Abstract

This study aimed to estimate the COVID-19 lethality in the Mexican Indigenous population from 2020 to 2022, considering clinical characteristics and social conditions. Data were retrieved from the Epidemiological Surveillance System of Respiratory Diseases, identifying the COVID-19-positive cases among the Indigenous population. Lethality was evaluated per clinical conditions and vulnerability due to social deprivation. The number of COVID-19-positive cases in the Indigenous population represented 0.7% of the total number of cases. The case fatality rate in the Indigenous population was 9.8% against 4.6% in the non-Indigenous population. Lethality was higher in men. However, the association with diabetes, hypertension, chronic kidney disease, obesity, and smoking was lower in the Indigenous population than in the non-Indigenous population. A greater vulnerability to social conditions was identified among the Indigenous population than the non-Indigenous population, mainly regarding income, education, and access to health services.

Key words:
COVID-19; Indigenous Peoples; Fatality Rate; Social Determinants of Health

Introduction

Approximately 476 million indigenous people are estimated worldwide, representing 6% of the world’s population. In Latin American countries, approximately 50 million people are Indigenous, corresponding to 8% of the population, distributed mainly in countries such as Mexico, Guatemala, Peru, and Bolivia. Most of them live in extreme poverty and social marginalization¹1 Organización de las Naciones Unidas (ONU). Los pueblos indígenas y la pandemia de la COVID-19 [Internet]. 2020 [citado 2023 jun 2]. Disponible en: https://social.desa.un.org/es/issues/los-pueblos-indigenas/news/los-pueblos-ind%C3%ADgenas-y-la-pandemia-de-la-covid-19.
https://social.desa.un.org/es/issues/los...

2 Banco Mundial. Pueblos indígenas [Internet]. 2020 [citado 2023 jun 22]. Disponible en: https://www.bancomundial.org/es/topic/indigenouspeoples#:~:text=Se%20estima%20que%20hay%20476,de%20las%20personas%20extremadamente%20pobres.
https://www.bancomundial.org/es/topic/in... ^-33 Programa de las Naciones Unidas para el Desarrollo (PNUD). Impacto y situación de la población indígena latinoamericana ante el Covid-19 [Internet]. 2019 [citado 2023 jun 10]. Disponible en: https://www.undp.org/es/latin-america/blog/impacto-y-situaci%C3%B3n-de-la-poblaci%C3%B3n-ind%C3%ADgena-latinoamericana-ante-el-covid-19#:~:text=La%20poblaci%C3%B3n%20ind%C3%ADgena%20en%20Am%C3%A9rica,la%20poblaci%C3%B3n%20de%20la%20regi%C3%B3n.
https://www.undp.org/es/latin-america/bl... .

According to Mexico’s 2020 National Population Census, the Indigenous population, identified as those who descend from native or ancestral populations or preserve Indigenous peoples’ traditions or customs, totals 11,800,247 individuals, equivalent to 9.4% of the country’s total population; 50.5% are distributed in the states of Oaxaca, Chiapas, Yucatán, and Guerrero. Around 52% of the Indigenous population lives in rural communities (less than 2,500 inhabitants)⁴4 Instituto Nacional de Estadística y Geografía (INEGI). Estadísticas a propósito del día internacional de los pueblos indígenas [Internet]. 2022 [citado 2023 jun 10]. Disponible en: https://www.inegi.org.mx/contenidos/saladeprensa/aproposito/2022/EAP_PueblosInd22.pdf.
https://www.inegi.org.mx/contenidos/sala... .

Indigenous populations often bear social and economic conditions that increase their vulnerability to diseases⁵5 Jiménez-Benítez D, Rodríguez-Martín A, Jiménez-Rodríguez R. Análisis de determinantes sociales de la desnutrición en Latinoamérica. Nutr Hosp 2010; 25(Supl. 3):18-25.^,66 Pelcastre-Villafuerte BE, Meneses-Navarro S, Sánchez-Domínguez M, Meléndez-Navarro D, Freyermuth-Enciso G. Condiciones de salud y uso de servicios en pueblos indígenas de México. Salud Publica Mex 2020; 62(6):810-819.. They tend to live in isolated or poorly connected communities, with limited and poor-quality access to health services, which, in the context of a pandemic such as that caused by COVID-19, leads to a delay in seeking medical care, complicating timely diagnosis and treatment and increasing the risk of complications and mortality.

