The COVID-AM blog is a partnership between the UMI 3157 iGLOBES and the Institut des Amériques, coordinated by François-Michel Le Tourneau, Deputy Director and Marion Magnan, researcher at the Institute. About the blog.
what role do tests have in managing COVID-19 in brazil?
April 30, 2021
by Koichi Kameda, Ph.D in sociology from EHESS and jurist, currently postdoctoral researcher with IFRIS at the Centre Populations et Développement.
by Mady Barbeitas, sociologist and veterinarian, doctoral student in sociology at the EHESS in the CERMES3, Research Assistant for the CoBRATestes project.
Input from Marilena Corrêa, Associate Professor at the Social Medicine Institute of the Federal University of the State of Rio de Janeiro
In March 2020, over a year ago, the World Health Organization Director was asking all countries to invest into doing more screening tests in order to control the spread of SARS-CoV-2, the virus that causes Covid-19. Furthermore, at the start of the pandemic, tests were the primary public health response of most countries. Countries considered "models" by public health experts were those who put a huge testing system in place. Screening tests based on the polymerase chain reaction technique (PCR) represent the gold standard when it comes to detecting people infected with the new coronavirus.
What is good about testing is that people who test positive can quickly be isolated, then contact tracing can be done to break the cycle of transmission. Adopting a policy such as this one, however, was not easy for all countries. Mexico, Argentina and Colombia, so all the countries in Latin America the most affected after Brazil, have total testing rates of 46.37 (Mexico, April 18, 2021), 179.95 (Argentina, April 14, 2021) and 272.56 (Colombia, April 19, 2021) per 1000 people. We're far from the leaders in this area: total test rate in the United States is 1,201.12 per 1000 (April 16, 2021)[1]. So the role of testing within national strategies to deal with the pandemic seem to have differing priorities in the Americas.
This blog will analyze Brazil's case more closely in order to shed light on the role of diagnostic testing in response to Covid-19, using data coming from the on-going research project "CoBRATestes - Testing Capacity for Covid-19 in Brazil: National technological production and universal access to health in times of political uncertainty" financed by the Agence National de Recherche sur le Sida et les Hépatites Virales and the Institut Francilien Recherche, Innovation, Société. The project is led by a network of researchers that belong to the University of Rio de Janeiro, the Fondation Oswaldo Cruz, the Centre Population et Développement (CEPED) and the Centre de Recherche Médecine, Sciences, Santé, Santé Mentale, Société (CERMES3).
AN ISSUE OF CAPABILITY OR POLITICS?
One major issue for a PCR testing strategy is the ability to increase the number of tests that can be offered to the population. This means production and/or imports of reagents and specialized equipment, and the transportation and treatment of the samples.
In Brazil, the logistics and capacity to produce molecular tests and the treatment of samples do not seem to be a problem anymore. Although the country was severely impacted by the lack of reagents on the international market at the start of the epidemic (March 2020), the situation changed in the second semester of 2020. Investments made by the public and private sectors increased this capacity. First of all, the Fondation Oswaldo Cruz, part of the Ministry of Health, with its institute for research and production of vaccines and immunobiology (Biomanguinhos) committed to the production of part of the material inputs for the PCR tests used in the public health system. Then, the Fondation organized the installation of four big centers in four Brazilian states (Rio de Janeiro, Sao Paulo, Paraná et Ceará) to analyze molecular tests. Infrastructure investments, such as the construction of hospitals (rural and clinical research) and factories for vaccine production that benefited from these types of donations. Also, a group of private laboratories temporarily took on for free the production of part of the tests for the public sector of Sao Paulo. For sure, it is too soon to confirm whether these initiatives will open the door to a new tendency toward private financing in the public health domain. It may be specific to a pandemic situation.
The four newly built centers provided an additional capacity of about 1 million PCR tests per month to the network of public laboratories (Lacens) previously established. Furthermore, the private medical screening laboratories also increased their capacity, providing a large variety of tests for Covid-19, accessible to those who have private insurance and those who can pay out of pocket (less than 30% of the Brazilian population).
