Trends in COVID-19 case-fatality rates in Brazilian public hospitals: A longitudinal cohort of 398,063 hospital admissions from 1st March to 3rd October 2020

Abstract

Background Almost 200,000 deaths from COVID-19 were reported in Brazil in 2020. The case fatality rate of a new infectious disease can vary by different risk factors and over time. We analysed the trends and associated factors of COVID-19 case fatality rates in Brazilian public hospital admissions during the first wave of the pandemic. Methods A retrospective cohort of all COVID-19-related admissions between epidemiological weeks 10–40 in the Brazilian Public Health System (SUS) was delimited from available reimbursement records. Smoothing time series and survival analyses were conducted to evaluate the trends of hospital case fatality rates (CFR) and the probability of death according to factors such as sex, age, ethnicity, comorbidities, length of stay and ICU use. Results With 398,063 admissions and 86,452 (21.7%) deaths, the overall age-standardized hospital CFR trend decreased throughout the period, varying from 31.8% (95%CI: 31.2 to 32.5%) in week 10 to 18.2% (95%CI: 17.6 to 18.8%) in week 40. This decreasing trend was observed in all sex, age, ethnic groups, length of stay and ICU admissions. Consistently, later admission (from July to September) was an independent protective factor. Patients 80+ year old had a hazard ratio of 8.18 (95% CI: 7.51 to 8.91). Ethnicity, comorbidities, and ICU need were also associated with the death risk. Although also decreasing, the CFR was always around 40–50% in people who needed an ICU admission. Conclusions The overall hospital CFR of COVID-19 has decreased in Brazilian public hospitals during the first wave of the pandemic in 2020. Nevertheless, during the entire period, the CFR was still very high, suggesting the need for improving COVID-19 hospital care in Brazil.

Coronavirus disease-related in-hospital mortality: a cohort study in a private healthcare network in Brazil

“…In Brazil, three large population-based studies including 522,167 [age 61 (IQR 47–73) years], 254,288 (age 60 ± 17 years) (232,036 of whom had a defined outcome), and 228,196 [age 61 (IQR 48–73) years] COVID-19 patients reported 30.7% 8 , 38% 4 and 37% 6 in-hospital mortality, respectively, whereas two smaller cohorts (mean/median ages not reported) of 46,285 and 11,321 in-hospital patients (6882 of whom had a defined outcome) found much higher mortality rates of 46.2% 9 and 47.3% 7 , respectively (Supplementary Table 10 ). None of these studies, however, discriminated the in-hospital mortality between public and private hospitals 4 , 6 – 10 . In fact, a lower (24.4%) in-hospital mortality was found in a cohort of 89,405 patients (age 58.9 ± 16.8 years) attended exclusively by the Brazilian unified public healthcare system 15 .…”

“…Nevertheless, COVID-19 is widely distributed across Brazil’s 5 macro-regions (North, Northeast, Central-West, Southeast, and South) with not only a high incidence, but also a high, albeit uneven, in-hospital mortality, which likely relates in part to the existing regional discrepancies of the country’s healthcare system 4 . Previous studies, which combined account for ≥ 1 million patients hospitalized due to COVID-19 in Brazil, have reported mortality rates ranging from 21.7 to 47.3% 4 , 6 – 10 . All of these studies, however, originated from “SIVEP-Gripe”—the main Brazilian Ministry of Health’s (BMH) repository of notifications of COVID-19 hospitalizations—and none of them discriminated the in-hospital mortality between public and private institutions 4 , 6 – 10 .…”

“…Previous studies, which combined account for ≥ 1 million patients hospitalized due to COVID-19 in Brazil, have reported mortality rates ranging from 21.7 to 47.3% 4 , 6 – 10 . All of these studies, however, originated from “SIVEP-Gripe”—the main Brazilian Ministry of Health’s (BMH) repository of notifications of COVID-19 hospitalizations—and none of them discriminated the in-hospital mortality between public and private institutions 4 , 6 – 10 . Despite high heterogeneity between (and within) the Brazilian public and private health systems, public hospitals have been largely and chronically underfunded compared to the private sector which (indisputably) has overall better infrastructure and offers better remuneration to healthcare personnel (thereby attracting the most qualified human resources).…”

The impact of COVID-19 vaccination on case fatality rates in a city in Southern Brazil

“…Brazil witnessed a widespread distribution of COVID-19 across all regions and was most severely affected by the pandemic 8 , 9 . Almost 200,000 COVID-19 deaths were reported just in 2020 10 . The country started vaccination campaigns against COVID-19 on January 17 th , 2021, prioritizing health workers, older adults (starting at age 85 and gradually vaccinating younger age groups), indigenous populations, and institutionalized individuals 11 .…”

Assessing sex differential in COVID-19 mortality rate by age and polymerase chain reaction test results: an Iranian multi-center study

“…The results differed in a systematic review of 33 studies of other countries, which showed a CFR of 17.1% among hospitalized patients [ 23 ]. In Brazil, the CFR trend even showed a decline in the overall hospital CFR of COVID-19 with a minimum value of 20% [ 24 ]. A similar downward trend was observed in studies of hospitalized patients in Spain and United States [ 25 , 26 ].…”