Excess deaths among adults in the state of Santa Catarina: an ecological study during the COVID-19 pandemic, Brazil, 2020-2021

Holzbach, Rebeca Heyse; Silva, Gabriel Resun Gomes da; Bianchi, Jean Carlos; Hillesheim, Danúbia; Menegon, Fabrício Augusto; Hallal, Ana Luiza de Lima Curi

doi:10.1590/s2237-96222023000200003

ABSTRACT

Objective:

to estimate excess deaths during the COVID-19 pandemic in the state of Santa Catarina and its macro-regions, Brazil, 2020-2021.

Methods:

this was an ecological study, using data from the Mortality Information System; excess deaths in adults were calculated by the difference between the observed number of deaths and expected number of deaths, taking into account the average of deaths that occurred between 2015 and 2019; the variables “macro-region of residence”, “quarter”, “month”, “sex” and “age group” were analyzed; data were analyzed in a descriptive manner.

Results:

a total of 6,315 excess deaths in 2020 and 17,391 in 2021, mostly in males (57.4%) and those aged 60 years and older (74.0%); macro-regions and periods with the greatest excess deaths were those in which there were most deaths due to COVID-19; the greatest excess deaths occurred in March 2021 (n = 4,207), with a progressive decrease until the end of the year.

Conclusion:

there were excess deaths in the state of Santa Catarina and in all its macro-regions during the COVID-19 pandemic.

Keywords:
COVID-19; Coronavirus; Excess Mortality; Mortality; Descriptive Epidemiology

RESUMEN

Objetivo:

estimar el exceso de muertes en Santa Catarina y macrorregiones durante la pandemia de COVID-19, en los años 2020 y 2021.

Métodos:

estudio ecológico utilizando Sistema de Información de Mortalidad. El exceso de defunciones en adultos se calculó por la diferencia entre defunciones observadas y esperadas, considerando el promedio de defunciones entre 2015 y 2019. Las variables analizadas fueron: macrorregión de residencia, trimestre, mes, sexo y grupo de edad. Los datos se analizaron descriptivamente.

Resultados:

el exceso fue de 6.315 defunciones en 2020 y 17.391 en 2021, mayor en varones (57,4%) y mayores de 60 años (74,0%). Las macrorregiones y periodos con mayor superávit fueron los que registraron más muertes por COVID-19. El mayor exceso de muertes ocurrió en marzo de 2021 (n=4.207), con una disminución progresiva hasta el final del año.

Conclusión:

hubo exceso de muertes en Santa Catarina y en todas macrorregiones durante la pandemia de COVID-19.

Palabras-clave:
COVID-19; Coronavirus; Exceso de Mortalidad; Mortalidad; Epidemiología Descriptiva

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INTRODUCTION

In 2021, Brazil became the epicenter of the COVID-19 pandemic, reaching an average of 4,000 deaths in 24 hours.¹1 Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Brasil Livre da Tuberculose: Plano Nacional pelo Fim da Tuberculose como Problema de Saúde Pública: Estratégias para 2021-2025. Brasília: Ministério da Saúde; 2021 [citado 2022 Maio 17]. Disponível em: Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/publicacoes-svs/tuberculose/plano-nacional-pelo-fim-da-tuberculose-como-problema-de-saude-publica_-estrategias-para-2021-2925.pdf/view
https://www.gov.br/saude/pt-br/centrais-... By the end of June 2022, Brazil recorded 669,530 deaths from COVID-19.²2 Trauer JM, Dodd PJ, Gomes MGM, Gomes GB, Houben RMGJ, McBryde EM, et al. The importance of heterogeneity to the epidemiology of tuberculosis. Clin Infect Dis. 2019;69(1):159-66. doi: 10.1093/cid/ciy938
https://doi.org/10.1093/cid/ciy938... However, the data seem to underestimate the impact of COVID-19 on the country, not only because of significant underreporting, but also for the indirect consequences of the pandemic.³3 Zhang Q, Song W, Liu S, An Q, Tao N, Zhu X, et al. An ecological study of tuberculosis incidence in China, from 2002 to 2018. Front Public Health. 2022;18(9):766362. doi: 10.3389/fpubh.2021.766362
https://doi.org/10.3389/fpubh.2021.76636... ^,⁴4 Benchimol EI, Smeeth L, Guttmann A, Harron K, Moher D, Petersen I, et al. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med. 2015;12(10):e1001885. doi: 10.1371/journal.pmed.1001885
https://doi.org/10.1371/journal.pmed.100...

Problems related to resource scarcity, conflicts of interest involving political parties, lack of coordination between the spheres of the executive branch and non-compliance with social isolation measures culminated in what is considered the greatest healthcare and hospital collapse in Brazil’s history.³3 Zhang Q, Song W, Liu S, An Q, Tao N, Zhu X, et al. An ecological study of tuberculosis incidence in China, from 2002 to 2018. Front Public Health. 2022;18(9):766362. doi: 10.3389/fpubh.2021.766362
https://doi.org/10.3389/fpubh.2021.76636... ^,⁵5 Instituto Brasileiro de Geografia e Estatística. Cidades e estados: Paraná. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2022 [citado 2023 Nov 23]. Disponível em: Disponível em: https://www.ibge.gov.br/cidades-e-estados/pr.html
https://www.ibge.gov.br/cidades-e-estado... ^,⁶6 Santos L. Região de saúde e suas redes de atenção: modelo organizativo-sistêmico do SUS. Cien Saude Colet. 2017;22(4):1281-9. doi: 10.1590/1413-81232017224.26392016
https://doi.org/10.1590/1413-81232017224... Overloaded health system, delay in receiving care and difficulties in accessing services probably led to greater morbidity and mortality from other diseases, as observed in countries such as the United States and England.³3 Zhang Q, Song W, Liu S, An Q, Tao N, Zhu X, et al. An ecological study of tuberculosis incidence in China, from 2002 to 2018. Front Public Health. 2022;18(9):766362. doi: 10.3389/fpubh.2021.766362
https://doi.org/10.3389/fpubh.2021.76636... ^,⁷7 Khan MK, Islam MN, Ferdous J, Alam MM. An overview on epidemiology of tuberculosis. Mymensingh Med J. 2019;28(1):259-66.

8 Prado Junior JC, Medronho RA. Spatial analysis of tuberculosis cure in primary care in Rio de Janeiro, Brazil. BMC Public Health. 2021;21(1):1841. doi: 10.1186/s12889-021-11834-1
https://doi.org/10.1186/s12889-021-11834... ^-⁹9 Pereira TV, Nogueira MC, Campos EMS. Spatial analysis of tuberculosis and its relationship with socioeconomic indicators in a medium-sized city in Minas Gerais. Rev Bras Epidemiol. 2021;24(suppl 1):e210021. doi: 10.1590/1980-549720210021.supl.1
https://doi.org/10.1590/1980-54972021002...

