Population-based Ecological Study Research Articles

Climate factors associated with cancer incidence: An ecological study covering 33 cancers from population-based registries in 37 countries

Cancer etiology is multifactorial, with climate change and environmental factors such as extreme weather events and ozone layer destruction potentially increasing cancer risk. Investigating climate factors with cancer incidence can provide valuable insights for prevention and future disease burden prediction. We conducted a population-based ecological study using data from the World Health Organization’s Cancer Incidence in Five Continents (CI5plus, 89 cancer registries from 1998 to 2012) and the Surveillance, Epidemiology, and End Results (SEER, 607 US counties from 2000 to 2018) Program. We tracked climate factors through satellite-based remote sensing, including green space, stratospheric ozone concentration, solar radiation, precipitation, and temperature. We performed linear panel regression models to estimate the effects of both long-term exposure, lag effect, and change rate of climate factors on cancer incidences. We adjusted for smoking prevalence, air pollution, and gross domestic product (GDP) per capita to account for potential confounding factors. Our study included more than 430 million underlying populations across 37 countries. Higher green space exposure (per 0.1-unit normalized difference vegetation index, NDVI) was associated with decreased incidence of lung cancer (up to 6.66 cases [95%CI 4.38–8.93] per 100,000) and prostate cancer (up to 10.84 cases [95% CI 7.73–13.95] per 100,000). Increased solar radiation was associated with a higher incidence of melanoma, but a lower incidence of prostate cancer. No evidence was found to suggest associations between temperature or precipitation and cancer incidence. However, a rapid increase in temperature was linked to higher incidences of corpus uteri cancer and melanoma. Long-term exposure and rapid changes in climate factors may influence changes in cancer incidence, particularly lung and prostate cancers. While some associations were supported by existing evidence (such as solar radiation and melanoma), further research is necessary to investigate the etiology of novel cancer risk factors.

Trends in Systemic Glucocorticoid Utilization in the United Kingdom from 1990 to 2019: A Population-Based, Serial Cross-Sectional Analysis.

Associations between systemic glucocorticoid (SGC) exposure and risk for adverse outcomes have spurred a move toward steroid-sparing treatment strategies. Real-world changes in SGC exposure over time, after the introduction of steroid-sparing treatment strategies, reveal areas of successful risk mitigation as well as unmet needs. A population-based ecological study was performed from the Optimum Patient Care Research Database to describe SGC prescribing trends of steroid-sparing treatment strategies in primary care practices before and after licensure of biologics in the United Kingdom from 1990 to 2019. Each analysis year included patients aged ≥5 years who were registered for ≥1 year with a participating primary care practice. The primary analysis was SGC exposure, defined as total cumulative SGC dose per patient per year, for asthma, severe asthma, chronic obstructive pulmonary disease (COPD), nasal polyps, Crohn's disease, rheumatoid arthritis, ulcerative colitis, and systemic lupus erythematosus. Secondary outcomes were percentages of patients prescribed SGCs and number of SGC prescriptions per patient per year. The number of patients who met study inclusion criteria ranged from 219,862 (1990) to 1,261,550 (2019). At the population level, patients with asthma or COPD accounted for 67.7% to 73.2% of patients per year with an SGC prescription. Over three decades, decreases in SGC total yearly dose ≥1000 mg have been achieved in multiple conditions. Patients with COPD prescribed SGCs increased from 5.8% (1990) to 34.8% (2017). SGC prescribing trends for severe asthma, Crohn's disease, and ulcerative colitis show decreased prescribing trends after the introduction of biologics. Decreases in total yearly SGC doses have been shown in multiple conditions; however, for conditions such as severe asthma and COPD, an unmet need remains for increased awareness of SGC burden and the adoption or development of SGC-sparing alternatives to reduce overuse.

