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Insufficient quality of the underlying cause of death in the Brazilian Mortality Information System (SIM), acronym in Portuguese underlists violence and it is necessary to redistribute garbage causes (GC) into valid causes in public health prevention. This study estimated mortality from external causes using the GC redistribution method (GBD-Brazil) and compared it with SIM and estimated data from the GBD-IHME study from 2010 to 2019 in Brazil and its states. The GBD-Brazil GC redistribution algorithm applies previous steps of the GBD-IHME with modifications, using two criteria: proportion of target causes (valid) or reclassification of investigated causes. The SIM data were not adjusted. Standardized rates by direct method, local regression in the time series, and the ratio of the GBD-Brazil and SIM rates are used as correction factors for traffic injuries, falls, suicides, and homicides. Brazil recorded 1.34 million deaths with valid external causes and 171,700 CG in ten years. The redistribution of GC from GBD-Brazil increased valid causes by 12.2%, and the trend curve of the rates was similar to that found with SIM data, but diverged from each other and from the GBD-IHME in states in the North and Northeast regions. The GBD-Brazil estimates changed the pattern of external causes in the states, applying greater corrections to falls in the states of the North and Northeast and homicides in the other states. The GBD-Brazil method can be used in the analysis of violent deaths because it seeks greater methodological simplicity, which guarantees both replication by public managers and consistency of the estimated data, considering the local composition of the data in the redistribution process.

Objectives: The objective of this study was to identify Brazil's most critical garbage codes (GCs) reclassified to Chagas disease (ChD) in mortality data and their proportions. We also estimated the potential impact of misclassification on the number of deaths attributed to ChD., Study Design: Population-based descriptive study., Methods: We used the Mortality Information System (SIM; in Portuguese) data before and after routine GC investigation in 2015-2019 to evaluate ChD deaths detected among them. We identified priority GCs, which contributed more than 0.1 % to the percentage of total ChD deaths registered. Spearman's correlation was used to evaluate the association between the reclassification of priority GCs and ChD prevalence. Then, we applied the GC correction factors to estimate the number of deaths attributed to ChD., Results: 22,154 deaths were reported as ChD in the study period. Among them, 1004 deaths originally listed as priority GCs were deaths reclassified to ChD after an investigation in the SIM final database. Unspecific cardiomyopathy (10.2 %), unspecific heart diseases (4.7 %), and heart failure (2.8 %) were GCs with the highest proportions of reclassification to ChD in Brazil. Higher ChD prevalence at the state level was associated with a higher proportion of GC deaths reclassified as ChD. When applying correction factors identified after investigation, we estimated an increase of 26.4 % in registered ChD deaths, mostly in states with higher endemicity., Conclusions: GCs might conceal deaths due to ChD, particularly in Brazil's states with higher endemicity. The approach suggested in this study may offer an alternative method for estimating ChD-related deaths in endemic countries., (Copyright © 2023 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

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.

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., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 França et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Reliable mortality data are essential for the development of public health policies. In Brazil, although there is a well-consolidated universal system for mortality data, the quality of information on causes of death (CoD) is not even among Brazilian regions, with a high proportion of ill-defined CoD. Verbal autopsy (VA) is an alternative to improve mortality data. This study aimed to evaluate the performance of an adapted and reduced version of VA in identifying the underlying causes of non-forensic deaths, in São Paulo, Brazil. This is the first time that a version of the questionnaire has been validated considering the autopsy as the gold standard., Methods: The performance of a physician-certified verbal autopsy (PCVA) was evaluated considering conventional autopsy (macroscopy plus microscopy) as gold standard, based on a sample of 2060 decedents that were sent to the Post-Mortem Verification Service (SVOC-USP). All CoD, from the underlying to the immediate, were listed by both parties, and ICD-10 attributed by a senior coder. For each cause, sensitivity and chance corrected concordance (CCC) were computed considering first the underlying causes attributed by the pathologist and PCVA, and then any CoD listed in the death certificate given by PCVA. Cause specific mortality fraction accuracy (CSMF-accuracy) and chance corrected CSMF-accuracy were computed to evaluate the PCVA performance at the populational level., Results: There was substantial variability of the sensitivities and CCC across the causes. Well-known chronic diseases with accurate diagnoses that had been informed by physicians to family members, such as various cancers, had sensitivities above 40% or 50%. However, PCVA was not effective in attributing Pneumonia, Cardiomyopathy and Leukemia/Lymphoma as underlying CoD. At populational level, the PCVA estimated cause specific mortality fractions (CSMF) may be considered close to the fractions pointed by the gold standard. The CSMF-accuracy was 0.81 and the chance corrected CSMF-accuracy was 0.49., Conclusions: The PCVA was efficient in attributing some causes individually and proved effective in estimating the CSMF, which indicates that the method is useful to establish public health priorities., (© 2022. The Author(s).)

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.

Introduction: Musculoskeletal (MSK) disorders are a major cause of disability worldwide. Different modifiable risk factors are associated to these disorders. The objective of this study was to analyze the burden of low back pain (LBP), rheumatoid arthritis (RA), osteoarthritis (OA), and gout, attributable to risk factors, in 2017., Methods: The burden of LBP, RA, OA, and gout, and attributable risk factors were analyzed using data extracted from the Global Burden of Disease (GBD) Brasil-2017 study. Descriptive analysis was conducted to compare disability-adjusted life years (DALY) rates between sexes and age groups (15-49 and 50-69 years), in 2017., Results: The highest rates of DALY due to LBP were attributed to occupational ergonomic factors in the 15-49-year group, regardless of sex and males aged 50-69 years, whereas smoking was the major contributor in the 50-69-year female group. RA-related DALY rates were attributed to smoking and were higher among women aged 50-69 years. High body mass index (BMI) was the most relevant risk factor for the burden of OA, with higher rates detected in the 50-69-year group, and it was the most significant risk factor for DALY rate attributed to gout, regardless of sex or age group., Conclusions: Occupational surveillance measures are indicated to prevent LBP. Actions to decrease smoking and overweight, and the surveillance of weight gain are warranted to decrease the burden of LBP, RA and OA, and gout, respectively. These actions will be more effective if age and sex differentials are considered in planning.

