HTML

ePub

PDF

INTRODUCTION

Coronavirus Disease 2019 (COVID-19), a disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection, emerged in Wuhan in China in 2019 and was declared a pandemic by the World Health Organization (WHO) in March 2020, with repercussions on the world social and economic scenario¹. COVID-19 affected over 7 million people worldwide, and on June 10, 2020, the following scenario in the World (and in Brazil; Brazil’s position in the world ranking) was described: 7,447,151 (775,184; 2^nd place) cases of the disease; 418,135 (39,797; 3^rd place) deaths caused by the disease; 3,730,056 (380,300; 2^nd place) patients recovered clinically from the disease; 3,298,960 (355,097; 2^nd place) active cases and in follow-up; 53,812 (8,318; 3^rd place) serious cases and being followed up by the health system; 955 (3,648; 30^th place) cases confirmed by one million inhabitants; 53.6 (187; 19^th place) deaths per one million inhabitants². On the same date, in relation to the number of real time-polymerase chain reactions (RT-PCRs) specific to SARS-CoV-2, Brazil had carried out a total of 1,182,581 tests in specialized laboratories, 5,666 of which were performed by a million inhabitants; thus, the country occupied the 126^th position in the ranking of tests per one million inhabitants in the world compared to other territories².

In health surveillance, taking the Brazilian context as an example, it is necessary that knowledge about the factors determining the presence and progression of a disease be described and made available. Among the factors, the need to detect and prevent the disease through the correct quantification and notification to be performed in health systems can be highlighted. However, in many cases, especially in pandemic situations, there may be underreporting and the presence of discrepancies in epidemiological data in relation to the impact of the disease on the community.³

In Brazil, there are sentinel units for the registration of Severe Acute Respiratory Syndrome (SARS) that work in the registration, investigation and diagnosis of suspected and confirmed cases of SARS. Sentinel units, according to Ordinance 183 of January 30, 2014 by the Ministry of Health, aimed to register at least 80% of cases of SARS in Intensive Care Units (ICUs) and to register 90% of the weeks epidemiological aspects of hospitalization aspects of SARS cases. In the ordinance, the justification for assessing the decision-making on the financial transfer according to the status described for SARS is liable.⁴

In the world and, mainly, in Brazil, the limitation to obtain original and correct data, consistent with the impact of the pandemic in the community through census, has been described as an obstacle. Concomitantly, in Brazil, there have been changes in the Ministry of Health’s approach to the official epidemiological description of the disease, mainly regarding the number of deaths associated with COVID-19. The described fact made it more difficult to obtain concrete and evolutionary data for COVID-19 in Brazil. Thus, there was a discrepancy between different sources of information about the disease and a greater difficulty in carrying out comparative studies between the national and international scenario.

The difficulty in obtaining information that represents the COVID-19 pandemic scenario regarding epidemiological data, including the number of cases of patients colonized by the SARS-CoV-2 virus (asymptomatic) or infected by the virus with mild symptom severity, is a landmark in Brazil. During the pandemic COVID-19, the Brazilian scenario was characterized by the public health policy adopted by the Ministry of Health for testing the SARS-CoV-2 virus, mainly aimed at analyzing severe cases of the disease. As observed in the literature, in some places, there was an increase in SARS diagnosis compared to other years, which may reflect limitations in diagnosing COVID-19, mainly by performing RT-PCR tests for the SARS-CoV-2 virus.^5-7 Thus, the present study aimed to describe the overview of COVID-19 in Brazil regarding the presentation of epidemiological data and its importance for the control of COVID-19 pandemic caused by the SARS-CoV-2 virus. In the study, data on the COVID-19 pandemic in Brazil were described with an elucidative character of its importance for the correct direction of governmental decision-making and to highlight the importance of understanding the processes involved with the nuance of health and disease in the character prospective evolution of the disease in a single territory.

METHODS

The study was conducted by an active search in different databases that had free access to data about the COVID-19 pandemic in Brazil. All data were accounted for on the different platforms for the date of June 12, 2020, a period in which there was a change in the presentation of data made by the Ministry of Health of Brazil⁸.

