Republic of the Philippines

Department of Health
OFFICE OF THE SECRETARY

08124 2018

ADMINISTRATIVEORDER
No. 2018- 002,3

SUBJECT: Guidelines in Strengthening the Capacity of Public Health Units of

DOH Hospitals and All Level Three Hospitals {Government and
Private) on Sentinel Surveillance Svstem for Notifiable Diseases of
Epidemic Potential

I. BACKGROUND AND RATIONALE

Public health surveillance is an important component of the Service Delivery Network.

Needless to over emphasize, a good surveillance system will generate data that will serve as
basis for early warning system of impending public health emergencies; document disease
trends, determine the impact of an intervention, or track progress towards specified goals; and
monitor and clarify the epidemiology of health problems, to allow priorities to be set and to
inform public health policy and strategies.

However, underreporting is a common limitation seen in a traditional reporting system such as

notifiable disease not to mention timeliness, completeness and regularity of reporting. Aside
from these constraints, compliance to the reporting process, the non-uniformity of structure in
a hospital setting and the financial burden for sustaining a population-based surveillance
system are major considerations to opt for a sentinel reporting system as affirmed by the
Centers for Disease Control and Prevention (CDC).

A sentinel surveillance system provides an alternative to population—based surveillance. The

World Health Organization (WHO) defines Sentinel Surveillance System as a type of
surveillance used when high—quality data are needed about a particular disease that cannot be
obtained through a passive system.

It is important at this point to emphasize that the process of strengthening the hospital
surveillance system should be taken in the context of strengthening the implementation of a
Sentinel Surveillance System (active type of surveillance), which is the principle behind the
Philippine Integrated Disease Surveillance and Response (PIDSR) system. Therefore,
providing these hospitals a guide for standardized steps in setting—up the structure and process
of the system as well as capacitating the personnel in the Public Health Units (PHU) are
important steps towards achieving the intention of the policy.

This document will serve as a guide for strengthening the PHU in DOH hospitals and all level
three hospitals (Government and Private) and as sentinel surveillance sites on hospital
surveillance system with focus on the four (4) surveillance processes, namely: data collection,
analysis and interpretation and dissemination/communication (as a feedback mechanism) of
hospital data to those who need to know and are supposed to act on the information received.
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II. OBJECTIVE

This guideline is aimed to strengthen the capacity of Public Health Units of DOH Hospitals
and all level three hospitals (Government and Private) on Sentinel Surveillance System for
Notifiable Diseases.

III. SCOPE

All DOH hospitals (DOH Hospitals, Medical Centers and Specialty Centers) and level three
(3) hospitals either government or private will be covered by this Order.

IV. DEFINITION OF TERMS

1. DOH Hospital — refers to government hospitals owned and managed by the
Department of Health

2. Hospital Surveillance System - a type of surveillance system that utilizes hospital as

sentinel site for disease and event surveillance

3. Level 3 Hospital shall have a minimum, all of Level 2 capacity including, but not
—

limited to the following: i) Teaching and/or training hospital with accredited residency
training program for physicians in the four (4) major specialties namely: Medicine,
Pediatrics, Obstetrics and Gynecology, and Surgery; ii) Provision for physical medicine
and rehabilitation unit; iii) Provision for ambulatory surgical clinic; iv) Provision for
dialysis facility; v) Provision of blood bank; vi) DOH licensed tertiary clinical
laboratory with standard equipment/reagents/supplies necessary for the performance of
histopathology examinations; vii) DOH licensed level 3 imaging facility with
interventional radiology

4. Notifiable Disease - refers to a disease that, by legal requirements, must be reported to

the public health or the authority in the pertinent jurisdiction when diagnosis is made.

5. Public Health Unit - involved in the preventive and promotive aspects of health care.
Public Health Units focuses on protecting health; preventing disease, illness and injury,
and promoting health and wellbeing at a population or whole of community level.

V. GUIDING PRINCIPLES

1. The AD. No. 120, s2000 on the Integration of Public Health and Hospital Services in
Support of the NOH and the creation of the PHU in all DOH Hospitals, Medical Centers
and Specialty Centers underscores the importance of a comprehensive quality health
care service in support of the National Objective for Health. In the said Order, one of
the functions of the PHU is to consolidate and analyze local epidemiology reports in
relation to hospital epidemiology reports and to ensure that hospital policies and
services are responsive and relevant to disease patterns and trends in the community.

