The translation into Portuguese of the 11th International Statistical Classification of Diseases and Related Health Problems (ICD-11). / Tradução para a língua portuguesa da 11a Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde (CID-11).

The 11th International Statistical Classification of Diseases and Related Health Problems (ICD-11) represents an advance in the focus on knowledge and new disease approaches. The ICD is used for different practical purposes, enabling assessment of progress in the global health agenda, resource allocation, patient safety, health care qualification, and health insurance reimbursement. It is entirely digital, with technological resources that allow periodic updating. In early 2022, ICD-11 entered into official force, having been made available in several official ICD languages such as Arabic, Chinese, Spanish, French, and English. The translation process into Brazilian Portuguese, coordinated by the Federal University of Minas Gerais (UFMG), with support from the Brazilian Ministry of Health (MS) and PAHO/WHO, is presented here. The work was carried out in three stages between August 2021 and December 2022 by translators with different backgrounds: medical specialists (49), physiotherapists (1), pharmacologists (1), and dentists (1). This methodological article aims to broaden the discussion of perspectives on implementing the ICD-11 in Brazil and build an opportunity for its adaptation and use by other Portuguese-speaking countries.

A 11a Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde representa um avanço no enfoque do conhecimento e em novas abordagens das doenças. A Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde é utilizada para diferentes finalidades práticas, possibilitando avaliação do avanço da agenda de saúde global, alocação de recursos, segurança do paciente, qualificação da assistência à saúde e reembolso de seguros de saúde. É inteiramente digital, com recursos tecnológicos que permitem sua atualização periódica. No início de 2022, a 11a Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde entrou em vigência oficial, tendo sido disponibilizada em vários de seus idiomas oficiais, como o árabe, chinês, espanhol, francês e inglês. Apresenta-se aqui o processo de tradução para a língua portuguesa em uso no Brasil, coordenado pela Universidade Federal de Minas Gerais, com apoio do Ministério da Saúde do Brasil e da Organização Pan-Americana da Saúde/Organização Mundial da Saúde. O trabalho foi realizado em três etapas entre agosto de 2021 e dezembro de 2022 por tradutores com diferentes formações: médicos especialistas (49), fisioterapeuta (1), farmacologista (1) e odontologista (1). Com este artigo metodológico, almeja-se ampliar a discussão de perspectivas para implementação da 11a Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde no Brasil e construir uma oportunidade para sua adaptação e uso por outros países de língua oficial portuguesa.

Tradução para a língua portuguesa da 11a Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde (CID-11) / The translation into Portuguese of the 11th International Statistical Classification of Diseases and Related Health Problems (ICD-11)

RESUMO A 11a Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde representa um avanço no enfoque do conhecimento e em novas abordagens das doenças. A Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde é utilizada para diferentes finalidades práticas, possibilitando avaliação do avanço da agenda de saúde global, alocação de recursos, segurança do paciente, qualificação da assistência à saúde e reembolso de seguros de saúde. É inteiramente digital, com recursos tecnológicos que permitem sua atualização periódica. No início de 2022, a 11a Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde entrou em vigência oficial, tendo sido disponibilizada em vários de seus idiomas oficiais, como o árabe, chinês, espanhol, francês e inglês. Apresenta-se aqui o processo de tradução para a língua portuguesa em uso no Brasil, coordenado pela Universidade Federal de Minas Gerais, com apoio do Ministério da Saúde do Brasil e da Organização Pan-Americana da Saúde/Organização Mundial da Saúde. O trabalho foi realizado em três etapas entre agosto de 2021 e dezembro de 2022 por tradutores com diferentes formações: médicos especialistas (49), fisioterapeuta (1), farmacologista (1) e odontologista (1). Com este artigo metodológico, almeja-se ampliar a discussão de perspectivas para implementação da 11a Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde no Brasil e construir uma oportunidade para sua adaptação e uso por outros países de língua oficial portuguesa.

