Biosafety Capacity Building During the COVID-19 Pandemic: Results, Insights, and Lessons Learned from an Online Approach in the Philippines

Abstract

Introduction:

COVID-19 diagnosis was one of the most pressing needs during the early stages of the pandemic. Its entire procedure has inherent biosafety risks that if not properly managed and mitigated can be life threatening. Cognizant of this vital aspect, the Department of Health (DOH) imposed a biosafety training requirement to all laboratories and institutions before they could perform COVID-19 diagnostic testing. But with the mandatory lockdown, conventional face-to-face training could not be conducted. To address this need, the Biosafety Education and Awareness Training COVID-19 Online Program was offered by the National Training Center for Biosafety and Biosecurity of the University of the Philippines Manila.

Methods and Materials:

This online training program implemented a distance learning approach made available through the Canvas Learning Management System. It consisted of seven modules on biosafety that were sufficient enough to capacitate the participants with information for them to effectively implement a biorisk management system. The participants were evaluated based on quiz, examination, and case analysis. Certificates of completion were awarded to participants who passed all evaluation methods.

Results:

A total of 3371 trainees from various medical professions passed and obtained the certificate. This resulted in >100 DOH-accredited COVID-19 testing laboratories by the end of 2020.

Discussion and Conclusion:

The online availability of this program proved to be an effective innovative solution to a unique problem. Therefore, this training program demonstrated that biosafety training can be effectively conducted online and in a distance learning approach.

Introduction

COVID-19 diagnosis was one of the most pressing needs during the early stages of the global pandemic. At the onset of the pandemic in the Philippines, there was only one authorized laboratory that could perform the COVID-19 diagnostic testing due to the lack of capability of other laboratories. This resulted in massive backlogs while the disease was spreading itself undetected. The lack of government-authorized testing facilities was primarily because of the inherent biosafety risks of the conduct of the COVID-19 testing, which if not properly managed and mitigated, can be life threatening.

Before the COVID-19 pandemic, laboratory biosafety was an unfamiliar field and discipline in the Philippines and only a few institutions were at least familiar with it and had the capacity to manage and mitigate the accompanying risks. However, it was finally recognized as an important component in the laboratory and workplace during the start of the pandemic in the Philippines. In March 2020,¹ the average daily diagnosed COVID-19 cases were recorded at 7000–8000 cases. However, this number was less than the actual number of cases because of the limited testing capacity in the country. Increased laboratory testing was then one of the urgent demands, but the lack of biosafety training, appropriate facilities, equipment, safety gear, molecular biology training, and laboratory supplies as required by the department of health (DOH) of the Philippines for licensing² prevented other laboratories and institutions from offering COVID-19 diagnostic testing.

With the imposed lockdown during the pandemic where physical gathering of people was prohibited, conventional face-to-face training could not be conducted. In response to this urgent need and in fulfillment of its mandate, the National Training Center for Biosafety and Biosecurity (NTCBB) of the University of the Philippines Manila started to offer the Biosafety Education and Awareness Training (BEAT) COVID-19 Online Training Program last March 31, 2020. This was a biosafety training program designed to provide all essential concepts needed to effectively manage and mitigate the biosafety risks involved in conducting COVID-19 laboratory testing. The availability of the online training allowed the safe conduct of the biosafety training because participants need not be physically gathered in a room.³ In addition, the distance learning approach enabled the participants to take the training at their convenience,⁴ making the training more flexible.

In recognition of the vital need for biosafety training in conducting COVID-19 diagnostic testing, the Philippine government through the DOH released the Administrative Order 2020–014,² requiring all institutions and laboratories that were planning to offer COVID-19 diagnostic testing to take the online biosafety training program offered by NTCBB. The online BEAT COVID-19 Online Training Program of NTCBB had trained thousands of laboratory personnel by the end of December 2020. In this article, we discuss how we conceptualized and conducted the training program and also the results that we have obtained. In addition, we provide some insights and we share the lessons that we have learned during and after the implementation of this training program.

