PIH's Coronavirus Full Response

COVID-19 continues to spread around the world at an alarming rate, demanding global action to contain the spread and ensure that care is available for the most vulnerable.

The World Health Organization (WHO) is urging countries to improve efforts to contain the disease and protect health care workers, and notes that a solution calls for “aggressive preparedness,” all around the world. On March 11, 2020, the WHO officially declared COVID-19 a pandemic.

Partners In Health (PIH) knows that COVID-19 will disproportionately affect the most vulnerable and hit countries with weak health systems the hardest. The currently reported case fatality rate cannot be used to predict how this virus will devastate many areas globally where there are not high functioning and resourced health systems that can respond to an aggressive infectious disease, and where the population suffers from conditions such as malnutrition, HIV, and tuberculosis. Mortality is anticipated to be far worse in the places where PIH works, and it is unclear if the current global response accounts for the factors in these settings.

PIH is launching a comprehensive effort to support this response across its network of supported countries around the world to:

contain and control the spread of the virus,
ensure that patients are provided with dignified care, and
demonstrate to the world what aggressive action in vulnerable settings can achieve.

PIH is uniquely positioned to respond to COVID-19, leveraging deep experience in treating infectious disease outbreaks and responding to emergency situations around the world. PIH’s approach of working directly alongside Ministries of Health, our leadership’s connections to the world’s leading COVID-19 responders, and our strong relationships within the communities where we work will enable PIH to effectively mobilize high-impact programs to control the spread of the virus and ensure that the most vulnerable receive access to dignified care.

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Global Operational Framework

As PIH has seen in other infectious disease response settings (like Ebola, HIV, TB, cholera, and Zika), people will come forward for screening efforts if they believe they will be treated humanely and receive good care. To do that, strong health systems are necessary. PIH’s work in the prevention, control, and treatment of infectious diseases is guided by the following key principles:

Engagement of the community: Paid, trained and coordinated community health workers (CHW) are vital to health education, case detection, and linking people to care;
Support of the public provision of care and the strengthening of national, district, and local response efforts: PIH works tirelessly to support the public system because we know that the public sector’s ability to respond to health threats is tied to the strength of its local health systems;
Full provision of care for all diseases to build trust in the system: Vertical efforts fail because they do not address the broad health needs of the population. Responses to infectious diseases and health emergencies work best when they’re integrated into a trusted system that cares for the comprehensive needs of the patient.

Objectives and Activities

In order to ensure a preferential option for the most vulnerable, PIH will mobilize a response to COVID-19 through a four-pronged strategy to save as many lives as possible in the communities in which we serve and support global efforts to contain the spread of disease as quickly as possible. PIH will continue to update, hone, and adjust its response plan and budget as global circumstances evolve and according to the needs faced in the communities where we work.

Objective 1: Protect patients, communities, and staff against COVID-19 through the initiation of safe testing, triage, and isolation at PIH-supported health facilities.

There is a window of time to prevent or significantly slow the spread of COVID-19, which can only be achieved with widespread COVID-19 testing. In countries like South Korea, Italy, and the United States, we have seen that a single case of COVID-19 can rapidly create a cluster of tens or even hundreds of secondary cases in settings like hospitals, nursing homes, churches, and conferences. Laboratory testing is the only way to identify these clusters and break the chain of transmission quickly. Wide-scale laboratory testing through skilled personnel is the only way to identify clusters, break the chain of transmission, and contain the spread of COVID-19. The currently limited testing approaches in many countries around the world limit accurate data on rates of infection and case fatality, thereby skewing the global view of COVID-19’s spread around the world. Importantly, this lack of evidence on cases in communities around the world also reduces the ability of governments to influence and call for local and global funding to effectively respond.

Unfortunately, the current WHO-approved COVID-19 testing (called RT-PCR) requires advanced laboratory capability that often does not exist in the most resource poor countries, including the countries where PIH works. In some countries, clinicians are instructed to send samples to the national reference laboratory, which may even have to send the sample for COVID-19 testing internationally, imposing enormous logistical and biosafety challenges, and increasing the risk of infection for those handling the specimens. In practice as it currently stands, COVID-19 testing is limited to a small number of people with a history of travel to specific countries. This is allowing COVID-19 to spread undetected in communities all around the world.