ABSTRACT The 11th International Statistical Classification of Diseases and Related Health Problems (ICD-11) represents an advance in the focus on knowledge and new disease approaches. The ICD is used for different practical purposes, enabling assessment of progress in the global health agenda, resource allocation, patient safety, health care qualification, and health insurance reimbursement. It is entirely digital, with technological resources that allow periodic updating. In early 2022, ICD-11 entered into official force, having been made available in several official ICD languages such as Arabic, Chinese, Spanish, French, and English. The translation process into Brazilian Portuguese, coordinated by the Federal University of Minas Gerais (UFMG), with support from the Brazilian Ministry of Health (MS) and PAHO/WHO, is presented here. The work was carried out in three stages between August 2021 and December 2022 by translators with different backgrounds: medical specialists (49), physiotherapists (1), pharmacologists (1), and dentists (1). This methodological article aims to broaden the discussion of perspectives on implementing the ICD-11 in Brazil and build an opportunity for its adaptation and use by other Portuguese-speaking countries.

Physical activity to prevent stroke mortality in Brazil (1990-2019).

INTRODUCTION: This study aimed to estimate the burden of stroke mortality due to low levels of physical activity (PA) in Brazil from 1990 to 2019. METHODS: Data from the 2019 Global Burden of Disease (GBD) study for Brazil and Brazilian states were used. We used the number of deaths, age-standardized mortality rates, summary exposure value, and fraction of population risk attributable to low levels of PA. To standardize all estimates, data from the population aged 25 years or older were considered. RESULTS: The risk of exposure to low PA, SEV values, for the Brazilian male population was 11.8% (95%UI: 6.7; 19.9) and for the Brazilian female population was 13.2% (95%UI: 8.6; 19.2) in 2019. For males, it was estimated that there were, respectively, 2,025 (95%UI: 271; 4,839) and 3,595 (95%UI: 658; 7,302) deaths in 1990 and 2019 due to stroke attributable to low PA. For females, there were 2,518 (95%UI: 498; 5,006) and 4,735 (95%UI: 1,286; 8,495) deaths in 1990 and 2019 due to stroke attributable to low PA, respectively. From 1990 to 2019, reductions of 44.0% for males (95%UI: -0.54; -0.05) and 52.0% for females (95%UI: -0.60; -0.30) in age-standardized mortality rates due to stroke attributed to low PA were observed. Approximately 6.1% (for males) and 7.3% (for females) of deaths in 2019 due to stroke could be avoided if the Brazilian population were physically active. CONCLUSIONS: These findings support the promotion of PA in all Brazilian states for preventing early mortality due to stroke.

Excess Mortality due to natural causes among whites and blacks during the COVID-19 pandemic in Brazil.

INTRODUCTION: Excess Mortality by all causes considers deaths directly related to COVID-19 and those attributed to conditions caused by the pandemic. When stratified by social dimensions, such as race/color, it allows for the evaluation of more vulnerable populations. The study estimated the excess mortality by natural causes, separating the white and black populations in 2020. METHODS: Public civil registration data on deaths observed in 2020, corrected for under registration, were used. The expected number of deaths was estimated based on the mortality rates observed in 2019, applied to the estimated population in 2020. The difference between the values expected and observed and the proportion of excess was considered the excess mortality. RESULTS: The present study found an excess of 270,321 deaths (22.2% above the expected) in 2020. Every state of Brazil reported deaths above the corresponding expected figure. The excess was higher for men (25.2%) than for women (19.0%). Blacks showed an excess of 27.8%, as compared to whites at 17.6%. In both sexes and all age groups, excess was higher in the black population, especially in the South, Southeast, and Midwest regions. São Paulo, the largest in population number, had twice as much excess death in the black population (25.1%) than in the white population (11.5%). CONCLUSIONS: The present study showed racial disparities in excess mortality during the COVID-19 pandemic in Brazil. The higher excess found for the black suggests an intrinsic relationship with the socioeconomic situation, further exposing the Brazilian reality, in which social and structural inequality is evident.

