Questions/Answers

The Specialized Service in the Treatment of Allergies of the State of Bahia (SETAB) aims at the development of a reference center for the diagnosis and treatment of allergic and immunological diseases aiming at standardizing the service to users of the Unified Health System (SUS) through medical consultations and training of human resources for the proper management of these pathologies, with the creation of care protocols, linking the patient to the health team. According to the Brazilian Constitution, it is the population's right free access to quality health services. SUS must be universal and equal in meeting health demands and should reach all inhabitants of the country in a wide way, being mainly responsible for covering the low-income population. In Bahia, the percentage of SUS users corresponds to 85% of the population. The need for implementation is due to the increase in the prevalence of allergic and immunological diseases in recent years worldwide. Allergic diseases affect around 30% of the population in large urban centers. In addition, there is concern about the diagnosis of innate immunity errors, which today embraces the diagnosis of about 440 diseases and which are underdiagnosed. Despite the impact on public health, the services in Bahia that provide health care in the SUS to patients with these pathologies are few, fragmented, not meeting the existing demand and mainly without the provision of diagnostic and therapeutic methods available in private centers. The work developed by SETAB intends to highlight the Specialized Center in question, as a State reference unit in the provision of excellent health care and in an integrated manner, with an interdisciplinary team, in the area of allergy and immunology, promoting access to clinical treatment and qualification resources of basic health units in Bahia.

The program encourages the care of all people with allergic and immune system diseases in a specialized service for the diagnosis and treatment of their pathology. It seeks to reach the poorest and most vulnerable through the education of teams in basic health units and the population in general, about pathologies in an inclusive way, aiming to serve users who depend on SUS to have access to curative and preventive health measures. In 2019, the program carried out 3,838 specialized consultations with individuals from more than 100 different municipalities in the state.

The initiative contributes to an inclusive and equitable way, with the effort to end neonatal and child mortality under five years. The innate immunity errors, especially the most serious diseases, affect young children, the early diagnosis and treatment of these pathologies allow these children to survive and have a different quality of life. Food allergies also occur early and their correct diagnosis avoids nutritional problems and deaths from anaphylaxis that are often preventable with the right guidance. Medical classes and inter-consultations have already been held in a state reference maternity hospital to facilitate early diagnosis. Likewise, premature deaths from uncontrolled asthma, allergies to hymenopterans, and adverse drug reactions can be avoided if they are properly managed. Offering specialized care in a reference center and promoting a training and retraining program for health professionals involved in the care of patients with diseases of an allergic and immunological nature, who work in the Basic Health Units and in the Family Health Program of Bahia, can reduce preventable or premature deaths, guaranteeing SUS users excellent care and reducing inequality in access to health due to differences in income and social class.

The initiative is essential in the scenario of the public health system by unrestricted access, regardless of race, age, religion, social class, municipality of residence. Including the protection of financial risk, access to quality specialized health service, means of reference diagnosis in international consensus, medications for SUS users, and development and training of health personnel. Access to the patient is free, the necessary resources are provided by the Octávio Mangabeira Specialized Hospital (HEOM) that houses the initiative. It is environmentally sustainable because the material is reused whenever possible, disposed of properly when necessary and biological material disposed of according to health surveillance standards.

World Health Organization (WHO) estimates that Brazil has 35% of the population suffering from some type of allergy. There is no established prevalence in the country, for innate immunity errors (EII), but in the USA it is about 2% of the population. According to the Brazilian Institute of Geography and Statistics (IBGE), Bahia has 14.9 million inhabitants. An estimated 5 million people with an allergy and 298,000 people with EII. Access to care for these people is insufficient and restricted to a few cities. The initiative brings awareness of care and knowledge about these pathologies, providing health and quality of life to these patients. Located in northeastern Brazil, Bahia is the fourth most populous Brazilian state, however, with precarious health and educational indicators. The absence of adequate public policies leads to increased morbidity and mortality, high direct and indirect costs. To change this scenario, the initiative aims to expand the multidisciplinary service of this demand, to train more professionals, even from distant and unassisted places, decentralizing the service of this population. In addition, SETAB seeks partnerships with pharmaceutical industries and other services of the State to carry out clinical research, purchase inputs for exams and expand treatment.

The project does not differentiate the patient's gender when scheduling appointments. It seeks to welcome people in a global and sensitive way. Knowing that women habitually have a double workday, and are often the providers of their families and, therefore, they have limited time to take care of their health and well-being, we seek to support initiatives that take care of their health.

