Abstract

Objective: To synthesize the elements of vulnerability to Covid-19 among the adult population. Method: Integrative review carried out between August and November 2020, with defined criteria of inclusion, exclusion and retrieving of studies. Data were extracted and synthesized by means of the categorical thematic analysis, and systematized by the vulnerability concept. Most relevant results: From 2247 articles retrieved, 70 original studies were selected, fully read and assessed. Four vulnerability markers emerged: Chronic Health Conditions; Daily Life Experiences; Social Insertion; and Health Services and Actions. Main conclusions: The identified vulnerability markers may support health professionals in the identification of patients with less autonomy and resources for self-care and protection against Covid-19. They may also foster the adoption of health and intersectoral interventions to protect patients against Covid-19, as well as the reduction of SARS-Cov-2 transmission rates within communities and other settings, with significant decline in the impact of the virus on society.

Keywords:
Adult; Middle-Aged People; Social Health Determinants; Health Vulnerability; Covid-19

Introduction

This study proposes the reconstruction of an instrument that allows health professionals to recognize the elements of vulnerability in adults for the Coronavirus disease 2019 or Covid-19. In addition, it may help them identify patients’ real needs, facilitating the adoption of integral health care.

Covid-19 is caused by the SARS-CoV-2 (Severe Acute Respiratory Syndrome - Coronavirus 2) virus, a beta Coronavirus from the same subgenre as the Middle East respiratory Syndrome (MERS), but from another sub-type (ORTIZ-PRADO ., 2020ORTIZ-PRADO, E. et al. Clinical, Molecular, and Epidemiological Characterization of the SARS-CoV-2 Virus and the Coronavirus Disease 2019 (Covid-19), a Comprehensive Literature Review. Diagnostic Microbiology and Infectious Disease, v. 98, n. 1, 2020, p. 115094, 30 maio 2020.). This microorganism, currently troublesome for global health, causes a potentially lethal disease (ROTHAN; SIDDAPPA, 2020ROTHAN, H. A.; SIDDAPPA, N. B. The Epidemiology and Pathogenesis of Coronavirus Disease (Covid-19) Outbreak. Journal of Autoimmunity, v. 109, p. 102433, 26 fev. 2020.). The virus ascendance has likely evolved from the large number of infected people exposed to the animal market in the city of Wuhan, China, suggesting the probable zoonotic origin of the Covid-19 (TAZERJI ., 2020TAZERJI, S. S. et al. Transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to animals: an updated review. Journal of Translational Medicine, v. 18, n. 1, p. 358, 21 set. 2020.).

Until May 2022, about 525,039,437 confirmed cases were reported worldwide, totaling 6,282,176 deaths. The United States of America has been the epicenter of the disease with 82,811,372 confirmed cases and 1,000,430 deaths due to the SARS-CoV-2. In Brazil, there were 30,701,900 confirmed cases and 665,216 deaths due to Covid-19 (JOHNS HOPKINS CORONAVIRUS RESOURCE CENTER, 2022JOHNS HOPKINS CORONAVIRUS RESOURCE CENTER. Overview of Covid-19, cases, and deaths - Brazil. Baltimore-MA; 2022. Disponível em: https://coronavirus.jhu.edu/region/brazil Acesso em: 18 mai. 2022.
https://coronavirus.jhu.edu/region/brazi... ).

Community transmission of the SARS-CoV-2 was confirmed in all countries around the globe, primarily occurring by means of the contact with respiratory droplets and/or aerosols from symptomatic or asymptomatic infected patients. Incubation period varies from 0 to 14 days, an estimation of 5 to 6 days after infection (LU ., 2020LU, R. et al. Genomic Characterisation and Epidemiology of 2019 Novel Coronavirus: Implications for Virus Origins and Receptor Binding. The Lancet, v. 395, n. 10224, p. 565-574, 2020.; BRASIL, 2022BRASIL. Ministério da Saúde. Guia de vigilância epidemiológica: emergência de saúde pública de importância nacional pela doença pelo coronavírus 2019 - Covid-19. Brasília: Ministério da Saúde, 2022.).

Suspected cases of Covid-19 are commonly reported as: flu syndrome, “acute respiratory condition characterized by at least two of these signs and symptoms – fever (even though reported), chills, sore throat, headache, cough, rhinorrhea, olfactory or gustatory disorders”; or severe acute respiratory syndrome (SARS), “dyspnea or respiratory discomfort or chest pressure or persistent pain or O2 saturation below 95% in the environment air or bluish color (cyanosis) of lips or face” (BRASIL, 2022BRASIL. Ministério da Saúde. Guia de vigilância epidemiológica: emergência de saúde pública de importância nacional pela doença pelo coronavírus 2019 - Covid-19. Brasília: Ministério da Saúde, 2022., p. 22). However, a Covid-19 case (fly syndrome or SARS) must be confirmed or ruled out following these criteria: clinical, clinical-epidemiological, clinical-imaging tests and laboratory tests (molecular biology, immunology and search for antigens) in asymptomatic or symptomatic, vaccinated or non-vaccinated subjects against Covid-19 (BRASIL, 2022BRASIL. Ministério da Saúde. Guia de vigilância epidemiológica: emergência de saúde pública de importância nacional pela doença pelo coronavírus 2019 - Covid-19. Brasília: Ministério da Saúde, 2022.).

People with certain chronic morbidities are more vulnerable to develop SARS. Thus, older individuals – over 80 years old – with chronic respiratory diseases, hypertension and cardiovascular diseases are considered risk groups for SARS (YANG ., 2020YANG, J. et al. Prevalence of comorbidities in the novel Wuhan coronavirus (Covid-19) infection: a systematic review and meta-analysis. International Journal of Infectious Diseases, v. 94, p. 91-95, 12 mar. 2020.). Covid-19 may have inflammatory outcomes to heart, kidneys and/or liver due to generalized inflammation in response to the infection (TAHIR ., 2020TAHIR, F. et al. Cardiac Manifestations of Coronavirus Disease 2019 (Covid-19): A Comprehensive Review. Cureus, v. 12, n. 5, p. e8021, 8 maio 2020.).