Scorpion envenomation in Brazil and its relationship with the social determinants of health: A population-based ecological study

This study comprehensively analyzed cases of scorpion envenomation in Brazil, exploring the temporal trends and geographic patterns of such incidents between January 1, 2012, and December 31, 2022. Simultaneously, we assessed the correlation between scorpion envenomation and social determinants of health and social vulnerability. We conducted a population-based ecological study, gathering information on the number of scorpion envenomation cases in Brazil, as well as socioeconomic data and social vulnerability indicators across the 5,570 Brazilian municipalities. The season-trend model, based on the classical additive decomposition method, informed estimations of scorpion envenomation variations over time. The spatial correlation of scorpion envenomation with socioeconomic and vulnerability indicators was assessed using the Bivariate Moran's I. A total of 1,343,224 cases of scorpion envenomation were recorded in Brazil from Jan 2012 to Dec 2022. A single increasing time trend was observed for the entire country for this period (APC 8.94, P < 0.001). The seasonal analysis was significant for Brazil as a whole and all regions (p < 0.001), with peaks evident between October and November. The spatial distribution of cases was heterogeneous, with spatial clusters concentrated in the high-risk Southeast and Northeast regions. There was a high incidence of scorpion envenomation in municipalities facing social vulnerability, and, paradoxically, in those with better sanitation and waste collection. Our study revealed a heterogeneous geographical distribution of scorpion accidents in Brazil. Municipalities with higher social vulnerability exhibited a high incidence of scorpion envenomation.

Time trends and geographical variation in major lower limb amputation related to peripheral arterial disease in England.

Above and below knee amputation (AKA, BKA) are treatments of last resort for peripheral arterial disease (PAD). The aim was to examine amputation rates, AKA:BKA ratios, previous revascularization and minor amputation, lengths of stay in hospital, mortality following amputation, and regional variation in people with and without diabetes in England. The study used population-based ecological and cohort study designs, 31 672 census areas, hospital admissions from 2006 to 2018 and Poisson, logistic and Cox regression. There were 47 249 major lower limb amputations (50.7% AKA; 48% had diabetes), giving an annual PAD-related amputation rate of 11 per 100 000 in the population aged 25+ years. Amputation rates were higher in men and substantially higher in people with diabetes. The AKA:BKA ratio was 0.63 in patients with diabetes (n = 22 702) and 1.62 in patients without diabetes (n = 24 547). Of patients having AKA, 25.3% died within 90 days of amputation compared with 11.9% for BKA. Median survival following amputation ranged from only 1.68 years following AKA in patients with diabetes to 5.72 years following BKA in patients without diabetes. Amputation rates decreased over time mainly in the population with diabetes. Short-term mortality and lengths of stay in hospital also decreased over time, while the percentage with previous revascularization generally increased. Amputation rates and AKA:BKA ratios were highest in the North. Adjustment for age, sex and deprivation did not substantially alter geographical patterns. Adjusted 90-day mortality was generally higher in the North and the Midlands but also high in London. There were also regional variations in adjusted duration from admission to amputation, duration from amputation to discharge or death in hospital, previous revascularization and previous minor amputation. There were large variations in amputation rates and survival following amputation in relation to diabetes status and amputation level, and regional variations which remained after adjustment for deprivation.

Maternal mortality and COVID-19: A nationwide ecological analysis from Ecuador.

