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This is an online COVID-19 pre-publication manuscript which has been submitted to WPSAR. Pre-publication manuscripts
are preliminary reports and have not been peer-reviewed. They should not be regarded as conclusive,
guide clinical practice/health-related behavior, or be reported in news media as established information.
TITLE: Experiences in COVID-free Vanuatu: initial establishment of surveillance and challenges
of no in-country testing and Tropical Cyclone Harold, January – April 2020
Author: Wendy Williams, Caroline van Gemert, Joanne Mariasua, Edna Iavro, Debbie Fred, Johnny
Nausien, Obed Manwo, Griffith Harrion, Vincent Atua, George Junior Pakoa, Annie Tassiets, Tessa
B Knox, Michael Buttsworth, Geoff Clark, Matt Cornish, Posikai Samuel Tapo, Len Tarivonda,
Philippe Guyant
MANUSCRIPT
Introduction
The World Health Organization (WHO) Western Pacific Region is comprised of 37 Member
States, including the 22 Pacific Island Countries and Territories (PICTs) that are marked by
expansive geography, relatively small populations and diverse cultures. PICTs are vulnerable to
emerging infectious diseases, including epidemics and pandemics, chronic food and water insecurity,
and to natural hazards including cyclones, earthquakes/tsunamis, landslides and flooding. For this
reason, the Asia Pacific Strategy for Emerging Diseases and Public Health Emergencies (1) guides
Member States to adopt an all-hazards approach encompassing both disease outbreaks and natural
disasters in order to strengthen their capacity to detect, prepare for and respond to emerging
infectious diseases and public health emergencies.
Following the declaration by the WHO Director-General that the outbreak of novel coronavirus
disease (COVID-19) constituted a Public Health Emergency of International Concern, six PICTs
have thus far reported confirmed cases of COVID-19 to WHO (2), five of which are also the only
PICTs that currently have in-country capacity to test for the causative agent of COVID-19, severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (3).
In Vanuatu, a country of approximately 290,000 people and comprised of 83 islands, the
response to COVID-19 is guided by the COVID-19 Health Sector Preparedness and Response Plan
initially developed in January 2020 and further revised as the situation evolved (4). Priority actions
within are dependent on the current situation categorised as Scenario 1 (No cases), Scenario 2 (One
or more case/s OR cluster/s of cases) and Scenario 3 (Community transmission, Figure 1). An active
and functional surveillance system is highlighted as a strategic objective of the Plan. Since January
2020, the Government of Vanuatu has implemented several measures to prevent importation of
COVID-19 and mitigate community transmission in Scenarios 1 and 2. These include quarantine of
all incoming passengers, suspension of all international ports of entry into Vanuatu for both land and
sea, and the declaration of a State of Emergency; former encompasses school closures, social
distancing measures, restrictions on inter-island travel, cancellation of large gatherings and sporting
events and other restrictions. Some of these measures were implemented or lifted as the situation
evolved (see www.covid.gov.vu for more information).
In addition to the regional preparedness and response to COVID-19, several PICTs were affected
by Tropical Cyclone (TC) Harold in April 2020 (5). TC Harold impacted Vanuatu on 6-7 April 2020
as a Category 5 cyclone. Over 160,000 people, amounting to around 55% of the Vanuatu population,
resided in areas that were affected by the cyclone (6).
We describe the initial COVID-19 surveillance system established in Vanuatu between January
and April 2020, focusing on its design, challenges, and modifications required based on the local
context of no identified cases, limited laboratory capacity and TC Harold.
Methods
Several data sources are collected in the COVID-19 surveillance system to provide an overview
of the COVID-19 situation in Vanuatu. A schematic view is presented in Figure 1.
