Revista de Saúde Pública
I SSN 0034- 8910 versão im pressaRev Saúde Pública 2004; 38(1)
Mortality among children enrolled in public day care center s in
Braz il
Eneida S Ram os Vicoa and Ruy Laurent ib a
Secret aria Municipal da Saúde de São Paulo. São Paulo, SP, Brasil. bDepart am ent o de Epidem iologia da Faculdade de Saúde Pública da Univer sidade de São Paulo. São Paulo, SP, Br asil
ABSTRACT
Objective
To describe t he m ort alit y pat t ern am ong children enrolled in public day care cent ers.
M et h ods
This w as a descr ipt iv e st udy of t he m or t alit y pat t er n am ong childr en aged fr om 0 t o 6 y ear s and 11 m ont hs who were enrolled in all t he public day care cent ers in t he cit y of São Paulo, Brazil, from 1995 t o 1 9 9 9 . The v ar iables of int er est w er e sex , age, under ly ing cause of deat h, dur at ion of day car e at t endance and seasonalit y .
Results
54.2% of t hese childr en occur r ed befor e com plet ing six m ont hs in t he day car e cent er , w it h a concent r at ion of 36.3% dur ing t he fir st t hr ee m ont hs. The m aj or it y of t he deat hs occur r ed dur ing t he wint er and aut um n seasons: 31.8% and 29.6% , r espect ively. The m ain under lying causes of deat h were infect ions: pneum onia ( 29.6% ) , m eningococcal disease ( 13.0% ) , non- m eningococcal m eningit is ( 8.5% ) , gast roent erit is ( 7.6% ) and chickenpox ( 5.4% ) . Ext ernal causes were responsible for 13.5% of t h e deat h s and included falls, being run over, drowning, burns and physical aggression.
Conclusions
The st udy indicat ed t hat y ounger childr en ( 0- 3 year s) w er e t he m ost vulner able gr oup and t hat t he m aj orit y of deat hs derived from avoidable causes, som e of which pre v ent able by v accinat ion now aday s.
Keywords
I nfant m or t alit y . Child day car e cent er s. Under ly ing cause of deat h. Mor t alit y r at e. Seasonal var iat ions.
I N TRODUCTION
The gr ow ing availabilit y over r ecent decades of at t endance for childr en in day car e cent er s or inst it ut ions of t his t y pe has been a sour ce of new st udies. Wit hin t he field of healt hcar e, such cent er s now give rise t o a furt her quest ion for public healt h, in relat ion t o groups at risk. I n addit ion t o young childr en’s nat ur al vulner abilit y, t hose t hat ar e enr olled in day car e cent er s have a gr eat er pr obabilit y of acquir ing and developing infect ions, especially r epeat ed infect ions of a r espir at or y, gast r oint est inal and sk in nat ur e. The collect ive envir onm ent of day car e cent er s pr ovides t he condit ions for lar ge - scale cir culat ion and t r ansm ission of pat hogenic agent s.2 , 6 , 9 , 1 9 I n Brazil, recent research exist s on child dev elopm ent , car e giv en t o childr en in day car e cent er s and t he effect s of such car e on t heir healt h. The infor m at ion m ade available has in som e m anner cont r ibut ed t ow ar ds consolidat ing t he specific at t endance m odel as w ell as in t he adopt ion of st andar ds for pr ocedur es and m or e appr opr iat e car e, bot h in t he individual and colle ct iv e spher es. I t has also r educed t he r isk s and dam age t o healt h, t hereby result ing in im provem ent in t he qualit y of at t endance.
How ever, t he sit uat ion regarding m ort alit y has not been analyzed, despit e it s im port ance in t he con t ex t of day car e cen t er s. The pr esent w or k t her efor e had t he obj ect iv e of descr ibing t he m or t alit y pat t er n am ong childr en w ho w er e placed in day car e cent er s.
M ETHODS
Table 1- Number of day care centers in the municipal network of São Paulo and the respective number of children attended, for the period from 1995 to 1999.
Year Municipal day care center network
1995 1996 1997 1998 1999
No. of day care centers 696 698 716 723 726
No. of children attended 114,570 124,003 123,595 123,243 127,606
Source: São Paulo Municipal Department of Social Assistance, 2000.
