Table of Contents

Foreword ………………………………………………………………………………………………………... 3
Acknowledgement ............................................................................................................................ 4
Use of the Manual of Procedures .................................................................................................... 6
List of abbreviations …………………………………………………………………………………………. . 8
Definition of Terms ....................................................................................................................... 10

I. Introduction ………………………………………………………………………………………………. .. 12
A. Event-based Surveillance vs. Indicator-based Surveillance of PIDSR ............................ 13
B. Policies/Guidelines in Support of ESR .......................................................................... 13

II. Objectives and Framework ........................................................................................................ 15

A. Objectives .................................................................................................................... 15
B. Basic Features ............................................................................................................. 16
C. ESR Framework .......................................................................................................... 17

III. ESR Processes ........................................................................................................................ 19

A. Capture ........................................................................................................................ 19
B. Filter ............................................................................................................................ 21
C. Verification ................................................................................................................... 21
D. Assessment ................................................................................................................. 21
E. Response .................................................................................................................... 24
F. Feedback and Information Dissemination ..................................................................... 25

IV. Online ESR ……………………………………… ........................................................................... 27

A. Objectives ………………………………………………………….…………………………..... 27
B. Guiding Principles ……………………………………………………………………………… 27
C. System Architecture ………………………………………………….………………………... 28
D. Users and Types of User Accounts ………………………………………………………… .. 29
E. Roles and Responsibilities …………………………………………………………………… . 30
F. Composition of Online ESR Unit and Staff …………………………………………………. . 31

V. Forms ……………………………………………………………………………………………………… 33
A. Standard Forms for ESR ................................................................................................ 33
A.1. ESR Captured Health Event Log Sheet ……………………………………..……….. 33
A.2. ESR Verification Form ……………………………….………………………………........ 33
A.3. ESR Follow-up Form …………………………………………………………………… ... 35
B. Criteria on Status of Health Event ……………………………………………………….…. ... 37

1
 B.1. Criteria for an ongoing event ………………………………………………………… ...... 37
B.2. Criteria for controlled event ……………………………………………………………… . 37
B.3. Criteria for closing an event …………………………………………………… ............... 37
C. Filling up of ESR Forms… ………………………………………………………………… ...... 38

VI. ESR Unit ................................................................................................................................. 39

A. Physical Structure ........................................................................................................ 39
B. Staff Requirements ...................................................................................................... 39
C. Relationship with Other Agencies ................................................................................. 40
D. Roles and Responsibilities of Different Levels of Health System ................................... 41
E. Archiving and Confidentiality ........................................................................................ 42

VII. Monitoring and Evaluation of ESR Unit .................................................................................. 43

A. Objectives of M and E .................................................................................................. 43
B. Significant Indicators .................................................................................................... 43

VIII. Annexes ………………………………………………………………………………………………….. 46

Annex 1a. ESR Captured Event Log Sheet …………………………………………………… .. 47
Annex 1b. ESR Verification Form ……………………………………………………………... .. 48
Annex 1c. ESR Follow-up Form ……………………………………………………………….. .. 49
Annex 1d. Weekly Feedback Report Form …………………………………………………… .. 50
Annex 2. Flowchart on the Use of IHR Annex 2 ……………………………………………… .. 51
Annex 3. List of Addressees of ESR Reports ………………………………………………… .. 52
Annex 4. Designation of the National Epidemiology Center (NEC) as the National……... .... 62
International Health Regulations Focal Point (NFP)
Annex 5. ESR Monitoring and Evaluation Tool ………………………………………….…… .. 63

2
 Foreword

In the revised 2005 International Health Regulations (IHR), there was a call to its Member
States to designate a National Focal Point for the IHR. The members were also encouraged to maintain
and strengthen their core capacities for surveillance and response. In response to IHR, the Secretary
of Health through Administrative Order 2007-002 designated the National Epidemiology Center (NEC)
as the International Health Regulations Focal Point for the Philippines. The DOH-NEC in collaboration
with the World Health Organization (WHO) has decided to formally institutionalize the Event-based
Surveillance and Response (ESR) and the first move is the creation of the ESR Manual of Procedures.

The Manual of Procedures (MOP) will describe in detail the processes involve in the ESR. It
will also serve as a guide for those who will be implementing, adapting or supporting the system. The
development of ESR-MOP also serves as an important stepping stone to meet many of the new
obligations under IHR (2005), particularly the core capacity requirements for surveillance and response.

ESR has been in existence since 2004, also known as the Epidemic Intelligence Unit (EIU), in
which its core function is to collect, verify, assess and give appropriate response to any information
(formal or informal) that may pose untoward health event in the community. In line with the DOH thrust
in strengthening the surveillance system, the ESR was designed to complement the Philippine
Integrated Disease Surveillance and Response (PIDSR), the existing structured surveillance arm of the
DOH. ESR would complement the PIDSR in terms of its ability to easily pick-up information on health
events that may pose a risk in the communities and be able to provide an appropriate response to those
places where PIDSR is not yet fully functional or established. It would also cater for those diseases
and other health events (e.g. Ebola on pigs, salmonella in peanut butter, etc.) that are not covered by
the PIDSR.

The development of the ESR-MOP is an important initiative in institutionalizing the Event-based

Surveillance thus the combination of the PIDSR and ESR would be a milestone in terms of the country’s’
health surveillance system. We are very grateful for the support of the stakeholders and partners at the
international, national, regional and local levels for all their contribution in the accomplishment of this
ESR-MOP.

In 2013, ESR online reporting was pilot-tested and implemented in 2 regions (I and VI) in
collaboration with Knowledge Management and Information Technology Service (KMITS). In 2014, it
was rolled-out nationwide.

3
 ACKNOWLEDGEMENTS

The contributions and technical inputs of the following organizations, consultants and staff in
the development of this manual of procedure are greatly acknowledged.

Enrique A. Tayag, MD, PHSAE, FPSMID, CESO III Jessie Glen L. Alonsabe, MD, PHSAE
Director IV, Epidemiology Bureau RESU Head, Regional Office VI

Ma. Nemia L. Sucaldito, MD, PHSAE AuroraTeresa Daluro, MD, MPH, PHSAE
Division Chief, Applied Epidemiology Health RESU Head, Regional Office V
Management Division, Epidemiology Bureau
Rosario Pamintuan, MD, PHSAE
Juan M. Lopez, MD,PHSAE, PGradDipPH, MPH + RESU Head, Regional Office I
OIC, Director III, PNAC
Tamano Matsui, MD
Charito P. Aumentado, MD, MPH, PHSAE Consultant, DSE/ESR
World Health Organization WHO-WPRO

Joy Althea Pabellon, MD, PHSAE Edna M. Lopez, RN

FETP Alumni Epidemiology Bureau

Joselito Feliciano, MD, PHSAE Noel Orosco, RN, PHSAE

Medical Officer III , PNAC Consultant

Vikki Carr de los Reyes, MD, PHSAE Boyd Roderick Cerro, RN

Medical Specialist III RESU Nurse, Regional Office VIII
Epidemiology Bureau
Mark Salvador, RN (resigned)
Rosanna Rosell, RN, PHSAE Nurse II, National Epidemiology Center
Nurse II, Regional Office III
Karen B. Lonogan, RN
Ma. Justina G. Zapanta, RN Nurse I, Regional Office CAR
Nurse II, Epidemiology Bureau
Julius Velasquez, RN
Julius Erving Ballera, RN Nurse II , Epidemiology Bureau
Nurse II , Epidemiology Bureau
Gilberto D. Santos
Patricia Aubrey Fariñas, RN (resigned) Librarian II, Epidemiology Bureau
Nurse II, Epidemiology Bureau
Vilma V. Diez, MD, PHSAE
Herdie L. Hizon Epidemiology Bureau
Supervising Health Program Officer
Epidemiology Bureau Jovita Aragona
Knowledge Management & Information
Nancy Dabu, RN Technology Service
Nurse II, Epidemiology Bureau
Rowena Capistrano
Cherrie Esteban Research Institute for Tropical Medicine
Knowledge Management & Information
Technology Service Carmina Balbin, RN
Nurse I, Epidemiology Bureau
Troy Vincent Lucena Denisse Lou Manalili, RN
Knowledge Management & Information Nurse I, Epidemiology Bureau
Technology Service
Glenda Pajarillo, RMT
Issa Fe Erwa Regional Office I
Knowledge Management & Information
Technology Service Victor Lorca
Regional Office VI

4
Ma. Cecilia Montaño
Regional Office VI Charito B. Boado, RMT
Health Program Researcher, RO I
Victoria L. Malicdan, RN
Nurse III, RO CAR Ruth P. Tio, RN, RM, MAN
RESU Assistant Program Coordinator, RO IV-A
Aldrin S. Adriano, RN
Nurse III, NCRO Rudilio S. Divino
Computer Operator III, NCRO
Julius Cesar T. Estrada, RN, MPH
Nurse III, RO II Manuel C. Mapue II, RMT, MD, CFP, PHSAE
Head, RESU NCRO
Alethea R. De Guzman, MD, MCHM
Development Management Officer IV, RO II Albert D. Anduyon
Data Manager, RITM Surveillance Unit
Leodymar H. Jorduela, RN
Nurse II, RO III Ayr R. Altavas, RN
Nurse II, Capiz PHO
Alah Baby Columna-Vingno, MD, PHSAE
RESU/HEMS Chief, RO XII Kathleen R. Gecosala, RN
Nurse I, RO XII
Arnel Santiago
Epidemiology Assistant, RO V Ardhel J. Peñaflor, RN, MPA
Health Program Researcher, RO XII
Monina P. Araña, BSCoE, MGM
Computer Programmer I, KMITS

We also acknowledge the contributions of other individuals and partners not mentioned above,
who worked with NEC during the development of the content of this document.

