Abstract

We conducted an integrated literature review aimed at reflecting on the challenges related to primary care-based health surveillance actions in response to the COVID-19 pandemic in selected countries. The study included countries with different PHC models that adopted surveillance as an approach to control the transmission of COVID-19. We performed a search in October 2020 for relevant literature and norms and guidelines related to the organization of primary health care (PHC) in response to the pandemic on official government websites and the databases Web of Science and Science Direct. The integrated health surveillance actions demonstrated that efforts were more focused on risks, with some countries adopting innovative and effective measures to respond to COVID-19, considering emerging needs within PHC. However, in addition to ethical controversies and operational difficulties, access to technology was a challenge in actions developed by some countries due to social inequalities.

Key words:
Coronavirus infection; Public health surveillance; Primary health care; Health policy

Introduction

Since the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic on 11 March 2020, serious concerns have been raised about the effects of the coronavirus (SARS-CoV-2) on global health, society and the economy, particularly among vulnerable populations in low and middle-income countries with fragile health systems¹1 Hopman J, Allegranzi B, Mehtar S. Managing COVID-19 in Low- and Middle-IncomeCountries. JAMA 2020; 323(16):1549-1550.^,22 Lloyd-Sherlock P, Ebrahim S, Geffen L, McKee M. Bearing the brunt of covid-19: older people in low and middle income countries. BMJ 2020 Mar 13; 368:m1052..

As with previous outbreaks and pandemics, the control of the COVID-19 pandemic depends on the early detection of cases and contacts, followed by isolation measures and quarantine to interrupt community transmission and mitigate the health impacts of the coronavirus³3 Tognotti E. Lessons from the History of Quarantine, from Plague to Influenza A. Emerg Infect Dis February 2013; 19 (2): 254-259..

Globally, countries have adopted a variety of strategies to tackle and control the COVID-19 pandemic - such as community-based testing, contact tracing, isolation and other social and public health measures - which are crucial to slowing down transmission and reducing mortality⁴4 Nussbaumer-Streit B, Mayr V, Dobrescu AI, Chapman A, Persad E, Klerings I, Wagner G, Siebert U, Christof C, Zachariah C, Gartlehner G. Quarantine alone or in combination with other public health measures to control COVID-19: a rapid review. Cochrane Database Syst Rev 2020; 4(4):CD013574.. Within this context, a robust health surveillance system is essential to control spread and guide the ongoing implementation of prevention measures.

A critical element of public health systems, health surveillance includes the collection, analysis, interpretation and systematic and continuous dissemination of data that is essential to the planning and implementation of interventions⁵5 Thacker SB, Berkelman RL. Public Health Surveillance in the United States. Epidemiologic Reviews 1988; 10:164-190.. Other authors suggest that health surveillance is essential for providing information and guiding both individual diagnosis and treatment (clinical approach) and interventions targeting specific population groups addressing the social determinants of health⁶6 Paim JS. Vigilância da saúde: tendências de reorientação de modelos assistenciais para a promoção da saúde. In: Czeresnia D, Freitas CM, organizadores. Promoção da saúde: conceitos, reflexões e tendências. Rio de Janeiro: Fiocruz; 2003.^,77 Teixeira CF, Paim JS, Vilasboas AL. SUS, modelos assistenciais e vigilância da saúde. Inf Epidemiol SUS 1998; 7(2):7-28.. Health surveillance is mediated by the traditional generation of surveillance data or by the interpretation of data from surveillance systems, adapted and used by the various levels of the health system to meet the needs and cultural and population dynamics of each country⁵5 Thacker SB, Berkelman RL. Public Health Surveillance in the United States. Epidemiologic Reviews 1988; 10:164-190..

Considered the main point of entry of the health system, primary health care (PHC) is the foundation for direct surveillance with a timely response and outbreak management. With the intensification of the pandemic, the initial failure to detect and trace contacts and the consequent safe relaxation of social isolation, coordination between public health surveillance and PHC has become critical to guaranteeing technical, operational and logistical support and providing the necessary resources to develop and implement a new modus operandi, facilitating greater public participation and optimizing the use of the social facilities necessary for the effective containment of the spread of COVID-19⁸8 Rawaf S, Allen LN, Stigler FL, Kringos D, Quezada Yamamoto H, van Weel C. Lessons on the COVID-19 pandemic, for and by primary care professionals worldwide. Eur J Gen Pract 2020; 26(1): 129-133..

A variety of approaches used in different disease outbreaks support the integration of health surveillance at the primary care level with wider responses at regional level⁹9 Sarti TD, Lazarini WS, Fontenelle LF, Almeida APSC. Organization of Primary Health Care in pandemics: a rapid systematic review of the literature in times of COVID-19. Med Rxiv [Preprint] 2020.. These approaches involve the use of data aggregation systems, data dashboards and digital epidemiological surveillance. These data sources are increasingly being integrated into the formal surveillance landscape and play a role in COVID-19 surveillance¹⁰10 Budd J, Miller BS, Manning EM, Lampos V, Zhuang M, Edelstein M, Rees G, Emery VC, Stevens MM, Keegan N, Short MJ, Pillay D, Manley E, Cox IJ, Heymann D, Johnson AM, McKendry RA. Digital technologies in the public health response to COVID-19. Nat Med 2020; 26:1183-1192.^,1111 Mei X, Lee HC, Diao K, et al. Artificial intelligence-enabled rapid diagnosis of COVID-19 patients. Med Rxiv [Preprint] 2020.. Such monitoring initiatives are part of a set of actions designed to address the social determinants of health and health risks in a given population and region, ensuring the comprehensiveness of health care, which includes both individual and collective approaches¹²12 Thorlund K, Dron L, Park J, Hsu G, Forrest JI, Mills EJ. A real-time dashboard of clinical trials for COVID-19. Lancet Digit Health 2020 Jun; 2(6):e286-e287.

