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.

Relationship between salt consumption measured by 24-h urine collection and blood pressure in the adult population of Vitória (Brazil).

High salt intake is related to an increase in blood pressure and development of hypertension. However, currently, there are no national representative data in Brazil using the gold standard method of 24-h urine collection to measure sodium consumption. This study aimed to determine salt intake based on 24-h urine collection in a sample of 272 adults of both genders and to correlate it with blood pressure levels. We used a rigorous protocol to assure an empty bladder prior to initiating urine collection. We excluded subjects with a urine volume <500 mL, collection period outside of an interval of 23-25 h, and subjects with creatinine excretion that was not within the range of 14.4-33.6 mg/kg (men) and 10.8-25.2 mg/kg (women). The mean salt intake was 10.4±4.1 g/day (d), and 94% of the participants (98% of men and 90% of women) ingested more than the recommended level of 5 g/d. We found a positive association between salt and body mass index (BMI) categories, as well as with salt and blood pressure, independent of age and BMI. The difference in systolic blood pressure reached 13 mmHg between subjects consuming less than 6 g/d of salt and those ingesting more than 18 g/d. Subjects with hypertension had a higher estimated salt intake than normotensive subjects (11.4±5.0 vs 9.8±3.6 g/d, P<0.01), regardless of whether they were under treatment. Our data indicate the need for interventions to reduce sodium intake, as well the need for ongoing, appropriate monitoring of salt consumption in the general population.

Anti-HIV-1 seroreactivity and HIV transmission route[R1]. The HEC/FIOCRUZ AIDS Clinical Research Group.

BACKGROUND: Antibody binding assays carried out by our group have consistently indicated a higher reactivity of sera from male HIV-1 infected individuals. This study was carried out in order to analyze the importance of gender, route of transmission, disease progression and HIV-1 genotype in seroreactivity assays. STUDY DESIGN: Specificity of antibody binding was studied in plasma of 247 HIV-1 seropositive individuals belonging to patient groups of pregnant women, injecting drug users (IDUs) and recent seroconvertors, resident in Rio de Janeiro, RJ. Recognition of synthetic peptides corresponding to antigenically important epitopes in the envelope of HIV-1 (gp41 immunodominant epitope, V3 loop, V2 loop and gp41 735-752 epitope) was determined. RESULTS: The immunodominant gp41 peptide (amino acids 594-613, HIV-1 MN sequence) was recognized by 85% of all plasma tested. Reactivity with the gp41 735-752 peptide and gp120 V2 loop peptides was low but quite variable, being generally more often specific to a Brazilian V2 peptide used than to the HIV-1 MN derived V2 peptide. The overall recognition of the different V3 peptides tested varied from 41 to 76%. Patients with more advanced disease showed a more frequent reactivity with the peptides studied than did asymptomatic patients. Statistically significant differences in peptide recognition were observed by multiple logistic analyses comparing plasma derived from individuals infected by blood or sexual HIV transmission, adjusting for disease progression and gender. Plasma from individuals infected by sexual transmission showed lower peptide recognition than did plasma from individuals infected through HIV positive blood. Association attempts between seroreactivity and genotype indicated that plasma derived from patients infected with HIV-1 of the F subtype showed highest recognition of heterologous V3 peptides, as well as a slightly more frequent recognition of the non-V3 peptides tested. Recognition of homologous peptides was generally higher than recognition of heterologous peptides. Differences were most pronounced between the prototypical HIV-1 B subtype and the Brazilian B" variant of this subtype but almost non-existent between the HIV-1 B and F subtypes. CONCLUSIONS: Individual gender was shown to be a confounder when investigating the relationships of peptide reaction to HIV-1 route of transmission through multivariate statistical methods: patients infected by blood transmission (IDU) present higher frequency of peptide recognition than individuals infected by sexual HIV-1 transmission. Plasma from individuals infected with the B" variant (GWG) of B subtype HIV-1 showed lower heterologous peptide recognition than that from HIV-1 B (GPG) or F infected individuals.

Health conditions and residential concentration of poverty: a study in Rio de Janeiro, Brazil.