Thus, death rate has been estimated in 10.5% for cardiovascular diseases, 7.3% for Diabetes Mellitus, 6.3% for chronic respiratory diseases, and 6% for hypertension (MOREIRA, 2020MOREIRA, R.S. Covid-19: Intensive Care Units, Mechanical Ventilators, and Latent Mortality Profiles Associated with Case-Fatality in Brazil. Cadernos de Saúde Pública, v. 36, n. 5, p. E00080020, 18 maio 2020.). From a demographic perspective, 60% of Covid-19 cases were observed to affect individuals between 18 and 59 years of age, 30% of individuals over 60 years, and 54.3% of males (LO ., 2020LO, I. L. et al. Evaluation of SARS-CoV-2 RNA Shedding in Clinical Specimens and Clinical Characteristics of 10 Patients with Covid-19 in Macau. International Journal of Biological Sciences, v. 16, n. 10, p. 1698-1707, 15 mar. 2020.; SOHRABI ., 2020SOHRABI, C. et al. World Health Organization Declares Global Emergency: A Review of the 2019 Novel Coronavirus (Covid-19). International Journal of Surgery, v. 76, p. 71-76, 26 fev. 2020.).

Regarding the above-mentioned factors of biological risk, this study assumes that the vulnerability of adult individuals to Covid-19 is related to the available prevention resources, as well as subjects’ self-care and autonomy to make their own decisions. Such elements can be understood under the concept of vulnerability in health, that is, a set of individual, social and political conditions that concomitantly determine the health preservation of subjects and communities, and their protection against diseases and/or disabilities (AYRES; PAIVA; FRANÇA JÚNIOR, 2011AYRES, J. R. C. M.; PAIVA, V.; FRANÇA JUNIOR, I. From natural history of disease to vulnerability. In: PARKER, R.; SOMMER, M. Routledge handbook in global public health. New York: Taylor & Francis Group, 2011, p. 98-107.; SILVA ., 2016SILVA, D. I. et al. Children’s vulnerability to health damages: elements, applicability, and perspectives. IOSR Journal of Nursing and Health Science, v. 5, n. 5, p. 15-20, 2016.).

In the context of the Covid-19, worldwide, millions of human beings live in densely populated communities, poor housing quality, lack of basic sanitation and access to water treatment. Such groups have no resources or autonomy to adopt prevention measures against the spread of SARS-Cov-2, such as social distancing and frequent hand washing (THE LANCET, 2020THE LANCET. Redefining vulnerability in the era of Covid-19. The Lancet, v. 395, n.10230 p. 1089, 10 abr. 2020.). Greater incidence of Covid-19 among African-Americans and its disproportionate effects reflect the racial inequality and social exclusion of these groups, already existent before the pandemic (KIM; BOSTWICK, 2020KIM, S. J.; BOSTWICK, W. Social Vulnerability and Racial Inequality in Covid-19 Deaths in Chicago. Health education & behavior, v. 47, n. 4, p. 509-513, 21 maio 2020.).

Those conditions of vulnerability are grouped and organized as markers of vulnerability, encompassing a health care technology. This instrument may subsidize health professionals for the identification of patients with less autonomy and resources for self-care and protection against Covid-19 (CARNEIRO; AYRES, 2021CARNEIRO, J. L. S.; AYRES, J. R. C. M. Older adult health and primary care: autonomy, vulnerabilities and challenges of care. Revista de Saúde Pública, v. 55, p. 29, 2021.). This scale of vulnerability degrees enables the adoption of intersectoral health interventions, which provide those people with better protection against Covid-19 infection. In addition, they reduce SARS-Cov-2 transmission rates within communities and other settings, with significant reduction of the virus impact on the society.

Acknowledging the most vulnerable groups allows equity-based planning of public policies, a tenant from the Unified Health System (SUS), as well as the whole-person care within health-care services. Thus, this study aimed to synthesize the vulnerability markers to Covid-19 among the adult population.

Method

Integrative review grounded in the research question: “What conditions determine the vulnerability to Covid-19 among the adult population? The following methodological steps were taken: definition of the criteria for study inclusion (participants, exposure factors, results and types of studies, definition of the search strategies, data extraction and synthesis), aiming at the necessary clarity and strictness for the study (WHITTEMORE; KNAFL, 2005WHITTEMORE, R.; KNAFL, K. The Integrative Review: Updated Methodology. Journal of Advanced Nursing, v. 52, n. 5, p. 546-553, 2005.).

Inclusion and exclusion criteria were established for the selection of the studies. Regarding the participants, studies developed with males and females between 20-59 years of age were considered due to the magnitude of the cases of Covid-19 within this age range in the searched studies (LO ., 2020LO, I. L. et al. Evaluation of SARS-CoV-2 RNA Shedding in Clinical Specimens and Clinical Characteristics of 10 Patients with Covid-19 in Macau. International Journal of Biological Sciences, v. 16, n. 10, p. 1698-1707, 15 mar. 2020.).

Regarding the exposure factors, biological, psychosocial, socioeconomic and sociocultural conditions, leading to the Covid-19, were considered. Included studies were as follows: studies addressing risk factors, studies measured by means of prospective and retrospective statistical methods, as well as logistic regression and correlation.

The selected studies addressed the Covid-19 disease, described by the International Classification of Diseases and Related Health Problems, code (ICD -10) – U07.1, used for hospital discharges after April 1 2020. The code was developed by the World Health Organization (WHO), and must be used as the main diagnosis (KADRI ., 2020KADRI, S. S. et al. Uptake and Accuracy of the Diagnosis Code for Covid-19 Among US Hospitalizations. JAMA, v. 324, n. 24, p. 2553–2554, 22 dec. 2020.).

The included studies were as follows: observational cohort studies, case-control or cross-sectional studies, quasi-experimental, qualitative, exploratory, theoretical, ethnographic studies, action-research and case study. The idioms of the published studies comprised English, Portuguese and Spanish, as researchers master such languages. The timespan 2019-2020 (1 retrospective year) was chosen due to its current evidence, considering that the first outbreaks of the disease occurred at the end of 2019. The studies were retrieved between October 2020 and January 2021.

