Epidemiological profile and risk factors associated with death in patients receiving invasive mechanical ventilation in an adult intensive care unit from Brazil: a retrospective study.

Introduction: Understanding the epidemiological profile and risk factors associated with invasive mechanical ventilation (IMV) is essential to manage the patients better and to improve health services. Therefore, our objective was to describe the epidemiological profile of adult patients in intensive care that required IMV in-hospital treatment. Also, to evaluate the risks associated with death and the influence of positive end-expiratory pressure (PEEP) and arterial oxygen pressure (PaO2) at admission in the clinical outcome. Methods: We conducted an epidemiological study analyzing medical records of inpatients who received IMV from January 2016 to December 2019 prior to the Coronavirus Disease (COVID)-19 pandemic in Brazil. We considered the following characteristics in the statistical analysis: demographic data, diagnostic hypothesis, hospitalization data, and PEEP and PaO2 during IMV. We associated the patients' features with the risk of death using a multivariate binary logistic regression analysis. We adopted an alpha error of 0.05. Results: We analyzed 1,443 medical records; out of those, 570 (39.5%) recorded the patients' deaths. The binary logistic regression was significant in predicting the patients' risk of death [X2(9) = 288.335; p < 0.001]. Among predictors, the most significant in relation to death risk were: age [elderly ≥65 years old; OR = 2.226 (95%CI = 1.728-2.867)]; male sex (OR = 0.754; 95%CI = 0.593-0.959); sepsis diagnosis (OR = 1.961; 95%CI = 1.481-2.595); need for elective surgery (OR = 0.469; 95%CI = 0.362-0.608); the presence of cerebrovascular accident (OR = 2.304; 95%CI = 1.502-3.534); time of hospital care (OR = 0.946; 95%CI = 0.935-0.956); hypoxemia at admission (OR = 1.635; 95%CI = 1.024-2.611), and PEEP >8 cmH2O at admission (OR = 2.153; 95%CI = 1.426-3.250). Conclusion: The death rate of the studied intensive care unit was equivalent to that of other similar units. Regarding risk predictors, several demographic and clinical characteristics were associated with enhanced mortality in intensive care unit patients under mechanical ventilation, such as diabetes mellitus, systemic arterial hypertension, and older age. The PEEP >8 cmH2O at admission was also associated with increased mortality since this value is a marker of initially severe hypoxia.

Hospitalized patients with X-linked disease and infected with SARS-CoV-2 in Brazil: a serial case report from the first two years of the pandemic

We described the characteristics of 18 patients with coronavirus disease (COVID)-19 and X-linked disorders in a cohort of 2,066,678 Brazilian patients hospitalized due to COVID-19. The patients were diagnosed with Hemophilia B (one patient), Klinefelter syndrome [eight patients– three deaths occurred, one unrelated to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection], and Turner syndrome (nine patients– two patients died). Half of the patients with X-linked disorders and COVID-19 (9/18) were male, the age varied from 1 to 71 years, and most patients were White (9/12;six patients had missing data). The most common symptoms were cough (13/17;one patient had missing data) and fever (12/16;two patients had missing data), whereas the most common comorbidities were diabetes mellitus (3/11;seven patients had missing data) and cardiopathy (2/12;six patients had missing data). Nearly half of the patients needed intensive care unit (8/17;one patient had missing data), and a quarter required invasive mechanical ventilation (4/16;two patients had missing data). Our study accounted for a total of five deaths, one unrelated to COVID-19. There may be several reasons for the low number of X-linked patients found in our data, such as limited access to genetic diagnosis tools causing underdiagnosis and a lack of knowledge by health professionals to identify the necessity of a genetic diagnosis or even forgetting to fill in the Brazilian database for hospitalization due to severe acute respiratory syndrome.

Epidemiologic Profile of Severe Acute Respiratory Infection in Brazil During the COVID-19 Pandemic: An Epidemiological Study.