Background: Accurate cause of death data are essential to guide health policy. However, mortality surveillance is limited in many low-income countries. In such settings, verbal autopsy (VA) is increasingly used to provide population-level cause of death data. VAs are now widely interpreted using the automated algorithms SmartVA and InterVA. Here we use conventional autopsy as the gold standard to validate SmartVA methodology., Methods: This study included adult deaths from natural causes in São Paulo and Recife for which conventional autopsy was indicated. VA was conducted with a relative of the deceased using an amended version of the SmartVA instrument to suit the local context. Causes of death from VA were produced using the SmartVA-Analyze program. Physician coded verbal autopsy (PCVA), conducted on the same questionnaires, and Global Burden of Disease Study data were used as additional comparators. Cause of death data were grouped into 10 broad causes for the validation due to the real-world utility of VA lying in identifying broad population cause of death patterns., Findings: The study included 2,060 deaths in São Paulo and 1,079 in Recife. The cause specific mortality fractions (CSMFs) estimated using SmartVA were broadly similar to conventional autopsy for: cardiovascular diseases (46.8% vs 54.0%, respectively), cancers (10.6% vs 11.4%), infections (7.0% vs 10.4%) and chronic respiratory disease (4.1% vs 3.7%), causes accounting for 76.1% of the autopsy dataset. The SmartVA CSMF estimates were lower than autopsy for "Other NCDs" (7.8% vs 14.6%) and higher for diabetes (13.0% vs 6.6%). CSMF accuracy of SmartVA compared to autopsy was 84.5%. CSMF accuracy for PCVA was 93.0%., Interpretation: The results suggest that SmartVA can, with reasonable accuracy, predict the broad cause of death groups important to assess a population's epidemiological transition. VA remains a useful tool for understanding causes of death where medical certification is not possible., Competing Interests: The authors declare no conflicts of interest., (© 2021 The Author(s).)

This study investigated the underreporting of deaths due to Acquired Immunodeficiency Syndrome (AIDS) in Brazil, using the product of the linkage between the Mortality Information System (SIM) and the Hospital Information System (SIH) for the years 2008 to 2012. The hypothesis was that there were deaths recorded in the SIM that should have AIDS as the underlying cause of death, but that had been poorly classified. Many of the decedents had previous hospitalizations due to the illness. Underreported AIDS deaths were defined taking into account the coding rules of the International Classification of Diseases 10th Revision, in order to discriminate AIDS deaths from those due to other causes in people living with HIV / AIDS. In this period, 60,362 deceased had AIDS as the underlying cause, and we found another 2,671 (4.2%) as underreported causes. Underreported deaths increased the average AIDS mortality rate from 6.3/100,000 to 6.6/100,000. In conclusion, this study demonstrated that, through linkage in between SIH and SIM, it is possible to find underreporting of AIDS deaths in Brazil. These results serve as a warning for the need for actions that would promote a better certification of the causes of death among AIDS patients.

Background: In this study, infant mortality rate (IMR) inequalities are analyzed from 1990 to 2015 in different geographic scales., Methods: The Ministry of Health (MoH) IMR estimates by Federative Units (FU) were compared to those obtained by the Global Burden of Disease (GBD) group. In order to measure the inequalities of the IMR by FU, the ratios from highest to lowest from 1990 to 2015 were calculated. Maps were elaborated in 2000, 2010, and 2015 at the municipality level. To analyze the effect of income, IMR inequalities by GDP per capita were analyzed, comparing Brazil and the FU to other same-income level countries in 2015, and the IMR municipal estimates were analyzed by income deciles, in 2000 and 2010., Results: IMR decreased from 47.1 to 13.4 per 1000 live births (LB) from 1990 to 2015, with an annual decrease rate of 4.9%. The decline was less pronounced for the early neonatal annual rate (3.5%). The Northeast region showed the most significant annual decline (6.2%). The IMR estimates carried out by the GBD were about 20% higher than those obtained by the MoH, but in terms of their inequalities, the ratio from the highest to the lowest IMR among the 27 FU decreased from 4 to 2, for both methods. The percentage of municipalities with IMR higher than 40 per 1000 LB decreased from 23% to 2%, between 2000 and 2015. Comparing the IMR distribution by income deciles, all inequality measures of the IMR decreased markedly from 2000 to 2010., Conclusion: The results showed a marked decrease in the IMR inequalities in Brazil, regardless of the geographic breakdown and the calculation method. Despite clear signs of progress in curbing infant mortality, there are still challenges in reducing its level, such as the concentration of deaths in the early neonatal period, and the specific increases of post neonatal mortality in 2016, after the recent cuts in social investments.

Background: The Global Burden of Diseases (GBD) 2017 database permits an up-to-date evaluation of the frequency and burden of diabetes at the state level in Brazil and by type of diabetes. The objective of this report is to describe, using these updated GBD data, the current and projected future burden of diabetes and hyperglycemia in Brazil, as well as its variation over time and space., Methods: We derived all estimates using the GBD 2016 and 2017 databases to characterize disease burden related to diabetes and hyperglycemia in Brazil, from 1990 to 2040, using standard GBD methodologies., Results: The overall estimated prevalence of diabetes in Brazil in 2017 was 4.4% (95%UI 4.0-4.9%), with 4.0% of those with diabetes being identified as having type 1 disease. While the crude prevalence of type 1 disease has remained relatively stable from 1990, type 2 prevalence has increased 30% for males and 26% for females. In 2017, approximately 3.3% of all disability-adjusted life years lost were due to diabetes and 5.9% to hyperglycemia. Diabetes prevalence and mortality were highest in the Northeast region and growing fastest in the North, Northeast, and Center-West regions. Over this period, despite a slight decrease in age-standardized incidence of type 2 diabetes, crude overall burden due to hyperglycemia has increased 19%, with population aging being a main cause for this rise. Cardiovascular diseases, responsible for 38.3% of this burden in 1990, caused only 25.9% of it in 2017, with premature mortality attributed directly to diabetes causing 31.6% of the 2017 burden. Future projections suggest that the diabetes mortality burden will increase 144% by 2040, more than twice the expected increase in crude disease burden overall (54%). By 2040, diabetes is projected to be Brazil's third leading cause of death and hyperglycemia its third leading risk factor, in terms of deaths., Conclusions: The disease burden in Brazil attributable to diabetes and hyperglycemia, already large, is predicted by GBD estimates to more than double to 2040. Strong actions by the Ministry of Health are necessary to counterbalance the major deleterious effects of population aging.

