with a 1:1 allocation ratio, with primary care practices from Rio de Janeiro as clusters. Physicians from the intervention group practices will receive teleconsultation support from a cardiologist to assist patients discharged from hospitals after admission for heart failure. In contrast, physicians from the control group practices will perform usual care. We will include 10 patients per each of the 80 enrolled practices (n = 800). The primary outcome will be a composite of mortality and hospital admissions after six months. Secondary outcomes will be adverse events, symptoms frequency, quality of life, and primary care physicians' compliance with treatment guidelines. We hypothesise that teleconsulting support will improve patient outcomes.

Tracking excess of maternal deaths associated with COVID-19 in Brazil: a nationwide analysis

BACKGROUND

The COVID-19 pandemic brought a new challenge to maternal mortality in Brazil. Throughout 2020, Brazil registered 549 maternal deaths, mainly in second and third-trimester pregnant women. The objective of this study was to estimate the excess maternal deaths in Brazil caused directly and indirectly by Covid-19 in the year 2020. In addition, we sought to identify clinical, social and health care factors associated with the direct maternal deaths caused by Covid-19.

METHODS

We performed nationwide analyses based on data from the Mortality Information System (SIM) for general and maternal deaths and the Influenza Epidemiological Surveillance System (SIVEP-Influenza) for estimates of female and maternal deaths due to COVID-19. Two distinct techniques were adopted. First, we describe maternal deaths directly caused by covid-19 and compare them with the historical series of deaths from covid-19 among women of childbearing age (15 to 49 years). Next, we estimated the total excess maternal mortality. Then, we calculated odds ratios for symptoms, comorbidities, social determination proxies and hospital care aspects between COVID-19 maternal deaths and deaths of women of childbearing age who were not pregnant or no maternal deaths. We chose women of childbearing age (15 to 49 years) as a reference because sex and age introduce differentials in the risk of COVID-19 death.

RESULTS

Most maternal deaths occurred during pregnancy compared to postpartum deaths month by month in 2020 (μ = 59.8%, SD = 14.3%). The excess maternal mortality in 2020 in Brazil was 1.40 (95% CI 1.35-1.46). Even considering excess mortality due to COVID-19 for the childbearing age female population (MMR 1.14; 95% CI 1.13-1.15), maternal mortality exceeded the expected number. The odds of being a black woman, living in a rural area and being hospitalized outside the residence municipality among maternal deaths were 44, 61 and 28% higher than the control group. Odds of hospitalization (OR 4.37; 95% CI 3.39-5.37), ICU admission (OR 1.73; 95% CI 1.50-1.98) and invasive ventilatory support use (OR 1.64; CI 95% 1.42-1.86) among maternal deaths were higher than in the control group.

CONCLUSIONS

There was excess maternal mortality in 2020 in Brazil. Even with adjustment for the expected excess mortality from Covid-19 in women of childbearing age, the number of maternal deaths exceeds expectations, suggesting that there were deaths among pregnant and postpartum women indirectly caused by the pandemic, compromising access to prenatal care., adequate childbirth and puerperium.

Burden of occupational cancer in Brazil and federative units, 1990-2019

OBJECTIVE

To analyze the spatiotemporal distribution of the burden of occupational cancer in Brazil and federative units between 1990 and 2019.

METHODS

Data were extracted from the Global Burden of Disease (GBD) study. Deaths from cancer whose attributable risk factor was occupational carcinogens were considered. Spatial analysis was performed with the first and last years of the series (1990 and 2019). Age-adjusted mortality rates were used to estimate the global Moran's Index (Moran's I), and the local indicator of spatial association (LISA) to identify clusters in the country with the respective statistical significance. The occupational cancer mortality rate, adjusted for age, was analyzed based on its trend for Brazil and federative units, in the period between 1990 and 2019.

RESULTS

Between 1990 and 2019, occupational cancer mortality rate showed a decreasing trend (R2=0.62; p<0.001) as well as the burden of disease indicator - DALY (R2=0.84; p<0.001). However, mortality is increasing in most states, suggesting that a minority of federative units induce the country's global trend. There is also the development of a spatial pattern of autocorrelation, indicating clusters of states with low mortality and DALY rates in the Northeast and high values in the South of the country.

CONCLUSION

The overall decreasing trend in the trend of occupational cancer masks the heterogeneity across states. This scenario may be associated with the diversity of economic activities, and suggests a decentralized and equitable plan for occupational cancer surveillance.

Carga de câncer relacionado ao trabalho no Brasil e unidades da federação, 1990–2019

RESUMO: Objetivo: Analisar a carga de câncer relacionado ao trabalho no Brasil e unidades da federação, entre 1990 e 2019. Métodos: Extraímos os dados do estudo Carga Global de Doenças (GBD). Consideramos as mortes por câncer cujo fator de risco atribuível fossem agentes ocupacionais carcinogênicos. A análise espacial foi realizada com o primeiro e último anos da série (1990 e 2019). As taxas de mortalidade ajustadas por idade foram utilizadas para calcular o índice de Moran global (I de Moran) e o indicador local de associação espacial (LISA). A taxa de mortalidade por câncer relacionado ao trabalho, ajustada por idade, foi analisada com base em sua tendência, para Brasil e unidades da federação, no período entre 1990 e 2019. Resultados: No período citado, a taxa de mortalidade por câncer relacionado ao trabalho exibiu tendência de decréscimo (R2=0,62; p<0,001), assim como o indicador de carga de doença — DALY (R2=0,84; p<0,001). Contudo, a mortalidade é crescente na maioria dos estados, o que sugere que uma minoria de unidades induz a tendência global do país. Há ainda formação de um padrão espacial de autocorrelação, indicando agrupamentos de estados com baixas taxas de mortalidade e DALY no Nordeste e valores altos no Sul do país. Conclusão: A tendência global de decréscimo na tendência do câncer relacionado ao trabalho mascara a heterogeneidade entre estados. Esse cenário pode estar associado à diversidade de atividades econômicas e sugere um plano descentralizado e equitativo da vigilância do câncer relacionado ao trabalho.

