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.

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.

[Does the inverse theory hypothesis apply to primary health care? Evidence from 5 564 Brazilian municipalities¿Se aplica la hipótesis de la equidad inversa a la atención primaria de salud? Pruebas obtenidas en 5 564 municipios brasileños]. / A teoria da equidade reversa se aplica na atenção primária à saúde? Evidências de 5 564 municípios brasileiros.

OBJECTIVE: To investigate the evolution of primary health care (PHC) coverage in Brazilian municipalities from 2007 to 2016 from the perspective of the inverse theory hypothesis. METHOD: This ecological study was performed with data from 5 564 Brazilian municipalities. Data were obtained from the Brazilian Institute of Geography and Statistics (IBGE) and from the Unified Health System database (DATASUS). The municipalities were classified according to their social development status using selected cluster indicators. After classification of the municipalities, PHC was analyzed by determining Family health Strategy (FHS) coverage through means and interquartile distance, with analysis of time series and correlations between variables. RESULTS: Two groups of municipalities were detected: a group with more favorable (n = 3 293) and a group with less favorable conditions (n = 2 271). The difference between the groups for all indicators was statistically significant (P < 0.001). In general, regardless of the group, an increase in FHS coverage was detected along the study period. However, from 2009 on, mean FHS coverage became higher in the group with less favorable conditions. The increase in coverage was also faster in this group. Finally, a change in the correlation between indicators and PHC coverage in the first vs. last year of the historical series indicates that the criteria used to expand coverage in the group with less favorable conditions shifted to favor absolute poverty rather than inequality. CONCLUSIONS: PHC in Brazil fulfills its role of reducing access inequalities. Therefore, the inverse theory hypothesis does not apply to this case.

OBJETIVO: Investigar la evolución de la cobertura de la atención primaria de salud en los municipios brasileños desde el 2007 hasta el 2016 en el contexto de la hipótesis de la equidad inversa. MÉTODOS: Estudio ecológico realizado con datos de 5 564 municipios brasileños, obtenidos a partir del censo del 2010 y de la base de datos del Sistema Ünico de Salud (DATASUS). Los municipios se clasificaron según su grado de desarrollo con un análisis por conglomerados, a partir de algunos indicadores sociales seleccionados. Se examinó la cobertura con la estrategia de salud de la familia en los grupos creados sobre la base de la mediana y del rango intercuartílico, con análisis de series temporales y correlación entre variables. RESULTADOS: Se crearon dos grupos de municipios con condiciones más favorables (n = 3 293) o menos favorables (n = 2 271). Se observó una diferencia significativa (P < 0,001) entre los grupos en todos los indicadores evaluados. En general, independientemente del grupo, aumentó la cobertura con la estrategia de salud de la familia a lo largo del período de estudio. Sin embargo, a partir del 2009, la tasa mediana de cobertura con dicha estrategia se incrementó en el grupo con condiciones menos favorables. El aumento de la cobertura también fue más acelerado en ese grupo. Finalmente, un cambio de la correlación entre los indicadores y la cobertura de la atención primaria de salud en el primero y el último año de la serie histórica indica que los criterios utilizados para la ampliación de la cobertura en el grupo con condiciones menos favorables asignaron valor a la pobreza absoluta, pero no a la inequidad. CONCLUSIONES: La atención primaria de salud en Brasil cumple su función como política de reducción de la desigualdad en el acceso. Por lo tanto, la hipótesis de la equidad inversa no se aplica en este caso.

[Analysis of age-period-cohort effect on breast cancer mortality in Brazil and regions]. / Análise de efeito idade-período-coorte na mortalidade por câncer de mama no Brasil e regiões.

OBJECTIVE: To estimate the effect of age, period and birth cohort on mortality from breast cancer in Brazil and regions. METHODS: Data on mortality from breast cancer were analyzed for women aged > 30 years in Brazil and regions from 1980 to 2009. The effect of age, period, and birth cohort was calculated by Poisson regression model using estimable functions: deviations, curvatures and drift through the Epi library of R statistical software version 3.2.1. RESULTS: The mean mortality rate for the period was 22.3 per 100 000 women in Brazil. The highest rate was 32.4 deaths per 100 000 women in the South, and the lowest, 8.6 deaths per 100 000 women in the North. The analysis of birth cohorts showed a progressive increase in the risk of death in women born after the 1930s, except in the Southeast, where a decrease in relative risk was noted for this group. CONCLUSIONS: The analyses revealed a reduction in the risk of death from breast cancer in Brazil and in most regions for birth cohorts starting in the 1930s, and an increased in the risk of death starting in the 1990s until the period from 2000 to 2005.

[Regional differences in cardiovascular mortality transition in Brazil, 1980 to 2012]. / Diferenças regionais na transição da mortalidade por doenças cardiovasculares no Brasil, 1980 a 2012.

OBJECTIVE: To estimate the time trend of cardiovascular mortality from 1980 to 2012. METHODS: We performed an ecological time series study of cardiovascular mortality in Brazil. Data regarding deaths were obtained from the Mortality Information System and divided into two groups: deaths from ischemic heart disease (IHD) and deaths from cerebrovascular disorders (CBVD). RESULTS: A -34.73% variation in IHD standardized mortality rates was recorded for Brazil. Concerning specific regions, an increase was observed in the Northeast (117.98%%) and the Midwest (10.26%). IHD mortality rates fell in the Southeast (-53.08%), South (-44.56%) and North (-4.39%). For CBVD, the overall variation was -48.10%. Mortality rates were reduced in most regions: -61.99% in the Southeast, -55.49% in the South, -26.91% in the Midwest, and -20.78% in the North. Only the Northeast recorded an increase in CBVD mortality (13.77%). CONCLUSIONS: We observed an overall declining trend for IHD and CBVD mortality in Brazil from 1980 to 2012, with strong regional variation. Mortality rates were highest in the Southeast and South for both groups of disorders, and lowest in the North and Northeast. Surveillance efforts should take into account the regional differences in epidemiological profile.