The initiative provides specialized health care to people with allergic and immunological diseases, including rare diseases, regardless of gender, without age limits. It enabled specialized assistance to residents of 111 different municipalities in Bahia, improving the quality of life of these people and significantly reducing their consequences and public spending. The initiative promotes a reduction in the mortality rate in children under 5 years old, in the mortality rate due to chronic respiratory diseases and access to safe and effective medicines and specific immunotherapy, in addition to promoting an increase in the proportion of health facilities that have a basic set essential medicines, increase in the number of health professionals per inhabitant. In the period 25,253 people were assisted and more than 34 thousand specialized complementary exams were performed.

SETAB started in 2012 with the hiring, through a public tender, by the Health Secretariat of the State of Bahia (SESAB) of medical allergists, who together wrote a project for the implementation of reference service in Bahia to meet the growing number of people with defects in immunity. Later, they joined the group of women doctors, a specialist in otolaryngology and another in gastropediatrics. The intention was to contemplate the flow of assistance to patients with these pathologies in a tertiary hospital, education of professionals from Bahia and implementation of a medical residency program in the future. In the first medical consultation, there is screening and referral to a specific clinic where he will receive treatment in the area of Respiratory allergies, Dermatological allergies, Urticaria, Hymenoptera allergy, Reaction to medicines and Food allergy. When necessary, laboratory tests are performed (total and specific serum IgE dosage) and skin tests with immediate and late reading, oral provocation tests for medications and food, and general guidelines on pathologies in the doctor's office or monthly in meetings with patients in the amphitheater HEOM. Treatment is offered in full with clinical follow-up, environmental control measures or by inducing tolerance with specific immunotherapy. In the last three years, there have been around 4000 specialized services per year. This initiative is part of the expansion of the state program for the control of asthma and other allergic diseases and innate immunity errors and the high-cost medication program, in the qualification of human resources in the technical areas in order to link the patient to the health team basic health units in Bahia. A booklet with the main signs and symptoms of allergic diseases was also developed to promote this project, available on the institution's website, awaiting wide distribution.

Due to the demand of children with recurrent infections beyond the expected, there was a partnership with services from other specialties to alert doctors about how to identify innate immunity errors, through classes and support material, and some consultations were held with children hospitalized in a maternity reference hospital. A booklet was also made addressing diseases that are treated at SETAB. Many patients need to travel long distances to be seen. The way to overcome this obstacle was to train general practitioners who work in the Basic Health Units and in the Family Health Program to minimize this challenge.

The initiative is a pioneer in Bahia, as it encompasses the provision of specialized health care and improvement in the patient's quality of life, through a welcoming, promoting education about diseases in meetings with the health team, decentralizing medical care by providing remote training and in-person to regional health teams avoiding unnecessary travel, elaboration of treatment protocols for health situations with medicines unavailable in the Brazilian public sector, all in order to provide dignified health care, valuing the equality of economic and social class and gender.

The initiative was inspired by the Proar - Asthma Control Program in Bahia, which since 2003 has provided free medications for patients with severe asthma in the SUS, in the pilot project implemented in 1997 that promoted the reorganization of care for asthmatic patients in Belo Horizonte during outline training and retraining actions for health professionals and at the Allergy and Immunology outpatient clinic at the Professor Edgar Santos Hospital Complex (C-HUPES) at the Federal University of Bahia for being an international center of excellence in the treatment of urticaria.

Technological perspectives were not used in this initiative.

No.

The initiative may be implemented in another medium / large cities in Bahia and Brazil, to meet their macro-regions. Avoiding large displacements by patients, since some treatments, especially for people with innate immunity errors, may require monthly or even fortnightly evaluations. With the continuing education program advancing little by little, all municipalities in the federative unit will have general practitioners capable of identifying and treating low complexity diseases. Initiatives similar to those currently taking place in Salvador to deal with cases of medium and high complexity can be installed in strategic municipalities in each of the other 5 macro-regions of the state, such as Feira de Santana, Ilhéus, and Vitória da Conquista. In this way, there would be an agility of service and cost reduction to make diagnosis and treatment available to the largest number of people possible. Professionals qualified to work in these centers in the future will be able to be trained and regularly trained in the existing service and little by little take on the education and support program of the municipalities in their region.

SETAB team is composed of eight specialist doctors, five of whom are allergists, a gastropediatrician, an otolaryngologist and a pulmonologist. In addition, a team of nurses and four nursing technicians trained in the organization and carrying out of skin tests are part of the team. Other HEOM professionals collaborated in the preparation of the booklet, ASBAI - Brazilian Association of Allergy and Immunopathology, which kindly provided the first diagnostic kits for skin allergy tests and partnership with the laboratory reagents company, which in commodate, made available a machine to carry out the specific serum dosages of immunoglobulins E.