STUDY OBJECTIVES: To establish the geographical relation of health conditions to socioeconomic status in the city of Rio de Janeiro, Brazil. DESIGN: All reported deaths in the municipality of Rio de Janeiro, from 1987 to 1995, obtained from the Mortality Information System, were considered in the study. The 24 "administrative regions" that compose the city were used as the geographical units. A geographical information system (GIS) was used to link mortality data and population census data, and allowed the authors to establish the geographical pattern of the health indicators considered in this study: "infant mortality rate"; "standardised mortality rate"; "life expectancy" and "homicide rate". Information on location of low income communities (slums) was also provided by the GIS. A varimax rotation principal component analysis combined information on socioeconomic conditions and provided a two dimension basis to assess contextual variation. MAIN RESULTS: The 24 administrative regions were aggregated into three different clusters, identified as relevant to reflect the socioeconomic variation. Almost all health indicator thematic maps showed the same socioeconomic stratification pattern. The worst health situation was found in the cluster composed of the harbour area and northern vicinity, precisely in the sector where the highest concentration of slum residents are present. This sector of the city exhibited an extremely high homicide rate and a seven year lower life expectancy than the remainder of the city. The sector that concentrates affluence, composed of the geographical units located along the coast, showed the best health situation. Intermediate health conditions were found in the west area, which also has poor living standards but low concentration of slums. CONCLUSIONS: The findings suggest that social and organisation characteristics of low income communities may have a relevant role in understanding health variations. Local health and other social programmes specifically targeting these communities are recommended.

[AIDS and HIV infection in Brazil: a multifaceted epidemic]. / AIDS e infecção pelo HIV no Brasil: uma epidemia multifacetada.

The HIV/AIDS epidemic is a dynamic unstable global phenomenon, constituting a veritable mosaic of regional sub-epidemics. As a consequence of the deep inequalities that exist in Brazilian society, the spread of HIV infection has revealed an epidemic of multiple dimensions undergoing extensive epidemiological transformations. Initially restricted to large urban centers and markedly masculine, the HIV/AIDS epidemic is currently characterized by heterosexualization, feminization, interiorization and pauperization. The evolution of the profile of AIDS in Brazil is above all due to the geographical diffusion of the disease from large urban centers towards medium and small municipalities in the interior, to the increase in heterosexual transmission and the persistent growth of cases among injecting drug users. The increase in transmission through heterosexual contact has resulted in substantial growth of cases among women, which has been pointed out as the most important characteristic of the epidemic's current dynamic in Brazil.

[AIDS and pauperization: principal concepts and empirical evidence]. / AIDS e pauperização: principais conceitos e evidências empíricas.

This paper discusses methodologies for analyzing relations between social inequalities, marginalization, prejudice, and vulnerability to HIV/AIDS, highlighting current difficulties and alternative research strategies. It also reviews the international and Brazilian literature, emphasizing: economic and macropolitical dimensions in the spread of HIV/AIDS; the role of drug policies and consumption; gender inequalities and prejudice; racial/ethnic inequalities and prejudice; and interaction with other STIs and their relationship to poverty; HIV/AIDS and health care standards, especially access to antiretroviral therapy; and human rights violations. Despite current methodological dilemmas in analyzing relations between psychosocial, cultural, and sociopolitical variables and vulnerability to HIV/AIDS and the limited Brazil literature, such themes merit further investigation, addressing Brazilian social and cultural specificities and profiting from recently developed research strategies.

[Estimated number of HIV-infected individuals aged 15-49 years in Brazil, 1998]. / Estimativa do número de pessoas de 15 a 49 anos infectadas pelo HIV, Brasil, 1998.

This study estimates the number of HIV-infected individuals from 15 to 49 years of age in Brazil in 1998 based on sentinel population studies in pregnant women, with a selection bias in the sample. A principal components procedure was used to group 44 counties in homogeneous 13 clusters. Two indicators were constructed for each cluster: a) the logarithm of the accumulated AIDS incidence rate among women from 15 to 34 years of age (1996) and b) the logarithm of the growth ratio for the mean AIDS incidence rate for women from 15 to 34 years of age for the period from 1990-1992 to 1993-1996. Taking the log of the proportion of HIV-infected pregnant women as the dependent variable and the two above-mentioned indicators as the independent variables, a regression line was fitted to the aggregate data. Estimation of the model's parameters allowed us to calculate the proportion of infected individuals by macro-region, by age (15-34 and 35-49 years) and gender. The point estimate was 536 thousand HIV-infected adults with a 68% CI (470.689 - 603.305).

[Economic crisis and infant mortality in Latin America since the 1980's]. / Crisis económica y mortalidad infantil en Latinoamérica desde los años ochenta.