Objective: To assess the years of life lost due to premature death and disability-adjusted life years (DALY) as a result of chronic noncommunicable diseases attributable to occupational hazard factors, and to compare their position according to the risk ranking for chronic noncommunicable diseases in 1990 and 2016., Methods: Data for the DALY indicator, estimated from the Global Burden of Disease 2016 (GBD 2016) study, were analyzed for noncommunicable chronic diseases attributable to occupational, and other risk factors, selected in Brazil. A descriptive analysis was performed comparing the proportion of DALY by sex and age group (15 to 49 and 50 to 69 years old), as well as the ranking of occupational hazard factors in 1990 and 2016., Results: In 2016, ergonomic risk factors, carcinogenic agents, and noise in the workplace were among the 25 largest contributors to DALY for chronic noncommunicable diseases affecting the age group between 15 and 49 years. The contribution of all occupational hazard factors increased in 2016, except for occupational aerodispersoids affecting men. Concerning the age group between 50 and 69, occupational carcinogens stand out, with an increase of 26.0% for men, and 17.1% for women in 2016. Risk factors evaluated according to their 1990 and 2016 ranking show that occupational hazards have all scored higher on the second evaluation (2016), especially when compared with other risks., Conclusions: The global burden of chronic noncommunicable diseases attributed to occupational hazard factors has become increasingly important. We suggest the strengthening of the approach of occupational hazard factors in the agendas for tackling these diseases in Brazil.

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.

Introduction: Reliable cause-of-death statistics are an important source of information on trends and differentials in population health. In Brazil, the Mortality Information System is responsible for compiling cause of death (CoD) data. Despite the success in reducing R-codes ill-defined causes of death, other garbage codes (GC), classified as causes that cannot be the underlying CoD, according to the Global Burden of Disease study, remain a challenge. The Ministry of Health (MoH) aims to decrease the proportion of all GCs, and a pilot study tested a comprehensive strategy to investigate GC deaths that occurred in 2015., Methods: The research was conducted in seven Brazilian cities during five months in 2016: two rural cities, one metropolitan area, and four capitals. For all GCs selected, municipal healthcare workers collected information about the terminal disease from hospital records, autopsies, family health teams, and home investigation. The fieldwork was coordinated at Federal level in partnership with State and municipal teams., Results: Out of 1,242 deaths selected, physicians analyzed the information collected and certified the CoD in 1,055 deaths, resulting in 92.6% of cases having their underlying cause changed to a usable ICD-10 code., Discussion: It is noteworthy the capacity the health teams in the seven cities showed during the implementation of the pilot., Conclusion: After results analysis, the GC investigation protocol was modified, and the implementation scaled up to 60 cities in 2017.

Introduction: The study objective was to analyze the quality of data on causes of death in southern Brazil., Methods: Mortality Information System (SIM - Sistema de Informações sobre Mortalidade) data were used to evaluate the occurrence of Garbage Causes (GC) in death certificates (DCs) of residents of South states and their capitals between 2015 and 2016. The GC of each state were compared to the other states and grouped by severity level (N1 to N4, according to decreasing potential impact on mortality profile). We evaluated the N1 and N2 GC in the 0-74 years, in accordance with local of occurrence and attesting professional., Results: The occurrence of GC ranged from 29 to 31% among the three states, below the national average (34%). The GC of levels N1 and N2 were similar between states and heterogeneous between capitals. Most deaths were in-hospital, between 55%-64% of N1 and N2 GC occurred in the states and 39%-55% in the capitals. As for home deaths, this number ranged between 25%-31% and 25%-40%, respectively. More than 30% of the attesting professionals (except in Florianópolis) were declared as "others" in the corresponding DC field. Physicians from the Forensic Medical Institute (IML) and Death Verification Service (SVO) attested 15 to 24% of N1 and N2 GC in the states and 33 to 66% in the state capitals., Conclusion: The improvement of mortality data should involve strategies aimed at hospital physicians, in accordance with the volume of deaths and the IML and SVO services in addition to support for the emission of home DC, due to the importance in generating more severe GC.

Introduction: reliability of mortality data is essential for health assessment and planning. In Brazil, a high proportion of deaths is attributed to causes that should not be considered as underlying causes of deaths, named garbage codes (GC). To tackle this issue, in 2005, the Brazilian Ministry of Health (MoH) implements the investigation of GC-R codes (codes from chapter 18 "Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified, ICD-10") to improve the quality of cause-of-death data. This study analyzes the GC cause of death, considered as the indicator of data quality, in Brazil, regions, states and municipalities in 2000 and 2015., Methods: death records from the Brazilian Mortality Information System (SIM) were used. Analysis was performed for two GC groups: R codes and non-R codes, such as J18.0-J18.9 (Pneumonia unspecified). Crude and age-standardized rates, number of deaths and proportions were considered., Results: an overall improvement in the quality of mortality data in 2015 was detected, with variations among regions, age groups and size of municipalities. The improvement in the quality of mortality data in the Northeastern and Northern regions for GC-R codes is emphasized. Higher GC rates were observed among the older adults (60+ years old). The differences among the areas observed in 2015 were smaller., Conclusion: the efforts of the MoH in implementing the investigation of GC-R codes have contributed to the progress of data quality. Investment is still necessary to improve the quality of cause-of-death statistics.

Introduction: Sepsis represents the occurrence of systemic inflammatory response syndrome triggered by the initial infection of an organ or system. When sepsis is certified as the cause of death, the first diagnosis is lost, leading to inaccurate information as to its origin., Objective: To analyze the underlying causes of death from sepsis after investigation in 60 Brazilian municipalities in 2017., Methodology: All deaths recorded in the Mortality Information System (SIM) as sepsis in 2017 were selected, and the proportions of reclassified deaths were calculated based on the results of research conducted in hospitals and other health services., Results: Of the 6,486 deaths from sepsis that occurred in the 60 municipalities, 1,584 (24.4%) were investigated, and of these, 1,308 (82.6%) were reclassified with other underlying causes. Individuals aged from 70 to 89 years old showed the highest concentration in the records, with 49.3% of cases. More than 60% of the deaths from sepsis reclassified after the investigation had chronic non-communicable diseases as underlying causes (65.6%), with diabetes being the most common specific cause in this group. Communicable diseases (9.6%) and external causes (5.6%) such as falls were also detected as underlying causes., Conclusion: The investigation of deaths from sepsis made it possible to identify the true causes of death and the proportions of reclassification. This information will improve the quality of mortality data and support the planning of public health actions in Brazil.

