Questions/Answers

Thailand has confronted emerging diseases and natural disasters over the past decade that have affected public health, society and the economy. In 2015, there were Middle East Respiratory Syndrome (MERS) outbreaks in more than 20 countries, including Thailand, with more than 1,200 deaths. In 2011, a tsunami in Thailand caused approximately 5,400 deaths and 8,000 injuries and left more than 1,400 children as orphans. In 1980-2014, the Communicable Disease Act (CDA) was established for rising public health as a national issue. The act led to the establishment of the Field Epidemiology Training Program (FETP) which was inspired by the Centers for Disease Control and Prevention (CDC). The program aimed to enhance epidemiologists’ s expertise in dealing with emergency and health threats. Then, the program imparted the knowledge to health staff and volunteers result in establishing a 1030 Surveillance Rapid Response Team (SRRT). Therefore, the Department of Disease Control (DDC) was able to handle public health emergencies timely and conducted a more effective plan to mitigate risk. In 2015, there were various emerging diseases from globalization, such as SARS, Avian Influenza, DDC revised the act to CDA 2015. The act led to the establish National-Centers for Disease Control (NCDC), Provincial-CDCs (PCDCs), and Communicable Disease Control Unit (CDCU) which monitor the local SRRT and report back to DDC for responding rapidly. The CDCU was an operation that consists of the Situation Awareness Team (SAT) and Joint Investigate Team (JIT). In 2015, DDC developed an Emergency Operation Center (EOC). The EOC is a central command and control facility responsible for carrying out emergency preparedness and emergency response. Thailand’s EOC was the first country outside of China to detect cases of novel coronavirus (COVID-19). Assessment of DDC’s experience implementing a successful operational model will help identify the factors, and achievement of Sustainable Development Goals (SDGs).

The initiative demonstrates sustainable expertise in crisis preparedness which is the key to ensuring that governments can act quickly and effectively in times such as outbreaks or epidemics, natural disasters including effects of climate change, and other health crises. The initiative was established as an institutional link with a myriad of networks, namely government agencies, the private sector, civil society, and volunteers to deal with disease and health threats. It offers policies (top-down) and Public hearing and participation (bottom-up) to develop and implement successful interventions, and achievement of Sustainable Development Goals (SDGs).

This system focuses on creating and implementing a consistent emergency response that is consistent with and promotes national strategies. The initiative supports SDG 3D, strengthening the capacity of all countries, in particular those in developing countries for early warning, risk reduction and management of national and global health risks. The initiative also supports SDG 17.6, enhancing the global partnership for sustainable development, complemented by multi-stakeholder partnerships that mobilize and share knowledge, expertise, technology and financial resources to support the achievement of the SDGs in Thailand. In addition, the initiative supports SDG 17.17, encouraging and promoting effective public, public-private and civil society partnerships, building on the experience and resourcing strategies of partnerships. Successes in the achievement of these SDGs include: strengthening the surveillance system to control and prevent disease and national health hazards; enhancing information systems, surveillance, and medical treatment -- increasing access to accurate and timely information are the important targets to protect Thai citizens from disease, illness and injury; reducing mortality by providing equality and access to health services without discrimination; and supporting and protecting the Thai economy and employment the impacts of diseases and other health hazards.

DDC’s vision is that “Citizens have acquired an international standard of prevention and controlling in health hazards by 2030” which cascaded from 20 years National Strategy of Thailand Plan. The National Strategy focuses on several dimensions including ensuring health security, competitiveness, social equality, and a sustainable environment. DDC has continuously modified the initiative based on previous experiences and its expertise in disease control to achieve goals and targets. The initiative not only raises awareness of Thai citizens but also achieve community self-reliance.

