COVID-19 Mortality in Brazil, 2020-21: Consequences of the pandemic inadequate management

doi:10.21203/rs.3.rs-1678072/v2

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COVID-19 Mortality in Brazil, 2020-21: Consequences of the pandemic inadequate management

https://doi.org/10.21203/rs.3.rs-1678072/v2

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Background

The COVID-19 pandemic brought countless challenges to public health and highlighted the Brazilian health system vulnerabilities to face the emergency situation. In this article, we analyze data on COVID-19-related deaths in Brazil in 2020-21 to show the tragic consequences of the pandemic on the Brazilian population.

Methods

The Mortality Information System and the Live Birth Information System were the main information sources. We used the population estimates in 2020-21 to calculate COVID-19 specific mortality rates by age and sex and educational level. Considering the total number of deaths in 2020-21, the COVID-19 proportional mortality (%) was estimated for each age group and sex. A graph of the daily deaths from January 2020 to December 2021 by sex was elaborated to show the temporal evolution of COVID-19 deaths in Brazil. In addition, four indicators related to COVID-19 mortality were estimated: infant mortality rate; maternal mortality ratio (MMR); number of orphans due to mother's death; average number of years lost.

Results

The overall COVID-19 mortality rate was 14.8 (/10,000). The mortality rates increase with age and show a decreasing gradient with higher schooling. Among illiterate people, the rate was 38.8/10,000, three times higher than those with college education. Male mortality was 31% higher than female mortality. COVID-19 deaths represented 19.1% of all deaths, with the highest proportions in the median age groups. The average number of years lost due to COVID-19 was 19 years. The MMR due to COVID-19 was 35.7 per 100,000 LB, representing 37.4% of the overall MMR. Regarding the number of orphans due to COVID-19, we estimated that 40,830 children under 18 years old lost their mothers during the pandemic, with an orphans' rate of 7.5/10,000 children aged 0–17 years. The pandemic peak occurred in March 2021, reaching almost 4,000 deaths per day, higher than the average number of deaths per day from all causes in 2019.

Conclusions

The COVID-19 lethality rate in Brazil was 2.2%, twice the global lethality rate. The delay in adopting public health measures necessary to control the epidemic has exacerbated the spread of the disease, resulting in several avoidable deaths.

COVID-19

mortality

maternal mortality

number of years lost

orphanhood

pandemic denial

vaccination

From reporting the first SARS-CoV-2 infection in 2019 to the end of April 2022, around 510 million infected and 6.2 million deaths from COVID-19 have been reported globally, with a lethality rate of 1.2% [1].

The COVID-19 pandemic evolution was directly related to the emergence of “variants of concern” (VOC) of the SARS-CoV-2 virus, classified as such due to the increasing transmissibility and worsened epidemiological situation in places where they have expanded [2]. The variants Alpha (B.1.1.7), initially identified in the United Kingdom, Beta (B.1.351), discovered in South Africa, and P.1, which originated in the Brazilian state of Amazonas (Manaus), have been subject of international concern [3]. All three variants have been associated with growing transmissibility. Lineage B.1.1.7 was associated with a higher lethality rate in the United Kingdom. The Manaus variant (P.1) was 1.7 to 2.4 times more transmissible than the other lineages of the virus [4–6]. “Omicron” was identified in several countries in November 2021, including descendant lineages and the combination of both [7].

The COVID-19 pandemic brought countless challenges to public health and highlighted the vulnerabilities of the health system and the weakness of the Brazilian public policies to face the emergency situation. Testing all suspected cases was one of the international recommendations for controlling the epidemic spread [8]. However, months after the arrival of the COVID-19 pandemic in Brazil, diagnostic testing supplies in public health services were still unavailable [9, 10]. Further, the pandemic management was not in place at the national level, delegating social restriction of physical contacts and other prevention measures to state and municipal governments [11, 12]. The activities implemented by the Federal Government were focused on minimizing COVID-19 severity, setting a strategy of disseminating fake news, with the guidance of using medicines that were proven ineffective against COVID-19 [13, 14]. Moreover, it was impossible to access official mortality data neither information on incident COVID-19 cases from the Ministry of Health, leading to the establishment of a state management consortium for parallel analysis of data [15, 16].

An emblematic situation of the COVID-19 pandemic in Brazil took place in the city of Manaus, the capital of the state of Amazonas, located in the North Region. A group of researchers found that the virus evolved into the P.1 variant in mid-November 2020 [17]. With greater transmissibility, the Manaus variant spread rapidly nationwide and the likelihood of dying from COVID-19 increased shortly after the outbreak emergence of the P.1 variant. However, other factors also increased lethality, especially the health system unpreparedness to provide care for all cases in need of medical assistance [18]. In January 2021, Manaus experienced a severe health crisis, with a shortage of (mechanical) ventilators and hospital beds in Intensive Care Units (ICU), amid the dramatic lack of oxygen gas to treat people hospitalized with COVID-19 [19].

