WhatsApp as a Humanized Communication Tool during SARS-CoV-2 Monitoring

Abstract

Due to the COVID-19 pandemic, Universities studied safe ways to return to activities, which pointed out that the effective biosecurity measures were the use of masks, social distancing, personal hygiene, and monitoring programs by testing and isolation of contaminated individuals. Not only monitoring and testing itself but also the entire community orientation process is essential for the successful mitigation of SARS-CoV-2 infections. The aim of this study was the development of communication tools for monitoring SARS-CoV-2 by testing a Brazilian University community, during the gradual return to face-to-face activities, from May 2021 to December 2022. The tests were performed by RTqPCR, in a laboratory with biosafety level 2, using saliva samples self-collected, on dry cotton, in a dry collection tube, wrapped in a 70% isopropyl alcohol wipe, transported in an envelope with individual epidemiological and symptoms data, and maintained at room temperature until analysis. The results were delivered by a health professional by email and WhatsApp which was a humanized channel constituted to receive doubts and anxieties, as well as contact and guidance regarding the biosafety protocols adopted at the university, and health issues in general, which subsidized the monitoring by providing a rich and detailed collection of data.

1. Introduction

In December 2019, a series of pneumonia cases caused by a then-unknown virus was linked to the fish and seafood market in Wuhan, China. When the pneumonia’s cause was identified, the new coronavirus was described [1]. On February 11, 2020, the World Health Organization (WHO) named the disease caused by SARS-CoV-2 as COVID-19 (coronavirus disease 2019) [2]. Exactly 1 month later, on March 11 2020, the WHO declared COVID 19 pandemic, reporting 118,000 cases in 114 countries and 4291 deaths [3]. By the end of 2022, more than 700 million cases and almost 7 million deaths from COVID-19 had been recorded worldwide [4].

Due to the pandemic, nonessential activities were restricted in 2020. Realizing it to be unsustainable to maintain restricted activities for long periods, educational institutions and universities, in particular, began to study safe ways to return to activities. Several studies point out that the biosecurity measures that were sustained as effective were the use of masks, social distancing, personal hygiene, in addition to monitoring programs by testing and the isolation of contaminated individuals, whether in a university environment [5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16], school environment [17], health [18, 19] or work [11, 20].

In educational institutions, there was great concern about the possibility of high transmission rates among students, the community of workers, and individuals around them [8, 12]. However, it was observed that, with the sanitary measures adopted, the occurrence of transmission of SARS-CoV-2 was minimized internally, in educational institutions [13], while sanitary measures were maintained, with a lower incidence of contamination when compared to the surroundings [9, 17]. An important example was the conditions for monitoring SARS-CoV-2, associated with the sanitary measures adopted by Delaware State University, which is a publicly funded university for the black community, which made the university environment protective for a historically vulnerable population, becoming not only an educational space but also one of the social securities [12].

Monitoring by testing is a rich source of epidemiological information, capable of helping to understand the impact of vaccination, emergence and behavior of variants, time of infection, prediction/detection of outbreaks, community guidance, and development of protocols, among others [8, 11, 17, 20]. Testing and isolating confirmed cases are the most effective way to control virus dissemination. Different institutions have implemented various forms of testing, whether on demand (of symptomatic people or people who have had contact with the virus), random monitoring, or even universal and high-frequency testing [7, 9, 19]. A model developed in research on regular testing in the university environment to control the virus points out that 96% of infections could be prevented with routine testing [5]. In a survey conducted by the University of California, 90% of respondents reported that they would not feel comfortable working knowing that their colleagues were not being regularly tested [14].

For monitoring by testing to be carried out efficiently on a large scale, four steps must be organized: collection of biological material, carrying out the test in the laboratory, dissemination of results, and result-based transmission control measures. The gold standard method for detecting SARS-CoV-2 corresponds to the collection of nasal and oropharyngeal secretions, with a test performed by reverse transcription and real-time polymerase chain reaction (RTqPCR), with at least two virus markers. The infrastructure needed to carry out the gold standard test includes specialized personnel for sample collection, storage, and transport conditions with refrigeration at least −20°C, and a laboratory with level III biosafety, so that the contaminated sample is not a source of transmission to the professionals involved. This level of infrastructure comes with a high cost and, in underdeveloped countries such as Brazil, is available only in a few health institutions, making mass testing difficult.

