Strategies for epidemiological surveillance of COVID-19 infection



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## Strategies for epidemiological surveillance of COVID-19 infection Opinion article by María Luisa Rebagliato Ruso, lecturer in Preventive Medicine and Public Health, Predepartmental Unit of Medicine, Universitat Jaume I

05/05/2020 |
SCP

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The information we currently have on the number of cases infected in our country by COVID-19 has the great limitation that it only collects data on cases confirmed microbiologically by laboratory tests. The evolution of the epidemic and the limited capacity to carry out diagnostic tests by PCR, have meant that the tests for the detection of COVID-19 infection have been restricted mainly to patients with serious conditions, to symptomatic health personnel, or other personnel considered essential. This strategy, although understandable due to logistical limitations, has the great disadvantage of not including asymptomatic, mild, moderate or even severe cases that have not had access to diagnostic testing, all of which could represent, according to WHO estimates,1 more than 80% of those affected.  Having information on the real dimension of the COVID-19 infection in Spain, it is essential to be able to progressively reverse the current containment measures, as well as to plan future public health measures related to the control of COVID-19.2

The European Centre for Disease Prevention and Control (ECDC) and the World Health Organization (WHO) recommend the diagnosis of COVID-19 based on the detection of viral genetic material (RNA) using PCR techniques, in respiratory samples from patients with compatible symptoms.  However, the performance of these tests requires qualified personnel, laboratory facilities and specific reagents, and it also usually takes several hours to provide results. Currently, infrastructure limitations and supply shortages in the face of growing demand for COVID-19 diagnostics worldwide have prompted the development of rapid diagnostic tests for the detection of antigens or antibodies to the virus.3 The use of these rapid tests, in combination with PCR tests where indicated, has the potential to increase the diagnostic capacity of the health system, thereby facilitating decisions on patients with symptoms of acute respiratory infection; detecting mild or asymptomatic cases that could further spread the virus; testing health workers to guide decisions on their protection, isolation and return to work; and monitoring the evolution of the COVID-19 infection at the community level.

The sero-epidemiological survey at the population level that the Ministry of Health is currently planning would be along these lines, since its purpose is to estimate, from a representative sample of the population, the frequency of current or past infection by COVID-19 in Spain. It is planned to include all members of the selected households in the study, and subsequent follow-up visits would be made to maintain surveillance. Rapid antibody tests are planned, as well as PCR tests in those cases in which they are indicated in order to know their infectivity, and thus adopt the pertinent control measures. This information will make it possible to estimate the prevalence of COVID-19 infection and the immunological status of the Spanish population, thus assessing its susceptibility to the possible reactivation of the epidemic after the reduction of control measures and social distancing, as well as to a possible reintroduction of the virus in a second epidemic wave.2

But in addition to sero-epidemiological surveys, other basic public health surveillance strategies must be considered, which are crucial for the continued containment of the epidemic, not only in the initial phases of containment, but also in the current phase of mitigation and once community transmission begins to decline. One of these strategies is the contact study, which aims to rapidly identify new cases arising from transmission from already identified cases, in order to reduce transmission. This is achieved by rapidly identifying contacts of a case of COVID-19 (from 2 days before the onset of symptoms to 14 days after), conducting laboratory tests on contacts (where possible), especially if they are symptomatic, and providing asymptomatic contacts with information on quarantine, hand hygiene measures and respiratory etiquette, as well as advice on what to do if they develop symptoms.

Evidence related to the current pandemic shows the importance of the contact study. For example, Singapore and several provinces in China have been able to limit the size of the outbreak through widespread testing, contact tracing and quarantine. The contact survey was very successful in identifying many new cases, often asymptomatic or before the onset of symptoms, thus reducing the likelihood of transmission. However, it is true that contact tracing can be resource intensive, and if resources are limited, or the number of cases exceeds the capacity for such tracing, at least the contacts with the highest exposure in each case (closest contacts) and those working in health services or with vulnerable populations should be traced, followed by as many contacts with lower levels of exposure as possible. Where resources permit, contact tracing should still be considered in areas with widespread transmission, along with measures of social distancing.4,5

It would therefore be essential to increase the number of health professionals working at care level and in public health, and to provide them with the necessary means to be able to tackle this crisis - as they are doing admirably - but in conditions that are appropriate and safe for their physical and mental health. And let us not forget, when the curve drops, the need to defend a public health system that is universal, strong, well managed and supported by the community.

**María Luisa Rebagliato Ruso, lecturer in Preventive Medicine and Public Health, Predepartmental Unit of Medicine, Universitat Jaume I.**

**References**

1. WHO. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) [Internet]. 2020: [https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19- final-report.pdf](https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-%20final-report.pdf)
2. Instituto de Salud Carlos III. Propuesta de diseño para llevar a cabo la encuesta sero-epidemiológica de la infección por SARS-COV-2 en España. [Internet]. 2020. <http://cadenaser00.epimg.net/descargables/2020/04/06/9e8cf1112ff914621956e1b519130636.pdf>
3. European Centre for Disease Prevention and Control. An overview of the rapid test situation for COVID-19 diagnosis in the EU/EEA. [Internet]. 2020. <https://www.ecdc.europa.eu/en/publications-data/overview-rapid-test-situation-covid-19-diagnosis-eueea>
4. European Centre for Disease Prevention and Control. Rapid risk assessment: Coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK – seventh update. [Internet]. 2020. <https://www.ecdc.europa.eu/en/publications-data/rapid-risk-assessment-coronavirus-disease-2019-covid-19-pandemic>
5. European Centre for Disease Prevention and Control. Contact tracing: Public health management of persons, including healthcare workers, having had contact with COVID-19 cases in the European Union. [Internet]. 2020. <https://www.ecdc.europa.eu/en/publications-data/public-health-management-persons-including-health-care-workers-having-had-contact>

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