Among all these aspects, the delay in acquiring vaccines for the epidemic control stands out [15, 20]. The first vaccine (CoronaVac) was made available to healthcare professionals in January 2021. However, due to the vaccine shortage in the country, the vaccination of the Brazilian population followed slowly during the first half of 2021, scheduled by age group, and prioritizing the elderly [21]. Vaccination was started among people less than 60 years only in May 2021.

In April 2022, the Ministry of Health released official data from the 2020 Mortality Information System and the 2021 preliminary database. In this article, we analyze data on COVID-19-related deaths in Brazil in 2020-21 and use COVID-19 mortality indicators to show the impact and the tragic consequences of the pandemic on the Brazilian population.

The Mortality Information System (SIM in Portuguese) and the Live Birth Information System (Sinasc in Portuguese) were the main information sources. For population estimates, we used the projected population by the Brazilian Institute of Geography and Statistics (IBGE in Portuguese) for 2020-21, available at the site of the Department of Informatics of the Unified Health System (DATASUS), Ministry of Health [22].

In Brazil, deaths due to COVID-19 were defined as having in any line of the medical certificate the code B342 accompanied by one of the two codes U071 (confirmed by laboratory testing) or U072 (diagnosed clinically or epidemiologically but laboratory testing is inconclusive or not available).

In this study, we analyzed all deaths due to COVID-19 in Brazil reported to SIM in 2020 and 2021, according to the definition above and regardless of the classification of the underlying cause of death, such as maternal death or death from HIV/AIDS.

Analysis of deaths and mortality rates

We used the IBGE population estimates in 2020-21 to calculate COVID-19 specific mortality rates by age and sex. We estimated the average COVID-19 mortality rate per 10,000 inhabitants by the ratio between the total number of deaths and the population sum in both years (2020 and 2021) for each age group (0–9, 10–19, 20–29, 30–39, 40–49, 50–59, 60–69, 70–79, 80+) and sex.

Mortality rates due to COVID-19 were also calculated by educational level among people aged 18 years or over (Illiterate; incomplete elementary school; complete elementary school; finished high school; finished college education). Deaths with missing data on education level were proportionally distributed in all categories. We used data from the National Health Survey, 2019 [23] to estimate the population distribution by educational level.

To verify the burden of COVID-19 mortality by age and sex, we considered the total number of deaths in 2020 and 2021 and estimated the proportion (%) of COVID-19 deaths for each age group and sex.

A graph of the daily deaths from January 2020 to December 2021 by sex was elaborated to show the temporal evolution of COVID-19 deaths in Brazil.

Indicators related to COVID-19 mortality

We estimated four indicators:

Infant mortality rate due to COVID-19 (/1,000 LB): The infant mortality rate was calculated as the average number of COVID-19 deaths in children under one year of age in 2020-2021 per 1,000 live births (LB), given by the number of LB informed to Sinasc, 2020 and adjusted by the inverse of Sinasc completeness (96%) [24].
Maternal mortality ratio due to COVID-19 (/100,000 LB): Estimated by the ratio between the average number of maternal deaths from complications in pregnancy caused by COVID-19 in 2020-21 and the total number of live births in 2020, adjusted by the inverse of Sinasc estimated completeness (96%) [24].
Number of orphans (0-17 years old) resulting from the mother’s death due to COVID-19: In this analysis, orphanhood was defined by the mother's death. First, the fertility rate was estimated from 2003 to 2020 by the mother's age group using data from the Live Birth Information System (Sinasc). Secondly, the number of COVID-19 deaths among females was multiplied by the estimated fertility rate for each 5-year age-group and the number of orphans was calculated by the sum of the products between the number of females’ COVID-19 deaths and the fertility rates. Finally, we adjusted the number of orphans based on IBGE’s estimates of survival rate to reach adulthood [25]. The orphans` rate was calculated by the ratio between the estimated number of children under 18 years of age who lost their mother due to COVID-19 and the estimated population under 18 years old, 2020 [22].
Average number of years of life lost due to COVID-19: We used the complete 2020 IBGE mortality tables [25] as the source of information. The number of years lost by sex at each age was given by the life expectancy at that age (from 0 to 80+) multiplied by the number of COVID-19 deaths at the same age. The average number of years of life lost was calculated by the ratio between the sum of the number of years lost and the total number of COVID-19 deaths.

In this study, we analyzed 631,697 deaths by COVID-19, 206,460 in 2020 and 425,237 in 2021. Table 1 shows the COVID-19 mortality rates by age and sex in the two years combined. The overall mortality rate from COVID-19 was 14.8 per 10,000 population. Mortality rates increase with age, reaching 83.5 and 161.5 per 10,000 inhabitants in the age groups of 70–79 years and 80 years or over, respectively, which means more than one death by COVID-19 for every 100 individuals aged 70 or over. COVID-19 mortality rates for males were higher than for females in all age groups over 20 years. Sex ratios show that overall COVID-19 male mortality was 31% higher than female mortality and 50% higher among people aged 40 years or over.

