Site selection for nature-based solutions for stormwater management in urban areas: An approach combining GIS and multi-criteria analysis.

In recent years, particularly following the definition of the UN Sustainable Development Goals (SDGs) for 2030, Nature-Based Solutions (NBS) have gained considerable attention, capturing the interest of both the scientific community and policymakers committed to addressing urban environmental issues. However, the need for studies to guide decision-makers in identifying suitable locations for NBS implementation within urban stormwater management is evident. To address this gap, the present study employs a methodological approach grounded in multi-criteria analysis integrated with Geographic Information Systems (GIS) to identify areas with potential for NBS implementation. In this process, ten NBS were proposed and tested in the drainage area of a shallow tropical urban lake in Londrina, southern Brazil. Additionally, the study investigates areas hosting lower-income populations, a relevant aspect for public managers given the diverse economic subsidies required to implement NBS. Furthermore, the study incorporates a preliminary analysis that evaluates the potential ecosystem benefits to determine the most suitable NBS for a specific site. The result shows that all the ten analyzed NBS were deemed suitable for the study area. Rain barrels had the highest percentage coverage in the study area (37.1%), followed by tree pits (27.9%), and rain gardens (25.4%). Despite having the highest distribution in the basin area, rain barrels exhibited only moderate ecosystem benefits, prompting the prioritization of other NBS with more significant ecological advantages in the final integrated map. In summary, the methodology proposed showed to be a robust approach to selecting optimal solutions in densely populated urban areas.

Prevalence and temporal trends in prepregnancy nutritional status and gestational weight gain of adult women followed in the Brazilian Food and Nutrition Surveillance System from 2008 to 2018.

Prepregnancy body mass index (BMI) and gestational weight gain (GWG) are the most investigated indicators of maternal nutritional status, which is a modifiable factor that plays a vital role in maternal and infant health. This study describes prepregnancy BMI and GWG of 840,243 women with 2,087,765 weight observations in the Brazilian Food and Nutrition Surveillance System from 2008 to 2018. Prepregnancy BMI was classified according to the World Health Organization cut-offs. Total GWG was calculated from weight measurements taken after 36 weeks of pregnancy and classified according to the Institute of Medicine guidelines. Temporal trends in prepregnancy BMI status were examined, and maps were used to evaluate changes in excessive GWG in each Brazilian federation unit. On overall, prepregnancy overweight and obesity increased from 22.6% to 28.8% and from 9.8% to 19.8%, respectively, between 2008 and 2018. The prevalence of excessive GWG rose from 34.2% to 38.7% during the same period and in 11 of the 27 Brazilian federation units between 2008 and 2016. Women with underweight showed the highest values for mean total GWG for all the compared years (overall variation from 12.3 to 13.1 kg), followed by those with normal weight (11.9 to 12.5 kg), overweight (10.1 to 10.9 kg) and obesity (from 8.2 to 8.9 kg). Within each BMI group, values remained fairly stable throughout the studied period for first- and second-trimester GWG and total GWG. These results help to fill a significant gap in understanding the distribution of prepregnancy BMI and GWG in Brazilian women.

Inducible nitric oxide synthase controls experimental Strongyloides infection.

Infection with Strongyloides sp. induces a host immune response, predominantly the Th2 type, that is able to eliminate the parasite. However, little is known about the role of the nitric oxide (NO) mediator, induced by the enzyme nitric oxide synthase (NOS), in strongyloidiasis. Therefore, in this study, we investigated the immune response of mice genetically deficient in the enzyme inducible nitric oxide synthase (iNOS-/- ), infected with Strongyloides venezuelensis. C57BL/6 wild-type (WT) and iNOS-/- mice were individually inoculated by subcutaneous injection of 3000 S. venezuelensis L3 larvae. In the absence of iNOS, mice were more susceptible to the infection than WT animals, in which the parasite was completely eliminated. The overall production of cytokines and specific IgG, IgG1 or IgE antibodies against the parasite was significantly lowered in infected iNOS-/- mice. The expression of iNOS was observed in the intestine of WT hosts but mainly in the wall of the parasite, despite the presence of iNOS in mice. Altogether, we concluded that iNOS expression may play an important role in the control of S. venezuelensis infection.

Educational inequalities in hypertension: complex patterns in intersections with gender and race in Brazil.