Several studies have pointed to the presence of SARS-CoV-2 in saliva [8, 10, 21], making it possible to use it as a sample for RTqPCR. Systematic reviews have indicated that this type of material presents similar accuracy to nasal and oropharyngeal secretions [15, 21], with the advantage that its collection does not require the presence of health professionals (cheapening, simplifying, and reducing risks during collection) and is less invasive and more comfortable [10, 22], thus increasing the likelihood of people joining mass testing [14]. These facilities have led several testing programs that started with the collection of nasal and oropharyngeal secretions to adhere to the use of saliva in their samples [12, 17, 22]. Despite the aforementioned facilities, some laboratories reported difficulties in working with saliva due to sample quality, excess viscosity, or insufficient quantity [14]. In addition, most studies that use saliva as a sample require 2 mL of saliva, which is a large amount that must be transported quickly in a refrigerated environment and in appropriate biosafety conditions. Therefore, in institutions that are not in the health area, it is difficult to obtain the necessary infrastructure for sample collection, even though self-collection of saliva.

An alternative for obtaining biological samples to use the gold standard diagnostic method for detecting SARS-CoV-2 was developed by our research group using self-collected saliva on dry cotton with a 0.5 cm diameter and transported in temperature environment in blood collection tubes without additives, wrapped with 70% ethanol tissue and a transport system with seal-type envelopes containing a label with the information of the individuals [21]. This system was successfully used to monitor SARS-CoV-2 in the community of Universidade Federal do ABC (UFABC). Once the issue of the diagnosis of SARS-CoV-2 has been resolved, another essential step in monitoring the virus consists of disclosing the results and control measures taken after learning of positive cases. In a community as diverse as the university, made up of undergraduate and graduate students, outsourced workers (security, cleaning, food promotion, gardening, transportation, etc.), workers with technical administrative activities, teachers, and researchers, it is important to report positive cases in a humanized and individualized way. The objective of this study was the development of communication tools for monitoring SARS-CoV-2 by testing in the UFABC community, during the gradual return to face-to-face activities, from May 2021 to December 2022.

2. Monitoring of SARS-CoV-2 in a university community

2.1 Saliva and community information data collection

The saliva sample collection kit comprises a plastic safety envelope with a printed form to be filled in with the subject’s data; a dry collection tube; 2 wipes with 70% isopropyl alcohol; and a flexible rod with a sterile hydrophilic cotton tip and a diameter of 0.5 cm. This material is packaged in another sealed safety plastic envelope. The outer envelope is labeled with instructions on filling out the form and collecting the material, in addition to a QR code for accessing the “monitora COVID” (Monitoring COVID) WhatsApp. The content of both the label external to the kit, and the form to be completed, evolved throughout the test to improve the data collected about the subject and facilitate the location of people and organization of delivery of results.

The kits contained different colors and symbols, but they differ only in relation to the content of the form. They were classified into public workers and interns (symbol is a pink circle); undergraduate students (symbol is a light blue pentagon); researchers – graduate, scientific initiation, external researchers, etc. (symbol is a green rectangle); outsourced workers; and external public (the symbol is an orange diamond).

In all kits, the information requested was date and time of collection, institutional localization, demographical data, residence address, data on vaccination, symptoms presented in the week, and whether the individual had contact anyone who tested positive for SARS-CoV-2 and where. In the public employee’s kit, it was add the area of work, immediate superior, professional category, institutional identification, and if there was any face-to-face interaction. In the undergraduate student kit, was add academic record, which course/subject you are studying, and which room and laboratory you attended. In the researchers’ kit, was add category (graduate, postdoc, external researcher, or others) and name of advisor/supervisor. Finally, in the kit for outsourced workers or external public, was add company name, category; and if external, the contact person at UFABC.

To carry out the test, just follow the steps indicated on the envelope, also described in the institutional orientation video prepared together with the university’s communication team (available at https://youtu.be/-bJpdROUMZU). In short, the person must fill out the form; clean their hands and the area with one of the alcohol wipes; take the swab with cotton to the mouth and soak it in saliva; deposit the rod inside the dry tube; close it; wrap the tube with the second alcohol wipe; deposit the tube wrapped in the tissue inside the plastic bag; seal it; and, finally, deposit it in one of the collection boxes scattered around the campus. The collection boxes containing the kits were collected twice a day and transported to the agent pathogen laboratory, where the material would be analyzed.

The fact that the sample is collected on cotton and in small quantities, also because it is involved in 70% isopropyl alcohol, allows the sample to remain viable for until 2 weeks at room temperature, and the collection boxes can be handled by workers without risk of contamination, which was crucial to facilitate and reduce the cost of transporting the material. At the time of analysis, these samples can be handled in a laboratory with biosafety level 2 (SBL2).