This system plays as an important mechanism in setting guidelines for all departments to work together to solve the silo-modular operation problem that has long been a challenge in Thailand and improve working methods to offer suitable means mechanism in addressing many challenges. As a result, the initiative is able to leverage the standards of prevention and control of disease and transform into be learning organization. The initiative heavily relies on three crucial factors: (1) the Communicable Diseases Act, Epidemiology course on disease prevention, control and emergency response that help strengthen the system with Incident Commander System (ICS), which are the keys compounded with (Single Command); (2) Using information technology and innovation to increase the accuracy of (Single Data); (3) focusing on risk communication (Single Communication) which is a conceptual framework centered on people development as a surveillance system to prevent and control the disease with new mechanisms resulting in work processes and time reduction, work effectiveness and strengthening the emergency response system, including disease response and the impact on the environment.

The initiative normally was developed for preparing to respond to a health emergency. There are five key services which are surveillance system, case management, and hospital infection and control, laboratory testing, preparedness of healthcare staff, and medical supply and risk communication that providing equally for people on Thai soil. However, risk groups such as pregnant women, the elderly, etc. will be a priority providing the service. for example, In the case of a Zika outbreak, pregnant women will be treated priority. Therefore, an infant will have more opportunity to be alive.

The system focuses on 5 target groups: 1) Risk groups, including the elderly, patients with congenital disease, children, pregnant women, and patients with immune deficiency. They have been received disease surveillance services, screening, and access the rapid treatment; 2) Vulnerable groups (The elderly people, pregnant women, people with chronic disease) have served with efficient innovation to prevent infection during the epidemic taken place. For example, more than 4,659,191 people traveling at the airport were screened by Thermo-scan. Similarly, diagnosis, treatment, and referral system for both public and private hospitals; 3) frontier professionals who are working for ICS operating team consists of personals acting according to the incident command system, the SRRT team, and the personnel in the EOC center are concerned to receive essential care; 4) citizens who are suffered from health hazard would be able to receive health care and subsidies by DDC. For example, state quarantine is available in international border areas as a collaborative effort of public and private sectors to streamline the screening process; 5) Government agencies and collaborated organizations that gain knowledge and opportunities to work with DDC.

Phase 1, 1980-2004, Thailand had witnessed an increase in Endemic disease, so Bureau of Epidemiology, DDC established FETP course by offering scholarship for talented individuals to study abroad to become an expert in epidemiology. Those are key persons who drive policy and impart knowledge to staff and volunteers. Phase 2, 2004–2015, as a pandemic disease was taken place, DDC revised CDA 2015 in accordance with International Health Regulations 2005 (IHR) to respond to the health crisis. As a result, NCDC and PCDCs were established as a formal network to offer timely treatment to all. EOC with SRRT 1030 teams was established to act as coordinators. Phase 3, 2015–2019, there was a rise in the outbreak of emerging diseases and disasters. DDC had continuously developed an emergency response system using the ICS and CDA, SAT and JIT establishment, initiated EOC and CDCU in epidemic areas. Phase 4, 2019–present, DDC used the ICS mechanism and CDA 2015 to drive the Emergency Decree on Public Administration in Emergency Situation 2005 on the COVID-19 situation, initiated Smart EOC with digital technology to prepare for the international disease. Smart EOC opens more opportunities for people to easily communicate with DDC as a two-way communication platform. The chatbot is also available to serve the public 24 hours. Hotline 1422 with multilingual language is offered. When an emergency occurs, the EOC system will be opened for operation and DDC authorizes the area to open the emergency operations center immediately. Let personnel see the interests of the people and the importance of each department in solving problems. Continuously train personnel and practice plans for public health emergencies. Applying information technology to management to respond to the needs and expectations of the people who receive services according to the conventional standard.

The primary problem has been the insufficient number of medical personnel. This problem can be mitigated by decentralization of the CDA for each organization to provide care to patients. Moreover, a collaboration has been incomplete due to having multiple sectors such as government, private, and institutes, which can result in misinformation. A possible solution would be to implement the One Health Approach that is integrated at the national, provincial, and local levels, which would include establishing a central platform for NCDC and staff to ensure that they have all of the information needed for surveillance, risk assessment, and epidemiological analyses.

