Abstract

Objective:

to estimate the vaccination coverage against influenza and pneumonia and to analyze the utilization of Brazilian National Health System-SUS for vaccination in adults and elderly with self-reported diabetes in São Paulo, Brazil, in 2003, 2008 and 2015.

Methods:

Cross-sectional studies with data from the ISA-Capital (population-based household surveys).

Results:

3,357, 3,271 and 4,043 were interviewed in 2003, 2008 and 2015; the prevalence of diabetes mellitus were 5.0% (2003), 6.4% (2008) and 7.7% (2015); fewer than half of people with diabetes, vaccinated against influenza (47.2%) and pneumonia (17.9%) in 2003, with a small increase in 2015 (59.2% and 26.1%, respectively); the majority of people who are vaccinated against influenza and pneumonia used SUS, 88.7% (2003) and 97.2% (2015) for influenza; 84.7% (2003) and 94.5% (2015) for pneumonia, without difference among age, sex, education level and ethnicity.

Conclusion:

despite the low vaccination coverage against influenza and pneumonia in the population with diabetes mellitus since 2003 the utilization of SUS to vaccination has been progressively expanding.

Keywords:
Vaccination; Brazilian National Health System; Cross-sectional studies; Diabetes Mellitus

Introduction

Immunization policies have become increasingly complex in their global and national dimensions.¹1. Hochman G, Bhattacharya S. Imunização, vacinas: passado e futuro. Ciênc Saúde Coletiva. 2011 fev;16(2):372. The culture of immunization in Brazil, expressed by the adherence of the population to immunization programs and demand for new vaccines offered by the public sector, dates back to the process of introduction of vaccines in the 19th century and the mass vaccination campaigns undertaken by the Brazilian State.²2. Hochman G. Vacinação, varíola e uma cultura de imunização no Brasil. Ciênc Saúde Coletiva. 2011 fev;16(2):375-86. In Brazil, which is a reference for many other countries in the area of immunization, vaccination occupies a prominent place among Public Health actions.³3. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet. 2011 May;377(9779):1778-97.

Established in 1973, the Brazilian National Immunization Program (Programa Nacional de Imunizações-PNI) has reached high vaccination coverage nationwide,³3. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet. 2011 May;377(9779):1778-97.^,44. Ministério da Saúde (BR), Secretaria de Vigilância em Saúde. Programa Nacional de Imunizações - 30 anos [Internet]. Brasília: Ministério da Saúde; 2003 [citado 2018 jan 25]. 208 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/livro_30_anos_pni.pdf .
http://bvsms.saude.gov.br/bvs/publicacoe... this being of great importance for controlling preventable diseases using immunobiological products.⁵5. Silva ZP, Ribeiro MCSA, Barata RB, Almeida MF. Perfil sociodemográfico e padrão de utilização dos serviços de saúde do Sistema Único de Saúde (SUS), 2003- 2008. Ciênc Saúde Coletiva. 2011 set;16(9):3807-16. Following the creation of the Brazilian National Health System (SUS) in 1988,⁶6. Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria P, et al. Priority actions for the non-communicable disease crisis. Lancet. 2011 Apr;377(9775): 1438-47. PNI has been strengthened. The national vaccination campaigns, aimed at different age groups - according to the occasion -, have resulted in the growth of social awareness about the culture of immunization.⁴4. Ministério da Saúde (BR), Secretaria de Vigilância em Saúde. Programa Nacional de Imunizações - 30 anos [Internet]. Brasília: Ministério da Saúde; 2003 [citado 2018 jan 25]. 208 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/livro_30_anos_pni.pdf .
http://bvsms.saude.gov.br/bvs/publicacoe... ^,55. Silva ZP, Ribeiro MCSA, Barata RB, Almeida MF. Perfil sociodemográfico e padrão de utilização dos serviços de saúde do Sistema Único de Saúde (SUS), 2003- 2008. Ciênc Saúde Coletiva. 2011 set;16(9):3807-16.