BACKGROUND: Hypertension is a major public health issue worldwide, but knowledge is scarce about its patterns and its relationship to multiple axes of social disadvantages in Latin American countries. This study describes the educational inequality in the prevalence of hypertension in Brazil, including a joint stratification by gender and race. METHODS: We analyzed interview-based data and blood pressure measurements from 59,402 participants aged 18 years or older at the 2013 Brazilian National Health Survey (PNS). Sociodemographic characteristics analyzed were gender (male, female), racial self-identification (white, brown, black), age (5-years intervals), and educational attainment (pre-primary, primary, secondary, tertiary). Hypertension was defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg, and/or self-reported use of antihypertensive medications in the last 2 weeks. We used logistic regression to evaluate the age-adjusted prevalences of hypertension (via marginal modeling), and pair-wise associations between education level and odds of hypertension. Further, the educational inequality in hypertension was summarized through the Relative Index of Inequality (RII) and the Slope Index of Inequality (SII). All analyses considered the appropriate sampling weights and intersections with gender, race, and education. RESULTS: Age-adjusted prevalence of hypertension was 34.0 % and 30.8 % among men and women, respectively. Black and brown women had a higher prevalence than whites (34.5 % vs. 31.8 % vs. 29.5 %), whereas no racial differences were observed among men. White and brown, but not black women, showed graded inverse associations between hypertension and educational attainment; among men, non-statistically significant associations were observed in all racial strata. The RII and SII estimated inverse gradients among white (RII = 2.5, SII = 18.1 %) and brown women (RII = 2.3, SII = 14.5 %), and homogeneous distributions of hypertension in educational subgroups among black women and among men. CONCLUSION: In this representative sample of Brazilian adults, the association between educational attainment and hypertension was influenced by gender and race - a topic still poorly understood. Our findings highlight the importance of assessing intersections of multiple sociodemographic characteristics in health inequalities research. The use of comprehensive measures of inequality, such as RII and SII, provide useful insights for monitoring health inequalities in an intersectional perspective.

Increased susceptibility to Strongyloides venezuelensis infection is related to the parasite load and absence of major histocompatibility complex (MHC) class II molecules.

In human and murine models strongyloidiasis induce a Th2 type response. In the current study we investigated the role of different loads of Strongyloides venezuelensis in the immune response raised against the parasite and the participation of the major histocompatibility complex (MHC) class II molecule in the disease outcome in face of the different parasite burden. The C57BL/6 wild type (WT) and MHC II(-/-) mice were individually inoculated by subcutaneous injection with 500 or 3000 S. venezuelensis L3. The MHC II(-/-) mice infected with 3000L3 were more susceptible to S. venezuelensis infection when compared with WT groups, in which the parasite was completely eliminated. The production of Th2 cytokines and specific IgG1 or IgE antibodies against parasite were significantly lowered in MHC II(-/-) infected mice with different larvae inoculums. The infection of MHC II(-/-) mice with S. venezuelensis induced slight inflammatory alterations in the small intestine, and these lesions were lower when compared with WT mice, irrespective of the parasite load utilized to infect animals. Finally, we concluded that MHC class II molecules are essential in the immune response against S. venezuelensis mainly when infection occurs with high parasite inoculum.

Primary health care coverage in Brazil: a dataset from 1998 to 2020.

OBJECTIVES: Primary health care builds the backbone of an effective healthcare system and can improve population health, reduce cost growth, and lessen inequality. We offer a machine-readable and open-access dataset on primary health care coverage in Brazil from 1998 to 2020. This dataset is interoperable with epidemiological data from two major studies and reusable by the research community worldwide for other purposes, such as monitoring progress toward universal health coverage and studying the association between primary health care and health outcomes. DATA DESCRIPTION: The dataset gathers official and public information from the "e-Gestor AB" platform of the Ministry of Health of Brazil and restricted data obtained by the Brazilian Access to Information Law. It includes 1,509,870 observations and 35 attributes aggregated by months/years and policy-relevant geographic units (country, macroregions, states, municipalities, and capitals) on primary health care team count and their absolute and relative population coverage estimates, information on the More Doctors Program implementation and physician counts, and spatial, demographic, and socioeconomic characteristics. We automated all data processing and curation in the free and open software R. The codes can be audited, replicated, and reused to produce alternative analyses.

Dataset on child vaccination in Brazil from 1996 to 2021.

