Abstract

Introduction

The global rate of suicide was 16 deaths per 100,000 inhabitants in 2000¹1. World Health Organization. Suicide [Internet] Disponível em: http://www.who.int/mental_ health/prevention/suicide/suicideprevent/en/ (Acessado em março de 2011).
http://www.who.int/mental_ health/preven... . In Brazil, according to the Sistema de Informações sobre Mortalidade (SIM – Mortality Information System), this rate is not high (5 deaths/100,000 inhabitants, in 2008) when compared to the world rate. However, there was an increase of 29.5% between 1980 and 2006. Exogenous intoxication is one of the three main means used in suicides and suicide attempts and intoxication occurred in approximately 70% of cases²2. Damas FB, Zannin M, Serrano AI. Tentativas de suicídio com agentes tóxicos: análise estatística dos dados do CIT/SC (1994 a 2006). Rev Bras Toxicol 2009; 22(1-2): 21-26.

3. Lovisi GM, Santos SA, Legay L, Abelha L, Valencia E. Epidemiological analysis of suicide in Brazil from 1980 to 2006. Rev Bras Psiquiatr 2009; 31(II): 86-93.

4. Macente LB, Santos EG, Zandonade E. Tentativas de suicídio e suicídio em município de cultura Pomerana no interior do estado do Espírito Santo. J Bras Psiquiatr 2009; 58(4): 238-44. ^{- 5}5. Santos AS, Lovisi G, Legay L, Abelha L. Prevalência de transtornos mentais nas tentativas de suicídio em um hospital de emergência no Rio de Janeiro, Brasil. Cad Saúde Pública 2009; 25(9): 2064-74..

National and international studies showed that the main substances used in these events are pesticides, which varied between 60% and 90%, mainly in developing countries, whereas medications ranged between 12% and 60% and were more frequent in developed countries³3. Lovisi GM, Santos SA, Legay L, Abelha L, Valencia E. Epidemiological analysis of suicide in Brazil from 1980 to 2006. Rev Bras Psiquiatr 2009; 31(II): 86-93. ^{, 5}5. Santos AS, Lovisi G, Legay L, Abelha L. Prevalência de transtornos mentais nas tentativas de suicídio em um hospital de emergência no Rio de Janeiro, Brasil. Cad Saúde Pública 2009; 25(9): 2064-74.

6. Bertolote JM, Fleischmann A, Butchart A, Besbelli N. Suicide, suicide attempts and pesticides: a major hidden public health problem. Bull World Health Organ 2006; 84(4): 260-261.

7. Bertolote JM, Fleischmann A. A global perspective in the epidemiology of suicide. Suicidologie 2002; 7(2): 6-8.

8. Gunnell D, Eddleston M. Suicide by intentional ingestion of pesticides: a continuing tragedy in developing countries. Int J Epidemiol 2003; 32: 902-9.

9. Werneck G, Hasselmann MH, Phebo LB, Vieira DE, Gomes VLO. Tentativas de suicídio em um hospital geral no Rio de Janeiro, Brasil. Cad Saúde Pública 2006; 22(10): 2201-6.-¹⁰10. Bossuyt N, van Casteren V. Epidemiology of suicide and suicide attempts in Belgium: results from the sentinel network of general practitioners. Int J Public Health 2007; 52(3): 153-7..

In the state of Rio de Janeiro, few studies have been performed to investigate suicides and suicide attempts by exogenous intoxication. Studies conducted in two general emergency hospitals found a higher frequency of use of pesticides (between 33% and 52%) and medications (39%) in both services⁵5. Santos AS, Lovisi G, Legay L, Abelha L. Prevalência de transtornos mentais nas tentativas de suicídio em um hospital de emergência no Rio de Janeiro, Brasil. Cad Saúde Pública 2009; 25(9): 2064-74. ^{, 9}9. Werneck G, Hasselmann MH, Phebo LB, Vieira DE, Gomes VLO. Tentativas de suicídio em um hospital geral no Rio de Janeiro, Brasil. Cad Saúde Pública 2006; 22(10): 2201-6.. Due to the scarce knowledge about the magnitude and profile of exogenous intoxications in cases of suicides and suicide attempts in the state of Rio de Janeiro, the present study aimed to describe the profile of suicides and suicide attempts by exogenous intoxication and the comprehensiveness of information recorded in the Centro de Controle de Intoxicações de Niterói (CCIn-Niterói – City of Niterói Poisoning Control Center), Sistema de Informações de Agravos de Notificação (Sinan – Information System for Notifiable Diseases) and Sistema de Informações sobre Mortalidade (SIM – Mortality Information System) for the state of Rio de Janeiro.

