HOSPI TAL MORBI DI TY AMONG ELDERLY PATI ENTS, BEFORE AND AFTER I NFLUENZA
VACCI NATI ON I N THE STATE OF PARANÁ
Ana Lúcia Mendes Fer r er1 Sonia Silv a Mar con2 Rosan gela Get ir an a San t an a3 Fer r er ALM, Mar con SS, San t an a RG. Hospit al m or bidit y am on g elder ly pat ien t s, bef or e an d af t er in f lu en za v accinat ion in t he St at e of Par aná. Rev Lat ino- am Enfer m agem 2008 set em br o- out ubr o; 16( 5) : 832- 7.
Th is ecological st u dy w as dev eloped t o ev alu at e t h e pat t er n s in h ospit al m or bidit y du e r espir at or y diseases am on g p eop le ov er 6 0 y ear s old r esid in g in t h e St at e of Par an á, b ef or e an d af t er t h e im p lem en t at ion of vaccinat ion cam paigns against influenza. The dat a about hospit alizat ions in t he 1995- 2005 per iod w er e obt ained fr om t he Hospit al I nfor m at ion Syst em and gr ouped accor ding t o healt h cent er m acr o- r egions, m ont h of occur r ence, gender and age gr oup. The dat a w as subm it t ed t o Analysis of Var iance and Tukey st at ist ical t est s, and show ed a decr easing t endency in hospit alizat ions in bot h gender s aft er t he v accinat ions st ar t ed, w it h differ ent lev els am ong age gr oups, gender , m ont hs of t he y ear and healt h cent er m acr o- r egions. The r isk for hospit alizat ion w as higher for m ales and for older pat ient s, fr om June t o Oct ober , and in m acr o- r egion num ber 3, follow ed by r egions 4, 5, 6, 2 and 1.
DESCRI PTORS: influenza vaccines; m ass im m unizat ion; influenza, hum an; r espir at or y t r act diseases; m or bidit y; aged; healt h of t he elder ly
MORBI LI DAD HOSPI TALARI A, EN ANCI ANOS, ANTES Y DESPUÉS DE LA VACUNACI ÓN
CON TRA LA I N FLUEN ZA EN EL ESTADO DE PARAN Á
Se t r at a de un est udio ecológico desar r ollado con el obj et iv o de ev aluar el com por t am ient o de la m or bilidad h osp it alar ia r elacion ad a a en f er m ed ad es r esp ir at or ias en m ay or es d e 6 0 añ os, r esid en t es en el Est ad o d e Par aná, ant es y después del inicio de las cam pañas de v acunación cont r a la influenza. Los dat os r efer ent es a las in t er n acion es, ocu r r idas en el per íodo de 1 9 9 5 a 2 0 0 5 , f u er on obt en idos del Sist em a de I n f or m acion es Hospit alar ias y agr upados por m acr o r egiones de salud, m eses de ocur r encia, sex o e int er v alos de edad. Los dat os fuer on som et idos a las pr uebas est adíst icas Análisis de Var ianza y Tukey y dem ost r ar on una t endencia a dism inuir las int er naciones después del inicio de la v acunación en am bos sex os, con est ándar es difer ent es en t r e los in t er v alos de edad, sex o, m eses del añ o y m acr o r egion es de salu d. El r iesgo de in t er n ación f u e m ayor en los hom br es m ás ancianos, dur ant e los m eses de j unio a oct ubr e y en la m acr o r egión 3, seguida por la 4, 5, 6, 2 y 1.
DESCRI PTORES: vacunas cont r a la influenza; inm unización m asiva; gr ipe hum ana; enfer m edades r espir at or ias; m or bilidad; anciano; salud del anciano
MORBI DADE HOSPI TALAR EM I DOSOS ANTES E APÓS VACI NAÇÃO CONTRA I NFLUENZA
NO ESTADO DO PARANÁ
Tr at a- se de est udo ecológico, desenvolvido com o obj et ivo de avaliar o com por t am ent o da m or bidade hospit alar por doenças r espir at ór ias em m aior es de 60 anos, r esident es no Est ado do Par aná, ant es e após o início das cam panhas de v acinação cont r a influenza. Os dados r efer ent es às int er nações ocor r idas no per íodo de 1995 a 2 0 0 5 f or am ob t id os d o Sist em a d e I n f or m ações Hosp it alar es e ag r u p ad os p or m acr or r eg ion ais d e saú d e, m eses d e ocor r ên cia, sex o e g r u p o et ár io. Os d ad os f or am su b m et id os aos t est es est at íst icos An álise d e Var iância e Tuk ey e dem onst r ar am t endência à queda das int er nações após início da v acinação em am bos os sex os, com padr ões dif er en t es en t r e as f aix as et ár ias, sex o, m eses do an o e m acr or r egion ais de saú de. O r isco de int er nar foi m aior ent r e os hom ens e ent r e os m ais idosos, dur ant e os m eses de j unho a out ubr o e na m acr or r egional 3, seguida pelas m acr or r egionais 4, 5, 6, 2 e 1.
