Painel Abramed 2021 - O DNA do Diagnóstico - inglês

Brazil holds around 13.9 MRI devices per million inhabitants in June 2021, and occupies the penultimate position in comparison with the group of selected countries and below the average of OECD member countries, that have around 16.7 devices per million inhabitants GRAPH MRI EQUIPMENT AND EXAMINATIONS (2018 OR LATEST YEAR) 57 Source: OECD Health Statistics 2020. Prepared by Abramed. Note: Devices per million inhabitants and exams per thousand inhabitants. Brasil SUS and Brasis SS (Supplementary Health) devices consider the same number of devices. Brasil SUS Exams consider the total population and the number of exams conducted at SUS, and Brasis SS (Supplementary Health) consider the average number of beneficiaries in 2020 and the number of exams conducted in Supplementary Healthcare. Japan 55,2 112,3 United States 128,0 40,4 149,2 Germany South Korea 34,7 49,0 119,6 30,1 135,0 Italy Switzerland 28,7 73,7 77.8 Spain 24,3 92,4 OECD France 17,2 72,1 Australia Brazil SUS 16,7 Brazil SS Canada 15,4 51,3 14,8 29,7 13,9 13,9 54,5 10,4 Exams (per thousand) Devices (per million) 151THE DIAGNOSTIC MEDICINE SECTOR ABRAMED PANEL

The supply of diagnostic imaging equipment municipalities and metropolitan regions in Brazil is not homogeneous. There is greater concentrate a relevant part of the number of availability in certain municipalities and equipments, others are distant and have no scarcity in others. Therefore, essential tests for access to diagnostic imaging services. the detection and early diagnosis of several diseases are not performed. While some GRAPH CT EQUIPMENT AND EXAMINATIONS (2018 OR LATEST YEAR) 58 Source: OECD Health Statistics 2020. Prepared by Abramed. Note: Devices per million inhabitants and exams per thousand inhabitants. Brasil SUS and Brasis SS (Supplementary Healthcare) devices consider the same number of devices. Brasil SUS exams consider the total population and the number of exams conducted by SUS, and Brasis SS (Supplementary Healthcare) considers the average number of beneficiaries in 2020 and the number of exams conducted by Supplementary Healthcare. Japan 111,5 230,8 Australia 134,6 271,5 United States Switzerland 70,3 228,1 South Korea 44,6 113,9 195,7 Germany 39,7 Italy OECD 38,6 93,6 153,2 76,0 152,1 Brazil SUS 35,1 156,3 Brazil SS Spain 35,1 France Canada 26,6 29,9 26,3 26,3 19,1 18,2 156,2 15,4 Exams (per thousand) Devices (per million) 152 ABRAMED PANEL THE DIAGNOSTIC MEDICINE SECTOR

MAP GAMA CAMERA EQUIPMENT - BY MUNICIPALITY (JUN.2021) 7 Source: Ministry of Health - Brazilian National Register of Health Establishments - CNES. Extracted on July 1st, 2021. Prepared by Abramed. 0 >=1 Total devices Gama- camera Amount Available Not 749 225 City Available 5.345 Available 4% % Not 96% Available MAP MAMMOGRAPH EQUIPMENTS PER MUNICIPALITY (JUN.2021) 8 Source: Ministry of Health - Brazilian National Register of Health Establishments - CNES. Extracted on July 1st, 2021. Prepared by Abramed. 0 >=1 Mammograph Total devices 5.929 1.265 Amount Available 4.305 Not 22,7% City Available 77,3% Available % Not Available 153THE DIAGNOSTIC MEDICINE SECTOR ABRAMED PANEL

MAP X-RAY EQUIPMENT - BY MUNICIPALITY (JUN.2021) 9 Source: Ministry of Health - Brazilian National Register of Health Establishments - CNES. Extracted on July 1st, 2021. Prepared by Abramed. 0 >=1 Total devices X - Ray Amount Available 29.237 Not 3.310 2.260 City Available % Available 59,4% Not 40,6% Available MAP PET/CT EQUIPMENTS PER MUNICIPALITY (JUN.2021) 10 Source: Ministry of Health - Brazilian National Register of Health Establishments - CNES. Extracted on July 1st, 2021. Prepared by Abramed. 0 >=1 Total devices PET/CT Amount Available 116 Not 42 5.528 City Available % Available 0,8% Not 99,3% Available 154 ABRAMED PANEL THE DIAGNOSTIC MEDICINE SECTOR

MAP CT SCANNERS PER MUNICIPALITY (JUN.2021) 11 Source: Ministry of Health - Brazilian National Register of Health Establishments - CNES. Extracted on July 1st, 2021. Prepared by Abramed. 0 >=1 Total devices CT Scanner Amount Available Not 5.569 944 City Available 4.626 % Available Not 17,0% 83,1% Available MAP MRI EQUIPMENTS PER MUNICIPALITY (JUN.2021) 12 Source: Ministry of Health - Brazilian National Register of Health Establishments - CNES. Extracted on July 1st, 2021. Prepared by Abramed. 0 >=1 Total devices MRI Amount Available 2.944 Not 551 5.019 City Available 9,9% Available 90,1% % Not Available 155THE DIAGNOSTIC MEDICINE SECTOR ABRAMED PANEL

There is a lack of uniformity in the distribution and supply of diagnostic imaging equipment in the country. MAP ULTRASOUND EQUIPMENTS PER MUNICIPALITY (JUN.2021) 13 Source: Ministry of Health - Brazilian National Register of Health Establishments - CNES. Extracted on July 1st, 2021. Prepared by Abramed. 0 >=1 Total devices Ultrasound Amount Available 44.626 Not 3.831 1.739 City Available % Available 68,8% Not 31,2% Available 156 ABRAMED PANEL THE DIAGNOSTIC MEDICINE SECTOR

04.3 Physicians in the field of diagnostic medicine THE PROFESSIONALS WORKING IN THE SECTOR HAVE PLAYED AN IMPORTANT ADVISORY ROLE ALIGNED WITH THE PROGRESS IN DIAGNOSTIC MEDICINE, BOTH IN OUT-PATIENT AND IN-PATIENT SETTINGS. In the clinical care cycle, the existence of professionals with the title of specialist and with reference training to provide excellence to the physician who assists the patient is paramount. The performance of these professionals is essential to determine the clinical condition and provide greater assertiveness in the medical-hospital follow-up processes and, thereby, more quality of life for the patient. 157THE DIAGNOSTIC MEDICINE SECTOR ABRAMED PANEL

TABLE GENERAL CHARACTERISTICS OF MEDICAL PROFESSIONALS WORKING IN THE DIAGNOSTIC MEDICINE SEGMENT (2020) 31 Source: CFM - Medical Demography in Brazil 2020. Prepared by Abramed. Radiology and Pathology Endoscopy Clinical Nuclear Medical Diagnostic 3.740 Pathology / medicine genetics Imaging Laboratorial Medicine 1.009 332 Number of 14.125 3.445 0,16 Specialists 6,77 1,64 1.597 Specialist ratio per 100,000 inhabitants 1,78 0,76 0,48 Share over total 3,30% 0,80% 0,90% 0,40% 0,20% 0,10% specialities Distribution by gender 63,8% 44,0% 70,5% 50,7% 62,1% 36,4% Male 36,2% 56,0% 29,5% 49,3% 37,9% 63,6% Female 1,76 0,79 2,39 1,03% 1,64 0,57 Male/ Female ratio Distribution by age 3,6% 2,1% 0,7% 0,3% 1,4% 4,8% ≤ 29 17,3% 9,4% 9,7% 1,2% 15,8% 16,0% 30 - 34 years old 18,8% 12,0% 15,6% 4,0% 16,7% 21,1% 35 - 39 years old 14,1% 13,3% 13,9% 5,8% 11,8% 40 - 44 years old 11,8% 11,1% 13,0% 8,5% 14,7% 9,3% 45 - 49 years old 10,0% 9,4% 12,5% 9,1% 15,6% 11,2% 50 - 54 years old 7,8% 9,3% 12,1% 12,8% 9,6% 7,5% 55 - 59 years old 6,3% 10,7% 9,2% 15,8% 5,8% 6,9% 60 - 64 years old 5,4% 10,7% 7,6% 20,0% 4,5% 5,1% 65 - 69 years old 4,9% 12,0% 5,7% 22,5% 7,2% 6,3% ≥ 70 years old 8,7% 51,6 49,4 46 Average (years) 45,7 3,4 3,0 60,1 47,5 3,6 Age 3,3 3,9 Time since graduation 3,4 158 ABRAMED PANEL THE DIAGNOSTIC MEDICINE SECTOR

