Abstract

Definition and relevance of COVID-19

In December 2019, the World Health Organization (WHO) office in China ¹1. World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf (acessado em 20/Fev/2020).
https://www.who.int/docs/default-source/... reported the first official case of a pneumonia, still of unknown cause, in Wuhan, Hubei province, triggering particular interest among health authorities. By late January 2020, a state of public health emergency of international concern had been declared. By February 2020, the acute respiratory distress syndrome (ARDS) that was spreading with exponential progression was named COVID-19 by World Health Organization (WHO) ¹1. World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf (acessado em 20/Fev/2020).
https://www.who.int/docs/default-source/... , and on March 11, 2020, WHO declared the disease a pandemic. By that time, COVID-19 was present in some 100 countries, with more than 100,000 confirmed cases of the disease, and specific measures were needed for its identification, prevention, and control ¹1. World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf (acessado em 20/Fev/2020).
https://www.who.int/docs/default-source/... ^,22. Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet 2020; 395:470-73.^,33. Velavan TP, Meyer CG. The COVID-19 epidemic. Trop Med Int Health 2020; 25:278-80. doi:10.1111/tmi.13383.
https://doi.org/10.1111/tmi.13383... .

COVID-19 is an infectious ARDS caused by the novel coronavirus, the etiological agent SARS-CoV-2. Other epidemics had been reported with similar etiological agents, such as SARS-CoV-1 and MERS, but none of them with such magnitude ²2. Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet 2020; 395:470-73.. SARS-CoV-2 presented particularly rapid spread and increase of new cases.

In Wuhan, the indicator of transmissibility (R₀), which indicates the speed of viral spread in humans, was 2.2 (95%CI: 1.4; 3.9), indicating that each infected person can infect two more persons on average through actual contact ⁴4. Kolifarhood G, Aghaali M, Saadati HM, Taherpour N, Izadi N, Nazari SSH. Epidemiological and clinical aspects of COVID-19: a narrative review. Arch Acad Emerg Med 2020; 8:e41.. In the recent literature, the R₀ of SARS-CoV-2 varied from 1.95 (95%CI: 1.4; 2.5) ¹1. World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf (acessado em 20/Fev/2020).
https://www.who.int/docs/default-source/... to 6.5 (95%CI: 5.7; 7.2) ⁴4. Kolifarhood G, Aghaali M, Saadati HM, Taherpour N, Izadi N, Nazari SSH. Epidemiological and clinical aspects of COVID-19: a narrative review. Arch Acad Emerg Med 2020; 8:e41., with an estimated mean R₀ of 3.3 and median of 2.8 ⁴4. Kolifarhood G, Aghaali M, Saadati HM, Taherpour N, Izadi N, Nazari SSH. Epidemiological and clinical aspects of COVID-19: a narrative review. Arch Acad Emerg Med 2020; 8:e41.. The observed variation is due to estimates at different moments in the outbreak of COVID-19 ¹1. World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf (acessado em 20/Fev/2020).
https://www.who.int/docs/default-source/... ^,44. Kolifarhood G, Aghaali M, Saadati HM, Taherpour N, Izadi N, Nazari SSH. Epidemiological and clinical aspects of COVID-19: a narrative review. Arch Acad Emerg Med 2020; 8:e41..

Concerning pathogenesis, 70% to 80% of infected individuals are either asymptomatic or present mild symptoms of the disease. Still without consensus in the literature, an estimated 20% will develop the more severe form of the disease in hospital care and may reach 5%-10% in intensive care ¹1. World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf (acessado em 20/Fev/2020).
https://www.who.int/docs/default-source/... ^,55. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020; 323:1239-42.. Mean convalescence time is 19 days (2 to 5 days until the appearance of symptoms and 14 days after symptoms until recovery), but cases in intensive care take 3 to 6 weeks ¹1. World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf (acessado em 20/Fev/2020).
https://www.who.int/docs/default-source/... . Since the entire population is susceptible, a very rapid increase in the number of infected individuals will lead to an overload on hospital beds, procedures, and equipment ⁵5. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020; 323:1239-42.^,66. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020; 382:1199-207.. The risk factors associated with severity feature advanced age (over 60 years, especially for increased risk of mortality) and presence of comorbidities (cardiovascular diseases, obesity, diabetes, hypertension, pulmonary diseases, etc.), accelerating the progression of symptoms, with worse prognosis ⁴4. Kolifarhood G, Aghaali M, Saadati HM, Taherpour N, Izadi N, Nazari SSH. Epidemiological and clinical aspects of COVID-19: a narrative review. Arch Acad Emerg Med 2020; 8:e41..

According to WHO data (https://www.covidvisualizer.com, accessed on 30/May/2020), the world had reported approximately 6 million confirmed cases of COVID-19, with more than 365,000 deaths associated with the disease. By the same date, the Brazilian Ministry of Health had reported 470,000 confirmed cases (incidence of 221.5 per 100,000 inhabitants) and nearly 30,000 deaths from the disease, with a case-fatality rate of 6% (mortality rate of 13.3 per 100,000 inhabitants), noting that the first case had been reported on February 26, 2020, and the first official death on March 17, 2020 (Ministério da Saúde. https://covid.saude.gov.br/, accessed on 30/May/2020). The current scenario is due to Brazil’s adherence to the social distancing protocol recommended by the WHO and adopted since March 12, 2020 ⁷7. Ministério da Saúde. Portaria nº 356, de 11 de março de 2020. Dispõe sobre a regulamentação e operacionalização do disposto na Lei nº 13.979, de 6 de fevereiro de 2020, que estabelece as medidas para enfrentamento da emergência de saúde pública de importância internacional decorrente do coronavírus (COVID-19). Diário Oficial da União 2020; 12 mar..

Measurement of DALYs from COVID-19: reflections, limits, and possibilities

Despite the importance of measurement and analysis of morbidity and mortality for understanding the impact of COVID-19, we highlight the relevance of a methodology that more effectively computes how much this disease influences the population’s health status, considering such aspects as severity, duration, and the potential to generate chronic complications according to age bracket, sex, and location, besides the impact on the Brazilian Unified National Health System (SUS).

Thus, an extremely useful indicator is disability-adjusted life years (DALYs), developed by Murray & Lopez ⁸8. Murray CJL, Lopez AD. The Global Burden of Disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020 - summary. Geneva: World Health Organization; 1996.^,99. Murray CJL, Lopez AD. Global health statistics: a compendium of incidence, prevalence and mortality estimates for over 200 conditions. Geneva: World Health Organization; 1996. in the mid-1990s in the context of the Global Burden of Disease (GBD) study. The indicator is divided into two components: (1) mortality, estimated years of life lost (YLLs), and (2) morbidity, estimated as years lived with disability (YLDs).

Nearly three decades since studies on global burden of disease emerged ⁹9. Murray CJL, Lopez AD. Global health statistics: a compendium of incidence, prevalence and mortality estimates for over 200 conditions. Geneva: World Health Organization; 1996., they have incorporated updates and methodological refinements ¹⁰10. Murray CL, Ezzati M, Flaxman AD, Lim S, Lozano R, Michaud C, et al. GBD 2010: a multi-investigator collaboration for global comparative descriptive epidemiology. Lancet 2012; 380:2055-8.^,1111. World Health Organization. The Global Burden of Disease: 2004 update. Geneva: World Health Organization; 2008.. This period has witnessed intense debates on the methodological proposal for measuring DALYs, and various methodological refinements have been incorporated. The field has also incorporated researchers, research groups, and institutions from throughout the world as collaborators in the various editions of the national/global estimates of GBD, under the coordination of Christopher Murray, who heads the core group of the Institute of Health Metrics and Evaluation (IHME), Washington University (Seattle, USA). There was a significant increase in the number of target diseases and sequelae, as well as the potential risk factors ⁸8. Murray CJL, Lopez AD. The Global Burden of Disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020 - summary. Geneva: World Health Organization; 1996.^,1010. Murray CL, Ezzati M, Flaxman AD, Lim S, Lozano R, Michaud C, et al. GBD 2010: a multi-investigator collaboration for global comparative descriptive epidemiology. Lancet 2012; 380:2055-8.^,1212. Department of Information, Evidence and Research, World Health Organization. WHO methods and data sources for country-level causes of death 2000-2016. Geneva: World Heath Organization; 2018.^,1313. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392:1789-858..

The challenges and the emergence/resurgence of new and old diseases require updates, new methodologies to estimate the years lived with disability (YLDs), often with an important degree of incompleteness, given the limited knowledge on the natural history of the disease, like arbovirus infections, more specifically Zika and chikungunya, and currently the SARS-CoV-2 pandemic. In addition, questions related to the specificities, given the economic and demographic characteristics and social inequalities, are still debated to reflect on the national/global estimates.

