Pitfalls in acute febrile illness diagnosis: Interobserver agreement of signs and symptoms during a dengue outbreak.

AIMS AND OBJECTIVES: To compare and evaluate interobserver (nurses and physicians) agreement for dengue clinical signs and symptoms, including the World Health Organization diagnostic algorithm. BACKGROUND: Agreement of clinical history defines the capacity of the examiner to measure a given clinical parameter in a reproducible and consistent manner, which is prerequisite for diagnosis validity. Nurses play a major role in the triage and care of dengue patients in many countries. STUDY DESIGN: This is a sub-study on interobserver agreement performed as part of a cross-sectional diagnostic accuracy study for acute febrile illness (AFI) using the checklist STARD. METHODS: A previously validated semi-structured sign and symptom standardised questionnaire for AFI was independently administered to 374 patients by physician and nurse pairs. The interobserver agreement was estimated using kappa statistics. RESULTS: For a set of 27 signs and symptoms, we found six interobserver discrepancies (examiner detected red eyes, lethargy, exanthema, dyspnoea, bleeding and myalgia) as identified by regular and moderate kappa indexes. Four signs (patient observed red eyes, cough, diarrhoea and vomiting) and one symptom (earache) had near-perfect agreement. Most signs and symptoms showed substantial agreement. The WHO (Dengue guidelines for diagnosis, treatment, prevention and control: new edition, World Health Organization, 2009) clinical criteria for dengue comprise a group of symptoms known as "pains and aches." Interobserver agreement for abdominal pain, retro-orbital pain and arthralgia exceed that found for headache and myalgia. CONCLUSIONS: During a dengue outbreak, the interobserver agreement for most of the signs and symptoms used to assess AFI was substantial. RELEVANCE TO CLINICAL PRACTICE: This result suggests good potential applicability of the tool by health professionals following training. A well-trained health professional is qualified to apply the standardised questionnaire to evaluate suspected dengue cases during outbreaks.

30 years of fatal dengue cases in Brazil: a review.

BACKGROUND: Over the last 30 years, extensive dengue epidemics have occurred in Brazil, characterized by emergences and re-emergences of different serotypes, a change in the epidemiological profile and an increase in the number of severe and fatal cases. Here, we present a review on the dengue fatal cases that occurred in Brazil in 30 years (1986-2015). METHODS: We performed an ecological study by using secondary data on dengue fatal cases obtained in the National System of Reported Diseases (Sistema de Informação de Agravos de Notificação -SINAN) and in the Mortality Information System (SIM), both maintained by the Brazilian Ministry of Health. Cases were analyzed by region, demographic variables, clinical classification and complications based on the data available. RESULTS: In 30 years (1986-2015), the Southeast region reported 43% (n = 2225) of all dengue deaths in the country. The Midwest region was responsible for 18% of the fatal cases. After 2000, deaths occurred in almost all states, with the exception of Santa Catarina and Rio Grande do Sul, South region. From 2006 to 2010, the number of deaths increased, with higher rates of mortality, especially in Goiás and Mato Grosso. From 2011 to 2015, Goiás became the state with the highest mortality rate in the country, and Rio Grande do Sul reported its first dengue deaths. In 30 years, a total of 2682 dengue deaths occurred in males and 2455 in females, and an equal distribution between the sexes was observed. From 1986 to 2006, dengue deaths occurred predominantly in individuals over 15 years old, but this scenario changed in 2007-2008. After 2009, fatal cases on individuals above 15 years old became more frequent, with peaks in the years of 2010, 2013 and 2015. CONCLUSIONS: The Brazil is experiencing a hyperendemic scenario, which has resulted in the co-circulation of the four DENV serotypes and with the increasing occurrence of severe and fatal cases. The disease surveillance and studies characterizing what has been reported overtime, are still important tools to better understand the factors involved in the disease outcome.

Increased sensitivity of NS1 ELISA by heat dissociation in acute dengue 4 cases.

