 Health emergencies of all kinds happen annually. Occasionally, an emerging infectious disease would shock our health system, examples of which include the Spanish influenza of 1918, the cholera outbreaks and tropics, the SARS, Ebola, Zika, dengue, measles, polio, and now we have COVID-19. For this episode, we will try and understand health emergencies with specific attention to outbreaks and epidemics and how the health system prepares and responds to such overload of the health system. This is Dr. Teddy Herbosa, your host for health issues here at TVU Peace. For this episode, our guest is a career official of the Department of Health. I met her in the early 90s in the Original Disaster Management Unit, or DMU of the Department of Health under the time of Secretary Pengson. She eventually became the Regional Director of Mi Maropa, or Region 4A of the Department of Health, and of Region 5, Bicol Region of the Department of Health. She played major role in eruptions of Mayan volcano and typhoons that happened in the Bicol Region, and eventually played a vital role as our resource hub manager based in Samar during our response to the typhoon hyan in 2013. Soon thereafter, she was rewarded a post as Director of the Health Emergency Management Bureau at the Central Office of the Department of Health. Viewers, let's welcome Dr. Gloria Balboa to help issues to discuss emergency response operations in outbreaks and epidemics. Welcome, Glow. Thank you very much, Yusek Ted. He's my former boss here at the Department of Health. Thank you for that kind introduction. And hello to everyone watching. Thank you very much. Yes, Director Glow, let's start off with what is the DOH response plan for a pandemic or a plan for emerging infectious diseases? Okay. Actually, we have specific bureau that is the Disease Prevention and Control Bureau that has the Emerging and Re-emerging Disease Program and actually, they are really the ones in charge of pandemic emergencies, fairness, but since this is already an outbreak, so this is when the Health Emergency Management Bureau is coming in because this is already an event, a disaster event. So the coordinating function of the Health Emergency Management Bureau is there, okay? But of course, the data are supposed to be provided by the Epidemiology Bureau. So they work hand-in-hand at the Epidemiology Bureau with the Disease Prevention and Control Bureau coming up with the policies, guidelines, the plans, and then the Health Emergency Management Bureau comes in to sort of coordinate all these efforts that the Department of Health are doing. And in fact, the Health Emergency Management Bureau is the one sitting at the National Disaster Risk Reduction and Management Council of the Philippines. And now also sitting at the National Incident Command, Emergency Operations Center of the National Task Force. So, I know for a fact that during our time, the Department of Health submitted a pandemic influenza preparedness plan to the World Health Organization. Can you tell us more about this because I think you were a regional director then, so I'm sure you also had some inputs to that pandemic preparedness plan. Okay, yes. Based on the pandemic preparedness plan of the Department of Health, and actually it was an option, option of a lot of disasters or special epidemics that we have already experienced. And as you have probably listened to our plan during the start of this COVID-19, we have forced first when we had the presence of the COVID virus in other parts of the country, like in China, that is our door one, okay? Where we tried to really limit the entrance of this virus to the Philippines because it's still outside of the country. And then we went into door two when we have already, there are already cases that has in our borders and has entered the Philippines. So, we were into that door. And then door three is when we are trying to prevent social community or local transmission, okay? And then when we already had the local transmission, we went immediately into door four. And this is when it was just a cluster or a small patches of areas having the disease, it's just the sub-level one. This is already the code red alert, okay? But sub-level one. And then when we had the sub-level two, this is when we already had local transmission in a lot of areas. So, that is the door for sub-level two. So, that is still code red, but already sub-level two, okay? So, our plan is... So, that is how we prepared for it, yes? Correct. The prepared plan involved is situating where the country is at particular levels of an outbreak or a pandemic. So, in that case, we have a unit in the Department of Health called the Epidemiology Bureau. They're the ones tasked to actually do the surveillance. Can you discuss to our people how epidemiologic surveillance is done and what is the function of the Epidemiology Bureau? Okay. The surveillance bureau, the surveillance activities of the Epidemiology Bureau is there actually even during normal situation. We have the regional epidemiology surveillance unit at the regional level and then at the local levels, provincial, municipal, city levels. We also have this Epidemiology Surveillance Unit. Now, they do this monitoring or surveillance of cases, especially the notifiable diseases, okay? We have the sleep notifiable diseases. And when there is this increasing number of disease, number of that disease, then they would report it going up to the regional and then the Epidemiology Bureau so that immediate intervention can be done already and that is when they do the epidemiologic investigation. Okay, so this is to really insinitute the necessary actions so that for it becoming an outbreak can be prevented. Okay, so that is how we do it. And although, of course, there are some limitations because not all are part of that surveillance unit because only hospitals identified as sentinel sites are included. So not all private hospitals are part of this sentinel surveillance system. That