EPIDEMIOLOGICAL B U L L E T I N ISSN AIDS STD. year VII No. 01

Transcrição

1 EPIDEMIOLOGICAL B U L L E T I N ISSN AIDS STD year VII No. 01 Epidemiological Weeks 27-52: July-December 2009 Epidemiological Weeks 01-26: January-July 2010

2 2010. Ministry of Health This publication may be partially or wholly reproduced, provided the source is quoted. Publication Details Epidemiological Bulletin AIDS and STD Year VII No Epidemiological Weeks 27-52: July-December 2009 Year VII No Epidemiological Weeks 01-26: January-July 2010 No. of Copies Printed: 10,000 ISSN: Ministry of Health - Health Surveillance Secretariat - STD, AIDS and Viral Hepatitis Department SAF SUL Trecho 2 Bloco F - Torre I - Ed. Premium - Andar Auditório - sala 4 Postcode Brasília DF, Brazil Telephone: Health Line aids@aids.gov.br Website: Contents prepared by: Information and Surveillance Unit Alessandro Ricardo Caruso da Cunha Edivaldo Luiz dos Santos Gerson Fernando Mendes Pereira Juliana Machado Givisiez Silvano Barbosa de Oliveira Luana da Silva Carvalho Maria Bernadete Rocha Moreira Ronaldo de Almeida Coelho Sandro Magno Costa Pereira Thiago Rodrigues de Amorim Revision: Angela Gasperin Martinazzo Graphic Design: Information and Surveillance Unit Marcos Cleuton de Oliveira English version: David Ian Harrad

3 Epidemiological Bulletin AIDS STD Contents young people Presentation Introduction HIV Prevalence in Brazil AIDS in young people aged 13 to Graph 1 - AIDS case incidence rate (per 100,000 inhab.) among young people aged 13 to 24, by sex, year of diagnosis and sex ratio. Brazil, Graph 2 - Percentage distribution of AIDS cases in young males aged 13 to 24 by hierarchized exposure category per year of diagnosis. Brazil, Data on AIDS in Brazil Graph 3 - AIDS case incidence rate (per 100,000 inhab.) by region of residence and year of diagnosis. Brazil, Graph 4 - AIDS case incidence rate (per 100,000 inhab.) by age group and sex. Brazil, Graph 5 - Percentage distribution of AIDS cases in males aged 13 and over by hierarchized exposure category per year of diagnosis. Brazil, Graph 6 - AIDS case mortality coefficient (per 100,000 inhab.), by region of residence and year of diagnosis. Brazil, Classification of the Federative Units (FU), state capitals and municipalities with 50 thousand inhabitants and over, by AIDS detection rate HIV in pregnant women Syphilis in pregnant women Congenital syphilis Table 1 - AIDS cases (number and incidence rate per 100,000 inhab.) in young people aged 13 to 24 reported on the SINAN system, informed on the SIM system and recorded on the SISCEL/SICLOM, by Federative Unit (FU), region of residence and year of diagnosis. Brazil, Table 2 - AIDS cases (number and incidence rate per 100,000 inhab.) in young people aged 13 to 24 reported on the SINAN system, informed on the SIM system and recorded on the SISCEL/SICLOM systems by sex and sex ratios, and by year of diagnosis. Brazil, Table 3 - AIDS cases reported on the SINAN system (number and percentage) in young people aged 13 to 24, by hierarchized exposure category, by sex and year of diagnosis. Brazil Table 4 - AIDS deaths (number and mortality coefficient per 100,000 inhab.) in young people aged 13 to 24, by Federative Unit (FU) and region of residence per year of death. Brazil, Table 5A - AIDS cases reported on the SINAN system by Federative Unit (FU) and region of residence, per year of diagnosis. Brazil, Table 5B - AIDS cases reported on the SINAN system, informed on the SIM system and recorded on the SISCEL/SICLOM systems, by Federative Unit (FU) and region of residence, per year of diagnosis. Brazil, Table 6A - AIDS case incidence rate (per 100,000 inhab.) reported on the SINAN system, by Federative Unit (FU) and region of residence, per year of diagnosis. Brazil, Table 6B - AIDS case incidence rate (per 100,000 inhab.) reported on the SINAN system, informed on the SIM system and recorded on the SISCEL/SICLOM systems, by Federative Unit (FU) and region of residence, per year of diagnosis. Brazil, Table 7A - AIDS cases (number and incidence rate per 100,000 inhab.) reported on the SINAN system by sex and sex ratios, per year of diagnosis. Brazil, Table 7B - AIDS cases (number and incidencerate per 100,000 inhab.) reported on the SINAN system, informed on the SIM system and recorded on the SISCEL/SICLOM systems by sex and sex ratios, per year of diagnosis. Brazil, Table 8A - AIDS cases reported on the SINAN system by sex and age group per year of diagnosis. Brazil, Table 8B - AIDS cases reported on the SINAN system, informed on the SIM system and recorded on the SISCEL/SICLOM systems by sex and age group per year of diagnosis. Brazil, Table 9A - AIDS case incidence rate (per 100,000 inhab.) reported on the SINAN system by sex and age group per year of diagnosis. Brazil, Table 9B - AIDS case incidence rate (per 100,000 inhab.) reported on the SINAN system, informed on the SIM system and recorded on the SISCEL/SICLOM systems, by sex and age group per year of diagnosis. Brazil,