Vaccination against influenza and pneumonia in vulnerable populations is provided for in the immunization schedule.³3. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet. 2011 May;377(9779):1778-97.^,44. Ministério da Saúde (BR), Secretaria de Vigilância em Saúde. Programa Nacional de Imunizações - 30 anos [Internet]. Brasília: Ministério da Saúde; 2003 [citado 2018 jan 25]. 208 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/livro_30_anos_pni.pdf .
http://bvsms.saude.gov.br/bvs/publicacoe... Among its target groups is the population with diabetes mellitus, a disease with a high global burden and high prevalence, and one of the challenges of Public Health agenda.⁶6. Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria P, et al. Priority actions for the non-communicable disease crisis. Lancet. 2011 Apr;377(9775): 1438-47. The 2013 National Health Survey (Pesquisa Nacional de Saúde-PNS) estimated prevalence of self-reported diabetes in Brazil as being 6.2%.⁷7. Ministério do Planejamento, Orçamento e Gestão (BR), Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde 2013: percepção do estado de saúde, estilos de vida e doenças crônicas. Brasil, grandes regiões e unidades da Federação [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2014 [citado 2017 jun 25]. 180 p. Disponível em: ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf.
ftp://ftp.ibge.gov.br/PNS/2013/pns2013.p... There is little data on vaccination coverage in special populations in the country, as is the case of people with diabetics.

The objective of this study was to analyze vaccination against influenza and pneumonia and the use of SUS for obtaining this vaccination, according to sociodemographic and socioeconomic variables, among adults with self-reported diabetes in the municipality of São Paulo in the years 2003, 2008 and 2015.

Methods

This is a panel of cross-sectional studies using data from population-based household health surveys (ISA-Capital) in São Paulo City, held in 2003, 2008 and 2015, obtained from household interviews.

The main focus of the ISA-Capital survey is to diagnose the living and health conditions of the population and their use of health care services. ISA-Capital 2003 data collection occurred from February 2003 to January 2004; ISA-Capital 2008 from April 2008 to May 2009, and ISA-Capital 2015 from September 2014 to December 2015.

Individuals with self-reported diabetes and age equal to or greater than 20 years old were selected from among the total number of participants for each one of the surveys, by means of probability sampling by conglomerates in two stages: census tracks and households. The list of census tracks was obtained from the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística).

The calculation of the sample size of the ISA-Capital surveys was similar in the three surveys, with differences in the number of census tracks selected, in sampling errors and design effect. The sample size calculated for each survey was 4,270 individuals in 2003, 4,024 in 2008 and 4,250 in 2015.⁸8. Alves MCGP. Plano de amostragem. In: Cesar CLG, Carandina L, Alves MCGP, Barros MBA, Goldbaum M. Saúde e condição de vida em São Paulo. São Paulo: USP/FSP; 2005. p. 47-63.

9. Alves MCGP, Escuder MML. Plano de amostragem ISA Capital 2008 [Internet]. 2009 [citado 2015 fev 27]. Disponível em: http://www.fsp.usp.br/isa-sp/pdf/planoamostral2008.pdf.^-1010. Cesar CLG. Metodologia. In: Cesar CLG, Carandina L, Alves MCGP, Barros MBA, Goldbaum M. Saúde e condição de vida em São Paulo. São Paulo: USP/FSP ; 2005. p. 37-47.

Survey data collection was performed using a questionnaire with closed-ended questions, administered by interviewers who had been trained beforehand and who were evaluated throughout the survey period. The ISA-Capital survey methodology is described in the literature,⁸8. Alves MCGP. Plano de amostragem. In: Cesar CLG, Carandina L, Alves MCGP, Barros MBA, Goldbaum M. Saúde e condição de vida em São Paulo. São Paulo: USP/FSP; 2005. p. 47-63.

9. Alves MCGP, Escuder MML. Plano de amostragem ISA Capital 2008 [Internet]. 2009 [citado 2015 fev 27]. Disponível em: http://www.fsp.usp.br/isa-sp/pdf/planoamostral2008.pdf.^-1010. Cesar CLG. Metodologia. In: Cesar CLG, Carandina L, Alves MCGP, Barros MBA, Goldbaum M. Saúde e condição de vida em São Paulo. São Paulo: USP/FSP ; 2005. p. 37-47. and available at www.fsp.usp.br/isa-sp/

The demographic and socioeconomic variables selected were:

The other variables studied were:

Information about the type of service used for vaccination against influenza and pneumonia was obtained in response to the following question:

Was the service where you were vaccinated public or private?