13 Menni C, Valdes AM, Freidin MB, Sudre CH, Nguyen LH, Drew DA, Ganesh S, Varsavsky T, Cardoso MJ, El-Sayed Moustafa JS, Visconti A, Hysi P, Bowyer RCE, Mangino M, Falchi M, Wolf J, Ourselin S, Chan AT, Steves CJ, Spector TD. Real-time tracking of self-reported symptoms to predict potential COVID-19. Nat Med 2020; 26(7):1037-1040.^-1414 Armitage H. Stanford Medicine scientists hope to use data from wearable devices to predict illness, including COVID-19. [cited 2020 Apr 14]. Stanford Medicine News Center [Internet]. Available from: http://med.stanford.edu/news/all-news/2020/04/wearable-devices-for-predicting-illness-.html
http://med.stanford.edu/news/all-news/20... .

In view of the above, this article aims to identify and reflect upon the experiences and limitations of health surveillance actions integrated with primary care developed in response to COVID-19 in the health systems of selected countries.

Methodology

We conducted an integrative literature review to compile experiences related to primary care-based health surveillance in response to COVID-19 in a selection of countries affected by the pandemic.

Given the countless challenges of undertaking comparative studies in the field of health policy, the risk of semantic confusion, superficiality, mistaken descriptions, caricatures, rhetorical distortion and unwarranted inferences is great¹⁵15 Okma KG, Marmor TR. Comparative studies and healthcare policy: learning and mislearning across borders. Clin Med (Lond) 2013; 13(5):487-491..

Despite the similarities and differences between the actions developed by different countries, the objective of this study was not to compare the different approaches adopted and replicate them in Brazil, but rather to develop a synthesis of international experiences of integrated surveillance actions in the response to COVID-19. In this respect, we depart from the assumption that a critical comparative analysis of the responses adopted by different health systems requires a more in-depth understanding of the context in which they were produced¹⁶16 Calvo RA, Deterding S, Ryan RM. Health surveillance during covid-19 pandemic. BMJ 2020; 369:m1373..

The study includes experiences from South Africa, Argentina, Australia, China, South Korea, Cuba, the United States, France, Italy, India, Singapore and the United Kingdom. Despite having different PHC models, the selected countries adopted an active surveillance approach (intensive and extensive) to control the transmission of COVID-19. Surveillance is directed at both asymptomatic and symptomatic people with the support of PHC professionals and the community and referral flow coordinated with other emergency and hospital services. Except for the United States, whose care and public health surveillance models are fragmented and differ from state to state, meaning that the federal government has a low regulatory and coordination capacity (Chart 1).

The integration of PHC with other levels of care is an essential feature of a wider-reaching PHC approach, the concept adopted here. In addition to integration within the health system, intersectoral coordination is another crucial element of effective PHC.

We performed a search of the Web of Science and Science Direct databases for publications on the COVID-19 response in PHC, using a combination of the following descriptors: Health Primary Care AND Public Health Surveillance AND Coronavirus Infections. The data were collected in October 2020.

Articles written in Portuguese, English and Spanish were read in the original language. Those written in Chinese and French were translated using Google Translate. After the search, selection and reading of the full-text version of the articles, the publications were synthesized as follows: author and year of publication, country of origin, title and health surveillance actions (Chart 2).

Health surveillance actions

Public health emergencies have a major impact on local populations and health surveillance systems. The adoption of multiple surveillance mechanisms helps ensure broader coverage, since every lost case can lead to chains of transmission that may be difficult to contain afterwards.

Countries vary widely in their capacity to prevent, detect and respond to outbreaks and in relation to the capacity for government response and degree of local autonomy and responsibility for health surveillance. Generally speaking, the actions consist of active and passive public health surveillance, with some variations, or a mixture of the two approaches, depending on the possible technological arrangements within the organization of practices¹⁶16 Calvo RA, Deterding S, Ryan RM. Health surveillance during covid-19 pandemic. BMJ 2020; 369:m1373.^,1717 French M, Monahan T. Dis-ease Surveillance: How Might Surveillance Studies Address COVID-19? Surveill Soc 2020; 18:1-11..

With regard to surveillance approaches, active surveillance consists of regular monitoring to obtain information on population health status and behavioral risk factors. It is performed by health professionals with or without the participation of the community and with the support of Information Technologies and Health Care and communications channels¹⁸18 Nsubuga P, White ME., Thacker SB, Anderson MA, Blount SB, Broome CV, Chiller TB, Espitia V, Imtiaz R, Sosin D, Stroup DF, Tauxe V, Vijayaraghavan M, Trostle M. Vigilância em saúde pública: uma ferramenta para direcionar e monitorar atividades. In: Jamison DT, Breman J, Measham AR, Alleyne G, Claeson M, Evans D, Jha P, Mills A, Musgrove P. Priorities for disease control in developing countries. 2ª ed. Washington, DC: Banco Mundial e Oxford University Press; 2006.. Passive surveillance is a system in which health authorities examine reports provided by hospitals, clinics, public health facilities and other sources, stories, rumors and other data on health events using strategies based on sentinel health centers, aggregation methods or digital surveillance and through contact tracing¹⁹19 Qin L, Sun Q, Wang Y, Wu KF, Chen M, Shia BC, Wu SY. Prediction of number of cases of 2019 novel coronavirus (COVID-19) Using social media search index. Int J Environ Res Public Health 2020; 17(7):2365.^,2020 Sun K, Chen J, Viboud C. Early epidemiological analysis of the coronavirus disease 2019 outbreak based on crowdsourced data: a population-level observational study. Lancet Digit Health 2020; 2(4):e201-e208. and passive monitoring of social media data to measure disease activity (Figure 1).

