Introduction

A Little on Demographics

Brazil is the sixth most populous country in the world, comprising 2.7% of the world’s population, with over 212 million inhabitants. Its free market economy is the eighth largest in the world by purchasing power parity (PPP). Its projected gross domestic product (GDP) comprising 2.38% of the world’s share decreases to 1.73% and twelfth position if the nominal GDP is considered [1, 2]. Notwithstanding its somewhat privileged status, Brazil is tainted for having one of the highest socioeconomic disparities globally. It holds the 87th place in the world according to per capita GDP (or 86th if we consider PPP) [1,2,3]. Almost a fifth of its population (38.1 million as of the 2018 national census update) is said to be under the poverty line (USD 100 per capita per month), most of which (72.7%) is self-identified as Blacks and Pardos (Browns). These minorities (13.5 million) have a monthly per capita income of a mere USD1.9 a day (cut-off adopted by the World Bank for the extreme poverty line) [1, 4,5,6,7]. According to recent updates provided by the last nationwide census, Brazil has over 13 million of its people living in favelas (slums), a population surpassing that of Portugal and Greece [8, 9]. These slums are overcrowded, multigenerational households with little access to sanitary conditions. Given this scenario, one can foresee the grim future that can be caused by a pandemic.

Despite a slight drop over the past decade, Brazil’s illiteracy rate remains high, with over 11.5 million (7.0%) of its age-adjusted population still unable to read. The last National Census Bureau (IBGE) update showed that the main reason for this was that young people needed to join the workforce to help support their families [10,11,12]. Almost 20% of the country’s population is over 60 years of age. This age group is most vulnerable to COVID-19. The illiteracy rate is two times in Blacks (9.9%) as compared to Caucasians (4.2%), reflecting the low socioeconomic and educational status of the most underserved racial and ethnic minorities in the country [13].

Of greater immediate concern is that overall unemployment has affected over 12.0% of the country’s available workforce with informal jobs. Unpaid leave represents more than 50% in over a third of the states in Brazil [14]. Despite government support schemes with stimulus and cash transfer programs for the most needy and underprivileged, including a monthly aid package of roughly USD 100,00 for up to two family members during the first wave of the pandemic and the Auxílio Brasil of around USD 7,500, which is expected to benefit more than 14.5 million families during the current (third) wave, many have not yet benefited from these measures [15]. While logistical issues may partly explain this, since the deposits are conditioned upon having access to and knowing how to handle a specific mobile application from the country’s main government owned bank, fraud at various levels has prevented these benefits from reaching the people in need. This has rendered many of those who lack savings and are bread winners unassisted. It is estimated that of the 60 million Brazilians who are eligible for the benefit, up to six million represent small rural workers who largely depend on family farming for their livelihood [11, 12]. While Brazil’s food supplies are still somewhat sustained, millions struggle to stay above the poverty line. Concurrently, violence rates are also on the rise, as depicted by recent accounts of domestic violence [16].

Overview of the Chapter

Two years after the COVID-19 pandemic began, it became clear that its overall impact on the country depended upon intertwined health, social, and political actions. The heterogeneity of the vaccination rollout further underscored the importance of providing equitable access to preventive and therapeutic resources around the country without which Brazil could face dreadful consequences. Hence, a global approach is key to overcoming the impact of COVID-19 [17].

This chapter provides an overview of the first two years of the COVID-19 epidemic in Brazil from social and political perspectives. While highlighting Brazil’s regional and social disparities, it sheds light on how these have modulated the impact of the pandemic in the country.

This review is based on official and scientific data drawn from PubMed, Medline, and SciELO databases as well as from publicly available sources including press releases presumed to contain timely and credible information. Since Brazil lacks standardization of these datasets, the COVID-19 databases need to be improved. Reliable data should be shared across regions and states. This is key to providing a reliable picture of the evolving status of the pandemic in the country.

The Wider Scope of the Pandemic

Since its outbreak in late 2019, the COVID-19 pandemic spread at an alarming speed across the globe, with a case tally of over 370 million and a death toll of more than 5.6 million as of late January 2022. Ranking third among the world’s most affected hotspots, Brazil was by far the hardest hit among its Latin American neighbors. Brazil had over 25 million cases, a death toll in excess of 625,000, and an overall fatality rate of 2.5% [4, 18, 19]. The actual toll is likely higher. It is underestimated because of limited testing and inconsistency in cause-of-death reports [18, 19]. Despite global efforts and billions of dollars of investment, no vaccine was available in Brazil at scalable and nationwide levels until the first quarter of 2021 [20]. Apart from the evidence provided around mid-July 2020 on the benefit of dexamethasone (and other steroids) in patients with COVID-19-related acute respiratory distress syndrome (ARDS), no other treatment was shown to reduce mortality from this disease until 2021 [21]. Many of the currently available treatment options for COVID-19 have yet to be approved in the country.

