Higher risk of death from COVID-19 in low-income and non-White populations of São Paulo, Brazil

A historical perspective of malaria policy and control in India

Malaria is a major public health problem in India, with ∼0.18 million cases reported in 2022 and 1,309 million population living at risk of infection. The Indian government has introduced various intervention strategies to reduce and manage the number of outbreaks with proper mechanisms. In this policy paper, we have extensively reviewed these intervention strategies using a quantitative approach. The success of the Urban Malaria Scheme, focusing on the 131 urban regions distributed across the country, along with the Intensified Malaria Control Project implemented in the seven hotspots, has been highlighted. The recently formulated National Framework for Malaria Elimination in India has resulted in declining malaria cases in hotspots like Odisha. However, states like West Bengal, Maharashtra, and Tripura have emerged as new hotspots in recent years. A systematic platform for data dissemination and active public-private partnership will expedite malaria elimination in India.

Seroprevalence trends of anti-SARS-CoV-2 antibodies in the adult population of the São Paulo Municipality, Brazil: Results from seven serosurveys from June 2020 to April 2022. The SoroEpi MSP Study

BACKGROUND

Sequential population-based household serosurveys of SARS-CoV-2 covering the COVID-19 pre- and post-vaccination periods are scarce in Brazil. This study investigated seropositivity trends in the municipality of São Paulo.

METHODS

We conducted seven cross-sectional surveys of adult population-representative samples between June 2020 and April 2022. The study design included probabilistic sampling, test for SARS-CoV-2 antibodies using the Roche Elecsys anti-nucleocapsid assay, and statistical adjustments for population demographics and non-response. The weighted seroprevalences with 95% confidence intervals (CI) were estimated by sex, age group, race, schooling, and mean income study strata. Time trends in seropositivity were assessed using the Joinpoint model. We compared infection-induced seroprevalences with COVID-19 reported cases in the pre-vaccination period.

RESULTS

The study sample comprised 8,134 adults. The overall SARS-CoV-2 seroprevalence increased from 11.4% (95%CI: 9.2-13.6) in June 2020 to 24.9% (95%CI: 21.0-28.7) in January 2021; from 38.1% (95%CI: 34.3-41.9) in April 2021 to 77.7% (95%CI: 74.4-81.0) in April 2022. The prevalence over time was higher in the subgroup 18-39 years old than in the older groups from Survey 3 onwards. The self-declared Black or mixed (Pardo) group showed a higher prevalence in all surveys compared to the White group. Monthly prevalence rose steeply from January 2021 onwards, particularly among those aged 60 years or older. The infection-to-case ratios ranged from 8.9 in June 2020 to 4.3 in January 2021.

CONCLUSIONS

The overall seroprevalence rose significantly over time and with age and race subgroup variations. Increases in the 60 years or older age and the White groups were faster than in younger ages and Black or mixed (Pardo) race groups in the post-vaccination period. Our data may add to the understanding of the complex and changing population dynamics of the SARS-CoV-2 infection, including the impact of vaccination strategies and the modelling of future epidemiological scenarios.

COVID-19 mortality: educational inequalities and socio-spatial context in two provinces of Argentina

Motivation for the study. There are very few studies on the educational inequalities in COVID-19 mortality, taking into account social contextual factors. Main findings. We found educational inequalities of COVID-19 mortality during both the 2020 and 2021 waves, regardless of the level of poverty and urbanization in the departments of Mendoza and San Juan provinces (Argentina). Implications. Preventive policies should focus not only in areas with high levels of poverty, but also in areas with adults of low educational level. With the aim of describing the association between sociodemographic characteristics and contextual factors with COVID-19 mortality during 2020-2021 in the provinces of Mendoza and San Juan in Argentina, we conducted an ecological study, which included the sociodemographic factors: age, sex and educational level, and the contextual factors: poverty and urbanization at the departmental level. The analyses were estimated using negative binomial Bayesian hierarchical models. Educational inequalities existed regardless of socioeconomic context and level of urbanization. The exception was the age group 65 years and older during 2021, which, regardless of educational level, showed a higher risk of death by COVID-19 in departments with high levels of structural poverty. In conclusion, educational inequality is an indicator of social inequality that increases vulnerability to COVID-19 mortality.

Acute and long COVID-19 symptoms and associated factors in the omicron-dominant period: a nationwide survey via the online platform Wenjuanxing in China

BACKGROUNDS

To our knowledge, there is no available nationwide data on omicron symptom patterns in China mainland. We aim to determine the acute and long COVID-19 symptoms in the omicron-dominant period and to evaluate its association with risk factors.

METHODS

We designed a cross-sectional nationwide study and data about self-reported symptoms were collected by an online platform named Wenjuanxing. Eligible participants were aged 25-65 years and were symptomatic. In this study, the ratios of the number of people of different ages and genders were weighted by the data from the Seventh National Census (2020 years), and validated by a published nationwide representative study through comparing smoking rates. Descriptive indicators were calculated for demographic characteristics, diagnosis ways, and duration time, acute symptoms, hospitalization, severity and long COVID-19 symptoms. And, the associations between risk factors and acute and long COVID-19 symptoms were analyzed by multivariable logistic regression models.

RESULTS

A total of 32,528 individuals diagnosed as COVID-19 infection from October 1, 2022 to February 21, 2023 were included. The first three acute symptoms of COVID-19 infection were fever (69.90%), headache (62.63%), and sore throat (54.29%), respectively. The hospitalization rate within 7 days was 3.07% and symptoms disappearance rate within 21 days was 68.84%, respectively. Among 3983 COVID-19 patients with 3 months or more time difference between first infection and participation into the study, the long COVID-19 rate was 19.68% and the primary symptoms were muscle weakness (19.39%), headache (17.98%) and smell/taste disorder (15.18%). Age groups, smoking, marriage status and vaccination were risk factors for numbers of acute phase symptoms and long COVID-19 symptoms. Lastly, female and current smokers also showed more numbers of symptoms during acute infection period.

CONCLUSIONS

In Chinese mainland, our respondent indicated that current smokers and women were associated with acute COVID-19 symptoms, which should be treated with caution due to the lack of representative.

The impact of the SARS-CoV-2 pandemic on tuberculosis notifications and deaths in the state of São Paulo, Brazil: a cross-sectional study

Background

The state of São Paulo reports the highest number of tuberculosis cases in Brazil. We aimed to analyze the SARS-CoV-2 pandemic's impact on tuberculosis notifications and identify factors associated with reduced notifications and tuberculosis deaths in 2020-2021.

Methods

This retrospective cross-sectional study analyzed data from 126,649 patients with tuberculosis notified in São Paulo from 2016 to 2021. Interrupted time series analysis assessed the pandemic's impact on notifications. Descriptive statistics and logistic regressions identified factors associated with decreased tuberculosis notifications and deaths during the pandemic (2020-2021) compared to the pre-pandemic period (2019).