In China, the initial epicenter of the pandemic, active surveillance measures were implemented. With the support of local committees, PHC doctors played an active role in health education, the mobilization of residents and volunteers, and monitoring confirmed cases (daily monitoring of health status and psychological support for individuals in quarantine)²¹21 Gong M, Liu L, Sun X, Yang Y, Wang S, Zhu H. Cloud-Based System for Effective Surveillance and Control of COVID-19: Useful experiences from Hubei, China. J Med Internet Res 2020; 22(4):e18948.. Passive surveillance approaches were also used, using digital surveillance to provide online prescriptions, instant messaging and electronic dashboards to disseminate information and maintain contact with specialist outpatient centers²²22 Jao N, Cohen D, Udemans C. Technode. 2020. How China is using QR code apps to contain Covid-19. [Internet]. 25 de fevereiro. [cited 2020 Apr 8] Available from: https://technode.com/2020/02/25/how-china-is-using-qr-code-apps-to-contain-covid-19/
https://technode.com/2020/02/25/how-chin... .

Networks led by PHC doctors made a significant contribution to data collection and epidemiological research, through health screening committees, contact tracing and investigation of infection sources, as well as the use of social media apps to generate a combination of aggregated health data and personal risk of infection classification²³23 Kraemer MUG, Yang CH, Gutierrez B, Wu CH, Klein B, Pigott DM; Open COVID-19 Data Working Group, du Plessis L, Faria NR, Li R, Hanage WP, Brownstein JS, Layan M, Vespignani A, Tian H, Dye C, Pybus OG, Scarpino SV. The effect of human mobility and control measures on the COVID-19 epidemic in China. Science 2020; 368(6490):493-497.

24 Jia JS, Lu X, Yuan Y, Xu G, Jia J, Christakis NA. Population flow drives spatio-temporal distribution of COVID-19 in China. Nature 2020; 582(7812):389-394.^-2525 Grind K, McMillan R, Wilde Mathews A. To Track Virus, Governments Weigh Surveillance Tools That Push Privacy Limits. The Wall Street Journal 2020 março 23.[cited 2020 Apr 8]. Available from: https://www.wsj.com/%0Darticles/to-track-virus-governments-weigh-surveillance-tools-that-push-privacy-limits-11584479841
https://www.wsj.com/%0Darticles/to-track... . Other actions included surveillance of people who had been in contact with wildlife and behavioral risk factors (certain eating habits, such as eating bats)²⁶26 Oliver N, Lepri B, Sterly H, et al. Mobile phone data for informing public health actions across the COVID-19 pandemic life cycle. Sci Adv 2020; 6(23):eabc0764..

Singapore prioritized passive surveillance through the implementation of an enhanced surveillance system and contact tracing, identifying and reporting the location of people in quarantine using a global positioning system (GPS). This information was linked to the results of serological testing, permitting the creation a map of the chain of transmission and sharing of information on infectious diseases from previous experiences of respiratory outbreaks between epidemiology services²⁷27 Lin RJ, Lee TH, Lye DCB. From SARS to COVID-19: the Singapore journey. Med J Aust 2020; 212(11): 497-502..

In South Korea, all PHC services carry out active screening in households and passive screening by telescreening²⁸28 Park SY, Kim YM, Yi S, Lee S, Na BJ, Kim CB, Kim JI, Kim HS, Kim YB, Park Y, Huh IS, Kim HK, Yoon HJ, Jang H, Kim K, Chang Y, Kim I, Lee H, Gwack J, Kim SS, Kim M, Kweon S, Choe YJ, Park O, Park YJ, Jeong EK. Outbreak of coronavirus disease in Call Center, South Korea. Emerg Infect Diseases 2020; 26(8):1666-1670.. People who tested positive were referred to health centers for face-to-face appointments, testing and diagnosis. Confirmed, probable and suspected cases were then monitored on a daily basis through the application of individual risk assessments by PHC doctors to determine the severity of the disease and the necessary parameters for quarantine and isolation. PHC appointments were integrated with health surveillance and provided an estimation of the local and national epidemiological situation of COVID-19²⁹29 COVID-19 National Emergency Response Center, Epidemiology and Case Management Team, Korea Centers for Disease Control and Prevention. Early Epidemiological and Clinical Characteristics of 28 Cases of Coronavirus Disease in South Korea. Osong Public Health Res Perspect 2020; 11(1):8-14..