D ESCRI TORES: v a ci n a s co n t r a g r i p e; i m u n i za çã o em m a ssa ; i n f l u en za h u m a n a ; d o en ça s r esp i r a t ó r i a s; m or bidade; idoso; saúde do idoso
1 M.Sc. in Nur sing, Nur se at Mar ingá Healt h Secr et ar y, Br asil, e- m ail: analufer r er @hot m ail.com ; 2 Ph.D. in Nur sing Philosophy, Facult y, Mar ingá St at e
Univer sit y, Brazil, e- m ail: soniasilva.m ar con@gm ail.com ; 3 Ph.D. in St at ist ics, Facult y, Mar ingá St at e Univer sit y, Brazil, e- m ail: r gsant ana@uem .br.
I NTRODUCTI ON
P
opulat ion aging w as a char act er ist ic r ealit y of t h e w or ld du r in g t h e 2 0t h cen t u r y. I n Br azil, t h epr ocess of aging occur s abr upt ly, fast and in a cont ext
o f h u g e s o c i a l i n e q u a l i t i e s , i . e . w i t h o u t t h e
est ab lish m en t of econ om ic an d social ch an g es t h at
could w arrant a bet t er qualit y of life for t he elderly( 1).
W i t h h i g h e r n u m b e r s o f s e n i o r s i n t h e
populat ion, im por t ant changes ar e evident in t he cause
of diseases and deat hs, w it h an increasing prevalence
of sequelae and com plicat ions of chronic- degenerat ive
co n d i t i o n s( 2 ). Am o n g t h e ca u ses o f m o r b i d i t y a n d
m o r t a l i t y i n t h e p o p u l a t i o n o v e r 6 0 y e a r s o l d ,
r esp i r at o r y d i seases co n st i t u t e t h e m ai n cau se o f
hospit alizat ion, in w hich infect ion by t he influenza virus
infect ion and it s com plicat ions st and out in t he past
d eca d es.
Am o n g t h e a ct i o n s f o r p r e v e n t i o n h e a l t h
p r ob lem s in t h e eld er ly, in f lu en za v accin at ion s ar e
t h e pr im ar y st r at egy, sin ce t h ey can pr ev en t u p t o
70% of t he cases of hospit alizat ion due t o pneum onia
and influenza( 3). For t he sev er e for m of t he disease,
secondary com plicat ions and deat hs, effect iveness can
be as high as 60%( 3).
Co n si d e r i n g t h a t t h e m e a su r e s o f h e a l t h
pr om ot ion and pr ev ent ion t ow ar ds t he elder ly w hich
aim t o r educe com plicat ions of influenza can im pact
t h e q u al i t y o f l i f e an d su r v i v al o f t h i s g r o u p , t h e
obj ect ive of his st udy w as t o evaluat e t he behavior of
som e in dicat or s of h ospit al m or bidit y, in t h e elder ly
popu lat ion of t h e st at e of Par an á, du r in g t h e 1 9 9 5
-2 0 0 5 per iod.
METHOD
This is a descr ipt ive ecologic st udy about t he
e l d e r l y p o p u l a t i o n l i v i n g i n t h e St a t e o f Pa r a n á ,
a d m i t t ed t o h o sp i t a l s d u e t o r esp i r a t o r y d i sea ses
dur ing t he 1995- 2005 per iod. St udies w it h a spat
ial-t em por al appr oach allow f or ial-t h e ch ar acial-t er izaial-t ion of
t h e t en d en cies of p h en om en a t h at d o n ot sh ar e a
si n g l e ep i d em i o l o g i ca l p r o f i l e w i t h i n t h e Br a zi l i a n
t er r i t o r y, b ei n g r eg i on al l y d i f f er en t d u e t o sev er al
fact or s. Ecologic st udies ar e appr opr iat e t o ev aluat e
t he effect iveness of int ervent ions in a group of people
belonging t o a giv en geogr aphic ar ea.
