EFFECTS OF GOVERNMENT DECREES ON COVID-19 2 MORTALITY RATES IN SOUTHERN BRAZIL

Abstract

Palabras clave: COVID-19, pandemia, institucional, organizacional, gestión de crisis.However, a recent examination of the existing public health structures for evaluating epidemic responses has identified five critical "lines of analysis" (JENEI et al., 2020).Among these, few, if any, frameworks offer a holistic interpretation of "context analysis," which has prompted the proposal for a case study in the Southern region of Brazil.Numerous "upstream" or contextual factors are believed to shape the effectiveness of the public health response, both in terms of utilizing scientific evidence to guide action and in persuading the population to adhere to recommendations.Therefore, the primary focus of this study is on the two-year period of the pandemic in the Southern region of Brazil, spanning from March 2020 to February 2022.

EFEITOS DOS DECRETOS GOVERNAMENTAIS NAS TAXAS DE MORTALIDADE POR COVID-19 NO SUL DO BRASIL Resumo
According to the census, 85% of the population in the South region resides in urban areas, with a significant demographic concentration in the metropolitan regions of the three capital cities.In the extreme south of Rio Grande do Sul, intensive livestock farming is prevalent, featuring high technological use but low labor demand, resulting in low demographic density (FRANCISCO, 2021).Another noteworthy sociodemographic factor in the Southern region is the significant decline in the birth rate observed in recent years.This decision was prompted by the complete occupation of ICU beds in the state.In Paraná, a pattern of rising cases and deaths, mirroring the situation in Rio Grande do Sul, has been evident since the early stages of the pandemic.Notably, all public events were canceled, with the exception of the municipal elections in October 2020.The situation worsened significantly in the first weeks of December and early January, resulting in Paraná reporting the highest number of COVID-19 cases and deaths.On February 27, 2021, there was a substantial 45.9% increase in cases over a 15-day period.Meanwhile, in Santa Catarina, during February 2021, authorities reinstated restrictive measures in response to a new wave of COVID-19 cases in the South Region (KERR et al., 2020).The state of Santa Catarina adopted a more flexible approach compared to the other two states, particularly concerning access and mobility restrictions, and this flexibility was primarily coordinated through the state's Health Emergency Operations Center.
This case study seeks to investigate the effects of government decrees on the institutional, organizational, governance and political factors (IOGP) that occurred during the pandemic period in Brazil and how the states in the southern region managed the different factors.

Methods
Case study of a region of Brazil.Sociodemographic, cultural and climatic aspects were investigated to better understand its characteristics and spread the virus in 2020-2022.This document describes case studies to explore how institutional, organizational, governance and policy (IOGP) factors shape decision-making factors and the choice and implementation of public health interventions to manage COVID-19 in the Southern Region of Brazil.The Method was proposed by the University of British Columbia, in Canada, by Dr. Peter Berman's team (Figure 1).The framework comprises the following:

Upstream Factors (those influencing decisions to choose and implement interventions):
§ Broader context -representing more stable social, cultural, behavioral, and economic factors that vary across jurisdictions, but less so over shorter time periods.§ Institutions -representing both institutional structures and widely accepted norms of behavior and rules of conduct, building on the concepts elaborated by North, Ostrom, and others.§ Politics -including features of the political ideology of parties, the role and position of elected officials and leaders, the role of key social interests, and the influence of electoral events.§ Organizations -primarily focusing on the government organizations charged with public health functions but also other health system organizations within and outside government that may be important in implementing or influencing the public health response.§ Governance -focussing on understanding the processes of decision-making and implementation at the interface between politics, organizations, and citizens.

Results
Data on the number of cases, deaths and recoveries are presented in Table 1 along

Discussion
The In the first months of the pandemic, Brazil took significant measures to address the crisis, including expanding the capacity of the Unified Health System (UHS), improving health infrastructure, increasing the availability of ICU beds for patients with COVID-19 and the reinforcement of human resources through doctors.recruitment via notices.
Furthermore, there was a change in health service provision protocols, mainly in the regulation of telemedicine (CIMINI, JULIÃO & SOUZA, 2021).Field hospitals, temporary emergency care units with multidisciplinary teams, were created in almost all Brazilian states to respond to the growing number of COVID-19 cases (AIRES, 2020).
Assessing the effectiveness of these field hospitals was a challenge.

