Estudo de Mortalidade e Morbidade do Acidente Vascular Cerebral no Brasil: The Lancet Neurology

Abaixo, encontra-se carta publicada no The Lancet Neurology a respeito da vigilância epidemiológica da doença que mais mata no Brasil, mas ainda é muito pouco estudada: a doença cerebrovascular. Apresentamos as bases do EMMA (Estudo de Mortalidade e Morbidade do Acidente Vascular Cerebral) que utiliza a metodologia desenvolvida por Ruth Bonita na Organização Mundial da Saúde. O estudo foi financiado inicialmente pelo Conselho Nacional de Pesquisa e depois pela FAPESP. Completará um ano em maio próximo e, permitirá entender vários aspectos da epidemiologia e clínica das diversas formas da doença cerebrovascular. Clicando o título será possível chegar na página do The Lancet Neurology, mas será necessário registro para acessar o artigo. Ou então, solicitar no email desse blogue.

Lancet Neurology 2007; 6:387-388 Improving WHO STEPS Stroke in Brazil Paulo A Lotufo and Isabela M Bensenor Further to your editorial and the article by Truelsen and colleagues, which emphasise the importance of WHO STEPS Stroke methodology for cerebrovascular disease surveillance, we would like to comment on our experience with regard to the use of this surveillance tool. The rationale for studying cerebrovascular epidemiology in a country like Brazil is obvious, but paradoxically, there are few researchers focusing on clinical and epidemiological research about stroke. Death rates from cerebrovascular and coronary heart diseases surpassed those for infectious diseases in the 1960s and stroke mortality rates in Brazil are the highest in Latin America. However, most vascular research in Brazil is focused on coronary heart disease rather than stroke. There is a simple reason for this discrepancy: mortality due to stroke is twice as common among people living in neighbourhoods with low socioeconomic indicators than in those in more affluent ones. In the past 40 years, coronary care units have spread across the country; by contrast, there are no public stroke units. Patients with stroke are treated in emergency wards, and hospitalisation in a critical care unit is not considered a priority. Thrombolysis is common for patients with acute coronary syndromes but is unavailable for people with ischaemic stroke. By contrast with classic surveys located in small towns, our aim is to assess stroke distribution in São Paulo, a large metropolitan area with more than 10 million inhabitants. We chose the neighbourhoods located in the western area of the city, in which a teaching hospital with a 260-bed facility offers the only support for emergencies and is responsible for 80% of the hospitalisations of people living in the area. Here, we launched Estudo de Mortalidade e Morbidade do Acidente Vascular Cerebral (EMMA) study, funded by the Brazilian National Research Council. EMMA enrolled its first participant on May 10, 2006, applying the form proposed for step one of STEPS Stroke. In this phase, objectives are to characterise the delay in hospitalisation since the start of symptoms, to determine the frequency of stroke by hour of the day, day of the week, and month of the year, and to calculate the 28 day, 180 day, and 1 year case-fatality rates. For step two—which began in November, 2006—we included the assessment of housing conditions, with a detailed assessment of the place in which each stroke survivor lives. Step three, due to start this year, will offer strong support from primary care physicians in the area, mainly community health agents who are working together in the Family Primary Care Program. In addition to STEPS Stroke, we are implementing other tools to verify motor, speech, and alimentary tract disabilities with specific questionnaires and a clinical consultation with physiotherapists and speech disorder specialists

O boicote à vacina contra a pólio na Nigéria.

Na Plos Medicine desse mês há um relato muito interessante sobre o boicote à vacinação contra a poliomielite em cinco estados da região norte da Nigéria. O tema é interessante para verificar que não bastam recursos financeiros, mas sim uma rede mínima - social, política, cultural - para permitir políticas de saúde pública.

O texto completo está em http://medicine.plos.org. Abaixo, um resumo.

Community Prevent Further Boycotts? The vaccine boycott in Nigeria was influenced by a complex interplay of factors. These factors included lack of trust in modern medicine, political and religious motives, a history of perceived betrayal by the federal government, the medical establishment, and big business, and a conceivably genuine—albeit misplaced and ineffective—attempt by the local leadership to protect its people. A recent editorial in The Lancet argued that “few data exist on the best way to stop the spread of false information” . One lesson from the Kano boycott is that research is needed to investigate why people have concerns and fears about vaccination, and what steps should be taken to avoid boycotts in the future. Other lessons are discussed below. Governments should be sensitive to local politics, especially as they affect health-care delivery Immunization campaign programs should be a participatory event involving state and local governments, community leaders, and parents. There are three types of community leaders in northern Nigeria—traditional rulers, political leaders, and religious leaders. Traditional rulers acquire their status through succession and their authority is rooted in traditions and customs [40–42]. Political leaders acquire their status through the political process and religious leaders do so on a religious basis. Among the three, the traditional ruler is best placed to represent the interests of children. Community leaders may contribute to the success or failure of health research and delivery . Public awareness campaigns about vaccination are crucial. These should stress the value of immunization and involve the media. Reaching the community requires radio, television, and folk media (such as local music, theatre, and festivals). Immunization messages can be packaged into songs by local musicians and can be communicated through drama in the language that local people understand. Research ethics committees should be established in each local government. These committees would examine and approve or reject health research in its sphere of influence. Members of these community-based ethics committees should include volunteers who are ready to undergo basic ethics training relevant to their duties. The committees should be under the supervision of, and funded by, the local government's councils, and the committees should work with local medical associations. They should choose their own chairperson and determine their own agenda in line with the national ethics code. Barriers to the formation of local ethics committees include inadequate capacity, funding, and communication.

Vigitel: longa vida!

Ontem, o Ministério da Saúde liberou na sua página (http://saude.gov.br) os resultados de 2006 do Vigitel, ou Vigilância de Fatores de Risco e de Proteção das Doenças Crônicas por Inquérito Telefônico. A imprensa divulgou amplamente, sempre enfatizando a diferença entre as capitais.

Esqueceram -os jornais - do principal. Esse belo estudo (que tive a oportunidade de ver nascer) da equipe do NUPENS da Faculdade de Saúde Pública da USP coordenado pelo Professor Carlos Augusto Monteiro com recurso do Ministério da Saúde também avaliou a distribuição desses fatores por nível de escolaridade. E, quase que invariavelmente, aqueles com menor escolaridade apresentam prevalência maior de fatores de risco e menor de fatores de proteção. No caso do tabagismo é incrível: aqueles com educação formal até 8 anos, a prevalência é de 24,2%, mas para quem estudou 12 anos ou mais, esse valor se reduz a 14,4%.

Alguns comentários sobre esse método:

(1) é muito, mas muito mais barato do que as pesquisas de porta em porta com amostragem e, a comparação com os estudos de prevalência de porta em porta são semelhantes;

(2) permite realizar estudos seriados anuais mostrando tendências de cada um dos fatores de risco e proteção;

(3) se por um lado deixa de diagnosticar os casos assintomáticos de hipertensão e diabetes, por outro consegue identificar o acesso a esse diagnóstico.

Aproveito o momento para cumprimentar o novo Ministro da Saúde e, solicitar a manutenção do Vigitel.