The data referring to the number of cases of COVID-19, number of deaths associated with the disease, lethality, number of patients and number of deaths per 100 thousand inhabitants, were collected on various platforms with data from Brazil (national) and international, being them: (a) COVID-19 pandemic of the Word Health Organization (https://www.who.int/emergencies/diseases/novel-coronavirus-2019);¹ (b) Word of Meters (https://www.worldometers.info/coronavirus/country/brazil/)²; (c) Epidemiological Surveillance of the State Department of Health (https://www.saude.go.gov.br/vigilancia-em-saude/vigilancia-epidemiologica)³; (d) Ministry of Health website (https://www.saude.gov.br/)⁹.

Data on the prevalence of SARS caused by the SARS-CoV-2 virus, SARS caused by other infectious agents and the prevalence of SARS in the period between 2015 and 2019 were acquired on the website of Fundação Instituto Oswaldo Cruz (FioCruz) - InfoGripe (http://info.gripe.fiocruz.br)⁵.

The percentage of ICU occupancy during the pandemic, the percentage of social isolation, the total number of SARS-CoV-2 RT-PCR tests performed and the percentage of tests performed against the total of samples collected according to the states and the Federal District of Brazil are presented in the study and were obtained on the following platforms: (a) Epidemiological Surveillance of the Department of State for Health (https://www.saude.go.gov.br/vigilancia-em-saude/vigilancia-epidemiologica);³ (b) Ministry of Health website (https://www.saude.gov.br/);⁹ (c) website that reflects the Brazilian map of COVID-19 (https://mapabrasileirodacovid.inloco.com.br/pt/.);¹⁰ (d) São Paulo State Government website, which tabulated the level of social isolation in the state during the pandemic for some cities (https://www.saopaulo.sp.gov.br/coronavirus/isolamento/).¹¹

Due to the ease of access to data, the status of São Paulo’s regional indicators for hospital capacity, the evolution of the pandemic and decision-making were presented in the study as models for addressing the economic factor with the correct management of patients with COVID-19 in the social perspective. All the information was compiled by the use of information present in the legislation of the city of São Paulo and the legislation of the state of São Paulo.^12,13

The average value of SARS cases in Brazil, prior to the COVID-19 pandemic period, was calculated using the data recorded from 2015 to 2019 by InfoGripe⁵. After calculating the annual mean, an adjustment was made to weight the cases corresponding to the initial five months of the year, i.e., between January and June, which reflects the analysis period of this study. The value obtained in the described calculations was used to estimate the index of probable underreporting of serious cases of COVID-19 in Brazil according to the state and the Federal District. The index was calculated by the difference between the average number of SARS cases and the number of SARS cases registered in 2020 after excluding confirmed cases of COVID-19.

The epidemiological data analyzed in the study were associated with each other using the Spearman correlation in the Statistical Package for the Social Sciences software (IBM SPSS Statistics for Macintosh, version 25.0). An alpha error of 0.05 was adopted in the correlations carried out between the study markers.

RESULTS

Brazil is a country with a large territorial extension and with high social, ethnic and economic diversity among the different regions that make up its territory and that reflect regional particularities to deal with the COVID-19 pandemic and other diseases.^15,16 Data referring to the number of cases and deaths associated with COVID-19, lethality of the disease, incidence and mortality per 100 thousand inhabitants, SARS per confirmed COVID-19 or other causes, percentage of ICU occupancy and social isolation, the number of SARS-CoV-2 RT-PCRs performed and the percentage of tests performed relative to the total of samples collected to perform the SARS-CoV-2 RT-PCRs are shown in Table 1.

In the data described, the greater number of confirmed cases in the Northeast than in the Southeast is noteworthy. The COVID-19 pandemic started in the Southeast, the region of Brazil with the largest number of inhabitants and with the greatest flexibility of transit of individuals on a national and international basis. the Southeast has the largest number of beds in the ICUs, greater capacity to process the RT-PCR exams of the SARS-CoV-2 and the best data control regarding the COVID-19 pandemic.

