RIO DE JANEIRO, BRAZIL – In the same Brazil where a task force was organized to ensure that there was no shortage of chloroquine for the early treatment of patients with the novel coronavirus, even before the drug had its efficacy proven, there is a shortage of drugs to sedate and intubate the most critical Covid-19 patients in ICUs. For weeks, municipal and state Health Secretariats have been raising this demand to the Ministry of Health.
They submitted a list of 21 drugs included in their protocols that mayors and governors have been unable to purchase. A more effective response from the Ministry of Health on the issue was presented on Monday, June 29th: an agreement with the PAHO (Pan American Health Organization) to import part of the drugs, a new bidding notice for purchase and the requisition of what had not yet been sold in contracts by the pharmaceutical companies. Nevertheless, the government is unable to guarantee that it will be able to supply the demand for drugs within the seven-day period requested by the states, when Brazil currently counts over 1.3 million people infected, 552,000 of them hospitalized.
“It will not immediately meet this seven-day requirement, but it is already an answer,” says Sandra de Castro Barros, director of the Department of Pharmaceutical Assistance and Strategic Supplies. These drugs are used in the public hospital protocols to sedate and stabilize patients severely affected by Covid-19 and who needed to be intubated. Demand has increased during the epidemic, due to the increase in both the volume of patients in ICUs and their length of stay there, also adding to the amount of drugs used. This has caused a surge in demand for these drugs, whose prices have exploded.
The dollar fluctuations during the pandemic also added to the states’ difficulty in purchasing the drugs, explains the Ministry of Health. The portfolio – which also says the pharmaceutical sector is not having problems importing supplies or producing the drugs – is starting to intervene to mitigate the problem that can cost the lives of Brazilians.
Asked about which states are in a more critical situation regarding the drugs they currently have in stock, the Ministry of Health said only that, in general, everyone “needs something to complement their protocols” – that is, they need items for treating patients with the novel coronavirus.
“This demand is very fast and there is great stock variation between the states. If we say that one needs less than the other, we are not being fair,” says Sandra de Castro.
The National Council of State Health Secretaries (CONASS) prepared a document with the situation faced by the states. In it, it shows how many inventory days are left of drugs used in ICUs for Covid-19 per state in the federation. The document considers all public hospitals, whether managed by states or municipalities.
On June 24th, 14 states did not have a drug called Cisatracurium Besilate (recommended to be used during intensive care procedures), for no more treatment at all. But the list is longer. The document includes a list of at least 21 drugs with purchasing issues – some are lacking more in certain places and less in others.
The issue stems from a “market imbalance,” says Elcio Franco, the Ministry of Health’s executive secretary. According to him, the government met with pharmaceutical companies and did not find problems to produce the drugs. Nevertheless, due to logistical issues and the price increase due to the high demand, they have become obstacles for the purchase, which is assigned to the states and municipalities.
Franco says drugs for intubation of critically ill patients are important, but points out that the Government has directed non-invasive oxygenation therapy and a drug protocol at the onset of symptoms (which includes chloroquine) to prevent patients from evolving to a severe form of the disease and need ICU hospitalization.
Since the start of the crisis, the Brazilian government has focused its efforts on ensuring that covid-19 patients are treated with chloroquine. President Jair Bolsonaro has been a major proponent of the drug, even when there are still inconclusive studies on its efficacy in treating Covid-19. Two Ministers of Health stepped down from the government due to differences with the President.
The army increased chloroquine production by 80 times during the crisis. The interim Minister of Health, General Eduardo Pazuello, published a new protocol so that this drug -very widely used in Brazil to treat malaria- could be used in the initial symptoms of the disease. More recently, the Ministry of Health extended its use in pregnant women and children with Covid-19. In this context, the government has reached the mark of 4,374,000 chloroquine tablets distributed throughout the country during the crisis.
Asked whether the government was wrong to focus on distributing a drug with no proven efficacy, rather than ensuring that there was no shortage of drugs for the intubation of more critical patients, Élcio Franco advocated the use of chloroquine to prevent infected patients from seeing their cases worsen. He said that there are studies that show good results, but he did not specifically mention any of them, and said that India has shown positive results with its use associated with other drugs.
“We only seek to preserve the physician’s autonomy in prescribing according to their clinical analysis,” he said. The Executive Secretary also said that it is common for an action like this in pandemic times and that more robust evidence should come out soon, probably in a year. Regarding the shortage of intubation drugs, Franco said that it was caused by the increased cost due to high demand and argued that the government has not neglected its responsibilities.
In turn, Sandra de Castro argued that the government has not failed to buy the drugs used in the ICU to the detriment of chloroquine. According to her, the purchase of drugs for hospital use, such as those for intubation, is not centralized in the Ministry. She explains that the funding sources are different, and that the shortage of drugs is due to increased demand, which has raised the price of these products.
“We have already adopted strategies. We are not going to harm the private sector of Brazil’s health system either,” she said.
Source: El País