The st at e of Paraná is divided in six healt hcar e
m acr o- r egions,. Macr o- r egions 1, 2 and 4, locat ed in
t he Sout h of t he st at e, pr esent a t em per at e clim at e,
w it h harsher w int ers. I n t he ot her regions, t he clim at e
is hum id and subt r opical.
Ther efor e, t he ex ist ence of a lar ge dat abase
com pilin g in f or m at ion abou t h ospit alizat ion s f or t h e
cou n t r y an d it s r eg ion s, st at es, cit ies, m acr o- an d
m icr o- ar eas w ould be an im por t ant condit ion for t he
d e f i n i t i o n o f t h e r e s e a r c h d e s i g n , a l l o w i n g f o r
com p ar ison s am on g t h e m acr o- r eg ion al h ealt h car e
div isions of t he St at e.
The DATASUS dat abase was used as a sour ce
f or collect in g p op u lat ion an d m or b id it y d at a. Mor e
s p e c i f i c a l l y, t h e H o s p i t a l i z a t i o n Au t h o r i z a t i o n s
-Au t or izações de I n t er n ação Hospit alar ( AI Hs) , w er e used t o ident ify t he var iables: m ain diagnosis, gender,
age gr ou ps an d places of r esiden ce for people ov er
60 year s old, w ho had been hospit alized by t he Single
Healt h Sy st em ( SUS) , dur ing t he 1995- 2005 per iod.
These dat a w er e t he base for t he calculat ion
of t h e f ollow in g in d icat or s: Rat e of h osp it alizat ion s
d u e t o r e s p i r a t o r y d i s e a s e s p e r 1 0 0 0 e l d e r l y
i n h a b i t a n t s ( TI RD S / 1 0 0 0 i n h a b i t a n t s ) ; Ra t i o o f
h ospit alizat ion s du e t o r espir at or y diseases select ed
am ong t he t ot al of hospit alizat ions due t o r espir at or y
d i s e a s e s ( PI D RS/ TI D R) ; Ra t i o b e t w e e n m o n t h l y
i n t e r n m e n t s d u e t o r e sp i r a t o r y d i se a se s a n d t h e
m on t h ly am ou n t of av ailable beds in m edical clin ics
( RI D RS/ LCM)
Th e s e l e c t e d r e s p i r a t o r y d i s e a s e s w e r e
pneum onia, influenza and chr onic obst r uct ion of t he
u p p e r a i r w a y s, si n ce t h e se d i a g n o se s r e f l e ct t h e
i m p a c t o f i n f l u e n z a i n t h e c o m m u n i t y( 4 ). I n t h e
I n t e r n a t i o n a l Cl a s s i f i c a t i o n o f D i s e a s e s , t h e s e
diagnoses r efer t o t he it em s: 480- 483, 485- 487,
490-491 and 496 for t he 9t h I CD r evision and J10-J19 and
J22; J40-J42 and J44 for t he 10t h I CD revision.
Af t e r d a t a co l l e ct i n g , r e v i e w i n g a n d p r e
-coding, t ables w ere built w it h a percent ile dist ribut ion
f o r q u a l i t a t i v e o r ca t e g o r i ca l v a r i a b l e s, a n d t h e
calcu lat ion of m easu r em en t s f or t h e qu an t it at iv e or
n o n - c a t e g o r i c a l v a r i a b l e s . Th e A N OV A v a r i a n c e
a n a l y si s st a t i st i ca l t est w a s u sed t o co m p a r e t h e
av er age v ar iat ion of t he st udied indicat or s, and also
t o v er i f y w h et h er t h i s v a r i a t i o n h a p p en ed d u e t o
v a c c i n a t i o n s o r b y c h a n c e . A f t e r t h e d i f f e r e n c e
bet w een t h e av er ages h ad been con f ir m ed, Tu k ey ’s
t est w as u sed f or t h e ex am in at ion of av er ages an d
t h e d i f f e r e n c e b e t w e e n t h e m , c o n s i d e r i n g a
RESULTS
Dur ing t he per iod st udied ( 1995 t o 2005) , t he
r e sp i r a t o r y t r a ct d i se a se s o ccu p i e d a n o t e w o r t h y
posit ion am on g t h e ot h er h ospit alizat ion s of elder ly
pat ient s in t he st at e of Paraná, const it ut ing t he second
cau se of h ospit alizat ion , ex cept in 1 9 9 8 , w h en t h ey
r ank ed fir st( 5).