With regard to the Brazilian scenario, disorganization of services, lack of coordination among federal entities and excessive distances to be traveled when seeking care were other factors that may have contributed to an increase in morbidity and mortality.⁶6 Santos L. Região de saúde e suas redes de atenção: modelo organizativo-sistêmico do SUS. Cien Saude Colet. 2017;22(4):1281-9. doi: 10.1590/1413-81232017224.26392016
https://doi.org/10.1590/1413-81232017224... ^,¹⁰10 Nogueira VD, Xavier-Gomes LM, Barbosa TLA. Mortalidade por homicídios em linha de fronteira no Paraná, Brasil. Cien Saude Colet. 2020;25(8):3107-18. doi: 10.1590/1413-81232020258.28522018
https://doi.org/10.1590/1413-81232020258... Especially among people with chronic diseases and groups at risk from COVID-19, there was a low demand for health services as a result of more severe measures of social isolation.³3 Zhang Q, Song W, Liu S, An Q, Tao N, Zhu X, et al. An ecological study of tuberculosis incidence in China, from 2002 to 2018. Front Public Health. 2022;18(9):766362. doi: 10.3389/fpubh.2021.766362
https://doi.org/10.3389/fpubh.2021.76636... Furthermore, it is noteworthy that the supply of essential services for other conditions and injuries has been reduced, and even interrupted in several regions,⁴4 Benchimol EI, Smeeth L, Guttmann A, Harron K, Moher D, Petersen I, et al. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med. 2015;12(10):e1001885. doi: 10.1371/journal.pmed.1001885
https://doi.org/10.1371/journal.pmed.100... impairing the continuity of care and increasing the risk of death from other causes.³3 Zhang Q, Song W, Liu S, An Q, Tao N, Zhu X, et al. An ecological study of tuberculosis incidence in China, from 2002 to 2018. Front Public Health. 2022;18(9):766362. doi: 10.3389/fpubh.2021.766362
https://doi.org/10.3389/fpubh.2021.76636... ^,⁸8 Prado Junior JC, Medronho RA. Spatial analysis of tuberculosis cure in primary care in Rio de Janeiro, Brazil. BMC Public Health. 2021;21(1):1841. doi: 10.1186/s12889-021-11834-1
https://doi.org/10.1186/s12889-021-11834...

Estimating the effects of the pandemic has therefore become a challenge. Studies that take into account only the notifications of deaths due to COVID-19, and disregard the indirect consequences generated by the disease, underestimate the impact of the pandemic on mortality.¹¹11 Aikes S, Rizzotto MLF. Integração regional em cidades gêmeas do Paraná, Brasil, no âmbito da saúde. Cad Saude Publica. 2018;34(8):e00182117. doi: 10.1590/0102-311X00182117
https://doi.org/10.1590/0102-311X0018211... ^,¹²12 Hortelan MS, Almeida ML, Fumincelli L, Zilly A, Nihei OK, Peres AM, et al. Papel do gestor de saúde pública em região de fronteira: scoping review. Acta Paul Enferm. 2019;32(2):229-36. doi: 10.1590/1982-0194201900031
https://doi.org/10.1590/1982-01942019000... Thus, the World Health Organization (WHO) recommends the calculation of excess deaths as a powerful tool to estimate the real impact of the pandemic on overall mortality among the population.¹¹11 Aikes S, Rizzotto MLF. Integração regional em cidades gêmeas do Paraná, Brasil, no âmbito da saúde. Cad Saude Publica. 2018;34(8):e00182117. doi: 10.1590/0102-311X00182117
https://doi.org/10.1590/0102-311X0018211...

12 Hortelan MS, Almeida ML, Fumincelli L, Zilly A, Nihei OK, Peres AM, et al. Papel do gestor de saúde pública em região de fronteira: scoping review. Acta Paul Enferm. 2019;32(2):229-36. doi: 10.1590/1982-0194201900031
https://doi.org/10.1590/1982-01942019000... ^-¹³13 Gelaw YA, Yu W, Magalhães RJS, Assefa Y, Williams G. Effect of temperature and altitude difference on tuberculosis notification: a systematic review. J Glob Infect Dis. 2019;11(2):63-8. doi: 10.4103/jgid.jgid_95_18
https://doi.org/10.4103/jgid.jgid_95_18...

The objective of this study was to estimate excess deaths in the state of Santa Catarina and its macro-regions during the COVID-19 pandemic between 2020 and 2021.

METHODS

This was an ecological study conducted with the death notifications registered on the Mortality Information System (Sistema de Informações sobre Mortalidade - SIM) between January 1, 2020 and December 31, 2021, with the state of Santa Catarina as a unit of analysis. Data were accessed on January 28, 2022, via the Brazilian National Health System Information Technology Department (Departamento de Informática do Sistema Único de Saúde - DATASUS) website, (https://datasus.saude.gov.br/).

The following variables were analyzed:

sex (male; female);
Macro-region of residence in the state of Santa Catarina (Great West; Midwest, and Serra; Foz do Rio Itajaí; Vale do Itajaí ; Greater Florianópolis; South; Northeast and North Plateau);
age group (in years: 20 to 29; 30 to 39; 40 to 49; 50 to 59; 60 to 69; 70 to 79; 80 and older);
quarter (1^st; 2^nd; 3^rd; 4^th); and
calendar months.

Individuals from 0 to 19 years of age were excluded from the study, since COVID-19 manifests itself differently in children and adolescents,¹⁴14 Magnabosco GT, Órfão NH, Brunello MEF, Wysocki AD, Lopes LM, Campoy LT. Novas doenças e ameaças antigas: a repercussão da covid-19 no manejo da tuberculose. Saude Coletiva (Barueri). 2020;10(54):2639-44. doi: 10.36489/saudecoletiva.2020v10i54p2639-2644
https://doi.org/10.36489/saudecoletiva.2... while adults aged 20 years or older and whose death was recorded during the study period were included.