The influence of the age-period-cohort effects on male suicide in Brazil from 1980 to 2019

Suicide is a complex and multi-determined phenomenon. Higher rates are observed in men and are related to multiple risk factors, including mental disorders, financial crises, unemployment, and easy access to highly lethal means of perpetration, such as firearms. We studied the effects of age, period, and cohort (APC) on total and firearm-related suicides in men in Brazil and its major regions from 1980 to 2019. Death records were extracted from the Brazilian Ministry of Health's Mortality Information System. Estimable functions were used to estimate APC models, through the Epi library of the R statistical program, version 4.2.1. During the study period, Brazil had an average rate of 10.22 deaths per 100,000 men. Among regions, rates ranged from 8.62 (Northeast) to 16.93 (South). The same profile was observed in suicides by firearms. After estimating the APC models, we observed a temporal trend of increasing total suicides for Brazil and regions, except for the South region, where the trend was stationary. The trend was downward for firearm suicides for all locations. A positive gradient was observed in the mortality rate with advancing age for total suicides; and peak incidence between 20-29 years, with subsequent stabilization, for suicides perpetrated by firearms. There was a reduction in the risk of death for suicides perpetrated by firearms in relation to the reference period (1995-1999) for all locations, except in the North region, where the effect was not significant. The younger generations from the 1960s onwards had a higher risk of death from total suicide and a lower risk for those perpetrated by firearms in relation to the reference cohort (1950-1954). We observed a reduction in the mortality trend for suicides perpetrated by firearms, a reduction in the risk of death in the 2000s and for men born after 1960. Our results suggest reducing the risk of death from suicide by firearms in Brazil and regions. However, there is an upward trend in mortality from total suicides in the study period (1980-2019) and for younger cohorts.

Vigilância civil em saúde, estudos de população e participação popular

RESUMO Em meados dos anos 1990, Victor Valla propôs a incorporação da participação da população à prática da vigilância em saúde, por meio da educação popular de Paulo Freire. Esse contraponto às práticas tradicionais da vigilância, nomeadas vigilância civil da saúde, somam-se à concepção ampliada de saúde, e possuem forte ligação com a perspectiva crítica da epidemiologia enquanto meio de compreender a relação dialética entre classes sociais e seus espaços vividos. A prática da vigilância civil pretende superar lacunas importantes deixadas pelos métodos tradicionais de investigação em saúde pública, como falta de atenção aos contextos socioculturais, construção do risco localizada somente no indivíduo e representação de agendas de saúde pública que privilegiam e patologizam certos comportamentos. Nesse sentido, o presente trabalho debate o conceito de vigilância civil da saúde, o locus de discussão dos estudos de população na reificação do papel do efeito contextual para a explicação da produção social da saúde e a incorporação da participação popular à vigilância em saúde como elemento de transformação social. O aprofundamento dessa discussão, no limite, permite uma construção participativa de novos modelos de saúde concentrados na redução efetiva das iniquidades em saúde e, consequentemente, universalização efetiva do direito à saúde.

Civilian health surveillance, population studies and participation

ABSTRACT In the mid-1990s, Victor Valla proposed to incorporate the population participation in the practice of health surveillance, through Paulo Freire’s popular education. This counterpoint to traditional surveillance practices, called civil health surveillance, added to the expanded concept of health, and has a strong connection with the critical perspective of Epidemiology as a means to understand the dialectical relationship between social classes and their lived spaces. The practice of civil surveillance aims to overcome essential gaps left by traditional methods of public health investigation. It includes a lack of attention to socio-cultural contexts, the construction of risk located only in the individual, and the representation of public health agendas that privilege and pathologize certain behaviors. This paper discusses the concept of civil health surveillance, the locus of discussion of population studies in the reification of the role of the contextual effect in explaining the social production of health and the incorporation of popular participation in health surveillance as an element of social transformation. The deepening of this discussion allows a participatory construction of new health models focused on the effective reduction of health inequities and, consequently, the effective universalization of the right to health.

Confiabilidade do EORTC QLQ-INFO25 para Avaliar a Necessidade de Informação de Pacientes Oncológicos

Introdução: A maioria dos pacientes não possui um grau satisfatório de compreensão acerca do câncer. Para que o processo de comunicação de informações seja verdadeiramente efetivo, e necessário identificar anteriormente o nível de conhecimento do paciente. Objetivo: Verificar a estabilidade teste-reteste do instrumento EORTC QLQ-INFO25 em sua versão em português do Brasil, para avaliação da necessidade de informação do paciente oncológico. Método: O instrumento foi aplicado em 253 pacientes hospitalizados nas enfermarias clinicas e cirúrgicas de um hospital de alta complexidade no tratamento do câncer situado no município do Rio de Janeiro, por meio de um questionário com entrevista individual. Para testar a adequação do processo de aferição, 85 pacientes aderiram ao reteste, com intervalo de sete a 15 dias. Os dados foram inseridos em um banco de dados por dupla digitação independente no programa Microsoft Excel. A análise foi realizada por meio da estatística Kappa simples e ponderada. Resultados: As respostas mostraram-se estáveis, e as estimativas de confiabilidade teste-reteste variaram de boas a excelentes (0,66 a 0,99). O instrumento também demonstrou boa estabilidade quando aplicado em outras populações e em pacientes com diferentes tipos de câncer. Conclusão: O instrumento EORTEC QLQ-INFO25 pode contribuir para a mensuração da satisfação do paciente em relação a sua necessidade de informação, uma vez que os resultados sugerem alta estabilidade das informações, tornando viável a sua aplicabilidade na população brasileira.