Methods

The BEAT COVID-19 Online Training Program offered by NTCBB implemented a distance learning approach by providing relevant information and materials essential to managing the biosafety risks and concerns of the COVID-19 diagnostics. The biosafety training was composed of seven modules: introduction to biorisk management with focus on biosafety; biorisk assessment; biocontainment facilities; basics of biosafety cabinets; personal protective equipment (PPE); disinfection, sterilization, and decontamination; and biological waste management. The modules were designed based on the Centers for Disease Control and Prevention (CDC's) Biosafety in Microbiological and Biomedical Laboratories (BMBL) (5th Edition), World Health Organization (WHO) Laboratory Biosafety Manual (3rd Edition), and local guidelines from DOH and Research Institute for Tropical Medicine. A pool of certified biorisk officers from the Philippine Advanced Biosafety Officers' Training Course participated in the creation and development of an extensive curriculum that was used in the BEAT COVID-19 Online Training Program. Lecture video presentations, reading materials, and applicable evaluation metrics were prepared for each module and were all organized and made available in the online learning platform Canvas Learning Management System (CLMS). The results presented in this paper came from the training program of which the authors ensured that no identifiers that can link the data to any participant are found within the manuscript.

For each session, the training was conducted for 5 days. Fifty participants were enrolled one week before the start of training and were given three days to activate their respective online learning platform accounts. Those participants who failed to activate their accounts were replaced. During the training, the participants could access the CLMS platform anytime to watch the lecture video presentations, download and study the reading materials, complete the quizzes, take the final examination, and submit the case analysis. Also, participants could join the weekly live panel discussion through Zoom to consult with subject matter experts on anything related to the course or biosafety management. At the end of the training, each participant who obtained a passing mark (70%) in the comprehensive case analysis was given a completion certificate. The Philippine government, through the DOH Administrative Order 2020–014, required this certificate for the participant's respective laboratory or institution to offer the COVID-19 diagnostic test.

Results

A total of 3371 training participants composed of physicians, pharmacists, biologists, chemists, nurses, medical microbiologists, medical technologists, teachers, and laboratory personnel had passed the “BEAT COVID-19 Program” held between March 31 and December 11, 2020. This had enabled the participants to proceed in the molecular biology training, and ultimately having their institutions eligible to apply for COVID-19 diagnostics accreditation. At the end of 2020, there were already >100 accredited COVID-19 testing laboratories in the Philippines.

The digital platform allowed the training program to reach more individuals across the country.³ Most of the participants were from the National Capital Region (39%) and the rest were from different regions of the country (Figure 1). The BEAT COVID-19 Online Training Program was also able to cater Overseas Filipino health workers, which we can infer that the demand for biosafety education global and is of utmost importance, especially during a pandemic.

Figure 1.

Distribution of participants per region in the Philippines. Color images are available online.

The data show that the majority of the participants were medical technologists (52%) who were needed to perform the collection and processing of samples from patients. The rest of the participants were health and laboratory personnel (18%), research and faculty members (16%), students (8%), and other professionals (6%) (Table 1). The data gathered also show that the majority of the participants came from hospitals (51%). In comparison, institutions such as laboratories (20%), schools (17%), research facilities (6%), and nongovernmental organizations (1%) also participated in the program (Table 2).

Table 1.

Distribution of participants enrolled in the training by profession. Data showing participants were majority medical technologists, followed by faculty members and students

Profession type	Total participants	Percent composition
Medical technologist	1753	52%
Faculty	337	10%
Student	270	8%
Researcher	202	6%
Physician	202	6%
Others	202	6%
Other allied medical professions	135	4%
Laboratory personnel	101	3%
Nurse	67	2%
Microbiologist	67	2%
Chemist	34	1%
Biologist	1	0%
Total	3371	100

Table 2.

Distribution of participants enrolled in the training by type of institution

Type of institution	Total participants	Percent composition
Hospital	1719	51%
Laboratory	674	20%
Academe	573	17%
Research	202	6%
Others	101	3%
Medical/laboratory sales	34	1%
Regulatory	34	1%
NGO	34	1%
Total	3371	100

Data showing majority of the participants came from hospitals, followed by laboratories, schools, and research facilities.

In general, the participants expressed their appreciation to the course creators, lecturers, and facilitators for the timely conduct of the training and complimented that the training was held online. However, points for improvements in the training experience were also noted, such as improving the quality of the video and audio of the recorded materials, providing a rationale for each answer in the quizzes, and visual aids in the lectures.⁵ They also mentioned that releasing a collective manual that includes all the course information, including those in the lecture videos, would be helpful.

Other themes and topics of interest for future NTCBB training generally include the following content: more in-depth training in biosafety and biosecurity practices, processes, and procedures, for example; standard operative procedures (SOPs) in anticipating and responding to unwanted laboratory situations; and updated information on molecular pathology and diagnostics. Workshops in assessment tools, practical workflows, and SOPs on detecting emerging and re-emerging infectious diseases were also mentioned in the participants' feedback.

