Epidemiological and Prognostic Factors Related to COVID-19 in

Primary Care in a Municipality in Southern Brazil

Luís Rafaeli Coutinho

1 a

, Lecian Cardoso Lopes

2 b

, Henrique Pereira Oliveira d’Eça Neves

3 c

Hidelbrando Rodrigues

4 d

, Sibele Holsbach Costa

5 e

and Fábio Sensever

6 f

Family Health Support Center of the Municipal Health Department, Porto Belo, Brazil

Universidade Regional de Blumenau, Blumenau, Brazil

Centro Universitário Municipal de São José, São José, Brazil

Universidade Federal do Amazonas Itacoatiara, Brazil

Family Health Support Center of the Municipal Health Department, Florianópolis, Brazil

Family Health Strategy of the Municipal Health Department, Porto Belo, Brazil

Keywords: COVID-19, SARS-COV-2, Telehealth.

Abstract: The COVID-19 pandemic crisis led to a reflection on health systems in general, addressing the importance

not only of equitable, but also universal, care to populations in a global context. Numerous ways to identify

and propose alternatives to COVID-19 issues are enabled by technological advances, specifically those

applied to health. This study aimed to investigate COVID-19-related epidemiological and prognostic factors

remotely in primary care in the Brazilian public health system. The sample consisted of 77 users of primary

care who had records of respiratory symptoms during the pandemic, aged between 5 and 83 years. The

study was carried out in 07 Health Centers in Porto Belo (SC), Brazil. Data analysis and subsequent

evaluation found a possible demand with symptoms and sequelae of COVID-19 that was shown mainly by

users who reported difficulty or

“tiredness” in basic Activities of Daily Living (ADLs) and Instrumental

Activities of Daily Living (IADLs), which may result in patients with chronic muscle fatigue and dyspnea

as a future demand in the municipality.

https://orcid.org/0000-0003-0367-8637

https://orcid.org/0000-0003-4439-6193

https://orcid.org/0000-0003-0000-5197

https://orcid.org/0000-0003-1266-0957

https://orcid.org/0000-0001-9358-2094

https://orcid.org/0000-0003-1632-8134

1 INTRODUCTION

Since December 2019, a new coronavirus-infected

pneumonia (SARS-CoV-2) (COVID-19) has

emerged in Wuhan and has spread rapidly

throughout China (MO, 2020). The coronavirus

disease 2019 (COVID-19) is caused by SARS-COV-

2 and refers to the causative agent of a potentially

fatal disease that has resulted in a major concern for

global public health (Rothan; Byrareddy, 2020).

The epidemic then expanded to an increasing

number of countries, some of which have reported

progressive transmission. There is an urgent need to

expand activities in public health to clarify the

epidemiology of the new virus and characterize its

potential impact (Lipsitch; Swerdlow; Finelli, 2020).

Broad measures have been implemented to reduce

COVID-19 person-to-person transmission and

control the current outbreak. Special attention and

efforts are required to protect or reduce transmission

in susceptible populations, including children,

healthcare professionals and the elderly (Rothan;

Byrareddy, 2020).

Scientists from around the world work tirelessly

while information on transmission, the mechanisms,

clinical spectrum of the disease, new diagnoses and

prevention and therapeutic strategies are being

developed. Preventive strategies are focused on

patient isolation and careful infection control,

Coutinho, L., Lopes, L., Neves, H., Rodrigues, H., Costa, S. and Sensever, F.

Epidemiological and Prognostic Factors Related to COVID-19 in Primary Care in a Municipality in Southern Brazil.

DOI: 10.5220/0010265705150521

In Proceedings of the 14th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2021) - Volume 5: HEALTHINF, pages 515-521

ISBN: 978-989-758-490-9

515

including measures to be taken during diagnosis and

provision of clinical care to the infected patient

(Cascella et al, 2020).

In response to COVID-19, many countries are

using a combination of containment and mitigation

activities in order to delay large outbreaks of

patients. Response strategies include various levels

of tracking and self-isolation or quarantine, in

addition to promoting public health measures. Some

countries should consider a combination of response

measures, and monitoring of cases and contacts.

These measures should include public awareness,

promotion of personal hygiene and protection,

preparation of health systems for a wave of critically

ill patients, stronger infection prevention and control

in health facilities, nursing homes and long-term

care facilities, and postponement or large-scale

cancellation of public meetings (Bedford et al,

2020).