2. Whereas most passive surveillance systems (e. g. ESR and notifiable disease) receive
data from as many health workers or health facilities as possible, a sentinel system
deliberately involves only a limited network of carefully selected reporting sites.
Findings from sentinel data collection are useful for documenting trends but are not
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 population-based. Furthermore, as per the WHO, data generated by this type of
surveillance identifies outbreaks and monitor the burden of disease in a community and
the impact of control or response activities, providing a rapid, economical alternative
to other surveillance methods.

VI. GENERAL GUIDELINES

. ALL hospitals covered by this Order shall establish a functional Hospital Surveillance
System (HSS) within the PHU under the supervision of the Head of the Hospital.

. Under this Order, DOH Hospitals and all level three (Government and Private) shall
serve as the sentinel hospital sites for diseases with epidemic potential and other health
events. The PHUs in these hospitals that are tasked to analyze epidemiology report for
designing hospital policies and services as articulated in AD. 120, s2000, shall be
mandated to collect data and submit report on diseases being monitored under the
PIDSR on a weekly basis to be reported and integrated with the regional surveillance
system of the Regional Epidemiology and Surveillance Units (RESU) at the regional
level.

. HSS shall have the following components:

a) Case Detection: case reports shall be based on the diseases case definitions in
PIDSR MOP
b) Registration: completely filled-out Case Investigation Form (CIF) or Case Repot
Form (CRF) forms
0) Reporting: timely reporting of notifiable diseases mean that cases are being reported
within the morbidity week the case was managed to the RESU of their respective
DOH Regional Office.
(1) Confirmation: collection of appropriate and adequate specimen for laboratory
confirmation of notifiable diseases
e) Investigation and Response: detect and report any clustering of cases seen and
managed at the hospital and investigate clustering of hospital-acquired infections

VII. SPECIFIC GUIDELINES

Criteria for Selecting Sentinel Sites

The following are basis for selecting facilities as sentinel sites:

1. a general or infectious disease hospital
2. serves a relatively large population that has easy access to the said health facility
3. has medical staff sufficiently specialized to diagnose, treat and report cases of the
disease under surveillance.
4. has an existing or access to a high-quality diagnostic laboratory.

Organizational Structure

. The Hospital Surveillance System (HSS) shall be strengthened within the hospital
public health unit of all DOH Hospitals and level three hospitals (government and
private).

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2. The HSS shall be led by the head of the Public Health Unit and other staff shall support
the operation of the HSS.
3. Designated staffing for HSS shall include the following:
i. Nurse Disease Surveillance Coordinator(s) (DSC)
ii. Nurse Disease Surveillance Officer (DSOs) per service/unit/department
iii. HSS encoder
The DSC will work closely with the D803 from the department of Obstetrics and
Gynecology, Pediatrics, Medicine and Surgery, to cover their respective wards, the
Outpatient Department (OPD), Emergency Room (ER) and Intensive Care Units (ICU).

Responsibilities of designated PHU staffs in relation to the operation of the

Hospital Surveillance System (HSS)

Medical Center Chief (MCC)

- designates personnel to operate the HSS.

- in consultation with the Chief of Clinics and head of the Nursing Service,
identify nurse disease surveillance officers (DSO) for the Department of
Pediatrics, Obstetrics and Gynecology, Medicine and Surgery.

C.1. HSS Medical Officer (HMO)

The designated HSS Medical Officer will be identified and designated through a
Hospital Order. The following are his/her functions:

team leader in ensuring the operation of HSS in the PHU

.
. will be the focal person for the disease surveillance system in the hospital
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. ensure that weekly surveillance report is being forwarded/submitted to the RESU

