Artigos

INTRODUCTION
According to the International Labour Organization (ILO), absenteeism is the term that designates absence from work for one or more days, in a period in which its attendance would be expected. This is a multifactorial phenomenon and therefore cannot be fully understood by the evaluation of only one of its dimensions1. It is influenced by individual factors, factors related to the environment and factors associated with work organization2 and, thus, it is an important indicator of worker’s health3.
Among the various reasons for absence from work, the main motivation is health problems4. In these cases, there is talk of absenteeism-disease, which is that resulting from disease or accidental injury, communicated to the employer and/or Social Security5, which makes these records of absences better documented4,6.
Absenteeism due to sick leave is an indicator of imbalance and can be used as a predictor of mortality and as a parameter to assess the health situation of workers7. By investigating absenteeism, we obtain an understanding of the disease burden and the magnitude of its repercussions in the labour world. It is considered a public health problem because it is associated with medical expenses, early retirement, high mortality, and it also causes a loss of productivity at work and affects the physical and mental health of workers4,5. A great example of this impact of ailments in the world of work could be observed mainly in the year 2020, due to the occurrence of the pandemic of the disease caused by SARS-CoV-28.
In the public service, civil servants have greater job stability, which makes it possible to relate diseases with absenteeism in a more reliable way, given that, in other types of employment contracts, illnesses may be underreported and leave due to incapacity is not required for fear of retaliation, although undue, from employers9. In addition, the greater job stability and low turnover of workers allows and favors the longitudinal study of the population, with less losses due to leaving work than could be observed in a private service.
Among the Brazilian federal public service, the judicial sector stands out, in which functions related to planning and executing jurisprudence and procedural judgments, besides other activities, are carried out. In this sector, occupations are diverse and require specific training in various areas of knowledge, specifically focused on labor justice, in the case of the labor court 10.
Regarding the main clinical conditions that motivate absenteeism-disease, musculoskeletal disorders, respiratory problems and mental disorders stand out5,6,11. Respiratory diseases proved to be the most frequent causes of absenteeism in public servants in different studies carried out in Brazil over the last 15 years3,11,12. However, there are few studies in the literature that explore the risk factors associated with this health outcome.
In this perspective, the surveillance of respiratory diseases and their risk factors is imposed in the workplace, given the existence of confined environments, without natural ventilation, not aerated, where workers interact for many hours of the workday every day, in which the population under study is located throughout the work shift, thus being exposed to situations of rapid transmission of infectious diseases that could be prevented with some preventive measures13.
Thus, in the context of Preventive and Occupational Medicine, Occupational Health Surveillance is the axis that should structure the identification of risk situations that guide, based on evidence, interventions to promote health and prevent diseases14,15. It is in this scenario that the present investigation arises, which seeks to study absenteeism due to respiratory diseases, describing its incidence rate, analyzing sociodemographic and occupational characteristics, in order to identify risk factors. In addition, seeks to describe the main diagnoses of respiratory diseases that motivate this kind of sick leave, its duration and frequency.


METHODS
A fixed and ambispective cohort study with a ten-year follow-up started in 2016. First, the data was followed retrospectively from 01/01/2011 to 12/31/2015 and, after the starting point of the study, the follow-up was carried out until 2020. It was conducted in a Judiciary Sector of Bahia, Brazil, which covered all civil servants active on the base date of the research (01/01/2011), totaling a population of 2,661 workers. There were no workers on medical leave due to respiratory disease on this date, so the entire population was included in the baseline of the cohort.
The data studied, which relate to episodes of absenteeism and the characteristics of the study population, were provided by the Secretariat of Information Technology of the Institution, in secondary data sheets, in which individuals were coded, meaning that only non-identifiable data were available. The court has a multidisciplinary health care structure, which includes its own medical staff and, also, conducts regular employee health check-ups, so measures for the health surveillance of employees could be developed. In this Judiciary Sector, judicial and administrative activities are carried out, distributed in four municipalities in the Metropolitan Region of Salvador, Bahia, and 28 municipalities in the Countryside of the state of Bahia, Brazil.
The descriptive approach of the data was divided into two stages: a descriptive stage of the cohort, according to the variables of interest, divided into two categories: sociodemographic characteristics, which include sex, age, education and region of work; and occupational characteristics, which include position, sector and length of service. Another descriptive stage was performed regarding the episodes of sick leave certificates, in which the observation unit was the medical leave.
