The COVID-19-Tsunami on a small island

1. Introduction

At the end of the year 2021, the Omikron-COVID-19 wave has also reached the Caribbean Island of Aruba. The Department of Public Health (DVG) and the closely cooperating MedCare Clinic (MedCare; where I work as a general practitioner) were flooded with Corona cases. The protocol at the time turned out not to be able to withstand the tsunami of tourists who tested positive.

2. Description of situation

At the beginning of December 2021, the number of intakes averaged at 4 positive test subjects (positive case, from now on called PC) per day. An intake itself took about 30-60 minutes, patients were monitored and a house visit was made a few days later. This was labor-intensive, but feasible given the low numbers. Just before Christmas 2021, the numbers were on the rise: the start of a peak we were unprepared for. The number of reported infections in Aruba at that time was the highest in the world (source Volkskrant, January 3, 2022). The absence of fallen-sick colleagues and a team that was too small, made it even more difficult to maintain the then-used protocol. Change was forced to take place within a very short period of time.

In this article I will describe the changes that have taken place in the organizational and automation field. Or in other words: the transformation it took to turn a COVID-19-ravaged Aruba into a COVID-tsunami resilient island.

3. Method, automation and visualization

• Method

In the first column of table 1, the method is described that MedCare used in collaboration with the DVG in October 2021. We used Google Sheet for this, where we were able to correlate the numbers with the names of the PCs in a secured file. An individual medical file was also created for each patient.

Table 1 Intake description and time indication October 2021 vs. January 2022

As described in table 1, the time investment per case has decreased drastically due to the automation. Now, there is a better overview of any symptoms and the patient's medical history. It immediately became clear whether patients needed (more) medical attention.

• Automation

The automation process was done manually until December 2021. From January 2022 it was performed online. The automation process took place in several steps according to the 'trial-and-error method' (table 2).

Table 2: Steps in the form of the 'Trial-and-Error' method

• Visualization
  • Intakes and positive tests per period

Figure 1 shows the translation towards the Online Form. This shows the increase in the number of patients, including the transition to the new system.

Figure 1: Intakes using the old system (blue) vs. new system (orange), with the dates and numbers of positive tests.

Discussion: COVID-19 peak
As can be seen in figure 1, the final automation step could not have come a day later. At the time of the implementation of the online form, the entire MedCare team was overloaded, with some employees working continuously for 16 days. Figure 1 also shows that the number of positive tested persons has decreased drastically since January 8, 2022. One reason for this could be, for example, the entry restrictions: Aruba uses access on the condition that a negative COVID test result can be presented, which is performed less than 24 hours before arriving. In America (where most tourists come from) the test locations were overloaded, resulting in many tourists who could not get their test results in time to travel. In addition, it can be argued that tourists are less inclined to travel to a high-endemic areas. Another explanation is that the corona peak is simply decreasing.

Discussion: Five days of isolation
According to the CDC (Center for Disease Control, America), patients were allowed to be out of isolation overnight after five days, instead of seven to ten days. In daily practice, this meant that MedCare had to provide three times the number of people with a medical certificate within a few days. This created complications, because PCs had already rebooked flights and were allowed out of isolation earlier, which meant that they were no longer reimbursed by the Aruba Visitors Insurance for the remaining days on the island. In addition, we saw a number of PCs that, after the five days of isolation, presented themselves again with an increase in COVID-related symptoms. 

• Positive test results MedCare and DVG per period

Figure 2 shows an overview of the data on which the patients tested positive for COVID-19. In this figure, the registered patients with MedCare resp. DVG side by side. The data from DVG is based on the positive tests from the day before. In the figure, the numbers are corrected for test data, and double tests.

Figure 2: Trend of positively registered patients at MedCare vs. DVG with associated data

From December 10, 2021 to January 28, 2022, 2584 PCs were registered by DVG. MedCare registered 2548 PCs out of the 2584. This corresponds to 98.6% intake rate.

Discussion: Trend actual numbers vs. registered numbers
During the drastic increase in cases at the beginning of this wave, we, as a medical clinic, were concerned that we might miss patients with severe symptoms. Figure 2 shows the official test data of the registered positive persons known by the DVG (the so-called actual numbers) versus the numbers registered with MedCare. Absolutes cannot be compared due to selection bias. MedCare, for example, has no direct access to laboratory results, and only works with the information that comes to them through various channels (via the DVG and/or online form). However, this figure shows a clear trend in which the patients known to DVG, were also registered and monitored by MedCare.