. maintain a close coordination
a. with different departments of the hospital to discuss the case definition as set
in the PIDSR
b. with their respective RESU
c. with reference laboratory
. review
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data collected for the day and analyze them
. review the surveillance report and present it to the MCC and the Chief of Clinics
for appropriate actions
7. disseminate surveillance report (any unusual incidence of diseases and or any
health event) to the MCC, hospital committee and when needed to communicate
this report to the community
8. orient the staff of different departments on the hospital surveillance system
9. represent the hospital during meeting and surveillance updates
10. inclusion of operating requirement in the annual budget of the PHU
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CJyNurse Disease Surveillance Coordinator (DSC)
The nurse disease surveillance coordinator shall be identified and designated through a
Hospital Order. He or she will be tasked with the following:

1.responsible for day to day collection of hospital data from the different DSOs
2. assist the HMO in organizing an orientation for doctors assigned at the OPD/ER

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 and ward on hospital surveillance.
. collect daily report from the different DSOs diseases and or conditions that are
under surveillance at the following departments: Pediatrics, Obstetrics and
Gynecology, Medicine and Surgery
. notify the HMO on any diseases or health event that are highly contagious or
unusual for appropriate action
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. do data analysis and prepare reports as warranted.
. prepare the weekly surveillance report for submission to the RESU. All HSS
reports must be reviewed and approved by the HMO before its submission.
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CflgNurse Disease Surveillance Officers (DSO)
The DSO will be identified and designated through a hospital order. They will be tasked
to:
1. ensure the list of diseases/conditions to be reported is placed on the table under a
glass or hung on the wall at site easily visible to doctors sitting in OPD/ER and
ward for ready reference.
2. remind physician on duty at OPD/ER in completing provisional diagnosis.
3. daily collection and recording of cases seen and managed in their
service/unit/division and report these cases to the nurse disease surveillance
coordinator of PHU for encoding, consolidation and reporting to the MCC and
the RESU.
4
C5.5{HSS Encoder

A HSS encoder will have the following functions:

1. assist the DSC in the conduct of the hospital disease surveillance such as data
collection and recording/encoding
2. maintain a data management system such as (data entry, encoding, cleaning and
merging)
3. assist the DSC in the preparation of weekly surveillance reports
4. assist in the orientation of hospital staff on N88
5. perform administrative function related to HSS

D. Data Management

Existing methods for Data Management used in the PIDSR System shall be used for the HSS.
Mechanism of reporting shall follow the timeline described in Annex A.

E. Monitoring and Evaluation

The implementation of HSS in the hospitals covered by this Order shall be monitored and
evaluated based on the following indicators (Annex A):

l. Regularity and Timeliness of Report — All Reporting Units (hospital at the regional
level and the RESU at the national level) shall submit their weekly report on a scheduled
day and time of submission in a given quarter.

2. Completeness of Report — All reports submitted to the RESU shall have the necessary
or appropriate variables in the Case Investigation Form (CIF) and cover all required

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 health conditions and events (infectious, non-infectious diseases and injuries) from
Monday to Sunday of the previous week in a given quarter. Further, a “zero reporting”
mechanism shall be observed. No report does not mean zero report.

Data Utilization - Data generated by the Weekly Morbidity and Mortality Report
(WMMR) shall be used as basis for Projects, Plans and Activities (PPA) or any
dissemination activity in a given quarter.

F. Auxiliary and Ancillary Support

The MOOE and needed CO for the operation of the HSS shall be included and charged against
the funds allocated for the operation of the PHU. Operation of the HSS shall include but not
limited to the following:

1. Human Resource Development

In order to develop their capabilities, designated PHU staff to HSS shall attend
appropriate capacity building activities such as training and seminars, provided that
their attendance in such activities do not disrupt the delivery of health services or
compromise the fulfillment of their functions. The timeline for the conduct of capacity
building for HSS is in Annex A.

Information and Communication Technology

To ensure the integrity of data, dedicated computers (at least, desktop computers) shall
be provided for the HSS. Other equipment in the PHU may be made available such as
scanners, printers, documentation and presentation equipment, internet service and
mobile phones these are essential for disease surveillance and response activities. It
—

is highly encouraged that there be a landline phone and dedicated regular internet
service with a bandwidth that can maintain the needs of the surveillance systems. Such
equipment shall be made available charged against the hospital funds.

Courier service laboratory specimens

When needed and in the absence of a confirmation test in their facility, the PHU shall
closely coordinate with their respective RESU in the transport of specimens to the
National Reference Laboratories. T0 this end, resources for regular courier services that
allow transport of biological samples to the RESU should be made available. For PHU
with access to RITM, they may directly transport the specimen and notify the RESU of
such.