The outcome studied was the first episode of absenteeism due to respiratory disease verified during the follow-up period. The information on the motivation of the sick leave certificate came from the certificates approved by the occupational physician at the Health Coordination of the Institution, whose records were defined according to the tenth edition of the International Classification of Disease (ICD/10). For the study in question, we evaluated the classifications of respiratory diseases, identified by the codes of group J. Due to the pandemic of the disease caused by SARS-CoV-2, experienced during the follow-up of the cohort in 2020 and in which respiratory diseases were mainly observed, we also evaluated the leaves motivated by ICD B34.2, referring to coronavirus infection.
Due to the atypical situation of this year 2020, initially, a cohort analysis was carried out with follow-up until February 2020, therefore, before the pandemic, since in early March of this year the first cases of SARS-CoV-2 virus infection were recorded in the state of Bahia, Brazil16. Then, observing the results found, with and without the inclusion of that year, it was decided to present the results of the cohort with the inclusion of the year 2020.
The incidence rate of absenteeism was calculated, describing it according to sex, age, and schooling, region of work, position, sector and length of service. The cumulative incidences of absenteeism due to respiratory disease were also calculated for each year of follow-up of the cohort, in order to verify changes in incidence throughout the follow-up and changes imposed by the pandemic in 2020.
The stage of description of the episodes of sick leave included the 751 individuals who took a leave due to respiratory disease and each sick leave certificate was constituted in the observation unit, through which the duration and frequency of sick leave certificates and the impact of sick leave days were presented, considering the subgroups of diagnoses.
In order to identify the risk factors for the outcome – the first episode of absenteeism due to respiratory disease – the analytical stage of the data was performed. Initially, Kaplan-Meier survival curves were obtained. For this analysis, the variables of interest were categorized: age with cut in the median, position was stratified into magistrate or non-magistrate (technicians, analysts and commissioned). Due to the high proportion of ignored data for the Sector variable it was excluded from the analytical stage. Due to the low proportion of elementary level workers in the cohort (1.7%), this stratum was joined to that of workers with high school education, thus forming the category of those without higher education.
After graphical evaluation of Kaplan-Meier curves and verification of risk proportionality, multivariable Cox regression analysis was conducted. Sociodemographic and occupational variables were included in the modeling according to the theoretical and pathophysiological criteria. The corresponding hazard ratio (HR) was calculated for each independent variable.
Considering that the entire population of active workers in the Service was included in the study, therefore, as it was a census, analytical procedures compatible with the nature of the study population were adopted. In this case, the study population is not a sample, but is the target population itself17,18,19.
The data were organized and processed through an electronic spreadsheet in Microsoft Excel 2019 and the multivariable analysis was performed using the 20th version of the SPSS.
The project in which this study is inserted was submitted to and approved by the Research Ethics Committee (REC) of the School of Medicine of Bahia of the Federal University of Bahia, Brazil. The research was carried out according to the norms expressed in resolution 466/12 of the National Health Council.

RESULTS
A total of 2661 civil servants were studied, of which 1252 (47%) were men and 1409 (52.9%) were women. The mean age was 42 years (SD=9.8) and the median was 43 years; ranging from 21 to 73 years. Only 443 (16.7%) employees didn’t have complete university education, while 2216 (83.3%) had completed college.
The majority of workers (73.7%) are based in the Metropolitan Region of Salvador. The occupation of judicial technician is the most frequent in the population (49.8%), followed by judicial analysts (30.8%).
The mean length of service found was 11.8 years (SD=9.4), with a median of 13 years; ranging from <1 to 38 years of work. For at least 13 years, 49.5% of the workers had been in the service.
The incidence rate of leaves due to respiratory disease was 4.33/100 person-years. It was higher among women than among men and also among those with higher education. Workers in the administrative sector had an incidence rate of sick leave certificates of 7.57/100 person-years. Those with longer service were also more affected (Table 1).
A população inicial do estudo foi constituída de 2661 trabalhadores, houve 614 saídas por diferentes desfechos, como óbito, redistribuição para outro órgão e aposentadoria. No tempo de acompanhamento da coorte, houve perda anual de seguimento de 119, 114, 114, 82, 82, 96, 108, 79 e 116 trabalhadores, respectivamente para cada ano, de 2011 a 2019.
