Brazil COVID-19: 'Humanitarian Crisis' With More Than 3000 Deaths A Day


NPR 15 April, 2021 - 06:32pm 236 views

Health officials in Brazil say many hospitals are running dangerously short of sedatives and other crucial medications used for treating gravely ill COVID-19 patients.

They say some health services have already exhausted stocks of certain drugs, while others expect to do so within the next few days unless they receive fresh supplies.

The warning comes amid intense international concern over the spiraling pandemic in Brazil, where the average daily death toll has risen above 3,000, the highest in the world. To date, 365,444 people in the country have died of COVID-19, according to Brazil's health ministry.

Brazil's health crisis is being described as a "humanitarian catastrophe" by the international medical aid agency Doctors Without Borders (known by its French acronym, MSF), which has teams in parts of the country.

The "Brazilian authorities' ... refusal to adopt evidence-based public health measures has sent far too many to an early grave," MSF's international president Dr. Christos Christou said in a statement on Wednesday.

He said this has put Brazil in "a permanent state of mourning" and has caused "the near collapse of Brazil's health system."

The alarm over the lack of medicines is being raised, in particular, by the country's richest and most populous state, São Paulo, which has so far registered almost one in four of Brazil's total COVID-19 deaths.

São Paulo's state government says its health services are facing "very serious" shortages, notably of muscle relaxants and sedatives needed for patients on respirators in intensive care units.

In a letter sent Tuesday to Brazil's Health Ministry, the state issued an urgent appeal for fresh supplies and accused the ministry of ignoring nine recent requests.

The scale of the problem has been underscored by a survey conducted by an organization representing local health officials: This found that more than two thirds of the 3,126 municipal health services in São Paulo were completely out of muscle relaxants, while 961 had no sedatives.

Front-line medical staff are reportedly turning to less effective alternative drugs, yet there have also been Brazilian media accounts of patients being tied by their arms to their beds to prevent them reacting violently to intubation when they wake up.

One of the country's leading news organizations, Folha de S. Paulo, recently published photographs and video of patients on respirators with their arms tied to the sides of their beds in a hospital in the northwestern city of Porto Velho.

Medicine shortages are adding to the already intense pressure on the country's intensive care units, where often exhausted and depleted staff are struggling to cope with a second wave of the pandemic, propelled by new variants of the virus. In parts of the country, patients have died while waiting for ICU beds to become available, according to medical staff and victims' families.

Overall occupancy rates for ICU beds have dropped slightly recently but remain critical in most of Brazil, according to a bulletin issued Wednesday by Fiocruz, a national health research institution. It said 16 of Brazil's 26 states have ICU bed occupancy levels of 90% or above. In São Paulo, it was 86%.

Brazil's Health Ministry has reportedly had significant problems buying anything close to sufficient quantities of medicines to cope with the surge in intensive care patients. It said Thursday that a large consignment of medicines donated by businesses was to be flown into the country in the coming hours, including sedatives, muscle relaxants and other drugs.

São Paulo has long been highly critical of the response to the pandemic by President Jair Bolsonaro, who has had four health ministers since the first coronavirus case was reported in Brazil early last year.

The state is far from alone.

Bolsonaro is facing ferocious criticism at home and abroad for scoffing at the threat of the virus, undermining social distancing and isolation measures, advocating unproven remedies, bungling the national vaccination program and discouraging people from being vaccinated.

The far-right president's position has become still more uncomfortable following a decision by Brazil's Supreme Court on Wednesday to give the go-ahead to a Senate inquiry into his government's handling of the pandemic.

Bolsonaro has argued throughout that lockdowns and other pandemic restrictions inflict more economic and social misery than the virus itself. He fell back on that defense again Wednesday, with a vaguely worded warning that there will soon be "enormous crises" in Brazil.

"I am not threatening anyone, but Brazil is at the limit," he told supporters, adding mysteriously: "I am waiting for the people to give a signal because the hunger, misery and unemployment is there."

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“A threat to the world”: Brazil’s Covid-19 tragedy

New Statesman 31 December, 1969 - 06:00pm

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Brazil's COVID-19 response cost thousands of lives, says humanitarian group

CNA 16 April, 2021 - 04:14am

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Brazil's COVID-19 outbreak is the deadliest in the world after the United States and is currently leading in average daily mortalities. Last week more than a quarter of all global deaths were in Brazil.

