Fundação Oswaldo Cruz is one of the World’s most respected tropical disease and public health research institutions. Founded in Rio de Janeiro by epidemiologist Oswaldo Cruz in 1900 to fight a series of pandemics that were sweeping through Rio de Janeiro’s favelas and boarding houses, during it’s 120 year history it has made important scientific contributions to vaccine and drug development and developed effective public health strategies for fighting diseases like HIV, Tuberculosis and Dengue. Today, Fiocruz is a federally funded agglomeration of 12 research institutions located across Brazil, and the nations’ foremost public health school. With a budget of nearly $1 billion USD in 2019, it is one of Brazil’s most important institutions in the current fight against the coronavirus pandemic. Dr. Margareth Dalcomo is a pneumologist, professor at Fiocruz National School of Public Health and a member of Boston Medical School’s “Resist TB” steering committee. The following interview with her, about Covid 19, was published on March 27 in by Ápublica, and translated and edited for readabilty by Brian Mier.
During several weeks, the Health Minister gave recommendations for social distancing and self-isolation. Now there has been a change in tone. The President is saying that “Brazil can’t stop” and is planning to flexibilize quarantine starting on April 7th. What are the risks of Bolsonaro’s proposal for “vertical isolation”?
They are different things. What our President proposed is ending social isolation. The risk that this would bring is that the disease, which has already reached the most poor and vulnerable areas, will spread at a speed that is out of control. It will overflow our public health services. The SUS system, which will have to serve 80% of the Brazilian population during this huge current epidemic, does not have the means to curve, and we will see a general collapse which will further increase preventable mortalities. We are talking about a pathogen that is highly contagious, that spreads with a greater speed and intensity than the common cold. It is believed that one person can spread it to three or four others.
Realistically, a vaccine is something that can can only be thought of in terms of two years from now, at the least. Therefore, the only thing to do, in my opinion, is to maintain social isolation. At this moment, which is the sharpest moment of this epidemic, there is no other way to impede its transmission. Therefore, it is fundamental that we separate and isolate people to intercept this transmission chain. We have no other weapon against this.
Would ending isolation now mean that there would be more deaths that could be avoided otherwise?
Yes. But this will not happen because the President’s voice on this seems very isolated. This is not what anyone else has been saying, not even his Health Minister. Our Minister listened to the academic community and is working closely with us and the Health Ministry continues to officially recommend social isolation.
What is vertical isolation?
Bolsonaro is proposing that we only keep elderly people in isolation. We do not agree with this as a public health policy because other countries that thought about doing this backed down from the idea, as can be seen with what is happening now in New York State.
I am speaking from a technical standpoint. Technically, we can follow the experiences of countries that came before us that thought about doing vertical isolation. The biggest example of this is England, and it backed down from the idea after verifying that the strategy would not work. They backed down because of the risk caused by a highly contagious new disease with risks that have not yet been fully determined. Now, due to the progression of the epidemic, England is proposing a more radical isolation strategy.
The economy will have to have alternative solutions, obviously, as everyone is looking for, to solve its problems during this period.
Vertical isolation is very efficient when dealing with a smaller epidemic. But with a highly contagious disease like this one, it is impossible. The greatest thinkers in epidemiology have all revised their opinions on this now. All knowledge on a situation that is so new is very dynamic. Everything is revised on a nearly permanent basis.
What is the “herd immunity” strategy originally supported by England?
Herd immunity means that we will all be infected at some point. We will develop antibodies, have contact but will not necessarily develop the disease. Herd immunity is expected to happen with any new contagious disease but it takes a long time. You achieve herd immunity, for example, when you have a vaccine. If everyone in the World is vaccinated there is herd immunity. Now we cannot talk about this yet with a new disease with this level of transmissibility.
Furthermore, it has not been proven that vertical isolation leads to herd immunity. They are different and independent things.
The Health Minister has spoken about implementing some measures more gradually in a less radical manner. Do you agree with this?
No, I don’t. I think that there has to be common sense among families, public institutions and private institutions that concentrate large numbers of people. In the case of services that are considered essential that need to remain in operation, there have to be alternatives. Partial or alternative freedom for different labor groups, these are measures that I see as sensible. The rest of the population should, yes, remain in social isolation.
