MANUSCRIPT

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This is an online COVID-19 pre-publication manuscript which has been submitted to WPSAR. Pre-publication manuscripts are preliminary reports and have not been peer-reviewed. They should not be regarded as conclusive,

guide clinical practice/health-related behavior, or be reported in news media as established information.

TITLE:

Experiences in COVID-free Vanuatu: initial establishment of surveillance and challenges of no in-country testing and Tropical Cyclone Harold, January – April 2020

Author: Wendy Williams, Caroline van Gemert, Joanne Mariasua, Edna Iavro, Debbie Fred, Johnny

Nausien, Obed Manwo, Griffith Harrion, Vincent Atua, George Junior Pakoa, Annie Tassiets, Tessa B Knox, Michael Buttsworth, Geoff Clark, Matt Cornish, Posikai Samuel Tapo, Len Tarivonda, Philippe Guyant

MANUSCRIPT

Introduction

The World Health Organization (WHO) Western Pacific Region is comprised of 37 Member States, including the 22 Pacific Island Countries and Territories (PICTs) that are marked by expansive geography, relatively small populations and diverse cultures. PICTs are vulnerable to emerging infectious diseases, including epidemics and pandemics, chronic food and water insecurity, and to natural hazards including cyclones, earthquakes/tsunamis, landslides and flooding. For this reason, the Asia Pacific Strategy for Emerging Diseases and Public Health Emergencies (1) guides Member States to adopt an all-hazards approach encompassing both disease outbreaks and natural disasters in order to strengthen their capacity to detect, prepare for and respond to emerging infectious diseases and public health emergencies.

Following the declaration by the WHO Director-General that the outbreak of novel coronavirus disease (COVID-19) constituted a Public Health Emergency of International Concern, six PICTs have thus far reported confirmed cases of COVID-19 to WHO (2), five of which are also the only PICTs that currently have in-country capacity to test for the causative agent of COVID-19, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (3).

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In Vanuatu, a country of approximately 290,000 people and comprised of 83 islands, the

response to COVID-19 is guided by the COVID-19 Health Sector Preparedness and Response Plan initially developed in January 2020 and further revised as the situation evolved (4). Priority actions within are dependent on the current situation categorised as Scenario 1 (No cases), Scenario 2 (One or more case/s OR cluster/s of cases) and Scenario 3 (Community transmission, Figure 1). An active and functional surveillance system is highlighted as a strategic objective of the Plan. Since January 2020, the Government of Vanuatu has implemented several measures to prevent importation of COVID-19 and mitigate community transmission in Scenarios 1 and 2. These include quarantine of all incoming passengers, suspension of all international ports of entry into Vanuatu for both land and sea, and the declaration of a State of Emergency; former encompasses school closures, social

distancing measures, restrictions on inter-island travel, cancellation of large gatherings and sporting events and other restrictions. Some of these measures were implemented or lifted as the situation evolved (see www.covid.gov.vu for more information).

In addition to the regional preparedness and response to COVID-19, several PICTs were affected by Tropical Cyclone (TC) Harold in April 2020 (5). TC Harold impacted Vanuatu on 6-7 April 2020 as a Category 5 cyclone. Over 160,000 people, amounting to around 55% of the Vanuatu population, resided in areas that were affected by the cyclone (6).

We describe the initial COVID-19 surveillance system established in Vanuatu between January and April 2020, focusing on its design, challenges, and modifications required based on the local context of no identified cases, limited laboratory capacity and TC Harold.

Methods

Several data sources are collected in the COVID-19 surveillance system to provide an overview of the COVID-19 situation in Vanuatu. A schematic view is presented in Figure 1.

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Case investigation

Case investigation encompasses assessment and verification of the clinical and epidemiological criteria, laboratory testing, isolation, contact tracing and quarantine of contacts. Vanuatu’s COVID- 19 testing strategy during Scenario 1 is to test individuals that meet the WHO case definition of a suspected case (7). In limited circumstances and in consideration of the global shortage of molecular testing reagents for COVID-19 (8) precautionary testing may be undertaken for additional

individuals. Individuals that meet the WHO case definition have a nasopharyngeal swab collected and a case investigation is initiated. Between January and April 2020, COVID-19 testing was not available in Vanuatu and all tests were sent to New Caledonia for laboratory testing. All suspected and confirmed cases are to be immediately isolated in hospital to prevent onward transmission. Since February 2020, the Vanuatu MOH has undertaken significant measures to strengthen medical

capacity to manage severe or critical COVID-19 cases including a COVID-19 ICU ward for severe or critical care patients and a ward for mild cases that cannot be isolated at home.