Mortality and years of life lost to death or disability by interpersonal violence against women in Brazil: Global Burden of Disease Study, 1990 and 2019.

INTRODUCTION: Aggression against women is an important cause of morbidity and death. This study compares the variation of deaths and years of life lost to death or disability (DALY) caused by interpersonal violence against women in Brazil and its states. METHODS: This descriptive study analyzed estimates from the Global Burden of Disease Study (GBD) referring to interpersonal violence against women, aged 15 to 49 years, examining the mortality and DALY rates for Brazil and its states, in 1990 and 2019. RESULTS: In this study, 3,168 deaths of women between 15 and 49 years of age, caused by interpersonal violence, were estimated in 1990, and 4,262 in 2019, which represents an increase of 33.8%. Regardless of the Maria da Penha Law and the progress in policies for curbing violence against women, one can observe a stability in the mortality and DALY rates in most of the Brazilian states. Only Bahia had a significant increase in those rates, while Federal District, Rio de Janeiro, and São Paulo showed a significant decline. CONCLUSIONS: The rates of female homicide have remained stable when comparing 1990 and 2019. Although there were improvements in terms of women's rights in the early 2000's, the chauvinist and conservative society of Brazil has not been able to protect women, and the country might not reach the targets established by the UN's 2030 Agenda.

Measuring misclassification of Covid-19 as garbage codes: Results of investigating 1,365 deaths and implications for vital statistics in Brazil.

The purpose of this article is to quantify the amount of misclassification of the Coronavirus Disease-2019 (COVID-19) mortality occurring in hospitals and other health facilities in selected cities in Brazil, discuss potential factors contributing to this misclassification, and consider the implications for vital statistics. Hospital deaths assigned to causes classified as garbage code (GC) COVID-related cases (severe acute respiratory syndrome, pneumonia unspecified, sepsis, respiratory failure and ill-defined causes) were selected in three Brazilian state capitals. Data from medical charts and forensic reports were extracted from standard forms and analyzed by study physicians who re-assigned the underlying cause based on standardized criteria. Descriptive statistical analysis was performed and the potential impact in vital statistics in the country was also evaluated. Among 1,365 investigated deaths due to GC-COVID-related causes, COVID-19 was detected in 17.3% in the age group 0-59 years and 25.5% deaths in 60 years and over. These GCs rose substantially in 2020 in the country and were responsible for 211,611 registered deaths. Applying observed proportions by age, location and specific GC-COVID-related cause to national data, there would be an increase of 37,163 cases in the total of COVID-19 deaths, higher in the elderly. In conclusion, important undercount of deaths from COVID-19 among GC-COVID-related causes was detected in three selected capitals of Brazil. After extrapolating the study results for national GC-COVID-related deaths we infer that the burden of COVID-19 disease in Brazil in official vital statistics was probably under estimated by at least 18% in the country in 2020.

Physical activity to prevent stroke mortality in Brazil (1990-2019)

Abstract INTRODUCTION: This study aimed to estimate the burden of stroke mortality due to low levels of physical activity (PA) in Brazil from 1990 to 2019. METHODS: Data from the 2019 Global Burden of Disease (GBD) study for Brazil and Brazilian states were used. We used the number of deaths, age-standardized mortality rates, summary exposure value, and fraction of population risk attributable to low levels of PA. To standardize all estimates, data from the population aged 25 years or older were considered. RESULTS: The risk of exposure to low PA, SEV values, for the Brazilian male population was 11.8% (95%UI: 6.7; 19.9) and for the Brazilian female population was 13.2% (95%UI: 8.6; 19.2) in 2019. For males, it was estimated that there were, respectively, 2,025 (95%UI: 271; 4,839) and 3,595 (95%UI: 658; 7,302) deaths in 1990 and 2019 due to stroke attributable to low PA. For females, there were 2,518 (95%UI: 498; 5,006) and 4,735 (95%UI: 1,286; 8,495) deaths in 1990 and 2019 due to stroke attributable to low PA, respectively. From 1990 to 2019, reductions of 44.0% for males (95%UI: −0.54; -0.05) and 52.0% for females (95%UI: −0.60; -0.30) in age-standardized mortality rates due to stroke attributed to low PA were observed. Approximately 6.1% (for males) and 7.3% (for females) of deaths in 2019 due to stroke could be avoided if the Brazilian population were physically active. CONCLUSIONS: These findings support the promotion of PA in all Brazilian states for preventing early mortality due to stroke.

