ABSTRACT

The COVID-19 pandemic required the reorganization of PHC Units (UBS) to ensure greater laboratory diagnostic capacity timely, which demanded trained health professionals, availability of inputs/materials, and adequate sample management strategies at the Central Laboratory (LACEN). In 2020-2021, an analytical cross-sectional census study evaluated the UBS structure in the Federal District (DF). Data were collected remotely through structured telephone interviews and a self-completed questionnaire. Statistical analysis was carried out in Software R, comparing UBS-Sentinel with UBS-Traditional units. Nurse training in rapid testing or swab sample collection was almost universal (> 99%) and high among nursing technicians (70%). On the other hand, only 9% of doctors received any training. A defined flow was registered to forward samples to LACEN in 89% of UBS to diagnose SARS-CoV-2. The deadlines for returning laboratory results were met in 70% of cases. Inputs, materials, and equipment were available in sufficient amounts, especially at UBS-Sentinel units. In these UBS, 63% of the teams knew the MA-LACEN-0007 collection manual, compared to 35% at UBS-Traditional units (p < 0.001). Despite the challenges, the DF showed a satisfactory response capacity regarding the COVID-19 laboratory diagnosis.

KEYWORDS
Surge capacity; Primary Health Care; Public health surveillance; COVID-19

Introduction

On December 31, 2019, several cases of pneumonia of unknown etiology in Wuhan, China, were reported by the People’s Republic of China to the World Health Organization (WHO), later attributed to the SARS-CoV-2 virus. The first known South American case occurred on February 26, 2020¹1 World Health Organization. WHO Coronavirus Disease (COVID-19) Dashboard. World Health Organization Data [Internet]. 2020 [acesso em 2023 jul 13]. Disponível em: https://covid19.who.int/
https://covid19.who.int/... ,²2 World Health Organization. Disease Outbreak News: Pneumonia of unknown cause – China. WHO [Internet]. 2020 jan 5 [acesso em 2023 jul 13]. Disponível em: https://www.who.int/csr/don/05-january-2020-pneumonia-of-unkown-cause-china/en/
https://www.who.int/csr/don/05-january-2... . In Brazil, the Federal District (DF) registered the first case on March 5, 2020³3 Ministério da Saúde (BR), Secretaria de Vigilância em Saúde. COVID-19 Painel Coronavirus [Internet]. Brasília, DF: Ministério da Saúde; 2020 [acesso em 2023 set 19]. Disponível em: https://covid.saude.gov.br/
https://covid.saude.gov.br/... – and on March 11, the WHO declared the COVID-19 outbreak a Public Health Emergency of International Concern (PHEIC)¹1 World Health Organization. WHO Coronavirus Disease (COVID-19) Dashboard. World Health Organization Data [Internet]. 2020 [acesso em 2023 jul 13]. Disponível em: https://covid19.who.int/
https://covid19.who.int/... ,²2 World Health Organization. Disease Outbreak News: Pneumonia of unknown cause – China. WHO [Internet]. 2020 jan 5 [acesso em 2023 jul 13]. Disponível em: https://www.who.int/csr/don/05-january-2020-pneumonia-of-unkown-cause-china/en/
https://www.who.int/csr/don/05-january-2... . This disease’s most common signs and symptoms are respiratory infection, fever, cough, dyspnea, muscle pain, diarrhea, chest pain, and headache⁴4 Rader B, Scarpino SV, Nande A, et al. Crowding and the shape of COVID-19 epidemics. Nat Med. 2020;26(12):1829-1834. DOI: https://doi.org/10.1038/s41591-020-1104-0
https://doi.org/10.1038/s41591-020-1104-... ,⁶6 Zhang H, Liao YS, Gong J, et al. Clinical characteristics of coronavirus disease (COVID-19) patients with gastrointestinal symptoms: A report of 164 cases. Dig Liver Dis. 2020;52(10):1076-1079. DOI: https://doi.org/10.1016%2Fj.dld.2020.04.034
https://doi.org/10.1016%2Fj.dld.2020.04.... .

On May 5, 2023, the WHO declared the end of the PHEIC for COVID-19 due to the declining incidence of morbimortality and the high levels of immunization of the population against SARS-CoV-2. However, COVID-19 remains characterized as a pandemic because it is an infectious disease that still causes deaths worldwide⁷7 Organização Mundial da Saúde, Organização Pan-Americana da Saúde. OMS declara fim da Emergência de Saúde Pública de Importância Internacional referente à Covid-19. OMS [Internet]. 2023 maio 5 [acesso em 2023 out 28]. Disponível em: https://www.paho.org/pt/notidas/5-5-2023-oms-dedara-fim-da-emer-gencia-saude-publica-importancia-internacional-referente
https://www.paho.org/pt/notidas/5-5-2023... . In Brazil, as of October 30, 2023, there were 37,905,713 cases and 706,531 deaths (fatality rate of 1.9%)³3 Ministério da Saúde (BR), Secretaria de Vigilância em Saúde. COVID-19 Painel Coronavirus [Internet]. Brasília, DF: Ministério da Saúde; 2020 [acesso em 2023 set 19]. Disponível em: https://covid.saude.gov.br/
https://covid.saude.gov.br/... .