Prevalence and its intervals were estimated with 95% confidence (95%CI) for self-reported diabetes and coverage of vaccination against influenza and pneumonia, according to the demographic and socioeconomic characteristics selected and the years in which the survey took place. Diabetes prevalence was calculated taking the total number of interviewees in each year as the denominator. Differences were considered significant when there was absence of confidence interval overlap; association was estimated using Pearson's chi-square test, with a significance level of 5%. Vaccination prevalence rates and 95%CI were also estimated according to demographic and socioeconomic variables, in addition to the type of service used (SUS; not SUS). Individuals with lack of data on education level and ethnicity/skin color (missing data) were excluded from the sample. ISA-Capital data were weighted to compensate for the different probabilities of selection. The analysis of these data was conducted using Stata 11.0, applying the command survey, which considers the complex sampling effects.

The study project was approved by the Research Ethics Committee of the University of São Paulo Faculty of Medicine Hospital de Clínicas, and by the Ethics Committee of the University of São Paulo School of Public Health: Report No. 357/2013 and Report No. 719.661/2014, approved on 09/17/2013 and 16/07/2014, respectively.

Results

The total number of interviewees was 3,357 in 2003, 3,271 in 2008 and 4,043 in 2015. The response rate in 2003, 2008 and 2015 was 75%, 76% and 74%, respectively.

Prevalence of self-reported diabetes was 5.0% (95%CI; 3.9;6.2) (N=170) in 2003, 6.4% (95%CI; 5.4;7.5) (N=246) in 2008 and 7.7% (95%CI; 6.8;8.7) (N=348) in 2015, as can be observed in Table 1.

Table 1 also presents the prevalence of diabetes mellitus according to demographic and socioeconomic characteristics. Prevalence of diabetes increased with age and according to education level, in the three years studied. There was no difference between the female and male sex in 2003 and 2008. In 2015 prevalence was higher in females. There was no difference between diabetes prevalence and ethnicity/white, black or brown skin color in the three years studied.

Less than half of people with diabetes mellitus vaccinated against influenza in 2003 (47.2%: 95%CI; 37.6;57.0) and in 2008 (43%: 95%CI; 35.6;50.7]), with a small increase in 2015 (59.2% -[95%CI; 52.2;65.9]) (Table 2). In 2003, the frequency of vaccination against pneumonia was 17.9% (95%CI; 11.1;27.6), and in 2008, 13.2% (95%CI; 9.4;18.3), with a slight increase in 2015, 26.1% (95%CI; 20.1;33.0). The elderly (>60 years) vaccinated more than other adults (20-59 years), both against influenza and against pneumonia, in the three years studied. There was no difference in vaccination according to sex, ethnicity/skin color and education level, in 2003, 2008 and 2015 (Table 2).

The majority of people that were vaccinated did so on the SUS. In the case of influenza, the proportion of people vaccinated on the SUS was 88.7% in 2003, 80.7% in 2008 and 97.2% in 2015; with regard to pneumonia, this proportion was 84.7% in 2003, 76,2% in 2008 and 94.5% in 2015 (Table 3).

Discussion

Less than half of people with diabetes mellitus were vaccinated against influenza and pneumonia in 2003 and 2008, with a slight increase in 2015. The majority of those vaccinated against influenza and pneumonia used SUS in all years studied, with no difference regarding age, sex, education level and ethnicity/skin color. Diabetes prevalence grew as aged increased and as education level decreased.

This study has some limitations such as the small sample size of self-reported diabetes, which may have influenced the statistical analyses, particularly in the case of vaccination against pneumonia. Identification of diabetes mellitus and vaccination against influenza and pneumonia in all three surveys was self-reported.

An important factor to be considered in studies on morbidity is the individual's perception about their health, which can vary according to factors related to each person’s social experiences and the availability of health care services.¹¹11. Francisco PMSB, Belon AP, Barros MBA, Carandina L, Alves MCGP, Goldbaum M, Cesar CLG . Diabetes auto-referido em idosos: prevalência, fatores associados e práticas de controle. Cad Saúde Pública. 2010 jan;26(1):175-84. This was not considered in this study. In addition, there may be information bias owing to fact of vaccination being self-reported, since it was not possible to consult the vaccination card of each interviewee.