The full functioning of SETAB and the recycling of the health team that accompanies patients in their homes of origin will benefit the population of Bahia that does not have specialists in their cities, reducing morbidity, preventable mortality cases, hospitalizations, health expenses and improving health quality of life for people globally. Secondarily, but not least, the diagnostic procedures performed by SETAB will strengthen Bahia Health Service, especially the health unit linked to the initiative, HEOM, generating more resources and visibility as a reference hospital in the field of allergy and immunology.

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Since its implementation, the idealizing team itself holds meetings with the purpose of evaluating the progress of the project, organizing actions that provide optimization of care and the possibility of correction of identified issues. As an example of the proposed activities we have: the search for inputs, educational activity programming and hiring of professionals with the purpose of guaranteeing comprehensive care to patients monitored by SETAB. The evaluations represent an essential point for planning an excellence service.

The hospital production data available from the SIA - Outpatient Information System - were used, with follow-up and criticism spreadsheets referring to the reduction or absence of production during a certain period, constantly seeking solutions to correct distortions in order to optimize the provision of services and promote comprehensive and equal care. As the project contemplates other items besides hospital production, analysis and search for financial and partnership resources are also carried out to allow the realization of the other items that represent the pillars of the project.

The project is based on 3 pillars: 1- Individualized assistance with tests and laboratory evaluation allowing comprehensive assistance to patients with allergies and immunodeficiency. The service is carried out from Monday to Friday in an uninterrupted way, however, it is possible to observe fluctuation of essential diagnostic procedures, caused by the lack of inputs, emphasizing that during this period the timely search of the resource for their purchase is observed. 2- Immunotherapy with training for the level of Primary Care, however, the vaccine that would be purchased at the State level to be dispensed, was not authorized by ANVISA (National Health Surveillance Agency) and the service is waiting for the release or replacement of immunotherapy to restart the process. 3- As the last pillar, the training of human resources of professionals linked to Primary Care for this purpose, Booklets were prepared aiming at educational actions and informative materials, in addition to the participation of service professionals in the training program for patients with asthma. It is noteworthy that the project currently affects 29.6% of the municipalities in Bahia, the initiative represents an important impact on the life of patients with allergic disease and immunodeficiency in Bahia.

SETAB started its activities by hiring five doctors specialized in allergy and immunology admitted through a public tender by the Department of Health of 2008, published in the official diary of November 19, 2010. Until 2008, there was no allergist in the State Health Network. In May 2012, a team composed of seven female doctors, including a doctor specialized in gastro-pediatrics, and one in otorhinolaryngology was established at the Outpatient Clinic of the Octávio Mangabeira Specialized Hospital. The service includes treating all allergic and immunological diseases in the state of Bahia. Pathologies such as respiratory and skin allergies, hives, contact, and atopic dermatitis, food allergies, Hymenoptera, and drugs, in addition to innate immunity errors. SETAB works on an outpatient basis during administrative hours, with scheduling through e-mails, which include reports of the clinical condition or diseases that are easy to handle. The program is registered with CNES 0004065 and CNPJ 13.937.131 / 0015-47, which is intended for the institution Octávio Mangabeira Specialized Hospital.

The parties involved in the conception, implementation and evaluation of the initiative were: Bahia State Health Department (SESAB), Octávio Mangabeira Specialized Hospital (HEOM), the State Regulation Center, TFD (treatment outside home) and SUS, since the service network is made up of 143 municipalities in the State of Bahia). The involvement occurred due to the absence of a public tender for professionals specialized in allergology. The initiative arose out of a concern among the professionals involved, who, when attending daily to patients with various allergic conditions, sought to organize a service that would be appreciated by SESAB. In addition, there is a lack of training for professionals in the interior of Bahia on the subject and the increased demand from patients with various allergies.

During this period, we learned by working together that patience, dialogue and cooperation are fundamental for the realization of any project. We serve a large number of people with the most diverse pathologies relevant to our specialty, doing the best we could for each one of them. We received their fondness and affection in verbal and written form many times, thanking us for the change in their quality of life, reduction in their visits to the emergency room and tranquility regarding the medications they could use and the food they could eat. We focused on winning, with the program partially implemented, and we have already reached almost 30% of the state's municipalities. We intend to reach other municipalities and educate professionals so that most of the monitoring of these people can take place in the city of origin. We also think about offering periodic support to professionals at distance, to ensure the safety of doctor and patient in this partnership. The team also plans to expand its partnerships and seek ways with SESAB to ensure regular funding for inputs and training for general practitioners to keep the project working to its fullest.