The dat a w er e obt ained fr om t he deat h not ificat ion r ecor ds t hat , t oget her w it h r epor t s on t he hist or ies t hat led t o t he deat hs, for m t he m or t alit y infor m at ion sy st em of t he day car e cent er net w or k adm inist er ed by t he Municipal Depar t m ent of Social Assist ance of São Paulo. This sy st em w as im plem ent ed in January 1995 and not ificat ion in t his syst em is com pulsory. I t has t he aim of m onitoring t he occur r ence of deat hs am ong t hose enr olled in t he net w or k , as w ell as t he pr ocesses t hat led t o t hese deat hs, t her eby allow ing gr eat er r esponsiv eness in act ions t ak en. This infor m at ion w as com plem ent ed w it h copies of t he or iginal deat h cer t ificat es, fur nished t hrough t he m ort alit y inform at ion im provem ent program ( PRO- AI M) or t he SEADE Foundat ion.
The follow ing v ar iables w er e obser v ed: sex , age at deat h, seasonalit y , m ot her ’s educat ion lev el, dur at ion of day car e at t endance ( fr om t he dat e of enr ollm ent unt il t he child’s last day of pr esence) and t he under ly ing cause of deat h. These w er e select ed and gr ouped in accor dance w it h t he 10t h Revision of t he I nt ernat ional St at ist ical Classificat ion of Diseases and Relat ed Healt h Problem s ( I CD-10) . To st andar dize t he dat a analy sis, t he deat hs t hat occur r ed in 1995, w hen t he I CD- 9 was st ill in for ce, had t heir under ly ing causes of deat h r ecoded in accor dance w it h I CD- 10, in conform it y wit h guidance from t he Brazilian Cent er for Disease Classificat ion of t he Depart m e nt of Epidem iology of t he Facult y of Public Healt h of USP.
The dat abank w as const r uct ed using t he Epi I nfo pr ogr am , ver sion 6.04/ CDC/ WHO.
The descr ipt iv e analy sis w as based on t he fr equency dist r ibut ion ( in absolut e and per cent age v alues) , av er ages, m or t alit y r at es per 100,000 childr en per day car e cent er for t he set of cause and age -specific deat hs, and aver age r at es for t he w hole per iod. The r elat ionship bet w een t he num ber of ev ent s t hat occur r ed and t he t ot al num ber of childr en at t ended in t he day car e cent er net w or k for t he sam e y ear w as consider ed. For t he calculat ion of t he m or t alit y r at es, it w as not possible t o ut ilize t he per sons- lengt h of observat ion denom inat or, which would be m ore appropriat e for dynam ic populat ion st udies, due t o insufficiency of inform at ion.
RESULT S
I nform at ion was obt ained regarding all t he deat hs ( 223) . From t his t ot al, it was observed t hat 15.2% w er e cer t ified by t he I nst it ut o Médico Legal ( t he for ensic m edicine ser v ice) and 31.8% by t he hospit al ser v ices t hem selv es w her e t hese childr en w er e at t ended. I t becam e t he r esponsibilit y of t he deat h v er ificat ion ser v ice t o cer t ify 53% of t he cases in w hich t he diagnosis of t he causes of deat h w as not clear ly defined.
I n t he dist r ibut ion by sex , 57.4% of t he childr en w ho died w er e boy s. The fact t hat t he m unicipal net w or k does not have infor m at ion available regarding age and sex of t he children enrolled m ade it im possible t o per for m cer t ain com par at iv e analy ses concer ning t he set of day car e cent er user s.
Table 2 – Deaths, according to sex and age in years, among children enrolled in the municipal day care center network of São Paulo, for the period from 1995 to 1999.
Sex Male Female Total
Age (years) N % N % N %
Accumulated frequency
0 1 44 34.4 29 30.5 73 32.7 32.7 1 2 32 25.0 23 24.2 55 24.6 57.3 2 3 24 18.8 23 24.2 47 21.1 78.4 3 4 13 10.1 12 12.6 25 11.2 89.6 4 5 4 3.1 6 6.3 10 4.5 94.1 5 6 9 7.0 1 1.1 10 4.5 98.6 6 7 2 1.6 1 1.1 3 1.4 100.0 Total 128 100.0 95 100.0 223 100.0
: Indicates limit of frequency interval
Table 3 pr esent s t he m or t alit y r at es calculat ed for each y ear of t he per iod. Ther e is a possibilit y t hat t hese v alues indicat e a decline in t he r at es, but t he shor t ness of t he obser v at ion per iod and t he sm all num ber of cases do not allow such an affir m at ion.