Information about the use of public or private services for vaccination was also self-reported. In Brazil, there are many private services providing health care funded by SUS and as such it is difficult to categorize 'SUS' service and 'not SUS' service in health surveys and the possibility exists of information about the nature of the service being biased. It was not possible to analyze the population’s income owing to the excess of missing data on this variable; education level and ethnicity/skin color were used as proxy variables when analyzing vaccination according to socioeconomic characteristics.

In the case of diabetes mellitus, vaccination against influenza and pneumonia is an important Public Health preventive intervention.⁴4. Ministério da Saúde (BR), Secretaria de Vigilância em Saúde. Programa Nacional de Imunizações - 30 anos [Internet]. Brasília: Ministério da Saúde; 2003 [citado 2018 jan 25]. 208 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/livro_30_anos_pni.pdf .
http://bvsms.saude.gov.br/bvs/publicacoe... ^,1212. Ministério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Envelhecimento e saúde da pessoa idosa. [Internet]. Brasília: Ministério da Saúde ; 2006 [citado 2018 jan 25]. 192 p. (Cadernos de Atenção Básica. n. 19). Disponível em: Disponível em: http://189.28.128.100/dab/docs/publicacoes/cadernos_ab/abcad19.pdf
http://189.28.128.100/dab/docs/publicaco...

13. Ministério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Estratégias para o cuidado da pessoa com doença crônica: diabetes mellitus [Internet]. Brasília: Ministério da Saúde ; 2013 [citado 2018 jan 25]. 160 p. (Cadernos de Atenção Básica, n. 36). Disponível em: Disponível em: http://189.28.128.100/dab/docs/portaldab/publicacoes/caderno_36.pdf .
http://189.28.128.100/dab/docs/portaldab...

14. Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Departamento de Vigilância das Doenças Transmissíveis. Manual dos centros de referência para imunobiológicos especiais [Internet]. 4. ed. Brasília: Ministério da Saúde ; 2014 [citado 2018 jan 25]. 160 p. Disponível em: Disponível em: http://www.saude.pr.gov.br/arquivos/File/-01VACINA/manual_crie_.pdf .
http://www.saude.pr.gov.br/arquivos/File... ^-1515. Marques SC, Maia A, Veloso L. A importância da vacinacão dos adultos com diabetes tipo 2 na prevencão da doenca invasiva pneumocócica. Rev Port Endocrinol Diabetes Metab. 2016 jan-jun;11(1):60-8. Vaccination against influenza in people e with diabetes is recommended annually, before the onset of winter; vaccine against pneumonia is administered once during lifetime, with a booster after 65 years of age, according to Brazilian Ministry of Health guideline specifications for the elderly and people with diabetes.¹²12. Ministério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Envelhecimento e saúde da pessoa idosa. [Internet]. Brasília: Ministério da Saúde ; 2006 [citado 2018 jan 25]. 192 p. (Cadernos de Atenção Básica. n. 19). Disponível em: Disponível em: http://189.28.128.100/dab/docs/publicacoes/cadernos_ab/abcad19.pdf
http://189.28.128.100/dab/docs/publicaco... ^.1313. Ministério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Estratégias para o cuidado da pessoa com doença crônica: diabetes mellitus [Internet]. Brasília: Ministério da Saúde ; 2013 [citado 2018 jan 25]. 160 p. (Cadernos de Atenção Básica, n. 36). Disponível em: Disponível em: http://189.28.128.100/dab/docs/portaldab/publicacoes/caderno_36.pdf .
http://189.28.128.100/dab/docs/portaldab... The National Immunization Program (PNI) recommendation is different: one dose of pneumococcal vaccine followed by a second dose five years later, regardless of age.¹⁴14. Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Departamento de Vigilância das Doenças Transmissíveis. Manual dos centros de referência para imunobiológicos especiais [Internet]. 4. ed. Brasília: Ministério da Saúde ; 2014 [citado 2018 jan 25]. 160 p. Disponível em: Disponível em: http://www.saude.pr.gov.br/arquivos/File/-01VACINA/manual_crie_.pdf .
http://www.saude.pr.gov.br/arquivos/File... Although it is important, estimated coverage in this study falls short of health expectations: a low percentage of people with diabetes who are vaccinated against influenza and pneumonia was estimated in 2003 and 2008. Even in 2015, despite the increase, the proportion of vaccination in this segment of the population remained low, especially in adults, despite its being indicated for vulnerable people regardless of age, as is the case of people with diabetes. Possible causes of low adherence may be suggested. For example, the lack of recommendation of vaccination against pneumonia and influenza on the part of health professionals caring for people with diabetes. Moreover, the fact of diabetes being self-reported suggests the possibility of individuals, especially adults, not having been vaccinated because of the requirement to provide some form of proof of having diabetes, this being a common practice in primary health care centres, these being one of the main vaccination sites.¹⁶16. Oliveira LP, Lima ABLS, Sá KVCS, Freitas DS, Aguiar MIDS, Rabêlo PPC, et al. Perfil e situação vacinal de idosos em unidade de estratégia Saúde da Família. Rev Pesq Saúde. 2016 jan-abr;17(1):23-6.^.1717. Neves RG, Duro SMS, Tomasi E. Vacinação contra influenza em idosos de Pelotas-RS, 2014: um estudo transversal de base populacional. Epidemiol Serv Saúde. 2016 out-dez;25(4):755-66.

