On February 26, 2020 the first case of COVID-19 was confirmed in Brazil. One day before, this patient, who had recently returned from Italy, sought care in the emergency department at a private hospital in the city of São Paulo, the largest city in Brazil. After 2 months, Brazil registered 58,973 cases of COVID-19, with 4047confirmed deaths. Most COVID-19 cases and deaths remained in the State of São Paulo, contributing to 34% of confirmed cases and 41% of deaths by that period.1
The hospital that took care of patient No. 1 is part of a large Brazilian health system dedicated to healthcare, teaching, research, and philanthropy. Providing all levels of care (from primary to quaternary care) in the private and public sectors of São Paulo and other Brazilian cities, the health system's workforce totals around 15,000 employees. The workforce was mostly women (70%), with average age of 36 years old and divided into direct health assistance group (49%), health assistance support (24%), administrative group (26%), and trainees (1%). The company grants integral health care for employees and their families combining the provision of a regular health insurance with population health management strategies that rely on the health system's own infrastructure based on a primary care network. Aiming to provide a more integrated health care, this network includes primary care services, telemedicine, care coordination, and surveillance of individuals admitted to hospitals covered by the health insurance.
Health workers are at the forefront of actions to combat COVID-19 and have higher risk of infection,2–4 hence early implementation of surveillance and care plans targeting this population wellbeing and safety are mandatory. Since January 2020, when the World Health Organization declared COVID-19 an emergency of international concern,5 the company's leadership set up a special task force to deal with the upcoming crisis. As soon as the disease was confirmed in Brazil, this task force was called into action to establish care strategies for the workforce.
To the present date, there is a lack of scientific studies describing how workforces could be cared for during the COVID-19 crisis. Therefore, our study aimed to describe the strategy developed and implemented to monitor and care for the workforce of a healthcare system during the first 2 months of the COVID-19 epidemic in Brazil.
This is an experience report with an exploratory approach based on documental sources containing the guidelines developed to address the surveillance and expansion of access to care of the health system's workforce in the COVID-19 epidemic. Information was also achieved from the daily panels used to report the COVID-19 status among employees to the company's leadership, such as the number of individuals tested with real-time reverse transcriptase polymerase chain reaction for SARS-Cov-2 (RT-PCR), the number of confirmed cases, the number of sick-leave spells and hospitalizations due to COVID-19 among employees. The plan developed to monitor the employees and to expand their access to care was elaborated by the health management team alongside the occupational health department and the nosocomial infection control committee. All steps were documented in flowcharts which were used to guide the description presented below. The phases of the strategy are presented following the chronological order in which they were implemented. The coverage of each phase is presented as absolute and relative frequencies. The study was approved by the National Council on Ethics Research (Conselho Nacional de Ética em Pesquisa) and waiver of informed consent was granted because the study describes a strategy and does not rely on individual data.
In response to the arrival of SARS-CoV-2 in Brazil, the population health management department presented a plan for its employees that integrated surveillance and expansion of access to care. This plan was renewed and adapted to the changing epidemic dynamics. Figure 1 shows the timeline and an overview of the implemented actions during the first 2 months of the Brazilian COVID-19 epidemic. A dashboard was created to display updated information of critical metrics among the workforce, such as the number of tests performed, the number of confirmed cases, sick-leave spells, and hospitalizations due to COVID-19. Real time access to these metrics had a central role on the leadership's decision-making processes.
Monitoring and Expansion of Access to Care Strategy—Phase 1
The first phase of the monitoring strategy started on February 25, at the same day that the first patient with suspected COVID-19 sought care at the emergency department. Initially, all six employees who had had direct contact with the patient were monitored. The surveillance was soon expanded to any member of the workforce who had had direct contact with patients with suspected or confirmed COVID-19 and had inadequately used personal protective equipment (PPE). These employees were identified and submitted to a brief questionnaire of PPE use by the Occupational Health Department and started periods of sickness absence of 14 days, in which they received daily phone calls from the care coordination team to monitor symptoms. We considered inadequate use of PPE when the employee reported not using gloves, mask, coat, and glasses during direct contact with suspected or confirmed COVID-19. Testing for COVID-19 with RT-PCR was recommended for the employees who had developed indicative symptoms (defined by the Brazilian Health Ministry as: fever over 37.8 °C and one or more respiratory sign or symptom as cough, difficulty breathing, sputum production, nasal or conjunctival congestion, difficulty swallowing, sore throat, runny nose, O2 saturation less than 95%, signs of cyanosis, nose flat beat, and dyspnoea).6 Furthermore, symptomatic employees who had recently returned from countries with known COVID-19 epidemic (listed by the Brazilian Ministry of Health, as China, Italy, Spain, and other) were also tested,6 isolated and monitored for 14 days. On the daily phone calls the care coordination team assessed symptoms, the sick-leave status, whether employees had been tested, and the need of hospitalization.