BACKGROUND: Dengue is an acute febrile illness considered the major arboviral disease in terms of morbidity, mortality, economic impact and dissemination worldwide. Brazil accounts for the highest notification rate, with circulation of all four dengue serotypes. The NS1 antigen is a dengue highly conserved specific soluble glycoprotein essential for viral replication and viability that can be detected 0 to 18 days from the onset of fever (peak first 3 days). It induces a strong humoral response and is known as a complement-fixing antigen. Lower NS1 test sensitivity occurs in secondary dengue infections probably due to immune complex formation impairing antigen detection by ELISA. METHODS: We compared the sensitivity of NS1 ELISA in heat dissociated and non-dissociated samples from 156 RT-PCR confirmed acute dengue-4 cases from 362 prospectively enrolled patients. RESULTS: Secondary infections accounted for 83.3% of cases. NS1 ELISA was positive in 42.5% and indeterminate in 10.2% of dengue-4 cases. After heat dissociation, 7 negative and 16 indeterminate samples turned positive, increasing the overall test sensitivity to 57.7%. CONCLUSIONS: Although it is time consuming and requires the use of specific laboratory equipment, NS1 ELISA combined with heat dissociation could be a slightly better alternative for triage in suspected dengue cases.

Accuracy of clinical criteria and an immunochromatographic strip test for dengue diagnosis in a DENV-4 epidemic.

BACKGROUND: Early diagnosis of dengue infection is important for decision-making and timely implementation of therapeutic measures. Although rapid NS1 assays have been used for dengue diagnosis since 2008, their performance in DENV-4 cases has not yet been fully assessed. METHODS: We evaluated the accuracy of NS1 Bioeasy™ immunochromatographic strip test and of three clinical criteria for dengue diagnosis. Patients presenting at an emergency care center within 72 h of an acute febrile illness during the 2013 DENV-4 epidemic in Rio de Janeiro were consecutively enrolled for clinical and laboratory evaluation. We classified patients as suspected dengue or not according to three clinical criteria: WHO 2009, WHO 1997, and INI-FIOCRUZ. Dengue diagnosis was defined by RNA detection using RT-PCR and the negative cases were negative for all dengue serotypes and also Platelia™ NS1 ELISA. We obtained accuracy indices for NS1 Bioeasy™ alone and in combination with the clinical criteria. RESULTS: RT-PCR for DENV-4 was positive in 148 out of 325 patients. Positive likelihood ratio, sensitivity, and specificity of NS1 Bioeasy™ with WHO 2009, WHO 1997, and INI-FIOCRUZ criteria were 22.6 (95% CI 7.2-70.6), 40.6% (95% CI 32.3-49.3), and 98.2% (95% CI 94.9-99.6); 18.3 (95% CI 6.8-49.2), 44.2 (95% CI 35.8-52.9), 97.6 (95% CI 94.0-99.3); 26.2 (95% CI 6.5-106.5), 29.7 (95% CI 22.4-37.8), 98.9 (95% CI 96.0-99.9), respectively. WHO 1997 clinical criteria presented high sensitivity to rule out disease, but extremely low specificity. INI-FIOCRUZ had moderate sensitivity and specificity, and could target a group to a more specific test. CONCLUSIONS: Although the large rates of false negative results using NS1 Bioeasy™ rapid test advise against its use for triaging (rule out) purposes in DENV-4 epidemics, it could be used as a confirmatory tool in a bedside algorithm.

Tuberculosis DALY-Gap: Spatial and Quantitative Comparison of Disease Burden Across Urban Slum and Non-slum Census Tracts.

To quantitatively assess disease burden due to tuberculosis between populations residing in and outside of urban informal settlements in Rio de Janeiro, Brazil, we compared disability-adjusted life years (DALYs), or "DALY-gap." Using the 2010 Brazilian census definition of informal settlements as aglomerados subnormais (AGSN), we allocated tuberculosis (TB) DALYs to AGSN vs non-AGSN census tracts based on geocoded addresses of TB cases reported to the Brazilian Information System for Notifiable Diseases in 2005 and 2010. DALYs were calculated based on the 2010 Global Burden of Disease methodology. DALY-gap was calculated as the difference between age-adjusted DALYs/100,000 population between AGSN and non-AGSN. Total TB DALY in Rio in 2010 was 16,731 (266 DALYs/100,000). DALYs were higher in AGSN census tracts (306 vs 236 DALYs/100,000), yielding a DALY-gap of 70 DALYs/100,000. Attributable DALY fraction for living in an AGSN was 25.4%. DALY-gap was highest for males 40-59 years of age (501 DALYs/100,000) and in census tracts with <60% electricity (12,327 DALYs/100,000). DALY-gap comparison revealed spatial and quantitative differences in TB burden between slum vs non-slum census tracts that were not apparent using traditional measures of incidence and mortality. This metric could be applied to compare TB burden or burden for other diseases in mega-cities with large informal settlements for more targeted resource allocation and evaluation of intervention programs.

Risk factors for the ill-defined causes of death in the Brazilian states: a multilevel analysis.