A brutal second wave has hospitals saying they are running short of crucial drugs for intubating patients and most Brazilian states report that intensive care units are at or near capacity.

Right-wing President Jair Bolsonaro has opposed lockdowns, and has held large events in which he often does not wear a mask. He has only recently embraced vaccines as a possible solution.

"More than one year into the COVID-19 pandemic, the failed response in Brazil has caused a humanitarian catastrophe," said Christos Christou, a medical doctor and president of MSF, sometimes called Doctors Without Borders in English.

"Each week there is a grim new record of deaths and infections - the hospitals are overflowing and yet there is still no coordinated centralised response," Christou said in a briefing with reporters, adding the situation was expected to become even worse in the weeks ahead.

Bolsonaro has openly fought against state and local governments seeking to institute lockdowns, saying Brazilians need to get on with normal life and that job losses are more dangerous than the virus.

MSF Director-General Meinie Nicolai said the surge in cases cannot be blamed only on the contagious Brazilian COVID-19 variant, known as P1.

"The P1 variant is certainly a problem, but this doesn't explain the situation in Brazil," she said.

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COVID-19: Patients 'tied to beds and intubated without sedatives' as coronavirus crisis worsens in Brazil

Sky News 15 April, 2021 - 11:46pm

A doctor at the Albert Schweitzer municipal hospital in Rio de Janeiro said that doctors are resorting to tying patients to their beds in order to ventilate them.

Medics have also been diluting sedative medication to make it last longer and using neuromuscular blockers so patients can't resist, they said on the condition of anonymity.

Brazil has become the epicentre of the coronavirus pandemic, with daily deaths averaging around 3,000 a day and oxygen supplies for intensive care patients at breaking point.

On Thursday, the country reported 3,560 COVID-19 fatalities and 73,174 new cases.

Describing the situation at the hospital in Rio, the doctor said: "You relax the muscles and do the procedure easily, but we don't have sedation. Some try to talk, resist. They're conscious."

Brazilian newspaper O Globo reported on Thursday that other hospitals in the Rio metropolitan region were experiencing similar issues, with patients' relatives desperately calling other medical facilities in search of sedatives.

A spokesperson for Rio de Janeiro's health secretariat said "occasional" shortages at the Albert Schweitzer hospital are being caused by difficulties obtaining supplies on the global market.

They said that "substitutions are made so that there is no damage to the assistance provided" to patients.

The spokesperson did not comment on claims patients are being tied to their beds.

In Sao Paulo, state health secretary Jean Carlo Gorinchteyn said at a news briefing on Wednesday that 640 hospitals there were on the verge of collapse.

He said medicine shortages are possible within days and the need for medical supplies is urgent.

"This is not a necessity for Sao Paulo; it is a necessity for the whole country," he told reporters.

Nine requests for intubation medication have been made by his health ministry over the past 40 days, he added.

The last delivery of supplies only covered 6% of what was needed that month in Sao Paulo, state officials said.

Federal health minister Marcelo Queiroga said on Wednesday that a shipment of sedatives was due to arrive within the next 10 days following a deal with the Pan American Health Organisation.

An order of 3.4 million doses of intubation drugs - enough to treat 500 patients for six weeks - has also been ordered from private sector firms, officials added.

The first batch of 2.3 million doses was due to arrive in Brazil from China on Thursday.

Brazil: Failed COVID-19 Response Drives Humanitarian Catastrophe

Doctors Without Borders / MSF-USA 15 April, 2021 - 10:48pm

Covid-19: Brazil's health system faces collapse as coronavirus cases surge 15 April, 2021 - 10:45pm

More than a year into the pandemic and Brazil is struggling amid a huge influx of cases, largely driven by a more transmissible variant of the virus and lack of restrictive measures to curb the spread of Covid-19.

The strain on the country’s hospital system is immense, with intensive care beds either full or close to capacity in many states across the country. Some areas have also faced oxygen and medical supply shortages at times throughout the pandemic.

More than 13.6 million people in Brazil have been infected with the virus. Brazil also has the second-highest Covid death toll in the world with 361,000 deaths, data shows.

As Brazil buckles under the weight of the pandemic, many other countries are seeing the opposite as their vaccine rollouts prove effective, and lockdowns are eased.