The expected number of deaths was calculated by the simple average of the number of deaths in the years 2015 and 2019, that is, the number of deaths in each of the five years was added (according to the location and period determined) and the result of the addition was divided by 5, according to the methodology proposed by other authors.¹²12 Hortelan MS, Almeida ML, Fumincelli L, Zilly A, Nihei OK, Peres AM, et al. Papel do gestor de saúde pública em região de fronteira: scoping review. Acta Paul Enferm. 2019;32(2):229-36. doi: 10.1590/1982-0194201900031
https://doi.org/10.1590/1982-01942019000... ^,¹⁵15 Siqueira TC, Martellet MG, Tavernard GLN, Silva VM, Moura STS, Silva LAF, et al. Percepção de enfermeiros: enfoque na família e orientação para a comunidade nas ações de tuberculose. Cienc Cuid Saude. 2020;19:e50175. doi: 10.4025/ciencuidsaude.v19i0.50175
https://doi.org/10.4025/ciencuidsaude.v1... Excess deaths were estimated by the difference between the observed number of deaths in 2020 and 2021 and expected number of deaths for the same period. The mathematical ratio between the observed number of deaths and expected number of deaths in the period was calculated for each quarter of 2020 and 2021, according to the macro-region.

Data analysis was performed using Microsoft Office Excel 2016. Absolute frequencies (n), averages, standard deviation (SD) and the percentage change of the data was calculated. The percentage change of excess deaths between 2020 and 2021, in each macro-region, was calculated by using the following formula:

Percentage change = (Excess deaths in 2021 - Excess deaths in 2020) x 100÷ Excess deaths in 2020

This study was not submitted for approval of a Research Ethics Committee, given that information from secondary databases, without identification of individuals, and in the public domain was used.

RESULTS

In the five years prior to the COVID-19 pandemic, the average number of deaths in the state of Santa Catarina was 38,522 [(SD) = 1,546.3]. In 2020, there was a 16.3% increase in the number of deaths in relation to this average; and in 2021, a 45.1% increase. In all macro-regions the number of deaths was higher than expected (Table 1).

As for the year 2020, there were 6,315 excess deaths. The South (1,362) and Greater Florianópolis (1,146) macro-regions showed the largest increase, in addition to the highest number of notifications of deaths due to COVID-19. In 2021, there were 17,391 excess deaths, and this number was more significant in the Northeast and North Plateau (3,515), South (2,855) and Midwest and Serra (2,691) macro-regions, as well as there were more deaths due to COVID-19. It could be seen an increase in death ratios in most macro-regions, in almost all quarters; with the exception of the 2^nd quarter of 2020 (Tables 1 and 2).

The highest number of excess deaths was observed in the periods when there were more deaths due to COVID-19. In 2020, the highest excess deaths occurred during two peaks, one in July-August and another at the end of the year. The highest values for both excess deaths (4,207) and deaths due to COVID-19 (3,752), occurred in March 2021 (Figure 1a).

Excess deaths were found for all age groups, both in 2020 and 2021; with the exception of the male age group 20-29 in 2020. Excess deaths were higher in males (57.4%), in all other age groups, in both years, when compared to excess deaths in females. For both sexes, it could be seen excess deaths in the population aged 60 years and older (74.0%) (Figure 1b).

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Table 1
- Overall deaths and COVID-19 deaths reported by macro-region of residence and year, state of Santa Catarina, Brazil, 2015-2021

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Table 2
- The ratio between the observed number of deaths and expected number of deaths by quarter, excess deaths and percentage change according to macro-region, state of Santa Catarina, Brazil, 2020-2021

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Figure 1
- Evolution of COVID-19 deaths and excess deaths in the period (a) and distribution of excess deaths according to sex and age group (b), state of Santa Catarina, Brazil, 2020-2021

DISCUSSION

In 2020 and 2021, there were excess deaths in the state of Santa Catarina, higher in males and for the variable age, in individuals aged 60 years and older. It could be seen excess deaths and an increasing death ratio for most macro-regions of the state and periods, with the exception of the 2^nd quarter of 2020 and December 2021. The largest excess deaths occurred in the same periods and locations where there was a higher number of deaths due to COVID-19.

In a context of low testing and lack of standardization in data notification, a technical note pointed out rates of underreporting of deaths in Santa Catarina during the COVID-19 pandemic near 278%.¹⁶16 Silva GDM, Duarte EC, Cruz OG, Garcia LP. Identificação de microrregiões com subnotificação de casos de tuberculose no Brasil, 2012 a 2014. Epidemiol Serv Saude. 2020;29(1):e2018485. doi: 10.5123/S1679-49742020000100025
https://doi.org/10.5123/S1679-4974202000... The excess deaths found in this study was 27.4% higher than the number of cumulative deaths due to COVID-19 and reported by the state. A possible explanation for this lies in the fact that excess deaths are not an indicator affected by the classification of causes of death, therefore they have not been affected by the high underreporting.¹¹11 Aikes S, Rizzotto MLF. Integração regional em cidades gêmeas do Paraná, Brasil, no âmbito da saúde. Cad Saude Publica. 2018;34(8):e00182117. doi: 10.1590/0102-311X00182117
https://doi.org/10.1590/0102-311X0018211... ^,¹²12 Hortelan MS, Almeida ML, Fumincelli L, Zilly A, Nihei OK, Peres AM, et al. Papel do gestor de saúde pública em região de fronteira: scoping review. Acta Paul Enferm. 2019;32(2):229-36. doi: 10.1590/1982-0194201900031
https://doi.org/10.1590/1982-01942019000... In addition, excess deaths encompass not only deaths due to COVID-19, but may also be a reflection of indirect mortality, resulting, among other factors, from health system overload that led to an increase in deaths from other conditions.³3 Zhang Q, Song W, Liu S, An Q, Tao N, Zhu X, et al. An ecological study of tuberculosis incidence in China, from 2002 to 2018. Front Public Health. 2022;18(9):766362. doi: 10.3389/fpubh.2021.766362
https://doi.org/10.3389/fpubh.2021.76636...

Studies show the association between higher COVID-19 morbidity and mortality and regions and locations with high population density, where there are usually higher transmission rates and lower social isolation.¹⁷17 Arentz M, Ma J, Zheng P, Vos T, Murray CJL, Kyu HH. The impact of the COVID-19 pandemic and associated suppression measures on the burden of tuberculosis in India. BMC Infect Dis. 2022;22(1):92. doi: 10.1186/s12879-022-07078-y
https://doi.org/10.1186/s12879-022-07078...

