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COVID-19 International Perspectives: Brazil, 10/2 · The SHEA Podcast

• 0:10
  SPEAKER_01: Welcome to the Rapid Response Podcast, brought to you by the Society for Healthcare Epidemiology of America, Shay, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:25
  SPEAKER_01: I am Dr.
• 0:25
  SPEAKER_01: David Bannock from the University of Connecticut and I will serve as your moderator for today's podcast.
• 0:30
  SPEAKER_01: Discussion on the podcast does not reflect Shay's perspective but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:40
  SPEAKER_01: Shay is excited to launch this episode of the podcast, COVID-19 updates, What We Know Now.
• 0:45
  SPEAKER_01: Today's discussion will focus on international perspectives in Latin America.
• 0:50
  SPEAKER_01: Our speaker today is Dr.
• 0:52
  SPEAKER_01: Maria Clara Potovesi, an associate professor at the School of Nursing, University of Sao Paulo, Brazil.
• 0:59
  SPEAKER_01: She is currently the Vice President of the Brazilian Association of Professionals in Hospital Epidemiology and Infection Prevention.
• 1:06
  SPEAKER_01: Thank you for joining us today.
• 1:07
  SPEAKER_01: Before we start our discussion, I would like to turn it over to Dr.
• 1:09
  SPEAKER_01: Cindy Prinz to get us started with a brief news and guidance update from the week.
• 1:15
  SPEAKER_00: This week, the world surpassed 1 million deaths from COVID-19, with 206,000 of those deaths in the U.S.
• 1:22
  SPEAKER_00: Several reports were posted as early releases in the MMWR this week.
• 1:26
  SPEAKER_00: In the first of those, changing age distribution of the COVID-19 pandemic, United States, May to August 2020, authors examined a shift in age trends for COVID-19-like illness FD visits, positive SARS COVID-2 RTP-CR test results, and confirmed cases of COVID-19.
• 1:46
  SPEAKER_00: Nationally, they noted a shift in the median age of confirmed COVID-1925 from a median of 46 in May to a median of 38 in August, and also noted that from June to August, incidence was highest among those aged 20 to 29 years.
• 2:03
  SPEAKER_00: Of note, in age of gas represents 4, 6, and 9, which includes dates in the Southeast, South Central, and Southwest of the U.S., the 15% positivity in the 20 to 39-year-old group was followed an average of 8.7 days later by a trend to an upward slope in those aged 60 and older, with this being most evident in the Southeast but notable in each region.
• 2:27
  SPEAKER_00: Authors concluded that younger adults contributed to transmission in the community of COVID-19 to older adults.
• 2:34
  SPEAKER_00: In another report, authors looked at COVID-19 trends among school-age children in the United States from March 1st to September 19, 2020.
• 2:43
  SPEAKER_00: During this time period, the average weekly incidence of COVID-19 and the 12 to 17 year age group was double that of the 5 to 11 year age group.
• 2:53
  SPEAKER_00: For school-age children who were hospitalized, 16% had at least one underlying condition.
• 2:59
  SPEAKER_00: While for those who were admitted to an ICU, it was 27%.
• 3:03
  SPEAKER_00: And for those who died, 28% had at least one underlying condition.
• 3:08
  SPEAKER_00: Chronic lung disease was the most frequently recorded underlying condition overall.
• 3:12
  SPEAKER_00: Demographically, of all cases recorded in the 5 to 17 year age group, 50.8% were female.
• 3:19
  SPEAKER_00: For those who had data on race and ethnicity, 17% were non-Hispanic black, 32% were non-Hispanic white, and 42% were Hispanic Latino.
• 3:31
  SPEAKER_00: 5% of cases in the 5 to 17 year age group reported no symptoms, 58% recorded at least one symptom, and data was missing or unknown for 37%.
• 3:43
  SPEAKER_00: 1.2% of children in this age group were hospitalized, one-tenth of a percent were admitted to an ICU, and one hundredth of a percent died.
• 3:53
  SPEAKER_00: And finally, COVID-19 vaccine candidates continued to be in the news.
