Abstract

Objective:

To describe compulsorily notifiable diseases, health conditions and public health events (DAEs as per the Brazilian acronym) registered by the National Hospital Epidemiological Surveillance Network (RENAVEH as per the Brazilian acronym), before and during the COVID-19 pandemic.

Methods:

This was a descriptive ecological study using records held on the Notifiable Health Conditions Information System (SINAN as per the Brazilian acronym) between Epidemiological Week (EW) 1 of 2017 (January 1^st, 2017) and 52 of 2020 (December 26, 2020).

Results:

Between 2017 and 2020, RENAVEH notified 1,258,455 DAE form records, with only 225,081 (17.9%) notifications in 2020, representing a decrease of 146,340 records compared to 2019. The temporal analysis showed a decrease per EW of more than 1,000 notified records with effect from EW 12.

Conclusion:

There was a decrease in compulsorily notifiable DAEs registered by RENAVEH in Brazil taking the period analyzed as a whole, in particular in 2020.

Keywords:
COVID-19; Disease Notification; Epidemiology, Descriptive; Health Information Systems; Health Services Research

Introduction

Hospital epidemiological surveillance plays an extremely important role since the product of its work provides health service managers with essential and concise elements to support decision making when facing public health emergencies in Brazil.¹1. Lima CRC, Piva SGN, Almeida ES, Almeida VM, Vilas Boas JM. Núcleos hospitalares de vigilância epidemiológica no Brasil: uma revisão integrativa de literatura científica. Rev Epidemiol Controle Infecç. 2019;9(2):1-10. doi: 10.17058/reci.v9i2.12379
https://doi.org/10.17058/reci.v9i2.12379...

2. Escosteguy CC, Pereira AGL, Medronho RA. Três décadas de epidemiologia hospitalar e o desafio da integração da vigilância em saúde: reflexões a partir de um caso. Cien Saude Colet. 2017;22(10):3365-79. doi: 10.1590/1413-812320172210.17562017
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3. Medeiros ARP. Saberes instrumentais e ideológicos de enfermeiros no processo de trabalho em vigilância epidemiológica hospitalar [tese]. Curitiba (PR): Universidade Federal do Paraná; 2012. Disponível em: https://acervodigital.ufpr.br/handle/1884/29353
https://acervodigital.ufpr.br/handle/188... ^-44. Goldmann DA. Comtemporary challenges for hospital epidemiology. Am J Med. 1991;91(3 Suppl 2):8S-15S. doi: 10.1016/0002-9343(91)90337-w
https://doi.org/10.1016/0002-9343(91)903... The National Hospital Epidemiological Surveillance Subsystem set up Hospital Epidemiology Hubs to achieve the objectives expected of hospital epidemiological surveillance.⁵5. Secretaria Estadual de Saúde (SP). Vigilância epidemiológica em âmbito hospitalar. Rev Saúd Pub. 2007;41(3):487-91. doi: 10.1590/S0034-89102007000300025
https://doi.org/10.1590/S0034-8910200700... ^,66. Gabrois V, Castelar RM, Mordelet P. Gestão hospitalar: um desafio para o hospital brasileiro. Rio de Janeiro: ENSP; 1995. The Hubs centers are articulating operational units which identify and monitor specific situations and thus ensure continuous monitoring of the local epidemiological situation, including subtle changes in the population’s morbidity and mortality profile.¹1. Lima CRC, Piva SGN, Almeida ES, Almeida VM, Vilas Boas JM. Núcleos hospitalares de vigilância epidemiológica no Brasil: uma revisão integrativa de literatura científica. Rev Epidemiol Controle Infecç. 2019;9(2):1-10. doi: 10.17058/reci.v9i2.12379
https://doi.org/10.17058/reci.v9i2.12379... ^,66. Gabrois V, Castelar RM, Mordelet P. Gestão hospitalar: um desafio para o hospital brasileiro. Rio de Janeiro: ENSP; 1995.