Introduction: Brazil presented a high proportion of ill-defined causes of death (IDCD) in 2000, compromising accurate cause-of-death analysis., Objective: To analyze specific underlying causes for deaths originally assigned as IDCD in the Mortality Information System (SIM - Sistema de Informação sobre Mortalidade), after investigation activities implemented in country between 2006 and 2017., Method: For all IDCD identified in the SIM, municipal health professionals collected information about the final disease obtained from hospital records, autopsies, forms of family health teams, and home investigation. Specific causes among reclassified IDCD after investigation were evaluated according to age groups and four calendar periods., Results: Proportions of IDCD reassigned to other causes after review increased over time, reaching 30.1% in 2017. From a total of 257,367 IDCD reclassified in 2006-2017, neonatal-related conditions, injury, ischemic heart disease and stroke were the leading causes detected in the age groups 0-9 years, 10-29 years, 30-69 years, 70 years and over, respectively., Discussion: The similarity and plausibility of cause-specific proportions derived from the reclassification of IDCD by age group over time indicate the accuracy of the investigation data., Conclusion: High proportions of IDCD reassigned to more informative causes after review indicate the success of this approach to correct misclassification in the SIM, an initiative that should be maintained. Training physicians on death certification along with better quality of medical care and access to health services would lead to further improvement.

Introduction: Unspecified stroke (UnST) is of great importance in mortality statistics, as it is the fourth leading cause of death in Brazil. The objective of this study was to identify the profile of reclassified causes of death after investigation of deaths caused by UnST in Brazil., Methods: All deaths registered as UnST in 2017 in the Mortality Information System (SIM) were considered as garbage codes. The specific causes, detected after investigation in 60 selected cities, were analyzed by age and sex., Results: Of the total deaths due to UnST identified in these 60 cities (n = 11,289), 25.8% were investigated. Of these, 56.3% were reclassified to ischemic stroke, 12.7% to hemorrhagic stroke, and 23.3% to other specific causes, such as diabetes and chronic kidney disease, in both sexes., Discussion: The higher proportion of deaths due to ischemic stroke in comparison to hemorrhagic stroke was expected. However, the detection of other specific causes outside the stroke group indicates possible quality problems in the filling of death certificate (DC)., Conclusion: The investigations allowed the identification of subgroups of deaths due to stroke. In addition to the research, however, it is important to conduct physician training in the adequate filling in of the DC, in order to improve estimates of specific stroke mortality, and to enable appropriate targeting of health actions and services.

Introduction: A smartphone application named AtestaDO was developed to support physicians with medical certification of the cause of death. The objective of this study is to evaluate the acceptability of the app., Methods: Physicians were invited to attend meetings on the proper certification of cause of death, and to evaluate the application in a national workshop in Natal (first stage) and in two large hospitals in Belo Horizonte (second and third stages)., Results: In Natal, 82% of 38 physicians had more than 20 years of experience and in Belo Horizonte, more than 67% of 58 physicians had less than 5 years of experience. The sections "Application interface", "How to certify the causes of death", "Practice with exercises" and "Other information for physicians" were positively evaluated by more than 50% of physicians in Belo Horizonte. In Natal, all sections were positively evaluated by at least 80% of participants. More than 70% of the participants in both Natal and the second stage of Belo Horizonte indicated they would possibly use AtestaDO to guide filling of a death certificate. The probability of using AtestaDO to teach classes on filling death certificates was 83.3% for Natal's physicians but less than 60% in Belo Horizonte. In the three stages, most physicians would recommend using the application to other colleagues., Conclusion: The evaluation of AtestaDO showed good acceptability. We expect that the use of this tool enables improvements in medical certification of causes of death.

Objective: to evaluate the impact of investigation of deaths classified as garbage codes (GC) on the quality of the causes-of-death information in municipalities in the Northeast region of Brazil in 2017., Method: an investigation was conducted on the deaths classified as GC in 18 municipalities in the Northeast region as follows: identification of deaths with priority GC; review of medical records from health services and forensic institutes; and evaluation of the reclassification of causes of death according to the International Classification of Diseases (ICD-10) and groupings of the Global Burden of Disease 2015 (GBD 2015)., Results: among 18,681 deaths classified as priority GC, 7,352 (39%) were investigated and, of these, 5,160 (70%) had reclassified causes, of which 4,087 (79%) were changed to specified causes. Ill-defined causes (n = 4,392) were the most frequent among GC and those with a higher proportion of cause change (80%), and 57% were changed to specified causes. The reduction of GC contributed to the detection of a wide variety of specific causes according to groups of level 3 of the GBD 2015, being the interpersonal violence the cause that obtained the highest percentage change (11.8%)., Conclusion: The investigation of deaths with priority GC proved to be an important strategy to specify causes of death, and it may influence the formulation, execution and evaluation of health policies.

Introduction: Deaths certified with ill-defined causes or garbage codes (GC) compromise the analysis of mortality and its use for planning and evaluation of public health policies. The hospital investigation of these causes is one of the strategies qualifying the profile of mortality in the country., Objective: To evaluate the change in the hospital mortality profile after investigation of deaths certified with GC in 2017 in Belo Horizonte, Brazil., Methods: A sample of hospital deaths reported with GC in the Mortality Information System (SIM) of Belo Horizonte in 2017 was investigated and subsequently certified by a physician to compare the mortality profile before and after investigation., Results: After investigating 1,395 deaths out of 3,038 reported with GC, a reduction of 35.5% of these causes was observed. Groups of all ages presented decreases in GC occurrence. A higher proportional increase was observed for deaths due to ischemic heart diseases, Alzheimer's disease, chronic obstructive pulmonary disease, ischemic and hemorrhagic stroke, and external causes of death (accidental falls, homicides and traffic/transport accidents)., Conclusion: The investigation on reported hospital deaths is one of the strategies to improve mortality statistics, reducing the occurrence of GC among reported deaths and changing the mortality profile in these facilities. The importance of continuous physician training in cause-of-death certification is emphasized.