Contact tracing is conducted to identify close contacts of confirmed cases to determine possible sources of infection and to prevent onward transmission. Close contacts include people who had physical contact without PPE or more than 15 minutes of face-to-face close contact (within one metre) with the suspected cases in the two days prior to and 14 days after symptom onset (7). Any close contact with current or recent symptoms after exposure to the case is considered to be a suspected case and is referred to hospitals for isolation and testing as part of active case finding.

Asymptomatic close contacts are quarantined in a designated facility or at home for 14 days from their last date of exposure (as per Section 12 of the Vanuatu Public Health Act of 1994, see http://www.paclii.org/vu/legis/num_act/pha1994126/). Quarantine in a designated facility for a

period of 14 days is also required for all people arriving to Vanuatu since 20/3/2020; commercial flights have been suspended since 20/3/2020 however citizens and residents may return on repatriation flights.

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Syndromic surveillance

Two syndromic surveillance systems are in place; 1) the Vanuatu Public Health Sentinel

Surveillance Network and 2) a network of private clinics in the capital, Port Vila, that report cases of influenza like illness (ILI). The Vanuatu public health sentinel surveillance network is an existing surveillance system in Vanuatu and part of the regional Pacific Public Health Surveillance Network (PPHSN) (9). Eleven sites report weekly on five core syndromes (acute fever and rash, prolonged fever, ILI, watery diarrhoea and dengue/zika/chikungunya-like-illness) (9). Data are compiled weekly and sent to the national surveillance unit via email, phone and short message service and are manually entered into a custom Excel database. ILI data are monitored as the symptoms of COVID- 19 are clinically similar to influenza (

Objectives and

interventions

Scenario 1: No cases

Scenario 2: 1 or more cases, imported or locally detected

(Sporadic cases) OR Cluster(s) of cases

Scenario 3: Community transmission

Early detection and isolation of suspected COVID- 19 cases through an active and

functional

surveillance system

Test suspect cases per WHO case definition Train sentinel sites, health

care workers and private practitioners on case definition, notification and

reporting channels

Test suspect cases per WHO case definition Train (refresher) sentinel sites,

health care workers and private practitioners on case

definition, notification and reporting channels Enhance syndromic surveillance system focusing

on ILI and COVID-19 in public health facilities and

event-based surveillance system in private health

facilities.

Contact tracing and monitoring, test if symptoms

Enhanced syndromic surveillance system focusing on

ILI and COVID-19 in public health facilities and event-based

surveillance system in private health facilities.

Sampling strategy for testing (depending on number of

suspected cases)

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Table 2). A pre-established threshold is set (n~426 per week) to generate an alert and prompt action if the number of reported cases is greater than expected for seasonal influenza. Standard reporting is by epiweek, with week 1 ending 5/1/2020, and so forth (Table 3).

An additional sentinel syndromic surveillance system of ILI was established in March 2020 amongst private clinics in Port Vila. The objective is to rapidly identify imported cases and monitor community-level transmission of COVID-19. Private medical clinics are requested to submit daily reports via a web-form the number of consultations and the number of people presenting with ILI,

interventions

functional

surveillance system

reporting channels

facilities.

suspected cases)

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Table 2).

Hospital-based surveillance

Active hospital-based surveillance activities were established in April 2020 as part of the COVID-19 response and in addition to Health Information System data reporting. The purpose is to monitor and rapidly identify any Severe Acute Respiratory Infections (SARI) or pneumonia-related emergency department presentations, hospitalisations and/or deaths. Data are collected daily from the main referral hospital in Port Vila and five provincial hospitals around the country (

interventions

functional

surveillance system

reporting channels

facilities.

suspected cases)

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Table 2). In some provincial hospitals, data forms were expanded to facilitate monitoring of injuries and illnesses arising from the impact of TC Harold. In addition, data on the hospital pharmacy dispensing of paracetamol through the emergency department is collected weekly. A surveillance officer contacts all hospitals daily to verbally collect information on new admissions for SARI and/or pneumonia, and paracetamol dispensing. .

