Region, Nicoya, COVID-19

Epidemiological surveillance: behind the “front line” at Nicoya

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Without saying much, in the middle of a street in the central district of Nicoya, two officials from the Caja Costarricense del Seguro Social (CCSS), the country’s social safety net, begin to put on full-body impermeable suits, two types of facemasks,  and two layers of gloves. Dressed as “astronauts,” they joke, they walk into a small house to perform six COVID-19 tests at once. That’s their new normal.

There’s a gentle wind today. The officials look like “astronauts”, but they’re not in space. They’re in Nicoya, at a temperature of 32 degrees Celsius. The humidity from last night’s rain, along with the 11 a.m. sun and the plastic materials on their clothes, makes them sweat and causes them a sense of discomfort.

In an ideal scenario they would be in a laboratory, using facilities built especially for their work and with air conditioning. However, the Ministry of Health and Caja have ordered that all suspected cases of COVID-19 that can stay at home should be tested there, no matter the conditions of the home; and this is the preference of epidemiologists as well. 

“It is very helpful for us to go to the patient’s home rather than have a permanent station, because that way we can also see the social context of that person,” says Sugeidy Castillo, head of the epidemiology department in Nicoya and also part of the test sampling teams in the area. 

Since these guidelines were implemented, the testing teams have taken to the streets as their new workplaces, visiting every site with suspected cases and taking patients’ homes as if they were laboratories. They are called Rapid Home Sampling Teams because they were trained to take tests in any possible setting. 

In the Chorotega region there are usually a total of 14 teams, one for each Health Area in the province, plus the ones in Upala and Jicaral. When there is a larger number of possible cases, the teams can be divided among several units.

In early March, with the first case of COVID-19, the pace of life changed for every person in the country. The perception of time transformed and brought with it confusing schedules, overlapping days, and a more sedentary routine… all under the principle of staying home. For the epidemiological teams in each center however, these have been the most stressful months of their lives. 

For them, their workstation is now the back of the institutional truck, next to the tables and chairs that patients can provide, if they are lucky. On other days, they can do the tests in the middle of the street, on makeshift tables over water barrels, or whatever scenario they discover when they arrive. 

“Our day-to-day is never-ending, I can say that this is almost 24/7,” says Castillo.

The testing, she says, is just one part of her field work, another is to protect the integrity of those who may be infected and their own identities. 

Since they leave the Ebais, there are usually cars chasing them trying to find out where the suspected cases live, so the Caja vehicle must always make extra turns to attempt misleading the drivers. 

This time one followed them. The driver parks a few meters ahead of the van, pulls out his phone to apparently take pictures, and after a few minutes, decides to pull out. 

“It’s like we’re having a party of lights on top of the cars,” says the doctor.

In total, officials are only scheduled to perform six tests, all in the same house. A white plastic chair and a clean breakfast table await them, where they place a blue cooler that will hold the completed exams, plus a plastic compartment marked “Insumos COVID”. That’s today’s office. 

The family living in the house reported a few days ago that they had come in contact with a positive case of COVID-19 and have been feeling flu symptoms ever since. The Ministry of Health instructed them not to leave the house until they had been tested and subsequently obtained the results.

The testing, in theory, should take about 5 minutes per person. It involves inserting a long swab into the nasal walls and another into the tonsils, looking for cells indicating the presence of the virus. 

The swabs are stored in packages previously labeled with the patient’s name, and placed in the cooler, which will remain closed until they reach the laboratory.

When they leave, officials must spray alcohol all over their bodies, put the discarded clothing – which they will then incinerate – into red bags left on the sidewalk, and again spray themselves with alcohol. It is such a common process that they do it almost automatically, in silence. When they return to the Ebais, they must check that there is no evidence pending. If so, the process must be repeated. 

In Nicoya, as of July 1st, there are 62 active cases of the virus. Although the situation is roughly controlled under detected clusters, the increase in testing throughout the canton has changed the dynamics in the Health Area. 

Nicoya before COVID-19

From left to right: The head of the Nicoya Health Area, Luis Carlos Villalobos, the head of the Epidemiology team in Nicoya, Sugeidy Castillo, and the coordinator of Epidemiological Surveillance of the Chorotega region, Bismarck Villegas. Credit: César Arroyo

Before going to see the sampling, we talked inside the epidemiological surveillance room of the Ebais in the center of Nicoya with Dr. Castillo, the head of the Health Area of Nicoya, Luis Carlos Villalobos, the head of the Health Areas of the Caja, Giselle Guzmán, and the coordinator of Epidemiological Surveillance of the Chorotega region, Bismarck Villegas.

