Article Text
Abstract
Emerging infectious diseases present a significant challenge to healthcare systems with their need for a rapid response and reallocation of resources. This paper explores the implementation of the Practical Approach to Care Kit (PACK) programme in Florianópolis, Brazil as a strategic tool for reinforcing primary healthcare (PHC) responses to emergent communicable diseases. With its focus on enhancing PHC delivery in resource-limited settings, PACK provides a flexible, evidence-based framework that integrates into local health systems. The paper describes experiences adapting PACK to provide rapid responses to outbreaks of Zika, leishmaniasis, COVID-19, Mpox and dengue in primary care between 2014 and 2023. Key features of PACK, including its flexibility to incorporate new clinical content, responsive implementation strategy and health system strengthening approach, are highlighted. The paper emphasises how PACK supported responses to specific disease outbreaks and helped maintain mainstream PHC delivery, preventing the system from becoming condition-centric during crises. We describe the limitations of the PACK approach in an outbreak scenario, the challenges experienced and efforts to tackle these. The lessons learnt from Florianópolis underscore the adaptability and relevance of comprehensive primary care approaches like PACK in supporting PHC professionals and local health systems to navigate emerging health challenges.
- COVID-19
- Diagnostics and tools
- Global Health
- Other infection, disease, disorder, or injury
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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SUMMARY BOX
Emerging infectious disease responses often compromise regular primary care delivery.
The Practical Approach to Care Kit (PACK) programme supports primary care reforms in several low-income and middle-income countries by consolidating comprehensive policy-aligned clinical decision support for clinicians and system strengthening initiatives for its delivery.
The Municipal Health Department in Florianópolis, Brazil, used PACK to support the identification and management of several emerging infectious diseases, including Zika, leishmaniasis, COVID-19, Mpox and dengue, by integrating disease-specific content, training and system improvements.
PACK’s adaptability and comprehensive approach enabled an all-learning paradigm to support workforce capacity building and system resilience to support responses to infectious disease outbreaks.
Comprehensive approaches to support front-line healthcare workers, like the PACK programme, have the potential to augment the global diffusion and innovation of responses to emerging infectious diseases.
Introduction
Emerging infectious diseases are infections with a novel pathogen or known diseases that re-emerge and spread rapidly, infecting more people or extending to new regions.1 2 They place a substantial burden on healthcare systems, especially in low-income and middle-income countries (LMICs).3
Brazil is a middle-income country with experience of emerging infectious diseases. Rio de Janeiro saw the first compulsory vaccination programme, against smallpox in 1904, introduced by the Director General of Public Health, Oswaldo Cruz, who also led the city’s sanitary response to yellow fever. More recently, a 2015/2016 Zika virus outbreak saw a rapid rise in newborn cases of microcephaly and other neurological impairments.4 Dengue, well-known in several Brazilian states, is appearing for the first time elsewhere, challenging vector control efforts.5 Visceral leishmaniasis, previously endemic only to northern Brazil, emerged in the south in 2006.6 The COVID-19 pandemic in 2020 further strained healthcare systems, particularly primary healthcare (PHC) in regions with limited resources and vulnerable populations.7 An Mpox outbreak in 2022 made Brazil the second most affected country globally and first in Latin America, with 9312 of 51 519 confirmed cases in the region.8
Brazil’s Unified Health System (SUS) provides universal, free, comprehensive healthcare,9 with PHC encompassing prevention, detection, acute management and ongoing care for chronic conditions across the life course.10 Although SUS’s investment in PHC is credited with health gains over the past three decades,9 PHC services remain poorly prepared for emerging infectious disease outbreaks, struggling to reorganise services rapidly while continuing to provide routine services.11–14
The global COVID-19 response emphasised the need for epidemic-ready PHC.15 This practice paper describes how a comprehensive primary care strategy called Practical Approach to Care Kit (PACK), established to strengthen primary care, supported rapid responses to several infectious disease outbreaks while maintaining routine PHC services in Florianópolis, a city in southern Brazil. We share the elements of the PACK strategy that facilitated this response and reflect on the challenges encountered and lessons learnt.