During the COVID-19 pandemic, distinct population subsets, including pregnant women, have been differentially affected. While over 90% of COVID-19-infected pregnant women experience a benign course, a subset demonstrates marked clinical exacerbation. Symptomatic pregnant individuals, in particular, present a heightened risk of severe disease in comparison to their non-pregnant counterparts. The objective of this study is to systematically evaluate the epidemiological characteristics of COVID-19 in pregnant women, assess related maternal mortalities, ascertain the case fatality rate, and delineate associated risk factors. This is a comprehensive population-based ecological study. A population-based study was conducted to investigate the epidemiological patterns of COVID-19-associated morbidity and mortality in pregnant women in Ecuador from 27 February 2020 to 14 May 2021. A total of 3274 positive COVID-19 cases were identified among pregnant women, with 22 official fatalities, yielding a case fatality rate of 0.67%. The majority of cases were of Mestizo ethnicity (92.66%); however, the highest case fatality rate was noted among indigenous pregnant women (case fatality rate = 1.25%), those aged between 40 and 44 years (case fatality rate = 2.68%), and those with a history of comorbidities (2.08%). Pregnant women residing at lower altitudes (<2500 m) exhibited a higher incidence rate (0.20/100,000) compared to those at higher altitudes (>2500 m), which stood at 0.17/100,000. The COVID-19 pandemic has profoundly impacted pregnant women in Ecuador during the first 14 months, particularly those with comorbidities, older age, and of indigenous ethnicity. These factors have heightened their vulnerability and susceptibility to severe COVID-19 infection and subsequent mortality. This underscores the urgency for comprehensive protective measures, including prioritization for vaccination. Further studies are needed to inform tailored prevention strategies and therapeutic interventions for these high-risk groups.

The Association of County-level Prostate-specific Antigen Screening with Metastatic Prostate Cancer and Prostate Cancer Mortality

Background and objectiveThere exists ongoing debate about the benefits and harms of prostate-specific antigen (PSA) screening for prostate cancer. This study sought to evaluate the association of county-level PSA screening rates with county-level incidence of metastatic prostate cancer and prostate cancer mortality in the USA. MethodsThis ecological study used data from the 2004–2012 Behavioral Risk Factor Surveillance System (BRFSS) to build a multilevel mixed-effect model with poststratification using US Census data to estimate county-level PSA screening rates for all 3143 US counties adjusted for age, race, ethnicity, and county-level poverty rates. The exposure of interest was average county-level PSA screening rate from 2004 to 2012, defined as the proportion of men aged 40–79 yr who underwent PSA screening within the prior 2 yr. The primary outcomes were county-level age-adjusted incidence of regional/distant prostate cancer during 2015–2019 and age-adjusted prostate cancer mortality during 2016–2020. Key findings and limitationsA total of 416221 male BRFSS respondents aged 40–79 yr met the inclusion criteria and were used in the multilevel mixed-effect model. The model was poststratified using 63.4 million men aged 40–79 yr from all 3143 counties in the 2010 Decennial Census. County-level estimated PSA screening rates exhibited geographic variability and were pooled at the state level for internal validation with direct BRFSS state-level estimates, showing a strong correlation with Pearson correlation coefficients 0.77–0.90. A 10% higher county-level probability of PSA screening in 2004–2012 was associated with a 14% lower county-level incidence of regional/distant prostate cancer in 2015–2019 (rate ratio 0.86, 95% confidence interval [CI] 0.85–0.87, p < 0.001) and 10% lower county-level prostate cancer mortality in 2016–2020 (rate ratio 0.90, 95% CI 0.89–0.91, p < 0.001). Conclusions and clinical implicationsIn this population-based ecological study of all US counties, higher PSA screening rates were associated with a lower incidence of regional/distant prostate cancer and lower prostate cancer mortality at extended follow-up. Patient summaryUS counties with higher rates of prostate-specific antigen (PSA) screening had significantly lower rates of metastatic prostate cancer and prostate cancer mortality in subsequent years. These data may inform shared decision-making regarding PSA screening for prostate cancer.