The Hospital Epidemiology Hubs linked to the Ministry of Health comprise the National Hospital Epidemiological Surveillance Network (Rede Nacional de Vigilância Epidemiológica Hospitalar - RENAVEH) the main objective of which is to detect, monitor and provide an immediate response to potential public health emergencies within the hospital context.⁶6. Gabrois V, Castelar RM, Mordelet P. Gestão hospitalar: um desafio para o hospital brasileiro. Rio de Janeiro: ENSP; 1995.

7. Dantas DI, Freitas RF, Batista DA, Almeida RB, Guerreiro JV. Contribuição do Núcleo de Vigilância Epidemiológica em uma unidade de pronto atendimento para a notificação compulsória de agravos. R Bras Ci Saude. 2014;18:21-6. doi: 10.4034/RBCS.2014.18.s1.03
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8. Brisse B, Medronho RA. A epidemiologia hospitalar no âmbito da Secretaria Municipal de Saúde do Rio de Janeiro. Cad Saude Colet. [Internet] 2005 [citado 2021 abr 27];13(3):631-48. Disponível em: http://www.cadernos.iesc.ufrj.br/cadernos/images/csc/2005_3/artigos/CSC_2005-3_beti.pdf
http://www.cadernos.iesc.ufrj.br/caderno... ^-99. Associação Brasileira de Pós-Graduação em Saúde Coletiva. II plano diretor para o desenvolvimento da epidemiologia no Brasil: 1995-1999. Rio de Janeiro: Associação Brasileira de Pós-Graduação em Saúde Coletiva; 1995. The notifications of Diseases, Health Conditions and Public Health Events (Doenças, Agravos e Eventos de Saúde Pública - DAEs) recorded by RENAVEH in recent years accounted on average for 8% of overall notifications recorded in Brazil.¹⁰10. Duailibe FT, França GVA, Delácio AS, Carmo GMI. Contribuição dos Núcleos Hospitalares de Epidemiologia para as notificações compulsórias no Brasil. In: Anais do 54o. Congresso da Sociedade Brasileira de Medicina Tropical [Internet]; 2018 set 2-5; Olinda, Pernambuco. Olinda: Sociedade Brasileira de Medicina Tropical; 2018 [citado 2021 abr 27]. Disponível em: http://www.adaltech.com.br/anais/medtrop2018/listaresumos.htm
http://www.adaltech.com.br/anais/medtrop...

The COVID-19 pandemic, as declared by the World Health Organization (WHO) in March 2020, has exposed healthcare workers to constant stress and has overburdened healthcare systems at all levels of care, especially hospitals, in every country in the world.¹¹11. Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Biomed. 2020; 91(1):157-60. doi: 10.23750/abm.v91i1.9397
https://doi.org/10.23750/abm.v91i1.9397...

12. World Health Organization. Who Director-General's opening remarks at the media briefing on Covid-19 [Internet] 2020 [update 2020 mar 11, cited 2021 apr 27]. World Health Organization: Geneva; 2020. Avaible from: https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-Covid-19---11-march-2020
https://www.who.int/director-general/spe...

13. Narain JP, Dawa N, Bhatia R. Health system response to COVID-19 and future pandemics. J Health Manag. 2020;22(2):138-45. doi: 10.1177/0972063420935538
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14. Blumenthal D, Fowler EJ, Abrams M, Collins SR. Covid-19 - implications for the health care system. N Engl J Med. 2020;383(15):1483-8. doi: 10.1056/NEJMsb2021088
https://doi.org/10.1056/NEJMsb2021088... ^-1515. Ibrahim NK. Epidemiologic surveillance for controlling Covid-19 pandemic: types, challenges and implications. J Infect Public Health. 2020;13(11):1630-8. doi: 10.1016/j.jiph.2020.07.019
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Both health care teams and health surveillance teams have been affected by the high demand for insalubrious work, in addition to the physical, mental and social strain faced by these professionals.¹⁶16. Mehta S, Machado F, Kwizera A, Papazian L, Moss M, Azoulay É, et al. COVID-19: a heavy toll on health-care workers. Lancet Respir Med. 2021;9(3):226-8. doi: 10.1016/S2213-2600(21)00068-0
https://doi.org/10.1016/S2213-2600(21)00...