We present a machine-readable and open-access dataset on vaccination results among children under five years old in Brazil from 1996 to 2021. This dataset is interoperable with epidemiological data from the VAX*SIM project and reusable by the research community worldwide for other purposes, such as monitoring vaccination coverage and studying its determinants and impacts on child morbidity and mortality. The dataset gathers official and public information from the Brazilian National Immunisation Program, the Institute of Geography and Statistics, the Institute for Applied Economic Research, and the Ministry of Health. It includes 2,442,863 observations and 35 attributes aggregated by years, policy-relevant geographic units (country, macroregions, states, municipalities, and capitals), and age groups on 1,344,480,329 doses of 28 vaccines aimed to prevent 15 diseases, estimates of their target-population coverage, indicators of the vaccination coverage's homogeneity, dropout rates, and spatial, demographic, and socioeconomic data. We automated all data processing and curation in the free and open software R. The codes can be audited, replicated, and reused to produce alternative analyses.

A comprehensive integrated dataset on Brazilian health facilities: from 2005 to 2021.

OBJECTIVES: The National Registry of Healthcare Facilities is a system with the registry of every healthcare facility in Brazil with information on the capacity building and healthcare workforce regarding its public or private nature. Despite being publicly available, it can only be accessed in separated disjoint tables, with different primary units of analysis. The objective is to offer an interoperable dataset containing monthly data from 2005 to 2021 with information on healthcare facilities, including their physical and human resources, services and teams, enriched with municipal information. DATA DESCRIPTION: Database with historical data and geographic information for each health facility in Brazil. It is composed by 5 distinct tables, organized according to combinations of time, space, and types of resources, services and teams. This database opens up a range of possibilities for research topics, from case studies in a single health facility and period, analysis of a group of health facilities with characteristics of interest, to a broader study using the entire dataset and aggregated data by municipality. Furthermore, the fact that there is a row for each health facility/month/year facilitates the integration with other datasets from the Brazilian healthcare system. In addition to being a potential object of study in the health area, the dataset is also convenient in data science, especially for studies focused on time series.

Brazilian spatial, demographic, and socioeconomic data from 1996 to 2020.

OBJECTIVES: We present a database on Brazilian spatial, demographic, and socioeconomic characteristics from 1996 to 2020. This database aims for integration and harmonization with epidemiological data from two major studies. It can also be a valuable database for designing and conducting various types of epidemiologic research, such as health inequality studies, ecological studies (mapping and time-trends), and multi-level analysis. DATA DESCRIPTION: The database gathers official information obtained via open sources from the Brazilian Institute of Geography and Statistics, the Institute for Applied Economic Research, and the Ministry of Health. It includes 139,153 observations and 26 attributes aggregated by years and policy-relevant geographic units on geocoding of municipality centroids, total population size, child population by age-group, birth and mortality measures, Brazilian Municipal Human Development Index, Gini coefficient, Gross Domestic Product, and sanitation. We automated all data processing and curation in the free and open software R.

Database on the coverage of the "Bolsa-Família" conditioning cash-transfer program: Brazil, 2005 to 2021.

OBJECTIVES: The "Bolsa-Família" Program (PBF) is a Brazilian conditional cash-transfer program in which families should comply with health, education, and social assistance conditionalities. The program aims to fight poverty and hunger, promoting nutrition and health services for low-income populations. This paper presents a database on the coverage of monitoring and compliance with the PBF health conditionalities in Brazil from January 2005 to July 2021. DATA DESCRIPTION: Database on the PBF conditioning cash-transfer program coverage in Brazil from 2005 to 2021. It comprises information on the number of families benefited, health conditionalities, and the follow-up on vaccination and nutrition of children under seven years old. The cities and semesters are the minimal aggregation units.

National congenital anomaly registers in the world: historical and operational aspects. / Registros nacionais de anomalias congênitas no mundo: aspectos históricos e operacionais.

OBJECTIVE: To identify registers of congenital anomalies with national coverage currently available around the world, highlighting their main historical and operational characteristics. METHODS: This was a documentary study by means of a Medline database search (via PubMed) and searches involving reports, official documents and websites. Studies reporting at least one national registry were included. RESULTS: 40 registers of national congenital anomalies were identified in 39 different countries. All registers included in the study were concentrated in upper-middle or high-income countries located in Europe. Most of the registers were population-based, compulsory notification and with a time limit for notification of up to 1 year of age. The Brazilian register showed the highest annual coverage. CONCLUSION: The registers analyzed showed different characteristics, related to the reality of each country. The results presented provide support for the theme of congenital anomalies surveillance, especially in places where such activity is intended to be implemented.

