‘If you can detect an outbreak early, then you can have better control’: Dr. Arun Balajee

Dr. Arun Balajee knows all too well what often happens – and doesn't happen – when a pathogen emerges in a community, having coordinated numerous infectious disease outbreak investigations, including Ebola, MERS CoV, and SARS CoV2.

Dr. Balajee, who is currently Senior Specialist, Pandemic Surveillance, in the Technical Advice and Partnerships Department, at the Global Fund, has a decade of field experience designing and implementing surveillance programs. In her former role as Associate Director for Global Health Sciences in the Division of Viral Diseases at the US Centers for Disease Control and Prevention, she led a team of epidemiologists who implemented early warning surveillance in countries around the world.

Exemplars News spoke with Dr. Balajee, who also sits on the Technical Advisory Group for the Advance Warning and Response Exemplars (AWARE) project, about her work on event-based surveillance and early warning systems and AWARE, including her lessons learned from containing deadly outbreaks.

Could you tell us about yourself and how you came to be interested in surveillance and early warning systems?

Dr. Balajee: I started my career as a researcher. I was a molecular biologist at the University of Washington. I started working at the US CDC 18 years ago. I spent my first couple of years setting up early programs to understand outbreaks – specifically how do you detect an outbreak using lab-based methods? I was later deployed to Haiti just after the 2010 earthquake. Within a few months of the earthquake, the country had its first cholera outbreak in reported history. That's when I started to understand how important it is for countries like Haiti to have a system in place to detect early cases of things like cholera when they happen.

After working with Haiti for two years, I started working in environments such as refugee settings to implement early warning surveillance in low-resource settings. These experiences gave me a deep understanding of why there needs to be a minimum infrastructure and capacity for detecting [disease outbreaks].

With surveillance, you need to have options depending on the context – a Kia, an Audi, or maybe a Rolls-Royce model – that are fit for purpose. In some countries, you just can't start with the high-end model. You have to build it in a phased way. You have to ask – what is the fundamental basic capacity the countries need to have? For surveillance, you have to start with early warning surveillance. If you can build a sustainable system to detect and control outbreaks, then everything else is gravy.

Could you tell us about your work on event-based surveillance and early warning systems at the Global Fund?

Dr. Balajee: When I came to the Global Fund, there was an interest in thinking about what areas of pandemic preparedness would best suit the organization. As you probably know, the Global Fund has been putting in place capacities for HIV, TB, and malaria for the past two decades. [Event-based surveillance] is something very new for the organization. I think that, before I came, they had recognized there were opportunities to also strengthen pandemic preparedness and then they received significant COVID-19 response money to help countries respond to the pandemic.

When I came in [to the organization] and better understood the Global Fund system, I discovered there were three areas the Global Fund really excels in – community health worker capacity building, community engagement, and health systems strengthening. It's a country-driven process. And one of the key components of event-based surveillance is engaging all walks of community and building trust with communities so they report [potential outbreaks] early.

I always think about those signs you see in airports – if you see something, say something. That's exactly what we want to do with event-based surveillance. We want communities to trust public health systems and governments. We want them to understand that when something is happening [like an outbreak], they can pick up the phone or walk into a public health department and say something.

Because of the Global Fund's experience with key HIV and TB populations and supporting malaria initiatives, they know how to [encourage these behaviors]. Which is why layering event-based surveillance on top of their fundamental strengths in countries was very appealing to the Global Fund, as well as me. We want to offer countries the additional resources to build on what they already have for pandemic preparedness.

How did the COVID-19 pandemic underscore the need for surveillance to anticipate emerging infections and offer early outbreak warnings?

Dr. Balajee: That's a very difficult question – I've been thinking about this for some time now. First of all, COVID-19 is an extraordinary case. It's highly transmissible and would have been difficult to contain even if we had tried to control the outbreak more quickly, unless it had been detected very, very early and aggressive containment measures had been taken quickly. The whole idea of event-based surveillance and early-warning surveillance is to detect the first few cases and be able to control [the outbreak] at the source. But this was not only a highly transmissible disease, it was a highly politicized one as well. It's very difficult to know what role an early-warning surveillance system could have played, because it was also a political challenge.