17. Ornell F, Halpern HC, Kessler FHP, Narvaez JCM. The impact of the COVID-19 pandemic on the mental health of healthcare professionals. Cad Saude Publica. 2020;36(4):e00063520. doi: 10.1590/0102-311X00063520
https://doi.org/10.1590/0102-311X0006352... ^-1818. Naser AY, Al-Hadithi HT, Dahmash EZ, Alwafi H, Alwan SS, Abdullah ZA. The effect of the 2019 coronavirus disease outbreak on social relationships: A cross-sectional study in Jordan. Int J Soc Psychiatry. 2020;67(6):664-74. doi: 10.1177/0020764020966631
https://doi.org/10.1177/0020764020966631...

Considering the relevance and importance of the work done by hospital epidemiological surveillance in formulating strategies, within the scope of public health policies, it is essential to evaluate the consequences of the pandemic for the hospital epidemiological surveillance service in Brazil.

The objective of this study was to describe compulsorily notifiable DAEs registered by the RENAVEH, before and during the COVID-19 pandemic in Brazil.

Methods

We conducted a descriptive ecological study of compulsory DAEs notifications recorded in Brazil by the Hospital Epidemiology Hubs linked to RENAVEH. The network is composed of 238 Hospital Epidemiology Hubs, distributed over 145 municipalities of the country’s 27 Federative Units.¹⁹19. Brasil. Ministério da Saúde. Portaria n° 48, de 20 de janeiro de 2015. Habilita os entes federativos ao recebimento do incentivo financeiro de custeio para implantação e manutenção de ações e serviços público estratégicos de Vigilância em Saúde. [Internet]. Diário Oficial da União, Brasília (DF), 2015 jan 21 [citado 2021 abr 27]; Seção 1:24. Disponível em: https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?data=21/01/2015&jornal=1&pagina=24&totalArquivos=68
https://pesquisa.in.gov.br/imprensa/jsp/... We analyzed the notifications made between Epidemiological Week (EW) 1 of 2017 (January 1^st, 2017) and EW 52 of 2020 (December 26, 2020). The pre-pandemic period refers to notifications made until WE 11 of 2020; while pandemic period begins with effect from EW 12 of the same year.¹²12. World Health Organization. Who Director-General's opening remarks at the media briefing on Covid-19 [Internet] 2020 [update 2020 mar 11, cited 2021 apr 27]. World Health Organization: Geneva; 2020. Avaible from: https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-Covid-19---11-march-2020
https://www.who.int/director-general/spe...

The data used in this research were retrieved from the Notifiable Health Conditions Information System (Sistema de Informação de Agravos de Notificação - SINAN) and refer to the period from 2017 to 2020. The anonymous secondary data were authorized for use by the Health Ministry’s Health Surveillance Secretariat on February 27, 2021 and were retrieved and made available on February 30 of the same year.

We analyzed the following variables: notification number (NU_NOTIFIC); year of notification (NU_ANO); EW of notification (SEM_NOT); and health condition notified (ID_AGRAVO).

Data tabulation and analysis were performed using Microsoft Excel version 2010. The following formula was used to calculate simple proportions: Sample size/total value x 100 (for each variable).

The following formula was used when analyzing means, for each mean between all the study variables, by year and EW:

The following formula was used to calculate variation: Variation = [(Final Value of NU_NOTIFIC - Initial Values of NU NOTIFIC)/Initial Value of NU_NOTIFIC)].

Variations were shown in dark grey when there was an increase, and in light grey when there was a decrease.

As the study used public information, with no possibility of cases being identified, the research project did not need to be submitted for analysis and approval by a Research Ethics Committee.

RESULTS

In the period between EW 1 of 2017 and EW 52 of 2020, the Hospital Epidemiology Hubs linked to RENAVEH recorded 1,258,455 DAEs forms in Brazil: 327,793 (26.0%) in 2017; 334,160 (26.6%) in 2018; 371,421 (29.5%) in 2019; and 225,081 (17.9%) in 2020. More than 60 health conditions were reported each year, with domestic violence, sexual and/or other violence, venomous animal accidents and dengue being most reported in the period analyzed (Table 1).

