key: cord-0690048-dwcyh3jd authors: Zimmermann, Ivan Ricardo; Sanchez, Mauro Niskier; Alves, Layana Costa; Frio, Gustavo Saraiva; Cavalcante, Fabrício Vieira; Cortez-Escalante, Juan José; da Silva, Everton Nunes; Santos, Leonor Maria Pacheco title: COVID-19 as a leading cause of hospitalizations with death in the Brazilian Public Health System in 2020 date: 2021-10-02 journal: Int J Infect Dis DOI: 10.1016/j.ijid.2021.09.077 sha: 5eef01ef055612e1347af8227ff824fc15fb8b75 doc_id: 690048 cord_uid: dwcyh3jd Objectives To describe the profile of hospital deaths in Brazil according to the cause of hospitalization during the pre-pandemic (2019) and pandemic period (2020). Methods Descriptive study based on individual-level records of all hospital admissions with death outcomes reimbursed by the Brazilian National Health System (SUS) in the years 2019 and 2020. Results There was a 16.7% increase on the number of hospital deaths in 2020 compared to 2019 (522,686 vs 609,755). COVID-19 was related with 19.5% (118,879) of the total hospital deaths in 2020, surpassing diseases of the circulatory system, 15.4% (93,735), and diseases of the respiratory system, 14.9% (91,035). Conclusions COVID-19 was the main cause associated with hospital deaths in Brazilian public hospitals in 2020.  There was a 16.7% increase of hospital deaths in 2020 compared to 2019 in Brazil  More than 19% of the hospital deaths in 2020 were related to standing out as the leading cause  40% of COVID-19 deaths were from black/brown and 75% from 60 years or older adults  Brazil experienced a high death toll related with COVID-19 pandemic in 2020 4 TEXT Introduction: As a consequence of COVID-19 high death toll, some countries, as the United States, already states COVID-19 as one of the leading causes of death of the year 2020 (Ahmad and Anderson, 2021) . Since the beginning of the COVID-19 pandemic, Brazil has also experienced a rapid growing number of cases and deaths (Castro et al., 2021b) . In addition, COVID-19 has spread asymmetrically and unequally across social and economic groups, as well as geographic regions in Brazil, with the most vulnerable population and the Northeastern and Northern regions being the most affected (Dall'Alba and Rocha et al., 2021) . On this basis, we present and discuss data on the leading causes of admission in Brazilian public hospital deaths in 2019 and 2020. After extracting 1,132,441 records from all in-hospital deaths occurred in 2019 and 2020 from the National Hospital Information System (SIH-SUS), we have classified the deaths by admission cause according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) chapters. Any admission including ICD-10 (-U07.1", "U07.2", "B97.2" or "B34.2") (Tanno et al., 2020) or specific COVID-19 medical procedure codes ("0802010296", "0802010300", "0802010318" or "0303010223") (Brasil. Ministério da Saúde. Departamento de Informática do SUS, 2021) was classified as a -COVID-19‖ admission. Our data cover all the hospital deaths that took place in the year 2019 and 2020 (from January to December). We present descriptive statistics on patient characteristics (sex, age, ethnicity), severity of the hospital admissions 5 (length of stay, use of ICU) and geographic region according to the leading groups of causes of hospitalizations with deaths during 2019 and 2020. All analyses were conducted in R language and based on de-identified individual level data available on the hospitalization authorization (AIH) repository (ftp://ftp.datasus.gov.br/dissemin/publicos/SIHSUS/200801_/Dados) by the end of August, Circulatory system diseases were the leading cause related with hospital deaths in 2019, matching for 18.7% (97,867) of the death records, which was close to other infectious diseases (97,842), respiratory system diseases (97.585) and followed by cancer, with 13.7% (71,550) of the hospital deaths (Table 1) . Compared to 2019, there was a 16.7% increase in the number of hospital deaths in 2020 (522,686 vs 609,755, respectively). Although this increase follows the trend of deaths related to COVID-19, there was a slight decrease in the other causes, ranging from a 4.2% decrease in Circulatory system diseases to a 12.3% decrease in Other infectious diseases (not including COVID-19). Figure 1 illustrates that, although the death trends from other groups remaining relatively stable during the entire 2020 period, around the 20th epidemic week (May 10-16), COVID-19 was already the main related