Brazil has conducted two national editions of the burden of disease study. The first was in the year 1998 ¹⁴14. Gadelha AMJ, Leite IC, Valente JG, Schramm JMA, Campos MR. Relatório final do projeto Estimativa da Carga de Doença do Brasil, 1998. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 1998.^,1515. Schramm JMA, Oliveira AF, Leite IC, Valente JG, Gadelha AMJ, Portela MC, et al. Transição epidemiológica e o estudo de carga de doença no Brasil. Ciênc Saúde Colet 2004; 9:897-908.^,1616. Leite IC, Schramm JMA, Gadelha AMJ, Valente JG, Campos MR, Portela MC, et al. Comparação das informações sobre as prevalências de doenças crônicas obtidas pelo suplemento saúde da PNAD/98 e as estimadas pelo estudo Carga de Doença no Brasil. Ciênc Saúde Colet 2002; 7:733-41. and the second in 2008 ¹⁷17. Leite IC, Valente J, Schramm JMA. Relatório final do projeto Carga de Doença do Brasil, 2008. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2008.^,1818. Leite IC, Valente JG, Schramm JMA, Daumas RP, Rodrigues RN, Costa MFS, et al. Burden of disease in Brazil and its regions, 2008. Cad Saúde Pública 2015; 31:1551-64.^,1919. Leite IC, Valente JG, Schramm J, Oliveira AF, Costa MFS, Campos MR. National and regional estimates of disability-adjusted life-years (DALYs) in Brazil, 2008: a systematic analysis. Lancet 2013; 381 Suppl:S83., besides studies on specific diseases such as diabetes ²⁰20. Costa AF, Flor LS, Campos MR, Oliveira AF, Costa MFS, Silva RS, et al. Carga do diabetes mellitus tipo 2 no Brasil. Cad Saúde Pública 2017; 33:e00197915.^,2121. Flor LS, Campos MR, Oliveira AF, Schramm JMA. Diabetes burden in Brazil: fraction attributable to overweight, obesity, and excess weight. Rev Saúde Pública 2015; 49:29., hepatitis/cirrhosis ²²22. Carvalho JR, Villela-Nogueira CA, Perez RM, Portugal FB, Flor LS, Campose MR, et al. Burden of chronic viral hepatitis and liver cirrhosis in Brazil - the Brazilian Global Burden of Disease Study. Ann Hepatol 2017; 16:893-900.^,2323. Portugal FB, Campos MR, Carvalho JR, Flor LS, Schramm JMA, Costa MFS. Carga de doença no Brasil: um olhar sobre o álcool e a cirrose não viral. Ciênc Saúde Colet 2015; 20:491-501.^,2424. Carvalho JR, Portugal FB, Flor LS, Campos MR, Schramm JMA. Método para estimação de prevalência de hepatites B e C crônicas e cirrose hepática - Brasil, 2008. Epidemiol Serv Saúde 2014; 23:691-700., external causes ²⁵25. Campos MR, von Doellinger VR, Mendes LVP, Costa MFS, Pimentel TG, Schramm JMA. Morbidity and mortality associated with injuries: results of the Global Burden of Disease study in Brazil, 2008. Cad Saúde Pública 2015; 31:121-36.^,2626. Mendes LVP, Campos MR, von-Doellinger VR, Mota JC, Pimentel TG, Schramm JMA. A evolução da carga de causas externas no Brasil: uma comparação entre os anos de 1998 e 2008. Cad Saúde Pública 2015; 31:2169-84.^,2727. von-Doellinger V, Campos M, Mendes L, Schramm J. The 2008 Global Burden of Disease study in Brazil: a new methodological approach for estimation of injury morbidity. Rev Panam Salud Pública 2014; 36:368-75., and neglected diseases ²⁸28. Schramm JMA, Campos MR, Emmerick ICM, Mendes LVP, Mota JC, Silva Júnior SHA. Spatial analysis of neglected diseases in Brazil, 2007-2009. Tempus (Brasília) 2016; 10:119-42.. The last version of the Brazilian study features methodological refinements that underscore the originality of national studies, representing an important difference in relation to the GBD, more specifically in relation to the morbidity component (YLDs). In this sense, the two versions of the Brazilian Burden of Disease Study (1998 ¹⁴14. Gadelha AMJ, Leite IC, Valente JG, Schramm JMA, Campos MR. Relatório final do projeto Estimativa da Carga de Doença do Brasil, 1998. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 1998. and 2008 ¹⁷17. Leite IC, Valente J, Schramm JMA. Relatório final do projeto Carga de Doença do Brasil, 2008. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2008.) cannot be compared directly, which would require the replication of methodological contributions for each disease ²⁶26. Mendes LVP, Campos MR, von-Doellinger VR, Mota JC, Pimentel TG, Schramm JMA. A evolução da carga de causas externas no Brasil: uma comparação entre os anos de 1998 e 2008. Cad Saúde Pública 2015; 31:2169-84..

In the case of COVID-19, the clinical and epidemiological panorama of the acute and chronic complications requires some time for execution. The available and necessary scientific literature for performing estimates of YLDs, given the short time since the onset of COVID-19 for investigation of recovered cases, points to challenges for calculating DALYs: mapping acute and chronic complications of COVID-19 and the respective clinical and epidemiological parameters.

DALY is sensitive to the quality and precision of the information used as the data source to obtain inputs for estimates, as well as the weights assigned to the severity of measured chronic complications (measurements to be constructed), which currently introduces a relevant degree of uncertainty for DALYs in COVID-19. This emphasizes the relevance of studies with sensitivity analysis that assess the observed uncertainty in the estimates, considering the different scenarios of inputs and the decision-making process, for example, in relation to assigning weights and/or sources of information ²⁹29. Salje H, Tran Kiem C, Lefrancq N, Courtejoie N, Bosetti P, Paireau J, et al. Estimating the burden of SARS-CoV-2 in France. Science 2020; 369:208-11.; as well as weighting according to the presence and amounts of associated comorbidities, which introduce so much variability in YLLs ³⁰30. Hanlon P, Chadwick F, Shah A, Wood R, Minton J, McCartney G, et al. COVID-19 - exploring the implications of long-term condition type and extent of multimorbidity on years of life lost: a modelling study. Wellcome Open Research 2020; 23 abr. https://wellcomeopenresearch.org/articles/5-75.
https://wellcomeopenresearch.org/article... . Two scenarios of possible sources could thus be considered: (a) official data from the State Health Departments/Brazilian Ministry of Health (Ministério da Saúde. https://covid.saude.gov.br/, accessed on 30/May/2020) and (b) alternative sources such as the SIVEP-Gripe database (http://info.gripe.fiocruz.br, accessed on 30/May/2020) and the Civil Registry of Deaths (Portal da Transparência. Painel registral. https://transparencia.registrocivil.org.br/especial-covid, accessed on 23/Apr/2020). Based on these compositions of scenarios, sets of sensitivity analyses could be performed: official data versus data corrected for underreporting, which would certainly involve differences in the final set of DALYs.

The DALY indicator has the further advantage of specific analysis by age structure, a significant risk factor for COVID-19, added to the presence/number of comorbidities, as seen in the study by Hanlon et al. ³⁰30. Hanlon P, Chadwick F, Shah A, Wood R, Minton J, McCartney G, et al. COVID-19 - exploring the implications of long-term condition type and extent of multimorbidity on years of life lost: a modelling study. Wellcome Open Research 2020; 23 abr. https://wellcomeopenresearch.org/articles/5-75.
https://wellcomeopenresearch.org/article... showing an important variation in YLLs by age, based on the presence of other preexisting chronic conditions. For example, there are 35 YLLs (on average) for men 50-59 years of age (without comorbidities) and 19 YLLs for those with five comorbidities, due to the lower life expectancy and lower incidence in this group with more comorbidities. Meanwhile, for those 80 years and older, the loss is 11 YLLs (without comorbidities) and 1.5 YLLs for 11 comorbidities, despite the higher risk and higher incidence in this age group.

Another relevant in the decision-making process for calculating YLDs is the challenge of defining the set of weights assigned to the severity of acute and chronic complications associated with COVID-19, given the current lack of complete knowledge on the natural history of the disease, its clinical and epidemiological horizon (which affects the duration), changes in the treatment protocol due to technological innovations from emerging studies at the global level, both to measure the efficacy of known medicines and the search for new drugs and vaccines (which will mean the indicator of percentage of treated individuals, also incorporated into the YLDs).

All these questions will have a direct impact on measurement of YLDs, translated as the time lived with disability associated with the underlying disease, given access to the treatment protocol, weighted by the severity of each acute or chronic complication ⁸8. Murray CJL, Lopez AD. The Global Burden of Disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020 - summary. Geneva: World Health Organization; 1996.^,99. Murray CJL, Lopez AD. Global health statistics: a compendium of incidence, prevalence and mortality estimates for over 200 conditions. Geneva: World Health Organization; 1996..

