Health Surveillance within the Primary Healthcare scope to face the Covid-19 pandemics: a document review

Health Surveillance strategies are crucial to organize a strong national response against the coronavirus disease 2019. In Brazil, it is necessary to think about the integration of the Primary Health Care (PHC) and local Health Surveillance. This review aims to analyze the normative documents produced by the Federal Government on this topic. Official documents published by the Federal Government were reviewed, finding 21 related. It was identified a greater support for implementation of intramural actions related to detection and notification of cases and contacts than for active search of community Covid-19 cases, local educational actions, community engagement, strengthening adherence to preventive measures, improvement of information sharing, or support of community’s social facilities. Little was produced about the articulation of PHC with local surveillance teams. Our findings reinforce what was found by other authors, who attested the insufficient importance attributed to PHC in Brazil, especially with regard to Health Surveillance actions. Unfortunately, our country has stood out for one of the worst managements of the health crisis in the world, and there is an urgent need to strengthen surveillance actions based on a strong, capillary, and community-based PHC.


Introduction
The 2019 coronavirus disease  pandemic is currently the biggest threat to the health of the world's population, accounting for more than 130 million cases and nearly 3 million deaths worldwide by April 2021 1 . Similar to what happened more than a hundred years ago, with the 1918 influenza pandemic, responsible for more than 50 million deaths, the planet faced again, at least until December 2020, a similar catastrophe without curative treatments or access to vaccines 2, 3 . Despite this, it is known that non-pharmacological measures reduce the spread of the virus and limit the occurrence of serious illness and death 4-6 . The international experience on such measures to combat infection by Sars-CoV-2 (coronavirus responsible for severe acute respiratory syndrome type-2) has shown how much unprecedented mobilization of health systems and national-level responses was needed 7-10 , recognizing the importance of decisive government leadership to implement surveillance interventions aimed at containing the transmission of this virus 11, 12 . A major challenge is to implement these measures quickly, strategically and with effective engagement of the population, in a context of constant tension 13 .
The Brazilian Unified Health System (SUS), based on the principles of universality, integrality and equity, with the capillarity of its services, has the potential to deal with the pandemic 14 . Public Health Surveillance (PHS) strategies allow the identification and monitoring of diseases, occurrences and health indicators of the population, and the production of agile and reliable information to support decision-making 15 . Therefore, in the context of the current pandemic, they are indispensable strategies to organize a strong national response 16 . Efforts to expand and give greater precision to measures require organizing surveillance actions in health regions with Primary Health Care (PHC) as the organizing center and considering the different levels of complexity 16 . The strengthening of the Brazilian PHC care model, characterized by a territorial and community approach, and with an important role in improving the population's health conditions, can constitute one of the fundamental supports of the actions necessary to contain the problem 17 . PHC teams know their population and territory well, which allows for a better analysis and interpretation of risks and vulnerabilities of individuals, families and the community 15 . In this way, PHC is essential in improving traditional surveillance actions through early and accurate detection of cases in the population for which they are responsible, tracing the contacts of identified cases, supervising patients in isolation, coordinating in close cooperation with the sectors of PHS of the municipality, mechanisms and flows of referral, counter-referral and matrix support, contributing, among other things, to a better understanding of the epidemiological evolution of the disease 14,16,18 . Furthermore, actions such as articulation with the PHS of the municipalities to establish information flows, educational activities in the territory, awareness of the population, combating fake news or dissemination of measures to protect workers and users in the various social facilities can be actions developed in the scope of APS to combat the Covid-19 pandemic 19 .
This review intends to identify the official documents produced by the Brazilian government to deal with Covid-19 related to the PHS that advocate interventions by PHC teams, and to analyze the proposed interventions in relation to the possibilities of action of PHC services in the SUS network, considered a one of the pillars of the response to emergency situations. and excluding epidemiological bulletins and public calls. The title, summary and objective of the documents identified were read and analyzed in order to select those related to the topic addressed, that is, actions to combat the pandemic within the scope of PHC, and from them, those that involved PHS measures. In cases where the title and the syllabus or subject did not make the objective of the research clear or the document did not present an outline or subject, this data was sought by analyzing the complete document. Once the publications were collected, a duplicity check was carried out to remove the repeated documents. Those selected were read in full; and, still at this stage, some texts that did not correspond to the objectives of this research were excluded. In all, 3,274 official documents were located. After applying the inclusion and exclusion criteria, 386 documents were selected for reading. The detailed reading of the publications determined the need to deepen in 21 texts, which were read in their entirety, composing all the corpus of this research. The list of documents included in this analysis is presented in table 1.