Findings

Tuberculosis notifications decreased by 10% and 8% in 2020 and 2021, respectively, with declines 2-3 times higher among individuals with no education or deprived of liberty. Contrastingly, tuberculosis notifications increased 68% among corrections workers in 2021. Diagnostics and contact tracing were compromised. Individuals with HIV, drug addiction, or deprived of liberty had lower odds of notification during the pandemic. Black and Pardo individuals or those with diabetes, treatment interruption history, or treatment changes post-adverse events had higher odds of notification. However, adverse events and tuberculosis-diabetes cases have been increasing since 2016. During the pandemic, tuberculosis-related deaths rose 5.0%-12.7%. Risk factors for mortality remained similar to 2019, with Pardo ethnicity, drug addiction and re-treatment post-adverse events emerging as risk factors in 2020/2021.

Interpretation

The pandemic affected tuberculosis notifications and deaths differently among populations, exacerbating inequalities. Treatment interruption, loss of follow-up, and challenges in accessing healthcare led to increased mortality.

Funding

FAPESP, CNPq and CAPES, Brazil.

Incorporating social vulnerability in infectious disease mathematical modelling: a scoping review

BACKGROUND

Highlighted by the rise of COVID-19, climate change, and conflict, socially vulnerable populations are least resilient to disaster. In infectious disease management, mathematical models are a commonly used tool. Researchers should include social vulnerability in models to strengthen their utility in reflecting real-world dynamics. We conducted a scoping review to evaluate how researchers have incorporated social vulnerability into infectious disease mathematical models.

METHODS

The methodology followed the Joanna Briggs Institute and updated Arksey and O'Malley frameworks, verified by the PRISMA-ScR checklist. PubMed, Clarivate Web of Science, Scopus, EBSCO Africa Wide Information, and Cochrane Library were systematically searched for peer-reviewed published articles. Screening and extracting data were done by two independent researchers.

RESULTS

Of 4075 results, 89 articles were identified. Two-thirds of articles used a compartmental model (n = 58, 65.2%), with a quarter using agent-based models (n = 24, 27.0%). Overall, routine indicators, namely age and sex, were among the most frequently used measures (n = 42, 12.3%; n = 22, 6.4%, respectively). Only one measure related to culture and social behaviour (0.3%). For compartmental models, researchers commonly constructed distinct models for each level of a social vulnerability measure and included new parameters or influenced standard parameters in model equations (n = 30, 51.7%). For all agent-based models, characteristics were assigned to hosts (n = 24, 100.0%), with most models including age, contact behaviour, and/or sex (n = 18, 75.0%; n = 14, 53.3%; n = 10, 41.7%, respectively).

CONCLUSIONS

Given the importance of equitable and effective infectious disease management, there is potential to further the field. Our findings demonstrate that social vulnerability is not considered holistically. There is a focus on incorporating routine demographic indicators but important cultural and social behaviours that impact health outcomes are excluded. It is crucial to develop models that foreground social vulnerability to not only design more equitable interventions, but also to develop more effective infectious disease control and elimination strategies. Furthermore, this study revealed the lack of transparency around data sources, inconsistent reporting, lack of collaboration with local experts, and limited studies focused on modelling cultural indicators. These challenges are priorities for future research.

The impact of the socioeconomic factor on Parkinson's disease medication adherence: a scoping review

BACKGROUND

 Therapeutic adherence is a decisive issue on chronic disease management in patients requiring long-term pharmacotherapy, such as Parkinson's disease (PD). Although it is well known that socioeconomic factor is a barrier to medication adherence in many chronic diseases, its impacts on PD still need to be investigated.

OBJECTIVE

 Explore what and how socioeconomic factors impact medication adherence in people with PD.

METHODS

 We carried out a scoping review across three databases to identify studies exploring what and how socioeconomic factors impact medication adherence in people with PD considering eight attributes: 1. educational level, 2. disease-related knowledge, 3. income, 4. cost of medication, 5. drug subsidy (meaning presence of subsidies in the cost of medication), 6. employability, and 7. ethnicity (black, indigenous, immigrants).

RESULTS

 Of the 399 identified studies (Embase = 294, Medline = 88, LILACS = 17), eight met inclusion criteria. We identified factors covering the eight attributes of socioeconomic impact, and all of them negatively impacted the medication adherence of people with PD. The most prevalent factor in the studies was low patient educational level (four studies), followed by costs of medications (three studies), income (three studies), and disease-related knowledge (three studies). Distinctly from most of the studies selected, one of them evidenced suboptimal adherence in individuals receiving the medication free of charge, and another one could not find correlation between suboptimal adherence and educational level.

CONCLUSION

 Socioeconomic factors negatively impact medication adherence in PD patients. This review provides basis for developing patient and population-based interventions to improve adherence to treatment in PD.

The Brazilian COVID-19 vaccination campaign: a modelling analysis of sociodemographic factors on uptake

OBJECTIVE

Dose shortages delayed access to COVID-19 vaccination. We aim to characterise inequality in two-dose vaccination by sociodemographic group across Brazil.

DESIGN

This is a cross-sectional study.

SETTING

We used data retrieved from the Brazilian Ministry of Health databases published between 17 January 2021 and 6 September 2021.

METHODS

We assessed geographical inequalities in full vaccination coverage and dose by age, sex, race and socioeconomic status. We developed a Campaign Optimality Index to characterise inequality in vaccination access due to premature vaccination towards younger populations before older and vulnerable populations were fully vaccinated. Generalised linear regression was used to investigate the risk of death and hospitalisation by age group, socioeconomic status and vaccination coverage.

RESULTS

Vaccination coverage is higher in the wealthier South and Southeast. Men, people of colour and low-income groups were more likely to be only partially vaccinated due to missing or delaying a second dose. Vaccination started prematurely for age groups under 50 years which may have hindered uptake in older age groups. Vaccination coverage was associated with a lower risk of death, especially in older age groups (ORs 9.7 to 29.0, 95% CI 9. 4 to 29.9). Risk of hospitalisation was greater in areas with higher vaccination rates due to higher access to care and reporting.

CONCLUSIONS

Vaccination inequality persists between states, age and demographic groups despite increasing uptake. The association between hospitalisation rates and vaccination is attributed to preferential delivery to areas of greater transmission and access to healthcare.

COVID-19, SDGs and public health systems: Linkages in Brazil

Background

The global 2030 Agenda covers a range of interconnected issues which need interdisciplinary and holistic approaches to improve human well-being and protect the natural environment. The COVID-19 pandemic has brought to light critical inequities in society and policy gaps in health services. As highlighted through analyses of the interlinkages among the Sustainable Development Goals (SDGs), connections between human health and well-being and the environment, can help support new policy needs in addressing systemic health crises, including widespread pandemics.

Method

We identify links between the COVID-19 crisis and multiple SDGs in the context of Brazil based on a review of the current literature in the health sector.Findings: We identify synergistic connections between 88 out of 169 SDG targets and COVID-19, notably around themes such as City Environment, Contextual Policies and the value created by improved Information and Technology. Using the context of the Brazilian National Health Service (SUS) highlights recurrent interconnections from the focal point of target 3.8. This includes topics such as challenges for universal healthcare coverage, budget allocation, and universalisation.

Conclusions

The framework developed for supporting policy-making decisions and the design of toolkits for dealing with future health-related emergency scenarios offers a practical solution in the health sector. It is worth noting that progress and action on public health systems and policies must go hand in hand with addressing existing socio-economic vulnerabilities in society. This is vital for tackling future pandemics and simultaneously addressing the SDGs.