Current and future problems: acute and chronic complications of COVID-19 and construction of the metric for burden of COVID-19

The essential elements for calculation of YLDs involve incorporation of the “lost” time resulting from the complications and their respective severities, compiled via the weights of the disabilities and duration of acute and chronic complications, even though the possible complications of COVID-19 have not been exhausted, given the need for more studies on cell tropism and pathogenic mechanism ³¹31. Paniz-Mondolfi A, Bryce C, Grimes Z, Gordon RE, Reidy J, Lednicky J, et al. Central nervous system involvement by severe acute respiratory syndrome coronavirus -2 (SARS-CoV-2). J Med Virol 2020; 92:699-702.^,3232. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395:1054-62.. The disease requires a systemic approach, given the evidence of possible complications in vital organs. Thus, the dissemination and thus the effects of SARS-CoV-2 in the body are extensive ³³33. Sun J, Aghemo A, Forner A, Valenti L. COVID-19 and liver disease. Liver Int 2020; 40:1278-81.^,3434. Diao B, Wang C, Wang R, Feng Z, Tan Y, Wang H, et al. Human kidney is a target for novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. medRxiv 2020; 10 abr. https://www.medrxiv.org/content/10.1101/2020.03.04.20031120v4.
https://www.medrxiv.org/content/10.1101/... ^,3535. Zhang C, Shi L, Wang F-S. Liver injury in COVID-19: management and challenges. Lancet Gastroenterol Hepatol 2020; 5:428-30..

When the etiological agent SARS-CoV-2 enters the host organism, it binds to the angiotensin- converting enzyme-2 (ACE-2) receptor, allowing entry into the target cell and replication, triggering an immune response in the host and the first symptoms and clinical manifestations ³⁵35. Zhang C, Shi L, Wang F-S. Liver injury in COVID-19: management and challenges. Lancet Gastroenterol Hepatol 2020; 5:428-30.. Despite the known tropism of the virus for the upper respiratory tract and lung tissue, due to the portal of entry, other organs that also express this receptor can be affected ³⁶36. Fellet J. Covid-19 não pode ser pensada só como doença respiratória, diz epidemiologista. BBC News Brasil 2020; 15 mai. https://www.bbc.com/portuguese/geral-52672009.
https://www.bbc.com/portuguese/geral-526... , and the individual can develop other corresponding clinical manifestations ³⁷37. Oxley TJ, Mocco J, Majidi S, Kellner CP, Shoirah H, Singh P, et al. Large-vessel stroke as a presenting feature of Covid-19 in the young. N Engl J Med 2020; 382:e60..

To understand the distribution of the disease in the humans, Wu et al. ³⁸38. Wu D, Shu T, Yang X, Song J-X, Zhang M, Yao C, et al. Plasma metabolomic and lipidomic alterations associated with COVID-19. medRxiv 2020; 26 abr. http://medrxiv.org/lookup/doi/10.1101/2020.04.05.20053819.
http://medrxiv.org/lookup/doi/10.1101/20... conducted studies on metabolomic and lipidomic alterations in which they demonstrated an apparent correlation between them and the development of COVID-19, indicating that the disease altered metabolism throughout the body, with effects ranging from the cellular level to various organ systems.

These metabolic alterations, due to the relative underlying susceptibility to the infectious process by endothelial deregulation from the inflammatory mechanism, reduce the vessels’ capacity to perform important regulatory functions ³¹31. Paniz-Mondolfi A, Bryce C, Grimes Z, Gordon RE, Reidy J, Lednicky J, et al. Central nervous system involvement by severe acute respiratory syndrome coronavirus -2 (SARS-CoV-2). J Med Virol 2020; 92:699-702.^,3737. Oxley TJ, Mocco J, Majidi S, Kellner CP, Shoirah H, Singh P, et al. Large-vessel stroke as a presenting feature of Covid-19 in the young. N Engl J Med 2020; 382:e60.. These alterations can thus lead to acute or chronic complications that are related to the more serious forms of the disease ³⁰30. Hanlon P, Chadwick F, Shah A, Wood R, Minton J, McCartney G, et al. COVID-19 - exploring the implications of long-term condition type and extent of multimorbidity on years of life lost: a modelling study. Wellcome Open Research 2020; 23 abr. https://wellcomeopenresearch.org/articles/5-75.
https://wellcomeopenresearch.org/article... ^,3131. Paniz-Mondolfi A, Bryce C, Grimes Z, Gordon RE, Reidy J, Lednicky J, et al. Central nervous system involvement by severe acute respiratory syndrome coronavirus -2 (SARS-CoV-2). J Med Virol 2020; 92:699-702.^,3737. Oxley TJ, Mocco J, Majidi S, Kellner CP, Shoirah H, Singh P, et al. Large-vessel stroke as a presenting feature of Covid-19 in the young. N Engl J Med 2020; 382:e60.^,3939. Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ 2020; 368:m1091.^,4040. Madjid M, Safavi-Naeini P, Solomon SD, Vardeny O. Potential effects of coronaviruses on the cardiovascular system: a review. JAMA Cardiol 2020; 5:831-40..

In the current scientific literature, the above-mentioned target organs include the lungs, but the lack of oxygen and the systemic inflammation can also acutely damage the kidneys ⁴¹41. Wadman M, Couzin-Frankel J, Kaiser J, Matacic C. How does coronavirus kill? Clinicians trace a ferocious rampage through the body, from brain to toes. Science 2020; 17 abr. https://www.sciencemag.org/news/2020/04/how-does-coronavirus-kill-clinicians-trace-ferocious-rampage-through-body-brain-toes.
https://www.sciencemag.org/news/2020/04/... (27%), liver ⁴²42. Xu L, Liu J, Lu M, Yang D, Zheng X. Liver injury during highly pathogenic human coronavirus infections. Liver Int 2020; 40:998-1004. (50%), and gastrointestinal tract ⁴³43. Gu J, Han B, Wang J. COVID-19: gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology 2020; 158:1518-9.^,4444. Wu Y, Guo C, Tang L, Hong Z, Zhou J, Dong X, et al. Prolonged presence of SARS-CoV-2 viral RNA in faecal samples. Lancet Gastroenterol Hepatol 2020; 5:434-5.^,4545. Wang H, Qiu P, Liu J, Wang F, Zhao Q. The liver injury and gastrointestinal symptoms in patients with coronavirus disease 19: a systematic review and meta-analysis. Clin Res Hepatol Gastroenterol 2020; 44:653-61. (20%) and cause alterations in the coagulation cascade and hematopoietic system, heart, and cardiovascular system ⁴⁶46. Cascella M, Rajnik M, Cuomo A, Dulebohn SC, Di Napoli R. Features, evaluation and treatment coronavirus (COVID-19). Treasure Island: StatPearls Publishing; 2020., brain and central nervous system (CNS) ⁴⁷47. Servick K. For survivors of severe COVID-19, beating the virus is just the beginning. Science 2020; 8 abr. https://www.sciencemag.org/news/2020/04/survivors-severe-covid-19-beating-virus-just-beginning.
https://www.sciencemag.org/news/2020/04/... , and other organs ⁴¹41. Wadman M, Couzin-Frankel J, Kaiser J, Matacic C. How does coronavirus kill? Clinicians trace a ferocious rampage through the body, from brain to toes. Science 2020; 17 abr. https://www.sciencemag.org/news/2020/04/how-does-coronavirus-kill-clinicians-trace-ferocious-rampage-through-body-brain-toes.
https://www.sciencemag.org/news/2020/04/... .

As for acute complications ³⁶36. Fellet J. Covid-19 não pode ser pensada só como doença respiratória, diz epidemiologista. BBC News Brasil 2020; 15 mai. https://www.bbc.com/portuguese/geral-52672009.
https://www.bbc.com/portuguese/geral-526... , the propensity to develop blood clots from inflammation in these vessels, especially in the lungs, can account for the development of more severe forms of the disease, since the thrombi can play a direct and significant role in the gas exchange abnormalities and multisystem organ dysfunction ³¹31. Paniz-Mondolfi A, Bryce C, Grimes Z, Gordon RE, Reidy J, Lednicky J, et al. Central nervous system involvement by severe acute respiratory syndrome coronavirus -2 (SARS-CoV-2). J Med Virol 2020; 92:699-702.^,3232. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395:1054-62.^,3737. Oxley TJ, Mocco J, Majidi S, Kellner CP, Shoirah H, Singh P, et al. Large-vessel stroke as a presenting feature of Covid-19 in the young. N Engl J Med 2020; 382:e60..

The central nervous system sequelae can be devastating, especially due to respiratory viral infections, since there are at least two known entry routes for the virus into the CNS, the bloodborne route mediated by ACE-2 receptors and the retrograde neuronal pathways and infection induced by neuropathic virus, which can explain the increase in the occurrence of stroke, behavior changes, and anosmia ³¹31. Paniz-Mondolfi A, Bryce C, Grimes Z, Gordon RE, Reidy J, Lednicky J, et al. Central nervous system involvement by severe acute respiratory syndrome coronavirus -2 (SARS-CoV-2). J Med Virol 2020; 92:699-702..