The question that we received the most from our readers is: when will this end? Let’s address this in parts. At what stage of the epidemiological curve are we in today?
We are still in the stage of growth. The epidemic is growing in Brazil and it has not reached the peak of the curve yet. It is growing and it is disseminating and this is why the minimum amount of time predicted for a more radical social isolation is at least two to three weeks, realistically speaking. The epidemiologists calculate that the peak of the epidemic’s curve will occur in Brazil by mid-April. And from there we imagine that with these measures we can begin to soften this sharp point of the epidemic’s curve a bit.
The Health Minister says that the number of cases will increase in April, May and June, start to slow down in July and August and begin to drop in September. Does Fiocruz agree or are you working with a different scenario?
This depends on various variables, the speed of transmission, the number of deaths, the paralyzation of services. A prognostic depends on many variables.
What does it mean to control an epidemic? To impede it from continuing to spread on a large scale. I think that we may be able to do this in two months and that from there, the disease will have a certain endemicity. It will no longer be an epidemic, since many infected people will have developed antibodies and will not develop the disease. This is what we hope happens.
I would say that the Minister was pessimistic in imagining that we will still have all of these months ahead. But China is already monitoring the situation and imagining that there could be a second wave. China has not relaxed its standards of social isolation yet. This is taking place gradually and very carefully because they know, epidimiologically speaking, that there could be a second wave.
Controlling an epidemic does not mean that the problem is solved. There will continue to be many cases, but the number of deaths will start to decrease, along with the social and human impacts.
Is it possible to evaluate whether the large scale isolation of many people, adopted last week, will have an effect?
No. We do not have this information. We do not have this information because the official number of cases is still very distant from reality. This process, this timing between cases existing and being confirmed and notified takes many days. We believe that the two thousand official current cases represents around 10% of the real numbers. There is no doubt that Brazil has passed this number ten times over.
So, it will take a while for us to know if we are really flattening the curve? Is there any idea when we will know?
Certainly this week, during which we started isolation, has already lowered the speed of transmission. This is a fact – there is no doubt about this. We expected to have more cases by now.
Since the disease was brought to Brazil by the middle class, it is an imported disease and the sustained or community transmission started over the course of a slightly longer time period. Now, it will depend on the speed with which it spreads through the densest communities. This is the variable which we depend on now.
If we maintain the slowing down of the transmission process we will be able to ensure that the health services are prepared to receive the 20% of severe cases which will require hospitalization. Otherwise, it will collapse as we can see is happening in a rich and developed city with a spectacular infrastructure like New York. New York’s health system is collapsing, with an enormous number of deaths and infections and the health services do not have the number of respirators needed to handle so many severe cases.
In terms of data and projections of government actions, does it make sense to compare Brazil’s situation with that of any other country?
No. We have our own peculiarities. We do not have wide-scale testing. In an ideal world we would have 200 million tests to test the entire population. But this does not exist and it won’t happen. Our situation cannot be considered similar to that of South Korea, for example, which tested everyone. We have a much greater and more heterogeneous population with very different levels of population density. The Southeast is very different from the North, for example.
But there are certainly lessons we can learn from these other countries. What can we learn from them?
We are learning from all of the countries which have come before us in this epidemic. We have learned the most from Italy and France, which took a long time to recognize the problem and where there is this human tragedy which we are witnessing. The situation in Spain is also very dramatic today.
Brazil is trying, in my opinion, to take measures to avoid repeating those tragic models. It is for this reason that we proposed social isolation early and are mobilizing the private sector to create a new culture.
When you see 4 banks uniting to by 5 or 10 million new test kits to donate to the Health Ministry, this is an extraordinary initiative for us, but it is very normal in any situation where human solidarity is clearly needed like the current one
There are factories that were not working at full capacity that have started making masks, and cosmetic producers that have stopped making perfume to make liquid soap. This has to reach the most vulnerable communities, according to the recommendations that we are now making.