The unfavorable pandemic scenario with which the world was faced during the third quarter of 2021 was recently reinforced by the appearance and worldwide increase of SARS-CoV-2 viral Variants of Concern (VOC) which have already been shown to be resistant to novel medications, particularly monoclonal antibodies (mAbs), thus resulting in treatment failure and limiting treatment options [22, 23]. With the advent of the SARS-CoV-2 B.1.1.529 Omicron VOC in late January 2022, the Food and Drug Administration (FDA) of the United States of America (USA) decided to revoke its emergency use authorization (EUA) for two mAbs against COVID-19, namely casirivimab and imdevimab, manufactured by Regeneron Pharmaceuticals, and bamlanivimab and etesevimab, by Eli Lilly. There is a lack of evidence regarding the effectiveness of these treatment options for patients at high risk of developing severe disease caused by Omicron, which currently accounts for virtually 100% of cases in the USA, Brazil, as well as in other parts of the world [24, 25]. The Brazilian Regulatory Agency, ANVISA, has not yet withdrawn its EUA but has advised that extra caution be taken and sound clinical judgment be made when prescribing this treatment amid the current upsurge of Omicron cases [26]. As possibly effective therapeutic options for mitigating the risk of severe disease, hospitalization, and death due to Omicron, the FDA recently laid stress on the effectiveness of sotrovimab, the only previously available anti-SARS-CoV-2 mAb with activity against this variant, and ritonavir boosted nirmatrelvir (Paxlovid®), remdesivir, and molnupiravir, for which it issued an EUA in the USA. Neither Paxlovid® nor molnupiravir have yet been approved by ANVISA in Brazil. While Omicron cases seem to be less severe, case rates are skyrocketing worldwide and have not yet peaked in Brazil [27, 28]. Hence, it remains to be seen how the country will cope with the third wave of the pandemic.

The Brazilian COVID-19 Epidemic: An Overview

Seventy five percent of Brazil’s population depend on its Unified Health System (Sistema Único de Saúde -SUS), recognized by the World Health Organization (WHO) as the world’s largest publicly funded unified healthcare system to date. In fact, it was supposed to have celebrated its 30th birthday in 2020 [29]. Because of the COVID-19 pandemic, both the public and private healthcare sectors (including individual health plans) have been faced with the challenge of providing support to the country’s more than 210 million residents. During the first two waves of the pandemic, the health system failed in its efforts to keep pace with the increased need for healthcare personnel. This was further aggravated by the lack of specialized medical staff for managing mechanical ventilation and other life support measures [30]. Even though Brazil has an overall physician per inhabitant ratio of 2.3/1,000, which is greater than most of its middle-income neighbors, the majority of its medical workforce is concentrated in the cities [31, 32].

SARS-CoV-2 serology or polymerase chain reaction (PCR) testing coverage remains at regrettably low levels in Brazil [33]. Intensive care unit (ICU) occupancy reached alarming rates, nearing 80–100% in even the most well-equipped cities. In the northeast region, for instance, around mid-2020, it reached desperate levels, with some states witnessing a virtual collapse of their local health systems.

Furthermore, over the past couple of years, virtually coinciding with the pandemic, the country has been engulfed in ever worsening political turmoil, with counterattacks between state governors and the country’s President, Mr. Jair Bolsonaro, and between the executive leader and the country’s Supreme Federal Court (SFC), the highest organ of the Brazilian judiciary. This has greatly hampered concerted efforts to fight the pandemic ever since it began. While grappling with the best response to prevent the spread of SARS-CoV-2 across the nation, the President has found himself colliding with his own Health Ministry’s recommendations. On May 15, 2020, Brazil’s Health Minister, Mr. Nelson Teich, announced his resignation after disagreement with the President regarding the use of hydroxychloroquine, which was backed by the President at the time, and the adoption of social distancing measures. Mr. Teich was the second in a row to fall after the previous minister, Mr. Luiz Henrique Mandetta, was sacked less than a month before [34, 35]. As the disease spread during the third wave of the pandemic, mounting tensions between Mr. Jair Bolsonaro and his cabinet, the National Congress, and SFC led to great unease across the nation. There is ongoing concern about the stability of the country’s somewhat young democratic institutions [36].

Although a political crisis would be highly unwelcome at a time when united efforts are needed to tackle COVID-19, Brazil seems to be heading in that direction. Such divergence between its most prominent leaders comes at a delicate time when the country is faced with an overall health, social, economic, and political crisis in the midst of a swelling pandemic. There have been nationwide protests from both sides, with its executive, legislative, and judicial powers at odds on several matters. Such political unrest is bound to increase the impact of the pandemic, especially on the most vulnerable. The country is faced with the challenge of navigating a delicate civil military balance amid a new surge of COVID-19 cases and health system overload. The scientific community and the people are puzzled by the opposing views conveyed by the country’s leaders [36].

