key: cord-278558-znqscgxb authors: Carvalho, Tatiana Aline; Boschiero, Matheus Negri; Marson, Fernando Augusto Lima title: COVID-19 in Brazil: 150,000 deaths and the Brazilian underreporting date: 2020-10-21 journal: Diagn Microbiol Infect Dis DOI: 10.1016/j.diagmicrobio.2020.115258 sha: doc_id: 278558 cord_uid: znqscgxb Brazil is one of the epicenters of the COVID-19 pandemic and has reported 5,113,628 cases and 150,998 deaths by the disease. Comparing the deaths by natural causes expected and the excess mortality rate, there is a 22% increase in deaths mainly of male patients and individuals over 60 years old. with political, technological and economic burden associated with different territories. (iii) In our data, the high number of unexpected deaths by natural causes during the COVID-19 pandemic is evident; (iv) A total of 118,406 unexpected deaths by natural causes was observed during the COVID-19 pandemic; (v) Maybe, our data represents the Brazilian underreporting for severe patients affected by due to limitations to perform the SARS-CoV-2 screen by RT-PCR. On 12 October 2020, Brazil reported a total of 5,113,628 confirmed cases of COVID-19, being 4,526,975 recovered, 435,655 active COVID-19 and 150,998 deaths, besides, on this same date, in a 24hour period, Brazil also reported 10,220 new confirmed cases and 309 deaths [1, 2] . The incidence (ratio between the number of cases and the number of individuals in the population) and mortality (ratio between the number of deaths and the number of individuals in the population) rate were, respectively, 2,433.4 and 71.9 individuals per 100,000 inhabitants. Moreover, the case fatality rate (CFR; ratio between the number of deaths and the number of cases in the population) was 3 [1] . In the same period, the total deaths by natural causes expected was 529,659 and the excess mortality rate (deaths) by natural causes was 118,406, thus, an increase of 22% in deaths by natural causes was observed by official government agencies [3] . Brazil has an annual increase in deaths by natural causes ~1,000 to 2,000 new deaths, mainly related to an aging population. Brazilian regions presented a rise in the percentage of excess deaths, with the lowest rates in the South region (5%) and the highest in the North region (48%). Regarding Brazilian states and the Federal District (FD), the lowest percentage of excess deaths was 2%, observed in the state of Rio Grande do Sul. Furthermore, the highest percentage of excess deaths among states occurred in the state of Amazonas, which reached 74%. Curiously, both males and individuals over 60 years old demonstrated a higher excess death percentage, compared to deaths by natural causes expected for 2020. In this context, a data analysis was performed for the COVID-19 pandemic epidemiology and for the number of deaths in Brazil. The following markers were evaluated: COVID-19 cases with diagnoses by SARS-CoV-2 real-time polymerase chain reaction (RT-PCR); deaths by COVID-19; CFR; incidence per 100,000 inhabitants; mortality per 100,000 inhabitants; excess mortality rate (deaths) by natural causes; deaths by natural causes expected according to previous years and excess mortality rate (%). The expected deaths by natural causes in 2020 were projected according to data collected from the Brazilian The main findings included: data for confirmed COVID-19 cases; deaths by COVID-19; CFR; incidence and mortality per 100,000 inhabitants; excess mortality rate (deaths) by natural causes; deaths by natural causes expected according to previous years and its percentage (excess deaths by natural causes per expected deaths by natural causes). These data are presented according to gender and age for Brazilian States and the FD and geographic regions ( Table 1) . A significant Spearman correlation coefficient (CC) was found between the excess mortality rate by natural causes (number of cases) and (i) number of COVID-19 cases (CC=0.765; P-value≤0.001); (ii) number of deaths by COVID-19 (CC=0.862; P-value≤0.001); (iii) CFR (CC=0.664; P-value≤0.001) and (iv) incidence per 1000,000 inhabitants for COVID-19 (CC=-0.530; P-value=0.004); as well as, excess deaths by natural causes per expected deaths by natural causes with the mortality per 100,000 inhabitants due COVID-19 (CC=0.464; P-value=0.015). Currently, monitoring of death indicators is a strategy recommended by the World Health Organization to assess the direct and indirect effects of the COVID-19 pandemic [4] . However, the excess deaths should not be associated as a direct cause of the COVID-19 pandemic; even