is why, you know, that is part of the limitation. But it's good that here, when we had this COVID-19, we have already included everybody, you know, all the private hospitals, local government unit hospitals and, of course, the D-Wage hospitals are already part of this and we are doing this to our data data collect application because we already have this on mandatory reporting of notifiable diseases. So all health facilities are expected to report already all notifiable diseases. Otherwise, they will be, they're sort of a penalty. Could you give us a list or name some of the app notifiable diseases that the Department of Health and the other epidemiology surveillance units are monitoring or continually assessing? What are these diseases? Well, we have, of course, HIV-AIDS. Yes, HIV. TB. Missiles. TB. Dengue. And cholera. Cholera. Yeah, a lot more. Okay, those which are all public health emergencies. And then it's another unit that looks at the emerging and we emerging, right? We have polio, right? We were not monitoring polio before, but suddenly there was an outbreak. So now polio is being monitored, correct? Yes, yes. So that's what we call a re-emerging. Re-emerging disease. Yes. So this one, the COVID is in emerging diseases. So it's a new, it's a novel virus. We had SARS, which was similar to it. And remember during our time, we had MERS-CoV during that time from the Middle East. These are what we call the emerging. These are the new diseases and we monitor them. Gula, you need to describe to our tele viewers when do you say there is an outbreak of these diseases? If we monitor these diseases for you all year round, dengue, TB, HIV, when do you say there is an outbreak of missiles? When do we say there is an outbreak of dengue? Yes. Okay, yeah. It's not that easy to declare an outbreak. No, that is why we really need the technical, the experts to do that. But basically when we say there's an outbreak is when the number of cases have increased beyond the usual, meaning to say we have to look at the past five, at least five years incidents of that particular disease. This is if it is an old disease, okay? So for the last five years who have to look at the other rates or the number of cases and then when suddenly there's an spike or an increase at least half, no more than half of the previous incidents then we can say that there is an outbreak. But for new diseases like COVID when it's not there, there's never a case before. So even just one case would really fit the definition already of an outbreak. That is why when we had the first case that was March of COVID-19 because we are already monitoring it because it's in other countries. So the moment that we had that first case then it declared already that there's an outbreak. Yes. So we've become part of the countries with a COVID outbreak. Yes. So we're part of the pandemic. That's correct. So can you tell me you mentioned it a while ago that the different levels of government have what is called the ESU or the Epidemiologic Surveillance Unit. Yes. You have the CESU, the RESU, the PESU. So can you explain this network because these are our, I call them our disease detectives because every time I visit them they are like detectives. They have on the wall the contact cases. They are the ones that do contact tracing. Is that correct? Yes. Can you explain the ESUs? Okay. Yes. Well, we have two levels, national and the local level. So at the first national is the Epidemiology Bureau and then the regional which is also part of the National Surveillance Unit because we are on a devolved setup, right? So at the national DOH is up to the regional level. Okay. And then provincial down to the municipal and city level. So these are proving our local Epidemiology Surveillance Units. Okay. What does this unit do? First is when, first this is surveillance. They are the ones really monitoring the incidence of diseases in this different, in a different sentinel sites. Okay. And then once there is an increasing number of cases then they would do Epidemiologic Investigation. So they are the ones like detectives as you have said, no? Going to that area where there are increasing number of cases to really do this Epidemiologic Investigation. They try to see where are the cases, what are the causes and the signs and symptoms and then they try to really look at the source of that infection. And then of course there are tests that needs to be done. Then once the test would show that it's positive then they would do contact tracing of these positive cases. Ayon. So the close contacts will have to be investigated and then the contacts also so that preventive measures can already be done. Like if there are things that particular contacts need to do or like for example if it can be prevented by immunization then immunization will have to be done. And it is already a lot a significant number in a particular area. Then mass immunization can be done. But this are for diseases that can be prevented by immunization. So that's a vaccine available. Yes, yes. But we also find the source, right? For example, I remember Yes, of course, the source is very the source was a pigary linked to a to the river where in the waste of the pigary was going into the river it was contaminating the water sources of all the communities downstream. So that's one of the the other thing that I noticed in the current situation that's a lot of confusion is the term quarantine and isolation. Can you differentiate the two terms? What is the quarantine done for? And what is the isolation? Yes. Okay, based on the guidelines that the Department of Health released, I don't remember the number of that Department memorandum but they tried to differentiate between the quarantine and isolation. When you say quarantine this would mean putting in areas those who are close contacts. Okay, so and those who are suspects and probable cases this are not just positive. Okay. And so they are put in a quarantine facility to limit the