BASE Manual of Operations

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A C it E t B d S ill S t f E l D t ti f


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A Community Event Based Surveillance System for Early Detection of

Barangay Alerto sa Sakit at Epidemiya

A Community Event-Based Surveillance System for

Early Detection of Epidemic-Prone Diseases and Other Public Health Threats

Manual of Operations

1st

Edition


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Table of Contents

Acknowledgement iii

Acronyms. v

1. Rationale for an Early Warning System.. 6

Its Getting HotterGlobal Warming and Impact to Human Health

The Importance of an Early Warning System

67

7

2. Overview of the BASE System.. 9

What is Barangay Alerto sa Sakit at Epidemiya or BASE?.........................................

Why do we need BASE?.............................................................................................

Guiding Principles.Goal

Objective.

Surveillance Approach..

9

9

910

10

10

3. The BASE Framework 12

Event-based Surveillance

C di ti B t BASE d th N tifi bl Di R ti S t f

12


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Annex DPIDSR Guidelines

Acronyms and Abbreviations

BOQ Bureau of Quarantine

CHD Center for Health Development

CESU City Epidemiology and Surveillance UnitEBS Event-based Surveillance

HAI Human avian influenza

HEMS Health Emergency Management Staff

ILI Influenza-like Illness

NEC National Epidemiology Center

NIC N ti l I fl C t


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Section 1

Rationale for an Early Warning System

Its Getting Hotter

The earths climate is changing. In most places, average temperatures are rising.Scientists have observed a warming trend beginning around the late 1800s. The

most rapid warming has occurred in recent decades. Most of this recent warming

is very likely the result of human activities.1

The earth is heating up because gases (e.g. carbon dioxide) produced from

vehicles, power plants, deforestation, and other sources are building up in the

atmosphere, acting like a thick blanket over our planet. The levels of these gasesare increasing at a faster rate than at any time in hundreds of thousands of years.

This thick blanket of gases traps heat. We call this phenomenon as greenhouse

effect(Figure 1).

If more gases accumulate in the atmosphere, the greenhouse effect is enhanced

resulting to increases in global temperatures (also known as global warming) that

ill h i ifi t l t ff t l d th i t


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Global Warming and Impact to Human Health

Because global temperatures, precipitation, sea levels and the frequency of some

extreme weather are expected to increase, global warming could affect you in

many ways. Our health, agriculture, forests, water resources, energy, coasts,

wildlife and recreational opportunities would all react to climate changes.

In a warming climate, extreme events like floods and droughts are likely to

become more frequent. More frequent floods and droughts will affect water

quality and availability. For example, increases in drought in some areas may

increase the frequency of water shortages and lead to more restrictions on water

usage. An overall increase in precipitation may increase water availability in

some regions, but also create greater flood potential.

Global warming will have a direct effect on human health but many of the

changes will have mainly indirect effects by changing natural ecosystems,

affecting such aspects as food production, vector-borne diseases, and a number

of other infectious and non-infectious diseases. Figure 2displays the chain of

events that results from an increasing accumulation of gases in the atmosphere.

The Importance of an Early Warning System

In order to minimize the health impact of

li t h f th i t t


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Figure 2. Effects of climate change to human health and the role of health monitoring and

surveillance

Increase in the

level of carbon

dioxide, methane,

nitrous oxide in

the atmosphere

Enhanced

greenhouse

effect

Global

warming

Climate

Change


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Section 2

Overview of the BASE System

What is Barangay Alerto sa Sakit at Epidemiya (BASE)?

BASE is an early warning system at the community level for early detection andresponse to epidemic-prone diseases and other public health threats.

Basically, BASE functions as a smoke detectorthat calls for prompt

investigation and response.

Why do we need BASE?

We need BASE to increase the sensitivity

of existing routine (or indicator-based)

surveillance system (Philippine

Integrated Disease Surveillance System

or PIDSR) for detection of outbreaks and

other events of public health

i t B BASE i l th

Box 2

What is sensitivity?

Sensitivity refers to the ability of a


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BASE upholds the principle of transparency in providing warning and response.