During the COVID-19 pandemic in Mexico, prevention strategies were implemented to break transmission chains. A vaccination plan was implemented, prioritizing older adults, healthcare staff, and people with comorbidities. However, no specific actions were aimed at the Indigenous population beyond disseminating health promotion and prevention information in native languages. This population was not considered a priority group for vaccination against COVID-19, besides an increase in access barriers to health services that led to higher mortality from other conditions⁷7 Medina-Gómez OS. Impacto de la pandemia de COVID-19 en las tendencias de mortalidad por enfermedades cardiovasculares en México, 2000-2022. Semergen 2024; 50(3):102170..

Several studies have analyzed mortality due to COVID-19⁸8 Soares GH, Jamieson L, Biazevic MGH, Michel-Crosato E. Disparities in Excess Mortality Between Indigenous and Non-Indigenous Brazilians in 2020: Measuring the Effects of the COVID-19 Pandemic. J Racial Ethn Health Disparities 2022; 9(6):2227-2236.

9 Ortiz-Hernández L, Pérez-Sastre MA. Social inequalities in the progression of COVID-19 in the Mexican population. Rev Panam Salud Publica 2020; 44:e106.

10 Li X, Xu S, Yu M, Wang K, Tao Y, Zhou Y, Shi J, Zhou M, Wu B, Yang Z, Zhang C, Yue J, Zhang Z, Renz H, Lui X, Xie M, Zhao J. Risk factors for severity and mortality in adult COVID-19 inpatients in Wuhan. J Allergy Clin Immunol 2020; 146(1):110-118.

11 Alcendor DJ. Racial Disparities-Associated COVID-19 Mortality among Minority Populations in the US. J Clin Med 2020; 9(8):2442.

12 Leon-Jimenez F, Vives-Kufoy C, Failoc-Rojas VE, Valladares-Garrido MJ. Mortalidad en pacientes hospitalizados con COVID-19 en el norte de Peru. Rev Med Chil 2021; 149(10):1459-1466.

13 Sousa GJB, Garces TS, Cestari VRF, Florencio RS, Moreira TMM, Pereira MLD. Mortality and survival of COVID-19. Epidemiol Infect 2020; 148:e123.

14 Setel P, AbouZahr C, Atuheire EB, Bratschi M, Cercone E, Chinganya O, Clapham B, Clark S, Congdon C, de Savigny D, Karpati A, Nichols E, Jakob R, Wwanza J, Muhwava W, Nahmaias P, Ortiz E, Tshangela A. Mortality surveillance during the COVID-19 pandemic. Bull World Health Organ 2020; 98(6):374.^-1515 Prieto-Silva R, Sarmiento-Hernandez CA, Prieto-Silva F. Morbilidad y mortalidad por COVID-19 en Latinoamérica: estudio en tres países - febrero a julio de 2020. Rev Salud Publica (Bogota) 2020; 22(2):198-204.. However, no studies have been conducted in Mexico determining the disease’s lethality, especially in this specific social group. This is important because mortality refers to the number of people who die due to a disease in the general population. In contrast, lethality refers to the proportion of people who die among confirmed cases of disease and provides a measure of the severity of the disease among diagnosed cases, which allows assessing the risk of severe or fatal complications associated with the disease and reflects the detection capacity, availability, accessibility, and quality of medical care and not only by the disease prevalence.

COVID-19 fatality rates varied widely across countries in the Americas. In Peru, the reported fatality rate was 9.1%, while in Bolivia, it reached 6.2% at the onset of the pandemic. In Brazil, the fatality rate in 2022 was 15.4%, the highest in the region. Among the Indigenous population, some studies report that the fatality rate was 53.3% at the hospital level and up to 4.03% in the community in Brazil, while in Colombia, it reached 3.41%¹⁶16 Ayala-Pazos V, Oscanoa-Espinoza T, Apolaya-Segura M, Amado-Tineo J. Letalidad por COVID-19 en adultos hospitalizados durante las dos primeras olas pandémicas: Una experiencia del sector privado en Perú. Acta Med Peru 2022; 39(4):337-343.

17 Mamani-Ortiz Y, Luizaga-López JM, Illanes-Velarde DE. Situación epidemiológica por Covid-19 en Bolivia ante el fin de la emergencia sanitaria internacional. Gac Med Bol 2023; 46(2):93-102.