Regarding sick leave, during the follow-up period, there were 14,934 of cases of sick leave certificate, totaling 168,381 days of absence from work. There were 2937 leaves due to diseases of the musculoskeletal system and connective tissue, representing 19.7% of the total number of episodes of absence. Respiratory system diseases contributed to 11.3% of general absenteeism, with 1694 episodes of leaves due to respiratory disease in the period. These respiratory diseases affected 751 workers, who presented at least one episode of sick leave certificate, from 2011 to 2020. Mental and behavioral disorders appeared in third place, with the contribution of 1608 episodes of leave, representing 10.7% of the total sick leave certificates in the period.
The most frequent cause of absences due to respiratory diseases was acute upper airway infection, representing 61.8% of cases, followed by cases of influenza and pneumonia, with 17.1%. The mean duration of leave for these groups of conditions was 2.4 and 3.1 days, respectively. On the other hand, despite representing few cases of absences from work, pulmonary diseases due to external agents, such as inorganic dust, gases, fumes and vapors, were responsible for the longest sick leave certificates, with mean duration of leave of 34.3 days, followed by other respiratory diseases that mainly affect the interstitium, with 30.1 days. In the third place are the cases of coronavirus infection, with mean duration of sick leave certificates of 10.3 days, but representing only 2.0% of the leaves (Table 2).
Although there is some fluctuation in incidences over the period, in 2020, during the COVID-19 pandemic, there was a bigger decrease in the record of episodes of sick leave certificates due to respiratory diseases, observed in the form of a decrease in the mean incidence of absenteeism due to respiratory diseases (0.04), when compared to the mean incidence of previous years (on mean, 0.06) (Graph 1).
Cohort analyses were performed with follow-up until before the beginning of the SARS-CoV-2 virus infection pandemic. In this evaluation, an incidence rate for respiratory disease of 4.40/100 person-years was observed. The incidence rates found according to the variables of interest were also not very different from those observed in the follow-up of the cohort for 10 years, that is, from 2011 to 2020. Thus, the data of the entire follow-up period are presented.
In the multivariable analysis, there was no redundancy between the variables by the Kaplan-Meier survival curves, that is, there were no intersections. Thus, all variables were maintained in the modeling. The hazard ratio (HR) results in multivariable Cox regression are shown in Table 3.
Women had an increased risk of 42% compared to men for absenteeism due to respiratory disease. Non-magistrate servants and those with more than 13 years of service also had a higher risk of absenteeism due to respiratory diseases. The strongest association was seen for workers of the Metropolitan Region of Salvador (MRS), who were at risk of taking a leave 58% higher than workers in the countryside of the state.

DISCUSSION
The study followed a cohort of workers from a Judiciary Sector for ten years, observing the incidence rate of sick leave certificates due to respiratory diseases. The multivariate analysis pointed out that women in this Judiciary Sector are more at risk of taking a leave due to respiratory disease, as well as workers enrolled in MRS Courts. Servers who were not magistrates and had a longer service also presented a higher risk of leave. Although there are published studies on absenteeism-disease among different groups of workers, no other cohort studies with a specific approach on absenteeism due to respiratory diseases were found in the national and international literature.
The higher incidence rate of sick leave certificate among women is already well known in the literature1,3,11. This is mainly attributable to the fact that women culturally, when recognizing themselves as sick, seek medical care in a greater proportion than men. Given that in this study the episodes of absenteeism were computed upon presentation of a medical certificate, this finding of greater absenteeism among women is compatible with what was expected. Thus, it is necessary to consider the higher risk of respiratory disease among women in this population, given the importance of absenteeism as an indicator of morbidity, which should guide interventions for the most affected groups20.
Many of the identified national studies that address absenteeism in public servants are concentrated at the municipal level2,5,11,12,21, causing the work region (metropolitan or rural) not to configure as an analyzed variable. In this statewide cohort, the workers of the MRS had a higher incidence rate of absenteeism. It is possible to consider that the civil servants of the capital and its surroundings have greater access to assistance and seek the registration of sick leave certificates; however, the environmental exposure to pollution in the largest cities is directly related to the increase in respiratory symptoms and the search for medical care22 and in this perspective this finding of the present study should be considered.
Age was not shown to be a risk factor for absenteeism due to respiratory diseases. Taking into account that the most observed diagnoses were predominantly acute respiratory disorders, it is understandable that there is no association with the age of the workers, given that environmental exposure and interpersonal contagion say more about this type of impairment.