As for the heart and vascular system, the most frequently reported complications are acute cardiac lesion, cardiac insufficiency, myocarditis, vascular inflammation, and cardiac arrythmias ³⁹39. Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ 2020; 368:m1091.^,4040. Madjid M, Safavi-Naeini P, Solomon SD, Vardeny O. Potential effects of coronaviruses on the cardiovascular system: a review. JAMA Cardiol 2020; 5:831-40.^,4848. Yang F, Shi S, Zhu J, Shi J, Dai K, Chen X. Analysis of 92 deceased patients with COVID-19. J Med Virol 2020; [Online ahead of print].. The heart problems, associated with an increase in cardiac enzyme levels, can be related to a combination of a significant systemic inflammatory response and vascular inflammation located at the arterial plaque ⁴⁶46. Cascella M, Rajnik M, Cuomo A, Dulebohn SC, Di Napoli R. Features, evaluation and treatment coronavirus (COVID-19). Treasure Island: StatPearls Publishing; 2020..

Liver complications include hepatic insufficiency, with liver enzymes three times higher than the reference values ³⁴34. Diao B, Wang C, Wang R, Feng Z, Tan Y, Wang H, et al. Human kidney is a target for novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. medRxiv 2020; 10 abr. https://www.medrxiv.org/content/10.1101/2020.03.04.20031120v4.
https://www.medrxiv.org/content/10.1101/... ^,4848. Yang F, Shi S, Zhu J, Shi J, Dai K, Chen X. Analysis of 92 deceased patients with COVID-19. J Med Virol 2020; [Online ahead of print]., more common in men ³³33. Sun J, Aghemo A, Forner A, Valenti L. COVID-19 and liver disease. Liver Int 2020; 40:1278-81.^,4949. Fan Z, Chen L, Li J, Tian C, Zhang Y, Huang S, Liu Z, et al. Clinical features of COVID-19-related liver functional abnormality. J Clin Gastroenterol Hepatol 2020; 18:1561-6. and in more severe cases ³³33. Sun J, Aghemo A, Forner A, Valenti L. COVID-19 and liver disease. Liver Int 2020; 40:1278-81.^,4848. Yang F, Shi S, Zhu J, Shi J, Dai K, Chen X. Analysis of 92 deceased patients with COVID-19. J Med Virol 2020; [Online ahead of print].. Moderate microvascular steatosis and mild lobular and portal activity have been identified, but beyond the SARS-Cov-2 infection itself, hepatic involvement may be related to induction from polypharmacy ³³33. Sun J, Aghemo A, Forner A, Valenti L. COVID-19 and liver disease. Liver Int 2020; 40:1278-81.^,3535. Zhang C, Shi L, Wang F-S. Liver injury in COVID-19: management and challenges. Lancet Gastroenterol Hepatol 2020; 5:428-30.^,4949. Fan Z, Chen L, Li J, Tian C, Zhang Y, Huang S, Liu Z, et al. Clinical features of COVID-19-related liver functional abnormality. J Clin Gastroenterol Hepatol 2020; 18:1561-6.. To date, there is no robust evidence to support chronic liver failure in these patients ³³33. Sun J, Aghemo A, Forner A, Valenti L. COVID-19 and liver disease. Liver Int 2020; 40:1278-81., despite some studies ³⁹39. Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ 2020; 368:m1091.^,4949. Fan Z, Chen L, Li J, Tian C, Zhang Y, Huang S, Liu Z, et al. Clinical features of COVID-19-related liver functional abnormality. J Clin Gastroenterol Hepatol 2020; 18:1561-6..

Renal insufficiency in COVID-19 patients has occurred due to increased serum creatinine and decreased glomerular filtration rate. SARS-CoV-2 infection can induce severe acute tubular necrosis and lymphocyte infiltration, causing more tubular damage via recruitment of macrophages to infiltrate the interstitial tubule ³⁴34. Diao B, Wang C, Wang R, Feng Z, Tan Y, Wang H, et al. Human kidney is a target for novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. medRxiv 2020; 10 abr. https://www.medrxiv.org/content/10.1101/2020.03.04.20031120v4.
https://www.medrxiv.org/content/10.1101/... ^,4848. Yang F, Shi S, Zhu J, Shi J, Dai K, Chen X. Analysis of 92 deceased patients with COVID-19. J Med Virol 2020; [Online ahead of print].^,5050. Li J, Fan J-G. Characteristics and mechanism of liver injury in 2019 coronavirus disease. J Clin Transl Hepatol 2020; 8:13-7., potentially explained by ACE-2 receptor expression in the renal tubules ³⁴34. Diao B, Wang C, Wang R, Feng Z, Tan Y, Wang H, et al. Human kidney is a target for novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. medRxiv 2020; 10 abr. https://www.medrxiv.org/content/10.1101/2020.03.04.20031120v4.
https://www.medrxiv.org/content/10.1101/... ^,5050. Li J, Fan J-G. Characteristics and mechanism of liver injury in 2019 coronavirus disease. J Clin Transl Hepatol 2020; 8:13-7..

Thrombotic alterations have been identified in COVID-19 patients ³²32. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395:1054-62.^,3737. Oxley TJ, Mocco J, Majidi S, Kellner CP, Shoirah H, Singh P, et al. Large-vessel stroke as a presenting feature of Covid-19 in the young. N Engl J Med 2020; 382:e60.^,5151. Giannis D, Ziogas IA, Gianni P. Coagulation disorders in coronavirus infected patients: COVID-19, SARS-CoV-1, MERS-CoV and lessons from the past. J Clin Virol 2020; 127:104362.^,5252. Lippi G, Plebani M, Henry BM. Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: a meta-analysis. Clin Chim Acta 2020; 506:145-8., and thrombocytopenia has been associated with fivefold higher odds of developing the more severe form of the disease ⁴⁹49. Fan Z, Chen L, Li J, Tian C, Zhang Y, Huang S, Liu Z, et al. Clinical features of COVID-19-related liver functional abnormality. J Clin Gastroenterol Hepatol 2020; 18:1561-6.^,5050. Li J, Fan J-G. Characteristics and mechanism of liver injury in 2019 coronavirus disease. J Clin Transl Hepatol 2020; 8:13-7.. Studies show that COVID-19 can increase the risk of developing disseminated intravascular coagulation ⁵¹51. Giannis D, Ziogas IA, Gianni P. Coagulation disorders in coronavirus infected patients: COVID-19, SARS-CoV-1, MERS-CoV and lessons from the past. J Clin Virol 2020; 127:104362.. One can infer that deregulation of the coagulation cascade and the resulting formation of intra-alveolar or systemic fibrin clots are prominent findings in both COVID-19 and in other severe respiratory diseases ⁵¹51. Giannis D, Ziogas IA, Gianni P. Coagulation disorders in coronavirus infected patients: COVID-19, SARS-CoV-1, MERS-CoV and lessons from the past. J Clin Virol 2020; 127:104362..

The virus thus acts on a receptor that is involved in control of the circulatory system, acting on the small arteries, which leads to numerous acute complications ³⁶36. Fellet J. Covid-19 não pode ser pensada só como doença respiratória, diz epidemiologista. BBC News Brasil 2020; 15 mai. https://www.bbc.com/portuguese/geral-52672009.
https://www.bbc.com/portuguese/geral-526... . Therefore, when calculating YLDs, it is necessary to consider that the complications require practically a “complete burden of disease study”, with workup of clinical and epidemiological parameters for each of these conditions. A “more simplified” estimate would be to aggregate cases by differentiated severities and thus estimate the YLDs for COVID-19 in mild, moderate, and severe/ICU cases with complications. This lends considerable complexity to the estimate. The same is obviously true for chronic complications in relation to the estimate of duration and weights of disabilities.

In this scenario in which the natural history of the disease is in constant evolution, it is also impossible to determine all the chronic complications that COVID-19 survivors will experience. Thus, one cannot rule out that chronic complications will be related to the acute complications cited above, such as renal insufficiency, stroke, and liver failure, among others ³⁷37. Oxley TJ, Mocco J, Majidi S, Kellner CP, Shoirah H, Singh P, et al. Large-vessel stroke as a presenting feature of Covid-19 in the young. N Engl J Med 2020; 382:e60.^,3838. Wu D, Shu T, Yang X, Song J-X, Zhang M, Yao C, et al. Plasma metabolomic and lipidomic alterations associated with COVID-19. medRxiv 2020; 26 abr. http://medrxiv.org/lookup/doi/10.1101/2020.04.05.20053819.
http://medrxiv.org/lookup/doi/10.1101/20... ^,3939. Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ 2020; 368:m1091.^,4747. Servick K. For survivors of severe COVID-19, beating the virus is just the beginning. Science 2020; 8 abr. https://www.sciencemag.org/news/2020/04/survivors-severe-covid-19-beating-virus-just-beginning.
https://www.sciencemag.org/news/2020/04/... ^,4848. Yang F, Shi S, Zhu J, Shi J, Dai K, Chen X. Analysis of 92 deceased patients with COVID-19. J Med Virol 2020; [Online ahead of print].^,5151. Giannis D, Ziogas IA, Gianni P. Coagulation disorders in coronavirus infected patients: COVID-19, SARS-CoV-1, MERS-CoV and lessons from the past. J Clin Virol 2020; 127:104362..