In the US, health surveillance was developed by Centers for Disease Control and Prevention (CDC) and the Department of Defense Global Emerging Infections Surveillance and Response System (DoD-GEIS). The following systems were used: ILINet, a national surveillance system for influenza-like illnesses, the databases ProMed and Epi-X, and reports derived from the Outbreaks Near Me app. However, while informative, these systems can result in selection bias, excessive interpretation of results due to lack of integration with official surveillance resulting from the fragmentation of the health system and PHC, and variations in decision-making by state health managers³⁰30 Outbreaks near me. [cited 2020 dec 28]. Available from: https://outbreaksnearme.org/us/en-US/
https://outbreaksnearme.org/us/en-US... .

Italy opted for passive surveillance, using integrated COVID-19 surveillance data³¹31 L'istituto Superiore Di Sanità. Informazioni Privacy Per La Sorveglianza Sanitaria Integrata Covid-19. [cited 2020 Mai 12]. Available from: https://www.epicentro.iss.it/coronavirus/pdf/informazioni-privacy-iss-sorveglianza-integrata-covid-19.pdf.
https://www.epicentro.iss.it/coronavirus... collected by the Instituto Superiore di Sanità (ISS) via an exclusive online platform, electronic questionnaires and daily infographics processed exclusively for the purposes of epidemiological and microbiological surveillance in the context of the COVID-19 pandemic. The data permit the government to monitor the epidemiological situation at national and regional level³¹31 L'istituto Superiore Di Sanità. Informazioni Privacy Per La Sorveglianza Sanitaria Integrata Covid-19. [cited 2020 Mai 12]. Available from: https://www.epicentro.iss.it/coronavirus/pdf/informazioni-privacy-iss-sorveglianza-integrata-covid-19.pdf.
https://www.epicentro.iss.it/coronavirus... ^,3232 Pezzotti P, Punzo O, Bella A, Del Manso M, Urdiales AM, Fabiani M, Ciervo A, Andrianou X, Riccardo F, Stefanelli P. The challenges of the outbreak: the Italian COVID-19 integrated surveillance system. Eur J Public Health 2020; 30(Supl. 5):ckaa165.356..

The interprofessional health teams in Medicare Locals in Australia prioritize contact tracing and vulnerable groups - especially the elderly - and monitoring people with mild respiratory disease symptoms (syndromic surveillance) in the community³⁵35 Australian Health Protection Principal Committee (AHPPC). Coronavirus (COVID-19) in Australia, Pandemic Health Intelligence Plan. [cited 2020 Maio 22]. Available from: https://www.health.gov.au/sites/default/files/documents/2020/05/coronaviruscovid-19-in-australia-pandemic-health-intelligence-plan_1.pdf
https://www.health.gov.au/sites/default/... . At national level, data is provided by the internet-based FluTracking syndromic surveillance system, the Australian Sentinel Practices Research Network (ASPREN), Victoria Sentinel Practice Influenza Network (VicSPIN), general practice (GP) sentinel surveillance systems, and the Commonwealth GP Respiratory Clinics³⁴34 COVID-19 National Incident Room Surveillance Team. COVID-19, Australia: Epidemiology Report 23 (Fortnightly reporting period ending 16 August 2020). Commun Dis Intell (2018) 2020; 44.. Surveillance includes the aboriginal population and Torres Strait islanders³⁵35 Australian Health Protection Principal Committee (AHPPC). Coronavirus (COVID-19) in Australia, Pandemic Health Intelligence Plan. [cited 2020 Maio 22]. Available from: https://www.health.gov.au/sites/default/files/documents/2020/05/coronaviruscovid-19-in-australia-pandemic-health-intelligence-plan_1.pdf
https://www.health.gov.au/sites/default/... .

South Africa chose active community-based surveillance to promote early detection and rapid confirmation through contact tracing, setting up quarantine centers and care support under the Integrated Disease Surveillance and Response framework (IDSR), which provides a framework for syndromic surveillance and entry point for identifying, characterizing and responding to community transmission of COVID-19³⁶36 Ihekweazu C, Agogo E. Africa's response to COVID-19. BMC Med 2020; 18(1):51.. In addition, the Africa Health Research Institute (AHRI) implemented demographic surveillance systems for community surveillance in rural areas. These systems are a vital tool in the COVID-19 response in remote areas, permitting screening of symptoms in household members³⁷37 Kapata N, Ihekweazu C, Ntoumi F, Raji T, Chanda-Kapata P, Mwaba P, Mukonka V, Bates M, Tembo J, Corman V, Mfinanga S, Asogun D, Elton L, Arruda LB, Thomason MJ, Mboera L, Yavlinsky A, Haider N, Simons D, Hollmann L, Lule SA, Veas F, Abdel Hamid MM, Dar O, Edwards S, Vairo F, McHugh TD, Drosten C, Kock R, Ippolito G, Zumla A. Is Africa prepared for tackling the COVID-19 (SARS-CoV-2) epidemic. Lessons from past outbreaks, ongoing pan-African public health efforts, and implications for the future. Int J Infect Dis 2020; 93:233-236.^-3838 Siedner MJ, Harling G, Derache A, Smit T, Khoza T, Gunda R, Mngomezulu T, Gareta D, Majozi N, Ehlers E, Dreyer J, Nxumalo S, Dayi N, Ording-Jesperson G, Ngwenya N, Wong E, Iwuji C , Shahmanesh M, Seeley J. Protocol: Leveraging a demographic and health surveillance system for Covid-19 Surveillance in rural KwaZulu-Natal. Wellcome Open Res 2020; 5:109..

