INTEGRATED FRAMEWORK for COVID-19 RESPONSE

The COVID-19 pandemic^[1] continues to impact the world profoundly and has had far-reaching consequences beyond health and disease outcomes in populations. Recognizing this pandemic’s complex, multi-faceted nature, READY has developed an integrated response framework to minimize COVID-19 transmission in vulnerable communities. By supporting the adherence to two selected non-pharmaceutical interventions (NPIs) through integrated multi-sectoral, holistic humanitarian services and designing an integrated response framework around specific NPIs, the framework promotes an integrated lens for outbreak readiness and response. This framework enables us to accomplish greater multi-sector cohesiveness, implement holistic service models, improve communications and coordination among various actors, maximize limited resources, minimize possible trade-offs, and promote more efficient ways of working.

While it is recommended that an effective COVID-19 response includes a comprehensive set of mitigation and containment interventions, this framework focuses primarily on enabling holistic services around a sub-set of common interventions: 1) Quarantine and isolation in the household, and 2) Quarantine Facilities and Community Isolation Centers. Quarantine and isolation are commonly used by national and local officials to reduce disease transmission. For example, to reduce transmission, the World Health Organization (WHO) recommends that individuals suspected or confirmed for COVID-19 should quarantine or isolate for up to two weeks. Asymptomatic individuals or individuals with mild to moderate symptoms can isolate at home. They may have to do so with household members who are also encouraged to quarantine. In low-resource settings, it is challenging to ensure these isolated and/or quarantined households have sufficient access to basic needs such as food and water, other essential services, and information. In particular, these households need to be protected from any increased vulnerabilities caused or made worse by isolation. Many of these services may be missing or delivered through vertical sectoral programming, which aligns funds, benchmarks, and technical expertise solely to one technical area. While recognizing that this framework does not include the full menu of possible mitigation and containment measures, its goal is to guide detailed planning and implementation around quarantine and isolation with hopes to expand and consider other interventions in the future iterations.

The framework, through desk research and consultations, has adapted several tools and approaches from agencies such as the WHO, Inter-Agency Standing Committee (IASC), Active Learning Network for Accountability and Performance (ALNAP), and from non-governmental organizations (NGOs) such as Save the Children, International Rescue Committee, and academic institutions such as the London School of Hygiene and Tropical Medicine and the Johns Hopkins University.

The Framework

This framework is intended for technical experts, country directors, program directors, program managers, and program staff of national and international NGOs to guide their organization’s strategy, proposal development, program implementation, and operational activities for the COVID-19 emergency response. By promoting holistic support to individuals with suspected or confirmed COVID-19 (who have been quarantined or isolated either in their households or at voluntary or involuntary facilities/centers), the framework aims to minimize transmission of COVID-19 in vulnerable communities through improved adherence to the two selected non-pharmaceutical interventions (NPIs).

The framework builds on a foundation of key principles and entry points for effective multi-sectoral integrated programming to accomplish this goal. These entry points are organized along the program cycle (Strategic Leadership and Coordination, Planning, Proposal Development & Project Design, Program Implementation, and Monitoring, Evaluation, Accountability & Learning (MEAL)). The design guides the process for enabling multiple sectors and cross-cutting areas to contribute to the same goals and objectives. The framework then aligns each sector, with considerations from the cross-cutting areas, to enable relevant activities and services to contribute to these common goals and objectives.

The framework brings together existing sector-specific technical and operational guidelines that have been developed by the humanitarian community, including guidelines from Health [Community Health Programming; Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH); and Mental Health and Psychological Support (MHPSS); Water, Sanitation, and Hygiene (WASH); Protection (Child Protection and Gender-Based Violence); Nutrition; and Food Security.

Cross-cutting themes relevant to all sectors need to be kept at the forefront of how outbreak responses are designed and implemented. These themes include Social and Behavior Change (SBC), specifically through Risk Communication and Community Engagement (RCCE), age, gender, ability, ethics, and OneHealth.

^[1] Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is the name given to the 2019 novel coronavirus. COVID-19 is the name given to the disease associated with the virus. To appeal to a wider audience, including non-health and entry-level program staff, this document will refer to programming in COVID-19.

What is integration?

Integrated programming holistically addresses the multiple and inter-related rights, needs, risks, and vulnerabilities of individuals and communities. An integrated approach ensures that interventions from different sectors and teams do not occur in isolation (i.e., siloed). Instead, these interventions will reinforce one another to achieve the best possible outcomes with existing resources.

Why is integrated programming important in response to COVID-19?

