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Salud colectiva

versión impresa ISSN 1669-2381versión On-line ISSN 1851-8265

Salud colect. vol.16  Lanús  2020 


The use of “virado” as a harm reduction strategy among crack users in the State of Pernambuco, Brazil

Renata Barreto Fernandes de Almeida

Naíde Teodósio Valois Santos

Ana Maria de Brito

Keila Silene de Brito e Silva

Iracema de Jesus Almeida Alves Jacques

Solange Aparecida Nappo

1Corresponding author. Psychologist. PhD in Preventive Medicine. Full professor, Centro Universitário do Vale do Ipojuca, Recife, Pernambuco, Brazil.

2Public health physician. PhD in Public Health. Researcher, Instituto Aggeu Magalhães, Fundação Oswaldo Cruz, Recife, Pernambuco, Brazil.

3Physician. PhD in Public Health. Researcher, Instituto Aggeu Magalhães, Fundação Oswaldo Cruz, Recife, Pernambuco, Brazil.

4Phonoaudiologist. PhD in Public Health. Professor, Centro Acadêmico de Vitória, Universidade Federal de Pernambuco, Pernambuco, Brazil.

5Nurse. Doctoral student in Public Health, Instituto Aggeu Magalhães, Fundação Oswaldo Cruz, Recife, Pernambuco, Brazil.

6 Pharmacist. PhD in Psychobiology. Profesora Adjunta, Universidade Federal de São Paulo, São Paulo, Brazil.


The aim of the study is to discuss the use of crack in the form of “virado” as a harm reduction strategy in Pernambuco, Brazil. This is a cross-sectional study with a qualitative approach in which semi-structured interviews were conducted regarding aspects related to the culture of crack use with 39 crack users between March and August 2016. Participants were recruited using saturation criteria and data were analyzed through content analysis. Respondents discussed the use of “virado” and compared its effects in relation to crack, addressing improvement in interpersonal relationships, libido, and non-compulsive drug use, which can all be understood as harm reduction strategies. On the other hand, equipment sharing for the use of “virado” was identified as a high-risk practice with regards to the transmission of infectious diseases. Knowing about the culture of crack use in different contexts is essential in order to plan and develop health care actions.

KEY WORDS: Crack Cocaine; Drug Users; Harm Reduction; Brazil


Crack cocaine consumption emerged in Brazil at the end of the 1980s and became a rapidly growing phenomenon,1 mainly among the socially vulnerable. Bastos and Bertoni2) corroborate this profile and state that the majority of users of crack cocaine and/or similar substances are young black men who are poorly educated, live on the streets and do not have a permanent job nor a regular income.

In the field of health, it is also possible to find problems associated with drug consumption, especially crack, like a higher exposure to HIV infection and to other sexually transmitted diseases (STD), traffic accidents, overdoses, cardiorespiratory diseases, and violence-related problems.3,4 Thus, crack cocaine has a high potential for causing damages, including harm caused by the substance itself, which makes crack addiction be a complex problem in Brazil.5

According to Bastos and Bertoni,2 crack users, when compared to intranasal cocaine users, seem to have a more severe consumption pattern, higher involvement in illicit activities, higher risk of presenting adverse effects resulting from cocaine use, higher involvement in prostitution, and higher chances of living or having lived on the streets.

In this scenario, abusive use of drugs, especially crack, was included in the public policy agenda in Brazil, and it was considered that people experiencing health problems deriving from drug abuse or dependence on psychoactive substances need effective treatment. According to Petuco,6 for many years, the way in which problems deriving from drug consumption were tackled “oscillated between a medical question and a strictly social problem; on the other hand, the extreme rigor applied to illicit drugs was not applied to alcohol consumption.”

Furthermore, the author argues that, nowadays, the professionals who work in the area recognize the complexity of the risks associated with drug use. However great the conceptual differences between researchers and theorists, there is a consensus in relation to the need for comprehensive care, which must always include families and social networks. Another important matter addressed by the author is the need of joint actions, as this problem cannot be easily solved with unilateral interventions. The strategies must involve health, safety, sports, culture, education, social work and other areas.