Table 3 – Deaths among children enrolled in the municipal day care center network of São Paulo, for the period from 1995 to 1999.
Deaths Year
N Rate*
1995 57 49.7
1996 42 33.9
1997 42 34.0
1998 40 32.4
1999 42 33.0
Total 223 36.4**
*Rate per 100,000 children enrolled in the day care centers.
**Average rate for the period.
The gr eat est fr equency of deat hs occur r ed in t he aut um n and w int er m ont hs. The causes seen m ost were pneum onia ( 31.8% and 39.4% , respect ively) , m eningococcal infect ion ( 10.6% and 12.7% ) and non- m eningococcal m eningit is ( 10.6% and 8.5% ) . These t w o seasons account ed for 74% of t he deat hs am ong children under one year old, 60% of deat hs am ong t hose aged one year and 55.3% of deat hs am ong t hose aged t w o y ear s.
The educat ion lev el dat a for t he m ot her s of t he childr en t hat died dur ing t he st udy per iod show ed t hat 8.5% were illit erat e, 58.3% had com plet ed up t o t he end of grade school, 6.3% up t o t he end of high school and for 26.5% t here w as no dat a. I t m ust be em phasized t hat t his w as a populat ion w it h an incom e level of up t o four m inim um m ont hly wages.
The causes of death
When t he under lying causes w er e gr ouped accor ding t o t he divisions of I CD- 10 ( Table 4) , t her e w er e four m ain groups. First , in order of im port ance, were respirat ory diseases ( 36.8% ) , which in 94.0% of t he cases affect ed children aged under t hree years, w it h predom inance of pneum onia ( 80.5% ) . Next were infect ious and parasit ic diseases ( 31.8% ) , of which 71.9% occurred am ong t hose aged under t hree years. I n t his group, m eningococcal infect ions ( 40.8% ) , gast r oent er it is ( 24.0% ) and chickenpox ( 17.0% ) were prom inent . I n t hird place were ext ernal causes ( 13.5% ) , of which falls, being run over, drow ning, burns and physical aggression w ere t he m ain circum st ances. I n fourt h place w ere diseases of t he nervous syst em ( 9.4% ) , basically due t o m eningit is, occurring exclusively am ong children aged under t hr ee y ear s.
Table 4 – Deaths, according to underlying cause of death, grouped according to the divisions of ICD-10, for children enrolled in the municipal day care center network of São Paulo, for the period from 1995 to 1999.
Underlying cause of death N %
I - Infectious or parasitic diseases 71 31.8
• Diarrhea and gastroenteritis of presumed infectious origin (17) (7.6)
• Tuberculosis (1) (0.4)
• Meningococcal infection (29) (13.0)
• Other septicemia (6) (2.7)
• Chickenpox (12) (5.4)
• Measles (1) (0.4)
• Viral hepatitis (4) (1.8)
• Diseases from HIV (1) (0.4)
II - Neoplasia 2 0.9
III – Diseases of the blood and hematopoietic organs 2 0.9
IV – Endocrine, nutritional and metabolic diseases 5 2.3
• Malnutrition (4) (1.8)
• Metabolic disturbances (1) (0.4)
VI – Nervous system diseases 21 9.4
• Inflammatory diseases of the central nervous system (19) (8.5)
• Other disturbances of the nervous system (2) (0.9)
VIII-Diseases of the ear and mastoid apophysis 1 0.4
IX – Diseases of the circulatory system 4 1.8
X - Diseases of the respiratory system 82 36.8
• Bronchopneumonia/Pneumonia (66) (29.6)
• Other acute infections of the lower airways (5) (2.2)
• Chronic diseases of the lower airways (4) (1.8)
• Pulmonary diseases due to external agents (3) (1.3)
• Other respiratory diseases (4) (1.8)
• Liver diseases (2) (0.9) XVII – Congenital malformations, deformities and chromosome anomalies 3 1.3
XX – External causes of morbidity and mortality 30 13.5
• Transportation accidents (8) (3.6)
• Other external causes of trauma in accidents (19) (8.5)
• Physical aggression (3) (1.3)
Total 223 100.0
The m or t alit y r at es for r espir at or y diseases, for each y ear inv est igat ed, w er e r espect iv ely 18.3, 15.3, 9.7, 10.5 and 13.3 per 100,000 children. I n percent age t erm s t hese were 36.8% , 45.2% , 28.5% , 32.5% and 40.5% . The Figure shows t he proport ional decline in deat hs over t he period, observing it s dist ribut ion by age.