Transportation
Transportation shall be made available to transport the specimen when needed.

Office space and supplies

The HSS shall be housed in the PHU. A dedicated office space wherein security of data
and surveillance documents can be ensured shall be identified in the said office.

VIII. ROLES AND RESPONSIBILITIES

Epidemiology Bureau (EB)

a. Provide capacity building related to HSS for Public Health Unit Staff of ALL
DOH Hospital and Level 3 Hospitals (Government and Private).

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 b. Provide surveillance feedback to regional level.
0. Oversee the design and implementation of the HSS.

2. Knowledge Management and Information Technology Service (KMITS)

a. Develop an online Hospital Reporting System.
b. Provide technical support in software maintenance, implementation,
deployment and operations, such as but not limited to the following — user
account management, software enhancement, system troubleshooting,
debugging, database backup and recovery, server management, network
administration, database administration, and others.
0. Train HSS point persons on software use at different levels.
(1. Monitor and evaluate the operations and performance of the
hospital reporting
system. .

e. Provides help desk support for HSS.

3. Regional Epidemiology Surveillance Unit (RESU)

a. Consolidate surveillance data from the different reporting sentinel hospitals,
analysed and interpreted together with data coming from the community
surveillance reports from different primary health care facilities. \
b. Validate all reports, do initial analysis and interpretation for regional response
and timely submission to the Epidemiology Bureau.
c. Provide technical assistance visit to different Public Health Units
implementing Hospital Surveillance System.

4. DOH Hospitals and All Level 3 Hospitals (Government and Private) shall:
a. Establish a functional Public Health Unit or equivalent unit in private hospitals
that will house the HSS.
b. Institute a functional HSS within the hospital.

IX. TRANSITORY PROVISION

All DOH Hospitals and all level three hospitals (Government and Private) is given one (1) year
after the capacity building to complete all the requirements for strengthening the capacity of
Public Health Units on Sentinel Surveillance System for Notifiable Diseases of Epidemic
Potential.

X. REPEALING CLAUSE

Provisions from previous and related issuances inconsistent or contrary with the provisions of
this Administrative Order are hereby revised, modified, and rescinded accordingly. All other
provisions of existing issuances which are not affected by this Administrative Order, still
remain valid and in effect.

XI. EFFECTIVITY

This Order shall take effect immediately.

ANNEX A. Supplementary Document on Hospital Surveillance System
(HSS) Implementation

I. Objectives

The guideline aims to strengthen the capacity ‘of Hospital Public Health Units of all DOH
Hospitals and level three hospital (Government and Private) on Sentinel Surveillance System
for Notifiable Diseases of Epidemic Potential.

II. Intended Deliverable

The Hospital Sentinel Report will be on the following health conditions and events:
a. infectious diseases as identified to be monitored under the PIDSR MOP

b. leading cause of non-communicable diseases as identified in the top leading causes of

morbidity in the Integrated Chronic Non-Communicable Disease Registry of hospital
statistics

0. leading cause of injuries as identified in the top leading causes of injury reported in
the Online National Electronic Injury Surveillance System in the hospital statistics

III. Intended Outcome

Established trends of diseases and health events that is being monitored by the HSS to input
in health policies, programs and activities.

IV. Mechanism of Reporting

HSS on a weekly basis collects data on the above mentioned diseases and health events and
submits the e—report from hospitals to the RESU before noontime of Monday. The RESU is
given one day to validate all e-reports, do initial analysis and interpretation for regional
response; and, submit to the Epidemiology Bureau (EB) before noontime 0f Wednesday. The
EB will do the national consolidation of all regional reports, analyze and draft a report for
submission to the office of the Secretary, member of the Executive Committee and concerned
programs by noontime of Friday. The figure below shows the timeline of reporting:
 ‘
5

‘Monday' 'Ihesday Wednesday Thursday Friday Satu rday Sunday

1‘ 2 3 4 5 6 7

8 9 10 ll 12 I3 14
“
Hospital RESU RESU submits e- EB OSec receives
them
‘,

_
1
. i
submits e-t validates e- regional report to Consolidates
, ‘
\
report to“ reports. EB regional e-
RESU“
p ‘

analyze.
'
“
“ ‘

reports.
“ “
interpret for analyze.
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H W ‘ ‘

‘
‘
‘
Regional interpret and
response prepares
Weekly
Morbidity and
Mortality
Report
‘

(WMMR)
‘

before {12 by 12
noon; noon

V. Indicators of HSS

J
Regulaty and Timelines Hopital
of report means that a Sentinel
Number of report'mg
Reporting Unit (hospital at . . level: RESU Medical Center
. Umts (Hospitals or
the reglonal level and the .
Reporting Chief and
.

