The triple epidemic tragedy due to Covid-19 and the death underreporting in Manaus

Por Jesem Orellana Publicado em: 07/02/2022 às 18:50

In the first wave of COVID-19 (from March to August 2020), Manaus was marked by the strong spread of Sars-Cov-2. The healthcare system had been overwhelmed, resulting in an explosive number of deaths and further collapse on the funerary system, marked by inhuman burials, in mass graves, of part of the more than 2.500 victims with the cause of death confirmed as COVID-19 or even people who didn’t die specifically by the disease, but had their lives shortened due to the chaotic context, mainly in April and May 2020, as it is observed in Figure 1.

Figure 1. Monthly mortality rates due to COVID-19 during the first epidemic wave and per 100 thousand inhabitants, according to the death occurrence date (March to August), Manaus, Amazonas, Brazil, 2020.

Source: DATASUS/MS – Confidence interval (95%) of each mortality rate (per 100 thousand inhabitants)

An example of the healthcare’s system collapse, on the first wave peak (April 2020), is related to the 312 confirmed deaths due to COVID-19 until April 30th, a value approximately three times smaller than the 1.072 confirmed deaths in the end of January 2022 for the same period, after investigation and updating data related to Fundação de Vigilância em Saúde Dra. Rosemary Costa Pinto (FVS-RCP), the public agency which is responsible for the promotion and protection of Amazonas state people’s health.

Though the current number of confirmed deaths during the first wave is notably higher than the scarce registers of Manaus epidemiologic surveillance and FVS-RCP during the epidemic crisis peak, it doesn’t mean that every death would be recovered by the limited strategies of Manaus and Amazonas state’s epidemiologic surveillances.

Data of late 2021’s deaths due to respiratory causes shows the problem of death surveillance in Manaus is beyond the mere lag or reporting delay (when the information systems related to the healthcare, due many reasons, took weeks or even months to account it/launch registers). It is because the research which aimed to evaluate the death excess related to respiratory causes (underreporting indicator or when the healthcare services leave off counting deaths by certain cause, due to failures on deaths surveillance) in individuals aged 20 years or older in Manaus¹, during February 23 to August 8, 2020, showed that among the eight metropolis evaluated on the research, Manaus was the one which presented the highest excess of deaths, with 758% more deaths by respiratory causes than predicted values.

The referred research showed an amount of 2.653 deaths in excess by respiratory causes in Manaus and, even discounting the total number of deaths captured by Ministry of Health in January, 2022 (2.434), it is possible to note that about 9% of them are not explained directly by COVID-19, showing a glimpse of the hundreds of deaths that could had occurred during the epidemic in Manaus and which have left to be reported as such, pinpointing the known underreporting problem.

Despite one of the main recommendations of the research destined to sanitary authorities had been the review of death causes related to respiratory symptoms, in cities as Manaus, with a weak tradition in laboratorial and epidemiologic surveillance, such a work keeps limited to investigations of deaths at home (small part of the total of deaths that occur), held by Manaus city hall. Therefore, such a work of wide review on death certificates never was done by the responsible healthcare units, in general hospitals or emergency services which are under state government’s management.

It is important to clarify that “Issuance Service of Death Certificates to Natural Deaths occurred at Home” (Centro de Emissão de Declaração de Óbito por Causa Natural em Domicílio – CEDO) was implanted on May 18, 2020 due to the civil society and court order’s pressure, after the healthcare system overwhelmed and the plain aggravation on the data creation on deaths, specially due to COVID-19.

On the other hand, the “Deaths Verification Service” (Serviço de Verificação de Óbitos -SVO) which, in general, aims to improve the death surveillance, as well as the natural causes deaths’ determinations (it excludes homicides, accidents and suicides, for example) and the improvement of “Mortality Information System” (Sistema de Informações sobre Mortalidade – SIM), keeps not being implemented in Amazonas, despite the historical problem related to the creation of trustworthy informations about population mortality².

