Brazil 'Facing Many Epidemics Right Now': Former Health Minister

Monica Tarantino

July 28, 2020

As President Jair Bolsonaro claims he is now negative for coronavirus, less than 3 weeks after he tested positive for the virus — during which time he controversially hyped the drug hydroxychloroquine — Brazil is still experiencing a rollercoaster ride when it comes to the pandemic.

The chaos, which has ensued there since the beginning of March, is fueled by the atrocious response of the federal government to tackle the novel coronavirus, and this continues to be the case to date as much of Brazil languishes in mid-Winter.

Bolsonaro sacked his first health minister, Luiz Henrique Mandetta, in April, and the one after that, Nelson Teich, resigned barely a month later, while other leaders heading up the public health response to the pandemic also fell by the wayside. All of this happened as the federal government "sat" on billions of dollars earmarked for the emergency response. The current minister of health is an army general.  

Now the virus is spreading to rural areas, which are less equipped to treat people than the towns. In addition, there is no consistency in terms of controlling the novel coronavirus: some areas are heading for a second wave while reopening their economies, others are locking down. Policies on wearing masks differ from region to region, and in any case, these regulations are not always enforced. Decisions about school reopenings vary from place to place, too, and in an ironic twist, the high rate of SARS-CoV-2 infection has resulted in Brazil becoming one of the testing grounds for vaccines. At the heart of all of this are a lack of effective leadership, chaos in the public health response, and a polarized electorate.

So that 4 months after the first case of COVID-19 was recorded in Brazil, on February 26, there are still more than 1000 deaths a day from the virus and it is the second most badly affected country in the world — the United States still holds first place.

Still a Long Way to Go to Get the Situation Under Control

As of July 28, Brazil had more than 2.4 million confirmed cases and >87,000 deaths, according to data provided daily by a network of media outlets formed after a "blackout" of official data undermined confidence in government information.

Although there are signs of a trend towards stabilization of the epidemic in some Brazilian states — numbers suggest that COVID-19 deaths have neither dropped nor increased significantly in 11 of the 27 states — the figures diverge elsewhere, continuing to rise in nine other states while falling in the remaining seven. (The comparison considers the average number of deaths in the last 7 days contrasted with that recorded 2 weeks previously.)

But former Health Minister José Gomes Temporão, MD, refutes the claim of the federal government that the country has reached some kind of plateau, arguing that the statistics paint a very different picture.

Temporão was Brazil's minister of health from 2007 to 2010, when he faced the dengue and yellow fever epidemics (both of which return every year), and the arrival of H1N1 flu. Temporão left an epidemic containment plan in place when he left office.

Regarding COVID-19, "There has been a decrease in the number of cases in cities in the north, northeast, and southeast, but the pandemic has moved to the countryside, to the south and midwest, increasing the number of deaths in these regions," he told Medscape Medical News.

"This explains the thousand deaths a day trend that we are seeing.”

Thus, said Temporão, the disease is displaying different dynamics in each region and state, so, "We are facing many epidemics right now."

The pandemic has moved to the countryside, to the south and midwest, increasing the number of deaths in these regions.

And Wanderson Oliveira, PhD, former national secretary of health surveillance, who resigned in April after the health minister, Mandetta, was fired, agreed.

"The numbers we look at every day are a picture of what happened 2 or 3 weeks ago. These are records that were under scrutiny and that have been completed," Oliveira told Medscape Medical News.

It takes time for patients to be seen and tested, and for the information to be released via databases, an operation subject to delays and bottlenecks, he added.

A doctor in epidemiology, Oliveira headed the team that was responsible for the strategy to combat COVID-19 at the beginning of the pandemic, a phase marked by disputes about testing and personal protective equipment (PPE).

The arrival of COVID-19 fell on a poorly equipped and undersized structure in Brazil, which resulted in long waits for tests and delays in obtaining results.

Oliveira said that, even now, "The number of new cases and daily deaths seem much more an expression of laboratory capacity" than true figures. Accurate figures for cases and deaths are higher than those reported, he believes.

New labs are expected to open this month, and it is hoped this will increase the number of samples processed daily to 60,000.

Still, there is a long way to go to get the situation under control.

Respiratory Virus Monitoring Indicates Second Waves of COVID-19  

Oliveira said one way of gauging the state of the COVID-19 pandemic in Brazil is to keep an eye on new cases of flu.

"A good way to have a better forecast of what is happening now would be to assess what proportion of flu tests are positive each week," he said.