In Brazil, the highest lethality rates were described in the states of Rio de Janeiro and Pernambuco, respectively, being 9.6 and 8.42; followed by the states of Pará, Ceará and São Paulo, with a value of approximately 6.3. Among the states, the highest mortality per 100 thousand inhabitants occurred in the states of Amazonas, Ceará and Pará, with a value of 57, 49.1 and 45.6, respectively. All states and the Federal District showed a high ratio between the number of SARS and the number of confirmed cases of COVID-19, with a maximum value of 26.77 in Mato Grosso do Sul. Interestingly, the state of Mato Grosso do Sul is the one with the lowest number of cases and deaths associated with COVID-19 (Table 1).

The ICU occupancy rate was over 80% in five states in Brazil (Amazonas, Maranhão, Rio Grande do Norte, Espírito Santo and Rio de Janeiro). In all states and the Federal District, the isolation rate was less than 50%.

From the nasopharynx material collected to perform RT-PCR tests for the SARS-CoV-2 virus, one state processed only 4%; a state, between 30% and 40%; three states, between 40% and 50%; two states, between 50% and 60%; four states, between 60% and 70%; finally, four states, between 70% and 80% of the samples collected, mainly from patients with the highest degree of disease severity (Table 1). Finally, the high number of SARS-CoV-2 RT-PCR tests carried out in the Federal District is noteworthy, since it presented the largest number of tests performed in Brazil and had only three million inhabitants. The Federal District is where representatives of the federal government are concentrated, including the three branches (executive, legislative, and judicial).

DISCUSSION

Considering the importance of epidemiological data, some aspects can be highlighted and discussed despite information that has been released so far about the COVID-19 pandemic in Brazil, which includes:

SARS-CoV-2 identification by RT-PCR

In Brazil, RT-PCR was recommended to identify infection by the SARS-CoV-2 virus, especially in patients with a greater degree of disease severity.¹⁴

COVID-19 is characterized by different clinical signs, with subgroups of asymptomatic, mild symptomatic and severe symptomatic patients. Asymptomatic patients are classified as those who tested positive for the SARS-CoV-2 virus, but there is no clinical manifestation of the disease. Symptoms such as body pain, diarrhea, sore throat, conjunctivitis, headache, loss of smell and/or taste, skin rash and discoloration of the feet are considered mild symptoms of the disease and require home care.^16,17 Serious symptoms, such as difficulty in breathing, loss of speech and/or movement, pain and tightness in the chest, are important signs that need attention and medical assessment in a referenced unit.^16,17 The manifestations of clinical signs can appear about five days after contact with the SARS-CoV-2 virus and can last for up to fourteen days. Because of this, RT-PCR tests for the SARS-CoV-2 virus have become necessary to recognize possible transmitting agents, in addition to enabling large-scale differential diagnosis.

However, in Brazil, patients with COVID-19 and in need of hospitalization were preferentially eligible patients to collect nasopharyngeal material and further analysis by RT-PCR of the SARS-CoV-2 virus. Thus, asymptomatic patients and/or those with mild symptoms were not tested, which may have optimized the virus spread in the population due to the lack of knowledge of the actual prevalence of the disease or the expansion of the virus throughout the country. Concomitantly, asymptomatic individuals who had contact with patients with COVID-19 were also not selected for screening by the SARS-CoV-2 virus RT-PCR.

In Brazil, there are few institutions and/or laboratories with the necessary and available equipment to perform RT-PCR identification for SARS-CoV-2. With the expansion of the pandemic in the world, there was an increase in costs for obtaining equipment and supplies for COVID-19 diagnosis. Brazil, even though it is considered the second country with the highest number of cases in the world, occupied 130^thposition in relation to the number of tests per million inhabitants; at the moment, in Brazil it is impossible to perform RT-PCR tests to identify the SARS-CoV-2 virus en masse, as has been the case in some countries.

Although the collection of material for the RT-PCR of the SARS-CoV-2 virus was performed only in patients with greater clinical severity than COVID-19, the tests were not completed on all samples. In Brazil, it is noteworthy that five states did not perform at least the analysis of 50% of the samples collected, whereas in Acre, only 4% of the samples were processed. The inclusion of all results needs to be optimized so that we can at least estimate the number of real cases of COVID-19 among inpatients and those with severe SARS symptoms. In addition, part of the collected material was lost due to errors in the description of patient samples, storage and/or transportation problems, as described in the state health departments.¹⁸ However, the correct number of material losses has not been described by Brazil so far and we will hardly have access to this information. Additionally, the time between the collection, the processing of the collected material and the disclosure of the exam results needs to be reduced so that patient management, especially in hospital, is carried out according to their effective diagnosis.