Several lockdown restrictions were gradually eased across the country when the first and the second wave receded. Some might argue that there is no one-size-fits-all approach to prevent an upswing in the SARS-CoV-2 epidemic curve. Early experience in some developed countries such as Sweden, which actually tried to challenge the need for strict social distancing policies and relied on herd immunity as the way out of the crisis, also could not refute the effectiveness of social distancing measures [37]. Because of the lack of universally available testing in Brazil, an upsurge in both the disease burden and the death toll is being witnessed countrywide. Therefore, to decrease the transmission of the Omicron SARS-CoV-2 variant while gradually lifting restrictions and tackling economic stagnation requires aggressive surveillance by widespread testing and contact tracing, for which the country is ill-prepared [36].

The Imperial College London, UK, undertook a study that showed that 300,000 deaths could have been prevented if the government had followed the WHO’s and the Health Ministry’s guidance during the first year of the pandemic [38]. Not implementing preventable measures has led to the present tragic situation in Brazil.

On the positive side, Brazil has the largest publicly funded healthcare system in the world. Despite having lagged behind in vaccination rollout initially, the country took a giant leap over the past six months, which resulted in two thirds of its population being vaccinated and a tremendous drop in COVID-19 cases and deaths.

There have been a number of private and public as well as volunteer and non-governmental organization (NGO) initiatives to counter the problem of inadequate supplies, particularly of personal protective equipment (PPE), respirators, and testing kits. Food supplies were made available through partnerships fostered by community leaders in the favelas, where average wages dropped by over 70% [9]. Research, still highly underfunded, has been accelerated particularly in the vaccine arena. On March 2, 2021, Brazil officially connected with the COVAX Facility as part of the “Access to COVID-19 Tools (ACT) Accelerator” partnership program launched in April 2020. This is a global collaboration led by the WHO to foster the development, production, and equitable access to new COVID-19 diagnostics (e.g., halving the costs of SARS-CoV-2 rapid tests), therapeutics, and vaccines and to ensure access to other supplies such as supplemental oxygen, PPE, and treatment [39]. On December 20, 2021, in accordance with the COVAX operating landscape, the ACT-Accelerator vaccine pillar, in light of the global vaccination target of 70% by mid-2022, Brazil agreed to make a vaccine donation of over 10 million doses to low-income, neighboring countries in need. Such collaborative efforts could pave the way towards more equitable access to the COVID-19 vaccine around the globe [39, 40].

Despite the apparent success of the vaccination rollout in the country, which, in a sense, managed to compensate for the initial inertia in the authorization of vaccines against SARS-CoV-2 (lagging behind other upper-middle income countries such as Chile and Mexico), Brazil witnessed a myriad of flaws within its public healthcare system, both in its management and infrastructure. This was in stark contrast to the private sector. The lack of mass testing and viral spread tracking, coupled with the lack of preparedness and leadership in setting strict social distancing and lockdown measures, was further aggravated by the nationwide political turmoil, with ever-changing Ministers of Health, mentioned above. Anti-science efforts, downplay of disease severity, the spread of fake news, and inadequate government support for COVID-19 treatment schemes (the so-called ‘COVID-19 kit’) further underscored the interference of the Federal Government in the country’s public health policies, the most controversial of which was its vaccination plan [20, 41].

Table 1 shows some demographic characteristics of Brazil.

Table 1 COVID-19 epidemic in Brazil: overall demographics
Full size table

Public and Private Healthcare Systems and the COVID-19 Pandemic in Brazil

Brazil has two healthcare systems, the larger of which is its public system, the so-called Unified Health System (SUS), which covers the entire nation and is offered to every citizen with no direct costs. The SUS has been recognized by the WHO as the world’s largest publicly funded healthcare system to date [29]. Seventy five percent of Brazil’s population depends on it. The second is the private sector, which may be individually or collectively paid for and acts in a supplementary manner. It is currently regulated by Brazil’s National Agency of Supplementary Health Care, ANS [41]. In Brazil, private health care providers are required to refund the SUS when any procedure covered by the provider is undertaken by the public healthcare service. Unfortunately, the country’s private healthcare service is tainted with access barriers and inequalities. As of 2021, for instance, 14 companies reached 40% of the market while only 20–25% of the population had access to private healthcare assistance. Moreover, 70% of these people live in the southeastern region where healthcare resources and intensive care unit (ICU) bed capacity are considerably higher as compared to the other regions in the country [46].