Diabetes related phenotypes and their influence on outcomes of patients with corona virus disease 2019 (COVID-19)

INTRODUCTION

Diabetes mellitus (DM) is associated with severe forms of COVID-19 but little is known about the diabetes-related phenotype considering pre-admission, on-admission and data covering the entire hospitalization period.

METHODS

We analyzed COVID-19 inpatients (n = 3327) aged 61.2(48.2-71.4) years attended from March to September 2020 in a public hospital.

RESULTS

DM group (n = 1218) differed from Non-DM group (n = 2109) by higher age, body mass index (BMI), systolic blood pressure and lower O2 saturation on admission. Gender, ethnicity and COVID-19-related symptoms were similar. Glucose and several markers of inflammation, tissue injury and organ dysfunction were higher among patients with diabetes: troponin, lactate dehydrogenase, creatine phosphokinase (CPK), C-reactive protein (CRP), lactate, brain natriuretic peptide, urea, creatinine, sodium, potassium but lower albumin levels. Hospital (12 × 11 days) and intensive care unit permanence (10 × 9 days) were similar but DM group needed more vasoactive, anticoagulant and anti-platelet drugs, oxygen therapy, endotracheal intubation and dialysis. Lethality was higher in patients with diabetes (39.3% × 30.7%) and increased with glucose levels and age, in male sex and with BMI < 30 kg/m2 in both groups (obesity paradox). It was lower with previous treatment with ACEi/BRA in both groups. Ethnicity and education level did not result in different outcomes between groups. Higher frequency of comorbidities (hypertension, cardiovascular/renal disease, stroke), of inflammatory (higher leucocyte number, RCP, LDH, troponin) and renal markers (urea, creatinine, potassium levels and lower sodium, magnesium) differentiated lethality risk between patients with and without diabetes.

CONCLUSIONS

Comorbidities, inflammatory markers and renal disfunction but not Covid-19-related symptoms, obesity, ethnicity and education level differentiated lethality risk between patients with and without diabetes.

A novel N95 respirator with chitosan nanoparticles: mechanical, antiviral, microbiological and cytotoxicity evaluations

BACKGROUND

It is known that some sectors of hospitals have high bacteria and virus loads that can remain as aerosols in the air and represent a significant health threat for patients and mainly professionals that work in the place daily. Therefore, the need for a respirator able to improve the filtration barrier of N95 masks and even inactivating airborne virus and bacteria becomes apparent. Such a fact motivated the creation of a new N95 respirator which employs chitosan nanoparticles on its intermediate layer (SN95 + CNP).

RESULTS

The average chitosan nanoparticle size obtained was 165.20 ± 35.00 nm, with a polydispersity index of 0.36 ± 0.03 and a zeta potential of 47.50 ± 1.70 mV. Mechanical tests demonstrate that the SN95 + CNP respirator is more resistant and meets the safety requisites of aerosol penetration, resistance to breath and flammability, presenting higher potential to filtrate microbial and viral particles when compared to conventional SN95 respirators. Furthermore, biological in vitro tests on bacteria, fungi and mammalian cell lines (HaCat, Vero E6 and CCL-81) corroborate the hypothesis that our SN95 + CNP respirator presents strong antimicrobial activity and is safe for human use. There was a reduction of 96.83% of the alphacoronavirus virus and 99% of H1N1 virus and MHV-3 betacoronavirus after 120 min of contact compared to the conventional respirator (SN95), demonstrating that SN95 + CNP have a relevant potential as personal protection equipment.

CONCLUSIONS

Due to chitosan nanotechnology, our novel N95 respirator presents improved mechanical, antimicrobial and antiviral characteristics.

Barriers and shortcomings in access to cardiovascular management and prevention for familial hypercholesterolemia during the COVID-19 pandemic

Familial hypercholesterolemia (FH) is a hereditary condition caused by mutations in the lipid pathway. The goal in managing FH is to reduce circulating low-density lipoprotein cholesterol and, therefore, reduce the risk of developing atherosclerotic cardiovascular disease (ASCVD). Because FH patients were considered high risk groups due to an increased susceptible for contracting COVID-19 infection, we hypothesized whether the effects of the pandemic hindered access to cardiovascular care. In this review, we conducted a literature search in databases Pubmed/Medline and ScienceDirect. We included a comprehensive analysis of findings from articles in English related and summarized the effects of the pandemic on cardiovascular care through direct and indirect effects. During the COVID-19 pandemic, FH patients presented with worse outcomes and prognosis, especially those that have suffered from early ASCVD. This caused avoidance in seeking care due to fear of transmission. The pandemic severely impacted consultations with lipidologists and cardiologists, causing a decline in lipid profile evaluations. Low socioeconomic communities and ethnic minorities were hit the hardest with job displacements and lacked healthcare coverage respectively, leading to treatment nonadherence. Lock-down restrictions promoted sedentary lifestyles and intake of fatty meals, but it is unclear whether these factors attenuated cardiovascular risk in FH. To prevent early atherogenesis in FH patients, universal screening programs, telemedicine, and lifestyle interventions are important recommendations that could improve outcomes in FH patients. However, the need to research in depth on the disproportionate impact within different subgroups should be the forefront of FH research.

Association of sociodemographic characteristics with self-perceived access to COVID-19 information and adherence to preventive measures among migrant origin and general populations in Finland: a cross-sectional study

OBJECTIVES

This study examines how access to COVID-19 information and adherence to preventive measures varies by sociodemographic characteristics, and whether the associations differ among the migrant origin and the general Finnish population. Additionally, the association of perceived access to information with adherence to preventive measures is examined.

DESIGN

Cross-sectional, population-based random sample.

BACKGROUND

Equity in access to information is crucial for securing individual well-being and successful management of a crisis at population level.

SETTING

Persons who have a residence permit in Finland.

PARTICIPANTS

Migrant origin population constituted of persons aged 21-66 years born abroad, who took part in the Impact of the Coronavirus on the Wellbeing of the Foreign Born Population (MigCOVID) Survey conducted from October 2020 to February 2021 (n=3611). Participants in the FinHealth 2017 Follow-up Survey conducted within the same time frame, representing the general Finnish population, constituted the reference group (n=3490).

OUTCOME MEASURES

Self-perceived access to COVID-19 information, adherence to preventive measures.

RESULTS

Self-perceived access to information and adherence to preventive measures was overall high both among the migrant origin and the general population. Perceived adequate access to information was associated with living in Finland for 12 years or longer (OR 1.94, 95% CI 1.05-3.57) and excellent Finnish/Swedish language skills (OR 2.71, 95% CI 1.62-4.53) among the migrant origin population and with higher education (OR 3.56, 95% CI 1.49-8.55 for tertiary and OR 2.87, 95% CI 1.25-6.59 for secondary) among the general population. The association between examined sociodemographic characteristics with adherence to preventive measures varied by study group.

CONCLUSIONS

Findings on the association of perceived access to information with language proficiency in official languages highlight the need for rapid multilingual and simple language crisis communications. Findings also suggest that crisis communications and measures designed to influence health behaviours at population level may not be directly transferable if the aim is to influence health behaviours also among ethnically and culturally diverse populations.

