Julio Croda - Foto: Wilson Dias - Agência Brasil (EBC)In an interview to Fiotec, Julio Croda, an infectologist and researcher at Fiocruz and professor at UFMS (Federal University of Mato Grosso do Sul), affirms that we experience a breakdown of the Brazilian health system. Our present reality has four actors: the Federal Government, the States, the Municipalities and the society, “each one bears a share of responsibility and guilt in the Brazilian response to the pandemic,” he says. The professor claims we failed to follow the individual and collective preventive measures. Therefore, our only alternative now is to adopt “more restrictive measures, associated with the immunization of the entire population.”

Read the hole interview:

Are we experiencing a breakdown in Brazil? What do you think is the reason?

We are currently facing a breakdown of the health system, especially due to Covid-19. We can mention some factors: we failed to implement the preventive measures, both individual and collectives, that is, the population started to use less the protective masks, to keep a shorter distance from each other and to gather more. Dada from the gathering/people locomotion monitoring platform, an indicator of Google, showed that the Tuesday of Carnival was the day with the highest gathering rate in Brazil since the beginning of the pandemic, which evidences precisely what we are facing today, after approximately 15 days: the increase in the number of hospitalizations and deaths. Our moving average is the highest in Brazil throughout the pandemic, and we are the country with the highest moving average in the world nowadays.

In addition, we have a new variant of the virus, which is more transmissible than the one that already circulated. Consequently, the preventive measures that would previously decelerate, to some extent, our curve of cases and hospitalizations are no longer enough; in other words, if we keep doing the same thing we did in the past, only these measures will not be sufficient to reduce the contagion rate.

Another factor that brought us to this critical moment is the slow vaccination pace. We bought a quite low number of doses, and we did not enter into agreements with other companies so as to ensure a significant number of doses for Brazil in this first quarter.

Are we facing a second wave? Or we did not even recover from the first one? Did Brazil have a moment of stability?

Brazil had a first wave, with a discrete reduction of 50%/60% in terms of moving average of deaths per day. Then, there was an important increase, the so-called second wave, especially after the elections that took place in 2020. We are still at a high plateau: one thousand deaths per day during the entire period of Christmas, New Year, December and January. Now, which would be a moment of decrease in this plateau, we are living a continued second wave, with a new and rapid acceleration, which means a third wave, without us having importantly reduced first one.

Do you believe that the start of the vaccination campaign led people to think they could already loosen the restrictions?

I think so. The vaccination brings us hope, the hope of the end, and this is very risky, since people believe the vaccine is quite close and cease to adopt the preventive measures, to keep social distancing, and to avoid gatherings.

It is always worth to reinforce that our vaccination pace is slow, not even 5% of the population has been vaccinated so far. In order to reach some sort of control through collective immunity, we will have to vaccinate 70%/80% of the population, which will probably occur as of the second semester.

In your opinion, what is the critical point in the fight against this pandemic in Brazil?

With respect to the public health emergency, the critical point is communication, which is paramount to the extent of proper prevention and guidance. The Federal Government should had encouraged preventive measures, such as the use of protective masks, as well as punctual and more restrictive measures in different regions where it was no longer possible to offer intensive care beds. We know that the health system collapsed in many cities, and that it is now on the verge of collapsing is other areas too. In these moments of breakdown, the only alternative is to adhere to more restrictive measures, from the community point of view, which have important social impacts. These measures shall be adopted, and especially instructed, by the Federal Government, with clear technical indicators of the regions that should implement them.

It is also important to understand the responsibilities of the state and local governments. The offer of RT/PCR tests, for instance, is quite related to the central labs and is to be handled by each State. On the other hand, searching for contact cases is a task of the municipalities, which shall identify all cases and contacts, making sure that these people will remain in home isolation. Each one bears a share of responsibility and guilt in the Brazilian response to the pandemic.

What we have to clarify is that the society’s attitude in the face of the pandemic, especially that of the Brazilian society, has been very individualistic. A pandemic is a moment of pain, with the loss of people and with impacts not only on health, but also on the economy. So we, in the capacity of society, need to reflect and protect the populations most vulnerable to the economic impacts associated with the more restrictive locomotion measures, which decelerate the economy. Generally, those who do not have a formal job, the poorest portion of the population, suffer the most in this moment. We should discuss the pandemic better and have a united answer from the point of view of Federal, State and Local Governments, which has not happened in Brazil by now.

In our current scenario, each actor has its own responsibility. The Federal Government, the States and the Municipalities, as well as the society, ought to organize themselves so as to respond to the pandemic; have more empathy regarding the isolation of sick people, to the use of masks, to individual and collective measures concerning social protection, that is, empathy in terms of helping poorer people who need social support in this hard moment.

In relation to the vaccine, how to explain and convince the population of the importance of getting immunized?