5
Purpose of the Manual

The manual provides general guidance on event-based surveillance and response. It is intended for
use as:

 A general reference for event-based surveillance and response activities across all levels.

 A resource for training, monitoring, supervision and evaluation of event-based surveillance

and response activities.

 A guide for improving early detection and preparedness of unusual and rare health events
activities.

Who should use this manual?

This manual is designed to be used primarily by the Epidemiology Bureau-Event-based

Surveillance and Response Unit (EB-ESRU) and all the units involved in the Event-Based Surveillance
and Response (ESR). The EB-ESRU will be housed at the Epidemiology Bureau. It will be responsible
in providing guidelines and direction in the implementation of the ESR nationwide. The Manual was
developed:

1. To provide guidelines on the operation and management of Event-based Surveillance and

Response (ESR);
2. To serve as reference for surveillance activities in the early detection of events and timely
response to outbreaks;
3. Guide health personnel and the general public on reporting events which are potential risk to
public health;
4. To define the roles of other Government agencies in ESR to help them understand the meaning
of health events with potential public health risk.
5. To guide health facilities understand the ESR processes and procedures, their roles and
upgrade the capabilities. Health facilities are partners in the future evolution of ESR.

How the Manual was Developed

This manual was developed based on guidelines provided by WHO on setting-up Early Warning
System and Event-Based Surveillance and Response as well as with consultation with the different staff
of the Epidemiology Bureau, regional and local ESUs and representatives from other offices such as
Health Emergency and Management staff and Media Relations Unit.

Major Sections of the Manual

The guide is divided into seven sections as follows:

I. Introduction – briefly provides background on the development of ESR to complement the

existing Philippine Integrated Disease Surveillance and Response (PIDSR). It also enumerates
the existing policies to support the implementation of ESR.

6
II. Objectives and Framework – provides description and definition of an Event-Based
Surveillance and Response. It describes the framework that guides its implementation.

III. ESR Processes – enumerates and define the different ESR processes and the criteria for each
processes.

IV. Online ESR System – provides guidelines on the use of web-based technologies in reporting
health events

V. ESR Unit – defines the roles and responsibilities of each staff of the ESR Unit. It also provides
the roles and functions of agencies that may be involved in the ESR implementation.

VI. Standard ESR Forms – describe the different ESR forms to be used for recording and
reporting. It also provides the flow of reports from the different level.

VII. Monitoring and Evaluation of ESR Unit – describes the different indicators to be used in
monitoring the ESR implementation

7
 List of abbreviations

APSED Asia Pacific Strategy for Emerging Diseases

AFRIMS Armed Forces Research Institute of Medical Sciences

BAI Bureau of Animal Industry

BPI Bureau of Plant Industry

BFAR Bureau of Fisheries and Aquatic Resources

BOQ Bureau of Quarantine

CESU City Epidemiology and Surveillance Unit

DOH Department of Health

DENR Department of Environment and Natural Resources

DESU District Epidemiology and Surveillance Unit

EB Epidemiology Bureau

ESR Event-based Surveillance and Response

ESU Epidemiology and Surveillance Unit

FDA Food and Drug Administration

HEMB Health Emergency Management Bureau

IHR International Health Regulations

KMITS Knowledge Management and Information Technology Service

KP Kalusugan Pangkalahatan

LESU Local Epidemiology and Surveillance Unit

MDG Millennium Development Goals

MESU Municipal epidemiology and Surveillance Unit

MRU Media Relation Unit

NPMCC National Poison Management Control Center

NDCPB National Disease Control and Prevention Bureau

NFP National Focal Point

NMIS National Meat Inspection Service

OPCEN Operation Center

PAWB Protected Areas and Wildlife Bureau

8
PESU Provincial Epidemiology and Surveillance Unit

PHEIC Public Health Emergency of International Concern

PHELC Public Health Event of Local Concern

PHENC Public Health Event of National Concern

PHERC Public Health Event of Regional Concern

DRU Disease Reporting Unit

PIDSR Philippine Integrated Disease Surveillance and Response

RESU Regional Epidemiology and Surveillance Unit

RITM Research Institute of Tropical Medicine

RO Regional Office

SARS Severe Acute Respiratory Syndrome

UHC Universal Health Care

URL Uniform Resource Locator

WHO World Health Organization

WHA World Health Assembly

9
 Definition of Terms

Assessment – evaluation and classification of the reported event. Event may be assessed as
to severity. Assessment will be the basis on what would be the appropriate response. Guide
questions will be used in classifying the event if it is of IHR concern.

Capture– collection of events and can come from 3 types of sources of information from (1)
media including internet and other social networks, (2) health facilities, DOH, attached
agencies, partner agencies and local government units and (3) general public.

Closed Health Events – no cases or deaths are added. No pending laboratory results.

Controlled Health Events – Gradual or abrupt decrease of number of cases showed good
prognosis or event has already been managed but other information is still on verification.

DOH level of capture – National ESR, Regional ESR, other attached national agencies (FDA,
BAI, DENR, BOQ, RITM, etc.)

Emerging Diseases – infections that newly appear in the population, or have existed but are
rapidly increasing in incidence or geographic range, including new diseases as well as re-
emerging and resurging known diseases, with epidemic-prone potential. The term “emerging
diseases” is used interchangeably with emerging infectious diseases.

Epidemiology and Surveillance Unit (ESU) - refers to a unit established in the Regional
Health Office (RESU), Provincial Health Offices (PESU), City Health Offices (CESU) and
Municipal Health Offices (MESU) or Inter-local Health Zones such as District Epidemiology and
Surveillance Unit (DESU) that provides services on public health surveillance and
epidemiology.

Event-Based Surveillance – the organized and rapid capture of information about events that
are a potential risk to public health including events related to the occurrence of a disease in
humans and events related to potential risk-exposures in humans. This information can be
rumors or other ad-hoc reports transmitted through formal channels (e.g. established routine
reporting systems) or informal channels (e.g. media, health workers and non-governmental
organizations reports).

Feedback – system of providing a response or report to the concerned institution and

stakeholders (OSEC, WHO, IHR etc.) on the reported event. Feedback could be in a form of
report, phone call, SMS, web update etc. A weekly feedback to Regional Offices is also done.

Filter - It is the process of reviewing which health events should be discarded or warrants
further investigation based on criteria.

Health Event – a manifestation of disease or an occurrence that creates a potential for a

disease as result of events including, but not limited to those that are of infectious, zoonotic,
chemical, radiological, or nuclear origin or source. This also includes food safety.

International Health Regulations (IHR) of 2005 – refers to the international legal instrument
that binds all WHO member states to implement a set of international standards with the aim to
prevent, protect against, control and provide a public health response to the international
spread of disease in ways that commensurate with and restricted to public health risks, and
which avoid unnecessarily interference with international traffic and trade.

10
Indicator-Based Surveillance – the routine reporting of cases of disease through notifiable
disease surveillance systems, sentinel surveillance, laboratory based surveillance etc. This
routine reporting originates typically from health care facility where reports are submitted at
weekly or monthly intervals.

National IHR Focal Point – the national center, designated by each State Party, which shall
be accessible at all times for communication with WHO IHR Contact Points in accordance with
IHR (2005)

Online ESR - it refers to the electronic information system utilizing web technologies in
reporting health events

Public Health Emergency of International Concern (PHEIC) - An extraordinary event which,

as provided in the IHR is determined (i) to constitute a public health risk to other States through
the international spread of disease and (ii) to potentially require a coordinated international
response.

Public Health Event of National Concern (PHENC) – the health event may have potential
risk to more than one region including diseases for elimination and eradication.

Public Health Event of Regional Concern (PHERC) – health event has potential spread to
other provinces/cities/municipalities.

Public Health Event of Local Concern (PHELC) – the health event is confined in a specific
geographical location or involves vulnerable groups in the locality.

Public Health Risk – defined as a likelihood of an event that may affect adversely the health
of human populations, with an emphasis on one which my spread internationally or may present
a serious and direct danger (Asia Pacific Strategy for Emerging Diseases, WHO 2010, p. 48).
This is the basis for filtering captured public health events.