Despite the increase in the ability to produce tests, the outcome of the results within the Brazilian management of the epidemic does not seem very clear. The total amount of tests done are hard to find, and they do not differentiate between the various tests (PCR or serological), nor the part done by the private sector - the government has only recorded the number of positive cases. Then, the rate of testing has not increased continuously. On the contrary, the number of PCR tests done per day in the public sector has decreased from 57,319 to 47,232 between January and February 2021. And the number of PCR tests - around 30 million tests done by the public and private sectors up through March 13, 2021, - seems insufficient for a population of over 210 million people.
Yet, the low number of tests done does not come from a lack of availability. A November 27 2020 report had counted 15 million PCR tests stocked by the Ministry of Health, unused, most of it soon to expire. In reality, these tests, bought from a Korean company, were not compatible with the equipment set up in the public laboratories. In order to avoid losing them completely, the government decided to give them to private Brazilian institutions and to other countries in the region, such as Haiti.
So, despite the effort to increase the production capacity and test treatment, the country never put a real strategy in place for their use. During the first months of the epidemic, the Ministry of Health had created the policy Diagnosticar para cuidar (screen in order to treat) in which the increase in capacity to test was tied to isolation and tracing of contact cases. But this policy seems to have been put aside because of diverging opinions between the Ministry of Health and the president on the social isolation measures and on the use of chloroquine, the reason for the firing of two ministers in April and May 2020.
REASONS FOR THE ABSENCE OF A SCREENING STRATEGY
The absence of a real screening strategy can have other reasons, especially political. Molecular tests of Covid-19 are part of an international health policy known under the acronym TTI "test, trace, isolate". If the test is disassociated from this triad, it loses its function in terms of control of the epidemic. Yet, the increase in capacity in Brazil in this domain has to do with only the offer of tests, not its use. In terms of use, the quantity is even lower. However, the promise of a "massive offer" of tests without objectively encouraging their use is often mentioned by political entities in order to influence votes in the next presidential election. A promise imbued with political interest that has no results on public health.
The tests also play a major role in giving information to the public health authorities on the status of the epidemic. This role is even more important with the need to follow the arrival of new variants of the virus. Accordingly, the absence of a real strategy to screen and of an exhaustive database of the testing results seems coherent with the way the Brazilian authorities governed Covid-19, trying to eliminate information on the evolution of the epidemic in June 2020[2] (Ortega and Orsini 2020).
[1] Our World In Data, Cumulative COVID-19 tests. Last accessed on April 22, 2021
[2] At the start of June 2020, the Ministry of Health temporarily erased from its internet page information on the total amount of SARS-COV-2 confirmed cases. The government also expressed its intention to relate the number of Covid-19 deaths by arguing that the State and municipal officials would have inflated their numbers in order to get additional funds.
REFERENCES
Kameda K, Barbeitas MM, Caetano R, Löwy I, Oliveira ACD, Corrêa MCDV, Cassier M. Testing COVID-19 in Brazil: fragmented efforts and challenges to expand diagnostic capacity at the Brazilian Unified National Health System. Cad Saude Publica. 2021 Apr 7;37(3):e00277420.
Ortega, Francisco, and Michael Orsini. 2020. “Governing COVID-19 without Government in Brazil: Ignorance, Neoliberal Authoritarianism, and the Collapse of Public Health Leadership.” Global Public Health, 1–21.
Koichi Kameda holds a Ph.D in sociology from EHESS and is a jurist. He is currently a postdoctoral researcher with IFRIS at the Centre Populations et Développement. He is one of the coordinators of the "CoBRATestes – Testing Capacity for COVID-19 in Brazil: National technological production and universal access to health in times of political uncertainty" project, financed by the Agence National de Recherche sur le Sida et les Hépatites Virales
by Mady Barbeitas is a sociologist and veterinarian. She is a doctoral student in sociology at École des Hautes Etudes en Sciences Sociales at the Centre de Recherche Médecine, Sciences, Santé, Santé Mentale, Société (CERMES3). She is a Research Assistant for the CoBRATestes project.