These professionals work mainly in the Southeast, Northeast and South regions. This distribution is associated, among other factors, with the demand for medical services, better employment conditions, income and the specialization possibilities. GRAPH SHARE OF PHYSICIANS IN THE MEDICAL DIAGNOSTICS SECTOR BY REGION (IN % – 2020) 59 Source: CFM - Medical Demography in Brazil 2020. Prepared by Abramed. North 3,5 3,1 3,9 3,5 3,0 1,5 Northeast 18,3 20,2 18,3 24,4 14,0 12,4 Southeast 51,9 53,0 47,9 57,1 58,2 58,4 South 17,1 Centre-West 14,5 21,1 8,0 15,0 18,7 9,2 9,2 8,8 7,0 9,8 9,0 Radiology and Diagnostic Imaging Pathology Endoscopy Medical genetics Clinical Pathology / Laboratorial Medicine Nuclear Medicine 159THE DIAGNOSTIC MEDICINE SECTOR ABRAMED PANEL

04.4 Labor market in the diagnostic medicine sector IN 2020, THE DIAGNOSTIC MEDICINE SECTOR WAS RESPONSIBLE FOR MAINTAINING 275.7 THOUSAND JOBS35, AN INCREASE OF 2.4%, COMPARED TO 2019. Clinical analysis labs account for 126,500 diagnostic imaging facilities, clinical analysis, jobs and 45.9% of the jobs in the sector, while and other diagnostic medicine activities in the imaging services account for 54,800 jobs country. However, despite the gains in scale and 19.9%, according to CAGED data. In the achieved through technological advances and group of activities related to the healthcare the opening of new units, the sector is strongly market36, there were more than 2.3 million impacted by regulations that lead to an increase jobs, an increase of 5.6% over the same basis of in the cost of compliance. comparison. Every year, the healthcare sector has increased its share of the formal labor marketl37, from 5.2% in 2016 to 5.8% in 2020. The growth rate of the diagnostic medicine sector has been more intense in comparison with the general labor market. In the last five years, average growth in the sector was 2.4% per year38, and 0.8% in the labor market. This rate of growth is associated with the opening of 35 Data elaborated based on the sector’s job stock in the year 2018 and the sum of movements in the year 2019. 36 Hospital care activities, Mobile emergency care services, Patient removal services except mobile emergency care services, Outpatient care activities provided by physicians and dentists, Complementary diagnostic and therapeutic service activities, Activities of healthcare professionals other than physi- cians and dentists, Support activities for healthcare management, Human healthcare activities not otherwise specified, Residential care activities for the elderly, physically handicapped, immunosuppressed and convalescents provided in collective and private residences, Home-based care activities providing supportive infrastructure and assistance to patients, Psychosocial and health care activities for the mentally disturbed, mentally disabled and drug addicts. 37 Formal employment considering hiring through CLT. 38 CAGR–2015/2019. 160 ABRAMED PANEL THE DIAGNOSTIC MEDICINE SECTOR

TABLE JOB STOCK IN THE DIAGNOSTIC AND THERAPEUTIC MEDICINE SECTOR, HEALTHCARE MARKET AND LABOUR MARKET (2016/2020) 32 Source: CAGED - General Registry of Employed and Unemployed and New Caged. Prepared by Abramed. Extracted on June 25th, 2021. Note: 1 Hospital care activities, Mobile emergency care services, Patient removal services, except mobile emergency care services, Outpatient care activities provided by physicians and dentists, Complementary diagnostic and therapeutic service activities, Activities of health professionals, except physicians and dentists, Health management support activities, Human health care activities not previously specified, Activities of assistance to the elderly, physically disabled, immunosuppressed and convalescents provided in collective and private residences, Activities of provision of support infrastructure and assistance to patients in the home, Activities of psychosocial and health care for persons with mental disorders, mental disability and chemical dependency. Note: 2 Data 2016 to 2019: Stock Evolution: CLT Jobs - January 2013 to December 2019: series with adjustments. 2020: NEW CAGED Monthly Formal Employment Statistics. 2016 2017 2018 2019 2020 Pathological Anatomy and Cytolo- 12.773 12.734 13.290 12.888 12.880 gical Labs Clinical Labs 103.588 107.776 117.540 119.827 126.497 Dialysis and nephrology services 15.270 16.228 17.625 20.274 21.140 CT scanning services 4.339 4.521 4.541 5.154 5.341 Diagnostic imaging services using ionizing 39.258 39.301 41.408 45.952 44.887 radiation, except for CT Scanning 5.173 5.958 MRI Services 3.666 7.561 8.235 6.415 6.401 8.953 8.896 5.961 1.992 2.164 Diagnostic imaging services without the use of ionising radiation, except for MRI 3.303 3.046 5.054 4.827 Diagnostic services by graphic record, ECG, 1.797 1.264 1.153 2.364 2.316 EEG, and other similar tests 7.968 5.290 Diagnostic services using optical methods, 3.009 80 85 3.154 3.194 endoscopy, and other similar examinations 180 309 Chemotherapy services 4.832 5.596 5.660 1.194 1.019 1.010 Radiotherapy services 7.886 7.926 8.242 Hemotherapy services 70 133 123 Lithotripsy services 222 210 203 Human cell and tissue banking services Supplementary diagnostic and therapeutic 32.324 31.267 30.768 29.260 18.907 service activities not specified above Total Diagnostic and therapeutic 236.189 256.239 256.239 269.125 275.697 complementary service activities Total Healthcare Market¹ 1.964.655 2.003.652 2.087.332 2.175.991 2.298.332 Labor Market Time² 37.875.947 37.863.983 38.410.428 39.054.507 39.362.968 161THE DIAGNOSTIC MEDICINE SECTOR ABRAMED PANEL

The Southeastern region concentrates more than half of the employees in the formal labor sector and this proportion is similar, both in the distribution of employees in the diagnostic medicine sector and in other activities related to the healthcare market. As indicated, this region has the largest number of healthcare establishments and beneficiaries of private healthcare plans and insurance. The distribution of the number of employees in the activities of diagnostic and therapeutic supplementary services amounts to 143.6 thousand in the Southeast, which represents 52.1% by the end of 2020. The Northeast concentrates 19.1%; the South, 14.2%; the Centre- West, 10.1%, and the North 4.5%. 162 ABRAMED PANEL THE DIAGNOSTIC MEDICINE SECTOR

TABLE JOBS IN THE DIAGNOSTIC AND THERAPEUTIC MEDICINE SECTOR, BY REGION (2020) 33 Source: CAGED - General Registry of Employed and Unemployed and New Caged. Prepared by Abramed. Extracted on June 25th, 2021. Note: 1 Hospital care activities, Mobile emergency care services, Patient removal services, except mobile emergency care services, Outpatient care activities provided by physicians and dentists, Complementary diagnostic and therapeutic service activities, Activities of health professionals, except physicians and dentists, Health management support activities, Human health care activities not previously specified, Activities of assistance to the elderly, physically disabled, immunosuppressed and convalescents provided in collective and private residences, Activities of provision of support infrastructure and assistance to patients in the home, Activities of psychosocial and health care for persons with mental disorders, mental disability and chemical dependency. Note :2 Data 2016 to 2019: Stock Evolution: CLT Jobs - January 2013 to December 2019: series with adjustments. 2020: NEW CAGED Monthly Formal Employment Statistics Norte Nordeste Sudeste Sul Centro- -Oeste Pathological Anatomy and 1.309 2.765 5.677 1.884 1.244 Cytological Labs Clinical Labs 6.074 26.511 61.662 19.383 12.886 Dialysis and nephrology services 1.197 4.660 10.231 2.605 2.447 CT scanning services 221 1.353 2.020 1.181 566 Diagnostic imaging services using ionizing 1.903 6.691 24.520 6.589 5.184 radiation, except for CT Scanning MRI Services 249 1.256 2.942 1.357 597 2.276 3.636 1.393 1.224 367 Diagnostic imaging services without the use of ionising radiation, except for MRI Diagnostic services by graphic record, ECG, 270 580 853 269 343 EEG, and other similar tests Diagnostic services using optical methods, 209 642 1.524 465 354 endoscopy, and other similar examinations Chemotherapy services 271 866 2.964 808 751 24 114 535 164 173 Radiotherapy services 79 1.296 5.687 548 632 Hemotherapy services 10 4 80 21 7 Lithotripsy services -- 13 171 17 2 Human cell and tissue banking services 3.629 21.134 2.335 1.495 Supplementary diagnostic and therapeutic 314 service activities not specified above Total Diagnostic and therapeutic 12.497 52.656 143.637 39.020 27.887 complementary service activities Total Healthcare Market¹ 89.170 402.645 1.238.861 363.114 204.542 Labor Market Time² 3.318.584 1.825.265 6.386.469 20.290.064 7.432.155 163THE DIAGNOSTIC MEDICINE SECTOR ABRAMED PANEL