I t is int er est ing t o obser v e t hat , despit e t he
p r o g r e s s i v e i n c r e a s e o f s u r v i v a l r a t e s a n d t h e
consequent incr ease of t he elder ly populat ion in t he
st at e, t he num ber of adm it t ances due t o r espir at or y
diseases w as st able in all m acr o- r egional healt hcar e
div isions. Fur t her m or e, t he analy sis of t he indicat or s
TI DRS/ 1000 inhabit ant s, PI DRS/ TI DR and RI DRS/ LCM
t h r ou g h ANOVA sh ow ed t h at t h er e is a sig n if ican t
d i f f e r e n c e w h e n t h e i n d i c a t o r s b e f o r e 1 9 9 9 a r e
co m p ar ed . Th at w as t h e y ear w h en t h e i n f l u en za
v accin at ion cam paign s w er e st ar t ed.
A s f o r t h e m a c r o - r e g i o n a l d i v i s i o n s , w e
o b ser v ed t h at t h er e ar e d i f f er en ces am o n g t h em .
Macr o- r egional divisions 1, 2 and 6, besides behaving
sim ilar ly for t h e ev alu at ed in dicat or s, pr esen t ed t h e
best in dicat or s. Macr o- r egion al div ision s 5 , 4 an d 3
sh ow ed m u t u al d if f er en ces an d also w it h t h e ot h er
divisions, w it h division 5 having bet t er rat es, follow ed
by 4 and 3, in t his or der.
The TI DRS/ 1000 inhabit ant s indicat or show s
t hat t he select ed respirat ory diseases w ere responsible
for 24 t o 25% of t ot al hospit alizat ions due t o r espir at or y
diseases for t he populat ion ov er 60 y ear s old in t he
s t a t e o f Pa r a n á , b e t w e e n 1 9 9 5 a n d 1 9 9 8 . Th i s
per cent age gr adually decr eased fr om 1999 ( 22.92% )
onw ar ds, r eaching 18. 06% in 2005.
The com par ison bet w een t he aver ages of t he
TI DRS/ 1 0 0 0 elder ly in h abit an t s, f ou n d in t h e y ear s
b ef o r e an d af t er t h e b eg i n n i n g o f t h e v acci n at i o n
cam p aig n s sh ow ed a sig n if ican t d if f er en ce b et w een
bot h gr oups, w it h t he fir st gr oup pr esent ing a higher
av er age r at e of h ospit alizat ion .
Th e r e d u ct i o n o f t h e i n d i ca t o r p r e se n t e d
st at ist ical sign if ican ce f or bot h gen der s an d f or t h e
fiv e- y ear age gr oups, w it h t he r isk of hospit alizat ion
due t o r espir at or y disease being 1.09 t im es ( 8.36% )
h igh er for m ales an d gr adu ally in cr easin g w it h age,
since, w hen 60 t o 64 year - old pat ient s w er e com par ed
w it h t he ot her age gr oups, t he r isk of hospit alizat ion
b ecau se of su ch d iseases w as 3 . 2 t im es h ig h er f or
t hose older t han 80, 2.84 t im es higher am ong t hose
aged 75 t o 79, 2.18 t im es higher for t hose aged 70 t o
74 and 1.47 t im es higher for t hose aged 65 t o 69.
I n t h e h ealt h car e m acr o- r eg ion al d iv ision s,
a sim ilar behavior t o t hat of t he St at e as a w hole w as
obser ved. This indicat or w as seen t o be higher am ong
w om en only in m acr o- r egional division 3. This aspect
is int er est ing and can ev en be t he obj ect of fur t her
st udies, since t his is t he only m acr o- r egional div ision
w it h a higher m ale populat ion ( 50.3% m ales) over 60
year s old. The m acr o- r egional division pr esent ing t he
low est hospit alizat ion rat e for t he select ed respirat ory
diseases w as 1, follow ed by 6 and 2, w it h sim ilar r at es,
and t hen by 5, 4 and 3, in t his or der.