The worsening situation in Brazil can be attributed to a number of things. The more transmissible Brazil variant is a key driver behind the surge in infections.

On April 7, Brazil reported more than 4000 deaths in a 24-hour period for the first time since the pandemic began. Its daily case numbers have also rocketed to new levels. That same day the high death toll was recorded, an additional 87,000 cases were reported in a 24-hour period.

March 2021 was the deadliest month in Brazil since the pandemic began. About 66,570 people died from the virus in March, which was more than double the previous monthly record.

An estimate from the University of Washington has predicted that Brazil could see a total of more than 500,000 deaths by July.

Dr Miguel Nicolelis, a Brazilian professor of neuroscience at Duke University, told the BBC that the country was in a nationwide hospital collapse right now.

He called it the “largest human tragedy in Brazilian history”.

Studies have shown the Brazil variant – also called P1 – is up to 2.5 times more contagious than the original coronavirus, and is more resistant to antibodies, Reuters reported.

Scientists studying the virus have shared concerns that it's mutating in ways that could make it better placed to evade antibodies.

Research conducted by the public health institute Fiocruz found mutations in the spike region of the virus that is used to enter and infect cells. It's these changes that could possibly make the virus more resistant to vaccines, according to experts.

Reuters reported Felipe Naveca, one of the study’s authors, saying they believed it was “another escape mechanism” the virus was creating to evade the response of antibodies.

These changes also appeared to have similarities to the mutations seen in the South African variant.

Concern is also growing about the rising number of young people who are critically ill in hospital with the virus. Research suggests that more than half of the patients being treated in intensive care in March were under the age of 40, the BBC reported.

Brazil's worsening situation can also be linked to the lack of a national lockdown or mandated restrictive measures to help curb virus spread.

President Jair Bolsonaro has consistently downplayed the threat of virus, and has adamantly opposed lockdown measures, arguing that restrictions would damage the economy. His stance has become a highly contentious issue and has led to tensions flaring among state governors.

Many states have instead imposed their own restrictions within their jurisdictions to try and stop outbreaks. In São Paulo, which is the country’s largest state, measures were put in place around schools, non-essential businesses, contactless delivery, as well as a night-time curfew.

According to the BBC, Bolsonaro criticised state governors and mayors who had imposed lockdowns and described them as “tyrants”.

In March, São Paulo governor João Doria said in an interview that millions of people were paying a high price for having an unprepared and “psychopathic” leader in charge of a nation.

“The situation is in a collapse right now in Brazil,” he said.

On Thursday (NZ time), Al-Jazeera reported that the Brazilian Senate had launched an inquiry into Bolsonaro’s handling of the Covid-19 pandemic.

While a lot of the focus in Brazil has been on Covid-19 and the country’s vaccine rollout, further social issues are having a significant effect on its citizens. Hunger and food insecurity is another crisis unfolding throughout many states.

A study found that nearly 117 million people – more than half the population – are living with some level of food insecurity, an issue linked to the high levels of unemployment and worsened by the pandemic.

Brazil Supreme Court greenlights probe of president’s COVID-19 response

Jamaica Gleaner 15 April, 2021 - 10:45pm

The full court started weighing the political future of former President Luiz Inácio Lula da Silva, a potentially powerful rival to Bolsonaro.

One of the judges earlier ruled he had been unjustly convicted in a corruption case, a decision that effectively reinstated his right to run for the presidency again.

The court voted 10-1 Wednesday to uphold Justice Luís Roberto Barroso’s order that the Senate should start an investigation into Bolsonaro’s management of the crisis because a required number of senators had sponsored such a call.

The Senate president had tried to delay the probe, citing pandemic health restrictions.

Critics, including those calling for or leading the investigation, say Bolsonaro has bungled Brazil’s response to the pandemic by resisting health-driven restrictions on activity, failing to marshal resources for vaccines and stimulating the use of drugs that don’t work against the virus.

Bolsonaro and his allies say he’s being unfairly blamed for Brazil’s surge in COVID-19 deaths, a toll that trails only that of the United States. Brazil’s seven-day average death toll hit a new record on Monday.

The Senate probe “is an attempted political coup against the president,” said Senator Márcio Bittar, a Bolsonaro ally, in a Twitter post on Wednesday.

He’s also cried foul as the Supreme Court has issued rulings that go against him, prompting outrage from his conservative base that claims the court is overstepping constitutional bounds.