Speaking of the most vulnerable communities, many of the reccomendations being made right now cannot be followed by these people, such as stay at home, wash your hands and keeping a distance of 2 meters from other people. If a person has to work, if she does not have access to basic sanitation and lives in a one room apartment, for example. What measures can these people take to protect themselves in the realities that they live in?
I can’t tell these people that if there is an elderly person in their family, a grandmother or grandfather, that they should isolate them in their room because they will tell me, “there are 5 people living in the same room here.” We can’t engage in rhetoric over something that has no practical application. There is no way to do it. This is the answer.
Within the realm of the possible, what should these people do?
Maintain very rigid hygiene standards. Drink a lot of liquids to maintain hydration and eat as much as possible, at least eat adequately.
What can the government do to support coronavirus prevention in these places?
I have my own personal opinion about this. I don’t think that this can all depend on the government at this moment. The system will not be able to handle it. The Public Health System (SUS) will not be able to handle it. If we don’t get help from the private sector or there will be a very severe and rapid collapse.
Why isn’t Covid 19 just a “little flu”?
It starts off with symptoms which are very similar to the common flu. But in a determined number of people – and to date, what epidemiology is showing is that this population group is made up of older people or people who have other illnesses or symptoms such as high blood pressure, diabetes, immune system deficiencies caused by the use of medicines or any other disease that weakens immunity such as organ transplant recipients or people with HIV….
Those who die from Covid-19 die from pneumonia. The pneumonia that it causes is very severe and different from common pneumonia. It is characterized by a much greater level of inflammation that evolves with early fibrosis, evolving into a syndrome of respiratory anguish and into sepsis, which requires mechanical ventilation because the lungs stop working. And there is a very high mortality rate caused by these factors, in the population groups which I described.
Regarding medication, there are some preliminary studies on drugs that are already being used for malaria, Ebola and HIV, which could block coronavirus. Should they be viewed as possible cures?
No. Our position in Brazil is to not recommend any treatment. There are several studies that have been published and over 700 academic papers have been published on the subject during the last 3 months. Of these, some are based on evaluation, but they are studies that are not randomized with no control groups and have a series of impediments. They are based on cohorts, case series which test some antiviral drugs, some antimalarial medications that are used in some autoimmune deficiency illnesses. But the conclusions to date to not enable us to recommend this or that treatment.
We have decided to wait for the publication of a large scale clinical study that is being conducted in China which should come out during the next two months to confirm if these medication associations work. This is our position on the issue.
How much have budget cuts for research, public universities and for the SUS public health system damaged and weakened our capacity to fight this pandemic?
We are now trying to undue some of the cuts that were made. We have managed to undue some things. But, without a doubt, the Brazilian virologists and geneticists have made some extraordinary contributions, starting with the researchers in São Paulo who isolated the genome 3 days after it arrived in Brazil from Europe. Now we have a group of researchers from universities in Minas Gerais, Sâo Paulo, Rio Grande do Sul, Rio de Janeiro and Fiocruz who are working on developing an epidemiological profile of existing mutations.
Today, we can say that the virus which is circulating in Brazil already has Brazilian characteristics. In other words, it has already mutated to adapt to our country. The Brazilian virus already has a cluster, or viral conglomerates, which makes it different from that which is circulating in China or in European countries.
What measures should people take with food when they bring it in from outside the house, with pets, hair and beards, to not get contaminated?
They should follow hygiene standards. Wash packaging with soap and water. When food is ordered for home delivery, always take care to pass a rag or something else, preferably disposable, on the packaging to clean those surfaces, since the virus can stay on them for hours. The number of hours has not been established yet, but we know it can survive for several hours on smooth surfaces.
There a lot of people who have coronavirus who don’t know they have it, since 80% of infections are asymptomatic. Is there any kind of home testing kit that people can use to find out if they have coronavirus?
So a lot of people don’t know they have it, mainly youth…
They will never know. However, the recommendations are the same for everyone: continue in social isolation, don’t hold parties, don’t go to bars. This is a moment in which everyone has to help out. And take care of your elderly relatives: parents, stepparents, uncles, etc. Take care of means stay away from them as much as possible for now. And for now, no hugs or kisses.