By Kaymart Gimutao, published in RITM Update Volume 2 Issue 1 (January to March 2015)
In the photo: RITM SRU in field response. A surveillance nurse collects blood samples from a symptomatic patient of Henipah virus disease during an outbreak investigation in Sultan Kudarat.
On April 16, 2014, the Department of Health (DOH) announced the first case of the Middle East Respiratory Syndrome-Corona Virus (MERSCoV) in the Philippines. It was Holy Wednesday. The news prompted the responding laboratories at RITM and the RITM Surveillance and Response Unit (SRU) to report on duty amid the holiday streak, while most of Filipinos were enjoying their Lenten break.
The patient was a male Filipino nurse who initially tested positive for MERS-CoV in the United Arab Emirates. DOH officials were informed about the test results when the patient arrived in the Philippines. Although the patient eventually tested negative at RITM, the incident sounded the alarm of a public health threat. Experts believe that the virus has probably been cleared while the patient was recovering on his way home.
As the country’s National Referral Center for Emerging and Re-emerging Infectious Diseases, RITM was immediately on alert upon receiving information on the patient’s laboratory result.
RITM SRU’s Baptism of Fire
For the newly-established RITM SRU, the announcement of the country’s first MERSCoV case served as their baptism of fire. The Unit has been functioning for only a year before the MERS-CoV incident happened.
DOH assigned the RITM SRU, together with the National Epidemiology Center (NEC, now Epidemiology Bureau), to lead the contact tracing team of all 414 passengers of the Etihad Flight EY 0424, the plane which carried the male Filipino nurse.
It was a logistical challenge but with the help of the Department of Justice (Bureau of Immigration and the National Bureau of Investigation), Department of Foreign Affairs, Department of Labor and Employment, and Department of Interior and Local Government (Philippine National Police), all but four of the 414 passengers of EY 0424 were tracked. All yielded negative results for MERS-CoV after testing at RITM and the DOH subnational laboratory in Cebu. Meanwhile, the four remaining passengers who were not traced already left the country when the surveillance for the MERS-CoV was activated.
The RITM SRU also worked towards promptly coordinating laboratory results to recipients such as the concerned Regional Epidemiology and Surveillance Units (RESUs), the Epidemiology Bureau, Disease Prevention and Control Bureau and the Office of the Secretary of Health. The SRU was also responsible for coordination of documents, coming from Epidemiology and Surveillance Units and Hospital Disease Surveillance Officers. At the same time, the SRU also responded to further queries by the RESUs, rural heath units and local hospitals on the status of the tested passengers.
“Since that was the first MERS-CoV Case in the Philippines, it was somehow fulfilling for us that we were part of the team which was at the frontline in safeguarding our country from the potential public health threat. The safety of our countrymen [largely] depended on us,” said Albert Anduyon of the RITM SRU.
The need to establish the RITM SRU
The RITM SRU’s response during threats of emerging infectious diseases is just one of its many functions.
Dr. Beatriz Quiambao, Head of the RITM SRU and Chief of the Clinical Research Division, explains that setting up a Surveillance and Response Unit at RITM is important since the Institute plays a very significant role in the surveillance efforts of the DOH and the World Health Organization (WHO). “RITM serves as both the National Referral Center for Emerging and Re-emerging diseases and the National Reference Laboratory for various infectious and tropical diseases,” Dr. Quiambao added. Hence, RITM has to rapidly coordinate its results for an efficient public health response.
Through the RITM Office Order No. 511 series of 2013, the RITM SRU was created to integrate, coordinate, and report clinical and laboratory surveillance data generated by the Institute. These include data on the specimens which were tested at RITM and data on patients who sought consultation or were admitted at the RITM Hospital.
Rowena Capistrano, RITM Surveillance Officer, added that since RITM’s role is notably seen in confirmatory testing, the bulk of RITM SRU’s work falls under laboratory surveillance.
“In this case, the RITM SRU monitors all the laboratory samples received by RITM to see the trend of a certain disease. From
there, we can report to the Epidemiology Bureau and NCDPC [National Center for Disease Prevention and Control] if there is
an increasing number of confirmed cases of an infectious disease in a particular area. This way, the SRU can give an early signal to the DOH Central office of a possible outbreak. The SRU staff can also go to the field if needed, for technical assistance in cases of outbreaks. [This is] where the ‘response’ part comes in, “explained Capistrano.
Aside from outbreak samples, RESUs also send samples regularly to RITM for surveillance of diseases that fall under the elimination target by WHO or DOH. Additionally, a surveillance nurse regularly checks reportable cases in RITM Hospital admissions. The surveillance nurse also looks for clustering of cases (two or more cases of a certain disease in one area/
barangay) that may potentially cause an outbreak.
Proactive surveillance and response
As the repository of surveillance data generated by RITM, the SRU is also expected to assist in epidemiological studies of various infectious diseases, especially with an increasing rate of emerging and re-emerging diseases due to factors such as population inflation, climate change, and other environmental factors.
The WHO 2015 Report on Neglected Tropical Diseases notes that some of the world’s tropical diseases, particularly vector-borne and zoonotic diseases (diseases involving vectors such as blood-feeding insects or animal hosts), are highly sensitive to climate variables. Factors such as climate variability and long-term changes in temperature, rainfall and relative humidity are expected to increase the distribution and incidence of vector-borne and zoonotic diseases. Dengue, for instance, has already re-emerged in countries in which it had been absent for many years.
With the health threats posed by climate change, the RITM SRU’s analysis of surveillance data can be helpful for epidemiological modelling and studies on various infectious diseases for early warning and impact reduction.
Planning for forthcoming challenges
Since the RITM SRU is on its early years, work still needs to be done to optimize its functions. For instance, the finalization of the SRU Manual of Operations and Standard of Protocols (SOPs) was put on hold to give way to responding to outbreaks. Once finalized, the RITM SRU Manual of Operations and SOPs will serve as guide documents to fully -implement the primary tasks of the Unit.
The SRU also plans to be connected with RITM Laboratory Information System (LIS). The RITM LIS will integrate all the records of laboratory operations of the Institute in a centralized system which will make SRU’s work easier in terms of tracking laboratory surveillance data from different National Reference Laboratories.
The RITM SRU accomplished an impressive job despite some limitations and challenges that they encountered as a newly-established unit. As RITM Director Dr. Socorro Lupisan opined, it is reassuring that the RITM Surveillance and Response Unit exists during this time of the continuing threat of emerging and reemerging infectious diseases.
“With the presence of RITM SRU, everyone can [be assured] at the height of outbreaks in the country because you know that there are people who vigilantly monitor the situation and are ready to respond [and coordinate] come the worst-case scenario,” added Dr. Lupisan.