{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,7]],"date-time":"2026-05-07T23:19:01Z","timestamp":1778195941075,"version":"3.51.4"},"reference-count":75,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2025,11,20]],"date-time":"2025-11-20T00:00:00Z","timestamp":1763596800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Rede Corona-\u00f4mica BR MCTI\/FINEP"},{"DOI":"10.13039\/501100004809","name":"Rede V\u00edrus\/MCTI","doi-asserted-by":"publisher","award":["01.20.0029.000462\/20"],"award-info":[{"award-number":["01.20.0029.000462\/20"]}],"id":[{"id":"10.13039\/501100004809","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100004809","name":"Rede V\u00edrus\/MCTI","doi-asserted-by":"publisher","award":["404096\/2020-4"],"award-info":[{"award-number":["404096\/2020-4"]}],"id":[{"id":"10.13039\/501100004809","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Viruses"],"abstract":"<jats:p>The coronavirus disease 2019 (COVID-19) pandemic in Tocantins, Brazil, exhibited distinct phases between 2020 and 2025, with high mortality concentrated in 2020\u20132021 and subsequent stabilization at residual levels. Using epidemiological data, statistical modeling, and genomic surveillance, we show that the crisis peaked in 2021, coinciding with the circulation of Gamma and Delta, when health system capacity was severely strained. From 2022 onwards, the spread of Omicron led to record incidence but proportionally low mortality, reflecting accumulated immunity, vaccination, and improved clinical management. Vaccination represented the turning point, reducing hospitalizations and deaths by over 90% and driving a clear decoupling between incidence and severity. Interrupted time-series and generalized additive model (GAM) analyses confirmed sustained reductions in transmission and severity associated with mass immunization. Genomic sequencing of 3941 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) genomes identified 166 lineages and successive variant replacements, culminating in the predominance of LP.8.1.4 in 2025. To our knowledge, this is one of the few integrated, long-term analyses (2020\u20132025) combining epidemiological and genomic data, capturing the full succession of variants up to LP.8.1.4 and highlighting Tocantins as a strategic \u201cvariant corridor\u201d linking Brazil\u2019s North and Central-West regions. These findings underscore the dual role of vaccination and genomic surveillance in shaping the epidemic trajectory and the importance of sustaining both strategies to mitigate future health crises.<\/jats:p>","DOI":"10.3390\/v17111521","type":"journal-article","created":{"date-parts":[[2025,11,20]],"date-time":"2025-11-20T10:30:59Z","timestamp":1763634659000},"page":"1521","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Five Years of COVID-19 in Tocantins, Brazil: Epidemiology, Vaccination Impact, and SARS-CoV-2 Genomic Dynamics (2020\u20132025)"],"prefix":"10.3390","volume":"17","author":[{"given":"Olivia de Souza da","family":"Concei\u00e7\u00e3o","sequence":"first","affiliation":[{"name":"Bioinformatics and Biotechnology Laboratory, Campus of Gurupi, Federal University of Tocantins, Gurupi 77410-570, TO, Brazil"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1442-4771","authenticated-orcid":false,"given":"Ueric Jos\u00e9 Borges de","family":"Souza","sequence":"additional","affiliation":[{"name":"Bioinformatics and Biotechnology Laboratory, Campus of Gurupi, Federal University of Tocantins, Gurupi 77410-570, TO, Brazil"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0559-3082","authenticated-orcid":false,"given":"Franciano Dias Pereira","family":"Cardoso","sequence":"additional","affiliation":[{"name":"Central Public Health Laboratory of the State of Tocantins, Palmas 77054-970, TO, Brazil"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1919-1460","authenticated-orcid":false,"given":"Evgeni Evgeniev","family":"Gabev","sequence":"additional","affiliation":[{"name":"Department of Physiology and Pathophysiology, Medical University of Sofia, 1431 