Community surveillance of COVID-19 by village health volunteers, Thailand

Abstract Problem To control the increasing spread of coronavirus disease 2019 (COVID-19), the government of Thailand enforced the closure of public and business areas in Bangkok on 22 March 2020. As a result, large numbers of unemployed workers returned to their hometowns during April 2020, increasing the risk of spreading the virus across the entire country. Approach In anticipation of the large-scale movement of unemployed workers, the Thai government trained existing village health volunteers to recognize the symptoms of COVID-19 and educate members of their communities. Provincial health offices assembled COVID-19 surveillance teams of these volunteers to identify returnees from high-risk areas, encourage self-quarantine for 14 days, and monitor and report the development of any relevant symptoms. Local setting Despite a significant and recent expansion of the health-care workforce to meet sustainable development goal targets, there still exists a shortage of professional health personnel in rural areas of Thailand. To compensate for this, the primary health-care system includes trained village health volunteers who provide basic health care to their communities. Relevant changes Village health volunteers visited more than 14 million households during March and April 2020. Volunteers identified and monitored 809 911 returnees, and referred a total of 3346 symptomatic patients to hospitals by 13 July 2020. Lessons learnt The timely mobilization of Thailand’s trusted village health volunteers, educated and experienced in infectious disease surveillance, enabled the robust response of the country to the COVID-19 pandemic. The virus was initially contained without the use of a costly country-wide lockdown or widespread testing.


Introduction
Thailand reported the first case of coronavirus disease 2019 (COVID-19) on 13 January 2020. On 3 March 2020, the Thai government initiated a mandatory 14-day quarantine for all travellers from countries with high numbers of new cases, and began to promote preventive measures such as the wearing of face masks and regular washing of hands. The number of new cases peaked at 188 per day on 22 March as a result of three clusters of super-spreaders in Bangkok and the southern provinces (Fig. 1). The Thai government contained the transmission and the success was attributable to the primary health-care system, including community (village) health volunteers. [2][3][4] We describe this unique aspect of the health-care system in Thailand and its effect on the response to the pandemic. We demonstrate how the exhaustive surveillance conducted by the volunteers, an approach that goes much further than tracing the contacts of COVID-19-positive cases, was effective in containing the virus. 5

Local setting Primary health care
To provide basic health care to rural areas lacking professional health-care personnel, the Thai health authorities use village health volunteers from local communities. Village leaders and existing volunteers recruit volunteers, who receive an intensive week of training at local health centres in health education, health promotion, disease prevention and basic medical treatment. Since 2004, when volunteers contributed to avian influenza surveillance, training in infectious disease surveillance has also been included. 4 The training is funded by the public health ministry, the sub-district administrative office and provincial health offices, and delivered by local health officers or district or provincial hospital staff. Volunteers are subsequently supervised by sub-district-level health officials. In the situation where volunteers encounter health problems beyond their care abilities, they refer individuals to a health centre or a hospital via health officials.
Over 1 million village health volunteers currently serve their communities, with each volunteer covering five to 15 households within their neighbourhood. The amount of time donated by volunteers varies from a few hours per week to long shifts over a period of several days, depending on the health situation and the particular province. Through their work, the volunteers obtain an awareness of the health-care needs of their community and develop a close relationship with their beneficiaries. 4 Volunteers receive 1000 Thai Bhat (equivalent to 32 United States dollars or around 3 days' minimum wage) per month from the government towards expenses (e.g. travel costs), and this was temporarily increased by 50% during March-December 2020. Other incentives include: discounted hospital costs for volunteers and their families; the opportunity for the offspring of volunteers to become health-care students; the potential honour of receiving a Royal Decoration; or simply the opportunity to serve their communities. 6