4 2AIDS STD Ministry of Health Table 10 - AIDS cases (number and incidence rate per 100,000 inhab.) in under fives reported on the SINAN system, informed on the SIM system and recorded on the SISCEL/SICLOM systems, by Federative Unit (FU) and region of residence, per year of diagnosis. Brazil, Table 11 - AIDS cases reported on the SINAN system (number and percentage) in individuals aged under 13, by hierarchized exposure category per year of diagnosis. Brazil, Table12 - AIDS cases reported on the SINAN system (number and percentage) in individuals aged 13 and over, by hierarchized exposure category, by sex and year of diagnosis. Brazil, Table 13 - AIDS cases (number and percentage) reported on the SINAN system in the vertical transmission category, by age and year of diagnosis. Brazil, Table 14 - AIDS cases (number and percentage) reported on the SINAN system, by race/colour and by sex and year of diagnosis. Brazil, Table 15 - AIDS cases (number and percentage) reported on the SINAN system, by formal education, by sex and year of diagnosis. Brazil, Table 16 - AIDS deaths, by Federative Unit (FU) and region of residence per year of death. Brazil, Table 17 - AIDS mortality coefficient (per 100,000 inhab.) crude and standardized, by Federative Unit (FU) and region of residence per year of death. Brazil, Table 18 - AIDS deaths (number and mortality coefficient per 100,000 inhab.) and sex ratios, by year of death. Brazil, Table 19 - AIDS deaths (number and percentage), by race/colour and sex, per year of death. Brazil, Table 20 - AIDS case incidence rate (per 100,000 inhab.) reported on the SINAN system, informed on the SIM system and recorded on the SISCEL/SICLOM systems, by Federative Unit (UF) of residence per year of diagnosis. Brazil, Table 21 - AIDS case incidence rate (per 100,000 inhab.) reported on the SINAN system, informed on the SIM system and recorded on the SISCEL/SICLOM systems, by state capital city of residence per year of diagnosis. Brazil, Table 22 - AIDS case incidence rate (per 100,000 inhab.) reported on the SINAN system, informed on the SIM system and recorded on the SISCEL/SICLOM systems in 100 Brazilian municipalities with more than 50 thousand inhabitants and the highest detection rates. Brazil, Table 23 - HIV-infected pregnant women (cases and detection coefficient per 1,000 live births), by Federative Unit (FU), region of residence and year of childbirth. Brazil, Table 24 - Cases of HIV-infected pregnant women (number and percentage) by age group and year of childbirth. Brazil, Table 25 - Cases of HIV-infected pregnant women (number and percentage) by level of formal education, race/colour and year of childbirth. Brazil, Table 26 - Cases and detection coefficient (per live births) of pregnant women with syphilis, by Federative Unit (FU), reporting region and year reported. Brazil, Table 27 - Cases of pregnant women with syphilis (number and percentage) by age group, level of formal education and race, by year reported. Brazil, Table 28 - Reported cases of congenital syphilis in infants aged under one year old (number and incidence rate per 1,000 live births), by Federative Unit (FU), region of residence and year of diagnosis. Brazil, Table 29 - Reported cases of congenital syphilis (number and percentage), according to case characteristics by year of diagnosis. Brazil, Table 30 - Reported cases of congenital syphilis (number and percentage), by selected variables and by year of diagnosis. Brazil, Table 31 - Congenital syphilis deaths (number and coefficient per 100,000 live births), by Federative Unit (FU), region of residence and year. Brazil, Appendix Epidemiological indicators for monitoring diseases covered by the STD, AIDS and Viral Hepatitis Department Operational indicators for monitoring diseases covered by the STD, AIDS and Viral Hepatitis Department... 52

5 Epidemiological Bulletin AIDS STD Presentation This publication has been produced by the STD, AIDS and Viral Hepatitis Department, located within the structure of the Brazilian Ministry of Health s Secretariat for Health Surveillance. It contains data on AIDS cases, cases of HIV-infected pregnant women, cases of syphilis during pregnancy and cases of congenital syphilis, with details provided based on selected variables. This edition features states, state capital cities and municipalities classified according to the highest incidence rates in This publication reaffirms its mission as an information tool for making evidence-based decisions and for programming health actions. All the information contained in this bulletin is also available on-line at: 3

6 4AIDS STD Ministry of Health

7 Epidemiological Bulletin AIDS STD Introduction The data on the occurrence of Sexually Transmitted Diseases (STD) and HIV/AIDS in Brazil are presented and analysed annually in the Epidemiological Bulletin. They are also available on the STD, AIDS and Viral Hepatitis Department s internet portal. The data are obtained through the mandatory reporting of AIDS cases, cases of HIV and syphilis-infected pregnant women and cases of congenital syphilis. These data are gathered from the Notifiable Diseases Information System (Sistema de Informação de Agravos de Notificação - SINAN), the Mortality Information System (Sistema de Informações sobre Mortalidade - SIM), the Laboratory Tests Control System (Sistema de Controle de Exames Laboratoriais - SISCEL) and the Medication Logistics Control System (Sistema de Controle Logístico de Medicamentos - SICLOM). In use since the year 2000, the procedures for linking the databases of all these information systems have lead to a significant increase and have enabled greater accuracy in AIDS case reporting in Brazil. The data obtained from the information systems and studies undertaken or funded by the Department have contributed to HIV/ AIDS and STD case monitoring, enabling an understanding of the epidemiological scenario and of the determining factors of these infections in the Brazilian population. The studies referred above include Parturient Sentinel studies, studies with Brazilian Army Conscripts, Knowledge, Attitudes and Practices (KAP) studies on risk relating to sexually transmitted infections, and KAP studies aimed at reaching hard-to-reach populations, such as men who have sex with men (MSM), female sex workers (SW) and drug users (DU), for example. This edition of the bulletin will place special emphasis on the occurrence of AIDS cases in young people aged 13 to 24 who account for 11.3% (66,751) of the country s cumulative AIDS cases between 1980 and June

8 6AIDS STD Ministry of Health HIV Prevalence in Brazil The information presented here on HIV prevalence in Brazil has been obtained from studies conducted or funded by the STD, AIDS and Viral Hepatitis Department, including the studies with Brazilian Army Conscripts, Parturient Sentinel studies, KAP studies and Respondent Driven Sampling (RDS) studies with specific populations. The investigations show that HIV infection prevalence in Brazil is as follows: 0.6% in the population aged 15 to 49 (0.4% female and 0.8% male) 1, 0.12% 2 in young men aged 17 to 20 and 0.28% 1 in young women aged 15 to 24. Prevalence is higher among vulnerable populations, in particular among illicit drug users (5.9%) 3, men who have sex with men (10.5%) 4 and female sex workers (5.1%) 5. AIDS in young people aged 13 to 24 In 2009 database linkage enabled the identification of 3,398 AIDS cases in young people aged 13 to 24. The incidence rate was 8.3 cases per 100,000 inhabitants (Table 1), with 1,875 male cases (9.1/100,000 inhabitants) and 1,523 female cases (7.5/100,000 inhabitants). The sex ratio in this age group, which was 3.7:1 (37 males to 10 females) in 1990, fell to 1.1:1 (11 males to 10 females) in In the year 2000 the ratio became inverted (0.9:1 9 males to 10 females). Between 2007 and 2009, however, young males accounted once more for a higher number of AIDS cases (Table 2 and Graph 1). Graph 1 - AIDS case incidence rate (per 100,000 inhab.) among young people aged 13 to 24, by sex, year of diagnosis and sex ratio. Brazil, Incidence rate , , , , , , ,4 1, ,1 1,0 0,9 0,9 0,9 0,9 0, Year of diagnosis M ale Female Sex ratio. NOTES: Cases reported on the SINAN system and recorded on the SISCEL system as at 30/06/2010, and cases recorded on the SIM system between 2000 and Preliminary data for the last five years. POPULATION: MoH/ES/DATASUS, available at < de saúde/demográficas e socioeconômicas>, access on 09/11/ ,0 1,0 1, ,2 1,2 1 Szwarcwald CL et al. HIV Testing during Pregnancy: Use of Secondary Data to Estimate 2006 Test Coverage and Prevalence in Brazil. The Brazilian Journal of Infectious Diseases, vol. 12, nº 3: , Szwarcwald CL. et al. Temporal trends of HIV-related risk behavior among Brazilian Military Conscripts, Clinics. 2005; 60(5): Bastos, FI. Taxas de infecção de HIV e sífilis e inventário de conhecimento, atitudes e práticas de risco relacionadas às infecções sexualmente transmissíveis entre usuários de drogas em 10 municípios brasileiros. Technical report submitted to the STD, AIDS and Viral Hepatitis Department in Kerr, L. Comportamento, atitudes, práticas e prevalência de HIV e sífilis entre homens que fazem sexo com homens (HSH) em 10 cidades brasileiras. Technical report submitted to the STD, AIDS and Viral Hepatitis Department in Szwarcwald CL. Taxas de prevalência de HIV e sífilis e conhecimento, atitudes e práticas de risco relacionadas às infecções sexualmente transmissíveis no grupo das mulheres profissionais do sexo, no Brasil. Technical report submitted to the STD, AIDS and Viral Hepatitis Department in

