Dynamics of SARS-CoV-2 seroprevalence during the first year of the COVID-19 pandemic in the Northeast region of Brazil.

In this household-based seroepidemiological survey, we analyzed the dynamics of SARS-CoV-2 seroprevalence during the first year of the COVID-19 pandemic in Sergipe State, Northeast Brazil, the poorest region of the country. A total of 16,547 individuals were tested using a rapid IgM-IgG antibody test and fluorescence immunoassay (FIA). Seroprevalence rates were presented according to age, sex, and geographic region. A comparative analysis was performed between the results obtained in July 2020 (peak of the first wave), August - November 2020 (end of the first wave), and February - March 2021 (beginning of the second wave). Seroprevalence rates in the three phases were estimated at 9.3% (95% CI 8.5-10.1), 12.0% (95% CI 11.2-12.9) and 15.4% (95% CI 14.5-16.4). At the end of the first wave, there was a rise in seroprevalence in the countryside (p < 0.001). At the beginning of the second wave, we found an increase in seroprevalence among women (p < 0.001), adults aged 20 to 59 years (p < 0.001), and the elderly (p < 0.001). In this phase, we found an increase in estimates both in metropolitan areas and in the countryside (p < 0.001). This study showed an increase in SARS-CoV-2 seroprevalence over the first year of the pandemic, with approximately one in six people having anti-SARS-CoV-2 antibodies at the beginning of the second wave of COVID-19. Furthermore, our results suggest a rapid spread of COVID-19 from metropolitan areas to the countryside during the first months of the pandemic.

Spatial clusters, social determinants of health and risk of COVID-19 mortality in Brazilian children and adolescents: A nationwide population-based ecological study.

Background: Data regarding the geographical distribution of cases and risk factors for COVID-19 death in children and adolescents are scarce. We describe the spatial distribution of COVID-19 cases and deaths in paediatric population and their association with social determinants of health in Brazil. Methods: This is a population-based ecological study with a spatial analysis of all cases and deaths due to COVID-19 in Brazil among children and adolescents aged 0-19 years from March 2020 to October 2021. The units of analysis were the 5570 municipalities. Data on COVID-19 cases and deaths, social vulnerability, health inequities, and health system capacity were obtained from publicly available databases. Municipalities were stratified from low to very high COVID-19 incidence and mortality using K-means clustering procedures, and spatial clusters and relative risks were estimated using spatial statistics with Poisson probability models. The relationship between COVID-19 estimates and social determinants of health was explored by using multivariate Beta regression techniques. Findings: A total of 33,991 COVID-19 cases and 2424 deaths among children and adolescents aged 0-19 years were recorded from March 2020 to October 2021. There was a spatial dependence for the crude mortality coefficient per 100,000 population in the paediatric population aged 0-19 years (I Moran 0·10; P < 0·001). Forty municipalities had higher mortality rates, of which 20 were in states from the Northeast region. Seven spatial clusters were identified for COVID-19 mortality, with four clusters in the Northeast region and three in the North region. Municipalities with higher social inequality and vulnerability had higher COVID-19 mortality in the paediatric population. Interpretation: The main clusters of risk for mortality among children and adolescents were identified in municipalities in the North and Northeast regions, which are the regions with the worst socioeconomic indicators and greatest health disparities in the country. Our findings confirmed the higher burden of COVID-19 for Brazilian paediatric population in municipalities with higher social inequality and vulnerability and worse socioeconomic indicators. To reduce the burden of COVID-19 on children, mass immunisation is necessary. Funding: None.

Pooling of sputum samples to increase tuberculosis diagnostic capacity in Brazil during the COVID-19 pandemic.