Table 1

COVID-19 Mortality Rates (/10,000 population) by sex and age group. Brazil, 2020-21
Age-group	Mortality Rates (/10,000)			Sex Ratio
Age-group	Males	Females	Total	Sex Ratio
0–9	0.3	0.3	0.3	1.06
10–19	0.2	0.2	0.2	0.89
20–29	1.3	1.2	1.2	1.11
30–39	5.0	3.3	4.2	1.49
40–49	12.3	7.7	10.0	1.59
50–59	26.6	17.0	21.6	1.56
60–69	52.6	34.6	43.0	1.52
70–79	107.8	64.7	83.5	1.67
80+	213.8	130.2	161.5	1.64
Total	16.9	12.9	14.8	1.31
Information sources: 1 - Mortality Information System (SIM), Division of Health Surveillance, Ministry of Health. 2 - DATASUS. Projection of the population of Brazil by sex and age for the period 2000–2060. Brazil [22].

The COVID-19 mortality rates by educational level among people aged 18 years or over show a decreasing gradient with higher schooling. Among illiterate people, the rate was 38.8 per 10,000 inhabitants, three times higher than those with college education (Table 2).

Table 2

COVID-19 Mortality Rates (/10,000 population) by educational level among people aged 18 years or over. Brazil, 2020-21
Educational Level	Mortality Rate (/10,000)
Illiterate	38.8
Incomplete elementary school	23.2
Complete elementary school	25.0
Finished high school	14.4
Finished college education	13.0
Total	19.8
Information sources: 1 - Mortality Information System (SIM), Division of Health Surveillance, Ministry of Health. 2 - National Health Survey, 2019.

Regarding the proportional mortality (%) by age group and sex, the highest proportions were found among men and women aged 40–49 and 50–59 years. Deaths due to COVID-19 in 2020-21 represent 19.1% of all deaths and correspond to 14.4% among the oldest (80 years or over) for both males and females. Those proportions indicate that the median age groups were more affected than the extreme categories (Table 3).

Table 3

COVID-19 Proportional Mortality (%) by sex and age group. Brazil, 2020-21
Age-group	Proportional Mortality (%)
Age-group	Males	Females	Total
0–9	2.0	2.3	2.1
10–19	2.3	7.4	3.6
20–29	5.3	16.7	7.9
30–39	16.6	24.6	19.1
40–49	23.0	26.3	24.2
50–59	23.7	26.7	24.9
60–69	22.3	24.5	23.2
70–79	21.2	20.2	20.8
80+	16.4	12.9	14.4
Total	19.1	19.0	19.1
Information sources: 1 - Mortality Information System (SIM), Division of Health Surveillance, Ministry of Health.

The daily time series of COVID-19 deaths in Brazil from January 2020 to December 2021 are shown in Fig. 1. The first pandemic wave occurred in the first months of 2020 and reached more than 1,000 daily deaths in May 2020. The first wave was followed by a slight decrease until November 2020, with the country’s onset of the second COVID-19 wave. The pandemic peaked at the end of March 2021, reaching almost 4,000 deaths per day, decreasing again to the level of 1,000 deaths only in July of the same year. In the second half of 2021, a significant decrease in deaths was observed, reaching less than 100 daily deaths at the end of the year. The time trends by sex were the same as the total number of deaths. The number of deaths among men was always higher than those among women, nearing each other, however, at the pandemic peak.

As for the indicators related to COVID-19 mortality (Table 4), total infant mortality was 11.7 per 1,000 live births (LB), with 0.2 per 1,000 LB caused by COVID-19. The maternal mortality ratio (MMR) was much more affected. The overall estimate of the MMR was 95.5 per 100,000 LB, while the MMR due to COVID-19 was 35.7 per 100,000 LB, representing 37.4% of the total MMR. Considering the number of years lost among people who died from COVID-19, the average was 18.8 years overall, 18.1 for males and 19.8 for females. Regarding the number of orphans resulting from the mother's death due to COVID-19, we estimated that 40,830 children under 18 years old lost their mothers during the pandemic, with an orphans' rate of 7.5/10,000 children aged 0–17 years.

Table 4

Selected indicators related to COVID-19 mortality. Brazil, 2020-21
Indicator	Category	Estimate
Infant Mortality Rate (/1,000 LB)	By COVID-19	0.2
	Due to other causes	11.5
	Total	11.7
Maternal Mortality Ratio (/100,000 LB)	By COVID-19	35.7
	Due to other causes	59.7
	Total	95.5
Average number of years lost (y)	Males	18.1
	Females	19.8
	Total	18.8
Orphanhood due to mother's death by COVID-19	Orphans' rate (/10,000 children < 18y)	7.5
Orphanhood due to mother's death by COVID-19	Number of orphans	40,830
Legend: LB = live births; y = years.