SARS-CoV-2 incidence and hospitalisation in South Tyrol (Italy): a population-based ecological study

Abstract Background Literature associating SARS-CoV-2 spread to environmental variables such as altitude, tourism, vaccination adherence and demographics, is inconclusive and contrasting. This study aimed at studying these relationships during the first unrestricted winter in South Tyrol, a multicultural Italian alpine province. Methods An ecological study was performed, based on the 20 districts of the area. Data about incidence and hospitalization between November ’21 and February ’22 was collected and associated to geographical, demographic and health-related characteristics via bivariate analyses. Results Incidence (range: 15% - 22%) and hospitalization (range: overall = 0.09% - 0.26%/ intensive care unit (ICU) = 0 - 0.06%) varied widely among districts. Incidence showed positive correlations with average altitude (Rho=0.62, p &amp;lt; 0.001), tourist amount (0.54, p &amp;lt; 0.04) and average family size (0.66, p &amp;lt; 0.005); whereas negative ones with vaccination coverage (-0.62, p &amp;lt; 0.04) and population density (-0.44, p &amp;lt; 0.05). Similar trends were observed for ICU admissions. Incidence was significantly higher in Ladin speaking districts and lower in Italian ones, while ordinary wards admission appeared lowest in Ladin districts and higher in the Italian ones, as well as close to main cities and hospitals. Conclusions Living in urban districts, geographically and linguistically closer to the Health Authorities, may have played a protective role against infection and severe disease, through an increased adherence to public health preventive measures. The concomitant higher rate of admissions might be due to the easier access to the structures. By contrast, infection spread was higher in rural and sparsely populated districts, associated with greater winter tourism and family sizes, but also characterized by lower herd immunity and institutional closeness. More attention should be paid to communities with special needs (geographical and cultural) to ensure equitable means for future pandemics. Key messages • Living in urban districts may protect against infection spread through increased adherence to public health preventive measures, and facilitate hospitalisations due to easier access to the structures. • More attention should be paid to communities geographically and culturally distant from Public Health Institutions to ensure equitable means for future pandemics.

Food environment index and preterm birth rate in the counties of the United States.

To determine the relationship between Food Environment Index (FEI) and Preterm Birth (PTB) rate at the county level of the United States of America (USA) (primary), while evaluating the interaction of multiple factors within a framework of sociodemographic, maternal health, maternal behavioral, and environmental factors. This is a population-based retrospective cohort ecological study from 2015-2018. The study compares the characteristics of the population of the counties of the USA. All counties with complete data on their PTB rate and the independent variables were included in the study. Independent variables with greater than 20% missing data were excluded from the study. Purposive sampling technique was applied. A total of 2983/3142 counties were included in the study. The median PTB rate of all counties was 9.90%. The highest PTB rate (23.3%) was in Tallapoosa County, Alabama and the lowest (3.4%) in San Juan County, Washington State. After adjusting for variables, PTB rate had a significant association with FEI (coefficient of correlation - 0.36, p < 0.01, 95% CI - 0.19 to - 0.04). Increase in the rate of unemployment, African American race, adult smoking, obesity, uninsured rate, sexually transmitted diseases (STD), high school education and air pollution was associated with an increase in PTB rate, while an increase in FEI and alcohol abuse rates was associated with a decrease in PTB rate. FEI can predict the PTB rate in USA counties after adjusting for sociodemographic, health, behavioral and environmental factors. Future studies are needed to confirm these associations and consider them when making policies to reduce PTBs.

Association of socioeconomic indicators with COVID-19 mortality in Brazil: a population-based ecological study.

The article presents an analysis of the spatial distribution of mortality from COVID-19 and its association with socioeconomic indicators in the north-eastern region of Brazil - an area particularly vulnerable with regard to these indicators. This populationbased ecology study was carried out at the municipal level in the years 2020 and 2021, with analyses performed by spatial autocorrelation, multiple linear regression and spatial autoregressive models. The results showed that mortality from COVID-19 in this part of Brazil was higher in the most populous cities with better socioeconomic indicators. Factors such as the onset of the COVID-19 pandemic in large cities, the agglomerations existing within them, the pressure to maintain economic activities and mistakes in the management of the pandemic by the Brazilian federal Government were part of the complex scenario related to the spread of COVID-19 in the country and this study was undertaken in an attempt to understand this situation. Analysing the different scenarios is essential to face the challenges posed by the pandemic to the world's health systems.

