Abstract / Summary
Abstract Background In 2024, COVID-19 entered a post-emergency phase, but in-hospital mortality remains a relevant public health concern in Brazil. As population immunity, vaccination, and clinical management evolved, the hierarchy of mortality predictors may have shifted from traditional metabolic risk factors toward clinical severity and social vulnerability. This study aimed to identify sociodemographic, clinical, management, and vaccination-related variables associated with in-hospital COVID-19 mortality among adults in Brazil in 2024, with emphasis on racial and socioeconomic inequities. Methods A retrospective national cohort study was conducted using the SIVEP-Gripe surveillance database. Adults aged ≥ 18 years hospitalized with laboratory-confirmed COVID-19 between January and December 2024 were included. The primary analysis was restricted to patients with observed hospital outcomes, resulting in an analytical sample of 19,718 individuals. Crude and adjusted associations were estimated using binary logistic regression. Race/color was modeled using White patients as the reference category. Robustness to unmeasured confounding was assessed using E-values, and model performance was evaluated using AUC-ROC. Results The in-hospital fatality rate was 23.5% ( n = 4,633). Invasive ventilatory support was the strongest predictor of death (aOR: 7.574; 95% CI: 6.801–8.435; E-value: 4.95). Black patients had higher odds of death compared with White patients (aOR: 1.506; 95% CI: 1.233–1.838; E-value: 1.76), as did Pardo/mixed-race patients, although with lower magnitude (aOR: 1.103; 95% CI: 1.006–1.209). A strong educational gradient was observed, with illiterate patients having more than twice the odds of death compared with those with higher education (aOR: 2.148; 95% CI: 1.628–2.833). Incomplete COVID-19 vaccination was also associated with increased mortality, while influenza vaccination was associated with lower odds of death. Diabetes, obesity, and chronic cardiovascular disease were not independently associated with mortality after adjustment. Conclusions In-hospital COVID-19 mortality in Brazil in 2024 was shaped by respiratory severity, incomplete vaccination, and persistent racial and socioeconomic inequities. Although structural racism was not directly measured, the persistence of racialized mortality differences after adjustment is compatible with structural barriers in the healthcare pathway. Equity-oriented strategies should complement vaccination and clinical management to reduce preventable mortality among socially vulnerable populations.