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Revista de Saúde Pública

On-line version ISSN 1518-8787

Rev. Saúde Pública vol.51  São Paulo  2017  Epub Dec 11, 2017

https://doi.org/10.11606/s1518-8787.2017051000064 

Original Articles

Quality of the record of data on fatal workplace injuries in Brazil

Adriana GaldinoI 

Vilma Sousa SantanaII 

Silvia FerriteIII 

IUniversidade Estadual do Sudoeste da Bahia. Departamento de Saúde II. Jequié, BA, Brasil

IIUniversidade Federal da Bahia. Instituto de Saúde Coletiva. Programa Integrado de Pesquisa e Cooperação Técnica em Saúde Ambiental e do Trabalhador. Salvador, BA, Brasil

IIIUniversidade Federal da Bahia. Departamento de Fonoaudiologia. Instituto de Ciências da Saúde. Programa Integrado de Pesquisa e Cooperação Técnica em Saúde Ambiental e do Trabalhador. Salvador, BA, Brasil


ABSTRACT

OBJECTIVE

To evaluate the quality of the data on fatal workplace injuries in Brazil, in the Mortality Information System (SIM) and the Information System of Notifiable Diseases (SINAN-AT), analyzing the spatial and temporal distribution between 2007 and 2012.

METHODS

We identified fields related to fatal workplace injuries, which were examined for completeness and the use of the “ignored” option. From the SIM, we extracted the records of deaths from external causes, which require the completing of the <acidtrab> field about their relation with work. From the SINAN, we analyzed the <evolution> field, which allows us to identify fatal cases among s severe workplace injuries.

RESULTS

In the SIM, from 469,121 records, the <acidtrab> field was left unfilled or filled as ignored in 84.2% of them; the Brazilian region with the highest proportion was the Northeast (79.1%), from which the state of Alagoas (94.4%) had the highest amount. There was a 5.5% decreasing trend between 2007 (86.6%) and 2012 (81.8%). Among the 251,681 records found in the SINAN-AT, 28.3% had unfilled or ignored responses for <evolution>, varying from 39.7% in 2007 to 23.2% in 2012, a 41.6% decrease.

CONCLUSIONS

The quality of the records on the fields of interest needed to identify fatal workplace injuries is poor in the SIM, but gradually improving. Recording quality was better for SINAN-AT, which has also been strongly getting better lately.

DESCRIPTORS Injuries; Occupational; mortality; Mortality Registries; classification; Data Accuracy

RESUMO

OBJETIVO

Avaliar a qualidade do registro de dados sobre acidentes de trabalho fatais no Brasil nos Sistema de Informação sobre Mortalidade (SIM) e Sistema de Informação de Agravos de Notificação para acidentes de trabalho grave (Sinan-AT), analisando a distribuição espacial e temporal entre 2007 e 2012.

MÉTODOS

Identificaram -se os campos relacionados ao acidente de trabalho fatal, que foram examinados para a completude e uso da opção “ignorado”. Do SIM, foram extraídos os registros de óbitos por causas externas, para os quais é requerido o preenchimento do campo <acidtrab>, sobre a relação com o trabalho. Do Sinan, analisou-se o campo <evolucao>, que permite a identificação dos casos fatais dentre os acidentes de trabalho graves.

RESULTADOS

No SIM, dos 469.121 registros, o campo <acidtrab> foi deixado sem preenchimento ou foi preenchido como ignorado em 84,2%, maior na região Nordeste (79,1%) e, em especial, no estado do Alagoas (94,4%). A tendência foi de queda de 5,5% entre 2007 (86,6%) e 2012 (81,8%). Para os 251.681 registros no Sinan-AT, a falta de preenchimento ou o uso de resposta ignorada no campo <evolucao> representaram, juntos, 28,3%, passando de 39,7% em 2007 para 23,2% em 2012, um declínio de 41,6%.

CONCLUSÕES

A qualidade do preenchimento de campos de interesse para o reconhecimento de casos de acidentes de trabalho fatais é ruim no SIM, mas vem gradualmente melhorando. No Sinan-AT, a qualidade dos registros foi melhor do que no SIM e vem melhorando acentuadamente.