The excluded studies were established as follows: studies addressing clinical conditions, tests of therapeutic efficacy, diagnostic accuracy, and those that did not report correlated risk factors; secondary studies of systematic, integrated and narrative review, theses, dissertations, technical documents, and articles published in other idioms rather than the selected ones.

For study retrieval, the following databases were selected: CINAHL (Cumulative Index of Nursing and Allied Health Literature), BDENF (Nursing Database - Base de Dados de Enfermagem); IBECS (Spanish Bibliographic Index of the Health Sciences) and LILACS (Scientific Health Literature from Latin-American and Caribbean countries) – accessed at the BVS portal (Virtual Health Library); and MEDLINE (Index Medicus) – accessed at the BVS e PubMed (National Library of Medicine) portals.

Search strategies were built for each database in order to ensure more focused and accurate search. Such strategies were built with descriptors and/or keywords, validated to conduct the search, according to table 1, below.

The articles retrieved from the databases were tabulated in the Endnote® Platform and, after the exclusion of the repetitions, had their titles and abstracts fully read. By means of the inclusion and exclusion criteria, the final sample of the assessed articles was obtained. The selected studies from the databases and portal had their methodological quality evaluated by the PRISMA-P © strategy (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols), and their titles and abstracts fully read, being applied the established inclusion and exclusion criteria (MOHER ., 2015MOHER, D. et al. Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). Systematic Reviews, v. 4, n. 1, p. 1-9, 2015.).

The articles included at this step of the study were fully read and their contents were tabulated in the Microsoft Excel® spreadsheet. The determinant conditions of life for Covid-19 comprised the corpus for data synthesis. Thematic analysis of the categories was used (BARDIN, 2010BARDIN, L. Análise de conteúdo. Lisboa: Edições 70; 2010.). Data were presented in a descriptive way, with their synthesis shown in graphic representation, and the categories emerging from this study were named as vulnerability markers (AYRES; PAIVA; FRANÇA JÚNIOR, 2011).

Results

From 2,247 retrieved articles, 95 repeated studies were excluded, identified in the Endnote® platform. Thus, 2,152 articles were selected, their titles and abstracts fully read; 2,082 studies, which did not meet the inclusion criteria, were excluded. Therefore, 70 original, fully-read studies were assessed, according to description in Figure 1.

By means of the full reading of the 70 assessed studies, the elements of vulnerability were grouped according to subjects’ individual conditions, the sociocultural, socioeconomic elements, and the availability of health care actions and services, subsequently shown.

Finally, the reflection on the exclusion of studies which “are not available for free search”. Although it is justifiable, in times when the so called Open Science has been claimed, it may result in a selection bias, as many highly relevant studies are sent to renowned and prestigious journals, which charge for the access to their publications.

Chronic health conditions

The first synthesized marker refers to the conditions of health and disease that curb adult subjects to access care to their health needs during the pandemic. Their components are the physical disability (LAKHANI, 2020LAKHANI, A. Which Melbourne Metropolitan Areas Are Vulnerable to Covid-19 Based on Age, Disability, and Access to Health Services? Using Spatial Analysis to Identify Service Gaps and Inform Delivery. Journal of Pain and Symptom Management, v. 60, n. 1, p. e41-e44, 2020.; MESA VIEIRA ., 2020MESA VIEIRA, C. et al. Covid-19: The forgotten priorities of the pandemic. Maturitas, v. 136, p. 38-41, 2020.), communication disorders (SHER; STAMPER; LUNDY, 2020), Alzheimer disease and/or related dementias (BROWN ., 2020BROWN, E. et al. Anticipating and Mitigating the Impact of the Covid-19 Pandemic on Alzheimer’s Disease and Related Dementias. The American Journal of Geriatric Psychiatry, v. 28, n. 7, p. 712-721, 2020.), and psychiatric disorder (SERAFINI ., 2020SERAFINI, G. et al. Aged Patients with Mental Disorders in the Covid-19 Era: The Experience of Northern Italy. The American Journal of Geriatric Psychiatry, v. 28, n. 7, p. 794-795, 2020.).

Thus, adult subjects with chronic diseases, such as cardiopathy, pneumopathy, systemic arterial hypertension, diabetes mellitus, neoplasia, nephropathy, smoking and HIV/AIDS (ADAMS ., 2020ADAMS, S. et al. Medical Vulnerability of Young Adults to Severe Covid-19 Illness. Data From the National Health Interview Survey. Journal of Adolescent Health, v. 67, n. 3, p. 362-368, 2020.; ALCÁNTARA MONTERO ., 2020ALCÁNTARA MONTERO, A. et al. Posibles factores protectores de la infección por SARS-CoV-2 en una paciente vulnerable: a propósito de un caso. Semergen, v. 46, p. 95-98, 2020.; BASU, 2020BASU, S. Non-communicable disease management in vulnerable patients during Covid-19. Indian Journal of Medical Ethics, v. 5, n. 2, p. 103-105, 2020.; BERHAN, 2020BERHAN, Y. Covid-19, a Disease of Enigma: Why Pregnant Women are Less Vulnerable? Ethiopian Journal of Health Sciences, v. 30, n. 3, 2020.; FORMIGA; TARAZONA-SANTABALBINA, 2020FORMIGA, F.; TARAZONA-SANTABALBINA, F. Diabetes y Covid-19 en el adulto mayor, simbiosis nociva. Revista Española de Geriatría y Gerontología, v. 55, n. 6, p. 315-316, 2020.; DE LUSIGNAN ., 2020DE LUSIGNAN, S. et al. Risk factors for SARS-CoV-2 among patients in the Oxford Royal College of General Practitioners Research and Surveillance Centre primary care network: a cross-sectional study. The Lancet Infectious Diseases, v. 20, n. 9, p. 1034-1042, 2020.; KALICHMAN ., 2020KALICHMAN, S. et al. Intersecting Pandemics: Impact of SARS-CoV-2 (Covid-19) Protective Behaviors on People Living With HIV, Atlanta, Georgia. JAIDS Journal of Acquired Immune Deficiency Syndromes, v. 85, n. 1, p. 66-72, 2020.; KUDERER ., 2020KUDERER, N. et al. Clinical impact of Covid-19 on patients with cancer (CCC19): a cohort study. The Lancet, v. 395, n. 10241, p. 1907-1918, 2020.) are also vulnerable. From the life cycles, pregnant women were also considered vulnerable (BERHAN, 2020BERHAN, Y. Covid-19, a Disease of Enigma: Why Pregnant Women are Less Vulnerable? Ethiopian Journal of Health Sciences, v. 30, n. 3, 2020.), as well as older people (PRINA, 2020PRINA, L. Grantwatch: Funders’ Efforts: Aging and Health, Covid-19. Health Affairs, v. 39, n. 6, p. 1092-1093, 2020.; GÓMEZ-MORENO ., 2020GÓMEZ-MORENO, C. et al. Clinical Decision Making in Older Adults with Covid-19 in Developing Countries: Looking Beyond Chronological Age. Revista de investigación clínica, v. 72, n. 3, p. 127-134, 2020.; KNIGHTS ., 2020KNIGHTS, H. et al. Characteristics and outcomes of patients with Covid-19 at a district general hospital in Surrey, UK. Clinical Medicine, v. 20, n. 5, p. e148-e153, 2020.; MARCON ., 2020MARCON, G. et al. Covid-19 mortality in Lombardy: the vulnerability of the oldest old and the resilience of male centenarians. Aging, v. 12, n. 15, p. 15186-15195, 2020.; MESA VIEIRA ., 2020MESA VIEIRA, C. et al. Covid-19: The forgotten priorities of the pandemic. Maturitas, v. 136, p. 38-41, 2020.).