There was no difference between 2003 and 2008 as to the percentage of people vaccinated against influenza and pneumonia. The growth observed in 2015 suggests an increase in access to the service. Moreover, 2013 National Health Survey (PNS) data shows that from 2013 onwards, there is a significant increase in access to all segments of health care services.¹⁸18. Iser BPM, Stopa SR, Chueiri PS, Szwarcwald CL, Malta DC, Monteiro HOC et al. Prevalência de diabetes autorreferido no Brasil: resultados da Pesquisa Nacional de Saúde 2013. Epidemiol Serv Saúde. 2015 abr-jun;24(2):305-14. A study conducted in 2014 in the municipality of Pelotas, RS, found that 71% of the elderly were vaccinated against influenza.¹⁷17. Neves RG, Duro SMS, Tomasi E. Vacinação contra influenza em idosos de Pelotas-RS, 2014: um estudo transversal de base populacional. Epidemiol Serv Saúde. 2016 out-dez;25(4):755-66.

The proportion of people vaccinated against influenza was much greater than the proportion vaccinated against pneumonia. The explanation for this finding may be found in the intense seasonal vaccination campaigns, in the case of influenza, while the pneumococcal vaccine is offered as part of the health care service routine.

The higher prevalence of vaccination against influenza in the elderly may possibly be due to the fact that those over 60 years of age use health services more, compared to other adults (20-59-year), despite vaccination campaigns being directed to other populations. The occurrence of acute diseases among elderly people with diabetes, such as influenza and pneumonia, is much more serious than in elderly patients without diabetes,¹²12. Ministério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Envelhecimento e saúde da pessoa idosa. [Internet]. Brasília: Ministério da Saúde ; 2006 [citado 2018 jan 25]. 192 p. (Cadernos de Atenção Básica. n. 19). Disponível em: Disponível em: http://189.28.128.100/dab/docs/publicacoes/cadernos_ab/abcad19.pdf
http://189.28.128.100/dab/docs/publicaco... ^,1313. Ministério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Estratégias para o cuidado da pessoa com doença crônica: diabetes mellitus [Internet]. Brasília: Ministério da Saúde ; 2013 [citado 2018 jan 25]. 160 p. (Cadernos de Atenção Básica, n. 36). Disponível em: Disponível em: http://189.28.128.100/dab/docs/portaldab/publicacoes/caderno_36.pdf .
http://189.28.128.100/dab/docs/portaldab... and there is a need for this population to be vaccinated.¹⁹19. Moura RF, Andrade FB, Duarte YAO, Lebrão ML, Antunes JLF. Fatores associados à adesão à vacinação anti-influenza em idosos não institucionalizados, São Paulo, Brasil. Cad Saúde Pública. 2015 out;31(10):2157-68.^.2020. Bós AJG, Mirandola AR. Cobertura vacinal está relacionada à menor mortalidade por doenças respiratórias. Ciênc Saúde Coletiva. 2013 maio;18(5):1459-62.