Background: Unspecified causes of death are among the traditional indicators of quality of information., Objective: To verify the performance of the 60 cities in the Data for Health Initiative project and to analyze the reclassification of unspecified external causes of death (UEC)., Methods: Using the 2017 records from the Mortality Information System, the proportion and percent change in UEC were compared after investigation between project cities and other cities, and the percent of reclassification to specific external causes was calculated., Results: The project cities comprised 52% (n = 11,759) of the total UEC in Brazil, of which 64.5% were reclassified after investigation, whereas the other cities reclassified 31% of UEC. Results were similar for men, youth, blacks, metropolitan cities, the Southeast region, and deaths attested by forensic institutes. In the project cities, pedestrian traffic accidents were external causes with greater reclassification. In men, the UEC was reclassified to homicides (23.8%) and accident of terrestrial transportation (ATT) (11.1%), with motorcyclists (4.4%) and pedestrians (4.3%) being the most prominent. In women, these causes were changed to other accident causes (20.8%), ATT (10.6%) and homicides (7.9%). UEC changed to ATT (18.3%) in the age groups of 0-14 years old and to homicides (32.5%) in the age groups of 15-44 years., Conclusion: The project cities obtained better results after investigation of UEC, enabling analysis of the reclassification to specific causes by sex and age groups.

Introduction: Knowing the number of deaths and their causes is relevant information for public health managers. However, the cause of death is often classified with codes that are not useful for mortality analysis, called garbage codes (GC)., Objective: To describe and evaluate the impact of investigation of the underlying cause of poorly classified deaths on death certificates in 2017., Methods: Based on a standardized protocol, GC deaths from 60 municipalities were investigated, mainly in hospital records and autopsy services. Managers at the state level of the Mortality Information System also developed procedures to improve the classification of causes of death, with the consequent adherence of other municipalities (n = 4022). This made it possible to compare the results of GC research between these two groups of municipalities., Results: In the country, among the 108,826 GC investigated in 2017, 48% were reclassified to specific causes. In the 60 focus municipalities, 58% of the 35,366 investigated deaths from GC were reclassified. After the intervention, the proportion of deaths classified as GC decreased by 11% in the country and 17% in the municipalities., Discussion: The research in hospital records enabled almost half of the deaths from GC investigated to be reclassified. This is the first study to investigate GC in hospital records of more than 100,000 deaths. The 60 cities targeted by the intervention had better results than the other cities., Conclusion: The intervention proved to be an appropriate initiative to improve the quality of information on cause of death and should be encouraged.

Heart failure is considered a garbage code when assigned as the underlying cause of death. Reassigning garbage codes to plausible causes reduces bias and increases comparability of mortality data. Two redistribution methods were applied to Brazilian data, from 2008 to 2012, for decedents aged 55 years and older. In the multiple causes of death method, heart failure deaths were redistributed based on the proportion of underlying causes found in matched deaths that had heart failure listed as an intermediate cause. In the hospitalization data method, heart failure deaths were redistributed based on data from the decedents' corresponding hospitalization record. There were 123,269 (3.7%) heart failure deaths. The method with multiple causes of death redistributed 25.3% to hypertensive heart and kidney diseases, 22.6% to coronary heart diseases and 9.6% to diabetes. The total of 41,324 heart failure deaths were linked to hospitalization records. Heart failure was listed as the principal diagnosis in 45.8% of the corresponding hospitalization records. For those, no redistribution occurred. For the remaining ones, the hospitalization data method redistributed 21.2% to a group with other (non-cardiac) diseases, 6.5% to lower respiratory infections and 9.3% to other garbage codes. Heart failure is a frequently used garbage code in Brazil. We used two redistribution methods, which were straightforwardly applied but led to different results. These methods need to be validated, which can be done in the wake of a recent national study that will investigate a big sample of hospital deaths with garbage codes listed as underlying causes.

The Unified Healthcare System (SUS) was created to ensure the population's right to universal, free and comprehensive healthcare. This study compares the health indicators measured in 1990 to those measured in 2015 in Brazil and its states. The goal is to contribute to understanding the role SUS played in changing the nation's health profile. Analyses use estimates in the Global Burden of Disease (GBD) study for Brazil and its states, and compares 1990 and 2015. The main results are increased life expectancy, as well as an increase in the population's longevity measured in health-adjusted life expectancy. These in turn are due to a sharp decline in mortality due to transmissible diseases, in maternal and infant morbi-mortality, and avoidable causes of death. NTCDs are the leading cause of death, followed by violence. Poor diet is the leading risk factor, followed by metabolic issues. Tobacco use decreased over the period, as did infant malnutrition. In the thirty years since the SUS was created, health indicators in this country have improved, and major progress has been made to reduce inequality across the country's regions.

Background: Reliable data on cause of death (COD) are fundamental for planning and resource allocation priorities. We used GBD 2015 estimates to examine levels and trends for the leading causes of death in Brazil from 1990 to 2015., Methods: We describe the main analytical approaches focused on both overall and specific causes of death for Brazil and Brazilian states., Results: There was an overall improvement in life expectancy at birth from 1990 to 2015, but with important heterogeneity among states. Reduced mortality due to diarrhea, lower respiratory infections, and other infectious diseases contributed the most for increasing life expectancy in most states from the North and Northeast regions. Reduced mortality due to cardiovascular diseases was the highest contributor in the South, Southeast, and Center West regions. However, among men, intentional injuries reduced life expectancy in 17 out of 27 states. Although age-standardized rates due to ischemic heart disease (IHD) and cerebrovascular disease declined over time, these remained the leading CODs in the country and states. In contrast, leading causes of premature mortality changed substantially - e.g., diarrheal diseases moved from 1st to 13th and then the 36th position in 1990, 2005, and 2015, respectively, while violence moved from 7th to 1st and to 2nd. Overall, the total age-standardized years of life lost (YLL) rate was reduced from 1990 to 2015, bringing the burden of premature deaths closer to expected rates given the country's Socio-demographic Index (SDI). In 1990, IHD, stroke, diarrhea, neonatal preterm birth complications, road injury, and violence had ratios higher than the expected, while in 2015 only violence was higher, overall and in all states, according to the SDI., Conclusions: A widespread reduction of mortality levels occurred in Brazil from 1990 to 2015, particularly among children under 5 years old. Major shifts in mortality rates took place among communicable, maternal, neonatal, and nutritional disorders. The mortality profile has shifted to older ages with increases in non-communicable diseases as well as premature deaths due to violence. Policymakers should address health interventions accordingly.