This study describes the spatial-temporal changes of the proportion of ill-defined causes of death in Brazil (1998-2012) and investigates which demographic and socioeconomic factors affect this proportion. We collected information of the proportion of ill-defined causes of death by age (15-59 years), sex, period, locality, and socioeconomic data. We used a multilevel Poisson model to investigate which factors affect the risk of ill-defined causes of death. Unlike states located in the South and Midwest, we detected clusters with high proportional levels of these deaths in states in the North and Northeast regions. A greater proportion occurred in 1998-2002 (0.09), in the North and Northeast (0.14 and 0.12, respectively), in older age groups (0.09), and in places with poor socioeconomic conditions. The adjusted analysis showed differences in proportion according to the region, age, period, schooling, social inequality, and income. The results indicate that the lower the age group and the better the socioeconomic situation, the lower the risk to register the cause of death as ill-defined. Although over the past years, the quality of Brazil's mortality data has gradually increased, investments towards improving mortality registries cannot be discontinued.

Risk factors for arbovirus infections in a low-income community of Rio de Janeiro, Brazil, 2015-2016.

BACKGROUND: Dengue epidemics have occurred in the city of Rio de Janeiro (Brazil) since 1986. In the year 2015, Zika and chikungunya viruses were introduced in the city, causing sequential and simultaneous epidemics. Poor socioeconomic conditions have been suggested as contributing factors of arboviral infection. OBJECTIVE: To describe the spatial distribution of human cases of symptomatic arboviral infections and to identify risk factors for infection in a poor community of Rio de Janeiro in the years 2015 and 2016. METHODS: We built thematic maps of incidence rates for 78 micro-areas in the Manguinhos neighborhood. The micro-areas congregate about 600 inhabitants. Simple and multiple multilevel logistic regression models were used to evaluate the association between the incidence of arboviral diseases and socio-demographic factors at both the individual and micro-area levels. RESULTS: From 2015 to 2016, 370 human cases of arbovirus infection were reported in the Manguinhos community: 123 in 2015 and 247 in 2016. There was a significant difference in the risk of arbovirus diseases among different micro-areas, but this was not explained by water and sanitation indicators. The cumulative incidence rate was 849/100,000 in two years. The incidence was greater in those individuals with familiar vulnerability (1,156/100,000 vs. 794/100,000). The multilevel adjusted model showed that the odds of acquiring an arbovirus infection was 55% greater in those with familiar vulnerability. CONCLUSION: Arbovirus infections cause a high burden of disease in Brazilian urban centers. Our results suggest that even in poor neighborhoods, there is a high spatial variability in the risk of acquiring an arbovirus infection. The conditions that favor vector proliferation and infection by arboviruses are complex and involve both individual and environmental characteristics that vary from place to place. To reduce the burden of arboviral diseases, continued public health policies and basic services should be provided to the communities at risk that consider specific local needs.

Participatory evaluation of the quality of health information on the internet: the case of dengue sites. / Avaliação participativa da qualidade da informação de saúde na internet: o caso de sites de dengue.

The world has witnessed a powerful and radical transformation of social, economic and cultural relationships promoted by the Internet. The Internet provides opportunities for access, dissemination and production of information worldwide. Health, for example, stands out as one of the main areas with information of interest to a growing number of users. However, this information is often unsatisfactory, incorrect or incomprehensible. This paper analyzes an experiment of evaluation of information on dengue websites developed in a laboratory of the Oswaldo Cruz Foundation. It counted on the participation of a group of Manguinhos dwellers and Public Health PHC physicians, infectious disease specialists and public health physicians in the development of criteria and the evaluation of websites. This paper shows the main results of this experience, which is innovative because its paper and product differ from those proposed by national and foreign agencies and analysts. This experience supports the establishment of an institutional process that issues a quality seal to websites that comply with the suggested criteria and indicators.

Accuracy of Zika virus disease case definition during simultaneous Dengue and Chikungunya epidemics.