Communication inequalities and health disparities among vulnerable groups during the COVID-19 pandemic - a scoping review of qualitative and quantitative evidence

BACKGROUND

The COVID-19 pandemic has exacerbated health disparities in vulnerable groups (e.g., increased infection, hospitalization, and mortality rates in people with lower income, lower education, or ethnic minorities). Communication inequalities can act as mediating factors in this relationship. Understanding this link is vital to prevent communication inequalities and health disparities in public health crises. This study aims to map and summarize the current literature on communication inequalities linked with health disparities (CIHD) in vulnerable groups during the COVID-19 pandemic and to identify research gaps.

METHODS

A scoping review of quantitative and qualitative evidence was conducted. The literature search followed the guidelines of PRISMA extension for scoping reviews and was performed on PubMed and PsycInfo. Findings were summarized using a conceptual framework based on the Structural Influence Model by Viswanath et al. RESULTS: The search yielded 92 studies, mainly assessing low education as a social determinant and knowledge as an indicator for communication inequalities. CIHD in vulnerable groups were identified in 45 studies. The association of low education with insufficient knowledge and inadequate preventive behavior was the most frequently observed. Other studies only found part of the link: communication inequalities (n = 25) or health disparities (n = 5). In 17 studies, neither inequalities nor disparities were found.

CONCLUSIONS

This review supports the findings of studies on past public health crises. Public health institutions should specifically target their communication to people with low education to reduce communication inequalities. More research about CIHD is needed on groups with migrant status, financial hardship, not speaking the language in the country of residence, sexual minorities, and living in deprived neighborhoods. Future research should also assess communication input factors to derive specific communication strategies for public health institutions to overcome CIHD in public health crises.

Impact of network centrality and income on slowing infection spread after outbreaks

The COVID-19 pandemic has shed light on how the spread of infectious diseases worldwide are importantly shaped by both human mobility networks and socio-economic factors. However, few studies look at how both socio-economic conditions and the complex network properties of human mobility patterns interact, and how they influence outbreaks together. We introduce a novel methodology, called the Infection Delay Model, to calculate how the arrival time of an infection varies geographically, considering both effective distance-based metrics and differences in regions' capacity to isolate-a feature associated with socio-economic inequalities. To illustrate an application of the Infection Delay Model, this paper integrates household travel survey data with cell phone mobility data from the São Paulo metropolitan region to assess the effectiveness of lockdowns to slow the spread of COVID-19. Rather than operating under the assumption that the next pandemic will begin in the same region as the last, the model estimates infection delays under every possible outbreak scenario, allowing for generalizable insights into the effectiveness of interventions to delay a region's first case. The model sheds light on how the effectiveness of lockdowns to slow the spread of disease is influenced by the interaction of mobility networks and socio-economic levels. We find that a negative relationship emerges between network centrality and the infection delay after a lockdown, irrespective of income. Furthermore, for regions across all income and centrality levels, outbreaks starting in less central locations were more effectively slowed by a lockdown. Using the Infection Delay Model, this paper identifies and quantifies a new dimension of disease risk faced by those most central in a mobility network.

The impact of built and socio-economic environment factors on Covid-19 transmission at the ZIP-code level in Florida

Most studies have explored the Covid-19 outbreak by mainly focusing on restrictive public policies, human health, and behaviors at the macro level. However, the impacts of built and socio-economic environments, accounting for spatial effects on the spread at the local levels, have not been thoroughly studied. In this study, the relationships between the spatial spread of the virus and various indicators of the built and socio-economic environments are investigated, using Florida ZIP-code data on accumulated cases before large-scale vaccination campaigns began in 2021. Spatial regression models are used to account for the spatial dependencies and interactions that are core factors in Covid-19 spread. This study reveals both the spillover dynamics of the coronavirus spread at the ZIP code level and the existence of spatial dependencies among the unobserved variables represented by the error term. In addition, the findings show a positive association between the expected number of Covid-19 cases and specific land uses, such as education facilities and retail densities. Finally, the study highlights critical socio-economic characteristics causing a substantial increase in Covid-19 spread. Such results could help policymakers, public health experts, and urban planners design strategies to mitigate the spread of future Covid-19-like diseases.

Risk Factors of Severe COVID-19: A Review of Host, Viral and Environmental Factors

The clinical course and outcome of COVID-19 are highly variable, ranging from asymptomatic infections to severe disease and death. Understanding the risk factors of severe COVID-19 is relevant both in the clinical setting and at the epidemiological level. Here, we provide an overview of host, viral and environmental factors that have been shown or (in some cases) hypothesized to be associated with severe clinical outcomes. The factors considered in detail include the age and frailty, genetic polymorphisms, biological sex (and pregnancy), co- and superinfections, non-communicable comorbidities, immunological history, microbiota, and lifestyle of the patient; viral genetic variation and infecting dose; socioeconomic factors; and air pollution. For each category, we compile (sometimes conflicting) evidence for the association of the factor with COVID-19 outcomes (including the strength of the effect) and outline possible action mechanisms. We also discuss the complex interactions between the various risk factors.

Influence of socioeconomic inequality on the distribution of COVID-19 hospitalizations and deaths in Brazilian municipalities, 2020: an ecological study

OBJECTIVE

to analyze the influence of socioeconomic inequality on COVID-19 distribution in larger Brazilian municipalities, controlling for effect of hospital infrastructure, comorbidities and other variables.

METHODS

this was an ecological study of COVID-19 hospitalizations and deaths in 2020; outcome data were obtained from the Ministry of Health; incidence ratios were estimated using a generalized linear model.

RESULTS

we identified 291,073 hospitalizations and 139,953 deaths; we found higher mortality rates in municipalities with a higher proportion of non-White people (95%CI 1.01;1.16) and with more households with more than two people per room (95%CI 1.01;1.13); presence of sewerage systems was protective for both outcomes (hospitalizations: 95%CI 0.87;0.99 - deaths: 95%CI 0.90;0.99), while a higher proportion of the population in subnormal housing clusters was a risk factor (hospitalizations: 95%CI 1.01;1.16 - deaths: 95%CI 1.09;1.21), with this variable interacting with the proportion of people receiving Emergency Aid (hospitalizations: 95%CI 0.88;1.00 - deaths: 95%CI 0.89;0.98).

CONCLUSION

socioeconomic conditions affected illness and death due to COVID-19 in Brazil.

Men are the main COVID-19 transmitters: behavior or biology?

Background

COVID-19 has affected millions of people worldwide. Clinical manifestations range from severe cases with lethal outcome to mild or asymptomatic cases. Although the proportion of infected individuals does not differ between sexes, men are more susceptible to severe COVID-19, with a higher risk of death than women. Also, men are pointed out as more lax regarding protective measures, mask wearing and vaccination. Thus, we questioned whether sex-bias may be explained by biological pathways and/or behavioral aspects or both.

Methods

Between July 2020 and July 2021, we performed an epidemiological survey including 1744 unvaccinated adult Brazilian couples, with there was at least one infected symptomatic member, who were living together during the COVID-19 infection without protective measures. Presence or absence of infection was confirmed by RT-PCR and/or serology results. Couples were divided into two groups: (1) both partners were infected (concordant couples) and (2) one partner was infected and the spouse remained asymptomatic despite the close contact with the COVID-19 symptomatic partner (discordant couples). Statistical analysis of the collected data was performed aiming to verify a differential transmission potential between genders in couples keeping contact without protective measures.