18 Wolf JM, Petek H, Maccari JG, Nasi LA. COVID-19 pandemic in Southern Brazil: Hospitalizations, intensive care unit admissions, lethality rates, and length of stay between March 2020 and April 2022. J Med Virol 2022; 94(10):4839-4849.^-1919 Hernández-Vásquez A, Chavez-Ecos F, Barrenechea-Pulache A, Comandé D, Bendezu-Quispe G. Seroprevalence and lethality by SARS-CoV-2 in indigenous populations of Latin America and the Caribbean: a systematic review. PeerJ 2021; 9:e12552..

For this reason, this study aimed to estimate the lethality due to COVID-19 in the Indigenous population in Mexico from 2020 to 2022, considering the clinical characteristics and their social conditions.

Methods

A cross-sectional study was conducted considering the COVID-19-positive cases and the deaths that occurred due to this disease in the Indigenous population reported in the 2020-2022 period by the General Directorate of Epidemiology of the Mexican Ministry of Health²⁰20 Instituto Nacional de Estadística y Geografía (INEGI). Mortalidad [Internet]. 2023 [citado 2023 jun 10]. Disponible en: https://www.inegi.org.mx/programas/mortalidad/#Datos_abiertos.
https://www.inegi.org.mx/programas/morta... .

People whose final classification issued by health authorities was confirmed by epidemiological association were classified as COVID-19-positive cases; that is, when the case reported being a contact of a COVID-19 positive case (and is registered in the Epidemiological Surveillance System for Respiratory Diseases) even when the case did not have a sample or the sample was invalid; those confirmed by ruling in deaths where the case did or did not have a sample taken, or a sample was taken, but was invalid; or when a laboratory sample or antigen test was available, and it was positive for SARS-CoV-2.

The number of deaths from COVID-19 was calculated considering all people who tested positive for the disease as the denominator to assess the lethality of the disease. The study population was classified per their Indigenous status. Age was classified into two groups (up to 60 years, 60 years and above), considering those over 60 as the most vulnerable population. Clinical characteristics such as pneumonia, diabetes, hypertension, asthma, chronic obstructive pulmonary disease (COPD), immunosuppression, cardiovascular diseases, obesity, chronic kidney disease, and obesity were studied. The type of institution of the National Health System that provided the care was not considered since care in the services was provided regardless of whether or not people were assigned to any public service where they were treated during the pandemic.

Regarding the social conditions associated with COVID-19 lethality in the Indigenous population, the economic and social deprivations defined by the National Council for the Evaluation of Social Development Policy (CONEVAL) were considered per the federal entity of habitual residence²¹21 Consejo Nacional de Evaluacion de la Politica de Desarrollo Social (CONEVAL). Medición de la pobreza [Internet]. 2023 [citado 2023 jun 18]. Disponible en: https://www.coneval.org.mx/Medicion/Paginas/Medici%C3%B3n/Indicadore s-de-carencia-social.aspx.
https://www.coneval.org.mx/Medicion/Pagi... . The deprivations studied included vulnerability due to economic deprivation, educational backwardness, access to health services, access to social security, housing quality and space, and lack of access to fundamental housing services, such as access to water, drainage service, electricity, and type of fuel used for cooking. Finally, access to nutritious and quality food was analyzed and identified when households have moderate or severe food insecurity.

The percentage values of the population with these conditions at the state level were obtained from the latest report published by CONEVAL (2020) and were subsequently classified into quintiles.

The statistical analysis performed for the clinical variables consisted of a descriptive analysis, the prevalence odds ratio (POR) was calculated, contrasting the deaths among Indigenous and non-Indigenous people. Subsequently, logistic regression was performed considering the statistically significant variables and those with biological plausibility concerning the disease regardless of the p-value. Regarding social deprivation conditions, the odds ratio was estimated using a Poisson regression considering the number of deaths in the Indigenous population as the dependent variable, while the independent variables were each of the social deprivations studied, taking quintile 1 as a reference, which represents the group with the lowest deprivation. The statistical package Stata version 16 was employed for the statistical analysis.

This study analyzed secondary sources of information available to the public. No primary data were collected for this analysis, so prior submission to an ethics committee was not required.

Results

A total of 7,285,192 COVID-19-positive cases were reported during the period analyzed, of which 0.7% occurred in the Indigenous population. In both groups, a higher number of cases occurred in men.

