Essay: Public Health and COVID-19 – Weak Public Health Infrastructure Hinders our ability to respond to this and Future outbreaks

Modernizing Puerto Rico’s public health surveillance systems should be a top priority. 

Author: Arnaldo Cruz, FOMB's Director of the Research and Policy Dept.
As Puerto Rico moves towards re-opening the economy, the Government should do whatever it can to avoid or reduce the causes and effects of a second wave of infections by developing smart prevention capabilities. This means being able to keep enough numbers of infected people tightly in isolation to prevent or minimize new outbreaks that would overwhelm the health system. Therefore, it is critical for the CW to strengthen its public health infrastructure, particularly as it relates to research/epidemiology, statistics, and emergency preparedness/response. Public health information is the essential ingredient of all of its work and the key to effective public health decision making. The White House recently unveiled Guidelines for Opening Up America Again, a three-phased approach based on the advice of public health experts to help state and local officials when re-opening their economies. As it relates to state responsibilities, the White House enumerated a set of data-driven conditions each state should satisfy before proceeding to a phased opening:
  • Ability to quickly set up safe and efficient screening and testing sites for symptomatic individuals and trace contacts of COVID+ results.
  • Ability to test Syndromic/ILI-indicated persons for COVID and trace contacts of COVID+ results.
  • Ensure sentinel surveillance sites are screening for asymptomatic cases, and contacts for COVID+ results are traced.
  • Monitor conditions and immediately take steps to limit and mitigate any rebounds or outbreaks by restarting a phase or returning to an earlier phase, depending on severity.
At the moment, the Commonwealth lacks the data infrastructure to meet most of those conditions. According to the Institute of Statistics, there were data deficiencies and quality issues with about one-third of the results of the COVID-19 tests, only some of which can be corrected. In some cases, the patients’ age, gender, and addresses were missing, and there is no way to recover that information. It was through news reports that many on the Island learned that the agency had been mixing the results of molecular tests, which confirm that a person has the virus, with the results of serological tests, or “rapid test kits,” which should not be used to inform infection status. The current Health Secretary has acknowledged many times that the Island’s COVID-19 related data is not entirely accurate. As a result of all these shortcomings, vital information about the scope of the outbreak has been delayed, hindering decision making. Surveillance systems are the backbone of the public health response during emergencies, as they provide national and international public health authorities with information that they need to plan and manage efforts to control these diseases. The World Health Organization (WHO) defines public health surveillance as “the continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice” and calls it the “bedrock of outbreak and epidemic response.” Responding effectively to public health emergencies like COVID-19 requires timely and accurate information. Even after a crisis has passed, all countries will need to unwind extraordinary surveillance activities to be able to respond to future outbreaks. Disease surveillance in Puerto Rico is constrained by poor coordination of surveillance activities at the Department of Health. Many surveillance systems run as independent instruments, focused on internal data processes instead of being part of a comprehensive public health overview. For example, the surveillance systems of influenza, vector-borne diseases, and chronic illnesses work independently and are not part of an integrated system architecture. This prevents the Department from quickly developing disease control and prevention strategies, which are critical in response to pandemics like COVID-19. Given the lack of timely information and disease intelligence, the biosecurity team is usually forced to create new systems and protocols to collect and analyze new data during emergencies, which further disrupts coordination efforts at the Department. Multiple reporting systems, unclear lines of authority in the event of an outbreak, poor integration of laboratories into public health systems, and nonparticipation among private health care providers have combined to hamper surveillance efforts in Puerto Rico further. While these problems exist in other places, they are particularly severe in Puerto Rico. Over the last four years, Puerto Rico has faced four public health emergencies; the lack of public health data is one of the causes of poor emergency management. This was made evident during the recent pandemic, where the Commonwealth was unable to produce information that was timely or reliable enough to be useful. Surveillance in Puerto Rico is further constrained by uncertain linkages between data collection, analysis, and response. Some of the routine reporting systems at the Department are obsolete. They often do not provide data that can be used to make long-term disease control management decisions, even though they were designed with this purpose. There are also issues with information governance, with units within the Department using different standards, formats, and conventions for collecting and recording data. As well, vital statistics are not delivered in real-time to the various disease surveillance systems in the Department, nor does the Department conduct effective outbreak investigations, which can help in understanding disease trends. In 2012, the Electronic Health Information Exchange Management Act (Act 40 of 2012), created the Health Information Network (PRHIN). It was tasked with the interconnection of information systems used by doctors, laboratories, hospitals, and the Department. PRHIN would have allowed the electronic exchange of medical records among all health care providers and send real-time alerts to the Department to monitor any public health threat. But according to a recent report by the Center for Investigative Journalism, the information network system, which had cost more than $ 7.7 million in federal funds, has not been fully implemented. In sum, disease surveillance systems are hindered by fragmented and disorganized management information systems, lack of coordination, and inadequate governance over data and statistics at the Department.  