Validation of verbal autopsy and nasopharyngeal swab collection for the investigation of deaths at home during the COVID-19 pandemics in Brazil

Brazil currently holds the second highest record of cases and deaths due to the Coronavirus Disease 2019 in the world [1].The state of Ceara ´, with >9 million inhabitants, in Northeastern Brazil, was the epicenter of the epidemic and one of the first states to present community transmission of the COVID-19.Forty-five days after the first confirmed case, there was a collapse of health services, contributing to the increase in the number of people dying at home [2].In the scenario of a pandemic associated with an increase in the number of deaths outside a hospital environment, a specialized service in the investigation of fatalities was necessary to increase the capacity of the health system and to detect and report the death burden from the disease."Dr.Rocha Furtado" Death Verification Service (SVO-RF) is located in the capital Fortaleza and, in partnership with the Epidemiological Surveillance Office and the local public health laboratory, it acts in the investigation of deaths in the state, which was already reported in recent arboviruses epidemics [3,4].To fulfill its mission, SVO-RF performs complete diagnostic autopsies (CDA) for the investigation of deaths at home without medical assistance, as well as deaths without bona fide diagnosis prior to death [5].Moreover, unlike most other Death Verification Services in Brazil, the SVO-RF also implemented a medical team that drives to the houses where the death occurred, to investigate cases where a clinical necropsy was not indicated, such as with patients with advanced cancer diagnoses or other chronic terminal illnesses that die at home, without any home care program.This team, called SVO-Mobile, is composed of a physician, a social worker, and a driver and usually acts in a complementary way to clinical necropsies that take place at the headquarters.In the COVID-19 pandemic, however, the SVO-Mobile played a significant role since clinical necropsies were suspended following the Ministry of Health's guidelines [6].Due to the lack of biosafety at the headquarters, including an air treatment system at the facility, added to the community transmission of the virus and the risk of transmission by asymptomatic and presymptomatic patients, all autopsies were suspended.The SVO-RF leadership saw then the need to expand the number of SVO-Mobile teams from 1 to 3, while still maintaining its regular team at the headquarters.All deaths from this period were investigated