In parallel, a massive orientational campaign, aired on multiple internal communication channels, encouraged symptomatic employees to seek care in the company's telemedicine service. Suspected cases that fulfilled the criteria were tested, isolated, and monitored. If symptoms indicating clinical severity were identified during the telemedicine consultation, the employee was referred to an emergency department covered by the health insurance provided by the company. The strategic plans also relied on an efficient communication system, available to all employees, presenting information about the epidemic, what to do in case of symptoms, who to address, and what safety measures should be adopted. The communication channels were: (1) intranet system, (2) information sheets displayed on murals in areas restricted to employees (ie, restrooms, cafeteria, and staff elevators), and (3) by E-mail. Another interactive strategy was based on broadcast live videos promoted by the Human Resources Team (eg, lives talking directly with employees to answer questions) and training leaders to disseminate information about COVID-19 and to promote the early identification of suspected cases among workers. Additionally, all employees have free and unlimited internet access at all institutional buildings.
Phase 1 lasted until March 12 and a total of 26 employees were daily monitored. Only five of those were tested for COVID-19, although the recommendation to test was given by providers outside the company's health system and did not follow the established criteria. Among the tested, one had returned from a country with known COVID-19 epidemic and was tested by developing symptoms, while the other four were tested according the closeness contact criteria. Only one had a positive result and this employee was not hospitalized.
Monitoring and Expansion of Access to Care Strategy—Phase 2
On March 13, 2 days after the first employee tested positive for SARS-Cov-2 and at the same day the Brazilian Ministry of Health declared community transmission of COVID-19 in the city of São Paulo, changes in the surveillance and access to care strategy were implemented.
Testing recommendation was expanded to all employees that had presented fever and any other flu-like symptoms identified either during a primary care appointment or telemedicine consultation in the company's primary care network. Additionally, the previous recommendations of testing employees who had had contact with a suspected or confirmed case, or who had recently traveled abroad were maintained. Suspected cases were isolated for at least 3 days, until the RT-PCR result was released. A total of 4483 tests were performed among 2643 employees from March 13 to April 25 (some employees tested more than once). Negative results were found among 1554 employees, who were able to resume their activities. However, a total of 1089 employees tested positive and were isolated for at least 14 days, counted from the beginning of symptoms (Fig. 1).
To expand the access to care, the health system converted one of its own primary care units into a specialized and exclusive ambulatory dedicated to COVID-19. With expanded working hours, this unit became the reference center for COVID-19 to all employees. Working hours were further expanded on March 25 and the center started to operate 24/7 in the care of patients with suspected SARS-CoV-2 infection. Additionally, besides the regular operation, the primary care network (telemedicine service, primary care units, and care coordination) was also available to provide orientation concerning COVID-19 or to care for symptomatic employees. In the presence of severe symptoms, defined as shortness of breath, dyspnoea, or constant fever, employees were referred to an emergency department covered by the company's health insurance. Information on the care plan was massively displayed in multiple internal communication channels.
Since the number of suspected cases exponentially increased after community transmission, phone monitoring was restricted to employees with confirmed COVID-19. As soon as the results of the RT-PCR were available, all employees who had tested positive received an e-mail with information on the disease course, and hygiene and isolation recommendations. They also received orientation on the required actions in case of disease severity and the provision of a direct communication channel with the care coordination team. Phone calls to monitor symptoms were performed at days 7 and 14 after the beginning of symptoms. Employees were referred to the telemedicine service when needed.