Primary Health Care (PHC) is the gateway to the Unified Health System (SUS). It plays a crucial role in the reception, prevention, diagnosis, and management of patients in the community due to its ability to reduce the overload of specialized care, especially in hospitals, organize the flow of users, and coordinate care⁸8 Ministério da Saúde (BR). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União, Brasília, DF. 2017 set 22; Seção I:68..

PHC has been discussed worldwide as one of the main strategies for controlling the COVID-19 pandemic, including testing and reporting.⁹9 Secretaria da Saúde do Estado (BA). Organização da APS pelo mundo durante a pandemia da COVID-19 [Internet]. Salvador: Sesab; 2020 [acesso em 2023 jul 13]. Disponível em: http://telessaude.saude.ba.gov.br/organizacao-da-aps-pelo-mundo-durante-a-pande-mia-da-covid-19/
http://telessaude.saude.ba.gov.br/organi... Early in the pandemic, diagnostic testing was recommended for individuals with symptoms or those exposed to people with suspected or confirmed COVID-19. Testing was also recommended for travel, leisure, and social and professional gatherings¹⁰10 Ministério da Saúde (BR); Conselho Nacional de Secretarias Municipais de Saúde. Guia Orientador Para o Enfrentamento Da Pandemia Covid-19 Na Rede de Atenção à Saúde. [Internet] Brasília, DF: Conasems; 2020 [acesso em 2023 jul 13]. Disponível em: https://www.conasems.org.br/guia-orienta-estados-e-municipios-para-o-enfrentamento-da-pandemia-de-covid-19-na-rede-de-atencao-a-saude/
https://www.conasems.org.br/guia-orienta... ,¹¹11 Ministério da Saúde (BR), Secretaria de Atenção Primária à Saúde. Protocolo de manejo clínico do Coronavírus (COVID-19) na Atenção Primária a Saúde [Internet]. Versão 9. Brasília, DF: Ministério da Saúde; 2020 [acesso em 2023 jul 13]. Disponível em: https://docs.bvsalud.org/biblioref/2020/05/1095920/20200504-protocolomanejo-ver09.pdf
https://docs.bvsalud.org/biblioref/2020/... . Timely test results helped inform patient recommendations, protect healthcare workers, and limit COVID-19 transmission¹²12 Kierkegaard P, McLister A, Buckle P. Rapid point-of-care testing for COVID-19: quality of supportive information for lateral flow serology assays. BMJ Open. 2021;11(3):e047163. DOI: https://doi.org/10.1136/bmjopen-2020-047163
https://doi.org/10.1136/bmjopen-2020-047... .

Thus, PHC contributed significantly to achieving equity and universality and acting in an integrated manner in health surveillance actions in the territories during the health crisis¹³13 Haldane V, Morgan GT. From resilient to transilient health systems: the deep transformation of health systems in response to the COVID-19 pandemic. Health Policy Plan. 2021;36(1):134-135. DOI: https://doi.org/10.1093/heapol/czaa169
https://doi.org/10.1093/heapol/czaa169... ,¹⁴14 Haldane V, Zhang Z, Abbas RF, et al. National primary care responses to COVID-19: a rapid review of the literature. BMJ Open. 2020;10:e041622. DOI: https://doi.org/10.1136/bmjopen-2020-041622
https://doi.org/10.1136/bmjopen-2020-041... ,¹⁵15 Wanat M, Hoste M, Gobat N, et al. Transformation of primary care during the COVID-19 pandemic: experiences of healthcare professionals in eight European countries. Br J Gen Pract. 2021;71(709):e634-e642. DOI: https://doi.org/10.3399/bjgp.2020.1112
https://doi.org/10.3399/bjgp.2020.1112... ,¹⁶16 Aslanyan L, Arakelyan Z, Atanyan A, et al. Primary healthcare providers challenged during the COVID-19 pandemic: a qualitative study. BMC Prim Care. 2022;23(1):1-0. DOI: https://doi.org/10.1186/s12875-022-01923-4
https://doi.org/10.1186/s12875-022-01923... ,¹⁷17 Harzheim E, Martins C, Wollmann L, et al. Ações federais para apoio e fortalecimento local no combate ao COVID-19: a Atenção Primária à Saúde (APS) no assento do condutor. Ciênc saúde coletiva. 2020;25(supl1):2493-2497. DOI: https://doi.org/10.1590/1413-81232020256.1.11492020
https://doi.org/10.1590/1413-81232020256... . Despite this, PHC health professionals faced insufficient training and input shortages and had to reorganize themselves for the new care flows¹⁸18 Xu Z, Ye Y, Wang Y, et al. Primary care practitioners’ barriers to and experience of COVID-19 epidemic control in China: a qualitative study. J Gen Intern Med. 2020;35(11):3278-3284. DOI: https://doi.org/10.1007/s11606-020-06107-3
https://doi.org/10.1007/s11606-020-06107... ,¹⁹19 Oseni TIA, Agbede RO, Fatusin BB, et al. The role of the family physician in the fight against Coronavirus disease 2019 in Nigeria. Afr J Prim Health Care Fam Med. 2020;12(1):1-3. DOI: https://doi.org/10.4102/PHCFM.V12I1.2492
https://doi.org/10.4102/PHCFM.V12I1.2492... ,²⁰20 Huston P, Campbell J, Russell G, et al. COVID-19 and primary care in six countries. BJGP Open. 2020;4(4):bjgpopen20X101128. DOI: https://doi.org/10.3399/bjgpopen20x101128
https://doi.org/10.3399/bjgpopen20x10112... . Furthermore, substandard working conditions have been documented in Asian and European countries, which resulted in lower care quality, representing a threat to the safety of patients and health professionals¹⁹19 Oseni TIA, Agbede RO, Fatusin BB, et al. The role of the family physician in the fight against Coronavirus disease 2019 in Nigeria. Afr J Prim Health Care Fam Med. 2020;12(1):1-3. DOI: https://doi.org/10.4102/PHCFM.V12I1.2492
https://doi.org/10.4102/PHCFM.V12I1.2492... ,²¹21 Mughal F, Khunti K, Mallen CD. The impact of COVID-19 on primary care: Insights from the National Health Service (NHS) and future recommendations. J Family Med Prim Care. 2021;10(12):4345. DOI: https://doi.org/10.4103/jfmpc.jfmpc_756_21
https://doi.org/10.4103/jfmpc.jfmpc_756_... ,²²22 Ismail M, Joudeh A, Neshnash M, et al. Original research: primary health care physicians’ perspective on COVID-19 pandemic management in Qatar: a web-based survey. BMJ Open. 2021;11(9):49456. DOI:https://doi.org/10.1136/BMJOPEN-2021-049456
https://doi.org/10.1136/BMJOPEN-2021-049... .