COVID-19 changed the practice of palliative

care and clinical medicine as we know it. In this

context, telehealth emerged as a technology capable

of providing medical care to patients at a critical

moment, as a way of trying to reduce the

transmission of COVID-19 between patients,

families and healthcare professionals. However,

ensuring equitable access and accessible means of

telemedicine technology for vulnerable populations,

through creative solutions, has become a necessary

challenge in preserving scarce resources, especially

in developing countries (Calton; Albedini; Fratkin,

2020).

Integrated mobile health programs allow patients

to be treated at home, with virtual top-level medical

support. Other health professionals (e.g. as nurses,

physiotherapists, and medical assistants) also

contribute to telehealth, allowing continuous care for

patients during the pandemic (Hollander; Carr,

2020).

The prevention and control of COVID-19 is

extremely important due to the rapid increase in

confirmed cases (Zheng et al, 2020). Therefore,

some measures are recommended, such as the close

monitoring of changes in local epidemiology and the

effectiveness of public health with strategies and

their social adherence. As well as contact tracking

and health monitoring, in addition to specific

guidelines in health facilities and support for

individual preventive measures. In addition to health

control with continued surveillance activities and

restrictions imposed on the population. Monitoring

the health of symptomatic individuals is also

suggested through remote health consultation by

phone or online and providing essential vital support

for emergency services, if required (Heymann;

Shindo, 2020).

Healthcare professionals must be protected from

SARS-CoV-2 infection during clinical care. In this

context, telehealth has become necessary and

reduces the number of health professionals who

interact with infected patients (Gandhi; Lynch; del

Rio; 2020). This study aimed to investigate COVID-

19-related epidemiological and prognostic factors

remotely in public primary care.

2 METHODS

The sample consisted of 77 users of primary care

who had records of respiratory symptoms during the

pandemic, aged between 5 and 83 years. The study

was carried out in 07 Health Centers in Porto Belo-

SC (Brazil), which are among the 08 Primary Health

Units (UBS) in the municipality. Data were

collected between September 22 and 30, 2020.

A form was developed on Google Forms in order

to identify epidemiological and prognostic factors

related to COVID-19 infection. The questionnaire

included questions on demographic, epidemio-

logical, clinical and laboratory aspects for COVID-

19 and was developed for each UBS. An initial

telephone contact was made to explain the

procedures that would be performed and the form of

access, then a link was provided to answer the

questions. The link included information on the

work, its relevance and how it would be conducted,

following the completion of the study form provided

via WhatsApp. Data was collected through Google

Forms and then introduced in Excel spreadsheets for

further analysis.

This study was approved by the Research Ethics

Committee of the UDESC – Universidade do Estado

de Santa Catarina, based on the Resolution 466/12,

which defines the Guidelines and Regulatory

Standards for Research involving Human Beings

under no. 4,268,895.

3 RESULTS

Telemedicine is a proven and consolidated way to

provide care to the most vulnerable people. Now,

caring for people and their families requires strict

social distancing measures to protect patients and all

health staff. Therefore, creative ways are required to

ensure that all patients have equal access to this

valuable resource, including the poorest and most

HEALTHINF 2021 - 14th International Conference on Health Informatics

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vulnerable individuals. Even though through

outdated technology, people who do not have access

to the most advanced technologies need access to

health care (Calton; Albedini; Fratkin, 2020).

The study collected information from 77

individuals in 7 (seven) Primary Health Units in

Porto Belo (SC). Porto Belo is located in the

southern region of Brazil, in the state of Santa

Catarina, with a territorial area of 93,673 km², an

estimated population of 21,932, demographic

density of 171.77 inhabitants/km² and MHDI

(Municipal Human Development Index) of 0.760

(IBGE, 2019).

Choices are required during the epidemic on the

interventions to be carried out and under what

circumstances. The early start of surveillance

activities will allow to select the most efficient ways

to fight the epidemic and avoid interventions that

may be unnecessarily expensive or overly restrictive

(Lipsitch; Swerdlow; Finelli, 2020).