Sofia, Bulgaria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1061-196X","authenticated-orcid":false,"given":"Bergmann Morais","family":"Ribeiro","sequence":"additional","affiliation":[{"name":"Baculovirus Laboratory, Department of Cell Biology, Institute of Biological Sciences, University of Brasilia, Bras\u00edlia 70910-900, DF, Brazil"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gil Rodrigues dos","family":"Santos","sequence":"additional","affiliation":[{"name":"Laboratory of Phytopathology, Campus of Gurupi, Federal University of Tocantins, Gurupi 77402-970, TO, Brazil"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Renisson Neponuceno de","family":"Ara\u00fajo Filho","sequence":"additional","affiliation":[{"name":"Departamento de Tecnologia Rural, Universidade Federal Rural de Pernambuco, Recife 52171-900, PE, Brazil"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6474-6640","authenticated-orcid":false,"given":"Marcos Gontijo da","family":"Silva","sequence":"additional","affiliation":[{"name":"Programa de P\u00f3s-Gradua\u00e7\u00e3o em Biotecnologia, Campus of Gurupi, Universidade Federal do Tocantins, Gurupi 77402-970, TO, Brazil"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5804-7045","authenticated-orcid":false,"given":"Fernando Rosado","family":"Spilki","sequence":"additional","affiliation":[{"name":"Molecular Microbiology Laboratory, Health Sciences Institute, Feevale University, Novo Hamburgo 93525-075, RS, Brazil"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5948-472X","authenticated-orcid":false,"given":"Fabr\u00edcio Souza","family":"Campos","sequence":"additional","affiliation":[{"name":"Bioinformatics and Biotechnology Laboratory, Campus of Gurupi, Federal University of Tocantins, Gurupi 77410-570, TO, Brazil"},{"name":"Laborat\u00f3rio de Bioinform\u00e1tica & Biotecnologia, Instituto de Ci\u00eancias B\u00e1sicas da Sa\u00fade, Universidade Federal do Rio Grande do Sul, Porto Alegre 90010-150, RS, Brazil"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,11,20]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"537","DOI":"10.1038\/s12276-021-00604-z","article-title":"On the Origin and Evolution of SARS-CoV-2","volume":"53","author":"Singh","year":"2021","journal-title":"Exp. Mol. Med."},{"key":"ref_2","unstructured":"World Health Organization (WHO) (2025, August 21). Statement on the Fifteenth Meeting of the IHR (2005) Emergency Committee on the COVID-19 Pandemic. Available online: https:\/\/www.who.int\/news\/item\/05-05-2023-statement-on-the-fifteenth-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus-disease-(COVID-19)-pandemic."},{"key":"ref_3","first-page":"e2020044","article-title":"Como o Brasil Pode Deter a COVID-19","volume":"29","author":"Duarte","year":"2020","journal-title":"Epidemiol. E Servi\u00e7os Sa\u00fade"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"6","DOI":"10.5216\/ag.v14i2.63987","article-title":"A Pandemia de COVID-19 e as Particularidades Regionais Da Sua Difus\u00e3o No Segmento de Rede Urbana No Estado Do Tocantins, Brasil","volume":"14","author":"Bessa","year":"2020","journal-title":"Ateli\u00ea Geogr\u00e1fico"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"409","DOI":"10.1038\/s41579-021-00573-0","article-title":"SARS-CoV-2 Variants, Spike Mutations and Immune Escape","volume":"19","author":"Harvey","year":"2021","journal-title":"Nat. Rev. Microbiol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e2106379119","DOI":"10.1073\/pnas.2106379119","article-title":"Structure and Dynamics of SARS-CoV-2 Proofreading Exoribonuclease ExoN","volume":"119","author":"Moeller","year":"2022","journal-title":"Proc. Natl. Acad. Sci. USA"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"001584","DOI":"10.1099\/jgv.0.001584","article-title":"SARS-CoV-2 One Year on: Evidence for Ongoing Viral Adaptation","volume":"102","author":"Peacock","year":"2021","journal-title":"J. Gen. Virol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"408","DOI":"10.1038\/s41586-021-04188-6","article-title":"The