TECHNICAL
NOTES
Webinar series
Innovative Primary
Health Care Models
in Colombia
6
Sixth Webinar
Innovations in the prevention and
control of communicable diseases
from Primary Care
Tuesday, September 27, 2022
Document prepared by Reviewed by
Janet Bonilla Torres Luis Gabriel Bernal Pulido
Oscar Alberto Bernal Acevedo
Manuela Villar Uribe
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Innovations in the prevention and control
of communicable diseases from Primary Care
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Content*
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Key Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Context Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
The New Surveillance in Public Health for Communicable Diseases
Lessons from the Pandemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Main Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Innovations in Immunoprevention, Diagnosis, and Treatment
of Infectious Diseases from PHC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Implementation of an Intervention Strategy to Improve Access
to Care for Chagas Disease in Colombia . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Implementation of an Intervention Strategy to Improve Access to Care
for Chagas Disease. The Experience of the Department of Boyacá . . . . . . . . . . . 26
Challenges of the Expanded Program of Immunization -PAI- in Colombia . . . . . . 30
Discussion Panel
Innovations in the Prevention and Control for
Communicable Diseases in Primary Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
* This document was translated by Ethical Method Language Solutions
Introduction
The Primary Health Care Performance Initiative - PHCPI, has been working for
several years with different countries around the world in the measurement of
Primary Health Care (APS, by its initials in Spanish) performance. In the case
of Colombia, PHCPI has been building with the Ministry of Health and Social
Protection of Colombia the profile of the country’s vital signs in PHC.
In this context, PHCPI wants to create a national Community of Practice that
allows to learn and document lessons learned about the innovative models of
Primary Health Care developed in Colombia.
The webinar series Innovative Primary Health Care Models in Colombia seeks
to promote discussion on this topic. This document reviews the sixth webinar of
the series: Innovations in the prevention and control of Communicable Diseases
in Primary Care, held on September 27, 2022.
Special thanks to the speakers of the sixth webinar, who with their experience
and knowledge initiated this dialogue that we hope will enrich the reflection
and the work of Primary Health Care in Colombia. We would also like to thank
the team of leaders and organizers of the webinars and the community of
practitioners: Luis Gabriel Bernal, Oscar Bernal, Janet Bonilla, Yulieth Rodríguez,
and Juan Carlos Jiménez.
Manuela Villa Uribe
Health Specialist, World Bank
Key Messages
Innovations in the Prevention
and Control of Communicable
Diseases in Primary Care
“The International Health Regulations are a legally binding and obligatory
document for all countries. It was adopted at the 58th Assembly of the United
Nations and updated after the COVID 19 pandemic. The regulation seeks to
ensure that there is capacity to prevent the spread of communicable diseases
on the planet.” Martha Ospina
“Making available to the community the technologies and human resources
needed to solve problems where they occur is the true philosophy of Primary
Health Care. A health reform must take into account that tests must be where
they are needed and must be done by those who are close to the people. For
example, it is outlandish to think that a glycosylated hemoglobin is level 2 and
that it cannot be at the health posts. So, where are the diabetics?” Martha Ospina
“Point-of-care testing and molecular testing are innovations at the first level
that generate a timely diagnosis. Failure to have a correct early diagnosis can
lead to inadequate treatment or a change in treatment and further costs in the
future.” Carlos Arturo Álvarez
“Rapid tests are a very useful element, but they have to be modified at the rate
at which microorganisms are modified. This is why it is important to maintain
active surveillance so that the performance of rapid tests remains effective.”
Carlos Arturo Álvarez
“Ideally, early diagnosis should be carried out in primary care. It is important
to prioritize tests for multiple diagnoses that allow the detection of different
microorganisms, whether they are respiratory, or microorganisms that cause
diarrheal disease, diseases of the central nervous system, or cause other clinical
conditions such as sexually transmitted diseases. In the case of Colombia, out
of 180,000 people living with HIV, only 130,000 know their diagnosis. Rapid and
point-of-care testing is needed.” Carlos Arturo Álvarez
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“Chagas disease is a neglected and silent pathology. It presents
multidimensional barriers that hinder its care; these include structural, clinical,
systemic, and psychosocial obstacles. Hence, surveillance and treatment
models should be adapted to the different circumstances and contexts,
considering that they should be within the reach of patients.” Andrea Marchiol
“Chagas disease needs a model of care: less than 10% of people have been
diagnosed and less than 1% have been treated.” Andrea Marchiol
“In the Boyacá experience, developed in conjunction with DNDi, fundamental
factors have been identified to reduce barriers to diagnosis and treatment. The
first has to do with informing the community. The population must be aware
of the problems related to Chagas disease and what they are really facing. The
second has to do with the fact that all medical personnel in endemic areas must
have Chagas disease on their agenda. They must know what they are talking
about.” Manuel Medina
“In Chagas disease, it was previously considered that treatment could
be formulated from the level of specialization, that is, by the decision of the
internal medicine specialist. One of the issues addressed by this training is that
treatment and follow-up can begin at the first level. In Boyacá, the diagnosis
of Chagas disease increased 220% and the number of positive cases detected
increased by 1,100%.” Manuel Medina
“The worrying decline in immunization coverage for some of the most
common communicable diseases puts the most vulnerable population groups at
greater risk.” Dr. Luis Gabriel Bernal
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After drinking water, what has had the greatest impact on public health is vaccines
By 2031 Colombia must have vaccination coverage of more than 95%
“Looking at the data for the last two years, polio, which has not existed since 1991, nor of
coverage began to fall in the wake of the vaccine-derived polio.
pandemic. By August 2022, BCG coverage was
Since 2014, HPV vaccination figures have not
at 57%, DPT at 58%, pentavalent and MMR at
improved, and worsened when the pandemic
59%, measles, rubella, and mumps at 57%, and
hit. For the two doses, which start at age nine,
booster at 53%. In other words, a few points
only 32% have been vaccinated for the first
below the target of 66%.
dose and 9% for the second.
In July 2022, only one-third of pregnant
This year, the first dose is at 10% and the
women who should have received the
second at 3%.
pertussis vaccine had it.
It is necessary to strengthen communication
For the elimination of measles and rubella,
with clear messages addressed to the
76% has been achieved. There are 7.5 million
community, making them aware of the risks.
children, 5.7 million of whom have already
been vaccinated. Communication must engage families by
giving them the certainty and assurance
All children in Colombia receive three doses of
that vaccines are efficient, effective, and
polio in the first year, this year the fourth dose
lifesaving.”
was included. The idea is that there will be
only one dose of oral polio at five years of age José Alejandro Mojica
and that by 2026 there will be no cases of wild
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Presentation
Innovations in the Prevention
and Control of Communicable
Diseases in Primary Care
Increasing early diagnosis and implementing
appropriate education and communication
strategies are key to the prevention of
communicable diseases such as Chagas
disease, HIV, or influenza
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The Colombian and Argentinean speakers of the webinar: Innovations in the
Prevention and Control of Communicable Diseases in Primary Care, agree on the
urgency of improving early diagnosis with rapid tests, molecular technology,
routine testing, patient search, and in general, elimination of social and clinical
barriers against these diseases. The implementation of new community-
based public health surveillance strategies, as well as increased access to
technologies for prevention, diagnosis, and treatment, contribute to modifying
the natural course of the most common and prevalent communicable diseases.
The panelists stated.