Excess Mortality due to natural causes among whites and blacks during the COVID-19 pandemic in Brazil

Abstract INTRODUCTION: Excess Mortality by all causes considers deaths directly related to COVID-19 and those attributed to conditions caused by the pandemic. When stratified by social dimensions, such as race/color, it allows for the evaluation of more vulnerable populations. The study estimated the excess mortality by natural causes, separating the white and black populations in 2020. METHODS Public civil registration data on deaths observed in 2020, corrected for under registration, were used. The expected number of deaths was estimated based on the mortality rates observed in 2019, applied to the estimated population in 2020. The difference between the values expected and observed and the proportion of excess was considered the excess mortality. RESULTS: The present study found an excess of 270,321 deaths (22.2% above the expected) in 2020. Every state of Brazil reported deaths above the corresponding expected figure. The excess was higher for men (25.2%) than for women (19.0%). Blacks showed an excess of 27.8%, as compared to whites at 17.6%. In both sexes and all age groups, excess was higher in the black population, especially in the South, Southeast, and Midwest regions. São Paulo, the largest in population number, had twice as much excess death in the black population (25.1%) than in the white population (11.5%). CONCLUSIONS: The present study showed racial disparities in excess mortality during the COVID-19 pandemic in Brazil. The higher excess found for the black suggests an intrinsic relationship with the socioeconomic situation, further exposing the Brazilian reality, in which social and structural inequality is evident.

Mortality and years of life lost to death or disability by interpersonal violence against women in Brazil: Global Burden of Disease Study, 1990 and 2019

Abstract INTRODUCTION Aggression against women is an important cause of morbidity and death. This study compares the variation of deaths and years of life lost to death or disability (DALY) caused by interpersonal violence against women in Brazil and its states. METHODS This descriptive study analyzed estimates from the Global Burden of Disease Study (GBD) referring to interpersonal violence against women, aged 15 to 49 years, examining the mortality and DALY rates for Brazil and its states, in 1990 and 2019. RESULTS In this study, 3,168 deaths of women between 15 and 49 years of age, caused by interpersonal violence, were estimated in 1990, and 4,262 in 2019, which represents an increase of 33.8%. Regardless of the Maria da Penha Law and the progress in policies for curbing violence against women, one can observe a stability in the mortality and DALY rates in most of the Brazilian states. Only Bahia had a significant increase in those rates, while Federal District, Rio de Janeiro, and São Paulo showed a significant decline. CONCLUSIONS The rates of female homicide have remained stable when comparing 1990 and 2019. Although there were improvements in terms of women's rights in the early 2000's, the chauvinist and conservative society of Brazil has not been able to protect women, and the country might not reach the targets established by the UN's 2030 Agenda.

The COVID-19 Pandemic: Effects on Civil Registration of Births and Deaths and on Availability and Utility of Vital Events Data.