• 3:57
  SPEAKER_00: The New England Journal of Medicine published an article looking at the response of older adults to the Moderna mRNA 1273 vaccine candidate.
• 4:06
  SPEAKER_00: The authors recorded mild to moderate side effects in the 40-person trial with age groups of 56 to 70 years and greater than 71 years.
• 4:16
  SPEAKER_00: Compared to the 25-microgram dose, the 100-microgram dose included higher binding and neutralizing antibody tighters, and the authors concluded that these immune responses in these groups were similar to those in the 18 to 55-year-old recipients.
• 4:30
  SPEAKER_00: Johnson Johnson reported that they began their phase three trial of their adenovirus vaccine.
• 4:36
  SPEAKER_00: They planned for 60,000 study participants aged 18 and older to be enrolled in seven countries to test the single dose vaccine.
• 4:45
  SPEAKER_01: Well, thank you, Dr.
• 4:47
  SPEAKER_01: Prinz.
• 4:47
  SPEAKER_01: Let's move into the discussion with Dr.
• 4:49
  SPEAKER_01: Potovese.
• 4:50
  SPEAKER_01: So, Dr.
• 4:51
  SPEAKER_01: Podovese, thank you again for joining us on the podcast.
• 4:54
  SPEAKER_01: I'm interested in hearing some of your experiences in Brazil.
• 4:57
  SPEAKER_01: We've had a lot of discussions on the United States experience, and we most recently had a discussion with Dr.
• 5:03
  SPEAKER_01: Timbaya about his experience in Singapore.
• 5:05
  SPEAKER_01: I think it's really helpful for us to hear about how others throughout the world are experiencing the COVID-19 pandemic.
• 5:12
  SPEAKER_01: Today we're interested in hearing about your experience in Brazil.
• 5:15
  SPEAKER_01: I was hoping you could give us sort of an overview as to where things stand right now with regard to COVID-19, and then we'll talk a little bit about some of the recent months of how the pandemic hasn't unfolded, has unfolded in Brazil.
• 5:30
  SPEAKER_02: Okay, thank you.
• 5:31
  SPEAKER_02: Thank you for having me.
• 5:34
  SPEAKER_02: The current situation in Brazil, well, in terms of our official numbers, it shows nearly five million cases, with 140,000 deaths, unfortunately.
• 5:46
  SPEAKER_02: These cases were spread over the country with large numbers in the southeast region, because this is the most populated region.
• 5:56
  SPEAKER_02: And however, in the northeast and north regions, we also have a higher number of cases.
• 6:02
  SPEAKER_02: Regarding deaths per 100,000 inhabitants, the highest mortality rate occurred so far in the north regions.
• 6:11
  SPEAKER_02: Although the number of newer cases are slightly declining, it's still too early to say that the curve is completely going down in the country.
• 6:23
  SPEAKER_01: So thanks for sharing that.
• 6:24
  SPEAKER_01: I'm pleased to hear that you're seeing declining rates in uh your country.
• 6:28
  SPEAKER_01: Although uh here in the United States we've seen that, but we are still uh maintaining a lot of caution with what the future might look like and kind of making our preparations.
• 6:38
  SPEAKER_01: So can you take us back to the early months of the pandemic, like around maybe uh January through March, when things were starting to unfold throughout the globe, and yeah, that was when we started to see cases here in the United States.
• 6:50
  SPEAKER_01: But when we go back to that time, could you kind of walk us through what uh Brazil's experience was in the early months of the pandemic, both in terms of where cases started to appear, but then also what the country's response was to those early cases.
• 7:05
  SPEAKER_02: So we have the first case detected in Brazil one uh in the 25th February in São Paulo State.
• 7:14
  SPEAKER_02: As you know, January and February are vacation period, so we receive lots of visitors as well.
• 7:22
  SPEAKER_02: People go abroad.
• 7:24
  SPEAKER_02: So an individual that came from Italy comes to Brazil is a Brazilian person.
• 7:31
  SPEAKER_02: So we cannot say this is what the index case because we have all this exchange.
• 7:37
  SPEAKER_02: But uh, since then we begin to have cases.