RESU at the national level RESU) with timely

Hospitals Regional
will have to submit their weekl'y 361“?t
Directors
submrssrone total
weekly report on a .
scheduled day and time of "u.“‘ber 0f reporting
submrssron 1n
. . . . umtsx 100 .
a glven Regional EB
quarter. Level:
Completeness of report RESU Regional
means that the report Directors and
submitted to the RESU will the USec/ASec
be having all the necessary of Field
or appropriate variables in Number of reporting Quarterly
Implementation
the Case Investigation Form Units (Hospitals or and
(CIF), cover all required RESU) who Coordination
health conditions and events submitted a Team (FICT)
(infectious, non-infectious complete(infectious, and Public
diseases and injuries) from non-infectious Health Services
Monday to Sunday of the diseases and Team (PHST)
previous week in a given injuries)weekly
quarter. Further, a “zero report—z— total number
reporting” mechanism in of reports xlOO
reporting the health
condition and event must be
observed. No report does
not mean zero report
Data utilization means the Counts of Policies Annually
number of times the data and PPA where
generated by the WMMR WMMR was utilized
had been used in any as basis
dissemination activity or
used as a basis for PPA in a
given quarter.
Accuracy
Correct value (as validated)
with comparison to standard
if any
No duplicates , No errors

VI. Timelines of Implementation

The development of an online hospital reporting system has been initiated together with KMITS.
Lists of health conditions and events are being finalized. These lists will be the basis for data
collection in the HSS. Once this AC has been signed the following phases of implementation will
take effect:

Phase 1: (3rd Otr of 2018 to 1St Otr of 2019)

0 Distribution of copies of the A0 with the Regional Directors and Medical Center Chief during the
National Health Sector Meeting to generate list of names of staff of the hospital public health unit

0 Initial implementation of the HSS will be at the National Capital Region (NCR)

0 Capacity Development of four day skills training (excluding travel time).

Area Number of Number of Pax per Number of Pax Number of

DOH Hospital per Training Training Batches
Hospitals
NCR 20 hospital 7 pax 35 pax four (4) batches
(IHMO, I DSC, I Encoder and
4 DSO, one per department)

Installation of Hospital Surveillance software

From the trainings, selected personnel will be chosen to be part of the TOT together with the
RESU.

- NOTE: After the training, Reporting Sites are expected to implement the HSS.

A system assessment will be conducted Mid of 2019 for NCR to determine areas for
improvement.

Phase 2: (2nd Qtr 01' 2019 until 3'd Qtr)

0 Training of all DOH hospitals to be divided into 3 main groups:

Area Number of Number of Pax Number of Fax Number of

DOH Hospitals per Hospital per Training Training Batches
Luzon
(excluding the 20 21 hospital 7 pax 37 pax four (4) batches
NCR Hospitals)
Visayas 12 hospitals 7 pax 30 pax three (3) batches
Mindanao 13 hospitals 7 pax 31 pax three (3) batches
Phase 3: 115‘s [tr of 2020 to lsfltr of 2021!
0 Endorsement of the signed AD by the HFDB and HFSRB to concern hospitals to generate list of
participants to be trained

0 Training of all level 3 hospitals (private and other government hospitals) to be divided into 3
main groups:

Area Number of Number of Fax Number of Fax Number of

DOH Hospitals per Hospital per Training Training Batches
Luzon 12 hospitals 7 pax 30 pax three (3) batches
Visayas 14 hospitals 7 pax 33 pax three (3) batches

- Installation of Hospital Surveillance software

- NOTE: After the training, Reporting Sites are expected to implement the HSS.