Methods

Study design

An exploratory descriptive study was conducted to analyze the frequencies of suicide attempts, recorded in the CCIn-Niterói, Sinan and SIM systems, between 2006 and 2008. In this study, the coverage of these databases was not assessed, as the specific objective was to initially identify the quality of information about suicides and suicide attempts by exogenous intoxication.

Study groups

The cases analyzed were divided into two groups. Suicide attempt (SA) cases by exogenous intoxication were identified with the “circumstance” variable in the Sinan and CCIn-Niterói systems, made available by the Sub-Department of Health Surveillance and the Antônio Pedro University Hospital of the Fluminense Federal University, respectively. The Sinan and CCIn-Niterói information systems about intoxications were selected because they were the only official systems that concentrated specific information about these health problems. The SIH-SUS (Hospital Information System of the Unified Health System) also provides such information, although it is restricted to hospitalizations in public health units or those affiliated with the SUS, without sufficient details required for the monitoring of exogenous intoxications. Finally, the SIM system only has records of deaths.

Suicide cases by exogenous intoxication were identified with the “evolution” variable in the Sinan and CCIn-Niterói systems. In the SIM system, the “primary cause” variable was used to identify the cases of death relevant for this study. In this way, all deaths whose primary causes were coded X60-X69, according to the WHO International Classification of Diseases - 10^threvision (ICD-10), were included. Data from this system were also made available by the Sub-Department of Health Surveillance.

Official sources of data on exogenous intoxication

The CCIn-Niterói is part of the Rede Nacional de Centros de Informação e Assistência Toxicológica (Renaciat – National Network of Toxicological Information and Support Centers), which is coordinated by the Agência Nacional de Vigilância Sanitária (Anvisa – National Health Surveillance Agency), the only referral center in the state of Rio de Janeiro. Professionals from this center record the services in files and type this information into a notification database. These are the services provided to meet the spontaneous demand of intoxicated individuals, health professionals or lay people seeking information about treatment and/or guidance on the procedures to be performed in case of poisoning.

The Sinan is fed by the information present in the disease notification and investigation files included in the National List of Diseases of Compulsory Notification¹¹11. Ministério da Saúde. Portaria GM/MS Nº 104, de 25 de janeiro de 2011. Define as terminologias adotadas em legislação nacional, conforme o disposto no Regulamento Sanitário Internacional 2005 (RSI 2005), a relação de doenças, agravos e eventos em saúde pública de notificação compulsória em todo o território nacional e estabelece fluxo, critérios, responsabilidades e atribuições aos profissionais e serviços de saúde. Diário Oficial União. 26 de janeiro de 2011; Seção 1: 37.and other health problems of interest in the states and cities. Until the end of 2006, the Sinan only recorded cases of poisoning caused by pesticides. After this period, it began to record several types of toxic agents. Files are completed by professionals from the health units (public, health plan-affiliated and private) that care for cases of poisoning on a national basis. This system enables the online consultation of its database at http://dtr2004.saude.gov.br/sinanweb/ .

The SIM is one of the first national health information systems. This system is fed by information included in death certificates (DC) and causes of death are standardized according to the ICD-10. These certificates are completed by physicians or forensic experts. The system also enables online consultation of its database on the website of the Unified Health System Data Processing Department (Datasus) at http://www2.datasus.gov.br/DATASUS/index.php .

Study variables

The variables analyzed were sex, age, toxic agents and place of occurrence. Ages were stratified into the following groups: 10-14, 15-19, 20-29, 30-49, 50-59, ≥ 60 years, according to the WHO. Toxic agents were grouped into medications, unspecified medications and drugs, pesticides, and others. Substances that had an incidence equal to or lower than 5% were grouped under “others”.

