Coping Action Oriented to Early Stimulation of Children with Congenital Zika Virus Infection in Rio de Janeiro State

New health care demands directed at children with chronic conditions have been demanded mainly after the Zika virus epidemic. Given this, the Brazilian states have produced plans to cope with this congenital infection. In the state of Rio de Janeiro, the elaborated plan had as one of its actions a training proposal for physiotherapists, speech therapists and occupational therapists, focusing on early stimulation and focused on the health care network, especially primary care and specialized rehabilitation centers. Thus the purpose of this article is to describe the impact of a response strategy to Zika virus congenital infection, based on the multi-professional training proposal in earlier stimulation in the public health attention network of Rio de Janeiro State. Descriptive study, observational from the earlier stimulation training course to the public health attention network of Rio de Janeiro State as a coping action to the health care of children with Zika virus congenital infection. At the time of writing, partial results are available after 11 classes were performed. Based on the analysis of the evaluation form of the 11 courses taught by professionals of a referral hospital in Rio de Janeiro and student form, using the Excel program, 299 health network professionals were qualified, from 56 different municipalities of RJ, mostly females (n = 259; 86.82%). 175 physiotherapists (59%), 88 speech therapists (29%), 32 occupational therapists (11%) and 4 academics or other professional backgrounds (1%). The articulation between the different levels of public assistance, specifically: primary, secHow to cite this paper: de Sá, M.R.C., de Almeida Thomazinho, P., Ribeiro, C.T.M., Molleri, N.A., de Siqueira Mayirink, M.L., Mendes, P.N., Hamanaka, T., Rossi, L.P., da Silva, T.S., Lucena, D. and Moreira, M.E.L. (2019) Coping Action Oriented to Early Stimulation of Children with Congenital Zika Virus Infection in Rio de Janeiro State. Health, 11, 1152-1161. https://doi.org/10.4236/health.2019.119089 Received: August 14, 2019 Accepted: September 23, 2019 Published: September 26, 2019 Copyright © 2019 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/


Introduction
New care demands directed at child health are required considering the continuous increase in prevalence of chronic aggravated health conditions and/or chronic disease throughout the world, including developing countries [1]. Among these conditions, the congenital alterations related to the Zika virus outbreak, identified in Brazil in 2015, stands out. Given the identified neurological deficit conditions, exposure to Zika virus impacts in a greater or lesser degree on infant growth and development with life-long repercussions [2].
The congenital syndrome associated with the Zika virus (CZS) is characterized by presenting among its clinical manifestations: those stemming from central nervous system malformation such as microcephaly, spasticity, irritability, seizure episodes with control difficulties, sensory alterations (hearing and visual), on the ocular structures and orthopedics (arthrogryposis, congenital club foot, hip dislocation), dysphagia and neurogenic bladder. Thereby neurosensory-motor development is significantly compromised and early specialized and continuous care, performed by a multitask professional team is essential [3] [4] [5] [6] [7].
In Brazil in November 2015, the Ministry of Health declared a Public Health Emergency related to Zika and microcephaly [8] and immediately afterwards in February 2016, the World Health Organization (WHO) declared a Public Health Emergency of International Concern [9]. According to the Epidemiological Report from the Ministry of Health of April 2019, an actual incidence of Zikainfeccion is of 1.1 cases per 1000 inhabitants. The epidemic had an asymmetrical distribution throughout Brazil and the most affected regions were the Northeast, Southeast and Central [8]. From  were notified up to the period described [10].
However, despite a large number of confirmed cases of infants and children exposed to the Zika virus throughout the country, and recognizing the repercussion of this infection in childhood development, only 1,000 (34.9%) received specialized early stimulation treatment [10].
Considering the magnitude of cases of children with chronic aggravations in Rio de Janeiro, it was necessary to elaborate a coping plan to combat the Zika virus infection and other infectious contagious diseases in the State, composed of 9 axes (Axis I-Epidemiologic Surveillance, Axis II-Promotion and Prevention, Axis III Basic Attention, Axis IV-Specialized Attention, Axis V-Clinical Attention, Axis VI-Rehabilitation, Axis VII-Permanent Education, Axis VIII-Intersectoriality and Axis IX-Management) with the attendance of health professionals, education, State management welfare, research institutions, professional councils and reference services including the reference hospital that participated in this study [10].
Through the Rio de Janeiro State Health Department (SES/RJ), the Superintendent of Primary Health Attention and the reference hospital (RH), a training proposal was developed that focused on earlier stimulation, aimed at the child health attention network of Rio de Janeiro State as a part of the "Implementation Plan for the Strengthening Strategy for Treatment of children suspected or confirmed with the Congenital Zika Syndrome (CZS) and others syndromes caused by syphilis, toxoplasmosis, rubella, cytomegalovirus and herpes virus (STORCH)", which is the subject of this work. The aim of this proposal is to give support and enable healthcare professionals to assist children with Zika virus congenital infections, particularly those who assist with primary health attention and specialized rehabilitation centers [11]. Thus the purpose of this article is to describe the impact of a response strategy to Zika virus congenital infection, based on the multi-professional training proposal in earlier stimulation in the public health attention network of Rio de Janeiro State.