• 7:41
  SPEAKER_02: After that, at least I may say we have a variety of behavior uh in the country because this, you know, uh Brazil is a federation and the states and cities have relative autonomy to decide about health measures.
• 7:59
  SPEAKER_02: So in at least I may say you that uh the government in the Sao Paulo state delivered a decree uh about the closure of non-essential activities and the restriction of public transport from 22nd March.
• 8:16
  SPEAKER_02: And furthermore, a second decree from May 4th made the use of face mask communities in community settings mandatory, and this is still like the same.
• 8:28
  SPEAKER_02: And there are at least two studies that have demonstrated the beneficial effect of this disclosure in the reduction of deaths.
• 8:38
  SPEAKER_02: But regarding the impact of the use of masks in the community, it is still not demonstrated.
• 8:45
  SPEAKER_02: We also have several guidelines delivered by the national regulation agents, especially related to healthcare facility management of COVID-19.
• 8:59
  SPEAKER_01: So it sounds like the initial cases were sort of localized into one specific area.
• 9:06
  SPEAKER_01: Was that in urban area?
• 9:08
  SPEAKER_01: And then how did the spread proceed from those initial cases?
• 9:12
  SPEAKER_01: Was it still fairly local in a specific region or did it start to spread very quickly throughout the entire country?
• 9:19
  SPEAKER_02: Now, in the early times of the epidemic, the cases occurred uh mostly in large cities in capitals, but as the progress of the epidemic cases went to the inner part of the country, so today we are uh having a spread situation.
• 9:40
  SPEAKER_02: So, of course, this is natural because people are more in the agglomeration, crowded people in large cities.
• 9:47
  SPEAKER_01: Yeah, we so we had the same experience here in the United States.
• 9:50
  SPEAKER_01: Certainly uh in the early phases, the cities were the main focus of infections, and we saw the highest rates of infections in some of the largest cities, and then as time has unfolded, we've seen more cases spread out to suburban and even more rural areas in the country.
• 10:06
  SPEAKER_01: Now it's interesting that you mention that Brazil's composition is sort of several different states within the country.
• 10:15
  SPEAKER_01: That's something that in the United States has posed somewhat of a challenge.
• 10:19
  SPEAKER_01: A lot of the decisions regarding the public health response measures have been delegated to the states.
• 10:26
  SPEAKER_01: So each state was able to make its own decisions about masking, about whether certain activities would be allowed, whether certain types of buildings and facilities would be closed or not.
• 10:37
  SPEAKER_01: And that was somewhat of a challenge in that there was not a uniformity across all the states.
• 10:42
  SPEAKER_01: Can you speak to Brazil a little bit in that regard?
• 10:45
  SPEAKER_01: Whether all of the different states within Brazil are responded in the same way, or whether there was a lot of difference between the different states in the way that they responded?
• 10:55
  SPEAKER_02: So the states respond differently.
• 10:58
  SPEAKER_02: As you know, Brazil is a country, a continental country with marked social inequality and social cultural heterogeneity as well.
• 11:09
  SPEAKER_02: So this is not only about the different response in different states, but also we have several differences, and inequality is uh huge in the country in many states.
• 11:24
  SPEAKER_02: So we do not have a unique response, we have several responses depending on the state, and sometimes depending on the city as well, because the cities they have also relative autonomy and uh they are delegated to do mostly the public health measures.
• 11:44
  SPEAKER_01: Okay, that's interesting.
• 11:46
  SPEAKER_01: Sounds like some similarity with our response here in the United States.
• 11:49
  SPEAKER_02: Yeah, yeah, yeah, yeah.
• 11:51
  SPEAKER_02: There are similarities, of course.
• 11:53
  SPEAKER_02: Each state has their own way of dealing with things.
• 11:57
  SPEAKER_02: So my experience is pretty much more linked to the Sao Paulo State health measures.
• 12:04
  SPEAKER_01: So can you speak maybe a little bit specific to Sapolo, but uh with regard to how the community responded to these recommendations, things like masking, limiting large groups, activities, what was the general response of the community once these measures were starting to be implemented?
• 12:22
  SPEAKER_01: Was the community accepting of them?