Tendência Temporal da Mortalidade por Câncer de Boca e da Cobertura de Atenção Primária no Estado do Rio de Janeiro

Introdução: O câncer de boca e comumente diagnosticado de forma tardia, comprometendo a qualidade de vida dos indivíduos ou os levando a óbito. Objetivo: Verificar a tendencia temporal da mortalidade por câncer de boca no Estado do Rio de Janeiro e da cobertura da Estratégia Saúde da Família (ESF) e de equipes de saúde bucal (ESB). Método: Estudo ecológico com análise da tendencia temporal da mortalidade por câncer de boca, entre 1999 e 2018, e da cobertura da ESF e ESB, no período de 2002 a 2018, no Estado e Regiões de Saúde. Utilizou-se a regressão linear generalizada de Prais-Winsten no cálculo das tendencias para o Estado, cada Região de Saúde, sexo, faixa etária e localização do tumor. Resultados: Houve tendencia de mortalidade por câncer de boca decrescente no Estado e nas Regiões Metropolitana I e II; nas demais Regiões de Saúde, foi estacionaria. As tendencias dos óbitos em homens, das faixas etárias 40 a 59 anos e 80 anos ou mais, foram decrescentes. Na localização do tumor, houve tendencia decrescente entre óbitos por outras partes e partes não especificadas (C06) e uma tendencia crescente na mortalidade por câncer de base de língua (C01). Na cobertura de ESF e ESB, na maioria das Regiões de Saúde e no Estado, a tendencia foi crescente. Conclusão: A tendencia decrescente na mortalidade por câncer de boca e a tendencia crescente de ESF e ESB, no Estado do Rio de Janeiro, não foram observadas em todas as Regiões de Saúde.

Spatio-temporal analysis of infant mortality in the city of Rio de Janeiro, 2010-2019

OBJECTIVE

To describe the spatio-temporal distribution of infant mortality and its components in the city of Rio de Janeiro, Brazil, in 2010 and 2019.

METHODS

Infant mortality rate and the neonatal and postneonatal components were estimated. The standardized mortality rate was calculated to detect excess child mortality in the planning areas. Poisson regression was performed to estimate the effect of these planning areas on the years 2010 and 2019. Spatial analysis per neighborhoods was performed to identify the spatial autocorrelation rates, using the Moran's Index and local indicator of spatial association (LISA).

RESULTS

The planning areas are very heterogeneous, depending on the history and evolution of occupation. There is an excess of mortality in planning areas with greater social vulnerability. In the Poisson model, it was observed that in all components, the planning area (PA) of residence was statistically significant as well as the year. Moran's index did not show global spatial autocorrelation. However, when applying the LISA method, autocorrelation was observed at the local level and spatial clusters in the municipality of Rio de Janeiro.

CONCLUSIONS

The spatial heterogeneity of the infant mortality rate in Rio de Janeiro suggests that local health policy strategies of each region consist in an efficient measure for reducing this rate.

How to overcome the stagnation of the first dose vaccine coverage curve against coronavirus disease 2019 in Brazil?

BACKGROUND

A large percentage of the population has not yet started vaccination, for which the increase in coverage is almost null.

METHODS

We used segmented regression analysis to estimate trends in the first dose coverage curve.

RESULTS

There has been a slowdown in the application of the first doses in Brazil since epidemiological week 36 (average percent change [APC] 0.83%, 95% confidence interval [CI] 0.75-0.91%), with a trend close to stagnation.

CONCLUSIONS

It is important to develop strategies to increase access to vaccination posts. Furthermore, it is recommended to expand vaccination to children, thereby increasing the eligible population.

Transição da idade de casos, internações e óbitos em internações por Covid-19 no município do Rio de Janeiro

O presente trabalho objetiva analisar a evolução de casos, internações e óbitos por Covid-19 no município do Rio de Janeiro por faixas etárias entre março de 2020 e abril de 2021. Foram calculadas as frequências absolutas e relativas de casos e óbitos por Covid-19 para faixas etárias decenais das semanas epidemiológicas (SE) 13 de 2020 a 21 de 2021 e intervalos de valores esperados por grupo etário e SE. Os resultados mostram que a maior carga de casos correspondeu às faixas etárias de 20 a 29 e 30 a 39 anos. Internações e óbitos se concentraram nos grupos de 60 a 69, 70 a 79 e 80 anos ou mais, com uma marcante tendência de rejuvenescimento da carga de óbitos a partir da SE 10 de 2021. Conclui-se que há uma transição da idade da pandemia no Rio de Janeiro, possivelmente pelo progresso da vacinação, mostrando, portanto, o sucesso desta medida. Reforçamos a necessidade de aceleração do processo de imunização da população para controle e prevenção da Covid-19.

Prevalência e fatores associados ao diagnóstico de câncer de mama em estágio avançado

Resumo Este estudo transversal investigou a prevalência e os fatores associados ao diagnóstico de câncer de mama em estágio avançado entre 18.890 mulheres assistidas em hospital especializado da capital do Rio de Janeiro, Brasil, entre os anos 1999 e 2016. Utilizou-se regressão de Poisson com variância robusta para estimar razões de prevalência e respectivos intervalos de 95% de confiança. Apresentaram maiores prevalências de diagnóstico nessa condição mulheres com idade entre 20-39 e 40-49 anos, de raça/cor da pele preta e parda, que viviam sem companheiro(a), procedentes de outros municípios do estado do Rio de Janeiro, que tiveram o Sistema Único de Saúde como origem do encaminhamento e que foram diagnosticadas nos sexênios 1999-2004 e 2005-2010. Em contrapartida, mulheres com idade entre 60-69 e 70-99 anos, que cursaram algum nível de escolaridade, com histórico familiar de câncer e que chegaram ao hospital com diagnóstico e sem tratamento apresentaram menores prevalências de diagnóstico em estágio avançado. Esses resultados podem ser considerados no planejamento de ações de prevenção secundária, a fim de antecipar o diagnóstico de câncer de mama dos grupos mais vulneráveis e assim colaborar para a redução da prevalência do diagnóstico em estágio avançado.