Risk Assessment – is a systematic process for gathering, assessing and documenting

information to assign a level of risk for a potential public health event. This enables objective
evidence-based decisions while giving consideration to the uncertainties and limitations of the
information available at a particular point in time (Asia Pacific Strategy for Emerging Diseases,
WHO 2010, p. 48).

Response – Public Health response refers to action and decisions carried out immediately
including verification or field investigation of health events through coordination with local health
authorities and other involved institutions (RITM / laboratories, Hospitals, Hazardous Material
Dept, Embassies, and DENR etc.).

Verification – process by which the health event report is substantiated. It includes confirming
the basic information about the time, place and person.

Ongoing Health Events – Other information is still on verification

11
ESR Manual of Procedures

I. Introduction

Strengthening surveillance systems starts with developing policies and strategies to make
system more efficient and effective. The revised IHR, adopted by the World Health Assembly in May
2005, emphasizes early detection and response capacity for member states in preventing outbreak.
ESR is an early warning and response system developed in the Philippines in response to the IHR
requirement and 2009 AH1N1 pandemic.

The WHO Western Pacific Regional Office has developed APSED as a strategy to implement
IHR in the region. One of the component areas of APSED for surveillance, risk assessment and
response is the Event-based Surveillance. This manual complements capacity building and technical
standards for ESR.

One of the strategic thrusts of the Department of Health for Universal Health Care or Kalusugan
Pangkalahatan is attainment of the health-related Millennium Development Goals (MDG). Event based
Surveillance can contribute in the prevention and control of communicable diseases, through early
detection, reporting and response for emerging and re-emerging diseases

To complement the indicator-based surveillance of the Philippine Integrated Disease

Surveillance and Response (PIDSR), the Event-based Surveillance and Response was established
under the Applied Epidemiology and Management (AEHM) of Epidemiology Bureau (Figure 1).

Figure 1. Epidemiology Bureau Organizational Chart

The Epidemiology Bureau (EB) is the National Focal Point for the revised International Health
Regulations (IHR 2005), which is aimed “to prevent, protect against, control and provide a public health
response to the international spread of diseases in ways commensurate with and restricted to public
health risks, and which avoids any interference with international traffic or trade”. Reference in the
footnote…

12
ESR Manual of Procedures Chapter I. Introduction

In line with the IHR and Asia Pacific Strategy for Emerging Diseases (APSED), the EB shall be
primarily responsible for immediately communicating with the World Health Organization those events
that may be strongly considered public health emergency of international concern (PHEIC). This
requires early detection, assessment, notification and reporting of such events on a 24/7 basis.

Event-Based Surveillance vs Indicator-Based Surveillance of PIDSR

Event-Based Surveillance and Response (ESR) shall complement the existing indicator-based
disease surveillance in detecting IHR events with the added advantage of rapid reporting because it
does not support data aggregation by morbidity week, with a wider scope (since PIDSR is limited to a
set number of reportable diseases and syndromes), greater geographic spread (as reports will not be
coming from predetermined sentinel sites although PIDSR was envisioned to have a universal
coverage) and most importantly, initially at a relatively low cost.

The ESR has unique characteristics that will define its purpose. ESR is the organized,
unstructured capture of information on new events that are not included in indicator- based surveillance,
events that occur in populations which do not access health care through formal channels, rare, unusual
or unexpected events to distinguish it from indicator-based surveillance, which employs a systematic
collection of variables to characterize specific illnesses.

Furthermore, ESR describes illnesses or deaths occurring in individuals or clusters or those

related to potential exposures that threaten public health. Clearly, ESR may detect similarly PIDSR-
listed diseases and syndromes or others not from this list. Then, information is filtered to require only
those that need further assessment and for which, finally, some actions are intended. Such actions from
indicator-based surveillance are triggered following pre-defined thresholds. No such thresholds exist for
event-based surveillance. Instead, an assessment is made on pertinent findings about each event
having a potential or even an actual risk to public health that ultimately leads to a timely and appropriate
response.

Thus, Epidemiology Bureau shall build, develop and maintain its capacity for disease
surveillance and ensure that assessments of these events will lead to timely, relevant intervention, alone
or with other stakeholders as well. Assessments should comply with provisions contained in Annex 2 of
the revised IHR. Response may involve domestic or international representatives, or individual or multi-
disciplinary teams.

Policies/Guidelines in Support of ESR

The Philippines as a member state implementing the revised IHR with the Department of Health
formed several policies in response to Resolution WHA48.13 “urges member states to strengthen
national and local programs of active surveillance for infectious diseases, ensuring that efforts were
directed towards early detection of epidemics and prompt identification of new emerging and re-
emerging infectious diseases.” These policies are:

1. Republic Act 3573 (Law of Reporting of Communicable Diseases – An Act providing for the
prevention and suppression of dangerous communicable diseases…) [November 26, 1929];
requires all individuals and health facilities to report notifiable diseases to local and national
health authorities.

13
ESR Manual of Procedures Chapter I. Introduction

2. Resolution WHA48.13 (1995) urges Member States to strengthen national and local programs
of active surveillance for infectious diseases, ensuring that efforts were directed towards early
detection of epidemics and prompt identification of new, emerging and re-emerging infectious
diseases.

3. International Health Regulations of 2005, Article 5-1 Surveillance, urges Member States to
develop, strengthen and maintain, as soon as possible but no later than five years from the
entry into force of these Regulations, the capacity to detect, assess, notify and report events in
accordance with these Regulations.

4. Asia Pacific Strategies for Emerging Diseases: The Asia Pacific Strategy for Emerging
Diseases is a common strategic framework for countries and areas of the region to strengthen
their capacity to manage and respond to emerging disease threats. It is intended to further
support progress towards meeting the obligations under the international Health Regulations
(IHR, 2005) and consolidate gains already made in establishing collective regional public health
security

5. Department Personnel Order No. 2005 -1585: Creation of Management Committees on

Prevention and Control of Emerging and Re-emerging Infectious Diseases (DOHMC-PCREID)-
creates the epidemiology and surveillance subcommittees in which one of its major functions is
to formulate and recommend policies, standards, procedures, guidelines and systems on early
detection, contact tracing, surveillance, investigation and follow-up of Re-emerging and Emerging
Infectious Diseases .

6. Administrative Order No. 2007 – 0002: Designation of the National Epidemiology Center (NEC)
as the National International Health Regulations Focal Point (Annex 4).

7. Administrative Order No. 2007 – 0036: Guidelines on the Philippine Integrated Disease
Surveillance and Response (PIDSR) framework.

8. Administrative Order No. 2012: 0036: The Aquino Health Agenda: Achieving Universal Health
Care for Filipinos. Specific thrust on attaining health-related MDGs such as, “ensuring public
health measures to prevent and control communicable diseases and adequate surveillance and
preparedness for emerging and re-emerging diseases.”

9. Executive Order 168: Creating the Inter-agency Task Force for the Management of Emerging
Infectious Diseases in the Philippines. Task Force functions include “establish a system to
identify, screen and assist Filipinos suspected or confirmed to be infected with Emerging
Infectious Diseases and to prevent and minimize local spread of EID in the country.”

10. National Objectives for Health 2011-2016: Chapter 6.2 on Health Information System with the
following strategic objective: to increase efficiency of processes and systems in health care
delivery and administration through functional health service statistics reporting and disease
surveillance capacities in the municipal and city levels.

The manual defines and discusses the framework, component and processes of event-based
surveillance. It defines the roles and responsibilities of each component. It introduces the different
forms to be used. And provides information on how the system will be monitored and evaluated.

14
ESR Manual of Procedures

II. Objectives and Framework

Event-based surveillance is the organized and rapid capture of information about a public health
event that may affect or has already affected an individual, a group of individuals or an institution.1 It is
the process wherein reports or information received are rapidly assessed for the risk the event poses
to public health and responded to immediately and appropriately.

It is based on unstructured descriptions and reports. The information can be rumors and other
reports transmitted through routine reporting system or reports from the media, health workers, non-
governmental organizations and community. Reporting may be through standard reporting forms or
through informal channels e.g. phone calls, short messaging system, and social media.

A. Objectives

1. To capture all types of health events with potential public health risk including rare and new
events;

2. To immediately assess and respond to all captured health events in order to decrease
morbidity, mortality and disability to minimize economic impact

3. To immediately disseminate available information regarding ongoing health events to relevant

or concerned agencies for proper coordination of response and support activities.

4. To provide information for IHR notification.

5. To enhance data quality and real time reporting of health events through application of
electronic web-based technologies

Definition of Health Event

1. Involve all health events (existing or rare) that raise concern, fear and alarm in the community
or which may have known, suspected or possible impact on human health.

2. No “standard” case definition but the event maybe a syndrome occurring over a period of two
weeks2 (cluster of deaths of children in a school with high grade fever, diarrhea and rashes).

