SPACE-TIME TREND OF ARBOVIRUSES IN HEALTH REGIONS OF BAHIA: NA ECOLOGICAL STUDY DURING THE COVID-19 PANDEMIC

Objective: To analyze the temporal trend of Dengue, Zika and Chikungunya rates in the Health Regions of the State of Bahia (RSEBA) from March 2020 to June 2021. Theoretical reference: Arboviruses are considered a group of emerging and re-emerging zoonoses that cause serious consequences for the health of the population, generating concern for health authorities. With the impacts generated by the Covid-19 pandemic, it was postponed, requiring efforts for this health emergency. Therefore, studying the spatio-temporal trend of arboviruses becomes necessary to analyze the dynamics of the number of arbovirus cases registered in the health regions of the state of Bahia. Method : The spatial distribution of average rates by Health Region (RS) in Bahia will be investigated and trend analysis will be carried out using simple linear regression with PraisWinsten correction . Results and discussion: The possible findings raise the hypothesis that the fluctuations in the time series evaluated are associated with the Covid-19 pandemic and the consequent underreporting of cases Implications of the research: As there is a lack of research in the literature that evaluates the rates of arbovirus cases in time and space, considering them as health regions, it is possible to affirm that our findings can offer the scientific community and/or public health investors subsidies to direct public policies that optimize actions on the part of these agents, taking into account the health region most affected by these diseases.


INTRODUCTION
Arbovirosis is composed of a group of emerging and reemerging infectious diseases, caused by viruses that through the bite of their vector, the Aedes Aegypti mosquito contaminates man or animal (Ribeiro, T.;M. et al, 2019;Easter, F. et al., 2018) In addition to being considered one of the most important endemic zoonoses in the country (Santos, et al., 2016).
Aedes Aegypti is responsible for transmitting dengue, yellow fever, Zika virus and Chikungunya that bring serious sequelae and concern the world health authorities, provoking debates in which are public policy issues with the purpose of mitigating the incidence of arboviruses (Rosa, 2016).
Tropical and intertropical countries are the most affected by arboviruses (Mendes, Meliani and Spanghero, 2017).In the first five months of 2020, 1,040,481 (39.4%) cases of arbovirosis were recorded in Brazil, demonstrating a reduction in the number of cases of this disease may be related to the increase in the working hours of health service providers, reducing surveillance with arbovirosis., being 95.0% of the cases of Chikungunya, and 41.5% of the cases of Chikungunya reported was in Bahia, which grew 434.0% in the periods of 200019 and 202 0, noting the need to continue the elimination of Aedes Aegypti even at the apex of the covid-19 pandemic (PAHO,2020;PAHO,2021;Sesab,2020;Epidemiological Bulletin, 2020;Brazil, 2014).
At 22nd SE, the first semester of 2021 in Brazil, reported cases of arbovirosis decreased by 58.0% compared to the same period of 2020.There were 83.0%(559,587) of cases of Dengue; 0.07% (172) of cases of severe Dengue and in the Northeast region there were 80.3 cases reported per 100,000 inhabitants.According to SE (1 to 20) in 2021, 48,044 cases of Chikungunya were reported, the Northeast region had the highest incidence rate with 31.8 cases per 100,000 inhabitants.As regards the numbers of cases notified from Zika, 6,012 cases were registered during SE 1 to 22 in 2021 (PAHO, 2020;Epidemiological Bulletin, 2021).
Up to the 29th SE, 440,012 probable cases of Dengue were registered in Brazil, with a reduction of 51.8% of the cases registered in the same period of the previous year; 63,713 probable cases of Chikungunya, a decrease of 3.6% in relation to the previous year and 3,458 probable cases of Zika, a reduction of 35.6% of the cases in the previous year (PAHO, 2021).
In Bahia,up to 24th SE,20,809 probable cases of Dengue were recorded (68.2%), representing a reduction of 68.6% compared to the previous year and 550 probable cases of Zika (1.8%), reducing 83.7% compared to the previous year (Epidemiological Bulletin, 2021;Sesab, 2021).4 The numbers of cases of covid-19 have progressively increased in Brazil, along with the cases of arbovirosis, so that both deserve due care, especially with the influence of climatic variables that favor survival and its proliferation (Halles et al, 2002;Confalonieri, 2003;Degallier et al, 2010;Ignotti and Viana, 2013;Antunes and Cardoso, 2015).And these factors contribute to the increase in population density of the Aedes Aegypti mosquitoes, resulting in the incidence of Dengue (Ribeiro et al, 2006).In comparison to a recent study carried out in Bahia in the municipality of Feira de Santana , which showed that the time series of the climatic variables temperature and relative humidity of the air do not have a strong correlation with the time series of the rates of the recorded cases of arbovirosis (Souza et al,2021).
Based on what has already been evidenced and the relevance of the topic, this article proposes an analysis of the temporal trend of the rates of recorded cases of arboviruses in the health regions of the state of Bahia during the COVID-19 pandemic, in the period from March 2020 to June 2021.