04.5 Assistential production of the diagnostic medicine sector 04.5.1 Supplementary HealthCare THE IMPACT OF THE COVID-19 PANDEMIC ON THE HEALTH CARE PRODUCTION IN THE SUPPLEMENTARY HEALTH MARKET WAS QUITE CLEAR. IN 2020, THE BENEFICIARIES OF PRIVATE HEALTHCARE PLANS AND INSURANCE PLANS PERFORMED ABOUT 1.3 BILLION CARE PROCEDURES - MEDICAL CONSULTATIONS, COMPLEMENTARY EXAMS, THERAPIES, HOSPITALIZATIONS AND DENTAL PROCEDURES. The reduction was 17.2% in comparison with Medical consultations fell 25.1% and were the the previous year and, for the first time, most impacted by social isolation measures. there was a reduction in the number of Therapies decreased 23.7% and the number of healthcare events in supplementary health. hospitalizations fell 14.7%. TABLE NUMBER OF PROCEDURES PERFORMED IN SUPPLEMENTARY HEALTHCARE (MILHÕES - 2016/2020) 34 Source: ANS - Assistance Map of Supplementary Health 2020. Prepared by Abramed. 2016 2017 2018 2019 2020 ∆ (%) 2020/2019 Total 1.465,6 1.515,5 1.577,7 1.616,4 1.338,5 Medical Consultations 273,0 270,3 274,4 277,5 208,0 -17,2 Other outpatient 141,2 157,0 164,2 158,8 131,3 -25,1 services -17,4 Supplementary exams 796,8 816,9 861,5 916,5 783,0 Therapies 70,0 77,2 93,4 72,1 54,9 -14,6 Hospitalizations 7,8 8,0 8,1 8,6 7,4 -23,7 Dental Procedures 176,9 186,1 176,2 182,8 153,9 -14,7 -15,8 164 ABRAMED PANEL THE DIAGNOSTIC MEDICINE SECTOR

The pandemic impacted the number of care adopted to address the pandemic, including procedures in the supplementary healthcare the adoption of social isolation measures to market, especially in the first semester of prevent the spread of the covid-19. 2019. With the enactment of Law No. 13,979 in February 2020, several measures were GRAPH NUMBER OF PROCEDURES PERFORMED IN SUPPLEMENTARY HEALTHCARE PER SEMESTER (MILLIONS - 2019/ 2020) 60 Source: ANS - Assistance Map of Supplementary Health 2020. Prepared by Abramed. Medical 139,3 Consultations 138,2 99,1 Outpatient 108,9 Medical 109,8 Consultations 110,1 Emergency 77,9 Room 86,5 Consultations 29,3 Other 27,9 21,0 outpatient 22,3 services 75,3 Exams 83,5 63,8 67,4 349,4 455,5 461,1 433,6 Therapies 34,9 Hospitalizations 37,2 27,2 Dental 27,7 Procedures 4,2 4,4 3,7 3,6 87,9 94,9 70,1 83,8 1st Semester 2019 2nd Semester 2019 1st Semester 2020 2nd Semester 2020 165THE DIAGNOSTIC MEDICINE SECTOR ABRAMED PANEL

GRAPH VARIANCE IN THE NUMBER OF PROCEDURES PERFORMED IN SUPPLEMENTARY HEALTH BY SEMESTER (IN % - 1ST AND 2ND SEMESTER OF EACH YEAR – 2019/2020) 61 Source: ANS - Assistance Map of Supplementary Health 2020. Prepared by Abramed. -20,2 -11,7 Dental -17,9 -11,4 Procedures Hospitalizations -25,4 -22,0 Therapies -23,3 -6,0 Exams Other outpatient -19,3 services -15,2 Emergency Room Consultations -28,3 -20,0 Outpatient Medical Consultations -29,0 -21,4 Medical Consultations -28,8 -21,2 1st Semester 2nd Semester With the suspension of outpatient Approximately 783 million supplementary consultations and elective procedures, exams were performed in 2020, with a there was a retraction in the diagnostic reduction of 14.6% compared to 2019. medicine activities. This reduction was Considering the set of exams in which the more pronounced in the diagnostic imaging information submission is specified in the SIP segment, which depends essentially on (Product Information System - ANS) by the demand from elective medical and outpatient healthcare providers, the negative variation consultations, all suspended due to the of all indicated exams, without exception, unfolding of the pandemic. It is important stands out. The most utilized imaging to stress that many of these exams are related exams decreased: 33.4% (radiography), 14.4% to the process of cancer diagnosis, preventive (magnetic resonance imaging) and 3.8% measures and disease monitoring. According (computed tomography). Other extremely to the Oncoguia Institute39, approximately relevant tests for early detection of several 43% of cancer patients had their treatment diseases also underwent a reduction: 37.3% cancelled or postponed by the covid-19 (fecal occult blood test), 28.3% (conventional pandemic. This negative impact was evidenced and digital mammography) and 31.8% in an analysis of data from England, Northern (colonoscopy). Ireland and the United States. It is estimated that there will be a 20% increase in cancer deaths in the months following the pandemic lockdown periods.40 39 http://www.oncoguia.org.br/conteudo/covid19-atrasou-o-tratamento-de-43-dos-pacientes-com-cancer/13719/42/ 40 Estimating excess mortality in people with cancer and multimorbidity in the Covid-19 emergency. 166 ABRAMED PANEL THE DIAGNOSTIC MEDICINE SECTOR

TABLE NUMBER OF SUPPLEMENTARY EXAMS PERFORMED IN SUPPLEMENTARY HEALTHCARE (MILLIONS - 2016/2020) 35 Source: ANS - Assistance Map of Supplementary Health 2020. Prepared by Abramed. 2016 2017 2018 2019 2020 ∆ (%) 861,5 916,5 783,0 2020/2019 Supplementary exams 796,8 816,9 31,8 31,7 21,1 -14,6 X-Ray 34,4 33,1 7,9 8,3 6,4 -33,4 MRI 7,1 7,4 7,4 7,7 7,4 -23,7 CT Scannig 7,1 7,2 -3,8 6,9 7,4 5,6 Total Abdominal diagnostic 6,4 6,5 -23,9 ultrasound 7,7 7,0 6,7 7,0 5,3 Inferior Abdominal diagnostic -24,9 ultrasound 6,6 6,3 6,1 6,3 4,8 Cervico-vaginal oncotic -24,4 cytopathology in women 5,1 5,2 5,2 5,7 4,4 (25to59years old) 5,1 5,0 -23,4 5,0 5,1 3,6 Transthoracic echodoppler 2,3 2,3 -28,3 echocardiogram 3,5 3,4 2,3 2,4 1,7 Conventional and digital 3,1 3,2 -29,5 mammography 2,2 2,2 3,4 3,6 2,5 1,2 1,2 3,3 3,4 2,3 -31,4 Mammography (women 1,1 1,2 2,3 2,3 1,5 -32,2 between 50 and 69 years old) 1,0 1,0 1,3 1,5 1,2 -33,9 Ergometry test 1,0 1,0 1,2 1,3 0,9 -18,7 Upper digestive endoscopy 0,6 0,5 0,9 1,0 0,7 -31,8 Bone densitometry - any 0,1 0,1 1,0 1,0 0,9 -26,4 segment 0,5 0,5 0,4 24 h Holter 0,04 0,04 0,1 0,1 0,1 -10,1 Colonoscopy 11,0 12,0 -35,2 Upper abdomen diagnostic 1,0 1,1 0,04 0,04 0,03 -30,4 ultrasonography 13,5 15,7 14,0 Obstetric morphological 1,1 1,2 0,8 -29,8 ultrasonography -11,1 Myocardial scintigraphy -37,3 Bronchoscopy with or without biopsy Dynamic kidney scintigraphy Glycated Hemoglobin Fecal occult blood test (50 to 69 years) 167THE DIAGNOSTIC MEDICINE SECTOR ABRAMED PANEL