Socioeconomic disparities in surgery for carotid artery disease in England.

Carotid artery disease and stroke are more prevalent in socioeconomically deprived areas. The aim was to investigate socioeconomic disparities in carotid artery disease surgery rates and in outcomes following surgery. The study used population-based ecological and cohort study designs, 31 672 census areas in England, hospital admissions from April 2006 to March 2018, the Index of Multiple Deprivation 2010 as the area-level deprivation indicator, and Poisson, logistic, and Cox regression. A total of 54 377 patients (67 per cent men) from a population aged 55 years and older of 14.7 million had carotid artery disease procedures (95 per cent carotid endarterectomy). Carotid endarterectomy rates were 116 per cent (95% c.i. 101 to 132) higher in men and 180 per cent (95% c.i. 155 to 207) higher in women aged 55-64 years in the most compared with the least socioeconomically deprived areas by quintile. However, this difference diminished and appeared to reverse with increasing age, with 24 per cent (95% c.i. 14 to 33) and 12 per cent (95% c.i. -3 to 24) lower carotid endarterectomy rates respectively in men and women aged 85 years and older in the most deprived areas. Patients in deprived areas having carotid endarterectomy were more likely to have been admitted as symptomatic emergency carotid artery disease admissions. Mortality, and a combined outcome of mortality or stroke-related re-admission, were both worse in patients living in more deprived areas and were only partially accounted for by the higher prevalence of co-morbidities. There was, however, no clear pattern of association between deprivation and elective waiting time for carotid endarterectomy. These results provide evidence of socioeconomic disparities in surgery for carotid artery disease. Clear policies are needed to address these disparities.

Relationship between primary vaccination coverage and booster coverage against COVID-19, socio-economic indicators, and healthcare structure in Brazil

ObjectiveTo investigate the relationship between vaccination coverage and booster coverage against COVID-19, socio-economic indicators, and healthcare structure in Brazil. Study designThis is a nationwide population-based ecological study. MethodsWe have obtained data on COVID-19 vaccination for each Brazilian state until December 22, 2022. Our outcomes of interest were primary and booster vaccination coverage. The independent variables included: human development index (HDI); Gini index; population density; unemployment rate; percentage of the population covered by primary health care (PHC); percentage of the population covered by community health workers; number of family health teams; and number of public health establishments. Statistics were performed by using a multivariable linear regression model. ResultsLower rates of primary vaccination coverage were found in states with lower HDI (P = 0.048), population covered by PHC (P = 0.006), and number of public health establishments (P = 0.004). Lower rates of booster coverage were also found in states with lower population density (first booster: P = 0.004; second booster: P = 0.022), PHC (first booster: P = 0.033; second booster: P = 0.042), and public health establishments (first booster: P < 0.001; second booster: P = 0.027). ConclusionOur findings showed heterogeneity in access to vaccination against COVID-19 in Brazil, with lower vaccination coverage in localities with the worst socio-economic indicators and limited healthcare resources.

Space-time risk clusters of Covid-19 in a tourism area in the northeastern Brazil: an epidemiological overview after two years of pandemic

The world is facing a serious viral infection caused by the new Severe Acute Respiratory Syndrome Coronavirus 2. We aimed to evaluate and map the high-risk clusters of COVID-19 in the State of Alagoas, a touristic area in northeastern Brazil, after two years of pandemic by a population-based ecological study, using COVID-19 cases reported in the State of Alagoas, between March, 2020 and April, 2022. We performed a descriptive and statistical analysis of epidemiological data. We then map high-risk areas for COVID-19, using spatial analysis, considering the incidence rate by municipality. 297,972 positive cases were registered; 56.9% were female and 42.7% aged between 20 and 39 years old. Men (OR = 1.59) and older than 60 years old (OR = 29.64) had a higher risk of death, while the highest incidence rates of the disease occurred in the metropolitan region. Our data demonstrate the impact of COVID-19 in the State of Alagoas, through the two years of pandemic. Although the number of cases were greater among women and young adults, the chance of death was greater among men and older adults. High-risk clusters of the disease initially occur in metropolitan cities and tourist areas. KEY WORDS: SARS-CoV-2; COVID-19; spatial analysis; Brazil.