Methodology
Descriptive study, observational from the earlier stimulation training course to the public health attention network of Rio de Janeiro State as a coping action to the health care of children with Zika virus congenital infection, based on course students' records, attendees' registration forms, assessment sheets from each group, and the "Implementation Plan for the Strengthening Strategy for Treatment of children suspected or confirmed with the Congenital Zika Syndrome (CZS) and others syndromes caused by syphilis, toxoplasmosis, rubella, cytomegalovirus and herpes virus (STORCH)".
The study began with the identification of the demands and needs of the assistance network in Rio de Janeiro, listed by an inter-institutional and intersectorial working group, elaborated through a SWOT (strengths, weakness, opportunities and threats) analysis; and followed the stage of building on the earlier stimulation training course. An initial meeting took place with a specialized team composed of physiotherapists, speech therapists, occupational therapists, and care specialists, where a brainstorming session was conducted with the aim of pointing out all the strengths, weakness, opportunities and threats. The list of items produced in the SWOT was refined using following parameters: the power of a factor indicated, and the probability of its occurrence. Finally, a strategy was mapped for each final list item, in order to explore the advantages and opportunities and address weakness and threats.

Results
At the time of writing, partial results are available after 11 classes were performed in the following areas: Metropolitan I and II (5)  In regard to the workplace, among attendees who responded to the registration items, from the specialized services comprised 53.82% of the total (n = 155) and those attached to basic attention strategies were 43.18% (n = 133).
The training course evaluation, considering the attendee's expectation, was rated as positive by 89.90% of professionals. All evaluated items had an excellence rating above 70%, except the course load that had 57.65% approval among the attendees, where they registered the desire for a program extension, including the possibility of an advanced module.
A communication channel to continue the discussion was provided by a virtual knowledge portal, where professionals can send doubts derived from their assistance practice related to the topic, and these doubts are addressed through expositive activities presented by the reference hospital specialists.

Discussion
The duction across different age ranges [12].
The articulation between the different levels of public assistance, specifically: primary, secondary and tertiary, in this context assumes a fundamental action for good practices being undertaken considering the population's health demands. Especially in relation to childhood chronic disease conditions, this action permits the building of lines of care that meet the population's health demands so that in any of a child's entry points on the assistance network, either prevention or treatment of the aggravated cases, there is integration of the actions and a better resolving response [11].
This articulation is in accord with the Sustainable Development Goals (SDG), which as part of Agenda 2030 [13] are a global call to action for eradicating poverty, protect the planet and assure that all people live in peace and prosperity.
The SDG intend to "not leave anyone behind" and they make a commitment to Thereby, there is a premise that strategies for integration between levels of assistance and permanent training of health teams to new demands, contribute to networking and agreements between health actions undertaken [15] [16]. Health attention network is understood as "the organizational arrangements of health actions and services, of different technological densities, that are integrated through technical support systems, logistics and management that lead to assurance of integrality of care" [17].
The presentation of this proposal of capacitation shows that from a targeted plan, a huge number of professionals can be reached, even in actions that incor- 22.88% of its residents have a per capita income below ½ minimum wage [19].
The difference in weighting of professionals' participation in relation to their specialties reflects the distribution profile that they presented on the public network of child health assistance, until this moment a minimum level considered appropriate to the presented population demands was not observed, and was not also identified in totality, these factors constituting important research points to be answered.
It could be also identified that the strategy covered both the primary health attention team and the specialized rehabilitation team equally, composing one more important dialogue point to build an articulated and integrated assistance Health network. It's important to emphasize that the professionals who work on primary health attention mostly had a poor formal qualification for monitoring children with CZS, as reported by many of them throughout the performed activities, and many reported never having monitored a pediatric patient before, because they had other specialties in the health field. It is encouraging to note this level of involvement of the professionals during the discussions, especially because they are based on a critical analysis of the problems.
It is worthwhile to emphasize that all children with CZS and STORCH must have early stimulation, and it is not mandatory that this occur only in Rehabilitation Centre, because this care is fundamental to the development of many organic systems in the critical period to acquire motor, sensorial and adaptive be- In general, it is expected to achieve a higher degree of capacity for health education actions, since the repositioning of professionals in relation to families and their role in care can also contribute to the construction of more positive bonds between health workers and users; a better understanding of attitudes that, shared with the teams, allows a better quality of life as well as health promotion for children and their families/caregivers; early multidisciplinary care to these children, preventing morbidity associated with the lack of intervention; minimizing the family flow through multiple specialized health services, searching for rehabilitation care, that sometimes may prolong this search for months, which certainly optimizes the availability of vacancies in the public system of specialized attention [20].

Final Considerations
The proposal presented represents an integration of different strategic health sectors for the implementation of actions that specifically address integral care. The proposed action design appears to have allowed greater participation of health professionals working in primary care (NASFs and Primary Health Care) and specialized rehabilitation services in the State of Rio de Janeiro, and represents an important step towards the provision of a comprehensive care network for children with CZS. The action can also be transposed to other types of chronic health problems.