• In locations with widespread community transmission or where access and movement are restricted, we must continue to maximize our resources to make the biggest collective impact across sectors and teams. Now more than ever, it is vital to adopt a collaborative approach.
• Building on the existing structures within countries, governments, national and international organizations, coordination bodies, and communities enables us to pursue a coordinated response with a clear flow of information to support the service continuation, build trust, and meet community needs.
• Adopting an integrated lens in this pandemic promotes efficient ways of working; thereby, enabling a more community-centered approach and greater care for frontline and aid workers. Simultaneously, this approach reinforces Do No Harm practices by ensuring a balance between public health guidance and protection principles, as well as through practical measures such as physical distancing and the consistent use of personal protective equipment (PPE).

What are Non-Pharmaceutical Interventions (NPIs)?

NPIs include all measures or actions, outside of vaccines or medicines, that can be implemented to prevent, slow the spread of, or treat, a communicable disease in a population.^[2] NPIs are also known as community mitigation strategies. With no known vaccine or treatment for COVID-19, the most effective ways to reduce transmission and save lives are through:

1. Personal NPIs, including hand-washing, respiratory hygiene, physical distancing, self-isolation, household quarantine, and protecting vulnerable individuals (such as the elderly) within the household.
2. Environmental NPIs, including regular cleaning and disinfecting surfaces and ensuring ventilation in public buildings.
3. Community NPIs, such as physical distancing, closure of schools and universities, the closing of non-essential businesses, and bans on mass gatherings.
4. Containment Measures, including surveillance, testing, isolation, contact tracing, quarantine, and border measures, if needed.

How are household quarantine and household isolation defined?

In the context of COVID-19, the quarantine of contacts is the restriction of activities and/or the separation of persons who are not ill but who may have been exposed to an infected person.^[3] The objective is to monitor their symptoms and ensure the early detection of cases. On the other hand, isolation is the separation of infected persons from others to prevent the virus’s spread.^[4] At the household level, if a member of the household is suspected or confirmed to have COVID-19 and is either asymptomatic or has mild to moderate symptoms, they can isolate at home under certain conditions. Additionally, household members are encouraged, as high-risk contacts, to self-quarantine within the house to reduce the likelihood of transmission to the broader community.

How are quarantine facilities and community isolation centers defined?

In resource-restricted settings, such as refugee camps and crowded urban settings, it may be difficult for individuals to isolate or quarantine at home. In some cases, governments and local authorities are requiring facility-based isolation. Therefore, quarantine facilities and community isolation centers (CICs) are being set up to enable early detection and treatment referral. Quarantine facilities enable the separation of persons who have been in contact with someone suspected or confirmed to have COVID-19. Community isolation centers provide people with mild to moderate symptoms, who are not at increased risk for severe disease, with a safe space to voluntarily isolate until they are no longer considered infectious according to the respective country’s Ministry of Health guidelines.^[5] It is essential to distinguish CICs from isolation treatment centers: CICs offer individuals with mild or moderate symptoms a voluntary option to isolate if they cannot do so in their homes. Isolation treatment centers are for individuals with severe symptoms requiring medical treatment and care. Both quarantine facilities and CICs will monitor the daily symptoms of those admitted, and the CIC staff refer people to isolation treatment centers if needed.

Quarantine facilities and community isolation centers should be voluntary spaces, although we recognize that this isn’t always the case, and some governments and local authorities are enforcing facility-based isolation and quarantine. We recognize the inherent risks and rights issues that exist with involuntary centers. This integrated framework is designed to identify and reduce those risks through holistic multi-sectoral support. This guidance does not advocate for establishing or implementing forced quarantine or isolation facilities, especially given the possible distress and family separation this may cause. The preference is always to have contacts self-quarantine at home. Additionally, contacts with suspected or confirmed cases, whether they are asymptomatic or with mild or moderate symptoms, should self-isolate at home. However, given contextual realities, this guidance seeks to offer recommendations to humanitarian actors to help them mitigate risks and provide best practices for offering holistic care to individuals in quarantine or CICs.

How did READY prioritize isolation and quarantine as the focus of this framework?

Through consultations with partners and country offices responding to the COVID-19 pandemic, READY determined that authorities would continue to prioritize physical distancing measures in the current context and for the immediate future, especially where case numbers are low and where there is a capacity for containment interventions in resource-constrained settings, such as refugee camps. In addition to consultations, READY conducted a scoring exercise to further narrow the type of NPI physical distancing. READY selected the most relevant NPIs for illustrating this framework. The criteria used for this exercise included:

1. Evidence: Level of current evidence to support implementing the NPI.
2. Applicability: The NPI is applicable in various geographical contexts where NGOs are implementing programs.
3. Timing: The NPI will be directly applicable in the planning and response phases for COVID-19.
4. Multi-sector Programming: Ability to demonstrate relevance and applicability of multi-sector programming (at least four sectors) to encourage and maintain adherence to the NPI.
5. Contribute to Evidence: The potential to contribute to ongoing and future evidence of implementing these NPIs in a respiratory epidemic/pandemic.