Working with Ministry of Health (MOH) counterparts in the countries in which we work, PIH will seek to leverage new rapid testing technologies, alongside our organizational experience in community mobilization, to implement systematic widespread screening and surveillance for COVID-19 in multiple countries in which we work. PIH will work to set up a functional surveillance system that can be operational within the next two months and will execute our response through the following:

Roll out new rapid tests for COVID-19. New COVID-19 rapid tests have been developed by Chinese and South Korean companies to control huge epidemics in those countries. Similar to rapid tests already used for HIV and malaria, these tests detect the presence of SARS-CoV-2 antigen or antibodies (IgG/IgM) within 15 minutes. They are simple enough to be used by community health workers or even patients for home use, after basic training/demonstration by lab teams. These tests are complementary to the more complicated RT-PCR tests available in specialized laboratories, but will allow for rapid decentralization of testing capacity at orders of magnitude higher than what currently exists. PIH will seek to use rapid tests for detection of antibodies and antigen as a screening method to identify infected patients.
Roll-out of molecular testing (RT-PCR). Molecular testing will also be necessary within each country for confirmatory testing of patients who test positive from a rapid test. In some countries, in support of our MOH colleagues, PIH will help to build capacity for molecular testing at central laboratories (with Cepheid's new COVID-19 cartridge), slated to be available at the end of April or early May 2020, or other automated PCR systems. In all countries, PIH will support transport of samples to the national laboratory for confirmatory testing. PIH will capitalize on its network of GeneXpert machines across PIH-supported hospitals, used for tuberculosis and drug-resistant tuberculosis testing and HIV viral load, as well as well-trained personnel that already exists in those facilities. This approach minimizes the risks by referring samples to a central lab, and accelerates the turnaround of results.
Mobilize PIH-supported public hospitals and health centers as the first stage of roll-out of the rapid tests. As was the case in the United States, patients with undiagnosed COVID-19 may already be admitted to hospitals, suffering from unexplained respiratory illness or pneumonia. Until testing is widely available in the countries where we work, these undiagnosed patients will unknowingly transmit infection to other patients and health workers. Without aggressive testing measures, PIH-supported health facilities, as with health facilities around the world without intentional responses, will turn into “hot zones,” further accelerating the spread of COVID-19, while also furthering the risk to health care providers essential to containment and care efforts. PIH will train health workers to prioritize rapid testing of all patients who meet case definition for COVID-19.

PIH knows that rapid tests will also be needed beyond the catchment areas of PIH-supported health facilities. PIH is also working with MOHs at national levels to prioritize the rollout of rapid testing strategies in priority facilities and locations, such as national referral hospitals to support MOHs in national-level COVID-19 strategies and support robust country-level responses.

Making testing available to all health facilities and to health workers is fundamental to preventing transmission at health facilities. With limited human resources for health in the countries where PIH works, protecting all health workers is paramount. PIH will ensure the following:

Provide health care workers with personal protective equipment (PPE), such as masks, gloves, gowns, and hand sanitizers. PIH will procure and ensure a robust supply chain for a six-month supply of necessary PPE for all staff.
In some facilities, PIH will provide simple infrastructure enhancements, such as outdoor fever tents, as needed, to reduce the risk of transmission at health facilities and ensure proper triage.
PIH will work rapidly with MOH colleagues to quickly train all health care workers in standard Infection Protection and Control (IPC) measures for COVID-19 and provide general education to patients at health facilities. PIH will also work with MOH colleagues to establish robust and consistent standard operating procedures (SOPs) for handwashing, ensuring constant access to soap and clean water for all handwashing stations.
In addition, PIH will establish triaging protocols for those meeting COVID-19 case definition to ensure designated isolated areas are available to commence treatment, as a means of preventing further infections at health facilities.

In addition, PIH is working with Ministries of Health to leverage existing isolation facilities (i.e., those that had been set up for treatment of acute diarrheal diseases, tuberculosis, and/or Ebola) to set up capacity for treatment, if needed. To-date, staff at the PIH-supported University Hospital of Mirebalais (HUM) in Haiti have established isolation capacity in the acute diarrheal disease ward and are outfitting the unit with available equipment on site.

Objective 2: Provide dignified, high-quality treatment for people with COVID-19, and all patients at PIH supported facilities.

PIH will provide supportive care and treatment for patients with COVID-19, across all PIH-supported health facilities. PIH also knows that as cases are identified, additional staff support will be required to properly staff 24-hour acute care needs of patients with severe symptoms. Investments in critical inputs will be key, including: human resources, oxygen supply, and fuel for generators (to ensure monitors and oxygen concentrators are connected to stable electricity), among other critical costs to ensure full access to care and treatment. PIH will continue to hone targeted country-specific strategies, in partnership with ministries of health, that will include ensuring high-quality provision of care, alongside containment efforts, as well as social support for vulnerable patients and their families in coming days and weeks.

While necessary attention is placed on controlling the spread of COVID-19 in the communities in which we serve, PIH will work to ensure that essential routine health services are not impacted during the outbreak preparedness and response efforts. PIH is procuring a buffer supply of essential medications and oxygen, recognizing that the global market for medications and medical supplies has already been greatly impacted by slowing production globally, and specifically by Chinese manufacturers, due to COVID-19- related factory closures and quarantine measures. During the West Africa Ebola response, more people died from HIV, TB, malaria, and maternal death than from the Ebola Virus Disease itself, as routine health services were all but closed in many locations, leaving patients with chronic diseases without access to their medications, and leaving pregnant women without access to lifesaving cesarean sections and other critical care. PIH seeks to ensure that history not repeat itself in this pandemic, and therefore will proactively prioritize procurement of buffer stock for all countries in which we currently provide support for essential medications.