• 12:24
  SPEAKER_01: Was there variation in the way that communities responded?
• 12:28
  SPEAKER_01: Can you sort of reflect on some of that experience?
• 12:31
  SPEAKER_02: Well, this is a very good question because, again, this is highly variable depending on the regions and cities.
• 12:38
  SPEAKER_02: So the acceptation, for example, of mask use varies a lot, but I can say that overall people are masking themselves most of the time.
• 12:49
  SPEAKER_02: Something that it's necessary to think about is how much relevant is the use of masks as the main protective measure in poor communities where access to water, hygiene products, and physical distance is not a possibility.
• 13:05
  SPEAKER_02: So there are different uh possibilities of measures for different people due to the inequality in the country.
• 13:13
  SPEAKER_02: And also the crowded public transport is a huge challenge for many people, including healthcare workers, that have to spend significant amounts of time in the public transport, mainly in large cities such as Sao Paulo.
• 13:30
  SPEAKER_02: And besides, you know, people using masks they seem to feel comfortable, and sometimes they are neglecting other uh measures such as hand hygiene and uh physical distances.
• 13:46
  SPEAKER_02: So this is a very complex uh situation, especially in this context of social inequality.
• 13:54
  SPEAKER_01: I think that's a really great point.
• 13:56
  SPEAKER_01: It certainly shows that even if there are some principles that should guide responses, really the importance of individualizing responses to specific communities and being aware of the whole picture for each of these communities in terms of what the biggest challenges are really important.
• 14:14
  SPEAKER_01: And it sounds like in Brazil that's been uh really highlighted given how different certain communities are in terms of their social and demographic and uh living conditions are uh are very variable.
• 14:25
  SPEAKER_01: So I think I think that's a really good point that we should all be thinking about in terms of how to best respond to the needs of uh the country and the community.
• 14:33
  SPEAKER_02: Yeah.
• 14:34
  SPEAKER_01: I'm interested in hearing about the experience of hospitals in Brazil.
• 14:38
  SPEAKER_01: You know, here in the United States, we've seen certainly some challenges within healthcare settings and hospitals specifically.
• 14:46
  SPEAKER_01: Initially, there were challenges with testing availability, and then uh the subsequent challenges were in uh PPE, the personal protective equipment supplying, that uh you know became a very difficult situation.
• 14:59
  SPEAKER_01: But I'm interested in hearing how the hospitals in Brazil and maybe even specifically within Sao Paulo, what kind of challenges arose within the healthcare system and how the healthcare community responded to those challenges?
• 15:13
  SPEAKER_02: Okay, thank you.
• 15:14
  SPEAKER_02: So, in terms of um Brazil, you know we have the health national regulatory agents and visa.
• 15:22
  SPEAKER_02: So, in general, they deliver guidelines, evidence-based guidelines.
• 15:28
  SPEAKER_02: So, overall, we have a guideline at national level for healthcare facilities to follow.
• 15:35
  SPEAKER_02: For Sao Paulo State, we also have the hospital infection division that deals with guidelines specific for Sao Paulo.
• 15:45
  SPEAKER_02: In general, they are very aligned in general, I'm saying, because uh in this pandemic we have many different situations in terms of guidelines, not only in the country, but uh I think all over the world, uh many guidelines, international guidelines, and sometimes conflicting guidelines as well.
• 16:05
  SPEAKER_02: So, in terms of guidelines, I think we have some support at both national and state level.
• 16:14
  SPEAKER_02: But when it comes to PPE, of course, uh PPE supply is not only a problem for this moment.
• 16:24
  SPEAKER_02: This is a long-time problem in the country, mainly in some underfunded healthcare settings.
• 16:31
  SPEAKER_02: Therefore, in the first moment, this problem has extremely aggravated.
• 16:37
  SPEAKER_02: However, with mobilization of healthcare workers, organizations, and professional societies, many solutions were developed to minimize the problem.
• 16:47
  SPEAKER_02: And even the public university had an important role of bringing up innovative solutions.
• 16:53
  SPEAKER_02: For example, I can mention studies on masculine reprocessing and development and low-cost phase shield as an example on how to deal with problem.