With limited resources and a not so robust health system, India uses a participatory surveillance system called Aarogya Setu (“bridge to health” in Sanskrit) to prevent spread and control the pandemic³⁹39 Lallukka T, Pietiläinen O, Jäppinen S, Laaksonen M, Lahti J, Rahkonen O. Factors associated with health survey response among young employees: a register-based study using online, mailed and telephone interview data collection methods. BMC Public Health 2020; 20(1):184.. This system complements the India Integrated Disease Surveillance Program using Bluetooth and telephone data to identify the proximity of infected people, comparing databases of confirmed cases to classify individual risk status (low, medium and high)⁴⁰40 Senegal. A Promising practice on multisectoral communication efforts in Senegal Phcpi. CoviD-19 Promisi N G Practices. [cited 2020 Apr 18]. Available from: https://improvingphc.org/sites/default/files/Senegal_Risk%20Communication.pdf
https://improvingphc.org/sites/default/f... . Individuals are advised of the measures that should be taken based on risk assessments and test counselling and informed the location of the nearest test center. The application also has a chatbot, which provides constant updates from the Ministry of Health and state help line numbers⁴⁰40 Senegal. A Promising practice on multisectoral communication efforts in Senegal Phcpi. CoviD-19 Promisi N G Practices. [cited 2020 Apr 18]. Available from: https://improvingphc.org/sites/default/files/Senegal_Risk%20Communication.pdf
https://improvingphc.org/sites/default/f... ^,4141 Garg S, Bhatnagar N, Gangadharan N. A Case for Participatory Disease Surveillance of the COVID-19 Pandemic in India. JMIR Public Health Surveill 2020; 6(2):e18795..

In France, the use of a sentinel network by PHC doctors was supported by the installation of java-coded applications on health center computers. The app allows the reporting of cases, implementation of surveillance protocols and questionnaires and case description in areas with poor internet access, since the computers are linked to a central server in national surveillance centers^43.

In the United Kingdom, the National Health Service and Public Health England implement a community-based surveillance system integrated with various national syndromic surveillance systems coordinated by the Real-Time Syndromic Surveillance Team (ReSST). The Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) provides weekly surveillance data reports¹¹11 Mei X, Lee HC, Diao K, et al. Artificial intelligence-enabled rapid diagnosis of COVID-19 patients. Med Rxiv [Preprint] 2020.. The web-based syndromic surveillance system uses daily search query frequency statistics obtained from the Google Health Trends API focusing on queries about COVID-19 symptoms and monitoring models⁴³43 de Lusignan S, Jones N, Dorward J, Byford R, Liyanage H, Briggs J, Ferreira F, Akinyemi O, Amirthalingam G, Bates C, Lopez Bernal J, Dabrera G, Eavis A, Elliot AJ, Feher M, Krajenbrink E, Hoang U, Howsam G, Leach J, Okusi C, Nicholson B, Nieri P, Sherlock J, Smith G, Thomas M, Thomas N, Tripathy M, Victor W, Williams J, Wood I, Zambon M, Parry J, O'Hanlon S, Joy M, Butler C, Marshall M, Hobbs FDR. The Oxford Royal College of General Practitioners Clinical Informatics Digital Hub: Protocol to Develop Extended COVID-19 Surveillance and Trial Platforms. JMIR Public Health Surveill 2020; 6(3):e19773. based on previously established Influenza internet search algorithms (FluSurvey) currently included in Public Health England’s weekly COVID-19 reports⁴⁴44 Turbelin C, Boëlle PY. Improving general practice based epidemiologic surveillance using desktop clients: the French Sentinel Network experience. Stud Health Technol Inform 2010; 160(Pt 1):442-446.^,4545 Public Health England. Weekly Coronavirus Disease 2019 (COVID-19) Surveillance Report Summary of COVID-19 surveillance systems. [cited 2020 Ago 8]. Available from: https://assets.publishing.service.gov. uk/government/uploads/system/uploads/attachment_data/file/888254/COVID19_Epidemiological_Summary_w22_Final.pdf.
https://assets.publishing.service.gov. u... . This allows for the analysis of anonymous health data from various sources and facilitates the search for trends that indicate above normal disease levels. Bulletins are published to keep public health professionals up to date, aggregating symptom data in outpatient settings⁴⁴44 Turbelin C, Boëlle PY. Improving general practice based epidemiologic surveillance using desktop clients: the French Sentinel Network experience. Stud Health Technol Inform 2010; 160(Pt 1):442-446.^,4545 Public Health England. Weekly Coronavirus Disease 2019 (COVID-19) Surveillance Report Summary of COVID-19 surveillance systems. [cited 2020 Ago 8]. Available from: https://assets.publishing.service.gov. uk/government/uploads/system/uploads/attachment_data/file/888254/COVID19_Epidemiological_Summary_w22_Final.pdf.
https://assets.publishing.service.gov. u... .

Argentina’s Ministry of Health implemented a contact tracing plan called Detectar in areas in which an increase in the number of cases has been detected or estimated. Launched in May after a sharp rise in the number of cases among lower-income families in densely populated neighborhoods in Greater Buenos Aires, the plan was subsequently expanded to the rest of the country⁴⁶46 Arenas A, Cota W, Gómez-Gardeñes J, Gómez S,Granell C, Matamalas JT, Soriano D, Steinegger B. A mathematical model for the spatiotemporal epidemic spreading of COVID19. [preprint] Med Rxiv 2020. [cited 2020 Ago 8]. Available from: https://doi.org/10.1101/2020.03.21.20040022
https://doi.org/10.1101/2020.03.21.20040...

