By Jake Spring, Eduardo Simões and Bruno Kelly

BRASILIA/SAO PAULO/MANAUS, Brazil (Reuters) – The death toll from COVID-19 in the worst hit part of Brazil’s remote Amazon region may be three times the official count, according to data from public notaries reviewed by Reuters, as the spread of the disease overwhelms the public health system.

Officials in Manaus, state capital of Amazonas, said they were out of hospital beds and struggling to keep pace with the burials needed. The largest of nine states in Brazil’s Amazon rainforest, Amazonas has registered nearly 19.4 coronavirus deaths per 100,000 residents, compared to 4.4 for all of Brazil, according to a Reuters calculation based on the death toll released by the federal Health Ministry on Thursday.

The coronavirus killed 422 people in Amazonas in April, according to the ministry. Yet death registry data from public notaries indicates the ministry’s statistics may far underestimate the actual toll. Officials have previously acknowledged in media briefings that the toll is likely higher as cases go undetected because of a lack of testing, without saying by how much.

Data from the national association of public notaries as of Thursday showed 385 people died of COVID-19 in Amazonas in April. However, the notaries also registered 999 other deaths – attributed to pneumonia, severe acute respiratory syndrome and other respiratory failures, which some officials in the state believe should be counted as COVID-19 deaths for a total of 1,384. The 999 deaths are four times the 249 fatalities attributed to those other diseases in April 2019.

“In Brazil, there is a harmful phenomenon of under reporting. It’s absurd to have deaths without a cause,” Manaus Mayor Virgilio Neto told Reuters by phone.

“Deaths from pneumonia, I’d rather call COVID. Deaths from severe respiratory failure, I’d rather call COVID.”

A health ministry press representative told Reuters on Thursday that the ministry follows a set procedure for tracking coronavirus cases and all respiratory problems cannot be presumed to be COVID-19 related, but acknowledged that as a result there could be undercounting.

“The number could be higher. We have to wait for the process of investigation into what really was the cause of death of the person. The question of deaths is sensitive and you have to be sure about the cause of death of a person,” said the representative, who asked not be named, citing ministry policy.

“It could be another respiratory virus, not necessarily coronavirus,” she said.


The ministry representative said that it is only possible to know for certain if a person had coronavirus by testing for it. The government plans to ramp up testing later in May, she said, predicting it would reveal a larger number of cases.

The ministry said in a statement on Thursday it has distributed 5.1 million tests. The press representative said the ministry did not know how many had been used.

Brazil had only tested 181,000 people as of April 22, the most recent government statistics available. That represents less than 0.1% of the population, compared to testing rates of 3.5% in Italy and 1.2% in South Korea.

The health ministry has blamed a shortage of materials to make testing kits amid huge global demand for coronavirus tests.

Brazil is the country worst hit by the coronavirus in Latin America and some public health officials, politicians and other observers around the world say they are concerned by President Jair Bolsonaro playing down the gravity of the crisis.

Bolsonaro, seeing Brazil’s economy damaged by social distancing measures, has said the economic impact of keeping people at home outweighs the health risk of letting them work.

The death toll for all of Brazil rose by 610 on Thursday to more than 9,100 people, the health ministry said, with over 135,000 coronavirus cases confirmed.

The ministry’s overall count relies on hospitals testing patients, reporting positive cases to municipal authorities, who then pass the data to state health secretaries and then up to the ministry.


Manaus, a city of more than 2 million, is accessible only by plane or riverboat from the rest of Brazil for much of the year. The outbreak has begun to spread to indigenous communities up and down the Amazon River that flows past Manaus, stirring calls from human rights advocates and public figures from Paul McCartney to Oprah Winfrey to protect the tribes.

Three Brazilian doctors and a local official interviewed by Reuters said they had little doubt that the wave of deadly respiratory illnesses without a firm coronavirus diagnosis are part of the same pandemic.

Guilherme Pivoto, head of Amazonas state infectologists association, said many patients don’t have access to full-service hospitals and die without having been tested. Bodies are quickly sent off to be buried or cremated, Pivoto said.

In certain instances, Manaus has resorted to burying five at a time in shared graves, according to a Reuters photographer who has seen more than 50 burials in local cemeteries. Mayor Virgilio Neto said some 120 people are being buried a day.

The municipal burial service SOS Funeral serves families who cannot afford a private ceremony.

SOS Funeral workers – some in white hooded body suits, masks and gloves for protection – load coffins into the back of white utility vans before picking up bodies from hospitals and homes.

The number of “removals” of the dead have tripled to between 24 and 36 per day, with 52 pickups on the worst day, according to a spokeswoman for SOS Funeral, who asked not to be named.

Virgilio Neto said his efforts to slow the outbreak through social distancing have been hurt by Bolsonaro’s criticism of such isolation orders, estimating less than 40% of the city is following his guidelines.

“It’s hard when the top national leader tells people to go outside … here he has a very strong hold,” the mayor said.

Bolsonaro on Thursday again defended his desire to reopen Brazil’s economy and criticized business closures and stay-at-home orders issued by some state leaders as too restrictive.

(GRAPHIC: World-focused tracker with country-by-country interactive –

(Reporting by Jake Spring in Brasilia, Eduardo Simoes in Sao Paulo and Bruno Kelly in Manaus; Additional reporting by Pedro Fonseca in Rio de Janeiro, Stephen Eisenhammer in Sao Paulo and Lisandra Paraguassu in Brasilia; Editing by Brad Haynes and Grant McCool)