Material and methods
The selected documents were analyzed in terms of the following aspects: 'body that prepared the document', 'publication date' and 'type of intervention'. For the analysis of the type of intervention, as the main reference, the categories proposed by Medina et al. 19 were adopted when analyzing the possibilities of action of PHC services in the SUS network that contribute to the control of the epidemic and that, simultaneously, fulfill their essential function of guaranteeing daily and capillary care, identifying that PHC performance can be systematized in four axes: i) PHS in the territories; ii) attention to users with Covid-19; iii) social support to vulnerable groups; and iv) continuity of APS' actions. For this review, only official documents associated with the PHS in the territories axis were analyzed.
For this analysis, the PHS is understood, according to the theoretical model proposed by Silva and Vieira da Silva 20 , as a process of organizing practices that articulate the promotion of the population's health, prevention, risk control and the timely and adequate care of diseases. In this sense, Medina et al. 19 propose that the PHS in the territories to face the epidemic implies the performance of interventions by the PHC teams that aim to block and reduce the risk of expansion, acting in an articulated way with the PHS of the municipalities, establishing flows of information to improve the quality of actions. Notification, detection, monitoring of cases, home isolation and quarantine of contacts are also central epidemic mitigation activities to be developed, as well as the encouragement of social isolation, that can be carried out by all team professionals, especially Community Health Agents (ACS), mobilizing local leaders and resources with wide dissemination of information and implementation of concrete measures. Other actions that may be developed by ACS are included, such as raising awareness among the population and combating stigma related to the disease, disseminating correct information on the prevention of Covid-19, combating fake news and supporting educational activities in the territory related to hygiene and protection of workers and users in the various social facilities, so that they constitute safe environments for the population.   One of the first documents to be produced was the National Contingency Plan, on February 26, 2020, in a single version, followed by documents with specific objects, such as pharmaceutical assistance, recommendations for ACS, oral health strategy and general documents on individual preventive measures, safety at work and changes in the work process aimed at other PHC workers, among others. Ordinances were also published on financial incentives, reorganization of activities carried out within the scope of PHC, such as vaccination, consultation on the street, assistance to indigenous health and vulnerable populations. Subsequently, guides and guiding protocols for the prevention, control, surveillance, diagnosis and treatment of Covid-19 were published, being quickly updated in new versions, such as the case of the Protocol for the clinical management of Covid-19 in PHC, reaching the ninth version. The classification of official documents included in the analysis, according to the analysis categories adopted, is presented in table 2.

Public health surveillance in the territories
Articulation with municipal health surveillance X X X X X X X Establishment of information flows X X Notification of cases X X X X X X X X X X Detection of cases X X X X X X X X X X X X X X Follow-up and monitoring of contacts X X X X X Encouraging social isolation and disseminating information on concrete measures X X X X X population awareness X X X

Dissemination of correct information on preventing and combating fake news
Educational activities in the territory X X X X X X X X X Regarding the investigation, tracing and monitoring of contacts, in the second version of the 'Epidemiological Surveillance Guide', it is clearly stated that, even in a poorly structured way, these are exclusive actions of the 'investigator teams' that would be composed of at least one technician from municipal health surveillance and another from primary care (document 17). It is evident that, even if the importance of surveillance of new suspected cases of ILI and contacts in the community is recognized, procedures are not detailed to make these actions possible, such as the coordination of PHS with municipal surveillance to encourage the functioning of these teams of investigators and to carry out the active search of the cases in a broad way. For the identification of intra-household contacts, nothing is mentioned about the approximation of the PHC teams with the municipal surveillance teams, minimizing the importance of exchanging information for the coordination of actions (documents 12 and 17).
Actions regarding the interaction between the PHC teams and the surveillance teams are only mentioned more clearly in document 17, but in a succinct way, highlighting that, during the care of all suspected patients, it is important to test the patient, notify the case and trigger surveillance to investigate the contacts. As for the 'Consultation on the Streets' teams, there is a special indication on the active search and continuity of care (document 6). The indication of isolation for people with respiratory symptoms and for their contacts residing at the same address was maintained exclusively by medical prescription, for a maximum of 14 days (document 5), without being clear the role of incentive mechanisms for isolation that could be adopted, incorporating the participation of other professionals from the health teams, or even from the surveillance teams. Document 12 refers to the role of PHC teams in supporting active surveillance, but very succinctly, and on actions restricted to nursing homes/elderly homes, specifically on prevention, education on hygiene and distancing, and to reduce the risk of contagion (document 12). However, other documents suggested the possibility of APS acting in partnership with local surveillance teams in testing actions, guidance to the population on home isolation measures and preventive measures, remote monitoring of contacts and establishment of partnerships with residents' associations, educational institutions and other bodies (documents 11,13,14,17). These actions were specifically strengthened for the Psychosocial Care Network and to support strategic actions to support pregnancy, prenatal care and the puerperium, in documents that also incorporate a specific format for funding these actions (document 18 and 21). It will only be in September that two documents operationalized and allocated financial incentives to the actions of tracking and monitoring cases in a broad way, clearly establishing in their objectives to maintain and strengthen the integration of PHS and PHC, with a local perspective to identify in a timely manner the cases of Covid-19 and contacts, among other actions of PHS (documents 19 and 20).
The participation of ACS in specific surveillance actions is briefly suggested in the second version of the Surveillance Guide, as potential participants in the 'investigator teams' in charge of making home visits to monitor contacts (document 17). Even so, regarding the performance of this professional category, in previous documents, the home visit was recognized as a tool to inform and actively search for suspected cases and contacts of confirmed cases, in compliance with patient and professional safety measures (documents 7 and 9). Other surveillance actions that can be carried out by ACS were also detailed, such as: assisting the team in identifying suspected cases of ILI and Covid-19; assist the team in monitoring suspected and confirmed cases; carry out an active search for new suspected cases of ILI, indication of home isolation; advise the population about the disease, prevention measures and signs and symptoms (document 7 and 9).
In the documents evaluated, little was discussed about the flow of information between testing centers, laboratories, hospital centers and the municipal PHC network, and the sharing of information is carried out exclusively by the Laboratory Environment Manager (GAL) system for the Central Laboratories for Public Health (Lacen), and other laboratories would have to make the necessary adjustments regarding the use of the National Health Data Network (RNDS), making it difficult to exchange information and affecting the quality of surveillance actions (document 17). Likewise, no discussion was identified about the possibility of extensive testing within the scope of the PHC and the flows for transporting samples from the PHC network to the Lacen. It was only pointed out that this could be done through the use of rapid tests in symptomatic people with more than seven days of symptoms, prioritizing testing for risk groups, for which the intention of progressively providing more tests was mentioned (document 12).
Another aspect that was also mentioned, but briefly, was the importance of implementing actions that increase the population's engagement with preventive measures such as social isolation, based on the mobilization of local leaders and resources in the various measures to combat Covid-19 (document 17). Only document 16 provides guidelines for action in social facilities, specifically on strengthening measures to prevent and control Sars-CoV-2 infections in Institutional Shelter Units for the elderly -Long-stay Institution for the Elderly (Ilpi). Likewise, little was mentioned about actions to disseminate correct information on the prevention of Covid-19, measures to support educational activities in the territory or measures to combat fake news, actions that could be carried out by ACS.