18 Lakoh S, Jiba DF, Baldeh M, Adekanmbi O, Barrie U, Seissay AL, et al. Impact of COVID-19 on tuberculosis case detection and treatment outcomes in Sierra Leone. Trop Med Infect Dis. 2021;6(3):154. doi: 10.3390/tropicalmed6030154
https://doi.org/10.3390/tropicalmed60301... ^-¹⁹19 Souza ASR, Amorim MMR, Melo ASO, Delgado AM, Forêncio ACMCC, Oliveira TV, et al. Aspectos gerais da pandemia da covid-19. Rev Bras Saude Mater Infant. 2021;21(Suppl 1):529-46. doi: 10.1590/1806-9304202100S100003
https://doi.org/10.1590/1806-9304202100S... In this study, the macro-regions with the highest demographic density were those with the highest excess deaths and most deaths due to COVID-19, in line with what is described in the literature.¹⁷17 Arentz M, Ma J, Zheng P, Vos T, Murray CJL, Kyu HH. The impact of the COVID-19 pandemic and associated suppression measures on the burden of tuberculosis in India. BMC Infect Dis. 2022;22(1):92. doi: 10.1186/s12879-022-07078-y
https://doi.org/10.1186/s12879-022-07078...

18 Lakoh S, Jiba DF, Baldeh M, Adekanmbi O, Barrie U, Seissay AL, et al. Impact of COVID-19 on tuberculosis case detection and treatment outcomes in Sierra Leone. Trop Med Infect Dis. 2021;6(3):154. doi: 10.3390/tropicalmed6030154
https://doi.org/10.3390/tropicalmed60301...

19 Souza ASR, Amorim MMR, Melo ASO, Delgado AM, Forêncio ACMCC, Oliveira TV, et al. Aspectos gerais da pandemia da covid-19. Rev Bras Saude Mater Infant. 2021;21(Suppl 1):529-46. doi: 10.1590/1806-9304202100S100003
https://doi.org/10.1590/1806-9304202100S... ^-²⁰20 Couto MT, Barbieri CLA, Matos CCSA. Considerações sobre o impacto da covid-19 na relação indivíduo-sociedade: da hesitação vacinal ao clamor por uma vacina. Saude Soc. 2021;30(1):e200450. doi: 10.1590/S0104-12902021200450
https://doi.org/10.1590/S0104-1290202120... Great West and Midwest and Serra, although they are locations of low population density, showed high excess deaths, especially in 2021, and possible explanations for this finding would be the intense flow of people and unfavorable sanitary conditions in meat industries in the region, which are favorable to the spread of the virus.²⁰20 Couto MT, Barbieri CLA, Matos CCSA. Considerações sobre o impacto da covid-19 na relação indivíduo-sociedade: da hesitação vacinal ao clamor por uma vacina. Saude Soc. 2021;30(1):e200450. doi: 10.1590/S0104-12902021200450
https://doi.org/10.1590/S0104-1290202120...

21 Jain VK, Iyengar KP, Samy DA, Vaishya R. Tuberculosis in the era of COVID-19 in India. Diabetes Metab Syndr. 2020;14(5):1439-43. doi: 10.1016/j.dsx.2020.07.034
https://doi.org/10.1016/j.dsx.2020.07.03...

22 Fei H, Yinyin X, Hui C, Ni W, Xin D, Wei C, et al. The impact of the COVID-19 epidemic on tuberculosis control in China. Lancet Reg Health West Pac. 2020;3:100032 doi: 10.1016/j.lanwpc.2020.100032
https://doi.org/10.1016/j.lanwpc.2020.10...

23 Governo do Estado (SC). Secretaria do Estado de Saúde de Santa Catarina. Coronavírus [Internet]. 2020[atualizado 2022 Mar 8; citado 2022 Mar 8]. Disponível em: Disponível em: http://www.coronavirus.sc.gov.br/
http://www.coronavirus.sc.gov.br/... ^-²⁴24 Ripplinger F, Dalmora TWR, Scherma RA. Geografia da covid-19 em Santa Catarina: notas sobre o trabalho na criação e na indústria de abates de animais. Revista Pegada. 2020;21(2):463-92. doi: 10.33026/peg.v21i2.7816
https://doi.org/10.33026/peg.v21i2.7816...

The first death due to COVID-19 in the state of Santa Catarina occurred in March 2020, when the social isolation rate reached 72.8% - probably attributed to the implementation of social distancing measures.²³23 Governo do Estado (SC). Secretaria do Estado de Saúde de Santa Catarina. Coronavírus [Internet]. 2020[atualizado 2022 Mar 8; citado 2022 Mar 8]. Disponível em: Disponível em: http://www.coronavirus.sc.gov.br/
http://www.coronavirus.sc.gov.br/... ^,²⁵25 Inloco. Mapa brasileiro da COVID-19 [Internet]. [s.l.]: Inloco; 2020 [atualizado 2022 Mar 8; citado 2022 Mar 8]. Disponível em: Disponível em: https://mapabrasileirodacovid.inloco.com.br/pt/
https://mapabrasileirodacovid.inloco.com... ^,²⁶26 Hughes HMFBR, Carneiro RAVD, Hillesheim D, Hallal ALC. Evolução da COVID-19 em Santa Catarina: decretos estaduais e indicadores epidemiológicos até agosto de 2020. Epidemiol Serv Saude. 2021;30(4):e2021521. doi: 10.1590/S1679-49742021000400025
https://doi.org/10.1590/S1679-4974202100... However, a study indicated inconsistency with the reality of the pandemic at the time of publication of state decrees, especially in the 2^nd half, with early flexibility and partial restrictions. At the end of the year, there was also government and media encouragement of tourism, increasing the risk of spreading the virus.²⁷27 Caponi S. Covid-19 em Santa Catarina: um triste experimento populacional. Hist Cienc Saude Manguinhos. 2021;28(2):593-8. doi: 10.1590/S0104-59702021005000004
https://doi.org/10.1590/S0104-5970202100... This scenario seems to explain the evolution of excess deaths in the state in 2020, with higher surplus in the 2^nd half of the year.²⁷27 Caponi S. Covid-19 em Santa Catarina: um triste experimento populacional. Hist Cienc Saude Manguinhos. 2021;28(2):593-8. doi: 10.1590/S0104-59702021005000004
https://doi.org/10.1590/S0104-5970202100...

In the state of Santa Catarina, the stratification of excess deaths by sex and age showed excess deaths in males and growth with increasing age. It is commonly known that the risk of dying from COVID-19 is higher in males, associated with hormonal, immunological factors and their lower tendency to self-care.²⁸28 Bwire GM. Coronavirus: why men are more vulnerable to covid-19 than women?. SN Comp Clin Med. 2020;2(7):874-6. doi: 10.1007/s42399-020-00341-w
https://doi.org/10.1007/s42399-020-00341... The risk of death is also higher in older adults, given that, in addition to the natural consequences of aging, there is a high prevalence of comorbidities in this age group, making it more susceptible to both COVID-19 and lack of healthcare services during the pandemic.²⁹29 Perrotta F, Corbi G, Mazzeo G, Boccia M, Aronne L, D’Agnano V, et al. COVID-19 and the elderly: insights into pathogenesis and clinical decision-making. Aging Clin Exp Res. 2020;32(8):1599-608. doi: 10.1007/s40520-020-01631-y
https://doi.org/10.1007/s40520-020-01631...