The number of assistential procedures per beneficiary decreased in all segments, especially in medical consultations, which went from 5.9 consultations per beneficiary in 2019 to 4.4 consultations in 2020, a decrease of 25.5%. The supplementary exams followed GRAPH AVERAGE NUMBER OF ASSISTENTIAL EVENTS PER BENEFICIARY (2016/2020) 62 Source: ANS - Assistance Map of Supplementary Health 2020. Prepared by Abramed. 0 5 10 15 20 25 Medical 4,4 Consultations 2,8 Other Outpatient Services Supplementary exams 16,6 Therapies 1,5 Hospitalizations 0,16 2016 2017 2018 2019 2020 168 ABRAMED PANEL THE DIAGNOSTIC MEDICINE SECTOR

this trend and went from 19.5 exams per About 177 million beneficiary to 16.6 exams, in the same period. complementary Even with the increase in the number of examinations beneficiaries in the last year, the access and will no longer use of healthcare services were impacted by be performed in the social isolation measures. supplementary health in 2020 as At the beginning of the year, before the a consequence of pandemic unfolded, the projection was of the pandemic. approximately 960 million supplementary examinations performed in 2020, with an expected increase of 4.9% compared to 2019. GRAPH EXAMS PERFORMED AND PROJECTED IN SUPPLEMENTARY HEALTHCARE (PROJEÇÃO LINEAR MENSAL EM MILHÕES - 2020) 63 Source: ANS - Assistance Map of Supplementary Health 2020. Prepared by Abramed. Note: Estimated distribution of the monthly number of exams considers the variation in the number of authorisations issued for examinations and therapies. MONTHLY PROJECTED ESTIMATE EXAMINATIONS 100 100 90 77,5 75,4 71,5 84,1 90 77,0 62,5 64,8 67,8 79,1 80 80 70 70 57,1 60 60 50 50 41,1 40 30 40 30 28,9 20 20 10 10 00 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 169THE DIAGNOSTIC MEDICINE SECTOR ABRAMED PANEL

Early Diagnosis IN THE LAST DECADES, SEVERAL TECHNOLOGICAL AND SCIENTIFIC BREAKTHROUGHS HAVE BEEN MADE SEEKING TO IMPROVE THE DIAGNOSIS AND TREATMENT OF CANCER CASES WORLDWIDE. These advances provide a new perspective in According to the World Health Organization, tackling the disease, as early detection increases cancer is one of the main causes of death, the chances of cure and can considerably accounting for almost 10 million deaths in 2020. reduce treatment costs. However, cancer is The most common among women is breast amongst the many diseases whose prevention cancer, with 2.26 million cases, and among men, and treatment have been negatively impacted prostate cancer, with 1.41 million new cases per by the covid-19 pandemic. According to year. In Brazil, the National Cancer Institute data from the Brazilian Society of Clinical (INCA) estimates about 625.4 thousand new Oncology (SBOC)41,74% of oncologists cases of the disease each year, between 2020 reported the interruption of treatment during and 2022. It is estimated approximately 65,840 the most critical months of the pandemic due new cases of prostate cancer, which represents to social isolation measures, which hindered the diagnosis and treatment of the disease. 41 https://sboc.org.br/noticias/item/2099-pesquisa-sboc-74-dos-oncologistas-observaram-interrupcao-do-tratamento-durante-a-pandemia 170 ABRAMED PANEL THE DIAGNOSTIC MEDICINE SECTOR

a 62.95 new cases per 100,000 men and, 66,280 Early diagnosis new cases of breast cancer, with an estimated saves lives and can risk of 61.61 new cases per 100,000 women. The considerably reduce incidence and mortality from cancer increase healthcare costs. due to the demographic transition process, with the rise in the proportion of elderly people in The understanding that early diagnosis saves the population, as well as the prevalence of risk lives and can considerably reduce healthcare factors, mainly associated with socioeconomic costs has been well established for a long time. development, with the incidence of habits and There is no doubt that late diagnosis, on the lifestyles, such as sedentary lifestyle, unhealthy contrary, may foster worse life expectancy diet, among others. and result in more costly and often inefficient treatments. This information is essential for the planning of prevention, early diagnosis, and screening 171THE DIAGNOSTIC MEDICINE SECTOR ABRAMED PANEL actions, in addition to the priorities for the treatment of the disease. In this sense, it is critical to establish detection actions with guaranteed access to diagnostic tests, in a timely manner and with quality in all stages of the disease’s line of care.

04.5.2 Unified Health System (SUS) THE IMPACTS OF COVID-19 WERE ALSO OBSERVED IN THE HEALTHCARE PRODUCTION OF THE UNIFIED HEALTH SYSTEM(SUS). In 2020, the total number of events dropped purposes were performed at SUS in the first six by 16.2% compared to 2019. There were about months of 2019. With the start of the pandemic, 3.2 billion procedures performed in 2020, there were only 365.3 million in the same period compared to 3.8 billion in the previous year. of 2020, a decrease of 24.5% in the comparison Procedures with diagnostic purposes decreased between January and June of each year. In by about 20%, from 981 million in 2019 to 785 2021, the number of examinations grew again, million in 2020. 21.1% compared to the first six months of 2020. However, this result is still 8.6% lower than that The impact of the pandemic on the lack of recorded in 2019. The interruption or reduction healthcare at all levels becomes even more in elective care of other specialties not related obvious when comparing the period from to covid-19 continued in the first six months of January to June of each year, before and after 2021, and the return to pre-pandemic levels still the beginning of the pandemic in the country. depends on actions to contain the spread of the Some 484.1 million procedures with diagnostic coronavirus. 172 ABRAMED PANEL THE DIAGNOSTIC MEDICINE SECTOR

TABLE OUTPATIENT PRODUCTION IN SUS BY PROCEDURE GROUP (MILLIONS - 2019/2021) 36 Source: Ministry of Health - SUS Outpatient Information System (SIA/SUS). Prepared by Abramed. Note: Outpatient production - Volume approved per site of care and year of processing, by procedure group. Amount ranked in descending order for the entire year 2020. Extracted on September 1st, 2021. Full year January to June of each year 2019 2020 ∆ (%) 2019 2020 2021 Δ (%) Δ (%) ∆ (%) 2020/ 2020/ 2021/ 2021/ 2019 2019 2020 2019 Total 3.761,1 3.153,4 -16,2 1.841,6 1.569,4 1.622,4 -14,8 3,4 -11,9 Medications 1.022,2 1.127,1 10,3 480,8 566,6 573,6 17,8 1,2 19,3 686,5 503,9 486,9 -26,6 -3,4 -29,1 Clinical Procedures 1.380,3 982,7 -28,8 484,1 365,3 442,6 -24,5 21,1 -8,6 144,7 100,2 91,9 Diagnostic purpose 981,7 785,6 -20,0 procedures 18,0 13,9 15,1 Actions of health promotion 285,5 197,3 -30,9 23,0 15,0 7,5 -30,7 -8,3 -36,5 and prevention Supplementary health care 38,4 27,9 -27,4 -22,7 8,6 -16,1 actions Surgical procedures 43,6 23,9 -45,2 -34,8 -50,3 -67,6 Orthoses, prosthetics and 7,5 7,6 0,5 3,6 3,7 4,1 3,3 11,2 14,8 special materials Organ, tissue and cell 1,8 1,4 -22,9 0,9 0,7 0,7 -19,9 3,8 -15,9 transplants The exams in the clinical analysis segment represent an average of 73.7% of the total procedures performed at SUS for diagnostic purposes. The decrease was of 23.7% in the first six months of 2020 compared to the same period of the previous year. Endoscopy exams showed the sharpest drop in the period, 40.2%, on the same basis of comparison. Endoscopy is an exam capable of diagnosing several diseases, among them stomach and esophagus cancer. Together, they rank second in cancer incidence among men and sixth among women. 173THE DIAGNOSTIC MEDICINE SECTOR ABRAMED PANEL

