Why are so many children in Brazil dying from Covid-19?

With a death toll of more than half a million from Covid-19, Brazil is behind only the US in terms of the impact of the pandemic.

The bare figures hide a particularly tragic aspect of the South American nation’s experience of the coronavirus: possibly thousands of deaths of young children.

“We found a huge number of child deaths from Covid and we started to compare to the US … We found we have much more, more than 10 times the number of deaths compared to the US,” says Dr Fatima Marinho, senior technical adviser in Brazil for Vital Strategies, a non-profit organisation that aims to help governments improve their public health systems.

Brazil has suffered about 529,000 deaths from Covid-19 among its population of 211 million, and of those who have died, about 1,122 have been children under age 10, recent figures from the country’s Ministry of Health showed.

However, analysis by Vital Strategies released in late June found in excess of 2,975 deaths among young children during the pandemic, most thought to be due to Covid-19.

For comparison, in the US, where the coronavirus death toll has reached about 606,000, just 335 deaths have been reported among young people, according to the American Academy of Paediatrics and the Children’s Hospital Association.

This figure covers a much larger age range, so the difference with Brazil is even more stark.

Many factors are thought to be responsible for Brazil’s elevated child deaths from Covid-19, which have mirrored a general susceptibility to respiratory illness among the country’s children.

High rates of coronavirus transmission among pregnant women have affected babies, with doctors forced to make what Dr Marinho describes as the “really cruel” decision to induce delivery because of the mother’s illness.

Crowded housing in poorer communities, where social distancing in impossible, results in what Dr Marinho, a former official with Brazil’s Ministry of Health, describes as “free virus transmission”.

“Children from one year up to nine years have been infected despite the fact that the schools are closed. They were infected at home in poor communities where there’s no control of virus circulation,” she says.

Brazil’s high rates of inequality also make malnutrition a significant issue. Dr Marinho says that the immune systems of malnourished children respond poorly to infection.

Large disparities in the quality of health care also affect disadvantaged children. Among the most vulnerable, she says, are black children, who are more likely to live in poorer housing and experience other inequalities.

The highly transmissible Gamma or P. 1 variant, first detected in Brazil, has been suggested as a cause for higher rates of the disease in younger people, although this is uncertain, as child deaths are thought to have been high even before the variant emerged.

Children often present with very different symptoms to adults, with abdominal pain, chest pain and diarrhoea being common. This means cases are often identified late, doctors may be reluctant to carry out testing and treatment is not started promptly.

Many deaths among children are the result of multisystem inflammatory syndrome.

“That’s why we need to track case numbers of children and we have to pay attention,” says Dr Marinho.

“After 10 days or two weeks, they start to get sick, really sick and this system affects all organs.”

Many experts feel that the most significant factor likely to be elevating Brazil's Covid-19 death rate among children is poverty.

“A country like Brazil has got a lot of poverty, and poverty unfortunately harms children and adults,” said Dr Bharat Pankhania, an infectious diseases specialist and senior clinical lecturer at the University of Exeter in the UK

“[There is] a difficulty of early intervention when you haven’t got facilities and haven’t got the access and haven’t got the monitoring. It’s not that there’s something special happening there; there are more poor families.”

As well as children, younger adults aged 30 to 59 in Brazil are being increasingly affected by the disease. Dr Marinho says the average age of those dying from Covid-19 in Brazil has fallen.

This is in part because older people are more likely to have been vaccinated, but the Gamma variant may also be a reason.

The age-based criteria for vaccination “reinforces inequalities”, because for many older, wealthier people — many of whom are white — social distancing and working from home are easier.

As of now, less than 40 per cent of Brazil’s population has had a single coronavirus vaccine dose and fewer than one in seven are fully vaccinated.

“The age between 30 and 59 years old are now responsible for 50 per cent of deaths. The epidemic is affecting much more these people,” she says.

The actions of the central government, led by President Jair Bolsonaro, who has been heavily criticised for his handling of the pandemic, have hampered efforts, Dr Marinho says.

There is, she says, inadequate testing, a “lack of national coordination” and pushback from federal authorities against states that have introduced lockdowns and other measures to prevent the spread of the virus.

In addition to carrying out intensive monitoring of the pandemic in Brazil, Vital Strategies, an international organisation, has been working with local mayors in the country to promote measures to prevent the spread of the virus.

With Covid-19 case rates still high, more than 10,000 people dying each week and the rising possibility of new variants, there is no end in sight to Brazil’s continuing coronavirus ordeal.

“We are starting this phase where it could get worse or not,” says Dr Marinho. “It depends on the virus dissemination.”

Prof David Taylor, professor emeritus in pharmaceutical and public health policy at University College London, said that, even if Brazil’s child death rate from Covid-19 was five or 10 times that of the US, it was still a low rate.

A lack of testing of mild cases in Brazil could, he said, have led to an inflated death rate for a given number of Covid-19 cases. Another possible explanation for the apparently high death rate among children was, he said, an increased frequency of underlying conditions among children in Brazil.

“If it’s true [that the paediatric death rate from Covid-19 is higher], it’s probably due to the fact that some vulnerable children are not so well treated, although Brazil is a fairly sophisticated country,” he said.

“I would be looking for a proportion of children being ill anyway. I would be looking for background conditions that would make them more vulnerable.”

Do coronavirus figures tell us the full story?

Limited testing – cited as a widescale problem in Brazil – could be partly why the country’s paediatric Covid-19 death total is an underestimate.

Bereaved parents have reportedly said that doctors were reluctant to have their children tested.

Without a positive test result, a doctor may decide not to record Covid-19 on the death certificate, and that fatality will be excluded from the official death toll.

This has been an issue other countries, including the UK, according to comments made earlier this year by Dr Sarah Scobie, deputy director of research at the Nuffield Trust, a health think tank.

“For patients who were not tested, and more particularly if the patient had tested negatively for the coronavirus, doctors may have been reluctant to include the diagnosis on the death certificate, even though the clinical pattern suggested that Covid was a factor,” she said.

In some poorer countries, official statistics are seen as being even more likely to give an inaccurate picture of events.

“In many low- and middle-income countries, civil registration and vital statistics systems are not yet capable of producing timely total mortality statistics with high levels of population coverage,” Dr Adam Karpati, Vital Strategies’ senior vice president for public health programmes, said in a statement released in late May.

His comments were made when the UN revealed that excess mortality worldwide last year was 3m, which is 1.2m more than the official number of deaths from the coronavirus.

The UN figure highlighted the way that official statistics may underestimate the numbers who have died from the condition or been affected by the pandemic in other ways.

“This data provides a better understanding of the true toll of Covid-19 rather than relying solely on deaths determined by test-confirmed Covid-19 cases and deaths,” Dr Karpati said.