Results

The combination of our collected data showed that the man is the first (or the only) affected member in most cases when compared to women and that this difference may be explained by biological and behavioral factors.

Conclusions

The present study confirmed the existence of gender differences not only for susceptibility to infection and resistance to COVID-19 but also in its transmission rate.

There are sex differences in COVID-19 susceptibility and transmission between couples highly exposed to SARS-Cov-2 without protective measures;

Men are more efficient virus transmitters than women;

Sex-bias in COVID-19 transmission can be explained by differences in viral load in saliva, immune response and also behavioral protective differences between genders.

Area-level inequalities in Covid-19 outcomes in Brazil in 2020 and 2021: An analysis of 1,894,165 severe Covid-19 cases

The study aims to analyze inequalities in Covid-19 outcomes in Brazil in 2020/2021 according to the per capita Gross Domestic Product (pcGDP) of municipalities. All cases of Severe Acute Respiratory Syndrome (SARS) who were hospitalized or died, regardless of hospitalization, registered in Brazil in 2020 and 2021 were analyzed (n = 2,902,742), including those with a confirmed diagnosis of Covid-19 (n = 1,894,165). We calculated lethality due to Covid-19, the performance of diagnostic tests among patients with SARS, and the hospital care received by those with Covid-19 according to the pcGDP of the patients' municipalities of residence. Data were analyzed for each epidemiological week and the risk of each outcome was estimated using Poisson regression. Municipalities in the lowest pcGDP decile had (i) 30% (95%CI 28%-32%) higher lethality from Covid-19, (ii) three times higher proportion of patients with SARS without the collection of biological material for the diagnosis of Covid-19, (iii) 16% (95%CI 15%-16%) higher proportion of SARS patients testing in a period longer than two days from the onset of symptoms, (iv) 140% (95%CI 134%-145%) higher absence of CT scan use. There is deep socioeconomic inequality among Brazilian municipalities regarding the occurrence of Covid-19 negative outcomes.

Mortality Risk Factors for Coronavirus Infection in Hospitalized Adults in Brazil: A Retrospective Cohort Study

BACKGROUND

The COVID-19 pandemic has presented high morbidity and mortality, with associated high socioeconomic costs. Brazil ranks third in the number of COVID-19 cases, behind only India and the United States.

OBJECTIVE

To analyze risk factors for mortality in adults hospitalized with COVID-19 in Brazil.

METHODS

Observational retrospective cohort study including data from all Brazilian states and regions. The study included information from 468,226 in-hospital patients from all regions of Brazil from 1 January 2021 to 31 July 2021. Data from the influenza epidemiological surveillance system were used. The participants were adults hospitalized with COVID-19. A Cox regression model was used to analyze factors associated with mortality in adults with COVID-19.

RESULTS

The in-hospital mortality lethality was 37.5%. The risk factors associated with COVID-19 mortality were older age, with a linear increase with increments in age, male sex, black or mixed race, low education level, comorbidities, use of ventilatory support, and living in the southeast, north, or northeast regions of the country.

CONCLUSIONS

Our results illustrate the severity of the COVID-19 pandemic in Brazil and reinforce that policies and practices to deal with this disease should focus on groups and regions with higher risk, whereas public policies should promote nonpharmacological measures and vaccination in the Brazilian population.

SARS-CoV-2 antibody dynamics in blood donors and COVID-19 epidemiology in eight Brazilian state capitals: A serial cross-sectional study

Background

The COVID-19 situation in Brazil is complex due to large differences in the shape and size of regional epidemics. Understanding these patterns is crucial to understand future outbreaks of SARS-CoV-2 or other respiratory pathogens in the country.

Methods

We tested 97,950 blood donation samples for IgG antibodies from March 2020 to March 2021 in 8 of Brazil's most populous cities. Residential postal codes were used to obtain representative samples. Weekly age- and sex-specific seroprevalence were estimated by correcting the crude seroprevalence by test sensitivity, specificity, and antibody waning.

Results

The inferred attack rate of SARS-CoV-2 in December 2020, before the Gamma variant of concern (VOC) was dominant, ranged from 19.3% (95% credible interval [CrI] 17.5-21.2%) in Curitiba to 75.0% (95% CrI 70.8-80.3%) in Manaus. Seroprevalence was consistently smaller in women and donors older than 55 years. The age-specific infection fatality rate (IFR) differed between cities and consistently increased with age. The infection hospitalisation rate increased significantly during the Gamma-dominated second wave in Manaus, suggesting increased morbidity of the Gamma VOC compared to previous variants circulating in Manaus. The higher disease penetrance associated with the health system's collapse increased the overall IFR by a minimum factor of 2.91 (95% CrI 2.43-3.53).

Conclusions

These results highlight the utility of blood donor serosurveillance to track epidemic maturity and demonstrate demographic and spatial heterogeneity in SARS-CoV-2 spread.

Funding

This work was supported by Itaú Unibanco 'Todos pela Saude' program; FAPESP (grants 18/14389-0, 2019/21585-0); Wellcome Trust and Royal Society Sir Henry Dale Fellowship 204311/Z/16/Z; the Gates Foundation (INV- 034540 and INV-034652); REDS-IV-P (grant HHSN268201100007I); the UK Medical Research Council (MR/S0195/1, MR/V038109/1); CAPES; CNPq (304714/2018-6); Fundação Faculdade de Medicina; Programa Inova Fiocruz-CE/Funcap - Edital 01/2020 Number: FIO-0167-00065.01.00/20 SPU N°06531047/2020; JBS - Fazer o bem faz bem.

Effects of infection fatality ratio and social contact matrices on vaccine prioritization strategies

Effective strategies of vaccine prioritization are essential to mitigate the impacts of severe infectious diseases. We investigate the role of infection fatality ratio (IFR) and social contact matrices on vaccination prioritization using a compartmental epidemic model fueled by real-world data of different diseases and countries. Our study confirms that massive and early vaccination is extremely effective to reduce the disease fatality if the contagion is mitigated, but the effectiveness is increasingly reduced as vaccination beginning delays in an uncontrolled epidemiological scenario. The optimal and least effective prioritization strategies depend non-linearly on epidemiological variables. Regions of the epidemiological parameter space, in which prioritizing the most vulnerable population is more effective than the most contagious individuals, depend strongly on the IFR age profile being, for example, substantially broader for COVID-19 in comparison with seasonal influenza. Demographics and social contact matrices deform the phase diagrams but do not alter their qualitative shapes.

Clinical, sociodemographic and environmental factors impact post-COVID-19 syndrome

Background

Sociodemographic and environmental factors are associated with incidence, severity, and mortality of COVID-19. However, little is known about the role of such factors in persisting symptoms among recovering patients. We designed a cohort study of hospitalized COVID-19 survivors to describe persistent symptoms and identify factors associated with post-COVID-19 syndrome.

Methods

We included patients hospitalized between March to August 2020 who were alive six months after hospitalization. We collected individual and clinical characteristics during hospitalization and at follow-up assessed ten symptoms with standardized scales, 19 yes/no symptoms, a functional status and a quality-of-life scale and performed four clinical tests. We examined individual exposure to greenspace and air pollution and considered neighbourhood´s population density and socioeconomic conditions as contextual factors in multilevel regression analysis.