9 Epidemiological Bulletin AIDS STD Case distribution by region in 2009 shows that 38.2% of cases are found in the South-East Region, followed by the North-East (21.9%), South (21.1%), North (11.1%) and Midwest (7.7%). Although the South-East Region has the largest number of cases in 2009, the South stands out as having the highest detection rate in the same year: 12.6/100,000 inhabitants. In 2009 the highest percentage of AIDS cases in young people aged 13 to 24, in both sexes, is attributed to the sexual exposure category, namely 73.8% in males and 94.0% in females (Table 3 and Graph 2). Between 1998 and 2009 there were 7,443 deaths among young people (58% males and 42% females). During the last ten years Brazil has recorded an annual average of 589 deaths among young people. This represents a reduction of 31.6% when comparing the 1999 mortality coefficient (1.9 deaths per 100,000 inhabitants) with that of the year 2009 (1.3/100,000 inhabitants) (Table 4). Graph 2 - Percentage distribution of AIDS cases in young males aged 13 to 24 by hierarchized exposure category per year of diagnosis. Brazil, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Year of diagnosis MSM Heterosexual IDU Hemophiliac Transfusion Vertical Transmission Unknown. NOTE: Cases reported on the SINAN system as at 30/06/2010. Preliminary data for the last five years. Data on AIDS in Brazil 492,581 AIDS cases were reported on the SINAN system in Brazil between 1980 and June 2010 (Table 5A). The use of database linkage has resulted in a 37% increase in relation to AIDS cases reported on the SINAN system, so that altogether 592,914 cases have been identified between 1980 and 2010 (Table 5B). When this increase is stratified by region, 54% of cases have not been reported on the SINAN system AIDS database in the Northern region, 47% in the North-East, 35% in the South- East, 33% in the South and 32% in the Midwest, in the period between the year 2000 and June Analysis by region shows that between 1980 and June 2010, 344,150 AIDS cases were identified in the South-East Region (58.0% of Brazil s cumulative cases), 115,598 cases in the South (19.5%), cases in the North-East (12.5%), 34,057 cases in the Midwest (5.7%) and 24,745 cases in the Northern Region (4.2%) (Table 5B). In 2009, 20,832 AIDS cases were reported on the SINAN system, whilst 38,538 cases were identified through database linkage. In the same year the AIDS incidence rate in Brazil was 20.1 cases per 100,000 inhabitants, as follows: 32.4 in the Southern Region, 20.4 in the South-East, 20.1 in the North, 18.0 in the Midwest and 13.9 in the North-East (Table 6B). The South-East Region contributes in a more significant manner to Brazil s high incidence rate. With effect from 2007, however, the Southern Region has the highest incidence rate. The reduction in case detection in the South-East Region has a determining influence on the stabilization of the rate in Brazil (Graph 3). 7

10 8AIDS STD Ministry of Health Graph 3 - AIDS case incidence rate (per 100,000 inhab.) by region of residence and year of diagnosis. Brazil, Incidence rate Table 7B shows that there are more male AIDS cases (385,818) than female cases (207,080). Over the years, however, a reduction occurred in the difference in the sex ratio, before becoming stable with effect from the year 2002 at 1.5:1 (15 male cases to 10 female cases). With regard to age groups, the highest percentage of AIDS cases is found in those aged between 40 and 49. There has been a significant increase in AIDS cases in both sexes in individuals aged 60 and over, from 394 cases in 1999 to 938 cases in 2009 among men, and from 191 cases in 1999 to 685 cases in 2009 among women. On the other hand, the country s highest Graph 4 - AIDS case incidence rate (per 100,000 inhab.) by age group and sex. Brazil, 2009 Age group to to to to to to to to 12 < 5 anos NOTES: Cases reported on the SINAN system and recorded on the SISCEL system as at 30/06/2010, and cases recorded on the SIM system between 2000 and Preliminary data for the last five years. POPULATION: MoH/ES/DATASUS, available at < no menu Informações de saúde > Demográficas e socioeconômicas, access on 09/11/ Incidence rate Female 2003 Year of diagnosis Brazil North North-East South-East South Midwest. NOTES: Cases reported on the SINAN system and recorded on the SISCEL system as at 30/06/2010, and cases recorded on the SIM system between 2000 and Preliminary data for the last five years. POPULATION: MoH/ES/DATASUS, available at < de saúde/demográficas e socioeconômicas>, access on 09/11/ Male incidence rate is found in those aged 35 to 39: 46.7 cases per 100,000 inhabitants in 2009 (Tables 8B and 9B). The AIDS case incidence rate in children aged under five has fallen since the year 2002 (6.2 cases per 100,000 inhabitants), whereby in 2009 the rate was 3.0 (Table 10 and Graph 4). Although this drop refers to Brazil as a whole, in fact it is the result of the decrease seen in the South-East, South and Midwest Regions, given that over the time period analysed there has been an increase in the rate in the North and North-East Regions.

