Covid changes the circulation of other viruses and hospitals deal with unseasonable outbreaks

The Covid pandemic has altered the frequency and circulation of other common respiratory viruses in children and adults, such as those that cause colds and flu.

The closure period of the last three years has changed the seasonality of these pathogens, which was generally well established, in the autumn and winter periods. As a result, hospitals face unseasonable outbreaks of respiratory disease.

“Covid has greatly disrupted seasonality [dos outros vírus] and even with the seasons, it’s out of the ordinary. It is difficult now to predict the protagonism, that is which virus will be dominant in each season”, explains the pediatrician and director of vaccinations of the Brazilian Society of Pediatrics, Renato Kfouri.

Kfouri recalls that the period of school closures has ended up delaying this first contact of newborns with respiratory viruses in general, not just the coronavirus.

While it was positive because there was a period without the onset of respiratory problems, the delay in building immunity made the children more susceptible to these different agents.

“More important than the dominant virus is when that child has their first infection, and we’ve seen that has changed a lot during the pandemic,” she says.

This is the case of João Lucca, who at almost three months old was hospitalized in the Sabará children’s hospital for respiratory problems at the beginning of December. He was diagnosed with bronchiolitis caused by respiratory syncytial virus (RSV), which he contracted from his older brother, 2-year-old Pedro Henrique.

“I went to look for the symptoms and then I discovered that it could be bronchiolitis. The worst phase was on the fifth day, that is, when the doctors define the peak of the disease, but now he is recovering and will soon be discharged, “said the mother . by João Lucca, Joelma dos Santos, 40.

In addition to the change in seasonality, the cold out of season also contributes to this, but it is still difficult to predict when the scenario will return to normal. “At the end of December 2021 we had a flu epidemic [causador da gripe], then syncytial virus, then flu again in September. It’s starting to have a better known seasonality, but it’s still very early,” says Kfouri.

In Sabará, RSV cases exploded in October and November, which is considered the off-season. From November 27 to December 3, one third of the tests performed had a positive diagnosis for RSV.

“Every year we experience absolutely dramatic situations in the seasonal period of respiratory viruses, with lack of beds, demand that exceeds supply, and because they are seasonal, the structures are not maintained for a long time. And without this predictability, it has also become messier,” says Daniella Bonfim, the hospital’s technical director.

It is common for young children to contract viruses common in infancy from other older children, such as adenoviruses, rhinoviruses, and RSV itself, which, although they have relatively mild clinical manifestations in older children, such as influenza, can cause complications in children.

This is the case of Gabriela, a seven-month-old girl, admitted to the Intensive Care Unit (ICU) of Sabará at the end of November for bronchiolitis. Due to a co-infection of adenovirus and RSV, Gabriela and her three-year-old older brother Pedro, also with flu-like symptoms, were infected along with other children in the school.

“It started with him, with eye and ear symptoms. It was difficult because we had to come to the hospital with two small children, with different conditions, as she was having difficulty breathing and it was more of an ear infection in him,” reports the father and project analyst, Lucas Pegorari Espósito, 33 years old.

Although it seems worrying, the infectologist and medical director of Sabará, Francisco de Oliveira Júnior, points out that contracting infections at this age is common. “This relationship between children’s schools and the appearance of respiratory viruses has always been well known, the difference is that with the Covid isolation, and also with the use of masks, we have managed to delay this process,” he explains.

However, Junior warns of the possible discharge of cases of respiratory syndromes after the end-of-year holidays, as happened in previous years. “We will most likely see a recovery,” he recalls.

Therefore, the protective measures must continue even after the emergency period of the pandemic. “It is very important to strengthen hygiene and protective measures at this time, to prevent that small child or infant from having contact with someone with respiratory syndrome at the slightest sign of the flu,” says Bonfim.

virus monitoring

In Brazil, epidemiological surveillance monitors circulating viruses and is carried out in three instances: municipal, through the municipal surveillance services, state, with the epidemiological surveillance centers (CVE), which coordinate the services in the municipalities, and national, under the supervision of the Health Surveillance Secretariat of the Ministry of Health.

Often the services that report and identify respiratory viruses are the same for other pathogens such as Zika and dengue. Notification of flu syndromes is carried out by e-SUS Notifica, and of Srag (severe acute respiratory syndrome) by Sivep-Flu, both of the Ministry of Health.

The sentinel centers carry out the notification of flu syndromes, while the registration of the Srag has been mandatory since 2009 (with the H1N1 epidemic). Sentinel hospitals are infectious disease surveillance centers that collect a defined percentage of samples for virus type analysis. The goal is to provide data on the frequency of pathogens in circulation, thus being able to identify outbreaks and seasonal variations.

With a good performance in the pandemic, Júnior hopes these existing services will not be disrupted after the Covid health emergency period. “These surveillance services already existed, but they have been strengthened with the pandemic, when hospitals and the population itself have become more interested in identifying, knowing what the virus is, and this has led to more accurate reporting,” he says.

According to the Municipal Secretary of Health of São Paulo, all hospitals in the private or public network have a professional responsible for reporting flu syndromes or Srag. The capital also has seven sentinel units that collect five samples a day, the main one for viruses in children being the Infantil Menino de Jesus Municipal Hospital.

Also according to the file, the ministerial ordinances ensure the funding of laboratories for the sequencing of viruses, with the units of the Instituto Adolfo Lutz and Butantan recognized in São Paulo.

The Secretary of State for Health, wanted during the administration of Rodrigo Garcia (PSDB), confirmed the identification in times of the year outside the typical seasons, the circulation of other viruses, such as influenza A H3N2 at end of December 2021 and beginning of January 2022, and reiterated that the coronavirus continues to circulate, together with other respiratory viruses affecting children, adults and the elderly.

According to the file, there has been a strengthening of surveillance structures during the pandemic, with new techniques for laboratory and genomic analyses, and which regularly publishes epidemiological bulletins.

The Ministry of Health, wanted at the end of the management of Jair Bolsonaro (PL), has declared that it continues with active surveillance, even with the end of the Espin (Public Health Emergency of National Importance). The file reported that surveillance services have been enhanced with the pandemic, going from 114 sentinel units in 2019 to 342 in 2022 (200% increase), and that the monitoring of Sars-CoV-2 has been integrated with that of other respiratory viruses of public health importance.

Finally, the ministry said the pandemic has also accelerated the expansion of the National Genetic Sequencing Network (RNSG) due to the need for genomic surveillance of circulating lineages of Sars-CoV-2 in Brazil. “Since then, the Ministry of Health has started publishing weekly COVID-19 epidemiological bulletins, which provide information on SRAG caused by other viruses,” he added.

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