The initiative consists of both non-technological and technological innovation. Non-technological innovation is a policy innovation that drives legislation. Legislation developed through the CDA 2015 promoting top-down and bottom-up processes. Technological innovation is planned on design thinking and epidemiological principles during each epidemic to make the system more efficient and increase the number of people who can access services such as ChatBot COVID-19 Protected and DDC Care Application for patient monitoring. Sydekick for Thai Fight COVID application for tracking people from risky countries, which can reduce medical expenses by up to 100,000 baht per person.

The initiative has applied the experience and expertise of international organizations to transfer and develop curricula, standards, and technology. Thailand was the first country to adopt a US CDC-based applied epidemiology program training epidemiologists through FETP. The Thai FETP differs from the US EIS program in that it includes the establishment of SRRTs at provincial and district levels. SRRTs monitor infectious diseases and detect public health emergencies in accordance with IHR. In addition, the initiative developed a curriculum and ICS to establish an EOC by modifying existing structures to suit Thailand’s needs.

DDC set up a system to link the databases in various organizations so they can be used together throughout the system to support emergency response quickly and efficiently. We provided accurate information to the public through two-way communication by using a broadcasting tower and VHVs. DDC also brought big data methods to process data into Data Visualize and GIS. DDC works with government and private sectors such as the Ministry of Digital Economy and Society, NECTEC, GDCC, DEPA, AOT, DGA, the Immigration Police Office, and the Startup Thailand. DDC has opened API and integrated the government's digital central portal data.

The initiative has promoted the development of EOC and extension of ICS to provincial levels. Examples of how the initiative has been transferred to or informed emergency response in other countries. 1) Thailand’s EOC has been expanded to the Association of Southeast Asian Nations (ASEAN) by practicing an emergency response plan in Cambodia, Laos, Myanmar, and Malaysia. 2) Thailand used the initiative to provide assistance to victims of the Tsunami disaster, the Great Bangkok Flood, and the earthquake in Nepal, which led the emergency response system to help the victims by sending more than 6 medical teams. 3) We conducted a Training Programs in Epidemiology Intervention Network and Pubic Health Intervention Network (TEPHINIT) yearly which was a professional network of 75 FETPs sharing knowledge across more than 100 countries. Lastly, the success in handling the COVID-19 has been sharing the tacit knowledge through Intra-Action review (IAR) with the World Health Organization (WHO) globally.

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The system consists of 1) staff in each mission group 2) items such as computers, communication tools, information technology systems such as Linkable and real-time display system, and 3) systems such as budget plans, operational standards, and agile operations in human resource. Public health scholars, provincial epidemiologists preparing for public health emergencies, and personnel who have completed Leadership Development Courses (LDC). In addition, emergency response is driven by the CDA 2015, which can be used as a financial resource for the project to continue and sustain.

There are 4 key success factors: 1) epidemiological and medical knowledge by a team of trained specialists and personnel. In addition, FETP courses are offered annually to produce personnel with epidemiological knowledge. 2) innovative services 3) the implementation of CDA 2015 and 4) the Regulation and Standard of ICS incident command measures. There are supported by all departments that have been involved as a multidisciplinary team of operations, then developed from epidemiologists to SRRT teams. For the first time, the governors of 77 provinces have been seriously decentralized, so there is an awareness of emergency response.

Yes

This initiative has evaluated by Johns Hopkins University in 2019, based on 140 quantitative and qualitative questions, organized across 6 categories, 34 indicators, and 85 sub-indicators. However, the indicator relative to the system was placed on 3 main categories which were Detect, Respond, and Norm divided into 5 indicators. The evaluation had a score of 100 for the most favorable health security conditions possible and was calculated under four sets of weights model. Each indicator was then ranked compared with a total of 195 countries.

Global Health Security Index (GHSI) is an international tool that was used to evaluate the system using the following indicators: 1) real-time surveillance and reporting; 2) epidemiology workforce; 3) emergency response operation; 4) linking public health and security authorities; 5) IHR reporting compliance and disaster risk reduction. The first and second indicators measure the system in terms of whether there are fast and corrective detection and reporting of biological threats. The third and fourth indicators measure preparation and response to public health emergencies to rapidly mitigate biological events. The fifth indicator measures compliance with national and international standards.

