Social and racial inequalities in COVID-19 risk of hospitalisation and death across Sao Paulo state, Brazil

BackgroundLittle evidence exists on the differential health effects of COVID-19 on disadvantaged population groups. Here we characterise the differential risk of hospitalisation and death in Sao Paulo state, Brazil and show how vulnerability to COVID-19 is shaped by socioeconomic inequalities. MethodsWe conducted a cross-sectional study using hospitalised severe acute respiratory infections (SARI) notified from March to August 2020, in the Sistema de Monitoramento Inteligente de Sao Paulo (SIMI-SP) database. We examined the risk of hospitalisation and death by race and socioeconomic status using multiple datasets for individual-level and spatio-temporal analyses. We explained these inequalities according to differences in daily mobility from mobile phone data, teleworking behaviour, and comorbidities. FindingsThroughout the study period, patients living in the 40% poorest areas were more likely to die when compared to patients living in the 5% wealthiest areas (OR: 1{middle dot}60, 95% CI: 1{middle dot}48 - 1{middle dot}74) and were more likely to be hospitalised between April and July, 2020 (OR: 1{middle dot}08, 95% CI: 1{middle dot}04 - 1{middle dot}12). Black and Pardo individuals were more likely to be hospitalised when compared to White individuals (OR: 1{middle dot}37, 95% CI: 1{middle dot}32 - 1{middle dot}41; OR: 1{middle dot}23, 95% CI: 1{middle dot}21 - 1{middle dot}25, respectively), and were more likely to die (OR: 1{middle dot}14, 95% CI: 1{middle dot}07 - 1{middle dot}21; 1{middle dot}09, 95% CI: 1{middle dot}05 - 1{middle dot}13, respectively). InterpretationLow-income and Black and Pardo communities are more likely to die with COVID-19. This is associated with differential access to healthcare, adherence to social distancing, and the higher prevalence of comorbidities. FundingThis project was supported by a Medical Research Council-Sao Paulo Research Foundation (FAPESP) CADDE partnership award (MR/S0195/1 and FAPESP 18/14389-0) (http://caddecentre.org/). This work received funding from the U.K. Medical Research Council under a concordat with the U.K. Department for International Development.

Geographic access to COVID-19 healthcare in Brazil using a balanced float catchment area approach

The rapid spread of the new coronavirus across the world has raised concerns about the responsiveness of cities and healthcare systems during pandemics. Recent studies try to model how the number of COVID-19 infections will likely grow and impact the demand for hospitalization services at national and regional levels. However, less attention has been paid to the geographic access to COVID-19 healthcare services and to the response capacity of hospitals at the local level, particularly in urban areas in the Global South. This paper shows how transport accessibility analysis can provide actionable information to help improve healthcare coverage and responsiveness. It analyzes accessibility to COVID-19 healthcare at high spatial resolution in the 20 largest cities of Brazil. Using network-distance metrics, we estimate the vulnerable population living in areas with poor access to healthcare facilities that could either screen or hospitalize COVID-19 patients. We then use a new balanced floating catchment area (BFCA) indicator to estimate spatial, income and racial inequalities in access to hospitals with intensive care unit (ICU) beds and mechanical ventilators while taking into account congestion effects. Based on this analysis, we identify substantial social and spatial inequalities in access to health services during the pandemic. The availability of ICU equipment varies considerably between cities and it is substantially lower among black and poor communities. The study maps territorial inequalities in healthcare access and reflects on different policy lessons that can be learned for other countries based on the Brazilian case.

Epidemiological and clinical characteristics of the early phase of the COVID-19 epidemic in Brazil

BackgroundThe first case of COVID-19 was detected in Brazil on February 25, 2020. We report the epidemiological, demographic, and clinical findings for confirmed COVID-19 cases during the first month of the epidemic in Brazil. MethodsIndividual-level and aggregated COVID-19 data were analysed to investigate demographic profiles, socioeconomic drivers and age-sex structure of COVID-19 tested cases. Basic reproduction numbers (R0) were investigated for Sao Paulo and Rio de Janeiro. Multivariate logistic regression analyses were used to identify symptoms associated with confirmed cases and risk factors associated with hospitalization. Laboratory diagnosis for eight respiratory viruses were obtained for 2,429 cases. FindingsBy March 25, 1,468 confirmed cases were notified in Brazil, of whom 10% (147 of 1,468) were hospitalised. Of the cases acquired locally (77{middle dot}8%), two thirds (66{middle dot}9% of 5,746) were confirmed in private laboratories. Overall, positive association between higher per capita income and COVID-19 diagnosis was identified. The median age of detected cases was 39 years (IQR 30-53). The median R0 was 2{middle dot}9 for Sao Paulo and Rio de Janeiro. Cardiovascular disease/hypertension were associated with hospitalization. Co-circulation of six respiratory viruses, including influenza A and B and human rhinovirus was detected in low levels. InterpretationSocioeconomic disparity determines access to SARS-CoV-2 testing in Brazil. The lower median age of infection and hospitalization compared to other countries is expected due to a younger population structure. Enhanced surveillance of respiratory pathogens across socioeconomic statuses is essential to better understand and halt SARS-CoV-2 transmission. FundingSao Paulo Research Foundation, Medical Research Council, Wellcome Trust and Royal Society.