TABLE SUS OUTPATIENT PRODUCTION BY SUBGROUP OF DIAGNOSTIC PURPOSE (MILLIONS - 2019/2021) 37 Source: Ministry of Health - SUS Outpatient Information System (SIA/SUS). Prepared by Abramed. Note: Outpatient production - Volume approved per site of care and year of processing, by procedure group. Amount ranked in descending order for the entire year 2020. Extracted on September 1st, 2021. Full year January to June of each year 2019 2020 ∆ (%) 2019 2020 2021 ∆ (%) ∆ (%) ∆ (%) 2020/ 2020/ 2021/ 2021/ 2019 2019 2020 2019 Total 981,7 785,6 -20,0 484,1 365,3 442,6 -24,5 21,1 -8,6 Clinical labs 716,9 584,3 -18,5 355,0 271,0 332,5 -23,7 22,7 -6,3 Radiology 63,8 48,2 -24,5 31,4 22,9 23,9 -27,2 4,3 -24,0 Rapid testing 41,2 36,8 -10,7 19,7 17,3 18,4 -12,3 6,6 -6,5 Diagnostic methods in 49,0 34,3 -30,1 23,6 15,9 19,6 -32,7 23,5 -16,8 specialties Material collection 51,4 33,5 -34,8 25,6 15,8 19,4 -38,2 22,6 -24,3 Hemotherapy 16,6 15,1 -9,4 8,3 7,3 7,8 -11,1 6,5 -5,4 Ultrasonography 19,4 14,4 -26,0 9,4 6,5 8,3 -30,3 26,6 -11,8 Pathological anatomy and 12,0 7,6 -37,7 5,8 3,8 4,4 -33,1 14,0 -23,8 cytopathology CT scanning 6,0 6,3 6,2 2,9 2,8 3,8 -2,5 36,3 32,9 Epidemiological and environmental surveillance 1,3 2,2 73,5 0,6 0,7 2,9 5,7 342,5 367,9 Endoscopy MRI 2,1 1,3 -38,2 1,0 0,6 0,7 -40,2 17,9 -29,5 In vivo nuclear medicine 1,4 1,2 -14,9 0,7 0,5 0,7 -19,9 26,9 1,7 Interventional radiology 0,5 0,4 -21,1 0,2 0,2 0,2 -23,9 18,1 -10,1 0,1 0,0 -17,1 0,0 0,0 0,0 -22,6 18,2 -8,5 In 2021, the main imaging exams performed at SUS were X-rays, with 65.2% of the total, followed by ultrasound with 22.5%, CT scan with 10.4% and MRI with 1.9%. 174 ABRAMED PANEL THE DIAGNOSTIC MEDICINE SECTOR

The interruption or reduction in elective care of other non- Covid-19 related specialties has continued in the first six months of 2021. GRAPH OUTPATIENT PRODUCTION OF SUS PER DIAGNOSTIC IMAGING PROCEDURE (2021) 64 Source: Ministry of Health - SUS Outpatient Information System (SIA/SUS). Prepared by Abramed. Note: Outpatient production - Volume approved per year of care, by procedure group. Extracted on September 1st, 2021. 1,9% 65,2% MRI Radiology 10,4% CT Scanning 22,5 % Ultrasound Since the first studies in several countries42, are performed by elderly people (60 it has been shown that people over 60 years years of age or older). Thus, the effects of age are more vulnerable to covid-19, in of the pandemic in this population were several aspects, especially with regard to even greater considering the amount of health conditions. Nevertheless, about 33% procedures with diagnostic purpose that of procedures with diagnostic purposes were not performed. 42 Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China 175THE DIAGNOSTIC MEDICINE SECTOR ABRAMED PANEL

A sharp decrease in examinations among the population aged 60 and over. GRAPH DIAGNOSTIC PROCEDURES IN SUS BY AGE BRACKET (JANUARY TO JUNE EACH YEAR – 2019/2021) 65 Source: Ministry of Health - SUS Outpatient Information System (SIA/SUS). Prepared by Abramed. Note: Outpa- tient production by place of residence - Volume approved by year of processing, by group of procedures with diagnostic purposes. The amount per age group was calculated considering the proportion observed according to age bracket and the total not informed/not required and Total. 50,0 45,0 40,0 35,0 30,0 25,0 20,0 15,0 10,0 5,0 -- <1 year 1 - 4 5 - 9 10 - 14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 80+ 2019 2020 2021 The reduction in the number of tests in age groups over 60 years old was 17.7%, on average, between January and June 2020, compared to the same period in 2019. This reduction, although not as significant when compared to the groups up to 20 years of age, represents significant impacts in terms of volume and, especially from the healthcare perspective. 176 ABRAMED PANEL THE DIAGNOSTIC MEDICINE SECTOR

GRAPH VARIANCE IN THE AMOUNT OF PROCEDURES FOR DIAGNOSTIC PURPOSES IN SUS BY AGE BRACKET (JANUARY TO JUNE OF EACH YEAR COMPARED TO THE 66 SAME PERIOD IN THE PREVIOUS YEAR – 2019/2021 – IN %) Source: Ministry of Health - SUS Outpatient Information System (SIA/SUS). Prepared by Abramed. Note: Outpatient production by place of residence - Volume approved by year of processing, by group of procedures with diagnostic purposes. 40 32,6 32,4 35,5 33,4 29,8 33,9 30,2 31,1 30,8 30 28,8 28,9 29,2 27,7 27,5 25,4 24,8 20 10 25,5 6,8 14,2 11,2 9,9 7,4 9,3 8,7 7,1 5,3 4,8 5,6 0 -1,0 3,3 2,9 2,2 -5,9 -8,7 -11,9 -10 -13,9 -14,5 -14,7 -15,4 -17,2 -15,4 -23,1 -20 -15,2 -17,9 -17,9 -17,7 -17,8 -18,4 -19,7 -19,2 -19,4 -30 -32,6 -29,7 -35,4 -40 <1 year 1 - 4 5 - 9 10 - 14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 80+ 2020/2019 2021/2020 2021/2019 177THE DIAGNOSTIC MEDICINE SECTOR ABRAMED PANEL

178 ABRAMED PANEL

Covid-19 05 179ABRAMED PANEL

05 COVID-19 X-ray of the pandemic THE EMERGENCE OF THE NEW CORONAVIRUS IN HUBEI PROVINCE, CHINA, IN LATE 2019 AND ITS ARRIVAL IN BRAZIL IN EARLY 2020, TRANSFORMED THE DAILY LIVES OF THE POPULATION AND BROUGHT MASSIVE CHALLENGES TO THE HEALTHCARE SYSTEM. The pandemic reached all 5,570 municipalities causing a growing demand for hospitalizations, intensive care beds, respirators, oxygen and health professionals. The unbalance in the availability and access to health services and the poor structural readiness to face 180 ABRAMED PANEL COVID-19

The diagnostic medicine sector reacted quickly and adapted to the new reality brought about by the coronavirus. this unprecedented situation were evident, and epidemiological impacts, the actions to considering the heterogeneity among the contain social mobility, such as social isolation country’s municipalities. and quarantine, produced social and economic impacts that had no precedent in history. The exposure of vulnerable populations and groups produced alarming numbers and In this context, the diagnostic medicine sector ranked Brazil third in the number of confirmed reacted quickly and adapted to the new reality, cases of the disease and second in the number becoming a cornerstone for an effective of deaths. The country concentrated the record response, focused on solving the problems in number of deaths in March 2021, a number the most serious health crisis ever faced by the higher than that of 109 countries together in a country. full year of pandemic. In addition to the health 181COVID-19 ABRAMED PANEL

05.1 The role of the diagnostic medicine sector DIAGNOSTIC MEDICINE HAS PLAYED A KEY ROLE IN PROVIDING MOLECULAR TESTS RECOMMENDED BY THE WORLD HEALTH ORGANISATION (WHO). Imaging tests, such as CT scans, have also to prevent a quicker spread in society and, been essential to diagnose and monitor more consequently, contributing to a faster pace of severe cases involving respiratory failure, in economic recovery. conjunction with other laboratory tests. The ability to detect the virus has been essential Numerous actions were continuously carried to determine whether a person is infected out to improve diagnostic methods and and to assist in the indication of the most improve access to the Brazilian population. It appropriate clinical treatment, in addition was necessary to expand the testing capacity to enabling the management of cases and and, at the same time, laboratorial units determining the necessary isolation measures adapted their structures to serve patients with 182 ABRAMED PANEL COVID-19

suspected covid-19 separately from others Countless actions who went to perform other exams. One of have been taken the alternatives found by the laboratories was to improve to offer drive-thru or home collection of the diagnostic test to detect the new coronavirus as a way methods and to minimize any risk to the patient and the facilitate access population. to the Brazilian population. The cooperation of the various agents was essential for the advancement and laboratories remained active in expanding the consolidation of the measures necessary testing capabilities in the country, including to deal with the pandemic. The groups developing partnerships with SUS. and companies associated with Abramed remain in the forefront of the fight against The creation of the SARS-CoV-2 Kits the pandemic through science, innovation, Evaluation Program was another important and technology, valuing and recognizing the step in the response to the pandemic, in essential role of science in the struggle against partnership with Abramed, the Brazilian the coronavirus. Abramed has always been Chamber of Laboratory Diagnosis (CBDL), committed to finding solutions that enable the the Brazilian Society of Clinical Analyses maintenance of the activities of the associated (SBAC) and the Brazilian Society of Clinical companies and other agents of the healthcare Pathology and Laboratorial Medicine (SBPC/ market in Brazil, considering several sectorial ML). The program, first of its kind in the aspects such as logistics, human, economic world, validated the efficacy and performance and financial resources, vital for the stability of different tests for diagnosis of covid-19 and sustainability of the sector. registered by the National Health Surveillance Agency (Anvisa) and available in the Brazilian The sector faced structural adversities and market. challenges, such as the lack of imported raw materials and reagents. In addition, despite 183COVID-19 ABRAMED PANEL logistical problems caused by the restricted and scarce air network availability. The

