How do structural inequalities influence COVID-19 hospital mortality among traditional peoples and communities? A cross-sectional study in São Paulo, Brazil, 2021–2023

Introduction: The COVID-19 pandemic exposed and deepened structural inequalities, disproportionately affecting vulnerable populations. Traditional peoples and communities (TPCs) in Brazil, including Indigenous groups, face socioeconomic vulnerabilities. This study aimed to investigate factors associated with COVID-19 mortality among hospitalised individuals from these populations in São Paulo, Brazil. Methods: A cross-sectional study was conducted using data from the Influenza Epidemiological Surveillance Information System from 2021 to 2023, focusing on cases of severe acute respiratory infection (SARI) caused by COVID-19. Sociodemographic data, clinical conditions, comorbidities and hospital support information were analysed. Multivariate logistic regression was performed to identify factors associated with mortality, with adjusted ORs and 95% CIs calculated for each variable. Results: A total of 965 hospitalisations were analysed. Factors associated with higher mortality included low education levels, such as primary education (first cycle: OR=11.20, 95% CI 2.16 to 20.70; second cycle: OR=11.30, 95% CI 2.14 to 20.80), dyspnoea (OR=3.15, 95% CI 1.54 to 6.91), diarrhoea (OR=1.95, 95% CI 1.11 to 3.39), asthma (OR=4.49, 95% CI 1.35 to 16.00), chronic respiratory disease (OR=2.10, 95% CI 1.13 to 4.45) and chronic liver disease (OR=6.50, 95% CI 2.10 to 8.34). The use of invasive ventilation was the strongest predictor of mortality (OR=23.70, 95% CI 19.80 to 56.20), followed by non-invasive ventilation (OR=3.25, 95% CI 1.62 to 7.44). Admission to the intensive care unit was marginally associated with mortality (OR=1.56, 95% CI 1.01 to 2.41). Conclusions: The study findings highlights how structural inequalities affect COVID-19 mortality among TPCs in São Paulo. Education, clinical conditions and invasive hospital support were key predictors of death. These findings emphasise the need for public health strategies that address inequities and focus on vulnerable groups to reduce the impact of future health crises.