One of the main challenges in the management of Chagas disease, HIV, and
other communicable diseases is the lack of knowledge of the diagnosis on the
part of those affected and the barriers to the management and care of these
conditions. In the case of Chagas disease, according to the speakers, a model of
care is needed, given that less than 10% of people have been diagnosed and less
than 1% have been treated.
The work developed in Chagas by DNDi in several countries of the region,
including Colombia, shows very positive results. In the pilot of the model of
care performed in Soata (Boyacá), the diagnosis of positive cases increased
by 1100% and the timely initiation of treatment by 63%. In the case of HIV in
Colombia, more than 30% of people affected have not been diagnosed.
The webinar also provided an insight into Colombia’s vaccination challenges
in view of the worrying decline in immunization coverage for some of the most
common communicable diseases, which puts the most vulnerable population
groups at greater risk. In this regard, the speakers pointed out, it is necessary
to strengthen communication with clear messages aimed at the community,
making the risks known. It is necessary for the population to identify that, after
drinking water, the thing that has had the greatest impact on public health is
vaccines. Communication must engage families by giving them the certainty
and assurance that vaccines are efficient, effective, and lifesaving.
Watch video in Spanish
Watch video in English
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Context Interventions
The New Surveillance
in Public Health for
Communicable Diseases.
Lessons from the Pandemic
Martha Lucía Ospina
General director of the Insituto Nacional de Salud de Colombia - INS
(National Health Institute of Colombia)
Physician. PhD candidate in public policy modeling.
Specialist in public health management. Master in epidemiology.
Master in health economics and field epidemiologist.
With more than 25 years of experience in the health sector.
Former Director of the Cuenta de Alto Costo de Colombia (High Cost Account of Colombia), Director of Epidemiology of the
Ministerio de Salud y Protección Social (Ministry of Health and Social Protection), and Vice Minister of Health of Colombia.
Has worked as a university professor for more than 15 years.
Updating the International Health
Regulations: Epidemiology highlights the
importance of transmission chains across
the globe
Dr. Martha Lucia Ospina began her presentation with a historical account of the
importance and significance of the International Health Regulations, which are
a central element in addressing public health in the context of Communicable
Diseases. Before the pandemic, says Dr. Ospina, this regulation seemed
irrelevant, but it began to gain increasing visibility.
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Since the IV World Health Assembly of the United Nations in 1951, a
document was already in circulation that sought to bring countries into
agreement to carry out actions for the control of some specific communicable
diseases, in particular at ports of entry and exit for international trade. In
1969, these regulations were updated to define how to combat six diseases.
The United Nations member countries are responsible for ensuring that these
conditions are recognized throughout the world and are quarantinable, in order
to prevent their spread from one territory to another, explains Dr. Martha Lucia.
New revisions were made in 1973 and 1981. The regulation defined a group of
three diseases.
Since 1995, with an unstoppable globalization, abundant commercial
exchange and a constant flow of travelers -mainly using air transport-,
epidemiology has provided evidence of the importance of transmission
chains throughout the planet. In 2005, a complete and definitive version of the
regulations was drawn up which is still in force, but after the COVID 19 pandemic
it has been amended, says Dr. Ospina. The regulations were adopted at the 58th
Assembly of the United Nations. It seeks to ensure that there are capacities
to prevent the spread of communicable diseases on the planet. It is a legally
binding and mandatory document for all countries.
Dr. Ospina points out that this regulation has a national scope, in that it
must be applied within the countries. She points out that, at a given moment,
all countries, departments, and municipalities turn out to be weak. For this
reason, it is necessary to deploy basic control and prevention capabilities to the
maximum.
The five capabilities established in the Regulations
The International Health Regulations establish five capacities. Countries,
departments, or municipalities must have the powers indicated in the
regulations, explains Dr. Ospina in her presentation.
1. Monitor and identify something abnormal: abnormal refers to
epidemiological behavior that is not what it used to be. It is also an
emerging event that is arriving or has never been seen before.
2. Diagnose: it consists of identifying the event, understanding what it is
and what its characteristics are.
3. Respond and prevent the spread: in addition to recognizing the event, it is
necessary to know what to do, according to its nature, seeking to prevent
or mitigate the spread.
4. Collect, organize, analyze, interpret, and disclose information: so that
those who must have an impact on prevention or mitigation have a
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thorough understanding of the situation and its implications and can act
in accordance with their functions.
5. Communicate: information about what is happening must circulate and
reach different points.
Dr. Martha Ospina points out that the regulation has been socialized in
multiple national and international workshops and conferences. The COVID 19
pandemic led to an update. In it, the lessons learned by high, middle, and low
income countries that were very affected have been included.
Update of the International Health Regulations
after COVID 19
Dr. Ospina explains how each of the capabilities have had post-pandemic
adjustments and refinements.
1. Monitor and identify anything abnormal. This capability has the following
updates:
a. High-complexity healthcare providers survey: These institutions have
a natural ability to identify emerging events that were previously
wasted, says Dr. Ospina. There is evidence of COVID 19 cases that
occurred prior to December 2019 outside of China. If the Intensive
Care Units had done the respective isolations of the virus that
the patients had, they would have been able to identify the agent
in a timely manner. The diagnostic capacity of high complexity
healthcare providers is the first line of defense for a country to
become aware of an event, before it has an overflow of cases. When,
from surveillance, the deviation of a behavior was identified, it was
because there was an excess of cases, explains Dr. Martha. Today
we know that it is important for any patient in an Intensive Care Unit
to have a diagnosis. There cannot be patients without a diagnosis.
That is why isolations are important.
b. Laboratory-based surveillance reengineering: Surveillance by
laboratories has traditionally been passive, explains Dr. Martha
Lucia. Departmental public health laboratories used to wait for
samples to arrive from the territories. Now, the laboratories must
have two systems engineers who handle data and not paper
records. It is powerful data that has all the clinical information. But,
in addition, there must be those who make probabilistic samples
in the national territory. The laboratory is in charge of ensuring that
representative samples arrive to give an account of how the possible
events are behaving and to give timely warning to surveillance.
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c. Human epidemiological surveillance based on animal surveillance:
This is an important lesson for Colombia, Dr. Ospina points out.
There is no national animal authority in this country. The ICA
(Agricultural Colombian Institute) is the national authority for
production animals and the Ministry of Environment has an area
for wild animals; there is a lack for an institution for pets. Routine
animal surveillance gives some very early alerts, which allow for an
intervention in the animal world before the pathologies jump to the
human world. This surveillance must be integrated: pets, production
animals, and wild animals. In this case, it is not about animal
welfare, it is about integrating the three animal foci in order to carry
out human surveillance.
d. Expansion of the type of notifiers: Today, any person is a civil notifier.
It can be a geneticist in a laboratory or a physician in a private
practice. In the case of Colombia, Dr. Ospina points out, it is enough
to enter the website of the National Institute of Health and notify
an alert. This alert is collected and confirmed. Patient associations,
community leaders, parents, school principals, or teachers, anyone
can do it. In this way, a large base of rumors, messages, or news is
gathered, which makes it possible to expand the notification base.
Everything follows a confirmation path. The world is no longer the
laboratory notification, it has changed. The large volume of data
replaces the lack of precision that the laboratory may have, says Dr.
Ospina.