Análise espaço-temporal da mortalidade infantil no município do Rio de Janeiro, 2010–2019

RESUMO Objetivo: Descrever a distribuição espaçotemporal da mortalidade infantil eseus componentes no município do Rio de Janeiro nos anos de 2010 e 2019. Métodos: Estimamos a taxa de mortalidade infantil e os componentes neonatal e pós-neonatal. Calculamos a taxa de mortalidade padronizada para detectar excesso de mortalidade infantil nas áreas de planejamento e realizamos regressão de Poisson para estimar o efeito dessas áreas nos anos de 2010 e 2019. Efetuamos análise espacial por bairros para detectar autocorrelação espacial das taxas, com uso do índice de Moran e do indicador local de associação espacial (LISA). Resultados: As áreas de planejamento são muito heterogêneas em função da história e da evolução da ocupação. Há excesso de mortalidade nas áreas de planejamento com maior vulnerabilidade social. No modelo de Poisson, observamos que em todos os componentes a área de planejamento de residência teve significância estatística, assim como o ano. O índice de Moran não mostrou autocorrelação espacial global. Contudo, ao aplicarmos o método LISA, observou-se autocorrelação em nível local e aglomerados espaciais no município do Rio de Janeiro. Conclusões: A heterogeneidade espacial da taxa de mortalidade infantil no Rio de Janeiro sugere que estratégias locais de políticas de saúde para cada região são uma medida eficiente para sua redução.

Excess mortality according to group of causes in the first year of the COVID-19 pandemic in Brazil

ABSTRACT Objective: To estimate excess mortality by cause of death in Brazil and states in 2020. Methods: We estimated the expected number of deaths considering a linear trend analysis with the number of deaths between 2015 and 2019 for each group of causes and each federative unit. We calculated standardized mortality ratios (SMR) and 95% confidence intervals for each SMR assuming a Poisson distribution. We performed the analyses in the R program, version 4.1.3. Results: We observed a 19% excess in deaths in 2020 (SMR=1.19; 95%CI=1.18–1.20). The Infectious and Parasitic Diseases group stood out among the defined causes (SMR=4.80; 95%CI 4.78–4.82). The ill-defined causes showed great magnitude in this period (SMR=6.08; 95%CI 6.06–6.10). Some groups had lower-than-expected deaths: respiratory diseases (10% lower than expected) and external causes (4% lower than expected). In addition to the global analysis of the country, we identified significant heterogeneity among the federative units. States with the highest SMR are concentrated in the northern region, and those with the lowest SMR are concentrated in the southern and southeastern regions. Conclusion: Excess mortality occurs during the COVID-19 pandemic. This excess results not only from COVID-19 itself, but also from the social response and the management of the health system in responding to a myriad of causes that already had a trend pattern before it.

Exposição ocupacional e câncer: uma revisão guarda-chuva

Resumo Objetivo: fornecer uma visão geral das associações entre exposição ocupacional e risco da ocorrência ou morte por câncer. Métodos: esta revisão guarda-chuva da literatura utilizou as bases Medline e Web of Science. A partir de protocolo de busca, foram incluídas metanálises para diversas circunstâncias ocupacionais e cânceres selecionados que possuíssem algum nível de evidência para associação com ocupação. Resultados: foram incluídas 37 metanálises, abrangendo 18 localizações de câncer. Considerando a avaliação da heterogeneidade dos estudos, da qualidade da evidência e da força de associação, obteve-se evidências altamente sugestivas de associações entre exposição a solvente e mieloma múltiplo; amianto e câncer de pulmão; hidrocarbonetos e câncer de trato aerodigestivo superior; e estresse ocupacional e câncer colorretal. Conclusão: há evidências robustas para associar exposições ocupacionais e tipos de câncer não previstos, inicialmente, nas orientações de vigilância do câncer relacionado ao trabalho no Brasil. Permanecem lacunas sobre exposições de grande relevância, que carecem de metanálises mais consistentes, por exemplo, exposição a poeiras inorgânicas e câncer de pulmão e mesotelioma; exposição a solventes e tumores hematológicos. Evidências de câncer em outras regiões anatômicas foram menos robustas, apresentando indícios de incerteza ou viés.

Distanciamento social durante a pandemia da Covid-19 e a crise do Estado federativo: um ensaio do contexto brasileiro

RESUMO Este artigo propõe uma análise das medidas de distanciamento social adotadas durante a pan- demia da Covid-19 no Brasil a partir de um recorte temporal desde março de 2020 até o início do ano de 2021. O estudo se baseia em uma análise retrospectiva das medidas de distanciamento social instituídas por cada Unidade Federada (UF) e o respectivo contexto de adoção das medidas de flexibilização nelas. Posteriormente, é feita uma reflexão acerca do impacto do regime federalista vigente no Brasil na adoção das políticas de distanciamento social durante a pandemia da Covid-19. Para tanto, foi feita uma análise documental em notas técnicas, artigos científicos, páginas eletrônicas oficiais do governo, Diário Oficial das UF e boletins epidemiológicos, visando abarcar todas as deliberações legais e orientações oficiais dos governos referentes às medidas de distanciamento social. O estudo evidenciou a necessidade premente de fortalecimento da coordenação federativa na gestão da crise sanitária da Covid-19 e o incentivo a campanhas sociais que endossem a importância e a efetividade das medidas de distanciamento social, além da tomada de decisões que viabilizem isso, como a reinstituição do auxílio emergencial pelo governo.