It is necessary to understand this phenomenon from the perspective of workers exposure to internal pollution of buildings, which often lack adequate ventilation and maintenance. This context of poor air circulation and insufficient hygiene of air conditioners can contribute to labor exposure to dust, fungi, viruses, bacteria and chemical contaminants13. When users of a specific building present respiratory symptoms of nonspecific etiology, the World Health Organization (WHO) speaks of sick building syndrome (SBS).
Workers who remain daily indoors, without natural ventilation, are more exposed to the possibility of transmissibility of respiratory infections and are also more likely to experience symptoms related to SBS. In agreement, judicial technicians and analysts presented the highest densities of absenteeism compared to magistrates, whose permanence in the closed environments of the Courts is known to be lower. For magistrates, long before the pandemic, the work at home, when exercising the study and decisions of judicial proceedings, was already a reality.
However, it is important to highlight that this study presents gaps in information to characterize health conditions and the work environment. Due to the use of secondary data, the most frequent data in no prospective cohorts, no primary data was obtained on the health of the civil servers as well as there are no objective records regarding environmental factors. Given that these are important data for the proposed analysis, environmental factors were indirectly considered, based on the occupational situation of workers, that is, the time of working day spent at closed environment, without natural ventilation, for example.
During the cohort's follow-up period, there was an annual loss to follow-up of 119, 114, 114, 82, 82, 96, 108, 79 and 116 workers, respectively for each year from 2011 to 2019. In the case of a fixed cohort, it is common to lose individuals during follow-up, especially in long-term tracking. In this cohort, despite the 10-year follow-up, there is a low loss of civil servants, who, governed by job stability, exited due to death, retirement or transfer from the court. This is a strong point of the study, which contrasts with the private sector, in which, in addition to difficulties in accessing corporate data for researchers, there are also challenges in monitoring workers due to higher employee turnover.
Investigations on the main pathologies that motivate absenteeism-disease indicate respiratory disorders as the most prevalent, along with diseases of the musculoskeletal system and mental disorders3,11,12. Among the respiratory diseases, absences due to Influenza (ICD J11), Sinusitis (ICD J01) and Tonsillitis (ICD J03) stand out6. These data are similar to those found in this cohort. Sick leave certificates due to diseases of the musculoskeletal system and connective tissue were the most observed, along with diseases of the respiratory system and mental disorders, which is consistent with that described in the literature for other populations of public servants. In the present study, acute infections of the upper airways (J00-J06) accounted for 61.8% of the sick leave certificates due to respiratory diseases in the period, followed by cases of influenza and pneumonia (J09-J18), representing 17.1% of these leaves. In addition to other acute infections of the lower airways (J20-J22), with 4.8%, we have that absenteeism due to acute respiratory diseases represents 83.7% of the leaves due to respiratory causes.
Although, as revealed in some studies6,23, sick leave certificates due to acute respiratory diseases generally generate few days of absence – the mean duration of the leaves is 3.2 days –, the expressive frequency of these acute cases has a great impact on the workers and on the organization of work. In this sense, the adoption of preventive measures recommended by the Ministry of Health in Brazil24,25, such as annual immunization against influenza; frequent hand hygiene; covering the nose and mouth when sneezing or coughing, followed by hand hygiene; avoiding touching the mucous membranes of the eyes, nose and mouth; not sharing objects for personal use; keeping the environments well-ventilated and avoiding crowds and closed environments would be useful in reducing absenteeism24,25. These recommendations took a leading role in the course of the COVID-19 pandemic and should be central, from the learning of the health crisis, in occupational health surveillance actions.
These recommendations, although already present in the Brazilian Ministry of Health's Health Surveillance Guide before 202024, gained greater visibility after the emergence of the new coronavirus, SARS-CoV-2, and the beginning of the pandemic resulting from its infection. In view of the epidemiological situation experienced, more extreme measures were taken to control contamination by the virus25. In this context, as of 19th March 2020, the judicial sector started to operate remotely, in order to promote social distancing of workers, as the main biosecurity measure, in an attempt to mitigate the transmission of the disease26.