According to the Brazilian Society of Intensive Care Medicine, there are currently 45,848 ICU beds in the country—2.2 beds per 10,000 residents. In the case of the 22,844 beds available for SUS patients, this ratio drops to a mere 1.4 SUS bed per 10,000 residents. It is even lower in some regions, particularly in the northern (mainly Amazonian) and northeastern regions [47]. Around 21.5% of the ICU beds available in the public sector were originally private, and about 64% were offered by philanthropic entities. Thus, the number of beds actually offered by the public service is even lower. This is due to the fact that hospitals in Brazil can simultaneously merge both public and private healthcare networks. Additionally, about 31% of all ICU beds in Brazil are in the private healthcare sector. A report from the Oswaldo Cruz Foundation (Fiocruz), which is considered the most prominent institution of science and technology in the health field in Latin America and is under the Brazilian Ministry of Health, showed that the private healthcare network, despite being accessed by fewer than a quarter of the country’s population, has a higher proportion of ICU beds per user (62.6 per 100,000 users) than the SUS (13.6 per 100,000 population) [48]. This SUS ratio may be even lower. There are reports showing that it is as low as 7.1 beds per 100,000 inhabitants. According to the Institute of Studies for Health Policies, ICU capacity should be doubled across 53% of the Brazilian territory to prevent the collapse of the public healthcare system like the one that occurred at the beginning of the COVID-19 pandemic in 2020 [48].

There is great discrepancy in patients with COVID-19 treated by the public and private health services. For instance, according to a report from the Intensive Medicine Association of Brazil (AMIB), 106,546 COVID-19 patients were hospitalized from March 1, 2020 to March 10, 2021. Of these, 4,405 (69.83%) were assisted by the private sector and 32,141 (30.16%) by the public system. A higher proportion of SUS patients required mechanical ventilation as compared to those in the private healthcare system (64.00% vs 39.60%, respectively) [49]. Likewise, overall ICU mortality rates were higher (51.90% vs 28.90%) among those assisted by the public than among those in the private sector [49]. This may be partly explained by the fact that SUS patients were placed under mechanical ventilation for a shorter period of time than those in the private health system (11.5 days vs 14.0 days, respectively) since the latter is equipped with better infrastructure for managing COVID-19 patients as compared to the public healthcare system, particularly in the proportion of ICU beds.

Despite an array of emergency government policies aimed at increasing investments in the public healthcare system to combat the pandemic, corruption and misuse of healthcare resources greatly contributed to the abyssal differences seen between the systems. Some of the imbalances relate to lower ICU bed occupation rates in private hospitals as compared to those in the SUS, which rendered several beds idle in the former. Solving this issue is somewhat challenged because there is widespread underreporting of ICU bed occupation in the private setting. For example, in the states of São Paulo and Rio de Janeiro, the private and public sector data are merged. The Brazilian National Health Council (CNS) recently advised the Ministry of Health and the state and municipal health authorities to apply a single policy for ICU bed occupation, which should be guided solely by demand and not by the location of beds in the public or private settings, as has been done in several European countries such as France, Italy, Spain, and Ireland [50, 51]. This led to a bill being passed by which the use of beds located in private hospitals would be made available to SUS patients with acute respiratory distress syndrome (ARDS) due to suspected or confirmed COVID-19. The ever-changing numbers of beds in private hospitals needs to be reported at regular intervals [51]. Despite resistance from a number of private sector enterprises, a few public–private partnerships, particularly those seen in São Paulo and Rio de Janeiro, enabled private companies to handle the costs of temporary ICU facilities in public spaces such as parks and football stadiums [52]. Such joint efforts, however, tended to be limited because of the lack of resources. Moreover, private healthcare companies tended to charge a lower price for individual, family, and collective healthcare plans which, in turn, resulted in offering services of lower quality than the standards recommended by the ANS [53, 54].

Although the number of hospital beds were more than doubled in both the public and private sectors and several medical schools waived end-of-course examinations to increase the number of newly graduated healthcare workers to be integrated into the frontlines, the healthcare system failed to keep pace with the increased need for healthcare personnel. This was further aggravated by the lack of specialized medical staff for managing mechanical ventilation and the like, particularly during the first wave of the pandemic around mid-2020 [30]. Even though Brazil has an overall physician per population ratio of 2.3/1,000 which is greater than that of most of its middle-income neighbors, the majority of its medical workforce is concentrated in cities [55].

Brazil’s Indigenous Peoples and COVID-19

With 87.6% of Brazil’s population concentrated in overcrowded urban centers, SARS-CoV-2 cases in rural areas and villages initially lagged behind those in urban centers. This did not prevent the almost 900,000 indigenous people (~0.5% of Brazil’s population), who live sparsely around the country, from being hit by the virus. These minorities, among which 57% live on officially recognized indigenous lands, comprise more than 300 ethnic groups and are spread around 12.5% of the country’s territory in 723 officially protected lands (according to the data from the last complete census in 2010) [45, 50]. Roughly a third of these people live in urban centers, which results in their not being counted for epidemiologic purposes. Thus, SARS-CoV-2 infection in these populations are largely underestimated.