Mapping the chronic complications of COVID-19 and understanding their onset can draw on studies of severe pneumonias that evolve to acute respiratory distress syndrome (ARDS) ⁵³53. Herridge MS, Tansey CM, Matté A, Tomlinson G, Diaz-Granados N, Cooper A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011; 364:1293-304., leading to scars that generally cause long-term respiratory problems and that increase the risk of heart attack and stroke ⁴⁷47. Servick K. For survivors of severe COVID-19, beating the virus is just the beginning. Science 2020; 8 abr. https://www.sciencemag.org/news/2020/04/survivors-severe-covid-19-beating-virus-just-beginning.
https://www.sciencemag.org/news/2020/04/... . Patients following hospitalization for severe pneumonia with ARDS have presented fourfold higher risks of heart attack and stroke in the first year and 1.5 times higher in the nine subsequent years.

Extremely severe COVID-19 patients who spend long periods in the ICU are prone to developing “intensive care syndrome” ⁵³53. Herridge MS, Tansey CM, Matté A, Tomlinson G, Diaz-Granados N, Cooper A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011; 364:1293-304.^,5454. Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: an overview. J Transl Intern Med 2017; 5:90-2.^,5555. Robinson CC, Rosa RG, Kochhann R, Schneider D, Sganzerla D, Dietrich C, et al. Quality of life after intensive care unit: a multicenter cohort study protocol for assessment of long-term outcomes among intensive care survivors in Brazil. Rev Bras Ter Intensiva 2018; 30:405-13.^,5656. Ramsay P, Huby G, Merriweather J, Salisbury L, Rattray J, Griffith D, et al. Patient and carer experience of hospital-based rehabilitation from intensive care to hospital discharge: mixed methods process evaluation of the RECOVER randomised clinical trial. BMJ Open 2016; 6:e012041., characterized by a set of physical (muscle atrophy and weakness, 50%), cognitive (79%), and mental alterations (28%) that jeopardize the quality of life for both patients and their caregivers ⁵³53. Herridge MS, Tansey CM, Matté A, Tomlinson G, Diaz-Granados N, Cooper A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011; 364:1293-304.^,5555. Robinson CC, Rosa RG, Kochhann R, Schneider D, Sganzerla D, Dietrich C, et al. Quality of life after intensive care unit: a multicenter cohort study protocol for assessment of long-term outcomes among intensive care survivors in Brazil. Rev Bras Ter Intensiva 2018; 30:405-13..

As for cognitive impairment, the risk factors associated with this process feature the duration of delirium in the ICU, acute cerebral dysfunction (stroke, alcoholism), hypoxia (ARDS, cardiac arrest), hypotension (severe sepsis, trauma), respiratory insufficiency that requires prolonged mechanical ventilation, and the use of renal replacement therapy ⁵⁴54. Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: an overview. J Transl Intern Med 2017; 5:90-2.^,5555. Robinson CC, Rosa RG, Kochhann R, Schneider D, Sganzerla D, Dietrich C, et al. Quality of life after intensive care unit: a multicenter cohort study protocol for assessment of long-term outcomes among intensive care survivors in Brazil. Rev Bras Ter Intensiva 2018; 30:405-13..

Neuromuscular weakness acquired in the ICU is the most frequent physical alteration, occurring in more than 25% of ICU survivors, with reduced mobility, recurrent falls, or quadriparesis ⁵³53. Herridge MS, Tansey CM, Matté A, Tomlinson G, Diaz-Granados N, Cooper A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011; 364:1293-304.^,5454. Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: an overview. J Transl Intern Med 2017; 5:90-2..

Mental alterations include the risk of developing psychological changes that can exceed 60% ⁵⁴54. Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: an overview. J Transl Intern Med 2017; 5:90-2. with such symptoms as anxiety, depression, and posttraumatic stress ⁵³53. Herridge MS, Tansey CM, Matté A, Tomlinson G, Diaz-Granados N, Cooper A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011; 364:1293-304.^,5454. Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: an overview. J Transl Intern Med 2017; 5:90-2.^,5555. Robinson CC, Rosa RG, Kochhann R, Schneider D, Sganzerla D, Dietrich C, et al. Quality of life after intensive care unit: a multicenter cohort study protocol for assessment of long-term outcomes among intensive care survivors in Brazil. Rev Bras Ter Intensiva 2018; 30:405-13..

Given the above, improving the patient’s quality of life after post-ICU hospital discharge encompasses a series of measures such as post-hospitalization physical therapy, nutritional care, and psychological support ⁵⁸58. Toubiana J, Poirault C, Corsia A, Bajolle F, Fougeaud J, Angoulvant F, et al. Kawasaki-like multisystem inflammatory syndrome in children during the covid-19 pandemic in Paris, France: prospective observational study. BMJ 2020; 369:m2094.. This supports the hypothesis of the impact on caregivers and increased costs associated with care in convalescent COVID-19 patients.

As reported above, SARS-CoV-2 has the potential for systemic coagulation ³¹31. Paniz-Mondolfi A, Bryce C, Grimes Z, Gordon RE, Reidy J, Lednicky J, et al. Central nervous system involvement by severe acute respiratory syndrome coronavirus -2 (SARS-CoV-2). J Med Virol 2020; 92:699-702.^,3737. Oxley TJ, Mocco J, Majidi S, Kellner CP, Shoirah H, Singh P, et al. Large-vessel stroke as a presenting feature of Covid-19 in the young. N Engl J Med 2020; 382:e60. and thus reduced blood flow to the brain, causing CNS complications such as seizures, loss of consciousness, anosmia or loss of smell (5% to 10%), and “intense and prolonged delirium”, which can lead to long-term cognitive impairment including memory deficit ⁴⁷47. Servick K. For survivors of severe COVID-19, beating the virus is just the beginning. Science 2020; 8 abr. https://www.sciencemag.org/news/2020/04/survivors-severe-covid-19-beating-virus-just-beginning.
https://www.sciencemag.org/news/2020/04/... ^,5353. Herridge MS, Tansey CM, Matté A, Tomlinson G, Diaz-Granados N, Cooper A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011; 364:1293-304.^,5454. Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: an overview. J Transl Intern Med 2017; 5:90-2.^,5656. Ramsay P, Huby G, Merriweather J, Salisbury L, Rattray J, Griffith D, et al. Patient and carer experience of hospital-based rehabilitation from intensive care to hospital discharge: mixed methods process evaluation of the RECOVER randomised clinical trial. BMJ Open 2016; 6:e012041.. In COVID-19, the delirium can be aggravated by the use of sedatives (benzodiazepines) ⁵⁷57. Lonergan E, Luxenberg J, Areosa Sastre A. Benzodiazepines for delirium. Cochrane Database Syst Rev 2009; (1):CD006379. to treat the violent coughing attacks and the anxiety and discomfort from the breathing tube ⁴⁷47. Servick K. For survivors of severe COVID-19, beating the virus is just the beginning. Science 2020; 8 abr. https://www.sciencemag.org/news/2020/04/survivors-severe-covid-19-beating-virus-just-beginning.
https://www.sciencemag.org/news/2020/04/... ^,5353. Herridge MS, Tansey CM, Matté A, Tomlinson G, Diaz-Granados N, Cooper A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011; 364:1293-304.^,5454. Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: an overview. J Transl Intern Med 2017; 5:90-2.^,5656. Ramsay P, Huby G, Merriweather J, Salisbury L, Rattray J, Griffith D, et al. Patient and carer experience of hospital-based rehabilitation from intensive care to hospital discharge: mixed methods process evaluation of the RECOVER randomised clinical trial. BMJ Open 2016; 6:e012041.. The emerging literature also reports the following complications: symptoms similar to Kawasaki syndrome in children ⁵⁸58. Toubiana J, Poirault C, Corsia A, Bajolle F, Fougeaud J, Angoulvant F, et al. Kawasaki-like multisystem inflammatory syndrome in children during the covid-19 pandemic in Paris, France: prospective observational study. BMJ 2020; 369:m2094.^,5959. Whittaker E, Bamford A, Kenny J, Kaforou M, Jones CE, Shah P, et al. Clinical characteristics of 58 children with a pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2. JAMA 2020; 324:259-69., Guillain-Barré syndrome ⁶⁰60. Toscano G, Palmerini F, Ravaglia S, Ruiz L, Invernizzi P, Cuzzoni MG, et al. Guillain-Barré syndrome associated with SARS-CoV-2. N Engl J Med 2020; 382:2574-6.^,6161. Needham EJ, Chou SH-Y, Coles AJ, Menon DK. Neurological implications of COVID-19 infections. Neurocrit Care 2020; 32:667-71.^,6262. Alberti P, Beretta S, Piatti M, Karantzoulis A, Piatti ML, Santoro P, et al. Guillain-Barré syndrome related to COVID-19 infection. Neurol Neuroimmunol Neuroinflamm 2020; 7:e741.^,6363. Camdessanche J-P, Morel J, Pozzetto B, Paul S, Tholance Y, Botelho-Nevers E. COVID-19 may induce Guillain-Barré syndrome. Rev Neurol (Paris) 2020; 176:516-8., and complications of the retina ⁶⁴64. Marinho PM, Marcos AAA, Romano AC, Nascimento H, Belfort R. Retinal findings in patients with COVID-19. Lancet 2020; 395:1610. and testes, the latter possibly affecting fertility ⁶⁵65. Fan C, Li K, Ding Y, Lu WL, Wang J. ACE2 expression in kidney and testis may cause kidney and testis damage after 2019-NCoV infection. medRxiv 2020; 13 fev. https://www.medrxiv.org/content/10.1101/2020.02.12.20022418v1.
https://www.medrxiv.org/content/10.1101/... .

