By Meirelayne Duarte^a,b Monica Frank^a,b, Janine Soub^b,c, Helena Patáro^b,c, Júlia Costa^b,c, Diana Oliveira^b,c

^a Universidade Salvador – UNIFACS
^b Centro de Referência Estadual de Atenção à Saúde do Idoso – CREASI
^c Comissão Intersetorial de Monitoramento de ILPIs do Estado da Bahia 

Brazil has 27 states, grouped in five regions: the North, Northeast, Southeast, South and Midwest. Bahia is the largest state in the Northeast, with 417 municipalities and an estimated population of 15 million. The state capital, Salvador, has approximately three million inhabitants. The Brazilian Institute of Geography and Statistics estimates that people aged 60 or more make up 14% of the population of Bahia and 17% of the population of Salvador.

In recent decades, some public policies for older people have been implemented in Brazil. However there are still many gaps, especially with regard to Long-Term Care Facilities (LTCFs). The Covid-19 pandemic, with a high lethality rate in LTCFs across of the world, signalled the need for new emergency strategies to protect this vulnerable population.

In this context, the INTERSECTORIAL COMMITTEE ON MONITORING LTCFs IN THE STATE OF BAHIA was established by the Health Department of the State of Bahia (SESAB) Ordinance 133 on April 3, 2020. It consists of representatives of SESAB, the Secretariat of Justice, Human Rights and Social Development and the Federal University of Bahia. The Commission aims to monitor health actions at LTCFs, in order to intervene and advise on the care for the people who live there, in the face of the Covid-19 pandemic.

The Commission is managed by the State Reference Centre for Older People’s Health Care. It has six work-teams, linked to SESAB’s Care Management Directorate. Four teams systematically monitor every LTCFs every 72 hours. One team provides daily monitoring of LTCFs with symptomatic/positive cases. A technical-operational team supports coordination between municipal and state agencies in areas such as testing and hospital referrals.

Mapping of local LTCFs was based on information provided by the State Health Surveillance agency, as well as local health and social assistance managers and a national Social Assistance register of facilities. Although several agencies had lists of LTCFs, these all had discrepancies and sometimes duplicated data. Therefore, a priority action was to analyse these lists, checking for duplicates and errors. This work was essential for the compilation of a single list of LTCFs. This is now a shared reference list for all agencies involved. In the case of LTCFs where attempts to make contact (by phone or e-mail) were unsuccessful, the support team contacts the Directorate of Primary Care to request updated information from managers working at the municipal level.

The Commission monitors any institutional setting that contains at least one older person. These include care facilities that do not exclusively contain older residents, as well as emergency shelters. These institutions are not legally defined as LTCFs by the National Health Surveillance Agency ((RDC 286/2005 of).

By 6 October 2020, 200 LTCFs had been mapped across 83 (20%) of the 417 municipalities in the state of Bahia. All were being monitored by the Commission’s teams, representing 5,154 older residents. Four of these LTCFs have so far closed in the course of the pandemic. Of the remaining 196, 75 are in the municipality of Salvador, housing 1,923 older people.

By 6 October 2020, 152 LTCFs (76%) had been included in daily follow-ups, due to suspected/confirmed cases of Covid-19 among residents/employees, with a total of 1,033 confirmed cases in the residents (20% of all residents). By this date, 2.3% of the population of LTCFs in the state of Bahia had died from Covid-19, and the case fatality rate for this population was 11.2%.

These levels of morbidity and mortality in LTCFs in Bahia are well below those described in other regions of the world. They can be explained by, among other factors, the monitoring and interventions promoted by the Commission. This included: 

• Mapping all LTCFs in Bahia State;
• Emailing all LTCFs documents with guidance for managers and staff (Annex A);
• Developing an electronic monitoring form for each LTCF, managed by telephone contact every 72 hours and every 24 hours for LTCFs with suspected/ confirmed cases of Covid-19;
• Production of video classes with educational guidelines;
• Holding a meeting with the State Civil Defence Agency to estimate the need for basic food parcels and hygiene kits to be delivered to the LTCFs;
• Conducting web conferences with municipal health managers and LTCFs in partnership with Telessaúde [Tele-Health] Bahia (Annex B) and with the support of the Brazilian Society of Geriatrics and Gerontology (Bahia Branch);
• Developing strategies for epidemiological and health surveillance with municipal health departments;
• Developing with municipal agencies new health actions in collaboration with social assistance;
• Coordination across municipal social assistance secretariats, the Ministry of Public Affairs, the Public Defender’s Office and the Council for the Rights of Older People;
• Working with the SESAB Central Public Health Laboratory to provide testing for older people in LTCFs and with the supply of testing kits to local municipalities;
• Preparing flowcharts for LTCFs with: a) guidance for managing Covid-19 risk for older residents; b) risk classification for older residents, based on notions of therapeutic proportionality; c) testing of residents’ contact persons; d) hospital transfer of residents tested positive;
• Meetings with representatives of the State Operational Health Committee to support technical and scientific alignment of the different forms of LTCF support proposed by the Commission;
• Holding web conferences with the president of the National Front for the Strengthening of LTCFs [this is a national network of academics and other stakeholders interested in supporting LTCFs during the pandemic, see https://www.frentenacionalilpi.com.br/], to align our emergency plans, to update our clinical-care protocols and to develop a tele-education intervention with 150 Bahian LTCFs;
• Participation in web conferences to monitor LTCFs in four local municipalities as part of a specific project funded by Banco Itaú;
• Participation in a public hearing on LTCFs held by the Municipality of Salvador on ILPIs.

ANNEX A – GUIDANCE DOCUMENTS SENT TO LTCFS. 

1. Nota Técnica 27/2020 COE/SESAB. Available at http://www.saude.ba.gov.br/wp-content/uploads/2020/04/NT-n%C2%BA-53-de-06.04.2020-Orientacoes-Gerais-Trabalhadores-no-enfrentamento-a-pandemia-ATUALIZADA-EM-27-DE-ABRIL-DE-2020.pdf;
2. Nota Técnica 09/2020 -COSAPI/CGCIVI/DAPES/SAPS/MS; Available at https://idoso.mppr.mp.br/arquivos/File/ILPI_NT_N_9_2020_COSAPI_CGCIVI_DAPES_SAPS_MS.pdf
3. Nota Técnica 23/2020-SAPS/GAB/SAPS/MS; Available at   http://189.28.128.100/dab/docs/portaldab/documentos/nt_23_2020_SAPS_GAB_SAPS_MS.pdf
4. Portaria 65, de 06 demaio de 2020, do Ministério da Cidadania; Available at https://www.in.gov.br/web/dou/-/portaria-n-65-de-6-de-maio-de-2020-255614645
5. Relatório da Frente Nacional de Fortalecimento das ILPIs; Available at http://www.ampid.org.br/v1/wp-content/uploads/2020/04/Relato%CC%81rio-final-1.pdf

ANNEX B – WEB CONFERENCE 

Plantão Coronavírus: orientações gerais para o cuidado da pessoa idosa. Available at https://www.youtube.com/watch?v=brWaZIhi5aM

REFERENCES

Boletim Informativo nº 03/2020 da Comissão Intersetorial de Monitoramento das Instituições de Longa Permanência para Idosos no Estado da Bahia

Instituto Brasileiro de Geografia e Estatísticas (IBGE). Pesquisa Nacional por Amostra de Domicílios Contínua (PNAD-C). Disponível em: https://www.ibge.gov.br/estatisticas/sociais/educacao/9173-pesquisa-nacional-por-amostra-de-domicilios-continua-trimestral.html?edicao=26895&t=resultados