MSF teams struggle to keep up as COVID-19 cases surge, health system collapses
NEW YORK/RIO DE JANEIRO —The descent into a second COVID-19 catastrophe in Brazil’s Amazon region is now unfolding in the Amazonas State capital, Manaus, said the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF). All intensive care unit beds are full, there are long waiting lists of people seeking care for severe or critical cases, and there’s no capacity to transfer people from rural towns to the capital for advanced treatment.
Official figures for Manaus show that the number of COVID-19 deaths in January (2,522) almost equalled the combined death toll registered during the previous peak in April and May (2,850). These figures are more than five times the number of deaths reported in December (460). The complete saturation of the health system in Manaus means people in towns upriver are facing delays in care, and medical providers simply cannot refer their critical patients to hospitals in larger cities. Instead, health workers are having to take emergency measures to try to cope with rising numbers of sick patients.
“Our plan A was to try to help slow the flow of critical patients from rural areas to the capital by boosting intermediate care for moderate and severe cases, but that plan is out the window now,” said Pierre Van Heddegem, MSF emergency coordinator in Brazil. “We’re now fully into plan B, doing lifesaving critical care in facilities that don’t have an intensive care unit and worrying every day that we’ll run out of oxygen. This second wave of COVID-19 is overwhelming everything and everyone. We’re doing all we can to get through each day. Our fear is that we will not be able to keep up.”
In the remote town of Tefé, which is a few days’ boat journey upriver from the state capital, MSF is helping the hospital implement significant changes. Teams are moving all the medical departments out into nearby buildings, such as the school, and turning the rural hospital as much as possible into a dedicated COVID-19 treatment referral centre due to the high numbers of cases in the community. Under normal circumstances, this rural hospital would send all critical patients by air ambulance to Manaus, but with most COVID-19 beds in Manaus full, the Tefé hospital is having to find ways to treat critical patients. So far, the COVID-19 treatment capacity has grown from 27 to 67 beds, but this is pushing beyond the limit of what is possible.
The MSF team has coached and trained the doctors and nurses at this hospital on how to care for critical COVID-19 patients on oxygen. However, the lack of oxygen supply itself is a permanent worry.
“We were scraping by on a day-to-day basis in Tefé [with the oxygen supply],” Van Heddegem said. “There were days when we came very close to a disastrous situation.” A new oxygen generation plant has just been installed by the authorities, but at the current rate of use, even the new plant may not provide enough oxygen for all the people who need it. MSF is working on urgently importing individual patient oxygen concentrators to plug some of the gaps, both for Tefé and for Manaus.
In Manaus, MSF is supporting the José Rodrigues Emergency Unit (UPA), which should provide an intermediate level of care, stabilizing patients before they need to go to a higher-level hospital for more advanced treatment. Like in Tefé, with Manaus hospital COVID-19 beds full, this centre now has to find ways to provide its own high-level COVID-19 treatment.
“The UPA was totally overloaded, with a lack of doctors, nurses, and intensive care protocols,” said MSF project coordinator in Manaus, Fabio Biolchini Duarte. “When we were there for the first time, the unit had 18 beds and there were 45 patients. Virtually the entire place had become a COVID-19 infirmary. It was one of the health facilities where several patients died because of the lack of oxygen.”
Staff—both medical and non-medical—working in this emergency unit and in the bigger hospitals in the region are grappling with the emotional burden of having multiple patients die each day. To address this struggle, MSF has brought in mental health specialists to provide psychosocial support, including in Manaus’ largest public health facility, the Hospital 28 de Agosto, where an MSF medical team provided patient care during the first wave last year.
“We see that the employees are incredibly dedicated, but we also realize they are absolutely exhausted,” said MSF psychologist Andréa Chagas. “In many cases, it is not even possible for them to find relief at home from the anguish experienced at work since many have sick relatives or have lost loved ones. The speed and intensity of what is happening does not allow space for processing so many feelings.”
In Amazonas State, MSF is now managing or supporting nearly 100 COVID-19 beds. This is occupying most of the emergency team’s capacity, but they are also working on some initiatives to prevent people from getting COVID-19. For example, MSF’s health promotion teams are preparing to work at strategic points in Manaus to promote proper hygiene, social distance, and testing protocols.
The team’s goal when it comes to testing is to allow rapid diagnosis and follow-up of patients who test positive to prevent cases from being detected after they are already in serious condition. MSF is also lobbying for a wider use of the rapid antigen COVID-19 test—the one that indicates if a person has the active virus now, in real time. The test most commonly used in Brazil is the antibody test, which detects if you have had the disease at some point in the past. This means it may indicate positive cases among people who had COVID-19 weeks or months ago but no longer have it today. Using the antigen test, only sick patients are placed in isolation, which avoids unnecessary hospitalizations at a time of great shortage of personnel and resources. MSF has successfully encouraged the health authorities in Tefé and another rural Amazonian town, São Gabriel da Cachoeira, to use this test, and it continues to urge the authorities in Manaus and other affected areas to also make the switch.
MSF also has a team in the rural Amazonian town of São Gabriel da Cachoeira, where the situation seems more stable for the moment but where continued vigilance is needed. The team is supporting the health centre for care of COVID-19 patients, and health educators are giving hygiene and social distancing guidelines in the barracões, used as accommodation when members of the indigenous population come to the town. This should enable teams to monitor to some extent any trends among indigenous people showing symptoms of the disease.
Additionally, MSF teams are also in early-stage preparation in case of a surge of COVID-19 in Boa Vista, the capital of neighboring Roraima state.