Laboratory surveillance

Laboratory surveillance, separate to laboratory-testing as part of case investigation as described above, includes testing data for influenza A and B and is conducted at the main referral hospital in Port Vila (

interventions

functional

surveillance system

reporting channels

facilities.

suspected cases)

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Table 2). As noted above, in-country laboratory testing was not available during the period January-April 2020.

Ethics statement

The Vanuatu Health Ethics Committee advised that ethics approval was not required as data were collected as part of the pandemic response and in line with the Vanuatu Public Health Act of 1994 and only routinely collected and non-identifiable data were collated.

Results

Case investigation and management

To date, specimens from 19 people (24 samples) have been sent to New Caledonia for SARS- CoV-2 testing. Due to borders control measures in place in both Vanuatu and New Caledonia, each dispatch of samples has required government approval and significant logistical coordination.

Among the 19 individuals tested thus far, the average number of days from specimen collection to testing was 3.4 days. Of these, only two samples were from patients that met the WHO suspected case definition, with remainder precautionary testing. None of the samples tested positive. Both suspected cases were isolated at home.

To date, a total of 98 people have been released from government-designated quarantine

facilities. The majority of these people (n=61, 62%) were passengers on the two last flights arriving into Vanuatu on 21/3/2010 and the remainder were associated with a cruise-ship visit to an outer island that subsequently was found to have had had passengers who tested positive for COVID-19 (10).

Syndromic surveillance

The number of ILI cases reported through the Vanuatu Public Health Sentinel Surveillance Network fluctuated between epi-week 1 (EW1, refer to Table 3) and EW17 (range 156-489). In

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EW18, there were 212 reports of ILI, an increase of 25 since the previous week (n=237). The number of ILI reports is not currently near the threshold (Table 3).

Among reports submitted from seven clinics in the GP sentinel-surveillance system between EW14-EW18, there were also fluctuations in consultations for ILI (range 6-45) and a sustained increase has not been observed (Table 3).

Hospital-based surveillance

Only pneumonia-related hospitalisation data was available for the time period. Pneumonia hospitalisation data were received from five of six hospitals in Vanuatu since EW14. The number of new admissions for pneumonia decreased from four in EW14 to one in EW18 (Table 3). Paracetamol dispensed through the emergency department was greatest in EW17 (n=1370, Table 3).

Laboratory surveillance

Between EW1 and EW17, 22 samples were tested for influenza A and B and one was positive for influenza A.

Discussion

The purpose of a national surveillance system is dependent on its’ pandemic response strategy as well as the local epidemiological context and laboratory and health facility capacity. The purpose may therefore be to identify severe cases, to identify asymptomatic cases, to identify clusters of cases, or a combination of these. The aim of surveillance for COVID-19 in Vanuatu in the current scenario of no cases is to rapidly detect and contain any imported cases. This relies on timely and accurate laboratory testing. The absence of in-country laboratory testing between January and April 2020 limited Vanuatu’s initial capacity to respond effectively to the COVID-19 threat. This is likely to change imminently in Vanuatu (and several other PICTs). In March 2020, Cepheid received

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approval from the US Food and Drug Administration for a rapid molecular test that could be operated on the GeneXpert platform, which provides fully automated, easy-to-use point-of-care molecular testing (11). Vanuatu has four GeneXpert machines, used for rapid detection of TB and other infections. In response to the need for local testing capacity in PICTs, a Joint Incident Management Team (including the Australian Department of Foreign Affairs, the New Zealand Ministry of Foreign Affairs and Trade, SPC, WHO and the Pacific Island Health Officers' Association)procured GeneXpert cartridges and machines from Cepheid for distribution in the Pacific (12). Once in-country testing is available, it is imperative to develop and implement a clear testing strategy in Vanuatu that considers both the epidemiological situation in Vanuatu and the anticipated limited availability of cartridges given that distribution will be staggered and the global shortage of consumables, including swabs.

The absence of confirmed cases in Vanuatu, and other countries, cannot be interpreted as absence of circulating virus. This is particularly true in countries where there is limited or no laboratory testing capacity. Currently, international guidance is not available on how to verify the absence of confirmed cases. Data collected in the various syndromic surveillance systems in Vanuatu will continue to be used to monitor and verify Vanuatu’s absence of confirmed cases. Severe and critical cases comprise around 20% of diagnosed cases of COVID-19 internationally (13) and therefore we assume that any undetected circulating cases in the community would result in an increase in ILI in primary health care facilities and pneumonia in hospitals. Testing of a proportion of mild ILI cases in the community (~80% of cases), dependent on the supply of laboratory tests, would complement data presented here.

