In the frontline: Disease Control Agents' role, an insight from Brazil

Vector control and environmental management are crucial aspects of dengue control, with professionals in the field delivering these interventions as thoroughly as possible and providing an essential link between communities and the health and prevention sector. However, a number of challenges mean that it can remain difficult to maintain staff numbers and momentum in these positions - globally, technical knowledge of vectors can remain insufficient, training opportunities are limited, and job prospects in this field can feel limited at the municipal level where the positions operate. There also remain significant gaps in the perception by local communities of these agents' role. In recently published work, a team of researchers have spoken to Disease Control Agents in disease-endemic regions of Brazil to gain a better understanding of their own and the public's perceptions about their role. In this Infectious Thoughts interview, we speak about the results to Cíntia Donateli from the Federal University of Viçosa, in Minas Gerais, Brazil, and how to overcome the current challenges and limitations in the work of Disease Control Agents to ultimately improve the control of disease and their vectors.

Can you describe the role of individuals which you were interviewing in this research? How important are these Disease Control Agents (ACE) for the control of disease?

Endemic Disease Control Agents (ACE) are agents with a role in disease prevention and in health promotion, both at an individual and collective level. ACE focus in Brazil is prevention and vector control, with actions of integrated environmental management which involve the execution of chemical and biological control measures, visits at households and at critical areas, such as abandoned terrains. Besides inspections in places where water accumulates, as water tanks and pools, ACE agents also act as health promoters through actions of health education. An example of these actions is the execution of activities of awareness-raising activities carried out by ACE, mainly in schools and basic health units.

The importance of ACE stems from the fact that this professional is in direct and continuous contact with the population and with the environment, which makes them the main articulators between the community and health service. Through the knowledge of territory specificities and particularities, of vulnerability and health risks mapping, ACE can act with a wide vision of health determinants and the environment.

Vector control and environmental management are crucial aspects of dengue control, with professionals in the field delivering these interventions as thoroughly as possible. Why was it important for you to speak directly to the professionals involved in delivering these interventions in the field?

Given the successive epidemics of arboviruses, it is essential to examine the factors that potentiate and hinder ACE fieldwork, seeing that ACE agents are primordial in the process of change and transformation in the way of managing the environment and of fomenting vector control together with the community. Only by recognizing ACE professional practice and the inherent challenges in its work process will we be able to understand the dimension and complexity of their activities and establish priorities and more efficient goals in the control of arboviruses.

Thus, in ACE’s own perspective, from the issues that are crucial for the realization of territory interventions we will be able to reflect critically about the current approach of disease prevention and vector control, which is currently focused in immediate actions that they point out as non-effective and without long term outcomes.

What are the main challenges that Disease Control Agents face in their work?

The challenges of ACE’s professional practice are innumerous. We identify the following as some of the main challenges: the lack of recognition about the professional performance and the non-comprehension of this professional’s role by population, the disqualification and unpreparedness for field work (lack of capacitation and adequate training in time and contents), coupled with poor working conditions, such as incipient infrastructure and shortage of materials which undermine the quality of executed activities.

We emphasize the difficulty in the construction of a bond with the community. The absence of this bond makes impossible the participative process that is extremely necessary to the execution of vector control. Population refusal to receive the agents is due to the lack of comprehension of their function and by the high rotation of these professionals. On the other hand, the difficulties of household visits and inspections in the community are added to the violence and criminality existent in many neighborhoods.

Other relevant matter about the challenges that ACE agents face is the evaluation of their work process. The lack of communication and dialogue between agents and their superiors harms the comprehension of produced data which do not become information. Thus, it is necessary that practice agents are effectively included in the process and understand management matters of vigilance, being able to spread, in a consistent manner, the information to population.

We often hear of the shortage of professionals in the field of vector control. What has your research determined in terms of the causes of this and which research, investment or partnerships would you like to see developed to improve this?

Insufficient numbers of professionals to cover the entire territory was a weakness reported by ACE agents and it was also presented on SWOT analysis. Some identified causes, which favor the high rotation of these professionals, were the lack of investment in capacitation and training to the professional practice, low payments, precarious employment relationships and unsatisfactory working conditions. In addition to it, working through temporary contracts and with inflexible hours are some factors that contribute to the weakening of professional identity and to the perpetuation of the reductionist stigma of ACE performance.

Based on these considerations, the overcoming of practical challenges and the quality improvement of provided services through professional valorization and capacitation, besides the reliability of outcome evaluation and cost-effective interventions will contribute to the confrontation of health problems, causing a reduction on the impact of arboviruses, still neglected diseases, and promoting better life and health conditions for the population.

In order for this to happen, governmental investment in public health policies are urgently needed, which will guarantee and strengthen the Universal Health System (SUS) and integrate vigilance actions in health as a primary attention.

To support this, the VigSUS research group, which I am part of and is coordinated by Professor Glauce Dias da Costa, is developing tools and technologies for improving the capitation and the quality of data in order to transform it into policy information, including analysis of the impact of ACE agents and their role in the monitoring of arboviruses transmitted by Aedes Aegypti, and the integration of ACEs with health community agents (ACS) in the workfield.

Your research focused on an area of Minas Gerais, Brazil - which lessons from your research can be applied more broadly worldwide? Which aspects were specific to this region?

Arboviruses are a growing public health concern worldwide, mainly due to the impressive spreading and proliferation capacity of Aedes aegypti mosquito, a common vector of main arboviruses, such as dengue, zika and chikungunya. Given their high impact on health and recurrent epidemics, prevention and control actions of these diseases, as well as health education, need to be effective.