11 Epidemiological Bulletin AIDS STD Mother-to-child (vertical) transmission is the predominant exposure category in individuals aged under 13 since the beginning of the epidemic, with percentages above 85% since 2006 (Table 11). Table 12 shows that 60.1% of children in the vertical transmission category were diagnosed before they were two years old. Analysis of the cumulative reported AIDS cases in males aged 13 and over reveals that the majority (63.6%) relate to the sexual exposure category, distributed between heterosexual (31.2%), homosexual (20.6%) and bisexual (11.8%) exposure. In the blood exposure category, injecting drug use can be seen in 17.6% of the cases. Among females AIDS cases are primarily (91.2%) related to the heterosexual exposure category (Table 12 and Graph 5). Graph 5 - Percentage distribution of AIDS cases in males aged 13 and over by hierarchized exposure category per year of diagnosis. Brazil, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Year of diagnosis. NOTE: Cases reported on the SINAN system as at 30/06/2010. Preliminary data for the last five years. MSM Heterosexual IDU Hemophiliac Transfusion Vertical Transmission Unknown In relation to AIDS case distribution in 2009 by race/colour, 9,944 (47.7%) cases were reported in white skinned people, 7,454 (35.8%) in brown skinned people, 2,290 (11.0%) in black skinned people, 103 (0.5%) in yellow skinned people and (0.3%) among indigenous people. Considerable improvement can be seen in the quality of this information, given the reduction in the number of unknown cases with regard to race/colour. In the year 2000, 47.3% of cases were unknown. By the year 2009 this percentage decreased tenfold, to 4.7% unknown cases. Stabilization in the number of unknown cases can be seen with effect from 2007, with percentages not exceeding 4.7% (Table 14). In terms of formal education, 28.9% of the total of individuals reported had attended school for between 4 and 7 years, 23.2% between 8 and 11 years and 14.9% between 1 and 3 years. A trend of increased schooling in individuals reported as having AIDS in Brazil can be seen, specifically with effect from 1999 (Table 15). The total number of deaths caused essentially by AIDS reported on the SIM system between 1980 and 2009 was 229,222, the majority (65.1%) being concentrated in the South-East Region (Table 16). The AIDS mortality coefficient, standardized in 2009, was 6.2 deaths per 100,000 inhabitants. Between 1997 and 2004 this coefficient tended to reduce, and with effect from 2004 it stabilized (Table 17 and Graph 6). In 2009 the mortality coefficient in the male sex was two times higher than among females, at 8.2 and 4.2 per 100,000 inhabitants, respectively (Table 18). 9

12 AIDS STD Ministry of Health Graph 6 - AIDS case mortality coefficient (per 100,000 inhab.), by region of residence and year of diagnosis. Brazil, Mortality coefficient Year of death Brazil North North-East South-East South Midwest SOURCE: MOH/HSS/DASIS/Mortality Information System (Sistema de Informações sobre Mortalidade SIM). Preliminary data. POPULATION: MoH/ES/DATASUS, available at < menu: Informações de saúde > Demográficas e socioeconômicas, access on 09/11/2010. Classification of the Federative Units (FU), state capitals and municipalities with 50 thousand inhabitants and over, by AIDS incidence rate Analysis of incidence rates over time in the Federative Units reveals that since the year 2000 five states have been at the forefront in terms of higher rates, alternating between the highest four positions. The states are: Rio Grande do Sul, Roraima, Rio de Janeiro, Santa Catarina and São Paulo. With the exception of 2004 and 2005, the State of Rio Grande do Sul had the highest AIDS case incidence rates from the year 2000 onwards. In 2009 it had 47.5 cases per 100,000 inhabitants, followed by the states of Roraima (34.9); Santa Catarina (33.1); and Rio de Janeiro (30.7) (Table 20). Among the Brazilian state capitals, Porto Alegre and Florianópolis have been the top of the list, in first and second place respectively, since the year In 2009, the incidence rates for these two cities were and 89.7 AIDS cases per 100,000 inhabitants respectively, followed by Vitória (72.8), Recife (58.4) and Manaus (53.5) (Table 21). With regard to all of Brazil s municipalities it is noteworthy that between 2000 and 2009, the five with the highest rates of AIDS incidence were located in the Southern Region, in the states of Rio Grande do Sul and Santa Catarina. In 2009, in decreasing order of detection rates, we have Porto Alegre/RS (172.1 per 100,000 inhabitants), Rio do Sul/SC (96.7), Florianópolis/SC (89.7), São Leopoldo/RS (82.7) and Cruz Alta/RS (82.3) (Table 22). HIV in pregnant women Antenatal healthcare is an important opportunity for reducing the incidence of congenital syphilis and HIV transmission from mothers to their babies, by means of early diagnosis and adequate treatment. Given that the prevalence of HIV infection is 0.41% in pregnant women, it is estimated that 12,456 new born babies are exposed to HIV annually (2004 Sentinel Parturient Study). A multicentre Ministry of Health study conducted by the Brazilian Paediatric Society in 2004 estimated the rate of vertical HIV transmission in Brazil to be 6.8%, varying between 13.4% in the Northern Region and 4.3% in the Midwest Region. The study found that vertical transmission rates had fallen below 2% in places where Ministry of Health recommended prophylactic measures had been implanted as part of the antenatal routine. Between 2000 and 2009, 54,218 cases of HIV infection in pregnant women were reported in Brazil, of which 40,999 (75.6%) were concentrated in the South and South-East Regions. In 2009 the number of cases in the entire country was 6,104 and the detection rate was 2.1 cases per 1,000 live births. Of the country s five regions, the Southern Region stands out historically as having higher detection rates on average the rate is 4.4 cases of HIV in pregnant women per 1,000 live births. This number is twice that observed for the country as a whole in the same period (average detection rate of 1.8). The states with the highest detection rates in 2009 were Rio Grande do Sul (8.5), Santa Catarina (5.5), Paraná (2.9), São Paulo (2.4) and Amazonas (2,4) (Table 23). The highest percentages of HIV-infected pregnant women are concentrated in the 20 to 29 age group, with between 4 and 11 years of formal schooling and white and brown skin colour (Tables 24 and 25). 10

