How to control an epidemic: Three things you need to keep in mind

Epidemics are the test of fire of any public health professional's career and of a country's public health programs. Why? Because in addition to creating the need for more health services, in the absence of a clear epidemic control strategy, epidemics cause a lot of confusion, fear and panic. Maintaining clarity is the cornerstone of an effective public health program.

The goal of this article is to help clarify some facts about epidemics and how to respond to them in an effective and efficient way. I will first define what an epidemic is so we are on the same page, and next, I will discuss the three pillars of how to control an epidemic.

What is an epidemic? An epidemic is diagnosed when the incidence of a disease is higher than expected for a certain place and time of the year. For example, a large number of flu cases or opioid overdose deaths in NYC are regrettable and preventable, but they are not an epidemic if the number cases is what is expected for that city and time of the year. This does not mean that the NYC public health departments should not do something about the problem. On the other hand, one case of CORVID-19 or Ebola in NYC is an epidemic because we would expect “0” cases of those diseases. This definition is important because when there is a higher than expected number of cases of any disease, this means the disease pattern has changed and the usual public health control measures are no longer effective and need to change to control the disease. Outbreak and epidemic are usually used as synonyms, but outbreak usually refers to each site. Thus, one epidemic can have several outbreaks. Studying each site helps understand how the disease spreads.

The epidemic is worsened when the existing prevention and control measures are not effective or not implemented correctly. The goal of a public health program is to eliminate or at least reduce the number of cases of a disease or health problem. This is usually done by stopping the spread of the disease and promptly identifying and treating those affected . Ideally, a country's effective public health programs should prevent and control all diseases that affect the country's people. An increase of the number of cases of a preventable or treatable disease is a sign of an ineffective public health program that needs to be improved.

If you are wondering what a public health program is, you need to know that a public health program is how a country’s health system organizes the prevention and control of the health problems that affect the well-being of the people of that country. Most countries have a number of public health programs: child health programs, maternal health programs, disease prevention, early detection and control programs, and rehabilitation and palliative care programs. For example, most countries have vaccination programs to prevent diseases, nutrition programs to prevent under-nutrition and/or obesity, mosquito net distribution programs that prevent malaria, cancer screening for early detection of various cancers, etc. Effective public health programs are essential to the efficient management of country’s health system. Just treating patients when they get sick is not enough to stop or control a health problem, the same way that it is not enough to wipe floor to stop it from getting wet. One has to find ways to close the faucet or at least reduce the water flow that wets the floor. Otherwise, you will have to wipe the floor forever!

How to control an epidemic? There are three pillars that they teach us public health professionals about epidemics and public health programs to control diseases. They are information, prevention and strengthened health system, that is, IPS for short. These are the three things you need to keep in mind before, during and after an epidemic. Keep reading to find out what IPS means and let me know what you think and if this is helpful and want to learn more about IPS.

1. Information is the first pillar. Every country needs an effective health information system (HIS) that monitors the numbers of cases of each and every disease. In this way, public health professionals can detect an epidemic, that is an increase higher than “normal,” higher than what is expected. The ideal case is to detect the "index case," that is, the first case of an epidemic, as soon as possible to stop transmission and control the epidemic. We can't do that if we do not have timely information and an effective HIS.

The HIS also helps monitor how effective existing and new public health programs are and make informed corrections. Every health care provider must report information on the cases they treat to the HIS. What is the problem with the HIS? In some countries, the HIS is fragmented, not complete because only government-run facilities report and not private health facilities. Also, some countries’ HIS are slow in gathering and consolidating the information and do not provide timely warning, nor can inform decisions.

Most countries’ HIS also do not “talk” with other countries' HIS to share information. Consequently, the WHO does not have a complete picture of the world’s health at any given time. This is important in the case of a pandemic, that is, an epidemic that affects several countries. WHO needs to have a way to gather data from every country’s HIS and monitor at least the most important health problems that affect several countries, starting with COVID-19, TB and other priority diseases. In this way, WHO will finally be able to monitor and compare what programs do work and work with countries to make effective public health program management decisions.

The HIS also helps countries have the evidence to transparently and responsibly inform the population of the current risks in a timely and regular manner. Information also helps reinforce the messages of all preventive programs such as overall hygiene, hand washing, nutrition, vaccination, etc. Early, regular and clear information builds trust in the country’s public health institutions and prevents the many negative consequences of fear, panic and stigma.