Emergence, Genomic Diversity and Global Spread of SARS-CoV-2","volume":"600","author":"Li","year":"2021","journal-title":"Nature"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1007\/s15010-020-01531-3","article-title":"Epidemiology of SARS-CoV-2","volume":"49","author":"Salzberger","year":"2021","journal-title":"Infection"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Souza, U.J.B.d., Spilki, F.R., Tanuri, A., Roehe, P.M., and Campos, F.S. (2025). Two Years of SARS-CoV-2 Omicron Genomic Evolution in Brazil (2022\u20132024): Subvariant Tracking and Assessment of Regional Sequencing Efforts. Viruses, 17.","DOI":"10.3390\/v17010064"},{"key":"ref_11","first-page":"109","article-title":"Main SARS-CoV-2 Variants Notified in Brazil","volume":"53","author":"Michelon","year":"2021","journal-title":"Rev. Bras. An\u00e1lises Cl\u00ednicas"},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Lamarca, A.P., Souza, U.J.B.d., Moreira, F.R.R., Almeida, L.G.P.d., Menezes, M.T.d., Souza, A.B.d., Ferreira, A.C.d.S., Gerber, A.L., Lima, A.B.d., and Guimar\u00e3es, A.P.d.C. (2023). The Omicron Lineages BA.1 and BA.2 (Betacoronavirus SARS-CoV-2) Have Repeatedly Entered Brazil through a Single Dispersal Hub. Viruses, 15.","DOI":"10.3390\/v15040888"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"veac024","DOI":"10.1093\/ve\/veac024","article-title":"Replacement of the Gamma by the Delta Variant in Brazil: Impact of Lineage Displacement on the Ongoing Pandemic","volume":"8","author":"Giovanetti","year":"2022","journal-title":"Virus Evol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"198785","DOI":"10.1016\/j.virusres.2022.198785","article-title":"SARS-CoV-2 Epidemic in Brazil: How the Displacement of Variants Has Driven Distinct Epidemic Waves","volume":"315","author":"Alcantara","year":"2022","journal-title":"Virus Res."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e02641-21","DOI":"10.1128\/spectrum.02641-21","article-title":"Emergence and Spread of the SARS-CoV-2 Variant of Concern Delta across Different Brazilian Regions","volume":"10","author":"Arantes","year":"2022","journal-title":"Microbiol. Spectr."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e40113","DOI":"10.1016\/j.heliyon.2024.e40113","article-title":"Impact of SARS-CoV-2 Variants on COVID-19 Symptomatology and Severity during Five Waves","volume":"10","author":"Gomes","year":"2024","journal-title":"Heliyon"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"De Souza, U.J.B., dos Santos, R.N., Campos, F.S., Louren\u00e7o, K.L., da Fonseca, F.G., and Spilki, F.R. (2021). High Rate of Mutational Events in SARS-CoV-2 Genomes across Brazilian Geographical Regions, February 2020 to June 2021. Viruses, 13.","DOI":"10.1101\/2021.07.10.451922"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"e570","DOI":"10.1016\/S2589-7500(24)00099-2","article-title":"Human Mobility Patterns in Brazil to Inform Sampling Sites for Early Pathogen Detection and Routes of Spread: A Network Modelling and Validation Study","volume":"6","author":"Oliveira","year":"2024","journal-title":"Lancet Digit. Health"},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Vitorino, L.C., de Souza, U.J.B., Oliveira Reis, M.N., and Bessa, L.A. (2022). The Impact of COVID-19 on the Indigenous Peoples Related to Air and Road Networks and Habitat Loss. PLoS Glob. Public Health, 2.","DOI":"10.1371\/journal.pgph.0000166"},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Souza, U.J.B.d., Macedo, Y.d.S.M., Santos, R.N.d., Cardoso, F.D.P., Galv\u00e3o, J.D., Gabev, E.E., Franco, A.C., Roehe, P.M., Spilki, F.R., and Campos, F.S. (2023). Circulation of Dengue Virus Serotype 1 Genotype V and Dengue Virus Serotype 2 Genotype III in Tocantins State, Northern Brazil, 2021\u20132022. Viruses, 15.","DOI":"10.20944\/preprints202309.1376.v1"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Souza, U.J.B.d., Santos, R.N.d., Giovanetti, M., Alcantara, L.C.J., Galv\u00e3o, J.D., Cardoso, F.D.P., Brito, F.C.S., Franco, A.C., Roehe, P.M., and Ribeiro, B.M. (2022). Genomic Epidemiology Reveals the Circulation of the Chikungunya Virus East\/Central\/South African Lineage in Tocantins State, North Brazil. Viruses, 14.","DOI":"10.3390\/v14102311"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"taaa106","DOI":"10.1093\/jtm\/taaa106","article-title":"Expansion of COVID-19 within Brazil: The Importance of Highways","volume":"27","author":"Carmo","year":"2020","journal-title":"J. Travel Med."