In the case of the COVID-19 pandemic, following the guidelines established by the WHO and the Ministry of Health²³23 World Health Organization. Global Influenza Surveillance and Response System (GISRS) sentinel surveillance for COVID-19: frequently asked questions (FAQ), 10 March 2022. Geneva: WHO; 2022.,²⁴24 Ministério da Saúde (BR). Portaria nº 205, de 17 de fevereiro de 2016. Define a lista nacional de doenças e agravos, na forma do anexo, a serem monitorados por meio da estratégia de vigilância em unidades sentinelas e suas diretrizes. Diário Oficial da União [Internet], Brasília, DF. 2016 fev 18 [acesso em 2023 ago 28]. Seção I:24. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2016/prt0205_17_02_2016.html
https://bvsms.saude.gov.br/bvs/saudelegi... , the Sentinel PHC units (UBS-Sentinel) developed actions to investigate outbreaks in a systematic, continuous, routine, and timely manner to respond to the pandemic. A sentinel unit collaborates in realizing health surveillance actions. It is an efficient and cost-effective way of collecting and managing data for managing diseases, especially infectious diseases²⁴24 Ministério da Saúde (BR). Portaria nº 205, de 17 de fevereiro de 2016. Define a lista nacional de doenças e agravos, na forma do anexo, a serem monitorados por meio da estratégia de vigilância em unidades sentinelas e suas diretrizes. Diário Oficial da União [Internet], Brasília, DF. 2016 fev 18 [acesso em 2023 ago 28]. Seção I:24. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2016/prt0205_17_02_2016.html
https://bvsms.saude.gov.br/bvs/saudelegi... .

In the Federal District, in addition to the UBS-Sentinel actions, the PHC Qualification Program (QualisAPS), established by Ordinance Nº 39 of January 23, 2019²⁵25 Secretaria de Estado de Saúde (DF). Portaria 39 de 23/01/2019. Institui, no âmbito do Sistema Único de Saúde do Distrito Federal, o Programa de Qualificação da Atenção Primária à Saúde. Diário Oficial do Distrito Federal [Internet], Brasília, DF. 2019 fev 14 [acesso em 2023 ago 10]; Seção I:6-7. Disponível em: https://www.sinj.df.gov.br/sinj/Norma/0bb8bd0f26ba4396a23602f2b993e613/Portaria_39_23_01_2019.html
https://www.sinj.df.gov.br/sinj/Norma/0b... , has closely monitored the restructuring of UBS to better qualify care for users and, in 2020, evaluated the APS response to the COVID-19 pandemic²⁶26 Furlanetto DDLC, Santos WD, Scherer MDDA, et al. Estrutura e responsividade: a Atenção Primária à Saúde está preparada para o enfrentamento da Covid-19? Saúde debate. 2022;46(134):630-647. DOI: https://doi.org/10.1590/0103-1104202213403
https://doi.org/10.1590/0103-11042022134... .

After the declared end of the international health emergency, COVID-19 took on another aspect: it became an infectious disease requiring continuous management, as with other notifiable diseases in Brazil that require constant monitoring⁷7 Organização Mundial da Saúde, Organização Pan-Americana da Saúde. OMS declara fim da Emergência de Saúde Pública de Importância Internacional referente à Covid-19. OMS [Internet]. 2023 maio 5 [acesso em 2023 out 28]. Disponível em: https://www.paho.org/pt/notidas/5-5-2023-oms-dedara-fim-da-emer-gencia-saude-publica-importancia-internacional-referente
https://www.paho.org/pt/notidas/5-5-2023... .

Despite the importance of knowing the epidemiological scenario experienced and the adaptations made in PHC to confront and diagnose the disease, there is a shortage of Brazilian studies that show this learning, which can be preserved and improved to sustain its control and prepare for other epidemics, supporting strategic programming, monitoring, and evaluation actions targeting infectious diseases at the first healthcare level.