In the context of no confirmed cases and the absence of widespread availability of

pharmaceutical interventions, such as treatment or vaccination, border re-opening may result in importation of COVID-19 to Vanuatu. The role of the various surveillance components described here is critical to rapidly detect and contain any imported cases. Mathematical modelling data to

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predict the impact of imported cases to Vanuatu using current population data and COVID-19

parameters is currently not available for Vanuatu but would be useful to guide the evolving response.

Several limitations should be considered when considering the implementation of the Vanuatu COVID-19 surveillance; these include pre-existing clinical and public health workforce shortages, limited existing epidemiological capacity within the Vanuatu MOH, geographical isolation, small population and the limited laboratory capacity. Additional workforce shortages and competing priorities have been experienced in the response post TC Harold. Nonetheless, the Vanuatu MOH and partners have rapidly scaled up surveillance activities in a complex, challenging and rapidly changing epidemiological landscape.

The COVID-19 response is continuing in Vanuatu, and will adapt as the epidemiological context changes. Learnings from the early implementation of surveillance activities during Scenario 1, the changing landscape of laboratory-testing and pharmaceutical interventions, as well as the global experience, particularly in other PICTs, will inform the refinement of COVID-19 surveillance activities in Vanuatu.

Acknowledgements

**The Vanuatu Ministry of Health Emergency Operations Centre is comprised of the following individuals from the following organisations: Vanuatu Ministry of Health (Agnes Matthias, Cassidy Vusi, Edmond Tavala, George Pakoa, Henry lakeleo, Henry lakeleo, Jean Jacques Rory, Jimmy Obed, Julian Lasekula, Karel Haal, Kenslyne Lele, Len Tarivonda, , Leonard Tabilip, Mahlon Tari, Melissa Binihi, Menie Nakomaha, Meriam Ben, Nellie Ham, Nerida Hinge, Rebecca Iaken, Renata Amos, Robinson Charlie, Roderick Mera , Russel Tamata, Sam Posikai, Sam Mahit, Sandy Moses Sawan , Sero Kalkie, Vincent Atua, Viran Tovu, Wendy Williams, Wesley Donald, Wilson Lilip, Yvette Nale), Australian Volunteers Program (Danielle Clark, Melanie Wratten), IsraAid (Kristina

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Mitchell), RedR (Rowan Lulu), SPC (Mia Ramon), UNFPA (Emily Deed), UNICEF (Lawrence Nimoho, Rebecca Olul, Suren Vanchinkhuu), Vanuatu Health Program (Caroline van Gemert, Geoff Clark, Jack Obed, Nish Vivekananthan, Shirley Tokon, Tim Egerton), World Health Organization (Fasihah Taleo, Griffith Harrison, Michael Buttsworth, Myriam Abel, Philippe Guyant, Tessa Knox, Tsogy Bayandorj).

Thank you to clinics participating in the private clinic sentinel surveillance system, including Novo Medical, The Medical Centre, Family Care Centre, NTM, Medical Options, and Vanuatu Private Hospital. Thank you also to all the health facilities participating in the PPHSN and/ hospital surveillance.

Caroline holds an Early Career Research Fellowship, funded by the Australian National Health and Medical Research Council. The Vanuatu Health Program is funded by the Australian

Department of Foreign Affairs and Trade Australian Aid program.

Conflicts of interest

All authors declare no conflicts of interest.

Ethics statement

The Vanuatu Health Ethics Committee advised that ethics approval was not required as data were collected as part of the pandemic response and in line with the Vanuatu Public Health Act of 1994 and only routinely collected and non-identifiable data were collated.

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REFERENCES

1. World Health Organization Regional Office for the Western Pacific. Asia Pacific Strategy for Emerging Diseases and Public Health Emergencies (APSED III): Advancing implementation of the International Health Regulations (2005). Manila, Philippines; 2017.

2. Coronavirus disease 2019 (COVID-19)Situation Report –101 [press release]. Geneva20 April, 2020.

3. The Pacific Community. Dr Paula Vivili, Director of SPC’s Public Health division, discusses COVID-19 in the Pacific. 2020.

4. Vanuatu Ministry of Health. COVID-19 Health Sector Preparedness and Response Plan, v3 (8 April 2020). Port Vila, Vanuatu: Vanuatu Ministry of Health; 2020.

