Costs related to immunopreventable diseases: Brazil and its geographic areas (immunopreventable diseases’ costs in Brazil)

Introduction The occurrence of the immunopreventable diseases in a population global reality. Objective To discriminate the direct costs of the hospitalizations from the immunopreventable diseases in the Unified Health System (SUS), in Brazil and their areas, between 2008 and 2018. Methods A population, observational, descriptive and retrospective study, with data from the information supplied by the DATASUS website, these data were collected during the 2019. Results It was identified 457,479 hospitalizations in the period; with a total of 2,450,870 days of hospital stay, with total costs of R$389,243,264.85. Only the disease mumps presented a growing tendency in whole areas; the chickenpox was decreasing; the illness whooping cough, yellow fever and tetanus were stationary in this period. Conclusions The costs related to immunopreventable diseases were relevant in all the Brazil areas, with tendencies different between the geographic areas and between the several illnesses analysed.


Introduction
The World Health Organization (WHO) estimates that a fourth of the deaths in children under five years old are caused by preventable diseases [1][2][3][4][5][6][7]. According to the international literature [8][9][10], an important proportion of the health care is attributed to communicable diseases, one in six cases assisted by the primary health care, and about 128,000 hospitalizations (84% in public hospitals) were related to these conditions (data from 2010).
Therefore, it is a national public interest the rising of data by health care in this context of preventable diseases. Other countries already had made similar researches with very relevant data about the Immunizations Programs interfere positively in the reduction of the care costs and of rehabilitation, productivity increase, reduction of work absenteeism, and indirect social impact from these diseases [11,12]. In this context, it is necessary an analysis of the Brazilian reality of the immunopreventable diseases, considering that the Immunization Program is a national reality [13], and considering the campaigns anti-vaccination and the fall of the vaccination coverages in all Brazilian geographic area (the national vaccination coverages don't reach the minimum of 95% of coverage - Table 1) and in the whole world [8].

Methods
In this manuscript, it was defined to analysis the data regarding the Brazil, discriminated by its geographical official country areas: North, Northeast, Center-west, Southeast and South.
It was accomplished a population study, observational, descriptive, retrospective, with multiple groups and temporary series, with aggregated public data, through information supplied by the public website of the System of information of the Department of the Unified Health System (DATASUS -http://www2.datasus.gov.br/ DATASUS/index.php?area=02). The research methodology used by the website of DATASUS was established according to the available tools in the consultation system: through the following links: "Information of Health (TABNET)", "Epidemiology and Morbidity"; "SUS Hospital morbidity (SIH/SUS) "; "General hospitalization place -starting from 2008"; "Brazil for Area and Federation Units"; Line = "Area / Federation Units"; Column = it hadn't been "activated", content = "Hospitalizations; Hospitalization approved authorizations (AIH); Total value; Value of the hospital services; Value of the professional services; AIH average value; days of hospital stay; Average days of hospital stay; Deaths; Mortality tax"; available period of January 2008 to December 2018; chapter of CID 10 = "infectious and parasitic diseases"; list of morbidities / CID 10 = "Neonatal tetanus and other tetanus; Diphtheria; Whooping cough; Yellow fever; Meningococcal disease; Measles; Rubella; Mumps; Human rabies virus; Chickenpox / Herpes Zoster; Acute hepatitis B" (these diseases had been chosen because The analysed variables were the immunopreventable diseases above-mentioned, year, age groups, gender and economic variables. The partner-demographic data were tabulated and appraised for descriptive statistics (average and percentages, standard deviation SD, confidence interval CI), by the programs Excel® (Microsoft Corp., United States version 2007), Stata® (StataCorpLP, College Station, United States version 14.0), and Epi info 7®, by the research team. For the continuous variables (numeric), the analysis of lineal regression was used in the cases of verification of the correlations between the economic variables and immunopreventable disease. It was also analysed the temporary tendencies (Yt) of the economic variables correlated to the hospitalizations, the age groups and the gender, that was defined by the lineal regression equation Yt = b0 + b1t + et. In that expression, the parameter b0 corresponds to a constant, b1 corresponds to the inclination of the straight line and et is a random mistake, by the Prais-Winsten method. When the parameter Beta was positive, the temporary series was considered growing; when negative, it was considered decreasing; and stationary when there was no significant difference between its value and the zero. To measure the tax of variation of the straight line that adjusts the points of the temporary series the logarithmic transformation of base 10 of the coefficients it was accomplished (Y), because it contributes to the reduction of the heterogeneity of the variance for the residues of the analysis of lineal regression.  Table 2). These data were updated at DATASUS system site in 2021.

Results
Regarding the regional distribution of Brazil, it was observed that the different geographic areas of the country presented, in this analysed period, several behaviours in relation to each researched disease. The time series analysis (that was represented in the Table 3) demonstrated, in its majority, a stationary tendency of the illness costs in relation to the total of hospitalizations and to their total hospital costs. Some

Discussion
The immunopreventable diseases answer for half of all the deaths in countries with smaller development index: 90% of these deaths attributed to diarrheal diseases, breathing diseases, AIDS, tuberculosis, malaria and measles [12,[14][15][16], and many of them could be preventable through the vaccines. Based on the data collected in this research, still today citizens get sick and are hospitalized by immunopreventable diseases. analysing the direct costs with hospitalizations related to the immunopreventable diseases in SUS, it was observed the reflex of the actions of the public politics of health indirectly, mainly in the country, independent of the regional differences that knowingly exist. If was observed the total expenses here lifted, it is possible saving more than R$389 million avoiding diseases that can be forewarned for measures effective and thoroughly accessible for every Brazilian population = the vaccines. Another observed interesting data is the fact that the hospitalizations for the immunopreventable disease didn't decline in uniform way in the different country's areas, and some illness until presented growing tendencies (as mumps, for instance). This situation should be analysed with very carefully, because it raises the existence of regional differences among health care quality, services structures installed, social inequalities that impact in the population's health, and differences in the regional public politics of facing each immunopreventable disease (despite the national politics of prevention, promotion, diagnosis and treatment of each illness) [17][18][19][20][21][22][23][24].
Nowadays, the financial resources are being destined to the hospitalizations of Immunopreventable diseases can be forewarned with effective measures as the vaccines, if the population was appropriately vaccinated, these resources could be used for other situations, so many needs of public health. This manuscript brings an opportunity for improvement that is the importance of employing awareness public and private campaigns for the importance of increase the vaccination coverage in all geographic areas (Table 1), regarding the regional differences (differences in vaccination's culture, health services access, health budget, health services territorial distribution, and many differences in the population reality that differ between the Brazilian geographic area).
All studies based on public secondary databases have the limitation, already known, of under-reporting and under-reporting of the analysed system itself, because these are dependent on the databases being fed by the employees responsible for the system. In the case of the SUS, these data are feeders in a decentralized manner and regionalized by States and Municipalities. However, despite the notorious underutilization of the system, these are the official data that are used for the development of public health policies in Brazil.