Were the socio-economic determinants of municipalities relevant to the increment of COVID-19 related deaths in Brazil in 2020?

Geography versus sociodemographics as predictors of changes in daily mobility across the USA during the COVID-19 pandemic: a two-stage regression analysis across 26 metropolitan areas

OBJECTIVE

We investigated whether a zip code's location or demographics are most predictive of changes in daily mobility throughout the course of the COVID-19 pandemic.

DESIGN

We used a population-level study to examine the predictability of daily mobility during the COVID-19 pandemic using a two-stage regression approach, where generalised additive models (GAM) predicted mobility trends over time at a large spatial level, then the residuals were used to determine which factors (location, zip code-level features or number of non-pharmaceutical interventions (NPIs) in place) best predict the difference between a zip code's measured mobility and the average trend on a given date.

SETTING

We analyse zip code-level mobile phone records from 26 metropolitan areas in the USA on 15 March-31 September 2020, relative to October 2020.

RESULTS

While relative mobility had a general trend, a zip code's city-level location significantly helped to predict its daily mobility patterns. This effect was time-dependent, with a city's deviation from general mobility trends differing in both direction and magnitude throughout the course of 2020. The characteristics of a zip code further increased predictive power, with the densest zip codes closest to a city centre tended to have the largest decrease in mobility. However, the effect on mobility change varied by city and became less important over the course of the pandemic.

CONCLUSIONS

The location and characteristics of a zip code are important for determining changes in daily mobility patterns throughout the course of the COVID-19 pandemic. These results can determine the efficacy of NPI implementation on multiple spatial scales and inform policy makers on whether certain NPIs should be implemented or lifted during the ongoing COVID-19 pandemic and when preparing for future public health emergencies.

Profile of COVID-19 in Brazil-risk factors and socioeconomic vulnerability associated with disease outcome: retrospective analysis of population-based registers

OBJECTIVES

To classify the most up-to-date factors associated with COVID-19 disease outcomes in Brazil.

DESIGN

Retrospective study.

SETTING

Nationwide Brazilian COVID-19 healthcare registers.

PARTICIPANTS

We used healthcare data of individuals diagnosed with mild/moderate (n=70 056 602) or severe (n=2801 380) COVID-19 disease in Brazil between 26 February 2020 and 15 November 2021.

MAIN OUTCOME MEASURES

Risk of hospitalisation and mortality affected by demographic, clinical and socioeconomic variables were estimated. The impacts of socioeconomic inequalities on vaccination rates, cases and deaths were also evaluated.

RESULTS

15.6 million SARS-CoV-2 infection cases and 584 761 COVID-19-related deaths occurred in Brazil between 26 February 2020 and 15 November 2021. Overall, men presented a higher odds of death than women (OR=1.14, 95% CI 1.13 to 1.15), but postpartum patients admitted to hospital wards were at increased odds of dying (OR=1.23, 95% CI 1.13 to 1.34) compared with individuals without reported comorbidities. Death in younger age groups was notably higher in most deprived municipalities and also among individuals <40 years belonging to indigenous backgrounds compared with white patients, as shown by descriptive analysis. Ethnic/racial backgrounds exhibited a continuum of decreasing survival chances of mixed-race (OR=1.11, 95% CI 1.10 to 1.12), black (OR=1.34, 95% CI 1.32 to 1.36) and indigenous (OR=1.42, 95% CI 1.31 to 1.54) individuals, while those in most deprived municipalities also presented an increased odds of death (OR=1.38, 95% CI 1.36 to 1.40). Deprivation levels also affect the prompt referral of patients to adequate care. Our results show that the odds of death of individuals hospitalised for less than 4 days is more than double that of patients with close-to-average hospital stays (OR=2.07, 95% CI 2.05 to 2.10). Finally, negative vaccination status also increased the odds of dying from the disease (OR=1.29, 95% CI 1.28 to 1.31).

CONCLUSIONS

The data provide evidence that the patterns of COVID-19 mortality in Brazil are influenced by both individual-level health and social risk factors, as well as municipality-level deprivation. In addition, these data suggest that there may be inequalities in the timely provision of appropriate healthcare that are related to municipality-level deprivation.

The multiple uses of telemedicine during the pandemic: the evidence from a cross-sectional survey of medical doctors in Brazil

BACKGROUND

The use of telemedicine, or the provision of healthcare and communication services through distance-based technologies, has increased substantially since the 2019 novel coronavirus (COVID-19) pandemic. However, it is still unclear what are the innovative features of the widespread use of such modality, its forms of employment and the context in which it is used across pluralist health systems, particularly in low- and middle-income settings. We have sought to provide empirical evidence on the above issues by analysing the responses of medical doctors in a representative cross-sectional survey in two states in Brazil: São Paulo and Maranhão.

METHODS

We analysed the responses of 1,183 physicians to a survey on the impact of COVID-19 on their livelihood and working practice. Two independent samples per state were calculated based on a total of 152,511 active medical registries in São Paulo and Maranhão. Proportional stratified sampling was performed and the distributions for gender, age, state and location of address (capital or countryside) were preserved. The survey contained questions on the frequency of physicians' employment of telemedicine services; the specific activities where these were employed, and; the forms in which the pandemic had influenced the adoption or consolidation of this technology. We performed descriptive and univariate analysis based on the chi-square test or Fisher's exact test for the qualitative data, and the Mann-Whitney test in the quantitative cases. Data were shown as absolute frequency and proportion with a 95% confidence interval.

RESULTS

In our sample of physicians, telemedicine was employed as a form of clinical collaboration by most doctors (76.0%, 95 CI 73.6-78.5), but only less than a third of them (30.6%, 95 CI 28.0-33.3) used it as a modality to provide healthcare services. During the pandemic, telemedicine was used predominantly in COVID-19-related areas, particularly for hospital-based in-patient services, and in private clinics and ambulatory settings. Male, younger doctors used it the most. Doctors in São Paulo employed telemedicine more frequently than in Maranhão (p < 0.001), in urban settings more than in rural areas (p < 0.001). Approximately three-quarters of doctors in large hospitals reported using telemedicine services (78.3%, 95 CI 75.9-80.6), followed by doctors working for smaller private clinics (66.4%, 95 CI 63.7-69.1), and by a smaller proportion of primary care doctors (58.4%, 95 CI 55.6-61.2).

CONCLUSIONS

Our study suggests that telemedicine may have helped ensure and expand the range of communication and healthcare services in low- and middle-income settings during the COVID-19 pandemic. However, the modality appears to lend itself to be disproportionally used by doctors working in specific, priviledged sections of pluralistic health systems, and presumably by patients seeking care there. Regulation and incentives will be required to support the use of the technology across health systems in low- and middle-income countries in order to increase access to services for less disadvantaged populations.