2.2 Diagnosis of SARS-CoV-2 and disclosure of positive results

The extraction of nucleic acids was performed according to the protocol developed by our research group with a TRIZOL-type reagent prepared with reagents obtained from the national market [21]. The diagnosis of SARS-CoV-2 was carried out according to a protocol developed by our research group and has been used in the monitoring of the virus in the UFABC community since May 2021. The test is performed by reverse transcription and chain reaction of the real-time polymerase (RTqPCR), using reagents for the detection of SARS-CoV-2 by TaqMan with three different markers (genes that encode the envelope proteins – E; nucleocapsid – N; and RNA Polymerase – RdRp), from acids nucleic acids obtained from self-collected saliva on a sterile cotton ball. Nucleic acid samples from individuals who test positive for SARS-CoV-2 are stored for further study.

The disclosure of positive results was carried out in two different ways according to the number of positive individuals and the period of epidemic waves in the region. Thus, when the test started, the subjects who tested positive were contacted via telephone by a health professional who, in addition to informing the result, provided guidance on the protocols to be followed, on health issues, questioned their general condition, and clarified any doubts that might arise. In some situations, telephone contact was not possible, so the immediate supervisor was contacted, so that the person could be located and properly oriented.

In addition to this contact by the health professional, emails were sent, with a copy to the boss and/or supervisor, formalizing the result and passing on the protocols to be followed in writing. At the beginning of week 32 of monitoring, on January 17, 2022, the new tool, WhatsApp “Monitora Corona UFABC”, was used, in which the results and guidelines are delivered by a psychology professional. As there was a great diversity of profiles in the community, each conversation was adapted so that the language and content were accessible to the interlocutors. However, as a backdrop to the dialog, a kind of script was developed with topics to be addressed:

• Call the person, wait for them to answer, and then say that they tested positive for SARS-Cov-2;

• Ask about your health status at the moment and if you have been contaminated other times;

• Question whether the person resides alone or accompanied and provide guidance on the contagion of the virus;

• Guidance on the biosafety protocols to be followed (isolation, distancing, ventilation, use of masks, and hygiene);

• Advise on medical care to be sought;

• Guidance on vaccination (which group could already be vaccinated at the time, how many doses, and when they could be vaccinated after being infected);

• Advise on the protocols for attending the university in person;

• Welcome doubts and anxieties;

• Solve possible doubts regarding the registration (data not filled in or unintelligible).

It is important to emphasize that this script was used as a basis and was not always strictly followed but adapted to the needs of each subject and each pandemic period. An interesting and illustrative example was given regarding the issue of vaccination. In early 2022, there were still many questions about who could be vaccinated, at what time, how many doses, and types of vaccine, among others. Over the course of the year, these doubts diminished until they disappeared.

2.3 UFABC institutional actions and incidence of SARS-CoV-2 during pandemic and community monitoring

On March 13, 2020, the UFABC suspended face-to-face academic and administrative activities, with the suspension extended indefinitely on the 25th of the same month. In June 2020, the university administration established the UFABC Planning and Management Actions Committee regarding coronavirus. The purpose of this committee was to study the conditions of return and offer subsidies so that the necessary measures could be taken regarding the resumption of face-to-face activities at UFABC. As a result of this committee, the Monitoring and Testing Center was created, which monitored the epidemiological situation of the university community through weekly tests on people who have justification to attend. Testing took place from May 2021 to December 2022, completing 80 weeks of community monitoring. Just over 51,000 tests were performed with 1800 positive results, corresponding to 1364 infections in 1128 people (Figure 1).

Figure 1.

Total tests and percentage of positive results.

The blue bars correspond to the total number of tests performed in each epidemiological week. The red line corresponds to the percentage of positive tests for SARS-CoV-2.

The tested community was made up of civil servants, whether administrative technicians or teachers; workers in a situation of outsourcing various contracts such as concierge, surveillance, maintenance, cleaning, and gardening; researchers, mostly graduate students; and undergraduate students. Although the collection could be carried out autonomously, in the first weeks of testing, health professionals were in person at the testing sites for proper guidance and to resolve possible doubts. In addition, the university’s communication team made videos available instructing the material collection procedure (https://youtu.be/-bJpdROUMZU).

At first, the idea was to develop a platform that would serve both as a database for epidemiological monitoring and as a tool for delivering test results. However, there was an understanding that, as this is a new and delicate topic, the tests whose results were positive for SARS-CoV-2 should be delivered in a personalized way.

Between epidemiological weeks 30 and 31, there was a recess period from December 18, 2021 to January 9, 2022, when there was a significant increase in infected people. Therefore, on the return from recess, in the week of January 10 to 16, 2022, the monitoring and testing core detected 43 positive cases, when the accumulated result for the previous 30 weeks totaled only 51 cases.