Background: The COVID-19 is a significant public health issue, and monitoring confirmed cases and deaths is an essential epidemiologic tool. We evaluated the features in Brazilian hospitalized patients due to severe acute respiratory infection (SARI) during the COVID-19 pandemic in Brazil. We grouped the patients into the following categories: Influenza virus infection (G1), other respiratory viruses' infection (G2), other known etiologic agents (G3), SARS-CoV-2 infection (patients with COVID-19, G4), and undefined etiological agent (G5). Methods: We performed an epidemiological study using data from DataSUS (https://opendatasus.saude.gov.br/) from December 2019 to October 2021. The dataset included Brazilian hospitalized patients due to SARI. We considered the clinical evolution of the patients with SARI during the COVID-19 pandemic according to the SARI patient groups as the outcome. We performed the multivariate statistical analysis using logistic regression, and we adopted an Alpha error of 0.05. Results: A total of 2,740,272 patients were hospitalized due to SARI in Brazil, being the São Paulo state responsible for most of the cases [802,367 (29.3%)]. Most of the patients were male (1,495,416; 54.6%), aged between 25 and 60 years (1,269,398; 46.3%), and were White (1,105,123; 49.8%). A total of 1,577,279 (68.3%) patients recovered from SARI, whereas 701,607 (30.4%) died due to SARI, and 30,551 (1.3%) did not have their deaths related to SARI. A major part of the patients was grouped in G4 (1,817,098; 66.3%) and G5 (896,207; 32.7%). The other groups account for <1% of our sample [G1: 3,474 (0.1%), G2: 16,627 (0.6%), and G3: 6,866 (0.3%)]. The deaths related to SARI were more frequent in G4 (574,887; 34.7%); however, the deaths not related to SARI were more frequent among the patients categorized into the G3 (1,339; 21.3%) and G5 (25,829; 4.1%). In the multivariate analysis, the main predictors to classify the patients in the G5 when compared with G4 or G1-G4 were female sex, younger age, Black race, low educational level, rural place of residence, and the use of antiviral to treat the clinical signs. Furthermore, several features predict the risk of death by SARI, such as older age, race (Black, Indigenous, and multiracial background), low educational level, residence in a flu outbreak region, need for intensive care unit, and need for mechanical ventilatory support. Conclusions: The possible COVID-19 underreporting (G5) might be associated with an enhanced mortality rate, more evident in distinct social groups. In addition, the patients' features are unequal between the patients' groups and can be used to determine the risk of possible COVID-19 underreporting in our population. Patients with a higher risk of death had a different epidemiological profile when compared with patients who recovered from SARI, like older age, Black, Indigenous, and multiracial background races, low educational level, residence in a flu outbreak region, need for intensive care unit and need for mechanical ventilatory support.

Characterization of Clinical Features of Hospitalized Patients Due to the SARS-CoV-2 Infection in the Absence of Comorbidities Regarding the Sex: An Epidemiological Study of the First Year of the Pandemic in Brazil.