The detailed analysis of types of medication was performed with a single study group (suicide attempts + suicides) to generate a higher number of observations. Medications were gathered into the following therapeutic classes: antidepressants, anxiolytics, anticonvulsants, analgesics, neuroleptics, sedative-hypnotics, anti-hypertensives, antibiotics, other specified medications, and unspecified medications. “Other specified medications” included the toxic agents with an incidence equal to or lower than 5%. In contrast, “unspecified medications” referred to data described as “medications” exclusively.

With regard to the percentage of ignored or blank information, the following classification was used: excellent, when the percentage of ignored information was lower than or equal to 10%; good, between 10% and 29.9%; and poor, when equal to or higher than 30%¹².

The frequencies of each group studied were used to show the respective epidemiological profiles. They were calculated by taking into consideration the absolute number of suicide attempts and suicides in the total number of cases of intoxication per group of substances involved, between 2006 and 2008. The SPSS 13 software (SPSS Inc., Chicago, USA) was used for the statistical analyses.

Ethical considerations

The present study was approved by the Research Ethics Committee of the Institute of Collective Health Studies at the Federal University of Rio de Janeiro (number 68/2009 CEP/IESC/UFRJ). Authors declared there were no conflicts of interest.

Results

The variables associated with the 940 cases of suicide attempts and suicides recorded in the CCIn-Niterói database were analyzed, which represented 15.0% of all causes of intoxication. The same was performed with the 470 cases of suicide attempts and suicides recorded in the Sinan, i.e. 12.2% of all causes of intoxication. In the SIM, there were 180 cases of suicide by exogenous intoxication (17.4% of all records of suicide made by any method). As previously described, these analyses were performed between 2006 and 2008.

Upon analysis of the completion of the “circumstance” field, which is essential to identify cases of suicide attempts, the Sinan showed 73.6% of ignored and blank data, whereas these data totaled 2.4% in the CCIn-Niterói. Additionally, the Sinan system contributed to more than 30% of the lack of information about toxic agents. With regard to the “evolution” field, the Sinan and CCIn-Niterói systems recorded 22.3% (n = 105) and 12.6% (n = 119) of follow-up losses/ignored and blank data, respectively.

Cases of suicide attempts

Table 1 shows that women predominated in both systems. Adults aged between 20 and 49 years represented from 60 to 76% of all cases in these systems, although younger adults stood out (27.3% and 33.0% in the CCIn and SINAN, respectively), whereas those aged 50 years and more totaled 14.7% (CCIn) and 10.7% (SINAN) of cases. More detailed results found in the Sinan on the consumption of pesticides showed a 4.5:1 ratio (n = 112 vs. n = 25) for the use of a type of rodenticide known as chumbinho , when compared to other pesticides, while this ratio was 1.14:1 (n = 165 vs. n = 144) in the CCIn-Niterói system.

Table 2 shows the toxic agents involved in suicide attempts according to sex. The data from the Sinan shown in Table 1 do not reveal differences among the substances used (medications and pesticides), whereas this difference is evident in the CCIn-Niterói, with a clear predominance of medications. In this case, the CCIn-Niterói records corroborated the predominance of women observed. Additionally, the Sinan system showed a high percentage of ignored/blank data (nearly 30%), which were excluded for the calculation of frequencies.

Suicide cases

The results in Table 3 indicate that there is an excessive mortality of women (60.6% vs. 39.4%) according to data from the CCIn-Niterói, whereas the other two systems show the opposite. Nearly 50% of suicides in the Sinan and SIM were committed by individuals aged between 20 and 49 years; in the CCIn-Niterói, 28.2% were children and adolescents aged between ten and 19 years.

Table 4 shows the analysis of toxic agents in suicides. In general, the use of medications, pesticides and chemical products stood out.

With regard to the therapeutic classes of medications used in suicide attempts and suicides, only the CCIn-Niterói and Sinan systems made this information available. The data from these two systems showed that more than 70% of the medications used were psychotropics.

Discussion

The systems analyzed in this study provided varied information, including about different toxic agents. The use of different types of products and substances in suicide attempts and suicides has been previously reported in other national studies²2. Damas FB, Zannin M, Serrano AI. Tentativas de suicídio com agentes tóxicos: análise estatística dos dados do CIT/SC (1994 a 2006). Rev Bras Toxicol 2009; 22(1-2): 21-26.,⁴4. Macente LB, Santos EG, Zandonade E. Tentativas de suicídio e suicídio em município de cultura Pomerana no interior do estado do Espírito Santo. J Bras Psiquiatr 2009; 58(4): 238-44.,¹³13. Regadas RP, Veras TN, Lins EB, Cavalcante LO, Aguiar JC, Braga MDM. Tentativa de suicídio por auto-envenenamento: um estudo retrospectivo de 446 casos. Pesqui Méd Fortaleza 2000; 3(1-4): 50-3..