Case investigation
Case investigation encompasses assessment and verification of the clinical and epidemiological
criteria, laboratory testing, isolation, contact tracing and quarantine of contacts. Vanuatu’s COVID-
19 testing strategy during Scenario 1 is to test individuals that meet the WHO case definition of a
suspected case (7). In limited circumstances and in consideration of the global shortage of molecular
testing reagents for COVID-19 (8) precautionary testing may be undertaken for additional
individuals. Individuals that meet the WHO case definition have a nasopharyngeal swab collected
and a case investigation is initiated. Between January and April 2020, COVID-19 testing was not
available in Vanuatu and all tests were sent to New Caledonia for laboratory testing. All suspected
and confirmed cases are to be immediately isolated in hospital to prevent onward transmission. Since
February 2020, the Vanuatu MOH has undertaken significant measures to strengthen medical
capacity to manage severe or critical COVID-19 cases including a COVID-19 ICU ward for severe
or critical care patients and a ward for mild cases that cannot be isolated at home.
Contact tracing is conducted to identify close contacts of confirmed cases to determine possible
sources of infection and to prevent onward transmission. Close contacts include people who had
physical contact without PPE or more than 15 minutes of face-to-face close contact (within one
metre) with the suspected cases in the two days prior to and 14 days after symptom onset (7). Any
close contact with current or recent symptoms after exposure to the case is considered to be a
suspected case and is referred to hospitals for isolation and testing as part of active case finding.
Asymptomatic close contacts are quarantined in a designated facility or at home for 14 days from
their last date of exposure (as per Section 12 of the Vanuatu Public Health Act of 1994, see
http://www.paclii.org/vu/legis/num_act/pha1994126/). Quarantine in a designated facility for a
period of 14 days is also required for all people arriving to Vanuatu since 20/3/2020; commercial
flights have been suspended since 20/3/2020 however citizens and residents may return on
repatriation flights.
Syndromic surveillance
Two syndromic surveillance systems are in place; 1) the Vanuatu Public Health Sentinel
Surveillance Network and 2) a network of private clinics in the capital, Port Vila, that report cases of
influenza like illness (ILI). The Vanuatu public health sentinel surveillance network is an existing
surveillance system in Vanuatu and part of the regional Pacific Public Health Surveillance Network
(PPHSN) (9). Eleven sites report weekly on five core syndromes (acute fever and rash, prolonged
fever, ILI, watery diarrhoea and dengue/zika/chikungunya-like-illness) (9). Data are compiled
weekly and sent to the national surveillance unit via email, phone and short message service and are
manually entered into a custom Excel database. ILI data are monitored as the symptoms of COVID-
19 are clinically similar to influenza (
Objectives
and
interventions Scenario 1: No cases
Scenario 2: 1 or more cases,
imported or locally detected
(Sporadic cases) OR
Cluster(s) of cases
Scenario 3: Community
transmission
Early detection and
isolation of
suspected COVID-
19 cases through an
active and
functional
surveillance system
Test suspect cases per
WHO case definition
Train sentinel sites, health
care workers and private
practitioners on case
definition, notification and
reporting channels
Test suspect cases per WHO
case definition
Train (refresher) sentinel sites,
health care workers and
private practitioners on case
definition, notification and
reporting channels
Enhance syndromic
surveillance system focusing
on ILI and COVID-19 in
public health facilities and event-based surveillance
system in private health
facilities.
Contact tracing and
monitoring, test if symptoms
Enhanced syndromic
surveillance system focusing on
ILI and COVID-19 in public
health facilities and event-based
surveillance system in private
health facilities.
Sampling strategy for testing
(depending on number of
suspected cases)
Table 2). A pre-established threshold is set (n~426 per week) to generate an alert and prompt
action if the number of reported cases is greater than expected for seasonal influenza. Standard
reporting is by epiweek, with week 1 ending 5/1/2020, and so forth (Table 3).