The male sex, due to the presence of genetic, immunological, hormonal, social, and environmental factors, is associated with higher severity and death in Coronavirus Disease (COVID)-19. We conducted an epidemiological study to characterize the COVID-19 clinical profile, severity, and outcome according to sex in patients with the severe acute respiratory syndrome (SARS) due to the fact of this disease. We carried out an epidemiological analysis using epidemiological data made available by the OpenDataSUS, which stores information about SARS in Brazil. We recorded the features of the patients admitted to the hospital for SARS treatment due to the presence of COVID-19 (in the absence of comorbidities) and associated these characteristics with sex and risk of death. The study comprised 336,463 patients, 213,151 of whom were men. Male patients presented a higher number of clinical signs, for example, fever (OR = 1.424; 95%CI = 1.399-1.448), peripheral arterial oxygen saturation (SpO2) < 95% (OR = 1.253; 95%CI = 1.232-1.274), and dyspnea (OR = 1.146; 95%CI = 1.125-1.166) as well as greater need for admission in intensive care unit (ICU, OR = 1.189; 95%CI = 1.168-1.210), and the use of invasive ventilatory support (OR = 1.306; 95%CI = 1.273-1.339) and noninvasive ventilatory support (OR = 1.238; 95%CI = 1.216-1.260) when compared with female patients. Curiously, the male sex was associated only with a small increase in the risk of death when compared with the female sex (OR = 1.041; 95%CI = 1.023-1.060). We did a secondary analysis to identify the main predictors of death. In that sense, the multivariate analysis enabled the prediction of the risk of death, and the male sex was one of the predictors (OR = 1.101; 95%CI = 1.011-1.199); however, with a small effect size. In addition, other factors also contributed to this prediction and presented a great effect size, they are listed below: older age (61-72 years old (OR = 15.778; 95%CI = 1.865-133.492), 73-85 years old (OR = 31.978; 95%CI = 3.779-270.600), and +85 years old (OR = 68.385; 95%CI = 8.164-589.705)); race (Black (OR = 1.247; 95%CI = 1.016-1.531), Pardos (multiracial background; OR = 1.585; 95%CI = 1.450-1.732), and Indigenous (OR = 3.186; 95%CI = 1.927-5.266)); clinical signs (for instance, dyspnea (OR = 1.231; 95%CI = 1.110-1.365) and SpO2 < 95% (OR = 1.367; 95%CI = 1.238-1.508)); need for admission in the ICU (OR = 3.069; 95%CI = 2.789-3.377); and for ventilatory support (invasive (OR = 10.174; 95%CI = 8.803-11.759) and noninvasive (OR = 1.609; 95%CI = 1.438-1.800)). In conclusion, in Brazil, male patients tend to present the phenotype of higher severity in COVID-19, however, with a small effect on the risk of death.

Clinical characteristics and comorbidities of COVID-19 in unvaccinated patients with Down syndrome: first year report in Brazil.

Patients with Down syndrome (DS) are more affected by the Coronavirus Disease (COVID)-19 pandemic when compared with other populations. Therefore, the primary aim of our study was to report the death (case fatality rate) from SARS-CoV-2 infection in Brazilian hospitalized patients with DS from 03 January 2020 to 04 April 2021. The secondary objectives were (i) to compare the features of patients with DS and positive for COVID-19 (G1) to those with DS and with a severe acute respiratory infection (SARI) from other etiological factors (G2) to tease apart the unique influence of COVID-19, and (ii) to compare the features of patients with DS and positive for COVID-19 to those without DS, but positive for COVID-19 (G3) to tease apart the unique influence of DS. We obtained the markers for demographic profile, clinical symptoms, comorbidities, and the clinical features for SARI evolution during hospitalization in the first year of the COVID-19 pandemic in Brazil from a Brazilian open-access database. The data were compared between (i) G1 [1619 (0.4%) patients] and G2 [1431 (0.4%) patients]; and between (ii) G1 and G3 [222,181 (64.8%) patients]. The case fatality rate was higher in patients with DS and COVID-19 (G1: 39.2%), followed by individuals from G2 (18.1%) and G3 (14.0%). Patients from G1, when compared to G2, were older (≥ 25 years of age), presented more clinical symptoms related to severe illness and comorbidities, needed intensive care unit (ICU) treatment and non-invasive mechanical ventilation (MV) more frequently, and presented a nearly two fold-increased chance of death (OR = 2.92 [95% CI 2.44-3.50]). Patients from G1, when compared to G3, were younger (< 24 years of age), more prone to nosocomial infection, presented an increased chance for clinical symptoms related to a more severe illness; frequently needed ICU treatment, and invasive and non-invasive MV, and raised almost a three fold-increased chance of death (OR = 3.96 [95% CI 3.60-4.41]). The high case fatality rate in G1 was associated with older age (≥ 25 years of age), presence of clinical symptoms, and comorbidities, such as obesity, related to a more severe clinical condition. Unvaccinated patients with DS affected by COVID-19 had a high case fatality rate, and these patients had a different profile for comorbidities, clinical symptoms, and treatment (such as the need for ICU and MV) when compared with other study populations.

Human Development Index Is Associated with COVID-19 Case Fatality Rate in Brazil: An Ecological Study.