Daily life experiences

The second synthesized marker points out all living situations of adult subjects regarding their cultural, humanistic, geopolitical status that hinder their access to healthcare during the pandemic of Covid-19. The immigrant condition is considered a component of this marker. (TACKLE..., 2020; BRITO, 2020BRITO, M. Covid-19 in the Americas: Who’s Looking After Refugees and Migrants? Annals of Global Health, v. 86, n. 1, 2020.; CLARK ., 2020CLARK, E. et al. Disproportionate impact of the Covid-19 pandemic on immigrant communities in the United States. PLOS Neglected Tropical Diseases, v. 14, n. 7, p. e0008484, 2020.; KOH, 2020KOH, D. Migrant workers and Covid-19. Occupational and Environmental Medicine, v. 77, n. 9, p. 634-636, 2020.; MESA VIEIRA ., 2020MESA VIEIRA, C. et al. Covid-19: The forgotten priorities of the pandemic. Maturitas, v. 136, p. 38-41, 2020.; SURESH; JAMESR, 2020; BRITO, 2020BRITO, M. Covid-19 in the Americas: Who’s Looking After Refugees and Migrants? Annals of Global Health, v. 86, n. 1, 2020.; CLARK ., 2020CLARK, E. et al. Disproportionate impact of the Covid-19 pandemic on immigrant communities in the United States. PLOS Neglected Tropical Diseases, v. 14, n. 7, p. e0008484, 2020.; HAMIDIAN JAHROMI; HAMIDIAN JAHROMI, 2020), as well as the refugee status (BRITO, 2020BRITO, M. Covid-19 in the Americas: Who’s Looking After Refugees and Migrants? Annals of Global Health, v. 86, n. 1, 2020.).

Adult people are also limited by cultural barriers (AHMAD ., 2020AHMAD, A. et al. What does it mean to be made vulnerable in the era of Covid-19? The Lancet, v. 395, n. 10235, p. 1481-1482, 2020.; BRADLEY; KIRBY; WHEATSTONE, 2020BRADLEY, S.; KIRBY, E.; WHEATSTONE, P. Managing individual and population risk from Covid-19. BMJ, p. m2098, 2020.; KHAZANCHI ., 2020KHAZANCHI, R. et al. County-Level Association of Social Vulnerability with Covid-19 Cases and Deaths in the USA. Journal of General Internal Medicine, v. 35, n. 9, p. 2784-2787, 2020.), such as the ethnic minorities (CUPERTINO ., 2020CUPERTINO, G. et al. Covid-19 and Brazilian Indigenous Populations. The American Journal of Tropical Medicine and Hygiene, v. 103, n. 2, p. 609-612, 2020.; DÍAZ DE LEÓN-MARTÍNEZ ., 2020DÍAZ DE LEÓN-MARTÍNEZ, L. et al. Critical review of social, environmental and health risk factors in the Mexican indigenous population and their capacity to respond to the Covid-19. Science of The Total Environment, v. 733, p. 1-6, 2020.; GRAY ., 2020GRAY, D. et al. Covid-19 and the other pandemic: populations made vulnerable by systemic inequity. Nature Reviews Gastroenterology & Hepatology, v. 17, n. 9, p. 520-522, 2020.; KHAZANCHI ., 2020KHAZANCHI, R. et al. County-Level Association of Social Vulnerability with Covid-19 Cases and Deaths in the USA. Journal of General Internal Medicine, v. 35, n. 9, p. 2784-2787, 2020.; MESA VIEIRA ., 2020MESA VIEIRA, C. et al. Covid-19: The forgotten priorities of the pandemic. Maturitas, v. 136, p. 38-41, 2020.; RAIFMAN; RAIFMAN, 2020RAIFMAN, M.; RAIFMAN, J. Disparities in the Population at Risk of Severe Illness from Covid-19 by Race/Ethnicity and Income. American Journal of Preventive Medicine, v. 59, n. 1, p. 137-139, 2020.; DE LUSIGNAN ., 2020DE LUSIGNAN, S. et al. Risk factors for SARS-CoV-2 among patients in the Oxford Royal College of General Practitioners Research and Surveillance Centre primary care network: a cross-sectional study. The Lancet Infectious Diseases, v. 20, n. 9, p. 1034-1042, 2020.; HAMIDIAN JAHROMI; HAMIDIAN JAHROMI, 2020; NIEDZWIEDZ ., 2020NIEDZWIEDZ, C. et al. Ethnic and socioeconomic differences in SARS-CoV-2 infection: prospective cohort study using UK Biobank. BMC Medicine, v. 18, n. 1, 2020.), and women oppressed by a misogynist and male-chauvinist culture (BETRON ., 2020BETRON, M. et al. Men and Covid-19: Adding a gender lens. Global Public Health, v. 15, n. 7, p. 1090-1092, 2020.; AMALAKANTI; RAMAN AREPALLI; KOPPOLU, 2020AMALAKANTI, S.; RAMAN AREPALLI, K.; KOPPOLU, R. Gender and Occupation Predict Coronavirus Disease 2019 Knowledge, Attitude and Practices of a Cohort of a South Indian State Population. Indian Journal of Medical Microbiology, v. 38, n. 2, p. 144-156, 2020.).