COVID-19 response
The Thai government closed all schools on 18 March 2020 and all Bangkok public and business areas on 22 March 2020, declared a state of emergency and enforced a curfew over all Problem To control the increasing spread of coronavirus disease 2019 (COVID-19), the government of Thailand enforced the closure of public and business areas in Bangkok on 22 March 2020. As a result, large numbers of unemployed workers returned to their hometowns during April 2020, increasing the risk of spreading the virus across the entire country. Approach In anticipation of the large-scale movement of unemployed workers, the Thai government trained existing village health volunteers to recognize the symptoms of COVID-19 and educate members of their communities. Provincial health offices assembled COVID-19 surveillance teams of these volunteers to identify returnees from high-risk areas, encourage self-quarantine for 14 days, and monitor and report the development of any relevant symptoms. Local setting Despite a significant and recent expansion of the health-care workforce to meet sustainable development goal targets, there still exists a shortage of professional health personnel in rural areas of Thailand. To compensate for this, the primary health-care system includes trained village health volunteers who provide basic health care to their communities. Relevant changes Village health volunteers visited more than 14 million households during March and April 2020. Volunteers identified and monitored 809 911 returnees, and referred a total of 3346 symptomatic patients to hospitals by 13 July 2020. Lessons learnt The timely mobilization of Thailand's trusted village health volunteers, educated and experienced in infectious disease surveillance, enabled the robust response of the country to the COVID-19 pandemic. The virus was initially contained without the use of a costly country-wide lockdown or widespread testing. a Khon Kaen Regional Hospital, Khon Kaen, Thailand. b Graduate School of Health Innovation, Kanagawa University of Human Services, 3-25-10 Tonomchi, Kawasaki, Kanagawa 210-0821, Japan. Correspondence to Shinji Nakahara (email: snakahara -tky@ umin .net).

Community surveillance of COVID-19 by village health volunteers, Thailand
Nayawadee Kaweenuttayanon, a Ratrawee Pattanarattanamolee, a Nithikorn Sorncha a & Shinji Nakahara b Lessons from the field COVID-19 surveillance by village health volunteers, Thailand Nayawadee Kaweenuttayanon et al.
of Thailand on 26 March 2020, and suspended the arrivals of all international commercial flights on 4 April 2020. To avoid a large increase in unemployment in the capital as a result of these restrictions, the government allowed interprovincial travel during April. Thai citizens working abroad were also permitted to return to Thailand and, after a mandatory 14-day quarantine in Bangkok, to their hometowns. However, the nationwide movement of people in large numbers (at the peak of interprovincial travel, 70 000-80 000 unemployed returned to their hometowns per day) increased the risk of spreading the virus across the entire country. Workers attempting to return to their provinces were therefore screened at airports and train and bus stations; 7 any showing symptoms were referred to the nearest hospital for further testing.

Approach
In preparation for the large-scale movement of people across the country, the public health ministry delivered online courses and local health officers provided in-person training for the volunteers. 2,8 The training included basic knowledge of COVID-19, educating the population in how to stay safe, identifying and monitoring members of the community at high risk (either older people or those with chronic illness such as cardiovascular disease, diabetes or hypertension), and data collection and reporting. Although volunteers could submit hard copies of records, the public health ministry strongly encouraged the online reporting of data using their specially designed smartphone or internet application (app).
After the effective closure of Bangkok, the National Communicable Disease Committee instructed provincial governors to mobilize community health resources to limit the spread of COVID-19 across the country. 7 The provincial health offices assembled local COVID-19 surveillance teams of village health volunteers in all sub-districts. The volunteers were provided with personal protective equipment, such as face shields or goggles, head covers, surgical masks, gloves and raincoats (as substitutes for gowns), by the central and local governments, health offices and in donations from their community.
The local surveillance teams (i) educated their community members about the disease, preventive measures and relevant symptoms to self-monitor and report; (ii) identified and monitored the returnees from Bangkok or abroad, as well as members of the community classified as being at high risk (i.e. recorded temperature and any other symptoms); (iii) reported the list of those being monitored to the sub-district health officials; and (iv) notified the sub-district health officials of symptomatic patients for further action (i.e. referral to a designated hospital for testing and initiating of contact-tracing procedures if positive).
Instead of relying on the contacttracing approach that is only used when a positive case is newly identified, volunteer surveillance teams adopted a strategy involving exhaustive monitoring of individuals arriving from Bangkok and abroad. 9 Volunteers visited their allocated households and requested that any returnees, if encountered, self-quarantine for 14 days at home. The surveillance teams noted the medical histories of any returnees, and encouraged them to report any symptoms daily using a smartphone app. 2 If returnees were not able to use the app, the volunteers conducted daily household visits to record any symptoms while wearing personal protective equipment. Volunteers also continued their usual routine of monitoring the health conditions of other people within their allocated households.
Volunteers used a web-based CO-VID-19 surveillance database, developed by the public health ministry and password-protected to maintain confidentiality, to register all the returnees, returnees who developed symptoms, close contacts of confirmed cases and groups considered to be at high risk. 2,10 In the case where volunteers preferred to complete physical printed forms, local health officers uploaded data to the online system on behalf of the volunteers. The database was also used to record volunteer activities such as household visits for monitoring home quarantine, screening of groups at high risk at the designated areas in their community (e.g. village entrance, market or bus station), and supporting chronically ill or disabled patients. This record was also used as a performance report for each volunteer; maintaining volunteer status is conditional on achieving a satisfactory performance report. 2