In the historical context related to actions of care for drug users, up to the end of the 1980s, prohibitionist strategies aligned with the war on drugs conception did not open space for reflection nor for the understanding of drug consumption as a multi-determined phenomenon that needed an interdisciplinary intervention.7

It was from the understanding of the concept of vulnerability, with the emergence of AIDS, where the chance the subject has in the illness process results from a set of aspects that are not solely individual, but also collective and contextual,8 that the Harm Reduction (HR) strategies were devised. Subsequently, they were extended from AIDS prevention, with the syringe exchange programs, to the conception of reduction in social damages and health damages. To Machado and Boarini,7 it was at this moment that it was realized that harm reduction actions should be planned according to the sociocultural context to which they would be applied.

It is important to highlight that HR strategies are characterized as low demand measures, in opposition to high demand prohibitionist strategies, as they do not establish, as an initial goal for care, or for treatment, abstinence from drug use. HR also establishes that healthcare should go, preferably, to the place where the person is, and not the contrary.9

HR allows the person who is addicted to drugs to participate in his or her care process, which characterizes it as a bottom-up measure that is jointly constructed in defense of drug users.9,10

In light of what was discussed so far, this article aims to discuss the consumption of virado as a HR strategy by crack users, a practice identified in previous studies carried out in the State of Pernambuco, Brazil. Virado is obtained through the transformation of the crack cocaine rock into a powder that can be inhaled, through the addition of boric acid. By heating the mixture composed of the previously ground crack cocaine rock and boric acid, the user obtains cocaine borate, a white powder that is aspirated and absorbed by the nasal mucosa.11

This discussion is based on data from an exploratory and qualitative research that investigates aspects related to the culture of crack use in the State of Pernambuco. The study is integrated into the research project entitled “Vulnerability of crack cocaine users to HIV and other communicable diseases: A socio-behavioral and prevalence study in the state of Pernambuco,” developed by the Aggeu Magalhães Institute, Oswaldo Cruz Foundation - Pernambuco.

In a previous study originated from this research, users mentioned, as important aspects of treatment, voluntariness, inclusion of spirituality, diversity in the offer of activities, a space protected from the drug, and professional qualification with socio-productive inclusion.12

Another published study that used data from the above-mentioned research showed that the abusive use of crack cocaine, which is strongly related to social exclusion, results in marginality situations associated with the culture of use and promotes conflicting, violent and unhealthy environments. The feeling of loss of identity that derives from the drug-related stigma was also present in the interviewees’ discourse.13 In addition, another study was published on the history of violence among women who use crack.14


In view of the need to understand the social dynamics related to the culture of crack use,15 we decided to employ a qualitative approach, which enables to describe and analyze cultures and behaviors from the standpoint of the investigated subjects,16 identifying values, beliefs, opinions and behaviors.17,18

To develop the study, semi-structured interviews were conducted, from March to August 2016, with 39 people (men, women and transvestites) older than 18 years, who used crack cocaine regularly (for at least 25 days in the six previous months) and were assisted in the four regional centers of the Atitude (Attitude) Program, Comprehensive Care Program for Drug Users and their Families of the Executive Drug Policy Department of the State of Pernambuco, Northeastern Brazil. The centers are located in the cities of Recife, Jaboatão dos Guararapes, Cabo de Santo Agostinho and Caruaru.

The Atitude Program is part of the state’s welfare policy and aims to respond to the social vulnerability situation of drug users and their families. Today, it is reference in the care provided for users of crack cocaine and other drugs in Pernambuco.19) It prioritizes individuals who are in a situation of exposure to violence, who need to get away from their communities, and whose family bonds are weakened or broken.

As the authors of this study did not have bonds with the Atitude Program, the recruitment of the individuals was supported by the Program’s team of professionals. They played the role of gatekeepers, that is, bearing the inclusion criteria in mind, they indicated people with a narrative potential about the theme who, on the day of the interviews, were not under the effect of crack or other drugs. After the identification of possible participants, they were invited to participate in the study. The objectives were explained to them and they were requested to sign a consent document. The interviewees’ names were replaced by names of precious stones in order to preserve secrecy and to guarantee data confidentiality.

Semi-structured interviews were conducted by means of a script based on the literature about the culture of crack use and approached different themes. In this article, we will present the results referring to the discussion of the use of virado as an HR strategy by crack users.

