the case of Brazil Deep impact of COVID-19 in the healthcare of LatinAmerica: INFECTIOUS DISEASES

brazjinfectdis2020;24(2):93–95

w w w . e l s e v i e r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Editorial

Deep

impact

of

COVID-19

in

the

healthcare

of

Latin

America:

the

case

of

Brazil

Inlessthantwomonths,anemergingthreatentirelyand rad-icallychangedthelifeofthepopulationinLatinAmerica.1 FromFebruary25,2020,whentheSevereAcuteRespiratory SyndromeCoronavirus2(SARS-CoV-2),theetiologicalagent oftheCoronavirusDisease2019(COVID-19),wasfirstly con-firmedinBrazil,proceedingasanimportedcasefromItaly,up toApril23,2020,morethan124,000caseshavebeenreported intheLatinAmericaandCaribbeanregion.2_{Morethan97,000} oftheminSouthAmerica,andmorethan45,000justinBrazil.3 COVID-19endanger a broadspectrum of disease,going fromasymptomaticcasesthatmayrecoverwithnospecific interventions,uptocomplicatedsevere,life-threateningand evenfataldisease,thatmayleadtounknownnon-acute con-sequences,still to be better defined.1,2 _{In such a complex} clinicalscenario,theepidemiologicalsituationofBraziland mostcountries inLatin America beforeFebruary 25,2020, wasalreadyintricate,withoverlappingepidemicsofmultiple vector-bornediseases,includingespeciallydengueandyellow fever,butalso,stillstrugglingwithlong-termconsequences, andendemicity,of2014–2016epidemicsofchikungunyaand Zika.1,4

Sadly,also the lastyears’vaccine coverages in multiple countriesofLatinAmerica,butalsosomeareasofindividual nations,havesignificantlydecrease,allowingtheimminent menaceofimportedcasesandspreadingwithlocal transmis-sionofthisoncenotreportedolddiseases,suchasisespecially thecaseofmeasles,thatinfact,duetoforcedmigrationfrom VenezuelaarrivedespeciallytoRoraimaandAmazonastolead tothousandsofcasesintheregion.4

Ifthisisnotenough,thepoliticalscenarioisnotfriendly for evidence-based decisions. The high-rank stakeholders havenotbroadlyfollowedtherecommendationsoftheWorld Health Organization (WHO) before or after the arrival of COVID-19tothe newworld.Onceworld-recognizedforthe effortsinthefightagainstmajorinfectiousthreats,suchas HIV,tuberculosis,andmalaria, Brazilisgoingfacingnow a challengeinthecontroloftheseinfectiousdiseasesbutalso confrontingnowoneofthemajorepidemicsinthehistoryof thecountrywiththepandemicCOVID-19.1

Brazilnowhasmorethan1900recognizeddeathsdueto COVID-19,reachingevenmorethan3000newreportedcases perdayinApril.5 _{Asexpected,morethan halfofthecases} havebeenreportedintheSouthEastregion,whereSãoPaulo stateislocated,andwherethefirstcasearrivedfromMilan, Italy,lessthantwomonthsago.1_{Sofar,SãoPaulostatehas} reportedmorethan11,000cases,whichismorethanthe inci-denceinthewholeEcuador,Chile,orArgentina.Indeed,allthe regionsandallthestatesofBrazilhavebeensofaraffected. AllofthemreportedCOVID-19associateddeaths.Thecurrent nationalincidencerateis145casesper1,000,000inhabitants, butstatesarereachingmorethan400,andcapitalcities,such asFortaleza,withmorethan700.InSãoPaulocityis634.5

There isconcern about those cases notexplicitly diag-nosedallovertheregion,astheconfirmationofanexampleof COVID-19ismadewiththemoleculartestingreal-timereverse transcriptase-polymerasechainreaction(rRT-PCR).Currently, epidemiological datafrom Brazilclearly showthat thereis an unexpected increase in the number of hospitalizations duetosevereacuterespiratoryinfections(SARI)(Fig.1), espe-ciallytwoweeksafterthefirstcasediagnosedinSãoPaulo, coincidingwiththediseaseincubationperiod.Atthe11◦ epi-demiological weekof2020,thecumulativenumber ofSARI hospitalizationswas1.8timeshigherthanthesameweekof 2019,butat12◦wasalreadythreetimes.Lastweek(15◦),April 5–11,2020,therewasmorethan4.6timeshighernumberof hospitalizationsthaninthesameweekof2019(Fig.1).Muchof thatwouldbeduetoundiagnosedCOVID-19andexplainedin partduetotheprofileofinfectedpatients,asignificant propor-tionoccurringinolderpeople,withriskfactors.Infact,from thetotalnumberofdeathsconfirmed(1924),61.3%occurred inthose≥60yearsold.5