Th e PI DRS/ TI DR in d icat or sh ow ed t h at t h e
rat io of hospit alizat ions in t he St at e of Paraná due t o
t he select ed respirat ory diseases is significant ly low er
aft er t he vaccinat ion int er vent ions w hen com par ed t o
t he t ot al am ount of respirat ory disease hospit alizat ion,
decreasing from 23.70% in 1995 t o 18.06% in 2005.
During t he t w o st udied periods, PI DRS/ TDR w as 1.03
t im es h igh er am on g m ale sen ior s, an d t h e select ed
r esp i r at o r y d i seases b eh av ed seaso n al l y, w i t h t h e
m ont hs of June, July, August and Sept em ber showing
t he highest rat es for t he indicat or.
As for t he spat ial dist r ibut ion, m acr o- r egional
div ision 1 w as obser v ed t o pr esent t he low est index
f or t h is in d icat or, f ollow ed b y 6 . Div ision s 5 an d 2
hold t he t hird place, and last ly, divisions 4 and 3.
Th e RI DRS/ LCM in d icat or sh ow ed t h at t h e
r at io bet w een m ont hly hospit alizat ions due t o select ed
r espir at or y diseases and t he num ber of available beds
in m edical clin ics f or t h e St at e of Par an á in cr eased
pr ogr essiv ely bet w een 1995 ( 0.26) and 1992 ( 0.31) ,
w it h a significant dow nw ar d t endency bet w een 1999
( 0 . 3 4 ) an d 2 0 0 5 ( 0 . 2 9 ) . Th is d r op , ob ser v ed sin ce
t h e v a cci n a t i o n i n t e r v e n t i o n s, h a p p e n e d f o r b o t h
genders and t he t hree age ranges evaluat ed, wit h t he
average RI DRS/ LCM indicat or lower for t hose over 80
y ear s old, follow ed by t hose aged 70- 79 and w it h a
higher rat e of hospit alizat ion for pat ient s aged 60- 69.
S e a s o n a l i t y w a s a l s o p e r c e i v e d f o r t h i s
i n d i ca t o r, w i t h t h e m o n t h s o f Ju n e t o No v e m b e r
pr esen t in g h igh er RI DRS/ LCM.
A m o n g t h e m a c r o - r e g i o n a l h e a l t h c a r e
div isions of Par aná, t he ev olut ion of t he RI DRS/ LCM
accor ding t o age r anges and gender show ed t hat t he
in dicat or in cr eased pr opor t ion ally t o age in t h e fir st
y ear s. How ev er, it w as alt er ed in all m acr o- r egion s
t h r ou g h ou t t h e p er iod , w it h a h ig h er p r ev alen ce of
h ospit alizat ion s for sen ior s aged 7 0 - 7 4 , follow ed by
t h ose aged 6 0 - 6 9 , an d f in ally, t h ose ov er 8 0 y ear s
old . Wh en g en d er s w er e com p ar ed , t h e occu r r en ce
of t his phenom enon w as obser v ed t o st ar t pr im ar ily
Table 1 – Com par ison of t he av er age values for t he
in dicat or s: TI DRS/ 1 0 0 0 elder ly in h abit an t s, PI DRS/
TDR and RI DRS/ LCM accor ding t o vaccinat ion, gender,
ag e r an g e, h ealt h car e m acr o- r eg ion al d iv ision an d
m ont hs of t he y ear. St at e of Par aná, 1995- 2005
Not e: Sim ilar let t er s m ean t hat t he var iables behaved sim ilar ly. Differ ent let t er s r epr esent significant 5% - differ ences.
DI SCUSSI ON
Alt hough it w as difficult t o deal w it h a dat abase
co m p i l i n g a l ar g e am o u n t o f i n f o r m at i o n , su ch as
D a t a s u s , a n d t o o b t a i n u p d a t e d a n d c o m p l e t e
infor m at ion, t he t r end of m or bidit y due t o t he select ed
r espir at or y diseases for t h e St at e of Par an á r ev eals
a significant dr op of t he indicat or s aft er t he st ar t of
v accin at ion in t er v en t ion s again st in flu en za.