though, they might be indirectly associated to it, due to overload in health services, interruption of chronic disease treatments and patient's resistance to seek health assistance due to fear of SARS-CoV-2 infection. In our data, the high number of unexpected deaths by natural causes during the COVID-19 pandemic is evident. Perhaps our data represents under reporting by the Brazilian government for severe patients affected by COVID-19 due limitations to perform the SARS-CoV-2 screen by RT-PCR [5] . The Brazilian regions with the highest percentage of unexpected deaths by natural causes had the lowest availability for RT-PCR tests and intensive care units (ICUs) during the pandemic, mainly, in the North region [6] . In brief, Brazil should improve the COVID-19 diagnosis, implement better clinical policy guidelines by the government to treat patients with COVID-19 mainly for severe cases when the ICU beds and intubation are needed, improve the adherence to social distancing, improve awareness of the severity of the disease to residents and optimize the acquisition of drugs and personal protective equipment necessary for the management of COVID-19, mainly anesthetics and muscle relaxants that are lacking in the Brazilian market as well as other drugs such as Dexamethasone, Remdesivir and Tocilizumab that showed efficacy to treat patients with COVID-19 [7, 8, 9] . So what? As discussed in the Lancet editorial, in Brazil, the authors concluded: "The challenge is ultimately political, requiring continuous engagement by Brazilian society as a whole to secure the right to health for all Brazilian people." [10] At the same time, it is necessary to have transparency and clarity in the data about COVID-19, which includes the real rate of deaths and cases associated with the disease. (i) Monitoring of death indicators is a strategy recommended by the World Health Organization to assess the direct and indirect effects of the COVID-19 pandemic; (ii) The global underreporting is a challenge to deal with the COVID-19 pandemic and it is associated with political, technological and economic burden associated with different territories. (i) In our data, the high number of unexpected deaths by natural causes during the COVID-19 pandemic is evident; (ii) A total of 118,406 unexpected deaths by natural causes was observed during the COVID-19 pandemic; (iii) Maybe, our data represents the Brazilian underreporting for severe patients affected by COVID-19 due to limitations to perform the SARS-CoV-2 screen by RT-PCR. Conselho Nacional de Secretário da Saúde do Brasil (In English language -COVID-19 Panel. National Council of Health Secretary of Brazil) Ministério da Saúde do Brasil (In English language -COVID-19 Panel. Ministry of Health of Brazil) Painel de análise do excesso de mortalidade por causas naturais no Brasil em 2020. Conselho Nacional de Secretário da Saúde do Brasil (In English language -Analysis panel of excess mortality due to natural causes in Brazil in 2020. National Council of Secretary of Health of Brazil) Revealing the Toll of COVID-19: A Technical Package for Rapid Mortality Surveillance and Epidemic Response COVID-19 -six million cases worldwide and an overview of the diagnosis in Brazil: a tragedy to be announced COVID-19 -The Availability of ICU Beds in Brazil during the Onset of Pandemic. Annals of Global Health Epub ahead of print Remdesivir for the Treatment of Covid-19 -Final Report Tocilizumab in patients with severe COVID-19: a retrospective cohort study COVID-19 in Brazil: "So what September 2020 and the data collection was carried out on13 October 2020. The data was retrieved from https://www.conass.org.br/indicadores-de-obitos-por-causas-naturais/. c , The first line for each region represents the excess mortality rate (number of deaths) by natural causes and the percentage at each group according to sex and age. The second line for each region represents the excess mortality rate (%) according to sex and age groups. The number of expected deaths by natural causes in 2020 was projected according to the data collected from Sistema de Informações sobre Mortalidade (Mortality Information System) of Brazil between 2015 and 2019. The data on deaths in 2020 was obtained from Portal da Transparência do Registro Civil (Civil Registry Transparency Portal). Both datasets were compiled by the National Council of Health Secretary of Brazil. Excess mortality rate (%) was calculated based on the ratio between excess number of deaths by natural causes and the expected number of deaths by natural causes to date.