Introduction and Objective:: Mortality studies are essential for the monitoring of the HIV/AIDS epidemic. Quality and completeness of data from the mortality information system (SIM) require complementary approaches., Methods:: Two sources of data were used to assess mortality trends due to HIV/AIDS in Brazil from 2000 and 2014/15: a) data from the SIM published by the Department of STDs, AIDS, and viral hepatitis, and b) Global Burden of Disease 2015 (GBD 2015) studies. Descriptive analyses were carried out and trends in relative reduction of age-adjusted mortality rates per 100,000 inhabitants were compared according to the two methods., Results:: Overall, the magnitude of the mortality rates estimated by the GBD method, for Brazil and its Federative Units (FU), was greater than those obtained from the SIM. The relative reduction was higher for SIM data and there were shifts in the ranking according to the FUs. Between 2000 and 2014/15 there was an increase in the mortality rates for most of the FUs (78 and 88% according to the SIM and GBD, respectively)., Conclusion:: Data regarding mortality due to HIV/AIDS in Brazil should be of concern, regardless of the method used. Differences in magnitude, relative reductions, and ranking can be attributed to methodological differences, but the GBD is broader, with a higher capacity to capture incorrectly classified data and causes of death not registered or not coded as being due to HIV/AIDS. Alternative and complementary data sources can provide important information for HIV/AIDS public policies in Brazil.

Introduction and Objective:: The global burden of disease (GBD) 2015 project, extends GBD analyses to include Brazilian federative units separately. We take advantage of GBD methodological advances to describe the current burden of diabetes and hyperglycemia in Brazil., Methods:: Using standard GBD 2015 methods, we analyzed the burden of diabetes, chronic kidney disease due to diabetes and high fasting plasma glucose in Brazil and its states., Results:: The age-standardized rate of disability-adjusted life years (DALYs) which was lost to high fasting plasma glucose, a category which encompasses burdens of diabetes and of lesser hyperglycemia, were 2448.85 (95% UI 2165.96-2778.69) /100000 for males, and 1863.90 (95% UI 1648.18-2123.47) /100000 for females in 2015. This rate was more than twice as great in states with highest burden, these being overwhelmingly in the northeast and north, compared with those with lowest rates. The rate of crude DALYs for high fasting plasma glucose, increased by 35% since 1990, while DALYs due to all non-communicable diseases increased only by 12.7%, and DALYs from all causes declined by 20.5%., Discussion:: The worldwide pandemic of diabetes and hyperglycemia now causes a major and growing disease burden in Brazil, especially in states with greater poverty and a lesser educational level., Conclusion:: Diabetes and chronic kidney disease due to diabetes, as well as high fasting plasma glucose in general, currently constitute a major and growing public health problem in Brazil. Actions to date for their prevention and control have been slow considering the magnitude of this burden.

Objective:: To verify the time trends of mortality rates, years of lost life (YLL), and years lived with disability (YLD) caused by cerebrovascular disease in Brazil between 1990 and 2015., Methods:: The estimates from the Global Burden of Diseases 2015 were used to analyze the magnitude and trends of mortality rates and disability-adjusted life years (DALY) for cerebrovascular disease (ICD-10: I-60-69) in the 27 units of the Federation between 1990 and 2015. The states were analyzed by the social development index (SDI), based on average income per person, educational attainment at 15 years- old and total fertility rate., Results:: Despite the increase in the absolute number of deaths due to cerebrovascular disease, the proportion of deaths below 70 years of age has been halved between 1990 and 2015. The acceleration of the reduction was higher among women; and increased from 1990 to 2005, when compared to the period from 2005 to 2015. The risk of death has been halved across the country, but states in the lower SDI tertile had less significant reductions (-1.23 and -1.84% a year) compared to the middle tertile (-1.94 and - 2.22%) and the upper tertile (-2.85 and -2.82%) for men and women, respectively. The years lived with disability also presented a reduction among states, but less expressively., Conclusion:: Despite the reduction of age-adjusted mortality rates throughout the country, cerebrovascular disease still presents a high disease burden, especially in states with lower socioeconomic development.

Objective:: To analyze under-5 mortality rates and leading causes in Brazil and states in 1990 and 2015, using the Global Burden of Disease Study (GBD) 2015 estimates., Methods:: The main sources of data for all-causes under-5 mortality and live births estimates were the mortality information system, surveys, and censuses. Proportions and rates per 1,000 live births (LB) were calculated for total deaths and leading causes., Results:: Estimates of under-5 deaths in Brazil were 191,505 in 1990, and 51,226 in 2015, 90% of which were infant deaths. The rates per 1,000 LB showed a reduction of 67.6% from 1990 to 2015, achieving the proposed target established by the Millennium Development Goals (MDGs). The reduction generally was more than 60% in states, with a faster reduction in the poorest Northeast region. The ratio of the highest and lowest rates in the states decreased from 4.9 in 1990 to 2.3 in 2015, indicating a reduction in socioeconomic regional disparities. Although prematurity showed a 72% reduction, it still remains as the leading cause of death (COD), followed by diarrheal diseases in 1990, and congenital anomalies, birth asphyxia and septicemia neonatal in 2015., Conclusion:: Under-5 mortality has decreased over the past 25 years, with reduction of regional disparities. However, pregnancy and childbirth-related causes remain as major causes of death, together with congenital anomalies. Intersectoral and specific public health policies must be continued to improve living conditions and health care in order to achieve further reduction of under-5 mortality rates in Brazil.

