Pivoting in a Pandemic

PAHO/WHO Collaborates to Strengthen the Covid-19 Response in the Dominican Republic

Dr. Olivier Ronveaux is a physician and epidemiologist, specializing in public health and tropical diseases. He joined WHO headquarters in 2001 as an advisor supporting the Immunization program and has since held various positions in different regional offices. He then returned to Geneva where he served as Head of the High Impact Epidemics Unit until assuming the representation of PAHO / WHO in the Dominican Republic.

Describe the COVID-19 situation in Dominican Republic and how the vaccine roll-out is progressing.

The Dominican Republic reported the first imported COVID-19 case on March 1, 2020, becoming the fourth Latin American country to confirm a positive case. To date, the country has faced three major waves of COVID-19 and has reported 334,836 cases. The most recent increase occurred in May and June 2021 – with reported incidences of over 2,000 cases a day.

Overall, integrating all components of Covid19 control, the authorities have managed to avoid the collapse of the health services, secured quality attention while the case fatality rate remained low (under 2%).[1]. However, the socio-economic impact on the population as well as the impact of the continuity of other health services is huge[2] (CRNA ref).

Regarding the vaccine roll-out, the national authorities have made a great effort to secure enough vaccines for the entire population, mainly through direct procurement contracts with different manufacturers, including Sinovac, AstraZeneca, and Pfizer-BioNTech but also adhering to the COVAX mechanism. Since February 16th, the National Vaccination Plan against COVID-19 started with the immunization of the health personnel, then the elderly and people with comorbidities. Since May 10th, the population 18 and older started to be vaccinated and by May 31st, the population of 12 years of age and older were included. Hundreds of vaccination centers were deployed, most of them offering immunization services seven days a week and under extended schedules.

Within six months, over 4 million people have received a second dose of the COVID-19 vaccine, which represents the 39.5% of the total population[3].

Briefly, describe your role in Dominican Republic, and your involvement in the pandemic and the national vaccination plan.

As the representative of PAHO/WHO in the country, my main role is to engage with the national authorities to technically cooperate with the country and advance the implementation of programs to fight diseases and their causes, to strengthen health systems, and to respond to emergencies and disasters.

The PAHO/WHO country office worked in coordination with national authorities in actions to prepare, mitigate and contain the pandemic. These efforts resulted in the development of a COVID-19 Contingency Plan—based on the nine pillars of the COVID-19 Strategic Preparedness and Response Plan—which included the creation of inter and multisectoral committees for COVID-19.

One of the main successes of the country’s response was to link public, private, and military networks, which contributed to avoiding the saturation of hospital beds and intensive care units (ICUs) in much of the country.

Through technical cooperation, training and donations we have collaborated to strengthen the national capacities, using the COVID19 response to build stronger systems.

For instance, PAHO/WHO worked with National Epidemiology Direction (DIGEPI) in establishing a Situation Room and a Centre for Public Health Intelligence (CISP). This represented a milestone in the country’s surveillance and data analysis capacity for public health decision-making: while the Ministry of Health (MOH) had a previously existing Situation Room, it lacked functionalities offered by the CISP, such as connecting in real-time with Situation Rooms in Provincial Health Directorates across the country.

It is now being used for surveillance of other epidemiological events such as dengue and tuberculosis.

PAHO/WHO’s collaboration has included the hiring of rapid response teams to respond to the emergency in the provinces, including hiring close to 140 professionals such as epidemiologists, laboratory specialists, data entry clerks, and interviewers, with the financial support of USAID.

PAHO/WHO has also supported training National Laboratory of Public Health Dr. Defilló (LNSPDD) personnel by facilitating their participation in a workshop on laboratory diagnostic and detection of SARS-CoV-2, held in Mexico in February by PAHO/WHO and the Institute of Diagnosis and Reference Epidemiological of the Ministry of Health of Mexico. In addition, PAHO/WHO donated equipment and supplies to increase the processing capacity of PCR testing of SARS-CoV-2 in open and closed platforms as well as viral transport media and extraction kits. On 6 November 2020, PAHO/WHO donated 15.000 rapid antigen tests to the National Laboratory to help expanding the diagnosis to remote places and make it easier for first-level personnel to detect and isolate people. As of 30 November, the country counted ten laboratories—five public and five private laboratories— authorized to carry out PCR tests.