An additional sentinel syndromic surveillance system of ILI was established in March 2020
amongst private clinics in Port Vila. The objective is to rapidly identify imported cases and monitor
community-level transmission of COVID-19. Private medical clinics are requested to submit daily
reports via a web-form the number of consultations and the number of people presenting with ILI,
Objectives
and
interventions Scenario 1: No cases
Scenario 2: 1 or more cases,
imported or locally detected
(Sporadic cases) OR
Cluster(s) of cases
Scenario 3: Community
transmission
Early detection and
isolation of
suspected COVID-
19 cases through an
active and
functional
surveillance system
Test suspect cases per
WHO case definition
Train sentinel sites, health
care workers and private
practitioners on case
definition, notification and
reporting channels
Test suspect cases per WHO
case definition
Train (refresher) sentinel sites,
health care workers and
private practitioners on case
definition, notification and
reporting channels
Enhance syndromic
surveillance system focusing
on ILI and COVID-19 in
public health facilities and
event-based surveillance system in private health
facilities.
Contact tracing and
monitoring, test if symptoms
Enhanced syndromic
surveillance system focusing on
ILI and COVID-19 in public
health facilities and event-based
surveillance system in private
health facilities.
Sampling strategy for testing
(depending on number of
suspected cases)
Table 2).
Hospital-based surveillance
Active hospital-based surveillance activities were established in April 2020 as part of the
COVID-19 response and in addition to Health Information System data reporting. The purpose is to
monitor and rapidly identify any Severe Acute Respiratory Infections (SARI) or pneumonia-related
emergency department presentations, hospitalisations and/or deaths. Data are collected daily from
the main referral hospital in Port Vila and five provincial hospitals around the country (
Objectives
and
interventions Scenario 1: No cases
Scenario 2: 1 or more cases,
imported or locally detected
(Sporadic cases) OR
Cluster(s) of cases
Scenario 3: Community
transmission
Early detection and
isolation of
suspected COVID-
19 cases through an
active and
functional
surveillance system
Test suspect cases per
WHO case definition
Train sentinel sites, health
care workers and private
practitioners on case
definition, notification and
reporting channels
Test suspect cases per WHO
case definition
Train (refresher) sentinel sites,
health care workers and
private practitioners on case
definition, notification and
reporting channels Enhance syndromic
surveillance system focusing
on ILI and COVID-19 in
public health facilities and
event-based surveillance
system in private health
facilities.
Contact tracing and
monitoring, test if symptoms
Enhanced syndromic
surveillance system focusing on
ILI and COVID-19 in public
health facilities and event-based
surveillance system in private
health facilities.
Sampling strategy for testing (depending on number of
suspected cases)
Table 2). In some provincial hospitals, data forms were expanded to facilitate monitoring of
injuries and illnesses arising from the impact of TC Harold. In addition, data on the hospital
pharmacy dispensing of paracetamol through the emergency department is collected weekly. A
surveillance officer contacts all hospitals daily to verbally collect information on new admissions for
SARI and/or pneumonia, and paracetamol dispensing. .
Laboratory surveillance
Laboratory surveillance, separate to laboratory-testing as part of case investigation as described
above, includes testing data for influenza A and B and is conducted at the main referral hospital in
Port Vila (
Objectives
and
interventions Scenario 1: No cases
Scenario 2: 1 or more cases,
imported or locally detected
(Sporadic cases) OR
Cluster(s) of cases
Scenario 3: Community
transmission
Early detection and
isolation of
suspected COVID-
19 cases through an
active and
functional
surveillance system
Test suspect cases per
WHO case definition
Train sentinel sites, health
care workers and private
practitioners on case
definition, notification and
reporting channels
Test suspect cases per WHO
case definition
Train (refresher) sentinel sites,
health care workers and
private practitioners on case
definition, notification and
reporting channels Enhance syndromic
surveillance system focusing
on ILI and COVID-19 in
public health facilities and
event-based surveillance
system in private health
facilities.
Contact tracing and
monitoring, test if symptoms
Enhanced syndromic
surveillance system focusing on
ILI and COVID-19 in public
health facilities and event-based
surveillance system in private
health facilities.