Quarantine,isolation,andphysicaldistancing,inthis con-text, are of utmost relevance.6 _{Work and study activities} shouldbecarriedoutvirtually.Still,manycommercial activi-tiesshouldbepartiallyrestricted.7_{Caseswithmildrespiratory} symptomsshouldstayathomeinrespiratoryisolationand be treatedwith hydration and paracetamol if needed. Vis-its to health centers should only be made when justified

94

Fig.1–HospitalizationsduetoSevereAcuteRespiratoryInfections(SARI),duringthefirst15epidemiologicalweeksof2019 and2020.(A)Newnumberperweek.(B)Cumulativeperweek.

bythe presenceof riskfactors (underlyingsevere disease) orwarningsigns (suchasbreathingdifficultiesorcognitive impairment).7 _{Older patients are especially susceptible to} complications,andthen,thispopulationshouldberestricted athome.However,toreducetransmission,peopleofallages

mustbecommittedtotheprevention,education,andhealth promotion.Thus,intheabsenceofvaccines(thatwilltakeat leastayear)orotherpreventivestrategies,reducingthe con-tactratewillbetheonlystrategytoslowtheprogressionofthis pandemic.7

brazj infect dis.2020;24(2):93–95

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Thesemeasuresandthepropersupportandadvicefrom scientificsocieties,suchastheBrazilianSocietyofInfectious Diseases,inadditiontotheinternationalorganizations,such as the Pan-American Health Organization (PAHO) and the WHO,adequatelyapplied,will helptoslowthe number of newcasesexpected, willhelp todecrease them.7 _Itis dif-ficulttopredict how long these preventivemeasuresmust bemaintained,butepidemiologicalevolutionshouldbe care-fullyand closelyassessedtoredefinestrategicintervention approaches. As has been indicated before, the earlier and morerigorouslytheyareincorporated,thefasterthe epidemi-ologicalconditionswillbereversed,andourregularroutines resumed.7

Funding

None.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1.Rodriguez-MoralesAJ,GallegoV,Escalera-AntezanaJP,etal. COVID-19inLatinAmerica:theimplicationsofthefirst confirmedcaseinBrazil.TravelMedInfectDis.2020:101613. 2.Rodriguez-MoralesAJ,Sánchez-DuqueJA,Hernández-BoteroS,

etal.Preparaciónycontroldelaenfermedadporcoronavirus 2019(COVID-19)enAméricaLatina.ActaMedPeruana. 2020;37:3–7.

3.PAHO.COVID-19situationreports;2020.https://www.paho. org/en/tag/covid-19-situation-reports

4.Rodriguez-MoralesAJ,SuarezJA,RisquezA,Delgado-Noguera L,Paniz-MondolfiA.ThecurrentsyndemicinVenezuela: measles,malariaandmoreco-infectionscoupledwitha

breakdownofsocialandhealthcareinfrastructure.Quovadis? TravelMedInfectDis.2019;27:5–8.

5.SecretariadeVigilânciaemSaúde-MinistériodaSaúde. Situac¸ãoEpidemiológicadaCOVID-19-Doenc¸apelo Coronavírus2019;2020.https://portalarquivos.saude.gov.br/ images/pdf/2020/April/17/2020-04-16—BE10—Boletim-do-COE-21h.pdf

6.Wilder-SmithA,ChiewCJ,LeeVJ.Canwecontainthe COVID-19outbreakwiththesamemeasuresasforSARS? LancetInfectDis.2020.

7.Diaz-QuijanoFA,Rodriguez-MoralesAJ,WaldmanEA. Translatingtransmissibilitymeasuresintorecommendations forcoronavirusprevention.RevSaudePublica.2020;54:43.

SergioCimermana,b,c,∗_{,AlbertoChebabo}b,d_, ClovisArnsdaCunhab,e_, AlfonsoJ.Rodríguez-Morales c,f,g,∗

a_{InstituteofInfectiousDiseasesEmilioRibas,SãoPaulo,SP,Brazil}

b_{BrazilianSocietyforInfectiousDiseases,SãoPaulo,SP,Brazil}

c_{LatinAmericanNetworkofCoronavirusDisease2019-COVID-19}

Research(LANCOVID-19),Pereira,Colombia

d_{UniversidadeFederaldoRiodeJaneiro,RiodeJaneiro,RJ,Brazil}

e_{UniversidadeFederaldoParaná,Curitiba,PR,Brazil}

f_{PublicHealthandInfectionResearchGroup,FacultyofHealth}

Sciences,UniversidadTecnológicadePereira,Pereira,Risaralda,

Colombia

g_{GrupodeInvestigaciónBiomedicina,FacultyofMedicine,}

FundaciónUniversitariaAutónomadelasAméricas,Pereira,

Risaralda,Colombia

∗_{Correspondingauthor.}

E-mailaddress:arodriguezm@utp.edu.co (A.J.Rodríguez-Morales). Availableonline23April2020 1413-8670/©2020SociedadeBrasileiradeInfectologia. PublishedbyElsevierEspa ˜na,S.L.U.Thisisanopenaccess articleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/). https://doi.org/10.1016/j.bjid.2020.04.005