All the interviews were conducted by the main author and the transcriptions were performed by one single trained professional, which reduced variations in the form of conduction and transcription, and possible biases in the analysis process. Still concerning the procedure of validation of the interviews, the transcribed material was fully compared with the original audio version. In the preparation of the material for subsequent analysis, the software NVivo version 10.0 was used. Today, it is the most used tool for qualitative data analysis in the articles indexed in the PubMed database.

The content analysis technique was applied to the analysis of the interviews, and the theoretical framework was based on Bardin’s definitions.20 To the author, the procedure is a set of techniques that permeates qualitative analysis and consists of making explicit and systematizing the content of messages in order to enable logical and justified deductions. To achieve this, the three stages recommended by the method were performed: pre-analysis, exploration of the material, and treatment of the results.

Initially, the interviews were fully read so that we could have a deep understanding of the experience lived by each participant, enabling us to identify thematic axes. Then, the first meanings were attributed to the crude analyzed results. The process was performed through categorization, which enabled us to classify the signification elements. The technique consists in qualifying different elements according to criteria that give meaning to them.20 The categories represent the discovery of patterns and themes in the collected data. Each category is the main meaning found in the material explored by the analysis of its content.18

Therefore, in the results, the so-called “thematic axes” and their respective analysis categories are presented. In the present article, the analyzed thematic axis was the use of virado and HR, and the following categories were identified: escape from social stigma; controlled use of virado to achieve greater sociability; increased libido; and risk of transmission of infectious diseases.

The project was approved in the research ethics committees of the Aggeu Magalhães Institute, Oswaldo Cruz Foundation - Pernambuco (CAE 25250413.6.0000.5190) and of the Federal University of São Paulo (CAAE 33243514.3.0000.5505).


Among the identified forms of crack consumption, virado was one of the important findings of this study and also of research developed in the State of Pernambuco. It has become a great differential in Pernambuco’s culture of crack use.11,21,22

Crack use in the form of virado has been frequently referred by Pernambuco’s crack users, which was shown by the research report of an epidemiological study developed with 1,062 users, in which 54.3% reported they had already consumed crack in this way.22 These data corroborate the findings of Nappo and collaborators,11 who showed there has been a significant increase in this form of use in Pernambuco since its identification. It is important to mention that these studies have also shown that the consumption of virado is characteristic of this State. It has not been registered in any other place in Brazil nor in any other country until now.

Escape from social stigma

During the interviews, we could understand the context of the form of use and, above all, identify possible differences between crack and virado. When do people decide to consume crack or virado? Is virado really a strategy of protection against the risks brought by compulsive use, characteristic of crack consumption? In the fragments below, it is possible to distinguish some aspects of crack and of virado to understand not only the context of use, but also the specificities of each form of using this substance.

It doesn’t have the taste that you feel when you smoke the stone, and when you snort the stone you don’t feel the taste, you feel a burning sensation in your nose. It won’t fill you up, you don’t have that feeling of being full that you do when you smoke a stone. It’ll keep you awake and full of energy, but you won’t get paranoid as we usually get... The sensation of snorting virado is that you feel energetic, powerful, courageous... With crack, you feel scared, cornered. You don’t leave the corner where you are. You don’t want anybody looking at you. You feel ashamed because you are a drug addict. When people pass, they look at you and see that you are paranoid. You can’t control yourself. These are the differences. (Lodolite, transvestite, 20 years old)

In this narrative, Lodolite explains the difference between crack and virado based on the stigma that is attached to people who use crack. Stigma is a physical or social mark with a negative connotation that makes its bearer be marginalized or excluded from some social situations. Thus, the stigma can be considered a social construction of a mark that confers an undervalued status on the person when compared to the other members of society. This process happens when individuals are identified through some undesirable characteristic they have and, from that moment onwards, are discriminated and undervalued by society. This type of stigma is called social or public stigma.23

According to the same authors,23 people who use drugs, especially crack, suffer daily with the consequences of this stigmatization process revealed in society. Some of these consequences are: loss of self-esteem, restricted social interactions, lower perception of problems that need care, and limited perspectives for recovery. These aspects influence treatment in a negative way.

Almeida24 corroborates these findings, emphasizing that prejudiced and moralistic postures create a representation of drug users as criminals, dangerous people of bad character, stigmatizing them and driving them away from the health services or from any person who can offer some type of care. This stigma also increases the difficulty to approach the theme and favors the approximation between people who establish a harmful relationship with drugs. Thus, a vicious circle is constructed.