OBJECTIVES: We assessed whether combining (pooling) four individual's samples and testing with Xpert Ultra has the same accuracy as testing samples individually as a more efficient testing method. METHODS: We conducted a cross-sectional study of individuals with presumptive tuberculosis attending primary health care or general hospital facilities in Alagoas, Brazil. The sputum samples of four consecutive individuals were pooled and the pool and individual samples were tested with Xpert Ultra. The agreement of the tests was compared using kappa statistics. We estimated the sensitivity and specificity of pooling using the individual test as the reference standard and potential cartridge savings. RESULTS: A total of 396 participants were tested. A total of 95 (24.0%) individual samples were Mycobacterium tuberculosis (MTB)-positive, 300 (75.8%) "MTB not detected", including 20 "MTB trace", and one reported an error. A total of 99 pools of four samples were tested, of which 62 (62.6%) had MTB detected and 37 (37.4%) MTB not detected, including six (6.1%) with MTB trace. The agreement between individual and pooled testing was 96.0%. Pooling had a sensitivity of 95.0% (95% confidence interval 86.9-99%), specificity of 97.1% (95% confidence interval 85.1-99.9%), and kappa of 0.913. The method saved 12.4% of cartridge costs. CONCLUSION: The pooled testing of specimens had a high level of agreement with individual testing. The pooling of samples for testing improves the efficiency of testing, potentially enabling the screening and testing of larger numbers of individuals more cost-effectively.

Relationship between living conditions in neighborhoods in the Northeast Brazil and COVID-19 estimates during the third wave associated with the Omicron variant.

Brazil experienced a critical increase in COVID-19 cases during the first weeks of 2022 due to community transmission of the SARS-CoV-2 Omicron variant. Furthermore, there has been a significant increase in the country's demand for hospital beds, especially among those unvaccinated or partially vaccinated. Despite this scenario, the number of deaths was considerably lower than in previous COVID-19 waves. However, evidence is limited regarding the disease burden at this stage of the pandemic in more vulnerable regions. In this ecological study, we investigated the impacts of the third wave of COVID-19 caused by the Omicron on cases and deaths in a region of Northeast Brazil, and their relationship with the living conditions of the population in a neighborhood-level analysis. We found that neighborhoods with worse living conditions had a lower COVID-19 incidence (median 193.4 cases per 10 000) than those with better living conditions (median 335.1 cases per 10 000) (p < .001), but no differences were found regarding mortality. Despite advances in vaccination coverage against the disease in Brazil and the significant reduction in the number of deaths during the third wave, our findings may suggest differences in access to diagnostic resources for COVID-19 in the poorest communities.

Analytical evaluation of thirty-two severe acute respiratory syndrome 2 lateral flow antigen tests demonstrates sensitivity remains with the SARS-CoV-2 Gamma lineage.

BACKGROUND: The emergence of variants of concern (VOCs) requires an ongoing assessment of the performance of antigen lateral flow tests (Ag-RDTs). The limit of detection (LOD) of 32 Ag-RDTs was evaluated using the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Gamma variant. METHODS: Ag-RDTs were performed according to the manufacturer's instructions with a clinical isolate of the Gamma variant. RESULTS: Twenty-eight of the 32 Ag-RDTs exceeded the World Health Organization criteria. CONCLUSIONS: This comprehensive analytical evaluation of Ag-RDTs demonstrated that the test performance was maintained with Gamma VOC.

Dynamics of hospitalizations and in-hospital deaths from COVID-19 in northeast Brazil: a retrospective analysis based on the circulation of SARS-CoV-2 variants and vaccination coverage.

This study investigated the dynamics of hospitalizations and in-hospital deaths from coronavirus disease 2019 (COVID-19) throughout the pandemic in northeast Brazil, the Brazilian region with the worst socioeconomic indicators. In total, 141,445 cases, 8,213 hospital admissions, and 1,644 in-hospital deaths from COVID-19 were registered from March 14, 2020 to February 5, 2022. The overall rates of hospitalization and in-hospital deaths were 5.8% and 20.0%, respectively. The hospitalization and death rates significantly decreased over time, which may have been related to progress in vaccination. During the spread of the Gamma variant (January to June 2021), most hospitalized individuals were young adults, and approximately 40% of deaths occurred in this age group. During the predominance of Delta (July to December 2021), over 75% of deaths occurred among the elderly and unvaccinated or partially vaccinated individuals. This rate decreased to 42.3% during the transmission of the Omicron variant (January to February 2022), during which 34.6% of deaths were recorded among fully vaccinated individuals (2 doses) and 23.1% among those who received full vaccination and a booster. The Omicron-driven third wave was associated with a rise in the proportion of deaths among vaccinated individuals, especially among those who had not received a booster dose.

