The epidemic has had an enormous psychological impact on health workers in Manaus. MSF is trying to address that with mental health support at the José Rodrigues Emergency Unit (UPA) - in this photo - and 28 de Agosto hospital in Manaus, one of the biggest in the Amazonian capital. Psychological support is offered to all hospital staff, medical and non-medical. What we are seeing is not only professionals who have had to deal with long shifts and a high number of patients, but also manage their own concerns about getting contaminated and contaminating their loved ones. Sometimes they have already experienced loss of family and friends but have to move on with their everyday duties, without time to mourn the ones who are gone.

Brazilian Amazon: COVID-19 disaster unfolding

Cases surging, health system collapsing, and a daily struggle for Doctors Without Borders/Médecins Sans Frontières (MSF) teams to keep up.

The prospect of a descent into a second COVID-19 catastrophe in Brazil’s Amazon region is happening, now, day by day. In the Amazonas State capital, Manaus, all Intensive Care Unit (ICU) beds are full, and the waiting lists of severe or critical patients have remained in a very high level over the last weeks.

Official figures for Manaus show that the number of COVID-19 deaths in January (2,522) almost equaled the combined death toll registered in April and May (2,850) during the previous peak, and is more than five times the December statistic (460). The complete saturation of the health system in Manaus means other towns upriver are facing delays or simply cannot refer their critical patients to the bigger city hospitals, and are having to take emergency measures to try to cope with rising numbers of sick patients.

Lifesaving critical care in facilities without ICUs

“Our plan A was to try to help slow the flow of critical patients by boosting intermediate care for moderate and severe cases, but that plan is out of the window now,” says Pierre Van Heddegem, MSF emergency coordinator in Brazil. “We’re now fully into plan B, doing life-saving critical care; in facilities that don’t have an intensive care unit and with a worry every day that we’ll run out of oxygen. This second wave of COVID is overwhelming everything and everyone and we’re doing all we can to get through each day. Our fear is that we will not be able to keep up.”

In Tefé, a few days’ boat journey upriver from the state capital, MSF is helping the hospital go through some radical changes. They are moving all the medical departments out into nearby buildings, such as the school, and turning the regional hospital as much as possible into a dedicated COVID-19 treatment referral centre. Under normal circumstances, this rural hospital would send all critical patients by air ambulance to Manaus, but with most COVID-19 beds in Manaus full, the Tefé hospital is having to find ways to treat critical patients. So far the COVID-19 treatment capacity has grown from 27 to 67 beds, but this is pushing beyond the limit of what is possible. The MSF team has put huge work into coaching and training the doctors and nurses in care for critical COVID-19 patients on oxygen. But the supply of oxygen itself is a permanent worry.

“We were scraping by on a day to day basis in Tefé,” says Van Heddegem. “There were days when we came very close to a disastrous situation.” A new oxygen generation plant has just been installed by the authorities, but at the current rate of use, even the new plant may not provide enough oxygen for all the patients. MSF is working on urgently importing scores of individual-patient oxygen concentrators to plug some of the gaps, both for Tefé and for Manaus.

In Manaus, MSF is supporting José Rodrigues Emergency Unit (UPA), which is now adapted to focus on COVID-19 patients, with doctors, nurses and mental health care.Mariana Abdalla/MSF

In Manaus, MSF is supporting the José Rodrigues Emergency Unit (UPA), which should in theory provide an intermediate level of care, stabilizing patients before they need to go to a higher level hospital. Like in Tefé, with Manaus hospital COVID-19 beds overwhelmed, this centre now has to find ways to provide its own high-level COVID-19 treatment.

“The UPA was totally overloaded, with a lack of doctors, nurses and intensive care protocols”, says MSF Manaus coordinator, Fabio Biolchini Duarte. “When we were there for the first time, the unit had 18 beds and there were 45 patients. Virtually the entire place had become a COVID-19 infirmary. It was one the health facilities where several patients died because of the lack of oxygen.”

Mental health support for frontline workers

Staff – both medical and non-medical – working in this Emergency Unit and in the bigger hospitals are being gradually crushed by the emotional burden of having multiple patients die each day. MSF has brought in mental health specialists to provide psychosocial support, including in Manaus’ largest public health facility, the Hospital 28 de Agosto, where an MSF medical team had provided patient care during the first wave last year.

“We see that the employees are incredibly dedicated, but we also realize they are absolutely exhausted”, says MSF psychologist Andréa Chagas. “In many cases, it is not even possible for them to find relief at home from the anguish experienced at work, since many have sick relatives or have lost loved ones. The speed and intensity of what is happening does not allow space for processing so many feelings.”

Psychological support is offered to all hospital staff, medical and non-medical. What we are seeing is not only professionals who have had to deal with long shifts and a high number of patients, but also manage their own concerns about getting contaminated and contaminating their loved ones.

In Amazonas State MSF is now managing or supporting nearly 100 COVID-19 beds. This is occupying most of the emergency team’s capacity, but there are also some initiatives to assist with prevention.

Heath Promotion teams are preparing to work at strategic points in Manaus, with guidelines for hygiene and social distance and testing. The goal is to allow rapid diagnosis and follow-up of patients who test positive to prevent cases from being detected when they are already in a serious condition.

MSF is also lobbying hard for a wider use of the rapid antigen COVID-19 test – the one that indicates if a person has the active virus now, in real time. It is a point of amazement and frustration for the team that the antibody test continues to be the staple used in Brazil; this antibody test can only tell if you have had the disease at some stage in the past, so could pick up people who had COVID-19 weeks or months ago, but who no longer have it today. Using the antigen test, only sick patients are placed in isolation, which avoids unnecessary hospitalizations at a time of great shortage of personnel and material resources. MSF has successfully encouraged the health authorities in Tefé and another rural Amazonian town, São Gabriel da Cachoeira, to use this test, and we continue to urge the authorities in Manaus and other affected areas to also make the switch.

MSF also has a team in the rural Amazonian town of São Gabriel da Cachoeira, where the situation seems more stable for the moment but where continued vigilance is needed. The team is supporting the health centre for care of COVID-19 patients, and health educators are giving hygiene and social distancing guidelines in the barracões, used as accommodation when members of the indigenous population come to the town. This should enable us to monitor to some extent any trends in indigenous people showing symptoms of the disease.

MSF teams are also in early-stage preparation in case of a surge of COVID-19 in Boa Vista, the capital of neighbouring Roraima state.