THEORETICAL FRAME
The arboviruses cause impacts on the health of the population ranging from the difficulty of implementing preventive measures, the maintenance of measures and actions of control to the vector, and basic sanitation is an excellent strategy for the control, providing the unveiling of other forms of intervention (Queiroz, Silva e Heller, 2020).Questions have been debated such as: its characteristics; the chance; the potential of epidemiological transmission; the relationship environment versus human behavior, capacity for eradication and prevention (Lima;Camara, 2016).
The environmental modification that comes from the interference of human actions associated with the economy; the disordered urban growth; the climatic changes, the deforestation; the irrigation systems.These and other factors have led to the disorderly growth of arboviruses (Epsten, 2000;Norris, 2004;Fauci, Morens, 2012;Mcmichael, Woodruff, 2008).
It is essential to determine the location of the breeding sites, to define the strategies with the greatest investment, providing for a better surveillance action through the adoption of specific measures to combat the mosquito (Terra et al, 2017).
Analyzing the epidemiology of arbovirosis, it is noted that the year 2020, the reported cases of the diseases have reduced, where the world scenario was entirely focused on the 5 authorities; characteristic for the high degree of lethality; transmissivity and worldwide dissemination (Sesab, 2021;Epidemiological Bulletin, 2021;Leandro et al, 2020).In this context, Brazil with problems in its economic, political and health environment, resulting in the health sector; the underfunding of the SUS intensified by a limited economic model and contrary to investments in social policies, promoting social vulnerability, entered a period of collapse aggravated by the increase in the numbers of cases of COVID-19 (Sesab, 2021;Epidemiological Bulletin, 2021) As a result of this global health crisis, the Ministry of Health together with the General Coordination of Surveillance of Arboviroses (CGARB), temporarily suspended the rapid survey of indices for Aedes Aegypti with the aim of avoiding contact of endemic agents (ACE) that are the key pieces in the control of arboviruses with the population at the time of the home visit, resulting from the scarcity of data on outbreaks of mosquito breeding making it difficult to carry out public policies and programs to raise awareness for combat (Pereira, 2021;Andrade;Peixoto e Coelho, 2020).
It is important to report that in regions where Dengue cases are prevalent, there may be co-infection between the covid-19 virus and Dengue virus (Velasco et al., 2020;Barroso et al., 2020).Dengue symptoms are similar to those of COVID-19, and can lead to a false positive through rapid testing and less sensitive laboratory methods, providing a late diagnosis in the case of COVID-19, favoring the spread of the disease (Barroso et al., 2020;Velasco et al., 2020 andMascarenhas et al., 2020).It is essential to make the differential diagnosis, both have febrile period, are systemic infections, the initial symptoms may be similar (Torres and Garcia, 2020;Unb, 2020).For the diagnosis of these diseases, it is necessary to observe the epidemiological criteria, the order of signs and symptoms, the results of laboratory examinations to finally notify (Torres andGarcia, 2020 andMascarenhas et al., 2020).