In the present study, based on data from nine Latin American countries, we found evidence of an association between the economic crisis and infant mortality during the last decades. The paper initially review previous studies on this issue and shows the need for a greater research focus on shorter time intervals. We then describe the deterioration and unequal conditions among the countries based on trends in selected social and economic indicators and the evolution of infant mortality rates. According to our statistical analysis, infant mortality bore an inverse association to short-term economic variations. We also found a significant and negative correlation between decreasing infant mortality rates and increasing poverty. The economic crisis displayed effects of varying intensity among the countries we analyzed, with social inequality appearing as the most probable explanatory variable.

[Spatial analysis of early neonatal mortality in the municipality of Rio de Janeiro, 1995-1996]. / Análise espacial da mortalidade neonatal precoce no Município do Rio de Janeiro, 1995-1996.

The objective of this study was to establish the spatial distribution of the early neonatal mortality rate (0-3 days) in the municipality of Rio de Janeiro for 1995-1996, identifying the best explanatory factors for spatial variations. By considering Rio de Janeiro's 153 neighborhoods as ecological units of analysis, socioeconomic and maternal indicators were analyzed according to place of residence. Spatial statistical analysis was performed using the Cliff & Ord methodology, appropriate for lattice data. From the 0-3 day mortality thematic map, we clearly identified two clusters of high early neonatal mortality rates. Spatial dependence was also confirmed by the statistical results of the spatial analysis. The variables that explain the clusters are the proportions of "adolescent mothers", "slum-dwellers", and "heads of households below the poverty level". Spatial statistics provided a better understanding of the geographic distribution of early neonatal mortality and suggested potential hypotheses for further investigation, which could support preventive programs and contribute to a decrease in infant mortality.

[Differences between neonatal mortality and stillbirth rates in Brazil: a study based on the Unified Health System (SIH/SUS) Hospital Information System]. / Diferenciais nas taxas de mortalidade neonatal e natimortalidade hospitalares no Brasil: um estudo com base no Sistema de Informações Hospitalares do Sistema Unico de Saúde (SIH/SUS).

The main objective of this article is to estimate stillbirth and neonatal mortality rates in Brazilian States based upon the country's Hospital Information System. Analysis of 1995 data reveals contrasting rates between the various regions of the country. In order to elucidate the States' different rates, we focused on the association between indicators of coverage, utilization, and access to the Unified Health System (SUS). The results for the neonatal period mostly showed higher early neonatal mortality rates when compared to late neonatal mortality rates, higher neonatal mortality rates in the States comprising the South and Southeast regions, less variable rates between those States, and extremely low rates in some States of the North, Central-West, and Northeast regions. The limited supply of SUS services and low access to same are relevant constraints on health care for the population in the North and Northeast. Aspects related to quality of childbirth and neonatal care are also reflected in the rates studied. The findings suggest that spatial and temporal monitoring of these rates could provide analytical support for organizing the Maternal and Child Health Program.

[Estimated number of orphans due to maternal AIDS in Brazil, 1987-99]. / Estimativa do número de órfãos decorrentes da AIDS materna, Brasil, 1987-1999.

This study proposes a procedure to estimate the number of orphans due to maternal AIDS. The procedure estimates the number of orphans by calendar year, multiplying the cumulative fertility rate by the number of AIDS deaths among women aged 15-49 years. Because the procedure refers to the number of children that are alive, the estimate is adjusted by contemplating the proportion of pediatric AIDS cases due to vertical transmission and the probability of survival in the 5-9-year age group. To estimate the number of AIDS orphans in Brazil from 1987 to 1999, the procedure was applied by stratifying according to geographical region, taking into account the differences in regional fertility rates, completeness of death reporting, and misclassification of AIDS-related deaths as due to other causes. The total number of cumulative AIDS orphans for 1987-99 was estimated at approximately 30,000.

[The spread of the AIDS epidemic in Brazil from 1987 to 1996: a spatial analysis]. / A disseminação da epidemia da AIDS no Brasil, no período de 1987-1996: uma análise espacial.