BASE is apolitical in performing its functions. Its operation is objective and

uninfluenced by local or national politics.

BASE is an adjunct to, not a replacement of, routine disease surveillance (PIDSR).

Goal

The goal of BASE is to minimize

morbidity, mortality and

disability caused by infectious

diseases and other conditions.

Objective

To detect outbreaks of infectious diseases and other public health threats at its

earliest possible stage in order to implement timely and effective public health

response.

Surveillance Approach

B 3

BASE aims to compliment NOT

replace the Philippine Integrated

Disease Surveillance and Response

system.


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events related to diseases and deaths in animals, contaminated food products or

water, and environmental hazards including chemical and radio-nuclear events.


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Section 3

The BASE Framework

Event-based Surveillance

Event-based reporting is the main surveillance mechanism in which BASEoperates. The system operates at the barangay level with the following basic

activities: 1) event detection, 2) event assessment and 3) response (Figure 3).

Figure 3. The BASE Framework

Philippine Integrated Disease Surveillance and Response

Barangay Sensors

Barangay Alerto sa Sakit at Epidemiya

(BASE)

WHO

Notifiable Disease Reporting

System


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The BASE Unit receives reports from the sensors and conducts event

confirmation and preliminary assessment. If the event does not fit into the

definition of a reportable event then no further action is needed and the case

is considered closed. The whole process of reporting and response to an event is

discussed in Section 5.

The process of filtering reports at the barangay and municipal/city levels offers

two advantages: 1) It triggers prompt response at the barangay level, 2) The

higher levels of the system (e.g., national or provincial) are not overwhelmed bythe voluminous reports from the local level and they can focus most of their time

on routine disease surveillance activities and providing technical assistance to

local levels.

Coordination Between BASE and the

Notifiable Disease Reporting System of PIDSR

The CESU/MESU performs both the event-based and routine surveillance

systems. The routine surveillance refers to the Notifiable Disease Reporting

System (NDRS) of the Philippine Integrated Disease Surveillance and Response

(PIDSR) system.

Some events may not necessarily be detected and reported early at the barangay

l l F l i i h b f d h f h l i i l


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The primary function of the BASE unit is to receive reports and conduct

preliminary assessment of the event. The details of this are discussed in the

succeeding parts of this section.

Steps in Establishing a BASE System

If the minimum requirements are met, the following steps in establishing a BASE system

should be followed:

Step 1.The Municipal or City Health Officer takes the leadership in establishing BASE

The MHOs or CHOs are the most senior officials at the local level that should

provide overall leadership and direction during the process. Without their

commitment and support it would be difficult to convince the barangay officials

and other community stakeholders to participate in the BASE system.

Step 2.Prepare for the establishment of BASE

This step involves the following activities:

a) Designate MESU/CESU staff to carry out Step 2 activities and act as secretariat

for the succeeding activities in the establishment of BASE.

b) P ll i l d d f h bli h f BASE Thi i l d


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stakeholders the MHO/CHO believes would have a major role to play in the

surveillance operations.

The final output of Step 4 is an approved plan with the corresponding budget.

The plan should be part of the overall PIDSR plan of the RHU/CHO.

Step 5.Implement the plan

The MESU/CESU staff shall be responsible in overseeing the implementation of

the plan.

Among the priority activities under this step are training, installation of the

software, coordination and response.

Step 6.Feedback and monitoring

There should be an agreed mechanism of feedback. This includes regular(monthly or quarterly) meeting with stakeholders and post-outbreak assessment.

Develop a simple monitoring tool that could be used to assess the performance

of the system. The performance indicators may include timeliness of reporting,

completeness of reports and timeliness of event assessment and response.

I h ld b h i d h h i f h i i


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Section 5

Surveillance Procedures

Reportable Events

What are the two types of reportable events?

There are two types of events:

1. Human health events - these events

involve human cases of diseases

(known or unknown) and deaths (e.g.,

dengue fever, poliomyelitis, ebola).

2. Non-human health eventsthese

events involve environmental hazards (e.g., contaminated food or water, oil

spill), diseases and deaths in animals (e.g., avian influenza).

What are the broad descriptions of reportable

?