5. World Meteorological Organization. Tropical Cyclone Harold challenges disaster and public health management 2020 [

6. Vanuatu National Disaster Management Office. Situation Update 02: Tropical Cyclone Harold 2020 [cited 2020 8/5/20]. Available from: https://ndmo.gov.vu/tropical-cyclone-

harold/category/99-situation-update-infograph#.

7. World Health Organization. Global Surveillance for human infection with coronavirus disease (COVID-19). 2020.

8. World Health Organization. Laboratory testing strategy recommendations for COVID. 2020.

9. Kool JL, Paterson B, Pavlin BI, Durrheim D, Musto J, Kolbe A. Pacific-wide simplified syndromic surveillance for early warning of outbreaks. Glob Public Health. 2012;7(7):670-81.

10. Vanuatu Ministry of Health. Vanuatu Situation Report 3 - 23 March 2020 Port Vila: Vanuatu Ministry of Health 23 March 2020 [Available from: https://covid19.gov.vu/images/Situation-

reports/Situation_Report_3.pdf.

11. U.S Food & Drug Administration. Emergency Use Authorizations. In: Cepheid, editor.: US Food & Drug Administration; 20 March, 2020.

12. World Health Organization Representative Office for the South Pacific. Novel Coronavirus (COVID-19) Pacific Preparedness & Response: Joint External Situation Report #10 2 April 2020 [Available from: https://www.who.int/docs/default-source/wpro---documents/dps/outbreaks-and- emergencies/covid-19/covid-19-pacific-situation-report-10.pdf?sfvrsn=b1c45d82_6.

13. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. Jama. 2020.

14. Kvalsvig A, Telfar Barnard L, Gray L, Wilson N, Baker M. Supporting the COVID-19 pandemic response: Surveillance and Outbreak Analytics. University of Otago Wellington; 20 March, 2020.

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TABLES AND FIGURES

Table 1Main objectives and interventions of the surveillance response to COVID-19, as per the C OVID-19 Health Sector Preparedness and Response Plan

Objectives and

interventions Scenario 1: No cases

functional

surveillance system

reporting channels

facilities.

suspected cases)

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Table 2. Summary of sentinel and hospital surveillance activities related to COViD-19

Number of sites

Coverage Site type and number

N weeks reporting

Data used for COVID-19 surveillance

PPHSN 11 National Hospital (n=6)

Health centre (n=5)

Ongoing ILI

GP sentinel sites 7 Port Vila only

Private GP clinics (n=

Primary health clinics

Since 23 March 2020

ILI

Hospital-based surveillance

6 National Hospital (n=6) Since 20 March 2020

ILI (captured through PPHSN) Pneumonia Death Paracetamol dispensing Laboratory

surveillance

1 National Hospital laboratory (n=1)

Ongoing Influenza

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Table 3. Data collected in various surveillance activities, by epi-week

Start End Epi-

week

ILI (Vanuatu

public health sentinel surveillance

network)

ILI (private clinic syndromic surveillance)

Pneumonia (hospital surveillance)

Paracetamol dispensed through ED

5/01/2020 1 489 NC NC NC

6/01/2020 12/01/2020 2 250 NC NC NC

13/01/2020 19/01/2020 3 205 NC NC NC

20/01/2020 26/01/2020 4 341 NC NC NC

27/01/2020 2/02/2020 5 191 NC NC NC

3/02/2020 9/02/2020 6 238 NC NC NC

10/02/2020 16/02/2020 7 205 NC NC NC

17/02/2020 23/02/2020 8 171 NC NC NC

24/02/2020 1/03/2020 9 319 NC NC NC

2/03/2020 8/03/2020 10 198 NC NC NC

9/03/2020 15/03/2020 11 292 NC NC NC

16/03/2020 22/03/2020 12 273 NC NC NC

23/03/2020 29/03/2020 13 268 18 NC NC

30/03/2020 5/04/2020 14 224 45 4 50

6/04/2020 12/04/2020 15 156 40 4 170

13/04/2020 19/04/2020 16 209 14 2 915

20/04/2020 26/04/2020 17 237 6 1 1,340

27/04/2020 3/05/2020 18 212 13 1 790

NC=not collected as additional surveillance activities were implemented in March 2020

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Figure 1. Health facility-level application of surveillance activities in Vanuatu, March-April 2020

Based on the Covid-19 severity pyramid, presented in (14)