BACKGROUND: Zika is a new disease in the American continent and its surveillance is of utmost importance, especially because of its ability to cause neurological manifestations as Guillain-Barré syndrome and serious congenital malformations through vertical transmission. The detection of suspected cases by the surveillance system depends on the case definition adopted. As the laboratory diagnosis of Zika infection still relies on the use of expensive and complex molecular techniques with low sensitivity due to a narrow window of detection, most suspected cases are not confirmed by laboratory tests, mainly reserved for pregnant women and newborns. In this context, an accurate definition of a suspected Zika case is crucial in order for the surveillance system to gauge the magnitude of an epidemic. METHODOLOGY: We evaluated the accuracy of various Zika case definitions in a scenario where Dengue and Chikungunya viruses co-circulate. Signs and symptoms that best discriminated PCR confirmed Zika from other laboratory confirmed febrile or exanthematic diseases were identified to propose and test predictive models for Zika infection based on these clinical features. RESULTS AND DISCUSSION: Our derived score prediction model had the best performance because it demonstrated the highest sensitivity and specificity, 86·6% and 78·3%, respectively. This Zika case definition also had the highest values for auROC (0·903) and R2 (0·417), and the lowest Brier score 0·096. CONCLUSIONS: In areas where multiple arboviruses circulate, the presence of rash with pruritus or conjunctival hyperemia, without any other general clinical manifestations such as fever, petechia or anorexia is the best Zika case definition.

Clinical and laboratory signs associated to serious dengue disease in hospitalized children.

OBJECTIVE: To evaluate the validity of clinical and laboratory signs to serious dengue disease in hospitalized children. METHODS: Retrospective cohort of children (<18 years) hospitalized with dengue diagnosis (2007-2008). Serious dengue disease was defined as death or use of advanced life support therapy. Accuracy measures and area under the receiver operating characteristic curve were calculated. RESULTS: Of the total (n=145), 53.1% were female, 69% aged 2-11 years, and 15.9% evolved to the worse outcome. Lethargy had the best accuracy (positive likelihood ratio >19 and negative likelihood ratio <0.6). Pleural effusion and abdominal distension had higher sensitivity (82.6%). History of bleeding (epistaxis, gingival or gastrointestinal bleeding) and severe hemorrhage (pulmonary or gastrointestinal bleeding) in physical examination were more frequent in serious dengue disease (p<0.01), but with poor accuracy (positive likelihood ratio=1.89 and 3.89; negative likelihood ratio=0.53 and 0.60, respectively). Serum albumin was lower in serious dengue forms (p<0.01). Despite statistical significance (p<0.05), both groups presented thrombocytopenia. Platelets count, hematocrit, and hemoglobin parameters had area under the curve <0.5. CONCLUSIONS: Lethargy, abdominal distension, pleural effusion, and hypoalbuminemia were the best clinical and laboratorial markers of serious dengue disease in hospitalized children, while bleeding, severe hemorrhage, hemoconcentration and thrombocytopenia did not reach adequate diagnostic accuracy. In pediatric referral hospitals, the absence of hemoconcentration does not imply absence of plasma leakage, particularly in children with previous fluid replacement. These findings may contribute to the clinical management of dengue in children at referral hospitals.

Use of Warning Signs for Dengue by Pediatric Health Care Staff in Brazil.

OBJECTIVE: The aim of this study was to describe the use of dengue warning signs by pediatric healthcare staff in the Brazilian public health care system. METHODS: Cross-sectional study (2012) with physicians, nurses, and nurse technicians assisting children in five health care facilities. Participants reported the use and importance of dengue warning signs in pediatrics clinical practice through a structured questionnaire. Differences in the use of signs (chi-square test) and in the ranking assigned to each of them (Kruskal-Wallis) were assessed according to health care occupation and level of care (p<0.05). RESULTS: The final sample comprised 474 participants (97%), mean age of 37 years (standard deviation = 10.3), mainly females (83.8%), physicians (40.1%) and from tertiary care (75.1%). The majority (91%) reported using warning signs for dengue in pediatrics clinical practice. The most widely used and highly valued signs were major hemorrhages (gastrointestinal, urinary), abdominal pain, and increase in hematocrit concurrent or not with rapid decrease in platelet count. Persistent vomiting as well as other signs of plasma leakage such as respiratory distress and lethargy/restlessness were not identified as having the same degree of importance, especially by nurse technicians and in primary or secondary care. DISCUSSION: Although most health care staff reported using dengue warning signs, it would be useful to extend the training for identifying easily recognizable signs of plasma leakage that occur regardless of bleeding.

Temporal and Spatial Evolution of Dengue Incidence in Brazil, 2001-2012.

