RIO DE JANEIRO, BRAZIL – Brazil may have already passed the 220,000 death mark for the novel coronavirus. Officially, on Thursday, December 24th, the country registered 190,000 Covid-19 deaths.
A survey by Vital Strategies – a global organization comprised of experts and researchers working with governments – estimates the omission of nearly 33,000 deaths from the balance. These cases entered the statistics as SARS (severe acute respiratory syndrome) with no specific cause.
However, these patients who died had three or more clinical symptoms of Covid. Therefore, even if tests were negative, the cases should have been diagnosed as Covid-suspected, according to the World Health Organization protocol.
Vital Strategies has shared the data with Ministry of Health officials. The portfolio stated that these cases are reviewed and only then included in the monitoring system.
The data were collected from the Ministry of Halth’s Sivep-Gripe (Influenza Epidemiological Surveillance Information System). According to Vital Strategies epidemiologist and senior specialist Fátima Marinho, there are 242,249 deaths from SARS this year, through December 14th.
Of this total, 68,631 had no specified cause, but 32,923 of the patients registered symptoms of Covid. This would result in 221,208 potential deaths from the novel coronavirus.
In 2018, there were 5,473 SARS deaths in Brazil, of which 3,474 were due to non-specific causes. There were 5,343 deaths in 2019, and in 3,615 of these, the cause was not identified. The number of deaths through December 14th is thus 45 times higher than last year’s figure for the whole year.
SARS is a condition that can be caused by either the novel coronavirus or other respiratory viruses, such as H1N1, the infectious agent of Influenza A. It is the main cause of death of patients with Covid-19.
According to experts, the country shows a significant underreporting of deaths caused by the novel coronavirus.
Marinho, from Vital Strategies, said that the most common symptoms found in the cases analyzed were dyspnea (shortness of breath), coughing and oxygen saturation lower than 95%. These are also the main symptoms observed in patients who died of SARS caused by Covid-19 in Brazil, said the epidemiologist.
The expert criticized the Ministry of Health’s investigation and notification procedures defined for municipalities.
“If you already have an epidemic in the country, you have no reason to demand a person’s epidemiological history [contact with someone with Covid or travel to affected areas]. These citizens died in full pandemic and at the peak of deaths. There’s no reason not to at least classify them as suspected cases,” she said.
In Brazil, the Ministry of Health allows cases to be confirmed and reported by clinical diagnosis as well, i.e., by a doctor’s examination based on the patient’s symptoms and history.
In all, there are five accepted criteria for cases to be confirmed: laboratory; clinical-epidemiological; by imaging; clinical; laboratory in an asymptomatic individual, such as healthcare professionals and other groups more exposed to the risk of infection.
Responsible for the survey, Marinho said that a Vital Strategies survey in partnership with UFMG (Federal University of Minas Gerais) sought to prove that there are Covid-19 cases in unspecified SARS data. To this end, an as yet undisclosed study was conducted in three Brazilian municipalities.
Out of 2,000 assessed deaths of patients with three or more symptoms of the new disease and a negative result for the coronavirus, 90% were confirmed as Covid after the autopsy.
“We wanted to show that the majority of these cases is Covid-19. They are people who meet the clinical criteria, have no epidemiological history, but live in an area with many cases,” said Marinho.
In her opinion, the Ministry of Health’s database proves that further investigation of cases is warranted. Marinho has already met with officials from the portfolio’s epidemiological area to discuss the matter.
According to her, there is still a lack of coordination by the Ministry of Health in Brazil.
“We need to have a criteria that defines cases of Covid-19. We are certainly not identifying all the cases of death by the disease, nor all the cases. There are deaths of patients by Covid-19 in unspecified cases, I have no doubt about this. We have at least 20% more deaths than what is being reported today,” she said.
Marinho mentioned Colombia as an example of notification. According to her, the South American country has used clinical criteria for deaths with Covid features despite negative, inconclusive or no tests performed (if the patient has had contact with infected people).
The coordinator of InfoGripe and public health researcher at Fiocruz (Oswaldo Cruz Foundation), Marcelo Gomes, shares Marinho’s opinion that there are Covid-19 deaths in cases classified as unspecified.
According to him, many cases are not detected in tests for several reasons, such as the time of symptom onset until the test is performed, quality and type of collection performed, storage and transport until reaching the laboratory.
According to Gomes, 99% of SARS deaths in the country identified with the virus are related to Sars-CoV-2. This suggests that, in unidentified cases, a good part should be Covid-19. “We can’t specify exactly how many cases that tested negative and entered this statistic are Covid-19, but we can say that a large part is associated with the disease,” he said.
On Friday, December 25th, ex-Minister of Health Nelson Teich discussed the underreporting of Covid cases on a social media posting, mentioning the current total of deaths from the disease in the country. He estimates even more deaths.
“If we include in this figure [190,000] the underreported deaths, which conservatively represent 20% of the current total, we are now at about 230,000 deaths by Covid-19, and the numbers are growing significantly,” wrote the ex-Minister.
“Moments like this demand humanity and nobility from leaders, features that do not exist when personal and political positions are defined as a priority,” he wrote on Friday.
José David Urbaez, a consultant with the SBI (Brazilian Society of Infectology), said that healthcare professionals have handled non-specific SARS deaths as cases of Covid-19. This is because most respiratory syndrome related deaths are associated with the novel coronavirus. “The amount of SARS in Brazil is frightening. We never had a calm moment during the pandemic, we moved from a very intense to an intense level. Now we are returning to the old level again,” he said.
The Ministry of Health stated in a note that SARS cases with no determined cause have already been investigated. The portfolio said the data have been entered in Sivep-Gripe system.
“The difference observed between SARS case notifications from 2020 to preceding years and their respective final classifications are expected and accurate, because the surveillance network for Influenza and other respiratory viruses is more sensitive in capturing/notifying cases because of the Covid-19 pandemic,” the Ministry said.
According to the Ministry, unspecified cases and deaths from SARS are routinely monitored in the Influenza and other respiratory virus surveillance network.
The Ministry stated that these cases were not identified because of the collection quality, delay in submitting samples, negative test results or undetectable for the respiratory viruses investigated. According to the portfolio, all these factors are expected in the laboratory diagnosis results.
The portfolio further said that the data systems being used for case records are online, in the three government spheres. Therefore, no national coordination is lacking with respect to case and death notifications.
“It is necessary to understand that it is not only a matter of notifying and registering the case, because even after being entered into the system, the experts review the data in order to update the information, as well as the laboratory results,” he said.