2. Prevention is the second pillar. Public health programs include a number of activities to prevent disease, detect it as early as possible to treat it and prevent complications and its spread, and rehabilitate the patient to his or her life. The specific preventive activities of a public health program will depend on the specific disease or health problem to be prevented and/or controlled. For example, an antenatal program prevents and detects a number of pregnancy related problems and diseases. Antenatal care program activities differ from the activities of a vaccination program to prevent polio, or a lung cancer prevention program which includes education against smoking or to quit smoking, or and a colon cancer early detection program that includes occult blood stool testing and colonoscopies. Effective public health programs increase a country’s life expectancy rate, and the survival of each patient because timely treatment prevents complications. In the case of COVID-19, hand washing, and social distancing along with timely testing prevents the spread of the infection to vulnerable populations and contacts. Timely testing allows timely treatment and also prevents complications. An effective COVID-19 prevention and control program will eventually include vaccination when that is developed. At this time, we need all the information we can have from country outbreaks that have gone through longer than others, such as China and Italy, to find out the most effective prevention and control strategy.

3. System Strengthening is the third and essential pillar of an epidemic control strategy. An epidemic means more cases than usual or normal. The larger number of cases puts a strain on most health systems which are already working at full or almost full capacity. Without any reserve capacity, a larger than expected number of cases will overwhelm the health system and people will suffer and die. That is what happened during the Ebola epidemic. Not only Ebola patients died, but people with other treatable conditions such as malaria or victims of traffic accidents. These patients died because the health system did not have the capacity to treat them. The missing capacity needed to be created and hospitals were eventually built to treat the large number of Ebola cases. The same is believed to have happened in Wuhan where a new hospital was built to isolate and treat the large number of COVID-19 cases. Several states in the US are increasing hospital beds and buying respirators to expand their capacity to respond to COVID-19 cases, as well.

What is a health system and what needs to be strengthened to control an epidemic? A health system is the way a country organizes how healthcare is delivered. Health system organization can be by design or by default and there are examples of everything in between; by design like in the UK and Canada that have national health systems, or by default, like in the US where each private provider organizes themselves in their own proprietary and branded way. Neither is intrinsically better or worse as long as they fulfill the goal of an appropriately funded health system, which is to ensure every citizen has access to quality affordable healthcare in a timely manner. An appropriately funded health system mainly includes funding of three main types of resources in adequate quantities according to population needs: healthcare providers, health facilities and health supplies and equipment. Efficient distribution of these three resources is an essential task of the job of public health professionals to avoid inefficient duplication in some parts of the country while others are lacking. Let's see each of these resources:

Healthcare providers are the ones that deliver care to patients, report to the HIS and implement the public health programs I described above. They need to be trained and prepared to diagnose and treat the most common health problems. They also need regular refresher training and preparation drills to rehearse and be ready to detect and respond to an epidemic.

Health facilities need to be organized and managed to implement procedures so healthcare providers efficiently work as efficient teams and can deliver quality health care. Hospital admission procedures need to flow smoothly and efficiently, labs need to handle samples with minimum backlog, health providers need to get lab reports and other test reports in a timely manner, etc. All these procedures are no rocket science now. There are proven standard procedures for most health services that address most conditions. Facilities need to be managed so procedures are followed by trained healthcare providers and quality care is delivered to every patient every time everywhere.

Finally, the third resource is medicines, protective equipment, oxygen and other supplies and technology. These resources need to be distributed and maintained properly and be ready to be used when and where needed. Remember that some healthcare workers that treated Ebola patients died due to the lack of personal protective equipment. There are standard treatment protocols for most conditions that need to met for every patient and the required medicines, supplies and equipment need to be available. Public health professionals know what is necessary. WHO has standard essential lists of all these. As I said, what resources are needed is no rocket science for most known diseases. COVID-19 is a new disease but we have enough knowledge about respiratory infections to know what to do.

These three resources need to be planned, managed and deployed efficiently by efficient public health professionals so the health system does not waste any of these resources. Public health professionals also need to build a certain degree of reserve capacity to ensure the health system can respond to the current COVID-19 epidemic, other concurrent conditions and then fold back and be ready to deploy for the next epidemic in the future.

When is it a good time to strengthen IPS? Before an epidemic starts is the ideal time, but it is never too late. Investing in being prepared saves lives. However, if your country has not done so yet, start now. “Now is always a good time” is my favorite public health mantra. Now is the time for countries to strengthen their HIS. Now is the time for countries to assess and improve their public health programs to prevent and detect most prevalent and serious conditions, not just COVID-19. You cannot afford to have tunnel vision and ignore all the other infectious and non-infectious conditions that affect and kill millions of people. Doing so will cost lives. All patients, including COVID-19 patients will benefit from improved IPS. 

Now is the time to invest in and strengthen your country’s health system, build reserve capacity to respond to the COVD-19 and other epidemics that are ongoing (HIV, TB, etc). If there is one lesson the world needs to learn from COVID-19 is that health is not a commodity that only those that can afford it can get it. Health is a human right and governments need to lead, coordinate and work with public and private stakeholders to ensure that all available resources are used to fulfill the right to health of every citizen. That is what public health professionals are trained to do. It is not part of a liberal political agenda or any kind of agenda. It is the right thing to do. It is science. Governments need to work with the WHO and other governments to improve their “IPS score” because public health like diseases knows no borders. We are all in this together.