DESCRITORES Acidentes de Trabalho; mortalidade; Registros de Mortalidade; classificação; Confiabilidade dos Dados

INTRODUCTION

Fatal workplace injuries (FWA) are one of the health surveillance targets. Therefore, accurate epidemiological estimates are needed, which require good quality records on injuries from the many information systems available. For FWA, data of interest comprise three dimensions: the type of injury, i.e. lesions resulting from injuries; their work-relatedness identification; and whether the outcome was death. Only one-third of the World Health Organization country members had reliable information on workplace injuries in 200022. Underreporting from limited coverage and record quality is a worldwide problem22, also found in Brazil14. Few studies focus on FWA record quality. A research conducted in the United States has found low accuracy and completeness16 in the field for workplace injuries in death certificates. Other studies reported common inconsistencies in the recording fields related to causes of death and their work-relatedness, from information systems10,20.

In Brazil, the main universal data source of FWA is the Mortality Information System (SIM) based on death certificate data. Despite its advances in coverage and quality, shown by the decrease in ill-defined causes, the SIM is still affected by the poor training of fillers, especially for the coding of causes using the International Classification of Diseases (ICD)13,17. In the SIM, the relation between the cause of death and work is recorded in the field named “workplace injury”. However, more than three decades after its introduction, the incompleteness of this field is still expressive2,12,19. Another data source of FWA is the Information System of Notifiable Diseases (SINAN), whose subsystem of Severe Workplace Injuries (SINAN-AT), created in 2007, records deaths in the field named “clinical evolution”. Studies on the quality of the SINAN-AT are few and limited to some country areas. In the state of Rio Grande do Norte, in the period of 2007 to 2009, the proportion of incompleteness of the clinical evolution field was 3.9%6, much lower than the 24.0% estimated in Betim, state of Minas Gerais, between 2007 and 20111. National estimates and descriptions of spatial distribution and trends over time are lacking. The objective of this study was to estimate measures about the FWA quality of data records, in the SIM and SINAN-AT and to analyze spatial distributions and time changes between 2007 and 2012.

METHODS

This research was carried out with all deaths from external cause records from the SIM and the work-related injuries from the SINAN-AT, among individuals aged 18 to 65 years, from 2007 to 2012. The SIM database was extracted from the Ministry of Health website, while SINAN-AT data were available at the Collaborating Center for the Surveillance of Workers’ Health, webpage of the Universidade Federal da Bahia. The SIM data analysis focused on work-relatedness, which corresponds to the <acidtrab> field or <evolution> from the SINAN-AT.

The variable injury work-relatedness has the following categories: 1 = yes; 2 = no; or 9 = ignored. In the SINAN-AT, correspondingly, the variable clinical evolution groups are: 1 = cure; 2 = temporary disability; 3 = partial permanent disability; 4 = total permanent disability; 5 = death from work-related injuries; 6 = death from other causes; 7 = other; and 9 = ignored. For both information systems, descriptive variables were calendar year, state or federal district, and region. Data incompleteness was assessed with boxes left unfilled or with ignored answers, analyzed together and separately. These variables were categorized based on quintiles: for the SIM, I (≤ 71.2%), II (71.3 to 77.2%), III (77.3 to 85.8%), IV (85.8 to 90.7%), and V (≥ 90.8%); and for the SINAN-AT, I (≤ 7.5%), II (7.6 to 13.1%), III (13.2 to 16.1%), IV (16.2 to 25.5%), and V (> 25.5%). In addition to absolute and relative frequencies, the percentage proportional variation (PPV) for the time period was calculated. Maps present the spatial distributions. Data were processed in the SAS application, version 9.4. The Project protocol was registered in the National System of Ethics in Research and approved by the Research Ethics Committee of the Instituto de Saúde Coletiva of the Universidade Federal da Bahia (Protocol 927,439, December 15, 2014).