The complex and evolving picture of COVID-19-related mortality highlights the need for data to guide the response. Yet many countries are struggling to maintain their data systems, including the civil registration system, which is the foundation for detailed and continuously available mortality statistics. We conducted a search of country and development agency Web sites and partner and media reports describing disruptions to the civil registration of births and deaths associated with COVID-19 related restrictions.We found considerable intercountry variation and grouped countries according to the level of disruption to birth and particularly death registration. Only a minority of the 66 countries were able to maintain service continuity during the COVID-19 restrictions. In the majority, a combination of legal and operational challenges resulted in declines in birth and death registration. Few countries established business continuity plans or developed strategies to deal with the backlog when restrictions are lifted.Civil registration systems and the vital statistics they generate must be strengthened as essential services during health emergencies and as core components of the response to COVID-19.

Methodological proposal for the redistribution of deaths due to garbage codes in mortality estimates for Noncommunicable Chronic Diseases.

OBJECTIVE: To propose a method for improving mortality estimates from noncommunicable diseases (NCD), including the redistribution of garbage codes in Brazilian municipalities. METHODS: Brazilian Mortality Information System (MIS) was used as a data source to estimate age standardized mortality rates, before and after correction, for NCD (cardiovascular, chronic respiratory, diabetes, and neoplasms). The treatment for the correction of data addressed missing data, under-registration, and redistribution of garbage codes (GCs). Three-year periods 2010-2012 and 2015-2017, and the Bayesian method were used to estimate mortality rates, reducing the effect of fluctuation caused by small numbers at the municipal level. RESULTS: GCs redistribution step showed greater weight in corrections, about 40% in 2000 and roughly 20% as from 2007, with stabilization starting in this year. Throughout the historical series, the quality of information on causes of death has improved in Brazil, with heterogeneous results being observed among municipalities. CONCLUSION: Methodological studies that propose correction and improvement of the MIS are essential for monitoring mortality rates due to NCD at regional levels. The methodological proposal applied, for the first time in real data from Brazilian municipalities, is challenging and deserves further improvements. Improving the quality of the data is essential in order to build more accurate estimates based on the raw data from the SIM.

Methodological proposal for the redistribution of deaths due to garbage codes in mortality estimates for Noncommunicable Chronic Diseases / Proposta metodológica para redistribuição de óbitos por causas garbage nas estimativas de mortalidade para doenças crônicas não transmissíveis

ABSTRACT: Objective: To propose a method for improving mortality estimates from noncommunicable diseases (NCD), including the redistribution of garbage codes in Brazilian municipalities. Methods: Brazilian Mortality Information System (MIS) was used as a data source to estimate age standardized mortality rates, before and after correction, for NCD (cardiovascular, chronic respiratory, diabetes, and neoplasms). The treatment for the correction of data addressed missing data, under-registration, and redistribution of garbage codes (GCs). Three-year periods 2010-2012 and 2015-2017, and the Bayesian method were used to estimate mortality rates, reducing the effect of fluctuation caused by small numbers at the municipal level. Results: GCs redistribution step showed greater weight in corrections, about 40% in 2000 and roughly 20% as from 2007, with stabilization starting in this year. Throughout the historical series, the quality of information on causes of death has improved in Brazil, with heterogeneous results being observed among municipalities. Conclusion: Methodological studies that propose correction and improvement of the MIS are essential for monitoring mortality rates due to NCD at regional levels. The methodological proposal applied, for the first time in real data from Brazilian municipalities, is challenging and deserves further improvements. Improving the quality of the data is essential in order to build more accurate estimates based on the raw data from the SIM.