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.

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.

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.

Factors associated with time-to-treatment initiation of breast cancer. / Fatores associados ao tempo para submissão ao primeiro tratamento do câncer de mama.

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.

Este estudo retrospectivo investigou fatores associados ao tempo para submissão ao primeiro tratamento do câncer de mama entre 12.100 casos assistidos em estabelecimentos de saúde habilitados para a alta complexidade em oncologia no âmbito do SUS localizados no Rio de Janeiro entre 2013 e 2019. Regressão logística multivariada estimou razões de chances e intervalos de 95% de confiança. Foram submetidos ao primeiro tratamento em tempo >60 dias 82,1% dos casos. Entre aqueles sem histórico de diagnóstico anterior, alta escolaridade e estadiamento III e IV exibiram menor probabilidade de submissão ao primeiro tratamento em tempo >60 dias, enquanto tratamento em estabelecimento de saúde não localizado na capital exibiu probabilidade maior. Entre aqueles com histórico de diagnóstico anterior, idade ≥50 anos, raça/cor da pele não branca e estadiamento I exibiram maior probabilidade de submissão ao primeiro tratamento em tempo >60 dias, enquanto alta escolaridade, tratamento em estabelecimento de saúde não localizado na capital e estadiamento IV exibiram probabilidade menor. Em suma, fatores sociodemográficos, clínicos e relacionados ao estabelecimento de saúde estão associados ao tempo para submissão ao primeiro tratamento do câncer de mama.

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.

Covid-19 Fiocruz Observatory - an analysis of the evolution of the pandemic from February 2020 to April 2022. / Observatório Covid-19 Fiocruz - uma análise da evolução da pandemia de fevereiro de 2020 a abril de 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.

A pandemia de COVID-19 teve um imenso impacto nas condições de vida e trabalho de toda a população do país, impactando de modo diferenciado e mais intenso os grupos considerados vulneráveis. O objetivo deste artigo é apresentar um panorama da evolução da pandemia no país segundo os boletins do Observatório Covid-19 Fiocruz, no período entre as declarações de início e de encerramento da Emergência em Saúde Pública de Importância Nacional (ESPIN), fevereiro de 2020 a abril de 2022. Foram utilizados diversos dos indicadores adotados nos 69 boletins publicados para a análise da pandemia, como casos e óbitos por SRAGs e COVID-19, grupos etários, taxas de ocupação de leitos UTI e vacinação, entre outros. A análise da evolução foi organizada entre anos e fases da pandemia, procurando destacar o que caracterizou cada momento. A declaração de encerramento da ESPIN no Brasil coincide com as discussões acerca da transição de pandemia para a endemia, sem que isso represente a eliminação do vírus, das infecções e da doença, colocando-se os desafios de avanços nos processos de vacinação no Brasil e no mundo e da convivência com cenários que poderão exigir a adoção de medidas de proteção temporárias em períodos epidêmicos e de maior risco para grupos vulneráveis.

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.

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.

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.

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

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.

[Prevalence and factors associated to advanced stage breast cancer diagnosis]. / Prevalência e fatores associados ao diagnóstico de câncer de mama em estágio avançado.

This cross-sectional study investigated the prevalence and factors associated with advanced stage breast cancer diagnosis among 18,890 women assisted in a specialized hospital in the capital of Rio de Janeiro, Brazil, from 1999 to 2016. We used Poisson regression with robust variance to estimate prevalence ratios and respective 95% confidence intervals. The highest prevalence of diagnosis in this condition was in women aged 20-39 and 40-49 years, black and brown, living without a partner, from other cities of the state of Rio de Janeiro, who were referred by the Unified Health System and diagnosed in the 1999-2004 and 2005-2010 six-year periods. On the other hand, women aged 60-69 and 70-99 years, with some schooling level, with a family history of cancer and who arrived at the hospital with diagnosis and without treatment had lower prevalence of advanced stage breast cancer diagnosis. These results can be considered when planning secondary prevention actions to anticipate and, thus, collaborate to reduce the prevalence the breast cancer diagnosis in the most vulnerable groups.

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.

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.

Simpson's paradox: a demographic case study of population dynamics, poverty, and inequality. / O paradoxo de Simpson: um estudo de caso demográfico sobre dinâmica da população, pobreza e desigualdade.

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.

O Brasil experimenta uma transição demográfica marcada por desigualdades regionais. É possível supor que aspectos relacionados à pobreza, desenvolvimento e desigualdade possam reverter os efeitos de associação dos indicadores da transição demográfica, tipificando um fenômeno conhecido como Paradoxo de Simpson. O objetivo foi analisar o efeito da desigualdade, pobreza e desenvolvimento social na dinâmica populacional brasileira, verificando a ocorrência do paradoxo de Simpson na transição demográfica. Foram utilizados dados populacionais oriundos dos Censos Demográficos brasileiros de 1991 a 2010, segundo idade e unidades da federação. Foi avaliada a correlação entre os indicadores demográficos, estratificando das unidades da federação em grupos de acordo com os indicadores sociais. Há um avanço das unidades federativas (UF) com relação aos indicadores sociais. A transição vem ocorrendo em todas as UF, com persistência da distância entre elas, mesmo que com redução ao longo dos anos. Observou-se o paradoxo de Simpson quando a análise foi realizada segundo ano censitário e indicador social, principalmente para o ano de 1991. O principal desafio é compreender como a dinâmica demográfica brasileira pode ser analisada e compreender de que forma os fatores contextuais alteram seu ritmo, quantum e padrão.

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.

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.