If an optimal event-based surveillance and early-warning surveillance system had been in place, then a clinician could have recognized a couple of cases from the same market suffering from the same illness. Or a person in the market could have called the public health department saying, 'Four of my workers haven't shown up. I'm hearing one is dead.' If the system had been optimal and the virus was not quite so transmissible, we would have seen very early that something was going on there. If that had been the case, we could have controlled it – maybe closed the borders, maybe told people and other countries quickly that something was emerging.

That wasn't exactly possible in the COVID-19 situation. But we know from our multiple experiences with Ebola that, if you have the systems in place, you can detect the first case or two and control it more quickly. Every outbreak, we learn the same lessons, that early detection and recognition is key to control. Over the past two years, there's been an increasing ask of the Global Fund and the WHO and other agencies by countries to support early-warning surveillance. We hear anecdotally [from countries] that if we had event-based surveillance and early warning surveillance, then maybe we could have detected some of these outbreaks more rapidly and controlled them better.

You’ve worked in numerous infectious disease outbreak investigations including Ebola, MERS CoV, and SARS CoV2. What are some of your lessons learned? 

Dr. Balajee: Let's take the example of MERS coronavirus in Riyadh, in Saudi Arabia, in 2012. The clinician who saw the case didn't quite understand it, but he saw that it was different from what he usually saw. He collected a specimen and sent it to a lab. The sample didn't test [positive] for known pathogens, so the clinician sent it to the Netherlands for testing. In the meantime, the patient passed away. Three months later, he got the results back saying that it was a new pathogen. There were so many lessons there. This clinician was vigilant and recognized that something unusual was happening and he reached out. That's what we want. We want clinicians – and communities – to say, 'Look, this is not ordinary, and we want to elevate this to the public health department to help us investigate.’

Here’s another example – as we were setting up early warning systems in Vietnam in June of 2018, there was an outbreak at a rubber plantation in a province near the border with Cambodia. A young man got sick, sought care at a local health station where he was given antibiotics, but he died. A few days later, a second young man developed a similar illness and sought care at a different facility. The clinicians there also failed to recognize the cause of his illness and he also died.

At that point, a plantation worker notified the community health station that there was an unusual cluster of severe illnesses among the workers on his plantation, including some deaths. The community health station subsequently notified district authorities who immediately came out to investigate. They determined that the outbreak was due to diphtheria and launched a large vaccination campaign, administering 10,000 doses of vaccine and effectively preventing further spread of the disease.

This is a great example of an early warning system where community health workers and prominent members of the community were sensitized to the importance of recognizing unusual events and reporting them immediately, even when the cause was unknown. It also illustrates the limitations of surveillance systems that are based solely on health care networks that require clinicians to both recognize an illness that might not have a classic appearance and know when it’s occurring as part of a cluster.

Could you tell us about the AWARE project and what you’re hoping to accomplish, especially in terms of helping to mitigate outbreaks of pathogens of pandemic potential and climate-sensitive infectious diseases?

Dr. Balajee: I'll start my answer this way – you could have asked me, 'If this is so important, why isn't every country demanding this be done? Why, after all these outbreaks, do we not have these systems in place already?' That's a question I constantly ask myself. If early warning surveillance systems are so important, shouldn't every country actually want to have them, and shouldn't donors support them? We are hoping AWARE can provide some insight into opportunities and challenges to make these systems more sustained.

However, there are barriers to implementing these systems in an optimal way. Firstly, there are clear governance challenges – there is often suboptimal governance and leadership to implement sustainable, scalable models of early warning systems. So [the AWARE project] will be looking at the barriers to governance and asking questions about how they can be solved. Another aim of the project is to understand the barriers and opportunities of engaging communities in reporting. What are the needs of the communities? Do they trust the public health system?

What are some of the barriers and facilitators to developing, implementing, and sustaining robust early warning systems, especially in LMICs?

Dr. Balajee: In some cases, there's massive fragmentation at the country level in terms of who's doing what. There are a lot of different departments responsible for different parts of early warning surveillance. Bringing them all together and speaking with one voice is challenging. Donors also fund these different departments in different ways, so there's no incentive to actually defragment. How can one fund these systems more sustainably? How do we bring in communities more routinely including the private sector for improved reporting? How do we keep communities adequately sensitized and engaged? And what is a cost-effective way of doing all this? AWARE may be providing some much-needed answers.