There is a great difficulty in comparing the frequencies of exogenous intoxications as means for suicide attempts and suicides, due to the methodological diversity used in national and international studies conducted on such theme. When different sources of information are used for the analysis of this theme, similar difficulties also occur, due to the diversity found among the proposed systems and the variables comprising such systems.

However, this difficulty did not prevent pieces of evidence pointed out by other authors^5,9,14, such as the impact of easy access to a type of rodenticide known as chumbinho , from being corroborated.

In the state of Rio de Janeiro, carbamate and organophosphate pesticides are usually found in a substance popularly known as chumbinho , which is often sold illegally as rodenticide and also used in suicide attempts and suicides^5,9,14. However, in general, there were no differences between chumbinho and other pesticides in suicide cases and the ratio remained at 1:1 (CCIn-Niterói and Sinan). The SIM system does not specify the chemical groups of pesticides. Another piece of information found in the other systems (CCIn-Niterói and Sinan), which apparently indicates the irregular distribution and use of this pesticide, is the fact that nearly 90% of cases of suicide attempts and suicides occurred in urban areas, rather than rural areas, where access with other purposes could have been justified.

According to data from poisoning information centers, other Brazilian states have also reported the use of chumbinho in suicide attempts and suicides with rates close to 75% (Bahia, n = 415¹⁵15. Martins EHC, Farias AJC, Gonçalves CSM, Bárbara EBS, Cunha Filho EP, Braga AMCB. Intoxicações por Aldicarb no Estado da Bahia, Brasil. Rev Bahiana Saúde Pública 2005; 29 (S1): 77-88.; Santa Catarina, n = 478¹⁶16. Lanzarin, LD. Intoxicações por agrotóxicos anticolinesterásicos – popular “chumbinho”. Estudo dos registros do CIT/SC [monografia]. Santa Catarina: Universidade Federal de Santa Catarina; 2007.). In the present findings, there were seven deaths (46.7%) caused by this substance, recorded in the CCIn-Niterói, and six (54.5%), in the Sinan.

The cases reported show the need for greater inspection and control by the competent institutions, evidencing the illegal urban trade. The carbamate pesticide known as Aldicarb , whose brand name is Temik®, manufactured by Bayer, is exclusively recommended for use as pesticide in agriculture. According to the Department of Environmental Protection, in 2001, the illegal trade of Aldicarb totaled R$ 3 million in the state of Rio de Janeiro, exclusively¹⁷17. Instituto Brasileiro de Defesa do Consumidor. Idec pede proibição de agrotóxico . Edição junho/julho 2003. Disponível em http://www.idec.org.br/materia.asp?id=108 (Acessado em maio de 2011).
http://www.idec.org.br/materia.asp?id=10... .

With regard to pesticides in general, in 2010, the Anvisa reported that at least ten products with pesticide agents, freely used in Brazilian agriculture, were forbidden in the European Union and in the United States, among other countries. Nowadays, Brazil is the greatest consumer of pesticides in the world¹⁸18. Estadão.com.br. Brasil é destino de agrotóxicos banidos no exterior . 30 de maio de 2010. Disponível em http://www.estadao.com.br/noticias/geral,brasil-e-destino-de-agrotoxicos-banidos-no-exterior,558953,0.htm (Acessado em maio de 2011).
http://www.estadao.com.br/noticias/geral... . Giraldo¹⁹19. Giraldo, L. Há muitas evidências de danos dos agrotóxicos à saúde. Disponível em http://www.epsjv.fiocruz.br/index.php?Area=Entrevista&Num=22 (Acessado em março de 2011).
http://www.epsjv.fiocruz.br/index.php?Ar... argues that the legislation of 1976 has promoted the current situation, as it associated rural funding with pesticide use, resulting in a development model based on agribusiness. Consequently, the process of reevaluation of these products in Brazil is hindered by the political and legal approach towards their production, rather than health protection.

