COVID-19 IN BRAZIL: CURRENT SITUATION AND FUTURE SCENARIOS FOR THE BRAZILIAN HEALTH CARE SYSTEM.*

The COVID-19 pandemic is no doubt an enormous challenge to all countries in the world. Nonetheless, it has been impacting countries in different ways and degrees.

For example, in Australia, the virus infection curve has already flattened, but this not yet the case for Brazil.

It seems that the way countries are facing the epidemic does not depend only on their wealth, but also on cultural and political characteristics.

Will Brazil be successful in dealing with the COVID-19 epidemic? What are the biggest challenges and possible solutions? What is the current situation and the present scenario?

To not rely solely on the press, I have interviewed Dr Renato Couto, an expert in the field.

Dr Renato Couto is a doctor with a PhD in infectious diseases. He is the CEO and founder of Grupo IAG Saúde, which provides hospitals with technological management solutions as well as health plans in Brazil, and a former associate professor of the Federal University of Minas Gerais (UFMG).

The interview follows, below.

Luiz Carneiro: Regarding the COVID-19 situation in Brazil, on the 13th April 2020, the Brazilian Ministry of Health reported a total of 22,169 cases, 1,223 deaths and, consequently, a death rate of 5.5%.

At the same time, the Brazilian Ministry of Health has stated that there is not a register of all tests performed in Brazil, so this piece of information is lacking.

The reported 22,169 cases are most probably underestimated.  So the following questions arise:

  1. What is the current situation of COVID-19 tests in Brazil?
  2. Is the virus spreading under the radar?
  3. Which tests are being used in Brazil? RT-PCR tests or serology tests? Are they reliable?
  4. Which other statistics could we use to have a better picture of the situation?

Dr Renato Couto: Regarding the serology tests, they are still under assessment, so they are not an option at the moment.

The only reliable test is the RT-PCR test done in the first week after the symptoms start.

After the eighth day, there is a much higher chance that people with the coronavirus will test negative to the disease, even when tested twice.

One of the reasons why the coronavirus could go undetected is that the most critical cases are admitted to hospitals between the fifth day and the tenth day after symptoms have started, when the false-negative rate is already high.

In Brazil, besides this inherent drawback in the RT-PCR testing, the enormous delay in receiving test results is a consequence not only of the shortage of supplies but also of failures in operational processes.

To have a better sense of the current situation, the COVID-19-positive death rate per 100,000 inhabitants is the most reliable indicator available today, given limitations with RT-PCR testing.

However, a better indicator for the actual number of COVID-19 cases would be the death rate per 100,000 inhabitants in which the numerator accounted not only for COVID-19-positive deaths but also for the suspected COVID-19-positive deaths. Unfortunately, to the best of my knowledge, this indicator is not available.

Luiz Carneiro: Some experts have been arguing that mass testing is an essential tool to manage the COVID-19 pandemic. How can Brazil have a safe strategy to face the crisis when it is not able to duly test the population and keep a centralised record of those tests?

Dr Renato Couto: Social distancing is the only safe strategy.

Even with more tests, there would still be a lot of false-negative results. That means that, without social distancing, those contaminated people who tested negative to COVID-19 would keep spreading the virus.

Some countries which implemented mass testing and were successful in controlling the spread of the virus may have reached that result because of other factors, such as cultural and behavioural factors.

There is no scientific evidence that their success has been due to mass testing.

Given the lack of scientific evidence on it, these are only opinions.

My opinion is that mass testing may contribute to the loosening of social distancing, which is a risk to the control of this epidemic.

The COVID-19-positive death rate per million people is the most reliable indicator available, according to Dr Renato Couto.

Luiz Carneiro: But even without mass testing, tests are still needed. What is the infrastructure situation in Brazil at the moment?

Dr Renato Couto: the RT-PCR test requires more sophisticated equipment than other tests. The necessary materials and equipment are short in supply, and it requires highly skilled staff. Those resources are not readily available in Brazil, so having more money will not necessarily help.

The private health care sector has not developed an appropriated infrastructure for the RT-PCR test because it was not profitable.

A viable solution that started two weeks ago is to use the equipment and staff available in public federal universities and public laboratories.