13 Epidemiological Bulletin AIDS STD Syphilis in pregnant women Syphilis prevalence in parturient women is 1.6%. This is around four times higher than the prevalence of HIV infection, representing some 50 thousand infected pregnant women in 2005 and an estimate of 12 thousand cases of congenital syphilis. This disease is considered to be a clear marker of the quality of antenatal health care. In Brazil it continues to be underreported, with 5,710 new cases in 2005 and an incidence rate of 1.9 cases per one thousand live births. 29,544 cases of syphilis in pregnant women were reported in Brazil by the SINAN system between 2005 and The majority of these cases occurred in the South-East and North-East Regions, with 9,340 (31.6%) and 8,054 (27.3%) cases, respectively. The national detection rate in 2009 was 3.0 cases per 1,000 live births, although the rate was higher in the Midwest Region (5.2) and Northern Region (4.5). In terms of the country s states, the highest rates were found in Mato Grosso do Sul (14.3) and Amapá (13.6) (Table 26). As a general rule the majority of pregnant women with syphilis are in the 20 to 29 age group, distributed between two distinct education levels, i.e. 4 years of middle school education, or incomplete secondary education. With regard to race, the majority of cases occurs in white and brown skinned women (Table 27). Congenital syphilis 54,141 cases of congenital syphilis were detected in babies under one year old in Brazil between the year 2000 and June Of the cumulative total, the South-East Region reported 24,260 (44.8%) cases; the North-East, 17,397 (32.1%); the North, 5,223 (9.6%); the South, 3,764 (7.0%); and the Midwest, 3,497 (6.5%). Rio de Janeiro was the state with the highest number of cumulative cases (11,741), accounting for 21.7% of congenital syphilis cases detected nationally. In Brazil in 2009 the congenital syphilis detection rate was 1.7 cases per 1,000 live births. The North-East and Northern regions had the highest rates that year: 2.2 and 2.1, respectively. In 2009 the highest rates in the country s states occurred in Amapá (5.8 per 1,000 live births), Ceará (4.7) and Rio Grande do Norte (3.6) (Table 28). The availability of adequate antenatal care for all pregnant women is one of the most relevant measures for controlling congenital syphilis. The Ministry of Health recommends that three VDRL tests be performed, two during the antenatal period and one at child delivery. The last Parturient Sentinel Study, carried out in 2006, found coverage of antenatal syphilis testing (two tests) of just 17%. In 2009 in Brazil as a whole the highest percentage of congenital syphilis cases occurred in children whose mothers were aged between 20 and 29 (52.7%), with between four and seven years of formal education (28.1%) and who had had antenatal care (75.5%). Among those pregnant women who had antenatal care, 55.4% were diagnosed as have syphilis whilst they were pregnant and the partners of 53.7% of these women were not treated (Table 30). Between 1998 and 2009, 1,249 deaths caused by congenital syphilis were reported on the SIM system, with 618 deaths (49.5%) in the South-East Region, 369 (29.5%) in the North-East, 118 (9.4%) in the South, 103 (8.2%) in the North and 41 (3.3%) in the Midwest (Table 31). Table 31 shows that 63 deaths due to congenital syphilis were reported in 2009, representing a mortality coefficient of 2.1 per 100,000 live births. In terms of region of residence, the coefficient was 2.5 in the Northern Region (8 deaths), 2.5 in the North-East (22 deaths), 2.3 in the South-East (26 deaths), 1.3 in the Midwest (3 deaths) and 1.1 in the South (4 deaths). 11

14 AIDS young people Table 1 - AIDS cases (number and incidence rate per 100,000 inhab.) in young people aged 13 to 24 reported on the SINAN system, informed on the SIM system and recorded on the SISCEL/SICLOM (1), by Federative Unit (FU), region of residence and year of diagnosis. Brazil, (2) Ministry of Health Total FU of residence No. rate No. rate No. rate No. rate No. rate No. rate No. rate No. rate No. rate No. rate No. rate No. rate No. rate No. No. Brazil , , , , , , , , , , , , , North 96 3, , , , , , , , , , , , , Rondônia 20 6,1 17 5,1 10 2,9 22 6,1 13 3,6 22 5,9 23 6,1 25 6,5 18 4,5 28 6,9 22 5,6 19 5,3 15 4, Acre 4 2,9 2 1,4 6 4,2 1 0,7 9 5,8 6 3,8 5 3,1 5 3,0 7 3,9 4 2,2 9 5,1 11 6,5 4 2, Amazonas 32 4,8 48 7,0 50 7,2 60 7,9 58 7, , , , , , , , , Roraima 1 1,5 2 2,9 2 2,9 4 4,7 7 7,9 6 6,6 9 9, ,4 9 8, , , , , Pará 29 1,9 34 2,2 46 2,9 31 1,9 81 4,8 79 4,6 92 5, , , , , , , Amapá 6 5,4 10 8, ,8 7 5,4 10 7, ,1 9 6,2 12 8,0 5 3,1 6 3, , ,2 11 6, Tocantins 4 1,4 8 2,7 9 3,0 11 3,6 10 3,2 10 3,1 4 1,2 10 3,0 9 2,6 10 2,8 12 3,5 10 3,2 22 7, North-East 272 2, , , , , , , , , , , , , Maranhão 28 2,0 42 3,0 40 2,8 56 3,6 59 3,8 59 3,7 80 5,0 95 5,8 80 4,8 89 5,2 71 4,3 81 5, , Piauí 10 1,4 16 2,2 22 3,0 14 1,8 19 2,5 30 3,8 16 2,0 37 4,7 37 4,6 41 5,0 49 6,4 50 6,6 46 6, Ceará 42 2,5 71 4,1 67 3,8 71 3,8 69 3,7 73 3,8 95 4, ,7 92 4,6 75 3,7 92 4, , , Rio Grande do Norte 13 2,0 15 2,3 16 2,4 19 2,7 19 2,7 9 1,3 19 2,6 15 2,0 33 4,4 26 3,4 46 6,3 22 3,0 22 3, Paraíba 14 1,7 28 3,3 36 4,2 34 3,9 21 2,4 24 2,7 34 3,8 31 3,5 41 4,5 27 2,9 41 4,7 49 5,6 51 5, Pernambuco 53 2,8 75 3,9 93 4,8 81 4, , , , , , , , , , Alagoas 14 2,0 15 2,1 17 2,4 18 2,4 23 3,1 28 3,7 33 4,3 26 3,4 30 3,8 36 4,5 37 5,0 52 7,0 41 5, Sergipe 14 3,2 19 4,3 13 2,9 7 1,5 8 1,7 11 2,3 18 3,7 19 3,8 12 2,3 20 3,8 22 4,5 29 6,2 20 4, Bahia 84 2,5 61 1,8 80 2, , , , , , , , , , , South-East , , , , , , , , , , , , , Minas Gerais 213 5, , , , , , , , , , , , , Espírito Santo 43 6,1 53 7,4 48 6,6 49 6,4 62 8,0 56 7,1 60 7,5 52 6,4 56 6,7 62 7,2 46 5,9 56 7,5 52 7, Rio de Janeiro , , , , , , , , , , , , , São Paulo , , , , , , , , , , , , , South , , , , , , , , , , , , , Paraná , , , , , , , , , , , , , Santa Catarina , , , , , , , , , , , , , Rio Grande do Sul , , , , , , , , , , , , , Midwest 225 8, , , , , , , , , , , , , Mato Grosso do Sul 37 7,7 33 6,7 27 5,4 31 6,2 34 6,7 45 8, , ,4 27 5,0 42 7,6 39 7,4 38 7,3 48 9, Mato Grosso 65 11,0 59 9,8 35 5,7 47 7,4 61 9, , , ,2 69 9,7 36 5,0 62 9,1 66 9, , Goiás 95 8,0 69 5,7 64 5,2 84 6, ,2 93 7, , , , ,9 67 5,2 51 4,0 85 6, Federal District 28 5,5 39 7,4 25 4,7 38 7,1 29 5,3 25 4,4 41 7,1 39 6,7 34 5,6 43 6, ,0 38 6, , NOTES: (1) SICLOM used to validate SISCEL data. (2) SINAN and SISCEL systems as at 30/06/2010 and SIM system between 2000 and POPULATION: MoH/ES/DATASUS, available at < menu: Informações em saúde > Demográficas e socioeconômicas, access on 09/11/