International studies have led to important results in the reduction in the number of suicides with restrictive measures against pesticide use⁶6. Bertolote JM, Fleischmann A, Butchart A, Besbelli N. Suicide, suicide attempts and pesticides: a major hidden public health problem. Bull World Health Organ 2006; 84(4): 260-261. ^{, 20}20. Eddleston M, Bateman DN. Major reductions in global suicide numbers can be made rapidly through pesticide regulation without the need for psychosocial interventions. Soc Sci Med 2011; 72(1): 1-2.. In Brazil, as previously discussed, policy-making should be sped up so that this does not harm the health of the population.

The other group of agents that stood out were the medications. The findings of this study did not differ from those of European countries and other Brazilian states. A study conducted in Madrid revealed that nearly 80% (n = 1,240/1,508) of the intoxications were suicide attempts and 68% of these attempts involved psychoactive drug use. These authors pointed out that in Spain, as in other developed countries, the use of tranquilizers has increased approximately 5% per year since 2005 and that women are the main consumers²¹21. Caballero Vallés, PJ, Dorado Pombo, S, Díaz Brasero, A, García Gil, ME, Yubero Salgado, L, Torres Pacho, N et al. Vigilancia epidemiológica de la intoxicación aguda en el área sur de la Comunidad de Madrid: estudio VEIA 2004. An Med Interna 2008; 25(6): 262-8.. In the state of Paraná, Brazil, Margonato et al.²²22. Margonato FB, Thomson ZE, Paoliello MMB. Acute intentional and accidental poisoning with medications in a southern Brazilian city. Cad Saúde Pública 2009; 25(4): 849-56.(2009) analyzed 546 records from the City of Maringá Poisoning Control Center, of which 38.3% were suicide attempts, where psychoactive drugs stood out (43.3%). Rios et al.²³23. Rios D P, Bastos FM, Cunha LC, Valadares MC. Tentativa de suicídio com o uso de medicamentos registrados pelo CIT-GO nos anos de 2003 e 2004. Rev Elet Farm 2005; 2(1): 6-14.(2005) also pointed out the presence of these drugs in 60% of all suicide attempt cases studied.

With regard to psychotropic drug use, it should be emphasized that they are not exclusively prescribed by psychiatrists. Studies have shown that general practitioners are those who most frequently prescribe such drugs, especially anxiolytics and antidepressants²⁴24. Andrade MF, Andrade RCG, Santos V. Prescrição de psicotrópicos: avaliação das informações contidas em receitas e notificações. Rev Bras de Cienc Farm 2004; 40(4): 471-9. ^{, 25}25. Orlandi PE, Noto AR. Uso indevido de benzodiazepínicos: um estudo com informantes-chave no município de São Paulo. Rev Latino-Am Enfermagem 2005; 13: 896-902.. Although the legislation is aimed at the regulation of controlled drugs²⁶26. Ministério da Saúde. Agência Nacional de Vigilância Sanitária. Portaria Nº 344, de 12 de maior de 1998. Aprova o Regulamento Técnico sobre substâncias e medicamentos sujeitos a controle especial. Disponível em http://www.anvisa.gov.br/legis/portarias/344_98.htm (Acessado em fevereiro de 2011).
http://www.anvisa.gov.br/legis/portarias... , including parameters for the prescription and sales of these products, physicians often prescribe psychotropic drugs without adequate evaluation, at times even without a formal consultation²⁵25. Orlandi PE, Noto AR. Uso indevido de benzodiazepínicos: um estudo com informantes-chave no município de São Paulo. Rev Latino-Am Enfermagem 2005; 13: 896-902.. This discussion shows that, more than an inspection effort, there is the clear need to reevaluate the regulatory model adopted, as the implemented measures are not achieving the expected results.