Carlos Melo, a political science professor at Insper University in Sao Paulo, said the investigation poses risks for Bolsonaro

“The desperation with the pandemic tends to increase as deaths continue to grow. Economic issues are also far from being solved. And at the same time his administration is fighting with its base in congress over next year’s budget,” Melo said.

“The surroundings of the inquiry don’t favour Bolsonaro.”

The top court last year knocked down Bolsonaro’s attempt to overturn local restrictions meant to slow the advance of COVID-19, ruling that governors and mayors are free to determine their own COVID-19 protocols.

On Tuesday, a justice also suspended parts of four Bolsonaro decrees aimed at loosening gun controls.

The Brazilian leader, who has long downplayed the risks of the disease and still denounces lockdowns, has argued lawmakers should also investigate the actions of governors and mayors to whom the federal government provided funds.

He and his allies scored a partial win at the Senate on Tuesday when the use of such funds was made part of the investigation.

Bolsonaro on Wednesday complained that Justice Barroso’s April 8 ruling that the Senate probe should go forward had created “an atmosphere of animosity.”

“That justice is interfering with the Senate in order to go after me,” he said.

More than the required 27 senators had signed a request for the investigation, but the president of the Senate, Rodrigo Pacheco, had refrained from greenlighting the probe, citing health concerns amid the pandemic.

The court on Wednesday also began assessing the decision by Justice Luiz Edson Fachin on March 8 to annul da Silva’s two corruption convictions, which were related to the massive “Car Wash” scandal focused on the state oil company.

The hearing will continue Thursday after the justices agreed by 9 votes to 2 that the case should indeed be heard in a full court session.

Early polling for the 2022 election shows the 75-year-old leftist, who governed Brazil between 2003 and 2010, neck-and-neck with Bolsonaro.

Da Silva was leading polls in 2018 when he was knocked out of the race by a conviction involving a beachfront apartment that prosecutors alleged — and he denied — belonged to him.

Bolsonaro won the election and the judge who oversaw da Silva’s conviction, Sergio Moro, became his justice minister.

One of the top court’s two panels of justices already ruled Moro was biased against da Silva.

Coronavirus: Brazilian government blamed for 'humanitarian catastrophe' as COVID-19 death toll rises

Newshub 15 April, 2021 - 10:45pm

Related video: Ashley Bloomfield leads panel on COVID-19 vaccine rollout. Credits: Video - Newshub; Image - Reuters

The Brazilian government's "failed response" to the pandemic led to thousands of otherwise avoidable deaths and created a humanitarian catastrophe that is still playing out, aid group Médecins Sans Frontières said on Thursday.

Brazil's COVID-19 outbreak is the deadliest in the world after the United States and is currently leading in average daily mortalities. Last week more than a quarter of all global deaths were in Brazil.

A brutal second wave has hospitals saying they are running short of crucial drugs for intubating patients and most Brazilian states report that intensive care units are at or near capacity.

Right-wing President Jair Bolsonaro has opposed lockdowns, and has held large events in which he often does not wear a mask. He has only recently embraced vaccines as a possible solution.

"Each week there is a grim new record of deaths and infections - the hospitals are overflowing and yet there is still no coordinated centralized response," Christou said in a briefing with reporters, adding the situation was expected to become even worse in the weeks ahead.

Bolsonaro has openly fought against state and local governments seeking to institute lockdowns, saying Brazilians need to get on with normal life and that job losses are more dangerous than the virus.

MSF director-general Meinie Nicolai said the surge in cases cannot be blamed only on the contagious Brazilian COVID-19 variant, known as P.1.

"The P.1 variant is certainly a problem, but this doesn't explain the situation in Brazil," she said. 

Spatiotemporal pattern of COVID-19 spread in Brazil

Science 15 April, 2021 - 10:45pm

Brazil has been severely hit by COVID-19, with rapid spatial spread of both cases and deaths. We use daily data on reported cases and deaths to understand, measure, and compare the spatiotemporal pattern of the spread across municipalities. Indicators of clustering, trajectories, speed, and intensity of the movement of COVID-19 to interior areas, combined with indices of policy measures show that while no single narrative explains the diversity in the spread, an overall failure of implementing prompt, coordinated, and equitable responses in a context of stark local inequalities fueled disease spread. This resulted in high and unequal infection and mortality burdens. With a current surge in cases and deaths and several variants of concern in circulation, failure to mitigate the spread could further aggravate the burden.

