key: cord-0989338-3hju5f3i authors: Alves, Joao Guilherme; Ferreira Lima, Tiago Pessoa title: International air traffic and COVID-19 geographical incidence in Brazil date: 2020-10-03 journal: J Microbiol Immunol Infect DOI: 10.1016/j.jmii.2020.09.009 sha: 41c1c787d45dddc56577d5a0cb6de3beb4435294 doc_id: 989338 cord_uid: 3hju5f3i nan International air traffic and COVID-19 geographical incidence in Brazil Dear Editor, We read with interest the article of Lau and co-workers 1 that described for the first time the relevant risk of total air passengers for the spread of COVID-19. At that time, March 2020, risk for COVID-19 exposure was relatively low in South America. However, America is becoming the world's epicenter of the COVID-19 pandemic. Brazil, since the first case registered on February 26, count almost 4 million cases and 110.019 deaths (August 19). The COVID-19 incidence and mortality in Brazil has shown many regional differences in the 26 Brazilian states. It has been accepted that the spread of SARS-CoV-2 to Brazil occurred by flights from Europe in February 2020. For this reason it can be assumed that the explanation for this uneven distribution lies in the number of flights/passengers received in each state. Here, we analyzed the COVID-19 incidence with the number of flights and passengers in 15 Brazilian states that received flights from Europe in February/2020. COVID-19 incidence and mortality data were collected from the Ministry of Health of Brazil (https://covid.saude. gov.br/) on May 26, 2020. International flight data were collected from ANAC [National Civil Aviation Agency] (https://www.anac.gov.br/assuntos/dados-e-estatisticas/ dados-estatisticos/dados-estatisticos). The analysis included a health assistance indicator, Intensive Care Unit (ICU) beds, 2 and a socioeconomic indicator, Human Development Index (HDI). 3 Brazil received 3545 flights from Europe during February 2020. São Paulo state was the final destination of more than half (56.8%) of the flights, followed by Rio de Janeiro (17.0%). COVID-19 geographical incidence/mortality and number of flights/passengers, ICU beds and HDI in 15 states of Brazil are shown at Table 1 . We fit a logelog linear multiple regression iables. An increase of flights in 1% was associated with an increase of 0.6% of the COVID-19 incidence. An association of the number of international flights and COVID-19 geographical incidence in Brazilian states was observed. However, this association was not regularly observed in all 15 states and it is possible that other factors may have had an influence on COVID-19 incidence. Brazil is a country with continental dimensions and many regional inequalities. In China, it was shown that the number of flight routes and passengers were relevant risk factors for the spread of SARS-CoV-2. 4 Our study has limitations. Other factors associated with COVID-19 geographic distribution were not analyzed and the states studied have many socioeconomic differences. Besides, this is the first time that COVID-19 affected a country with very poor regions. At the beginning, COVID-19 reached basically people of the highest social class that had travelled to Europe. Currently, COVID-19 is spreading rapidly in vulnerable populations with more devastating effects especially in the slums. In conclusion, the number of flights from Europe is associated with the current COVID-19 geographical distribution in many Brazilian states. Possibly a better control of these flights could have lessened the impact of COVID-19 in Brazil. The association between international and domestic air traffic and the coronavirus (COVID-19) outbreak Leitos de UTI 2018 e Estados e Capitais Atlas do Desenvolvimento Humano no Brasil The association between international and domestic air traffic and the coronavirus (COVID-19) outbreak Tiago Pessoa Ferreira Lima Doctoral Program, Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) Rua dos Coelhos, 300 e Boa Vista The authors declare that there is no conflict of interest or financial disclosure about this manuscript.