Needless to say, 274 different dialects and idioms is another serious challenge for getting messages across to these people. In 1999, with a view to better adjusting the Brazilian healthcare system to the needs of the indigenous people and enhancing their access to healthcare, the Federal Government created an indigenous healthcare ‘subsystem’ consisting of 34 Special Indigenous Health Districts [12]. A decade later, in 2010, a Special Secretariat for Indigenous Health, linked to the Ministry of Health, was created, setting the stage for providing greater focus on this underserved population.

Despite these advancements, according to the Articulation of Indigenous Peoples of Brazil (APIB), the largest indigenous organization in the country, as of June 14, 2020, 2,390 people among 93 indigenous groups, most of which were from the Amazon Rainforest, had been infected by SARS-CoV-2, and 236 had died [44]. By the end of 2020, 44,648 indigenous people had been infected, among whom 605 (1.3%) had died; 41,589 had recovered from the disease [50]. The death rate doubled by January 30, 2022, with 1,260 having passed away [44]. In fact, at the beginning of the pandemic, some feared that these native communities would be ‘wiped out’, in reminiscence of the tragic impact of previous outbreaks such as that in the 1950s and 60s, which is said to have killed roughly a third of the Yanomami near the border of Venezuela [56].

As in the general population, the elderly were the most affected by COVID-19 among the indigenous tribes. Tribal chiefs, the so-called ‘caciques’, are highly regarded for their lifelong wisdom and leadership role within their tribes. Death among these tribal pillars is a great loss and is a trigger that unsettles these people. As a matter of fact, COVID-19 can be particularly devastating for indigenous groups whose tribes are smaller. The Juma tribe, for instance, lost its last individual in February 2021, Aruká Juma, an 86-year-old man who died due to severe complications of the disease. There is a need to draw greater attention to other ethnic groups given the widespread reports of COVID-related deaths among Pardos and Blacks, as well as to individuals living in the northern region, which accounts for the largest share of poor people in the country [57,58,59]. Such socioeconomic heterogeneity in access to healthcare, diagnosis, and treatment clearly places these people at greater risk of getting COVID-19 and of dying from the disease [60].

In the past, in response to the COVID-19 pandemic, some indigenous communities began to split into smaller groups and to seek refuge in the forest. They gathered material for hunting and fishing and set up camps. Some took measures into their own hands by setting up roadblocks and barriers warning outsiders to stay away from their villages. They also avoided going to urban centers, which, however, became a problem when food stocks ran out [61].

There might be a greater threat of SARS-CoV-2 for some 100 groups who live in strict isolation from the outside world. These forest dwellers were impacted by an alarming increase (~58% on a year-on-year comparison between 2019 and 2020) in illegal logging, gold mining, and land grabbing in the Amazon region [62]. This is an old but, as yet, largely unresolved issue resulting from centuries of rapacious agricultural development, cattle raising, and colonial exploitation, rendering these people particularly vulnerable to foreign diseases and infections [63]. From a broader perspective, the disruption in food supply chains, in consonance with the increase in food insecurity worldwide, represents another downturn for these peoples. They also suffer from tuberculosis, malaria, and other mosquito-borne diseases that are endemic not only among forest dwellers, but also in several urban areas across the country [60, 64].

With the support of non-governmental organizations (NGOs), both the federal and state governments should design policies directed at this particularly vulnerable population to reduce the spread of SARS-CoV-2 and to ensure that indigenous lands are kept protected from invasion and deforestation [62, 65]. In a pandemic scenario, these should include preventative measures, such as the use of masks, vaccination, and widespread testing, to curb viral spread, make timely diagnosis, and facilitate access to effective healthcare.

SARS-CoV-2 Testing in Brazil

Underreporting has been a major issue since the beginning of the COVID-19 pandemic in Brazil in late February 2020 [66]. This was at least partly due to the underdiagnosis that resulted from the lack of widespread SARS-CoV-2 testing across the country owing particularly to the lack of coronavirus real-time polymerase chain reaction (RT-PCR) kits [67]. According to data from the Ministry of Health, most of these tests were performed in the southeastern region of the country as opposed to its mid-western region, where the lowest number of tests were reported (an exception was the Federal District, which harbors the capital city’s headquarters). Likewise, in the northern region of Brazil, remote locations in the Amazon Rainforest posed an additional challenge for getting testing kits and other healthcare resources to their final destination [50]. For several months, most SARS-CoV-2 diagnoses were made through quick blood and antibody-based tests such as those based on lateral flow immunoassays (LFIA). Fortunately, from mid-2020 onwards, the Federal Government increased public expenditure on RT-PCR tests, the gold standard for diagnosing COVID-19 [50, 68]. Since the so-called ‘quick tests’ basically rely on the detection of SARS-CoV-2-specific IgM and IgG, which typically take around 10–14 days for seroconversion, they are appropriate for surveillance. COVID-19 remains largely underdiagnosed, rendering real time reporting and management not possible [69, 70]. Although there were a number of drawbacks for both types of tests regarding the timely delivery of testing kits across the states, the RT-PCR tests posed the additional challenge of the high costs of the basic testing kit components. The ever-increasing market demand, the lack of appropriate equipment, the inadequate number of qualified people for conducting the tests and of specialized centers and laboratories, as well as the barriers for the transportation of samples from one place to another, were serious challenges [67, 71]. The WHO has emphasized the importance of mass testing since this is the main means to track the virus and reduce the spread of SARS-CoV-2, with around 30% of infected individuals being virtually asymptomatic yet capable of spreading the virus [72]. Therefore, the lack of a robust, publicly sponsored testing policy, along with the sluggishness in the distribution of test kits across the country rendered the COVID-19 pandemic notorious for being mismanaged. This was especially true for locations in which social distancing was not possible such as in the favelas and indigenous villages.