Faced with this significant increase, it was necessary to rethink the results delivery strategy, as telephone contact, in addition to being limited to synchronous conversations, cannot be carried out concurrently by the same professional, demanding much time and resources. In view of this, it was thought of delivering these results via Information and Communication Technology (ICT), specifically via WhatsApp web, a tool in which it would be possible to contact several people simultaneously, in addition to enabling asynchronous communication and automatic recording of the collected data.

At the beginning of June 2022, all servers and university workers were to return in person, as well as a partial return of students. This moment corresponded to the beginning of a new wave of contamination in the community. In the middle of June, we had, in epidemiological week number 54, a peak of 116 positive cases. As there was only one professional responsible for delivering results via WhatsApp, and a large number of positive cases, it was necessary, once again, to rethink the logic.

It was observed that, in this new epidemiological moment, doubts were concentrated much more around practical and bureaucratic issues (such as those related to removal from face-to-face activities) and less on issues related to health. Therefore, it was understood that the WhatsApp communication channel should become secondary to the informative email; thus, the delivery of results was prioritized via email, and the WhatsApp number no longer was used to call people to inform positive results but it was passed on to the community as a space to solve doubts related to testing. However, despite the non-prioritization of delivering positive results via WhatsApp, given the cooling of this new wave and as far as the professionals involved were able, the choice for communication via this channel persisted, which was more direct with the infected person.

To keep the tests within the limits of the laboratory’s capacity for analysis of pathogenic agents, at the time of the mass return of the community, in June 2022, the monitoring public was restricted to only outsourced workers and public servants. However, throughout the second semester, it was observed that the testing of workers was not reaching the capacity of the laboratory, making it possible, from the academic recess, in September, to resume testing of students and researchers, even if without wide disclosure of this fact.

2.4 Monitoring of SARS-CoV-2 in the different phases of the plan for the gradual resumption of face-to-face activities in the UFABC

Throughout the community monitoring period (between May 2021 and December 2022), UFABC administration presented several changes to the biosafety protocol, according to the epidemiological period experienced and the public policies in place at each moment.

There was a more restricted moment, when there was limited access to the campus, mandatory use of masks, and mandatory weekly testing. Throughout 2022, the classes were gradually taught face-to-face again, reaching totality in the third quarter. In June 2022, the university workers returned en masse. In September, the positive result for SARS-CoV-2 in the monitoring and testing at UFABC is no longer sufficient for removal from face-to-face activities (requiring a medical certificate). At the end of October, mask wearing is no longer mandatory. At the end of December, the monitoring and testing center was demobilized.

It was possible to observe that the change in protocols, whether within the university or public policies (Table 1), had an impact on the community’s behavior regarding testing. The formation of two, almost opposites, main groups stand out: one that, as the biosecurity measures were softened, felt more comfortable resuming their pre-pandemic behaviors; and a second group that, when they felt the community biosecurity measures decreased, started to reinforce their individual care, in an attempt to preserve protection against the virus.