This paper forms part of a collection of papers on PACK which describes its role as part of health system strengthening reforms in LMICs. It will be of interest to policy-makers, managers and providers working in primary care who are responsible for marshalling a rapid response to an infectious disease outbreak, as well as to applied health researchers exploring strategies for primary care pandemic preparedness.
The Practical Approach to Care Kit
PACK was developed by the Knowledge Translation Unit (KTU) of the University of Cape Town in South Africa to simplify, standardise and strengthen PHC in resource-limited settings.16 It has been implemented in South Africa, Ethiopia,17 Brazil, Nigeria,18 Botswana,19 Malawi20 and Indonesia—in South Africa and Ethiopia it has been scaled up countrywide by national ministries of health for over 10 and 7 years,21 respectively.
PACK comprises a clinical decision support tool, the ‘PACK guide’ and an evidence-based implementation strategy. The guide offers an approach to 40 common symptoms and 24 chronic conditions in adults presenting to PHC and is easy to use, with algorithms and checklists supporting clinical decision-making. Drawing on the latest WHO guidance and recommendations sourced through BMJ’s Best Practice evidence synthesis product, it integrates content across non-communicable diseases (NCDs), communicable diseases, mental illness and women’s health. A short video outlining its features was developed to support implementation (https://www.youtube.com/watch?v=ZDSpbqQOmoU). Localisation of the PACK guide sees adjustments to reflect local guidelines, policy, resources and health worker skillsets.22 Regular updating involving local stakeholders responds to evolving policy, evidence and feedback, generating a forum for resolving policy and guideline conflicts and allowing for systems strengthening initiatives, including clarifying scope of practice, tackling medication availability, streamlining referral pathways and enabling task-sharing. A training strategy that targets the PHC team embeds the guide into practice using case scenarios focused on clinical and systems issues in short, onsite interactive sessions. Facilitated by trainers in the health system, the sessions promote teamwork and communication, and the resulting community of practice often continues via WhatsApp groups.23
In Florianópolis, a team of municipal health PHC managers, doctors and nurses, mentored by the KTU, localised PACK between 2014 and 2016 as part of the municipality’s efforts to strengthen PHC. Localisation included expanding the scope of PHC services, upskilling healthcare professionals and providing practical user-friendly tools to keep them up to date with evidence and policy.24 This occurred as part of broad primary care reform which included implementation of advanced access, local protocols for nurse prescribing and standardisation of the PHC clinical offering. This reform and the context that favoured PACK implementation are described elsewhere.25–27 The first edition of ‘PACK Brasil Adulto’ was published in 2016, and 160 nurses and doctors from 24 Florianópolis PHC facilities were trained to use it. The guide has since been updated by the municipal health team every 1–2 years with KTU mentorship to reflect the latest policy and evidence, to become an established, trusted resource for PHC delivery. Its use expanded to PHC initiatives across Santa Catarina state and it was integrated into nursing, medical student and family physician teaching.
The KTU–Florianópolis collaboration inspired the establishment in 2023 of a KTU (Unidade de Tradução do Conhecimento, UTC) in Brazil. It aims to introduce PACK to other municipalities, initially focusing on expanding PHC for people living with or at risk of HIV and tuberculosis (TB). Discussions are underway with the National Health Department to implement PACK as a national strategy. The PACK Brazil guide and training modules are available on the UTC’s online learning platform, https://bit.ly/programapackbrasil.
Several pragmatic randomised controlled trials (RCTs) in South Africa have shown improvements in quality of care and health outcomes across a range of conditions and healthcare activities, including HIV, TB, chronic respiratory disease, diabetes and appropriate antibiotic prescribing.28–30 An RCT in Brazil reproduced some of these findings and demonstrated that they were sustained beyond initial implementation.31 32
Qualitative studies conducted in Florianópolis suggested that PACK implementation had good initial acceptability among doctors and nurses and improved interprofessional communication, task sharing and teamwork.33 34
These studies demonstrate that PACK’s comprehensive strategy for primary care can have an impact on health system priorities.
Using the PACK strategy to respond to emerging infectious disease outbreaks
PACK’s introduction to Florianópolis in 2015 overlapped with several emerging infectious disease outbreaks, with the Municipal Health Department responding to five over an 8-year period. Characteristics of these diseases, their pathogens, clinical presentation, treatment and prevention are summarised in table 1.