3. Any health event that contributes to the achievement of IHR, MDGs, KP and NOH.

4. May be rumors.

1
A Guide to Establishing Event-Based Surveillance, WHO p. 7
2
A Guide to Establishing Event-Based Surveillance, WHO p. 13.

15
ESR Manual of Procedures Chapter II. Objectives and Framework

Events related to the occurrence of disease in humans – clustered cases of a disease or

syndrome, unusual disease patterns or unexpected deaths. These may include the following:

1. Epidemic-prone diseases: Cholera, meningococcal diseases, emerging viral diseases

– Avian influenza in humans, SARS, West Nile Fever
2. Food and Water borne diseases: classic food-borne diseases such as salmonella and
new food-borne diseases such as the new variant of Creutzfeldt-Jakob disease
associated with bovine spongiform encephalopathy
3. Diseases with limited treatment such as Ebola
4. Diseases with consequences for trade or travel such as SARS
5. Diseases related to international release of biological or chemical agents such as
anthrax
6. Changes of trends of person to person transmission (Influenza)
7. Changes in resistance profiles (Malaria, TB)3
8. Deaths related to MDGs e.q. Maternal Deaths and HIV/AIDS deaths
9. Diseases for eradication and elimination (Poliomyelitis, Measles)
10. Adverse event following immunization, administration of drugs/cosmetics and use of
medical devices.

Events related to potential exposure for humans – events related to diseases and deaths
in animals, contaminated water, and may also include the following:

1. Accidental and deliberate outbreaks: accidental release of infectious agents in

laboratory settings
2. Toxic Chemical Accidents
3. Radio-nuclear accidents
4. Environmental disasters such as earthquakes, storm surges and flooding
5. Zoonotic diseases with potential harm for humans

B. Basic Features

Reporting units

Since ESR is centrally based, there are no identified reporting units. It is unstructured
because an individual or an agency or institution may report or provide the information about
the event. It can involve both government and private entities and any local health facilities.

Reporting Forms and Flow

1. There are recommended forms but may accommodate qualitative information. Enough
information about the event should be gathered in order that an initial assessment can be done.
All assessment, outcomes and subsequent responses should be documented and kept in a
database system.

3
Unpublished WHO Guidelines on Implementation of National Early Warning Function within National Public Health
Surveillance Systems, WHO February 2009.

16
ESR Manual of Procedures Chapter II. Objectives and Framework

2. All methods of immediate communication should be made available to all agencies involved in
ESR.

3. All captured health events should be submitted within 24 hours.

4. Reporting flow serves as guide to all agencies.

C. ESR Framework

ESR surveillance will complement the existing indicator-based surveillance (PIDSR). Some
health events captured by the ESR will be conditions or diseases already defined in the PIDSR
system. Both systems require confirmation and verification of the reported diseases and events to
detect signal of public health alert for further assessment. Thorough assessment will be done so that
immediate decisions and actions are made. Figure 2 illustrates the interaction between the two
surveillance systems.

Both systems are important to capture events and diseases that are considered of
international concern. Indicator – based surveillance requires threshold analysis for a response to be
conducted. However, ESR may require immediate actions when the result of the risk assessment
conducted is of a public health risk to the community.

Figure 2. Framework of the ESR System

17
ESR Manual of Procedures Chapter II. Objectives and Framework

Note:

 Illustration/figure based on Epidemic Intelligence Framework by Denis Coulombier, ECDC

with modifications

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ESR Manual of Procedures

III. ESR Processes

ESR employs six standard core processes that are followed at all levels of implementation. This
includes Capture, Filter, Verification, Assessment, Response and Feedback. Figure __ shows the link
between the 6 processes and outlines the basic procedures of ESR.

Figure 3. Six Core Processes of Event-based Surveillance and Response (ESR)

A. Capture

This process involves early reporting of a health event, regardless of veracity, to ESR. Early
capture of all possible health events is crucial so that missed opportunity to respond to events with
public health importance is kept to a minimum. Rumors of events that may present possible health
risks will not be ignored and would need further investigation from health authorities.

There are two (2) types of capture, namely:

Active - purposeful daily gathering of health events by the ESR staff through surfing the internet
and other media sources such as television, radio and print,

Passive - capture of health events reported by the media people, health facilities such as DOH
and other attached agencies, partner agencies and local government units (see Table 1) through email,
fax, phone calls or text messages to the ESR staff.

Sources of reports of health events usually emanate from three broad categories, namely, the
media, facility-based reports and general public. Examples of sources under each category are
enumerated in Table 1.

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ESR Manual of Procedures Chapter III. ESR Processes

Table 1. Sources of Reports and Rumors for Event-Based Surveillance System

Media

Print
Internet (e.g. Twitter, Includes all kind of health events such as increasing number of
Facebook, cases of infectious diseases, high number of deaths, animal
Instagram,Tumbler, Rappler) deaths, high number of hospitalized cases, extraordinary public
health event which may have potential for international spread,
Television
cases or deaths with unknown cause
Radio

Facility

HEMB – toxic chemical accidents, radio-active accidents,

environmental accidents or changes with implications to health

MRU – events captured by their staff from the different print media
and radio

RO’s /RESU’s – local health events in the region like re-emerging

infectious disease, unusual deaths, undefined cases and deaths,
changes in patterns of diseases
DOH and other
Attached Agencies DOH Hospitals/Laboratories – laboratory accidents which may
involve infectious agents, high number of admitted cases or deaths
caused by infectious agents or chemical toxins, emergence of
resistance strain in existing infectious agents
Bureau of Quarantine (BOQ) – health events captured in all ports
of entry
Food and Drug Administration (FDA) – diseases related to food
safety and all health events related to administration of
medications, cosmetics or use of medical devices

Partner Agencies Health events which may involve specialized

(BFAR, NPCC, BPI, DOST, expertise/support/assistance particularly provided by, or available
DA, BAI, DENR, NMIS, from, specific government agencies or non-government
AFRIMS, PGH, NGOs) organizations

Local Government Units

LGU Health Facilities Local health events like number of cases and deaths for infectious
(hospitals, RHUs, BHS) and diseases, re-emerging infectious disease, unusual deaths,
Local ESU’s, undefined cases and deaths, changes in patterns of diseases,
Local Officials chemical accidents, cases related to toxins and chemical
Police poisoning
Private Hospitals

General Public

Any private citizen can call or text the ESR hot line numbers to report the health event.

The ESR unit captures health events from the different media sources. Health events may be
captured passively as media people may report it through phone call or text messages and actively by
the ESR staff through surfing the Internet and the print media, radio and television daily. Basic
information should be gathered and describe the event in terms of person, time and place. All health
events captured should be recorded by the ESR staff in the ESR Capture Log Sheet.

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ESR Manual of Procedures Chapter III. ESR Processes

The ESR unit coordinates with the different health facilities at the different level (national,
regional or local) in capturing health events. These facilities are not mandated to report on a regular
basis to the ESR unit regarding any health event. However, they may report a health event upon their
own assessment if it warrants further evaluation by the ESR unit or the event is either of national or
international concern.

The general public may also report any health event they judged to be of potential health risk
to the community. The ESR unit will provide the hot line numbers that the public can use in reporting
these events.

B. Filter

It is the process of reviewing which health events should be discarded or warrants further
investigation. The ESR team leader reviews daily the list of health events captured by the unit. He/she
will decide which of these health events will be discarded or verified based on the following criteria:

• Unknown illness/unusual event

• High mortality or morbidity
• International disease spread
• Interference with travel or trade
• Disease for elimination/eradication
• Suspected, accidental or deliberate biologic/chemical threats
• Double/multiple reporting of same health event

C. Verification

Verification is the process by which a health event report can be substantiated and should be
possibly done within 24 hours time period from date and time of capture. It should involve asking
another informant about the event, if possible from trained health personnel. It should also include
confirming the basic information about time, place and person.

Criteria for a Verified Health Event:

1. Confirmed by different sources of information.

2. Reported by persons in authority (RHU staff, PHO, RO)

D. Assessment

Event assessment is the process by which the available information about a confirmed health
event is analyzed and judged whether it is a public health risk within 48 hours time period. The
assessment will be done by the assessment team.

For the EB-ESRU Team, the team composes the EB Director, Division Chiefs or one
representative from each division and the ESR Team leader. The team will decide on the magnitude of
the said event (if the event is of Local, Provincial, Regional, National and International Concern).The
team will also make recommendations for possible interventions/response of the reported public health
event and proper referral to the Field Epidemiology Training Program (FETP) fellows for investigation.

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ESR Manual of Procedures Chapter III. ESR Processes

Health events classified other than National or International Concern, will be referred to the
Regional Health level (RESU) for proper assessment and response.

For the Regional ESR Team, the team will be composed of the RO Director, RESU Head,
representative(s) from other concerned divisions/units within the RO and the ESR Team leader (if
different from RESU Head). The team will decide on the magnitude of the said event (if the event is of
Local, Provincial, Regional, National and International Concern).