SUS was used more for vaccination against influenza and pneumonia than supplementary health services and this corroborates the literature.²¹21. Monteiro CN, Gianini RJ, Goldbaum M, Cesar CLG, Barros MBA. Cobertura de serviços públicos de saúde para gastos com medicamentos e vacinas na população com diabetes mellitus. Ciênc Saúde Coletiva. 2015 fev;20(2):557-64. Approximately 5% of the population studied did not get vaccinated via SUS and informed having used private services to get vaccinated. A study conducted in 1996 in four municipalities in the state of São Paulo,²²22. Moraes JC, Barata RCB, Ribeiro MCSA, Castro PC. Utilização vacinal no primeiro ano de vida em quatro cidades do estado de São Paulo, Brasil. Rev Panam Salud Publ. 2000;8(5):332-41. indicated that even the clients of private health plans routinely use the public service for vaccination. Our study confirms this fact.

The high use of SUS for vaccination against influenza and pneumonia, as evidenced here, also occurs in cases of vaccination against other diseases.²²22. Moraes JC, Barata RCB, Ribeiro MCSA, Castro PC. Utilização vacinal no primeiro ano de vida em quatro cidades do estado de São Paulo, Brasil. Rev Panam Salud Publ. 2000;8(5):332-41.^,2323. Victora CG, Barreto ML, Leal MC, Monteiro CA, Schimidt MI, Paim J, et al. Health conditions and health-policy innovations in Brazil: the way forward. Lancet. 2011 Jun;377(9782):2042-53. The results of a survey conducted in 1996, the objective of which was to estimate vaccine use in children less than 1 year old in the municipalities of São Paulo, Osasco, São Francisco Morato and Guarulhos, indicated vaccination above 90% for almost all the municipalities studied. The same survey found that the use of SUS for vaccination increased as living conditions worsened,²²22. Moraes JC, Barata RCB, Ribeiro MCSA, Castro PC. Utilização vacinal no primeiro ano de vida em quatro cidades do estado de São Paulo, Brasil. Rev Panam Salud Publ. 2000;8(5):332-41. this being a finding that strengthens the conclusions of this study, highlighting the role played by SUS in reducing inequalities thanks to greater access and utilization of health services by the population in worse socioeconomic conditions.

The analysis of use of SUS for vaccination according to socioeconomic and sociodemographic characteristics showed no differences regarding education level and ethnicity/skin color categories. This is in agreement with the literature.⁴4. Ministério da Saúde (BR), Secretaria de Vigilância em Saúde. Programa Nacional de Imunizações - 30 anos [Internet]. Brasília: Ministério da Saúde; 2003 [citado 2018 jan 25]. 208 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/livro_30_anos_pni.pdf .
http://bvsms.saude.gov.br/bvs/publicacoe... ^,55. Silva ZP, Ribeiro MCSA, Barata RB, Almeida MF. Perfil sociodemográfico e padrão de utilização dos serviços de saúde do Sistema Único de Saúde (SUS), 2003- 2008. Ciênc Saúde Coletiva. 2011 set;16(9):3807-16.^,2121. Monteiro CN, Gianini RJ, Goldbaum M, Cesar CLG, Barros MBA. Cobertura de serviços públicos de saúde para gastos com medicamentos e vacinas na população com diabetes mellitus. Ciênc Saúde Coletiva. 2015 fev;20(2):557-64.

22. Moraes JC, Barata RCB, Ribeiro MCSA, Castro PC. Utilização vacinal no primeiro ano de vida em quatro cidades do estado de São Paulo, Brasil. Rev Panam Salud Publ. 2000;8(5):332-41.^-2323. Victora CG, Barreto ML, Leal MC, Monteiro CA, Schimidt MI, Paim J, et al. Health conditions and health-policy innovations in Brazil: the way forward. Lancet. 2011 Jun;377(9782):2042-53. This conclusion suggests that PNI should provide care to the general population, regardless of socioeconomic status. As a universal health system, SUS is bound to provide universal vaccination distribution²¹21. Monteiro CN, Gianini RJ, Goldbaum M, Cesar CLG, Barros MBA. Cobertura de serviços públicos de saúde para gastos com medicamentos e vacinas na população com diabetes mellitus. Ciênc Saúde Coletiva. 2015 fev;20(2):557-64.