The WHO argues that, although medications are the therapeutic resource with the best cost-effectiveness ratio, their inadequate use has become a world problem, with consequences for the health and economy²⁸28. Ribeiro MA, Heineck I. Estoque Domiciliar de Medicamentos na Comunidade Ibiaense Acompanhada pelo Programa Saúde da Família, em Ibiá-MG, Brasil. Saúde Soc São Paulo 2010, 19(3): 653-63.. National studies have shown that storing medicines at home promotes self-medication and their access as a means for suicide attempts and suicides²⁸28. Ribeiro MA, Heineck I. Estoque Domiciliar de Medicamentos na Comunidade Ibiaense Acompanhada pelo Programa Saúde da Família, em Ibiá-MG, Brasil. Saúde Soc São Paulo 2010, 19(3): 653-63. ^{, 29}29. Fernandes LC. Caracterização e análise da Farmácia caseira ou Estoque Domiciliar de Medicamentos [dissertação de mestrado]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2000.. A measure that could change this situation is the portioning of medications. Bill 7,029 of 2006 guarantees the mandatory sale of portioned medications; however, this bill has yet to be approved by the Brazilian government. What can be observed is that, despite the existing public policies, little has been effectively achieved such as preventive measures and restriction to the access to these medications. Social organizations, health sectors and the pharmaceutical industry have discussed such bill, although without considering the urgency to find solutions.

Another observation made from the Sinan and CCIn systems was the predominance of men among those who used pesticides as a means for suicide attempts/suicide, whereas the consumption of medications in suicide attempts (CCIn and Sinan) and pesticides in suicides (CCIn and SIM) predominated among women. These findings are in agreement with the literature⁵5. Santos AS, Lovisi G, Legay L, Abelha L. Prevalência de transtornos mentais nas tentativas de suicídio em um hospital de emergência no Rio de Janeiro, Brasil. Cad Saúde Pública 2009; 25(9): 2064-74. ^{, 13}13. Regadas RP, Veras TN, Lins EB, Cavalcante LO, Aguiar JC, Braga MDM. Tentativa de suicídio por auto-envenenamento: um estudo retrospectivo de 446 casos. Pesqui Méd Fortaleza 2000; 3(1-4): 50-3. ^{, 21}21. Caballero Vallés, PJ, Dorado Pombo, S, Díaz Brasero, A, García Gil, ME, Yubero Salgado, L, Torres Pacho, N et al. Vigilancia epidemiológica de la intoxicación aguda en el área sur de la Comunidad de Madrid: estudio VEIA 2004. An Med Interna 2008; 25(6): 262-8. ^{, 30}30. Fleischmann A, Bertolote JM, De Leo D, Botega N, Phillips M, Sisask M et al. Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight low- and middle-income countries. Psychol Med 2005, 35: 1467-74.. With regard to these differences, the literature emphasizes that men use more deadly methods and, for this reason, are more successful in their suicide attempts. However, Beautrais³¹31. Beautrais AL. Women and suicidal behavior. Crisis 2006; 27(4): 153-6.argues that, if the mortality of suicide is predominantly masculine, its morbidity is mainly feminine, as women are two times more likely to attempt suicide than men on average.

Canetto & Sakinofsky³³33. Caetano R. Sistema de Informação de Agravos de Notificação (Sinan). In: Brasil. Ministério da Saúde. A experiência brasileira em sistemas de informação em saúde . Ministério da Saúde, Organização Pan-Americana da Saúde, Fundação Oswaldo Cruz. Brasília: Editora do Ministério da Saúde; 2009.state that the lethality of a certain method to commit suicide is not directly associated with the intention of dying per se, but rather with the social acceptance involving gender when selecting this method. Thus, women choose medications as a means for suicide as this would be more socially acceptable for them than for men. Results from several studies seem to corroborate this statement, as women use more medications, although these are accessible to both women and men. This discussion is particularly important in a country such as Brazil, where little is understood about the role of gender differences in suicidal behavior. Thus, there is a clear need for studies that investigate the roles of gender and the influence of culture in the selection of means for suicide attempts/suicide, aiming to provide adequate resources to support the cases and control these means.

The information systems used as instruments in the present research are relevant for health condition analyses, as previously argued. To achieve this, the quality of data becomes essential. Among quality dimensions, ignored and blank information affects the magnitude of health problems or diseases. In the present study, information was missing in the “circumstance”, “toxic agents” and “evolution” fields, i.e. the key fields for surveillance. In addition, this could have negatively interfered with the magnitude of suicide.

Furthermore, regarding the CCIn-Niterói, Sinan and SIM information systems, it should be emphasized that these have distinct functions. In this way, it should be clarified that the present study did not aim to compare such systems, but rather access the best coverage provided by each of them and the quality of the information obtained.