BACKGROUND: In Brazil, the incidence of dengue greatly increased in the last two decades and there are several factors impeding the control of the disease. The present study focused on describing the space-time evolution of dengue in Brazil from 2001 to 2012 and analyzing the relationship of the reported cases with socio-demographic and environmental factors. METHODS: The analytic units used in the preparation of thematic maps were municipalities. Statistical tests and multilevel regression models were used to evaluate the association between dengue incidence and the following factors: climate, diagnostic period, demographic density, percentage of people living in rural areas, Gross Domestic Product, Gini index, percentage of garbage collection and the rate of households with a sewage network. RESULTS: The largest accumulation of dengue cases in Brazil was concentrated on the Atlantic coast and in the interior part of São Paulo State. The risk of dengue in subtropical and tropical climates was 1.20-11 times lower than that observed in semi-arid climates. In 2009-2010 and 2011-2012, the risks were ten and six times higher than in 2003-2004, respectively. CONCLUSION: Dengue is a common infection in the Brazilian population, with the largest accumulation of dengue cases concentrated on the Atlantic coast and in the interior area of São Paulo State. The high dengue rates observed in the Brazilian coastal region suggest that the cases imported from neighboring countries contribute to the spread of the disease in the country. Our results suggest that several socio-demographic and environmental factors resulted in the increase of dengue in the country over time. This is likely applicable to the occurrence of other arboviruses like Zika and chikungunya. To reverse the situation, Brazil must implement effective public policies that offer basic services such as garbage collection and sanitation networks as well as reduce vector populations.

The Fraction of Cancer Attributable to Ways of Life, Infections, Occupation, and Environmental Agents in Brazil in 2020.

Many human cancers develop as a result of exposure to risk factors related to the environment and ways of life. The aim of this study was to estimate attributable fractions of 25 types of cancers resulting from exposure to modifiable risk factors in Brazil. The prevalence of exposure to selected risk factors among adults was obtained from population-based surveys conducted from 2000 to 2008. Risk estimates were based on data drawn from meta-analyses or large, high quality studies. Population-attributable fractions (PAF) for a combination of risk factors, as well as the number of preventable deaths and cancer cases, were calculated for 2020. The known preventable risk factors studied will account for 34% of cancer cases among men and 35% among women in 2020, and for 46% and 39% deaths, respectively. The highest attributable fractions were estimated for tobacco smoking, infections, low consumption of fruits and vegetables, excess weight, reproductive factors, and physical inactivity. This is the first study to systematically estimate the fraction of cancer attributable to potentially modifiable risk factors in Brazil. Strategies for primary prevention of tobacco smoking and control of infection and the promotion of a healthy diet and physical activity should be the main priorities in policies for cancer prevention in the country.

[Translation and cross-cultural adaptation of the World Health Organization staff questionnaire on dengue warning signs for use in Brazil]. / Tradução e adaptação transcultural do instrumento da Organização Mundial da Saúde sobre o uso de sinais de alarme para dengue por profissionais de saúde.

Early recognition of warning signs and treatment of severe dengue cases is the main strategy for reducing case-fatality, especially in children, who usually present few symptoms and can progress rapidly to dengue shock syndrome. The objective of this study was to elaborate the Brazilian version of the World Health Organization (WHO) staff questionnaire on the use and value of dengue warning signs, through translation and back-translation of the WHO questionnaire, followed by an expert panel consensus, pretest (n = 13), and pilot study (n = 20) of the preliminary version. Comparison of the original questionnaire in English and the back-translation showed that 8 of the 49 items had been extensively or completely altered, and three were rephrased. The expert panel added the warning signs listed by the Brazilian Ministry of Health. In the final version of the questionnaire, the item "ranking of warning signs" was rephrased and the answer option "do not know" was excluded. The Brazilian version of the WHO staff questionnaire allows assessing health professionals' experience and perceptions regarding the use of warning signs included in the recent dengue guidelines.

[Factors associated with late initiation of breastfeeding in the Brazilian Unified National Health System in the city of Rio de Janeiro, Brazil, 2009]. / Fatores associados ao início tardio da amamentação em hospitais do Sistema Único de Saúde no Município do Rio de Janeiro, Brasil, 2009.

This study aimed to analyze factors associated with delayed initiation of breastfeeding (lack of breastfeeding in the first hour of life). This was a cross-sectional study conducted in 2009 with 673 postpartum women at hospitals belonging to the Brazilian Unified National Health System (SUS) in the city of Rio de Janeiro, Brazil. Statistical analysis used multilevel logistic regression, with two levels (individual and hospital). Prevalence of delayed initiation of breastfeeding was 49.2%. Delivery in a Baby-Friendly Hospital (BFH) had a protective effect against late initiation of breastfeeding (OR = 0.17; 95%CI: 0.05-0.55), while cesarean section (OR = 5.95; 95%CI: 3.88-9.12) and ignorance of HIV status until delivery (OR = 2.16; 95%CI: 1.04-4.50) increased the odds of delay. Reduction in cesarean rates, adherence to protocols to prevent vertical HIV transmission, and expanded accreditation of hospitals in the BFH are important strategies to promote breastfeeding in the first hour of life.