Objective:: To analyze the mortality rates from malignant neoplasia in Brazil and Federal Units (FU) in the years 1990 and 2015, according to sex and main types of cancer., Methods:: Using estimates of global disease burden for Brazil made by the GBD 2015 study, age-adjusted cancer mortality rates and respective 95% uncertainty intervals were calculated for Brazil and FU in 1990 and 2015, as well as their percentage variation in the period. The main causes of cancer mortality by sex were analyzed, considering the five highest rates in the country and for each state., Results:: The cancer mortality rate for male and female population remained stable between the two years in the country. The same behavior pattern was observed in almost all the FU, and the majority of states in the northeast region and half of the north region showed a non-significant increase in mortality rates. Regarding the types of cancer, there was a drop in mortality rates for stomach cancers in both sexes (women: -38.9%, men: -37.3%), cervical cancer in women (-33.9%), and lung and esophagus cancer in men (-12.0% and -14.1%, respectively); in contrast, there was an increase in lung cancers in women (+20.7%) and colon and rectum cancers in men (+29.5%)., Conclusion:: Differences in the behavior of major cancers, with a decrease mainly in the more developed regions and an increase in the less developed regions of the country, seem to reflect the socioeconomic inequalities as well as difficulties in access to health services by the Brazilian population.

Objective:: To assess the quality of mortality information by analyzing the frequency of garbage codes (GC) registered as underlying cause-of-death in Belo Horizonte, Minas Gerais, Brazil., Methods:: Data of deaths of residents from 2011 to 2013 were selected. GC causes were classified as proposed by the Global Burden of Disease Study (GBD) 2015. They were grouped into GCs from ICD-10 Chapter XVIII and GCs excluding codes of Chapter XVIII. Proportions of GC were calculated by sex, age, and place of occurrence., Results:: In Belo Horizonte, 30.5% of the total of 44,123 deaths were GC. Higher proportion of these codes was observed in children (1 to 4 years) and in people aged over 60 years. The following leading GCs observed were: other ill-defined and unspecified causes of death (code R99), unspecified pneumonia (J18.9), unspecified stroke (hemorrhagic or ischemic) (I64), and unspecified septicemia (A41.9). The proportions of GC were 28.7% and 36.9% in deaths that occurred in hospitals and at home, respectively. An important difference occurred in the GC group from Chapter XVIII of ICD-10: 1.7% occurred in hospitals and 16.9% at home., Conclusion:: The high proportions of GC in mortality statistics in Belo Horizonte demonstrated its importance for assessing the quality of information on causes of death.

Introduction:: Alcohol use is one of the main preventable risk factors affecting mortality and premature disability., Objective:: To describe the estimates of mortality and years of life lost as a result of premature death (YLL) due to cirrhosis, liver cancer, and disorders attributed to alcohol use in Brazil and its federated units in 1990 and 2015., Methods:: Descriptive study using data from the Global Burden of Disease Study (2015) and the Mortality Information System (SIM). Statistical models were used to obtain corrected mortality estimates for selected causes. Rates were standardized by age., Results:: In 1990, 16,226 deaths were estimated for the three conditions (17.0/100 thousand inhabitants), while in 2015 there were 28,337 deaths (15.7/100 thousand inhabitants). There was a reduction in mortality (per 100 thousand) due to cirrhosis (from 11.4 to 9.5), stability in mortality rates related to liver cancer (1.5 and 1.9), and stability in mortality rates caused by alcohol use disorders (4.1 and 4.3). Mortality rates were 5.1 times higher among men, and the five states with the highest mortality rates and YLL were from the Northeast Region: Sergipe, Ceará, Pernambuco, Paraíba, and Alagoas. Mortality and YLL rates for the three conditions studied increased in the ranking of causes of death in both sexes, with the exception of cirrhosis in the female population., Conclusion:: The three conditions studied are responsible for a significant burden of premature mortality in Brazil, especially among men and residents of the northeast region. These results reinforce the urgent need for public policies that address harmful alcohol consumption in Brazil.

Introduction:: The global tobacco epidemic has taken pandemic proportions, with about 1.3 billion users and 6 million annual deaths. This study aimed to analyze the trends in mortality from chronic obstructive pulmonary disease (COPD) and lung, lips, oral cavity, pharynx, and esophagus cancer in Brazil between 1990 and 2015., Methods:: The study was made possible through a partnership between the Metrics and Health Assessment Institute (IHME), University of Washington, Ministry of Health and the GBD Brazil technical group, using estimates from the Global Disease Charge 2015 study., Results:: The mortality rates due to COPD fell; in 1990, it was 64.5/100,000 inhabitants and in 2015, 44.5, a decrease of 31%. For the various types of cancer related to smoking, the decrease was in a lower proportion than for COPD. For lung cancer, rates were 18.7/100,000 inhabitants in 1990 to 18.3 in 2015. For women, there is an upward curve for lung cancer from 1990 to 2015, with an increase of 20.7%., Discussion:: The study points to smoking as a risk factor for premature mortality and disability due to COPD and cancer. The significant reduction in tobacco prevalence in recent decades could explain reductions in tobacco-related disease trends. The higher mortality from lung cancer in women may express the delayed increase in smoking in this gender., Conclusion:: Nationwide actions taken in the last decades have had a great effect on reducing mortality from tobacco-related diseases, but there are still major challenges, especially when it comes to women and young people.

Introduction:: Lower respiratory tract infections (LRTIs) present significant incidence and mortality in the world. This article presents the impact of LRTIs in the burden of disease, according to the metrics used in the Global Burden of Disease study (GBD 2015) for Brazil in 1990 and 2015., Methods:: Analysis of estimates from the GBD 2015: years of life lost due to premature death (YLLs), years lived with disability (YLDs), years of life lost due to death or disability (DALYs = YLLs + YLDs)., Results:: LRTIs were the third cause of mortality in Brazil in 1990 and 2015, with 63.5 and 47.0 deaths/100,000 people, respectively. Although the number of deaths increased 26.8%, there was a reduction of 25.5% in mortality rates standardized by age, with emphasis on children under 5 years of age. The disability indicators, as measured by the DALYs, demonstrate a progressive reduction of the disease burden by LRTIs., Discussion:: Despite the reduction in mortality rates in the period, LRTIs were an important cause of disability and still the third cause of death in Brazil in 2015. The increase in the number of deaths occurred due to the increase in population and its aging. The reduction in mortality rates accompanied the improvement of socioeconomic conditions, broader access to health care, national availability of antibiotics, and vaccination policies adopted in the country., Conclusion:: Despite the current socioeconomic difficulties, there has been a progressive reduction of the LRTIs load effect in Brazil, mostly in mortality and disability, and among children under 5 years of age.