^[2]  Centers for Disease Control
^[3]  International Health Regulations (2005) Third edition. 2016. Geneva: World Health Organization; 2020. Posted at https://www.who.int/ihr/publications/9789241580496/en/, accessed August 26, 2020)
^[4]  Considerations for Quarantine of Contacts of COVID-19 Cases. Interim Guidance. 2020. Geneva: World Health Organization; 2020. Posted at https://www.who.int/publications/i/item/considerations-for-quarantine-of-individuals-in-the-context-of-containment-for-coronavirus-disease-(covid-19)/, accessed August 26, 2020)
^[5]  Operational Guidelines for Community Isolation Centers for COVID-19 in Low Resource Settings. 2020. Centers for Disease Control and Prevention; 2020. Posted at https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/operational-considerations-isolation-centers.html/, accessed August 26, 2020)

Term	Full Expression
AAP	Accountability to Affected Populations
ALNAP	Active Learning Network for Accountability and Performance
ANC	Antenatal care
ART	Anti-retroviral therapy
BBC	British Broadcasting Corporation
BEMONC	Basic Emergency Obstetric and Newborn Care
BHA	(USAID) Bureau for Humanitarian Assistance
CEMONC	Comprehensive Emergency Obstetric and Newborn Care
CHA	Community health assistant
CHW	Community health worker
CIC	Community isolation center
CIC	Isolation Treatment Center
CMAM	Community-based management of acute malnutrition
CMR	Clinical management of rape
CP	Child Protection
CSG	Child Safeguarding
CSO	Civil Society Organization
DHIS	District Health Information Software
DPO	Department of Peace Operations
EFSP	Emergency Food Security Program
EWARS	WHO’s Early Warning, Alert and Response System
FAO	Food and Agriculture Organization
FEWSNET	Famine Early Warning System Network
FOCUS 1000	Facilitating and Organizing Communities to Unite for Sustainable Development
FP	Family Planning
GBV	Gender-Based Violence
GHRP	Global Humanitarian Response Plan
GOAL	GOAL International (not an acronym: GOAL is an international humanitarian response agency with its headquarters in Dublin, Ireland)
IASC	Inter-Agency Standing Committee
ICC	Interim care center
IEC	Information, Education, and Communication
IFRC	International Federation of Red Cross and Red Crescent Societies
INGO	International non-governmental organization
IPC	Infection Prevention and Control
IPV	Intimate partner violence
KAP	Knowledge, Attitudes, and Practices
LGBTIQ	Lesbian, gay, bisexual, transgender, intersex, questioning
LHW	Lady health worker
MEAL	Monitoring, Evaluation, Accountability, and Learning
MHPSS	Mental Health and Psychosocial Support
MIRA	Multi-Sector Initial Rapid Assessment
MISP	Minimum Initial Services Package
MOH	Ministry of Health
MQSUN+	Maximizing the Quality of Scaling Up Nutrition Plus
MSNAP	multi-sectoral nutrition action plan
MUAC	Mid-Upper Arm Circumference
NGO	Non-governmental organization
NPI	Non-pharmaceutical intervention
PEP	Post-exposure prophylaxis
PNC	Postnatal care
PPE	Personal protective equipment
PPH	Post-partum hemmorhage
PSEA	Preventing Sexual and Exploitation Abuse
PSS	Psycho-social support
RCCE	Risk Communication and Community Engagement
READY	READY is the complete name (not an acronym) of the initiative that produced this Integrated Framework (more at www.ready-initiative.org)
RH	Reproductive Health
RMNCAH	Reproductive, Maternal, Newborn, Child and Adolescent Health
RUTF	Ready-to-use therapeutic food
SBC	Social and Behavior Change
SMAC	Social Mobilization Action Consortium
SMS	Simple Messaging Service (also called “text messaging” or “texting”)
SOP	Standard Operating Procedure
SRH	Sexual and Reproductive Health
STI	Sexually transmitted infection
SUN	Scaling Up Nutrition
TA	Technical Assistance
TBA	Traditional birth attendant
UN	United Nations
USAID	United States Agency for International Development
WASH	Water, Sanitation, and Hygiene
WFP	World Food Programme
WHO	World Health Organization