The most frequent clinical conditions in positive cases were hypertension (11.9%), obesity (9.6%), and diabetes (8.8%). These conditions were even more frequent among the Indigenous population. Deaths from COVID-19 among Indigenous and non-Indigenous people showed no differences regarding gender (p=0.633) or diabetes (p=0.650). Deaths in Indigenous people aged 65 and above were higher than in non-Indigenous people (p<0.001), as was obesity (p<0.0001). However, hypertension (p<0.001), cardiovascular diseases (p=0.020), and chronic kidney disease were more frequent among non-Indigenous people. The clinical conditions in Indigenous and non-Indigenous groups are shown in Table 1.

The fatality rate in the general population was 4.6%, and 9.8% in the Indigenous population. By gender, men were more likely to die than women in the Indigenous and non-Indigenous populations, 74% and 88%, respectively. Case fatality from COVID-19 associated with diabetes was higher among non-Indigenous people (ORp=7.31; 95%CI=7.26-7.37) than among Indigenous people (ORp=4.68; 95%CI=4.39-4.98). The same situation occurred with hypertension, chronic kidney disease, obesity, and cardiovascular disease (Table 2).

The analysis of social deprivations showed a gradient with a higher lethality due to COVID-19 as educational backwardness increases among the population, which is more evident among Indigenous people, where the most vulnerable quintile is three times more likely to die from COVID-19 than the least vulnerable group.

On the other hand, higher mortality from COVID-19 was associated with vulnerability due to lack of income, mainly among quintiles 3 and 4. Lack of access to health services affected all strata. However, it increased in the most vulnerable sectors. Security access did not show significant differences between the groups, except in the most vulnerable quintile, where it was a protective factor. No significant association was found regarding reported deaths with deprivations in the quality of housing or fundamental services (Table 3).

Discussion

During the COVID-19 pandemic, the most vulnerable social groups had limitations in performing disease containment actions, such as reinforcing hygiene measures and home isolation²²22 Lustig N, Tommasi M. Covid-19 y la protección social de las personas pobres y los grupos vulnerables en América Latina: un marco conceptual. Rev CEPAL 2020; 132:283-295.^,2323 Medina-Gomez OS. Vulnerability of access to health services for informal workers in Mexico in the face of the SARS-CoV-2 pandemic. Cien Saude Colet 2021; 26(12):5897-5904., which increased inequality in income, employment, and access to health services, affecting mortality and lethality in Indigenous groups in several countries in the region²⁴24 Lancet COVID-19 Commissioners, Task Force Chairs, and Commission Secretariat. Lancet COVID-19 Commission Statement on the occasion of the 75th session of the UN General Assembly. Lancet 2020; 396(10257):1102-1124.

25 Hallal PC, Hartwig FP, Horta BL, Silveira MF, Struchiner CJ, Vidaletti LP, Neumann NA, Pellanda LC, Dellagostin OA, Burattini MN, Victora GD, Menezes A, Barros F, Barros A, Victora C. SARS-CoV-2 antibody prevalence in Brazil: results from two successive nationwide serological household surveys. Lancet Glob Health 2020; 8(11):e1390-e1398.

26 Ranzani OT, Bastos LSL, Gelli JGM, Marchesi JF, Baião F, Hamacher S, Bozza F. Characterisation of the first 250,000 hospital admissions for COVID-19 in Brazil: a retrospective analysis of nationwide data. Lancet Respir Med 2021; 9(4):407-418.

27 Soto-Cabezas MG, Reyes MF, Soriano AN, Velásquez-Rodriguez JP, Ordoñez-Ibargüen L, Martel KS, Flores-Jaime N, Munayco C. COVID-19 among Amazonian indigenous in Peru: mortality, incidence, and clinical characteristics. J Public Health. 2022; 44(3):e359-e365.^-2828 Henriquez-Trujillo AR, Ortiz-Prado E, Rivera-Olivero IA, Nenquimo N, Tapia A, Anderson M, Lozada T, García-Bereguiain MA. COVID-19 outbreaks among isolated Amazonian indigenous people, Ecuador. Bull World Health Organ 2021; 99(7):478-A..