Excesso de mortalidade segundo grupo de causas no primeiro ano de pandemia de COVID-19 no Brasil

RESUMO Objetivo: Estimar o excesso de mortalidade segundo causa de óbito no Brasil e estados em 2020. Métodos: O número de óbitos esperado foi estimado considerando análise de tendência linear com o número de mortes entre os anos de 2015 e 2019, para cada grupo de causas e cada unidade da federação. Calculamos as razões de mortalidade padronizadas, e os intervalos com 95% de confiança para cada SMR foram calculados assumindo uma distribuição Poisson. As análises foram realizadas no programa R, versão 4.1.3. Resultados: Observamos um excesso de 19% nos óbitos em 2020 (SMR=1,19; IC=1,18–1,20). O grupo de Doenças Infecciosas e Parasitárias obteve maior destaque entre as causas definidas (SMR=4,80; IC95% 4,78–4,82). As causas mal definidas apresentaram grande magnitude neste período (SMR=6,08; IC95% 6,06–6,10). Há, ainda, grupos que apresentaram número de óbitos abaixo do esperado: doenças do aparelho respiratório (10% abaixo do esperado) e causas externas (4% abaixo do esperado). Além da análise global para o país, identificamos grande heterogeneidade entre as unidades da federação. Os estados com maiores SMR estão concentrados na região norte, e os que possuem menores SMR estão concentrados nas regiões sul e sudeste. Conclusões: Há um excesso de mortalidade ocorrendo durante a pandemia de COVID-19. Este excesso é resultado não apenas da COVID-19 em si, mas da resposta social e da gestão do sistema de saúde em responder a uma miríade de causas que já possuíam um ritmo de tendência anterior a ela.

Occupational exposure and cancer: an umbrella review

Abstract Objective: to provide an overview of the associations between occupational exposure and risk of occurrence or death from cancer. Methods: this umbrella review used the Medline and Web of Science databases. Based on the search protocol, meta-analysis was included for several occupational circumstances and selected cancers that had some level of evidence associated with the occupation. Results: 37 meta-analysis were included, covering 18 cancer locations. By assessing the heterogeneity of studies, quality of evidence, and strength of association, results highly indicated associations between solvent exposure and multiple myeloma, asbestos and lung cancer, hydrocarbons and upper aerodigestive tract cancer, occupational stress and colorectal cancer. Conclusion: robust evidence shows an association between occupational exposures and types of cancer not initially foreseen in the guidelines for work-related cancer surveillance in Brazil. Gaps in relevant exposures require further research and more consistent meta-analysis, including: exposure to inorganic dust and lung cancer and mesothelioma; solvents and hematological tumors. Evidence of cancer in other anatomical regions was less robust, showing signs of uncertainty or bias.

Tendências na Mortalidade por Câncer de Pele não Melanoma no Brasil e suas Macrorregiões

Introdução: O câncer de pele não melanoma (CPNM) e o mais comum entre todas as malignidades. Objetivo: Descrever as tendências da mortalidade por CPNM no Brasil e nas suas Macrorregiões, de 2001 a 2018. Método: As taxas de mortalidade ajustadas por idade e estratificadas por sexo foram apresentadas por 100 mil pessoas-ano. Uma análise autorregressiva foi implementada para avaliar tendências, Mudança Percentual Anual (MPA) e intervalos de confiança de 95% (IC 95%). Resultados: Houve 27.550 óbitos por CPNM no Brasil com maior frequência em homens (58,1%) e entre pessoas de 70 anos e mais (64,3%). As taxas globais foram de 2,25 (homens) e 1,22 (mulheres) por 100 mil pessoas-ano. As tendências seguiram em elevação no Brasil, em homens (MPA: 2,91%; IC95%: 1,96%; 3,86%) e em mulheres (MPA: 3,51%; IC95%: 2,68%; 4,34%). O mesmo ocorreu na Região Norte, em homens (MPA: 9,75%; IC95%: 7,68%; 11,86%) e em mulheres (MPA: 10,38%; IC95%: 5,77%; 15,21%), bem como na Região Nordeste, em homens (MPA: 9,98%; IC95%: 5,59%; 14,57%) e em mulheres (MPA: 8,34%; IC95%: 3,29%; 13,64%). Conclusão: Os óbitos por CPNM não são raridade no Brasil. O país e as Regiões Norte e Nordeste experimentaram taxas com tendência em elevação. Norte e Nordeste são as Regiões mais próximas da Linha do Equador e as menos desenvolvidas socioeconomicamente. Nessas Macrorregiões, um sinergismo entre diferentes tipos de desigualdades e exposições ambientais pode estar promovendo um aumento dos óbitos por esse tipo de câncer considerado totalmente evitável.

Effect of physical distancing on Covid-19 incidence in Brazil: does the strictness of mandatory rules matter?

This study aims to examine the association between physical distancing measures and coronavirus disease 2019 (COVID-19) incidence among Brazilian states. We divided the methodology was divided into three steps. In the first step, we used nationwide global positioning system daily data to estimate country and state-level physical distancing and examined the association with COVID-19 incidence through a Generalized Additive Model. Secondly, using National Household Sample Survey COVID19 data, a cluster analysis categorized the Brazilian states into different categories of physical distancing policies promoting adoption and political inclination of their governments. Finally, through a Poisson Regression Model, we examined the association of state physical distancing with variables related to the socio-economic situation, test coverage and early adoption of policies promoting physical distancing of each state. Physical distancing effects on reduction of COVID-19 spread are heterogeneous among states. Estimation of incidence rate ratio (IRR) suggests that in a scenario of 100% of social isolation incidence of COVID-19 will have reached approximately only 2.6% of the magnitude compared to when there is no social isolation for Brazil [95% confidence interval (CI) 0.8-8.3]. Only a 10% increase in Social Isolation Index in the country could have reflected in a 30.5% decrease in number of cases in 14 days. Adoption of physical distancing was associated with test coverage (IRR 0.976, 95% CI 0.973-0.979), home office (IRR 1.042, 95% CI 1.039-1.046), informal work proportion (IRR 0.961, 95% CI 0.958-0.965), political spectrum (IRR 0.961, 95% CI 0.958-0.965) and early moment of restrictive politics implementation (IRR 1.017, 95% CI 1.013-1.021). Physical distancing measures play a crucial role in mitigating the pandemic's spread. These analyses are crucial to support government decisions and improve the community's adherence to preventive measures.

Space-time analysis of the first year of COVID-19 pandemic in the city of Rio de Janeiro, Brazil

OBJECTIVE

To describe the space-time evolution of cases and deaths due to COVID-19 in the Rio de Janeiro municipality, Brazil, during the first year of the pandemic.

