SRU begins outbreak manual roll-out to regions

Donning and doffing of Personal Protective Equipment (PPE)

Four years ago, in 2014 when the first MERS-CoV case surfaced in Dubai, RITM Surveillance and Response Unit (SRU) Head Rowena Capistrano found herself being questioned by then-President Benigno “Noynoy” Aquino III in front of secretaries from different departments of the Department of Health (DOH). The case was admitted in a hospital in Bicol and had to be sent to RITM for confirmation, which prompted the president’s questioning.

“How did the samples get to RITM? Who travelled with the samples?” Pres. Aquino inquired. The samples had travelled roughly 400km through courier, in a bus, unsupervised. “What would have happened if the bus ran into an accident and the sample spilled? What will happen to those that were exposed?” Pres. Aquino followed up.

Though the RESUs are trained on how to pack and transport samples through a triple packaging system that ensures their safety even in rough conditions, Capistrano says that the interrogation was her wake-up call in realizing that knowledge on the proper handling and packaging of samples shouldn’t be limited to health workers alone.

“It should especially be known by those immersed in the communities where the samples are sourced. How they handle the samples will have an impact from the barangay level up to the laboratories,” Capistrano ponders, “When a sample leaves the outbreak field, it is left to the mercy of people who are put at a risk of exposure.”

Hence, the RITM Manual on Specimen Collection, Storage, Handling and Transport during Infectious Disease Outbreak was made.

Keeping up with the changing health system
The RITM Manual on Specimen Collection, Storage, Handling and Transport during Infectious Disease Outbreak produced by the SRU was first launched in 2013. However, certain changes in the health system necessitated its revision.

For one, the World Health Organization (WHO) critiqued that the first manual was very disease-specific, listing down the signs and symptoms of particular diseases. They suggested a more syndromic approach, where investigations are based on clinical signs and symptoms from which suggestions of possible diseases are drawn. For instance, a more syndromic approach would exhibit a case of diarrhea as not only a symptom of cholera, but also possibly rotavirus, norovirus, or a parasitic disease, among others. This way, no diseases are missed out on.

Assisted by the RITM Biorisk Management Office (BRMO), the revised version of the six-module Outbreak Manual also includes one whole module dedicated solely to the topic of biosafety and biosecurity.

“We want our partners in the LGU to properly and safely ensure that samples collected will not be part of a bigger problem. We do not want healthy people in the community to be victimized by improper transport and packaging of samples,” says Capistrano on the importance of knowledge in biosafety. “There is also a possibility that these samples will be used by bad people; we’re collecting bad bugs, we don’t want those bad bugs to be in the hands of bad people,” Capistrano adds, hinting on bioterrorism.

With the strengthening of the Public Health Laboratory Network (PHLN), the revised manual also addressed organizational changes and established the flow of information and transport of samples among the institutions involved. This clarifies the mandate of RITM as National Reference Laboratory (NRL) for infectious and tropical diseases and its partnership with other NRLs. This means that if, for instance, the manifesting signs and symptoms indicate a possible involvement of toxins, samples should be collected both for RITM and its partner NRL for toxicology East Avenue Medical Center (EAMC).

Capistrano also highlighted the addition of the One Health approach to the manual, which considers animal and environmental factors that come into play during an outbreak. The One Health approach consequently calls for a “One Health response” where there should be a joint outbreak investigation involving the interagency network on zoonosis, such as the Department of Agriculture (DA) and the Department of Environment and Natural Resources (DENR).

Food-and-water-borne diseases have also been included in the manual, highly recommending to collect not only human samples but also food samples that are possible vehicles of outbreak, which are then investigated by the Food and Drug Administration (FDA).

“Outbreaks are not only the concern of RITM nor of just the human health side, but also of different agencies involved in keeping the community safe especially from infectious and tropical diseases,” Capistrano explains.

The revised manual also added newly-developed diagnostic techniques and rapid diagnostic tests (RDTs) such as the Dengue NS1 antigen test, the Cholera RDT, and the like.

After several consultations and revisions, the updated manual was finally launched in 2018 with the help of the RITM Laboratory Research Division.

Empowering regional counterparts
SRU pushes that the immediate response during outbreaks should come from the communities themselves, hence the objective of the current manual being internalized not only in the regional level but also in the local government units (LGUs). “The Outbreak Manual should be used by LGUs for it to be effective, otherwise we will still be receiving samples that contain the wrong specimens or are inadequate in terms of quality, significantly decreasing our chances of verifying the outbreak,” Capistrano stressed.

As a first step, SRU conducted a Training of Trainers participated in by Field Epidemiology Training Program (FETP) graduates to prime them into becoming partners in rolling out the manual in the LGUs. They also conducted pilot testing of the roll-out training in the provinces of Aurora and Iloilo. The series of trainings ran from November 2017 to March 2018 with the funding assistance of Canada’s Global Partnership Program (Canada GPP).

SRU has already been able to cover all the regions in Mindanao, such as in Zamboanga Peninsula, Northern Mindanao, CARAGA, Davao, SOCCSKSARGEN, and ARMM, last July to October 2018. The trainings were aided by the expertise of staff from the RITM Department of Virology, Department of Microbiology, and BRMO, and the funding of the Health Security Partners.

Mindanao was intentionally chosen as the launch pad of the manual’s roll-out due to the region’s central role in the Henipavirus outbreak in 2014. Capistrano says that the workshop series is part of SRU’s response on their gaps during the said phenomenon, where the Henipavirus has not yet completely undergone genome sequencing due to the low number of quality samples that they received. “We need to enhance their knowledge and practice of our counterparts in Mindanao for us to get good samples for outbreak verification and confirmation.”

The three-day training is targeted towards field health workers, specifically doctors, nurses, and medical technologists in Regional (RESU), Provincial (PESU), Municipal (MESU), and City Epidemiology Surveillance Units (CESU). It aims to equip field health workers with skills on the donning and doffing of Personal Protective Equipment (PPE), Nasopharyngeal (NPS) and Oropharyngeal swab (OPS) collection which are not usually taught in the allied health professions but are highly effective for testing respiratory diseases, as well as the proper packaging and labelling of samples.

“We want them to learn these things because they’re very important not only in terms of getting quality samples but also to keep them as well as the community safe,” Capistrano notes.

Through the capacity-building workshop, health workers, who apparently have been in service for a long time but have never undergone any formal training, are empowered to investigate outbreaks in their respective areas, from the RESUs down to the local surveillance units.

SRU has already submitted a proposal to Canada GPP for a similar roll-out in the Luzon and Visayas area.

By the end of 2019, SRU aims to have trained at least one staff per PESU in all 81 provinces of the Philippines on the outbreak manual.

When rolled out to LGUs, SRU hopes for the improved quality of samples received in the NRLs; enhanced planning for outbreak investigations, including the integration of laboratories as well as the One Health approach hence improving the quality of investigations in the whole country; and the heightened capacity of how health workers investigate outbreaks while also ensuring their safety.

by Eunice Brito, Project Matyag [RITM Web Team]