COVID-19 had a significant impact on the Brazilian Indigenous population. Santos et al.²⁹29 Santos VS, Souza Araújo AA, Riveiro J, Quintans-Júnior LJ, Martins-Filho PR. COVID-19 mortality among Indigenous people in Brazil: a nationwide register-based study. J Public Health 2021; 43(2):e250-e251. reported a case fatality rate of 1.8% in the Indigenous population. However, the case fatality rate in this group was 3.2% for those living in the Midwest region of the country, which is lower than what was found in our study, where the case fatality rate in the Indigenous population reached 9.8%. This study identified that the COVID-19 case fatality rates among Indigenous peoples are higher than those observed in the general population, without considering possible underreported cases, which is common in these social groups³⁰30 Fellows M, Paye V, Alencar A, Nicácio M, Castro I, Coelho ME, Silva C, Bandeira M, Lourival R, Basta PC. Under-Reporting of COVID-19 Cases Among Indigenous Peoples in Brazil: A New Expression of Old Inequalities. Front Psychiatry 2021; 12:638359..

Argoty-Pantoja et al.³¹31 Argoty-Pantoja AD, Robles-Rivera K, Rivera-Paredez B, Salmeron J. COVID-19 fatality in Mexico's indigenous populations. Public Health 2021; 193:69-75. point out that the factors associated with higher mortality rates among non-Indigenous and Indigenous outpatients were gender and comorbidities, which is similar to what was found in our study where chronic kidney disease, hypertension, diabetes, and obesity were associated with higher COVID-19 mortality. However, this association was higher among non-Indigenous people.

The lethality in men was higher than in women in Indigenous and non-Indigenous people. The same results were published by several authors³¹31 Argoty-Pantoja AD, Robles-Rivera K, Rivera-Paredez B, Salmeron J. COVID-19 fatality in Mexico's indigenous populations. Public Health 2021; 193:69-75.

32 Peña JE, Rascon-Pacheco RA, Ascencio-Montiel IJ, Gonzalez-Figueroa E, Fernandez-Garate JE, Medina-Gomez OS, Borja-Bustamante P, Santillán-Oropeza JA, Borja-Aburto VH. Hypertension, Diabetes and Obesity, Major Risk Factors for Death in Patients with COVID-19 in Mexico. Arch Med Res 2021; 52(4):443-449.^-3333 Perez-Lopez FR, Tajada M, Savirón-Cornudella R, Sánchez-Prieto M, Chedraui P, Terán E. Coronavirus disease 2019 and gender-related mortality in European countries: A meta-analysis. Maturitas 2020; 141:59-62., which can be explained by the occupational exposure to which men were subjected during the pandemic, making them more vulnerable to contracting the disease and dying³⁴34 Robles-Pérez E, González-Díaz B, Miranda-García M, Borja-Aburto VH. Infection and death by COVID-19 in a cohort of healthcare workers in Mexico. Scand J Work Environ Health 2021; 47(5):349-355..

Social and economic deprivations are determinants in increasing the risk of infectious diseases, such as COVID-19. They are prevalent among Indigenous groups, who lack access to health centers and basic sanitation and live under substandard health conditions²²22 Lustig N, Tommasi M. Covid-19 y la protección social de las personas pobres y los grupos vulnerables en América Latina: un marco conceptual. Rev CEPAL 2020; 132:283-295.. Our results show that the lack of access to education was significantly associated in all quintiles regarding death from COVID-19, which is more evident among Indigenous people even in the most vulnerable quintile, while the results obtained for the lack of access to health services in the Indigenous group, mainly in the most vulnerable population quintile, reveal barriers to care and timely diagnosis similar to those faced at the pandemic onset³⁵35 Chávez-Almazán LA, Díaz-González L, Rosales-Rivera M. Socioeconomic determinants of health and COVID-19 in Mexico. Gac Med Mex 2022; 158(1):3-10..

Contrary to what has been reported in other studies³⁵35 Chávez-Almazán LA, Díaz-González L, Rosales-Rivera M. Socioeconomic determinants of health and COVID-19 in Mexico. Gac Med Mex 2022; 158(1):3-10., the results did not show any association regarding the lack of public services and housing quality concerning COVID-19 lethality, the results of which are similar to those reported by Khan et al.³⁶36 Khan KS, Torpiano G, McLellan M, Mahmud S. The impact of socioeconomic status on 30-day mortality in hospitalized patients with COVID-19 infection. J Med Virol 2021; 93(2):995-1001., which may result from the implementation of some measures, such as the use of alcohol gel, which could have alleviated the lack of water for hand hygiene and influenced the transmission of the disease.