Figure – Deaths due to respiratory diseases, according to age (in years), among children enrolled in the municipal day care center network of São Paulo, during the period from 1995 to 1999.
The deat hs due t o gast r oent er it is occur r ed basically am ong childr en aged under one y ear and pr esent ed pr ogr essiv e y ear- on- y ear decline, such t hat no cases w ere r ecor ded in 1999. On t he ot her hand, at t ent ion w as dr aw n t o t he deat hs due t o chick enpox , for w hich t he m or t alit y r at es w er e on av er age t w o and a half t im es w hat is obser v ed for t he m unicipalit y of São Paulo ( Table 5) .
Table 5 – Deaths due to chickenpox among children aged under seven years. Municipality of São Paulo and the municipal day care center network of São Paulo, for the period from 1996 to 1999.
Year Municipality of São Paulo Day care center network Population Deathsa Rate Populationc Deathsb Rate
1996 1,118,364d 11 0.98 124,003 3 2.41
1997 1,129,502e 9 0.79 123,595 - -
1998 1,141,448e 7 0.61 123,243 2 1.62
1999 1,148,500e 21 1.82 127,606 7 5.48
Total - 48 1.05* - 12 2.40*
Sources:
a
Mortality information improvement program (PRO-AIM/SP), 1996-1999.
b
Municipal Department of Social Assistance (SAS/SGPC/Healthcare team), 1996-1999.
c
Municipal Department of Social Assistance (SAS/DTDI/executive data/day care centers, 1989-1999.
d
IBGE population census, 1996.
e
Municipal Planning Department (SEMPLA/DEINFO) – estimates for 1997, 1998 and 1999.
Ther e w er e four deat hs r ecor ded as due t o hepat it is A. How ev er , giv en it s low let halit y ( 0.05% ) ,4 t his r ecor ded cause only gav e ev idence of t he final sit uat ion of t he pr ocess of m or bidit y .
D ISCUSSION
I n v iew of t he fact t hat t he day car e cent er net w or k does not consolidat e t he infor m at ion on t he num ber of children at t ended each m ont h via t he crit erion of age, but by at t endance m odule ( low e r and upper nursery, m ini - gr oup, m at er nal I and I I , k inder gar t en) , it w as not possible t o calculat e m or t alit y r at es. The classificat ion adopt ed by t he day car e net w or k does not cor r espond ex act ly t o t he age gr oups of t he pr esent st udy , t her eby lim it ing t he analysis possibilit ies.
The m ain causes of deat h w er e of infect ious nat ur e and w er e m ost ly t he r esult of causes t hat can be consider ed av oidable and capable of r educt ion.
The gr eat est num ber of cases w as concent r at ed am ong t he gr oup aged under t hr ee y ears. I n t he m unicipalit y of São Paulo for t he sam e period, t he deat hs am ong t his sam e age segm ent of under t hree years ( excluding children aged under 28 days) com prised an average of 86.7% ( PRO- AI M) .*
* Calculat ions per for m ed on t he basis of t he deat hs dat aba nk of t he m ort alit y inform at ion im provem ent program of t he m unicipalit y of São Paulo ( PRO - AI M) .