Mean AIDS incidence rates were calculated for three time periods, 1987-89, 1990-92, and 1993-96, using reported adult AIDS cases by county. The analysis included the following variables: "population of counties for resident AIDS cases"; "proportion of population residing in urban areas", and "concentration of poverty", stratifying by gender and exposure categories. The Southeast region has experienced the lowest increase, contrasting with the steep rise observed in the North and South between the second and third study periods. Comparing variations in incidence rates from 1990-92 and 1993-96 by region or population, the greatest increase was among women. In the larger cities, AIDS cases among "homo/bisexual men" predominate, although the proportion of cases among men who have sex with men has decreased as heterosexual cases have undergone a continuous increase. IDUs have been the core stratum in medium-sized counties. For the smallest counties, heterosexual transmission has been the basic element in local dynamics. Even though AIDS is still an urban phenomenon in Brazil, the epidemic is spreading to rural counties. Until recently it has mainly affecting relatively more affluent areas, but there is now an evident spread of the epidemic to poorer areas.

[AIDS and level of education in Brazil: temporal evolution from 1986 to 1996]. / AIDS e grau de escolaridade no Brasil: evolução temporal de 1986 a 1996.

This article analyzes the temporal distribution of reported AIDS cases by level of education used as a proxy variable for individual socioeconomic status. All AIDS cases aged 20-69 years and reported through May 29, 1999, with date of diagnosis between 1986-1996, were included in the study. Incidence rates were calculated for men and women according to level of education ("level 1" up to 8 years of schooling and "level 2" with over 8 years of schooling), by five geographic regions, and by year of diagnosis. Incidence rates for men with less schooling were close to or higher than those for men with more schooling (particularly in the Southeast region). For women, a time series showed that incidence rates increased at a higher rate among women with less schooling in all regions of the country; in the Southeast, the incidence rate for women with less schooling was already greater than for women with more schooling by 1989. According to the present analysis, the AIDS epidemic in Brazil began among people from the more highly educated social strata and progressed steadily through to the less educated social strata, especially among women.

[AIDS epidemic dynamics in the municipality of Rio de Janeiro, Brazil, 1988-1996: Spatial-temporal statistic modeling]. / Dinâmica da epidemia de AIDS no Município do Rio de Janeiro, no período de 1988-1996: uma aplicação de análise estatística espaço-temporal.

This study uses a spatial-temporal model to analyze the spatial spread of the AIDS epidemic (adult cases) in the municipality of Rio de Janeiro, Brazil, during three periods: 1988-1990, 1991-1993, and 1994-1996. City districts were used as the geographic units of analysis. A spatial analysis was also performed for pediatric AIDS cases due to vertical HIV transmission, according to period of birth, 1985-90 and 1991-96. For total adult AIDS cases, the initial period was characterized by a polygonal cluster located around the harbor area, which expanded from west to east. Among homosexual cases, in situ growth predominated, and a decrease in the intensity of the diffusion process was observed from the second to the final period. Among heterosexual cases, the epidemic displayed a relevant geographic spread, mainly from 1988-1990 to 1991-1993. Among female cases in the final time period, a cluster of high incidence rates was found towards the northwest, including very poor areas. Among pediatric cases in 1991-1996, a significant correlation was found between AIDS incidence rates and poverty levels in the respective municipal districts. The results suggest that a more complete understanding of AIDS spatial-temporal dynamics can make a major contribution to preventive measures.

[Income inequality and health: the case of Rio de Janeiro]. / Desigualdade de renda e situação de saúde: o caso do Rio de Janeiro.

This ecological analysis addresses the association between income inequality and health status in the municipality of Rio de Janeiro. Data were analyzed using geo-processing and multiple regression techniques. The following health indicators were used: infant mortality rate; standardized mortality rate; life expectancy at birth; and homicide rate among 15-29-year-old males. Patterns of income inequality were assessed through income distribution indicators: Gini index, Robin Hood index, and top 10 %/bottom 40% average income ratio. The results indicate significant correlations between income distribution indicators and health indicators, providing additional empirical evidence of the association between health status and income inequality. For the homicide rate, the effect of the indicator "density of slum residents" was also relevant, suggesting that further deterioration in health standards may be due to social disruption of deprived communities and the resultant increase in criminal activity. The geo-epidemiological analysis presented here highlights the association between adverse health outcomes and residential concentration of poverty. Social policies focused on slum residents are needed to reduce the harmful effects of relative deprivation.

Considerations on methodology used in the World Health Organization 2000 Report.