By the end of 2021, Brazil had registered around 30 million cases and more than 630 thousand deaths by COVID-19, with a lethality rate of 2.2%, twice the global lethality rate of the disease [21].

The country of 212 million inhabitants (3% of the global population) reached almost 4,000 deaths/day at the end of March 2021, the peak of the second COVID-19 wave that started in November 2020. This daily number of COVID-19 deaths was higher than the average number of deaths per day from all causes in 2019, around 3,700 deaths/day. The epidemic spread in late 2020 occurred after the introduction of the Manaus variant (P.1) with higher transmissibility [17]. The continuity of air travels between Manaus and the rest of Brazil, crowding events at the end of the year, such as Christmas and New Year's Eve parties, and the lack of a national coordination in implementing social distancing measures have contributed to the rapid spread of cases. In turn, inadequate management of the COVID-19 pandemic caused an unprecedented crisis in Brazilian health. The unavailability of equipment, inpatient beds, places in ICUs, and health care teams to meet emergency health needs has undoubtedly aggravated the COVID-19 lethality in the country [26–28].

In this study, the results stratified by educational level showed higher mortality rates among less educated people. A possible explanatory hypothesis is that individuals with lower educational levels, generally working outside the home and unable to stop working during the pandemic, became more exposed to COVID-19 infection [29]. Additionally, the urban population of low socioeconomic status is concentrated in slum communities in the large Brazilian metropolises, preventing compliance with social distancing measures and isolation of cases diagnosed with COVID-19 [30]. On the other hand, differences in mortality rates by educational level, with the mortality rate at the lowest educational level three times greater than at the highest level, reflect the uneven impact of the pandemic on Brazilian socially disadvantaged families [31]. As have been discussed before, the population with lower education and income has less access to health services and a greater number of comorbidities, increasing vulnerability to COVID-19 [32].

The results of this study emphasized the impact of the pandemic on the mortality among people aged 40–59 years. The highest proportions of COVID-19 deaths were found in the median age groups, and the average number of years lost due to COVID-19 was approximately 19 years of life. One of the explanatory factors for the more significant burden of deaths in the non-elderly Brazilian population was the delayed vaccination of this population group. The peak of deaths at the end of March 2021 occurred in a stage of high SARS-CoV-2 infection transmissibility when the population under 60 years of age had not yet been vaccinated [21].

From a social viewpoint, the distribution of infection exposure is unequal by socioeconomic level, regarding not only working outside the home and use of public transportation but also prevention behaviors [33]. In Brazil, most individuals in the working-age range continued to perform work activities outside the home [34], resulting in greater exposure to the virus and leading to a disproportionate increase in deaths in the economically active population.

A study carried out in the state of Amazonas analyzed the mortality profile before and after the emergence of the P.1 variant in the state of Amazonas. Like our findings, the comparison of the two epidemiological periods, April/May 2020 and January 2021, the month when the new variant started to predominate, showed a higher incidence of COVID-19 cases in the younger age groups. An increase was also found in the proportion of women among severe acute respiratory infection cases. The proportion of deaths among people aged 20–59 years increased for both males and females, and the lethality rate among those aged 20–39 years during the second wave was 2.7 times higher than the rate observed in the first wave [17].

Another aspect of young women’s mortality was the increase in the number of maternal deaths due to pregnancy complications caused by COVID-19. Our study evidenced an over-mortality from COVID-19 of 37% in relation to the maternal mortality from other causes. The MMR in Brazil, which was already high – 62.1/100,000 LB in 2019 [35], reached a value close to 1 per 1,000 live births after adding COVID-19 maternal deaths.

In this study, we estimated that 7.5 out of every 10,000 children under 18 years old lost their mother during the pandemic, totaling about 40,830 orphans due to COVID-19. Our result is similar to that found in the study by Unwin et al. [36], who compared COVID-19 orphans' estimates in several countries. The findings showed that the orphans' rate in Brazil was the 6th highest among the countries considered in the study. Furthermore, the number of orphans by one or both parents has been estimated in Brazil at approximately 170,000 children under 18 years of age [36]. Admittedly, the death of a parent, particularly the mother, is linked to adverse outcomes throughout life and has severe consequences for the family's well-being, profoundly affecting the family structure and dynamics [37]. The experience of the HIV/AIDS epidemic has shown that orphaned children are particularly vulnerable in terms of emotional and behavioral problems, requiring intervention programs to improve the psychological sequelae of losing a parent [38].