METHODS

An ecological study was carried out. The units of analysis were the neighborhoods of the city of Rio de Janeiro. Incidence and mortality rates, excess risk, Global Moran's Index (Moran's I), local indicator for spatial association, standardized incidence ratio, and standardized mortality ratio were estimated for neighborhoods in the municipality of Rio de Janeiro.

RESULTS

Over the first year of the pandemic, registries in the city of Rio de Janeiro included 204,888 cases and 19,017 deaths due to COVID-19. During the first three months of the pandemic, higher incidence rates were verified in the municipality compared with the state of Rio de Janeiro and Brazil, in addition to higher mortality rates compared with the state of Rio de Janeiro and Brazil from May 2020 to February 2021. Bonsucesso was the neighborhood with the highest incidence and mortality rates, and throughout the neighborhoods and months, there is no synchrony between the worst moments of the COVID-19 pandemic.

CONCLUSION

The authors emphasize the need for implementing more rigid control and prevention measures, increasing case detection, and accelerating the COVID-19 immunization campaign.

[Transition of morbidity and mortality in Brazil: a challenge on the thirtieth anniversary of the SUS]

In 2020, the 30th anniversary of the publication of the Organic Laws of the Unified Health System was celebrated. Since then, the change in the profile of morbidity and mortality has been a challenge to management to ensure that the health services can attend the significant heterogeneity of approximately 6,000 municipalities. To achieve this, it is necessary to monitor the leading indicators of the country. The scope of this study was to present an overview of trends in mortality and morbidity in Brazil between 1990 and 2019. Data from the Study on the Global Burden of Disease was used to describe morbidity and mortality by major groupings (infectious diseases, chronic diseases, and external causes), according to gender and age groups. There was a reduction in morbidity and mortality in the period, irrespective of the cause or age group, albeit with a varied difference between the sexes depending on the cause. The contribution of chronic diseases increases with age, with a marked difference according to gender. The curves for mortality and years lost due to disability have a typical profile, with a different pattern of curves for men due to external causes, with marked excess mortality at young ages. The trend confirms the decline of indicators in a linear manner over the period.

Simpson's paradox: a demographic case study of population dynamics, poverty, and inequality

Brazil is undergoing a demographic transition characterized by regional inequalities. It is reasonable to assume that aspects related to poverty, development and inequality might reverse the sign of the association of indicators of demographic transition, exemplifying a phenomenon known as Simpson's Paradox. The aim of this study was to analyze the effect of inequality, poverty and social development on population dynamics in Brazil, verifying the occurrence of Simpson's paradox in demographic transition. We used population data from the 1991, 2000 and 2010 national censuses, broken down by age and federative unit (FU). The correlation between demographic indicators was assessed by stratifying the FUs into groups according to their median social indicators. The findings show that all FUs have progressed against social indicators and are undergoing demographic transition; however, despite reductions in disparities over the study period, persistent gaps exist between regions. Simpson's paradox was present when the analysis was carried out by census year and social indicators, and was particularly pronounced in 1991. The main challenge is to define how to analyze demographic dynamics in Brazil and understand how contextual factors alter the pace, quantum, and pattern of demographic transition.

The effect of primary care policy changes on hospitalisation for ambulatory care sensitive conditions: notes from Brazil

OBJECTIVES

The aim of this study was to assess the effect of the Primary Health Care Reform and the impact of recent national policy changes on the trend in hospitalisation rates for Ambulatory Conditions Sensitive to Primary Care (ACSC) in the city of Rio de Janeiro, Brazil.

STUDY DESIGN

Ecological study with data from the Brazilian National Health Information System.

METHODS

This study performed an interrupted time-series analysis, comparing three different time periods related to important changes in primary care policies in Brazil: Baseline (2008-2009); Primary Health Care Reform (RCAPS) (2010-2017); and National Primary Health Care Policy (PNAB) (2018-2019). Data included total monthly admissions for ACSC and rates for 19 groups of causes for hospitalisation.

RESULTS

There was a non-significant increasing trend in ACSC hospital admissions between January 2008 and December 2009 (β = 4.01, 95% confidence interval [CI] -12.14 to 20.15). The Primary Health Care Reform (RCAPS), which commenced in January 2010, resulted in a significant reduction in ACSC hospital admission trends during this time period (β = -7.97, 95% CI -9.78 to -6.16). Change in the PNAB did not change the declining ACSC hospital admission trend but it did reduce the rate of decline. In addition, the coefficient was no longer significant (β = -1.93, 95% CI -2.46 to 0.59), suggesting that monitoring of the historical series for a long time may show a reversal of the downward trend in some months. The most consistent change in ACSC hospital admission trend occurred between baseline and the RCAPS (β slope = -0.143, P < 0.001) and the level between the RCAPS period and the new PNAB (β step = 7.00, P = 0.008). Trends and differences in the time periods vary in the different ACSC hospitalisation-cause groups.

CONCLUSION

Changes in public health policies impact ACSC hospitalisation rates, which can thus be used as an indicator for monitoring primary health care. We also recommend analysing admission rates by the individual ACSC hospitalisation-cause groups.

Spatial analysis of the origin-destination flow of admissions for severe acute respiratory syndrome caused by COVID-19 in the Metropolitan Region of Rio de Janeiro

This study analyzed the inter-municipality flow of hospital admissions due to severe acute respiratory syndrome by COVID-19 in the metropolitan region of Rio de Janeiro. We identified 12,676 inter-municipality hospitalizations for COVID-19 involving the municipality of Rio de Janeiro. In total, 11,288 (89.0%) admissions were of residents of the Metropolitan Region (RM), 87% residents in other municipalities of the same region and admitted to hospitals from the state capital, and 13% residents of the capital admitted to hospitals from other municipalities in the RM. There was a negative correlation when it comes to the distance between cities and the origin-destination flow (r=0.62, p<0.001). The RM of the capital Rio de Janeiro imports more admissions for SARS by COVID-19 than it exports. This study highlights the importance of care networks intended for more severe cases that mainly require specialized care.