Adherence to social isolation by the Brazilian population

Since the beginning of the COVID-19 pandemic, the importance of social isolation has been advocated, in order to slow the progression of new infections and which could lead to an increase in the demand for ICU admissions, causing the collapse of health systems and a high mortality rate.^19-21 The collapse of the health system can occur, mainly, in states where the availability of beds is small in relation to the total number of inhabitants or where the concentration of beds occurs in regions with a higher number of inhabitants, mainly capitals.

In Brazil, the rate of social isolation occurs and occurred in a heterogeneous manner among states, having a strong influence on the action of decisions taken by local, state and federal governments. At the beginning of July 2020, the states of Rondônia, Acre, Sergipe and Goiás had the lowest isolation rates in Brazil, 55.18%, 53.63%, 44.22% and 43.56%, respectively.¹⁰ However, changes were observed regarding the need to reactivate commercial activities aiming at economic improvement under pressure from the federal government, together with the misunderstanding despite the possibility of treatment and the actual transmission of the virus by asymptomatic individuals, which caused a reduction of adherence to social isolation in all states of Brazil and the Federal District. Thus, on July 9, even in the face of a progressive increase in the number of cases and deaths by COVID-19 in Brazil, adherence to social isolation was less than 50% in all states and in the Federal District. At this time, the lowest rates were 34.59%, 35.36%, 36.07% and 36.33%, respectively, for the states of Tocantins, Goiás, Mato Grosso do Sul and Minas Gerais. São Paulo, the state with the largest population in Brazil, had an adhesion of 38.84%; Rio de Janeiro, the state with the highest lethality, had an adherence of 40.73%.

The values of adherence to social isolation from the literature and from government or private health platforms do not represent the real scenario in Brazil, with data obtained only by assessing part of the population and, mainly, for cities with a higher number of inhabitants. Together, as described by the press, the population of Brazil partially insulated and maintained, in part, physical contact with close individuals, including friends, neighbors and relatives, which may have favored the increase in cases of COVID-19 mainly in countryside cities. The advance of the pandemic in Brazil, from the state capitals to countryside cities is worrying, since the smaller cities have a smaller relative number of ICU beds, if present, in proportion to the total number of inhabitants. Additionally, in these cities, the ability to process RT-PCRs for the SARS-CoV-2 virus is generally dependent on centers and/or laboratories located in other cities, which can lead to data loss and/or absence/diagnostic errors.

The serial assessment of adherence to social isolation with the increase in the number of cases, mainly in countryside cities and with the lowest number of inhabitants, may provide support for understanding about the progression of COVID-19 and the possibility of implementing local public health policies to stem the spread of the disease.

SARS index during pandemic COVID-19 compared to values obtained from epidemiological data from years prior to the pandemic

Table 2 shows the number of SARS cases between 2015 and 2020, as well as the average number of cases for 2015 to 2019. In the comparison between the values obtained in 2020 versus the mean of previous years, there seems to be an increase in the number of SARS cases in 2020, except for the state of Acre, where there was a decrease in the number of cases. Counting the total value of described cases higher than the mean of previous years, we have a total of 44 thousand cases that, possibly, can be elective to COVID-19 diagnosis and characterize in a high degree of underdiagnosis of the disease, superior to that described in literature.²²

The status of the regional indicators of the state of São Paulo for hospital capacity, evolution of the pandemic and decision-making as a model for addressing the economic factor in COVID-19 management

Due to the need for social isolation on March 16, 2020, through Decree 59.283, an emergency situation was declared in the municipality of São Paulo, with coping measures for the pandemic COVID-19, such as easing debts, prohibiting the operation of public and private institutions, such as museums and schools, in addition to not allowing the operation of events that needed agglomeration.¹² On June 9, 2020, Mayor Bruno Covas of the city of São Paulo instituted a protocol for resuming activities decreeing the resumption of essential activities for four hours a day, depending on the classification of the municipality’s isolation phases and contamination rates instituted by the Government of São Paulo (Table 3).^12,13