Th e f i r s t r e s u l t t o b e c o n s i d e r e d i s t h e
cont inued second posit ion of respir at or y t r act diseases
as t he cause of hospit alizat ions am ong seniors in t he
St a t e o f Pa r a n á t h r o u g h o u t t h e s t u d y p e r i o d( 5 ).
Resp ir at or y d iseases also occu p y t h e secon d p lace
f or h osp it alizat ion s am on g sen ior s in all r eg ion s of
t h e cou n t r y. How ev er, in t h e Sou t h an d Sou t h east
regions, t his rat io is m uch higher t han in ot her regions,
sin ce t h ey accou n t f or 2 9 . 1 3 % an d 3 5 . 4 2 % of t h e
t ot al h osp it alizat ion s of sen ior s, r esp ect iv ely, w it h
v alues of 4.31% for t he Nor t h r egion, 8.21% for t he
Cent ral-West and 22.92% in t he Nor t heast . This leads
u s t o i n f e r t h a t , i n t h e st a t e s o f t h e So u t h a n d
So u t h east r eg i o n s, r esp i r at o r y d i seases i n el d er l y
pat ient s ar e m uch m or e im por t ant t han in st at es of
ot h er r egion s.
A hospit al m or bidit y st udy per for m ed in t he
St at e of São Paulo fr om 1995 t o 2002 show ed a low er
per cent age of hospit alizat ions due t o r espir at or y t r act
diseases t han t hose found in Paraná. Whereas, in São
Paulo, r espir at or y t r act diseases w er e r esponsible for
10% - 11% of t he t ot al hospit alizat ions of t he populat ion
ov er 6 0 y ear s old( 4), t h is r at io w as ar ou n d 2 4 % for
Par an á. How ev er, in bot h st at es, a r edu ct ion in t h e
am ou n t of h osp it alizat ion s d u e t o r esp ir at or y t r act
diseases w as obser ved aft er vaccinat ion int er vent ions
against influenza( 6). I n Port o Alegre, t he im pact of t he
vaccinat ion cam paigns against influence w as analyzed
fr om 1996 t o 2000, and show ed a decr ease of 25.2%
for pneum onia hospit alizat ions( 7 ).
A s t u d y a b o u t t h e s t r a t e g y o f i n f l u e n z a
vaccinat ion in Brazil realized t hat t he cam paigns have
ex er t ed a posit iv e im pact in t he t em per at e Sout her n
and Sout heast er n r egions of t he count r y, but not in
t h e ot h er s, w it h t r op ical clim at es, esp ecially in t h e
N o r t h a n d N o r t h e a s t( 8 ). S t u d i e s p e r f o r m e d i n
Fo r t al eza( 9 ) an d t h e Fed er al Di st r i ct , f o r ex am p l e,
show ed no r educt ion in t he hospit alizat ion and deat h
r at es in people ov er 60 y ear s old( 10).
The falling t endency of t he hospit alizat ion r at e
d u e t o t h e select ed r esp ir at or y d iseases p er 1 0 0 0
senior inhabit ant s ( TI DRS/ 1000 inhabit ant s) bet w een
1 9 9 5 an d 2 0 0 5 , p ar t icu lar ly m or e ex p r essiv e af t er
1 9 9 9 , co n f i r m s w h at h as b een t o u t ed ab o u t an t i
-i n f l u e n za v a cc-i n e s b e -i n g ca p a b l e o f r e d u c-i n g t h e
num ber of hospit alizat ions of elder ly people( 11). Som e
st udies show , for exam ple, t hat t he influenza vaccine
r educes hospit alizat ions due t o pneum onia, influenza
and chronic r espir at or y diseases in 30- 70% for seniors
w ho do not live in nursing hom es( 12). I n Ar gent ina, a
30- 45% r educt ion w as found in hospit alizat ion r at es
d u e t o p n e u m o n i a a f t e r r e c e i v i n g i n f l u e n z a
v accin es( 1 3 ).
When t he evolut ion of hospit al m or bidit y due
t o r e sp i r a t o r y d i se a se s i s co m p a r e d b e t w e e n t h e
st at es of São Paulo and Par aná, t he t ot al am ount of
h osp it alizat ion s d ecr eased in Par an á b u t r em ain ed
st able in São Paulo( 4).