Conclusion
Studying the effect of government decrees during the COVID-19 pandemic in southern Brazil demonstrated the intricate relationship between policy implementation and its farreaching consequences.It becomes clear that these decrees not only dictated immediate responses, but also significantly shaped organizational structures, governance dynamics and decision-making processes at various levels of authority.Furthermore, it showed the importance of political considerations in defining responses, evident in the way events impacted virus transmission.This research also highlighted the complexities of managing a pandemic within a decentralized governance framework, shedding light on the interaction between government decrees, institutional dynamics and the implementation of public health strategies.
): § Implementation of interventions to mitigate pandemic spread and address clinical and social needs.§ Stringency of interventions -assessment of how widely and well interventions are implemented.§ Timing of interventions related to the epidemiology of pandemic evolution in a jurisdiction.§ Health outcomes such as cases, hospitalization, and deaths.§ Other outcomes such as those related to mental health, economic stresses, education performance.For this study, sociodemographic, cultural and climatic information were first researched.After this step, the first pandemic decree was researched in each state in the southern region of Brazil and data on the number of deaths, cases and recovered were obtained from the platform of the Ministry of Health and each state.From these data, the numbers of deaths and cases per 100,000 inhabitants were calculated.Another piece of information was the number of inhabitants per state researched on the website of the Brazilian Institute of Geography and Statistics (IBGE).SPSS Statistics 21 software (IBM Corporation) was used to perform the analyses.Data were transcribed as mean and standard deviation.
with the total number of inhabitants by state in the southern region of Brazil, in addition to the date of the first state pandemic decree.The First Pandemic Decree of each state was issued between the months of February (Decree No. 40,475 of February 28, 2020 -Federal District) and May (Decree No. 55,240, of May 10, 2020-State of Rio Grande do Sul).When analyzing the number of cases, there were similar numbers in the three states of the southern region in relation to the number of infected: Paraná (1,963.743),Santa Catarina (1,442.511)and Rio Grande do Sul (1,826.295).When analyzing the number of deaths in each state, the highest death records occurred in Paraná (41,017) and Rio Grande do Sul (36,873).In relation to deaths by sex, the highest number of deaths occurred in women in Paraná (53%) and Rio Grande do Sul and in Santa Catarina in men (57.7%).In relation to vaccination by state until February 2022, Paraná had vaccinated 9,683,790 people with two doses, 5,101,650 in Santa Catarina and 8,027,190 in Rio Grande do Sul.
COVID-19 pandemic, caused by the new coronavirus SARS-CoV-2, generated significant global repercussions in the medical, epidemiological, social, economic, political, cultural and historical dimensions (MELLO et al., 2020).The challenges in combating COVID-19 arose from limited knowledge about the virus, its rapid transmission and its potential to cause fatalities in vulnerable populations, creating uncertainty regarding the most effective strategies around the world (WERNECK & CARVALHO, 2020).In Brazil, a national public health emergency was declared in February 2020, initiating technical training for coronavirus laboratory diagnosis.The quarantine law (BRASIL, Law No. 13,979) came into effect on March 20, 2020, coinciding with the Ministry of Health's declaration of community transmission after confirming the first COVID-19 case in São Paulo on February 26, 2020.The country experienced two pandemic waves, with the first peaking in July and the second commencing in January following year-end and summer festivals, resulting in approximately 254,221 deaths by early 2021.The COVID-19 outbreak exacerbated political, economic, and social challenges (AQUINO et al., 2021).Brazil's vast size, regional disparities, and the decentralization of pandemic response actions, as dictated by the Supreme Federal Court (STF), allowed states and municipalities to adopt their own measures, granting each state autonomy, with financial support provided by the Federal Government (MORAES, 2020).The COVID-19 pandemic in Brazil witnessed varying moments of contagion and death influenced by a range of factors.Initial cases were associated with the failure to cancel Carnival celebrations in February 2020, leading to public health chaos in several states.Throughout 2020, flexibility in pandemic control measures was observed during celebrations like Mother's Day, Father's Day, and Valentine's Day, particularly in commerce and entertainment.In November, municipal elections for 5,570 City Halls further facilitated gatherings.Brazil's approach to relaxing social distancing measures differed from that of most countries, which emphasized monitoring the pandemic's transmission speed (AQUINO et al., 2021).At the national level, Law No. 14,019/2020, enacted on July 3, 2020, made the use of personal protective masks mandatory in public and private spaces during the COVID-19 pandemic.Initially, several measures, including restrictions on gatherings and compulsory mask usage in essential activities, were rigorously enforced (HOUVÈSSOU et al., 2020).These measures were simultaneously implemented, with different regions issuing pandemic onset decrees between February and May.Responses from each state varied, making it challenging to assess the impact of social isolation.Interestingly, the state of Rio Grande do Sul, which was the last to declare a pandemic situation, had fewer cases and lower total deaths per inhabitants compared to the national average.Few studies have comprehensively assessed the actual impact of social distancing in combating COVID-19 transmission, emphasizing the need for implementing multiple preventive measures to enhance intervention strategies (AQUINO et al., 2021).In 2020, there were no federal or state decrees identified that controlled the entry of international flights.Notably, it was only on May 14, 2021, that Ordinance No. 653 was issued, imposing exceptional and temporary restrictions on the entry of foreigners, irrespective of nationality, as recommended by the National Health Surveillance Agency (NHSA) (BRASIL, Ordinance No. 653 of May 14, 2021).The COVID-19 quarantine lifestyle led to changes in circadian rhythms, affecting eating and sleeping patterns in both adults (SILVA et al., 2020) and adolescents (BRITO et al., 2020).Such changes contributed to increased body weight and increased susceptibility to COVID-19.Excess weight aggravates the inflammatory processes associated with the second phase of the virus, potentially increasing the risk of therapeutic failure (SALES-PERES, 2020).Some Brazilian cities have banned outdoor activities, such as visits to parks and trips to the beach.However, regular physical activity has emerged as a crucial protective factor (SALLIS, PRATT, 2020), with physical inactivity linked to greater morbidity and mortality in cases of COVID-19 (SALLIS et al., 2021).