All this underscores the importance of studies to measure the burden of disease in COVID-19, since temporary and permanent comorbidities place a growing demand on health services for follow-up of these patients, both in primary and medium-complexity care, which historically display limits to patients’ access, with an impact on diagnosis, monitoring, and rehabilitation.

To date, the lack of knowledge on COVID-19 determinants and complications hinders the decision-making process for determining clinical and epidemiological parameters to calculate YLDs and to define the associated weights of severity, which have such great influence on the indicator’s sensitivity.

Mental health burden from COVID-19: where are we heading?

In addition to the acute and chronic complications cited in the previous section, the COVID-19 pandemic also creates a global scenario of risk factors for short and long-term mental health problems. This situation impacts both patients (due to social isolation, quarantine, and/or medical treatment of COVID-19, especially prolonged hospitalization and intensive care) and the population under social distancing ⁷7. Ministério da Saúde. Portaria nº 356, de 11 de março de 2020. Dispõe sobre a regulamentação e operacionalização do disposto na Lei nº 13.979, de 6 de fevereiro de 2020, que estabelece as medidas para enfrentamento da emergência de saúde pública de importância internacional decorrente do coronavírus (COVID-19). Diário Oficial da União 2020; 12 mar., creating an environment prone to mental health problems such as anxiety, depression, and feelings of helplessness and uncertainties about the future ⁶⁶66. Ozamiz-Etxebarria N, Dosil-Santamaria M, Picaza-Gorrochategui M, Idoiaga-Mondragon N. Niveles de estrés, ansiedad y depresión en la primera fase del brote del COVID-19 en una muestra recogida en el norte de España. Cad Saúde Pública 2020; 36:e00054020.^,6767. Liu S, Yang L, Zhang C, Xiang Y-T, Liu Z, Hu S, et al. Online mental health services in China during the COVID-19 outbreak. Lancet Psychiatry 2020; 7:e17-8..

A special focus is thus needed on the mental health of target groups with heightened risks: healthcare workers, patients with prior psychiatric diagnoses, patients recovered from COVID-19, or the general population without mental health diagnoses but subject to becoming clinical cases ⁶⁸68. The Lancet Psychiatry. Mental health and COVID-19: change the conversation. Lancet Psychiatry 2020; 7:463..

Essential workers, especially in healthcare, will be overburdened by an environment of stressful work, contributing to the development of mental disorders like anxiety, post-traumatic stress disorder (PTSD), and burnout ⁶⁶66. Ozamiz-Etxebarria N, Dosil-Santamaria M, Picaza-Gorrochategui M, Idoiaga-Mondragon N. Niveles de estrés, ansiedad y depresión en la primera fase del brote del COVID-19 en una muestra recogida en el norte de España. Cad Saúde Pública 2020; 36:e00054020.^,6767. Liu S, Yang L, Zhang C, Xiang Y-T, Liu Z, Hu S, et al. Online mental health services in China during the COVID-19 outbreak. Lancet Psychiatry 2020; 7:e17-8.^,6969. Camargo Jr. KR. Trying to make sense out of chaos: science, politics and the COVID-19 pandemic. Cad Saúde Pública 2020; 36:e00088120.. This scenario means a major increase in the demand for psychiatric care, as well as care for individuals diagnosed with COVID-19, leading healthcare workers to require mental health care for themselves, to the extent that they are burned out from the work. This can lead to absenteeism and presenteeism, reducing the health system’s capacity to provide care when healthcare workers themselves fall ill. Care for the health of essential workers in the pandemic is essential for minimizing their burnout and thereby guaranteeing better conditions for them to perform their work.

Patients with mental disorders who were in psychiatric treatment before COVID-19 experience difficulty in accessing mental health services due to the pandemic, due to social distancing and the overload on the health system, and may have their clinical status aggravated by the feeling of loneliness and isolation ⁶⁶66. Ozamiz-Etxebarria N, Dosil-Santamaria M, Picaza-Gorrochategui M, Idoiaga-Mondragon N. Niveles de estrés, ansiedad y depresión en la primera fase del brote del COVID-19 en una muestra recogida en el norte de España. Cad Saúde Pública 2020; 36:e00054020.^,6767. Liu S, Yang L, Zhang C, Xiang Y-T, Liu Z, Hu S, et al. Online mental health services in China during the COVID-19 outbreak. Lancet Psychiatry 2020; 7:e17-8.^,6969. Camargo Jr. KR. Trying to make sense out of chaos: science, politics and the COVID-19 pandemic. Cad Saúde Pública 2020; 36:e00088120.. Especially for severe patients, chronic or permanent sequelae may occur, leading in turn to mental disorders related to loss of physical capacity ⁷⁰70. Girolamo G, Cerveri G, Clerici M, Monzani E, Spinogatti F, Starace F, et al. Mental health in the coronavirus disease 2019 emergency - the Italian response. JAMA Psychiatry 2020; 77:974-6..

From the population perspective, especially in developing countries like Brazil, the economic impacts of measures to prevent transmission of the disease are being felt and will continue to be reflected in the rise in poverty, unemployment, and the homeless population ⁶⁹69. Camargo Jr. KR. Trying to make sense out of chaos: science, politics and the COVID-19 pandemic. Cad Saúde Pública 2020; 36:e00088120.. Untreated preexisting mental health conditions may be aggravated and new conditions may emerge, leading us in turn to infer the increase in depression, anxiety, psychoactive substance abuse, self-harm, and suicide attempts ⁶⁹69. Camargo Jr. KR. Trying to make sense out of chaos: science, politics and the COVID-19 pandemic. Cad Saúde Pública 2020; 36:e00088120.^,7171. Druss BG. Addressing the COVID-19 pandemic in populations with serious mental illness. JAMA Psychiatry 2020; 77:891-2.. That is, worsening socioeconomic conditions can lead to an increase in the prevalence of mental complications in the post-pandemic scenario.

The current scenario with the COVID-19 control strategy can exacerbate family conflicts and isolate the family from external environments, fueling an increase in domestic violence and abuse of vulnerable family members ⁶⁶66. Ozamiz-Etxebarria N, Dosil-Santamaria M, Picaza-Gorrochategui M, Idoiaga-Mondragon N. Niveles de estrés, ansiedad y depresión en la primera fase del brote del COVID-19 en una muestra recogida en el norte de España. Cad Saúde Pública 2020; 36:e00054020.^,6969. Camargo Jr. KR. Trying to make sense out of chaos: science, politics and the COVID-19 pandemic. Cad Saúde Pública 2020; 36:e00088120.^,7070. Girolamo G, Cerveri G, Clerici M, Monzani E, Spinogatti F, Starace F, et al. Mental health in the coronavirus disease 2019 emergency - the Italian response. JAMA Psychiatry 2020; 77:974-6.^,7171. Druss BG. Addressing the COVID-19 pandemic in populations with serious mental illness. JAMA Psychiatry 2020; 77:891-2., producing hostile environments that can be prone to the development of psychological traumas.

A potential strategy is to restructure the dynamics of mental health care during pandemics, with online psychological care and collective care approaches as possible alternatives for dealing with the increase in this demand ⁷²72. Tsamakis K, Rizos E, Manolis A, Chaidou S, Kympouropoulos S, Spartalis E, et al. COVID-19 pandemic and its impact on mental health of healthcare professionals. Exp Ther Med 2020; 19:3451-3.^,7373. Guterres A. We need to take action to address the mental health crisis. Time 2020; 21 may. https://time.com/5839553/un-action-mental-health-crisis/.
https://time.com/5839553/un-action-menta... .