PAHO/WHO provided technical and financial support for the preparation of health care centers for COVID-19 patients as well and for the definition of care and case management protocols. This work included the development of tools (dynamic matrices) to strengthen the reporting of hospital beds and ICU bed occupancy rates, use of ventilators, and discharge of patients, as well as collaboration with the National Health Service (SNS) to analyze the needs of health facilities to enable expansion of hospital and ICU beds. PAHO/WHO also provided technical cooperation to the SNS for data collection (matrices) related to existing resources (beds, supplies, equipment, and HHR) and to identify gaps in health centers in complex settings.

The Organization also collaborated in the SNS’ response through an organization and expansion plans for health services, resulting in the evaluation, designation, and preparation of specialized health care centers (CEAS) equipped with hospital and ICU beds specifically for COVID-19 patients with serious or critical conditions requiring isolation or specialized life support.  We also supported the development of guidelines and protocols for the surveillance of the multisystemic inflammatory syndrome in newborns, children, and adolescents associated with COVID-19.

Coordination with other agencies of the United Nations system and members of civil society was also critical. Over one thousand people were trained on COVID-19 prevention and mitigation issues through a series of 16 webinars managed jointly by PAHO/WHO, the United Nations High Commissioner for Refugees (UNHCR), the MOH, and the National School for Migration. These sessions—aimed at both health personnel and the community in general—addressed topics such as the correct use of personal protective equipment, disinfection of public spaces, management of coronavirus disease in pregnant women and newborns, and basic prevention guidelines for the home and in the community.

The Organization also carried out a project with the Pontificia Universidad Católica Madre y Maestra (PUCMM) to strengthen the capacities of the first and second level of care in the context of COVID-19, in the border provinces of Dajabón and Independencia. The information obtained from this project will contribute to maintain essential health services in the area.

Thanks to collaborations between PAHO/WHO, UNHCR, IOM, inhabitants of rural and border areas have been informed with COVID-19 prevention messages through the dissemination of radio spots both in Spanish and Creole, a language mostly spoken by the Haitian population.

These messages were broadcasted through the network of community stations—dependent on the Office for the Coordination of Social Policies of the Vice Presidency of the Republic—that make up the Community Technology Centers (CTC). In order to reach vulnerable populations, PAHO/WHO produced nine COVID-19 prevention radio spots targeting older adults, people living with HIV, and people who engage in harmful consumption of alcohol, which were also broadcasted through the community radio network[4].

How has PAHO collaborated with the Dominican Government and other partners in preparations and in carrying out the vaccination campaign?

PAHO worked with the national Expanded Program of Immunization in the development of the National Plan for the introduction of the COVID-19 vaccine, and in the preparation of operational technical guidelines, vaccinator and supervisor manuals. We contributed to a review of the cold chain capacity.

We also supported the program by preparing guidelines for the continuity of the immunization services during the pandemic, and in planning the vaccines and supplies required for 2020 and 2021. Furthermore, the Organization donated 3.050 masks for vaccination staff in order to contribute to the prevention of infections.

In addition, the Organization collaborated in the preparation of technical operating guidelines, manuals for vaccinators and supervisors, spokesperson folder and other tools that were used in the training process for the health personnel.

Likewise, PAHO/WHO supported the digital marketing strategy through the “VacunateRd” account on Twitter, Facebook and Instagram, a space created to educate the general population through with information related to the vaccination campaign, myths and truths about the vaccine, and other related issues.

PAHO accompanied the country in its inclusion in the COVAX mechanism, through which the Dominican Republic will receive two million vaccine doses throughout 2021.

What are some key lessons learned in Dominican Republic as far as preparations for vaccine distribution, access, and equity?

In a global race where high-income countries were served first, Dominican Republic faced significant vaccine delivery delays, including through the COVAX mechanism. However, right from the start, the country authorities established very ambitious targets (80% of the population to be vaccinated in 2021) and invested consequently, mainly through bilateral agreements. Thanks to these efforts, the country secured enough doses for the population.

The local authorities sought and obtained support from the private sector, which has invested resources for communications campaigns to promote the vaccination and for other operational components of the Plan. This multisector coordination was very helpful for the achievements of the vaccination roll-out.

In the preparation phase, the country worked to improve the cold chain in order to assure the deployment of the doses nationally while the safety and quality of the vaccines is guaranteed, especially for vaccines such as Pfizer that require very low temperatures for their storage.