As a limitation, it is noteworthy that the way to estimate the excess deaths is not among the most robust ones, although it is pointed out as a standard and effective approach.¹⁵15 Siqueira TC, Martellet MG, Tavernard GLN, Silva VM, Moura STS, Silva LAF, et al. Percepção de enfermeiros: enfoque na família e orientação para a comunidade nas ações de tuberculose. Cienc Cuid Saude. 2020;19:e50175. doi: 10.4025/ciencuidsaude.v19i0.50175
https://doi.org/10.4025/ciencuidsaude.v1... Secondary databases are also directly influenced by the quality of filling out, and their heterogeneous coverage in the territory. As a potentiality, the analyzed indicator has been pointed out as one of the most important in the COVID-19 pandemic scenario, because, in addition to capturing the direct and indirect impact of mortality due to the pandemic, it is independent of testing strategies or the final classification of causes of death.¹¹11 Aikes S, Rizzotto MLF. Integração regional em cidades gêmeas do Paraná, Brasil, no âmbito da saúde. Cad Saude Publica. 2018;34(8):e00182117. doi: 10.1590/0102-311X00182117
https://doi.org/10.1590/0102-311X0018211...

12 Hortelan MS, Almeida ML, Fumincelli L, Zilly A, Nihei OK, Peres AM, et al. Papel do gestor de saúde pública em região de fronteira: scoping review. Acta Paul Enferm. 2019;32(2):229-36. doi: 10.1590/1982-0194201900031
https://doi.org/10.1590/1982-01942019000... ^-¹³13 Gelaw YA, Yu W, Magalhães RJS, Assefa Y, Williams G. Effect of temperature and altitude difference on tuberculosis notification: a systematic review. J Glob Infect Dis. 2019;11(2):63-8. doi: 10.4103/jgid.jgid_95_18
https://doi.org/10.4103/jgid.jgid_95_18...

It can be concluded that there were excess deaths in Santa Catarina and in all its macro-regions during the years 2020 and 2021, in most of the periods analyzed, higher in males and in those aged 60 years and older.