Sampling strategy for testing (depending on number of
suspected cases)
Table 2). As noted above, in-country laboratory testing was not available during the period
January-April 2020.
Ethics statement
The Vanuatu Health Ethics Committee advised that ethics approval was not required as data were
collected as part of the pandemic response and in line with the Vanuatu Public Health Act of 1994
and only routinely collected and non-identifiable data were collated.
Results
Case investigation and management
To date, specimens from 19 people (24 samples) have been sent to New Caledonia for SARS-
CoV-2 testing. Due to borders control measures in place in both Vanuatu and New Caledonia, each
dispatch of samples has required government approval and significant logistical coordination.
Among the 19 individuals tested thus far, the average number of days from specimen collection to
testing was 3.4 days. Of these, only two samples were from patients that met the WHO suspected
case definition, with remainder precautionary testing. None of the samples tested positive. Both
suspected cases were isolated at home.
To date, a total of 98 people have been released from government-designated quarantine
facilities. The majority of these people (n=61, 62%) were passengers on the two last flights arriving
into Vanuatu on 21/3/2010 and the remainder were associated with a cruise-ship visit to an outer
island that subsequently was found to have had had passengers who tested positive for COVID-19
(10).
Syndromic surveillance
The number of ILI cases reported through the Vanuatu Public Health Sentinel Surveillance
Network fluctuated between epi-week 1 (EW1, refer to Table 3) and EW17 (range 156-489). In
EW18, there were 212 reports of ILI, an increase of 25 since the previous week (n=237). The number
of ILI reports is not currently near the threshold (Table 3).
Among reports submitted from seven clinics in the GP sentinel-surveillance system between
EW14-EW18, there were also fluctuations in consultations for ILI (range 6-45) and a sustained
increase has not been observed (Table 3).
Hospital-based surveillance
Only pneumonia-related hospitalisation data was available for the time period. Pneumonia
hospitalisation data were received from five of six hospitals in Vanuatu since EW14. The number of
new admissions for pneumonia decreased from four in EW14 to one in EW18 (Table 3). Paracetamol
dispensed through the emergency department was greatest in EW17 (n=1370, Table 3).
Laboratory surveillance
Between EW1 and EW17, 22 samples were tested for influenza A and B and one was positive for
influenza A.
Discussion
The purpose of a national surveillance system is dependent on its’ pandemic response strategy as
well as the local epidemiological context and laboratory and health facility capacity. The purpose
may therefore be to identify severe cases, to identify asymptomatic cases, to identify clusters of
cases, or a combination of these. The aim of surveillance for COVID-19 in Vanuatu in the current
scenario of no cases is to rapidly detect and contain any imported cases. This relies on timely and
accurate laboratory testing. The absence of in-country laboratory testing between January and April
2020 limited Vanuatu’s initial capacity to respond effectively to the COVID-19 threat. This is likely
to change imminently in Vanuatu (and several other PICTs). In March 2020, Cepheid received
approval from the US Food and Drug Administration for a rapid molecular test that could be
operated on the GeneXpert platform, which provides fully automated, easy-to-use point-of-care
molecular testing (11). Vanuatu has four GeneXpert machines, used for rapid detection of TB and
other infections. In response to the need for local testing capacity in PICTs, a Joint Incident
Management Team (including the Australian Department of Foreign Affairs, the New Zealand
Ministry of Foreign Affairs and Trade, SPC, WHO and the Pacific Island Health Officers'
Association) procured GeneXpert cartridges and machines from Cepheid for distribution in the
Pacific (12). Once in-country testing is available, it is imperative to develop and implement a clear
testing strategy in Vanuatu that considers both the epidemiological situation in Vanuatu and the
anticipated limited availability of cartridges given that distribution will be staggered and the global
shortage of consumables, including swabs.