RESULTS

In the SIM, we found 652,155 records of external cause deaths between 2007 and 2012. Among them, 469,121 (71.9%) had the <acidtrab> field unfilled (Table 1). From the remaining ones 183,034 cases, 80,055 have “ignored” marks, 43.7% of the total. Missing records plus ignored answers amounted to 549,176 (84.2%). Over the study years, the proportion of unfilled fields decreased 8.2%, varying from 75.5% in 2007 to 69.3% in 2012. In contrast, “ignored” answers increased from 11.1% to 12.4%, a PPV = 11.7%. For both, there was a small decline, starting with 86.6% and ending with 81.8%, a 5.5% reduction (Table 1).

Table 1 Filling status of the field <acidtrab> in the Mortality Information System (SIM), by calendar year. Brazil, 2007-2012. 

Year Deaths from external causes Filling status of the field of workplace accident <acidtrab>
Unfilled A Filled 1 = yes or 2 = no B Filled 9 = ignored C Unfilled or ignored A+C
n % n % n % n %
Total 652,155 469,121 71.9 102,979 15.8 80,055 12.3 549,1 76 84.2
2007 101,080 76,335 75.5 13,567 13.4 11,178 11.1 87,513 86.6
2008 104,989 77,910 74.2 14,694 14.0 12,385 11.8 90,295 86.0
2009 107,018 78,258 73.1 15,708 14.7 13,052 12.2 91,310 85.3
2010 110,089 77,224 70.1 17,959 16.3 14,906 13.5 92,130 83.7
2011 111,770 78,118 69.9 19,694 17.6 13,958 12.5 92,076 82.4
2012 117,209 81,276 69.3 21,357 18.2 14,576 12.4 95,852 81.8
PPV (2007-2012) -8.2 35.8 11.7 -5.5

PPV: percentage proportional variation

In Table 2, the amount of unfiled <acidtrab> was expressive, a national average of 71.9%, ranging from 61.4% in the South region to 79.1% in the Northeast; in addition, the highest estimate (94.4%) was for the state of Alagoas while the lowest corresponds to the state of Santa Catarina (49.5%). The estimate of the Midwest region are noticeable as it is below the national average estimate (66.6%), and its low state-specific proportions for Goiás (68.0%), Mato Grosso do Sul (60.9%) and Mato Grosso (57.8%). In 2007, the Northeast (83.5%) held the highest proportion of unfilled <acidtrab>, close to the 2012 estimate of 76.5%. In contrast, the South region had the lowest proportion of this field unfilled, in 2007 (65.0%) and in 2012 (58.6%). Along this time period, there was a slight decrease in the proportion of unfilled <acidtrab> in all regions and most of the country states except for Paraíba, Espírito Santo, and Goiás, in which it increased. The greatest improvement trend in the filing of this field was for the state of Amapá (-17.5%) and Santa Catarina (-17.1%). For both missing data or ignored answers, four states were found in the highest proportion quintile, namely: Alagoas (97.6%), Federal District (94.8%), Rio de Janeiro (92.6%), and Espírito Santo (91.5%). respectively. The lowest quintile, however, were estimated for Tocantins (64.7%), Piauí (69.3%), Roraima (70.4%), and Maranhão (71.1%) (Figure).

Table 2 Distribution of records with unfilled <acidtrab> in the Mortality Information System (SIM), by region and federated unit. Brazil, 2007-2012. 