The Human Development Index measures a region's development and is a step for development debate beyond the traditional, economic perspective. It can also determine the success of a country's response to the COVID-19 pandemic, mainly affecting the case fatality rate among severe cases of SARS-CoV-2 infection. We aimed to associate the Human Development Index with the case fatality rate due to COVID-19 in each Brazilian state and the Federal District, taking into account comorbidities and the need for invasive mechanical ventilation. We also evaluated the influence of the GINI index, number of intensive care unit beds, and occupied households in subnormal clusters on the case fatality rate. We performed an ecological study including two populations: COVID-19 individuals that did not require the mechanical ventilation protocol; and COVID-19 individuals under invasive mechanical ventilation. We performed a Pearson correlation test and a univariate linear regression analysis on the relationship between Human Development Index, Human Development Index-Education Level, Human Development Index-Life Expectancy, and Human Development Index-Gross National Income per capita and COVID-19 deaths. The same analyses were performed using the other markers. We grouped the patients with COVID-19 according to comorbidities and the need for invasive mechanical ventilation. Alpha = 0.05. We included 848,501 COVID-19 individuals, out of which 153,710 needed invasive mechanical ventilation and 314,164 died, and 280,533 COVID-19 individuals without comorbidity, out of which 33,312 needed invasive mechanical ventilation and 73,723 died. We observed a low negative Pearson correlation between the Human Development Index and death and a moderate negative Pearson correlation between the Human Development Index and deaths of individuals on invasive mechanical ventilation, with or without comorbidity. The univariate linear analysis showed the case fatality rate depends on at least 20-40% of the Human Development Index. In Brazil, regions with a low Human Development Index demonstrated a higher case fatality rate due to COVID-19, mainly in individuals who needed invasive mechanical ventilation, than regions with a higher Human Development Index. Although other indexes studied, such as intensive care unit beds and GINI, were also associated with the COVID-19 case fatality rate, they were not as relevant as the Human Development Index. Brazil is a vast territory comprising cultural, social, and economic diversity, which mirrors the diversity of the Human Development Index. Brazil is a model nation for the study of the Human Development Index's influence on aspects of the COVID-19 pandemic, such as its impact on the case fatality rate.

Opioids in COVID-19: Two Sides of a Coin.

Introduction: The treatment of most severe COVID-19 patients included the large-scale use of sedatives and analgesics-possibly in higher doses than usual-which was reported in the literature. The use of drugs that decrease mortality is necessary and opioids are important agents in procedures such as orotracheal intubation. However, these drugs seem to have been overestimated in the COVID-19 pandemic. We performed a review of the PubMed-Medline database to evaluate the use of opioids during this period. The following descriptors were used to enhance the search for papers: "Opioids", "COVID-19," "COVID-19 pandemic," "SARS-CoV-2," "Opioid use disorder," "Opioid dependence" and the names of the drugs used. We also evaluated the distribution of COVID-19 patients in Brazil and the applicability of opioids in our country during the COVID-19 pandemic. Results: Several positive points were found in the use of opioids in the COVID-19 pandemic, for instance, they can be used for analgesia in orotracheal intubation, for chronic pain management, and as coadjutant in the management of acute intensification of pain. However, high doses of opioids might exacerbate the respiratory depression found in COVID-19 patients, their chronic use can trigger opioid tolerance and the higher doses used during the pandemic might result in greater adverse effects. Unfortunately, the pandemic also affected individuals with opioid use disorder, not only those individuals are at higher risk of mortality, hospitalization and need for ventilatory support, but measures taken to decrease the SARS-CoV-2 spread such as social isolation, might negatively affect the treatment for opioid use disorder. In Brazil, only morphine, remifentanil and fentanyl are available in the basic health care system for the treatment of COVID-19 patients. Out of the 5,273,598 opioid units used in this period all over the country, morphine, fentanyl, and remifentanil, accounted for, respectively, 559,270 (10.6%), 4,624,328 (87.6%), and 90,000 (1.8%) units. Many Brazilian regions with high number of confirmed cases of COVID-19 had few units of opioids available, as the Southeast region, with a 0.23 units of opioids per confirmed COVID-19 case, and the South region, with 0.05 units. In the COVID-19 pandemic scenario, positive points related to opioids were mainly the occurrence of analgesia, to facilitate intubation and their use as coadjutants in the management of acute intensification of pain, whereas the negative points were indiscriminate use, the presence of human immunosuppressor response and increased adverse effects due to higher doses of the drug. Conclusion: The importance of rational and individualized use of analgesic hypnotics and sedative anesthetics should be considered at all times, especially in situations of high demand such as the COVID-19 pandemic.