The main objective of the system was to deal with emergencies that arise in the country with maximum efficiency. Although the overall score of the evaluation placed Thailand at the most prepared level, the evaluation indicated that improvements are required in order for Thailand’s initiative to achieve maximum efficiency. For example, the epidemiology workforce ranked at 36th with a score of 50, showing that there is an insufficient number of trained field epidemiologists to covering Thailand’s population. In response, DDC decided to build more connections with local people via VHVs and using FETP fellow to raise awareness of epidemiology in practice. Though Thailand’s EOC ranked second place, its score of 66.7 was quite low. DDC is developing its EOC into a Smart EOC to attract more attention from people in Thailand and to increase the accuracy of information and reporting of cases in real-time. DDC has continuously improved every aspect of the initiative based on experiences in the country, expertise attained, prevailing conditions, and international regulation. The example of Covid-19 has demonstrated the initiative’s potential and the benefits of modifying it based on lessons learned and efforts to ensure its sustainability.

The initiative began with 3 epidemiologists when Thailand considered public health to be a national problem and implemented CDA 1980. The act led to the FETP development which was used for educating health staff and volunteers who eventually became 1030 SRRT teams. Then, CDA was updated in the 2015 version to expand collaboration between the government sectors to counter biological threats. Besides, DDC considered following a public hearing process to validate the CDA 2015 to promote public sector’ engagement. Therefore, we conducted a draft of the Communicable Disease Act to found National Communicable Diseases Committee and Provincial Communicable Disease Committee and implemented it in the same year. The ACT allowed the system to distribute an authority covering provincial and sub-provincial levels. The NCDC consisted of 17 government sectors, public and private medical agencies, and 4 experts in disease control while PCDCs are part of the provincial government sector. PCDCs have the authority to exercise mitigation practices as responsible and reporting to NCDC. Furthermore, to expand the scope of surveillance and response, DDC transferred FETP knowledge and experience to VHVs and established their role as a part of SRRTs for reporting cases at the village level.

DDC recognizes that the most effective way to respond to public emergencies is to ensure maximum preparedness. To achieve this, the engagement of the public sector is imperative. Therefore, the initiative has focused on laying a foundation to increase people’s awareness of health in the context of Thai culture. DDC used a campaign to communicate the importance of self-protection from communicable diseases and maintaining ones when public health emergencies occur, even at early stages. The campaign could be via infographics, mass, and social media. Recently, an application such as Chatbot has allowed people to be more engaged in reporting and updating the information provided by DDC during emergencies. Besides, CDA 2015 was being developed under the public hearing process. CDA 2015 called for the establishment of NCDC and the PCDCs. CDA 2015 decentralize to other government sectors at the provincial level to conduct surveillance and response during emergencies as the requirement and report back to DDC rapidly. DDC also established a memorandum of understanding with leading educational institutions to study and develop new technologies. Besides, DDC has a policy to partner with the private sector, as for example with travelers staying for state quarantine because of COVID-19.

Thailand has been confronted with several public health emergencies and so DDC has continuously developed systems to respond to these emergencies. The key to successfully responding to public health emergencies has been preparation, which can be divided into 5 main ideas areas: 1) ensuring there are sufficient resources, such as trained staff who have authority and financial support; 2) effective communication – having rapid, accurate, and accessible communication provides people with information that can protect them; 3) resilient administrative systems whereby SRRTs at all levels have the authority to detect and report cases to DDC in real-time; 4) management of knowledge and lessons learned that has been obtained experiences and continually revising curricula, training, processes, and policies to ensure they are always up to date; 5) collaboration in all sectors, including the government, private and public sectors —this might be the most important factor in Thailand’s successful response to COVID-19. In the next phase, we will continue to improve the system with a people-centric focus to increase collaboration with the public sector through the Smart EOC to promote equality and sustainability.