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Background: Globally, there are 10 million new cases of tuberculosis (TB) disease annually and 95% of cases occur in low- and middle-income countries (LMIC). More than 1 billion people use tobacco, and 80% of tobacco users reside in LMIC. Smoking approximately doubles the risk of TB disease and is associated with excess mortality during TB treatment. We aimed to estimate the proportion of annual incident TB cases and TB mortality attributable to tobacco smoking in high burden TB countries. Methods: To estimate population attributable fractions (PAF), we obtained country specific estimates of TB incidence and TB mortality rates from the WHO 2015 Global TB Report. Country specific smoking prevalence was estimated from WHO 2015 tobacco surveillance reports and the Tobacco Atlas. Risk ratios for the effect of smoking on TB incidence and TB mortality were obtained from previously published meta-analyses. Country specific PAF of smoking for TB disease were age and sex adjusted. Results: In high burden countries during 2014, an estimated 4.5 million adults developed TB disease and 163,000 people died from TB. An estimated 740 million adult smokers lived in those high burden countries in 2014. We estimated that tobacco smoking was attributable for 17.7% (95% confidence interval [CI] 8.6-21.9%) of TB cases and 15.0% (95% CI 1.9-31.6%) of TB mortality. Of the high burden countries, Russia had the highest proportion of smoking attributable TB disease (31.8%, 95% CI 16.0-37.8%) and death (28.1%, 95% CI 3.8-51.3%). India had the greatest absolute number of TB cases (233,000) and TB deaths (7,400) attributable to smoking. Men (30.5%, 95% CI 14.9%-36.9%) had a greater proportion of TB cases attributable to smoking than women (4.7%, 95% CI 1.9%-6.2%). Conclusion: In high-burden TB countries, nearly one-sixth of all TB cases and TB deaths were attributable to smoking. Our findings highlight the need for tobacco control in high TB burden regions and specifically among patients with TB. Reaching key populations and integrating smoking cessation efforts into TB programs will be essential to achieve global TB control goals.

MSc (Med), Population-Based Field Epidemiology, School of Public Health, Faculty of health Sciences, University of the Witwatersrand / Introduction: The achievements of the United Nations’ millennium development goals (MDGs) are not possible in isolation. Adult health and mortality with the exception of maternal health is one of the health issues that were openly missing among the list of MDGs. But eradicating extreme poverty and hunger would not be possible if the economically active population is not supported to be healthy and to live longer. Little has been done on adult health, especially to reduce mortality as compared to child health. Adult mortality is expected to equal or exceed child mortality in sub-Saharan Africa if nothing is done. There are varying factors associated with specific-causes of adult deaths within and among different settings. Obtaining more and better data on adult deaths and understanding issues relating to adult deaths in Africa are crucial for long life and development. Objectives: The study seeks to (i) describe causes of adult mortality, (ii) estimate adult cause-specific mortality rates and trends and (iii) identify risk factors of cause-specific mortality in the Ifakara Health and Demographic Surveillance System (IHDSS) population from 2003 – 2007 among adults aged 15 – 59 years. Methodology: The data for the study was extracted from the database of the Ifakara Health and Demographic Surveillance System (IHDSS) in Tanzania from 2003-2007. It was an open cohort study. The cohort was selected based on age (15-59years) and active residency from 1st January 2003 to 31st December 2007. Survival estimates were computed using Kaplan-Meier survival technique and adult mortality rates were estimated expressed per 1000 person years observed (PYO). Verbal autopsy method was used to ascertain causes of deaths. Cox proportional hazards method was used to identify socio-demographic factors associated with specific-causes of adult deaths. v Findings: A total 65,548 adults were identified and followed up, yielding a total of 184,000 person years. A total of 1,352 deaths occurred during the follow-up. The crude adult mortality rate (AMR) estimated over the period was 7.3/1000PYO. There was an insignificant steady increase in annual AMR over the period. The AMR in 2007 increased by 11% over year 2003. Most people died from HIV/AIDS (20.4%) followed by Malaria (13.2%). The AMR for the period was 2.49 per 1000PYO for communicable disease (CD) causes, 1.21 per 1000PYO for non communicable disease (NCD) causes and 0.53 per 1000PYO for causes related to accidents/injuries. Over the