Results

We included 749 patients with a median follow-up of 200 (IQR = 185-235) days, and 618 (83%) had at least one of the ten symptoms measured with scales. Pain (41%), fatigue (38%) and posttraumatic stress disorder (35%) were the most frequent. COVID-19 severity, comorbidities, BMI, female sex, younger age, and low socioeconomic position were associated with different symptoms. Exposure to ambient air pollution was associated with higher dyspnoea and fatigue scores and lower functional status.

Conclusions

We identified a high frequency of persistent symptoms among COVID-19 survivors that were associated with clinical, sociodemographic, and environmental variables. These findings indicate that most patients recovering from COVID-19 will need post-discharge care, and an additional burden to health care systems, especially in LMICs, should be expected.

Developmental Origins of Health and Disease, resilience and social justice in the COVID era

The COVID-19 pandemic has shone a spotlight on how health outcomes are unequally distributed among different population groups, with disadvantaged communities and individuals being disproportionality affected in terms of infection, morbidity and mortality, as well as vaccine access. Recently, there has been considerable debate about how social disadvantage and inequality intersect with developmental processes to result in a heightened susceptibility to environmental stressors, economic shocks and large-scale health emergencies. We argue that DOHaD Society members can make important contributions to addressing issues of inequality and improving community resilience in response to COVID-19. In order to do so, it is beneficial to engage with and adopt a social justice framework. We detail how DOHaD can align its research and policy recommendations with a social justice perspective to ensure that we contribute to improving the health of present and future generations in an equitable and socially just way.

Characterization of demographic data, clinical signs, comorbidities, and outcomes according to the race in hospitalized individuals with COVID-19 in Brazil: An observational study

Background

Brazil is a multiracial country with five major official races: White, Black, individuals with multiracial backgrounds, Asian, and Indigenous. Brazil is also one of the epicentres of the Coronavirus Disease (COVID)-19 pandemic. Thus, we evaluated how the races of the Brazilian population contribute to the outcomes in hospitalized individuals with COVID-19, and we also described the clinical profile of the five official Brazilian races.

Methods

We performed an epidemiological analysis for the first 67 epidemiological weeks of the COVID-19 pandemic in Brazil (from February 22, 2020, to April 04, 2021) using the data available at OpenDataSUS of the Brazilian Ministry of Health, a data set containing data from Brazilian hospitalized individuals. We evaluated more than 30 characteristics, including demographic data, clinical symptoms, comorbidities, need for intensive care unit and mechanical ventilation, and outcomes.

Results

In our data, 585 655 hospitalized individuals with a positive result in SARS-CoV-2 real-time chain reaction (RT-PCR) were included. Of these total, 309 646 (52.9%) identified as White, 31 872 (5.4%) identified as Black, 7108 (1.2%) identified as Asian, 235 108 (40.1%) identified as individuals with multiracial background, and 1921 (0.3%) identified as Indigenous. The multivariate analysis demonstrated that race was significative to predict the death being that Black (OR = 1.43; 95% CI = 1.39-1.48), individuals with multiracial background (OR = 1.36; 95% CI = 1.34-1.38), and Indigenous (OR = 1.91; 95% CI = 1.70-2.15) races were more prone to die compared to the White race. The Asian individuals did not have a higher chance of dying due to SARS-CoV-2 infection compared to White individuals (OR = 0.99; 95% CI = 0.94-1.06). In addition, other characteristics contributed as such as being male (OR = 1.17; 95% CI = 1.16-1.19), age (mainly, +85 years old – OR = 23.02; 95% CI = 20.05-26.42) compared to 1-year-old individuals, living in rural areas (OR = 1.22; 95% CI = 1.18-1.26) or in peri-urban places (OR = 1.25; 95% CI = 1.11-1.40), and the presence of nosocomial infection (OR = 1.91; 95% CI = 1.82-2.01). Among the clinical symptoms, the main predictors were dyspnoea (OR = 1.25; 95% CI = 1.23-1.28), respiratory discomfort (OR = 1.30; 95% CI = 1.28-1.32), oxygen saturation <95% (OR = 1.40; 95% CI = 1.38-1.43). Also, among the comorbidities, the main predictors were the presence of immunosuppressive disorder (OR = 1.44; 95% CI = 1.39-1.49), neurological disorder (OR = 1.21; 95% CI = 1.17-1.25), hepatic disorder (OR = 1.41; 95% CI = 1.34-1.50), diabetes mellitus (OR = 1.40; 95% CI = 1.37-1.42), cardiopathy (OR = 1.13; 95%CI = 1.11-1.14), hematologic disorder (OR = 1.34; 95% CI = 1.24-1.43), Down syndrome (OR = 1.61; 95% CI = 1.43-1.81), renal disease (OR = 1.15; 95% CI = 1.11-1.18), and obesity (OR = 1.18; 95% CI = 1.15-1.21). Individuals on intensive care unit (OR = 2.25; 95% CI = 2.22-2.29) and on invasive (OR = 10.92; 95% CI = 10.66-11.18) or non-invasive (OR = 1.33; 95% CI = 1.30-1.35) mechanical ventilation were more prone to die.

Conclusions

Alongside several clinical symptoms and comorbidities, we associated race with an enhanced risk of death in Black individuals, individuals with multiracial backgrounds, and Indigenous peoples.

Examining the Influence of Housing Conditions and Daily Greenspace Exposure on People's Perceived COVID-19 Risk and Distress

Many people have worried about COVID-19 infection, job loss, income reduction, and family conflict during the COVID-19 pandemic. Some social groups may be particularly vulnerable due to their residential neighborhoods and daily activities. On the other hand, people's daily exposure to greenspace offers promising pathways for reducing these worries associated with COVID-19. Using data collected with a questionnaire and a two-day activity diary from two typical neighborhoods in Hong Kong, this study examines how people's housing conditions and daily greenspace exposure affect their perceived COVID-19 risk and distress (i.e., worries about job loss, income reduction, and family conflict) during the pandemic. First, the study compares people's perceived COVID-19 risk and distress based on their residential neighborhoods. Further, it examines the associations between people's perceived COVID-19 risk and distress with their housing conditions and daily greenspace exposure using ordinal logistic regression models. The results indicate that living in a high-risk neighborhood, being married, renting a residential unit, and living in a large household are significantly associated with a higher neighborhood-based perceived COVID-19 risk and distress during the pandemic. In addition, people also reported lower mobility-based perceived COVID-19 risk when compared to their neighborhood-based perceived COVID-19 risk, while they still have a high perceived COVID-19 risk in their occupational venues if they have to work in a high-risk district (e.g., Kowloon). Lastly, daily greenspace exposure (i.e., woodland) could reduce people's perceived COVID-19 risk and distress. These results have important implications for the public health authority when formulating the measures during the COVID-19 pandemic.

da Paixão Melo M, Ferreira da Silva M, de Jesus Gonçalves dos Santos N, de Souza Pessoa N, Silva de Araujo R, de Macedo Godim T, Fraga de Oliveira Tosta S, Brandão Nardy V, Cristina Faria E, Frederico de Carvalho Dominguez Souza B, Laís Almeida dos Santos J, Wikramaratna P, Giovanetti M, Alcântara LCJ, Lourenço J, Leal e Silva de Mello A. Dynamics and Determinants of SARS-CoV-2 RT-PCR Testing on Symptomatic Individuals Attending Healthcare Centers during 2020 in Bahia, Brazil

