Training the Armed Forces personnel in COVID-19 contact tracing: a Portuguese case study

Background

Local contact tracing teams needed to be reinforced in preparation for a peak in Covid-19 cases. The Portuguese Armed Forces showed availability and their members initiated a formal training facilitated by the Public Health Unit (PHU) of Amadora. Health systems must be prepared to respond to all threats, as the COVID-19 pandemic showed us the need for quick task shifting and the training of non-experts’ workers.

Objectives

The aim of the project was to develop contact tracing skills by non-health professionals, in the context of the COVID-19 pandemic. The training program was held online, with a total duration of 48 hours, distributed by the topics described: introduction to health and epidemiology concepts, the national guidelines, and the information systems (13h). We privileged demonstrative and participatory training methods, followed by continuous supervision of each contact tracing survey and constant feedback (35h). Learning support materials were sent out to assist the trainees, including written and video support.

Results

More than 200 personnel - sailors, soldiers and airmen - were trained. Each Lisbon and Tagus Valley area PHU was reinforced with a team of military professionals in order to support the contact tracing process, with an increase in the number of surveys completed. We highlight as positive aspects: increased number of contact tracing surveys carried out; growth of inter-institutional partnerships; freeing up of specialized PHU resources to other important tasks. As for negative aspects we focus on the complexity in health communication, the limited time for training, and the lack of specific health knowledge of the trainees.

Conclusions

This pandemic revealed the Portuguese need for a transdisciplinary approach in the provision of care, specially at a Public Health level. Training programs like these highlight the vital role of reshaping and reorganizing the healthcare workforce answering Public Health necessities.

Key messages

• Training programs for non-health workers must be prepared to reinforce health systems when necessary. The reinforcement of contact tracing teams by the Portuguese Armed Forces was a great example.

• A transdisciplinary approach in the provision of care was essential during the COVID-19 pandemic. Specific training of non-health workers can be planned in time to respond to health threats.

Ending female genital mutilation – a city’s coordinated effort

Female genital mutilation (FGM) has short and long-term impacts on the health of girls/women. In Portugal, an estimated 5246 women were subjected to it, with 568 of them residing in the city of Amadora, in the metropolitan area of the capital Lisbon. As such, Amadora was considered a priority area for developing strategies to prevent female genital mutilation, under the coordination of the local public health unit.

Our aim was to capacitate professionals to recognise and act on risk/danger and on minimising potential health impacts of FGM on the local institutions these girls/women might come into contact with.

We created a task force that held meetings with different local actors: hospital, teams at the primary healthcare facility, city hall of Amadora, child protection services, a school, social inclusion projects, representatives of the justice system and a non-governmental organisation. We designed different scenarios for the different needs and entry points of these girls/women in the system and created appropriate procedures for all these actors. Within the primary healthcare facility, we created guidelines specifying criteria for referral to other specialties. This led to the development of a county protocol targeting FGM during the summer of 2019.

We trained 160 healthcare professionals. In addition, we created a booklet for schools and held sessions in school groups targeting teachers, psychologists and operational assistants with a focus on risk and danger indicators and on how to proceed. Overall, 360 school professionals received training. During these sessions, we also presented resources on how to integrate FGM in discussions with students regarding gender violence and human rights.

This intervention will be evaluated after one year (summer of 2020) through mixed-methods to understand the impact on the practice of the professionals in Amadora. We will conduct interviews and apply questionnaires to capture the implementation of this city-wide protocol.

Key messages

Given the complexity of FGM a wide societal and multidisciplinary approach should be used with a public health team coordinating the intervention. In Portugal there is a need for an organised and systematic response by professionals regarding FGM; our county-specific protocol aimed to create that response.

Assessing the implementation of population based cervical cancer screening in Amadora, Portugal

Background

Population-based cervical cancer screening (CCS) are deemed to be more cost-effective than opportunistic screening and to reduce inequalities. Implementation in Portugal has been heterogeneous, at the regional level. In Amadora healthcare cluster (Lisbon area), implementation started in April 2018 in a pilot unit and was scaled-up. We aimed to assess population-based CCS implementation in Amadora.

Methods

Population-based CCS targets women aged 30-65, and utilises liquid-based cytology with partial HPV genotyping (HPV16/18 and other high-risk HPV - hrHPV). Samples positive for other hrHPV undergo a cytology. HPV16/18+ and other hrHPV+ with ≥ASCUS (atypical squamous cells of undetermined significance) are referred to colposcopy. We assessed implementation according to key indicators extracted from our information system: geographic coverage, number of tests, positive results, positive predictive value of referral (number of cervical intraepithelial neoplasia-CIN/number colposcopies).

Results

As of 30 August 2019, CCS were in place in 4 of the 9 units, potentially covering 20904 women (48.4% of the target population). 1797 womem performed screening within the programme. Invitation for screening is currently implemented in 1 of the 4 units. Screening results were available for 1702 women, 11,1% were HPV+. From these, 26,5% were HPV 16/18+ and 86.2% positive for other hrHPV. Among the latter, 63.2% were negative for intraepithelial lesion and 36.8% were ≥ASCUS. Overall, of these 189 women, 51.3% (n = 97) were referred for colposcopy. Colposcopy results were available for 37 women, of which 13 had a CIN. PPV of referral was 35.1% (95%confidence interval: 20.7;52.6).