On April 8, the phone monitoring schedule was changed to facilitate the back to work plan in accordance with the Brazilian labor legislation, and phone calls were scheduled to days 7 and 12 after the beginning of symptoms. Besides checking symptoms at day 12, care coordinators referred monitored employees to repeat the RT-PCR test. Criteria to resume working activities at the health system's facilities at the time were the absence of fever for at least 3 days and a negative RT-PCR after day 12. Workers who had had positive RT-PCR after day 12 remained isolated and away from their duties, with repeated monitoring of symptoms and recommendation of retesting every week, until the required conditions to return to work were achieved.
Finally, the population health management department screened employees working in the frontline for conditions that could increase the risk of disease severity, such as pregnancy, immunosuppression, chronic pulmonary diseases, uncontrolled diabetes, severe hypertension, cardiovascular diseases, and autoimmune diseases. These workers were relocated to non-patient-facing roles. Moreover, home-office was encouraged to administrative workers whenever applicable.
Surveillance of Hospitalized Employees
The surveillance of hospitalizations started on March 18, when the first employee was hospitalized with COVID-19. All employees admitted to hospitals covered by the health insurance or to the main health system's hospital due to suspected or confirmed COVID-19 were monitored by a team of internists. Clinical follow up information were obtained through chart revision, daily phone calls to the health insurance auditors’ team, and occasional phone calls to family members when needed. Severe cases admitted to hospitals covered by the health insurance provided by the company were transferred to the intensive care unit at the company's main hospital. Initially, the following criteria were adopted for removal of severe cases: the need of mechanical ventilation with severe lung injury or with two or more organ dysfunctions, and the need of extracorporeal membrane oxygenation.
To improve access of care for employees with severe disease, these criteria were expanded on April 8 to include hospitalized employees with the following laboratory and/or clinical markers of poorer outcomes: persistent fever, organ dysfunction (hypotension, tachycardia, renal function decline, acute hepatic failure, and/or acute neurologic dysfunction), requirement of high flow nasal oxygen therapy, radiographically extensive lung injury (lung compromise more than or equal to 50% at computed tomography), increasing reactive protein C, and elevated D-dimer test at admission. Additionally, employees with the following risk factors associated with higher risk of severe COVID-19 were also transferred to the company's main hospital: age more than or equal to 65 years, pregnancy, diabetes mellitus, morbid obesity, chronic kidney disease, chronic respiratory disease, immunosuppressive conditions, and previous history of cardiovascular diseases, uncontrolled hypertension, and cerebrovascular disease.
During the first 2 months of COVID-19 in Brazil, a total of 102 employees were hospitalized due to respiratory conditions, and COVID-19 were confirmed in 89 of them. From these confirmed cases, 31 fulfilled the criteria and were transferred to the company's main hospital (23 were admitted to clinical wards, three to semi-intensive care unit, and five to intensive care unit). As of April 25, 78% of the employees hospitalized with COVID-19 had been discharged and none of them had died (Fig. 2).
This study reported the experience of a large health system in designing and implementing a strategy to monitor and expand access to care for its workforce during the COVID-19 epidemic in Brazil. The strategy was tailored to accommodate the constant epidemiologic changes of the disease. Surveillance started with the monitoring of employees who had had direct contact with suspected patients or had returned from high risk countries. When community transmission was declared, surveillance evolved to monitoring employees who had had confirmed COVID-19 or who had been hospitalized due to respiratory diseases. Meanwhile, the health system's infrastructure was adapted to the needs of a large workforce in high risk of exposure, aiming to expand access to care. After 2 months of the Brazilian epidemic, around 7% of the workforce had had COVID-19. However, less than 1% had been hospitalized and no one had died.