Clinical characteristics and risk factors for maternal deaths due to COVID-19 in Brazil: a nationwide population-based cohort study.

BACKGROUND: Monitoring the characteristics and associated factors for death among pregnant and postpartum women with coronavirus disease 19 (COVID-19) is necessary. We investigated the clinical characteristics and risk factors associated with maternal deaths in a nationwide cohort of Brazil. METHODS: This was a population-based cohort of all pregnant and postpartum women hospitalised with COVID-19 notified to the Sistema de Informação de Vigilância Epidemiológica da Gripe of Brazil (SIVEP-Gripe), from February 2020 to September 2021. The primary outcome was time to in-hospital death, with risk factors analysed with univariable and multivariable Cox proportional hazards regression models. RESULTS: Cumulative observation time was 248 821 person-days from hospital admission to the end of follow-up for 15 105 individuals. There were 1858 deaths (12.3%) for a maternal mortality rate of 7.5 (95% CI 7.1-7.8) per 1000 patients-days. The cumulative mortality increased over time. Black/Brown ethnicity had a higher risk of death than women self-identifying as White. Women in the North, Northeast, Central-West and Southeast regions had higher risk of death than women in the South region. The characteristics independently associated with death were a postpartum status on admission [adjusted hazard ratio, HR 1.4 (95% confidence interval, CI 1.2-1.6)], pre-existing clinical conditions [adjusted HRs 1.2 (95%CI 1.1-1.3) for one and 1.3 (95%CI 1.1-1.5) for two comorbidities], hypoxaemia on admission [adjusted HR 1.2 (95%CI 1.1-1.4)] and requiring non-invasive [adjusted HR 2.6 (95%CI 2.1-3.3)] or invasive ventilatory support [adjusted HR 7.1 (95%CI 5.6-9.2)]. CONCLUSION: In Brazil, the in-hospital maternal mortality rate due to COVID-19 is high and the risk of death increases with the length of hospitalisation. Socio-demographic and biological factors are associated with an increased risk of maternal death. The presence of respiratory signs and symptoms should be considered early markers of disease severity and an adequate management is necessary. Our findings reinforce the need for vaccination of pregnant and postpartum women against COVID-19.

Effects of the COVID-19 pandemic on routine pediatric vaccination in Brazil.

BACKGROUND: COVID-19 pandemic has disrupted health services, including vaccination demand. We describe the impact of the COVID-19 pandemic on routine pediatric vaccination in Brazil. METHODS: We conducted a retrospective analysis of all vaccine doses provided to children aged 0-6 years from January 2019 to December 2020. We obtained data stratified by age group (0 to 2 years and >2 to 6 years) and Brazilian region. Difference-in-difference (DiD) analyses were performed to compare vaccine uptake in the pre-pandemic (January-February), stay-at-home (March-June), and reopening (July-December) periods. RESULTS: The number of vaccine doses administered declined in the stay-at-home period. For children aged 0 to 2 years, the highest reductions were recorded in the North (-25.3%), Northeast (-16.8%) and Central-West (-10.2%) regions. For children aged >2 to 6 years, the highest decline was observed in the North (DiD = -27.2%) and South (DiD = -14.0%) regions. The number of vaccine doses administered in the reopening period has slightly increased in all regions. CONCLUSIONS: Vaccination decreased during the COVID-19 pandemic. Although the number of doses recovered in part during the reopening phase, additional strategies, such as increased public awareness and vaccination booster campaigns are required.