Region or Federated Unit Records with unfilled workplace accident <acidtrab>
Total 2007 2012 PPV
n % n % n % (2007-2012)
Brazil 469,121 71.9 76,335 75.5 81,276 69.3 -8.2
North 38,735 70.5 5,281 72.0 7,102 66.9 -7.1
Acre 1,496 74.2 223 85.1 297 70.2 -17.5
Amapá 1,660 75.0 263 79.0 322 75.1 -4.9
Amazonas 7,656 75.5 976 75.8 1,551 74.2 -2.1
Pará 19,803 73.4 2,662 74.5 3,408 67.3 -9.7
Rondônia 4,243 64.3 563 66.5 772 60.5 -9.0
Roraima 1,083 62.8 182 62.1 188 61.4 -1.1
Tocantins 2,794 52.8 412 55.5 564 54.9 -1.1
Northeast 157,767 79.1 24,066 83.8 29,004 76.5 -8.7
Alagoas 15,453 94.4 2,374 95.6 2,667 94.6 -1.0
Bahia 45,506 83.1 6,584 88.3 8,426 79.3 -10.2
Ceará 25,037 78.3 3,787 85.7 5,220 75.9 -11.4
Maranhão 11,922 66.5 1,668 71.6 2,447 65.4 -8.7
Paraíba 11,224 85.4 1.342 83.0 2.260 88.9 7.1
Pernambuco 27,597 75.6 5,122 80.0 3,982 69.7 -12.9
Piauí 6,558 66.5 994 71.8 1,213 61.1 -14.9
Rio Grande do Norte 8,815 81.7 1,334 86.1 1,640 79.8 -7.3
Sergipe 5,655 70.0 861 78.8 1,149 73.2 -7.1
Southeast 1 75,583 71.8 31,346 76.0 28,230 68.6 -9.7
Espírito Santo 12,524 66.5 1,999 64.0 2,099 66.4 3.8
Minas Gerais 44,127 72.1 7,549 77.7 7,223 65.5 -15.7
Rio de Janeiro 48,076 81.7 9,429 85.7 7,180 80.4 -6.2
São Paulo 70,856 67.1 12,369 71.1 11,728 65.2 -8.3
South 59141 61.4 10,012 65.0 9,831 58.6 -9.8
Paraná 25,494 58.7 4,055 59.3 4,333 56.2 -5.2
Rio Grande do Sul 23,846 71.9 4,212 77.6 3,977 69.1 -11.0
Santa Catarina 9,801 49.5 1,745 55.4 1,521 45.9 -17.1
Midwest 10,012 66.6 5,630 67.3 7,109 66.1 -1.8
Federal District 7,823 81.3 1,210 78.6 1,243 75.2 -4.3
Goiás 16,269 68.0 2,146 66.2 3,531 71.1 7.4
Mato Grosso 7,960 57.8 1,261 61.8 1,387 55.5 -10.2
Mato Grosso do Sul 5,843 60.9 1,013 65.8 948 57.8 -12.2

PPV: percentage proportional variation

Figure Proportion of records with ignored or unfilled <acidtrab> in the SIM and <evolution> in the SINAN-AT by federated unit. Brazil, 2007-2012. 

The SINAN-AT had 251,681 cases reported in the study period (Table 3), from which 16,899 (6.7%) had unfilled <evolucao>. Among the 234,782 cases having this field filled, 54,354 (21.6%) had “ignored” marks. Unfilled plus ignored answers amounted to 71,253 cases (28.3%). The trend over the study time of unfilled <evolucao> boxes ranged from 1,714 (9.0%) in 2007 to 3,030 (4.4%) in 2012, a 51.1% decrease, although the “ignored” answers decreased 38.8%; this is smaller than the declining trend observed for both unfilled and ignored (-41.6%) (Table 3).

Table 3 Filing status of the field <evolucao> in the Information System of Notifiable Diseases (SINAN-AT), by calendar year. Brazil, 2007-2012. 

Year Severe workplace injuries Filing status of the field of evolution of the case <evolucao>
Unfilled A Other types of filling* B Filled 9 = ignored C Unfilled or ignored A+C
n % n % n % n %
Total 251,681 16,899 6.7 80,428 71.7 54,354 21.6 71,253 28.3
2007 19,131 1,714 9.0 11,544 60.3 5,873 30.7 7,587 39.7
2008 30,175 2,669 8.8 8,498 61.3 9,008 29.9 11,677 38.7
2009 33,761 2,609 7.7 22,737 67.3 8,415 24.9 11,024 32.7
2010 42,264 4,108 9.7 30,717 72.7 7,439 17.6 11,547 27.3
2011 57,078 2,769 4.8 43,680 76.5 10,629 18.6 13,398 23.4
2012 69,2 72 3,030 4.4 53,252 76.9 12,990 18.8 16,020 23.2
PPV (2007-2012) -51.1 27.4 -38.8 -41.6

PPV: percentage proportional variation

*1 = cure; 2 = temporary disability; 3 = partial disability; 4 = permanent total disability; 5 = death from a severe workplace accident; 6 = death from other causes; 7 = another.