study period, deaths resulting from NCDs increased significantly by 50%. The proportion of deaths due to NCDs in 2003 was 16% increasing to 24% in year 2007. Adult deaths from Accidents/Injuries were significantly higher among men (hazard ratio (HR) = 2.2) after adjusting for socioeconomic status (SES), level of education and household size. For communicable and NCDs, most people died at home while for Accidents/Injuries most people died elsewhere (neither home nor health facility). The risk factors that were found to be associated with adult deaths due to NCDs were age and level of education. An improvement in level of education saw a reduction in the risk of dying from NCDs ((HR(Primary)=0.67, 95%CI:0.49, 0.92) and (HR(beyond Primary)=0.11, 95%CI:0.02, 0.40) after adjusting for age and sex. Age, SES and “entry type” were the factors found to be associated with dying from communicable diseases among the adults. In-migrants were 1.7 times more likely to die from communicable disease causes than residents having adjusted for age, household size, educational level, employment status of the head of household and SES. Conclusion: HIV/AIDS is the leading cause of adult deaths in IHDSS area followed by malaria. Most adult deaths occurred outside health facility in rural areas. This could probably be explained by the health seeking behavior and or health care accessibility in vi the rural area of sub-Saharan Africa. NCDs are increasing as a result of demographic and epidemiological transitions taking place in most African countries including Tanzania. Without preventions the rural community in Tanzania will soon face increased triple disease burden; (CD), NCD and Accident/Injuries. Policies on accident/injury preventions in developing countries will be effective if based on local evidence and research.

ABSTRACT Objectives: To determine what obstetric complications can be associated with end-stage AIDS and maternal death. Method: From 1990 to 2005 the maternal death files of patients with either AIDS-defining illnesses or CD4 counts of less than 200x106/ℓ were analyzed in a descriptive study. All patients died undelivered or within 42 days of delivery. Result: Sixty six percent (49/74) of pregnancies ended prematurely by preterm delivery or miscarriage. Twenty perinatal deaths occurred. The average birth weight was 1498g at an average gestational age of 30.5 weeks. The mean CD4 count was 45.5x106/ℓ. The majority of maternal deaths were caused by respiratory illnesses. Conclusion: Preterm ABSTRACT Objectives: To determine what obstetric complications can be associated with end-stage AIDS and maternal death. Method: From 1990 to 2005 the maternal death files of patients with either AIDS-defining illnesses or CD4 counts of less than 200x106/ℓ were analyzed in a descriptive study. All patients died undelivered or within 42 days of delivery. Result: Sixty six percent (49/74) of pregnancies ended prematurely by preterm delivery or miscarriage. Twenty perinatal deaths occurred. The average birth weight was 1498g at an average gestational age of 30.5 weeks. The mean CD4 count was 45.5x106/ℓ. The majority of maternal deaths were caused by respiratory illnesses. Conclusion: Preterm labour and early pregnancy loss are common among terminally ill pregnant women with AIDS. It is proposed that hypoxia in the presence of respiratory disease could lead to cytokine production in the uterine cavity, leading to preterm delivery, even in the absence of intrauterine infection.

MSc, Population-Based Field Epidemiology, Faculty of Health Sciences,University of the Witwatersrand / Introduction: The spread and prevalence of the HIV epidemic has resulted in extensive demographic, social and economic impacts among families in the communities affected in Sub Saharan Africa which increase with the severity and duration of the epidemic. The dramatic increase in adult mortality attributable to HIV/AIDS in households in these communities may increase the number of households that do not survive as a functional and cohesive social group in the years to come. The migration of household members and possible dissolution of these households are the challenges stemming from the epidemic. We therefore require rigorous empirical research on the socioeconomic effects of HIV/AIDS in order to develop appropriate strategies to mitigate these impacts and ultimately improve living standards in these communities. This report describes the extent at which these impacts are felt by a rural community using data from the Rufiji HDSS in rural Tanzania. Design: The study will use a longitudinal study design to identify antecedent events and dynamics and trans-temporal aspects in establishing the effects HIV/AIDS, and particularly how adult deaths from the disease determine migration of individual