potential for them to be able to spread the disease because we still don't know whether they are positive or negative. And so and the design for that quarantine facility is such that they are put in one room each, okay? Because you don't want to, you know, them to be mingling with others, okay? So that is what we call a quarantine facility. You prevent them from moving around so that, you know, even if you are not sure yet if they are positive negative, but well, if they are positive then you could limit the transmission, okay? So that's a quarantine. But for the isolation these are already the positive cases since they're already positive the design of that isolation facility is such that they can be put already. No, it doesn't they don't have to be in one a room with their own comfort rooms but they can as long as they have this at least 2 meters distance between the beds so cohorting na pwede that is why pwede sa ward in the hospital ward or in a gym where it does just have to be designed that, you know, we will still limit the transmission. But since they are all positive already then they can be cohorted. So Yunyong, quarantine di pa siya positive isolate those positive ones. And so well, we also use quarantine for people that come in from outside the country, right? Can you explain that procedure? Yes. Yes. Okay. First, if they're coming from countries especially in countries where there is local transmission so we really would want that when we receive them they are not symptomatic okay, and they are negative. That is why the procedure is that they should be tested when they're still in their country and they're supposed to have a negative test. But, you know, of course because of the this scarcity already of the test kits because globally we have shortage of the test kits. So if they have not been tested yet then they should be asymptomatic, okay? So if they once they when they board the plane they have to be checked, of course, the usual B.O.Q. procedures those who are asymptomatic will be allowed to board. Those symptomatic should not be allowed to board. Should not be allowed to board. And then upon arrival in the country again they will be tested by the Bureau of Quarantine Thermals County and signing the Health Declaration card and those again asymptomatic will be brought to a quarantine facility because they will have to undergo 14-day quarantine because they have not been tested yet, okay? And then but for those who are symptomatic they will be brought directly to a hospital, okay? Because we don't miss them to those who are... We isolate them those that are symptomatic we isolate them. So, look, you said it's a 14-day quarantine. I remember during the Ebola we had the soldiers from West Africa and we quarantined them in an island, Cavalio Island but it was 21 days. So, can you explain the difference in days why in Ebola it was 21 and why for COVID we use 14? Okay. The 14 days or the 21s would refer to the incubation period wherein within that period that's a time that you are supposed to present signs and symptoms, okay? So after that if you don't show signs and symptoms then you are sure to have not contracted or the disease, okay? So, yun po yun. And since these are different different viruses they have different incubation period, okay? So, yun na yung sa Ebola I said it's 21 days but for COVID based on studies it's 14 days. Although first we know that there are some that are extending beyond 14 days but majority it's really 14 days. So, yun po yun and that's a basis for our quarantine period. So, it now becomes clear how the epidemiology bureau the epidemiologic surveillance unit quarantine, isolate, contact trace. Now, tell me more about the health emergency management bureau. What is the HMB? What is HMB of the Department of Health? Okay. Yes. But I mentioned that the health emergency management bureau is the bureau within the Department of Health that coordinates all the emergency and disaster management operations in the country, no? And this, when we say health emergencies and disasters so this would refer to the natural, the human injuries and even outbreaks, okay? So, that is why we're here. HMB is supposed to be the repository of all this information about any health emergency and disaster and yun na. We are very strong in coordinating all these responses because we have to manage from the prevention mitigation preparedness phase to response and then up to the recovery habilitation. So, we cover the entire management cycle. And then when before it's more of the responses are more on the actual response but now we are more proactive that's why disaster risk reduction we changed the name even the National Disaster Risk Reduction Management Council because we want to focus more on the pre-disaster activities so that we can prepare better to respond. Paranganon. So, it's not just responding, no? But really preparing for it which is a lot, lot more job. Okay. So, now that you're here at the National Incident Command Center Emergency Operations Center representing Yusek Bayugo and Secretary Duque in this multi-agency operation can you kind of summarize what DOH Department of Health has accomplished so far in the response operations task group of COVID-19? Yes. The test group response operation is one of the four task groups under the National Task Force so the other three would be the task group this resource management and logistics and then eStratcom and then the food security. Okay, so since this is a health event so the task group response operation is headed by the Department and in fact it is a major task group among the four task groups it is a major task group because all the others would really depend on the task group response operations. Correct. So, yeah, we are in our action plan national action plan specific for that task group response operation we have when before it's just when detect isolate treat now it has evolved into prevent okay, detect isolate test treat and then