0 0 0 1 / S R D I T . b a h n
i PIDRS/TDR RIDRS/LCM
e t a t S n o it a n i c c a V 9 9 9 1 e r o f e
B 62.444b 27.50214b 0.051977b 9 9 9 1 r e t f
A 75.703a 30.50516a 0.056375a r e d n e G e l a m e
F 64.30445b 28.15342b
-e l a
M 70.22594a 29.03487a
-p u o r G e g A d l o s r a e y 9 6 -0
6 37.1331c - 0.064001c
d l o s r a e y 9 7 -0
7 75.2692b - 0.066103b
r e d l o r o s r a e y 0
8 111.5214a - 0.034222a
n o i s i v i d l a n o i g e r -o r c a M
1 37.8986e 19.57773d 0.037794f 2 46.6487d 29.13747b 0.040718e 3 123.5716a 36.04503a 0.074728a 4 87.5429b 35.09621a 0.066610b 5 61.6286c 28.08009b 0.063592c
6 46.3006d 23.62835c 0.045212d h t n o M y r a u n a
J - 26.16679hi 0.048821d
y r a u r b e
F - 24.78552i 0.047416d
h c r a
M - 25.34475i 0.048401d
li r p
A - 26.28262hi 0.048033d
y a
M - 27.35835fgh 0.051231d
e n u
J - 30.68478bc 0.058148bc
y l u
J - 33.13092a 0.064980a
t s u g u
A - 32.35056ab 0.062072ab
r e b m e t p e
S - 31.30750abc 0.061325ab
r e b o t c
O - 29.79814cd 0.059509bc
r e b m e v o
N - 28.59808def 0.056276c
r e b m e c e
Th e TI D RS / 1 0 0 0 i n h a b i t a n t s r a t i o w a s
sign ifican t ly r edu ced for bot h gen der s an d fiv e- y ear
age gr oups in t he st at e of Par aná fr om 1995 t o 2005.
Mo r eo v er, as seen i n t h e st at e o f São Pau l o, t h i s
indicat or w as also higher am ong m en and gr adually
incr eased accor ding t o age in t he st at e of Par aná( 4).
The hospit alizat ion r at io due t o t he select ed
r espir at or y diseases am ong t he t ot al hospit alizat ions
due t o r espir at or y disease – PI DRS/ TDR in Par aná is
low er t h an t h e ov er all Br azilian r at io. Wh er eas t h is
in d icat or in cr eased f r om 2 3 . 7 9 % t o 2 4 . 1 5 % in t h e
st at e of Par aná in 1995- 1998, it fell pr ogr essively aft er
1999, r eaching 18. 06% in 2005. For Br azil, PODRS/
TDR h as p r o g r essi v el y i n cr eased , f r o m 5 7 . 6 4 % i n
1995 t o 61.83% in 1997. I n 1998, it dr opped t o 35.11%
an d , af t er t h e v accin at ion in t er v en t ion s st ar t ed , it
show ed a falling t r end, r egist er ing 3 4 . 1 2 % in 2 0 0 2 .
How ev er, it in cr eased ag ain in t h e t h r ee f ollow in g
y ear s, r eaching 40.56% in 2005( 5).
Co n v er sel y, d u r i n g t h e 1 9 9 5 - 2 0 0 2 p er i o d ,
PI DRS/ TDR w as low er in t he st at e of São Paulo t han
in Par an á. How ev er, t h is in dicat or beh av ed sim ilar ly
bet w een bot h st at es, increasing in t he fir st year s and
t e n d i n g t o d e c r e a s e a f t e r t h e v a c c i n a t i o n
int ervent ions( 4). The low er rat io of hospit alizat ions due
t o p n eu m on ia in r elat ion t o t h e ov er all n u m b er of
hospit alizat ions due t o r espir at or y diseases w as also
descr ibed for senior s liv ing in Por t o Alegr e( 7).
I n Par aná, t his r at io w as higher am ong m ale
sen ior s, an d t h e season al ch ar act er of t h e diseases
t hat afflict t his share of t he populat ion due t o influenza
w as ev iden t , w it h h igh er v alu es in t h e per iod f r om
June t o Oct ober.