Time trend of infant mortality in Pernambuco, 2001-2019: a population-based ecological study

Resumo Objetivos: analisar a tendência temporal e a distribuição espacial da mortalidade infantil em Pernambuco no período de 2001 a 2019. Métodos: estudo ecológico envolvendo todos os óbitos em crianças menores de um ano residentes no estado. Os dados foram coletados no Sistema de Informações sobre Mortalidade e no Sistema de Informação sobre Nascidos Vivos. Foram calculados quatro coeficientes de mortalidade e a análise temporal foi realizada aplicando o modelo de regressão por pontos de inflexão dos coeficientes em diferentes níveis espaciais. Resultados: foram registrados 47.949 óbitos, dos quais 51,0% (n=24.447) ocorreram nos seis primeiros dias de vida. Foi observada tendência de declínio estatisticamente significativo em todos os coeficientes analisados (-4,5%/ano na mortalidade geral, -3,6%/ano na neonatal precoce, -1,9%/ano no componente neonatal tardio e de -6,3%/ano no componente pós-neonatal). Adicionalmente, 64,3% dos municípios (n=119) apresentaram tendência de declínio no coeficiente de mortalidade infantil geral. Menos de 50% dos municípios apresentaram tendência de redução na mortalidade neonatal precoce e neonatal tardia (41,08%; n=76 e 43,2%; n=80, respectivamente). Na mortalidade pós-neonatal, 57,3% (n=106) apresentaram tendências decrescentes. Conclusões: houve tendência temporal de declínio da mortalidade infantil geral, embora haja importante parcela de municípios com tendência estacionária, justificando a necessidade de reduzir desigualdades sociais e assimetrias geográficas.

Spatial clustering of low rates of COVID-19 vaccination among children and adolescents and their relationship with social determinants of health in Brazil: a nationwide population-based ecological study

ObjectiveThis study aimed to investigate the spatial clusters of high and low COVID-19 vaccination rates among children and adolescents across Brazilian municipalities and their relationship to social determinants of health. Study designThis is a nationwide population-based ecological study. MethodsWe have obtained for each of the 5570 Brazilian municipalities data on the COVID-19 vaccination rate of children and adolescents by August 16, 2022, the Gini index, the social vulnerability index and the municipal human development index. A Bayesian empirical local model was used to identify fluctuations in the COVID-19 vaccination rates. Spatial clusters were identified using scan spatial statistic tests. The relationship among COVID-19 vaccination rates and social determinants of health was explored by using multiple linear regression models. ResultsOverall, 52.1% of children aged 5–11 years and 72.8% of adolescents aged 12–17 years have been fully vaccinated against COVID-19 in Brazil by mid-August 2022. There was spatial dependence on the smoothed rates for both children (I Moran 0.66; P < 0.001) and adolescent (I Moran 0.65; P < 0.001) groups. The lowest rates occurred in municipalities in the North and Northeast regions. Municipalities with a higher Gini Index, higher social vulnerability index and lower municipal human development index were more likely to have a lower COVID-19 vaccination rate for both children and adolescent groups. ConclusionCOVID-19 vaccination of children and adolescents was heterogeneously distributed, with spatial clusters of the lowest vaccination rates occurring mainly in municipalities with marked socio-economic disparities and social vulnerability, especially in the North and Northeast regions.