Challenges and Lessons Learned

• 1.Participant Self-Regulation. Having an asynchronous online course allowed participants to take the lessons at their own convenience, making the training more inclusive. Thus, it was observed that they try to finish all the lessons and course materials toward the end of the week.⁶ We tried to address this by posting announcements and reminders to the participants to complete the training within the course timeline. A comprehensive course guide with a proposed daily schedule was also made available to participants. Looking forward, this BEAT COVID-19 Online Training Program can be converted into an intensive Massive Online Open Course (MOOC) that can be delivered for an 8-week period.⁷ This would then entail that each module will be taken per week by the participant. This MOOC can be looked at after the pandemic and whether there is still a need for offering such courses. By following a relatively more rigid schedule, it will hopefully increase the passing rate of the training course.
• 2.Social Presence and Participation. This is an essential part of online learning and teaching where social presence, whether with co-learners or teachers, can motivate the participants.⁸ However, in this course, with the fast-paced nature and the asynchronous format of the course, this may well be seen as one of the main issues of why participants could not finish the course, aside from them not having enough time to fulfill the requirements. The live panel discussion sessions with the subject matter experts were opportunities for the participants to ask questions about biosafety and helped in keeping them engaged in the course. To further stimulate learners to engage with one another, discussion boards may be required in the future so that they can share their best practices.⁹ Likewise, they can also share their questions and issues that may be essential in the learning process.
• 3.Allotted Time for Training. The asynchronous training of 5 days was sufficient enough to complete a 16-h self-paced training.¹⁰ Participants could have finished the training earlier if they were relieved of work for that training duration. This was one of the main concerns of participants as they still had to go to work and then do the training after working hours. Facilitators were also requested to monitor questions in the CLMS even after work hours to ensure they were addressed promptly. To ensure that participants can complete the course, they should be allowed to be excused from their work. As already mentioned, converting the course into a longer MOOC might address this issue.¹¹
• 4.Content. The content of the BEAT COVID-19 Online Training Program needed to be regularly updated to include the most recent biosafety information and guidelines for COVID-19.¹² This was ensured by consistent monitoring of information by the training moderators and sharing of all pertinent files and documents in Google Drive that can be accessed by all participants. These included relevant international guidelines and applicable Philippine administrative orders and circulars. Because biosafety was a relatively new concept to the participants, video demonstrations were found helpful. For instance, videos on donning and doffing of PPE, spill drills, and respirators were provided in the modules. A video on COVID-19 testing workflow (Figure 2) developed by the University of the Philippines National Institutes of Health COVID-19 Testing Laboratory was specifically created and uploaded to the platform to give the participants an idea of COVID-19 testing laboratory processes and its biorisk management considerations. Moreover, with the release of the BMBL 6th Edition and the WHO Laboratory Biosafety Manual 4th Edition after the course was administered, the content will need to be realigned with new guidelines and updates from these two manuals. Furthermore, we need to regularly update the curriculum based on the DOH guidelines that might be released in the future in response to changing paradigms of the pandemic.
• 5.Content Creators. The content creators needed to have diverse backgrounds and specializations as they were essential for the course's success. A biosafety officer with laboratory and hospital experience was particularly instrumental in developing the modules. An instructional designer with background in online module development contributed in structuring the content materials.¹³ In addition, having one module creator per subtopic enabled a more focused discussion when participants had questions on the materials. Looking forward, we might partner with multimedia creators in the development of multimedia materials.¹² This will ensure that the multimedia materials follow principles of effective learning techniques to make the training program more effective.
• 6.Multimedia Materials. It was observed that there were different types of learners and not all were accustomed to visual and auditory learning.¹⁴ Because of this, each lecture video was trimmed to around 10 to 30 min in length so that it would not be too long to watch per session. Supplemental reading materials were also provided to enhance their learning on a particular topic. These multimedia materials already mentioned should adhere to the principles of effective learning to ensure memory retention and effective understanding.¹⁵
• 7.Platform. The course utilized a free learning management system, which enabled NTCBB to upload all the materials on the internet. Since online training is new to most participants, a step-by-step guide was made available to help them navigate the platform. One thing that was observed was that the instructions should be clear and, as much as possible, be numbered or in bulleted form. Otherwise, they might navigate around the platform randomly, which was observed in their activity logs. Another advantage of the platform is its mobile version that allows the participants to download the study materials and access them offline. This allowed the participants to take the course anytime and anywhere, at their own convenience.¹⁶
• 8.Assessment Methods. The training used several assessment methods such as pretest, quizzes, final examination, and case analysis.¹⁷ Although virtual training would inevitably face challenges of academic integrity, assessment security was implemented throughout the course planning, test administration, and incident response to limit the effects of cheating. Security measures applied include the online presence and rotation of course staff, limitations in test taking, pooling, and randomization of questions. Furthermore, correct responses were deliberately hidden to prevent answer sharing. The case analysis was useful in determining the level of understanding of participants in responding to practical scenarios. Examples of case analysis presented in the training were topics related to risk assessment, PPE, mitigation controls, and waste management. A rubric guided the course staff in maintaining uniformity and fairness in assessing the merit of responses toward the case analysis (Table 3). Lastly, it was recommended that instead of having a Pass-All system for the assessment methods, weights for the different tools should be instituted so that all the participants will be given a chance to pass even if they fail one or two requirements. Participants who failed are given the chance to retake the course.
• 9.Internet Connection. Participants and teachers had varying quality of internet connections, making it a significant challenge especially during the live sessions.¹⁸ Other considerations, such as power interruption, should be taken into account as well. Having the course mostly asynchronous and making the modules available offline alleviated the need to have reliable internet. Participants were also advised to inform the facilitators immediately for instances when they lost their internet connection in the middle of taking the final examination. Activity logs were monitored to validate the progress of the participants.
• 10.Program Evaluation. Given the fast-paced nature and the need to continually offer it, the training program was only evaluated toward the end of its offering. The coordination between the DOH and the NTCBB should be more streamlined in identifying who should take the training. The program should have been evaluated at least every month to improve the offering with a 1-week break to implement and improve the course.¹⁹

