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

Silva, Gabriela Drummond Marques da; Souza, Anelise Andrade de; Castro, Mônica Silva Monteiro de; Miranda, Wanessa Debôrtoli de; Jardim, Leticia Lemos; Sousa, Rômulo Paes de

Gabriela Drummond Marques da Silva

Contributed to the concept of the article and performing the analyses. All the authors contributed to drafting and reviewing the article and approved its final version. They are responsible for all aspects thereof, including the guarantee of its accuracy and integrity

Fundação Oswaldo Cruz, Instituto René Rachou, Belo Horizonte, MG, Brazil

http://orcid.org/0000-0002-1145-3940

Anelise Andrade de Souza

Contributed to the concept of the article and performing the analyses. All the authors contributed to drafting and reviewing the article and approved its final version. They are responsible for all aspects thereof, including the guarantee of its accuracy and integrity

Universidade Federal de Ouro Preto, Escola de Nutrição, Ouro Preto, MG, Brazil

http://orcid.org/0000-0002-2408-7054

Mônica Silva Monteiro de Castro

Contributed to the concept of the article and performing the analyses. All the authors contributed to drafting and reviewing the article and approved its final version. They are responsible for all aspects thereof, including the guarantee of its accuracy and integrity

Fundação Oswaldo Cruz, Instituto René Rachou, Belo Horizonte, MG, Brazil

http://orcid.org/0000-0003-2461-3699

Wanessa Debôrtoli de Miranda

Interpreting the data and conducting a bibliographical review for the study. All the authors contributed to drafting and reviewing the article and approved its final version. They are responsible for all aspects thereof, including the guarantee of its accuracy and integrity

Universidade Federal de Minas Gerais, Escola de Enfermagem, Belo Horizonte, MG, Brazil

http://orcid.org/0000-0002-0838-9861

Leticia Lemos Jardim

Interpreting the data and conducting a bibliographical review for the study. All the authors contributed to drafting and reviewing the article and approved its final version. They are responsible for all aspects thereof, including the guarantee of its accuracy and integrity

Fundação Oswaldo Cruz, Instituto René Rachou, Belo Horizonte, MG, Brazil

http://orcid.org/0000-0003-3358-0075

Rômulo Paes de Sousa

Contributed to the concept of the article and performing the analyses. All the authors contributed to drafting and reviewing the article and approved its final version. They are responsible for all aspects thereof, including the guarantee of its accuracy and integrity

Fundação Oswaldo Cruz, Instituto René Rachou, Belo Horizonte, MG, Brazil

http://orcid.org/0000-0002-3384-6657

Correspondence: Gabriela Drummond Marques da Silva. E-mail: gabriela.marques@fiocruz.br

Associate editor: Elisângela Aparecida da Silva Lizzi - orcid.org/0000-0001-7064-263X

conflicts of interest

The authors declare they have no conflicts of interest.

Figures (4)
Tables (2)

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Figure 1
– Mechanisms linking economic and social inequalities to COVID-19 morbidityd and mortality

a) Proximal determinants; b) Distal determinants; c) Outcome; d) In this study, morbidity was estimated based on COVID-19 hospitalizations.

Note: ICU = intensive care unit; PHC = Primary Health Care.

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Figure 2
– Spatial distribution (A) of COVID-19 hospitalization rates (per 100,000 inhab.) and (B) mortality (per 100,000 inhab.), standardized indirectly by age and sex, in municipalities with more than 100,000 inhabitants, Brazil, 2020

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Figure 3
– Distribution of COVID-19 mortality rates (per 100,000 inhab.) and hospitalization rates (per 100,000 inhab.), standardized indirectly by age and sex, in municipalities with more than 100,000 inhabitants, Brazil, 2020

a) Mortality rate histogram (per 100,000 inhab.); b) Scatter plot showing hospitalization rate (per 100,000 inhab.) and mortality rate (per 100,000 inhab.); c) Hospitalization rate histogram (per 100,000 inhab.)