List of priority congenital anomalies for surveillance under the Brazilian Live Birth Information System. / Lista de anomalias congênitas prioritárias para vigilância no âmbito do Sistema de Informações sobre Nascidos Vivos do Brasil.

OBJECTIVE: To define the list of priority congenital anomalies for improving their recording on the Brazilian Live Birth Information System (Sinasc). METHODS: Based on the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), international protocols and meetings with specialists, the list of priority anomalies was built considering two main criteria: being diagnosable at birth and having intervention available at different levels. The list was submitted for consideration by the Brazilian Medical Genetics and Genomics Society. RESULTS: The list comprised eight groups of congenital anomalies distributed according to the type of related anomaly, as well as the affected part of the body and its corresponding code in ICD-10 Chapter XVII. CONCLUSION: The list of priority congenital anomalies for notification provides a basis for improving case recording on Sinasc.

Multisystem inflammatory syndrome in children: a cross-sectional study of cases and factors associated with deaths during the COVID-19 pandemic in Brazil, 2020. / Síndrome inflamatória multissistêmica pediátrica: estudo seccional dos casos e fatores associados aos óbitos durante a pandemia de COVID-19 no Brasil, 2020.

OBJECTIVE: To characterize the clinical-epidemiological profile of multisystem inflammatory syndrome in children temporally associated with COVID-19 (MIS-C), and to identify factors associated with MIS-C deaths in Brazil, 2020. METHODS: This was a cross-sectional study, using national MIS-C monitoring data. Logistical regression was performed to estimate crude and adjusted odds ratios (OR). RESULTS: Median case (n=652) age was 5 years, 57.1% were male, 52.0% were of brown race/skin color and 6.4% died. Likelihood of death was greater among those who presented O2 saturation <95% (ORa=4.35 - 95%CI 1.69;11.20) and altered urea results (ORa=5.18 - 95%CI 1.91;14.04); likelihood of death was lower when red skin blotches were not present (ORa=0.23 - 95%CI 0.09;0.62), when anticoagulants were used (ORa=0.32 - 95%CI 0.12;0.89) and when immunoglobulins were used (ORa=0.38 - 95%CI 0.15;1.01). CONCLUSION: Fatality ratios were higher among cases that presented O2 saturation <95% and altered urea results. Fatality ratios were lower among those with red skin blotches, and those who used immunoglobulins and anticoagulants.

Antibody and cytokine responses to house dust mite allergens and Toxoplasma gondii antigens in atopic and non-atopic Brazilian subjects.

According to hygiene hypothesis, a lower exposure to infection is associated with increased prevalence of allergic diseases. This study aimed to investigate the association between atopy and Toxoplasma gondii (Tg) infection by analyzing the antibody and cytokine responses to house dust mite allergens and T. gondii antigens in Brazilian subjects. A total of 275 individuals were assessed and divided into atopics (n=129) and non-atopics (n=146) based on markers of allergy (positive skin prick test and ELISA-IgE to mite allergens) or Tg-seropositive (n=116) and Tg-seronegative (n=159) groups according to infection markers (positive ELISA-IgG to T. gondii). Tg-seropositive individuals presented lower allergenic sensitization (37%) to mite allergens than Tg-seronegative subjects (54%). A significant association was found between atopy and negative serology to T. gondii (OR: 2.0; 95% CI: 1.23-3.26; P<0.05). Proliferative responses and cytokine production after antigenic stimulation showed predominant synthesis of Th1-cytokines as IFN-gamma in Tg-seropositive patients, whether atopics or non-atopics. Conversely, Th2-cytokines as IL-5 prevailed in atopics compared to non-atopics, regardless the seropositivity to T. gondii. Levels of IL-10, IL-13, IL-17, and TGF-beta were not able to discriminate the groups. Hence, a negative association between atopy and infection by T. gondii was demonstrated for the first time in Brazilian subjects, focusing on the antibody and cytokine responses and indicating that the immunomodulation induced by the parasite may play a protective role in the development of allergic diseases.