The proportion of missing records for evolution varied from 3.8% in the South to 11.2% for the North region (Table 4). Across the country regions and states, the PPV for missing evolution data varies widely. Specifically, between 2007 and 2012, unfiled fields fell from 9.0% to 4.3%, a 51.7% decline. However, it increased in the Northeast and South regions.

Table 4 Distribution of records with unfilled evolution of the case <evolucao> in the Information System of Notifiable Diseases (SINAN-AT), by region and federated unit. Brazil, 2007-2012. 

Region or Federated Unit Records with unfilled evolution of the case <evolucao>
Total 2007 2012 PPV
n % n % n % (2007-2012)
Brazil 17,668 6.6 14,775 9.0 3,210 4.3 -51.7
North 1,753 11.2 43 15.2 412 7.9 -48.0
Acre 25 5.1 0 - 22 7.6 -
Amapá 1,037 30.1 1 5.0 113 10.7 114.4
Amazonas 118 5.0 3 23.1 31 4.6 53.8
Pará 24 3.6 0 - 11 3.3 -
Rondônia 40 3.3 0 - 18 3.3 -
Roraima 162 6.0 1 25.0 102 9.1 -63.7
Tocantins 347 7.4 38 15.8 115 9.4 -75.3
Northeast 1,349 5.1 22 3.8 432 5.0 31.6
Alagoas 80 8.5 1 20.0 21 6.2 -68.9
Bahia 3 74 6.5 12 3.6 131 7.9 -33.9
Ceará 200 3.2 1 1.9 115 4.4 137.8
Maranhão 243 7.8 0 - 41 3.4 -
Paraíba 79 4.3 8 6.5 33 7.7 -3.8
Pernambuco 79 3.2 0 - 35 3.1 -
Piauí 147 5.9 0 - 3 0.5 -
Rio Grande do Norte 125 4.8 0 - 50 9.1 -
Sergipe 22 2,6 0 - 3 1.7 -
Southeast 12,935 7.0 1,672 9.5 1,756 3.9 -58.9
Espírito Santo 11 3.2 1 14.3 6 4.2 -70.4
Minas Gerais 792 2.8 13 1.9 314 3.3 75.2
Rio de Janeiro 380 13.9 89 26.6 75 7.5 -71.9
São Paulo 11,752 7.7 1,569 9.4 1,361 4.0 -58.1
South 734 3.8 18 2.0 390 4.9 145.0
Paraná 441 3.1 17 2.2 150 2.7 24.1
Rio Grande do Sul 2 73 12.3 0 - 232 21.1 -
Santa Catarina 20 0.7 1 1.4 8 0.7 -52.8
Midwest 897 4.4 20 6.4 220 3.1 -51.6
Federal District 140 3.1 0 - 0 - -
Goiás 344 5.3 1 3.8 49 1.8 -54.4
Mato Grosso 297 5.8 19 9.5 117 6.7 -64.5
Mato Grosso do Sul 116 2.8 0 - 54 3.1 -

PPV: percentage proportional variation

Regarding the states, the highest unfiled PPV change over time was estimated for Ceará (137.8%) and Amapá (114.4%). Moreover, reduced missing evolution data was found in Rio de Janeiro (-71.9) and Espírito Santo (-70.4%) (Table 4). Overall, findings for both, unfilled or ignored data show the smallest proportions in Santa Catarina (1.9%) and in Sergipe (4.5%). However, it reached 74.1%, in the state of Piauí (Figure).