At least at the Federal University of Minas Gerais (UFMG) the laboratories are now integrated and will be able to process the necessary test if enough resources are available.

Luiz Carneiro: The Brazilian Ministry of Health has recently published a report which states that the COVID-19 epidemic in Brazil will peak in April or May this year and that the virus will keep circulating until mid-September. Based on the available data, is it possible to make this type of prediction at the moment?

Dr Renato Couto: the only certainty is this will be a long and tough journey. The WHO says that this pandemic will have two peaks, but that a third peak is also possible. However, the Brazilian epidemic curve has been flattening if we consider the COVID-19-positive death rate per 100,000 inhabitants. Seven days ago, the Brazilian curve started to diverge from that of Italy.

Luiz Carneiro: Many studies show that the number of COVID-19 cases in the world is underestimated. Does your company have an estimate for the current situation in Brazil? Do you have a prediction for the future scenario?

Dr Renato Couto: nobody has an estimate. I hope the epidemic will have a flattish curve. Otherwise, we will not have enough resources in Brazil, in the public and private sectors. And if the curve flattens, then it means it will be a long-lasting epidemic.

Luiz Carneiro: Which is the most likely scenario? Which will arrive first, the vaccine or herd immunity?

Dr Renato Couto: Herd immunity will arrive before the vaccine. And I hope the Brazilian population acquires this immunity in a flat-curve journey, in which the available resources will not be exhausted.

Luiz Carneiro: But what if there is a peak? Will Brazil have enough hospital beds and ventilators? What is the scenario in the public and private sectors?

Dr Renato Couto: We will have enough beds for non-critically ill patients, but if there is a peak in this epidemic, then there will not be enough ventilators in either the public or the private sector.

In any scenario, it is vital to properly manage the stock of necessary resources: ventilators, N95 protection masks, ICU beds, non-ICU beds, doctors, nurses, physiotherapists, etc. The shortage of any of these resources will impact that proper supply of mechanical ventilation to patients.

Our group has a technological solution to help solve this problem by managing the necessary resources. We are making this solution available free of charge to healthcare institutions. Those interested in it may obtain more information via the following link:

www.drgbrasil.com.br/especial-covid-19/

Luiz Carneiro: What is the current situation on social distancing in Brazil? The Brazilian press has recently shown that many people are not following social distancing rules, with an increase of people using public transport.

Dr Renato Couto:We have two forces against social distancing in Brazil. Poverty and the false assumptions many people have about the coronavirus.

Regarding poverty, the lack of food will make/is making people move around. It is necessary to take food to the poor people on the periphery of society. The Congress has recently approved a monthly payment of R$ 600.00, which is a correct measure.

Regarding the false assumptions, the first is that COVID-19 is just another flu, and the second is that there is a proper drug to cure the virus: chloroquine. Unfortunately, it is not just another flu, and chloroquine is just a weak hypothesis for research. Previous studies of chloroquine as an antivirotic have been a total failure, which was the case for mononucleosis.

Luiz Carneiro: But according to the Brazilian press, the Brazilian Ministry of Health has not discarded the use of chloroquine and promises to have a “safe answer” for it this month. In the case it is effective and safe, would it be a viable solution to save critically ill patients?

Dr Renato Couto: We have only two certainties: first, chloroquine has severe side effects, it may kill; second, there is no evidence whatsoever that its use is beneficial. It is about an experiment, acceptable only under well-defined and well-supervised research protocols.

Luiz Carneiro: According to the international press, poorer countries like Brazil are at a disadvantage compared to wealthier nations when acquiring the necessary material and equipment to face the COVID-19 epidemic. Is this true for Brazil? What is the scenario for the Brazilian health care system (public and private)?

Dr Renato Couto: The undersupply of critical resources to face COVID-19 is a global reality. If we are not able to flatten the curve, then we will have a calamity because of the lack of resources.

Luiz Carneiro is an Economist and a Board Member of AUBRBC.

* This disclaimer informs readers that the views, thoughts, and opinions expressed in the interview text belong solely to the author interviewed, and not necessarily to the author’s interviewer, the Australia Brazil Business Council organization, the organiser’s committee or other group or individual.