The COVID-19 pandemic has had negative impacts globally, some with more dramatic consequences than others. Among the lessons learned, disease denial has undoubtedly influenced the performance of national health systems in mitigating the harmful impact of the COVID-19 pandemic. In Brazil [39] as in other countries [40–42], the lack of information on incident cases and deaths by COVID-19 and the delay in adopting the public health measures necessary to control the epidemic has exacerbated the spread of the disease, resulting in avoidable losses of human lives. Denial in some countries leads critically ill patients with severe health risks to a state of abandonment, with no possibility of receiving medical care [41].

From an individual perspective, skepticism towards COVID-19 can be conceptualized as the denial of the disease's severity and the perception that the pandemic is exaggerated or a hoax. In a study carried out in the United States, skepticism was strongly associated with a reduction in prevention behaviors [43]. As it is a highly transmissible infection, individual freedom to adopt prevention behaviors has been widely discussed since the individual option can harm others or society in general [44].

A limitation of this study is that we used preliminary mortality data from 2021, which will still undergo a process of improving the quality of the cause of death. Possibly with less impact on COVID-19 mortality because a surveillance alert process for timely notification deaths by COVID-19 has been implemented in Brazil since May 2020 [45].

At the beginning of 2021, Brazil woke up to the urgent need to vaccinate the population as a strategy to control the pandemic. The national production of large-scale vaccines for COVID-19 from imported active pharmaceutical ingredients (API) began in the first months of 2021. The acquisition of imported vaccines, alongside the gradual increase in national production and the distribution of the vaccine in the primary health care (PHC) units of the Unified Health System (SUS) have contributed enormously to the mass vaccination of the Brazilian population. The percentage of the people with one dose of vaccine is 83.2%, the percentage of complete immunization (2 doses) is 76.9%, and 42.0% have a booster dose. Additionally, the vaccine technology was internalized, and the first doses of the fully nationalized vaccine were delivered in February 2022.

After the COVID-19 toll over the Brazilian population and the subsequent sadness and grief over the loss of family and friends, the worsening of socioeconomic conditions, the stressful situations, and the distance from loved ones, it is time to rebuild. It takes courage to overcome new challenges, smile again, enjoy the freedom to come and go, embrace others, and value life.

Since the beginning of the pandemic, Brazil has reported around 30 million cases and more than 630 thousand deaths by COVID-19, with a lethality rate of 2.2%, twice the global lethality rate. The disease denial has undoubtedly influenced the performance of the national health system in mitigating the harmful impact of the COVID-19 pandemic in Brazil, especially the unpreparedness to provide care for all cases in need of medical assistance. The subsequent delay in adopting the public health measures necessary to control the epidemic has exacerbated the spread of the disease, resulting in several avoidable deaths.

COVID-19: Coronavirus Disease 2019; SARS-CoV-2: Severe Acute Respiratory Syndrome Coronavirus 2; VOC: Variants of Concern; ICU: Intensive Care Units; SIM: Brazilian Mortality Information System; Sinasc: Brazilian Live Birth Information System; IBGE: Brazilian Institute of Geography and Statistics; DATASUS: Department of Informatics of the Brazilian Unified Health System; HIV: Human Immunodeficiency Virus; AIDS: Acquired Immunodeficiency Syndrome; LB: Live Births; MMR: Maternal Mortality Ratio; API: Active Pharmaceutical Ingredients; PHC: Primary Health Care; SUS: Brazilian Unified Health System.

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Availability of data and materials

Not applicable

Competing interests

The authors declare that they have no competing interests

Funding

Bill & Melinda Gates Foundation and Nacional Council for Scientific and Technological Development (CNPq) [Grant ID INV 027961]

FIOCRUZ program to foster innovation – Knowledge generation – Coping with the COVID-19 pandemic and post-pandemic – Strategic orders [VPPCB-005-FIO-20-2-23]

Authors' contributions

CLS and CSB wrote the main text of the manuscript. CLS, WSA and AMSF analyzed the data. CSB and DCM collaborated in the discussion of the results. All authors reviewed the final version of the manuscript.