The pr edom inance of deat hs due t o pneum onia, especially am ong t hose aged under t w o year s, and t he high m or bidit y due t o t his am ong t hose enr olled in day car e cent ers, higher t han am ong children car ed for at hom e,2 , 5 , 1 3 , 1 8 dem and different iat ed m easures for prevent ion, early det ect ion and adequat e t r eat m ent w it hin t he spher es of day car e cent er s, fam ilies and t he healt hcar e ser v ice net w or k . I t w as obser v ed t hat , in t he m unicipalit y of São Paulo, t he per cent ages of m or t alit y due t o respirat ory diseases for t he sam e period and age group ( excluding children aged under 28 days) were proport ionally lower: 35.3% , 29.9% , 28.4% , 29.0% and 25.5% , respect ively ( PRO- AI M) .*
The decline in deat hs due t o gast r oent er it is t hat w as obser v ed y ear - on- year t ook place in parallel wit h a significant r educt ion in t he r isk of deat h due t o t his cause am ong childr en aged under fiv e y ear s t hat has been occurring in t he m u nicipalit y of São Paulo1 4 and Brazil.8 Ev en so, t hese ar e unaccept able r at es, consider ing t hat t he w ay t o deal w it h such illnesses is w ell- known, sim ple and inexpensive.8 Acut e diar r hea is st ill a m or bid ev ent of high incidence in day car e cent er s. I t affect s t he child’s nut r it ional st at e and, w hen t he illness is r ecur r ent , it cont r ibut es t ow ar ds r et ar ding gr ow t h and dev elopm ent .5,6
Hepat it is t ype A is a disease of low let halit y. How ever , it pr esent s high r at es of m or bidit y in day car e cen t er s. Accor din g t o Gaze et al1 0 ( 2000) , t he per cent ages of concealed infect ion m ay r each 90.0% am ong children aged under five years.
The deat hs due t o chick enpox const it ut ed an epidem iological finding, w it h a m or t alit y r at e gr eat er t han found for t he m unicipalit y of São Paulo, as show n in Table 5.
There is a scarcit y of Brazilian st udies and inform at ion in t he lit erat ure regarding m orbidit y and m ort alit y due t o chickenpox am ong children. This is a highly cont agious disease and present s great er incidence am ong t hose enrolled in day car e cent er s t han in t he gener al child populat ion.5 I n sit uat ions of collect iv e at t endance ( such as day car e cent er s) , t he ser iousness of t he clinical m anifest at ions of secondar y cases is gr eat er t han t hose of t he init ial case, because of t he r eplic at ion of t he agent , w hich becom es m or e v ir ulent w it h each new infect ion. The quant it y inoculat ed also incr eases w hen t he lengt h of exposure t im e is prolonged. For t hese reasons, prophylact ic ut ilizat ion of vaccine is recom m endable.1 , 2 0
Alt h ou gh t h e acciden t s and phy sical aggr ession did not occur w it hin t he day car e cent er s and w er e perhaps less significant in num erical t erm s, t hey deserve at t ent ion because such m ort alit y represent s j ust t he m ost ev ident por t ion of a quest ion t hat has a com plex causal dim ension.1 2 , 1 7
As t he children’s nut rit ional condit ions im prove and som e infect ious disease wit h sim ple prevent ion and t r eat m ent ar e cont r olled and r educed, t he pat t er n of m or bidit y - m ort alit y wit hin t his age group is being m odified. Thus, ext er nal causes incr easingly com e int o v iew . These t her efor e r equir e t he prevent ion m easures t hat can and m ust exist , t hereby overcom ing not ions of fat alism and inevit abilit y.1 2 , 1 7
The findings of gr eat er m or t alit y w it hin t he fir st six m ont hs of enr ollm ent in t he day car e cent er, especially am ong childr en aged under t w o year s, ar e difficult t o int er pr et . I t w as, how ever , obser ved t hat deat hs declined as ages and lengt hs of st ay in t he day car e cent er incr eased.
Ther e ar e so far no ot her st udies analy zing t he pict ur e of m or t alit y am ong children enrolled in day car e cent er s. St udies on m or bidit y , on t he ot her hand, m ent ion t he benefit pr ov ided by t he gr ow ing qualit at iv e and quant it at iv e acquisit ion of nat ur al and post - vaccine im m unit y against m ain pat hogenic agen t s t h at af f ect ch ildren in t heir first years of life.2 0 Collet et al6 ( 1994) observed aft er m aking age adj ust m ent s t hat childr en gained gr eat er pr ot ect ion against r epeat ed r espir at or y and gast r oint est inal infect ions aft er six m ont hs of enr ollm ent in t he day car e cent er .