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"De Souza, U.J.B., dos Santos, R.N., de Melo, F.L., Belmok, A., Galv\u00e3o, J.D., de Rezende, T.C.V., Cardoso, F.D.P., Carvalho, R.F., da Silva Oliveira, M., and Ribeiro Junior, J.C. (2022). Genomic Epidemiology of SARS-CoV-2 in Tocantins State and the Diffusion of P.1.7 and AY.99.2 Lineages in Brazil. Viruses, 14.","DOI":"10.3390\/v14040659"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"496","DOI":"10.36311\/jhgd.v31.12744","article-title":"Analysis of COVID-19 Mortality and Case-Fatality in a Low- Income Region: An Ecological Time-Series Study in Tocantins, Brazilian Amazon","volume":"31","author":"Portugal","year":"2021","journal-title":"J. Hum. Growth Dev."},{"key":"ref_25","first-page":"13","article-title":"An\u00e1lise Da Distribui\u00e7\u00e3o Do SARS-CoV-2 Nas Regi\u00f5es de Sa\u00fade Do Estado Do Tocantins","volume":"9","year":"2021","journal-title":"Amaz. Sci. Health"},{"key":"ref_26","first-page":"23","article-title":"The R Project in Statistical Computing. MSOR connections","volume":"1","author":"Ripley","year":"2001","journal-title":"Newsl. LTSN Maths Stats OR Netw."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"180","DOI":"10.1002\/wics.147","article-title":"Ggplot2","volume":"3","author":"Wickham","year":"2011","journal-title":"WIREs Comput. Stat."},{"key":"ref_28","first-page":"3","article-title":"STL: A Seasonal-Trend Decomposition","volume":"6","author":"Cleveland","year":"1990","journal-title":"J. off. Stat."},{"key":"ref_29","unstructured":"(2019). Date and Time\u2014Representations for Information Interchange (Standard No. ISO 8601:2019). Available online: https:\/\/www.iso.org\/standard\/70907.html."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"30494","DOI":"10.2807\/1560-7917.ES.2017.22.13.30494","article-title":"GISAID: Global Initiative on Sharing All Influenza Data\u2013from Vision to Reality","volume":"22","author":"Shu","year":"2017","journal-title":"Eurosurveillance"},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"O\u2019Toole, \u00c1., Pybus, O.G., Abram, M.E., Kelly, E.J., and Rambaut, A. (2022). Pango Lineage Designation and Assignment Using SARS-CoV-2 Spike Gene Nucleotide Sequences. BMC Genom., 23.","DOI":"10.1186\/s12864-022-08358-2"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"4121","DOI":"10.1093\/bioinformatics\/bty407","article-title":"Nextstrain: Real-Time Tracking of Pathogen Evolution","volume":"34","author":"Hadfield","year":"2018","journal-title":"Bioinformatics"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"3773","DOI":"10.21105\/joss.03773","article-title":"Nextclade: Clade Assignment, Mutation Calling and Quality Control for Viral Genomes","volume":"6","author":"Aksamentov","year":"2021","journal-title":"J. Open Source Softw."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"vex042","DOI":"10.1093\/ve\/vex042","article-title":"TreeTime: Maximum-Likelihood Phylodynamic Analysis","volume":"4","author":"Sagulenko","year":"2018","journal-title":"Virus Evol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1490","DOI":"10.1038\/s41564-022-01191-z","article-title":"Genomic Epidemiology of the SARS-CoV-2 Epidemic in Brazil","volume":"7","author":"Giovanetti","year":"2022","journal-title":"Nat. Microbiol."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Takasaki, Y., Abizaid, C., and Coomes, O.T. (2022). COVID-19 Contagion across Remote Communities in Tropical Forests. Sci. Rep., 12.","DOI":"10.1038\/s41598-022-25238-7"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"tay100","DOI":"10.1093\/jtm\/tay100","article-title":"Decreasing Vaccine Coverage Rates Lead to Increased Vulnerability to the Importation of Vaccine-Preventable Diseases in Brazil","volume":"25","author":"Fujita","year":"2018","journal-title":"J. Travel. Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"e20200673","DOI":"10.1590\/0034-7167-2020-0673","article-title":"Social Determinants of Health and COVID-19 Infection in Brazil: An Analysis of the Pandemic","volume":"73","author":"Figueiredo","year":"2020","journal-title":"Rev. Bras. Enferm."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"e200095","DOI":"10.1590\/1980-549720200095","article-title":"Income Inequality and Risk of Infection and Death by COVID-19 in Brazil","volume":"23","author":"Demenech","year":"2020","journal-title":"Rev. Bras. Epidemiol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"107298","DOI":"10.1016\/j.ypmed.2022.107298","article-title":"Area-Level Inequalities in COVID-19 Outcomes in Brazil in 2020 and 2021: An Analysis of 1,894,165 Severe COVID-19 Cases","volume":"164","author":"Boing","year":"2022","journal-title":"Prev. Med."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Santangelo, O.E., Provenzano, S., Di Martino, G., and Ferrara, P. (2024). COVID-19 Vaccination and Public Health: Addressing Global, Regional, and Within-Country Inequalities. Vaccines, 12.","DOI":"10.3390\/vaccines12080885"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1093\/imammb\/dqab017","article-title":"Modelling the Spreading of the SARS-CoV-2 in Presence of the Lockdown and Quarantine Measures by a Kinetic-Type Reactions Approach","volume":"39","author":"Sonnino","year":"2022","journal-title":"Math. Med. Biol."},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Sonnino, G., Mora, F., and Nardone, P. (2021). A Stochastic Kinetic Type Reactions Model for COVID-19. Mathematics, 9.","DOI":"10.3390\/math9111221"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"2969","DOI":"10.18103\/mra.v10i7.2969","article-title":"Modelling the Spread of SARS-CoV2 and Its Variants. Comparison with Real Data. Relations That Have to Be Satisfied to Achieve the Total Regression of the SARS-CoV2 Infection","volume":"10","author":"Sonnino","year":"2022","journal-title":"Med. Res. Arch."},{"key":"ref_45","doi-asserted-by":"crossref","unstructured":"Jang, S.Y., Hussain-Alkhateeb, L., Rivera Ramirez, T., Al-Aghbari, A.A., Chackalackal, D.J., Cardenas-Sanchez, R., Carrillo, M.A., Oh, I.-H., Alfonso-Sierra, E.A., and Oechsner, P. (2021). Factors Shaping the COVID-19 Epidemic Curve: A Multi-Country Analysis. BMC Infect. Dis., 21.","DOI":"10.1186\/s12879-021-06714-3"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"102152","DOI":"10.1016\/j.pmedr.2023.102152","article-title":"COVID-19 Vaccination Decreased COVID-19 Hospital Length of Stay, in-Hospital Death, and Increased Home Discharge","volume":"32","author":"Lee","year":"2023","journal-title":"Prev. Med. Rep."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"3174","DOI":"10.1016\/j.vaccine.2022.04.046","article-title":"Impact of COVID-19 Vaccine-Associated Side Effects on Health Care Worker Absenteeism and Future Booster Vaccination","volume":"40","author":"Chrissian","year":"2022","journal-title":"Vaccine"},{"key":"ref_48","first-page":"33","article-title":"The Effect of the COVID-19 Pandemic on the Elderly: Population Fatality Rates, COVID Mortality Percentage, and Life Expectancy Loss","volume":"30","author":"Parra","year":"2022","journal-title":"Elder. Law. J."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"9959","DOI":"10.18632\/aging.103344","article-title":"Why Does COVID-19 Disproportionately Affect Older People?","volume":"12","author":"Mueller","year":"2020","journal-title":"Aging"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"112342","DOI":"10.1016\/j.envres.2021.112342","article-title":"Change in Age Distribution of COVID-19 Deaths with the Introduction of COVID-19 Vaccination","volume":"204","author":"Pastorino","year":"2022","journal-title":"Environ. Res."