key: cord-0776794-41w9dluz authors: Cabral, Ivone Evangelista; Pestana-Santos, Márcia; Ciuffo, Lia Leão; Nunes, Yan do Rosario; Lomba, Maria de Lurdes Lopes de Freitas title: Child health vulnerabilities during the COVID-19 pandemic in Brazil and Portugal date: 2021-07-02 journal: Revista latino-americana de enfermagem DOI: 10.1590/1518-8345.4805.3422 sha: e489c85e751ac564419517b06a9a8a245077bdb8 doc_id: 776794 cord_uid: 41w9dluz OBJECTIVE: to analyze the vulnerabilities of children in the access to primary health care during the COVID-19 pandemic in Brazil and Portugal. METHOD: documentary study based on Brazilian and Portuguese governmental guidelines issued between March and August 2020 regarding access of children to primary health care. Thematic analysis was based on the precepts of health vulnerability. RESULTS: 13 documents were issued in both countries addressing access to vaccination and childcare. Due to the SARS-CoV-2, restrictions were imposed on the circulation of people in social environments, health services, and social protection, decreasing the demand for health services. Both countries continued programs to promote the health of breastfeeding infants. In-person childcare consultations were suspended for low-risk children in both countries. Portugal maintained routine vaccination while Brazil interrupted vaccination in the first 15 days of the pandemic. The countries adopted remote care strategies - telemonitoring, teleconsultation, and mobile applications - to maintain the bond between children and health services. CONCLUSION: longitudinality was affected due to restricted access of children to health promotion actions, determining greater programmatic vulnerability. Individual vulnerabilities are related to exposure to preventable and primary health care-sensitive diseases. The United Nations Children's Fund (UNICEF) released its action agenda in defense of children who are most vulnerable to COVID-19 (Coronavirus disease 2019), caused by the coronavirus (SARS-CoV2), in the context of global health, highlighting the need for urgent actions to avoid a health crisis that results in violating children's rights in the broadest sense (1) . Vulnerability refers to a context of social relations that limits the ability of people to act when institutional support that would ensure social security is no longer available. These are situations that deny people the possibility to effectively exercise their citizenship rights and, consequently, individuals experience insecurity in the present that may frustrate future projects (2) . Even though statistically, children are less likely to be infected with the disease compared to adult and elderly individuals, the COVID-19 pandemic leads to a context of vulnerability. Prevalence of the disease in different countries is below 5% in the child population (from one day to 15 years old), with an even lower number of cases during lactation (3) (4) . It is unknown why morbidity caused by COVID-19 is less severe in this group though, considering that the virus is transmitted person-to-person when having direct contact with an infected individual or with his/her respiratory droplets. This lower susceptibility has been explained by the lower likelihood of children crowding or traveling to epidemic countries. Even though morbidity and mortality rates are low, one has to be attentive to a greater vulnerability to other diseases not associated with SARS-CoV-2, which may indirectly increase morbidity and mortality in this population. Another explanation refers to the distribution, maturation, and functioning of viral receptors. SARS-CoV-2 uses the angiotensin-converting enzyme 2 (ACE2) as a cell receptor, which in mice lungs decreases drastically with age. Additionally, it has been found to protect against lung injuries due to infections caused by respiratory viruses and severe acute lung injuries triggered by sepsis, acid aspiration, severe acute respiratory syndrome (SARS), and lethal infection caused by the avian influenza virus. Thus, these findings suggest that children are less susceptible to COVID-19 (5) . The duration of the disease (3, 6, and 12 months) was associated, in mathematical modeling applied in hypothetical scenarios, with a restricted supply of child health services, and mortality among 5-year-old children was estimated in 118 countries with low to moderate income levels. The findings show that children are more vulnerable to the effects of the COVID-19 pandemic due to decreased access and coverage of services, among which, vaccination. Decreased access, between 9.8% and 18.5%, in a less severe context (6 months) could cause the death of 253,500 children. In a more severe context (12 months) , decreased access between 39.3 and 51.9% could cause more than 1,157,000 deaths. These additional deaths would represent a monthly increase from 9.8 to 44.7% in the number of deaths of children younger than 5 years old (6) . The conclusion is that the prolonged effects of the pandemic on children's health could severely harm children and increase the rates of morbidity and mortality due to preventable causes in proportions equal to or greater than that of the COVID-19. Additionally, conditions affecting children with special health care needs (CSHCN) are more likely to become chronic due to the specificity and differential care required, particularly if follow-up and rehabilitation visits are discontinued (7) . In general, vulnerabilities among children imply even greater exposure to mental health diseases