Date	Federal	State	Municipal	UFABC
January 2020		Establishes the State Public Health Emergency Operations Center (COE-SP) of the São Paulo State Health Department and takes related measures (SS No. 13, of 1/29/2020)
February 2020	Declares Public Health Emergency of National Importance (ESPIN) due to Human Infection by the new Coronavirus (2019-nCoV) Ordinance No. 188, of 2.3.2020
March 2020			Emergency period (Municipal Decree 21.111 SBC and 17.317, STA)	Suspends the academic and administrative activities of the University (ORDINANCE No. 378/2020 - REIT (11.01))
April 2020		Adds to Decree No. 64.881, of March 22, 2020 (which decrees quarantine in the State), an article recommending the use of masks by the population (No. 64.949, of 4/23/2020)		Establishes authorization for Emergency Continuing Studies (ECE) in Undergraduate and Graduate Studies (RESOLUTION No. 239/2020 - CONSEPE (11.99))
May 2020		Provides for the general and mandatory use of face protection masks, preferably non-professional ones, in public spaces, inside establishments, among others (N° 64.959, of 5/4/2020).	Establishes the obligation to wear masks (DECREE No. 21.157, of 06.05.20, SBC and Municipal Decree 17.370 STA)
July 2020	Amends Law No. 13,979, of February 6, 2020, to provide for the mandatory use of personal protective masks for circulation in public and private spaces accessible to the public, on public roads and public transport, on the adoption of asepsis measures in places of public access, including public transport, and on the provision of sanitizing products to users during the validity of measures to deal with the public health emergency of international importance resulting from the COVID-19 pandemic (Law No. 19 of 7/2/2020)			Regulates the mandatory use of face protection masks on UFABC premises while the situation resulting from the COVID-19 pandemic persists (ORDINANCE No. 595/2020 - REIT (11.01)).
November 2020				Art. 1st Approve the Plan for the gradual resumption of face-to-face activities at UFABC (DECISORARY ACT No. 188/2020 - CONSUNI (11.00.06))
January 2021			Beginning of return to face-to-face classes (DECREE No. 15.568 - STA)
July 2021		Beginning of return to face-to-face classes (DECREE No. 65,849)	Return of face-to-face classes (DECREE No. 21.652 SBC;)
March 2022				Suspends the Plan for the Gradual Resumption of On-site Activities at UFABC. Resumption of face-to-face activities in June 2022 (RESOLUTION No. 217/2022 - CONSUNI (11.00.06)).
April 2022	Declares the closure of the Public Health Emergency of National Importance (ESPIN) as a result of human infection with the new coronavirus (2019-nCoV) and revokes Ordinance GM/MS No. 188, of February 3, 2020 (Ordinance No. 913, of 4.22.
September 2022				Updates biosafety guidelines and standards on campuses, in order to ensure the necessary safety conditions for carrying out face-to-face activities – need for a medical certificate for removal (ORDINANCE No. 2800/2022 - REIT (11.01)).
October 2022				Updates biosecurity guidelines and standards on campuses, in order to guarantee the necessary safety conditions for carrying out face-to-face activities - Optional use of mask (ORDINANCE N° 2880 and 2882/2022 - REIT (11.01))
December 2022				Suspends, indefinitely, the activities of the UFABC Monitoring and Testing Center (ORDINANCE No. 2997/2022 - REIT (11.01)).

Table 1.

Main biosecurity measures adopted by the government and UFABC.

Main biosecurity measures adopted by the federal, state, municipal governments (of the municipalities in which the university is located), and by UFABC, respectively. Data were obtained from: https://www.planalto.gov.br/ccivil_03/Portaria/quadro_portaria.htm; https://www.saobernardo.sp.gov.br/web/transparencia/legislacao-relacionada; https://www3.santoandre.sp.gov.br/coronavirus/?page_id=90; https://www.saopaulo.sp.gov.br/coronavirus/legislacao/; https://www.ufabc.edu.br/acesso-a-informacao/boletim-de-servico.

By correlating the fluctuation in the number of tests performed and the protocol changes, some issues are observed: during 2021, at the time of greater restriction of access to the campus, the number of tests performed was more stable (average of 448 tests per week, with a standard deviation of 68), while in 2022, there was a much greater fluctuation in the number of tests (average of 757 weekly tests, with a standard deviation rising to 211) following important changes in biosafety protocols.

At the beginning of 2022, it was observed that the peak of the first wave occurred in the testing period, at which time there was also a progressive increase in the number of tests performed. Around April, we saw a drop in the number of tests, and this drop may have some correlation with the suspension of the “gradual plan to resume face-to-face activities at UFABC,” approved by the superior council on March 31, 2022. In June, occurred the mass return of university workers, a period that corresponds to both the increase in tests carried out and the second wave of infection that occurred during the testing period.

At the beginning of September 2022 occurred the school recesses and a simultaneous drop in test taking. At the end of the recess (September 19, 2022), the end of administrative removals (automatic to the positive result of internal testing) was announced. At the end of October, the mandatory use of masks finished. In November, the third wave of infection began, which corresponded to a return to the increase in the number of tests carried out, which, this time, will jointly reduce the number of positive results.

The divergence of information disclosed, whether in the municipal, state, or federal public sphere, or in the private sphere, about the pandemic, also proved to be an important obstacle to community orientation and, consequently, the dissemination of correct, updated, and adequate information.

One of the main obstacles was related to the medical advice received by the community, both in the public and private networks. Several diagnoses were given based only on clinical examinations; misguided guidelines regarding the time and form of transmission of the virus; and lack of knowledge about the different types of tests available on the market, also leading to inadequate guidelines.

The lack of testing carried out in the health network also had a relevant impact on how the community received information about the positive result at UFABC. At first, the difficulty in obtaining tests meant that there was a greater demand for the test at the University, including by people who were not part of the community, making guidance and acceptance of the anxieties of the people involved valuable.

When antigen tests become more popular, including being used by almost all Brazilians public health system (SUS – Sistema Unico de Saúde) primary care facilities and made available in pharmacies to the general public, there was a mismatch of information regarding positive and negative results. As RTqPCR is more sensitive than the antigen test, there would be no sense in the latter being used as a counterproof of the former. However, the ease of access to the antigen test and the lack of adequate disclosure of its real effectiveness made the question continually arise “my test was negative outside UFABC, your test must be flawed.”