In Brazil, the federal response has been a dangerous combination of inaction and wrongdoing, including the promotion of chloroquine as treatment despite a lack of evidence (5, 6). Without a coordinated national strategy, local responses varied in form, intensity, duration, and start and end times, to some extent associated with political alignments (7, 8). The country has seen very high attack rates (9) and disproportionally higher burden among the most vulnerable (10, 11), illuminating local inequalities (12). Following multiple introductions of SARS-CoV-2, Brazil had an initial epidemic phase (February 15 to March 18, 2020) with restricted circulation (13), preceded by undetected virus circulation (14). While the initial spread was determined by existing socioeconomic inequalities, the lack of a coordinated, effective, and equitable response likely fueled the widespread spatial propagation of SARS-CoV-2 (12). The goal of this study was to understand, measure, and compare the pattern of spread of COVID-19 cases and deaths in Brazil at fine spatial and temporal scales. We use daily data from State Health Offices covering the period from epidemiological week 9 (February 23-29) to week 41 (October 4-10).

In all states, it took less than a month between the first case and the first death; only 11 days in Amazonas and 21 in São Paulo (table S1). Epidemiological curves for Brazil (fig. S1) hide distinct patterns of initial reporting, propagation, and containment of SARS-CoV-2 across administrative units. As states and cities imposed and relaxed restrictive measures at different times, population mobility facilitated the circulation of the virus and acted as a trigger of disease spread (15). Figure 1, A and B, show that cumulative cases and deaths, respectively, per 100,000 people were not uniformly distributed across municipalities. We used the space-time scan statistic (16) to identify areas that significantly recorded a high number of cases (Fig. 1C and table S2) or deaths (Fig. 1D and table S3) over a defined period.

Cumulative number of COVID-19 cases (A) and deaths (B) per 100,000 people by municipality. Dark lines on the maps show state boundaries. State acronyms by region, North: AC=Acre, AP=Amapá, AM=Amazonas, PA=Pará, RO=Rondônia, RR=Roraima, and TO=Tocantins; Northeast: AL=Alagoas, BA=Bahia, CE=Ceará, MA=Maranhão, PB=Paraíba, PE=Pernambuco, PI=Piauí, RN=Rio Grande do Norte, and SE=Sergipe; Center-West: DF=Distrito Federal, GO=Goiás, MT=Mato Grosso, and MS=Mato Grosso do Sul; Southeast: ES=Espírito Santo; MG=Minas Gerais; RJ=Rio de Janeiro; and SP=São Paulo; South: PR=Paraná; RS=Rio Grande do Sul; and SC=Santa Catarina. Spatio-temporal clustering of cases (C) and deaths (D) across Brazilian municipalities. Color and number codes in the clusters and the table on the left are the same, and the table indicates the interval during which each cluster was statistically significant. The color gradient (dark red to dark blue) indicates the temporal change based on the initial date of the cluster, and the cluster number indicates the rank of the relative risk for each cluster (tables S2 and S3). Clusters were assessed with the space-time scan statistic (see supplementary materials).

Deaths clustered about a month before cases. This likely reflects problems in surveillance, data reporting, and low testing capacity. The first significant cluster of COVID-19 deaths started on May 18 (Fig. 1D, #5), centered around Recife (capital of Pernambuco). Five other clusters of deaths occurred before the first cluster of cases was observed on June 16 (Fig. 1C, #7). Among those are clusters around Fortaleza and Rio de Janeiro (capital cities of Ceará and Rio de Janeiro, respectively), and in a large area including Amazonas, Pará, and Amapá, states that have a disproportionally lower hospital capacity. Amazonas (whose capital is Manaus) has the highest mortality per 100,000 people in the country, more than double the rate for Brazil. By October, about 76% of its population was estimated to have been infected (9, 17). Except for one cluster in August (Fig. 1D, #1), the duration of death clusters did not reduce over time, ranging from 10 to 13 days. This is different than what was observed in South Korea, where successful containment reduced the duration and the geographic extent of clusters over time (18). A similar pattern was observed for COVID-19 cases (Fig. 1C). In the center and southern areas, clusters occurred later (August and September), corroborating a regional pattern of propagation of SARS-CoV-2 (19).