The later introduction of the virus in Brazil presented an opportunity to observe and learn from other countries experiences. The health system described in this paper had a central role in the early days of the Brazilian epidemic scenario and the prompt reaction of the leadership was crucial to the required course of actions. In many instances, the strategies adopted preceded National policies. Because of the delay in providing a reliable test with adequate coverage, the Brazilian Ministry of Health approved the expansion of testing for health professionals and severe cases who required hospitalization only after 30 days of viral circulation in the country.7 However, the company's leadership adopted a strategy of testing all employees who were suspected cases of COVID-19 or who had been exposed to the virus without adequate protection since the first case was diagnosed, in order to prevent and monitor possible transmission to coworkers and patients.8
The population health management team, working alongside with the company's occupational health department, created a tailored strategy focused on monitoring and access to care targeting timely adaptations to the changing needs of the employees. This process was favored by experiences in caring for health workers reported by other countries that faced COVID-19 before Brazil.9,10 Moreover, the health system had the advantage of relying on an established population health management plan based on a primary care network and regular health surveillance of the employees, which is central to health promotion and to prevent work-related diseases.11,12 It is relevant to report that the developed strategies described in the paper were not the only management changes related to the workforce safety. Actions such as adequate provision of PPE to all employees in accordance with different job requirements, daily temperature control, ensuring interpersonal distancing in usually crowded spaces among others were also implemented but were out of the scope of this article.
It should be noted that relying of self-reporting is a strategy subject to under-identification of cases.13 Fear of stigma, shame, disruption of work-life balance, paucity of symptoms amid other reasons could have inhibited workers to report travels or symptoms. To minimize this aspect, the institution employed a broad communication plan through several platforms to reach all employees. According to Men,14 using multiple networks to achieve employees is effective to reach different worker profiles. This communication plan aimed to sensitize workers and leaders on the importance of self-reporting to early access to care and to prevent the spread of the virus among colleagues. However, it was not possible to assess its effectiveness to avoid underreporting.
The existing care coordination infrastructure in the company's primary care network allowed phone monitoring to be immediately implemented. Therefore, continuity of care was possible through remote monitoring, avoiding the need of in-person consultations to reduce the risk of disease transmission. Another crisis response adopted with the aim to prevent the spread of the disease and poor outcomes among employees was the removal of pregnant women from the frontline, relocation of employees with risky conditions, rotating work, and a home office scheme to administrative workers. Additionally, the health system infrastructure was adapted to expand access to medical care, including virtual medical consultations by telemedicine and an outpatient clinic fully redesigned for the care of COVID-19. Finally, the monitoring of hospitalized employees allowed a personalized care for those with severe disease progression.
Unfortunately, uncertainties around COVID-19 abound. The scientific community lacks information on many relevant features, such as the possibility of chronicity, the development of durable immunity, the impact of genetic mutations, and the possibility of reinfection.15–17 Therefore, it is hard to define which measures provide a safe work environment for healthcare professionals or allow them to safely return to work after being infected. Nevertheless, the actions described in this article were in accordance with previous international recommendations focused on the monitoring of healthcare professionals and sick-leave policies,18 and surpassed the local public health police.19 While the Brazilian Ministry of Health recommended that testing should be restricted to individuals with severe respiratory distress, the health system provided testing for workers with suspected COVID-19 independently of disease severity. Moreover, because testing was broadly available, the company was able to implement a thorough return-to-work policy based on RT-PCR negativation, in compliance with the Brazilian labor legislation.20
Our study has some limitations. As a descriptive study based on an experience report, it was not intended to present measures of efficacy of the adopted strategies and clinical follow-up of employees with COVID-19. Future longitudinal quantitative studies are needed to assess the efficacy of such strategies and allow comparison between different health systems. Moreover, although care coordination was broadly implemented before the beginning of the epidemic, some monitoring losses of employees may have occurred in the process. Employees who had tested outside the health system's network and did not present the results to the occupational health sector were not monitored. Even so, we believe these cases were rare and the strategy of surveillance of hospitalizations allowed the health management team to follow any such losses that had had severe disease.
The future of the COVID-19 pandemic in Brazil is still uncertain. As of April 25, although the reported prevalence of the disease was low, the daily number of cases and mortality were quickly climbing.1 Thus, we believe the strategies adopted to monitor and expand the access to care for the workforce of a large health system during the beginning of the Brazilian COVID-19 epidemic were promptly implemented and were adapted to the changing epidemic dynamics.
The authors gratefully thank Raquel D. de O. Conceição, MD and the support received from Ingrid Ivanezuk, Rafael Dadão, and Michele Carreto.
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