The absence of confirmed cases in Vanuatu, and other countries, cannot be interpreted as absence
of circulating virus. This is particularly true in countries where there is limited or no laboratory
testing capacity. Currently, international guidance is not available on how to verify the absence of
confirmed cases. Data collected in the various syndromic surveillance systems in Vanuatu will
continue to be used to monitor and verify Vanuatu’s absence of confirmed cases. Severe and critical
cases comprise around 20% of diagnosed cases of COVID-19 internationally (13) and therefore we
assume that any undetected circulating cases in the community would result in an increase in ILI in
primary health care facilities and pneumonia in hospitals. Testing of a proportion of mild ILI cases in
the community (~80% of cases), dependent on the supply of laboratory tests, would complement data
presented here.
In the context of no confirmed cases and the absence of widespread availability of
pharmaceutical interventions, such as treatment or vaccination, border re-opening may result in
importation of COVID-19 to Vanuatu. The role of the various surveillance components described
here is critical to rapidly detect and contain any imported cases. Mathematical modelling data to
predict the impact of imported cases to Vanuatu using current population data and COVID-19
parameters is currently not available for Vanuatu but would be useful to guide the evolving response.
Several limitations should be considered when considering the implementation of the Vanuatu
COVID-19 surveillance; these include pre-existing clinical and public health workforce shortages,
limited existing epidemiological capacity within the Vanuatu MOH, geographical isolation, small
population and the limited laboratory capacity. Additional workforce shortages and competing
priorities have been experienced in the response post TC Harold. Nonetheless, the Vanuatu MOH
and partners have rapidly scaled up surveillance activities in a complex, challenging and rapidly
changing epidemiological landscape.
The COVID-19 response is continuing in Vanuatu, and will adapt as the epidemiological context
changes. Learnings from the early implementation of surveillance activities during Scenario 1, the
changing landscape of laboratory-testing and pharmaceutical interventions, as well as the global
experience, particularly in other PICTs, will inform the refinement of COVID-19 surveillance
activities in Vanuatu.
Acknowledgements
**The Vanuatu Ministry of Health Emergency Operations Centre is comprised of the following
individuals from the following organisations: Vanuatu Ministry of Health (Agnes Matthias, Cassidy
Vusi, Edmond Tavala, George Pakoa, Henry lakeleo, Henry lakeleo, Jean Jacques Rory, Jimmy
Obed, Julian Lasekula, Karel Haal, Kenslyne Lele, Len Tarivonda, , Leonard Tabilip, Mahlon Tari,
Melissa Binihi, Menie Nakomaha, Meriam Ben, Nellie Ham, Nerida Hinge, Rebecca Iaken, Renata
Amos, Robinson Charlie, Roderick Mera , Russel Tamata, Sam Posikai, Sam Mahit, Sandy Moses
Sawan , Sero Kalkie, Vincent Atua, Viran Tovu, Wendy Williams, Wesley Donald, Wilson Lilip,
Yvette Nale), Australian Volunteers Program (Danielle Clark, Melanie Wratten), IsraAid (Kristina
Mitchell), RedR (Rowan Lulu), SPC (Mia Ramon), UNFPA (Emily Deed), UNICEF (Lawrence
Nimoho, Rebecca Olul, Suren Vanchinkhuu), Vanuatu Health Program (Caroline van Gemert, Geoff
Clark, Jack Obed, Nish Vivekananthan, Shirley Tokon, Tim Egerton), World Health Organization
(Fasihah Taleo, Griffith Harrison, Michael Buttsworth, Myriam Abel, Philippe Guyant, Tessa Knox,
Tsogy Bayandorj).
Thank you to clinics participating in the private clinic sentinel surveillance system, including
Novo Medical, The Medical Centre, Family Care Centre, NTM, Medical Options, and Vanuatu
Private Hospital. Thank you also to all the health facilities participating in the PPHSN and/ hospital
surveillance.
Caroline holds an Early Career Research Fellowship, funded by the Australian National Health
and Medical Research Council. The Vanuatu Health Program is funded by the Australian
Department of Foreign Affairs and Trade Australian Aid program.