PIH is working with MOH colleagues at the more than 200 PIH-supported facilities globally to establish staffing and other response plans. As PIH implements its testing strategy in PIH-supported facilities and at the national level, in collaboration with Ministries of Health, we will continue to glean the full view of the current and potential burden of COVID-19 in each of the countries where we work, and PIH will prepare to respond accordingly.

Objective 3: Accompany Ministry of Health colleagues to support government response in each care delivery site and advocate for long-term health systems funding globally.

In response to the needs identified by MOH leadership across many PIH-supported care delivery sites, PIH will hire personnel to be embedded in the MOH offices to deeply accompany and support needs at the national level. This request, which pre-dates COVID-19, was requested based on PIH’s track record of investing in community-driven, patient-centered health care delivery strategies that have shown long-term impact in patient outcomes and strengthened overall health systems. PIH will enhance its current efforts of engaging with MOH colleagues, as well as key implementing and donor partners, in national technical working groups that have rapidly formed to establish strategies for preventing the spread of COVID-19, thereby enhancing a coordinated response at the highest levels. PIH will support MOH partners to:

Develop guidelines for prevention, screening and case management; supporting use of global best practices;
Establish training curricula and training clinicians, laboratory specialists, and supply chain colleagues;
Reinforce their supply chain by procuring test kits, PPE, and essential medicines;
Access available funding;
Work together to reinforce data surveillance systems; and
Document and publish the outcomes of our collective efforts to share evidence with other countries.

In order to serve as strong partners and ensure strong coordination efforts, PIH will invest in additional staff urgently. COVID-19 heightens the urgency to support governments in positioning their countries in the global community (including among funding agencies), and ensuring robust response among all stakeholders to contain the spread of COVID-19. As with the 2014 to 2016 Ebola outbreak in West Africa, this past week we have seen announcements from the World Bank, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and other donor agencies indicating that funds are being allocated for preparedness and response to COVID-19. Most decisions on how these funds will be used will be made at country level, and therefore having a seat at the table alongside our MOH partners to advocate for these resources to be invested, not only in “temporary tarps and tents,” but through long-term investments in surveillance systems, laboratory capacity, critical care capacity, and health workers, is critical. This will deeply bolster PIH’s overall global capacity to support policy development and resource mobilization from major funding agencies, in ways that aligns with MOH and PIH priorities, and elevates global discussions on the importance of strengthening entire health systems amid health crises.

Simultaneously, PIH will rapidly increase its advocacy efforts by engaging with U.S. policy makers at all levels of the government at this critical moment of heightened political attention to global health, to translate fear into commitments of long-term investments in global health funding that builds from PIH’s “five S” approach—focusing on staff, stuff, space, systems, and social support—and advocating for people-centered, rights-based approaches to emergency response and longer term health systems (care vs. containment, durable investments vs. temporary quick fixes, etc.).

Objective 4: Mobilize strong contact tracing systems via PIH’s network of skilled community health workers.

As with any outbreak response, epidemic control relies on finding index cases before significant transmission occurs. Contact tracing will be immediately implemented whenever a COVID-19 patient is diagnosed. This will include family members, but also workplaces, churches, schools, and any other locations visited by a person with confirmed COVID-19. PIH will rely on extensive experience in mobilizing community health workers to implement similar efforts, including responses to Ebola in West Africa and cholera in Haiti. Index cases will remain isolated in health facilities, and patients who are diagnosed through contact tracing will be isolated at home if they have mild disease but will be instructed and monitored to prevent transmission to others in the community, and will be asked to seek medical attention at health facility if symptoms worsen. For those contacts, support will be provided by CHWs to support families in implementing social distancing protocols, and all asymptomatic contacts will be monitored for 14 days. In some cases, this will require isolating at home, where access to food, water, and ongoing follow-up will be necessary.

Conclusion

A strong global response to COVID-19 is needed to effectively contain the spread of disease and save lives among the most vulnerable. These efforts will be most difficult in resource-poor settings around the world. PIH is well-positioned to respond to this crisis, and through this comprehensive approach, PIH will mobilize a high-impact containment effort, while deeply prioritizing care for those we serve, and importantly, ensuring that these efforts underpin a larger effort to strengthen public health systems for the long term. COVID-19 represents yet another challenge in PIH’s fight to find a cure for injustice. These efforts are needed, now more than ever, on the global stage to continue to challenge the notion of “containment only” and to offer an antidote to despair. Through this initiative, PIH will save lives, support the broader global effort in containing COVID-19, and bolster its long-term effort to ensure that vulnerable countries around the world are better prepared to respond to future emergencies.

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