There was also much difficulty in guiding the community regarding the importance of biosafety measures and the severity of the disease, as the government was already talking about the post pandemic moment, in which people should resume their normal activities and behaviors, now without risk. This situation is reinforced by the lack of testing and the high number of false negatives caused by inadequate testing. With regard to the severity of the disease, specifically, the advancement of vaccination and the consequent decrease in hospitalizations and, mainly, deaths, contributed with the message of “there is no more risk.” The deletion of information regarding the existence of a long COVID and post-COVID is noted, leading the population to view SARS-CoV-2 as just another endemic virus, with which we must live without major consequences.

Despite the obstacles mentioned above, there are indications that, due to the monitoring carried out, the UFABC community, especially with regard to workers, remained more oriented and protected than the average population, showing little evidence of internal SARS-CoV-2 transmission.

2.5 Comparing the experience of UFABC community SARS-CoV-2 monitoring among other strategies around the world

When reviewing monitoring and testing, studies are concentrated in Europe, North America, and Central Asia. The scarcity of publications in South America and India could, for example, be correlated with their high infection rates, suggesting low adherence to pandemic monitoring practices. However, Australia and New Zealand are countries that have high adherence to biosafety protocols and have not published literature on the subject [19].

Although there is an understanding that the best strategy is universal and high-frequency testing, many institutions do not have the financial conditions to carry it out [7], and, although testing has proven to be an essential instrument for mitigating contamination, it is not enough, needing to be complemented with the other measures already mentioned, such as the use of masks and ventilated environments [9].

It is interesting to note that, although universities and schools were called to resume their activities, the testing of students was controversial, especially at the beginning of the pandemic (2020), sometimes discouraged by the North American Centers for Disease Control and Prevention (CDC), or simply not advising about it [6, 17]. However, researchers had already warned that, without monitoring and testing, there would be a high probability of outbreaks [6], which in fact happened at the end of 2020. Several North American colleges and universities had outbreaks of COVID-19, thus deciding to initiate monitoring and testing programs [7, 8]. However, it is estimated that only approximately 6% of large American colleges and universities were able to implement mass testing in their communities, one of the causes being the high cost involved [7].

In the United Kingdom, for example, although the government at the time also did not recommend it, some universities implemented monitoring and testing of asymptomatic people to reduce transmission on campus. Cambridge University organized weekly RT-PCR pool testing; the University of Nottingham had weekly testing added to sentinel monitoring; University of East Anglia had a testing program that was known to virtually eliminate COVID-19 from its campus; and the University of Southampton implemented RT-LAMP testing in saliva samples, which monitored students and staff [16].

One way to make RTqPCR testing cheaper and faster is to combine collections from several individuals into a single sample, the so-called pooling test [22]. Studies have shown that samples with high viral load in an individual PCR test (CT < 28) were detected after combining 5 or 10 samples; however, when the viral load decreases, there is an increase in the frequency of false negatives, especially in pools of 10 samples. Furthermore, subjects with CT > 31 could not be detected in pools of 10, and CT > 33 were not detected in pools of 5 [10]. Although there is this important loss of sensitivity of the test, a study carried out in Japan comparing individual RTqPCR and by combining several samples, suggests that, in a scenario of budget constraints when choosing more tests with less sensitivity, the probability of success of curbing the virus is larger [10]. However, it should be noted that, in a scenario such as that of UFABC, in which the incidence of positives reached more than 10% of the tests, pooling is no longer an interesting strategy, as it could lead to the need to retest all samples.

In the United States, Boston University carried out more than 500,000 COVID-19 tests in its monitoring [13]; Delaware State University (publicly funded historically Black university) tested twice a week, performing RTqPCR for all university students and workers between August 2020 and April 2021 [12]; at Berkeley, University of California, performed RTqPCR testing on almost 5000 participants [14]; and 18 university residential campuses in Connecticut performed monitoring, ranging from antigen testing, pooling PCR, or individual testing [6]. Duke University implemented mandatory testing twice a week for students residing on campus; Clemson University conducted its testing with volunteers; Olivet Nazarene University, in Illinois, performed a pooling PCR test once or twice a week [5]. Table 2 summarize some types and frequency of testing carried out in UK and US universities.

		Frequency	Type of sample and test
UK	Cambridge	Weekly	Pool RTPCR
	Nottingham	Weekly	Sentinel
	Southampton		RT-LAMP
U.S	Massachusetts		PCR
	Delaware	Twice a week	RTPCR
	Connecticut		Pool PCR, individual PCR or antigen
	North Caroline	Twice a week
	Illinois	Twice a week	Pool RTPCR

Table 2.