22. Moraes JC, Barata RCB, Ribeiro MCSA, Castro PC. Utilização vacinal no primeiro ano de vida em quatro cidades do estado de São Paulo, Brasil. Rev Panam Salud Publ. 2000;8(5):332-41.^-2323. Victora CG, Barreto ML, Leal MC, Monteiro CA, Schimidt MI, Paim J, et al. Health conditions and health-policy innovations in Brazil: the way forward. Lancet. 2011 Jun;377(9782):2042-53.. This is partially confirmed in our study, considering that the majority of respondents have been vaccinated via SUS.

The high prevalence of diabetes in Brazil and in the world, as evidenced in this study and confirmed by consulting the literature,²⁴24. Magalhães J, Bastos ACN, Barroso W. Cenário global e glocal das tendências científicas e tecnológicas em diabetes: uma abordagem do big data em saúde no século 21. Rev Gest Sist Saúde. 2016 jan-jun;5(1):1-14.^,2525. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003- 2008. Ciênc Saúde Coletiva. 2011 set;16(9):3755-68. justifies the effort of public health services to reduce the impacts of the disease in the population and, consequently, reduce comorbidities, including the impact of influenza and pneumonia in diabetic patients. Diabetes prevalence was found to be higher in the elderly and this result also agrees with the literature.¹⁴14. Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Departamento de Vigilância das Doenças Transmissíveis. Manual dos centros de referência para imunobiológicos especiais [Internet]. 4. ed. Brasília: Ministério da Saúde ; 2014 [citado 2018 jan 25]. 160 p. Disponível em: Disponível em: http://www.saude.pr.gov.br/arquivos/File/-01VACINA/manual_crie_.pdf .
http://www.saude.pr.gov.br/arquivos/File... Although no adjustments were made for age, no difference in diabetes prevalence was observed among the ethnicity/skin color categories, similarly to what was observed in the 2003 National Household Sample Survey²⁶26. Ministério do Planejamento, Orçamento e Gestão (BR), Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional por amostra de domicílios: PNAD 2003 [Internet]. 2003 [citado 2017 jun 25]. Disponível em: Disponível em: https://ww2.ibge.gov.br/home/estatistica/populacao/trabalhoerendimento/pnad2003/coeficiente_brasil.shtm .
https://ww2.ibge.gov.br/home/estatistica... and the 2013 National Health Survey (PNS).⁷7. Ministério do Planejamento, Orçamento e Gestão (BR), Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde 2013: percepção do estado de saúde, estilos de vida e doenças crônicas. Brasil, grandes regiões e unidades da Federação [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2014 [citado 2017 jun 25]. 180 p. Disponível em: ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf.
ftp://ftp.ibge.gov.br/PNS/2013/pns2013.p... Higher diabetes prevalence was estimated in the population with less schooling. Inequalities in health, widely reported in the literature,²⁴24. Magalhães J, Bastos ACN, Barroso W. Cenário global e glocal das tendências científicas e tecnológicas em diabetes: uma abordagem do big data em saúde no século 21. Rev Gest Sist Saúde. 2016 jan-jun;5(1):1-14.^,2525. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003- 2008. Ciênc Saúde Coletiva. 2011 set;16(9):3755-68.^,2727. Dachs JNS. Using household survey and other information sources to study health equity in Latin America and the Caribbean. Rev Panam Salud Pública. 2002;11(5/6):413-7.^,2828. Mackenbach JP. Persistence of social inequalities in modern welfare states: explanation of a paradox. Scand J Public Health. 2017 Mar;45(2):113-20. are evidenced in this study when taking education level and ethnicity/skin color as a proxy for socioeconomic condition.

In face of the low percentage of the population with diabetes mellitus who are vaccinated, it is necessary to intensify campaigns, provide clarification and promote vaccination among users of health care services - especially the young adult population - providing information about all the risks and ways of prevention of this disease and its complications.

SUS is clearly a protagonist in vaccination against influenza and pneumonia in people with diabetes mellitus, ratifying, in the case of vaccination, the successful experience in the universalization of the constitutional right to health by SUS.

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