To understand and compare how COVID-19 cases and deaths spread across Brazil we calculated the geographic center of the epidemic. Trajectories of the center by epidemiological week show that after the introduction in São Paulo, both cases (Fig. 2A and movie S1) and deaths (Fig. 2B and movie S2) progressively moved north until week 20 (starting May 10), when the epidemic started to recede in Amazonas and Ceará, but gained force in Rio de Janeiro and São Paulo. Comparing trajectories in each state (fig. S2) we calculated a ratio of the distance the center moved each week to the distance between the capital city and the most distant municipality (tables S4 and S5). In eight states the median weekly ratio for deaths was larger than cases (Fig. 2C), suggesting a faster movement of the focus of deaths.

COVID-19 case- (A) and death-weighted (B) geographic centers by epidemiological week. Thick lines show the geographic center for Brazil, thin lines show the trajectory of the center in each state, and the black dot indicates the state capital city (see supplementary materials). The first case in each state was recorded in the capital city, except for Rio de Janeiro, Rondônia, Bahia, Minas Gerais, and Rio Grande do Sul, and thus the trajectory of the center starts in the interior. This was more common for deaths (14 states did not report the first death in the capital: Rio de Janeiro, Amazonas, Pará, Piauí, Rio Grande do Norte, Paraíba, Espírito Santo, Paraná, Santa Catarina, Mato Grosso do Sul, Mato Grosso, and Goiás). Figure S2 shows detailed maps for each state. (C) Scatterplot of the median distance that the geographical center of cases (X-axis) and deaths (Y-axis) shifted weekly in each state (measured as the ratio of the distance that the geographical center of cases shifted weekly in each state to the distance between the capital city and the furthest municipality in the state). (D) Scatterplot of the number of days that it took for a state to reach 50 COVID-19 cases (X-axis) after the first case was reported and 50 deaths after the first COVID-19 confirmed death (Y-axis). (E) Scatterplot of the standardized number of cases per 100,000 people (X-axis) and deaths per 100,000 people (Y-axis) by state. The 45-degree lines in (C), (D), and (E) describe equal values for variables in the scatterplot.

On average, it took 17.3 and 32.3 days to reach 50 cases and deaths, respectively. However, in four states deaths accumulated to a 50-count first (Fig. 2D), and in Amazonas, Ceará, and Rio de Janeiro the difference between the time it took for cases and deaths to reach a 50-count was 6, 1, and 3 days, respectively (table S1). This short interval suggests undetected (and thus unmitigated) introduction and propagation of the virus for some time. This was confirmed in Ceará (20) where a retrospective epidemiological investigation revealed that the virus was already circulating in January. Also, if the initial cases occurred in high-income areas, it is possible that consultations in private practices were not reported into national systems of the Ministry of Health (20) and remained silent to the surveillance system. In addition, testing capacity in Brazil was limited, and the first diagnostic RT-PCR test kits started to be produced in the country only in March. Although efforts of retrospective investigation were not scaled-up in the country, a comparison of standardized rates of cases and deaths per 100,000 people (Fig. 2E) show that in 11 states the death toll was larger than incidence, including Amazonas, Ceará, and Rio de Janeiro.

To quantitatively measure the intensity of the spread of COVID-19 cases and deaths over time we used the locational Hoover Index (HI) (21, 22). Values closer to 100 indicate concentration in few municipalities, while those close to zero suggest more homogeneous spreading. If containment measures were effective, we would expect the index to decline slowly, remaining relatively high over time. Also, if measures were effective to avoid a collapse of the hospital system, we would expect a higher index for deaths, compared to cases. Figure 3A shows the HI for Brazil, and a clear trend toward extensive spread for both cases and deaths until about week 30 (July 19-25). The pattern, however, varied across states. In the first week with reported events, Amazonas, Roraima, and Amapá had HI below 50 for both cases and deaths. This suggests either undetected circulation of the virus before initial reports (and therefore when reporting started there was already a large fraction of the population that had been infected), or fast and multiple introductions of the virus immediately followed by rapid spatial propagation (tables S6 and S7).