household members, controlling for other individual level and household factors. Objectives: The main objectives of the study include the description of the adult mortality patterns in the area with an emphasis on the HIV/AIDS related adult deaths, the description of the socioeconomic and demographic characteristics of households experiencing these adult deaths; the characterisation of the members migrating from the households as a result of these adult deaths or otherwise. We also estimate the proportion of household members migrating following the deaths of adult members and further compare these rates of migrations from households experiencing adult HIV/AIDS, Non-HIV/AIDS deaths and where there is no experience of death. Methods: Migrating individuals from 4,019 households that experienced at least one adult death were compared with migrating individuals from other households experiencing Non-HIV/AIDS deaths and those from households without deaths. A total of 32, 787 households were included in the study. An adult death was defined as a death of a household member aged 18 years and above. Those aged 60+ years were considered elderly deaths. A total of 4,603 adult deaths were recorded over the period 1st January 2000 to 31st December 2007. The mortality trends were shown by the rates calculated by Kaplan-Meier survival estimates expressed per 1000 PYO. Migration rates were computed while the association between adult mortality and out-migration of household members was assessed using Cox proportional Hazard model controlling for other individual level and household level factors. Results: Adult deaths increase by about 9% the chance of a child, male or female, to migrate within or without the DSA while HIV/AIDS adult deaths increase by a further 19 percentage point the risk of 5 the child to migrate out of the DSA. The results also show that HIV/AIDS adult deaths enhance the risk of adult female internal migration by 6% (adj. HR 1.06; 95% CI 0.91-1.23, p-value 0.01) but is not significantly associated with adult male migration. Non-HIV/AIDS adult deaths also enhance the risk for female internal migration by 5% albeit hardly significantly (adj. HR 1.05; 95% CI 1.0-1.10, pvalue 0.05) but decreases the chance of male internal migration by 13% (adj. HR 0.87; 95% CI 0.81- 0.93, p-value 0.01). Additionally, HIV/AIDS adult death is strongly associated with out-migration of adults, whatever the gender. They predispose female out-migration to 19% (adj. HR 1.19; 95% CI 1.09-1.30, p-value <0.001) and male migration to 30% increased risk (adj. HR 1.30; 95% CI 1.16-1.45, p-value <0.001). This gender difference is however non-significant (the confidence intervals overlap). Non-HIV/AIDS adult death has the inverse effect on out-migration, and the gender difference is significant: 18% increased risk for males (adj. HR 1.18 95% CI 1.14-1.22, p-value <0.001) and 29% for females (adj. HR 1.29; 95% CI 1.26-1.33, p-value <0.001). Conclusion: Adult deaths have a positive impact on out-migration, with some variation by gender. The effect of HIV/AIDS death on out-migration is not very different from other deaths‟ effect.

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Uneducated working-class individuals in the United States are dying from suicide, drug overdose, and alcoholic-related liver disease at unprecedented rates; a phenomenon economists Anne Case and Angus Deaton describe as deaths of despair. This paper focuses on deaths of despair in the Appalachian region, where mortality rates from these types of deaths are disproportionately higher than the rest of the country. Marxism and intersectionality are two philosophical frameworks that I will apply to Appalachian despair to test the adequacy of their explanatory power. By placing Marxism and intersectionality in the context of the data surrounding deaths of despair, I can test their capability to accurately diagnose and understand this health issue.

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No. of bitstreams: 2 Dissertação - Ivaneusa Gomes de Ávila Maciel - 2015.pdf: 1756633 bytes, checksum: 75e68e889364469e8132461b5cf1be85 (MD5) license_rdf: 19874 bytes, checksum: 38cb62ef53e6f513db2fb7e337df6485 (MD5) Previous issue date: 2015-11-16 / Introduction: the ineffectiveness of control measures, the lack of an effective vaccine against dengue and the increase of deaths from severe forms is a challenge to global public health. In Goiania, since 1994, realize an increase of dengue´s mortality rates, especially in young adults, which is the driving force economic development. Objectives: evaluate the epidemiological profile of dengue´s deaths in Goiania, the factors that contributed to the severity and importance of the State Committee of the Serious Case Assessment Technical and Deaths Suspected Dengue