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"4488","DOI":"10.1016\/j.vaccine.2023.06.005","article-title":"Effect of COVID-19 Vaccination on Mortality by COVID-19 and on Mortality by Other Causes, The Netherlands, January 2021\u2013January 2022","volume":"41","author":"Boere","year":"2023","journal-title":"Vaccine"},{"key":"ref_52","doi-asserted-by":"crossref","unstructured":"Zaher, K., Basingab, F., Alrahimi, J., Basahel, K., and Aldahlawi, A. (2023). Gender Differences in Response to COVID-19 Infection and Vaccination. Biomedicines, 11.","DOI":"10.3390\/biomedicines11061677"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"e99","DOI":"10.1017\/cts.2021.23","article-title":"Health Disparities and Equity in the Era of COVID-19","volume":"5","author":"Kraschnewski","year":"2021","journal-title":"J. Clin. Transl. Sci."},{"key":"ref_54","doi-asserted-by":"crossref","unstructured":"Silaghi-Dumitrescu, R., Patrascu, I., Lehene, M., and Bercea, I. (2023). Comorbidities of COVID-19 Patients. Medicina, 59.","DOI":"10.3390\/medicina59081393"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"113754","DOI":"10.1016\/j.envres.2022.113754","article-title":"Comparison of Pandemic Excess Mortality in 2020\u20132021 across Different Empirical Calculations","volume":"213","author":"Levitt","year":"2022","journal-title":"Environ. Res"},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"103315","DOI":"10.1016\/j.eclinm.2025.103315","article-title":"Impact of COVID-19 on Disease-Specific Mortality, Healthcare Resource Utilization, and Disease Burden across a Population over 1 Billion in 31 Countries: An Interrupted Time-Series Analysis","volume":"85","author":"Choi","year":"2025","journal-title":"EClinicalMedicine"},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"e966","DOI":"10.1016\/S2468-2667(22)00223-7","article-title":"COVID-19 Mortality and Deprivation: Pandemic, Syndemic, and Endemic Health Inequalities","volume":"7","author":"McGowan","year":"2022","journal-title":"Lancet Public Health"},{"key":"ref_58","first-page":"e20240613","article-title":"Impact of Vaccination and SARS-CoV-2 Variants on Severe COVID-19 Outcomes: A Cross-Sectional Study, Brazil, 2021\u20132022","volume":"34","author":"Moraes","year":"2025","journal-title":"Epidemiol. E Servi\u00e7os Sa\u00fade"},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"101205","DOI":"10.1016\/j.arr.2020.101205","article-title":"Aging in COVID-19: Vulnerability, Immunity and Intervention","volume":"65","author":"Chen","year":"2021","journal-title":"Ageing Res. Rev."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"e782","DOI":"10.1016\/S2214-109X(21)00081-4","article-title":"Effect of Socioeconomic Inequalities and Vulnerabilities on Health-System Preparedness and Response to COVID-19 in Brazil: A Comprehensive Analysis","volume":"9","author":"Rocha","year":"2021","journal-title":"Lancet Glob. Health"},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"e1018","DOI":"10.1016\/S2214-109X(20)30285-0","article-title":"Ethnic and Regional Variations in Hospital Mortality from COVID-19 in Brazil: A Cross-Sectional Observational Study","volume":"8","author":"Baqui","year":"2020","journal-title":"Lancet Glob. Health"},{"key":"ref_62","doi-asserted-by":"crossref","unstructured":"Machado, B.A.S., Hodel, K.V.S., Fonseca, L.M.d.S., Pires, V.C., Mascarenhas, L.A.B., da Silva Andrade, L.P.C., Moret, M.A., and Badar\u00f3, R. (2022). The Importance of Vaccination in the Context of the COVID-19 Pandemic: A Brief Update Regarding the Use of Vaccines. Vaccines, 10.","DOI":"10.3390\/vaccines10040591"},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"7021","DOI":"10.1016\/j.vaccine.2021.10.054","article-title":"COVID-19 Vaccination Significantly Reduces Morbidity and Absenteeism among Healthcare Personnel: A Prospective Multicenter Study","volume":"39","author":"Maltezou","year":"2021","journal-title":"Vaccine"},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"211","DOI":"10.12788\/jhm.3539","article-title":"Analysis of Hospital Resource Availability and COVID-19 Mortality Across the United States","volume":"16","author":"Janke","year":"2021","journal-title":"J. Hosp. Med."