The state government chose to direct the return of activities according to hospital capacity and the evolution of the pandemic. Both markers should and should be assessed in isolation and, subsequently, weighted in common. In an analysis of hospital capacity, two groups need to be assessed, namely the occupancy of ICU beds by patients with COVID-19 and the number of beds occupied by patients with COVID-19 per 100 thousand inhabitants. In an analysis of the evolution of the pandemic, three groups were assessed, all of which consider the variation of data between the periods. The selected markers were the number of cases, number of deaths and number of hospitalizations. The final score should and should be categorized into phases that allow modulation of face-to-face assistance, as described in Table 4.

The resumption of economic activity is necessary. However, Brazil has an increase in the number of cases and deaths associated with COVID-19. At the moment, the number of deaths is close to 40 thousand. Using the state of São Paulo as an example, it is observed that the different regional health districts vary in terms of the capacity of the health system and the progression of the disease. However, all were classified within the orange and red bands, the most worrying fact being the increase in the progression of the disease and which can and could change the favorable overview of the health system’s capacity for a collapse profile. In the general view, for the capacity of the health system, elective regions were observed for the return of activities, but, in the progression of the disease, the scenario was quite the opposite.

Data accounting and the importance of information management.

During the beginning of COVID-19 pandemic, the Ministry of Health of Brazil progressively described the data obtained by the state health departments. In other words, each day, the value was added to the previous one, mainly for the number of cases, the number of deaths and the number of patients recovered. However, over a short period of time, there was a decision to change the presentation to report “only” the case numbers for the day of analysis. Due to an intervention by the judiciary, the Federal Government by the Ministry of Health had to return for the presentation of all cases.

Clearly, the totality of data makes it possible to understand the impact of the disease on the population and the number of new cases and daily deaths to understand the disease progression. Thus, both data must be presented for the correct decision-making by the health authorities. Concomitantly, special attention must be paid to the daily accounting and overlapping of new cases and/or deaths that occurred on previous dates and that had the diagnosis by RT-PCR of the SARS-CoV-2 virus disclosed after patients’ confirmed cure or death.

COVID-19 omission index

Although there are attempts to change the accounting for the reality and the credibility of the cases, there is incongruity between the data released by the Ministry of Health, in which updates and corrections of data have already been published. In addition, the official Ministry of Health website specific to COVID-19 was removed from the virtual environment in June.

In the process of updating data, for instance, Roraima had 762 registered deaths, however, after correcting the information, there were 172 deaths associated with COVID-19⁹. Other errors were found after the data were released and led to less credibility of the information presented by the Federal Government of Brazil. However, despite the fact that Brazil is in a difficult time to deal with the pandemic COVID-19, the real situation is possibly much worse than what was announced. This fact can be seen by the sporadic and rapid increase in cases of SARS in 2020 and the need for hospitalization. If the approximately 40 thousand cases of SARS (5%) more than expected were described as being from patients with severe COVID-19, we would have at least 760 thousand (95%) other individuals infected with SARS-CoV-2 and without diagnosis.

In Brazil, two additional factors draw attention to the progression of the pandemic, namely: (a) a high number of health professionals who were infected with SARS-CoV-2, mainly nurses, in relation to the number of cases by specialty in comparison with international values;²³ (b) low availability of ICUs in the period before the start of the pandemic.²⁴

Number of cases and deaths reported by the Ministry of Health and the media consortium (G1, O Globo, Extra, Estadão, Folha, and UOL)

As described in the topic on the omission index on COVID-19, Brazil failed to present epidemiological data for a short period of time, and after that period, the data were presented according to the daily findings. Thus, some national press vehicles opted for the acquisition of the data together with the state health departments. Some divergences were observed regarding the number of cases and deaths between both surveys using the same sources of information. Inconsistencies need to be better assessed so that we can have a greater degree of reliability in the data presented by the federal government for COVID-19 pandemic.

Concern with minority groups.