Local clinicians required guidance to recognise, diagnose and manage conditions never or rarely seen in southern Brazil. A priority was the rapid dissemination of evidence-based and policy-aligned information. Emerging evidence needed clarification and in the case of COVID-19, non-evidence-based practices discouraged, especially as some national authorities supported ineffective interventions (eg, hydroxychloroquine) and the regional medical council authorised the prescription of off-label and unproven medications that contributed to COVID-19 deaths.35–37
To support screening, identification, diagnosis, management, referral and notification activities, the municipal team developed clinical decision support material for each outbreak. They drew on local policy and evidence and used a similar approach to PACK content development to create symptom-based guidance arranged in algorithms that made step-by-step decision-making processes explicit. The interrogation of local clinical and health system policy during PACK content development provided the opportunity to clarify and standardise workflow and scope of practice among the PHC team, rationalise resource use and support notification processes. The process involved broad stakeholder review, drawing in primary care and specialist clinicians as well as managers and policy-makers.
Depending on when the outbreak occurred in relation to regular PACK Adulto guide publications, the clinical content was either incorporated into the latest PACK Adulto version (Zika and dengue) or developed as a standalone tool that used the PACK clinical decision support tool format and design (Leishmaniasis, COVID-19 and Mpox). A summary of the 11 PACK COVID publications is included in online supplemental file 1. The content of these standalone publications was subsequently integrated into updates of the PACK Adulto guide. Figure 1 shows the timing of each outbreak, along with the PACK publications and implementation initiatives between 2015 and 2023.
Supplemental material
For the COVID-19 content, ‘PACK Brasil Adulto COVID-19’ was localised from the PACK COVID guide that had been rapidly developed by the KTU for the South African context at the start of the pandemic. For the other outbreaks, the municipal team developed the content de novo (as these infectious diseases do not occur in South Africa) with ad hoc clinical editorial and PACK clinical decision support ‘style’ input from the KTU team if the municipal team required it and where KTU capacity allowed. The KTU provided graphical design support for the content to maintain its PACK ‘look and feel’.
The implementation strategy for these outbreak content sets varied based on available resources, municipal team capacity and urgency for its dissemination. While Zika was included in the PACK case-based training curriculum and delivered during PACK on-site educational outreach training sessions, implementation strategies for the other outbreaks veered away from this model, using training webinars (COVID, Mpox), an explainer video (Mpox), self-guided online training course (Mpox), dissemination of content via email and hard copy (leishmaniasis) and an off-site training workshop (dengue).
The PACK Brasil COVID-19 guides were made available via the KTU website, which reported 8119 downloads. As there were approximately 240 health workers (160 doctors and nurses plus 80 family medicine and nursing residents) in Florianópolis at the time, this suggests that the guide’s reach extended far beyond the expected audience.
How did PACK support an emerging infectious disease response?
The PACK programme contains clinical decision support, training and health system strengthening features that support the municipality’s responses to the outbreaks. Table 2 itemises these features and provides examples of each for the various outbreaks.
Key characteristics that facilitated an outbreak response included the following:
A syndromic approach prompts identification of the emerging infectious disease
PACK’s syndromic assessment of an undifferentiated presentation allows for the identification of the infectious disease and ensures other common conditions are not missed, for example, the fever algorithm prompts users to consider dengue in patients with fever and other suggestive symptoms but also flags likely respiratory tract infection or TB diagnosis where appropriate. Figure 2 displays content from the PACK Brasil Adulto 2016 guide that prompts the user to consider Zika. Possible scenarios can be overlooked when constructing clinical guidance in narrative format, and the process of algorithm construction assists translation of policy and clinical guidance into actionable clinical and system responses.38
A familiar layout supports usability
The use of the PACK layout in the standalone content sets for leishmaniasis, Mpox and COVID-19 ensured a look and feel known and trusted by end-users. Healthcare providers are more likely to use and adhere to clinical guidelines and decision support tools when presented in a familiar format.39
An established and responsive updating mechanism facilitates quick updates
PACK’s established and responsive updating mechanism is consultative, addressing concerns from clinicians alongside policy-makers. This allowed for rapid incorporation of new diagnostics, treatment and vaccines and regular revisions of case definitions and testing criteria during the COVID-19 pandemic (with 11 PACK COVID-19 publications in 2 years), and the expansion of dengue content in response to the 2023 outbreak.