Reasons for never receiving a pap test among Brazilian women: National health survey

OBJECTIVE

To identify reasons among Brazilian women for never having a Pap test.

DESIGN

We designed a cross-sectional study that used data from the National Health Survey.

SAMPLE

Two thousand four hundred and two women 25-64 years old who never had a pap test.

MEASURES

Variables were age, race, education, marital status, housing condition, primary health care access, health insurance, self-perceived health, and social support network. We calculated the prevalence of different reasons and odds ratios for each.

RESULTS

The most frequent reason for never having a test were linked to women thinking the test was unnecessary (42.3%) which had a significant association with marital status (OR = 1.52; 95% CI = 1.07-1.91), age (OR = 1.56; 95% CI = 1.21-1.99), area of residence (OR = 1.15; 95% CI = 1.02-1.39), having a health insurance (OR = 1.18; 95% CI = 1.01-1.36), and self-perceived health (OR = 1.42; 95% CI = 1.28-1.56). The second most frequent reason was not knowing they needed a test (22.9%) which was associated with age (OR = 1.95; 95% CI = 1.74-2.16) and self-perceived health (OR = 1.56; 95% CI = 1.33-1.80).

CONCLUSIONS

The findings suggest lack of knowledge about cervical cancer and its prevention among Brazilian women. We consider it essential that the health service can provide the test, as well as the necessary guidelines for raising the awareness of the target audience.

Race inequalities in maternal mortality in the city of Rio de Janeiro, Brazil: 2010-2019

OBJECTIVE

To analyze the behavior of maternal mortality according to the race/color variable in the city of Rio de Janeiro, Brazil, between 2010 and 2019.

METHODS

This is a cross-sectional study that used microdata collected in the Sistema de Informações sobre Mortalidade and Sistema de Informações sobre Nascidos Vivos. Data were disaggregated by race/color and age groups of childbearing age. Pearson's χ2 test was used to compare the ratio in each category of covariates. In order to explore the differences in the maternal mortality ratio of the respective variables, the data were adjusted using Poisson's model. Polynomial regression models were tested to describe the trend.

RESULTS

There were 732 maternal deaths in the city of Rio de Janeiro between 2010 and 2019. The time trend analysis of general maternal mortality showed a significant decline between 2010 and 2018 followed by a new upward trend in 2019. There was a greater maternal mortality ratio for older age groups, especially for women over 40 (prevalence ratio of 18.80, 95%CI 13.54-26.78; p<0.0001) and black ones (prevalence ratio of 2.31, 95%CI 1.90-2.80; p<0.0001).

CONCLUSION

There is evidence that maternal mortality is associated with issues of race, which suggests the racial disparity in obstetric care in the city of Rio de Janeiro.

Occupational exposure to carcinogens in Brazil: An approach

This study aims to estimate the prevalence of the primary occupational exposures, considered risk factors for Cancer in Brazil. We elaborated two exposure scenarios considering the agents' classification and the intensity of exposure, stratified by Brazilian regions and sex. Two pairs of specialists performed the classification of economic activities and occupations due to exposure. There was an excellent overall agreement (94%) and acceptable overall reliability (kappa 0.92, 95% CI 0.89-0.95). There is a notable difference (595%) in occupational exposure between the north (with a higher concentration of rural areas and extractivism) and southeast (with a higher level of industrial activities). There is a difference in prevalence from 833% for solvents to 1170% for inorganic dust between the two scenarios. There is a heterogeneity of exposures according to location, sex, circumstance, and sensitiveness of classification.

Assessing antiretroviral therapy success in HIV/AIDS morbidity and mortality trends in Brazil, 1990-2017: an interrupted time series study

To describe the trends of HIV/AIDS metrics related to the burden of disease for Brazil between 1990 and 2017 we conducted a timeseries analysis for HIV/AIDS indicators by extracting data from the Global Burden of Disease study. We calculated traditional prevalence, incidence and mortality rates, the number of years lost by HIV-related deaths (YLL) and disability (YLD), and disability-adjusted life years (DALY). We estimated time series models and assessed the impact of highly active antiretroviral therapy (HAART) on the same indicators. In the set of disability-adjusted life years (DALY), the highest weight of its magnitude was due to YLL. There was a decline, especially after 1996, of DALY, mortality and YLL for HIV/AIDS. However, YLD, incidence, and prevalence increased over the same period. Also, the analysis of interrupted time series showed that the introduction of HAART into health policy had a significant impact on indicators, especially for DALY and YLL. We need to assess the quality of life of people living with HIV, especially among older adults. In addition, we need to focus on primary prevention, emphasizing methods to avoid infection and public policies should reflect this.

Estratificação de risco para predição de disseminação e gravidade da Covid-19 no Brasil

Objetivo: realizar estratificação de risco para disseminação e gravidade da Covid-19 nas unidades da federação (UF) brasileiras a partir de características apontadas como situações de risco. Métodos: foram selecionados alguns indicadores sociais, demográficos e de saúde e submetidos à análise de componentes principais. Em seguida foi possível dividir as UF por análise de cluster. A partir da carga fatorial dos componentes, obtivemos um escore para as UF, que foram estratificadas quanto ao risco de disseminação e mortalidade da Covid-19. Resultados: os componentes referem-se às condições assistenciais, de saúde (incluindo fatores de risco), demográficas e sociais. Estes componentes permitiram a classificação final das 27 UF, com diferença na ordem quanto ao potencial de disseminação e a mortalidade. Conclusão: espera-se que a estratificação de risco possa ser uma medida de apoio à saúde pública, definindo áreas com maior potencial de dano, no sentido de subsidiar a criação de estratégias de intervenção prioritárias.