In addition, misleading information printed by the media, as well as lack of knowledge about the disorder, make people who use drugs be feared and evaluated as incapable of recovering. Thus, they experience a process of suffering because of the distrust brought by negative stereotypes, prejudices and discrimination. According to Petuco,25 on the pages of big newspapers, or even on television and in prevention campaigns, the “crack user” is pictured as an inhuman and irrational monster.

Noia, like noiado, is a term created in Brazilian Portuguese to refer to people who are under the effect of psychoactive substances, frequently employed to refer to crack users. Noia is short for paranoia and noiado derives from paranoia, that is, a person who suffers from paranoia. The noia is seen as a person who disrespects social norms and ethical parameters just to obtain the crack stone; thus, he or she is seen with distrust and is not able to establish relationships in a different way with people.26 In this sense, Merhy27 states that

Today, there is an enormous effort on the part of conservative sectors to conduct the construction of a social mental imagery that portrays drug users as zombies, not as humans. They are victimized by the capture-dependence that chemical illicit substances cause, in such a way that they have ceased to be desiring subjects and have become merely inert and irresponsible objects as far as their own acts are concerned.

Many people who use crack do not accept this stigmatizing place of being seen as a zombie or even as a non-human. Being in this position means having failed, having denied their human condition, and the protection strategy of continuing to use crack in the form of virado emerges as a possibility of care - in this moment, care as an HR strategy constructed from the experience of these people who use other forms of consumption of the same substance.

Controlled use of virado to achieve greater sociability

In this category, it can be noticed that the use of virado emerges as an HR strategy to avoid the compulsive use of crack. Studies have shown that, due to the psychopharmacological specificities of crack, the predominant pattern of use is of the binge type, that is, the compulsive user utilizes large quantities of the substance in a short period of time. Crack users promote many binge episodes, as they tend to use crack for hours or even intermittent days. They can alternate it with days without using the drug, and this, sometimes, can last months, but always with episodes of intense use.28,29 Among the identified patterns of use, compulsive consumption was the most frequently reported, characterizing a daily use of crack that can extend over the day, being interrupted only when the user achieves physical, psychological or financial exhaustion.30

Virado turns you on. You can’t sleep. You snort it, you drink beer, and the sun rises. Once I spent three days and three nights snorting virado. I think that virado harms less, I think it’s less. The paranoia is weaker than when you smoke. Virado turns you on, you talk to people. With crack, it’s not like this. You smoke it and you don’t want to talk to anyone, you go silent, you get scared. Virado doesn’t do this, it turns you on, you snort it, you talk, you play, but crack doesn’t have this effect. (Garnet, man, 27 years old)

You don’t use virado every day, you don’t go out to steal things, you use it on weekends. If the folks go out, go to a brega, to a pagode [popular parties], I take the powder and I snort it there, you snort it and on the next day you’re fine. You don’t want to use it anymore. You use it today, tomorrow you don’t want to use it anymore. With crack, it is different: as long as you have money to buy it, you don’t sleep for a couple of days or more. (Emerald, man, 21 years old)

The narratives above show that the use of virado occurs in settings of parties and fun. When the interviewees compare it with crack, they say that virado “turns the person on”; he or she becomes “energetic” and does not feel the paranoia caused by crack. The use of virado is more sociable; users do not search for isolation due to the drug’s negative effects, like in the use of crack. Consumption is well contextualized. The compulsion caused by crack is not identified in the use of virado.

The compulsive relation of crack users has been well identified by Nappo1 and Oliveira,31 when they state that this consumption pattern installs itself right after experimentation. In the research carried out by Oliveira,31 many interviewees disregarded basic needs like eating, sleeping and hygiene due to the use of the drug. They also reported that their quality of life worsened when they prioritized crack consumption to the detriment of all their other activities.

Leite, Oliveira and Cruz30 also identified the pattern of compulsive use among their interviewees: they describe crack use in a frequent and intense way, limiting their daily routine to focus exclusively on the use of the drug. To these researchers, describing this experience is like describing compulsion and lack of control in relation to crack, where freedom of choice is replaced by the increasing consumption of the drug, even though the body signals that it has become unbearable.

The narratives show that the interviewees know about this possibility of compulsive use with crack and decide to use virado to be able to maintain a sociable and pleasant life, which strengthens the possibility of using virado as an HR strategy.

