The unequal impact of the pandemic at subnational levels and educational attainment-related inequalities in COVID-19 mortality, Brazil, 2020-2021.

OBJECTIVES: We estimated COVID-19 mortality indicators in 2020-2021 to show the epidemic's impact at subnational levels and to analyze educational attainment-related inequalities in COVID-19 mortality in Brazil. STUDY DESIGN: This was an ecological study with secondary mortality information. METHODS: Crude and age-standardized COVID-19 mortality rates were calculated by gender, major regions, and states. The COVID-19 proportional mortality (percentage) was estimated by gender and age in each region. Measures of education-related inequalities in COVID-19 mortality were calculated per state, in each of which the COVID-19 maternal mortality rate (MMR) was estimated by the number of COVID-19 maternal deaths per 100,000 live births (LBs). RESULTS: The analysis of mortality rates at subnational levels showed critical regional differences. The North region proved to be the most affected by the pandemic, followed by the Center-West, with age-standardized COVID-19 mortality rates above 2 per 1000 inhabitants. The peak of COVID-19 mortality occurred in mid-March/April 2021 in all regions. Great inequality by educational level was found, with the illiterate population being the most negatively impacted in all states. The proportional mortality showed that males and females aged 50-69 years were the most affected. The MMR reached critical values (>100/100,000 LB) in several states of the North, Northeast, Southeast, and Center-West regions. CONCLUSIONS: This study highlights stark regional and educational disparities in COVID-19 mortality in Brazil. Exacerbated by the pandemic, these inequalities reveal potential areas for intervention to reduce disparities. The results also revealed high MMRs in certain states, underscoring pre-existing healthcare access challenges that worsened during the pandemic.

Mortality by avoidable causes in Brazil from 1990 to 2019: data from the Global Burden of Disease Study.

OBJECTIVES: The aim of this study was to analyse the trends of avoidable mortality in Brazil from 1990 to 2019 and its correlation with sociodemographic indexes (SDIs). STUDY DESIGN: Epidemiological mortality trends. METHODS: This study analysed data from the Global Burden of Disease database. The list of causes of avoidable death, as proposed by Nolte and McKee, was applied and included 32 causes. The current study used age-standardised mortality rates and the rates of change, in addition to a correlation analysis between avoidable death and the SDI. RESULTS: Mortality rates decreased from 343.90/100,000 inhabitants in 1990 to 155.80/100,000 inhabitants in 2019. Infectious diseases showed the largest decline in mortality rates, but notable decreases were also found for diarrhoeal diseases (-94.9%), maternal conditions (-66.5%) and neonatal conditions (-60.5%). Mortality rates for non-communicable diseases (NCDs) also decreased (-48%) but maintained a similar absolute number of deaths in 2019 compared with 1990. Decreased mortality rates were also found for ischaemic heart disease (-49.1%), stroke (-61.4%) and deaths due to adverse effects caused by medical treatments (-26.2%). Avoidable mortality rates declined in all of the 27 Brazilian states, and a high correlation was found between deaths and SDI (R = -0.74; P < 0.000001). CONCLUSIONS: A reduction in avoidable deaths was found throughout Brazil over the study period, although major regional inequalities were revealed. Richer states presented the best overall reduction in mortality rates. The biggest decreases in mortality were seen in maternal and paediatric infectious diseases in the poorest states due to the expansion of the Primary Health System and improvements in sanitation. Today, NCDs predominate and efforts should be made to formulate public policies for the prevention and control of NCDs.

Spatial association of homicide rate with violence, sociodemographic, and public security factors: global burden of disease study 2018 for municipalities in Brazil.

OBJECTIVES: To analyse spatial-temporal changes and spatial association of homicide rates with violence, sociodemographic, public security and human rights indicators in Brazilian municipalities. STUDY DESIGN: An ecological study using homicide estimates from the Global Burden of Disease and population from the Brazilian Ministry of Health, 2000 to 2018. The explanatory variables come from the systems of mortality, notifications of violence and security, and the Brazilian Institute of Geography and Statistics. METHODS: Moran indices and maps identified clusters of high and low risk for homicides in three trienniums (p < 0.05). Multivariate linear and spatial regressions estimated explanatory factors' contributions for the last triennium. RESULTS: Municipalities with high rates of homicides (>34/100,000) doubled, reaching 21.5 %. Those rates were concentrated in big cities, and increased in smaller municipalities. Increases in critical areas were found in the Northeast and North regions: more than 40 % in the states of Sergipe, Bahia, Ceará, Rio Grande do Norte and Roraima. Decreases occurred in the Southeast and Midwest regions: more than 35 % in São Paulo and Rio de Janeiro states. The spatial model, with an 18.9 % higher R2 (0.706), showed a positive association for records of violence, Blacks, low-level education, municipalities >50,000 inhabitants and municipalities with homicide and municipal police. CONCLUSIONS: An increase in and the interiorisation of homicide risk areas in Brazil was observed, with displacement among regions (from the Southeast to the North/Northeast). The level of violence was the main explanatory factor for homicides. Territorial space proved to be important to understand and prevent lethal crime.