(A) Locational Hoover index (see supplementary materials) for cases (blue line) and deaths (red line) by epidemiological week. The area around each curve indicates the maximum and minimum index observed across states. (B) States and weeks when the locational Hoover index for cases was bigger than the index for deaths, indicating a faster spread of deaths. Bivariate choropleth map of the locational Hoover Index for cases and deaths in epidemiological week 14 (March 29-April 4) (C) and epidemiological week 41 (October 4-10) (D). Since SARS-CoV-2 reached states at different epidemiological weeks, (C) shows data from week 12 for RJ and SP; week 13 for AM, PI, RN, PE, PR, SC, RS, and GO; week 15 for AC; and week 16 for TO. Similarly, (D) shows data for week 33 for MT, and week 39 for ES.

Overall, a higher percentage of COVID-19 cases and deaths were observed outside capital cities in weeks 20 (May 10-16) and 22 (May 24-30), respectively (Fig. 4A), with varied patterns across states (table S1). Rio Grande do Sul, Santa Catarina, and Paraná, all in the South region, had earlier and concurrent shifts in cases and deaths (in March), and this was the last region to show a major surge in COVID-19. In Rio de Janeiro and Amazonas, the shift in deaths was much later than cases, 10 and 8 weeks, respectively.

To better capture policies adopted at the national and local levels and their associations with movement of COVID-19 toward the interior of states, we used three indicators, the Stringency Index (STR), the Containment Index (CTN – all policies in STR except for the use of masks), and the Social Distancing Index (SD – based on mobile devices). Because states introduced measures at different times with various duration, national indices hide much variation (Fig. 4B). We observed expected correlations (table S8) between policy indicators and HI for cases and deaths (Fig. 4C), but a positive correlation between HI and the distance by which the national geographical center of cases shifted weekly. This suggests a pattern of progressive concentration of cases and deaths in few but widespread areas. Considering each state (fig. S3), Amapá showed a negative correlation between STR and HI for deaths, indicating that policy measures failed to prevent the movement of deaths (this was the only state where deaths moved to the interior faster than cases by week 41; Fig. 3D).

We used hierarchical clustering analysis (25) in an attempt to group states into categories based on measures that captured the overall COVID-19 mortality burden, intensity of transmission, speed of COVID-19 deaths toward the interior of states, and adoption of distancing measures (Fig. 4D). Categories 3 and 4 include the top 10 states in deaths/100,000 people, as well as those that observed the first spatiotemporal clustering of deaths, and fast reporting and movement of deaths. Category 2 has the highest number of contiguous states and the lowest death burden by week 41. However, all categories combine states with different levels of inequality and distinct political alignment.

In summary, our results highlight the fast spread of both cases and deaths of COVID-19 in Brazil, with distinct patterns and burden by state. They demonstrate that no single narrative explains the propagation of the virus across states in Brazil. Instead, layers of complex scenarios interweave, resulting in varied and concurrent COVID-19 epidemics across the country. First, Brazil is large and unequal, with disparities in quantity and quality of health resources (e.g., hospital beds, physicians), and income (e.g., an emergency cash transfer program started only in June 2020, and by November 41% of the households were receiving it). Second, a dense urban network that connects and influences municipalities through transportation, services, and business (26) was not fully interrupted during peaks in cases or deaths. Third, political alignment between governors and the president had a role in the timing and intensity of distancing measures (7), and polarization politicized the pandemic with consequences to adherence to control actions (27). Fourth, SARS-CoV-2 was circulating undetected in Brazil for more than a month (20), a result of the lack of well-structured genomic surveillance (28). Fifth, cities imposed and relaxed measures at different moments, based on distinct criteria, facilitating propagation (15). Our findings speak to those issues, but also show that some states were resilient, such as Ceará, while others that comparatively had more resources failed to contain the propagation of COVID-19, such as Rio de Janeiro.