Health events classified as other than Regional, will be referred to the appropriate level such
as EB for National and International Concern and to the LGUs for local concerns, for proper assessment
and response.

When assessment is done, one should look into the public health impact of the event, need for
assistance and assessment for response strategy requirements.

1. The following are the criteria for assessing the public health impact of the event:

 The number of cases and deaths in relation to the time, place and population affected
 The pathogen involved with high potential to cause epidemic
 Cases indicates possibility of treatment failure
 Population at risk involves vulnerable groups
 Event occurred in areas with high population density
 Unusual event (caused by unknown agent, vehicle or route of transmission unusual,
unusual signs and symptoms and the occurrence of the event is unusual in the area)
 Event caused by pathogen or disease that has been eliminated or eradicated in the
area
 Risk of International spread (epidemiologic link to similar events in other countries, any
factor that may indicate potential cross-border movement of agent, vehicle or host and
environmental contamination with potential to spread across international border).

2. The following are the needs for assistance:

 Human resource: Technical expert or trained health staff that may be needed during
the response activity
 Laboratory or equipment: Lack of or insufficient laboratory and equipment to be used
for diagnosis and response activities
 Existing surveillance system is inadequate to detect new cases early

3. The following are the requirements for response strategy:

 Technical expert or trained health staff on outbreak investigation

 Technical expert on policies for control and preventive measures (may be program
coordinators, central office staff or consultant)

Event confirmation and assessment should be conducted by the EB ESR unit. However, the
RESU/LESU may be tasked to do these processes if a trained staff is on hand to confirm, and logistical
needs are available to properly assess the health event on the following conditions:

1. The health event reported may be related to an existing disease or syndrome or with
existing control and preventive measures such as reported cases of illness after intake of
water or food from a certain source or a reported case of malaria in a malaria-free area.
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ESR Manual of Procedures Chapter III. ESR Processes

2. The health event reported may be of international concern or non-health event (chemical
poisoning or spillage, animal deaths with related consequence to humans) with an
existing policy and guidelines such as SARS.

Based on the different factors mentioned above the EB ESRU may decide whether the event
is of local, provincial, regional, national or International concern. However, the Secretary of Health has
the prerogative to ask the EB ESRU to lead or provide support in the assessment and response
activities to a health event whether it is of local concern. There are general guidelines to determine
whether the health event is local, regional, national or international concern. This will also serve as a
guide to decide who will conduct the response activities.

Classification of Events as to Level of Concern

1. Public Health Event of Local Concern (PHELC)

a. The health event includes signs and symptoms that may involve diseases included
in PIDSR like a report of cases of gastroenteritis.
b. The health event does not require the use of extensive laboratory examination for
confirmation and diagnosis like cases of febrile illnesses
c. The health event is confined in a specific geographical location or involves
vulnerable groups in the locality.
d. The health event may involve diseases with existing guidelines for control
measures like events pertaining to vaccine preventable diseases.
e. There is a trained health staff to assess and conduct control measures

2. Public Health Event of Regional Concern (PHERC)

a. The health event may involve diseases that have already been eradicated or with
eradication program in the region.
b. The health event requires additional technical and laboratory support not existing
in the local area.
c. The health event has potential to spread to other provinces/cities/municipalities.
d. The health event showed possible changes in the disease pattern.
e. There is no trained local/provincial staff to assess and conduct control measures.

3. Public Health Event of National Concern (PHENC)

a. The health event is rare and with undefined cause.

b. The health event has potential characteristics to cross boundaries or borders.
c. The health event shows failure in control measures being implemented
d. The health event may have potential risk to a wider population (e.g. peanut butter
contamination).
e. The health event involves possible development of resistant strain and may require
wider surveillance for similar cases.
f. There is no trained health staff at the regional level to assess and conduct control
measures.

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ESR Manual of Procedures Chapter III. ESR Processes

4. Public Health Emergency of International Concern (PHEIC)

a. The health event is rare and similar to those reported in other countries
(e.g. SARS)
b. The health event has possible implication for International trade
c. The health event may involve diseases not previously reported in the country

The verification form should be filled-out by the agency confirming and assessing the health
event. This form should be submitted through fax or email to the EB ESRU within the eight (8) hours
period upon receiving the health event report.

Assessment and notification of health events should follow the use of Annex 2 (Decision
instrument for assessment and notification of events that may constitute a public health emergency of
international concern) of the International Health Regulations. The flowchart for assessment and
notification is shown in Annex 2.

E. Response

Immediate detection and assessment of all health events with potential for public risk and
international spread is important. However, actions and decisions must be carried out immediately
(within 48 hours from verification)

It is impossible for each unit to respond to every outbreak, so that there must be a criteria or
trigger for higher level on when to respond directly to affected LGUs. Response activities may vary
according to the level and capabilities of the agencies involved. Response should be managed by the
head of office (e.g. mayor for municipalities and cities). FETP will only conduct outbreak investigations
in coordination with the LGUs.

Local ESUs (LESUs)

1. Verification
2. Coordination with RESU or EB-ESRU for assessment of health event by level of concern
3. Conduct Outbreak investigation
4. Referral for laboratory support
5. Referral for technical support (technical expertise, additional manpower, coordination with
other agencies)
6. Referral for further evaluation or operational research

At the Regional ESUs, the following should be done:

1. Assist the local ESUs in verification and assessment activities.

2. Assist the local ESUs in outbreak investigation, implementation of control and preventive
measures’
3. Coordinate technical support needs of the Local ESUs to EB ESRU and appropriate
agencies.
4. Conduct verification, assessment and response activities for health events of regional
concern.
5. Continue surveillance for events that may at present have no potential public health risk
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ESR Manual of Procedures Chapter III. ESR Processes

6. Facilitates laboratory confirmation.

At the EB-ESRU, the following should be done:

1. Decide and coordinate with concerned agencies for verification and assessment activities.
2. Provide multidisciplinary technical support to regional and local ESUs during outbreak
investigation, implementation of control and preventive measures. Coordinate technical
support to local ESUs for outbreak investigations
3. Conduct assessment using IHR decision instrument for health events that may have
potential for International spread or border crossing issues to be used by the EB Director
for IHR/WHO notification.
4. Assist ESU’s in facilitating laboratory confirmation.

Note: Outbreak investigations are being conducted by FETP fellows/graduate.

All details of all actions undertaken and decisions made during the response activity should be
documented. This will serve as reference document for future outbreak/event investigations.

F. Feedback and Information Dissemination

Feedback and/or timely information dissemination to stakeholders (reporting sources, people

and organizations involved in event response and policy makers) are important. It encourages the
sources to continue reporting health events, and for concerned agencies, to effectively participate in
the course of actions. Information should be simple and brief. It can be verbal or written.

A written report is preferred because it documents all actions and decisions made in relation to
the health event. Written reports should be presented as summary/feedback report (Annex 1d), news
brief or technical reports. The different formats may be used and be tailored to the type of stakeholder.
Sources of the reported health events may also be included in the report. For events wherein response
has been undertaken, a brief description may be included. Feedback may be done on a weekly or
monthly basis and are sent to different stakeholders (Annex 3).

The ESR processes are the same whether events are captured at the national level or at the
regional /local level. At the national level (Figure 2), verification process may be through the
surveillance division or concerned agencies covering the health events. The national assessment
team decides if the health event can be acted upon by the local agencies.

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 ESR Manual of Procedures Chapter III. ESR Processes

Figure 4. Flow Chart of Central ESR Processes

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ESR Manual of Procedures

IV. Online ESR

Online ESR is a web-based system for managing electronic information of health events. The
system was developed by the Knowledge Management and Information Service in consultation with
the Epidemiology Bureau. The system aims to enhance the system of capturing, sharing and
reporting health events through electronic data transmission and use of web-based technologies.

A. Objectives
The system has the following objectives:

General:
To improve the existing manual system of reporting health events.

Specific:
• To serve as an online tool for recording, reporting and monitoring health events.
• To promote efficiency in data collection, processing, validation, analysis and dissemination of
health event surveillance data;
• To improve coordination among agencies, offices, institutions, and other entities involved in
response.
• To improve data quality and implement timely interventions.
• To enhance the capability of the ESUs on Online Reporting of Health Events

The use of Online ESR provides important benefits in managing health events. People with
valid user accounts may use Online ESR depending on the type of user privileges. Data on
health events may be accessed anytime and anywhere. Databases are protected and secured
since restrictions are well defined. ESR coordinators can easily track health events and checking
of reports can be done by more individuals more rapidly and control strategies can be quickly be
made.