05.2 Epidemiological profile THE NUMBER OF COVID-19 CASES AND DEATHS IS UPDATED DAILY AND VARIES CONSIDERABLY ACCORDING TO THE TRANSMISSION RATE AND THE COUNTERMEASURES ADOPTED TO CONTAIN THE PANDEMIC’S SPREAD. Therefore, the presented numbers represented Among the 20 countries with the highest a historic record at the end of September number of confirmed cases of covid-19, 2021. At the time, more than 230 million cases the United States stands out with about of covid-19 had been confirmed worldwide. 42.3 million, followed by India with 35.5 Although the virus spread at a different rate million and Brazil, with approximately 21.2 in each country, the greatest number of people million cases. The United Kingdom had 7.5 infected were in Asia (74.3 million), Europe million cases and Russia with 7.2 million. (58.2 million), North America (50.8 million), Together, these 5 countries account for South America (37.5 million) and Africa (8.2 almost 50% of the total number of cases in million). the world. GRAPH COVID-19 CASES REGISTERED ACROSS SELECTED CONTINENTS (2020/2021 – IN MILLIONS) 67 Source: Covid-19 Data Repository by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. 22 January 2020 to 20 September 2021. Prepared by Abramed. 80 74,3 70 60 58,2 50 50,8 40 37,5 30 20 10 8,2 0 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG 2020 2021 North America Asia Europe South America Africa 184 ABRAMED PANEL COVID-19

GRAPH CASES REPORTED BY COVID-19 BY COUNTRY WITH THE HIGHEST CUMULATIVE NUMBER OF CASES – TOP 20 (MILLIONS - 2020/2021) 68 Source:Covid-19 Data Repository by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. 22 January 2020 to 20 September 2021. Prepared by Abramed. United States 42,3 India Brazil 33,5 United Kingdom 21,2 Russia France 7,5 Turkey 7,2 Iran 7,0 6,9 Argentina 5,4 Colombia 5,2 4,9 Spain 4,9 Italy 4,6 4,2 Indonesia 4,2 Germany 3,6 2,9 Mexico 2,9 Poland 2,5 South Africa 2,4 Ucraine 2,2 Philippinas Peru The number of deaths from the covid-19 and the highest lethality rate among pandemic totalled more than 4.7 million the continents, 3.1%. This rate above the worldwide, with a lethality rate of 2.1%. In world average is associated with several Europe, 1.2 million deaths were recorded, factors, among them, the demographic with a lethality rate of 2.8%. In South characteristics, as well as the infrastructure America, there were 1.1 million deaths conditions and access to healthcare services. 185COVID-19 ABRAMED PANEL

More than 567,000 Brazilians lost their lives in a year and a half of the pandemic. GRAPH COVID-19 REGISTERED DEATHS BY SELECTED CONTINENTS (2020/2021 – IN MILLIONS) 69 Source: Covid-19 Data Repository by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. 22 January 2020 to 20 September 2021. Prepared by Abramed. 1,4 1,2 1,2 1,1 1,0 1,0 0,8 1,0 0,6 0,4 0,2 0,2 0 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL 2020 2021 North America Asia Europe South America Africa United States, Brazil and India, stand out for the number of covid-19 deaths. Together, they account for over a third of the global deaths, 36.4%. Among the three countries, Brazil had the highest lethality rate, 2.8% compared to 1.3% in India and 1.7% in the United States. 186 ABRAMED PANEL COVID-19

GRAPH COVID-19 REGISTERED DEATHS BY COUNTRY WITH THE HIGHEST CUMULATIVE NUMBER – TOP 20 (2020/2021) 70 Source: Covid-19 Data Repository by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. 22 January 2020 to 20 September 2021. Prepared by Abramed. United States 100.000 200.000 300.000 400.000 500.000 600.000 700.000 Brazil india Mexico Peru Russia Indonesia United Kingdom Italy Colombia Iran France Argentina Germany South Africa Spain Poland Turkey Ucraine Chile 0 Another approach on covid-19 is related to time, for each infected person the virus was the virus transmission rate, or reproduction transmitted to almost three people. After rate, which represents the average number the adoption of social isolation measures, of new infections caused by a single infected the rate was kept at a level between 1.0 and individual. If the rate is greater than 1, the 1.5. infection tends to spread in the population more rapidly. If it is less than 1, the number In Brazil, the first case of the new coronavirus of cases occurring in the population will was reported in late February 2020. Since gradually decrease to zero. In the first then, more than 20.3 million Brazilians have months of the pandemic, the highest been contaminated by covid-19 and more transmission rates were observed, including than 567,000 have lost their lives in a year in Brazil, which reached a rate of 2.7. At that and a half of pandemic. 187COVID-19 ABRAMED PANEL

GRAPH COVID-19 TRANSMISSION RATE BY COUNTRY WITH THE HIGHEST CUMULATIVE NUMBER OF CASES (2020/2021) 71 Source: Covid-19 Data Repository by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. 22 January 2020 to 20 September 2021. Prepared by Abramed. 4 3,5 3 2,5 2 1,5 1 0,5 0 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL 2020 2021 United States United Kingdom Brazil Russia India World GRAPH COVID-19 REGISTERED CASES AND DEATHS IN BRAZIL (2020/2021) 72 Source: Covid-19 Data Repository by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. 22 January 2020 to 20 September 2021. Prepared by Abramed. 2.500.000 90.000 2.000.000 80.000 70.000 60.000 1.500.000 50.000 1.000.000 40.000 30.000 20.000 500.000 10.000 0 0 -10.000 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP 2020 2021 Confirmed cases Registered Deaths 188 ABRAMED PANEL COVID-19

The world population totals almost 7.8 billion The mortality of covid-19 is associated, people, and Brazil, with 213 million, represents among other factors, with demographic only 2.7% of the population. Although the profile, comorbidities, hospital structure participation over the total population is small, and availability of both medical supplies the number of cases corresponds to 9.3% and and healthcare professionals, and diagnostic deaths 12.1%, at the end of September 2021. In confirmation capacity through laboratory tests other words, for every 100 covid-19 deaths in andimaginginthepropertimeforthetreatment the world, 12.1 occurred in Brazil. of the disease. Covid-19 wasmostlethal in Rio de Janeiro (5.1%), São Paulo (3.4%) and Furthermore, in Brazil, the accumulated records Amazonas (3.2%). In the first two states, there until the end of the first half of August show is a wide offer of healthcare services and a that the ten states with the highest number more elderly population. The third state has a of cases total 15.4 million and are responsible younger population and precarious healthcare for 72.7% of the total and 76.7% of deaths in infrastructure. Vulnerable populations that the country. Considering the number of cases have poor healthcare infrastructure have a per 100,000 inhabitants, the states of Roraima higher chance of death, and are generally (19,319), Santa Catarina (15,939), and the also more affected by risk factors, such as Federal District (15,749) stand out. Regarding hypertension and diabetes.43 mortality per 100,000 inhabitants, the highest proportions are observed in Mato Grosso (378), Rio de Janeiro (372), and Rondônia (359). GRAPH POPULATION RATIO, CASES AND DEATHS BY COVID-19 IN BRAZIL RELATIVE TO THE WORLD (AS OF AUGUST 2021) 73 Source: Covid-19 Data Repository by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. 22 January 2020 to 20 September 2021. Prepared by Abramed. 7,8 billions 206,2 millions 4,4 millions 2,7% 9,3% 12,1% 213,0 millions 20,3 millions 567,8 millions Population Cases Deaths World Brazil 43 Covid-19 fatality rates related to social inequaity in Northeast Brazil: a neighbourhood-level analysis. 189COVID-19 ABRAMED PANEL