Frequency of respiratory pathogens other than SARS-CoV-2 detected during COVID-19 testing.

The frequencies of 19 respiratory pathogens other than SARS-CoV-2 were assessed in 6,"?>235 Brazilian individuals tested for COVID-19. Overall, only 83 individuals who tested positive for SARS-CoV-2 had codetection of other pathogens. Individuals infected with Rhinovirus/Enterovirus, Human Coronavirus (HCoV)-HKU1, HCoV-NL63, HPIV-4, Influenza A (-H1N1 and other subtypes), Influenza B, Human Respiratory Syncytial Virus and Human Metapneumovirus were less likely to test positive for SARS-CoV-2. Infection with Streptococcys pyogenes, Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Bordetella pertussis were more frequent in individuals who tested negative for SARS-CoV-2, but without significancy. We found 150 individuals infected with ≥2 pathogens other than SARS-CoV-2, only 3 out of whom tested positive for COVID-19. The codetection frequency was low in individuals diagnosed with COVID-19. Other viral infections may provide a cross-reactive, protective immune response against SARS-CoV-2. Screening for bacterial respiratory infections upon COVID-19 testing is important to drive suitable therapeutic approaches and avoid unnecessary antibiotic prescription.

The hindrances to perform the COVID-19 vaccination in Brazil.

INTRODUCTION: Brazil is one of the epicenters of COVID-19 pandemic and faces several hindrances to make his COVID-19 vaccination plan efficient. METHODS: The Brazilian COVID-19 vaccination plan was evaluated and the hindrances to make the COVID-19 vaccination plan efficient were described and discussed. RESULTS: High territorial extension might contribute to a delay on the COVID-19 vaccination, due to difficulty in delivering vaccines to furthest Brazilian states and to all the interior cities. The choice among the vaccines should be done based on the type of storage and must consider the transport conditions necessary to maintain its effectiveness. The indigenous individuals were included with health-care workers as the first group to be vaccinated, inflaming the number of vaccines doses distributed in states where the indigenous population have higher prevalence. The antivaccine movement and the politicization of the vaccine are also hindrances to be overcome in Brazil. The COVID-19 incidence or mortality rate and the distribution of intensive care units (ICUs) are not a criterion to distribute the vaccines, as we did not identify a correlation between these markers and the number of vaccines. However, a strong or very strong correlation occurred between the number of COVID-19 vaccines and the number of COVID-19 cases, deaths by COVID-19, gross domestic product, as well as populational density. A total of 83,280,475 doses of COVID-19 vaccines were distributed in Brazil. In the first dose, the Coronavac (Sinovac™), AZD1222 (AstraZeneca/Oxford™), and BNT162b (Pfizer/BioNTech™) vaccines were responsible to vaccinate, respectively, 9.61%, 6.69%, and 0.35% of the Brazilian population. In the second dose, the Coronavac, AZD1222, and BNT162b vaccines were responsible to vaccinate, respectively, 7.52%, 0.53%, and <0.01% of the Brazilian population. CONCLUSIONS: The Federal Government must evaluate the hindrances and propose solutions to maximize the immunization against COVID-19 on Brazil.

One Year of Coronavirus Disease 2019 (COVID-19) in Brazil: A Political and Social Overview.