to reduce the fatality rate. Methodology: descriptive and retrospective study from 2011 to 2013. We investigated 73 dengue´s deaths confirmed by laboratory and epidemiological criteria, which were assessed by the Committee. Data were collected on sheets Dengue Research (SINAN / MS), Medical records and deaths Assessment Worksheet. The database was analyzed in SPSS Statistics 22.0 and Open Epi. Results: from the 73 deaths, 60.3% were male and 74% were aged between 15-59 years. In 57.5% of the deaths were classified as dengue with complications (DCC) and 42.5% as Dengue Hemorrhagic Fever (DHF). As you increase the clinical symptoms, greater the risk of death is. In 56.2% of the deaths were observed fever and more 4 clinical symptoms of the disease. Haemorrhagic manifestations occurred in 72.6% of the deaths. Examination of the tourniquet test showed effectiveness in the diagnosis of dengue, with a positivity of 80%. The warning signs were important indicators for the evolution of the disease because they were present in 98.6% of deaths and comorbidities in 67.1% of the patients. Regarding care, 50.7% sought for health care only in the public sector and 24.6% in both sectors. About 52.1% of patients sought treatment early, within 2 days from the start date of symptoms. Of the total, who sought treatment after two days, noticed that 71.2% had a fatal outcome. The public health sector registered 60.3% of deaths. The average attendance of patients was about 2 times. Clinical management was considered inappropriate in 42.5% of deaths. All the deaths were assessed by the Committee. Most of the deaths were reported by the Death Verification Service (69.9%). Conclusion: study showed underreporting of dengue´s deaths in the public and private sector. The majority of reports were late. The Coroner's system constituted an important source of funding dengue´s deaths. The Case of the Evaluation Technical Committee Graves and Deaths Suspected Dengue proved to be of low utility for the implementation of measures to reduce dengue´s mortality. / Introdução: a ineficácia das medidas de controle, a falta de uma vacina eficaz contra a dengue e o aumento dos óbitos pelas formas graves constituem desafio para a saúde pública mundial. Em Goiânia, desde 1994, observa-se o aumento crescente das taxas de letalidade de dengue, principalmente nos adultos jovens, o que constitui a força motriz do desenvolvimento econômico. Objetivos: avaliar o perfil epidemiológico dos óbitos de dengue em Goiânia, os fatores que contribuíram para a gravidade e a importância do Comitê Técnico Estadual de Avaliação dos Casos Graves e Óbitos Suspeitos de Dengue para a redução da taxa de letalidade. Metodologia: estudo descritivo e retrospectivo de 2011 a 2013. Foram investigados 73 óbitos de dengue confirmados por critério laboratorial e epidemiológico, os quais foram avaliados pelo Comitê. Os dados foram coletados nas Fichas de Investigação de Dengue (Sinan/MS), Prontuários e Planilha de Avaliação dos Óbitos. O banco de dados foi analisado no pacote estatístico SPSS Statistics 22.0 e Open Epi. Resultados: dos 73 óbitos, 60,3% desses foram do sexo masculino e 74% estavam na faixa etária entre 15 a 59 anos. Dos óbitos, 57,5% foram classificados como Dengue com Complicações (DCC) e 42,5% como Febre Hemorrágica da Dengue (FHD). À medida que aumentam os sintomas clínicos, maior o risco de óbito. Em 56,2% dos óbitos foram observados febre e mais 4 sintomas clínicos da doença. As manifestações hemorrágicas ocorreram em 72,6% dos óbitos. O exame da prova do laço apresentou-se eficaz no diagnóstico da dengue, com uma positividade de 80%. Os sinais de alarme constituíram indicadores importantes para a evolução da doença, pois foram presentes em 98,6% dos óbitos e as comorbidades em 67,1% dos pacientes. Em relação à assistência, 50,7% procuraram somente o setor público e 24,6% ambos os setores. Cerca de 52,1% dos pacientes buscaram atendimento precocemente, até 2 dias da data de início dos sintomas. Do total que buscou atendimento após 2 dias, observou-se que 71,2% evoluíram para o óbito. O setor público de saúde registrou 60,3% dos óbitos. A média de atendimentos dos pacientes foi de cerca de 2 vezes. O manejo clínico foi considerado inadequado em 42,5% dos óbitos. Todos os óbitos foram avaliados pelo Comitê. A maioria deles foi notificada pelo Serviço de Verificação de Óbitos – SVO (69.9%). Conclusão: o estudo mostrou subnotificação dos óbitos de dengue tanto no setor público quanto no privado. A maioria das notificações foi tardia. O Sistema de Verificação de Óbitos constituiu uma importante fonte de captação dos óbitos de dengue. O Comitê Técnico de Avaliação dos Casos Graves e Óbitos Suspeitos de Dengue mostrou-se de baixa utilidade para a implementação das medidas de redução da letalidade de dengue.