When considering the need to identify PHC preparedness to respond to the demands of the pandemic in the epidemiological scenario of the international health emergency, this study analyzes the capacity of the PHC units (UBS) of the Brazilian Federal District (DF) for the laboratory diagnosis of COVID-19, including training of professionals, sample management strategies, and availability of diagnostic tests from 2020 to 2021.

Material and methods

This cross-sectional, analytical, census study was developed within the QualisAPS Program context. The data of interest were collected remotely from August 2020 onwards. Two (1.2%) of the 165 UBS in the Federal District delayed data collection but completed it on January 4 and 7, 2021. Thus, more than 99% of the data were collected in the first year of the pandemic (2020). Thus, we completed the research with 159 UBS (sample loss of 3.6%).

The managers of all UBS were contacted in advance to clarify the research and the requirement to sign the Informed Consent Form (TCLE), which must be done electronically before the interview.

The methodology involved interviews and completing a form. The interviews were structured and conducted via telephone calls with managers or supervisors from 159 UBS in the Federal District. After that, each respondent self-completed the electronic form, the link to which was made available via email.

An instrument developed as part of the activities of the QualisAPS Program was used to analyze the structure and response capacity of UBS to COVID-19 to produce information and collect data. This instrument comprises 11 Axes: Axis 1 (Respondent identification); Axis 2 (UBS identification); Axis 3 (UBS operation during the COVID-19 pandemic); Axis 4 (Workforce training); Axis 5 (Work organization and process); Axis 6 (Structure); Axis 7 (Equipment, furniture, and inputs); Axis 8 (Personal Protective Equipment – PPE); Axis 9 (Patient monitoring and exams); Axis 10 (Information, surveillance, integration and communication); and Axis 11 (Management). In total, 127 items made up the instrument. Furthermore, its application was divided into two modules: telephone (average duration of 45 minutes) and self-completion (average duration of 60 minutes)²⁶26 Furlanetto DDLC, Santos WD, Scherer MDDA, et al. Estrutura e responsividade: a Atenção Primária à Saúde está preparada para o enfrentamento da Covid-19? Saúde debate. 2022;46(134):630-647. DOI: https://doi.org/10.1590/0103-1104202213403
https://doi.org/10.1590/0103-11042022134... .

For Axis 4, we chose to analyze the variables related to the professional nurses, nursing technicians, doctors, dental surgeons, and oral health technicians who were legally qualified to perform the COVID-19 tests and diagnoses during the pandemic, sometimes because it is an action inherent to their professional practice (Medicine and Nursing) or because their professional entity authorized them to do so (Dentistry)²⁷27 Conselho Regional de Odontologia do Distrito Federal (BR). Decisão CRO-DF nº 20, de 26 de março de 2021 [Internet]. Distrito Federal: CRO; 2021 [acesso em 2023 set 24]. Disponível em: https://www.cro-df.org.br/
https://www.cro-df.org.br/... .

The instrument was hosted on the Research Electronic Data Capture Software (REDCap), an open-access data collection platform created by Vanderbilt University in Tennessee, United States of America²⁹29 Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: building an international community of software platform partners. J Biomed Inform. 2019;95:103208. DOI: https://doi.org/10.1016/j.jbi.2019.103208
https://doi.org/10.1016/j.jbi.2019.10320... .

The DF has 165 UBS, 61 of which are UBS-Sentinel for monitoring flu and severe acute respiratory syndrome; the remaining 104 are UBS-Traditional. The geographic distribution of the 159 participating UBS by Health Region (HR) was verified to identify the locations with the highest concentration of UBS-Sentinel units, specifying the Traditional and Sentinel UBS, using QGIS (version 3.20 .2, Odense), free and open-source Geographic Information System.

Statistical analyses were performed using R software (version 4.3.1), including relative frequency and Chi-square and Fisher’s tests. All study variables were crossed with the UBS-Sentinel variable to identify the percentage differences between these types and the UBS-Traditional, adopting a significance level of 5%. Therefore, the null hypothesis was rejected per each test applied for a p-value below 0.05.

This study was approved by the Research Ethics Committee of the Faculty of Health Sciences of the University of Brasília under the Certificate of Presentation of Ethical Appreciation (CAAE) Nº 29640120.6.0000.0030 and Opinion Nº 3.937.242, per Resolution N° 510/2016 of the National Health Council³⁰30 Ministério da Saúde (BR); Conselho Nacional de Saúde. Resolução nº 510, de 7 de abril de 2016. Dispõe sobre as normas aplicáveis a pesquisas em Ciências Humanas e Sociais cujos procedimentos metodológicos envolvam a utilização de dados diretamente obtidos com os participantes ou de informações identificáveis ou que possam acarretar riscos maiores do que os existentes na vida cotidiana. Diário Oficial da União, Brasília, DF. 2016 maio 24; Edição 98; Seção I:44..

Results

The 57 UBS-Sentinel are concentrated in more significant numbers in HR Southwest and West, both with 15. In this study, we described the qualification for the diagnosis of COVID-19 of 159 UBS that responded to the instrument to evaluate the structure. The UBS are distributed across the seven HRs of the DF, namely: Central (n=9), Center-South (n=18), East (n=24), North (n=35), West (n=27), Southwest (n=28), and South (n=18); 35.8% (n=57) are UBS-Sentinels, and 64.2% (n = 102) are UBS-Traditional (figure 1).