REFERENCES

¹
Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Brasil Livre da Tuberculose: Plano Nacional pelo Fim da Tuberculose como Problema de Saúde Pública: Estratégias para 2021-2025. Brasília: Ministério da Saúde; 2021 [citado 2022 Maio 17]. Disponível em: Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/publicacoes-svs/tuberculose/plano-nacional-pelo-fim-da-tuberculose-como-problema-de-saude-publica_-estrategias-para-2021-2925.pdf/view
» https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/publicacoes-svs/tuberculose/plano-nacional-pelo-fim-da-tuberculose-como-problema-de-saude-publica_-estrategias-para-2021-2925.pdf/view
²
Trauer JM, Dodd PJ, Gomes MGM, Gomes GB, Houben RMGJ, McBryde EM, et al. The importance of heterogeneity to the epidemiology of tuberculosis. Clin Infect Dis. 2019;69(1):159-66. doi: 10.1093/cid/ciy938
» https://doi.org/10.1093/cid/ciy938
³
Zhang Q, Song W, Liu S, An Q, Tao N, Zhu X, et al. An ecological study of tuberculosis incidence in China, from 2002 to 2018. Front Public Health. 2022;18(9):766362. doi: 10.3389/fpubh.2021.766362
» https://doi.org/10.3389/fpubh.2021.766362
⁴
Benchimol EI, Smeeth L, Guttmann A, Harron K, Moher D, Petersen I, et al. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med. 2015;12(10):e1001885. doi: 10.1371/journal.pmed.1001885
» https://doi.org/10.1371/journal.pmed.1001885
⁵
Instituto Brasileiro de Geografia e Estatística. Cidades e estados: Paraná. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2022 [citado 2023 Nov 23]. Disponível em: Disponível em: https://www.ibge.gov.br/cidades-e-estados/pr.html
» https://www.ibge.gov.br/cidades-e-estados/pr.html
⁶
Santos L. Região de saúde e suas redes de atenção: modelo organizativo-sistêmico do SUS. Cien Saude Colet. 2017;22(4):1281-9. doi: 10.1590/1413-81232017224.26392016
» https://doi.org/10.1590/1413-81232017224.26392016
⁷
Khan MK, Islam MN, Ferdous J, Alam MM. An overview on epidemiology of tuberculosis. Mymensingh Med J. 2019;28(1):259-66.
⁸
Prado Junior JC, Medronho RA. Spatial analysis of tuberculosis cure in primary care in Rio de Janeiro, Brazil. BMC Public Health. 2021;21(1):1841. doi: 10.1186/s12889-021-11834-1
» https://doi.org/10.1186/s12889-021-11834-1
⁹
Pereira TV, Nogueira MC, Campos EMS. Spatial analysis of tuberculosis and its relationship with socioeconomic indicators in a medium-sized city in Minas Gerais. Rev Bras Epidemiol. 2021;24(suppl 1):e210021. doi: 10.1590/1980-549720210021.supl.1
» https://doi.org/10.1590/1980-549720210021.supl.1
¹⁰
Nogueira VD, Xavier-Gomes LM, Barbosa TLA. Mortalidade por homicídios em linha de fronteira no Paraná, Brasil. Cien Saude Colet. 2020;25(8):3107-18. doi: 10.1590/1413-81232020258.28522018
» https://doi.org/10.1590/1413-81232020258.28522018
¹¹
Aikes S, Rizzotto MLF. Integração regional em cidades gêmeas do Paraná, Brasil, no âmbito da saúde. Cad Saude Publica. 2018;34(8):e00182117. doi: 10.1590/0102-311X00182117
» https://doi.org/10.1590/0102-311X00182117
¹²
Hortelan MS, Almeida ML, Fumincelli L, Zilly A, Nihei OK, Peres AM, et al. Papel do gestor de saúde pública em região de fronteira: scoping review. Acta Paul Enferm. 2019;32(2):229-36. doi: 10.1590/1982-0194201900031
» https://doi.org/10.1590/1982-0194201900031
¹³
Gelaw YA, Yu W, Magalhães RJS, Assefa Y, Williams G. Effect of temperature and altitude difference on tuberculosis notification: a systematic review. J Glob Infect Dis. 2019;11(2):63-8. doi: 10.4103/jgid.jgid_95_18
» https://doi.org/10.4103/jgid.jgid_95_18
¹⁴
Magnabosco GT, Órfão NH, Brunello MEF, Wysocki AD, Lopes LM, Campoy LT. Novas doenças e ameaças antigas: a repercussão da covid-19 no manejo da tuberculose. Saude Coletiva (Barueri). 2020;10(54):2639-44. doi: 10.36489/saudecoletiva.2020v10i54p2639-2644
» https://doi.org/10.36489/saudecoletiva.2020v10i54p2639-2644
¹⁵
Siqueira TC, Martellet MG, Tavernard GLN, Silva VM, Moura STS, Silva LAF, et al. Percepção de enfermeiros: enfoque na família e orientação para a comunidade nas ações de tuberculose. Cienc Cuid Saude. 2020;19:e50175. doi: 10.4025/ciencuidsaude.v19i0.50175
» https://doi.org/10.4025/ciencuidsaude.v19i0.50175
¹⁶
Silva GDM, Duarte EC, Cruz OG, Garcia LP. Identificação de microrregiões com subnotificação de casos de tuberculose no Brasil, 2012 a 2014. Epidemiol Serv Saude. 2020;29(1):e2018485. doi: 10.5123/S1679-49742020000100025
» https://doi.org/10.5123/S1679-49742020000100025
¹⁷
Arentz M, Ma J, Zheng P, Vos T, Murray CJL, Kyu HH. The impact of the COVID-19 pandemic and associated suppression measures on the burden of tuberculosis in India. BMC Infect Dis. 2022;22(1):92. doi: 10.1186/s12879-022-07078-y
» https://doi.org/10.1186/s12879-022-07078-y
¹⁸
Lakoh S, Jiba DF, Baldeh M, Adekanmbi O, Barrie U, Seissay AL, et al. Impact of COVID-19 on tuberculosis case detection and treatment outcomes in Sierra Leone. Trop Med Infect Dis. 2021;6(3):154. doi: 10.3390/tropicalmed6030154
» https://doi.org/10.3390/tropicalmed6030154
¹⁹
Souza ASR, Amorim MMR, Melo ASO, Delgado AM, Forêncio ACMCC, Oliveira TV, et al. Aspectos gerais da pandemia da covid-19. Rev Bras Saude Mater Infant. 2021;21(Suppl 1):529-46. doi: 10.1590/1806-9304202100S100003
» https://doi.org/10.1590/1806-9304202100S100003
²⁰
Couto MT, Barbieri CLA, Matos CCSA. Considerações sobre o impacto da covid-19 na relação indivíduo-sociedade: da hesitação vacinal ao clamor por uma vacina. Saude Soc. 2021;30(1):e200450. doi: 10.1590/S0104-12902021200450
» https://doi.org/10.1590/S0104-12902021200450
²¹
Jain VK, Iyengar KP, Samy DA, Vaishya R. Tuberculosis in the era of COVID-19 in India. Diabetes Metab Syndr. 2020;14(5):1439-43. doi: 10.1016/j.dsx.2020.07.034
» https://doi.org/10.1016/j.dsx.2020.07.034
²²
Fei H, Yinyin X, Hui C, Ni W, Xin D, Wei C, et al. The impact of the COVID-19 epidemic on tuberculosis control in China. Lancet Reg Health West Pac. 2020;3:100032 doi: 10.1016/j.lanwpc.2020.100032
» https://doi.org/10.1016/j.lanwpc.2020.100032
²³
Governo do Estado (SC). Secretaria do Estado de Saúde de Santa Catarina. Coronavírus [Internet]. 2020[atualizado 2022 Mar 8; citado 2022 Mar 8]. Disponível em: Disponível em: http://www.coronavirus.sc.gov.br/
» http://www.coronavirus.sc.gov.br/
²⁴
Ripplinger F, Dalmora TWR, Scherma RA. Geografia da covid-19 em Santa Catarina: notas sobre o trabalho na criação e na indústria de abates de animais. Revista Pegada. 2020;21(2):463-92. doi: 10.33026/peg.v21i2.7816
» https://doi.org/10.33026/peg.v21i2.7816
²⁵
Inloco. Mapa brasileiro da COVID-19 [Internet]. [s.l.]: Inloco; 2020 [atualizado 2022 Mar 8; citado 2022 Mar 8]. Disponível em: Disponível em: https://mapabrasileirodacovid.inloco.com.br/pt/
» https://mapabrasileirodacovid.inloco.com.br/pt/
²⁶
Hughes HMFBR, Carneiro RAVD, Hillesheim D, Hallal ALC. Evolução da COVID-19 em Santa Catarina: decretos estaduais e indicadores epidemiológicos até agosto de 2020. Epidemiol Serv Saude. 2021;30(4):e2021521. doi: 10.1590/S1679-49742021000400025
» https://doi.org/10.1590/S1679-49742021000400025
²⁷
Caponi S. Covid-19 em Santa Catarina: um triste experimento populacional. Hist Cienc Saude Manguinhos. 2021;28(2):593-8. doi: 10.1590/S0104-59702021005000004
» https://doi.org/10.1590/S0104-59702021005000004
²⁸
Bwire GM. Coronavirus: why men are more vulnerable to covid-19 than women?. SN Comp Clin Med. 2020;2(7):874-6. doi: 10.1007/s42399-020-00341-w
» https://doi.org/10.1007/s42399-020-00341-w
²⁹
Perrotta F, Corbi G, Mazzeo G, Boccia M, Aronne L, D’Agnano V, et al. COVID-19 and the elderly: insights into pathogenesis and clinical decision-making. Aging Clin Exp Res. 2020;32(8):1599-608. doi: 10.1007/s40520-020-01631-y
» https://doi.org/10.1007/s40520-020-01631-y

ASSOCIATE ACADEMIC WORK
Article derived from an undergraduate dissertation entitled Excess mortality in Santa Catarina and macro-regions during the COVID-19 pandemic, submitted by Rebeca Heyse Holzbach to the Medical School of the Universidade Federal de Santa Catarina, in 2022.