A novel gun law strength index and influential state gun laws for firearm homicide in the United States, 1999–2018

ObjectivesAlthough some existing indices quantified the mixture strength of state gun laws, methodological supports are still lacking. The study aimed to build a new state gun law strength (GLS) index, evaluate the contribution of all state gun laws to the new index, and assess the association between the new index and firearm homicide mortality. Study designThis is a population-based ecological study. MethodsWe condensed 134 state gun laws into a mixture GLS index at the state level to quantify each state's overall GLS by using the weighted quantile sum regression in each year from 1999 to 2018. The weights of state gun laws in the GLS index revealed their influence on GLS. The model also estimated the association between the GLS index and state-level firearm homicide mortality. ResultsFrom 1999 to 2018, 15 of 134 (11.19%) state gun laws significantly contributed to the GLS index for firearm homicide every year, five of which related to the minimum age of possessing firearms. The most influential gun law was “no possession of handguns until age 21.” The GLS index was significantly and negatively associated with firearm homicide mortality; however, the association gradually diminished over time. ConclusionsThe GLS index has methodological support and can take different gun violence outcomes into account. Future research can adopt the GLS index to conduct additional gun violence research or apply the modeling approach to build new GLS indexes for other gun violence outcomes.

Trends and Geographic Variabilities in Benzodiazepines Prescription in Primary Care to Older Adults: A 3-Year Population-Based Ecological Study in Portugal.

(1) Background: According to the World Health Organization (WHO), benzodiazepines (BZD) are considered essential medicines for the treatment of several mental disorders in older adults over 65 years old. However, the long-term use of BZD could present a harmful impact on this population, leading to cognitive deficits, drug dependence, falls, and fractures. This study aims to analyze trends of BZD prescription to Portuguese older adults in the primary care setting, and to analyze the change in the prescription rate of BZD over time, assessing the geographical variability in mainland Portugal. (2) Methods: A nationwide, retrospective ecological study was performed between January 2019 and December 2021 for BZD prescribing data reported in a national public database for all persons aged 65 and older in mainland Portugal (about 2.4 million). Trends of BZD by defined daily doses (DDD) and per 1000 older adults’ inhabitants per day (DID) were analyzed. (3) Results: A total of 19 BZD were included in this study and more than 1 million BZD prescriptions were recorded in each year of this study period. BZD prescriptions were three times higher in females than in males. Alprazolam, lorazepam, diazepam, ethyl loflazepate, and bromazepam were the most prescribed BZD over the years, presenting the higher DDD and DID values. (4) Conclusions: Despite the DID value growth of several BZD, Portugal is now showing stable BZD prescriptions in older adults, between the years 2019 to 2021. More studies are needed to access if these results are a consequence of successful health programs or just a consequence of the pandemic context that we are facing, which limited older adults’ clinical appointments.

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

BackgroundData 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.MethodsThis 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.FindingsA 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.InterpretationThe 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.FundingNone.

Geospatial Analysis of Social Determinants of Health Identifies Neighborhood Hot Spots Associated With Pediatric Intensive Care Use for Acute Respiratory Failure Requiring Mechanical Ventilation.

Poverty, racial bias, and disparities are linked to adverse health outcomes for children in the United States. The social vulnerability and child opportunity indices are composite measures of the social, economic, education, health, and environmental qualities that affect human health for every U.S. census tract. Composite measures of social vulnerability and child opportunity were compared for neighborhood hot spots, where PICU admissions for acute respiratory failure requiring invasive mechanical ventilation were at the 90th percentile or greater per 1,000 children, versus non-hot spots. Population-based ecological study. Two urban free-standing children's hospital PICUs consisting of a 36-bed quaternary academic and a 56-bed tertiary community center, in Atlanta, GA. Mechanically ventilated children who were 17 years of age or younger with a geocodable Georgia residential address admitted to a PICU for at least 1 day. None. Residential addresses were geocoded and spatially joined to census tracts. Composite measures of social vulnerability and childhood opportunity, PICU readmission rates, and hospital length of stay were compared between neighborhood hot spots versus non-hot spots. There were 340 of 3,514 children (9.7%) who lived within a hot spot. Hot spots were associated with a higher (worse) composite social vulnerability index ranking, reflecting differences in socioeconomic status, household composition and disability, and housing type and transportation. Hot spots also had a lower (worse) composite childhood opportunity index percentile ranking, reflecting differences in the education, health and environment, and social and economic domains. Higher social vulnerability and lower childhood opportunity were not associated with readmission rates but were associated with longer total median duration of hospital days per 1,000 children in a census tract. Social determinants of health identified by geospatial analyses are associated with acute respiratory failure requiring invasive mechanical ventilation in critically ill children. Interventions addressing the neighborhood social vulnerability and child opportunity are needed to decrease disparities in intensive care admissions for acute respiratory failure requiring mechanical ventilation.

