The coronavirus black box in Brazil


On the east side of São Paulo, the most populous region of the largest Brazilian city, a group of ten patients awaits the Covid-19 test. All were seen at an Ambulatory Medical Assistance Unit (AMA) and underwent the exam last week, after presenting symptoms such as cough or fever. The group, however, is not on the list of suspected coronavirus infection. And the responsibility lies with the Ministry of Health.

THE Public Agency found that the Federal Government took too long to compel all cases to be notified, leaving these people and hundreds of other suspicious cases off the radar – including the case of first Brazilian to die of coronavirus, on March 16, in the capital of São Paulo.

“I totally disagree with the stance of the Ministry of Health. All cases, since when a community transmission started in Brazil, should have been notified,” he told the Public Agency a health professional who works at AMA, on condition of anonymity.

The Ministry had already issued an alert on the community transmission of Covid-19 in São Paulo in March 13, but it took about a week to update the disease notification protocol – in that period, the state of São Paulo saw the numbers jump from 56 confirmed cases on the 13th to 286 on the 19th, and recorded four deaths from the disease.

Notification of coronavirus infections has been mandatory for the entire healthcare network, public or private, since 2016 – but only if the patient develops severe acute respiratory syndrome. This criterion already existed in the list of notifications from the Ministry of Health because of other viruses of the corona family, such as SARS-CoV, which generated an epidemic in China in 2002.

With the arrival of the pandemic in Brazil, the Ministry of Health produced a notification form for suspected and probable cases of infection with the new coronavirus. The chart, however, only considered suspicious cases if, in addition to the symptoms, the patient had traveled abroad or had close contact with a suspected or confirmed case for the disease in the previous 14 days.

This failure left out of the Ministry’s notification system all people infected by the coronavirus in the community and who did not show serious symptoms. Community transmission means that the virus is spread within the country and cases are not restricted to those who have traveled abroad.

This was the case for the first death from coronavirus in Brazil, recorded on the 16th, of a 62-year-old man with diabetes and hypertension and who had not traveled abroad. He passed away after just two days in the ICU of the private hospital Sancta Maggiore, in the South Zone of São Paulo. According to Estadão, he had not entered the list of suspected cases. The same would have occurred with family members who had contact with the man. In a report by Buzzfeed, the capital’s health secretary criticized the Ministry’s protocol and stated that “the lack of notification hinders the mapping of pandemic cases”.

“The big problem with the first protocol – and, moreover, its little use now, given the sustained transmission within the country – was that it needed to meet two criteria to be considered a case. That is why suspicious cases may have been lost ”, criticizes Carla Machado, professor at the Department of Preventive and Social Medicine at the Federal University of Minas Gerais (UFMG), who researches epidemiology and quantitative methods in health.

THE Public he sought out the Ministry of Health who stated that, after March 19, “with the declaration of community transmission, all respiratory syndrome will be seen as a possible case of Covid-19”. Since the date, the ministry has established as mandatory immediate notification within 24 hours of suspected cases of coronavirus, including from mild symptoms, which are diagnosed as flu-like syndrome clinically, that is, without the need for laboratory examination. This applies to the public or private network, which must inform the data by telephone or through the systems that the ministry provides.

Government coronavirus platform goes down

The Federal Government’s erratic stance in relation to the disclosure of the numbers goes beyond the notification protocol. On March 19, Minister Luiz Henrique Mandetta announced another change: the ministry’s IVIS platform – which gathered and published national and state data on deaths, confirmed, suspected and discarded cases of the disease – would be down for a week. According to Mandetta, the reason was high traffic. But to this day, the platform still doesn’t work.

The system had received criticism for being outdated in relation to data released by state departments, with updates that took up to 24 hours. In February, the data was updated by the ministry at noon. In March, the government started to disclose only in the late afternoon. Now, with the platform down, cases reported by state departments and city halls at night are released only the next day.

Researchers disagree on disclosure of data

The transparency of the Ministry of Health has been criticized by researchers who try to monitor and account for data released by the government.

This Wednesday, the 25th, the Federal Public Defender’s Office recommended that the government increase the transparency of data on the coronavirus. The agency asked the portfolio to start disclosing, within five working days, data on the profile of patients by municipality, number of tests, equipment and ICU beds contracted.

One of the criticisms, made by Fernanda Campagnucci, executive director of Open Knowledge Brasil, is that the ministry does not disclose disaggregated data, for example, as the number of cases per city, in addition to not publicly documenting the data collection methodology.

“Countries that have fought more transparently have been more successful. Of course, there is no need to divulge people’s names, nor do we defend it, but we need more details to know how to better deal with the disease. Reporters have been struggling. There are initiatives by civil society to compile the cases, but there is a limit, because we can only compile what is disclosed ”, he comments.