Publication Dates

Publication in this collection
14 July 2023
Date of issue
2023

History

Received
01 June 2022
Accepted
07 Feb 2023

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] ¹
Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Brasil Livre da Tuberculose: Plano Nacional pelo Fim da Tuberculose como Problema de Saúde Pública: Estratégias para 2021-2025. Brasília: Ministério da Saúde; 2021 [citado 2022 Maio 17]. Disponível em: Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/publicacoes-svs/tuberculose/plano-nacional-pelo-fim-da-tuberculose-como-problema-de-saude-publica_-estrategias-para-2021-2925.pdf/view
» https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/publicacoes-svs/tuberculose/plano-nacional-pelo-fim-da-tuberculose-como-problema-de-saude-publica_-estrategias-para-2021-2925.pdf/view

[2] ²
Trauer JM, Dodd PJ, Gomes MGM, Gomes GB, Houben RMGJ, McBryde EM, et al. The importance of heterogeneity to the epidemiology of tuberculosis. Clin Infect Dis. 2019;69(1):159-66. doi: 10.1093/cid/ciy938
» https://doi.org/10.1093/cid/ciy938

[3] ³
Zhang Q, Song W, Liu S, An Q, Tao N, Zhu X, et al. An ecological study of tuberculosis incidence in China, from 2002 to 2018. Front Public Health. 2022;18(9):766362. doi: 10.3389/fpubh.2021.766362
» https://doi.org/10.3389/fpubh.2021.766362

[4] ⁴
Benchimol EI, Smeeth L, Guttmann A, Harron K, Moher D, Petersen I, et al. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med. 2015;12(10):e1001885. doi: 10.1371/journal.pmed.1001885
» https://doi.org/10.1371/journal.pmed.1001885

[5] ⁵
Instituto Brasileiro de Geografia e Estatística. Cidades e estados: Paraná. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2022 [citado 2023 Nov 23]. Disponível em: Disponível em: https://www.ibge.gov.br/cidades-e-estados/pr.html
» https://www.ibge.gov.br/cidades-e-estados/pr.html

[6] ⁶
Santos L. Região de saúde e suas redes de atenção: modelo organizativo-sistêmico do SUS. Cien Saude Colet. 2017;22(4):1281-9. doi: 10.1590/1413-81232017224.26392016
» https://doi.org/10.1590/1413-81232017224.26392016

[7] ⁷
Khan MK, Islam MN, Ferdous J, Alam MM. An overview on epidemiology of tuberculosis. Mymensingh Med J. 2019;28(1):259-66.

[8] ⁸
Prado Junior JC, Medronho RA. Spatial analysis of tuberculosis cure in primary care in Rio de Janeiro, Brazil. BMC Public Health. 2021;21(1):1841. doi: 10.1186/s12889-021-11834-1
» https://doi.org/10.1186/s12889-021-11834-1

[9] ⁹
Pereira TV, Nogueira MC, Campos EMS. Spatial analysis of tuberculosis and its relationship with socioeconomic indicators in a medium-sized city in Minas Gerais. Rev Bras Epidemiol. 2021;24(suppl 1):e210021. doi: 10.1590/1980-549720210021.supl.1
» https://doi.org/10.1590/1980-549720210021.supl.1

[10] ¹⁰
Nogueira VD, Xavier-Gomes LM, Barbosa TLA. Mortalidade por homicídios em linha de fronteira no Paraná, Brasil. Cien Saude Colet. 2020;25(8):3107-18. doi: 10.1590/1413-81232020258.28522018
» https://doi.org/10.1590/1413-81232020258.28522018

[11] ¹¹
Aikes S, Rizzotto MLF. Integração regional em cidades gêmeas do Paraná, Brasil, no âmbito da saúde. Cad Saude Publica. 2018;34(8):e00182117. doi: 10.1590/0102-311X00182117
» https://doi.org/10.1590/0102-311X00182117

[12] ¹²
Hortelan MS, Almeida ML, Fumincelli L, Zilly A, Nihei OK, Peres AM, et al. Papel do gestor de saúde pública em região de fronteira: scoping review. Acta Paul Enferm. 2019;32(2):229-36. doi: 10.1590/1982-0194201900031
» https://doi.org/10.1590/1982-0194201900031

[13] ¹³
Gelaw YA, Yu W, Magalhães RJS, Assefa Y, Williams G. Effect of temperature and altitude difference on tuberculosis notification: a systematic review. J Glob Infect Dis. 2019;11(2):63-8. doi: 10.4103/jgid.jgid_95_18
» https://doi.org/10.4103/jgid.jgid_95_18

[14] ¹⁴
Magnabosco GT, Órfão NH, Brunello MEF, Wysocki AD, Lopes LM, Campoy LT. Novas doenças e ameaças antigas: a repercussão da covid-19 no manejo da tuberculose. Saude Coletiva (Barueri). 2020;10(54):2639-44. doi: 10.36489/saudecoletiva.2020v10i54p2639-2644
» https://doi.org/10.36489/saudecoletiva.2020v10i54p2639-2644

[15] ¹⁵
Siqueira TC, Martellet MG, Tavernard GLN, Silva VM, Moura STS, Silva LAF, et al. Percepção de enfermeiros: enfoque na família e orientação para a comunidade nas ações de tuberculose. Cienc Cuid Saude. 2020;19:e50175. doi: 10.4025/ciencuidsaude.v19i0.50175
» https://doi.org/10.4025/ciencuidsaude.v19i0.50175

[16] ¹⁶
Silva GDM, Duarte EC, Cruz OG, Garcia LP. Identificação de microrregiões com subnotificação de casos de tuberculose no Brasil, 2012 a 2014. Epidemiol Serv Saude. 2020;29(1):e2018485. doi: 10.5123/S1679-49742020000100025
» https://doi.org/10.5123/S1679-49742020000100025

[17] ¹⁷
Arentz M, Ma J, Zheng P, Vos T, Murray CJL, Kyu HH. The impact of the COVID-19 pandemic and associated suppression measures on the burden of tuberculosis in India. BMC Infect Dis. 2022;22(1):92. doi: 10.1186/s12879-022-07078-y
» https://doi.org/10.1186/s12879-022-07078-y

[18] ¹⁸
Lakoh S, Jiba DF, Baldeh M, Adekanmbi O, Barrie U, Seissay AL, et al. Impact of COVID-19 on tuberculosis case detection and treatment outcomes in Sierra Leone. Trop Med Infect Dis. 2021;6(3):154. doi: 10.3390/tropicalmed6030154
» https://doi.org/10.3390/tropicalmed6030154

[19] ¹⁹
Souza ASR, Amorim MMR, Melo ASO, Delgado AM, Forêncio ACMCC, Oliveira TV, et al. Aspectos gerais da pandemia da covid-19. Rev Bras Saude Mater Infant. 2021;21(Suppl 1):529-46. doi: 10.1590/1806-9304202100S100003
» https://doi.org/10.1590/1806-9304202100S100003

[20] ²⁰
Couto MT, Barbieri CLA, Matos CCSA. Considerações sobre o impacto da covid-19 na relação indivíduo-sociedade: da hesitação vacinal ao clamor por uma vacina. Saude Soc. 2021;30(1):e200450. doi: 10.1590/S0104-12902021200450
» https://doi.org/10.1590/S0104-12902021200450