In their daily lives, mothers without family and social support are vulnerable individuals (CHOI; BYOUN; KIM, 2020CHOI, S.; BYOUN, S.; KIM, E. Unwed single mothers in South Korea: Increased vulnerabilities during the Covid-19 pandemic. International Social Work, v. 63, n. 5, p. 676-680, 2020.), sex workers (PLATT ., 2020PLATT, L. et al. Sex workers must not be forgotten in the Covid-19 response. The Lancet, v. 396, n. 10243, p. 9-11, 2020.), LGBTQIA+ population (SALERNO; WILLIAMS; GATTAMORTA, 2020SALERNO, J.; WILLIAMS, N.; GATTAMORTA, K. LGBTQ populations: Psychologically vulnerable communities in the Covid-19 pandemic. Psychological Trauma: Theory, Research, Practice, and Policy, v. 12, n. S1, p. S239-S242, 2020.), dwellers in shelters or halfway houses (PAHO, 2021PAN-AMERICAN HEALTH ORGANIZATION. Recommendations on Environmental Public Health for Temporary Shelters. Place where shelter, food, clothing, and health are temporarily provided to vulnerable people who cannot stay at home: General Publications. Washington, D.C.: Pan American Health Organization, 2021. Disponível em: <https://iris.paho.org/handle/10665.2/52189>. Acesso em: 1 jul. 2021.
https://iris.paho.org/handle/10665.2/521... ), and institutionalized elders (BURKI, 2020BURKI, T. England and Wales see 20 000 excess deaths in care homes. The Lancet, v. 395, n. 10237, p. 1602, 2020.; DANIS ., 2020DANIS, K. et al. High impact of Covid-19 in long-term care facilities, suggestion for monitoring in the EU/EEA, May 2020. Eurosurveillance, v. 25, n. 22, p. 1-5, 2020.).

Still in the humanitarian context, there is more vulnerability among the prison population (BARNERT, 2020BARNERT, E. Covid-19 and Youth Impacted by Juvenile and Adult Criminal Justice Systems. Pediatrics, v. 146, n. 2, p. e20201299, 2020.; MESA VIEIRA ., 2020MESA VIEIRA, C. et al. Covid-19: The forgotten priorities of the pandemic. Maturitas, v. 136, p. 38-41, 2020.; MONTOYA-BARTHELEMY ., 2020MONTOYA-BARTHELEMY, A. et al. Covid-19 and the Correctional Environment: The American Prison as a Focal Point for Public Health. American Journal of Preventive Medicine, v. 58, n. 6, p. 888-891, 2020.; DE LUSIGNAN ., 2020DE LUSIGNAN, S. et al. Risk factors for SARS-CoV-2 among patients in the Oxford Royal College of General Practitioners Research and Surveillance Centre primary care network: a cross-sectional study. The Lancet Infectious Diseases, v. 20, n. 9, p. 1034-1042, 2020.), and street population (TACKLE..., 2020; BARBIERI, 2021BARBIERI, A. Covid-19 in Italy: homeless population needs protection. Recenti progressi in medicina, v. 111, n. 5, p. 295-296, 2021.; MESA VIEIRA ., 2020MESA VIEIRA, C. et al. Covid-19: The forgotten priorities of the pandemic. Maturitas, v. 136, p. 38-41, 2020.).

Social insertion

The third synthesized marker addresses the population’s material living conditions and their limitations to ensure their support and biosafety during the current pandemic. This marker comprises the conditions of low educational level (AHMAD ., 2020AHMAD, A. et al. What does it mean to be made vulnerable in the era of Covid-19? The Lancet, v. 395, n. 10235, p. 1481-1482, 2020.; CALDERÓN-LARRAÑAGA ., 2020CALDERÓN-LARRAÑAGA, A. et al. Covid-19: risk accumulation among biologically and socially vulnerable older populations. Ageing Research Reviews, v. 63, p. 1-5, 2020.; CHRISTOFFEL ., 2020CHRISTOFFEL, M. et al. Children’s (in)visibility in social vulnerability and the impact of the novel coronavirus (Covid-19). Revista Brasileira de Enfermagem, v. 73, n. supl. 2, 2020.; HIMMELFARB; BAPTISTE, 2020HIMMELFARB, C.; BAPTISTE, D. Coronavirus disease (Covid-19). Journal of Cardiovascular Nursing, v. 35, n. 4, p. 318-321, 2020.; AMALAKANTI; RAMAN AREPALLI; KOPPOLU, 2020), low family income (AHMAD ., 2020AHMAD, A. et al. What does it mean to be made vulnerable in the era of Covid-19? The Lancet, v. 395, n. 10235, p. 1481-1482, 2020.; CALDERÓN LARRAÑAGA et al., 2020; CHRISTOFFEL ., 2020CHRISTOFFEL, M. et al. Children’s (in)visibility in social vulnerability and the impact of the novel coronavirus (Covid-19). Revista Brasileira de Enfermagem, v. 73, n. supl. 2, 2020.; CUBRICH, 2020CUBRICH, M. On the frontlines: Protecting low-wage workers during Covid-19. Psychological Trauma: Theory, Research, Practice, and Policy, v. 12, n. S1, p. S186-S187, 2020.; HIMMELFARB; BAPTISTE, 2020HIMMELFARB, C.; BAPTISTE, D. Coronavirus disease (Covid-19). Journal of Cardiovascular Nursing, v. 35, n. 4, p. 318-321, 2020.; KANTER; SEGAL; GROENEVELD, 2020KANTER, G.; SEGAL, A.; GROENEVELD, P. Income Disparities in Access to Critical Care Services. Health Affairs, v. 39, n. 8, p. 1362-1367, 2020.; RAIFMAN; RAIFMAN, 2020RAIFMAN, M.; RAIFMAN, J. Disparities in the Population at Risk of Severe Illness from Covid-19 by Race/Ethnicity and Income. American Journal of Preventive Medicine, v. 59, n. 1, p. 137-139, 2020.), unemployment (AHMAD ., 2020AHMAD, A. et al. What does it mean to be made vulnerable in the era of Covid-19? The Lancet, v. 395, n. 10235, p. 1481-1482, 2020.; CALDERÓN-LARRAÑAGA ., 2020CALDERÓN-LARRAÑAGA, A. et al. Covid-19: risk accumulation among biologically and socially vulnerable older populations. Ageing Research Reviews, v. 63, p. 1-5, 2020.; CHRISTOFFEL ., 2020CHRISTOFFEL, M. et al. Children’s (in)visibility in social vulnerability and the impact of the novel coronavirus (Covid-19). Revista Brasileira de Enfermagem, v. 73, n. supl. 2, 2020.; HIMMELFARB; BAPTISTE, 2020HIMMELFARB, C.; BAPTISTE, D. Coronavirus disease (Covid-19). Journal of Cardiovascular Nursing, v. 35, n. 4, p. 318-321, 2020.; KHAZANCHI ., 2020KHAZANCHI, R. et al. County-Level Association of Social Vulnerability with Covid-19 Cases and Deaths in the USA. Journal of General Internal Medicine, v. 35, n. 9, p. 2784-2787, 2020.), and work in food services (PARKS ., 2020PARKS, C. et al. Food System Workers are the Unexpected but Under Protected Covid Heroes. The Journal of Nutrition, v. 150, n. 8, p. 2006-2008, 2020.).