Acknowledgements

Not applicable

World Health Organization (WHO). WHO Coronavirus (COVID-19). Dashboard. 2022. https://covid19.who.int/. Accessed 2 May 2022.
Mukherjee S, Ray SK. A new wave of COVID-19 in 2021 with unique genetic characters -present global scenario and beholding onwards. Infect Disord Drug Targets. 2022.
Hirabara SM, Serdan TDA, Gorjao R, Masi LN, Pithon-Curi TC, Covas DT, Curi R, Durigon EL. SARS-COV-2 Variants: Differences and Potential of Immune Evasion. Front Cell Infect Microbiol. 2022;11:781429.
Zimerman RA, Ferrareze PAG, Cadegiani FA, Wambier CG, Fonseca DDN, de Souza AR, Goren A, Rotta LN, Ren Z, Thompson CE. Comparative Genomics and Characterization of SARS-CoV-2 P.1 (Gamma) Variant of Concern From Amazonas, Brazil. Front Med (Lausanne). 2022;9:806611.
Giovanetti M, Fonseca V, Wilkinson E, Tegally H, San EJ, Althaus CL, Xavier J, Nanev Slavov S, Viala VL, Ranieri Jerônimo Lima A, Ribeiro G, Souza-Neto JA, Fukumasu H, Lehmann Coutinho L, Venancio da Cunha R, Freitas C, Campelo de A E Melo CF, Navegantes de Araújo W, Do Carmo Said RF, Almiron M, de Oliveira T, Coccuzzo Sampaio S, Elias MC, Covas DT, Holmes EC, Lourenço J, Kashima S, de Alcantara LCJ. Replacement of the Gamma by the Delta variant in Brazil: Impact of lineage displacement on the ongoing pandemic. Virus Evol. 2022;8(1):veac024.
Wink PL, Ramalho R, Monteiro FL, Volpato FCZ, Willig JB, Lovison OVA, Zavascki AP, Barth AL, Martins AF. Genomic Surveillance of SARS-CoV-2 Lineages Indicates Early Circulation of P.1 (Gamma) Variant of Concern in Southern Brazil. Microbiol Spectr. 2022;10(1):e0151121.
World Health Organization (WHO). Tracking SARS-CoV-2 variants. 2022b. https://www.who.int/en/activities/tracking-SARS-CoV-2-variants. Accessed 2 May 2022.
Li R, Pei S, Chen B, Song Y, Zhang T, Yang W, Shaman J. Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV-2). Science. 2020;368(6490):489-493.
Prado MFD, Antunes BBP, Bastos LDSL, Peres IT, Silva AABD, Dantas LF, Baião FA, Maçaira P, Hamacher S, Bozza FA. Analysis of COVID-19 under-reporting in Brazil. Rev Bras Ter Intensiva. 2020;32(2):224-228.
Reis RF, de Melo Quintela B, de Oliveira Campos J, Gomes JM, Rocha BM, Lobosco M, Weber Dos Santos R. Characterization of the COVID-19 pandemic and the impact of uncertainties, mitigation strategies, and underreporting of cases in South Korea, Italy, and Brazil. Chaos Solitons Fractals. 2020;136:109888.
Leite SN, Finkler M, Martini JG, Heidemann I, Verdi M, Hellmann F, Vásquez MF. Management of the health workforce in facing COVID-19: disinformation and absences in Brazil's Public Policies. Cien Saude Colet. 2021;26(5):1873-1884.
Freitas VLS, Moreira GJP, Santos LBL. Robustness analysis in an inter-cities mobility network: modeling municipal, state and federal initiatives as failures and attacks toward SARS-CoV-2 containment. PeerJ. 2020;8:e10287.
Taylor L. Covid-19: Trial of experimental "covid cure" is among worst medical ethics violations in Brazil's history, says regulator. BMJ. 2021;375:n2819.
Falavigna M, Belli KC, Barbosa AN, Zavascki AP, Nastri ACSS, Santana CM, Stein C, Gräf DD, Cadegiani FA, Guimarães HP, Monteiro JT, Ferreira JC, de Azevedo LCP, Magri MMC, Sobreira ML, Dias MBGS, de Oliveira MS, Corradi MFDB, Rosa R, Heinzelmann RS, da Silva RM, Junior RB, Cimerman S, Colpani V, Veiga VC, de Carvalho CRR. Brazilian guidelines for the treatment of outpatients with suspected or confirmed COVID-19. A joint guideline of the Brazilian Association of Emergency Medicine (ABRAMEDE), Brazilian Medical Association (AMB), Brazilian Society of Angiology and Vascular Surgery (SBACV), Brazilian Society of Geriatrics and Gerontology (SBGG), Brazilian Society of Infectious Diseases (SBI), Brazilian Society of Family and Community Medicine (SBFMC), and Brazilian Thoracic Society (SBPT). Braz J Infect Dis. 2022;26(2):102347.
Xavier DR, Lima E Silva E, Lara FA, E Silva GRR, Oliveira MF, Gurgel H, Barcellos C. Involvement of political and socio-economic factors in the spatial and temporal dynamics of COVID-19 outcomes in Brazil: A population-based study. Lancet Reg Health Am. 2022;100221.
Taylor L. Covid-19: Brazil sees omicron cases soar but data blackout obscures true impact. BMJ. 2022;376:o133.