The COVID- 19
pandemic has brought significant global challenges, with the emergence of more aggressive SARS-CoV-2 variants leading to additional waves of contamination, raising concerns about vaccine effectiveness (Sweijd & Zaitchik, 2021).Worldwide, policy responses have varied, including extensive testing, lockdowns, and voluntary social distancing (Peña, 2020).Initially, the focus was on reducing virus transmission, but over time, policies shifted to address broader health and well-being impacts (Cimini, Julião & Souza, 2021).Efforts have also concentrated on strengthening healthcare capacity and governance responses (Delivorias & Scholz, 2020; Peña et al., 2020; Smith et al., 2020).In May 2020, Brazil experienced a high daily death toll, leading the Ministry of Health to recommend easing restrictions despite the lack of a significant decline in the number of cases.The state of Santa Catarina, adopting more flexible containment measures, had lower rates in the southern region.Effective state contingency plans should encompass strategies for healthcare, management, actions to reduce social inequalities, specialized care for vulnerable groups, and the promotion of healthy behaviors like physical activity.With additional waves of infections caused by new, more aggressive virus variants, influenced by several factors, including vaccine distribution, concerns have arisen regarding vaccine effectiveness.The global response to the COVID-19 pandemic has involved a range of policy measures focused on reducing transmission of the virus and addressing broader impacts on health and well-being (Cimini, Julião & Souza, 2021).These measures included strengthening health capacity and governance responses (Delivorias & Scholz, 2020; Peña et al., 2020; Smith et al., 2020).

Table 1 . Population characteristics and epidemiological data since the date of the First pandemic Decree of each State in South Region and number cases, deaths and recovered for State 2019-2022
Tabel 2 -Mortality rate, cases rate and death to 100.000 inhabitants in South Region of Brazil, 2020.
(Zhao, 2020;Netz, 2017)RIS et al., 2021) and municipal governments, compounded by the struggle to balance economic stability and public health, have likely contributed to the worsening health crisis in Brazil, especially in southern BrazilThe systematic analysis of 28 Contingency Plans, including a national plan and state plans, highlighted commonalities between national and state levels in proposals for healthcare reorientation, case detection, and referral hospital recommendations.BERRY et al., 2021;SAVARIS et al., 2021).The absence of clear guidance complicated public engagement in combating the disease.On the other hand, early mitigation measures, initiated as soon as the first cases were identified, helped mitigate the pandemic's impact.Despite varying state responses due to the absence of centralized federal measures, there was a reduction in COVID-19 deaths.In May 2020, Brazil witnessed a grim milestone, with a thousand deaths occurring within 24 hours, following a prolonged period of increasing transmission cases.This was followed by a stabilization in the number of infections and deaths, prompting the Ministry of Health to advise the easing of certain restrictive measures, even though a significant decrease in cases had not been observed.Notably, the state of Santa Catarina, known for its flexibility in implementing containment measures, had among the lowest rates in the southern region and across Brazil.The importance of state contingency plans is evident, highlighting that they should cover strategies and actions that go beyond guaranteeing hospital care for serious cases.These plans should address the organization of care for COVID-19 cases at different health points and include initiatives to reduce social inequalities and provide specialized care to vulnerable groups (Santos et al., 2021; Lana et al., 2020; Massuda et al., 2020; Massuda et al., 2020; Santos et al., 2021; Lana et al., 2021; Lana et al., 2020).From a public health perspective, promoting healthy behaviors was essential.In addition to the well-documented impact on physical and metabolic health, both physical activity and sedentary behaviors have been strongly associated with mental health, including depression, anxiety, stress, and general well-being(Zhao, 2020;Netz, 2017).Regrettably, during the period of social (Brito et al., 2021;Brito et al., 2020)re was a decrease in physical activity, leading to worsened sleep and dietary habits among children, adolescents, adults, and the elderly(Brito et al., 2021;Brito et al., 2020).