47 Czubaj F. Coronavirus en la Argentina: las clínicas privadas podrán hasta 7500 tests diarios for descomprimir el sistema de salud público. La Nación; 2020 Abr 28.^-4848 Vales L. Coronavirus: el operativo detectar estrena protocolo para todo el país. 25 de mayo de 2020. [cited 2020 Jul 12]. Available from: https://www.pagina12.com.ar/268006-coronavirus-el-operativo-detectar-estrena-protocolo-para-tod.
https://www.pagina12.com.ar/268006-coron... .

In Cuba, the country’s previous experience with the dengue and Zika epidemics proved to be an advantage. The country already had a national diagnosis and surveillance network, supported by Provincial Hygiene, Epidemiology and Microbiology Centers, a national network of WHO-compliant diagnostic laboratories and a national reference center lab for infectious diseases at Havana’s Pedro Kourí Tropical Medicine Institute de Havana⁴⁹49 Gemelli, N. Management of the COVID-19 outbreak in Argentina: the beginning. Disaster Medicine and Public Health Preparation 2020; 1-3.^,5050 Gorry C. COVID-19 case detection: Cuba's active screening approach. Medical Review 2020; 22(2).. Before the appearance of the first case, the Ministry of Health had trained its health professionals in disease management and community-based surveillance⁴⁹49 Gemelli, N. Management of the COVID-19 outbreak in Argentina: the beginning. Disaster Medicine and Public Health Preparation 2020; 1-3.^,5050 Gorry C. COVID-19 case detection: Cuba's active screening approach. Medical Review 2020; 22(2)..

Following protocols, PHC teams conduct continuous community health assessments (public health and epidemiological situation) and individual and family health assessments to detect respiratory symptoms. Daily screening of suspected and confirmed cases was performed in every neighborhood with the participation of approximately 28,000 volunteer medical students⁴⁹49 Gemelli, N. Management of the COVID-19 outbreak in Argentina: the beginning. Disaster Medicine and Public Health Preparation 2020; 1-3.^,5050 Gorry C. COVID-19 case detection: Cuba's active screening approach. Medical Review 2020; 22(2).. Home visits were used to broaden the monitoring of high-risk people and confirmed cases in home isolation, conducting physical examinations and comprehensive assessments with emphasis on vulnerable groups⁵⁰50 Gorry C. COVID-19 case detection: Cuba's active screening approach. Medical Review 2020; 22(2).^,5151 Aguilar-Guerra, Tania L Reed, Gail. Mobilization of primary health care: Cuba's powerful weapon against COVID-19. Medical Review 2020; 22(2):58-63..

A little-used method of surveillance was the detection of SARS-CoV-2 in longitudinal samples of metropolitan waste water collected during the early stages of the pandemic in countries like Spain and France, enabling the detection of viral RNA, which is related to the increase in number of declared cases⁴³43 de Lusignan S, Jones N, Dorward J, Byford R, Liyanage H, Briggs J, Ferreira F, Akinyemi O, Amirthalingam G, Bates C, Lopez Bernal J, Dabrera G, Eavis A, Elliot AJ, Feher M, Krajenbrink E, Hoang U, Howsam G, Leach J, Okusi C, Nicholson B, Nieri P, Sherlock J, Smith G, Thomas M, Thomas N, Tripathy M, Victor W, Williams J, Wood I, Zambon M, Parry J, O'Hanlon S, Joy M, Butler C, Marshall M, Hobbs FDR. The Oxford Royal College of General Practitioners Clinical Informatics Digital Hub: Protocol to Develop Extended COVID-19 Surveillance and Trial Platforms. JMIR Public Health Surveill 2020; 6(3):e19773.. The routine analysis of waste water is a sensitive and cost‐effective COVID-19 surveillance technique, resulting in a significant improvement in preparedness in the event of future or reoccurring viral outbreaks ⁵³53 Randazzo W, Cuevas-Ferrando E, Sanjuán R, Domingo-Calap P, Sánchez G. Metropolitan wastewater analysis for COVID-19 epidemiological surveillance. Int J Hyg Environ Health 2020; 230:113621..

Challenges, limitations and final considerations

Public health surveillance is essential for understanding the epidemiology of diseases and provides a solid foundation for the implementation of control measures. The majority of countries included in this study adopted different approaches to public health surveillance, ranging from the systematic recording of common medical conditions using administrative data systems, vital statistics and annual health surveys. However, the scope of public health surveillance actions may be limited, even in countries with universal health systems, due to the poor quality of surveillance and public health response, for example as a result of the decentralization of actions to districts or provinces, which can lead to a loss of locally collected data⁵³53 Randazzo W, Cuevas-Ferrando E, Sanjuán R, Domingo-Calap P, Sánchez G. Metropolitan wastewater analysis for COVID-19 epidemiological surveillance. Int J Hyg Environ Health 2020; 230:113621..

Despite having systems considered to be effective for detecting major public health problems, the countries that adopted sentinel systems, such as France, the United Kingdom and US (with private PHC), showed a low level of sensitivity to rare events such as the early emergence of a new disease. This is because these infections can emerge in any part of the population and require large-scale monitoring integrated across all levels of care.