Summary of types and frequency of SARS-CoV-2 testing at UK and US universities.

There is a complexity to be evaluated to ascertain the ideal frequency of testing, weekly testing, for example, may be sufficient to detect most infections but, perhaps, not enough to stop new contaminations [6, 20]. The model developed by the University of California suggests that when the prevalence of the virus is less than 1% of the population, universal and biweekly testing is sufficient to contain an outbreak [14]. In studies carried out on 18 residential campuses in Connecticut, it was evaluated that each week added per student implied a decrease of 0.0014 positive cases per student per week [6].

The testing carried out at UFABC proposed a weekly frequency to its participants, with a new sample when presented results were considered inconclusive. In the case of positives, at first a new sample was called after 14 days. For contractual reasons, some outsourced workers could not be removed for 14 consecutive days, requiring a new test after 7 days in symptomatic cases, or 5 days when asymptomatic. Monitoring these workers was essential for tracking the behavior of the virus over time. When the tests often started to come back negative before 14 days, it was decided to reduce the quarantine (and retest) from 2 weeks to 10 days.

It should be noted that, during the period of restricted access to the campus, there were members of the community who attended the University on time; in these cases, the recommended testing frequency was “whenever you are on campus, without exceeding one test per week.” However, in some specific situations, there was flexibility in allowing, or even requesting, more frequent testing, usually referring to suspected infection or viral load monitoring, as the dynamics of the virus changes greatly among the different variants [8]. This closer contact, as mentioned, was fundamental for the development of more accurate and effective protocols to combat the infection.

It was observed during monitoring, and corroborated by the results of other studies, that disease symptoms or severity are not associated with the viral load detected in the tests performed, that is, asymptomatic or pre-symptomatic subjects can present high viral loads, thus transmitting the virus [10]. Thus, testing and isolating symptomatic people is no longer interesting, leading to the need to test asymptomatic subjects so that it is possible to break the chain of transmission [5, 15, 16, 20]. In a North American emergency care unit, the transition from testing symptomatic to asymptomatic patients took, in a period of 7 months, from one of the highest prevalences of infection in the country to one of the lowest [18].

Research indicates that random testing of asymptomatic individuals has not been effective in containing outbreaks, whereas universal testing during the COVID-19 wave was effective in containing transmission in the workplace [19]. In universities, it was also found that random or voluntary testing was less effective than sample selection based on monitoring, for example [15].

It was observed that, in several situations, the budget difficulty was circumvented with strategies that restricted the number of people tested and/or reduced the sensitivity of the tests, as in the case of pooling, or with inappropriate use of antigen tests (which had been developed to use symptomatic screening, with confirmation by RTqPCR of negative results). The development of the testing protocol by the laboratory of pathogenic agents at UFABC managed to make the testing process cheaper and simpler.

Starting with the use of local inputs, passing through the use of simple and everyday materials, such as a plastic safety envelope (used by the post office), alcohol wipes (often used in the restaurant business, for hand hygiene), and flexible rods for babies. Paying special attention to these last two items because cotton was responsible for preserving the saliva sample, an essential factor for lowering the entire logistics of transport and pretest storage; also, allowing collection in small quantities contributes not only to ease for the user but also to a reduction in the contamination probability (both from the people who manipulate it and from the sample itself, thus protected from the action of RNases, for example). In this way, it was possible to structure a simple, autonomous test, accessible to a diverse public, with a molecular test of high sensitivity and specificity, using the SL 2 laboratory, in a university that does not have courses in the health area, therefore having a small number of professionals in the field area.

Although, given the effectiveness of vaccines, some institutions dismantled their testing programs [20], even after vaccination progressed, the rate of infection, hospitalization, and death from SARS-CoV-2 was still considered high, as the vaccine does not block transmission of the virus. Therefore, it is relevant to continue tracking, by testing, infected people who are asymptomatic or pre symptomatic, as while the virus circulates, new variants tend to emerge [10].

However, as mentioned, there is some difficulty in following through monitoring and testing amidst the erasure of the importance and severity of the consequences of SARS-CoV-2 infection. In monitoring a university in the United Kingdom, for example, there was a decline in participation in weekly testing from 58–5% of students [15]. At UFABC, it was possible to observe a decrease in adherence to testing, especially when administrative leave for employees and allowed absences for students ceased, and medical certificates were requested. In contact via WhatsApp, this became a recurring theme, whether from people questioning the reason for monitoring without automatic removal or from people inquiring about the need for testing with “the end of the pandemic.”