The difference is that the inhaled smoke hits you immediately. Its impact is that it paralyzes you immediately, you get paralyzed, the high lasts five seconds, after those five seconds you get just a little scared and a little nervous. Virado, in turn, takes a while to hit you, it takes more time for it to dilute inside our body, to reach our mind, to reach that little cell, to hit... (Agate, man, 34 years old)

In this narrative, the interviewee distinguishes the sensation caused by crack from the sensation caused by virado. The described distinction occurs through the form of intake of the same active principle of cocaine. The effect of smoked drugs is characterized by a rapid onset and a short duration. In case of inhaled drugs, the onset of the effect takes longer to happen and its duration in the organism is longer. According to Nappo,1 when drugs are smoked, the absorption of the gas occurs in the lung, an organ that has a large absorption area. It rapidly reaches the central nervous system due to the shorter way promoted by this path. When the drug is inhaled, like virado, the absorption occurs in the nasal mucosa. This process is slower and it takes longer to reach the central nervous system. In this pathway, the drug suffers the action of enzymes that destroy it and only a small part of what was inhaled reaches the brain.

Crack is a drug that, when smoked, produces a state of great euphoria; however, the sensation has a short duration, followed by an almost uncontrollable desire to use the substance one more time, characterizing craving. People who make an abusive use of crack commonly have difficulty in controlling its use - they usually spend nights and days consuming the drug without interruption.28

However, it is also common to see people who use drugs like crack employing strategies to mitigate the effects and to reduce the harm caused by their use. The adopted strategies are actions like drinking liquids, eating before using the drug, sleeping, intercalating or associating crack with drugs they consider to be softer, like marijuana, nicotine and alcohol.29

In the context of our study, the use of virado probably has the same connotation, as users believe that it is a softer drug whose effect has a longer duration and makes users more sociable. They also believe that the consumption of this drug is not attached to social stigmas.

Increased libido

In this category, it was possible to analyze differences in one of the interviewees’ sexual behavior when she is under the effects of crack and of virado. Sexual behavior can be understood as a set of characteristics related to the type of partnership, number of sexual partners, relationship established with the partner, among others.32 In the user’s discourse, it is possible to perceive that, under the effect of crack, the type of partnership was exclusively commercial and the relationships established with her partners had a specific interest - obtaining the drug. She did not necessarily feel sexual pleasure. Lack of libido can lead to alienation from care with the body,33 which results in the performance of unsafe sexual practices.

The difference between powder and crack, to me, is that with the powder you can drink, you can make love, you can have relationships, you become energetic. With crack, it’s not like this. Crack puts an end to sexual desire and causes sexual impotence. You don’t have sex with pleasure. If you have sex, you do it for money, to consume the drug, as I’ve done many times, but there’s no pleasure involved. (Gold, woman, 32 years old)

The report made by the participant Gold draws our attention to the form of crack use, by means of virado, as a strategy to increase the libido and the interaction with her partners in sexual relations, considering the fact that virado causes an effect of euphoria that is the opposite of the paranoia caused by crack. This form of use could contribute to sexual behaviors with lower transmission risks of HIV and other sexually transmitted infections (STI). According to the literature, unprotected sexual practices are directly related to the type of relationship established with the partner, the type of partnership, and the pattern of compulsive drug use.34,35

Risk of transmission of infectious diseases

Another important aspect for reflection in this study is the question of nosebleeds, very frequent in the use of virado, which points to a higher risk of transmission of infectious diseases like HIV and hepatitis C, when objects used to consume the drug are shared. Usually, the straw used to consume virado is shared. This practice puts users at risk.

This category counterbalances the HR strategies established by people who use crack, as, in this moment, the consumption of virado puts these people in a situation of higher risk. Therefore, they need specific instructions to consume crack in this way. This prevention action is fundamental, as we did not identify, in the interviewees’ discourse, knowledge about risk of infection by HIV or other diseases, nor any reference to some form of protection concerning the sharing of straws.

The difference is that, in some people, it can cause nosebleed because the person is not used to it; in my case, the first time I snorted virado, I snorted it and other people snorted it too, so, when I snorted it for the first time, it made my nose bleed. (Agate, man, 34 years old)

People who use cocaine have always shared straws or other devices. According to Niel and Silveira,36 when the person uses powdered cocaine, he or she places the drug on a flat surface, divides it into small rows and aspirates it through an object similar to a straw, made with banknotes, paper sheets or plastic straws. Although it is less common, it is also possible to place the powder directly on the region of the hand located between the index finger and the thumb and take the hand directly to the nose for aspiration.