The mean number of notifications in the pre-pandemic period was 344,458 per year, this being 119,377 records more than the total number of notifications recorded in the pandemic year 2020 (Table 1). The difference in the total number of DAEs notifications made between 2017 and 2018 was 6,367 records, representing a 2.0% increase. Between 2018 and 2019 the difference was 37,261 records, representing an 11.0% increase. Between 2019 and 2020, the difference was 146,340 records, representing a 39.0% decrease (Table 1).

When analyzing by EW the behavior of the time series of DAEs notifications recorded between 2017 and 2020, we found that the weekly notifications made by RENAVEH were predominantly greater than 5,000. In 2020, the same behavior was found between EW 2 and EW 11. However, from EW 12 on, there was a decrease in the epidemiological curve, showing a linear pattern of approximately 4,000 DAEs notifications until EW 52 (Figure 1).

Regarding the variation of notifications made in the period from 2017 to 2020, it was not possible to identify a pattern in notification behavior between the months of the same year, nor between the months of the analyzed years (Box 1).

When analyzing variation in DAEs notification, a decrease in the monthly mean was found in all the years studied: -0.001 in 2017; -0.010 in 2018; -0.007 in 2019; and -0.078 in 2020. It is noteworthy that the highest mean monthly decrease was recorded in 2020 (Box 1).

Discussion

The results of this study showed a change in the profile of the notifications made by RENAVEH, characterized by a marked difference in the number of notifications between the pre-pandemic period (2017-2019) and during the pandemic (2020).

The hypothesis of association between the pandemic and the decrease in the notifications made by the Network was reinforced by there being 1,000 fewer records per EW with effect from when the WHO declared the SARS-CoV2 pandemic in EW 12 of 2020.¹²12. World Health Organization. Who Director-General's opening remarks at the media briefing on Covid-19 [Internet] 2020 [update 2020 mar 11, cited 2021 apr 27]. World Health Organization: Geneva; 2020. Avaible from: https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-Covid-19---11-march-2020
https://www.who.int/director-general/spe... This reduction may be due to the negative repercussions of the pandemic on health services, especially high complexity services,²⁰20. Birkmeyer JD, Barnato A, Birkmeyer N, Bessler R, Skinner J. The impact of the COVID-19 pandemic on hospital admissions in the United States. Healt Aff. 2020;39(11):2010-7. doi: 10.1377/hlthaff.2020.00980
https://doi.org/10.1377/hlthaff.2020.009... ^,2121. Sun S, Xie Z, Yu K, Jiang B, Zheng S, Pan X. COVID-19 and healthcare system in China: challenges and progression for a sustainable future. Global Health. 2021;17(1):14. doi: 10.1186/s12992-021-00665-9
https://doi.org/10.1186/s12992-021-00665... which began prioritizing care provision to people with COVID-19, in often overcrowded facilities, with scarce resources, and with health professionals on the verge of physical and psychological exhaustion.¹³13. Narain JP, Dawa N, Bhatia R. Health system response to COVID-19 and future pandemics. J Health Manag. 2020;22(2):138-45. doi: 10.1177/0972063420935538
https://doi.org/10.1177/0972063420935538... ^,1616. Mehta S, Machado F, Kwizera A, Papazian L, Moss M, Azoulay É, et al. COVID-19: a heavy toll on health-care workers. Lancet Respir Med. 2021;9(3):226-8. doi: 10.1016/S2213-2600(21)00068-0
https://doi.org/10.1016/S2213-2600(21)00... ^,2222. Silva GABE, Saraiva EV, Ferreira GJSN, Junior RMP, Ferreira LF. Healthcare system capacity of the municipalities in the state of Rio de Janeiro: Infrastructure to confront COVID-19. Rev Adm Publica. 2020;54(4):578-94. doi: 10.1590/0034-761220200128x
https://doi.org/10.1590/0034-76122020012... At the same time, the population’s fear of contracting SARS-CoV2 infection in health care services and, as a consequence, difficulties in maintaining the epidemiological surveillance system active, may have contributed to the reduction in notifications.