15 Epidemiological Bulletin AIDS STD Table 2 - AIDS cases (number and incidence rate per 100,000 inhab.) in young people aged 13 to 24 reported on the SINAN system, informed on the SIM system and recorded on the SISCEL/SICLOM systems (1) by sex and sex ratios, and by year of diagnosis. Brazil, (2) Number of cases Incidence rate Year of diagnosis Ratio M:F Male Female Total (3) Male Female Total ,0 0,0 0, ,0 0,1 0,0 0, ,5 0,3 0,0 0, ,0 1,4 0,1 0, ,8 2,9 0,3 1, ,4 7,2 1,3 4, ,5 10,8 2,4 6, ,4 14,2 3,1 8, ,7 20,3 5,4 12, ,5 9,8 2,7 6, ,7 26,2 9,7 17, ,3 26,0 10,9 18, ,1 25,0 11,5 18, ,8 23,9 13,0 18, ,4 8,6 6,2 7, ,3 9,3 7,2 8, ,1 9,2 8,7 8, ,0 8,1 8,0 8, ,9 8,3 9,1 8, ,9 8,0 9,3 8, ,9 8,9 10,3 9, ,9 9,0 10,0 9, ,8 8,0 9,6 8, ,0 7,7 8,1 7, ,0 7,0 7,1 7, ,0 7,4 7,5 7, ,2 8,5 7,5 8, ,2 9,1 7,5 8, (4) ,3 3,6 2,8 3,2 NOTES: (1) SICLOM used to validate SISCEL data. (2) SINAN and SISCEL systems as at 30/06/2010 and SIM system between 2000 and (3) 2 unknown cases with regard to sex. (4) The rate was calculated based on the 2009 population. POPULATION: MoH/ES/DATASUS, available at < menu: Informações em saúde > Demográficas e socioeconômicas, access on 09/11/2010. young people 13

16 AIDS young people Table 3 - AIDS cases reported on the SINAN system (number and percentage) in young people aged 13 to 24, by hierarchized exposure category, by sex and year of diagnosis. Brazil Ministry of Health (2) (1) 2010 Total no. % no. % no. % no. % no. % no. % no. % no. % no. % no. % no. % no. % no. % no. % no. % Exposure category Male Homosexual , , , , , , , , , , , , , , ,5 Bisexual , , , , , , , , , , , , , , ,2 Heterosexual , , , , , , , , , , , , , , ,6 Sexual IDU , , , , , , , , ,1 89 7,5 64 6,0 57 5,2 55 5,3 3 1, ,4 Hemophiliac 428 2,7 16 0,9 7 0,4 1 0,1 2 0,1 2 0,1 2 0,1 1 0,1 0 0,0 1 0,1 0 0,0 0 0,0 1 0,1 0 0, ,4 Transfusion 93 0,6 2 0,1 1 0,1 2 0,1 1 0,1 3 0,2 1 0,1 3 0,2 4 0,3 4 0,3 0 0,0 1 0,1 1 0,1 0 0, ,3 Blood Vertical transmission 3 0,0 3 0,2 5 0,3 5 0,3 8 0,5 4 0,2 11 0,7 14 0,9 9 0,6 10 0,8 23 2,1 27 2,5 23 2,2 7 2, ,5 Unknown , , , , , , , , , , , , , , ,1 Total , , , , , , , , , , , , , , ,0 Female Homosexual , , , , , , , , , , , , , , ,3 Sexual IDU , , , , , , ,4 92 5,4 46 3,4 43 3,9 22 2,2 21 2,6 14 1,9 8 4, ,1 Transfusion 108 1,5 2 0,1 0 0,0 1 0,1 2 0,1 0 0,0 0 0,0 6 0,4 2 0,1 0 0,0 0 0,0 0 0,0 0 0,0 0 0, ,5 Blood Vertical transmission 2 0,0 1 0,1 2 0,1 5 0,3 12 0,7 13 0,7 18 1,0 12 0,7 11 0,8 20 1,8 25 2,6 25 3,0 26 3,6 11 5, ,7 Unknown 18 0,3 1 0,1 1 0,1 3 0,2 5 0,3 5 0,3 2 0,1 5 0,3 7 0,5 4 0,4 10 1,0 10 1,2 4 0,5 0 0,0 75 0,3 Total , , , , , , , , , , , , , , ,0 SOURCE: MoH/HSS/DASIS/Mortality Information System (Sistema de Informações sobre Mortalidade SIM) NOTES: (1) Cases as at 30/06/2010. (2) For the period , please consult previous Epidemiological Bulletins or access menu: Technical Area > Epidemiological Bulletin. POPULATION: MoH/ES/DATASUS, available at < menu: Informações em saúde > Demográficas e socioeconômicas, access on 09/11/