B. Guiding Principles

 Online ESR will serve as the official information system to collect, consolidate health event
information under the Event-based Surveillance and Response program
 Online ESR should be consistent with the six processes (capture, filter, verification,
assessment, response and feedback) of the ESR
 Design and enhancements of Online ESR should be consistent with the data and IT
standards prescribed by the Department of Health
 All ESUs and other units are encouraged to participate in online reporting of health events
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ESR Manual of Procedures Chapter IV. Online ESR

 ESR Online shall promote sharing of information amongst stakeholders yet maintain
confidentiality of the health events

C. Systems Architecture

Figure 5. System Architecture of Online ESR

User Rights and Privileges

Privilege Description

View User can browse records (HE)

Add ability to add a new record (health event) including HE for discard

Edit Ability to change the entries in an existing record (HE)

Delete Ability to PERMANENTLY remove an existing record (HE)

Activate/Deactivate To activate or deactivate records (HE)

Accept/Reject Privilege by EB-ESRU and RESU whether to accept or reject a record (HE)
submitted to them

Close To close a health event; Closed health event can no longer accept revision
or follow-up

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ESR Manual of Procedures Chapter IV. Online ESR

Reports ability to view and produce reports

User Account ability to create new accounts, delete user accounts, change account type
Management and user equivalent rights

Note:

Verified Record - are records that are certified as true health events
Deactivated record - records that are viewable but will not be included in reports or analysis of health events and can be
activated.
Active record - are records that are being viewed and ready for use in generating reports. These records may be
deactivated if the record is not a true health event (for discard).
Accepted record - are records seen by EB-ESRU to be verified.
Rejected record - are records that are seen by the EB ESRU and RESU

D. Users and Type of User Accounts

Epidemiology Bureau, DOH

Official/Staff User Rights and Privileges

EB Director View, Reports

AEHM Head View, Close, Reports

FETP Supervisor View, Close, Reports

ESR Unit Head View, Add, Edit, Delete, Activate/Deactivate, Accept/Reject,

Close, Reports, User Account Management

ESR Officers View, Add, Edit, Delete, Activate/Deactivate, Accept/Reject,

Close, Reports

Regional Epidemiology and Surveillance Unit, Regional Office

Official/Staff User Rights and Privileges

Director, Division Head, View, Reports

Immediate Supervisor

RESU Head View, Close, Reports

ESR Coordinators/Officer View, Add, Edit, Delete, Activate/Deactivate, Accept/Reject,

Close, Reports

ESR Encoder View, Add, Edit, Delete, Activate/Deactivate, Reports

Admin View, Add, Edit, Delete, Activate/Deactivate, Close, Reports

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ESR Manual of Procedures Chapter IV. Online ESR

Local Epidemiology and Surveillance Units (LESUs)

Official/Staff User Rights and Privileges

PHO/CHO/MHO View, Reports

Head of technical unit View, Reports

LESU head View, Close, Reports

ESR Coordinator View, Add, Edit, Delete, Activate/Deactivate, Close, Reports

Encoder View, Add, Edit, Delete, Activate/Deactivate, Reports

Other Stakeholders

User Rights and Privileges - View, Reports

E. Roles and Responsibilities on Online ESR

The following are specific roles and responsibilities on Online ESR of implementing units:

1. The Epidemiology Bureau, as the system owner and over-all lead office in managing and
implementing Online ESR, shall:
 Set policies, standards and procedures, in collaboration with KMITS, on Online ESR
 Oversee the management and implementation of the Online ESR
 Performs oversight roles over regional offices and LGUs related to online reporting of health
events
 Carry out data validation and ensures quality and reliability of reports
 Provide logistics and resources to ensure sustainability of Online ESR
 Develop regional and local capacities in Online ESR
 Performs monitoring and evaluation of the implementation of Online ESR
 Carry out data processing, validation, analysis and dissemination of health events
 Safeguards data and maintains backup of national ESR databases

2. The KMITS shall:

 Provide technical support in software maintenance, implementation, deployment and
operations, such as but not limited to the following – user account management, software
enhancement, system troubleshooting, debugging, database backup and recovery, server
management, network administration, database administration, and others.
 Performs training of Online ESR point persons at different levels
 Monitor and evaluate the operations and performance of the system
 Provides help desk support

3. CHD-RESU
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ESR Manual of Procedures Chapter IV. Online ESR

 Advocate for the use of Online ESR among LGUs

 Oversee the management and implementation of the ESR-online at the regional level
 Perform oversight roles over LGUs in online reporting of health events
 Carry out data validation and ensures quality and reliability of reports
 Provide resources and logistics in the implementation of Online ESR at the regional level
 Performs monitoring and evaluation of Online ESR
 Builds local capacities on Online ESR
 Carry out data processing, validation, analysis and dissemination of health events
 Safeguards data and maintains backup of regional databases

4. Local ESUs
 Encodes all health events reported by the DRUs thru ESR Online Reporting
 Lobby to provincial/city government for approval of allocation of funds for ESR
operationalization
 Designate an Online ESR point person who will be responsible for online reporting of health
events
 Send staff for training on online ESR
 Ensures that every single ESR Reports are encoded by local Online ESR coordinator and
checked by the Regional ESR Officer for approval or discard
 Performs data validation and ensures quality and reliability of reports

F. Composition of Online ESR Unit and Staff

Epidemiology Bureau
• EB Director
o Receives and analyses Online ESR reports
o Provides logistics and resources for Online ESR
• Chief, Applied Epidemiology Health Management Division
o Performs data quality assessment and data validation at set intervals
o Generate, reviews and approves Online ESR reports
o Approves application for user accounts
o Develop plans and lobby for resources for the continued implementation of Online
ESR
• ESR Unit Head
o Ensures data quality encoded by the EB ESR coordinators, RESUs and LESUs
o Assist the Chief (AHEMS) in developing plans and lobby for resources for the
continued implementation of Online ESR
o Analyze, generate, reviews and submit reports to the Chief (AHEMS) for approval
o Performs monitoring of Online ESR implementation at the regional and local levels
• ESR Coordinators
o Encode ESR forms into the Online ESR
o Accepts/discard reports from the RESUs and LESUs
o Analyze and generate reports and submit these to the ESR Unit Head for review and
approval

Regional Office

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ESR Manual of Procedures Chapter IV. Online ESR

• RD/ARD
o Reviews and assesses health events thru Online ESR
o Provide funds for the continued implementation of Online ESR
• ESR Team Leader/RESU Head
o Validates and ensures accuracy of data encoded by the ESR assistants and data
encoded by LESUs
o Analyze, generate and disseminates Online ESR reports to stakeholders
o Assist during training of LESUs on Online ESR
o Develop plans and lobby for resources for the continued implementation of Online
ESR at the regional level
o Performs monitoring of LESUs on Online ESR implementation
• ESR Point Person
o Assist the ESR Team Leader in validation and ensuring accuracy of data encoded by
the ESR assistants and data encoded by LESUs
o Analyze and prepare reports for review and approval of the ESR Team Leader
o Conducts training on Online ESR
o Accepts/discard reports from the LESUs
o Performs monitoring of LESUs on Online ESR implementation
o Provide the ESR assistant with ESR forms for encoding
• ESR Assistant
o responsible for encoding the Health Events in the Online ESR
o Accepts/discard reports from the LESUs
o Print and generate Online ESR reports
• Admin Clerks
o Provide the ESR assistant with ESR forms for encoding

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ESR Manual of Procedures

V. ESR Forms
ESR uses standard reporting forms for capturing and reporting health events. These forms
include:
1. ESR Capture Event Log Sheet
2. ESR Follow-up Form
3. ESR Verification Form
4. ESR Weekly Feedback Report

A. Standard ESR Forms

A.1. ESR Captured Health Event Log Sheet (Annex 1a)

ESR Captured Log Sheet is used to record a health event that was recently captured by an
ESR Staff. It consists of initial and raw information that was received or gathered from multiple
sources (Print, Internet, Television, Radio, DOH, Others) and would be further verified by an ESR
Staff. It is usually filled-out before making an ESR Verification Report.

Question Description and Instructions

Code Write identifier of the report code. (e.g. yyyy-mm-000)

Date Captured Write the date the health event was captured (mm-dd-year)

Time Captured Write the time the health event was captured (12 hr-clock)

Source Write primary source of information as: P (Print), I (Internet) T

(Television) R (Radio), D (DOH) and O (Others and specify)
Reporting source Write the name of agency or facility reporting the event

Health Event Write the health event captured (e.g. chemical spillage, cases of
fever, etc.)

Location of Health Event Write the place of the event including street number, purok/sitio,
barangay, municipality/city, province, region; as much as possible
Number of cases Write the number of people affected. This can be an estimate

Number of deaths Write the number of reported death/s

ESR Staff Write the name of the ESR Staff responsible for verification and the
follow-up of health event. This may include more than one ESR staff

Remarks Write other pertinent information about the health event

A.2. ESR Verification form (Annex 1b)

The Verification form will be used by an ESR staff who received any reported event.
There are 28 entries that should be completely filled out by the designated staff upon
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ESR Manual of Procedures Chapter V. Standard ESR Forms

verification. All efforts must be exerted to complete the verification forms within 8 (eight)
hours.