TABLE NUMBER OF REPORTED CASES AND DEATHS DUE TO COVID-19 BY FE- DERAL STATE (AS OF AUGUST 16TH, 2021) 38 Sources: State Health Secretariats. Brazil, 2021. Extracted on September 21st, 2021. IBGE. Diretoria de Pesquisas - DPE - Coordenação de População e Indicadores Sociais - COPIS. Prepared by Abramed. State Cases Deaths Population Cases per Deaths per Lethality 100,000 100,000 rate inhabitants inhabitants Brazil 21.247.094 591.440 213.317.639 9.960 277 2,8% 1st São Paulo SP 4.352.832 148.295 46.649.132 9.331 318 3,4% 2nd Minas Gerais MG 2.114.292 54.095 21.411.923 9.874 253 2,6% 3rd Paraná PR 1.494.156 38.556 11.597.484 12.883 332 2,6% 4th Rio Grande do Sul RS 1.429.276 34.617 11.466.630 12.465 302 2,4% 5th Rio de Janeiro RJ 1.269.239 64.918 17.463.349 7.268 372 5,1% 6th Bahia BA 1.229.200 26.781 14.985.284 8.203 179 2,2% 7.338.473 15.939 261 1,6% 7th Santa Catarina SC 1.169.652 19.119 8th Ceará CE 923.903 24.157 9.240.580 9.998 261 2,6% 9th Goiás GO 847.159 23.212 7.206.589 11.755 322 2,7% 10th Pernambuco PE 616.128 19.639 9.674.793 6.368 203 3,2% 11th Pará PA 588.511 16.600 8.777.124 6.705 189 2,8% 12th Espírito Santo ES 577.782 12.463 4.108.508 14.063 303 2,2% 13th Mato Grosso MT 529.273 13.489 3.567.234 14.837 378 2,5% 14th Distrito Federal DF 487.325 10.311 3.094.325 15.749 333 2,1% 15th Paraíba PB 440.131 9.278 4.059.905 10.841 229 2,1% 16th Amazonas AM 426.072 13.716 4.269.995 9.978 321 3,2% 17th Mato Grosso do Sul MS 371.861 9.507 2.839.188 13.097 335 2,6% 18th Rio Grande do Norte RN 367.784 7.324 3.560.903 10.328 206 2,0% 19th Maranhão MA 354.073 10.140 7.153.262 4.950 142 2,9% 20th Piauí PI 318.566 6.988 3.289.290 9.685 212 2,2% 21th Sergipe SE 277.909 6.005 2.338.474 11.884 257 2,2% 22th Rondônia RO 265.010 6.512 1.815.278 14.599 359 2,5% 23th Alagoas AL 237.702 6.177 3.365.351 7.063 184 2,6% 24th Tocantins TO 222.522 3.747 1.607.363 13.844 233 1,7% 25th Roraima RR 126.100 1.987 652.713 19.319 304 1,6% 26th Amapá AP 122.704 1.972 877.613 13.982 225 1,6% 27th Acre AC 87.932 1.835 906.876 9.696 202 2,1% 190 ABRAMED PANEL COVID-19

GRAPH COVID-19 CASES AND DEATHS RATIO BY AGE BRACKET (2021 – IN %) 74 Source: Ministry of Health. Secretariat of Health Surveillance. Special epidemiological bulletin - Disease by the New Coronavirus - Covid-19. Epidemiological Week 31 1/8 to 7/8/2021). Prepared by Abramed. Note: 2021 until Epidemiological Week 31. 90 or older 5 10 15 20 25 80 to 89 70 to 79 60 to 69 50 to 59 40 to 49 30 to 39 20 to 29 6 to 19 1 to 5 <1 0 Cases Deaths GRAPH COVID-19 CASES AND DEATHS RATIO BY GENDER (2021) 75 Source: Ministry of Health. Secretariat of Health Surveillance. Special epidemiological bulletin - Disease by the New Coronavirus - Covid-19. Epidemiological Week 31 1/8 to 7/8/2021). Prepared by Abramed. Note: 2021 until Epidemiological Week 31. Female 10 20 30 40 50 60 Male 0 Cases Deaths One of the pandemic’s characteristics is In relation to the ratio according to gender, related to the higher incidence of deaths both in the number of cases and deaths, men in the population aged 50 and over. The have a greater share. Studies indicate that numbers indicate that 8 out of 10 deaths men produce a weaker immune response were among this age group. against covid-1944 and are therefore more likely to develop severe cases of the disease. 44 Frontiers in Public Health 191COVID-19 ABRAMED PANEL

05.3 O diagnóstico da covid-19 POPULATION TESTING WAS ONE OF THE MAIN RECOMMENDATIONS OF THE WHO’S TO CONTAIN THE ADVANCE OF THE COVID-19 PANDEMIC. Population testing was one of the WHO’s key In the same period, the number of RT- recommendations to contain the advance of PCR exams performed by Abramed the covid-19 pandemic. Viral testing, as well as members totaled 14.3 million and represents serological testing for antibodies and potential approximately 36% of the total. This result immunity, is paramount to assess the spread shows the expressive performance of this of covid-19. Only through testing is it possible group of companies in dealing with the to pinpoint symptomatic and asymptomatic coronavirus since the beginning of the persons who may transmit the virus and thus pandemic. In total, more than 23.7 million adopt preventive measures in places of public exams were performed to detect covid-19, attendance. The relaxation of social isolation which corresponds to 37.4% of the total and quarantine measures depends especially exams performed in the country. on testing and screening of potential cases. In Brazil, since the beginning of the pandemic, approximately 39.8 million tests were performed to detect covid-19. Of this total, 25.5 million RT-PCR tests and 14.3 million rapid tests, according to data from the Ministry of Health.45 45 Data updated to August 17th, 2021. 192 ABRAMED PANEL COVID-19

TABLE NUMBER OF COVID-19 TESTS PERFORMED PER STATE (2020/2021) 39 Sources: State Health Secretariats. Brazil, 2021. Extracted on September 21st, 2021. IBGE. Diretoria de Pesquisas - DPE - Coordenação de População e Indicadores Sociais - COPIS. Prepared by Abramed. States RT-PCR Rapid Test Total tests Brasil 25.512.196 14.289.320 39.801.516 4.301.448 2.925.860 7.227.308 1st São Paulo SP 3.899.124 1.303.980 5.203.104 RJ 4.222.672 527.125 4.749.797 2nd Rio de Janeiro PR 1.182.624 3.011.370 4.193.994 3rd Paraná MG 1.806.304 451.460 2.257.764 CE 1.455.080 677.550 2.132.630 4th Minas Gerais BA 982.372 615.700 1.598.072 310.276 862.200 1.172.476 5th Ceará RS 744.416 347.040 1.091.456 MA 751.680 196.660 948.340 6th Bahia SC 468.232 416.040 884.272 SE 459.648 420.615 880.263 7th Rio Grande DF 624.432 141.250 765.682 do Sul PE 396.492 364.610 761.102 MS 453.240 210.105 663.345 8th Maranhão PA 439.788 209.510 649.298 RN 376.684 226.055 602.739 9th Santa Catarina PB 239.944 341.010 580.954 10th Sergipe AM 338.292 175.205 513.497 11th Distrito Federal GO 325.388 156.545 481.933 PI 185.488 257.725 443.213 12th Pernambuco MT 359.512 74.325 433.837 ES 367.968 34.815 402.783 13th Mato Grosso TO 227.856 143.745 371.601 do Sul AP 282.896 75.360 358.256 AL 159.724 87.660 247.384 14th Pará RO 150.616 35.800 186.416 AC 15th Rio Grande RR do Norte 16th Paraíba 17th Amazonas 18th Goiás 19th Piauí 20th Mato Grosso 21th Espírito Santo 22th Tocantins 23th Amapá 24th Alagoas 25th Rondônia 26th Acre 27th Roraima 193COVID-19 ABRAMED PANEL