According to the authors, this practice brought risk of infections, including HIV infection, due to the sharing of the material by the people who were using the drug. Thus, instead of banknotes or of any other type of paper, the person was instructed to prefer the plastic straws that were distributed in harm reduction kits. At that moment, they were instructed not to share the straws because as this substance is a powerful vasoconstrictor, it could cause nosebleeds and facilitate the transmission of diseases.

In the case of virado, these instructions are rarely given to users because the greatest concern is the use of smoked crack. The great majority of HR strategies developed for crack users are related to consumption using cans of beverages and to the use of condoms.

The forms of consumption discovered by drug users are strategies constructed from the social exchanges that occur at the moment of use. These possibilities of consumption do not emerge in isolation, nor independently of the effects of the used substance; they are collective constructions that result from the social dynamics established in the group, which can produce less harmful forms of use.37


This study aimed to analyze the use of virado as a Harm Reduction strategy by crack users assisted by the Atitude Program in the State of Pernambuco, so that new interventions can be devised from the experiences of the interviewees in our region. We do not intend to suggest that these experiences can be generalized; however, we believe that their singularity can relate to other people involved in the same problem. Thus, we believe that, although these users’ experiences are singular, they can produce resonances to professionals who work in this area. This is a challenge to be faced by all the individuals who work with drug users, mainly crack users: guaranteeing that their demands will be adequately met.

In view of the issues brought by this study, it was possible to recognize that knowledge about the culture of drug use in different contexts is fundamental to plan and develop healthcare actions, including prevention actions.

The study pointed to the need of understanding not only the forms of crack consumption and their Harm Reduction strategies, but also the meanings that these strategies have for each crack user.

We found that the use of crack in the form of virado was mentioned by some participants as a strategy of protection against the social stigma that is commonly directed at people who use crack compulsively. In addition, it is a strategy to control the compulsion, to maintain the libido, and to enable social interaction.

On the other hand, this form of crack consumption represents a higher risk of transmission of infectious diseases like HIV and hepatitis C due to the practice of sharing devices to consume crack in the form of virado. The interviewees did not have knowledge about this form of infection, which reaffirms that the professionals need to focus on the culture of crack use in its various forms of consumption and in different contexts.


The research entitled “Vulnerabilidade de usuários de crack ao HIV e outras doenças transmissíveis: estudo sociocomportamental e de prevalência no estado de Pernambuco” was funded by the Secretaria de Vigilância em Saúde, Ministério da Saúde by means of Notice 20/2013.

We would like to thank all the institutional partnerships: Programa Atitude of the Secretaria Executiva de Políticas Sobre Drogas, Secretaria de Desenvolvimento Social, Criança e Juventude del Gobierno de Pernambuco [Executive Drug Policy Department, Department of Social Development, Child and Youth of the Government of Pernambuco]; State Health Programs of Pernambuco: Programa Estadual de DST/Aids and Programa de Controle da Tuberculose [STD/Aids and Tuberculosis Control]; Laboratório Central de Saúde Pública, Secretaria Estadual de Saúde de Pernambuco; Secretaria Municipal de Saúde, Cabo de Santo Agostinho [Central Public Health Laboratory of the Health Department of the State of Pernambuco; Municipal Health Department of Cabo de Santo Agostinho]; Secretaria de Saúde de Caruaru [Health Department of Caruaru]; Secretaria Executiva de Promoção da Saúde, Secretaria Municipal de Desenvolvimento e Mobilização Social de Jaboatão dos Guararapes [Executive Department for Health Promotion of the Municipal Department of Development and Social Mobilization of Jaboatão dos Guararapes]; Secretaria de Saúde do Recife [Health Department of Recife]; Centro Brasileiro de Informações sobre Drogas Psicotrópicas- Universidade Federal de São Paulo (CEBRID-UNIFESP) [Brazilian Center of Information on Psychotropic Drugs (CEBRID-UNIFESP)].


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Received: September 01, 2019; corrected: April 03, 2020; Accepted: April 14, 2020; pub: May 16, 2020

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