RT-PCR testing data provides opportunities to explore regional and individual determinants of test positivity and surveillance infrastructure. Using Generalized Additive Models, we explored 222,515 tests of a random sample of individuals with COVID-19 compatible symptoms in the Brazilian state of Bahia during 2020. We found that age and male gender were the most significant determinants of test positivity. There was evidence of an unequal impact among socio-demographic strata, with higher positivity among those living in areas with low education levels during the first epidemic wave, followed by those living in areas with higher education levels in the second wave. Our estimated probability of testing positive after symptom onset corroborates previous reports that the probability decreases with time, more than halving by about two weeks and converging to zero by three weeks. Test positivity rates generally followed state-level reported cases, and while a single laboratory performed ~90% of tests covering ~99% of the state's area, test turn-around time generally remained below four days. This testing effort is a testimony to the Bahian surveillance capacity during public health emergencies, as previously witnessed during the recent Zika and Yellow Fever outbreaks.

Spatial and temporal fluctuations in COVID-19 fatality rates in Brazilian hospitals

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Gamma variant of concern has spread rapidly across Brazil since late 2020, causing substantial infection and death waves. Here we used individual-level patient records after hospitalization with suspected or confirmed coronavirus disease 2019 (COVID-19) between 20 January 2020 and 26 July 2021 to document temporary, sweeping shocks in hospital fatality rates that followed the spread of Gamma across 14 state capitals, during which typically more than half of hospitalized patients aged 70 years and older died. We show that such extensive shocks in COVID-19 in-hospital fatality rates also existed before the detection of Gamma. Using a Bayesian fatality rate model, we found that the geographic and temporal fluctuations in Brazil's COVID-19 in-hospital fatality rates were primarily associated with geographic inequities and shortages in healthcare capacity. We estimate that approximately half of the COVID-19 deaths in hospitals in the 14 cities could have been avoided without pre-pandemic geographic inequities and without pandemic healthcare pressure. Our results suggest that investments in healthcare resources, healthcare optimization and pandemic preparedness are critical to minimize population-wide mortality and morbidity caused by highly transmissible and deadly pathogens such as SARS-CoV-2, especially in low- and middle-income countries.

Long-term commuting times and air quality relationship to COVID-19 in São Paulo

The Coronavirus Disease 2019 (COVID-19) epidemic is an unprecedented global health crisis and the effects may be related to environmental and socio-economic factors. In São Paulo, Brazil, the first death occurred in March 2020 and since then the numbers have grown to 175 new deaths per day in April 2021, positioning the city as the epicenter of the number of cases and deaths in Brazil. São Paulo is one of the largest cities in the world with more than 12 million inhabitants, a fleet of about 8 million vehicles and frequent pollutant concentrations above recommended values. Social inequalities are evident in the municipality, similarly to other cities in the world. This paper focuses on transportation activities related to air pollution and associated with cardiovascular and respiratory diseases especially on people who developed comorbidities during their whole life. This study relates travel trip data to air quality analysis and expanded to COVID-19 disease. This work studied the relationship of deaths in São Paulo due to COVID-19 with demographic density, with family income, with the use of public transport and with atmospheric pollution for the period between March 17th, 2020 and April 29th, 2021. The main results showed that generally passenger kilometers traveled, commuting times and air quality related diseases increase with residential distance from the city center, and thus, with decreasing residential density. PM2.5 concentrations are positively correlated with COVID-19 deaths, regions with high urban densities have higher numbers of deaths and long-distance frequent trips can contribute to spread of the disease.

Effects of non-pharmaceutical interventions on social distancing during the COVID-19 pandemic: Evidence from the 27 Brazilian states

Background

Despite substantial evidence on the effectiveness of non-pharmaceutical interventions (NPIs), there is still limited evidence on the individual effects of different types of NPIs on social distancing, especially in low- and middle-income countries.

Methods

We used panel data analysis to evaluate the effects of mandatory social distancing rules on social distancing. We obtained data on six different categories of mandatory restrictions implemented in Brazil, by date and state, from state government gazettes (diários oficiais). We then defined a social distancing rules index (SDI) to measure the strictness of social distancing rules, assigning each a value of 2, 1, or 0 depending on whether restrictions were full, partial, or very limited/non-existent at every given time. A separate variable was defined for masking mandates. We tested whether the following variables were associated to social distancing: SDI, masking mandates, COVID-19 incidence, population socioeconomic status, and political orientation. Data is for each day between March 11th and November 10th, 2020 in the 27 Brazilian states (N = 6615).

Findings

Social distancing increased when social distancing rules were stricter, and decreased when the use of face masks became mandatory. The effects of different types of restrictions varied: suspending in-person classes and gatherings, religious/sport/cultural activities had a greater effect than other types of restrictions. Also, the effect of social distancing rules on people’s behaviour decreased over time, especially when rules were stricter.

Interpretation

Mandatory social distancing rules must be adopted to increase social distancing. Stricter rules have a higher impact, but result in decreased compliance over time. Policymakers should prioritize more targeted policies.

COVID-19 seen from a syndemic perspective: Impact of unhealthy habits and future perspectives to combat these negative interactions in Latin America

COVID-19 has to this point led to more than 5 million deaths and has imposed numerous measures restricting populations worldwide, including Latin America (LA). However, analyzing COVID-19 from the perspective of a syndemic, it demonstrates the relationship between the interaction of multiple comorbidities and the increase of contagion in people who are socially vulnerable. The number of deaths by COVID-19 in LA is strongly associated with multi-morbidities (diabetes, obesity, sedentary, smoking, among others) and disproportionately attacks communities located in poorer, low-income regions and ethnic minorities. This review aims to revisit the relationship between COVID-19 and both unhealthy living habits (i.e., sedentary lifestyle, poor nutritional habits, overweight and obesity, smoking) and cardiovascular disease in Latin American countries. In addition, this review aims to introduce strategies and policies that combat social inequalities and enable healthy living behaviors in LA countries. If LA countries do not work on public policies that decrease multi-morbidities and social inequalities, we will be unable to eliminate COVID-19, as well as possible other outbreaks that may arise in the future.

Educational status and COVID-19 related outcomes in India: hospital-based cross-sectional study

OBJECTIVE

Association of educational status, as marker of socioeconomic status, with COVID-19 outcomes has not been well studied. We performed a hospital-based cross-sectional study to determine its association with outcomes.

METHODS

Successive patients of COVID-19 presenting at government hospital were recruited. Demographic and clinical details were obtained at admission, and in-hospital outcomes were assessed. Cohort was classified according to self-reported educational status into group 1: illiterate or ≤primary; group 2: higher secondary; and group 3: some college. To compare intergroup outcomes, we performed logistic regression.

