Long Covid is an ongoing health hazard to many patients who had an original Covid-19 diagnosis. Whilst there has been much debate about the phenotypic nature of the disease, the implications of these among differing populations is yet to be comprehensively reviewed. This is particularly important for low-to-middle-income countries such as Brazil, that have limited resources and infrastructure within their healthcare systems to manage patients long-term that have had Covid-19 and Long covid. Brazil have had to stare at the Covid abyss with over-crowding of their intensive care units that left their healthcare system in chaos. The ongoing long-Covid case numbers therefore are exacerbating an ongoing issue for patients, policy makers and healthcare professionals. In line with this, and the population density of Brazil, we have explored the prevalence of long-Covid in one of the largest municipalities in northeast Brazil to report active patient and clinical reported outcomes that would enable a better understanding of the next steps require to curb these issues to a manageable situation.

Methods: We designed a two-step approach to demonstrate the wider implications of long-covid using a commentary and a retrospective, cross-sectional study using realworld data.

Findings: In this commentary we highlight the current issues and potential barriers Brazil faces. We will follow this up with a retrospective, cross-sectional study using real world data to report on the prevalence of long covid within 1,600 patients.

Cavalini HFS, Delanerolle G, Shi JQ, Shetty A, Magalhães PF, et al. (2021) The Long Covid abyss in Brazil; Is this another concern for an overwhelmed healthcare system? Ann Public Health Res 8(2): 1111.

LC: Long Covid; BMI: Body Mass Index; INR: International normalised ratio; CRP: C-reactive protein; BIPOC: Black, indigenous and other people of color

SARS-CoV-2 (Covid-19) has led to high levels of morbidity and mortality globally. For most SARS-CoV-2 survivors, recovery could be classed into two broad outcomes; they could make a complete recovery or following an acute phase they continue to have ongoing symptoms such as fatigue and myalgia. In Brazil, the first SARS-CoV-2 case was registered on the 26th of February 2020, in Sao Paulo, whilst the first registered death was recorded on the 17th of March 2020 [1]. Most centres in Brazil struggled to manage morbidity due to the prevailing socioeconomical conditions during the national crisis [2]. The epidemiological data indicate an incidence of 10.7 million with 596.122 deaths, as illustrated in (Figure 1a & 1b) [3]. The state of São Paulo had the highest confirmed cases in Brazil with 4,330,000, and 148,170 confirmed deaths [4].

Patients with acute and persistent symptomatologies following a Covid-19 positive test are facing challenges to access ongoing clinical care for a variety of reasons within Brazil. This can be partly attributed to the lack of resources to diagnose and manage the ‘novel’ condition about which there was paucity of clinical evidence at the time. Universally accepted clinical definitions and a suitable phenotype for “long-covid (LC)” remains a distant objective. In view of this, the healthcare authorities in Brazil use broader characteristics associated with respiratory, cardiovascular and neuropsychiatry symptoms to be the basis of managing this condition. It is reported that 20% of patients categorized to have LC develop more complex issues such as respiratory failure, respiratory acute stress syndrome, and multiple organ dysfunction [5].

Present diagnosis of LC is based on multiple phenotypic features as demonstrated by Luszek and colleagues [6] who reported 33 variables of body mass index (BMI), heart rate, respiratory rate, pulse pressure, systolic blood pressure, total protein, mean corpuscular volume, alkaline phosphatase, calcium, anion gap, bicarbonate, haematocrit, aspartate aminotransferase, glucose, absolute monocyte count, absolute neutrophil count, absolute lymphocyte count, white blood cell count, platelet, albumin, bilirubin, international normalised ratio (INR), lactate dehydrogenase, potassium, sodium, D-dimer, haemoglobin, C-reactive protein (CRP), creatinine, gamma gap, age and oxygen saturation. This in turn is vital for adequately managing effect modifiers such as diabetes or migraine that could potential worsen for those with a pre-existing diagnosis. This is an important facet for healthcare professionals and systems to consider, to better prepare to care for patients. For instance, in the region of Petrolina, a city in the state of Pernambuco, within North-eastern Brazil, patients showed heart dysfunction, respiratory, and neurological problems after the acute period of the disease [7].

The lack of comprehensive clinical data, and limitations in current literature to generate a more evidence-based approach to manage LC, is a major hurdle. The lack of generalisability and problems with accessing meta-data in hospital systems also attributes to limiting clinical management of LC patients. This further raise complications around affirming a suitable phenotype and, the conceptualisation of its’ relevance to explore both future research and clinical management plans.

There has been challenges around obtaining SARS-CoV-2 surveillance data in Brazil given the lack of a central repository and network system that is able to identify and track patients’ outcomes short and medium term. Many publications appear to use websites, and non-standardised access points to gather data, such as social media platforms which could lead to unreliable data issues that may result in implementing healthcare policies that lack an evidence base. Therefore, standardisation of information gathering is still a requirement, where appropriate analysis could be conducted that is reflective of the population needs within Petrolina. The socioeconomic burden due to the spread of SARS-CoV-2 and any new variants need to be managed more vigorously. Additionally, vulnerable populations (e.g., patients who are from Black, indigenous and other people of color (BIPOC), children, the elderly, socioeconomically disadvantaged) [8] and municipalities with elevated socially deprived scores should be made the primary focus to introduce preventive measures. Those who have contracted the disease and recovered should be followed-up long-term using multiple clinical and community-based strategies. Approximately 37 million Brazilian workers are in the retail-sector based jobs, thus increasing the probability of contamination of covid-19 to populations. Obeying social isolation and staying at home, is likely to be a challenge since most of them rely on this source of income to sustain their families. Emergency public policies are required, given that voluntary social isolation remains difficult in Brazil.

Dr Phiri has received research grant from Novo Nordisk, and other, educational from Queen Mary University of London, Stanford University other from John Wiley & Sons, other from Otsuka, outside the submitted work. All other authors report no conflict of interest.

FSC and VRN wrote the first draft of the manuscript GD, JQS, AS, PFM, EF, RDFMP, and PP critically appraised and revised the manuscript. All authors approved the final version of the manuscript for submission.

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2. Carlos Dornels Freire de Souza, Michael Ferreira Machado, Rodrigo Feliciano do Carmo. Human development, social vulnerability and COVID-19 in Brazil: a study of the social determinants of health. Infect Dis Poverty. 2020; 9: 124.

3. Covid-19 Map. Johns’ Hopkins coronavirus resource Cent. 4. Coronavírus Brasil. Painel geral.

5. Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical Course and outcomes of critically ill patients with COVID19 in Wuhan China. Lancet Respir Med. 2020; 8: 475–481.

6. Lusczek ER, Ingraham NE, Karam BS, Proper J, Siegel L, et al. Characterizing COVID-19 clinical phenotypes and associated comorbidities and complication profiles. PLOS ONE. 2021; 16: e0248956.

7. Secretaria de saúde do município de Petrolina. Dados atualizados do número de casos no município e boletim epidemiológico

8. Waisel & David B. Vulnerable populations in healthcare Curr. Opin Anaesthesiol. 2013; 26: 186-192