Also in this aspect, we can cite the established social isolation to contain the spread of COVID-19, starting with the cancelation of events, suspension of school classes; sports tournaments and championships; closure of cinemas, shopping centers and theaters, the reduction of the movement of people, enabled the population a fear in seeking care in health units, reducing the records of diseases caused by arboviruses.All the above factors have interfered with the underreporting or delay of the notifications (Werneck, Carvalho, 2020;Epidemiological Bulletin, 2021).
The big challenge to address this change in the behavior of the epidemiological profile of arbovirosis in COVID-19 is to analyze changes in reporting, as underreporting changes the reality of cases and consequently masks the severity.Furthermore, territorial organization interferes with the appearance of diseases by establishing a relationship with the environment, because analyzing the territory enables the effective participation of the community, an important factor for the control, prevention and promotion of health (Lisboa et al., 2022; Queiroz, Silva e Heller, 2020).The place of study is the state of Bahia, located in northeastern Brazil, considered the fourth state in population in Brazil with the estimated population in the year 2020 of approximately 14,930,634 inhabitants and 2021 of 14,985,284 inhabitants, occupying a territorial area of 564,760,427 Km² (6.6% of the geographic area of the country) possesses the city of Salvador as capital, predominate the tropical climates characteristic for being hot and humid and hot and dry and hot semi-arid mainly in the interior (Ibge, 2021 andsei, 2021) .In 2017, the water supply in the state of Bahia had relatively low distributed units (Ibge, 2021).
In order to meet one of the principles of SUS, the regionalization of health services through the decentralization of actions and health services, optimizing resources and the increase of autonomy between the territories, Bahia was divided into 28 health regions: health macro-regions (Sesab, 2018 andSesab, 2021) 3.2 METHODS For temporal and spatial analysis, the rate of arboviral cases per 100 thousand inhabitants was defined, considering the estimated population for each year, as follows: In the trend analysis and estimation of the Monthly Percent Variation (VPM), the simple linear regression model with Prais Winsten correlation (Prais, Winsten, 1954) with the use of the computational and statistical language R (R core Team, 2020) Already in the spatial  recorded the lowest average rates of dengue cases reported per 100,000 inhabitants respectively (Figure 1).Cruz das Almas (-31.0%) and Serrinha (-29.8%).The smallest HGV with decreasing trend and statistical significance, with 95% significance, occurred in: Itabuna (-8.7%),Camaçari (-14.6%) and Feira de Santana (-18.0%).It should be noted that most of the health regions had a decreasing trend with statistical significance (57.1%) and none of them had increasing HPV with statistical significance (Figure 4).The analysis of the trend of the time series of Zika rates in the health regions of Bahia presented higher estimated and statistically significant values, with 95% confidence of HPV in: Teixeira de Freitas (-35.6%),Cruz das Almas (-33.4%) and Porto Seguro (-31.5%).The smallest HGV with statistical significance (p-value<0.05) were registered in the regions of Itabuna (-8.5%),Alagoinhas (-15.3%) and Juazeiro (-24.3%).Among the analyzed regions, 50.0% had decreasing and statistically significant HPV, with 95% confidence and only 17.8% growing behavior without statistical significance (Figure 6).