An established PHC programme allows for its rapid leverage during an outbreak
Entering the pandemic with a programme established in the health system allowed its rapid leverage as part of the response. Users expect PACK’s regular updates and rely on the guide as a quick-look reference. The case-based training curriculum was flexible, allowing for rapid inclusion of new conditions while familiarity with the clinical decision support approach and training methodology eased uptake. Each outbreak prompted augmentation of an established programme rather than the addition of a siloed response.40
A comprehensive programme supports ongoing delivery of usual PHC
The fact that PACK was a comprehensive programme supported ongoing delivery of usual PHC services rather than succumbing to the distraction of the outbreak, a common response that compromises usual care.41–43 Brazil’s federal government encouraged shifting professionals from PHC into stand-alone COVID-19 services. Despite this, Florianópolis municipal PHC teams continued to deliver comprehensive care using PACK while addressing COVID-19 pressures. The PACK COVID-19 guide enabled continued care for common conditions by signposting differential diagnoses, including prevalent respiratory conditions like TB, easily overlooked given the hyperfocus on COVID-19. This is consistent with KTU experience in South Africa where diagnostic algorithms for respiratory syndromes and active implementation enabled improved TB case detection during the COVID-19 pandemic.44
PACK can be a mechanism for diffusion of PHC outbreak responses
The Lancet Commission on lessons for the future from the COVID-19 pandemic45 included global innovation and diffusion in its five-pillar framework (along with prevention, containment, health services and equity) for responding to an emerging infectious disease. However, this pillar omitted cross-border sharing of initiatives to build workforce capacity, focusing instead on pharmaceutical and vaccine innovations. The clinical approach developed for dengue in PACK Brasil Adulto was subsequently aligned by the KTU to international evidence and WHO guidance and absorbed into the generic PACK Global guide’s fever algorithm. It was also adapted as part of PACK localisation for Indonesia and included in an approach to fever in clinical decision support content commissioned by the WHO Clinical Services and Systems Unit. PACK offers a mechanism for global innovation and diffusion of PHC outbreak responses that are tangible and practical. Our South-to-South collaboration demonstrates that it can generate global communities of practice with opportunities for content-sharing—especially between LMICs where resource constraints determine what can be implemented.
Tackling the limitations of PACK to support an infectious disease outbreak response
PACK clinical content generation and maintenance is onerous
HIV and TB prompt PACK updates every 1–2 years in South Africa, which has generated a mechanism that can be rapidly deployed to support the health workforce during more acute outbreaks—and beyond sub-Saharan Africa. However, while a dedicated team in the Florianópolis municipal health department had protected time to develop and maintain the PACK clinical content and curriculum during non-outbreak periods, they struggled when infectious disease outbreaks required faster updates and real-time incorporation of new evidence as evidenced by 11 publications of PACK COVID-19 in Florianópolis over a 2-year period. Living guideline methodologies may well offer an even more streamlined mechanism of content generation and publication.46
Lack of healthcare services user input into content development
Drawing patients and the public into both outbreak responses and clinical guidance development is considered best practice to ensure healthcare service users are active participants in healthcare decision-making and that these decisions are locally relevant and acceptable.47 We did not involve healthcare service users in clinical content development, an omission that occurred largely due to urgent development timelines along with concerns around risk of spread at in-person sessions. We would need to explore feasible methodologies for ensuring meaningful but rapid healthcare user input in an outbreak scenario and strengthen existing community engagement in preparation for this eventuality.
PACK’s usual training model had its limitations in an outbreak scenario
The PACK usual training approach of a cascade model of implementation with onsite, outreach sessions was used only during the Zika outbreak as the timing of this outbreak coincided with the publication of the PACK Adulto guide and launch of the onsite training sessions. Alternative approaches were implemented with the other outbreaks, for a variety of reasons, including the limited capacity of the municipal team to design a training curriculum given their other clinical and managerial responsibilities (leishmaniasis), social distancing restrictions (COVID-19 and Mpox) and an urgent response leaving no time for the flow of the cascade (dengue). The experiences reported in this paper showed how the team flexed the PACK training approach to allow rapid dissemination of new content while attempting to maintain its key elements, such as case scenarios and support to navigate the guide. These implementation innovations contribute to the training and implementation offerings for the PACK programme but will require evaluation as to their effectiveness.