More recently, during the so-called ‘third wave’ of the pandemic, self-testing kits were shown to be an important strategy for containing the spread of the virus in Europe and the USA [73]. As of January 2022, the Brazilian Health Regulatory Agency, ANVISA, approved the use of at home COVID-19 testing kits and is now waiting for the Ministry of Health to decide on how to report test results and how to distribute these kits across the country [74].

The Imperial College London COVID-19 Response Team, UK, a WHO collaborating center for infectious disease modeling, studied the possible factors driving spatial and temporal fluctuations in COVID-19 fatality rates following hospitalization across 14 state capitals in Brazil. The SARS-CoV-2 Gamma variant spread rapidly across the country, causing significant infections and deaths. More than half of the hospitalized patients died over sustained time periods [38]. The authors found that the geographic and temporal fluctuations in Brazil’s COVID-19 in-hospital fatality rates were primarily associated with geographic inequities and shortages in healthcare capacity. They projected that roughly half of the country’s COVID-19-related hospital deaths could have been prevented. The authors concluded that investments in healthcare resources, healthcare optimization, and pandemic preparedness are critical for decreasing the rates of morbidity and mortality resulting from a highly contagious and deadly pathogen such as SARS-CoV-2, particularly in low- and middle-income countries such as Brazil [38].

SARS-CoV-2 Vaccination in Brazil

Manaus, the capital city of the State of Amazonas, was the first to see its healthcare system completely collapse amid an exponential increase in the number of SARS-CoV-2 cases less than two months after the start of the pandemic in the country, in March 2020. In June, the cumulative rate of seropositivity reached 52%, after which it started to decline, suggesting that herd immunity had been achieved [75]. The demand for mass graves also began to decline. Nonetheless, only a few months later, Manaus faced a devastating second wave of COVID-19 after witnessing the emergence of the P1 lineage of SARS-CoV-2, which was shown to be more contagious and was able to reinfect individuals. This not only became a matter of global concern, but represented a great setback for any hope of achieving herd immunity to the infection [76]. In Sweden, where hopes were high in this regard, particularly at the beginning of the pandemic, it eventually became clear that herd immunity was a far off dream, further fostering the notion that widespread vaccination is the best means to reduce the spread of the virus [77]. Bearing this in mind, pre-clinical and clinical trials were undertaken at unprecedented speed, resulting in the development of several next generation vaccines, some of which started to be rolled out by December 2020, just a year after the COVID-19 pandemic began in Wuhan, China [78].

In Brazil, the second half of 2020 was marked by failed attempts of the scientific community and of several state governments to ensure that the Federal Government could make deals with vaccine makers in order to acquire the basic supplies and infrastructure needed to set up a nationwide vaccination program. Despite efforts of the Ministry of Health, the lack of interest of the government in acquiring vaccines and related supplies resulted in the country lagging behind several others even though both the BNT162b2 vaccine developed by Pfizer and BioNTech and CoronaVac developed by the Chinese company Sinovac Biotech could have been made available by late 2020 [79, 80]. After struggling amid public pressure involving Brazil’s Regulatory Agency (ANVISA), state governors, the scientific community, and biotechnology partners, namely the Butantan Institute, the Institute of Technology in Immunobiologicals (Bio-Manguinhos), and Fiocruz, Brazil finally started its vaccine roll out on January 18, 2021. It scheduled four sequential vaccination phases, the first of which would focus on healthcare workers, older adults (over 60 years of age) and those residing in institutional settings, and indigenous people [50, 81].