Another interpretive challenges observed in this article is the comparison of ways of life and territorial occupation in different countries and their respective care models. Even with robust surveillance systems, hospital-centric care models in high-income countries may be less effective for vulnerable groups living in densely populated areas, especially when social distancing is not maintained. Hospital-centric systems tend to be less effective for vulnerable populations in lower and middle-income countries, regardless of the type of surveillance and/or degree of integration with PHC.

In contrast, PHC models strongly oriented towards the community tend to achieve more effective surveillance outcomes as they promote actions drawing upon cultural competence implemented in social spaces by interprofessional teams, often including community workers. In this regard, the integration of surveillance and PHC catalyzes the performance of the entire health system, minimizing the adverse effects of the pandemic, even in areas with limited social protection.

Over the last two decades, other approaches have been used to address the gap between PHC and health surveillance, such as the use of data from online news sites, news aggregation services, social media and web searches by countries like Australia, South Korea and Singapore, and longitudinal community-based cohorts in India and the United Kingdom⁵⁴54 Ricoca PV, Nunes C, Abrantes A. Vigilância epidêmica de Covid-19: considerando a incerteza e subavaliação. Karger AG, Basel (2020), pp. 1-7.. Digital surveillance uses technologies to support active and passive epidemiological intelligence using digital platforms to aggregate datasets that enable the identification of cases and groups of infections, rapid tracing of contacts, monitoring of travel patterns during lockdowns and public health messaging to wide audiences⁵⁵55 Lodder W, de Roda Husman AM. SARS-CoV-2 in wastewater: potential health risk, but also data source. Lancet Gastroenterol Hepatol 2020; S2468-1253(20)30087-X.^,5656 Nsubuga P, Nwanyanwu O, Nkengasong JN, Mukanga D, Trostle M. Strengthening public health surveillance and response using the health systems strengthening agenda in developing countries. BMC Public Health 2010; 10 (Supl. 1):S5-S6..

It is important to highlight that the widespread use of digital surveillance raises some concerns, including the violation of privacy both during and after the outbreak, as not all digital interventions were consensual or explicitly mentioned the consent option for the use of data for specific ends and a given period of time⁵⁷57 Ienca M, Vayena E. On the responsible use of digital data to tackle the COVID-19 pandemic. Nat Med 2020; 26:463-464..

One example of the above is the use of smartphone apps by South Korea to report the movement of people with COVID-19, raising fears that this initiative could lead people to avoid testing (or other measures imposed by the government) so as not to suffer a violation of their privacy²⁵25 Grind K, McMillan R, Wilde Mathews A. To Track Virus, Governments Weigh Surveillance Tools That Push Privacy Limits. The Wall Street Journal 2020 março 23.[cited 2020 Apr 8]. Available from: https://www.wsj.com/%0Darticles/to-track-virus-governments-weigh-surveillance-tools-that-push-privacy-limits-11584479841
https://www.wsj.com/%0Darticles/to-track... . One of the weaknesses of contact tracing apps is that a large part of the population need to use them and follow the guidance for them to effectively interrupt community transmission⁵⁸58 Ferretti L, Wymant C, Kendall M, Zhao L, Nurtay A, Abeler-Dörner L, Parker M, Bonsall D, Fraser C. Quantifying SARS-CoV-2 transmission suggests epidemic control with digital contact tracing. Med Rxiv [Preprint] 2020.. Practical questions also remain, such as which contacts are considered close enough for transmission and when the exposure time is considered long enough to trigger an alert.

Digital surveillance can therefore generate a sense of being controlled and be seen as an obstacle to autonomy, having negative effects on motivation and well-being⁵⁹59 Jensen JM, Raver JL. When Self-Management and Surveillance Collide: Consequences for Employees' Organizational Citizenship and Counterproductive Work Behaviors. Group & Organization Management 2012:37(3).. Infrared sensors, including the use of thermal imaging cameras to identify possible cases by detecting fever (for example in airports), may generate a false sense of control over the situation. Another obvious concern is the large number of false positive and false negative results, meaning that monitoring strategies are unlikely to have a substantial effect other than raising awareness⁶⁰60 Gostic K, Gomez AC, Mummah RO, Kucharski AJ, Lloyd-Smith JO. Estimated effectiveness of symptom and risk screening to prevent the spread of COVID-19. Elife 2020; 9:e55570..

Data dashboards have been used extensively during the pandemic, collecting public health data (including confirmed cases, deaths and number of tests) in real time to keep the public informed and helping policy-makers refine interventions. COVID-19 dashboards⁶¹61 Lampos V, Majumder MS, Yom-Tov E, Edelstein M, Moura S, Hamada Y, Rangaka MX, McKendry RA, Cox IJ. Tracking COVID-19 using online search. npj Digit. Med. 4, 17 (2021). https://doi.org/10.1038/s41746-021-00384-w
https://doi.org/10.1038/s41746-021-00384... normally focus on time series graphs and geographical maps, ranging from regional statistics to case-level coordinate data. Few dashboards include an analysis of contact tracing or community surveillance data⁶²62 McKendry RA, Rees G, Cox IJ, Johnson A, Edelstein M, Eland A, Stevens MM, Heymann D. Share mobile and social-media data to curb COVID-19. Nature 2020 Apr; 580(7801):29..

