University of São Paulo: Six out of 10 patients with covid in the ICU died in Brazil by August; in the North, eight out of 10

Um article published this Friday (15) in the scientific journal The Lancet Respiratory Medicine brings the results of a retrospective analysis of the 254,288 hospitalizations of patients over 20 years of age diagnosed with covid-19 in Brazil between February 16 and August 15 of 2020. The hospital mortality rate due to the disease is high in the country, and with an important difference for nations like the United Kingdom: the average age of the Brazilian population is lower, the age group in which a lower lethality of the disease is expected. In Brazil, however, mortality was also high among people under 60 years of age. The data are part of a study done in collaboration between institutions that include USP and Fiocruz.

In addition to other data, this means that our health system did not cope with the high flow of patients, especially in the North Region, where a new collapse of the system was already taking place, reaching its peak this week, with the end of the supply of oxygen in Manaus.


Otávio Ranzani, epidemiologist
Doctor Otavio Ranzani, a researcher at FMUSP and the Institute of Global Health (ISGlobal) in Barcelona, Spain, says that the number of ICUs in the North Region is very low compared to others. And opening an ICU bed involves much more than releasing a bed and a fan, including other resources and specialized staff. “We can see that in the North Region the patients arrived more seriously. They had more hypoxemia, more respiratory stress ”. The time between admission to the hospital and death in the Northern Region was seven days; in other regions, 10 to 12. “It is a sign that people arrived there and died quickly, that they got worse, due to limited access, since there are few beds. They only got this service very late. ”

Another cut that brings alarming data was the mortality, throughout the country, of patients who needed invasive mechanical ventilation, that is, intubation: 80%. “In the North and Northeast, even young ventilated people died a lot,” says Ranzani, who is the study’s first author.

The doctor explains that Brazilian law requires a specialized intensivist for every 10 ICU beds. But the rate of beds per nurse, nursing technicians, physical therapists is equally important, which can be very high. “Even a place that used to work well, with less severe patients, can collapse when all the patients who are there are very serious, because it increases the burden on professionals.”


The study
Fiocruz researcher Fernando Bozza explains that at first the group thought about making models, but throughout the development of the analysis, he ended up choosing to do a descriptive study, “to present the data that portray the epidemic in Brazil, in a direct way”. And all the data is open. “We have very little information about what happened or is happening in hospitals. We wanted to make a document on the effect of the pandemic on the Brazilian health system, even so that the seriousness of the disease and the pandemic is not put into perspective. ”

Leonardo Bastos, a researcher at the Pontifical Catholic University of Rio de Janeiro (PUC-RJ) who worked on data analysis and shares the first authorship, points out that the article has supplementary material “which is almost another paper ”, including data from diagnosed patients by other methods (for the main analysis only diagnosis by RT-PCR was considered). “When we look at these figures, which were left out of the main study, they are more cases, and the differences from the North Region to the others are even more pronounced.”

When commenting on the study, in which she did not participate, the professor at the Faculty of Philosophy, Letters and Human Sciences (FFLCH) at USP Lorena Barberia also sees as a strong point the amount of data generated and says that now other questions and hypotheses can be explored. “Why are the North and Northeast behaving so differently? We need to see what are the characteristics of these ICUs and the teams that explain the regional differences. How many people did these teams have to deal with simultaneously? Could it be that in the most stable phase of the pandemic the difference remained? ”

Another important point raised, in her evaluation, is that the right therapy, arriving at the right time, can save lives. “The study allows us to compare groups and events and to detect if there are important differences. In the Northern Region, for example, patients who needed respiratory assistance but not intubation, received this assistance in a greater proportion outside intensive care (85%), when compared to other regions. ”

Researchers were also concerned with showing the importance of having a fair and equitable health system, especially for vulnerable populations. “We defend SUS and we are only able to show what we are showing because there is SUS and a surveillance system that has been built over the years. On the other hand, these data show very high hospital mortality, especially when compared to other countries that have populations older than ours, showing that the effect of covid is greater not only in the most vulnerable populations, but also where the system of health is more vulnerable, like the Amazon region. ”

In the analysis, indigenous populations had higher mortality rates, as well as blacks and browns, compared to whites. Mortality is also higher among those with low education. Another research in the publication phase should better explore these sociodemographic characteristics.

Perspectives
The new rise in cases shows signs that there will be a very large service load, which can lead to the collapse of the system again, not only in the North Region, as we are already seeing.