Brazil has about 300 sentinel units devoted to influenza surveillance. The data are gathered using a respiratory virus monitoring system called InfoGripe, the result of a partnership established in 2014 between the Ministry of Health and the Oswaldo Cruz Foundation (Fiocruz).

Based on what has been seen with regard to severe cases of acute respiratory distress syndrome (ARDS) across Brazil — known as severe acute respiratory syndrome there — cases of SARS-CoV-2 "are increasing across the country," said InfoGripe's head, Marcelo Gomes, MD.

According to the latest InfoGripe bulletin, the percentage of cases of severe ARDS that tested positive for SARS-CoV-2 reported in epidemiological week 29 (closed on July 18) is very high, at 96.7%.

It's not possible to know from these data if the worst is over, said Gomes, but the numbers suggest there was a first peak followed by a small fall and new growth.

"It is noteworthy that several states are now showing signs of hitting the second wave," he noted.

It is noteworthy that several states are now showing signs of hitting the second wave.

In the southeast region, the number of cases of severe ARDS fluctuates around a peak each year, without a significant drop in the numbers.

In Rio de Janeiro, where the total number of cases fell for a few weeks in a row, InfoGripe detected further increases, indicating a second wave of COVID-19 may have already started there.

In the north, the epidemic was devastating in the state of Amazonas, which only now shows signs that the numbers are decreasing, but severe ARDS cases are growing in the state of Tocantins and there are indications of a second wave starting in the state of Amapá.

And in the south of Brazil, where it is now mid-winter and temperatures can easily reach 2ºC (36ºF), all states are experiencing an increase in respiratory syndromes.

It's the same in the northeast: states that were showing falling numbers, such as Maranhão, Ceará, and Pernambuco, have started to see increases in numbers of severe ARDS again, suggesting a second wave of COVID-19 is on the way.

Meanwhile in the midwest, there are signs the pandemic may have reached its peak in the federal district where the capital, Brasília, is located.

Lack of Any National Coordination as COVID-19 Spreads to Rural Areas

It's a puzzling scenario. While some cities, such as Rio de Janeiro, are planning to reopen the economy by October despite hints of a second wave, others are in lockdown decreed by the State Court — which is the case in Cuiabá (Midwest).

And in the northeast, while the city of Fortaleza registered a decrease in cases, the town of Juazeiro do Norte, just 174 miles away, saw a 400% increase in the number of infected individuals in 30 days.

And throughout the country, the SARS-CoV-2 virus has now reached rural regions with poor health care, and there isn't a good system to organize the flow of patients to regional centers with better infrastructure.

In addition to these difficulties, the denial of federal authorities and lack of consistent messages continue to hinder the population's adherence to social distancing.

Although the country seems committed to increasing testing, the lack of central coordination has resulted in the responsibility for fighting the pandemic falling to individual states, with all of them following different strategies but with one common goal: to stabilize the curve of new cases and guarantee the reopening of the economy.

The problem is tests are not arriving when and where they are most needed, and there are other issues. As just one example, the Ministry of Health distributed part of the testing kits without the essential substance to extract the RNA from the virus.

So this absence of national coordination is one of Brazil's central problems in facing the pandemic.

One of the most remarkable signs of this...disaster is the government's deliberate sabotage of any consistent control measure.

"One of the most remarkable signs of this...disaster we are experiencing is the government's deliberate sabotage of any consistent control measure," said Temporão.

"This was very clear in the dismissal of two ministers of health during this period and in the placing of unqualified people at the head of the ministry," he continued, referring to the fact that for almost 2 months now, the post of health minister has been occupied by an interim appointee, General Eduardo Pazuello.

Pazuello approved the use of hydroxychloroquine and chloroquine for COVID-19 prophylaxis and mild infection — responding to a request from President Bolsonaro, despite the lack of evidence to support use of the drugs.

General Pazuello has also appointed dozens of army members to replace highly trained specialists in strategic positions to tackle the pandemic

"It is not just a case of the government's wrong or incompetent performance," wrote Temporão and six other former ministers in an article published July 17 in one of Brazil's biggest newspapers.

"The decisions made in the...economic and social spheres clearly express the government's perverse logic that subjugates the needs of the population to the principle of fiscal austerity, regardless of the damage it can cause in people's lives," they added.

Alternative Health Authority Formed, Federal Government Sits on Funds

The newspaper article, among other things, states that the situation could have been so different if the federal government had assumed its responsibility to lead and coordinated the national effort to tackle the pandemic from the start.

To fill this power void, an alternative health authority was set up in the country.

Although not formalized as such, it is composed of governors, mayors, health care workers, and other specialists from the fields of public health, science, medicine, different political parties, the National Congress, the Judiciary, and the mainstream media — the latter have been working in the face of great limitations to try to report accurately on the state of the pandemic.