Figure 2.

The COVID-19 diagnosis workflow used at the National Institutes of Health, University of the Philippines Manila COVID-19 Testing Laboratory. ^ADonning of PPE is different from sample preparation and PCR assay preparation; these processes are dependent on risk assessment. ^BDoffing of PPE is different from sample preparation and PCR assay preparation; these processes are dependent on risk assessment. ^CWaste generated coming from sample preparation and PCR assay preparation is treated differently during waste disposal based on risk assessment. PPE, personal protective equipment. Color images are available online.

Table 3.

Rubrics used to grade the case analysis of participants

Criteria	Ratings
	Excellent (4–5)	Fair (2–3)	Needs improvement (0–1)
Risk identification	The hazard and situation identified corresponds correctly to the risk	Only one of the hazard or situation identified corresponds correctly to the risk	The hazard and situation identified does not correspond correctly to the risk
Risk characterization	The likelihood and consequence characterized corresponds correctly to the risk	Only one of the likelihood or consequence characterized corresponds correctly to the risk	The likelihood or consequence characterized does not correspond correctly to the risk
Risk evaluation	The risk is accepted or not accepted correctly based on the risk evaluation	The risk is accepted or not accepted partially correct.	The risk is accepted or not accepted incorrectly
Existing mitigation	All the mitigation steps identified aligns with how the likelihood of the risk characterization step was made	Only three or four mitigation steps identified aligns with how the likelihood of the risk characterization step was made	Only one or two mitigation steps identified aligns with how the likelihood of the risk characterization step was made
Mitigation changes	All the mitigation changes identified align with how the consequence of the risk characterization step can be lowered	Only three or four mitigation changes identified align with how the consequence of the risk characterization step can be lowered	Only one or two mitigation changes identified align with how the consequence of the risk characterization step can be lowered
Biosafety cabinets	The proposed methods of ensuring the safe use of BSCs are complete.	One of the methods proposed in ensuring the safe use of BSCs can cause problems.	The methods proposed will not allow proper utilization of the BSCs
DSD and biological waste management	The proposed waste management practice corresponds to sound practice and will prevent risks from occurring	One of the proposed waste management practice is not adhering to standards that may cause risks from occurring	The proposed waste management practice is not suitable for utilization with COVID-19 diagnosis

BSC, biosafety cabinets; DSD, disinfection, sterilization, and decontamination.

Discussion

The University of the Philippines Manila, through the National Institutes of Health, has been conducting the Philippine Advances Biorisk Officers Training (PhABOT) since 2011, where the core topics include Introduction to Biorisk Management, Biorisk Assessment, Biocontainment, Personal Protective Equipment, and Waste Management. When the NTCBB was established in 2018, it became its flagship training program, producing five batches of successful graduates so far. During the start of the pandemic, healthcare institutions were clamoring for biosafety training in order for them to establish and operate COVID-19 testing laboratories. With the initiative of NTCBB, the BEAT COVID-19 Online Training Program was conceptualized and then subsequently offered to the general interested public to address the urgent need for biosafety training. Likewise, cognizant of the serious biosafety risk involved in COVID-19 testing, the DOH of the Philippines then made this a mandatory requirement for all institutions planning to conduct and offer the said testing.