2. Diagnose. This capability has the following updates:
a. Replacement of old diagnostic techniques by molecular techniques,
which are here to stay. The COVID 19 pandemic transformed the way
of diagnosing, with a significant increase in PCR tests.
b. Expansion of the molecular laboratory network with a public-private
strategy. Dr. Martha Ospina points out that, in Colombia, each
departmental laboratory is being asked to have three in public-
private networks, ready for when an emergency arises. Public-private
networks are needed with laboratories that deal with three types of
threats: enterohemorrhagic, exanthematic and respiratory. Alliances
and networks must be alive and up to date so that, in the event of
a new event, all the rings are activated, and diagnostic capacity
continues to grow at the speed required.
c. Metagenomics: this change leads to overcoming the practice of
making a blind diagnosis. Metagenomics makes it possible to
extract the nucleic acids in the sample, reconstruct a genome, and
send the information to a worldwide database to determine what it is
and identify it.
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3. Respond and prevent the spread. This capability has the following
updates:
a. Expanding the human resources of field and frontline epidemiologists:
Dr. Ospina points out that there are few field epidemiologists in the
country. We have, she says, 140 field epidemiologists plus a new
cohort of 19. The country needs at least 1,400. It is a basis that has
to be increased and it is necessary to ensure their recruitment and
permanence. Territorial entities must modify the hiring structure of
these professionals and it is necessary to ensure their permanence.
In a system in which the electoral dynamics define the hiring
process, there is a risk of losing human resources. You cannot
imagine, says Dr. Ospina, what it was like to deal with the pandemic
in March 2020 with new professionals who had been hired in
January 2020. Those who were trained in the battle against measles
had already left.
b. Risk Analysis Rooms and territorial Emergency Operation Centers: It
is new that there are Risk Analysis Rooms in all territorial entities.
Today there are more than 18 permanent rooms. These are
epidemiological analysis rooms. These rooms examine the data and
report alerts. The Emergency Operations Centers must be able to
collect rumors, gather information from everywhere, and thus build
their own conclusions in an early manner.
c. Expand and stabilize the human resources in the Health Departments
in order to have immediate response teams on 24/7 shifts. The
National Institute of Health arrives within eight hours to any point
in the country, but this does not replace territorial responsibility. Dr.
Ospina stresses that it is a matter of the Primary Health Care field.
Making available to the community the technologies and human
resources necessary to solve problems where they occur is the true
philosophy of Primary Health Care.
4. Collect, organize, analyze, interpret, and disclose information. This
capability has the following updates:
a. Boards for public use: The publication of bulletins for
epidemiologists continues, says Dr. Ospina, but now there are also
news pages, and it is taken into account that users want quick
readings. The novelty is in the presentation of public use boards in
which there is also graphic information that is easier to understand.
b. Open Data - Downloadable Datasets: In addition to the bulletins, we
offer the State’s open data, explains Dr. Ospina. These datasets
(downloadable datasets) are the best way to combine the
contributions of different experts. These Datasets are also a record
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of history, they remain published permanently. They are a snapshot
of what was happening at a specific time.
5. Communicate. This capability has the following updates:
Addressing mass media and social networks: Dr. Ospina emphasizes how
during the COVID 19 pandemic, everyone experienced an outpouring of
communications from experts and influencers who, with mass messages,
created an “infodemic” around the world through social networks. Now,
this is the main focus of communication, and messages must be classified
according to their origin, relevance, interference, and even the damage they
can cause. Careful management of this information helps to ensure that
the population is aligned with the actions that we know can be strategic,
says the director of the National Institute of Health. From the orientation
given to the messages, it is possible to obtain the collaboration of the
citizenship with behaviors that help to face communicable diseases. It is
known that there is no success without the help and participation of the
community.
Watch video in Spanish
Watch video in English
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Main Interventions
Innovations in
Immunoprevention,
Diagnosis, and Treatment of
Communicable Diseases from
PHC
Carlos Arturo Álvarez Moreno
Vice President of Innovation and Scientific Development, Colsanitas Clinic
Infectious Diseases Physician. Master in HIV and clinical epidemiology.
Doctor in Biological Sciences. Professor of Medicine at the Universidad Nacional de Colombia (National University of
Colombia). Member of the National Academy of Medicine. Honorary Fellow of the American Society of Infectious Diseases.
Coordinator of the COVID 19 study in Colombia for WHO.
Point-of-care testing and molecular testing
are innovations that generate a timely
diagnosis at the first level of care
Dr. Carlos Álvarez focuses his presentation on the subject of diagnosis and
takes as reference scientific publications that offer keys for the strategic
approach to the diagnosis and immunoprevention of communicable diseases.
He begins by pointing out that there is a change in the approach to disease
diagnosis. There are traditional methods that have helped the development
of mankind, but at this time, a timely diagnosis built with technologies that
guarantee speed and precision and replace traditional methods is a priority.
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The value of point-of-care testing
Dr. Álvarez explains what appears in one of the publications of the European
Center for Disease Prevention and Control, ECDC, on “point-of-care testing.”
These tests are designed so that patients do not have to go from one place
to another or jump from a first level hospital to a second or third level hospital
to have a diagnosis, but that the tests can be done in offices and first level
hospitals.
Dr. Álvarez shows the results of a survey conducted in European Union
countries by the ECDC that shows how they have replaced classic tests with
point-of-care testing (POCT). Tests for communicable diseases or sexually
transmitted infections are some examples of this practice in countries of the
old continent, says Dr. Carlos Álvarez. Point-of-care testing prevents the patient
from returning to the office. These tests are used to diagnose respiratory
diseases, dengue or cholera. Although Malaria is not frequent in Europe, it is also
diagnosed in this way, says Dr. Álvarez.
In the survey, Dr. Carlos Arturo said they ask what they use the tests for. The
results indicate that they are used for surveillance systems, national reporting
of communicable diseases, observing outbreaks and infection control problems,
for diagnostic purposes and others related to resistance monitoring. Dr. Álvarez
points out that these tests help to have diagnoses in less than an hour, even in
ten minutes or less, which facilitates timely diagnosis. He adds that one of the
public health problems, in the case of communicable diseases, is antimicrobial
resistance. One of the difficulties in prescribing antimicrobials, says Dr. Álvarez,
is precisely not having a diagnosis with good certainty. Timely diagnosis can
facilitate the reduced use of antimicrobials.
Dr. Álvarez presents data from the Journal of Clinical Microbiology on testing
with different techniques at the first levels of care that are used for the diagnosis
of streptococcus, mononucleosis, and helicobacter. These are lateral flow
methods and molecular methods that can facilitate timely diagnosis. The latter
were used with COVID 19 and for detection of the infection caused by Sars Cov 2.
Dr. Álvarez goes on to show data from a Taylor and Francis Group molecular
diagnostics expert review that refers to the inclusion of antigen testing for
COVID 19 as one of the cases that definitely shorten times. Other technologies
such as PCR or RT-PCR, which were unthinkable two decades ago, can now be
used at the point of care to facilitate timely diagnosis.
Dr. Álvarez details the usual pathway of a traditional versus point-of-care
test based on information from an article in the BioChip Journal. The traditional
test requires, says Dr. Carlos Arturo, that after the consultation with the primary
care physician who requests a laboratory test and the collection of the sample,
the patient must wait for the sample to be transported to a higher level of care
laboratory to make a molecular diagnosis or a classic culture diagnosis, and
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it is not that I am suggesting that cultures should not be done, they should be
maintained in some cases, Dr. Álvarez specifies. Testing at the point-of-care
shortens times, reaching a ratio of less than one hour versus 24 hours for
traditional testing in European times. In our territory, the time gap may be even
greater, says Dr. Álvarez.