There were technical and political challenges related to inclusion of the undocumented population in the vaccination plan, considering that the Dominican Republic has a significant immigrant undocumented population, mainly from Haiti. PAHO/WHO[5] and other UN agencies and partners insisted on creating mechanisms to guarantee vaccine access for these groups.  A few months after the start of the Vaccination Plan, the Authorities announced that a person without an identity document could receive the vaccine if he/she attended the vaccination center with another person who was properly identified. This measure was an important step towards a more equitable access to the vaccine roll-out in the country.

Other challenges that local authorities have tackled include the initial vaccination hesitancy from different groups of the population; and because the country made deals with diverse manufacturers, some groups wanted to wait for a certain vaccine brands that took longer to be introduced in the country. The authorities have maintained a strong communications component and constantly updated the key messages.

What have you learned about community engagement and vaccine communications for the general population?

As stated above, it has been imperative for the local authorities to have communications campaigns to inform the population about the logistics of the Vaccination Plan while counteracting the fake news and the infodemic that has developed around the pandemic and the COVID-19 vaccine. For instance, the MOH has weekly press conferences to update on the COVID-19 situation and the development of the Vaccination Plan. This gives the general population a sense of transparency by having an authorized source of regular information.

In addition to the campaigns and the regular press conferences, the MOH implemented community vaccination days and located vaccination centers within the communities to make it as easy as possible for everyone to access the immunization services. These measures proved to be successful because there has been a great turnout of people This approach demonstrated the importance of working jointly with community leaders to understand what ideas and circumstances prevent the community members from getting the vaccines.

Through their official channels, PAHO/WHO, UN agencies and many other partners have collaborated with the communications outreach to motivate people to vaccinate and to fight the myths and doubts about the COVID-19 vaccine.

Do you expect Dominican Republic will emerge stronger by strengthening the foundations of equitable health systems?

Yes, I believe the country can emerge stronger from this emergency that has impacted not only the health sector but all aspects of society and the economy.

For instance, the Government has implemented diverse social welfare benefits that target economically vulnerable groups. A good example is the most recent social program called SUPERATE (improve yourself). This program has three pillars, which are capacity development, productive inclusion, and economic empowerment; the protection of vulnerable groups; and systems of care. Each pillar is based on a Sustainable Development Goal (SDG) 2030 and encompasses different components such as health, food security and support for emergencies; economic inclusion; housing; SUPERATE for women; socio-family accompaniment, among others.

PAHO/WHO has partnered with other UN agencies to collaborate with the country on this matter. The Organization has contributed to the COVID19 Recovery Assessment – CRNA led by the Ministry of Economy, Planning, and Development in coordination with the other UN agencies. This initiative identifies gaps and additional needs of social and economic recovery, to advance in the formulation of recovery strategies and guide the budgetary reorientation of the country and the international cooperation. The improvement of the health system is crucial in this assessment.

However, it is a priority to allocate more resources for the health sector and implement a strong Primary Attention strategy, not only for the Dominican Republic but also for most of the countries in Latin America and the Caribbean. PAHO/WHO strongly advocates for the necessity to increase public health spending to at least 6% of the GDP, and invest at least 30% of those resources in the first level of attention. This current pandemic reflects the urgency of this calling in order to have more resilient health systems for future emergencies.

Any other information you would like to share regarding PAHO or your work?

As part of the response to the pandemic, PAHO/WHO adapted its technical cooperation lines in order to support the maintenance of essential services in the areas of communicable diseases, maternal and child health, and noncommunicable diseases and mental health. I would like to provide a few successful examples of what the Organization achieved in those areas.

With the support of the Organization, during 2020 the Dominican Republic became the second country in the Region to implement the virtual course on clinical management of dengue in the context of the pandemic, through which 20 national facilitators were trained. In addition, the country had a Malaria Response Plan in the Field of COVID-19 since July 2020, as well as a National Plan for the Response to Dengue Outbreaks and other Arboviruses.

Reducing maternal morbidity and mortality is one of the country’s priorities. Through the support of the Organization, more than 700 health professionals were trained on maternal, child, and adolescent health within the framework of COVID-19.

Likewise, PAHO/WHO has accompanied the MOH and the National Health Service in a series of activities such as the expansion of the HEARTS program throughout the country, with a view to positioning it as a crucial tool for the prevention of COVID-19 in patients with cardiovascular diseases and other NCDs. PAHO/WHO has also supported the organization and training of a network of more than 700 volunteer psychologists and psychiatrists that provide psychological care to people affected by COVID-19 and their families, as well as front-line personnel (doctors, nurses, policemen, among others).