Conflicts of interest
All authors declare no conflicts of interest.
Ethics statement
The Vanuatu Health Ethics Committee advised that ethics approval was not required as data were
collected as part of the pandemic response and in line with the Vanuatu Public Health Act of 1994
and only routinely collected and non-identifiable data were collated.
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(8 April 2020). Port Vila, Vanuatu: Vanuatu Ministry of Health; 2020.
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TABLES AND FIGURES
Table 1Main objectives and interventions of the surveillance response to COVID-19, as per the C OVID-19 Health Sector
Preparedness and Response Plan
Objectives and
interventions Scenario 1: No cases
Scenario 2: 1 or more cases,
imported or locally detected
(Sporadic cases) OR
Cluster(s) of cases
Scenario 3: Community
transmission
Early detection and
isolation of
suspected COVID-
19 cases through an
active and
functional
surveillance system
Test suspect cases per
WHO case definition
Train sentinel sites, health
care workers and private
practitioners on case
definition, notification and
reporting channels
Test suspect cases per WHO
case definition
Train (refresher) sentinel sites,
health care workers and
private practitioners on case
definition, notification and
reporting channels
Enhance syndromic
surveillance system focusing
on ILI and COVID-19 in
public health facilities and event-based surveillance
system in private health
facilities.
Contact tracing and
monitoring, test if symptoms
Enhanced syndromic
surveillance system focusing on
ILI and COVID-19 in public
health facilities and event-based
surveillance system in private
health facilities.
Sampling strategy for testing
(depending on number of
suspected cases)
Table 2. Summary of sentinel and hospital surveillance activities related to COViD-19
Number of
sites
Coverage Site type and
number
N weeks
reporting
Data used for
COVID-19
surveillance
PPHSN 11 National Hospital (n=6)
Health centre (n=5)
Ongoing ILI
GP sentinel sites 7 Port Vila
only
Private GP clinics
(n=
Primary health
clinics
Since 23
March 2020
ILI
Hospital-based
surveillance
6 National Hospital (n=6) Since 20
March 2020
ILI (captured through
PPHSN)
Pneumonia
Death
Paracetamol
dispensing
Laboratory
surveillance
1 National Hospital laboratory
(n=1)
Ongoing Influenza
Table 3. Data collected in various surveillance activities, by epi-week
Start End Epi-
week
ILI
(Vanuatu
public
health
sentinel
surveillance
network)
ILI (private
clinic
syndromic
surveillance)
Pneumonia
(hospital
surveillance)
Paracetamol
dispensed
through ED
5/01/2020 1 489 NC NC NC
6/01/2020 12/01/2020 2 250 NC NC NC
13/01/2020 19/01/2020 3 205 NC NC NC
20/01/2020 26/01/2020 4 341 NC NC NC
27/01/2020 2/02/2020 5 191 NC NC NC
3/02/2020 9/02/2020 6 238 NC NC NC
10/02/2020 16/02/2020 7 205 NC NC NC
17/02/2020 23/02/2020 8 171 NC NC NC
24/02/2020 1/03/2020 9 319 NC NC NC
2/03/2020 8/03/2020 10 198 NC NC NC
9/03/2020 15/03/2020 11 292 NC NC NC
16/03/2020 22/03/2020 12 273 NC NC NC
23/03/2020 29/03/2020 13 268 18 NC NC
30/03/2020 5/04/2020 14 224 45 4 50
6/04/2020 12/04/2020 15 156 40 4 170
13/04/2020 19/04/2020 16 209 14 2 915
20/04/2020 26/04/2020 17 237 6 1 1,340
27/04/2020 3/05/2020 18 212 13 1 790
NC=not collected as additional surveillance activities were implemented in March 2020
Figure 1. Health facility-level application of surveillance activities in Vanuatu, March-April 2020
Based on the Covid-19 severity pyramid, presented in (14)