RESUMO: Objetivo: Propor método para melhoria das estimativas de mortalidade por doenças crônicas não transmissíveis, incluindo a redistribuição de causas garbage nos municípios brasileiros. Métodos: O Sistema de Informações sobre Mortalidade foi utilizado como fonte de dados para estimar as taxas padronizadas por idade, antes e depois da correção de dados, para as doenças crônicas não transmissíveis (cardiovasculares, respiratórias crônicas, diabetes e neoplasias). O tratamento para correção dos dados abordou dados faltantes, sub-registro e redistribuição de causas garbage. Foram utilizados os triênios 2010-2012 e 2015-2017 e o método bayesiano para estimar as taxas de mortalidade, diminuindo-se o efeito da flutuação provocada pelos pequenos números no nível municipal. Resultados: A etapa de redistribuição causas garbage mostrou maior peso nas correções: cerca de 40% em 2000 e aproximadamente 20% a partir de 2007, com estabilização neste ano. Ao longo da série histórica, a qualidade da informação sobre causas de morte melhorou no Brasil, sendo vistos resultados heterogêneos nos municípios. Observaram-se clusters com as maiores proporções de correção nas regiões Nordeste e Norte. O diabetes foi a causa com maior proporção de acréscimo (mais de 40%, em 2000). Conclusão: Estudos metodológicos que propõem correção e melhoria do Sistema de Informação sobre Mortalidade são essenciais para o monitoramento das taxas de mortalidade por doenças crônicas não transmissíveis em níveis regionais. A proposta metodológica aplicada, pela primeira vez em dados reais de municípios brasileiros, é desafiadora e merece aprimoramentos. Apesar da melhora nos dados, o método utilizado neste estudo para tratamento dos dados brutos mostrou grande impacto nas estimativas finais.

Physical inactivity as a risk factor for all-cause mortality in Brazil (1990-2017).

BACKGROUND: The aim of this study was to estimate the mortality from all causes as a result of physical inactivity in Brazil and in Brazilian states over 28 years (1990-2017). METHODS: Data from the Global Burden of Disease (GBD) study for Brazil and states were used. The metrics used were the summary exposure value (SEV), the number of deaths, age-standardized mortality rates, and the fraction of population risk attributable to physical inactivity. RESULTS: The Brazilian population presented risk of exposure to physical inactivity of (age-standardized SEV) of 59% (95% U.I. 22-97) in 1990 and 59% in 2017 (95% U.I. 25-99). Physical inactivity contributed a significant number of deaths (1990, 22,537, 95% U.I. 12,157-34,745; 2017, 32,410, 95% U.I. 17,976-49,657) in the analyzed period. These values represented mortality rates standardized by age (per 100,000 inhabitants) of 31 (95% U.I. 17-48) in 1990 and 15 (95% U.I. 8-23) in 2017. From 1990 to 2017, a decrease in standardized death rate from all causes attributable to physical inactivity was observed in Brazil (- 52%, 95% U.I. - 54 to - 49). The Brazilian states with better socioeconomic conditions presented greater reductions in age-standardized mortality (male: rho = 0.80; female: rho 0.84) over the period of 28 years. CONCLUSIONS: These findings support the promotion of physical activity in the Brazilian population for the prevention of early mortality.

Changes in the quality of cause-of-death statistics in Brazil: garbage codes among registered deaths in 1996-2016.

BACKGROUND: Registered causes in vital statistics classified as garbage codes (GC) are considered indicators of quality of cause-of-death data. Our aim was to describe temporal changes in this quality in Brazil, and the leading GCs according to levels assembled for the Global Burden of Disease (GBD) study. We also assessed socioeconomic differences in the burden of different levels of GCs at a regional level. METHODS: We extracted data from the Brazilian Mortality Information System from 1996 to 2016. All three- and four-digit ICD-10 codes considered GC were selected and classified into four categories, according to the GBD study proposal. GC levels 1 and 2 are the most damaging unusable codes, or major GCs. Proportionate distribution of deaths by GC levels according selected variables were performed. Age-standardized mortality rates after correction of underreporting of deaths were calculated to investigate temporal relationships as was the linear association adjusted for completeness between GC rates in states and the Sociodemographic Index (SDI) from the GBD study, for 1996-2005 and 2006-2016. We classified Brazilian states into three classes of development by applying tertiles cutoffs in the SDI state-level estimates. RESULTS: Age-standardized mortality rates due to GCs in Brazil decreased from 1996 to 2016, particularly level 1 GCs. The most important GC groups were ill-defined causes (level 1) in 1996, and pneumonia unspecified (level 4) in 2016. At state level, there was a significant inverse association between SDI and the rate of level 1-2 GCs in 1996-2005, but both SDI and completeness had a non-expected significant direct association with levels 3-4. In 2006-2016, states with higher SDIs tended to have lower rates of all types of GCs. Mortality rates due to major GCs decreased in all three SDI classes in 1996-2016, but GC levels 3-4 decreased only in the high SDI category. States classified in the low or medium SDI groups were responsible for the most important decline of major GCs. CONCLUSION: Occurrence of major GCs are associated with socioeconomic determinants over time in Brazil. Their reduction with decreasing disparity in rates between socioeconomic groups indicates progress in reducing inequalities and strengthening cause-of-death statistics in the country.