There is no doubts that the problem of data on death’s low quality and its timely availability, as well as the incidence cases and hospitalizations due to COVID-19, not only compromises the credibility but also allows the use of lagged and/or undercounted data for the decision makings which tend to minimize the epidemics effects as the one caused by the novel coronavirus. Unfortunately, this kind of problem perpetuates a vicious cycle of errors, because poor quality, lagged data result in inappropriate and/or late sanitary decision making, and, finally, in further, violent infection cycles and avoidable deaths.

The example of Manaus during COVID-19 pandemic is iconic, because due to the weak performance of epidemiologic surveillance, specially the laboratory’s, and to the negligence by different authorities and by part of its population, the catastrophic effects of the second wave were repeatedly ignored, despite the alerts done by an undervalued part of the scientific community^3,4 and by healthcare workers, conscious about the increase of infections due to COVID-19 in Manaus from September 2020.

According to what is seen in Figure 2, there is a significant increase in death rate due to COVID-19 in Manaus in September 2020. From then on, the epidemic keeps evolving until reaching even higher values in December, already under important influence of Gamma strain (P.1)⁵, and reach the second wave’s catastrophic peak in January 2021, when it was reported about of three thousand deaths due to COVID-19 and mortality rate approximately three times higher in comparison with the first wave’s peak, in April 2020 (Figure 1).

Figure 2. Monthly mortality rates due to COVID-19 during the second epidemic wave and per 100 thousand inhabitants, according to the death occurrence date (from September 2020 to November 2021), Manaus, Amazonas, 2020 and 2021.

Source: DATASUS/MS
Confidence interval (95%) of each Mortality rate (per 100 thousand inhabitants)

Despite the mortality rate due to COVID-19 still to be substantially high in March 2021, Amazonas government kept promoting early relaxations related to measures which aimed to contain the novel coronavirus spread. From June on, the mortality rates were stabilized in relatively low standards and it began an even bigger fall from August on (beginning of vaccination of teenagers aged 12-17), until staying in values close to one per 100 thousand inhabitants, in October and November 2021.

At the late November 2021, a new Sars-Cov-2 lineage becomes classified as concern variant by World Health Organization (WHO), which spreads itself really fast throughout Europe, until being detected in Amazonas in December.

This time, the underreporting issue once again would charge a high price to Manaus population, because there was already a silent spread of the novel coronavirus in December 2021, late valued by sanitary authorities and by population in general, from the second week of January 2022, when a violent, unprecedented viral spread ravaged Manaus by the third time in a row. In a few weeks the clinical beds occupation increased more than 10 times. Then, it was observed a strong increase of patients in Intensive Care Unit (ICU) and, already in late January 2022, it was the time when deaths due to COVID-19 substantially increased, though in drastically smaller standards than the second wave peak’s.

In early February, it was already counted about 192 deaths due to COVID-19, during January 2022, at least twice than the total deaths registered between September and December 2021 (96), letting clear the voluble number of preventable deaths that once again occurred in Manaus.

As noted in older people of Manaus⁶, it is very probable that the high vaccination coverages in risk groups to development of grave cases and deaths has avoided a new collapse in hospitals, despite the strong pressure in healthcare system and the more than 700 inpatients in late January.

Another fact caught attention, beyond the repetition of the same mistakes by sanitary authorities and by part of the population related to the containment of viral circulation in Manaus, is the repetitive and harmful data lag problem and probably the underreporting of deaths due to COVID-19 in January 2022. It is because the last Manaus data update alongside the Ministry of Health, on January 25, 2022, showed the city had 49 confirmed deaths due to COVID-19 between 11th and 24th of January. However, FVS-RCP’s daily bulletin of the same January 25, 2022 counted only 36 deaths or the expressive lag of 36%.

Certainly, the mortality indicator is only part of the indicator matrix used by FVS-RCP to carry out the COVID-19 risk evaluation in Amazonas state. However, it makes it clear how limited is such strategy on huge problems with data referred to the epidemic evolution in the state. Maybe because of the same FVS-RCP had changed the Amazonas’ risk classification only in late January 2022, after the explosion of new cases and clinical bed admissions, as well as the strong occupancy of ICU beds and, above all, of deaths due to COVID-19 as it was observed in late 2020, prelude of the chaos of deaths by asphyxia in Manaus.