Concerning the training of UBS professionals, training in rapid testing or swab sample collection among nurses was almost universal (99.7%) and high (70.4%) among nursing technicians, with no significant association between the proportion of trained professionals and UBS type. Doctors’ lack of training to run both tests is noteworthy in UBS-Sentinel and UBS-Traditional (91.2% and 90.2%, respectively, without any training) (table 1). Oral health technicians were trained to run rapid tests (antibody tests) for the timely diagnosis of COVID-19, which was more frequent at UBS-Sentinel (38.6%) than at UBS-Traditional (26 .5%) units, and statistically significant (p < 0.016).

Regarding how training was conducted to perform COVID-19 tests in the professional categories studied, 93.1% of professionals from UBS-Traditional, compared to 86% of professionals from UBS-Sentinel, indicated that they underwent this training by reading technical notes and analyzing COVID-19 management protocols (92.2% UBS-Traditional and 80.7% UBS-Sentinel) (table 2).

When checking the availability of materials and inputs for processing or sending tests for the diagnosis of COVID-19, we observed no significant difference between the UBS-Sentinel and the UBS-Traditional for most of the items researched (except labels). In the case of having a refrigerator, 80.7% of UBS-Sentinel units stated that they had this equipment for storing samples for COVID-19 compared to 60.8% of UBS-Traditional units, which highlights an association between having a label and refrigerator (p < 0.019 and p < 0.009 respectively) and being a UBS-Sentinel unit.

More than 50% of the UBS, regardless of whether they were Sentinel or Traditional, had a thermometer, isothermal box, and rigid reusable artificial ice to preserve samples for COVID-19 at the ideal temperature (table 3).

When managers were asked about the availability of COVID-19 diagnostic tests in their UBS at the time of the research, more than half of the UBS (Sentinel or Traditional) had sufficient swab test kits and rapid tests (table 3).

For the managing test samples, that is, the flow between PHC and the Central Public Health Laboratory of the Federal District (LACEN-DF), the results showed an association between being UBS-Sentinel and the team knowing the MA-LACEN-0007 collection manual, emphasizing that more than half of the Sentinel UBS teams (63.2%) reported knowing it when compared to the Traditional UBS teams (35.3%) (p < 0.000).

The materials collected at the UBS were mainly sent to LACEN-DF at the Sentinel and Traditional UBS (92.9% and 85.3%, respectively). The significant majority of UBS-Sentinel (94.7%) and UBS-Traditional (85.3%) stated that they had a defined laboratory flow for forwarding samples and the availability of a vehicle to transport samples with a defined route (around 80% to 90%). The proportions were higher in the UBS-Sentinel, although the differences were insignificant (table 4).

Although there was no evidence of an association between the Sentinel and Traditional UBS in meeting laboratory return deadlines, more than half of both UBS (73.7% and 67.6%, respectively) reported receiving the results of COVID-19 laboratory tests within the deadlines.

Discussion

In 2020, the Brazilian Institute of Geography and Statistics (IBGE) did not perform the census, but population estimates for the DF that year indicated 3,052,546 inhabitants³¹31 Secretaria de Estado de Saúde (DF). Relatório Anual de Gestão 2020 [Internet]. Brasília, DF: Secretaria de Estado de Saúde; 2021 [acesso em 2023 set 14]. 214 p. il. Disponível em: https://www.saude.df.gov.br/documents/37101/0/Relat%C3%B3rio+Anual+de+-Gest%C3%A3o+2020.pdf/b6093f42-f425-7854-72d-9-5604cc8479a8?t=1718888512239
https://www.saude.df.gov.br/documents/37... . The results revealed that the distribution of UBS-Sentinel units in the HR was proportional to the number of inhabitants, with a more significant number of UBS-Sentinel units concentrated in the two most populous HRs: Southwest, with 829,672 inhabitants, and West, with 507,851 inhabitants. Furthermore, they were the regions with the highest number of cases and deaths³3 Ministério da Saúde (BR), Secretaria de Vigilância em Saúde. COVID-19 Painel Coronavirus [Internet]. Brasília, DF: Ministério da Saúde; 2020 [acesso em 2023 set 19]. Disponível em: https://covid.saude.gov.br/
https://covid.saude.gov.br/... . Conversely, HR South, which has 272,959 inhabitants, appeared with the lowest number of UBS-Sentinel units.

Due to its premise established in the National Primary Care Policy (PNAB), the Traditional UBS units are characterized by care based on the SUS principles and guidelines regarding health promotion and disease prevention activities. During the pandemic, they were restructured for immediate care to contain the disease, with service offerings targeting almost exclusively COVID-19 due to its high incidence³²32 Aleluia ÍRS, Vilasbôas ALQ, Pereira GE, et al. Gestão estadual da atenção primária à saúde em resposta à COVID-19 na Bahia, Brasil. Ciênc saúde coletiva. 2023;28(5):1341-1353. DOI: https://doi.org/10.1590/1413-81232023285.12732022
https://doi.org/10.1590/1413-81232023285... . However, in 2023, given the end of the international health emergency, actions targeting COVID-19 are still offered in the Traditional UBS. However, they focus on managing it as a notifiable disease, whose vaccine is now included in the National Immunization Program (PNI) calendar and no longer in the Operational Plan for Vaccination Against the New Coronavirus.