The COVID-19 social distancing measures adopted in Brazil may have influenced the epidemiological scenario of other communicable diseases.²³23. Kwak N, Hwang SS, Yim JJ. Effect of COVID-19 on tuberculosis notification, South Korea. Emerg Infect Dis. 2020;26(10):2506-8. doi: 10.3201/eid2610.202782
https://doi.org/10.3201/eid2610.202782...

24. Pang Y, Liu Y, Du J, Gao J, Li L. Impact of COVID-19 on tuberculosis control in China. Int J Tuberc Lung Dis. 2020;24(5):545-7. doi: 10.5588/ijtld.20.0127
https://doi.org/10.5588/ijtld.20.0127...

25. Belingheri M, Paladino ME, Piacenti S, Riva MA. Effects of COVID-19 lockdown on epidemic diseases of childhood. J Med Virol. 2020;93(1):153-4. doi: 10.1002/jmv.26253
https://doi.org/10.1002/jmv.26253...

26. Steffen R, Lautenschlager S, Fehr J. Travel restrictions and lockdown during the COVID-19 pandemic-impact on notified infectious diseases in Switzerland. J Travel Med. 2020;27(8):1-3. doi: 10.1093/jtm/taaa180
https://doi.org/10.1093/jtm/taaa180... ^-2727. Brady O, Wilder-Smith A. What is the impact of lockdowns on dengue?. Curr Infect Dis Rep. 2021;23(2):2. doi: 10.1007/s11908-020-00744-9
https://doi.org/10.1007/s11908-020-00744... Studies conducted in Brazil have analyzed the potential impact of the COVID-19 pandemic on dengue control actions and found that there has probably been underreporting of dengue cases, influenced by dengue control program activities being compromised and inaccessibility to care services due to the pandemic.²⁸28. Leandro CS, Barros FB, Cândido EL, Azevedo FR. Redução da incidência de dengue no Brasil em 2020: controle ou subnotificação de casos por COVID-19? Res Soc Dev. 2020;9(11):e76891110442. doi: 10.33448/rsd-v9i11.10442
https://doi.org/10.33448/rsd-v9i11.10442... ^,2929. Macarenhas MDM, Batista FMA, Rodrigues MTP, Barbosa OAA, Barros VC. Simultaneous occurrence of COVID-19 and dengue: what do the data show?. Cad Saude Publica. 2020;36(6):e00126520. doi: 10.1590/0102-311X00126520
https://doi.org/10.1590/0102-311X0012652... Another study showed that in Brazil, from January to August 2020, there was a 23% and 14% increase in dengue hospitalization and mortality rates, respectively, confirming the underreporting hypothesis.³⁰30. Dias NLC, Faccini-Martínez AA, Oliveira SV. Analysis of hospitalizations and mortality from to febrile, infectious, and parasitic diseases during the COVID-19 pandemic in Brazil. Inter Ame J Med Health. 2021;4:e202101005. doi: 10.31005/iajmh.v4i.173
https://doi.org/10.31005/iajmh.v4i.173...

Regarding interpretation of data from this study, the discussion needs to take into consideration the geographical context in which the RENAVEH network operates. The Hospital Epidemiology Hubs linked to the network are distributed over only 2.6% (145) of the country’s municipalities, and it is possible that the results of this study do not reflect the reality of all Brazilian municipalities. Another point to consider is that the findings of this study are limited to the three years prior to the pandemic, so that it is not possible to make comparisons taking previous periods into account. It is also important to point out that the sharp drop in notifications in EW 52 of 2018 is probably not related to notification failures but rather to data recording problems in the database we consulted.

We conclude that there was a decrease of approximately 150,000 compulsory notifications of DAEs made by the RENAVEH in 2020. This reduction in the number of notifications may be related to the repercussions of the COVID-19 pandemic on Brazil’s health system. It is therefore important that, in addition to actions aimed at controlling the pandemic, the epidemiological surveillance of other diseases in health services be strengthened, and it is necessary to ensure that measures for health promotion, prevention and recovery be developed alongside measures for responding to the COVID-19 pandemic.

References

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