Mapping disparities in homicide trends across Brazil: 2000-2014.

BACKGROUND: Homicides are a major problem in Brazil. Drugs and arms trafficking, and land conflicts are three of the many factors driving homicide rates in Brazil. Understanding long-term spatiotemporal trends and social structural factors associated with homicides in Brazil would be useful for designing policies aimed at reducing homicide rates. METHODS: We obtained data from 2000 to 2014 from the Brazil Ministry of Health (MOH) Mortality Information System and sociodemographic data from the Brazil Institute of Geography and Statistics (IBGE). First, we quantified the rate of change in homicides at the municipality and state levels. Second, we used principal component regression and k-medoids clustering to examine differences in temporal trends across municipalities. Lastly, we used Bayesian hierarchical space-time models to describe spatio-temporal patterns and to assess the contribution of structural factors. RESULTS: There were significant variations in homicide rates across states and municipalities. We noted the largest decrease in homicide rates in the western and southeastern states of Sao Paulo, Rio de Janeiro and Espirito Santo, which coincided with an increase in homicide rates in the northeastern states of Ceará, Alagoas, Paraiba, Rio Grande Norte, Sergipe and Bahia during the fifteen-year period. The decrease in homicides in municipalities with populations of at least 250,000 coincided with an increase in municipalities with 25,000 people or less. Structural factors that predicted municipality-level homicide rates included crude domestic product, urbanization, border with neighboring countries and proportion of population aged fifteen to twenty-nine. CONCLUSIONS: Our findings support both a dissemination hypothesis and an interiorization hypothesis. These findings should be considered when designing interventions to curb homicide rates.

The importance of surveillance in cases of and mortality from the COVID-19 epidemic in Belo Horizonte, Brazil, 2020. / A importância da vigilância de casos e óbitos e a epidemia da COVID-19 em Belo Horizonte, 2020.

OBJECTIVES: This study aims to describe the actions carried out by the epidemiological surveillance system in Belo Horizonte to address the COVID-19 epidemic and the timeless of the data for detecting transmission in 2020. METHODS: The sources of information used by the epidemiological surveillance of the municipality for COVID-19 were identified and the temporal distribution and interval for detection of confirmed cases of the disease were analyzed. RESULTS: The city's epidemiological surveillance uses outpatient, hospital, public and private laboratory notifications as data sources. For reporting COVID-19 cases in official information systems, there is also an active search of laboratory results linked to suspected deaths investigated. From January to April 2020, 1,449 hospitalized cases of COVID-19 were reported, the first case being detected in late February 2020. Of the total 1,025 laboratory samples of cases hospitalized after the 8th epidemiological week, 87 (8.5%) of COVID-19 cases were confirmed. The median time between the onset of symptoms and the release of laboratory results was 12 days for the analyzed period. CONCLUSION: Epidemiological surveillance uses several data sources to monitor and analyze the transmission of COVID-19. The timeliness of this system to detect cases of the disease is compromised by the delay in the release of laboratory results, which has been a considerable challenge for adequate surveillance.