DISCUSSION

In Brazil, between 2007 and 2012, the SIM had an expressive degree of incompleteness of the “work-related injury” field in all regions and federated units, but this has been decreasing, although slowly. In contrast, the proportion of ignored answers showed a slight increase throughout this time. For the SINAN-AT, the overall record quality of the “clinical evolution” field increased, which is a result of the completeness growth while there was a decrease in “ignored” answers. Moreover, the regions with the best SINAN-AT performance were the South and Midwest.

The data quality improvement in relation to FWA, in the SIM, coincides with its system overall advances, such as the coverage increase which reached 96.1% in 20119, and the reduction of non-natural deaths reported as having undetermined intention, which reduced from 10.1% in 2000 to 7.1% in 20119. This contrasts with the persistence of the poor quality in the <acidtrab> filling, which is required to be completed for all external causes of deaths. Presumable explanations are: 1) lack of training of death certificate fillers regarding FWA-related data17; 2) poor willing for data recording and limited awareness about the information importance of the work-relatedness registration; 3) lack of infrastructure and personnel to look for additional information needed to determine the relation between work and the injury that cause the death7; 4) fear of death certificate fillers, including coroners, about the potential legal consequences of work-relatedness reporting, the police involvement, or law prosecution, when the injury can be framed as a crime13.

The high proportions of incompleteness or ignored records found for <acidtrab> in the SIM (national average of 84.2%) are consistent with results from previous studies. For instance, with data from 1997 to 2006, an average 82.9% of external causes deaths had the <acidtrab> filled as ignored13; comparable findings have been reported by Santana19 for non-filling, 80% on the national average between 2000 and 2010. Distinctively, in the United States, non-filling of the work-relatedness box in death certificates varied from 10% to 30%, across the states18.

Examining only the unfilled <acidtrab> in the SIM, high proportions were found in all regions across the country. The worst performance regions and states were those having low income, such as the Northeast, which also have poor performance on health surveillance and other health data21. With data from the state of Amazonas, the <acidtrab> field was marked as ignored in 70.0% of the external cause deaths between 2000 and 20115, close to the 75.5% estimated in our study. In this analysis, the state of Tocantins had 52.8% of unfilled “<acidtrab>”, a much lower proportion than the 90.4% estimated in 2004 in another research2. Most states had a decrease in incompleteness proportion over their corresponding study times.

In addition, our data on unfiled <acidtrab> need to be interpreted with caution. First, in the electronic form used to feed the SIM, presumably because of the misconception of work-related injuries, the occupational injury option becomes disabled for cases when death is a consequence of violent events8,23. Thus, even when death certificates are correct, violent-related deaths which could be classified as work-related injuries, are being coded as “homicides,” “suicides,” or “others” This was revealed by the almost total incompleteness of the field <acidtrab> in violent causes of death (99.7%). Narratives from workers in charge of on-line data entry confirm this hypothesis. Work-related injuries do not exclude events involving violence, although it is a common mistake not to recognize their causal relation to work, common in cases of homicides among security personnel.

In the SINAN-AT, the data quality of the “evolution” field was expressive, with high percentages of completeness, although “ignored” answers were common. Over the study time, there was a substantial reduction of unfilled or ignored records. In general, the SINAN data quality is systematically monitored by health surveillance teams, ensuring good performance, notably for death-related data, of great relevance regardless their cause. In addition, the SINAN data are used to end the investigation of notified cases, crucial for evaluation and decision-making in the grounds of epidemiological surveillance3. Among all country regions and states, small percentages of unfilled <evolution> fields were estimated. Specifically for the state of Rio Grande do Norte, the 4.8% incompleteness is close to other study findings of 3.9%, from 2007 to 20096. In the city of Betim, state of Minas Gerais, incompleteness of 24.0% between 2007 and 2011 was reported1. In our study, for the whole state of Minas Gerais, this was only 3.2%. However, incompleteness decreased over the study time in most regions and states.

