DOI: 10.1590/1980-549720200057 SPECIAL ARTICLE / ARTIGO ESPECIAL Initial analysis of the spatial correlation between the incidence of COVID-19 and human development in the municipalities of the state of Ceará in Brazil Análise inicial da correlação espacial entre a incidência de COVID-19 e o desenvolvimento humano nos municípios do estado do Ceará no Brasil Jacques Antonio Cavalcante MacielI , Igor Iuco Castro-SilvaI , Mariana Ramalho de FariasI ABSTRACT: Objective: To analyze the spatial distribution of the incidence of COVID-19 and its correlation with the municipal human development index (MHDI) of the municipalities of Ceará. Methods: This is an ecological study with data recovered from the 15th epidemiological week and the 19th one of the year 2020 using the MHDI and the COVID-19 incidence coefficient for each municipality as variables. The univariate spatial correlation and the bivariate one were analyzed using the TerraView and GeoDa softwares. Results: The incidence of COVID-19 has spatial dependence with moderate positive correlation and the formation of high-high clusters located in the metropolitan region of Fortaleza and municipalities in the north region. The lowest incidence was a low-low cluster in the south and west regions. There was a positive bivariate correlation between MHDI and the incidence of COVID-19 with the formation of a cluster in the metropolitan region of Fortaleza. Conclusion: The uneven mapping of COVID-19 and its relationship with MHDI in Ceará can contribute to actions to regional combat the pandemic. Keywords: Coronavirus. SARS virus. Development indicators. Geographic mapping. IDental Course, Universidade Federal do Ceará – Sobral (CE), Brazil. Corresponding author: Jacques Antonio Cavalcante Maciel. Rua Conselheiro José Júlio, s/n., Centro, CEP: 62010-820, Sobral, CE, Brasil. E-mail: [email protected] Conflict of interests: nothing to declare – Financial support: none. 1 REV BRAS EPIDEMIOL 2020; 23: E200057 MACIEL, J.A.C. ET AL. RESUMO: Objetivo: Analisar a distribuição espacial da incidência de Covid-19 e sua correlação com o índice de desenvolvimento humano municipal (IDHM) dos municípios do Ceará. Métodos: Trata-se de um estudo ecológico com dados recuperados da 15ª e da 19ª semana epidemiológica do ano de 2020 utilizando como variáveis o IDHM e o coeficiente de incidência de Covid-19 para cada município. Foi analisada a correlação espacial uni e bivariada por meio dos softwares TerraView e GeoDa. Resultados: A incidência da Covid-19 possui dependência espacial com correlação positiva moderada e formação de clusters do tipo alto-alto localizados na região metropolitana de Fortaleza e municípios da região norte. As menores incidências foram cluster tipo baixo-baixo na região sul e na região oeste. Houve correlação bivariada positiva entre IDHM e incidência de Covid-19 com formação de cluster na região metropolitana de Fortaleza. Conclusão: O mapeamento desigual de Covid-19 e sua relação com IDHM no Ceará podem contribuir com ações de enfrentamento regional à pandemia. Palavras-chave: Coronavírus. Vírus da SARS. Indicadores de desenvolvimento. Mapeamento geográfico. INTRODUCTION On December 31, 2019, the World Health Organization (WHO) headquarters, in China, was informed about cases of pneumonia, of unknown etiology, detected in the city of Wuhan, province of Hubei. A new type of coronavirus was isolated on January 7, 2020, and new cases were confirmed in Thailand, Vietnam, Japan, and South Korea. On January 30, 2020, the WHO declared an international public health emergency, due to the fast dissemination of the coronavirus, after a meeting with specialists. At that point, there were 7.7 thousand confirmed cases and 170 deaths in China, main location of the virus dissemination, besides 98 cases in 18 other countries1. The disease is highly contagious and its main clinical symptoms include fever, dry cough, fatigue, myalgia and dyspnea. The severe cases are characterized by acute respiratory dis- tress syndrome, septic shock, metabolic acidosis, which is difficult to treat, and blood and coagulation disorders2. On March 11, 2020, the WHO classified the disease caused by coronavirus 2019 (Covid-19) as a pandemic. This means that the virus is circulating in all continents, and that there are oligosymptomatic cases, or with unspecific clinical and imaging presen- tation, which makes it difficult to identify it, and facilitates the fast transmission, with a very high level of severity3,4. A global systematic review evaluated the epidemiological profile of Covid-19 and veri- fied that the mortality rate reaches 0.3% of the population, especially affecting elderly men4. The first case of Covid-19 was confirmed in Brazil on February 26, 2020, in an elderly man who had come from Italy5. Until May 7, 2020, the country had 135,106 confirmed cases and 9,146 deaths. The Northeast region has 31.2% of the cases in Brazil, and the state of Ceará is the third with the highest number