A year on, as of January 18, 2022, this state funded nationwide vaccination program included vaccines from the main companies available, i.e., BNT162b2 (Pfizer/BioNTech), ChAdOx-1 (developed by the University of Oxford and Astra-Zeneca in partnership with Biomanguinhos/Fiocruz in Rio de Janeiro), AD26.COV2.S (developed by Janssen, Johnson & Johnson), and CoronaVac Sinovac Biotech, in partnership with the Butantan institute, in São Paulo [81, 82]. While some negotiations were made with the Covax Facility Consortium (coordinated by the WHO), others were cancelled, namely that with the Gamaleya Institute in Russia responsible for Sputnik V [83, 84].

Despite a number of anti-vaccine statements spurred by the Federal Government and an ever-growing ‘anti-vaxxer’ movement, by the end of December 2021, the Ministry of Health announced that the country would have more than 400 million doses of vaccines against COVID-19 available for Brazilian citizens [85,86,87]. By then, the country had witnessed a steep drop in COVID-19 cases and deaths and a considerable decline in hospitalizations [19]. One of the probable reasons for the success of the vaccination program in the country, despite an initial period of inertia, relates to its century-long program of publicly sponsored vaccination across the country, coupled with the availability of state-funded facilities aimed at large-scale vaccine production and distribution [41].

Figure 1 depicts the current status of the COVID-19 vaccine roll out across different regions and states in Brazil [17].

Fig. 1
A map of Brazil depicts its vaccination rate distribution. The North has the highest vaccination rate and the South has the least vaccination rate.

Source Portal G1-Bem Estar—Vacina—Consórcio de veículos de imprensa [17]. Adapted from Brasil Consórcio de veículos de imprensa [17]

Map of Brazil depicting its five regions and the current vaccination rate distribution among its 26 states and its federal district, January 28, 2022.

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A significant proportion of the globe, particularly the African continent, remains largely unvaccinated with rates of vaccination less than 10% as of January 24, 2022 [20]. As a result, potentially more virulent and/or more contagious lineages of SARS-CoV-2 are bound to appear and circulate around the world, as the coronavirus has been shown to undergo myriad mutations. The advent of Omicron, for instance, in late 2021, shows how the virus can spread and reinfect individuals despite high rates of vaccination across the globe, although those who have been vaccinated with a complete vaccine schedule including a booster shot have a significantly lower chance of hospitalization and death (estimates in Switzerland point to an almost 50-fold drop of deaths due to COVID-19 for those with a complete schedule) [22, 23]. Several countries are suffering the consequences of the so-called ‘third wave’ of the pandemic [88]. Even though vaccines have conferred at least partial protection against the Omicron strain, infection rates have swelled across all regions, with a resulting increase in hospitalizations and deaths as well as loss of healthcare staff due to COVID-19. This was not different in Brazil, where both infections and deaths took an over 100% leap every day or so. The situation was worsened by the concomitant spread of a new strain of influenza A virus in the country (the H3N2 subtype). On the positive side, the vast majority of COVID-19 cases (of which Omicron already accounts for almost 100% in all regions) were mild, except among those who were unvaccinated.

Widespread vaccination is key for both individual and collective protection, as has been made clear by real world evidence. The odds of becoming severely ill are greatly reduced by vaccination [18, 19]. Vaccination also seems the most effective way for preventing the healthcare system from collapsing.

The Epidemic Curve in Brazil and Its Latest Trends

At the beginning of the pandemic, several states, particularly those in the northeastern region of Brazil, witnessed an overspill of both the public and the private healthcare systems, with healthcare workers facing the ethical dilemma of having to make heart-wrenching life-and-death choices. Manaus was the first to see its healthcare system completely collapse amid an exponential increase in the number of SARS-CoV-2 cases less than two months after the start of the pandemic in Brazil. The demand for mass graves began to decline some two months later. Such disruption in the healthcare system around mid-2020 hit hard virtually the whole country. In its richest southeastern region, calamity struck the state of Rio de Janeiro, where, because of the caseload, a number of patients had to be taken to hospitals over 100 miles away from their hometowns, after having queued relentlessly for hours outside the city’s largest hospitals. This situation was aggravated by a government fraud scheme in which medical and protective gear were acquired. This further hampered efforts aimed at providing the needed healthcare support. São Paulo, the richest and most populous state in the country, was faced with a tireless struggle to achieve a social distancing rate of over 50% (the goal being 70% then). After witnessing the first recorded death in the country on March 13, 2020, a few months later, by July 2020, it had already more reported deaths than other highly affected countries such as Italy and Spain [4, 18]. Measures to counteract the epidemic, such as an amplified vehicle rotation restriction decreed in May 2020, were judged to be utterly futile after a mere couple of days. Instead of reducing the circulation rates across the city, it resulted in over 300,000 people (many of whom were unmasked) using public transport, with dire consequences. Such grim circumstances recurred at even greater rates during the second wave of the pandemic in the second quarter of 2021.

