key: cord-0875414-6tuzxmnl authors: Tanisaka, Laura Silveira; Paiva, Laércio da Silva; Werneck de Carvalho, Luis Eduardo; Fonseca, Fernando Luiz Affonso; Feder, David; do Nascimento, Vânia Barbosa; Adami, Fernando title: Stroke Hospital Admissions during the COVID-19 Outbreak in São Paulo, Brazil date: 2022-02-17 journal: Cerebrovasc Dis DOI: 10.1159/000521794 sha: 81cbf10c698464c4449deb5ef104c3fd90162d79 doc_id: 875414 cord_uid: 6tuzxmnl BACKGROUND: Globally, stroke remains an important cause of death and long-term disability, and the impact of coronavirus disease (COVID-19) on the health system may have impaired stroke care. Previous studies suggest significant reduction in hospital admissions for stroke after COVID-19 onset as patients may hesitate seeking medical help due to fear of exposure. METHODS: This cross-sectional study included cases of hospital admissions for stroke, identified from the Hospital Information System of the Unified Health System (Sistema Único de Saúde), which contains official and public data in Brazil. Data were collected in duplicate, then categorized according to the International Classification of Diseases, tenth revision (ICD-10), considering codes I60–I69. Linear regression was used to estimate the variation in hospital admissions for stroke in the city of São Paulo (SP) − the largest and most populous city in Brazil and Latin America, between January and June of each analyzed year (2017–2020). The percentage variation between June and January 2020 was also compared. The level of significance was set at 5%, and the statistical program used was Stata, version 14.0. RESULTS: In the city of SP, during the first wave of COVID-19, from January to June 2020, there were registered decreases in absolute numbers and mean monthly admissions for stroke. Compared to January 2020, data from June 2020 showed 17% reduction in hospitalizations for intracerebral hemorrhage, 32% for cerebral infarction, 26% for stroke unspecified, and 47% for other cerebrovascular diseases. CONCLUSION: We argue for policies aimed at improving stroke care and developing awareness campaigns regarding the importance of early diagnosis and treatment, as even in less severe presentations, stroke can trigger an increase in mortality, cost, and long-term disability. Globally, the coronavirus disease (COVID-19) pandemic has posed a significant challenge to healthcare systems owing to difficulties in the reallocation of resources, increased demand in intensive care centers, and the implementation of social distancing. Consequently, care of 2 DOI: 10.1159/000521794 clinical emergencies with time-dependent prognosis, such as stroke, has become impaired. Stroke remains the second leading cause of death worldwide and the third cause of death and disability combined [1, 2] . In this context, delayed admission of patients with stroke may lead to worse outcomes [3] . In Brazil, only few studies have evaluated the influence of the pandemic on stroke care attendance during the first wave of COVID-19. In this study, we compared stroke admissions between January and June 2020 to the same periods of the last 3 years, in hospitals of São Paulo (SP). The city of SP is the largest and most populous city in Brazil and Latin America. This cross-sectional study included cases of hospital admissions for stroke, identified from the Hospital Information System of the Unified Health System (Sistema Único de Saúde), which contains official and public data in Brazil. Data were collected in duplicate and then categorized according to the International Classification of Diseases, tenth revision (ICD-10). We considered the following stroke subtypes: nontraumatic intracranial hemorrhage (ICD-10 codes I60-I62), cerebral infarction (ICD-10 code I63), stroke not specified between ischemic and hemorrhagic (ICD-10 code I64), and other cerebrovascular diseases (ICD-10 codes I65-I69). Linear regression was used to estimate the variation in hospital admissions for stroke in the city of SP, Brazil, between January and June of each analyzed year (2017-2020). Moreover, the percentage variation between the months of June and January 2020 was compared, with the latter corresponding to the month before the first case of COVID-19 was reported in the city (February 26, 2020). The level of significance was set at 5%, and the statistical program used was Stata, version 14.0. As these were secondary data, no approval from the Brazilian Research Ethics Committee was required, in reference to resolution 510/2016 of the Brazilian Ministry of Health. The STROBE guidelines for observational studies in epidemiology were followed. During 2017-2020, there were 40,867 hospitalizations for stroke in the city of SP, Brazil. Between January and June of the years 2017-2019, there were no significant changes in hospital admissions for stroke. However, from January to June 2020, there were registered decreases in absolute numbers and mean monthly admissions of 11.6 (95% confidence interval [CI]: 4.5; 18.7) for cerebral in- 3) for other cerebrovascular diseases, except for intracranial hemorrhage, which was stable (−5; 95% CI: −10.6; 0.6) ( Table 1 ). Compared to January 2020, data from June 2020 showed 17% reduction