Traditional culture-based vs. molecular methods in
diagnostic tests
The comparison between traditional culture methods and molecular methods
involves different aspects, explains Dr. Álvarez:
• Response time: The traditional method may take days; the molecular,
minutes or hours.
• Sensitivity: Low average for the traditional method and high for the
molecular ones.
• Cost: Low for traditional, can be relatively expensive for molecular
methods.
• Expertise: High for traditional methods and medium for molecular
methods. This may be debatable, says Dr. Álvarez.
• Number of pathogens that can be identified: One with traditional; several
in parallel with molecular.
• Accuracy: Can be subjective in the traditional method and high in the
molecular method.
Failure to have a correct early diagnosis can lead to
inadequate treatment or change of treatment and future
expenses.
The cost factor, Dr. Álvarez notes, turns out to be very relative. Many times, not
having a correct early diagnosis can lead to inadequate treatment or to changing
the treatment and, in the future, more expenses.
Dr. Álvarez brings to the presentation an example of the management of
pneumonia, which may occur differently if the empirical or the directed method
is used in its diagnosis. In the first case, it is diagnosed and treated according to
the recommendations of the clinical practice guidelines, the patient receives a
combined therapy, at least two antibiotics are prescribed, an antiviral is started,
another antibiotic is added if there are risk factors, and there is little possibility
of identifying microorganisms by classical methods. If done the other way,
Dr. Alvarez points out, there is a rapid de-escalation of antibiotics, a targeted
management of viral infections, a high possibility of identifying microorganisms,
as well as less antibiotic pressure and, therefore, less antimicrobial resistance.
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Molecular testing, a paradigm shift in different scenarios
The advantages of molecular testing, Dr. Carlos Arturo explains, can also be
seen in other scenarios such as tuberculosis. Although, for many years we
have encouraged, promoted, and taught the use of culture tests despite the
sensitivity that we know these tests have. But today the recommendation from
the World Health Organization is to move towards the use of molecular tests
instead of culture tests for the initial diagnosis of this disease. This initiative
may seem an outburst, he says, but it is necessary to start demystifying the
use of rapid molecular tests, not only for reference laboratories or tertiary care
hospitals, but as the INS did in different parts of the territory with Sars Cov 2.
The recommendation in the new WHO guideline notes that these paradigm
shifts also apply to pap smears, which are starting to be performed with rapid
molecular tests for the detection of human papillomavirus. We have a lot of
progress to make in this field, says Dr. Alvarez.
Ideally, early diagnosis should be made in primary care
When Sars Cov 2 is circulating and about 5 or 7 respiratory viruses are still
circulating, it becomes necessary to know the etiologic agents, says Dr. Carlos
Álvarez. This is not only important for epidemiological surveillance, but also
for the clinical management of patients in a health institution. It is ideal for
early diagnosis to be carried out from primary care itself. It is important to
prioritize tests for multiple diagnoses that allow the detection of different
microorganisms, whether they are respiratory, or microorganisms that cause
diarrheal disease, diseases of the central nervous system or cause other clinical
conditions such as sexually transmitted diseases.
At this point, Dr. Álvarez emphasizes the importance of a correct diagnosis
at the first level, as it helps to avoid what has been seen with COVID 19: 3.5%
of patients had coinfection, but 71% of patients received antimicrobials. This
explains the excessive use of antimicrobials at the beginning of the pandemic.
In the case of Sars Cov 2, in addition to molecular testing, antigen testing
improved the timeliness of diagnosis and facilitated access to outpatient
therapies at the first levels of care.
Colombia was a leader in the use of this type of tests and had the possibility
of having the combination of antigen and molecular tests in different parts of
the territory.
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In the case of Colombia, out of 180,000 people living with
HIV, only 130,000 know their diagnosis. Rapid and point-
of-care testing is required
Dr. Álvarez explains that the use of rapid tests in Primary Care also contributes
to the case of sexually transmitted diseases, which include individual or
combined diagnoses for chlamydia, treponema, and others. This facilitates
treatment decisions. In the case of people living with HIV, Dr. Álvarez points
out, only 81% know their diagnosis. A significant percentage remains to reach
the WHO goal of 90 or 95%. In the case of Colombia, out of 180,000 people
living with the disease, only 130,000 know their diagnosis. This gap is present
in different Latin American countries and, specifically, in Colombia, being even
greater than 33%. This may be due to a low supply of rapid tests in places where
people consult, but also because of the early initiation of sexual relations, which
in some cases leads to infection.
Globally, the recommendation is, therefore, to increase diagnosis in order to
decrease transmission. Just as in the case of Sars CoV 2, if diagnosed early,
the possibility of transmission is reduced; the same happens with HIV. If people
know their diagnosis early and start antiretroviral therapies of viral suppression
status, transmission decreases very quickly and this means that the diagnostic
strategy not only achieves a personal benefit but also a global one, explains Dr.
Álvarez, an expert in HIV.
Although strategies based on first level institutions have prevailed in
Colombia, the recommendation is to design tactics based on the community.
Individuals, community leaders, and key groups should contribute to
interventions in homes and similar settings to facilitate diagnosis and, in this
way, reduce transmission.
Molecular tests are not less efficient
just because they are fast
Molecular tests are not less efficient just because they are fast, stresses
Dr. Carlos Álvarez. There are rapid tests that have the same or even higher
performance than classical tests. The important thing is that these tests are
applied and that the appropriate controls and follow-up are carried out.
Rapid tests in primary care and in the community are already being used. For
example, in Canada there is a level of acceptance for these to be distributed in
places such as pharmacies, kiosks, public events, or in rapid testing machines,
among others. In Colombia there is still a limitation and a certain timidity in the
development of these strategies.
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Dr. Álvarez indicates that outbreaks such as those of smallpox make it
necessary to keep in mind that rapid tests are needed in a timely manner in order
to reach an early diagnosis and help avoid the impact of this manifestation of
communicable diseases.
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Implementation of an
Intervention Strategy to
Improve Access to Care for
Chagas Disease in Colombia
Andrea Marchiol
Senior Manager of the Chagas Access Project - DNDi
Physician. Argentina. Coordinator of Doctors without Borders in Bolivia.
Works in the medical and access management of DNDi,
Drugs for Neglected Diseases Initiative.
Chagas disease needs a model of care: Less
than 10% of people have been diagnosed
and less than 1% have been treated
To begin with, Dr. Andrea Marchiol presents an overview of the purposes
and characteristics of DNDi (Drugs for Neglected Diseases Initiative). It is an
international organization whose mandate is to research new therapeutic tools
for neglected diseases. To this end, it has made a selection of these diseases,
explains Dr. Marcholi. Today it has ten in its portfolio.
DNDi was created in 2003 by several public and private institutions. It is
permanently supported by the World Health Organization and Médecins Sans
Frontières. Since its creation, DNDi has launched nine treatments for neglected
diseases. These treatments are adapted to the contexts of those who need
them, seeking ease of use. DNDi works in a networked research process, with
more than 120 institutions around the world. It has more than eighty partners
from public health platforms.
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Dr. Andrea Marchiol explains some of the reasons for the design of a specific
model of care for Chagas disease.
1. It is a neglected disease: Despite some progress in the control of Chagas
disease in Latin America, it is estimated that less than 10% of people
have been diagnosed, and less than 1% have been treated with specific
antiparasitic drugs. In the Colombian epidemiological profile, the figures
are at the same level as in the region.
