Seven-Country Study Examining COVID-19 Impacts on Health Services

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Lab professionals working with Socios En Salud, as Partners In Health is known in Peru, complete tests for COVID-19. A new COVID-19 study will examine the pandemic's impacts on health services in seven PIH-supported countries, including Haiti, to provide data to inform effective response efforts in coming months. (Photo courtesy of Zanmi Lasante)

This article was written by PIH Canada volunteer Leah Rosenkrantz, a member of the PIH Canada Spark Steering Committee.

Lab professionals working with Socios En Salud, as Partners In Health is known in Peru, complete tests for COVID-19.  A new COVID-19 study will examine the pandemic's impacts on health services in seven PIH-supported countries, including Haiti, to provide data to inform effective response efforts in coming months. (Photo courtesy of Zanmi Lasante)
Lab professionals working with Socios En Salud, as Partners In Health is known in Peru, complete tests for COVID-19. (Photo courtesy of Socios En Salud)

Confirmed cases of COVID-19 have grown to over 20 million globally, overwhelming health care systems in some of the world’s wealthiest countries. Predictably, the situation is even more challenging in low- and middle-income countries, where over-burdened health care systems often lack the resources and capacity necessary to test, trace, and treat patients who contract the virus. COVID-19 also threatens to undermine the care and outcomes for other important areas like maternal health, family planning, childhood vaccinations, HIV, TB, and malaria, and treatment of non-communicable diseases.

A lack of reliable data can be an enormous roadblock for understanding the burden of disease and changes in the use of health services during a public health crisis, severely affecting countries’ ability to plan effective responses.

This was the challenge taken on by clinical and research leads from multiple Partners In Health sites, which will be bolstered by technical support and recent funding from the Canadian Institutes for Health Research (CIHR) for a proposal led by Dr. Michael Law of the University of British Columbia and Dr. Bethany Hedt-Gauthier of Harvard University. This funding will also support postdoctoral researcher Dr. Isabel Fulcher, who has been leading the development of the data and analytic methods for this project for several months.

The study is underway in seven countries where PIH operates and will use routine health data to perform ‘syndromic surveillance’ of COVID-19. This means that the data will be used to look for abnormal spikes in COVID-19 related symptoms, such as pneumonia, respiratory infection, or flu and cold symptoms. The same methods will also be used to quantify whether health service utilization has changed as a result of the pandemic, as limited resources may be diverted from other areas to address COVID-19, and fear of contracting the disease can prevent people from seeking care at health facilities.

By working with routine health data that is already collected, Drs. Law and Hedt-Gauthier hope to overcome COVID-19 testing restraints and provide a much-needed source of proxy data on COVID-19 in low- and middle-income countries.  

PIH Canada volunteer Leah Rosenkrantz spoke with Dr. Law to find out more details on the study. The interview has been edited for length and clarity:   

Q: What are the study’s objectives?

A: The study has two key objectives. The first is to perform syndromic surveillance to detect early signs of a COVID-19 outbreak, and the second is to investigate potential declines in health service use to design and target interventions. Each of these objectives will be carried out in the following seven countries: Haiti, Lesotho, Liberia, Malawi, Mexico, Rwanda, and Sierra Leone.

Q: Why were these seven countries chosen?

A: Actually, the seven sites were already working together and had identified these two topics as a priority. The CIHR funding call provided an opportunity for us to rally resources to respond to these identified needs.

Because each of these countries are PIH sites, the other important aspect here is that it allows the research project to rapidly scale since we already have the existing relationships and infrastructure within the country to do that. Our research team has really benefitted from the leadership of Jean Claude Mugunga, the Deputy Chief Medical Officer at Partners In Health, and Harvard Professor Megan Murray, who is also the PIH Research Director, who have been coordinating cross-site research for COVID-19-related work more broadly.

Excitingly, this is the most countries that have participated in a single PIH research project at the same time to date!

Q: What exactly is syndromic surveillance? Is it a replacement for testing?

A: Syndromic surveillance is essentially a way to use the data that we have. We know these routine data are being collected, we know they are being assembled. And so, the hope is that those will be useful for being a ‘canary in a coal mine’ in helping highlight when testing might be necessary.

Syndromic surveillance is especially important in low and middle-income countries, where testing is both limited and expensive. And while not a replacement for testing, it serves as more of a complementary procedure in which you can glean information on where potential hotspots of COVID-19 may be occurring to target your testing, and subsequently focus health care efforts. For example, if you see a spike in a region with people showing up with respiratory issues, then you might think that would be an area you would like to focus on more closely.

Q: Why look at other non-COVID-19 health outcomes?

A: With the rise of COVID-19 cases, it is likely that people will be more reticent to seek out health care services at a facility where they fear COVID-19 may be spreading. This study is particularly focused on comparing the number of individuals receiving care for things like maternal health, family planning services, childhood vaccinations, and malaria treatment to expected numbers pre-pandemic. If it turns out there is a decline in the use of these services, there can be a lot of downstream impacts. Afterall, these are services that are really important to protecting and producing population health in these settings.

The benefit of this data-forward approach is that you can go full circle with it. In other words, you can see where problems are coming up and target a policy towards those problems. Then, the real advantage of using routine data is that you can turn around and evaluate the impact of those policies that you have put in place.  

There is evidence to show that this approach works. We did some work in the past with the Ebola virus outbreak in the Democratic Republic of the Congo and found that when we instituted a free care policy after the virus outbreak, visits to health facilities actually increased. So, there are policy measures you can take to try and ensure that people don’t stop seeking out health care that we would otherwise want them to continue on with.

Q: What will this study ultimately accomplish?

A: The fundamental goal of this research project is to support the national COVID-19 responses in these seven countries. The study will provide ways of using data to identify hotspots and deal with some of the secondary consequences of COVID-19.

But there is also the hope to take it one step further by using this study to help demonstrate the value of health data as countries continue to invest in data collection and use. What is going to happen in the coming months with regard to COVID-19 in low- and middle-income countries will largely depend on the policy responses, which in turn are heavily reliant on the data.

As a result, it is critical that we recognize the importance of data and policy working hand-in-hand to tackle the COVID-19 pandemic and bring it under control.

See how PIH volunteer Robert-Lee Dahn’s successful stay in a precautionary observation center for COVID-19 in Maryland County, Liberia, has enabled him to safely reunite with his family, rejoin his community, and improve local perceptions about quarantining during the pandemic.

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