Covid case explosion can be masked by data blackout

Despite appearing to have given a truce in the indicators of hospitalizations and deaths, with the moving average of deaths below 150 for 20 consecutive days, doctors and experts say that the Covid-19 pandemic in Brazil may be growing at an accelerated rate.

This is because, in addition to the fall in the Ministry of Health’s official notification system since the beginning of December, when it suffered a cyber attack, the data sent to the folder by state and municipal governments, which were already suffering from damming at other times of the pandemic, may be considerably underreported.

Since the attack, several states have stopped reporting new cases and deaths by Covid, many of them justifying lack of access to Ministry of Health data, extracted from notification portals, or difficulties in entering data into the federal system.

Tocantins, Mato Grosso do Sul, Roraima and Goiás, for example, have not updated for at least 12 days. The longest of them, Tocantins, has been at least 22 days without an update.

In a statement, the Health Department of the State of Roraima said that it has not yet been possible to fully update the data due to the difficulty of accessing the ministry’s systems.

The State Department of Health of Tocantins reported that since the cyber attack it has been without the possibility of notification and access to the database of the Sivep-Gripe, e-SUS Notifica and SI-PNI vaccination systems.

Asked about the delays, the Ministry of Health said, in a note, that the Sivep-Gripe, e-SUS Notifica and SI-PNI systems were restored for more than ten days and that normalization is expected for January.

Other units of the Federation, such as the Federal District, say they were not impacted by the blackout, as the Health Department captures new cases directly from public and private laboratories.

The main reasons for underreporting reported by experts are two: the lack of mass testing policies, which causes a natural underreporting of cases —only those that are moderately to severely symptomatic, in general — and a delay, or, often, complete absence of record of cases.

As shown in a report from leaf Since early December, the records of positive cases of infection by Sars-CoV-2 have suffered a blackout since September, after the Ministry of Health changed, in August, the rules for notification of antigen-type tests on the e-SUS Notifica platform.

With the change, it was verified, from September, an abrupt drop in the rate of positivity of antigen tests compared to RT-PCR. In the past few months, the positivity rates for the two tests had gone hand in hand—that is, if the positive RT-PCR tests went up, the antigens went up as well.

The two tests look for the RNA of the virus in the body through a nasal swab (swab). The difference is that the antigen test uses a card similar to diabetes tests and the result appears in 15 minutes. RT-PCR, which is considered the gold standard, needs to be performed in a laboratory and can take 12 to 72 hours to produce a result.

In cities like Rio de Janeiro and São Paulo, the positivity of antigen tests in pharmacies – as well as the demand for them – has exploded in the last two weeks, a reflection of the increase in post-meeting cases at Christmas and New Year’s Eve. In São Paulo, the rate of positive tests carried out in pharmacies, according to Abrafarma (an association that brings together the large pharmaceutical networks) jumped from 5% to 17% in December.

However, data collected by both the Municipal Health Departments and the State Departments do not reflect this increase. On the Conass (National Council of Health Secretaries) panel, there was a drop in the number of cases reported per week from December 5 to 26, 2021, period corresponding to the time when the Ministry of Health system went down, causing delays in the notifications of the secretariats.

In the last epidemiological week of the year, from December 26th to January 1st, 2022, there was an increase of 155% of cases compared to the previous week (from December 19th to 25th), going from 22,283 to 56,881. In the last second (3), the moving average of cases had a similar increase, from 153% compared to the number two weeks ago, from 3,397 to 8,386.

According to Julio Croda, a researcher at Fiocruz, the federal government’s system was regularized only last week and an explosion of cases is expected in the coming days due to the damming of data.

“We know that in December there was a significant increase in cases due to the micron, but everything has been dammed since the 10th [de dezembro]. The government should regularize a new system for reporting health data on the next 7th, and then we will see a dizzying rise”, says Croda.

Although the ministry is seeking solutions to resolve the system for reporting cases, experts report that this is just one of the elements of Covid’s data blackout in the country. The other, they say, is that Brazil has never adopted a comprehensive testing strategy.

“We are in the dark about cases, as we have been since the beginning. Investing in testing, tracing contacts and isolating suspects is the bê-a-ba of facing any communicable disease. The micron is booming and we won’t know about it until a few weeks ago , precisely because of the insistence on not being tested,” says epidemiologist Pedro Hallal, a columnist for Folha.

As there is no testing policy, even cases for which there is notification represent only the tip of the iceberg, says health care physician and former director of Anvisa Cláudio Maierovitch. “It is necessary to differentiate underreporting from ‘underdiagnosis’. There are a lot of people with mild symptoms and who will not have access to tests even if they sought health services”, he says.

For Maierovitch, serological studies carried out during the pandemic, such as the one by the Federal University of Pelotas and others carried out in the city of São Paulo, confirm this “underdiagnosis” of those infected in the pandemic. The works indicated a number in the order of 6 to 10 times greater than that officially reported.

In São Paulo, the last serological mapping, in September, indicated that 52.8% of the adult population had antibodies against the Sars-CoV-2 nucleoprotein in their blood, that is, they had previous infection by the virus, which corresponds to 3, 3 times that reported by the municipality.

The difficulty in accessing the tests is translated both into the waiting lines for an exam at health centers in the capital and the difficulty in scheduling exams in pharmacies.

For the epidemiologist and president of the Sabin Institute, Denise Garrett, Brazil has always been far behind in terms of testing compared to other countries. “We always fly a little blind, but now we’re flying completely in the dark. And the indicators that best reflect [a propagação] are the positivity and case notification rate. What we do is use very late indicators, such as bed occupancy and hospitalization rate,” he says.

Even the number of hospitalized with Covid has grown again in recent weeks in São Paulo, indicating an already advanced scenario of the pandemic. “These are data that appear two to three weeks after the increase in cases, so there is, yes, a suspicion of a much greater number than is being reported”, completes the epidemiologist.

Garrett exemplifies with the policy adopted in many countries of testing widely available with antigen-type tests that can be done at home. These tests make testing more accessible and can be a tool to interrupt the virus transmission chain early in the infection.

Maierovitch also advocates a strategy for detecting Covid’s early cases. “We will never have in a universe of cases of flu syndrome the exact number of Covid, but the lack of testing makes us be in a complete blackout”, he says.

Even the use of tests at home should be part of state policy, something that never took off in the country. In May, the Ministry of Health announced that it would expand testing, with a goal of carrying out 26.6 million tests per month by the end of 2021. Two months after the announcement, the plan had not even come out of the paper.

For the researcher at the Department of Political Science at USP Lorena Barberia, there has never been an adequate study to know the types of tests to be implemented and for which target audience.

“In several countries we know of weekly testing strategies for students in schools, health professionals in hospitals, employees and students in universities. Here the government announces the purchase of 60 million tests, but for what function? How often will people be tested? Is it enough? We don’t know, and we don’t know because there is no transparency either from the federal government, or from the states and municipalities on the strategy and frequency of testing,” he says.

According to Barberia, there is also a lack of guidance on how and when to test, in addition to what to do with contacts. “There are reports of people who seek health care after having contact with someone with Covid and are advised to return to their homes if they do not show symptoms. Even at the end of 2021, think about a testing strategy based on having or not having fever , is a clear example of how we were not able to have an adequate conduct in the control of the pandemic”, he says.