Human Milk Oligosaccharide Profile Variation Throughout Postpartum in Healthy Women in a Brazilian Cohort.

Human milk oligosaccharide (HMO) composition varies throughout lactation and can be influenced by maternal characteristics. This study describes HMO variation up to three months postpartum and explores the influences of maternal sociodemographic and anthropometric characteristics in a Brazilian prospective cohort. We followed 101 subjects from 28-35 gestational weeks (baseline) and throughout lactation at 2-8 (visit 1), 28-50 (visit 2) and 88-119 days postpartum (visit 3). Milk samples were collected at visits 1, 2 and 3, and 19 HMOs were quantified usinghigh-performance liquid chromatography with fluorescence detection (HPLC-FL). Friedman post-hoc test, Spearman rank correlation for maternal characteristics and HMOs and non-negative matrix factorization (NMF) were used to define the HMO profile. Most women were secretors (89.1%) and presented high proportion of 2'-fucosyllactose (2ꞌFL) at all three sample times, while lacto-N-tetraose (LNT, 2-8 days) and lacto-N-fucopentaose II (LNFPII, 28-50 and 88-119 days) were the most abundant HMOs in non-secretor women. Over the course of lactation, total HMO weight concentrations (g/L) decreased, but total HMO molar concentrations (mmol/L) increased, highlighting differential changes in HMO composition over time. In addition, maternal pre-pregnancy body mass index (BMI) and parity influence the HMO composition in healthy women in this Brazilian cohort.

International collaboration networks for the surveillance of congenital anomalies: a narrative review. / Redes internacionais de colaboração para a vigilância das anomalias congênitas: uma revisão narrativa.

Objective to identify international congenital anomaly surveillance collaboration networks, to list the programs that compose them and to compare their main characteristics. Methods this was a narrative literature review by means of a MEDLINE database search (via PubMed) and searches involving websites, reports and official documents. Results six international congenital anomaly surveillance collaboration networks were identified (ECLAMC, ICBDSR, EUROCAT, BINOCAR, SEAR-NBBD and ReLAMC), comprised of 98 programs present in 58 different countries on all continents, except Africa; the main characteristics regarding type of surveillance, coverage and location were discussed in a comparative manner. Conclusion international collaborative networks are important players for congenital anomaly surveillance, contributing to the understanding of the global epidemiological scenario of these conditions, in addition to acting both to strengthen individual existing programs and also to create surveillance initiatives in unassisted regions.

Congenital anomalies from the health surveillance perspective: compilation of a list based on ICD-10. / Anomalias congênitas na perspectiva da vigilância em saúde: compilação de uma lista com base na CID-10.

OBJECTIVE: To propose a list of congenital anomalies having corresponding codes in the International Statistical Classification of Diseases and Related Health Problems, 10thRevision (ICD-10), with the aim of applying it in health surveillance. METHODS: In December 2019, the following data sources were searched: ICD-10; ICD-11; anomalies monitored by three surveillance programs; and a database of rare diseases (Orphanet). Anomalies were retrieved from these data sources, processed to check for correspondence with ICD-10 and reviewed manually to compile the list. RESULTS: 898 codes were identified, of which 619 (68.9%) were contained in ICD-10 Chapter XVII. Of the 279 codes contained in other chapters, 19 were exclusive to the ICD-11 search, 72 to the surveillance programs, 79 to Orphanet and 36 to the search for terms in ICD-10. CONCLUSION: The codes contained in ICD-10 Chapter XVII do not capture the totality of congenital anomalies, indicating the need to adopt an expanded list.

Major histocompatibility complex (MHC) class II but not MHC class I molecules are required for efficient control of Strongyloides venezuelensis infection in mice.