That material deprivation makes vulnerable those living in poor housing conditions (AHMAD ., 2020AHMAD, A. et al. What does it mean to be made vulnerable in the era of Covid-19? The Lancet, v. 395, n. 10235, p. 1481-1482, 2020.; CALDERÓN-LARRAÑAGA ., 2020CALDERÓN-LARRAÑAGA, A. et al. Covid-19: risk accumulation among biologically and socially vulnerable older populations. Ageing Research Reviews, v. 63, p. 1-5, 2020.; CHRISTOFFEL ., 2020CHRISTOFFEL, M. et al. Children’s (in)visibility in social vulnerability and the impact of the novel coronavirus (Covid-19). Revista Brasileira de Enfermagem, v. 73, n. supl. 2, 2020.; HIMMELFARB; BAPTISTE, 2020HIMMELFARB, C.; BAPTISTE, D. Coronavirus disease (Covid-19). Journal of Cardiovascular Nursing, v. 35, n. 4, p. 318-321, 2020.; KIRBY, 2020KIRBY, T. Efforts escalate to protect homeless people from Covid-19 in UK. The Lancet Respiratory Medicine, v. 8, n. 5, p. 447-449, 2020.), homelessness (DE LUSIGNAN ., 2020DE LUSIGNAN, S. et al. Risk factors for SARS-CoV-2 among patients in the Oxford Royal College of General Practitioners Research and Surveillance Centre primary care network: a cross-sectional study. The Lancet Infectious Diseases, v. 20, n. 9, p. 1034-1042, 2020.; (“TACKLE CORONAVIRUS IN VULNERABLE COMMUNITIES”, 2020; KHAZANCHI ., 2020KHAZANCHI, R. et al. County-Level Association of Social Vulnerability with Covid-19 Cases and Deaths in the USA. Journal of General Internal Medicine, v. 35, n. 9, p. 2784-2787, 2020.). Therefore, dwellers in overcrowded cities have more vulnerability and fewer resources for their health care (SURESH; JAMESR, 2020), the population living in cities with high pollution levels (DÍAZ DE LEÓN-MARTÍNEZ ., 2020DÍAZ DE LEÓN-MARTÍNEZ, L. et al. Critical review of social, environmental and health risk factors in the Mexican indigenous population and their capacity to respond to the Covid-19. Science of The Total Environment, v. 733, p. 1-6, 2020.), and those who live in isolated rural communities (FORTALEZA ., 2020FORTALEZA, C. et al. Taking the inner route: spatial and demographic factors affecting vulnerability to Covid-19 among 604 cities from inner São Paulo State, Brazil. Epidemiology and Infection, v. 148, e118, 2020.), in the outskirts of urban areas (SANTOS ., 2020SANTOS, J. et al. Vulnerabilidade a formas graves de Covid-19: uma análise intramunicipal na cidade do Rio de Janeiro, Brasil. Cadernos de Saúde Pública, v. 36, n. 5, 2020.), with poor transportation system (KHAZANCHI ., 2020KHAZANCHI, R. et al. County-Level Association of Social Vulnerability with Covid-19 Cases and Deaths in the USA. Journal of General Internal Medicine, v. 35, n. 9, p. 2784-2787, 2020.).

Health services and actions

The fourth and last synthesized marker is related to the availability of human and physical resources to deliver care to patients affected by Covid-19, and their protection in the face of the community transmission by the SARS-Cov2 virus. It encompasses the availability of primary health care services (RAIFMAN; RAIFMAN, 2020RAIFMAN, M.; RAIFMAN, J. Disparities in the Population at Risk of Severe Illness from Covid-19 by Race/Ethnicity and Income. American Journal of Preventive Medicine, v. 59, n. 1, p. 137-139, 2020.; ATIF; MALIK, 2020ATIF, M.; MALIK, I. Why is Pakistan vulnerable to Covid-19 associated morbidity and mortality? A scoping review. The International Journal of Health Planning and Management, v. 35, n. 5, p. 1041-1054, 2020.; BENJAMIN, 2020BENJAMIN, G. Ensuring health equity during the Covid-19 pandemic: the role of public health infrastructure. Revista Panamericana de Salud Pública, p. 1-4, 2020.), home care and/or palliative care (LAKHANI, 2020LAKHANI, A. Which Melbourne Metropolitan Areas Are Vulnerable to Covid-19 Based on Age, Disability, and Access to Health Services? Using Spatial Analysis to Identify Service Gaps and Inform Delivery. Journal of Pain and Symptom Management, v. 60, n. 1, p. e41-e44, 2020.), and tertiary health care, which provides hemodynamic ventilation support for those who developed severe Covid-19 symptoms (KANTER; SEGAL; GROENEVELD, 2020).