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Figure 4
– Incidence rate ratios estimated according to a multivariable generalized linear model (GLM) for (A) COVID-19 hospitalization and (B) COVID-19 deaths, com with respective confidence intervals, in municipalities with more than 100,000 inhabitants, Brazil, 2020

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Study contributions Main results The COVID-19 mortality rate was higher in municipalities with a larger non-White population, subnormal housing clusters and households with more than two persons per room, and without sewerage. Effect of interaction between subnormal housing clusters and Emergency Aid. Implications for services Addressing socioeconomic inequalities demands inclusive policies for vulnerable people, in order to favor their access to public and private goods and services essential for their health and well-being. Perspectives It is fundamental to go beyond interventions focused on single strategies in a context in which sectoral systems act in isolation, and instead invest in universal interventions that seek transversal and intersectoral articulation.

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Table 1
– Univariate analysis of outcome (COVID-19 hospitalization and mortality rates) association with the main control and exposure variables, according to a generalized linear model (GLM), in municipalities with more than 100,000 inhabitants, Brazil, 2020

Study contributions
Main results	The COVID-19 mortality rate was higher in municipalities with a larger non-White population, subnormal housing clusters and households with more than two persons per room, and without sewerage. Effect of interaction between subnormal housing clusters and Emergency Aid.
Implications for services	Addressing socioeconomic inequalities demands inclusive policies for vulnerable people, in order to favor their access to public and private goods and services essential for their health and well-being.
Perspectives	It is fundamental to go beyond interventions focused on single strategies in a context in which sectoral systems act in isolation, and instead invest in universal interventions that seek transversal and intersectoral articulation.

Group	Variables	Hospitalization			Deaths
Group	Variables	IRR^a	95%CI^b	p-value	IRR^a	95%CI^b	p-value
Control variables	Diabetes mellitus hospitalization rate	1.18	1.11;1.25	< 0.001	1.07	1.01;1.12	0.011
	Respiratory diseases hospitalization rate	1.14	1.08;1.21	< 0.001	1.01	0.96;1.07	0.627
	Hypertension hospitalization rate	1.13	1.06;1.22	< 0.001	1.04	0.99;1.10	0.103
	Cardiovascular diseases mortality rate	1.17	1.10;1.24	< 0.001	1.19	1.13;1.24	< 0.001
	Diabetes mellitus mortality rate	1.14	1.07;1.21	< 0.001	1.10	1.05;1.16	< 0.001
	Respiratory diseases mortality rate	1.02	0.96;1.08	0.552	1.08	1.03;1.13	0.003
	Cancer mortality rate	0.98	0.92;1.03	0.410	1.04	0.99;1.10	0.107
	Clinical beds available-SUS/100,000 inhab. (January 2020)	1.03	0.98;1.09	0.358	1.00	0.95;1.04	0.878
	Clinical beds available/private system/100,000 inhab. (January 2020)	1.06	1.00;1.14	0.047	0.98	0.94;1.05	0.555
	Clinical beds available-SUS/100,000 inhab. (July 2020)	1.09	1.03;1.15	0.007	1.02	0.98;1.08	0.343
	Clinical beds available-private system/100,000 inhab. (July 2020)	1.06	1.00;1.14	0.059	0.98	0.94;1.04	0.523
Main exposure variables^c	Primary Healthcare Coverage	1.01	0.96;1.07	0.700	0.97	0.93;1.02	0.260
	Outpatient testing per case	0.98	0.93;1.03	0.401	0.98	0.93;1.03	0.318
	Distance from primary healthcare center	1.07	1.02;1.14	0.010	1.06	1.01;1.11	0.014
	Subnormal housing clusters	1.09	1.02;1.16	0.003	1.17	1.12;1.22	< 0.001
	People per bedroom (> 2)	1.22	1.15;1.30	< 0.001	1.17	1.11;1.23	< 0.001
	Proportion of non-Whites	1.15	1.08;1.22	< 0.001	1.19	1.13;1.25	< 0.001
	Literacy rate of the population aged 15 years or over	0.93	0.87;0.98	0.013	1.02	0.97;1.07	0.437
	Access to water (at least basic)	0.87	0.83;0.92	< 0.001	0.92	0.87;0.96	< 0.001
	Access to sewerage (at least basic)	0.89	0.84;0.95	< 0.001	0.88	0.84;0.93	< 0.001
	Gini index	1.03	0.97;1.09	0.395	1.11	1.06;1.16	< 0.001
	Emergency Aid	1.14	1.07;1.21	< 0.001	1.16	1.09;1.22	< 0.001

[1] Correspondence: Gabriela Drummond Marques da Silva. E-mail: gabriela.marques@fiocruz.br

Brasil

Brasil

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

Abstract

Objective

Methods

Results

Conclusion