Th is season alit y, w h ich cor r esp on d s t o t h e
colder period of t he year, was also observed in several
regions of Brazil, such as t he st at es of Rio Grande do
Sul( 14) and São Paulo( 4) and t he cit ies of Maceió( 15) and
Belém( 16). I n For t aleza, how ever, t he per iod w it h t he
h i g h e st n u m b e r o f h o sp i t a l i za t i o n s co m p r e h e n d s
M a r c h a n d A p r i l , t h i s b e i n g o n e o f t h e f a c t o r s
associat ed t o t he low effect iveness of t he vaccinat ion
cam paigns in t hese regions, because t he vaccines are
on ly m ade av ailable by t h e Min ist r y of Healt h f r om
Apr il onw ar ds( 9).
The indicat or rat io of m ont hly hospit alizat ions
d u e t o t h e se l e ct e d r e sp i r a t o r y d i se a se s a n d t h e
available beds in m edical clinics ( RI DRS/ LCM) for t he
St at e of Paraná is low er t han t he one found for Brazil
a s a w h o l e . W h i l e t h e RI D RS / LCM i n c r e a s e d
pr ogr essively in Par aná fr om 1995 ( 0.26) t o 1998 ( 0.31)
and pr esent ed a significant falling t endency bet w een
1999 ( 0.34) and 2005 ( 0.29) , t he indicat or r em ained
st able for Br azil in t he t hr ee fir st y ear s of t he st udy
( 0.15) , incr easing in 1998- 1999 t o 0.19, and r em aining
m ost ly st able since t hen( 5).
The dr op obser v ed for RI DRS/ LCM in Par aná
a f t e r t h e v a cci n a t i o n i n t e r v e n t i o n s a f f e ct e d b o t h
g en d er s an d t h e t h r ee ag e g r ou p s ev alu at ed , w it h
t h e av er ag e v alu e of t h is in d icat or b ein g in v er sely
pr opor t ional t o age. This fact , higher aver age num ber
of hospit alizat ions am ong t he younger age gr oups, is
a consequence of it s ow n percent ile represent at ion in
t he elder ly populat ion of Par aná, since t he num ber of
senior s is inv er sely pr opor t ional t o age.
S e a s o n a l i t y w a s a l s o o b s e r v e d f o r t h i s
in dicat or, w it h t h e h igh er RI DRS/ LCM m on t h s bein g
t hose fr om June t o Nov em ber.
I n t he st at e of São Paulo, as w ell as in Paraná,
af t er t h e in f lu en za v accin at ion s f or p eop le ov er 6 0
w er e st ar t ed, a ch an ge w as obser v ed in t h e ch ar t s
an d t ab les sh ow in g t h e in d icat or, w it h low er p eak s
dur ing t he influenza seasons( 4).
I f w e co n si d er t h e g r o w t h o f t h e el d er l y
population in Paraná during the studied period, from 6.82
t o 8 . 3 3 % , an d t h e r ed u ct ion of av ailab le b ed s f or
hospitalization, from 10,725 in 1995 to 8,654 in 2002, it
can be inferred that the drop in the RI DRS/ LCM was higher
and m ore significant than the results presented here.
FI NAL CONSI DERATI ONS
Thr ough t hese hospit al m or bidit y indicat or s,
w e co u l d o b se r v e d i f f e r e n ce s i n t h e b e h a v i o r o f
hospit alizat ions am ong r egions of t he sam e st at e, in
ad d i t i o n t o t h e p o si t i v e i m p act o f t h e v acci n at i o n
int er v ent ions t o r educe hospit alizat ion of senior s due
t o r espir at or y diseases. This fact m ay be r elat ed, on
t he one hand, t o unavoidable fact or s like t he cur r ent
viral st rain, clim at e fact ors, represent at ion of t he
five-y ear g r ou p s an d g en d er in t h e com p osit ion of t h e
sen ior p op u lat ion s of each m acr o- r eg ion al d iv ision .
How ever, on t he ot her hand, it could be a consequence
of t h e con dit ion s an d qu alit y of h ealt h car e an d t h e
r esou r ces av ailab le/ of f er ed .
An y w ay, t h e d i f f er en ces f o u n d am o n g t h e
healt hcar e m acr o- r egional div isions r em ind us of t he
need for st udies t hat can also ev aluat e t he behav ior
of t h ese in dicat or s bet w een t h e dif f er en t r egion s of
Br azil, so t hat t he sim ilar it ies and differ ences am ong
t hese r egions can be ident ified as det er m iner s in t he
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