Mortalidade relacionada às doenças tropicais negligenciadas no Brasil, 2000-2011: magnitude, padrões espaço-temporais e fatores associados

Abstract

Brazil accounts for most of the disease burden related to Neglected Tropical Diseases (NTDs) in Latin America. We analyzed temporal trends, spatiotemporal patterns and associated factors to NTD-related mortality in Brazil. We performed a series of ecological studies based on secondary mortality data from the Mortality Information System. We included all NTD-related deaths recorded in Brazil from 2000 to 2011. The thesis is organized into seven Thematic Axes according to their methodological characteristics and diseases analyzed: Time trends and spatiotemporal patterns of mortality related to NTDs’ group (Axis 1) and specific NTDs with high mortality impact in Brazil (schistosomiasis, leprosy, neurocysticercosis, visceral leishmaniasis, and visceral leishmaniasis and HIV/AIDS co-infection) (Axes 2 to 6); analysis of socioeconomic, demographic, environmental and health care ecological factors associated with the NTD-related mortality at municipal level in Brazil, using multivariate linear regression and local spatial regression models (Axis 7). During the study period, 12,491,280 deaths were recorded in Brazil. We identified 100,814 (0.81%) death certificates in which at least one cause of death related to NTDs was mentioned. Chagas disease was the most commonly mentioned NTD (72,827; 72.0%), followed by schistosomiasis (8,756, 8.7%) and leprosy (7,732; 7.6%). The average annual age-adjusted mortality rate was 5.67 deaths/100.000 inhabitants (95% confidence interval [95% CI]: 5.56-5.77). The highest mortality rates were observed in males, age group ≥70 years, black race/color and residents in the Central-West region. The mortality rates presented a significant decreasing trend at national level during the period (annual percentage change [APC]: -2.1%; 95% CI: -2.8; -1.3), with decreasing mortality in the Southeast, South and Central-West regions, increase in the North region and stability in the Northeast region. We identified high-risk clusters in all Brazilian regions, highlighting a major cluster covering a wide geographical area in central Brazil. The multivariate linear regression analysis indicated a global positive relationship between NTD-related mortality rates and urbanization, migration, Gini index, unemployment, inadequate sanitation, black population, Bolsa Família Program coverage and temperature, while there was a negative relationship with household income, density of physicians, extreme poverty, household density, humidity and precipitation. The results of the Geographically Weighted Regression (GWR) models indicated significant spatial variations in all associations between the explanatory variables and NTD-related mortality throughout the country; each ecological factor had a different effect on mortality in the different regions. NTDs remain important causes of preventable death and a public health problem in Brazil. The geographical overlap and areas of high-risk for NTD-related deaths identified call attention to implementation of integrated measures of control in areas with higher morbidity and mortality. The spatial distribution of NTD-related mortality in Brazilian municipalities is correlated with socioeconomic, demographic and environmental/climate factors, with significant geographic variations. Comprehensive local strategies and control and prevention measures for NTDs should be planned according to these characteristics in Brazilian endemic regions.