reintegrate. Okay, and this is going to the new normal so the different activities that we're doing are based on these strategies so when we say prevent of course we have there the different precautionary measures that need to be done by the community the individuals acting social distancing hand washing okay the face mask okay and then really staying at home staying at home of course and then there's a lot of information dissemination that's really needs to be done okay and then crisis communication yes, especially crisis communication and then for the detect the main activity that we're doing here is contact tracing okay and when before it's just our rescue which is national scope because of them increasing then well we have a lot of cases already so we need to do contact tracing by the local epidemiology surveillance units okay so sila na po ang ako contact tracing and we have been hiring we have hired additional contact tracers and then involving the different agencies especially in the local government units to be doing the contact tracing go headed by our lessers okay and the DILG yes, DILG is really yeah it's headed by DILG because the task group response operation yeah it's headed by the department of health but the secretary is DILG and they're really doing a lot of job a great job and the other members A, AFP, PNP um post guard maybe Red Cross is also our partner or a member of this task group okay and then going back okay detect basically it's more on contact tracing and then isolate this is when we once were able to trace the close contacts then we put them in a quarantine facility okay close contacts and then if they are asymptomatic but for the symptomatic they are classified further into the suspect and the probable cases because this are not tested yet okay so after that then uh once they are in a quarantine facility we do the testing because well we cannot test them immediately no so we put them first in a quarantine facility and then we test and then because the result would take about three days before we get the result then uh they would stay first in the quarantine facility once they are tested positive then we treat them okay we put them in the isolation facility for the uh positive asymptomatic and mild but those who are severe and critical cases uh would be put in the hospitals okay so input uh because they would be needing you know they have to be in isolation units uh intensive care units and maybe they would be needing these ventilators no because this would really affect the respiratory system and a lot are dying because of pneumonia as a complication of this COVID-19 okay so there they undergo the treatment and hopefully when they uh get well then they are reintegrated into the community no uh in fact if they do not uh after after treatment if they are tested already negative no once they are positive and then uh if they are getting well they are tested again only when they are tested negative can they be brought back to the community now if they have not completed the the 14 days in the hospital because they're uh relatively well then they are allowed to go home if they are negative already but they have to complete the 14 days who are in isolation in the in their home sorry it's quarantine they have to do home quarantine to complete their 14 day quarantine at home and of course there are guidelines that so ayunpo and then of course they have to still practice the usual precautionary measures so that they don't of course for everybody to be protected the other thing that the Department of Health has done very well is that you have increased the number of tests per day I remember we started with only three test centers but today we have about 206 can you talk about the different testing 30 can you talk about the different testing centers okay can you describe the efforts in increasing our capacity for testing yes okay yeah initially it's just RITM the research institute tropical medicine that is doing the test and then we have five additional sub national testing laboratories so they are strategically located in Duzon with CIS Mindanao and then an NCR okay and then because of the need to have more testing laboratories then we have opened it to even private hospitals well there are stages of the accreditation process there are five stages first stage is the submission of self-assessment form so that they would know what they need to prepare to be able to become at laboratory testing facility and then once they have complied they go to stage two validation that is when at UH regulatory people would go visit the testing laboratory to see if they have you know they're ready and if they see that there are some deficiencies then they have to comply so that's going to the stage three and then they have to comply in terms of the equipment of the environment there and then of course when you speak of equipment they see our machine and very important which is quite difficult for a lot yung biosafety cabinet standards yeah biosafety yeah standard ja and aside from expensive no it's really difficult to buy and then but once this are in place already then this is the time they go into the next stage which is the proficiency not proficiency stage where the personnel because this is a new knowledge so not any medtech or a professional can just do it so they still need to be trained on how to do it and then ayon so once they pass the proficiency test then they become they are accredited they're issued the accreditation and they can now operate a testing laboratory so we are very happy because from that time february ayon we have one and then six and now we have ah 30 okay we have now 30 and marikina is already accredited yes yes marikina nani yes passed of proficiency I heard they had difficulty at proficiency stage okay yeah also right cross and of course UP UP NIH NIA UP PGC and UP PGH we have V at the centers at the yes and then we had this one GBL ah which was inaugurated GBL ah HOSI HOSI HOSI yes