Conclusions

Despite being a population-based screening most tests are still opportunistic. There is still a limited number of colposcopies results but the current PPV of referral is low and requires further investigation. Implementation towards a full population-based screening in Amadora should continue.

Key messages

Implementation of a population-based cervical cancer screening in Amadora, Portugal is underway but most screening tests are still applied in an opportunistic manner. A limited number of results is avaliable to estimate positive predictive value of referral to colposcopy. Results available indicate a value of 35.1%, which requires further investigation.

Benefits from a tabletop exercise in a Heat-Health Action Plan in Amadora, Portugal

Issue

National guidelines for Heat-Health Action Plans (HHAP) in Portugal exist since 2004. These guidelines are further developed and implemented at Local Public Health Units (LPHU) together with local partners. Tabletop exercises are a useful tool to improve preparedness. Despite the long experience with HHAP there has not been any tabletop exercise in Amadora.

Description

Amadora’s LPHU organized a tabletop exercise with local partners to improve HHAP preparedness (12th July 2018). It included: LPHU, city hall, civil protection services, local social services, primary healthcare services, local public hospital, and firefighters. The exercise hypothesized a scenario of an unprecedented increase of temperature for an extended period of time, activating the highest level of warning (red) and action in the HHAP.

Results

During the exercise several issues were identified. Some partners were not clear about the pathway established for red warnings and partners were not aware of relevant HHAP activities. Also, from the 8 sites listed as climate shelters, only 2 were deemed as adequate for using in this scenario, even though they have been listed for several HHAP. Due to the exercise, it was possible to conduct an inspection of said shelters, which hadn’t took place yet due to the lack of resources. It was possible to find out that only one shelter was fit for purpose. Additional private facilities were identified as desirable shelter locations during the exercise. A few weeks later, a red warning was issued and clarification arising from the tabletop exercise was useful to properly implement measures.

Lessons

Despite the perceived frequent and good communication among partners of the HHAP, several issues - mainly regarding the adequacy of shelters - were identified with a tabletop exercise. It also improved preparedness for the following HHAP warning. As such, tabletop exercises should be promoted within HHAP.

Key messages

Despite developing heat-health action plans for several years, with the involvement of community partners, unidentified constraints existed in Amadora, Portugal. Tabletop exercises should be used more frequently, as we were able to identify and solve constraints within our heat-health action plan using one.

Evaluating implementation of an Heat-health action plan during 2018 heatwave in Amadora, Portugal

Issue

Heatwave-health effects are preventable. Heat-health action plans (HHAPs) include preventive measures aimed at protecting population. In Portugal, HHAPs exist since 2004 and have been operationalized at local level. Heatwaves occur infrequently, thus experience with HHAPs is relevant to countries implementing their own HHAPs.

Description

In the summer of 2018, Amadora (Lisbon, Portugal) issued a warning from the 2nd-6th August (highest level:4th-6th). Before/during the warning we implemented: 1.climatized shelter opened available upon request;2.text messages with recommendations and information on the walk-in clinic services available;3.information to nursing homes regarding available services (walk-in services/shelter);4.contact with individuals receiving home support and identified as vulnerable. Nationwide media publicity of individual protection measures was also ongoing. We aimed at evaluating these HHAP measures. We compared demand of walk-in clinic (primary care) and emergency department with existing capacity, updated during the heatwave. Mortality was analysed using an observed-expected ratio (O/E) of week 32 (following the heatwave) and 95% confidence interval (95%CI) under a Poisson distribution. Expected deaths were the average deaths in week 32 of the previous 4 years (2014-17).

Results

In the primary care walk-in clinic the demand was ½ of capacity; hospital emergency services demand did not increase. We had no requests for the shelter unit. Regarding mortality, O/E was 1.57 (95%CI:1.12-2.14). These results are preliminary; we are producing more detailed analyses of mortality data.

Lessons

We have no counterfactual to assess the effect of our HHAP but our results indicate the possibility to reduce heatwaves-mortality further and thus the need for additional measures. We did not observed the expected surge in service demand; the adequacy of supply-based measures is currently under debate. More detailed mortality analysis will provide further insights.

Key messages

We implemented several measures during a heatwave in Amadora, Portugal with no increased demand in available health services in the area. We detected an increased mortality following the heatwave, suggesting the need to implement further measures.

Fatal case of imported human rabies in Amadora, Portugal, August 2011

We report on a case of imported human rabies in Portugal, in July 2011 in a woman who presented initially complaining of back pain, without relating exposure to animal bites. She had travelled from Portugal to Bissau, Guinea-Bissau, in April where she had been bitten by a dog on 1 May. She was diagnosed with rabies on 26 July and died two weeks later in spite of being treated following the Milwaukee protocol.