},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"100831","DOI":"10.1016\/j.epidem.2025.100831","article-title":"Modelling the Interplay between Responsive Individual Vaccination Decisions and the Spread of SARS-CoV-2","volume":"51","author":"Quesada","year":"2025","journal-title":"Epidemics"},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1007\/s41549-022-00071-z","article-title":"COVID-19 and Seasonal Adjustment","volume":"18","author":"Abeln","year":"2022","journal-title":"J. Bus. Cycle Res."},{"key":"ref_67","doi-asserted-by":"crossref","unstructured":"Cohen, A., Reyes, B., Burola, M.L., Lomeli, A., Escoto, A.A., Salgin, L., Rabin, B.A., Stadnick, N.A., Zaslavsky, I., and Tukey, R. (2025). Real-World Impact of COVID-19 Vaccination, Household Exposure, and Circulating SARS-CoV-2 Variants on Infection Risk and Symptom Presentation in a U.S.\/Mexico Border Community. Front. Public Health, 13.","DOI":"10.3389\/fpubh.2025.1497390"},{"key":"ref_68","doi-asserted-by":"crossref","unstructured":"Gonz\u00e1lez Rodr\u00edguez, J.L., Oprescu, A.M., Mu\u00f1oz Lezcano, S., Cordero Ramos, J., Romero Cabrera, J.L., Armengol de la Hoz, M.\u00c1., and Estella, \u00c1. (2024). Assessing the Impact of Vaccines on COVID-19 Efficacy in Survival Rates: A Survival Analysis Approach for Clinical Decision Support. Front. Public Health, 12.","DOI":"10.3389\/fpubh.2024.1437388"},{"key":"ref_69","doi-asserted-by":"crossref","unstructured":"Chen, X., Huang, H., Ju, J., Sun, R., and Zhang, J. (2022). Impact of Vaccination on the COVID-19 Pandemic in U.S. States. Sci. Rep., 12.","DOI":"10.1038\/s41598-022-05498-z"},{"key":"ref_70","doi-asserted-by":"crossref","unstructured":"Oliveira Roster, K.I., Kissler, S.M., Omoregie, E., Wang, J.C., Amin, H., Di Lonardo, S., Hughes, S., and Grad, Y.H. (2024). Surveillance Strategies for the Detection of New Pathogen Variants across Epidemiological Contexts. PLoS Comput. Biol., 20.","DOI":"10.1371\/journal.pcbi.1012416"},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"116440","DOI":"10.1016\/j.celrep.2025.116440","article-title":"Antibody Evasion and Receptor Binding of SARS-CoV-2 LP.8.1.1, NB.1.8.1, XFG, and Related Subvariants","volume":"44","author":"Mellis","year":"2025","journal-title":"Cell Rep."},{"key":"ref_72","doi-asserted-by":"crossref","first-page":"e193","DOI":"10.1016\/S1473-3099(25)00079-9","article-title":"Virological Characteristics of the SARS-CoV-2 LP.8.1 Variant","volume":"25","author":"Chen","year":"2025","journal-title":"Lancet Infect. Dis."},{"key":"ref_73","first-page":"100107","article-title":"First and Second COVID-19 Waves in Brazil: A Cross-Sectional Study of Patients\u2019 Characteristics Related to Hospitalization and in-Hospital Mortality","volume":"6","author":"Zeiser","year":"2022","journal-title":"Lancet Reg. Health-Am."},{"key":"ref_74","doi-asserted-by":"crossref","first-page":"7003","DOI":"10.1038\/s41467-022-33713-y","article-title":"Global Disparities in SARS-CoV-2 Genomic Surveillance","volume":"13","author":"Brito","year":"2022","journal-title":"Nat. Commun."},{"key":"ref_75","doi-asserted-by":"crossref","first-page":"4279","DOI":"10.1038\/s41467-023-39661-5","article-title":"Epidemiological Drivers of Transmissibility and Severity of SARS-CoV-2 in England","volume":"14","author":"Knock","year":"2023","journal-title":"Nat. Commun."}],"container-title":["Viruses"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1999-4915\/17\/11\/1521\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,20]],"date-time":"2025-11-20T10:39:46Z","timestamp":1763635186000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1999-4915\/17\/11\/1521"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,20]]},"references-count":75,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2025,11]]}},"alternative-id":["v17111521"],"URL":"https:\/\/doi.org\/10.3390\/v17111521","relation":{},"ISSN":["1999-4915"],"issn-type":[{"value":"1999-4915","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,11,20]]}}}