RESULTS

4645 patients (men 3386, women 1259) with confirmed COVID-19 were recruited. Mean age was 46±18 years, most lived in large households and 30.5% had low educational status. Smoking or tobacco use was in 29.5%, comorbidities in 28.6% and low oxygen concentration (SpO₂ <95%) at admission in 30%. Average length of hospital stay was 6.8±3.7 days, supplemental oxygen was provided in 18.4%, high flow oxygen or non-invasive ventilation 7.1% and mechanical ventilation 3.6%, 340 patients (7.3%) died. Group 1 patients had more tobacco use, hypoxia at admission, lymphocytopaenia, and liver and kidney dysfunction. In group 1 versus groups 2 and 3, requirement of oxygen (21.6% vs 16.7% and 17.0%), non-invasive ventilation (8.0% vs 5.9% and 7.1%), invasive ventilation (4.6% vs 3.5% and 3.1%) and deaths (10.0% vs 6.8% and 5.5%) were significantly greater (p<0.05). OR for deaths were higher in group 1 (1.91, 95% CI 1.46 to 2.51) and group 2 (1.24, 95% CI 0.93 to 1.66) compared with group 3. Adjustment for demographic and comorbidities led to some attenuation in groups 1 (1.44, 95% CI 1.07 to 1.93) and 2 (1.38, 95% CI 1.02 to 1.85); this persisted with adjustments for clinical parameters and oxygen support in groups 1 (1.38, 95% CI 0.99 to 1.93) and 2 (1.52, 95% CI 1.01 to 2.11).

CONCLUSION

Low educational status patients with COVID-19 in India have significantly greater adverse in-hospital outcomes and mortality.

TRIAL REGISTRATION NUMBER

REF/2020/06/034036.

Disparities in Excess Mortality Between Indigenous and Non-Indigenous Brazilians in 2020: Measuring the Effects of the COVID-19 Pandemic

This study aimed to estimate the number of excess deaths among Indigenous Peoples associated with the COVID-19 pandemic in 2020 and to assess the disparities in excess mortality between Indigenous and non-Indigenous Brazilians. A time series analysis of weekly mortality data including all deaths from January 2015 to December 2020 was conducted. The number of expected deaths for 2020 was estimated using an over-dispersed Poisson model that accounts for demographic changes, temporal trends, and seasonal effects in mortality. Weekly excess deaths were calculated as the difference between the number of observed deaths and the expected deaths. Regional differences in Indigenous mortality were investigated. A significant increase in Indigenous mortality was observed from April 1 to December 31, 2020. An estimated 1149 (95% CI 1018-1281) excess deaths was found among Indigenous Brazilians in 2020, representing a 34.8% increase from the expected deaths for this population. The overall increase in non-Indigenous mortality was 18.1%. The Indigenous population living in the Brazilian Amazon area was the earliest-affected Indigenous group, with one of the highest proportional increases in mortality. Disparities in excess mortality revealed a disproportionate burden of COVID-19 among Indigenous Brazilians compared to their non-Indigenous counterparts. Findings highlight the importance of implementing an effective emergency plan that addresses the increased vulnerability of Indigenous Peoples to COVID-19.

A decomposition analysis for socioeconomic inequalities in health status associated with the COVID-19 diagnosis and related symptoms during Brazil's first wave of infections☆

Recent studies have shown that COVID-19 affects different population groups asymmetrically. This work uses data from the National Survey of Households—PNAD COVID-19/IBGE—to quantify the socioeconomic inequality in health during the first wave of COVID-19 infections in Brazil. We use the concentration curve, the concentration index, and a decomposition analysis to verify the factors that most influence the inequalities in the specified health variables. We find a positive concentration index for the incidence rate, indicating a greater concentration of diagnoses (number of tests) among groups with higher income levels. When considering symptoms similar to a COVID-19 infection, inequality practically disappears. Among people with higher income, a pre-existing disease has a more significant contribution to the concentration of COVID-19 in the presence of correlated symptoms than in its diagnosis. Tests of dominance support the findings. Moreover, the decomposition results show that if the inequalities were explained only by race (non-white) and place of living (North and Northeast), there would be a concentration of COVID-19 among the poorest.

Report 46: Factors driving extensive spatial and temporal fluctuations in COVID-19 fatality rates in Brazilian hospitals

The SARS-CoV-2 Gamma variant spread rapidly across Brazil, causing substantial infection and death waves. We use individual-level patient records following hospitalisation with suspected or confirmed COVID-19 to document the extensive shocks in hospital fatality rates that followed Gamma's spread across 14 state capitals, and in which more than half of hospitalised patients died over sustained time periods. We show that extensive fluctuations in COVID-19 in-hospital fatality rates also existed prior to Gamma's detection, and were largely transient after Gamma's detection, subsiding with hospital demand. Using a Bayesian fatality rate model, we find that the geographic and temporal fluctuations in Brazil's COVID-19 in-hospital fatality rates are primarily associated with geographic inequities and shortages in healthcare capacity. We project that approximately half of Brazil's COVID-19 deaths in hospitals could have been avoided without pre-pandemic geographic inequities and without pandemic healthcare pressure. Our results suggest that investments in healthcare resources, healthcare optimization, and pandemic preparedness are critical to minimize population wide mortality and morbidity caused by highly transmissible and deadly pathogens such as SARS-CoV-2, especially in low- and middle-income countries.

NOTE

The following manuscript has appeared as 'Report 46 - Factors driving extensive spatial and temporal fluctuations in COVID-19 fatality rates in Brazilian hospitals' at https://spiral.imperial.ac.uk:8443/handle/10044/1/91875 .

ONE SENTENCE SUMMARY

COVID-19 in-hospital fatality rates fluctuate dramatically in Brazil, and these fluctuations are primarily associated with geographic inequities and shortages in healthcare capacity.

Preventing the Next Pandemic: The Case for Investing in Circulatory Health - A Global Coalition for Circulatory Health Position Paper

The Coronavirus Disease 2019 (COVID-19) has had a continuous and robust impact on world health. The resulting COVID-19 pandemic has had a devastating physical, mental and fiscal impact on the millions of people living with noncommunicable diseases (NCDs). In addition to older age, people living with CVD, stroke, obesity, diabetes, kidney disease, and hypertension are at a particularly greater risk for severe forms of COVID-19 and its consequences. Meta-analysis indicates that hypertension, diabetes, chronic kidney disease, and thrombotic complications have been observed as both the most prevalent and most dangerous co-morbidities in COVID-19 patients. And despite the nearly incalculable physical, mental, emotional, and economic toll of this pandemic, forthcoming public health figures continue to place cardiovascular disease as the number one cause of death across the globe in the year 2020. The world simply cannot wait for the next pandemic to invest in NCDs. Social determinants of health cannot be addressed only through the healthcare system, but a more holistic multisectoral approach with at its basis the Sustainable Development Goals (SDGs) is needed to truly address social and economic inequalities and build more resilient systems. Yet there is reason for hope: the 2019 UN Political Declaration on UHC provides a strong framework for building more resilient health systems, with explicit calls for investment in NCDs and references to fiscal policies that put such investment firmly within reach. By further cementing the importance of addressing circulatory health in a future Framework Convention on Emergency Preparedness, WHO Member States can take concrete steps towards a pandemic-free future. As the chief representatives of the global circulatory health community and patients, the Global Coalition for Circulatory Health calls for increased support for the healthcare workforce, global vaccine equity, embracing new models of care and digital health solutions, as well as fiscal policies on unhealthy commodities to support these investments.