Question Description and Instructions

Date of this report Date the report was submitted to ESR Unit

Code Write the code of the report in this format (YYYY-MM-Number)

Report date and time Write the date and time the health event was first reported to the
ESR unit

Verification date and time Write the date and time the health event was confirmed/verified by
the health staff

Health event Write the type of health event reported

Location Complete address (number, Street/Barangay, municipality province)

where the reported event was observed. For multiple location
(specify on description of cases)

Start date Date of start of event or date of onset of first case

Number of cases Number of people affected

Description of cases Pertains to Who were affected (age and sex or nature of work), What
are the common signs and symptoms of cases, When, Where

Number of death/s Initial number of reported death/s from the event

Description of death/s Who were affected (age and sex), from Where? (address of fatalities)
When? (dates of fatalities) and What are the causes of deaths or
description of symptoms prior to death of cases?

Laboratory Examination Write laboratory examinations done on specimens collected/tested

Is this an outbreak? Write yes or no

Who made the Write report such as press release, city ordinance creation
announcement?

Was a report made? Write if yes or no. If yes, was there an official ESU report?

Assessment Write the level of risk of this public health event (PHELC / PHERC /
PHENC / PHEIC)

IHR notification decision Please check what is applicable from the using the Annex 2 of IHR
questions document

Status of Health Event If the health event is Ongoing, Controlled and Closed

Actions taken What was done? By Whom? When?

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ESR Manual of Procedures Chapter V. Standard ESR Forms

Assistance needed Specific assistance needed, if there is any

ESRU Action To just continue monitoring or will assistance be provided, etc.

Remarks Other important information not elsewhere mentioned before

Who has been informed? To whom the information have been shared (DOH offices, LHO,
WHO and other stake holders)

Source/s of information Name, Office, Designation and the contact numbers of the person
who gave the information

Prepared by* Name and signature of the ESR staff/Point Person who prepared the
report, designation and his/her contact details

Reviewed by* Name and signature of the Supervisor who reviewed the report,
designation and contact number/s (if any)

Noted by* Name and signature of the supervisor on duty and his contact details

Approved By* Name and signature of RESU Head, Division Chief, Director

* Note: Entries should be signed prior to release of verification form

A.3. ESR Follow-up form (Annex 1c)

The ESR follow-up form will be used by an ESR unit to monitor the progress of health events
The ESR follow-up form is almost the same as the ESR verification form. The follow-up form aims to
complete or collect additional data about the event. This form will also be used to validate the
information from the verification form. The frequency of reporting will depend on the need for information
which will be decided upon by the ESR unit Team Leader.

Question Description and Instructions

Date of this Report date the report was submitted to ESR Unit

Code Year-MM-Number

Report date and time This is the date and time the health event was first reported to the
ESR unit

Update Number This reflects the number of follow-up reports received since
Verification Report

Date of previous report The date indicated in the last verification/follow-up report

Health event Update on the status of the health event (areas of involvement
compared to the first reported case, changes in the pattern of the
health event)

Location Complete address (number, Street/Barangay, municipality province)

where the reported event was observed

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ESR Manual of Procedures Chapter V. Standard ESR Forms

Start date Date of start of event or date of onset of first case

Number of Cases # Previously Reported - Number of previously reported cases.

# Added in this Report - Number of reported case/s added
Total Cases as of date – Number of case/s (Previously reported
case/s + new case/s)
Updated Description of all Pertains to new information about the cases reported. (Who? When?
Cases Where? Why?)

Number of Deaths #Previously Reported - Number of previously reported death/s.

#Added in this Report - Number of reported death/s added.
Updated Description of all Pertains to new information about the death/s reported. (Who?
Death/s When? Where? Why?

Laboratory Examination

Is there a procedure done? Check Yes or No

Specimen collected Check Blood/Serum, Stool, Urine or CSF. Fill-in the Others, specify
option if otherwise

Type of examination done Indicate what type of examination was done

Result Laboratory findings as to specimen collected from the event

Type of Health Event: Check if nature of event is Clustering, Unusual or Outbreak

If an outbreak, check who made the validation – NEC-DOH, RESU-

If an outbreak? RO, or CHO/PHO. Fill-in Others, specify if another unit made the
validation for outbreak.

Check who made the announcement of the outbreak – NEC-DOH,

Who made the RESU-RO, or CHO/PHO. Fill-in Others, specify if another unit made
announcement? the validation for outbreak.

Check if Yes or No
Was a report made?

Assessment PHELC / PHERC / PHENC / PHEIC

Status of Health Event If the health event is Ongoing, Controlled or Closed

Actions taken What was done? By Whom? When?

Planned Activities Describe planned activities, if any

Assistance needed Specify additional assistance if needed

ESRU Action To just continue monitoring or will assistance be provided, etc.

Remarks Other important information not elsewhere mentioned before

Who has been informed? To whom the information have been shared (DOH offices, LHO,
WHO and other stake holders)

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ESR Manual of Procedures Chapter V. Standard ESR Forms

Source/s of information Name, Office, Designation and the contact numbers of the person
who gave the information

Prepared by* Name and signature of the ESR staff/Point Person who prepared the
report, designation and his/her contact details.

Reviewed by* Name and signature of the Supervisor who reviewed the report,
designation and contact number/s (if any)

Noted by* Name and signature of the supervisor on duty and his contact details

Approved By* Name and signature of RESU Head, Division Chief, Director

*Note: Print-out Verification and Follow up Reports should be completely signed daily.

B. Criteria on Status of health event

B.1. Criteria for an ongoing event

• Other information is still on verification.

• Specimens are to be collected and pending laboratory results.
• The concerned team is currently monitoring the event.
• There are planned activities for the event.
• There are continuous additional cases or deaths.

B.2. Criteria for controlled event

• Gradual or abrupt decrease of cases.

• Cases showed good prognosis or event has already been managed but other information
is still on verification such as description of cases, laboratory findings, etc.
• There are still planned activities for the event.
• Some or additional collected specimen with pending laboratory result.
• No cases or deaths had been added.
• Event was controlled or managed by the concerned team.

B.3. Criteria for closing an event

• Laboratory results have no significant findings that are potential for endangering health.
• Cases were already discharged and in good condition (For admitted cases).
• Follow-up reports indicate no further monitoring, assistance and investigation needed.
• Health event was referred to the concerned health agency/team and appropriate actions
are being prepared.

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ESR Manual of Procedures Chapter V. Standard ESR Forms

C. Filling out of ESR Forms

The flow of reports will be standard for all units involved in the ESR activities.

Instructions in filling out the ESR forms:

1. During the capture of health events, the ESR Captured Event Log Sheet is filled out. All events
will be recorded regardless of the source.

2. Filtered health events will then be verified by assigned staff

3. Once verified the assigned staff will fill out the ESR verification form.

4. If the health event is still ongoing, an ESR Follow Up form must be filled up upon receipt of
report.

5. Assessment of events is made to determine the type of response activities and resources
needed.

6. A Weekly Feedback Report is filled out and sent to the respective region where the event
took place.

For events of local/provincial and regional concern the said units will proceed to the
other processes of ESR. All activities and decisions made will be documented. If the event is
of national and international concern, the report will be submitted immediately to the national
unit. For other events, report will be submitted to their stakeholders and be filed at their offices
for future reference

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ESR Manual of Procedures

VI. ESR Unit

The ESR unit has the capability to capture, assess and respond promptly to the events that are of
public health risk. The ESR structure needs the following minimum resources to accomplish its function:

A. Physical Structure
1. Office space
2. Phone line (NDD and IDD capability)
3. Mobile phones with communication allowance
4. Fax machine
5. Desktop computers
- Printer, ink
- Soft ware
6. Laptop computers
7. Radio and TV
8. Transportation service
9. Access to internet connection
10. Camera
11. External Hard Drive

B. Staff Requirements

The ESR Team is composed of the following personnel:

1. The ESR Team Leader

He should have a basic knowledge in the establishment and maintenance of ESR.

Responsibilities:

a. Plan for, organize, coordinate and supervise the entire ESR Unit.
b. Oversees overall ESR activities and will be accountable for all health events reported.
c. Supervises the ESR officer(s).
d. Responsible for answering queries from other agencies.
e. Will be responsible in the coordination with KMITS on ESR system architecture
(assigning user accounts, editing and deleting reports) issues, online data
management, updates and other protocols.

2. ESR Officer/s

Responsibilities:

a. He will capture health events daily through different sources of information.

b. He will review and filter daily all captured health events. If the reported event is a
disease included in the indicator-based surveillance, he will refer this to PIDSR for
validation.
c. He will verify events filtered as true health events.

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ESR Manual of Procedures Chapter VI. ESR Unit

d. He will prepare the final list of health events to be assessed.

e. He will be responsible to keep an update on all response activities. He will prepare all
documents needed in response activities and providing technical assistance to local
ESUs.
f. He will give feedback to all stakeholders.
g. He will be responsible in recording all health events.
h. He will ensure that all reporting forms are encoded and filed.
i. He will be responsible in updating the Online ESR database on all information of the
reported events.