Freitas ARR, Beckedorff OA, Cavalcanti LPG, Siqueira AM, Castro DB, Costa CFD, Lemos DRQ, Barros ENC. The emergence of novel SARS-CoV-2 variant P.1 in Amazonas (Brazil) was temporally associated with a change in the age and sex profile of COVID-19 mortality: A population based ecological study. Lancet Reg Health Am. 2021;1:100021.
Souza PMM, Gerson G, Soares CEL, Souza SG, Dias JS, Melo DN, Ruiz EM, Tavora F, Cavalcanti LPG. COVID-19 Home Deaths without Medical Assistance in Northeastern Brazil. Am J Trop Med Hyg. 2020;104(2):514-518.
Buss LF, Prete CA Jr, Abrahim CMM, Mendrone A Jr, Salomon T, de Almeida-Neto C, França RFO, Belotti MC, Carvalho MPSS, Costa AG, Crispim MAE, Ferreira SC, Fraiji NA, Gurzenda S, Whittaker C, Kamaura LT, Takecian PL, da Silva Peixoto P, Oikawa MK, Nishiya AS, Rocha V, Salles NA, de Souza Santos AA, da Silva MA, Custer B, Parag KV, Barral-Netto M, Kraemer MUG, Pereira RHM, Pybus OG, Busch MP, Castro MC, Dye C, Nascimento VH, Faria NR, Sabino EC. Three-quarters attack rate of SARS-CoV-2 in the Brazilian Amazon during a largely unmitigated epidemic. Science. 2021;371(6526):288-292.
Malta M, Vettore MV, da Silva CMFP, Silva AB, Strathdee SA. The foreseen loss of the battle against COVID-19 in South America: A foretold tragedy. EClinicalMedicine. 2021;39:101068.
Instituto de Comunicação e Informação Científica e Tecnológica em Saúde (ICICT). Fundação Oswaldo Cruz, Ministério da Saúde. MonitoraCOVID-19. 2022. https://bigdata-covid19.icict.fiocruz.br/. Accessed 2 May 2022.
DATASUS. Informações de saúde. População residente-estudo de estimativas populacionais por município, idade e sexo 2000-2021. Brasil. 2022. http://tabnet.datasus.gov.br/cgi/deftohtm.exe?popsvs/cnv/popbr.def. Accessed 2 May 2022.
Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, Sardinha LMV, Macário EM. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saude. 2020;29(5):e2020315.
Leal MDC, Szwarcwald CL, Almeida PVB, Aquino EML, Barreto ML, Barros F, Victora C. Reproductive, maternal, neonatal and child health in the 30 years since the creation of the Unified Health System (SUS). Cien Saude Colet. 2018;23(6):1915-1928.
Instituto Brasileiro de Geografia e Estatística (IBGE). Tábuas de Mortalidade 2010/2060. Projeções da População do Brasil e Unidades da Federação por sexo e idade: 2010-2060. 2018. https://www.ibge.gov.br/estatisticas/sociais/populacao/9109-projecao-da-populacao.html?=&t=resultados. Accessed 2 May 2022.
Silva LL, de Carvalho Dutra A, de Andrade L, Iora PH, Rodrigues Ramajo GL, Peres Gualda IA, Costa Scheidt JFH, Vasconcelos Maia do Amaral P, Hernandes Rocha TA, Staton CA, Nickenig Vissoci JR, Fressatti Cardoso R. Emergency Care Gap in Brazil: Geographical Accessibility as a Proxy of Response Capacity to Tackle COVID-19. Front Public Health. 2021;9:740284.
Boschiero MN, Palamim CVC, Ortega MM, Mauch RM, Marson FAL. One Year of Coronavirus Disease 2019 (COVID-19) in Brazil: A Political and Social Overview. Ann Glob Health. 2021;87(1):44.
Brizzi A, Whittaker C, Servo LMS, Hawryluk I, Prete CA Jr, de Souza WM, Aguiar RS, Araujo LJT, Bastos LS, Blenkinsop A, Buss LF, Candido D, Castro MC, Costa SF, Croda J, de Souza Santos AA, Dye C, Flaxman S, Fonseca PLC, Geddes VEV, Gutierrez B, Lemey P, Levin AS, Mellan T, Bonfim DM, Miscouridou X, Mishra S, Monod M, Moreira FRR, Nelson B, Pereira RHM, Ranzani O, Schnekenberg RP, Semenova E, Sonnabend R, Souza RP, Xi X, Sabino EC, Faria NR, Bhatt S, Ratmann O. Spatial and temporal fluctuations in COVID-19 fatality rates in Brazilian hospitals. Nat Med. 2022.
Almeida WDS, Szwarcwald CL, Malta DC, Barros MBA, Souza Júnior PRB, Azevedo LO, Romero D, Lima MG, Damacena GN, Machado ÍE, Gomes CS, Pina MF, Gracie R, Werneck AO, Silva DRPD. Changes in Brazilians' socioeconomic and health conditions during the COVID-19 pandemic. Rev Bras Epidemiol. 2021;23:e200105.
Aquino EML, Silveira IH, Pescarini JM, Aquino R, Souza-Filho JA, Rocha AS, Ferreira A, Victor A, Teixeira C, Machado DB, Paixão E, Alves FJO, Pilecco F, Menezes G, Gabrielli L, Leite L, Almeida MCC, Ortelan N, Fernandes QHRF, Ortiz RJF, Palmeira RN, Junior EPP, Aragão E, Souza LEPF, Netto MB, Teixeira MG, Barreto ML, Ichihara MY, Lima RTRS. Social distancing measures to control the COVID-19 pandemic: potential impacts and challenges in Brazil. Cien Saude Colet. 2020;25(suppl 1):2423-2446.