Furthermore, several programs, services, and workshops were resumed due to the disease’s reduced incidence and behavior for specific groups and general users³³33 Ministério da Saúde (BR); Fundo Nacional de Saúde. Cartilha para apresentação de propostas ao Ministério da Saúde – 202 [Internet]. Brasília, DF: Ministério da Saúde; 2023 [acesso em 2023 out 29]. 176 p. Disponível em: https://portalfns.saude.gov.br/wp-content/uploads/2023/03/CARTILHA_2023Jivro-digital.pdf
https://portalfns.saude.gov.br/wp-conten... . The UBS-Sentinel units remain active as they are intended to operate as an active observatory of the quality and safety of products and services regardless of pandemics. Among their objectives are assistance to the continuous improvement of risk management in health services and the contribution to the training activities of health professionals, such as continuing education and production of knowledge in their scope of action³⁴34 Ministério da Saúde (BR); Agência Nacional de Vigilância Sanitária. Resolução da Diretoria Colegiada – RDC nº 51, de 29 de setembro de 2014. Dispõe sobre a Rede Sentinela para o Sistema Nacional de Vigilância Sanitária. Diário Oficial da União, Brasília, DF [Internet]. 2014 out 1 [acesso em 2023 set 19]; Seção I:50-51. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/anvisa/2014/rdc0051_29_09_2014.html
https://bvsms.saude.gov.br/bvs/saudelegi... .

During the COVID-19 pandemic, the UBS-Sentinel units supported trend analysis and management of disease transmission risk by recording and monitoring cases. The WHO provided Member States, including Brazil, with guidance on preparation, readiness, and response, highlighting the relevance of strengthening existing national systems to increase surveillance capacity³⁵35 World Health Organization. Laboratory testing of 2019 novel coronavirus (2019-nCoV) in suspected human cases: interim guidance, 17 January 2020 [Internet]. Geneva: WHO; 2020 [acesso em 2023 set 2]. Disponível em: https://www.who.int/publications/i/item/10665-331501
https://www.who.int/publications/i/item/... .

In 2020, the DF government issued Technical Note Nº 5, defining the response levels of the PHC service to combat COVID-19. These include monitoring care by HR to provide opportunities for case resolution and mitigating the disease, increasing response capacity, ensuring access, diagnosis, adequate treatment, and referral of complex cases to other care levels besides telemonitoring confirmed or suspected cases. Diagnostic capacity refers to the health system’s response to mobilizing quickly in the face of increased demand arising from large-scale needs or public health emergencies³⁶36 Secretaria de Estado de Saúde (DF). Nota Técnica nº 5 de 02 de setembro de 2020 [Internet]. Distrito Federal: SES-DF; 2020 [acesso em 2023 set 19]. Disponível em: https://www.saude.df.gov.br/documents/37101/1264413/Nota-Te%CC%81cnica-NIVEIS-DE-RESPOSTA-APS.pdf
https://www.saude.df.gov.br/documents/37... .

Implementing work reorganization and applying diagnostic tests required timely training of front-line health professionals to minimize risks to themselves and users¹⁹19 Oseni TIA, Agbede RO, Fatusin BB, et al. The role of the family physician in the fight against Coronavirus disease 2019 in Nigeria. Afr J Prim Health Care Fam Med. 2020;12(1):1-3. DOI: https://doi.org/10.4102/PHCFM.V12I1.2492
https://doi.org/10.4102/PHCFM.V12I1.2492... ,²⁰20 Huston P, Campbell J, Russell G, et al. COVID-19 and primary care in six countries. BJGP Open. 2020;4(4):bjgpopen20X101128. DOI: https://doi.org/10.3399/bjgpopen20x101128
https://doi.org/10.3399/bjgpopen20x10112... . PHC health professionals were trained in strategies for understanding flu syndrome, infection risk control measures, biosafety improvement, investigating suspected cases of SARS-CoV-2 infection, health education in the community on safety measures protection against the virus, and procedures to ensure their health during the collection and handling of samples that cause health problems³⁷37 Vieira SL, Souza SG, Figueiredo CF, et al. Ações de educação permanente em saúde em tempos de pandemia: prioridades nos planos estaduais e nacional de contingência. Ciênc saúde coletiva. 2023;28(5):1377-1386. DOI: https://doi.org/10.1590/1413-81232023285.11252022
https://doi.org/10.1590/1413-81232023285... .

In-service training through reproducing real-world situations in a safe environment is an appropriate methodology for preparing professionals to address diseases³⁸38 Santos TM, Pedrosa RB, Carvalho DR, et al. Implementing healthcare professionals’ training during COVID-19: a pre and post-test design for simulation training. São Paulo Med J. 2021;139(5):514-519. DOI: https://doi.org/10.1590/1516-3180.2021.0190.R1.27052021
https://doi.org/10.1590/1516-3180.2021.0... . However, considering the COVID-19 pandemic, which surged with an accelerated spread of cases and deaths and a shortage of inputs and materials, health services were required to adapt rapidly. This meant that most of the training occurred online and was self-instructional, with the dissemination of technical notes and protocols prepared by the WHO and the DF State Health Secretariat. This development of standards, routines, protocols, and service flows guided the reorganization of care provision in this scenario³⁹39 Silva VG, Silva BN, Pinto ÉS, et al. Trabalho do enfermeiro no contexto da pandemia de COVID-19. Rev Bras Enferm. 2021;74:e20200594. DOI: https://doi.org/10.1590/0034-7167-2020-0594
https://doi.org/10.1590/0034-7167-2020-0... and was probably favored by the Family Health teams (eSF).