Miller Fisher Syndrome in Patients With Severe Acute Respiratory Syndrome Coronavirus 2 Infection: A Systematic Review.

BACKGROUND AND PURPOSE: Miller Fisher syndrome (MFS) is a subtype of Guillain-Barré syndrome characterized by the triad of ophthalmoparesis, areflexia, and ataxia. Although cases of MFS have been associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, no studies have synthesized the clinical characteristics of patients with this condition. METHODS: In this rapid systematic review, we searched the PubMed database to identify studies on MFS associated with SARS-CoV-2 infection. RESULTS: This review identified 11 cases, of whom 3 were hospitalized with motor and/or sensory polyneuropathy as the first sign of SARS-CoV-2 infection. SARS-CoV-2 RNA was not detected in analyses of cerebrospinal fluid, suggesting a mechanism of immune-mediated injury rather than direct viral neurotropism. However, antiganglioside antibodies were found in only two of the nine patients tested. It is possible that target antigens other than gangliosides are involved in MFS associated with SARS-CoV-2 infection. CONCLUSIONS: The present patients exhibited clinical improvement after being treated with intravenous immunoglobulin. Although rare, patients with SARS-CoV-2 infection may present neurological symptoms suggestive of MFS. Early recognition of the MFS clinical triad is essential for the timely initiation of treatment.

Spatial clusters, social determinants of health and risk of maternal mortality by COVID-19 in Brazil: a national population-based ecological study.

BACKGROUND: Detailed information on how socio-economic characteristics are related to COVID-19 incident cases and maternal deaths is needed. We investigated the spatial distribution of COVID-19 cases and maternal deaths in Brazil and their association with social determinants of health. METHODS: This was a population-based ecological study with a spatial analysis of all cases and deaths of COVID-19 in the obstetric population. Data on COVID-19 cases and deaths in the obstetric population, social vulnerability, health inequities, and health system capacity at the municipal level were obtained from several publicly sources in Brazil. A Bayesian empirical local model was used to identify fluctuations of the indicators. Spatial statistic tests were used to identity the spatial clusters and measure the municipalities' risk of COVID-19 in the obstetric population. Beta regression was used to characterise the association between socio-economic indicators and the burden of COVID-19. FINDINGS: A total of 13,858 cases and 1,396 deaths due to COVID-19 were recorded in Brazil from March 2020 to June 2021. There was a variation in the number of cases per municipality, with 105 municipalities with rates from 2,210 to 3,884 cases and 45 municipalities with rates from 3,884 to 7,418 cases per 100,000 live births. The maternal mortality ratio also varied widely across municipalities. There was a spatial dependence on smoothed maternal mortality rates (I Moran 0•10; P = 0•010), and 15 municipalities had higher risk of maternal deaths. Municipalities characterized by lower health resources and higher socioeconomic inequalities presented the highest rates of incidence and maternal mortality by COVID-19. INTERPRETATION: In Brazil, COVID-19 cases and deaths in the obstetric population had a heterogeneous geographical distribution, with well-defined spatial clusters mostly located in the countryside. Municipalities with a high degree of socioeconomic dissimilarities showed higher maternal mortality rates than areas with better social and infrastructure indicators. FUNDING: None.

Factors Associated with Mortality among Hospitalized Patients with COVID-19: A Retrospective Cohort Study.

Information on the risk factors for COVID-19 mortality in low- and middle-income countries is still scarce. In this retrospective cohort study, we analyzed the factors associated with COVID-19 mortality in hospitalized patients in a poor area of Brazil. Logistic regression was used to identify factors independently associated with mortality, including gender, age, and the presence of underlying medical conditions. A total of 1,207 patients were included in the analysis, and a 1.5-fold increase in COVID-19 mortality was found among patients aged > 65 years with hypertension and diabetes (odds ratio [OR]: 1.50, 95% CI: 1.02-2.19). Moreover, infectious disease (OR: 4.31, 95% CI: 1.39-13.39), kidney disease (OR: 2.59, 95% CI: 1.27-5.27), and heart disease (OR: 2.00, 95% CI: 1.31-3.04) were also predictive for COVID-19 in-hospital death. This large cohort provides important data on potential factors associated with COVID-19 mortality in Brazil.