On the other hand, the dimension of access to food security was not relevant regarding the mortality rate in the Indigenous and non-Indigenous populations, which the food collection and delivery to vulnerable populations can explain. This fact shows the importance of community strengthening to increase and maintain food resilience and the public policies implemented during the COVID-19 pandemic³⁷37 Nadal A, Nazar-Beutelspacher DA. COVID-19: Solidarity initiatives for food security in the Mayan indigenous region of south-southeast Mexico. Glob Food Sec 2023; 37:100697.^,3838 Gobierno de México. COVID-19 Medidas económicas [Internet]. 2023 [citado 2023 jun 14]. Disponible en: https://www.gob.mx/covid19medidaseconomicas.
https://www.gob.mx/covid19medidaseconomi... .

It is necessary to build dialogue and active participation of communities in the design and implementation of strategies for the promotion, prevention, care, and rehabilitation adapted to different contexts based on autonomy and integrating each community’s knowledge systems in order to address the health problems of minorities, including the Indigenous population, which allows for building a health system with a community-based approach and strengthening of support networks to produce more effective strategies³⁹39 Organización Panamericana de la Salud (OPS). Los Yuquis: un pueblo indígena que previene la COVID-19 en comunidad [Internet]. 2023 [citado 2023 jun 20]. Disponible en: https://www.paho.org/es/historias/yuquis-pueblo-indigena-que-previene-covid-19-comunidad.
https://www.paho.org/es/historias/yuquis...

40 Organización Panamericana de la Salud (OPS). Con una campaña protagonizada por miembros de pueblos indígenas, Ecuador promueve la vacunación contra la COVID-19 [Internet]. 2023 [citado 2023 jun 20]. Disponible en: https://www.paho.org/es/historias/con-campana-protagonizada-por-miembros-pueblos-indigenas-ecuador-promueve-vacunacion.
https://www.paho.org/es/historias/con-ca... ^-4141 Organización Panamericana de la Salud (OPS). Salud comunitaria en los pueblos Guaranies en tiempo de COVID-19 yayeopia mbaerasi guasuigui yaiko kavi vaëra [Internet]. 2023 [citado 2023 jun 20]. Disponible en: https://www.paho.org/es/historias/salud-comunitaria-pueblos-guaranies-tiempo-covid-19-yayeopia-mbaerasi-guasuigui-yaiko.
https://www.paho.org/es/historias/salud-... .

As a result, health must be considered as a cohesive element to include development and progress proposals under multi-sectoral work in Indigenous communities in order to reduce the social, environmental, and health inequality gaps, given the vulnerability to which they were exposed to the COVID-19 pandemic⁴²42 Díaz de León-Martínez L, de la Sierra-de la Vega L, Palacios-Ramírez A, Rodriguez-Aguilar M, Flores-Ramírez R. Critical review of social, environmental and health risk factors in the Mexican indigenous population and their capacity to respond to the COVID-19. Sci Total Environ 2020; 733:139357., as shown in the final report “Monitoring MDGs through an Indigenous Peoples’ Perspective”, which presents the results of 47 programs implemented in Africa, Latin America, and Asia⁴³43 Pueblos indígenas y ODM. Implementación de buenas prácticas para el empoderamiento de los pueblos indígenas. Foro Internacional de Mujeres Indígenas. Informe final [Internet]. 2017 [citado 2024 jan 20]. Disponible en: https://www.inee.edu.mx/wp-content/uploads/2018/12/mdgif-informe-pueblos-indigenas-y-odm.pdf.
https://www.inee.edu.mx/wp-content/uploa... .

Finally, we should underscore the limitations of using secondary sources to analyze the social determinants of health because they were created for specific purposes other than the objectives of this research. So, the information retrieved from records and databases does not always respond to the needs for which they are used, and the record’s quality cannot be fully guaranteed⁴⁴44 Medina-Gómez OS, López-Arellano O. Asociación de los tipos de carencia y grado de desarrollo humano con la mortalidad infantil en México, 2008. Cad Saude Publica 2011; 27(8):1603-1610.^,4545 Ramirez-Villalobos D, Stewart AL, Romero M, Gomez S, Flaxman AD, Hernandez B. Analysis of causes of death using verbal autopsies and vital registration in Hidalgo, Mexico. PLoS ONE 2019; 14(7):e0218438..

Furthermore, the results obtained consider the pandemic outlook during the years studied. However, we should recognize that they may vary if we consider our country’s different waves, affecting lethality at different intensities among the several social groups.

References

Publication Dates

History