Although evidence points to the Family Health Strategy (ESF) as a tool that favors an organized response to health problems in PHC, the coordination of care, and referral to specialized services⁴⁰40 Souza CDF, Gois-Santos VT, Correia DS, et al. The need to strengthen primary health care in Brazil in the context of the COVID-19 pandemic. Braz Oral Res. 2020;34:e047. DOI: https://doi.org/10.1590/1807-3107bor-2020.vol34.0047
https://doi.org/10.1590/1807-3107bor-202... , the DF PHC was only organized as such in 2017, when the ‘Converte APS’⁴¹41 Corrêa DSRC, Moura AGDOM, Quito MV, et al. Movimentos de reforma do sistema de saúde do Distrito Federal: a conversão do modelo assistencial da Atenção Primária à Saúde. Ciênc saúde coletiva. 2019;24(6):2031-2041. DOI: https://doi.org/10.1590/1413-81232018246.08802019
https://doi.org/10.1590/1413-81232018246... was implemented.

Among other actions, when Converte APS was implemented, besides training professionals in family and community medicine toward the new generalist way of offering care to the population, opening hours expanded in the UBS with four or more eSFs (due to the possibility of composing schedules), moving to 7 am to 7 pm, uninterruptedly and 7 am to 12 pm on Saturdays, with the possibility of opening until 10 pm. Considering that the pandemic began in 2020, we can infer that the change in flows and routines imposed by SARS-CoV-2 found PHC better focused on the concepts of client enrollment and longitudinal monitoring, fundamental to sentinel surveillance and COVID-19 management⁴¹41 Corrêa DSRC, Moura AGDOM, Quito MV, et al. Movimentos de reforma do sistema de saúde do Distrito Federal: a conversão do modelo assistencial da Atenção Primária à Saúde. Ciênc saúde coletiva. 2019;24(6):2031-2041. DOI: https://doi.org/10.1590/1413-81232018246.08802019
https://doi.org/10.1590/1413-81232018246... .

Another critical point is that almost all nurses stated they were qualified to perform rapid tests (and swab collection), contributing to the early diagnosis of suspected COVID-19 cases, contact screening, and conducting educational actions. In this context, nursing was center-stage in the organization of services, searching for the provision of necessary inputs and materials and conducting training with other team professionals to run tests, manage inputs and samples, and be updated on vaccines³⁹39 Silva VG, Silva BN, Pinto ÉS, et al. Trabalho do enfermeiro no contexto da pandemia de COVID-19. Rev Bras Enferm. 2021;74:e20200594. DOI: https://doi.org/10.1590/0034-7167-2020-0594
https://doi.org/10.1590/0034-7167-2020-0... . The pandemic’s dynamics modified the work process and care offerings of medical professionals and other PHC workers. Although they recognize their relevance in managing infected patients, preventing disease, ensuring continuity of treatment for non-infected patients, and being trained to act in emergencies, a study in São Paulo showed that this was insufficient to prepare them to face COVID-19⁴²42 Fernandez M, Lotta G, Oliveira GSS. Por Trás da Máscara: Percepções dos Médicos que Atuam na Linha de Frente da Pandemia de COVID-19 no Estado de São Paulo. Nota Técnica n. 12 [Internet]. São Paulo: IEPS; 2020 [acesso em 2023 set 2]. Disponível em: https://ieps.org.br/wp-content/uploads/2021/11/IEPS_NT12_Medicos.pdf
https://ieps.org.br/wp-content/uploads/2... .

Tackling this disease required inputs, the development of diagnostic tests to detect SARS-CoV-2 by industries⁴³43 Loeffelholz MJ, Tang YW. Laboratory diagnosis ofemerging human coronavirus infections-the state of the art. Emerg Microbes Infect. 2020;9(1):747-756. DOI: https://doi.org/10.1080/22221751.2020.1745095
https://doi.org/10.1080/22221751.2020.17... , the contribution of teaching and research institutions⁴⁴44 Cavalcante FV, Oliveira A, Araujo SQ, et al. Testes diagnósticos nacionais: insumos essenciais para a vigilância sindrômica da Covid-19. Saúde debate. 2022;46(134):665-681. DOI: https://doi.org/10.1590/0103-1104202213405
https://doi.org/10.1590/0103-11042022134... , and laboratory operationalization⁴⁵45 Ministério da Saúde (BR), Secretaria de Vigilância em Saúde. Guia de vigilância epidemiológica: emergência de saúde pública de importância nacional pela doença pelo coronavírus 2019 – covid-19 [Internet]. Brasília, DF: MS; 2020 [acesso em 2023 set 21]. Disponível em: https://www.gov.br/saude/pt-br/coronavirus/publicacoes-tecnicas/guias-e-planos/guia-de-vigilancia-epidemiologica-covid-19/
https://www.gov.br/saude/pt-br/coronavir... . The findings of this study highlight the relevance of inputs and the management and definition of sample flows to laboratories by PHC in the DF, aligned with studies by other authors⁴⁶46 Magno L, Rossi TA, Mendonça-Lima FW, et al. Desafios e propostas para ampliação da testagem e diagnóstico para COVID-19 no Brasil. Ciênc saúde coletiva. 2020;25(9):3355-3364. DOI: https://doi.org/10.1590/1413-81232020259.17812020
https://doi.org/10.1590/1413-81232020259... , who reported the essential role of PHC due to its capillarization in the Brazilian territory and for its ability to reorganize in the face of the health crisis, increasing epidemiological surveillance actions, with adequate reception, tracking, diagnosis, and notification of COVID-19 cases.