• 17:04
  SPEAKER_02: And uh perhaps uh we still have a problem with PPE, but uh I don't think uh we are now kind of dealing with the problem better than in the beginning, of course.
• 17:17
  SPEAKER_01: I think that's true across the globe.
• 17:20
  SPEAKER_01: Each time that we found a challenge, we've been working to find unique solutions, things like reprocessing of mass, things that we hadn't previously considered in uh in terms of infection prevention practices that became necessary solutions to some of the challenges.
• 17:35
  SPEAKER_01: And it sounds like some of that experience has been reflected in Brazil as well, and as a way to kind of meet the needs and take care of patients in the safest way that we uh that we reasonably can.
• 17:46
  SPEAKER_02: Yeah.
• 17:46
  SPEAKER_02: And I would like to add about tests, because uh this has been a challenge overall.
• 17:53
  SPEAKER_02: We have availability of tests of PCR uh for individuals that have symptoms.
• 18:01
  SPEAKER_02: So overall, this has not been a problem.
• 18:04
  SPEAKER_02: We we do not have tests for all the population, but in the healthcare facilities in general, if someone is having symptoms, we can test using PCR.
• 18:17
  SPEAKER_01: Good.
• 18:17
  SPEAKER_01: I'm glad to hear that that testing is available for symptomatic patients.
• 18:22
  SPEAKER_01: I think when we reflect on the early days when testing wasn't available, the the challenge associated with that was tremendous.
• 18:29
  SPEAKER_01: Being able to test symptomatic individuals and even moving towards kind of focused testing of asymptomatic individuals that can have a really important public health measure, I think think about the bigger picture and what the next steps might look like.
• 18:42
  SPEAKER_01: So I'm interested, you know, as you reflect on the last few months to hear what you think has happened uh in a very positive way, and maybe some areas that you think there uh could have been lessons learned for the future.
• 18:54
  SPEAKER_01: If you think about the last six months, is there something that you can reflect upon that has been a very positive thing either for your healthcare system or for the country as a whole going through the pandemic, something that you're very proud of and you think that maybe other countries can learn from?
• 19:10
  SPEAKER_02: Yeah, I can mention that one of the most challenging parts of the response was to deal with the misinformation that spread faster than good quality and evidence-based information.
• 19:24
  SPEAKER_02: Because this affects the ability of the infection prevention and control team at healthcare setting, because misinformation undermines the trust of healthcare workers and infection control teams.
• 19:36
  SPEAKER_02: Just to give you an example, we recently performed a study using the World Health Organization research protocol to access the perception of healthcare workers regarding the local infection prevention and control procedures of COVID-19.
• 19:52
  SPEAKER_02: This is a study was coordinated by Dr.
• 19:55
  SPEAKER_02: Anasara Levin from the University of Sao Paulo in cooperation with Hospital Infection Division in the State Health Department.
• 20:02
  SPEAKER_02: We have some preliminary results showing that media probably influences the concerns of healthcare workers.
• 20:09
  SPEAKER_02: So, for example, 67% of participants, healthcare workers in this study would like to have full body suits, despite this is not a WHO or national recommendation.
• 20:22
  SPEAKER_02: So it seems that media somehow affects their perception and their feeling of being protected.
• 20:29
  SPEAKER_02: Besides this, most participants demonstrate that overall they trust in their organization in which they work, but mixed messages being delivered by different levels of governments are confusing there.
• 20:44
  SPEAKER_02: So besides providing PPE and good work conditions, delivering updated training programs and good communications are essential to mitigate the healthcare workers' concern.
• 20:57
  SPEAKER_02: And this is what we are proposing to the healthcare authorities.
• 21:01
  SPEAKER_02: Also, as I mentioned, these several and conflicting guidelines, our professional association led an initiative to assemble specialists from different areas, representatives from Brazilian health regulatory agents and the Ministry of Health to promote an interdisciplinary debate aiming to building technical scientific consensus to guide and assist healthcare workers in understanding, managing, and coping with COVID-19 pandemic.
• 21:33
  SPEAKER_02: This group was denominated COVID-19 Brazil Task Force.