Current limited capacity for programme monitoring and evaluation of reach and impact
The monitoring and evaluation (M&E) component of the PACK programme is designed to be tailored to existing local M&E frameworks and needs. This requires the system to link PACK to local health outcome indicators. Electronic medical record systems in Brazil while widely implemented, have limited capacity to capture clinical decision-making or compliance with local guidelines and thus currently cannot produce routine data (eg, around diagnosis, prescriptions, written advice or contact tracing) that could be used to assess the impact of new evidence or training on clinical decision-making.48 We anticipate that this will be one focus of the newly formed UTC as it supports the scale-up of PACK in other municipalities, enabling evaluation of the programme’s effectiveness at containing an emerging infectious disease and its disruption to routine services. In addition, more work needs to be done to evaluate the mechanism for how PACK intends to strengthen health systems as well as the acceptability of the PACK programme to healthcare providers and health service users. This might prove particularly challenging during an infectious disease outbreak where resources are stretched and priorities lie elsewhere.
Conclusion
The response of Florianópolis to five infectious disease outbreaks over 8 years highlights the adaptability of the PACK programme to address new clinical conditions and support PHC healthcare provider and system needs. The formation of the UTC provides impetus and resources to add to initial evaluations of PACK’s impact, reach and acceptability to end-users. Moving forward, the focus will be on expanding the PACK programme to other municipalities in Brazil and integrating it into national strategies. This will involve continuous innovation, using and building on established PACK mechanisms for updating clinical content and responsive implementation. By fostering global collaboration and sharing lessons learnt, PACK offers a model for LMICs to support PHC workforce capacity building and system resilience to cope with future infectious disease outbreaks and other health system shocks.
Abstract translation
Abstract translation
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Ethics statements
Patient consent for publication
Acknowledgments
We extend our sincere thanks to the doctors and nurses at the primary care facilities in Florianópolis for their active engagement in using the PACK guide, participating in training sessions and serving as the backbone of health system strengthening efforts. Our gratitude also goes to the dedicated workers of the Municipal Health Department of Florianópolis for their invaluable contributions during outbreaks and ongoing support. Additionally, we express our appreciation to Marly Cruz, Vanda Cota and Ana Carolina F e S Santelli for their belief in 9 the potential of the PACK program to enhance healthcare in Brazil and for their support in its recent expansion.
References
Footnotes
Handling editor Rachael Hinton
Contributors RZ, MZG, FdBP, BME, RVC and LRF conceived, primarily wrote and edited the paper; JZ, MPdA and FKKMSP reviewed and edited it; JPMdS, ACMFB, EFS, AA, PWS, CW, CJR and DG-P reviewed the paper. RVC is the guarantor.
Funding The PACK programme has been implemented in Brazil since 2015 with in-kind support from the Florianópolis Municipal Health Department and the Knowledge Translation Unit, University of Cape Town. The establishment of a Knowledge Translation Unit (Unidade de Tradução do Conhecimento, UTC) in Brazil is being supported by a 2022 Cooperation Agreement (grant agreement number NU2GGH002174) between the Sergio Arouca National School of Public Health (ENSP) of the Oswaldo Cruz Foundation (Fiocruz), the US Centers for Disease Control and Prevention (CDC), the Knowledge Translation Unit of the University of Cape Town and The Health Foundation, with funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR). This paper forms part of a Collection on PACK sponsored by the UK’s National Institutes for Health and Care Research (NIHR) (NIHR201816) using UK aid from the UK government to profile the contribution of PACK across several countries towards the realisation of comprehensive primary healthcare as envisaged in the Declarations of Alma Ata and Astana and towards Universal Health Coverage and the Sustainable Development Goals.
Disclaimer The views and opinions expressed in this paper are those of the authors. They do not necessarily reflect those of their institutions or funders or of the NIHR or the Department of Health and Social Care.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.