The Federal Government should provide clear information, but it does not do so. Instead, it has disclosed inappropriate data, such as the possibility of turning into an alligator after receiving the RNA vaccine. We know the studies are carefully assessed. The data are published, and the phase 3 studies are reviewed by regulatory agencies worldwide. In Brazil, Anvisa is the agency representing the federal government. When a vaccine is approved by Anvisa, it means that it is safe and effective, and that the population has no reason to fear it. So, the way I see it, we lack a communication that demystifies many of the myths. The greatest problem is that the government itself disseminates fake news, like the president’s punctual declaration that receiving a specific RNA vaccine could turn us into alligators.

You are involved in the project of using the BCG vaccine against Covid-19, the Brace Trial Brazil. Could you explain us about this vaccine and which phase it is in?

The BCG study is funded by Bill & Melinda Gates Foundation, and conducted in Australia, United Kingdom, Spain, Netherlands and Brazil. Here in Brazil, we have three sites: Manaus, Campo Grande and Rio de Janeiro. They belong to Fiocruz and are coordinated by me and by the researchers Marcus Lacerda and Margareth Dalcolmo. We count on over 2,000 volunteers recruited in each of these sites. The initial purpose was to assess if BCG could protect against the severe forms of Covid-19. Our goal was to recruit 10,000 health workers, and we managed to get to 7,000.

Now that these workers are being massively immunized with the specific Covid-19 vaccine, we also make use of the study to assess the impact of the vaccination in this particular study. That is to say, we vaccinated with BCG through the clinical essay and now we have the mass vaccination of this population. So we will check if BCG manages to generate a more robust response. This means that BCG would be an initial vaccine that, after a specific vaccine, would have a sounder response. We shall also verify if the association of BCG with the Covid-19 vaccine or not protects more the severe forms of the disease.

Furthermore, we shall assess, in addition to the immunological response and protection, if the Covid-19-specific vaccine for both the control group that did not receive the BCG and the group that received BCG and the Covid-19-specific vaccine protect against the new P1 variant, which is becoming predominant in Brazil.

Are we facing new coronavirus strains? Why does it happen?

The new variants have a direct impact on the pandemic, for they have a greater transmissibility, which somehow impacts the capacity of States and Municipalities to respond to the pandemic. If a variant is more transmissible, we have more people falling ill at the same time, and more people who need to be hospitalized (some in intensive care units) at the same time. As a consequence, the capacity to respond to the pandemic that we had before becomes limited. We have evidence that this new strain is 10 times more transmissible. The researcher Felipe Naveca, from Manaus, reported this. Therefore, from the point of view of transmission, it has a greater impact, leads to more restrictive measures, and requires more attention and adhesion to the individual measures.

Another point is the immunological aspect. It seems that the new variant is associated with a greater frequency of reinfection, which discards the concept of herd immunity. Since we have a new variant, with an immune system evasion in relation to the previous infection, you will never attain herd immunity, as new variants will always arise. The more the virus circulates, the more it can mutate. Consequently, there is a greater chance of appearing new variants, with significant epidemiological impacts, such as the P1 variant identified in Manaus.

What is the major concern in relation to this? Does this have an impact on the vaccines already developed?

We have verified that, regarding the Novavax and Johnson & Johnson vaccines, there was a reduction in the number of neutralizing antibodies, but with no clinical impact on the effectiveness of the vaccine. I am conducting a study in Manaus, in partnership with the Health Surveillance Foundation of Amazonas and with the Municipal Department of Health of Manaus, supported by the Pan American Health Organization (PAHO), in order to check if the CoronaVac and AstraZeneca vaccines are still effective against the new variant.

Since Manaus was the first city where the new variant circulated, and the State of Amazonas is the one which has vaccinated the most, in comparison to the other Brazilian States, it will also be the first place where we will understand if the vaccines remain working for this new variant. We intend to get the partial results of this study by the end of March, so that not only the State, but also the country and the society as a whole, get informed. The main purpose is to stress the importance of vaccination or to update the vaccine components, aiming to provide the population with a more effective immunization, if applicable.

What are the expectations for the months to come, when it comes to the fight against the pandemic?

March is expected to be the worst month of the pandemic, with a growing number of cases. I believe we will have a relief closer to the end of the first quarter. We will probably receive another 30/40 million doses from Butantan Institute and Fiocruz by the end of March, which allows us to vaccinate at least all senior citizens; maybe people with comorbidities (who exert a strong pressure on the health system) too. Thus, with a faster vaccination pace of this population, which shall be seen in April, we will have a reduction in the number of hospitalization cases, probably in May and June. However, the virus will keep circulating, and we will have to receive the vaccine every year.

With respect to our current situation, which would be the ideal scenario to fight the pandemic?

We need to implement more severe restrictive measures, and some cities shall adopt the lockdown, for we have a more transmissible variant. We will have no alternative other than to follow more restrictive measures, in association with the increase in the vaccination rate for the entire population, starting with the risk groups. This has to occur in a very quick way. Portugal was also experiencing an impactful moment of the pandemic, its worst moment, and managed to decelerate the curve of new cases and to reduce the number of hospitalizations after the adoption of these two measures.