We need to keep on mind that the SINAN-AT implementation is still undergoing throughout the country. Although work-related injuries are of compulsory notification since 2004, their data entry was only made possible after 2007 with SINAN. However, according to a 2004 norm, notifications were exclusively reported from sentinel units, i.e., health care units having adequate infrastructure for case identification and reporting, mainly by the Regional Reference Centers for Workers’ Health (CEREST), and specialized hospitals and outpatient facilities. These injury notifications became universal only in 2014. The degree of work-related injury notification was found as “advanced implemented” in only 10 states for 200811. Consistently, only 35.6% of the CEREST considered having reached the status of fully implemented notification of work-related injuries for 2010-201115. In addition, only 28.3% of the total Brazilian municipalities reported work-related injuries in 20114.

The ignored marks in <acidtrab> or in <evolution> must be interpreted considering their operational meaning. The “ignored” code should be chosen when the true response is unknown, and does not represent an error or negligence. The “ignored” answer may be true, reflecting lack of knowledge about the causes of the event of interest, lacking family and colleagues’ information, the inability to carry out visits to workplaces or when the event had occurred for investigation. For <acidtrab>, the overlap between medical and legal aspects may imply failure to provide true responses, thus reducing the filler commitment for accurate recording. The understanding of “ignored” answers as indicating poor data quality is common in studies focusing on the quality of information.

The conclusions of this study should consider its methodological limitations. First, the most important aspect of information quality is the sub-enumeration of cases, which compromises the mortality estimate magnitude. However, in spite of multiple data sources, sub-enumeration was not examined given the difficulties for the identification of all cases, particularly, the lack of a common identifier in the anonymous available databases. Failure to fill <acidtrab>, for example, could be occurring for non-occupational injury cases, although it should be marked as “no”. Unfortunately, this could not be verified given the lack of appropriate data, the same reason why the high SIM field completeness was associated with ignored answers, i.e., lack of knowledge on work-relatedness, despite completion of the field. Regarding SINAN-AT, our conclusions need to take into account the stage of its implementation, not yet completed. The SINAN-AT development involves the training of personnel, often affected by an imbalance between the number of available health workers and the job task demands. Among the limits and challenges faced by the National Network of Integral Care for Workers’ Health (RENAST), the notification of work-related injuries is still under development. For the SINAN-AT, it is also important to consider that the PPV for unfilled boxes presented great variation across states which showed data overdispersion. Specifically, some states had no data for 2007, while in this same year, other states had very small estimates compared to 2012, which contributes to extreme PPV increasing, limiting conclusions.

It is important to notice that both the SIM and SINAN-AT capture work-related injuries for formal and informal workers, the latter excluded from workers’ health statistics until a few years ago, when only workers insured by the Social Insurance were considered.

This study advances the knowledge on the quality of available information systems, a fundamental aspect for workers’ health surveillance. The identification of FWA recording limits can help design strategies to overcome manageable problems. Further studies are recommended focusing on the field filling procedures by directly observing fillers on duty. Research with national estimates of FWA underreporting is also relevant to obtain accurate occupational injury mortality estimates. Our results support the need for consistent investments in the professional training of fillers, the monitoring of the information flow, the data review and analysis, and the dissemination of information, thus improving the quality of FWA data.

Funding: This work was conducted as part of the Projeto Morbimortalidade de Agravos Relacionados à Saúde of the Centro Colaborador em Vigilância dos Agravos à Saúde Relacionados ao Trabalho, Instituto de Saúde Coletiva, Universidade Federal da Bahia, and the Ministry of Health, Health Surveillance Department, General Coordination of Occupational Health (TED 106/2014). National Council for Scientific and Technological Development (CNPq - Process 309099/2015-3, productivity scholarship for Santana VS).

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Received: June 14, 2016; Accepted: October 21, 2016

Correspondence: Adriana Galdino Caminho Q, 31, Urbis 1, Jequiezinho 45208-497 Jequié, BA, Brasil E-mail: agaldino@uesb.edu.br

Conflict of Interest: The authors declare no conflict of interest.

Authors' Contribution: AG, VSS, and SF have participated in all stages of the article, approved the final version of the study, and assume public responsibility for its content.

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