Th e child’s im m at urit y of im m une response at t his phase of it s life and it s dependence on care given by out sider s, am ong ot her fact or s, m ake it m or e suscept ible t o illnesses of any t ype.1 5
Cer t ain inher ent aspect s of at t endance of t his nat ur e ar e consider ed t o be fundam ent al et iological f act or s, su ch as:
- t he fact t hat t he env ir onm ent br ings people t oget her in a sit uat ion of prolonged living t oget her ( 10 t o 12 hour s) ;
- t he gr eat adult - child and child - child phy sical cont act t hat is dev eloped t hr ough t he v ar ious car e and educat ional act iv it ies;
- t he occur r ence of out br eak s of infect ion t ha t ar e pot ent ially m or e sever e, favor ed by t he lar ge cir culat ion of pat hogenic m icr oor ganism s, especially som e ent er ic and r espir at or y ones t hat ar e rapidly t ransm it t ed bet ween em ployees and children, t hus reaching t heir fam ilies and t he com m unit ies t hey live in.5 , 1 6
This infor m at ion point s t ow ar ds t he need t o r edir ect pr ocedur es and at t it udes r elat ing t o t he adapt at ion period for children ( and t heir fam ilies) at t he day care cent er, from an underst anding of t he gr eat est r isk s t o healt h.
I t w ould be oppor t une t o est ablish gradat ional at t ent ion, wit h em phasis on t he init ial six m ont hs, in w hich all t he aspect s r elat ed t o t he child’s gr ow t h and dev elopm ent w ould be obser v ed. This w ould encom pass it s affect iv e, social and nut r it ional needs, w it h em phasis on it s w eight , t he pr esence of anem ia, hist or y of infect ions, especially r epeat ed infect ions, suscept ibilit y , fam ily habit s, t he healt hcar e suppor t net w or k , and ot her aspect s.
I n v iew of t he char act er izat ion of t his gr oup as one t hat is at r isk , one of t he possible int er v ent ion st r at egies for r educing t he m or bidit y - m ort alit y rat es of day care cent ers w ould be t he com plem ent ary im m unizat ion of t hese children and suscept ible em ployees, using vaccines such as influenza, hepat it is A, chick enpox and ot her s.
An ot h er fact or ident ified w as t he low educat ional lev el am ong t he m ot her s, w hich is consider ed t o be an im por t ant fact or in t he cont ex t of infancy . The bet t er t his lev el, t he gr eat er t he possibilit ies ar e for dispensing adequat e car e and st im ulat ion, and for pr ev ent ing and t r eat ing diseases, t her eby cont ribut ing t owards reducing m orbidit y and m ort alit y am ong t he children.1 8
Anot her im port ant quest ion, which was analyzed by Drum ond Jr. & Barros7 ( 1999) , is t he social-spat ial inequalit ies w it hin t he cit y of São Paulo and t he consequences of socially differ ent iat ed healt hcar e assist ance in det er m ining individual sur vival. These aut hor s consider ed t hat som e causes of deat h m ight be dir ect ly r elat ed t o t he low qualit y of t he r out ine and/ or em er gency ser v ices, t he im possib ilit y of perform ing com plem ent ary t est s and t he m ost appropriat e t herapy, or t he lack of access t o su ch ser v ices.
All t hese dat a suggest t hat fur t her epidem iological st udies in r elat ion t o m or bidit y in day car e cent er s should be perform ed. When added t o t he m or t alit y infor m at ion, t hese could cont r ibut e t ow ar ds im proving public policies in t his sect or, under t he focus of individual and collect ive care and at t ent ion, w it hout det r act ing fr om t heir m ain at t r ibut e: t hat of pr om ot ing child educat ion.
REFE REN CES
1 . Baldacci ER, Vico ESR. Mort alidade por varicela em crianças at endidas em creche. Pediat ria ( São Paulo) 2001; 23: 213 - 6 .
2 . Barros AJ, Ross DA, Fonseca WV, William s LA, Moreira - Filho DC. Prevent ing acut e r espir at or y infect ions and diar r hoea in child car e cent r es. Act a Paediat r 1999; 88: 1113- 8.
3 . Berg AT, Shapiro ED, Capobianco LA. Group day care and t he risk of serious infect ions illnesses. Am J Epidem iol 1991; 133: 154- 63.