Background: Coronavirus Disease 2019 (COVID-19) became the deadliest pandemic of the new millennium. One year after it became a pandemic, the current COVID-19 situation in Brazil is an example of how the impacts of a pandemic are beyond health outcomes and how health, social, and political actions are intertwined. Objectives: We aimed to provide an overview of the first year of the COVID-19 pandemic in Brazil, from a social and political point of view, and to discuss the perspectives from now on. Methods: This is a narrative review using official, scientific (PubMed, Medline, and SciELO databases) and publicly available data. Press articles were also used that contain important information not found in these databases. Findings: We address the impacts of COVID-19 in different regions of Brazil, on indigenous populations, health care workers, and how internal social contrasts impacted the pandemics advance across the country. We also discuss key points that culminated in the countrys failed management of the COVID-19 spread, such as poor management of the public health care system, disparities between public and private health care infrastructure, lack of mass testing and viral spread tracking, lack of preparedness and planning to implement strict isolation and social distancing measures, and, most importantly, political instability, a deteriorating Health Ministry and sabotaging attitudes of the countrys president, including anti-scientific actions, underplaying COVID-19 severity, spreading and powering fake news about the pandemic, promoting knowingly inefficient medications for COVID-19 treatment, and interference in collective health policies, including the countrys vaccination plan. Conclusions: After one year of COVID-19 and a disastrous management of the disease, Brazil has more than 11 million cases, 270,000 deaths, and the highest number of daily deaths due to COVID-19 in the world, most of which could have been avoided and can be credited to negligence of municipal, state, and federal authorities, especially President Jair Messias Bolsonaro. Unfortunately, the country is an example of what not to do in a pandemic setting. Key Points: One year after COVID-19 was declared a pandemic, Brazil had the second higher number of cases and deaths, and the highest number of daily deaths due to the disease. Lack of massive testing, non-stringent and ineffective collective health policies, poor management of the public health care system, and political instability were the main drivers of the countrys flawed management of the COVID-19 advancement. Anti-science and sabotaging actions by government had a pivotal role in the countrys current situation. Brazil has a large territory and is marked by social contrasts among different regions and states, which showed contrasting data regarding the impact caused by COVID-19. COVID-19 databases and data sharing are important to provide an overview of epidemiological aspects of the disease; however, Brazil lacks standardization in these datasets.

COVID-19 pandemic evolution in the Brazilian Indigenous population.

INTRODUCTION: The COVID-19 pandemic has affected several neglected populations such as the Indigenous peoples, which have suffered a high impact from the pandemic. OBJECTIVES: To analyze the impact on the health and disease process according to the COVID-19 evolution in the Brazilian Indigenous population. METHODS: Data was collected from press releases by the Health Ministry and a descriptive analysis of the numbers of Indigenous individuals infected with the SARS-CoV-2 in Brazil was carried out. RESULTS: In February 2021, there were 41,855 confirmed cases of Indigenous individuals infected by the SARS-CoV-2, including 4,387 active cases, 36,809 recovered cases, and 549 deaths. The Brazilian Indigenous population is distributed in over 300 ethnic groups and, due to the high number of deaths by the COVID-19, many of these groups are endangered. The elderly are the most affected age group, and they play a fundamental role among the Indigenous population for transmitting their customs mainly orally. Indigenous populations do not have proper access to transport to specialized health centers, since many areas are inaccessible and other cases require air or river transportation, which many times results in late assistance. When managing the COVID-19, it is important to emphasize the need for social isolation to prevent the virus from spreading among the Indigenous groups, mainly due to their contact with other ethnic groups represented by missionaries, hunters, and wood explorers, among others. CONCLUSION: The adoption of practices that can reduce the virus transmission among the Indigenous population and provide them with better access to treatment, mainly for the elderly, must be prioritized in Brazil.

COVID-19 in Brazil: 150,000 deaths and the Brazilian underreporting.

Brazil is one of the epicenters of the COVID-19 pandemic and has reported 5,113,628 cases and 150,998 deaths by the disease. Comparing the deaths by natural causes expected and the excess mortality rate, there is a 22% increase in deaths mainly of male patients and individuals over 60 years old.