Paulo Roberto Figueroa Junior.

Emergency Medicine Resident, São João de Deus Health Complex, Divinópolis, Minas Gerais, Brasil.

In Brazil, deaths from external causes, which encompass both accidents and violence, represent a significant public health concern. These deaths are categorized based on the intentionality behind the events—accidents being unintentional injuries and violence referring to intentional harm.

The numbers are alarming: according to DATASUS data from the Brazilian Ministry of Health, there were 30,149 deaths related to external causes in 2023, followed by 30,010 in 2024 (until November 2024). The persistence of such high numbers underscores the urgent need for effective interventions and policies to address both accidental and violent deaths in the country.

The Violence and Accident Surveillance in Urgent and Emergency Sentinel Services (VIVA), a study conducted in 2017, highlights the extensive and multifaceted economic impact of external causes. In that year, expenditures related solely to hospital admissions recorded in the Hospital Information System (SIH) exceeded 1.4 billion Brazilian reais. These figures do not account for additional costs related to emergency care, including pre-hospital, hospital-based, and non-hospital-based services. Rehabilitation services also contribute to the overall financial impact.

Regarding road traffic accidents, the Brazilian Institute for Applied Economic Research (IPEA) estimated annual costs at 40 billion reais in 2014. Of this total, highway-related expenses alone amounted to 12.3 billion reais, with approximately 64% attributed to healthcare-related services.

The VIVA, established by Brazil’s Ministry of Health in 2006, is a vital tool for monitoring and analyzing violence and accidents in the country. It aims to guide the development of public policies, intervention strategies, and preventive actions. The system is composed of two main components: Viva/Sinan, which provides continuous surveillance of interpersonal and self-inflicted violence through mandatory reporting, and Viva Inquiry, a research initiative carried out in sentinel emergency units across select capitals and municipalities.

This initiative collects detailed data on victims of violence and accidents treated in these services, including variables like establishment, type of incident, mechanism of injury, and the progression of the case. These studies have been collected from 2007, 2009, 2011, 2014, 2017 and are planned to occur in 2024.

The surveillance system provides an essential complement to existing epidemiological data from mortality and hospital morbidity records. It sheds light on important details about victims, the contexts in which violence occurs, and potential aggressors—offering insights that might otherwise go unnoticed. This is particularly valuable for identifying less severe cases that would not be captured by conventional health data systems, including domestic and sexual violence, which often remain underreported or hidden in society.

In parallel, the Hospital Information System and Unified Health System (SIH/SUS), managed by the Ministry of Health and supported by state and municipal health departments, serves as a cornerstone of the system’s data-gathering process. Hospitals that participate in the SUS, whether public or contracted private institutions, submit hospitalization data via AIH (Hospital Admission Authorization) to local or state authorities. These reports are processed by DATASUS, the Department of Informatics for SUS, generating financial credits for services provided while building an extensive database that covers a significant number of hospital admissions in Brazil.

According to DATASUS, between January and November 2024, there were 1,428,860 hospitalizations for hospital morbidity due to external causes, based on the place of residence. Of these, 256,316 were due to transport accidents, 804,499 were caused by other external accidental injuries, 10,927 were self-inflicted injuries, 43,763 were cases of assault, 149,879 were events with undetermined intent, 591 were related to legal interventions and acts of war, 55,285 were complications from medical and surgical assistance, 68,656 were sequelae from external causes, 11,360 were linked to supplementary factors from other causes, and 27,584 were from unclassified external causes.

In addition, there were 6,945,136 days of hospitalization recorded for hospital morbidity due to external causes, based on the place of residence. Of these, 1,368,272 days were due to transport accidents, 3,687,063 were caused by other external accidental injuries, 48,865 were related to self-inflicted injuries, 232,291 were from assaults, 724,915 were from events with undetermined intent, 2,732 were due to legal interventions and acts of war, 336,027 were complications from medical and surgical assistance, 349,563 were sequelae from external causes, 56,051 were linked to supplementary factors from other causes, and 139,357 were from unclassified external causes.

The total number of deaths was 30,010, with 5,279 resulting from transport accidents, 15,984 from other external accidental injuries, 422 from self-inflicted injuries, 1,606 from assaults, 3,104 with undetermined intent, 9 from legal interventions and acts of war, 1,501 from complications of medical and surgical assistance, 1,503 from sequelae of external causes, 253 from supplementary factors related to other causes, and 349 from unclassified external causes.

When combined with the data from VIVA, this information significantly strengthens the country’s ability to monitor the impact of external causes on healthcare resources, enhancing care management and enabling more precise and targeted interventions.

Pre-hospital emergency care in Brazil is provided by the Emergency Care Service (Serviço de Atendimento Móvel de Urgência - SAMU 192), designed to handle urgent and emergency situations and supported by public funding. Launched in 2003 as part of the National Emergency and Urgent Care Policy, SAMU serves nearly 87% of Brazil’s population. This service is supported by federal, state, and municipal governments to improve the quality of care for the population.

SAMU teams are composed of emergency drivers, nursing staff, and physicians, trained to manage critical cases involving trauma, medical conditions, psychiatric episodes, obstetric emergencies, and pediatric care. SAMU operates in both urban and rural areas, utilizing ambulances, motorbikes, boats, and aircraft, with support from the fire department, aeronautics, navy, army, and federal highway police.