Background: Diabetes, hyperglycemia, and their complications are a growing problem in Brazil. However, no comprehensive picture of this disease burden has yet been presented to date., Methods: We used Global Burden of Disease 2015 data to characterize diabetes prevalence, incidence and risk factors from 1990 to 2015 in Brazil. Additionally, we provide mortality, years of life lost prematurely (YLL), years of life lived with disability (YLD) and disability-adjusted life years (DALYs) lost due to diabetes, as well as similar data for chronic kidney disease (CKD) due to diabetes and, as an overall summary measure, for hyperglycemia, the latter expressed as high fasting plasma glucose (HFPG)., Results: From 1990 to 2015 diabetes prevalence rose from around 3.6 to 6.1%, and YLLs, YLDs, and DALYs attributable to diabetes increased steadily. The crude diabetes death rate increased 90% while that of CKD due to diabetes more than doubled. In 2015, HFPG became Brazil's 4th leading cause of disability, responsible for 65% of CKD, for 7.0% of all disability and for the staggering annual loss of 4,049,510 DALYs. Diabetes DALYs increased by 118.6% during the period, increasing 42% due to growth in Brazil´s population, 72.1% due to population ageing, and 4.6% due to the change in the underlying, age-standardized rate of DALY due to diabetes. Main risk factors for diabetes were high body mass index; a series of dietary factors, most notably low intake of whole grains and of nuts and seeds, and high intake of processed meats; low physical activity and tobacco use, in that order., Conclusions: Our study demonstrates that diabetes, CKD due to diabetes, and hyperglycemia produce a large and increasing burden in Brazil. These findings call for renewed efforts to control the joint epidemics of obesity and diabetes, and to develop strategies to deal with the ever-increasing burden resulting from these diseases.

Objective: to describe the burden of disease in Brazil from 1990 to 2010., Methods: analysis of the estimates of the Global Burden of Disease Study 2010 - Years of Life Lost due to premature mortality (YLL), Years Lost due to Disability (YLD), Disability-Adjusted Life Year (DALY=YLL+YLD) and risk factors., Results: there was a decrease in deaths due to diarrhea and an increase in deaths due to diabetes and kidney disease, whilst deaths due to homicides and traffic accidents remained stable; cardiovascular diseases continued to be the leading cause of death despite a 30% reduction; the largest increases in DALY were due to diabetes and musculoskeletal diseases in women and alcohol abuse and low back pain in men; the main risk factors were poor diet and high blood pressure; smoking, domestic pollution and insufficient breastfeeding were found to have reduced., Conclusion: the rapid epidemiological transition highlights the need to control infectious diseases and invest in reducing violence and non-communicable diseases.

Stroke mortality rates are declining in Brazil, but diferences among regions need to be better investigated. The age-adjusted stroke mortality trends among adults (30-69 years-old) from Brazilian regions were studied between 1996 and 2011. Method Data were analyzed after: 1) reallocation of deaths with non-registered sex or age; 2) redistribution of garbage codes and 3) underreporting correction. A linear regression model with autoregressive errors and a state space model were fitted to the data, aiming the estimation of annual trends at every point in time. Results Although there were high values, a steady decrease of rates was observed. The decreasing trends among all regions were statistically significant, with higher values of decline among the Northeast and Northern regions, where rates were the highest. Conclusion Standardized methodology use is mandatory for correct interpretation of mortality estimates. Although declining, rates are still extremely high and efforts must be made towards prevention of stroke incidence, reduction of case-fatality rates and prevention of sequelae.

Objective: to analyze the circulation of respiratory viruses in people living in the metropolitan area of Belo Horizonte, Brazil, and hospitalized in Belo Horizonte from 2011 to 2013., Methods: this is a descriptive study of 5,158 patients with Severe Acute Respiratory Syndrome; a comparison was made between the characteristics of confirmed cases and those of discarded cases or cases without swab samples., Results: Influenza A virus accounted for half the isolated viruses, especially subtype A(H1N1)pdm09 among patients aged 20-59 years old, and subtype A(H3N2) in those aged 60 or over; the most frequently identified respiratory virus among children under five years old was respiratory syncytial virus (65.6%), followed by influenza A virus (21.2%); influenza virus circulated in all seasons of the year and its periods of greatest incidence were interspersed with those of higher Respiratory Syncytial Virus activity., Conclusion: monitoring respiratory viruses contributes to knowledge about periods of virus circulation and the adoption of specific control measures.

The objective of this study was to analyze factors associated with failure to take a Pap smear test among quilombola women living in Vitória da Conquista in the state of Bahia. A cross-sectional, population-based study was conducted with women aged 18 to 64. Descriptive analysis and univariate and multivariate analysis using a multinomial logistic model was applied. Women who had never performed the test or had not had one for over three years were compared separately from those who were examined within the preceding three years. Of the 348 women included in the analysis, 27.3%, reported never having a Pap smear test. The following factors were independently associated with never having taken the test: age of 18 to 29 years and 50 to 59 years; lack of education; not having a partner; seeking care in health-related units/establishments other than their place of residence; and having a clinical breast examination three or more years ago or never having one. The findings indicate a need for reflection in order to combat factors that are associated with not having a Pap smear test among quilombola women, since it is important to implement actions for the prevention of cervical cancer.

This study aimed to assess the quality of data on deaths from external causes in Viçosa, Minas Gerais State, Brazil, from 2000 to 2009, and the completeness of the Mortality Information System (SIM). The data were obtained from the SIM of the Municipal Health Department, municipal police enquiries, and local newspaper articles, resulting in a databank with 495 deaths from external causes. The results showed a high proportion of deaths with indeterminate intent (21%) in the SIM, suggesting problems with quality of information. Comparison of data from the SIM and police department detected problems with coverage in the SIM (21%) and thus in the official statistics on mortality from accidents and violence. The results emphasize the importance of searches in other data sources to upgrade the SIM and expand its coverage, and especially the need for studies to identify and analyze problems faced by small and medium-sized cities in the production of mortality data.