in hospitalizations for intracerebral hemorrhage, 32% for cerebral infarction, 26% for stroke unspecified, and 47% for other cerebrovascular diseases (shown in Fig. 1 ). In this cross-sectional study, we provide evidence for a reduction in hospital admissions after the onset of the COVID-19 pandemic. This may be attributed to the fear of exposure to severe respiratory syndrome coronavirus-2 (SARS-CoV-2), which may have caused patients to hesitate seeking medical help in the face of acute symptoms, especially for mild stroke cases. A study that compared pre-COVID-19 period with the COVID-19 lockdown period found a reduction in ischemic stroke admis-sions to emergency departments from 73.9% to 56.8% in Brazil. Furthermore, the study evidenced a substantial increase in the proportion of stroke admissions beyond 48 h from symptoms onset. Therefore, it is possible that the delay in diagnosis and treatment of stroke, demonstrated by a larger time to consultation during lockdown period, may have contributed to an increase in mortality [4] . The decrease in the absolute number and mean monthly hospitalizations is consistent with the information reported in literature. Nogueira et al. [5] demonstrated a significant global decline for overall stroke admissions (19.2%), ischemic stroke/transient ischemic attack admissions (15.1%), and intracranial hemorrhage hospitalization (11.5%), when comparing COVID-19 pandemic period during 3 months to the immediately preceding tertile. It is important to notice that the stable trend for intracranial hemorrhage in our findings is also revealed in this study, in which there was no significant statistical difference in admission numbers for intracranial hemorrhage when considering high-volume COVID-19 centers. Also, compared to the same 3 months of the prior year, the Color version available online study indicated that there was a decline in the monthly admissions for stroke, ischemic stroke, and transient ischemic attack, but not for intracranial hemorrhage [5] . Furthermore, a population-based study in Joinville, Brazil, correlated the onset of the pandemic with a significant reduction in hospital admissions for cases of milder strokes [6] . Another study in Iran, an upper middle-income country like Brazil, indicated a decrease in hospital admissions, especially for cases of less severe neurological deficit strokes, and indicated a significant increase in disability on discharge [7] . These data, together with the present study, constitute an alarming scenario wherein even in less severe presentations, stroke can trigger an increase in mortality, cost, and long-term disability. Limitations of this study include its cross-sectional design and the possibility of incomplete or inaccurate records in the official system, which were collected during the pandemic. To minimize these issues, data from the first 6 months of 2020 were compared with those from the same period in each of the previous 3 years. Recent studies have quantified the change in hospital admissions for stroke or other pathologies during the CO-VID-19 pandemic in upper middle-income countries such as Brazil [7, 8] . Given that the impact of the pandemic will be sustained, our results may be considered by hospital systems, healthcare providers, and authorities for strategic management and stroke care efficiency. Moreover, the development of awareness campaigns regarding the importance of early diagnosis and treatment of stroke can help reduce its economic consequences and prevent worsening of the burden on the healthcare system. Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study Global burden of stroke Management of acute stroke and urgent neurointerventional procedures during CO-VID-19 pandemic: recommendations on the scientific department on cerebrovascular diseases of the Brazilian Academy of Neurology, Brazilian Society of Cerebrovascular Diseases and Brazilian Society of Neuroradiology COVID-19 lockdown effects on acute stroke care in Latin America Global impact of COVID-19 on stroke care Decrease in hospital admissions for transient ischemic attack, mild, and moderate stroke during the COVID-19 era Stroke care trends during COVID-19 pandemic in Zanjan province, Iran. From the cascade initiative: statistical analysis plan and preliminary results Adami F. Hospital admissions associated with noncommunicable diseases during the CO-VID-19 outbreak in Brazil The authors thank the state agency Fundação de Amparo à Pesquisa do Estado de São Paulo for funding this study. As these were secondary data, no approval from the Brazilian Research Ethics Committee was required, in reference to resolution 510/2016 of the Brazilian Ministry of Health. The STROBE guidelines for observational studies in epidemiology were followed. The authors have no conflicts of interest to declare. This study was funded by the state agency Fundação de Amparo à Pesquisa do Estado de São Paulo, with process No. 2020/14637-4. Through a fellowship of scientific initiation, the mentioned agency funded the scholarship grant to Laura Silveira Tanisaka, which made her involvement in the project possible. All data generated or analyzed during this study are included in this article.