Discussion
Through this research, it was possible to see in general, a decrease in arboviral records in the periods from March 2020 to June 2021.In Brazil, generally the rainiest months are between the months of March and April and in this period, due to various factors, there is also an increase in the cases of Dengue (Oliveira et al., 2022;Pinheiro et al, 2020;Barcellos et al, 2009;Braga and Valle, 2007;Confalonieri, 2003;Dantes The Aedes Aegypti survives to depend on climatic conditions, providing the contamination in large proportion to the population of the diseases caused by arboviruses, as in medium and small towns.The year 2020, from the month of February, was marked by a 39% decline in the numbers of arboviral case reports in Brazil (Docile, Chaiblich, Miyashiro, 2020;Epidemiological Bulletin, 2020;Lisboa et al., 2022).
A study conducted by Vicente et al., 2020 in Espírito Santo states that in the first half of 2020, the number of arbovirosis reported must have been higher, a combination of epidemics occurs because with the rise of SARS-COV-2 the health professionals fell ill, therefore affected the quality of access to health of the population, challenging the government to maintain the efficient health system.Diverging from our findings, Faria et al., (2022) concluded that in Bahia there was a considerable increase in Zika and Chikungunya, and the months of highest prevalence were May and June 2020.

CONCLUSION
According to this study, the health regions of the state of Bahia, presented a decrease in trend and the decline in the average rates of arbovirosis per 100,000 inhabitants per residence during the periods of March 2020 to June 2021, possibly provided by the global health emergency, arising from SARCS-COV 2, which intensified the need for monitoring public health and the environment.In this scenario, besides the circulation of the new virus, in Bahia, the diseases caused by arboviroses were also circulating (Dantés, et al.,2020).
According to Fiocruz (2021), discussions exposed during the 20th Advanced Seminar on Global Health, the pandemic camouflaged the cases of diseases brought about by arboviruses.Whether due to the lack or scarcity of notifications, the attention of health authorities is focused on COVID-19, favoring the transfer of human and material resources in favor of combat, besides exposing the fragility of the health system.Social distancing measures such as the lockdown, led to social isolation, which people had to stay "locked up" in their homes, generated losses in the home visit carried out by the ACES, as well as consumption of products, causing exacerbated production of waste and its inappropriate disposal by increasing the breeding places, favoring the dissemination of the diseases caused by arboviruses.The demand for health services was scarce or non-existent, due to the risk of contamination due to SARCS-2, many people who are affected by Dengue, Zika and Chikungunya stopped seeking care, opting to be treated at home (Leandro et al., 2020;Lisboa et al., 2022).15 It is well known that arboviruses should not be neglected, and constant improvements are needed regarding treatment and its control.It shows that Chikungunya causes rare problems, but they should not be forgotten, resulting in factors that impact the economy and society.Once aggravated, it makes it impossible for the individual to enter the labor market, causing job losses and diseases of emotional factors (Santana et al., 2021).
In order to minimize the number of cases of arboviral consequences, it is necessary to bring together the community, political and health authorities through the creation of effective and capable public policies, as well as the increase of resources and strategies to alleviate this situation such as: use of drones to identify possible breeding grounds and spray insecticides, constant environmental and health education, SMS messages with measures aimed at covid and diseases caused by Aedes aimed at linking family and community in the control of vectors, joining of hand sanitizer with repellents; surveillance should be strengthened by being part of programs in the control of diseases (Fiocruz, 20020 21;Gubler, 2012;Gubler et al, 2014;Lopes, Nozawa and Linhares, 2014).In addition, promote accessibility to health services by strengthening SUS, ensuring universal and equitable access to society (Saavedra et al., 2021).
As a limitation of this study, the use of secondary data from passive reporting of arboviral diseases by residence is highlighted, and may not portray the entire history of existing cases.There is also a possible intervention in the notification of cases, due to changes in the notification criteria in the course of the historical series (Brazil, 2014).
As there is in the literature a lack of research that evaluates in time and space the rates of arboviral cases, considering the health regions of the state of Bahia, it is possible to say that our findings may offer the scientific community and/or public health managers subsidies for directing public policies that optimize actions on the part of these agents, taking into consideration the health region most affected by these diseases.
arbovirus case numbers at the expense of COVID-19 mobilization may contribute to the hypothesis of underreporting, providing increased demand for intensive care by targeting resources and health professionals to fight COVID-19, making it difficult to Pandemic ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.8 | p.1-22 | e08233 | 2024.
mixed exploratory ecological study to assess the time trend and geographical distribution of recorded cases of arbovirosis in the health regions of the state of Bahia during the COVID-19 pandemic.The data used correspond to the period from March 2020 to June 2021 and were made available by the following institutions: the data of the population by the Brazilian Institute of Geography and Statistics (IBGE); data notified of the cases of arbovirosis obtained from the State Secretariat of Health of the State of Bahia (SESAB) through the Information System of Notification Agravos of the Ministry of Health (SINAN/BA).
analysis, the cartographic program Qgis version3.2.0 (Qgis, 2021)  , which allowed the construction of cartograms with the average rates of arboviruses per residence in the 28 municipal health regions of the state of Bahia being used limits Most found in the continuous base of Brazil in a scale of 1:250.000,made available by IBGE (Brazilian Institute of Geography and Statistics), linking the cartographic base to tabular data originating from the Secretariat of Health of the State of Bahia (SESAB).The time unit considered in this survey were the months, in the period from March 2020 to June 2021, constituting (16 points) in the series, the trend was tested for each health region of the state of Bahia and classified as increasing and statistically significant (VPM>0 and p-value<0.05),decreasing and statistically significant (VPM<0 and p-value<0.05)and without trend, according to the adopted model (p-value>0.05)(Antunesand Cardoso, 2015).Space-Time Trend of Arboviruses in Health Regions of Bahia: Na Ecological Study During the Covid-19 Pandemic ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.8 | p.1-22 | e08233 | from March 2020 to June 2021,

Figure 1
Figure 1Average dengue rate per health region of Bahia in the period from March 2020 to June 2021.