The authorities have been working together since the early hours of the morning because they will be making an epidemiological tour of the area, since Nicoya has brought national attention in recent weeks because it is the canton with the most cases in all of Guanacaste.

They are sitting in a small room on the second floor of the district’s central Ebais, which previously appeared to be a meeting room. There are metal cabinets labeled “Epidemiological Surveillance”, and several plastic compartments that say “Insumos COVID”. There, the sample teams prepare everything they need to take with them for field testing. 

“We spend more time here than in our own homes,” Dr. Villalobos jokes. 

While the whole world wants to distance itself completely from COVID-19, doctors are living with the threat of infection. They are dedicated to examining, tracking and researching a disease we know little about so they can translate it into the reality of the region. 

In the room we are in, they also carry out the epidemiological surveillance of the canton. Every day they analyze the behavior of the virus and the factors that affect the health conditions of the positive patients, in order to determine the real status of the COVID in Nicoya. 

 This way they have been able to conclude that the canton does not need an Orange alert because it is currently in a containment phase, with all the cases identified and controlled in isolation spaces. 

They can also know when the containment phase in Nicoya will eventually change to the mitigation phase, where they will have to prioritize those serious patients with risk factors. 

For the Health Area in Nicoya, says Guzmán, the population at greatest risk from the COVID is the elderly – over 80 years old – since the canton is a blue zone. They would be the priority if the situation were to worsen.   

“Guanacaste is a challenge in itself,” says Dr. Villegas. Part of the work of epidemiological surveillance is to understand the social characteristics of the population. 

Unlike other regions, he says, in the province the immediate family nucleus is more than 8 people and they carry out their common activities around the elderly. 

“It’s part of the Guanacastean culture that grandmothers are incredibly important, so our job is to distance these families so that they don’t infect them,” Villegas emphasizes.

Dr. Castillo adds that another peculiarity is that part of the population lives in places that are difficult to reach. 

She says that a few weeks ago, a sampling team traveled to a distant district and reached a point where they could no longer get there by car. The patient then had to ride his motorcycle to meet them and have the test done in the middle of a dirt road. 

“Day by day, when we go to sample, we never know what we’re going to find,” says Dr. Castillo. 

“We are people too”

Nationwide, Caja works in conjunction with the Ministry of Health, which is also collaborating with the National Emergency Commission (CNE), the Joint Institute for Social Assistance (IMAS) and the corresponding municipalities. Nicoya is no exception.

“I have never seen so much unity. It’s constant communication, support and backing. Knowing that there are thousands of people working for the same thing keeps me sane,” says Dr. Guzmán.

Four months into the crisis, they say they need to remind each other that they are still people, and not just “those on the front lines,” as they are constantly being told. 

During the conversation they make jokes to each other, remembering that the epidemiologists are also singers, dancers and “mejengueros” (football players). However, they have had to change everything for the laboratories where they spend, in the worst days, up to 12 hours locked up. 

Dr. Castillo says that photos are constantly being taken of her team and posted on social networks, where they receive threats and derogatory comments. 

“People don’t seem to understand that we have families waiting for us too,” she says. 

Guzmán says that for the same reason she has decided to limit her use of social networks. As head of the Health Areas, she has traveled to border areas where she has seen, as she describes, “comments full of hate and anger” toward foreign populations. 

“It’s horrible to see that some people don’t understand that people are first and foremost people, and a sick person is a sick person, and whether they have a regular immigration status or not, we’re still going to treat them,” she says. 

The fear of infecting a loved one is a common factor among all of them. Days before the visit, the sampling teams and epidemiologists in the laboratory tested themselves, because of the constant contact they have had with the virus in recent weeks. 

“It’s fortunate that none of them tested positive and rather prompted everyone to work harder,” Villalobos said. 

We talked for an hour and a half, until the officials had to leave to have more meetings with other workers from the Fund and take us to see the tests being done. Talking about their experiences, says Dr. Villalobos, has been therapeutic for workers who in the last four months have been working on “automatic”. 

That same June 24, Health Minister Daniel Salas recalled that COVID-19 “is not going anywhere soon. Constant work is now the new normality for them.