Strongyloides stercoralis is an intestinal nematode capable of chronic, persistent infection and hyperinfection of the host; this can lead to dissemination, mainly in immunosuppressive states, in which the infection can become severe and result in the death of the host. In this study, we investigated the immune response against Strongyloides venezuelensis infection in major histocompatibility complex (MHC) class I or class II deficient mice. We found that MHC II(-/-) animals were more susceptible to S. venezuelensis infection as a result of the presence of an elevated number of eggs in the faeces and a delay in the elimination of adult worms compared with wild-type (WT) and MHC I(-/-) mice. Histopathological analysis revealed that MHC II(-/-) mice had a mild inflammatory infiltration in the small intestine with a reduction in tissue eosinophilia. These mice also presented a significantly lower frequency of eosinophils and mononuclear cells in the blood, together with reduced T helper type 2 (Th2) cytokines in small intestine homogenates and sera compared with WT and MHC I(-/-) animals. Additionally, levels of parasite-specific immunoglobulin M (IgM), IgA, IgE, total IgG and IgG1 were also significantly reduced in the sera of MHC II(-/-) infected mice, while a non-significant increase in the level of IgG2a was found in comparison to WT or MHC I(-/-) infected mice. Together, these data demonstrate that expression of MHC class II but not class I molecules is required to induce a predominantly Th2 response and to achieve efficient control of S. venezuelensis infection in mice.

IgE, IgG1, and IgG4 Reactivity to Dermatophagoides pteronyssinus Glycosylated Extract in Allergic Patients.

BACKGROUND: House dust mites are important allergen sources and some of these allergenic proteins may contain carbohydrate moieties, which are able to be isolated using lectins, as Concanavalin A (ConA). This study aimed to investigate allergenicity (IgE) and antigenicity (IgG1 and IgG4) of ConA-unbound and ConA-bound Dermatophagoides pteronyssinus (Dpt) crude extracts using sera of mite-allergic patients as well as inhibition capacity of antibody binding. MATERIAL AND METHODS: We obtained mannose-enriched and mannose-depleted fractions from Dpt by ConA affinity chromatography. Both ConA-bound and ConA-unbound fractions were evaluated by ELISA and Western Blotting for specific IgE, IgG1, and IgG4 reactivity with sera obtained from 95 mite-allergic patients (DP+) and 92 nonallergic (NA) subjects. Inhibition ELISA was used to assess cross-reactivity between Dpt extract and its fractions. RESULTS: Among the DP+ patients, no difference was found between ConA-unbound and ConA-bound fractions regarding the levels of specific IgE, IgG1, and IgG4. Nonallergic subjects had the same levels of specific IgG1 to both ConA-unbound and ConA-bound fractions, although for specific IgG4, values were higher for ConA-bound. A positive correlation was found among specific IgE, IgG1, and IgG4 levels when Dpt was compared to ConA-unbound and ConA-bound fractions. Recognition of crude Dpt by IgE, IgG1, and IgG4 was highly inhibited by ConA-unbound and ConA-bound fractions. Western Blotting revealed a broad spectrum of bands ranging from 14 to 116 kDa recognized by specific IgE and IgG4. However, IgG1 reached higher frequency values on high molecular weight polypeptides. CONCLUSION: ConA-unbound and ConA-bound fractions derived from D. pteronyssinus crude extract revealed important components involved in the IgE recognition in allergic patients as well as IgG1 and/or IgG4 in allergic and healthy subjects.

Educational inequality in Rio de Janeiro and its impact on multimorbidity: evidence from the Pró-Saúde study. A cross-sectional analysis.

BACKGROUND: Information about multimorbidity is scarce in developing countries. This study aimed to estimate the association of educational attainment with occurrences of multimorbidity in a population of public employees on university campuses in Rio de Janeiro. DESIGN AND SETTING: We conducted cross-sectional analyses on baseline data (1999-2001) from 3,253 participants in the Pró-Saúde study, conducted in Brazil. METHODS: The prevalence of multimorbidity, defined as a self-reported history of medical diagnoses of two or more chronic conditions, was estimated according to sex, age, smoking, obesity and educational level. The association between education and multimorbidity was estimated using odds ratios (OR) and the relative and slope indices of inequality, in order to quantify the degree of educational inequality among individuals with multimorbidity in this population. RESULTS: Greater age, female sex, smoking and obesity had direct associations with multimorbidity; and tobacco exposure and obesity also showed direct relationships with poorer educational level. There was a monotonic inverse linear trend between educational level and the presence of multimorbidity among women, with twice the odds (OR 2.47; 95% confidence interval, CI: 1.42-4.40) between extremities of schooling categories. There was excess multimorbidity of 22% at the lowest extremity of schooling, thus showing that women with worse educational status were more affected by the outcome. No trend and no excess multimorbidity was seen among men. CONCLUSIONS: Educational inequality is an important determinant for development of multimorbidity. Men and women experience its effect differently. Researchers need to consider that sex may be an effect modifier in multimorbidity studies.