Based on daily updates of COVID-19 deaths and reported cases by the Ministry of Health, with data stratified at state level, SARS-CoV-2 attack rates (Rt) dropped dramatically following the adoption of social distancing measures in compliance with WHO recommendations [19]. Nonetheless, except for a mere three of its 27 (including the Federal District) states, this was not shown, at first, to bring the Rt below 1, which starkly contrasted with data published in other countries that had adopted strict lockdown policies [89, 90]. In early May 2020, a study from the Imperial College London, UK, showed that Brazil had the highest SARS-CoV-2 transmission rate in the world, with an initial reproduction number (R0) consistently in the range of 3–4 across all states [37]. As shown in this study, attack rates (and deaths) varied widely across states and regions, ranging from 3.3% in São Paulo to 10.6% in Amazonas. In fact, as of early May that year, five states (São Paulo, Rio de Janeiro, Ceará, Pernambuco, and Amazonas) were responsible for 81% of the reported deaths in the country. No matter how dismal these figures may appear, Brazil still remained far short of the 60–70% herd immunity said to be needed to prevent an upsurge of SARS-CoV-2 infection should control measures be weaned off [37, 91,92,93].

As for the latest trends in the country, according to data from the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University, as of January 29, 2022, an average of 183,443 cases per day were reported in Brazil over the past week, which reflects an increase of 166% from the preceding two weeks. The same situation occurred with respect to death rates, which increased by 166%. Thus far, January 2022 has been the month with the highest average cases per day (over a period of seven days). April 2021 was the month with the highest average deaths per day in the country [18, 94].

As of mid-January 2022, less than 50% of the indigenous people had been vaccinated with a complete dose schedule, despite being part of a priority group according to the federal vaccination rollout plan. As for the booster dose, a mere 13.5% (103,878 of 755,000) of those living within protected lands had received it by late December 2021. Moreover, SARS-CoV-2 testing was very low among these people, further defying the measures needed to decrease the impact of the disease [95].

On January 28, 2022, the Brazilian drug regulator agency, ANVISA, approved the use and marketing of COVID-19 self-tests provided some minimal requirements for registration were ensured [96]. However, while becoming part of the country’s testing policies might help to tackle this unmet need, self-test kits will not be readily available to the public since they have to undergo licensing. Companies have been asked to build a dedicated platform accessible through QR codes to keep track of the positive cases [96].

Figures 2 and 3 depict the overall trend of COVID-19 case and death rates since the start of the pandemic in Brazil in March 2020 [18, 94].

Fig. 2
An area graph depicts the overall trend of COVID-19 cases and the death rates of the pandemic in Brazil. The graph peaks after November beyond 150,000 cases.

Adapted from The New York Times [94]. Primary source Center for Systems and Engineering (CSSE) at Johns Hopkins University [18]

Overall trend of COVID-19 case and death rates since the start of the pandemic in Brazil, March 2020 to January 2022.

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Fig. 3
An area graph plots the newly reported cases per day from March 2020 to January 2022. The 7-day average peaks after November beyond 150,000 cases. Another area graph plots the newly reported deaths, and the 7-day average deaths peak in March 2021 up to 3,000.

Adapted from The New York Times [94]. Primary source Center for Systems and Engineering (CSSE) at Johns Hopkins University [18]

a New reported cases per day since the outbreak in Brazil from March 2020 to January 2022. b New reported deaths per day since the outbreak in Brazil from March 2020 to January 2022.

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Concluding Remarks and Future Perspectives

Brazil has faced a terribly difficult period in the past two years since the COVID-19 pandemic began. It is ranked among the most highly affected countries worldwide both in the number of cases and the number of deaths. The situation has been aggravated by a lack of strong leadership from the government, political turmoil, misleading policies, and fake news. The lack of unbiased countrywide policies and large-scale SARS-CoV-2 RT-PCR testing, as well as the use of futile approaches to combat COVID-19 have contributed to the dire straits with which the country is currently faced. Of note is the lack of specific policies for the most vulnerable such as the indigenous people and the poor. The lack of access to healthcare facilities, particularly due to high treatment costs, has further undermined the efforts aimed at combating the pandemic. Likewise, anti-vaccination (resulting in persisting SARS-CoV-2 vulnerable ‘bubbles’) and “anti-science” have hampered the attempts to impact the pandemic in Brazil. The state of the pandemic is not homogenous. Significant differences in resource availability among its regions and states explain the variable impact of the pandemic across the country.

In a country already battered by endless hardship, in which health policy has virtually turned into health politics, any concerted efforts aimed to combating the pandemic are grossly undermined. Needless to say, with the public health, political, and economic collapse in the country, going against the tide seems inconceivable and somewhat naïve at a time where the entire world is grappling with the pandemic. Social support systems that are able to provide a solid safety net for those in need are urgently required. It now seems that SARS-CoV-2 is here to stay. It remains to be seen how the country will cope with the COVID-19 waves to come.