2. It is a silent disease: Its evolution is stealthy and chronic. This makes
health services take less account of it than other diseases. Finding
patients can be very difficult.
3. Multidimensional barriers hinder their care: Structural, clinical, systemic,
and psychosocial obstacles. Hence, surveillance and treatment models
must be adapted to the different circumstances and contexts, so that
they are within the reach of patients.
Among the multidimensional barriers that hinder care, Dr. Andrea points
out:
• Systemic barriers: There are regulatory impediments to access
medications and diagnostic tests; there are supply problems; lack
of routine testing, which translates into insufficient screening
of patients; low awareness of Chagas disease; communication
problems, and lack of visibility of the disease.
• Structural barriers: These are related to poverty, rurality, migration,
unemployment, and informal employment.
• Clinical barriers: These are reflected in the lack of updated
guidelines, in medications that have safety limitations, in problems
in healing the disease, and in the complexity of achieving
diagnoses.
• Psychosocial barriers: Fear and stigma persist, as well as
normalization and acceptance of Chagas disease.
Model 4 D: Intervention in Colombia for Chagas disease.
In Colombia, DNDi, says Dr. Andrea, began working with partners, stakeholders,
responsible authorities, programs, and territorial entities to create a strategy
to identify and define an area of intervention based on a networking model. A
pilot was proposed to start on a smaller scale and demonstrate the feasibility
of implementation, successes, and lessons learned. It started with a low
investment in the hope that, if the results are successful, the strategy can be
replicated, expanded, and scaled up. This guarantees sustainability from the
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outset since it is implemented within the framework of the country’s own health
system.
The 4D Model consists of four steps, explains Dr. Marcholi:
1. Diagnostic phase, which includes a barrier seminar in which, collectively,
the difficulties that exist in health care for Chagas disease are identified.
2. Design of the model, based on the identification of obstacles, solutions
aimed at eliminating them are proposed; care pathways are designed
with partners and counterparts (health system, ministries, vector control
programs for Chagas disease). A monitoring and evaluation plan is
included, as well as a plan focused on information, education, and
communication aimed at both the health system and the community.
In the case of Colombia, the design of the care pathway is aligned with
the priorities of the Ministry of Health and Social Protection and the
recommendations of the Pan American Health Organization and WHO.
3. Implementation of the care route, which triggers the access plan, the
information, education, and training plan. Work is also being done to
strengthen local capacities to ensure sustainability. These capacities
correspond to different areas: human resources, laboratory network,
and management network. In this step, the training of health personnel,
the strengthening of data recording, surveillance, and the possibility
of having trainers of trainers for the future sustainability of the actions
stand out. In addition, there is the accompaniment and technical support
in the updating of guides, manuals, and guidelines.
4. Impact demonstration, which is based on the analysis of pre- and
post-intervention data and the compilation of lessons learned, in order
to make visible and share experiences. The factors underpinning the
demonstration are total number of patients screened, patients confirmed
per year, days waiting for results, and days waiting to initiate treatment.
On this subject, Dr. Marchiol notes that Dr. Manuel Medina’s presentation
will include data from the department of Boyacá (Colombia), which can be
summarized as an exponential increase in the number of patients screened
and confirmed, and a reduction in the number of days waiting to confirm the
diagnosis and initiate treatment.
Access milestones in Colombia
Dr. Andrea Marchiol closes her presentation by mentioning the stages applied in
Colombia:
• Identification of access barriers.
• Assistance to the National Institute of Health – INS in the design of a
new serological diagnostic algorithm.
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• Implementation of five pilot projects in the most endemic areas of the
country, with a successful impact.
• Replication of the simplified model to be much more effective in terms
of implementation at the primary care level. This is expected to lead
to an expansion and scaling up of the comprehensive care routes. All
this goes hand in hand with the strategy of eliminating not only Chagas
disease, but also hepatitis B, HIV, and syphilis in the maternal and infant
population.
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Implementation of an
Intervention Strategy to
Improve Access to Care for
Chagas Disease.
The Experience of the
Department of Boyacá
Manuel Alfonso Medina Camargo
Coordinator of the Vector-Borne Disease Control Program of the Secretariat of Health of Boyacá.
Veterinary Doctor from UDCA.
Second year student of the Master of Public Health at the Juan N Corpas University.
In Boyacá, the diagnosis of Chagas disease
increased 220% and the number of positive
cases detected increased by 1,100%.
Dr. Manuel Medina’s presentation focuses on the implementation of the model
of care for Chagas disease in the department of Boyacá, Colombia. Dr. Medina
explains how the implementation of the pilot was aimed at reducing barriers
to access and treatment at a collective level that are made at a national level
articulated with individual actions.
Soatá, the pilot implementation site, is an endemic territory.
The municipality of Soatá is located in the north of the department of Boyacá
in the center of the country. It has a high demand for diagnosis of cases in
pregnant women and chronic cases, explains Dr. Medina. It is an endemic
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territory in which the barriers to confirmation and authorization in all procedures
had already been studied. Soatá is a second level regional center that
concentrates eight nearby municipalities. It is a municipality certified under a
home transmission interruption plan. Soatá is part of five municipalities directly
associated with the hospital from the administrative and financial point of view,
and there are three municipalities that are independent.
Following the structure of the model presented by Dr. Andrea Marchiol, Dr.
Manuela Medina explains how it was implemented at the local level.
1. Diagnosis: This was the first step, explains Dr. Medina; an update
workshop was held in 2017. There, the community, the actors of the
health system, the public, and private network of the municipality and
surrounding municipalities were integrated. The workshop sought to
inform and socialize the different aspects of the disease, seeking to
empower people to learn about and face it.
2. Implementation: Dr. Medina points out that the pilot program in Soatá
was designed so that with just one sample taken, the diagnosis could
be made from the outpatient clinic, passing through the laboratory and
the Public Health Office of the municipality of Soatá, which was aware of
each case in order to carry out the treatment in each of the municipalities
where the patients were located.
3. Results of the implementation: After the implementation of the pilot,
it was found that around 2,000 people were diagnosed in a period of
32 months, which meant an increase of 220% in access to diagnosis,
explains Dr. Manuel. The number of positive cases detected increased
by 1,100% over the baseline. In addition, the time from medical order
to diagnosis was reduced by 64% and by 63% between diagnosis and
initiation of treatment.
Dr. Medina emphasizes that these results led to the conclusion that the
comprehensive care route for Chagas disease had positive results, which is
why we proceeded to the stage of scaling up to other municipalities, such as
Moniquirá and Garagoa. In this process, some barriers were identified, such as
the lack of equipment for diagnosis and treatment. In response, DNDi, with the
support of the Department of Boyacá, donated this equipment, strengthening the
installed capacity. In the same way, action was taken to address other barriers
encountered. This ensured the success of the project, says Dr. Medina.
In the Tenza Valley, testing increased by 347%
Following the implementation of the pilot, the diagnostic network and access
to treatment in the department of Boyacá have increased. Dr. Medina specifies
that before 2017 there was only testing capacity in Tunja, the capital of the
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department, and in Bogotá. Today, the network is strengthened in other
municipalities.
Regarding the progress made in the department, Dr. Medina pointed out
the results of the scaling up in the Tenza Valley, where the variable of tests
performed for the general population went from 47 in 2018 to 201 in 2019,
which implied an increase of 347%. For Elisa tests in pregnant women, it went
from 159 in 2018 to 252 in 2019, with an increase of 60% over the baseline.