In Brazil, the situation is worrying for two groups in particular: (a) slum residents; (b) indigenous population. Both populations have restricted access to health services and, possibly, a high degree of underdiagnosis of COVID-19. Despite widespread publicity in the media, in Brazil, for both scenarios, government measures to contain the pandemic were scarce and had low success and reach. On July 12, 2020, 2,749 cases were confirmed in the indigenous population, including 97 deaths. For this population, the best management is social isolation. However, due to the progression of environmental degradation through deforestation, mining and land use, contact with other individuals has been optimized in recent years, and current environmental policies have provided an exponential increase in forest degradation in Brazil, especially in Amazon. Regarding the populations of residents in the favelas, information on the progression of COVID-19 is extremely scarce; however, an increase in the number of deaths has been documented, mainly in homes and actions by members of the community itself to contain the pandemic.

Correlation between the markers assessed in the study despite the COVID-19 pandemic

In the study carried out, numerous correlations were positive, as shown in Table 5, with emphasis on the following correlations:

(a) number of cases of COVID-19 with the percentage of ICU occupancy [correlation coefficient (CC) = 0.577], the number of RT-PCRs of the SARS-CoV-2 virus performed (CC = 0.703) and the probable underreporting (CC = 0.535);

(b) number of deaths associated with COVID-19 with the ratio between SARS and SARS by COVID-19 (CC = -0.428), the percentage of ICU occupancy (CC = 0.473), the number of RT-PCRs from the SARS virus -CoV-2 performed (CC = 0.631) and the probable underreporting of COVID-19 (CC = 0.535);

(c) lethality by COVID-19 with the ratio between SARS and SARS by COVID-19 (CC = -0.575);

(d) incidence of COVID-19 per 100 thousand inhabitants with the ratio between SARS and SARS by COVID-19 (CC = -0.475), ICU occupancy percentage (CC = 0.555) and probable underreporting of COVID-19 (CC = -0.396);

(e) mortality of COVID-19 per 100 thousand inhabitants with the number of cases of COVID-19 (CC = 0.603), incidence of COVID-19 per 100 thousand inhabitants (CC = 0.821), ratio between SARS and SARS by COVID- 19 (CC = -0.559) and the percentage of ICU occupancy (CC = 0.562);

(f) probable underreporting by COVID-19 with the number of tests performed for RT-PCRs of the SARS-CoV-2 virus (CC = 0.461).

In conclusion, epidemiological data, mainly referring to the number of new cases, deaths and hospitalizations associated with COVID-19 and analysis of adherence to social isolation and the overview of health services, are extremely important to enable decision-making by part of health managers and government, mainly federal.

However, in Brazil, access to information that characterizes the reality of the moment in which we live before the pandemic COVID-19 has been limited and we need to optimize the RT-PCR diagnosis of the SARS-CoV-2 virus, especially in asymptomatic cases. and mild infections of individuals colonized by the virus. A better structuring of the information system of COVID-19 in Brazil, by the Ministry of Health, should be carried out in order to promote a detailed description of the evolution of the disease on a national basis.

REFERENCES

1. Coronavirus disease. (COVID-19) pandemic [Internet]. https://www.who.int/emergencies/diseases/novel-coronavirus-2019. Accessed on 11 Jun 2020.

2. World of Meters. Coronavirus Cases [Internet]. https://www.worldometers.info/coronavirus/country/brazil/ Accessed on 11 Jun 2020.

3. Secretaria de Estado da Saúde. Vigilância Epidemiológica[Internet]. https://www.saude.go.gov.br/vigilancia-em-saude/vigilancia-epidemiologica Accessed on 14 Sept 2020.

4. Ministério da Saúde. Guia de Vigilância em Saúde. Volume único. 4.ed. Brasília, DF. 2019.

5. Fundação Instituto Oswaldo Cruz. (FioCruz) – InfoGripe [Internet].. http://info.gripe.fiocruz.br .Accessed on 11 Jun 2020.