COVID-19 thus affects all of society, generating a favorable space for mental disorders ⁶⁶66. Ozamiz-Etxebarria N, Dosil-Santamaria M, Picaza-Gorrochategui M, Idoiaga-Mondragon N. Niveles de estrés, ansiedad y depresión en la primera fase del brote del COVID-19 en una muestra recogida en el norte de España. Cad Saúde Pública 2020; 36:e00054020.^,6767. Liu S, Yang L, Zhang C, Xiang Y-T, Liu Z, Hu S, et al. Online mental health services in China during the COVID-19 outbreak. Lancet Psychiatry 2020; 7:e17-8.^,6868. The Lancet Psychiatry. Mental health and COVID-19: change the conversation. Lancet Psychiatry 2020; 7:463.^,6969. Camargo Jr. KR. Trying to make sense out of chaos: science, politics and the COVID-19 pandemic. Cad Saúde Pública 2020; 36:e00088120.^,7070. Girolamo G, Cerveri G, Clerici M, Monzani E, Spinogatti F, Starace F, et al. Mental health in the coronavirus disease 2019 emergency - the Italian response. JAMA Psychiatry 2020; 77:974-6.^,7171. Druss BG. Addressing the COVID-19 pandemic in populations with serious mental illness. JAMA Psychiatry 2020; 77:891-2.^,7474. Shamasunder S, Holmes SM, Goronga T, Carrasco H, Katz E, Frankfurter R, et al. COVID-19 reveals weak health systems by design: why we must re-make global health in this historic moment. Glob Public Health 2020; 15:1083-9., and one can logically expect a pandemic of mental disorders during and after the COVID-19 pandemic.

Considering that the burden on mental health historically adds the largest share of YLDs (an estimated 50%) ⁸8. Murray CJL, Lopez AD. The Global Burden of Disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020 - summary. Geneva: World Health Organization; 1996.^,1010. Murray CL, Ezzati M, Flaxman AD, Lim S, Lozano R, Michaud C, et al. GBD 2010: a multi-investigator collaboration for global comparative descriptive epidemiology. Lancet 2012; 380:2055-8.^,1414. Gadelha AMJ, Leite IC, Valente JG, Schramm JMA, Campos MR. Relatório final do projeto Estimativa da Carga de Doença do Brasil, 1998. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 1998.^,1818. Leite IC, Valente JG, Schramm JMA, Daumas RP, Rodrigues RN, Costa MFS, et al. Burden of disease in Brazil and its regions, 2008. Cad Saúde Pública 2015; 31:1551-64. and that the current COVID-19 pandemic intensifies this group of chronic diseases, it is essential to investigate the clinical and epidemiological parameters for measurement of these conditions (YLDs).

Importantly, the DALY indicator, as discussed above, consists of two components, mortality (YLLs) and morbidity (YLDs). However, health system programming and administration traditionally uses only the mortality indicator, which is not effective for mental health. This highlights the need for measurement of YLDs, which will impact programming of human resources and installed capacity for care for these disorders, since the construction of this indicator is capable of evoking this component’s weight, so relevant in these groups.

Future challenges for dealing with COVID-19 in the SUS and reflections on DALYs

The literature on estimates of the global burden of disease emphasizes the importance of the DALY indicator in measuring mortality and morbidity in the same metric. The component that measures temporary and permanent disabilities even represents the strategic thrust to support planning, programming, and the economic impact on the health system, where it is possible to identify the differences between the public SUS and the private healthcare system.

Studies on burden of disease in Brazil for the reference years 1998 ¹⁴14. Gadelha AMJ, Leite IC, Valente JG, Schramm JMA, Campos MR. Relatório final do projeto Estimativa da Carga de Doença do Brasil, 1998. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 1998. and 2008 ¹⁷17. Leite IC, Valente J, Schramm JMA. Relatório final do projeto Carga de Doença do Brasil, 2008. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2008. and the estimates by the WHO for the years 2000, 2010, and 2016 ¹²12. Department of Information, Evidence and Research, World Health Organization. WHO methods and data sources for country-level causes of death 2000-2016. Geneva: World Heath Organization; 2018. presented results for the morbidity component (YLDs) of some 50% ¹²12. Department of Information, Evidence and Research, World Health Organization. WHO methods and data sources for country-level causes of death 2000-2016. Geneva: World Heath Organization; 2018.^,1313. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392:1789-858.^,7575. World Health Organization. Global health estimates 2016: deaths by cause, age, sex, by country and by region, 2000-2016. Geneva: World Health Organization; 2018.. This percentage means that half of the burden of disease in Brazil expresses the weight of living with the temporary and permanent sequelae from the diseases included in the studies. A major share of the sequelae are complications from chronic noncommunicable diseases, which however does not rule out the complications related to chronic infectious diseases such as Chagas, AIDS, Zika, and particularly those related to COVID-19 and still not completely defined, given the partial knowledge on the natural history of this novel disease.

Complications from diseases vary in the degree of impairment to the persons’ autonomy, and they influence quality of life, often leading to early retirement and increased demand for medium and high-complexity care, which in turn show unequal distribution across the country’s territory, furthering limiting access to services and resulting in late diagnosis and limited capacity for rehabilitation, even though the public SUS guarantees universal and comprehensive access to the health system ⁷⁶76. Schramm JMA, Campos MR, Emmerick I, Sabino R, Sorio LF, Costa MFS, et al. Relatório de pesquisa: Projeto Carga do Diabetes e acesso ao tratamento e serviços de saúde no Estado do Rio Grande do Sul: um instrumento para gestão, organização e planejamento dos serviços de saúde. Rio de Janeiro: Fundação Oswaldo Cruz; 2018.. The passage of Constitutional Amendment n. 95 (EC95, Portuguese) by the Brazilian Congress further reduced the investment in health for an already chronically underfunded SUS ⁷⁷77. Schramm JM Andrade, Paes-Souza R, Mendes LVP. Políticas de austeridade e seus impactos na saúde. Rio de Janeiro: Centro de Estudos Estratégicos. Fundação Oswaldo Cruz; 2018. (Textos para Debate, 1)., reducing the quality of public health services and further limiting patients’ access. This scenario was aggravated by the reduction of budget funding for policies in social protection and promotion, besides closing family health clinics and fueling the resurgence of previously eliminated diseases like measles ⁷⁸78. Dweck E. Austeridade é a maior aliada do coronavírus no Brasil. Carta Maior 2020; 16 mar. https://www.cartamaior.com.br/?/Editoria/Economia-Politica/Austeridade-e-a-maior-aliada-do-coronavirus-no-Brasil/7/46797.
https://www.cartamaior.com.br/?/Editoria... .

The COVID-19 epidemic has hit Brazil in a scenario of unemployment, impoverishment, and other risk factors related to transmissibility of the disease. Economic crises can facilitate the transmission of infectious diseases and hinder the implementation of control measures which, in the context of a pandemic, can express mortality comparable to that of wartime situations, further exacerbating the economic crisis ⁷⁸78. Dweck E. Austeridade é a maior aliada do coronavírus no Brasil. Carta Maior 2020; 16 mar. https://www.cartamaior.com.br/?/Editoria/Economia-Politica/Austeridade-e-a-maior-aliada-do-coronavirus-no-Brasil/7/46797.
https://www.cartamaior.com.br/?/Editoria... . According to Sands et al. ⁷⁹79. Sands P, El Turabi A, Saynisch PA, Dzau VJ. Assessment of economic vulnerability to infectious disease crises. Lancet 2016; 388:2443-8., infectious diseases are one of the greatest risks to economic growth, although the economic recession’s impact on the control of infectious diseases depends on the context, mapping of risk areas, the situation of vulnerability, and political decisions on financing, for example in the case of a possible repeal of the budget freeze implemented by EC95 in order to increase the funds needed to bolster the budget for health and social protection ⁸⁰80. Deccache D, Nascimento F, Ramos AP, Lemos I. Pandemia de coronavírus e a urgência da revogação do teto dos gastos. Brasil de Fato 2020; 16 mar. https://www.brasildefato.com.br/2020/03/16/artigo-pandemia-de-coronavirus-e-a-urgencia-da-revogacao-do-teto-dos-gastos.
https://www.brasildefato.com.br/2020/03/... .

The individual and collective conditions (socioeconomic and demographic) for dealing with the public health crisis caused by COVID-19 are heavily unequal in Brazil. According to data from a Brazilian study ⁸¹81. Castro CS, Holzgrefe Júnior JV, Reis RB, Andrade BB, Quintanilha LF. Pandemia da COVID-19: cenário do sistema de saúde brasileiro para o enfrentamento da crise. Research, Society and Development 2020; 9:516974383., while the South and Southeast proportionally concentrate the majority of specialized human resources (critical and respiratory care physicians) and hospital equipment (ICUs and mechanical ventilators), the North and Northeast have lower parameters in relation to their shares of the national population. The study thus suggests that given this discrepancy in the availability of installed capacity and human resources, the response to the crisis is unequal, impacting the COVID-19 case-fatality rates and the collapse of the SUS.

In addition, in relation to sociodemographic differences in the response to the pandemic, the national seroprevalence sample survey EPICOVID ⁸²82. Hallal P, Hartwig F, Horta B, Victora GD, Silveira M, Struchiner C, et al. Remarkable variability in SARS-CoV-2 antibodies across Brazilian regions: Nationwide Serological Household Survey in 27 states. medRxiv 2020; 30 mai. https://www.medrxiv.org/content/10.1101/2020.05.30.20117531v1.
https://www.medrxiv.org/content/10.1101/... demonstrates the significant differentiation according to self-reported race: 0.7% prevalence in whites, 2.3% in browns, and 4.3% in indigenous people.