such as profound sadness and anxiety, which may worsen with social isolation (8) (9) (10) (11) . To address these vulnerabilities, the Plano Nacional (12) . Detecting situations that can be corrected early includes monitoring and referral to deal with those situations that interfere in children's health (12) . There has been a dilemma in Brazil in the context of the COVID-19 pandemic. When the health crisis was enacted, in March 2020, the Brazilian Ministry of Health issued a technical note (13) , corroborated by the (state and municipal) Health Departments, restricting the care provided to children in primary health care units. The intention was to avoid agglomerations in health units, however, exposed children with greater vulnerabilities to hospitalizations to treat primary care-sensitive conditions (PCSC). Particularly conditions that may result from poor orientation provided by the primary care network to families or from the population's difficulty to understand the broad role of this level of care, centered on the child, family, and community, instead of focusing on the complaint or disease (14) . In this sense, this study's objective was to analyze the vulnerabilities of children regarding access to primary health care during the COVID-19 pandemic in Brazil and Portugal. This is a documentary study in which data sources were regulatory devices addressing childcare in the context of the COVID-19 pandemic. This type of research is taken as the object of investigation, that is, sources of information that clarify questions and serve as evidence for other new questions, the content of which has not been previously analyzed. Thus, these are primary sources used to answer the study objectives (15) . representative, and credible documents that record the investigated facts. It occurs in three stages: preliminary assessment, documentary analysis, and interpretation. The first stage consists of seeking the dimensions of the context in the texts, the authors, authenticity and reliability, nature, key expressions, and logic of the texts. In documentary analysis, thematic or lexical signifiers are extracted from texts, seeking the simplest elements. in underfunding contexts of both systems (16) (17) (18) (19) . Regulatory documents issued from March to August 2020 were selected, which corresponds to the period in which the services were organized to meet the needs of patients within the COVID-19 pandemic. Key expressions were extracted during the preliminary and exhaustive reading of the documents to generate possibilities to interpret content in the light of the theoretical framework (20) . Based on these guidelines, the coding of the convergent thematic units of each country was regrouped in new tables containing common and different concepts, which were then interpreted in the light of the theoretical framework of vulnerability (2, 21) . Individuals become resilient when experiencing socially vulnerable situations because they persist, assert themselves as individuals, and recognize fragility as a condition inherent to living beings. The specificity of resilience is defined in the limits that life circumstances allow as part of a creative or innovative path (2) . The concept of vulnerability in the health field, from the perspective of human rights, has two collective dimensions (social and programmatic) and one individual In summary, the health systems ensured the continuity of care for children with limited access within primary health care (Figure 3) . Temporarily suspended Resuming on April 16th, 2020. Working hours were expanded. Separate service entrance door for the children. Growth and development surveillance Routine consultations suspended. Low-and medium-risk children recommended for teleconsultation. Neonatal screening Maintained through collection at home. Collection remained in the health unit. Maintenance of breastfeeding even if the nursing mother had the COVID-19 Use and replacement of mask whenever it is humid Hand washing for 20 seconds before breastfeeding. Outpatient monitoring of children with special and differentiated health needs (CSHCN) In-person visits suspended In-person or telemonitoring (application of telephone) Both countries: telemonitoring (applications, telephone) Home care (separate beds, masks, individual bathrooms, environment, utensils, and hands hygiene). Hospitalization in cases of severe respiratory distress syndrome/COVID-19 Rev. Latino-Am. Enfermagem 2021;29:e3422. In Brazil, on the first day of the health crisis caused (25) . In this sense, when there are barriers to access, whether these are caused by temporary governmental guidelines or the families' fear that their children will be exposed to viral load, there is a risk of increasing vulnerabilities of children to preventable diseases and hospitalizations due to primary health care-sensitive conditions (5) . pandemic. As for childcare, both countries presented programmatic vulnerabilities that were associated with restricted face-to-face access to primary health care intended to decrease the spread of the COVID-19. Consequently, this measure affected the longitudinality of follow-up during the pandemic with no expectation when it will end, whether due to a decision on the part of the Impact of COVID-19 pandemic on the mental health of children in Bangladesh: a cross-sectional study Programa Nacional de Saúde Infantil e Juvenil Portaria MS nº 356, de internacional decorrente do coronavírus (COVID-19). 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