GRAPH NUMBER AND RATIO OF TESTS PERFORMED FOR COVID-19 (2020/2021) 76 Fontes: Ministério da Saúde – Coordenação Geral de Laboratórios de Saúde Pública - CGLAB. Extraído em 20/9/21. Painel Abramed. Elaboração Abramed. RT-PCR Total (RT-PCR, Rapid tests, Serological, etc.) 36,0 % 37,4 % 14.324.570 23.756.012 ABRAMED ABRAMED 64,0 % 62,6 % 25.512.196 39.801.516 Brazil Brazil Data from the Abramed Panel 2021 show the pandemic - and December 2020, these that between January and September of same companies have accounted for 5.6 this year, 8.7 million RT-PCR tests were million tests. Comparing the number of performed by associated companies, a tests performed in 2020 and 2021, there was highly complex molecular test considered a progressive growth in the number of RT- by the World Health Organization (WHO) PCR tests, in line with the evolution in the the gold standard for diagnosis of the number of confirmed cases of the disease. disease. Between March - beginning of GRAPH NUMBER OF TESTS PERFORMED (ABRAMED) AND CONFIRMED COVID-19 CASES (2020/2021) IN THOUSANDS 77 Sources: Abramed Panel. Covid-19 Data Repository by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. Extracted in September 20th, 2021. Prepared by Abramed. 3 2,2 2,0 2 1,7 1,3 1,2 1,5 1,9 1,9 1,3 1 0,9 0,9 0,8 1,2 1,3 1,4 0,9 1,2 0,1 0,4 0,7 0,7 0,6 0,7 0,8 1,0 0,9 0,9 0,8 0,2 0,7 0,8 0,8 0,5 0,1 0 0 0,3 0,5 0 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP 2020 2021 Confirmed cases covid-19 RT-PCR Abramed 194 ABRAMED PANEL COVID-19

GRAPH EVOLUTION IN THE NUMBER OF COVID-19 SCREENING TESTS (ANS – 2020/2021) 78 Source: Covid-19 ANS Bulletin August/21. Adapted by Abramed. Note: According to ANS, the numbers may change as the deadlines of the subsequent competencies close, especially, numbers of the last competency presented. 1.000.000 MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY 900.000 2020 2021 800.000 700.000 600.000 500.000 400.000 300.000 200.000 100.000 -- RT-PCR Antibody screening GRAPH SHARE (%) OF RESULTS OF COVID-19 SCREENING TESTS, ACCORDING TO GAL,PER DAY, MARCH 2020 TO AUGUST 2021, BRAZIL 79 Source: Laboratory Environment Manager (GAL) 2021. 100% 2021 90% 80% Negative/Undetectable Positive/Detectable 70% 60% 195COVID-19 ABRAMED PANEL 50% 40% 30% 20% 10% 0% 2020

Within the supplementary healthcare system, After a decrease in January and February 2021, the test for covid-19 screening - test by RT - the number of RT-PCR examinations reached PCR” (with guidelines for use) - was included the highest level in March 2021. in the Health Procedures and Events Roll with mandatory coverage as of March 2020. The se- Chest imaging tests and CT scans have been rological exams performed with the antibody essential in the detection of covid-19 and are testing were incorporated into the Roll in June indispensable in the follow-up and definition and July of the same year and permanently as of medical treatment. For this reason, there has of August 2020. Since then, 7.9 million exams been a systematic increase in the number of CT were performed between March 2020 and May scans, widely used in the diagnosis of covid-19. 2021, according to data from the Covid-19 ANS Bulletin. GRAPH MONTHLY VARIANCE IN THE NUMBER OF CHEST X-RAYS AND CT SCANS (MONTHLY VARIANCE RELATIVE TO MARCH/2020 - IN %) 80 Sources: Technical Note No. 26/2021/DIDES-DIFIS-DIOPE-DIPRO/ANS. Novo Caged - SEPRT/ME. Prepared by Abramed. 350 300 250 200 150 100 50 0 -50 -100 MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR 2020 2021 Chest X-ray Chest CT scan 196 ABRAMED PANEL COVID-19

RT-PCR (reverse transcription polymerase chain reaction) CONSIDERED THE GOLD STANDARD TEST BY THE WHO DUE TO ITS HIGH SENSITIVITY AND SPECIFICITY, IT IS IDEAL FOR THE CONTAINMENT OF THE SPREAD OF THE PATHOGEN BECAUSE IT ALLOWS INFECTED INDIVIDUALS TO BE IDENTIFIED AND REMAIN IN ISOLATION, BESIDES GUARANTEEING THAT PEOPLE WHO HAVE BEEN IN DIRECT CONTACT WITH THIS PATIENT ARE ALSO TESTED AND, IF POSITIVE, THEN ISOLATED. RT-PCR is the ideal test to detect the infection Chest imaging by the new coronavirus in the first days after examinations the onset of symptoms. It is a molecular and CT scans biology method that amplifies and identifies were essential in the genetic material of the virus. The collection defining medical is done through a nasal secretion or sputum treatment in the sample. The result can be positive within the most severe cases first few days after the onset of symptoms, of the disease. but tends to become negative as the infection progresses, usually more than seven days. 197COVID-19 ABRAMED PANEL The efficacy of the results depends on the time of collection in relation to the onset of disease symptoms. According to studies, the specificity of most RT-PCR tests is 100% because the primer design is specific for the covid-19 genome sequence. Eventually, false positives may occur due to technical failures and reagent contamination.

Serology (neutralizing antibodies, IgA, IgG , IgM and total antibodies) SEROLOGICAL TESTS DETECT ANTIBODIES IN THE BLOOD, SUBSTANCES PRODUCED BY OUR IMMUNE SYSTEM TO NEUTRALISE THE VIRUS. There are different serological test with equipment that allows scalability and methodologies. Rapid tests, which are quality assurance. It is necessary to respect performed by digital puncture, that is, through the immunological window (time that a small hole in the fingertip of the patient, the organism takes to produce detectable are qualitative and there is great variability in antibodies) performing these tests at least sensitivity. The serological tests performed in a eight days after the symptoms onset (published laboratory are done in venous samples collected studies show that the sensibility of these exams in an appropriate environment and processed increases after the third week of the infection). in several methodologies, such as ELISA and chemiluminescence, among others. These exams, differently from rapid tests, are quantitative, that is, capable of indicating the quantity of each antibody present in that sample and it is performed by trained professionals, in laboratory environments 198 ABRAMED PANEL COVID-19

Proteomics THIS METHOD ANALYSES PROTEINS FROM THE NEW CORONAVIRUS (SARS-COV-2) DIRECTLY FROM CLINICAL SPECIMENS FROM THE RESPIRATORY TRACT. As well as the molecular test, besides being a Viral testing, highly reliable method and being an alternative as well as for the lack of inputs of the RT-PCR serological tests examination. The samples must be collected up for antibodies to the seventh day of the symptoms onset for and potential virus detection in the acute phase. As it is fully immunity, are automated, it is pointed out as an alternative paramount to RT-PCR and observed as an opportunity for assessing for mass testing and for the control of the the spread of spreading of cases. Covid-19 Considering that the protein is more stable 199COVID-19 ABRAMED PANEL than the virus RNA, the method offers better stability allowing samples to be transported at room temperature, an excellent feature for a continental country like Brazil, where samples often travel thousands of kilometers between collection and processing. The results are ready in an average of three working days.

Next RT-LAMP Generation (reverse Sequencing transcription (NGS) loop-mediated isothermal BRAZIL HAS DEVELOPED THE WORLD’S amplification) FIRST GENETIC TEST FOR LARGE-SCALE DETECTION OF THE NEW CORONAVIRUS MOLECULAR EXAMINATION BY THE USING THE NEXT GENERATION GENETIC RT-LAMP METHODOLOGY (REVERSE SEQUENCING TECHNIQUE (NGS). TRANSCRIPTION LOOP-MEDIATED ISOTHERMAL AMPLIFICATION), AS With 100% specificity, the test has no cases WELL AS THE RT-PCR, ALLOWS THE of false positives and offers 90% sensitivity, DETECTION OF THE GENETIC MATERIAL which also drastically reduces the chance of OF THE NEW CORONAVIRUS, BUT IN false negatives. The test is processed by samples SALIVA SAMPLES FROM PATIENTS THAT collected with swabs in contact with the nasal MUST BE COLLECTED IN THE FIRST region or with the saliva of the patients in the DAYS OF THE ONSET OF SYMPTOMS. first days of the symptom’sonset. The test has the same sensitivity as the The test is considered a viable alternative RT-PCR (low chance of false negatives) for mass diagnosis because it allows a higher and emerges as a reinforcement for the processing volume than RT-PCR and thus Brazilian society to increase its testing can contribute to halt the spread of infection. capacity, mainly because it uses reagents Test results are available in an average of three and equipment that are not scarce and working days. generates results within one hour. 200 ABRAMED PANEL COVID-19