COVID-19 e desigualdades territoriais: padrões espaciais, complexidade assistencial, fatores associados e morbimortalidade durante a Pandemia em diferentes contextos no Brasil, 2020-2022

Abstract

Public health emergencies require rapid preparedness and response due to the risk to human health and need timely response to these risks demands preparation and coordinated responses that integrate all health services. The objective of this study is to review the related factors and analyze the epidemiological profile, related factors, and the spatiotemporal distribution of cases, hospitalizations, and deaths due to SARS COVID-19 in municipalities of the RMBH and specifically in the municipality of Contagem, from March 2020 to December 2022, considering individual factors for death and those related to the place of hospitalization. Methodology: 1) To identify factors associated with the occurrence of COVID-19: a systematic review was conducted on factors related to the occurrence of COVID-19 in Brazil from 2020 to 2022. The research included studies published in Medline, Lilacs, PubMed, Cochrane, VHL, Web of Science and Scopus using descriptors cataloged in DeCs and MeSH, with the use of descriptors referring to social, environmental, and climatic factors related to the dynamics of COVID-19 occurrence in Brazil. Specific objectives (2, 3, and 4): To describe the epidemiological profile of hospitalizations and deaths, to analyze the temporal and spatial trends of hospitalization, mortality, and case-fatality rates, and to identify priority municipalities and those at highest risk for the disease: an ecological study was conducted, including the description of hospitalizations and deaths, and the spatial and spatiotemporal distribution of hospitalization, mortality, and case-fatality rates among patients hospitalized for Severe Acute Respiratory Syndrome (SARS) due to COVID-19 in 50 municipalities of the Metropolitan Region of Belo Horizonte (RMBH) from 2020 to 2022. Data were obtained from the SIVEP-Gripe system of the State Health Department of Minas Gerais and population data from the 2022 IBGE Census. Specific objective (5): To analyze the influence of the size of the hospitalization facility on the occurrence of deaths: a historical cohort study was conducted using SIVEP-Gripe data from the Municipal Health Department of Contagem. A multilevel analysis was performed, with individuals at the first level and hospitalization facilities at the second level, including patients who died from SARS due to COVID-19 between 2020 and 2022. Results: 1) A total of 41 studies were included, revealing that increases in COVID-19 cases, lethality, and mortality were positively correlated with Black populations, illiterate individuals, and those over 60 years old. Municipalities with lower HDI/IHDI and reduced access to healthcare services reported more severe cases. Higher mortality was linked to lower income, unemployment, and the absence of formal employment. Additionally, areas with higher urbanization, proximity to highways, and reduced vegetation were associated with more cases. Lower temperatures and higher relative humidity were also positively correlated with case counts. 2) The highest mortality risk in the RMBH (RR = 5,96) was observed in municipalities located in the northern region, while case fatality among hospitalized patients was higher in Itabirito and Rio Acima, in the southern region (RR = 2,42). Municipalities in the central area of the Metropolitan Region of Belo Horizonte presented higher hospitalization rates, associated with a greater concentration of health infrastructure. In contrast, mortality and case fatality among hospitalized patients were higher in peripheral municipalities, characterized by lower availability of health resources and greater social vulnerability. 3) The ICC of 12% indicates that the probability of progressing to death was associated with the hospital of admission, and lethality among large hospitals showed significant heterogeneity, demonstrating that hospital size is not the only determinant of death. First-level results revealed individual-related factors: individuals aged >60 years had a 2,28-fold higher risk of death compared with those under 60 years (OR = 2,28, p < 0.001), and those with more than three comorbidities had over eight times the risk of death compared with individuals without comorbidities (OR = 8,84). Conclusion: The preparedness and response to the COVID-19 PHEIC represented the greatest public health challenge in reducing morbidity and mortality. Differences in hospitalization and mortality rates revealed inequalities related to social determinants and weaknesses in healthcare structures, highlighting that exposure to risk factors and access to quality health services are unequal. These findings underscore the need for timely interventions in situations of greater vulnerability.