Final considerations
This review highlights that documentary production to combat the pandemic began before the diagnosis of the first confirmed case, still in January, when the Emergency Operations Center of the Ministry of Health -coordinated by the Health Surveillance Secretariat (SPHS/MS) -was implemented. This production was the majority between the months of March and June 2020, coinciding with the first wave of the pandemic; but only later, starting in August, with the second version of the Surveillance Guide, initiatives to articulate surveillance between the municipalities and the PHC health teams were clearly identified. During this period, the Ministry of Health underwent two ministerial changes, highlighting the inauguration of the last interim minister, a general with no experience in the field of health 22 . Since December, the crisis has been worsening with a progressive increase in the incidence and mortality due to Covid-19 1,23 , in contrast to a scarce production of official documents on the subject. Regarding the reorganization of PHC services to face the pandemic, the limited technical normative production of the federal government attests to the low priority, making it difficult to implement effective measures to combat the pandemic. This production placed greater emphasis on case detection and notification strategies, relegating crucial aspects such as guidelines for technical support to the teams, dissemination of correct information on prevention, combating fake news, public awareness or the establishment of information flows with other points in the network.
International experience has shown how essential the coordination of actions at the national level is for a successful management of the health crisis 7,8 . However, in the case of Brazil, the government has contributed to the lack of coordination and inefficiency of the national response 22 , when the most important thing would be to guarantee the technical and operational support necessary for the development and implementation of measures to contain the transmission of the disease 24 . One of the crucial mechanisms for combating any epidemic is the establishment of PHS strategies 24 , in order to structure a rapid, comprehensive response that allows the entire population to be made aware of preventive measures. In this context, the articulation between surveillance and PHC appears as a key issue 24 . However, the Brazilian PHC has been suffering serious threats and dangerous setbacks, which are decharacterizing it, approaching it to a model of individual assistance, which responds only to acute problems, without link, continuity, coordination or population responsibility 22, 25 . Faced with a limited response from the federal government, Brazilian states and municipalities have been faced with the challenge of regulating, inspecting, carrying out the necessary surveillance and providing health care 26 .
Currently, there is a second pandemic wave in full expansion, and it is more than urgent to expand PHS actions, especially the capacity to detect and trace contacts, imperative to contain the expansion of Covid-19, as has it been amply demonstrated by the international experience, emphasizing that the PHC is the privileged place of the health system to coordinate this type of action 15,19,27, 28 .
The analysis presented in this article, despite its possible limitations, such as being based exclusively on documentation produced by the federal government, corroborates what has been warned by several authors who attest to the insufficient importance that has been attributed to PHC in the country, in the management and implementation of actions to control the pandemic, especially regarding PHS 17,22,24,29,30 . These findings reinforce the argument that, unfortunately, Brazil has been highlighted as one of the worst managements of the health crisis in the world.