SAMU’s emergency response includes handling trauma cases such as blunt and penetrating injuries, especially in the context of road traffic accidents, which remain a significant public health concern in Brazil. Motorcycle-related injuries, in particular, have been persistent. Between 2011 and 2021, the number of fatalities among motorcyclists showed little variation, with 11,485 deaths in 2011 and 11,115 in 2021. However, hospitalizations for motorcycle-related injuries increased by 55% during the same period, considering only the public healthcare system (SUS) and affiliated providers. In 2011, the hospitalization rate for motorcyclists was 3.9 per 10,000 inhabitants, rising to 6.1 in 2021, at a cost of 167 million reais that year alone.

Globally, traffic injuries are among the top ten causes of death in low- and middle-income countries and rank as the sixth leading cause of Disability-Adjusted Life Years (DALYs). In Brazil, these injuries accounted for over 190,000 hospitalizations within the SUS network as of 2020, with motorcyclists representing more than 61% of these cases.

As a first-year resident of Emergency Medicine in Divinópolis, Minas Gerais - Brazil, working on an Urgency Hospital type III in Minas Gerais, I have witnessed firsthand the critical role that trauma care systems, structured across various levels of care, play in addressing the public health challenges posed by trauma.

My experience as a regulatory physician with SAMU deepened my understanding of the urgent need for highly trained professionals to manage emergencies, particularly in the emergency department. This experience ignited my passion for scientific research in the field, setting me on a journey to deepen my knowledge and contribute to improvements in trauma care.

However, significant challenges remain—particularly in resource allocation, the persistent burden of traffic accidents, and the need to shift the mindset of hospital administrators regarding the crucial role of emergency medicine.

A comprehensive epidemiology, based on data science and big data, is essential to demonstrate the long-term benefits of these services in saving lives and improving patient outcomes, which is the target of the TRAUMA (Unified Data Rapid Access Technology for Accident Mitigation) project, an initiative of the Institutional Development Support Program of the Unified Health System (Proadi-SUS), sponsored and financed by Hospital Israelita Albert Einstein (HIAE) in partnership for a national injury registry.

References:

1. Brazil, Ministry of Health. Hospital Information System of SUS - Variable descriptions. Department of Informatics of SUS. [online] http://tabnet.datasus.gov.br/cgi/sih/midescr.htm
2. Brazil Ministry of Health, Secretariat of Health Surveillance, & Department of Health Analysis and Surveillance of Non-Communicable Diseases. (2019). Viva Inquiry 2017: Surveillance of violence and accidents in sentinel emergency and urgent care services – Capitals and municipalities. Ministry of Health.
3. Brazil. Ministry of Health. (2015). SAIPS system usage manual - Health Policy Implementation Support System [PDF]. Ministry of Health. https://www.gov.br/saude/pt-br/composicao/saes/saips/manuais/manuais-cgae/manu al-saips-cuidado-trauma-i-ii-ii.pdf Brazil.
4. Ministry of Health. (2009). Ordinance No. 90, of March 27, 2009. Ministry of Health. https://bvsms.saude.gov.br/bvs/saudelegis/sas/2009/prt0090_27_03_2009.html
5. Brazil. Ministry of Health. (n.d.). National Health Establishments Registry - Qualifications. Ministry of Health. https://cnes2.datasus.gov.br/Mod_Ind_Habilitacoes.asp?VEstado=00&VTipo=H
6. Brazil, Ministry of Health, Secretariat of Health Surveillance. Interpersonal and self-inflicted violence. Department of Health Informatics of SUS. [online] https://portalsinan.saude.gov.br/violencia-interpessoal-autoprovocada
7. Brazilian Ministry of Health. Datasus: Hospital Information System (SIH) - Hospitalization data. http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sih/cnv/fruf.def
8. de Souza, A. C. M., Lopes, L. E. S., de Oliveira, B. Z., Rother, E. T., & Correia, L. R. (2024). Effects of injury registry data on policy making, hospitalizations, and mortality: Protocol for a systematic review and meta-analysis. JMIR Research Protocols, 13, e55029. https://doi.org/10.2196/55029
9. Ministry of Health: Primary care and specialized care: Learn about the levels of care in the world's largest public health system, in: Ministry of Health, 2022, [online] https://www.gov.br/saude/pt-br/assuntos/noticias/2022/marco/atencao-primaria-e-ate ncao-especializada-conheca-os-niveis-de-assistencia-do-maior-sistema-publico-de-s aude-do-mundo.
10. Ministry of Health: National Registry of Health Establishments (CNES), in: DATASUS Information System, 2024, [online] https://cnes.datasus.gov.br/.
11. Ministry of Health: Ministry of Health releases document with data on motorcycle injuries in traffic, in: Ministry of Health, 2023, [online] https://www.gov.br/saude/pt-br/assuntos/noticias/2023/abril/ministerio-da-saude-lanc a-documento-com-dados-sobre-lesoes-de-motociclistas-no-transito.
12. Ministry of Justice: Deaths from external causes: Qualification of nonspecific records, in: Ministry of Justice, 2024, [online] https://www.gov.br/mj/pt-br/assuntos/sua-seguranca/seguranca-publica/mortes-por-c ausas-externas-qualificacao-dos-registros-inespecificos.pdf.
13. Ministry of Health: Portaria GM/MS No. 1366, of July 8, 2013, in: Ministry of Health, 2013,[online]https://bvsms.saude.gov.br/bvs/saudelegis/gm/2013/prt1366_08_07_2013.html. Ministry of Health: Portaria GM/MS No. 479, of April 15, 1999, in: Ministry of Health,1999,[online]https://bvsms.saude.gov.br/bvs/saudelegis/gm/1999/prt0479_15_04_1999.html.

I would like to express my gratitude from SAMU/Consórcio Intermunicipal de Saúde Oeste and CGAE/DAET/MS, for their invaluable assistance and data contribution, which were essential to the development of this article.