Box 4

What is a reportable event?

A reportable event is any event

which may have a known,

suspected or possible impact to

human health.


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A cluster may occur in any of the

following places in the barangay:

a) in a house or group of houses

b) in one purok or street

c) in a public gathering (e.g., party,

fiesta, wedding ceremony)

d) in a school, food establishment,

company or office, and otherinstitutions

e) in a health facility (e.g., hospital,

clinic, laboratory)

f) any location within the barangay

as long as there are three or

more cases identified with

similar signs and symptomswhether it is sudden or slow

clustering

Clusters could be due to a single

occurrence or combination of any of

the following signs and symptoms:

Box 6

What is a cluster?

A clusteris an aggregation of cases

of a disease in a given area over a

particular period of time without

regard to whether the situation is

an outbreak or not.

Since most outbreaks often begin

as a cluster, therefore, clustering of

cases will serve as an early warning

sign of an impending outbreak.

This warrants immediate

investigation and implementation

of control measures.


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the occurrence of a single case of these diseases in their areas would

constitute an outbreak.

These diseases are captured by the routine disease surveillance system

(PIDSR) because these cases are most likely seen in health facilities.

3. Occurrence of a single case of an unusual/unexpected disease in the community

The deadly African Ebola Virus Hemorrhagic Fever disease does not exist in

any area of the Philippines. Therefore, one reported case of this disease andlaboratory-confirmed would constitute an outbreak. Among the emerging

diseases included in this category are SARS and human avian influenza.

This event would most likely be captured in the routine surveillance system.

4. Cluster of deaths in humans

The cause of death could be due to an infectious or non-infectious disease

(e.g., chemical poisoning, paralytic shellfish poisoning). This event could be

identified in the community or in a health facility.

A cluster of deaths of patients with respiratory symptoms could be an early

warning of a new emerging disease (e.g., SARS, human avian influenza, novel

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implemented to prevent the spread of the outbreak to other areas of the

country and possibly to international communities.

7. Any public health event that raises concern, fear and alarm in the community. This

includes rumors of a new disease, disease outbreaks, or breakdown of the public health

system.

Detection of an Event

Who will detect or identify the events in the barangay?

Primary Sensors

a) Barangay Health Workers (BHW) the BHWs are primary event identifiers in

the barangay. This would be part of their routine activity in the barangay that

includes household visits.

b) Health Care Workers (HCW)- the HCWs are the midwives and nurses of the

RHU/CHO assigned in the barangay. This also includes malaria field personnel in

malaria endemic areas. The HCWs and BHWs are the primary event identifiers in

the barangay. Since BASE does not involve routine reporting, the participation of

HCWs in this activity does not necessarily add significant load to the HCWs daily

activities.


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Reporting Methods

How do members of the community report an event to BASE?

Hotline

A hotline communication should be established at the BASE Unit and MESU/CESU.

The hotline could be a dedicated cell phone/telephone landline or both. These

hotlines should be open to the general public 24 hours a day, 7 days a week.

Direct Reporting

Any member of the community may report to the BASE Unit by personal

appearance, through text (SMS), radio or by phone. The report should have the

what, where, when, and who information about the event. There is no form that the

reporter needs to fill in. It is the primary responsibility of the BASE staff to extract

this information from the reporter or from other reliable sources during theverification process.

Verification

Who will verify the reported event and


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4) Inquire for case/s of the reported illness that may have been admitted or sought

consultation from any of the health facilities in the area.

5)

Inquire from local media practitioners who may have knowledge of the event.

The BASE unit staff should explore other appropriate methods of determining the

existence of the reported event.

Whenever an event is reported, the BASE staff will obtain basic information of the

event and record this in a logbook. A sample logbook is shown in Annex B. In

barangays where BASE units have access to computer and internet connection, thedata could be entered directly into an electronic database.