As a result of these shortcomings, the Epidemiology and Research unit currently lacks the capacity to conduct thorough outbreak investigations, which end up affecting statistical stability and precision. Based on conversations with local stakeholders, staffing, and training hinder the Department’s ability to operate. There are only a few surveillance workers at the Department who possess the epidemiological and statistical skills that make CDC in the US so effective at clarifying and resolving infectious disease challenges. Given the size of the Department’s budget, surveillance systems, data, and statistics have clearly not been a priority. Consequently, the Commonwealth should transform and modernize the Island’s surveillance systems, demonstrate rapid improvements, and inspire trust with surveillance partners in the field and the general public. Efforts should be made to consolidate its public health surveillance and information infrastructure into an integrated system. While a wide range of diverse individual information systems can continue to exist, these systems must be coordinated, interconnected, comparable, and easy to use. Establishing standard operating procedures for core surveillance and response activities, building the Department’s capacity for rapid response teams, and linking outbreak response structures with broader emergency management arrangements will enhance the utility of the surveillance system. Modernizing the Island’s public health surveillance systems should be a top priority for the Commonwealth. The small number of staff available to support DoH will be a critical factor limiting system advancement. Opportunities to capitalize on broader workforce investments (such as through in-Island training, apprenticeships programs for colleges and graduate students, mentoring programs for new employees, or through participating in field epidemiology training programs) should be explored. If resources are limited, the Commonwealth can explore temporary assignments of personnel from the Federal Government through the Intergovernmental Personnel Act Mobility Program, or have visiting scientists/engineers through the National Science Foundation. Recently the Oversight Board sent a letter to the Governor encouraging the Commonwealth to be thoughtful and strategic with the $ 2.2 billion received from Congress to finance unbudgeted expenses related to the coronavirus pandemic. One of the areas suggested by the Oversight Board was around surveillance systems. Given the major implications it can have on our economy, we should all urge the Commonwealth to invest some of these funds to modernize the surveillance infrastructure at the Department of Health. Below some of the areas that could significantly benefit from strategic investments:
  • Develop a strategic plan to provide a strong public health data infrastructure in support of data-driven policymaking in Puerto Rico
  • A new, “best in class” integrated islandwide public health surveillance system using enterprise architecture to simplify, standardize, and automate reporting for notifiable diseases to enable early detection and rapid assessment.
  • Accelerate the use of emerging tools and approaches to improve the availability of quality and timely surveillance data.
  • Enhance field epidemiology operations to prevent, contain and control infectious diseases (i.e., high-tech networks for tracking infection, which improve the productivity of human-contact tracers)
  • Migrate existing IT infrastructure to open source tools and cloud services, to guarantee continuous availability and flexibility to model and merge diverse sources of information into a compliant dataset for analysis and visualization. Cloud-based technology and analysis tools allow the government to share information with health providers and critical stakeholders easily.
  • Expand the capabilities of electronic case reporting to extract raw data from providers’ electronic medical records (EMRs) to communicate results to the Department of Health automatically. Emerging surveillance systems can automatically scan the data that clinicians routinely record in EMRs during clinical care.
  • Integrate GIS technology to generate maps and spatial analysis of disease conditions in specific geographic areas. GIS has emerged as a powerful evidenced-based practice technology for early detection and timely response to a disease outbreak.
These investments would be vital in the fight against coronavirus and future pandemics. In addition to supporting modeling efforts and predicting the flow of a pandemic, big data, machine learning, and other technology can quickly and effectively analyze information to help the Government figure out the best preparation and response to this and future pandemics. Building robust health security infrastructure takes innovation and partnerships at all levels of public health, coordination across government agencies, and multiple public-private partnerships. Thus, the Department of Health should work with other government entities like the Institute of Statistics, academic programs, and nonprofit organizations like CienciaPR to ensure the system architecture is designed appropriately and progress is made with all investments. Failing to do so risks accidentally perpetuating the very data silos that are causing so many issues during this pandemic. As we work towards a good recovery, we should put in place the foundation to ensure we are stronger, faster, and more adaptable for the next pandemic. 
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