During this period, a bigger reduction in the incidence of recorded episodes of absenteeism due to respiratory disease was observed in the population studied – in 2020 the accumulated mean incidence was 0.04, while in previous years the mean incidence was 0.06. Considering that there was greater alertness about respiratory symptoms, it would be expected that there would be an increase in the search for medical care in the presence of symptoms that would not motivate the search for assistance in previous years and, therefore, an increase in the incidence of sick leave certificates would be expected if the working conditions in the pandemic had been maintained under the same face-to-face work regime. However, in remote work, the server left the environment of occupational and social exposure to communicable respiratory diseases, which may explain this decrease in sick leave. In addition, this finding is relevant because it can indicate the effectiveness of measures to contain the transmission of respiratory disease in the workplace, whatever its infectious etiology. Considering that in the midst of the pandemic, given the high incidence of respiratory disease in the general population, with considerable severity before the vaccination campaign, if the Judiciary servers had become sick and sought supplementary medical assistance, the registration of work incapacity would be an expected procedure. Thus, it is reasonable to admit that the reduction in the incidence of absenteeism indicates a reduction in disease.
In any case, it is necessary to consider another explanation for the drop in the incidence of absenteeism due to respiratory diseases in 2020, which is the reduction of disease registration during remote work. Thus, the reduction in the incidence of absenteeism, in this case, would indicate only the lack of registration of the worker's disease, who was already at home, and not the reduction of disease in fact. In any case, given that the incidence of absenteeism in 2020 was not zero, even though the entire contingent of employees was working remotely, it is clear that the registration of sick leave occurred, even without face-to-face work sick leave certificates has occurred, as no meetings or work groups were held in the course of an acute symptomatic condition. This reinforces the hypothesis of reducing respiratory disease in 2020, which may highlight the role of inadequately ventilated work environments in the origin of respiratory diseases and consequent absenteeism.
Finally, it is important to highlight the relevance of measures of Epidemiological Surveillance and prevention of transmission of infectious-contagious respiratory diseases, necessary not only in a pandemic context, but in the routine of daily, usual work, in order to reduce personal and labor losses arising from disease and consequent incapacity for work, and absenteeism-disease.
This study is linked to the Occupational Health Surveillance, which assumed centrality in the discussion about the role of work in the COVID-19 pandemic, in particular, by indicating that policies aimed at the health of workers should consider as priorities the measures of adequacy of workplaces, in their physical and organizational dimensions. This centrality is imposed in the post-pandemic, and should guide the definition of priority for the adequacy of work environments, favoring the basic conditions of comfort, optimizing natural ventilation and airy places. Remote work, amid the largest health crisis of the last hundred years, was a biosecurity measure to which Judiciary workers had access, through Resolution 313/2020 of the National Council of Justice. Thus, in the post-pandemic period, it is necessary for work management to be guided by health information and epidemiological results, such as the findings of this study, in order to continue promoting sustained policies for disease prevention and health promotion.

CONCLUSIONS
This investigation contributed with empirical data that characterized the occurrence of absenteeism due to respiratory diseases in a population of public servants over a period of ten years. Furthermore, it traced the sociodemographic and occupational profile of those affected by the event and also identified the main respiratory diagnoses that motivated absences.
The findings of this study should contribute to health interventions for employees, developed by the institution's own multidisciplinary healthcare team. Additionally, the occupational pattern in this sector aligns with those in other public services, rendering the approach and considerations both valid and externally applicable. This is derived from non-statistical inference, analyzing by the shared sociodemographic, occupational, and environmental characteristics observed across various Brazilian labor courts.
The job stability of the studied population also allowed for a long period of follow-up of the cohort with few losses, strengthening the results found. The use of corporate data has proven to be an interesting approach for analyzing occupational health and can be explored in future research and can constitute a useful tool in managing workers' health, guiding the implementation of measures for improvements.
In this case, the relevance of investigating absenteeism due to diseases of the respiratory system and its predictors becomes evident with the demonstration of the high impact of acute respiratory diseases on the frequency of leaves from work. This finding strengthens the indication and guides the adoption of the preventive measures recommended by the Occupational Health Surveillance in Brazil, especially in the post-pandemic period, when it gets clear that is necessary for work management to be guided by health information and epidemiological results in order to continue promoting sustained policies for respiratory diseases prevention and health promotion.

DATA STATEMENT
The data that support the findings of this study were available from Secretariat of Information Technology of the Judiciary Sector of Bahia, Brazil, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the Tribunal Regional do Trabalho.



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