Despite the limitations during the pandemic, the data suggest a trend towards
strengthening screening in pregnant women and an increase in the general
population, compared to previous periods, says Medina.
Despite the pandemic, access to treatment has been
maintained and improved
In regard to access to treatment, Dr. Medina points out that in both the pilot
and the staging, it is possible to confirm that in the municipalities of Soatá,
Moniquirá, Garagoa, and Cubará, 78, 9, 15, and 89 diagnoses were made in 2020,
respectively, for a total of 191.
In relation to adherence to treatment, Dr. Medina emphasizes that it is not
close to 100%, so it is an aspect to be strengthened, although it exceeds the
national level, which is 1% of the population. However, he also emphasizes
that, despite the limitations during the pandemic, access to treatment was
maintained and improved compared to the two previous years.
Chagas disease with a differential approach: U’wa
indigenous population
Dr. Medina presents a project being developed with the U’wa indigenous
community. Since 2014, more than 4,500 people have been screened. This work
is done in coordination with DNDi and with several organizations, public and
private entities at the national and departmental level, as well as with WHO,
PAHO and the Pedagogical University of Tunja. More than 200 people with
Chagas disease have been identified. For treatment, they have been transferred
to the same site for a period of two months. This has been done with the
support of healthcare providers and insurance companies. This experience, says
Dr. Medina, should be highlighted and imitated in other places.
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Challenges to improve the model and its application.
To close the presentation, Dr. Manuel mentions the major challenges arising
from the implemented model:
1. To have administrative processes that facilitate access and contribute to
the reduction of time.
2. To promote, from general medicine, the initiation of etiological treatment,
follow-up, and pharmacovigilance.
3. To develop new simplified technologies for diagnosis and care from
the first level of care. Dr. Medina takes up what Dr. Álvarez said and
reiterates the need to use rapid tests, for which he points out that there
are already advanced studies.
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Challenges of the Expanded
Program of Immunization
-PAI- in Colombia
José Alejandro Mojica
Subdirection of Communicable Diseases of the Ministerio de Salud y Protección Social of Colombia
(Ministry of Health and Social Protection)
Pediatrician from the Universidad Militar (Military University).
Infectologist from the Universidad Autónoma de México (Autonomous University of Mexico). Specialist in clinical
epidemiology.
He has been linked to the Subred Sur and Clínica del Country in Bogotá.
University professor. Former medical director of Sanofi Pasteur.
By 2031 Colombia should reach a
vaccination coverage of more than 95%.
Dr. José Alejandro Mojica began his presentation by saying that the Ten-Year
Public Health Plan 2022- 2031 establishes that by 2031 the country must have
vaccination coverage of over 95%. Colombia has international commitments
such as the eradication of polio, the elimination of measles, and the control of
other diseases. It has the responsibility to ensure vaccination without barriers
for the entire population of the country, regardless of their origin or migratory
status; people arriving in the country have the same vaccination rights as
Colombians. Based on these major goals, Dr. Mojica presents the current status
of vaccination in Colombia, the plans that are being advanced, the commitments
that exist at the international level, and their challenges.
General strategic actions
Achieving the goals, says Dr. Mojica, requires a set of actions ranging from
the sufficient purchase of biologicals, the introduction of new vaccines in the
scheme, and the analysis of the impact of vaccines already implemented, to
the strengthening of the articulation processes between the areas of public
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health, surveillance and PAI (Expanded Program of Immunization, by its initials in
Spanish), including the strengthening of the logistics operation, monitoring, and
evaluation of indicators, among others.
Currently, Dr. José Mojica explains, Colombia has 21 biologics for 29
diseases and has the immunoglobulins to deal with rabies, diphtheria -which is
now a threat-, and hepatitis.
Vaccination schedule in Colombia
Parents, says Dr. Mojica, are clear about the importance of having their children
vaccinated eight times before the age of five: at birth, 2 months, 4 months, 6
months, 7 months, 1 year, 18 months, and 5 years. In addition, girls receive HPV
vaccines at age 9. Women of childbearing age are vaccinated against diphtheria
and as a result they have not been affected. Pregnant women receive three
vaccines: influenza vaccine since 2005; the vaccine in the 14th week of gestation;
pertussis vaccine in the 26th week. Now they receive the COVID vaccine at week
12. Older adults receive the influenza vaccine at 60 years of age.
Vaccination coverage began to decline in 2020 and in 2021,
it stood at 86%
The country has been above 95% in vaccination coverage. There has been
acceptable coverage for vaccines such as pentavalent, MMR, annual or booster
vaccines. However, there is room for improvement. If you look at the data for
the last two years, says Dr. Mojica, these coverages began to fall as a result of
the pandemic. In 2020 they started to drop and, in 2021, they were at 86%. By
August 2022, BCG coverage was at 57%, DPT at 58%, pentavalent and MMR at
59%, measles, rubella and mumps at 57%, and booster at 53%. That is, a few
points below the target of 66%. At that time, the aspiration was to reach 86%
or 87% coverage by December, says the representative of the Subdirection of
communicable diseases of the Ministry of Health and Social Protection.
There are major challenges in the prevention of pertussis:
only one third of pregnant women had received the vaccine.
In light of these indicators, Dr. Mojica says, there is a big coverage challenge
in Colombia. One example is Tdap (pertussis) in pregnant women, which is the
primary strategy to prevent pertussis in infants by vaccinating pregnant women.
This was implemented around 2012. As of July 2022, coverage was supposed
to be at 57% but was at 39%, meaning that barely a third of pregnant women had
received pertussis vaccination. Dr. Mojica points out that with these indicators,
a great challenge is looming because cases of pertussis and mumps are
occurring in children under five years of age.
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Only four out of ten seniors have received the seasonal
influenza vaccine
In Colombia there are two epidemiological peaks, says Dr. Mojica, one in May-
June and the other in September-December. Of all the viruses circulating,
influenza is the most preventable, as is COVID 19. The vaccination strategy
gives priority to a group of people: children from 6 to 23 months, pregnant
women from the 14th week of pregnancy, people over 60 years of age, people
with risk diagnoses (particularly those with chronic diseases), and health sector
personnel.
In the specific case of children, Dr. José Mojica continues, nine out of ten
have received a dose of influenza. But the second dose, which is important
because it guarantees efficacy, barely reaches half of them. A new dose comes
every year and only 7 out of 10 have received it. On the other hand, coverage
in pregnant women reaches 75%, and only half of the human resources in
the health sector has received the vaccines. Dr. Mojica stresses that in 2021
health personnel were reluctant to get vaccinated. But what is most worrisome,
considering that this is a population more likely to get sick and become
complicated, is that only four out of ten seniors have received the seasonal
influenza vaccine; the same happens with 70% of the population at risk.
If coverage is reviewed by territory, in about half of the country, older adults,
persons at risk and children have not received the second dose of vaccination.
Challenges of COVID 19 vaccination
According to the National Vaccination Plan, Dr. Mojica explains, in Colombia
84% of the population has received at least one dose. 71% have received at
least two doses. The first booster, he says, has been received by 42%, especially
by the elderly; and only 13% have received the second booster. This situation
raises several challenges in the field of vaccination against COVID 19. In the
case of children, 66% have received one dose and 46%, the second, despite the
fact that vaccination has been underway since October 2021 for children aged
three to eleven years, with Sinovac. Of children 12 years and older, only 68% have
received two doses and 26% have received the booster.