of confirmed cases in the country6. In May, 2020, the transmission rate of Covid-19 in Brazil was considered as one of the 11 highest rates in 2 REV BRAS EPIDEMIOL 2020; 23: E200057 COVID-19 AND HUMAN DEVELOPMENT IN CEARÁ the world. The estimation was that each infected person could favor the contamination of three other people, being the country with the third highest absolute lethality, after the United States and the United Kingdom7. Studies about Covid-19 have been increasing fast in the country; there were 162 obser- vational studies and 37 clinical trials until May 1st, 2020. The Northeast region had only one clinical trial approved by the National Research Ethics Commission, located in Ceará, including 300 patients with pneumonia caused by Covid-19, treated with new pharmaco- logical agents8. Since until the present moment there is no scientific evidence that ensures the ther- apeutic efficacy of antiretroviral drugs to fight the pandemic, the non-pharmacological interventions are being prioritized in Brazil. The objective is to postpone the peak of the epidemic curve, reduce the demand for health care and decrease the number of cases and effects on the health of the population9. The most recommended strategies to control the dissemination of Covid-19 are social distancing and frequent hand washing; however, these actions are not feasible for the millions of people who live in highly dense commu- nities or precarious households, without basic sanitation and access to drinkable water10. It is believed that, in the initial stages of the epidemic process of Covid-19 in the state of Ceará, there was a spatial correlation between the coefficient of incidence of Covid-19 and its different municipalities. Brazil is one of the countries in which Covid-19 is progressing, alongside with Canada, Colombia, Dominican Republic, Equator, India, Mexico, Pakistan, Peru, Russia and South Africa. This reinforces the fact that contamination is higher in emerg- ing countries, even though nations with continental proportions and heterogeneous economy represent a new epidemiological profile for the disease7. In this sense, it is important to verify the ecological association between human development and the Covid-19 pandemic. Therefore, the objective of this study was to analyze the spatial distribution of the incidence of Covid-19 and its correlation with the municipal human development index (HDI-M) in the municipalities of Ceará. METHODS This is an ecological, exploratory and analytical study whose analysis units were the 184 municipalities in the state of Ceará. We used the coefficients of incidence of Covid-19 in the municipalities in 2020. The social information about the cities were collected in the Atlas of Human Development in Brazil11, systematized by the United Nations Development Programme (UNDP) in 2010. The official estimation of the population of each municipality in Ceará, as well as this federative unit, was obtained for 2019 after consulting the Unified Health System computing department (DATASUS/Health information (TABNET), on May 12, 202012. 3 REV BRAS EPIDEMIOL 2020; 23: E200057 MACIEL, J.A.C. ET AL. The incidence rates of Covid-19 were obtained based on the confirmed cases made available by the Secretariat of Health in the State of Ceará (SESA), through the electronic platform Integra SUS13. To calculate the coefficient of incidence of each municipality with cases, the number of confirmed cases was divided by the resident population and multi- plied by the population base of 100 thousand inhabitants. The coefficients were calculated in two moments: the first considered the cases made available until 2 p.m., on April 12, 2020, enabling the inference of risk of impact in each municipality until the 15th epidemi- ologic week; and the second moment collected data until 6:11 p.m. on May 7, 2020 (19th epidemiologic week). Social development was used as an independent variable, and the HDI-M estimated for each municipality in 2010 was used, according to the data by the UNDP. HDI-M can be classified as very low (0 to 0.499), low (0.500 to 0.599), medium (0.600 to 0.699), high (0.700 to 0.799) and very high (0.800 to 1). HDI-M synthetizes a mean of three sub-indexes calcu- lated in the base of a few indicators, easily collected in the different nations; three basic and universal dimensions of life, which are the conditions for the choices and opportunities of individuals to be amplified: access to knowledge (education), right to a long and healthy life (longevity) and right to a worthy life pattern (income). Because of its simplicity, HDI-M does not deeply analyze any of these dimensions particularly, but allows to compare the general level reached by the units of analysis in the assistance of these basic needs, so that individuals can develop their capacities and choices14. The Statistical Package for the Social Sciences (SPSS, version 20.0, IBM, United States) was used for the descriptive data analysis.