“What saddens me about this story is that, after almost a year, the country did not learn from what happened at the beginning of the pandemic, and we will live in the coming months, a very dramatic period”, says Fernando Bozza. “The Government continued to underestimate the pandemic and say that it was over, and this prevented the preparation, planning for new case growth,” says the Fiocruz researcher.


For Otávio Ranzani, something that can change this story, at least in part, is the vaccine, “as long as the use of a mask, distance and other measures are maintained”. Another resource that can be used, according to him, is telemedicine.

“At FMUSP, professor Carlos Carvalho implemented telemedicine care for severe ventilated respiratory disease, to provide remote assistance to professionals who are overburdened in ICUs, and who are not so used to seeing this patient profile. The ICU needs multidisciplinary care: nursing, nutrition, physiotherapy, doctors of more than one specialty ”, he explains.

“Once the system is full, transfers are also super important in critically ill patients. Here in Brazil, in general what we can do is with an ambulance within reasonable distances. In the North, the distances are very long, but in other places I think it would be possible to have an optimization of screening and reference for specialized centers ”, affirms Otavio Ranzani, emphasizing that the safety margin of beds in the North Region is very small. “So the most immediate focus there needs to be to prevent people from becoming infected,” he says.

In this sense, Lorena Barberia, recalls that in Manaus the Rigidity of Social Distancing was very low, an index created by her research group to compare measures of different governments in the country to contain the pandemic. In the index, which goes from zero to 100, the capital of Amazonas was below 20 in most of the first half, and slightly above 20 in the second half of 2020, which is worrying.

The FFLCH professor, who coordinates the Solidarity Research Network, also stresses the importance of testing. “We have to look at this more carefully. When the infection is detected earlier, we can monitor this person and detect earlier if he needs hospitalization, for example. In the North and Northeast, mainly at the beginning of the pandemic, most tests were performed by serology, when the ideal is that the detection be made by RT-PCR, or by the antigen test, which point to the present infection ”.

The article Characterization of the first 250,000 hospital admissions for COVID-19 in Brazil: a retrospective analysis of nationwide data was published on January 15 in The Lancet Respiratory Medicine , doi: 10.1016 / S2213-2600 (20) 30560-9

Photo: Agência Brasil
The crisis in Brazilian ICUs
By Beatriz Azevedo

For epidemiologist Gonzalo Vecina Neto, a professor at the School of Public Health (FSP) at USP and founder of Anvisa, at the beginning of the pandemic, the country responded well to the increase in ICU beds. “We move from an average of eight to ten ICU beds per 100,000 inhabitants, to a number of 10 to 12 ICU beds per 100,000 inhabitants,” he says. He also says that the crisis hit more heavily in cities like Manaus, Belém, Fortaleza, which faced a very complicated situation in relation to the virus, but the rest of the country performed well, to some extent, in the availability of beds. In São Paulo, it was even questioned whether the use of field hospitals would be necessary, because the beds were sufficient.


Gonzalo Vecina Neto – Photo: Reproduction / FGV EAESP

Marília Cristina Prado Louvison – Photo: Marcos Santos / USP Images
Marília Louvison, professor at FSP, at USP, adds that, although some regions have been successful in this regard, the expansion of the number of ICU beds was uneven in the country. “We have enormous territorial inequalities in this coverage between the States, being close to one bed for every ten thousand inhabitants in the North Region and three in the Southeast Region”, he explains. This unequal reality was maintained in the expansion of covid beds, showing the difficulties previously existing and, not always aligned with the strategies to contain the transmission of the virus in the various States.

When the average number of cases dropped, around September 2020, about 40% of the beds were disabled. The number of cases started to increase again, in January, related to the end of the year parties. “An increase in demand as it has occurred at this point in the second wave of the pandemic requires permanent planning mechanisms and much of what has been learned and implemented throughout 2020 cannot be lost,” explains Louvison.


Manaus
For Vecina, we are heading towards a disaster of the proportions of Manaus, in some regions. Cities like Fortaleza and Belém may see a crisis in the same direction. The professor says that one of the culprits for what is going on is the companies responsible for the production of industrial oxygen. “It is an oligopolized market and exclusively for them. Of course, the government is the biggest culprit but I believe that companies are part of the solution and the problem, the market is theirs and nobody can come close ”. He adds that companies will need to respond to this demand if they do not want to be extinguished by the pandemic.

An important point to be observed in Manaus, is the geographic location of the city, islet, and the production of local oxygen was not enough to meet the demand. Vecina explains that this issue is not a problem in the South and Southeast regions, which makes the risk of lack of oxygen in hospitals less.

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