Ribeiro F, Leist A. Who is going to pay the price of Covid-19? Reflections about an unequal Brazil. Int J Equity Health. 2020;19(1):91.
Malta DC, Gomes CS, Silva AGD, Cardoso LSM, Barros MBA, Lima MG, Souza Junior PRB, Szwarcwald CL. Use of health services and adherence to social distancing by adults with Noncommunicable Diseases during the COVID-19 pandemic, Brazil, 2020. Cien Saude Colet. 2021;26(7):2833-2842.
Gosselin A, Warszawski J, Bajos N; EpiCov Study Group. Higher risk, higher protection. COVID-19 risk among immigrants in France: results from the population-based EpiCov survey. Eur J Public Health. 2022:ckac046.
Szwarcwald CL, Souza Júnior PRB, Malta DC, Barros MBA, Magalhães MAFM, Xavier DR, Saldanha RF, Damacena GN, Azevedo LO, Lima MG, Romero D, Machado ÍE, Gomes CS, Werneck AO, Silva DRPD, Gracie R, Pina MF. Adherence to physical contact restriction measures and the spread of COVID-19 in Brazil. Epidemiol Serv Saude. 2020;29(5):e2020432.
Leal LF, Malta DC, Souza MFM, Vasconcelos AMN, Teixeira RA, Veloso GA, Lansky S, Ribeiro ALP, França GVA, Naghavi M. Maternal Mortality in Brazil, 1990 to 2019: a systematic analysis of the Global Burden of Disease Study 2019. Rev Soc Bras Med Trop. 2022;55(suppl 1):e0279.
Unwin HJT, Hillis S, Cluver L, Flaxman S, Goldman PS, Butchart A, Bachman G, Rawlings L, Donnelly CA, Ratmann O, Green P, Nelson CA, Blenkinsop A, Bhatt S, Desmond C, Villaveces A, Sherr L. Global, regional, and national minimum estimates of children affected by COVID-19-associated orphanhood and caregiver death, by age and family circumstance up to Oct 31, 2021: an updated modelling study. Lancet Child Adolesc Health. 2022;6(4):249-259.
Schacht R, Meeks H, Fraser A, Smith KR. Was Cinderella just a fairy tale? Survival differences between stepchildren and their half-siblings. Philos Trans R Soc Lond B Biol Sci. 2021;376(1827):20200032.
Cluver L, Gardner F, Operario D. Psychological distress amongst AIDS-orphaned children in urban South Africa. J Child Psychol Psychiatry. 2007;48(8):755-63.
Malta M, Vettore MV, da Silva CMFP, Silva AB, Strathdee SA. Political neglect of COVID-19 and the public health consequences in Brazil: The high costs of science denial. EClinicalMedicine. 2021;35:100878.
Solomon S, Rostellato D, Testoni I, Calabrese F, Biasco G. Journalistic Denial of Death during the Very First Traumatic Period of the Italian COVID-19 Pandemic. Behav Sci (Basel). 2021;11(3):41.
Hashim HT, El Rassoul AEA, Bchara J, Ahmadi A, Lucero-Prisno DE 3rd. COVID-19 denial in Turkmenistan veiling the real situation. Arch Public Health. 2022 Jan 4;80(1):8.
Villa S, Lombardi A, Mangioni D, Bozzi G, Bandera A, Gori A, Raviglione MC. The COVID-19 pandemic preparedness ... or lack thereof: from China to Italy. Glob Health Med. 2020;2(2):73-77.
Latkin CA, Dayton L, Moran M, Strickland JC, Collins K. Behavioral and psychosocial factors associated with COVID-19 skepticism in the United States. Curr Psychol. 2021;1-9.
Dobson GP. Wired to Doubt: Why People Fear Vaccines and Climate Change and Mistrust Science. Front Med (Lausanne). 2022;8:809395.
Brasil. Ministério da Saúde / Secretaria de Vigilância em Saúde. Orientações para codificação das causas de morte no contexto da COVID-19. 2020. http://plataforma.saude.gov.br/cta-br-fic/codificacao-Covid-19.pdf. Accessed 11 May 2022.

No competing interests reported.

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Editorial decision: Major revision
21 Nov, 2022
Reviews received at journal
14 Jun, 2022
Reviewers agreed at journal
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Reviewers invited by journal
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COVID-19 Mortality in Brazil, 2020-21: Consequences of the pandemic inadequate management

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Background

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Analysis of deaths and mortality rates

Indicators related to COVID-19 mortality

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Version 2