Relevant changes
Village health volunteers visited more than 14 million households during the period of interprovincial travel (March to April 2020). The volunteers identified and monitored 809 911 returnees and 64 552 people at high risk, and referred a total of 3346 symptomatic patients to hospitals by 13 July 2020. 10 The countrywide number of new cases steadily declined from the peak on 22 March 2020 to reach less than 10 new cases per day by 27 April 2020 (Fig. 1).

Lessons learnt
In combination with an approach of exhaustive monitoring, the timely mobilization of Thailand's village health volunteers was successful in containing the COVID-19 pandemic. The low number of COVID-19-positive cases in Thailand provides an indication of the robustness of the Thai health-care system in responding to public health emergencies. Volunteers have played a pivotal role in detecting and reporting unusual symptoms among animals and humans since the avian influenza outbreak in 2004; 4 having these functional systems already in place enabled immediate activation of the required response and surveillance activities when the pandemic struck (Box 1). Encouraged and advised by health volunteers, the prompt and thorough self-quarantine of returnees prevented the case numbers from surging as a result of interprovincial travel. Although this approach may be considered excessive by some members of the community, the observed containment of the virus could not have been achieved through case-based methods that require testing of symptomatic patients and epidemiological surveillance skills for contact-tracing. 9 Although digital contact-tracing systems using mobile phones are available in Thailand, some people choose not to use these technologies or may not report positive test results because of their desire for privacy. 5,11 Two important issues remain to be addressed. First, daily visits to potentially infected people may have caused stigmatization of the volunteers in some cases; this could have been addressed by enhanced personal protective equipment and raising awareness of the transmission mechanisms of the virus. 12 Second, the important contribution of the volunteers, their labour-intensive role and their risk of exposure to infected individuals should be recognized. Although steps have been taken to address this issue -for example, the volunteers' monthly allowance was temporarily increased during the height of the pandemic, hospital costs were discounted further for volunteers, and a small number of outstanding volunteers (< 20 per year) receive a Royal Decoration -whether these steps are sufficient is a topic under discussion.
The strategies adopted in Thailand were very different from those of other countries that achieved early containment of the outbreak; as opposed to strict travel restrictions or extensive COVID-19 testing, 13-15 the exhaustive surveillance conducted by the village health volunteers was the most significant contribution to successful containment of the virus. The close relationship of the high-volume volunteer workforce with community members enabled the smooth functioning of the disease surveillance, which might otherwise have been considered an intrusion of privacy. We encourage other resourceconstrained settings to consider such a response in future situations. ■

. Summary of key lessons learnt
• The timely mobilization of Thailand's village health volunteers, educated and experienced in infectious disease surveillance, enabled the robust response of the country's health service to the COVID-19 pandemic. • Following the return of those employed in Bangkok to their rural homes during the widespread closure of businesses, the exhaustive surveillance of all returnees by village health volunteers was crucial in containing the spread of the virus without a costly countrywide lockdown or widespread testing. • The close relationship between the volunteer workforce and members of their rural communities enabled the smooth functioning of the disease surveillance, which might otherwise have been considered an intrusion of privacy.