Robust disease surveillance and ‘outbreak drill’

AS the Philippine government continues to expand it's testing capacity and isolation facilities, building a national COVID-19 surveillance and outbreak preparedness system is critical for containing transmission of the virus now and preparing for potential waves of the infection in the future.  During a pandemic like COVID-19, one of the most important public health tools is a reliable system of quick data reporting of any signs of an outbreak from communities to the government so officials can rapidly identify and implement the appropriate interventions. World Health Organization defines public health surveillance as a continuous, systematic collection, analysis, and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice.

In the Philippine setup, implementing such a surveillance system will require collaboration among the Department of Health (DOH), local health authorities, and private facilities. On regional and local levels, every region of the country should aim for key outbreak surveillance and response capabilities: a test-and-trace infrastructure, rapid response in the form of isolation, aggressive contact tracing, and quarantine. This can be fully attained with clear and consistent guidelines and comprehensive support from the DOH and private sectors.  

Test-and-Trace Infrastructure must be in place

Aggressive contact tracing and isolation are the foundation for minimizing the risk of new outbreaks while slowly easing community restrictions. This would entail having the capacity to conduct rapid, widespread testing for every individual with COVID-19 symptoms, the contacts, and clusters. What is not emphasized in the current Philippine strategy is the identification of clusters (positive cases and their contacts). This could have been achieved if we had a mechanism to easily identify clusters through a digital tracking system (i.e. Taiwan, South Korea, China, Iceland) or dedicated teams that religiously identify and follow up cases and contacts (i.e. Singapore, Vietnam, New Zealand). Along with these measures, an independent contact tracing audit must be done to evaluate the timeliness of identification and the extent of tracing. This raises a red flag if certain cases fall through the tracing cracks.

To allow early identification of small outbreaks, a key element of the test-and-trace infrastructure would be a robust regional surveillance system that would routinely monitor targeted populations, particularly those who have regular proximity to cases like frontline workers or those in crowded settings such as detention, mental health facilities, and slums.

Rapid response is non-negotiable

Timely reporting of quality data is a prerequisite for rapid public health response. Currently, the capacity of health authorities to respond to the data generated by the surveillance activities is limited. That means that the government needs to scale up the capacity to rapidly isolate newly identified cases, conduct contact tracing, and quarantine contacts. Improved capacity will be most effective if coordinated with different reporting facilities in the primary care centers, public and private hospitals, airports, and seaports, and supported by timely and harmonized electronic data sharing. Hong Kong, Taiwan, and Australia were able to ramp up very rapid outbreak control at the early stage of the pandemic because of their intensive surveillance at their borders and strict monitoring of all incoming passengers who were put into mandatory quarantine. This was clearly a gap in our country when the system failed to catch all incoming travelers and monitor their movement. Unfortunately, health workers had to fully rely on patients’ disclosure of travel history and exposure.

According to the 2018 Philippine Health System Review, coordination among hospitals, local governments, and the Bureau of Quarantine continues to be a challenge in ensuring timely detection and management of outbreaks. Our weak disease surveillance has been a problem for a very long time due to a lack of funding, understaffed facilities, and insufficient access to working communication equipment. And it would even be more disastrous when the pandemic hit the country during typhoon season. This is an opportunity to review the new surveillance law- Republic Act No. 11332 or the Mandatory Reporting of Notifiable Diseases and Health Events of Public Concern Act – that was signed in 2019 and to make sure that all surveillance gaps are addressed and clear actions are thoroughly outlined. 

Another key gap is limited laboratory capacity in other regions outside of Metro Manila. For instance, all test samples from all over Mindanao are being processed at the Southern Philippine Medical Center in Davao city, the lone satellite laboratory for six regions. A similar problem was noted in the Visayas and some parts of Luzon. As a result, real-time reporting has been a huge limitation. Satellite laboratories must be strategically located across the country to prevent delayed case-based intervention.

To prevent burdening health care facilities and any potential contagion risks, increasing the capacity to treat new cases effectively at home or in local isolation facilities is a priority. The ability of the patient to observe strict home quarantine must be taken into account. It would be impractical in our context given the country’s multi-generational household. Thus, the government’s response to expanding quarantine facilities has been a welcome development.

Outbreak drill

One strategy to test the community’s preparedness to any epidemic is through an “outbreak drill” or a series of simulated activities akin to disaster drill regularly done in the country. This can be integrated into the existing national disaster framework. On the national level, the overarching elements are border protection and internal control. On the community level, this would serve as an opportunity to determine the necessary mechanisms and processes during the outbreak. The parameters must include a lockdown scenario, referral network, isolation facilities, communication, equipment, and the number of key personnel or frontline workers. The drill would allow the community to assess and strengthen its preparedness and response for a pandemic.

Moving forward

It’s already known that pandemics are a threat to our country’s security, our economy, and our well-being as a society. It is a clear reminder to address them seriously and to recognize that the current national health system is ill-equipped, and major health reforms have to be instituted.

Let’s bring these lessons along as we prepare for a new normal.