The impact of super-spreader cities, highways, and intensive care availability in the early stages of the COVID-19 epidemic in Brazil

Abstract

Although international airports served as main entry points for SARS-CoV-2, the factors driving the uneven geographic spread of COVID-19 cases and deaths in Brazil remain mostly unknown. Here we show that three major factors influenced the early macro-geographical dynamics of COVID-19 in Brazil. Mathematical modeling revealed that the “super-spreading city” of São Paulo initially accounted for more than 85% of the case spread in the entire country. By adding only 16 other spreading cities, we accounted for 98–99% of the cases reported during the first 3 months of the pandemic in Brazil. Moreover, 26 federal highways accounted for about 30% of SARS-CoV-2’s case spread. As cases increased in the Brazilian interior, the distribution of COVID-19 deaths began to correlate with the allocation of the country’s intensive care units (ICUs), which is heavily weighted towards state capitals. Thus, severely ill patients living in the countryside had to be transported to state capitals to access ICU beds, creating a “boomerang effect” that contributed to skew the distribution of COVID-19 deaths. Therefore, if (i) a lockdown had been imposed earlier on in spreader-capitals, (ii) mandatory road traffic restrictions had been enforced, and (iii) a more equitable geographic distribution of ICU beds existed, the impact of COVID-19 in Brazil would be significantly lower.

Genomic surveillance of SARS-CoV-2 tracks early interstate transmission of P.1 lineage and diversification within P.2 clade in Brazil

“…During the first phase of the COVID-19 pandemic in Brazil, long-distance travel between large urban cities in southeastern states and less populated states from North and Northeast regions played an important role in the explosion of cases across the country [ 1 , 13 , 14 ]. Since mid-November, there has been a new surge in COVID-19 cases in Brazil, prompting the delimitation of a second phase of the pandemic in the country.…”

Double Trouble: Dengue Followed by COVID-19 Infection Acquired in Two Different Regions: A Doctor’s Case Report and Spatial Distribution of Cases in Presidente Prudente, São Paulo, Brazil

“…We highlight the epidemiological significance of presenting a case report and spatial analysis of COVID-19 in the same study in the context of a dengue outbreak. Furthermore, this study illustrates the burden of both infections in different settings and emphasizes the role of geoprocessing tools in monitoring the dispersion of both pathogens [3,4,16]. In 2020, in Presidente Prudente, the largest and most important city in the western region of São Paulo (Figure 1E), an outbreak of dengue was on course in the first months of the year at the same time as the COVID-19 pandemic was emerging.…”

“…Studies on co-infection of dengue and COVID-19 are limited to case reports and, as far as we know, no spatial analysis demonstrating clusters of infected individuals of both viruses simultaneously have been published. Recently, concomitant circulation of the COVID-19 pandemic and the triple arboviral epidemic of dengue, chikungunya, and Zika virus was demonstrated in various states of Brazil, highlighting the challenges faced by the Brazilian public health system in dealing with these viruses [4]. In a spatial analysis of the COVID-19 distribution pattern in São Paulo state, when the pandemic was recently introduced in Brazil, a higher density of cases was found in the metropolitan region of the capital São Paulo, including Osasco, where our case report is based [16].…”

“…Brazil ranks third for the number of patients infected and second for mortality rate worldwide [2]. As expected, São Paulo state, the most populous state of Brazil, and its capital, São Paulo, including the metropolitan area, ranks first for the number of cases and deaths from COVID-19 [3,4]. Individuals living in closed settings, including nursing homes and prisons, and those with an occupational health risk, particularly health care workers (HCWs), have increased vulnerability to the transmission of COVID-19.…”

A modelling study on the vaccination against COVID-19 in the state of Rio de Janeiro, Brazil

“…SARS-CoV-2 circulated undetected in Brazil for more than a month 2 and, even after Brazil declared COVID-19 (coronavirus disease) a national public health emergency on February 3, 2020 3 , the Brazilian government has managed the epidemic very loosely so far [4][5][6] , without a cooperative effort and strategic planning to fight the pandemic. Brazil also faces many economic and socio-cultural challenges that affect mitigation strategies, such as large disparity in the mortality rate in economically disadvantaged regions 7 , the uneven geographic distribution of intensive care unit (ICU) beds 8,9 , and lack of investment and vulnerability of the health system 10 . Each federative unit is self-governing for decisions regarding efforts to curb the spread of the disease 11 , which leads to inequalities, such as unbalanced social distancing measures and lack of mass testing and viral spread tracking.…”