Expectativa de vida com e sem multimorbidade entre idosos brasileiros: Pesquisa Nacional de Saúde 2013

O objetivo do presente estudo é analisar diferenças na expectativa de vida com e sem  multimorbidade (duas ou mais condições crônicas) entre idosos nos estados brasileiros, segundo sexo e idade. Foram utilizados os dados de mortalidade do Sistema de Informações sobre Mortalidade e projeções populacionais do Instituto Brasileiro de Geografia e Estatística (IBGE) para elaborar tábuas de vida para os estados, por sexo. Informação sobre a prevalência de multimorbidade foi obtida a partir da Pesquisa Nacional de Saúde (PNS) de 2013. A partir do método de Sullivan, estimaram-se a expectativa de vida com e sem multimorbidade e a proporção de anos vividos com multimorbidade. A amostra de idosos da PNS possuía um total de 11.697 entrevistados, cuja idade média foi de 70,08 anos (DP 0,09 ano). A proporção de anos a serem vividos com multimorbidade aumenta com a idade (53,6% aos 60 anos e 57,3% aos 75 anos). Mulheres possuem expectativa de vida maior do que os homens, mas convivem mais com multimorbidade. Aos 60 anos, as mulheres brasileiras esperam viver, em média, 13,5 anos com multimorbidade e os homens 8,3 anos. Constatou-se grande diferença na expectativa de vida com multimorbidade quando comparadas as unidades da federação, com amplitude de 8,2 a 14,2 anos (aos 60 anos de idade). É importante considerar estas diferenças na priorização de ações e grupos para intervenção em saúde pública.

Healthy life-expectancy and multimorbidity among older adults: Do inequality and poverty matter?

Multimorbidity among older adults increases with age. There are large socioeconomic differences across states in Brazil. We believe that estimates of healthy life expectancy differ according to poverty and income inequality status. The objective of the study is to describe patterns of life expectancy with multimorbidity with distinct levels of poverty and inequality in Brazil. We constructed life tables for Brazilian states and estimated the prevalence of multimorbidity for populations aged 60 and over, and divided the states into three groups according to poverty and inequality status and compare them. The group with high poverty and inequality lives fewer years with multimorbidity than the group with lower poverty and inequality. We believe this approach can be used to compare estimates between populations and to identify health inequalities within the country that require attention, optimizing resources, and planning interventions to improve population health, mainly through primary health care.

High-priority carcinogenic occupational agents and activities for health surveillance in Brazil

The aims of the present study were to assemble a list of carcinogens considered as having high priority for occupational health actions in Brazil and to describe the process followed to validate it. Through a literature review we retrieved the main carcinogens used in production activities in Brazil, the carcinogenicity classification developed by the International Agency for Research on Cancer (IARC) and corresponding types of cancer relevant within the Brazilian context. The list thus assembled was reviewed and validated by an expert panel. It includes known and suspected carcinogens found in the production process of some industries in Brazil, and might serve as orientation for future studies on the burden of occupational cancer.

Padrão Sintomatológico em Pacientes do Câncer Colorretal de acordo com a Idade

Introdução: O câncer colorretal está entre os tipos de câncer mais comuns na população brasileira e mundial com altos índices de mortalidade. Alguns estudos mostram que há uma diferença de carga sintomatológica para esse tipo de câncer entre adultos jovens e idosos que, consequentemente, podem deteriorar a qualidade de vida nesses pacientes. Objetivo: Investigar a diferença no padrão de sintomas entre pacientes adultos e idosos com câncer de cólon e reto. Método: Estudo transversal que utilizou um conjunto de dados sobre a prevalência de sintomas entre pacientes com câncer colorretal atendidos no Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA), por meio de um inventário de sintomas recentemente adaptado para o Brasil. Resultados: Foram entrevistados 348 pacientes, destes, 101 pacientes eram adultos jovens (29,1%) e 247 idosos (70,9%). Obteve-se diferença entre os sintomas analisados para dor (p=0,033), nervosismo (p=0,013), sonolência (p=0,033), tristeza (p=0,003), problemas com desejo sexual ou atividade sexual (p=0,014), falta de apetite (p=0,028), irritação (p=0,013), mudança nos gostos dos alimentos (p=0,042), perda de cabelo (p=0,002) e “eu não pareço mais o mesmo” (p<0,001). Conclusão: A carga sintomatológica frente ao câncer colorretal pode apresentar distinção conforme a idade. Isso é relevante, pois reforça a ideia de individualizar o tratamento para melhorar a assistência e, consequentemente, a qualidade de vida desses doentes.

Analysis of the effects of the age-period-birth cohort on cervical cancer mortality in the Brazilian Northeast

Cervical cancer (CC) is a public health problem with a high disease burden and mortality in developing countries. In Brazil, areas with low human development index have the highest incidence rates of Brazil and upward temporal trend for this disease. The Northeast region has the second highest incidence of cervical cancer (20.47 new cases / 100,000 women). In this region, the mortality rates are similar to rates in countries that do not have a health system with a universal access screening program, as in Brazil. Thus, this study aimed to analyze the effects of age, period and birth cohorts on mortality from cervical cancer in the Northeast region of Brazil. Estimable functions predicted the effects of age, period and birth cohort. The average mortality rate was 10.35 deaths per 100,000 women during the period analyzed (1980–2014). The highest mortality rate per 100,000 women was observed in Maranhão (24.39 deaths), and the lowest mortality rate was observed in Bahia (11.24 deaths). According to the period effects, only the state of Rio Grande do Norte showed a reduction in mortality risk in the five years of the 2000s. There was a reduction in mortality risk for birth cohorts of women after the 1950s, except in Maranhão State, which showed an increasing trend in mortality risk for younger generations. We found that the high rates of cervical cancer mortality in the states of northeastern Brazil remain constant over time. Even after an increase in access to health services in the 2000s, associated with increased access to the cancer care network, which includes early detection (Pap Test), cervical cancer treatment and palliative care. However, it is important to note that the decreased risk of death and the mortality rates from CC among women born after the 1960s may be correlated with increased screening coverage, as well as increased access to health services for cancer treatment observed in younger women.