Figure 2 Average
Figure 2 Average Chikungunya rate by health region of Bahia in the period from March 2020 to June 2021

Figure 3 Average
Figure 3Average Zika rate per health region of Bahia in the period from March 2020 to June 2021.

Figure 4
Figure 4 Monthly percentage change in rates per 100 thousand dengue inhabitants and their respective confidence intervals, in the period from March 2020 to June 2021.Note: The dotted vertical line denotes the critical value of the null hypothesis of WGV.

Figure 5
Figure 5 Monthly percentage change in rates per 100,000 Chikungunya inhabitants and their respective confidence intervals in the period from March 2020 to June 2021.Note: The dotted vertical line denotes the critical value of the null hypothesis of WGV.

Figure 6
Figure 6 Monthly percentage change in rates per 100,000 Zika inhabitants and their respective confidence intervals, from March 2020 to June 2021.Note: The dotted vertical line denotes the critical value of the null hypothesis of WGV.

(
Dengue, Zika and Chikungunya), probably due to some factors such as: clinical manifestations of arbovirosis in some cases have signs and symptoms similar to those of covid-19.Due to the Space-Time Trend of Arboviruses in Health Regions of Bahia: Na Ecological Study During the Covid-19 Pandemic ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.8 | p.1-22 | e08233 | 2024.13 pandemic, attention was focused on COVID-19; visits by ACES were restricted; the fear of going to the health facility and contaminating itself with COVID-19, contributing to the underreporting of cases, consequently causing a reduction in rates (Epidemiological Bulletin, 2020; Andrade, Peixoto and Coelho, 2020; Neto concluded that in Itajaí (SC) the pandemic period presented a high infestation rate for Dengue, redoubling attention to an outbreak of the disease.Also in a retrospective observational epidemiological study conducted byLopo et al. (2022), in which arbovirosis was analyzed in Salvador (BA) during the COVID-19 pandemic, there is a substantial increase in arbovirosis cases in the year 2020.This shows that arboviruses are still a serious public health problem, making it a challenge for Bahia's public health.The survey conducted by Nascimento; Oliveira e Lima (2022) in the municipality of Várzea Nova (Ba), it was noted that the data collected through the municipality's Health Department, had an increase in the numbers of cases notified of arboviruses since the beginning of the pandemic by SARCS-COV-2, making it difficult to supervise and monitor professionals.Nascimento et al., (2021) state that in the state of Sergipe, there was a reduction in the incidence of dengue cases, while the cases of covid increased exponentially.As for the Chikungunya cases, they increased, reflecting on underreporting, the reduction of vector control measures and the demand for medical help due to intense arthralgia.As well as our findings the Municipal Health Department of Feira deSantana (2021), stated that the municipality presented a reduction in the notification of arboviral cases, and the covid-19 may have favored this reduction.Mulinari et al., (2021) also points out that the city of Montanhas (ES), presented a considerable reduction in 2020 regarding the proportion of cases of Dengue (78%), assuming undernotification; the mobilization of the epidemiological surveillance team in facing the pandemic; the relocation of resources for the control as financing of training, equipment and Space-Time Trend of Arboviruses in Health Regions of Bahia: Na Ecological Study During the Covid-19 Pandemic ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.8 | p.1-22 | e08233 | 2024.14 installation of hospital beds to meet the demand of patients affected by covid-19, targeting the investments destined to the programs of basic health care.Gagossian, Martins and Batista, (2022), in the state of Tocantins in the municipality of Palmas during the pandemic period, found that the incidence of cases of covid-19 in the years 2020 and 2021 were higher than that of Dengue.And according to the authors, this reality may have led to the under-reporting of Dengue cases in the face of the COVID-19 pandemic.Also from this perspective, PAHO (2021), found a reduction of cases of Chikungunya in the Americas in 2020, already in Brazil in 2021 a higher number of cases Chikungunya 48.044 and a reduction of the number of cases of Zika 6.012 in the Americas.It is essential to increase actions for the control of COVID-19, the extension of innovations and the improvement of the control of arboviruses Space-Time Trend of Arboviruses in Health Regions of Bahia: Na Ecological Study During the Covid-19 Pandemic ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.8 | p.1-22 | e08233 | 2024.