Part 1of the logbook contains the basic information gathered during the verification

process. This includes the following:

Event ID....................... This is a unique identification number assigned to each event

reported. The number contains the abbreviated name of the region,province, municipality or city, barangay and the number assigned to

that specific event. For example the Event ID R5-Bicol-Daraga-Naba-

001 means that the event comes from Region 5, Bicol province,

Daraga municipality, Barangay Nabasan. The number 001 indicates

that this is first event reported in the barangay. The primary aim of

assigning an Event ID is to create a unique identification of each

event to prevent duplication of reports. In a computerized system,


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Description of the case/s

No. of cases Indicate how many individuals were affected or having the illness.This could just be an estimate at the beginning particularly if the

event involves a lot of cases. Write none or 0 if there were no

cases.

Age and sex Specify the age and sex if there are few (


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Event Assessment

Event assessmentis the process by which the available information about an

existing event is analyzed and a judgment is made as to whether it poses a risk to

public health.

Once an event is confirmed to be real, the BASE coordinator or any of the BASE

trained staff shall proceed in the preliminary assessment. If the BASE unit has no

technical capacity to perform the assessment, the MESU/CESU shall take the lead in

the assessment.

Table 1presents the questions that will guide the assessment process. If any of the

questions has a YESanswer, then the event is considered a potential public health

risk and a response is triggered.

Table 1. Guide questions for the assessment of events

Type of Event Assessment QuestionResponse

YES NO

Human health

events

Does the event involve a notifiable disease or syndrome

(i.e diphtheria, watery diarrhoea)?

Can the suspected disease cause outbreaks with a high potential for


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After the assessment, Part 2of the event logbook (Annex B) should be filled up

which includes the following information:

Event ID......................... This is the same unique identification number assigned to the event

specified in Part 1.

Is the event a potential risk

to public health?...................This could only be answered if a thorough assessment was done.

Check YES if the answer of one of the questions presented in Table 1

is YES. Check the option could not be determined if there is not

enough evidence to neither confirm nor deny its potential risk to

public health.

Actions taken. Specify the initial actions done to address the problem. Examples of

these activities include,

coordination with appropriate government agency/ies

BHERT or Outbreak investigation team sent to the area to

conduct further investigation preliminary response activities such as early treatment and

referral of cases, provision of drugs and medicines,

community education campaign, etc.

house-to-house search for new cases

Remarks. Indicate other information relevant or related to the event. This

includes information on whether,


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Event Updates

If the status of the event is Ongoing, then the BASE unit should provide regular

updates on the situation. The frequency of releasing updates may vary depending on

the severity or urgency of the situation. Daily update for at least three days to one

week is required for ongoing disease outbreaks and non-human health events such

as environmental hazards that are categorized to have high public health risk.

For ongoing events, the BASE staff should fill in Part 3of the Event Logbook (Annex

C). If the system is computerized, then the update information shall be encoded intoan electronic database. The information required in Part 3 are the following:

Event ID......................... This is the same unique identification number assigned to the event

specified in Parts 1and 2.

Event update as of

(date and time)

Indicate the date and time the update was recorded into the event

logbook or encoded into the computer database.

Cases Indicate the previous reported/recorded total number of cases,

number of new cases and add the two figures in the total of number

of cases column. This information provides guidance on whether

the event has been effectively controlled or not.

Deaths. Indicate the previous reported/recorded total number of deaths,


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provide regular update of the situation. NEC as the designated IHR (International

Health Regulation) focal point shall provide these updates to WHO.

Responding to an Event

Response to an event has two basic components. These are

1) investigation and surveillance, and

2)

implementation of control measures.

Preliminary investigation and surveillance is the primary responsibility of the BASE

unit staff. This activity however, should be closely coordinated with the MESU/CESU.

In some situations, in-depth epidemiologic investigation of the event is required.

Since this is a highly technical work, only trained personnel from the RHU or CHO

should perform this activity.

The BHERT should be organized. The primary functions of the team includes the

following:

a. Provide preliminary response activities to a confirmed event. This includes

early detection and management of cases.

b. Conduct community information and education campaign.


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Figure 5. Flow of reporting, investigation and response to a reported event

NoEvent

recorded

as closed

Sensor collects

information and report

the event to BASE unit

Real

event?

BASE staff records and

confirms the report

BASE staff conducts

event assessment

Yes

No

Event is a

public health

risk?