O papel da atenção primária na rede de atenção à saúde no Brasil: limites e possibilidades no enfrentamento da COVID-19 / The role of primary care in the Brazilian healthcare system: limits and possibilities for fighting COVID-19

Em 12 de março de 2020, a Organização Mundial da Saúde (OMS) declarou como pandemia a doença causada pelo novo coronavírus (SARS-CoV-2). A infecção (COVID-19), além de ser mais transmissível, tem letalidade estimada em cerca de 14 vezes a da influenza. O alto índice de contágio, com cada indivíduo infectando de 2 a 3 pessoas, em média, causa a expansão da epidemia em progressão geométrica. No Brasil, onde a transmissão comunitária em todo o território nacional foi declarada em 20 de março, mais de 147 mil casos e 10 mil mortes pela COVID-19 haviam sido confirmados até 9 de maio de 2020. A assistência à COVID-19 precisa dar conta das necessidades dos pacientes nas diferentes fases da infecção e em todo o espectro de gravidade, em uma linha de cuidado que envolve desde o monitoramento de casos leves em isolamento domiciliar, com orientações para o manejo de sintomas e para a identificação precoce de sinais de alerta, até a internação em unidades de terapia intensiva (UTI) e a reabilitação após a alta hospitalar. A minimização dos riscos de infecção dos profissionais de saúde e demais pacientes deve balizar a escolha das melhores estratégias de organização da rede para atender a essas necessidades.

Spatial dynamics of AIDS incidence in the elderly in Rio de Janeiro, Brazil, 1997-2011.

The dynamics of the spread of the AIDS epidemic ranges according to the characteristics of each geographical region in different population groups. The aim of this study was to evaluate spatial and temporal trends of the AIDS epidemic among the elderly in the State of Rio de Janeiro, Brazil. A retrospective study using spatial analysis techniques was conducted among AIDS cases (≥ 60 years) diagnosed from 1997-2011. The Poisson regression model was used to assess the relationship between year of diagnosis and incidence of AIDS, adjusted by sex. The AIDS epidemic began in the south coast of the state and gradually reached neighboring cities. The highest rates were found in regions around Rio de Janeiro and Niterói cities. The highest smoothed rates of the period were observed in Niterói in 2002-2006: 11.87/100,000 (men) and 8,5/100,000 (women). AIDS incidence rates among the elderly have stabilized in recent decades. To prevent HIV from spreading further among the general population, greater attention should be given to the older population.

Burden of disease in Brazil and its regions, 2008.

The current study estimated DALY (disability-adjusted life years), an indicator of burden of disease, for Brazil in 2008. The North and Northeast regions showed higher burden of disease. Chronic noncommunicable diseases predominated in all regions of the country, especially cardiovascular diseases, mental disorders (particularly depression), diabetes, and chronic obstructive pulmonary disease. The study also showed a high burden of homicides and traffic accidents. Brazil's epidemiological profile appears even more complex when one considers the non-negligible burden of communicable diseases, maternal and perinatal conditions, and nutritional deficiencies. The analyses allowed a more detailed understanding of the Brazilian's population's health status, underscoring the need for crosscutting actions beyond specific health sector policies and greater attention to the quality of information on morbidity and mortality.

[Air pollution and mortality in the elderly in Rio de Janeiro: a time-series analysis]. / Poluição do ar e mortalidade em idosos no Município do Rio de Janeiro: análise de série temporal.

This study investigates the association between particulate air pollution and mortality from cardiovascular and respiratory diseases among the elderly in the city of Rio de Janeiro. Death counts, levels of total suspended particles (TSP), and meteorological data were obtained from secondary databases. Daily counts of deaths and daily TSP levels from 1990 to 1993 were analyzed in Poisson regression models adjusted for long-term temporal trends, seasonality, weekdays, temperature, and humidity. For an increase in TSP levels from the 10th to the 90th percentile (104.7 microg/m3), the relative risks for mortality in elderly people from cardiovascular and respiratory diseases were 1.04 (95%CI: 0.96-1.13) and 1.10 (95%CI: 0.97-1.26) respectively. Although an upward trend in risk was observed, the associations were not statistically significant, which could be explained partially by the small number of pollution measures available for the period analyzed.