In addition, the Federal Government announced the decision to no longer inform the population of the number of suspected cases.

Initially, the Ministry even officially confirmed the suspicions reported by city halls, before reporting them in the system. On the 17th, the government changed the guideline and allowed states to report data directly to the system. The data has not been published since the 20th.

The decision is criticized by Professor Luiz Gustavo Bentim Góes, from the scientific platform Pasteur-USP, in partnership with the University of São Paulo and the Pasteur Institute. “I believe that the government is working with the real possibility of a lack of diagnostic inputs. I do not believe it is ideal because we will no longer have an idea of ​​the potential of infected people or the network of contacts of those infected ”, he evaluates.

As for the professor of the Department of Infectious and Parasitic Diseases at the Medical School of USP, Marcos Boulos, the government’s stance of not disclosing suspects is correct. “It is an appropriate decision for the moment that we are going through because it will increase even [a quantidade de casos suspeitos e confirmados]. Disclosure does not help ”, he ponders.

It is similar to the evaluation of Pedro Amaral, professor at the Center for Development and Regional Planning (Cedeplar) at the Federal University of Minas Gerais (UFMG): “it makes sense because there is no way to control suspected cases. Confirmed cases, deaths and recovered are the three variables that we see most often in international databases ”, he comments.

On March 17, the Ministry of Health announced that it would buy another 40,000 tests by the end of April. On the 24th, he said he would distribute 22.9 million

Some departments continue to report suspicious cases; others, no

The Ministry’s decision was replicated by the São Paulo Department of Health, the state with the highest absolute number of confirmed cases and deaths by Covid-19. The portfolio advisory informed the Public Agency who would also fail to report suspicious cases. The Municipal Health Secretariat reported that suspicious cases are being reported in the daily bulletins.

The Rio de Janeiro Department of Health reported that it maintains disclosure of suspected cases. Minas Gerais also maintains disclosure. The Health Secretariat of Bahia said it will notify cases under investigation to the Ministry, but on the state government website there are only confirmed cases. Those in Rio Grande do Sul and Santa Catarina said they will keep publishing suspicious cases. The Federal District also reports cases under investigation in its bulletins. The Pernambuco secretariat did not respond to the report.

According to the estimate of the president of Albert Einstein Hospital, doctor Sidney Klajner, for each notified case of Covid-19, there are at least 15 that are not being diagnosed.

Controversy in the number of tests: from 32 thousand to 22 million

Another fact that has changed radically from one day to the next is the amount of tests to be performed. On March 17, the Ministry of Health announced that it had purchased 30,000 test kits from Bio-Manguinhos / Fiocruz and planned to purchase another 40,000 by the end of April. Two days later, at a press conference, the Ministry said it had made 17,000, and that it would make another 10,000 more by the end of the week. The Ministry’s advisors even informed the magazine Piauí that 46 thousand tests had already been carried out by March 18.

THE Public Agency, the press office said that by March 19, 17,900 tests had been distributed to the 27 Central Public Health Laboratories (LACENs) and national reference laboratories. According to the folder, the government had purchased 150,000 tests from Bio-Manguinhos / Fiocruz. At the time, the consultancy informed that planning was to purchase approximately 2.5 million tests from Bio-Manguinhos / Fiocruz and another 10 million, without informing the origin or estimated date.

On March 24, the Ministry of Health almost doubled the figure: now, it is claimed that 22.9 million tests will be distributed to diagnose Covid-19 in Brazil. According to the folder, up to that date 32,500 had already been distributed on the public network.

The recommendation of the World Health Organization (WHO) is that countries with the Covid-19 epidemic test as many people as possible. “The central message is: test, test and test. You cannot stop this pandemic if you do not know who is infected, ”said WHO Director-General Tedros Adhanom Ghebreyesus.

The speech was answered by the executive secretary of the Ministry of Health, João Gabbardo. “We will maintain our position, [que é] test in places where there is a community transmission of serious cases and [de pessoas] hospitalized. I am very surprised that the WHO recommends this way since the inputs are insufficient to test everyone, ”he said.

The stance is supported by specialists such as Pedro Amaral, from the Federal University of Minas Gerais (UFMG). “The serious cases should be prioritized. For others, the policy of self-isolation must be very convincing. What we should convince the population: if you have any symptoms, even if they are mild, if you think you may have a coronavirus, you have to assume that you are. If you just show up at the hospital or health center to get tested for mild symptoms, you put everyone else at risk at risk, ”he says.

But currently, in contradiction to previous statements, the Ministry is also considering testing cases of suspected Covid-19 with mild symptoms. According to a note released on the 24th, “a new protocol is being defined to test the lightest cases in health posts or mobile units”. The new practice could be used in cities with more than 500 thousand inhabitants.

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