The proposal of the CCIn-Niterói system is to reach the universe of spontaneous demands of exogenous intoxications in the state of Rio de Janeiro. It operates on a daily basis, providing information to the lay population, health professionals and institutions. The records of exogenous intoxication events are mainly based on telephone consultations. In contrast, the Sinan is a national system for compulsory notification of health problems and diseases, where all exogenous intoxication cases must be recorded. The records are made in the health units by health professionals. Finally, the SIM system is aimed at gathering data on mortality, supporting health policies and actions, in addition to research. These characteristics are important to understand the comprehensiveness of the records from each system.

Certain studies have shown an important improvement in the quality of information systems when the integration of these systems is performed, particularly the relationship between databases and the investment in the capacity-building of human resources, with the organization of workshops and permanent discussion forums, retrieval and complementing of information through different sources³³33. Caetano R. Sistema de Informação de Agravos de Notificação (Sinan). In: Brasil. Ministério da Saúde. A experiência brasileira em sistemas de informação em saúde . Ministério da Saúde, Organização Pan-Americana da Saúde, Fundação Oswaldo Cruz. Brasília: Editora do Ministério da Saúde; 2009.

34. Cascão AM, Flores APM. Aprimoramento dos dados de mortalidade por causas externas tendo a imprensa como fonte de dados . In: 6aExpoepi: mostra nacional de experiências bem-sucedidas em epidemiologia, prevenção e controle de doenças: anais/Ministério da Saúde, Secretaria de Vigilância em Saúde. Brasília: Ministério da Saúde; 2007.

35. Ciríaco DL, Oliveira DMC. Sinan e interfaces: revisão de estratégias na prática da equipe estadual. In : 5aExpoepi: Mostra Nacional de Experiências Bem-Sucedidas em Epidemiologia, Prevenção e Controle de Doenças: Brasília, DF, 4 a 6 de dezembro de 2005: anais/Ministério da Saúde, Secretaria de Vigilância em Saúde. Brasília: Ministério da Saúde; 2006. ^{- 36}36. Oliveira C, Oliveira LCS, Guimarães MJB, Lyra T. Integração dos bancos de dados do SIM e do Sinan: a contribuição da vigilância dos óbitos relacionados às doenças de notificação compulsória no município do Recife. In: 5aExpoepi: Mostra Nacional de Experiências Bem-Sucedidas em Epidemiologia, Prevenção e Controle de Doenças: Brasília, DF, 4 a 6 de dezembro de 2005: anais/Ministério da Saúde, Secretaria de Vigilância em Saúde. Brasília: Ministério da Saúde; 2006..

In this way, it could be observed that strategies have been adopted aiming to improve the quality of data. However, the different methodologies used and their limitations should be assessed, guiding the adoption of that which is the most adequate for the local reality faced by the professionals involved in the process of construction and dissemination of such information.

The limitations of this study refer to the heterogeneity of data collection (spontaneous demand vs. mandatory notification), preventing a comparison of information coverage to be made. Another weak point was the impossibility of consulting health units caring for cases of suicide attempt and suicide by exogenous intoxication during this period. Access to such information would increase the reliability of the epidemiological profile of health problems. Nonetheless, the standardization of records enabled cases to be well characterized.

Conclusion

It is known that information for the development of public policies and decision-making is important. Thus, the CCIn-Niterói would be expected to operate in a way that complements the information obtained from Sinan, developing intercommunication between them, promoting disease surveillance, and enabling greater effectiveness and accuracy in decision-making. The standardization of variables such as group of toxic agents, occurrence, means of exposure and evolution can contribute to this intercommunication. Another important piece of information to be taken into account in both systems is the source of the medications used, whether they are for one's own use or belong to someone else's. This information is important to obtain the actual epidemiological profile of exogenous intoxications.

With regard to the SIM system, although the present study did not perform an assessment of underreporting among systems, it was evident that suicides by intoxication had not been recorded in the Sinan or CCIn-Niterói. Whether due to loss of follow-up or ignored/blank information, there is a clear need for systematic evaluations and the development of mechanisms that enable the integration of these systems.

Advances have been made in recent years, but what remains are the problems with the coverage provided by systems and the need to improve their quality, so that they can support health policies and actions in a safe way.

References

Publication Dates

History