Event

recorded

as closed

Yes

Event

Yes

BASE

coordinator/staff

records and reports

the event to

CESU/MESU.

CESU/MESU

enters event into

the BASE

database.

BASE staff notifies

Event is of

national or

international

concern?

No

Yes

BASE in

coordinationBASE capable

for preliminary

BASE

cannot

decide

BASE


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Feedback and Monitoring

The BASE unit should maintain an Event Bulletin Board. The bulletin contains basic

information of the recent events monitored. The board should be located in a

conspicuous place in the barangay hall. In this manner, the barangay hall officials,

employees and the public are aware of the events monitored by BASE. This type of

feedback should maintained even if the BASE unit is utilizing an electronic database

system.

Figure 6. Sample event bulletin board for public viewing

Event Bulletin Board

Event Where When Who Actions Taken Status

Cases ofseverediarrhea andvomiting

Bgy.Nabasan,Daraga,

Albay

First case:08-19-10

1st case: 5 yrs old,male

2nd case: 20 yrsold male3rd case: 10 yrs old

female

1 death

BHERT was deployed in the

area immediately 1 hourafter the report was verified

BHS is opened 24 hrs for

immediate treatment ofdiarrhea cases

PHO, CHD, and NEC have

already been notified

Standby ambulanceprovided by LGU for referral

Ongoing


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Annex A

Sample Event Logbook

Part 1Event Verification*

Event ID

Date and

time

report

received

What is the

event?

Where did

this

happen?

When did

this

happen?

Description of the Case/sOther

Information

Reporter Information

Verification

StatusNo. of

cases

Age and sex No. of

deaths

Name Contact No.

R5-Alb-Dar-Naba-001

08-20-104:00 PM

Cases of severediarrhea and

vomiting

Bgy.Nabasan,

Daraga,Albay

First case:08-19-10

3

1st case: 5 yrs old, male2nd case: 20 yrs old

male3rd case: 10 yrs old

female

1

Two of the caseswere admitted in

Albay DistrictHospital

RomeoCagas

09066506986 Verification

ongoingEvent does

not existEvent exists

NCR-D1-Mla-

B10-001

08-24-10

9:00 am

Foreigners

suspected ofhaving ebola

Manila Not known

3 Not known 1

The cases were

reported to beadmitted in Manila

Doctors Hospital

James

Buhain

741-89-65

VerificationongoingEvent does


NCR-D4-Mla-B20-002

08-24-109:00 am

Chicken died ofavian flu sold in

public markets ofManila

Not known Not known

none none none

The reporter gotthis information

from the localradionews

MeriamAlamo

09153457891 Verification

ongoingEvent does


* The information contained in this form are subject to changes during the course of event verification.


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Annex B

Part 2Event Assessment and Initial Response

Event ID

Is the event a

potential risk to

public health?

Actions Taken Remarks Status of the Event

R5-Alb-Dar-Naba-001 Yes

No Could not be

determined

BHERT was deployed in the area immediately 1 hour after the reportwas verified

BHS is opened 24 hrs for immediate treatment of diarrhea cases

PHO, CHD, and NEC have already been notified

Standby ambulance provided by LGU for referral of severe cases

Information campaign intensified in the affected and neighboringbarangays

This could be an early stage of acholera outbreak. Stool samples have

already been sent to RITM for culture.

The last case seen was on 08-21-10.

No more cases as of 08-25-10.

Ongoing

ControlledClosed


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Annex C

Part 3Event Update

Event ID

Event update

as of

(date andtime)

Cases Deaths

Actions Taken RemarksStatus of the

Event

Previous

no. of

cases

New

cases

Total no.

of cases

Previous

no. of

deaths

New

deaths

Total no.

of deaths

R5-Alb-Dar-

Naba-001

08-20-10

4:00 PM

3 10 13 1 2 3

Additional choleratreatment centers wereestablished in adjacent

barangays with suspectedcholera cases.

Residents were advised toboil their drinking water and

practice personal hygiene

Initial investigation revealed

that the possible source of the

outbreak was the contaminatedwater from local water district.

Ongoing Controlled Closed

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