Delay in head and neck cancer care during the COVID-19 pandemic and its impact on health outcomes

The coronavirus disease 2019 (COVID-19) outbreak has created unprecedent challenges for healthcare systems worldwide. Oncology services have been reorganized to decrease the risk of nosocomial acquisition of SARS-CoV-2, but changes in treatment pathways and follow-up cancer care can result in patients receiving suboptimal or delayed care. Herein, we describe a cross-sectional nested cohort study conducted to evaluate delays in care for patients with head and neck cancer (HNC) in post-treatment follow-up or palliative care during the COVID-19 pandemic in Northeast Brazil and its impact on health outcomes. Information was extracted from medical records and supplemented by telephone interviews. We compared the following health outcomes: self-perception of anxiety or sadness, fear of COVID-19 infection, cancer-related complications during social isolation, self-medication, diagnosis of COVID-19, and death between patients with and without delayed cancer care. The Mann-Whitney U test was used to compare distributions of continuous variables and the Fisher exact test was used for categorical variables. Thirty-one HNC patients were included in the study, and no case of confirmed SARS-CoV-2 was found. Delayed cancer care due to restriction in health services was reported in 58.1% of cases, and there was no report of telemedicine use during the COVID-19 outbreak. Cancer-related complications during the COVID-19 pandemic were described for most patients (67.7%) and included pain or discomfort, swelling, and dyspnea. Eight (25.8%) patients reported use of prescribed morphine or codeine to manage pain and six (19.4%) patients reported self-medication with over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs). We found an association between delayed HNC care and the use of self-medication (p = 0.028). This study indicated that patients with delayed HNC care during the COVID-19 outbreak are more likely to use self-medication with NSAIDs for pain management. Better strategies to follow HNC patients in socioeconomically disadvantaged communities need to be discussed and implemented.

To breastfeed or not to breastfeed? Lack of evidence on the presence of SARS-CoV-2 in breastmilk of pregnant women with COVID-19.

A rapid systematic review was carried out to evaluate the current evidence related to the presence of SARS-CoV-2 in breast milk from pregnant women with COVID-19. Eight studies analyzing the presence of SARS-CoV-2 RNA in the breast milk of 24 pregnant women with COVID-19 during the third trimester of pregnancy were found. All patients had fever and/or symptoms of acute respiratory illness and chest computed tomography images indicative of COVID-19 pneumonia. Most pregnant women had cesarean delivery (91.7%) and two neonates had low birthweight (< 2 500 g). Biological samples collected immediately after birth from upper respiratory tract (throat or nasopharyngeal) of neonates and placental tissues showed negative results for the presence SARS-CoV-2 by RT-PCR test. No breast milk samples were positive for SARS-CoV-2 and, to date, there is no evidence on the presence of SARS-CoV-2 in breast milk of pregnant women with COVID-19. However, data are still limited and breastfeeding of women with COVID-19 remains a controversial issue. There are no restrictions on the use of milk from a human breast milk bank.