Time varying association between deprivation, ethnicity and SARS-CoV-2 infections in England: A population-based ecological study.

BackgroundEthnically diverse and socio-economically deprived communities have been differentially affected by the COVID-19 pandemic in the UK.MethodUsing a multilevel regression model we assessed the time-varying association between SARS-CoV-2 infections and areal level deprivation and ethnicity from 1st of June 2020 to the 19th of September 2021. We separately considered weekly test positivity rate and estimated debiased prevalence at the Lower Tier Local Authority (LTLA) level, adjusting for confounders and spatio-temporal correlation structure.FindingsComparing the least deprived and predominantly White areas with most deprived and predominantly non-White areas over the whole study period, the weekly positivity rate increases from 2·977% (95% CrI 2.913%-3.029%) to 3·347% (95% CrI 3.300%-3.402%). Similarly, prevalence increases from 0·369% (95% CrI 0.361%-0.375%) to 0·405% (95% CrI 0.399%-0.412%). Deprivation has a stronger effect until October 2020, while the effect of ethnicity becomes more pronounced at the peak of the second wave and then again in May-June 2021. In the second wave of the pandemic, LTLAs with large South Asian populations were the most affected, whereas areas with large Black populations did not show increased values for either outcome during the entire period under analysis.InterpretationDeprivation and proportion of non-White populations are both associated with an increased COVID-19 burden in terms of disease spread and monitoring, but the strength of association varies over the course of the pandemic and for different ethnic subgroups. The consistency of results across the two outcomes suggests that deprivation and ethnicity have a differential impact on disease exposure or susceptibility rather than testing access and habits.FundingsEPSRC, MRC, The Alan Turing Institute, NIH, UKHSA, DHSC.

Concordance between the Clinical Diagnosis of Influenza in Primary Care and Epidemiological Surveillance Systems (PREVIGrip Study).

Introduction: Health authorities use different systems of influenza surveillance. Sentinel networks, which are recommended by the World Health Organization, provide information on weekly influenza incidence in a monitored population, based on laboratory-confirmed cases. In Catalonia there is a public website, DiagnostiCat, that publishes the number of weekly clinical diagnoses at the end of each week of disease registration, while the sentinel network publishes its reports later. The objective of this study was to determine whether there is concordance between the number of cases of clinical diagnoses and the number of confirmed cases of influenza, in order to evaluate the predictive potential of a clinical diagnosis-based system. Methods: Population-based ecological time series study in Catalonia. The period runs from the 2010–2011 to the 2018–2019 season. The concordance between the clinical diagnostic cases and the confirmed cases was evaluated. The degree of agreement and the concordance were analysed using Bland–Altman graphs and intraclass correlation coefficients. Results: There was greater concordance between the clinical diagnoses and the sum of the cases confirmed outside and within the sentinel network than between the diagnoses and the confirmed sentinel cases. The degree of agreement was higher when influenza rates were low. Conclusions: There is concordance between the clinical diagnosis and the confirmed cases of influenza. Registered clinical diagnostic cases could provide a good alternative to traditional surveillance, based on case confirmation. Cases of clinical diagnosis of influenza may have the potential to predict the onset of annual influenza epidemics.