and ah this was assisted by ADB okay asian development the asian development path yes because I think a modular lab that was flown in yes and attached to the hospital yeah it was inaugurated last Saturday and they're already ah operating and they can do as much as ah about 10,000 a day tests I think they're also ah the resources that are available soon like the gene expert the one being used for the TB program can you tell us about that? yes okay yes I should mention this gene experts are used for the TB program and then it was found out that they could also be used for COVID-19 but there's this special card trades for that and then so right now we have two gene experts laboratories accredited already one is lang center and then the other one in Samwanga city medical center three DA Department of Agriculture what is good there is they complemented each other no so they were able to have that accredited as a gene expert laboratory and then we have ah 14 more ah to be ah in the process of accreditation yes government as a total of 16 in government and then three private gene expert laboratories so they're all into this process of accreditation so by the end of May probably we'll have more than 50 testing centers including the gene experts correct that's the target and how many tests we'll be doing a day by that time when all this are functional ah so both the testing lab and the gene experts correct okay well initially we have targeted by 8,000 where ngayon nakapanatayo we are over 8,000 8,637 tests yesterday yesterday yesterday and then but of course that is not enough so from 8,000 we're targeting 10,000 and then hopefully 30,000 today 30,000 a day so that we can test and have a more accurate picture of COVID-19 yes well last question for you director Boa is where I let you go because of your busy schedule any other issues major issues and concerns in the operations in the response operations for COVID-19 that you'd like to discuss okay well of course the issue and availability of logistics would always be there because there is this global shortage so that is something that is you know quite be on our control then but of course we're doing our best okay we are also having some locally produced like for example okay and other supplies so that's one and then one issue also is on repatriation okay that's a major issue a lot yes there are a lot of Filipinos that are being repatriated and in fact Sabina is 100,000 or even more so I believe there are now 20 how many thousand 20,000 almost 25,000 that came in already yes and they filled up our quarantine facilities yes what I thought were very huge mega quarantine facilities became filled up in an instant and went to stop the airplanes flying them in for a week right so now they're coming back we will be having more of them for the coming weeks right yes so yeah that's a good move very to government suspending for quite the time the repatriation so that we can you know let this those who are already here know occupying already all our quarantine facilities to be able to go home and that is after they tested past people to see our test because even the LGUs of course they don't want to accept them if they are not tested so we have to test them all and then hopefully they can go home even if they don't finish yet the 14 days quarantine and then we are again accepting repatriation but on sort of a controlled number yes controlled number okay so Yunpo but of course since there are a lot we need so many okay swabbers to test them mega swab centers are being sent out yes so we have four mega swabbing centers okay and guys two are working already and malaking baga yun so there are already those who are able to go home and of course we have to involve a lot of agencies here ang in charge kasi ang cost guard but of course OWA DFA POEA of course DOH and DOTR because they are the ones providing the transportation for this so are going home and we have to make sure that with the assistance of the LGP&P that they have a smooth travel going back to the provinces and that they are really accepted by by their respective local government units and Yunya with the pronouncement of our president saying that the LGUs and not refuse them because they are going home so there are just these requirements ayon there should be this medical clearance from the quarantine facility manager that they have completed their quarantine period or if not at least they are tested positive no sorry negative they have undergone the PCR test and showing that they are negative so even if hindi pa-completo yung 14 days they can be allowed to go home and then of course they have to get the travel authority from our joint task force shield so that you know they are going back home would be smooth at makarating nang maga okay so and that process would really require a lot of people a lot of procedures so yun po yung ating pinakakabalahan din ay well director Glaw on behalf of the Filipino people I'd like to thank you for your dedicated service in the field of disaster medicine and now in this pandemic that you are actually having manaming manaming salamat I hope you do stay safe and be healthy to lead the department of health in its response operations manaming manaming salamat thank you very much sir and thank you for it's my pleasure to be part of this program thank you po so ladies and gentlemen we've seen how the department of health organized itself in an epidemic we have several units the epidemiology bureau the epidemiologic surveillance units the HEMB the health emergency management bureau and all assets of the department of health are used to actually fight and combat the new new epidemic or the new pandemic called COVID-19 we welcome the efforts of the department of health in trying to save the Filipino people and we do hope that everyone cooperates at home and stay safe manaming salamat po this is your host Dr. Teddy Herbosa of health issues here at 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