When reviewing the situation in the territories, vaccination is concentrated in
the Andean region. The periphery, which is the most difficult area in Colombia,
is in the red. The first booster has been effective in the Andean region and in the
Amazon.
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Challenges and international commitments
Colombia has international commitments in vaccination that are translated into
plans. Dr. Mojica mentions them in detail:
Sustainability plan for the elimination of measles-rubella and RSV, 2021-
2031. The challenge comes because of vaccination gaps, as well as the
geographical proximity, border, and migratory movements with Brazil, which,
since 2017, has had measles outbreaks. For this reason, an additional dose of
measles-rubella is being given in Colombia. This measure has also been taken
in the Americas, where there are thirty million children to be vaccinated. Mexico
has already done so. In Colombia it is an additional dose at five years of age.
Seventy-six percent has been reached. There are 7.5 million children, of which
5.7 million have already been vaccinated.
Polio elimination plan 2019 -2026. It is a major challenge for the country.
Colombia has been certified since 1994. The country is in the process of
phasing out oral polio and seeks to have coverage above 95%. In the last ten
years, coverage has been above 90%. However, surveillance for flaccid paralysis,
which is one of the important indicators, has been partially achieved, explains Dr.
Mojica. He says that 15 days ago an alert was issued by the United States due
to a case of polio in a 20-year-old unvaccinated young man. Dr. Mojica explains
that in Colombia the fourth dose was Included this year. All children in Colombia,
he says, receive three doses of polio in the first year and this year the fourth
dose was included, and the idea is that there will be only one dose of oral polio
at five years of age, and that in 2026 there will be no cases of wild polio, which
has not existed since 1991, nor derived from the vaccine.
Yellow fever elimination plan, 2026. This plan is strategic in a region like
Latin America, where there is now an active outbreak in Brazil, Bolivia, Peru, and
Venezuela. This requires catch-up vaccination of all children and adults up to 59
years of age. Also, migrants and people traveling to areas where the vector is
present.
HPV control plan. It is a distressing situation, says Dr. Mojica. The episode
that took place in the municipality of Carmen de Bolívar (department of Sucre) in
2014 was a milestone. Since that time, the figures have not improved and even
worsened when the pandemic arrived. For the two doses, which start at nine
years of age, only 32% have been vaccinated for the first dose and 9% for the
second. This year, he says, the first dose is 10% and the second dose is 3%.
2030 Hepatitis A and B elimination plan. By 2030, the idea is to eliminate
hepatitis B, says Dr. Mojica. Colombia began universal vaccination in
1994. Today, priority is given to a group of people who are determinant in
seroprevalence: men who have sex with men, transgender women, sex workers,
people who inject drugs, and street dwellers. Vaccination is done in a 0-1 form
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and at 2 months to update and impact this population. In this strategy, we work
with the World Bank.
2030 Meningitis elimination plan. In Colombia, vaccination with PCV10
started in 2012. Then another vaccine, PCV13, was applied at two, four, and
twelve months. We hope that this impact will be seen in the future.
Dr. Mojica also mentions the Tetanus Elimination Plan by 2030.
PAI 2022 - 2024 Challenges
Dr. Mojica presents the projection with which it is hoped to advance towards the
major goals based on specific actions:
• Eradicate polio with all four doses and aim for a fifth dose by 2026.
• Maintain the measles-rubella campaign and in 2023 introduce a measles
booster, not at five years of age but at 18 months.
• Eliminate hepatitis B including other groups. That was initiated in 2021
with the difficulties that the pandemic has entailed.
• Advance in the control of yellow fever.
• Defeat meningitis by switching from PVC10 to PCV13. This goes hand
in hand with the application of an additional dose of haemophilus
influenzae at 18 months.
• Continue the pilot hexavalent plan for premature babies in nine new
centers in Bogota.
• Vaccinate against meningococcus.
Permanent challenges
Dr. José Alejandro Mojica presents the set of objectives and strategies that are
being advanced in terms of vaccination to face the permanent challenges that
the country faces in this area.
• To recover vaccination coverage in the population within the framework
of the COVID 19 pandemic, considering vaccination as an essential
health service.
• Strengthen communication directed to the family regarding access
to vaccination and thus increase the population’s confidence in the
vaccination program, access to vaccines and safety profile.
• Strengthen extra-mural vaccination actions, developing inter-institutional,
house-to-house vaccination tactics and strategies.
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• Integrate vaccination against COVID 19 into the permanent program and
guarantee its application in the 3,000 centers in the country. 2,000 have
already incorporated it.
• Continue the response to the migratory phenomenon.
• Strengthenthe nominal information system Paiweb.
• Implement the fourth dose of polio and PCV13.
• Strengthen the technical capacity of the health sector personnel.
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Discussion Panel
Innovations in the Prevention
and Control of Communicable
Diseases in Primary Care
Martha Lucía Ospina
Director of the National Health Institute of Colombia
Carlos Arturo Álvarez Moreno
Vice President of Innovation and Scientific Development, Colsanitas Clinic
Andrea Marchiol
Senior Manager of the Chagas Access Project - DNDi
Manuel Alfonso Medina Camargo
Coordinator of the Vector-Borne Disease Control Program of the Secretariat of Health of Boyacá
José Alejandro Mojica
Subdirection of Communicable Diseases of the Ministry of Health and Social Protection
Modera: Gabriel Carrasquilla
Physician. Master and PhD in Public Health from Harvard University. Former Secretary of Health of Valle del Cauca,
Director of Health of the FES Foundation, Director of the Research Center of the Santafé Foundation of Bogotá, founder
and director of ASIESALUD, Vice President of the National Academy of Medicine of Colombia, foreign corresponding
member of the Academy of Medicine of Venezuela, member of the Malaria WHO policy advisory committee, emeritus
researcher of Colciencias, advisor of the national health program of Colciencias and of the independent committee
of proposals of Gaby; university professor. He has conducted and directed national and international research and
projects. He has more than 100 publications in national and international journals.
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The panel moderated by Dr. Gabriel Carrasquilla addresses the topics of
reporting strategy, rapid tests, their evolution and access, the need to include
some new vaccines in the country’s Expanded Program of Immunization, and
the importance of education, information, and communication in all health
prevention strategies in both Chagas and vaccination.
A paradigm shift in the reporting strategy
Dr. Gabriel Carrasquilla points out that Primary Health Care is one of the central
aspects of the next country health reform and, along these lines, asks Dr.
Martha Ospina how to implement the reporting strategy she referred to in her
presentation, taking into account that multiple actors such as communities and
social leaders, among others, are expected to participate in this strategy.
Dr. Martha Lucía Ospina, director of the INS (National Institute of Health),
explains that when different sources of information are mentioned in a reporting
strategy, such as those already used in Colombia in various instances (in
emergency operations centers, for example), it is necessary to consider that they
work by drawing on different sources. These sources can contribute to build
paths to the truth, although there are other paths.
It is possible, for example, to use trends in social networks today to find
clues about specific situations. In Colombia, at the National Institute of Health,
says Dr. Ospina, it is a type of information that is taken into account to track
situations. Before the COVID 19 pandemic, during the second respiratory
epidemic peak, there was a predominance of H1N1 in Cali; this was identified
thanks to WhatsApp networks that grouped parents. We used these entry routes,
says Dr. Martha Lucía.