17 Epidemiological Bulletin AIDS STD Table 4 - AIDS deaths (number and mortality coefficient per 100,000 inhab.) in young people aged 13 to 24, by Federative Unit (FU) and region of residence per year of death. Brazil, FU of residence (1) Total nº coef. nº coef. nº coef. nº coef. nº coef. nº coef. nº coef. nº coef. nº coef. nº coef. nº coef. nº coef. nº Brazil 812 2, , , , , , , , , , , , North 22 0,7 38 1,2 34 1,0 39 1,1 46 1,3 42 1,1 49 1,3 57 1,5 49 1,2 64 1,7 57 1,5 64 1,7 561 Rondônia 3 0,9 3 0,9 4 1,1 5 1,4 3 0,8 4 1,1 5 1,3 2 0,5 2 0,5 6 1,5 3 0,8 2 0,6 42 Acre 0 0,0 1 0,7 3 2,0 2 1,3 1 0,6 1 0,6 3 1,8 5 2,8 0 0,0 1 0,6 0 0,0 1 0,6 18 Amazonas 4 0,6 11 1,6 11 1,4 6 0,8 12 1,5 10 1,2 18 2,1 14 1,6 13 1,5 17 2,0 18 2,1 21 2,5 155 Roraima 2 2,9 1 1,4 0 0,0 2 2,3 2 2,2 0 0,0 0 0,0 3 2,9 3 2,8 4 3,9 4 4,0 5 4,9 26 Pará 11 0,7 16 1,0 15 0,9 21 1,2 24 1,4 26 1,5 20 1,1 32 1,7 31 1,6 33 1,8 31 1,7 34 1,9 294 Amapá 0 0,0 5 4,1 1 0,8 1 0,7 3 2,1 0 0,0 0 0,0 1 0,6 0 0,0 1 0,6 0 0,0 0 0,0 12 Tocantins 2 0,7 1 0,3 0 0,0 2 0,6 1 0,3 1 0,3 3 0,9 0 0,0 0 0,0 2 0,6 1 0,3 1 0,3 14 North-East 70 0,6 83 0, , , , , , , , , , , Maranhão 6 0,4 9 0,6 8 0,5 12 0,8 11 0,7 19 1,2 12 0,7 18 1,1 16 0,9 17 1,0 18 1,1 27 1,7 173 Piauí 2 0,3 2 0,3 3 0,4 5 0,6 2 0,3 4 0,5 7 0,9 4 0,5 4 0,5 6 0,8 3 0,4 4 0,5 46 Ceará 1 0,1 11 0,6 17 0,9 12 0,6 10 0,5 11 0,6 12 0,6 15 0,7 11 0,5 10 0,5 19 0,9 17 0,8 146 Rio Grande do Norte 1 0,2 2 0,3 4 0,6 5 0,7 0 0,0 3 0,4 3 0,4 1 0,1 1 0,1 3 0,4 2 0,3 6 0,8 31 Paraíba 1 0,1 3 0,4 4 0,5 8 0,9 4 0,5 6 0,7 6 0,7 6 0,7 5 0,5 2 0,2 6 0,7 4 0,5 55 Pernambuco 30 1,6 32 1,6 34 1,7 41 2,0 45 2,2 27 1,3 29 1,4 34 1,6 35 1,6 40 2,0 27 1,4 40 2,0 414 Alagoas 1 0,1 1 0,1 1 0,1 7 0,9 5 0,7 7 0,9 2 0,3 5 0,6 3 0,4 7 0,9 7 0,9 2 0,3 48 Sergipe 2 0,5 0 0,0 5 1,1 3 0,6 2 0,4 3 0,6 3 0,6 2 0,4 3 0,6 2 0,4 2 0,4 5 1,1 32 Bahia 26 0,8 23 0,7 35 1,0 35 1,0 34 0,9 33 0,9 26 0,7 19 0,5 33 0,9 24 0,7 22 0,7 29 0,9 339 South-East 484 3, , , , , , , , , , , , Minas Gerais 54 1,3 58 1,4 43 1,0 40 0,9 45 1,0 42 0,9 41 0,9 24 0,5 40 0,9 26 0,6 22 0,5 28 0,7 463 Espírito Santo 12 1,7 11 1,5 17 2,2 11 1,4 9 1,1 4 0,5 12 1,5 8 1,0 11 1,3 8 1,0 13 1,7 9 1,2 125 Rio de Janeiro 125 4,1 88 2, , , , ,2 80 2,5 67 2,0 65 1,9 78 2,6 80 2,7 78 2, São Paulo 293 3, , , , , , , ,1 91 1,0 88 1, , , South 185 3, , , , , , , , , , ,8 89 1, Paraná 33 1,5 37 1,7 39 1,8 24 1,1 24 1,1 29 1,3 25 1,1 29 1,2 23 1,0 25 1,1 19 0,8 18 0,8 325 Santa Catarina 33 2,8 37 3,1 24 2,0 28 2,2 22 1,7 18 1,4 22 1,7 20 1,5 17 1,2 22 1,7 21 1,6 18 1,4 282 Rio Grande do Sul 119 5, ,3 86 3, ,1 91 4,1 94 4,2 78 3,4 66 2,8 72 3,1 68 3,0 64 2,9 53 2, Midwest 51 1,8 44 1,5 37 1,3 41 1,4 36 1,2 40 1,3 33 1,1 28 0,9 17 0,5 25 0,8 37 1,2 32 1,1 421 Mato Grosso do Sul 12 2,5 10 2,0 10 2,0 10 2,0 8 1,6 13 2,5 6 1,1 6 1,1 5 0,9 6 1,1 6 1,2 8 1,5 100 Mato Grosso 17 2,8 11 1,8 5 0,8 14 2,2 9 1,4 8 1,2 9 1,3 11 1,6 3 0,4 5 0,7 9 1,3 12 1,8 113 Goiás 13 1,1 18 1,5 14 1,1 13 1,0 14 1,1 15 1,2 13 1,0 9 0,7 7 0,5 10 0,8 12 0,9 8 0,6 146 Federal District 9 1,7 5 0,9 8 1,5 4 0,7 5 0,9 4 0,7 5 0,9 2 0,3 2 0,3 4 0,7 10 1,8 4 0,7 62 SOURCE: MOH/HSS/DASIS/Mortality Information System (Sistema de Informações sobre Mortalidade SIM) NOTE: (1) Preliminary data. POPULATION: MoH/ES/DATASUS, available at < menu: Informações de saúde > Demográficas e socioeconômicas>, access on 09/11/2010. young people 15

18 AIDS Table 5A - AIDS cases reported on the SINAN system by Federative Unit (FU) and region of residence, per year of diagnosis. Brazil, (1) Ministry of Health FU of residence (2) Total Brazil North Rondônia Acre Amazonas Roraima Pará Amapá Tocantins North-East Maranhão Piauí Ceará Rio Grande do Norte Paraíba Pernambuco Alagoas Sergipe Bahia South-East Minas Gerais Espírito Santo Rio de Janeiro São Paulo South Paraná Santa Catarina Rio Grande do Sul Midwest Mato Grosso do Sul Mato Grosso Goiás Federal District NOTES: (1) Cases as at 30/06/2010. (2) For the period , please consult previous Epidemiological Bulletins or access < menu: Technical Area > Epidemiological Bulletin. 16