3. Administrative Clerk

Responsibilities:

a. He will assist the ESR Officers on capturing health events through print media and
internet.
b. He fills-out the captured event log sheet.
c. He will make a list of all significant health events and submit to the ESR team
leader/officers daily.

C. Relationship with Regional Offices, Attached DOH Agencies and Other Partner
Agencies (Government and NGOs)

The ESR unit may work with other agencies and institutions in the conduct of their activities.
They may support the National ESR Unit in the different processes depending on their capabilities.

1. Health Emergency Management Bureau (DOH)

The HEMB is a service directly under the Office of the Secretary of Health or Regional
Director. It maintains an Operation Center (OPCEN-24/7) 24 hours a day which monitors all health
emergencies and disasters including all national events with the potential to be an emergency.

a. It will verify and report to ESR unit health events captured from media and its other sources,
especially events related to accidents (toxic chemicals, radio-active), poisonings,
environmental accidents or changes.

b. It will assist the ESR in response activities by mobilizing resources required and
coordinate with other agencies for technical expertise support needed.

c. It provides medical team for diagnosis and treatment of cases and logistics for treatment.

2. Media Relations Unit (DOH):

Another unit that monitors any health related events at the National Office is the Media
Relations Unit (MRU). It captures health related events through mass media like radio, television,
and print. It will report all these health events to the ESR unit either by telephone call or using the
reporting form.

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ESR Manual of Procedures Chapter VI. ESR Unit

3. Research Institute for Tropical Medicine and other Hospital Laboratories:

These agencies will report to the ESR unit the following health events:

a. Laboratory accidents that may involve infectious agents or toxic chemicals

b. Increasing number of resistant strains for certain infectious agents
c. Changes in the pathogenesis of infectious agents
d. Confirmed cases or death of diseases with International concern

4. Bureau of Animal Industry:

The Bureau of Animal Industry (BAI) will report to ESR unit any zoonotic diseases or
death that may have potential effect on human health such as poultry death for Avian influenza
and Ebola. However, it will be the main agency to verify, assess and respond to these public
health events.

5. Bureau of Quarantine (DOH)

Bureau of Quarantine monitors ports and airports. It will verify and assess any health
events occurring in ports and airports. It will report to ESR unit unusual death or undetermined
cases or death that may pose public health risk and diseases of International concern.

6. World Health Organization (WHO)

The World Health Organization provides technical expertise and international assistance.

7. Other Government Agencies and Non-government Organizations

DA, FDA, DENR, BFAR, NMIS, DOST, BPI, NPC, PIPAC, CHEMPRO, UP Toxicology
Department, UP Marine Science, NBI and PNP Crime laboratory

Other partner agencies/organizations may provide support or assistance to ESR unit

or to Regional/Local ESR counterpart through participation in health event notification or
through provision of their specialized service or expertise as deemed necessary to promptly
and effectively respond to a given health event.

D. Roles and Responsibilities of the Different Levels of the Health System

1. The National ESR

a. Overall responsibility is to ensure capability and functionality of all ESR Units

b. Processes of ESR: Capture, Filter, Verify, Assess, Respond and Feedback are
implemented
c. Ensure IHR Notification

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ESR Manual of Procedures Chapter VI. ESR Unit

2. The Regional ESUs

The Regional ESUs are units within the Regional Office. It manages the PIDSR system in
their region. It will be the main extension arm of the ESR unit for verification, assessment and
response activities. Their responsibilities in the ESR are the following:

a. Processes of ESR are implemented

b. Submits to the National ESR unit the verification and follow-up reports of health events
verified
c. Conduct outbreak investigations, refer to concerned offices health events for preventive
and control measures, coordinate with the National ESR unit for other technical support for
all response activities
d. Assists the local health personnel in conducting disease surveillance in the communities.
e. Continue surveillance and submission of follow-up reports to the National ESR unit for :

 public health events that may be assessed to cause no threat at present but may
have potential to affect a larger population later on
 diseases with vague signs and symptoms
 cases with potential for International spread
 newly defined diseases

3. The Local (province, city or municipality) ESUs

The Local ESUs will be supporting the Regional Office in the implementation of ESR. It will
be the main extension arm of the Regional ESUs for verification, assessment and response
activities. Their responsibilities in the ESR are the following:

a. Processes of ESR are implemented

b. Submits to the RESU the verification and follow-up reports of health events verified
c. Conduct outbreak investigations, refer to concerned offices health events for preventive
and control measures, coordinate with the RESU for other technical support for all response
activities
d. Continue surveillance and submission of follow-up report to the RESU for :

 public health events that may be assessed to cause no threat at present but may have
potential to affect a larger population later on
 diseases with vague signs and symptoms
 cases with potential for International spread
 newly defined diseases

E. Archiving and Confidentiality

All the data about the reported public health events will be stored and protected by the
ESR Unit in the main computer database and Online ESR site, hard copies signed, compiled and
kept confidential. Policies and procedures on the release of information should follow the national
policies as per ISO guidelines.

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ESR Manual of Procedures

VII. Monitoring and Evaluation of ESR Unit

Monitoring and Evaluation (M&E) are vital component of programs and systems. Monitoring
may be defined as the routine (continuous) tracking of performance and response. It will ensure that
the system is functioning effectively. Development of indicators will help in tracking the performance of
the system. Presence of a checklist (Annex 5) can facilitate monitoring activities. Regular feedback on
the result of monitoring activities may identify problem areas in the system.

A. Objectives of M and E

1. To track progress in the implementation of the ESR System

2. To identify areas for improvement in the ESR System
3. To identify points of improvement in existing guidelines and policies

B. Significant Indicators

ESR
Indicator Definition/Standard Data Source
Process
Numerator:
Number of health events
Sources of captured by types of
reported health sources (PITRDO) Capture Log
events sheet
Denominator:
Total number of captured
HE (at all levels)
Health events
Number of health events
Capture and captured Capture Log
filtered/number of health
Filter sheet
events captured

Numerator:
Health events reported
Proportion of online
health events
captured online Denominator:
Total number of health
events reported
Number of health events
Health events of
reported with potential
PHEIC
PHEIC

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ESR Manual of Procedures Chapter VII. Monitoring and Evaluation of ESR Unit

Numerator:
Number of health events
Proportion of verified
Verification form
verified health
Key Informants
events Denominator:
Number of health events
captured
Verification Numerator:
Number of health events
Proportion of HE verified within 24 hours
ESR Log sheet
verified within 24
ESR Verification
hours Denominator:
form
Total number of health
events captured

Numerator:
Number of health events
Proportion of
assessed as to level of 6. ESR
verified health
concern verification
Assessment events that were form
assessed as to
Denominator:
level of concern
Total number of health
events verified
Proportion of
Numerator:  ESR
verified health
Proportion of health events verification
events that were
assessed within 48 hours form
assessed within
 Assessment
48 hrs.
Denominator: report
Total number of verified IHR Annex 2(if
health events applicable)

Numerator:
Number of health events
Proportion of Health event
responded
verified health report
events responded
Response Denominator:
as to level of ESR Verification
Number of health events
concern (monthly, Report/
verified
quarterly, annual) IMRAD

Proportion of Numerator:
Health Event
verified health Number of verified health
report
events responded events responded within
ESR Verification/
within 48hrs 48 hrs
Report
(monthly,
IMRAD
quarterly, annual) Denominator:

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ESR Manual of Procedures Chapter VII. Monitoring and Evaluation of ESR Unit

Total of verified health

events

Numerator:
Proportion of Number of regions given Weekly
Feedback/
regions who weekly feedback report Feedback Report
Disseminati
received weekly per region
on
feedback report Denominator:
Total number of regions

Report validation – For online ESR, this function includes verification of reports through the
network – the ESU’s, Bureau of Quarantine and with other independent institutions like the
Embassies. The validation process also intends to inform the concern ESU’s or institution
about the reported event.

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ESR Manual of Procedures

VIII. Annexes

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 1a. ESR Captured Event Log Sheet

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 1b. ESR Verification Form

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 1c. ESR Follow-up Form

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 1d. Weekly Feedback Report Form

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 2. Flowchart on the Use of IHR Annex 2

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 3. List of Addressees of ESR Reports

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 3. … continuation

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 3. … continuation

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 3. … continuation

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 3. … continuation

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 3. … continuation

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 3. … continuation

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 3. … continuation

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 3. … continuation

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 4. Designation of the National Epidemiology Center (NEC) as the National International
Health Regulations Focal Point (NFP)

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 4…. continuation

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 5. ESR Monitoring and Evaluation Tool

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 5…. continuation

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 5…. continuation

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 5…. continuation

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 5…. continuation

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 5…. continuation

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 5…. continuation

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ESR Manual of Procedures Chapter VIII. Annexes

Annex 5…. continuation

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