2.6 Communication strategies used on SARS-CoV-2 monitoring and testing programs

In the literature review carried out on monitoring and testing programs, few mentions were made regarding the communication of test results, as well as the orientation of the people involved. Table 3 summarizes some forms of communication adopted by monitoring carried out in the United Kingdom and the United States.

		Communication channel		Observations
		Positive result	negative result
UK	University I	Email	Email	Multiple students encouraging testing
	University II	Telephone by health professionals	Texting
U.S	Illinois	Own app	Own app	Add-on via email
	Boston	Telephone by health professionals	Email	Isolation of positives and their contacts
	Delaware	Email	Email	Guided to seek teleassistance
	NY	Telephone	Telephone	Advised to seek care in severe cases
	Clemson (rural area)	Telephone by health professionals	Email and texting
	California	Telephone by health professionals and email	Email	Inconclusive contacted via telephone for new collection

Table 3.

Communication used in tests carried out in the United Kingdom and United States.

References: United Kingdom I [15]; United Kingdom II [16]; Illinois [8]; Boston [13]; Delaware [12]; NY [11]; Clemson (rural area) [7]; California [14].

According to Kola et al.’s study [23], training in psychosocial support and mental health is now recommended for workers who make contact with those infected during infectious disease control, as it has proven essential to build a safe relationship with the community, strengthen their engagement in the adoption of biosafety protocols, and recognize the need for physical or mental health care.

Studies point to the pertinence of mental health interventions in the course of an infection, from the initial stages. Objective information about the disease – such as mode of transmission, course of infection, symptoms, quarantine and vaccines – is essential both for the promotion of mental health and for the population’s literacy. Furthermore, it is understood that access to mental health can and should be complemented by information and communication technology (ICT) when face-to-face interaction is limited [24].

In research carried out focused on the response of middle and low-income countries to the pandemic, the creation of several programs based on previous humanitarian emergencies added to the peculiar characteristics of COVID-19 was raised. In China, for example, guidelines were created that suggested a decentralized and territorialized organization that included mental health support. In Lebanon, South Africa, Kenya, Uganda, India, and the Maldives, government action plans were created that highlighted the promotion of mental health for people in quarantine and frontline workers, and that ensured continuity of care for people already diagnosed with psychiatric issues [23].

As mentioned, and, as observed in North American and European teaching environments [17], the monitoring and testing measures implemented at UFABC led to the development of biosafety protocols and community guidance capable of making the monitored environment safer than the surroundings. There is an increase in positive cases in moments after socialization outside the school environment, such as holidays and vacations. Infections are detected but without leaving signs of large virus transmission chains, even pointing to lower infection rates than in situations where protective measures are not adopted [17].

Thus said, not only monitoring and testing itself but also the entire community orientation process is essential for the successful mitigation of SARS-CoV-2 infections. Although this consequence has been pointed out in several studies, there are few publications that dedicate space in their writings to mention or detail this process of guiding their audience.

3. Conclusions

WhatsApp web “monitor COVID” proved to be a valuable tool for contacting the community, providing a two-way street, in which health professionals have access to the public who, in turn, also have access to the professional, regardless of having tested positive for SARS-CoV-2. Thus, a humanized channel was constituted to receive the doubts and anxieties of the community, as well as contact and guidance regarding the biosafety protocols adopted at the university, and health issues in general. It is interesting to note that, unlike telephone contact, conversations carried out via WhatsApp are recorded for later consultation if necessary, and, unlike contact via email, it is possible to have a fluid conversation, bringing the interlocutors closer together and avoiding communication failures. Furthermore, this close contact with the community subsidized the monitoring by providing a rich and detailed collection of data.

Acknowledgments

This work was financed by Fundação Universidade Federal do ABC (UFABC) (COVID-19 actions program grants 41/2020, 48/2020 and 73/2020) and Coordenação de Aperfeiçoamento de Pessoal de Ensino Superior (CAPES). The self-collection video was produced and available by Assessoria de Comunicação e Imprensa da UFABC. We are grateful to Comitê de Ações e Gestão da Pandemia de COVID-19 da UFABC for providing administrative support to carry out this work. We are grateful to all UFABC community that contributed with their saliva samples and data and to all who participated directly or indirectly to this work.

Conflict of interest

The authors declare no conflict of interest.

Appendices and nomenclature

SBL2	biosafety level 2
CDC	Centers for Disease Control and Prevention
ICT	information and communication technology
RTqPCR	reverse transcription and chain reaction of the real-time polymerase
UFABC	Universidade Federal do ABC
WHO	World Health Organization