To understand the relevance of the information found in social networks,
Dr. Ospina explains, one could think of a Cartesian plane in which on the Y-axis
there is a greater degree of diagnostic prediction, because there is access to
laboratory tests (from prescriptive, antibody tests to very accurate molecular
tests), and on the X-axis there is a volume of data. What the map shows is that
it is possible to have a volume of data such as trends in social networks (Y-axis)
while having very little diagnostic prediction (X-axis). Giving sensitivity to that
measure is the same as having a cluster of cases identified with PCR.
The orthodoxy of the case, Dr. Martha Lucía points out, finding something
suspicious that requires confirmation is not necessary in all events. With the
notifications we feed ourselves daily, she says. In addition, we already know
that there are families of notifiers, including independent professionals who are
people through whose hands important information passes, but since they were
not part of the notification system before, we were left without their information.
Now we have that information. It was, then, a matter of alleviating that orthodoxy
a bit and accepting these types of notifications, explains Dr. Ospina. You have
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to rely on the apps to notify. Then there is the confirmation exercise. This is not
only happening in Colombia, says the INS director, it is operating in surveillance
systems around the world. Rapid tests, for example, says Dr. Martha Lucia, have
a use in a context. Steps in hospital services can be bypassed if tests from
emergency departments are used appropriately. Knowing how to use these
algorithms even saves money. In short, it is a paradigm shift. In this type of “new
surveillance,” she concludes.
Tests have to be adapted to the needs of each territory
Dr. Carrasquilla wonders how to ensure that rapid tests do not fail to identify
parasites, viruses, or bacteriae that are not always easy to detect. Considering
that at the first level these difficulties can be resolved if they occur. This is an
issue, says Dr. Gabriel, that can happen, for example, with malaria.
Dr. Carlos Álvarez points out that addressing the difficulties of testing is
emerging and that means continuing to learn, both in cases such as malaria and
in cases of Sars Cov 2 and other diseases. There may be changes that cause
yields to change, but that does not mean that tests cannot be taken where they
are needed. They must be adjusted technologically and innovatively for different
realities. It is clear that these tests are a good alternative, but when there is
a resistance greater than 10%, they are not recommended. The diagnosis of
malaria with rapid tests, says Dr. Álvarez, obliges us to modify them at the
speed with which the microorganisms can be modified, and in this sense, it is
important to maintain active surveillance so that the performance of the rapid
tests continues to be effective. Rapid tests also have to be updated according to
epidemiology, Dr. Álvarez points out.
On this aspect, Dr. Martha Ospina says that it is absurd to confuse the
operational needs in health services with the payment structure for certain
services. For this reason, she says, a healthcare reform should take into account
that tests should be where they are needed and should be performed by those
who are close to the people. For example, Dr. Ospina explains, it is absurd to
think that a glycosylated hemoglobin is level 2 and therefore cannot be at the
health posts. Where are the diabetics? In that sense, she continues, Chagas
tests, including ultrasound scans for Chagas, have to be where the population is.
The cost structure has confused the real routes of healthcare to the service of
people.
Actions on education, information, and communication are
relevant
Dr. Gabriel Carrasquilla wonders how to ensure that in the departments with
the highest prevalence of Chagas disease in Colombia, such as Santander,
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Arauca, and Boyacá, there is an adequate response on the part of the insurance
companies responsible for health promotion.
Dr. Manuel Medina points out that the pilot project began in the departments
of Arauca, Casanare, Santander, and Boyacá. Each one, with some municipalities
in which the operational aspects were validated. Now, the intention is to scale up
to the departments of Norte de Santander and Cundinamarca.
Dr. Manuel Medina points out that, in the Boyacá experience, developed
in conjunction with DNDi, several key factors have been identified to reduce
barriers to diagnosis and treatment. The first factor has to do with informing
the community. The population must be aware of the problems related to
Chagas disease and what they are facing. Actions in education, information, and
communication are relevant.
In Chagas disease, treatment and follow-up can be started
at the first level.
All medical personnel in endemic areas, says Dr. Medina, should have Chagas
disease on their agenda and in their minds, and know what they are talking
about. To achieve this, it has been important to socialize guidelines that explain
its variants, forms of transmission, and presentation of the disease. In this task,
we have gone from training 10 or 20 people to training 450 people directly in the
endemic municipalities. Part of the content of this training has to do with the
initiation of treatment. In the past, it was considered that treatment could be
formulated from the level of specialization, i.e., by the internist’s decision. One
of the issues addressed by this training is that treatment and follow-up can be
initiated at the first level of care.
Dr. Andrea Marchiol adds that there is a consensus that when care is
strengthened at the first level, there is a greater capacity to reduce the barriers
to it. To achieve this, she says, it is necessary to simplify procedures. In the case
of diagnosis, rapid tests have been discussed in this webinar. Progress is being
made with the National Institute of Health of Colombia for the evaluation of the
performance of serological tests and the validation of rapid tests in the field is
being monitored. In addition, DNDi is studying the reduction of treatment time.
For this reason, a clinical trial is underway in which new times and new dosages
are being tested, which would make it possible to simplify treatment with greater
safety, less time, and greater adherence.
Territories must have the capacity to respond to timely
diagnoses
Dr. Medina explains that the territories must have the necessary response
capacity to carry out timely diagnosis. Until recently, he says, the tests had to
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go to the National Health Institute and then to the departmental public health
laboratories. Today, with a single sample, Chagas disease can be diagnosed
directly in each of the territories, facilitating access.
Administrative barriers and paperwork for authorization were difficult to
overcome. With the model that has been implemented, this aspect is simplified,
given the clarity of roles at the departmental and national levels. Providers and
insurers have obligations related to promotion and prevention. It is a model
that adapts to the particularities of each territory in order to overcome scientific
obstacles, which, although transversal in some places, are different in others.
After drinking water, vaccines have had the greatest impact
on public health
Dr. Gabriel Carrasquilla asks about the plan of the Ministry of Health and Social
Protection regarding the vaccination of the elderly for Pneumococcus and
Herpes Zoster, which is a more painful disease than cancer. He points out that
there are studies that show that vaccines such as Haemophilus influenzae,
Hepatitis b, and Rotavirus entered the schedule very late.
Dr. José Alejandro Mojica explains that WHO recommendations are taken
into account when introducing a vaccine. For Herpes, the data is being collected,
but there is already data for pneumococcus. The other aspect that is being
considered is the cost-effectiveness study. This study exists for pneumococcus
in children; now it has to be done for the elderly, as well as for Herpes, says Dr.
Mojica. In almost all the region, Mexico, Costa Rica, Panama, Peru, and Brazil,
there is vaccination for Pneumococcus in the elderly. Colombia is awaiting the
change from children to adults.
In the case of Herpes, the study, the disease burden, the budget and, in
addition, the national and international political will must be brought together, Dr.
Mojica points out.
In relation to coverage, the Expanded Program of Immunization (PAI) must
be positioned, says the representative of the Direction of Communicable
Diseases. COVID 19 has gained prominence, but we must continue to insist on
the entire PAI and the diseases it includes. To this end, he says, it is necessary
to strengthen communication with clear messages aimed at the community,
making them aware of the risks. It is necessary for people to identify that after
drinking water, what has had the greatest impact on public health are vaccines.
Communication must engage families by giving them the certainty and
guarantee that vaccines are efficient, effective, and lifesaving.
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