Se llevó a cabo una revisión sistemática rápida para evaluar la evidencia disponible sobre la presencia de SARS-CoV-2 en la leche materna de mujeres embarazadas afectadas con COVID-19. Se encontraron ocho estudios que analizaron la presencia de ARN de SARS-CoV-2 en la leche materna de 24 mujeres embarazadas con COVID-19 durante el tercer trimestre del embarazo. Todas las pacientes tenían fiebre o síntomas de enfermedad respiratoria aguda e imágenes de tomografía computarizada de tórax indicativas de neumonía por COVID-19. La mayoría de las mujeres embarazadas (91,7%) tuvieron un parto por cesárea y dos neonatos presentaron bajo peso al nacer (< 2 500 g). Las muestras biológicas recogidas inmediatamente después del parto de las vías respiratorias superiores (faringe o nasofaringe) de los neonatos y los tejidos placentarios mostraron resultados negativos para SARS-CoV-2 mediante RT-PCR. Ninguna muestra de leche materna fue positiva para SARS-CoV-2 y, hasta la fecha, no hay evidencia de la presencia de SARS-CoV-2 en la leche materna de las mujeres embarazadas con COVID-19. Sin embargo, los datos disponibles todavía son limitados y la lactancia materna en las mujeres con COVID-19 sigue siendo un tema controvertido. No hay restricciones para el uso de leche materna de banco.

Foi realizada uma revisão sistemática rápida para avaliar as evidências atuais relacionadas à presença da SARS-CoV-2 no leite materno de mulheres grávidas com COVID-19. Foram encontrados oito estudos analisando a presença de RNA do SARS-CoV-2 no leite materno de 24 gestantes com COVID-19 durante o terceiro trimestre de gravidez. Todas as pacientes apresentavam febre ou sintomas de doença respiratória aguda e imagens de tomografia computadorizada do tórax indicativas de pneumonia pela COVID-19. A maioria das gestantes teve parto cesáreo (91,7%) e dois recém-nascidos tiveram baixo peso ao nascer (< 2 500 g). As amostras biológicas coletadas imediatamente após o nascimento do trato respiratório superior (faringe ou nasofaringe) de neonatos e tecidos placentários apresentaram resultados negativos para a presença do SARS-CoV-2 pelo teste RT-PCR. Nenhuma amostra de leite materno foi positiva para o SARS-CoV-2 e, até à data, não há evidências da presença do SARS-CoV-2 no leite materno de mulheres grávidas com COVID-19. No entanto, os dados ainda são limitados e a amamentação de mulheres com COVID-19 continua a ser uma questão controversa. Não há restrições ao uso de leite de um banco de leite materno humano.

Delay in head and neck cancer care during the COVID-19 pandemic and its impact on health outcomes

The coronavirus disease 2019 (COVID-19) outbreak has created unprecedent challenges for healthcare systems worldwide. Oncology services have been reorganized to decrease the risk of nosocomial acquisition of SARS-CoV-2, but changes in treatment pathways and follow-up cancer care can result in patients receiving suboptimal or delayed care. Herein, we describe a cross-sectional nested cohort study conducted to evaluate delays in care for patients with head and neck cancer (HNC) in post-treatment follow-up or palliative care during the COVID-19 pandemic in Northeast Brazil and its impact on health outcomes. Information was extracted from medical records and supplemented by telephone interviews. We compared the following health outcomes: self-perception of anxiety or sadness, fear of COVID-19 infection, cancer-related complications during social isolation, self-medication, diagnosis of COVID-19, and death between patients with and without delayed cancer care. The Mann-Whitney U test was used to compare distributions of continuous variables and the Fisher exact test was used for categorical variables. Thirty-one HNC patients were included in the study, and no case of confirmed SARS-CoV-2 was found. Delayed cancer care due to restriction in health services was reported in 58.1% of cases, and there was no report of telemedicine use during the COVID-19 outbreak. Cancer-related complications during the COVID-19 pandemic were described for most patients (67.7%) and included pain or discomfort, swelling, and dyspnea. Eight (25.8%) patients reported use of prescribed morphine or codeine to manage pain and six (19.4%) patients reported self-medication with over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs). We found an association between delayed HNC care and the use of self-medication (p = 0.028). This study indicated that patients with delayed HNC care during the COVID-19 outbreak are more likely to use self-medication with NSAIDs for pain management. Better strategies to follow HNC patients in socioeconomically disadvantaged communities need to be discussed and implemented.