A tool with a standard screening questionnaire

recommended by the Ministry of Health of Brazil

(202a and 2020b) was developed in Google Forms

to assist in the telemonitoring of symptomatic

respiratory patients, including questions about

influenza-like illness, comorbidities and questions

about COVID-19 (appendix). The links of the

referred medical record were submitted by the teams

to the patients of each Primary Health Unit

according to their territory. The monitoring

instrument was provided via WhatsApp, thus

providing an effective and easy tool for family

health teams and simple handling by patients. Chart

1 shows the amount of data collected, by UBS.

Chart 1: Distribution of Data Collection by UBS, Porto

Belo (SC), 2020.

Source: Prepared by the authors (2020)

As shown by the distribution of patients by

Gender in Chart 2, 60% of the participants are

female.

Chart 2: Percentage of Patients by Gender, in Porto Belo

(SC), 2020.

Source: Prepared by the authors (2020)

Users were asked if they were tested to COVID-

19 and to report their results. Table 1 shows the

results of the question about testing for COVID-19,

including the 5 (five) participants who preferred not

to answer. Among the respondents, 51.4% had

already taken the test, 30.6% being female and

20.8% male.

Table 1: Contingency Table of Total People who took the

COVID-19 test, by Gender, Porto Belo (SC), 2020.

Gender

Tested for COVID-19

Total

No Yes

Female 26.4% 30.6% 57.0%

Male 22.2% 20.8% 43.0%

Total 48.6% 51.4% 100.0%

Source: Prepared by the authors (2020)

Table 2 shows the percentage of responses

obtained between positive and negative cases in

performed tests. Although 8 (eight) participants

decided not to answer, most of the 69 (sixty-nine)

participants who answered had not taken the test

(73.9%). Thus showing a trend of denial to the

diagnosis of COVID-19, even without performing

the test to confirm the result. Among the people who

tested positive for COVID-19, 17.4% were female,

Table 2: Contingency Table of the Test Result for

COVID-19, by Gender, Porto Belo (SC), 2020.

Gender

COVID-19 Test Result

Total

Negative Positive

Female 37.7% 17.4% 55.1%

Male 36.2% 8.7% 44.9%

Overall 73.9% 26.1% 100.0%

Source: Prepared by the authors (2020)

Epidemiological and Prognostic Factors Related to COVID-19 in Primary Care in a Municipality in Southern Brazil

517

while 8.7%, were male. Overall, the number of

females who tested positive for COVID-19 (12

cases) is exactly twice as many cases reported

among males (6 cases).

In turn, this data is not in line with a study

carried out in Italy comparing the number of cases

by gender, which reported a greater number of cases

of COVID-19 in males (59.8%) when compared to

females (40.2%) (Livingston; Bucher, 2020). Public

health policies and efforts have barely addressed the

possible impacts of gender on COVID-19 outbreaks,

so there is little knowledge of any gender analysis

related to the outbreak by global health institutions

or governments in affected countries or in the

preparation stages (Wenham; Smith; Morgan, 2020).

As for the contact with people who tested

positive for COVID-19, Table 3 shows that most

participants reported not having had contact with

people who tested positive (54.7%), while 45.3%

reported that they had. Regarding those who

reported that have been in contact with people

infected with COVID-19, 28.0% were female, while

17.3% were male.

Table 3: Contingency Table of Total People Who Have

Been in Contact With People Infected With COVID-19,

by Gender, Porto Belo (SC), 2020.

Gender

Have been in contact with

people who tested positive

for COVID-19

Total

No Yes

Female 32.0% 28.0% 60.0%

Male 22.7% 17.3% 40.0%

Total 54.7% 45.3% 100.0%

Source: Prepared by the authors (2020)

Tables 1, 2 and 3 show that the gender should be

considered when analyzing the data during the

COVID-19 pandemic. On the one hand, the

percentage of females who answered the questions

in this research (60%) should be highlighted, which

is much higher than that of males (40%). At least in

part, this imbalance may explain the percentage of

females who tested positive for COVID-19 to be

twice (17.4%) the percentage of males (8.7%) who

tested positive. On the other hand, females

performed more COVID-19 tests (30.6%) than

males (20.8%). However, Table 3 shows a greater

exposure of females with positive results in tests, as

28.0% of them reported that they have been in

contact with people who had tested positive for

COVID-19, while 17.3% of males have been in

contact with confirmed cases.