In the northeast, for example, the creation of a governors' consortium, along with a scientific committee that brings together prestigious Brazilian universities and research institutes, is guiding the fight against COVID-19, with an emphasis on the action of health professionals to track contacts and guide protection and isolation measures.

"The lack of a central command hinders society's save lives," said Temporão.

"Unfortunately, at this moment, what Brazil is doing is just counting the deaths."

"Who will be held accountable for this situation is something that will have to be addressed sooner or later," he emphasized.

Unfortunately, at this moment, what Brazil is doing is just counting the deaths.

One of the most serious consequences of the federal government's failure to face the pandemic is the slow pace to release emergency resources to combat the new coronavirus.

From the 39 billion reais (US $7.5 billion) earmarked for tackling COVID-19 between March, April, and May, as far as June 23, only 11.6 billion reais (US $2.2 billion) left the federal vaults.

And further, "On that date, 8.5 billion reais (US $1.6 billion) were sitting there, in the budget, waiting to be spent on direct expenses such as the installation of more intensive care beds and the purchase of testing kits, ventilators, and PPE to be distributed all over the country," Francisco Funcia told Medscape Medical News.

Funcia is an economist and a consultant for the National Health Council, an organization linked to the Ministry of Health; the Council inspects, controls, and advises on health policies and management of the public health system.

"This means 'the manager' has not decided what to do with the resources," said Funcia.

'The manager' has not decided what to do with the resources.

Even if health authorities can circumvent market difficulties and find the supplies needed to fight COVID-19, more than 150 days have passed since the beginning of the pandemic, wasting valuable time.

Since April, the National Health Council has published weekly bulletins detailing the financial constraints hindering the allocation of additional resources to fight the novel coronavirus.

"On June 23, about 66% of funds destined for municipalities and 59% of the money destined for the states had not been delivered because they were stuck in the Ministry of Health budget waiting for this decision," said Funcia.

For example, molecular tests are sitting in storage due to the lack of swabs to collect oral or nasal samples, and there is a shortage of drugs to treat patients, to name but a few of the challenges.

Studies carried out by the National Health Council found that there was an increase in transfers of funds to municipalities as of July, however.

This appears to coincide with government efforts to approach both the Congress and Senate for the approval of bills and to bar the several requests for Bolsonaro's impeachment.

Meanwhile, the Federal Public Prosecutor's Office and Federal Audit Court (which monitor federal expenditures) are investigating why the government has so far spent only one third of the estimated funds to fight the pandemic.

Return to School Debated, Volunteers Test Vaccines

There are many other challenges facing Brazil in the coming weeks and months.

One of the most important is the discussion about kids going back to school.

In São Paulo, classes are scheduled to restart on September 8 if the numbers of infections and deaths continue to fall. In Rio de Janeiro, some schools plan to return to activities in early August.

Experts are still discussing acceptable levels of transmission and strategies to be adopted by the country's private and public education systems, profoundly marked by social inequality.

If not carefully planned, students returning to school will likely increase the number of new infections, some experts believe.

A recent survey released by the Oswaldo Cruz Foundation (Fiocruz) showed that 9.3 million people with heart disease, diabetes, and other comorbidities (and therefore more vulnerable to the complications of COVID-19) live with school-age children in Brazil, accounting for 4.4% of the population.

"If we take the rate of lethality observed in the country as a reference, this may represent 35,000 deaths in this population alone," wrote Fiocruz's researchers in a technical note.

According to the document, the probability of SARS-CoV-2 secondary transmission in the domestic environment is estimated at 12% to 30%, with the elderly population being the most susceptible.

Ironically, the health chaos and high infection and death rates have turned Brazil into an ideal testing ground for vaccine candidates.

One of these is the potential vaccine being developed by Oxford University in partnership with AstraZeneca, which is being evaluated in tests conducted by the Federal University of São Paulo (UNIFESP) on 5000 volunteers.

The other candidate is from the Chinese biotechnology company Sinovac, which has a partnership with the Butantan Institute, a traditional vaccine research and manufacturing center in São Paulo. The tests started on July 21 with 9000 volunteers selected from among health professionals slated to receive the vaccine.

And on July 21, Brazil's drug regulatory agency Anvisa announced the approval of a third phase 3 clinical trial, this time two vaccine candidates, BNT162b1 and BNT162b2, from Pfizer and BioNTech (Germany). The study will recruit 29,000 participants worldwide, including 1000 in Brazil, and is scheduled to start in August.

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