The adult population requires health care services with proper conditions to meet their health needs. Such services need the availability of personal protective equipment, such as masks, face shields, glasses, aprons, among others (SMITH, 2020SMITH, C. The structural vulnerability of healthcare workers during Covid-19: Observations on the social context of risk and the equitable distribution of resources. Social Science & Medicine, v. 258, p. 113-119, 2020.; BELINGHERI; PALADINO; RIVA, 2020BELINGHERI, M.; PALADINO, M.; RIVA, M. Beyond the assistance: additional exposure situations to Covid-19 for healthcare workers. Journal of Hospital Infection, v. 105, n. 2, p. 353, 2020.), as well as their implementation must meet the daily health care routine (CANOVA ., 2020CANOVA, V. et al. Transmission risk of SARS-CoV-2 to healthcare workers: observational results of a primary care hospital contact tracing. Swiss Medical Weekly, 2020.).

Health care services must qualify professionals and users to the early recognition and isolation of probable Covid-19 cases (HEINZERLING ., 2020HEINZERLING, A. et al. Transmission of Covid-19 to Health Care Personnel During Exposures to a Hospitalized Patient. Solano County, California, February 2020. MMWR. Morbidity and Mortality Weekly Report, v. 69, n. 15, p. 472-476, 2020.; NG ., 2020NG, Y. et al. Evaluation of the Effectiveness of Surveillance and Containment Measures for the First 100 Patients with Covid-19 in Singapore. January 2-February 29, 2020. MMWR. Morbidity and Mortality Weekly Report, v. 69, n. 11, p. 307-311, 2020.), and provide guidance on handwashing, use of 70% alcohol, use of masks in public places, social distancing, among others (BELINGHERI; PALADINO; RIVA, 2020; KIKUCHI ., 2020KIKUCHI, K. et al. Covid-19 of dialysis patients in Japan: current status and guidance on preventive measures. Therapeutic Apheresis and Dialysis, v. 24, n. 4, p. 361-365, 2020.; BORRACCIGIGLIO, 2021BORRACCI, R.; GIGLIO, N. Forecasting the effect of social distancing on Covid-19 autumn-winter outbreak in the metropolitan area of Buenos Aires. Medicina (Buenos Aires), v. 80, n. supl. III, p. 7-15, 2021.). Similarly, governments must provide fast responses to the monitoring of migration flows (DING ., 2020DING, Y. et al. Association between population migration and epidemic control of Coronavirus disease 2019. Science China Life Sciences, v. 63, n. 6, p. 936-939, 2020.).

Discussion

Chronic Health Conditions point to social groups that have fewer conditions to access health care and social services, more possibility for isolation and complications in their clinical conditions due to the lack of social support (LAKHANI, 2020LAKHANI, A. Which Melbourne Metropolitan Areas Are Vulnerable to Covid-19 Based on Age, Disability, and Access to Health Services? Using Spatial Analysis to Identify Service Gaps and Inform Delivery. Journal of Pain and Symptom Management, v. 60, n. 1, p. e41-e44, 2020.). Therefore, these people may have lower adherence to preventive measures and self-care due to their difficulty in understanding the infection hazards and treatment to Covid-19, associated to senility and other comorbidities (PRINA, 2020PRINA, L. Grantwatch: Funders’ Efforts: Aging and Health, Covid-19. Health Affairs, v. 39, n. 6, p. 1092-1093, 2020.; SHER; STAMPER; LUNDY, 2020SHER, T.; STAMPER, G.; LUNDY, L. Covid-19 and Vulnerable Population with Communication Disorders. Mayo Clinic Proceedings, v. 95, n. 9, p. 1845-1847, 2020.).

During the pandemic, those chronic patients may have discontinued their visits to the health care services, not taking their medication for continuous treatment, and not performing their clinical follow-up and laboratory testing (FORMIGA; TARAZONA-SANTABALBINA, 2020FORMIGA, F.; TARAZONA-SANTABALBINA, F. Diabetes y Covid-19 en el adulto mayor, simbiosis nociva. Revista Española de Geriatría y Gerontología, v. 55, n. 6, p. 315-316, 2020.). It must be considered that most health care services altered their workflow, not seeing their patients with chronic conditions in order to meet the high demand of Covid-19 cases (ADAMS ., 2020ADAMS, S. et al. Medical Vulnerability of Young Adults to Severe Covid-19 Illness. Data From the National Health Interview Survey. Journal of Adolescent Health, v. 67, n. 3, p. 362-368, 2020.; KUDERER ., 2020KUDERER, N. et al. Clinical impact of Covid-19 on patients with cancer (CCC19): a cohort study. The Lancet, v. 395, n. 10241, p. 1907-1918, 2020.).

The Daily Life Experiences entail the barriers imposed by social, cultural, humanistic, geopolitical and economic issues, which are decisive for the increase of vulnerability among those people during the pandemic (BRITO, 2020BRITO, M. Covid-19 in the Americas: Who’s Looking After Refugees and Migrants? Annals of Global Health, v. 86, n. 1, 2020.; HAMIDIAN JAHROMI; HAMIDIAN JAHROMI, 2020HAMIDIAN JAHROMI, A.; HAMIDIANJAHROMI, A. Why African Americans Are a Potential Target for Covid-19 Infection in the United States. Journal of Medical Internet Research, v. 22, n. 6, e19934, 2020.).

Linguistic and cultural adversities hinder the access to information on prevention, such as hand hygiene and use of masks, which contributes to the greater spread of the coronavirus in the community (RAIFMAN; RAIFMAN, 2020RAIFMAN, M.; RAIFMAN, J. Disparities in the Population at Risk of Severe Illness from Covid-19 by Race/Ethnicity and Income. American Journal of Preventive Medicine, v. 59, n. 1, p. 137-139, 2020.). Many times, there has been difficulty in delivering care to this group, which may have their access to the health care services prevented due to legal migration issues (CLARK ., 2020CLARK, E. et al. Disproportionate impact of the Covid-19 pandemic on immigrant communities in the United States. PLOS Neglected Tropical Diseases, v. 14, n. 7, p. e0008484, 2020.; KHAZANCHI ., 2020KHAZANCHI, R. et al. County-Level Association of Social Vulnerability with Covid-19 Cases and Deaths in the USA. Journal of General Internal Medicine, v. 35, n. 9, p. 2784-2787, 2020.).