[21] ²¹
Jain VK, Iyengar KP, Samy DA, Vaishya R. Tuberculosis in the era of COVID-19 in India. Diabetes Metab Syndr. 2020;14(5):1439-43. doi: 10.1016/j.dsx.2020.07.034
» https://doi.org/10.1016/j.dsx.2020.07.034

[22] ²²
Fei H, Yinyin X, Hui C, Ni W, Xin D, Wei C, et al. The impact of the COVID-19 epidemic on tuberculosis control in China. Lancet Reg Health West Pac. 2020;3:100032 doi: 10.1016/j.lanwpc.2020.100032
» https://doi.org/10.1016/j.lanwpc.2020.100032

[23] ²³
Governo do Estado (SC). Secretaria do Estado de Saúde de Santa Catarina. Coronavírus [Internet]. 2020[atualizado 2022 Mar 8; citado 2022 Mar 8]. Disponível em: Disponível em: http://www.coronavirus.sc.gov.br/
» http://www.coronavirus.sc.gov.br/

[24] ²⁴
Ripplinger F, Dalmora TWR, Scherma RA. Geografia da covid-19 em Santa Catarina: notas sobre o trabalho na criação e na indústria de abates de animais. Revista Pegada. 2020;21(2):463-92. doi: 10.33026/peg.v21i2.7816
» https://doi.org/10.33026/peg.v21i2.7816

[25] ²⁵
Inloco. Mapa brasileiro da COVID-19 [Internet]. [s.l.]: Inloco; 2020 [atualizado 2022 Mar 8; citado 2022 Mar 8]. Disponível em: Disponível em: https://mapabrasileirodacovid.inloco.com.br/pt/
» https://mapabrasileirodacovid.inloco.com.br/pt/

[26] ²⁶
Hughes HMFBR, Carneiro RAVD, Hillesheim D, Hallal ALC. Evolução da COVID-19 em Santa Catarina: decretos estaduais e indicadores epidemiológicos até agosto de 2020. Epidemiol Serv Saude. 2021;30(4):e2021521. doi: 10.1590/S1679-49742021000400025
» https://doi.org/10.1590/S1679-49742021000400025

[27] ²⁷
Caponi S. Covid-19 em Santa Catarina: um triste experimento populacional. Hist Cienc Saude Manguinhos. 2021;28(2):593-8. doi: 10.1590/S0104-59702021005000004
» https://doi.org/10.1590/S0104-59702021005000004

[28] ²⁸
Bwire GM. Coronavirus: why men are more vulnerable to covid-19 than women?. SN Comp Clin Med. 2020;2(7):874-6. doi: 10.1007/s42399-020-00341-w
» https://doi.org/10.1007/s42399-020-00341-w

[29] ²⁹
Perrotta F, Corbi G, Mazzeo G, Boccia M, Aronne L, D’Agnano V, et al. COVID-19 and the elderly: insights into pathogenesis and clinical decision-making. Aging Clin Exp Res. 2020;32(8):1599-608. doi: 10.1007/s40520-020-01631-y
» https://doi.org/10.1007/s40520-020-01631-y

Study contributions
Main results	The number of deaths in the state of Santa Catarina was higher than expected in 2020 (16.3%) and 2021 (45.1%), when compared to the pre-pandemic years. There were excess deaths in all macro-regions of the state, and it was more significant where the highest number of COVID-19 deaths occurred.
Implications for services	The excess deaths found reflect the underreporting of COVID-19 cases, in addition to lack of health care for people with other diseases. The services should expand their capacity for health care, testing, and continuity of care.
Perspectives	Organization of services with an emphasis on case notifications, access and capacity of active search for health care for individuals in social isolation. Future studies should evaluate excess deaths in Santa Catarina taking into consideration specific causes.

Macro-region of residence	2015	2016	2017	2018	2019	Average^a (SD^b)	2020		2021
Macro-region of residence	2015	2016	2017	2018	2019	Average^a (SD^b)	Overall	Covid-19	Overall	Covid-19
Great West	4,103	4,473	4,309	4,353	4,350	4,317 (134.7)	4,666	400	6,613	1,904
Midwet and Serra	5,482	5,723	5,690	5,818	5,989	5,740 (185.4)	6,504	596	8,431	2,154
Foz do Rio Itajaí	3,137	3,400	3,414	3,511	3,621	3,416 (179.7)	4,331	737	5,254	1,461
Vale do Itajaí	5,564	5,877	5,716	5,968	5,947	5,814 (171.4)	6,545	698	7,755	1,572
Great Florianópolis	5,563	5,947	6,106	6,033	6,250	5,979 (258.1)	7,125	852	8,238	1,876
South	5,478	5,943	5,745	6,141	6,306	5,922 (325.7)	7,284	1,088	8,777	2,227
Northeast and North Plateau	6,839	7,215	7,182	7,612	7,804	7,330 (380.9)	8,382	909	10,845	3,347
TOTAL	36,166	38,578	38,162	39,436	40,267	38,522 (1,546.3)	44,837	5,280	55,913	14,541

Macro-region	1^st quarter		2^nd quarter		3^rd quarter		4^th quarter		Excess deaths
Macro-region	2020	2021	2020	2021	2020	2021	2020	2021	2020 (n)	2021 (n)	Percentage change^a (%)
Great west	1.08	2.12	0.96	1.60	1.08	1.28	1.20	1.19	349	2,296	557.9
Midwest and Serra	1.13	1.71	1.01	1.84	1.12	1.26	1.28	1.08	764	2,691	252.2
Foz do Rio Itajaí	1.10	1.84	1.16	1.70	1.37	1.38	1.42	1.25	915	1,838	100.9
Vale do Itajaí	1.04	1.56	0.93	1.46	1.20	1.26	1.33	1.07	731	1,941	165.5
Great Florianópolis	1.08	1.97	1.02	1.41	1.28	1.21	1.37	0.97	1,146	2,259	97.1
South	1.12	1.76	0.95	1.80	1.34	1.23	1.50	1.17	1,362	2,855	109.6
Northeast e North Plateau	1.11	1.84	0.99	1.89	1.24	1.39	1.23	0.83	1,052	3,515	234.2
TOTAL	1.10	1.82	0.99	1.68	1.23	1.29	1.33	1.06	6,315	17,391	175.4

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Excess deaths among adults in the state of Santa Catarina: an ecological study during the COVID-19 pandemic, Brazil, 2020-2021

Exceso de muertes en adultos en el estado de Santa Catarina: un estúdio ecológico en el período de la pandemia de COVID-19, Brasil, 2020-2021

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INTRODUCTION

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ASSOCIATE ACADEMIC WORK

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History