4 . [ CDC] Cent ers for Disease Cont rol and Prevent ion. Viral hepat it is. [ on line] 2000. Available fr om < ht t p: w w w .cdc.gov / ncidod/ diseases/ hepat it is> [ 2000 sep 20]
5 . Churchill RB, Pickering LK. I nfect ion cont rol challenges in child- car e cen t er s. I nfect Dis Clin
Nort h Am 1997; 11: 347- 65.
6 . Collet JP, Burt in P, Kram er MS, Floret D, Bossard N, Ducruet T. Type of day- car e set t ing and r isk of r epet ead infect ions. Pediat r ics 1994; 6 Suppl 2: 997- 9 .
7 . Drum ond Jr M, Barros MBA. Desigualdades socioespaciais na m ort alidade do adult o no Município de São Paulo. Rev Br as Epidem iol 1999; 2: 34 - 49.
8 . Drum ond Jr M, Lira MMTA. Mort alidade precoce no Brasil. Coeficient es de m ort alidade por sexo e faixa et ária em 1980 e 1997. Brasília ( DF) : Minist ério da Saúde/ Fundação Nacional de Saúde; 2000. ( Est udos Epidem iológicos) .
9 . Fuchs SC, Maynar t RC, Cost a LF, Car dozo A, Schier holt R. Dur at ion of day- car e at t en dan ce an d acut e r espir at or y infect ion. Cad Saúde Pública 1996; 12: 291 - 6 .
10. Gaze R, Carvalho DM, Luiz RR, Servino VRR, Berro OJ, Bravim Y. Laborat órios sent inelas – uma pr opost a par a o m onit or am ent o das infecções pelos v ír us das hepat it es A e B. I nf Epidem iol SUS 2000; 9( 1) : 5- 21.
11. Maranhão DG. O processo saúde- doença e os cuidados com a saúde na per spect iv a dos educador es infant is. Cad Saúde Pública 2000; 16: 1143- 8 .
12. Mello Jorge MHP, Laurent i R. Acident es e violências no Brasil – apr esent ação. Rev Saúde Pública 1997; 31 Supl 4: 1- 4 .
13. Nafst ad P, Hagen JA, Oie L, Magnus P, Jaakkola JJK. Day car e cent er s and r espir at or y healt h. Pediat r ics 1999; 103: 753- 8 .
14. Prefeit ura do Município de São Paulo. Program a de Aprim oram ent o de I nform ações de Mort alidade. PRO- AI M. Mor t alidade na cidade de São Paulo no ano de 1999. Bol Pro- AI M 1999; ( 38) .
16. Régnier F, Flor et D. Mesur es pr év ent iv es d’hy giène dans les cr èches. Ar ch Pédiat r 1999; 6 Suppl 3: 636- 8.
17. Souza ER, Minayo MCS. O im pact o da violência social na saúde pública do Br asil: década de 80. I n: Minayo MCS, organizadora. Os m uit os brasis: saúde e população na década de 80. São Paulo: Hucit ec; 1995. p. 87 - 116.
18. Vict ora CG, Barros FC, Vaughan JP. Epidem iologia da desigualdade. 2ª ed. São Paulo: HUCI TEC; 1989.
19. Vict ora CG, Fuchs SC, Flores JA, Fonseca W, Kirkwood B. Risk fact ors for pneum onia am ong brazilian children: a hierarchical analysis. Pediat r ics 1994; 93: 977 - 85.
20. Vigneron P, Bégué P. Quel est l’âge d’a cquisit ion de l’im m unit é cont re les principaux agent s pat hogènes dans les pr em ièr es années de vie? Y a- t - il un âge idéal pour ent rer en collect ivit é? Ar ch
Pédiat r 1999; 6 Suppl 3: 602- 10.
Address to correspondence
Eneida Sanches Ram os Vico R. Gal. Calado, 301/ 52 Tat uapé 03334 - 060 São Paulo, SP, Brasil E- m ail: eneidavico@uol.com .br
Based on m ast er ’s degr ee disser t at ion pr esent ed t o t he Faculdade de Saúde Pública of t he Universidade de São Paulo, 2001.
Received on 10/ 12/ 2002. Reviewed on 30/ 6/ 2003. Approved on 21/ 7/ 2003.
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