In the more specific context, in the city of Rio de Janeiro, COVID-19 case-fatality was 12%, ranging from 9.2% in neighborhoods “without favelas” to 19.5% in those with an “extremely high concentration of favelas” (more than 50% of favelas in the neighborhood). High COVID-19 case-fatality in these vulnerable territories may indicate low testing and higher severity associated with preexisting diseases or risk factors, besides difficult access to healthcare ⁸³83. Observatório COVID-19 Fiocruz. Análise da frequência, incidência, mortalidade e letalidade por COVID-19 em favelas cariocas. Boletim Socioepidemiológico da COVID-19 nas Favelas 2020; (1). https://portal.fiocruz.br/sites/portal.fiocruz.br/files/documentos/boletim_socioepidemiologicos_covid_nas_favelas_1.pdf.
https://portal.fiocruz.br/sites/portal.f... .

Measures to control the pandemic will have substantial short and long-term consequences; the restrictions from physical distancing and quarantine will reduce physical activity and increase other unhealthy lifestyles, leading to an increase in risk factors (smoking, alcohol consumption, sedentary behavior, and obesity) for chronic noncommunicable diseases, with the exacerbation of clinical symptoms. Alterations in routine outpatient and inpatient care, such as ⁸⁴84. Palmer K, Monaco A, Kivipelto M, Onder G, Maggi S, Michel J-P, et al. The potential long-term impact of the COVID-19 outbreak on patients with non-communicable diseases in Europe: consequences for healthy ageing. Aging Clin Exp Res 2020; 32:1189-94.: cancellation/ postponement of appointments or prenatal follow-up and/or postponement of elective surgeries, reduction of coverage, and delays in the vaccination calendar, among others, will have important implications for health of the population as whole, overloading the health system.

Even after overcoming the pandemic’s emergency phase, when the number of cases and deaths wanes, there is still the challenge of dealing with the increased demand on the SUS for diagnosis, treatment, and rehabilitation of recovered patients from the possible chronic complications of COVID-19, such as: increased demand for rehabilitation services due to respiratory complications; consultations and psychotherapies both for “new” and prior psychiatric cases aggravated by difficult access during the pandemic; overload on care by cardiologists due to the accumulated consultations postponed in the protocol for control to avoid transmission and increased incidence of cardiovascular conditions from COVID-19, with increased risk of stroke and heart attack; and aggravation of the scenario of drug therapy and elective surgeries for chronic diseases due to rescheduling of prescriptions.

This all underscores the enormous current and future effects of the COVID-19 pandemic on the SUS, and the metrics to be constructed need to consider these aspects. Thus, the timing and natural history of the disease are essential elements for constructing the components (YLL and YLD) of DALY. Without this, the uncertainty can compromise the indicator’s estimates. The complications associated with COVID-19 not only add to those related to other diseases, but represent an even greater burden for health services and families ⁸⁵85. Carvalho MS, Lima LD, Coeli CM. Ciência em tempos de pandemia. Cad Saúde Pública 2020; 36:e00055520.. The focus on the importance of the burden of morbidity (YLDs) will thus be strategic in organizing networks of care and planning and programming health actions.

Currently, considering the debate on the control measures deployed thus far, it is necessary determine which epidemiological surveillance actions in the territory represent a structuring strategy, together with primary healthcare (PHC), for monitoring COVID-19 infection ⁸⁴84. Palmer K, Monaco A, Kivipelto M, Onder G, Maggi S, Michel J-P, et al. The potential long-term impact of the COVID-19 outbreak on patients with non-communicable diseases in Europe: consequences for healthy ageing. Aging Clin Exp Res 2020; 32:1189-94.^,8585. Carvalho MS, Lima LD, Coeli CM. Ciência em tempos de pandemia. Cad Saúde Pública 2020; 36:e00055520.^,8686. Ministério da Saúde. Guia de vigilância epidemiológica. Emergência de saúde pública de importância nacional pela doença pelo coronavírus 2019 - vigilância integrada de síndromes respiratórias agudas. Brasília: Ministério da Saúde; 2020.. Proper monitoring of the disease in the country also provides essential information for estimating the classical epidemiological parameters needed to construct the DALY.

A suggested strategy for dealing with the pandemic and post-pandemic to generate more precise clinical and epidemiological parameters of the disease and its sequelae, necessary for the DALY, is to guarantee appropriate action by PHC in screening and monitoring infected individuals and their contacts, applying social distancing strategies recommended by family health teams and work by community health agents, according to guidelines from the Department of Primary Health Care (SAPS, in Portuguese), Brazilian Ministry of Health ⁸⁶86. Ministério da Saúde. Guia de vigilância epidemiológica. Emergência de saúde pública de importância nacional pela doença pelo coronavírus 2019 - vigilância integrada de síndromes respiratórias agudas. Brasília: Ministério da Saúde; 2020.^,8787. Secretaria de Atenção Primária à Saúde. Recomendações para adequação das ações dos agentes comunitários de saúde frente à atual situação epidemiológica referente à COVID-19. Brasília: Secretaria de Atenção Primária à Saúde; 2020.. That is, recommendations for organization of COVID-19 care in PHC in the SUS ⁸⁸88. Engstrom E, Melo E, Giovanella L, Mendes A, Grabois V. Recomendações para a Organização da Atenção Primária à Saúde no SUS no enfrentamento da Covid-19. Rio de Janeiro: Observatório COVID-19 Fiocruz; 2020. (Série Linha de Cuidado Covid-19 na Rede de Atenção à Saúde). should be followed, based on identification of suspected cases, with household contacts and if possible community contacts in the previous 14 days to orient home isolation for 14 days, reducing transmission and avoiding simultaneous generation of serious cases and overload on the SUS.

The system requires strong PHC in order to flatten the pandemic’s curve and ensure sufficient ICU beds ⁸⁹89. Vitória AM, Campos GWS. Só com APS forte o sistema pode ser capaz de achatar a curva de crescimento da pandemia e garantir suficiência de leitos UTI. https://frenteestamira.org/wp-content/uploads/2020/04/A.Vit%C3%B3ria-Gast%C3%A3o-W.-S%C3%B3-APS-forte-assegura-achatar-a-curva-e-funcionamento-de-leitos-de-UTI.-mar%C3%A7o2020.pdf (acessado em 28/Mai/2020).
https://frenteestamira.org/wp-content/up... and a safer and more efficient alternative path for dealing with the pandemic. As for the current control strategies’ effectiveness, the longer person-to-person transmission is stretched out, the more manageable the situation will be for the SUS.

According to Vitória & Campos ⁸⁹89. Vitória AM, Campos GWS. Só com APS forte o sistema pode ser capaz de achatar a curva de crescimento da pandemia e garantir suficiência de leitos UTI. https://frenteestamira.org/wp-content/uploads/2020/04/A.Vit%C3%B3ria-Gast%C3%A3o-W.-S%C3%B3-APS-forte-assegura-achatar-a-curva-e-funcionamento-de-leitos-de-UTI.-mar%C3%A7o2020.pdf (acessado em 28/Mai/2020).
https://frenteestamira.org/wp-content/up... , adequate guidelines for PHC in dealing with the pandemic consist of: (1) guaranteeing safe access to basic healthcare units (UBS in Portuguese) with adjustment of the physical infrastructure and online PHC (with separation of an exclusive entrance for COVID patients or use of tents); (2) guaranteeing safety in immunizations; (3) protecting healthcare workers (orienting and providing use of personal protective equipment); (4) guaranteeing continuity of care over time; (5) strengthening the family approach; and (6) strengthening the community approach.

On the specific item (4) concerning continuity of care over time, the following are crosscutting strategies: telecare, which avoids public circulation of symptomatic individuals who only require orientation; and keeping the family health teams alert to the evolution of patients with low oxygen saturation (but without symptoms) and/or aggravation of their clinical condition. In item (5), on the family approach, PHC should orient families on caring for their patients, providing adequate nutrition, sufficient liquids, and medication for fever and avoiding transmission to others. In item (6), the community approach, the UBS know the vulnerable families in their respective territories, those with heavy indoor crowding, for whom alternative places for quarantining are necessary to avoid further transmission. The family health teams thus have key elements that allow better analysis and interpretation of risks and vulnerabilities of individuals, families, and the community.

Finally, failures in access to diagnosis have an important impact on the morbidity and mortality profile, expressed in the increased demand on medium and high-complexity services. And based on an accurate diagnosis of COVID-19’s epidemiology and particularly that of its chronic complications via estimation of DALYs, it is possible to provide backing to draft new strategies and policies to deal with the pandemic. However, this goal will only be achieved with the appropriate knowledge, appreciation, and financing of the SUS and its workers, especially in primary healthcare.

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