Use of verbal autopsy in a national health information system: Effects of the investigation of ill-defined causes of death on proportional mortality due to injury in small municipalities in Brazil.

BACKGROUND: The Mortality Information System (MIS) in Brazil records mortality data in hospitals and civil registries with the responsibility of compiling underlying cause of death. Despite continuous improvements in the MIS, some areas still maintain a high proportion of deaths assigned to ill-defined causes. Deaths coded to this category have most likely been considered as miscoded deaths from communicable and noncommunicable diseases. However, some local studies have provided evidence of underreporting of injury in Brazil. The aim of this study was to investigate ill-defined causes of death using the verbal autopsy (VA) method to estimate injury-specific mortality fraction in small municipalities in northeastern Minas Gerais, Brazil. METHODS: A sample size of reported death certificates with ill-defined conditions in a random sample of 10 municipalities was obtained, and then trained interviewers questioned family members using a standardized VA questionnaire to elicit information on symptoms experienced by the deceased before death. All attempts were made to collect existing information about the disease or death using health facilities records. Probable causes of death were assigned by a physician after review of the completed questionnaires following rules of the 10th revision of the International Classification of Diseases (ICD-10). RESULTS: Of 202 eligible ill-defined deaths, 151 were investigated using the VA methodology, and 12.6% had injury as the underlying cause of death. The proportional mortality fraction from injury among all causes of death increases from 4.4% to 8.2% after investigation. Different specific injury category causes were observed between recorded injury causes and those detected by VA. Drowning was the top specific injury cause detected after investigation. CONCLUSIONS: This study provides evidence that the use of VA in the investigation of registered ill-defined conditions in an existing MIS can furnish information on the relevance of injury as a priority health problem in small municipalities of Minas Gerais. Local research with VA should be brought to the attention of regional health policymakers to improve the quality of data for their planning.

A potential syndemic effect associated with symptoms of depression among men who have sex with men

Introduction: Globally, depression rates are high among men who have sex with men (MSM). Multiple factors may interact synergistically to increase this risk. This analysis assessed the prevalence of symptoms of depression among MSM in Brazil and synergistic effects of several factors. Methods: Cross-sectional study conducted in 12 cities using respondent-driven sampling. Sociodemographic and behavioral characteristics were collected. The PHQ-9 was used to screen for depression. Having moderate-severe depressive symptoms was compared to none-mild using logistic regression. The syndemic factor was a composite of hazardous alcohol use, sexual violence, and discrimination due to sexual orientation. Those with one to three of these factors were compared to those with none. Results: The weighted prevalence of moderate-severe depressive symptoms was 24.9% (95%CI = 21.8-28.8) and 16.2%, 22.9%, 46.0% and 51.0% when none, one, two, or three syndemic factors were present, respectively, indicating a dose-response effect. Perception of HIV risk, high level of HIV knowledge, known HIV infection, and health self-rated as poor or very poor were also associated with depressive symptoms. Conclusion: The prevalence of moderate-severe depressive symptoms among MSM in Brazil is high, and selected factors act synergistically in increasing their prevalence. Public health policies should consider holistic depression prevention and treatment interventions for this population.

Interrupçäo do acompanhamento clínico ambulatorial de pacientes infectados pelo HIV / The interruption of outpatient clinical care of HIV-infected patients

OBJETIVO: Determinar os fatores associados à interrupçäo do acompanhamento clínico ambulatorial de pacientes com infecçäo pelo HIV. MÉTODOS: Foi realizado um estudo do tipo prospectivo näo-concorrente (coorte histórica) no município de Belo Horizonte, MG, em um ambulatório público de referência para atendimento de pacientes com infecçäo pelo HIV/Aids. Foram revisados registros médicos para se avaliar os fatores associados à interrupçäo do acompanhamento clínico por pacientes soropositivos para o HIV admitidos no serviço entre 1993 e 1995. Os pacientes deveriam ter comparecido a pelo menos uma consulta de retorno no prazo de sete meses. A análise estatística incluiu c2 e Relative Hazard - RH com intervalo de 95 por cento de confiança (IC) estimado pelo Modelo de Regressäo de Cox. RESULTADOS: A incidência acumulada da interrupçäo do acompanhamento clínico foi de 54,3 por cento entre os 517 pacientes incluídos no estudo (tempo médio de acompanhamento =24,6 meses; incidência pessoa tempo =26,5/100 pessoas-ano). A análise multivariada mostrou que realizar menos que duas contagens de linfócitos T CD4+ (RH =1.94; IC 95 por cento =1.32-2.84) näo realizar medida de carga viral (RH =14.94; IC 95 por cento =5.44-41.04), comparecer a seis retornos ou menos (RH =2.80; IC 95 por cento =1.89-4.14), näo mudar de categoria clínica (RH =1.40; IC 95 por cento =1.00-1.93) e näo usar anti-retroviral, (RH =1.43; IC 95 por cento =1.06-1.93) estava associado a um maior risco de interromper o acompanhamento clínico no serviço estudado. CONCLUSOES: Foi alta a taxa de interrupçäo do acompanhamento clínico aos pacientes estudados, sugerindo que a interrupçäo do acompanhamento pode ser uma funçäo que vise a priorizar os pacientes com pior situaçäo clínica, podendo ser um marcador de futura aderência ao uso de anti-retroviral