cause of hospital deaths in Brazil, except to South and Midwest regions. By the end 2020, COVID-19 was related with 19.5% (118,879) of the hospital deaths, followed only by circulatory system diseases, 15.4% (93,735), respiratory system diseases, 14.9% (91,035), other infectious diseases, 14.1% (85,830) and cancer, 11.1% (67,808). Compared with 2019, the largest increase was observed in the age groups of 40 to 60 years and 60 to 79 years, with 20.3% (123,565) and 44.8% (272,238) of the total deaths in 2020, respectively. The number of hospital deaths related to COVID-19 among children and teenagers (0 to 19 years old) represented the smallest group when compared to all other causes in 2020. Regarding ethnicity, the major increases were observed among blacks (33.9%), yellows (32.6%) and native Brazilian (30.9%). The black/brown group represented 39.8% (47,306) of the COVID-19 hospital deaths. There was an increase in the number of deaths in all length of stay groups in 2020, but a more pronounced increase was observed with admissions lasting 7 to 14 days (23.2%) and with ICU use (38,0%), respectively. However, it is noteworthy that half of the deaths by COVID-19 occurred in hospitalizations with up to seven days duration. Although the Southeast region concentrating the highest proportion (44.3%) of hospital deaths by COVID-19, Northern region showed the highest increase (31.58%) in the total number of hospital deaths. COVID-19 was the leading cause related to hospital deaths in Brazilian public hospitals during 2020, surpassing diseases of the circulatory system, diseases of the respiratory system, other infectious diseases, and cancer. Even accounting only for hospital deaths data, this leading cause-of-death scenario is in line with wider studies in other contexts, like the one conducted by Ahmad & Anderson (2021) with US provisional death records. Nevertheless, instead of the main cause, COVID-19 places only as the third cause of death during 2020 in the US. This a very worrying scenario, as the emergence of the new variants can make the scenario even more worrying in 2021 (Abdool Karim and de Oliveira, 2021). As well as COVID-19, the numbers of hospital deaths from Respiratory system diseases were also important in 2020, suggesting consequences of a scenario of 7 weak preparedness like low numbers of available beds at the public hospitals. Indeed, as a result of failing to mitigate the spread (Castro et al., 2021b) , estimates also show the high impact of COVID-19 in terms of reducing overall life expectancy in 1.3 years in Brazil, highlighting the impact of local inequities (Castro et al., 2021a) . In addition, our results show disparities among ethnicity, which were also observed and related to socioeconomical status in previous analyses (Baqui et al., 2020; Castro et al., 2021b) . It is unlikely that this scenario of having the COVID-19 as one of the leading causes of deaths in 2020 will change in 2021. In fact, civil registration data (ARPEN, 2021) already reports COVID-19 as the major cause of death in the country during March, 2021. Based on our criteria, none of the 2019 death records were classified as a COVID-19 death, suggesting a lack of misclassification. Though, our data are restricted to deaths that occurred in hospitalization reimbursed by the SUS, not including deaths in private hospitalizations, at home or in other settings. Our estimates can shed some light on the leading causes of hospital death in Brazil and indicate the need for better strategies to prevent COVID-19 direct and indirect effects on the Brazilian population. We declare no competing interests. The study was funded by the Call for Proposals MCTIC / CNPq / FNDCT / MS / SCTIE / Decit No. 07/2020 -Research to address the COVID-19 Pandemic, its consequences, and other severe acute respiratory syndromes, under the coordination of LMPS. GSF and LCA received a research grant from CNPq during the study. The study sponsor had no role in the study design, data collection, data analysis, data interpretation or report writing. The 8 authors had full access to all study data and were responsible for the decision to submit this work for publication. All the analyses were based on public data sets available to the public at large and not restricted to researchers. The records were all de-identified before being public and The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. 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