The article analyzes the World Health Organization Report for 2000, with emphasis placed on the methodology used to analyze the indicators utilized to compare and classify the performance of the health systems of the 191 member countries. The Report's contribution was the compromise of monitoring the performance of the health systems of member countries, but because of the inconsistent way it was elaborated, and the utilization of questionable scientific evaluation methodologies, the Report fails to give a clear picture. A criterion-based methodology revision is imposed. The main problems in evidence are the choice of individual indicators of disparity in health that discount the population profile, the inadequate control of the impact of social disparities over the performance of the systems, the evaluation of the responsibility of systems that are only partially articulated to the right of the citizens, the lack of data for a great number of countries, consequently having inconsistent estimations, and the lack of transparency in the methodological procedures in the calculation of some indicators. The article suggests a wide methodological revision of the Report.

[Risk behavior among Brazilian Military conscripts, 1998: an study of HIV infections following socioeconomic differences]. / Comportamento de risco dos conscritos do Exército Brasileiro, 1998: uma apreciação da infecção pelo HIV segundo diferenciais sócio-econômicos.

A study of HIV-related risk behavior was carried out in 1998 among Brazilian military conscripts aged 17-20 years. A sample of 30,318 subjects was selected in three strata, pertaining to counties from: 1) the North and Central-West (N/CW); 2) South (S); and the states of Rio de Janeiro and São Paulo. HIV prevalence rates were estimated in all strata. The objective of this paper was to analyze the results according to differences in socioeconomic status (SES). The statistical analysis used an index of sexual risk behavior and logistic regression models. The N/CW stratum showed the worst indicators for SES, sexual risk behavior, and sexually transmitted infections (STIs), as well as the highest HIV seroprevalence rate. The best indicators for all variables were found in the RJ/SP stratum. The South showed intermediate results. Level of schooling also played a relevant role. In all three strata the conscripts with an incomplete high school education displayed the worst sexual risk behavior index, shown to be a relevant predictor of STI-related problems, including HIV infection.

[Hospital system as a source of information to estimate stillbirth and neonatal mortality rates]. / Sistema hospitalar como fonte de informações para estimar a mortalidade neonatal e a natimortalidade.

OBJECTIVE: Studies on the evolution of infant mortality rate are very relevant. Nevertheless, lack of vital statistics in Brazil limits the temporal and spatial analysis of this indicator. This study aims to investigate the possible use of the Brazilian Hospital Information System as an alternative information source for stillbirth and neonatal mortality rates by age group. METHODS: A new method to estimate the stillbirth and neonatal mortality rates is proposed. It was applied in a set of selected Brazilian states in the year of 1995. For comparative purposes, the Brazilian Death Information System was assessed to estimate the mortality rates under study, after adjusting the registered number of live births by using a demographic tool. RESULTS: By assessing the Hospital Information System a larger number of fetal and early neonatal deaths were observed when compared to data given by the death information system of the Northeastern states. Besides, in the Southern and Southeastern states, where death records are more thorough, the mortality rates calculated using both information sources were very similar. CONCLUSIONS: The results suggest that the proposed methodology could greatly contribute to the analysis of the spatial-time evolution of stillbirth and neonatal death rates in recent years in Brazil, as data on death registration in the majority of the Brazilian states are less thorough than those from the hospital information system.

[Estimates of infant mortality in Brazil in the 80's: a proposal for a methodological procedure]. / Estimativas da mortalidade infantil no Brasil, década de oitenta: proposta de procedimento metodológico.

A procedure for the estimation of the infant mortality rate in Brazil, in the 1980's, based only on the age distribution of registered deaths, is here proposed. Using this technique, it is possible to estimate the probabilities of dying in the first year of life in a continuous way, year by year, for different regions of the country. The space-time distribution of the main causes of infant deaths is analysed and the relevance of using this coefficient to express the social and economic conditions of the Brazilian population from 1979 to 1989 is discussed.

[Proposal for a model for the desaggregation of demographic projections of large areas into their geographical components]. / Proposta de um modelo para desagregar projeções demográficas de grandes áreas em seus componentes geográficos.

The problem of the preparation of estimates of the total population of geographic subdivisions after the 1980 census is studied with a view to the tabulation on mortality data of Rio de Janeiro State (Brazil) by municipal districts and the estimation of regional mortality rates. In Brazil, the calculation of the official population estimates is undertaken by the Brazilian Institute of Geography and Statistics. The method employed to estimate the population of geographic subdivisions is known as the "AiBi method". This procedure is analysed and an alternative mathematical model is proposed that also satisfies the closure condition, that is, the projected values for the sum of the segments up to the total population projection. As an application of the proposed model, estimates of the population of the municipal districts of Rio de Janeiro State were prepared covering the period from 1981 to 1990.