This study identified that rapid tests and swab tests existed in sufficient amounts in more than 60% of UBS in the DF, corroborating the recommendations of the Guide on Integrated Surveillance of Acute Respiratory Syndromes Coronavirus Disease 2019, Influenza, and other respiratory viruses⁴⁷47 Ministério da Saúde (BR), Secretaria de Vigilância em saúde. Doença pelo coronavírus Covid-19. Boletim Epidemiológico Especial nº 59 [Internet]. Semana Epidemiológica 8 (21 a 27/2/2021). 2021 [acesso em 2023 set 23]. Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/boletins/epidemiologicos/covid-19/2021/boletim_epidemiologico_covid_52_final2.pdf
https://www.gov.br/saude/pt-br/centrais-... and Technical Note N° 3048, which describes PHC actions as a starting point for investigating COVID-19 cases, diagnosis through the tests mentioned above, and monitoring of service users tested with a positive result for SARS-CoV-2.

The diagnostic methods used to detect COVID-19 in PHC were rapid tests found in two types on the market: I) Those that identify proteins in the infection’s active phase, known as antigen tests, and II) Those that detect antibodies as the body’s immune response when exposed to the virus, both called serological methods. There were also molecular methods with the Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) technique, considered the gold standard by the WHO³⁵35 World Health Organization. Laboratory testing of 2019 novel coronavirus (2019-nCoV) in suspected human cases: interim guidance, 17 January 2020 [Internet]. Geneva: WHO; 2020 [acesso em 2023 set 2]. Disponível em: https://www.who.int/publications/i/item/10665-331501
https://www.who.int/publications/i/item/... due to its high sensitivity and specificity and for identifying the virus RNA by amplifying nucleic acid by polymerase chain reaction in the sample collected by the oral/nasal swab test⁴⁹49 Oliveira MAL, Watanabe ASA, Cesar DE, et al. Testes diagnósticos para o SARS-COV-2: uma reflexão crítica. Quím Nova. 2022;45(6):760-766. DOI: https://doi.org/10.21577/0100-4042.20170895
https://doi.org/10.21577/0100-4042.20170... .

Thus, in addition to the availability of tests, we underscore the relevance of available materials and inputs, such as a refrigerator, isothermal box, and rigid recycled artificial ice, for handling samples in PHC. These align with WHO recommendations²³23 World Health Organization. Global Influenza Surveillance and Response System (GISRS) sentinel surveillance for COVID-19: frequently asked questions (FAQ), 10 March 2022. Geneva: WHO; 2022. for storing samples collected by the oropharyngeal and nasopharyngeal swab test at temperatures around 2-8 ºC. Furthermore, the literature review by Loeffelholz et al.⁴³43 Loeffelholz MJ, Tang YW. Laboratory diagnosis ofemerging human coronavirus infections-the state of the art. Emerg Microbes Infect. 2020;9(1):747-756. DOI: https://doi.org/10.1080/22221751.2020.1745095
https://doi.org/10.1080/22221751.2020.17... reported the importance of sample handling to increase the likelihood of diagnosis of the analyzed biological marker.

This study has limitations inherent to cross-sectional studies regarding the temporality of observation and the data collection method, by telephone and self-completed questionnaire, having obtained the data mentioned above, given the impossibility of doing it in person due to the pandemic outlook.

Conclusions

We noticed that the UBS COVID-19 diagnostic capacity was linked to challenges related to testing and diagnosis. Doctors were the UBS-Sentinel professionals who reported less training to run the tests than nurses and oral health technicians. This training for all professionals studied occurred mainly in a self-instructional way, with online courses as reading protocols. Protocols for handling samples and flows for their processing were in place. Also, communication with LACEN-DF was satisfactory, as most of the samples were sent promptly.

The materials and supplies for collecting, storing, and processing the samples were available in sufficient amounts most of the time at the UBS-Sentinel, such as adhesive labels for identifying the samples and the refrigerator. Considering that PHC is the organizer of care in Healthcare Networks, having trained professionals to run tests, manage samples, coordinate the laboratory, and having inputs, materials, and equipment available meant that the DF had adequate diagnostic capacity for COVID-19. Although this study shows a satisfactory response in facing the COVID-19 pandemic, it is necessary to analyze the potentialities and challenges faced by PHC in the DF so that new interventions can be implemented in the context of strategic planning at different levels of local management to prepare in advance for other health crises.

References

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