The DOH has determined the following topics as essential for the COVID-19 diagnostics: introduction to biorisk management, biorisk assessment, biocontainment, PPEs, and waste management. The NTCBB then added the following topics to better equip the participants with information to effectively manage the biosafety risks in the laboratory: biosafety cabinets and disinfection, sterilization, and decontamination lectures. These lectures consisted of core knowledge that healthcare workers should be familiar with, especially if working in the laboratory. In contrast, assessments focused on both formative and summative assessments to evaluate the learning of participants²⁰ were implemented. Formative assessments were made through the module quizzes that prepared the participants on how the final assessment will be like. However, the summative assessments were for the NTCBB to assess whether the participants were knowledgeable on the fundamentals of biorisk management and were eligible to receive the certificate of completion. As such, it served as a positive sign for training centers such as the NTCBB, although these systems should have been in place long before the pandemic took place.²¹ The call for strengthened policies for biosafety and biosecurity must be instituted by the government, in partnership with the academe, to ensure that the Philippines is ready in case of another pandemic.

Training and education have been identified globally as important factors in ensuring that health and research facility workers follow and adhere to biosafety measures and practices.²² This is then an opportunity for institutions that specialize in biosafety and biosecurity to engage with the community, in collaboration with the relevant regulatory institutions, and provide a comprehensive guide on safe laboratory practices to prevent laboratory-acquired infection.

In general, studies involving diseases need to be conducted alongside laboratory biosafety. In the Philippines, the imposed lockdown during the pandemic particularly manifested the importance of doing classes, training, and workshops through digital means to decrease the risk of contracting the disease in face-to-face setups. However, the conduct of training was not without its challenges. As already discussed, we have provided the significant challenges we have encountered, how we address them, what were the lessons we have learned, and the things that can be done to further improve the training.

Online education during the COVID-19 pandemic has also faced its fair share of difficulties. In a national survey conducted among medical students in the Philippines regarding barriers to online learning experienced during the COVID-19 pandemic, it was found out that the surveyed medical participants experienced technological, individual, domestic, institutional, and community hurdles.²³ Specifically, some of these difficulties included having slow and/or unreliable internet connection and the inability to adapt to online learning. Suggestions for improvement included the conduct of an asynchronous mode of content delivery with minimal technical and data requirements and the availability of open communication channels among administrators, educators, and students.²³

Furthermore, the importance of digital platforms should also be taken into account. The broad reach of training programs during the pandemic was made possible by utilizing social media platforms, such as Facebook, for the advertisement and having Zoom and CLMS for the online conduct of the training sessions. Institutions should consider adapting to the digital age to facilitate transactions effectively, to share knowledge, and to expand business opportunities. Cooperation with the government in transitioning to the digital age is also important to guarantee a more efficient network building among stakeholders_.²⁴

Overall, the online training allowed the participants to gather additional information to connect with what they currently know on biosafety protocols, focusing on COVID-19. The online training also served as a refresher on baseline information for current best practices among participants, so that biorisk management procedures and processes may be uniformly practiced. Another critical aspect of the online training was it provided the participants a platform to exchange experiences, ideas, and realizations, which can also improve future implementations of the online training.¹³

Conducting the training on a digital platform was crucial since the pandemic forced people to lessen physical contact. The digital interventions provided many opportunities for strengthening health systems and served as vital resources in the current public health emergency.²⁵ Not only was infection control managed through virtual e-learning avenues, the online training focusing on biosafety and biosecurity also prevented further spread of infection, which was one of the priorities of the training.

Conclusion

Overall, the BEAT COVID-19 Online Training Program offered by NTCBB provided the training participants with knowledge and updated best practices on biosafety and biorisk management. It was observed that given some of the issues previously mentioned, the online training program was successful given that it led to producing >100 accredited COVID-19 testing laboratories at the end of the course in 2020. Not only that, the online biosafety training course overcame the physical limitations brought about by the COVID-19 pandemic by focusing on teaching biosafety and biosecurity in the practical context of COVID-19. Having the biosafety course fully online also strengthened the training's purpose of continuous learning without the increased risk of COVID-19 infection among teachers and participants.

Authors' Contributions

All authors contributed to the article and approved the submitted version.

Authors' Disclosure Statement

No competing financial interests exist.

Funding Information

This study was funded by the Philippines Department of Health.