In such a scenario, prompt and equitable responses, coordinated at the federal level, are imperative to avoid fast virus propagation and disparities in outcomes (12). Yet, the COVID-19 response in Brazil was neither prompt nor equitable. It still isn’t. Brazil is currently facing the worst moment of the pandemic, with a record number of cases and deaths, and near collapse of the hospital system. Vaccination has started but at a slow pace due to limited availability of doses. A new variant of concern (VOC), which emerged in Manaus (P1) in December, is estimated to be 1.4-2.2 times more transmissible, and able to evade immunity from previous non-P1 infection (29). That variant is spreading across the country. It became the most prevalent in circulation in six of eight states where investigations were performed (30). As of March 11, 2021, Brazil already reported 40% of the total COVID-19 deaths that occurred in 2020. In January 2021, Manaus witnessed a spike in cases and hospitalizations, a collapse of the hospital system, including a shortage of oxygen for patients (31). The death toll is unbearable, as Manaus already recorded 39.8% more COVID-19 deaths in 2021 than in 2020. Without immediate action, this could be a preview of what is yet to happen in other localities in Brazil. Without immediate containment, coordinated epidemiological and genomic surveillance measures, and an effort to vaccinate the largest number of people in the shortest possible time, the propagation of P1 will likely resemble the patterns here demonstrated, leading to unimaginable loss of lives. Failure to avoid this new round of propagation will facilitate the emergence of new VOCs, isolate Brazil as a threat to global health security, and lead to a completely avoidable humanitarian crisis.

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By Marcia C. Castro, Sun Kim, Lorena Barberia, Ana Freitas Ribeiro, Susie Gurzenda, Karina Braga Ribeiro, Erin Abbott, Jeffrey Blossom, Beatriz Rache, Burton H. Singer

By Marcia C. Castro, Sun Kim, Lorena Barberia, Ana Freitas Ribeiro, Susie Gurzenda, Karina Braga Ribeiro, Erin Abbott, Jeffrey Blossom, Beatriz Rache, Burton H. Singer

India, Brazil grapple with massive COVID-19 surges

CIDRAP 15 April, 2021 - 10:45pm

India's cases topped 200,000 today with some of its major cities announcing new restrictions, as Brazil's outbreak continues to overwhelm many of the country's hospitals, a situation Doctors Without Borders said today is a humanitarian catastrophe.

The World Health Organization (WHO) has said different parts of the world are facing different COVID situations, with some parts of Europe see promising signs of declining cases.

Surges in India and Brazil are fueling a steady rise in global cases, given that they are among the world's most populous countries: India the second, and Brazil as the sixth.

India reported a record single-day high of 200,739 cases, and the burden of cases has pushed the country's oxygen production to full capacity over the last 2 days, with the health ministry announcing that it now needs to import 50,000 metric tons, according to Reuters. Media reports describe patients waiting for hospital beds to open up and even patients on oxygen being placed two to a bed.

Mumbai, India's financial capital, began a lockdown last night, and officials today announced a weekend curfew for Delhi, the country's capital region, according to CNN.

The new wave of lockdowns is raising fears in India again of a mass exodus from cities, heightening the risk of people carrying the virus to more rural areas that aren't equipped to handle the virus, according to the New York Times.

Meanwhile in Brazil, Doctors Without Borders (MSF) today said the Brazilian government's failed response is fueling a humanitarian catastrophe, and it called on the country's leaders to muster the political will to respond to the threat, which it said is killing people by the thousands.

Christos Christou, MD, PhD, MSF's international president, said public health measures have become a political battlefield in Brazil, with science-based policies relegated to political opinions rather than measures to protect people and communities. "Brazilian authorities’ refusal to adopt evidence-based public health measures has sent far too many to an early grave," Christou said. "This has put Brazil in a permanent state of mourning and led to the near collapse of Brazil's health system."

MSF said last week, intensive care units (ICUs) were at capacity in 21 of 27 states, and hospitals across the country are struggling with shortages of oxygen for treatment and sedatives needed for intubation. It also said the country has a critical need for rapid antigen tests to quickly confirm infections in an effort to limit spread.

Pierre Van Heddegem, who coordinates MSF's emergency response in Brazil, said, "The devastation due to shortages and high demand for care that MSF teams first witnessed in the Amazonas region has become the reality across the majority of Brazil." He added that a lack of coordination between federal health officials and those in states and cities has led to life or death consequences, with patients dying from lack of healthcare access and medical staff exhausted and experiencing emotional trauma.

An overwhelming amount of misinformation is complicating Brazil's outbreak response, with masks, physical distancing, and other measures shunned or politicized and unproven treatment such as hydroxychloroquine and ivermectin touted by politicians and prescribed by doctors, MSF said.

In a related development, scientists from Brazil's Fiocruz Institute warned that the P1 SARS-CoV-2 variant, which is currently fueling the country's massive outbreak, is evolving in ways that would make it more able to evade antibodies, according to Reuters. Researchers said the changes are similar to the B1351 variant, first seen in South Africa, which has already been shown to evade some vaccines.

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