Worldwide, many minority groups are observed to suffer lack of access to health, education and the basic human rights, fundamentally among the refugees, LGBTQIA+ people, sex workers and women from patriarchal, authoritarian societies (BETRON ., 2020BETRON, M. et al. Men and Covid-19: Adding a gender lens. Global Public Health, v. 15, n. 7, p. 1090-1092, 2020.; SALERNO; WILLIAMS; GATTAMORTA, 2020). Institutionalized people, prison inmates have greater chance to get infected by Covid-19 due to the overpopulation within such institutions, and the lack of health care infrastructure for them (BARNERT, 2020BARNERT, E. Covid-19 and Youth Impacted by Juvenile and Adult Criminal Justice Systems. Pediatrics, v. 146, n. 2, p. e20201299, 2020.). Similarly, people who live on the streets, where there are no hygiene or isolation conditions in case of infection (BARBIERI, 2021BARBIERI, A. Covid-19 in Italy: homeless population needs protection. Recenti progressi in medicina, v. 111, n. 5, p. 295-296, 2021.).

The Social Insertion points to the lack of material resources among needier social classes, which hinders their subsistence, and directly reflects on the control and prevention of the Covid-19 (AHMAD ., 2020AHMAD, A. et al. What does it mean to be made vulnerable in the era of Covid-19? The Lancet, v. 395, n. 10235, p. 1481-1482, 2020.). Such people are uneducated, which makes them perform precarious, informal jobs, with fewer resources for their protection, thus, they become more vulnerable to the disease (CHRISTOFFEL ., 2020CHRISTOFFEL, M. et al. Children’s (in)visibility in social vulnerability and the impact of the novel coronavirus (Covid-19). Revista Brasileira de Enfermagem, v. 73, n. supl. 2, 2020.).

The unemployment is an important element of vulnerability among those populations, as they have to search for survival by performing menial, subhuman labor activities. Many of them survive by collecting garbage and recycling materials, or begging and collecting contributions on the streets and public places (CALDERÓN LARRAÑAGA et al., 2020). Therefore, low educational level, inserted in lower social classes, hinders their access to information and subsequent understanding of prevention and fight against the pandemic (HIMMELFARB; BAPTISTE, 2020HIMMELFARB, C.; BAPTISTE, D. Coronavirus disease (Covid-19). Journal of Cardiovascular Nursing, v. 35, n. 4, p. 318-321, 2020.).

Such communities live in isolated areas or in overcrowded settings, without the access to the health care sectors, determinant conditions for the vulnerability of these groups (DÍAZ DE LEÓN-MARTÍNEZ ., 2020DÍAZ DE LEÓN-MARTÍNEZ, L. et al. Critical review of social, environmental and health risk factors in the Mexican indigenous population and their capacity to respond to the Covid-19. Science of The Total Environment, v. 733, p. 1-6, 2020.). Similarly, the pollution in big cities and the lack of basic sanitation for their dwellers also contribute to the increase in the risk of SARS-CoV-2 Transmission (SURESH; JAMES, 2020SURESH, R.; JAMES, J. B. Migrant Workers at Crossroads–The Covid-19 Pandemic and the Migrant Experience in India. Social Work in Public Health, v. 35, n. 7, p. 633-643, 2020.).

Therefore, the Health Actions and Services represent the availability of physical and human resources to deliver care to people with signs and symptoms of Covid-19, as well as the measures of prevention and control of the community transmission of the SARS-CoV-2 (BELINGHERI; PALADINO; RIVA, 2020). The lack of personal protective equipment promoted greater exposure to the infection among health professionals and increase in cases of hospital cross infection caused by the Covid-19 (SMITH, 2020SMITH, C. The structural vulnerability of healthcare workers during Covid-19: Observations on the social context of risk and the equitable distribution of resources. Social Science & Medicine, v. 258, p. 113-119, 2020.; CANOVA ., 2020CANOVA, V. et al. Transmission risk of SARS-CoV-2 to healthcare workers: observational results of a primary care hospital contact tracing. Swiss Medical Weekly, 2020.).

The huge demand of ill patients overcrowded health care services, hindering the early risk classification and diagnosis of the disease. Although it is acknowledged that the access of the population to the Primary Care Attention was ensured (RAIFMAN; RAIFMAN, 2020RAIFMAN, M.; RAIFMAN, J. Disparities in the Population at Risk of Severe Illness from Covid-19 by Race/Ethnicity and Income. American Journal of Preventive Medicine, v. 59, n. 1, p. 137-139, 2020.; ATIF; MALIK, 2020ATIF, M.; MALIK, I. Why is Pakistan vulnerable to Covid-19 associated morbidity and mortality? A scoping review. The International Journal of Health Planning and Management, v. 35, n. 5, p. 1041-1054, 2020.; BENJAMIN, 2020BENJAMIN, G. Ensuring health equity during the Covid-19 pandemic: the role of public health infrastructure. Revista Panamericana de Salud Pública, p. 1-4, 2020.), difficulties in referring severely ill patients to secondary and tertiary health care services, in addition to the occurrence of delays in monitoring patients with Covid-19 were observed (KANTER; SEGAL; GROENEVELD, 2020).

Conclusion

The vulnerability of the adult population to the Covid-19 is determined by chronic health conditions, humanistic, cultural and geopolitical issues, social inequality, poverty and health care services with poor physical and human structure, in addition to the lack of flows and guidance processes to professionals and population.

This analytic matrix is a theoretical construct elaborated from this review, and requires semantic, clinical validation to be used in primary health care services, emergency and urgency units or hospital services. This technology may contribute to strengthen the equity in health care services, operationalizing professionals to identify which patients require more generalized and acute care.

Thus, in order to overcome the pandemic as an event of emergency in public health, it is necessary that countries over the world contribute, in a solidary way, to actions of health surveillance along their borders, distribution of vaccines, and socioeconomic support to the most vulnerable populations, which can make us more humane and ethical.

References

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