Mathematical models have been widely used to estimate spread and other COVID-19 health outcomes, as well as disease burden. Such models require knowledge of the main transmission parameters, such as the serial interval (SI) and the interval between onset of symptoms in the infecting and infected person in the chain of transmission⁶³63 Buckee CO, Balsari S, Chan J, Crosas M, Dominici F, Gasser U, Grad YH, Grenfell B, Halloran ME, Kraemer MUG, Lipsitch M, Metcalf CJE, Meyers LA, Perkins TA, Santillana M, Scarpino SV, Viboud C, Wesolowski A, Schroeder A. Aggregated mobility data could help fght COVID-19. Science 2020: 368(6487):145-146.

64 Black AJ, Ross JV. Estimating a markovian epidemic model using household serial interval data from the early phase of an epidemic. PLoS One 2003; 8(8): e73420.^-6565 Yom-Tov E, Johansson-Cox I, Lampos V, Hayward AC. Estimating the secondary attack rate and serial interval of influenza like illnesses using social media. Influenza and Other Respiratory Viruses 2015; 9(4):191-199., to enable the estimation of the interval between infection of primary and secondary cases and time-varying reproduction numbers (how many secondary cases are caused by a typical primary case during the infectious period) during the course of the pandemic⁵⁹59 Jensen JM, Raver JL. When Self-Management and Surveillance Collide: Consequences for Employees' Organizational Citizenship and Counterproductive Work Behaviors. Group & Organization Management 2012:37(3).^,6666 Zhou L, Li Q, Uyeki TM. Estimated incubation period and serial interval for human-to-human influenza A(H7N9) virus transmission. Emerging Infectious Diseases 2019; 25(10):1982-1983.^,6767 Smolinski MS, Crawley AW, Olsen JM, Jayaraman T, Libel M. Participatory disease surveillance: engaging communities directly in the notification, monitoring and response to health threats. JMIR Public Health Surveill 2017 October 11; 3(4):e62..

The quality and consistency of data remains a concern. The lack of official standards and inconsistencies in government statistics between countries make global comparisons difficult¹²12 Thorlund K, Dron L, Park J, Hsu G, Forrest JI, Mills EJ. A real-time dashboard of clinical trials for COVID-19. Lancet Digit Health 2020 Jun; 2(6):e286-e287., especially in countries with striking regional differences, such as Brazil, France and Canada. In addition, up-to-date and accurate offline government statistics are not always evenly accessible.

In China, current policies and technology systems have marked limitations, preventing the integration of clinical care and PHC and collaboration between PHC and other levels of care (for example, hospitals), and make it difficult to ensure a sufficient number of properly trained and an adequately paid PHC professionals⁶⁸68 Xi Li, Jiapeng Lu, Shuang Hu, KK Cheng, Jan De Maeseneer, Qingyue Meng et al.. The primary health-care system in China. Lancet 2017; 390 (10112):2584-2594..

The literature also shows that surveillance services should not operate in isolation and need to be integrated into existing public health systems. Although innovative digital technologies and data sharing enhance the effectiveness of control measures, they have a number of limitations in relation to the COVID-19 response. This is because they are vertical interventions based on traditional case reporting, recording and investigation and syndromic surveillance practices, meaning PHC actions - which account for 80% of all mild cases - remain disjointed. In contrast, comprehensive multi-sectoral health surveillance integrated with PHC has shown itself to be effective and capable of ensuring continuous monitoring of the range of health problems affecting the local population, both during and after the pandemic. A surveillance system integrated with PHC contributes to the control of transmission in the community, orienting the implementation of mitigation measures towards the community, taking into account scale, time and duration and promoting strategies tailored to local demands.

In this respect, participatory disease surveillance has also shown itself to be an effective strategy for monitoring communicable diseases, in which citizens are actively involved in self-reporting symptoms or events in order to help public health experts to aggregate and analyze data to inform public health interventions⁶⁹69 Souty C, Turbelin C, Blanchon T, Hanslik T, Le Strat Y, Boëlle PY. Improving disease incidence estimates in primary care surveillance systems. Popul Health Metr 2014 Jul 26; 12:19.. However, biased results may arise in primary care surveillance systems based on voluntary participation due to the lack of representativeness of the monitored population and uncertainty about population denominators.

The Cuban experience reveals a common element for the organization and professional integration of PHC into the surveillance system and broader analysis of health problems, focusing not only on the systematization of general indicators, but aimed at informing the planning and organization of systems and services. This requires a PHC model that seeks to understand local living and working conditions and the forms of organization and operation of local government and non-governmental organizations. In other words, a care model articulated with representative collective decision-making spaces within society and tailored to different realities in order to provide comprehensive and equitable care⁵¹51 Aguilar-Guerra, Tania L Reed, Gail. Mobilization of primary health care: Cuba's powerful weapon against COVID-19. Medical Review 2020; 22(2):58-63.^,7070 Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in primary care. BMJ 2020 Mar 25; 368:m1182.^,7171 Stevenson Rowan, M., Hogg, W., & Huston, P. (2007). Integrating public health and primary care. Politiques de Sante 2007; 3(1):e160-e181..

The primary care-based surveillance model should include the following: the articulation of interprofessional team practices, including primary care providers; a health surveillance, health promotion and disease prevention funding system or incentive program; information technology systems to promote the continuous and systematic collection of data and implementation of common plans and protocols; and the capacity to detect and report new and emerging diseases using platforms integrated across local, provincial, national and international health systems.

Finally, the experiences analyzed by this study demonstrate that, although robust surveillance systems are essential tools for detecting and monitoring outbreaks and public health emergencies, strong primary care systems form the foundation for any response to health emergencies.

References

Publication Dates

History