19 Epidemiological Bulletin AIDS STD Table 5B - AIDS cases reported on the SINAN system, informed on the SIM system and recorded on the SISCEL/SICLOM systems (1), by Federative Unit (FU) and region of residence, per year of diagnosis. Brazil, (2) FU of residence (3) Total Brazil North Rondônia Acre Amazonas Roraima Pará Amapá Tocantins North-East Maranhão Piauí Ceará Rio Grande do Norte Paraíba Pernambuco Alagoas Sergipe Bahia South-East Minas Gerais Espírito Santo Rio de Janeiro São Paulo South Paraná Santa Catarina Rio Grande do Sul Midwest Mato Grosso do Sul Mato Grosso Goiás Federal District NOTES: (1) SICLOM used to validate SISCEL data. (2) SINAN and SISCEL systems as at 30/06/2010 and SIM system between 2000 and (3) For the period , please consult previous Epidemiological Bulletins or access < menu: Technical Area > Epidemiological Bulletin. 17

20 AIDS Table 6A - AIDS case incidence rate (per 100,000 inhab.) reported on the SINAN system, by Federative Unit (FU) and region of residence, per year of diagnosis. Brazil, (1) Ministry of Health FU of residence Brazil 17,3 18,9 17,1 17,2 16,7 17,3 17,4 16,2 14,5 13,1 12,0 11,7 10,9 North 5,2 6,1 6,7 6,1 7,4 7,9 8,0 10,8 9,5 9,3 10,1 10,9 9,8 Rondônia 5,8 7,0 5,7 8,0 8,6 11,2 12,0 11,2 9,9 11,5 13,1 11,3 9,0 Acre 2,6 3,7 5,7 3,9 5,0 7,2 5,8 7,2 7,2 4,1 6,8 4,9 4,1 Amazonas 7,6 8,8 11,4 10,3 10,0 10,8 9,7 13,9 14,4 14,0 12,1 12,9 15,5 Roraima 5,9 8,4 9,0 14,2 13,9 8,9 19,6 26,1 14,1 15,9 20,9 26,9 20,6 Pará 4,4 5,1 5,0 3,7 6,0 6,0 6,4 9,9 8,1 7,3 8,6 9,6 7,1 Amapá 8,2 5,9 9,6 6,9 9,4 11,2 7,1 8,5 10,1 11,2 14,0 13,9 13,2 Tocantins 3,1 4,8 4,9 4,8 5,4 5,4 5,4 6,1 3,9 5,5 6,4 8,8 9,8 North-East 5,4 6,6 6,4 6,4 6,4 7,4 8,1 8,0 7,6 7,0 7,1 7,0 6,9 Maranhão 4,0 5,5 5,1 5,3 5,5 5,9 7,8 7,9 5,7 7,3 5,5 5,8 5,0 Piauí 3,8 3,5 4,1 5,7 5,2 5,9 6,2 7,1 8,0 7,0 9,9 10,3 9,0 Ceará 5,4 9,2 8,0 7,4 7,6 7,7 9,4 9,3 7,7 6,8 7,4 6,7 6,6 Rio Grande do Norte 5,3 7,0 5,0 5,9 5,7 4,8 6,6 4,3 5,6 4,0 6,9 6,2 7,0 Paraíba 4,5 5,8 7,4 6,4 6,0 6,2 6,3 6,0 6,1 5,2 6,4 6,7 6,4 Pernambuco 8,0 10,3 9,0 8,7 10,1 13,7 12,7 12,3 12,9 11,1 9,9 9,9 9,4 Alagoas 5,7 4,4 4,9 5,5 6,2 5,7 7,0 6,3 7,4 6,8 7,6 9,3 8,4 Sergipe 6,2 6,2 6,7 5,7 4,3 5,3 7,7 6,9 7,7 7,2 8,2 10,2 8,4 Bahia 4,9 4,6 5,5 5,4 4,8 5,8 6,2 6,6 6,1 5,6 5,1 4,6 5,4 South-East 26,7 28,2 24,9 24,1 22,8 22,7 22,5 20,1 17,7 15,2 12,9 12,1 11,0 Minas Gerais 10,8 10,4 10,6 9,9 9,7 10,9 12,4 11,0 9,9 8,8 8,7 8,4 7,0 Espírito Santo 12,5 13,8 14,3 13,5 14,7 16,0 16,2 15,7 13,7 10,8 8,7 8,2 9,5 Rio de Janeiro 29,8 30,7 27,1 26,9 26,3 24,8 23,4 23,8 19,7 16,8 14,0 11,8 14,1 São Paulo 34,4 37,0 31,9 30,7 28,4 28,1 27,6 23,3 21,0 18,0 14,8 14,3 11,8 South 20,0 24,4 22,6 25,4 24,9 26,4 25,7 23,4 20,9 20,7 19,6 20,5 19,4 Paraná 15,8 16,8 17,2 18,6 17,6 18,2 17,8 16,8 15,4 13,7 12,1 13,1 10,9 Santa Catarina 23,9 29,8 27,4 29,7 31,0 30,6 28,0 26,5 23,2 24,0 21,9 21,5 22,4 Rio Grande do Sul 22,0 28,8 25,2 29,6 28,6 31,8 31,8 28,0 24,8 25,6 25,5 27,1 25,9 Midwest 14,7 13,1 11,6 13,5 13,3 15,2 16,7 16,3 14,1 12,8 11,9 10,8 9,9 Mato Grosso do Sul 14,7 14,9 13,0 12,9 13,1 15,1 14,7 14,3 9,5 11,3 14,0 14,2 13,0 Mato Grosso 15,0 12,6 8,6 10,8 11,5 15,4 17,2 19,3 17,7 12,8 12,8 11,7 9,6 Goiás 12,5 10,7 10,1 12,5 13,4 13,8 13,6 14,5 12,8 12,3 9,0 7,6 7,3 Federal District 19,9 17,6 17,6 19,7 15,4 18,5 25,3 19,0 17,6 15,6 15,7 14,1 13,3 NOTES: (1) Cases as at 30/06/2010. POPULATION: MoH/ES/DATASUS, available at < menu: Informações em saúde > Demográficas e socioeconômicas, access on 09/11/