Whether nothing extraordinary occurs, as the emergence of a Sars-Cov-2 new version with wide spreading power and/or substantially capability to evade our immunological system, whether by acquired immunity (defense) through our main ally in pandemic, the vaccines, or even through previous natural infection, it is few probable we would have grave sanitary problems in the next 60 or 90 days in Manaus, in spite of the worrisome investigation on Omicron’s new descendent lineage led by WHO, the “BA.2”.

Finally, Manaus could leave the third wave in the next four or six weeks, with a wide negative balance in terms of residual effects about physical and mental health of people who somehow were impacted during the epidemic. Furthermore, there were thousands of avoidable deaths, as well as the irreversible wear or casualties among healthcare workers and the weak incorporation of sanitary lessons and learnings.

The image that illustrates this article shows the public cemetery of Manaus, Nossa Senhora Aparecida, located in the Tarumã neighborhood, on November 13, 2020

(Photo: Bruno Kelly/Amazônia Real)

REFERENCES

1. ORELLANA, Jesem Douglas Yamall; MARRERO, Lihsieh; HORTA, Bernardo Lessa. Excess deaths from respiratory causes in eight Brazilian metropolises during the first six months of the COVID-19 pandemic. Cad Saude Publica, v. 37, p. e00328720, 2021.

2. BENEDETTI, Maria Soledade Garcia et al. Evaluation study of the garbage codes research project in the Northern region of Brazil. Rev Bras Epidemiol, v. 22, p. e19006. supl. 3, 2019.

3. ORELLANA, Jesem Douglas Yamall; MARRERO, Lihsieh; HORTA, Bernardo Lessa. In-hospital case fatality ratio due to COVID-19 in four Brazilian state capitals and its possible temporal relationship with the Gamma variant, 2020-2021. Epidemiol Serv Saude, v. 30, 2021.

4. FERRANTE, Lucas et al. Brazil’s COVID-19 epicenter in Manaus: how much of the population has already been exposed and are vulnerable to SARS-CoV-2? Journal of racial and ethnic health disparities, p. 1-7, 2021.

5. NAVECA, Felipe Gomes et al. COVID-19 in Amazonas, Brazil, was driven by the persistence of endemic lineages and P. 1 emergence. Nature Medicine, p. 1-9, 2021.

6. ORELLANA, Jesem Douglas Yamall; CUNHA, Geraldo Marcelo; MARRERO, Lihsieh; HORTA, Leite, Iuri Costa; DOMINGUES, Carla Magda Allan Santos; Bernardo Lessa. Changes in the pattern of hospital admissions and deaths due to COVID-19 after substantial vaccination of elderly in Manaus, Brazil. Cad Saude Publica, v. 38, (in press), 2022.

Jesem Orellana is Oswaldo Cruz Foundation epidemiologist since 2006. He has a Bachelor ‘s Degree in Nursery, Master’s Degree in Public Health and PhD Degree in Epidemiology. He is a reviewer in national and international journals and has manuscripts and book chapters published in many journals and publishers inside Brazil as well as abroad. He has worked, since 2020, in projects, consultancies and production of diverse materials of scientific subjects on the COVID-19 epidemic in Brazil, especially in Manaus, besides having given hundreds of interviews for national and international press. ([email protected])

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"Unfortunately, this kind of problem perpetuates a vicious cycle of mistakes, because poor quality, lagged datas follow in inappropriate and/or late sanitary decision making, and, finally, in further, violent infection cycles and preventable deaths”.

Jesem Orellana

Jesem Orellana é epidemiologista da Fundação Oswaldo Cruz desde 2006, tem graduação em Enfermagem, mestrado em Saúde Pública e doutorado em Epidemiologia. É revisor de periódicos nacionais e internacionais e tem artigos e capítulos de livro publicados em diversas revistas e editoras do Brasil e do exterior. Também tem atuado, desde fevereiro de 2020, em projetos, consultorias e produção de diferentes materiais de cunho científico sobre a epidemia de COVID-19 no Brasil, em especial em Manaus, além de ter fornecido centenas de entrevistas para a imprensa nacional e internacional.([email protected])