Table 4 summarizes the crossing of three

variables: close contact with any confirmed case of

COVID-19 or an unwell family member, whether

the participant tested positive or not, and whether or

not the participant had difficulty or “tiredness” in

basic Activities of Daily Living (ADLs) (e.g. self-

care, hygiene and dressing). Of the 58 (fifty-eight)

participants who answered the three questions, 6.9%

reported having difficulty in basic ADLs. Of these,

1.7% has been in close contact with a confirmed

case of COVID-19 or an unwell family member, and

1.7% also tested positive for COVID-19.

Table 4: Percentage of participants who have been in

contact with people who tested positive for COVID-19 or

a suspected family member, and who also tested positive,

and if they reported difficulties or “tiredness” in basic

ADLs, Porto Belo (SC), 2020.

Have been in

contact with people

who tested positive

for COVID-19 or a

suspected family

member / Tested

positive for COVID-

Had difficulty or

“tiredness” in basic

ADLs

Total

No Yes

Tested negative for

COVID-19

34.6% 0.0% 34.6%

Yes and tested

positive for COVID-

17.2% 5.2% 22.4%

Subtotal 1 - No

contact

51.8% 5.2% 57.0%

Tested negative for

COVID-19

17.2% 0.0% 17.2%

Yes, have been in

contact with people

who tested positive

24.1% 1.7% 25.8%

Subtotal 2 - Yes,

have been in contact

41.3% 1.7% 43.0%

Total 93.1% 6.9% 100.0%

Source: Prepared by the authors (2020)

Table 5 summarizes the crossing of three

variables: close contact with any confirmed case of

COVID-19 or an unwell family member, whether

the participant tested positive or not, and whether

or not the participant had difficulty or “tiredness”

in Instrumental Activities of Daily Living (IADLs),

such as work, leisure and physical activities. Of the

55 (fifty-five) participants who answered the three

questions, 5.5% reported having difficulty in

IADLs. Of these, 1.8% have been in close contact

with a confirmed case of COVID-19 or an unwell

HEALTHINF 2021 - 14th International Conference on Health Informatics

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family member, and 1.8% also tested positive for

COVID-19.

Although Tables 4 and 5 show a higher

percentage of people who did not report difficulty or

“tiredness” in ADLs or IADLs (93.1% and 94.5%,

respectively), 22.4% of the first group and 18.2% of

the second group, tested positive for COVID-19.

The percentage of those who tested positive for

COVID-19 and also had dyspnea in basic ADLs was

higher compared to those who had dyspnea in

IADLs (5.2% and 3.6%, respectively), thus

suggesting a smaller number of people with more

serious sequelae and confirming the high

transmission rates of the virus when compared with

the contact of these individuals with confirmed cases

of COVID-19 or suspected family member (also

1.7% and 1.8%, respectively).

Table 5: Percentage of participants who have been in

contact with people who tested positive for COVID-19 or

a suspected family member, and who also tested positive,

and if they reported difficulties or

“tiredness” in IADLs,

Porto Belo (SC), 2020.

Have been in contact with

people who tested positive

for COVID-19 or a

suspected family member

/ Tested positive for

COVID-19

Had difficulty or

“tiredness” in

IADLs

Total

No Yes

Tested negative for

COVID-19

36.4% 0.0% 36.4%

Yes and tested positive for

COVID-19

14.5% 3.6% 18.2%

Subtotal 1 - No contact 50.9% 3.6% 54.5%

Tested negative for

COVID-19

18.2% 0.0% 18.2%

Yes and tested positive for

COVID-19

25.5% 1.8% 27.3%

Subtotal 2 - Yes, have

been in contact

43.6% 1.8% 45.5%

Total 94.5% 5.5% 100.0%

Source: Prepared by the authors (2020)

Outbreaks of new and reemerging diseases, such

as the current COVID-19 epidemic, can potentially

overwhelm health systems at the expense of primary

health care requirements in low-income countries

(Velavan; Meyer, 2020). These outbreaks can have

huge potential implications for planning and

decision-making in confirmed cases of COVID-19,

especially in high-risk areas (Petropoulos;

Makridakis 2020). Each outbreak also provides an

opportunity to obtain relevant information, some of

which are associated with a limited window of

opportunity (Fauci; Lane; Redfield, 2020).

In this context, telemonitoring contributed to the

planning of health actions within the scope of each

of the Primary Health Units in the municipality, in

addition to generating data for epidemiological

surveillance regarding the prevalence of symptoms

and prognostic factors for COVID-19 in the

population of each territory. Therefore, it contributes

to the performance of diagnostic tests and to assist

team decision making in the UBS according to the

Operational Structure of the Primary Health Care

Network, as proposed in Figure 1. The results were

analyzed in order to generate data focused on health

planning and assisting team decision making within

the health field.