6. Lau H, Khosrawipour V, Kocbach P, Mikolajczyk A, Ichii H, Schubert J et al. Internationally lost COVID-19 cases. J Microbiol Immunol Infect 2020; 53 (3): 454-458. http://dx.doi.org/10.1016/j.jmii.2020.03.013

7. Krantz SG, Rao ASRS. Level of underreporting including underdiagnosis before the first peak of COVID-19 in various countries: Preliminary retrospective results based on wavelets and deterministic modeling. Infect Control Hosp Epidemiol 2020: 1-3. http://dx.doi.org/10.1017/ice.2020.116

8. Agência Brasil. [Internet]. https://agenciabrasil.ebc.com.br/saude/noticia/2020-06/ministerio-da-saude-muda-formato-de-divulgacao-de-dados-de-covid-19. Accessed on 12 Jun 2020.

9. Ministério da Saúde. (BR), Governo Federal do Brasil [Internet] https://www.gov.br/saude/pt-br. Accessed on 12 Jun 2020.

10. Mapa brasileiro da COVID-19. [Internet]. https://mapabrasileirodacovid.inloco.com.br/pt

11. Isolamento Social no estado de São Paulo. [Internet]. https://www.saopaulo.sp.gov.br/coronavirus/isolamento. Accessed on 11. Jun 2020.

12. Legislação do Estado de São Paulo. [Internet]. http://legislacao.prefeitura.sp.gov.br .Accessed on 12^th Jun 2020.

13. Lei 194040, Estado de São Paulo. [Internet]. https://www.al.sp.gov.br/norma/194040 Accessed on 12^th Jun 2020.

14. Marson FAL, Ortega MM. COVID-19 in Brazil. Pulmonology 2020; 26(4): 241-244. https://dx.doi.org/10.1016/j.pulmoe.2020.04.008

15. Marson, F. Um Milhão de casos de COVID-19. Rev Med (São Paulo) 2020; 99: 209-212. https://dx.doi.org/10.11606/issn.1679-9836.v99i2p209-212

16. Lake MA. What we know so far: COVID-19 current clinical knowledge and research. Clin Med (Lond) 2020; 20(2): 124-127. http://dx.doi.org/10.7861/clinmed.2019-coron

17. Ge H, Wang X, Yuan X, Xiao G, Wang C, Deng T et al. The epidemiology and clinical information about COVID-19. Eur J Clin Microbiol Infect Dis 2020; 39 (6): 1011-1019. http://dx.doi.org/10.1007/s10096-020-03874-z

18. Marson FAL. COVID-19 - 6 million cases worldwide and an overview of the diagnosis in Brazil: a tragedy to be announced. Diagn Microbiol Infect Dis 2020; 98(2): 115113. http://dx.doi.org/10.1016/j.diagmicrobio.2020.115113

19. Chinazzi M, Davis JT, Ajelli M, Gioannini C, Litvinova M, Merler S et al. The effect of travel restrictions on the spread of the 2019 novel coronavirus (COVID-19) outbreak. Science 2020; 368 (6489): 395-400. http://dx.doi.org/10.1126/science.aba9757

20. Hou C, Chen J, Zhou Y, Hua L, Yuan J, He S et al. The effectiveness of quarantine of Wuhan city against the Corona Virus Disease 2019 (COVID-19): A well-mixed SEIR model analysis. J Med Virol 2020; 92 (7): 841-848. http://dx.doi.org/10.1002/jmv.25827

21. Mishra BK, Keshri AK, Rao YS, Mishra BK, Mahato B, Ayesha S et al. COVID-19 created chaos across the globe: Three novel quarantine epidemic models. Chaos Solitons Fractals 2020; 138: 109928. http://dx.doi.org/10.1016/j.chaos.2020.109928

22. Lau H, Khosrawipour T, Kocbach P, Ichii H, Bania J, Khosrawipour V. Evaluating the massive underreporting and undertesting of COVID-19 cases in multiple global epicenters. Pulmonology 2020: S2531-0437(20)30129-X. http://dx.doi.org/10.1016/j.pulmoe.2020.05.015

23. Coronavirus Disease: 4 Million Cases Worldwide and the Importance of Multidisciplinary Health Care Teams During the Pandemic. J Emerg Nurs 2020;4 6(5): 570-571. http://dx.doi.org/10.1016/j.jen.2020.06.004

24. Palamim CVC, Marson FAL. COVID-19 - The Availability of ICU Beds in Brazil during the Onset of Pandemic. Ann Glob Health 2020; 86(1): 100. http://dx.doi.org/10.5334/aogh.3025

IR