• 21:37
  SPEAKER_02: So I think this is a good experience.
• 21:40
  SPEAKER_02: So it's a way, it's not the only solution, of course, but this is a way to deal in this so difficult waters.
• 21:48
  SPEAKER_02: And this is a potential uh lesson learned from the epidemic.
• 21:54
  SPEAKER_01: Thank you.
• 21:54
  SPEAKER_01: I think those are such important points that we can all reflect upon.
• 21:58
  SPEAKER_01: You know, communication.
• 22:00
  SPEAKER_01: To healthcare workers, but also to the public at large, has been a challenge.
• 22:05
  SPEAKER_01: And we always think about it in terms of how do we provide the most accurate information to people that want it and need it.
• 22:13
  SPEAKER_01: And I think that's been a challenge, but something that we're constantly working on through different types of communication methods.
• 22:19
  SPEAKER_01: And then, you know, I totally agree with your multidisciplinary approach.
• 22:23
  SPEAKER_01: I think when we think about how we're going to affect change in a meaningful way, bringing groups of individuals with different backgrounds is really critical in order to understand how we can best develop and implement new guidelines that are going to change practice.
• 22:39
  SPEAKER_01: Before we close, I'm interested in sharing your thoughts about the future for Brazil.
• 22:45
  SPEAKER_01: Do you have any anticipation as to where things may go?
• 22:48
  SPEAKER_01: Granted, there's always going to be some uncertainty with the future is going to look like, but can you share where things stand with the country and what you're working towards at the moment thinking about the future?
• 22:59
  SPEAKER_02: So I think it's hard to say how things can go forward in terms of the whole country, especially because we are living a very difficult time in terms of economical situation, and also because I do not have a full experience in the country.
• 23:21
  SPEAKER_02: But I think we have learned a lot and we are much more prepared for the next epidemic, may I say, maybe influenza or any other type, because we have some plans, we have in place preparedness plans that already exist and we are improving it.
• 23:41
  SPEAKER_02: So I think working more on around preparedness plan is necessary because we will have other epidemics.
• 23:50
  SPEAKER_02: I don't want, but this will probably happen.
• 23:54
  SPEAKER_02: So we need to be better prepared.
• 23:56
  SPEAKER_02: We need to be better prepared in terms of having a multidisciplinary approach, but also we need to provide more conditions for healthcare settings and healthcare workers to work on safety situations.
• 24:12
  SPEAKER_02: This is, I hope at least this is a lessons learned for the whole country.
• 24:18
  SPEAKER_01: Great, thank you for sharing that.
• 24:20
  SPEAKER_01: So I really want to thank you for joining the podcast.
• 24:22
  SPEAKER_01: I think this has been a great discussion, and I think that the listeners to this podcast will be very excited to hear about uh your experience in Brazil and some of the uh successes that you've had and uh thinking about the future.
• 24:34
  SPEAKER_01: So thank you again for joining us.
• 24:37
  SPEAKER_02: Oh, thank you a lot.
• 24:38
  SPEAKER_02: Thank you for having me, and I hope this can be helpful and can I like the idea of sharing ideas.
• 24:45
  SPEAKER_01: Absolutely.
• 24:46
  SPEAKER_01: So thank you very much to our speaker for sharing experiences and perspectives, and a sincere thank you from Shay to all healthcare personnel for all that you are doing to respond to COVID-19.
• 24:58
  SPEAKER_01: This podcast can be accessed on Shay's online education center, Learning CE, under the Rapid Response Program.
• 25:04
  SPEAKER_01: You'll also find resources such as the recorded webinars, healthcare facility outbreak preparedness, and the SHAY COVID-19 town halls.
• 25:12
  SPEAKER_01: Additional resources available on Learning CE pertinent to this pandemic include the SHA CDC RTP and the prevention course in HII Knowledge and Control Prevention Check.
• 25:23
  SPEAKER_01: You can now receive 75% off SHA membership for the remainder of 2020 using the coupon code podcast during checkout.
• 25:31
  SPEAKER_01: That concludes this episode of the Rapid Response Podcast.
• 25:34
  SPEAKER_01: Thank you for tuning in.