Source: Prepared by the authors (2020)

Figure 1: Operational Structure of the Primary Health Care

Network, Porto Belo (SC), 2020.

Given the above, there is still much to be

developed despite the experience and robustness of

the surveillance system and public policies (Turci;

Holliday; de Oliveira, 2020). Continuous

surveillance of the various countries facing the

pandemic is required to better understand the global

epidemiology of COVID-19, including transparent

and accurate reporting of patient characteristics and

symptoms (Onder; Rezza; Brusaferro, 2020).

4 CONCLUSIONS

A longer period of monitoring in Health Centers is

required to reach broader conclusions among

suspected and confirmed cases of COVID-19 in the

primary care facilities in Porto Belo.

Data analysis and subsequent evaluation found a

possible demand with symptoms and sequelae of

COVID-19. This was shown mainly by users who

reported difficulty or “tiredness” in basic ADLs and

IADLs, which may result in patients with chronic

Epidemiological and Prognostic Factors Related to COVID-19 in Primary Care in a Municipality in Southern Brazil

519

muscle fatigue and dyspnea as a future demand in

the municipality.

These data are essential for the health decision-

making process of managers, through the

formulation of public policies and the rational

application of resources in the most sensitive

segments in care, as in promotion and prevention.

The COVID-19 pandemic led to a reflection on

public health systems and strategies, as well as the

importance of care that is not only equitable, but

also universal to populations in a global context.

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APPENDIX

Questionnaire used for telemonitoring of patients

with respiratory symptoms:

Name:

Date of birth:

Gender:

( ) Male

( ) Female

Questionnaire on Influenza-like illness and

Comorbidities

Do you have or had any of the following factors?

( ) Cough

( ) Temperature between 35.7ºC and 38ºC

( ) Temperature greater than 38ºC

( ) Fatigue

( ) Mucus

( ) Shortness of breath

( ) Muscle pain

( ) Sore throat / Difficulty swallowing

( ) Headache

( ) Chills

( ) Nasal congestion / runny nose

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( ) Diarrhea

( ) Nausea or vomiting

Do you have any of the following comorbidities?

( ) Heart diseases

( ) Asthma, emphysema, bronchitis or other lung

disease

( ) Hypertension

( ) Depression

( ) Chronic kidney or liver disease

( ) Previous transplant

( ) Immunosuppression due to disease or

chemotherapy/radiotherapy (other medicines).

( ) Diabetes mellitus

( ) Smoking

Questionnaire on COVID‐19

Do you have or had any of the following factors

since the start of the pandemic?

( ) Severe shortness of breath at rest

( ) Difficulty breathing

( ) Chest pain or pressure

( ) Cold, moist or pale and stained skin

( ) Sudden confusion

( ) Difficulty awakening

( ) Bluish lips or face

( ) Little or no urine production

( ) Coughing up blood

Other conditions, such as:

( ) Neck stiffness

( ) Rash

Do you have or had any of the following factors

before the emergence of the pandemic in Brazil?

( ) yes ( ) no

Have you been in close contact with someone who

has tested positive for COVID‐19 or an unwell

family member?

( ) yes ( ) no

Have you been tested for COVID-19?

( ) yes ( ) no

If so, was it positive?

( ) yes ( ) no

Do you have tiredness or difficulties in performing

basic activities of daily living (e.g. self-care, hygiene

and dressing) after the diagnosis of COVID‐19?

( ) yes ( ) no

Do you have tiredness or difficulties in performing

instrumental activities of daily living (e.g. work,

leisure and physical activities) after the diagnosis of

COVID‐19?

( ) yes ( ) no

Assistance in team decision making:

- Refer for immediate medical care if the subject has

severe symptoms and report the case to the Family

Health Strategy;

- In cases of relevant comorbidities, provide

proactive and complete assistance to the patient;

- Refer for testing and reporting in Epidemiological

Surveillance;

- Specific referral to the Support Center for Family

Health, if required;

- Arrange video conference follow-up and monitor

closely if pneumonia is suspected.

Epidemiological and Prognostic Factors Related to COVID-19 in Primary Care in a Municipality in Southern Brazil

521